The Medical Detectives Volume I

by Berton Roueche

  "That completed that phase of the investigation. I was ready to begin on Ajax. Peter drove me back to the city and across the river and down through the Kentucky bluegrass country to the Cincinnati airport. I had a reservation on a late afternoon flight to Milwaukee, and while I was waiting, I telephoned Mrs. Hoffman and satisfied myself about some clinical odds and ends. Then I flew to Milwaukee and found a hotel and went to bed. The next morning—that would be Thursday—I took a cab out to the Ajax plant and introduced myself to the manager. He was a little stiff at first, but as soon as I mentioned their hair felt number 303, he completely relaxed. I've seldom seen a friendlier man. It seemed that his plant didn't make number 303 hair felt. Number 303 was made exclusively at the Newark plant. It was composed of several different kinds of animal hair. Only cattle hair was used here in Milwaukee. It was all domestic fiber, he said, and it came from a number of Midwestern tanneries. He led me out to the warehouse and showed me several hundred bales of cattle hair and cattle hair felt. I knew it was a waste of time, but I took a couple of pictures of the layout and some samples of hair and felt for the record, and got out as fast as I could.

  "I spent that night in New York, and took the Hudson Tube over to Newark the first thing in the morning. I had a hunch it was going to be a long day. The Ajax manager there was expecting me. He was ready and waiting. Milwaukee must have called him. He allowed that his plant made number 303 hair felt, and also number 318. The composition of the latter was seventy-five per cent jute and the rest animal hair—usually cattle hair, but sometimes calf or horse. Number 303 felt was half cattle hair and half goat hair. Practically all of the animal hair they used was domestic hair. The chief exception was goat hair. That was usually imported. I found that very provocative. Animal anthrax is pretty well under control in this country, you know, but it isn't everywhere. There are plenty of places where it is still enzootic—North Africa, southern Europe, the Middle East. And those are all big goat-raising areas. At my suggestion, the manager brought out his records and we looked up their recent goat hair purchases. The record showed that in 1963 they had bought approximately one hundred and twenty thousand pounds of goat hair—all of it imported. Moreover, only foreign hair had been used in the manufacture of 303 felt. A total of thirteen hundred rolls of 303 had been made and distributed in 1963. About sixty different customers were involved, including the Cincinnati company. Their inclusion was also explained in the records. It was quite true that Cincinnati always ordered number 318 hair felt. But last December, when a Cincinnati order came in, it so happened that Ajax was temporarily out of stock on number 318, and filled the order with 303 instead. The price was the same, the manager said, and the quality of 303 was, if anything, higher. Goat hair was the best of the animal fibers, and the most expensive. That's why it was used so little. Actually, they had done the Cincinnati company a favor. We then moved on to the warehouse. I spent the afternoon there, taking pictures and collecting samples. I took four samples of cattle hair, four of horse hair, two of buffalo hair, two of domestic goat hair, and eight of imported goat hair. All were raw, unprocessed fiber.

  "I got back to Atlanta late Friday night, and on Monday morning, I carried my samples down to the laboratory to be cultured and analyzed. The first step was to wash the anthrax spores, if any, from the hair. The procedure we used was this. We immersed each sample in an Erlenmeyer flask containing a liter of distilled water and a drop or two of detergent. The flasks were stoppered and placed in a mechanical agitator and shaken for about an hour. They were allowed to stand for five minutes. The next step was to streak a sample of liquid, or wash-water, from each flask onto nutrient blood agar plates, and the plates were then incubated. But the anthrax organism isn't the only organism that will grow on such a medium, so the next step was a further screening. Two hundred and fifty cc.s of the liquid were poured into a centrifuge bottle which we had heated in a water bath at a high temperature for ten minutes to kill organisms other than B. anthracis. The bottle was then centrifuged at two thousand rpms for ten minutes The supernatant liquid was discarded and the sediment resuspended in distilled water. Then a sample of that was streaked on nutrient blood agar plates. We then tucked the plates away in an incubator and let nature take its course. The results, if any, would be visible in the morning.

