The Medical Detectives Volume I

by Berton Roueche

  "Smart helped me get his wife and the Masons into the examining room. Mason really needed help. He couldn't even stand alone. We got him stretched out on a cot and as comfortable as possible, and settled the two women in chairs. The blurred vision they all complained of was easy to understand. They all had widely dilated pupils—very glassy-looking. The immediate problem as far as Mason and Mrs. Smart were concerned was nausea. They were sick as dogs, and, to make matters worse, they both had an insatiable thirst. I gave them each an intramuscular injection of trimethobenzamide hydrochloride. That seemed to help the nausea a bit, but it was obvious that they were getting sicker by the minute. Mason was so wild it was hard to keep him from falling off the cot. He kept reaching for imaginary doorknobs, as if he wanted to get out of the room. Sometimes he would be fighting off a swarm of bugs. Then at times he seemed to calm down, and he would point across the room or up at the ceiling and say something about all the beautiful flowers. But most of the time nothing he said made any kind of sense. And Mrs. Smart was almost as bad. She was beginning to hallucinate, too, and raving and thrashing around in her chair. It was unnerving. I really didn't know what to think. Or, rather, there was only one thing I could think of, and that possibility was almost too frightening to contemplate. I mean botulism. Botulism, as you probably know, is the most dangerous of the bacterial food poisonings. It has a mortality rate of about sixty-five per cent. It is also, of course, a pretty rare bird. But it happens. As a matter of fact, it had happened right here in eastern Tennessee—in Knoxville—only a couple of weeks before. You probably read about it in the paper. There were seven cases in the outbreak, and two of them were fatal. So botulism was more or less on my mind. I didn't have far to reach. I thought of it the minute I saw those central nervous-system symptoms.

  "I don't mean to say I was certain. Not at all. There wen- several points that didn't quite fit a diagnosis of botulism. The onset, for one thing, seemed a little too sudden. And the symptoms were not exactly right. The central-nervous-system symptoms that Mrs. Smart and Mason had were more pronounced—more violent —than the central-nervous-system symptoms that are classically characteristic of botulism. But they were close enough. They were certainly too close to ignore. Botulism can be treated, you know There's an antitoxin, and if it's given in time it can make all the difference. Dr. Craig agreed with me. I called him at the hospital and gave him the facts and asked him what he thought, and he wasn't for taking any chances, either. He proposed that I call the ambulance service and get them right into the hospital. I was glad to take his advice."

  Mason and Mrs. Smart were carried into the emergency room of the Holston Valley Community Hospital in Kingsport at five minutes after four. Mrs. Mason arrived at four-fifteen with Smart and his little boy. They were received by Dr. Craig and (such was his aversion to taking any chances) three hurriedly recruited consultants—a neurosurgeon; the hospital pathologist, Dr. William Harrison; and an internist whom I'll call Richard Johnson. Both Mason and Mrs. Smart were now wildly delirious and almost totally helpless. They were also deeply flushed, dry of mouth, and tormented by an unquenchable thirst, and Mason was shaken by frequent muscle spasms. Mrs. Mason, however, was still only weak, dry-mouthed, and vertiginous. The emergency-room examination was diagnostically uninstructive. Mason's pulse rate was a hundred, or about thirty beats faster than normal for a man, and Mrs. Smart's was eighty-eight, or only slightly faster than normal for a woman, and both had a temperature of ninety-nine degrees. Mrs. Mason had no fever, and her pulse rate was normal. All three had widely dilated pupils that reacted sluggishly to light. The results of the other routine tests —blood pressure, blood count, urinalysis—were normal in all three cases.

