The Medical Detectives Volume I

by Berton Roueche

  "Then I held my breath. Nobody tried to challenge me or contradict me. Nobody said a word. But you should have seen their faces. The public-health nurses looked stunned. I saw Dr. Enriquez smiling and nodding. The parents of the sick children looked horrified and insulted—I was telling them their children were crazy. But most of the others—the teachers and the school- board people and the firemen and the head secretary—just stood there looking thoughtful. The truth was dawning. I think that maybe some of them had half suspected the truth all along. Well, I started in all over again. I gave them my reasons and my reasoning. I could see heads beginning to nod and faces starting to relax. And then, all of a sudden, the tension dissolved. The firemen and the police just sort of disappeared. People began to turn to each other and talk. The sick kids stopped looking so sick. The head secretary went out to the kitchen, and the teachers began to clear the room. It was all over.

  "I mean, the emergency was over. There was still plenty of work to do. I still had to justify my decision—and not only to the school and the public. I had to explain it to the satisfaction of my office. I had made a bold move, and bold moves are not encouraged in the bureaucratic world. I had some very angry calls from parents. One mother demanded that I apologize to her child. I was finally able to convince her that being suggestible at the age of eleven was not a sign of insanity. But, thank God, I was lucky. The proof was forthcoming. I acquired one useful piece of information even before I left the cafetorium. A teacher came up to me at the end of my speech and said she was sure I was right. She said there could not have been any poison gas or fumes in the cafetorium, because when the first rehearsal class let out, and the first wave of illness broke, a second rehearsal class had marched into the cafetorium and spent the hour rehearsing, and none of the children in that class had been taken ill. So, gas or no gas, the cafetorium could not have been the site of the trouble. But it was in the cafetorium that the first victim—the girl I'm calling Sandy—took sick. How come?

  "I hung around the school, trying to figure it out. It was amazing how quickly everything got back to normal. I talked to more teachers. I talked to some of the children. I talked with a neighborhood doctor who had been called when the trouble first began. They gave me a brainful of bits and pieces. I could see what had happened, but I couldn't see how it had happened. Sandy was what we call in epidemiology the index case. Everything that happened stemmed from her. But I couldn't find a clear connection. The timetable didn't seem to tell the right time. Sandy had slipped out of the cafetorium and collapsed in the clinic at about nine-thirty. But it wasn't until ten o'clock—until the nine-o'clock classes let out—that the wave of illness broke. Why did it take so long? And why did it happen when it did? I wandered around talking and listening, and trying to fit the pieces together. It's hard to remember now just how I did it. Did somebody tell me something? Or did I simply take a different look at something I already knew? Anyway, it suddenly all came together. The whole thing hung on coincidence—on two coincidences, actually. One of them had to do with Sandy and the fire-rescue people. They arrived at the school on the head secretary's summons a couple of minutes before ten. Sandy was still in her faint, or whatever it was. They lifted her onto a stretcher and carried her out and down the hall —at the very moment that the nine-o'clock classes, including the group rehearsing in the cafetorium, let out. The kids flowed out of the cafetorium. They saw Sandy passed out on a stretcher. They had seen her slip out of the rehearsal, and now they knew why. Something was wrong. And somebody reacted—I'm reconstructing now. Somebody complained of feeling sick. That triggered it That's all it takes in these cases. Hysteria took over. And then the second coincidence happened. That was the neighborhood doctor. He arrived at the school, he saw the fire-rescue squad, he saw the children reacting—and he smelled the funny smell of the adhesive on the new library carpet. He thought it was the smell of something toxic. He said something to that effect to somebody. And the word spread. That pulled the trigger on the second barrel.

  "When I went back to the office, I knew what had happened, and why, and how. The rest was documentation. I was confident that it would bear me out. And it did. DiSalvo's thorough investigation confirmed his preliminary study. The physical environment of the building was safe and clean. We also did a comprehensive clinical study. The heart of it was a student questionnaire. We found that a total of seventy-three children had reported at least some symptoms of illness—seventy-three out of a total enrollment of around four hundred and fifty. Most of them—sixty-three—were in either the fifth or the sixth grade. Most of the chief reactors were girls. Don't ask me why, but girls—young girls—seem to be more susceptible than boys. In the Berry outbreak, girls outnumbered boys by more than two to one. Anyway, we did a special study of the seven children who were hospitalized along with Sandy. All of them had been in the first rehearsal class, and they all knew Sandy. We looked into their psychological background, and came up with some interesting data. Five of the seven were girls. One of these had a clear history of hypochondria. Another was always sick or sickly. Another had a habit of hyperventilating in moments of stress. Another had come to school that day feeling vaguely ill. Another was one of Sandy's closest friends. One of the boys was a chronic discipline problem. The other boy was described by the school as highly excitable.

