Elixir Sulfanilamide: Deaths in North Carolina
The investigation and confiscation of Elixir Sulfanilamide in North Carolina was coordinated out of the FDA’s hub in Atlanta, under the direction of Station Chief John J. McManus (see Deaths in Florida, Deaths in Georgia, and Deaths in South Carolina). From an October 20th dispatch out of the FDA’s Eastern District office, McManus learned that more than 14 gallons of elixir had been distributed to three doctors and 21 drug stores in the North Carolina (for a Google map of the North Carolina distribution, go here). A large volume of the elixir, 6-1/2 gallons, was determined to be concentrated in the area of Rocky Mount, a cotton-milling town within the state’s coastal plain.
To intercept any further possibility of elixir prescriptions, McManus sent Inspector Shelbey T. Grey, a relative FDA newcomer,* from his post in eastern South Carolina to Rocky Mount. Outside of the town, particularly along the Atlantic coast and near the South Carolina border, Grey’s investigation was complimented by a handful of other federal inspectors; but the lion’s share of the work, at 20 sites, fell to Grey alone. Unfortunately the Tar Heel State, like South Carolina, did not employ a state drug inspector, and the city health officer of Rocky Mount “could offer no assistance in the matter,” wrote McManus.
From an initial canvass of North Carolina recipients, beginning on October 21st, the FDA quickly learned that about 9-1/2 gallons of elixir had been returned intact from the state to Massengill’s headquarters in Bristol, Tennessee. But this early tally left more than four gallons of elixir still at large, much of which remained in the Rocky Mount area. After considerable persistence, Grey would discover at least three deaths in North Carolina among at least 17 dispensed prescriptions (at least 15 of which were wholly or partially consumed).
* Grey had joined the FDA three years earlier as an inspector, through the agency’s New Orleans station.
Elixir-Related Deaths in North Carolina (2 confirmed, 1 probable)
Charles “Charlie” Richardson, a 24-year-old “negro” farmer from Nashville, died on October 17th at Rocky Mount Sanitarium. Inspector Grey did not learn of this death until the first week of December, when he revisited Rocky Mount to check up on salesmen’s samples of Massengill’s elixir. At that time, he learned of the death of a local “colored man.”
“Persistent follow-up” revealed that Richardson was admitted to the Rocky Mount Sanitarium by Dr. W. S. Jones on October 15th. The diagnosis, “acute post-cecal appendicitis,” was confirmed by surgery, which was performed by Dr. R. S. Anderson. The day after Richardson’s operation, Anderson left for Chicago and only returned to Rocky Mount 10 days later (on approximately October 25th). At that time, he was surprised to learn that Richardson had died three days after his hospital admission, with symptoms of “acute suppression of urine.”
Because of the widespread publicity given to the nation’s elixir-related deaths, Anderson took it upon himself to investigate whether Richardson had succumbed to the toxicity of the liquid antibiotic. The surgeon first contacted Dr. Jones, who was unable to reveal much, except that Richardson had been a patient of Dr. John H. Martin, 69, of nearby Red Oak.
Anderson then visited to Dr. Martin, who remembered the victim, but the doctor could not recall giving Richardson any Elixir Sulfanilamide. Anderson “let the matter drop,” Grey recorded, “after directing the family to throw away any medicine which they might have in the house.” Richardson’s death certificate, which was signed by Anderson, listed causes of death as “acute appendicitis,” with contributory causes of “acute urinary suppression” and “uremia.” No autopsy was conducted.
After learning of Richardson’s case in December, Inspector Grey contacted Dr. Jones, and with the physician, they went to the decedent’s home. There, after conducting a search, Grey found an eight-ounce bottle that contained about four ounces of what appeared to be Elixir Sulfanilamide. Richardson’s parents reported that their son “took the medicine for several days, but [that] it made him very sick and nauseated.” It was at that time, on October 15th, that Richardson had consulted Dr. Jones, who reported “no signs of anuria or other kidney complications.” (Richardson was presumably admitted to the Rocky Mount Sanitarium, therefore, on the basis of abdominal pain.)
