Bad Medicine

A respected and trusted doctor with nearly 30 years experience.
A late day appointment.
A prescription written in a hurry.

Welfare recipient Maud Fratz sent her 15-year-old daughter Isabella to Dr. John Raftery's office on Saturday afternoon, January 21, 1939 with a relief medical order. Isabella was suffering from what newspapers would repeatedly and vaguely describe as "a minor ailment" but the Philadelphia Inquirer revealed to be "hemorrhages."

AP photo, 1939

Dr. Raftery dashed off a prescription for a half-grain of strychnine (one 48th a grain per dose), and sent the girl on her way. It was 1 PM.

Yes, strychnine is a poison but back then it was commonly prescribed, in low doses, for a variety of conditions. Athletes had also been known to use it as a stimulant and performance enhancer.

William Fratz, an unemployed hosiery worker with a wife and five children to provide for, had to borrow the cost of the medicine ($1.00) from friends just to his pay for his daughter's prescription.

AP photo, 1939

Within the hour Dr. Raftery began to doubt what he'd written on the prescription. After all, he had been in a hurry to get out of the office when Isabella showed up.

Had he scribbled "SS" or "XX?" If Dr. Raftery had written "SS," he needn't worry but "XX" would indicate 20 grains of strychnine. That would be 40 times the amount he had intended to prescribe.

Dr. Raftery called the drug store, spoke to pharmacist Pearl Borow and learned that the prescription had already been filled, as written - "XX."

Dr. Raftery rushed to the Fratz home to warn Isabella but it was too late. It was now 5 PM. Isabella was already dead. She had died 5 minutes after taking a tablespoon of the bitter-tasting toxic poison. Dr. Raftery notified the coroner's office.

According to a Camden, NJ newspaper The Morning Post, Dr. Raftery, after finding Isabella dead, went to the drug store and "penned a correction over the original pencilling.

That was done, he said, not to try to cover up, but to avoid the possibility someone might call for a reorder of the prescription. That practice often is followed, it was pointed out."

Police arrested both Dr. John Raftery, 56 years old, and Pearl Borow, 26 years old, and charged them with criminally negligent homicide.

Appearing before Magistrate Dogole, AP photo, 1939

To his credit, as they stood before Magistrate Jacob Dogole, Dr. Raftery assumed full blame for the error which caused Isabella's death. His only excuse was that he had been "in a hurry" to leave his office. It was a careless mistake. Dr. Raftery, as far as I can tell, never said what his plans were for that afternoon and why he was "in a hurry."

Pearl Borow, a Temple University graduate and a pharmacist with 6 years experience, said she'd thought the dosage unusually large but that "Dr. Raftery was used to making strong prescriptions."

Moyamensing Prison, Philadelphia

Both were initially held without bail but Dr. Raftery quickly obtained the $5,000 bond money. Pearl Borow was remanded to Moyamensing Prison until her release Sunday evening. No word on who supplied the $5,000 bond for Pearl.

Point of interest - Moyamensing is the same prison that housed H.H. Holmes until he was hanged on May 7, 1896.

An autopsy, quickly performed by Dr. William S. Wadsworth, a Coroner's physician, confirmed that Isabella died from strychnine poisoning. Coroner Charles Hersch announced his intention to hold an inquest.

On February 16, 1939, the facts were presented to a Coroner's jury.

Maud Fratz testified about sending her daughter to Dr. Raftery's office for treatment of a minor ailment.

Detective William Meehan related to the jurors Dr. Raftery's admission of guilt, statements made by Pearl Borow and the chain of events leading up to the arrests.

Six fellow physicians and assorted patients of Dr. Raftery expressed their sympathy for the Fratz family but felt it was simply a tragic mistake and noted that often individuals can survive a dosage of 2 grains or more.

Dr. Charles Nassau, chief of the Department of Health testifying on behalf of Dr. Raftery, admitted the prescription in question was "potentially dangerous."

Some tried to shift the blame to Pearl Borow.

Dr. John McCloskey, Register of Wills, testified that there is a moral, rather than a legal obligation on the druggists's part to call the physician's attention to errors in prescriptions.

"It was a grievous error," said Dr. Wadsworth, who had performed the autopsy on Isabelle. "It is generally understood that pharmacists should use all care in compounding prescriptions, which care would include the noting of any excess amount of any common poisons. Any careful compounder would know, in my opinion, that this prescription was in excess of 24 doses."

