Elixir Sulfanilamide: Deaths in Tennessee
The government’s investigation of elixir shipments throughout Tennessee, Massengill’s home state, was coordinated out of the FDA’s station in Cincinnati, Ohio. The inspector assigned to the job, Ohio native Carl Stone McKellogg, 43, was sent to determine the whereabouts of more than 16 gallons of Elixir Sulfanilamide, which had been shipped directly from Massengill’s headquarters in Bristol throughout The Volunteer State (for a Google map of the state’s distribution, go here). Although these shipments were not interstate and therefore not strictly a federal matter, the FDA nevertheless assumed the authority and responsibility to pick up outstanding bottles of Elixir Sulfanilamide.
Among these elixir shipments, the FDA discovered that less than one third had been returned intact to Bristol (presumably as a result of Massengill’s recall telegrams). This left more than 11 gallons at large within Tennessee. The confirmed death count due to Elixir Sulfanilamide in the state, from 21 prescriptions or over-the-counter purchases, came to six and included the deaths of two individuals who had received their elixir prescriptions in Mississippi.
Elixir-related deaths in Tennessee (6 confirmed, 1 unlikely)
Horace Williams, a 25-year-old highway laborer from Sevierville, died on October 12th at St. Mary’s Hospital in Knoxville. Inspector McKellog learned of this case while investigating the whereabouts of two pints of elixir that had been purchased by Dr. C. P. Wilson (probably Caswell Pharoah Wilson, 46) of Sevierville.
Wilson reported to the FDA agent that he routinely gave out sulfanilamide tablets “quite freely,” and that he had purchased Massengill’s elixir because “it would offer another method of administering sulphanilamide since most of his patients were not satisfied unless they were taking several kinds of medicine.” The doctor admitted that he had given the elixir “to 4 or 5 patients,” and had prescribed redundant (and potentially dangerous) dual antibiotic therapy. While handing out two-ounce portions of the elixir, Wilson advised his patients to drink the liquid antibiotic while also taking sulfanilamide tablets.*
McKellog learned that Horace Williams had first shown up to Dr. Wilson’s office on September 6th, at which time the patient was given sulfanilamide tablets for chronic gonorrhea. (Inspector McKellogg “had the impression” that Dr. Wilson was not Williams’s regular family physician.) Five days later, Williams returned, complaining of weakness and dizziness, and about two weeks later, he again returned with a rash and looking “cyanotic”—possibly the result of antibiotic-induced sulfmethemoglobinemia or methemoglobinemia. Dr. Wilson advised his patient to stop the medication. However, “at some later date,” Williams returned for further treatment. Despite the patient’s possibly adverse reaction to sulfanilamide, Dr. Wilson supplied Williams with more tablets of the antibiotic, along with a two-ounce bottle of Massengill’s elixir.
Sometime between September 24th and October 8th, Williams was examined by a government-contract physician, Dr. John A. Conroy of Gatlinburg. Williams presented to the doctor because of a work-related injury (a “strain” after “cranking an air compressor”). But presumably Williams also complained of urinary suppression, because the doctor sent Williams to St. Mary’s Hospital in Knoxville, where he was diagnosed with acute hemorrhagic nephritis, anuria, and uremia.
Williams was admitted to the facility on October 8th. Urinary catheterization on October 11th “yielded only a few drops,” and Williams’s BUN level was markedly elevated, at 100 mg/dL. He died the following day. Pathologist Ralph Monger performed a postmortem examination. These results were not provided by McKellogg in his official report; however, they were included among the cases reviewed by the University of Chicago’s Dr. Eugene M. K. Geiling and Dr. Paul R. Cannon, in their 1938 JAMA article, “Pathologic Effects of Elixir of Sulfanilamide (Diethylene Glycol) Poisoning.”
From Dr. Otha Horace Yarberry of Sevierville (possibly Williams’s regular physician), McKellogg also learned that the victim’s father (Joseph M.) possessed “a bottle containing a small amount of red liquid” and was “intent on brin[g]ing a law suit against some one.”
The outcome of a lawsuit, if ever brought by Williams’s family, is unknown.