Grey, who was already familiar with Dr. Martin (see John Thomas Tanner below), revisited the physician in December. It was during this government interview that Martin finally admitted to treating Richardson for gonorrhea; however, the doctor did not remember giving the patient any Elixir Sulfanilamide. Grey then showed Martin the medicine bottle found at Richardson’s home. The doctor acknowledged that “it was identical with his stock of bottles.” Then, Grey recorded, “after much search he found a record in a little booklet where Richardson received some medicine on October 6, 1937, for which he paid 75¢ cash.” Martin told Grey that he believed this entry must have pertained to the elixir, because that was what he charged for the specific amount. Nevertheless Martin continued to hedge over the compelling evidence that he had, in fact, sold Elixir Sulfanilamide to Richardson.
John Thomas Tanner, a 59-year-old logger from Rocky Mount, died on October 31st at the town’s Park View Hospital. FDA Inspector Grey learned of Tanner’s death only after persistent investigation of the whereabouts of five pints of elixir, which had been received by Dr. John H. Martin of Red Oak on September 15th.
When Grey first visited Martin on October 23rd, the physician admitted to dispensing two prescriptions for Elixir Sulfanilamide, but he also stated that “he kept no records of the names of Gonorrheal infection patients and had no knowledge of their identities.” Further Martin “made no inquiries, since this class of patients with venereal infections try to keep their troubles secret and hide their identities.” The doctor then went on to conclude that his elixir-treated patients “must be all right as he had not heard from them.”
Five days later, on October 28th, Grey reinterviewed Dr. Martin, who recognized Tanner as one of his elixir-treated patients. How the inspector came to learn of Tanner’s name is not entirely unclear, but it appears that Grey was tipped off by health officials at the Park View Hospital, where Tanner had been admitted three days earlier. Grey then learned that it was Martin, in fact, who had sent Tanner to the hospital when the patient returned to Martin’s office, complaining of anuria.
Martin ultimately admitted to Inspector Grey that he had prescribed sulfanilamide tablets for Tanner’s “chronic gonorrhea,” but that on October 10th, the doctor had given his patient four ounces of Elixir Sulfanilamide. Before Tanner had taken about half of the liquid medication, he reported feeling “weak, dizzy and sick.” Tanner also noticed that his urine was becoming “scant,” and that “he had to rest frequently, which he did by lying on a blanket which he had brought with him for that purpose into the woods when he went logging.”
Grey also learned that when Tanner had finished the prescription, on October 18th, he “ceased entirely to urinate and was very nauseated.” Despite his critical condition, Tanner continued to work at his logging job for the next six days, until October 24th. The following day, he revisited Dr. Martin, who—given news reports of the elixir’s toxicity—advised Tanner to proceed to the hospital. With herculean fortitude, Tanner did so, walking “unassisted” to the Park View Hospital, where he was admitted at about noon on October 25th.*
According to Dr. C. T. Smith, a Park View physician, Tanner’s BUN level on admission was dangerously high, at 180 mg/dL. During his six-day hospitalization, Tanner “had kidney action only once or twice, two or three drams [~1/8 of an ounce] at the time.” He received “copious amounts of fluids in an effort to stimulate the kidneys but without success.” Smith diagnosed Elixir Sulfanilamide poisoning.
The FDA’s nationwide investigation would ultimately reveal that Tanner was the last known American to die of Elixir Sulfanilamide poisoning.
* FDA records do not specify the distance that Tanner walked to the hospital. The distance from Red Oak, the location of Martin’s practice, to Rocky Mount, the location of Park View Hospital, is about 10 miles.
N.B.–Other elixir-treated patients of Dr. Martin were suspected by the FDA. Specifically the agency and state inspectors discovered that at least one other four-ounce prescription had been dispensed by Martin. In this case, investigation was thwarted not so much by willful resistance as by apparent mental incapacity. Atlanta Station Chief McManus reported:
Repeated visits…to Dr. Martin failed to result in any information as to the patients who had taken the prescription dispensed, until one of the patients, J. T. Tanner, was taken to Parkview Hospital, Rocky Mount, in a dying condition. Even the State Board of Health officials had no satisfactory results from interviewing Martin. Further followup was made on November 7 by [FDA Inspectors] Simms and Grey who report that Martin is over 80 years old, very feeble, and in poor mental condition. His practice consists chiefly of venereal patients and there appears to be no hope of his recalling any of the patients, since he did not keep records of their names or addresses. He is also the local Registrant of births and deaths, and said there had been no recent deaths in his section, but many of his patients came from some distance, and check at the State Board of Health later in the month will be necessary.
