The Medical Detectives Volume I

by Berton Roueche

  "There was only one way to pin it down. We would have to interview the cases again. If we were right about Rush and the bakery, the proof would be forthcoming. We would find that all of the victims had consumed some iced or glazed pastry from the West Branch Bakery between Friday, April 5 and the end of the following week. The period could be a bit open-ended, but it had to begin on April 5. That was the day—the only day—that Miss Brown had visited the bakery. Page and I didn't do much work on Tuesday. We slept until early afternoon. At some point, I had a call from Atlanta. They were sending up a distinguished foreign visitor to observe our methods. His name was Zdenek Jezek, and he was a senior WHO medical officer stationed at Ulan Bator, in Outer Mongolia. He arrived that evening. I remember his greeting. 'I am Jezek of Czechoslovakia,' he said. So he was a Czech. That was a little disappointing. We had been expecting a Mongolian. As a matter of fact, he was a thorough Czech. We briefed him on the epidemic, and when we came to the age and sex distribution of the cases, he shook his head. There was something wrong. Teen-age boys didn't eat pastry. Not in Czechoslovakia. Bakery customers were women and young children. He couldn't believe that things were different in Michigan. He thought it over, and then announced that he would get the facts by conducting an investigation of his own. All we had to do was arrange for him to sit somewhere out of sight in the bakery and record exactly who came in. I thought that might be interesting, and I said I would make the arrangements, but maybe he ought to wait a day or two and get his bearings first. I suggested that he sit in with Page and me on our new round of interviews.

  "We began on Wednesday morning, and we began with the out-of-county cases. They would be the quickest way to determine if we were moving in the right direction or completely wrong. This time we worked by telephone. We had to. There were thirteen substantiated cases, including Miss Brown, and all of them were out of easy reach. Two were even out of state—it man in Indianapolis and another in Wethersfield, Connecticut The first case we called was a man in Mount Pleasant, about fifty miles to the south. He confirmed that he had hepatitis. The onset date was May 3. Yes, he had been in West Branch, and in early April—April 5 through April 7. He and his wife had driven up to attend a wedding. We knew about the wedding, and none of the principals or other guests was on our epidemic list. He and his wife had eaten all of their meals with the other wedding guests. He stopped and thought a minute. Except on the day they arrived. That was April 5, and he dropped in the West Branch Bakery and bought four iced cupcakes. Which he ate. He wasn't a teen-ager—he was twenty-two—but he ate them all. I don't know what Jezek made of that. But I do know that Page and I began to feel very good.

  "The other out-of-county cases told the same fascinating story. It was fantastic. There were two married sisters from Detroit with four children who spent three days in April—April 8 through April 10—in a cottage in the woods about ten miles out of town. On the morning of April 9, one of the women drove into West Branch alone to mail some letters, and brought back half a dozen fried cakes from the West Branch Bakery for lunch. Three of the cakes were glazed and three were plain. The two women and one of the children ate the glazed cakes, and they were all three sick with hepatitis. Two became sick on May 7 and the other on May 11. The three other children were well. I talked to the man in Connecticut. I ran him down in a hospital. Yes, he had hepatitis. Yes, he had been in West Branch. It was his home town and he had been there to visit his mother. He arrived on April 4 and left on April 6. On April 5 or April 6, he wasn't sure which, he had dropped into the West Branch Bakery to see the owner. They were old friends. The owner gave him a couple of glazed doughnuts, and he ate them while they talked. The man in Indianapolis was like the group from Detroit. He spent three days—April 7 through April 9—at a cottage down at Clear Lake, and on Monday, April 8, he came into town to get his shoes repaired. While he was waiting, he walked into the West Branch Bakery and bought a piece of iced Danish pastry. A thirteen-year-old boy from Roscommon County was in town on April 5—and so on. Every one of the out-of-county cases confirmed the place, the date, and the vehicle.

