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Elixir Sulfanilamide: Death in California

The FDA’s San Francisco station oversaw the confiscation of elixir that was sent from Massengill’s branch in the same city. Of the 30 gallons (in gallon, pint, or sample bottles) shipped from Bristol, Tennessee, to the San Francisco warehouse, more than three gallons, most in pint containers, were distributed in the state between September 23rd and October 13th to two physicians’ offices, one hospital, and more than a dozen pharmacies. A few shipments went to nearby Oakland, but most were shipped in seemingly random fashion to small towns in the middle of the state. (Two pints each were also sent to Meeker, Colorado, and Eugene, Oregon.) On October 19th, Chief Inspector Robert Born, 42, reported that only two pints of the elixir had been returned to the San Francisco branch as the result of Massengill’s recall telegrams. (For a Google map of elixir shipments to California, Colorado, and Oregon, go here.)

FDA chemical analyst Morris Yakowitz, 26, was charged with tracing and impounding Elixir Sulfanilamide in the Fresno area, where 19 pints had been shipped. Engaging the assistance of a young and willing Massengill salesman, Harry Orange, Yakowitz was able to account for all of the elixir in the area by October 25th, save that used for four prescriptions. Yakowitz discovered that three of these prescriptions (two for one person) had been consumed without ill effect, but that one prescription had been associated with a death.

Orvin Charles Kutz, Jr., the five-year-old son of Orvin (Sr.) and Cecilia of Fresno, died on October 24th. Analyst Yakowitz learned from the boy’s treating physician, Dr. Bernard Sorauf, that the child had consumed one ounce of Elixir Sulfanilamide in divided doses as treatment for a streptococcal sore throat and high fever. Dr. Sorauf, 32, chronicled the child’s clinical course for the governmentdescribing initial improvement (due to the elixir’s antibiotic) and then rapid deterioration (the result of diethylene glycol).

In twelve hours tempture [sic] subsided and the general condition was improved with the exception the patient became listless and began to have vomiting spells gradually becoming dehydrated and toxic. Approximately ten days later the patient developed a complete anuria and central nervous symptoms typical of those found in toxic encephalitis. A severe foul diarrhea also appeared.

Although treatment had been instituted to combat the above symptoms the child went into a coma and expired twelve hours later.

In April of 1938, the boy’s mother wrote the FDA, inquiring whether Elixir Sulfanilamide had killed her son. Chief Campbell responded to her in May, claiming that the boy’s death certificate revealed “toxic encephalitis” and “anuria.” Campbell concluded that the elixir “may have been a contributory cause of death, or it may actually have been the principal cause.” But he hedged, “This is […] a question which this Administration is not in a position to decide.” Campbell also revealed that no other deaths were apparently caused by Elixir Sulfanilamide in California.

Eleven months after the death of the Kutz boy, his parents filed a $25,000 damages complaint against The S. E. Massengill Company, the manager of Massengill’s San Francisco branch, the Fresno druggist who sold the elixir, and two drug wholesalers. Notably Dr. Sorauf was not a publicized defendant. Counsel for the Kutz parents, revealed the Fresno Bee on September 20, 1938, included high-profile attorney and US Congressman Bertrand W. Gearhart. The outcome of the case is unknown by this writer.

Primary sources

FDA historical records (AF1258), Rockville, MD: Letter from Dr. B. M. Sorauf to Mr. M. L. Yakowitz. October 22, 1937; letter from M. L. Yakowitz to Chief, San Francisco Station. October 25, 1937.

NARA, College Park, MD: Letter from W. G. Campbell to Mrs. Orvin Kutz. May 27,1938. Box 47.