The Medical Detectives Volume I

by Berton Roueche

  I can see it now," Dr. Pellitteri said. "And smell it. Especially the kitchen, where I spent most of my time. Weinberg had the proprietor and the cook out there, and I talked to them while he prowled around. They were very cooperative. Naturally. They were scared to death. They knew nothing about gas in the place until there was no sign of any, so I went to work on the food. None of what had been prepared for breakfast that morning was left. That, of course, would have been too much to hope for. But I was able to get together some of the kind of stuff that had gone into the men's breakfast, so that we could make a chemical determination at the Department. What I took was ground coffee, sugar, a mixture of evaporated milk and water that passed for cream, some bakery rolls, a five-pound carton of dry oatmeal, and some salt. The salt had been used in preparing the oatmeal. That morning, like every morning, the cook told me, he had prepared six gallons of oatmeal, enough to serve around a hundred and twenty-five people. To make it, he used five pounds of dry cereal, four gallons of water—regular city water—and a handful of salt. That was his term—a handful. There was an open gallon can of salt standing on the stove. He said the handful he'd put in that morning's oatmeal had come from that. He refilled the can on the stove every morning from a big supply can. He pointed out the big can—it was up on a shelf—and as I was getting it down to take with me, I saw another can, just like it, nearby. I took that one down, too. It was also full of salt, or, rather, something that looked like salt. The proprietor said it wasn't salt. He said it was saltpetre—sodium nitrate—that he used in corning beef and in making pastrami. Well, there isn't any harm in saltpetre; it doesn't even act as an antiaphrodisiac, as a lot of people seem to think. But I wrapped it up with the other loot and took it along, just for fun. The fact is, I guess, everything in that damn place looked like poison."

  After Dr. Pellitteri had deposited his loot with a Health Department chemist, Andrew J. Pensa, who promised to have a report ready by the following afternoon, he dined hurriedly at a restaurant in which he had confidence and returned to Chatham Square. There he spent the evening making the rounds of the lodging houses in the neighborhood. He had heard at Mr. Pensa's office that an eleventh blue man had been admitted to the hospital, and before going home he wanted to make sure that no other victims had been overlooked. By midnight, having covered all the likely places and having rechecked the downtown hospitals, he was satisfied. He repaired to his office and composed a formal progress report for Dr. Greenberg. Then he went home and to bed.

  The next morning, Tuesday, Dr. Pellitteri dropped by the Eclipse, which was still closed but whose proprietor and staff he had told to return for questioning. Dr. Pellitteri had another talk with the proprietor and the cook. He also had a few inconclusive words with the rest of the cafeteria's employees—two dishwashers, a busboy, and a counterman. As he was leaving, the cook, who had apparently passed an uneasy night with his conscience, remarked that it was possible that he had absent-mindedly refilled the salt can on the stove from the one that contained saltpetre. "That was interesting," Dr. Pellitteri told me, "even though such a possibility had already occurred to me, and even though I didn't know whether it was important or not. I assured him that he had nothing to worry about. We had been certain all along that nobody had deliberately poisoned the old men." From the Eclipse, Dr. Pellitteri went on to Dr. Greenberg's office, where Dr. Gettler's report was waiting.

  "Gettler's test for methemoglobin was positive," Dr. Greenberg said. "It had to be a drug now. Well, so far so good. Then we heard from Pensa."

  "Greenberg almost fell out of his chair when he read Pensa's report," Dr. Pellitteri observed cheerfully.

  "That's an exaggeration," Dr. Greenberg said. "I'm not easily dumfounded. We're inured to the incredible around here. Why, a few years ago we had a case involving some numskull who stuck a fistful of potassium-thiocyanate crystals, a very nasty poison, in the coils of an office water cooler, just for a practical joke. However, I can't deny that Pensa rather taxed our credulity. What he I mil found was that the small salt can and the one that was supposed to be full of sodium nitrate both contained sodium nitrite The other food samples, incidentally, were O.K."

  "That also taxed my credulity," Dr. Pellitteri said.