  "We got some results. There were forty-nine samples in the lot we cultured, and thirteen of them showed up positive for B. anthracis. Four of the positive cultures were from the Newark ware house—they were four of the eight samples I had taken from bales of imported goat hair. The other positives were samples of the number 303 hair felt. One came from the roll at the Cincinnati warehouse, five were from the roll in the hospital basement, and three were from the air-conditioning pipe in the nursery. Everything else—the number 318 felt and all the other animal fibers— was negative. I wasn't particularly surprised. I wasn't really surprised at all. What I mostly felt was relief. Number 303 was the only possible answer—the only bearable answer. Any other result would have meant starting all over again from scratch. Either that or something a great deal worse.

  "It was bad enough as it was. The fact that nine of about twenty samples of 303 and half of my goat hair samples were contaminated with anthrax spores raised a number of more or less urgent problems. Some of them, of course, were pretty much routine—the insulation at the hospital, the leftover yardage there and at the Cincinnati warehouse, and the imported goat hair in stock at Newark—and I handled them routinely. I began by calling Decker and Cockburn and putting them in the picture. The purely local aspects of the matter were their responsibility. Then I called the administrator at the Oxford hospital and told him what we had found. I advised him to remove at once the insulation in the kitchen and, as soon as convenient, the nursery insulation. And I told him how to do it in the safest possible way. The workmen were to thoroughly moisten the outside of the pipes with a five per cent Clorox solution in water, remove the hair felt in disposable bags, wash the area again with Clorox, and then burn the bags and carefully wash their hands. I also instructed him to return the remains of the roll of 303 to the Cincinnati company. It would be picked up there, along with the company's yardage, by the city health authorities and burned. I then got in touch with the Ajax people. I advised them to hold the imported goat hair at Newark in stock until further notice. They were only too willing to agree.

  "The other problems raised by the case were actually one big problem. It had to do with the dozen or more other insulation jobs in and around Cincinnati where the company had installed number 303 hair felt, and with those sixty other Ajax customers—their remaining supplies of 303 and the jobs on which they had used the stuff. My investigation indicated that roughly half of the 1963 production of 303 was contaminated. Did that require its removal wherever installed? What were the risks involved? How risky would it be to do nothing? Anthrax spores can lie dormant for many years. On the other hand, what risks would we run by removing it? The danger to the workmen was minimal—they could be fully safe-guarded. But a job of that size and scope could hardly be kept a secret. And when the news came out, just how would the public react? Would it panic? Well, questions like that, thank heavens, are not for me to decide. A committee was formed and we had a meeting in Washington. The members included an assistant surgeon general and representatives of all interested divisions of the U. S. Public Health Service, and the report we made was subsequently approved by the Surgeon General. I'll read you some of our recommendations: 'The consensus was that leaving the installed material in place involved the least risk. It was also decided not to publicize the information that it may be contaminated with B. anthracis. It was recommended that attempts be made to record the locations of all buildings in which this particular lot of hair felt may have been used. This data should be requested discreetly, and this activity should be under the direction of the Communicable Disease Center, working with the Division of Occupational Health. The recommendation is made that the [Ajax Corporation] should
prohibit further use of contaminated hair-felt material of type 303, and locate any from the involved batches that may be in warehouses of their customers throughout the country. All finished material in their own ware houses should either be disinfected or destroyed—in either ease with the assistance and supervision of the CDC. Depending upon the amount of unused material located throughout the country and its location, it will be either returned to the [manufacturer] or destroyed locally, with assistance from the CDC. The recommendation is made to either disinfect or destroy all imported contaminated goat hair in the [Ajax Corporation] warehouse, with the assistance and supervision of the CDC. Concerning the total problem of the importation of animal products contaminated with B. anthracis, the consensus was that the infrequency of cases and the gradual decline in the use of these materials did not justify any specific action by the Public Health Service at this time.' Those precautions, of course, have all been carried out. In addition, I understand, the various buildings where 303 was installed have all been identified, and they are under surveillance by the local authorities. If and when a building is remodeled or demolished, the workmen will be warned and instructed.

