11 Blue Men

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11 Blue Men Worksheet

1.Draw a timeline marking the time each of the 11 bluemen presented symptoms. Explain the point of mapping out the incident timeframe(i.e. why would epidemiologists need this information and how would it be used)

2.Describe the key symptoms and incubation period for theillness affecting the eleven blue men.

3.Describe each step of an outbreak investigation as itpertains to this particular event, indicating all of the key points in theinvestigation (include how it started, why epidemiologists got involved, wheredid the investigation take the epidemiologists, who was interviewed, what/whowere the potential culprits identified during the investigation)

4.Identify three questions that Dr. Greenberg and Dr.Pellitteri asked the patients. Explain why these three questions were relevant.

5.Identify three questions that the epidemiologists askedthe Eclipse Cafeteria employees. Explain why these three questions wererelevant.

6.Identify the final culprit and how it was discovered.

7.Explain why were these specific men more affected thanother people who ate in the cafeteria?

Eleven Blue Men (Berton Roueché)

Posted on October 12, 2014 by Admin

At about eight o’clock on Monday morning, September 25, 1944, aragged, aimless old man of eighty-two collapsed on the sidewalk on DeyStreet, near the Hudson Terminal. Innumerable people must have noticedhim, but he lay there alone for several minutes, dazed, doubled up withabdominal cramps, and in an agony of retching. Then a policeman camealong. Until the policeman bent over the old man, he may have supposedthat he had just a sick drunk on his hands; wanderers dropped by drinkare common in that part of town in the early morning. It was not anopinion that he could have held for long. The old man’s nose, lips,ears, and fingers were sky-blue. The policeman went to a telephone andput in an ambulance call to Beekman-Downtown Hospital, half a dozenblocks away. The old man was carried into the emergency room there ateight-thirty. By that time, he was unconscious and the blueness hadspread over a large part of his body. The examining physician attributedthe old man’s morbid color to cyanosis, a condition that usuallyresults from an insufficient supply of oxygen in the blood, and alsonoted that he was diarrheic and in a severe state of shock. The courseof treatment prescribed by the doctor was conventional. It included aninstant gastric lavage, heart stimulants, bed rest, and oxygen therapy.Presently, the old man recovered an encouraging, if painful,consciousness and demanded, irascibly and in the name of God, to knowwhat had happened to him. It was a question that, at the moment, nobodycould answer with much confidence.

For the immediate record, the doctor made a free-hand diagnosis ofcarbon-monoxide poisoning – from what source, whether an automobile or agas pipe, it was, of course, pointless even to guess. Then, because anisolated instance of gas poisoning is something of a rarity in a sectionof the city as crammed with human beings as downtown Manhattan he andhis colleagues in the emergency room braced themselves for at least acouple more victims. Their foresight was promptly and generouslyrewarded. A second man was rolled in at ten-twenty-five. Forty minuteslater, an ambulance drove up with three more men. At eleven-twenty, twoothers were brought in. An additional two arrived during the nextfifteen minutes. Around noon, still another was admitted. All of thenine men were also elderly and dilapidated, all had been misery for atleast an hour, and all were rigid, cyanotic, and in a state of shock.The entire body of one, a bony, seventy-three-year-old consumptive namedJohn Mitchell was blue. Five of the nine, including Mitchell, had beenstricken in the Globe Hotel, a sunless, upstairs flophouse at 190 ParkRow, and two in a similar place, called the Star Hotel, at 3 JamesStreet. Another had been found slumped in the doorway of a condemnedbuilding on Park Row not far from City Hall Park, by a policeman. Theninth had keeled over in front of the Eclipse Cafeteria, at 6 ChathamSquare. At a quarter to seven that evening, one more aged blue man wasbrought in. He had been lying, too sick to ask for help, on his cot in acubicle in the Lion Hotel, another flophouse, at 26 Bowery, since teno’clock that morning. A clerk had finally looked in and seen him.

