Disease detectives and the 12th blue man

Pretty much every disease-detection geek — which includes me, since I wrote a book about disease detectives — has read, at some point, the story “Eleven Blue Men” by Berton Roueche. Roueche was a journalist who worked for the New Yorker for almost 50 years, and for most of that time, he was responsible for the column “The Annals of Medicine,” which was created for him. “Eleven Blue Men” was the first installment. It ran June 5, 1948. It begins like this:

At about eight o’clock on Monday morning, September 25, 1944, a ragged, aimless old man of eighty-two collapsed on the sidewalk of Dey Street, near the Hudson Terminal. Innumerable people must have noticed him, but he lay there alone for several minutes, dazed, doubled up with abdominal cramps, and in an agony of retching. Then a policeman came along. Until the policeman bent over the old man, he may have supposed that he had just a sick drunk on his hands; wanderers dropped by drink are common in that part of town in the early morning. It was not an opinion that he could have held for long. The old man’s nose, lips, ears, and fingers were sky-blue.

That man is the first of 11 to be found that day in Manhattan; all of them, as Roueche says, were “rigid, cyanotic and in a state of shock.” They are all transported to the emergency room of the Beekman-Downtown Hospital on the southern tip of Manhattan, north of Wall Street but below the Bowery where most of the men have been sleeping in cheap rooming houses. The hospital thinks the men have all been poisoned by carbon monoxide, which blocks oxygen transport in the blood; the ER staff assume that is why the men are blue. They phone in a report to the New York City Department of Health, and two staff members decide to investigate: Dr. Morris Greenberg, chief of the Bureau of Preventable Diseases, and Dr. Ottavio Pellitteri, an epidemiologist.

Greenberg and Pellitteri are intrigued by the cases, but they doubt the diagnosis. They notice that some of the men have woken up and are alert and grouchy; those symptoms don’t match carbon monoxide poisoning, which makes you sleepy and dopey and leaves you with a ferocious headache, if you survive.

They note something else, too: All of the men ate breakfast that day at one place, the Eclipse Cafeteria in Chatham Square only a few blocks from the hospital. But they had not all eaten there at the same time. So if something at the cafeteria had affected them, it must have been something that went on for hours — yet the cafeteria was busy all morning, and these men are the only victims.

They notice one other thing: All of the men ate oatmeal.

That is enough of a clue to send them to the Eclipse’s kitchen, where they discover that the cook has accidentally filled the big container of salt above the stove not with common sodium chloride (NaCl), but with sodium nitrite (NaNO2), which he was using to make sausage. The cook demonstrates for them that he puts a handful of salt in the big pot of oatmeal he makes everyday. So everyone who ate oatmeal in the cafeteria — the 11 blue men, and 114 others — got a morning dose of the toxic salt.

But not a toxic dose, since only the 11 have fallen ill. Piecing together the story, Pellitteri and Greenberg remember the men are all down-on-their-luck alcoholics; that is why they are sleeping in flophouses and eating in a place like the Eclipse, which charges 15 cents for a meal. Alcoholics are often salt-deprived; maybe the men put extra salt on their oatmeal. So they check the saltshakers on the cafeteria’s tables. Sixteen contain regular salt. One contains almost pure sodium nitrite.

The busboy has made the same mistake the cook did, and filled the saltshaker from the wrong salt can. Salting their breakfast from that single saltshaker is how the men received their almost-lethal dose.

You’d think such a story would be an artifact of the 1940s: the confusion, the accidental consumption, the poisoning, the deaths. Not so. Thanks to linguistic confusion, there has been a remarkably similar episode in Jamaica in the last few weeks. Bizarrely, it too involves 11 people.

The tale unfolds like this: There is a party of friends staying at a villa in St. Mary, Jamaica. They are in Jamaica to celebrate the marriage of one of them, a Jamaican woman, to a man she met while teaching in Japan. The group includes some Americans, and also an Argentinean man. Because they are staying in a house, they are cooking for themselves at least part of the time. To cook, they need to shop.

The Argentine does at least some of the shopping, though he has a little language trouble. A few days before Christmas, he makes a big meal of fresh fish and potato salad for the group. He uses the groceries he has bought, including salt. A few hours later they become very sick and are taken to a local hospital.

Their symptoms are so remarkable that local doctors think at first that the fish was responsible: maybe the tourist bought barracuda, or puffer fish, not knowing how toxic they might be. But they cannot ask him. Within a few hours of being admitted to the hospital, the Argentine dies.

The Jamaican authorities go back to the villa, and there they find their answer: in the kitchen, there is a container of sodium nitrite, labeled “saltpetre.” The Jamaica Gleaner reports:

It is believed that (the Argentinean), whose command of the English language was limited, purchased the product, mistaking it for table salt. He reportedly used it excessively in the meal that he prepared, and this was evidenced by the half-empty bottle of saltpetre that was found at the villa he occupied in St Mary…

“Saltpetre prevents the haemoglobin in the blood from carrying oxygen at high levels. So you get headache, blue colour to skin and dizziness, trouble breathing, heart failure, and ultimately, death,” a biochemist, who is not part of the medical team investigating the case, told this newspaper.

The Jamaica Ministry of Health said Monday that there have been two other cases of sodium nitrite poisoning recently: “In all instances of poisoning, persons reported that they thought that they were using table salt.”

The Ministry has asked shops in Jamaica to take the product off the shelves and put it where customers will have to ask for it, to be sure that no one else makes the same mistake.

(As best I can tell, “Eleven Blue Men” is only available online behind the New Yorker’s archive paywall; here’s the link if you are a subscriber. It is collected in The Medical Detectives (Plume 1991). For more about poisonings of all kinds, including carbon monoxide and the blue condition known as argyria, the must-read resource is Deborah Blum’s Speakeasy Science. And finally: Sodium nitrite is sold in the US as well; it is still used for curing meats. But American consumers are much less likely to make the same mistake — because, precisely to prevent accidental poisonings, US sodium nitrite for years has been dyed bright fuchsia pink, like this.)

Image Flickr/ElFreddy/CC


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