  "The policy meeting officially closed the case. There were still some details, however, that bothered me a bit. They had to do with Hoffman. Why was he and not Jensen the victim—or rather, how did Jensen escape infection? The answer, once I started thinking about it, wasn't too hard to find. I found it in Peter's report. Jensen didn't have much to do with the felt. He only helped Hoffman install it. Moreover, it was Hoffman who lugged the stuff around to wherever it was needed on the job. Very well. Cutaneous anthrax thrives on contact. But how did Hoffman get infected? Mere exposure isn't enough. Well, suppose he carried the felt on his shoulder. That seemed a safe enough assumption. Suppose it kept rubbing and chafing against his neck until it made an abrasion? Would that explain what happened? No, I had to admit, it wouldn't. At least not very satisfactorily. The site of the lesion was much too low—it was almost down on his collarbone. His shirt would be in the way. And then I remembered something that Mrs. Hoffman had told me when I called her from the Cincinnati airport down in Kentucky. We were talking about the initial appearance of the lesion, and she said she first noticed it when Hoffman came home on Tuesday evening. That was the night before he was treated at the Miami University clinic. She said she noticed it the minute he took off his jacket. Because her husband didn't wear a shirt to work. He always worked in a sweatshirt."

  [1965]

  CHAPTER 13

  Three Sick Babies

  Dr. Paul M. Taylor, an assistant professor of pediatrics at the University of Pittsburgh School of Medicine, left his office on the first floor of Magee-Womens Hospital, an affiliate of the medical school, and climbed the stairs to the premature-baby nursery, on the second floor. It was twenty minutes to eleven on the morning of July 12, 1965, a Monday, and this was his regular weekday round. He was, in a way, attending physician to all the babies in the nursery. Two pediatric residents were waiting for him in the gown room. That, too, was as usual, and while Dr. Taylor scrubbed and disinfected his hands and got into a freshly laundered gown, they gave him the customary nursery news report. The weekend had been generally uneventful. All but one of the twenty-six babies in the nursery were progressing satisfactorily. The exception was one of the smallest—a twenty-five-day-old, two-and-a-half-pound boy. He was in Room 227. Dr. Taylor nodded. He knew the one they meant. Well, early that morning, just after midnight, a nurse had noted that his breathing was unusually slow and his behavior somewhat apathetic. The resident on duty, seeing these signs as suggestive of septicemia, had treated the baby with penicillin and kanamycin, but he still looked and acted sick. It was probable that he would soon need artificial respiration. Meanwhile, the usual samples (blood, stool, mucus, spinal fluid) had been taken and sent along to the laboratory for culture and analysis.

  Dr. Taylor heard his residents' review with no more than natural interest. Serious illness in a premature nursery is not an unusual occurrence, and a blood infection is only one of the many diseases that may afflict a premature baby during its first days of life. Trouble is inherent in the phenomenon of prematurity. For the truth of the matter is that premature birth is itself a serious affliction. A premature baby is a baby born in the seventh or eighth month of pregnancy. Its birth weight is largely determined by its relative prematurity, ranging from around two to five and a half pounds. The average term (or nine-month) baby weighs around seven pounds at birth, and it generally comes into the world alive and kicking. Premature babies begin life almost incapable of living. There is nothing more frail and fragile. Many of them are too meagerly developed to maintain normal body temperature. One in three requires immediate, and often prolonged, resuscitation, and about the same number are unable to nurse, or even to swallow. Some of them are even unable to cry. All of them are exquisitely susceptible to infection. Mental and neurological defects are also common in premature babies. One of the commonest of these is cerebral palsy. About half of all victims of the affliction are of premature birth. As recently as twenty-five years ago, most premature babies died. The technological innovations of the postwar era have greatly improved that record, but the mortality rate among newborn premature babies is still high. In even the best hospitals, some ninety per cent of all two-pound babies die. So do about fifty per cent of those weighing two to three pounds, around ten per cent of those weighing three to four pounds, and between five and eight per cent of those weighing four to five pounds. Such babies are simply too fetal to survive outside the womb. There are many causes of premature birth (including falls and blows), but most current investigators think that malnutrition is perhaps the most important cause. Prematurity would thus seem to be a socio economic problem, and this supposition is confirmed by statistics The great majority of premature babies are born to women too poor to buy the nutritious food they need.