By the time this last blue man arrived at the hospital, aninvestigation of the case by the Department of Health, to which alloutbreaks of an epidemiological nature must be reported, had been underway for five hours. Its findings thus far had not been illuminating. The‘investigation was conducted by two men. One was the HealthDepartment’s chief epidemiologist, Dr. Morris Greenberg, a small,fragile, reflective man of fifty-seven, who is now acting director ofthe Bureau of Preventable Diseases; the other was Dr. OttavioPellitteri, a field epidemiologist, who, since 1946, has beenadministrative medical inspector for the Bureau. He is thirty- six yearsold, pale, and stocky, and has a bristling black mustache. One day,when I was in Dr. Greenberg’s office, he and Dr. Pellitteri told meabout the case. Their recollection of it is, understandably, vivid. Thederelicts were the victims of a type of poisoning so rare that only tenprevious outbreaks of it had been recorded in medical literature. Ofthese, two were in the United States and two in Germany; the others hadbeen reported in France, England, Switzerland, Algeria, Australia, andIndia. Up to September 25, 1944, the largest number of people strickenin a single outbreak was four. That was in Algeria, in 1926.

The Beekman-Downtown Hospital telephoned a report of the occurrenceto the Health Department just before noon. As is customary, copies ofthe report were sent to all the Department’s administrative officers.“Mine was on my desk when I got back from lunch,” Dr. Greenberg said tome. “It didn’t sound like much. Nine persons believed to be sufferingfrom carbon-monoxide poisoning had been admitted during the morning, andall of them said that they had eaten breakfast at the EclipseCafeteria, at 6 Chatham Square. Still, it was a job for us. I checkedwith the clerk who handles assignments and found that Pellitteri hadgone out on. It. That was all I wanted to know. If it amounted toanything, I knew he’d phone me before making a written report. That’s anarrangement we have here. Well, a couple of hours later I got a callfrom him. My interest perked right up.”

“I was at the hospital,” Dr. Pellitteri told me, “and I’d talked tothe staff and most of the men. There were ten of them by then, ofcourse. They were sick as dogs, but only one was in really bad shape.”

“That was John Mitchell,” Dr. Greenberg put in. “He died the nextnight. I understand his condition was hopeless from the start. Theothers, including the old boy who came in last, pulled through allright. Excuse me, Ottavio, but I just thought I’d get that out of theway. Go on.”

Dr. Pellitteri nodded. “I wasn’t at all convinced that it was gaspoisoning,” he continued. “The staff was beginning to doubt it, too. Thesymptoms weren’t quite right. There didn’t seem to be any of theheadache and general dopiness that you get with gas. What really made mesuspicious was this: Only two or three of the men had eaten breakfastin the cafeteria at the same time. They had straggled in all the wayfrom seven o’clock to ten. That meant that the place would have had tobe full of gas for at least three hours which is preposterous. It alsoindicated that we ought to have had a lot more sick people than we did.Those Chatham Square eating places have a big turnover. Well, to makesure, I checked with Bellevue, Gouverneur, St. Vincent’s, and the otherdowntown hospitals. None of them had seen a trace of cyanosis. Then Italked to the sick men some more.

I learned two interesting things. One was that they had all got sickright after eating. Within thirty minutes. The other was that all butone had eaten oatmeal, rolls, and coffee. He ate just oatmeal. When tenmen eat the same thing in the same place on the same day and then allcome down with the same illness . . . I told Greenberg that my hunch wasfood poisoning.”

“I was willing to rule out gas,” Dr. Greenberg said. A foldercontaining data on the case lay on the desk before him. He lifted thecover thoughtfully, then let it drop. “And I agreed that the oatmealsounded pretty suspicious. That was as far as I was willing to go.Common, ordinary, everyday food poisoning – I gathered that was whatPellitteri had in mind – wasn’t a very satisfying answer. For one thing,cyanosis is hardly symptomatic of that. On the other hand, diarrhea andsevere vomiting are, almost invariably. But they weren’t in theclinical picture, I found, except in two or three of the cases.Moreover, the incubation periods – the time lapse between eating andillness – were extremely short. As you probably know, most foodpoisoning is caused by eating something that has been contaminated bybacteria. The usual offenders are the staphylococci- they’re mostlyresponsible for boils and skin infections and so on – and thesalmonella. The latter are related to the typhoid organism. In astaphylococcus case, the first symptoms rarely develop in under twohours. Often, it’s closer to five. The incubation period in the otherranges from twelve to thirty-six hours. But here we were with somethingthat hit in thirty minutes or less. Why, one of the men had got only asfar as the sidewalk in front of the cafeteria before he was knocked out.Another fact that Pellitteri had dug up struck me as very significant.All of the men told him that the illness had come on with extraordinarysuddenness. One minute they were feeling fine, and the next minute theywere practically helpless. That was another point against the ordinaryfood- poisoning theory. Its onset is never that fast. Well, thatsuddenness began to look like a lead. It led me to suspect that somedrug might be to blame. A quick and sudden reaction is characteristic ofa great many drugs. So is the combination of cyanosis and shock.”