A follow-up report one week later indicated “no further progress” and little hope of any fruitful developments, given Martin’s “advanced age and condition.” Inspector Grey went so far as to interview the doctor’s wife and son, hoping to obtain any useful bit of information.
However, it’s also possible that Dr. Martin pulled a fast one on the FDA, by exaggerating his age (according to census records, he was only 69 years in 1937) and feigning senility in an effort to stymie the government’s investigation of his elixir-treated patients.
Master Billy Lee Lindsey, the three-year-old son of William and Ruby from Nashville, died on October 23rd at the Park View Hospital in Rocky Mount, exactly one month before his fourth birthday. The elixir prescription was discovered by Grey on October 23rd (the date of the victim’s death) during his investigation of the Ward Drug Company, which had received one gallon of Massengill’s elixir on September 29th. Grey learned of the child’s recent history from his parents; the family physician, Dr. W. S. Jones, who prescribed the elixir; and the child’s hospital physician, Dr. J. F. Crumpler, who wrote a comprehensive report of Billy’s case for the FDA, which is reproduced here:
The onset of the present illness was during the early part of the first week in October with the history of sore throat, poor appetite, malaise, and low grade fever. These symptoms gradually progressed until on the 8th of October (5 or 6 days after the onset), Dr. W. S. Jones of Nashville, N. C. the family physician, was call in to see him. Upon examination Dr. Jones found temperature of 103 degrees F., the tonsils enlarged, inflamed, and covered with a grayish membrane resembling that seen in Diphtheria. He gave the child Diphtheria antitoxin, a warranted procedure in such cases under such circumstances, and took a throat culture which was sent to the State Laboratory at Raleigh, N. C. Two or three days later the report returned negative for diphtheria but positive for streptococcus. During this time the child was taking only liquids when forced with a great deal of difficulty and which were vomited immediately or within thirty minutes. The urinary output was of course becoming very much diminished.
On October 12th, Dr. Jones having a positive culture for a streptococcus infection of the throat, and seeing that the patient had not progressed satisfactorily, prescribed 1/2 teaspoonful of Elixir of Sulfanilamide four times daily. The throat still had the exudate present, was still inflamed, and swollen to the point that swallowing was difficult and the forcing of fluids or medicine was most difficult and the majority of times was vomited within a few minutes of administration.
On October 15, Dr. Jones referred the patient to me, and he was admitted to the hospital. At this time he still had a grayish membrane on either tonsil which were [sic] moderately enlarged and inflamed. A throat culture at this time showed a small staphlococcus [sic] aureus, a secondary infection which often follows diphtheritic or streptococcic infections of the throat. The child was dehydrated from inability to take and retain fluids. There was no cyanosis or respiratory difficulty. He was given intravenous fluids for the first two days in the hospital. After this time the urine was very scant, edema developed, a rapidly rising urea to 100 [mg/dL], and the patient died October 23rd, the 8th day after admission to the hospital of acute nephritis following a streptococcic infection of the throat.
Concerning past illnesses had had had whooping cough, mumps, malaria, and frequent colds. He had malaria the past summer during which time he was anuric for 3 or 4 days at the time.
In summarizing we have a streptococcic throat infection in a four year old male child which is an infection of common occurrence which was followed by acute nephritis, a common complication of this type throat infection, and death in about the usual rate of such occurrences. The patient received moderate doses of Elixir of Sulfanilamide most of which was not retained. He had no cyanosis, agranulocytosis (W.B.C. above 50,000 with 85% polys R.B.C. above 4 million and Hgb. 70% and above after transfusions).
I feed confident that the acute nephritis developed before the administration of the Sulfanilamide. However, there is the possibility that the drug could have aggravated the nephritis already present. On the other hand, the same sequel of events at the same rate of occurrence is a common thing in medical practice, and no definite fault can be placed on this drug in this particular case. Signed J. F. Crumpler, MD.
The FDA, presumably alluding to Crumpler’s assessment, concluded, “There is some doubt that this death was due solely to Elixir Sulphanilamide.” Yet despite this inconclusiveness, it seems probable that Elixir Sulfanilamide contributed to the boy’s nephritis and consequent death.