PART 1

A Curious Discovery

The Tylenol Murders

Who Will Protect America?

The Tylenol Crisis

All of Burke’s Men

The Developing Investigation

We Will Be Completely Honest

J&J and the FBI

Above the Law

The Madman Myth

Handling the Evidence

Selling the Myth

Rack Jobbers

The Vanishing Evidence

A Reluctant Recall

The Other Cyanide Murders

A Poisoned Investigation

The Tylenol Institution

The Louis Zahn Drug Company

We Know Who did It

The Closet Chemist

A Conspiracy Theory

The Eighth Bottle

The Conspiracy

The Last Suspect

Project Chatham

Death is a Manageable Side Effect

PART 2

The 1986 Tylenol Murder

We Never Said It Is Tamper Proof

The Great Capsule Debate

Burke’s Nightmare

The Puerto Rican Diversion

Our Credo

The Vergari Problem

Revisionist History

Big Jim’s Boys

PART 3

The Manhunt

How Do You Solve A Problem Like James Lewis?

A Second Look

A Novel Approach

A Familiar Pattern

The Judges of DuPage County

A Reactivated Cover-up

The New Case; Same as the Old Case

Mens Rea: Guilty Mind

The Madman

About the Author

Endnotes

THE TYLENOL MAFIA

Marketing, Murder, and Johnson & Johnson

(Revised 2nd Edition)

By Scott Bartz

New Light Publishing

Cover art by Michael P. Swanson

Copyright © 2011, 2012 by Scott Bartz

All rights reserved.

Scott Bartz

Acknowledgements

My editor, Linda, the “Write Watchman,” was a true partner in this endeavor. Her expertise and guidance were invaluable to me. Thank you, Linda.

Thank you, Jack O’Dwyer, for your encouragement and journalistic integrity. Jack has long been one of the few voices in the PR industry to call for some accuracy in the way J&J’s handling of the “Tylenol crisis” is reported.

Thank you, Michael P. Swanson, for creating the cover for this book.

I’d like to also thank Michelle Rosen for working tirelessly to dig up important facts about the Tylenol murders investigation. Michelle, along with several other people named in this book, provided critical information that brought this story to life in a way that could not have been done through the documented evidence alone.

Most of all, thank you Anne and Justin.

PART 1

1

________

A Curious Discovery

A man who would soon become notoriously anonymous slipped away unnoticed as Deputy Joseph Chavez pulled into the parking lot at the Howard Johnson’s Motor Lodge and Restaurant in Elgin, Illinois early Tuesday morning, September 28, 1982. Deputy Al Swanson arrived about a minute later and parked next to Chavez in one of fifteen spaces facing Route 25, known locally as Dundee Avenue. The deputies were working the midnight to 8 a.m. shift for the Kane County Sheriff’s Department and were meeting at the all-night restaurant for breakfast.

It was a clear night and about 55 degrees when Swanson and Chavez exited their vehicles at 2:32 a.m., exchanged pleasantries, and headed for the restaurant’s entrance. Chavez glanced down the line of mostly empty parking spaces and saw two cardboard boxes resting on the pavement next to the grass median that ran between the parking lot and Dundee Avenue. The boxes, identical in size, measured about 10 inches wide by 10 inches deep and were 8 inches tall. The labels on the boxes gradually came into focus as the deputies, obviously curious, walked toward them.

The words “EXTRA-STRENGTH TYLENOL CAPSULES” were embossed in bold black uppercase letters on the right half of each box-front. On the left half of each box-front, the Tylenol manufacturer’s name, “McNEIL,” was imprinted just below the description of the contents: Twelve 6-packs of 50-count bottles of Extra Strength Tylenol capsules.

One of the boxes was open. Two dozen Tylenol bottles remained in the open box, but two of those bottles were also open. Strewn on the pavement within a few feet of the boxes were hundreds of red and white capsule-parts labeled with the 500-milligram Extra Strength Tylenol dosage mark. In between the boxes was “a big pile of powder that looked as if it had been dumped.”

“It looked like hundreds of capsules had been emptied,” Deputy Chavez said later. “We looked at them and found a couple of capsules that had been put back together.”

Swanson and Chavez scraped up some of the powder and rubbed it between their fingers. They picked up and examined a few of the capsules and capsule-parts. The deputies guessed that the capsules might have been emptied by drug dealers who were planning to mix the acetaminophen with cocaine or some other illegal drug. Still, it was odd that some of the capsule-parts had been refilled and “put back together.” The Tylenol 500mg labels on the reassembled capsules were misaligned as a result.

Before the deputies had time to fully consider the possible implications of what they had found, Swanson suddenly became violently ill, with vomiting, a headache, and dizziness - all symptoms of cyanide poisoning, which can occur from inhalation or absorption through the skin. Deputy Chavez also became sick, with a headache and a strange rash and painful swelling on his arm. They made no immediate connection between the Tylenol capsules and the sudden onset of their mysterious illnesses, so they simply left the boxes of Extra Strength Tylenol capsules right where they found them; sitting in the Howard Johnson’s parking lot at the intersection of Route 25 and Interstate 90, about 38 miles northwest of Chicago.

2

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The Tylenol Murders

Twenty-eight hours after the Kane County deputies left the Elgin Howard Johnson’s Motor Lodge and Restaurant; twelve-year-old Mary Kellerman awoke with a sore throat and a cough on Wednesday morning, September 29, 1982. Mary’s father, Dennis, got out of bed and walked down the hall to check on her. He told Mary that she should stay home from school for the day. Then, he went into the bathroom, opened the medicine cabinet, and grabbed a bottle of Extra Strength Tylenol capsules. Mary’s mom, Jeanna, had purchased the Tylenol about 12 hours earlier at the nearby Jewel-Osco store at 948 Grove Mall in Elk Grove Village, 20 miles east of Elgin. Dennis returned to Mary’s bedroom, gave her one Tylenol capsule, and then went back to bed.

A few minutes later, Dennis heard Mary go into the bathroom and close the door. Then he heard something drop. He got out of bed again and walked back down the hall to the bathroom. “Mary, are you okay?” he asked. He got no response, so he asked again: “Mary, are you okay?” Then he opened the door and saw his daughter lying on the bathroom floor.

When the ambulance arrived several minutes later, Mary was in full cardiac arrest. The paramedics tried to revive Mary at her home, but were unsuccessful. They rushed her to Alexian Brothers Medical Center in Elk Grove Village where she was pronounced dead at about 10:00 a.m. from what the doctors could only guess at the time was an aneurism or a heart attack.

In nearby Arlington Heights, 27-year-old Adam Janus had taken the day off from his job at the Elk Grove Village Post Office. Adam had emigrated from Poland in 1970 in search of the American dream. He went back to Poland in 1975 to marry Teresa, and together they then moved into a modest home in Arlington Heights. Adam had learned to speak English and had gotten a good job as a postal carrier in Arlington Heights. After just four years, Adam had been promoted to the position he currently held as a supervisor at the Elk Grove Village Post Office.

Late Wednesday morning, Adam made a quick trip to the Jewel-Osco store at 122 Vail Avenue in Arlington Heights and bought a steak for dinner, some flowers, and a bottle of Extra Strength Tylenol capsules. Adam returned home and had lunch with Teresa. He then took two Extra Strength Tylenol capsules and told Teresa that he wasn’t feeling well. He went into the bedroom to lie down for a while. A few minutes later Teresa went to check on Adam and found him unconscious and convulsing. She called the Arlington Heights Fire Department at about 2 p.m. When the paramedics arrived, Adam was unconscious, his breathing was labored, his blood pressure dangerously low, and his pupils fixed and dilated. Adam was taken to the emergency room at Northwest Community Hospital and pronounced dead at 3:15 p.m. The emergency room doctor suspected that Adam’s death was the result of a massive heart attack.

“Nothing seemed to help,” said Dr. Thomas Kim, the chief of the hospital’s critical care unit. “He suffered sudden death without warning. It was most unusual.”

*****

Mary Magdalene Reiner, age 27, had checked out of the maternity ward at Central DuPage Hospital in Winfield with her newborn son, Joshua, on Tuesday, September 28, 1982. Mary’s friends and family all called her Lynn. Lynn and her husband Ed had two daughters, Dawn and Michelle; a son, Jacob; and now Joshua. On Wednesday afternoon, September 29th, Lynn made a quick trip to Frank’s Finer Foods, a local family-owned grocery store, and bought a bottle of Regular Strength Tylenol capsules. Upon returning home shortly before 3:30 p.m., Lynn went into the living room where her mother-in-law was watching Joshua and her 21-month-old son, Jacob.

Lynn sat down on the living-room couch and went through the bag of free goodies that she had received shortly before checking out of the hospital’s maternity ward the previous day. She put the goodie-bag aside and then took two Extra Strength Tylenol capsules and washed them down with a drink of water. Minutes later, she told her mother-in-law that she felt nauseous. She got up from the couch and walked through the kitchen on her way to the bathroom. Then, suddenly feeling very dizzy, she stopped at the kitchen table and sat down on one of the chairs.

Lynn’s mother-in-law, realizing something was wrong, rushed to her side. Outside, Ed and Michelle, the Reiner’s 8-year-old daughter, had just pulled into the driveway. When they walked into the kitchen, Lynn was sitting at the table; her breathing had now become labored. Lynn’s mother-in-law told Lynn to lower her head between her legs, hoping to encourage the flow of oxygenated blood to her brain. Ed immediately grabbed the telephone. Now frantic, he fumbled with the phone, dropped it, then quickly snatched it back up and dialed the operator. As Ed instructed the operator to send an ambulance, Lynn fell onto the floor and went into convulsions.

Michelle’s most vivid memories of that day are the sounds. She can still hear the thump of her mom hitting the floor, her mom’s labored breathing, and the firm voice of her father commanding her to take the dog and go upstairs. She watched from her bedroom window as her mom was rushed away in an ambulance, sirens blaring. It took just a few minutes for Michelle’s mom to die in front of her eyes, two days for her father to find a way to explain that her mom wasn’t coming back, and almost nine years for Johnson & Johnson to settle the lawsuits filed by the Tylenol victims’ families.

Lynn was clinically dead when she was admitted to Central DuPage Hospital at 5:00 p.m. on Wednesday evening, September 29th. Nevertheless, the doctors hooked her up to a respirator, which they turned off 16 hours later at 9:05 a.m. on Thursday morning. Peter Siekmann, the deputy coroner for DuPage County, said cyanide was found in some of Lynn’s unused Tylenol capsules. She had bought a bottle of Regular Strength Tylenol at Frank’s Finer Foods at around 3:00 p.m. the same day she was poisoned. However, officials said Lynn had apparently put eight Extra Strength Tylenol capsules into her bottle of Regular Strength Tylenol. None of the Regular Strength Tylenol capsules contained cyanide. One of the two Extra Strength Tylenol capsules Lynn had taken contained cyanide, and four of the six remaining Extra Strength Tylenol capsules also contained cyanide.

Shortly after Lynn had been rushed to Central DuPage Hospital, 31-year-old Mary McFarland was at work in Lombard, 10 miles east of Winfield, searching through her purse for a small bottle containing Extra Strength Tylenol capsules. Mary had told her co-workers at the Illinois Bell Phone Center in Yorktown Mall that she’d been fighting a bad headache all day long. The previous day, she had bought a bottle of Extra Strength Tylenol capsules at the Woolworth store in Yorktown Mall. She had dumped 17 capsules from that new 50-count Tylenol bottle into a small Dristan bottle she kept in her purse. By Wednesday afternoon, Mary had consumed five of those Tylenol capsules.

Early Wednesday evening, Mary stepped into the break room at the Bell Phone Center store and took two more Tylenol capsules. A few minutes later, she walked over to a table where some of her co-workers were sitting. “I don’t feel good, guys,” she said, and then she fell forward onto the table. Her coworkers called an ambulance and Mary was taken to Good Samaritan Hospital in Downers Grove, arriving at 7:20 p.m. She was put on life support, but like the other victims, she was already dead within minutes of taking the cyanide-laced Tylenol. The doctors turned the life-support machines off at 3:18 a.m. Thursday. Initially, they suspected that Mary, who left two children, ages one and four, had died from a stroke.

*****

After Adam Janus had been pronounced dead at 3:15 p.m. Wednesday afternoon, his 24-year-old brother, Stanley, and Stanley’s 19-year-old new bride, Theresa, went with Adam’s now widow, Teresa, back to her home in Arlington Heights. Upon arrival, they walked into the kitchen where the bottle of Extra Strength Tylenol was still sitting on the kitchen countertop. They had all been crying, and both Stanley and his wife Theresa had developed headaches. Stanley picked up the Tylenol bottle, dumped two of the red and white capsules into his hand and then popped them into his mouth. Theresa picked up the telephone, called her parents, and delivered the sad news of her brother-in-law’s death. After a short conversation, Theresa hung up the phone and then she too opened the bottle of Tylenol, poured out two capsules, and swallowed them.

Stanley then took the Tylenol bottle into the bathroom, where he placed it on a shelf in the medicine cabinet above the sink. Upon returning to the kitchen, Stanley collapsed and went into convulsions.

Stanley’s wife, Theresa, called the Arlington Heights Fire Department at 6 p.m., and for the second time that day, paramedic Chuck Kramer and the Arlington Heights emergency team rushed back to the Janus house. While they worked on Stanley in the kitchen, Theresa, now panic-stricken, called her parents again - this time to tell them that Stanley was being rushed to the hospital. Theresa hung up the phone. Then, as Chuck Kramer watched in horror, she collapsed onto the living room floor. The rescue team attempted to resuscitate the young newlyweds as the ambulance once again sped toward Northwest Community Hospital. Despite their best efforts, the paramedics could do nothing to keep the lives’ of Stanley and Theresa from slipping away, following the exact same pattern they had just witnessed a few hours earlier while trying to revive Adam.

Shortly after Stanley and Theresa were wheeled into the emergency room, Helen Jensen, the Elk Grove Village public health nurse, was sitting down for a late dinner at home. Halfway through her meal, the phone rang. Helen picked up the receiver, and the caller asked her if she could please come to Northwest Community Hospital right away. Something strange is going on she said.

Jensen left her half-eaten dinner, and rushed to the hospital. When she arrived, the emergency staff was involved in an anxious discussion about what could have happened to the Januses. The most plausible theory seemed to be that the deaths were the result of a gas leak somewhere inside the Janus home. Helen looked around the emergency room and saw Adam’s widow standing in the corner. Helen introduced herself and asked Teresa to describe the events that led up to the deaths. Teresa spoke only Polish, so with her brother-in-law acting as a translator, Teresa told Helen every detail she could remember about the incidents. In each case, the Januses had taken Tylenol before they collapsed.

It was against all protocols, but Helen knew that she had to go to the Januses’ house. Her co-workers, concerned that a gas leak or some other toxic substance inside the house might have poisoned the Januses, warned her to stay away. Helen insisted on going anyway. She recruited two police officers to escort her to the Janus home.

It took only a few minutes to drive from the hospital to the Januses’ house. Once inside, Helen and the police officers headed straight for the bathroom medicine cabinet. One of the officers opened the cabinet door. The bottle of Extra Strength Tylenol immediately caught Helen’s eye. She brought the bottle back into the kitchen and then poured the capsules out onto the countertop. Helen and the police officers each counted the capsules, and they all came up with the same number - forty-four. This has got to be it, Helen thought. Six capsules were missing from the 50-count bottle. Three people taking the recommended dose of Tylenol would account for those missing capsules, and those three people were now dead.

Jensen returned to Northwest Community Hospital and told Dr. Kim and the emergency workers that she believed the Tylenol capsules had caused the Januses’ deaths. “They pooh-poohed me,” she said later. They were stuck on the theory that the Januses had probably died as a result of a gas leak.

Dr. Kim then made a phone call to John Sullivan, a poison expert at the Rocky Mountain Poison Center in Colorado. Kim described to him the symptoms presented by the Januses and explained his theory that the deaths were the result of a gas leak. That theory did not sound right to Sullivan. He said the symptoms sounded more like cyanide poisoning than anything else. Dr. Kim immediately ordered blood samples to be taken from the Januses and sent to the lab for testing.

Meanwhile, Philip Cappitelli, an off-duty Arlington Heights fireman, had been monitoring his police radio at home that day. He heard the first ambulance call to the Janus house shortly after lunchtime, but he thought it was nothing out of the ordinary. He was stunned when he heard the second call of the day to the Janus home end with the same tragic outcome. Cappitelli was now also suspicious about the sudden death of Mary Kellerman, which his mother-in-law had told him about that morning.

Cappitelli called his friend, Richard Keyworth, a firefighter and arson investigator for the Elk Grove Village Fire Department. Keyworth had also been monitoring emergency calls that day. Cappitelli mentioned that the paramedic’s report for Mary Kellerman showed that she had taken Tylenol before she died. Both men were struck by the fact that Tylenol had been mentioned in both reports. “This is a wild stab,” Keyworth said. “But maybe it’s the Tylenol.”

Cappitelli next called Chuck Kramer, who had been on both calls to the Janus home. Kramer confirmed that Adam, Stanley, and Theresa had all taken Tylenol right before collapsing. Cappitelli relayed this information to his supervisor who then called the police to report their suspicions. Investigators examining other unexplained deaths in two adjacent suburbs were then alerted to the deaths of Kellerman and the Januses. Both of the bottles of Tylenol found at the Kellerman and Janus homes were taken to Northwest Community Hospital for testing late Wednesday night. Investigators concluded that both bottles contained cyanide.

The sun had not yet risen on Thursday, September 30, 1982, when Michael Schaffer, the chief toxicologist at the Cook County Medical Examiner’s Office, began examining the remaining capsules in the Tylenol bottles recovered from the Janus and Kellerman homes the previous day. Ten of the capsules were slightly swollen and discolored. Instead of the dry white acetaminophen powder that should have been inside the capsules, they contained a moist, off-white, chunky crystalline substance that he quickly identified as cyanide. These capsules contained only a trace amount of Tylenol.

“I could smell the cyanide as soon as I opened the containers,” Schaffer said. He also said that the cyanide would have deteriorated the gelatin shell of the capsule rather quickly.

When cyanide is moist, a chemical reaction called hydrolysis occurs in which molecules of water are split into hydrogen protons and hydroxide anions. A small amount of hydrogen cyanide is then emitted that smells like bitter almonds. Not everyone can smell this odor. The ability to do so is a genetic trait found in about 40 percent of the population. During hydrolysis, polymers like those found in the gelatin-based shells of Tylenol capsules will corrode. The corrosion process is essentially irreversible. The discolored and swollen appearance of ten of the capsules inspected by Schaffer was the result of moisture being transferred from the cyanide to the gelatin-based capsule-shells. The corrosion was not terribly evident though, so the victims did not notice that something looked wrong with their Tylenol capsules.

The toxicology tests for Adam, Stanley, and Theresa Janus came back Thursday morning, confirming that all three had consumed a lethal dose of cyanide. Dr. Kim said the poison had taken effect so quickly that none of them experienced the usual symptoms, such as vomiting, nausea, or dizziness. Later in the morning, the Cook County Medical Examiner confirmed that Mary Kellerman had also died of cyanide poisoning.

Years later, Richard Keyworth reflected on the events of that day. He marveled at the deadly implications of what could have been a much greater tragedy. “This could have gone on for years without someone knowing about it,” said Keyworth. “Without talking to each other, the chances of these deaths being connected were slim to none. Who knows how many could have died.”

Keyworth’s astute conclusion that “this could have gone on for years,” leaves a more troubling question left unanswered. Had this already gone on for years? At the time of the Tylenol murders, autopsies conducted in Cook and DuPage Counties did not check for the presence of cyanide unless specifically requested to do so. This was also the case in most coroners’ offices throughout the country. The local emergency workers uncovered the Tylenol killer’s deadly plot so quickly only because of the sudden deaths of three members of the Janus family on the same day, in the same house, which raised questions immediately.

Theresa Janus’s father, Jan Tarasewicz, recognized the importance of the sacrifice that had befallen the Januses and their friends and families. “Our Theresa is gone,” he said. “Nothing will bring her back. But all is quiet now. Our people were the victims. They seemed to die for somebody else, so other people could be saved.”

Officials have long cited the scarcity of physical evidence and apparent lack of motive as the reasons why they failed to capture the Tylenol killer. But now, new revelations and information not previously disclosed tell a very different story of a crime that should have been solved. To unravel the Tylenol murders mystery today, it is essential to first take a good look at the peculiar investigation that took place in Chicago in 1982 and the somewhat murky history of the company glorified for its handling of the “Tylenol crisis.”

3

________

Who Will Protect America?

Johnson & Johnson acquired McNeil Laboratories in 1959 along with its non-aspirin pain-reliever Tylenol. McNeil had first marketed prescription drugs containing acetaminophen, the active ingredient in Tylenol, in 1953. J&J launched Tylenol as an over-the-counter (OTC) medication in 1960, but continued to market Tylenol primarily to hospitals where it was used extensively. In 1961, J&J moved the McNeil Laboratories headquarters from Philadelphia to a newly constructed facility in Fort Washington, Pennsylvania.

McNeil Laboratories became McNeilab Inc. in 1978, and J&J formed two new operating companies under the McNeilab umbrella – the McNeil Pharmaceutical Company and the McNeil Consumer Products Company. J&J CEO James Burke, and Wayne Nelson, the first chairman of the reorganized McNeil, formed the McNeil Consumer Products Company to sell only non-prescription products that contained acetaminophen. At the time, those products were Tylenol, CoTylenol, Children’s Tylenol products, and Sine-Aid.

In 1982, the McNeil Consumer Products Company manufactured Tylenol at plants in Round Rock, Texas and Fort Washington, Pennsylvania. McNeil distributed Tylenol to wholesalers across the country from three Johnson & Johnson facilities located in Round Rock, TX, Montgomeryville, PA, and Glendale, CA.

Facts about the Tylenol distribution network, especially in Illinois, were conspicuously absent from the publicized accounts of the Tylenol murders investigation. The general public, still today, knows almost nothing about the immense manufacturing and distribution conglomerate that Johnson & Johnson operated in the Chicago area in 1982. Most of the products that Johnson & Johnson was known for then - Band-Aids, Adhesive Tapes, Gauze Pads, Cotton Swabs, Johnson & Johnson’s Baby Shampoo, Baby Powder, and Baby Oil - were all being manufactured in plants located just outside Chicago. The importance of Chicago as a major manufacturing hub for Johnson & Johnson began in 1933 during the depths of the Great Depression. At that time, J&J Chairman, Robert Wood Johnson II, decided that the company needed to open a manufacturing plant in Chicago to help the company ship its products west much faster and more efficiently.

Robert Wood Johnson II was born in New Brunswick, New Jersey in 1893 to Robert Wood Johnson Sr. and Evangeline Johnson. His father’s brothers, James Wood Johnson and Edward Mead Johnson, founded Johnson & Johnson in 1886. Soon after, Robert Wood Sr. joined the company and eventually dominated his brothers. When Robert Wood Johnson Jr. was sixteen, his father died, leaving him an estate of $2 million (about $45 million in 2012 dollars). Johnson was attending Rutgers Prep School at the time, but he dropped out a few months later and started working full-time at Johnson & Johnson. He also dropped “junior” from his name lest it detract from his desired air of social preeminence.

Johnson married Elizabeth Dixon Ross in 1916. They had one child, Robert “Bobby” Wood Johnson III. Robert and Elizabeth divorced in 1930. That same year, Robert married Margaret Shea. In 1943, Margaret was granted a divorce from Johnson on grounds of “extreme cruelty.” Johnson then married Evelyn Vernon Bruff, a brunette nightclub dancer, on August 16, 1943, only three weeks after his second divorce and one day after her first.

Johnson became president of Johnson & Johnson in 1932, and then chairman from 1938 to 1963. He was a dynamic, visionary businessman who was obsessed with power, writes biographer, Barbara Goldsmith. He controlled Johnson & Johnson with an iron hand. Johnson’s weak and self-indulgent brother, Seward, who sexually abused his eldest daughter from the time she was nine until she was fifteen, followed his every command. In 1941, Johnson brought his son Bobby into the company and elevated him to president in 1961. Goldsmith says Johnson then brutally turned on his son, denigrating him and telling him he would amount to nothing. Johnson fired Bobby in 1965. He also pushed Seward out of the company.

When Johnson decided in 1933 to build a new manufacturing plant in Chicago, Johnson & Johnson already had a small sutures manufacturing plant there, and Johnson now enlisted the general manager of that plant to help find a good Midwest location for the new plant. In commenting about the project, Johnson said, “Sites and factories were easy to find, but we were planning for the future, not merely for 1933. We, therefore, continued our search until we found a location that would give us what we needed for many years to come. We discovered it in the Clearing Industrial District, a modern development in the Southwestern part of Chicago.”

The Clearing District was founded in 1907, and got its name because farm goods from the area were “cleared” (delivered) through the Midway airport and the railroad yards. J&J’s new plant was located just one block south of Chicago’s Midway airport at 5540 West 65th Street on the southern boundary of the Clearing District. The plant’s first product line, Modess Sanitary Napkins, was in production just one month after the workers were hired and the plant opened.

By 1982, Johnson & Johnson had more than a dozen facilities in the Clearing District. Johnson & Johnson’s Midwest operation included the Consumer Products Company and the Ethicon Corporation in Bedford Park, Illinois. J&J also had a Consumer Products plant and distribution center in nearby Lemont, and a Johnson & Johnson Baby Products plant in Wilmington, Illinois. At its height, the 11-plant Bedford Park operation produced 492 products and was also a major shipping center for the company. It was the site of many developments in engineering, operations, and quality assurance programs for all of Johnson & Johnson, and it pioneered electronic recordkeeping for the company in the 1960s.

One of J&J’s largest and most profitable plants in Illinois, or anywhere else for that matter, does not normally come to mind when consumers think of Johnson & Johnson today. The plant, long since abandoned, was opened in Illiopolis in 1942 and fit right in with Robert Wood Johnson’s other occupation - the military. During World War I and World War II, the leaders of big corporations went to Washington in large numbers to direct industrial mobilization of resources for the war efforts. They were called “dollar-a-year” men because they drew an annual salary from the government of just one dollar. However, they maintained their profitable corporate connections and continued to receive salaries and bonuses from the companies they ran. Johnson held a Reserve Army commission as a colonel in the Quartermaster Corps during the 1930s, and was made a brigadier general during World War II. He also served as the chairman of the Smaller War Plants Corporation and as a vice chairman of the War Production Board (WPB).

President Franklin D. Roosevelt established the WPB in December 1941 to exercise general direction over the war procurement and production program. The Board’s primary task was converting civilian industry to war production. The president appointed the chairman of the Board, and the Army and Navy Munitions Boards reported to the president through the chairman of the WPB. From 1942 to 1945, the chairman of the WPB was Donald M. Nelson. Nelson’s private sector job was as chairman of the Sears Roebuck Company in Chicago.

In January 1943, Donald Nelson, at the direction of President Roosevelt, brought in big business owner, Robert Wood Johnson II, to run the Smaller War Plants Corporation (SWPC). The SWPC had been established in June 1942 as a division of the WPB to finance and aid smaller American businesses employing fewer than 500 employees. Harry S. Truman, then a U.S. Senator from Missouri, strongly objected to this appointment because he thought big business would have too much control of government contracts under Johnson’s leadership. Truman said he was also concerned about Johnson’s monopolistic business practices.

Johnson & Johnson was still privately held during World War II, with Robert Wood Johnson II and his brother, Seward, owning 84 percent of the company. These men directly benefited from the war production contracts awarded to Johnson & Johnson to supply the military with combat First-Aid kits, wound dressings, tape, paper products, sutures, and other products. As chairman of the SWPC, Johnson awarded government contracts to Johnson & Johnson’s smaller operating companies. As vice chairman of the WPB, Johnson also steered war contracts to Johnson & Johnson’s larger operating companies.

Much of Johnson & Johnson’s wartime revenue came from the products it produced at its factory in Illiopolis, Illinois. That plant was a United States Army ammunition manufacturing plant constructed in 1942 while Robert Wood Johnson II was a colonel in charge of the Army’s New York Ordnance District.

The ordnance plant was located west of Illiopolis in Sangamon County and encompassed 20,000 acres. It began as two plants separated by Illinois Route 36 - the Sangamon plant, operated by Remington Rand, and the Oak Ordnance Plant, operated by Johnson & Johnson. The Oak Ordnance Plant produced 20-, 57-, 75-, and 90-millimeter artillery shells as well as 3-inch (76mm) armor-piercing and high explosive artillery shells. It also produced bomb fuses and the core of firebombs known as “bursters.” When the war ended, Johnson & Johnson and Remington Rand simply abandoned these taxpayer-funded ordnance plants and left them for the government to clean up, once again using taxpayer dollars.

On May 4, 1943, Johnson was promoted to brigadier general; a commission he held for only three months. “General” Robert Wood Johnson relinquished his commission on August 10, 1943, two weeks after divorcing Margaret Shea, and one week before marrying Evelyn Vernon Bruff.

During his time as chairman of the SWPC, Johnson had rubbed some members of Congress and the SWPC the wrong way. A WPB official said Johnson believed that the SWPC had received “less desirable” employees from other agencies, leading Johnson to view his staff as incompetent. Johnson’s departure from the Army was at the request of the U.S. Congress, though Johnson suggested otherwise.

Johnson said he resigned his Army commission because he wanted to become a “champion of civilian economy to a large degree.” In announcing his “resignation” Johnson made public a letter from Donald Nelson to Secretary of War, Henry Stimson. It said that Nelson shared Johnson’s belief that “it would be embarrassing to himself and the Army” if Johnson was required to return to civilian status. Johnson was allowed to keep his title of “General,” thus avoiding the indignation of returning to “civilian status.” Until the day he died, Johnson insisted that his employees address him as “General” Johnson.

Four months after Johnson resigned his commission on the SWPC and WPB, he informed Johnson & Johnson’s board of directors that he had decided to take the company public. On September 24, 1944, Johnson & Johnson began trading on the New York Stock Exchange with an initial stock price of $37.50 per share.

Johnson was tremendously critical of the United States government, calling it inherently incompetent. The solution to the problem of government incompetence, as Johnson saw it, was to put big corporations in charge of government programs.

In an article titled “Dig-Son-Dig,” which appeared in Army Ordnance magazine in January 1947, Johnson urgently called for the appointment of a commission of five civilians to plan for the design and dispersion of new underground manufacturing plants that would be protected from damage in the event of a nuclear war. The recipients of these plants would be Johnson & Johnson and other large corporations. Johnson asked several questions regarding the administration of such a program: “To what extent should the Armed Services contribute to the increased costs of such installations? What new laws are necessary? Where is the authority to be centered?”

Johnson suggested that the government’s role in the building of these underground factories should be to dole out taxpayer money to civilian appointees - all leaders of large corporations - and let them spend that money any way they saw fit. “Let the military help spell out the problem – let them assist and advise,” Johnson urged. “But let industry solve the problem and put the solution into effect.”

“We will not be the audience for a weak sister who couldn’t get a job with industry,” wrote Johnson. “Sure, we feel tough. Well, are we playing with the lives of our people or are we playing mumblety-pegs?”

“Who will protect America if we don’t?” Johnson asked.

In 1982, after the Tylenol poisonings, Johnson & Johnson once again positioned itself as America’s protector. J&J President David Clare, when reflecting on the company’s response to the Tylenol poisonings, said, “We had to act to protect the public, whether [the tampering] was more widespread than it appeared to be, whether it was a condition that could be repeated by other copycats using our product. So first and foremost, we had to protect the public.”

J&J Chairman and Chief Executive Officer, James Burke, claimed to have foreseen a Tylenol problem on the horizon. Johnson & Johnson’s top executives had met for their annual three-day strategic planning review the week after the September 1982 Labor Day weekend. The company had been on a long run of steady earnings growth and 1982 was shaping up to be a banner year. In fact, Burke worried that things were going too well. “I took some kidding at that meeting for worrying about things I don’t have to,” Burke recalled later. “We had been marveling at how lucky we were to be in our industry, to have some very profitable brands doing so well, and I had said, offhand, what if something happens to one of them, like Tylenol?” Curiously, Burke’s premonition of trouble for the Tylenol brand came true just three weeks later.

4

________

The Tylenol Crisis

Dr. Edmund Donoghue, the deputy assistant medical examiner for Cook County, held a press conference at around 8 a.m. (Central time) Thursday morning, September 30, 1982, to report the deaths of the Janus brothers in Arlington Heights and Mary Kellerman in neighboring Elk Grove Village. Donoghue said they had died on Wednesday from cardio-pulmonary collapse after taking Extra Strength Tylenol capsules. He said the investigation had “definitely confirmed the presence of cyanide” in the Tylenol capsules.

Life support machines were still keeping Theresa Janus alive while her family flew in from Poland. She would be declared dead on Friday when the machines were turned off. Officials had not yet linked the deaths of Lynn Reiner and Mary McFarland to cyanide-laced Tylenol. The body of another victim, Paula Prince, would not be discovered until Friday evening.

Just prior to Donoghue’s press conference in Chicago, James Murray had answered his office phone at Johnson & Johnson’s headquarters in New Brunswick, New Jersey. John Ritter, a Chicago Sun-Times reporter, was seeking information about the history and sales volume of Tylenol. Murray, a J&J public relations executive, sensed that something was wrong. Immediately after ending his call with Ritter, Murray dialed McNeil’s Public Relations Director, Elsie Behmer.

“Is this about the terrible thing that happened in Chicago?” Behmer asked.

“No. What happened in Chicago?” Murray replied.

“We heard some people have been poisoned with Tylenol capsules,” said Behmer, “I’m going down to a meeting right now to find out more.”

As soon as Murray put his phone back on the hook, another call came in. It was Ritter again. He had just found out why he had been asked a few minutes earlier to get the background information on Tylenol, and now he wanted a comment from Murray on the Tylenol poisonings.

He didn’t get one.

Murray’s next call went to Arthur Quilty, a J&J Executive Committee member. Quilty had worked his way up through the ranks of Johnson & Johnson’s Personal Products Company, a manufacturer of women’s health-related products, to be company group chairman of Johnson & Johnson Products, Inc., a group of companies that included the McNeil Consumer Products Company. The Personal Products Company was based in Milltown, NJ, but had a major manufacturing facility in Wilmington, Illinois. When the Wilmington plant opened in 1960, it produced just one product - Modess sanitary napkins. J&J shut that plant down in 1992. In fact, most of Johnson & Johnson’s manufacturing plants in Illinois were shut down in the 1990s. J&J moved the operations for many of these plants to Puerto Rico where certain income generated from patented products made there were exempt from federal income tax.

When the call came in from Murray, Quilty’s first reaction was disbelief. “Are you sure this isn’t a hoax?” he asked. It did not take long to be convinced that it wasn’t.

Down the hall from Quilty’s executive office on the fifth floor, which was reserved for the top echelon of the company’s corporate executives, J&J President David Clare was meeting with J&J CEO James Burke. In the vernacular of Johnson & Johnson, it was their regular bimonthly “one-on-one” meeting. Burke and Clare were engaged in a casual conversation regarding the company’s healthcare program when Quilty barged into Burke’s office and told them about the poisonings near Chicago. Burke immediately picked up the phone and called David Collins, whose office was located several floors below.

Earlier that month, Collins had been appointed company group chairman and named to Johnson & Johnson’s twelve-man executive committee. He had also been given the additional job of chairman of the McNeil Consumer Products Company. Wayne Nelson, the previous chairman of McNeil, had just been named chairman of J&J International. Collins’s promotion had been so sudden and recent that the J&J Facilities Management group had not yet moved his office up to the fifth floor.

Collins, who was a former general counsel for Johnson & Johnson, had followed an unusual career path from J&J’s legal department to several top executive positions at J&J operating companies. Of his recent appointment, Collins said, “It was a felicitous appointment for me, or so I thought at the time. Before this promotion, I had responsibility for Mexico where there had been two devaluations in one year; in Central America where there had been a war; and several South American countries experiencing rampant inflation and more devaluations. I was coming from a scenario of problems to McNeil, a company with a great future and what I thought was an opportunity to win a few.”

Collins was on the phone with a J&J subsidiary in Mexico when his secretary interrupted him. She said Burke was on the other line and it was an emergency. Collins told her to relay the message that he would head up to Burke’s office as soon as he finished handling his own emergency. The Mexican government had implemented new monetary controls to try to curb the plunging value of the peso. If Collins could not get supplies fast enough to his Mexican company, it would be out of business by the end of the year. Soon enough, Collins made his way up to Burke’s office where Quilty, Clare, McNeil President Joseph Chiesa, and Burke had already begun to plan their strategy.

Larry Foster, J&J’s vice president of public relations, had taken the day off. He was at home writing a book titled, A Company That Cares, the History of Johnson & Johnson. Foster had been a reporter, bureau chief, and night editor of New Jersey’s largest newspaper, The Newark News, before Robert Wood Johnson II hired him in 1957 to help form Johnson & Johnson’s first public relations department.

Sometime around mid-morning Foster received a call from Murray with news of the Tylenol problem. “That was a bombshell,” Foster said later. Foster made a beeline to New Brunswick, arriving at Johnson & Johnson headquarters forty-five minutes after Murray’s call. He rushed up to Burke’s office and joined the strategy session.

“I never came home for two days,” said Foster. “Slept in the office - what sleep we had.”

“One-word description of my reaction – disbelief,” remarked Foster. “Second description - two words - total disbelief… I think that this best described how many in the company felt that our product could have been used as a murder weapon. I mean, a product that is designed to help you take care of pain would be used as a murder weapon?”

Foster said there were something like 150 or 175 calls the first day, and over a course of the weeks ahead, something like 2,500 reporters covered the story. His staff kept a log of every reporter’s name and the response they were given. Foster sensed very early on that the reporters from the television, print, and radio media thought that Johnson & Johnson was a victim and would, therefore, be cast publicly as a victim.

*****

News of what became known as the “Tylenol crisis” was broadcast nationwide on Thursday evening, September 30, 1982, on all three networks. The Tylenol murders case was the most extensively covered news event since the assassination of John F. Kennedy. Over 100,000 separate articles about the poisonings ran in U.S. newspapers. National and local television news programs broadcast hundreds of hours of coverage. Poison control centers nationwide reported being swamped with calls from worried consumers who had taken Tylenol capsules. One Chicago hospital received 700 calls about Tylenol in one day. Within 15 hours of the first death, investigators had determined that someone had replaced acetaminophen, the active ingredient in Tylenol capsules, with cyanide. “We have a madman out there,” declared Illinois Governor, James Thompson.

Overnight, the market share for Tylenol dropped from 37 percent of the over-the-counter (OTC) analgesic market to just 7 percent. Many public relations experts predicted the end of the Tylenol brand. “I don’t think they can ever sell another product under that name, said Jerry Della Femina, a well-known, outspoken advertising executive. “There may be an advertising person who thinks he can solve this and if they find him, I want to hire him, because then I want him to turn our water cooler into a wine cooler.” The expert consensus was that Tylenol was dead as a brand.

No one predicted that Johnson & Johnson would emerge from the Tylenol crisis with a reputation more highly regarded than before its best selling product was linked to seven murders. But it happened. Public Relations Vice President, Larry Foster, explained that Johnson & Johnson simply turned to their corporate business philosophy, known as “Our Credo,” when deciding how to handle the Tylenol situation. Johnson & Johnson still considers its handling of this crisis to be the finest example of the company’s adherence to the high ethical standards of the Credo.

J&J president David Clare said, “Looking back on the events, crisis planning did not see us through this tragedy nearly as much as the sound business management philosophy that is embodied in our Credo. It was the Credo that prompted the decisions that enabled us to make the right early decisions that eventually led to the comeback phase.”

James Burke agreed. “The guidance of the Credo played the most important role in the company’s decision-making,” he said. “After the crisis was over we realized that no meeting had been called to make the first critical decision. Every one of us knew what we had to do. We had the Credo to guide us.”

“The Tylenol crisis is without a doubt the most exemplary case ever known in the history of crisis communications,” proclaimed public relations expert, Ten Berge. “Any business executive who has ever stumbled into a public relations ambush ought to appreciate the way Johnson & Johnson responded to the Tylenol poisonings. They have effectively demonstrated how major business has to handle a disaster.”

Johnson & Johnson’s handling of the Tylenol crisis has been ingrained into the psyche of American consumers as the gold standard of crisis management and a standard widely accepted as a model of righteous corporate behavior to which all companies should aspire. Even today, companies in the midst of a major crisis are measured against the standard long attributed to Johnson & Johnson. That standard, however, is based on a myth - a cleverly crafted illusion propagated by the media and public relations industries with plenty of help from Johnson & Johnson. Only a few public relations experts view J&J’s actions in a less than favorable light.

Jack O’Dwyer, of the New York City public relations firm, O’Dwyer PR, has been steadfast in his criticism of the mischaracterization by academia, the media, and the PR industry of J&J’s handling of the Tylenol crisis. Johnson & Johnson did not act quickly in initiating the recall, and they were not at all open to the media, says O’Dwyer. He has been especially critical of Johnson & Johnson’s decision to continue selling the fatally flawed capsule version of Tylenol. The capsules presented the greatest risk for tampering because they could be easily opened and the medicine inside replaced with poison.

Counselor Helio Fred Garcia, of the public relations firm, Clark & Weinstock, said the myth about the Tylenol disaster is that the company reacted within 24 hours. Perpetuating this myth, said Garcia, was the 1999 movie The Insider, starring Russell Crowe as a tobacco industry whistleblower and Al Pacino as a journalist covering the story. In one dramatic scene, Crowe says to Pacino, “James Burke, the CEO of Johnson & Johnson...when he found out that some lunatic had put poison in Tylenol bottles, he didn’t argue with the FDA... He didn’t even wait for the FDA to tell him. He just pulled Tylenol off every shelf of every store right across America - Instantly. And then he developed the safety cap... Because, look, as a CEO, sure, he’s gotta be a great businessman, right? But he’s also a man of science. He’s not going to allow his company... to put on the shelf... a product that might hurt people.”

*****

James Burke began his career at Johnson & Johnson in 1953 as a product director of Band-Aids. He had previously worked for three and a half years at Procter & Gamble. Burke was a graduate of the Harvard MBA class of 1949. This 1949 graduating class, celebrated as “the class the dollars fell on,” and known as the “49ers,” is famous for the CEOs it produced and the wealth it amassed. In 1989, the median net worth of the living 575 members of the original all male group of 646 was $2 million. The group included the CEO’s of Bloomingdale’s, Capital Cities/ABC, Xerox, Rohm & Haas, Bristol Myers, General Housewares, and Johnson & Johnson, to name a few.

“HBS [Harvard Business School] had a powerful impact on me,” said Burke. “When I graduated from college, I was concerned about what I should do with my life. I knew I wanted a career in business, but it wasn’t until I was at HBS that I grasped that business could be a force for good in society. We were constantly reminded of the importance of moral values in our decision making. This attention to ethics shaped my entire career.”

According to a friend and classmate at Harvard Business School, Burke probably skipped years of ladder climbing by making friends when he was a young man with Robert Wood Johnson’s son, Bobby Johnson. Bobby died of cancer in 1970; five years after his father fired him.

Burke briefly interrupted his career at Johnson & Johnson after he had been with the company for just one year. Feeling constrained in his job, Burke quit so he could try his hand at entrepreneurship, launching three separate businesses. Burke brought out two new products on his own - one was a pink tablet that exploded into bubbles when dropped into a bathtub. Both products bombed, and all three of Burke’s business ventures failed.

Burke returned to Johnson & Johnson less than a year after leaving the company, and took charge of the New Products division. He was able to lure some of the best marketers away from Procter & Gamble, but success still eluded him. His early years at Johnson & Johnson were a sequence of failures. Burke later described how his boss had taken him to task early in his career, saying, “You’re a bachelor, and you’re bright. I’ll accept that you can bring a lot to the business. I’ll even accept that maybe Bobby Johnson is right about you, that you can someday run this company. But I don’t see that in you. And I don’t see any indication that you want to pay the price to do it. Now, if you do, we’ll take it a step at a time. You have this job for a year, and this door is open. Whenever you want me I’m available.”

Reflecting back on that conversation, Burke admitted, “He really gave it to me, and he was right.”

With a growing list of disappointing new product launches, “General” Robert Wood Johnson II soon summoned Burke into his office. Burke thought he was in trouble for his latest failure - A combination nose drops and spray for children, aptly called “Johnson & Johnson’s Nose Drops and Spray.” The bottle could be opened from the top or bottom. A dropper attached to the top cover could be used to drop the medicine into a child’s nose, and when the bottom cover was removed, the medicine could be sprayed out by squeezing the bottle.

At the scheduled time, Burke entered Johnson’s office, expecting the worst. “I was full of bravado,” said Burke. But he also said, “I thought I was going to get fired.”

Johnson, who was seated behind his desk, tossed out a bottle of Johnson & Johnson’s Nose Drops and Spray. “Are you the man who launched this thing?” asked “General” Johnson. Burke nervously replied that he was. Johnson then stood up and grasped Burke’s hand. “I want to congratulate you,” Johnson said. “Business is about taking risk. Keep doing it. Don’t ever make these mistakes again,” warned Johnson, “but please make many other mistakes. That’s what we’re paying you for.”

Burke moved up in the company, initially focusing on marketing and advertising. In 1961, Johnson & Johnson formed a new division called the Robert Wood Johnson Company. Burke was put in charge of this new division, which handled the marketing of Johnson & Johnson’s baby products and many of its proprietary products, including Tylenol.

Burke began running Tylenol ads on television in the 1960s. In the 1970s, he suggested to senior J&J executives that Tylenol, originally available only from physicians and hospitals, should be sold as a consumer product. At that time, Tylenol was tremendously successful in the hospital setting, but that success had not translated to the OTC market, primarily because the product was more expensive than other OTC analgesics.

In 1975, while Burke was President of Johnson & Johnson, he got his chance to take Tylenol into the mass market with the full backing of Johnson & Johnson’s vast resources. Bristol Myers had just introduced Datril with a series of advertisements promoting that drug as being much less expensive than Tylenol while having the same ingredients. Burke convinced J&J Chairman, Richard Sellars, that they should meet the new competition head-on. Burke then began aggressively marketing Tylenol directly to consumers. A large annual Tylenol advertising budget, which grew to $85 million by 1982, helped the company increase its share of the OTC pain-reliever market from 4% in 1976 to 37% in 1982.

In 1976, Burke was appointed the chief executive officer (CEO) of Johnson & Johnson and chairman of the company’s Board of Directors, positions he held until his retirement in 1989. Six years into Burke’s tenure as CEO, the Tylenol crisis erupted, spawning his legacy as the master of crisis management. Tylenol was bringing in $450 million in annual revenue at the time, and the brand accounted for 15% to 20% of Johnson & Johnson’s profits. No other J&J product generated anywhere near the revenue and profit that Tylenol did. Following Donoghue’s Thursday morning news conference at the Cook County Medical Examiner’s Office in Chicago; J&J executives acted quickly to protect that revenue stream. Within hours of learning about the Tylenol poisonings, James Burke already had his men in place at the scene of the crime.

5

________

All of Burke’s Men

While J&J executives put a crisis management team in place at corporate headquarters in New Jersey on Thursday morning, police cruisers in Arlington Heights and Elk Grove Village roamed the streets with loudspeakers blaring warnings of unexplained deaths possibly attributed to Tylenol. Some Chicago-based grocers had already removed Tylenol products from their shelves. Jewel Companies ordered their stores to pull the products on Thursday morning. Walgreens ordered its stores in the Midwest to remove Tylenol from their shelves at 9:15 a.m. and expanded the order nationwide at 11:15 a.m. Most retailers nationwide stopped selling only the Tylenol from Lot MC2880, which was the lot number on both the Janus and Kellerman Tylenol bottles, the only ones known to contain cyanide at the time.

Initially, Johnson & Johnson did not recall any Tylenol capsules. Instead, the company faxed mailgrams to retailers and wholesalers, assuring them that the problem rested in Chicago and was limited to Extra Strength Tylenol capsules from just one lot. By noon Thursday, J&J had faxed nearly half-a-million of these mailgrams to physicians, hospitals and wholesalers.

Buddy Willis, the owner of a distribution business in Virginia that sold about $35,000 to $40,000 worth of Tylenol products per year received one of the mailgrams from McNeil, stating that only Extra Strength Tylenol capsules in the Chicago area from Lot MC2880 were affected. The mailgram read in part, “We currently have no evidence that any other Extra Strength Tylenol capsule product or any other Tylenol product was similarly contaminated.”

Burke immediately focused his efforts on getting the right men in place at the scene of the crime and at J&J and McNeil headquarters. During the hastily organized meeting held in Burke’s office on Thursday morning, Burke named six senior executives to an Emergency Strategy Group. The team would meet twice daily to make decisions on how the evolving Tylenol situation should be handled. The group included J&J President, David Clare; International Company Group Chairman, Wayne Nelson; Company Group Chairman, Arthur Quilty; Company Group Chairman, David Collins; Corporate Public Relations, Vice President, Lawrence “Larry” Foster; and J&J General Counsel, George Frazza. The group met at 9 a.m. and 5 p.m. every day for close to six weeks. Many times, according to Foster, the morning meeting was still in session when the evening meeting was scheduled to begin.

Burke told David Collins on Thursday morning to take a lawyer, a public relations aide, and a security expert and fly out to McNeil headquarters in Fort Washington to handle the crisis from there. Burke commanded Collins to “Take charge.” Ninety minutes later, the corporate helicopter touched down at McNeil, 60 miles west of J&J’s New Brunswick headquarters. Collins’s first question to McNeil executives was to ask if any cyanide was used on the premises. Once inside the building, Collins made a phone call to attorney Paul Noland, a childhood friend and college roommate from his days at Notre Dame University. Noland was a partner in the law firm of Rooks, Pitts, and Poust, with offices in Chicago and Wheaton, Illinois. Noland had previously handled product liability cases in the Chicago area for Johnson & Johnson.

Collins asked Noland to go down to the Cook County Medical Examiner’s Office, find out as much as he could, and then call him back at McNeil. “I needed my own eyes and ears on the scene,” he said later. Collins also called another attorney pal, Francis “Mike” Heroux, to help him manage the crisis. Heroux, like Noland, was a partner at Rooks, Pitts, and Poust, in the firm’s Wheaton office in DuPage County.

Collins had many longtime friends living right there in the middle of the Tylenol murders crime scene. He had grown up in Oak Park, Illinois, just seven miles east of Jewel’s headquarters in Melrose Park, and nine miles west of Chicago. Oak Park is known for its expansive homes. The largest collection of Frank Lloyd Wright-designed residential properties in the world is in Oak Park. The town is also known for its excellent school system, which includes two public high schools, Oak Park High School and River Forest High School, and one private high school, Fenwick. David Collins, Paul Noland, and Mike Heroux all graduated from Fenwick High School in 1952.

In 2003, Collins was inducted into the Fenwick High School Hall of Fame. When addressing the Fenwick students and alumni attending the induction ceremony, Collins said Fenwick is “a place to build strong friendships that can help you through many situations – and a place to think about the values you will take with you through life.” In the fall of 1982, with the Tylenol brand in big trouble, Collins needed all the help he could get from his many friends still living near Fenwick High School.

After Collins got his lawyers in place in Illinois, he turned his attention to the hectic situation at McNeil headquarters. Thirty-three telephones were set up to handle the incoming calls. McNeil President, Joseph Chiesa, received continuous updates from harried managers as new reports came in of fatalities and other supposed poisonings, the vast majority of which were not actually Tylenol poisonings.

McNeil executives used a felt-tip marker to write down each bit of information on drawing paper attached to a big easel. As the reports accumulated, the sheets were ripped from the easel and pinned on the walls in a large conference room. Soon the walls were covered with dozens of sheets of paper, each containing disparate bits of information with arrows drawn between them: victims, causes of deaths, lot numbers on the poisoned Tylenol bottles, the outlets where they’d been purchased, dates when they’d been manufactured, and the route they’d taken through the distribution system. The data on those sheets of paper were never disclosed to the public, and the secrets they held never left the McNeil conference room.

A two-way video conference link was established between J&J headquarters in New Brunswick and McNeil headquarters in Fort Washington to facilitate face-to-face meetings between the executives at the two sites. Chicago-area sales reps from numerous J&J operating companies were put on alert to make sure that Extra Strength Tylenol capsules had been moved from the shelves to the stockrooms of the local retail stores and pharmacies. Twenty-five public relations employees from other J&J operating companies were recruited to assist the public relations staff of fifteen at J&J headquarters.

Public relations personnel from both McNeil and J&J quickly coordinated a media response to minimize any suspicion that the company was at fault. Larry Foster took care of the media for Johnson & Johnson. J&J Public Relations Director, Robert Kniffin, went to Fort Washington to handle the calls that came in to McNeil headquarters. Robert Andrews, the assistant director of public relations for J&J, was put in charge of handling the media in Chicago.

Andrews, along with security and public relations personnel and 30 toxicologists were immediately dispatched by corporate jet to Chicago to work with the authorities there and to establish their own lab. Upon their arrival at O’Hare International Airport, Andrews and two other J&J executives drove to Elk Grove Village and met for an hour-and-a-half on Thursday afternoon with Elk Grove Village detectives and evidence technicians. On Thursday evening, Andrews told reporters in Chicago that his firm was “collectively shocked.” He said Johnson & Johnson had launched an investigation that morning to track down the capsules from Lot MC2880.

Regarding the possibility that the cyanide had been put into the Tylenol at the manufacturing plant, McNeil Communications Director, Elsie Behmer, proclaimed, “We were clean.” Behmer said some of the bulk Tylenol powder from the recalled MC2880 batch still at the plant had been tested, and it was uncontaminated. She further stated that the company did not work with cyanide, and Tylenol was the only product produced at the plant. Much of that work was done by machine she said, thus lessening the possibility of employee sabotage. Larry Foster also assured reporters that cyanide was not stored at the Tylenol manufacturing plant or used in the production of Tylenol. “Whenever the poisoner is caught,” said Foster, “the problem will remain; how to protect the public against deranged people who might follow his ghastly example.”

On Thursday afternoon, before officials linked the deaths of Mary McFarland or Lynn Reiner to cyanide-laced Tylenol, James Burke decided to recall Tylenol capsules from Lot MC2880, which had been linked that morning to the cyanide-laced Tylenol capsules that had killed Mary Kellerman and the Januses. The recalled lot consisted of 93,000 bottles with 50 Extra Strength Tylenol capsules each, representing 0.85 percent of the 11 million bottles of Tylenol capsules in the company’s distribution channel, either in retail stores or in distribution centers.

Illinois Governor, “Big” Jim Thompson, put Tyrone Fahner in charge of the investigative team, now dubbed the Tylenol task force, which quickly grew to 140 local, state, and federal investigators. Thompson had handed the job of top Illinois lawyer-lawman to Tyrone Fahner in July 1980 when the immensely popular, long-time Attorney General, William J. Scott, was convicted of tax evasion and sentenced to 11 months in prison. Having never run for office, Fahner was a political neophyte when Thompson appointed him Illinois Attorney General. Fahner had been a virtual unknown 26 days ago, even to the residents of his home state. That anonymity had changed instantly when he became the official spokesperson for the task force charged with solving the Tylenol murders.

Fahner was in the midst of a seemingly hopeless campaign to be elected to the Attorney General position he’d been handed about two years earlier. A Chicago Tribune Poll released on October 2, 1982, showed Fahner trailing former Lieutenant Governor, Neil F. Hartigan, by 20 percentage points. After Fahner became the official spokesperson of the Tylenol task force, he was seen on television every day and his standing in the polls steadily improved.

One of Fahner’s first official acts as head of the Tylenol task force was to recommend that Illinois residents gather up all of their Tylenol capsules and flush them down the toilet. Chicago police officers were also advised on Thursday, September 30th, to ask Chicago area residents to destroy all of their Tylenol products. On Thursday night, NBC’s Chicago affiliate, WMAQ-TV, aired a video clip of a Chicago police dispatcher announcing over the police radio that Tylenol products “may be contaminated with cyanide, and should be destroyed.” Fahner’s recommendation that local residents flush their Tylenol capsules down the toilet was the first of his many miscues. Some of the destroyed capsules surely contained cyanide and could have helped investigators track down the Tylenol killer.

Late Thursday morning, the pathologist who conducted the autopsy of Mary McFarland’s body ruled that her skull examination for CVA (Cerebral Vascular Accident, i.e., stroke) was inconclusive. By mid-Thursday afternoon, authorities had come to suspect that the deaths of Mary McFarland and Lynn Reiner might have been caused by cyanide-laced Tylenol. The Winfield police had already recovered the Tylenol capsules from Lynn Reiner’s home late Thursday morning.

The Lombard police called Mary McFarland’s father Thursday afternoon and asked him to check Mary’s belongings for analgesic capsules. When he looked through her purse, he found a small Dristan bottle. The bottle held ten Extra Strength Tylenol capsules - five contained cyanide.

Authorities then also found a bottle of Extra Strength Tylenol capsules marked with the lot number 1910MD in the medicine cabinet at McFarland’s home. Of the remaining 33 Tylenol capsules in that 50-count bottle, one contained cyanide. Police also found an empty Extra Strength Tylenol bottle, bearing lot number MB2738, in the trashcan at McFarland’s house. Police determined that the cyanide-laced Extra Strength Tylenol capsules in Mary’s Dristan bottle had come from the Tylenol bottle marked with lot number 1910MD.

Authorities never disclosed the location where McFarland bought the poisoned Tylenol. However, they did in fact determine that she had purchased it at the Woolworth store in the Yorktown Mall where she worked. Detectives had checked the lot numbers on the bottles of Extra Strength Tylenol capsules in the stores surrounding McFarland’s home and work. The only local store carrying Tylenol from Lot 1910MD was the Woolworth store in Yorktown Mall. A lawsuit filed by the Tylenol victims’ families named Woolworth as a defendant and as the source of McFarland’s bottle of cyanide-laced Extra Strength Tylenol capsules. That lawsuit, as well as McFarland’s coroner’s report, confirmed that she had indeed purchased the poisoned Tylenol at the Woolworth store.

The Tylenol containers recovered from the homes of Reiner and McFarland were turned over and to the Illinois Department of Public Health in Wheaton early Thursday evening. Joerg Pirl, the assistant chief toxicologist for the Illinois Department of Public Health, said on Friday that the cyanide used by the killer was potassium cyanide. Pirl said the particular potassium cyanide from the capsules he tested was a “technical grade,” which is an inexpensive, low purity grade of potassium cyanide typically used in heavy industry, as opposed to the more expensive high purity grade typically used in laboratories. The chemical profile of the cyanide was important, but largely ignored in the developing investigation.

6

________

The Developing Investigation

David Collins had gone to bed one hour before the telephone in his hotel room rang at 3 a.m. on Friday morning, October 1st. The caller informed him that the lot number on Mary McFarland’s Tylenol bottle, 1910MD, indicated that it had come from the McNeil manufacturing plant in Round Rock, Texas. Tylenol from that lot had been manufactured in May 1982 and then distributed to the Chicago area and states west of the Mississippi River. The Tylenol from Lot MC2880, which had been recalled Thursday afternoon, had been manufactured at McNeil’s Fort Washington plant in April 1982 and then distributed to states east of the Mississippi River and to North Dakota, South Dakota, Nebraska, and Eastern Wyoming.

“The fact that the second batch came from Round Rock didn’t say a damn thing to me,” Collins recalled later, “Except that, oh Jesus, now I’ve got two lots to recall instead of one.”

However, J&J did not actually intend to recall Tylenol from lot 1910MD - at least not initially. A McNeil spokesperson told reporters on Friday morning that the company “wouldn’t make a decision on extending the voluntary withdrawal of its product to additional lot numbers until there was more definitive information about the capsules consumed by the DuPage woman [Mary McFarland].” J&J spokesperson, Marshall Malloy, then confirmed that the company was not issuing a recall for the Tylenol batch labeled Lot 1910MD. But later that day, J&J executives changed their minds and announced a recall of all Extra Strength Tylenol capsules from that lot.

Though Collins said he didn’t know until 3 a.m. Friday morning that the Tylenol from Lot 1910MD had been manufactured at the Round Rock plant - he must have known all along where that Tylenol had been manufactured. That information was incorporated into the lot number, as required by the U.S. Code of Federal Regulations, Title 21, Section 201.18, “Drugs; significance of control numbers,” which states:

The lot number on the label of a drug should be capable of yielding the complete manufacturing history of the package. An incorrect lot number may be regarded as causing the article to be misbranded.

The alpha characters in the lot numbers for the Tylenol manufactured in Round Rock came after the numeric characters (i.e. 1910MD), whereas alpha characters for the lots manufactured in Fort Washington came before the numeric characters (i.e. MC2880). However, it was the first numeric digit of each lot code that actually identified the manufacturing plant. The first numeric digit of the lot codes for Tylenol manufactured at Fort Washington was “2”, and for Round Rock it was “1”.

The 3 a.m. phone call to David Collins was obviously not made because someone had suddenly figured out that the Tylenol from Lot 1910MD had been manufactured in Round Rock. Collins likely received that phone call because someone at Johnson & Johnson had uncovered an extremely urgent problem regarding the distribution of Tylenol from Lot 1910MD.

Since the cyanide-laced Tylenol had come from two different lots, manufactured at two separate facilities, officials said they were confident that none of the poisoned Tylenol capsules had been adulterated at either of the McNeil plants. Larry Foster said the fact that the cyanide laced Tylenol came from two sources, but cropped up only in one area “leads us to believe strongly that the problem rests in Chicago.”

J&J’s initial public relations efforts focused on eliminating any suspicion that the tamperings may have occurred at the McNeil manufacturing plants. “Only if company officials were able to disprove the theory of in-plant tampering could they be sure the act of terrorism hadn’t happened on their watch,” explained Foster.

“In the beginning, they thought maybe the product had been poisoned [at the McNeil plant], “when in fact it turned out that because each lot has a [unique] number, the lot numbers in Chicago were traced back to Pennsylvania,” Foster later recalled. “But very soon thereafter, a lot number from Texas showed up, and that told us that this [Tylenol] could not have been poisoned at the factory.”

“Any plotter would have to have dumped huge amounts of the poisonous salt into the production process for it to end up in such a high concentration in capsules on drugstore shelves,” remarked Foster. “It was done outside the factory, and one of the engineers figured out that if it were to be poisoned at the factory, that the way these things were made in huge vats, mixed, and used in huge vats, that it would take a half ton of cyanide to do that and it was totally impractical,” said Foster.

A coordinated effort by multiple employees to poison Tylenol capsules at two separate plants was improbable, giving some support to Burke’s decision not to recall all Tylenol capsules nationwide. Yet the fact that the adulterated Tylenol capsules had been manufactured in two different plants was, according to David Collins, exactly what led J&J to expand the Tylenol recall to include all 171,000 bottles of Extra Strength Tylenol capsules from Lot 1910MD. With this second recall, J&J had now recalled 264,000 bottles of Extra Strength Tylenol capsules, representing 2.4 percent of the 11 million bottles of Tylenol capsules in the distribution system, retail stores, and hospitals.

Marshall Molloy said McNeil supplied Extra Strength Tylenol from plants in both Round Rock and Fort Washington to “100 or so” wholesale distributors in the Chicago area market. But McNeil did not ship Tylenol to those “100 or so” wholesalers directly from the McNeil manufacturing plants. The Tylenol was instead shipped to the wholesalers from one of J&J’s regional distribution centers. In 1982, Johnson & Johnson operated eleven regional distribution centers – a fact that the company’s executives never mentioned publicly. These distribution centers were, however, referenced in a 1983 Harvard Business School case study used still today to teach college students about the dynamics involved in Johnson & Johnson’s decision in September 1982 to centralize its order fulfillment and sales and logistics operations.

In February 1986, J&J spokesperson Robert Kniffin said Tylenol was distributed through three J&J regional distribution centers located in Montgomeryville, Pennsylvania; Round Rock, Texas; and Glendale, California. These same three distribution centers also handled the distribution of Tylenol in 1982 – a fact confirmed by several Department of Defense (DOD) contracts retrieved from the National Archives database. The DOD entered into contracts with McNeil between 1977 and 1983 to buy Tylenol products from the J&J facilities in Round Rock, Glendale, Montgomeryville, and Fort Washington.

The McNeil manufacturing plants in Fort Washington and Round Rock shipped Tylenol to J&J’s Montgomeryville facility for distribution to warehouses located primarily east of the Mississippi River. J&J’s regional distribution centers in Round Rock and Glendale received Tylenol from McNeil’s manufacturing plant in Round Rock for distribution to wholesalers located west of the Mississippi River. J&J’s regional distribution centers shipped the Tylenol to third party distributers. These third party distributors then shipped the Tylenol to secondary distributors and institutional and retail buyers.

Prior to the Tylenol murders, most Americans did not know that Tylenol was a Johnson & Johnson product. James Burke was rightfully concerned that the negative publicity from the Tylenol tamperings might damage Johnson & Johnson’s stellar reputation. He had initially hoped the news media would identify Tylenol only as a McNeil product. That’s why he told David Collins to fly out to McNeil headquarters in Fort Washington to manage the crisis and handle the media from there. However, the Tylenol problem was never just a McNeil problem; it was always primarily a Johnson & Johnson problem. Johnson & Johnson was in charge of the distribution of Tylenol from its regional distribution centers.

When Tyrone Fahner held his press conference on Friday evening, October 1st, it appeared that he did not necessarily agree with the J&J executives and the FDA officials who contended that an anonymous madman had put the cyanide-laced capsules into Tylenol bottles at the Chicago area retail stores. “We’re investigating stereotypes of disgruntled employees… all along the production chain,” Fahner said. He said authorities were seeking lists of all employees of retailers and all people in the distribution chain who could have handled the tainted Tylenol. Investigators had already identified 20 to 30 potential suspects and had begun combing the personnel files of people who might have had access to the Tylenol.

Fahner never revealed publicly that the suspects at the top of his list were members of the victims’ families. Statements by members of the victims’ families, and testimony by local police officers given under oath during a coroner’s inquest, reveal that the relatives who were considered suspects eventually took lie-detector tests after being pressured to do so by authorities. Members of the Tylenol task force focused their investigative efforts on several peculiarities they hoped might connect one of the victims’ relatives to the murders.

The Reiner case stood out because of the six red and white Extra Strength capsules in her bottle of gray and white Regular Strength Tylenol capsules. Mary McFarland’s cyanide-laced Extra Strength Tylenol capsules were found in a Dristan bottle in her purse. This also caught the attention of investigators. Three members of the Janus family had all taken cyanide-laced Extra Strength Tylenol capsules from one 50-count bottle that had contained twelve poisoned capsules. These unique circumstances were viewed by investigators as their best leads for solving the murders.

The New York Times said that Mr. Fahner appeared to switch, for unannounced reasons, between theories favoring a single disturbed individual and another theory suggesting a conspiracy. Fahner said that some of the capsules appeared to have been put together sloppily, whereas others showed no signs that they had been adulterated, suggesting that more than one person was involved in the tamperings. Mostly, though, Fahner went along with the story portraying the killer as a lone random murderer who did not know any of his victims.

“We’re trying to understand what kind of person could do these things,” said Fahner. “It is an act of a random murderer who then placed them [the cyanide-laced Tylenol capsules] in the stores.” Fahner said investigators were trying “to find the madman or madmen responsible for this sick behavior.”

7

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We Will Be Completely Honest

While Fahner was holding his Friday morning press conference in Illinois, J&J executives in New Jersey were cleaning up a bit of a public relations mess. The Associated Press had learned that Johnson & Johnson’s top PR man, Larry Foster, and McNeil’s Public Relations Director, Elsie Behmer, had released erroneous information regarding the use of cyanide at the McNeil plants. Now Johnson & Johnson executives had to call several reporters and make the astonishing admission that contrary to the statements they had made the previous day, cyanide was in fact stored and used at the McNeil manufacturing plants. McNeil used cyanide on a daily basis to test Povidone, the primary binder used in making Tylenol.

Foster had a reputation of being honest, fair, and ethical, according to public relations experts cited in a case study about the Tylenol crisis. These PR experts thus concluded that Foster’s false statement denying McNeil’s use of cyanide in making Tylenol, while embarrassing, was not a purposeful attempt by Foster to cover anything up. Yet, when the Associated Press reporter who first learned about the use of cyanide in making Tylenol called Foster to confirm this fact, Foster asked him to bury the story. The reporter agreed, stating that he would not run the story unless some other news outlet uncovered the same facts.

It wasn’t long before another reporter, this time from The Newark Star Ledger, called Foster to confirm the same information about McNeil’s use of cyanide. Foster also persuaded that reporter to bury the story. It was only after Foster received a call from The New York Times that he finally gave up.

In 2002, during an interview at his alma mater, Pennsylvania State University, Foster recounted his cyanide slip-up in a much more favorable light. When asked if he would have done anything differently during the Tylenol crisis, Foster responded:

There was one, the only one time that I gave some misinformation to the press inadvertently, was when I was asked if there was any [cyanide] on the manufacturing site in Pennsylvania where the product was made. I said no, there was no[ne], because I had asked that question and was told no. However, in a research lab on the same site, different building, there was a small amount of cyanide - and when I realized I had made the mistake I called the New York Times, and they called the AP and told them frankly, that I gave them the wrong information. They accepted that and ran it very low in the story, the next day’s story, about the misinformation. That’s one thing I think I would have done differently.

On the same day the story of J&J’s erroneous statement regarding the use of cyanide was barely mentioned in the news media; newspapers across the country ran the following statement from Larry Foster:

This is a tragic thing [the Tylenol murders]. Our response is simply that we will continue to be completely honest. The quality of the product will survive this. You can’t indict the whole product. The public is intelligent enough not to do that.

Johnson & Johnson’s public relations team already had the news media and the general public on their side when Chicago police detectives were called to the scene of another suspicious death, this time on Chicago’s North Side.

Paula Prince, a 35-year-old flight attendant, had returned to Chicago’s O’Hare International Airport Wednesday evening, September 29th, after a layover out east. On her drive home, she had stopped off at the Walgreens store on the corner of North Wells Street and North Avenue on Chicago’s North Side and bought a bottle of Extra Strength Tylenol capsules. She then made the short drive to her high-rise apartment on LaSalle Avenue. Once inside her seventh floor apartment, Paula got out of her flight attendant uniform and into a soft robe. She called a friend in her hometown of Omaha, Nebraska, and left a message on her answering machine. Then she went into the bathroom, swallowed one Extra Strength Tylenol capsule, opened a bottle of cold cream, and began removing her make-up.

Paula had the following day off, so she wasn’t missed until she failed to show up for work Friday afternoon. Her sister became concerned and drove to her apartment to check on her. With a spare key, she unlocked the door and then entered the apartment where she soon found Paula’s body lying on the bathroom floor. A bottle of Extra Strength Tylenol capsules was sitting on the vanity. One capsule from the 24-count bottle was missing.

Chicago Police were called to Prince’s apartment at about 5:00 p.m. Friday evening. They took possession of the Tylenol bottle and then rummaged around the apartment until they found the receipt showing that Paula had purchased the Tylenol at the nearby Walgreens store. Later, while viewing video footage from a security camera mounted above the automatic teller machine in that Walgreens store, police found a photo of Paula Prince paying for her bottle of Extra Strength Tylenol. The camera had automatically snapped the picture at about 9 p.m. Wednesday night, when someone withdrew cash from the teller machine.

Chicago Police Superintendant, Richard Brzeczek, said one of the remaining twenty-three capsules in Prince’s bottle contained cyanide, but six others were slightly discolored. The moisture from the two cyanide-laced capsules had leached onto six of the surrounding capsules, causing them to corrode slightly. The Tylenol in Prince’s bottle was from Lot 1801MA, and had been manufactured at the McNeil plant in Round Rock, Texas. This Tylenol, like the Tylenol involved in all the other poisonings, had been shipped to a warehouse in Illinois from Johnson & Johnson’s regional distribution center in Montgomeryville, Pennsylvania. Paula Prince was the seventh and final victim authorities linked to the Tylenol murders.

Chicago Mayor Jane Byrne held a news conference late Friday night after learning about the death of Paula. Byrne asked all city residents to turn in their Tylenol to local police stations, along with a note detailing where and when it was purchased. “Don’t take Tylenol,” she warned, “not even tablet or liquid form.”

Byrne’s warning scrolled across the television screens of nearly 8 million Chicago-area viewers over the weekend. The televised announcement apparently had an impact, not only in Chicago, but also in the Chicago suburbs. By late Saturday afternoon, more than 1,500 bottles of Tylenol products had been turned in to Chicago’s northwest suburban police stations.

Cook County Medical Examiner, Dr. Robert Stein, also addressed the press during Mayor Byrne’s Friday night news conference. Stein described the early results of tests being conducted to detect approximately when the adulterated Tylenol capsules had been filled with cyanide. Stein and his staff had opened several Extra Strength Tylenol capsules Thursday morning, dumped out the acetaminophen, and then refilled the capsules with cyanide from the cyanide-filled capsules in the Janus and Kellerman bottles. These “test capsules” showed no signs of corrosion 36 hours after they had been filled with cyanide.

The following day, Stein said tests indicated that the cyanide could have remained in the adulterated capsules “for at least 48 hours” without revealing any “tell-tale” signs of their content. “We’re at 48 hours now,” said Stein. “They [the test capsules] still look normal.”

If these test-capsules did not show signs of corrosion soon, the theory that cyanide would eat through the gelatin-based shells of the Tylenol capsules in just a couple days would be completely debunked. Also discredited, because of the timeframe involved, would be the theory that the tamperings had occurred at the local retail stores. Nevertheless, just prior to Mayor Byrne’s news conference, the FDA had unofficially cleared Johnson & Johnson of any responsibility for the tamperings.

The FDA, via network news broadcasts, informed consumers on Friday night that Johnson & Johnson bore no responsibility for the tamperings. This exoneration seemed premature at the time, because at this point, just two days into the investigation, the FDA could not have conducted even a preliminary investigation of Johnson & Johnson’s Tylenol manufacturing and distribution network. Standard FDA inspections of manufacturing plants take place over a matter of days, often lasting several weeks.

Recently, an FDA inspection of McNeil’s Tylenol manufacturing plant in Fort Washington, conducted in November 2010, required 25 full-day visits from FDA inspectors. In October of that same year, the FDA had conducted a 19-day inspection of McNeil’s Tylenol manufacturing plant in Las Piedras, Puerto Rico. But on October 1, 1982, just two days after the Tylenol murders, the FDA claimed to have already determined that the tamperings could not have happened within Johnson & Johnson’s manufacturing and distribution network. The FDA was astonishingly ill equipped to make any such determination.

In a report to the U.S. Congress on April 26, 1982, the U.S. Government Accountability Office (GAO) stated that the FDA could only estimate that somewhere around 200,000 to 300,000 OTC drug products were on the market. The GAO concluded: “Without information on the number of OTC products marketed, the FDA is unable to evaluate the relative magnitude of any identified problem with an OTC product. The net effect is that FDA is unaware of (1) the number of individual OTC products currently being marketed and (2) whether these products are safe and effective as determined by any type of FDA review.”

Incredibly, up until 1997, the FDA had no statutory authority to inspect records or documents at OTC drug manufacturing plants. The FDA could inspect only those records that were on display at the time of the inspection or voluntarily provided by the manufacturer. Companies like Johnson & Johnson were not inclined to provide this type of information to the FDA. Large manufacturers, said the FDA, were more likely than small ones to provide only limited access or no access at all to current Good Manufacturing Practices (cGMP) related documents.

After an investigation of the FDA’s procedures for monitoring OTC drugs in 1991, the GAO concluded that the FDA might be unable to fully protect public safety and health or validate compliance with the cGMP regulation, and thus, validate an OTC company’s ability to produce a quality product. The GAO determined that the lack of full access to OTC drug manufacturers’ records and files limited the FDA’s ability to evaluate the effectiveness of these manufacturers’ efforts to analyze complaints, remedy problems, and generally produce a safe and effective product. In effect, reported the GAO, the current situation hindered the FDA from fully carrying out its mandate to protect the public health and provide reasonable assurance of the safety and effectiveness of OTC drugs.

The FDA never even had access to the nearly 300 consumer complaints of Tylenol tamperings, mix-ups, and contaminations that Johnson & Johnson had received in the three years prior to the Tylenol murders. The existence of these complaints was not disclosed until 1991 after J&J had been forced to turn them over to the lawyers handling the lawsuits filed by relatives of the Tylenol murders victims.

By clearing Johnson & Johnson so quickly, without conducting an investigation of the McNeil plants, the FDA may have provided a hint as to the location where the tamperings actually occurred. The FDA may have known all along that an inspection of the McNeil plants was unnecessary, because the adulterated Tylenol had not been bottled there. FDA officials cleared the McNeil plants, but they never said the Tylenol had not been poisoned at a repackaging facility or distribution center in Johnson & Johnson’s channel of distribution.

Instead of bringing in FDA officials to inspect the McNeil manufacturing plants; J&J flew in Cook County Toxicologist, Michael Schaffer, on Monday, October 4th, to conduct a half-day “inspection” of McNeil’s 375,000 square-foot Tylenol manufacturing plant in Fort Washington. Schaffer spent just a few hours at the sprawling plant before declaring, “No human hands touched the Tylenol or its ingredients in the automated mixing and packaging process.” Schaffer then added, “I don’t think it’s impossible, but it’s a million to one” that the contamination occurred at the plant.

Schaffer knew next to nothing about the manufacturing process for Tylenol, and he was unqualified to offer a relevant opinion about the location where the tamperings had occurred. He knew nothing about how McNeil handled the raw materials used in making Tylenol, how the Tylenol was shipped, or how it was handled during distribution. He even failed to inquire about where the Tylenol implicated in the poisonings had been stored from the time it was manufactured in the spring of 1982 until it was shipped to Illinois in late August. With tampering at the McNeil plants ruled out, the Tylenol task force turned its attention to the only scenario it had ever really considered, namely, that someone had put cyanide-laced Tylenol capsules into the bottles in the local retail stores.

8

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J&J and the FBI

Company surveys taken before the Tylenol murders showed that less than one percent of consumers knew that Johnson & Johnson owned the company that made Tylenol. Shortly after the poisonings, however, more than 47 percent of those surveyed were aware of that fact.

“One of the things that was bothering me,” said James Burke, “is the extent to which Johnson & Johnson was becoming deeply involved in the affair. The public was learning that Tylenol was a Johnson & Johnson product, and the dilemma was how to protect the name and not incite whoever did this to attack other Johnson & Johnson products.” On the second day of the investigation, Burke had become so concerned about the Tylenol problem that he elevated the management of the crisis to the corporate level and took control of managing the company’s response himself.

According to Larry Foster, the public relations department had complete support from management to immediately make the first important decision that pointed Johnson & Johnson’s public relations program in the right direction. That decision, said Foster, was for the company to cooperate fully with all types of news media.

In reality, only a few J&J employees talked to the press, and only in a tightly controlled environment. They talked to reporters on a one-on-one basis, typically over the telephone. J&J never held a press conference about the Tylenol poisonings or took questions in an open forum about the tampering incident. The public has no way of knowing just how many important questions J&J spokespersons refused to answer. James Burke did make appearances on 60 Minutes and the Donahue Show, but he made those appearances weeks after the murders for the sole purpose of promoting Tylenol in its new tamper-resistant packaging.

Johnson & Johnson established close relations with the Chicago police, the FBI, and the FDA. In this way, according to a public relations executive from Burson-Marsteller, the company could play a role in searching for the person who poisoned the Tylenol capsules and could help prevent further tamperings. The rock-solid relationship that Johnson & Johnson had with the FBI started at the top with FBI Director William Webster, and went all the way down to the FBI agents in Chicago. Johnson & Johnson’s employment of retired FBI agents in its Worldwide Security division enhanced this cozy relationship. J&J further strengthened its ties with the FBI Office in Chicago by hiring Intertel Security Systems, a private detective agency in Norwood, Illinois, to “investigate” the Tylenol tamperings. Many of Intertel’s private investigators were former FBI agents.

J&J routinely hired private investigators when it wanted to remove certain Johnson & Johnson products from the marketplace. J&J hired private investigators and former FBI agents in the 1980s through the 2000s to track down, and remove from the marketplace, a variety of diverted J&J products, including diabetes test strips, toothbrushes, and Procrit (an anti-anemia drug). J&J executives did not hire Intertel to help track down the Tylenol killer, but rather to track down and destroy the Tylenol capsules that had been handled at the warehouse where the tamperings occurred.

The boundary between Johnson & Johnson and the government’s Tylenol task force was non-existent. According to Larry Foster, “Jim Burke spent much of the early days in Washington conferring with Arthur Hull Hayes, the FDA commissioner, and his staff, and with FBI Director William Webster and his staff.”

When Mike Wallace, of 60 Minutes, asked William Webster about J&J’s role in the Tylenol murders investigation, Webster said, “The attitude of top management has been first the interest of the public, then assisting law enforcement, and then their own corporate concerns for the product.”

The FBI had a surprisingly strong presence in the Tylenol murders investigation. Tampering with medicine was only a misdemeanor in 1982, and the murders were not a federal crime; they fell under the jurisdiction of the State of Illinois. Nevertheless, 50 of the 140 investigators on the Tylenol task force were FBI agents.

The Illinois Department of Law Enforcement (IDLE), at the direction of Illinois Attorney General, Tyrone Fahner, was in charge of the Tylenol murders investigation. The Illinois officials who dictated the investigative strategy were all current or former employees of the United States Department of Justice. All had been, currently were, or would become the director of IDLE. They were all Governor “Big” Jim Thompson’s boys.

Thompson had been the U.S. attorney in the Northern District of Illinois from 1970 to 1974. He was the governor of Illinois from 1979 to 1991, and the chairman of the Chicago law firm, Winston & Strawn, from 1991 to 2006. Indeed, Thompson’s experience in handling the Tylenol murders investigation may have been one of the criteria that led to his appointment as a member of the 9/11 Commission.

Governor Thompson had appointed Tyrone Fahner as his attorney general in 1980. Fahner had been an assistant U.S. attorney in the early 1970s under then U.S. Attorney, Jim Thompson. Thompson appointed Fahner as the director of IDLE in 1977, a position he held until 1979.

Thompson appointed Dan Webb as the director of IDLE in 1979. Webb had also been an assistant U.S. attorney under Thompson in the early 1970s. Webb served as the chief of the Special Prosecutions Division at the U.S. Department of Justice from 1970 to 1976. He was the U.S. attorney in the Northern District of Illinois from 1980 to 1985, and he led the Justice Department’s investigation of the Tylenol murders. Webb took over as chairman of Winston & Strawn in 2006 when Jim Thompson retired from that position.

From 1981 to 1984, Jeremy Margolis was an assistant U.S. attorney reporting directly to Dan Webb. In 1984, Governor Thompson appointed Margolis to the newly created position of Illinois inspector general. Thompson then appointed Margolis as the director of IDLE in 1987, a position he held until 1991.

Thomson appointed James Zagel as the director of IDLE in 1980, a position he held until 1987 when he became a judge in the United States District Court for the Northern District of Illinois. Under the direction of Tyrone Fahner, Zagel led the primary investigative force involved in the Tylenol murders investigation.

Fahner, Webb, and Margolis, the outspoken leaders of the Tylenol murders investigation, had absolute, unconditional loyalty to Big Jim. They were also extremely sympathetic to Johnson & Johnson, a corporation that operated more than a dozen plants in the Chicago area and brought thousands of jobs and hundreds-of-millions of dollars into the Illinois economy. The loyalties of Illinois officials became apparent on the second day of the Tylenol murders investigation, when, instead of inspecting the Tylenol capsules in the Chicago marketplace, authorities turned them over to Johnson & Johnson.

IDLE Commander Edward Cisowsk said on Friday, October 1st, that a warehouse in Lemont, 26 miles southwest of Chicago, had been cleared to store all of the Tylenol bottles turned over to police or confiscated from stores in the Chicago area. Fahner said a J&J official had informed his office on Thursday that Johnson & Johnson would pay all costs associated with collecting the Tylenol capsules from stores in Illinois and moving them to the temporary lab. J&J’s staff of 30 toxicologists at that lab had already begun testing Extra Strength Tylenol capsules on Friday, October 1st. The reason J&J was able to begin testing those capsules so quickly was because J&J had set up the temporary lab in one of its own warehouses – the Johnson & Johnson Midwest Distribution Center in Lemont. Johnson & Johnson had thus taken control of the physical evidence from the Tylenol murders crime scene, and was now in a good position to ensure that it would not be held liable for the poisonings in a court of law.

9

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Above the Law

Richard Epstein, a law professor at the University of Chicago and the author of several books on consumer law, explained the legal implications for J&J if the tamperings had occurred in the retail stores, versus the distribution channel. “If the tampering is not linked to the manufacture or distribution of Tylenol,” said Epstein, “McNeil could be free from any liability.” If, however, it turned out that a disgruntled employee altered the capsules at the manufacturing plant or somewhere along the way before the bottles were shipped, Epstein said McNeil “would be in a lot more trouble.”

The public accepted very quickly the theory that the Tylenol killer had put cyanide-laced Tylenol capsules into bottles that were already sitting on the shelves of Chicago area retail stores. This tampering at-the-retail-stores theory was the cornerstone of the “approved theory” for the Tylenol murders. The second and third components of this theory were that the cyanide would have eaten through the gelatin-based capsules within just one to a few days, and that the Tylenol killer was an anonymous madman.

The approved theory benefited Johnson & Johnson in a number of ways. If the tamperings were not linked to the manufacturing plants or the distribution channel, then neither J&J nor its distributors could be held liable for the tamperings or the murders. Officials touted the alleged super-corrosiveness of cyanide as “scientific proof” that the tamperings had occurred after the Tylenol was delivered to local retail stores. The FBI quickly developed a psychological profile of the Tylenol killer as a mentally unstable loner who had poisoned the Tylenol capsules at the retail stores. This illusory character drew attention away from the obvious suspects working within Johnson & Johnson’s channel of distribution.

Illinois Attorney General, Tyrone Fahner, laid out the basic premise of this approved theory. He said the Tylenol was not tampered with until it reached the stores, ruling out the possibility that the capsules were filled with cyanide during either manufacturing or distribution. According to Fahner, the cyanide-spiked capsules probably were placed in the stores on Tuesday, September 28th, apparently on the front of the shelves to ensure that they would sell quickly. Fahner said the Tylenol killer began with one bottle of cyanide-laced Tylenol capsules, and went from store to store replacing a random number of Tylenol capsules in bottles already in the stores, with poisoned capsules.

When Fahner was asked if there was any possibility that the tampering had occurred at the manufacturing plant; he replied, “It is a mathematical and physical impossibility. It could not have been done in the factory.” He said the potassium cyanide was a corrosive that would soon destroy the capsule’s gelatin shell. Officials cited this super-corrosive characteristic of cyanide as proof that the Tylenol capsules had been filled with cyanide and planted in the retail stores the day before the poisonings. But they had no real evidence to support this hypothesis.

Before noon on Thursday, September 30th, Johnson & Johnson already had its legal team in place at its corporate headquarters in New Brunswick, at the McNeil Consumer Products Company in Fort Washington, and at the crime scene just outside Chicago. Johnson & Johnson’s legal maneuvering came to the forefront when Chicago Mayor, Jane Byrne, ordered Chicago police and health officials to remove all Tylenol products from all 2,000 stores throughout the city by 6 p.m. Sunday, October 3rd. That order did not sit well with the J&J executives who had already put a great deal of effort into promoting the message that the tamperings affected only Extra Strength Tylenol capsules.

Just one day earlier, Johnson & Johnson had agreed to cover all costs associated with collecting and moving Tylenol capsules from Chicago area stores to J&J’s distribution center in Lemont. However, upon learning that Mayor Byrne was banning the sale of all Tylenol products - including Regular Strength Tylenol capsules – Johnson & Johnson immediately attached a few strings to that offer.

Attorney Paul Noland, one of Johnson & Johnson’s hired hands in Chicago, responded on Sunday to Mayor Byrne’s order, by amending the company’s previous offer of help. Noland now said that Johnson & Johnson would not pay to collect or inspect any Regular Strength Tylenol capsules. Furthermore, Noland said that all Extra-Strength Tylenol capsules collected in the Chicago area were to be delivered only to J&J’s distribution center in Lemont and inspected only by J&J employees. The FBI and Illinois officials agreed to these conditions, and thus allowed J&J to suppress information and evidence that might have been used to hold the company accountable and liable for damages.

At the time of the Tylenol murders, Johnson & Johnson was already in the midst of a successful campaign to hide information about the sometimes deadly side effects associated with Zomax, a McNeil painkiller that J&J would reluctantly withdraw from the U.S. market in March of 1983. A review of the Zomax case reveals a pattern of suppressing information that was remarkably similar to the tactics Johnson & Johnson used to conceal details about the distribution of Tylenol and about the Tylenol killer’s true modus operandi.

During the 28 months that Zomax was on the market in the United States, J&J received hundreds of reports of life-threatening allergic reactions from the drug. The FDA concluded that Zomax was probably a factor in fourteen deaths.

In February 1982, immediately following a report in the Journal of the American Medical Association of a case of anaphylactic shock in a Zomax user, a directive to play down this report went out to McNeil’s sales force. “This information is being sent to you, so you will be fully prepared to respond to a physician or pharmacist who initiates discussion on the article. You should not bring up the subject,” the memo said.

J&J used protective orders and confidentiality agreements to prevent disclosure of information that the company had given plaintiffs during the numerous lawsuits filed by Zomax victims. A Washington Post article published several years after the recall noted that the documents that were still being kept secret stated that there were “indications during pre-marketing that Zomax might cause a severe allergic reaction...which can lead to seizures and respiratory failure.” The notice about this danger was not included in the labeling until nine months after the drug went on the market. One internal memorandum to the company’s President criticized the company for not acting sooner.

The wife of one person who died from an allergic reaction to Zomax said she’d settled her case without knowing about a meeting in which McNeil’s own medical doctors had “declared their lack of confidence in Zomax’s safety.” According to McNeil Pharmaceutical Associate Medical Director, Dr. James A. Dale, who attended the February 5, 1983 meeting, three of McNeil’s four highest-ranking medical doctors had told McNeil Pharmaceutical President Jack O’Brien that they were so concerned about the safety of Zomax that they themselves would not prescribe it. Even so, McNeil executives still refused to recall the drug, deciding instead just to strengthen the warning on the labeling. While the new warning was being prepared, McNeil learned of three more cases of fatal anaphylactic shock in Zomax users. James Burke himself made the decision to keep the drug on the market anyway.

Robert Gussin, McNeil’s Vice President for Scientific Affairs, dismissed the concerns about Zomax that were expressed by Dr. John Harter, the FDA official in charge of regulating Zomax. In a January 25, 1982 memo to a McNeil colleague, Gussin described Harter as someone who “seems to have a different cause célèbre every week, and we would go out of our minds if we seriously followed up every one.”

On March 3, 1983, several nonfatal anaphylactic reactions were reported by a local television station in Syracuse, NY. The report featured a Syracuse physician’s account of his own life-threatening reaction to Zomax. This was the first bad publicity about Zomax to appear in the lay press. It was now clear that J&J could no longer effectively suppress the growing body of evidence on the dangers of Zomax, so Burke decided to recall the drug from the U.S. market, but only until the labeling could be rewritten. An FDA memo uncovered later stated that the “FDA and the manufacturer, McNeil Pharmaceutical, have been working on a stronger warning for the drug.” J&J continued to sell the drug abroad well into 1984.

The combined effort of J&J and the FDA to get Zomax back on the U.S. market ended abruptly when documents were publicized during Congressional hearings held in 1983 by the Intergovernmental Relations and Human Resources Subcommittee to investigate dangerous drugs approved by the FDA. Subcommittee Chairman, Ted Weiss, dismayed by the cooperative effort between J&J and the FDA to remarket Zomax, lambasted the FDA. “In view of Zomax’s higher risks, FDA had testified during the subcommittee’s hearings in April that it would not permit Zomax to be remarketed unless studies showed that there was a patient population for whom Zomax was better than other drugs in its class. Yet, in August, the FDA asked the advisory committee to decide whether to recommend that drug’s remarketing even though the agency had received no evidence proving the existence of such a patient population. In fact, one FDA official had urged the advisory committee to recommend remarketing without such evidence.”

“In seeking an advisory committee recommendation on the Zomax marketing issue,” wrote Chairman Weiss, “FDA totally disregarded its sworn testimony before the subcommittee.”

James Burke told The Washington Post that he was proud of his company’s handling of the Zomax problem. “I think we did a good job,” he said, “I don’t see how you could do it any faster.”

McNeil’s Associate Medical Director, Dr. James Dale, felt differently. “They were avoidable side effects. . . . I feel guilty. . . . We met and had the opportunity to take action. . . . We could have done something sooner.”

FDA spokesperson, William Grigg, shared none of Dr. Dale’s remorse. Regarding J&J’s handling of the Zomax issue, Grigg said, “This is a company that bends over backwards for safety.”

McNeil’s longtime head of regulatory affairs, Dr. Patrick Seay, disagreed with Grigg. Commenting in an internal memo about the delay in strengthening the warning in Zomax’s package insert, Seay wrote, “We resisted too much and waited too long.” Seay faulted the company for allowing its marketing division to gain “a greater role in the content and changes of the package insert,” an area traditionally left to the medical side.

McNeil used protective orders to bury damaging information that it had been compelled to turn over to plaintiffs’ attorneys in more than 600 Zomax product-liability lawsuits that had been filed. As of October 1988, McNeil had taken only three cases to trial, choosing instead to settle the other cases outside of court without admitting any liability. As part of these settlements, J&J obtained confidentiality agreements that prohibited opposing lawyers and their clients from revealing what they had learned about Zomax.

Larry Foster defended the manner in which J&J executives handled the Zomax situation, stating that they handled both the Tylenol poisoning deaths and the Zomax-related deaths in a similar manner. “As we demonstrated in response to the Tylenol poisonings and again in the way we managed Zomax, our first responsibility under our credo is to our customers,” proclaimed Larry Foster. “Anybody who manages a business for the long term, as we do, knows that putting the customer first is the only way to increase sales.”

Not long after Johnson & Johnson took Zomax off the market, another McNeil painkiller came under fire. In October 1986, the FDA disclosed that J&J scientists had deliberately falsified research test results to win approval for a new arthritis drug. The fake data was detected by FDA officials in reports on Suprol, an analgesic from the same class of drugs as Zomax. A leaked memo from the head of the FDA team that reviewed applications for licenses on arthritis drugs commented on the Suprol application: “I would be remiss if I did not comment on the quality of the data in this (application). It has been plagued from beginning to end with bad data. Some of it was deliberate falsification. Much of it has been the result of poor workmanship.”

In the last two months of 1985, the Institute for Clinical Pharmacology (IPHAR) in West Germany performed two more studies commissioned by Johnson & Johnson’s Swiss subsidiary. These studies showed clear evidence of Suprol’s adverse effect on the kidneys, but J&J did not submit that data to the FDA. On December 24, 1985, knowing nothing about the IPHAR studies, the FDA approved Suprol.

Johnson & Johnson suspended the sale of Suprol on May 16, 1987, after Congress had learned that 270 patients in the U.S. had suffered kidney damage while taking the drug. This suspension came just three days after the European Community had acted to halt sales of Suprol, and four days after Congressman Ted Weiss had scheduled a hearing for later that month to review Suprol’s approval by the FDA. Weis said, “The subcommittee’s 16-month investigation raised serious questions about why the Food and Drug Administration approved Suprol for marketing.”

J&J spokesperson, James Murray, said the decision to suspend sales of Suprol was not made because of the charges of kidney damage, but rather because of lagging sales.

It was standard practice at McNeil, before and after Johnson & Johnson acquired the company in 1959, to cover up dangerous adverse events linked to its drugs. Long before Zomax and Suprol - there was Flexin, a muscle relaxant with deadly side effects that were also kept hidden by McNeil. FDA Commissioner George Larrick testified in 1964 that mistakes by his agency and the withholding of information by Johnson & Johnson subsidiary, McNeil Labs, kept a harmful drug, Flexin, on the market for five years. Larrick said that in 1955, when McNeil Laboratories submitted Flexin as a drug to relieve muscle spasms, the company had a report that one test patient who used the drug had died from hepatitis. This information was not relayed to the FDA, which approved the drug in 1956.

In 1958, while asking the FDA to allow Flexin to be used in the treatment of gout, McNeil Labs stated: “Flexin has produced no irreversible toxic reactions to patients when administered daily for periods of over six months.”

Larrick testified otherwise. “The facts are that at that time the firm had received reports of seven deaths from hepatitis of patients who were also taking Flexin,” said Larrick. “In 1959, the firm then knew of 39 cases of hepatitis in patients taking Flexin, including 11 fatalities, and that 20 of these cases, including 6 deaths, had been directly ascribed to Flexin by the reporting physicians.” Larrick said the FDA reported the withholding of information by McNeil to the Justice Department. Yet the Justice Department took no action against McNeil or Johnson & Johnson.

In subsequent years, Johnson & Johnson did receive a couple of noteworthy slaps on the wrist. One very public embarrassment came after Johnson & Johnson had repeatedly ignored internal warnings by employees of J&J subsidiary, Lifescan, about their blood glucose-monitoring device that gave inaccurate readings. On March 31, 1998, the FBI raided the headquarters of Lifescan. J&J’s CEO at the time, Ralph Larsen, clearly remembers getting the news. “I was at a speaking engagement in Phoenix,” he remembers. “I got a phone call that said, ‘Ralph, you’re not going to believe this, but we just had a raid at our LifeScan headquarters by 30 or 40 armed federal agents. They’ve cordoned off the building and are serving a search warrant.’”

The raid came after two whistleblowers filed a claim with the government alleging that LifeScan was knowingly manufacturing and selling to the general public a faulty blood glucose monitoring system. The monitoring system erred by sometimes giving extremely low readings. It also improperly displayed an “error” message when the user’s blood glucose level was abnormally high, rather than indicating that the level was in fact high. The whistleblowers also said that LifeScan had sought to conceal these problems.

After a three-year investigation, the Justice Department intervened in the case and reached a settlement that required LifeScan to plead guilty to criminal violations and pay $60 million in fines and civil penalties. LifeScan acknowledged that they had introduced an adulterated and misbranded medical device, failed to provide appropriate notifications and information to the FDA, and submitted false and/or misleading reports to the FDA.

“Mistakes were made in the LifeScan situation,” said Larsen. “There were errors in judgment. We did too little, too late.”

Another notable sanction was handed out to Johnson & Johnson in 1995 when U.S. District Judge William Bassler levied a fine of $5 million on J&J subsidiary, Ortho Pharmaceutical, for destroying documents when a regulatory investigation into its marketing of Retin-A intensified. Ortho admitted its executives had ordered workers to shred thousands of documents on how it marketed Retin-A. J&J also paid an additional $2.5 million in legal fees and Ortho Pharmaceutical pleaded guilty to obstruction of justice and corruptly persuading others to destroy the material. Judge Bassler said in his ruling that the company “had absolutely no right to interfere with federal investigations of those activities.” He said the company tried to put itself “above the law.”

10

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The Madman Myth

Illinois Governor Jim Thompson described the Tylenol killer as a “madman.” Thompson complained that the State of Illinois was pouring millions of dollars into the “hunt for the mad Tylenol killer, a killer or killers who is putting a state, indeed a nation, into fear.”

In a similar vein, Health and Human Services Secretary Richard Schweiker said the poisoning of the Tylenol capsules appeared to be the work of “a maniac.”

After the Tylenol murders investigation had gone cold, Illinois officials admitted that they had only referred to the killer as a madman in an effort to draw him out. How exactly that strategy would have drawn out the killer was never explained.

On the one-year anniversary of the Tylenol murders, IDLE Commander Thomas Schumpp dismissed any suggestion that the killer was a madman. “We’ve got a person here who can operate in normal society,” he said. “I think this person used good planning. The person obviously doesn’t want to get caught, probably hasn’t discussed it with anyone.”

Tyrone Fahner said on the one-year anniversary of the murders, “I don’t think it’s some whimpering, simpering fool, but a cold, calculated, deadly person.”

Dr. Robert Reifman, Director of the Cook County Psychiatric Institute, theorized that the killer was a sadistic, well-organized loner. He suggested the killer was of above-average intelligence and predicted that authorities were “going to have a tough time” finding the culprit.

Dr. Daniel Faisal, a psychiatrist at Forest Hospital in Des Plaines, Illinois, said the Tylenol killer probably was not psychotic because his methods were too rational.

The FBI brought in John Douglas to develop a psychological profile of the Tylenol killer. Douglas, according to the biography on his web site, is the legendary head of the FBI Support Unit and a pioneer in developing profiles for some of the most notorious and sadistic criminals of our time, including the “Tylenol poisoner.” At the time of the Tylenol murders, however, Douglas admittedly had no experience in this type of case.

In his book, Mind Hunter, Douglas says, “Despite the fact that this was early in my career and I’d never done a product tampering case before, nor had I ever interviewed a convicted tamperer in prison, it seemed to me that the killer would likely fit the development models we’d observed for other types of cowardly predators.” Douglas said the Tylenol killer had not targeted a specific person or store, and there appeared to be no motive. “The country was witnessing a form of terrorism; someone, somewhere, could contaminate almost anything they bought and they would innocently consume it and die.” Douglas said the Tylenol tampering was, therefore, a crime involving psychological distance.

Douglas said he believed that the killer was a man with a long history of failures in all areas of life who would probably have a record of complaints of injustices against him. He would have gravitated toward positions of authority, but would have had trouble keeping a job and likely had a psychiatric record. He would have had periods of depression and hopelessness explained Douglas, and likely experienced some stressful event around the time when the deaths occurred late in September. He would also be talkative about the news story to anyone who would listen.

Dawn Hobbs, a journalist who covered the criminal justice system in the 1980s, said the profile constructed of a Tylenol terrorist was criticized by some as being too general to be of any assistance in the investigation. In a criminal case that lacks evidence and involves a random selection of victims, like those in the Tylenol murders, the chances of constructing an accurate profile significantly diminish, said Hobbs. Nonetheless, she said a profile is often an essential tool that can assist investigators, at least to a certain degree, in their search for the perpetrator. On the other hand, said Hobbs, a criminal profile also has the ability to mislead an investigation.

A glaring problem with the approved theory of the Tylenol murders was the implausible assumption that there were only eight bottles of cyanide-laced Tylenol capsules in the Chicago area, and that seven of those bottles were purchased within a 24-hour period. The idea that a madman could plant eight bottles of poisoned Tylenol in eight different stores without being caught was somewhat believable. That such a person could plant hundreds of bottles in dozens of stores was not. This hypothesis would have become less and less plausible with each new bottle of cyanide-laced Tylenol recovered.

Officials from the Tylenol task force admit today that consumers probably destroyed many cyanide-laced Tylenol capsules after being told to do so on September 30th. Several months after the murders, NBC reported that authorities involved in the investigation felt that some contaminated capsules were lost due to the statement by Tyrone Fahner suggesting that people flush their Tylenol down the toilet.

FBI Special Agent, Thomas Biebel, a member of the Tylenol task force, said, “We don’t know how many other stores were involved. Probably a lot of people flushed [poisoned] Tylenol down the toilet.”

A survey conducted on October 8, 1982 by Audits and Surveys Inc., found that 60 percent of Chicago area residents had in fact destroyed or discarded their Tylenol capsules during that first week after the poisonings. The Survey’s authors noted that “probably more Tylenol had gone down the toilet than did Tidy Bowl cleaner.”

Authorities intrinsically understood that there must have been many more than eight bottles of cyanide-laced Tylenol capsules in Chicago area stores, but they never followed through on the simple logic that should have led them to conclude that the “approved theory” was thus invalid. A simple statistical analysis of the evidence would have told investigators very quickly that the “madman” who supposedly planted bottles of cyanide-laced Extra Strength Tylenol capsules in Chicago area stores did not exist at all.

*****

Of the seven Tylenol murder victims, Mary McFarland was the outlier. She was the only one who did not die from the very first dose she took from a bottle of cyanide-laced Tylenol capsules. McFarland had purchased her 50-count bottle of Extra Strength Tylenol probably on Tuesday, September 28, 1982. None of the first five Tylenol capsules she took contained cyanide. When she took the sixth and seventh capsules in one dose on Wednesday evening, the odds caught up with her. One of those capsules contained cyanide.

There were seven cyanide-laced Tylenol capsules in McFarland’s 50-count bottle of Extra Strength Tylenol capsules. The calculations to determine the probability that any one of the first seven doses taken from McFarland’s Tylenol bottle would include a cyanide-filled capsule are shown below:

1st dosage (1 capsule) = 7 / 50 = 14%

2nd dosage (2 capsules) = (7/49) + (7/48) = 14.3% + 14.6% = 29%

3rd dosage (2 capsules) = (7/47) + (7/46) = 14.9% + 15.2% = 30.1%

4th dosage (2 capsules) = (7/45) + (7/44) = 15.6% + 15.9% = 31.5%

The probability that one or more of the first seven capsules taken from McFarland’s 50-count bottle would contain poison was 68 percent; calculated as follows:

43/50 x 43/49 x 43/48 x 43/47 x 43/46 x 43/45 x 43/44 = 86% x 86% x 85% x 85% x 85% x 85% x 84% = 32%;     100% - 32% = 68%

There must have been others like McFarland who also consumed Tylenol capsules from a bottle containing cyanide-laced capsules, but who took only the non-poisoned capsules and then heard the alerts and took no more. There also must have been people who bought bottles of poisoned Tylenol, but never even opened their bottles.

The first five Tylenol capsules that McFarland took from her Tylenol bottle did not contain cyanide. That was a reasonable outcome since the probability that one of those first five capsules would contain cyanide was about 54 percent (86% x 86% x 85% x 85% x 85% = 45.95%; 100% - 45.95% = 54.05%)

Conversely, it was extremely improbable that the very first dose taken from each of the other Tylenol victims’ four bottles would all contain cyanide - but they all did. This was a nearly impossible outcome – unless there were many more bottles of cyanide-laced Tylenol in the Chicago area that the public never knew about.

Mary Kellerman and Paula Prince had each taken just one Tylenol capsule from their brand new bottles of Tylenol, whereas Lynn Reiner and Adam Janus each took two capsules. The probability that the first dose consumed by these four victims would contain a cyanide-laced capsule can be determined from the available data, which includes the number of cyanide-laced capsules in each bottle, the total number of capsules in each bottle, and the number of capsules consumed by each victim. The probability that the very first dose taken from those four bottles would all contain cyanide is just 1 in 1,828, or 0.0547 percent, and is calculated from the following data:

Kellerman: 5 poisoned capsules in her 50-count bottle

Probability that the first dose (1 capsule) taken would contain cyanide = 10%:

(50 / 5) = 10%

Janus: 9 poisoned capsules in Janus’s 50-count bottle (6 cyanide-laced capsules were found in Janus’s bottle. Adam, Stanley, and Theresa Janus each swallowed 2 capsules. Medical examiners determined that each had swallowed one cyanide-laced capsule, so the bottle initially contained 9 cyanide-laced capsules).

Probability that the first dose (2 capsules) taken would contain cyanide = 36%:

(9 / 50) + (9 / 49) = 36%

Reiner: 5 poisoned capsules in her 50-count bottle

Probability that the first dose (2 capsules) taken would contain cyanide = 19%:

(5 / 50) + (5 / 49) = 19%

Prince: 2 poisoned capsules in her 24-count bottle

Probability that the first dose (1 capsule) taken would contain cyanide = 8%:

(2 / 24) = 8%

The Probability that the first dose taken from all four of the Kellerman, Janus, Reiner, and Prince Tylenol bottles would contain a cyanide-laced capsule was 0.0547 percent, or said another way: 1 in 1,828, calculated as follows:

10% x 36% x 19% x 8% = 0.0547% = 1 in 1,828

There was about an 18 percent probability, on average, that the first dose taken from the Kellerman, Janus, Reiner, and Prince bottles would contain cyanide. Using this average probability of 18 percent to calculate the odds that the first dose taken from all of those four bottles would contain cyanide produces a slightly more conservative result of 0.105 percent:

18% x 18% x 18% x 18% = 0.105% = 1 in 952

There was a 99.895 percent to 99.945 percent probability that the first dose taken from all four of the Kellerman, Janus, Reiner, and Prince Tylenol bottles would not all contain cyanide. It is simply not plausible that the first dose taken from all four of those bottles would all contain cyanide, unless there were many other people who consumed Tylenol capsules from many other bottles of cyanide-laced Tylenol, but avoided the poisoned capsules.

If twenty Chicago area residents each purchased one bottle containing cyanide-laced Tylenol capsules, and there was an 18 percent probability that the first dose taken from each of those bottles would contain cyanide, then the probability that the first dose taken from four of those 20 bottles would contain cyanide is about 50 percent, calculated as follows:

Binomial Distribution Calculation: Where the probability that the first dose taken will contain cyanide = 18%; the number of bottles opened and a dose consumed = 20; and the number of successes (i.e., the dose taken contains cyanide) = 4; then the probability that the first dose taken from 4 or more of those 20 bottles would contain cyanide equals 49.7 percent.