“None of the men were on dope,” Dr. Pellitteri said. “I told Greenberg I was sure of that. Their pleasure was booze.” “That was O.K.,” Dr.Greenberg said. “They could have got a toxic dose of some drug byaccident. In the oatmeal, most likely. I couldn’t help thinking that theoatmeal was relevant to our problem. At any rate, the drug idea wasvery persuasive.”

“So was Greenberg,” Dr. Pellitteri remarked with a smile.

“Actually, it was the only explanation in sight that seemed toaccount for everything we knew about the clinical and environmentalpicture.”

“All we had to do now was prove it,” Dr. Greenberg went on mildly. “Iasked Pellitteri to get a blood sample from each of the men beforeleaving the hospital for a look at the cafeteria. We agreed he wouldsend the specimens to the city toxicologist, Dr. Alexander O. Gettler,for an overnight analysis. I wanted to know if the blood containedmethemoglobin. Methemoglobin is a compound that’s formed only whenanyone of several drugs enters the blood. Gettler’s report would tell usif we were at least on the right track. That is, it would give us ayes-or-no answer on drugs. If the answer was yes, then we could go onfrom there to identify the particular drug. How we would go about thatwould depend on what Pellitteri was able to turn up at the cafeteria. Inthe meantime, there was nothing for me to do but wait for theirreports. I’d theorized myself hoarse.”

Dr. Pellitteri, having attended to his bloodletting with reasonabledispatch, reached the Eclipse Cafeteria at around five o’clock. “It wasabout what I’d expected,” he told me. “Strictly a horse market, anddirtier than most. The sort of place where you can get a full meal forfifteen cents. There was a grind house on one side, a cigar store on theother, and the ‘L’ overhead. Incidentally, the Eclipse went out ofbusiness a year or so after I was there, but that had nothing to do withus. It was just a coincidence. Well, the place looked deserted and thedoor was locked. I knocked, and a man came out of the back and let mein. He was one of our people, a health inspector for the Bureau of Foodand Drugs, named Weinberg. His bureau had stepped into the case as amatter of routine, because of the reference to a restaurant in thenotification report. I was glad to see him and to have his help. For onething, he had put a temporary embargo on everything in the cafeteria.That’s why It was closed up. His main job, though, was to check theplace for violations of the sanitation code. He was finding plenty.

“Let me read you a few of Weinberg’s findings,” Dr. Greenberg said,extracting a paper from the folder on his desk. “None of them had anydirect bearing on our problem but I think they’ll give you a good ideaof what the Eclipse was like – what too many restaurants are like. Thiscopy of his report lists fifteen specific violations. Here they are:‘Premises heavily infested with roaches. Fly infestation throughoutpremises. Floor defective in rear part of dining room. Kitchen walls andceiling encrusted with grease and soot. Kitchen floor encrusted withdirt. Refuse under kItchen fixtures. Sterilizing facilities inadequate.Sink defective. Floor and walls at serving tables and coffee urnsencrusted with dirt. Kitchen utensils encrusted with dirt and grease.Storage- cellar walls, ceiling, and floor encrusted with dirt. Floor andshelves in cellar covered with refuse and useless material cellarceiling defective. Sewer pipe leaking. Open sewer line in cellar.’ Well.. .” He gave me a squeamish smile and stuck the paper back in thefolder.

