The Medical Detectives Volume I

by Berton Roueche

  "She wasn't a carrier. The preliminary laboratory report on my specimens was negative for Pseudomonas. That was the following day—Wednesday afternoon. But by then it didn't matter. We had something much more interesting to think about. The way it happened was this. I was in the nursery that afternoon, and one of the residents came over and told me they had another infected baby. New babies had been coming along every day, of course, and this one was a term baby born on Monday and sent up to the premature nursery for special care. He had had trouble breathing at birth, and had required extensive resuscitation in the delivery room. Well, a routine nasopharyngeal culture taken when he was admitted to the nursery had just been found to be positive for I'seudomonas. I looked at the resident and the resident looked at mc. This was real news. That baby could not possibly have been infected in the nursery. The laboratory samples had been taken before he was even settled there. He could have been infected only in the delivery room. And there were just two possible sources of infection there. His mother was one, and the other was some piece of contaminated equipment. My guess was naturally the mother. I found out what room the new baby's mother was in, and made the necessary arrangements, and went up and took the standard nose, throat, and stool samples, and arranged for the hospital laboratory to culture them. When I got back to the nursery, Dr. Gezon was there talking to the resident, and I could tell from the look on his face that he had heard the news.

  "The three of us went down to the delivery suite. We found the nurse in charge and told her what we were doing. She was terribly upset. It was most distressing to her to have us arrive in her domain on such a mission. But she was a good nurse and she cooperated perfectly. The room where the baby had been born was not in use, and she took us in and showed us around. There was a delivery table in the middle of the room, and a row of scrub sinks along the left-hand wall. On the opposite wall was a resuscitator of the type described to me the day before. It consisted of a rubber face mask and a rubber Emerson bag enclosed in a cellophane casing, and it looked very neat and clean. But something made me take it down for a closer look. There was a little dribble of water in the bottom of the Emerson bag. I showed it to Dr. Gezon, and he raised his eyebrows and passed it on to the resident. The resident took a sample of the water. There were five other rooms in the delivery suite, and luckily none of them were in use. We checked the resuscitator in every room, and everyone was wet. The question was: How come? The nurse explained the delivery- suite cleaning procedure. There was one central wash sink, where all delivery-room equipment was washed. Everything was washed after every use, and then sterilized by steaming in an autoclave. Including the resuscitators? No—of course not. They were made of rubber, and rubber can't stand that kind of heat. The resuscitators were washed with a detergent, rinsed with tap water, and left on the drainboard to dry. It was possible, the nurse said, that they were sometimes returned to the delivery rooms before they were completely dry. We asked to see the wash sink. We were all beginning to feel sort of elated. I know I was. And when we saw the sink, that just about finished us. The faucet was equipped with an aerator—a standard five-screen water-bug heaven.

  "It was a water-bug heaven. The laboratory cultured Pseudomonas from the swab samples we took from the aerator. It also cultured Pseudomonas from five of the six resuscitator samples. You can imagine how the delivery-suite nurses felt when those reports came down. They were crushed. Dr. Gezon was able to reassure them, though. He didn't consider them guilty of negligence. He considered them guilty of ignorance. They assumed, like almost everybody else, that city drinking water is safe. It is and it isn't. It's perfectly safe to drink, but it isn't absolutely pure. This is something that has only recently been recognized. There are water bugs in even the best city water. The concentrations are much too low in ordinary circumstances to cause any trouble, but a dangerous concentration can occur in any situation—like that provided by an aerator—that enables the bugs to accumulate and breed. An aerator is a handy device, but you'd probably be better off letting the water splash. It's certainly a device that a hospital can do without.