Nathan Zonies, president of the Pennsylvania Pharmaceutical Association, in defense of Pearl Borow, said "If the age of Miss Fratz had been on that prescription, the pharmacist would probably have questioned the doctor's prescription." Zonies objected to what he called an attempt to "throw this error, which unfortunately cost a life, into the lap of the pharmacy."

Neither Dr. Raftery nor Pearl Borow testified.

On March 2, 1939, the verdict was read to a packed courtroom. Isabella Fratz's death was the result of "poison taken by mistake." Both doctor and druggist were exonerated.

William and Maud Fratz, the victim's parents, responded violently from the rear of the coroner's courtroom in the City Hall Annex. "I want to protest this! It's an outrage to let these people go," shouted William, rising from his seat. "This is an example of cracked justice!"

Maud sat there sobbing. "They took my child away," she said. "I hope that God will punish them!" Court attendants tried to quiet her.

"No one cares, either, what happens to us," Maud continued. "We're on the welfare so no one cares." Maud Fratz was hysterical as she was led from the courtroom.

Dr. John Shaw, secretary of the Department of Health, who was present at the inquest as an observer, said he would make a report to Governor Arthur H. James looking toward possible corrective legislation.

Out of the hearing came a recommendation by a pharmacist, probably Nathan Zonies, that physicians be required legally to state the age and weight of the patient on all prescriptions as a precautionary measure.

What became of the key players in this tragedy?

William Fratz died in June 1964. I can't find a death record for Maud Fratz.

www.findagrave.com photo
provided by Kate Pitluck

Dr. John Raftery continued to practice medicine and died on August 7, 1946, at the age of 65, following a short illness. His wife Mary Montgomery Gillen Raftery had died only 2 weeks earlier. They had one daughter, Ruth. The day after John's death, his 84-year-old mother Mary Jane Raftery passed away. Dr. Raftery's obituary credits him with having served as vice president of the Philadelphia County Medical Society and mentions he was president of the Northeast branch of that group. John was also president of the Doctors' Golf Association and vice president of the Physicians' Motor Club. Dr. and Mrs. Raftery are buried in the All Saints Episcopal Church Cemetery in Philadelphia.

Pearl Borow resumed her job as pharmacist. She married Carmi Hicks on August 19, 1946 when she was 33-years-old. Carmi Hicks was a 58-year-old divorced war veteran and co-founder of the Lions Club International. Pearl's marriage was short-lived. Carmi died in 1947.

Pearl married again but I'm not sure when or to whom. The 1974 obituary for Pearl's brother Maurice Borow lists her as Pearl Goodman and living in Somerset, NJ. However, when Pearl's brother Henry died in 1956, curiously, Pearl did not get a mention in his Courier-News September 10th obituary. An oversight since remaining brothers Louis, Ben and Maurice are included.

Ben Borow founded New Jersey's Bound Brook Hospital and all four Borow brothers (Ben, Louis, Maurice and Henry) had practices there.

Here is Pearl in a 1985 newspaper photo. If you compare this picture to the last time she was in the newspapers, there's little doubt it's her.

The Courier-News, December 10, 1985

Pearl's life ended at 12:33 AM on November 19, 1987. At approximately 7 PM day before, Pearl had been struck by a westbound car as she was walking towards her apartment building at 173 East Main Street in Somerville, NJ. She'd been out with friends and was being dropped back home but on the opposite side of the street. Pearl made it about halfway across East Main Street before being hit. Charges against the driver, Holly M. Baker, 30 of South Bound Brook, NJ, were unlikely. There was no indication Mrs. Baker had been speeding. Pearl was not only wearing dark clothing but walking in traffic.

According to Pearl's obituary, she moved from Philadelphia to Somerville, NJ in 1957 and was a retired pharmacist. Pearl was survived by three nephews and two nieces. No clues as to her second husband's first name. The obituary lists Pearl's age at the time of her death as 78 but her 1946 marriage license records her birth year as 1913. If the latter is accurate, Pearl would have been 74 when she died. This matches up with news reports following the 1939 death of Isabella that generally list Pearl's age as either 26, although I've her described as being 28-years-old.

I have been unable to find a photo of the victim Isabella Fratz or her parents.

If you like podcasts and have roughly 34 minutes to spare, I recommend a particular episode of the  Poisoncast by Scott Barnett for a background on strychnine and it's toxicity.
https://www.thepoisoncast.org/episodes/2017/4/30/strychnine-the-poisoncast-12