“I can see it now”, Dr. Pellitteri said. “And smell it. Especiallythe kitchen, where I spent most of my time. Weinberg had the proprietorand the cook out there and I talked to them while he prowled around.They were very cooperative. Naturally, they were scared to death. Theyknew nothing about gas in the place and there was no sign of any, so Iwent to work on the food. None of what had been prepared for breakfastthat morning was left. That, of course, would have been too much to hopefor. But I was able to get together some of the kind of stuff that hadgone into the men’s breakfast, so that we could make a chemicaldetermination at the Department. What I took was ground coffee, sugar, amixture of evaporated milk and water that passed for cream, some bakeryrolls, a five-pound carton of dry oatmeal, and some salt. The salt hadbeen used in preparing the oatmeal. That morning, like every morning,the cook told me, he had prepared six gallons of oatmeal, enough toserve around a hundred and twenty-five people. To make it he used fivepounds of dry cereal, four gallons of water – regular city water – and ahandful of salt. That was his term – a handful. There was an opengallon can of salt standing on the stove. He said the handful he’d putin that morning’s oatmeal had come from that. He refilled the can on thestove every morning from a big supply can. He pointed out the big can-it was up on a shelf- and as I was getting it down to take with me, Isaw another can, just like it, nearby. I took that one down, too. It wasalso full of salt, or, rather, something that looked like salt. Theproprietor said it wasn’t salt. He said it was saltpetre – sodiumnitrate – that he used in corning beef and in making pastrami. Well,there isn’t any harm in saltpetre; it doesn’t even act as ananti-aphrodisiac, as a lot of people seem to think. But I wrapped it upwith the other loot and took it along, just for fun. The fact is, Iguess, everything in that damn place looked like poison.”

After Dr. Pellitteri had deposited his loot with a Health Departmentchemist, Andrew J. Pensa, who promised to have a report ready by thefollowing afternoon, he dined hurriedly at a restaurant in which he hadconfidence and returned to Chatham Square. There he spent the eveningmaking the rounds of the lodging houses in the neighborhood. He hadheard at Mr. Pensa’s office that an eleventh blue man had been admittedto the hospital, and before going home he wanted to make sure that noother victims had been overlooked. By midnight, having covered all thelikely places and having rechecked the downtown hospitals, he wassatisfied. He repaired to his office and composed a formal progressreport for Dr. Greenberg. Then he went home and to bed.

The next morning, Tuesday, Dr. Pellitteri dropped by the Eclipse,which was still closed but whose proprietor and staff he had told toreturn for questioning. Dr. Pellitteri had another talk with theproprietor and the cook. He also had a few inconclusive words with therest of the cafeteria’s employees — two dishwashers, a busboy, and acounterman. As he was leaving, the cook, who had apparently passed anuneasy night with his conscience, remarked that it was possible that hehad absent-mindedly refilled the salt can on the stove from the one thatcontained saltpetre. “That was interesting,” Dr. Pellitteri told me,“even though such a possibility had already occurred to me, and eventhough I didn’t know whether it was important or not. I assured him thathe had nothing to worry about. We had been certain all along thatnobody had deliberately poisoned the old men.” From the Eclipse, Dr.Pellitteri went on to Dr. Greenberg’s office, where Dr. Gettler’s reportwas waiting.

“Gettler’s test for methemoglobin was positive,” Dr. Greenberg said.“It had to be a drug now. Well, so far so good. Then we heard fromPensa.”

“Greenberg almost fell out of his chair when he read Pensa’s report,” Dr. Pellitteri observed cheerfully.

“That’s an exaggeration,” Dr. Greenberg said. “I’m not easilydumfounded. We’re inured to the incredible around here. Why, a few yearsago we had a case involving some numskull who stuck a fistful ofpotassium-thiocyanate crystals, a very nasty poison, in the coils of anoffice water cooler, just for a practical joke. However, I can’t denythat Pensa rather taxed our credulity. What he had found was that thesmall salt can and the one that was supposed to be full of sodiumnitrate both contained sodium nitrite. The other food samples, incidentally, were O.K.”

“That also taxed my credulity,” Dr. Pellitteri said.