  "The laboratory gave us three reports in all. The third was on the mother of the new baby. They found her negative for Pseudomonas, and that was welcome news. A positive culture from her would have been an awkward complication. Because everything else was very satisfactory. The contaminated resuscitators seemed to explain the concentration of infected babies in Room 227 and Room 229. Seven of the ten infected babies—including the diarrheal baby and the two that died—had—received at least some resuscitation in the delivery room, and it was reasonable to suppose that the three others had got their infection from the resuscitated babies by way of the nurses. There's plenty of evidence for that in the literature. 1 remember one report that showed that nurses' hands were contaminated simply by changing the bedding of an infected patient. It was Dr. Shulman, however, who finally pinned it down. His pyocine typing confirmed the circumstantial evidence at every point. Shulman did two groups of studies for us—one on the original material I sent him, and then another on the new infected baby and the delivery-suite material. The results of his studies were doubly instructive. They identified the delivery-room resuscitators as the source of the epidemic, and they eliminated the contaminated sinks and bassinets in the nursery. The different pyocine types of Pseudomonas aeruginosa are indicated by numbers. The Pseudomonas strain cultured from the delivery-suite aerator was identified as Pyocine Type 4-6-8. So were the isolates from the resuscitator bags. And so were those of all of the infected babies. Type 4-6-8 was also recovered from two pieces of equipment in the nursery, but I think we can safely assume that they had been contaminated indirectly from the same delivery-room source. They were a bassinet used by an infected baby and the sink in Room 227. The other contaminations in the nursery were a wild variety of types—6, 4-6, 6-8, 1-2-3-4-6-7-8, and 1-3-4-6-7-8. And where they came from wasn't much of a mystery. There was only one possible explanation. They came out of the water faucets, too."

  That was the end of the formal investigation. It wasn't, however, the end of the trouble. The pockets of contamination in the sinks and elsewhere in the nursery and in the delivery suite were eliminated (and a system of ethylene-oxide sterilization set up for all resuscitation equipment), but the epidemic continued. In spite of the most sophisticated treatment (first with colistimethate and colistin sulphate, and then with colistin in combination with polymyxin B), the infected babies remained infected. Moreover, in the course of the next few weeks twelve new infections were discovered in the nursery. In two of the new victims, the infection developed into serious clinical illness. It was not until the middle of September, when the remaining infected babies were moved to an isolated ward in another part of the hospital, that the epidemic was finally brought under control.

  Hospital infections of any kind are seldom easily cured Pseudomonas aeruginosa is only somewhat more stubborn than such other institutional pathogens as Staphylococcus aureus and the many Salmonellae. These confined and yet all but unextinguishable conflagrations are, in fact, the despair of modern medicine. They are also, as it happens, one of its own creations. The sullen phenomenon of hospital infection is a product equally of medical progress and of medical presumption. It has its roots in the chemotherapeutic revolution that began with the development of the sulfonamides during the middle nineteen-thirties, and in the elaboration of new life-saving and life-sustaining techniques (open-heart surgery, catheterization, intravenous feeding) that the new antibacterial drugs made possible, and it came into being with the failure of these drugs (largely through the development of resistance in once susceptible germs) to realize their original millennial promise. Its continuation reflects a drug-inspired persuasion that prevention is no longer superior to cure. "In the midst of the development of modern antibacterial agents, infection has flourished with a vigor that rivals the days of Semmelweis," Dr. Sol Haberman, director (until his death last April) of the microbiology laboratories at Baylor Uni
versity Medical Center, once noted. "It would appear that the long sad history of disease transmission by attendants to the sick has been forgotten again."

  [1968]

  CHAPTER 14

  The West Branch Study

  Dr. Stephen C. Schoenbaum arrived at West Branch (pop. 2,025), the seat of Ogemaw County, in northeastern Michigan, in a rented Ford sedan at about four o'clock on the afternoon of May 19, 1968. It was a Sunday afternoon, and raining. His first stop was at the Tri-Terrace Motel, on the outskirts of town. That part of Michigan is resort country, and the motel was built around a trout pond. He booked a room and left his luggage and asked the manager where he could get something to eat. He was directed to the Model Restaurant, near the traffic light on Houghton Avenue (or Route 76), the main street of town. He drove to the restaurant and had his supper, and then walked around the corner to the office of the District Health Department. Dr. Schoenbaum was an Epidemic Intelligence Service officer. He was twenty-six years old, he had just completed a year of intensive epidemiological training at the National Communicable Disease Center, in Atlanta, and this was his first field assignment. He had come up to West Branch (by plane that morning from Atlanta to Saginaw), in response to a request for help from the Michigan Department of Public Health in its investigation of an outbreak of infectious hepatitis that in just two weeks had grown from two to thirty-two cases.

