Berton Roueche - The Medical Detectives Volume I

"A few days after the Houston meeting, I got a telephone call from Buzz. He had a lead. He had learned from Janet that she had had some surgery done about a year before their first meeting. There was some problem with her knees. She had chronically dislocated patellar tendons. They were corrected by a Hauser procedure, and the tendons were secured in the proper position with stainless-steel screws. Buzz had talked to the orthopedist, and the screws were still there. The problem now was to persuade the orthopod to go in and remove the screws. It wasn't that Janet needed the screws. The orthopod was satisfied that they had done their job, and that the tendons were now naturally secured. But he thought Buzz was out of his head. He thought the idea was preposterous. Those screws were stainless steel .

He had never heard of an allergic reaction to stainless steel. But Buzz had finally managed to persuade him. Janet was going into the hospital at the end of the week. He'd let me know. Which he did—on Saturday. The screws had been removed the day before, and there was already, he thought, some improvement. The erythema—the redness—had very definitely subsided. He would do a patch test as soon as he could. Meanwhile, he had the screws and the name of the maker, and he was writing the company for information about their composition. It was a week before I heard from Buzz again. And it was all over. Janet's dermatitis had completely cleared in just three days. Two days later, he did a patch test with a tray of six substances—pure nickel, nickel sulfate, one of the stainless-steel screws, potassium dichromate, cobalt sulfate, and mercuric chloride. The last three were negative, and the first three were all four-plus positive. Buzz said the orthopod was with him and watching but still had his doubts. So he did a test on his own. He took the screw and taped it to her back. Four hours later, she began to flare. The same generalized pruritus and erythema. And it took a couple of days to clear with topical cortisone. But by then the surgeon was doubly convinced. Buzz had heard from the manufacturer—the company that made the screws. Their stainless-steel screws were steel, all right, but the steel had a nickel content of up to fourteen per cent. That seemed to be a conventional formulation.

"That wasn't the end of the case, however. Not quite. Buzz saw Janet Walker one more time. She came out of the hospital and disappeared from follow-up. Several months went by, and then one day she walked into his office with the same old rash. It was easy to imagine how he felt. She told him that she had gone back to school for a while and had then quit to go to work, and that she had been working about a week in a dress factory. He questioned her about her job, and the answer soon came out. She did a lot of cutting in her job, and the scissors she used had a ring of some sort that kept them hanging on her thumb. Always in contact, all day long. And, of course, all scissors contain nickel. Buzz advised her to get another job. She was much too exquisitely sensitive to even think about handling nickel. It was the same with Mrs. Strong. Her sensitivity to copper was also extraordinarily pronounced. Most dermatologists are satisfied that an atopic constitution increases sensitivity, but I wonder if an internal exposure may not further heighten sensitivity. It's an interesting thought.

"I never saw Mrs. Strong again. But, even so, she gave me a little scare. I got a telephone call one day from her dermatologist down in Dallas. I had told him that I was planning a report on her case. His call was to tell me that I'd better slow down. Mrs. Strong had just had another bad attack. And it couldn't be related to an IUD this time. Her gynecologist had told him that her present IUD was one that contained no copper. Didn't that seem to suggest some other source of her trouble? I didn't think so. I didn't see how I could have been that wrong. But I did begin to wonder. He left me that way for about a week, and then he called me again. He had taken the precaution of having Mrs. Strong's new IUD removed, and she was much improved, but the picture was still confused. He also had been in touch with the manufacturer, and they had given him a full report on their IUD. It did contain copper. But the amount was so infinitesimal—it was thirteen ten-thousandths of one per cent. I had to admit that that wasn't much, but I thought it was enough. It had to be enough. He didn't think so. He thought it was most unlikely. But he did agree to have the IUD replaced. That was sometime in late March or early April. I didn't hear from him again until August. This time, he wrote me a letter. I'll read you what he said:

" 'This is a brief note to catch you up on Mrs. [Sara Strong]. I saw her again this morning for a wart on her hand, and it is interesting that she said that she had absolutely no breaking out since the last time I had seen her, but after three or four months of being clear she felt it peculiar that the IUD device would cause it, and tried it one more time, and had an almost immediate reflare on the wrists of the lichen planus-like eruption. She used her Lidex cream again, and it cleared very promptly, and she has had no difficulty since that time. I am sure that you will find this as fascinating as I did.'