Dr. Greenberg smiled. “There’s a great deal of difference betweennitrate and nitrite,” he continued. “Their only similarity, which is anunfortunate one, is that they both look and taste more or less likeordinary table salt. Sodium nitrite isn’t the most powerful poison inthe world, but a little of it will do a lot of harm. If you remember, Isaid before that this case was almost without precedent – only tenoutbreaks like it on record. Ten is practically none. In fact, sodium-nitrite poisoning is so unusual that some of the standard texts ontoxicology don’t even mention it. So Pensa’s report was prettystartling. But we accepted it, of course, without question orhesitation. Facts are facts. And we were glad to. It seemed to explaineverything very nicely. What I’ve been saying about sodium-nitritepoisoning doesn’t mean that sodium nitrite itself is rare. Actually,it’s fairly common. It’s used in the manufacture of dyes and as amedical drug. We use it in treating certain heart conditions and forhigh blood pressure. But it also has another important use, one thatmade its presence at the Eclipse sound plausible. In recent years, andparticularly during the war, sodium nitrite has been used as asubstitute for sodium nitrate in preserving meat. The government permitsit but stipulates that the finished meat must not contain more than onepart of sodium nitrite per five thousand parts of meat. Cooking willsafely destroy enough of that small quantity of the drug.” Dr. Greenbergshrugged. “Well, Pellitteri had had the cook pick up a handful of salt –the same amount, as nearly as possible, as went into the oatmeal- andthen had taken this to his office and found that it weighedapproximately a hundred grams. So we didn’t have to think twice torealize that the proportion of nitrite in that batch of cereal wasconsiderably higher than one to five thousand. Roughly, it must havebeen around one to about eighty before cooking destroyed part of thenitrite. It certainly looked as though Gettler, Pensa, and the cafeteriacook between them had given us our answer. I called up Gettler and toldhim what Pensa had discovered and asked him to run a specific test fornitrites on his blood samples. He had, as a matter of course, held someblood back for later examination. His confirmation came through in acouple of hours. I went home that night feeling pretty good.”

Dr. Greenberg’s serenity was a fugitive one. He awoke on Wednesdaymorning troubled in mind. A question had occurred to him that he wasunable to ignore. “Something like a hundred and twenty-five people ateoatmeal at the Eclipse that morning,” he said to me, “but only eleven ofthem got sick. Why? The undeniable fact that those eleven old men weremade sick by the ingestion of a toxic dose of sodium nitrite wasn’tenough to rest on. I wanted to know exactly how much sodium nitrite eachportion of that cooked oatmeal had contained. With Pensa’s help again, Ifound out. We prepared a batch just like the one the cook had made onMonday. Then Pensa measured out six ounces, the size of the averageportion served at the Eclipse, and analyzed it. It contained two and ahalf grains of sodium nitrite. That explained why the hundred andfourteen other people did not become ill. The toxic dose of sodiumnitrite is three grains. But it didn’t explain how each of our elevenold men had received an additional half grain. It seemed extremelyunlikely that the extra touch of nitrite had been in the oatmeal when itwas served. It had to come in later. Then I began to get a glimmer.Some people sprinkle a little salt, instead of sugar, on hot cereal.Suppose, I thought, that the busboy, or whoever had the job of keepingthe table salt shakers filled, had made the same mistake that the cookhad. It seemed plausible. Pellitteri was out of the office – I’veforgotten where – so I got Food and Drugs to step over to the Eclipse,which was still under embargo, and bring back the shakers for Pensa towork on. There were seventeen of them, all good-sized, one for eachtable. Sixteen contained either pure sodium chloride or just a fewinconsequential traces of sodium nitrite mixed in with the real salt,but the other was point thirty-seven per cent nitrite. That one wasenough. A spoonful of that salt contained a bit more than half a grain.”

“I went over to the hospital Thursday morning,” Dr. Pellitteri said.“Greenberg wanted me to check the table-salt angle with the men. Theycould tie the case up neatly for us. I drew a blank. They’d beendischarged the night before, and God only knew where they were.”

“Naturally,” Dr. Greenberg said, “it would have been nice to know fora fact that the old boys all sat at a certain table and that all ofthem put about a spoonful of salt from that particular shaker on theiroatmeal, but it wasn’t essential. I was morally certain that they had.There just wasn’t any other explanation. There was one other question,however. Why did they use so much salt? For my own peace ofmind, I wanted to know. All of a sudden, I remembered Pellitteri hadsaid they were all heavy drinkers. Well, several recent clinical studieshave demonstrated that there is usually a subnormal concentration ofsodium chloride in the blood of alcoholics. Either they don’t eat enoughto get sufficient salt or they lose it more rapidly than other peopledo, or both. Whatever the reasons are, the conclusion was all I needed.Any animal, you know, whether a mouse or a man, tends to try to obtain anecessary substance that his body lacks. The final question had beenanswered.”

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