  Hepatitis is an inflammation of the liver. Its name defines its nature: hepat derives from the Greek for "liver," and itis is a Greek suffix meaning "inflammation." Many different agents, in eluding drugs and chemicals, have the power to inflame the liver Infectious hepatitis is one of two closely related inflammatory diseases of the liver that are confidently assumed to be of viral origin. The other is called serum hepatitis. These two varieties of hepatitis are by far the most common forms of the disease, and they constitute a public-health problem of ever-increasing concern throughout the Western world. In 1969, the most recent year of record, some fifty-five hundred cases of serum hepatitis and some forty-eight thousand cases of infectious hepatitis were reported in the United States. This would seem to present a total of around fifty-four thousand cases of viral hepatitis for that year, but public- health authorities read the record differently. It is their conviction that (for reasons of indifference or carelessness or misdiagnosis or subclinical infection) only a fraction of all cases of viral hepatitis that occur in this country are actually reported—probably only one in ten. They therefore read the record not as fifty thousand cases but as upward of five hundred thousand.

  Until the middle nineteen-forties, when their differences were demonstrated by an international round of experiments involving human volunteers, infectious hepatitis and serum hepatitis were everywhere regarded as one and the same disease. It is not hard to understand why. They come on with equal abruptness, they produce identical signs and symptoms (chills, fever, lassitude, headache, loss of appetite, nausea, vomiting, abdominal pain, diarrhea, jaundice, prostration), and their impact on the liver is pathologically indistinguishable. They are also equally unresponsive to any specific treatment, and although full recovery (within two or three months) is the reassuring rule, both of them can permanently debilitate and sometimes even kill. They are not, however, identical. They spring from different viruses, and they are differently disseminated. Infectious hepatitis is usually transmitted by direct person-to-person contact or by food or water contaminated with the excreta of an earlier victim. Serum hepatitis is less conventionally, and less easily, spread. The virus of serum hepatitis lodges not in the gastrointestinal system but in the blood stream, and it can be conveyed only by an inoculation of infected blood. In addition to (and perhaps because of) these different modes of transmission, the different viruses establish themselves and multiply at different rates of speed. Infectious hepatitis generally manifests its presence about thirty days after exposure. In serum hepatitis, the incubation period ranges from three weeks to three or four months. An attack of hepatitis, like an attack of any viral disease (poliomyelitis, smallpox, measles, whooping cough) produces in its surviving victims an immunity to future infection. But the immunities conferred by infectious hepatitis and serum hepatitis are separate and distinct. An attack of infectious hepatitis protects against a second attack of infectious hepatitis but not against an attack of serum hepatitis, and serum hepatitis also protects only against itself. It is this fact—the fruit of a hundred painful human experiments—that makes it certain that infectious hepatitis and serum hepatitis are, at bottom, different diseases.

  The avoidance of the viral hepatitides, despite their immunological potential, is very largely a matter of chance. Medical science has not yet succeeded (as it has with smallpox and poliomyelitis and measles and so many other viral diseases) in developing a protective vaccine. It is far from certain that it ever will. There is a formidable reason for this. The development of a vaccine begins with the laboratory cultivation of the relevant pathogen, and to the best of current knowledge the viruses of human hepatitis are parasites so specialized that they can grow and proliferate only in a living human cell. A reliable passive protection against infectious hepatitis is offered by gamma globulin. Gamma, or immune, globulin is a blood protein extracted from the pooled blood of at least ten thousand donors that (because many of these donors will have had infectious hepatitis) contains infectious hepatitis antibodies. The force of an attack of infectious hepatitis can be bridled and held to a subclinical, or unapparent, infection by an injection of gamma globulin given soon after probable exposure. The effectiveness of gamma globulin, however, is limited to this prophylactic role, for antibodies thus acquired are quickly (in four or five weeks) metabolized and dismembered. The effectiveness of gamma globulin is limited also to infectious hepatitis. Serum hepatitis does not seem to lend itself to gamma-globulin prophylaxis Why this should be is uncertain. One suggested reason is that serum hepatitis is insufficiently common for its antibodies to be powerfully present in the ten-thousand-donor pools.