A reasonably conservative estimate is that about twenty Chicago area residents each bought a bottle of cyanide-laced Tylenol and then took the first dose from those bottles during the 24-hour period when the victims’ cyanide-laced Tylenol was purchased and the victims died. In addition, there were certainly other people who also bought bottles of cyanide-laced Tylenol capsules but did not consume any capsules from those bottles. If 50 percent of the Chicago area residents who bought bottles of Extra Strength Tylenol capsules during the relevant 24-hour period did not consume any of their capsules, then Chicago area residents must have purchased about 40 bottles of cyanide-laced Tylenol capsules:

20 bottles / 50% = 40 bottles

This estimate of 40 bottles of cyanide-laced Tylenol purchased from Chicago area stores tells only a portion of the story. There were certainly other bottles of cyanide-laced Tylenol capsules that were not purchased. Officials said they recovered just one unsold bottle of cyanide-laced Tylenol from Chicago area stores, but there certainly were many more.

Video footage shown on network news programs in the days following the murders showed between about one and three dozen bottles of Extra Strength Tylenol capsules sitting on the shelves of various Jewel-Osco stores. The front row typically held 4 to 12 bottles. Some Jewel-Osco store managers told NBC News that they were selling one or two bottles of Extra Strength Tylenol capsules per day. Tyrone Fahner suggested that one bottle of poisoned Tylenol had been placed at the front of the display in each of a number of Chicago-area stores. The odds of someone purchasing the one bottle of poisoned Tylenol from such a store were around 1 in 6, or 17 percent. In this scenario, the estimated number of bottles of cyanide-laced Tylenol capsules in the front row of the Tylenol display shelves in Chicago area stores on the day of the Tylenol murders was about 235 bottles, calculated by dividing 40 (the estimated bottles of cyanide-laced Tylenol purchased) by 17 percent:

Bottles of cyanide-laced Tylenol on the shelves of Chicago area stores = 40 / 17% = 235

Could one man really put hundreds of bottles of cyanide-laced Tylenol capsules on the shelves of dozens to a couple hundred Chicago area stores in just one day without being caught?

This implausible hypothesis was not blindly accepted by everyone. Dr. R.J. Cowles, Administrator of the Des Moines County Health Unit, told a reporter for The Hawkeye newspaper in Burlington, Iowa, that because cyanide had been found in capsules manufactured in Tylenol plants in Pennsylvania and Texas, the poison had probably been added at a warehouse or distribution facility in the Chicago area.

Jim Adamson, a spokesperson for the FDA’s regional office in Kansas City, Missouri, said authorities believed that the recalled bottles were tampered with during the distribution process.

In June 1983, Philip Corboy, the attorney who had filed product liability lawsuits against J&J on behalf of Mary Kellerman and Mary McFarland, said, “The media did an excellent job of informing the public that a madman was out there, but I don’t know of any evidence of that. Where along the line it happened is something a jury will decide.” Unfortunately, a jury never got the opportunity to decide that issue.

As of October 8, 1982, Chicago Police Superintendent, Richard Brzeczek, had also not accepted the tampering in the retail stores theory as an established fact. “We’re still in the process of trying to understand the scenario of events as to how the cyanide got into those bottles,” he said. “That’s what you need to do to tie it in with a specific person.”

Cook County Medical Examiner, Dr. Robert Stein, said the Tylenol killer struck him as more of a “rational evildoer.” Stein criticized officials for concentrating their efforts on the tampering in the retail stores scenario, and he rejected the contention that the tamperings occurred after the Tylenol bottles were delivered to the stores. He said the Tylenol capsules could have been poisoned at their distribution point or at the plant where they were produced.

In 1986, Bob Fletcher, a spokesman for the Illinois Department of Law Enforcement, commented on the failure of investigators to understand how the killer got away with the crime without leaving a trail. “Of course, the killer could have been operating on a completely rational plan that we simply don’t perceive yet,” said Fletcher. “It’s enormously frustrating.”

11

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Handling the Evidence

To track down the facility where the tamperings had actually occurred, it was critically important to gather all of the Tylenol capsules from all of the Chicago area outlets. At the very least, authorities needed to confiscate every bottle of Tylenol capsules from Chicago area stores so they could be tested for cyanide. But they actually did the exact opposite of that.

It is a longstanding myth that Johnson & Johnson inspected most or all of the Tylenol capsules that were in Chicago area outlets at the time of the Tylenol murders. This myth is debunked by one of Johnson & Johnson’s own documents.

Thomas N. Gates, the Medical Director for McNeil Consumer Products, wrote a “Dear Doctor letter,” dated October 13, 1982, in which he said J&J, the FDA, and the local authorities had tested two million Tylenol capsules nationwide. Gates wrote:

The Food and Drug Administration, the investigative authorities in the Chicago area, and McNeil Consumer Products Company scientists have collectively examined over 2 million individual capsules collected randomly throughout the country and have found no evidence of cyanide contamination.

The final count of inspected Tylenol capsules was two million; the same amount cited in Gates’ October 13th letter. Of those 2 million inspected capsules, 1.5 million were from outside the Chicago area; 500,000 were from inside the Chicago area. FDA Deputy Commissioner, Mark Novitch, confirmed that the FDA had randomly tested a total of 1.5 million Tylenol capsules nationwide, primarily from outside the Chicago area.

The New York Times reported on October 7, 1982 that Chicago authorities had tested more than 310,000 Tylenol capsules from about 6,200 bottles, and 170,000 tablets from about 3,400 bottles turned in by Chicago area residents. Of the 500,000 capsules tested from the Chicago area, 310,000 were tested by Chicago authorities, meaning 190,000 were tested by Johnson & Johnson. At 50 capsules per bottle, Johnson & Johnson tested just 3,800 bottles of Extra Strength Tylenol capsules out of about 10,000 bottles tested in the Chicago area and about 40,000 bottles tested nationwide.

There were about 165,000 retail outlets nationwide selling Tylenol products in 1982. About 11,000 were in the Chicago area; 2,000 were in the city of Chicago. If each of the 11,000 Chicago-area stores had 20 bottles of Extra Strength Tylenol capsules on hand, then about 220,000 bottles of Extra Strength Tylenol capsules were in Chicago area stores on the day of the murders. J&J tested just 3,800 of those Chicago Tylenol bottles, representing about 1.72 percent of the Extra Strength Tylenol capsules in Chicago area stores on the day of the Tylenol murders. J&J may have actually inspected fewer than 3,800 bottles of Tylenol capsules.

United Press International (UPI) reported on October 22, 1982, that “authorities said workers at J&J’s temporary lab in the company’s Lemont distribution center had examined more than 100,000 Tylenol capsules from the Chicago area, representing about 70 percent of those Tylenol capsules that had been shipped to Lemont.” This UPI report indicated that J&J inspected a total of only about 143,000 capsules from about 2,857 bottles (100,000 / 0.70 = 142,857; 142,857 / 50 = 2,857).

By Saturday afternoon, October 2nd, local residents had turned in about 1,500 bottles of Tylenol to authorities in Chicago’s suburbs and an unspecified number of bottles to authorities in the City of Chicago. They continued to turn in Tylenol capsules for several more days, so it appears that all 2,857 to 3,800 bottles of Extra Strength Tylenol capsules inspected by J&J had been turned in by Chicago area residents, meaning J&J must not have inspected any of the Tylenol capsules from Chicago area stores. The Tylenol capsules from Chicago area hospitals, repackaging facilities, and distribution centers were also not inspected.

The statistical analysis done in the previous chapter further suggests that hundreds of bottles of cyanide-laced Tylenol capsules had been distributed to Chicago area stores. Yet authorities will admit to finding only eight Tylenol bottles containing about 55 cyanide-laced Extra Strength Tylenol capsules.

In J&J’s letter to its shareholders, released in early 1983, James Burke wrote, “It is well to remember that two unused bottles of poisoned Tylenol [the seventh and eighth bottles] were recovered as a result of the withdrawal, so lives may have been saved.” According to officials, those two bottles, which were turned in by Chicago area residents, plus one unsold bottle recovered from an Osco Drug store, were the only bottles of cyanide-laced Tylenol capsules discovered during the inspection process.

J&J executives and government officials went out of their way to ensure that they did not find bottles of cyanide-laced Tylenol capsules. J&J brought in 30 toxicologists to test Tylenol capsules at the company’s temporary lab in Lemont. The testing procedure consisted of dropping a cyanide-detecting strip of litmus paper into each bottle and then checking the litmus paper a few minutes later to see if it had turned blue. If each J&J toxicologist inspected two bottles per minute and worked twelve hours per day, then each could have tested 1,440 bottles per day. At this rate, J&J’s 30 toxicologists working at the Lemont plant could have logically tested 43,220 bottles per day, and 302,400 bottles per week. In the entire inspection period, however, they tested only about 2,857 to 3,800 bottles of Extra Strength Tylenol capsules.

Authorities also could have used the imaging machine produced by Lixi Inc., in Downers Grove, Illinois, to inspect the Tylenol capsules rapidly. The Lixi device, a low-intensity fluoroscope, could detect as little as 20 milligrams of “foreign matter” in a 500-milligram Tylenol capsule without removing the capsules from the bottles or boxes. Joseph E. Pascente, the president of Lixi, later said that his fluoroscope was used by Bristol-Myers in October 1982 to screen for tainted Excedrin after a man in Denver swallowed an Excedrin capsule that had been filled with mercuric chloride. Authorities in Seattle also used this device to inspect bottles of Excedrin and Anacin capsules after tampering incidents in June 1986 involving those products. Pascente offered the Lixi device to Illinois authorities to search out the cyanide-laced Tylenol capsules after the Chicago area poisonings, but he said “nobody listened.”

12

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Selling the Myth

In J&J’s 1982 Annual Report, James Burke commented on the cooperation among officials during the Tylenol crisis. “The public was served well because of the extraordinary cooperation that occurred among all the responsible elements of society,” said Burke. “The regulatory agencies, the wholesale and retail parts of the distribution system; the various medical professionals, the local federal and state law enforcement agencies … all worked together with the media to alert the public to the danger and to protect them in the process.”

The cooperation between J&J, the FBI, and the FDA was, according to Burke, “A demonstration without parallel of government and business working with the news media to help protect the public.”

The victims’ families, however, did not benefit from this cooperative effort. They have never had access to pertinent information or documents related to the Tylenol murders investigation. Johnson & Johnson, on the other hand, had access to anything it wanted. The company’s executives talked daily with officials at the crime scene and at both FBI and FDA headquarters.

“Bob Andrews [assistant director of public relations at J&J] spent maybe three to five weeks at the scene in Chicago, following the story day to day,” said Larry Foster. “He knew the reporters that were covering [the story]. He knew the FBI and the other authorities who were working on the solution, and his information - the feedback - was invaluable,” Foster said.

Johnson & Johnson hired the powerful public relations firm Burson-Marsteller to help shape public perception about its handling of the tampering incident. The firm’s chairman, Harold Burson, later praised Burke’s handling of the Tylenol tamperings, saying, “The real Tylenol hero was Jim Burke.”

Johnson & Johnson’s handling of the Tylenol crisis quickly became the primary case study that experts in the public relations industry now point to as the perfect example of how a widely publicized crisis should be handled. J&J hired public relations firms, lawyers, and advertising agencies from outside the company to help manage the situation and the media. Johnson & Johnson also had a slate of influential Board members, including powerful media executives, who were capable of influencing what was reported in the media as news.

Joan Ganz-Cooney was a member of J&J’s Board of Directors from 1978 to 2001. She was aTrustee for the Educational Broadcasting Corporation, WNET, in New York City. WNET is the flagship station of the Public Broadcasting Service and a primary provider of PBS programming. Ganz-Cooney was also on the Executive Committee of the Children’s Television Workshop from 1968 to 1990. Early in her career, she was a newspaper reporter, a publicist for NBC, and a television consultant for Carnegie Corporation.

Thomas S. Murphy sat on Johnson & Johnson’s Board of Directors from 1980 to 1998. He was the chairman of Capital Cities/ABC from 1966 to 1996. Tom Murphy and Jim Burke were longtime friends. They both received MBAs from the Harvard Business School in 1949, and were even roommates for a time.

Burke had an even closer relationship with Murphy’s long-time business partner, Daniel Burke, the president and future CEO of Capital Cities/ABC. Daniel Burke is the younger brother of James Burke. Daniel had joined Capital Cities in 1961 as the general manager of WTEN-TV in Albany, New York. There he rose to the rank of executive vice president and director in 1967. From 1969 to 1972, he served as the president of the Capital Cities’ publishing division before being named the president and chief operating officer of Capital Cities. He continued in that position when Capital Cities acquired ABC in 1985. In 1990, Daniel took over as Capital Cities CEO. He retired four years later, and Murphy, who had maintained his position as chairman, stepped back into the CEO position. Daniel Burke has been a director at Consolidated Rail Corporation, Darden Restaurants, Inc., Morgan Stanley & Co., Inc., and Rohm and Haas Company.

The Burke family became one of the most powerful families in the media industry. While Daniel was running Capital Cities/ABC, he brought his son, Stephen, into the business. Stephen was the president of ABC Broadcasting when he joined Comcast in 1998. He is currently the president of Comcast, which acquired NBC in 2010. Stephen is a member of the Board of Directors at JP Morgan along with J&J’s current CEO, William Weldon. Daniel’s youngest son, Bill Burke, has worked for Ted Turner, the owner of Turner Broadcasting (TBS) and founder of CNN. Bill was named President of TBS in 1995, a position he retained when Time Warner acquired that company in 1996. Bill left the company shortly before the AOL merger and went on to write Ted Turner’s biography, Call Me Ted. Daniel and James Burke were both directors of The Washington Post Corporation in the 1990s.

Tom Murphy, James Burke, Daniel Burke, and Daniel’s sons - Stephen and Bill - all received MBAs from Harvard Business School. Another notable alumnus of the Harvard Business School was Don S. Perkins, the CEO of Jewel Companies, Inc., from 1970 to 1983. Perkins received an MBA from Harvard Business School in 1971. David Collins, J&J group company chairman and chairman of McNeil Consumer Products, was also a Harvard graduate, having received his J.D. from Harvard Law School in 1959.

In 1982, Daniel Burke and Tom Murphy controlled an impressive array of news outlets, including television stations, magazines, newspapers, radio networks, and radio stations. Capital Cities owned the ABC television stations in Houston, Buffalo, Hartford, New Haven, and Philadelphia. At the time of the Tylenol murders, Capital Cities also owned the Fort Worth Star Telegram, the Kansas City Star, Kansas City Times, and TIME magazine. Murphy said he liked the newspaper business because “In a sense, it’s a monopoly business like broadcasting, and it is advertiser supported.”

Johnson & Johnson, through its powerful connections in the media industry, successfully promoted its version of events regarding the Tylenol tamperings. Johnson & Johnson also had powerful friends at the FDA. The most important of these friends was FDA Commissioner Arthur Hull Hayes, Jr. In the days following the Tylenol murders, Hayes helped J&J executives convince consumers that Johnson & Johnson was just another victim of the Tylenol killer.

Hayes had received an M.D. from Cornell in 1964. He was a captain in the U.S. Army’s Chemical Weapons Division from 1965 to 1967, and then went on to hold several posts at Pennsylvania State University (PSU) – the alma mater of J&J’s Vice President of Public Relations, Larry Foster. At PSU, Hayes was an associate professor of medicine and pharmacology and director of the division of clinical pharmacology from 1972 to 1977, and a professor of medicine and pharmacology from 1977 to 1981.

During his stint in the Army’s Chemical Weapons Division, Hayes was assigned to Edgewood Arsenal at Fort Detrick, Maryland, the Army’s chemical warfare base of operations. Hayes was, according to The Washington Post, “one of a number of doctors who conducted drug tests for the Army on volunteers … to determine the effect of a mind-disorienting drug called CAR-301,060.” According to a declassified 1976 report prepared by the Army Inspector General, Hayes had planned a research study to develop the mind-altering CAR-301,060 as a “crowd control agent.”

Hayes was brought in as the commissioner of the FDA in 1981 at the recommendation of Donald Rumsfeld, who needed an ally to help him gain FDA approval for aspartame, an artificial sweetener developed by Chicago-based, G.D. Searle. Rumsfeld had been named the CEO of G.D. Searle in 1977, a position he held until 1985. Previously, Rumsfeld was the U.S. representative from the 13th district of Illinois from 1962 to 1969. He served in a cabinet position under President Nixon from 1969 to 1975, and then served for two years as secretary of defense under President Gerald Ford.

In the fall of 1980, an FDA advisory board - the Public Board of Inquiry (PBOI) - met to consider Searle’s application for aspartame. The board issued its decision on October 1, 1980, stating: “The evidence suggested aspartame ‘should not be approved for marketing until further animal testing is conducted to resolve the brain tumor issue.’”

Rumsfeld, undaunted by this setback, stood up at a national sales meeting in 1981 and told the Searle representatives that he would “call in his markers” to get aspartame approved. Twenty days later, Ronald Reagan was sworn in as president. Rumsfeld immediately sought payment for the markers he believed Reagan owed him for reneging on his promise to nominate him for vice president, nominating George H.W. Bush instead. Reagan named Rumsfeld to his transition team that nominated Hayes to the position of FDA Commissioner.

One day after Reagan’s inauguration, Searle re-applied for approval to use aspartame as a food sweetener, submitting ten “new” studies to the FDA. On that very same day, President Reagan appointed Arthur Hayes as the commissioner of the FDA. Reagan knew it would take months to get Hayes into the position; too late for him to overrule the Board of Inquiry, so Reagan wrote an Executive Order making the FDA powerless to do anything about aspartame until Hayes got there. When Hayes took over as the FDA commissioner in April, he appointed a 5-person scientific commission to review the Board of Inquiry’s decision. It soon became clear that the panel would uphold the ban by a 3-2 decision. But Hayes then installed a sixth member on the commission, and the vote became deadlocked. Hayes personally broke that tie, and aspartame was approved in July 1981.

*****

On October 5, 1982, during an emergency meeting of the Joint Committee on Product Security (JCPS) in Washington, D.C., Arthur Hayes and J&J Company Group Chairman, Wayne Nelson, met with other FDA and pharmaceutical industry officials to develop tamper-resistant packaging. JCPS was a joint venture between the FDA and the Proprietary Association, a Washington, D.C.-based lobbying group for the OTC pharmaceutical industry. Almost all OTC manufacturers, including Johnson & Johnson, belonged to the Proprietary Association. Congress later enacted the Anti-Tampering Act based on the tamper-resistant packaging guidelines developed by the JCPS for OTC drugs.

Hayes left the FDA in September of 1983. Two months later he took the post of senior medical consultant for Burson-Marsteller; the public relations firm for G.D. Searle and Johnson & Johnson. Hayes was hired under a ten-year contract that paid him $1,000 for each day he worked. Burson-Marsteller Vice President, Buck Buchwald, stressed that Hayes was not involved in aspartame issues and worked but 10 to 15 days a year. However, a former Burson-Marsteller employee, who requested anonymity, said Hayes was hired precisely because of his decision on aspartame and other issues affecting company clients.

Hayes was later named to top executive and director positions at several pharmaceutical companies. He was the president and CEO of EM Pharmaceuticals from 1986 to 1991. He served on the Board of Directors at Napro Biotherapsutics, Celgene, and QuantRX Biomedical, and he also received lucrative jobs from former Johnson & Johnson Company Group Chairman, Wayne Nelson.

Nelson, a graduate of Northwestern University in Evanston, Illinois, is credited with launching the Tylenol programs that made it the top selling analgesic in the United States. In September 1982, Nelson, then the chairman of McNeil, was named chairman of Johnson & Johnson International.

Nelson founded Nelson Communications in 1987. The company provided professional personal selling services to pharmaceutical companies through dozens of shell companies that offered a wide variety of marketing and advertising programs for promoting the drugs of major pharmaceutical manufacturers to doctors and consumers. Nelson brought Arthur Hayes into his company in July 1991 as the chief operating officer of MediScience Associates, a Nelson Communications subsidiary. Nelson later appointed Hayes as vice chairman and medical director of Nelson Communications.

For the first decade of Nelson Communications’ existence, its revenue came primarily from Johnson & Johnson. The company’s reliance on J&J gradually decreased as it gained business from other pharmaceutical manufacturers. Nevertheless, in 1996, nine years after the company was founded, J&J still accounted for 39 percent of Nelson Communications’ annual revenue of $86 million.

The connection between Johnson & Johnson and Arthur Hayes actually goes back to 1966 when Hayes was a captain in the United States Army. In addition to his role in overseeing the testing of mind-altering drugs for the CIA, Hayes was working on at least one experiment being conducted by Dr. Albert Kligman on behalf of the Army and Johnson & Johnson.

Since 1962, Dr. Kligman had been paid by the Army, Dow Chemical, and Johnson & Johnson to conduct experiments on inmates at Holmesburg Prison in Philadelphia. One of these experiments was a study on “the effects of poisonous vapors on the skin,” in which researchers dropped nitrogen mustard on “a limited area of [the inmates’] skin.” Nitrogen mustards are cytotoxic, and powerful and persistent blister agents. In principle, these compounds can also be deployed as chemical warfare agents. “This is a program for national defense,” Kligman proclaimed at the time, “…for once such vapors get through the skin they can destroy the nerve system and the central function of the brain.”

From 1964 to 1967, the University of Pennsylvania and the Ivy Research Lab Inc., which Kligman owned, received $326,840 ($2.25 million in 2012 dollars) from the U.S. Army, and an unknown amount of money from Johnson & Johnson to test the effects of nitrogen mustard on the skin. The tests were carried out on twenty Holmesburg Prison inmates who were issued up to $20 per week in commissary credit for their participation as research subjects. The Army’s contract project officer overseeing this experiment was none other than Captain Arthur Hull Hayes Jr.

Out of Kligman’s experiments at Holmesburg Prison, came Retin-A - a drug that would generate billions of dollars in revenue for Johnson & Johnson.

Hayes was sharply criticized for taking handouts from companies in the pharmaceutical industry while he was at the helm of the FDA. In May 1983, Jack Anderson, a Pulitzer Prize winning journalist and syndicated newspaper columnist, described the affinity Hayes had for accepting gifts from the companies he was supposed to regulate. “The slight, bespectacled Dr. Hayes, on his frequent travels around the country to speak to industry groups, had been mighty relaxed about accepting free plane trips and hotel accommodations from companies doing business with the FDA,” wrote Anderson.

When investigators for the Inspector General informed Hayes that he had violated ethics guidelines, “Dr. Hayes said that he is now being told that he violated rules he did not know existed.” One report stated, “He [Hayes] does not recall ever being briefed concerning the standards of conduct.” Yet in 1981, reported Anderson, Hayes told Congress of the need for these very standards, saying, the “FDA has made a major effort on a continuing basis to ensure that all employees are properly notified of the standards of conduct expected of them. We provide every new employee with an orientation to conflict-of-interest rules.” Though Hayes was never charged criminally for taking money from the industry he was supposed to regulate, the investigation into those payments did cause Hayes to resign under a cloud of impropriety.

13

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Rack Jobbers

No one from the Tylenol task force ever talked about the middlemen that actually distributed Tylenol to the Chicago area stores and pharmacies. Tom Dulan, of the Daily News Record in Harrisonburg, Virginia, did, however, dig up some information about the distribution of Tylenol that did not match the distribution model described by J&J and the FDA.

The Daily News Record reported on Saturday, October 2, 1982 that several bottles of Tylenol from a batch implicated in the Tylenol poisonings had been sold at an IGA supermarket in Bridgewater, Virginia. One of the store’s customers had reported Friday that a bottle she purchased on Wednesday, September 29th, bore lot number MC2880, the same lot number that was on the Kellerman and Janus Tylenol bottles. Jim Liptrap, the assistant manager of the Bridgewater IGA store, said another woman had also returned a bottle with that same lot number Thursday night. Liptrap said he then checked the store’s shelves and discovered more bottles from Lot MC2880, though he was not sure how many of the bottles from that suspect lot had been on the shelf and had no way of knowing how many bottles were sold.

“Sav-A-Stop,” a nationally known mass merchandiser, takes care “of the ordering and stocking,” said Liptrap. “We don’t keep an inventory of that,” he explained. Sav-A-Stop’s main warehouse for this area was in Richmond, Virginia, but the company maintained a small “receiving station” in Weyers Cave, near Harrisonburg, Virginia.

Ann Saylor, the manager of the IGA store in Grottoes, Virginia, said representatives from Sav-A-Stop, a “national receiving company” that orders Tylenol products for the store, had told her that none of the stock sent to Grottoes was from the suspect batches. Nevertheless, when employees checked their inventory, she said they found ten bottles with the MC2880 lot number. The suspect Tylenol bottles came from Sav-A-Stop’s warehouse in Salem, Virginia.

On Monday, October 4th, the general manager of Sav-A-Stop’s Salem warehouse, Howard Quoss, spoke to the Daily News Record. Quoss said he “would not have any idea” how many bottles from the lots implicated in the Tylenol poisonings have been supplied to area stores. “Lot numbers are not listed on supply invoices that Sav-A-Stop receives from McNeil,” Quoss said. He then added, “We’re not shipping any more [Tylenol] until this is over.”

Sav-A-Stop had annual sales of $250 million and was one of the nation’s largest “rack jobbers,” supplying some 18,000 health and beauty care products to 9,500 supermarkets and convenience stores nationwide. Companies referred to as “rack jobbers” rent space in retail stores and supermarkets to display and sell products. The people who actually restock the display-shelves are also called “rack jobbers,” or alternatively, merchandisers. As the job title implies, a rack jobber may bring in his or her own rack to display products. Retailers also allow rack jobbers to use store shelf space if it is available. Some rack jobbers work exclusively with one store or chain, while others do business with many retailers.

IGA, Kroger, and Safeway all contracted with Sav-A-Stop to deliver Tylenol and other healthcare-related products to their stores.  Officials from Kroger said they found 14 bottles from lot number MC2880 in the chain’s Roanoke, Virginia stores. A spokesperson for Safeway said Safeway Stores in North Carolina and central Virginia had sold an unknown number of bottles from Lot MC2880.

The distribution of Tylenol by rack jobbers exposes yet another problem with the “approved theory” of the Tylenol murders. The industry-wide use of rack jobbers to restock stores with OTC drugs like Tylenol certainly did not align with the version of reality espoused by spokespersons from Johnson & Johnson and the FDA. They had claimed that full cases of 72 bottles of Tylenol capsules were shipped unopened directly from the McNeil manufacturing plants to the retailers’ warehouses. According to Newsweek, many experts thought it was unlikely that any tampering occurred along the distribution chain, since the packages of Tylenol were “shrink-wrapped” in plastic in groups of six at the factory, and adulterating individual bottles before they reached retail stores would be readily apparent from the broken wrapping. Newsweek failed to name any of their “experts,” but one must have been FDA Deputy Commissioner, Mark Novitch.

Novitch had said that the Tylenol bottles were wrapped in plastic and put in cartons as they left the factory and remained that way until the retailers received them. “If a retailer had received an open package in which a bottle had been removed and tampered with, it would become immediately obvious,” said Novitch. But that simply wasn’t true. In reality, the cases of Tylenol bottles were typically opened and the plastic-wrap torn off the six-packs of Tylenol bottles before rack jobbers delivered the Tylenol bottles to retail stores.

In 1982, Safeway and Kroger were the two largest supermarket chains in the nation, and IGA represented the largest group of independent supermarkets in the nation. Tylenol was not delivered to these retailers in full un-opened cases. Instead, third-party rack jobbers ordered Tylenol for the retail stores and then restocked the stores’ shelves one bottle at a time. This process was nothing at all like the distribution process Mark Novitch had described.

Rack jobbers came into prominence in the grocery industry in the 1950s with the entry of supermarkets into non-food product-lines. Rack jobbers, principally in the grocery store trade, developed the “health and beauty care” category for a section of a supermarket or discount store that featured non-prescription drugs and a variety of other products, previously sold primarily in pharmacies. Rack jobbers provide retailers the opportunity to earn additional revenue while relieving them of all responsibility for warehousing, reordering, and re-stocking the products. Rack jobbers create the displays, guarantee the sale of all merchandise, and re-stock the displays. In return, the supermarket supplies the space and collects a percentage of the gross sales.

Sav-A-Stop was a privately held company headquartered in Jacksonville, Florida. The company had incorporated shell companies in Illinois and dozens of other states, under the Sav-A-Stop and Scottie Stores banners, so it could do business in those states. The vast majority of the company’s revenue, however, came from its rack jobber operation. Sav-A-Stop had four main distribution centers located in Salem, Virginia; Richmond, Virginia; Jacksonville, Florida; and McKinney, Texas. Sav-A-Stop described itself in a 1966 trademark registration with the U.S. Patent Office as follows:

For: Rack jobbing services – Namely filling and stocking shelves of various retail stores with sundry and drug merchandise manufactured by others, maintaining inventory, accounting and tax records for such stores, and advertising such merchandise displayed and sold from such stocked shelves.

Sav-A-Stop supplied Tylenol to stores throughout the country, including the Chicago area. On July 30, 1982, two months before the Tylenol murders, Sav-A-Stop ran a help-wanted ad in the Daily Herald, seeking a non-food merchandiser for stores located in malls in Chicago’s northwest suburban area:

The nation’s leading non-food merchandiser, Sav-A-Stop, Inc., is in need of permanent part-time help in Woodfield [Mall], Spring Hill Mall, Stratford Square, Hawthorne Center, Northbrook Court, Deerbrook Mall - to merchandise health and beauty aids in major Department Stores. Duties include writing orders, merchandising and maintaining shelves.

The geography covered by driving to these malls encompasses the entire Tylenol murders crime scene. It’s interesting that Sav-A-Stop was hiring rack jobbers to cover stores in Chicago-area malls. One of the many facts that did not fit the madman-in-the-retail–stores theory was that some of the contaminated bottles of Tylenol were found in stores in two different malls. Mary McFarland had purchased her Tylenol at the Woolworth store in Yorktown Mall in Lombard. Two unsold bottles of cyanide-laced Tylenol were recovered from the Osco Drug store in Woodfield Mall, the largest mall in America at the time. If there really had been a madman stalking Chicago area retail stores, it is unlikely that he would have taken the additional risk of planting poisoned Tylenol capsules at stores in high-traffic malls filled with security cameras and staffed with security guards. For a rack jobber, the delivery of Tylenol bottles to stores located in malls was just business as usual.

The person or persons who stocked Chicago area stores with bottles of cyanide-laced Tylenol capsules was likely working for Sav-A-Stop or some other third-party rack jobber company. Now it is clear how so many bottles of cyanide-laced Tylenol capsules turned up in Chicago area stores all at the same time. One or more rack jobbers or merchandisers, working their normal sales route, restocked the stores’ shelves with bottles of Extra Strength Tylenol capsules, some containing cyanide.

Officials mapped out the locations where the victims’ bottles of cyanide-laced Tylenol capsules had been purchased, and surmised that the killer had driven Highways 90/94, 290, and 294, following a near circular route. Investigators further concluded that the killer had probably placed the tampered product on store shelves on Tuesday afternoon, September 28th, suggesting that he had no daytime employment or at least no full-time employment. However, this daytime delivery actually suggested that the bottles containing cyanide-laced Tylenol capsules were delivered to the stores by a gainfully employed rack jobber making his normal deliveries.

The Tylenol task force never acknowledged the existence of the merchandisers and rack jobbers that restocked the shelves of Chicago area stores with bottles of Extra Strength Tylenol capsules.  Maybe this lack of disclosure had something to do with the well-connected chairman of Sav-A-Stop, Inc. - Chicago power broker, Bernard Brennan.

Bernard Brennan, better known today as the former CEO of Chicago-based Montgomery Ward, was the chairman and CEO of Sav-A-Stop in September 1982. Interestingly, Brennan had a special bond with the newly appointed chairman of the McNeil Consumer Products Company, David Collins. Brennan and Collins had both grown up in Oak Park, Illinois. They had even gone to the same private Catholic high school - Fenwick. Collins graduated in 1952, and Brennan graduated in 1956.

Brennan had joined Sears as a management trainee in 1964 after attending the College of St. Thomas in Minnesota. He worked his way up through executive positions at the company’s Chicago headquarters for 12 years before leaving in 1976 to become the chairman of Sav-A-Stop. Brennan described Sav-A-Stop as the ideal training ground for a turn-around artist. By 1982, Brennan had closed Sav-A-Stop’s poorly focused retail stores and nearly tripled its wholesaling business. It was one of the largest distributors of non-food items to supermarkets and convenience stores in the nation.

Bernard Brennan is the brother of Edward Brennan, the former CEO of the Chicago-based Sears Roebuck Company. Edward Brennan was chairman of the Sears Company Retail Group in 1982, and went on to become the CEO of Sears in 1986. Ed Brennan also went to Fenwick High School, graduating in 1951, one year ahead of David Collins.

In 1982, Sav-A-Stop route salespersons were responsible for stocking the health and beauty care departments at Sears’ stores throughout the country. The Brennan brothers, two of the most powerful retail businesspersons in Chicago – in the nation even – were probably not too keen on seeing an investigation conducted into the middlemen like Sav-A-Stop that distributed Tylenol and other health and beauty care products to supermarkets, drugstores, and mass merchandisers like Woolworth, Sears, and Montgomery Ward.

On September 10, 1982, Chicago-based Consolidated Foods, known today as Sara Lee, purchased Sav-A-Stop for $79 million. Shortly after the deal closed, Stephen Pistner, the CEO of Montgomery Ward, hired Brennan as the company’s executive vice president of store operations.

In the category of strange coincidences, the timing of Brennan’s departure from Sav-A-Stop ranks right up there with the fortuitous promotion of Oak Park native, David Collins, to chairman of McNeil Consumer Products less than thirty days before the Tylenol murders. Brennan left Sav-A-Stop, Inc., for Chicago-based Montgomery Ward on Monday, September 27, 1982. On that same day, while Brennan was settling in at his new office in Chicago, one or more rack jobbers were delivering at least some of the bottles of cyanide-laced Tylenol capsules to Chicago area stores. An employee at the Jewel store in Elk Grove Village told NBC-News that the Tylenol display at that store had been restocked with bottles of Extra Strength Tylenol capsules on Monday night, September 27th. Mary Kellerman’s mom purchased a bottle of cyanide-laced Extra Strength Tylenol capsules from that store the following night.

Sav-A-Stop did not own a distribution center in Illinois, so it must have had an arrangement with a local distribution company to receive the products that its rack jobbers delivered to local stores. It was standard practice in the 1980s, just as it is today, for national and regional retail chains to contract with third-party distributors to handle the warehousing and distribution of health and beauty care products.

Spokespersons for J&J and the FDA never succinctly described the true manufacturing, packaging, or distribution process of the Tylenol found poisoned in the Chicago area. They said the Tylenol was packaged at the “factory,” but they never actually said the Tylenol from the poisoned lots had been packaged at the “McNeil factory.” A brief news-clip that slipped into the public domain in 2001 provides a glimpse of what was also going on in with the packaging of Tylenol in 1982.

On June 28, 2001, the FDA’s district office in San Juan, Puerto Rico monitored the destruction of 16 drums of Tylenol 80mg Fruit Chewable Tablets that had been manufactured at McNeil’s plant in Las Piedras, Puerto Rico. The bulk containers of Tylenol had arrived at the San Juan port on April 22, 2000, and stood unclaimed by McNeil for over a year. The U.S. Customs Service, interested in auctioning off the Tylenol, contacted the FDA. An investigation found that the Tylenol tablets had been shipped to Canada to undergo the packaging process, but were returned intact because the repackager was unable to complete the process before the product expiration date. Representatives of the McNeil Consumer Products Company decided to destroy the Tylenol because it had been stored for more than one year under uncontrolled temperature conditions.

In 1982, just as in 2001, not all Tylenol was bottled at McNeil’s manufacturing plants. Some Tylenol was loaded into bulk containers and then shipped to third-party repackagers and contract manufacturers. These repackagers bottled and packaged the Tylenol and then sold it to distributors or distributed it themselves.

J&J said the Tylenol from Lot MC2880, which was in the Janus and Kellerman Tylenol bottles, had been delivered to a Franklin Park warehouse between August 19th and 25th. Larry Foster said the bottles of poisoned Tylenol probably had been shipped directly from Pennsylvania to Jewel’s warehouse in Franklin Park, and then directly to the stores. However, Jane Armstrong, the vice president of consumer relations at Jewel Companies, described a slightly different distribution route.

Armstrong said on October 1, 1982 that Tylenol products for all the Jewel stores came from the company’s central warehouse in Melrose Park – not the Franklin Park warehouse as Foster had suggested. Then, seven days later, Armstrong told a different story. October 8th, Armstrong was asked about the distribution of Tylenol to a Sheridan, Wyoming Buttrey-Osco store – a Jewel subsidiary store suspected of having received cyanide-laced Extra Strength Tylenol capsules months earlier. Armstrong said she was uncertain of how the Buttrey-Osco store in Sheridan received its supplies of Tylenol, but she said the Jewel stores near Chicago took their shipments of Tylenol directly from the manufacturer in Fort Washington, Pennsylvania, the McNeil Consumer Products Company. Armstrong had now indicated that Jewel did not handle the distribution of Tylenol to its own stores. The facts about the distribution of Tylenol were kept hidden, and the evidence that should have allowed investigators to uncover the true source of the cyanide-laced Tylenol capsules had a habit of disappearing.

14

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The Vanishing Evidence

The local Arlington Heights-based newspaper, The Daily Herald, accurately reported that the first poisoned capsules to turn up during the inspection of Tylenol bottles in Chicago-area stores had been discovered on Friday, in at least two unsold bottles of Tylenol confiscated from the shelves of the Osco Drug store in the Woodfield Shopping Center. The New York Times also reported that two unsold bottles of contaminated Tylenol had been recovered from that Osco Drug store. Fahner said these bottles would be “particularly helpful, because they had not been sold and may provide some fingerprints.”

Then, on Friday night, an FDA spokesperson said that seven cyanide-laced Tylenol capsules were found in one of the bottles removed from the Osco Drug store in Schaumburg, and seven more capsules from the same bottle were suspect. He made no mention of the second unsold bottle of cyanide-laced Tylenol.

On Saturday, the story changed a little more. FDA spokesperson William Grigg now said that investigators had found seven cyanide-filled Tylenol capsules in just one of the bottles seized from the Osco Drug store in Schaumburg, making no mention of the seven suspect capsules or the second unsold bottle of poisoned Tylenol. Grigg said the bottle was from Lot MC2880, which was the same lot as the Tylenol in the Kellerman and Janus bottles.

WMAQ-TV, the NBC affiliate in Chicago, reported Friday night that cyanide had been found in Extra Strength Tylenol capsules from four lots: MC2880, MC2884, 1910MD, and 1665LM. On Saturday, lot numbers MC2884 and 1665LM mysteriously disappeared from the danger list of contaminated lot numbers. In addition, what may have been the most important evidence in the case, the boxes of Tylenol capsules from the Howard Johnson’s parking lot, had also disappeared.

Reporters got an opportunity on Monday, October 4th, to question Deputies Al Swanson and Joseph Chavez about the cartons of Extra Strength Tylenol capsules they had found in the Howard Johnson’s parking lot in Elgin 28 ½ hours before the poisonings began. The deputies had heard about the poisonings the day after they occurred and only then realized the importance of those capsules. Officials from the Tylenol task force and the Kane County Sheriff’s Office went out to the Howard Johnson’s on Friday, October 1st, but the cartons of Extra Strength Tylenol capsules were gone.

Sergeant David Burrows, of the Kane County Sheriff’s Office, said most of the capsule-parts still in the parking lot had been run over and crushed in the ensuing two days. He said they did however send 31 capsules Friday morning by registered mail to the State Department of Public Health’s toxicology lab in Chicago. The results from the analysis of those capsules were never disclosed.

FBI agents were seen questioning employees at the Howard Johnson’s Restaurant again on Monday morning, October 4th. The motel bookkeeper said “people working on the case” had asked for and received a list of guests, but she declined to say what time period the list covered and who made the request. The media attention was wearing thin on at least one Howard Johnson’s employee. “I wish you guys would stop bugging me,” a Manager at the restaurant told an Associated Press reporter. “I didn’t see nothing.”

On Monday afternoon, Deputy Sheriff Cole answered reporters’ questions about the boxes that Chavez and Swanson had found in the Howard Johnson’s parking lot. The interview was done over the phone, with Cole relaying the reporters’ questions to Chavez and Swanson, who were on separate telephone lines.

The boxes “said Tylenol on them and one of them was open,” recalled Deputy Chavez. “I picked up the powder,” he said. “It looked like hundreds of capsules had been emptied. We looked at them and found a couple of capsules had been put together.” Since Tylenol was not a controlled substance, the officers did not report the incident. “We just blew it off,” said Chavez. “We just didn’t think anything about it.”

“It was evident they [the capsules] were tampered with,” added Cole. “Some of the capsules were empty. They had no powder in them. The officers assumed there evidently was something going on with drugs,” Cole explained. The deputies had suspected that the Tylenol powder was being used to cut cocaine or some other illegal drug.

Cole said the officers experienced dizziness, nausea, and vomiting minutes after handling the capsules. Swanson became so violently ill that he was relieved from his shift. Chavez had also become sick, but stayed on the clock until the end of the shift. He did not return to work until five days later. Dr. Barry Rumack, of the Rocky Mountain Poison Control Center in Denver said, “The symptoms reported by the officers are consistent with cyanide poisoning.”

“I was stupid,” said Chavez. “I should have picked it [the boxes of Tylenol] up and brought it in,” he said. “I kick myself in the head every time I think of it. Maybe we could have saved these people’s lives, or at least got an investigation started.”

Deputy Chavez, commenting about the capsules and capsule-parts strewn in the parking lot, said, “It looked like hundreds of capsules had been emptied.”

On Friday, October 1st, Tyrone Fahner called the Howard Johnson’s evidence one of the “very substantial leads” in the case. But now, three days later, on Monday night, Fahner changed his tune. Fahner now dismissed the entire incident as insignificant. “That appears to be a total washout,” he told Cable News Network (CNN).

Fahner also changed his tune regarding the symptoms of dizziness, nausea, and vomiting that the deputies had experienced minutes after handling the capsules. On Friday, Fahner had said, “The medical people tell me that if you don’t ingest cyanide, just getting it on your skin or in your system by breathing it could cause the kind of illness these two people [Swanson and Chavez] have experienced.” Now, on Monday night, Fahner said investigators were “reasonably certain” that the severe symptoms experienced by the deputies “were not symptoms of cyanide poisoning.”

But that’s not what the experts believed. Dr. Barry Rumack, of the Rocky Mountain Poison Control Center, said the symptoms reported by the officers were “consistent with a sub-lethal dose of cyanide poisoning.” Fahner’s own spokesperson, Paul Zemitzsch, said cyanide “can go right through the skin.” [The deputies] were sick for several days - nausea, headache, syndromes that can be associated with a very, very mild type of cyanide poisoning.”

It made no sense that Fahner would dismiss the Howard Johnson’s evidence as being irrelevant to the tamperings. Apparently, Fahner was deliberately using the press to get out a story that misstated the true focus of his investigation, thus concealing the fact that the Howard Johnson’s evidence was actually extremely important. Only someone with access to Tylenol in the channel of distribution could have gotten hold of those cases of Extra Strength Tylenol capsules. The easiest way for the Tylenol killer to get the poisoned capsules into local retail stores was to simply bring them back to the warehouse he had taken them from in the first place, knowing that the local delivery drivers would then unknowingly transport them to Chicago area outlets.

J&J executives and FDA officials indicated that the Tylenol capsules were packaged at McNeil and then shipped through a rather simple distribution system directly to the retailers’ warehouses. In reality, Tylenol was distributed through an extremely complex distribution system that investigators apparently did not understand.

In 1983, the FDA conducted an investigation into the distribution of the OTC drug, Maalox, a popular liquid antacid. This investigation provides a more realistic picture of the distribution channel for OTC drugs than the one painted during the Tylenol murders investigation. Shipments of Maalox that were intended to go to a foreign market were diverted in 1983 by “grey market” brokers and then sold to retailers in the United States. The grey market exists because of the multi-tiered wholesale pricing system. Manufacturers sell drugs at substantial discounts to buyers in certain classes of trade, and in foreign markets, under the stipulation that these discounted drugs cannot be sold to U.S. retail class-of-trade buyers. Buyers don’t always adhere to these terms though, because they can make more money by diverting these discounted drugs to the retail class of trade.

The Maalox diversion scheme came to light in January 1984 when a pharmacist at the Dart Drug store in Wheaton, Maryland, noticed something strange about their bottles of Maalox. The labels on the bottles did not include a list of ingredients, nor was there an expiration date, or national drug code number. An FDA investigator was dispatched to the Wheaton store and confirmed that the bottles of Maalox were never intended for U.S. distribution.

Maalox was manufactured by William H. Rorer, Inc., headquartered in Fort Washington, Pennsylvania, just down the road from the headquarters of the McNeil Consumer Products Company. Rorer executives said the suspect lots were part of a 164,496-bottle shipment originally destined for Iraq. That shipment also included 92,400 bottles of Ascriptin tablets (an aspirin-Maalox combination) and 83,436 bottles of Maalox tablets that should have gone to Saudi Arabia. These drugs had been ordered by the Meridian Ship Agency of Norfolk, Virginia, for Mainline Trading Ltd. of London, England. The drugs were shipped in January 1984 via Volpe Philadelphia Express to Meridian in care of Erskin Freight Forwarding Co. of Bayonne, New Jersey. Erskin rented space in a warehouse in Jersey City, New Jersey, and the shipment left that warehouse shortly after it arrived, but it did not go to the Middle East. Subsequent investigation by the FDA revealed that the drugs had been “diverted” to Interstate Cigar Co., a Long Island, New York, wholesale distributor, apparently on orders from someone in the Meridian Ship Agency.

Through two distributors - Interstate Cigar Co. and Inter American Cosmetic, of Carlstadt, New Jersey - Rorer was able to recapture 83,197 bottles of Maalox tablets, 81,615 bottles of Ascriptin tablets, and 59,000 bottles of Maalox liquid that had been diverted.

This investigation illustrates how the FDA, with help from Rorer, was able to track down most of the Maalox that was being sold on the grey market through a complex network of middlemen. Officials involved in the Tylenol murders investigation never described the inner-workings of the Tylenol distribution channel.

15

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A Reluctant Recall

James Burke, Wayne Nelson, and a few other J&J executives hopped on the company helicopter and flew to Washington D.C. on Monday afternoon, October 4th, to meet with FBI and FDA officials there. Burke later said that while he was in Washington he advocated for a recall of all Extra Strength Tylenol capsules. According to folklore, FBI and FDA officials counseled Burke against recalling the drug precipitously. “The FBI didn’t want us to do it,” explained Burke, “because it would say to whoever did this: ‘Hey, I’m winning. I can bring a major corporation to its knees.’ And the FDA argued that a recall might cause more public anxiety than it would relieve.”

Burke’s suggestion that he was the lone voice fighting on behalf of American consumers to remove all Tylenol capsules from the marketplace is refuted by the facts. Burke’s actions revealed that he had no intention of ordering a recall of all Tylenol capsules. The two lots that Burke recalled on Thursday, September 30th, and Friday, October 1st, were well publicized. Not so well publicized, were the other five lots linked to poisoned Tylenol capsules that Burke had not recalled.

Police had said that Lynn Reiner’s Tylenol capsules were from Lot 1833MB, but Tylenol from that lot was not recalled. The cyanide-laced Tylenol that killed Paula Prince was from Lot 1801MA, but Tylenol from that lot was not recalled. Authorities had also found cyanide in Tylenol capsules from Lots 1665LM and MC2884, but Burke refused to recall Tylenol from either of those lots. Strychnine-laced Tylenol capsules from yet another lot had been found in two bottles in California, but Burke did not recall Tylenol from that lot. By the end of the second day of the investigation, authorities had recovered poisoned Extra Strength Tylenol capsules from containers bearing seven different lot numbers, but Burke recalled Tylenol capsules from only two of those lots.

*****

James Burke and Wayne Nelson were in their second day of meetings in Washington D.C. when reports hit the newswire of another Tylenol poisoning - this time in California. Greg Blagg, a 27-year-old butcher from Oroville, California, told reporters on Tuesday afternoon that he had taken three Extra Strength Tylenol capsules on Thursday, September 30th, and then passed out. Blagg said his wife purchased the Tylenol two weeks earlier at Longs drugstore in Oroville. Tests completed Monday evening, October 4th, showed that some of the Tylenol capsules from Blagg’s bottle contained strychnine.

Soon after taking the capsules, said Blagg, “I displayed strange symptoms. I got ill, I vomited ... Later I passed out and woke up on the floor.”

His wife, Terry, took him to the hospital where he was treated and released at his own request four hours later. Blagg said he heard on the news that night about the deaths in Chicago, and the next day he took apart some of the capsules from his own Tylenol bottle and saw pink flecks in the powder. He then turned the bottle over to his physician, Dr. John Clay. That evening, at Dr. Clay’s suggestion, the Blaggs returned to the Longs drugstore in Oroville where they had purchased the original bottle, and bought two more bottles of Extra Strength Tylenol capsules. Some of the capsules in one of those bottles also contained pink flecks. When the Tylenol was tested, strychnine was found in the capsules from two of Blagg’s three bottles.

Ronald Tossano, the manager of the Oroville Longs drugstore, told NBC News, “We’re co-operating with an ongoing investigation being conducted by Johnson and Johnson, the parent company of McNeil Consumer Products, and the Food and Drug Administration.” Tossano clearly understood that Johnson & Johnson was in charge.

The FDA had not actually seen any of the bottles of strychnine-laced Tylenol capsules. The bottles had been mailed to McNeil headquarters in Fort Washington before the FDA knew anything about the Oroville tampering incident. Conversely, the FDA knew exactly what was going on, but simply let J&J take control of the evidence and the incident.

Larry Foster said Johnson & Johnson had received a telephone call on Friday from Blagg’s doctor regarding the possible strychnine contained in the Tylenol capsules. The J&J official told Dr. Clay to send the Tylenol capsules to McNeil’s lab in Fort Washington. Foster said the analysis of those capsules was not completed until late Monday night.

In addition to identifying strychnine in two of the three bottles purchased by the Blaggs, McNeil found a third bottle that “showed signs of tampering.” At that point, said Foster, the FDA was immediately notified. But this notification came three days after J&J had received reliable information from Blagg’s doctor that Blagg had been poisoned by adulterated Extra Strength Tylenol capsules. On Friday, when J&J had learned about the poisoning in California, a J&J representative removed the remaining bottles of Tylenol capsules from the Oroville store where the Blaggs had bought their Tylenol, and sent them to McNeil headquarters in Fort Washington.

As it turned out, the strychnine-laced Tylenol capsules were not actually planted by a wanna-be-killer. The press conference that announced the deaths of three Tylenol poisoning victims in Illinois was held at 8 a.m. (6 a.m. California time) on Thursday, September 30th. Greg Blagg swallowed his suspect Tylenol capsules in Oroville sometime that afternoon. The Greg Blagg story has too many holes in it to be anything other than a poorly executed scheme, possibly an attempt to extort money from J&J.

Officials in California were suspicious of Blagg’s story from the start. Greg Blagg and his wife, Terry, agreed to take lie detector tests when police suggested that there were “discrepancies” in their story. In the end, everyone involved in this case decided it was best to let sleeping dogs lie. The feds were not interested in pursuing a case that would have kept the Tylenol tampering incident in the news. The FBI officially closed the Oroville tampering case about two months later without prosecution.

FBI Special Agent, Ray Yelchak, made a formal statement about the Blagg case on Friday, November 26, 1982. “There is insufficient reason to believe the matter is related to similar incidents in the Chicago area,” he said. “There is insufficient evidence to pursue federal prosecution of any individual or individuals.” Yelchak noted that Blagg and his wife voluntarily submitted to lie detector tests, and the results were turned over to the Blaggs’ attorney. “In the interest of their privacy, the results of the Blaggs’ polygraph exam will not be made public by the FBI.”

In September 1984, Greg Blagg was back in the news. This time he was facing criminal charges, along with his parents, for a March 16, 1984, fire that destroyed their meatpacking plant. The Butte County District Attorney’s office filed charges of arson, insurance fraud, and conspiracy against then 29-year-old Blagg, his 48-year old father, Alan, and his mother, Clara, age 47. According to Butte County Deputy District Attorney, Howard Abbott, the legal action was taken at the request of the state fire marshal. There is no readily available record of the outcome of this case.

*****

After the Oroville tampering incident made headline news, Burke recognized that his only viable option for curtailing the growing damage to the Tylenol brand was to recall all Tylenol capsules nationwide. The story about the strychnine-laced Tylenol poisoning in Oroville was reported in the news media on Tuesday, October 5th. But Burke had known about that incident since Friday, October 1st. He ordered the nationwide recall of all Tylenol capsules on Tuesday - not because he had just learned about the tampering incident in Oroville - but because the public had just learned about the Tylenol tampering in Oroville.

On Tuesday afternoon, a McNeil spokesperson announced: “In conjunction with the FDA, we are notifying retailers to discontinue the sale of Tylenol extra strength capsules and regular strength capsules throughout the country until further notice.”

It has been widely reported that Johnson & Johnson recalled 31 million bottles of Tylenol capsules with a retail value of $100 million. However, two days after initiating the nationwide recall, J&J spokesperson, Robert Kniffin, said the company would destroy about 22 million bottles of Tylenol capsules with a retail value of $79.2 million. He said the recall included 11 million bottles previously sold to consumers and being returned and an additional 11 million bottles being returned by retailers and distributors.

The true number of recalled Tylenol bottles was confirmed in a lawsuit that J&J filed against its insurers, seeking to recover the costs associated with recalling 22 million bottles of Tylenol capsules. The genesis of the 31-million-bottle recall story was apparently the testimony of McNeil Chairman, David Collins, to the United States Congress on October 15, 1982, when he said Johnson & Johnson had withdrawn 31 million bottles of Tylenol capsules from the market.

Collins also used his testimony before Congress to remind the public to remain alert. “Not only the cap, and not only the bottle, but every capsule and every tablet should be examined, and in a good light,” advised Collins. “Then smell it to see if there are any peculiar odors.”

The tampering risk that Collins failed to address in his testimony before Congress was the use of unsealed capsules. It was too easy to pull the capsule-halves apart and replace the medicine with poison. The decision by Collins and other J&J executives to continue producing Tylenol in unsealed capsules was the solution also promoted by the Proprietary Association, the OTC drug manufacturers’ primary lobbying group.

The Proprietary Association was adamant that there should be no restrictions placed on the sale of capsules in the OTC market. The Association’s lobbyist, of course, had the ears of Washington politicians. In fact, it is fair to say that David Collins, in addition to representing Johnson & Johnson, was also acting on behalf of the Proprietary Association when he testified before Congress to assure its representatives that tamper-resistant packaging was the best solution to the tampering problem. Although the public didn’t know it, Collins was at that time a member of the Proprietary Association’s Board of Directors.

*****

On Wednesday, October 6th, David Collins appeared on NBC’s Today show; partly to comment about the Tylenol recall, but mostly to tell the public that the poisonings were the work of a madman. “The confidence of the American consumer built this product. Nothing has changed,” Collins assured the Today show viewers. “What has changed”, he said, “is that we have an insane individual or individuals out there who have elected to contaminate this product ... and we hope to reemphasize and reestablish consumers’ confidence in this product.”

J&J President, David Clare, later commented about the reaction of J&J executives upon learning of the poisonings. In a 1985 interview for Corporate Conscience Magazine, Clare said the climate within Johnson & Johnson at that time was one of sheer disbelief and incredulity that this had happened. There was “absolute unhappiness associated with the obvious fact that people were dying, potentially through the use of one of our products, and we just didn’t know what had happened,” said Clare. “We did not know how extensive it was, what the cause was, what the problem was in any dimension. It appeared to be localized, but we weren’t sure.”

Two days after the poisonings, Larry Foster had said the fact that the adulterated Tylenol capsules came from two sources, but cropped up only in one area, “leads us to believe strongly that the problem rests in Chicago.” But twenty years later, when Foster was in a forum where he could calmly reflect back on that time, he said “We naturally wanted to protect the good name of J&J and McNeil, and we wanted to get the product off the market for fear that it might be a nationwide plot.”

In the days following the poisonings, J&J did not publically disclose its concern of a possible nationwide plot, because such a message would have worsened the prospects for the quick return of Tylenol sales to its pre-poisoning level. Better for J&J to work quietly behind the scenes to remove from the marketplace the Tylenol capsules that had passed through the warehouse where the tamperings actually occurred.

Clare said that for a period of about 48 to 72 hours there was a debate within Johnson & Johnson as to whether or not the Tylenol capsules should be withdrawn from the market. “So there was the argument,” said Clare, “We should not withdraw - ‘You’re going to enhance the copycats. You’re going to enhance the process of adulterating a product for copycats.’ And [we] finally came down on the side [that] there was no choice from our standpoint. We had to act to protect the public, whether it was more widespread than it appeared to be, whether it was a condition that could be repeated by other copycats using our product. So the first and foremost, we had to protect the public.”

In the lawsuit that J&J filed against its insurers; J&J suggested that company executives had treated the recall with far greater urgency than they actually had. Judge Maryanne Trump Barry, the older sister of real estate magnate Donald Trump, presided over this lawsuit. She said the “Plaintiff [J&J] itself admits, both in its complaint and in its briefs, that it would have been negligent or grossly negligent were any subsequent deaths caused by its retention of Tylenol on the market. It is a well settled proposition of law that an actor who has negligently imperiled the life of another has a duty to aid that person and save him or her if at all possible.”

J&J argued that company executives, to avoid an even greater catastrophe, acted immediately to recall all of the Tylenol capsules. The transcript in re: McNeilab Inc. v. North River Insurance Co., et al., includes an interesting exchange regarding Johnson & Johnson’s after-the-fact reason for recalling all Tylenol capsules nationwide:

THE COURT: Well, what catastrophe were you stopping here?

COUNSEL FOR J&J: Stopping the death of the additional unknown numbers of people.

THE COURT: And that’s why you did it?

COUNSEL FOR J&J: That is a principal motivating factor for why we did it.

It was the contention of J&J’s lawyers that the company would have been negligent had it not recalled all Tylenol capsules nationwide. Judge Barry said, “[McNeil] and its parent [J&J] admit that they foresaw further poisoning incidents if they failed to act.” Yet J&J executives did not recall Tylenol capsules nationwide, “to protect the public,” until five days after they had learned about the poisonings.

Public relations expert, Jack O’Dwyer, bemoans the myth of the immediate recall played up for decades by most of his industry-peers. “Although it took about a week for J&J to order the withdrawal, which was somewhat after the fact by that time,” says O’Dwyer, “that is not how the withdrawal has entered public lore thanks to a massive advertising and PR campaign conducted by the company.” O’Dwyer concludes: “J&J was just another case of normal corporate foot-dragging during a crisis.”

The initial recall of 93,000 bottles from Lot MC2880 was a small price to pay to restore consumer confidence. As the number of lots implicated in the poisonings grew; the cost to recall those lots apparently exceeded the threshold acceptable to James Burke. Even so, Burke was not so careless that he would risk leaving cyanide-laced Tylenol capsules in stores and warehouses where they could get into the hands of consumers and cause even more deaths.

J&J’s knowledge about the Tylenol killer’s true modus operandi is betrayed by the manner in which the company selectively recalled Extra Strength Tylenol capsules from only a fraction of the lots known to have contained cyanide-laced Tylenol capsules. By the time J&J executives initiated the national recall, they had evidently already tracked down the facility where the tamperings occurred, and confiscated the Extra Strength Tylenol capsules that had been shipped from that warehouse.

The Tylenol murders investigation was one-week old when reports began to emerge indicating that the Tylenol poisonings may not have been the one-time local incident that officials had claimed it was.

16

________

The Other Cyanide Murders

One week after the Tylenol poisonings in Chicago, local authorities in Pennsylvania and Wyoming reopened investigations into two cyanide poisoning deaths, possibly linked to Tylenol. William Pascual, of Philadelphia, had died in April 1982 from a cyanide-laced Extra Strength Tylenol capsule. Pascual’s death appears to have been a suicide, but there is substantial evidence indicating that the July cyanide-poisoning death of Jay Mitchell in Wyoming may have been the work of the Tylenol killer.

On Friday, October 8, 1982, a Wyoming FBI agent and a Chicago police detective went to Sheridan, Wyoming, to help local authorities determine whether the death of Jay Adam Mitchell was linked to the Tylenol murders in Illinois. Mitchell, a 19-year-old school janitor from the town of Big Horn, had failed to turn off his alarm clock when it went off at 6:30 a.m., July 26, 1982. His father tried to wake him, but Mitchell was dead. An older brother told the Chicago detective that he thought Mitchell took Tylenol from a bottle in the kitchen four hours before his alarm went off. Mitchell’s mother also said he had taken Extra Strength Tylenol shortly before his death.

Sheridan County Coroner Jim Kane said the Tylenol capsules were not suspected until after Mitchell’s toxicology test results came back from Utah, three weeks before the Tylenol murders. By then, Mrs. Mitchell had thrown out the Tylenol bottle.

Dr. William E. Doughty, a pathologist at the Sheridan County Memorial Hospital who was familiar with the case, became suspicious about Mitchell’s death after hearing on Thursday, September 30th, about the deaths from cyanide-filled Tylenol capsules in Illinois. Dr. Doughty then asked the youth’s mother if her son had taken any medication before his death. She replied, ‘Nothing, just a headache pill; some Extra-Strength Tylenol,’ Doughty said. “She said she thought she had purchased it at Buttrey-Osco, a local food & drugstore, but she had since destroyed the bottle.”

Doughty asked the manager at the local Buttrey-Osco store where the Extra Strength Tylenol came from, and was told that since March 1982 the store has purchased its Tylenol from the Jewel Tea Company of Chicago - aka Jewel Companies, Inc., of Melrose Park. The Buttrey-Osco stores were part of Jewel’s Osco Drug subsidiary. Cyanide-laced Tylenol had now been linked to four Jewel Companies stores - the Buttrey-Osco store in Sheridan, the Jewel-Osco stores in Elk Grove Village and Arlington Heights, and the Osco Drug in Schaumburg.

A second analysis of the contents of Mitchell’s stomach, conducted the first week of October 1982, revealed the exact same dosage of cyanide as was found in the stomach contents of the Chicago victims. Dr. Bryan S. Finkle, Director of the Center for Human Toxicology at the University of Utah, compared the Wyoming death with the deaths in Illinois. Finkle conferred with Dr. Robert Stein in Chicago who told him that the dose of cyanide found in the stomachs of the Illinois victims, matched the amount found in Mitchell’s stomach.

“It turned out,” said Dr Finkle, “that there were a lot of similarities toxicologically” with the Mitchell case and the poisoning cases in Illinois. “It was exactly the same as the Mitchell dosage, said Dr. Finkle. “It’s a very tight link. It would be very difficult for these different people to take exactly the same dosage of cyanide without having taken the same-sized capsule with the same-sized dosage.”

The evidence “as it stands in no way makes a case,” said Dr. Finkle, but he also felt that considerable further research was necessary in this case and others. “If the deaths were not clustered, there is every reason to believe they would all have been signed out as cyanide deaths [not linked to Tylenol capsules] and there would have been no connection made, meaning the method, modus operandi.”

Investigators in Illinois would not comment about the Mitchell case, but another well-informed source close to the investigation said, “If the link through the distributor is confirmed, that would be big news.”

Officials never found the source of the cyanide that killed Mitchell – or if they did, they never disclosed that source. When the Chicago detective returned home from Wyoming on Sunday, October 10th, Chicago Police Sergeant, Michael Invergo, announced that investigators had turned up nothing new after traveling to Sheridan. Authorities quickly dismissed the similarities between the poisonings in Wyoming and Illinois, declaring them unrelated. In so doing, authorities had ignored an awful lot of evidence, as well as the advice of Dr Finkle who had said considerable further research was necessary in this case.

*****

In addition to the cyanide deaths linked to Tylenol capsules in Wyoming and Philadelphia, there were also other cyanide poisonings in Cook County around the time of the Tylenol murders. Robert Stein announced on October 1st that the Cook County Medical Examiner’s Office had begun to review all sudden unexplained deaths that had occurred after September 1, 1982. Stein said they were re-testing frozen blood samples from recent unexplained deaths in Cook County in cases where the victim had died suddenly and initial autopsy results showed the presence of Tylenol in the bloodstream.

Stein’s decision to use Tylenol (acetaminophen) as a qualifier for determining whether blood samples should be re-tested makes it clear that autopsies conducted in Cook County routinely tested for acetaminophen. That makes sense, because there are hundreds of deaths each year caused by acetaminophen poisoning. Acetaminophen is second only to alcohol as the most common drug involved in suicides from drug overdoses. Hundreds of people also die each year from accidental acetaminophen overdoses.

On January 13, 1983, Robert Stein said his office had reviewed the autopsy results from 17 unexplained deaths in Cook County. When the blood samples were retested, the Medical Examiners found that three of these deaths were from cyanide poisoning. Autopsies conducted in Cook and DuPage Counties did not routinely screen for the presence of cyanide, so the examiners in Cook County had initially misclassified rather innocently the cause of death for these three individuals.

Cyanide, as it turns out, is a good choice of a murder weapon for a killer interested in covering his or her tracks. According to Dr. Michael Baden, a forensic pathologist and author of Unnatural Death, Confessions of a Medical Examiner, time can erase traces of poison like cyanide. When describing his testimony in one murder case, Dr. Baden explained, “The defense was saying that no cyanide was found in the bodies, but the absence of cyanide didn’t mean they weren’t given it. After a few days, you can’t find cyanide in a body. That’s one of the reasons it’s such a good murder weapon.” That being said, investigators, upon reviewing 19 unexplained deaths, found five of them, all young adults, had died in 1982 from cyanide poisoning – the cyanide deaths of Jay Mitchell in Wyoming, William Pascual in Philadelphia, and three more cyanide deaths in Cook County.

The three reopened death investigations in Cook County came about because toxicologists had retested the blood samples recently taken from individuals suspected to have overdosed on cocaine. It turned out that they had actually died from cyanide poisoning. Michael Schaffer, the Cook County Chief Toxicologist, said officials were checking the deaths of Mark Husted, age 32, originally from West Dundee, IL; Galen Parriott, age 30, of Skokie, IL; and Marie Louise Watkins, age 21, of Chicago, “because of the close proximity [in time] to the cyanide deaths [of the Tylenol victims].”

Watkins had died on August 15th, six weeks before the Tylenol murders; Parriott had died December 1st, two months after the murders; and Mark Husted had died Tuesday, September 14th, two weeks before the Tylenol murders. Cook County medical examiners had found acetaminophen (Tylenol) and lethal levels of cyanide in the blood samples taken from all three victims.

“We are continuing these investigations [into other unexplained deaths] because we are finding now that cyanide is an easy poison to obtain,” Stein explained, “and we don’t want to overlook any possible cyanide poisoning case.”

An un-named detective on the Tylenol task force said it would be valuable information to know if the cyanide that caused these three deaths was the same type that had killed the Tylenol victims, but he said it was impossible to conduct such a test.

When Cook County medical examiners conducted an autopsy on Mary Watkins, following her death on August 15, 1982, they found only traces of metabolized cocaine in her body. They had ruled her death a cocaine overdose nonetheless. Upon retesting Watkins’s blood samples in October, authorities determined that cyanide, not cocaine, had caused her death. Toxicology tests found both cyanide and acetaminophen in her body, yet Jaye Schroeder, a Chicago police spokesperson, said on October 27th that the Tylenol task force was not investigating Watkins’s death because it was not clear whether her death was a homicide.

One day later, Kathryn Kajari, the director of news affairs for the Chicago police detectives, said they had obtained a two-page suicide note written by Watkins. Kajari said Ms. Watkins’s sister had recently turned in the letter, but Kajari did not reveal the letter’s contents. Officials obviously did not have this “suicide letter” ten weeks earlier when they ruled, erroneously, that Watkins had died from a cocaine overdose. That letter conveniently turned up just when it appeared that Watkins might be another victim of the Tylenol killer.

Dr. Mitra Kalelkar, the assistant medical examiner for Cook County who had examined Watkins’s remains, said, “We cannot definitely find a link between the other Tylenol cyanide cases and this case because we have not determined the source of the cyanide.” Kalelkar said she and her associates had not determined conclusively that there was no connection between the cyanide-poisoning death of Watkins and those of the seven victims officially linked to the Tylenol murders. “Anything is possible,” she said.

*****

The Mark Husted cyanide poisoning case is also interesting. Husted was a convicted drug dealer who was to appear in the U.S. District Court in Chicago on November 8, 1982, on charges of conspiring to sell cocaine. Husted and Louis Tedesco had both been charged in a 79-count indictment on December 3, 1980, along with thirteen others, for their involvement in a cocaine smuggling operation. Numerous hearings were held in the U.S. District Court in Chicago from July through November 1982 for various defendants in the case. Several defendants cut deals with government prosecutors who gave at least one defendant immunity. In December 1982, Tedesco was convicted and sentenced to two years in prison.

Mark Husted had recently completed a three-year prison term in Florida on a marijuana drug smuggling conviction. He was serving that sentence when he was indicted on charges of operating a $10-million-a-year cocaine ring from his Florida prison cell. The standard sentence for Husted’s marijuana conviction was five years, but Florida Circuit Court Judge, Charles Carlton, reduced the sentence to three years after receiving letters from then Illinois gubernatorial candidate Jim Thompson, U.S. Senator Charles Percy of Illinois, U.S. Representative Robert McClory of the 13th District in Illinois, and Elgin Mayor Richard Verbic. Those letters to Judge Carlton from such well-placed politicians can be attributed to the powerful connections of Mark Husted’s father, Richard Husted, who had been a state’s attorney in Greene County, Illinois, in the 1950s. At the time of his son’s death, Richard Husted was the Village Attorney for Carpentersville, Illinois, and had a private practice.

Mark Husted had flown to Chicago O’Hare International Airport from his home in Florida on Tuesday, September 14, 1982. He then drove to Louis Tedesco’s house on Anita Street in Des Plaines, Illinois. Husted was expected the next day at his father’s home in West Dundee, but he died Tuesday night. Tedesco told police that he had found Husted slumped over on the back porch, and he then called the paramedics.

Agents from the DEA reported on September 16th that Husted’s death was believed to have been caused by a drug overdose, but they said the autopsy conducted on September 15th was inconclusive. It was only because Richard Husted asked authorities to reopen the investigation of his son’s death that medical examiners went back and re-tested Mark’s blood and tissue samples for cyanide. Husted had urged the re-investigation because of “a feeling that his son may have been murdered.”

The second set of toxicology tests showed that Mark Husted’s body tissues contained a lethal level of cyanide. Results from those tests were known shortly before the Tylenol murders case broke, but they were not made public until January 13, 1983. Officials delayed publicizing the coroner’s findings for ten weeks, apparently to keep Husted’s case separate from the Tylenol murders.

Members of Mark Husted’s family said he had been mixed up with a Colombian drug cartel. He was facing a potentially long prison term for his alleged involvement in a drug smuggling operation. However, if someone related to drugs had wanted to murder him, they would probably not have used cyanide. Authorities never found the source of the cyanide that killed Husted.

Was Mark Husted murdered to keep him from talking - or was he another victim of the Tylenol killer? Husted had a habit that suggests the latter. Family members said he “ate Tylenol like candy.”

Some of the Tylenol killer’s cyanide-laced capsules may have already been in Tylenol bottles on the shelves of Chicago area stores when Mark Husted flew into O’Hare International Airport on September 14th. From that airport, Husted had driven to Tedesco’s house in Des Plaines, passing the exits to the Osco Drug store in Schaumburg and the Jewel-Osco store in Elk Grove Village where bottles of cyanide-laced Tylenol capsules were found or purchased two weeks later. Maybe Husted stopped to pick up a bottle of Extra Strength Tylenol capsules on the way to Tedesco’s house.

On the day of the Tylenol murders, an investigation of cyanide poisonings in the Chicago area may already have been underway. The New York Times reported that “Investigators independently examining some unexplained deaths Wednesday [September 29th] in two adjacent suburbs here [in the northwestern suburbs of Chicago] were alerted to the Tylenol threat by two firemen.” At that time, authorities were reviewing the unexplained death of Mark Husted in Des Plaines.

Cook County medical examiners found cyanide and acetaminophen in the blood or body tissues of cyanide-poisoning victims Mark Husted, Mary Watkins and Galen Parriott. In addition, Jay Mitchell had died of cyanide poisoning in Wyoming shortly after taking Extra Strength Tylenol capsules that had been purchased at a store in Sheridan, Wyoming that received its Tylenol from the same Illinois warehouse that distributed Tylenol to the Jewel-Osco stores in the Chicago area. The official Tylenol murders death toll is seven, but there is no evidence that has ever excluded any of these four individuals as additional victims of the Tylenol killer.

17

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A Poisoned Investigation

On Wednesday, October 6, 1982, Johnson & Johnson’s head of security brought a letter into the boardroom where the members of J&J’s Executive Committee were meeting. The word “TYLENOL” was written on the letter’s envelope. The letter itself said, in part: “If you want the killing to stop, then wire $1 million to #84-49-597 at Continental Illinois Bank in Chicago.” That bank account, closed five months earlier, had belonged to Frederick Miller McCahey, an heir to the Miller Brewing fortune.

Investigators from the FBI and IDLE questioned McCahey, and quickly determined that he had not written the letter. Authorities then asked McCahey to put together a list of names of the individuals who might have a grudge against him. One of the names on that list was Robert Richardson. Seven days after J&J received the extortion letter; authorities identified its author as Robert Richardson, aka James Lewis.

James Lewis was born in Memphis, Tennessee to Theodore and Opal Wilson. His given name was Theodore Wilson, Jr. In 1948, when Jim was just two years old, Theodore, Sr., left the family. Social workers soon intervened after determining that Opal was ill-equipped to take care of her son and two daughters, ages seven and nine. The siblings were separated, and Theodore was adopted by Floyd and Charlotte Lewis, and given the new name of James William Lewis.

James grew up in a small rural home in Carl Junction, Missouri, where his mother worked in a shirt factory and his father share-cropped 20 acres. The Lewises had no telephone, no automobile, and no modern agricultural equipment. While attending the University of Missouri at Kansas City, James met LeAnn Miller in 1967. They were married one year later. In the early 1970s, James and LeAnn opened their own business, the Lewis and Lewis Business Tax Service, in a store not far from their small house on Troost Avenue in Kansas City.

On December 4, 1981, Kansas City police officers showed up at the Lewises’ home. They were investigating James Lewis and George Rea, a former sheriff’s deputy, as possible suspects in a credit card fraud scheme. The next day, James and LeAnn left Kansas City and headed north to Chicago. They rented a room for $100 a month in a rundown, roach-infested apartment building in what was mostly a well-kept historic neighborhood on West Belden Avenue on Chicago’s North Side. They used the names Robert and Nancy Richardson to keep authorities in Kansas City off their trail.

In January 1982, LeAnn got a job at Lakeside Travel, but the company went belly-up just three months later. LeAnn and seventeen other employees were stiffed by the firm’s owner, Frederick Miller McCahey, when their final paychecks bounced.

Jim’s temporary job at First National Bank of Chicago ended in August 1982. So the Lewises, both now unemployed, packed up their few belongings on September 3rd, and took a train to New York City. On September 6th, they rented a room at the Hotel Rutledge on Lexington Avenue and 31st Street in Manhattan.

When the Tylenol murders made front-page news, Lewis saw his chance to draw attention to McCahey and possibly trigger an investigation into his business practices. Lewis’s ill-advised plan involved writing an extortion letter to Johnson & Johnson demanding that the company deposit $1 million into McCahey’s business account at Continental Bank of Illinois if they wanted the killings to stop. That account, as Lewis knew, had been closed since May 1982. Court documents state that Lewis’s reason for writing the extortion letter was to expose what he believed were McCahey’s “fraudulent business dealings.”

Assistant U.S. Attorney, Jeremy Margolis, said Lewis assumed that the FBI would eventually figure out that McCahey hadn’t done the Tylenol killings. Margolis said that during the course of the Bureau’s investigation of McCahey, Lewis expected that “they’d work [McCahey] up one side and down the other and figure out what a horrible white-collar criminal he was and he would suffer his just desserts for bouncing checks on employees.”

Margolis and U.S. Attorney Dan Webb led the team of Justice Department attorneys who prosecuted Lewis for writing the extortion letter. Lewis was convicted of attempted extortion in 1983, and sentenced to 10 years in prison. Several years later, Margolis said, “There’s nothing special about James Lewis. He’s a con man. He’s an experienced fraud artist. He’s a criminal and he belongs in the penitentiary.” That sentiment was proclaimed publicly by every one of Big Jim’s boys, with the exception of IDLE Director, James Zagel.

In 2002, Zagel, then a federal judge, told the Chicago Tribune that Lewis should no longer be identified as a suspect. “I’m in the business of withholding judgment,” said Zagel. “I, for one, cannot accuse him of more than what he was charged with.”

Zagel maintained an amazingly low profile during the Tylenol murders investigation, especially considering his position as the head of the Illinois Department of Law Enforcement. Maybe Zagel was unwilling to publicly endorse the improbable “approved theory” of the Tylenol murders.

It was nearly impossible, statistically, for someone to plant in the retail stores the number of adulterated Tylenol bottles that it would have taken for five of them to be purchased and the cyanide capsules consumed on that same day. There was also a problem with the hypothesis that the capsules had been filled with cyanide and planted one day before the murders.

Authorities claimed that the cyanide was highly corrosive and would have eaten through the gelatin-based Tylenol capsules very quickly; thus, according to Tyrone Fahner, the tamperings must have occurred at the local retail stores, probably on Tuesday, the day before the murders. When Fahner made that claim, on the second day of the investigation, it was already clear that the cyanide involved in the Tylenol murders did not have the super-corrosive properties Fahner described.

The evidence does in fact support the assertion of officials who said cyanide causes the gel-based Tylenol capsule-shells to corrode (the water in cyanide, not the cyanide itself, is what actually causes gelatin-based capsules to corrode). However, the evidence discredits their assertion that the cyanide-laced capsules would show visible signs of corrosion in just one or two days.

Cook County Toxicologist, Michael Schaffer, said the cyanide from the poisoned capsules in the Kellerman and Janus bottles was moist and had caused the capsules to corrode. Those capsules showed signs of corrosion when Schaffer inspected them just one day after the poisonings. They were somewhat swollen and discolored. The one remaining cyanide-laced capsule in Paula Prince’s Tylenol bottle, inspected two days after the murders, was also discolored and swollen.

On October 21, 1982, a J&J employee working at the company’s temporary lab in Lemont discovered another bottle of cyanide-laced Extra Strength Tylenol capsules. That bottle, the seventh bottle of cyanide-laced Tylenol, bore the lot number MC2880, the same lot number that was on the Kellerman and Janus bottles. The seventh bottle had been returned to a Dominick’s store in Chicago on October 3rd, but it had not been purchased there. The person who turned it in was never found. Fahner said the cyanide-laced capsules in the seventh bottle were in an “advanced state of deterioration.” They had corroded to a much greater degree than the cyanide-laced Tylenol capsules that Schaffer had inspected about three weeks earlier.

The cyanide-laced Extra Strength Tylenol capsules recovered after the poisoning death of William Pascual in Philadelphia on April 3, 1982, provides another example of the corrosive effects of moist cyanide. Philadelphia authorities re-examined Pascual’s capsules on October 9th, and found that they had degraded into nothing but powder – the result of extensive corrosion in the preceding six months caused by the moist cyanide.

To find out when and where the Tylenol tamperings had occurred, authorities needed to figure out how long it had taken the cyanide-laced Tylenol capsules to show signs of degradation. This is exactly what Cook County Medical Examiner, Dr. Robert Stein, had set out to do on Thursday morning, September 30, 1982. Dr. Stein and his staff had “duplicated” the victims’ cyanide-laced Tylenol capsules by putting some of the cyanide from those capsules into new Extra Strength Tylenol capsules. Stein then monitored the “test capsules” to determine how long it took them to show signs of corrosion. Officials from Johnson & Johnson and the Tylenol task force never talked about this forensic analysis, but Robert Stein did talk. Stein said that after the cyanide had been in the test capsules for 48 hours, they still showed no signs of corrosion.

A member of the Tylenol task force, who asked not to be identified, refused to comment on Stein’s findings. “We’re giving out what we feel we can,” he said. “We can’t comment on things that might in any way jeopardize the investigation.”

On October 9, 1982, Stein said he had completed tests indicating that the cyanide-loaded Tylenol capsules could have been doctored at their distribution points or at the plant where they were produced. Stein made this statement ten days after the test capsules had been filled with cyanide. These capsules obviously did not yet show (or had just begun to show) visible signs of corrosion. Instead of acknowledging the relevance of Stein’s findings, Tyrone Fahner sharply criticized Stein for suggesting the obvious: that the Tylenol capsules had been poisoned in the distribution channel.

When J&J discovered the seventh bottle of cyanide-laced Tylenol capsules on October 21st, Fahner said these capsules, because they were in an advanced state of deterioration from the corrosive poison, should help the authorities work back in time to determine when the contamination occurred and where the batch’s bottles were that day. However, as Fahner must have known, Robert Stein had already determined that some or all of the poisoned capsules had been filled with cyanide about 10 or more days before the murders. Stein already had effectively traced the location of the tamperings to the channel of distribution. Stein’s findings did not fit the approved theory, so officials quickly suppressed those findings.

Even James Lewis questioned the glaring failure of officials to produce clear evidence related to the corrosive capability of cyanide on the gelatin-based Tylenol capsule-shells. In 1992, Lewis commented about this curious fact during a prison interview with an ABC-News reporter. “The Illinois Department of Law Enforcement, the FBI - apparently none of those [agencies] ever did a shelf-life test,” said Lewis. “I have long contended that if you find the person who squelched the shelf-life test, you will be very close to the person who committed the Tylenol murders.”

Lewis did not intend to imply that the person who squelched the shelf life tests had positively identified the Tylenol killer. Lewis did, however, believe that this person, or persons, had suppressed information that should have been used to help investigators track down the Tylenol killer.

The cyanide found in the adulterated Tylenol capsules did cause the capsules to corrode, but not in just one to a few days as was suggested by every official who spoke publicly about the case, other than Robert Stein. Some or all of the cyanide-laced Tylenol capsules in the Kellerman, Janus, and Prince bottles showed visible signs of corrosion one to two days after the murders, and thus had been filled with cyanide about ten days or more before they were purchased on September 28th and 29th. However, not all of the cyanide-laced Tylenol capsules showed signs of corrosion.

On October 8, 1982, NBC-News showed video footage that had been taken at the Illinois Department of Health lab in DuPage County. The video showed the four cyanide-laced red and white Extra Strength Tylenol capsules that were still in Lynn Reiner’s bottle of gray and white Regular Strength Tylenol capsules. Extreme close-up shots revealed that none of these cyanide-laced capsules showed any visible signs of corrosion. They were in perfect condition, with no discoloration or swelling, and thus had been filled with cyanide more recently than the cyanide-laced Tylenol capsules from the Kellerman, Janus, and Prince bottles.

Tyrone Fahner said the cyanide-laced Tylenol capsules from the different bottles looked different. He said the tampering for some capsules could be detected “by the naked eye,” but others showed no visible evidence that they had been opened and their contents switched.

The Tylenol capsules that could be “detected by the naked eye” as having visible signs of corrosion had been filled with cyanide more than ten days before the murders. The Tylenol capsules that showed no signs of tampering had been filled with cyanide more recently.

The chemical make-up of the cyanide in all of the victims’ Tylenol capsules was identical and had been manufactured by DuPont Laboratories; the varying degrees of corrosion on different capsules were thus not a function of different chemical makeup. The FDA traced the cyanide to DuPont with the aid of an analytical tool developed by Ames Laboratory. The Chicago Tribune reported that the poisoned Tylenol capsules contained three different “mixes” of cyanide, but they differed only in the fineness to which the crystals were ground.

Robert Stein’s shelf life tests soundly debunked the claim made by officials who cited the super-corrosiveness of cyanide as their only “proof” that the tamperings had occurred in the retail stores one day before the Tylenol murders. In early 1986, the FDA conducted its own analysis of cyanide-laced Tylenol capsules at the agency’s most sophisticated lab for analyzing poisons. This analysis was done on Tylenol capsules containing cyanide with “low water content.” The FDA found that these cyanide-laced capsules would show no signs of degradation for many months.

J&J executives and government officials never found any evidence to support their contention that the cyanide-laced Tylenol capsules were planted in Chicago area retail stores shortly before the Tylenol murders. However, they did seem to understand that only Extra Strength Tylenol capsules had been filled with cyanide.

One obvious indication that Johnson & Johnson executives knew a lot more about the Tylenol killer’s modus operandi than they let on was their insistence that the killer had poisoned only Extra Strength Tylenol capsules. Instead of warning consumers to avoid all Tylenol capsules; J&J executives took extraordinary measures to assure the public that only Extra Strength Tylenol capsules had been poisoned.

Within hours of learning about the poisonings, J&J faxed a half million mailgram to retailers, wholesalers, and doctors, alerting them to possible tampering of only Extra Strength Tylenol capsules.  The mailgram read: “We currently have no evidence that any other Extra Strength Tylenol capsule product or any other Tylenol product was similarly contaminated.”

When Chicago Mayor, Jane Byrne, announced on Saturday, October 2nd, that all Tylenol products were being removed from the City’s 2,000 stores, Johnson & Johnson responded by refusing to collect or inspect any Regular Strength Tylenol capsules. This was a seemingly peculiar stance to take, because there was no apparent reason to assume that the killer had not put cyanide into Regular Strength Tylenol capsules.

On Monday, October 4th, Larry Foster told reporters that Johnson & Johnson had “temporarily suspended production of ONLY Extra-Strength Tylenol [capsules], but all other Tylenol products are unaffected” (emphasis added).

J&J sent a “Dear Doctor” letter to doctors, hospitals, and warehouses on October 13th, in which McNeil Medical Director, Thomas Gates, reminded customers: “There is widespread public confusion about which Tylenol products are involved. Many people do not understand that ONLY Extra-Strength Tylenol Capsules have been implicated” (emphasis added). This, however, was not entirely true.

J&J executives had learned on the very first day of the Tylenol murders investigation that a bottle of Regular Strength Tylenol - Lynn Reiner’s bottle – did contain cyanide-laced Tylenol capsules. Inside Reiner’s bottle of Regular Strength Tylenol capsules, were six Extra Strength Tylenol capsules; four contained cyanide. J&J executives could not have known that other bottles of Regular Strength Tylenol did not also contain cyanide-laced capsules – unless they knew that the tamperings had not actually occurred in the retail stores.

In October 1982, Chicago Police Lieutenant, August Locallo, said, “This case [the Tylenol murders] won’t be solved by deduction. Someone has to come forward and give us the key.” That key was in the evidence police had removed from Lynn Reiner’s home one day after the poisonings.

18

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The Tylenol Institution

Lynn Reiner had checked out of Central DuPage hospital on Tuesday, September 28, 1982, after giving birth to her son five days earlier. On the following afternoon, Lynn left her mother-in-law in charge of her 21-month old son, Jacob, and her newborn, Joshua, and made the short trip to Frank’s Finer Foods in Winfield, located right across the street from Central DuPage Hospital. Lynn bought one bottle of Regular Strength Tylenol capsules. She returned home shortly before 3:30 p.m. and then went through the bags she had brought home from the hospital - including the goodie-bag of product samples routinely given to moms at hospital maternity wards. That’s when she must have found the unit-dose package of Extra Strength Tylenol capsules she had been given at the hospital the previous day. Lynn opened the package of eight Extra Strength Tylenol capsules, swallowed two of them and then put the other six into her new bottle of Regular Strength Tylenol capsules.

Minutes later, Lynn’s husband, Ed, and their 8-year-old daughter, Michelle, returned home. They walked into the kitchen and entered what had suddenly become a chaotic and frightening scene. The emergency medical technicians from Leonard’s Ambulance Service and the Winfield Fire Department arrived at Reiner’s home at about 3:45 p.m. After working on Lynn at the house for several minutes, to no avail, the paramedics rushed her to Central DuPage Hospital. She was put on life support, but had already died minutes after swallowing the Tylenol capsule filled with the fast-acting cyanide.

Contrary to what officials have insinuated over the years, the cyanide-laced Extra Strength Tylenol capsule that killed Lynn Reiner had not been put into a bottle of Regular Strength Tylenol at the Frank’s Finer Foods store. It had instead come from a unit-dose package dispensed by a pharmacist at the closed-door pharmacy in Central DuPage Hospital. The hospital’s pharmacy was inaccessible to the public, and thus it was inaccessible to the Tylenol killer.

Moms like Lynn Reiner were routinely given Tylenol at hospital maternity wards. In fact, 90 percent of all non-prescription pain pills given to hospital patients in 1982 were Tylenol pills. So it makes perfect sense that before Lynn checked out of the hospital on Tuesday, she was given a unit-dose package of eight capsules - exactly one day’s worth of Extra Strength Tylenol at the recommended dose. Five of those capsules had been filled with cyanide before they were delivered to the hospital’s closed-door pharmacy.

In 1974, Central DuPage Hospital had converted its pharmacy to a unit-dose system. Drugs dispensed at unit-dose pharmacies are typically packaged at the hospital’s pharmacy in blister packs or plastic pouches in amounts that range from one dose to one day’s worth of doses.

The American Society of Hospital Pharmacists (AHSP) had published guidelines in 1980 for hospital-pharmacies. The guidelines said that for most medications, not more than a 24-hour supply of doses should be provided to outpatients at any one time (patients’ checking out of the hospital are considered outpatients). Reiner’s package of eight Extra Strength Tylenol capsules would have covered exactly 24 hours at the then recommended dose of two capsules every six hours.

The AHSP guidelines contained additional recommendations also relevant to the Reiner case:

Inpatient self-care and “discharge” medications are to be labeled as outpatient prescriptions. Outpatient medications are to be labeled in accordance with State Board of Pharmacy and federal regulations. Medications given to patients as “discharge medication” are to be labeled in the pharmacy (not by the nursing personnel) as outpatient prescriptions. The source of the medication and the initials of the dispenser are to be noted on the prescription form at the time of dispensing. If feasible, the lot number also is recorded. Nonprescription drugs are labeled like any other medication.

On Thursday morning, September 30th, the Tylenol capsules in the pharmacy at Central DuPage Hospital were quarantined in accordance with AHSP guidelines, which stated that in the event of a recall, the hospital pharmacists were to quarantine all recalled products they obtained (marked “Quarantined—Do Not Use”) until they were picked up by or returned to the manufacturer. This is exactly what Central DuPage Hospital and every other hospital in the Chicago area did after the Tylenol poisonings. They quarantined the Tylenol capsules and waited for a Johnson & Johnson representative to pick them up.

Any cyanide-laced Tylenol capsules still in the pharmacy at Central DuPage Hospital on the day Johnson & Johnson learned about the murders were probably not there for long. By that afternoon, J&J had assigned Chicago area sales reps the job of checking to make sure local retailers and hospitals were not selling Extra Strength Tylenol capsules. One of those reps was likely dispatched to Central DuPage Hospital to confiscate all of their quarantined Tylenol capsules.

*****

About three weeks after Lynn’s death, James Burke hosted a pep rally for the company’s sales representatives. He played a testimonial style TV ad in which a woman professed her trust in Tylenol. “My first experience with Tylenol was in a hospital, after my son, Christopher, was born. Since then, it’s become one of the things we can count on,” said Paige Nagle, a San Diego homemaker who actually had first taken Tylenol in the hospital after the birth of her son. The narrator then announced, “Tylenol. You can trust our good name.” Just like the mom in this advertisement, which ran on network television in early 1983, Lynn Reiner’s recent experience with Tylenol had been in a hospital after her son was born.

Doctors were an integral part of Johnson & Johnson’s marketing strategy to restore Tylenol’s market share after the poisonings. J&J said in 1982 that 70 percent of all Tylenol users had at some time received a recommendation to use the drug from their physicians. What better advertisement could Johnson & Johnson have asked for than “unsolicited” recommendations from the doctors who gave Tylenol to their patients? Burke’s best salespeople were doctors.

The Washington Post ran a story on July 7, 1987, summarizing a nationwide survey of nine hospitals by the editors of Consumer Reports. The only OTC analgesic stocked by eight of the nine hospitals surveyed was Tylenol. Hospitals used competitive bidding to buy drugs, so they usually stocked only one brand in each class of drugs. They preferred Tylenol said Consumer Reports because of the king-size discounts they received from Johnson & Johnson, which often underbid the competition, including the generic products. The reason Tylenol was “the pain reliever hospitals use most,” as the ads say, had little to do with quality, according to Consumer Reports. Rather, hospitals used Tylenol most because it was cheaper than other brands. Conversely, Consumer Reports found that for most individual consumers, Tylenol was one of the most expensive pain relievers when they later bought the drug at retail stores.

Since Tylenol owned a nearly monopolistic share of the nonprescription analgesic market in hospitals; doctors typically didn’t really have a choice of which OTC drug they gave to their hospital patients. This institutional marketing strategy served Johnson & Johnson well in November of 1982 when the company re-launched Tylenol in tamper-resistant packaging. Anyone harboring any fear about the safety of Tylenol probably overcame those fears when their very own doctor gave them Tylenol.

“People forget how we built up such a big and important franchise,” said Burke. “It was based on trust. People started taking Tylenol in hospitals or because their doctors recommended it. In other words, they were not well and in a highly emotional state,” said Burke. However, the “trust” that built the Tylenol franchise was the trust that patients had in their doctors.

*****

On the morning of September 30, 1982, just after the autopsy on Lynn Reiner’s body had begun at 9:45 a.m., the DuPage County Coroner’s Office received a call from Captain Enders of the Winfield Fire Department. Enders had been involved in the rescue call for Lynn the previous day. He told Deputy Coroner Peter Siekmann that Lynn had taken Tylenol shortly before she collapsed. Enders also advised Siekmann about the news reports of the Tylenol poisonings in Arlington Heights and Elk Grove Village.

As soon as he got off the phone with Enders, Siekmann called Winfield Police Chief, Carl Sostak, and asked him to go out to Reiner’s home to “retrieve any and all bottles of Tylenol or any Tylenol capsules which may not have been in any bottle.” Those are the exact words that Siekmann wrote in Reiner’s Coroner’s Report. Siekmann specifically asked Chief Sostak to check for any capsules that may not have been in any bottle. This statement implies that Siekmann had prior knowledge or at least a hunch that Reiner’s cyanide-laced capsules had been dispensed in a unit-dose package at the hospital, and thus would “not have been in any bottle.”

At around 11:00 a.m., Thursday morning, Winfield Police Officer Scott Watkins, accompanied by Chief Sostak, returned to the Reiner home to investigate what they now suspected was a murder. They sat down with Ed Reiner and gently questioned him about the events leading up to his wife’s death. They asked for details about her trip on Wednesday afternoon to Frank’s Finer Foods where she had purchased the bottle of Regular Strength Tylenol. They asked him if he knew anything about the Extra Strength Tylenol capsules that were inside Lynn’s Regular Strength Tylenol bottle. He did not. He guessed they were in the bottle when she bought them; probably put there at the manufacturing plant.

Sostak and Watkins then searched the Reiners’ home for Tylenol capsules, Tylenol bottles, and any other potential evidence. They found one bottle of Regular Strength Tylenol sitting on a shelf above the kitchen sink. Printed on the bottle’s label was the lot number, 1833MB. Police also found the box for the Regular Strength Tylenol bottle.

Chief Sostak brought Lynn’s Tylenol capsules to Peter Siekmann at the DuPage County Coroner’s Office in Wheaton. Siekmann turned them over to the Illinois Department of Health, also in Wheaton, shortly before 5 p.m. on Thursday afternoon. Toxicologists examined the capsules that evening, and completed their analysis just after midnight. Four of the remaining six Extra Strength Tylenol capsules in Reiner’s Regular Strength Tylenol bottle had been filled completely with cyanide. None of the Regular Strength Tylenol capsules contained cyanide.

On Friday, October 1st, Siekmann told reporters that shortly before Lynn died, she had taken two Extra Strength Tylenol capsules, one of which contained cyanide, from a bottle containing other capsules laced with cyanide. He said the lot number for the Extra Strength capsules was not immediately known because Mrs. Reiner had carried them in a bottle of Regular Strength Tylenol capsules. However, investigators had in fact already tracked down the source of Reiner’s Extra Strength Tylenol capsules. Those capsules were from a unit-dose package, bearing lot number 1665LM, dispensed at Central DuPage Hospital. The existence of that lot number was revealed Friday night, but then quickly covered up.

At the request of officials from the Tylenol task force, NBC’s Chicago affiliate, WMAQ-TV, warned Chicago area residents that cyanide had been found in Extra Strength Tylenol from four different lots. In its 10 p.m. news broadcast of Friday, October 1st, WMAQ-TV announced:

The task force is asking for help in solving the bizarre crime. They want those who still have Tylenol capsules from any of four lots to turn them over to their local police departments, or at least to the stores from which they were purchased. Those lots are labeled MC2880, MC2884, 1910MD, and 1665LM. Capsules are being tested around the clock for contamination and could provide valuable new leads in the case.

Prior to this WMAQ-TV news broadcast, officials had only disclosed the existence of cyanide-laced Extra Strength Tylenol capsules from Lots MC2880 and 1910MD. Nevertheless, officials had also found cyanide in Extra Strength Tylenol capsules from Lots MC2884 and 1665LM, but no national news outlet ever reported on the cyanide-laced Tylenol from these lots.

On Saturday, October 2nd, the local Arlington Heights newspaper, The Daily Herald, reported that the potential contamination had broadened Friday, as the poison had been found in three new batches of pills. These batches, 1910MD, 1665LM and MC2884, were added to the danger list on Friday, reported The Daily Herald. Late Friday night, shortly before midnight, officials said the cyanide-laced Tylenol that killed Paula Prince was from Lot 1801MA.

As of Friday night, authorities had publicly linked cyanide-laced Extra Strength Tylenol capsules from their specific lot numbers to each of the poisoning victims, with the exception of Lynn Reiner. The cyanide-laced Tylenol that killed Mary Kellerman and the Januses was from Lot MC2880. The poisoned Tylenol that killed Mary McFarland was from Lot 1910MD. The cyanide-laced Tylenol that killed Paula Prince was from Lot 1801MA.

For a number of reasons, Lynn Reiner’s cyanide-laced Extra Strength Tylenol capsules probably came from Lot 1665LM, rather than Lot MC2884. Tylenol from Lot MC2884, like the Tylenol from Lot MC2880, had been manufactured at McNeil’s Fort Washington plant in the spring of 1982. The Tylenol from Lot 1665LM had been manufactured at McNeil’s Round Rock plant in 1981.

McNeil sold the Tylenol from Lot 1665LM under an NDC (New Drug Code) for unit-dose Extra Strength Tylenol capsules, which wholesalers distributed in containers of 100 to 1,000 capsules only to hospitals and other institutional pharmacies. The Tylenol from Lots MC2880 and MC2884, since it was sold under the NDC for 50-count bottles of Extra Strength Tylenol capsules, was distributed to retailers.

Tylenol from Lot MC2884 must have been in the second contaminated bottle found at the Osco Drug store in Woodfield Mall, whereas Lynn’s cyanide-laced Extra Strength Tylenol capsules must have been from Lot 1665LM. The Tylenol from both these lots was shipped to Illinois through J&J’s regional distribution center in Montgomeryville.

On Saturday, October 2nd, lot numbers 1665LM and MC2884, were inexplicably removed from the “danger list” of cyanide-laced Tylenol lot numbers. The danger list now included only three lot numbers: MC2880, 1910MD, and 1801MA.

On Sunday, October 3rd, police - probably the Winfield police – told reporters for The Daily Herald and the Associated Press that they had identified a fourth lot number involved in the deaths. Police said Lynn Reiner had capsules from Lot 1833MB. But this was the lot number for Lynn’s bottle of Regular Strength Tylenol capsules - not her Extra Strength Tylenol capsules. Lynn’s coroner’s report confirms that “one bottle labeled Regular Strength Tylenol, Lot 1833MB,” was submitted to the lab by DuPage County Chief Deputy Coroner, Peter Siekmann, on Thursday, September 30th.

Interestingly, police did not say that Lynn had taken Tylenol capsules from Lot 1833MB, only that she had capsules from Lot 1833MB. Police explained that there had been “initial confusion over the lot number” in the Lynn Reiner case because “she apparently had mixed Extra-Strength Tylenol capsules with her Regular Strength Tylenol capsules.” Obviously, there could only have been confusion if there were two lot numbers to confuse. Yet, with just one brief news release, authorities had effectively replaced Lot 1665LM with Lot 1833MB, and thus buried the lot number of the poisoned Extra Strength Tylenol that had killed Lynn Reiner.

Winfield Police Officer Scott Watkins, now Lieutenant Watkins of the Lombard Police Department, was asked on August 19, 2010 what he knew about the investigation of Central DuPage Hospital as the probable source of Lynn Reiner’s cyanide-laced Extra Strength Tylenol capsules. He said he was unaware of any such investigation. When pressed further to offer some insight about the investigation that certainly must have included Central DuPage Hospital, Watkins shrugged his shoulders. It was the view of officials at that time, he said, that the tamperings were done at the retail stores.

When asked how authorities were able to identify the lot number for Lynn’s Extra Strength Tylenol capsules, Watkins replied, “I don’t know.”

Watkins also said that on Thursday morning, September 30, 1982, he and other investigators had searched through Reiner’s trash can and recovered the box for Lynn’s bottle of Regular Strength Tylenol. That trash can is probably also where they found the unit-dose package for Lynn’s Extra Strength Tylenol capsules. Printed on Lynn’s unit dose package were the lot number of her Extra Strength Tylenol capsules and the name of the Central DuPage Hospital pharmacy where they had been dispensed. Officials never disclosed the name of the distributor that delivered the poisoned Tylenol capsules to Central DuPage Hospital, but they did spend a great deal of time questioning employees at the largest distributor of Tylenol to hospitals in the Chicago area - the Louis Zahn Drug Company.

19

________

The Louis Zahn Drug Company

When Central DuPage Hospital converted its pharmacy to a unit-dose system in 1974, it also contracted with a local distributor to manage its inventory and provide frequent deliveries of drugs and other products to its pharmacy. Distributors make “just in time” deliveries to hospital pharmacies, usually several times per week. This system allows pharmacies to keep very low inventory levels and thus reduce costs.

The distribution company that gained the pharmacy-service-provider contract for Central DuPage Hospital is the same distribution company that delivered the cyanide-laced Extra Strength Tylenol capsules to the hospital’s pharmacy. Those poisoned capsules had already been filled with cyanide before they were loaded onto the delivery truck at the distribution center and then delivered to the pharmacy at Central DuPage Hospital.

On October 1st, and again on October 6th, 1982, ABC-News showed video footage of cases containing seventy-two 50-count bottles of Extra Strength Tylenol capsules inside the Louis Zahn Drug Company’s Melrose Park warehouse. Those Tylenol cases were just like the ones that deputies Al Swanson and Joseph Chavez had found in the parking lot at the Howard Johnson’s Motor Lodge and Restaurant in Elgin at 2:32 a.m. Tuesday, September 28th. Cases of Extra Strength Tylenol capsules were also in many other warehouses in Illinois at that time, but the Louis Zahn Drug Company likely was the pharmacy service provider that delivered the cyanide-laced Extra Strength Tylenol capsules to Central DuPage Hospital.

Louis Zahn founded the Louis Zahn Drug Company (Zahn Drug) in Melrose Park, Illinois, in 1931. In 1982, Zahn Drug was the largest independent drug wholesaler in the Midwest. It provided warehousing, merchandising, and purchasing management services to retail and institutional pharmacies, and stocked prescription drugs, OTC drugs, healthcare products, and a variety of other items normally stocked in drugstores. The company maintained its own delivery operation; leasing trucks and hiring union drivers to deliver drugs and healthcare products to pharmacies, retail stores, nursing homes, and hospitals. The company’s headquarters and primary distribution center were located at 1930 George Street, five blocks east of Jewel’s Melrose Park distribution center and about five blocks southeast of Jewel’s repackaging and distribution warehouse in Franklin Park.

When Louis Zahn died in 1976, the company’s majority ownership transferred to his son, Melvyn Zahn, who ran the company until 1989. The company’s chief operating officer since January 1982 was William P. Altman. Prior to joining Zahn Drug, Altman was vice president of Jewel Companies’ subsidiary Osco Drug.

The CFO of Zahn Drug, John Stockman, had been with the company since 1971. He left Zahn Drug in 1983 to become CFO of PRIDE (Prison Rehabilitative Industries and Diversified Enterprises) in Clearwater, Florida. Stockman began his career in 1964 as a store auditor for Walgreens in Chicago.

Louis Zahn was a well-known business leader in Chicago, and a long-time resident of Oak Park when he died from cancer at age 67. He had been a director of the White Sox and Sears Bank and Trust Company, and the honorary and former chairman of the Israel Bonds and Jewish National Fund. He was one of the founders and the first president of Gottlieb Memorial Hospital in Melrose Park, an original member of its Board of Governors, and the donor of the hospital’s first pharmacy. Zahn had also been the president of the West Towns Hospital Association.

Zahn Drug was the prime vendor for a group purchasing organization that consisted of hospitals affiliated with Chicago’s Northwestern Memorial Hospital. The hospitals in this group entered orders through an electronic data interchange communication system for hospital products manufactured by Baxter International, Abbot Laboratories, and Johnson & Johnson.

In 1982, Zahn Drug operated a state-of-the-art Automated Order Picking System at its Melrose Park headquarters. The company’s “Itematic” order fulfillment system was designed for extremely high throughput of a relatively small number of Stock Keeping Units (SKU’s). The Itematic was one of the most advanced systems of the time, with the capacity to select and deliver a variety of products in less than full-case quantities. Each customer’s order was entered into the system’s computer, and the system then automatically delivered the items to a workstation where they were manually picked (taken out of the bin) by a warehouse employee. The system used a number of rotating carousels, each having four columns of ten bins. The carousels moved along an oval track to the picking station and then rotated so the bin holding the appropriate item faced the human operator. A light on the bin containing the ordered item then lit up, and the warehouse employee picked the item from that bin and placed it into a tote (a plastic container). This process was repeated until all items from the order were picked and placed into the tote. The tote, containing the products and a shipping document, was then sent down a conveyor belt to a packing station. A warehouse employee packaged the items in a carton that was then loaded onto a delivery truck.

The capacity of the system at Zahn Drug was approximately 1,600 orders per day with 53 pieces per order; a rate of 850 items per hour for each of the 12 Itematic picking machines in the system. The 12 machines each contained approximately 8,000 items typical of those found at the corner drugstore. The system selected or “picked” items, such as bottles, cassettes, vials, and other individually packaged items. The system’s carousel-bins had to be manually replenished.

The video footage shown on ABC-News of the Zahn Drug warehouse showed only the warehouse area where the cases of Tylenol bottles were stored. It did not show the company’s 12 automated picking machines or the company’s employees manually loading the picking machines and manually filling individual stores’ orders. Based on the video footage shown on ABC, it appeared that everything was just as J&J and the FDA had claimed. It looked like Zahn Drug received cases of 72 bottles of Extra Strength Tylenol capsules from McNeil, and then shipped those cases, unopened, to retail stores and hospitals. But that’s not how the process actually worked.

In reality, warehouse employees opened the Tylenol cases and put the individual Tylenol bottles into the appropriate bins in the automated picking machines. A second employee, a “picker,” placed the Tylenol bottles from each order into a tote. Then, a third employee, working at the packing station, manually handled the Tylenol bottles again as he packaged the ordered items into boxes to be delivered to local retail stores and hospitals. Zahn Drug filled orders for bottles of Extra Strength Tylenol capsules in multiples of one bottle - not in full cases of 72 bottles as Johnson & Johnson and the FDA had indicated.

Zahn Drug also employed merchandisers who set up store-displays and restocked the store’s shelves with health and beauty care products. These employees provided the same type of services as the rack jobbers who worked for Sav-A-Stop, delivering Tylenol and other products to the local stores and placing them on the store’s shelves.

Bottles of Extra Strength Tylenol capsules were rarely delivered to retail customers by the full case of 72 bottles. Rather, they were delivered in multiples of six Tylenol bottles or one Tylenol bottle, depending on how the picking system was set up. Retail stores and hospital pharmacies received just-in-time deliveries of drugs and other products. Most retail stores ordered just enough Tylenol bottles to cover sales until the next shipment arrived, typically, no more than a week later.

Managers at Jewel stores told NBC-News that they were selling one or two bottles of Extra Strength Tylenol capsules per day. For those stores, a typical weekly order would have been around a dozen bottles of Extra Strength Tylenol capsules. The 165,000 stores nationwide that sold Tylenol sold an average of just one or two bottles of Extra Strength Tylenol capsules per week. They did not order Extra Strength Tylenol capsules by full cases of 72 bottles. In most cases, the ordering was left to rack jobbers and merchandisers who manually restocked the store’s shelves about once per week with just enough bottles to fill the displays.

Employees at distribution centers operated by wholesalers like Zahn Drug could have easily put cyanide-laced Tylenol capsules into the Tylenol bottles at the warehouse. The more likely scenario, however, is that the Tylenol killer dumped cyanide-laced Tylenol capsules into the bottling production lines at a repackaging facility in Illinois. That facility might have been operated by Jewel Companies, Zahn Drug, or some other local company. One thing is certain - whoever left those two cases of Extra Strength Tylenol capsules in the Howard Johnson’s parking lot had taken them from a local warehouse. That person obviously had access to Tylenol in the channel of distribution.