* It would be discovered that Wilson had prescribed Elixir Sulfanilamide to four patients, including Williams. The other three patients consumed all of their liquid-antibiotic prescription, three or four ounces each, “without ill effects.”
William E. Kyte (aka William Estus Kite), a 38-year-old “colored” butcher from the Bearden neighborhood of Knoxville, died on October 17th at the Knoxville General Hospital. McKellogg presumably learned of this case during his investigation of the Albers Drug Company in Knoxville, which had received 10 pints of Massengill’s elixir. McKellogg determined that the drug wholesaler, in turn, had sold pint bottles of the toxic medicine to three city retailers, including the Lane Drug Store, where Kyte had obtained his supply.
McKellogg reported that Kyte, suffering with “chronic gonorrhea,” first presented to the pharmacy on October 7th, asking “for some of that new medicine.” The druggist replied that Kyte needed a prescription, so the butcher proceeded to the office of Dr. E. F. Lennon, an African-American physician whose practice was located above the drug store.* Kyte promptly returned to the pharmacy with the required document, which specified “4 Oz Liquid sulphanilamide. Directions 1 Teaspoonful in a little water every 4 hours.”
On October 12th, Kyte returned to Lennon’s office, complaining of “vomiting and pain in his stomach.” The doctor advised his patient to discontinue the Elixir Sulfanilamide, and he wrote another prescription for a compounded treatment of nux vomica (a strychnine preparation for indigestion), phospho soda (a laxative), and “Elixir Peptozyme” (a digestive aid). McKellogg reported that this second prescription was filled at Carters, “a colored pharmacy in the neighborhood.”
Three days later, Kyte was admitted to the Knoxville General Hospital through uncertain means. However, it is known that he was attended there by Dr. Ed Clayton, 37, and two “internes.” Urinary catheterization performed by one of the doctors-in-training on October 16th produced only a “small amount of thick fluid that looked like pus and some blood.” A follow-up catheterization yielded nothing. Kyte died at 7:45 pm on October 17th. There was no autopsy. Kyte had apparently consumed all four ounces of his Elixir Sulfanilamide prescription.
* A Meharry graduate, Dr. Lennon (along with other African-American clinicians) provided medical services to Knoxville’s black community out of city’s Medical Arts Building on Vine Avenue (see Park City by Brewer and McDaniel, page 89).
Columbus Bryant, a 34-year-old “colored” road worker (or “concrete finisher”) from Memphis, died on October 17th at the city’s John Gaston Hospital, an inpatient facility for African Americans. This case was investigated by FDA Assistant Inspector W. H. Carpenter, who worked out of the agency’s St. Louis office (but was stationed in Memphis).
Carpenter learned that Bryant, while working out of town, had obtained Elixir Sulfanilamide from Dr. Sam Goodman of Cary, Mississippi. (Goodman had received one gallon of the product.) During a long-distance phone conversation, Carpenter learned that Goodman had dispensed only the one six-ounce prescription for Massengill’s elixir. Given Goodman’s location, details of Bryant’s case were wired by the physician to the FDA’s New Orleans Station, which had purview over Mississippi.
Goodman relayed further to the FDA that he had dispensed the elixir to Bryant as treatment for gonorrhea on October 7th. On the fourth day of treatment, Bryant was “in misery with pains in stomach, liver, and back over kidneys,” and acute nephritis was diagnosed on the basis of a urine sample. Possibly suspecting an adverse reaction to the elixir, Goodman advised its immediate discontinuation and recommended “calomel purge and large doses of sodium citrate,” in an apparent attempt to rid the body of the antibiotic solution. Five days after prescribing the elixir, Goodman advised hospitalization. The next day, October 13th, Bryant traveled back to Memphis; however, it wasn’t until four days later, on October 17th, that he was admitted to the city’s John Gaston Hospital, in a terminal condition. Three hours after admission, Bryant died. He had consumed a total of four ounces of Elixir Sulfanilamide.
