Berton Roueche - The Medical Detectives Volume I

"All that, of course, is largely by the way. Whatever Dr. Saltzman might have been or said wouldn't have made much difference. I might have settled down to work in somewhat higher spirits, but our procedure would have been the same. It isn't often that a public-health investigator can take anything for granted. The epidemiological discipline requires him to see and judge for himself. And the only place to start is at the bottom—with the victim and his environment. In this case, that meant thirty-six children, a school, and an unknown number of parakeets. The division of labor was no immediate problem. Beran's job was understood, and Paxton and I quite naturally took the children. That left the school for Mrs. Rakich. She could handle the preliminary survey there, and also give Beran any help he might need. The transportation problem was solved as soon as the matter came up. Dr. Saltzman had his own work to attend to—his practice and the health-department routine. But his nurse, Miss Whitmore, had a car, and, with his permission, she volunteered to drive Paxton and me around. So Mrs. Rakich and Beran kept ours. We all drove out to the school together. I wanted to make sure of their reception. The school was three or four blocks from the square—a one-story brick building, built since the war and in good repair, with twelve classrooms, an office, and an auditorium. The principal was expecting us. He and his staff, he said, were eager to cooperate in every possible way. That settled that. I left him to Beran and Mrs. Rakich, and Miss Whitmore and Paxton and I pulled out.

"We didn't see Beran and Mrs. Rakich again until evening. Faxton and I spent the day with the sickest children on the list. We examined all thirteen of them. Thirteen calls is a lot of calls, and they were scattered all over town, but with Miss Whitmore there to make the introductions and generally pave the way we managed. That's about all, however. I can't say we learned very much. The clinical picture we put together and the one we had had from Saltzman were practically identical. High fever. General malaise. Lassitude. Nonproductive cough. Occasional chest pains. A few complaints of nausea and vomiting. Those were the symptoms. In three or four cases, we found some enlargement of the liver and the spleen. Aside from that, the physical findings were essentially negative. The epidemiological picture also stood unchanged. No parties. No trips. No unusual group activities of any kind. The only environment common to all the children was the school—the building and the grounds. Nevertheless, it wasn't a wasted day. It was merely an unproductive one. We had done what had to be done. We had made a start.

"So had Beran and Mrs. Rakich. Only theirs was more than just that. They were waiting for us when we finally got back to the courthouse, and it was obvious that one or the other of them had turned up something interesting. They both had, in fact. Beran's contribution was a sick parakeet. There were six birds in all. Four of them had been bought in December and given as pets to the children in four lower-grade rooms—1-A, 1-B, 1-C, and 2-B. Just after the Christmas vacation, another bird was bought, and given to Room 2-C. The sixth parakeet was bought on January 24th. It went to Room 2-A, and that was the sick one. Its name was Liberace. The children named him that because he sang so prettily, but he wasn't singing now. According to Beran, he was a miserable sight. Ruffled feathers. Dull eyes. Listless stance. Loose green droppings all over his cage. The other parakeets, he said, were as bright and lively as crickets. Not, of course, that that meant much. An autopsy might show different. Psittacotic birds are often asymptomatic. Liberace also figured in Mrs. Rakich's report. While Beran was out gathering up the birds—they had been removed from the school, on Dr. Saltzman's orders, about a week before—she had settled down in the principal's office and checked the thirty-six known cases against the relevant classroom records. Her findings made interesting reading. The first child became sick on February 1. He was followed, at intervals of a few days, by five more. Then, between February 13 and February 24, there was an explosion. Twenty-six cases. Eight of them occurred on one day—February 17. Mrs. Rakich's report went on to break down the cases by classroom. One room—5-A—had had no children on the sick list. That room, incidentally, was the senior room. The school had only five grades. Sixth-graders went to another school—a junior high. Two rooms—1-B and 1-C—each had one case. There were two cases in each of four rooms—2-B, 2-C, 4-A, and 5-B. Rooms 1-A, 3-A, 3-B, and 4-B each had three. The Liberace room—2-A—had a total of fourteen. Mrs. Rakich ended her report with a kind of postscript. In the course of her room survey, she had talked with the various teachers. One of them, it developed, had been sick for several days at about the time of the onset peak. Nothing serious—no need to call the doctor. Just malaise. A little fever. Some coughing. I've forgotten her name, but I'll call her Miss Smith. Miss Smith taught Grade 4-A. Her room was across the hall and down a couple of doors from the Liberace room. However, for some reason or other, she had the job of supervising the children as they got into the school buses at the end of each day. And the place she found most convenient for doing that job was at a window in Room 2-A.

"I went to bed that night feeling pretty good. Of course, the picture was still confused. Miss Smith and the heavy concentration of cases in Room 2-A seemed enormously significant. Until you remembered the scattered cases in the other rooms, and the five other parakeets, and the teacher who taught 2-A. Why wasn't she sick, too? But Liberace was something else. If he turned out to be as psittacotic as he looked, we almost certainly had a lead. A post-mortem answer to that was Beran's job for Saturday. Dr. Saltzman gave him a place to work in his office, and he got started right after breakfast. The rest of us spent the day making house calls. Paxton and Mrs. Rakich tackled the twenty-three convalescent or recovered cases. I worked with Miss Whitmore. Our job was to revisit the thirteen sick children we had seen on Friday, and arrange for a number of diagnostic tests. They might or might not be illuminating, but it had to be done. It was routine. In general, the nature of the suspected disease determines the kind of test. Because of the number of possibilities in this case, we had to use two kinds. One was a series of simple skin tests for antibody reaction. Each child was injected intradermally with the antigens of four of our several suspects—tuberculosis, histoplasmosis, coccidioidomycosis, and blastomycosis. The results of such tests can be read in about forty-eight hours. A positive reaction—the appearance of a characteristic induration at the site of injection—is evidence that the patient has, or has had, the disease in question. There is no skin test for psittacosis. For that, as well as the other clinical possibilities, a blood test was required. A blood test is fairly complicated. It can be done only in a specially equipped laboratory, and it takes time. The nearest Public Health Service serological laboratory was the Rocky Mountain Laboratory, in Hamilton, Montana. We took samples from each of the thirteen children, packed them in dry ice, and sent them off by airmail that afternoon, along with a note of explanation and instruction. They were to be tested for Q fever, influenza, psittacosis, and histoplasmosis. The last was for insurance. In histoplasmosis, a serological examination is apt to be more conclusive than the skin test. Well, with any luck, we would have the results in about a week. Meanwhile, Paxton and Mrs. Rakich had made a good start on their twenty-three convalescent or recovered boys and girls. Not that they had anything much to report. The histories they had obtained merely confirmed the data we already had. They would finish that phase of the job on Sunday, and then get started on a round of tests and samplings of their own. The report of the day was Beran's. I don't mean that it was any sensation—his findings were only tentative. The results of gross examination are rarely anything else. They have to be substantiated by laboratory test. But he did have something to tell us. Liberace was very definitely sick, and in a very provocative way. The other birds had no visible signs of abnormality, but Liberace more than made up for that. In psittacosis, the most striking clinical manifestation is enlargement of the liver and the spleen. Liberace's liver was considerably larger than normal, and his spleen was huge. A parakeet spleen is usually about the size of a small seed. His was as big as the end of my middle finger.