*****

Zahn Drug served 1,400 drugstores in Illinois, Wisconsin, and Indiana. The company had formed a network of 50 independent charter pharmacies in 1974 called Family Drug Centers. The Family Drug Center (FDC) stores were located throughout the Greater Chicago area from the Illinois-Wisconsin border to Logansport, Indiana, and had grown to 75 members in 1982, ten of which were located in the Northwest suburbs of Chicago.

The communications between McNeil officials and the Zahn Drug FDC affiliate, Kesling Drug, further indicate that Zahn Drug handled some or all of the cyanide-laced Tylenol capsules delivered to Chicago area outlets.

Kesling Drug was located in Logansport, Indiana, about 144 miles southeast of Zahn Drug’s headquarters and warehouse in Melrose Park. The interaction between McNeil executives and the owner of Kesling Drug on the day after the Tylenol murders was extensive and well outside the norm. The vast majority of Chicago area pharmacies never received a single call regarding the Tylenol tamperings from J&J or McNeil officials. Kesling Drug, however, received a great deal of attention from McNeil - an inordinate amount of attention in fact.

On the morning Johnson & Johnson learned about the Tylenol poisonings, a McNeil official called Kesling Drug and told the store’s owner to remove all of the bottles of Extra Strength Tylenol capsules from the store’s shelves. Yet, on that same day, J&J executives told the general public that the tampering problem was local, affecting only a few stores in the Chicago area. So it was certainly odd, even suspicious, that J&J was so concerned about getting the Tylenol capsules out of the Kesling Drug store located all the way down in the small rural town of Logansport, Indiana.

On Friday, October 1st, David Maroney, from the Logansport Pharos-Tribune, interviewed Estel Kesling, the owner of Kesling Drug. Estel described the urgent calls she had received from McNeil executives the previous morning. “People started calling yesterday (Thursday), and we took it (Tylenol) all off the shelf,” she said. “McNeil already has called us twice on this. They made us go out and personally check all the lot numbers while they waited on the telephone. They called us twice, then said they would have a representative in here today (Friday),” recalled Kesling. These calls, because of the insistence, appear to have been emergency calls. They were followed the next day by a visit from a McNeil representative who then removed the Extra Strength Tylenol capsules from the Kesling Drug store.

J&J was especially concerned about the lot numbers on Kesling’s Tylenol bottles. The McNeil official who first called Estel Kesling told her to check the lot numbers on her Tylenol bottles while he waited on the phone. Surely, J&J’s madman had not gone all the way down to Logansport, Indiana to plant cyanide-laced capsules in Tylenol bottles specifically from Lot MC2880 at Kesling Drug.  J&J executives would have been concerned about the lot numbers only if they believed that the Tylenol from specific lots had been poisoned in a warehouse in the channel of distribution. The attention that McNeil officials paid to Kesling was inconsistent with the statements of J&J executives who assured consumers that the tamperings were a local issue only.

J&J Vice President, Larry Foster, told reporters, “It’s our strong belief that the contaminated product was limited to the Chicago area.” Logansport, Indiana is 130 miles southeast of Chicago. By no measure is Logansport in the Chicago area. Kesling Drug received its Tylenol from the Zahn Drug warehouse in Melrose Park. Johnson & Johnson officials were obviously very worried about Extra Strength Tylenol capsules in drugstores that had received shipments of Tylenol from Zahn Drug.

The official line is that Zahn Drug did not distribute any of the bottles of cyanide-laced Tylenol. The calls from McNeil executives to Kesling Drug suggest otherwise. Those calls were not made out of an overabundance of caution either. Rather, they were targeted emergency calls. Two drugstores located just down the road from Kesling Drug - the Hook’s and the Haag drugstores - received no such calls from J&J or McNeil. That makes sense, because the Hook’s and Haag stores did not receive their Tylenol from Zahn Drug. The vast majority of retail stores in the Chicago area also never received calls or visits like the ones from McNeil representatives to Kesling Drug.

Chicago pharmacist, Robert Wijas, from the Dinet & Delfosse Pharmacy in Chicago, was interviewed by ABC-News six days after McNeil had made those urgent calls to Kesling. Wijas said a representative from Johnson & Johnson had been out that day [October 6th] to pick up the pharmacy’s inventory of Tylenol capsules. The Dinet & Delfosse Pharmacy was located on North Michigan Avenue in Chicago, just two miles south of the Walgreens store where Paula Prince had purchased a bottle of cyanide-laced Tylenol. Yet no J&J representative visited the Dinet & Delfosse Pharmacy until after J&J announced the recall of all Tylenol capsules.J&J officials were obviously far more concerned about the source of a store’s Tylenol than its proximity to Chicago.

In addition to the close attention paid to Kesling Drug in Indiana, Johnson & Johnson was also extraordinarily concerned about the Extra Strength Tylenol capsules at a distributor’s warehouse in Altoona, Pennsylvania. On Friday, the day after the angst-ridden calls from McNeil executives to Kesling Drug, Jeff Montgomery, of the Altoona Mirror, contacted the owner of the “Altoona-area’s only pharmaceutical warehouse.” In 1982, the only pharmaceutical warehouse in the Altoona area was Value Drug, founded in 1934 by a cooperative of 19 local independent pharmacists to consolidate their purchasing power. Its products included pharmaceuticals and non-prescription medications, hospital equipment, health and beauty aids, nutritional supplies, and other healthcare-related products. Like Zahn Drug, Value Drug had a network of affiliated independent drugstores, and was the area’s largest independent drug distributor.

During a short period of time on Friday morning, October 1st, the owner of Value Drug had three intense conversations with McNeil representatives. “They [McNeil] checked us three times within an hour this morning [Friday],” the owner told the Altoona Mirror. “Naturally, we heard it all on television late last night, and the first thing this morning, McNeil was on the phone giving us the two lot numbers to check,” he said. “At 8:30 a.m. a McNeil pharmaceutical salesman checked our stock, and at 9 a.m. a McNeil consumer products man from Pittsburgh came and checked it again.”

“I think they bent over backwards,” said the owner of Value Drug, referring to the intense, rapid communication from McNeil officials and the speed with which they checked his stock of Tylenol capsules.

McNeil executives were obviously very concerned that Value Drug might have received a shipment of cyanide-laced Extra Strength Tylenol capsules. Once again, the actions of McNeil officials conflicted with Johnson & Johnson’s assertion that the tamperings had occurred at the Chicago area retail stores. Obviously, a madman, supposedly sabotaging Tylenol bottles in retail stores in Illinois, did not go to the Value Drug warehouse in Altoona, Pennsylvania, 563 miles east of the Tylenol murders crime scene, to sabotage bottles in that warehouse.

While McNeil representatives were rushing out to check the potentially poisoned Tylenol capsules at Value Drug, Larry Foster was telling reporters that the poisoned Tylenol capsules came from two different plants, which “leads us to believe strongly that the problem rests in Chicago.” But on that very same morning, a McNeil official called the owner of Value Drug in Altoona, Pennsylvania to make sure he did not deliver any Extra Strength Tylenol capsules to any of his customers. Then at 8:30 a.m., a McNeil representative went to the Value Drug warehouse in Altoona to “check” the Tylenol in the company’s warehouse. Thirty minutes later, at 9:00 a.m., a McNeil “product man” from Pittsburgh showed up at Value Drug to “check” the Tylenol inventory again. Pittsburgh is 96 miles west of Altoona, so this McNeil “product man” must have hit the road early in the morning to get out to Value Drug by 9:00 a.m.

On that same morning, J&J spokesperson, Marshall Malloy, said the company was not issuing a recall for Tylenol from Lot 1910MD. But J&J executives then reversed that decision soon after two McNeil representatives visited the Value Drug warehouse in Altoona, Pennsylvania, and checked that distributor’s stock of Tylenol capsules from Lots MC2880 and 1910MD. J&J executives evidently understood that the cyanide-laced Tylenol capsules from those lots had been poisoned in a warehouse in the channel of distribution.

Around the same time J&J officials were checking the Tylenol capsules at the Value Drug warehouse on Friday, October 1st, officials from the FBI, FDA, and IDLE initiated a series of visits to the Zahn Drug warehouse in Melrose Park and questioned the company’s employees about the Tylenol recently distributed from that warehouse. These officials had obviously traced at least some of the cyanide-laced Tylenol capsules back to Zahn Drug.

The Tylenol killer may have used Zahn Drug as an unwitting partner in his murderous plot. This company had a history of security problems dating all the way back to an infamous heist involving the notorious mob-connected Chicago lawman, Dick Cain. In October 1963, a truck loaded with $250,000 worth of drugs was stolen from Zahn Drug’s warehouse in Melrose Park. Four months later Dick Cain, then chief of inspectors for the Cook County Sheriff’s Department, received a tip from mobster, Guy Mendola, that some of the stolen drugs were stored at the Caravelle Motel in Rosemont. Cain, along with Lieutenant James Donnelly and Sergeant John Chaconas, raided the motel and recovered $43,000 of the stolen drugs.

Cain’s story sounded suspicious to State’s Attorney Daniel P. Ward, so he launched an investigation into Cain’s dealings with Mendola. The details of the scheme were never proven, but Ward maintained that Cain and Mendola had stolen the drugs. When they were unable to find a buyer for some of the drugs, Cain and his deputies conducted a fake raid to create the impression that their superb investigative work had led to the recovery of some of the stolen drugs, when in reality they were involved in the theft. Cain was fired and convicted of perjury for lying about the robbery to a Grand Jury. Cain’s sentence was later suspended.

Another puzzling crime involving Zahn Drug occurred in 1973 when Melvyn Zahn, the president of Zahn Drug at the time, was kidnapped. Melvyn had left the Zahn Drug warehouse at 6:15 p.m. on June 27, 1973, and told the guard to call his wife and let her know that he’d be home in 25 minutes. While driving home, Zahn was pulled over in Franklin Park by a dark car with a flashing red light. Witnesses reported seeing Zahn gesturing with his arms and apparently arguing with two men standing alongside both cars. One of the men then pulled a gun and forced Zahn into the back seat of the dark car.

Zahn’s kidnappers moved him several times between places in Chicago, its suburbs, and a house in Michigan City, Indiana. In a $1.5 million ransom note that his kidnappers forced him to write to his father, Melvyn wrote in part, “As long as you cooperate with their demands, I’ll see you soon... [but] the first police officer who shows on the scene means instant death for me... please believe me when I say they are serious...” However, the kidnappers never told Louis Zahn where to deliver the ransom money.

The next day, even though the kidnappers had told Louis Zahn not to go to the police, newspapers across the country reported the kidnapping. They even quoted Melvyn Zahn’s attorney, who said, “The family is only interested in Mel’s well-being, safety, and immediate return ... The family has informed authorities that they wish to be allowed without any interference to meet any instructions and demands that will ensure Mel’s safe return.”

Stranger still is the public statement released by Richard G. Held Sr., special agent in charge of the FBI’s Chicago office. “Of course we will stand aside,” Held said. “Our big concern is getting him [Zahn] back if he has been kidnapped.”

Zahn said that on Friday morning he gained the trust of his abductors who allowed him to use the bathroom un-shackled and un-watched. Zahn jumped from the first-floor bathroom window of the Michigan City house where he was being held and then fled from the house and waved down the first car he saw. As luck would have it, the car being driven by Michigan City Police Officer, Edward Wojasinski. The captain of the Michigan City police, Ralph Stormer, quickly organized a posse of police officers. Zahn then directed them back to the house where he had been held. As they approached the house, the suspects fled the scene in separate cars. Police immediately curbed one of the cars and grabbed the driver. As the other kidnapper sped away in the second car, police fired multiple “warning” shots at the car, and it rammed into several parked automobiles and stopped.

George Edward Ferris, age 53, and William Robert Calhoun, age 47, both from Chicago, were held on federal kidnapping charges. Investigators said the kidnappers had tracked Zahn for more than a year before abducting him. The FBI and federal sources would only say that the mysterious connection between Zahn and the two arrested kidnapers “is integral to the case,” but they never revealed what that mysterious connection was. Ferris and Calhoun pled guilty to charges of conspiracy and kidnapping, and they received prison terms of 12 and 15 years, respectively.

In later years, Zahn Drug was the target of other notable criminal schemes. On April 6, 1987, Art Walker, a driver for Zahn Drug, was found guilty of stealing $125,000 worth of drugs by placing bogus orders and then keeping the drugs himself. On December 9, 1992, William R. Deacon was sentenced to six months in prison after pleading guilty to tax fraud for accepting more than $416,000 in bribes from James E. Wells, the owner of Wells Trucking Company. Deacon had been the director of transportation at Zahn Drug when he took those bribes.

Zahn Drug also had a history of making some really bad hires. In the mid-1970s, Zahn Drug hired PDM Contracting of Norwood Park, Illinois to remodel drugstores that belonged to its group of Family Drug Centers. The firm’s owner, John Gacy, worked as an independent contractor for Zahn Drug for 2 1/2 years. Gacy often gained contracts by undercutting his competitors’ bids. He stayed profitable by hiring a number of teenage boys at low wages. Gacy was in the midst of a remodeling job for Zahn Drug FDC affiliate, Nisson Pharmacy, in Des Plaines, Illinois, when on December 13, 1978 police followed a man they believed had abducted a missing boy, last seen at Nisson Pharmacy. That man, John Wayne Gacy, was a politically active, prominent businessman who sometimes performed as a clown for children in local hospitals. He also had a secret history of luring young men to his home to strangle, rape, and kill them. He buried twenty-nine of his victims in the crawl space below his house, dumped two more into the Des Plaines River and two others into the Illinois River. At least five of Gacy’s teenage employees at PDM Contracting became his victims. On May 10, 1994, after a final meal of fried chicken, French fries, Coke, and strawberry shortcake, Gacy was executed by lethal injection. His final words were “Kiss my ass.”

Prior to Gacy’s arrest, he had employed Robin Gecht to work on some of the remodeling jobs he received from Zahn Drug. In 1981, Gecht, 28-years-old at the time, became the leader of a small satanic cult that became known as the Chicago Rippers. Gecht and three associates, 23-year-old Edward Spreitzer and two brothers, 20-year-old Andrew and 23-year-old Thomas Kokoraleis, were suspected of murdering as many as 18 women in Chicago’s Northwest suburbs between May 1981 and October 8, 1982. The gang spent many nights driving around in their van in the Villa Park area looking for prostitutes to sacrifice in Gecht’s apartment. They claimed to have removed one breast from each victim and eaten it as Gecht read passages from the Satanic Bible. They were arrested in October of 1982.

Gecht took the witness stand on September 21, 1983, and insisted that he had killed no one. He did, however, confess to the October 1982 attack on Beverly Washington, who had barely escaped with her life. Washington had been raped, beaten, and her left breast cut off before she was thrown into a dumpster and left for dead. Gecht was convicted of attempted murder, rape, deviate sexual assault, aggravated battery, and armed violence.  He was sentenced to 120 years in prison.

Gecht was never convicted for murder, but the other three members of the Chicago rippers were each convicted of one or more of the murders. Tom Kokoraleis received a sentence of life imprisonment. Andrew Kokoraleis and Edward Spreitzer were sentenced to death.  Andrew Kokoraleis was executed by lethal injection on March 16, 1999. Spreitzer’s execution was commuted when Governor George Ryan enacted a moratorium on the death penalty shortly before leaving office in 2003.

The history of Zahn Drug is marred by scandalous incidents. There seems to have been a criminal element always connected to this company’s operation – a criminal element that the Tylenol killer may have exploited. Authorities from the Tylenol task force spent a lot of time at Zahn Drug in the early days of the investigation; a good indication that this company had indeed distributed cyanide-laced Tylenol capsules to Chicago-area outlets.

There is a continuum in the drug distribution business in the Chicago area that begins with Zahn Drug and ends with McKesson. Zahn Drug, with $200 million in annual sales, was the largest distributor in the Midwest when FoxMeyer acquired it in 1989. FoxMeyer went bankrupt in 1996 and McKesson then bought the company’s remaining assets, which included Zahn Drug.

McKesson was the sole supplier of pharmaceuticals to Jewel-Osco stores in the 1990s and received supply management income for purchasing $1.5 billion annually of branded and repackaged pharmaceuticals for Osco Drug warehouses in La Habra, CA, and Elk Grove Village, IL. The five-year distribution agreement between McKesson and Jewel was renewed in 1998. The distribution agreement between McKesson and Jewel-Osco was renewed again in 2003. Distribution agreements tend to be renewed repeatedly, often for decades, so the genesis of the agreement between McKesson and Jewel might have been an agreement between Jewel Companies and Zahn Drug dating back to before 1982. McKesson is also the current pharmacy service provider for Central DuPage Hospital.

No one ever named Zahn Drug as the possible distributor of any of the Tylenol implicated in the poisonings. Nonetheless, officials from the FBI, IDLE, and the FDA spent a great deal of time at Zahn Drug’s headquarters and warehouse in Melrose Park. Officials from these agencies visited Zahn Drug a number of times, and questioned the company’s employees on multiple occasions.

On October 6, 1982, ABC aired an interview with Jim Dempsey, the vice president of operations at Zahn Drug. Dempsey described the scope of several recent visits to the company’s warehouse by government officials. “We’ve had the Illinois Department of Law Enforcement, we’ve had the FBI and we’ve had the FDA all come in,” said Dempsey. “They were principally interested in the lots of Tylenol Extra Strength capsules that we had, and they were also interested in what customers had purchased them, how many, and when.”

ABC aired the interview with Dempsey on October 6th, but the video footage of the Zahn Drug warehouse shown in that clip had been taken on October 1st, so the interview with Dempsey had evidently been taped back then. By Friday, October 1st, investigators had apparent.ly learned that Lynn Reiner’s Extra Strength Tylenol capsules had been dispensed at Central DuPage Hospital. They must also have learned that Central DuPage Hospital received its Tylenol from Zahn Drug. That explains why investigators from the FBI, the FDA, and IDLE were so interested in Zahn Drug.

Johnson & Johnson executives had evidently already identified Zahn Drug as the probable source of the cyanide-laced Extra Strength Tylenol capsules, when, on Thursday morning, September 30th, a McNeil executive phoned Kesling Drug and commanded Estel Kesling to remove all bottles of Extra Strength Tylenol capsules from the store’s shelves while he waited on the line for her to confirm that she had done what he had asked. At that time, the only two bottles of cyanide-laced Tylenol capsules recovered so far had been purchased at the Jewel-Osco stores in Arlington Heights and Elk Grove Village. J&J executives should have had no reason to suspect that Zahn Drug had delivered cyanide-laced Tylenol capsules to Kesling Drug – unless they knew that Zahn Drug had also distributed bottles of cyanide-laced Tylenol capsules to the Jewel-Osco stores in Elk Grove Village and Arlington Heights.

As the Tylenol task force entered the second week of its investigation, the available evidence pointed to a warehouse in the distribution channel as the location where the tamperings had occurred. But the FBI and IDLE were stuck on the tampering-in-the-retail-stores theory. They were focused on building a case against the man they had targeted on the first day of the investigation as the prime suspect.

20

________

We Know Who did It

In the first few days of the Tylenol murders investigation, the Tylenol task force interviewed about 1,000 people and developed list of about 24 suspects. Investigators quickly eliminated two-thirds of the names on that list. On Tuesday, October 5th, Fahner said there were only “eight or nine” prime suspects.  They all were Illinois residents, and some had a history of mental illness. “All were available to the location, exhibited peculiar behavior, or had a grudge as a possible motive,” Fahner revealed. “They are not being sought. We know who they are.”

One day later, Fanner said “the list of suspects has been narrowed,” but he refused to specify by how many. “I’ve been advised by investigators not to play a numbers game,” he explained.

Fahner was back in the numbers game again on October 9th, however, when he said investigators had cut their list of eight or nine suspects to “four main suspects.” Two had been interviewed, and some were under constant surveillance. By the end of that same day, authorities eliminated another suspect, leaving only three main suspects. Fahner said the six suspects were eliminated because they had recently passed lie detector tests.

Jerome Howard, the man removed from Fahner’s suspect list on October 9th, had left a letter on a receptionist’s desk at Gottlieb Memorial Hospital in Melrose Park on Thursday, October 7th, warning that patients would be poisoned with cyanide-laced Extra-Strength Tylenol unless a package containing $8,000 was left near the hospital’s maternity ward. The letter read, “Me and my gang put cyanide in every bottle of Extra-Strength Tylenol to see what it will do. ... Like seven deaths isn’t funny, but eight more will be.”

Howard, a 20-year-old former Gottlieb Memorial Hospital employee, was picked up on October 8th near the hospital maternity ward when he attempted to retrieve the ransom packet. A joint statement released by Tyrone Fahner and Edward Hegarty, the special agent in charge of the FBI’s Chicago office, said, “There is no credible evidence to indicate directly or indirectly” that Howard played any role in the Chicago area poisonings. Later that day, Fahner said the Howard case was “unrelated totally” to the Tylenol deaths, though he did admit Howard once had been one of their “main suspects.”

*****

The Tylenol task force got off the track early in the investigation, when they misinterpreted the evidence recovered at Lynn Reiner’s home. Lynn, after returning home from Frank’s Finer Foods on Wednesday afternoon, had swallowed two of the Extra Strength Tylenol capsules from her unit-dose package and dumped the other six capsules into her new bottle of Regular Strength Tylenol. She had then tossed the empty unit-dose package and the box for the Regular Strength Tylenol bottle into the trash can below her kitchen sink. Only Lynn Reiner knew about the unit-dose package of Extra Strength Tylenol capsules. And she threw away the only evidence of its existence minutes before she died.

The Winfield police would not confirm or deny whether they recovered the unit-dose package for Lynn’s Extra Strength Tylenol capsules. However, on March 9, 2010, Scott Watkins told Lynn’s daughter, Michelle, they had indeed found the box for Lynn’s bottle of Regular Strength Tylenol capsules in the trash can at Reiner’s home. They likely also found the unit-dose package bearing the lot number 1665LM and the name “Central DuPage Hospital” in the same trash can.

When investigators found six Extra Strength Tylenol capsules in Lynn’s bottle of Regular Strength Tylenol, they immediately became suspicious. They fixated on where those capsules were at the time of Lynn’s death, ignoring the relevance of where the capsules had been two days earlier. Their imaginations kicked in, and they hypothesized that the murder of Lynn Reiner was premeditated. Investigators then targeted a couple of Lynn’s relatives as the prime suspects.

On October 9th, an unidentified member of the Tylenol task force told reporters from USA Today that authorities knew who had committed the Tylenol murders. The source told USA Today that investigators had targeted a Chicago-area man as the prime suspect. “We know who did it. We just have to prove it.  If this guy doesn’t work out, we’re pretty much down to the end of the rope.”

USA Today held off reporting the story until March 1983, when the newspaper debuted in Chicago. When asked about the USA Today report, IDLE Commander Edward Cisowski said, “I really couldn’t make a comment either way about it. Our official stance is no comment.”

FBI Agent, Anthony DeLorenzo, commenting on the USA Today report in March 1983, said, “I don’t know where the heck they’re getting that from.” But he stopped short of calling the report false. “I don’t want to say it’s erroneous; that’s not proper to do,” he said. “The [newspaper] may have talked to somebody who said something like that. We have suspects, just like in any other case. But we don’t have any hot suspects like this article would indicate.”

On October 8, 1982, NBC led off its Nightly News broadcast with a story that, in retrospect, provides insight into what the unidentified investigator who talked to USA Today on October 9th meant when he said, “We know who did it. We just have to prove it.”

James Polk, reporting for NBC in Chicago, said, “Police believe the poisoned capsules [that killed Lynn Reiner] were placed in the Frank’s Finer Food store in Winfield on Wednesday.”

“This is the case that does not fit the pattern,” said Polk. “Winfield is a village 30 miles from downtown Chicago, and even the food store is hard to find. Lynn Reiner came here [to Frank’s Finer Foods] at 3 p.m. that day – as usual, she bought Regular Strength Tylenol. At home, Mrs. Reiner took one of these capsules (video showing Lynn’s Tylenol capsules being handled by a lab worker at the Illinois Department of Health in Wheaton) and it killed her. Mixed in with these gray Regular Strength capsules were red and white Extra Strength capsules - five laced with cyanide.”

“Investigators think Winfield may not have been chosen at random - that someone in a deliberate effort came here to make the switch at Frank’s Finer Foods,” said Polk. “The grocery is directly across the street from the entrance to Central DuPage Hospital. The FBI has asked for the records of all patients who have been through the psychiatric ward here.”

Investigators were clearly working on the assumption that Lynn Reiner had been the target of a premeditated murder plot. Un-named investigators told NBC that the killer had made a deliberate effort to poison capsules at the Frank’s Finer Foods store in Winfield on the same day Lynn Reiner went to that store, where, “as usual, she bought Regular Strength Tylenol.” This NBC report revealed that the authorities assumed that the Tylenol killer knew in advance that Lynn Reiner was going to buy a bottle of Regular Strength Tylenol at Frank’s Finer Foods on Wednesday afternoon. This was going to be the story that prosecutors would use to explain how eight red and white Extra Strength Tylenol capsules (five laced with cyanide) had gotten into Lynn’s bottle of gray and white Regular Strength Tylenol capsules.

Just when it looked like authorities were closing in on one of Lynn Reiner’s relatives as the prime suspect, a man who called himself a “closet chemist” entered the picture and muddled everything up.

21

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The Closet Chemist

On Saturday evening, October 9, 1982, Roger Arnold, a 48-year-old, wiry, chain-smoking warehouse worker, stopped off for a few drinks at O’Rourke’s Tavern, an Irish pub located in Lincoln Park on Chicago’s North Side. Arnold entered the tavern carrying a plastic bag of white powder that he said was cyanide. He then allegedly made comments about killing people with cyanide.

Tavern owner, Marty Sinclair, picked up the phone and called the Chicago Police. He told them Arnold was a peculiar bird who worked with the father of one of the Tylenol victims and kept test-tubes, guns, and two vials of cyanide in his house.

Two days later, Roger Arnold was in Lilly’s Bar, just down the street from O’Rourke’s Tavern, when Chicago police entered the bar at about 7 p.m. and picked him up on an outstanding arrest warrant for aggravated assault. With Arnold’s permission, the police searched his house on Chicago’s South Side. Police confiscated one bolt-action rifle, four handguns, and a stockpile of ammunition. Arnold was arrested and charged with failing to register the weapons and the prior charge of aggravated assault. The assault charge stemmed from a June 1982 incident when Arnold had gotten into a violent argument with Marty Sinclair - the same man who provided Chicago police the tip that led to Arnold’s arrest in the Tylenol case. During that altercation, Arnold had pointed a gun at Sinclair. The Chicago police held Arnold for questioning about the Tylenol murders.

Roger Arnold was born on July 29, 1934 to Alice Beam, who put him up for adoption through the Cradle Society of Evanston, Illinois. Arnold was adopted by Mable and Walter Arnold of Chicago in September 1934. Mable was a stay-at-home mom, and Walter was a supervisor for Butler Brothers, Inc. Arnold lived with his parents in a Pearl Court apartment in Chicago until he was 18. He had dropped out of school in the seventh grade and worked various jobs. At age 18, he got a job working at the Kemper Insurance warehouse in Chicago. Arnold entered the Army in 1957, and achieved the rank of corporal. He was discharged from the Army in 1959 and resumed his job at the Kemper Insurance warehouse.

In 1969, Arnold took a job as a warehouse worker for Jewel Companies and was still employed there when he became a suspect in the Tylenol murders case. Arnold was a foreman and union steward in Jewel’s salvage operation at the company’s Melrose Park distribution facility.

Prior to the aggravated assault charge in June of 1982 and his arrest in the Tylenol case in October, Arnold had a couple other brushes with the law. In 1968, Arnold was arrested in Chicago for aggravated assault and unlawful use of a weapon, charges later dismissed.  In 1981, Arnold was arrested in DuPage County and charged with possession of marijuana. He was found not guilty of that charge.

Of special interest to Chicago police was that Roger Arnold had recently stored cyanide in his basement and used it for unspecified “projects.” After arresting Arnold, authorities handcuffed him to a chair and questioned him Monday night and again on Tuesday.

Chicago Police Detective, James C. Gildea, said Arnold called himself a “closet chemist.” He apparently has “a working knowledge” of chemicals and compounds, said Gildea. Arnold said he had purchased cyanide “some months ago” but then discarded it in August 1982 – the same month that the Tylenol from some or all of the lots linked to the poisonings were shipped to Illinois.

On Tuesday afternoon, Chicago Police Detectives, Donald Eddy and Robert Rebholz, both members of the Tylenol task force, arrived at precinct headquarters on Chicago’s North Side at 4:00 p.m. They spent an hour and a half sifting through a stack of worthless tips from conspiracy theorists and psychics before Lieutenant August Locallo asked them to follow up on a lead. “You can read whatever you want into this,” said Locallo, but there are “a lot of suspicious coincidences” surrounding Arnold. Arnold had cyanide in his house, said Locallo, and he also worked at Jewel with the father [Howard Fearon, Sr.] of one of the victims [Lynn Reiner].

“At first [Arnold] denied that he had any cyanide,” said Locallo, “and then admitted that he did have some cyanide ... but got rid of it.” Arnold said he had previously kept cyanide in his basement for “experiments,” added Locallo. “He dropped the comment that he’s interested in catching the killer of this Tylenol case,” said Locallo, “that a friend of his is a truck spotter at the Jewel parking lot, and this friend of his daughter was the one [Lynn Reiner] that died in the Winfield incident.”

Locallo said they had received a tip that Arnold’s former wife had been hospitalized at the psychiatric ward at Central DuPage Hospital, right across the street from Frank’s Finer Foods. Locallo then stated incorrectly (a presumption it appears) that one of the victims [Lynn Reiner] had purchased cyanide-laced Tylenol capsules at Frank’s Finer Foods. “I want you to check out [Arnold’s] ex-wife and see what she knows.”

The detectives took a squad car and headed toward the North Side home of Arnold’s ex-wife, Delores Keas. A few minutes later they turned onto North Monticello Avenue and drove around the block twice before pulling into Delores’s driveway. She lived in the house with her 74-year-old brother, Philip Keas. Delores invited the detectives into her cluttered living room where they casually interviewed her for more than an hour.

Arnold had married Delores in 1970, and they moved into an apartment in Forrest Park, a Western suburb of Chicago. In 1981 they bought a house in nearby Oakbrook Terrace, but Arnold moved out the following year when Delores filed for divorce. The divorce was finalized in July of 1982.

Delores could not believe that her ex-husband was “goofy enough” to get involved in anything like the Tylenol killings. She said her husband had become interested in chemistry about six months ago, and chemicals were delivered to the house in Oakbrook Terrace. She said on one occasion, a number of years ago, Arnold had given her a Tylenol pill and she vomited, but that “was probably due to overeating,” she clarified.

Detectives Eddy and Rebholz finished questioning Delores and then took a break for dinner. On the way back to Headquarters, they received a call from dispatch with instructions to head down to Chicago’s South Side to stake out Roger Arnold’s house on the corner of South Hoyne Avenue and 34th Street.

For nearly two hours, Eddy and Rebholz sat in their car and watched Arnold’s small brown house. Finally, at 11:07 p.m., five police cars pulled up. A team of investigators from the forensic laboratory had a search warrant for Arnold’s residence. Chicago police, with Arnold’s consent, had searched the house Monday night, but now investigators went inside with vacuum cleaners to conduct a second, more thorough search. Warrants had also been granted to search Arnold’s car and work locker at Jewel. Eddy and Rebholz drove back to the North Side to keep an eye on Arnold’s red Chevrolet, which was parked on a street under the tracks for the “L” train. A forensic team arrived just before 1 a.m. and searched Arnold’s car.

While searching Arnold’s house, investigators found two one-way tickets to Thailand. Arnold’s reading material included a stash of Soldier of Fortune magazines, The Anarchist Cookbook of “recipes” for making explosive devices, and The Poor Man’s James Bond, a handbook written by right-wing survivalist and former minuteman, Kurt Saxon (aka Donald Sisco). Police confiscated several training manuals published in the mid-1960s by the United States Department of Defense for use by U.S. Army Special Forces. These training manuals were: Incendiaries, Boobytraps, Unconventional Warfare Devices & Techniques, and Military Chemistry & Chemical Agents. Police found lab equipment and various chemicals, including large quantities of a particular type of hair gel used in some of the bomb-making recipes found in The Anarchist Cookbook.

Police also turned up a suspicious-looking plastic bag of white powder, and a book that contained instructions for encapsulating cyanide. The white powder was turned over to the Chicago Health Department laboratory. A spokesperson for the Chicago police later said a lab test found that the powder was a harmless carbonate.

Arnold was held without bond while city detectives followed up on the “circumstantial evidence” that had led them to consider him a possible suspect in the Tylenol poisonings. Lieutenant Locallo said a “series of coincidences” had surfaced when Arnold talked with investigators, and they had to investigate further. The press reported these coincidences were that Arnold had told police that he had kept cyanide at his house until August; he allegedly had threatened to kill his estranged wife with cyanide capsules; he worked at a warehouse that officials said was a distribution point for some of the poisoned Tylenol; and he worked with the father of one of the Tylenol victims.

Arnold was released from jail on Wednesday night, October 13th, after paying $600 to a bondsman who then posted the $6,000 bail bond: $1,000 for each of the unregistered gun charges, and another $1,000 for the charge of aggravated assault.

Chicago Police Detective Jerry Beam said the assault charge stemmed from a recent incident involving Arnold and a bartender at a local tavern. Beam also said the bartender (Marty Sinclair) had provided police with the tip that led to Arnold’s arrest as a suspect in the Tylenol murders case.

Detective Marty Ryan confirmed that police had arrested Arnold because of a tip that he had two bottles of cyanide, but none of that poison was found in his South Side home. “It doesn’t appear the man [Arnold] is linked with the Tylenol poisonings,” said Ryan. Nevertheless, Chicago police immediately put Arnold under around-the-clock surveillance.

Arnold’s lawyer, Thomas Royce, a well known Chicago defense attorney, said later that the scrutiny was relentless and continued for weeks. Surveillance was so heavy, said Royce, that he and Arnold began meeting in McKinley Park, near Arnold’s home, to keep from being overheard. Even there, a detective walked up one day and demanded Royce’s identification.

Lieutenant Locallo said Arnold, on the day he made bail, had refused for the second time to take a lie detector test, saying the furor over the Tylenol case made it an inopportune time for him to do so.

The reading material confiscated from Arnold’s home, his recent order of cyanide, and his purchase in late September of two one-way tickets to Thailand were all suspicious. The tickets had a departure date of October 15th, for what Arnold said was going to be a 28-day vacation.

Arnold said he went to Thailand every year at this time. But Thomas Royce, who described Arnold as a “soldier-of-fortune type of guy,” said Arnold had never been to the country. He also said Arnold cancelled his Thailand vacation before posting bail.

Upon leaving the jailhouse on Wednesday, Arnold declared, “They can say what they want, I am not a suspect. I had nothing to do with this Tylenol thing at all. This is more circumstance than anything.”

Regarding his possession of cyanide, Arnold said, “It just happens that they blew it out of proportion. I’m not saying what the chemicals were used for, but it was nothing illegal. “I was willing to take a polygraph,” Arnold added, “but my lawyer advised against it.”

Arnold then said something that didn’t seem to make sense: “I knew the family, unfortunately, but not the suspect.” The relevance of that statement would become clear two weeks later.

Officer Jaye Schroeder, speaking for the Chicago Police Department, said of Arnold’s arrest, “There are too many coincidences to rule him out, but not enough evidence to say for certain it is him.”

Tyrone Fahner, on the other hand, completely dismissed Arnold as a viable suspect. Fahner described Arnold’s arrest as “another one of those [incidents] that are unrelated” to the killings. Fahner’s un-named spokesman said, “Based on what we know about Mr. Arnold, it does not appear likely that he is the main suspect in this case.”

Despite Fahner’s public dismissal of Arnold as a suspect, the circumstantial evidence against him was extremely compelling. Arnold admitted he had purchased cyanide, apparently in April of 1982, and then disposed of it in August. Arnold owned an array of books on bomb making, booby traps, and poisons, and he had access to Tylenol in the distribution channel. Furthermore, Marty Sinclair was not the only tavern owner who had heard Arnold talk about poisoning people with cyanide. According to the Daily Herald, Arnold had reportedly told several Chicago tavern owners rambling stories about killing people with cyanide.

Chicago cops believed they had a good case against Arnold, but Fahner appeared uninterested. In response to questions about Arnold’s arrest, Fahner simply said, “The lead in that case was developed by Chicago police… and their information to us is that it’s unrelated.”

In truth, the Chicago police never suggested that the Arnold case was “unrelated” to the Tylenol murders investigation. The leaders of the Tylenol task force, however, had targeted their prime suspect already. Arnold’s arrest was an unwelcome distraction. Law enforcement officials soon found a way to incorporate that distraction into a conspiracy theory.

22

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A Conspiracy Theory

On Friday, October 22, 1982, Tyrone Fahner set up weekend negotiations with Thomas Royce, reportedly to work out a deal with Roger Arnold in exchange for information he might have about the Tylenol murders. Three days later, the earlier portrayal of the Tylenol killer as a random murderer who did not know any of his victims suddenly changed.

The early edition of the Chicago Sun-Times, on Monday, October 25th, reported that investigators believed that two men had conspired to commit the Tylenol murders. Authorities had questioned a “prime suspect” on Sunday night who was a relative of one of the victims. The victim and the victim’s relative reportedly had a violent argument in late September before the poisonings occurred. Investigators said they believed that this relative - possibly acting with another person - had placed cyanide-tainted Extra Strength Tylenol capsules on the shelves of several stores to give the appearance that the targeted relative was one victim of several random murders. The Sun-Times further reported that the “prime suspect” was a “long-time friend” of Roger Arnold.

On Monday evening, NBC-News specifically named Roger Arnold as one of the alleged co-conspirator in the Tylenol murders. Two weeks earlier, police had said one of the “coincidences” that made Arnold a suspect was that he worked with a relative of one of the victims. Now, with the disclosure of a Tylenol murder conspiracy theory, the relevance of that alleged relationship was more apparent. Investigators had evidently been trying to connect Roger Arnold to Lynn Reiner’s father, Howard Fearon Sr., a truck driver for Jewel, ever since Arnold’s arrest two weeks earlier.

Shortly after Arnold’s arrest, the press began cleverly placing Fearon into their news stories, stating that Roger Arnold worked with Fearon, a relative of one of the victims, i.e., one of the “interesting coincidences” that made Arnold a suspect. Fearon had been under around-the-clock surveillance since the beginning of the investigation.

The New York Times said Arnold appeared to be a promising lead in the investigation because of his interest in poisons, his collection of literature on killing people, and his employment at Jewel Food. The victim’s relative who was a suspect was reportedly a “longtime friend” of Arnold’s. Chicago’s local NBC affiliate reported that Arnold and the victim’s relative were “drinking buddies.”

From the first day of the investigation, Tyrone Fahner and the agents from the FBI and IDLE had been trying to build a case against a relative of Lynn Reiner. Roger Arnold alluded to this fact twelve days before the Tylenol murder conspiracy story broke when he said, “I knew the family, unfortunately, but not the suspect.”

The “suspect” Arnold was referring to was apparently Howard Fearon, Sr. The “family” Arnold mentioned was the Reiner family. His use of the word “unfortunately” was probably a reference to the unfortunate death of Lynn Reiner.

Authorities interrogated Fearon on Sunday night, October 24th. On Monday, NBC reported that Roger Arnold’s lawyer, Thomas Royce, had conducted weekend negotiations with Illinois Attorney General, Tyrone Fahner. NBC quoted an unidentified high-ranking investigator as saying Royce was “trying to make a deal for Arnold” regarding information Arnold might have about the Tylenol case.

Royce, however, said he only met with Fahner to try to find out why investigators were interested in Arnold. “He is the most innocent person you can imagine,” Royce insisted.

Tom Brokaw opened NBC’s Monday evening news broadcast by saying, “Chicago authorities now believe they know the real story behind the Tylenol murders. They’re working on a substantial lead, but they’re not yet prepared to make an arrest. However, the investigation, which has involved false leads and sensational developments which turn out not to be true does now appear to be going in one direction.”

Jim Cummins, reporting for NBC in Chicago, said, “Investigators now believe the seven Tylenol murders were the work of two men, including the relative of one of the victims. Investigators believe the two men conspired to kill a member of the relative’s family and cover up that crime by planting poisoned Tylenol in stores, killing other people to make it look like the work of a madman.”

NBC did not identify the name of the victim’s relative who was the suspect, but a law enforcement source in Washington said “members of the family of Mrs. Reiner were interviewed Monday,” and “they have been very cooperative.”

NBC showed video footage of an unidentified detective sitting in an unmarked car outside the home of the “prime suspect.” Tom Brokaw said that this prime suspect - a relative of one of the victims - was under constant surveillance. Based on prior news reports from the Chicago Sun-Times and WMAQ-TV, the prime suspect Brokaw was talking about was apparently Lynn Reiner’s father, Howard Fearon Sr. As it turned out, however, that was not the case.

The unmarked police car parked in front of the “prime suspect’s” house on Monday afternoon was actually parked outside the home of Ed Reiner. The prime suspect referenced by Tom Brokaw on October 25th and Roger Arnold on October 13th was not Howard Fearon, Sr., after all. Fearon was a suspect; he just wasn’t the prime suspect. Ed Reiner had been under around-the-clock surveillance since the very beginning of the investigation. He had been the prime suspect all along.

Ed wasn’t home when NBC shot that video footage outside his home late Monday afternoon. He had snuck out the back door to attend an invitation-only meeting with agents from the FBI and the Illinois Department of Law Enforcement (IDLE). The press never specifically named Ed Reiner as a suspect, but they did set up camp outside his home, hoping to get the money-shot of police hauling him away in handcuffs.

IDLE investigators asked Ed to meet with them Monday, October 25th, to “help out with the investigation.” Agents from IDLE had leaked the Tylenol murder conspiracy story on Sunday night, so it would be headline news by the time they met with Reiner on Monday afternoon. The interrogation of Reiner, conducted by agents from the FBI and IDLE, went on for several hours, but it had barely begun when the interrogator’s true objective hit Reiner like a sharp slap to the face. They wanted Reiner to confess to the Tylenol murders.

An IDLE investigator began the interrogation by declaring that Reiner had murdered his wife with cyanide-laced Extra Strength Tylenol capsules. He also said that Reiner, with help from Roger Arnold, had planted bottles of cyanide-laced Tylenol capsules in Chicago area supermarkets and drugstores. He said investigators knew that Reiner and Arnold were drinking buddies and that they had planned the Tylenol murder conspiracy at a bar on Chicago’s North Side. The interrogator then falsely claimed that authorities even had photographs of Reiner and Arnold hanging out together inside that bar.

Reiner was flabbergasted. He had never met Roger Arnold. He did not hang out in any bars on Chicago’s North Side, and there were certainly no pictures of him and Arnold together at a North Side bar or anywhere else for that matter.

The IDLE agent spent an hour or more questioning Reiner before turning the interrogation over to the FBI. The FBI interrogator then made an astonishing revelation. The Tylenol murder conspiracy was not just a two-man conspiracy theory, as reported in the news media – it was a three-man conspiracy theory. The alleged co-conspirators were Ed Reiner, Roger Arnold, and Howard Fearon, Sr.

In a condescending, perverse tone, the interrogator told Reiner that the investigators knew that he, his father-in-law, and Roger Arnold were drinking buddies. The three of them, said the interrogator, had killed Reiner’s wife and then planted bottles of cyanide-laced Tylenol in local stores, to make it look like Lynn’s death was one of several random murders committed by a madman. The interrogator claimed that Reiner, Fearon, and Arnold were about to skip the country for Thailand when Arnold was picked up on October 11th.

As the inquisition dragged on, a foreboding concern was growing in Reiner’s mind. He was rightfully apprehensive that his name was about to be plastered all over the media as the prime suspect. Investigators from IDLE had planted the seed for that fear by leaking their fabricated story of the Tylenol murder conspiracy to the press. Several hours into his interrogation, the time was finally right to offer Reiner a way out of his predicament. The interrogators offered Reiner the same deal they had given his father-in-law the previous day. If Reiner was truly innocent, said one FBI interrogator, he should take a lie detector test.

To the consternation of his attorney, Reiner immediately agreed. Reiner was plenty pissed off, and he wanted to put a stop to all the ridiculous speculation about him. Reiner said he would take the lie detector test, but he wanted the results made public right away. That was probably the worst deal a suspect in a high-profile murder case could ever make.

Polygraphs, because they fail to conform to the Frye doctrine, were inadmissible in a court of law in 1982. The Frye doctrine states that in determining whether to admit scientific expert evidence, the court must examine whether the scientific method has attained “general acceptance” within the relevant scientific community. Polygraphy is widely rejected by the scientific community, which classifies it as “junk science.” According to polygraph expert, Michael Lawrence Langan, M.D., the accuracy of polygraphic lie detection is slightly above that of chance.

The polygraph test most commonly used in forensic settings, the Control Question Test (CQT), is based on an implausible set of assumptions that makes it biased against innocent individuals and easy for guilty persons to defeat using countermeasures, says William G. Iacono, PhD, a Distinguished McKnight University Professor at the University of Minnesota. Iacono has done extensive research on the detection of deception. His research found that a major goal of polygraph testing is to solve crimes by extracting occasional confessions from those who fail the tests.

Law enforcement agencies tend to administer polygraph tests only in certain cases. For most of these cases, says Iacono, investigative efforts have failed to yield compelling incriminating evidence, and it is likely the case will go unsolved unless a suspect confesses. Iacono says it is at this point that suspects are likely to be asked to take a polygraph test. This is exactly where Fahner and the Tylenol task force were in their Tylenol murders investigation in October 1982 when they cajoled Howard Fearon Sr., Ed Reiner, and several relatives of other Tylenol victims into taking lie detector tests.

Polygraph exams cannot produce evidence or solve crimes, but they are an applicable psychological weapon. They were the primary “investigative tool” used by the members of the Tylenol task force who put many relatives of the Tylenol victims on the suspect list. The only way these relatives could get off that list was to take a polygraph exam. Law enforcement officials who had conducted an inept investigation were thus using polygraph exams out of desperation. It was out of pure desperation that on Monday afternoon, October 25th, investigators from the FBI and IDLE interrogated Ed Reiner and accused him of being the ringleader of a Tylenol murder conspiracy.

After the grilling Reiner received during the interrogation, he was obviously not in a very good state of mind to take a test designed to measure his level of anxiety. Nevertheless, Reiner knew the allegations were ludicrous, and he wanted to put an end to them. He had just finished the polygraph exam when the press began reporting the discovery of an eighth bottle of cyanide-laced Extra Strength Tylenol capsules.

23

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The Eighth Bottle

Jim Cummins, reporting for NBC-News in Chicago on Monday, October 25, 1982, said, “Investigators say that since the negotiations [between Tyrone Fahner and Roger Arnold’s attorney] began, they’ve learned that at least two more bottles of cyanide contaminated Tylenol were planted in the Chicago area and have not yet been recovered. And they now believe the cyanide used in the murders was purchased in a store in Racine, Wisconsin.”

The two bottles “not yet recovered” were the eighth and ninth bottles of cyanide-laced Tylenol. The “ninth bottle,” which was actually Lynn Reiner’s unit dose package of Extra Strength Tylenol capsules, was never mentioned again. The “eighth bottle,” however, became a major news story.

The eighth bottle reportedly had been purchased at Frank’s Finer Foods. Consequently, almost every news story about that bottle included the erroneous report that Lynn Reiner had also purchased a bottle of cyanide-laced Tylenol at Frank’s Finer Foods.

The cyanide-laced capsules in the eighth bottle were discovered when a litmus test conducted by laboratory technicians at the McNeil Consumer Products facility in Fort Washington indicated the probable presence of cyanide. McNeil officials turned the contaminated bottle over to FBI agents who took the bottle to the FBI’s laboratory in Washington D.C. for an extensive forensic analysis that included laser analysis to detect fingerprints.

On Monday night, a law enforcement source in Washington who asked not to be identified by name or department said the eighth bottle of cyanide-laced Tylenol had been purchased by a woman from West Chicago, in Winfield Township, and then turned in to police “some time ago, perhaps weeks ago,” but was “just processed today.” He said the bottle was sent with “a notation that it might be contaminated,” and subsequent tests had confirmed the presence of cyanide.

The source said the woman - later identified as the wife of DuPage County Circuit Court Judge, Duane Walter - had given the bottle to the Wheaton police who then mailed it to a lab operated by the McNeil Consumer Products Company. However, the Wheaton police had actually mailed the bottle to The Maple Plain Company in Maple Plain, Minnesota, which then mailed it to the McNeil Consumer Products Company in Fort Washington, Pennsylvania. The Maple Plain Company was handling the reverse distribution of Tylenol capsules.

Reverse distribution is industry terminology for the return of a product in the marketplace back to the manufacturer. When consumers mailed their Tylenol capsules to the Maple Plain Company, the company sent them a coupon for $2.50 toward the purchase of a replacement Tylenol product. The company then shipped the bottles of returned Tylenol to McNeil headquarters in Fort Washington where, with the exception of the eighth bottle of cyanide-laced Tylenol, they were destroyed. J&J had used the Maple Plain Company for many years to manage coupon programs for its products.

Previously, the Wheaton police, just like the other Chicago-area police departments, had been forwarding all the bottles of Extra Strength Tylenol capsules turned in by area residents, to Johnson & Johnson’s distribution center in Lemont.  In fact, the seventh bottle of cyanide-laced Tylenol was discovered by J&J toxicologists at the company’s temporary lab in Lemont, just four days before the eighth bottle of poisoned Tylenol was discovered by J&J lab workers at the McNeil plant in Fort Washington. In mailing the eighth bottle to the Maple Plain Company, the Wheaton police had simply followed the directive in the “Dear Doctor” letter J&J had sent to retailers and wholesalers on October 13th, the same day the eighth bottle reportedly was turned over to the Wheaton police. The “Dear Doctor” letter, written by McNeil Medical Director, Dr. Thomas Gates, said:

In response to this rapidly changing situation, McNeil has established the following policy pertaining to hospital, wholesale, and retail customers and consumers:

In agreement with the FDA, McNeil Consumer Products Company is voluntarily withdrawing all non-blistered TYLENOL® capsule products (including Regular Strength TYLENOL® Capsules, Extra-Strength TYLENOL Capsules, non-blistered CoTYLENOL® Capsules, and Maximum-Strength TYLENOL® Sinus Medication Capsules) from hospital, wholesale, and retail accounts nationally….. Consumers are urged to return all TYLENOL capsule products to the place of purchase, or to mail bottles to Tylenol Exchange, P.O. Box 2000, Maple Plains, Minnesota 55348.

In a statement given Monday night to the City News Bureau of Chicago, Tyrone Fahner said the eighth bottle was from Lot MC2873 and had been purchased at the Frank’s Finer Foods in Wheaton. The next day, however, Wheaton Police Lieutenant, Terry Mee, insisted that the woman who turned in the eighth bottle said she had purchased it at Frank’s Finer Foods in Winfield, not Wheaton.

Mee said the woman brought the bottle in to the police station on October 13th and identified herself as the wife of a DuPage County Circuit Court judge. The woman “definitely said she bought it [the eighth bottle] in Winfield sometime in the past. We are speculating that she bought it one to two weeks earlier,” said Mee. “She told us she intended to turn it in right after this [Tylenol murders story] broke, but that she just let it go by.”

Since there seemed to be some confusion about where the eighth bottle was purchased, the sensible thing to do was to ask the woman who turned the bottle in, the wife of Judge Duane Walter, where she had actually bought it. But that posed another problem.

When the FBI interviewed Mrs. Walter on Tuesday, she told them she was not the person who had turned in the eighth bottle. “We don’t know why she [the woman who actually turned the bottle in] used that name, and now we are obviously concerned with determining who that person is,” said Mee. “We are looking for a woman between 40 and 50 years old.”

On Wednesday afternoon, the woman who actually had turned in the eighth bottle called the Wheaton Police Department and identified herself as Linda Morgan, the wife of Judge Lewis V. Morgan Jr. The Wheaton Police had gotten it wrong. They knew the woman was the wife of a judge in the 18th Circuit Court in DuPage County, but they apparently had picked the wrong judge. Wheaton Police Chief, Carl Dobbs, said a “clerical error” had led to the incorrect identification of the “mystery woman” as the wife of Judge Duane Walter.

Linda Morgan said she had purchased the Tylenol on the morning of the murders, but then didn’t turn it in to the Wheaton police until October 14th.

“I believe now in the theory that if God wants you to go, it’s going to be your turn; and for some reason it wasn’t mine,” said Morgan. “We had discovered the news of the poisonings the next day (the day after the poisonings) and we put it (the Tylenol) aside.” She said family matters prevented her from turning in the bottle earlier, but she never revealed what those family matters were.

Fahner held a news conference on Wednesday, October 27th, and provided an update on the forensic analysis of the cyanide-laced capsules from the eighth bottle. Earlier that day, an unidentified source in Washington had said that the FBI had found a fingerprint on the inside flap of the box from the eighth bottle. Fahner now said that the FBI had also found a fingerprint on a capsule inside the eighth bottle and that the results from these fingerprint tests were about to be released.

Fahner then said, we are “closer than we have ever been” to solving the Tylenol murders case.

Fahner’s confidence was dashed later that day when the likely source of the fingerprints on the capsules and box from the eighth bottle became apparent. Linda Morgan came forward that afternoon and revealed that she had opened the box for the eighth bottle, as well as the bottle itself. Amazingly, she said she had even opened one of the capsules inside the eighth bottle.

“I opened the capsule,” said Morgan. It didn’t look odd, she remembered. Yet, when the Wheaton police mailed Morgan’s Tylenol bottle to the Maple Plain Company in Minnesota, they attached a note to the bottle, saying it might be contaminated. If the capsules in that bottle did not look odd, as Morgan claimed, then why did the Wheaton police mail the bottle with a note saying the capsules might be contaminated? More importantly, why didn’t the Wheaton police turn that bottle over to the FBI or IDLE for testing?

According to Tyrone Fahner, the cyanide-laced capsules in Morgan’s Tylenol bottle did look odd. “The [eighth] bottle is clearly different than the other seven,” he said. “Some [of the cyanide-laced Tylenol capsules] were put together unartfully.” The poisoned medicine in the capsules from the eighth bottle had an “orangish” color, whereas the contents in the cyanide-laced capsules from the other seven bottles were off-white in color. In addition, the poisoned capsules in the eighth bottle contained a mixture of cyanide and acetaminophen, but the poisoned capsules in all the other bottles contained only microscopic trace levels of acetaminophen.

The condition of the cyanide laced capsules in the eighth bottle provided additional evidence that these capsules were not the work of the Tylenol killer. The cyanide-laced Tylenol capsules in the Kellerman and Janus bottles, inspected one day after the murders, were “swollen and discolored,” the result of corrosion caused by moist cyanide. The cyanide-laced capsules in the seventh bottle were in an “advanced state of deterioration” when inspected 22 days after the murders. Conversely, the cyanide-laced Tylenol capsules in the eighth bottle, inspected 26 days after the murders, showed no signs of corrosion at all.

Fahner said the seven cyanide-laced Tylenol capsules in the eighth bottle were “substantially different” from previous bottles. This difference suggested that this bottle “may be unrelated to the other bottles so far recovered,” he explained. The logical conclusion from these findings was that someone, not the Tylenol killer, had put cyanide into seven Tylenol capsules in the eighth bottle after the Tylenol murders occurred.

24

________

The Conspiracy

Ever since they found the poisoned Extra Strength capsules in Lynn Reiner’s Regular Strength Tylenol bottle on September 30, 1982, investigators had been working under the assumption that Ed Reiner had somehow gotten those cyanide-laced capsules into a Tylenol bottle at Frank’s Finer Foods. This investigative strategy was evident on October 8th when NBC reported: “Investigators think Winfield may not have been chosen at random - that someone in a deliberate effort came here to make the switch at Frank’s Finer Foods.” The NBC report further implied that the Tylenol killer knew in advance that Lynn Reiner would go to Frank’s Finer Foods at 3 p.m., where, “as usual,” she would buy Regular Strength Tylenol.

It made no sense that someone who intended to murder Lynn Reiner would plant eight red and white Extra Strength capsules, with only five capsules containing cyanide, into a bottle of gray and white Regular Strength Tylenol capsules at Frank’s Finer Foods.  This scenario would have required Lynn to purchase the one and only bottle of cyanide-laced Tylenol capsules that the killer had supposedly planted for her to buy.

This implausible scenario relied completely on luck and would have been extremely difficult to sell to a jury. To remedy this problem, local authorities evidently planted the evidence they needed - the eighth bottle of cyanide-laced Tylenol - to get the conviction they wanted. The Wheaton police then claimed that the eighth bottle of cyanide-laced Tylenol was purchased at the Frank’s Finer Foods in Winfield on September 29th. But it wasn’t.

What the local authorities did not know then – and what they still may not know today - is that it would have been impossible for anyone to purchase the eighth bottle of cyanide-laced Tylenol at any of the Frank’s Finer Foods stores.

All of the Tylenol shipped to the Frank’s Finer Foods stores was manufactured at McNeil’s plant in Round Rock, Texas. But the Tylenol in the eighth bottle of cyanide-laced Tylenol, bearing lot number MC2873, was manufactured at McNeil’s plant in Fort Washington, Pennsylvania. Linda Morgan could not have purchased that bottle at Frank’s Finer Foods, because there was never a bottle of Tylenol with lot number MC2873 sitting on the shelves of any of the Frank’s Finer Foods stores.

Under Title 21, Section 201.1 of the U.S. Code of Federal Regulations, drug containers must bear lot numbers that are formatted to indicate the identity of the plant where the drug was manufactured. “The lot number on the label of a drug [container] should be capable of yielding the complete manufacturing history of the package.”

As described earlier, the lot numbers for the Tylenol manufactured in Fort Washington began with two alpha characters followed by four numeric characters. The lot numbers for the Tylenol manufactured in Round Rock began with four numeric characters, followed by two alpha characters. The alpha characters represented the year and month of manufacture, the first numeric character identified the plant where the Tylenol was manufactured, and the last three numeric digits were the batch number.

The first numeric digit in the lot numbers for the Tylenol manufactured in Round Rock was “1”, whereas the first numeric digit in the lot numbers for the Tylenol manufactured in Fort Washington was “2”. The Tylenol in the eighth bottle of cyanide-laced Tylenol, bearing lot number MC2873, was thus manufactured in Fort Washington.

Tylenol manufactured in McNeil’s Fort Washington plant was distributed only through J&J’s regional distribution center in Montgomeryville, PA. Tylenol manufactured in McNeil’s Round Rock plant was distributed through J&J’s regional distribution centers in Round Rock, TX; Montgomeryville, PA; and Glendale, CA.

An investigation completed by Johnson & Johnson and the Winfield police on October 1, 1982, revealed that Frank’s Finer Foods received its Tylenol from the Certified Grocers distribution center in Hodgkins, Illinois. Winfield Police Officer Scott Watkins testified at Lynn Reiner’s coroner’s inquest that the Dependable Trucking Company delivered Tylenol to the Certified Grocers distribution center in Hodgkins. The California-based Dependable Trucking Company shipped that Tylenol to the Hodgkins warehouse from a warehouse in California that received its Tylenol from J&J’s regional distribution center in Glendale, California. That center received its Tylenol from the McNeil manufacturing plant in Round Rock.

All of the Tylenol in the Frank’s Finer Foods store in Winfield, including the bottle of Regular Strength Tylenol from Lot 1833MB that Lynn Reiner had purchased there, was manufactured in Round Rock. The Tylenol in the eighth bottle of cyanide-laced Tylenol, bearing lot number MC2873, had been manufactured in Fort Washington, and was never on a shelf in any of the Frank’s Finer Foods stores.

Local officials, by planting a bottle of cyanide-laced Extra Strength Tylenol capsules into evidence, claiming it had been purchased at Frank’s Finer Foods, evidently hoped to give prosecutors a more believable story that would implicate Ed Reiner in the Tylenol murders. Prosecutors might have been able to sell the premeditated murder hypothesis to a jury if that jury believed that at least two bottles of cyanide-laced Tylenol capsules had been planted at the Frank’s Finer Foods store in Winfield. Prosecutors could have claimed that the Tylenol killer planted one Extra Strength Tylenol bottle and one Regular Strength Tylenol bottle at the front of the display shelf to improve the odds that Lynn would buy a bottle containing cyanide-laced Tylenol capsules, regardless of which strength she bought.

On October 26, 1982, the press abruptly ended its coverage of the Tylenol murder conspiracy story. The demise of this story, it appeared at the time, was because Ed Reiner had passed a lie-detector test. But that wasn’t the case. The Chicago Sun-Times reported on Tuesday, October 26th, that a man previously considered to be the prime suspect [Reiner] in the Tylenol investigation had been cleared after passing a lie-detector test. However, officials said Reiner did remain under scrutiny, but not as the person who poisoned the Extra Strength Tylenol capsules. Officials said [Reiner] has been co-operating with investigators, and he might take another lie test. The FBI and IDLE clearly had not given up on Reiner just yet.

On Tuesday afternoon, Wheaton Police Lieutenant, Terry Mee, said that the eighth bottle of cyanide-laced Tylenol had been purchased at the Frank’s Finer Foods store in Winfield. Authorities had thus linked the planted eighth bottle of cyanide-laced Tylenol to the same Frank’s Finer Foods store where Lynn Reiner had purchased a bottle of Regular Strength Tylenol on the afternoon of her death.

When Linda Morgan came forward and said she had purchased the eighth bottle at the Frank’s Finer Foods store in Wheaton, instead of Winfield, the gig was up. Since the eighth bottle of cyanide-laced Tylenol could no longer be linked to the Winfield store, it could no longer be used to help authorities fabricate a case against Ed Reiner. Authorities in DuPage County had apparently intended to enter that bottle as evidence in a Tylenol murders trial that would have been held in the 18th Circuit Court in DuPage County.

DuPage County had two highly publicized and politicized murder cases in the 1980s -- the Jeanine Nicarico murder on February 25, 1983, and the Tylenol murders on September 29, 1982. In both these cases, officials in DuPage County fabricated, hid, and lied about the evidence.

Prosecutors from the DuPage County State’s Attorney’s office charged Rolando Cruz and Alex Hernandez in 1983 for the rape and murder of 10-year-old Jeanine Nicarico. DuPage County Sheriff’s detectives working on the Nicarico case hid exculpatory evidence that should have exonerated Cruz and Hernandez. They made up a “vision statement,” claiming it was Cruz’s confession to the Nicarico murder. That phony confession was the centerpiece of a prosecution that led to the wrongful convictions and death sentences for Cruz and Hernandez in 1985. During a lengthy appeals process, the defense won a second and then a third re-trial for each of the defendants.

DuPage County prosecutors pursued the third trials against Cruz and Hernandez even though their own forensic expert had found that the DNA evidence on the victim’s body matched the DNA of Brian Dugan, a man who had confessed to the murder and rape of Jeanine, and who had previously raped and murdered two other girls in DuPage County. Rolando Cruz’s third trial was a bench trial before Judge Ronald Mehling in 1995. Judge Mehling put a stop to the trial before the defense even presented their case. Mehling found Cruz not guilty after hearing jail-house witnesses for the prosecution recant their original testimony and after the testimony of a lieutenant for the DuPage County Sheriff’s Department revealed that Cruz’s alleged confession had been made up by two of his deputies. Hernandez was also absolved a few weeks later.

In the 1980s and 1990s, Illinois was a hotbed of wrongful prosecution in death penalty cases. In 2004, of the 289 men and women who had been sentenced to death in Illinois since 1977, eighteen had been exonerated and released from prison – an error rate of over 6 percent. Fourteen others had won reversals and were awaiting retrials or re-sentencing. The Illinois Governor’s Commission on Capital Punishment found that these wrongful convictions were not the result of innocent “mistakes,” but rather the product of the deliberate actions of prosecutors and law enforcement officials in Illinois who engaged knowingly in falsifying evidence, extracting coerced confessions, and relying on the testimony of jailhouse “snitches.” These tactics were used in the Nicarico and Tylenol murders cases by government officials who believed they needed convictions in big cases like these to advance their careers and achieve their political goals.

Tyrone Fahner, especially, felt the pressure to close out the Tylenol murders investigation quickly. Governor “Big” Jim Thompson was in a close gubernatorial race against Democrat challenger, Adlai Stevenson III, the son of the former Illinois governor and one-time presidential hopeful, Adlai Stevenson II. Fahner, in the race for Illinois attorney general, was trailing the Democrat challenger, Neil Hartigan. Fahner’s standing in the polls, however, had improved greatly since he’d become the official spokesperson of the Tylenol task force and was seen on television every day.

“He [Fahner] probably had more than the necessary number of press conferences… to get him on the news each night,” Chicago Police Superintendent, Richard Brzeczek, said later. “Fahner was running for election and nobody knew who he was, and they all figured, ‘we’ll get this solved and Ty will get a feather in his cap.’”

The creation of the Tylenol murder conspiracy scenario was a desperate effort to “solve” the case, make some arrests, and give Fahner the “feather in his cap” he needed to win the election. For the first 26 days of the Tylenol murders investigation, authorities had pursued an investigative strategy based on the erroneous hypothesis that six of the murders were “staged” as part of a conspiracy to cover up one premeditated murder. Along the way, authorities appeared to deliberately ignore the information and physical evidence that pointed directly to a warehouse within the channel of distribution as the source of the cyanide-laced Tylenol capsules.

The “discovery” of the eighth bottle generated news stories that helped to bury the true source of Lynn Reiner’s unit-dose package of cyanide-laced Extra Strength Tylenol capsules – the hospital. With the source of the cyanide-laced Tylenol that killed Lynn Reiner now obscured, an important piece of evidence linking the Tylenol tamperings to a warehouse in Johnson & Johnson’s distribution channel was also kept hidden.

Even if the authorities wanted to go back and track the cyanide-laced Tylenol capsules to their true source - it was too late. Investigators had long ago turned over the most important evidence they had - the Tylenol capsules themselves - to Johnson & Johnson, the one entity that had both the incentive and the resources to cover up any evidence that might have linked the tamperings to a location within the company’s distribution network.

Tyrone Fahner was compelled to call a news conference on October 27th to put the final nail in the coffin of the Tylenol murder conspiracy story. He told reporters that Ed Reiner had voluntarily taken a lie detector test, which he passed. Reiner had never been considered a suspect in the first place, Fahner insisted. “No Reiner family member is a suspect in the Tylenol murders or any other investigation.”

As it turned out, Linda Morgan’s fingerprints were not found on the box for the eighth bottle or on any of the capsules inside the bottle. The FBI reportedly never found a match for the fingerprint on the eighth bottle’s box-top flap, and they were unable to get a usable fingerprint from any of the capsules inside the bottle. Fahner said the prints on the capsules from the eighth bottle were smudged.

The Tylenol murder conspiracy, which had been a sensational story on Monday, October 25, 1982, was now dead in the water. The biggest news story of the entire Tylenol murders investigation had been made up of nothing but lies, and now it simply faded away.

25

________

The Last Suspect

When authorities cleared Ed Reiner and Howard Fearon, Sr., and decided not to pursue a case against Roger Arnold, Fahner’s list of suspects was reduced to one name - Kevin Masterson. Though Masterson was not really a legitimate suspect, his name was thrust into the limelight on November 1, 1982 - one day before the Illinois election for attorney general and governor.

One investigator who insisted on anonymity said Masterson had told friends in September that he had planned to settle a grudge against two stores where the poisoned Tylenol was bought. Investigators told the Chicago Tribune that these “friends” had quoted Masterson as saying, “Now is the time to even the score” against Jewel Food and Frank’s Finer Foods. One of the problems with this alleged quote is that there were never any cyanide-laced Tylenol capsules in any of the Frank’s Finer Foods stores. The reference to Franks Finer Foods appears to have been yet another effort by un-named sources to erroneously link cyanide-laced Tylenol to Frank’s Finer Foods. The manager of Frank’s Finer Foods in Wheaton, one of four stores in that independently owned chain, said he had “no idea” how such a grudge might have originated.

An affidavit filed in the 18th Circuit Court in DuPage County by Joseph McQuaid, a sergeant for the Illinois State Police, said Masterson’s anger toward Jewel arose from an incident in which his former wife, Joann, felt Jewel security officers had mistreated her after suspecting her of shoplifting. Jewel Vice President, Jane Armstrong, confirmed that the woman had filed a civil suit against Jewel in 1975 and that a settlement was reached four years later. Armstrong refused to give details about the suit, but the Chicago Tribune said Mrs. Masterson had accepted an $8,000 settlement.

In December 1982, after the heat had been taken off Masterson, his parents spoke to The Daily Herald about the havoc caused by that intense media focus. “I feel he [Kevin] was used, definitely by the media and others,” said Kevin’s father, John Masterson. The country’s Founding Fathers designed a system of “trial by jury, and you are innocent until proven guilty,” said Masterson. “The way things are today, it’s trial by media, and you are guilty until proven innocent.”

Kevin’s mother said, “The injustice done was so gross that I think some strong positive statement should be made. You can’t imagine the harm. Possibly the media could be made aware of the suffering this could cause a family. An individual is really at the mercy of the press.”

“A friend told me that the 6 o’clock news is entertainment. It’s showbiz,” said John Masterson. “I guess there’s some truth to that. It can certainly play havoc with people’s life.”

The Mastersons said their son was never a suspect in the murders, and it “was more than coincidental” that daily press conferences were held by Tyrone Fahner during the week before the November 2nd election.

Even the feds refused to call Kevin Masterson a suspect. On November 1st, a Washington-based law enforcement source who asked not to be identified told the Chicago Tribune, “There’s still nothing to indicate Masterson is anything other than a guy with a big mouth. There are some questions to ask him, but it would take a quantum leap from what is known to connect him to the Tylenol killings.”

A well-timed news story hinting that Governor Thompson’s Attorney General was closing in on the Tylenol killer could have definitely helped the election outcomes for both Fahner and Thompson. The story leaked to the press on November 1st, implying that Kevin Masterson was a legitimate suspect, was well-timed, but did not give Fahner the popularity boost he needed.

On November 2, 1982, Tyrone Fahner lost his election bid, and James Thomson narrowly defeated Adlai Stevenson. Masterson, in California at the time, soon turned himself in and then was immediately eliminated as a suspect. Masterson was just another pawn in the political game that the Tylenol murders investigation had become.

When Fahner said on October 9th that his list of suspects had been reduced to just three people; the names on that list were Ed Reiner, Howard Fearon, Sr., and Kevin Masterson. Roger Arnold wasn’t added to that list until one or two days later. Yet, in the months and years that followed; the rhetoric from Fahner, IDLE Commander Thomas Schumpp, Assistant U.S. Attorney Jeremy Margolis, and U.S. Attorney Dan Webb, indicated that James Lewis was one of those announced prime suspects. But that was not the case. Authorities did not identify Lewis as the writer of the extortion letter until October 13th.

The feds admitted that Lewis never intended to profit from the extortion letter, but Lewis had interjected himself into a high-profile, politically charged case, so Margolis and a team of Justice Department lawyers led by Dan Webb prosecuted him for extortion anyway. On October 27, 1983, a jury in the U.S. District Court in Chicago convicted Lewis of attempted extortion for writing the Tylenol extortion letter. That letter made Lewis a very unpopular fellow in late 1982 and the ideal scapegoat for Tyrone Fahner.

“As for James Lewis, there was not sufficient evidence to prosecute him for murder,” said Jeremy Margolis. Yet in the years following the Tylenol murders, several Illinois officials stated outright that they thought Lewis was the Tylenol killer. As the Tylenol case grew cold and then colder, Fahner became ever more direct in saying that he believed Lewis had committed the crime.

Fahner later worried that he had been too vociferous in his public speculations about Lewis. “I don’t need to have someone who’s in prison do some jail-house lawyering and sue me for libel,” he said in 1992. “There are plenty of people in law enforcement who believe he’s the one, and that’s not libelous,” Fahner insisted.

“Sometimes public officials get in a position and try to find ways of avoiding pressure,” Lewis suggested in 1992. “They are looking for a scapegoat, so they do not have to deal with the fact that they can’t find the Tylenol murderer.” Of the Tylenol case, Lewis said, “I am not fascinated with it. I am not intrigued with it. What I’m puzzled with is how I continue to be ensnared in all of this, and I’m unable to get myself extricated from it.”

The only man who was ever truly a legitimate suspect, Roger Arnold, appeared in court for a hearing on the unregistered gun charges on October 26, 1982, but the judge postponed the hearing until November 22nd of that year. Thomas Royce said the postponement was a “delay tactic” to keep Arnold under surveillance. Royce said he and his client were being harassed, and Arnold should be charged with the murders, or the police should back off.

The police did back off. Police ended their surveillance and investigation of Arnold on October 27th, one day after authorities stopped tailing Ed Reiner and Howard Fearon, Sr. Nonetheless, the intense surveillance of Roger Arnold by the Chicago police was a strong indication that they had been ready to make an arrest or certainly hoped they would be able to do so.

Chicago Police Sergeant, Monroe Vollick, said of Arnold, “I consider him a goof. One of those macho types who is into guns and making poisons, but not the Tylenol murders.” As Vollick would soon learn, Arnold did indeed have what it took to be a cold-blooded killer.

While being questioned about his possible involvement in the Tylenol murders, Arnold allegedly told his interrogators: “I’d like to be in on the homicide of the guy that turned me in for what he did to me.” Police said Arnold later sought revenge against Marty Sinclair, the man who turned him in.

On the morning of June 18, 1983, after a night of drinking, Arnold was outside a Lincoln Avenue bar on Chicago’s North Side just after “last call” when the man who was the focus of his anger walked out of the bar. Arnold approached the man. The two spoke briefly and then Arnold shot him in the chest. The bullet went straight through the man’s heart, allowing him only seconds to cry out, “I’m shot,” before he died. He was pronounced dead on arrival at Grant Hospital at 2:38 a.m. One of the witnesses chased Arnold to a getaway car and was able to get the license plate number before the car sped off.

As it turned out, Arnold had not killed Marty Sinclair. Instead, he had shot and killed John Stanisha, a 46-year-old computer consultant and father of three. He was a man who Arnold reportedly mistook for Marty Sinclair.

Roger Arnold turned himself in on the afternoon of June 18, 1983. Printed in large letters on his t-shirt was “Pattaya, Thailand,” a popular tourist area on the East coast of the Gulf of Thailand. It looked like Arnold had finally taken his vacation to Thailand. Three days later, a Cook County Grand Jury indicted Arnold for murder and armed violence.

During his trial, Arnold testified in his own defense. He said the bullet that killed Stanisha accidentally discharged from his gun. The jury didn’t buy this story. On March 30, 1984, Arnold was convicted of murdering John Stanisha and sentenced to 30 years in prison. After serving 15 years, Arnold was released in 1998, a 64-year-old man.

Almost nothing related to the Tylenol murders investigation was ever what it seemed. Even the true target and motivation for Arnold’s murder of John Stanisha were not as clear as suggested. Police said Arnold had mistaken Stanisha for a man he believed had made him a suspect in the Tylenol murders case. Prosecutors for the Cook County State’s Attorney Office also said Arnold had mistaken John Stanisha for Marty Sinclair. They called the shooting a “revenge murder,” but Arnold and his attorney said otherwise.

Thomas Royce denied that Arnold mistook Stanisha for the person who told police Arnold had cyanide in his apartment. “That couldn’t be further from the truth,” he said. Royce said that when Arnold turned himself in for the murder of Stanisha, he was with Arnold throughout his questioning. Arnold “made no statements to anybody,” said Royce. “We don’t know who the informant was in the Tylenol case.”

In fact, Arnold must have known that Marty Sinclair was the informant. Shortly after Arnold’s arrest on October 11, 1982, Chicago police detective, Jerry Beam, told reporters that the bartender who told police that Arnold kept cyanide at his home was the same man who had recently charged Arnold with assault. Arnold knew that Marty Sinclair had charged him with aggravated assault, so he must have also known that Sinclair had given police the tip that made him a suspect in the Tylenol murders case.

Arnold testified at his murder trial that Stanisha had taunted him in the bar and then later, outside the bar, took a threatening step toward him. When interviewed thirteen years later, in 1996, Arnold recanted that story. Arnold’s amended story, as told to Tom McNamee, a reporter for the Chicago Sun-Times, was that he had walked up to Stanisha outside the bar - convinced that Stanisha was Sinclair - and shot him dead in a cold act of revenge. “I was thinking to myself, you know, that’s it. This is going to be the end of this,” Arnold said. “I called out, ‘Marty, did you turn me in?’ And he turned around and said something like, ‘Yes, it was.’ And that was it.”

After a long pause, Arnold then said, “You know, he wasn’t even talking to me.”

Arnold had testified at his trial that he fully intended to assault Stanisha, but not kill him. He said the gun had “misfired.” But that was a lie, Arnold told McNamee. “I killed a man, a perfectly innocent person. I had choices. I could have walked away.”

The story Arnold told McNamee in 1996 matched the one told by the press in June of 1983 and by the attorneys who prosecuted Arnold for second degree murder in March, 1984. However, it seems unlikely that Arnold mistook Stanisha for Sinclair. Roger Arnold and Marty Sinclair knew each other fairly well. They had a history. Arnold was apparently a frequent patron at Sinclair’s tavern. Four months prior to the Tylenol murders, Sinclair filed assault charges against Arnold after they had gotten into an argument and Arnold pulled a gun on Sinclair. They engaged in a conversation at Sinclair’s bar in early October just before Sinclair dropped a dime on Arnold. Sinclair knew Arnold well enough to view him as a peculiar bird who kept cyanide, test tubes, and guns in his house.

Chicago Police Sergeant, Edward J. Flynn, described Stanisha as “a big husky fellow,” about 5 feet 10 inches tall and 250 pounds. But Chicago police described Marty Sinclair as having average height and build. Stanisha and Sinclair did not look alike. Roger Arnold shot John Stanisha at point blank range. He could not have mistaken Stanisha for Sinclair.

Arnold had insisted all along that he had not mistaken Stanisha for Sinclair - a fact he testified to during his murder trial. Nevertheless, prosecutors handed the mistaken-identity alibi to Arnold, charging him with second-degree murder and letting him off the hook for premeditated first-degree murder.

So why did Roger Arnold really kill John Stanisha? At his trial, Arnold claimed that Stanisha had taunted him in the bar about being a suspect in the Tylenol murders case. Arnold then angrily left the bar with murder on his mind. When Stanisha walked out of the bar after last call, Arnold was right there waiting. Roger Arnold killed John Stanisha because Stanisha had razzed him about his 15-minutes of infamy as the “Tylenol kid.”

Authorities never had a stitch of evidence implicating Fearon or Reiner in the Tylenol poisonings, but the evidence collected on Roger Arnold should have led to a thorough investigation of Arnold and the channel of distribution. It didn’t.

26

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Project Chatham

TIME magazine, in its decade-ending review of American business during the eighties, called J&J’s handling of the Tylenol crisis, the “Most Applauded Corporate Response to a Disaster.” The company’s “frank, decisive response won back customer loyalty and is now a textbook case in public relations.”

“Within one year, thanks to the intrinsic fairness of the public,” said Larry Foster, “Tylenol was back to its former pre-eminent position in the market. That seemingly impossible marketing achievement became a reality because the public realized that the company was not to blame for the tragedy, and because the press felt that the crisis had been handled with skill and in the public interest.”

“No disasters of this magnitude are handled flawlessly,” said Foster, “but by public and professional acclaim, Tylenol is still viewed as the classic example of how to manage a crisis. And the abiding interest in these heinous crimes, even today, is nurtured by the fact that they remain unsolved.”

“Perhaps because of the magnitude and complexity of the experience, said Foster, “those most closely involved in the Tylenol tragedy do not subscribe to the philosophy that a crisis plan on file assures successful management of a disaster. There was no such plan on file at J&J capable of guiding us through the months that followed the fateful morning of September 30, 1982, when we first learned of the Chicago murders.”

J&J President David Clare said the events surrounding the Tylenol crisis were so atypical that we found ourselves improvising every step of the way. In truth, the organizational moves Johnson & Johnson had made shortly before the Tylenol murders put the company in such an ideal position to manage this particular crisis that it raises the question: Did J&J executives have knowledge of a problem in the Tylenol distribution system prior to September 29, 1982?

In September 1982, there were some major changes made at Johnson & Johnson. Several high-level corporate executives connected to the manufacturing and distribution of Tylenol changed jobs, and the company was in the process of implementing a reorganization of its distribution infrastructure. Moreover, James Burke openly worried about the potential for a problem with the Tylenol business.

Johnson & Johnson had initiated “Project Chatham” in 1981 to explore the idea of centralizing the sales and logistics functions of 13 major J&J operating companies. The Project Chatham Committee recommended in April 1981 that J&J should create an operating unit to consolidate the sales and logistics functions and provide a common customer service group and electronic order entry system. Project Chatham sat dormant for the next 17 months. Then, in September 1982, just days before the Tylenol murders, J&J formed the Hospital Services Group (HSG) as a transitional corporate unit to develop action plans to implement the recommendations of the Project Chatham Committee.

The executives of J&J’s subsidiary, Ethicon, a manufacturer of sutures and other surgical closure devices, opposed the Project Chatham initiative. Robert Wood Johnson II had founded Ethicon in Chicago in 1941, and the company still had a major manufacturing and distribution operation in Chicago’s Clearing District. Ethicon already had an extensive sales and logistics system in place, and the subsidiary’s executives did not want to give up that profit center. H. Stuart Campbell was the Company group chairman with oversight for Ethicon.

In September 1982, when J&J decided to implement the recommendations of the Project Chatham Committee, Campbell resigned and founded Hyland Packaging - a contract pharmaceutical packaging company in Somerville, NJ. Edward Hartnett, the executive vice president of Ethicon, was then promoted to the position vacated by Campbell. In late 1982, J&J executives decided to make HSG a full-fledged Johnson & Johnson operating company, naming Edward Hartnett as its new general manager and Pete Ventrella as president.

Previously, the J&J operating companies had autonomy in running their sales and logistics and order fulfillment functions. Hartnett and Ventrella were now charged with centralizing these functions. HSG also took control of the distribution of raw materials and finished goods. Johnson & Johnson had thus begun to take control of the distribution channel in the same month that the cyanide-laced Extra Strength Tylenol capsules entered the distribution channel in Chicago.

Johnson & Johnson had also made some major executive changes in September 1982. Wayne Nelson was appointed chairman of J&J International, making way for David Collins to take over as chairman of the McNeil Consumer Products Company. Nelson was a former Chicago area resident and a graduate of Northwestern University in Evanston, Illinois. However, Nelson’s roots in the Chicago area were nowhere near as extensive as those of Oak Park, Illinois-native, David Collins.

It was indeed fortunate for Johnson & Johnson that Burke put Collins in charge of McNeil just days before seven people died from cyanide-laced Tylenol capsules near Collins’s boyhood home. The appointment of David Collins to the positions of company group chairman, chairman of McNeil, and a member of the J&J Executive Committee came so suddenly that as of September 30, 1982, his office had not yet been moved up to the fifth floor of Johnson & Johnson headquarters where the offices of all J&J Executive Committee members were located.

The press never reported on the interesting fact that Collins, who had just been put in charge of the company that made Tylenol, had grown up in a city located dead-center in the middle of the Tylenol murders crime scene. TIME magazine did mention that Collins had called his former college roommate, attorney Paul Noland, to ask him to be his “eyes and ears” at the Tylenol murders crime scene. But the press did not report that Collins had also hired another boyhood friend, attorney Mike Heroux, to help J&J navigate through the Tylenol crisis. The press also did not report that Collins, Noland, and Heroux had all graduated together in 1952 from Fenwick, a private catholic high school in Oak Park.

The fortuitous appointment of David Collins and the major restructuring of Johnson & Johnson’s order fulfillment and sales and logistics operations all took place less than 30 days before the Tylenol murders. Interestingly, one of the topics discussed during the J&J Executive Committee’s annual three-day strategic planning review following the September 1982 Labor Day weekend, was the disastrous effects that a problem with the Tylenol brand could have on Johnson & Johnson.

“I took some kidding at that meeting for worrying about things I don’t have to,” recalled Burke. “We had been marveling at how lucky we were to be in our industry, to have some very profitable brands doing so well, and I had said, offhand, what if something happens to one of them, like Tylenol? Nothing is impregnable, but it was such an extraordinary business, there didn’t seem to be any downside. Nobody could come up with anything.”

Sometime during or shortly after the J&J Executive Committee meetings in September 1982, Johnson & Johnson executives made significant changes at the top of two operating companies - one that manufactured and sold Tylenol, and one that managed the contracting, order fulfillment, and distribution of Tylenol. When the Chicago poisonings were linked to Tylenol, J&J took charge of the situation, and the FDA simply fell in line.  FDA Deputy Director, Mark Novitch, later described the events following the Tylenol murders as if the FDA had been merely a bystander, acting at the direction of James Burke. Novitch said:

The actions that followed [the Tylenol murders] have become a case study in responsible crisis management. Major players were: Jim Burke, chairman of J&J; Dave Collins, chairman of McNeil, the J&J subsidiary responsible for Tylenol; Joe Chiesa, McNeil president; Tom Gates, its medical director; and many other colleagues. If they felt despair and uncertainty, none was apparent. Four decades earlier, J&J had adopted a credo stating the principles on which they would conduct their business. Burke and Collins said the credo told them what to do in the Tylenol crisis and it is impossible to say otherwise.

J&J involved the FDA immediately and continuously. It withdrew the initial lots from which the tampered drugs came and then, in the wake of copycat tamperings, withdrew all Tylenol capsules even though both J&J and the FDA had determined that the tamperings did not occur in its plants. J&J kept the press and public fully informed and even put its chairman in the unaccustomed role of chief company spokesperson. This was one of the first times that the CEO of a major company was used as a spokesperson for a crisis. This effort set a precedent that exists to this day.

On Friday, October 22, 1982, the FDA sent a letter to Johnson & Johnson, officially clearing the company of any responsibility for the Tylenol tamperings. Joseph P. Hile, the associate commissioner for regulatory affairs at the FDA, wrote:

We conclude that the contamination did not occur at either [McNeil manufacturing] plant, and was the result of tampering after the capsules had been shipped to distribution points, and most likely after they reached the retail shelves.

Notably, the FDA did not rule out the distribution channel as the true source of the cyanide-laced Tylenol capsules. The FDA also never presented any information to support the tampering-in-the-retail-stores hypothesis.

27

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Death is a Manageable Side Effect

The manner in which the Tylenol murders investigation was conducted and the evidence inspected - or not inspected – indicates that officials at the time wanted to sweep the details of the Tylenol tamperings under the rug. The evidence that would have revealed the true extent of the tamperings – the Tylenol capsules from Chicago area stores – was destroyed. In addition, every bottle of cyanide-laced Tylenol recovered after the Tylenol murders, was engulfed by incredulous stories, unsubstantiated claims, and improbable circumstances.

Officials from the Tylenol task force said that Johnson & Johnson, while inspecting Tylenol capsules in October 1982, had discovered two bottles of cyanide-laced Tylenol – the seventh and eighth bottles. Johnson & Johnson, however, has never confirmed that it discovered any bottles of cyanide-laced Tylenol. J&J’s 1982 Annual Report states that two unused bottles of poisoned Tylenol were recovered as a result of the withdrawal of Tylenol capsules, but J&J did not actually take credit for finding those bottles. Furthermore, the eighth bottle of cyanide-laced Tylenol was planted into evidence two weeks after the Tylenol murders, and the seventh bottle wasn’t “discovered” until sixteen day after it had been turned over to Johnson & Johnson. Authorities initially misidentified the person who had supposedly turned in the eighth bottle, and they never identified the person who turned in the seventh bottle.

The sixth bottle of cyanide-laced Tylenol - the first one not from one of the Tylenol victims - was discovered among the Tylenol bottles removed from the Osco Drug store in Woodfield Mall. Officials initially said they had found two bottles of cyanide-laced Tylenol at the Osco store, but then changed that story, stating that they had found only one contaminated bottle. Years later, FDA Deputy Director, Mark Novitch, confirmed that two bottles had in fact been recovered from the Osco Drug store. “Two more poisoned containers were found on retail shelves during the sweep that followed [the Tylenol poisoning deaths], recalled Novitch.”

One financial analyst on Wall Street said, “Johnson & Johnson management was quick to cast themselves in the role of the self-sacrificing servants of the people. They generated enormous public sympathy and managed to convince most Tylenol consumers that they [the people] owed the company cooperation in saving the product.”

Larry Foster predicted that consumers would realize “we were victimized along with society” and that because of “goodwill” generated by the 95-year-old Johnson & Johnson, “we may come out of this with a stronger image.”  Foster was right. Johnson & Johnson emerged from the Tylenol crisis widely hailed as having provided a shining example of how to handle a major business calamity.

Amid the hysteria, said Foster, Johnson & Johnson tried not to forget about the families of the victims in Chicago, but ultimately he felt that he and his colleagues did not do as much for them as they could have. Foster said J&J originally considered the idea of setting up scholarships for the children affected by the deaths, but that idea fell through.  “We wrote them letters and we expressed our great sorrow and regret,” said Foster. “We couldn’t be as open with them as we wanted,” he said, “because the lawyers held us back. They were trying to protect the company.”

The employees at McNeil’s Fort Washington plant had offered to each provide $100 toward a reward for whoever found the person who tampered with their product. McNeil employees wanted to help the victims’ families with emotional support, counseling, and money from their own pockets. Johnson & Johnson executives rejected these generous offers, refusing to allow its employees to provide any emotional or financial help to the victims’ families. They were worried that any expression of compassion or offer of financial support might be construed as an admission of liability. Foster said the potential lawsuits against J&J hit a wall after it was determined that the company had been a victim as well.

As the trial-date for the Tylenol tamperings liability case approached, J&J’s lawyers filed a motion to secure a secret trial in the Circuit Court in Cook County, arguing before Judge Warren D. Wolfson that an open trial might spur copycat crimes. Judge Wolfson denied J&J’s motion for a secret trial. Then, on the eve of the trial, J&J’s lawyers, suddenly anxious to cut a deal, called the plaintiffs’ attorneys and offered to settle out of court. While secret settlement negotiations were being conducted behind closed doors, J&J spokesperson Robert Kniffin told reporters that negligence on the part of J&J could not be proven in any court. “As we’ve said all along, the poisoning and the tampering in Chicago was an unprecedented event,” remarked Kniffin. “We don’t believe there’s any way we could have anticipated them or prevented them.”

J&J’s attorneys pressured each of the plaintiffs to settle their individual Tylenol liability lawsuits, stating that if even one of them refused to sign a settlement agreement, the company would not settle any of their lawsuits. J&J used this all or none scare tactic to keep all of the Tylenol victims’ lawsuits out of an open courtroom. On the afternoon of May 13, 1991, less than 24 hours after the settlement negotiations began, settlement agreements with all of the plaintiffs were finalized.

The plaintiffs and their lawyers were all required to sign confidentiality agreements to keep the terms of the settlements secret. J&J also asked Judge Wolfson to grant a protective order keeping all of J&J’s documents confidential. Wolfson expressed distaste for this type of protective order, saying, “The public has a right to know about events that take place in courtrooms. Courts should not countenance (tolerate) the use of concealment as a bargaining chip.” Prior to making this judicious statement, however, Wolfson had already granted an order sealing all of the documents Johnson & Johnson had turned over to the court.

After the plaintiffs had signed the seven individual settlement agreements, Johnson & Johnson sent Robert Kniffin back out to regurgitate the company line. “Though there is no way we could have anticipated a criminal tampering with our product or prevented it,” said Kniffin, “we wanted to do something for the families and finally get this tragic event behind us.”

Jane Locke, a Loyola University law professor, said it is possible that the civil case against Johnson & Johnson was settled by the company because it was stronger than the company originally believed it was. According to the Chicago Sun-Times, “some estimates put the settlement at close to $50 million.” The actual settlement was nowhere near that much.

Based on settlement information provided by some of the Tylenol victims’ relatives, the settlement amounts ranged from about $500,000 to $990,000 per victim. The average settlement per victim was in the neighborhood of $650,000; about $4.5 million in total. The plaintiffs’ attorneys took 40 percent, leaving about $2.7 million ($4.4 million in 2012 dollars) to split up among the spouses, children, and parents of the seven victims.

J&J had dragged its feet for almost nine years before settling the Tylenol murders lawsuits. Conversely, just eight days after Burke had learned about the poisonings, he acknowledged that the original damage control group at corporate headquarters had evolved into three task forces that were working on an “image rescue project.” One task force that concentrated on employee morale had already produced an hour-long videotape made up of news reports and comments by company officials. Burke, in this taped message, informed his employees that “people don’t blame us. They feel we are being victimized just like everyone else.” J&J showed the tape on October 7, 1982, on the employee TV network.

Burke made up his mind on October 10th that all of Johnson & Johnson’s 150 operating companies would pitch in and help re-launch the Tylenol brand. There would be no new name for the brand or a second “fighting” brand as some experts had recommended. “It will take time, it will take money, and it will be very difficult, but we consider it a moral imperative, as well as good business, to restore Tylenol to its preeminent position,” said Burke.

Wayne Nelson agreed. “It would almost be an admission of some kind of guilt in my opinion to walk away from that name [Tylenol]. We’d be very foolish. And even if a third of this business never came back, we’d still have the top-selling pain reliever in the world,” said Nelson, “It’s better than a sharp stick in the eye.”

The planning for the “comeback” phase was already in the works when J&J announced the nationwide recall of all Tylenol capsules. Burke had hired market research consultants to conduct around-the-clock strategy meetings with top aides. He had brought in public relations firms like Burson-Marsteller to manage the media spin, and had enlisted advertising agencies like Sudler & Hennessey to promote the re-launch of Tylenol in tamper resistant packaging. Arthur Rosen, an executive from Sudler & Hennessey, advised Burke on the timing of the advertising campaign. “You hold back until you’ve created a new package, and then you advertise your product and package together,” he said. “You wait until the issue has been resolved satisfactorily in everyone’s eyes. Even then,” said Rosen, “the ads should totally ignore the cyanide tragedy.” When the new packaging was ready to go, Johnson & Johnson launched a massive advertising and public relations campaign to promote Tylenol products as the first on the market with tamper-resistant packaging.

Throughout the entire crisis, Johnson & Johnson kept reporters at bay, handling their questions only over the telephone. Yet J&J is widely portrayed as having been extraordinarily available to the press. In November 2002, Jack O’Dwyer, of O’Dwyer PR, called for some accuracy in the way J&J’s handling of the Tylenol crisis is portrayed in the media and taught in universities. What sparked his ire was an amicus brief filed by the law firm, Debevoise & Plimpton, on behalf of five public relations groups. The amicus brief has a fatal flaw, said O’Dwyer. It cited Johnson & Johnson’s handling of the Tylenol murders in 1982 as an example of ideal communication. The brief said, “Johnson & Johnson maintained an open dialogue with the press and public throughout the crisis.” It went on to state that the company’s “forthrightness with the public not only saved the Tylenol brand and perhaps even J&J itself, it [also] contributed to the way American consumer goods are packaged and labeled to be tamper-resistant.”

O’Dwyer sees it quite differently. Johnson & Johnson was not that open and forthright at all, he says. The Company never held a press conference, but rather chose to handle some 1,500 press calls on an individual basis. “Probably nearly all of these were phone calls,” O’Dwyer says. “Who knows what J&J told or didn’t tell these individual reporters?” Johnson & Johnson’s public stance was that it had no special knowledge of the case and, therefore, had nothing to say to reporters in a press conference, said O’Dwyer. When J&J was ready to re-launch Tylenol in its new tamper resistant packaging, Burke hit the talk show circuit and held three open teleconferences. However, back in early October, when the murders were front-page news almost every day, J&J held no press conferences.

Prior to re-launching Tylenol in tamper-resistant packaging, Burke hosted a pep rally for 2,259 sales representatives. He exhorted them to call on physicians and pharmacists and win back Tylenol’s market share. By year’s end, J&J sales representatives had made more than a million such presentations to promote the reintroduction of Tylenol. J&J gave out $2.50-off coupons toward the purchase of any Tylenol product. McNeil sales reps recovered former stock levels of Tylenol by implementing an off-invoice pricing program that provided retail companies with discounts linked to wholesale purchasing patterns that had been established prior to October 1982. These discounts, known as performance-based rebates, went as high as 25 percent. J&J began running commercials on October 24, 1982, to promote the upcoming launch of Tylenol in tamper-resistant packaging.

“We ran a series of campaigns that said, ‘trust us,’” recalled Larry Foster. “We don’t know what the answer is to this tragedy, but trust us. As soon as we find out what it is, we will tell you.” McNeil Medical Director, Dr. Thomas Gates, appeared in the commercials telling the public, “We want you to continue to trust Tylenol.”

For Burke, the tamper-resistant packaging provided a great opportunity to gain a competitive edge. In a world where consumers had suddenly taken a keen interest in how OTC medicines were packaged, J&J was the first company to sell OTC analgesics in tamper-resistant packages. The new packaging appeared in select markets on November 11, 1982, and was on store shelves nationwide in December. For safety conscious shoppers, the only OTC analgesic in tamper-resistant packaging on the market from late 1982 to early 1983 was Tylenol.

In mid-November 1982, the FDA ran a “public-service” ad in newspapers across the country to ease consumer fears about adulterated OTC drugs. Printed in bold type at the top of the ad was a heading that read: “A Public Service announcement about over-the-counter medicine.” The subtitle read, “From Dr. Arthur H. Hayes, Commissioner, U.S. Food and Drug Administration.” The entire body of the ad was a personal commentary from Arthur Hayes, covering off on Johnson & Johnson’s talking points, namely, that the tamperings could not have been anticipated and were done by a madman at the retail stores.

The poisonings were “a criminal tampering of medicine on store shelves,” wrote Hayes. “We’ve all been shocked by the incident.” Hayes called Tylenol an “innocent product,” and reinforced the message that the tamperings were the actions of a madman, stating, “We can’t guarantee protection against everything that a sick mind might think of.” Like any good salesperson, Hayes closed his sales pitch by asking for the business. “We don’t have to do without the medicines that make our lives more comfortable,” he assured consumers.

The New York Times reported on December 24, 1982, that Tylenol had regained 24 percent of the market for pain relievers, not too far off the 37 percent share the product had held before the crisis. Within a year, sales had returned to their pre-crisis level. Johnson & Johnson emerged from the Tylenol tampering incident more highly regarded than ever before. J&J had never actually addressed the real problem underscored with horrific clarity by the Tylenol murders. Johnson & Johnson put a band-aid on that problem by re-launching Tylenol in tamper-resistant packaging, rather than doing away with the unsealed capsules.

In 1984, Johnson & Johnson tested, but then rejected a system of sealing capsules shut. Robert Kniffin said the company had great hopes for the “Soniseal” machine, manufactured by the R.P. Scherer Corporation. Ultimately, J&J decided against using this new technique, saying it found the system wanting. “We found some incidences of leaking in which loose powder would fall to the bottom of the bottle in shipment,” Kniffin said. “Also, we felt that in some instances the capsule could be disassembled without destroying the capsule.”

The Sterling Drug company had been using the Scherer system since September 1984 to manufacture its brand of acetaminophen capsules, Panadol, and had experienced no such problems. “To my knowledge we’ve had no adverse reports from customers with regard to cracked or broken capsules,” commented Sterling spokesperson, Terry Kelley.

J&J had been aware of the tampering risk associated with capsules long before the Tylenol murders. Some pharmacists had refused to stock OTC drugs in capsule form. The problem they said was not with the Tylenol analgesic or the packaging, but with the capsule itself, which could easily be taken apart and “spiked.” Tamper-resistant packaging would have done nothing to thwart the Tylenol murders though, because the killer had put cyanide into the capsules before they were packaged and delivered to local outlets.

In late October 1982, Dr. Barry Rumack, the director of the Rocky Mountain Poison Control Center, called for an end to the use of capsules. “I believe it is time we remove all products made in capsules from sale,” said Rumack. “It’s too easy to contaminate them.”

Bruce Pfaff, an attorney for some of the Tylenol victims’ families said the issue of tampering was a common subject in trade journals of the packaging industry for 10 years or more before the Tylenol poisonings in 1982.

In February of 1986, FDA Public Information Officer, William Grigg, said that since the seven Tylenol poisoning deaths in 1982, there had been several incidents in which people were poisoned by OTC capsules. Grigg said he did not know how many of these cases involved Tylenol, but he did say that he believed some of them had turned out to be suicides. But how many were murders instead?

The Tylenol brand quickly recovered from the brief drop in sales that followed the Tylenol murders. Three years later, annual sales of Tylenol had grown by 13 percent. About 30 percent of those Tylenol sales were from Tylenol capsules. In 1985, Tylenol accounted for about 15 percent of Johnson & Johnson’s earnings and about $525 million of its total sales of $6.1 billion.

The Tylenol business was very good, and consumers never suspected that the cyanide-laced Tylenol capsules that caused at least seven deaths on September 29, 1982, had actually been planted in an Illinois warehouse. However, some of the evidence buried during the Tylenol murders’ investigation would be unearthed almost three decades later, providing important clues about the Tylenol killers’ true modus operandi. New evidence also emerged in February 1986, when Johnson & Johnson found itself in the midst of yet another Tylenol crisis. The “Chicago nightmare” had come back to haunt James Burke; but this time the crisis was centered in New York City.

PART 2

28

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The 1986 Tylenol Murder

On Friday, February 7, 1986, Johnson & Johnson executives received good news. Tylenol had captured its largest share ever of the OTC analgesic market. Chairman James Burke worried that things were going almost too well. This foreboding apprehension stayed with him even after the workday ended.

That evening, 23-year-old Diane Elsroth left the Manhattan real-estate firm where she worked as a stenographer and drove through light snow to the home of her boyfriend, Michael Notarnicola, in Yonkers, New York. She planned to spend the weekend there with Michael and his parents, Harriet and John. Diane and Michael had been dating for about three years, and they were unofficially engaged. Michael’s parents were “crazy about” Diane.

Michael and Diane spent Friday night watching television in the ground-floor den of the Notarnicolas’ split-level home until after midnight. At about 1 a.m., Diane said she wasn’t feeling well. Michael went into the kitchen and found an unopened bottle of Extra-Strength Tylenol capsules in the pantry. He tore open the box, ripped off the plastic shrink-wrap, and removed the lid. He then poked a hole into the metal foil that covered the mouth of the bottle and tore it open. He fished out the cotton ball inside the bottle, poured out two capsules and then brought them into the den. Diane took the capsules from Michael’s hand and went off to bed in the Notarnicola’s guest room.

Meanwhile, across the Hudson River, in Princeton, New Jersey, James Burke tossed and turned. Although the Tylenol comeback had been “absolutely brilliant,” there were still nights when the Chicago nightmare crept back into Burke’s normally peaceful slumber. After sleepless nights on the first two anniversaries of the Chicago poisonings, his anxieties had been largely relieved by the “hugely successful comeback of the business; the highest market share in its history, highest sales, highest profits - all in the face of five new competitors.” Burke said he had almost convinced himself that there would never be another tampering incident like the one in Chicago. Still, he worried.

Early Saturday afternoon, when Diane Elsroth missed breakfast and then did not appear for lunch, the Notarnicola family looked in on her. At 1:34 p.m., they called the Yonkers police. Diane Elsroth was dead. Shortly after the paramedics arrived, Mrs. Notarnicola picked up the bottle of Tylenol sitting on the kitchen countertop and swallowed one capsule. By sheer luck of the odds, she avoided the three remaining cyanide-filled capsules still inside that bottle.

Back across the Hudson, Burke went to bed Saturday night looking forward to the Johnson & Johnson earnings call set for Tuesday morning when the company would release its 1985 financial results, including record sales for Tylenol. As Burke drifted off to sleep, his pleasant thoughts of record profits were displaced by the Chicago nightmare. That night he dreamed that the Tylenol poisonings were happening all over again.

On Sunday morning, West Chester County toxicologist, Joan Vogel, removed the lid from the Tylenol bottle recovered from the Notarnicola home. She took a whiff and smelled the telltale scent of bitter almonds. It’s Chicago all over again, she thought.

Monday, February 10, 1986

The police returned to the Notarnicolas’ house on Monday and retrieved the outer cardboard box and packaging for the Tylenol bottle and a sales slip showing that the bottle of Extra Strength Tylenol capsules had been purchased about a week earlier from an A&P store in Bronxville, New York. The poisoned Tylenol was in a 24-count bottle of Extra Strength Tylenol capsules from Lot ADF916, and had been manufactured at the McNeil plant in Fort Washington, Pennsylvania. The lot code format had changed somewhat since 1982. Now the first three digits of the lot codes were alpha characters, and the last three digits were numerical. The first and second digit represented the year and month of manufacture, respectively. The third digit identified the plant where the Tylenol was produced. The last three numeric digits represented the batch number.

Since November 1982, Tylenol had been packaged in three layers of tamper-resistant packaging. The Tylenol capsules were sold in packages labeled “safety sealed.” The outer carton was sealed with a “hot-melt” adhesive. The cardboard was thin gauge, so that the flaps, sealed with the permanent adhesive, could not be opened without ripping the box. The cap was sealed to the lip of the bottle with a plastic band that was “heat shrunk” for a tight fit and had to be torn away to be removed. Underneath the cap, an aluminum foil seal was laminated to the lip of the bottle.

Harriet Notarnicola, Michael’s mother, had purchased the Tylenol at the Bronxville A&P store on Tuesday, February 4, 1986. She later testified that the package did not appear out of the ordinary in any way, i.e., she saw no evidence that there had been any product tampering. When she returned home after buying the Tylenol, she had placed the unopened box in her food pantry. Michael also later testified that he noticed nothing unusual about the packaging; the flaps to the box were glued shut, the shrink seal did not appear to be disturbed, and the foil seal further securing the capsules had not been broken.

At 4 p.m. Monday afternoon, J&J President David Clare entered Burke’s office. “Jim,” he said, “We have a serious problem.”

“He was pale,” Burke said later. “He didn’t have to tell me what it was. We’ve got lots of serious problems with a company this big and this complicated, but I could tell it was a Tylenol problem because of the look on his face.”

Burke ordered what turned out to be a continuous polling of consumers to monitor their fears, perceptions, and intentions toward all Tylenol products. Just like in 1982, Burke hired his own private investigators and sent his lawyers and public relations people out to the scene of the crime. He sent representatives to Yonkers to attempt to learn more and “assist” in the investigation. J&J executives also began conferring by telephone with the FDA and the FBI in Washington D.C. and at their respective field offices, just as they had done in 1982.

At a news conference late Monday afternoon, Yonkers Police Commissioner Joseph Fernandes, said, “The medical examiner’s office has indicated that [Elsroth’s] death was caused by cyanide, which may have been introduced by way of ingestion of a Tylenol capsule.” He said the capsules were believed to have come from a factory in Pennsylvania, but he did not know the name of the town. “It is not known where or when the cyanide may have been introduced into the Tylenol capsule.”

As “a precautionary measure,” the Great Atlantic and Pacific Tea Company (A&P) ordered the removal of Tylenol from all of its more than 1,000 stores in 24 states, most in the Eastern half of the nation. Late Monday afternoon, company spokesperson Michael Rourke said, “If this turns out to be an isolated incident, we’ll put it back on the shelves.”

Officials from the FBI, the FDA, and J&J dusted off the “approved theory” script from the 1982 Tylenol murders case and began once again to promote the madman-in-the-retail store scenario. This time the madman would be portrayed as a sick criminal mastermind.

The FDA immediately assured the public that the tampering was a local, isolated incident. FDA Commissioner Frank Young, who had been in that position since August 1984, said consumers in the Bronxville area should avoid taking Tylenol capsules, and people nationally should not take Tylenol from the batch in question. He said people did not need to be unduly concerned about Tylenol tablets or any other Tylenol medications.

Johnson & Johnson - in a statement released Monday evening - said, “While Johnson & Johnson has no reason to believe that this is more than an isolated event, we endorse the recommendation of the FDA and local authorities. We recommend that people in the Bronxville-Yonkers area not take any Tylenol capsules until the investigation has been completed.”

Burke said the company believed that no Tylenol capsules had been tampered with at the plant, and J&J was proceeding as though the tampering occurred near where Elsroth died. “We do believe what happened in Westchester is a local situation,” said Burke. He said he was “confident” the cyanide did not come from a company plant.

J&J spokesperson James Murray further reassured consumers that the tampering had no occurred within Johnson & Johnson. “We checked with our retained samples, and there was no problem there,” said Murray. “We’re reasonably certain that it’s not going to come out of our plant, but we had to be sure.”

New York Governor, Mario Cuomo, advised: “I have instructed my immediate family to discontinue the use of all Tylenol capsules until further notice. I make the same recommendation to everyone in this state.” Westchester County officials then embargoed the sale of Tylenol capsules and asked consumers to return the containers they had bought within the past two months to the store where they had purchased them so they could be returned to McNeil.