An autopsy, including “chemical tests” performed by Dr. William B. Wendel of the University of Tennessee at Memphis, revealed sulfanilamide “in the disintegrated kidney tissues.” Apparently early suspicions in Memphis—before knowledge of the elixir’s deadly solvent, diethylene glycol, was well publicized—focused on the toxicity of the antibiotic. This well-meaning, but incorrect, focus may have been stressed locally by Wendel, a chemistry professor, who was an emerging expert on the occurrence of adverse events, including methemoglobinemia, due to sulfanilamide therapy (see, for instance, Wendel’s “Use of Methylene Blue in Methemoglobinemia From Sulfanilamide Poisoning“).
One week later, however, the toxic culprit in Elixir Sulfanilamide, diethylene glycol, was readily acknowledged among medical professionals, including Wendel. He sent Bryant’s organs, reported the FDA’s St. Louis Station Chief on October 26th, to Dr. Eugene M. K. Geiling at the University of Chicago (again, for reference, see Geiling’s 1938 article “Pathologic Effects of Elixir of Sulfanilamide (Diethylene Glycol) Poisoning“). By this time, Wendel had also alerted the FDA to an article by Navasquez, “Experimental Tubular Necrosis of the Kidneys Accompanied by Liver Changes due to Dioxan Poisoning” in a 1935 issue of the Journal of Hygiene. The professor “thought that since dioxan [sic] and diethylene glycol are similar chemical compounds, this article might be of interest in connection with the current Elixir Sulfanilamide poisonings.”
Charles William Miller, a 25-year-old white filling-station attendant from Memphis, died on the afternoon of October 20th at the city’s Methodist Hospital. This case was presumably identified jointly by a Tennessee state inspector and FDA Inspector Carpenter through their investigation of one gallon of elixir, which had been shipped to the Fox Drug Company in Memphis on September 30th. Carpenter, who worked out of the FDA’s St. Louis office but was stationed in Memphis (see Columbus Bryant), discovered that the pharmacy had allowed the over-the-counter purchase of Elixir Sulfanilamide to three individuals, each of whom had been given eight ounces. One of these individuals was identified as “Joe Brown,” a “negro” coworker of the victim.*
According to a contemporary report in the Commercial Appeal (October 21,1937), a Memphis newspaper, Miller sent Brown to the drug store, along with a note describing “his suspected ailment,” venereal disease. It was the druggist who, in turn, recommended Massengill’s elixir and offered it for sale over the counter, without a prescription. (The date of the purchase was not reported by the paper, but, according to the FDA, it occurred sometime before October 14th.) Miller, after consuming an unknown quantity of the elixir, was admitted to the city’s Methodist Hospital on the afternoon of October 16th, a Saturday.
Carpenter’s investigation drew on interviews with Miller’s hospital physicians and his girlfriend (who was, in actuality, probably his wife, according to Miller’s death certificate). The unfolding story indicated that Miller began to experience “abdominal discomfort” on the night of October 13th. During the next few days, the pain escalated and was accompanied by nausea and vomiting. Miller’s condition, which appears to have included symptoms of reduced urinary output at some point (for example, the passing of “dark urine”), warranted hospitalization on October 16th.
On admission, Miller was “rational” but “answered questions slowly,” a possible sign of impending uremic encephalopathy. Nevertheless, he was sufficiently alert to dissemble: He adamantly denied taking any notable drugs, except for a couple of quinine preparations during the last two months. Miller’s physicians otherwise found his clinical condition to be significant for a “very rigid,” “boardlike,” and distended abdomen. Their initial diagnosis was acute anuria, “probably chemical in origin.” Poisoning due to mercury bichloride, a contemporary treatment for venereal disease, was initially suspected.
On October 19th, Miller became “more stuperous,” and Dr. William B. Wendel, associate professor of chemistry at the University of Tennessee’s College of Medicine in Memphis, was consulted. Wendel, an emerging expert on the side effects of sulfanilamide and assays for its detection (see Columbus Bryant), rejected the idea that the antibiotic might be the culprit poison. (At some point, Miller’s hospital physicians must have entertained the possibility of sulfanilamide toxicity in their differential diagnosis, possibly as a result of Wendel’s early, but incorrect, suspicions in the case of Columbus Bryant.) Miller’s “symptoms did not resemble any symptoms of Sulfanildmide poisoning that he had ever seen,” reported the doctor. Specifically the cyanosis associated with the antibiotic-induced condition of methemoglobinemia was absent, Wendel noted. Nevertheless, he took blood samples from Miller for laboratory analysis.