  "The questionnaire provided some very interesting information. The comments of some of the children who reported feeling sick that morning were particularly revealing. These were mostly in response to the question 'When you got sick, did you know that other children were sick, too?' I'll read you some of the comments. One girl answered, 'Yes, because Sandy fainted.' Another wrote, 'Yes—a lot of kids. I started to feel sick between Music and Language Arts, and then they carried me outside.' Another girl answered, 'I just knew that a boy vomited.' Her only symptom was nausea. Another girl wrote, 'Yes—Sandy was sick.' And a boy— one of the few boys—wrote, 'Yes, and after Sandy got sick and there was a fire drill, and when everybody was walking out of the building, I felt like a small headache.' Well, you get the drift. We also talked to Sandy. She turned out to be pretty much as expected. I mean, she was the right type. She was attractive. She was a good student. She was precocious. And she was very popular. She was looked up to."

  "She was a kind of leader?" I asked. "She set the pattern?"

  "Yes," he said. "I think you could say that."

  "But what about her?" I asked. "What made her get sick?"

  Dr. Nitzkin looked at me. "Oh," he said. "Sandy was really sick. She had some sort of virus. All that standing and singing in place was too much for her. She just passed out."

  [1978]

  CHAPTER 21

  A Rain Day on the Vineyard

  A little after one o'clock on the afternoon of Wednesday, August 16, 1978. a switchboard operator at the Bureau of Epidemiology of the national Center for Disease Control, in Atlanta, received a long-distance call from a man who asked to speak to someone in authority in the parasitic-disease division. He had, he said, some information to report, and he wanted some advice. The operator connected him with a young Epidemic Intelligence Service officer assigned to that division named Steven M. Teutsch.

  "I don't know about authority," Dr. Teutsch says. "But I guess I was in charge." A white smile stirs in the depths of a curly black beard. "I happened to be the only doctor in our office that afternoon. So I took the call and gave my name, and the caller identified himself. He was a physician in practice in Grand Junction, Colorado, and he needed help. He then went into a rather complicated story. It took me a minute or two to get it straight. It seemed he had a patient in a Grand Junction hospital seriously ill with pneumonia—a man I'll call Daniel Stafford. He had become ill on August 11th, with a fever of a hundred and four degrees, headache, muscular aches and pains, loss of appetite, nausea, and a cough. He had been treated with penicillin but had shown no improvement. It also seemed that Stafford's wife—I'll call her Anne Lord Stafford—had been
ill for several days with some similar pulmonary infection, but was now recovered. They were both in their early thirties, and they had recently returned from a family houseparty at her father's summer cottage on Martha's Vineyard. It was the doctor's understanding that two other guests at the family gathering had become sick and were hospitalized— one at the Martha's Vineyard hospital and the other at Beth Israel Hospital, in Boston. The patient at the Vineyard hospital was Mrs. Stafford's younger sister. I'll call her Patsy Lord Hooper. Mrs. Hooper had become sick on August 7 with much the same symptoms as her relatives out in Colorado. The Beth Israel patient was Patsy Lord Hooper's brother-in-law—John Hooper. And he was the particular reason for the Colorado doctor's call. The advice of a parasitologist was needed. John Hooper's illness was thought to be babesiosis.

  "Well! That was interesting—very interesting. And the doctor's concern was very easy to understand. Babesiosis is one of our newer diseases. I should say newly identified and described—it is probably as old as any of them. But it's new to medicine. It isn't even mentioned in the standard medical texts. It is primarily a tick-borne disease of wild rodents, but it is readily transmitted by infected ticks to man. The causative organism is a protozoa—a blood parasite named Babesia microti. Babesiosis came into prominence only four or five years ago, and most, if not all, known cases have been in and around coastal southern New England—the Cape Cod area, including Martha's Vineyard and the east end of Long Island. It's a serious disease. The Colorado doctor went on to say that he knew next to nothing about babesiosis, but if that was what John Hooper had, might it not also be the cause of Daniel Stafford's illness? If so, what should he do? That was a good question. There is a treatment for babesiosis—an agent called penamidine. But I wasn't about to recommend it in the case of Daniel Stafford. I didn't know about John Hooper up in Boston, but it didn't sound at all to me as if Daniel Stafford out in Grand Junction had babesiosis. Babesiosis is not a pneumonic disease. It tends to come on like malaria. Which is also, of course, a protozoan disease. I told the doctor what I thought. I thanked him for his call, his report. I said that his Martha's Vineyard houseparty sounded very much like something we would want to look into. I would keep him informed. And I was interested. I mean, all that pneumonia, all that pulmonary disease in one small group! 1 thought it sounded like a very unusual epidemic.