The Westchester Medical Examiner’s Office tested the capsules in the 24-count bottle removed from the Notarnicola’s home. Westchester County Medical Examiner, Dr. Millard Hyland, said the test results showed that the Tylenol compound had been replaced in three of the remaining 21 capsules by a brown mixture containing 60 percent potassium cyanide and 40 percent inert materials, including silver and iron. Hyland said the examination showed that Elsroth took two Tylenol capsules, one containing the poison and “perhaps one” with just acetaminophen, the active ingredient in Tylenol. He said the potassium cyanide would be expected to eat through the gelatin capsules within 8 to 10 days, so the poison presumably was placed in the bottles within the last 10 days.

Westchester County Executive, Andrew O’Rourke, confirmed Hyland’s timeline, saying officials believed that Elsroth had been murdered by someone who placed the poison inside the package within the last 10 days. “We are dealing with a case of murder,” he added.

Owen McClain, the Yonkers deputy police chief, took charge of the 15-member task force assigned to investigate the death of Elsroth as a homicide. The investigative team included ten Yonkers detectives, a few state troopers, and a couple of federal agents. “We don’t intend to start a national scare,” said McClain. “We don’t believe the nation is smothered with tainted Tylenol. We are looking at it as an isolated case because we have no evidence it’s anything else.”

When asked if any members of the Notarnicola family were suspects, Chief McClain responded, “We’re obviously exploring the relationship between anyone who was involved with either of the two families.” Michael Notarnicola and his family are considered “witnesses” in the homicide case, said McClain. “We do not have any suspects.” He also said that investigators were checking suppliers of potassium cyanide. “I’ve been led to believe it can be bought quite easily.”

Bruce Bendish, the chief of the homicide squad at the Westchester County District Attorney’s Office, also responded to reporters’ questions about the possible suspects and motive. “We have no reason to believe that she [Elsroth] was a target particularly,” he said. “While there are no suspects, we are not ruling anybody out. We have to find out if the tampering occurred pre-selling or post-selling before we decide on our next step.”

After a jurisdictional dispute among the local authorities, FDA officials obtained two of the three remaining poisoned capsules. An FBI agent put them in a brown paper bag, hopped on a Johnson & Johnson corporate jet, and delivered the capsules to the FDA’s lab in Cincinnati. The FDA completed its analysis of the cyanide sample by the end of the day Monday. Fred Fricke, the director of the FDA’s Elemental Analysis Research Center in Cincinnati, said, “The chemical profile of the cyanide in Elsroth’s adulterated capsules was not the same as the profile of the cyanide in the Chicago poisonings. The two compounds were different. There were no parallels,” said Fricke. FDA spokesperson William Grigg said the compounds had a different chemical structure, though both were potassium cyanide. He also said that the chemical profile was not similar to anything that was in the area of the McNeil plant in Fort Washington.

Tuesday, February 11, 1986

On Tuesday, toxicologists from both Johnson & Johnson and the FDA began testing the bottles of Tylenol capsules that had been shipped from the A&P stores to the FDA’s lab in Brooklyn, New York. FDA Commissioner Frank Young announced that the lab had examined all of the Tylenol capsules from the Bronxville A&P store, and no poison or tampering had been found in any other Tylenol bottles from that store. “There is no evidence of any bottles being involved beyond the particular one,” he said.

According to William Grigg, the Extra Strength Tylenol packaging made the capsules among the most protected in the industry. Grigg said that the FDA’s “negative findings” added to a number of other findings suggest there was “not a broad problem” with tainted Tylenol elsewhere or “any manufacturing problems.” Joseph Valiquette, an FBI spokesperson in New York City, said their investigation had turned up no evidence that poison had been placed in any packages of Tylenol other than the one used by Ms. Elsroth.

The Proprietary Association, the primary lobbying group for non-prescription drug manufacturers, also chimed in. The incident appeared to be “a single, isolated case of poisoning,” not part of a broader plot, said John Walden, the senior vice president of the Proprietary Association. He said there is no evidence that this was the kind of random tampering on the store shelf, as was the case in Chicago in 1982. Walden had thus implied that someone had targeted Diane Elsroth specifically.

William Grigg said it was unlikely that the Tylenol had been tampered with during manufacturing. Federal officials based this opinion on two main elements, he said. First, the bottle was part of a batch of 200,000 units manufactured in May 1985; second, the lot was shipped for sale in August 1985, and because it is a popular item, most of the lot units were likely sold within a month. If other bottles in the shipment had been tainted, said Grigg, officials would probably have known about it long ago. Johnson & Johnson concurred, stating that other people would have reported problems months ago if the batch had been tainted either at the manufacturing plant or at the distribution sites.

Officials from J&J and the FDA apparently had not considered the possibility that these “other people” might have been “too dead” from cyanide-laced Tylenol to report a problem with the drug. Unexplained deaths, especially of older persons, would not typically have resulted in a ruling of a homicide; thus, medical examiners would not have done toxicology tests for cyanide.

“Everything seems to point to a local perpetrator,” said J&J spokesperson James Murray.

“Everyone involved believes this is a local situation,” parroted FDA spokesperson William Grigg.

J&J spokesperson Robert Kniffin said the Tylenol batch in question consisted of 200,000 bottles of 24 capsules each. The batch shipped August 22, 1985, from Montgomeryville, Pennsylvania, to retail stores east of the Mississippi River. By now, most of that batch has probably been sold and used, he said. The company was of course checking with its distributors yesterday [Monday] to try to track down bottles marked with lot number ADF916, said Kniffin, but only a few had been found so far.

When asked if any product could survive two bouts with fatal tampering incidents, Burke relied, “Yes, of course. When the poisonings in Chicago occurred, we cashed in on over 95 years of trust that we had built with the consumer. Everybody in the country believed in us because of our history, because of what Johnson & Johnson was. Anyone who’d ever used the baby powder or a Band-Aid or whatever had that attitude toward the company. And what our research shows us is that even today, after having gone through one of these scares previously, the public still feels that trust. And that’s why we’re bringing Tylenol back.”

After giving no press conferences during the 1982 Tylenol murders investigation, J&J held three press conferences at corporate headquarters during the first week of the 1986 Tylenol murder investigation, and a fourth in Washington D.C, the following week. At the recommendation of Harold Burson, the chairman of Burson-Marsteller, J&J held its first press conference on Tuesday, February 11th. “We had nothing new to say,” Burson said. “But with the company [J&J] having trouble returning the deluge of calls, I was alarmed that we were jeopardizing our credibility.”

Burke put Joseph Chiesa, the president of the McNeil Consumer Products Company, in charge of managing the company’s response to the tampering incident. Burke himself, however, once again took on the role of primary spokesperson. “I really don’t like this personal publicity,” Burke said later. “I don’t feel comfortable with it. Still, as chief executive, I felt I had no choice but to act as the corporate spokesman because Johnson & Johnson can’t be faceless; it [the situation] has to be personalized.”

At Tuesday’s press conference, Burke responded to questions about the vulnerability of capsules to tampering, by declaring his intent to keep capsules on the market. Burke said he thought consumers would continue to want medication in the form of capsules because they were easy to swallow. When asked about the safety of the packaging, Burke replied, “The bottles are tamper-resistant, not tamper-proof.”

Burke said that at least 95 percent of the bottles in question had moved through stores, and about 50 percent to 60 percent of the 200,000 capsules probably had been consumed. Clearly, Johnson & Johnson had a great deal of data documenting the movement of Tylenol through the distribution channel.

Joseph Chiesa, flanked by Burke, explained the relevance of Millard Hyland’s assertion that the cyanide would have eaten through the Tylenol capsules in 8 to 10 days. Chiesa said cyanide breaks down the gelatin-based capsules, and the deterioration becomes evident “in less than a month.” He then added, “We have conviction that none of the poison was put in the capsules by a worker at the plant.”

J&J spokesperson, James Murray, then further highlighted the alleged super-corrosiveness of cyanide. Based on Medical Examiner Milliard Hyland’s findings that the cyanide would have eaten through the capsules, the company feels the tampering “did not take place at the factory,” said Murray. He said the cyanide must have been added to the Tylenol recently because the poison would have corroded through the gelatin capsule “within about two weeks.”

Westchester County District Attorney, Carl Vergari, was not at all convinced of the truthfulness of Murray’s statement. Soon, the executives of Johnson & Johnson would learn that the views of Carl Vergari should not be dismissed lightly.

Carl Vergari belongs to that rare class of individuals who choose careers in the government sector to actually serve the public. He retained that same altruistic goal throughout a long career as the Westchester County district attorney. Vergari was born in Yonkers, New York. He graduated from Fordham University and St. John’s Law School, taking time out for combat as a Marine in World War II. For ten years, he had been a prosecutor in the Manhattan District Attorney’s Office, and for another ten years, he had served on the State Investigation Commission. In 1968, New York Governor, Nelson Rockefeller, appointed Vergari as the Westchester district attorney to fill a vacancy. The extremely popular Vergari, who was a Republican, then won an unprecedented seven election victories in a row, almost all with 65 percent or more of the vote. He was credited with streamlining the criminal justice system in Westchester County during a record 26 years as district attorney until his retirement in 1993. During that time, the number of assistant district attorneys in that county grew from 17 to 109.

Vergari was “a straight shooter who was only interested in prosecuting according to law,” said Michael Edelman, a prosecutor under Vergari. “Everybody knew he was straight as an arrow,” Edelman said. “If you broke the law, you got prosecuted. If you didn’t break the law, you didn’t get prosecuted.”

“He was the kind of guy that also spoke to people about justice,” attorney Peter Goodrich said. “He just inspired people to do the right thing.”

Vergari oversaw the prosecution of several high-profile cases, but he rarely commented publicly about them. He was not a headline seeker. Vergari’s frequent news conferences and outspoken demeanor during the Tylenol murder investigation were thus out of character for the media-shy district attorney. He evidently understood that the only way to get federal officials to conduct a proper investigation was to speak publicly about evidence that the FBI, the FDA, and J&J refused to disclose.

Vergari was a seasoned prosecutor, not easily influenced by politicians engaged in partisan politics. He most certainly would not bow down to the almighty Johnson & Johnson. Nor would he blindly accept the unsubstantiated statements of J&J’s spin-doctors and the political appointees at the FDA.

From the outset, Vergari had serious doubts about the Tylenol tampering theory publicized by J&J and the FDA. He did not believe that cyanide would eat through gel-based Tylenol capsules in “8 to 10 days” as Hyland had claimed, or “within about two weeks” as J&J claimed. During a press conference on Tuesday, Vergari said several theories were being investigated, but tampering at the McNeil factory had not been ruled out.

A reporter then mentioned that other officials believed that the bottle may have been bought elsewhere, tampered with, and then put on the shelf in the Bronxville A&P store. “That’s one theory,” replied Vergari. “As far as I’m concerned, it [the tampering] could have happened anywhere. It might have happened at the factory, it might have happened during shipping, it might have happened at the store.”

The statements from Hyland and J&J executives regarding the super-corrosiveness of cyanide concerned Vergari. He said these officials, by stating that the tampering occurred within 10 days of Elsroth’s death, had created “the false and dangerous impression that people shouldn’t worry about the bottles they bought before that time.”

Vergari was right to worry. New York retailers were taking very lightly the directive to remove Tylenol capsules temporarily from their store-shelves. On Friday, four days after officials had learned about the Tylenol poisoning, New York City inspectors visited 350 stores, and 65 were still selling Tylenol capsules despite a ban by the city’s Health Department. Also on Friday, inspectors from the Onondaga County Health Department in New York visited stores throughout that county. Of the 308 stores visited, 30 were still selling Tylenol capsules.

James Burke seemed sure that the embargo of Tylenol capsules in New York would be short-lived. Moreover, he appeared confident that he would not fail, as he had in 1982, to get through this crisis without recalling Tylenol capsules. Burke sought to minimize any perceived parallel between the latest Tylenol poisoning and the poisoning incident in 1982. He did, however, suggest that this latest incident had opened up some old emotional wounds.

“I guess it’s true with lots of us; when things start going too well, we start to worry,” said Burke, referring to Tylenol’s record sales during the past year. “The first two anniversaries of the Chicago murders were sleepless nights for me,” he said, “because I thought; if somebody’s out there, that’s when they’ll do it. They didn’t. And I had come to the point where I was really quite convinced that that was an isolated incident and behind us once and for all,” Burke recalled. “I did worry - That Saturday night . . . I had a dream that Chicago had happened all over again. And, of course, Monday we found out that it didn’t happen in Chicago but, indeed, we had had an incident in Westchester [County].”

Burke later remarked that the poisoner was “someone who is mentally ill” and “these kinds of people, for the most part, know they’re not well. They don’t like to be called kooks, but they don’t mind being called sick. They understand at some level that they are sick.” Burke then suggested that the killer could be rehabilitated.

“There has been enormous progress in the area of mental health,” said Burke. “There are things that can be done. It doesn’t mean that the person wouldn’t have to deal with the halls of justice, but it does mean that the person might be able to get some help if they wanted. I don’t know; I’m just reaching,” Burke confessed.

While Burke speculated about the mental health of the Tylenol killer, Yonkers Deputy Chief John McClain worked day and night to track down leads and map out strategy. “We talked to the delivery men, the stock boys, the customers; even to some children at the store,” said McClain. “We want to know: ‘Who delivered these boxes?’ ‘Were they damaged?’ ‘Who put them on the shelves?’ ‘Were they rotated?’ You interview and re-interview, and then interview some more,” McClain said. “We’re looking for inconsistencies, half-truths; lies, if you will.”

Chief McClain did not know it then, but several inconsistencies, half-truths, and lies had already been told, but not by any of the potential suspects that McClain and his men had interviewed. These inconsistencies and half-truths had instead come from Johnson & Johnson and the FDA; and they were still well hidden when things took a sudden turn for the worse for Johnson & Johnson.

29

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We Never Said It Is Tamper Proof

By Thursday, February 13, 1986, officials from J&J and the FDA were beginning to feel a measure of relief. The Tylenol tampering apparently was an isolated incident, just as they said it was. Then, on Thursday afternoon, a paper litmus strip inserted into a Tylenol bottle at the FDA lab in Brooklyn, New York turned blue, indicating the presence of cyanide. Byron Tart, an FDA consumer safety officer at the lab, had examined the Tylenol package for signs of tampering. There were none. The outer package flap was glued shut, and the bottle’s seals showed no signs of tampering. He removed the tamper-resistant packaging and opened the bottle. Some of the capsules seemed misaligned. Five of the 24 capsules contained cyanide. The Tylenol in the bottle was from Lot AHA090 with an expiration date of April 1987. It had been manufactured in McNeil’s plant in Puerto Rico.

Within two hours of the FDA’s discovery, Burke received a telephone call from FDA Commissioner Frank Young. “Jim, are you sitting down?” Young asked. “We’ve found a second bottle.”

“Frank, that is the worst news you could give us,” Burke replied.

Young said the second bottle of cyanide-laced Extra Strength Tylenol capsules had been pulled off the shelves of a Woolworth store just two blocks from the A&P store where the first bottle of poisoned Tylenol had been purchased. He said that when chemists opened the capsules to examine them, they noticed that the words “Tylenol,” which normally appeared parallel to each other on each half of the capsules, were misaligned on five of the capsules. He also said, “You could see more brown color” than was normal in the acetaminophen powder in the capsules. “There were no visible signs of tampering on the packaging,” said Young.

Burke had initially assigned the job of managing the crisis to McNeil President, Joseph Chiesa. Now, with the discovery of more poisoned Tylenol, Burke took command. He put together a full-fledged “crisis team” of high-level executives who would meet daily to manage the crisis. The team included J&J President, David Clare; McNeil and Company Group Chairman, David Collins; J&J Public Relations Vice President, Larry Foster; J&J General Counsel, George Frazza; and McNeil Consumer Products Company President, Joseph Chiesa. It was decided early on, said Foster, “to be completely open” with the public.

In a collaborative effort, J&J and the FBI scoured the Westchester County area and picked up all bottles of Tylenol capsules within a three-mile radius of the Bronxville A&P and Woolworth stores that had been linked to the poisoned Tylenol. Already, the investigation had become a combined effort between Johnson & Johnson and the FBI.

Johnson & Johnson made preparations with federal officials to fly the latest sample to the FDA lab in Cincinnati to determine if the cyanide matched the poison that killed Elsroth. J&J’s corporate jet was not immediately available, so the FDA arranged for a late-night commercial flight scheduled to leave New York at 10 p.m. The flight was delayed two hours by bad weather in New York. When the plane touched down in Cincinnati, the cyanide sample was immediately rushed to the FDA lab.

At 2 a.m. Friday morning, Fred Fricke called from Cincinnati to report that the cyanide samples from both of the bottles were the same. The chemical analysis revealed that the cyanide in the second bottle of poisoned Extra Strength Tylenol was chemically identical to the potassium cyanide implicated in the death of Diane Elsroth. “Therefore, both samples must have come from the same source,” said Frank Young.

The FDA said the chemical make-up of the cyanide in the adulterated Tylenol capsules from both bottles was the same. Federal officials determined that five of the capsules in the second bottle contained a compound of 90% potassium cyanide and 10% inert materials. That was a substantially different mix than had initially been reported for the adulterated Tylenol capsules from Elsroth’s Tylenol bottle.

West Chester County Medical Examiner, Millard Hyland, had said previously that three of the remaining 21 capsules in Elsroth’s bottle contained a brown mixture that was 60 percent potassium cyanide and various inert materials. More specifically, the New York Times had reported on February 12th that the adulterated capsules in Elsroth’s bottle contained 60 percent potassium cyanide and 40 percent inert materials, including silver and iron. But now, the FDA said that the adulterated Tylenol capsules in both bottles contained an amount of potassium cyanide that was 90 percent pure, and thus the chemical components or “fingerprint” of the two batches of poison “line up exactly.”

The FDA never acknowledged or explained the discrepancy between the initial findings regarding the cyanide-mix in Elsroth’s bottle and the subsequent, amended findings. Instead, FDA Deputy Commissioner, John Norris, simply said that the “matching” chemical profiles raise “the possibility that the same person or persons who put the drug in the first bottle put it in the second.

All of a sudden,” said Norris, “it was clear that whoever did the first tampering was willing to have more people die. He was willing to kill more than once. The dimensions changed dramatically.”

FDA Commissioner Frank Young said the poisoning “still appears to be a local occurrence in the greater New York area.” Federal investigators “still think this is a local occurrence,” he added.

FDA Deputy Commissioner John Norris said that while the agency still believes “this is a localized matter; we can’t take the chance it’s not.”

Carl Vergari saw things differently. “The reports we’re getting, is that there was no tampering afterward [after the Tylenol was packaged]. So this would lend support to the theory that somewhere during the manufacturing process is when the cyanide was put into the capsules at the plant,” explained Vergari. He cited industrial sabotage and a disgruntled plant employee as two theories.

Tampering at the plant is “one avenue we are exploring, but not the only one,” said Vergari. “In all likelihood,” he said, “the probabilities are that the contamination occurred sometime during the manufacturing process.”

Burke reacted to the discovery of the second bottle of poisoned Tylenol by calling the tampering “an act of terrorism, pure and simple,” and a “national problem that affects everything” Americans “eat and drink.” Nevertheless, Burke said he had no plans “at this time” to initiate a nationwide recall, stating that such a recall would “remind the terrorist out there that he has won.”

“It is our belief,” said Burke, “that based on current knowledge, that a national recall is not indicated. However, if consumers in any part of the country wish to return their packages of Tylenol, the company would exchange them for the caplet or tablet forms of the drug or give them a full refund.” J&J enlisted the Maple Plain Company in Minnesota once again to handle the reverse distribution of Tylenol bottles returned by consumers.

Burke announced that Johnson & Johnson was offering a $100,000 reward for information leading to the identification of those responsible for the poisoning and asked anyone with such information to call the Federal Bureau of Investigation at 1-800-334-2344. Burke then blasted the local New York media for what he said was sensational reporting, objecting to such words and phrases as “horrors” and “terrified discovery.”

“I think the local broadcast media have turned this thing into a circus,” Burke complained. “I think it’s outrageous.” Burke even blamed the media for failing to inform the public that Johnson & Johnson believed Tylenol tablets and caplets were safe. “There are people out there who are suffering with pain or who have pain,” said Burke, “and I believe you owe it to them, as well as to us, to remind them that the [Tylenol] tablets and caplets are available”

Bubbling just underneath what Burke referred to as the “sensational reporting” in the local media was a story that threatened to cause unrest among Johnson & Johnson’s mostly unconcerned Tylenol customers. At about the same time the second bottle had tested positive for cyanide on Thursday, February 13th, a third bottle of Tylenol had also tested positive for cyanide. George Gerstenberg, the director of the FDA’s Brooklyn office, said a trace of cyanide had been found in one capsule from a third bottle. “It was so small an amount that we could barely detect it here, and that’s why we had to wait all day (Thursday) until we could confirm it in our Cincinnati plant.” Gerstenberg said this third bottle was from an A&P store in Shrub Oak, about 27 miles north of Bronxville.

Frank Young described the poison found in the third bottle as a blip. “We think it’s an industrial contaminant,” said Young. “It’s such a small trace that it wouldn’t have done anything anyway,” he said. “It’s just so small we don’t know what it is.”

Further tests on capsules from the third bottle were completed late Thursday at the FDA laboratory in Cincinnati, but the results of those tests were never released. Nevertheless, one of the capsules in the third bottle had in fact been tampered with. Gerstenberg said it had tested positive for cyanide, and the logos printed on the capsule-halves were misaligned, clearly evidence of tampering.

The FDA minimized the relevance of the contaminant in the third bottle. “It may be a cleaner and it may be cyanide, but it was a trace or harmless amount and would not have been harmful to anyone who ingested it,” said FDA Deputy Commissioner John Norris. Norris described the contamination as “dust” from the manufacturing process that occasionally can find its way into the product. Whatever the amount of the contaminant in the third bottle, it was enough to turn the litmus strip blue, and it should not have been in the Tylenol capsule.

On Friday morning, February 14th, John Norris was interviewed on Associated Press Radio about the latest developments in the tampering case. When asked if there were any signs that the packaging on the Tylenol bottles had been tampered with, he said, “The three seals on the tainted product were, from all external signs, intact.” The FDA had examined packaging from both the second and third bottles, and in both cases, there were no indications that the packaging had been tampered with after the bottles left the factory.

When asked to explain how the killer could have gotten poisoned capsules into the bottles while leaving no sign that the packaging had been breached, Norris pontificated, “It’s possible someone extremely skilled at tampering did it outside the factory.”

At Johnson & Johnson headquarters, Robert Kniffin said the company had no comment on how cyanide might be introduced into capsules in unopened tamper-resistant packages protected by glued flaps on the boxes. “All we have said in the past is that the packaging is tamper-resistant or tamper-evident,” said Kniffin, “We never said it is tamper-proof.” Johnson & Johnson’s dogma was far different back in 1982 when they were launching the new tamper-resistant packaging.

James Burke, along with J&J General Counsel George Frazza and J&J President David Clare, had flown in the corporate helicopter to Washington D.C. for an emergency meeting with Secretary of Health and Human Services, Richard Schweiker, and FDA Commissioner, Arthur Hull Hayes, on Thursday afternoon, November 4, 1982. In the middle of that meeting, Burke pulled out samples of the newly packaged capsules. Both Schweiker and Hayes had trouble getting the bottles open. Schweiker then turned to Burke and said, “Everybody else is going to have a package. You’ve got an armored tank.”

The “armored tank” message was not the one Johnson & Johnson wanted to convey in 1986 when they needed the public to believe that a sick criminal mastermind had removed and then replaced three layers of tamper-resistant packaging on Tylenol bottles, leaving behind no detectable signs of tampering.

Although the packaging had been torn off Elsroth’s bottle by her boyfriend, it was intact on the second and third bottles. When investigators cut open the triple-sealed packages on those bottles, the poison was there, right inside the red-and-white capsules. Even Johnson & Johnson admitted, probably in the first bottle found, and definitely in the second bottle - the original factory seals on the box, neck, and mouth of the container were still in place when taken from the store shelves.

J&J executives, FDA officials, and packaging industry experts suggested that the killer had done some elaborate and expensive tampering, involving special equipment to reseal and replace the heat-shrunk barriers. However, a J&J spokesperson said indicators such as the lettering on the shrink-ring around the neck and the tautness of the foil seal over the mouth showed no signs of even that type of tampering.

None of the three seals had been broken or showed any signs of tampering on either the second or third bottles of adulterated Tylenol capsules. The capsules themselves - as opposed to the packages – did show clear signs of tampering.

The word “Tylenol,” and the “500mg” dose printed on each capsule half, are always precisely aligned when they come out of the factory. The capsules are stamped with “Tylenol” and “500mg” labels after they are filled with acetaminophen and put together, ensuring perfect alignment. The poisoned capsules in all three contaminated bottles did not have that alignment, thus leaving the mark of the killer behind.

The FBI, in addition to inspecting the tamper-resistant seals, also closely examined the bottles themselves to determine if someone had somehow invaded them without removing the seals on the bottles. The FBI even took X-rays of the bottles, but found no sign that they had been breached. The evidence showed instead that the cyanide-laced Tylenol capsules had been put into the bottles before the bottles were packaged.

Even James Burke said, “The indication was that it [the packaging] was the original factory seal at all three points [all three layers of tamper-resistant packaging]. If this [invading the bottles undetected] was done, it was done by somebody very, very bright who has the technology.”

“It is utterly baffling,” remarked James Murray, Johnson & Johnson’s seemingly confounded spokesperson. “We just cannot understand what was done.” It is almost as if the crime were committed because it was an “exquisite challenge” to break through the tough triple seals without leaving a visible mark, said Murray.

Someone had gotten the cyanide-laced Tylenol capsules into the bottles before they were packaged, and Johnson & Johnson had nothing to support its claim that the tamperings had occurred in the retail stores. Then, right on cue, J&J got some help in the form of an article titled, “Seal on Drug Package Can Be Forged,” published in The New York Times on February 14th, one day after the second bottle of cyanide-laced Tylenol was discovered. The author, Malcolm Browne, was a prominent Pulitzer Prize-winning journalist who gave instant credibility to J&J’s suggestion that someone could have breached the packaging on the Tylenol bottles without leaving any detectable signs of tampering.

“Electric heat-sealing machines are readily available and comparatively inexpensive, and plastic or laminated-foil packaging material can be purchased from many manufacturers,” wrote Browne. “The specially shaped plastic seals that some manufacturers apply to pharmaceuticals could be reproduced with the devices some hobbyists use to form plastic parts for model airplanes and automobiles.”

“A terrorist bent on wrapping a tainted pill or capsule in a convincingly sealed package might accomplish the task fairly easily,” according to Browne. “Few consumers are likely to examine very carefully the sealed wrappings in which drugs are sold or to compare such wrappings with samples known to be authentic.”

Browne suggested that it was relatively easy for a run-of-the-mill hobbyist to remove and replace tamper-resistant packaging. This portrayal was far from accurate. Even J&J and the FBI said they did not know how the packaging could have been tampered with undetected. Agents at the FBI lab in Washington D.C. inspected the packaging from all three bottles of contaminated Tylenol. They found no evidence of tampering. Johnson & Johnson’s experts also said the packaging on the bottles were the original factory seals. The packaging had not been forged or penetrated, and no evidence was ever produced to suggest otherwise. Only the capsules showed signs of tampering.

“In any case” wrote Browne, “the security of the factories that manufacture and package drugs can probably never be guaranteed. A determined terrorist might gain access to a company’s own packaging machinery, introducing poisoned substances into properly sealed containers indistinguishable from containers used for the legitimate product.”

Browne’s simplistic solution to the problem of tampering was for consumers to be more diligent. But all the diligence in the world would not have helped Diane Elsroth, because the packaging on the bottles of poisoned Tylenol had not been tampered with.

On the day Browne’s article ran in the New York Times, J&J executives said they still believed that both packages of cyanide-laced Tylenol had been tampered with after they had arrived in Westchester County stores. For one thing, they noted, the two packages of 24 capsules had been produced in two different plants at different times. However, that was not entirely accurate.

As it turned out, both bottles of cyanide-laced Tylenol had been shipped though the very same distribution center. The owner of that distribution center was none other than Johnson & Johnson.

On Friday, February 14th, James Murray said that the two bottles of cyanide-laced Tylenol capsules were part of two separate batches received at the warehouse on Welsh Road (one of two entrances to J&J’s Montgomeryville facility). “They were essentially unloaded off of one truck and loaded onto another truck,” Murray said. He said the Tylenol in the first bottle was manufactured at the McNeil plant in Fort Washington on May 17, 1985. It arrived at the Montgomeryville warehouse on August 21, 1985, and was shipped out the next day by truck. Murray said the Tylenol in the second bottle was manufactured in Dorado, Puerto Rico, on July 17, 1985. It arrived at the Montgomeryville warehouse on September 5, 1985 and was shipped out the next day.

J&J spokesperson, Robert Kniffin, confirmed that both bottles of cyanide-laced Tylenol capsules had been shipped from a McNeil distribution center in Montgomeryville about two weeks apart in the summer of 1985. Yet during the previous three days, when describing the distribution path of the first bottle of cyanide-laced Tylenol, J&J spokespersons had said only that it was shipped from a warehouse in Montgomeryville. They had never mentioned the fact that Johnson & Johnson owned and operated that Montgomeryville warehouse.

Kniffin’s characterization of the Montgomeryville facility as a distribution center was also not completely accurate. It was actually much more than that. It was the home of several J&J operating companies, including the R. W. Johnson Pharmaceutical Research Institute and the McNeil Pharmaceutical Company. The Montgomeryville facility, located seven miles north of the McNeil Consumer Products Company in Fort Washington, did in fact ship Tylenol, but the operating company that handled that task was the Johnson & Johnson Sales & Logistics Company. In 1986, just as in 1982, the Tylenol poisoning was not really a McNeil problem – it was a Johnson & Johnson problem. J&J executives, by hiding important facts about the distribution of Tylenol, were playing the same game they had played in 1982.

The three J&J regional distribution centers that handled Tylenol in both 1982 and 1986 were located in Montgomeryville, Pennsylvania; Round Rock, Texas; and Glendale, California. Robert Kniffin said the distribution centers shipped generally, though not exclusively, to their respective regions of the nation. Thus, said Kniffin, Tylenol shipped through Montgomeryville goes to the Eastern region of the United States, which included all states east of the Mississippi River.

Carl Vergari said investigators were trying to determine if the Tylenol in the second bottle might have been made in Pennsylvania even though it had a Puerto Rican lot number. He said the discovery of the second contaminated bottle had increased “the focus of the investigation on the possibility of tampering at the plant.”

Vergari now believed that the Tylenol produced at McNeil’s plant in Puerto Rico had been shipped in bulk containers of Tylenol powder or capsules and then repackaged elsewhere, possibly at McNeil’s plant in Fort Washington. Vergari, thanks to his joint investigation with the FBI, had uncovered some of J&J’s secrets about the manufacturing and distribution of Tylenol.

Burke never addressed Vergari’s allegations, and he never once strayed from his talking points. “We still believe it’s local tampering, but we can’t prove it didn’t happen at the plant,” Burke said.  “You had two bottles produced at two separate places at two separate times. What are the chances of them going through the distribution system and ending up in the same city a block apart?” argued Burke. “The odds are something like one in a billion,” he said. We can’t even estimate it, it’s so great.”

Burke’s odds calculation of “one in a billion” was off by a factor of one billion. The probability that two bottles of Tylenol manufactured in two different plants thousands of miles apart would end up in two stores on the same city block in Bronxville, New York, were actually 100 percent. The odds were 100 percent because the Tylenol in all of the bottles shipped to stores in Bronxville, New York – no matter where that Tylenol had been manufactured - went through Johnson & Johnson’s Regional Distribution Center in Montgomeryville.

The discovery of the second bottle of poisoned Tylenol got the FBI’s full attention. The number of FBI agents working on the case in New York increased from two to about twenty, and an undisclosed number of additional agents outside of New York were also put on the case. Assistant FBI Director, William Baker, said his agency would “re-examine the whole case.” He said, “FBI Director William Webster has ordered that the highest priority be given to the poisonings, and we are looking into the matter right now.”

This case “is extremely hot,” said Chief FBI Spokesperson, Milt Ahlerich. “One little person can put cyanide in capsules and this can move mountains, literally - the media, hundreds of police officers and agents, millions of dollars,” he said.

The FBI assembled a team of agents who began culling records from the 1982 Tylenol murders. Ahlerich said these agents will try to trace the capsules from their point of manufacture - Fort Washington for the pills involved in Miss Elsroth’s death, and Dorado, Puerto Rico for the bottle of contaminated pills discovered Thursday - to what Ahlerich called “the point of adulteration.” Ahlerich said the FBI agents would be asking, “Do we have a warehouse situation, do we have an in-store situation, or do we have something that goes all the way back to the factory?”

The FBI never answered those questions though. Just as they had done in 1982, federal investigators limited their commentary to the psyche of the killer, never discussing the actual evidence. They freely speculated on their killer’s psychological tendencies, but refused to acknowledge the relevance of the physical evidence and the pure logic that said the tamperings had occurred in the channel of distribution. “We’re trying to think of the kind of person involved,” Ahlerich proclaimed. “What is the mentality of the killer here?”

On February 14, 1986, the press revealed that the FBI and Westchester County officials were working with J&J to schedule a visit to the McNeil plant in Fort Washington. Bruce Bendish, the Westchester County prosecutor in charge of the homicide unit, said the visit to the McNeil plant was “to make sure we’re familiar with procedures so it can help should further questions arise… For anybody to focus in on any one theory now would be premature.” Tampering in the distribution channel is one theory “we’ve been made aware of and [are] pursuing,” added Bendish.

Robert Kniffin spoke to the press on Saturday, February 15th, to report that J&J was in the process of reviewing the personnel files of about 30,000 employees. Kniffin said the company was also going over its Tylenol production, storage, and distribution process. He did not elaborate on exactly what that review entailed.

James Burke, when asked if he thought an employee or former worker was responsible for the tamperings, said, “We honestly don’t know that’s the case at all.”

Unfettered by the culture of silence that Johnson & Johnson normally strictly enforced, Burke peppered the media with speculative theories. “Premeditated murder has not been ruled out. Nothing has been ruled out,” Burke declared. “We are convinced the same person was involved” in the two incidents at the A&P and Woolworth stores in Bronxville. “This investigation is going to be absolutely massive at all levels. All employee records are being examined.”

While Johnson & Johnson’s human resources department took charge of the “massive” investigation, namely, the examination of J&J employees’ records; Burke turned his attention to the growing debate on the future of Tylenol capsules.

30

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The Great Capsule Debate

After the death of Diane Elsroth, it was apparent to some that the elimination of unsealed capsules was long past due. The pharmaceutical industry, of course, saw things differently. Manufacturers sold $1.5 billion in OTC capsules per year, so the industry’s lobbyists continued to fight to keep them on the market.

Proprietary Association spokesperson, John Walden, insisted that tamper-resistant packaging was still the best protection against tampering incidents involving capsules. “You can’t make anything tamper-proof,” he said. “You can’t even make a vault tamper-proof. Burglars prove it all the time,” said Walden. He said drug industry executives and FDA technical experts “feel absolute confidence in the system they had developed in 1982,” adding, “Everyone feels the basic system is in place, and they see no reason to throw it away.” Walden failed to acknowledge that no one was asking the industry to “throw away” the basic anti-tampering system. The industry only needed to do away with the use of unsealed capsules.

In 1986, according to Johnson & Johnson, 14 million people used Tylenol capsules. An additional 23 million used Tylenol tablets, and 12 million used caplets. Tylenol products accounted for $525 million in annual sales, of which about $157 million came from sales of Tylenol capsules.  Heading into the 1986 President’s Day weekend, James Burke met with his top executives at his luxurious New Brunswick office overlooking the Raritan River to determine the fate of Tylenol capsules. While these executives discussed the available options, Burke listened, but said little, according to those who attended the weekend meetings.

The market research that J&J conducted right after the discovery of the second bottle of cyanide-laced Tylenol showed that consumers no longer trusted Tylenol capsules. Telephone surveys revealed that J&J’s effort to persuade customers that the Tylenol tampering was a local incident was failing. One survey of 300 consumers in New York, Chicago, and Atlanta indicated that consumer loyalty to the product was not nearly as strong now as after the Chicago deaths. Burke said the public’s knowledge of the incident was almost universal. He said, “Ninety-seven percent of the public in the research that we’ve just completed know that something has happened to Tylenol. That’s more people than know the name of the President of the United States.”

“There was definitely a trend,” said McNeil Chairman David Collins. Although 78 percent of those surveyed in three cities agreed that Tylenol tablets were safe, a finding that Collins called “comforting,” he said that percentage should be much higher. Burke was not comforted at all by these findings. He blamed the unacceptable survey results on the media. The broadcast media in particular, said Burke, had failed to convey to the public that Tylenol tablets and caplets were safe and not at all involved in the tamperings.

Burke said that when he and J&J President, David Clare, began to push for the end of Tylenol capsules, McNeil executives argued that such a decision was too drastic. The deliberations that ultimately led to the decision to stop making capsules were far from harmonious, Burke recalled. The meetings were often punctuated by “yelling and screaming,” he said. According to Burke, such confrontational meetings were part of the normal Johnson & Johnson approach to forging a consensus.

“The anger that comes out in these meetings is just appalling,” said Burke. “If you walked in, you’d say, ‘Geez, these guys aren’t going to get anywhere; they hate each other!’ Well we not only don’t hate each other; we all love each other. And we’ve known each other long enough, so we can look somebody in the eye and say, ‘That’s crazy’ or ‘Will you shut up and listen to me?’” Burke remarked.

Yelling and screaming aside, the weekend meetings were really just academic. Burke had already decided privately that the capsules would have to go. He wanted to give his top managers a chance to debate the different choices, even though he had already made the choice for them. “It was very important to let people say whatever they thought because you are under terrible stress,” Burke explained.

On Friday, October 14th, the day after the second bottle of cyanide-laced Tylenol was found; Johnson & Johnson’s stock price had dropped $3.75 per share to $48. With the drop in share price and a scheduled appearance by Burke on the Donahue show on Tuesday, J&J decided to announce the discontinuation of Tylenol capsules on Monday while the stock market was closed for the President’s Day holiday. This way, when the stock market reopened on Tuesday, Burke would be seen across America promoting Tylenol caplets and discussing J&J’s “quick” response to the tampering problem on Donahue. The recall announcement also was timed to keep competitors from grabbing the empty shelf space created by the recall of Tylenol capsules. Before rack jobbers had a chance to put a competitor’s product in that empty shelf space, Burke wanted to make it clear that J&J would fill that space, but with Tylenol caplets.

The President’s Day weekend marked the beginning of a media blitz that included 12 appearances from Burke on shows like ABC’s This Week with David Brinkley, Nightline, World News Tonight, and WABC-TV News in New York City, as well as NBC’s Donahue show in New York City. Other J&J executives and FDA officials, including J&J President David Clare and FDA Commissioner Frank Young, also participated in this media blitz.

On February 16, 1986, Burke appeared with Frank Young and Westchester County Executive, Andrew O’Rourke, on ABC’s Sunday morning political affairs talk show, This Week With David Brinkley. Burke was on friendly turf. His brother, Daniel Burke, and his long-time friend, J&J Board-member, Thomas Murphy, had bought ABC in 1985, merged it into Capital Cities, and changed their company’s name to Capital Cities/ABC.

Burke must have been taken aback when in the midst of a nationally broadcast program on the network owned by his brother Daniel and J&J Director Tom Murphy – Andrew O’Rourke scolded him for failing to prevent the second Tylenol poisoning incident. O’Rourke’s tongue-lashing was probably motivated by his desire to score political points. O’Rourke, a politician through and through, thus directed his ire at both Burke and Frank Young.

“You’ve had this happen twice now,” said O’Rourke. “I think it’s time that the government came up with some type of a plan to prevent it from happening in the future. We don’t learn from history only because people are dumb,” he said. “You’ve got to learn from experience.”

O’Rourke proposed the elimination of all unsealed OTC capsules nationwide. Failing that, said O’Rourke, pharmacists should sell them behind counters or the capsules should be made tamper-resistant. “I’m no believer in more federal regulations,” said O’Rourke, “but in this case it would make all of us safer, and I, for one, am willing to give up convenience to feel that the stuff I get from the pharmacy is safe.” O’Rourke’s point was moot, of course, because the tamperings had occurred before the Tylenol bottles were delivered to the retail stores.

Burke, playing the role of the capitalist-patriot, countered O’Rourke by saying, “The only way that could be done, and I think it would be an overreaction, is to take the product and put it behind the shelf in the pharmacy stores. That would deprive the public of the freest system in the world in terms of marketing consumer products.”

During the panel discussion with the heads of both J&J and the FDA, O’Rourke took advantage of this once-in-a-lifetime opportunity to bring up previously undisclosed information about the second bottle of poisoned Tylenol. O’Rourke said, “This particular package in the Woolworth store had a different lot number than the rest of the packages in that same store. That would appear to be reverse shoplifting,” said O’Rourke. “Somebody came in and actually put it on the shelf.”

O’Rourke had now unknowingly disclosed a bit of information that J&J and the feds did not want publicized. The public knew nothing about this lot number discrepancy. And neither Burke nor Young were interested in discussing any of the actual evidence; especially not evidence that the public was not supposed to know about in the first place.

Rather than engage O’Rourke in a conversation about the source of the second bottle of cyanide-laced Tylenol, Burke ended the discussion by dropping the name of one of his powerful friends. Burke casually brought up a conversation he’d had that very morning with FBI Director William Webster. In talking to Mr. Webster this morning, said Burke, he informed me that “unfortunately, there’s nothing new at this time.”

Burke then went into a monologue designed to mitigate Carl Vergari’s contention that the poisoned capsules in both bottles of cyanide-laced Tylenol had been put into those bottles at a McNeil manufacturing plant. Burke skirted the true focus of Vergari’s allegations though, commenting only on J&J’s Montgomeryville distribution center.

“Even if you could tamper at the distribution center,” said Burke, “the culprit would have to deal with the individual bottles’ seals.” In addition to the three layers of tamper-resistant packaging, the individually sealed bottles are “packaged in six-packs, elaborately wrapped in plastic, and they’re packed in a case,” said Burke. “You’d have to get through an awful lot of material.” Burke had now actually underscored the absurdity of his contention that the Tylenol killer had somehow gotten though all of the elaborate packaging without leaving any sign of tampering.

*****

On President’s Day, Monday, February 17th, four days after the second bottle of cyanide-laced Tylenol had turned up, and seven days after J&J had learned about the death of Diane Elsroth, Burke announced that Johnson & Johnson would no longer sell over-the-counter drugs in capsules. J&J did continue to manufacture its patented prescription drug, Tylenol with Codeine, in unsealed capsules, sold only from behind the pharmacy counter.

The decision to withdraw capsules from the marketplace was made to “protect the public,” said Burke. Once again, Burke had positioned Johnson & Johnson as the protector of America, carrying on the tradition of his mentor, “General” Robert Wood Johnson. In 1947, Johnson had urged Congress to approve taxpayer dollars to fund the construction of underground manufacturing plants for Johnson & Johnson - rhetorically asking, “Who will protect America if we don’t?

“We feel the company can no longer guarantee the safety of capsules to a degree consistent with Johnson & Johnson’s standards of responsibility to its consumers,” said Burke; though he evidently felt no such compunction after the 1982 Tylenol murders or in the first several days after Diane Elsroth’s death. “We take this action with great reluctance and a heavy heart, but we cannot control random tampering with capsules after they leave our plant. Therefore, we feel our obligation to consumers is to remove capsules from the market to protect the public.”

“We fought our way back from the Chicago tragedy... thanks to the fairness and good judgment of consumers, said Burke. “We will do it again this time,” he declared. “While this decision is a financial burden to us, it does not begin to compare to the loss suffered by the family and friends of Diane Elsroth,” Burke remarked, his voice reportedly quivering. Burke then said he had expressed, on behalf of the company, “our heartfelt sympathy to Diane’s family and loved ones.”

“The so-called terrorist made no demands on us, said Burke. “We have not given in to any demands.” Then, speaking directly to the killer, Burke said, “What we’ve really done here is say to whoever made this act: ‘You’re not going to defeat us.’ We’re coming back again.”

FDA Deputy Commissioner John Norris praised Johnson & Johnson. “This Company has figured out if you do poorly by the American public, they won’t respect you; and if you do well by them and look out for their interests, they’ll give you a second chance.” Johnson & Johnson has acted in “enlightened self-interest,” said Norris. “The agency did not direct or pressure Johnson & Johnson to take this action.”

Frank Young called Johnson & Johnson’s decision “a responsible action under tough circumstances.” Young cautioned that it would be “premature” for the rest of the industry to follow suit.

Even before Burke had finalized his decision to discontinue Tylenol capsules, he had begun to promote Tylenol caplets during his many media appearances. Burke readily admitted that he wasted no opportunity to promote the message that Tylenol caplets were a safe alternative to capsules. “I am an aggressive marketing person,” Burke said. “I’ve never denied that.”

David Collins, as a J&J company group chairman and the chairman of McNeil, endorsed the elimination of capsules. But Collins was now also the Vice President of the Proprietary Association’s Board of Directors. In that role, Collins was among those industry leaders who were adamantly opposed to the elimination of capsules. Johnson & Johnson withdrew capsules from the OTC market, but the industry as a whole did not.

The 18 states that had banned capsules indefinitely, soon acquiesced; and unsealed capsules remained on the market in all 50 states. The Proprietary Association had easily won the great capsule debate. It would take several well publicized deaths later that year from poison-filled capsules before most manufacturers would grudgingly begin to withdraw OTC drugs packaged in unsealed capsules from the marketplace.

The beginning of the end of unsealed OTC capsules came in June 1986 when cyanide-laced Excedrin capsules turned up in stores in the Seattle, Washington area. In that tampering incident, authorities targeted a suspect relatively quickly. The FBI and the U.S. Attorney in Seattle, Joanne Maida, said Stella Nickell had poisoned her husband with cyanide-laced Excedrin capsules and then planted bottles of cyanide-laced Excedrin and Anacin in Seattle area stores so investigators would think her husband’s death was one of several random murders committed by an unknown madman.

Prosecutors charged Stella with the murders of her husband Bruce, and Sue Snow - just as investigators had hoped to charge Lynn Reiner’s husband four years earlier for the 1982 Tylenol murders, and just as the FBI had hoped to charge Diane Elsroth’s boyfriend for her murder in February 1986. Federal prosecutors never had any physical evidence connecting Stella to the poisoned capsules or to the cyanide. Their entire case was based on an unsubstantiated hypothesis. Still, it was enough to get a conviction. The prosecution’s star witness was Stella’s estranged daughter, Cindy Hamilton, who told the jury that prior to Bruce Nickell’s death, Stella had talked to her about killing him. No one corroborated her story.

The Proprietary Association paid Hamilton a reward of $250,000 for the testimony that led to her mother’s conviction. The Association paid an additional $50,000 to eight others who also came forward with unsubstantiated hearsay that served as the primary “evidence” used by the Justice Department to convict Stella Nickell.

James D. Cope, the president of the Proprietary Association, said on June 18, 1986, “Twelve confirmed deaths since 1982 have been associated with drug products in capsule form. And all 12 deaths were caused by cyanide put into those products, whether for criminal tampering or for murder or suicide in the home.” He then added, “In light of its recent popularity as a tool for suicide and murder, we think it’s time to take a hard look at cyanide’s perhaps too-easy availability.” Cope had thus evaded the real problem, which was not the “too-easy availability” of cyanide, but rather the too easily adulterated capsules.

James Burke described the torment he experienced after learning that Tylenol capsules had once again been used as a murder weapon: “The main anguish that any human being feels is that, somehow and some way, after doing everything we knew how to do, there’s another person dead out there - and that our product was an instrument of that death, a murder weapon. That is very painful for us.”

When Burke was asked during a February 17, 1986 interview on WABC-TV if he was sorry he had not discontinued the capsules after the 1982 murders, he responded, “Yes, Indeed I am. In hindsight, which is 20-20, I wish we had never gone back to marketing these capsules.” Burke’s newfound enlightenment came only after J&J’s market research showed that consumers no longer trusted capsules. They wanted an alternative.

The national concern generated by the death of Diane Elsroth provided Burke the ideal platform to launch a new marketing campaign to promote caplets as the tamper-proof replacement for capsules. As luck would have it, Johnson & Johnson was already prepared to fill the shelf-space left open by the withdrawal of Tylenol capsules. Shortly before Diane Elsroth died, Johnson & Johnson had manufactured a large batch of caplets that it had planned to market in the fall of 1986. With this head start, the company now prepared its manufacturing facilities in Puerto Rico, Texas, and Pennsylvania for bigger production runs and added new shifts of workers.

One day after announcing the elimination of capsules and publicly proclaiming his sorrow over the death of Diane Elsroth, Burke went on the Donahue show and suggested that Elsroth’s death was a case of premeditated murder. Burke said the same person who tampered with the pills that killed Miss Elsroth later took another “package off the shelf'” of some store and “then did a very professional job of putting five capsules in, putting it back on the shelf, probably to mislead people from the first bottle.” Burke implied that someone who knew Diane Elsroth had given her the cyanide-laced Tylenol capsules and then planted a second bottle of poisoned Tylenol to “mislead” investigators into believing that her murder was the work of an anonymous madman. Burke’s premeditated murder scenario, if it had been believed, would have put suspicion right back on Diane’s boyfriend, Michael Notarnicola.

Publicly, officials had said all along that Elsroth had not been specifically targeted. The FBI, however, did initially treat the Notarnicolas as suspects. Their friends and relatives would later reveal that before the second bottle turned up, the Notarnicolas were on the wrong side of a witch-hunt to convict anyone - just to get a conviction. The public consensus was that the second bottle of poisoned Tylenol, because the packaging was intact, proved that Elsroth was not a specific target, thus exonerating Michael.

Two of Michael’s friends - Joseph Granda and Peter Tripodi - were actually relieved when they heard that more poisoned Tylenol capsules had turned up. They viewed this finding as a fortuitous event, at least for Michael, because they believed the cloud of suspicion would then be taken off their long-time friend. “Thank God they found another one,” said Granda. “Just for that reason,” meaning the presumptive rumors would hopefully end. Tripodi said the whole incident and the speculation about it were “atrocious.”

Yonkers Deputy Police Chief, Owen McClain, later described the speculative theories that had been batted around regarding the Notarnicolas. “Automatically, you assume it has to happen in the house,” said McClain. “Police were immediately besieged with theories from numerous tipsters of dubious credibility, including fortunetellers and psychics. Everyone said the mother did it or the father did it or the son did it,” he said. “They said the mother was jealous of the son, the father had it out for the mother, the son wanted to kill the girl because she was pregnant,” McClain recalled.

Television crews had camped out in front of the Notarnicola home while FBI agents questioned the family on Tuesday, February 11th. A headline in the next day’s newspaper said, “Police Interview Yonkers’ Family,” and the story stated that investigators had “focused their attention” on the Notarnicola family. As the investigation progressed, all of the suggested motives for murdering Elsroth were discredited. Police discovered that a reported family argument was a meaningless, minor dispute. Elsroth was not pregnant. None of the theories checked out at all, said McClain.

“They have gone through everything,” said Felicia Elsroth, Diane’s mother. “Everybody who was a friend - everybody - was investigated.” The Notarnicolas, especially Michael, were the victims of a witch-hunt.

Elsroth’s Aunt, Debbie Marcano, called the public “vicious” for suspecting Michael. When the second bottle of poisoned Tylenol was discovered, Marcano said that the family acted “like we had won the lottery,” because the Notarnicolas would no longer be viewed as suspects.

31

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Burke’s Nightmare

James Burke gave the best performance of his entire Tylenol media tour when he appeared on the Donahue show on Tuesday, February 18, 1986. The studio audience applauded him repeatedly. J&J spokesperson James Murray said there would probably be more television appearances for Burke because “You can actually discuss and present your information in its context.” Murray said the benefit of doing shows such as Donahue was that, “You don’t get disjointed snippets.”

The highlight of Burke’s Donahue appearance came when a sympathetic viewer called in and referred to the Tylenol tamperings as an act of terrorism. Burke responded by thrusting his clenched fist into the air in jubilant support of the caller’s point of view. The Donahue studio audience erupted into loud applause. Burke then went on to describe a discussion that had recently taken place between J&J executives regarding what the public’s reaction might have been if it was determined that the tamperings had occurred at one of J&J’s facilities.

“I’m not sure it would be all bad if it was discovered that this did happen in our plant or did happen in the warehouses,” said Burke. “If it happened there, we would be able to narrow the number of suspects appreciably, and I think we’d have very little trouble finding who did it.” Burke said that when he raised this hypothetical notion to his colleagues, they said the public would ‘never forgive us for a lack of quality control.’ – “I don’t believe that,” said Burke.

Shortly after his Donahue appearance, Burke sat down and wrote a “personal letter” to Elsroth’s family. “I didn’t attempt to call, because I didn’t think they would find it a particularly helpful thing. I just tried to express my sympathies as best I could, Burke said. “Diane’s mother has said that when we took the capsules off [the market] - that we took them off three years too late, and I don’t blame her for saying that. I would too. It’s so easy to identify when you think about your own family. That’s very hard for us to take emotionally. That adds to the burden,” said Burke. “That’s the nightmare.”

The nightmare was about to get a lot worse for Burke if Carl Vergari continued to uncover evidence pointing to tampering within Johnson & Johnson’s manufacturing and distribution network. At the time of Burke’s Donahue appearance, it looked like Vergari was about to break the Tylenol poisoning case wide open. Vergari had made a string of evidentiary disclosures between February 12th and 15th that served to debunk every assertion J&J and the FDA had made in support of their declaration that the tamperings occurred after the Tylenol was delivered to the retail stores.

At the top of the list of fabricated evidence was the claim that the cyanide would have eaten through the gel-based Tylenol capsules in less than two weeks. J&J and the FDA contended that because the cyanide-laced Tylenol capsules showed no signs of degradation, they had to have been filled with cyanide recently and at the retail stores - not during manufacturing or distribution. Carl Vergari disagreed.

On Wednesday, February 12th, Vergari told reporters that tampering at the factory had not been ruled out.  He rejected Medical Examiner Millard Hyland’s contention that the cyanide would eat through the gel-based Tylenol capsules in 8 to 10 days and that the tampering had thus occurred recently and in the retail stores. The contamination of the capsules “could have happened anywhere,” he said. Johnson & Johnson, of course, argued otherwise.

On Friday, February 14th, Vergari pressed the issue further. I have it “on good authority,” said Vergari, “that given the right storage circumstances, the right conditions, it [cyanide-filled capsules] could have an indefinite shelf-life.” Vergari’s “good authority” was the FBI and the FDA.

The cyanide from the Tylenol poisonings in both 1982 and 1986 was analyzed at the FBI’s Cincinnati lab, its most sophisticated lab for analyzing poisons. According to Theresa Hoog, the consumer affairs director for the FDA’s Cincinnati office, the lab was especially proficient in analyzing chemicals like cyanide. “We have a small group of scientists who possess rather specific expertise,” she said. “That, coupled with some unique equipment we have, means we can offer a unique kind of expertise not available in other places.”

On Monday, February 10th, the FDA had released some of the findings from its analysis of the cyanide from Elsroth’s Tylenol bottle. They did so without refuting Hyland’s contention that the cyanide would eat through Tylenol capsules in “8 to 10 days. Four days later, the FDA completed a chemical analysis of the cyanide from the second bottle of adulterated capsules. Again, the FDA did not dispute the assertions of Hyland and J&J spokespersons regarding the super-corrosiveness of cyanide. The well-publicized official line was that the cyanide would eat through the gel-based shells of the Tylenol capsules in 8 to 10 days.

Through all of this, Carl Vergari knew the official line was a lie. On February 15th, the FDA finally admitted that Vergari was right; the cyanide would not eat though Tylenol capsules in 8 to 10 days. In fact, the cyanide-laced capsules could last for many months without showing signs of corrosion. This astonishing admission came straight from FDA Commissioner Frank Young - but not until five days after the FDA had completed the analysis of the cyanide-laced capsules from Elsroth’s Tylenol bottle.

A chemical analysis of the potassium cyanide in both containers showed that this particular batch of the poison was “not very water-absorbent,” said Young, and thus “would not degrade capsules quickly.” In explaining this sudden reversal, Young said, “The work we did showed no time restrictions such as were previously reported.”

Young said more sophisticated testing by the FDA had determined that the poison was 90 percent potassium cyanide, which “can exist for several months. We don’t know just how long.” Interestingly, the cyanide in the 1982 Tylenol murders was also 90 percent potassium cyanide.

Young’s assertion that it took these “more sophisticated” tests to determine that the cyanide would not eat through gel-based capsules in 8 to 10 days, was hogwash. The FBI had advised Carl Vergari back on February 10th that the cyanide would not eat through the Tylenol capsules within two weeks. Vergari had said then that “the potency of the poison could last almost indefinitely,” meaning the cyanide would have a negligible corrosive effect on the gel-based Tylenol capsules.

Since the cyanide-laced Tylenol capsules had a shelf life of many months, J&J’s manufacturing plants, warehouses, and distribution network could not be excluded as the likely source of the cyanide-filled Tylenol capsules. J&J and the FDA could no longer point to the pseudo-science of the super-corrosiveness of cyanide as evidence that the tamperings had occurred at the retail stores. Furthermore, the FBI and the FDA had also determined that the packaging on the bottles of poisoned Tylenol had not been tampered with, so it was obvious that the cyanide-laced Tylenol capsules had been put into the bottles before they were packaged.

On February 12th, three days before the FDA came clean on the long shelf life of cyanide-laced Tylenol capsules, Fred Fricke, the director of the FDA’s Elemental Analysis Research Center in Cincinnati, had commented about the chemical analysis of the cyanide. Citing FBI instructions, however, Fricke said he could not discuss specific information about the cyanide. The FDA had known all along that the cyanide-laced capsules actually had a shelf life of many months, possibly years, but said nothing. Carl Vergari refused to go along with this misinformation campaign, because he did not want consumers to be lulled into believing that the lack of visible signs of corrosion was a guarantee that their Tylenol capsules did not contain cyanide. The FDA, on the other hand, knowingly hid the truth about the long shelf life of the cyanide-laced capsules, putting the lives of American consumers in danger.

In addition to the misinformation disseminated about the corrosiveness of the cyanide, the information disclosed about the second bottle of cyanide-laced Tylenol capsules was also inaccurate.  Initially, officials said that the second bottle had come from the Woolworth store in Bronxville. Andrew O’Rourke had discredited that claim during his appearance with James Burke and Frank Young on ABC’s This Week, when he said, “This particular package in Woolworth’s had a different [lot] number than the rest of the packages in that same store. That would appear to be reverse shoplifting. Somebody came in and actually put it on the shelf.”

O’Rourke’s seemingly innocuous revelation triggered a flurry of “no comments” from FBI and FDA officials. The Bronxville police were more forthcoming, confirming that the lot number on the second bottle of cyanide-laced Tylenol was indeed different from the lot number on the six bottles of Extra Strength Tylenol capsules that had actually been in the Woolworth store. With the cat out of the bag, the FDA and the FBI then confirmed that the lot number on the second bottle of cyanide-laced Tylenol did not match the number on the six bottles from the Woolworth store. The second bottle of cyanide-laced Tylenol capsules had not been delivered to, or recovered from, the Woolworth store after all. It had actually come from an A&P store.

On Tuesday, February 11th, two days before the second and third bottles of contaminated Tylenol were discovered by J&J and FDA lab technicians at the FDA lab in Brooklyn, A&P released the following statement:

Yesterday A&P temporarily removed from sale all Tylenol capsules as a precautionary measure, related to a police investigation of a death in Westchester County, N.Y.

Since this type product is distributed from a central A&P warehouse, we were compelled to suspend sales in all [1,000] A&P stores pending further information and a 24-hour search for the questionable product code.

The code number of the product being examined, ADF916 - expiration date May 1987, has been removed from our stores and turned over to the U.S. Food and Drug Administration for inspection. Based on preliminary information received from the Food and Drug Administration and Johnson & Johnson, we anticipate clearance for a resumption of the sale of Tylenol products in the immediate future.

Frank Young said the second and third bottles of contaminated capsules were found during testing of 60,000 Tylenol capsules from somewhere around 1,500 bottles. Those 1,500 bottles had all come from A&P stores. Only A&P stores had turned their Tylenol over to the FDA.

James Burke said the Tylenol in the first and second bottles of cyanide-laced Tylenol had been shipped from J&J’s Montgomeryville distribution center to an A&P distribution center that moves Tylenol through 38 states, and a Woolworth’s distribution center that moves Tylenol through 26 states. However, since the second bottle was not actually shipped to the Woolworth store, it obviously had not gone through a Woolworth distribution center. Furthermore, Burke’s claim that the first bottle of cyanide-laced Tylenol had been shipped to an A&P warehouse was also not quite correct.

A&P said products like Tylenol are “distributed [to its stores] from a central A&P warehouse.” However, that warehouse was not actually owned or operated by A&P. Since 1981, C&S Wholesale Grocers had been under contract to act as A&P’s primary distributor. All three bottles of contaminated Tylenol were distributed from one central warehouse where the Tylenol killer likely planted the cyanide-laced Tylenol capsules.

*****

J&J spokesperson Robert Kniffin said, “The Company considered it unlikely that the tainting had occurred [at J&J’s Montgomeryville distribution center], because each bottle was usually safeguarded by five seals… The bottles at the distribution center are typically covered by two additional sealed wrappings: A clear plastic binder that is heat-sealed around all sides of six bottles, and a shrink-wrapped plastic binding around groups of cartons, each of which contains 12 groups of six-packs” (emphasis added). Not all Tylenol was bottled before it was shipped from the Montgomeryville facility. Some Tylenol was shipped in bulk containers and bottled at repackaging facilities.

McNeil President, Joseph Chiesa, inadvertently provided an additional clue that the Tylenol batches implicated in the tamperings had not yet been bottled when the Tylenol was shipped from Montgomeryville. Chiesa said there were about one-million bottles of Tylenol capsules in the distribution channel in February 1986. At that time, J&J was selling about $10 million worth of Tylenol per week. About 30 percent of that, or $3 million per week, was Tylenol capsules. At an average price of $3.70 per bottle (ten cents more than the avg. price in October 1982), J&J was selling about 811,000 bottles of Tylenol capsules per week ($3,000,000 / $3.70 = 810,810). That means there were enough bottles of Tylenol capsules in the distribution channel in February 1986 to cover about nine days of sales (1,000,000 / 811,000 = 1.23 weeks = 9 days of supply).

J&J and the FDA said Tylenol was a very high turnover product, meaning stores sold through their inventory of Tylenol capsules quickly. FDA spokesperson, William Grigg, said that because Tylenol is a popular item, most of the contaminated lot units were likely sold within a month. A wholesaler that purchased bottles of Tylenol would not still be shipping those bottles six months later to retailers that were turning their inventory over every nine days. The shipments of Tylenol capsules up to six months in advance of demand does not reconcile with that rapid turnover and the nine days of supply of Tylenol capsules in the distribution channel.

It is extremely unlikely that Johnson & Johnson was actually booking those Tylenol shipments as revenue six months ahead of actual demand. The Tylenol in the bottles of cyanide-laced capsules had apparently been shipped in bulk containers of Tylenol powder to a repackager under contract with Johnson & Johnson to package that Tylenol. The contract length must have been six months, because Chiesa and Burke both said that consumers had purchased 95 percent of the Tylenol from the first contaminated lot by February 10, 1986, which was about six months after it had been shipped from J&J’s Montgomeryville facility.

J&J booked the bulk Tylenol shipments as revenue, on multiple invoices over a period of time, as the repackager packaged and then sold it to distributors and retailers. This is how Johnson & Johnson recognizes revenue, and this is how Johnson & Johnson was able to ship Tylenol as much as six months in advance of demand but still have less than two weeks of supply of Extra Strength Tylenol capsules in the distribution channel.

Johnson & Johnson’s “Position Paper on Accounting for Inbound Finished Goods Freight” describes the treatment of finished goods, such as bulk Tylenol sold to a repackager, as follows:

In-bound finished goods freight is freight that moves finished goods, prior to being sold, from the sub-contractor or from the J&J manufacturing facility to a distribution center that is not part of the manufacturing facility. The distribut[or] can be a J&J or 3rd party distribution center. The inventory remains on J&J’s books since it has not yet been sold. The distribution center serves as the finished goods warehouse where the goods are stored until they are sold to 3rd parties.

In cases where J&J ships products to wholesale distributors and repackagers - these products remain on J&J’s books as inventory until the wholesaler sells them to retail and institutional buyers. The repackager is not actually a J&J customer/buyer – it is a J&J contractor. J&J’s policy on revenue recognition provides further insight:

If the customer specifies an intermediate delivery location where a significant portion of the sales price is not payable until delivery to a final location is made; then criteria for revenue recognition are satisfied when delivery to the final destination occurs.

In cases where J&J delivers bulk shipments of Tylenol to an “intermediate delivery location” for future delivery, J&J’s revenue recognition policy requires that these sales shall not be recorded as revenue until the Tylenol is delivered to the final destination - i.e., the retail or institutional buyer. In the case where the “intermediate delivery location” is a repackager – J&J invoices the Tylenol in multiple sales transactions as the Tylenol is packaged and delivered to the actual buyers over a period of time.

At the time of Diane Elsroth’s death, the fiber drums of bulk Tylenol powder from Lots ADF916 and AHA090 were nearly empty, and the repackager was probably about to receive another shipment of six months’ worth of bulk Tylenol from McNeil. When J&J and the FDA learned that Diane Elsroth’s Tylenol capsules had come from an A&P store, they apparently already knew the identity of the repackager where the tamperings had actually occurred, and also knew that this repackager serviced only A&P stores. Hence, there was no need to confiscate Tylenol capsules from stores other than the A&P stores.

The first clue to the true source of the cyanide-laced Tylenol that killed Diane Elsroth had been provided by Jack Ogun, the director of the Division of Drugs, Devices and Cosmetics for the Pennsylvania State Health Department. On February 10th, Ogun had told the Philadelphia Inquirer that Health Department investigators were going to contact Johnson & Johnson the next day to learn whether any of the Tylenol from the poisoned batch had made its way to Pennsylvania retail stores.

Ogun then provided a seemingly benign bit of information regarding the shelf life of Tylenol. Oddly, he was the only official to ever publicly mention the shelf life of Tylenol during the Tylenol tampering investigations in either 1982 or 1986. Ogun said that the May 1987 expiration date of Elsroth’s tainted bottle of Tylenol indicated that it would have been in stores for about two years, because non-prescription pain-relievers generally have a shelf life of about three years. The shelf life of Tylenol was in fact three years, just as Ogun had said. The Tylenol Professional Monograph states:

Under room temperature storage conditions, TYLENOL acetaminophen solid formulations are generally stable for 3 years from the date of manufacture for commercially available products.

By mentioning Tylenol’s three-year shelf life, Ogun had inadvertently exposed a problem with the shelf life of the Tylenol in Elsroth’s bottle, and subsequently, the shelf life of the Tylenol in the second bottle of cyanide-laced Tylenol. The Tylenol in Elsroth’s bottle was manufactured in May 1985, and had an expiration date of May 1987, meaning it had a shelf life of two years. The Tylenol in the second bottle was manufactured in July 1985, and had an expiration date of April 1987, meaning it had a shelf life of 21 months. This expiration dating was not in line with the three year shelf life of the Tylenol that was bottled at the McNeil manufacturing plants.

A drug’s shelf life is based on stability testing. The stability of a drug varies based on the container-closure system in which the drug product is being sold. A drug packaged and sold to repackagers in bulk containers typically has a shorter shelf life than the same drug bottled at the manufacturing plant. The obvious reason that the Tylenol from the two batches involved in the 1986 Tylenol tamperings had shelf lives of 21 months to 24 months, instead of three years, was because the Tylenol from these batches had not been bottled at the McNeil plants. It had instead been shipped in bulk containers of Tylenol powder to a repackaging facility where it was encapsulated, bottled, and packaged.

On Saturday, February 15th, Carl Vergari further discounted the possibility that the cyanide had been introduced into the capsules at the local retail stores. Explaining his belief, Vergari said that his office had been told by the Federal Bureau of Investigation that the seals on both bottles had not been broken after they left the factory. He said investigators should thus not eliminate the theory that the capsules were tainted at the point of manufacture. Vergari also said that despite lot numbers indicating two manufacturing sites, it was possible for a bottle of Tylenol to be made at the Fort Washington plant and still carry the Puerto Rican plant’s lot number. The evidence that put Vergari on track to find the true source of the cyanide-laced Tylenol capsules had come from Puerto Rico.

32

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The Puerto Rican Diversion

The discovery of the second bottle of cyanide-laced Tylenol made it abundantly clear that someone had gotten cyanide-laced Tylenol capsules into the Tylenol bottles before they were packaged and shipped to Westchester County retail stores. Vergari had also learned that the manufacture of the Tylenol at two different plants did not mean that the Tylenol had been bottled and packaged at two different plants.

Vergari said federal investigators had told him that it was possible for a bottle of Tylenol to be made at the Pennsylvania plant, but carry the Puerto Rican plant’s lot number. “The report we’re getting,” said Vergari, “is that there was no tampering afterwards [after the bottles were packaged at the plant], so this [finding] would lend support to the theory that somewhere during the manufacturing process is when the cyanide was put into the capsules... in the plant.”

Vergari was getting dangerously close to the truth. The Tylenol in the second bottle of cyanide-laced capsules had in fact been manufactured in Puerto Rico, but not bottled there. An incident that occurred in 2001, and mentioned earlier, illuminates this routine practice.

On June 28, 2001, the FDA’s district office in San Juan, Puerto Rico, witnessed the destruction of 16 drums of Tylenol 80mg Fruit Chewable Tablets that had been manufactured at McNeil’s plant in Las Piedras, Puerto Rico. The product arrived at the San Juan port on April 22, 2000, and stood unclaimed by McNeil for over a year. The Tylenol tablets had been shipped to a plant in Canada to undergo the packaging process, but then returned intact because the repackager was unable to complete the process before the product expiration date. This incident provides an illustration of the exact same scenario that Vergari and the FBI had uncovered in February of 1986, which was that the Tylenol from Lot AHA090 had been shipped in bulk containers from the McNeil plant in Puerto Rico to be packaged elsewhere.

Johnson & Johnson had a major incentive to manufacture drugs in Puerto Rico, because it paid no federal taxes on the profits from eligible drugs manufactured there. In 1921, the federal government enacted a tax exemption for qualifying income of “possession corporations” - U.S. corporations operating in U.S. territorial possessions. This provision, in its amended form, is known as Section 936 of the Internal Revenue Code, enacted by Congress in 1976 to help Puerto Rico obtain employment-producing investments. Section 936 allowed corporations to shelter from federal tax a substantial amount of U.S. income obtained from products with intangible assets, such as drug patents, manufactured in Puerto Rico.

In 1982, Congress made changes to Section 936 to “lessen the abuse caused by companies’ claiming tax-free income generated by intangibles developed outside of Puerto Rico.” The Tax Equity and Fiscal Responsibility Act of 1982 established that, in general, income from intangible assets, such as patents, trademarks, and trade names, transferred by a parent company to its Section 936 subsidiary would be taxable to U.S. shareholders. But the Act still gave corporations the right to claim income attributable to certain intangible assets as nontaxable. Thus, even after 1982, Section 936 corporations were able to shelter from federal tax a substantial portion of the income earned on certain products manufactured in Puerto Rico.

Carl Vergari’s only interest in J&J’s Puerto Rican operation was in discovering where the Tylenol manufactured there was actually packaged. What Vergari had already come to understand, or was very close to understanding, was that the Tylenol from Lot AHA090, in the second bottle of cyanide-laced Tylenol, had been shipped from Puerto Rico in bulk containers and had then undergone the packaging process at a repackaging facility in the continental United States.

Robert Kniffin said the Tylenol from Lot AHA090 “was manufactured in Dorado, Puerto Rico, on July 17, 1985, shipped by sea August 22nd to either Newark or Baltimore and trucked to Montgomeryville, where it arrived on September 5th.” He said, “It was shipped out the next day with a batch of 84,000 bottles.” This batch of Tylenol was shipped from Dorado on the same day that the Tylenol in the first bottle of cyanide-laced Tylenol was shipped from Montgomeryville; an indication that both lots were part of one large order for one repackager.

Several Johnson & Johnson spokespersons, including Larry Foster, Robert Kniffin, and James Murray said the Tylenol in the second bottle of cyanide-laced capsules had been manufactured in Dorado, Puerto Rico. The FBI and FDA also confirmed that the second batch of contaminated Tylenol had been manufactured in Dorado. Oddly, no one ever mentioned the curious fact that the McNeil Consumer Products Company did not have a manufacturing plant in Dorado. Since 1983, the McNeil Consumer Products Company had been manufacturing Tylenol in Las Piedras, Puerto Rico, 43 miles to the southeast of Dorado.

Johnson & Johnson did, however, own a manufacturing plant in Dorado. The McNeil Pharmaceutical Company - sister of the McNeil Consumer Products Company - had been manufacturing drugs in Dorado since 1976. The McNeil Pharmaceutical Company manufactured only prescription drugs, whereas the McNeil Consumer Products Company manufactured non-prescription drugs containing Tylenol. Both operating companies were subsidiaries of McNeilab Inc.

The McNeil Pharmaceutical Company had FDA approval to manufacture Tylenol with Codeine, a prescription drug, at the Dorado plant. The Dorado plant has never had FDA approval to manufacture non-prescription Tylenol.

The McNeil Pharmaceutical Company had its headquarters at Johnson & Johnson’s 270,000 square-foot facility in Montgomeryville, Pennsylvania. It also operated a manufacturing plant there.

Robert Kniffin said that the Montgomeryville facility was one of three “distribution points” for Tylenol products. In fact, the Montgomeryville facility was not really a distribution center in the traditional sense. It only had a couple truck bays and made relatively few shipments of J&J products to large third-party wholesalers, repackagers, and distributors.

In the 1980s, the McNeil Pharmaceutical plant in Montgomeryville manufactured the prescription analgesics Zomax, Tolectin, and Suprol, and the antipsychotic drug, Haldol. The plant also manufactured Tylox capsules, a painkiller that contains Tylenol and the narcotic, oxycodone. Johnson & Johnson’s Montgomeryville plant thus received bulk containers of Tylenol powder, which McNeil Pharmaceutical then used to manufacture Tylox.

The McNeil Pharmaceutical plant in Dorado manufactured Tylenol with Codeine. Non-prescription Tylenol has never been manufactured or bottled at either the Montgomeryville or Dorado plants. The 120,000 square-foot Dorado plant did, however, manufacture bulk Tylenol, which was then combined with codeine to make Tylenol with Codeine. Tylenol with Codeine was not actually bottled at the Dorado plant. Instead, pharmacists bottled Tylenol with Codeine at local drugstores when they filled consumers’ prescriptions, as is the norm with prescription drugs.

It didn’t seem to make sense that the Tylenol in the second bottle of cyanide-laced Tylenol was manufactured in the Dorado plant, but it was, and officials repeatedly confirmed this fact.

On Saturday, February 16th, Robert Kniffin said Johnson & Johnson had begun reviewing personnel files of about 1,400 workers employed at the McNeil Consumer Product Company’s three production facilities in Round Rock, Fort Washington, and Las Piedras. In this way, Kniffin had acknowledged that the McNeil Consumer Products Company manufactured Tylenol in Las Piedras – not Dorado. But Kniffin had previously stated that the Tylenol in the second bottle of cyanide-laced capsules had been manufactured in Dorado, Puerto Rico on July 17, 1985.

On Thursday, February 13th, J&J officials said they believed that a small amount of cyanide was kept at the factory in Dorado for “quality control testing,” - thus confirming again that the second contaminated batch of Tylenol had been manufactured in Dorado. The FBI also confirmed that the Tylenol in the second bottle had been manufactured in Dorado. The Tylenol manufacturing plant, however, was located in Las Piedras. Making this paradox even more perplexing is that the FDA had not given J&J approval to manufacture Tylenol capsules, tablets, elixir, or any other non-prescription Tylenol formulation at the Dorado plant.

Several contracts between McNeil and the Department of Defense further confirm that non-prescription Tylenol tablets, elixir, and capsules have never been manufactured in Dorado. Throughout the 1980s, the U.S. Department of Defense (DOD) contracted with the McNeil Pharmaceutical Company in Dorado to buy Tylenol with Codeine. The DOD contracted separately with the McNeil Consumer Products Company to buy non-prescription Tylenol at the company’s Las Piedras plant.

The Tylenol in the second bottle of cyanide-laced Extra Strength Tylenol capsules had indeed been manufactured at the McNeil Pharmaceutical plant in Dorado. Johnson & Johnson had shipped that Tylenol in large fiber drums of Tylenol powder to a repackager under contract with Johnson & Johnson to encapsulate, bottle, and package Tylenol. On multiple occasions, someone evidently dropped cyanide-laced Tylenol capsules into the Tylenol bottling production lines at that repackaging facility.

For a number of reasons, Johnson & Johnson covered up what was going on with the shipments of bulk Tylenol powder from the Dorado plant. J&J obviously wanted to avoid being held liable for the Tylenol tamperings and subsequent death of Diane Elsroth. It appears that Johnson & Johnson was also covering up its diversion of Tylenol that was supposed to be used to make Tylenol with Codeine. But what motive could Johnson & Johnson possibly have had for diverting that Tylenol to repackagers who then used it to make non-prescription Extra Strength Tylenol capsules?

Johnson & Johnson’s probable motive was, of course, money; specifically the exemption from federal income tax it received under Section 936 of the U.S. Tax code.

Johnson & Johnson did not pay federal income tax on the income earned from the sale of certain drugs manufactured in Puerto Rico. But J&J only received that Section 936 tax credit on patented drugs. Johnson & Johnson had no patent for acetaminophen, the active ingredient in Tylenol. However, it did have a patent for the combination drug of Tylenol with Codeine. Johnson & Johnson, it appears, received hundreds of millions of dollars in tax credits by reporting to the Internal Revenue Service some of its sales of non-prescription Tylenol capsules as if they were sales of the prescription drug, Tylenol with Codeine, manufactured in Dorado, Puerto Rico.

For the period 1980 to 1990, Johnson & Johnson received federal tax credits under Section 936 of $1.17 billion on sales of $2.78 billion (in 1990 dollars) on two drugs manufactured in Puerto Rico: Tylenol with Codeine and Ortho Novum 7/7/7 28. J&J subsidiary, Ortho McNeil, was licensed to manufacture Ortho Novum 7/7/7 28, and McNeil Pharmaceutical was licensed to manufacture Tylenol with Codeine at the Dorado plant. But what portion of those Tylenol with Codeine “sales” were really sales of bulk Tylenol then used to make OTC Tylenol capsules for which J&J should have paid federal taxes? And how much of that $1.17 billion, plus fines, would Johnson & Johnson have had to give back to U.S. taxpayers if the truth had come out about its diversion of Tylenol?

Carl Vergari had been right all along - the cyanide-laced Tylenol capsules had been poisoned during the manufacturing process (packaging is part of the manufacturing process). James Burke used his media ties to distract the public from the evidence that pointed to J&J’s knowledge of the true source of the cyanide-laced Tylenol that killed Diane Elsroth. An important part of that misinformation campaign was to promote Johnson & Johnson’s “Credo” values.

33

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Our Credo

Carl Vergari’s substantial progress in the Tylenol murder investigation was largely the result of what the FBI agents in New York City had uncovered. Nevertheless, as of February 16, 1986, the FBI officials in Washington D.C. still seemed perplexed. A key question, said FBI spokesperson, Milt Ahlerich, was whether the tampering occurred at the manufacturing plants, the distribution centers, or locally. Ahlerich said that none of these possibilities had been ruled out, but he said there had been “no significant progress” in the inquiry.

Despite Ahlerich’s contention that there had been no significant progress; there had obviously been a great deal of progress. Most of which had been made by the FBI. Vergari’s depth of knowledge about the evidence was the result of a coordinated investigation between his office and the FBI’s New York City office. The FBI’s forensic analysis had revealed that the tamper-resistant packaging on the bottles of cyanide-laced Tylenol had not been tampered with. The Tylenol in the contaminated bottles had followed the same distribution path, even passing through the same McNeil Pharmaceutical Company warehouse in Montgomeryville within a two-week period. Furthermore, Vergari was now closing in on the repackaging facility where the tamperings had actually occurred.

James Burke continued to claim that it was possible to remove and replace the three layers of tamper-resistant seals, but he admitted that there was no evidence that the packaging had been tampered with at all. “There’s no question you can take the package apart and put it back together again,” said Burke. “The question is this: Is there evidence that that has been done? The FBI says, looking at the package, that they have no evidence that it has been tampered with,” said Burke, apparently conceding that the packaging had not been tampered with. But then, with his next breath, Burke snatched that concession right back up.

Burke said experts within Johnson & Johnson had successfully removed and replaced the seals. “I’m not saying the average person could do it,” he clarified. Nevertheless, Burke said “It is our strong conviction that it didn’t happen in the plant or the warehouse, because we can’t figure out how it could have. And we’ve gone over and over and over again our production methods, and also our distribution methods to see how this could possibly have happened. And we’re even examining things like counterfeiting the labels and counterfeiting the numbers. If it happened, it was an elaborate, elaborate process.”

The experts at Johnson & Johnson, according to Burke, could not figure out how the poisoned pills could have gotten into the bottles during the production process. He said the tamperings did not happen at McNeil “because we can’t figure out how it could have.”

In 1986, the FDA did not have statutory authority to inspect records at OTC manufacturing plants. The FDA did, however, have that authority years later when it conducted inspections at the McNeil plant in Las Piedras, Puerto Rico in 2008 and 2009. The FDA reports from those inspections illustrate just how easily poisoned pills could have gotten into the bottles during the production process. The FDA found that during 2008 and 2009, the Las Piedras plant received 123 mix-up related consumer complaints for Tylenol and Motrin products manufactured there. “Mix-ups” are documented events in which a pill, like an Extra Strength Tylenol pill, for example, is found in the wrong bottling production line at the plant or in the wrong bottle after it is purchased at a retail store.

FDA inspection reports from 2008 to 2010 at the McNeil plants revealed that J&J executives were completely indifferent to the dangerous problems identified repeatedly by their own employees and by FDA inspectors. Johnson & Johnson did not investigate any consumer complaints of tampering and drug contamination during that period. The failure of management to investigate incidences of contamination and tampering is a decades-long theme at Johnson & Johnson.

In 1987, Johnson & Johnson received a Regulatory letter from the FDA stating: “Your firm failed to take appropriate measures to prevent [Delfen Contraceptive Foam from] being contaminated with objectionable micro-organisms.” Matthew Lewis, the FDA’s district director in Newark, told Gary Parlin, the president of J&J subsidiary, Ortho Pharmaceutical, that the company also “failed to conduct investigations of complaints, and it failed to include in the written record the reasons that investigations were not conducted.” McNeil sent two reply letters to the agency, but these were unresponsive to the violations, said Lewis.

In 1985, the McNeil Consumer Products Company had recalled 377,000 bottles of Children’s Tylenol Elixir after finding yeast and mold on the necks of some bottles. Don Phillips, director of the Arkansas Health Department’s Division of Pharmacy Services said the contamination could trigger a reaction similar to a penicillin injection, including skin welts and nausea. J&J told wholesalers nationwide to return batches of the product, but the bottles of contaminated Children’s Tylenol Elixir were not removed from any stores. Incredibly, J&J spokesperson, Robert Kniffin, advised parents to continue to give their children Tylenol from the contaminated lots. Larry Foster said a recall from stores or people’s homes was not necessary because, according to Foster, yeast does not pose a sufficient public health hazard.

Executives at Johnson & Johnson also have an established history of firing whistleblowers. In 1982, when McNeil’s Associate Medical Director, Dr. James Dale, and Senior Scientist, Edward Lemanowicz, told company executives that J&J needed to come clean about the dangers of Zomax, they were fired. In 1996, when Carlos Labanda reported that J&J subsidiary Cordis deliberately ignored quality control procedures when manufacturing the company’s best-selling coronary stent, he was fired. When Ronnie Belanger, a lab technician at Cordis, refused to alter her paperwork to obscure the existence of inferior products, she was fired. So was Cordis quality assurance technician, Williams Laws, for complaining to supervisors that products that had failed tests were noted as passing those tests on company documents. In 1999, when Hector Arce reported violations of current Good Manufacturing Practices at J&J’s Eprex manufacturing plant in Puerto Rico, he was fired. In the 2000s, when Chief Medical Officer, Joel Lippmann, asked J&J to report the problems with faulty medical devices and potentially deadly birth control patches, he was fired. Never once has the Justice Department enforced the laws that prohibit retaliation against whistleblowers, so Johnson & Johnson executives continue to fire employees who attempt to hold them accountable to the law, a basic level of morality, or even to the words in their beloved “Credo.”

OUR CREDO

We believe our first responsibility is to the doctors, nurses and patients, to mothers and fathers and all others who use our products and services. In meeting their needs everything we do must be of high quality. We must constantly strive to reduce our costs in order to maintain reasonable prices. Customers' orders must be serviced promptly and accurately. Our suppliers and distributors must have an opportunity to make a fair profit.

We are responsible to our employees, the men and women who work with us throughout the world. Everyone must be considered as an individual. We must respect their dignity and recognize their merit. They must have a sense of security in their jobs. Compensation must be fair and adequate, and working conditions clear, orderly and safe. We must be mindful of ways to help our employees fulfill their family responsibilities. Employees must feel free to make suggestions and complaints. There must be equal opportunity for employment, development and advancement for those qualified. We must provide competent management. And their actions must be just and ethical.

We are responsible to the community in which we live and work and to the world community as well. We must be good citizens - support good works and charities. And bear our fair share of taxes. We must encourage civic improvements and better health and education. We must maintain in good order the property we are privileged to use; protecting the environment and natural resources.

Our final responsibility is to our stockholders. Business must make a sound profit, we must experiment with new ideas. Research must be carried on, innovative programs developed and mistakes paid for. New equipment must be purchased, new facilities provided and new products launched. Reserves must be created to provide for adverse times. When we operate according to these principles, the stockholders should realize a fair return.

*****

There may have been whistleblowers in 1982 and 1986 who tried to disclose sensitive information about the Tylenol poisonings, but who were ignored, fired, or simply intimidated from saying what they knew. Any J&J employee who thought for a minute about the Tylenol tamperings would have realized that there were a number of ways to get cyanide-laced Tylenol capsules into bottles at the manufacturing plants and repackaging facilities. Yet James Burke supposedly could not figure out how such a feat could be accomplished.

An example of the type of investigation Johnson & Johnson conducts to ensure that they don’t ever “figure out how” drugs can be adulterated at their plants is made further evident in the reports from FDA inspections at the McNeil OTC drug manufacturing plant in Las Piedras, Puerto Rico in 2008 and 2009. These reports describe dozens of violations and the complete failure of J&J to investigate consumer complaints. The FDA inspection report said: “Even though your firm received 123 mix-up related complaints, from which you received over 50 consumer complaint samples for evaluation, none of them have been confirmed. Your Quality Control Unit considered all complaints as isolated occurrences of unknown origin. Most of the complaint investigations conclude that there is insufficient evidence to absolutely determine that the reported condition occurred at McNeil, even though your firm has reported over 12 mix-up event investigations.”

The FDA concluded: “There is a failure to thoroughly review any unexplained discrepancy whether or not the batch has been already distributed.”

The methods used by McNeil to “investigate” problems with its manufacturing and packaging of drugs have consistently failed to identify or eliminate problems. Its methods of “investigation” were thus designed to fail. So when James Burke said in 1986 that he was unable to figure out how the cyanide-laced Tylenol capsules could have gotten into bottles during manufacturing, it’s helpful to understand exactly how Johnson & Johnson conducts, or fails to conduct, its internal “investigations” and what precisely the phrase “couldn’t figure out” really meant for J&J.

In February of 1986, one week after the death of Diane Elsroth, Carl Vergari was ready to conduct a serious investigation of J&J’s Tylenol manufacturing and distribution network. He had already disclosed a great deal of evidence, all of which pointed to tampering in the Tylenol distribution channel. During the early days of the investigation, while Vergari was talking to the press about important developments in the case, the FBI had said next to nothing. With a growing body of evidence pointing to a Tylenol killer within Johnson & Johnson’s manufacturing and distribution network, the FBI was now conveniently about to find its voice.

34

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The Vergari Problem

Carl Vergari announced on Friday, February 14th, that he would send investigators to the McNeil plant in Fort Washington to look into the possibility that the adulteration had occurred there. Vergari said the review would examine manufacturing processes and might include looking at employee personnel files. The discovery of the second bottle, said Vergari, increased “the focus of the investigation on the possibility of tampering at the plant.” A tour of the Montgomeryville and Fort Washington plants was scheduled for President’s Day, February 17th.

With the inspection just three days away, Carl Vergari laid out the evidence that Johnson & Johnson had hoped to suppress. He said that based on the FBI tests on the packaging of both bottles of poisoned Tylenol, the tampering most likely occurred at the time of manufacture. The two bottles of poisoned Tylenol capsules had been sent to the FBI labs to determine “to a reasonable degree of certainty, through microscopic examination, whether the metal foil that was heat-welded to the top of the bottle has been tampered with after it left the factory,” said Vergari. “And they say in both cases that their laboratory examination reveals that it was not… that these bottles were not tampered with after they left the factory; that, ergo, the contamination was done at some time during the manufacturing process before the seal was placed on it. What could be clearer than that?”

The official spokespersons for the FBI refused to confirm what was perfectly clear to Vergari and the FBI agents who had actually inspected the packaging. Still, there was no longer any question that the evidence uncovered by FBI agents working with Vergari did not fit the approved theory. The tamperings had obviously occurred before the Tylenol capsules were packaged and shipped to the retail stores.

Reporters, eager to get a response to Vergari’s bombshell revelation, made calls to their usual FBI contacts, but all were unavailable, reportedly because of the President’s Day holiday. On Sunday evening, February 16th, FBI spokesperson Jack French picked up his phone at FBI headquarters in Washington D.C., and then declined to confirm or deny Vergari’s assertions. “We’re not commenting on anyone else’s comments,” French told the reporter. “We’re not commenting on the Tylenol case other than to say we are devoting all our resources to it. We are certainly not commenting on any evidence or the investigation thus far.”

Asked why, in view of Vergari’s statement, the FBI had not called on the manufacturer to issue a nationwide recall, French said he could not address “theoretical” questions. The next day, Burke recalled all Tylenol capsules nationwide.

On Monday, February 17th, the same day J&J withdrew OTC capsules from the market, authorities from the Westchester County District Attorney’s Office, the Yonkers Police Department, and the FBI toured J&J’s facilities in Montgomeryville and Fort Washington. Hundreds of employees worked at the Fort Washington plant, which had been built in 1961, while Robert Wood Johnson II was still at the helm of Johnson & Johnson. On the day of the tour, however, both the Fort Washington and Montgomeryville plants were empty. They were closed for the Presidents’ Day holiday, and their employees were thus not available for questioning. The tour was nothing more than a public relations stunt to give the appearance of an investigation; not unlike the sham investigation conducted by Cook County toxicologist Michael Schaffer at the Fort Washington plant five days after the 1982 Tylenol murders.

Yonkers’ Police Chief, Owen McClain, said the trip to the plants did not offer “any additional information,” thus confirming the futility of this 1986 Presidents’ Day “inspection.” The FBI refused to discuss the visit, stating only that it is “unlikely” the contamination occurred during the manufacturing process. Jack French assured the public that the FBI was still in the process of conducting a thorough investigation. “No leads are being left uncovered,” he proclaimed.

Westchester County Prosecutor, Bruce Bendish, shortly after touring the J&J facilities, conferred with Carl Vergari. They agreed that a proper investigation of the Fort Washington plant was needed. The next day, Vergari announced that the tour had “suggested additional broad areas of inquiries.”

“We still haven't eliminated anything,” Vergari said. “We haven’t had evidence to exclude tampering at the factory.” Vergari then declared that the case of the poisoned Extra Strength Tylenol capsules was “still wide open.”

One day after the tour of the Fort Washington and Montgomeryville facilities, the FBI gave its first official statement regarding the Tylenol tampering investigation. Milt Ahlerich, Chief of Public Affairs for the FBI, said the investigators who examined the bottles that had contained the cyanide-laced Tylenol capsules found “no evidence of tampering” with the containers or their packaging. The packaging, as the FBI had now officially confirmed, had not been tampered with. Yet Ahlerich refused to accept these findings at face value, making the inane statement that a lack of evidence “does not mean that the tampering did not occur.”

J&J and the FDA then also released public statements to discredit Vergari. They insisted that the weight of evidence suggested that the crime was a local one. “We do not have any proof it didn’t happen in the plant or the warehouse,” said Burke, “but all logic tells us it didn’t.” However, as any reasonable person would have concluded, all logic pointed to the fact that the cyanide-laced capsules were in the Tylenol bottles before they were packaged and shipped to the retail stores.

Burke went on to note a “considerable amount of confusion” in the case that may have led to an opinion held by Carl Vergari that the pills were probably adulterated at the manufacturing plants. In reality, as Burke certainly knew, there was no confusion on the part of Carl Vergari. Every bit of physical evidence pointed to tampering during the manufacturing and packaging process. The facts were overwhelmingly on Vergari’s side, but he was up against the most powerful entities in the land. The FDA and the FBI were firmly aligned with Johnson & Johnson. Even the president of the United States was in Johnson & Johnson’s corner.

On February 20, 1986, ten days after the nation learned about the Tylenol poisoning in New York, Burke attended an economic affairs meeting of business leaders at the White House. President Ronald Reagan stopped by to give his support to Burke and Johnson & Johnson. President Reagan stood before the group of corporate leaders and praised Burke for his handling of the Tylenol incidents. Mr. Burke “has lived up to the highest ideals of corporate responsibility and grace under pressure,” said President Reagan, adding: “Jim Burke of Johnson & Johnson, you have our deepest appreciation.” The corporate executives in attendance applauded the president’s remarks.

Later that day, Burke spoke at a news conference at the National Press Club. “We were flattered that he [President Reagan] was complimentary in Johnson & Johnson’s handling of the case, and I was a little tongue-tied,” said Burke, a bit too modestly. Burke knew President Reagan quite well, and it is unlikely that he would have been “tongue-tied” by Reagan’s remarks.

President Reagan had a soft spot for Johnson & Johnson. First Lady Nancy Reagan’s stepfather, Dr Loyal Davis, a neurosurgeon, had a long and profitable relationship with the company. Dr. Davis was the chairman of the Department of Surgery at Northwestern University in Illinois, and a longtime consultant for J&J subsidiary, Ethicon. Davis’s direct line to the White House had proved beneficial to Johnson & Johnson when Ethicon had a product up for FDA approval in 1981.

In May 1981, J&J was waiting, not very patiently, for FDA approval of a new Ethicon suture. Dr. Davis called Reagan’s Deputy Chief, Michael Deaver, to find out if maybe someone could check the status of that application. A White House official promptly made two phone calls to the FDA - one on May 5th, and a second on May 7th - about the Ethicon suture under review. Arthur Hayes, the recently appointed FDA commissioner, was inclined to give James Burke and Ronald Reagan whatever they wanted. Ethicon’s new PDS (polydioxanone) suture was approved on November 13, 1981.

Shortly after the FDA approved Ethicon’s application to market its new suture, someone from inside the White House told a reporter about the White House calls that had been made to the FDA on behalf of Ethicon. On November 19, 1981, a White House spokesperson admitted to the episode. The Department of Health and Human Services then tersely announced that its Inspector General had opened “a preliminary inquiry to establish the facts” in the case. That inquiry was quietly dropped.

Just six months after President Reagan praised Burke for his handling of the Tylenol poisonings, Burke was invited back to the White House for a black-tie dinner affair with President Reagan and his wife, Nancy. The dinner was held on July 16, 1986. Burke and five others, including Pat Murphy, a journalist and publisher of the Republic and The Phoenix Gazette, and Lynn Cheney, the wife of then Congressman Dick Cheney, were seated at Reagan’s table.

In 1986 Burke was a long-time friend of President Reagan. Reagan had appointed Burke to the President’s Commission on Executive Exchange (PCEE) on September 14, 1981. The PCEE, an agency of the Executive Branch, was created to increase knowledge and mutual understanding between the public and the private sectors. In support of its mission, the PCEE administered an executive exchange program between the Executive Branch and private corporations. The PCEE was the quintessential revolving door between big government and big business.

On February 10, 1986, the day Burke said he learned about the death of Diane Elsroth, President Reagan had re-appointed Burke to another two-year term on the PCEE. Burke was still a member of the PCEE in 1989 when it came under fire for fraud, gross waste, and mismanagement. Gordon Hamel, the Commission’s director of executive placement, had reported to the U.S. Office of Special Counsel (OSC) about the ongoing fraud and waste at the taxpayer-funded commission. In 1992, President George H.W. Bush issued an unusual Executive Order, abolishing the 11-member PCEE after it had come under the scrutiny of both Congress and a federal inspector general. In November 2002, Elaine Kaplan, the OSC chief, said a subsequent investigation by the OSC had substantiated claims by Hamel of “illegality, gross waste, and mismanagement” at PCEE.

*****

Neither Johnson & Johnson’s media blitz nor Burke’s close relationship with President Reagan changed the fact that Vergari had spilled the beans. Vergari had publicly disclosed the FBI’s evidentiary findings from its own forensic analysis, showing that the cyanide-laced Tylenol capsules were in the Tylenol bottles before they were packaged in three layers of tamper-resistant seals. Nevertheless, the FBI’s official line was that the lack of any evidence that the packaging had been tampered with “does not mean that the tampering did not occur.”

FBI spokesperson, Lane Bonner, said, “Our investigation to date indicates that it is unlikely that contamination occurred during the manufacturing stages.” Bonner offered no evidence to support his statement, because there was none.

Vergari’s public disclosure of the FBI’s findings had created a real problem for proponents of the “approved theory.” That problem needed to be rectified. So the FBI ordered a bogus second inspection of the tamper-resistant packaging and then fabricated new forensic findings that aligned with the approved theory. For this second inspection, the FBI claimed to have used a sophisticated investigatory technique; the mechanism for which they refused to disclose to the public.

FBI spokesperson, Milt Ahlerich, held a news conference on February 26, 1982 “because of the intense national interest in the case.” He made only a brief appearance to read the official FBI statement:

Previously undetected signs of tampering have now been discovered using sophisticated scientific examinations. Our examinations have further determined it was possible to invade the bottles after packaging was complete without detection through conventional means of examination.

Ahlerich provided no explanation of how this “inspection” was conducted and supplied no proof that the packaging had been tampered with or how it could have been done. But the official FBI statement, which in fact revealed no new information at all, did conform to the approved theory. Ahlerich refused to answer any questions, but several “un-named authorities” attending the news conference confirmed that the Bureau’s findings applied to both bottles of cyanide-laced Tylenol capsules.

Johnson & Johnson, elated by the FBI’s official statement, said they welcomed the Bureau’s finding. “The company has contended that it was extremely unlikely that the capsules were tainted during the manufacturing process,” said James Murray. “We were puzzled all along as to how someone could have breached the three safety seals on the bottle and carton without being detected,” he said. “We find the FBI statement very interesting.”

Larry Foster said, “The FBI statement supports what we have believed all along - that the tampering took place after it [the Tylenol] left the plant.”

“We have felt from the beginning that there was tampering,” said J&J spokesperson, Robert Kniffin. “There had been no evidence of it before this, and now there is.”

In fact, there still was no evidence of tampering - only a press release. Every fiber of evidence related to the murder of Diane Elsroth pointed to a killer who had gotten the cyanide-filled capsules into the Tylenol bottles at a repackaging facility before they were packaged in three layers of tamper-resistant seals.

Officials at the Westchester County District Attorney’s Office were not buying the FBI’s spin. Bruce Bendish, chief of the homicide unit, said he had not seen the FBI’s report “so we don’t know what scientific processes they used to determine this… we have eliminated no theory, no possibilities, including [tampering at] the factory,” he said. “We have eliminated nothing. We don’t consider this a major break and we’ll still consider all alternatives.” The well-substantiated theory that said the tamperings had occurred during manufacturing - as Bendish would soon realize - had, however, been eliminated behind a closed door at the FBI headquarters in Washington D.C.

The FBI used a fabricated, undocumented, bogus forensic analysis to discredit Carl Vergari and discount the accurate evidentiary findings made by its own agents. These bogus forensic findings were not at all surprising, considering their source. The FBI’s forensic lab in Washington D.C., where the Tylenol bottles and packaging were inspected, has a long history of falsifying, misrepresenting, and fabricating evidence. In 1995, investigative reporters John F. Kelly and Phillip K. Wearne published an expose of the sordid history of the FBI lab, titled, “Tainting Evidence: Inside the Scandals at the FBI Crime Lab.”

“As the FBI’s research and training facility in Washington D.C. came to dominate forensic science research in this country during the 1980s,” wrote Kelly and Wearne, “the laboratory division continued to employ and to promote researchers and examiners who patently ignored the most basic scientific procedures and fixed (i.e. falsified) results.”

In July 1994, believing that the claim that the bloody glove found on O. J. Simpson’s estate had been planted was far-fetched, USA Today and the Gannett News Service trawled legal and media databases for comparative cases. The research was done to study the quality of forensic research conducted at FBI labs. They found 85 instances that had occurred since 1974 in which prosecutors knowingly or unknowingly used tainted evidence that had convicted the innocent or freed the guilty. These were just the known cases, cases that for one reason or another had come to light or made the news.

“At the core of what the critical experts were alleging is the poor practice that riddles the FBI lab and much forensic science in the United States. Documentation is a case in point,” wrote Kelly and Wearne. “Examiners have proved remarkably loath to write up their bench notes in any adequate scientific manner. No names, no chain of custody history, no testing chronology, no details of supervisory oversight, no confirmatory tests, no signatures - such omissions are quite normal in FBI lab reports.”

In April 1997, the U.S. Justice Department released a report on the findings of an investigation into the FBI lab by the Office of Inspector General. The report, written by General Michael Bromwich, delved into fewer than two dozen cases from just three of the FBI’s 35 specialized units, but that was enough to cast serious doubt on the credibility of all the findings produced at the FBI labs.

The Oklahoma City bombing case was the biggest of those cited by the 500-page report. It strongly criticized explosives experts involved in the bombing investigation, particularly David Williams, who, according to the study, “reached conclusions that incriminated the defendants without a scientific basis.” The report further chastised Williams for his management of the on-site investigation of the 1993 World Trade Center bombing, saying that he “began with a presumption of guilt upon which to build inferences.” Williams “tailored” his testimony to fit the facts determined by the investigation. The report also sharply criticized Roger Martz, the chief of the FBI’s chemistry-toxicology unit, who “improperly deviated from...protocol in his examination of some specimens.”

Martz was again criticized for his handling of the murder case against George Trepal, who was sentenced to death in 1991 for adding the poison thallium nitrate to bottles of Coca-Cola, killing one woman. Bromwich concluded that during Trepal’s trial, Martz “offered an opinion stronger than his analytical results would support” and “failed to conduct certain tests that were appropriate under the circumstances, failed to document adequately his work, and testified inaccurately on various points.”

“The prevailing culture of the lab - examiners not properly performing or documenting tests, preparing inaccurate reports, testifying about matters beyond their expertise and much more - suggests that thousands of prosecutions may have been tainted,” said Judy Clarke, president of the National Association of Criminal Defense Lawyers.

Throughout the 1980s and 1990s the FBI frequently falsified findings, misrepresented and suppressed evidence, and gave false testimony. The release of phony forensic findings in the 1986 Tylenol tampering case was just business as usual at the FBI.

More than a week before Milt Ahlerich read the FBI’s official statement, implying that the packaging on the bottles of poisoned Tylenol might have been tampered with; the FBI agents working with Carl Vergari had told him the truth: the packaging and bottles had not been tampered with. These findings were confirmed by FBI spokesperson, Jack French, on February 16th, when he released the FBI’s first official statement. Ten days later, Ahlerich credited the FBI lab in Washington D.C. with the new fabricated findings.

No FBI spokesperson ever said that the FBI lab technicians actually found evidence of tampering. Ahlerich simply said, “It was possible to invade these bottles after packaging was complete without detection through conventional means of examination.” He never precisely stated that the packaging or bottles had been tampered with. After reading the FBI’s official statement, Ahlerich refused to take any questions at what the Bureau had billed as a news conference. Ahlerich evidently realized that this ruse would be exposed if he began answering specific questions about a non-existent forensic analysis.

Johnson & Johnson immediately commented on the FBI’s statement. “The company has contended that it was extremely unlikely that the capsules were tainted during the manufacturing process,” said James Murray. “We were puzzled all along as to how someone could have breached the three safety seals on the bottle and carton without being detected.” Even now, Murray merely commented about the FBI’s statement and claimed that Johnson & Johnson was puzzled. He used semantics to dance around the truth, yet suggested a potential, but false, possibility, just as Ahlerich had done.

Despite the innuendo coming from Johnson & Johnson and the FBI, it was still perfectly clear that the packaging and the bottles that contained the cyanide-laced Tylenol capsules had not been breached. The three layers of tamper-resistant packaging on all three bottles of contaminated Tylenol capsules – two containing cyanide-laced capsules, and one containing a tampered capsule with a “trace amount” of cyanide - had not been tampered with.

The FBI found no evidence that the Tylenol boxes, sealed shut with permanent adhesive, had been opened and then re-glued. The boxes showed no tears, cuts, or other signs of tampering. The only glue on the boxes was the glue used at the repackaging facility. The FBI found no evidence that the plastic shrink-wrap had been removed and then reheated, re-shrunk, and re-applied. They found no indication that the aluminum-foil seals laminated to the lips of the bottles had been removed and then re-laminated. The only adhesive on the lips of the bottles was the adhesive that the repackager had applied. They found no evidence that the killer had torn or cut the aluminum-foil seals. They found no scrapes or nicks on the lips or necks of the bottles to indicate a sharp knife or razor blade had been used to remove the aluminum-foil seals. X-rays that were taken of the bottles showed no signs that the bottles had been invaded. The bottles contained no cuts, no holes, and no needle marks. The bottles had not been invaded, and the packaging was not tampered with. The cyanide-laced Tylenol capsules were put into the bottles at a repackaging facility before the Tylenol was packaged and before the bottles of poisoned Tylenol were delivered to the retail stores.

On February 18, 1986, one day after the mock inspection of McNeil’s Tylenol manufacturing plant in Fort Washington, Carl Vergari had announced that the case of the poisoned Extra-Strength Tylenol capsules was “still wide open.” The tour of the Fort Washington plant “suggested additional broad areas of inquiries,” he had said. Two days later, James Burke met with President Ronald Reagan in Washington D.C. Six days after that meeting, an official from FBI headquarters in Washington D.C. issued a statement to convey the false message that the packaging on the bottles of poisoned Tylenol capsules had been breached, but he did not say how. Accordingly, there would be no investigation of Johnson & Johnson or the McNeil Consumer Products Company. The FBI had effectively shut down Vergari’s investigation of the Tylenol manufacturing and distribution network. In matters related to the 1986 Tylenol murder investigation, Vergari was never heard from again. Carl Vergari died on October 15, 2006 in West Palm Beach, Florida at the age of 84.

35

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Revisionist History

Sixteen years after the murder of Diane Elsroth, J&J Public Relations Vice President, Larry Foster, claimed that the mystery had been solved for how the killer had gotten cyanide-filled capsules into the Tylenol bottles in 1986 without leaving any detectable signs of tampering. Foster made this revelation during a 2002 interview at his alma mater, Pennsylvania State University. A student at the University had asked Foster this question: “On September 11, 2001, when you heard the news that they were grounding all the airlines all around the country, did your mind roll back to September 30, 1982?”

In a response that seemed unrelated to the question, Foster said in part, “You remember in 1986, there was another murder in Westchester County, New York; one woman died having ingested cyanide in an extra strength capsule. The problem there was the authorities in Westchester County could not figure out how the murderer invaded the extra strength [Tylenol bottle], the safety seal package, and they looked it over, and looked it over, and looked it over, and finally sent it to the FBI lab in Washington, and the FBI figured out how it was done. I won’t give you details, but I will tell you they managed to cut through the bottom of the plastic container bottle, remove the capsules, put the cyanide capsule in, and they managed to get the piece back in the bottle and get it on the shelf so it was undetectable. In other words, you didn’t have to go through any of the safety seals at the top of the bottle.”

Foster’s story is false and completely unbelievable. It conflicts with the known facts and even with what Johnson & Johnson and FBI officials have said over the years. These college students were of course too young to have any first-hand memory of the Tylenol murders investigation. Most people today don’t remember the events from back then. They especially don’t remember the specific details of the investigation. That makes it easy for Foster to offer such an “explanation” to young and middle-age adults today. However, Foster’s “explanation” explains nothing.

Foster said that “you didn’t have to go through any of the safety seals at the top of the bottle.” But there is no question that you did have to go through the box that contained the bottle. The Tylenol box was sealed with permanent adhesive to ensure that the only way it could be opened was by tearing it. To get to the bottle one would have to go through the box first. The boxes that contained the bottles of cyanide-filled capsules had not been tampered with, so obviously the poisoned capsules were put into the Tylenol bottles before the box was sealed shut at the repackaging facility.

The Packaging Corporation of America was one of many packagers that changed to the heat-sealed method used on the Tylenol boxes to seal them shut. Warren Hazelton, a spokesperson for the company said, “Boxes with sealed flaps make it impossible to reseal the package once it’s been opened.  Hanging flaps are one signal to consumers to avoid buying the package.”