In the meantime, Miller’s girlfriend/wife found a half-full eight-ounce bottle of liquid medicine that had recently been used by Miller. She gave it to one of the hospital physicians, who suspected the contents to be sulfanilamide on the basis of the printed directions. This discovery then led Miller’s physicians to the Fox Drug Company. There the druggist admitted to selling the elixir, along with sulfanilamide capsules, to Miller’s coworker. Evidently “the directions on the bottle called for [the] capsules to be used in connection with the liquid,” reported the FDA. Given these recommendations for dual antibiotic therapy, it is not surprising then that Wendel detected sulfanilamide in Miller’s blood as well as evidence of methemoglobinemia—the presumptive result of a double dose of sulfanilamide. (An in-house test for gonorrhea was negative, suggesting that the high-dose sulfanilamide treatment eradicated the causative bacteria.)
On October 20th, Miller’s condition was grave. He was described as “acidotic,” “bluish,” and having a “measly rash” over his body. More worrisome was the fact that he was convulsing. Miller’s end-stage agitation must have been severe, because he was placed in a “straight jacket,” per the FDA report. He died at 3 pm, with the official causes of death listed as “Elixir Sulphanilamide poisoning” and “uremia.”
In its next-day coverage, the Commercial Appeal wrongly implicated the antibiotic rather than diethylene glycol in Miller’s death. Alluding to Wendel’s laboratory data, the Memphis paper reported that Miller showed “strong traces of sulfanilamide” in his blood during hospitalization, and that he had died of sulfanilamide (not diethylene glycol) poisoning, according to an autopsy.
Wendel was quoted in the paper, but not in relation to Miller’s cause of death. What roused the doctor’s ire was the over-the-counter purchase of the antibiotic elixir—a then-legal, but controversial, practice. Wendel chastised:
This is a tragic instance of the danger of the public being prescribed for by a druggist. This over-the-counter prescribing is the cheapest medical advice in the world and the most costly. It costs nothing to get a clerk or druggist to prescribe but it can too easily cost a life.
Our medical society has long fought to prevent it. We have discussed it with the druggists as a body but our efforts here and everywhere else to stop the practice are futile. If the druggists won’t help us protect the public, the public should realize its danger and take medicine only when prescribed by a physician.[**]
Wendel sent Miller’s organs (along with the organs of Columbus Bryant) to Dr. Eugene M. K. Geiling at the University of Chicago (again, for reference, see Geiling’s and Cannon’s 1938 article “Pathologic Effects of Elixir of Sulfanilamide (Diethylene Glycol) Poisoning“). Wendel also alerted the FDA to an article by Navasquez, “Experimental Tubular Necrosis of the Kidneys Accompanied by Liver Changes due to Dioxan Poisoning” in a 1935 issue of the Journal of Hygiene. The professor “thought that since dioxan [sic] and diethylene glycol are similar chemical compounds, this article might be of interest in connection with the current Elixir Sulfanilamide poisonings.”
On November 12, 1937, news wires reported that Miller’s widow, Mayme (or Maymis), had filed suit against the Fox Drug Company and The S. E. Massengill Company in a Memphis circuit court, asking for $50,000 in damages. The outcome of the suit is unknown to this writer.
* Another purchaser consumed about four ounces of elixir before dropping and breaking the bottle. The third recipient, who was located “after much effort,” consumed all but one-half ounce. A member of the Memphis City Health Department and Inspector Carpenter escorted both patients to the John Gaston Hospital (affiliated with the University of Tennessee at Memphis), where “blood tests and other proper measures were taken.” The FDA reported, “Evidently neither the second patient…nor the third patient…suffered any ill effects, whatever, from consuming considerable portions of the Elixir Sulfanilamide.”
** Although it should be noted that a prescription in this case would not have averted death. Nevertheless, the uniform requirement for prescriptions would have raised the threshold for obtaining the poisonous elixir and, thereby, might have reduced the risk of death in the handful of fatal cases in which Massengill’s product was purchased over the counter.
