How one incident caused 47 patients to die at the Oregon State Hospital

A ghastly scene unfolded during dinner 75 years ago at Oregon State Hospital.

Patients began dropping like flies after eating a batch of poisoned scrambled eggs, vomiting blood and writhing on the floor in agony.

Some died within minutes, others succumbed hours later, 47 people in all. Officially, there were 263 cases. Newspapers, however, reported more 400 others were sickened.

Gov. Charles A. Sprague called it “mass murder.”

Sabotage was initially suspected, what today we would call a terrorist attack.

This happened in 1942, with the country engaged in World War II. Fears of sabotage were real, especially on the West Coast. The food supply was considered a vulnerable target.

The eggs used at the state hospital came from federal surplus commodities distributed by the U.S. government, part of a shipment received six months earlier and divided between state institutions, schools and other programs in Oregon.

Gov. Sprague immediately ordered all institutions to stop using the eggs, which came packed frozen in 30-pound tin cans. The federal government issued a similar order.

Investigators from the Army, the American Medical Association and the Food & Drug Administration rushed to the state hospital campus in Salem.

It happened so rapidly

Dr. Howard Baumann sets the scene today in one of the exhibit rooms at the Museum of Mental Health, which is dedicated to telling the stories of those who have lived and worked at the hospital.

Nov. 18, 1942 was a tragic day for patients and staff. The death toll was staggering, but it could have been worse. The hospital housed an estimated 2,700 patients at that time, more than five times the number today.

More Forward This columns: Willamette Heritage Center celebrates 160 years of Salem Fire Department

Survivors and witnesses are long gone. First-hand accounts are limited to what can be found in newspaper archives and a report submitted to the Journal of the America Medical Association by three doctors, two from the hospital and one from an Oregon State Police crime lab in Portland.

Dr. William L. Lidbeck, a pathologist, was one of those doctors. On call and living in a cottage on the hospital campus, he was one of the first to respond to the horrific scene.

Baumann, a retired gastroenterologist, portrays Lidbeck in reenactments at the museum. While sharing Lidbeck’s perspective, he stands in front of historic photographs of the hospital’s dining room and kitchen. Next to him is a large stainless steel vat with giant ladles hanging from above, much like what would have been used to mix and serve the scrambled eggs that evening.

When Lidbeck arrived, patients were suffering extreme nausea and abdominal cramping. Many were vomiting blood, having seizures and struggling to breathe. Others were experiencing paralysis.

Baumann can speak with authority about symptoms that would be experienced after ingesting such a virulent poison. His specialty, during his 35-year career at Salem Clinic, was gastroenterology, the branch of medicine focused on the digestive system.

“Even today, if this happened, probably the best we could do is support them,” Baumann says. “The trouble is, it happens so rapidly.”

He presumes those who ate the most eggs would have died the quickest. For others, death would have been prolonged.

The tiny morgue at the hospital could handle only the first few victims. Before the night was over, shrouded bodies were crammed into the chapel and lined up in hallways.

More might have died if not for the discerning taste buds of some patients and the heroic actions of one staff member.

Many patients put their spoons down after complaining the eggs tasted salty or soapy and experiencing immediate symptoms.

One survivor, only able to whisper through lips swollen and blue, described it this way in the Daily Capital Journal: "My face became numb. My teeth began to ache. Pretty soon my legs became paralyzed."

Nurse Allie Wassell took one bite of the eggs after dinner trays were brought to her ward and the taste was so off, she refused to let et her patients eat them.

Wassell became ill but survived and was credited with saving many lives by her actions.

Was it intentional or accidental?

The investigation was swift, considering the rudimentary technology that would have been available. This happened long before email and cell phones, and equipment would have been archaic compared to what we have now.

Autopsies were done on six patients. Samples from the cooked eggs and stomach contents were sent to the lab in Portland.

Bits of eggs, both from the plates of patients and from the hospital’s unused supply, were fed to rats. Those fed the cooked eggs died within a few minutes.

Surplus eggs were tested up and down the coast.

More Forward This columns: Exceptional workers with disabilities showcase Salem nonprofit's success

Within 22 hours, according to the report submitted by Lidbeck and his colleagues, the poison was identified as sodium fluoride, and it was found only in cooked eggs at Oregon State Hospital.

Sodium fluoride is commonly used in insecticides and in rat and cockroach poisons. It is a quick-acting white substance that might easily be mistaken for flour, baking powder, or powdered milk. Ingesting a minuscule amount can be fatal.

But how did it get in the eggs? And was it intentional or accidental?

The story unraveled when the hospital's assistant cook stepped forward with a confession. He had sent a patient to a basement storeroom for powdered milk and the patient mistakenly brought back roach poison that was mixed in the scrambled eggs.

Similar tragedies happened elsewhere before modern food safety regulations were adopted. In 1940, at a Salvation Army shelter in Pennsylvania, 12 men died and 48 others were sickened when roach powder was mixed into pancake batter.

Patients still help out in kitchen

The vocational rehabilitation services program at Oregon State Hospital is robust, exposing patients to a variety of work-experience opportunities that enable them to improve self-esteem, feel productive and earn a wage.

Jobs can be had in janitorial, landscaping and library services. And yes, food services, too.

“They’re not working where the food is actually being prepared,” says Tom Anhalt, director for vocational and educational services. “Where they’re really working is in the back, washing dishes, cleaning up and preparing for the lines.”

A grave mistake like the one with the scrambled eggs couldn’t happen today for many reasons, the most important of which is constant supervision.

Patients are assessed before leaving their living unit and heading to work. Supervisors are required to always have a line of sight on patients, escorting them to and from the kitchen area.