Even J&J executives agreed with the FBI and FDA officials who said there were no signs that the plastic bottles had been penetrated. A J&J spokesperson said scientists found no holes, cuts, or needle marks on the bottles. In addition, Vergari had said that after extensive tests of the bottles, the FBI agents examining them found “no evidence of tampering” with the containers or their packaging.

An article that ran in The Washington Post on February 14, 1986 stated, “Another possibility, also requiring expensive heat-sealing equipment, would require cutting into the plastic bottle itself and somehow melting the cutout back into place after tampering with the capsules.” The FBI had quickly ruled out this possibility back in February 1986. Foster’s revelation, sixteen years after the fact, was no revelation at all. It was just another fabricated public relations story.

Court documents make it abundantly clear that nobody from J&J or the FBI thought the killer “cut through the bottom of the plastic bottle.” In 1988, United States District Judge, Gerard L. Goettel, ruled on the liability lawsuit filed on behalf of Diane Elsroth against J&J and A&P. Judge Goettel’s decision included a review of the hypothesis presented by J&J and the FBI as to how the packaging was supposedly breached. That review makes it clear that the bottles had not been cut open by the killer.

Nothing in the documents turned over to Judge Goettel indicate that the bottles might have been cut open - because the bottles had not been cut open. In fact, when Foster told the PSU students “you didn’t have to go through any of the safety seals at the top of the bottle,” he had actually confirmed what J&J and the FBI had known all along – that the packaging on the bottles of poisoned Tylenol had not been tampered with.

*****

On November 15, 1988, Judge Gerhard Goettel dismissed Elsroth’s liability lawsuit against Johnson & Johnson, McNeil Consumer Products, and the Great Atlantic and Pacific Tea Company (A&P). “The companies could not be held responsible for the action of “an unknown third party” or for “a wrong that they did not truly commit,” wrote Judge Goettel. The Elsroth family never even got their day in court.

In ruling to dismiss the case, Judge Goettel wrote: “The murder remains unsolved, and it has not been determined conclusively how the product was tampered with. The most likely scenario appears to be as follows: An unknown third party purchased or stole the Extra-Strength Tylenol ...breached the packaging, and substituted cyanide for some of the medicine contained in several of the gelatin capsules… That individual replaced the now contaminated capsules in the container and somehow was able to reseal the container and box in such a way that the tampering was not readily detectable.”

Goettel came to this conclusion with no rational explanation of just how someone did all that. In fact, a little common sense would have led Goettel to conclude that this scenario was absurd and could not have been true at all.

Judge Goettel said the case left “difficult questions regarding the extent to which society is prepared to hold manufacturers and retailers liable for product tampering by unknown third parties.” The injustice of Goettel’s ruling is that the “unknown third party” who poisoned the Tylenol was not unknown. The tampering occurred at the warehouse of a repackager that had contracted with Johnson & Johnson to repackage the Tylenol. Diane Elsroth’s family would have “known” the identity of that third party repackager if the FBI had not put a stop to Carl Vergari’s investigation.

Diane’s father, John Elsroth, filed the product liability lawsuit against J&J and A&P. He may not have known it, but he had many things going against him when his lawsuit went before Judge Goettel. For starters, Johnson & Johnson had brought in its longtime go-to outside council, Patterson, Belknap, Webb & Tyler (PBWT) to handle the case. In addition, Elsroth was on Johnson & Johnson’s home turf - the Federal District Court in the Southern District of New York. This court was, and remains, one of PBWT’s favorite recruiting grounds. Many PBWT lawyers began their careers as law clerks for judges in the District Court in the Southern District of New York.

The relationship between Johnson & Johnson and PBWT began during World War II, when Robert Wood Johnson II was a “dollar-a-year man,” commissioned as a Colonel and then promoted to a brigadier general in the United States Army. At the time, Robert P. Patterson, Sr., the co-founder of Webb, Patterson & Hadley, which later became PBWT, was the under secretary of war. Since 1940, Patterson had been in charge of the war procurement program that Robert Wood Johnson II and other corporate titans managed as members of the War Production Board. Patterson was later appointed secretary of war in 1945. He returned to his private law practice in 1947.

Robert Patterson died on January 22, 1952 onboard American Airlines Flight 6780 when it crashed on approach to Newark Airport. He was returning from representing Schrine Theatres Inc., which had recently been convicted of engaging in numerous activities that violated anti-trust laws. Just hours before Patterson’s death, he had consented to a provision requiring Schrine to discontinue certain illegal monopolistic business practices.

At the time of Patterson’s death, the partnership between his law firm and Johnson & Johnson was already established and so was the link between PBWT and the U.S. District Court in the Southern District of New York. In 1930, President Herbert Hoover had appointed Patterson as a judge in the District Court for the Southern District of New York. In 1988, his son, Robert Patterson, Jr., became a judge in the U.S. District Court for the Southern District of New York.

PBWT did away with the Elsroth lawsuit less than three years after Diane Elsroth’s death. Conversely, Johnson & Johnson kept the 1982 Tylenol murders lawsuit out of court for almost nine years before it was settled. Elsroth’s lawsuit was heard in the U.S. District Court in New York, but John Elsroth had filed the complaint in a New York State Circuit Court. The case was then removed to the federal court on petition of the defendants on the basis of diversity, pursuant to CFR Title 28, Section 1332(a), (Diversity of citizenship; amount in controversy; costs), which states:

The district courts shall have original jurisdiction of all civil actions where the matter in controversy exceeds the sum or value of $75,000, exclusive of interest and costs, and is between citizens of different States.

For the purposes of such “diversity” jurisdiction, a corporation is deemed to be a citizen of the state in which it is incorporated and the state where it maintains its principal place of business. Civil actions exceeding $75,000 in damages can be removed, at the request of the defendants only, to federal court, which is generally deemed a more favorable forum for corporate defendants. Nevertheless, civil actions exceeding millions of dollars are commonly heard in State courts. In fact, the 1982 Tylenol murders lawsuit, seeking about $50 million in damages, was filed by Illinois citizens against Johnson & Johnson, a New Jersey citizen, in the Illinois State Circuit Court in Cook County, yet J&J did not seek to remove it to a federal District Court.

The removal of Elsroth’s lawsuit to a federal court had gotten the case firmly on PBWT’s favorite hunting grounds. Johnson & Johnson and A&P believed that they would get a favorable ruling in the federal courthouse in the Southern District of New York. And they were right. Judge Goettel dismissed this case specifically to keep it from going before a jury.

Judge Goettel prefaced his ruling by saying, “We are mindful that, although recent Supreme Court decisions have revitalized the use of summary judgment - Rule 56 [summary judgment] remains a disfavored remedy in this circuit.” Unfortunately, the disdain he professed for summary judgment was not at all apparent when he granted summary judgment in favor of Johnson & Johnson and A&P, stating, “We are aware of this circuit’s preference for ruling on difficult legal issues only upon a full evidentiary record.” Yet with virtually no evidentiary record, Goettel ruled in favor of Johnson & Johnson and A&P anyway. In fact, he ruled on the basis of a completely false evidentiary record.

In this instance, wrote Goettel, “We have resolved all disputed factual issues in the plaintiff’s favor, as we suspect a sympathetic jury would do. To take this matter to trial and then set aside a jury’s verdict as a matter of law would seem less desirable than ruling on these legal issues as presented by the motion papers.”

Judge Goettel had determined and indeed suggested that a jury may have ruled in favor of Elsroth, in which case he had already predetermined that he would set aside that jury’s verdict. Rather than go through a public trial in which Goettel would not allow a ruling against Johnson & Johnson to stand, he put an end to the judicial process, thus keeping the evidence of yet another Tylenol murder hidden from the public.

In a decision soaked with hypocrisy, Judge Goettel wrote: “The emotions in this case are strong, making our decision today all the more difficult. Our task, however, is to serve as a dispassionate arbiter of the law, guided always by the legal principles that are its lifeblood while ever cognizant of the pillars that serve as its foundation: fairness, equity, and justice. An injustice has been done, but we think a second would be perpetrated were we to permit recovery against these defendants for a wrong they did not truly commit.”

Goettel concluded his ruling as follows:

The doctrine of strict products liability is built upon those same supports of fairness and equity, oftentimes lumped together under the heading of “public policy.”

As recognized by the New York Court of Appeals: Imposition of strict liability against a manufacturer rests largely on public policy. The justification for it is that the seller, by marketing his product, has undertaken a special responsibility toward members of the consuming public who may be injured by it. The public has a right to expect that sellers will stand behind their goods. Thus, the burden of accidental injuries caused by products intended for consumption has been placed upon those who market them, to be treated as a cost of production because manufacturers are best able to protect against defective products and bear the cost if they fail.

When reduced to its essentials, it can be seen that this case involves none of these concerns. We do not have here a failure by the manufacturer and retailer to stand behind the goods they market; we do not have an accidental injury caused by goods they have placed in the stream of commerce. We instead are presented fundamentally with the proposition that manufacturers and retailers should be held liable in damages, as a cost of doing business, for the criminal conduct of unknown third parties who misuse the manufacturer’s product in carrying out the misdeeds because the criminal cannot be held accountable.  Notwithstanding the grievous harm here inflicted, we think such a result is not contemplated by the law, nor is it consonant with sound notions of fairness, equity, and justice.

Goettel dismissed this case based on the false premise that there was no negligence on the part of Johnson & Johnson. He simply assumed that the Tylenol had been tampered with at the retail stores. Wasn’t a jury supposed to decide what the facts were in this case and their truth or untruth?

“We hold that preventing acts of tampering off the merchant’s premises by an unknown third party does not fall within the ambit of duties owed by a retailer to his or her customers,” said Goettel. The obvious flaw with this argument is that the tampering did not occur on the “merchant’s premises.” A jury would likely have reached the same conclusion that Westchester District Attorney, Carl Vergari, had reached, namely, that the cyanide-laced Tylenol capsules were put into the Tylenol bottles during the manufacturing process, before they were packaged and delivered to the local retail stores. In fact, a substantial portion of Americans believed that the 1986 tamperings had actually occurred at a Johnson & Johnson facility.

Following the 1986 Tylenol murder, consumers were not nearly as willing to accept the madman-in-the-retail-stores theory, as they had been in 1982. Market researcher George Rosenbaum said, “Virtually everyone” thought someone outside the Company was to blame for the 1982 Tylenol tampering incident. Following the 1986 tampering incident, however, J&J’s own research showed that 36 percent of the public thought the tampering came from within the company.”

Judge Goettel did a big favor for Johnson & Johnson by “concluding” that the tampering occurred at the retail store when in fact the evidence in its entirety showed that the tampering had occurred at a repackaging facility. Ultimately, the liability for the tampering that led to the death of Diane Elsroth rested with Johnson & Johnson. As the manufacturer of Tylenol, Johnson & Johnson was responsible for all aspects involved in the manufacturing, processing, packaging, labeling, and distribution of Tylenol. The decision made by Judge Goettel was not one that would have been made by a reasonable person with full access to the facts. So why did he make this ruling?

The poor outcome of both the 1982 and 1986 Tylenol murders investigations may be attributed to a judicial system that favors corporate interests over those of individuals, as in a corporatocracy.

The concept of corporatocracy is that corporations, to a significant extent, “own” or have massive power over governments, including those governments nominally elected by the people. Corporations exercise such power not by back-room conspiracies, but by their enormous, concentrated economic power and influence and by legal in-the-open mechanisms, via lobbyists, campaign contributions to office holders and candidates, and threats to leave the state or country for another country with less oversight and more subsidies. The system retains the superficial appearance of being a democratic republic, by relying on the long-standing faith of the people in the fair outcomes of democratic voting, legislative, judicial, and executive processes - but below the surface, it is a system of government without full and true representation of the people.

In many cases, former corporate executives are appointed to be powerful decision-makers within government institutions. They are often charged with the regulation of their former or future employers. Government employees who collude with corporations often accept high-ranking positions within corporations once they have demonstrated their commitment to serve the corporate interest. This corporatocracy works exceedingly well for the powerful elite who control corporate entities like Johnson & Johnson, but not so well for everyday, average people like the Januses, Kellermans, McFarlands, Princes, Reiners, and Elsroths.

The division between corporate and governmental interests is indiscernible, and there is an active revolving door between government agencies and the industries they are supposed to regulate. Kevin Donovan, the current vice president of Johnson & Johnson Worldwide Security, was handed that job after a 25-year career with the FBI. Donovan had been the assistant director of the FBI in charge of the New York office where he was responsible for leading 2,500 FBI agents and other FBI employees. During prior years, Donovan served as the special agent in charge of the Newark, New Jersey office of the FBI.

The man Donovan replaced as head of J&J security, Wayne Gilbert, had a 28-year career with the FBI. Gilbert joined J&J in 1993, after retiring as the assistant director for counterintelligence and counterterrorism. Gilbert had assignments in Detroit, Albany, Washington D.C., and Oklahoma City and was the special agent in charge of the Pittsburgh and Philadelphia field divisions. He worked for the FDA prior to serving with the FBI.

Russell Deyo, the current general counsel for Johnson & Johnson, was an assistant U.S. attorney in New Jersey for eight years prior to joining Johnson & Johnson in 1985. As the corporate secretary at the McNeil Consumer Products Company in 1991, Deyo was the man who signed the 1982 Tylenol murders settlement agreements. He then moved up the ladder to his current position, which pays him a salary and bonus of more than $8 million per year.

Two months after Arthur Hayes resigned his position as the commissioner of the FDA, he took a consulting job with Burson-Marsteller, the public relations firm for G.D. Searle, Monsanto, and Johnson & Johnson. Hayes was later appointed to executive and director positions at numerous companies in the pharmaceutical industry. In 1991, former McNeil Chairman Wayne Nelson appointed Hayes as the chief operating officer of Nelson Communications’ subsidiary, MediScience Associates. Nelson later appointed Hayes as vice chairman and medical director of Nelson Communications.

FDA appointees generally do very well when they leave the FDA for the private sector. FDA Deputy Commissioner, John Norris, left the FDA in 1988 and then served on several Boards of Directors of pharmaceutical companies and worked as a consultant for numerous companies, including Johnson & Johnson. FDA Deputy Commissioner, Mark Novitch, left the FDA to join the Upjohn Pharmaceutical Company in 1985 where he served in senior executive positions, including vice chairman of the Board of Directors, corporate executive vice president, and corporate senior vice president for scientific administration. He also served on the Boards of Directors of Guidant Corporation, a medical device company, and several large pharmaceutical companies, including Kos, Neurogen, Alteon, and Calypte Biomedical.

Frank Young, during his time as FDA commissioner, from August 1984 to December 1989, seemed to always support the financial interests of the pharmaceutical manufacturers. In February 1986, after the death of Diane Elsroth from cyanide-laced Tylenol, Young sided with the pharmaceutical industry by refusing to consider the elimination of unsealed capsules from the OTC market. Even when the poisonings from OTC capsules continued to mount, Young did not reconsider his position.

Within a few months of Elsroth’s death, rat poison was found in Contac cold capsules in Houston, and in Teldrin allergy capsules in Orlando. In the Seattle area, two people died in June 1986 after consuming cyanide-laced Excedrin. That same month, cyanide-laced capsules were also found in unopened bottles of Excedrin and Anacin-3 in Seattle area stores. At least a half dozen people were known to have died from poisoned OTC drug capsules between February and June of 1986. Still, Frank Young toed the company line. “The FDA is not now considering any ban on capsules,” said Young. “You are on a slippery slope when you allow a group of terrorists to start driving products off the market.”

Then, the generic drug scandal hit, and Frank Young came under fire. From 1981 to 1987, FDA chemists had been pocketing thousands of dollars in cash or gifts to rig the drug approval process in favor of certain generic drug companies. By November 1987, it was clear that bribery was rampant in the FDA’s generic drug division. The White House asked Young to resign, giving him a make-work post in an advisory job for Health and Human Services. Young was never charged with anything other than being asleep at the wheel while staffers in the FDA’s generic division were on the take. Five FDA officials and 40 generic drug company employees were eventually convicted of felonies for their roles in the generic drug bribery scandal.

“[Young] was a good soldier for the Reagan regime,” wrote syndicated columnist, Jack Anderson. “But a good soldier in the Reagan army had to be an advocate of deregulation and hands-off government, even in the agency that is supposed to protect consumers from dangerous food and drugs. The hands-off approach didn’t work for the FDA much better than it worked for the savings and loan industry, the Defense Department, or the Housing and Urban Development Department,” wrote Anderson. “Now, with Reagan enjoying retirement, people like Frank Young are paying for what they did to please the big guy.”

Frank Young’s penance was short lived. Young, like former FDA Commissioner, Arthur Hayes, and Deputy Commissioners, Novitch and Norris, went on to a lucrative career in the industry he had been in charge of regulating, or rather deregulating. Young served as a director for numerous pharmaceutical and medical device companies, including Essex Woodlands Health Ventures, Agennix, Inc., La Jolla Pharmaceuticals Company, Light Sciences Oncology, Elusys Therapeutics, and Golden Pond Healthcare.

Corporate executives often hold positions in government agencies while simultaneously holding positions at their private sector corporations. During World War II, Robert Wood Johnson II was the chairman of J&J, a brigadier general in the United States Army, the chairman of the Smaller War Plants Corporation, and a vice-chairman of the War Production Board, all at the same time. In 1981, President Reagan appointed James Burke to the President’s Commission on Executive Exchange. Burke remained on that Commission throughout the remainder of his career at Johnson & Johnson. William O. Baker, a member of J&J’s Board of Directors in the 1980s, served on President Reagan’s Foreign Intelligence Advisory Board. He was also a consultant to the National Security Agency and consultant to the Department of Defense beginning in 1959. Clifton C. Garvin, a member of Johnson & Johnson’s Board of Directors in the 1980s was appointed to President Reagan’s National Productivity Advisory Committee in 1981, and he later served on President Reagan’s Private Sector Survey on Cost Control.

In the 1980s, J&J executives and Board members also belonged to private organizations that shape public policy. Two such groups, often called “secret societies,” were the Trilateral Commission and the Council on Foreign Relations. J&J CEO, James Burke, and J&J Vice-Chairman, Robert Wilson, were both members of the Trilateral Commission. Its 60 delegates from the United States also included Illinois Governor, Jim Thompson.

James Burke was a member of the Council on Foreign Relations. J&J Board members, Thomas Murphy and Joan Ganz Cooney, were also members of the Council on Foreign Relations. FBI Director, William Webster, was a regular attendee of Council on Foreign Relations meetings and became a member in 1995. Many of the most powerful politicians and business leaders in the world, regardless of their party affiliation, regularly attend meetings of the Trilateral Commission and the Council on Foreign Relations.

For the officials from government regulatory agencies involved in the Tylenol murders investigations, the interests of Johnson & Johnson carried far greater weight than did the interests of the Tylenol victims. In 1982, FDA Commissioner, Arthur Hayes, quickly exonerated Johnson & Johnson of any responsibility for the Tylenol tamperings. During the 1986 Tylenol tampering investigation, it was especially evident that the federal government was not going to allow a proper investigation of Johnson & Johnson or the Tylenol manufacturing and distribution network. The overt involvement of the FDA and the FBI in covering up the identity of the exact repackaging facility where the 1986 Tylenol tamperings occurred made it readily apparent on whose behalf these agencies were acting.

None of the evidence from the Tylenol poisoning incidents in 1982 or 1986 was ever presented in a public hearing. During both investigations, false information was publicized about the corrosiveness of cyanide, and information was suppressed regarding the packaging and the distribution of Tylenol. Officials used a red herring, which they called a madman, to divert the public’s attention away from the distribution channel. In 1982, this defective investigative strategy was directly implemented by a handful of men beholden to “Big” Jim Thompson.

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Big Jim’s Boys

“Big” Jim Thompson, the U.S. attorney in the Northern District of Illinois from 1971 to 1975, hired Dan Webb, Tyrone Fahner, and Anton Valukas as his assistant U.S. attorneys. Thompson, Webb, Fahner, and Valukas became loyal lifelong friends. These men all had roles in the investigation of the 1982 Tylenol murders. Journalist Cheryl Lavin wrote in the Chicago Tribune in 1990 that these former federal prosecutors dance at each other`s weddings, commiserate over their divorces, and refer cases to one another.

Commenting on his decision to hire Dan Webb as an assistant U.S. attorney, Thompson said, “I saw a very bright, ambitious, appealing kid who I thought could make a great trial lawyer. It turns out I was right. He`s one of the toughest, smartest ones I know. That`s how I raised him.”

Dan Webb was appointed to serve as U.S. attorney in the Northern District of Illinois in 1981. He led the prosecution team that convicted James Lewis for extortion. James Margolis, an assistant U.S. attorney at the time, was also a member of that team. In 1984, Big Jim appointed Margolis to the newly created position of state inspector general. In that position, Margolis continued to investigate only one Tylenol suspect – James Lewis.

Even Michael Monico, the lawyer who represented Lewis in his extortion trial, was one of Big Jim’s boys. Monico had worked as an assistant U.S. attorney under Thompson in the early 1970s. The National Law Journal, in an article about the Tylenol extortion case, noted the intensity between “the strikingly handsome” Michael Monico and the “boyish” Dan Webb. Before the ruling came down against Lewis - Monico told Webb, “after this is all over, I’ll still be ‘strikingly handsome’ and you’ll still just be ‘boyish.’”

Jim Thomson, as the U.S attorney in Illinois in the early 1970s and as the State’s governor from 1977 to 1991, surrounded himself with like-minded Republican loyalist. On November 12, 1980, Governor Thompson, by Executive Order, instituted a hiring freeze for all state agencies, boards, bureaus, and commissions under his control as governor. The order affected approximately 60,000 state positions. These positions could only be filled if the candidates were first approved by the Governor’s Office of Personnel, an office created by Thompson. The practice essentially consisted of denying the hiring of persons not affiliated with the Republican Party. Thompson’s Republican patronage mill rivaled even the Democratic patronage mill in Cook County, known as “The Chicago Democratic Machine.”

Near the end of Thompson’s fourteen-year reign as Governor, the U.S. Supreme Court held that Thompson’s policy of doling out state jobs to the party faithful violated the U.S. Constitution. The court ruling affirmed what critics had said all along: The hiring freezes Thompson imposed, more or less continuously, throughout his tenure were merely patronage tools used to ensure that Republicans got available state jobs.

In 1982, Big Jim’s boys handled the Tylenol murders investigation in a manner that reflected the homogeneous thinking of the administration in charge at the Governor’s Mansion in Springfield, Illinois, the White House in Washington D.C., and the headquarters of Johnson & Johnson’ in New Brunswick, New Jersey. Near the end of 1982, Tyrone Fahner gave a rather pitiful assessment of the Tylenol murders investigation. “When all this is said and done,” remarked Fahner, “the most interesting story to come out of this - outside of the terrible tragedy - will be that we drummed up every bit of scud walking around. We found the people who said they had done it, who had access to chemicals, who acted weird, who potentially were in the right place at the right time. And we did some incredibly fine investigative work… and we came up dry.”

When it came to the Tylenol murders, Big Jim’s boys were inclined to dismiss the relevance of the physical evidence available to them. However, they did understand that the two boxes of Tylenol capsules stumbled upon by deputies Al Swanson and Joseph Chavez in the Howard Johnson’s parking lot at 2:32 a.m. on September 28, 1982 were an important clue to identifying the Tylenol killer.

Both boxes of Extra Strength Tylenol capsules in the Howard Johnson’s parking lot had initially each contained 72 bottles, but one of the boxes had been opened, and only two dozen bottles remained in that box. Cyanide-laced Extra Strength Tylenol capsules from those boxes, or other boxes, were delivered by truck drivers, merchandisers, or rack jobbers to retail stores and pharmacies. The varying degree of corrosion indicated that the cyanide-laced Tylenol capsules had been filled with cyanide at different times, probably over a period of weeks.

In February 1986, J&J executives came clean, at least partially, about the Tylenol distribution network. They revealed that the company shipped Tylenol to wholesalers from three J&J regional distribution centers located in Glendale, CA, Montgomeryville, PA, and Round Rock, TX. J&J was shipping Tylenol through these same regional distribution centers in 1982 also. Tylenol was shipped to states east of the Mississippi River (including Illinois), from J&J’s Montgomeryville distribution center.

There is no question that Tylenol was being shipped in bulk containers of Tylenol powder from J&J’s Montgomeryville facility to repackagers’ warehouses in 1986. And there is really no question that J&J was also shipping bulk containers of Tylenol from its Montgomeryville facility to repackagers’ warehouses in 1982. A tip-off to these shipments of bulk Tylenol comes from the disparity in the number of Tylenol bottles purported to have been in the distribution channel in 1982, versus 1986.

On February 14, 1986, Joseph Chiesa, the president of McNeil Consumer Products, said 1 million bottles of Tylenol capsules (regular and extra strength) were estimated to be in the distribution system throughout the United States. That number did not jive with the number of capsules that J&J spokesperson, Robert Kniffin, had said were in the distribution channel in 1982.

After J&J announced the recall of all Tylenol capsules on October 5, 1982, Kniffin said that J&J would destroy 22 million bottles of Tylenol capsules (regular and extra strength) with a retail value of $79.2 million. Kniffin said this included 11 million bottles previously sold to consumers and being returned and an additional 11 million bottles in the channel of distribution that were being returned by retailers and distributors. It makes no sense that there were eleven times as many bottles of Tylenol capsules in the distribution channel in October 1982 than there were in February 1986.

Annual Tylenol sales were about $450 million in 1982 and $525 million in 1986. About 30 percent of those sales were from capsules. Weekly sales of Tylenol capsules in 1986 were about $3.0 million. At $3.70 per bottle, J&J was selling about 811,000 bottles of Tylenol capsules per week. The one million bottles of Tylenol capsules that J&J said were in the distribution channel in February 1986 represented 9 days, or about 1.23 weeks of supply (1,000,000 / 811,000 = 1.23 weeks = 9 days).

In 1982, J&J was selling about $2.6 million in Tylenol capsules each week. At $3.60 per bottle, J&J was selling about 722,000 bottles of Tylenol capsules per week. The 11 million bottles of Tylenol capsules that J&J said were in the distribution channel in October 1982 represented a whopping 107 days, or about 15.23 weeks of supply (11,000,000 / 722,000 = 15.23 = 107 days). The 1.23 weeks of supply in February 1986, and the 15.23 weeks of supply in September 1982 cannot both be correct.

Food and drug wholesalers keep very low levels of inventory on hand, typically carrying just enough of a given product to cover less than a month worth of sales. Food and drug stores also keep low inventory levels of food and non-food products on hand, typically just enough to cover less than two weeks of sales. A wholesaler that sold $10 million worth of products per week could easily handle that volume by keeping $40 million in inventory on hand, enough to cover four weeks of sales. If that same wholesaler kept a 12-week supply of inventory on hand, it would need to tie-up $120 million in inventory. No wholesaler would buy $120 million in inventory at once when it only needed to keep $40 million or less of inventory on hand to service its customers.

There should have been no more than about four to six weeks of supply of Tylenol capsules in the distribution channel in September of 1982. There were certainly not 11 million bottles of Tylenol capsules, constituting more than 15 weeks of sales, in the distribution channel. Rather, there was enough Tylenol powder or capsules in bulk containers in the distribution channel to fill 11 million bottles with Tylenol capsules. Some of that Tylenol had already been bottled, but most had not. Containers of bulk Tylenol manufactured at the McNeil plants in Round Rock and Fort Washington were shipped through J&J’s Montgomeryville distribution center in August of 1982 to the Chicago area repackager where the tamperings occurred.

A constant barrage of news stories of “copycat” tamperings in retail stores across the country diverted the public’s attention away from the Tylenol distribution network. The reports on these so-called copycat tamperings made it seem that the tampering-in-the-retail-stores hypothesis was an established fact. The FDA counted 270 incidents of suspected product tamperings reported around the country in the four weeks following the Chicago area deaths. The FDA judged that 36 of the incidents were “hardcore, true tamperings.” These tampering incidents were not really copycats though, because the Tylenol killer had planted the cyanide-laced capsules in the distribution channel – not in the retail stores.  What these tamperers were actually copying was the tampering-in-the-retail-stores scheme publicized by J&J, the FDA, and the Tylenol task force.

Dr. Park Dietz, a forensic psychiatrist and expert on criminal behavior, analyzed the data on the tampering incidents. He found that each of several sharp increases in the monthly rate of complaints occurred in the wake of high-intensity news coverage about tampering. Following press coverage of the fatal Tylenol tampering in Westchester County in February 1986, the rate rocketed to 326 a month. In the following month, tampering complaints reached an all-time high of 456. The rate of tampering complaints declined for a few months, but peaked again after the media publicized tampering fatalities in the summer of 1987. In 1987 and 1988, when there were no nationally publicized tampering stories, the complaint rate fell to approximately 25 per month.

Dr. Dietz concluded that these increases in reported tamperings were the result of an increase in actual tamperings. However, this increase in reported tamperings actually may have been the result of greater vigilance among consumers to inspect products, and an increased diligence in reporting tampering incidents. Nevertheless, there were indisputably, many people tampering with consumer products. And with so many people unable to resist the temptation to contaminate capsules and other products in retail stores, there were certainly also people working in repackaging facilities and distribution centers who also could not resist their urge to put poison in capsules.

In 2002, James Zagel reflected back on the Tylenol investigation in 1982, saying, “You’d come across certain suspects, and it would turn out they didn't do it - but they were actually very sorry they hadn’t thought of it. There are people out there who will commit terrible crimes, keep themselves hidden, and just enjoy the uproar they cause.”

Anyone who had access to the area where the capsules were stored or bottled only had to drop a handful of cyanide-laced capsules into the storage bins or production lines. As long as the killer dumped only a few handfuls of poisoned capsules at a time into the bottling production lines, it was likely that only one poisoned capsule would get into any given bottle. When the one cyanide-laced Tylenol capsule in that bottle was swallowed, the evidence of murder disappeared in the victim’s body. Eventually, the Tylenol killer may have become more aggressive, dumping hundreds or thousands of cyanide-laced Tylenol capsules into numerous bottling production lines at one repackaging facility over a short period of time until a few of his murders finally made headline news.

*****

In 1982, Tyrone Fahner, Dan Webb, and Jeremy Margolis decided who would and who would not be targeted as suspects in the Tylenol murders investigation. Partnering with this small, tight-knit group of past and future IDLE directors were a number of FBI agents, including Edward Hegarty, the special agent in charge of the FBI’s Chicago office, and Special Agent Roy J. Lane. After the 1982 Tylenol murders case had gone cold, these investigators settled on James Lewis as their “prime suspect.” They even treated Lewis as a suspect in the 1986 Tylenol murder of Diane Elsroth.

When news of the Tylenol murder in Westchester County reached Chicago on February 10, 1986, some authorities there wondered where Lewis was living at the time. After all, Lewis had at one time lived in New York City. Ironically, Lewis’s residency in New York City from September 6, 1982 to December 27, 1982 proved he could not have been involved in the Tylenol poisonings in Illinois. As it turned out, Lewis also had a pretty good alibi regarding his whereabouts at the time of the 1986 Tylenol murder. He was in prison serving ten years for writing the Tylenol extortion letter. More specifically, Lewis was in the Federal Prison Hospital in Springfield, Missouri. He had suffered a heart attack on February 8, 1986, the same day Diane Elsroth died.

With James Lewis out of the picture as a suspect in the 1986 Tylenol poisoning, two members of the disbanded 1982 Tylenol task force decided to snoop around the Cambridge, Massachusetts neighborhood where Lewis’s wife, LeAnn, was living. Jim Thompson’s political appointee, Jeremy Margolis, the Illinois inspector general at the time, went to Cambridge on Monday, February 10, 1986, to harass LeAnn. FBI Special Agent, Roy Lane, joined Margolis on this excursion. Lane had been part of the team of FBI agents and federal prosecutors from the U.S. Attorney’s Office in Chicago that had handled the extortion case against Lewis.

When contacted on February 11, 1986, Robert Long, an FBI spokesperson in Chicago, said he could not confirm or deny that agents were seeking information on Mrs. Lewis. “It wouldn’t be in law enforcement interests to say if we interviewed her and what she said,” remarked Long.

Donald Morano, Lewis’s attorney in Chicago, said Lane had visited Mrs. Lewis’s apartment building on Monday, February 10, 1986. Morano said Lane had asked the doorman where Mrs. Lewis had been just before Elsroth’s death from cyanide-laced Tylenol around 1 a.m. Saturday morning February 8th. FBI agents also questioned LeAnn’s neighbors. Lane then phoned Donald Morano on Tuesday and asked for permission to “debrief” Mrs. Lewis on her movements before the death of Diane Elsroth. Morano said he rejected the request as absurd. He said LeAnn Lewis had been working and “would have had no reason to go to New York.”

James Burke said that he had first learned about the cyanide-laced Tylenol poisoning of Diane Elsroth on the afternoon of Monday, February 10th, but, by then, Lane and Margolis were already in the lobby of LeAnn’s Cambridge apartment, waiting for LeAnn to return home from work. Burke, Lane, and Margolis must have known about the murder of Diane Elsroth on Sunday or early Monday morning, giving them a 12 to 24-hour head start to pursue their own agendas before the story was reported in the news media Monday evening.

Morano said Lane and Margolis initially asked the doorman at LeAnn’s apartment if they could enter her apartment while she was at work. They had no warrant to conduct a legal search, so the doorman refused. Morano said that Lane and Margolis then spoke to LeAnn in the building’s lobby for 90 minutes or more when she returned home from work. They warned LeAnn that unless she agreed to answer their questions, her husband would remain in prison for a long time. Apparently, LeAnn did not give Lane and Margolis the answers they wanted, because Margolis would later make good on that promise.

Neither the FBI spokesperson nor Margolis would comment on Morano’s charges. Margolis said the investigation of the Tylenol deaths in Illinois had been done “properly and professionally and will continue to proceed in that fashion until a resolution is obtained.” Margolis, who played no role whatsoever in the 1986 Tylenol murder investigation, apparently viewed the murder of Diane Elsroth as a good opportunity to harass LeAnn Lewis in the continuing effort of IDLE and the FBI to frame her husband for the 1982 Tylenol murders.

In fact, the jaunt by Lane and Margolis to LeAnn Lewis’s home in February 1986 was not their first. Morano said that Lane and Margolis had also visited LeAnn’s apartment building in October 1985 to question her on the movements of her and her husband in the week before the 1982 Tylenol deaths in Illinois. This October 1985 visit came just four months before the Tylenol murder in New York. Was this yet another unlikely coincidence, or did Lane and Margolis know about other Tylenol poisonings that continued to dot the landscape?

The FBI was able to track down LeAnn Lewis very quickly in 1986, arriving on her doorstep before the murder of Diane Elsroth was publicly disclosed. But in the fall of 1982, after officials linked James Lewis to the Tylenol extortion letter, the FBI had an awful time tracking down the Lewises. That manhunt, which began on October 13, 1982, ended two months later in New York City.

PART 3

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The Manhunt

An envelope, with the word “TYLENOL” written above Johnson & Johnson’s address, arrived at the company’s headquarters in New Brunswick, New Jersey, on October 6, 1982. Inside that envelope was an extortion letter with a preposterous demand: “If you want the killing to stop, then wire $1 million to #84-49-597 at Continental Illinois Bank in Chicago.”

One week after receiving the extortion letter, officials identified its author as Robert Richardson, aka James Lewis. The FBI launched a nationwide manhunt for Lewis, and his wife, LeAnn. Authorities released a “special nationwide bulletin” stating that the Lewises “should be considered armed and dangerous.” Then, Lewis sightings began coming in from all over the country.

Police in Amarillo, Texas, said Lewis’s picture closely resembled a composite sketch of a suspect in a $100,000 jewel heist. That person turned out not to be Lewis. At Boston’s Park Plaza Hotel, a woman carrying suspicious ID cards was arrested for passing a bad check, but police soon realized she was not LeAnn Lewis. A Texas woman mistakenly identified her own son as James Lewis based on a picture of Lewis in the newspaper. One person called police and insisted he had spotted the pair at a World Series game between the Milwaukee Brewers and the St Louis Cardinals. When police pressed him, he admitted he had not actually been at the game - he merely thought he had seen the couple when a TV camera scanned the crowd

In Carl Junction, Missouri, Jim Lewis’s hometown, at least six residents said they had recently seen the Lewises. Police rushed to an abandoned house after a woman reported that Lewis was hiding there, only to find a 19-year-old neighbor feeding his pet gophers. A hair stylist reported that a nervous man fitting Lewis’s description had come into her salon to have his hair bleached, but then bolted when she casually mentioned the Tylenol murders. She was “99-and-three-fourths sure” that the customer was James Lewis. Later, the man identified himself to police and explained that he had suddenly realized he wasn’t carrying enough money to pay for the dye job. A local convenience store clerk said the Lewises had stopped in once for candy bars, and again for cigarettes. That lead didn’t pan out either.

An investigator at the Tylenol task-force headquarters said, “Callers have spotted them [the Lewises] in Hartford and Honolulu the same day, and in Miami and Missouri the same day. As of now, the hard info is zilch.”

*****

James Lewis grew up on a small farm in Carl Junction, Missouri, without electricity, telephones, automobiles or modern agricultural equipment. His mother, Charlotte, worked in a shirt factory. His father, Floyd, a World War II veteran, sharecropped 20 acres. Floyd died of a heart attack in 1959 when Jim was twelve years old. Charlotte married Glen Nelson a few years later. Glen was a pacifist who had served in the U.S. Army Medical Corps in New Guinea and the Philippines during World War II. James realized early in life that he too was a pacifist.

Lewis attended Brick Elementary School, a one room schoolhouse located just a mile from his small rural home. In sixth grade Lewis was bussed to the “big” school in Carl Junction, which had two classrooms and two teachers. In high school, Lewis played the B-flat slide trombone and held first chair throughout all four years there. He got good grades, and he liked math.

James and LeAnn met while they were students at the University of Missouri at Kansas City. They were married on Thanksgiving Day, 1968. One year later, they had a baby girl, Toni Ann. She was born with Down’s syndrome and had a congenital heart defect, but whatever hardships this may have caused only seemed to bring the family closer together. Toni Ann didn’t learn as fast as most other kids, but she did have a special intellectual skill that allowed her to retain everything she did learn.

In the early 1970s, James and LeAnn leased a storefront in Kansas City and opened their own business, the Lewis & Lewis Business Tax Service. In 1974, Toni Ann underwent her fifth open-heart-surgery. Shortly thereafter, James and LeAnn suffered a heart-breaking loss when five-year-old Toni Ann died of complications from that surgery.

In 1975, Lewis collaborated with Viren Mehta to form a Company called Aljeev International, which they incorporated in Missouri. Mehta, who was born in India, had earned a Master’s degree from the University of Missouri-Kansas City in the 1970’s. The Aljeev business plan was to install tablet-making tools into rotary tablet machines already owned by pharmaceutical manufacturers in overseas markets. The factories targeted as their potential customers were located in Third World countries, but owned by giant multinational American drug firms based in the United States, such as Pfizer, Dow Chemical, Upjohn and others. Lewis and Mehta never actually sold any tablet-making tools, and Aljeev never had any assets. Lewis said the business venture was a total failure and underfunded.  “We were inexperienced kids, with illusions of grandeur, but without a written business plan,” recalled Lewis.

Lewis and Mehta quickly lost track of one another, and their paths went in markedly different directions. Mehta moved to California, where he earned a PharmD at the University of California and then founded Mehta & Isaly, an investment research group that focused on companies in the pharmaceutical industry. He became a very wealthy man. James and LeAnn Lewis stayed in Kansas City, Missouri, living modestly in a small house on Troost Avenue.

On December 4, 1981, the Kansas City police showed up on the Lewises’ doorstep with a search warrant in hand. They were investigating James Lewis and George Rea as suspects in a possible credit card fraud scheme. Rea was a former Sheriff’s deputy who leased office space at the Lewises’ place of business. Rea later admitted to his involvement in the fraud, but Lewis has always maintained that he was not involved. In 1983, prosecutors granted Rea immunity to testify against Lewis, and Lewis was then convicted on six counts of credit card fraud.

While Kansas City authorities were working on getting a warrant to conduct a more thorough search of the Lewises’ Kansas City home on December 5, 1981, the couple packed up their 1969 AMC Rambler and headed north. On December 10th, they checked into the Surf Hotel on Chicago’s North Side. A week later, using the names Robert and Nancy Richardson, they moved into a $100-a-month apartment at 549 West Belden Avenue on Chicago’s North Side.

In January 1982, James took a job with Chicago Tax Service, where he worked for about seven weeks. He then took a temporary job for one week in March as a word-processor operator at the A.G. Becker Investment Company. LeAnn had taken an accounting job at Lakeside Travel Agency in January, but by March 1982, she could see that the agency was in financial trouble. The company had been taken over a year earlier by Frederick Miller McCahey, an heir to the Miller Brewing fortune. LeAnn’s supervisor, Barbara Vaitkus, later testified that co-workers gossiped about McCahey having put other enterprises out of business. Vaitkus said she discovered evidence that McCahey had diverted company funds to pay his personal bills and was not properly depositing Lakeside’s receipts.

Lakeside Travel went bankrupt in April 1982, so LeAnn was out of a job. In that same month, the First National Bank of Chicago hired James as a temporary employee in its International Department. A senior vice president with First National Bank at that time was Neil Hartigan, who had been the lieutenant governor of Illinois from 1973 to 1977. While Lewis was working at the bank, Hartigan was in the midst of a successful election campaign to replace Tyrone Fahner as Illinois Attorney General.

On LeAnn’s last day at Lakeside Travel, she stamped a stack of blank envelopes with postage from a Pitney Bowes meter and a postmark date of April 15, 1982. The following week, Vaitkus issued 18 final paychecks that totaled about $8,000, including LeAnn’s check for $511.33. LeAnn cashed that check at a nearby currency exchange. The check ended up bouncing, and the currency exchange then sued LeAnn to recover the funds. All the other final paychecks from Lakeside also bounced.

A majority of the former Lakeside employees filed claims with the Wage Claim Division of the Illinois Department of Labor in an attempt to collect on the dishonored checks. Lewis volunteered his time to work as their advocate. In preparation for the coming wage claim hearing, Lewis gathered as much information as he could on Lakeside Travel. Barbara Vaitkus apparently told Lewis that McCahey was diverting company funds to pay personal bills and was not properly depositing receipts. She also gave Lewis one of McCahey’s account numbers, 84-49-597, at the Continental Illinois National Bank in Chicago. McCahey had opened that account on August 24, 1981, and closed it on May 10, 1982.

The wage hearing was held on August 3, 1982. Fredrick McCahey’s lawyer attended the hearing, but McCahey did not. Forty-five minutes after the hearing ended, the arbitrator ruled that because there was no money available to pay a claim, there was nothing he could do about the bounced checks. McCahey’s attorney left the hearing, and shortly thereafter McCahey himself arrived. Jim and LeAnn confronted him, and an argument developed between McCahey and the Lewises. The exchange ended with McCahey apparently threatening LeAnn.

Jim’s temporary job ended in August 1982, and the couple, now both unemployed, decided to move on. They spent a few days planning their next move, putting together a checklist that included such notations as “Look for Belden-type apartment in Manhattan,” “Plan production schedule,” and “Travel strategy for metropolitan area.” On September 3rd, they purchased two one-way tickets for $221 on an Amtrak train to New York City, using the names Karen and William Wagner. On September 6, 1982, they checked into the Hotel Rutledge, a 12-story building on Lexington Avenue at 31st Street in Manhattan, using the same aliases they had used in Chicago, Robert and Nancy Richardson. The Hotel Rutledge had opened in 1914 as a hotel for women. In 1982, it was a rundown boarding house. Some called it a fleabag hotel. The Lewises rented a room there for $95 per week.

Shortly after arriving in New York, LeAnn submitted her resume to the Robert Half Account-temps Agency. Abrams, Benisch, and Riker, a real estate company at 6 East 43rd Street in Manhattan, soon hired her. Her first day on the new job was September 20, 1982. Every day, without fail, Jim walked to the real estate firm to meet LeAnn for lunch and again at the end of the workday to escort her home.

On Thursday, September 30th, the nation learned about the Tylenol poisonings, and Lewis hatched a plan to draw attention to LeAnn’s former boss, Frederick Miller McCahey. One afternoon in early October, while LeAnn was at work, Jim wrote the Tylenol extortion letter demanding that J&J deposit $1 million into McCahey’s closed bank account at the Continental Bank. Court documents show that Lewis said his intent was “not to extort money, but to cause grief to [McCahey], to blow the whistle on him, and to spur a thorough and exhaustive investigation of his finances and fraudulent business dealings.”

Lewis wanted the extortion letter to appear authentic and threatening, but he could not bring himself to actually state that he had poisoned the Tylenol capsules. Nowhere in the letter did he include the word “Tylenol,” although he did write it on the envelope. The letter offered to stop the killings, but nowhere did it threaten to kill anyone or state that its author had killed anyone. However, Lewis concedes, “The double entendre does invite a lot of reading between the lines.” He mailed the letter to Johnson & Johnson in one of the envelopes postmarked April 15, 1982 that LeAnn had taken from Lakeside Travel the day before that firm went belly-up.

On October 6, 1982, the Director of Security at Johnson & Johnson distributed Lewis’s handwritten extortion note to the company’s Executive Committee. The extortion note read:

Gentlemen:

As you can see, it is easy to place cyanide (both potassium and sodium) into capsules sitting on store shelves. And since the cyanide is inside the gelatin, it is easy to get buyers to swallow the bitter pill. Another beauty is that cyanide operates quickly. It takes so very little. And there will be no time to take counter measures. If you don’t mind the publicity of these little capsules, then do nothing. So far, I have spent less than fifty dollars. And it takes me less than 10 minutes per bottle. If you want to stop the killing then wire $1 million to bank account 84-49-597 at Continental Illinois Bank, Chicago, Illinois. Don’t attempt to involve the FBI or local Chicago authorities with this letter. A couple of phone calls by me will undo anything you can possibly do.

It was immediately apparent that the authorities did not believe the extortion letter was relevant to the actual Tylenol poisonings. “It’s a long shot that this is the work of anything other than a kook,” said a law enforcement source in Washington who refused to be identified by name or department. “The killings were a very subtle and secretive crime, and it’s doubtful that would be topped off with the flagrant ignorance of [delivering] a payoff scheme with the identity attached to it,” the source added. “Our guess is it’s totally unrelated to whoever did the poisoning. These tag-a-longs happen all the time.”

Attorney General Tyrone Fahner downplayed the importance of the Tylenol extortion letter, saying, “It will not be relevant in solving the cyanide murders. It is a whole side issue ...a hoax.” Fahner said the disclosure of the letter was unfortunate because it sidetracked the investigators. He criticized local newspaper accounts of the extortion letter as being “based on more than the facts.” The extortion letter is not “relevant” to the hunt for the person who spiked the capsules with cyanide. “My suggestion to you [reporters],” said Fahner, “is the note received by Johnson & Johnson, and the Continental Bank records is leading to something else than solving [the poisonings].”

Lewis never intended to collect the $1 million dollars that the letter demanded. “The bank account that was named in it, I had no access to,” Lewis said later. “It was a closed bank account. I had no way of getting anything out of it - anymore than you do or anyone else,” he explained.

Lewis sent a letter to The Chicago Tribune in November 1982, charging McCahey with shady business practices. Lewis later said that the reason he wrote the extortion letter was to try to get attention focused on the soon-to-be insolvent Continental Illinois Bank. “If [the FBI] would have examined that bank account - if they would have pursued that - they would have found the fact that Continental was being raided,” Lewis said in 1992. “If I had been listened to, we may very well have not seen the savings and loan debacle.”

Regardless of whether Lewis’s overriding objective was to trigger an investigation of McCahey or expose extensive fraud at Continental Bank, there is no question that by 1982 massive fraud had been going on at the Continental Bank for the better part of a decade. In the mid-1970s, the management at Continental Bank had implemented a growth strategy focused on commercial lending, explicitly setting out to become one of the nation’s largest commercial lenders. By 1981, Continental Bank was the largest commercial and industrial lender in the United States. But late in 1981, problems related to the banks weakening balance sheet began to surface. The bank’s second quarter earnings fell 12 percent - a drop that CEO Roger Anderson explained was largely the result of backing interest rates the wrong way. Continental had bet that the rates would go down - instead, they went much higher as inflation heated up. The true problem, however, lay in the Bank’s risky lending practices. Several big loans, like the $200 million loan Continental gave to the near-bankrupt International Harvester company, headquartered in Melrose Park, Illinois, were causing an ever-weakening balance sheet at the bank.

In July 1982, Penn Square Bank in Oklahoma failed. Penn Square had generated billions of dollars in extremely speculative oil and gas exploration loans, many of which were nearly worthless, and Continental had purchased a monumental $1 billion in participations from Penn Square before the bank’s bad loans went south. Continental’s lending involvement with three of the largest corporate bankruptcies in 1982 helped turn the perceptions of the bank increasingly negative. Such perceptions were reinforced by the advent of the less-developed-country (LDC) debt crisis brought on by Mexico’s default in August of 1982. Continental had significant LDC exposure. Indeed, David Collins, the newly appointed McNeil chairman and J&J group company chairman,   had been dealing with this very same issue with J&J’s Mexican operating companies on September 30, 1982, when he learned about the Tylenol poisonings in Chicago.

In the spring of 1984, the situation at Continental rapidly deteriorated, and bank regulators worried that the crisis at Continental might envelop the entire banking system. In July 1984, the FDIC bailed out Continental by purchasing $4.5 billion in bad loans from the bank. It was the largest bank resolution in U.S. history, the genesis of today’s often quoted term “too big to fail,” and the beginning of the Federal Reserve’s policy of bailing out large banks when they become insolvent through fraudulent lending practices.

One of the Continental Bank directors who had fostered the bank’s irresponsible business practices was Paul J. Rizzo, the vice-chairman of IBM. Johnson & Johnson appointed Rizzo to its Board of Directors in October 1982. Rizzo was one of nine Continental Bank directors who the Federal Deposit Insurance Corporation (FDIC) fired in 1984 for sanctioning the reckless loans made in the 1970s that led to the Bank’s near collapse. Rizzo remained on Johnson & Johnson’s Board of Directors until 2007.

*****

David Collins described the dialogue between J&J executives after they received Lewis’s extortion letter. “Imagine our reaction,” said Collins. “We get this note that says send $1 million to a bank account number at Continental Bank in Illinois. We had to laugh. This guy’s gotta be an idiot. We’re still not convinced he did it.”

But that’s not what J&J’s “Tylenol Strategy Committee” said in the documents submitted into evidence in Lewis’s extortion trial in 1983. According to those court documents, J&J’s Tylenol Strategy Committee was concerned that the extortion letter was authentic, that it had been written by the person who had initially placed the cyanide in the Tylenol capsules, and that that person stood ready to do it again, unless his demands were met. This assertion conflicts completely with Collins’s characterization of the reaction of J&J executives to the extortion letter, of which Collins said, “We had to laugh. This guy’s gotta be an idiot.”

Judge Frank McGarr, who presided over Lewis’s extortion trial, wrote, “The evidence shows that the company [J&J] stood ready to transfer the money, but that the FBI instructed it not to do so. The evidence strongly suggests that Johnson & Johnson’s probable response [to the extortion letter] would be to wire the funds, and it is completely consistent with Lewis’s professed motive of exposing McCahey that he expected the corporation to part with the money. Even a temporary loss of the use of money constitutes a deprivation of property.”

The idea that Johnson & Johnson was actually going to deposit $1 million into a closed bank account because of the Tylenol extortion letter is ridiculous. Nevertheless, Lewis did write that letter, and he received a 10-year prison term for doing so. The court documents filed by J&J clearly overstate the veracity of Lewis’s intent. Lewis never had a chance of collecting any money, and he never intended to collect any money. In Lewis, J&J executives had a scapegoat for the Tylenol murders. By casting a dark shadow on Lewis, Johnson & Johnson’s problems were swept under the rug, and any suspicion that the tamperings had occurred in the channel of distribution went away.

Jeremy Margolis, the assistant U.S. attorney on the team of Justice Department lawyers who prosecuted Lewis for extortion, said Lewis “fancied himself a really brilliant guy.” Margolis said Lewis believed that he knew how law enforcement worked, and he had decided to wait and take advantage of the next catastrophe. “It could have been a plane crash, a train wreck, whatever. It just happened to be the Tylenol killings.” Margolis said Lewis “left Chicago with these envelopes in his possession and the bank account number, knowing that something bad would happen someplace, and he would take advantage of it and put the heat on Frederick McCahey.”

Margolis said, “He [Lewis] knew that the Bureau would eventually figure out that McCahey hadn’t done whatever it was that Lewis was claiming McCahey did in the letter - plane crash, train wreck, Tylenol killings, whatever.” Lewis figured that during the course of the Bureau’s investigation of McCahey, “they’d work [McCahey] up one side and down the other and figure out what a horrible white-collar criminal he was and he would suffer his just desserts for bouncing checks on employees,” said Margolis

After authorities determined that McCahey had not written the extortion letter, they asked McCahey if anyone might hold a grudge against him. McCahey named Robert and Nancy Richardson, aka James and LeAnn Lewis. Authorities connected the dots and then on October 13, 1982, they issued an arrest warrant and published a headshot of “Robert Richardson.” Kansas City police recognized the suspect and informed the Chicago cops that the name of the man they were looking for was actually James Lewis.

On October 14, 1982, Kansas City authorities sent three officers to Chicago with Lewis’s police file. Chicago Police Lt., August Locallo, said one of the Kansas City officers carried “some written material” to the FBI laboratory in Washington D.C. for fingerprint analysis against a smudge found on one of the cyanide-laced Tylenol bottles and another print lifted from items confiscated from Lewis during a 1978 murder investigation. Lewis’s fingerprints, of course, were not found on any of the Tylenol bottles.

The Kansas City police identified Lewis as the man who had been a suspect in the 1978 murder of Raymond West. In 1979, a judge dismissed the murder charge against Lewis at the request of the prosecutor who said the victim’s cause of death could not be determined, and police had illegally seized some evidence. Lewis was still wanted in Missouri on charges related to the credit card scheme that authorities were investigating when the Lewises left Kansas City for Chicago in December of 1981.

When Raymond West died in 1979, he was a lifelong bachelor and former truck driver who had lived with his mother in a small house on the corner of Campbell and Troost in Kansas City since 1946. His mother had died in 1977. On Sunday, July 23, 1978, West made his weekly trip to the local florist shop. A neighbor said West called her later that evening. He reported feeling a little sick, but talked mostly about getting his refrigerator fixed. That was the last anyone heard from him.

A longtime friend, Charles Banker, became concerned on Monday when he could not reach West by phone. Banker and his wife drove over to West’s home to investigate. The doors were locked, and West’s car was in the garage. They looked through West’s bedroom window and saw an unmade bed. Worried, they called police. According to Kansas City police reports, the responding officer found the house secured and asked Banker who else might know where West was. Banker mentioned a few neighbors, including the man who did West’s taxes, Jim Lewis.

The officer called Lewis, who said West had gone to the Ozarks for three or four days with his girlfriend. According to Banker, however, West had never had a romantic involvement during their 30-year friendship, and he never went anywhere significant without telling him. Banker filed a missing person’s report.

Banker returned to West’s home on Wednesday and saw a note stuck on the still-locked front door written on Lewis & Lewis letterhead. It read, “Ray is out of town until Thursday, for further information call Jim.” Again, Banker called police. The police arrived shortly thereafter and forced their way into the house. Everything appeared to be in order. Then they found a note on the living room coffee table. It said, “Please don’t disturb until after 1:00. - Sleeping late, Raymond.” West was nowhere to be found. Banker changed the locks on the doors and then gave one key to police and kept the other one.

About three weeks later, on August 14th, Banker went back to West’s home. There was an awful smell coming from inside the house. He unlocked the front door and went inside to search through the house again. When he entered the spare bedroom, he noticed some dried blood on the floor.  He called police back to the house again. This time they conducted a more extensive search. When they went down to the basement, they found a bloody lawn chair and garbage bag containing West’s toupee and eyeglasses as well as some bloodstained sheets.

Upon returning to West’s upstairs bedroom, officers noticed a foot-long stain on the ceiling. They found a ladder and then climbed up into the attic through a window from outside the house. A partially decomposed body was lying face down, still dressed in a striped polo shirt and tan corduroy pants. Both legs had been severed at the hip joint and then wrapped with sheets. The right leg lay near the head on the right side; the other rested farther down on the left. The head was also wrapped with sheets and a cord, and the torso was partially covered with a garbage bag tied with cotton rope. As the body had decomposed over the previous three weeks, all the wrappings had become saturated with blood and other bodily fluids that had soaked through the insulation, and dripped onto the floor of the bedroom  below.

Police drove down the street to talk to Lewis again. After a short conversation, they arrested Lewis and brought him in for questioning. Lewis had tried to cash a check for $5,000 from Raymond West dated July 23, 1978, the day West went missing. The bank had refused to cash it when they could not get hold of West to confirm its validity. Lewis said the check was a loan West had given him during a morning visit on Sunday, July 23. He also said that he had put the note on West’s front door, so folks like Banker wouldn’t worry about West. After submitting fingerprints and a handwriting sample, Lewis was released.

The following day, police returned to the Lewis home to inquire further about the check. Lewis said the $5,000 was a “business expansion” loan from West. He then produced a typed promissory note. Lewis agreed to sign a consent-to-search form, allowing police to search his home and office as well as his vehicles. Detectives searched Lewis’s car and discovered a black attaché case with papers bearing Raymond West’s name and a bundle of his checks. In late August 1978, the Jackson County Grand Jury charged Lewis with capital murder, despite the fact that the Medical Examiners had been unable to determine how West had actually died.

Just days before the October 1979 trial date, Prosecutor James Bell asked for a dismissal of the case. The entire case was a mess. Police had no probable cause to arrest Lewis the first time, and they had neglected to read him his Miranda warning. Prosecutors had a bag of bloody body parts and no known cause of death. Detectives had found nothing at West’s house that could tie Lewis to the crime. Bell told reporters that the case was “one of the most mysterious, confusing, befuddling, complex... and probably one of the most difficult cases I ever handled.”

When Lewis came under public scrutiny because of the Tylenol extortion letter, Jackson County Circuit Judge, Gene Martin, appointed a special prosecutor, James K. Fischer, on October 19, 1982, to reopen the Raymond West case. The reopened case went nowhere, and Fischer never charged anyone with a crime related to West’s death. There are few confirmed facts in this case, but one fact is indisputable: The Raymond West case has nothing to do with the Tylenol murders. Furthermore, as the Tylenol case illustrates all too well, it is a good idea to understand all the facts before blindly accepting as accurate the statements and theories put forth by officials in charge of a criminal investigation.

Upon learning about the Raymond West case, Fahner appeared to become more interested in talking to James Lewis. “The extortion demand we took as a hoax initially, but the murder charge and previous record puts it in a different light,” Fahner now said. “Obviously, this has great significance. We want these people [the Lewises] back. We still have no direct evidence that these people were involved in the cyanide-Tylenol deaths, but we want them back so we can pursue that angle.”

When Fahner made that statement on October 15, 1982, officials from the FBI and IDLE were then already committed to charging Ed Reiner, Roger Arnold, and possibly Howard Fearon Sr. with the fabricated Tylenol murder conspiracy. The FBI and IDLE continued to pursue these three men, coming within one day of making arrests before the Tylenol murder conspiracy theory evaporated into thin air on October 26, 1982. It was only after the FBI and IDLE failed to bring their Tylenol murder conspiracy theory to fruition that they targeted James Lewis as their “prime suspect.”

After a one-day media blast that promoted the Tylenol murder conspiracy theory story on October 25, 1982, Roger Arnold and the relatives of Lynn Reiner were out, and James Lewis was in as the patsy for the Tylenol murders. The problem with making Lewis the patsy was that Lewis had an ironclad alibi. He had been living in New York City since 23 days before the Tylenol poisonings, and 22 days before the Kane County Sheriff’s deputies found the boxes of Extra Strength Tylenol capsules in the Howard Johnson’s parking lot.

38

________

How Do You Solve A Problem Like James Lewis?

James Lewis was in his tiny studio apartment at the Hotel Rutledge, reading a newspaper and listening to the radio, when he first heard the news reports about the Tylenol extortion letter. “They hadn’t named me by name yet, but they were looking for me,” Lewis said. “When I first heard that on the radio, I froze. It was like, oh goodness.” The most difficult part was telling his wife. He broke the news to LeAnn that night while they were preparing dinner together. “I said, ‘Honey, I wrote a letter’ and she said, ‘Oh well, that’s good,’ and I said, well not exactly.”

On October 16, 1982, with Lewis’s face plastered all over the media, Jim and LeAnn checked out of the Hotel Rutledge and moved a few blocks down the road to Hotel 17. On Monday, October 18th, investigators released a grainy photo of a man they said might be the “prime suspect,” James Lewis. The picture was that of a middle-aged bearded man captured on a surveillance camera at the Walgreens store where Paula Prince had bought her bottle of poisoned Tylenol. The man was in the background, while in the foreground; Paula Prince was paying for her bottle of Extra Strength Tylenol capsules.

Unidentified sources “close to the investigation” said the photo could be the case’s first real homicide clue. Fanner said the photo would be an “extremely significant” clue if the man in the picture were identified as Lewis. “If it turns out it is,” said Fahner, “it’s dramatic as hell if you put it together with the $1 million extortion letter, the connection to the murder in Kansas City, and the fact that this guy used 17 aliases.” No one ever substantiated the “17 aliases” claim, because it was not true.

“It could be a tremendous stroke of irony that the person [in the picture] . . . turns out to be Paula Prince, and behind her, it turns out to be the man who salted those capsules,” Fahner mused. He said investigators had other photographs that provided a clearer image of the man in the published photo and experts were also using computer techniques to enhance and enlarge the images. “If the photo has [Lewis] in it, that’s big, important stuff,” Fahner said. “If it turns out not to be, we’re right back where we started.”

As it turned out, the man in the photo did not resemble James Lewis all that much after all. When shown an enlarged and enhanced copy of the photo by a television reporter, Lewis’s former landlord in Chicago, Tom Kline, said, “I’m very doubtful it is him.”

On October 20th, authorities confirmed that a computerized analysis of the photo, commissioned by a local television station but not made public, showed that the man in the photo did not look like Lewis. The original, unenhanced grainy version of the photo had been broadcast on October 18th by the local CBS television station in Chicago, WBBM, as though it had just been discovered. Chicago detectives had actually uncovered the picture nearly a week earlier after going through boxes of film from security cameras at six stores that authorities had linked to the cyanide-laced Tylenol capsules.

There were few professionals - if any - who ever thought the man in the Walgreens photo was Lewis. Nevertheless, the very same week that Fahner, IDLE, and the FBI secretly intensified their investigation of Roger Arnold, Howard Fearon Sr., and Ed Reiner, officials released that photo and suggested it showed James Lewis standing behind Paula Prince while she purchased a bottle of cyanide-laced Tylenol capsules. Behind the scenes, however, authorities from the FBI and IDLE were getting ever closer to dropping their net on the three men they had targeted as the co-conspirators in their contrived Tylenol murder conspiracy theory.

On the same day authorities in Chicago confirmed that the man in the Walgreens photo was not Lewis, authorities in New York City said they had tracked James and LeAnn to the Hotel Rutledge on Lexington Avenue in Manhattan, where they had stayed until four days ago. The police and the FBI had conducted an extensive investigation, reviewing hotel records, checking fingerprints, and interviewing witnesses at the hotel and at the real estate firm where LeAnn had worked until she called in sick on October 16th and never returned.

Kenneth Walton, the deputy assistant director of the FBI’s New York office, said the Lewises had stayed at the Manhattan hotel from September 6th until October 16th. Walton said that Mr. Lewis was last seen on Thursday, October 14th, and Mrs. Lewis was last seen on Saturday, October 16th, when she turned in her room key.  Jess Parker, an unemployed messenger who lived at the hotel, said that during the Lewises’ stay at the hotel, “I would see them leave at 7:30 in the morning, and they would come back after 11:00 at night.”

“We don’t think they were traveling back and forth during the period of time they were known to be in New York” from September 6th to October 16th, said James T. Sullivan, the New York City chief of detectives. He said that Mr. Lewis usually met his wife each day after she finished work as a bookkeeper at a Midtown real estate office and walked home with her. Kenneth Walton, the assistant director at the FBI’s New York City office, emphasized that there was no evidence that directly connected the Lewises to the murders. Yet Fahner said Lewis remained “a prime suspect” in the murders. “He is one of the more substantial leads or persons we are looking at.”

One reporter asked Fahner if Mr. or Mrs. Lewis could have made the two-hour flight to Chicago. The innuendo being that Lewis could have flown to Chicago, planted the poisoned capsules, and then returned to New York City. “That is one of the options,” Fahner replied. “Obviously, if they were there [in New York City] the whole time, they could not have been here [in Chicago]. But they have been seen at least in some reports to have moved around,” he said. “That’s why it’s important to find out which [Lewis-sightings] are real and which are imagined or fictitious.”

The “Lewis sightings” outside New York City, as Fahner must certainly have known, had all turned out to be bogus. Nevertheless, Fahner carried out his speculative rhetoric a bit further. “We obviously have not confirmed that they have been there - in New York - every minute during the time span involved here,” Fahner said. “And we will work that backward to find out.”

Fahner had now called Lewis a prime suspect, but Chicago police detectives still believed Roger Arnold was the only legitimate suspect. When the Tylenol murder conspiracy theory imploded and the investigation of Roger Arnold ended, the FBI and its little sister, the Illinois Department of Law Enforcement (IDLE), then targeted James Lewis. There was definitely a split along jurisdictional lines. Fahner, the FBI, and IDLE were on one side of that line, while rank-and-file Chicago police detectives were on the other side. Fahner denied reports that jurisdictional issues hindered the investigation, but his denial only strengthened that impression.

“I wasn’t the only one who had true jurisdiction,” Fahner said. “You don’t tell the feds what to do and they don’t like to be told what to do, Okay? And the same is true of the local police chiefs out there.” All in all, said Fahner, “It was truly a decent and very good and fine effort.”

“Everybody fought for a little place in the sun,” recalled Assistant U.S. Attorney, Jeremy Margolis. “You had literally hundreds of people working sometimes together and sometimes at odds under very difficult circumstances because nobody really knew what the heck was going on.”

Chicago Police Superintendent, Richard Brzeczek, provided a more realistic view of the discord between local cops and the FBI. “There is a general feeling of antagonism among local law enforcement against the FBI,” said Brzeczek. “We call them the one-way street. They want you to provide information, but refuse to divulge their own.”

The reality is that the relationship between the Chicago police and the FBI was dysfunctional. “People will withhold information, so they can be the ones who solve the case,” said Brzeczek. “They want their names up on the marquee. Some cooperation [existed] among a few chosen people, but the largesse did not extend to all participants,” he said.

In 2009, a Chicago police detective who was a member of the Tylenol task force in 1982, said, “Roger Arnold is without a doubt the real offender in this case.” He said the differing views are “likely a case of competing political venues and incompetence more than anything else.”

*****

The growing hysteria surrounding the manhunt caused Lewis to become more and more concerned about what he perceived as a witch-hunt. He was not about to turn himself in, but neither he nor LeAnn took extraordinary measures to avoid capture. Years later, Lewis reflected back on the time he and LeAnn spent in New York City. “[We] didn’t really run that much. We just moved to another hotel just a few blocks away; didn’t really hide. We were out on the streets in New York every day,” he said. “For example, the Thanksgiving Day parade, the Macy’s parade at Herald Square, there were about 400 policemen standing around waiting to get their orders about where they were going to be stationed. My wife and I walked hand and hand through all of those people at the time this big manhunt was going on. We did not hide.”

Hoping to cool down some of the negative rhetoric and explain his reason for writing the extortion letter, Lewis sent a letter to The Chicago Tribune. The letter was a public reminder of the embarrassing failure of IDLE and the FBI to locate Lewis. The Tribune published the letter’s contents in its Sunday edition on October 31st, a portion of which read: “As you have probably guessed, my wife and I have not committed the Chicago area Tylenol murders. We do not go around killing people... Contrary to reports, we are not armed, unless one means in the anatomical paraplegic sense. We shall never carry weapons no matter how bizarre the police and FBI reports. Domestically, weapons are for two quite similar types of mentalities: (1) criminals & (2) police. We are neither.”

Lewis also sent an inch-thick packet of materials relating to his wife’s former employment at the now defunct Lakeside Travel Agency in Chicago. The package contained documents intended to support Lewis’s claims regarding Frederick McCahey’s alleged shady business practices. The package also included a second letter from Lewis. “Does the FBI and the Attorney General do the sensible thing and investigate the bona fide criminal?” Lewis asked. “No . . . these well-paid lawmen have needlessly made the informant’s name a household word . . . I, too, am a victim, but so what . . . I hope the law finds whoever poisoned those capsules . . . But what are the chances of that in the hands of the FBI and Fahner’s Fumblers?”

Tyrone Fahner did not appreciate the “Fahner’s Fumblers” label coined by Lewis. This derogatory moniker was even worse than the nickname that local cops had given Fahner – “Tylenol Ty.” Fahner reacted to Lewis’s letters by issuing a plea on Saturday, October 30th, encouraging Lewis to surrender. “I would like to send a message to Mr. Lewis,” said Fahner. “We would like you to consider turning yourself in. I can understand your’ running if you are responsible, but that is all the more reason for you to turn yourself in. If you are innocent, your continued writing is pointless.”

Fahner assured Lewis that investigators would help him prove his innocence if he was in fact innocent. “In all our statements we have never said he did it,” Fahner declared. Then, in his next breath, Fahner made it apparent that he already considered Lewis a guilty man. “He says he has never killed anyone,” said Fahner. “But there are people in Kansas City who feel differently than that. All this [letter] demonstrates is [that] Lewis is an unusual person who writes a lot,” chided Fahner.

*****

On December 13, 1982, Librarian Donald Alexis, working at the New York Public Library annex at 40th Street and Fifth Avenue, spotted a familiar-looking man walk by the librarian’s fourth-floor reference desk. “I just glanced up at him,” Alexis said, “and in a flash, something seemed familiar.” Alexis went into the staff room and took another look at the FBI poster tacked up on the bulletin board. He then called police. “There’s a look-alike of Mr. Lewis here,” he told them.

Lewis was at a table quietly reading two reference books, Newspapers of the Southwest and Largest Corporations in America, when FBI agents surrounded him. Lewis was led away peacefully at 2 p.m., ending the 10-week manhunt. Kenneth Walton, Deputy Assistant Director at the FBI’s New York City office, told reporters that there was no evidence to link Mr. Lewis or his wife, LeAnn, directly to the seven deaths caused by cyanide-filled Extra-Strength Tylenol capsules bought in Chicago area stores.

Fahner, ignoring the statements of the authorities in charge of the Lewis manhunt in New York City, said Lewis “is high on our list of people.” Fahner said, “We have to determine whether or not he’s responsible. I hasten to make clear: He is a suspect, but we have others as well.” However, it was clear even then that Fahner had no legitimate suspects.

On October 26th, Fahner had exonerated suspects Ed Reiner and Howard Fearon Sr., and chose not to pursue a case against suspect, Roger Arnold. Fahner had zero legitimate suspects, so Lewis became the “prime suspect” by default. Maybe Fahner figured that the only way he could save face for the truly abysmal investigation he had led was by convincing the public that Lewis was responsible for the Tylenol murders.

Some reporters did question Fahner’s characterization of Lewis as a “prime suspect.” They asked Fahner how Lewis could possibly be a suspect in the Tylenol poisonings in light of statements from the FBI and New York City Police that Lewis had been in New York City since September 6, 1982. Fahner explained his apparent flight from logic by citing the “many people” who supposedly believed in Lewis’s guilt. “If he’s not guilty of the Tylenol murders, as many people believe that he is,” said Fahner, “he can absolve himself by accounting for his whereabouts. He can prove his own innocence.”

If Fahner could be taken for his word, it appeared that he was actually going to take an honest look at the facts. Sadly, the word of a lawyer-lawman, well versed in the ways of the shadow legal system, is not worth much. Fahner had dared Lewis to “prove his own innocence” by accounting for his whereabouts, but Lewis had already done that.

Records at the Hotel Rutledge showed that Lewis had stayed there from September 6 through October 16, 1982. Kenneth Walton, the deputy assistant director of the FBI office in New York City, said the Lewises had been staying in Room 200 and the FBI had found their fingerprints in that room. James and LeAnn were seen leaving Hotel Rutledge every morning at about 7:30 a.m. and returning after 11:00 p.m. every night during their entire stay at the hotel. Walton said LeAnn had reported to work every day between September 20th and October 14th and that she usually met James at lunchtime and after work. LeAnn’s co-workers saw Jim every day when he met her for lunch, and at the end of the work day. Walton said the evidence showed that Lewis was in New York City from September 6th until his arrest on December 13th. The New York City police agreed. Authorities checked all available bus, train, and airline records and found no evidence that Jim or LeAnn had ever left New York City during that period. To anyone interested in the truth, Lewis had already proven that he had been in New York City from September 6, 1982, to the day of his arrest on December 13, 1982.

Lewis was arraigned in Federal Court in Manhattan before United States Magistrate, Ruth V. Washington, on charges of extortion and unlawful flight. His bail was set at $5-million, and he was held in the Metropolitan Correctional Center, a federal facility in downtown Manhattan, until December 27, 1982, when he was transferred by “special security measures” to Chicago.

Before facing charges of extortion in the Tylenol case, Lewis was tried on charges of credit card fraud in the U.S. District Court in Kansas City, Missouri. Police had investigated Lewis and searched his Kansas City home in December 1981, but a grand jury did not indict him until eleven months later, after he was identified as the writer of the Tylenol extortion letter. Prosecutors said Lewis had used the mail to obtain credit cards from 13 different banks and businesses, using the name and background of his former tax client, John E. Ryan.

The key testimony in the trial came from prosecution witness, George W. Rea, a former deputy sheriff who had rented a small office in Lewis’s business. Rea testified that he and Lewis together had committed the credit card fraud scheme. Rea testified that he needed the money because his real estate appraisal work had dried up. Assistant U.S. Attorney, Robert Larsen, who prosecuted the case, had granted Rea immunity from all charges in exchange for his testimony against Lewis.

Lewis did not testify, but he has always maintained that Rea alone had carried out the credit card fraud scheme. Lewis’s only witness, Kansas City investigator, Gary Compton, told the court that the handwriting on the credit-card applications belonged to Rea – not Lewis. In his closing argument, Willard B. Bunch, one of Lewis’s court-appointed attorneys, called Rea “a master conman who is trying to send another man to jail for what he did.” Bunch said there was no evidence that Lewis actually mailed the credit card applications, a necessary element of the alleged offense. “Mr. Rea cut a deal so he won’t be prosecuted. He should have been a defendant, not a witness,” said Bunch. Lewis was convicted on May 26, 1983, of six federal counts of credit-card fraud, and later sentenced to a 10-year prison term.

Lewis’s trial for attempted extortion began on October 21, 1983, in the U.S. District Court in the Northern District of Illinois. It lasted five days. As the trial came to a close, Assistant U.S. Attorney, Jeremy Margolis, called Lewis a “diabolical” schemer who preyed on fear and grief and “turned the world on its ear” by writing the Tylenol letter. “All that matters in this case is when he wrote the letter, he recognized... he intended Johnson & Johnson would part with $1 million.” It is improbable that Margolis really believed that J&J would wire money to a closed account, or that Lewis could have gained access to that account, which had been in another man’s name.

U.S. Attorney Dan Webb provided the final monologue in the Justice Department’s closing argument against Lewis. Rather than summarize the mundane facts about the extortion letter, Webb chastised Lewis for not turning himself in. “When Mr. Lewis found out that he had a warrant out for his arrest for attempted extortion...what did he do? He went underground.... He changed his name, they changed their jobs, they did everything they could to avoid detection at that point in time,” declared Webb.

Webb continued his closing argument, seemingly far less concerned about convicting Lewis for attempted extortion than convincing the jury that Lewis was the Tylenol killer: “Mr. Monico said that it is because he [Lewis] read the newspaper that people were speculating that he might have done the Tylenol murders. By the way, he confesses being the murderer in the letter. I mean, is that our fault that he, in order to play upon a tragedy, confessed to the murder, so somebody said, ‘Maybe he did it,’ since people who confess to things sometimes do it. But think about it.... Why would you do what he did unless you had guilt on your mind?”

Webb closed his oration by declaring, “The man who wrote that letter was a premeditated manipulator of the fear of Johnson & Johnson. And the man who wrote that letter is an evil and depraved opportunist who was trying to turn a tragedy to his own benefit. That man was mean, he was vicious - That man, who was insensitive to human suffering - That man, who was a premeditated manipulator of fear - That man, who was an evil and depraved opportunist for his own benefit, that man is you, James Lewis.”

Lewis’s defense attorney, Michael Monico, said the government had failed to prove that Lewis intended to receive the money, saying Lewis only wanted to embarrass his wife’s former employer because he had failed to meet his last payroll. Monico argued that because the account had been closed and Lewis had no access to it, he could not have intended to obtain the money.

“This case is bizarre, but it is simple,” Monico said in his closing argument - an hour-long speech that was itself, truly bizarre in its denigration of Lewis. Monico said Lewis was guilty of an “immense overreaction” to his anger at McCahey - and that Lewis was a ‘bizarre” person who often overreacts - but is not guilty of attempted extortion. “The government mischarged this man in their rush to judgment,” Monico said. “You may convict him of being stupid and foolish and reckless, but you cannot convict him of this crime.” The letter “may be a crime, but it’s not the crime he is charged with,” said Monico. Then, standing inches away from Lewis, Monico stared at him and shouted, “You wrote a letter and because of it you were hunted like a dog.”

A federal jury of eight men and four women found Lewis guilty of attempted extortion after deliberating for three hours on October 28, 1983. Eight months later, at his sentencing hearing, Lewis acted as his own attorney. He addressed U.S. District Chief Judge, Frank J. McGarr, for almost an hour. Lewis ridiculed federal prosecutors and police for failing to solve the Tylenol murders. “The FBI and the Department of Justice simply blew it,” he said. “They desperately crave a scapegoat, and they’ve got me.”

Lewis often turned to confront U.S. Attorney Dan Webb, who sat a few feet from him. At one point Lewis said, “I do not lie, I do not cheat, and I do not steal.” Then, motioning toward Webb, he added, “I will leave that to other people.”

Judge McGarr quickly jumped in, stating, “In the face of two felony convictions, that’s a pretty hollow declaration.”

Lewis shot back, “Under the circumstances, with the pretrial publicity, you can get a conviction for anything. The government fabricated not only this case, but the two cases in Kansas City.”

Before sentencing Lewis, Judge McGarr assured him, “The emotional associations that go with the word Tylenol in connection with this case cannot be allowed to rub off on Mr. Lewis since there is no shred of evidence that he is guilty of the Tylenol murders and no suggestion along those lines should be allowed to influence my judgment in this matter.” McGarr then sentenced Lewis, who was 37 years old at the time, to ten years in prison for attempted extortion. The sentence would begin after Lewis completed his 10-year sentence for the prior fraud conviction in Missouri.

Even though the sentences ran consecutively, the maximum time Lewis could possibly have served was slightly less than 13 years. He would be eligible for parole in 1989, after serving 80 months - about 6 ½ years. He would have to serve 2 ½ years for the credit card fraud conviction, and 4 years for the attempted extortion conviction.

During his incarceration, Lewis was a model prisoner. He garnered exemplary ratings as a GED tutor; he painted murals with sports themes; he taught himself Latin and improved his French and Spanish skills by reading classics in the original languages; and he received no misconduct reports. The Parole Commission recognized Lewis’s good behavior by informing him on January 6, 1988 that it would grant parole after he had served his minimum sentence of 80 months. On March 9, 1989, Victor Reyes, the regional commissioner for the South Central Region in Texas, affirmed Lewis’s release date of August 27, 1989, by signing a “no change” notice. Big Jim’s boys, however, had other plans for Lewis.

When Jeremy Margolis and FBI Special Agent Roy Lane had flown to Cambridge, Massachusetts on February 10, 1986 to question LeAnn Lewis, Margolis had told her that if she didn’t answer his questions, her husband would stay in prison for a long time. Margolis was now going to make good on that promise.

On the same day Reyes affirmed the order granting Lewis’s parole, Jeremy Margolis sent a letter to Parole Commission Chairman, Benjamin Baer, in Maryland, urging an extension of Lewis’s parole date. Three weeks earlier, another one of Big Jim’s boy’s, U.S. Attorney Anton Valukas, had sent a letter to Baer urging the parole board to keep Lewis in prison for the maximum allowable time. Baer forwarded the letters from Margolis and Valukas to Reyes. Based on these letters, Reyes recommended that the National Parole Commissioners reopen Lewis’s case. The Commission said that it was asked to extend Lewis’s parole on the basis that he was the Tylenol murderer. But Lewis had never been charged with the Tylenol murders, and no evidence implicating him in the murders had ever been presented in a court of law or anywhere else.

What a jury could not do, and was not asked to do, was done easily within the United States shadow legal system. The U.S. Parole Commission “convicted” Lewis for the Tylenol murders in a kangaroo court.

The Commission, following a hearing on August 21, 1989, ruled that Lewis was indeed the Tylenol murderer, and accordingly, raised his “offense severity level” from Category 6 (for extortion) to Category 8 (for murder). Placing Lewis in Category 8 permitted the Commission to deny him parole. Six days before his scheduled release from prison, the Commission revoked Lewis’s parole, forcing him to serve the maximum sentence of nearly 13 years.

Lewis appealed the Parole Commission’s decision in the Tenth Circuit of the U.S. Court of Appeals. The Federal Appeals Court determined that to uphold the Parole Commission’s “murder conviction” of Lewis, all of the following questions had to be answered in the affirmative:

1. Can evidence that was known by investigative agencies but not by the United States Parole Commission (“the Commission”) at the time of a prisoner’s initial parole determination be considered “new information” sufficient for the Commission to reopen the prisoner’s case under 28 C.F.R. § 2.28(f)?

2. Once a prisoner’s case is reopened, can the Commission consider information in a sentencing transcript where

A. The transcript, though previously unseen by the Commission, was not the basis for reopening;

B. The information pertains to a crime for which the prisoner was not charged, but which was related to the crime for which he was convicted; and

C. Did the district judge decline to consider the information at sentencing?

3. Was the district judge’s statement during sentencing that there was not a “shred of evidence” that the Petitioner-Appellant (Lewis) committed the Tylenol murders merely a reiteration of his assurance that he was not going to consider any evidence of that crime since Lewis was not so charged, rather than a finding on the merits of such an allegation pursuant to Federal Rule of Criminal Procedure 32(c)(3)(D)(i)?

4. Did the Commission act within its discretion in determining that Lewis committed murder by lacing Tylenol capsules with cyanide?

“We answer all of these questions in the affirmative,” the Appeals Court declared, thus affirming the kangaroo court’s prior verdict.

Lewis was released from the Federal Corrections Institution in El Reno, Oklahoma on Friday, October 13, 1995. A long-time friend and childhood sweetheart of Lewis’s, who was living in Dallas at the time, met him at the airport in Oklahoma City and joined him on a flight to Boston. Lewis arrived at Boston’s Logan International Airport that evening and reunited with LeAnn, the love of his life. The next night James and LeAnn went to the Boston opera for a pleasant evening of culture and anonymity. For nearly a decade, they led a quiet, relatively normal life. Then, in the summer of 2004, Lewis came under fire again.

On a hot August afternoon in 2004, Police knocked on the door at Lewis’s Cambridge, Massachusetts apartment. Lewis opened the door and was immediately tackled and handcuffed. The police told Lewis that he had held his business partner hostage and drugged and raped her. Police found no bruises, cuts, or contusions on Lewis. When the alleged victim was examined, she too had no bruises, cuts, or contusions. The woman’s father had visited her apartment earlier that day and found that she was sick. The woman, an immigrant from China who spoke marginal English, had vomited all over the apartment. Her father thought something was not right, so he called police.

When the police arrived, they had a hard time communicating with the woman because she spoke only broken English. She did the best she could to answer their questions, though she was feeling very ill and was also very intimidated by the police officers. The police did glean one piece of information that caught their attention. Her business partner was James Lewis, whom they quickly connected to the Tylenol murders – or, maybe they had already made that connection before they talked to her.

The Middlesex County prosecutor charged Lewis with rape, kidnapping, and other offenses for the alleged attack. The County judge set Lewis’s bail at $1 million. Lewis could obviously not raise anywhere near that much money, so for three years he sat in a jail cell awaiting trial. On the day his trial was to begin, Lewis was escorted to the courtroom. Prosecutors approached the bench and had a short conversation with the judge, after which Lewis learned that they had dismissed all of the charges against him. The reason, according to the office of Middlesex District Attorney, Gerard “Gerry” Leone, was that the alleged victim refused to testify. This came as no surprise to prosecutors. They had known for three years that the woman was not going to testify against Lewis. They had also known all along that there was no physical evidence to indicate that a crime had even been committed.

In an August 2004 email, Middlesex County District Attorney, Lee Hettinger, had pressured the crime lab to expedite the test results from the rape kit and the toxicology screen. Hettinger had no actual evidence that there had even been a crime, but in his email to Gwen Pino, the forensic expert handling the case, he suggested otherwise. “As you may recall, this is the case where the suspect was involved in the tylenol [sic] tampering cases of 1982-1983. He recently drugged, kidnapped, and possibly raped our victim,” Hettinger wrote.

The tests were expedited, as Hettinger had requested, but the results were not what he wanted. There was no evidence of rape and no evidence that the woman had been drugged. Confirming the results of the lab findings was the alleged victim herself. She had told investigators repeatedly that there was no rape – there was no assault. Prosecutors had no forensic evidence and no witnesses. They didn’t even have a victim.

Michael Regal, a Cambridge police detective, had testified to a Grand Jury on September 9, 2004, that he had told District Attorney, Lee Hettinger, that the alleged victim told him, “No, there was no sex.” But the charges were not dropped, so Lewis stayed in prison until July 2007.

Meredith Lerner, a spokesperson for Middlesex County District Attorney, Gerry Leone, said the District Attorney would not answer any questions about the Lewis case beyond faxing the nolleprosequi petition informing the judge that the Commonwealth could not prove its case without the testimony of the complaining witness, signed by Hettinger on behalf of Leone. Lewis was back on the outside, but he soon learned that he had jumped out of the frying pan into the fire.

39

________

A Second Look

Jim Lewis threw on a jacket, grabbed his laptop computer, and walked out of his small apartment in Cambridge, Massachusetts, into the crisp early morning air on February 4, 2009. He could almost smell the freshly ground coffee as he neared his destination, the local Starbucks, when he was surrounded by seven FBI agents. One of the agents patted Lewis down and then four of the agents walked with Lewis into the Starbucks, ordered coffee, and found a comfortable booth. They were going to be there for a while. Meanwhile, a few blocks away, fifteen agents from the FBI and the State of Illinois served LeAnn with a search warrant and soon began hauling boxes of confiscated items out of the Lewises’ apartment. The 1982 Tylenol murders investigation had just been officially reactivated.

The FBI did not interrogate Lewis or read him his Miranda rights. They did, however, stay with him at the Starbucks from 8:30 a.m. to 7:20 p.m. and convinced him not to make any calls to his wife while the FBI searched his apartment and two storage facilities. They seized two iMac Apple computers, several pairs of blue jeans, t-shirts, running shoes, several books, and boxes of “privileged” legal documents. None of the seized items had even existed in 1982. There seemed to be no legal rationale for this search.

As officials stretched out the search of the Lewises’ 960-square-foot Cambridge apartment from early morning to well past sundown, the FBI released the following official statement regarding the reactivated investigation:

The FBI, in cooperation with the Illinois State Police [aka Illinois Department of Law Enforcement (IDLE)] and several local police departments, is conducting a complete review of all evidence developed in connection with the 1982 Tylenol murders. This review was prompted, in part, by the recent 25th anniversary of this crime and the resulting publicity. Further, given the many recent advances in forensic technology, it was only natural that a second look be taken at the case and recovered evidence.

In addition, the recent [25th] anniversary prompted many people to call law enforcement agencies with tips relating to this crime. All of these tips have been or will be thoroughly investigated in an effort to solve this crime and bring some measure of closure to the families of the victims.

In the fall of 2008, several months prior to this official reactivation, authorities had secretly formed a new Tylenol task force of investigators from the FBI, the State’s Attorney Offices in Cook and DuPage Counties, and Chicago and suburban police. Grand juries were convened in Cook and DuPage Counties to review evidence from the Tylenol murders. Within five months of convening the grand juries, a judge in the 18th Circuit Court in DuPage County granted the request of State’s Attorney Joe Birkett for a warrant to search Lewis’s home. Officials have never revealed the evidence they used to get a judge to grant that search warrant.

In June 2009, four months after searching Lewis’s apartment, FBI agents showed up on Lewis’s doorstep once again. This time the agents returned the computers, books, clothes, and other items they had confiscated in February. They even invited Lewis to join them for lunch. Lewis politely declined.

The press did not report on the return of Lewis’s items or the stupidity of confiscating items that did not even exist in 1982. The reactivated investigation was a complete bust, or so it appeared. It seemed that the only tangible outcome of the reactivated Tylenol murders investigation was that it kept the details of the case out of the public domain.

*****

The Freedom of Information Act (FOIA), enacted in 1966, allows for full or partial disclosure of previously unreleased information and documents controlled by the United States government.  However, the act includes exemptions relating to information where disclosure would constitute a breach of privacy, relating to investigatory records where the information would harm the proceedings, and relating to the agency’s participation in legal proceedings. Between 1995 and 1999, President Clinton issued executive directives requiring the release of previously classified national security documents more than 25 years old and of historical interest.

In January 2009, the Obama Administration made it harder for the FBI to ignore FOIA requests for documents related to the Tylenol murders. A few days after taking office, President Obama issued executive orders and memoranda that he said were designed to improve government ethics and make the government more open. During a press conference on January 21, 2009, President Obama said, “I will also hold myself as President to a new standard of openness. Let me say it as simply as I can: Transparency and the rule of law will be the touchstones of this Presidency.”

President Obama’s memorandum to the heads of executive departments and agencies stated in part:

Government should be transparent. Transparency promotes accountability and provides information for citizens about what their Government is doing. Information maintained by the Federal Government is a national asset. My Administration will take appropriate action, consistent with law and policy, to disclose information rapidly in forms that the public can readily find and use.

Two weeks after President Obama declared, “Transparency and the rule of law will be the touchstones of this presidency,” the Tylenol murders investigation was reactivated, and it became readily apparent that the same old rules of secrecy still applied.

The Tylenol murders investigation, though never really closed, was essentially inactive by 1984. By 2009, documents from the FBI and IDLE investigation of the Tylenol murders should have been declassified and made available to the public under the FOIA, which requires the declassification of previously classified documents more than 25 years old and of historical interest. Nevertheless, in July 2011 the FBI denied an FOIA request for documents related to the Tylenol murders investigation. Even in 2007, as the 25th anniversary of the Tylenol murders approached, the FBI, as will become apparent shortly, had already taken action to ensure that it would not have to declassify documents from the Tylenol murders case.

Officials from the FBI and the State’s Attorney Offices in DuPage and Cook Counties formed a new Tylenol task force in the fall of 2008 to take a new look at the Tylenol case. The secret formation of that task force, however, did not actually mark the birth of the renewed Tylenol murders investigation. An even more secret investigation, involving a rather novel approach, had been under way since two months before the 25th anniversary of the 1982 Tylenol murders.

40

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A Novel Approach

James Lewis had walked out of the Middlesex County jail in July 2007 after prosecutors dropped their trumped-up charges against him of kidnapping and rape. During his incarceration, Lewis had begun writing a novel under the working title, The Doctor’s Dilemma. He published the novel in January 2010, changing the title to POISON! The Doctor’s Dilemma. Lewis calls the novel a psychological fantasy that is both twisted and surreal. The story’s hero is the world famous Doctor, Charles “Chuck” Rivers, who battles the supreme evil doer, Agua Naranja.

Lewis had been out of jail for only a few days when he received a call from former Chicago FBI Special Agent, Roy J. Lane. Lane had retired from the FBI in 1996 and then took a job at U.S. Robotics in Schaumburg, Illinois. Lane had been a member of the team of FBI agents and federal prosecutors from the U.S. Attorney’s Office in Chicago that had handled the extortion case against Lewis. Lane and Jeremy Margolis had gone to Cambridge, Massachusetts to question LeAnn Lewis in October 1985, and again on February 10, 1986 when they learned about the cyanide-laced Tylenol poisoning death of Diane Elsroth in New York. When Lane called Lewis in 2007; it was to propose a collaborative project.

Lane told Lewis that he was now running a private security business, and was working for several nuclear power generation facilities. He was also working on a project with Sherry Nichols, a freelance journalist who was writing a book about the Tylenol murders, and he wanted to interview Lewis. Nichols would cover all of Lewis’s expenses to fly him and LeAnn out to New York City and Chicago to be interviewed by Nichols and Lane. Lewis agreed to give them several interviews. Nichols later paid Lewis a few thousand dollars for his troubles. In addition, Lane offered to provide his expertise as a 25-year veteran of the FBI to assist Lewis in writing POISON! The Doctor’s Dilemma. On a website for the book, Lewis thanked Lane for his help:

Without Roy Lane, this book could never have been written. Formerly a supervisor of a multi-jurisdictional, FBI-Directed Task Force investigating the cyanide-laced Tylenol capsules which killed seven victims in Chicago in 1982, Roy has been very insightful, making many useful suggestions for the Doctor’s Dilemma and in guiding me, and in helping me edit this fictional work…

On several occasions Nichols paid airfare, hotel, and other travel expenses to fly Jim and LeAnn to Chicago and New York City. She also paid for Jim’s one-week road trip through Missouri, where he did research for his novel. One of the computers confiscated by the FBI agents who searched Lewis’s apartment in February 2009 was purchased with money Lewis received from Nichols. Lewis wrote a brief comment on his website, praising Nichols:

Sherry’s experience as a writer, her encouragement, and her substantial financial support during some of my darkest hours energized me when I felt like giving up.

In 2008, Roy and Sherry took Jim to the Chicago location where Paula Prince’s high-rise apartment building, demolished years earlier, once stood. Then they walked to the pharmacy where Prince had purchased her bottle of poisoned Tylenol.  Roy and Jim walked to the back of the pharmacy to the shelves where the Tylenol was currently displayed. “There,” said Lewis, “standing side-by-side in total silence we stared at the displayed merchandise.”

Roy and Sherry also flew LeAnn and Jim on separate occasions to New York City. On separate days, they took Jim and LeAnn to the Manhattan buildings where the Lewises had lived from September 6 to December 13, 1982. They visited the Western Union office where LeAnn’s father had wired them rent money for a room at Hotel 17. They visited the New York City Public Library annex where Jim was arrested, the building where LeAnn had worked, and the place where Jim met LeAnn each evening from September 20th to October 14th to walk her home from work, an event witnessed each and every day by at least a dozen of LeAnn’s co-workers.

Lane and Nichols conducted many interviews with Lewis. They also exchanged dozens of emails discussing travel plans, politics, jurisprudence, the Tylenol extortion letter, and various theories about the Tylenol killer’s possible motive and modus operandi. They also communicated by phone, and from time-to-time they all got together for dinner. Nichols’s book about the Tylenol murders had been in editing for a couple of months when agents from the FBI and the Illinois State Police searched Lewis’s apartment on February 4, 2009. That search marked the end of the collaboration between Nichols, Lane, and Lewis.

As it turned out, Sherry Nichols – if that is her real name - was not really writing a book about the Tylenol murders. “Sherry Nichols” was evidently an undercover operative working with “retired” FBI agent, Roy Lane, in a futile attempt to dig up dirt on Lewis. The business address Nichols had given Lewis was for a post office box at Mail Plus in Winfield, Illinois, located one and a half miles from the Central DuPage Hospital where Lynn Reiner was taken after swallowing a cyanide-laced Tylenol capsule on September 29, 1982. What Sherry Nichols saw in James Lewis was not a bestselling expose’ about the Tylenol murders – instead, she apparently saw the fame that would come from pinning those murders on Lewis. From August 2007 through the end of 2008, Nichols and Lane taped 80 hours of interviews with Lewis, hoping to get some kind of incriminating statement that prosecutors could use against him.

It is noteworthy that Lane and Nichols began their sting operation just two months before the 25th anniversary of the Tylenol murders. When the Tylenol case was publicly reactivated, the FBI said that tips generated by the publicity surrounding the 25th anniversary, along with advances in DNA technology, had led to the reactivation of the Tylenol case. In reality, those “tips” were nothing more than bits of email conversation regarding the character, Dr. Charles “Chuck” Rivers, the hero of Lewis’s fictional novel, Poison! The Doctor’s Dilemma.

Lane’s emails to Lewis paint a picture of the true objective of his “collaboration” with Lewis. Those emails indicate that Lane had attempted to manipulate Lewis into writing a novel that could then  be used by prosecutors at the State’s Attorney Office in DuPage County to get an indictment against Lewis for the Tylenol murders. This strategy, as the case of John Orr reveals, was not a new one for the FBI.

In 1991, John Orr, a former captain and fire investigator for the Glendale Fire Department in southern California, was arrested and charged with starting several fires in California. The basis for the case against Orr was the fictional novel he had written, Points of Origin. “The serial arsonist [in the book] is the defendant himself,” Assistant U.S. Attorney, Stefan Stein, argued during one hearing.

Orr was convicted in 1992 on three counts of arson. He then appealed his conviction, arguing to the Ninth Circuit Court of Appeals that the district court abused its discretion by denying his motion to exclude the Points of Origin manuscript. The appellate court rejected Orr’s appeal, but it admitted, “The key to the government’s case was the manuscript of Orr’s unpublished book, Points of Origin.”

Orr pled guilty to three additional counts of arson in a plea deal in 1992 that probably would have allowed him to be paroled in 2002. Then, in 1998, Orr was convicted of arson and four counts of first-degree murder for a 1984 hardware store fire. He was sentenced to life in prison with no chance of parole. Federal ATF Agent, Mike Matassa, said that between October 1984 and March 1991 Orr set nearly 2,000 fires – a preposterously high number that would have required Orr to start six fires per week throughout that six and a half year period.

Despite pleading guilty to three arson-counts, Orr has always maintained that he did not start any of the fires. He says he was betrayed by the justice system. Orr, still professing his innocence in 1993, said, “I used the fires I studied as material for my book, not the other way around. Points of Origin is a work of fiction.”

It appears that the FBI had hoped to use a work of fiction, POISON! The Doctor’s Dilemma, as the centerpiece of a fabricated case against James Lewis. When authorities searched Lewis’s apartment on February 4, 2009, and confiscated his computers and writings, they were not looking for clues from the 1982 Tylenol murders; rather, they were looking for a work of fiction that prosecutors could present to a jury as a confession to the Tylenol murders. An unidentified source told the Chicago Tribune that authorities were looking into whether Lewis may have written anything incriminating stored on his computer.

Joe Birkett, the state’s attorney in DuPage County who had gotten the warrant to search Lewis’s home, evidently hoped to find a confession to some heinous crime by the fictional character, Chuck Rivers, in Lewis’s novel. Prosecutors hoped to pawn off any such confession as if it were really the confession of an actual living person, namely James Lewis, to a similarly heinous crime – the Tylenol murders.

Lane encouraged Lewis to write a biography for the character of Chuck Rivers that was amazingly similar to the biography that the press had already written for James Lewis. It also contained elements of the profile that FBI Profiler John Douglas had created in 1982 for the Tylenol killer.

Lane sent an email to Lewis on December 9, 2007, in which he described elements of a storyline he suggested Lewis should incorporate into his novel. Lane’s email included the factors that would lead Chuck Rivers to confess to some horrific crime involving the deaths of 12 people in Chicago:

As promised, here are my notes that I used in our breakfast discussion.

Big business represents the villain or evil

Morally repugnant act, but later in time when taken in full context, is defensible

Chuck’s bifurcated character, self and conscience. Violently at war with each other, yet still best friends

Chuck’s full revelation would be futile and suicidal or would it be liberating and cathartic?

Would Chuck confess to someone worthy?

Paul Snowden, the solid character, is the social and economic opposite of Chuck

Chuck and Paul working together

Sexual tension between man and woman

Love father/son and mother/son

Max Snyder is credible, fair guy, tolerates moonshiners and can be used for letting rumors into the community.

12 died in Chicago so more could be saved and their lives improved

Hope this is helpful, Roy

As Lane and Nichols carried out their con game on Lewis, they also tried to gain his trust. To that end, Lane sent an email to Lewis and Nichols on January 26, 2008, about “building trust” in their relationship. In that email, Lane asked Nichols about the possibility of including Lewis in their confidential conversations about her phantom book:

Sherry,

I reviewed your below message, and believe I understand the issue. I hesitated to respond yesterday because I wanted to reflect overnight on my initial thought on how this could be addressed. The thought remains the same today and is as follows. Dare we include Jim with us on the issue and solution? I think so and have taken the liberty of sending a copy of this email to him. This will also be an excellent opportunity to grade our relationship with him. Is it maturing, evolving, building trust, etc? We’ll see. Enjoy your weekend.

Lane then addressed Lewis regarding the input Lewis had given to Nichols about his reason for writing the extortion letter:

…As you see from Sherry’s email below, she is receiving some push back from her publisher regarding her paragraphs of you in Chapter 1. Just to further frame the issue and review what Sherry read in our last meeting: “…Lewis was a disgruntled opportunist that redirected the FBI investigative energy away from the truth. His motive was to humiliate the Continental Bank and instead, spent 13 years in jail for his failed extortion attempt. A big price to pay ....”

You objected to using the word “humiliate” as you stated it was inaccurate. You suggested replacing humiliate with “to expose the tenuous financial condition of the Continental Bank...” The publisher now asks, what evidence is there that proves your motive was in identifying a potential, serious, and critical issue rather than your motive being one of either extortion, embarrassment, or humiliation?

The request: If you have any other anecdotal evidence that would support/corroborate your motive already not discussed, please let us know. This could be anything from personal notes, drawings, letters to newspapers/government entities, protest meetings attended, or statements you may have made to others about the situation at Continental.

In his comments to Nichols - Lane indicated that Lewis had not yet earned their trust. However, Lane made it clear that Lewis could earn that trust if he acted in a way that pleased them. Lane then gave Lewis the opportunity to do just that by producing documents that might be useful to Lane and Nichols in building a sham case against Lewis.

On December 31, 2007, Lane replied to an email from Lewis about the development of the fictional biography of Chuck Rivers:

…After I read it and had time to think about it, I would suggest that we need to develop more internal conflict within Chuck. Maybe when Chuck was growing up, he did not have much of a social life. He never met a girl who matched or challenged his intellect and thus did not date much. While at Washington University, he met that person, fell in love, and they married shortly after. Over the next several years they had a child. Chuck was a devoted husband and doted on his only child. Chuck became world renown in his efforts to expose environmental hazards/corrupt business practices and in so doing lost the balance between his professional and personal life. When Chuck came home after an extended trip, his wife, who still loved him, told Chuck that she could not take his absences, both physical and mental, any longer and was leaving him. She then took their child, moved away, and over time married again. Chuck struggled to know that the woman he loved had another husband and that his daughter had another father. We can further vet this idea, but I think it sets up well for us to do something with Chuck’s conscience and with his interactions with Jogger [Chuck’s colleague and love interest].

The story that Lane created for Chuck Rivers would have made it very easy to plug in elements of James Lewis’s real life. Similar to Lane’s suggested storyline; Jim and LeAnn had fallen in love while at college, and married shortly after. They had one child. Lewis was a devoted husband, and he doted on his only child. Lewis was away for an extended period of time when he was in prison. These facets of Lewis’s life were all included in the biography that Lane had written for Chuck Rivers.

Lane sent an email to Lewis on March 1, 2008, in which he proposed a storyline that included Chuck’s reconciliation with his family, following his confession to a terrible crime that in Lane’s version of Lewis’s novel had led to the death of “10 adults and 2 children in Chicago alone.” Lane suggested that when taken in context of Chuck’s motivation for carrying out the crime that caused these deaths, his actions would be widely considered justifiable. Lane began the “reconciliation” email by proposing that Chuck Rivers should reunite with his family.

Chuck’s reconciliation: Chuck has a reconciliation with his conscience, estranged wife, and child, Roy, Alice, and the friends who now respect him in Carl Junction [Lewis’s hometown]. Although emotionally attached to her, Chuck Rivers loses Jogger when he reconciles with his wife. (As an aside, I sense we can do more with the relationship between Chuck and his father. Maybe there was physical/mental neglect or abuse, and Roy committed this crime to benefit Chuck after experiencing pains of guilt.)

Lane had apparently wanted Lewis to write a dysfunctional relationship between Chuck and his father that the public might speculate was possibly akin to Lewis’s relationship with his own father or stepfather. Lane’s “reconciliation” email continued with a description of Chuck’s “act of reconciliation,” which included his confession to a terrible secret crime:

Act of reconciliation: Chuck confesses to the secret in an open letter to respected journalists and academia. He is contrite in that he acknowledges his and his father’s wrongdoing and is willing to accept the consequences. Chuck is certainly distraught at this point. He next volunteers (penance) that 25% of his annual income will be used to establish scholarships in environmental studies at MIT. He offers to teach one environmental course per year without compensation. Lastly, he affirms that he will not participate in this type of wrongdoing again.

In the novel that Lewis actually wrote, Chuck’s father was an accessory to a terrible crime that Chuck only learned about decades later. The novel that Lane wanted Lewis to write would have made Chuck an active participant in that terrible crime. When the FBI searched Lewis’s home in 2009, they had evidently hoped to find an alternate storyline for Poison! The Doctor’s Dilemma that included a guilty Chuck Rivers.

The “penance” that Lane suggested Chuck Rivers should accept for committing some heinous crime was absurdly mild. Chuck would agree to pay 25 percent of his annual income to environmental studies at MIT and voluntarily teach one course per year at MIT, an institution for which Lewis, as Lane knew, has great respect. Lane suggested that the terrible crime in Lewis’s novel should be characterized as a crime committed against “big business” which “represents the villain or evil.” He further suggested that the “morally repugnant act” he wanted Lewis to attribute to Chuck Rivers, when “taken in full context” of the greater good, “is defensible.” The greater good was that this crime would serve to put an end to big business activities, which if not stopped, would cause an irreversible environmental disaster. The disaster in Lewis’s novel occurred in Missouri, but Lane wanted Lewis to place that disaster in Chicago.

According to the logic presented by Lane, the crime he wanted to attribute to Chuck Rivers - the murders of 12 people in Chicago - was a defensible act against an evil corporation, carried out for the greater good of all humanity.  Translating that line of thought to the Tylenol murders: The “morally repugnant act” of poisoning Tylenol capsules, a crime against the “evil” “big business,” i.e. Johnson & Johnson, when “taken in its full context” was “defensible.” At least that was apparently the message Lane wanted to convey to Lewis.

In Lane’s scenario, journalists and scholars would see the person who confessed to the Tylenol murders as an almost altruistic hero who they would accept as a respected member of the academic community. Society would vindicate this person upon learning that the Tylenol murders had somehow put an end to some unidentified greater evil committed by big business.

Lane completed his “act of reconciliation” scenario by describing the happy “results” of a confession by Chuck Rivers. This confession, if it had appeared in Lewis’s novel, would almost certainly have been promoted and argued by Lane and prosecutors at the State’s Attorney Office in DuPage County as a confession by Lewis to one of the most horrendous crimes of the past century.

The happy-ending Lane envisioned for Lewis’s novel went as follows:

Results: Chuck is forgiven and embraced for his admissions/courage not only by academia, but also by the citizens of our country/world who so desperately need his talents to save our environment. Might there be a popular uprising to name him environmental czar? He then reconciles with his conscience, wife and child, father and mother, and associates. The only down side to this ending is he loses Jogger. But hey, life goes on!

Lewis, to a certain extent, gave Lane and Nichols the benefit of the doubt early in their collaboration, hoping that maybe they were on the up and up. Yet he and LeAnn always assumed that Lane and Nichols were probably not the honest, trustworthy people they were trying to portray themselves as being. Lewis kept his guard up always, knowing that Lane and Nichols might twist anything he said to fit whatever their needs might be. “Without the either side ever saying so,” said Lewis, “both sides knew that I was the prey, and both sides always knew I was being stalked like a defenseless deer, and both sides always knew Roy and Sherry had complete immunity.”

Roy and Sherry took Jim and LeAnn to dinner on several occasions. They all acted as if they were friends having a nice casual dinner. Roy would drink three or four bourbon-and-waters, and Sherry, who seldom drank, would chide him for drinking too much. Roy encouraged LeAnn and Jim to order drinks – perhaps to loosen their lips – but being teetotalers, they always declined. Lewis could have just walked away from this unholy alliance, but the collaboration was of value to him in a number of ways. Lewis’s infamy and prison record greatly hindered his employability. Nichols was helping Lewis out financially – help that he really needed at that time.