Reverend James Edward Byrd (right), a 65-year-old Baptist preacher from Mount Olive, Mississippi, died in the early morning hours of October 21st at St. Mary’s Hospital in Knoxville. Inspector McKellogg learned of this death through press reports (see, for instance, an Associated Press report in the Kingsport Times, October 21, 1937, which ran a parallel story on the death of Charles Miller).
The longtime secretary of Mississippi’s Baptist Sunday School, Byrd traveled from his home in Mississippi to conduct a series of clerical meetings in Knoxville. Shortly before leaving for his trip, on October 11th, he received a prescription from his physician and friend, Dr. Archie Calhoun, for three ounces of the antibiotic elixir. The treatment was intended as a remedy for cystitis. McKellogg learned from Byrd’s hospital physician in Knoxville, Dr. Andrew Lafayette Rule, that the minister had experienced vomiting and diarrhea on October 15th, which he attributed to “bad” oysters.
The next day, Byrd “felt a constant urge to urinate,” but he found it “difficult to start the st[r]eam and very little was voided.” (Notably, before taking Massengill’s elixir, Byrd admitted to urinary urgency in some capacity for three weeks, and a urinalysis performed by Calhoun revealed “1+ pus.”) Byrd was admitted to the Knoxville hospital on October 17th, presumably as a result of an escalating inability to void.
In hospital, Byrd could not urinate voluntarily, and “most attempts” to acquire urine through catheterization were unsuccessful. On October 18th and 19th, miniscule volumes (~10 cc) were obtained, revealing marked spilling of albumin (4+), a sign of significant kidney dysfunction. Blood work on the 19th showed dangerously high creatinine and BUN levels: 7.5 and 160 mg/dL, respectively. Intravenous glucose and saline were given in an attempt to stimulate renal function, and Byrd was placed in an oxygen tent on the day of his death. The victim’s wife, Leona, and his two sons were reportedly at his deathbed.
An autopsy was performed by pathologist Ralph Monger, who had also examined an another elixir victim in Tennessee, Horace Williams. Byrd’s case, like that of Williams, was included among those considered by the University of Chicago’s Geiling and Cannon, in their 1938 JAMA article, “Pathologic Effects of Elixir of Sulfanilamide (Diethylene Glycol) Poisoning.” It is unknown how much Elixir Sulfanilamide was consumed by Byrd, but his hospital physician told the Associated Press that the minister took “13 doses,” probably about two ounces.
The reverend’s body was returned to his home, where “hundreds,” reported the News-Commercial, paid their final respects to the “statesman, churchman, schoolman, and temperance leader” on Saturday, October 24th. Byrd was interred at Mount Olive Cemetery.
Passport photo of Rev. James Edward Byrd at the age of 51, from an application dated 1923; obtained through Ancestry.com. Byrd described his physical stats thusly: height, 5 feet 11-1/2 inches; eyes, blue; hair, brown streaked with grey; and complexion, florid.
Charles “Charlie” Alexander Meredith, Jr., a 17-year-old “colored” student from Cleveland (the oldest child of Charles and Lena [née Henderson]), died on October 24th at the Physicians and Surgeons Hospital in the Piedmont community. Inspector McKellogg reported this case to the FDA’s Cincinnati Station on November 1st. It was presumably discovered through the investigation of Cleveland’s Shepherds Pharmacy, which had received one pint of Massengill’s elixir.
McKellogg wrote that Meredith, a high school football player, had gotten drunk after a Friday game on October 15th. The next day, he presented to his family physician, Dr. T. M. Perry (described as “colored”), for several injuries: a bruise on each leg, an “infected spot on a finger of his left hand,” and a left-hand abrasion “filled with pus.” Most concerning, however, was the condition of Meredith’s left arm, which was entirely swollen “to the shoulder.” The boy’s temperature was also elevated, exceeding 102 degrees Fahrenheit. Dr. Perry suspected a hemolytic strep infection.*
Perry initially prescribed Uritone (the Parke Davis brand name for hexamethylene tetramine, a urinary antiseptic derived from formaldehyde and ammonia), 12 capsules of salol (or phenyl salicylate, presumably intended as an anti-inflammatory agent), and two grains each of Phenacetin (Bayer’s antipyretic) and quinine. The latter medication had, at the time, a number of indications: to combat malaria, general inflammation, and pain.** The following day, October 17th, Meredith complained of nausea, and Perry wrote another prescription, this time for four ounces of Massengill’s antibiotic elixir, two teaspoonfuls in water every four hours.