“There’s no way they can go somewhere without supervision, not even to the bathroom,” says Kent Hunter, director of food and nutrition services for the Salem campus.

Patients who work in food services today must have a food handlers card and go through additional safety and sanitation training.

“We follow higher standards than what Marion County requires of us,” Hunter says.

Both he and Anhalt agree it would be next to impossible for someone today to mistakenly grab rat poison or any other dangerous substance and add it to a meal.

“None of those chemicals are even allowed anywhere near kitchen and food services,” Hunter says.

Cooks fold under pressure

George Nosen admitted himself to Oregon State Hospital in the summer of 1942. He was 27, paranoid schizophrenic, and assigned to kitchen work detail.

He was the one sent to the basement and unknowingly scooped up roach powder instead of powdered milk.

Assistant cook Abraham McKillop needed the ingredient to mix with the eggs that day and apparently didn’t have time to fetch it himself. The investigation found the institution to be understaffed and noted that the hospital dietician, responsible for the storing of foodstuffs, had recently left to work at Camp Adair.

The war took a toll on the staff. According to a timeline exhibit at the Museum of Mental Health, Oregon ranked second-to-last in the nation among staff-to-patient ratios at state institutions in 1939. Due to the number of employees drafted, it averaged one staff member per 10.4 patients.

On that regretful day, McKillop handed Nosen the key to a storeroom, a violation of Rule 8, which was established at the hospital in 1908, forbidding the entrusting of keys to patients.

Nosen reportedly had accompanied kitchen staff to the basement storerooms before. But there were two described in grand jury testimony as 11 feet apart and opened by the same key.

Nosen entered the wrong one and retrieved the wrong white powder.

As patients were dying before their eyes, McKillop and the chief cook, Mary O’Hare, retraced Nosen’s steps and discovered what had happened. They kept silent before cracking under the pressure of repeated questioning by investigators.

“We were both scared so bad we didn’t know what to do,” McKillop later testified.

On Nov. 23, five days after the deadly dinner was served, the two cooks were arrested. McKillop was charged with involuntary manslaughter. O’Hare was charged with accessory after the fact.

In the aftermath

After a lengthy probe, charges against the two cooks were dismissed, but there was plenty of blame to go around.

To hear Baumann reenact the story, the media pointed fingers at the hospital for failure to follow safety measures, and hospital officials pointed fingers at the legislature for failure to support an institution that was understaffed and overcrowded.

"Some good things did come out of it," Baumann says.

The tragedy had ramifications beyond the hospital. It brought about reforms in food safety. A poison label law was introduced during the next legislative session and eventually was adopted. It also contributed to major changes being made at mental hospitals across the country, including increased staffing and funding.

McKillop died in 1946 after a long illness. His obituary in The Oregon Statesman notes he was employed for 11 years at the state hospital.

No obituary could be found for O’Hare.

Nosen died in 1983 at the hospital after an altercation at the institution. The official cause of death was heart disease. He had a reputation of being combative and getting into fistfights with fellow patients, who never stopped blaming him for the poisoning.

It haunted him for the rest of his life.

But the most heartbreaking chapter of this tragic tale is about the 40 men and seven women — ranging from age 18 to 80 — who died from eating the contaminated eggs.

The cremated remains of 13 of them have yet to be claimed at the hospital.

“Forward This” appears Wednesdays and Sundays and highlights the people, places and organizations of the Mid-Willamette Valley. Contact Capi Lynn at clynn@StatesmanJournal.com or 503-399-6710, or follow her the rest of the week on Twitter @CapiLynn and Facebook @CapiLynnSJ.

In memory of those who died

Cecil Barkell, 42, Sheridan

Marion O. Bates, 43, Quincy, Illinois

Albert Beal, 42, Portland

James Beasley, 71, Roseburg

Henry Becker, age unknown, Portland

Joe Berg, 55, Portland

Otto Bergstrom, 61, Portland

Thomas H. Brown, 60, Klamath Falls

John F. Buckland, 71, Hillsboro

Harold Burnette, 38, Medford

Selma Carlson, 56, address unknown

Willard Curtis, 33, Marshfield

John Dean, 41, address unknown

Wyke Dixon, 80, Corvallis

Marjorie Donovan, 18, Junction City

Stefan Dosek, age unknown, Portland

Walter P. Feldman, 54, Portland

Frank Freer, 52, Klamath Falls

Rodney Garrett, 37, Dallas

Otis Gillette, 51, Portland

John Goodin, 48, Cornelius

D.F. Hanel, 42, Klamath Falls

John Hantok, 58, Portland

Adolph Hassel, 58, Oregon City

Roy Jorgenson, 50, Portland

Anthony G. Juba, 39, Kelso, Washington

Anna LaMascus, 44, Portland

Anna Maki, 53, Portland

Sczepan Mielczarek, 51, Portland

William Budd Moore, 65, Ashland

Edward L. Moses, 66, Portland

John O'Leary, 66, Portland

Anton Pederson, 54, St. Johns

Clifton Phelps, 34, Portland

Frank Pointer, 55, address unknown

James H. Pool, 57, Salem

Estella L. Sellwood, 50, Portland

Beatrice Shipley, 67, Silverton

Madeline Smith, 21, Portland

Joe Stasek, 56, Scio

Charles Stone, 56, Portland

Joe "aka Tonfanerto" Faganello, 55, Klamath Falls

Thomas P. Thompson, 55, Portland

George Uber, 54, Halsey

Lester Updegraff, 39, Portland

Carl Wise, 74, Bridal Veil

Pinkus Zollman, 62, Portland