Elixir of Sulfanilamide: The Beginning—Tulsa Deaths (2)

On Saturday, October 9, 1937, the following telegram was sent from the Springer Clinic in Tulsa, Oklahoma, to Dr. Morris Fishbein, editor of the Journal of the American Medical Association in Chicago [1].

ATTENTION IS CALLED TO AT LEAST SIX DEATHS IN TULSA FOLLOWING ADMINISTRATION OF ELIXIR OF SULFANILAMIDE SYMPTOMS OF ANURIA AND TOXIC DEGENERATION OF LIVER AND KIDNEYS

The necessary brevity of the clinic's wire understated the tragedy of the deaths. Five days earlier, a 5-year-old boy, Millard Wesley Wakeford, died in a Tulsa hospital (possibly Morningside Hospital or St. Joseph's), after receiving a 4-ounce prescription for the elixir [1,2]. Then the following night, a 6-year-old girl, Joan Marlar, died in hospital. She had received a 3-ounce prescription [1,3]. 

The deaths continued. Michael S. Sheehan, a 6-year-old boy, died October 6, and 8-year-old Kathleen E. Hobson died October 9. Both had received 4-ounce prescriptions for the elixir. Then a young man died Saturday, after taking Massengill's concoction: 19-year-old Glen F. Entler of Tuscola, Illinois, who had been visiting his aunt and uncle in the city [1,4].*

The deaths were not peaceful. Twenty-four hours after Entler had taken approximately 9 ounces of the elixir (about 260 cc), he developed symptoms of acute nephritis—nausea, vomiting, and intense flank pain. A day later he stopped producing urine altogether. (Dialysis for acute renal failure wouldn't be available for at least another decade.) He died 4 days after taking the last dose of medication [1]. Joan Marlar's mother described her daughter's anguish during the 9-day illness before her death. "[W]e can see her little body tossing to and fro and hear that little voice screaming with pain and it seems as though it would drive me insane"[5].

A pathologist in Tulsa, Dr. Ivo A. Nelson, had noticed the cluster of unusual nephritis cases and quickly suspected poisoning [6]. After dismissing the possibility of mercuric chloride toxicity, he interviewed the families and doctors of the victims and discovered, in all cases, that Massengill's elixir had been prescribed. In some cases, it was the only medication consumed by the deceased. 

After performing autopsies on 4 of the victims, Dr. Nelson "took his findings to his horrified associates in the Tulsa County Medical society, some of whom had prescribed the solution—notably child specialists" [6]. (Presumably Nelson presented his medical findings to the society on the evening of October 10, 1937, per Dr. James Stephenson's telegram to the AMA.)  

On October 12, the AMA determined by telegraph that Massengill's product contained a substantial amount of diethylene glycol, a known toxin. However, this information was too late for the parents of 4-year-old Charlene Canady of Tulsa, who had received the elixir for a sore throat. The girl died that day [1].

On Friday, October 15, Dr. Homer Ruprecht and Dr. Nelson telegraphed their autopsy findings on the Tulsa victims to the AMA. Eight out of 10 were now dead, and one was in critical condition. Astonishingly one patient had recovered. Urine production typically stopped within 2 days after patients received variable amounts (as little as one-half ounce) of the antibiotic elixir. Death occurred within 2-7 days after the onset of anuria. Gross postmortem findings revealed cortical necrosis of the kidneys, and microscopic examination showed a "consistent hydropic tubular nephrosis." No oxalate crystals were observed in the kidneys (as suggested by data conveyed by the AMA's Paul Leech). The telegram ended with, "Federal inspectors arrived today"[7].

In fact, the first word of the Tulsa deaths only came to the Food and Drug Administration the previous day. A New York physician "associated with a large drug manufacturing concern" had evidently telephoned the agency and repeated rumors, "presumably through professional or trade contacts, that fatalities had occurred at Tulsa" [5,8]. Immediately the agency telegraphed its Kansas City Office, and 2 agents, district chief William H. Hartigan and Walter E. Donaldson, "jumped into a motor car." They arrived in Tulsa, 250 miles away, the following morning and wired their findings to the FDA's Chicago office, which, in turn, wired Washington, DC [6,9].