  "We still had the community cases to question. There was no real doubt in our minds about the answers we would get, but we had to make the effort. We had to be thorough and sure. Most of what is known about viral hepatitis has come from epidemiological studies, and every careful study can be a contribution. There was also Jezek and his bakery survey. I introduced him to the bakery owner, and they worked out the details—the logistics. Jezek is a small man and they found a little corner where he could sit unnoticed behind a showcase and have a view between the shelves of all the comings and goings. He spent a full day there —from seven in the morning until the bakery closed at six o'clock that night. His findings were useful. They combined with the information that Page and I were getting to explain the big teenager clientele. He found that adults—mostly women—were in and out of the store all day. Very few young children—children under ten—ever came into the bakery, and then only in the late afternoon. The teen-agers showed up in a body at noon and again after three o'clock. The reason, as our interviews showed, was very simple. The teen-agers were, of course, high-school kids, and the high-school kids were allowed to leave the school grounds for lunch. The younger kids—the grade-school children and all of the children at the parochial school—had lunch at school. Jezek's tabulations showed that the bakery was a favorite teen-ager place had been there to visit his mother. He arrived on April 4 and left on April 6. On April 5 or April 6, he wasn't sure which, he had dropped into the West Branch Bakery to see the owner. They were old friends. The owner gave him a couple of glazed doughnuts, and he ate them while they talked. The man in Indianapolis was like the group from Detroit. He spent three days—April 7 through April 9—at a cottage down at Clear Lake, and on Monday, April 8, he came into town to get his shoes repaired. While he was waiting, he walked into the West Branch Bakery and bought a piece of iced Danish pastry. A thirteen-year-old boy from Roscommon County was in town on April 5—and so on. Every one of the out-of-county cases confirmed the place, the date, and the vehicle.

  "We still had the community cases to question. There was no real doubt in our minds about the answers we would get, but we had to make the effort. We had to be thorough and sure. Most of what is known about viral hepatitis has come from epidemiological studies, and every careful study can be a contribution. There was also Jezek and his bakery survey. I introduced him to the bakery owner, and they worked out the details—the logistics. Jezek is a small man and they found a little corner where he could sit unnoticed behind a showcase and have a view between the shelves of all the comings and goings. He spent a full day there —from seven in the morning until the bakery closed at six o'clock that night. His findings were useful. They combined with the information that Page and I were getting to explain the big teenager clientele. He found that adults—mostly women—were in and out of the store all day. Very few young children—children under ten—ever came into the bakery, and then only in the late afternoon. The teen-agers showed up in a body at noon and again after three o'clock. The reason, as our interviews showed, was very simple. The teen-agers were, of course, high-school kids, and the high-school kids were allowed to leave the school grounds for lunch. The younger kids—the grade-school children and all of the children at the parochial school—had lunch at school. Jezek's tabulations showed that the bakery was a favorite teen-ager place one piece of pastry left—a fried cake. They saw it and made a grab, and the one I'll call Jerry lost out. He didn't get any pastry. And he was also the twin who didn't get hepatitis."

  [1971]

  CHAPTER 15

  The Huckleby Hogs

  The telephone rang, and Dr. Likosky—William H. Likosky, an Epidemic Intelligence Service officer attached to the Neurotropic Viral Diseases Activity of the Center for Disease Control, in Atlanta—reached across his desk and answered it, and heard the voice of a friend and fellow-EIS officer named Paul Edward Pierce. Dr. Pierce was
attached to the New Mexico Department of Health and Social Services and he was calling from his office in Santa Fe. His call was a call for help. Three cases of unusual illness had just been reported to him by a district health officer. The victims were two girls and a boy, members of a family of nine, and they lived in Alamogordo, a town of around twenty thousand, just north of El Paso, Texas. The report noted that the family raised hogs, and that several months earlier some of the hogs had become sick and died. The children were seriously ill. Their symptoms included decreased vision, difficulty in walking, bizarre behavior, apathy, and coma. This complex of central-nervous-system aberrations had immediately suggested aural encephalitis, but that, on reflection, seemed hardly possible. The encephalitides that he had in mind were spread by ticks or mosquitoes, and the season was wrong for insects. This was winter. It was, in fact, midwinter. It was January—January 7, 1970.