On October 18th, Meredith ate “some veal steak,” which was followed by nausea and vomiting; but notably, his arm swelling had receded. The next day, he continued to experience nausea, which was accompanied by new cramps in the right lower abdomen. The diagnosis of appendicitis was entertained. Dr. Perry, presumably because of Meredith’s emerging urinary complaints, performed a catheterization of the bladder. This procedure yielded “about one-half ounce of urine.” An examination of the scant fluid showed marked levels of albumin (4+), an indicator of significant kidney damage.
Elixir Sulfanilamide was “withdrawn” the same day, an action possibly prompted by Massengill’s recall telegram and facilitated through the confiscation efforts of Kenneth Owen, one of Massengill’s regional salesmen. By this time, Meredith had consumed less than two ounces of the products. Perhaps to purge the boy of the poisonous treatment, Perry ordered “oil” as a laxative. “This did not prove effective,” the FDA recorded, “and […] the mother gave a dose of about one tablespoonful of epsom salt.”
The teenager was admitted to the hospital on October 19th by Dr. Madison S. Trewhitt, a white physician, who administered intravenous glucose and saline in an effort to promote kidney function. Three different catheterizations produced nothing more than “a few drops.” “The total urinary output from the time of hospitalization until time of death,” McKellogg wrote, “did not exceed 3 ounces,” or 6 tablespoons. In addition to anuria, Meredith experienced “marked swelling of the liver, marked general abdominal tenderness and rigidity and terminal edema and free fluid in the abdomen”—in other words, ascites, probably due to kidney or liver dysfunction or both. Surprisingly no blood chemistry tests and no postmortem examination were performed, despite the fact that Meredith was seen by two other physicians in consultation (Drs. Samuel Julian Sullivan, 37, and Jacob Lake McClary, 62). Meredith died on a Sunday afternoon, eight days after he was given Elixir Sulfanilamide.
On October 26th, Meredith’s parents buried their son in the Fort Hill Cemetery in Bradley county, Tennessee. The victim’s tombstone was inscribed with “Darling Son” and the words,
Although he sleeps
His memory doth live
And cheering comfort to the mourners give.
In an apparent afterthought, McKellogg wrote of Dr. Perry’s reluctance to publicize his prescription of Massengill’s elixir, particularly among his African-American clientele. “If my people here knew that I gave this,” Perry admitted to the FDA agent, “I would have to move to a new location.” McKellogg observed that the local white physicians rallied around their African-American colleague, demonstrating that professional fraternity could trump racial schism, even in 1937.
* It was reported that Meredith’s team practiced on a “stoney field”–the implication being that the boy suffered his injuries while playing in the game or engaging in drunken, postgame activities on the same field.
** Notwithstanding the treatment of Meredith’s physical injuries, it is worth noting that all of these medications, particularly Uritone, had their place in the treatment of venereal disease, particularly gonorrhea, before the widespread use of antibiotics. Their prescription by Dr. Perry suggests that Meredith may have been suffering from more than just injury-related skin infections.
“Baby” Thompson,* an infant of about one year of age, from Jacksboro, died on October 9th. The child probably consumed only about one teaspoonful of two-ounce prescription for Elixir Sulfanilamide,** which was intended for “advanced stage” erysipelas. The elixir prescription was written on October 7th and dispensed from a one-pint bottle at Winklers Pharmacy in nearby LaFollette. The baby died two days later. According to McKellogg, “There were no terminal symptoms of urine suppression or anything else to indicate toxic effects from the Elixir.” The FDA officially concluded, “All evidence indicates that this patient did not die as a result of Elixir Sulphanilamide.”
* A search of Tennessee death certificates failed to return a matching death record. The baby is possibly Elanor Thompson. Although this infant, buried in Jacksboro, died on October 13th and was about five months of age at the time of death.
** Directions were to administer 1/2 teaspoonful ever 24 hours.