Far more important than Nichols’ financial assistance to Lewis, was the chance, albeit very slim, that she might clear his name in the book she claimed to be writing. From a pragmatic point of view, Lewis knew that if Lane and Nichols were trying to frame him for the Tylenol murders - a suspicion that grew stronger in Lewis’s mind over time - they were going to keep coming after him whether he joined their loathsome cabal or not. The old adage – ‘Keep your friends close, but your enemies closer’ – seemed applicable to Lewis’s situation.

“No matter how scared I was, and no matter how surreal the circumstances, I could not back down and disengage,” recalled Lewis. “I had to keep fighting, no matter what, and I always knew I should never show any aberrant behavior which could have been grounds for immediate arrest.”

Lewis recognized early on that Lane wanted him to develop a profile of Chuck Rivers that included aspects of the Tylenol killer’s profile that John Douglas had developed in 1982. “I had already read Douglas’s fictional profile,” said Lewis, “so I knew what personality traits the FBI wanted. I was not about to design any character in my book that would sound very much like me, nor any real person, except in trivial, whacky ways.”

Lewis invited Lane to participate in writing the novel “but he never contributed any actual text in place, only weird advice,” said Lewis. “His suggestions were always at cross purposes to what I wanted to write, so I simply ignored his input, but I always listened carefully.”

During their eighteen-month affiliation, Lane provided Lewis with an occasional snippet of information regarding his frustration over his failure to bring the Tylenol killer to justice. “He [Lane] told me on several occasions that his biggest career failure was failing to solve the Tylenol murders,” said Lewis. “He seemed like a guy who seldom failed, so his claimed Tylenol failure embarrassment seemed a reasonable burden.”

Lane also gave out a few clues about what Lewis suspected was Lane’s involvement in an ongoing investigation of the Tylenol murders. “At one point, Roy and Sherry claimed that the investigation necessitated that Roy travel to Thailand. They never told me exactly why, and I never asked,” said Lewis. “At the time, I assumed they were looking into something connected with Roger Arnold.” Arnold had purchased two one-way tickets to Thailand a few days before the Tylenol murders.

Lane also asked Lewis about India. “Somehow, Roy also got the idea I had been to India, which I hadn’t,” said Lewis. “I also knew there was absolutely no evidence of me ever being in India. No airline tickets. No contacts. No correspondence. No passport records. I simply had never been on the subcontinent.”

Lane’s interest in a possible India connection evidently stemmed from Lewis’s involvement in Aljeev International; a business venture founded and incorporated by Lewis and Viren Mehta in Missouri in 1975. Through Aljeev International, Lewis and Mehta had hoped to sell tablet-making tools to pharmaceutical factories in Third World countries. Aljeev never actually sold any tablet-making tools, and the company was a complete failure that was quickly abandoned.

Lewis goaded Lane a bit by including in his novel several scenes that took place in India.  “I did character sketches of Doctor Rivers’ activities, in India, including jogging (which I've enjoyed for decades); just to play with Roy’s imagination, just in case he was not being honest with me.” Lewis studied satellite photos and other documents so he could describe very accurately in his novel, the specific geological features for the scenes that took place in India.

Lane never went to India, but the idea of Lane, overweight and a heavy smoker, hiking through remote areas of India under the hot summer sun was more than a little amusing to Lewis. “Believe me,” said Lewis, “Roy is not the type to take a vacation in that hellish terrain. He was too fat and lazy and would have died of heat stroke. Much of that area can never be accessed by car. The barren hills and desert are virtually uninhabited. There are no motels, stores, or gas stations for several hundred miles. Roy would have had either to hike, ride a horse, or flown in a helicopter to reach the places I visually described in detail.”

The trip to Thailand; the numerous meetings with Lewis; the 80 hours of interviews - every aspect of the con game Lane and Nichols carried out against Lewis went nowhere. They did not produce anything that prosecutors could use to bring charges against Lewis. A year and a half after the Lane/Nichols/Lewis collaboration had began, it ended when agents from the FBI barged in on what Lewis thought was going to be a relaxing morning at the local Starbucks on February 4, 2009. Officials reactivated the Tylenol murders investigation in a very public way because two undercover FBI operatives had failed to dig up anything that would allow prosecutors in DuPage County to bring murder charges against Lewis.

The “new leads” that the FBI said had been generated as a result of publicity from the 25th anniversary of the Tylenol murders, were apparently the fabricated story that Nichols and Lane had tried to create for the fictional character, Chuck Rivers. When Rivers refused to confess to a Tylenol murders-like crime, officials reactivated the investigation and wrote a new chapter in their own fictional tale of the Tylenol murders.

After the Tylenol case was reactivated, Lane sent a few more emails to Lewis and then cut off all contact. On February 5, 2009, one day after authorities searched the Lewises’ apartment; Lane sent his regards to Jim and LeAnn:

I’ve been on the road, home now and traveling again tomorrow. Wow, what news! Hope you and LeAnn are holding up well. It must be a media circus out there.

My thoughts are for your well-being.

Take care, Roy

On February 9, 2009, Lane replied to an email Lewis had sent one month earlier:

Sorry for the delay, but I have been on the road for the past few days. The below link to DD [Doctor’s Dilemma] is all I have available at this time.

Hope the media circus has calmed and you can go about your business. Amazing all the hoopla over something that happened 26 years ago. They must not be familiar with Confucius when he said, “Things that are done, it is needless to speak about....things that are past, it is needless to blame.”

Best to you and LeAnn.

Take care, Roy

Retired FBI agent, Grey Steed, who had worked on the Lewis extortion probe in 1982 and 1983, said investigators had contacted him to discuss the Tylenol case prior to its reactivation. “It wouldn’t surprise me if they weren’t looking for something in the way of memoirs or some type of journal he [Lewis] was keeping,” said Steed. With this public statement, Steed had primed the public to accept as plausible, the absurd idea that the fictional writings of James Lewis could provide the “evidence” that the state’s attorney in DuPage County needed, but didn’t have, to prosecute Lewis for the Tylenol murders.

And what exactly was the FBI hoping to find in those memoirs?  An email that Roy Lane sent to Jim Lewis thirteen months before authorities searched Lewis’s Cambridge apartment provides the answer:

Sherry told me that she spoke to you the other day and you had more material for me. Good. You also made a comment when we were in Boston that it might be necessary to prepare five different endings for our story just like they did for Who Shot JR. We would then choose the most fitting of the five. In the nuclear world, I had a boss who I very much admired and when we discussed problem solving he would always advise me to start with the answer. Knowing the answer, I could then build and act on a plan to achieve the desired result. Maybe we could use the same logic for the five endings. Let’s identify each of the five and use these endings to guide us in developing the entire story line. I have some thoughts on the five different endings. If you agree or have any comments, let me know. This does not have to be a major project at this time but just an exercise in identifying five possible outcomes for Chuck.

Regards, Roy

The IDLE and FBI agents who searched Lewis’s apartment on February 4, 2009 were looking for an alternative ending to POISON! The Doctor’s Dilemma that included a confession from Chuck Rivers. The FBI never found that alternative storyline, because Lewis never wrote it.

The FBI’s last-ditch effort to “solve” the Tylenol murders was to try to get Chuck Rivers to confess to the murder of 12 people in Chicago, and then use that confession to convict an innocent man for the Tylenol murders. This was to be the FBI’s way of bringing “some measure of closure to the families of the victims” of the 1982 Tylenol killer: Mary Kellerman, Adam Janus, Lynn Reiner, Stanley Janus, Theresa Janus, Mary McFarland, and Paula Prince. The FBI never really cared about justice for the Tylenol victims or their families.

Roy Lane’s sting operation failed to produce any information that prosecutors could use to bring a case against Lewis for the Tylenol murders. The FBI’s investigation of Lewis had, however, followed a familiar pattern.

41

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A Familiar Pattern

Maurice Possley and Ken Armstrong wrote a series of articles in 1999 for The Chicago Tribune on prosecutorial abuse. What they found was alarming: “With impunity, prosecutors across the country have violated their oaths and the law, committing the worst kinds of deception in the most serious of cases. They have prosecuted black men; hiding evidence the real killers were white. They have prosecuted a wife; hiding evidence her husband committed suicide. They have prosecuted parents, hiding evidence their daughter was killed by wild dogs. They do it to win. They do it because they won’t get punished.” Moreover, they do it to gain power – political power.

“Winning has become more important than doing justice,” says Harvard University law professor Alan Dershowitz. “Nobody runs for the Senate saying I did justice.”

Although the Tribune found 381 defendants whose homicide convictions were overturned based upon such misconduct, that number accounts for only a fraction of how often prosecutors commit such deception--which is by design hidden and can take extraordinary efforts to uncover. The reason they are not punished, said Lawrence Marshall, Professor of Law at Northwestern University, is because “Prosecutors just don’t prosecute prosecutors. We don’t ask people to investigate their own family, and prosecutors are like family.”

Because of this failure to reign in rogue prosecutors and the FBI agents and local law enforcement officers who aid them, innocent persons have been targeted as “prime suspects” in many high-profile murder cases. The FBI wrongly accused Richard Jewell in 1996 for the Olympic Park bombing, Steven Hatfill in 2002 for the Anthrax attacks, and Brandon Mayfield in 2004 for the Madrid terrorist attack. Another individual wrongly accused by the FBI, Stella Nickell, was convicted of carrying out the Excedrin poisonings in the Seattle, Washington area in June of 1986.

On the afternoon of June 5, 1986, Stella’s husband, Bruce Nickell, came home with a headache. He took four Excedrin capsules, walked out on the deck to watch the birds, and then collapsed. He was taken by helicopter to a Seattle hospital, but was dead on arrival from what the doctors said was emphysema. That didn’t make any sense to Stella, because Bruce did not have that disease.

Nearly two weeks after the death of Bruce Nickell, news reports said that Sue Snow had died in Auburn, Washington on June 11th from cyanide-laced Excedrin. Stella contacted the police and told them that her husband had taken Excedrin from the same lot as Snow’s Excedrin. Doctors soon realized that Bruce Nickell had also been poisoned. As political pressure mounted to get a conviction for these murders, FBI Director, William Webster, told several associates, according to one of them, that he was worried that if an arrest was not made soon in the Seattle area killings, tamperings nationwide could get out of hand. The FBI, under pressure to indict someone, then targeted Stella as its prime suspect in the poisoning deaths of her husband and Sue Snow.

Bruce’s life insurance policy paid $136,000. He also had a Death and Dismemberment policy that paid $40,000, but only if he died from an accident, including poisoning. Auburn Detective Mike Dunbar said, “I think that she [Stella] probably killed Bruce and expected them to find out that he died from cyanide poisoning.” Prosecutors claimed that Stella put poisoned painkillers in stores, hoping someone else would die and the tainted capsules would be discovered, and she would collect on Bruce’s Accidental Death and Dismemberment policy. However, Stella was already going to collect $136,000 on the life insurance policy. Why would she come forward and make herself an obvious suspect for the $40,000 in accidental insurance? If Stella had poisoned her husband, the hospital gave her the perfect cover – the disease – she would have gotten away with it.

The Justice Department’s prosecution of Stella relied primarily on the testimony of Cindy Hamilton, Stella’s estranged daughter. Hamilton, who had been in and out of Stella’s life for years and had a history of abusing drugs, testified that Stella had talked about killing Bruce for the insurance money. She made a formal statement to the FBI shortly after the federal government put her and a friend up at a trendy Ocean Shores resort for a week or so in January 1987 to give Hamilton and her roommate time to “think things over.” There was no witness to corroborate Hamilton’s claim, and prosecutors had no physical evidence whatsoever to connect Stella to the poisonings. Without Hamilton’s testimony, prosecutors had no case.

As it turned out, Hamilton’s testimony was enough. On May 9, 1988, a jury convicted Stella of murdering Bruce Nickell and Sue Snow. U.S. District Judge William Dryer sentenced her to 90 years in prison. Stella will be eligible for parole on December 7, 2017.

In 1999, private detectives Al Farr and Paul Ciolino decided to look into Stella’s case. After an extensive 19-month investigation, they concluded that she is innocent. During their investigation, they found the typical signs of prosecutorial abuse – a case built on speculation, fabricated “facts,” false stories leaked to the press, and FBI harassment of the suspect. One glaring problem had to do with Stella’s polygraph exam. Jack Cusack, the FBI agent who gave the exam, was the same FBI agent in charge of building a case against Stella. All the protocol for conducting an exam was violated, using it instead as a prosecutorial opportunity to intimidate and unnerve Stella. Stella never saw the results of that polygraph exam. In fact, nobody ever saw the polygraph exam results, not even Stella’s federal public defender, Tom Hillier.

“My belief is that the polygraph was a ruse to try and coerce a confession out of her,” said Stella’s new lawyer, Carl Colbert. Colbert has asked to see the polygraph, but the FBI will not let him.

The government claimed that all required documents had been handed over to Stella’s first lawyer. Yet Farr discovered thousands of pages of documents that had never been turned over to the defense. The jury also never knew about the reward money that would go to Cindy Hamilton if her testimony led to the conviction of her mother.

The Proprietary Association, the OTC drug manufacturer’s primary lobbying group, had put up a $300,000 reward to whoever provided information that led to a conviction in the Excedrin poisonings. The Proprietary Association, with McNeil Chairman David Collins as the vice president of the association’s Board of Directors, paid Hamilton $250,000. The remaining $50,000 went to eight others, including five who testified at trial.

The Proprietary Association paid Stella’s neighbor, Sandy Scott, $7,500. At the request of Jack Cusack, Sandy had been a spy for the FBI, maintaining surveillance and even searching Stella’s home for algae destroyer that the FBI hoped would link Stella to the poisoned capsules. Roger Martz, a “chemist” at the FBI Lab in Washington D.C., had found green specs in the cyanide-laced Excedrin capsules recovered in the Seattle area. He matched those green specs to a particular type of algae destroyer. The feds, theoretically, had connected the cyanide to the algae destroyer, and the algae destroyer to Stella Nickell. In reality, neither Sandy nor the feds ever found that algae destroyer at Stella’s house, something the jury also never heard. The FBI never linked the cyanide or the algae destroyer to Stella. Later, Sandy realized that the whole thing was a set-up and that Stella was wrongly convicted.

Thomas Noonan, the fish store manager who testified that he had sold Stella the specific kind of algae destroyer that the FBI said was found in the cyanide, was paid a $15,000 reward.  When Farr interviewed him later, Noonan said he never recalled selling algaecide to Stella. He had made that statement to the FBI because it seemed like it would help their case and because he did not specifically remember not selling the algaecide to Stella.

“Big business and big government got in bed together and cooked up a scheme to convict this woman, and they did it,” said Farr. “This is the craziest thing I’ve heard in 30 years of doing this. You find a lot of cases where maybe one witness was paid. You never have found a case that I’m aware of in the history of jurisprudence in this country where so many witnesses received a check from a third party for their testimony.”

Based on their findings, Stella’s new legal team, working pro bono, filed a request for a new trial. This third attempt to reopen the case was denied. Farr says the only thing that can get Stella off now is a confession from the actual killer. The best chance of informing the public about the wrongful conviction of Stella Nickell might have been the movie Who Killed Sue Snow?. But pressure from Johnson & Johnson led USA Network to shut down the production set of that movie on Thanksgiving eve 2000, just a few days before filming was to begin.

Not brought up at Nickell’s trial was that two of the five bottles of cyanide-laced capsules that the jury convicted Stella of poisoning were unopened and showed no signs that their tamper-resistant packaging had been breached. One of the unopened bottles was a bottle of cyanide-laced Extra Strength Excedrin capsules, and the other was a bottle of cyanide-laced Anacin-3 capsules. FDA spokesperson, Ellen Miller, said the presence of cyanide in the unopened bottle of Anacin-3 was detected by a fluoroscope examination, similar to an X-ray. This examination was done without removing the packaging. Officials found no signs that the unopened bottles had been tampered with, leaving a very important question unanswered: How did Stella supposedly get the cyanide-laced capsules into those two unopened bottles while leaving no signs that the taper-resistant packaging had been breached? The FBI and Justice Department had learned during the February 1986 Tylenol murder investigation in New York to avoid that topic.

The same modus operandi promoted during the Tylenol murders investigations in Illinois in 1982 and in New York in 1986 was the cornerstone of the prosecutors’ fabricated case against Stella Nickell. In each case, the FBI initially targeted a victim’s relative as the perpetrator of the tamperings. In each case, the FBI claimed that the killer used a cyanide-laced analgesic capsule to murder his or her intended victim after first planting cyanide-laced capsules in bottles in a number of stores, so others would die, making the alleged premeditated murder look like one of several random murders committed by a madman. If nothing else, the FBI is consistent. In effect, they “picked” the guilty party and then investigated backward to try to get a conviction.

*****

The Chicago Tribune found that the Illinois record for misconduct by prosecutors is particularly abysmal. Of the 381 people whose homicide convictions were reversed between 1963 and 1999, forty-six were tried in Illinois. Yet not a single prosecutor in those cases was ever brought to trial for misconduct or disbarred. Several years after the Tribune’s expose’, the wrongful prosecution of three men for the rape and murder of a young girl in DuPage County became the only such case to result in an indictment of prosecutors.  The three prosecutors and four DuPage County sheriff’s officers indicted in that case are known as the DuPage 7.

Rolando Cruz and Alejandro “Alex” Hernandez were convicted in 1985 for the 1983 rape and murder of ten-year-old Jeanine Nicarico. Jeanine had stayed home with the flu on February 25, 1983. Her father, an engineer, went to work in Chicago. Her mother, a school secretary, went to work in Naperville, the prosperous suburb in DuPage County where the Nicaricos lived. Jeanine was left home alone. That afternoon, Jeanine was abducted from her home, sexually assaulted, and her skull then crushed with a tire iron. A task force of local police, DuPage County sheriff's police, and the FBI began sifting through the evidence and tracking leads. Detective John Sam, who regularly led the DuPage County Sheriff’s Department in felony arrests, was the lead investigator.

DuPage County prosecutors, led by Assistant State’s Attorney Tom Knight, soon developed the hypothesis that three DuPage County residents - Rolando Cruz, Alex Hernandez, and Stephen Buckley - had gone into the Nicarico home to burglarize it, were surprised by Jeanine, raped her, and then killed her to prevent her from identifying them. As the investigation wore on, Detective Sam realized that the prosecutor’s theory was not credible. The odds against three burglars also being child molesters “are astronomical,” Sam said. There was no physical evidence no fingerprints, no hairs, no fibers, and no eyewitnesses. Sam became so sure that Cruz and Hernandez were innocent that he resigned from the Sheriff's Department and offered, in vain, to testify on their behalf.

On December 20, 1984, the Wheaton law firm of Callum, Anderson, and Deitsch held its annual Christmas party, attracting a variety of judges, lawyers, and law enforcement officials, including Assistant State’s Attorney Patrick King, and DuPage County Sheriff’s Detectives, Dennis Kurzawa and Thomas Vosburgh.  Vosburgh told King that he was concerned because neither he nor Kurzawa had been contacted to testify in the Nicarico case. Vosburgh said he and Kurzawa were particularly eager to testify about the “vision statement” that he said they had taken from Cruz 18 months earlier.

This vision statement, which Vosburgh said included specific details about the Nicarico murder that only the actual perpetrator could have known, was not mentioned in any of the thousands of pages of transcripts from the Grand Jury that indicted Cruz, Hernandez, and Buckley. Police never wrote it down or made a report about it. This lack of documentation about the vision statement, as was later revealed, was because Cruz had never made it.

The trial against Cruz, Hernandez, and Buckley went forward in January 1985 with the vision statement as the key piece of evidence. Detectives Kurzawa and Vosburgh testified that a distraught Cruz recounted a vision or dream he’d had about the Nicarico murder. Cruz allegedly told them that Jeanine’s nose had been broken, that she had been hit in the head so hard that a depression was left in the ground where her body was found, that she had been sodomized, and that she had been left in a farmer’s field.

The jury was unable to reach a verdict on Buckley’s guilt, and charges against him were ultimately dismissed, but the jury found Cruz and Hernandez guilty of kidnapping, raping, and murdering Jeanine Nicarico. On March 15, 1985, Judge Edward Kowal sentenced them to death.

Tim Gabrielsen, one of two attorneys appointed to represent Cruz’s appeal, began reading the 11,000 pages of trial transcripts in July 1985. “It became very clear how little evidence the State had against them,” said Gabrielsen. “There was no question the prosecution failed to prove these guys were guilty beyond a reasonable doubt. They were just out to convict somebody.”

In June 1985, Brian Dugan was arrested and charged with the rape and murder of 7-year-old Melissa Ackerman, and the rape and murder of 27-year-old Donna Schnorr. He had been arrested 27 times in the DuPage County area for burglaries and assaults on women. When Dugan was first interviewed by his public defender, George Mueller, he confessed to raping and murdering Ackerman and Schnorr. He pleaded guilty to those crimes in exchange for a life sentence. Dugan then told Mueller that he had also raped and murdered Jeanine Nicarico. He also wanted to cut a deal to plead guilty to that crime, but only if prosecutors would agree not to seek the death penalty.

Mueller then hinted to DuPage County prosecutors that his client might be connected to the Nicarico case. The prosecutors were skeptical, so they gave Mueller some questions about the case that only Jeanine’s assailant could answer. Mueller immediately met with Dugan and then returned an hour later with the answers and asked if Dugan had gotten them right. There was a “very long, pregnant pause,” said Mueller, and then the prosecutors said, “Listen, we’ll get back to you.” But they never did.

In November 1985, Brian Dugan confessed to IDLE Commander Ed Cisowski that sometime after 2 p.m., February 25, 1983, he had knocked on the door at the Nicarico house. Jeanine answered the knock but refused to open the door. Dugan called out that he needed a screwdriver to fix his car, but Jeanine told him she would not give him a screwdriver or let him in. As she turned to go back downstairs to the family room, Dugan said he saw her through a window. She was wearing a pink nightshirt with Sleepy the Dwarf on it and the inscription “I’m sleepy.” Dugan told Cisowski, “When I saw her I had to have her.” Dugan kicked in the front door, abducted the little girl, wrapping her in a sheet, and took her out to a wooded area near the Illinois Prairie Path in Aurora where he raped her and then hit her twice on the back of her head with a tire iron.

Work records corroborated Dugan’s claim that he had missed work the day Jeanine was killed. He was able to take investigators to the Nicarico’s house and to the site where Jeanine’s body was found. Dugan’s lengthy criminal record included abductions in which he concealed his victims by wrapping them in sheets or blankets, and burglaries in which he gained entry by kicking in a door.

Cisowski, convinced that Dugan alone had killed Jeanine Nicarico, presented his findings to the State’s Attorney’s Office in DuPage County in December 1985. “It was, for whatever reason, argued, resented, and unaccepted,” said Cisowski. The Illinois Attorney General Office then put Cisowski under investigation, accusing him of feeding Dugan information about the Nicarico murder.

George Mueller, told the Washington Post, “I had the attitude from day one that the DuPage County people weren’t going to want to hear any of this because it made them look real bad. We were asking them to let two guys off of death row… without putting anyone there in their place.”

On January 19, 1988, the Illinois Supreme Court ruled that the DuPage County judge had erred in not granting separate trials, overturned the convictions, and ordered new trials for Cruz and Hernandez. In May of 1988, scientific analysis of hair samples taken from the blindfold around Jeanine’s eyes revealed two “abnormalities” in the sample - one described as “fairly rare” - that were consistent with Dugan’s hair, but not with that of Cruz or Hernandez. Lawyers working on the case said the tests exonerated Hernandez and Buckley, were inconclusive regarding Cruz, and implicated Dugan.

“The forensic evidence establishes Dugan’s guilt, the circumstantial evidence and the eyewitness evidence show his guilt, and now the scientific evidence points to Dugan,” said defense attorney, Michael Metnick. “You compare all that to the paucity of evidence against Hernandez and Cruz, and it’s bewildering how the State can pursue this case. It’s morally dishonest.”

The vision statement was once again the centerpiece of the case brought by State’s Attorney Robert Kilander in Cruz’s second trial in February 1990. Cruz was found guilty again. Hernandez’s second trial ended in a hung jury, but in a third trial, in May 1991, he was also found guilty again. Cruz was sentenced to death, and Hernandez was sentenced to 80 years in prison.

The verdict was appealed again; and again Cruz and Hernandez were granted new trials. In September 1995, the prosecutor’s own DNA expert said Dugan’s DNA precisely matched sperm found on Jeanine’s body. Still, the DuPage County prosecutors forged ahead. Cruz’s third trial, a bench trial before Judge Ronald Mehling, began on September 21, 1995. The prosecutor’s case fell apart before the defense even began to present their case. The final straw came when DuPage County Sheriff’s Lieutenant, James Montesano, took the stand. He admitted that he had lied, though perhaps unintentionally, about being at home on the night that detectives Kurzawa and Vosburgh said they had called him to seek advice about Cruz’s alleged vision statement. He had never discussed the vision statement with Kurzawa and Vosburgh after all. With that revelation, and numerous discrepancies in the testimony of other state witnesses, Judge Mehling realized that the vision statement had been completely made up.

Judge Mehling took a short break. Then, upon reconvening, he held up a picture of Jeanine Nicarico and proceeded to disparage the DuPage County Sheriff’s police officers and the case brought by DuPage County prosecutors. “Let’s look at what the evidence shows or does not show,” Mehling said. “And what troubles me in this case is what the evidence does not show… Is there any physical evidence in connection with this case, anything at all, that connects this hideous crime and connects Mr. Cruz? Anything? Fingerprints, blood spots, blood, DNA, hair, fibers, clothes, something left there, something taken from the home that he had? Anything? . . . There is none. There is absolutely none.”

“I as a judge, frankly… can’t recall so many witnesses that have testified one way at one time and then now testified a different way,” said Judge Mehling. “I am sure the defense and State realize what actually occurred here today. It was devastating. It was unique in the annals of criminal justice. Did Cruz ever make that dream statement? I don’t think I need to answer that, because I’m going to enter a judgment of not guilty, and he will be discharged today. Case closed,” declared Judge Mehling.

After 10 years on death row, Cruz walked out of the 18th Circuit Court in DuPage County a free man. Six weeks later, Hernandez was also exonerated and released from prison. DuPage County, with the approval of State’s Attorney Joseph Birkett, paid $3.5 million in 1999 to settle a civil lawsuit brought by Cruz, Hernandez, and Buckley.

In November 2009, Birkett finally accepted Brian Dugan’s confession for the February 1983 rape and murder of Jeanine Nicarico. Dugan had first confessed to those crimes in November 1985. Birkett, while delivering a heated closing statement in the pre-sentencing hearing, turned to Dugan, pointed triumphantly and declared, “We got it right! We got it right, Brian! You raped and killed Jeanine Nicarico!”

Even though Joe Birkett had gotten it completely wrong for 26 years, he still claimed to have gotten it right. Prosecutors in DuPage County had gotten the Nicarico case wrong for almost as long as they have gotten the Tylenol murders case wrong.

In late 2008, while the prosecutors at the State’s Attorney’s Office in DuPage County were working on closing out the DuPage 7 scandal, they also secretly initiated new legal maneuvers in the Tylenol murders investigation in a reinvigorated effort that, if successful, would lead to the wrongful prosecution of James Lewis for the Tylenol murders. This objective was advanced with the help of one or more judges in the 18th Circuit Court in DuPage County.

42

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The Judges of DuPage County

The warrant to search James and LeAnn Lewis’s apartment on February 4, 2009 had been granted by a judge in the 18th Circuit Court in DuPage County. Nearly a year later, the reactivated Tylenol murders investigation had gone nowhere. Behind the scenes, however, prosecutors in DuPage County were working on getting a court order requiring the Lewises to submit fingerprints and DNA samples to the FBI. State’s Attorney, Joe Birkett, was leading that charge. Birkett had been hired in 1981 as an assistant state’s attorney in DuPage County. He was promoted to chief of the Major Crimes Unit in 1985, to deputy chief of the Criminal Division in 1986, and to chief of the Criminal Division in 1991. Birkett was elected state’s attorney in DuPage County in 1996, and then re-elected in 2000, 2004, and 2008.

In July 2009, prosecutors in DuPage County asked James Lewis to voluntarily provide DNA samples. Following the advice of his attorney, Lewis refused. Birkett then convinced a judge in the 18th Circuit Court to grant a Certificate of Materiality requiring James and LeAnn Lewis to submit fingerprints and DNA samples.

On December 23, 2009, a summons was issued requiring James and LeAnn to appear before the Middlesex Superior Court. That summons came at the request of Middlesex District Attorney, Gerry Leone, who had kept Lewis in jail from August 2004 to July 2007 on trumped-up charges of rape, kidnapping, and assault; dropping all charges as the trial was about to begin. On January 6, 2010, a hearing was held in Middlesex Superior Court to determine if the Certificate of Materiality was enforceable.

Despite the requirement of secrecy, the authorities leaked to the press the details of the Certificate of Materiality and the summons. A reporter from The Somerville News showed up at the Middlesex County courthouse to provide a play-by-play of the arrival of James and LeAnn Lewis: “The couple arrived in the front corridor of the courthouse at 8:45 a.m. and were briefly interviewed by one of our Somerville News/Cambridge News Weekly correspondents and later by FBI agents as well as by local authorities who escorted the couple to the hearing room.”

After a short hearing, the judge determined that the Certificate of Materiality, requiring the Lewises to submit buccal swabs and major case prints, was enforceable (Buccal swabs collect DNA samples by swabbing the inside of a person’s cheek, while major case prints are a set of prints taken from all fingers, thumbs, and palms). The Lewises immediately complied with the court order, submitting samples right after the hearing to the Boston FBI on behalf of the Chicago FBI and State’s Attorney Joe Birkett. According to Lewis, it was a rather amateurish affair.

“The FBI used the occasion as a training session for their greenest rookies,” said Lewis. “I have never seen such sloppy collection of fingerprints. I actually had to help one dude ink my hand and finger edges. Likewise, the DNA swabs were sometimes laid directly on unsterilized tabletops, and in one instance, dropped on the floor. Those swabs would have been thoroughly contaminated by the DNA of the dead skin cells and dandruff of FBI agents, which had fallen on the table tops and floors,” said Lewis. “I could be very wrong,” he added, “but I am convinced agents were only going through the motions in a futile case, fully knowing they would find nothing.”

Joe Birkett, when asked about the DNA hearing, said, “I will have no comment on that. I just won’t comment.” But someone from Birkett’s office had commented. In fact, several people had already leaked information about the grand jury proceedings and the court order to obtain the Lewises’ fingerprints and DNA samples.

Investigators working on the case who asked not to be identified, ironically because of grand jury secrecy laws, said the case was focused on returning state murder charges in Illinois. One unidentified official said the passage of time and the distance between Chicago, where the crimes had been committed, and Boston, where the prime suspect and his wife resided, complicated the investigation. These comments from unidentified officials served to persuade the public and potential jury pool that Lewis was indeed a legitimate suspect in the Tylenol murders case when in fact he was not.

Lewis’s attorney, David Meier, the former long-time head of the homicide unit for the Suffolk County, Massachusetts, District Attorney’s Office, chastised the officials who had leaked information in violation of the confidentiality requirements for grand jury proceedings. Meier told The Boston Globe, “Proceedings such as that reported by the Somerville News, to the extent that they occur, are supposed to be secret precisely to protect the reputations of innocent people like James Lewis and his wife. To comment further would be irresponsible, unprofessional, and unethical.’’

Ostensibly, the Certificate of Materiality was issued so that DNA samples from the Lewises could be compared to a “DNA smudge” from evidence collected in 1982. Officials seemed to believe that this DNA smudge, stored for 27 years at the FBI lab in Washington D.C., held the genetic DNA of the Tylenol killer. Also stored in that same FBI lab, were the items containing James Lewis’s fingerprints and DNA that had been collected in Kansas City in 1981. A Kansas City police officer had flown to Washington D.C. on October 16, 1982 to turn those items over to the FBI.

James Lewis had been fingerprinted dozens of times between 1982 and 2007. He was fingerprinted in December 1982 when he was arrested in Manhattan, then again when he was booked into Manhattan’s Metropolitan Correctional Center, and yet again when he was booked into Chicago’s Metropolitan Correctional Center. Each time Lewis was transferred through or into a new prison, and each time he exited that prison, he was fingerprinted. Lewis was fingerprinted when he was formally booked at the federal penitentiaries in Leavenworth, Lewisburg, Terre Haute, El Reno, Talladega, and the Federal Prison Hospital in Springfield, Missouri. His parole officer in Boston also fingerprinted him.

More recently, when Lewis was arrested in 2004 on the bogus kidnapping and rape charges, he was fingerprinted in Middlesex County and again when he arrived at the Middlesex County Jail. While this charge was pending trial, Lewis was transferred to Essex County Jail and fingerprinted again. In each of these three instances, the booking officers captured computer-based, high-resolution digital fingerprints. Nevertheless, in January 2010, the FBI and the prosecutors at the State’s Attorney Office in DuPage County wanted more. These officials did not really need a new set of fingerprints from Lewis – they needed a new story that falsely implicated their patsy as a suspect in the Tylenol murders.

Authorities who examined the Tylenol extortion letter back in October 1982 had found Lewis’s fingerprints on that note. Police had also found Lewis’s fingerprints on items collected from Lewis’s Kansas City home in 1981. United Press International reported on October 18, 1982 that FBI experts were “comparing Lewis’s prints with partial finger and palm prints on bottles that held the poison capsules.”

As for the DNA samples – the FBI already had the Lewises’ DNA on items collected when authorities search their Cambridge apartment in February of 2009. The pants, socks, and other clothes collected during that search did not even exist in 1982. Those items were collected because they contained Lewis’s DNA and for no other reason. Prosecutors in Middlesex County, Massachusetts, had also collected items with Lewis’s DNA when they arrested him in August 2004. In addition, “retired” FBI agent Roy Lane had plenty of opportunities to collect items containing the Lewises’ DNA during the meetings and dinners he and “Sherry Nichols” had with the Lewises. It’s hard to believe that the FBI had not already compared the DNA from Lewis’s items to DNA on the bottles and capsules of cyanide-laced Tylenol, which had all been sitting in the FBI lab in Washington D.C. since 1982.

DNA typing (profiling), a technique to perform human identity tests by examining the length variation of DNA repeat sequences, was developed in 1984 by English geneticist, Alec Jeffreys. The technology to do DNA profiling became commercially available in 1986. Since that time, human identity testing using DNA typing methods has become widespread. The methods of DNA profiling typically used today, short tandem repeat (STR) testing and polymerase chain reaction (PCR) analysis, have been in use since the mid-1990s. Smaller DNA samples can be analyzed more quickly and accurately today, but the basic technology has not changed since the mid-1990s.

Police forces can collect DNA samples without a suspect’s knowledge and then use that DNA as evidence, as long as it is collected from a public location that does not require a search warrant. Courts have ruled that with regard to DNA evidence, there is no expectation of privacy, citing California v. Greenwood (1985). In that case, the United States Supreme Court held that the Fourth Amendment does not prohibit the warrantless search and seizure of garbage left for collection outside the curtilage or property line of a home. That same legal authority applies to DNA evidence collected without a warrant. There was nothing to prohibit authorities from running a DNA profile of the DNA on Lewis’s items that were legally collected in public location and in earlier investigations. They did not need a court order to do that.

The failure of officials to disclose the results of the analysis of the Lewises’ DNA samples, submitted on January 6, 2010, is confirmation that those samples do not match any of the DNA evidence supposedly collected during the Tylenol murders investigation. That finding was, of course, a foregone conclusion. The only real question was whether the FBI, IDLE, or authorities in DuPage County had the gall to plant Lewis’s DNA on some of the evidence. That was apparently too dangerous even for them.

The totality of the physical evidence gathered during the 1982 Tylenol murders investigation came from eight bottles of cyanide-laced Tylenol capsules. The DNA smudge that authorities compared to the Lewises’ DNA samples came from one of those bottles.  More specifically, it came from a capsule inside one of those bottles.

On January 12, 2010, Bill Hemmer, of Fox News, interviewed Dr. Michael Baden, a pathologist and frequent contributor on Fox. This interview was one of several media events informing the public that the DNA evidence of interest was on a Tylenol capsule. Hemmer introduced Dr. Baden and then quickly got to the subject-matter at hand. “They are saying there’s a smudge on one of the containers. A smudge of what?” Hemmer asked Baden. “Is that a fingerprint, or what would that be?”

“Presumably,” Baden replied, “a fingerprint - and with the new DNA technology, one can pick up from a smudged fingerprint, [the] DNA from the skin cells.”

Then, to emphasize the point that the DNA smudge was from a Tylenol capsule - not a bottle - Hemmer and Baden each picked up an unsealed capsule similar to the Tylenol capsules that had been filled with cyanide in 1982 and 1986.

“This is a capsule,” Hammer continued, “You can take this apart. Right? And the medication is on the inside.”

“So we’re taking this [capsule] apart, Baden explained, “And see… and then the medication is on the inside… and one can then take other medication containing cyanide and put it in.”

“So your theory,” Hemmer said to Baden, “is that this killer… and I'll demonstrate it for the viewers here – we missed that a little bit here - is you take this apart, right, the medication is on the inside… then you would fill the capsule with an amount of cyanide.”

“That’s right,” Baden replied. “And this type of capsule contains enough cyanide to kill you.”

While Hemmer and Baden were talking, the camera zoomed in on their hands as they held the capsules between their fingers, thus bringing home the point that anyone who handled a cyanide-laced Tylenol capsule would have left his DNA on that capsule. The Tylenol killer, of course, must have worn gloves when he filled the capsules with cyanide. It doesn’t take much cyanide to kill a person who handles it with bare hands.

“Okay, now you’re 27 years down the road,” remarked Hemmer. “Why now would we have that technology to figure out what happened in 1982, and whether or not this guy [James Lewis] is guilty, or if the true guilty person is still running free?”

“Because right now,” Baden replied, “the police must have gotten some evidence that there was something on either the bottle container that they have in evidence, or the pills. One can leave fingerprints on the capsules themselves that can be picked up now with DNA… the new sensitive DNA. DNA [profiling] was not available in 1982, it’s now available, and it can pick up very small trace evidences of DNA, and if his [Lewis’s] DNA is on any of the capsules or the bottles that the police have in evidence, that’s a home run,” declared Baden. Baden did not mention that the evidence from 1982 was probably not handled or stored in a manner to avoid contamination, since DNA profiling technology was not even discovered until two years later.

“If this case is solved, it’s a big deal,” said Hemmer.

“It’s a very big deal,” echoed Baden.

The Huffington Post reported on January 9, 2010 that “one of the most harrowing serial murders in Chicago history has moved a step closer to trial, thanks to a tiny smudge of evidence. It’s thought that new advances in forensic science will be able to match this DNA to an old smudged fingerprint.” The consensus among the authorities who commented on the DNA smudge was that it was from a capsule in a bottle of cyanide-laced Tylenol recovered in the Chicago area in 1982. From where the capsule with this DNA smudge came, is, in retrospect, all too obvious.

On October 26, 1982, one day after discovering the eighth bottle of cyanide-laced Tylenol, officials said the FBI had found no fingerprints on any of the first seven bottles of cyanide-laced Tylenol. They apparently meant to say that the FBI had found no useable fingerprints, because two weeks earlier they had said that the FBI was comparing Lewis’s fingerprints to partial fingerprints and palm prints on one or more of those seven bottles.

Tyrone Fahner said on November 9, 1982 that a partial fingerprint “smudge” had been found on a capsule inside the eighth bottle of cyanide-laced Tylenol. Because that fingerprint was smudged, the FBI was unable to lift a clear print. That smudged fingerprint did, of course, contain DNA. That “DNA smudge,” since it came from a capsule inside the eighth bottle, left State’s Attorney Joe Birkett with a big problem. The eighth bottle of cyanide-laced Tylenol, as Birkett should have known, had been planted into evidence two weeks after the Tylenol murders.

On October 14, 1982, so the story goes, Linda Morgan gave the eighth bottle of cyanide-laced Tylenol to authorities at the Wheaton police station in DuPage County. Ten years later, she reminisced about her “near death” experience. “What’s going to happen happens - and I guess [my death] just wasn’t in God’s plan at that time,” she said. “I bought it, but I hadn’t taken it. My husband didn’t like Tylenol, and my daughter was very little, so I was the only one who would have taken it.”

Morgan did not need the Tylenol when she bought it, but she conveniently bought it on the same day she would need it. She said she put the Tylenol bottle in her medicine cabinet before attending a family outing at a local park. After a run in the park, Morgan said she told her sister that she wanted to go home to take a Tylenol capsule because her legs ached. Her sister then gave her a Bufferin instead. The next day, after hearing about the poisonings, Morgan said she pulled the Tylenol bottle out of the medicine cabinet and set it on her dresser. That bottle, according to Morgan, sat on her bedroom dresser for 14 days because family matters, which she never described, prevented her from turning it in earlier.

Morgan claimed to have bought the eighth bottle of cyanide-laced Tylenol at Frank’s Finer Foods on the morning of the Tylenol murders. However, as described earlier, the lot number on that bottle revealed that it had never been inside any of the Frank’s Finer Foods stores. The Tylenol in the Frank’s Finer Foods stores had been distributed through J&J’s regional distribution center in Glendale, California. But the Tylenol in the eighth bottle of cyanide-laced Tylenol had been distributed through J&J’s regional distribution center in Montgomeryville, Pennsylvania.

Instead of turning the eighth bottle of cyanide-laced Tylenol over to the FBI or IDLE for inspection, the Wheaton police said they had attached a note to the bottle, stating that it may be contaminated, and then mailed it to the Maple Plain Company in Minnesota. The Maple Plain Company, a coupon company handling the reverse distribution of the returned Tylenol, supposedly then mailed the bottle to the McNeil Consumer Products Company in Fort Washington, Pennsylvania.

Within days of Johnson & Johnson’s “discovery” of the eighth bottle of cyanide-laced Tylenol, it became clear that the poisoned capsules inside that bottle were not the work of the Tylenol killer. Tyrone Fahner said, “The [eighth] bottle is clearly different than the other seven… Some [of the cyanide-laced Tylenol capsules] were put together ‘unartfully,’” and the poisoned medicine inside those capsules had an “orangish” color, whereas the contents in the cyanide-laced capsules from the other seven bottles were off-white in color. Furthermore, the adulterated capsules in the eighth bottle showed no signs of corrosion when inspected 26 days after the Tylenol murders, yet the cyanide-laced capsules in the seventh bottle, inspected 22 days after the murders, were in an “advanced state of deterioration” from the corrosive effects of the moist cyanide. Someone, not the Tylenol killer, had put cyanide into seven Tylenol capsules in the eighth bottle sometime after the Tylenol murders. The eighth bottle was then planted into evidence on October 14, 1982; one day after Roger Arnold was released from jail.

It is an amazing coincidence that Linda Morgan, the only person identified as having turned in a bottle of cyanide-laced Tylenol capsules after the Tylenol murders, was married to an 18th Circuit Court judge who traveled in the same circles as the DuPage County lawyers hired by Johnson & Johnson “to help uncover the details” of the Tylenol murders.

Linda and Judge Lewis Morgan lived in Wheaton, a city of about 54,000 people, and the county seat of DuPage County. It is currently one of the nation’s wealthiest counties, with the highest per capita income in the Midwest; nineteen of the county’s towns have average household incomes of over $100,000. At the center of the legal community in Wheaton is the 18th Circuit Court, which has general jurisdiction over a wide variety of civil and criminal cases in DuPage County, ranging from small claim actions to domestic relations to criminal felonies.

Since 1990, the DuPage County courthouse has been located at County Farm Road and Manchester Road in Wheaton. In 1982, the courthouse was located at East Liberty Drive and Reber Street, two miles east of its current location. The law office of Rook, Pitts, and Poust, at 201 Naperville Road, was right across the street from the 18th Circuit Court, when, on the morning of September 30, 1982, McNeil Chairman, David Collins, called that office shortly after stepping off the helipad at the McNeil Consumer Products Company in Fort Washington, Pennsylvania. Collins first talked to his attorney pal, Paul Noland, and told him to immediately go to the Cook County Medical Examiner’s Office and find out all he could about the Tylenol poisonings. Then he talked to his attorney pal, Francis “Mike” Heroux, and asked him to also provide legal assistance to help J&J get through the Tylenol crisis.

Paul Noland was sworn in as a judge for the 18th Circuit Court in DuPage County in 1992. He retired in 1998. A judge in the 18th Circuit Court granted the warrant to search Lewis’s home on February 4, 2009. On November 23, 2009, Judge Paul Noland was recalled to the 18th Circuit Court to serve on the bench for one year. Exactly one month later, a summons was issued requiring the Lewises to appear in Middlesex Superior Court in Massachusetts to determine the enforceability of the Certificate of Materiality that had been granted by an 18th Circuit Court Judge. That order required the Lewises to submit DNA samples for comparison to a “DNA smudge” on a capsule in the planted eighth bottle of cyanide-laced Tylenol that the wife of Judge Lewis Morgan, of the 18th Circuit Court, had supposedly given to the Wheaton police two weeks after the Tylenol murders. The woman initially identified as having turned in that bottle, Marylou Walter, was the wife of Judge Duane Walter of the 18th Circuit Court.

The judicial careers of Lewis Morgan and Duane Walter were somewhat tumultuous. On June 25, 1985, the Illinois Courts Commission officially reprimanded Judges Morgan and Walter for retaining fees for solemnizing marriages outside of the regular session of the Court’s marriage division. Also embroiled in the wedding fees scandal was Judge Bruce Fawell, the chief judge of the 18th Circuit Court. After 20 years on the bench, Fawell resigned in 1984 to avoid censure from the Illinois Courts Commission. The Commission said the conduct of Duane Walter and Lewis Morgan as judges was “prejudicial to the administration of justice and tended to bring the judicial office into disrepute.”

Judges Morgan and Walter soon came under fire again. In 1986, Judge Walter made racist statements that led the Illinois Judicial Inquiry Board to file judicial misconduct complaints and reassign him to traffic court while it investigated the complaints. According to one courtroom transcript from an appearance before Judge Walter by an African American man from Cook County, Walter stated, “The guy lives in Chicago, he should stay in Chicago. I don’t invite Harold Washington (Chicago’s African-American Mayor at the time) out here. Harold has never invited me into Chicago, and I wouldn’t go if he did.”

Walter then warned the African American man appearing before him: “Johnny, you come back to DuPage County, you have deep troubles. It’s like the South. They never let you guys run around in the South.” Interestingly, Walter made these comments on September 29, 1986 - the four-year anniversary of the Tylenol murders. Walter also was accused of making rude remarks to a pregnant, unmarried teenager and her mother when they appeared before him at a juvenile hearing. To avoid censure, Judge Duane Walter left the bench in 1987.

Judge Lewis Morgan, after being accused of improper conduct, resigned from the bench in 1986. An article by Art Barnum in the October 25, 1989 edition of The Chicago Tribune described these allegations:

A former DuPage County judge who left the bench under a cloud of alleged improper judicial actions has been charged with several more legal improprieties by the state agency that regulates the legal profession. Lewis V. Morgan Jr., now a private Wheaton attorney who was a DuPage County judge from 1975 to 1986, has been accused of several legal profession violations stemming from his representation of a Florida woman whose divorce case he had heard as a judge in 1982.

Investigators for the State Commission had undertaken a preliminary investigation earlier in 1989 of the charges against Morgan. A three-lawyer panel had agreed that a formal hearing was called for, but the panel did not make its findings public.

The attorneys of Wheaton have always been a closely intertwined bunch, so it is not surprising that the attorneys involved in the Tylenol murders case and connected to the 18th Circuit Court were not limited to the attorneys for Johnson & Johnson. Ed Reiner, following the recommendation of an attorney acquaintance, hired Attorney Robert Dyer to file a liability lawsuit against Johnson & Johnson for the cyanide-laced Tylenol poisoning of his wife, Lynn.

Robert Dyer was a partner in the law firm of Rathje, Woodward, Dyer, and Burt, which was founded by Bert Rathje and John Woodward. Rathje was named the Chief Judge of the 18th circuit court in 1964. Rathje’s son, S. Louis Rathje, was a partner in his father’s firm from 1970 to 1992, and became a judge in the 18th Circuit Court in 1992. Alfred Woodward, the brother of the firm’s co-founder, was a partner in the firm from 1950 to 1970. He became a judge in the 18th Circuit court in 1970 and was Chief Judge from 1973 to 1975.

Alfred Woodward’s son is Bob Woodward, the journalist who broke the Watergate story that led to Richard Nixon’s resignation as President of the United States on August 9, 1974. Bob Woodward graduated from Wheaton Community High School in 1961 and left his hometown that year. He told the Daily Herald in 2002 that life in Wheaton had sparked his interest in finding the truth behind the façade of society. “You realize a small town like that has lots of secrets,” he said “There is a big difference in how people appear and how they actually are.” On the surface, it seems life is plugging along normally, but the reality is that under the surface, tensions and problems are trying to pull it all apart,” Woodward said. “You see that very dramatically in a place like Wheaton.”

Somewhere, just under the surface of the quiet suburban town of Wheaton, lays the secret truth about the conspiracy to plant the eighth bottle of cyanide-laced Tylenol capsules.

43

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A Reactivated Cover-up

Lawrence Marshall, a Professor of Law at Northwestern University, said in 1999, “We generally condone a great deal of misconduct when we think it serves the ultimate ends of justice. Many players in the system - judges, defense lawyers, prosecutors - know some of the stuff that happens, but nonetheless tend to turn a blind eye. There’s a feeling that that is how it works, that it’s legitimate to bend the truth sometimes when you are doing it with - quote, the greater good, end quote - in mind.”

There was plenty of truth-bending involved in getting the Tylenol murders case reactivated, but there was no greater good in play, just more questions and a huge risk that the prior misconduct by the J&J executives and government officials involved in the investigation would come to light. Why not let it all stay conveniently buried?

The problem with doing nothing was that in all likelihood, the truth about the Tylenol murders was not going to lie dead quietly. Under the federal Freedom of Information Act, the FBI should have declassified documents from the Tylenol murders investigation on the 25th anniversary of the case – but not if the case was being actively investigated.

In July 2007, with the imminent declassification of the Tylenol murders’ documents drawing near, “retired” FBI Agent, Roy Lane, and “Sherry Nichols,” posing as a freelance journalist writing a book about the Tylenol murders, initiated an operation that looked an awful lot like an attempt to frame James Lewis for the Tylenol murders. Lane and Nichols, apparently working as operatives of the FBI, met with James and LeAnn Lewis many times. They took the Lewises out to dinner, paid James thousands of dollars, and taped 80 hours of interviews with him. Lane attempted to persuade Lewis to write his novel, POISON! The Doctor’s Dilemma, in a way that the FBI and prosecutors in DuPage County hoped to pawn off as a confession from Lewis to the Tylenol murders. Neither Nichols nor Lane responded to emails inquiring about their “collaboration” with Lewis.

In the fall of 2008, authorities in Illinois secretly formed a new Tylenol task force of investigators from the FBI, the Chicago and suburban police, and the Illinois State Police (ISP); previously known as the Illinois Department of Law Enforcement (IDLE). Authorities convened grand juries in Cook and DuPage Counties to review evidence from the 1982 Tylenol murders. Sherry Nichols’s phantom Tylenol murders book was supposedly in editing at the time, marking the end of the covert investigation. It was now time for the FBI and DuPage County authorities to initiate the overt phase of their Tylenol murders operation – a decision possibly made easier by the recent death of Roger Arnold on June 16, 2008, at the age of 74. His death cleared the way for investigators to reactivate the Tylenol murders investigation with no worry that reporters might ask Arnold questions that officials did not want answered.

In January 2009, at the request of State’s Attorney, Joe Birkett, an 18th Circuit Court judge granted a warrant to search the apartment of James and LeAnn Lewis. This public reactivation of the Tylenol murders investigation generated a quick flurry of media coverage when FBI and ISP agents searched the Lewises’ apartment on February 4, 2009, and again when the FBI collected the Lewises’ DNA samples in Middlesex County on January 6, 2010. But that was it. There was no new evidence. The reactivated investigation was a good story for the press and a convenient cover story for government officials and J&J executives who wanted to keep the public in the dark about the real killer’s true modus operandi. The news stories claiming that the FBI and Illinois authorities were still investigating James Lewis after so many years definitely accomplished that goal.

The FBI now says that it is actively involved in the Tylenol murders investigation, but in 1999 the FBI denied any involvement at all. Wally Kowalski, of the Department of Engineering at Pennsylvania State University, filed a FOIA request in 1999 seeking documents related to the Tylenol murders investigation. He received a response from FBI Section Chief, John M. Kelso Jr., who said that a search of the central records system at FBI headquarters “located no records indicating that your subject [the 1982 Tylenol murders] was the subject of an investigation by the FBI.”

When the Tylenol case was reactivated in 2009, the lawyer-lawmen involved in the original investigation came out of the woodwork to demonize James Lewis. In an interview with NBC-News in Chicago, Tyrone Fahner declared: “[Lewis] was clearly the head and shoulders bad guy in the whole thing. And we felt that he committed the murders, but we couldn’t prove it at that time.” Fahner, of course, has never cited any evidence implicating Lewis in the tamperings.

Dan Webb, the U.S. attorney in the Northern District of Illinois from 1981 to 1985, also commented on the reactivated investigation while the FBI and ISP were still searching Lewis’s apartment. In an interview with ABC-7 in Chicago, Webb said, “As someone who was very much involved 27 years ago, the fact that they [FBI and ISP] have current information is at least encouraging to me. You cannot get a search warrant today to search a given house unless you actually have probable cause. That means the FBI has a reasonable basis to believe that there’s evidence of a crime being housed at a certain location.”

The FBI, as Webb should have known, since he “was very much involved in the case 27 years ago,” did not have probable cause to search Lewis’s home. None of the items that the FBI removed from Lewis’s home even existed in the 1980s. Apparently a judge had granted the search warrant on the basis of an alleged DNA smudge on a capsule in the planted eighth bottle of cyanide-laced Tylenol, and on the hope that James Lewis’s fictional novel, POISON! The Doctor’s Dilemma, contained a paragraph or two that prosecutors could claim was a confession to the Tylenol murders.

The FBI released a statement on February 4, 2009, claiming that new tips generated by the 25th anniversary of the Tylenol murders were being pursued in “a renewed effort to solve this crime and bring some measure of closure for the families of the victims.” Nearly a year later the FBI collected DNA samples from James and LeAnn Lewis.

The DNA technology available to the FBI and ISP had been in use for more than a decade. If these agencies did actually have DNA evidence from the Tylenol case, they could have compared the Lewises’ DNA to that “evidence” years ago. Human DNA typing (profiling) was invented in 1984, but was not available commercially until 1986. It was not used by the FBI until 1988. Still, the authorities who collected the evidence in the Tylenol murders investigation in 1982 might have preserved any potential DNA evidence if they had been extraordinarily careful with it. But they weren’t.

Network news video clips taken in October 1982 show lab workers handling the victims’ bottles of cyanide-laced Tylenol capsules in the labs at the Medical Examiner’s Office in Cook County and the Illinois Department of Health in DuPage County. These lab workers, who were not wearing gloves, were handling the bottles and repeatedly pouring the capsules into their hands and back into the bottles. In the video clips shown on NBC, the lot numbers from the victims’ Tylenol bottles can be seen on the bottles being handled by the lab workers. The commentary in these video clips further clarifies that the bottles and capsules being shown were from the Tylenol victims. All of the victims’ Tylenol bottles and capsules were handled in this same casual, unknowing manner.

The mishandling of evidence from the Tylenol murders case was first reported in 1984 by Pam Zekman, an investigative reporter for Chicago’s CBS affiliate, WBBM-TV. Zekman was especially critical of Cook County Toxicologist, Michael Schaffer; the star of at least one video-clip showing him with his paws all over the Tylenol bottles and capsules that had been recovered from some of the victim’s homes.

Schaffer responded to Zekman’s reports by hiring attorney Robert Maloney, who then filed a libel suit seeking $25 million in damages. Maloney told the Chicago Sun-Times in March 1986 that Schaffer was asking for $25 million in punitive damages and $100,000 in actual damages against Zekman. “She made statements that made him [Schaffer] out to be incompetent, to the point at which whoever is responsible for these foul crimes will never be found guilty,” said Maloney. The suit also named former WBBM-TV General Manager Gary Cummings as a co-defendant for airing an editorial repeating Zekman’s charges.

“I stand behind my story,” Zekman stated.

Ultimately, Schaffer’s lawsuit disappeared somewhere inside the shadow legal system, but it may have served to dissuade other Chicago area journalists from exposing the details about the mishandling of evidence. All of the bottles of cyanide-laced Tylenol capsules collected during the Tylenol murders investigation were contaminated by authorities in 1982. The “DNA smudge” - the only  “evidence” ever mentioned by spokespersons for the current Tylenol task force - is irrelevant to the Tylenol murders, because it came from a capsule in the planted eighth bottle of cyanide-laced Tylenol.

44

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The New Case; Same as the Old Case

Michelle (Reiner) Rosen, the daughter of Lynn Reiner, learned about the reactivated Tylenol murders investigation along with the rest of the country when the network news programs began beaming live video coverage of the Lewises’ Cambridge apartment building on February 4, 2009. Michelle was not buying the FBI’s story that it had received “new tips” in the case.

Michelle decided to find out what she could about the investigation conducted more than 26 years earlier into her mom’s death. She first went to the Central DuPage Hospital and asked for her mom’s medical records. Officials there told her that the hospital had destroyed those records long ago. Michelle then went to the Winfield Police Station and asked Police Chief Frank Bellisario if she could see the documents from their investigation into her mom’s death. Bellisario told her that whatever documents they had not turned over to the FBI had been destroyed in “the flood.”

Flooding does occur in DuPage County from time to time, but the Winfield Police Station where the Tylenol murders documents were stored sits on top of a hill. An article that ran in the Chicago Tribune on September 29, 2002, marking the twentieth anniversary of the Tylenol murders, included a picture of the Winfield Police Department’s evidence room. The picture showed the documents from the Tylenol murders all neatly boxed up and sitting on shelves several feet above the floor. The caption below the Chicago Tribune picture read:

In 2002, Winfield Police Department Lt. Bill Rizer stands in the basement of the police station, which contained old case files stacked on shelves concerning the Tylenol investigation. The Winfield, Ill. police department was part of the Tylenol Task Force investigation of the murders.

Lieutenant Rizer told the Tribune, “To be up front with you, our case has never been closed… The case is downstairs in our archives - many, many volumes’ worth. But we’re not doing anything on it. There’s nothing for us to do.”

Chief Bellisario’s contention that the Winfield police had turned their files over to the FBI, but retained no copies for themselves, is further discredited by the fact that the Tylenol murders were not a federal crime. Why would the Winfield Police turn their files over to the FBI, when the federal government had no jurisdiction to bring charges?

FBI officials told the Chicago Tribune in 2002 that they were no longer involved in the Tylenol murders case. The FBI said the case was a murder investigation that falls under the jurisdiction of the police departments where the deaths occurred: Winfield, Lombard, Arlington Heights, Elk Grove Village, and Chicago.

Frank Bellisario was a rookie Winfield police officer in 1982. After the death of Lynn Reiner, he and another Winfield police officer made a concerted effort to spend time with the Reiner children. They took Michelle and her sister, Dawn, bowling, and seemed truly interested in helping the kids cope during that tough time. Now, 26 years later, when Chief Bellisario could offer Michelle some real help, he seemed uninterested. He told Michelle to talk to Scott Watkins, the Winfield police officer who was primarily responsible in 1982 for investigating her mom’s murder.

Watkins met with Michelle on March 9, 2010. He told her that because of the six Extra Strength Tylenol capsules in her mom’s bottle of Regular Strength Tylenol, authorities had no choice but to investigate her father. He then apologized to Michelle for treating her father as a suspect, but justified his actions by saying that those six red and white Extra Strength Tylenol capsules “stood out like a sore thumb” in her mom’s bottle of gray and white Regular Strength Tylenol capsules. Michelle suggested that her mom’s cyanide-laced Extra Strength Tylenol capsules might have been in a bag of pharmaceutical company freebies given to her at the hospital. Watkins agreed that this was a reasonable theory.

Michelle also met with Peter Siekmann, currently the DuPage County coroner; a position he was first elected to in 2004. Siekmann was the deputy coroner for DuPage County in 1982, and had conducted the death investigation of Michelle’s mom. Siekmann was very kind to Michelle when he spoke to her in 2010, spending probably a half hour with her when she stopped by the coroner’s office to get a copy of her mom’s coroner’s inquest report. However, he didn’t seem to remember much about the investigation. Siekmann, who has been involved in over 10,000 death investigations, including over 165 homicides during his 35 years at the DuPage County Coroner’s Office, indicated that he had very little knowledge about any evidence related to the death of Lynn Reiner.

Peter Siekmann and Scott Watkins were members of the Tylenol task force in 1982. Watkins and presumably Siekmann were interviewed by some of the un-named members of the new Tylenol task force before an 18th Circuit Court judge gave Joe Birkett the warrant he needed to search Lewis’s apartment. Birkett, the state’s attorney in DuPage County from 1995 to December 2010, was an assistant state’s attorney in DuPage County during the Tylenol murders investigation in 1982. He is now a judge in the Illinois Second Appellate Court. Several other individuals who held important government positions in DuPage County when the Tylenol case was reactivated in 2009 were also government employees in DuPage County in 1982.

Robert Schillerstrom, the commissioner of the DuPage County Board of Directors from 2003 to December 2010, was an assistant state’s attorney in DuPage County at the time of the Tylenol murders. Schillerstrom has been a DuPage County Republican committeeman since 1980. He entered the Illinois gubernatorial race in June 2009, but dropped out seven months later. Schillerstrom joined the law firm of Ice Miller in 2003 as a partner in the firm’s Public Affairs Group. Ice Miller is based in Indianapolis, Indiana, and has offices in Washington D.C., DuPage County, and Chicago. One of Ice Miller’s long-time clients is Johnson & Johnson. Ice Miller has represented Johnson & Johnson in a number of product liability lawsuits filed against the company.

On the same day the State’s Attorney’s Office in DuPage County served a search warrant on James and LeAnn Lewis, thus publicly reopening the Tylenol murders investigation, it became readily apparent that Johnson & Johnson also had a stake in this reactivated sham. While authorities were searching Lewis’s Cambridge apartment, former J&J Group Company Chairman, Wayne Nelson, spoke publicly to ABC’s Brian Ross about the Tylenol case. Not since 1982 had a current or former J&J executive spoken to the press about the Tylenol murders investigation. Nelson broke that silence; maybe in a desperate effort to save his legacy, as well as the legacy of many other J&J executives.

Nelson, the co-founder and former chairman of the McNeil Consumer Products Company, was a member of both J&J executive teams that had handled the issues related to the Tylenol murders in 1982 and 1986. Just days before the 1982 Tylenol murders, J&J had moved Nelson out of his position as chairman of McNeil, and into the position of vice president of J&J International – making way for Oak Park Illinois-native David Collins to take over as McNeil chairman.

Nelson owes Johnson & Johnson a big debt of gratitude. The company he founded in 1987, Nelson Communication, was built with Johnson & Johnson’s money, and still gets a lot of business from Johnson & Johnson. Nelson made a fortune in 2000 when he sold Nelson Communications to the Publicis Groupe, pocketing an estimated $100 million or more for his 13.3 million shares of the company’s stock. Publicis then named Nelson chairman emeritus of Nelson Communications Worldwide, its newly created subsidiary.

Johnson & Johnson’s policy of media silence regarding the Tylenol murders had been set early on. In 1983, as the one-year anniversary of the Tylenol murders approached, Johnson & Johnson refused to respond to inquiries from reporters. Instead, a J&J spokesperson said they feared comments could trigger a round of copycat crimes. Johnson & Johnson’s only statement for the one-year anniversary articles was that the 1982 Tylenol tamperings drew company employees closer together and that it “still stimulates for us emotions of sadness about the deaths and indignation.”

During several speaking engagements over the years, a few select J&J executives have occasionally repeated snippets of the well-established company line about the company’s response to the tamperings. However, since 1982, they had never given a public statement about the actual investigation. Nelson’s statement on February 4, 2009 was the first.

Nelson’s interview with ABC’s Brian Ross was especially unusual in light of the fact that he had his own policy of media silence at Nelson Communications Worldwide. Nelson gave an interview in 1999 that represented a one-time break from that policy. The short interview appeared in the trade magazine, Medical Marketing & Media. The interviewer introduced Nelson by saying: “As Mr. Nelson will explain, this is the first time they [Nelson Communications] have “gone public,” breaking a long tradition of not talking to the press.”

After 26 years of media silence about the Tylenol murders, Nelson came out of the woodwork and put the spotlight back on James Lewis by suggesting that investigators had some kind of evidence linking him to the murders. “There were a lot of people who believed that what was available in terms of evidence pointed towards him [Lewis],” said Nelson. “But that was the extent; it wasn’t enough to convict or even prosecute.” Nelson spun his innuendo to imply guilt.

ABC news consultant, Brad Garrett, a retired 20-year FBI veteran of numerous investigations involving terrorism on United States soil, also contributed to Ross’s story. Garrett said that Lewis “was dismissed as a suspect because it was felt the cyanide, since it eats through the capsule, would have had to have been put in close to the time they were purchased, and the FBI could not put him [Lewis] in Chicago at the time.”

Once again, the FBI was promoting the bogus claim that the cyanide could eat through the gel-based capsules in just a few days – a claim that Garret should have known was false. Even Garrett’s statement that the FBI could not put Lewis in Chicago at the time of the Tylenol poisonings, was evidently just a set up for Wayne Nelson, who then suggested that he had some sort of special knowledge of a scheme that could explain how Lewis could have committed the Tylenol murders in Chicago while living in New York City.

“Based on an analysis of the stores where the tainted Tylenol was purchased,” said Nelson, “many close to the case believed that whoever dropped the drugs off had flown into Chicago, rented a car, gone and distributed the pills, and then flown back out of O’Hare airport.”

Nelson never mentioned that in October 1982, and again in December 1982, the New York City police and the FBI said James and LeAnn Lewis had not left the City since checking into the Hotel Rutledge on September 6, 1982. Nelson also never explained how Lewis, who was broke at the time, could have paid for airline tickets and carried out such an incredible feat without leaving behind a single clue of this purported one-day journey to Chicago and back to New York City. James and LeAnn do not wear wedding bands today because they had to hock them at a New York City pawnshop in the fall of 1982 so they could buy food.

Why would a powerful corporate executive like Wayne Nelson take time out of his busy day to make unsubstantiated claims, falsely implicating an innocent man for the Tylenol murders - unless Johnson & Johnson had something to hide? The planted eighth bottle of cyanide-laced Tylenol is the smoking gun that could, still today, cause big problems for a number of organizations, including Johnson & Johnson.

One person who might be able to clarify the circumstances surrounding the eighth bottle of cyanide-laced Tylenol is Marylou Crane. She has been a Winfield resident since 1954 and has been active in DuPage County politics since the 1970s. Marylou was the administrative assistant to State Representative Donald Hensel from 1982 to 1989. She was also the coordinator of Jim Edgar’s successful 1982 election campaign for Illinois secretary of state. Marylou served as the assistant to Secretary of State Jim Edgar (from 1987 to 1991) and George Ryan (from 1991 to 1993). Edgar went on to become Governor of Illinois from 1991 to 1998, and Ryan was the Illinois Governor from 1999 to 2003.

Marylou was a Winfield Village trustee from 1986 to 1993 and president of the Village of Winfield from 1993 to 1997. In March 2008, DuPage County Chairman, Robert Schillerstrom, reappointed Marylou to the DuPage County Fair and Exposition Authority. Marylou has served on several DuPage County Boards over the past few decades and has also served as the president of the Winfield Chamber of Commerce. While president of the Village of Winfield, she even wrote a monthly column, called “Municipal Matters,” in the Arlington Heights newspaper, The Daily Herald. Marylou is the chairperson of the Winfield Board of Fire & Police Commissioners, which makes appointments to the Winfield Police Department, and conducts and holds all entrance and promotional examinations. The Board decides who gets fired and hired at the Winfield Police Department.

Interestingly, Marylou Crane had her own moment of notoriety during the Tylenol murders investigation back in 1982. Marylou took on the last name of Crane in 1989 when she married J. Alan Crane. But in October of 1982, Marylou Crane, was Marylou Walter - the estranged wife of Judge Duane Walter. Marylou is the person who Wheaton Police Lieutenant Terry Mee identified on October 25, 1982 as the woman who had turned in the eighth bottle of cyanide-laced Tylenol.

When the FBI interviewed Marylou on October 26, 1982, she told them that they had the wrong woman. Marylou said she was not the one who had turned in the eighth bottle of cyanide-laced Tylenol to the Wheaton police. After a short search for the “mystery woman” who supposedly did actually turn that bottle in, Linda Morgan, the wife of Judge Lewis Morgan, came forward and took credit for turning in the eighth bottle.

At the time of the Tylenol murders, the Walters and Morgans had long been active in DuPage County politics. Marylou Walter was then working for Illinois State Representative, Donald Hensel, and was coordinating Jim Edgar’s election campaign. Duane Walter had been a committeeman for the Winfield Township until 1976. He became a judge in 1977. Lewis Morgan had been a state representative from Wheaton for 10 years before he became a judge in 1975. Lewis Morgan’s father had been the DuPage County superintendent of schools from the 1920s to the 1950s.

The Morgans lived in Wheaton, less than a mile from the Wheaton Police Station. The Walters lived in Winfield, just a few miles west of the Wheaton Police Station. The Wheaton Police Station was just a few blocks west of the 18th Circuit Courthouse where Judge Duane Walter and Judge Lewis Morgan worked in 1982. Judge Walter was a traffic court judge at the time of the Tylenol murders. Surely, Wheaton Police Lieutenant Terry Mee had appeared before him at numerous hearings. It seems odd that Mee did not know either Linda Morgan or Marylou Walter.

The fact that all of the turmoil surrounding the eighth bottle of cyanide-laced Tylenol was going on in the front yard of Johnson & Johnson’s local attorneys at the law firm of Rooks, Pitts and Poust, located right across the street from the 18th Circuit Court near the Wheaton Police Station, raises obvious questions regarding Johnson & Johnson’s knowledge of the conspiracy to plant the eighth bottle of cyanide-laced Tylenol. It was an unlikely coincidence that the only two individuals ever identified as having turned in a bottle of cyanide-laced Tylenol were both married to DuPage County judges who lived and worked in the same geographic and legal community as Johnson & Johnson’s local attorneys, Paul Noland and Francis “Mike” Heroux, who, along with McNeil Chairman David Collins, were all natives of Oak Park, Illinois, and members of the same Fenwick High School graduating class of 1952. These connections, coupled with the sordid details about the planted eighth bottle, would have raised suspicion among jurors if the Tylenol murders liability lawsuits had ever gone to trial.

It is notable that Johnson & Johnson filed a motion seeking a closed trial in the Tylenol murders liability case. When Judge Wolfson denied Johnson & Johnson’s request for a secret trial, the company quickly settled the lawsuits out of court, and required the plaintiffs to sign confidentiality agreements. J&J then convinced Judge Wolfson to seal all of the documents that the company had turned over to the court. Johnson & Johnson obviously did not want the public to see any evidence related to the Tylenol tamperings and murders.

An FOIA request was submitted on June 16, 2011 to the Winfield Village FOIA Officer, Sharon Samuels, requesting case reports, incident reports, and all investigation reports and documents related to the poisoning of Lynn Reiner and her subsequent death. Samuels’ reply, which came back one day later, was written on a Winfield Police Department letterhead. Samuels denied the FOIA request, saying, “We no longer have any copies of reports – they were all turned over to the Illinois State Police (ISP) task force at that time [in 1982].” That statement was, of course, not true.

Winfield Police Lieutenant, Bill Rizer, had told the Chicago Tribune in 2002 that the Tylenol murders investigation had never been closed. He made that statement while standing in front of the boxes of Tylenol murders investigation documents stacked on shelves in the evidence room of the Winfield Police Department. Nevertheless, Samuels now claims that the boxes of Tylenol murders documents that were photographed by a Chicago Tribune photographer in the Winfield Police Department’s evidence room on September 24, 2002, had been turned over to the Illinois State Police in 1982.

An FOIA request for documents from the Tylenol murders investigation was filed with the Illinois State Police in June 2011. Colonel Rob Haley denied this request on July 15, 2011, stating:

The case is still being investigated. The release of documents prior to an investigation being completed will negatively impact the investigation, including witnesses’ willingness to cooperate, and law enforcement’s ability to effectively complete its investigation. The requested information is withheld per the freedom act’s provisions regarding interference with pending or actually and reasonably contemplated law enforcement proceedings conducted by any enforcement or correctional agency (5 ILCS 140/7(1)(d)(i) and obstruct an ongoing investigation (5 ILCS 140/7(1)(d)(vii).

The FBI also promptly denied a June 2011 FOIA request seeking documents related to the Tylenol murders investigation. Since this investigation is, according to the FBI and the State of Illinois, “active,” the documents from the investigation will remain classified. Evidence from the Tylenol murders has been kept hidden from the public by the confidentiality requirements of the “active” investigation and the secrecy rules of grand jury proceedings.

The motivation of J&J and DuPage County authorities to keep evidence from the Tylenol murders hidden is obvious. J&J has its reputation and the reputations of its executives to protect. DuPage County authorities have their reputation, egos, and careers to protect. The truth about the planted eighth bottle of cyanide-laced Tylenol might cause major problems for officials from both Johnson & Johnson and DuPage County still today; possibly resulting in civil lawsuits against them for obstructing the investigation. But what is the FBI’s motive for taking such an active role in the reactivated Tylenol murders investigation?

45

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Mens Rea: Guilty Mind

The FBI’s role as the front-man in the reactivated Tylenol murders investigation is odd, because the federal government has absolutely no jurisdiction to bring charges in the 1982 Tylenol murders case. In fact, the FBI had publicly declared in 2002 that it was no longer involved in the Tylenol murders investigation. So why did the FBI get so heavily re-involved?

Several factors, including the expiration dating and the distribution path of the Tylenol involved in the 1982 and 1986 poisonings indicate that there was something different about how the Tylenol in both tampering incidents was packaged. The expiration dating of that Tylenol may just be the smoking gun that the feds had hoped to keep hidden.

In 1982, the six lots known to have contained cyanide-laced Extra Strength Tylenol capsules were Lots MC2880, 1910MD, 1665LM, MC2884, 1801MA, and MC2873. The press briefly publicized the manufacturing and expiration dates for only two of these lots. The sudden end to the release of lot-specific information might have had something to do with the expiration dates already revealed for Lots MC2880 and 1910MD. The Tylenol from Lot MC2880 was in the Janus and Kellerman bottles of cyanide-laced Tylenol, and had an expiration date of April 1987. The Tylenol from Lot 1910MD was in Mary McFarland’s bottle of cyanide-laced Tylenol, and had an expiration date of May 1987. Incredibly, the two bottles of cyanide-laced Tylenol capsules from the 1986 Tylenol tamperings in Westchester County, New York, had those exact same expiration dates.

The first bottle of cyanide-laced Tylenol recovered in 1986 (Diane Elsroth’s bottle) had an expiration date of May 1987; the same expiration date as McFarland’s Tylenol. The second bottle of cyanide-laced Tylenol recovered in 1986 had an expiration date of April 1987; the same expiration date as Kellerman’s and Janus’s Tylenol. These identical expiration dates indicate that the 1986 Tylenol killer may have intended to send an ominous message to Johnson & Johnson, the government, and the public regarding his ability to poison medicine in the distribution channel. The public never got that message, because the press never reported that the expiration dates of the Tylenol involved in the 1982 and the 1986 tampering incidents were identical.

Though the expiration dates of the adulterated Tylenol from the 1982 and 1986 tampering incidents were the same; the manufacturing dates were not. The Tylenol involved in the 1986 tamperings was manufactured about three years after the Tylenol involved in the 1982 Tylenol murders.

The Tylenol from the 1982 tamperings, manufactured in the spring of 1982, had a shelf life of 5 years. The Tylenol from the 1986 tamperings, manufactured in May and July of 1985, had shelf lives of 24 months and 21 months. The Tylenol bottled at the McNeil Consumer Products Company plants, however, had a shelf life of 3 years.

The Tylenol Professional Monograph states: “Under room temperature storage conditions, TYLENOL acetaminophen solid formulations are generally stable for 3 years from the date of manufacture” for commercially available products. The source of the stability data for this expiration dating is a 1974 study: Fairbrother J. Acetaminophen. New York, NY: Academic Press; 1974.

The three–year shelf life of Tylenol was mentioned in February 1986 by Jack Ogun, the director of the Division of Drugs, Devices and Cosmetics for the Pennsylvania State Health Department. Ogun told the Philadelphia Inquirer that the May 1987 expiration date of Elsroth’s tainted bottle of Tylenol indicated that it would have been in stores for about two years, because non-prescription pain-relievers generally have a shelf life of about three years.

In October 1982, Dean Mickelson, a pharmacist at the Revco drugstore in Taos, New Mexico, had also mentioned the three-year shelf life of Tylenol. Mickelson told The Taos News on October 6, 1982 that Tylenol has a shelf life to 1985, meaning the Tylenol manufactured in 1982 would expire three years later, in 1985.

An FOIA request was filed with the FDA in June 2011 seeking documents describing the expiration dating of Tylenol produced in McNeil’s manufacturing plants in 1982. The FDA responded, stating: “Tylenol and other acetaminophen products are marketed and labeled under the OTC drug monograph and without an approved application housing such records.” The FDA did not produce the requested information, but it did confirm that the Tylenol expiration dating is based on the acetaminophen/Tylenol monograph. The Tylenol monograph says that Tylenol manufactured and bottled at the McNeil plants has a shelf life of three years. The three year shelf life has not changed since the launch of Extra Strength Tylenol capsules in 1975.

A drug’s shelf life is based on stability testing. The stability of a drug varies depending on the container-closure system in which the drug product is being sold. A drug that is packaged and sold to repackagers in bulk containers typically has a shorter shelf life than the same drug bottled at the manufacturing plant. The Tylenol that was bottled at the McNeil plants in the containers that were sold in retail stores had a shelf life of three years. The Tylenol involved in the 1986 tampering incident, because it had been shipped in bulk containers to repackagers, had a shorter shelf life; about two years.

The five-year shelf life of the Tylenol involved in the 1982 Tylenol murders was well outside the shelf life of any Tylenol product - with the notable exception of the Tylenol that Johnson & Johnson sold to the United States Department of Defense (DOD).

In 1973, the DOD sought to defer drug replacement costs for date sensitive stockpiles of prescription and OTC drugs by extending their useful life beyond the manufacturer’s original expiration date. Subsequently, the Office of Management and Budget and the General Accounting Office completed studies to determine the feasibility of a “shelf life extension program.” These agencies found that the shelf life of OTC drugs, generally two to three years, could safely be extended to five years under properly controlled storage conditions.

On July 1, 1975, the FDA and the Veterans Administration (VA) entered into a “Memo of Understanding” implementing a program to extend the expiration dates of the prescription and non-prescription drugs that the VA purchased. The expiration dating on most drugs was extended to five years for prescription and OTC drugs sold to all branches of the DOD. The FDA was charged with monitoring this program, which applied only to drugs purchased by the DOD for use in military facilities, and for sale in military commissaries.

Throughout the 1980s, the DOD contracted with the McNeil Consumer Products Company to buy Tylenol from all three of the Johnson & Johnson facilities that distributed Tylenol. The DOD purchased Tylenol in bulk containers for use in Military treatment facilities and VA hospitals and clinics. The DOD also purchased Tylenol for sale in the retail class of trade through its military commissaries. Because of the shelf-life extension program, all of the Tylenol sold to the DOD was given a shelf life of five years. This required separate bottling production runs so that the labels on the Tylenol bottles being sold to the DOD reflected the 5-year shelf life rather than the typical 3-year shelf life of the Tylenol bottled at the McNeil manufacturing plants. The 5-year shelf life of the Tylenol involved in the 1982 Tylenol murders indicates that it may have been intended for the DOD.

At the time of the Tylenol murders, military commissaries were indeed selling bottles of Extra Strength Tylenol capsules from the lots involved in the poisonings. On October 1, 1982, State officials in Kansas said at least 180 bottles of Tylenol from the contaminated lots were found at Fort Riley. A Fort Riley spokesperson, Milt Sheeley, said Tylenol capsules were removed from the commissary and other shops that Friday. “We’re yanking it. We’re advising everybody to throw the capsules away,” said Sheeley.

Public Affairs Officer, Jane Wray, said the manager of the Fort Leavenworth Commissary found “a number of bottles” of Tylenol from the recalled lot, 1910MD. She was uncertain how many bottles were found on the commissary store shelves and how many had been sold. “We’ve also checked the hospitals and Post Exchange,” she said, “but this [the commissary] was the only place Tylenol was found.”

Air Force officials also discovered several cases of Extra Strength Tylenol capsules with recalled-lot numbers at the Chanute Air Force Base in Illinois, and at the Air Force Base in San Antonio, Texas. Air Force officials said that those cases were turned over to civilian authorities - aka, Johnson & Johnson.

Some of the Tylenol purchased in 1982 by the DOD and sold in military commissaries may have been diverted to the civilian retail class of trade. That would explain the five-year shelf life of the bottles of cyanide-laced Tylenol involved in the 1982 Tylenol murders. Drug diversion was a big problem in the 1980s, and the subject of several Congressional hearings. Diverters actively sought out hospitals, long-term-care pharmacies, and Federal Supply Schedule (FSS) purchasers that bought drugs at discounted prices not available to wholesalers in the retail class of trade. The diverters then sold these discounted drugs for a quick profit to wholesalers in the retail class of trade. One example of this type of diversion was described in a January 9, 2001 letter from George T. Patterson, the Executive Director of the VA Acquisition Center in Hines, Illinois, to FSS non-prescription pharmaceutical distribution contractors:

I am writing to alert you to the possible diversion of products sold under your Federal Supply Schedule (FSS) contract. Based upon information and inquiries from some contractors and from the Indian Health Service (IHS) Regional Supply Service Center (RSSC), Ada, Oklahoma, we have reason to believe that large orders for drugs are being placed by tribal health care clinics, sometimes using a non-government pharmaceutical Prime Vendor (PPV) as an ordering intermediary, for resale or distribution to persons and entities not entitled to FSS pricing…

…We suggest that you examine incoming direct orders and chargeback requests for unusually large quantities being requested by or delivered to another government agency activity, such as a tribal clinic. If you notice such unusual orders, we suggest that you ask the ordering activity to justify the quantity ordered in terms of its own federal mission and patient base. Also, we recommend you scrutinize for possible diversion all tribal clinic orders placed through a non-government PPV. Ordering activities may be asked for documentation to prove their contractual relationship with IHS. Recent experience has demonstrated even IHS-authorized clinics ordering drugs through an IHS RSSC may suddenly increase their ordering quantities to divert drugs to a profit-making tribal enterprise…

From 1975 to 1982, the General Accounting Office (GAO) conducted dozens of investigations into the procurement operations for DOD storage depots, military commissaries, and self-service stores. These investigations revealed widespread incompetence, corruption, and fraud. In one report in 1982, the GAO said, “In our opinion, the failure to identify causes and prevent recurrence of reported discrepancies perpetuates conditions of loss of control of government material and payments to vendors for material not received. …Current practices and procedures do not ensure that (1) the government is receiving the material it has paid for, (2) DLA [Defense Logistics Agency] supply centers adjust related records for valid shipping discrepancies, and (3) the supply centers analyze reported discrepancies to identify and correct problem areas.”

According to a March 19, 1982 GAO report, the Military Commissary procurement divisions conducted a substantial amount of business through vendors’ representatives who acted as the intermediary between the buyer and the manufacturer.  The representative was often an independent firm, which provided its services to one or more manufacturers on a commission basis. These services usually ranged from calling on buyers for the purpose of presenting a manufacturer’s merchandise to performing in-store service, such as reordering and inventorying stock. In other words, the intermediaries that provided these services to the DOD commissaries were rack jobbers and merchandisers like the ones employed in the Chicago area by Sav-A-Stop and Zahn Drug.

A Chicago area third-party distributor that delivered Tylenol to the DOD Supply Depot in Hines (four miles south of Zahn Drug), and to Chicago area military commissaries, may have been the same distributor that shipped cyanide-laced Extra Strength Tylenol capsules to Chicago area outlets in September of 1982. If the Tylenol killer put cyanide-laced Tylenol capsules into the bottling production lines at a repackaging facility under contract to bottle that Tylenol for the United States Department of Defense, then the federal government obviously might want to suppress that information.

*****

Despite all the evidence pointing to ongoing poisonings of Extra Strength Tylenol capsules in a Chicago area repackaging facility in 1982, the FBI and the Tylenol task force never conducted a proper investigation of the distribution channel. Instead, they simply turned over the Tylenol capsules from Chicago area stores, hospitals, and distribution centers to Johnson & Johnson. Their one legitimate suspect, Roger Arnold, worked in the distribution channel, but was effectively dropped from the investigation on October 26, 1982, just one day after he had been named as a co-conspirator in the Tylenol murder conspiracy story. The FBI, IDLE, and the press then became conspicuously silent about Roger Arnold.

In a nine-page synopsis of the Tylenol murders probe, IDLE Investigator, Richard Tetyk, wrote that Arnold had told his supervisor at Jewel that he was “mad at people and wanted to throw acid at them or poison them.” A few days before the Tylenol murders, Arnold purchased two one-way tickets to Thailand with a departure date of October 15, 1982. Arnold said he went to Thailand every year, but his lawyer said Arnold had never been to Thailand. A little more than a week after the Tylenol murders, Arnold, while holding a bag of white powder that he said was cyanide, walked into several North Side taverns and talked about killing people with cyanide. Arnold had access to Tylenol in the distribution channel, and he kept cyanide in the basement of his house just prior to the Tylenol murders. A substantial amount of circumstantial evidence makes Arnold a valid suspect in the Tylenol murders case, but no one has ever suggested a possible motive.

“One of the most sensational murder cases in this century has gone unsolved because the person who did it, randomly killed seven people,” said former U.S. Attorney, Dan Webb. “If you have no motive, if all you’re doing is killing people for no reason whatsoever, then that is likely to be the most perfect murder because there won’t be any ties back to you.”

There are, however, a couple of obvious motives that can be ascribed to Roger Arnold. For starters, he was angry at people in general and he was prone to violence. Arnold had talked about poisoning people, and he allegedly had threatened to kill his estranged wife with cyanide capsules. He was armed with cyanide and the necessary ingredients and knowledge to make deadly unconventional weapons. Arnold’s lawyer referred to Arnold as “a soldier of fortune type guy.” Arnold apparently adhered to the ideology of “posse comitatus,” a loosely organized far right social movement that opposes the United States federal government, believes in radical localism, and engages in paramilitary training. The term “posse comitatus” is a Latin phrase, meaning “force of the county.”

In the 1970s and 1980s, posse comitatus groups embraced the ideology of the American Christian Patriot Movement, which supports hostility against any form of government above the county level, vilifies Jews and non-whites as children of Satan, and advocates the overthrow of the U.S. government. Several active posse comitatus compounds were located not far from Chicago in 1982. The Posse at Tigerton Dells was in Tigerton, Wisconsin. The Covenant the Sword and the Arm of the Lord (CSA) was in the Ozarks on the border of Missouri and Arkansas, and the Christian Patriots Defense League was in Louisville, Illinois.

Arnold’s literature included The Anarchist Cookbook, an instruction manual for making explosives; a stash of Soldier of Fortune magazines and a copy of The Poor Man’s James Bond, a survivalist manual written by former Minuteman, Kurt Saxon, which contained instructions for using cyanide-filled capsules to make lethal weapons. The vast majority of people who own these magazines and books are, of course, law-abiding citizens. But it is also true that these publications were standard fare among adherents of the posse comitatus movement whose leaders had stockpiled cyanide and had advocated mass murder in a war against Jews and “Jew sympathizers.”

In September of 1981, Robert Miles, the former Grand Dragon of the Michigan Ku Klux Klan, had given about 200 pounds of cyanide to CSA leader, James Ellison, telling him: “Here, you’ll need this. It will kill a lot of people.” The FBI later confiscated that cyanide in a raid on CSA headquarters in 1985. Ellison testified that in 1981, Miles and Aryan Nation leader, Richard Butler, discussed using cyanide to pollute the water supplies of Chicago, New York City, or Washington D.C.

Just prior to the Tylenol murders, Arnold had used cyanide for unspecified “projects.” He was knowledgeable about the local distributors and had admitted to disposing of his cyanide in August 1982; the same month that J&J shipped some or all of the Tylenol involved in the poisonings to a Chicago area warehouse. Arnold was four days away from leaving the country when he was arrested on October 11, 1982. If prosecutors had brought a case against Arnold, they likely would have characterized his statements about poisoning people, made a week and a half after the Tylenol murders, as a confession to the Tylenol murders.

Guilty or not, a motivated attorney like Joseph Birkett, the state’s attorney in DuPage County from 1996 to December 2010, or Richard M. Daley, the state’s attorney in Cook County from 1981 to 1989, could probably have convinced a jury that Roger Arnold was the Tylenol killer. Charging Arnold with the Tylenol murders would have been an ideal way to close out the Tylenol tampering case as the work of a social outcast who had put cyanide-laced capsules into Tylenol bottles at the retail stores - unless an investigation of Arnold would have debunked this “approved theory” and unearthed the evidence of Johnson & Johnson’s liability for the tamperings. Pursuing Roger Arnold as a suspect, whether dead or alive, whether in 1982 or 2009, would have required an investigation of the distribution channel and might have led to a public disclosure of the true source of the cyanide-laced Tylenol capsules.

Under Title 21 of the U.S. Code of Federal Regulations, Johnson & Johnson was responsible for all aspects of manufacturing Tylenol, including all packaging and labeling operations, no matter where they were done. If authorities had traced the cyanide-laced Tylenol capsules to a warehouse in the distribution channel, Johnson & Johnson likely would have been held liable for the Tylenol murders. Lynn Reiner’s cyanide-laced Extra Strength Tylenol capsules, because they were dispensed at Central DuPage Hospital, represented the smoking gun for Johnson & Johnson. It was clear that those capsules, since they were dispensed at a secure closed-door pharmacy, were filled with cyanide before they were delivered to the hospital.

J&J executives suppressed information related to the packaging and distribution of Tylenol in 1982. They also kept secret their knowledge of hundreds of instances of Tylenol tamperings and contaminations that had occurred in the years prior to the Tylenol murders. J&J kept those complaints under wraps until 1991 when the attorneys for the Tylenol victims’ families revealed that J&J had received nearly 300 consumer complaints of adulterated and contaminated Tylenol products in the three-year period leading up to the Tylenol murders. In describing these complaints, attorney Bruce Pfaff said, “Either capsules were missing, or some other medication was mixed in or there were foreign objects, pieces of metal, and even fingernails.” These incidents apparently did not involve poison, but they did highlight a known problem regarding Johnson & Johnson’s inability to stop tamperings that were occurring in Tylenol bottling production lines at McNeil and at third-party repackaging facilities. Did Johnson & Johnson executives also know – even before September 29, 1982 - that cyanide-laced Tylenol capsules were getting into the production lines at a repackaging facility in Illinois?

46

________

The Madman

Just days before the deaths of seven Chicago area residents from cyanide-laced Tylenol capsules, Johnson & Johnson made some major personnel changes. James Burke appointed David Collins as the chairman of McNeil in September 1982. Collins was an Oak Park, Illinois-native, and had well-connected friends living at the center of the Tylenol murders crime scene. Collins hired two of his lifelong friends, both partners at the law office of Rooks, Pitts and Poust in DuPage County, “to help uncover the details” of the Tylenol murders.

Also in September 1982, Johnson & Johnson, a longtime proponent of decentralization, had begun to centralize the major processes related to the distribution of raw materials and finished goods. It had incorporated a new company, Johnson & Johnson Hospital Services Group, to take over the order fulfillment and the sales and logistics operations of J&J’s 13 largest operating companies.

Shortly before the Tylenol poisonings, in both 1982 and 1986, James Burke worried about potential problems that might be on the horizon for the Tylenol business. At the J&J Executive Committee’s annual three-day strategic planning review held after the Labor Day weekend in September 1982, Burke worried that things were going too well. “We had been marveling at how lucky we were to be in our industry,” recalled Burke, “to have some very profitable brands doing so well, and I had said, offhand, ‘What if something happens to one of them, like Tylenol?’” J&J had hundreds of products, but Burke singled out Tylenol alone as the focus of his concern.

On February 8, 1986, the same day Diane Elsroth died, Burke had a premonition of another “Chicago nightmare”. “I did worry,” Burke recalled. “That Saturday night . . . I had a dream that Chicago had happened all over again.” It was as if Burke already had information prior to Elsroth’s death of another Tylenol tampering incident. He certainly knew that another Tylenol poisoning incident could happen and that J&J couldn’t stop something like this because the problem was already imbedded in its manufacturing and distribution system.

Johnson & Johnson’s foreknowledge of deadly problems with its drugs is a recurring theme at this company. FDA Commissioner, George Larrick, testified in 1964 that mistakes by his agency and the withholding of information by Johnson & Johnson subsidiary, McNeil Labs, kept the harmful drug, Flexin, on the market for five years. Larrick said that in 1959, two years before the FDA suspended sales of Flexin, “The firm then knew of 39 cases of hepatitis in patients taking Flexin, including 11 fatalities, and that 20 of these cases, including 6 deaths, had been directly ascribed to Flexin by the reporting physicians.”

When Johnson & Johnson executives took the prescription painkiller, Zomax, off the market in 1983, they had known for two years that it was killing people. During its 28 months on the market, J&J had received hundreds of reports of severe allergic reactions from Zomax. The FDA concluded that Zomax was probably a factor in 14 deaths.

A study that J&J was conducting on the painkiller, Suprol, while the drug was under review for FDA approval in 1985, showed clear evidence of Suprol’s adverse effect on the kidneys. J&J hid that data from the FDA, which then approved Suprol in December of 1985. Seventeen months later, under pressure from Congress, J&J removed Suprol from the market. By then, 270 people had suffered kidney damage while on the drug. An FDA official said the Suprol application for FDA approval was “plagued from beginning to end with bad data. Some of it was deliberate falsification.”

More recently, Johnson & Johnson knew that Propulsid, a drug for treating heartburn, had been killing people for six years before they pulled it off the market in 2000. Propulsid had generated $2.5 billion in sales by then, but had also been cited as a suspect in 302 deaths. The drug was never approved for children, yet 24 children under the age of six died while on Propulsid. Despite the adverse effects associated with this drug, Johnson & Johnson had never conducted the safety studies urged by federal regulators and its own consultants. Instead, Johnson & Johnson continued to defend the safety of Propulsid, pulling it from the market just before a Congressional hearing was convened that threatened to draw attention to the drug’s long, largely hidden, record of trouble.

If Johnson & Johnson had knowledge of an ongoing Tylenol tampering problem in its distribution channel in the 1980s, it would have been out of character for the company not to cover up that problem. One of the factors that made it so easy for J&J to keep evidence related to the tamperings hidden was that the press never looked beyond J&J’s vague incomplete answers to questions about the packaging and distribution of Tylenol. J&J executives said the Tylenol involved in the 1982 Tylenol murders had been bottled and packaged at the “factory,” but they never actually disclosed the identity of that factory. Larry Foster said J&J believed that the Tylenol tampering “problem rests in Chicago.” But no J&J executive ever actually said that the tamperings had occurred in the Chicago-area retail stores – not until two decades after the fact anyway.

The Tylenol task force never disclosed the distribution path of any of the bottles of cyanide-laced Tylenol capsules. Authorities never even admitted to conducting an investigation of Zahn Drug, the likely distributor of all of the cyanide-laced Extra Strength Tylenol capsules to Chicago area outlets. However, officials from the FBI, FDA, and IDLE made several visit the company’s Melrose Park distribution center and questioned employees about the Tylenol that had been distributed through that warehouse. According to Zahn Drug Vice President, Jim Dempsey, “They were principally interested in the lots of Tylenol Extra Strength capsules that we had; and they were also interested in what customers had purchased them, how many, and when.”

Johnson & Johnson, within hours of learning about the poisonings, had apparently already traced the cyanide-laced Extra Strength Tylenol capsules to Zahn Drug. On the morning of September 30, 1982, McNeil executives made two extremely urgent phone calls to Kesling Drug. “People started calling yesterday [Thursday], and we took it [Extra Strength Tylenol capsules] all off the shelf, recalled Estel Kesling. “McNeil already has called us twice on this,” she said. “They made us go out and personally check all the lot numbers while they waited on the telephone. They called us twice, then said they would have a representative in here today [Friday].”

When McNeil executives made those urgent calls to Kesling Drug, only two bottles of cyanide-laced Tylenol had been recovered. Both had been purchased at Jewel-Osco stores. Kesling Drug received its Tylenol from Zahn Drug. Johnson & Johnson evidently knew from day one of the investigation that Zahn Drug had distributed the bottles of cyanide-laced Extra Strength Tylenol capsules to the Jewel-Osco stores.

The expiration dating of the Tylenol involved in the 1982 tamperings was an obvious clue that the packaging and distribution of that Tylenol was not what J&J and the FDA claimed it was. The Tylenol that was bottled at the McNeil manufacturing plants typically had a shelf life of three years, but the Tylenol involved in the 1982 poisonings had a shelf life of five years. It had been shipped through J&J’s Montgomeryville facility, evidently in fiber drums of bulk Tylenol, to a repackager’s warehouse in Illinois where the tamperings actually occurred. That repackaging facility likely had contracted with Johnson & Johnson, and possibly the Department of Defense, to bottle and package Extra Strength Tylenol capsules.

In 1986, Tylenol capsules were once again filled with cyanide, causing the death of Diane Elsroth on February 8, 1986. Elsroth’s death was being investigated as premeditated murder until a second bottle of cyanide-laced Tylenol capsules was discovered a few days later. The FDA and the FBI confirmed that the three layers of tamper-resistant packaging on both bottles of cyanide-laced Tylenol had not been tampered with. The Tylenol in these bottles had been shipped in fiber drums of bulk Tylenol powder through J&J’s Montgomeryville facility to a third party repackager where the tamperings actually occurred.

Following the 1986 tampering incident, government officials and J&J executives lied about the shelf life of the cyanide-laced Tylenol, and made false statements regarding the distribution and packaging of Tylenol. Eight days after stating that neither the tamper-resistant packaging nor the bottles containing the cyanide-laced Tylenol capsules had been tampered with, the FBI released an “official statement,” falsely implying that the packaging might have been tampered with after all. The FBI put an end to Carl Vergari’s investigation of the Tylenol manufacturing and distribution network just as he was closing in on the repackaging facility where the Tylenol killer had dropped cyanide-laced Tylenol capsules into the bottling production lines.

The FBI’s active participation in the reactivated 1982 Tylenol murders case may be primarily about keeping hidden its conspicuous role in covering up the 1986 Tylenol killer’s modus operandi. A clue to the real reason for the FBI’s involvement in this reactivated investigation came from Ted Kaczynski, aka the Unabomber. Court documents that Kaczynski filed in May 2011 revealed that the FBI had added him to its list of suspects in the reactivated Tylenol murders case. Kaczynski had been arrested in 1996 as the perpetrator of a mail bombing spree that spanned from 1978 to 1995, killing three people and injuring 23 others. He pled guilty on January 22, 1998 to thirteen bombings.

In a Motion for Retention of Evidence filed on May 9, 2011, Kaczynski wrote: “the Chicago office of the FBI wanted a sample of my DNA to compare with some partial DNA profiles connected with a 1982 event in which someone put cyanide in Tylenol.” Kaczynski had filed this motion in a failed attempt to stop a government auction of his belongings, stating that it would be advantageous to him, and the government as well, to retain this evidence “at least until the matter in Chicago is cleared up.” On May 19, 2011, the news media got wind of Kaczynski’s court filing and had a field day reporting that the Unabomber was now a suspect in the Tylenol murders.

FBI spokesperson Ross Rice confirmed that the FBI had asked Kaczynski for a DNA sample. “As part of our re-examination of the evidence developed in connection with the 1982 Tylenol poisonings,” said Ross, “we have attempted to secure DNA samples from numerous individuals, including Ted Kaczynski.

The feds cannot charge Kaczynski for the 1982 Tylenol murders, because those murders were not federal crimes. The 1986 Tylenol tamperings and murder, however, were federal crimes. In response to the 1982 Tylenol tamperings, Congress passed the Federal Anti-Tampering Act on October 13, 1983, making it a federal crime to tamper with consumer products. Under the Federal-Anti-Tampering Act:

Whoever, with reckless disregard for the risk that another person will be placed in danger of death or bodily injury and under circumstances manifesting extreme indifference to such risk, tampers with any consumer product that affects interstate or foreign commerce, or the labeling of, or container for, any such product, or attempts to do so, shall -

(1) in the case of an attempt, be fined under this title or imprisoned not more than ten years, or both;

(2) if death of an individual results, be fined under this title or imprisoned for any term of years or for life, or both;

(3) if serious bodily injury to any individual results, be fined under this title or imprisoned not more than twenty years, or both; and

(4) in any other case, be fined under this title or imprisoned not more than ten years, or both.

The FBI appears to be carrying out a stealthy investigation into the 1986 Tylenol murder; hoping to wrap up that murder and the 1982 Tylenol murders in one neat package. But first, it needs a patsy for the 1986 Tylenol murder who can also conveniently take the fall for the 1982 Tylenol murders. Ted Kaczynski would fit that role quite nicely.

The FBI’s search for someone who could take the fall for both the 1982 and 1986 Tylenol tampering incidents was evident back in January 2010 when the Certificate of Materiality was served on James and LeAnn Lewis, requiring them both to submit DNA samples. The FBI cannot frame James for the 1986 Tylenol murder because he was in prison at that time – hence, the FBI’s injudicious interest in LeAnn. The fact that the FBI collected fingerprints and DNA samples from both LeAnn and James in January 2010 suggests that authorities had hoped to close out the 1982 and 1986 Tylenol murders in one fell swoop.

It now appears that the FBI has moved on to Ted Kaczynski as the Tylenol murders patsy because officials from the FBI and the State’s Attorney’s Office in DuPage County were unable to frame James and LeAnn Lewis as the Bonnie and Clyde of the 1982 and 1986 Tylenol murders. Even Kaczynski’s former attorney, Robert Blazier, offered up Kaczynski as a scapegoat for the Tylenol murders. “If you had to pick somebody that might be responsible for those particular offenses,” said Blazier, “he [Kaczynski] is the logical person. He certainly has the technical know-how to come up with that kind of method for doing away with people.”

Michael Sneed, a veteran journalist for the Chicago Sun-Times, contacted Tyrone Fahner on May 20, 2011 to get his perspective on the FBI’s interest in Kaczynski. Fahner told Sneed, “I suppose the case can now be labeled a random act of terrorism. It was a terrible tragedy, and it would be good for all the families of the victims if this were solved. It would be wonderful to put this thing to bed.”

Back in October 1982, while Fahner was leading the Tylenol murders investigation, officials had tried to “put this thing to bed” by framing Ed Reiner as the mastermind of a fabricated Tylenol murder conspiracy. Fahner now seems quite agreeable to the idea of promoting Ted Kaczynski as the Tylenol killer. Fahner told Sneed, “I’m surprised none of us thought of this [making Kaczynski a suspect] before, but I have no knowledge whatsoever of what’s happening now. They [the FBI] haven’t contacted me, but most of the FBI agents who worked the case are retired by now.”

As recently as February 4, 2009, Fahner had publicly proclaimed that Lewis had always been his prime suspect in the Tylenol murders case. But during his May 20, 2011 interview with Sneed, Fahner acted as if he barely had any recollection of Lewis. “It’s been at least a dozen years since I’ve heard any updates on the case, said Fahner, “except for the screwball who was tried for extorting money in the Tylenol case,” said Fahner. After 28 years of promoting Lewis as his prime suspect in the Tylenol case, Fahner has apparently passed on the “Tylenol man” torch to Ted Kaczynski.

Irv Miller, a legal analyst for CBS-News commented on the FBI’s desire to collect Kaczynski’s DNA. Miller had been an assistant state’s attorney in Cook County, Illinois at the time of the 1982 Tylenol murders. “It [the testing of Kaczynski’s DNA] is a good law enforcement tool to rule out potential suspects in a case,” said Miller. However, if this is just good basic police work then why hadn’t the FBI asked Kaczynski for a DNA sample previously?

The FBI does, of course, already have Kaczynski’s DNA, but the FBI now says it wants a better quality DNA sample. What the FBI really wants, it appears, is to convince the public that the Unabomber is also the Tylenol killer. Then, when Kaczynski dies, the FBI can pin the Tylenol murders on him, just as they pinned the Anthrax attacks on Bruce Ivins shortly after he died from an overdose of Tylenol in June 2008. If the FBI succeeds in framing Kaczynski or some other patsy for the Tylenol murders, then the feds, the State of Illinois, and Johnson & Johnson will finally have their “madman” for the 1982 and 1986 Tylenol murders.

*****

In 1986, James Burke speculated about the mental make-up of the Tylenol killer. “A person who would put poison in the Tylenol capsules clearly was a deranged person,” said Burke. “Psychiatrists tell us that these people are saying they need help. These kinds of people know they are not well. They don’t want to be called kooks; they don’t mind being called sick. If that person came forward and asked for help, he would receive it, although that doesn’t mean the person would not have to deal with the halls of justice.”

In 1988, federal prosecutors in Seattle finally got the madman-in-the-retail-stores theory to stick when they convicted Stella Nickell for the cyanide-laced Excedrin poisonings of Bruce Nickell and Sue Snow. When commenting on Stella’s conviction, Private Detective Al Farr said, “Big business and big government got in bed together and cooked up a scheme to convict this woman, and they did it.”

The Stella Nickell case was not the only instance where big government and big business got together to cover up what was really going on in the drug supply system. By the time Bruce Nickell and Sue Snow died from cyanide-laced capsules in June 1986, the deaths from poisoned OTC capsules had been an ongoing problem for more than four years.

Jay Mitchell died of cyanide poisoning in July 1982 after taking an Extra Strength Tylenol capsule from a bottle of Tylenol purchased at the Buttrey-Osco store in Sheridan, Wyoming that received its Tylenol from an un-named wholesaler affiliated with Jewel-Osco in Illinois. There were also three deaths, initially unexplained, in Cook County between August 15, 1982 and December 1, 1982 that were actually cyanide poisoning deaths. In all of these cases, the victims had acetaminophen (Tylenol) in their blood when they died.

In February 1986, FDA spokesperson, William Grigg, said there had been several additional incidents since the 1982 Tylenol murders in which people were poisoned with Tylenol capsules. James Cope, of the Proprietary Association, said on June 18, 1986, that there had been twelve confirmed deaths from cyanide-filled capsules since the 1982 Tylenol murders. The actual number of deaths from cyanide-laced OTC capsules nationwide in the 1980s may be an astronomically horrific number.

After the seven deaths from cyanide-laced Tylenol in Chicago, and at least a dozen confirmed subsequent deaths from cyanide-laced OTC capsules through July 1986, the Proprietary Association, the primary lobbying group for OTC drug manufacturers, continued to lobby to keep unsealed capsules on the market. Instead of recommending that manufacturers use alternatives, such as sealed capsules, caplets, or gel-tabs - the Proprietary Association insisted that the real problem was that cyanide was too easy to buy. The FDA had turned the role of “regulator” over to the pharmaceutical industry lobbyists.

The term “self-regulation” was very much in vogue in the 1980s. Under self-regulation, corporations are supposed to monitor themselves and report to the Justice Department their regulatory violations and illegal activities. The motivation for self-reporting is that the federal government will go easy on repentant corporations. The reality is that corporations do not self-report their illegal activities, and the Justice Department rarely shows any interest in prosecuting corporations that misbehave. Nevertheless, federal regulatory agencies still today depend on the “free market” to ensure that corporations act in the best interests of consumers.

Johnson & Johnson has long portrayed itself as a company that puts the consumers’ interests first. In 1947, Robert Wood Johnson II made an impassioned plea to convince Congress to use taxpayer money to fund the construction of underground plants for Johnson & Johnson and other corporations. Johnson said these underground plants would ensure that production continued even in the event of a nuclear war. To emphasize his altruistic motive for increasing corporate welfare, Johnson patriotically declared, “Who will protect America if we don’t?” However, Johnson really just wanted to protect America’s money by taking control of it and using it to fund the growth of Johnson & Johnson. Today, a substantial portion of Johnson & Johnson’s U.S. pharmaceutical revenue comes from taxpayer-funded programs like Medicaid, Medicare, and TriCare. In 2004, the Medicaid program alone paid more than $2.8 billion for Johnson & Johnson drugs.

In the 1980s, there were simply no regulatory agencies, and certainly no lobbyists, working on behalf of consumers to force government officials to conduct proper investigations into the Tylenol tamperings. This is also true today. The new Tylenol task force has not presented any evidence related to its ongoing reactivated investigation. Instead, the un-named silent leaders of this new task force enlisted spokespersons from the 1982 investigation to parrot the old lines from the “approved theory” script. These spokespersons have never answered any questions about the evidence.