  "I'm afraid I wasn't much help," Dr. Likosky says. "I could only listen and agree. It was just as Ed Pierce said. The clinical picture was characteristic of the kind of brain inflammation that distinguishes the viral encephalitides. More or less. But there were certainly some confusing elements. It wasn't only that the time of year was odd for arthropod-borne disease. The attack rate was odd, too. There were too many cases. A cluster like that is unusual in an arbovirus disease. Also, the report to Ed had made no mention of fever. That was odd in a serious virus infection. It was odd, but not necessarily conclusive. The report was just a preliminary report. It was very possibly incomplete. At any rate, Ed was driving down to Alamogordo the following day and he would see for himself. Things might look different on the scene. Meanwhile, about all I could suggest was the obvious. Verify the facts. Check into the possibility of a wintering mosquito population. Check up on the hogs. This might be a zoonosis—an animal disease. It might be a disease of hogs that the three children had somehow contracted. Review the signs and symptoms. Not only for fever but also for stiff neck. Stiff neck is particularly characteristic of encephalitis.

  "That was a Wednesday. Ed called me from Alamogordo on Friday. He and one of his colleagues—Jon Thompson, supervisor of the Food Protection Unit of the Consumer Protection Section of the state health department—had been out to the house, and he had some more information. The victims were children of a couple named Huckleby. They were Ernestine, eight years old; Amos Charles, thirteen; and Dorothy, eighteen. Ernestine was in the hospital—Providence Memorial Hospital, in El Paso. She had been there since just after Christmas. Amos Charles and Dorothy were sick at home. None of the other children—two girls and two boys—was sick, and neither were the parents. Huckleby worked as a janitor at a junior high school in Alamogordo. He only raised hogs on the side. All that was by way of background. The interesting information was about the Huckleby hogs. There were several items. The hog sickness happened back in October. Huckleby hail a herd of seventeen hogs at the time, and all of a sudden one day fourteen of them were stricken with a sort of blind staggers— a stumbling gait and blindness. Twelve of the sick hogs died, and the two others went blind. That was interesting enough, but it was really only the beginning. In the course of their talk with Huckleby, Ed and Jon Thompson learned that the feed he gave his hogs included surplus seed grain. Well, seed grain isn't feed. Seed grain is chemically treated to resist all manner of diseases, and when it is past its season and has lost its germination value, it is considered waste and is supposed to be destroyed. Huckleby said that the grain—it was a mixture of several grains, apparently—was the floor sweepings of a seed company upstate. He said a friend had given it to him and he knew it contained treated grain. Or, rather, he knew it included treated grain. It was also partly chaff and culls, but he took care of that by cooking it with water and garbage in a metal trough before he fed it to his hogs. He said he had been given about two tons of the grain, and he still had some left. He also said that he had slaughtered one of his hogs back in September for home use. They had been eating it right along, but there was still some left in his freezer. Ed told him to leave it right where it was. There might be nothing wrong with it, but there was no use taking chances.