  Dr. Greenberg smiled. "There's a great deal of difference between nitrate and nitrite," he continued. "Their only similarity, which is an unfortunate one, is that they both look and taste more or less like ordinary table salt. Sodium nitrite isn't the most powerful poison in the world, but a little of it will do a lot of harm. If you remember, I said before that this case was almost without precedent—only ten outbreaks like it on record. Ten is practically none. In fact, sodium-nitrite poisoning is so unusual that some of I he standard texts on toxicology don't even mention it. So Pensa's report was pretty startling. But we accepted it, of course, without question or hesitation. Facts are facts. And we were glad to. It seemed to explain everything very nicely. What I've been saying about sodium-nitrite poisoning doesn't mean that sodium nitrite itself is rare. Actually, it's fairly common. It's used in the manufacture of dyes and as a medical drug. We use it in treating certain heart conditions and for high blood pressure. But it also has another important use, one that made its presence at the Eclipse sound plausible. In recent years, and particularly during the war, sodium nitrite has been used as a substitute for sodium nitrate in preserving meat. The government permits it but stipulates that the finished meat must not contain more than one part of sodium nitrite per five thousand parts of meat. Cooking will safely destroy enough of that small quantity of the drug." Dr. Greenberg shrugged. "Well, Pellitteri had had the cook pick up a handful of salt—the same amount, as nearly as possible, as went into the oatmeal—and then had taken this to his office and found that it weighed approximately a hundred grams. So we didn't have to think twice to realize that the proportion of nitrite in that batch of cereal was considerably higher than one to five thousand. Roughly, it must have been around one to about eighty before cooking destroyed part of the nitrite. It certainly looked as though Gettler, Pensa, and the cafeteria cook between them had given us our answer. I called up Gettler and told him what Pensa had discovered and asked him to run a specific test for nitrites on his blood samples. He had, as a matter of course, held some blood back for later examination. His confirmation came through in a couple of hours. I went home that night feeling pretty good."

  Dr. Greenberg's serenity was a fugitive one. He awoke on Wednesday morning troubled in mind. A question had occurred to him that he was unable to ignore. "Something like a hundred and twenty-five people ate oatmeal at the Eclipse that morning," he said to me, "but only eleven of them got sick. Why? The undeniable fact that those eleven old men were made sick by the ingestion of a toxic dose of sodium nitrite wasn't enough to rest on. I wanted to know exactly how much sodium nitrite each portion of that cooked oatmeal had contained. With Pensa's help again, I found out. We prepared a batch just like the one the cook had made on Monday. Then Pensa measured out six ounces, the size of the average portion served at the Eclipse, and analyzed it. It contained two and a half grains of sodium nitrite. That explained why the hundred and fourteen other people did not become ill. The toxic dose of sodium nitrite is three grains. But it didn't explain how each of our eleven old men had received an additional half grain. It seemed extremely unlikely that the extra touch of nitrite had been in the oatmeal when it was served. It had to come in later. Then I began to get a glimmer. Some people sprinkle a little salt, instead of sugar, on hot cereal. Suppose, I thought, that the bus- boy, or whoever had the job of keeping the table salt shakers filled, had made the same mistake that the cook had. It seemed plausible. Pellitteri was out of the office—I've forgotten where—so I got Food and Drugs to step over to the Eclipse, which was still under embargo, and bring back the shakers for Pensa to work on. There were seventeen of them, all good-sized, one for each table. Sixteen contained either pure sodium chloride or just a few inconsequential traces of sodium nitrite mixed i
n with the real salt, but the other was point thirty-seven per cent nitrite. That one was enough. A spoonful of that salt contained a bit more than half a grain."

  "I went over to the hospital Thursday morning," Dr. Pellitteri said. "Greenberg wanted me to check the table-salt angle with the men. They could tie the case up neatly for us. I drew a blank. They'd been discharged the night before, and God only knew where they were."