  "I had a little problem there, of course. I wanted to go ahead, but I was working in the Parasitic Diseases Division and pulmonary disease was out of my official capacity. I was tempted to wonder if maybe I was mistaken about babesiosis. I didn't think so . . . and yet. Well, I decided to take at least the first step. I put in a call to Boston—to Beth Israel—and talked to one of the doctors there about John Hooper. Babesiosis was still very much on their minds, and Hooper was being treated for that. Their thinking was based on a blood smear that seemed to show a protozoan organism. He was not doing too well. He was still running a fever—up to a hundred and three. On the other hand, of course, they were keeping an open mind. They had taken blood samples for a series of evaluations. Then I called Martha's Vineyard and talked to the doctor there who was treating Patsy Lord Hooper. It was his impression, based on a chest X-ray, that she was suffering from an atypical viral pneumonia. She had run a fever up to a hundred and two, but she was now much improved. We talked about other possibilities—more specific kinds of infection—and he told me he was arranging for the indicated serum studies. I later learned that he had also treated Patsy's husband for a febrile illness—a mild case, from which he was now recovered. Patsy and her husband had spent the summer on the Vineyard at the family cottage. They were joined there on Wednesday, July 30, by the Staffords and John Hooper and by her father and a woman friend of his. The party broke up on Tuesday, August 5. Everybody had arrived well and remained well during the week of the gathering. But every one of them had become ill with pulmonary symptoms of some sort within a few days after the party. It was, indeed, an interesting epidemic.

  "Well, I thought I'd made a start. In any event, I'd gone about as far as I could go on my own authority. And my superior was out of town. In an organization like C.D.C., everything is structured. Everything moves through channels. I put my notes together and got up and went down along the hall to what seemed to be the appropriate starting channel."

  The immediate course and consequence of Dr. Teutsch's alerting report is noted in a subsequent interoffice memorandum channeled to Dr. William H. Foege, the director of the Center. It begins:

  On August 16, 1978, Steven M. Teutsch, M.D., EIS Officer, Parasitic Diseases Division, Bureau of Epidemiology (BE), advised Arnold F. Kaufmann, D.V.M., Chief, Bacterial Zoonoses Branch, Bacterial Diseases Division; John Bennett, M.D., Director, Bacterial Diseases Division; William G. Winkler, D.V.M., Chief, Respiratory and Special Pathogens Branch (RSPB), Viral Diseases Division (VDD), BE; and Robert B. Craven, M.D., Chief, Respiratory Activity, RSPB, BE, of a possible outbreak of acute respiratory disease in humans on Martha's Vineyard, Massachusetts. Dr. Craven and Stanley I. Music, M.D., Deputy Director, Field Services Division, BE, contacted Joseph P. Rearden, M.D., Assistant State Epidemiologist, Massachusetts State Department of Public Health, and discussed this possible outbreak. . . .

  Additional discussions were held with Edward W. Brink, M.D., EIS Officer, located at the Connecticut Department of Health, and Timm A. Edell, M.D., EIS Officer, Colorado Department of Health. Frequent discussions were held with the Massachusetts Department of Public Health staff over the next 12 days. . . .

  On August 28, David R. Kimloch, M.D., Deputy Health Officer, Massachusetts Department of Public Health, spoke with Dr. Winkler and invited CDC to assist in the investigation. On August 29, Dr. Teutsch departed for Martha's Vineyard. . . .