  "Poison was a tempting possibility. The symptoms had the look of poison, but it wasn't a look that any of us were familiar with. That was the trouble. Nothing seemed to fit. Huckleby was even a little vague about whether the slaughtered hog had been fed the seed-grain feed. Moreover, he wasn't the only Alamogordan to feed that grain to his hogs. He said that five of his friends had got the same grain from the seed company, and none of their hogs had become ill. Apparently, that was true. Ed and Jon had talked with the other hog raisers. They weren't quite sure about the grain they had used, but they were positive that none of their hogs had sickened or died. The local records confirmed what they said. The local records also confirmed that the human outbreak was confined to the Huckleby family. There were no comparable illnesses anywhere in the Alamogordo area. Ed and Jon had visited the butcher shop where the Huckleby hog had been processed. The butcher testified that the meat had appeared to be in prime condition. An examination of the shop was negative—there was nothing to suggest that the meat might have become contaminated during processing. And, finally, there was the fact that others in the family had eaten quantities of the pork, and only those three were sick. Nevertheless, Ed was taking the usual steps. He had samples of grain from Huckleby's storehouse, samples of pork from the family freezer, and samples of urine from all members of the family then at home—that is to say, all but Ernestine. He had arranged for the State Laboratory to examine those for viral or bacterial contamination, and he was sending specimens to William Barthel, chief of the Toxicology Branch Laboratory of the Food and Drug Administration, in Atlanta, for toxicological analysis. But even that wasn't all. Ed had still another piece of information. The clinical picture was pretty much as originally reported. Except in one respect. Ernestine's symptoms did include fever. High fever. A local doctor reported that her temperature at one point got up to 104 degrees. And—oh, yes, there were no mosquitoes in Alamogordo in January.

  "I talked to Ed again on Saturday. He was back in Santa Fe, and that was the reason for his call. He called to invite me to participate in the field investigation. Ed had a big rubella-immunization program coming up at a Navajo reservation the next week that he couldn't put off, and there was nobody to run it but him. It was up to him to at least get it started. He had talked to his chief in New Mexico, Dr. Bruce Storrs, director of the Medical Services Division of the state health department, and he had talked to my boss at CDC, Dr. Michael Gregg, chief of the Viral Diseases Branch. They both approved the proposal. So did I. I was very eager."

  Dr. Likosky left Atlanta by plane the following morning. That was Sunday, January 11. He flew to Albuquerque, where, by prearrangement, he met Dr. Pierce in the early evening. They talked and ate dinner and talked until nearly eleven. Dr. Likosky thru rented a car and drove down through the mountains and the desert to Alamogordo. He spent the night (on Dr. Pierce's recommendation) at the Rocket Motel there, and on Monday morning (following Dr. Pierce's directions) he drove out to the Huckleby house.

  "I wasn't checking up on Ed or Jon Thompson or the district health officer, or anything like that," Dr. Likosky says. "I simply wanted to see for myself. I wanted to start at the beginning. I got to the Huckleby house at about eight-thirty. Huckleby was at work, at the school, but Mrs. Huckleby was at home, and she received me very nicely. The first thing I learned was that Amos Charles and Dorothy were now also in Providence Memorial Hospital. They were too far gone in coma to be treated at home anymore. They had been taken down to El Paso only the day before. I liked Mrs. Huckleby at once. You could tell she was a good mother. Easygoing, but kind and loving. And she was going to be a mother once again. She was very obviously pregnant. The baby was due, she said, sometime in March. She was a religious woman, too, and that gave her a certain serenity. She believed that everything was in the hands of God. She was also an excellent historian. She remembered ev
ery detail of each child's illness. We began with Ernestine. She came home sick from school a little before noon on December 4. She said she had fallen off the monkey bars at recess, and she had a pain in her left lower back. Mrs. Huckleby said she felt hot to the touch. A few days went by, and Ernestine continued to complain of pain and just not feeling right On December 8, Mrs. Huckleby took her to a neighborhood doctor. It was he who found that she had a temperature of 104, but he found nothing else of any significance. He prescribed aspirin and rest in bed. There was still no improvement, and on December 11, Mrs. Huckleby took her back to the doctor. It was a different doctor this time—the first doctor was off that day—and he did find something. He noticed that Ernestine wasn't walking right-that she was staggering—and he arranged to have her admitted to Providence Memorial the next day for observation. I got the de- Mils later from the doctor. Ernestine's walk and the history of her fall had frightened him a little. It raised the possibility in his mind of a subdural hematoma. A subdural hematoma is a gathering of Mood between certain membranes that cover the brain. It is usually caused by a blow or a fall, and it can be extremely dangerous. I saw his point. It was a perfectly reasonable suspicion. But, of course, he was mistaken. It wasn't that. The hospital made the various tests, and ruled it out.