  "I think we were all inclined to accept Dr. Rathbone's first impression," Dr. Johnson, the internist, says. "The trouble was obviously some kind of poisoning. What kind was hard to say. It looked like botulism, and yet it didn't. Hallucinations and disorientation very seldom occur in botulism, and when they do, they tend to be rather late-developing symptoms. Still, it wasn't a possibility that any of us were willing to rule out of the picture entirely. Even a hint of botulism is unsettling. We were standing there in the emergency room and feeling very unsettled when Smart got up from where he was sitting with his son and came over. He said his little boy was complaining about his eyes. Everything looked funny, Buddy said. That sounded like what had happened to his wife and the others, so he thought we ought to know. Also, Smart said, he wasn't feeling too good himself. His eyes were all right, but he had a cramping pain in his stomach, and he was beginning to feel a little nauseated. Well, that decided us. Botulism antitoxin isn't something you can get at any drugstore. Or at any hospital, for that matter. There isn't that much demand for it. The nearest possible source we could think of was the Poison Control Center at the University of Tennessee Memorial Hospital, in Knoxville. Robert Lash, the director of the Center, had laid in a supply of antitoxin during the botulism outbreak they had over there earlier in the month, and maybe some of it was left. I went to the phone and gave Dr. Lash a ring, and we were in luck. He still had several hundred thousand units on hand. He said he would get it off at once by a special highway-patrol messenger. It was now about a quarter to five. We should have it by seven o'clock."

  It took Dr. Lash about ten minutes to arrange with his dispensary and the Tennessee highway patrol for the dispatch of some five hundred thousand units of polyvalent botulinus antitoxin to the Holston Valley Community Hospital. He then returned to his desk and put in a call to Nashville—to Cecil B. Tucker, director of the Division of Preventable Diseases of the Tennessee State Department of Public Health, in the Cordell Hull State Office Building there. Botulism is a communicable disease, and consequently a notifiable one. In Tennessee, as in all other states, its appearance (proved or suspected) must be reported to the state health authorities for prompt investigation. When Dr. Tucker came on the line, Dr. Lash gave him the required report.

  "I wasn't as startled as I might have been by that call from Dr. Lash," Dr. Tucker says. "Botulism was no great novelty in Tennessee that month, you know. My only thought was something like 'Here we go again.' I thanked him and hung up and put in a call to Kingsport—to Dr. Johnson. I wanted a few more facts before sending an investigator up there. But I had Dan Jones standing by. Dr. Jones is an Epidemic Intelligence Service officer assigned to us by the U.S. Public Health Service through its Communicable Disease Center, in Atlanta. I got Dr. Johnson, and he described the cases. He gave me the clinical picture and what he could of the epidemiology, and I began to have my doubts. It just didn't sound like botulism. But that, of course, was only an opinion. Botulism was still a possibility, so we had to go and see. I told Dr. Johnson that Dr. Jones would be up there in the morning, and started to say goodbye. And Dr. Johnson said, 'Wait a minute.' I waited. Then Dr. Johnson came back on. 'By the way,' he said. 'One of the doctors here has been talking to one of the patients, and he says he just mentioned something about eating Jimson weed.' I don't remember what I said to that. Except that I would call him back.

  "Dr. Jones had heard what I heard. He was listening in on an extension. We lit out down the hall and up the stairs to the chemical lab. That's where we keep our file on poisons. I pulled out the card on Jimson-weed poisoning, and no wonder I'd had my doubts. I'll read you what it says under 'Symptoms and Findings': 'Pupils dilated, dry burning sensation of mouth, thirst, difficulty in swallowing, fever, generalized flushing, headache, nausea, excitement, confusion, delirium, rapid pulse and respiration, urinary retention, convulsions.' It was almost word for word the clinical picture that Dr. Johnson had given me on the two patients more seriously stricken. We went back downstairs to my office. I got Dr. Johnson on the phone again and told him what we had found. I said it very much looked to me as though Jimson-weed poisoning was the answer to his problem. Dr. Johnson said he thought I was right. They had done some checking themselves, he said, and they had come to that same conclusion."