The anonymous leaders of the new Tylenol task force brought out the founder and former chairman of the McNeil Consumer Products Company, Wayne Nelson, to tell America that “many people” involved in the Tylenol murders investigation in 1982 believed that James Lewis was the Tylenol killer. Former Illinois Attorney General, Tyrone Fahner, came out to say, “We felt that he [Lewis] committed the murders, but we couldn’t prove it at that time.” Former FBI Agent, Brad Garret, took advantage of his new job as an ABC consultant to perpetuate the lie of the super-corrosiveness of cyanide on gel-based Tylenol capsules. Former U.S Attorney, Dan Webb, took a break from his duties as chairman of Winston & Strawn to say that the FBI’s search of Lewis’s apartment meant that the FBI had a reasonable basis to believe that there was evidence of a crime being housed there. The FBI announced that they were going to deploy new DNA technology to solve the Tylenol murders. The FBI said that the 25th anniversary of the Tylenol murders had generated new tips. Not a single one of these statements is true.

This is what the evidence shows: James Lewis was in New York City from September 5, 1982 to December 27, 1982; the Tylenol task force never considered Lewis a valid suspect in the Tylenol murders; the Tylenol task force spent the first month of the investigation trying to pin the murders on one or more of the Tylenol victims’ relatives; authorities in DuPage County planted the eighth bottle of cyanide-laced Tylenol in an attempt to frame a relative of one of the Tylenol poisoning victims for the murders; cyanide did not cause the gel-based Tylenol capsules to corrode in just a few days; the FBI did not have probable cause to search the Lewises’ apartment in 2009; the FBI has no DNA evidence relevant to the Tylenol murders; the 25th anniversary did not generate new tips; and the FBI and Illinois officials are not following up on any new evidence related to the Tylenol murders.

The reactivated Tylenol murders investigation is a complete fraud. It is another red herring distracting the public from the evidence that indicts Johnson & Johnson, the FDA, and the United States Justice Department for their collusion in covering up a string of Tylenol tamperings and murders in the 1980s. In this sea of corruption, there is a seed of hope that had been quashed in 1982 and again in 1986, but might still germinate today. There was one government official during the Tylenol murders investigation in 1982 and another during the 1986 Tylenol murder investigation who went against the status quo, and disclosed important evidence relevant to these tampering incidents.

In 1982, the disclosures by Cook County Medical Examiner, Dr. Robert Stein, about the shelf life of the cyanide-laced Tylenol capsules revealed that the poisoned Tylenol capsules had been filled with cyanide before they were delivered to the retail stores. In 1986, Westchester District Attorney, Carl Vergari, disclosed a great deal of information revealing that the Tylenol killer had poisoned the capsules in a warehouse in the channel of distribution. There are government officials today who are knowledgeable of the Tylenol killers’ true modus operandi and the identity of the facilities where the tamperings occurred. These officials need to come forward, because the courageous leadership necessary to hold the appropriate individuals accountable for the Tylenol murders cover-up is certainly not going to come from within Johnson & Johnson.

The leadership standard set by James Burke continues today at Johnson & Johnson. Executives at this company have repeatedly failed to correct problems with the manufacturing processes at their plants; knowingly selling drugs that contain contaminants. Johnson & Johnson has run roughshod over feckless regulatory agencies for decades. From 2008 through 2010, the FDA apparently made an effort to crack down on Johnson & Johnson. In 2009, after J&J had refused for two years to recall Tylenol and other OTC products contaminated with TBA (a metabolite produced when TBP, a wood and plastic preservative, is exposed to mold), pressure from the FDA forced J&J to conduct numerous recalls of more than 150 million bottles of OTC medicines from hundreds of contaminated lots. J&J also had to shut down the McNeil manufacturing plant in Fort Washington indefinitely in April 2010 after the FDA publicly disclosed dozens of ongoing manufacturing violations at that plant. Johnson & Johnson is no longer the media darling it was in the 1980s; yet the company’s handling of the 1982 Tylenol murders is still portrayed in the media as the gold standard of crisis management.

Johnson & Johnson handled the Tylenol murders lawsuits just as it has handled many other liability lawsuits. It destroyed evidence, suppressed information, and turned the Tylenol investigation over to its lawyers who, with the cooperation of the Justice Department - a Justice Department that fully supports the use of protective orders to cover up corporate crimes - buried the truth. J&J convinced the judge who oversaw the 1982 Tylenol murders litigation to seal the court documents in that case so the public would never see the evidence that had been uncovered during discovery. A federal judge dismissed the 1986 Tylenol murder lawsuit based on false information about where and how the cyanide-laced Tylenol had been packaged. Johnson & Johnson managed the “Tylenol crisis” by covering up the facts. This behavior is the “gold standard” of crisis management celebrated by the Public Relations Society of America and Harvard Business School.

The gold standard of crisis management is rooted in the tenet that a corporation must never admit wrongdoing or take responsibility for its sins and crimes.  It is about creating a false reality for the public to look back on in the future. This “gold standard” requires corporate executives to lie, destroy evidence, and even cover up murders. In effect, they must do whatever is necessary to create a historical record that will be memorialized in the media in exactly the way the corporate entity wants that incident remembered. The crimes of executives, hiding behind the veil of the Corporation, are put into the shadow legal system where their sins are kept secret forever. The lawyer-lawmen of corporate America and the Justice Department have created a judicial system that is largely inaccessible to United States citizens. This system values political expediency over justice, closed-door arbitration over open trials, and secrecy over transparency. The result is a “justice” system designed for the benefit of corporations at the expense of individuals.

In an expose written in 1991, titled “Drug Fiends; Even Inside Johnson & Johnson, Public Safety Can Take a Back Seat to Profits,” Morton Mintz offered a sad commentary, still relevant today, of a society that allows Johnson & Johnson to practice business unfettered by morality and unencumbered by legal constraints. Mintz said, “When a corporation freely and repeatedly can do so much harm and then escape meaningful punishment, and when a CEO can stand by while hundreds are injured and some even killed and still be hailed as a champion of corporate ethics, there is something deeply wrong with the way America is doing business.”

Corporations have circumvented the ideal of the free market system by using their immense financial and political power to influence government agencies and officials to the point where corporations now dictate how the government “regulates” industry and “conducts” criminal and civil investigations. The sad truth is that Johnson & Johnson did indeed set the gold standard of crisis management with its handling of the Tylenol crisis. However, only through the eyes of a sociopathic corporate philosophy is this standard laudable. The actions of J&J executives after the Tylenol murders were certainly similar to the actions that the leaders of many large corporations would have taken then, and would still take today under similar circumstances.

Corporate entities rely on the shadow legal system and the silence of their employees to keep their crimes hidden. The corporate takeover of the justice system will be reversed only when individuals knowledgeable about corporate crimes come forward in large numbers to publicly disclose what they know. These honest Americans, by simply doing what is right, can take back America from the corporations that now own her. After all -- Who will protect America if we don’t?

About the Author

Scott Bartz embarked on a career as an independent journalist thanks to the support of Johnson & Johnson’s human resources and security personnel who encouraged him to seek a new line of work as they escorted him from the company’s premises on the morning he returned from a “secret” meeting with government prosecutors investigating allegations of Medicaid fraud at J&J. His fulltime career as a writer was precipitated by his work as the co-author of “United States of America, ex rel. Scott Bartz, vs. Johnson & Johnson, et al.” (Case 1:11-cv-10316-RGS).

Thank you for reading THE TYLENOL MAFIA: Marketing Murder and Johnson & Johnson. If you would like to help others find and enjoy this book, please take a few minutes to write a review on Amazon:

If you have information about the Tylenol murders, or just want to comment about the case or this book, you can email me at Fraudpi@gmail.com

Endnotes

1     A Curious Discovery

The words “EXTRA-STRENGTH”: Associated Press. “Officials report some leads in cyanide case.” The Paris News, October 4, 1982.

One of the boxes: Associated Press. “Officials report some leads in cyanide case.” The Paris News, October 4, 1982.

In between:  Dowling, John. “Cyanide Murders Hunt Has Dozen Suspcts.” Ironwood Daily Globe Oct. 5, 1982 -- Malcolm, Andrew H. “Cyanide Case Focuses on Find in Parking Lot at All-night Restaurant.” New York Times, October 5, 1982.

“It looked like”:  Dowling, John. “Cyanide Murders Hunt has Dozen Suspcts.” Ironwood Daily Globe, October 5, 1982.

Swanson and Chavez scraped: Cohen Sharon. “Tylenol found in lot were tampered with.” Syracuse Herald-Journal, October 4, 1982. -- Malcolm, Andrew H. “Cyanide Case Focuses on Find in Parking Lot at All-night Restaurant.” New York Times, October 5, 1982.

Before the deputies: Associated Press. “Officials report some leads in cyanide case.” The Paris News, October 4, 1982. -- Cohen Sharon. “Tylenol found in lot were tampered with.” Syracuse Herald-Journal, October 4, 1982. -- Malcolm, Andrew H. “Cyanide Case Focuses on Find in Parking Lot at All-night Restaurant.” New York Times, October 5, 1982.

2     The Tylenol Murders

Twenty-eight hours after: Beck, Melinda; Hagar, Mary; LaBreque, Ron; Monroe, Sylvester; Prout, Linda. “The Tylenol Scare.” Newsweek, October 11, 1982. – Greene, Bob. “An Open Letter to the Tylenol Killer.” The Post-Standard, October 22, 1982.

A few minutes later: Nenni, Pete; Van Wye, Joann. “5 dead after taking Tylenol capsules filled with cyanide.” The Daily Herald, October 1, 1982.

In nearby Arlington Heights: Associated Press. “Poison Tylenol Kills Five.” The Capital, October 1, 1982. -- Burris, Anne. “A string of coincidences linked Tylenol poisonings.” The Daily Herald, October 1, 1982. -- Associated Press. “Tylenol traces tale of tragedy.”  Lawrence Journal-World, October 3, 1982.

“Nothing seemed to help”:  Tifft, Susan; Lee, Griggs. “Poison Madness in the Midwest.” TIME, October 11, 1982.

Mary Magdalene Reiner: Daniel, Leon. “A Nightmare in capsule form.” Pacific Stars and Stripes, October 12, 1982.

On Wednesday afternoon, September 29th, Lynn made a quick trip: Nightly News. NBC: October 8, 1982. -- Coroner’s inquest, re: Lynn Reiner. Direct examination by DuPage County Coroner Richard Ballinger, 1982.

Lynn’s mother-in-law: Rosen, Michelle. Telephone interview by author, 2010.

Michelle’s most vivid memories. Rosen, Michelle. Telephone interview by author, 2010.

Lynn was clinically: Siekmann, Peter. DuPage County Coroner’s Office Preliminary Report, re: Mary Reiner, September 30, 1982. -- Coroner’s inquest, re: Lynn Reiner: Direct examination by DuPage County Coroner Richard Ballinger, 1982.

Peter Siekmann, the Deputy Coroner: Associated Press. “Poison Tylenol Kills Five.” The Capital, October 1, 1982. -- Duerksen, Susan. “6th poison victim dies; 2 more believed linked with Tylenol.” The Daily Herald, October 1, 1982.

However, officials said that Lynn had apparently: Beck, Melinda, Mary Hagar, Ron LaBreque, Sylvester Monroe, Linda Prout. "The Tylenol Scare." Newsweek, October 11, 1982. -- Litke, James; Associated Press. “Poisoning done in killer's home.” The Gettysburg Times, October 4, 1982.

Shortly after L:ynn had been rushed: Turner, K L. Coroner’s Report: Mary McFarland, September 30, 1982.

“I don’t feel good guys”: Turner, K L. Coroner’s Report: Mary McFarland, September 30, 1982.

After Adam Janus was: Pienciak, Richard T. “In reaching for relief, cyanide victims found death.” The Register, October 3, 1982.

Stanley’s wife, Theresa, called: McKinney, Dave. “A tainted drug, 7 lives shattered.” Daily Herald, Spetember 27, 1982. -- Sotonoff, Jamie. “Why cyanide deaths might go unsolved.” Daily Herald, September 29, 2002.

Shortly after Stanley and Theresa: Pienciak, Richard T. “In reaching for relief, cyanide victims found death.” The Register, October 3, 1982. – Huiras, Robin. “Illinois Nurse Connected Dots in Tylenol Murders.” Nurse.com. November 5, 2007. Accessed March 1, 2010. http://news.nurse.com/apps/pbcs.dll/article?AID=2007711050344

“This has got to be it”:  Beck, Melinda; Hagar, Mary; LaBreque, Ron; Monroe, Sylvester; Prout, Linda. “The Tylenol Scare.” Newsweek, October 11, 1982.

Jensen returned to Northwest: O’Donnell, Maureen. “‘Listening’ Solved Tylenol Killings.” Chicago Sun-Times, September 29, 1992. – Burris, Anne. “5 years later, the Tylenol mystery remains.” Daily Herald, September 30, 1987.

Meanwhile, Philip Cappitelli: Burris. Anne. “A string of coincidences linked Tylenol poisonings.” The Daily Herald, October 1, 1982.

“This is a wild stab”:  Beck, Melinda; Hagar, Mary; LaBreque, Ron; Monroe, Sylvester; Prout, Linda. “The Tylenol Scare.” Newsweek, October 11, 1982.

Cappitelli got off the phone: Malcolm, Andrew H. “100 Agents Hunt for Killer in 7 Tylenol.” The New York Times, October 3, 1982.

Before sunrise on Thursday: Beck, Melinda; Hagar, Mary; LaBreque, Ron; Monroe, Sylvester; Prout, Linda. “The Tylenol Scare.” Newsweek, October 11, 1982.

“I could smell”: Beck, Melinda; Hagar, Mary; LaBreque, Ron; Monroe, Sylvester; Prout, Linda. “The Tylenol Scare.” Newsweek, October 11, 1982.

The toxicology tests:  Nenni, Pete; Van Wye, Joann “5 Die after taking cyanide filled Tylenol.” The Daily Herald, October 1, 1982.

Years later, Richard Keyworth reflected:  Comerford, Michael Sean. “Tylenol case 25 years later: Cold case, cold hearts.” Daily Herald, September 28, 2007.

At the time of the Tylenol murders, autopsies conducted in Cook and DuPage Counties did not: “Drug death probes reopened.” The Daily Herald, January 13, 1983.

“Our Theresa is gone”:  Bannon, Tim: “Close-knit family waiting for justice.” The Daily Herald, October 7, 1982.

Officials have long cited: Slania, John. “Two years later. Tylenol murders haunt task force.” The Sunday Herald, September 30, 1984. -- Baumann, Ed; O’Brien, John. “Getting Away With Murder: Take 2 Capsules, Call The Coroner, The Tylenol Case.” Chicago Tribune, April 21, 1991. -- Avila, Oscar. “Tylenol murders linger in shadows.” Chicago Tribune, September 29, 2002.

3     Who Will Protect America?

McNeil Laboratories became McNeilab, Inc: About Tylenol/McNeil. McNeil website. 2011. Accessed June 30, 2011. http://www.tylenol.com/page.jhtml?id=tylenol/about/subty.inc

McNeil Laboratories became: About Tylenol/McNeil. McNeil website. 2011. Accessed June 30, 2011. http://www.tylenol.com/page.jhtml?id=tylenol/about/subty.inc

In 1982, the McNeil Consumer Products Company manufactured: Associated Press. “More poison is found in Tylenol pills.” The Chronicle-Telegram: October 1, 1982 -- Moore, Thomas. “The Fight to Save Tylenol.” TIME, November 29, 1982.

Most of the products:  Johnson, Robert Wood. “Johnson Talks It Over.” 1949.

Robert Wood Johnson II: Keene, Anne T. “Robert Wood Johnson.” American National Biography Online. Accessed July 1, 2011 http://www.anb.org/articles/10/10-02272.html

Johnson also dropped:  Goldsmith, Barbara. Johnson V. Johnson. Knopf. 1987.

In 1943, Margaret was granted a divorce: “Divorce Given.” The Evening Independent, July 23, 1943.

Johnson then married Evelyn Vernon Bruff: “Milestones.” TIME website, August 16, 1943. Accessed July 1, 2011. http://www.time.com/time/magazine/article/0,9171,933233,00.html#ixzz1CuJ0Eb1o

Johnson became President of Johnson & Johnson: Keene, Anne T. “Robert Wood Johnson.” American National Biography Online. July 1, 2011 http://www.anb.org/articles/10/10-02272.html

He was a dynamic: Goldsmith, Barbara. Johnson V. Johnson. Knopf, 1987. – Goldsmith, Barbara. “The Johnson Family Tears.” The Daily Beast, January 8, 2010. Accessed June 1, 2011. http://www.thedailybeast.com/articles/2010/01/07/the-johnson-family-tears.html

When Johnson decided: Foster, Larry.Robert Wood Johnson: The Gentlemen Rebel. Lillian Press, 1999.

“Sites and factories were easy to find”: Foster, Larry. Robert Wood Johnson: The Gentlemen Rebel. Lillian Press, 1999.

J&J’s new plant was located just one block south: “People in the News.” Economist Newspapers, February 28, 1971.

In 1982, Johnson & Johnson: Gurowitz, Margaret “If a Train leaves Chicago.” Kilmer House blog, September 18, 2009. Accessed July 2, 2011. http://www.kilmerhouse.com/2009/09/if-a-train-leaves-chicago/

During World War I and World War II: Catton, Bruce. The War Lords of Washington, 1948.

Johnson held a Reserve Army commission: Associated Press. “FDR Promotes 63 High Army Officers.” The San Antonio Light, May 5, 1943.

President Franklin D. Roosevelt had established the WPB: Roosevelt, Franklin. “Executive Order 9024 Establishing the War Production Board.” The American Presidency Project. January 16, 1942. Accessed July 1, 2011 http://www.presidency.ucsb.edu/ws/index.php?pid=16297#axzz1RUi6pKWQ

From 1942 to 1945, the chairman of the WPB was Donald M. Nelson: “Nelson gets World’s Biggest Single Job.” LIFE, January 26, 1942.

In January 1943, Donald Nelson: United Press International. “Nelson Acts to Save the Little Business Concerns.” The Hammond Times, January 24, 1943.

Truman said he was concerned: Truman, Harry S. “Monopolistic Tendencies of the War Production Board – Aid for Small Business.” Congressional Record, February 11, 1943.

Johnson & Johnson was still privately held during World War II: Goldsmith, Barbara. Johnson V. Johnson, 1988.

As chairman of the SWPC: Heath, Jim F., “American War Mobilization and the Use of Small Manufacturers, 1939-1943.”The Business History Review, Vol. 46, No. 3 (autumn, 1972), pp. 295-319.

The ordnance plant:  Sangamon Ordnance Plant. Wikipedia. Accessed May 28, 2010. http://en.wikipedia.org/wiki/Sangamon_Ordnance_Plant

On May 4, 1943: Associated Press. “FDR Promotes 63 High Army Officers.” The San Antonio Light, May 5, 1943.

During his time as chairman of the SWPC: Fowler, C. W. “History of the Administrative Policies of the Smaller War Plants Corporation.”Histories of the Smaller War Plants Corporation, 150-54

“champion of civilian economy to a large degree”: Associated Press. “Johnson Sheds Uniform to Fight for Civilians.” San Antonio Express, August 11, 1943.

In announcing his: Associated Press. “Johnson Sheds Uniform to Fight for Civilians.” San Antonio Express, August 11, 1943.

Until the day he died: Goldsmith, Barbara. Johnson V. Johnson. Knopf, 1987.

Four months after Johnson resigned: Gurowitz, Margaret. “1944: From Private to Public.” Kilmer House Blog. August 3, 2009. Accessed July 2, 2011.

Johnson was tremendously critical: “The Individualist.” The Billings Gazette, February 2, 1950, pg. 4.

In an article titled “Dig-Son-Dig”:  Johnson, Robert Wood. “Dig, son, dig - new weapons now threaten industrial strength of America.” Army Ordnance, Vol. 31, No. 160, January - February 1947, p.  347-9.

“To what extent should”: Associated Press. Factories Protected Against Atomic Bomb Assaults Urged.” The Galveston Daily News January 6, 1947.

“Let the military”:  “Underground is Proposed for Those Making Atomic Products.” The Norwich Sun, January 6, 1947.

“We will not be the audience: “Underground is Proposed for Those Making Atomic Products.” The Norwich Sun, January 6, 1947.

“Who will protect America”: “Underground is Proposed for Those Making Atomic Products.” The Norwich Sun, January 6, 1947.

“We had to act to protect the public”: “Interview with David R. Clare, President, Johnson & Johnson.” Corporate Conscience Magazine, 1985.

“I took some kidding”:  Moore, Thomas. “The Fight to Save Tylenol.” TIME, November 29, 1982.

4      The Tylenol Crisis

Dr. Edmund Donoghue: Associated Press. Pain Capsules Killed Three. Alton Telegraph, September 30, 1982.

Just prior to Donoghue’s press conference: Moore, Thomas. “The Fight to Save Tylenol.” TIME, November 29, 1982.

“Is this about”:  Moore, Thomas.“The Fight to Save Tylenol.” TIME, November 29, 1982.

Murray’s next call went to Arthur Quilty: Moore, Thomas. “The Fight to Save Tylenol.” TIME, November 29, 1982.

When the Wilmington plant opened: “Personal Products Co. plans major expansion.” The Circle, June 30, 1971, pg. 9.

J&J shut that plant down in 1992: Richards, Cindy. “Johnson & Johnson closing plant.” Chicago Sun-Times, March 7, 1990.

“Are you sure”:  Moore, Thomas. “The Fight to Save Tylenol.” TIME, November 29, 1982.

“It was a felicitous appointment for me”: Moore, Thomas. “The Fight to Save Tylenol.” TIME, November 29, 1982.

Larry Foster, J&J’s Vice President: Foster, Lawrence. Interview by PSU students. “Interview with Larry Foster (2002).” -- Foster, Lawrence. “The Tylenol Tragedy: A Crime Without Precedent,” in Communicating in a Healthcare Crisis, ed. Pines, Wayne L. 173-182, Church Falls: FDAnews, 2007.

“That was a bombshell”:  Cooke, Jeremy R. “PSU alumnus recalls 1982 Tylenol murders.” Collegian, October 18, 2002.

“I never came home”:  Cooke, Jeremy R. “PSU alumnus recalls 1982 Tylenol murders.” Collegian, October 18, 2002.

One-word description of my reaction: Cooke, Jeremy R. “PSU alumnus recalls 1982 Tylenol murders.” Collegian, October 18, 2002.

Foster said there were something like 150 or 175 calls:  Foster, Lawrence. Interview by PSU students, 2002. http://instruct.tri-c.edu/jkerezy/Larry_Foster_Video_Interview.pdf

News of what became:  Tifft, Susan; Lee, Griggs. “Poison Madness in the Midwest.” TIME, October 11, 1982. – Foster, Lawrence. “The Tylenol Tragedy: A Crime Without Precedent,” in Communicating in a Healthcare Crisis, ed. Pines, Wayne L. 173-182, Church Falls: FDAnews, 2007.

The Tylenol murders case:  Foster, Lawrence G. “The Johnson & Johnson Credo and the Tylenol Crisis.” New Jersey Bell Journal, Volume 6, Number 1. 1983.

“We have a madman”:  Beck, Melinda; Hagar, Mary; LaBreque, Ron; Monroe, Sylvester; Prout, Linda. “The Tylenol Scare.” Newsweek, October 11, 1982.

“I don’t think”:  Kleinfield, N.R. “Long, Uphill Odds for Tylenol.”  New York Times, October 8, 1982.

The expert consensus was that Tylenol was dead as a brand: Kleinfield, N.R. “Long, Uphill Odds for Tylenol.” New York Times, October 8, 1982.

“Our Credo”: Johnson, Robert Wood. “Our Credo.” 1943.

“Looking back on the events”: Foster, Lawrence. “The Tylenol Tragedy: A Crime Without Precedent,” in Communicating in a Healthcare Crisis, ed. Pines, Wayne L. 173-182, Church Falls: FDAnews, 2007.

“The guidance of the credo”: James E. Burke, “Ad Council Speech” (delivered on November 16, 1983), p. 6.

“The Tylenol crisis”:  Berge, T. “The First 24-Hours.” Basil Blackwell, Inc., 1990.

Johnson & Johnson’s handling: Knight, Jerry. “Tylenol's Maker Shows How to Respond to Crisis.” The Washington Post, October 11, 1982.

Jack O’Dwyer, of the New York City: O’Dwyer, Jack. “PR Industry's Amicus Brief Has a Flaw.” Reclaim Democracy website, November 19, 2002. http://reclaimdemocracy.org/nike/pr_brief_retort_kasky_nike.html

Counselor Helio Fred Garcia: O’Dwyer, Jack “Fortune Lauds Tylenol PR.” O’Dwyer PR website, May 22, 2007. Accessed June 1, 2011. http://www.odwyerpr.com/members/archived_stories_2007/may/0522tylenol_pr.htm

“James Burke, the CEO”:  The Insider. Touchstone Pictures, 1999.

James Burke began his career: “James Burke.” Reference for Business website. Accessed July 2, 2011. http://www.referenceforbusiness.com/biography/A-E/Burke-James-1925.html

“HBS (Harvard Business School) had”:  “2003 Alumni Achievement Awards.” Harvard Business School website, 2003. Accessed March 5, 2011. http://www.alumni.hbs.edu/awards/2003/burke.html

According to a friend: Sherman Stratford P. “You’re Invited to the CEOs’ Ball. FORTUNE, January 15, 1990.

Burke briefly interrupted:  Callahan David. Kindred Spirits: Harvard Business School's Extraordinary Class of 1949 and How They Transformed American Business. Hoboken: Wiley, 2002.

Burke returned to Johnson & Johnson: Georgescu, Peter. The Source of Success.Jossey Bass. San Francisco, 2005.

“You’re a bachelor”:  Badaracco, Joseph. Questions of Character: Illuminating the Heart of Leadership through Literature. Boston: Harvard Business Press, 2006.

“He really gave it to me”:  Badaracco, Joseph. Questions of Character: Illuminating the Heart of Leadership through Literature. Boston: Harvard Business Press, 2006.

With a growing list of disappointing: Callahan, David. Kindred Spirits: Harvard Business School's Extraordinary Class of 1949 and How They Transformed American Business: Hoboken: Wiley, 2002. -- Georgescu, Peter. The Source of Success. San Francisco: Jossey Bass, 2005.

“I was full of bravado”:  O’Reilly, Brian. “J&J Is On a Roll.” Fortune, December 26, 1994.

“Are you the man”:  Callahan David. Kindred Spirits: Harvard Business School's Extraordinary Class of 1949 and How They Transformed American Business: Wiley, 2002

Burke moved up: Georgescu, Peter. The Source of Success. San Francisco: Jossey Bass, 2005.-- “James Burke.” Reference for Business website, Accessed July 2, 2011. http://www.referenceforbusiness.com/biography/A-E/Burke-James-1925.html -- Johnson & Johnson. “Johnson & Johnson 1961 Annual Report.” 1962

In 1975, while Burke: “Johnson & Johnson.” International Directory of Company Histories, January 1, 1991.

A large annual Tylenol advertising budget: Church, George J.; Griggs, Lee; Zagorin, Adam “Murder by Remote Control.” TIME, October 18, 1982.

Tylenol was bringing in $450 million: Foster, Lawrence. “The Tylenol Tragedy: A Crime Without Precedent,” in Communicating in a Healthcare Crisis, ed. Pines, Wayne L. 173-182, Church Falls: FDAnews, 2007. -- Moore, Thomas. “The Fight to Save Tylenol.” TIME, November 29, 1982.

5      All of Burke’s Men

While J&J executives put: Tifft, Susan; Lee, Griggs. “Poison Madness in the Midwest.” TIME, October 11, 1982

Initially, Johnson & Johnson issued: Beck, Melinda, Mary Hagar, Ron LaBreque, Sylvester Monroe, Linda Prout. "The Tylenol Scare." Newsweek. October 11, 1982.

Buddy Willis, the owner: Cunningham, Kathy.  “Local Tylenol Distributor Sure of Safety.” The Winchester Star, October 2, 1982.

Burke immediately focused: David Berg and Stephen Robb. “Crisis Management and the ‘Paradigm Case,’” in Rhetorical and Critical Approaches to Public Relations, ed. Toth, Elizabeth. Hillsdale: Lawrence Erlbaum Associates, 1992, pg. 92-107. -- Foster, Lawrence. “The Tylenol Tragedy: A Crime Without Precedent,” in Communicating in a Healthcare Crisis, ed. Pines, Wayne L. 173-182, Church Falls: FDAnews, 2007.

Many times, according to Foster: Cooke, Jeremy R. “PSU alumnus recalls 1982 Tylenol murders.” Collegian, October 18, 2002 -- Foster, Lawrence. Interview by PSU students, 2002.

Burke told David Collins: Fink, Steven. Crisis Management: Planning for the Inevitable. American Management Association, 1986, 204-6.

“Take charge”:  Fink, Steven. Crisis Management: Planning for the Inevitable. American Management Association: 1986, 204-6.

Collins’s first question:  Moore, Thomas. “The Fight to Save Tylenol.” TIME, November 29, 1982.

“I needed my own”:  Moore, Thomas. “The Fight to Save Tylenol.” TIME, November 29, 1982.

“a place to build”: “New Hall of Fame Members.” Fenwick Magazine, spring 2003, 12.

McNeil executives used a felt-tip marker:  Moore, Thomas. “The Fight to Save Tylenol.” TIME, November 29, 1982.

A two-way video: Foster, Lawrence. “The Tylenol Tragedy: A Crime Without Precedent,” in Communicating in a Healthcare Crisis, ed. Pines, Wayne L. 173-182, Church Falls: FDAnews, 2007.

Chicago area sales reps: Associated Press. “Poisoned Tylenol kills 5.” The Capital, October 1, 1982.

Twenty-five public relations employees from other J&J operating companies: David Berg and Stephen Robb. “Crisis Management and the ‘Paradigm Case,’” in Rhetorical and Critical Approaches to Public Relations, ed. Toth, Elizabeth. Hillsdale: Lawrence Erlbaum Associates, 1992, pg. 92-107.

Public relations personnel: Foster, Lawrence. “The Tylenol Tragedy: A Crime Without Precedent,” in Communicating in a Healthcare Crisis, ed. Pines, Wayne L. 173-182, Church Falls: FDAnews, 2007.

Andrews, along with: David Berg and Stephen Robb. “Crisis Management and the ‘Paradigm Case,’” in Rhetorical and Critical Approaches to Public Relations, ed. Toth, Elizabeth. Hillsdale: Lawrence Erlbaum Associates, 1992, pg. 92-107. – Fearn-Banks, Kathleen. “Case: Johnson & Johnson and the Tylenol Murders.” Crisis communications: A Casebook Approach. Mahwah: Lawrence Erlbaum Associates, 1996, 86-96.

“collectively shocked”: Fearn-Banks, Kathleen. “Case: Johnson & Johnson and the Tylenol Murders.” Crisis communications: A Casebook Approach. Mahwah: Lawrence Erlbaum Associates, 1996, 86-96.

“We were clean”:  Nenni, Pete; Van Wye, Joann “5 Die after taking cyanide filled Tylenol.” The Daily Herald, October 1, 1982.

“Whenever the poisoner”:  Church, George J.; Griggs, Lee; Zagorin, Adam “Murder by Remote Control.” TIME, October 18, 1982.

On Thursday afternoon, before officials: Moore, Thomas. “The Fight to Save Tylenol.” TIME, November 29, 1982. -- Duerksen, Susan. “6th poison victim dies; 2 more believed linked with Tylenol.” The Daily Herald, October 1, 1982.

11 million bottles of Tylenol capsules in the company’s distribution channel: Associated Press.  “Stockbroker may have been victim in extortion letter hoax.” The News, October 9, 1982.

Governor “Big” Jim Thompson: Associated Press. “Fahner will lead Tylenol probe.” Chronicle-Telegram, October 4, 1982. – Lee, Thomas J. “Tylenol case easing Fanner’s ills.” The Daily Herald, October 5, 1982.

A Chicago Tribune Poll released October 2, 1982: Man in the News: Sheppard, Nathaniel. “Anonymous Investigator.” New York Times, October 5, 1982.

That anonymity had changed instantly: Hughes, T Lee. “Tylenol Capsules Change Course of Illinois race.” Chillicothe Constitution-Tribune, October 28, 1982.

One of Fahner’s first official acts: “Tylenol murders last year recalled.” Nightly News. NBC, September 28, 1983.

Chicago police officers were advised: ABC Eyewitness News. ABC, WLS-TV, Chicago, September 30, 1982.

“may be contaminated with cyanide, and should be destroyed”: ABC Eyewitness News. ABC, WLS-TV, Chicago, September 30, 1982.

Late Thursday morning, the pathologist: Turner, K L. Coroner’s Report for Mary McFarland, September 30, 1982.

The Lombard police called Mary: Turner, K L. Coroner’s Report for Mary McFarland, September 30, 1982.

Authorities then also found a bottle of Extra: Turner, K L. Coroner’s Report: Mary McFarland, September 30, 1982. -- McFadden, Robert D. “Poison Deaths Bring U.S. Warning on Tylenol Use.” The New York Times; October 2, 1982.

Authorities never disclosed: United Press International: Poisonings Cause Tylenol Recall.” Tyrone Daily Herald, October 1, 1982.

That lawsuit, as well as McFarland’s coroner’s report: Turner, K L. Coroner’s Report: Mary McFarland, September 30, 1982.

The Tylenol containers recovered: Duerksen, Susan. “6th poison victim dies; 2 more believed linked with Tylenol.” The Daily Herald, October 2, 1982. -- Pirl, Joerge. Telephone interview by author, 2010.

According to Pirl, the particular potassium cyanide:  Pirl, Joerge.Telephone interview by author, 2010.

6      The Developing Investigation

David Collins had gone:  Moore, Thomas. “The Fight to Save Tylenol.” TIME, November 29, 1982.

Tylenol from that lot:  McFadden, Robert D. “Poison Deaths Bring U.S. Warning on Tylenol Use.” The New York Times; October 2, 1982.

“The fact that”:  Moore, Thomas. “The Fight to Save Tylenol.” TIME, November 29, 1982.

Tylenol from Lot MC2880: McFadden, Robert D. “Poison Deaths Bring U.S. Warning on Tylenol Use.” New York Times; October 2, 1982 -- Rutenberg, Sharon. “Five poison deaths prompt.” The Hawk Eye, October 1, 1982.

“wouldn’t make a decision on extending”:  David Berg and Stephen Robb. “Crisis Management and the ‘Paradigm Case,’” in Rhetorical and Critical Approaches to Public Relations, ed. Toth, Elizabeth. Hillsdale: Lawrence Erlbaum Associates, 1992, pg. 92-107.

J&J spokesperson, Marshall Malloy: Rutenberg, Sharon. “Five poison deaths prompt.” The Hawk Eye, October 1, 1982.

But later that day, J&J executives changed their minds:  Duerksen, Susan. “6th poison victim dies; 2 more believed linked with Tylenol.” The Daily Herald, October 1, 1982.

David Collins had said he didn’t know:  Moore, Thomas. “The Fight to Save Tylenol.” TIME, November 29, 1982.

The lot number on the label: Code of Federal Regulations Title 21, Section 201.18.

“In the beginning”: Foster, Lawrence. Interview by PSU students, 2002.

“Any plotter would”: Foster, Lawrence. Interview by PSU students, 2002.

“leads us to believe strongly”:  Associated Press. “‘Madman’ sought in poisonings.” Wisconsin State Journal, October 2, 1982.

With this second recall, J&J had now recalled 264,000 bottles:  McFadden, Robert D. “Poison Deaths Bring U.S. Warning on Tylenol Use.” The New York Times; October 2, 1982.

Marshall Molloy said McNeil supplied:  Associated Press. “Sixth Victim Claimed By Cyanide Pills.” Bedford Gazette, October 2, 1982.

In 1982, Johnson & Johnson operated eleven regional distribution centers: Aguilar, Francis J.; Bhambri, Arvind. “Johnson & Johnson (B) Hospital Services.” Harvard Business School Publishing, June 30, 1986.

In February 1986, J&J spokesperson:  McFadden, Robert D. “Two Bottles of Poisoned Tylenol Were Shipped By Same Distributor.” New York Times, February 16, 1986.

The DOD entered into contracts with McNeil between 1977 and 1983: DOD Contract with McNeil Consumer Products Company, Fort Washington, Pennsylvania. Contract number DLA12083C0127, January 1983. --- DOD Contract with McNeil Consumer Products Company, Fort Washington, Pennsylvania. Contract number DLA12083C0677, September 1983. --- DOD Contract with McNeil Consumer Products Company, Round Rock, Texas, Contract number LA12082 C0776, May 1982. --- DOD (Air force) Contract with McNeil Consumer Products Co., Glendale, CA. Contract number SA13H 77 50158, Fiscal year 1980.

Prior to the Tylenol murders, most Americans didn’t even know that Tylenol:  Moore, Thomas. “The Fight to Save Tylenol.” TIME, November 29, 1982.

“We’re investigating stereotypes”:  Cohen, Sharon. “Investigators Hunt for Madman in Tylenol Case.” Chillicothe Constitution-Tribune, October 2, 1982.

Statements by victims’ relatives, and testimony: “Chicago lie tests clear 6.” Chicago Sun Times, October 27, 1982. – Coroner’s inquest, re: Mary McFarland. Direct examination by DuPage County Coroner Richard Ballinger, December 14, 1982.

The New York Times said:  Malcolm, Andrew H. “Search for the Tylenol Killer: Many Clues, But No Solution.” New York Times, October 10, 1982.

Fahner said that some of the capsules appeared: Rutenberg, Sharon. “More Than One ‘Madman’ Tylenol Killer is Hinted.” The Progress, October 4, 1982.

“We’re trying to”:  Dowling, John. “Leads ‘substantial’ in the Tylenol case.” Syracuse Herald Journal, October 4, 1982.

“to find the madman or madmen responsible for this sick behavior”:  Cohen, Sharon. “Investigators Hunt for Madman in Tylenol Case.” Chillicothe Constitution-Tribune, October 2, 1982.

7      We Will Be Completely Honest

While Fahner was holding: Foster, Larry. Robert Wood Johnson: The Gentlemen Rebel. Lillian Press, 1999. -- Foster, Lawrence. Interview by PSU students, 2002.

The Associated Press had learned: Fearn-Banks, Kathleen. “Case: Johnson & Johnson and the Tylenol Murders.” Crisis communications: A Casebook Approach. Mahwah: Lawrence Erlbaum Associates, 1996, 86-96.

Foster had a reputation: Fearn-Banks, Kathleen. “Case: Johnson & Johnson and the Tylenol Murders.” Crisis communications: A Casebook Approach. Mahwah: Lawrence Erlbaum Associates, 1996, 86-96.

It wasn’t long before: Foster, Lawrence, interview by PSU students. Interview with Larry Foster: 2002 -- Fearn-Banks, Kathleen. “Case: Johnson & Johnson and the Tylenol Murders.” Crisis communications: A Casebook Approach. Mahwah: Lawrence Erlbaum Associates, 1996, 86-96.

“There was one”: Foster, Lawrence, interview by PSU students. Interview with Larry Foster: 2002

“This is a tragic thing”:  Maliska, Gavin. “Tylenol’s comeback predicted.” The Daily Herald, October 2, 1982.

Paula Prince, a 35-year-old: Associated Press.  “Madman sought in cyanide deaths.” Lethbridge Herald, October 2, 1982.

Paula had the following: Pienciak, Richard T. “In reaching for relief, cyanide victims found death.” The Register, October 3, 1982. -- United Press International. “Laced Tylenol claims 7th; culprit unknown.” Pacific Stars and Stripes, October 4, 1982.

Later, while viewing video footage from a security camera: Associated Press. “Tylenol case photo clue ‘significant’.” The Paris New, October 19, 1982.

Chicago Police Superintendant: Associated Press. “Madman sought in cyanide deaths.” Lethbridge Herald, October 2, 1982.

The Tylenol in Prince’s bottle was from Lot 1801MA: Associated Press. “Byrne bans sale of all Tylenol in the big city.” Sunday Roswell Daily Record, October 3, 1982.

Chicago Mayor Jane Byrne held: Wolohan, Linda. “Poisoned Pills kill at Least Six Persons.” The Progress, October 2, 1982.

By late Saturday afternoon, more than 1,500 bottles: Madrzyk, Anna; Gores, Paul.  “Cyanide Killer Search Widens.” The Sunday Herald, October 3, 1982.

Cook County Medical Examiner: Associated Press.  “Suspects Studied in Cyanide Deaths.” Casa Grande Dispatch, October 4, 1982.

“We’re at 48 hours now”:  Litke, James. “Cyanide kills Philadelphian.” The Gettysburg Times, October 7, 1982.

The FDA, via network news: “Tylenol Contamination.” Nightline. ABC, October 1, 1982.

Standard FDA inspections: FDA 483 Inspection Observations: McNeil Consumer Products Co., Fort Washington, PA, December 9, 2010. -- FDA 483 Inspection Observations: McNeil Consumer Products Co., Las Piedras, PR, November 2, 2010.

In a report to the U.S. Congress:  Government Accountability Office. “FDA’s Approach to Reviewing Over-The-Counter Drugs is Reasonable, But Progress is Slow.” GAO Report, April 26, 1982.

Incredibly, up until 1997:  Government Accountability Office. “NONPRESCRIPTION DRUGS: Over the Counter and Underemphasized,” GAO Report, January 10, 1992.

After an investigation of the FDA’s procedures:  Government Accountability Office. “Non-Prescription Drugs: Over the Counter and Underemphasized.” GAO Report, January 10, 1992.

The existence of these complaints was not disclosed until 1991:  Janota, Laura. “Fear of negative publicity likely led to Tylenol settlement.” The Daily Herald, May 15, 1991.

“No human hands touched the Tylenol or its ingredients”: Janson, Donald. “Maker of Tylenol Cleared of Blame.” The New York Times, October 6, 1982.

8      J&J and the FBI

Company surveys taken:  Moore, Thomas. “The Fight to Save Tylenol.” TIME, November 29, 1982.

“One of the things”: Moore, Thomas. “The Fight to Save Tylenol.” TIME, November 29, 1982.

According to Larry Foster: Foster, Lawrence. “The Tylenol Tragedy: A Crime Without Precedent,” in Communicating in a Healthcare Crisis, ed. Pines, Wayne L. 173-182, Church Falls: FDAnews, 2007.

“Tylenol is as much”:  Associated Press. “Tylenol Investigation Continues.”  Bedford Gazette, October 4, 1982.

Johnson & Johnson established:  Kaplan, Tamara. “The Tylenol Crisis: How Effective Public Relations Saved Johnson & Johnson.” Pennsylvania State University: November 2003

In this way, according to a public relations executive: Kaplan, Tamara. “The Tylenol Crisis: How Effective Public Relations Saved Johnson & Johnson.” Pennsylvania State University, November 2003.

J&J further strengthened its ties with the FBI Office in Chicago:  United Press International. “Trucker's Death Probed; List of Suspects Reduced.” Altoona Mirror, October 6, 1982.

Historically, J&J has hired private investigators: Bloomberg. “China Counterfeit Diabetes Tests Tracked by J&J.” Bloomberg website, August 16, 2007. Accessed July 7, 2011. -- http://www.bloomberg.com/apps/news?pid=newsarchive&sid=aCAuLKG2YwKc . – Hubbard, William K. “Importation of Prescription Drugs.” FDA website, July 14, 2001. Accessed July 7, 2011. -- http://www.fda.gov/newsevents/testimony/ucm113655.htm . -- Eban, Katherine, “Drug theft goes big.” CNN website, March 31, 2011. Accessed July 7, 2011.

“Jim Burke spent”: Foster, Lawrence. “The Tylenol Tragedy: A Crime Without Precedent,” in Communicating in a Healthcare Crisis, ed. Pines, Wayne L. 173-182, Church Falls: FDAnews, 2007.

“The attitude of top”:  Mintz, Morton. “Drug fiends: even inside Johnson & Johnson, public safety can take a back seat to profits.” Washington Monthly, December 1991.

Jim Thompson had been the U.S. Attorney: Sink, Robert. “Prosecutor describes his work: We've been very scrupulous.” Southern Illinoisan, March 25, 1973. – James R. Thompson. Winston & Strawn website. Accessed July 2, 2011. http://www.winston.com/index.cfm?contentID=24&itemID=10873

Governor Thompson had appointed Tyrone Fahner: Associated Press. “Fahner will lead Tylenol probe.” Chronicle-Telegram, October 4, 1982.

Thompson appointed Dan Webb: Kantzavelos, Maria. “Chicago Lawyer’s 2008 Person of the Year: Dan Webb.” Chicago Lawyer, November 26, 2008. -- Dan K Webb. Winston & Strawn website. Accessed July 2, 2011. http://www.winston.com/index.cfm?contentID=24&itemID=10594

In 1984, Governor Thompson appointed Margolis: Davidson, Jean. “State Police Will Get New Boss.” Chicago Tribune, April 30, 1987.

Thomson appointed James Zagel: Manning, Al. “The Big Jim image through a looking glass: Thompson's appointees.”Illinois Issues, in Illinois Periodicals online. February 1981. Accessed July 2, 2011. http://www.lib.niu.edu/1981/ii810204.html

IDLE Commander Edward Cisowski:  Duerksin, Susan. “6th poison victim dies; 2 more believed linked with Tylenol.” The Daily Herald, October 2, 1982.

J&J’s staff of 30 toxicologists at that lab: ABC-News. ABC, October 1, 1982 – United Press International. “Authorities Expand Tylenol Search.” Altoona Mirror, October 2, 1982.

9      Above the Law

Richard Epstein, a law professor:  Bannon, Tim. “‘McNeil may not be liable’.” The Sunday Herald, October 3, 1982.

Illinois Attorney General, Tyrone Fahner: Associated Press. “Tylenol Investigation Continues.” Bedford Gazette, October 4, 1982.

According to Fahner, the cyanide-spiked capsules: Malcolm, Andrew H. “100 Agents Hunt for Killer in 7 Tylenol Deaths.” TheNew York Times, October 3, 1982.

“It is a mathematical”:  Malcolm, Andrew H. “Search for the Tylenol Killer: Many Clues, But No Solution.” The New York Times, October 10, 1982.

Officials cited this super-corrosive: Nightline. ABC, October 1, 1982. – United Press International. “Authorities Expand Tylenol Search.” Altoona Mirror, October 2, 1982.

Johnson & Johnson’s legal maneuvering:  David Berg and Stephen Robb. “Crisis Management and the ‘Paradigm Case,’” in Rhetorical and Critical Approaches to Public Relations, ed. Toth, Elizabeth. Hillsdale: Lawrence Erlbaum Associates, 1992, pg. 92-107.

Attorney Paul Noland:  David Berg and Stephen Robb. “Crisis Management and the ‘Paradigm Case,’” in Rhetorical and Critical Approaches to Public Relations, ed. Toth, Elizabeth. Hillsdale: Lawrence Erlbaum Associates, 1992, pg. 92-107.

During the 28 months Zomax: Weiser, Benjamin; Walsh, Elsa. “Drug Firm’s Strategy: Avoid Trial, Ask Secrecy.” The Washington Post, October 25, 1988.

In February 1982, immediately following Mintz, Morton. “Drug fiends: even inside Johnson & Johnson, public safety can take a back seat to profits.” Washington Monthly, December 1991.

“indications during pre-marketing”:  Weiser, Benjamin; Walsh, Elsa. “Drug Firm’s Strategy: Avoid Trial, Ask Secrecy.” The Washington Post, October 25, 1988.

The wife of one person Weiser, Benjamin; Walsh, Elsa. “Drug Firm’s Strategy: Avoid Trial, Ask Secrecy.” The Washington Post, October 25, 1988.

James Burke himself:  Mintz, Morton. “Drug fiends: even inside Johnson & Johnson, public safety can take a back seat to profits.” Washington Monthly, December 1991.

“seems to have a different cause”:  Weiser, Benjamin; Walsh, Elsa. “Drug Firm’s Strategy: Avoid Trial, Ask Secrecy.” The Washington Post, October 25, 1988.

FDA and the manufacturer, McNeil Pharmaceutical, have been working on a stronger warning for the drug: FDA. “Reactions to Zomax.” FDA Talk Paper: T83-11, March 4, 1983.

The combined effort:  Weiser, Benjamin; Walsh, Elsa. “Drug Firm’s Strategy: Avoid Trial, Ask Secrecy.” The Washington Post, October 25, 1988.

“In view of Zomax’s”:  Associated Press. “Zomax controversy:  FDA's regulation of painkiller shows agency not protecting public: report.” The Galveston Daily News, December 12, 1983.

“In seeking an advisory”:  House Committee on Government Operations, FDA’s Regulation of Zomax, House Report 98-584, 98th Cong., 1st session, 1983.

“I think we did a good job”:  Weiser, Benjamin; Walsh, Elsa. “Drug Firm’s Strategy: Avoid Trial, Ask Secrecy.” The Washington Post, October 25, 1988.

“They were avoidable”:  Weiser, Benjamin; Walsh, Elsa. “Drug Firm’s Strategy: Avoid Trial, Ask Secrecy.” The Washington Post, October 25, 1988.

“This is a company”:  Michael deCourcy Hinds. “Drug Withdrawn After Five Deaths.” The New York Times, March 5, 1983.

“We resisted too much”:  Weiser, Benjamin; Walsh, Elsa. “Drug Firm’s Strategy: Avoid Trial, Ask Secrecy.” The Washington Post, October 25, 1988.

McNeil used protective orders, Benjamin; Walsh, Elsa. “Drug Firm’s Strategy: Avoid Trial, Ask Secrecy.” The Washington Post, October 25, 1988.

“As we demonstrated”:  Weiser, Benjamin; Walsh, Elsa. “Drug Firm’s Strategy: Avoid Trial, Ask Secrecy.” The Washington Post, October 25, 1988.

“I would be remiss”:  Mintz, Morton. “Drug fiends: even inside Johnson & Johnson, public safety can take a back seat to profits.” Washington Monthly, December 1991.

In the last two months of 1985:  Mintz, Morton. “Drug fiends: even inside Johnson & Johnson, public safety can take a back seat to profits.” Washington Monthly, December 1991.

“The subcommittee’s 16-month”:  FDA’s Regulation of the New Drug Suprol, Hearing before a Subcommittee of the House Committee On Government Operations, 100th Cong. Session 417-418, 1987.

J&J spokesperson, James Murray:  “Company Halts Sale of Disputed Painkiller.” New York Times, May 16, 1987.

“Flexin has produced”:  Associated Press. “Cites Firm’s Secrecy on Drug’s Harm.” The Des Moines Register, April 29, 1964.

“The facts are”:  Associated Press. “Cites Firm’s Secrecy on Drug’s Harm.” The Des Moines Register, April 29, 1964.

One very public embarrassment : Seglin, Jeffrey L. The Right Thing; A Company Credo, as Applied or Not.” The New York Times, July 15, 2001.

The raid came: Mintz, Morton. “Drug fiends: even inside Johnson & Johnson, public safety can take a back seat to profits.” Washington Monthly, December 1991.

“Mistakes were made”:  Seglin, Jeffrey L. The Right Thing; A Company Credo, as Applied or Not.” The New York Times, July 15, 2001.

Another notable sanction:  Associated Press. “Company penalized over acne cream.” Chillicothe Constitution-Tribune, April 11, 1995.

10      The Madman Myth

“hunt for the mad Tylenol killer”:  Wolohan, Linda. “Poisoned Pills kill at Least Six Persons.” The Progress, October 2, 1982.

In a similar vein: Connell, Christopher. “New Laws Not Expected Soon.” The Daily Collegian, October 7, 1982.

“We’ve got a person”:  Doyle, Pat. “A year after Tylenol killings: sorrow lingers, answers elude.” The Sunday Herald, September 25, 1983.

“I don’t think”:  Doyle, Pat. “A year after Tylenol killings: sorrow lingers, answers elude.” The Sunday Herald, September 25, 1983.

Dr. Robert Reifman, Director of the Cook County:  United Press International. “Tylenol Killer ‘Sadistic Loner.’” Pharos-Tribune, October 4, 1982.

Douglas, according to the biography on his web site: John Douglas Mindhunter website. Accessed July 1, 2011 http://www.johndouglasmindhunter.com/home.php

“Despite the fact”: Douglas, John. Mind Hunter. New York: Pocket Books, 2000.

“The country was”:  Douglas, John. Mind Hunter. New York: Pocket Books, 2000.

Dawn Hobbs, a journalist:  Bell, Rachael. The Tylenol Terrorist. 2011 http://www.trutv.com/library/crime/terrorists_spies/terrorists/tylenol_murders/3.html

“We don’t know”:  Doyle, Pat. “A year after Tylenol killings: sorrow lingers, answers elude.” The Sunday Herald, September 25, 1983.

A survey conducted on October 8, 1982 by Audits and Surveys Inc. Zdep, Stanley M.; Roshwalb, Irving. “The Affects of the Tylenol Poisonings on Consumer Fears.” Audits and Surveys Inc., 1982.

Video footage shown: Nightly News. NBC, October 8, 1982.

Tyrone Fahner suggested that one bottle of poisoned Tylenol had been placed: Dowling, John. “Leads ‘substantial’ in the Tylenol case.” Syracuse Herald Journal, October 4, 1982.

Dr. R.J. Cowles:  Seery, Tom; Sutter, Jane. “Tylenol off Burlington shelves as a precaution.” The Hawkeye, October 1, 1982.

Jim Adamson, a spokesperson: United Press International. “Kansans told not to use Tylenol.” Salina Journal, October 3, 1982.

“The media did”:  Duerksen, Susan. “Last 2 families of Tylenol dead file damage suits.” The Daily Herald, June 2, 1983.

“We’re still in the process”: United Press International. “‘Not Close’ To Arrest: Tylenol Case Stumps Authorities.” Tyrone Daily Herald, October 8, 1982.

“rational evil doer”:  United Press International. “Tylenol poisoning probe narrowed to 4 suspects.” Pacific Stars and Stripes, October 11, 1982.

“Of course, the killer:  Malcolm, Andrew H. “3 Years Later, Illinois is Still Trying to Solve Tylenol Deaths.” The New York Times, February 21, 1986.

11      Handling the Evidence

The Food and Drug Administration, the investigative authorities: Gates, Thomas N.  “McNeil Consumer Products Co. ‘Dear Doctor’ Letter”: signed by Dr. Thomas N. Gates, October 13, 1982.

FDA Deputy Commissioner, Mark Novitch, confirmed: Associated Press. “Tylenol task force being cut back.” The Chronicle-Telegram: November 9, 1982 -- New York Times News Service. “Over-counter drug safety is a priority.” Wisconsin State Journal, October 6, 1982.

The New York Times reported: “Cyanide is Discovered in Tylenol in an April Death in Philadelphia.” The New York Times, October 7, 1982.

There were about 165,000 outlets nationwide: Reis, Al; Trout, Jack. Marketing Warfare. New York: The McGraw Hill Companies, 2006, Pg. 62.

About 11,000 retail outlets: Beck, Melinda, Mary Hagar, Ron LaBreque, Sylvester Monroe, Linda Prout. "The Tylenol Scare." Newsweek, October 11, 1982.

2,000 were in:  David Berg and Stephen Robb. “Crisis Management and the ‘Paradigm Case,’” in Rhetorical and Critical Approaches to Public Relations, ed. Toth, Elizabeth. Hillsdale: Lawrence Erlbaum Associates, 1992, pg. 92-107.

United Press International reported: United Press International. “Another Cyanide Death Prevented.” Altoona Mirror, October 22, 1982.

By Saturday afternoon: Madrzyk, Anna; Gores, Paul.  “Cyanide Killer Search Widens.” The Sunday Herald: October 3, 1982.

“It is well to remember that two unused bottles of Poisoned Tylenol were recovered”: “Letter to the Stockholders,” Johnson & Johnson 1982 Annual Report, 1983.

J&J had brought in 30 toxicologists: David Berg and Stephen Robb. “Crisis Management and the ‘Paradigm Case,’” in Rhetorical and Critical Approaches to Public Relations, ed. Toth, Elizabeth. Hillsdale: Lawrence Erlbaum Associates, 1992, pg. 92-107.

Authorities also could have:  Houston, Jack. “Local Firm Helps Put Tylenol to The Test.” Chicago Tribune, February 23, 1986.

12            Selling the Myth

In J&J’s 1982 Annual Report: “Letter to the Stockholders,” in Johnson & Johnson’s 1982 Annual Report, 1983.

“A demonstration without parallel”: Foster, Lawrence. “The Tylenol Tragedy: A Crime Without Precedent,” in Communicating in a Healthcare Crisis, ed. Pines, Wayne L. 173-182, Church Falls: FDAnews, 2007.

“Bob Andrews spent”:  Foster, Lawrence. Interview by PSU students, 2002.

“The real Tylenol hero”:  Foster, Lawrence G. “The Johnson & Johnson Credo and the Tylenol Crisis.” New Jersey Bell Journal, Volume 6, Number 1. 1983.

Joan Ganz-Cooney:  “Cooney, Joan Ganz.” Museum.tv website, accessed February 28, 2011. http://www.museum.tv/eotvsection.php?entrycode=cooneyjoan

Thomas S. Murphy:  Murphy, Thomas S.  Museum.tv. website, accessed February 28, 2011. http://www.museum.tv/eotvsection.php?entrycode=murphythoma

Burke had an even closer relationship:  Sherman, Stratford P.; Kirkpatrick, David. “Capital Cities’ Capital Coup.” Fortune, April 15, 1985.

The Burke family:  Fabrikant, Geraldine. “Bloodlines and Business Intersect for Cable TV Chief.” The New York Times, November 3, 2003.

Perkins received an:  Cruikshank, Jeffrey L. Shaping the Waves. Harvard Business Press. March 1, 2005.

“In a sense, it’s a monopoly business”:  Murphy, Thomas S.  Personal interview by Amy Blitz, Harvard Business School Director, December 2000.

Hayes had received an M.D.:  QUANTRX Biomedical Corp. Businessweek.com. Business Week. February 25, 2011. http://investing.businessweek.com/research/stocks/people/person.asp?personId=29095724&ticker=QTXB:US&previousCapId=364164&previousTitle=QUANTRX%20BIOMEDICAL%20CORP

During his stint:  “Head of FDA Tested Drugs on Volunteers.”The Washington Post, June 26, 1983, p. A4.

Hayes was brought in: Martin, Betty. “Food and Drug Regulation After 75 Years by Arthur Hull Hayes, Jr., FDA Commissioner who over-ruled the Board of Inquiry and got the deadly Aspartame marketed – JAMA, 9/11/81.” http://www.mpwhi.com/fda_regulation_after_75_years.htm

Previously, Rumsfeld had been the U.S. representative: Donald Rumsfeld: Donald Rumsfeld. NNDB.com. Accessed February 25, 2011.  http://www.nndb.com/people/634/000023565/

“The evidence suggested”:  Martin, Betty. “Food and Drug Regulation After 75 Years By Arthur Hull Hayes, Jr., FDA Commissioner who over-ruled the Board of Inquiry and got the deadly Aspartame marketed – JAMA, 9/11/81.” http://www.mpwhi.com/fda_regulation_after_75_years.htm

Rumsfeld, undaunted by:  Martin, Betty. “Food and Drug Regulation After 75 Years By Arthur Hul Hayes, Jr., FDA Commissioner who over-ruled the Board of Inquiry and got the deadly Aspartame marketed – JAMA, 9/11/81.” Mission Possible World Health International. http://www.mpwhi.com/fda_regulation_after_75_years.htm

One day after Reagan’s inauguration:  Martin, Betty. “Food and Drug Regulation After 75 Years by Arthur Hull Hayes, Jr., FDA Commissioner who over-ruled the Board of Inquiry and got the deadly Aspartame marketed – JAMA, 9/11/81.” Mission Possible World Health International. http://www.mpwhi.com/fda_regulation_after_75_years.htm

On October 5, 1982, during an emergency:  Associated Press. “FDA seeks defense against poisonings.” The Salina Journal, October 5, 1982.

On October 22, 1982:  Associated Press. “Investigators wait for results.” The Gettysburg Times, October 23, 1982.

Then, six weeks after the Tylenol murders:  Hayes, Arthur H. “A Public Service Announcement about over-the-counter medicines.” Daily News Record, November 6, 1982.

Hayes was hired under a ten-year contract:  Gordon, Gregory. “UPI Investigative Report: Part 2, by: Gregory Gordon.” United Press International, April 18, 2004.  http://www.wnho.net/upi_1987_aspartame2.htm

Hayes was later named to top:  NAPRO BIOTHERAPEUTICS, INC · 10-K/A. SEC.gov December 31, 2001. http://www.sec.gov/Archives/edgar/data/891504/000089973302000083/form10ka2001.htm

Nelson, a graduate of Northwestern University: KBL Healthcare Ventures - Advisory Board. December 13, 2008. February 26, 2011. http://cache.zoominfo.com/CachedPage/?archive_id=0&page_id=666453215&page_url=//www.kblvc.com/advisor.htm&page_last_updated=2/13/2008+6:50:04+AM&firstName=Wayne&lastName=Nelson

Nelson founded Nelson Communications:  Nelson Communications, form S-1. April 30, 1999. Accessed July 20, 2011. http://www.sec.gov/Archives/edgar/data/1082447/0000950123-99-003962.txt

Nelson brought Arthur Hayes:  Nelson Communications, form S-1. April 30, 1999. Accessed July 20, 2011. http://www.sec.gov/Archives/edgar/data/1082447/0000950123-99-003962.txt

For the first decade:  Nelson Communications, form S-1. April 30, 1999. Accessed July 20, 2011. http://www.sec.gov/Archives/edgar/data/1082447/0000950123-99-003962.txt

The connection between Arthur Hayes and Johnson & Johnson: “Head of FDA Tested Drugs on Volunteers.” Washington Post, June 26, 1983, p. A4. – Memo “From: Capt. Arthur H. Hayes, Jr., MC, Contract Project Officer. To: M. Royston, Publications Writer. Subject: Contract Reports, Contract No. DA-18-035-AMC-126(A). Document Type: Memorandum. Date: 21 November 1966,” in Results of DOD Human Radiation Experiment Record Search, Accessed June 30, 2011. http://www.defense.gov/pubs/dodhre/Append1.pdf

Since 1962, Kligman had: Albarelli Jr., H.P. “‘Human guinea pigs’ demand justice” World Net Daily, May 30, 2002. – “Results of DOD Human Radiation Experiment Record Search.” U.S. Department of Defense website, 2011. Accessed June 30, 2011.

From 1964 to 1967: Results of DOD Human Radiation Experiment Record Search. U.S. Department of Defense website. 2011. Accessed June 30, 2011. http://www.defense.gov/pubs/dodhre/Append1.pdf

The tests were conducted on twenty Holmesburg Prison inmates who were issued: Kaye, Jonathon. “Retin-A's Wrinkled Past.” Accessed June 30, 2011. http://marcosaba.tripod.com/dowcorporation.html

The Army’s Contract Project Officer overseeing: Memo “From: Capt. Arthur H. Hayes, Jr., MC, Contract Project Officer. To: M. Royston, Publications Writer. Subject: Contract Reports, Contract No. DA-18-035-AMC-126(A). Document Type: Memorandum. Date: 21 November 1966,” in Results of DOD Human Radiation Experiment Record Search, Accessed June 30, 2011. http://www.defense.gov/pubs/dodhre/Append1.pdf

Out of Kligman’s experiments: Hornblum, Allen.Acres of Skin. New York: Rutledge, 1998.

“The slight, bespectacled:  Anderson, Jack. “FDA head pleads ignorance.” The Chronicle-Telegram, May 28, 1983.

When investigators for the Inspector General:  Anderson, Jack. “FDA head pleads ignorance.” The Chronicle-Telegram, May 28, 1983.

Though Hayes was:  United Press International. “Hayes quits as FDA chief.” The Valley independent, July 29, 1983.

13            Rack Jobbers

The Daily News Record reported:  Dulan, Tom. “Suspect Tylenol Found Here.” Daily News Record, October 2, 1982.

“Sav-A-Stop,” a nationally:  Dulan, Tom. “Suspect Tylenol Found Here.” Daily News Record, October 2, 1982.

Ann Saylor, the manager:  “2nd IGA Finds Suspect Tylenol.” Daily News Record, October 4, 1982.

On Monday, October 4th, the general manager:  Dulan, Tom. “Suspect Tylenol Found Here.” Daily News Record, October 2, 1982.

Sav-A-Stop had annual sales: Key, Janet. “Brennan Going Back To Wards As Chief Exec.” Chicago Tribune, May 04, 1985.

IGA, Kroger, and Safeway all contracted:  Dulan, Tom. “Suspect Tylenol Found Here.” Daily News Record, October 2, 1982.

According to Newsweek, many experts:  Beck, Melinda, Mary Hagar, Ron LaBreque, Sylvester Monroe, Linda Prout. “The Tylenol Scare.” Newsweek, October 11, 1982.

Novitch had said that the Tylenol bottles:  Associated Press. “Cyanide Madman Sought.” The Titusville Herald, October 2, 1982.

In 1982, Safeway and Kroger: Morris, John; Ringer, Richard. “K mart joins financial services race: announcement today planned by retailer.” American Banker: January 12, 1984 -- Weinstein, Michael. “Supermarket chain, Bethesda bank in venture to operate ATM system.” American Banker, January 26, 1984.

Rack jobbers came into prominence:  FTC Complaint. In the Matter of Sterling Drug: Order and Opinion Etc, in regard to the alleged violation of section 7 of the Clayton Act 1972.

Sav-A-Stop was:  Key, Janet. “Brennan Going Back To Wards As Chief Exec.” Chicago Tribune, May 04, 1985.

The Company had incorporated:  Florida Department of State Division of Corporation web site. Accessed September 2, 2010. http://www.sunbiz.org/scripts/cornamelis.exe

For: Rack jobbing services:  U.S Patent 802,008, registered January 11, 1966.

95    The nation’s leading non-food:  Sav-A-Stop. “Stock Merchandisers.” The Daily Herald, July 30, 1982.

Officials mapped out the locations:  The Tylenol Murders. Kowalski, W.J. 2011 http://www.aerobiologicalengineering.com/wxk116/TylenolMurders/ -- Associated Press. “Tylenol Investigation Continues.”  Bedford Gazette, October 4, 1982.

Bernard Brennan, better known today:  “Brennan Going Back to Wards as Chief Exec.” Chicago Tribune, May 04, 1985.

They had even gone to the same private Catholic high school:  Fenwick  High School. “Fenwick Hall of Fame.” Accessed July 2, 2011. http://www.friarsonline.com/NETCOMMUNITY/Page.aspx?pid=325

Brennan had joined Sears: Burns, Greg. “Bernard Brennan, minding the store.” Chicago Sun-Times, March 13, 1988.

Edward Brennan was chairman:  Story, Louise. “Edward Brennan, Who Led Sears at Its Peak, Dies at 73.” The New York Time, January 1, 2008.

In 1982, Sav-A-Stop route sales persons: Resume of James Bombeck, Sav-A-Stop DSD Sales person 1981-1985.

On September 10, 1982, Chicago-based Consolidated:  “Acquisitions of Securities.” SEC News Digest; Issue 82-55: March 23, 1982.

Shortly after the deal closed, Stephen Pistner:  Barmash, Isadore.“Mobil Names Ward Executive.” The New York Times, September 9, 1982.

Spokespersons for J&J and the FDA:  Beck, Melinda; Hagar, Mary; LaBreque, Ron; Monroe, Sylvester; Prout, Linda. “The Tylenol Scare.” Newsweek, October 11, 1982. – Associated Press. “Cyanide Madman Sought.” The Titusville Herald, October 2, 1982. -- Associated Press. “Sixth Victim Claimed By Cyanide Pills.” Bedford Gazette, October 2, 1982.

On June 28, 2001:  FDA. “FDA Witnesses Destruction of Drug Products.” FDA website. June 28, 2001. Accessed July 1, 2011. http://www.fda.gov/ICECI/EnforcementActions/EnforcementStory/EnforcementStoryArchive/ucm107058.htm

J&J spokesperson, Robert Kniffin, said the Tylenol from Lot MC2880: Associated Press. “Cyanide found in another Tylenol batch.” The Paris News, October 1, 1982.

Larry Foster said the bottles of poisoned Tylenol:  Madrzyk, Anna; Gores, Paul.  “Cyanide Killer Search Widens.” The Sunday Herald, October 3, 1982.

Jane Armstrong, the Vice President:  Nenni, Pete; Van Wye, Joann.  “5 dead after taking Tylenol capsules filled with cyanide.” The Daily Herald, October 1, 1982.

On October 8th, Armstrong was asked: Malcolm, Andrew H. “Wyoming cyanide death investigated.” The New York Times, October 9, 1982.

14            The Vanishing Evidence

The local Arlington Heights-based newspaper, The Daily Herald, accurately reported: Madrzyk, Anna; Gores, Paul.  “Cyanide Killer Search Widens.” The Sunday Herald, October 3, 1982.

The New York Times also reported:  Malcolm, Andrew H. “Search for the Tylenol Killer: Many Clues, But No Solution.” New York Times, October 10, 1982.

Fahner said these bottles would be “particularly helpful”:  Madrzyk, Anna; Gores, Paul.  “Cyanide Killer Search Widens.” The Sunday Herald, October 3, 1982.

Then, on Friday night, an FDA: Associated Press. “7th Chicago-area death blamed on poisoned drug.” The News, October 2, 1982.

On Saturday, the story changed a little more: Associated Press. “Madman’s Plot Suspected; More Tainted Tylenol Found.” The News Record, October 2, 1982. -- Litke, James; Associated Press. “Poisoning done in killer's home.” The Gettysburg Times, October 4, 1982.

WMAQ-TV, the NBC affiliate: 10 p.m. News. WMAQ-TV, NBC, October 1, 1982. -- Duerksen, Susan. “6th poison victim dies; 2 more believed linked with Tylenol.” The Daily Herald, October 2, 1982.

Sergeant David Burrows: Associated Press. “Officials report some leads in cyanide case.” The Paris News, October 4, 1982.

Reporters spotted FBI agents: Malcolm, Andrew H. “Cyanide Case Focuses on Find in Parking Lot at All-night Restaurant.” The New York Times, October 5, 1982.

“I wish you guys”: Gores, Paul. “Poisonings draw top coverage.” The Daily Herald, October 7, 1982.

The boxes “said Tylenol”:  Associated Press. “Officials report some leads in cyanide case.” The Paris News, October 4, 1982.

“We just blew it off”:  Wolfe, John. “‘We should have known.’” Pacific Stars and Stripes, October 12, 1982.

“It was evident they”:  Associated Press. “Officials report some leads in cyanide case.” The Paris News, October 4, 1982.

“The symptoms reported”:  Associated Press. “Officials report some leads in cyanide case.” The Paris News, October 4, 1982.

“I was stupid”:  Wolfe, John. “‘We should have known.’” Pacific Stars and Stripes, October 12, 1982.

“It looked like hundreds of capsules”: Malcolm, Andrew H. “Cyanide Case Focuses on Find in Parking Lot at All-night Restaurant.” The New York Times, October 5, 1982.

“That appears to be a total washout”:  Nelson, Debbe. “Back room supplies of Tylenol hit.” The Daily Herald, October 5, 1982.

“the medical people”:  Litke, James; Associated Press. “Poisoning done in killer's home.” The Gettysburg Times, October 4, 1982.

Now, on Monday night, Fahner said investigators were “reasonably certain”: Dowling, John. “Cyanide Murders Hunt Has Dozen Suspects.” Ironwood Daily Globe, Oct. 5, 1982.

“consistent with a sub-lethal”:  Associated Press. “Officials report some leads in cyanide case.” The Paris News, October 4, 1982.

“can go right through the skin”:  Daniel, Leon. “More than one killer may have spiked Tylenol.” The Hutchinson News, October 4, 1982.

The Maalox diversion scheme:  Hecht, Annabel. “The Maalox had wanderlust (drug investigation)” FDA Consumer, March 1, 1985.

15            A Reluctant Recall

James Burke, Wayne Nelson: Fannin, Rebecca. “Tylenol: diary if an amazing comeback.” TIME, March 22, 1983. – Georgescu, Peter. The Source of Success. San Francisco: Jossey Bass, 2005.

“The FBI didn’t want us to do it”:  Moore, Thomas. “The Fight to Save Tylenol.” TIME, November 29, 1982.

Burke’s suggestion that he: “Tylenol’s “Miracle” Comeback: A year after the poisonings, public confidence is restored.” Time, October 17, 1983 -- David Berg and Stephen Robb. “Crisis Management and the ‘Paradigm Case,’” in Rhetorical and Critical Approaches to Public Relations, ed. Toth, Elizabeth. Hillsdale: Lawrence Erlbaum Associates, 1992, pg. 92-107.

Police said that Lynn Reiner’s:  Associated Press. “Search pressed for clues in poisonings.” The Frederick Post, October 4, 1982.

The cyanide-laced Tylenol that killed Paula Prince:  Associated Press. “Byrne bans sale of all Tylenol in the big city.” Sunday Roswell Daily Record, October 3, 1982.

Authorities had also found cyanide in Tylenol capsules:  Duerksen, Susan. “6th poison victim dies; 2 more believed linked with Tylenol.” The Daily Herald, October 1, 1982.

Strychnine-laced Tylenol capsules from yet another lot:  Dowling, John. “Strychnine-laced Tylenol found in California.”  The Sequin Gazette-Enterprise, October 6, 1982.

By the end of the second day of the investigation, authorities had recovered poisoned Tylenol capsules from seven different lots: Associated Press. “Tylenol Investigation Continues.” Bedford Gazette, October 4, 1982.

James Burke and Wayne Nelson were in their second day:  Church, George J.; Griggs, Lee; Zagorin, Adam “Murder by Remote Control.” TIME, October 18, 1982.

“I displayed strange”:  Dowling, John. “Strychnine-laced Tylenol found in California.” The Seguin Gazette-Enterprise, October 6, 1982.

His wife, Terry: Dowling, John. “Strychnine-laced Tylenol found in California.”  The Sequin Gazette-Enterprise, October 6, 1982.

Ronald Tossano, the Manager of the Longs: Nightly News. NBC, October 5, 1982.

The FDA had not:  Associated Press. “Strychnine-tainted Tylenol found”. Galveston Daily News, October 8, 1982.

Larry Foster said:  Associated Press. “Strychnine-tainted Tylenol found”. Galveston Daily News, October 8, 1982.

As it turned out:  Church, George J.; Griggs, Lee; Zagorin, Adam “Murder by Remote Control.”TIME, October 18, 1982.

Officials in California were:  Associated Press. “Tylenol victim quizzed by lie detector test.” Gazette, October 14, 1982.

FBI Special Agent, Ray:  Associated Press. “Probe of ‘copycat’ Tylenol case ends.”  The Register, November 27, 1982.

In September 1984, Greg Blagg:  Register News Service. “Tylenol-scare figure charged with arson.” The Register, September 17, 1984.

After the Oroville tampering:  Dowling, John. “Strychnine-laced Tylenol found in California.” The Seguin Gazette-Enterprise, October 6, 1982.

“In conjunction with”:  United Press International. “Over the Counter Pill Sales Dropping.”  The Progress, October 6, 1982.

It has been widely reported: Moore, Thomas. “The Fight to Save Tylenol.” TIME, November 29, 1982. – “Tylenol's “Miracle” Comeback: A year after the poisonings, public confidence is restored.” Time, October 17, 1983. -- Ryan, Nancy; O’Brien. “‘82 Tylenol Fallout Still Tampers With Our Minds.” Chicago Tribune, September 28, 1992. -- Kaplan, Tamara. “The Tylenol Crisis: How Effective Public Relations Saved Johnson & Johnson.” Pennsylvania State University, November 2003.

However, two days after initiating the nationwide recall: Associated Press: “Extortion plot not likely in Tylenol case.” The Iola Register, October 9, 1982.

The true number of recalled: McNeilab, Inc., Plaintiff v. North River Insurance Co. et al., Defendants, 645 F. Supp. 525, 543-45 (D.N.J.), September 17, 198.6

The genesis of the 31-million-bottle recall myth: United Press International. “Public Told to Be On Alert for Tampering.” The Progress, October 16, 1982.

Collins also used: United Press International. “Public Told to Be On Alert for Tampering.” The Progress, October 16, 1982.

The Proprietary Association was adamant that there should be no: New York Times News Service. “Over-counter drug safety is a priority.” Wisconsin State journal, October 6, 1982.

Although the public did not know it:  PR Newswire Association LLC. “Schering-Plough Healthcare President David Collins Elected Chairman of NDMA.” PR News, May 18, 1992

“The confidence of”:  Associated Press. “Contaminated Tylenol case may cost maker $75 million.” Waterloo Courier, October 7, 1982.

J&J President, David Clare, later commented:  Solomon, Robert C. It’s good business: ethics and free enterprise for the new millennium. Rowman & Littlefield Publishers Inc., 1997, p168-169.

Clare said that for a period of about 48 to 72 hours:  Solomon, Robert C. It’s good business: ethics and free enterprise for the new millennium. Rowman & Littlefield Publishers Inc. 1997, p168-169.

“leads us to believe strongly”:  Associated Press. “‘Madman’ sought in poisonings.” Wisconsin State Journal, October 2, 1982.

“We naturally wanted”:  Cooke, Jeremy R. “PSU alumnus recalls 1982 Tylenol murders.” Collegian, October 18, 2002.

“Plaintiff (J&J) itself admits”:  McNeilab, Inc., Plaintiff v. North River Insurance Co. et al., Defendants, 645 F. Supp. 525, 543-45 (D.N.J.), September 17, 1986.

The transcript in re: McNeilab Inc.:  McNeilab, Inc., Plaintiff v. North River Insurance Co. et al., Defendants, 645 F. Supp. 525, 543-45 (D.N.J.), September 17, 1986.

“[McNeil] and its parent (J&J):  McNeilab Inc.:  McNeilab, Inc., Plaintiff v. North River Insurance Co. et al., Defendants, 645 F. Supp. 525, 543-45 (D.N.J.), September 17, 1986.

Public relations expert, Jack O’Dwyer:  O’Dwyer, Jack. “PR Industry’s Amicus Brief Has a Flaw.” ReclaimDemocracy.org. Accessed June 1, 2011. http://www.reclaimdemocracy.org/nike/pr_brief_retort_kasky_nike.html

16     The Other Cyanide Murders

On October 8, 1982:  Malcolm, Andrew H. “Wyoming cyanide death investigated.” The New York Times, October 9, 1982.

Sheridan County Coroner Jim Kane said the capsules weren’t suspected: Associated Press. “Tylenol suspected in Unsolved Cyanide Death in Wyoming,” Syracuse Post Standard, October 9, 1982.

Dr. William E. Doughty:  Malcolm, Andrew H. “Wyoming cyanide death investigated.” The New York Times, October 9, 1982.

Doughty asked the manager:  Malcolm, Andrew H. “Wyoming cyanide death investigated.” The New York Times, October 9, 1982.

A second analysis:  Malcolm, Andrew H. “Wyoming cyanide death investigated.” The New York Times, October 9, 1982.

The evidence “as it stands:  Malcolm, Andrew H. “Wyoming cyanide death investigated.” The New York Times, October 9, 1982.

If the link through the distributor is confirmed: Malcolm, Andrew H. “Wyoming cyanide death investigated.” The New York Times, October 9, 1982.

When the Chicago detective:  Associated Press. “Cyanide probe narrowed to 3 or 4 primary leads.” The Galveston Daily News, October 11, 1982.

In addition to the cyanide:  Madrzyk, Anna; Gores, Paul.  “Cyanide Killer Search Widens.” The Sunday Herald, October 3, 1982.

Acetaminophen is second only: Ionescu, DN; Janssen, JK; Omalu. “Final Diagnosis -- Acute Combined Drug Overdose of Ethanol, Acetaminophen, Imipramine, Desipramine, Oxycodone and Diphenhydramine,” University of Pennsylvania School of Pathology website. Accessed July 20, 2011. http://path.upmc.edu/cases/case407/dx.html

On January 13, 1983:  “Drug death probes reopened.” The Daily Herald: January 13, 1983

“The defense was saying”:  Baden, Michael M. Unnatural Death: Confessions of a Medical Examiner. New York: Ballantine Books, 1990.

“because of the close proximity”:  “Drug death probes reopened.” The Daily Herald: January 13, 1983.

“We are continuing these investigations”:  “Drug death probes reopened.” The Daily Herald, January 13, 1983.

Toxicology tests had found both cyanide and acetaminophen: United Press International. “Excedrin removed from Colorado stores.” The Hutchinson News, October 27, 1982

Yet Jaye Schroeder, a Chicago police spokesperson:  United Press International. “Excedrin removed from Colorado stores.” The Hutchinson News, October 27, 1982.

One day later, Kathryn:  “Early Cyanide Death Not Tied to Tylenol, Authorities Believe.” The New York Times, October 28, 1982.

Dr. Mitra Kalelkar, the Assistant Medical Examiner: “Early Cyanide Death Not Tied to Tylenol, Authorities Believe.” New York Times, October 28, 1982.

Husted and Louis Tedesco:  United States of America, Plaintiff-appellee, v. Louis Tedesco, Defendant-appellant. United States Court of Appeals, Seventh Circuit. - 726 F.2d 1216,

Mark Husted had recently:  “Federal agents probe death of drug dealer.” The Daily Herald, September 17, 1982.

Mark Husted had flown: Mark Husted family members. Telephone interview by author, February 16, 2010.

Tedesco told police:  “Federal agents probe death of drug dealer.” The Daily Herald, September 17, 1982.

Agents from the DEA:  “Federal agents probe death of drug dealer.” The Daily Herald, September 17, 1982.

“a feeling that his son may have been murdered.”:  “Federal agents probe death of drug dealer.” The Daily Herald, September 17, 1982.

Members of Mark Husted’s family: Mark Husted family members. Telephone interview by author, February 16, 2010.

“ate Tylenol like candy”: Mark Husted family members. Telephone interview by author, February 16, 2010.

In the fall of 1982, Cook County: “Drug death probes reopened.” The Daily Herald, January 13, 1983.

At that time, authorities:  Malcolm, Andrew H.: “100 Agents Hunt for Killer in 7 Tylenol.” The New York Times, October 3, 1982. -- “Federal agents probe death of drug dealer.” The Daily Herald, September 17, 1982. -- United Press International. “Excedrin removed from Colorado stores.” The Hutchinson News, October 27, 1982.A review of local Illinois newspapers:  “Federal agents probe death of drug dealer.” The Daily Herald, September 17, 1982.

17            A Poisoned Investigation

One day after J&J had announced: USA, Plaintiff-Appellee, v. James William Lewis, Defendant-Appellant. No. 84-2011. US Court of Appeals, Seventh Circuit, May 31, 1985.

Seven days after: “Cyanide-Tylenol Extortion Hoax Suspect Was Indicted for Murder.” Syracuse Post Standard, October 15, 1982.

James Lewis was born: Lewis, James. Email interview by author, re: Aljeev International, July 31, 2010. -- Bergmann, Joy. “A Bitter Pill.” Chicago Reader, November 3, 2000.

James grew up: James, Lewis. Email, re: The Tylenol Speculation Drawing documents. March 8, 2008.

On December 4:  738 F.2d 91 USA, Appellee, v. James W. Lewis, Appellant. No. 83-1947 US Court of Appeals, Eighth Circuit, January 26, 1984.

In January 1982:  797 F.2d 358 21 Fed. R. Evid. Serv. 225 USA, Plaintiff-Appellee, v. James William Lewis, Defendant-Appellant. No. 84-2011. US Court of Appeals, Seventh Circuit, May 31, 1985.

On September 6:  Beck, Melinda; Foote, Donna; Michael, Renee; Shannon, Elaine. “The Tylenol Manhunt.” Newsweek, November 1, 1982.

When the Tylenol murders made: USA, Plaintiff-Appellee, v. James William Lewis, Defendant-Appellant. No. 84-2011. US Court of Appeals, Seventh Circuit, May 31, 1985.

“they’d work [McCahey] up one side and down the other and figure out what a horrible white-collar criminal he was”: Bergmann, Joy. “A Bitter Pill.” Chicago Reader, November 3, 2000.

“There's nothing special about James Lewis: Janota, Laura. “'Prime suspect' still maintains innocence.” Daily Herald, September 27, 1992.

“I’m in the business”: Avila, Oscar. “Tylenol murders linger in shadows.” Chicago Tribune, September 29, 2002.

Cook County Toxicologist, Michael Schaffer, said the cyanide: Beck, Melinda; Hagar, Mary; LaBreque, Ron; Monroe, Sylvester; Prout, Linda. “The Tylenol Scare.” Newsweek, October 11, 1982.

On October 21, 1982, a J&J employee: United Press International. “More Poisoned Tylenol Discovered In Chicago.” Pharos-Tribune, October 22, 1982.

A bottle of cyanide-laced Extra Strength: Cialini, Joe. “Death from cyanide linked to Tylenol.” The Progress, October 7, 1982.

To find out when and where:  Associated Press.  “Suspects Studied in Cyanide Deaths.” Casa Grande Dispatch, October 4, 1982.

Stein said that after the cyanide had been in the test capsules for 48 hours: Litke, James. “Cyanide kills Philadelphian.” The Gettysburg Times, October 7, 1982.

“We’re giving out what we feel we can”: Cohen, Sharon. “Citizens Turning in Capsules.” The Post Standard: October 3, 1982.

On October 9, 1982, Stein said:  United Press International. “Suspect List Cut to Four.” Pharos-Tribune, October 10, 1982.

Instead of acknowledging the relevance of Stein’s findings, Fahner sharply criticized: United Press International. “Suspect List Cut to Four.” Pharos-Tribune, October 10, 1982.

When J&J discovered the seventh bottle: Malcolm, Andrew H. “Another poisoned Tylenol bottle is found by Chicago investigators.”The New York Times, October 22, 1982.

“The Illinois Department of Law Enforcement, the FBI”: Lewis, James. ABC-7 Personal Interview by Chuck Goudie, 1992.

On October 8, 1982, NBC-News showed video footage: Nightly News. NBC, October 8, 1982.

Tyrone Fahner said the cyanide-laced Tylenol:  Rutenberg, Sharon. “More Than One ‘Madman’ Tylenol Killer is Hinted.” The Progress, October 4, 1982.

The chemical makeup:  Doyle, Pat. “A year after Tylenol killings: sorrow lingers, answers elude.” The Sunday Herald, September 25, 1983.

The FDA traced the cyanide to DuPont:  The Ames Lab: Creating Materials and Energy Solutions. “Did you know” brochure. https://www.ameslab.gov/files/DidYouKnowThat_0.pdf

The Chicago Tribune reported that the poisoned Tylenol capsules contained:  Associated Press. “Cyanide source to be probed.” The Galveston Daily News, November 13, 1982.

In early 1986, the FDA conducted its own analysis of cyanide-laced Tylenol capsules: Norman, Michael. “FBI is assigning Tylenol inquiry ‘highest priority.’” The New York Times, February 15, 1986.

“We currently have no evidence that any other Extra Strength Tylenol”:  Cunningham, Kathy. “Local Tylenol Distributor Sure of Safety.”  Winchester Star, October 2, 1982.

When Chicago Mayor:  David Berg and Stephen Robb. “Crisis Management and the ‘Paradigm Case,’” in Rhetorical and Critical Approaches to Public Relations, ed. Toth, Elizabeth. Hillsdale: Lawrence Erlbaum Associates, 1992, pg. 92-107.

“temporarily suspended production”: United Press International. “Tylenol Production Is Halted.” Pharos-Tribune, October 5, 1982.

“There is widespread”:  Gates, Thomas N.  “McNeil Consumer Products Co. ‘Dear Doctor’ Letter”: signed by Dr. Thomas N. Gates, October 13, 1982.

J&J executives had learned:  Duerksen, Susan. “6th poison victim dies; 2 more believed linked with Tylenol.” The Daily Herald, October 1, 1982.

“This case [the Tylenol murders] won’t”:  Beck, Melinda; Foote, Donna; Michael, Renee; Shannon, Elaine. “The Tylenol Manhunt.” Newsweek, November 1, 1982.

18            The Tylenol Institution

Lynn had checked out of Central DuPage hospital: Coroner’s inquest, re: Lynn Reiner. Direct examination by DuPage County Coroner Richard Ballinger, 1982.

Minutes later, Lynn’s:  Coroner’s inquest, re: Lynn Reiner. Direct examination by DuPage County Coroner Richard Ballinger, 1982. -- Rosen, Michelle. Telephone interview by author, 2009.

In fact, 90 percent:  Boatright, John R. Ethics and the Conduct of Business. Prentice Hall, 2002.

In 1974, Central DuPage Hospital:  Central DuPage Hospital. “Key Milestones in Our History.” CDH.org. http://www.cdh.org/About-Us/Our-History.aspx

The AHSP guidelines:  American Society of Hospital Pharmacists. “ASHP technical assistance bulletin on hospital drug distribution and control.” Am J Hosp Pharm., 1980.

Inpatient self-care and “discharge” medications: American Society of Hospital Pharmacists. “ASHP technical assistance bulletin on hospital drug distribution and control.” Am J Hosp Pharm., 1980.

By that aftenoon, J&J had assigned Chicago area sales reps: Associated Press. “Poisoned Tylenol kills 5.” The Capital, October 1, 1982.

“My first experience”:  “Tylenol's "Miracle" Comeback” A year after the poisonings, public confidence is restored.” TIME, October 17, 1983.

J&J said in 1982 that 70 percent of all Tylenol users:  Rosenfeld, Steven. “Trying to salvage Tylenol - again!” Gettysburg Times, February 28, 1986.

The Washington Post ran a story:  “Hospitals Opt For Tylenol Because Of Drug's Low Cost.” Washington Post, July 07, 1987.

“People forget how”:  Moore, Thomas. “The Fight to Save Tylenol.” TIME, November 29, 1982.

On the morning: Coroner’s inquest, re: Lynn Reiner. Direct examination by DuPage County Coroner Richard Ballinger, 1982

“retrieve any and all bottles of Tylenol”: Coroner’s inquest, re: Lynn Reiner. Direct examination by DuPage County Coroner Richard Ballinger, 1982.

At around 11:00 a.m.: Coroner’s inquest, re: Lynn Reiner. Direct examination by DuPage County Coroner Richard Ballinger, 1982.

He guessed they were in the bottle:  Reiner, Ed. Personal interview by author. Winfield, IL, May 22, 2010.

Chief Sostak brought Lynn’s Tylenol: Coroner’s inquest, re: Lynn Reiner. Direct examination by DuPage County Coroner Richard Ballinger, 1982.

Siekmann turned them over to the Illinois Department of Health: Pirl, Joerge. Telephone interview by author, 2010. -- Siekmann, Peter. DuPage County Coroner’s Office Preliminary Report, re: Mary Reiner, September 30, 1982.

On Friday, October 1st, Siekmann: Associated Press. “Poison Tylenol Kills Five.” The Capital, October 1, 1982. -- Duerksen, Susan. “6th poison victim dies; 2 more believed linked with Tylenol.” The Daily Herald, October 1, 1982.

“The task force is asking for help in solving the bizarre crime”: 10 p.m. News. WMAQ-TV. NBC, October 1, 1982.

On Saturday, October 2nd, the Daily Herald reported:  Duerksen, Susan. “6th poison victim dies; 2 more believed linked with Tylenol.” The Daily Herald, October 2, 1982.

As of Friday night, authorities had publicly linked:  Duerksen, Susan. “6th poison victim dies; 2 more believed linked with Tylenol.” The Daily Herald, October 2, 1982.

The poisoned Tylenol that killed Mary McFarland:  Associated Press. “Poison Found in Another Tylenol Batch.” Winchester Star, October 1, 1982.

The cyanide-laced Tylenol that killed Paula Prince: Associated Press. “Byrne bans sale of all Tylenol in the big city.” Sunday Roswell Daily Record, October 3, 1982.

On Saturday, October 2nd, lot numbers 1665LM and MC2884:  Associated Press. “7th Chicago-area death blamed on poisoned drug.” The News, October 2, 1982.

The danger list now included only lot numbers MC2880, 1910MD, and 1801MA:  Madrzyk, Anna; Gores, Paul.  “Cyanide Killer Search Widens.” The Sunday Herald, October 3, 1982.

On Sunday, October 3rd, police:  Associated Press. “Search pressed for clues in poisonings.” The Frederick Post, October 4, 1982.

“one bottle labeled Regular Strength Tylenol, Lot 1833MB”: Siekmann, Peter. DuPage County Coroner’s Office Preliminary Report, re: Mary Reiner, September 30, 1982.

Police explained that:  Associated Press.  “Police Seek Drug Killer.” Daily News Record, October 4, 1982.

Winfield Police Officer Scott Watkins, now Lieutenant: Watkins, Scott. Personal interview by author, August 19, 2010.

“I don’t know”: Watkins, Scott. Personal interview by author, August 19, 2010.

Watkins also said that on Thursday morning: Coroner’s inquest, re: Lynn Reiner. Direct examination by DuPage County Coroner Richard Ballinger, 1982. -- Siekman, Peter. DuPage County Coroner’s Office Preliminary Report, re: Mary Reiner, September 30, 1982. -- Watkins, Scott. Personal interview by Michelle Rosen, March 12, 2010.

19            The Louis Zahn Drug Company

When Central DuPage Hospital converted: Central DuPage Hospital.“Key Milestones in Our History.” CDH.org. http://www.cdh.org/About-Us/Our-History.aspx

On October 1, 1982, ABC-News:  World News Tonight. ABC, October 6, 1982. -- Madrzyk, Anna; Gores, Paul.  “Cyanide Killer Search Widens.” The Sunday Herald, October 3, 1982. -- ABC Nightline, ABC, October 1, 1982.

Louis Zahn founded:   “Louis Zahn dead at 67.” The World, August 28, 1977.

In 1982, Zahn Drug was one of the three largest:  “The Wall Street Transcript.” The Wall Street Transcript website, May 14, 2001. Accessed July 10, 2011. http://www.twst.com/pdf/visiontek.pdf

The company maintained its own delivery operation:  Chicago Truck Drivers, Helpers and Warehouse Workers Union Pension Fund, and Paul Glover v. Louis Zahn Drug Co. 88-2498. U.S. Court of Appeals, 7th Circuit, December 11, 1989.

The company’s headquarters:  “Help Wanted, Customer Service.”  The Daily Herald, July 18, 1982.

Since January of 1982, the Company’s Chief Operating Officer was William P. Altman: “Executives; Executive Changes.” The New York Times, January 27, 1982.

Prior to joining Zahn:  “A.L. Laboratories Inc. appoints William P. Altman vice president-U.S. pharmaceutical operations.” PR Newswire, August 7, 1986.

The CFO of Zahn Drug:  Heffes, Ellen M. “Balance Sheet.” Financial Executive, January 1, 2002. Accessed May 5, 2010. http://www.thefreelibrary.com/Balance+Sheet.-a082016603

Louis Zahn was:  “Louis Zahn dead at 67.” The World: August 28, 1977 -- “New Drug Center.” The World, January 7, 1977, p7.

He had been a Director:  “Let’s Talk Business.”  Waterloo Sunday Courier, January 4, 1970. -- “Louis Zahn dead at 67.” The World, August 28, 1977. -- “New Drug Center.” The World, January 7, 1977, p7. -- Lydon, Dan.  “Around N’ About.” Your Community Newspaper, April 30, 1958.

Zahn Drug was the prime vendor for a group purchasing organization: Wagner, Mary. “Tracking System Cuts Inventory Costs.”  Modern healthcare, March 17, 1989.

In 1982, Zahn Drug operated a state-of-the-art:  Angell, William M. “Material Handling Classics.”  Small Parts Orderpicking, 1980 Automated Material Handling Storage Systems Conference. Clay Bernard Systems International, April 23-25, 1980.

The capacity of the system: Angell, William M. “Material Handling Classics.”  Small Parts Orderpicking, 1980 Automated Material Handling Storage Systems Conference. Clay Bernard Systems International, April 23-25, 1980.

The video footage shown:  ABC-News. ABC, October 6, 1982. -- ABC Nightline, ABC, October 1, 1982.

Zahn Drug also employed merchandisers: “Drug store joins network.” The Herald, December 12, 1974.

Managers at Jewel stores told NBC-News: Nightly News, NBC: October 8, 1982.

The 165,000 stores that sold Tylenol nationwide: Reis, Al; Trout, Jack. Marketing Warfare. New York City: The McGraw Hill Companies, 2006, Pg. 62.

Zahn Drug served 1,400 drugstores:  Associated Press. “Hearing for two accused in kidnap delayed two days.” Winona Daily News, July 3, 1973.

The company had formed a network: “Medical info card available.” Forrest Park Review, October 12, 1977, p19. -- “Drug store joins network.” The Herald, December 12, 1974.

The Family Drug Center (FDC) stores were located:  “Medical info card available.” Forrest Park Review, October 12, 1977, p19. -- “Zahn Drug links with Familycare.” The Daily Herald, August 24, 1981.

On the morning Johnson & Johnson: Maroney, David.  “Logan Shelves Being Emptied.” Pharos Tribune, October 1, 1982.

“People started calling”:  Maroney, David.  “Logan Shelves Being Emptied.” Pharos Tribune: October 1, 1982

“It’s our strong belief that the contaminated product”: Associated Press. “More poison is found in Tylenol pills.” The Chronicle-Telegram, October 1, 1982.

The calls to Kesling were not made: Maroney, David.  “Logan Shelves Being Emptied.” Pharos Tribune, October 1, 1982.

Chicago pharmacist, Robert Wijas:  ABC World News Tonight. ABC, October 6, 1982.

In addition to the close attention paid: Montgomery, Jeff. “Tylenol Removed From Area Stores.” Altoona Mirror, October 2, 1982.

“They [McNeil] checked us three times:  Montgomery, Jeff. “Tylenol Removed From Area Stores.” Altoona Mirror, October 2, 1982.

“I think they”:  Montgomery, Jeff. “Tylenol Removed From Area Stores.” Altoona Mirror, October 2, 1982.

While McNeil representatives were: Rutenberg, Sharon. “Pill Poisonings Lead to Tylenol Recall.” The Progress, October 1, 1982. -- Associated Press. “FDA issues warning about Tylenol danger.” The Chillicothe Constitution, October 1, 1982.

Around the same time J&J officials: ABC Nightline, ABC, October 1, 1982.

In October 1963, a truck loaded with $250,000: Lindberg, Richard C. “Raising Cain.” RichardLindberg.net, 2002. http://www.richardlindberg.net/articles/reader_article.html

Cain’s story sounded suspicious:  Associated Press. “Cook Sheriff’s Aides Convicted of Perjury.” Southern Illinoisan, December 9, 1964.

Another puzzling crime:  United Press International. “Drug firm chief kidnap possible.” The Morgantown W.VA Post, June 29, 1973.

Zahn’s kidnappers moved:  Chicago Daily News. “Kidnap Drama Ends In Joy, Raises Mysteries” Charleston Daily Mail, June 6, 1973.

“The family is only”:  United Press International. “Drug firm chief kidnap possible.” The Morgantown W.VA Post, June 29, 1973.

“Of course we will”:  United Press International. “Drug firm chief kidnap possible.” The Morgantown W.VA Post, June 29, 1973.

“is integral to the case”:  Chicago Daily News. “Kidnap Drama Ends In Joy, Raises Mysteries” Charleston Daily Mail, June 6, 1973.

Ferris and Calhoun plead guilty:  Associated Press. “Innocent Pleas Are Reversed.” Edwardsville Intelligencer, September 21, 1983.

On April 6, 1987, Art Walker:  “Driver Convicted Of Theft Of Drugs.” The Chicago Tribune, April 7, 1987.

On December 9, 1992, William R. Deacon:  “Cosmopolitan Chronology.” Chicago Sun-Times, April 23, 1993.

Zahn Drug also had a history:  Gores, Paul.  “Gacy above suspicion: drug owners.” The Daily Herald, December 27, 1978.

He also had a secret history:  I Do Horrible Rotten Things.” TIME, January 8, 1979.

“Kiss my ass”:  Elder, Robert K. Last Words of the Executed. University Of Chicago Press, 2010.

Prior to Gacy’s arrest:  Ramsland, Katherine “The Chicago Rippers.” Trutv.com. Accessed January 11, 2011. http://www.trutv.com/library/crime/serial_killers/partners/chicago_rippers/index.html

the Chicago Rippers:  Ramsland, Katherine “The Chicago Rippers.” Trutv.com. Accessed January, 11 2011. http://www.trutv.com/library/crime/serial_killers/partners/chicago_rippers/index.html

Gecht took the witness stand:  Ramsland, Katherine “The Chicago Rippers.” Trutv.com. Accessed January, 11 2011. http://www.trutv.com/library/crime/serial_killers/partners/chicago_rippers/index.html

Spreitzer’s execution was commuted:  Ramsland, Katherine “The Chicago Rippers.” Trutv.com. Accessed January, 11 2011. http://www.trutv.com/library/crime/serial_killers/partners/chicago_rippers/index.html

There is a continuum:  McKesson Plants to Add FoxMeyer Health unit.” The New York Times, October 5, 1996. -- “Drug company acquires Zahn.” The Daily Herald, August 27, 1988.

McKesson was the sole supplier: McKesson Corp. “McKesson, American Drug Stores ink supply management pact.”  July 20, 1998. Accessed January, 11 2011. http://www.mckesson.com/en_us/McKesson.com/About%2BUs/Newsroom/Newsroom.html

“We’ve had the Illinois Department of Law Enforcement”:  ABC World News Tonight. ABC, October 6, 1982.

At that time, the only two bottles of cyanide-laced Tylenol recovered so far had been purchased at the Jewel-Osco stores: Beck, Melinda; Hagar, Mary; LaBreque, Ron; Monroe, Sylvester; Prout, Linda. “The Tylenol Scare.” Newsweek, October 11, 1982.

20            We Know Who Did It

In the first few days: Associated Press. “Cyanide is Discovered in Tylenol in an April Death in Philadelphia.” The New York Times, October 7, 1982.

On Tuesday, October 5th:  United Press International. “Philadelphia Cyanide Link Not Solid: Top Investigator.” Pharos-Tribune, October 7, 1982.

“the list of suspects has been narrowed”:  United Press International. “Philadelphia Cyanide Link Not Solid: Top Investigator.” Pharos-Tribune, October 7, 1982.

Fahner was back in the numbers game:  United Press International. “Tylenol poisoning probe narrowed to 4 suspects.” Pacific Stars and Stripes, October 11, 1982.

By the end of that day:  Associated Press. “Cyanide probe narrowed down to just a few leads.” Wisconsin State Journal, October 11, 1982.

Fahner said six suspects:  “Chicago lie tests clear 6.” Chicago Sun Times, October 27, 1982.

“Me and my gang put cyanide in every bottle”:  Associated Press. “No progress made in Tylenol deaths.” The Gettysburg Press, October 12, 1982.

Howard, a 20-year-old:  United Press International. “Chicago man hit for extortion; laced Tylenol link is ruled out.” Pacific Stars and Stripes, October 12, 1982.

“There is no credible”:  Associated Press. “No progress made in Tylenol deaths.” The Gettysburg Press, October 12, 1982.

Fahner said the Howard case was “unrelated totally”:  United Press International. “Chicago man hit for extortion; laced Tylenol link is ruled out.” Pacific Stars and Stripes, October 12, 1982.

The Winfield police will not confirm: Watkins, Scott. Personal Interview by author, August 19, 2010. - Watkins, Scott. Personal interview by Michelle Rosen, March 12, 2010. – Bellisario, Frank. Personal interview by Michelle Rosen, March 2010. – Samuels, Sharon. FOIA request reply, June 16, 2011.

However, on March 9, 2010. Watkins, Scott: Personal Interview by author, August 19, 2010.

“We know who did it.”: Associated Press. “Report says investigators know identity of Tylenol murderer.” Alton Telegraph, March 10, 1983.

On October 8th, NBC had led: Nightly News. NBC, October 8, 1982.

James Polk, reporting for NBC in Chicago: Nightly News. NBC, October 8, 1982.

“This is the case, “Investigators think Winfield”: Nightly News. NBC, October 8, 1982.

21            The Closet Chemist

On Saturday evening, October 9th: “Why Tylenol deaths might go unsolved.” The Daily Herald, September 29, 2002. -- Associated Press. “Cyanide suspect once indicted for murder.” Galveston Daily News, October 15, 1982. -- Chicago Police Detective. Confidential telephone interview by author, February 5, 2009.

Film critic Roger Ebert:  Parnell, Sean. O’Rourkes. Chicago Bar Project. Accessed January, 11 2011. http://www.chibarproject.com/Memoriam/O%27Rourke%27s/O%27Rourke%27s.htm

Tavern owner, Marty Sinclair:  “Cyanide-Tylenol Extortion Hoax Suspect Was Indicted for Murder.” Syracuse Post Standard, October 15, 1982. -- Chicago Detective on 1982 Tylenol task force. Confidential phone interview by author, February 5, 2009.

Two days later, Arnold was in Lilly’s Bar: Petition for Executive Clemency in Behalf of Roger Arnold. Cook County Circuit Court, 1996 -- Associated Press. “Man Questioned in Cyanide Deaths.” Dispatch, October 13, 1982. -- “Police Search Home Of Tylenol Suspect.” Daily Sitka Sentinel, October 14, 1982.

Roger Arnold was born: Petition for Executive Clemency in Behalf of Roger Arnold. Cook County Circuit Court, 1996.

In 1969, Arnold took a job: Petition for Executive Clemency in Behalf of Roger Arnold. Cook County Circuit Court, 1996. -- Associated Press. “Man Questioned in Cyanide Deaths.” Dispatch, October 13, 1982.

Prior to the aggravated assault charge: Petition for Executive Clemency in Behalf of Roger Arnold. Cook County Circuit Court, 1996.

After arresting Arnold, authorities handcuffed him to a chair: “Rush for Justice, Lifetime of Regret.” Chicago Sun-Times, March 3, 1996.

Chicago Police Detective, James C. Gildea: Associated Press. “Police Search Suspect's Home Again After Release on Bond.” Dispatch, October 14, 1982.

On Tuesday afternoon, Chicago police detectives: Blum, Howard. “It was a Typical Night for the Tylenol Task Force.” The New York Times, October 15, 1982.

“You can read”:  Blum, Howard. “It was a Typical Night for the Tylenol Task Force.” The New York Times, October 15, 1982.

“At first [Arnold] denied”: 10 p.m. News. NBC, WMAQ-TV: October 13, 1982.

“He (Arnold) dropped the comment”: 10 p.m. News. NBC, WMAQ-TV: October 13, 1982.

“I want you:  Blum, Howard. “It was a Typical Night for the Tylenol Task Force.” The New York Times, October 15, 1982.

Arnold had married Delores in 1970: Petition for Executive Clemency in Behalf of Roger Arnold. Cook County Circuit Court, 1996.

The divorce was finalized in July of 1982:  Blum, Howard. “It was a Typical Night for the Tylenol Task Force.” The New York Times, October 15, 1982.

Delores could not believe: Blum, Howard. “It was a Typical Night for the Tylenol Task Force.” The New York Times, October 15, 1982.

Detectives Eddy and Rebholz finished: Blum, Howard. “It was a Typical Night for the Tylenol Task Force.” The New York Times, October 15, 1982.

While searching Arnold’s house: United Press International: “More Poisoned Tylenol found.” Tyrone Daily, October 26, 1982. -- “Police Search Suspect's Home Again After Release on Bond.” Dispatch, October 14, 1982.

Arnold’s reading material included: Nightly News. NBC, October 13, 1982. -- Associated Press. “Police question ‘chemist’ in cyanide-deaths case.” The New Mexican, October 13, 1982.

Police found lab equipment and various chemicals: Chicago Police Detective. Phone interview by author, February 5, 2009.

a large amount of a certain type of hair-gel used in making homemade bombs: Chicago Detective on Tylenol task force. Confidential telephone interview by Scott Bartz, February 5, 2009.

Police also turned up a suspicious-looking: Wire Service. “‘Unrelated’ arrests made in Tylenol death case.” Pacific Stars and Stripes, October 15, 1982.

A spokesperson for the Chicago police later said:  “More Headaches.” TIME, October 25, 1982

Arnold was held without bond:  Associated Press. “Police Search Home of Tylenol Suspect.” Daily Sitka Sentinel, October 14, 1982.

Lieutenant Locallo said a “series of coincidences”:  “Cyanide-Tylenol Extortion Hoax Suspect Was Indicted for Murder.” Syracuse Post Standard, October 15, 1982.

The press frequently reported:  Associated Press. “Police Search Home of Tylenol Suspect.” Daily Sitka Sentinel, October 14, 1982.

Arnold was released:  United Press International. “Cyanide Suspect Released on Bail.” Tyrone Daily Herald, October 14, 1982.

Chicago Police Detective Jerry Beam:  Associated Press. “Man Questioned in Cyanide Deaths.” Dispatch, October 13, 1982.

“It doesn’t appear the man”:  Wire Service. “‘Unrelated’ arrests made in Tylenol death case.” Pacific Stars and Stripes: October 15, 1982

Arnold’s lawyer, Thomas Royce: Goudie, Chuck; Pistone, Ann. “Legendary Chicago defense lawyer dies at 64.” ABC-local website, October 6, 2009. Accessed, July 20, 2011. http://abclocal.go.com/wls/story?section=news/iteam&id=7051285

Nevertheless, when Arnold was released from jail:  Associated Press. “Eighth Poisoned Bottle Of Tylenol Discovered.” Daily News Record, October 26, 1982.