  "Naturally," Dr. Greenberg said, "it would have been nice to know for a fact that the old boys all sat at a certain table and that all of them put about a spoonful of salt from that particular shaker on their oatmeal, but it wasn't essential. I was morally certain that they had. There just wasn't any other explanation. There was one other question, however. Why did they use so much salt? For my own peace of mind, I wanted to know. All of a sudden, I remembered Pellitteri had said they were all heavy drinkers. Well, several recent clinical studies have demonstrated that there is usually a subnormal concentration of sodium chloride in the blood of alcoholics. Either they don't eat enough to get sufficient salt or they lose it more rapidly than other people do, or both. Whatever the reasons are, the conclusion was all I needed. Any animal, you know, whether a mouse or a man, tends to try to obtain a necessary substance that his body lacks. The final question had been answered."

  {1947}

  CHAPTER 2

  A Pig from Jersey

  Among those who passed through the general clinic of Lenox Hill Hospital, at Seventy-sixth Street and Park Avenue, on Monday morning, April 6, 1942, was a forty-year-old Yorkville dishwasher whom I will call Herman Sauer. His complaint, like his occupation, was an undistinguished one. He had a stomach ache. The pain had seized him early Sunday evening, he told the examining physician, and although it was not unendurably severe, its persistence worried him. He added that he was diarrheic and somewhat nauseated. Also, his head hurt. The doctor took his temperature and the usual soundings. Neither disclosed any cause for alarm. Then he turned his attention to the manifest symptoms. The course of treatment he chose for their alleviation was unexceptionable. It consisted of a dose of bismuth subcarbonate, a word of dietetic advice, and an invitation to come back the next day if the trouble continued. Sauer went home under the comforting impression that he was suffering from nothing more serious than a touch of dyspepsia.

  Sauer was worse in the morning. The pain had spread to his chest, and when he stood up, he felt dazed and dizzy. He did not, however, return to Lenox Hill. Instead, with the inconstancy of the ailing, he made his way to Metropolitan Hospital, on Welfare Island. He arrived there, shortly before noon, in such a state of confusion and collapse that a nurse had to assist him into the examining room. Half an hour later, having submitted to another potion of bismuth and what turned out to be an uninstructive blood count, he was admitted to a general ward for observation. During the afternoon, his temperature, which earlier had been, equivocally, normal, began to rise. When the resident physician reached him on his evening round, it was a trifle over a hundred and three. As is customary in all but the most crystalline cases, the doctor avoided a flat-footed diagnosis. In his record of the case, he suggested three compatible possibilities. One was aortitis, a heart condition caused by an inflammation of the great trunk artery. The others, both of which were inspired by an admission of intemperance that had been wrung from Sauer in the examining room, were cirrhosis of the liver and gastritis due to alcoholism. At the moment, the doctor indicated, the last appeared to be the most likely.

  Gastritis, aortitis, and cirrhosis of the liver, like innumerable other ailments, can seldom be repulsed by specific medication, but time is frequently effective. Sauer responded to neither. His fever held and his symptoms multiplied. He itched all over, an edema sealed his eyes, his voice faded and failed, and the seething pains in his chest and abdomen advanced to his arms and legs. Toward the end of the week, he sank into a stony, comalike apathy. Confronted by this disturbing decline, the house physician reopened his mind and reconsidered the evidence. His adaptability was soon rewarded. He concluded that he was up against an acute and, to judge from his patient's progressive dilapidation, a peculiarly rapacious infection. It was an insinuating notion, but it had one awkward flaw. The white-blood-cell count is a reliable barometer of infection, and Sauer's count had been entirely normal. On Wednesday, April 15, the doctor requested that another count be made. He did not question the accuracy of the original test, but the thought had occurred to him that it might have been made prematurely. The report from the laboratory was on his desk when he reached the hospital the following day. It more than confirmed his hunch. It also relieved him simultaneously of both uncertainty and hope. Sauer's white count was morbidly elevated by a preponderance of eosinophiles, a variety of cell that is produced by several potentially epidemic diseases but just one as formidably dishevelling as the case in question. The doctor put down the report and called the hospital superintendent's office. He asked the clerk who answered the phone to inform the Department of Health, to which the appearance of any disease of an epidemiological nature must be promptly communicated, that he had just uncovered a case of trichinosis.