  Infectious hepatitis has a natural history as long as that of any of the many epidemic diseases. There is no reason to doubt that its origins go back at least five thousand years, to the first coming together of men in city, or community, life. It is thought to have been glimpsed as an entity as early as the Hippocratic era, and it has certainly long been known (under such names as "field jaundice" and "camp jaundice") as a major military scourge. It has been recorded (by army surgeons) as a serious source of misery in every war since the Napoleonic Wars. Serum hepatitis has no such lineage, and its history is anything but natural. It is one of a growing number of upstart diseases that have been brought into being by a triumphant medical technology. Although it probably first appeared when man first learned to puncture his skin for religious or cosmetic purposes, serum hepatitis came into prominent medical view only with the development of smallpox vaccination, and it has mounted to its present eminence with the extension of that procedure to other diseases, and with the invention of the blood transfusion and the hypodermic syringe. Serum hepatitis very seldom occurs in epidemic form. Its rigid epidemiology inhibits its rapid spread. The few large outbreaks of serum hepatitis on record have chiefly stemmed from either blood-bank blood contaminated by infected donors or from slipshod immunization programs, and most of these have involved military or institutional personnel. Serum hepatitis most commonly occurs in occasional cases of insidious origin (its generally long incubation period makes retrospective explication difficult), and its typical appearances are almost always the result of a disregard of elementary hygiene. In 1961, a New Jersey osteopath infected some forty patients by not bothering to autoclave or otherwise sterilize the syringe he used for drug injections. More recently, in 1969, a girl was infected in a Larchmont jewelry store when she had her ears pierced with an unwashed communal punch. And the promiscuous tattoo needle has over the years produced almost as many cases of serum hepatitis as it has epidermal declarations of patriotism and filial love. But these ar
e not typical victims. The typical victim of serum hepatitis in the United States these days is a phenomenon as grimly specialized as the disease itself. He is a young heroin (or amphetamine) user who shares a syringe with a friend. Serum hepatitis would thus seem to be, as Dr. Michael B. Gregg, chief of the Viral Diseases Section of the National Communicable Disease Center, has put it, "a public-health problem compounded by a sociological problem."

  The typical victim of infectious hepatitis is a more prosaic person. He can be anyone confronted by a victim or who eats a contaminated meal or takes a drink of contaminated water. Not much (in the absence of a scrupulous universal cleanliness) can be done to protect him. The only defensive procedure possible is to block the spread (or a recurrence) of a discovered outbreak by finding and stopping its source and immunizing potential victims. That, however, is well worth doing, and that was Dr. Schoenbaum's job in West Branch.

  Dr. Schoenbaum was received at the West Branch office of the District Health Department by the District Health Officer. She was Dr. Ophelia Baker. Her husband, Dr. Thomas Baker, one of five physicians then practicing in West Branch, was with her. The Bakers led Dr. Schoenbaum into Dr. Ophelia's office and gave him a cup of coffee and brought him up to date on the epidemic.

  "It was still going," Dr. Schoenbaum says. "Seven new case reports had come in since Saturday. They raised the total from thirty-two to thirty-nine. There had been no deaths, and none was expected, but there were a couple of patients sick enough to be hospitalized. They were in the local hospital—the Tolfree Memorial Hospital. A gamma-globulin program had been started five days ago, on May 14, and the contacts of all the known cases were being inoculated. The epidemic was definitely an epidemic. Dr. Ophelia got out her records. Only seven cases of hepatitis had been reported in the preceding twelve months in the whole of Ogemaw County. There was as yet no epidemic curve—no chronological pattern. The data needed to draw it—the dates when the victims first became sick—were lacking. Dr. Ophelia had been too busy with the gamma-globulin program. It was quite a program. It ran almost two weeks, and they ended up immunizing something over seven thousand people. The information on the reported cases was the standard minimum—name, address, age. The cases were of both sexes, they seemed to live all over the county, and they ranged in age from five to thirty-nine. There was one moderately interesting fact. A majority of the cases were teen-agers, and most of them were boys. I didn't know what that signified, and I didn't try to guess. I simply copied off the names and addresses. All of them would have to be seen and interviewed. The results of the interviews would set the course of the investigation. I hoped they would, anyway. I knew there weren't any shortcuts. I could only hope that the truth would emerge from the evidence.