TULSA COUNTY MEDICAL SOCIETY SUSPECTS DEATHS EIGHT CHILD STREPTOCOCCIC THROAT CASES ONE ADULT GONORRHEAL DUE ALIXIR[sic] SULFANILAMIDE MASSENGILLS SYMPTOMS ACUTE ANURIA STOP MEDICAL SOCIETY SUBMITTED SAMPLE TO AMERICAN MEDICAL ASSOCIATION STOP THREE SAMPLES ELIXIR COLLECTED TODAY FROM RETAIL DRUGGISTS WHO WITHHELD STOCKS FROM SALE ON REQUEST MEDICAL SOCIETY AIR EXPRESS-ED BALTIMORE STOP STLOUIS NOTIFIED VIA WESTERNUNION RUMOR HERE SIMILAR CIRCUMSTANCES STLOUIS WILL CONTINUE INVESTIGATION INCLUDING CLINICAL RECORDS UNTIL FURTHER NOTICE...MEDICAL ASSOCIATION REPORTS DIETHYLENE GLYCOL FOUND IN THEIR SAMPLE STOP CINCINNATI INSPECTOR WITH KLUMPP PROCEEDING BRISTOL FOR INVESTIGATION MASSENGILL STOP WILL FORWARD SAMPLES FINISHED PRODUCT AND ALL RAW MATERIAL BALTIMORE STOP HARTIGAN INSTRUCTED EMBARGO ALL WHOLESALE AND RETAIL LOTS IN TULSA STOP CINCINNATI TO REPORT ALL DISTRIBUTIONS THIS AND OTHER CODES PROBABLY CONTAINING DEITHYLENEGLYCOL AND ALL LOTS WILL BE EMBARGOED PENDING COMPLETE INVESTIGATION STOP BALTIMORE BEING ADVISED.

Most concerning was a rumor that similar cases had been observed in St. Louis, Missouri. Indeed, a pathologist in East St. Louis, Illinois, who was unaware of the Tulsa deaths, was preparing his necropsy report of 4 patients who had consumed the new antibiotic elixir [10]. And in addition to notifying its St. Louis office, the FDA was sending investigators (ie, Cincinnati inspector William T. Ford and the FDA's Acting Chief of its Drug Division, Theodore G. Klumpp, MD) to the Massengill company in Bristol, Tennessee.

For his part, Massengill was engaged in shrouded damage control. (The company had also learned of the Tulsa deaths in a complaint from the city's Getman Drug Store, which had dispensed several prescriptions for the elixir, including those to the deceased.) The day that FDA agents arrived in Tulsa, the Massengill company sent out more than 1000 telegrams nationwide [5]:

To its customers: DO NOT USE ELIXIR SULFANILAMIDE SHIPPED. RETURN OUR EXPENSE.

To its salesmen: ELIXIR SULFANILAMIDE DISCONTINUED. PICK UP AS RAPIDLY AS POSSIBLE ALL SOLD IN YOUR TERRITORY.

To "jobbers" (presumably wholesalers), druggists, and doctors who had received the product: HAVE WITHDRAWN PRODUCT ELIXIR SULFANILAMIDE. PLEASE RETURN UNUSED STOCKS IMMEDIATELY.

But within 24 hours, Massengill's elixir claimed its ninth Tulsa victim, Earl L. Beard, 26 years. He had received an 8-ounce prescription for the product and was ill for 2 days before requiring hospitalization [11,12,13,14].

* The sixth death at this time has not been deduced by this blog writer. It was likely one of 3 children: John "Jack" King; Robert "Bobby" Sumner; or 10-month-old Mary Earline Watters (or Waters). Each had received either a 3- or 4-ounce prescription for Massengill's Elixir Sulfanilamide.

1. FDA records. Correspondence from AMA Council, October 13, 1937.

2. Tulsa Daily World. October 6, 1937.

3. Tulsa Daily World. October 7, 1937.

4. Tulsa Daily World. October 10, 1937.

5. Wallace HA. Report of the Secretary of Agriculture on the deaths due to Elixir-Sulfanilamide-Massengill. November 16, 1937. The AMA also reported that it telegraphed the FDA on October 14, 1937, regarding the presence of diethylene glycol in Massengill's product. See footnote in Deaths due to Elixir of Sulfanilamide-Massengill. J Am Med Assoc. 1937;109:1985-1987.

6. Frantic fight on death is heart-breaking job. Kansas City J. October 31, 1937. According to the article, "precious days, hours, minutes were saved by" the work of Dr. Nelson.

7. Ruprecht HA, Nelson IA. Elixir of Sulfanilamide-Massengill: clinical and pathologic observations. J Am Med Assoc. 1937;109:1537.

8. FDA records. Letter from Perrin H. Long to FDA, October 15, 1937. The letter conveys information that rumors regarding the Elixir-Sulfanilamide deaths began spreading in the Tulsa community on October 7, 1937. A representative from Squibb and Sons and a representative from Winthrop Chemical Company reportedly called on several hospitals in the Tulsa area to obtain additional information. The reps discovered that all patients who were dead at the time, 5 children, were attended by the same pediatricians and were prescribed Massengill's product.

9. FDA records. Record of telegraph correspondence, October 16, 1937.

10. Hagebusch OE. Elixir of Sulfanilamide-Massengill: necropsies of four patients following administration of Elixir of Sulfanilamide-Massengill. J Am Med Assoc. 1937;109:1537-1539.

11. Tulsa Daily World. October 17, 1937.

12. Tulsa Tribune. October 17, 1937.

13. FDA records. November 20, 1937, correspondence.

14. Tulsa Tribune. October 17, 1937.

Picture of bottle of DEG-tainted Elixir Sulfanilamide from the FDA.