"I did. I did indeed. And I still do."

[1978]

Dr. Joel L. Nitzkin, chief of the Office of Consumer Protection, a section of the Dade County, Florida, Department of Public Health, sat crouched (he is six feet nine) at his desk in the Civic Center complex in downtown Miami, stirring a mug of coffee that his secretary had just brought in. It was around half past ten on a sunny Monday morning in May—May 13, 1974. His telephone rang. He put down his coffee and picked up the phone and heard the voice of a colleague, Martha Sonderegger, the department's assistant nursing director. Miss Sonderegger was calling to report that her Miami Beach unit had just received a call for help—for the services of a team of public-health nurses—from the Bay Harbor Elementary School. There had been a pipe break or a leak of some kind, Miss Sonderegger had been told, and the school was engulfed in a pall of poison gas. Many of the children were ill, and some had been taken to a neighborhood hospital by the rescue squad of the municipal fire department. Dr. Nitzkin listened, considered.

He said, "What do you think, Martha?"

"It sounds a little strange."

"I think so, too."

"But I'm sending a team of nurses."

"Yes," Dr. Nitzkin said. "Of course. And I think I'd better drive out to the school and take a look myself."

He thanked her and hung up—and then picked up the phone again. He made two quick calls. One was to an industrial hygienist named Carl DiSalvo, in the Division of Environmental Health. The other was to a staff physician named Myriam Enriquez, in the Disease Control Section. He asked Dr. Enriquez to meet him at once at his car; as for Mr. DiSalvo, he was already on his way to the school. Dr. Nitzkin untangled his legs and got up. He was out of his office in two easy, five-foot strides. His coffee cooled on his desk, untasted and forgotten.

Dr. Nitzkin is no longer associated with the Dade County Department of Public Health. He has moved up, both professionally and geographically, to Rochester, New York, where he now serves as director of the Monroe County Department of Health, and it was there, on a winter day, that I talked with him about the summons to the Bay Harbor Elementary School. His recollection was un-dimmed, indelible.

"I remember it was hot," he told me, standing at his office window and gazing down through the palm trees in his memory at the bare maples and last night's foot of new snow. "Warm, anyway—warm enough to make me think that the 'poison gas' at the school might have something to do with the air-conditioning system. And I remember my first sight of the school. The scene was complete pandemonium. It had the look of a disaster. We had to park half a block away, because the school parking lot was full of trucks and vans and cars of all kinds—all parked every which way. Ambulances. Fire equipment. Police cars. All with their flashers flashing. And the media—they were swarming. Newspaper reporters and photographers. Radio people with microphones. Television cameras from four local stations. And even—good God!—local dignitaries. Members of the Dade County School Board. Members of the Bay Harbor Town Council. And neighbors and passersby and parents all rushing around. I had never seen anything like it, and I had to wonder how come. But the explanation, it turned out, was simple enough. The school had called the fire department, and the fire department had called the rescue squad—and the media all monitor the fire department's radio frequency. There was one oasis of calm and order. That was the children. They had been marched out of the building in fire-drill formation and were lined up quietly in the shade of some trees at the far end of the school grounds. There were a lot of them—several hundred, it looked like. Which was reassuring. I had got the impression that most of the school had been stricken by whatever the trouble was. Dr. Enriquez and I cut through the mob, looking for someone in charge. It turned out that the school principal was away somewhere at a meeting. We asked around and were finally directed to the head secretary. She was the person nominally in charge, but you couldn't say she was in control. Nobody was in control.