  "Actually," Dr. Teutsch says, "it wasn't quite as simple as that. The invitation from the Massachusetts Department of Public Health to C.D.C. to participate in the investigation was not entirely spontaneous. There was an eminence grise. He was Infamous Dr. Alexander Langauir. Alex—everybody calls him Ale* —was the founder of the Bureau of Epidemiology at C.D.C. and its first director. He's now retired, living in Boston, but it so happens that he has a summer cottage on Martha's Vineyard, and he was in it. He knew as well as anybody that state health departments do not automatically invite the participation of C.D.C. in local public-health investigations. They sometimes hesitate to appear to be in need of outside help. Which, of course, is only natural. Well, Alex had heard about the outbreak, and he knew that I had talked with the doctor who had treated Patsy Lord Hooper and her husband. He pulled some invisible strings and got himself appointed a temporary consultant to the local health department. Then he set about advising the local authorities to ask the state to ask C.D.C. to come in. And, as usual, Alex succeeded. And he was on hand to welcome me when I arrived on the Vineyard. I even stayed at his house.

  "On the drive in from the airport, Alex and I brought each other up to date. There really wasn't much to report. Patsy Hooper had been discharged from the Vineyard hospital, and her brother-in-law John Hooper had been discharged from Beth Israel. But Dan Stafford, out in Colorado, had been flown from Grand Junction to a Denver hospital. He was in intensive care, on a respirator, and his condition was considered critical. That was an extra incentive to us to try to identify the problem. Dan Stafford couldn't be properly treated until his doctors knew the cause of his illness. And that was still a mystery. The first round of laboratory evaluations were inconclusive—more or less as expected. Pneumonia of the sort we were dealing with here is diagnosed by serum antibody tests, and antibodies don't appear in the blood during the acute stage of the illness. Antibodies rise slowly, as the body mobilizes its defenses, and an accurate positive result can't be expected in much less than three weeks. Arrangements were being made now for a new collection of blood samples— convalescent samples. The tests would be run at the C.D.C. laboratories in Atlanta. Another complication was the sheer number of disease possibilities to be evaluated. Ther
e are a good many atypical pneumonias. Legionnaire's disease was one possibility, und one that was very much on our minds in C.D.C. It is also very much an epidemic disease. Another possibility was mycoplasmal pneumonia. The other possibilities included psittacosis, influenza A-type and B-type, adenovirus infection, respiratory syncytial virus disease, tularemia, parainfluenza types 1, 2, and 3, and the three major fungal infections—histoplasmosis, blastomycosis, and coccidioidomycosis. Alex's first choice was Legionnaire's disease, and his second choice was mycoplasmal pneumonia. His third choice was a little scary. He thought it might be something brand- new—something we knew nothing about.

  "I spent three days on the Vineyard. Ed Brink, a fellow E.I.S. officer assigned to the Connecticut Health Department, came over from Hartford, and we divided up the work. Our job was to get a standard epidemiological study under way. That involved two approaches. One was a study of the Lord cottage and its environment. The other was to determine the dimensions of the outbreak. Was it confined to the seven members of the houseparty, or were they part of a larger epidemic. Alex drove me over to the cottage. I don't know if you know Martha's Vineyard. It's roughly triangular in shape, about twenty miles long from east to west, and from two to ten miles wide. The chief town is Edgartown, at the east end, and the hospital is there. The Lord cottage is at the west end, facing the ocean across an inlet called Chilmark Pond. The Chilmark area is largely rural—hilly, with scrub woods and brush. Patsy and Tom Hooper were still on the Vineyard, and we talked to them at the cottage. Here's what we learned: The nearest neighbor was another summer cottage, about two hundred yards distant, and the two houses shared a well. There had been no illness of any kind at the neighboring house. The Lord party stayed pretty close to its cottage. The only outside activity in which all seven people participated was an annual Vineyard affair called 'The Illumination,' at Oak Bluffs, at the northeast end of the island. We went through the house—large living room with a fireplace, kitchen, bedrooms, and bath. The house is heated when necessary by the fireplace, and the fireplace is equipped with a device called a Heat-o-Lator, which distributes the hot air. The fireplace was used only once during the houseparty week—on the night of August 2. There was nothing significant in the food eaten during the week. The party often went swimming, and waded across the shallow, brackish Chilmark Pond to get to the ocean beach. The Hoopers had two dogs—a Labrador and a Chesapeake Bay retriever—both young and active. Mice had been seen in the cottage early in the season. Rabbits were abundant in the area, and so were ticks, mosquitoes, and flies. During the week of the gathering, the septic tank backed up, but did not overflow. A moldy wooden post supporting the front porch had collapsed early in the week—and moldy wood suggests fungus. We took samples of the pond water, samples of the rotten log, samples of earth at the septic tank, samples of household dust, samples of debris from the Heat-o-Lator, and a sample of drinking water from the kitchen tap. We hadn't picked up anything of much importance. But maybe the laboratory in Atlanta would.