&n
bsp; Jimson weed (or stinkweed, or thorn apple, or devil's-trumpet) is a big, hardy, cosmopolitan annual of Asian origin. It is known to science as Datura stramonium and is a member of the large and generally noxious Solanaceae, or nightshade, family of plants. Other members of this family include tobacco, horse nettle, henbane, belladonna, the petunia, the tomato, and the Irish potato. All these plants, including the tomato and the potato, are at least in some respects pernicious. Jimson weed is entirely so. Its leaves, its seeds, its flowers, and its roots all contain a toxic alkaloid called hyoscyamine. Hyoscyamine is closely related to atropine and is, if anything, more toxic. Jimson weed is distributed throughout most of the United States. It made its first appearance here in the early seventeenth century, possibly as early as 1607. Some authorities think it may have been introduced in ballast and other rubbish discharged from the ships that landed Captain John Smith and his fellow Virginia colonists at Jamestown in that year. In any event, it seems reasonably certain that it entered this country there. Early records indicate that the Powhatan Indians of coastal Virginia called it the "white man's weed." The white colonists of Virginia and elsewhere, on the other hand, called it "Jamestown weed." Robert Beverly refers to it as Jamestown weed in his History and Present State of Virginia, of 1705, and gives a recognizable, if somewhat excessive, depiction of its hallucinatory powers:

  This being an early Plant, was gathered very young for a boiled salad by some of the Soldiers . . . and some of them ate plentifully of it, the Effect of which was a very pleasant Comedy; for they turned natural Fools upon it for several Days. One would blow a Feather in the Air; another would dart Straws at it with much Fury; and another stark naked was sitting up in a Corner, like a Monkey grinning and making Mows at them; a Fourth would fondly kiss and paw his Companions, and sneer in their Faces, with a Countenance more antik than any in a Dutch Droll. In this frantic Condition they were confined, lest they in their Folly should destroy themselves; though it was observed that all their Actions were full of Innocence and Good Nature. Indeed, they were not very cleanly; for they would have wallowed in their own Excrements, if they had not been prevented. A Thousand such simple Tricks they played, and after Eleven Days, returned themselves again, not remembering anything that had passed.

  The other names by which Jimson weed—which is, of course, a corruption of "Jamestown weed"—is sometimes known are more conventionally descriptive. They call attention to one or another of its several notable characteristics. The plant gives off a fetid smell; its fruit, or seed pod, is barbed with thorns, like a chestnut bur; and its poisonous flowers—milky white and sometimes streaked with purple—are trumpet-shaped. Jimson weed is in every sense a weed. Like beggar's-lice and tumbleweed and the cocklebur, it flourishes almost everywhere and is everywhere detested. It sprouts early (as Beverly noted), it grows fast, and it blooms until late in the fall. Its size, for an annual, is considerable. It often reaches a height of six feet, and it averages around four. Like most other successful weeds, Jimson weed can exist on even the poorest land, but its existence there is no more than dogged survival. It does well only in fertile soil, and when it finds itself so placed it feeds voraciously—as voraciously, and as destructively, as corn or cotton. It is also, however, among the easiest of weeds to control. A couple of swipes with a scythe or a hoe before the seeds are formed will clear the most firmly established Jimson- weed jungle. Its presence on cropland or in pasture is thus traditionally taken as a sign of indifferent farming. Mark Twain was aware of its reputation, and in Tom Sawyer he turned it to effective atmospheric use: "She [Aunt Polly] went to the open door and stood in it and looked out among the tomato vines and 'jimpson' weeds that constituted the garden." Livestock are repelled by its smell, which is so rank that only animals addled by hunger are rash enough to ignore it. Jimson-weed poisoning in livestock is almost entirely limited to the ingestion of hay or ensilage accidentally contaminated with Jimson-weed seeds or leaves, and such cases are relatively few. Man is less instinctively prudent. Most people find the smell of Jimson weed repellent, but it frequently fails to repel them. Jimson-weed poisoning in man, though hardly commonplace, is anything but rare. "During the past five years at the University of Virginia Hospital, which services a large southern rural area, Datura has accounted for approximately four percent of pediatric patients admitted because of ingestion of a toxic substance," Joe E. Mitchell and Fred N. Mitchell, both members of the Department of Pediatrics of the University of Virginia School of Medicine, reported to the Journal of Pediatrics in 1955. "Although distinctly less frequent than kerosene or salicylate intoxication, Datura has had about the same incidence as lead, barbiturates, alcohol, rodenticides, and insecticides as a source of poisoning." Jimson-weed poisoning in children can usually be laid to innocence. The seeds are mistaken for nuts, or are used in play as "pills." Its adult victims are more variously poisoned. Some of them are victims of homespun credulity (folk medicine recommends a tea of Jimson-weed leaves for the relief of asthma, constipation, and certain other ills), and some are victims of a credulous sophistication (the street-corner pharmacopoeia recommends Jimson-weed seeds for a liberating hallucinatory experience). A few of them—including, as it turned out, Homer Mason and his family—are victims of simple ignorance.