  The cause of trichinosis is a voracious endoparasitic worm, Tri-chinella spiralis, commonly called trichina, that lodges in the muscle fibers of an animal host. It enters the host by way of the alimentary canal, and in the intestine produces larvae that penetrate the intestinal walls to enter the blood stream. The worm is staggeringly prolific, and it has been known to remain alive, though quiescent, in the body of a surviving victim for thirty-one years. In general, the number of trichinae that succeed in reaching the muscle determines the severity of an attack. As such parasitic organisms go, adult trichinae are relatively large, the males averaging one-twentieth of an inch in length and the females about twice that. The larvae are less statuesque. Pathologists have found as many as twelve hundred of them encysted in a single gram of tissue. Numerous animals, ranging in size from the mole to the hippopotamus, are hospitable to the trichina, but it has a strong predilection for swine and man. Man's only important source of infection is pork. The disease is perpetuated in swine by the practice common among hog raisers of using garbage, some of which inevitably contains trichinous meat, for feed. Swine have a high degree of tolerance for the trichina, but man's resistive powers are feeble. In 1931, in Detroit, a man suffered a violent seizure of trichinosis as a result of merely eating a piece of bread buttered with a knife that had been used to slice an infested sausage. The hog from which the sausage was made had appeared to be in excellent health. Few acute afflictions are more painful than trichinosis, or more prolonged and debilitating. Its victims are occasionally prostrated for many months, and relapses after apparent recoveries are not uncommon. Its mortality rate is disconcertingly variable. It is usually around six percent, but in some outbreaks nearly a third of those stricken have died, and the recovery of a patient from a full-scale attack is almost unheard of. Nobody is, or can be rendered, immune to trichinosis. Also, there is no specific cure. In the opinion of most investigators, it is far from likely that one will ever be found. They are persuaded that any therapeutic agent potent enough to kill a multitude of embedded trichinae would probably kill the patient, too.

  Although medical science is unable to terminate, or even lessen the severity of, an assault of trichinosis, no disease is easier to dodge. There are several dependable means of evasion. Abstention from pork is, of course, one. It is also the most venerable, having been known, vigorously recommended, and widely practiced for at least three thousand years. Some authorities, in fact, regard the Mosaic proscription of pork as the pioneering step in the development of preventive medicine. However, since the middle of the nineteenth century, when the cause and nature of trichinosis were illuminated by Sir James Paget, Rudolf Virchow, Friedrich Albert von Zenker, and others, less ascetic safeguards have become available. The trichinae are rugged but not indestructible. It has been amply demonstrated that thorough cooking (until the meat is bone-white)
will make even the wormiest pork harmless. So will refrigeration at a maximum temperature of five degrees for a minimum of twenty days. So, just as effectively, will certain scrupulous methods of salting, smoking, and pickling.

  Despite this abundance of easily applied defensive techniques, the incidence of trichinosis has not greatly diminished over the globe in the past fifty or sixty years. In some countries, it has even increased. The United States is one of them. Many epidemiologists are convinced that this country now leads the world in trichinosis.

  It is, at any rate, a major health problem here. According to a compendium of recent autopsy studies, approximately one American in five has at some time or another had trichinosis, and it is probable that well over a million are afflicted with it every year. As a considerable source of misery, it ranks with tuberculosis, syphilis, and undulant fever. It will probably continue to be one for some time to come. Its spread is almost unimpeded. A few states, New York among them, have statutes prohibiting the feeding of uncooked garbage to swine, but nowhere is a very determined effort made at enforcement, and the Bureau of Animal Industry of the United States Department of Agriculture, although it assumes all pork to be trichinous until proved otherwise, requires packing houses to administer a prophylactic freeze to only those varieties of the meat—frankfurters, salami, prosciutto, and the like—that are often eaten raw. Moreover, not all processed pork comes under the jurisdiction of the Department. At least a third of it is processed under local ordinances in small, neighborhood abattoirs beyond the reach of the Bureau, or on farms. Nearly two per cent of the hogs slaughtered in the United States are trichinous.