In October 1937, a government inspector in South Carolina was led out to a grave by the dead man’s sister. The grave was on a wooded knoll a mile and a half back in the fields, and on the single mound of fresh earth, in accordance with the family’s custom, stood the dead man’s medicines, his glasses, and his spoons. Among the items on the knoll sat a four-ounce bottle holding about an ounce of red medicine, under the doctor’s weathered but still legible label.
The inspector worked for the Food and Drug Administration, and he had come because of a medicine called Elixir Sulfanilamide. A local doctor had told him he gave the elixir to five patients and that none of them had died. Neighborhood talk about the last illness of a Black lumber mill worker said otherwise, and the inspector followed the talk. The doctor had in fact dosed seven patients. Four of them were dead.
The medicine had been made in Bristol, Tennessee, by the S. E. Massengill Company, and it had been checked for appearance, flavor, and fragrance, and for nothing else. No one at the company tested whether the solvent was safe to swallow, and no law then in force made them. The solvent was diethylene glycol, a kind of antifreeze. Between September 4 and October 15, the company sent out 633 shipments from Bristol and its branches, and when the deaths surfaced in a week of wires, the company sent telegrams asking for its own product back. The first wave said do not use it, return it at our expense, and said nothing about why. The government’s inspector in Bristol insisted on a second wave, and the second wave admitted the product may be dangerous to life. Return our expense. The postage was the clearest sentence in it.
What followed was a hunt conducted on paper, and it is the part of the story worth staying for. Nearly the whole field force of the Food and Drug Administration, 239 inspectors and chemists, went out after the bottles. There were about 200 salesmen to find, and the hunt moved down the chain of sale, from branch to druggist to doctor to patient. In a single establishment, clerks went through twenty thousand sales slips. In East St. Louis, the chase ran through forty-nine prescriptions, some of them identifying a patient by nothing more than a first name and an age in months, and a paper trail like that led almost nowhere. Six men named Willie Smith were found on the relief rolls before the right bottle came back.
The report tells the Willie Smith story as a success, and it was one, since the sixth Willie Smith was the right one. But read it again as a limit. The hunt reached least where the paper was thinnest: on the relief rolls, among people known by a first name. The government’s arithmetic of the liquid ran in gallons and pints, and the Secretary’s report counted at least 73 deaths caused by the elixir and 20 more not yet attributed, and later tallies passed a hundred. The report never gives the dead man on the knoll a name, because the government’s paper never held it. A notice can only reach the people its paper can find.
That is the lesson of 1937, and it did not stay in 1937.
The country now writes its recall notices by rule. The envelope’s three words are set in capitals larger than the owner’s name and address. The letter inside is drafted by the seller and read by the government before it mails. The car’s identification number is printed on it, and the owner is found through the state’s registration rolls. The machinery is real, and it is engineered, and it still measures its reach by its lists.
Ask where the lists end. They end where the paper thins. The car bought used at auction carries a recall letter addressed to whoever owned it first. The crib in the licensed childcare home came in secondhand, so no one knows to look for it; a recalled portable crib with folding rails stood in one for five years, and the state inspector had visited eight days before a sixteen-month-old boy died in it. The rented PT Cruiser on a California lot was a month into its recall for a hose that could leak and start a fire, and the counter gave it away as a free upgrade, and the two sisters who took the keys drove north and never came home. The address on a rural route changes when the tenant moves. The dresser from the yard sale carries nothing.
When the Consumer Product Safety Commission’s own staff stood up at a workshop in 2017 and gave the machinery’s account of itself, the consumer-level correction across about 865 closed defect cases ran to about 6 percent. The figure counts the consumers known to have taken part, and it cannot see the product thrown away, or the risk accepted, or the kit never installed. On the vehicle side, where the channel is the most regulated in the country, the largest recall in the highway agency’s history reached 91 percent repaired by the agency’s count, and about six million air bags remained on the road. The success is real. So is the remainder. The remainder is where the paper thins.
What a notice can do, when it works, is answer five questions. What does it say the danger is. What does it leave out: the reason, the count, the date of the first report. Who speaks, and in what words. What must the reader do, and what will it cost. What will count as fixed, and out of how many. The 1937 wire answers the fourth in full and fails the rest. The regulated envelope answers more. The difference between them is eighty-nine years of law learning to ask.
The bottle on the grave is still the honest picture of it. The evidence of what killed the man sat on his grave in a four-ounce bottle, waiting for an inspector to come find it, and the inspector found it because a sister walked him out there. Where the paper is thin, the notice arrives by other means, or it does not arrive. The count of what came in is a different count from the count of what happened, and the distance between the two is measured in people the machinery never reached.
This article grew out of a new book I have been writing and reading the documents for, and it is out now: No Injuries Have Been Reported: The Recall Notice, from the Wire to the Update, published by David Boles Books Writing and Publishing. It reads the American recall as a drafted document, from the 1937 wire to the over-the-air update, and it prints the five questions on a card you can keep. It is at BolesBooks.com, and on Amazon for Kindle and in paperback.