  The doctor to whom one of the patients in the emergency room of the Holston Valley Community Hospital that October afternoon in 1963 said "something about eating Jimson weed" was William Harrison, the hospital pathologist, and the patient was Leroy Smart. That wasn't, however, exactly what he said.

  "I'd been talking to Smart about the meal he had fixed that noon," Dr. Harrison says. "I wanted to know just what had been eaten and just how it had been prepared. It bothered me. I don't mean I had any ideas. It was only that Mason and Mrs. Smart had taken sick almost immediately after eating. That was a little suspicious. Either that or a rather odd coincidence. But the trouble was, of course, that ordinary bacterial food poisoning doesn't act that way. It doesn't come on that fast. It takes hours, and even days The same is true of most other kinds of food poisoning. About tin- only poisons that hit in a matter of minutes are chemical poisons, like antimony and sodium fluoride, and the symptoms they produce are nothing like those we had here. So I was simply floundering. But something I said must have struck a chord in Smart. His whole expression changed. Come to think of it, he said, there was something he hadn't thought to mention about that meal—something a little unusual. The tomatoes they'd had weren't ordinary tomatoes. They were grafts. They were grown on a tomato stalk that Mason had grafted onto a Jimson-weed plant. He wondered if that might have had anything to do with the trouble.

  "That was when I spoke to Dr. Johnson. I knew he was talking to Nashville, and I thought they ought to know. The way he heard it was a little confused. Or maybe I was a little confusing. I probably was. I mean, I knew without any question that Jimson weed was the answer. It answered all our questions—the central-nervous-system symptoms, the sudden onset after eating, everything. But the whole thing Was so fantastic. It was also such a relief. Jimson-weed poisoning can be extremely serious. It can be fatal. Still, almost anything is preferable to botulism. And not only that. It relieved our minds about Smart and his little boy. The late onset of their symptoms suggested a mild exposure. The same was largely true in the case of Mrs. Mason. Her symptoms were somewhat delayed, and they were also relatively mild. In fact, in the end we didn't even admit those three to the hospital. It was different, of course, with Mason and Mrs. Smart. They were really sick. They didn't seem to be in critical condition, but they certainly needed hospitalization. We put them to bed and started them on a course of oral pilocarpine, a nerve stimulant that would serve to counteract the action of the toxin on their vision by stimulating the parasympathetic nerves. But that was about all we could do for them. There is no specific treatment for Jimson-weed poisoning.

  "I had another talk with Smart just before he left the hospital. I had no real connection with the case, of course, but I was
interested—intensely interested. Smart was with his son and Mrs. Mason. Dr. Craig had given her ten milligrams of pilocarpine for symptomatic relief, and she seemed to be in pretty good shape. I was particularly interested in the nature of the tomato graft. Smart couldn't help me on that. He said I'd have to talk to Mason, since Mason did all the gardening. He was able to tell me the why of it, though. It was really a bright idea. Mistaken, to be sure, but most ingenious. Mason wanted a hardy, frost-resistant tomato— one that would ripen late in the fall. And he knew that Jimson weed was a hardy, frost-resistant plant that flourished until well into November. So he put the two together. He was right, too. The graft was completely successful. As a matter of fact, Smart said, that tomato they ate at dinner was the very first fruit of the experiment. It had only that morning turned ripe enough to pick. It was a good-sized, good-looking tomato, he said, and it had a good flavor. It tasted like any good home-grown, vine-ripened tomato. He had eaten one slice, and so had his wife and Mrs. Mason. It was possible that his wife's slice had been one of the big center slices. His own had been an end slice, and Buddy's had been only a sliver. Mason, on the other hand, had eaten three or four slices.