  Dr. Taylor tied up the back of his gown and led the way through an inner door to the central nursing station of the nursery. Room 227 was the second room on the right. The sick baby was one of five babies being cared for there. He lay on his side in his incubator bassinet with a stomach feeding tube in his mouth, and he looked even sicker than the resident had said. There was nothing, however, that Dr. Taylor could do that hadn't already been done. He confirmed the resident's course of treatment and agreed that a respirator would probably soon be required, and then moved on to the other babies in that and the other rooms. They were all, as far as he could read the almost imperceptible manifestations of the premature, in their usual precarious but normal condition. At the end of his rounds, Dr. Taylor had lunch, and after lunch he occupied himself with his other professorial duties. Before leaving for home, he put in a call to the nursery for a report on the sick baby. The report was not comforting. The baby's condition had continued to worsen, and he had been moved to Room 229, which is reserved for babies needing constant scrupulous care. Later that evening, on his way to bed, he called the nursery again. The nurse who picked up the telephone was able to answer his question. The sick baby from Room 227 was dead.

  Dr. Taylor's Tuesday-morning round was much like that of Monday. The resident's gown-room report included another sick baby. It also contained a post-mortem note on the baby from Room 227. The hospital laboratory had confirmed the general diagnosis of septicemia. A microbial culture had been grown from a sample of the baby's blood and identified as bacteria of the gram-negative type. It was one of some twenty-five species of bacteria (among them the causative organisms of typhoid fever, brucellosis, whooping cough, plague, and gonorrhea) that react negatively to the standard staining test devised in 1884 by the Danish bacteriologist Hans Christian Joachim Gram. A more specific identification was promised for the next day. Meanwhile, of course, the laboratory had been supplied with diagnostic samples from the second sick baby. This baby, also a boy, was one of the babies in Room 229. He was a term baby, three days old, but had been assigned to the premature
nursery directly from the delivery room because he required artificial respiration and other intensive care. Dr. Taylor remembered the baby when he saw him. He had begun life with a severe aspiration pneumonia, stemming from an original inability to breathe, but that had been quickly controlled with penicillin, kanamycin, and dexamethasone. His trouble now was diarrhea. Diarrhea in a newborn baby is not a common complaint, and Dr. Taylor wondered if this attack might be a septic aftermath of the earlier pneumonia. But that was a question that only the laboratory could readily answer. There was no doubt about the treatment the baby was receiving. That seemed to be entirely satisfactory.

  The Wednesday-morning gown-room news review contained three major items. One was that still another baby boy had become seriously ill overnight. The next item was a preliminary laboratory report on the second sick baby, which identified the cause of his diarrhea as a gram-negative bacillus. The third item was a more or less definitive laboratory report on the dead baby. After forty- eight hours of growth, the gram-negative bacteria cultured from his blood presented the colonial configuration, the fluorescent yellow-green pigmentation, and the spearmint odor generally characteristic of the type known as Pseudomonas aeruginosa.

  Dr. Taylor went to Room 229 for a look at the new sick baby. He was nine days old and weighed about three pounds. His illness appeared to be a pneumonia. This illness had come on abruptly, but, like so many other premature babies, he had never been really well. He had been unable at birth to breathe spontaneously and had spent the first five or six days of his life in a respirator. It was obvious to Dr. Taylor that the baby's condition was grave. It seemed equally clear, however, that he was receiving the best of care, and a conventional course of penicillin and kanamycin had been started. Dr. Taylor left the nursery in an uneasy state of mind. His uneasiness had to do with Room 229 and the sudden string of serious illnesses there. He was afraid that they might be more than merely coincidental.