Surveillance was so heavy, said Royce:  McNamee, Tom. Rush for Justice, Lifetime of Regret.” Chicago Sun-Times, March 3, 1996.

The reading material confiscated:  United Press International.  “Cyanide suspect freed on bond.” Altoona Mirror, October 14, 1982.

Arnold said he went to Thailand:  United Press International.  “Cyanide suspect freed on bond.” Altoona Mirror, October 14, 1982.

“soldier-of-fortune type”:  United Press International. “Cyanide Suspect Released on Bail.” Tyrone Daily Herald, October 14, 1982.

“They can say what they want”:  United Press International. “Cyanide Suspect Released on Bail.” Tyrone Daily Herald, October 14, 1982.

“I was willing to take a polygraph”:  United Press International.  “Cyanide suspect freed on bond.” Altoona Mirror, October 14, 1982.

“I knew the family”:  United Press International.  “Cyanide suspect freed on bond.” Altoona Mirror, October 14, 1982.

“There are too many coincidences to rule him out”:  Blum, Howard. “It was a Typical Night for the Tylenol Task Force.” The New York Times, October 15, 1982.

Tyrone Fahner, on the other hand:  Associated Press. “Man Questioned in Cyanide Deaths.” Dispatch, October 13, 1982.

According to the Daily Herald, Arnold:  “Why Tylenol deaths might go unsolved.”The Daily Herald, September 29, 2002.

Chicago cops believed they had a good case: Chicago Detective on Tylenol task force. Confidential telephone interview by Scott Bartz, February 5, 2009. -- Chicago Detective on Tylenol task force. Confidential email interview by Scott Bartz, February 5, 2009.

“The lead in that case”:  Associated Press. “Closet chemist not tied to deaths.” Chronicle-Telegram, October 14, 1982.

22            A Conspiracy Theory

On Friday, October 22nd: Nightly News, NBC: October 25, 1982.

Authorities had questioned: “6 Cyanide murders cover for seventh?” Ironwood Daily Globe, October 25, 1982. -- Associated Press “Tylenol victim's relative a suspect.” Marysville Journal, October 25, 1982. – Associated Press. “Tylenol victim’s relative a suspect.” Register, October 25, 1982. On Monday evening: Nightly News, NBC: October 25, 1982.

On Monday evening: Nightly News, NBC: October 25, 1982.

Shortly after Arnold’s arrest: Associated Press. “Kansas City slaying kinked to man sought in Tylenol questioning.” The Register, October 15, 1982. -- United Press International. “More Cyanide-Laced Tylenol Found; Colorado Incidents Investigated.” The Progress, October 26, 1982. -- Associated Press. Tylenol Victim's Kin Is Suspect.” The Winchester Star, October 25, 1982.

The New York Times said Arnold appeared for a while to be a promising lead: “Cyanide is Found in 8th Pill Bottle.” New York Times, October 26, 1982.

“drinking buddies”:  United Press International. “More Cyanide-Laced Tylenol Found; Colorado Incidents Investigated.” The Progress, October 26, 1982.

“I knew the family:  United Press International.  “Cyanide suspect freed on bond.” Altoona Mirror, October 14, 1982.

On Monday, NBC reported:  Nightly News. NBC, October 25, 1982.

“He is the most innocent person”:  The News Service. “Prime Suspect in Tylenol Case Passes Lie Detector Test.” Winnipeg Free Press, October 27, 1982.

“Chicago authorities now believe they know the real story”: Nightly News. NBC, October 25, 1982.

“Investigators now believe the seven Tylenol murders”: Nightly News. NBC, October 25, 1982.

“members of the family of Mrs. Reiner”:  Litke, James. “Eighth bottle of Tainted Tylenol is discovered.” Chillicothe Constitution-Tribune, October 26, 1982.

NBC showed video footage of an unidentified: Nightly News. NBC, October 25, 1982

The unmarked vehicle shown in the NBC video footage was actually parked outside the home of Ed Reiner: Reiner, Ed. Personal interview by author. Winfield, IL, May 22, 2010. – Rosen, Michelle. Personal interview by author, May 22, 2010.

The prime suspect referenced by Tom Brokaw: Reiner, Ed. Personal interview by author. Winfield, IL, May 22, 2010.

Ed wasn’t home when NBC: Reiner, Ed. Personal interview by author. Winfield, IL, May 22, 2010.

IDLE investigators asked Ed: Reiner, Ed. Personal interview by author. Winfield, IL, May 22, 2010.

The interrogation of Reiner: Litke, James. “Woman turns in bottle of tainted Tylenol.” Sequin Gazette-Enterprise: October 26, 1982 -- Personal interview by author. Winfield, IL, May 22, 2010.

An IDLE investigator began: Reiner, Ed. Personal interview by author. Winfield, IL, May 22, 2010.

Reiner was flabbergasted: Reiner, Ed. Reiner, Ed. Personal interview by author. Winfield, IL, May 22, 2010.

In a condescending, perverse tone: Reiner, Ed. Personal interview by author. Winfield, IL, May 22, 2010.

To the consternation of his attorney: Reiner, Ed. Personal interview by author. Winfield, IL, May 22, 2010.

The Frye doctrine: Del Carmen, Rolando V. Criminal Procedure: Law and Practice. Wadsworth Publishing: 2006, Pg. 329.

Polygraphy is widely rejected by the scientific community: Del Carmen, Rolando V. Criminal Procedure: Law and Practice, Wadsworth Publishing: 2006, Pg. 329. -- Langan, Michael Lawrence, M.D. “The Art of Deception: Polygraph Lie Detection.” Gray Areas, Vol. 4 No, 1, February 1999.

184    According to polygraph expert, Michael Lawrence Langan, M.D.: Langan, Michael Lawrence, M.D. “The Art of Deception: Polygraph Lie Detection.” Gray Areas, Vol. 4 No, 1, February 1999

The polygraph test most commonly used: Langan, Michael Lawrence, M.D. “The Art of Deception: Polygraph Lie Detection.” Gray Areas, Vol. 4 No, 1, February 1999.

Law enforcement agencies tend: Iacono, William G. “Forensic 'Lie Detection': Procedures Without Scientific Basis,” Journal of Forensic Psychology Practice, Vol. 1 (2001), No. 1, pp. 75-86.

23            The Eighth Bottle

“Investigators say that since the negotiations”:  NBC-News, NBC: October 25, 1982.

The eighth bottle reportedly: United Press International: “More Poisoned Tylenol found.” Tyrone Daily, October 26, 1982.

The cyanide-laced capsules in the eighth bottle:  Litke, James. “Police Seek Woman Who Turned in Tylenol.” The Galveston Daily News, October 27, 1982.

On Monday night, a law enforcement source: United Press International: “More Poisoned Tylenol found.” Tyrone Daily, October 26, 1982.

The source said the woman:  Associated Press. “More Tainted Tylenol Found in Chicago.” Syracuse Post-Standard, October 26, 1982.

The Maple Plain Company was handling the reverse distribution:  Associated Press. “Coupon company hired for Tylenol swap.” Gazette, October 8, 1982.

In response to this rapidly changing situation: Gates, Thomas N. “McNeil Consumer Products Co. ‘Dear Doctor’ Letter”: signed by Dr. Thomas N. Gates, October 13, 1982.

In a statement Monday night:  Associated Press. “More Tainted Tylenol Found in Chicago.” Syracuse Post-Standard, October 26, 1982.

The next day:  Associated Press. “Woman Who Turned in Tainted Tylenol is Sought.” The New York Times, October 27, 1982.

“definitely said she”:  Associated Press. “Woman Who Turned in Tainted Tylenol is Sought.” The New York Times, October 27, 1982.

When the FBI interviewed: Litke, James. “Police Seek Woman Who Turned in Tylenol.” The Galveston Daily News, October 27, 1982.

“We don’t know”:  Litke, James. “Police Seek Woman Who Turned in Tylenol.” The Galveston Daily News, October 27, 1982.

On Wednesday afternoon, the woman:  United Press International. “Fingerprint Found On Tainted Tylenol Bottle.” The Progress, October 28, 1982.

Wheaton Police Chief:  United Press International. “Fingerprint Found On Fainted Tylenol Bottle.” The Progress, October 28, 1982.

“I believe now”:  United Press International. “Fingerprint discovered on poison Tylenol.” Hutchinson News, October 28, 1982.

Fahner held a news conference on Wednesday:  United Press International. “Print Found On Tylenol Box May Not Aid Probe.” Pharos-Tribune, October 28, 1982. -- P-S Wire Service. “FBI Finds Fingerprint on Tylenol Box.” The Post-Standard, October 28, 1982.

“closer than we have ever been”:  United Press International. “Chicago Officials Closer to Tylenol Case Arrest.” Pharos Tribune, October 27, 1982.

“I opened the capsule”: United Press International. “New Tylenol-Cyanide Mix Found.” Pharos-Tribune, Oct 29, 1982.

According to Tyrone Fahner, the cyanide-laced capsules:  Associated Press. “Official: More than one may be responsible for poisonings.” The Register, October 29, 1982. -- Associated Press. “Latest capsule has differences.” The Lethbridge Herald: October 29, 1982.

The condition of the shells: Associated Press. “Latest capsule has differences.” The Lethbridge Herald, October 29, 1982.

“swollen and discolored”:  Beck, Melinda; Hagar, Mary; LaBreque, Ron; Monroe, Sylvester; Prout, Linda. “The Tylenol Scare.” Newsweek, October 11, 1982.

“advanced state of deterioration”:  Malcolm, Andrew H. “Another poisoned Tylenol bottle is found by Chicago investigators.” The New York Times, October 22, 1982.

Fahner said the cyanide in the adulterated: Associated Press. “Second Poisoner Pondered.” Chronicle-Telegram, October 29, 1982.

“Some [cyanide-laced capsules in the eighth bottle] were put together unartfully.”:  Associated Press. “Official: More than one may be responsible for poisonings.” The Register, October 29, 1982.

Fahner said the seven cyanide-laced Tylenol capsules in the eighth bottle: Associated Press. “Official: More than one may be responsible for poisonings.” The Register, October 29, 1982. -- Associated Press. “Latest capsule has differences.” The Lethbridge Herald: October 29, 1982.

24            The Conspiracy

“Investigators think Winfield may not have been chosen at random: Nightly News. NBC, October 8, 1982.

But the Tylenol in the eighth bottle: “Three Die After Taking Cyanide-Tainted Tylenol.” The Harvard Crimson website, October 1, 1982. Accessed July 1, 2011. -- 10 p.m. News.  WMAQ-TV, NBC, October 1, 1982. – Nightly News, NBC, October 8, 1982.

“The lot number on the label of a drug”: CFR Title 21, Section 201.1

An investigation competed by J&J: Coroner’s inquest, re: Lynn Reiner, direct examination by DuPage County Coroner Richard Ballinger, 1982. Watkins, Scott. Personal Interview by author, August 19, 2010. -- Dependable Distribution Centers: Family Owned Business Built on a ‘Dependable’ Foundation: Hernandez, Vincint, Recharger Magazine, February, 2006.

All of the Tylenol: Coroner’s inquest, re: Lynn Reiner, direct examination by DuPage County Coroner Richard Ballinger, 1982. -- Watkins, Scott. Personal Interview by author, August 19, 2010.

The Chicago Sun-Times reported on October 26th that: The News Service. “Prime Suspect in Tylenol Case Passes Lie Detector Test.” Winnipeg Free Press, October 27, 1982.

On Tuesday afternoon, Wheaton: Associated Press. “Woman Who Turned in Tainted Tylenol is Sought.” The New York Times, October 27, 1982.

When Linda Morgan: United Press International. “Fingerprint Found On Tainted Tylenol Bottle.” The Progress, October 28, 1982.

DuPage County Sheriff’s detectives working on the Nicarico: Sevener, Donald. “A Capital Blunder.” Chicago Reader, July 27, 1989. -- Possley, Maurice; Armstrong, Ken. “Prosecution on trial in DuPage.” Chicago Tribune, January 12, 1999.

In the 1980s and 1990s: Warden, Rob. “Illinois Death Penalty Reform: How it Happened, What it Promises.” The Journal of Criminal Law and Criminology. Northwestern University, School of Law, 2005.

The Illinois Governor’s Commission: Randall, Kate. “Law and order in Illinois—frame-up, torture and legal murder.” World Socialist Web Site, January 23, 2003. Accessed July 1, 2011. http://www.wsws.org/articles/2003/jan2003/ill-j23.shtml

“He [Fahner] probably had:  McNamee, Tom. “Rush for Justice, Lifetime of Regret.” Chicago Sun-Times, March 3, 1996.

“No Reiner family member is a suspect”:  United Press International. “Chicago Officials Closer To Tylenol Case Arrest.” Pharos Tribune, October 27, 1982.

As it turned out:  United Press International. “FBI Can't Match Fingerprint on Tylenol Bottle.” Altoona Mirror, October 29, 1982.

Fahner said the prints on the capsules from the eighth bottle were smudged:  United Press International. “FBI Can't Match Fingerprint on Tylenol Bottle.” Altoona Mirror, October 29, 1982.

25            The Last Suspect

When authorities cleared Ed Reiner: Associated Press. “Suspect in Tylenol case wanted to settle grudge.” Alton Telegraph, November 5, 1982.

“Now is the time”:  Associated Press. “Suspect in Tylenol case wanted to settle grudge.” Alton Telegraph, November 5, 1982.

The report that Masterson harbored:  Associated Press. “Cyanide suspect held grudge against two grocery stores.” The Lethbridge Herald, November 4, 1982.

The manager of Frank’s Finer Foods in Wheaton:  Associated Press. “Suspect in Tylenol case wanted to settle grudge.” Alton Telegraph, November 5, 1982.

An affidavit filed in the 18th Circuit Court:  Associated Press. “New suspect sought in Tylenol murders.” The Capital, November 2, 1982.

Jewel Vice President, Jane Armstrong, confirmed that the woman had filed:  Associated Press. “Suspect in Tylenol case wanted to settle grudge.” Alton Telegraph, November 5, 1982.

“I feel he [Kevin] was used”:  Constable, Burt. “Masterson: suspect or victim?” The Sunday Herald, October 2, 1983.

“The injustice done was so gross”:  Constable, Burt. “Masterson: suspect or victim?” The Sunday Herald, October 2, 1983.

“A friend told”:  Constable, Burt. “Masterson: suspect or victim?” The Sunday Herald, October 2, 1983.

The Mastersons said their son: Constable, Burt. “Masterson: suspect or victim?” The Sunday Herald, October 2, 1983.

“There’s still nothing to indicate Masterson is anything”: Associated Press. “Suspect in Tylenol case wanted to settle grudge.” Alton Telegraph, November 5, 1982.

Fahner’s standing in the polls had improved greatly: Lee, Thomas J. “Tylenol case easing Fanner’s ills.” The Daily Herald, October 5, 1982. – Associated Press. “Capsules change course of election.” Roswell Daily Record, October 26, 1982.

Authorities didn’t identify Lewis:  Associated Press. “Tylenol suspect called dangerous.” The Iola Register, October 16, 1982. -- “Cyanide-Tylenol Extortion Hoax Suspect Was Indicted for Murder.” Syracuse Post Standard, October 15, 1982.

All of the eight or nine suspects : Malcolm, Andrew H. “Tylenol Maker Recalls Capsules After Strychnine Incident in West” New York Times, October 6, 1982.

The feds had admitted: USA, Plaintiff-Appellee, v. James William Lewis, Defendant-Appellant. No. 84-2011. US Court of Appeals, Seventh Circuit, May 31, 1985.

On October 27, 1983, a jury: Associated Press. “Lewis convicted in Tylenol poisoning extortion case.” Daily Intelligencer, October 28, 1983.

“As for James Lewis”: Janota, Laura. “'Prime suspect' still maintains innocence.” Daily Herald, September 27, 1992.

“I don’t need”:  Janota, Laura. “'Prime suspect' still maintains innocence.” Daily Herald, September 27, 1992.

“Sometimes public officials”:  Janota, Laura. “'Prime suspect' still maintains innocence.” Daily Herald, September 27, 1992.

“I am not fascinated with”:  Janota, Laura. “'Prime suspect' still maintains innocence.” Daily Herald, September 27, 1992.

The only man who was ever: The News Service. “Prime Suspect in Tylenol Case Passes Lie Detector Test.” Winnipeg Free Press, October 27, 1982.

Thomas Royce said the postponement was a “delay tactic”: “Chicago Officials Set To Crack Tylenol Case.” The Daily New, October 27, 1982.

“I consider him a goof”:  United Press International. “2 arrested; not linked to Tylenol.” The Hawkeye, October 13, 1982.

“I’d like to be in on the homicide”:  Bergmann, Joy. “A Bitter Pill.” Chicago Reader, November 3, 2000. http://www.chicagoreader.com/chicago/tylenol-killings-a-bitter-pill/Content?oid=903786

On the morning of June 18:  McNamee, Tom. “Rush for Justice, Lifetime of Regret.” Chicago Sun-Times, March 3, 1996.

The two spoke:  Associated Press. “Ex-Tylenol suspect charged in murder.” Pacific Stars and Stripes, June 22, 1982.

“I’m shot”:  Associated Press. “One-time Tylenol Suspect Indicted.” The Galveston Daily News, June 21, 1983.

He was pronounced dead on arrival at Grant Hospital: United Press International. “Former Tylenol suspect linked to fatal shooting.” The Sunday Herald, June 19, 1983.

One of the witnesses:  United Press International. “Former Tylenol suspect linked to fatal shooting.” The Sunday Herald: June 19, 1983.

Printed in large letters on the t-shirt Arnold was wearing:  United Press International.  “Ex-Tylenol figure held in slaying.” Pharos-Tribune, June 20, 1983.

Three days later:  Associated Press. “One-time Tylenol Suspect Indicted.” The Galveston Daily News, June 21, 1983.

During his trial:  “Figure in Tylenol case guilty of slaying.” The Daily Herald, January 12, 1984.

Police said Arnold had mistaken Stanisha:  Associated Press. “One-time Tylenol Suspect Indicted.” The Galveston Daily News, June 21, 1983.

They called the shooting a “revenge murder.”:  “Figure in Tylenol case guilty of slaying.” The Daily Herald, January 12, 1984.

Thomas Royce denied that Arnold:  United Press International.  “Ex-Tylenol figure held in slaying.” Pharos-Tribune, June 20, 1983.

Shortly after Arnold’s arrest on October 11, 1982:  Associated Press. “Police question ‘chemist’ in cyanide-deaths case.” The New Mexican, October 13, 1982.

Arnold testified at his murder trial:  McNamee, Tom. “Rush for Justice, Lifetime of Regret.” Chicago Sun-Times, March 3, 1996.

“I was thinking”:  McNamee, Tom. “Rush for Justice, Lifetime of Regret.” Chicago Sun-Times, March 3, 1996.

“You know, he”:  McNamee, Tom. “Rush for Justice, Lifetime of Regret.” Chicago Sun-Times, March 3, 1996.

Arnold had testified at his trial that he fully intended to assault Stanisha: McNamee, Tom. “Rush for Justice, Lifetime of Regret.” Chicago Sun-Times, March 3, 1996.

Four months prior to the Tylenol murders, Sinclair had filed assault: Associated Press. “Police question ‘chemist’ in cyanide-deaths case.” The New Mexican, October 13, 1982. -- McNamee, Tom. Rush for Justice, Lifetime of Regret.” Chicago Sun-Times, March 3, 1996.

They had engaged in a conversation at Sinclair’s bar:  Chicago Detective on Tylenol task force. Confidential email Interview by author. February 5, 2009.

Sinclair knew Arnold well enough: McNamee, Tom. Rush for Justice, Lifetime of Regret.” Chicago Sun-Times, March 3, 1996.

Chicago Police Sergeant:  United Press International.  “Ex-Tylenol figure held in slaying.” Pharos-Tribune, June 20, 1983.

Minutes after a jury: “Figure in Tylenol case guilty of slaying.” The Daily Herald, January 12, 1984.

Yet Arnold had insisted all along that the murder was not: McNamee, Tom. “Rush for Justice, Lifetime of Regret.” Chicago Sun-Times, March 3, 1996.

26            Project Chatham

TIME magazine, in its decade-ending: “Most Applauded Corporate Response to a Disaster.” TIME, 1990, p. 81

“Within one year: Foster, Lawrence. “The Tylenol Tragedy: A Crime Without Precedent,” in Communicating in a Healthcare Crisis, ed. Pines, Wayne L. 173-182, Church Falls: FDAnews, 2007.

J&J President David Clare: Foster, Lawrence. “The Tylenol Tragedy: A Crime Without Precedent,” in Communicating in a Healthcare Crisis, ed. Pines, Wayne L. 173-182, Church Falls: FDAnews, 2007.

Johnson & Johnson had initiated “Project Chatham”: Aguilar, Francis J.; Bhambri, Arvind: “Johnson & Johnson (B): Hospital Services.” Harvard Business School Publishing, 1983.

The executives of J&J’s subsidiary: Aguilar, Francis J.; Bhambri, Arvind: “Johnson & Johnson (B): Hospital Services.” Harvard Business School Publishing, 1983.

In September 1982, when J&J decided to implement: “H. Stuart Campbell.” Forbes website. Accessed July 10, 2011.  http://people.forbes.com/profile/h-stuart-campbell/52987

In late 1982, J&J executives decided: “H. Stuart Campbell.” Forbes website. Accessed July 10, 2011.  http://people.forbes.com/profile/h-stuart-campbell/52987

Johnson & Johnson had also made: Moore, Thomas. “The Fight to Save Tylenol.” TIME, November 29, 1982.

Nelson was a former Chicago area resident and graduate of Northwestern University: “KBL Healthcare Ventures - Advisory Board.” December 13, 2008. Accessed February 26, 2011. http://cache.zoominfo.com/CachedPage/?archive_id=0&page_id=666453215&page_url=//www.kblvc.com/advisor.htm&page_last_updated=2/13/2008+6:50:04+AM&firstName=Wayne&lastName=Nelson -- “S-1 SEC Filing, filed by Nelson Communications Inc.”SEC website. April 30, 1999. Accessed July 10, 2011. http://sec.edgar-online.com/nelson-communications-inc/s-1-securities-registration-statement/1999/04/30/Section14.aspx

It was indeed fortunate: Moore, Thomas. “The Fight to Save Tylenol.” TIME, November 29, 1982.

Interestingly, the press: Moore, Thomas. “The Fight to Save Tylenol.” TIME, November 29, 1982.

“I took some kidding at that meeting”:  Moore, Thomas. “The Fight to Save Tylenol.” TIME, November 29, 1982.

The actions that followed: Novitch, Mark, “Tylenol: The Granddady of Crisis,” in Communicating in a Healthcare Crisis, ed. Pines, Wayne L. 183-186, Church Falls: FDAnews, 2007.

“We conclude that the contamination did not occur at either plant”:  United Press International. “FDA: Tylenol-maker blameless.” The Hutchinson News, October 23, 1982.

27     Death is a Manageable Side Effect

Officials from the Tylenol task force: United Press International. “Another Cyanide Death Prevented.” Altoona Mirror, October 22, 1982. -- United Press International: “More Poisoned Tylenol found.” Tyrone Daily, October 26, 1982.

Johnson & Johnson, however, has never confirmed that it found any bottles: Associated Press. “Blind luck: Poisoned Tylenol returned unopened.” New Braunfels Herald-Zeitung: October 22, 1982.

J&J’s 1982 Annual Report states that two unused bottles of Poisoned Tylenol: “Letter to the Stockholders,” in Johnson & Johnson 1982 Annual Report, 1983.

The sixth bottle: Madrzyk, Anna; Gores, Paul.  “Cyanide Killer Search Widens.” The Sunday Herald: October 3, 1982.

Officials initially said they found two: Malcolm, Andrew H. “Search for the Tylenol Killer: Many Clues, But No Solution.” The New York Times, October 10, 1982. -- Associated Press. “7th Chicago-area death blamed on poisoned drug.” The News, October 2, 1982. -- Associated Press. “Madman’s Plot Suspected; More Tainted Tylenol Found.” The News Record, October 2, 1982.

Years later, FDA Deputy Director Mark Novitch: Novitch, Mark, “Tylenol: The Granddady of Crisis,” in Communicating in a Healthcare Crisis, ed. Pines, Wayne L. 183-186, Church Falls: FDAnews, 2007.

“Johnson & Johnson management was quick”:  “Tylenol's “Miracle” Comeback: A year after the poisonings, public confidence is restored.” TIME, October 17, 1983.

Larry Foster predicted that consumers: Associated Press. “Tylenol producers face big task.” Kokomo Tribune, October 17, 1982.

Amid the hysteria: Cooke, Jeremy R. “PSU alumnus recalls 1982 Tylenol murders.” Collegian, October 18, 2002.

Foster said the potential:  Carpenter, John; Gregory, Ted “11th-hour deal closes Tylenol case.” The Daily Herald, May 14, 1991.

As the trial-date: Janota, Laura “Tainted Tylenol Civil Case Will Begin.” Daily Herald, May 13, 1991.

“As we’ve said all along, the poisoning and the tampering in Chicago”: Janota, Laura “Tainted Tylenol Civil Case Will Begin.” Daily Herald, May 13, 1991.

J&J’s attorneys pressured: Tylenol victims’ relatives. Confidential interviews by author, 2010.

On the afternoon of May 13, 1991: Carpenter, John; Gregory, Ted “11th-hour deal closes Tylenol case.” The Daily Herald, May 14, 1991.

The plaintiffs and their lawyers: Associated Press. “After Tylenol case confidential settlements debated.” Daily Herald, May 19, 1991.

“Though there is”:  Janota, Laura. “Fear of negative publicity likely led to Tylenol settlement.” The Daily Herald, May 15, 1991.

Jane Locke:  Janota, Laura. “Fear of negative publicity likely led to Tylenol settlement.” The Daily Herald, May 15, 1991.

Details of the settlement were sealed: Szymczak, P. Davis. “Settlement Reached In Tylenol Suit.” Chicago Tribune, May 14, 1991.

“some estimates put the settlement at close to $50 million”: Smith, Zay N. “Tylenol settlement - Kin of 7 dead to get millions in out-of-court agreement.” Chicago Sun-Times, May 14, 1991.

Based on settlement information: Deyo, Russell. Confidential Tylenol Settlement Agreement, May 13, 1991. – Relatives of Tylenol murder victims. Confidential interviews by author, 2010.

Conversely, just eight days:  David Berg and Stephen Robb. “Crisis Management and the ‘Paradigm Case,’” in Rhetorical and Critical Approaches to Public Relations, ed. Toth, Elizabeth. Hillsdale: Lawrence Erlbaum Associates, 1992, pg. 92-107.

“people don’t blame”: David Berg and Stephen Robb. “Crisis Management and the ‘Paradigm Case,’” in Rhetorical and Critical Approaches to Public Relations, ed. Toth, Elizabeth. Hillsdale: Lawrence Erlbaum Associates, 1992, pg. 92-107.

Burke made up his mind Johnson & Johnson: “The Comeback” A Special Report from the Editors of Worldwide Publication of Johnson & Johnson Corporate Public Relations,” 1982.

“It would almost”:  Atkinson, Rick. “The Tylenol Nightmare: How a Corporate Giant Fought Back.” The Kansas City Times, November 12, 1982.

“You hold back”:  David Berg and Stephen Robb. “Crisis Management and the ‘Paradigm Case,’” in Rhetorical and Critical Approaches to Public Relations, ed. Toth, Elizabeth. Hillsdale: Lawrence Erlbaum Associates, 1992, pg. 92-107.

In November 2002, Jack O’Dwyer, of O’Dwyer PR:  O’Dwyer, Jack. “PR Industry’s Amicus Brief Has a Flaw.” ReclaimDemocracy.org http://www.reclaimdemocracy.org/nike/pr_brief_retort_kasky_nike.html

The brief said, “Johnson & Johnson maintained an open dialogue”:  Nike Inc. et al. v. Marc Kasky. 02-575. U.S. Supreme Court, 2002.

O’Dwyer sees it quite differently:  O’Dwyer, Jack. “PR Industry’s Amicus Brief Has a Flaw.” ReclaimDemocracy.org http://www.reclaimdemocracy.org/nike/pr_brief_retort_kasky_nike.html

Prior to re-launching Tylenol:  Moore, Thomas. “The Fight to Save Tylenol.” TIME, November 29, 1982.

“We ran a series”:  Foster, Lawrence, interview by PSU students, 2002

“We want you”: Minderovic, Christine Miner. “Tylenol Ad Campaign.” Jiffynotes.com. http://www.jiffynotes.com/a_study_guides/book_notes_add/emmc_0001_0001_0/emmc_0001_0001_0_00177.html

For Burke, the tamper-resistant packaging:  Johnson & Johnson: “The Comeback: A Special Report From the Editors of Worldwide Publication of Johnson & Johnson Corporate Public Relations.” 1982.

In mid-November 1982:  Federal Drug Administration. “A Public Service announcement about over-the-counter medicine.”  The Galveston Daily News, November 8, 1982.

The poisonings were:  Federal Drug Administration. “A Public Service announcement about over-the-counter medicine.”  The Galveston Daily News, November 8, 1982.

The New York Times reported:  Kleinfield, N.R. “Tylenol’s Rapid Comeback.” New York Times, September 17, 1983.

In 1984, Johnson & Johnson tested:  United Press International. “Tylenol Maker Rejected New Tamper-Resistant Capsule in 1984.” LA Times, February 21, 1986.

The Sterling Drug company United Press International. “Tylenol Maker Rejected New Tamper-Resistant Capsule in 1984.” LA Times, February 21, 1986.

In late October 1982: Associated Press. “Man Recovering After Taking Tainted Capsule.” Dispatch, October 26, 1982.

Bruce Pfaff:  Associated Press. “Families of poisoning victims can sue Tylenol, judge rules.” Syracuse Herald-Journal, September 13, 1990.

In February of 1986:  Kerr, Peter Tylenol is Linked to a Cyanide Death in Yonkers.” The New York Times, February 11, 1986.

The Tylenol brand quickly recovered:  McFadden, Robert D. “Maker of Tylenol Discontinuing All Over-The-Counter Drug Capsule.”  The New York Time, February 18, 1986. – Shiver, Jube Jr. “Tylenol Maker Faces Difficult Task to Rescue Product.” The New York Times, February 15, 1986.

PART 2

28    The 1986 Tylenol Murder

On Friday, February:  Cimons, Marlene; Jackson, Robert L. “Latest Tylenol Poisoning: A Nightmare Comes True.” LA Times, February 23, 1986.

Michael and Diane spent:  Cimons, Marlene; Jackson, Robert L. “Latest Tylenol Poisoning: A Nightmare Comes True.” LA Times, February 23, 1986.

Although the Tylenol comeback had been “absolutely brilliant”: Green, Michelle. “Once More Cyanide Poisons the Market for a Popular Pill, but J&J Boss James Burke Stands Fast.” People, March 3, 1986.

“hugely successful comeback”:  Green, Michelle. “Once More Cyanide Poisons the Market for a Popular Pill, but J&J Boss James Burke Stands Fast.” People, March 3, 1986.

Early Saturday afternoon:  Cimons, Marlene; Jackson, Robert L. “Latest Tylenol Poisoning: A Nightmare Comes True.” LA Times, February 23, 1986.

That night he dreamed that the Tylenol poisonings:  Cimons, Marlene; Jackson, Robert L. “Latest Tylenol Poisoning: A Nightmare Comes True.” LA Times, February 23, 1986.

It’s Chicago all over again:  Cimons, Marlene; Jackson, Robert L. “Latest Tylenol Poisoning: A Nightmare Comes True.” LA Times, February 23, 1986.

The police returned:  Cimons, Marlene; Jackson, Robert L. “Latest Tylenol Poisoning: A Nightmare Comes True.” LA Times, February 23, 1986.

Since November 1982, Tylenol: Norman, Michael. “Officials Say Fatal Tampering of Tylenol was Isolated Case.”  The New York Times, February 12, 1986.

Harriet Notarnicola, Michael’s mother: John Elsroth as Administrator of the Estate of Diane Elsroth v. Johnson & Johnson et al. 87 Civ. 1524, US District Court for the Southern District of New York, November 14, 1988.

At 4 p.m. Monday:  Associated Press. “Tylenol pulled off store shelves after fatal poisoning in New York.” Daily Intelligencer, February 11, 1986.

“Jim,” he said, “We have a serious problem.”:  Cimons, Marlene; Jackson, Robert L. “Latest Tylenol Poisoning: A Nightmare Comes True.” LA Times, February 23, 1986.

“He was pale”:  Cimons, Marlene; Jackson, Robert L. “Latest Tylenol Poisoning: A Nightmare Comes True.” LA Times, February 23, 1986.

Burke ordered what:  Cimons, Marlene; Jackson, Robert L. “Latest Tylenol Poisoning: A Nightmare Comes True.” LA Times, February 23, 1986.

Yonkers Police Commissioner, Joseph Fernandes:  Herald news service. “Laced Tylenol kills NY woman.” The Daily Herald, February 11, 1986.

“It is not known”:  Kerr, Peter. “Tylenol is Linked to a Cyanide Death in Yonkers.” The New York Times, February 11, 1986.

As “a precautionary measure,”: News Service Reports. “Poisoned Tylenol Suspected in Death.” The Post-Standard, February 11, 1986.

The FDA immediately assured the public that the tampering was a local:  Herald news service. “Laced Tylenol kills NY woman.” The Daily Herald, February 11, 1986.

“While Johnson & Johnson has no reason to believe”:  Herald news service. “Laced Tylenol kills NY woman.” The Daily Herald, February 11, 1986.

James Burke said the company believed:  News Service Reports. “Tylenol Death Considered Isolated Incident.” The Post Standard, February 12, 1986.

J&J spokesperson, James Murray, further:  Associated Press. “Tylenol Poisoning A ‘Case Of Murder’.” Daily News-Record, February 12, 1986.

New York Governor, Mario Cuomo, advised, “I have instructed”:  News Service Reports. “Poisoned Tylenol Suspected in Death.” The Post-Standard, February 11, 1986.

The Westchester Medical Examiner’s Office tested: Norman, Michael. “Officials Say Fatal Tampering of Tylenol was Isolated Case.”  The New York Times, February 12, 1986.

He said the potassium cyanide would be expected to eat through the gelatin capsules within 8 to 10 days: Drogin, Bob. “Tylenol Death Called Isolated But Stores in 34 States Pull Bottles Off Shelves.” LA Times, February 12, 1986 -- Herald news service.  “Laced Tylenol kills NY woman.” The Daily Herald, February 11, 1986.

Westchester County Medical Examiner Dr. Millard Hyland said the test results:  Norman, Michael. “Officials Say Fatal Tampering of Tylenol was Isolated Case.”  The New York Times, February 12, 1986.

We are dealing with a case of murder”: Associated Press. “Tylenol Poisoning A 'Case Of Murder'.” Daily News-Record, February 12, 1986.

Owen McClain, the Yonkers Deputy Police Chief:  Drogin, Bob. “Tylenol Death Called Isolated But Stores in 34 States Pull Bottles Off Shelves.” LA Times, February 12, 1986.

“We don’t intend”:  Norman, Michael. “Officials Say Fatal Tampering of Tylenol was Isolated Case.”  The New York Times, February 12, 1986.

“We’re obviously exploring”:  Norman, Michael. Tylenol Inquiry Officials Find ’82 Case Unrelated.” The New York Times, February 13, 1986.

“We have no reason”:  Norman, Michael. “Officials Say Fatal Tampering of Tylenol was Isolated Case.”  The New York Times, February 12, 1986.

After a jurisdictional:  Cimons, Marlene; Jackson, Robert L. “Latest Tylenol Poisoning: A Nightmare Comes True.” LA Times, February 23, 1986

“The chemical profile of the cyanide”:  Associated Press. “Recent Cyanide Poisoning Differs From One In 1982.” Marysville Journal-Tribune, February 13, 1986.

FDA spokesperson William Grigg said the compounds had a different chemical structure:  Drogin, Bob. “Tylenol Death Called Isolated But Stores in 34 States Pull Bottles Off Shelves.” LA Times, February 12, 1986.

On Tuesday, toxicologists: Goldman, John J.; Cimons, Marlene. “Agencies Pursue Massive Probe of Tylenol Poisoning.” LA Times, February 15, 1986.

According to William Grigg:  Norman, Michael. Tylenol Inquiry Officials Find ’82 Case Unrelated.” The New York Times, February 13, 1986.

Joseph Valiquette, an FBI spokesperson in New York City, said their investigation: Associated Press. “Tylenol Poisoning A 'Case Of Murder'.” Daily News-Record, February 12, 1986.

The incident appeared to be “a single, isolated case of poisoning”:  Associated Press. “Tylenol Poisoning a ‘Case of Murder.’” Daily News-Record, February 12, 1986.

William Grigg said it was unlikely:  Norman, Michael. “Officials Say Fatal Tampering of Tylenol was Isolated Case.”  The New York Times, February 12, 1986.

Johnson & Johnson concurred:  Norman, Michael. “Officials Say Fatal Tampering of Tylenol was Isolated Case.”  The New York Times, February 12, 1986.

“Everything seems to point”:  Gannett News Service. “Tests show Tylenol poison different from 1982 incidents.” The New Mexican, February 13, 1986.

“Everyone involved believes”:  Kerr, Peter Tylenol is Linked to a Cyanide Death in Yonkers.” The New York Times, February 11, 1986.

J&J spokesperson Robert Kniffin:  Norman, Michael. “Officials Say Fatal Tampering of Tylenol was Isolated Case.” The New York Times, February 12, 1986.

“Yes, of course”:  Green, Michelle. “Once More Cyanide Poisons the Market for a Popular Pill, but J&J Boss James Burke Stands Fast.” People, March 3, 1986.

After giving no press:  Prokesch, Steven. Tylenol: Despite Sharp Dispute, Managers Coped.” The New York Times, February 23, 1986.

“We had nothing”:  Prokesch, Steven. Tylenol: Despite Sharp Dispute, Managers Coped.” The New York Times, February 23, 1986.

“I really don’t like this personal publicity”:  Prokesch, Steven. Tylenol: Despite Sharp Dispute, Managers Coped.” The New York Times, February 23, 1986.

At Tuesday’s press:  Lewin, Tamar. “Tylenol Maker Finding New Crisis Les Sever.” The New York Times, February 12, 1986.

“The bottles are tamper-resistant”:  Norman, Michael. “Officials Say Fatal Tampering of Tylenol was Isolated Case.” The New York Times, February 12, 1986.

Burke said that at least 95 percent:  Drogin, Bob. “Tylenol Death Called Isolated But Stores in 34 States Pull Bottles Off Shelves.” LA Times, February 12, 1986.

Joseph Chiesa, flanked by Burke, explained:  Norman, Michael. “Officials Say Fatal Tampering of Tylenol was Isolated Case.” The New York Times, February 12, 1986.

J&J spokesperson James Murray:  James A. Murray:  Kerr, Peter Tylenol is linked to a cyanide death in Yonkers.” The New York Times, February 11, 1986.

Carl Vergari belongs:  Golding, Bruce: “Former D.A. Vergari dies.” The Journal News, October 6, 2006.

Vergari was “a straight”:  Golding, Bruce: “Former D.A. Vergari dies.” The Journal News, October 6, 2006.

“He was the”:  Golding, Bruce: “Former D.A. Vergari dies.” The Journal News, October 6, 2006.

“That’s one theory,” replied Vergari:  Associated Press. “Poison in new Tylenol death differs from '82.” The Galveston Daily News, October 13, 1982.

““As far as I’m concerned”:  Associated Press. “Poison in new Tylenol death differs from '82.” The Galveston Daily News, October 13, 1982.

“the false and dangerous impression that people shouldn’t worry”:  Associated Press. “Poisoned Tylenol: no time limit.” Sunday Intelligencer/Montgomery County Record, February 16, 1986.

“On Friday, four days after officials had learned”:  McFadden, Robert D. “Two Bottle of Poisoned Tylenol Were hipped by ame Distributor.” New York Times, February 16, 1986.

Also on Friday, inspectors from the Onondaga County:  Washington Post. “A Puzzle for Investigators.” The Post Standard, February 15, 1986.

“I guess it’s true”: Cimons, Marlene “Tylenol Chief Says Seals Can Be Replaced.” LA Times, February 20, 1986

Burke later speculated:  Cimons, Marlene “Tylenol Chief Says Seals Can Be Replaced.” LA Times, February 20, 1986.

While Burke speculated: Johnson, Dirk. “On Tylenol case, trail goes cold.” The New York Times, February 22, 1986.

29            We Never Said It Is Tamper Proof

By Thursday, February 13, 1986: Cimons, Marlene; Jackson, Robert L. “Latest Tylenol Poisoning: A Nightmare Comes True.” LA Times: February 23, 1986

“Jim, are you sitting down?”: Powell, Bill; Kasindorf, Martin. “The Tylenol Rescue.” Newsweek, March 3, 1986.

“Frank, that is”: Powell, Bill; Kasindorf, Martin. “The Tylenol Rescue.” Newsweek, March 3, 1986.

Young said that when chemists: Powell, Bill; Kasindorf, Martin. “The Tylenol Rescue.” Newsweek, March 3, 1986.

He put together a full-fledged “crisis team”: Rosenfeld, Steven. “Trying to salvage Tylenol – Again!” The Gettysburg Times, February 28, 1986.

“to be completely open”: Cimons, Marlene; Jackson, Robert L. “Latest Tylenol Poisoning: A Nightmare Comes True.” LA Times, February 23, 1986.

In a collaborative effort: Goldman, John J.; Cimons, Marlene. “Agencies Pursue Massive Probe of Tylenol Poisoning.” LA Times, February 15, 1986.

Johnson & Johnson made preparations: Cimons, Marlene; Jackson, Robert L. “Latest Tylenol Poisoning: A Nightmare Comes True.” LA Times, February 23, 1986.

At 2 a.m. Friday morning: Cimons, Marlene; Jackson, Robert L. “Latest Tylenol Poisoning: A Nightmare Comes True.” LA Times, February 23, 1986.

“Therefore, both samples must have come from the same source”: Cimons, Marlene; Jackson, Robert L. “Latest Tylenol Poisoning: A Nightmare Comes True.” LA Times, February 23, 1986.

The FDA said the chemical make-up: Norman, Michael. FBI is Assigning Tylenol Inquiry ‘Highest Priority.’” The New York Times, February 15, 1986.

Medical Examiner, Millard Hyland, had said: Norman, Michael. “Officials Say Fatal Tampering of Tylenol was Isolated Case.”  The New York Times, February 12, 1986.

TheNew York Times had reported: Norman, Michael. “Officials Say Fatal Tampering of Tylenol was Isolated Case.”  The New York Times, February 12, 1986.

Instead, FDA Deputy Commissioner, John Norris, simply said that the matching chemical profiles: Cimons, Marlene; Jackson, Robert L. “Latest Tylenol Poisoning: A Nightmare Comes True.” LA Times, February 23, 1986.

“still appears to be”: Associated Press. “More Poisoned Tylenol brings Wide Warning.” Atchison Daily Globe, February 14, 1986.

“this is a localized matter”: Norman, Michael, 2D Tainted Bottle of Tylenol Found by Investigators.” New York Times, February 14, 1986.

“The reports we’re getting”: “Both Tylenol poisonings came from same source.” The Frederick Post, February 15, 1986.

Tampering at the plant is “one avenue we are exploring”: Associated Press. “$100,000 Bounty put on Poisoner.” The New Mexican, February 15, 1986.

“an act of terrorism pure and simple”: Associated Press. “$100,000 Bounty put on Poisoner.” The New Mexican, February 15, 1986.

“It is our belief”: Prokesch, Steven, “Tylenol Capsule Output is Suspended by Maker.” New York Times, February 15, 1986.

Burke announced: Associated Press. “$100,000 Bounty put on Poisoner.” The New Mexican, February 15, 1986.

“I think the local”:  Fox, Wendy. “Maker of Tylenol says capsule sales may never recover.” The Orange County Register, February 15, 1986.

“It was so small an amount”: Aig, Marlene. “Nation told not to use Tylenol Capsules.” The Orange County Register, February 14, 1986.

“We think it’s an industrial”: Aig, Marlene. “Nation told not to use Tylenol Capsules.” The Orange County Register, February 14, 1986.

Further tests on capsules: Aig, Marlene. “Nation told not to use Tylenol Capsules.” The Orange County Register, February 14, 1986.

“It may be a cleaner”: Norman, Michael, 2D Tainted Bottle of Tylenol Found by Investigators.” New York Times, February 14, 1986.

On Friday morning, February 14th, John Norris: Associated Press. “FDA: Don’t Take Tylenol.” Maryville Journal-Tribune, February 14, 1986.

The FDA had examined packaging from both the second and third bottles: Associated Press. “FDA: Don’t Take Tylenol.” Maryville Journal-Tribune, February 14, 1986.

“It’s possible someone extremely skilled”: Associated Press. “FDA: Don’t Take Tylenol.” Maryville Journal-Tribune, February 14, 1986.

“All we have said in the past”: United Press International. “More Tainted Tylenol may clear Elsroth’s Boyfriend.” Syracuse Herald-Journal, February 14, 1986.

“Everybody else is going to have a package”: Kerzner, Harold. Project Management. Hoboken: John Wiley & Sons Inc., 2006.

Although the packaging: Washington Post. “A Puzzle for Investigators.” The Post Standard, February 15, 1986.

J&J executives, FDA officials: Washington Post. “A Puzzle for Investigators.” The Post Standard, February 15, 1986.

None of the three seals: Washington Post. “A Puzzle for Investigators.” The Post Standard, February 15, 1986.

The FBI, in addition: Houston, Jack. “Local Firm Helps Put Tylenol to the Test.” Chicago Tribune, February 23, 1986.

Even James Burke said, “The indication”: Goldman, John J.; Cimons, Marlene. “Agencies Pursue Massive Probe of Tylenol Poisoning.” LA Times, February 15, 1986.

“It is utterly baffling”: Washington Post. “A Puzzle for Investigators.” The Post Standard, February 15, 1986.

“Seal on Drug Package Can Be Forged”: Browne, Malcolm. “Seal on Drug Package Can Be Forged.” The New York Times, February 14, 1986.

“Electric heat-sealing machines: Browne, Malcolm. “Seal on Drug Package Can Be Forged.” The New York Times, February 14, 1986.

On the day Browne’s article ran: Prokesch, Steven, “Tylenol Capsule Output is Suspended by Maker.”

The New York Times, February 15, 1986.

On Friday, February 14th, J&J spokesperson, James Murray: Associated Press. “Poison in 2 Tylenol Bottles Linked to the Same Source.” LA Times, February 15, 1986.

J&J spokesperson, Robert Kniffin, also said: McFadden, Robert D. “Two Bottles of Poisoned Tylenol Were Shipped By Same Distributor.” The New York Times, February 16, 1986.

The three J&J regional distribution centers: McFadden, Robert D. “Two Bottles of Poisoned Tylenol Were Shipped By Same Distributor.” The New York Times, February 16, 1986.

“the focus of the investigation on the possibility of tampering at the plant”: Associated Press. “Poison in 2 Tylenol Bottles Linked to the Same Source.” LA Times, February 15, 1986.

“We still believe it’s local tampering”: Goldman, John J.; Cimons, Marlene. “Agencies Pursue Massive Probe of Tylenol Poisoning.” LA Times, February 15, 1986.

“The odds are something like one in a billion”: Knight-Ridder. Billion to 1 odds against tampering at separate plants?” Syracuse Herald-Journal, February 18, 1986.

The discovery of the second bottle: United Press International. “FBI gives top priority to Tylenol case.” The Star and Stripes, February 17, 1986.

This case “is extremely hot”: Norman, Michael. “FBI is assigning Tylenol inquiry ‘highest priority.’” The New York Times, February 15, 1986.

The FBI assembled: Norman, Michael. “FBI is assigning Tylenol inquiry ‘highest priority.’” The New York Times, February 15, 1986.

“to make sure we’re familiar with procedures”: Herald News Services. “Tampering in Tylenol distribution plausible.” The Daily Herald, February 17, 1986.

“For anybody to focus”: United Press International. “Official advocates ban on all capsules” Hutchinson News, February 17, 1986.

Robert Kniffin spoke to the press: McFadden, Robert D. “Two Bottles of Poisoned Tylenol Were Shipped By Same Distributor.” New York Times, February 16, 1986.

“We honestly don’t know that’s the case at all”: Goldman, John J.; Cimons, Marlene. “Agencies Pursue Massive Probe of Tylenol Poisoning.” LA Times, February 15, 1986.

“Premeditated murder has not been ruled out”: United Press International “J&J Action Too Late Says Victim’s Mother.” Tyrone Daily Herald, February 19, 1982

30            The Great Capsule Debate

Manufacturers sold $1.5 billion: Rudolph, Barbara; Delaney, Patricia; Mitchell, William J. “The Great Capsule Controversy.” TIME, July 7, 1986.

Proprietary Association spokesperson, John Walden: Cimons, Marlene. “Drug Industry Defends Packaging Safety : Admits Little Can Be Done to Enhance Tamper-Resistant System.” LA Times, February 19, 1986.

In 1986, according to Johnson & Johnson: Prokesch, Steven, “Tylenol Capsule Output is Suspended by Maker.” The New York Times, February 14, 1986.

At the time, Tylenol products accounted for $525 million: McFadden, Robert D. “Maker of Tylenol Discontinuing All Over-The-Counter Drug Capsule.”  The New York Time: February 18, 1986

Heading into the 1986 President’s Day weekend, James Burke met with his top executives: Prokesch, Steven. Tylenol: Despite Sharp Disputes, Managers Coped.” The New York Times, February 23, 1986.

The market research: Prokesch, Steven, “Tylenol Capsule Output is Suspended by Maker.” The New York Times, February 14, 1986.

“Ninety-seven percent of the public in the research”: Goldman, John J.; Cimons, Marlene. “Tylenol's Maker Ends Capsule Use: Johnson & Johnson Switches to Pills for Patent Medicines.” LA Times, February 18, 1986.

“There was definitely”: Prokesch, Steven. Tylenol: Despite Sharp Disputes, Managers Coped.” The New York Times, February 23, 1986.

Burke said that when: Prokesch, Steven. Tylenol: Despite Sharp Disputes, Managers Coped.” The New York Times, February 23, 1986.

“The anger that comes”: Prokesch, Steven. Tylenol: Despite Sharp Disputes, Managers Coped.” The New York Times, February 23, 1986.

It was very important to let people say”: Prokesch, Steven. Tylenol: Despite Sharp Disputes, Managers Coped.” The New York Times, February 23, 1986.

On Friday, the day after: Prokesch, Steven. Tylenol: Despite Sharp Disputes, Managers Coped.” The New York Times, February 23, 1986.

The Presidents Day: Powell, Bill; Kasindorf, Martin. “The Tylenol Rescue.” Newsweek, March 3, 1986.

“You’ve had this happen”:  Associated Press. “FDA: Capsule ban not right response.” Casa Grande Dispatch, February 18, 1986.

“The only way that could be done”: McFadden, Robert D. “Westchester Leader Calls on U.S. to ban nonprescription capsules. The New York Times, February 17, 1986.

“This particular package in the Woolworth store”: Cimons, Marlene. “Tylenol Probe Shifts to Time of Delivery.” LA Times, February 17, 1986.

“unfortunately, there’s nothing new at this time”: Associated Press. “Theories, but no progess in Tylenol scare research.” The Galveston Daily News, February 17, 1986.

“Even if you could”: Cimons, Marlene. “Tylenol Probe Shifts to Time of Delivery.” LA Times, February 17, 1986.

On President’s Day, Monday: McFadden, Robert D. “Maker of Tylenol Discontinuing All Over-The-Counter Drug Capsule.”  The New York Time, February 18, 1986.

“Who will protect America”: “Underground is Proposed For Those Making Atomic Products.” The Norwich Sun, January 6, 1947.

“We feel the company”: McFadden, Robert D. “Maker of Tylenol Discontinuing All Over-The-Counter Drug Capsule.”  The New York Time, February 18, 1986.

“We fought our way back”:: Goldman, John J.; Cimons, Marlene. “Tylenol's Maker Ends Capsule Use: Johnson & Johnson Switches to Pills for Patent Medicines.” LA Times, February 18, 1986.

“The so-called terrorist”:  Goldman, John J.; Cimons, Marlene. “Tylenol's Maker Ends Capsule Use: Johnson & Johnson Switches to Pills for Patent Medicines.” LA Times, February 18, 1986.

“This Company has figured out”:  Prokesch, Steven. Tylenol: Despite Sharp Disputes, Managers Coped.” The New York Times, February 23, 1986.

“I am an aggressive marketing person”: Prokesch, Steven. Tylenol: Despite Sharp Disputes, Managers Coped.” The New York Times, February 23, 1986.

But Collins was now also the Vice President: “Schering-Plough Healthcare President David Collins Elected Chairman of NDMA.” PR Newswire, May 18, 1992.

FDA Commissioner, Frank Young, called Johnson & Johnson’s decision: Associated Press. “Tylenol capsule production halted.” The Galveston Daily News, February 18, 1986.

Prosecutors charged Stella: “Bitter Pill.” 48 Hours, CBS, June 4, 2001.

The Proprietary Association paid Hamilton: “O.C. Woman Gets Big Reward in Mom's Conviction.” LA Times, October 06, 1990.

“Twelve confirmed deaths since 1982”: “The Proprietary Association offers reward up to $300,000 for the arrest and conviction of person or persons responsible for Excedrin Extra-Strength capsule poisonings in Seattle.” PR Newswire, June 19, 1986.

“The main anguish that any human being feels”: Cimons, Marlene; Jackson, Robert L. “Latest Tylenol Poisoning: A Nightmare Comes True.” LA Times, February 23, 1986.

“Yes, Indeed I am”: Molotsky, Irvin, Tylenol Maker hopeful on solving poisoning case.” The New York Times, February 20, 1986.

As luck would have it: Prokesch, Steven. Tylenol: Despite Sharp Dispute, Managers Coped.” The New York Times, February 23, 1986.

“While the withdrawal of capsules is a financial burden”: McFadden, Robert D. “Maker of Tylenol Discontinuing All Over-The-Counter Drug Capsule.”  The New York Time, February 18, 1986.

One day after announcing: Norman, Michael. “FBI Finds No Tampering with Packaging of Tylenol.” New York Times, February 19, 1986.

Two of Michael’s friends: United Press International. “More tainted capsules may clear Elsroth's boyfriend.” Syracuse Herald-Journal, February 14, 1986.

“Automatically, you assume”: “Hundreds of leads going nowhere in cyanide deaths.” The Philadelphia Inquirer, September 15, 1986.

“They have gone”: “Hundreds of leads going nowhere in cyanide deaths.” The Philadelphia Inquirer, September 15, 1986.

Elsroth’s Aunt”: United Press International. “Italy bans Tylenol.” Pharos-Tribune, February 16, 1986.

31            Burke’s Nightmare

James Burke gave the best performance: Kempton, Murray. “Yet another happy ending on Donahue.” Chicago Sun-Times: February 25, 1986

“You can actually discuss and present”: Associated Press. “Tylenol maker launches PR drive to restore painkiller's good image.” The Stars and Stripes, February 20, 1986.

The highlight of Burke’s: Koepp, Stephen. “A Hard Decision to Swallow.” TIME, March 03, 1986.

“I’m not sure”: Norman, Michael. “FBI Finds No Tampering with Packaging of Tylenol.” The New York Times: February 19, 1986.

“I don’t believe that”: Norman, Michael. “FBI Finds No Tampering with Packaging of Tylenol.” The New York Times, February 19, 1986.

Shortly after his Donahue appearance, Burke said he: Cimons, Marlene; Jackson, Robert L. “Latest Tylenol Poisoning: A Nightmare Comes True.” LA Times, February 23, 1986.

On Wednesday, February 12th, Vergari told reporters: Associated Press. “Poison in new Tylenol death differs from '82.” The Galveston Daily News, February 13, 1986.

I have it “on good authority”: Norman, Michael. “FBI is assigning Tylenol inquiry ‘highest priority.’” The New York Times, February 15, 1986.

“We have a small group of scientists”: Associated Press. “Recent Cyanide Poisoning Differs From One In 1982.” Marysville Journal-Tribune, February 13, 1986.

A chemical analysis of the potassium cyanide in both containers: Norman, Michael. “FBI is assigning Tylenol inquiry ‘highest priority.’” The New York Times, February 15, 1986.

“The work we did”: Norman, Michael. “FBI is assigning Tylenol inquiry ‘highest priority.’” The New York Times, February 15, 1986.

Young said more sophisticated testing: Norman, Michael. “FBI is assigning Tylenol inquiry ‘highest priority.’” The New York Times, February 15, 1986.

“the potency of the poison could last almost indefinitely”: McFadden, Robert D. “Two Bottles of Poisoned Tylenol Were Shipped By Same Distributor.” The New York Times, February 16, 1986.

On February 12th, three days before the FDA came clean: Associated Press. “Recent Cyanide Poisoning Differs From One In 1982.” Marysville Journal-Tribune, February 13, 1986.

Carl Vergari refused to go along: Associated Press. “Poisoned Tylenol: no time limit.” Sunday Intelligencer/Montgomery County Record, February 16, 1986.

“This particular package in Woolworth’s”: Cimons, Marlene. “Tylenol Probe Shifts to Time of Delivery.” LA Times, February 17, 1986.

The Bronxville police were more forthcoming: Associated Press. “Ban urged on over-the-counter capsules.” The Stars and Stripes, February 18, 1986.

Yesterday A&P temporarily: “Great Atlantic and Pacific Tea Company Inc. removes from sales all Tylenol capsules as a precautionary measure, related to a police investigation of a death in Westchester County, N.Y.” PR Newswire, February 11, 1986.

Frank Young said the second and third bottles: News Service. “Second bottle of poisoned Tylenol found.” The Post Standard, February 14, 1986.

James Burke said the Tylenol in the first and second: Cimons, Marlene. “Tylenol Probe Shifts to Time of Delivery.” LA Times, February 17, 1986.

However, that warehouse was not actually owned: Gary, Macklin. “Grocers concentrate on sales, purchase distribution expertise.” Refrigerated Transporter, July 1, 2004.

Since 1981, C&S Wholesale Grocers: “A Difficult Decision.” C&S Wholesale Grocers website. Accessed June 1, 2011. http://www.cswg.com/company/history/difficult-descission.htm

J&J spokesperson Robert Kniffin said: McFadden, Robert D. “Two bottles of poisoned Tylenol were shipped by same distributor.” The New York Times, February 16, 1986.

McNeil President, Joseph Chiesa, inadvertently: Prokesch, Steven, “Tylenol Capsule Output is Suspended by Maker.” The New York Times, February 14, 1986.

J&J and the FDA said Tylenol was a very high turnover product: Kempton, Murray. “Yet another happy ending on Donahue.” Chicago Sun-Times, February 25, 1986. -- Norman, Michael. “Officials Say Fatal Tampering of Tylenol was Isolated Case.” The New York Times, February 12, 1986.

FDA Spokesperson, William Grigg, said that because Tylenol is a popular item: Norman, Michael. “Officials Say Fatal Tampering of Tylenol was Isolated Case.” The New York Times, February 12, 1986.

The contract length must have been six months: Knight-Ridder. Billion to 1 odds against tampering at separate plants?” Syracuse Herald-Journal, February 18, 1986.

In-bound finished goods: Johnson & Johnson “Position Paper on Accounting for Inbound Finished Goods Freight.”

If the customer specifies: Johnson & Johnson. “J&J Revenue Recognition Policy (WW-210A).” August 1, 2001.

The first clue to the true source:  Inquirer Wire Service (with contribution from Michael B. Coakley). “Cyanide in Tylenol; Woman Dead.” Inquirer, February 11, 1986.

Under room temperature: “Tylenol Professional Product Information.” 2010. June 20, 2011. http://www.tylenolprofessional.com/assets/TYL_PPI.pdf

A drug’s shelf life: CFR Title 21, Sec. 211.166 (Stability testing)

On Saturday, February 15, Vergari: McFadden, Robert D. “Two bottles of poisoned Tylenol were shipped by same distributor.” The New York Times, February 16, 1986.

32            The Puerto Rican Diversion

Vergari said Federal investigators: McFadden, Robert D. “Two bottles of poisoned Tylenol were shipped by same distributor.” The New York Times, February 16, 1986.

“The report we’re getting”:  “Tests Link Poisons in Two Tylenol Bottles.” The Post-Standard, February 15, 1986.

On June 28, 2001: FDA. “FDA Witnesses Destruction of Drug Products.” June 28, 2001. Accessed July 10, 2011. http://www.fda.gov/ICECI/EnforcementActions/EnforcementStory/EnforcementStoryArchive/ucm107058.htm

Johnson & Johnson had a major:  GAO Report. “Potential Economic Impacts of Changes in Puerto Rico’s Status Under S. 712.” April 1990.

Robert Kniffin said the Tylenol from Lot AHA090 “was manufactured in Dorado”: McFadden, Robert D. “Two bottles of poisoned Tylenol were shipped by same distributor.” The New York Times, February 16, 1986.

Several Johnson & Johnson spokespersons: Norman, Michael, 2D Tainted Bottle of Tylenol Found by Investigators.” The New York Times, February 14, 1986. -- McFadden, Robert D. “Two bottles of poisoned Tylenol were shipped by same distributor.” The New York Times, February 16, 1986.

The FBI also confirmed that the Tylenol: “FBI is assigning Tylenol inquiry ‘highest priority.’” The New York Times, February 15, 1986.

Since 1983, the McNeil Consumer Products Company had been manufacturing Tylenol in Las Piedras:  “2010 Resume: E. Cividanes-Freiría & Assoc. CIVIDANES & ROSA Architects – Consultants.” E. Cividanes-Freiría & Associates website, 2010. Accessed July 22, 2011. http://www.civirosa.com/documents/Resume%20ECF-A%202010-Industrial.pdf

Johnson & Johnson did, however, own: “Dorado Site Overview.” Biovail website. Accessed July 1, 2011  http://biovail-facility.com/overview.htm -- DOD Defense Logistics Agency (DLA) Contract with McNeil Pharmaceutical, Dorado, Puerto Rico. Contract number DLA12085C0390, April 13, 1985. -- “2010 Resume: E. Cividanes-Freiría & Assoc. CIVIDANES & ROSA Architects – Consultants.” E. Cividanes-Freiría & Associates website, 2010. Accessed July 22, 2011. http://www.civirosa.com/documents/Resume%20ECF-A%202010-Industrial.pdf

The McNeil Pharmaceutical Company had FDA approval: JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 74, NO. 4,1982 – “Dorado Site Overview.” Biovail website. Accessed July 1, 2011  http://biovail-facility.com/overview.htm

Robert Kniffin said that the Montgomeryville facility was one of three: McFadden, Robert D. “Two Bottles of Poisoned Tylenol Were Shipped By Same Distributor.” The New York Times, February 16, 1986.

The McNeil Pharmaceutical Company had its headquarters:  McNeil Pharmaceutical. “McNeil Pharmaceutical Company; SUPROL Brand Suprofen; 6505-00D001599.” DrugBank website. December 4, 1986. Accessed July 20, 2011 http://www.drugbank.ca/system/msds/DB00870.pdf?1265922742. – Reynolds, Brian E. “McNEil Pharmaceutical Div. of McNeil Labs Inc. -- HALDOL Brand Haloperidol Tablets; 10 MG; 6505-01-048-8982.” Vermont Safety Information Resources website, November 21, Accessed July 20, 2011. http://hazard.com/msds/f2/bgh/bghxx.html . -- Reitz, Allen. “About the Cover.” ACS Publications website, March 11, 1991. Accessed July 22, 2011. http://pubs.acs.org/doi/pdf/10.1021/bk-1991-0463.pr001 . -- Allen Reitz Biography on Planet Connect website. Accessed July 22, 2011. http://events.planetconnect.com/careerworkshopprogram.html

In the 1980s, the McNeil Pharmaceutical plant in Montgomeryville: McNeil Pharmaceutical. “McNeil Pharmaceutical Company; SUPROL Brand Suprofen; 6505-00D001599.” DrugBank website. December 4, 1986. Accessed July 20, 2011 http://www.drugbank.ca/system/msds/DB00870.pdf?1265922742.  – Mintz, Morton. “Drug fiends: even inside Johnson & Johnson, public safety can take a back seat to profits.” Washington Monthly, April 19, 1991. -- “2010 Resume: E. Cividanes-Freiría & Assoc. CIVIDANES & ROSA Architects – Consultants.” E. Cividanes-Freiría & Associates website, 2010. Accessed July 22, 2011. http://www.civirosa.com/documents/Resume%20ECF-A%202010-Industrial.pdf

The plant also manufactured Tylox capsules: “When it Really Hurts.” Tylox advertisement, on NCBI website 1986. Accessed July 22, 2011. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1251264/pdf/annsurg00091-0002.pdf

The McNeil Pharmaceutical plant in Dorado: JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 74, NO. 4,1982 – “Dorado Site Overview.” Biovail website. Accessed July 1, 2011. http://biovail-facility.com/overview.htm

On Saturday, February 16, Robert Kniffin said: Aig, Marlene. “Cyanide could have been in Tylenol for months.” Lawrence Journal World, February 16, 1986.

But Kniffin had previously stated that the Tylenol in the second bottle: McFadden, Robert D. “Two bottles of poisoned Tylenol were shipped by same distributor.” The New York Times, February 16, 1986.

On Thursday February 13th, Johnson & Johnson: Norman, Michael, 2D Tainted Bottle of Tylenol Found by Investigators.” The New York Times, February 14, 1986.

The FBI also confirmed: Norman, Michael. “FBI is assigning Tylenol inquiry ‘highest priority.’” The New York Times, February 15, 1986.

Throughout the 1980s, the U.S. Department of Defense (DOD) contracted with the McNeil Pharmaceutical Company in Dorado to buy Tylenol with Codeine: DOD Defense Logistics Agency (DLA) Contract with McNeil Pharmaceutical, Dorado, Puerto Rico. Contract number DLA12085C0390, April 13, 1985. – DOD Contract with McNeil Pharmaceutical, Dorado, Puerto Rico. Contract number DLA12085D0553, November 25, 1985. -- DOD Contract with McNeil Pharmaceutical, Dorado, Puerto Rico. Contract number DLA12086C0097, February, 10, 1986.

The DOD contracted separately with the McNeil Consumer Products Company to buy non-prescription Tylenol capsules, tablets, and elixir: DOD Contract with McNeil Consumer Products Company, Fort Washington, Pennsylvania. Contract number DLA12083C0127, January 1983. -- DOD Contract with McNeil Consumer Products Company, Fort Washington, Pennsylvania. Contract number DLA12083C0677, September 1983. – Department of Veterans Affairs, DLA Contract with McNeil Consumer Products, Round Rock, Texas. Contract number V797P5238L, October 1988.

Johnson & Johnson’s probable motive: GAO Report. “Potential Economic Impacts of Changes in Puerto Rico’s Status Under S. 712.” April 1990.

Johnson & Johnson did not pay Federal income tax: GAO. “GAO Briefing Report to the Chairman, Special Committee on Aging, U.S. Senate.” May 4, 1992.

For the period 1980 to 1990:  GAO. “GAO Briefing Report to the Chairman, Special Committee on Aging, U.S. Senate.” May 4, 1992.

33            Our Credo

A key question, said FBI spokesperson: Norman, Michael. “FBI is assigning Tylenol inquiry ‘highest priority.’” The New York Times, February 15, 1986.

“There’s no question: Cimons, Marlene. “Tylenol Chief Says Seals Can Be Replaced.” LA Times, February 20, 1986.

Burke said experts within J&J had successfully”: Cimons, Marlene. “Tylenol Chief Says Seals Can Be Replaced.” LA Times, February 20, 1986.

The FDA found that during 2008 and 2009, the Las Piedras plant: FDA. “FDA 483 Inspection Observations.” January 8, 2010.

In 1987, Johnson & Johnson received: Mintz, Morton. “Drug fiends: even inside Johnson & Johnson, public safety can take a back seat to profits.” Washington Monthly, April 19, 1991.

In 1985, the McNeil Consumer Products Company: Associated Press. “Kid’s Tylenol Recalled.” Ottawa Herald:, July 19, 1985. -- Associated Press. “Recall of Children’s Tylenol almost complete.” The Gettysburg Times, July 19, 1985.

In 1982, when McNeil’s Associate Medical Director: Weiser, Benjamin. “Suit Alleges Public Misled On Painkiller; Zomax's Side Effects Said to Be Concealed.” The Washington Post, October 5, 1989.

In 1996, when Carlos Labanda: Silverman, Edward. “Whistleblowers Sue Johnson & Johnson over Dismissals.” New Jersey Star Ledger, reprinted in Knight-Ridder-Tribune, May 16, 1997.

In 1999, when Hector: Pollack, Andrew. “Drug Factory of Johnson & Johnson Under Inquiry.” The New York Times, July 19, 2002.

In the 2000s, when Chief: “Former Vice President Of J&J Subsidiaries Files Lawsuit Claiming Unlawful Firing After Insisting On Recall Of Ortho Evra, Other Products.”  December 26, 2006 http://www.medicalnewstoday.com/articles/59450.php

OUR CREDO:  Johnson, Robert W. “Our Credo.” http://www.jnj.com/connect/about-jnj/jnj-credo/

“Even though your”:  FDA. “FDA 483 Inspection Observations.” January 8, 2010.

The FDA concluded: “There is a failure”:  FDA. “FDA 483 Inspection Observations.” April 4, 2010.

34            The Vergari Problem

Carl Vergari announced: Associated Press. “Poison in 2 Tylenol Bottles Linked to the Same Source.” LA Times, February 15, 1986.

Vergari said that based on the FBI tests: McFadden, Robert D. “Two Bottles of Poisoned Tylenol Were Shipped By Same Distributor.” The New York Times, February 16, 1986.

Reporters, eager to: Knight-Ridder. Billion to 1 odds against tampering at separate plants?” Syracuse Herald-Journal, February 18, 1986.

“We’re not commenting”: McFadden, Robert D. “Two Bottles of Poisoned Tylenol Were Shipped by Same Distributor.” The New York Times, February 16, 1986.

Asked why, in view: McFadden, Robert D. “Two Bottles of Poisoned Tylenol Were Shipped by Same Distributor.” TheNew York Times, February 16, 1986.

Yonkers’ Police Chief, Owen McClain: Associated Press. “Tylenol Probers to review deaths.” The Titusville Herald, February 19, 1986.

“No leads are being left uncovered”: United Press International. “Italy bans Tylenol.” Pharos-Tribune, February 16, 1986.

“suggested additional broad areas of inquiries”: Associated Press. “Death case gets second look.” Daily News-Record, February 19, 1986.

“We still haven't eliminated”: Associated Press. “Death case gets second look.” Daily News-Record, February 19, 1986.

One day after the tour: Norman, Michael. “FBI Finds No Tampering with Packaging of Tylenol.” The New York Times, February 19, 1986.

“does not mean that the tampering did not occur”: Norman, Michael. “FBI Finds No Tampering with Packaging of Tylenol.” The New York Times, February 19, 1986.

“We do not have any proof it didn’t happen in the plant or the warehouse”: Norman, Michael. “FBI Finds No Tampering with Packaging of Tylenol.” The New York Times, February 19, 1986.

On February 20, 1986, ten days after: Molotsky, Irvin. “Tylenol Maker hopeful on olving poisoning case.” The New York Times, February 20, 1986.

Later in the day, Burke spoke: Molotsky, Irvin. “Tylenol Maker hopeful on solving poisoning case.” The New York Times, February 20, 1986.

In May 1981, J&J was waiting: Associated Press. “Suture tie to Nancy explained.” The Daily Herald, November 20, 1981.

Just six months after President Reagan had praised Burke: “Gordon College President’s Report.” Gordon College, fall 2003.

In 1986 Burke was a long-time friend: Reagan, Ronald. “Appointment of the Chairman, Executive Director, and Membership of the President's Commission on Executive Exchange.” President’s Executive Order, September 14, 1981.

On February 10, 1986, the day Burke said he learned about the death: Reagan, Ronald. “Appointment of 14 Members of the President's Commission on Executive Exchange, and Designation of the Chairman.” President’s Executive Order, February 10, 1986.

Burke was still a member of the PCEE in 1989: Reagan, Ronald. “Appointment of 2 Members of the President’s Commission on Executive Exchange.” President’s Executive Order, January 1991.

In November 2002, Elaine Kaplan, the OSC Chief, said: Anderson, Martin Edward. “White House whistle-blower receives a belated apology.” Insight on the News, November 26, 2002.

“does not mean that the tampering”: Norman, Michael. “FBI Finds No Tampering with Packaging of Tylenol.” The New York Times, February 19, 1986.

FBI spokesperson, Lane Bonner, said: News Service Reports. “FBI: Tylenol Laced After Leaving Plant.” The Post-Standard, February 20, 1986.

FBI spokesperson, Milt Ahlerich, held a news conference: Norman, Michael. “Bottle Tampering Found.” The New York Times, February 27, 1986.

“Previously undetected signs”: Norman, Michael. “Bottle Tampering Found.” The New York Times, February 27, 1986.

Ahlerich provided no explanation: Norman, Michael. “Bottle Tampering Found.” The New York Times, February 27, 1986.

Johnson & Johnson, elated by the FBI’s reversal: Norman, Michael. “Bottle Tampering Found.” The New York Times, February 27, 1986.

Larry Foster said, “The FBI”: Cimons, Marlene; Ostrow, Ronald J. “Tylenol Held Tainted After Leaving Plant.” LA Times, February 27, 1986.

“We have felt”: Associated Press. “FBI Eases Tylenol Tension.” Ottawa Herald: February 27, 1982

“so we don’t know what scientific”: Associated Press. “Poison source not positive.” Bedford Gazette, February 28, 1986.

“We have eliminated nothing”: Associated Press. “Poison source not positive.” Bedford Gazette, February 28, 1986.

“As the FBI’s research and training facility in Washington D.C.”: Kelly, John; Wearne Phillip. Tainting Evidence: Inside the Scandals at the FBI Crime Lab. Free Press, 2002.

“At the core of what the critical experts”: Kelly, John; Wearne Phillip. Tainting Evidence: Inside the Scandals at the FBI Crime Lab. Free Press, 2002.

In April 1997, the U.S. Justice Department: Johnston, David. “FBI Crime lab methods substandard, report says: Another blow.” Daily News, April 16, 1997.

“The prevailing culture”: CNN. “Official FBI lab criticism will prompt case challenges.” April 16, 1997. http://articles.cnn.com/1997-04-16/us/9704_16_fbi.lab_1_frederic-whitehurst-lab-examiners-inspector-general-michael-bromwich?_s=PM:US

“It was possible to invade these bottles”: Norman, Michael. “Bottle Tampering Found.” The New York Times, February 27, 1986.

“We were puzzled all along”: Norman, Michael. “Bottle Tampering Found.” The New York Times, February 27, 1986.

On February 18, 1986, one day after the mock inspection: Associated Press. “Death case gets second look.” Daily News-Record, February 19, 1986.

Carl Vergari died on October 15, 2006: Golding, Bruce: “Former D.A. Vergari dies.” The Journal News, October 6, 2006.

35            Revisionist History

“You remember in 1986, there was another murder”: Foster, Lawrence, interview by PSU students. “Interview with Larry Foster.” 2002. Accessed July 21, 2011. http://instruct.tri-c.edu/jkerezy/Larry_Foster_Video_Interview.pdf

The Tylenol box was sealed with permanent adhesive: Norman, Michael. “Officials Say Fatal Tampering of Tylenol was Isolated Case.”  The New York Times, February 12, 1986.

“Boxes with sealed flaps make it impossible to reseal the package”: McEntee, Helene. “1982 deaths brought new packaging.” Chicago Sun-Times, February 12, 1986.

Even Johnson & Johnson executives agreed: Goldman, John J.; Cimons, Marlene. “Agencies Pursue Massive Probe of Tylenol Poisoning.” LA Times, February 15, 1986.

An article that ran in The Washington Post: Washington Post. “A Puzzle for Investigators.” The Post Standard, February 15, 1986.

Court documents make it: John Elsroth as Administrator of the Estate of Diane Elsroth v. Johnson & Johnson et al. 87 Civ. 1524, US District Court for the Southern District of New York, November 15, 1988.

Goettel wrote, “The murder remains unsolved”: John Elsroth as Administrator of the Estate of Diane Elsroth v. Johnson & Johnson et al. 87 Civ. 1524, US District Court for the Southern District of New York, November 15, 1988.

“The companies could not be held responsible”: John Elsroth as Administrator of the Estate of Diane Elsroth v. Johnson & Johnson et al. 87 Civ. 1524, US District Court for the Southern District of New York, November 15, 1988.

Judge Goettel said the case left “difficult questions”: John Elsroth as Administrator of the Estate of Diane Elsroth v. Johnson & Johnson et al. 87 Civ. 1524, US District Court for the Southern District of New York, November 15, 1988.

Many PBWT lawyers began their careers: Patterson, Belknap, Webb & Tyler website. Accessed July 10, 2011. http://www.pbwt.com/

The relationship between Johnson & Johnson and PBWT: Higgs, Robert. Depression, war, and cold war: Studies in Political Economy. Oxford University Press, 2006. Pg 51. – “Robert Porter Patterson: Soldier, Judge, Statesman, Citizen.” Patterson, Belknap, Webb & Tyler website. Accessed July 10, 2011. http://www.pbwt.com/files/FileControl/2e195806-13b9-48af-80d5-01111d723ff5/7483b893-e478-44a4-8fed-f49aa917d8cf/Presentation/File/DisplayBk-Printer.final_.pdf

Robert Patterson died: Associated Press. “2nd Disaster In Over Month Arouses Citizens: Investigation Underway.” The Evening Ledger, January 23, 1952. – Associated Press. “Patterson Said Last Month Death May Come Suddenly.” The Evening Ledger, January 23, 1952. - UNITED STATES v. SCHINE 260 F.2d 552 (1958), No. 234, Docket 24722. United States Court of Appeals Second Circuit, October 20, 1958.

“The district courts shall have original jurisdiction”: Code of Federal Regulations, Title 28, Section 1332(a).

“We are mindful”: John Elsroth as Administrator of the Estate of Diane Elsroth v. Johnson & Johnson et al. 87 Civ. 1524, US District Court for the Southern District of New York, November 15, 1988.

In a decision soaked with hypocrisy: John Elsroth as Administrator of the Estate of Diane Elsroth v. Johnson & Johnson et al. 87 Civ. 1524, US District Court for the Southern District of New York, November 15, 1988.

The doctrine of strict: John Elsroth as Administrator of the Estate of Diane Elsroth v. Johnson & Johnson et al. 87 Civ. 1524, US District Court for the Southern District of New York, November 15, 1988.

“We hold that preventing”: John Elsroth as Administrator of the Estate of Diane Elsroth v. Johnson & Johnson et al. 87 Civ. 1524, US District Court for the Southern District of New York, November 15, 1988.

Following the 1986 Tylenol murder: Powell, Bill; Kasindorf, Martin.“The Tylenol Rescue.” Newsweek, March 3, 1986.

Kevin Donovan, the current vice president: Milton, Pat. “New York’s FBI Chief Ending Career.” AP Online, March 1, 2002.

Donovan had been the Assistant Director: Newman, Richard. “Security blankets.” The Record, April 13, 2008.

The man Donovan replaced: Thomas, Pierre. “A New Strain of Terrorism; Groups Are Fast, Loose, Hard to Find.” The Washington Post, August 3, 1993.

Russell Deyo, the current General Counsel: “Management Team,” J&J website.  Accessed December 1, 2010. http://www.investor.jnj.com/governance/managementdetail.cfm?bioid=19178

As the Corporate Secretary: Deyo, Russell. Confidential Tylenol Settlement Agreement, May 13, 2991. – Relatives of Tylenol murders victims. Confidential interviews by author, 2010.

In 1991, former McNeil Chairman: Nelson Communications. Form S-1, April 30, 1999. http://www.sec.gov/Archives/edgar/data/1082447/0000950123-99-003962.txt -- NAPRO BIOTHERAPEUTICS, INC · 10-K/A. SEC.gov, December 31, 2001. http://www.sec.gov/Archives/edgar/data/891504/000089973302000083/form10ka2001.htm

John Norris: “Speaker Biographies: John A. Norris JD, MBA.” Yet2.com website. Accessed July 2, 2011. http://www.yet2.com/app/global/en/html/eb7bio_norris.html

Mark Novitch: “Upjohn announces organizational changes (Officers).” PR Newswire: November 18, 1988 – “Executive Profile: Mark Novitch M.D.” Bloomberg Businessweek website. Accessed July 2, 2011 http://investing.businessweek.com/businessweek/research/stocks/people/person.asp?personId=194520&ticker=SYNI:US&previousCapId=25798&previousTitle=Bristol-Myers%20Squibb%20Co.

Frank Young: Anderson, Jack. “FDA Chief down for the count.” The Valley Independent, December 14, 1989. -- “The Proprietary Association offers reward up to $300,000 for the arrest and conviction of person or persons responsible for Excedrin Extra-Strength capsule poisonings in Seattle.” PR Newswire, June 19, 1986. -- Church, George J; Griggs, Lee; Healy, Rita. “Copycats Are on the Prowl.” TIME, November 8, 1982. -- United Press International. “Tampering Found In Anacin Product” Pharos Tribune, June 25, 1986.

“The FDA is not now considering any ban on capsules”: Rudolph, Barbara; Delaney, Patricia. “The Great Capsule Controversy.” TIME, July 07, 1986.

Then, the generic drug: Rankin, Ken. “Bribery charges spur tight new drug procedures by FDA.” Drug Store News: March 15, 1989 -- Pines, Wayne L. “Communicating in a Healthcare Crisis.” FDAnews, 2007, pg. 197.

“[Young] was a good soldier”: Anderson, Jack. “FDA Chief down for the count.” The Valley Independent, December 14, 1989.

Frank Young’s penance was short lived: Frank E. Young Bio, Forbes website, Accessed July 10, 2011. http://people.forbes.com/profile/frank-e-young/37665

During World War II, Robert Wood Johnson: Keene, Anne T. “Robert Wood Johnson.” American National Biography Online, July 1, 2011. http://www.anb.org/articles/10/10-02272.html

In 1981, President Reagan appointed James Burke to the President’s Commission: Reagan, Ronald. “Appointment of the Chairman, Executive Director, and Membership of the President’s Commission on Executive Exchange.” President’s Executive Order, September 14, 1981. -- Reagan, Ronald. “Appointment of 14 Members of the President's Commission on Executive Exchange, and Designation of the Chairman.” President’s Executive Order, February 10, 1986.

William O. Baker: Noll, Michael A., “William O Baker Biography.” Williamobaker.org website, July 30, 2007. Accessed July 10, 2011. http://williamobaker.org/biography.html

Clifton C. Garvin: “Exxon CEO to Be Hatfield Fellow.” Cornell Chronicle, September 23, 1982, Vol. 14, No. 5, pg 3.

In the 1980s, J&J executives: The Trilateral Commission. “The Trilateral Commission at 25.” Scribd website, 1998. Accessed July 10, 2011. http://www.scribd.com/doc/30079700/T51-The-Trilateral-Commission-at-25-1998

Its 60 delegates from the United States also included: The Real Story Behind the Trilateral Commission. Citizens for LaRouche, March 1980.

James Burke was a member: “Council on Foreign Relations Membership Roster.” Accessed July 20, 2011. http://www.docstoc.com/docs/22027831/Council-on-Foreign-Relations--CFR--Membership-Lists-1950-2005

J&J Board members, Thomas Murphy and Joan Ganz Cooney: “Council on Foreign Relations Membership Roster.” Accessed July 20, 2011. http://www.docstoc.com/docs/22027831/Council-on-Foreign-Relations--CFR--Membership-Lists-1950-2005

FBI Director, William Webster, was a regular: “Council on Foreign Relations Membership Roster.” Accessed July 20, 2011. http://www.docstoc.com/docs/22027831/Council-on-Foreign-Relations--CFR--Membership-Lists-1950-2005

36            Big Jim’s Boys

When Jim Thompson: Lavin, Cheryl. “Mr. Webb Goes To Washington.” Chicago Tribune, March 4, 1990.

“I saw a very bright”: Lavin, Cheryl. “Mr. Webb Goes To Washington.” Chicago Tribune, March 4, 1990.

“after this is all over”: Lavin, Cheryl. “Mr. Webb Goes To Washington.” Chicago Tribune, March 4, 1990.

Jim Thomson surrounded himself: Wheeler, Charles N. III. “Gov. James R. Thompson, 1977-1991: the complete campaigner, the pragmatic centrist.” Illinois Issues, December 1990.

Near the end:  Wheeler, Charles N. III. “Gov. James R. Thompson, 1977-1991: the complete campaigner, the pragmatic centrist.” Illinois Issues, December 1990.

“some incredibly fine investigative work”: Coleman, Brenda. “Tylenol poisoner’s identity remains mystery after 6 months.” The Register, March 27, 1983.

“When all this is said and done”: Coleman, Brenda. “Tylenol poisoner’s identity remains mystery after 6 months.” The Register, March 27, 1983.

Both boxes of Extra Strength: Dowling, John. “Cyanide Murders Hunt has Dozen Suspcts.” Ironwood Daily Globe, October 5, 1982.

In February 1986:  McFadden, Robert D. “Two Bottles of Poisoned Tylenol Were Shipped By Same Distributor.” New York Times, February 16, 1986. -- Associated Press. “Tylenol banned in Texas.” The Post Standard, February 14, 1986.

On February 14, 1986, Joseph Chiesa: Prokesch, Steven, “Tylenol Capsule Output is Suspended by Maker.” New York Times, February 14, 1986.

After J&J announced the recall: Associated Press.  “Stockbroker may have been victim in extortion letter hoax.” The News, October 9, 1982.

Annual Tylenol sales were about $450 million in 1982 and $525 million in 1986: Foster, Lawrence. “The Tylenol Tragedy: A Crime Without Precedent,” in Communicating in a Healthcare Crisis, ed. Pines, Wayne L. 173-182, Church Falls: FDAnews, 2007. -- Moore, Thomas. “The Fight to Save Tylenol.” TIME, November 29, 1982. -- Kerr, Peter Tylenol is Linked to a Cyanide Death in Yonkers.” The New York Times, February 11, 1986.

About 30 percent of those sales were from capsules: McFadden, Robert D. “Maker of Tylenol Discontinuing All Over-The-Counter Drug Capsule.”  The New York Times, February 18, 1986.

Food and drug wholesalers: “Wholesale Inventory Turn Data.” Strategosinc website, Accessed July 11, 2011. http://www.strategosinc.com/articles/warehouse_inventory_turns.htm

Food and drug stores also: “Wholesale Inventory Turn Data.” Strategosinc website, Accessed July 11, 2011. http://www.strategosinc.com/articles/warehouse_inventory_turns.htm  -- Matyjewicz, George. “Inventory Turns.” Business know-how website. Accessed June 11, 2011. http://www.businessknowhow.com/manage/inventory.htm

A constant barrage of news: Church, George J; Griggs, Lee; Healy, Rita. “Copycats Are on the Prowl.” TIME, November 8, 1982.

Dr. Park Dietz:  Dietz, Park. “Product Tampering.” April 23, 1999.

In 2002, James Zagel: Shane, Scott. “Noticing a toxic similarity” Sun Journal, April 29, 2002.

He was in prison serving ten years: O’Connor, Phillip J. “Lewis wife harassed by FBI, lawyer says.” Chicago Sun-Times, February 15, 1986.

Lewis had suffered a heart attack: O’Connor, Phillip J. “Lewis wife harassed by FBI, lawyer says.” Chicago Sun-Times, February 15, 1986.

With James Lewis out: O’Connor, Phillip J. “Lewis wife harassed by FBI, lawyer says.” Chicago Sun-Times, February 15, 1986.

When contacted on February 11, 1986, Robert Long: Dungey, Diane “Illinois starts checking Tylenol.” Daily Herald, February 15, 1986.

Donald Morano, Lewis’s attorney: O’Connor, Phillip J. “Lewis wife harassed by FBI, lawyer says.” Chicago Sun-Times, February 15, 198.6

James Burke had said:  Associated Press. “Tylenol pulled off store shelves after fatal poisoning in New York.” Daily Intelligencer, February 11, 1986.

but Lane and Margolis were already in LeAnn’s Cambridge apartment by then: O’Connor, Phillip J. “Lewis wife harassed by FBI, lawyer says.” Chicago Sun-Times, February 15, 1986.

Morano said Lane and Margolis initially asked: O’Connor, Phillip J. “Lewis wife harassed by FBI, lawyer says.” Chicago Sun-Times, February 15, 1986.

“properly and professionally and will continue to proceed”: O’Connor, Phillip J. “Lewis wife harassed by FBI, lawyer says.” Chicago Sun-Times, February 15, 1986.

In fact, the jaunt: O’Connor, Phillip J. “Lewis wife harassed by FBI, lawyer says.” Chicago Sun-Times, February 15, 1986.

PART 3

37            The Manhunt

An envelope: 797 F.2d 358 21 Fed. R. Evid. Serv. 225 USA, Plaintiff-Appellee, v. James William Lewis, Defendant-Appellant. No. 84-2011. US Court of Appeals, Seventh Circuit, May 31, 1985.

One week after: Associated Press. “Tylenol suspect called dangerous.” The Iola Register, October 16, 1982.

Police in Amarillo: Beck, Melinda; Monroe, Sylvester; Buckley, Jerry. “ Tylenol: Many leads, No arrests.” Newsweek, October 25, 1982.

At Boston’s Park Plaza: Beck, Melinda; Foote, Donna; Michael, Renee; Shannon, Elaine. “The Tylenol Manhunt.” Newsweek, November 1, 1982.

In Carl Junction:  Beck, Melinda; Foote, Donna; Michael, Renee; Shannon, Elaine. “The Tylenol Manhunt.” Newsweek, November 1, 1982.

She was “99-and-three-fourths sure”: United Press International: “Tylenol recall saved at least one life.” The Hawk Eye, October 22, 1982.

An investigator at the Tylenol task-force headquarters: “Extra Suspects.” TIME, November 1, 1982.

James Lewis grew up on a small farm in Carl Junction: Lewis, James. Personal interview by author. Philadelphia, May 27, 2011.

In the early 1970s, James and LeAnn: James, Lewis. Email, re: The Tylenol Speculation Drawing documents. March 8, 2008.

In 1975, Lewis:  Lewis, James. Email interview with author, re: Aljeev International, July 31, 2010.

“We were inexperienced kids”:  Lewis, James. Email interview with author, re: Aljeev International, July 31, 2010.

Mehta moved to California: Lewis, James. Email interview with author, re: Aljeev International, July 31, 2010. – “Viren Mehta Director OSI Pharmaceuticals, Inc.” Forbes website. Accessed June1 2011. http://people.forbes.com/profile/viren-mehta/60990

On December 4:  738 F.2d 91 USA, Appellee, v. James W. Lewis, Appellant. No. 83-1947 US Court of Appeals, Eighth Circuit, January 26, 1984.

While Kansas City authorities:  738 F.2d 91 USA, Appellee, v. James W. Lewis, Appellant. No. 83-1947 US Court of Appeals, Eighth Circuit, January 26, 1984.

In January, James took a job: Cohen, Sharon. “suspect in poisoning, man of many faces.” Pittsburg Post-Gazette, October 21, 1982. -- 797 F.2d 358 21 Fed. R. Evid. Serv. 225 USA, Plaintiff-Appellee, v. James William Lewis, Defendant-Appellant. No. 84-2011. US Court of Appeals, Seventh Circuit, May 31, 1985.

Barbara Vaitkus, later testified: United Press International. “Neighbors Says Lewis Knew How.” The Daily News: October 21, 1983 -- 797 F.2d 358 21 Fed. R. Evid. Serv. 225 USA, Plaintiff-Appellee, v. James William Lewis, Defendant-Appellant. No. 84-2011. US Court of Appeals, Seventh Circuit, May 31, 1985.

Lakeside Travel went bankrupt: 797 F.2d 358 21 Fed. R. Evid. Serv. 225 USA, Plaintiff-Appellee, v. James William Lewis, Defendant-Appellant. No. 84-2011. US Court of Appeals, Seventh Circuit, May 31, 1985.

A Senior Vice President with First National Bank at that time was Neil Hartigan: Telegraph Capital Bureau. “Demos’ Hartigan would reorganize AG office.” Alton Telegraph, October 28, 1982.

On LeAnn’s last day: 797 F.2d 358 21 Fed. R. Evid. Serv. 225 USA, Plaintiff-Appellee, v. James William Lewis, Defendant-Appellant. No. 84-2011. US Court of Appeals, Seventh Circuit, May 31, 1985.

A majority of: 797 F.2d 358 21 Fed. R. Evid. Serv. 225 USA, Plaintiff-Appellee, v. James William Lewis, Defendant-Appellant. No. 84-2011. US Court of Appeals, Seventh Circuit, May 31, 1985.

The wage hearing: 797 F.2d 358 21 Fed. R. Evid. Serv. 225 USA, Plaintiff-Appellee, v. James William Lewis, Defendant-Appellant. No. 84-2011. US Court of Appeals, Seventh Circuit, May 31, 1985.

Jim’s temporary job: Beck, Melinda; Foote, Donna; Michael, Renee; Shannon, Elaine. “The Tylenol Manhunt.” Newsweek, November 1, 1982.

Shortly after arriving in New York: Beck, Melinda; Foote, Donna; Michael, Renee; Shannon, Elaine.“The Tylenol Manhunt.” Newsweek, November 1, 1982.

Court documents show that Lewis said his intent was “not to extort money”: 797 F.2d 358 21 Fed. R. Evid. Serv. 225 USA, Plaintiff-Appellee, v. James William Lewis, Defendant-Appellant. No. 84-2011. US Court of Appeals, Seventh Circuit, May 31, 1985.

Lewis wanted the letter to appear authentic: Lewis, James. Email interview by author, June 24, 2010.

On October 6, 1982, the Director of Security: 797 F.2d 358 21 Fed. R. Evid. Serv. 225 USA, Plaintiff-Appellee, v. James William Lewis, Defendant-Appellant. No. 84-2011. US Court of Appeals, Seventh Circuit, May 31, 1985.

“Gentlemen: As you can see”: 797 F.2d 358 21 Fed. R. Evid. Serv. 225 USA, Plaintiff-Appellee, v. James William Lewis, Defendant-Appellant. No. 84-2011. US Court of Appeals, Seventh Circuit, May 31, 1985.

Fahner said the disclosure: Associated Press. “Chicago Officials Check Wyoming Cyanide Death.” Tyrone Daily Herald, October 9, 1982. -- Associated Press. “Tylenol makers report $1 million extortion plot.” Alton Telegraph, October 8, 1982.

Lewis never intended to collect: McCabe, Neil W. “Been There.” The Alewife, October 3, 2007.

Lewis sent a letter to The Chicago Tribune in November: Janota, Laura. “'Prime suspect' still maintains innocence.” Daily Herald, September 27, 1992.

Regardless of whether: Subcommittee on Financial Institutions Supervision, Regulation, and Insurance Committee on Banking, Finance, and Urban Affairs. “Examination Findings Regarding Continental National Bank’s Loan Management and Capital.” September 18, 1984.

In July 1982, Penn Square: Subcommittee on Financial Institutions Supervision, Regulation, and Insurance Committee on Banking, Finance, and Urban Affairs. “Examination Findings Regarding Continental National Bank’s Loan Management and Capital.” September 18, 1984.

“too big to fail”: History of the Eighties – “Volume 1: Lessons for the Future An Examination of the Banking Crises of the 1980s and Early 1990s.” Federal Deposit Insurance Corporation, 1997.

Johnson & Johnson appointed Rizzo: “Letter to the Stockholders,” in Johnson & Johnson’s 1982 Annual Report, 1983.

Rizzo was one of nine directors at Continental Bank that the Federal Deposit Insurance Corporation (FDIC) fired: “Rolling Heads.” TIME, December 17, 1984.

David Collins described: Moore, Thomas. “The Fight to Save Tylenol.” TIME, November 29, 1982.

But that’s not what: 797 F.2d 358 21 Fed. R. Evid. Serv. 225 USA, Plaintiff-Appellee, v. James William Lewis, Defendant-Appellant. No. 84-2011. US Court of Appeals, Seventh Circuit, May 31, 1985.

Judge Frank McGarr, who presided: 797 F.2d 358 21 Fed. R. Evid. Serv. 225 USA, Plaintiff-Appellee, v. James William Lewis, Defendant-Appellant. No. 84-2011. US Court of Appeals, Seventh Circuit, May 31, 1985.

Jeremy Margolis, the Assistant U.S. Attorney: Bergmann, Joy. “A Bitter Pill.” Chicago Reader, November 3, 2000.

Margolis said, “He [Lewis] knew”: Bergmann, Joy. “A Bitter Pill.” Chicago Reader, November 3, 2000.

On October 14, 1982: Associated Press. “‘Chameleon’ Sought in Tylenol Case.” Casa Grande Dispatch, October 9, 1982.

The Kansas City police had identified: “Cyanide-Tylenol Extortion Hoax Suspect Was Indicted for Murder.” Syracuse Post Standard, October 15, 1982.

At the time of his death: Bergmann, Joy. “A Bitter Pill.” Chicago Reader, November 3, 2000.

Banker returned to West’s home: Bergmann, Joy. “A Bitter Pill.” Chicago Reader,  November 3, 2000.

Police drove down the street: Bergmann, Joy. “A Bitter Pill.” Chicago Reader, November 3, 2000.

When Lewis came under: Associated Press. “KC names prosecutor.” The Iola Register, October 21, 1982.

Upon learning about the Raymond West case: “Cyanide-Tylenol Extortion Hoax Suspect Was Indicted for Murder.”Syracuse Post Standard, October 15, 1982.

He had been living in New York City: United Press International. “Tylenol Suspect in N.Y. During Killings?” Pharos-Tribune, October 21, 1982.

38            How Do You Solve A Problem Like James Lewis?

James Lewis was in his tiny studio: McCabe, Neil W. “Been There.” The Alewife, October 3, 2007.

On October 16, 1982: Buder, Leonard. “At Time of Tylenol Deaths, Suspects were in New York.” The New York Times, October 21, 1982. -- Lewis, James. Personal interview by author. Philadelphia, May 27, 2011.

On Monday, October 18th, investigators released a grainy photo: Associated Press. “Tylenol case photo clue ‘significant’.” The Paris News, October 19, 1982.

Unidentified sources “close to the investigation”: Associated Press. “Tylenol victim, ‘suspect’ on film.” The Chronicle-Telegram, October 19, 1982.

“It could be”: Associated Press. “Tylenol victim, ‘suspect’ on film.” The Chronicle-Telegram, October 19, 1982.

“I’m very doubtful it is him.”: Dowling, John. “Photo ‘significant’ clue in Tylenol probe.” The Seguin Gazette-Enterprise, October 19, 1982.

On October 20th, authorities: Buder, Leonard. “At Time of Tylenol Deaths, Suspects were in New York.” The New York Times, October 21, 1982.

There were few professionals: Buder, Leonard. “At Time of Tylenol Deaths, Suspects were in New York.” The New York Times, October 21, 1982.

Kenneth Walton, the Deputy Assistant Director: “At Time of Tylenol Deaths, Suspects were in New York.” The New York Times, October 21, 1982.

“I would see them leave at 7:30 in the morning”: Buder, Leonard. “At Time of Tylenol Deaths, Suspects were in New York.” The New York Times, October 21, 1982.

“We don’t think”: Buder, Leonard. “At Time of Tylenol Deaths, Suspects were in New York.” The New York Times, October 21, 1982.

“He is one of the more substantial leads”: Buder, Leonard. “At Time of Tylenol Deaths, Suspects were in New York.” The New York Times, October 21, 1982.

“That is one of the options”: Buder, Leonard. “At Time of Tylenol Deaths, Suspects were in New York.” The New York Times, October 21, 1982.

365    We obviously have not confirmed that they have been there”: Buder, Leonard. “At Time of Tylenol Deaths, Suspects were in New York.” The New York Times, October 21, 1982.

“I wasn’t the only one”: Bergmann, Joy. “A Bitter Pill.” Chicago Reader, November 3, 2000.

“Everybody fought for”: Bergmann, Joy. “A Bitter Pill.” Chicago Reader, November 3, 2000.

“There is a general”: Bergmann, Joy. “A Bitter Pill.” Chicago Reader, November 3, 2000.

“People will withhold information”: Bergmann, Joy. “A Bitter Pill.” Chicago Reader, November 3, 2000.

“Roger Arnold is without a doubt”: Chicago Police Detective. Email Interview by author. February 5, 2009.

“[We] didn’t really run”: Bergmann, Joy. “A Bitter Pill.” Chicago Reader, November 3, 2000.

“As you have probably guessed”: United Press International. “Tylenol suspect asked to turn himself in after writing letter.” Hutchinson News, October 31, 1982.

“Does the FBI and the Attorney General”: Beck, Melinda; Foote, Donna. “Tylenol letter.” Newsweek, November 8, 1982.

“I would like to send a message”: United Press International. “Tylenol suspect asked to turn himself in after writing letter.” Hutchinson News, October 31, 1982.

Fahner assured Lewis: United Press International. “Tylenol suspect asked to turn himself in after writing letter.” Hutchinson News, October 31, 1982.

On December 13, 1982, Librarian Donald Alexis: “Booked.” TIME, December 27, 1982.

Lewis was at a table: 797 F.2d 358 21 Fed. R. Evid. Serv. 225 USA, Plaintiff-Appellee, v. James William Lewis, Defendant-Appellant. No. 84-2011. US Court of Appeals, Seventh Circuit, May 31, 1985.

In Chicago, Fahner ignored: “Tylenol Inquiry Centers on Couple.” The New York Times, December 19, 1982.

“If he’s not guilty of the Tylenol”: “Tylenol Inquiry Centers on Couple.” The New York Times, December 19, 1982.

Records at the Hotel Rutledge: Saxon, Wolfgang. “Pill Case Suspect Found In New York.” The New York Times, December 14, 1982.

Lewis was arraigned: Associated Press. “Suspect’s link to Tylenol deaths probed.” The New Mexican, December 14, 1982.

Lewis was held in the Metropolitan Correctional Center: Doyle, Pat. “Lewis arraignment on extortion plot today.” The Daily Herald, December 28, 1982.

Before facing charges: Associated Press. “Lewis denies tax, mail fraud charges.” The Stars and Stripes, January 15, 1982.

The key testimony: Associated Press. “Quick conviction ends Lewis trial in KC.” Lawrence Journal-World, May 27, 1983.

Lewis did not testify: Associated Press. “Quick conviction ends Lewis trial in KC.” Lawrence Journal-World, May 27, 1983.

“Mr. Rea cut a deal, so he won’t be prosecuted”: Associated Press. “Tylenol Scam Suspect Guilty.” The Victoria Advocate, May 27, 1982.

Lewis’s trial for attempted extortion: Associated Press. “Lewis convicted in Tylenol poisoning extortion case.” Daily Intelligencer, October 28, 1983.

“When Mr. Lewis found out”: Bergmann, Joy. “A Bitter Pill.” Chicago Reader, November 3, 2000.

“Mr. Monico said that it is because”: Bergmann, Joy. “A Bitter Pill.” Chicago Reader, November 3, 2000.

“The man who wrote”: Duerksen, Susan. “Lewis guilty of extortion attempt.” The Daily Herald, October 28, 1982.

Lewis’s defense attorney: Duerksen, Susan. “Lewis guilty of extortion attempt.” The Daily Herald, October 28, 1982.

“This case is bizarre”: Associated Press. “Lewis convicted in Tylenol poisoning extortion case.” Daily Intelligencer, October 28, 1983.

A federal jury: Duerksen, Susan. “Lewis guilty of extortion attempt.” The Daily Herald, October 28, 1982.

“I do not lie”: Duerksen, Susan. “Lewis sentenced to 10 years for Tylenol threats.” The Daily Herald, June 14, 1984.

“In the face of”: Duerksen, Susan. “Lewis sentenced to 10 years for Tylenol threats.” The Daily Herald, June 14, 1984.

“Under the circumstances”:  Duerksen, Susan. “Lewis sentenced to 10 years for Tylenol threats.” The Daily Herald, June 14, 1984.

Before sentencing Lewis: 738 F.2d 91 USA, Appellee, v. James W. Lewis, Appellant. No. 83-1947 US Court of Appeals, Eighth Circuit, January 26, 1984.

During his incarceration: 738 F.2d 91 USA, Appellee, v. James W. Lewis, Appellant. No. 83-1947 US Court of Appeals, Eighth Circuit, January 26, 1984.

On the same day Reyes: 738 F.2d 91 USA, Appellee, v. James W. Lewis, Appellant. No. 83-1947 US Court of Appeals, Eighth Circuit, January 26, 1984.

What a jury could not do: 738 F.2d 91 USA, Appellee, v. James W. Lewis, Appellant. No. 83-1947 US Court of Appeals, Eighth Circuit, January 26, 1984.

“We answer all of these questions in the affirmative”: 738 F.2d 91 USA, Appellee, v. James W. Lewis, Appellant. No. 83-1947 US Court of Appeals, Eighth Circuit, January 26, 1984.

On a hot August afternoon: McCabe, Neil W. “Been There.” The Alewife, October 3, 2007.

When police arrived: McCabe, Neil W. “Been There.”The Alewife, October 3, 2007.

The Middlesex County prosecutor: Lewis, James. Personal interview by author. Philadelphia, May 27, 2011.

In an August 2004 email: Hettenger, Lee. Lab case number 04-07342-2. Email, August 9, 2004.

Michael Regal, a Cambridge police: McCabe, Neil W. “Been There.” The Alewife, October 3, 2007.

Meredith Lerner, a spokesperson for Middlesex: McCabe, Neil W. “Been There.” The Alewife, October 3, 2007.

39            A Second Look

Jim Lewis threw: Lewis, James. Personal interview by author. Philadelphia, May 27, 2011.

The FBI did not interrogate: Lewis, James. Email interview by author, August 2, 2009.

“The FBI, in cooperation”: Rice, Ross. “Media Advisory on Review of 1982 Tylenol Murders,” FBI website, February 4, 2009. Accessed, July 20. 2011. www.FBI.gov . http://www.fbi.gov/chicago/press-releases/2009/feb04_09.htm

In June 2009: Lewis, James. Phone interview by author, July 9, 2009.

The Freedom of Information Act (FOIA): U.S.C. Title 5, Section 552. Public information; agency rules, opinions, orders, records, and proceedings

Between 1995 and 1999, President Clinton: Government Publications Access. Illinois Institute of Technology website. Freedom of Information Act (FOIA), Accessed June 30, 2011. http://www.gl.iit.edu/govdocs/foia.html

“I will also hold myself”: Obama, Barack. “REMARKS BY THE PRESIDENT IN WELCOMING SENIOR STAFF AND CABINET SECRETARIES TO THE WHITE HOUSE.” January 21, 2009. Accessed June 30, 2011 http://m.whitehouse.gov/the-press-office/remarks-president-welcoming-senior-staff-and-cabinet-secretaries-white-house

Government should be transparent: Obama, Barack. “MEMORANDUM FOR THE HEADS OF EXECUTIVE DEPARTMENTS AND AGENCIES.” January 21, 2009. Accessed June 30, 2011. http://www.whitehouse.gov/the-press-office/transparency-and-open-government

Nevertheless, in July 2011 the FBI denied an FOIA request for documents related to the Tylenol murders: Hardy, David M. (FBI Section Chief) Denial of FOIA Request No, 1169091-000, Tylenol Tampering Incident, July 19, 2011.

40            A Novel Approach

POISON! The Doctor’s Dilemma: Lewis, James. “The Doctor’s Dilemma - A Collaborative Novel being Co-Authored by: Roy J. Lane, FBI Agent Retired.” January 7, 2009.

Lewis says the novel is a psychological fantasy:Goudie, Chuck. “James Lewis writes the book on POISON! Deaths.”Daily Herald website, January 13, 2010. Accessed June 1, 2011. http://saxo.dailyherald.com/article/20100111/Discuss/301119938/

Lewis had been: Lewis, James. Email interview by author, re: Lane and Nichols, June 21, 2010.

Lane had retired from the FBI in 1996: O’Connor, Matt. “Corruption, Crime Met Match in Key FBI Agent.” Chicago Tribune, May 07, 1996.

Lane and Jeremy Margolis had gone out to Cambridge: O’Connor, Phillip J. “Lewis wife harassed by FBI, lawyer says.” Chicago Sun-Times, February 15, 1986.

Lane told Lewis: Lewis, James. Email interview by author, June 21, 2010.

“Without Roy Lane”:  Lewis, James. “The Doctor’s Dilemma - A Collaborative Novel being Co-Authored by: Roy J. Lane, FBI Agent Retired.” January 7, 2009

Lewis agreed to give:  Nichols, Sherry. “No Subject.” Email, February 29, 2008 -- Lane, Roy. “RE Boarding Pass.” March 9, 2008. -- Nichols, Sherry. “RE: February 5th, 6th, and possibly 7th.” Email, January 24, 2008.

One of the computers:  Nichols, Sherry. “RE: Thanks.” Email, January 14, 2008.

“Sherry’s experience as”:  Lewis, James. “The Doctor’s Dilemma - A Collaborative Novel being Co-Authored by: Roy J. Lane, FBI Agent Retired.” January 7, 2009.

In Chicago in 2008: Lewis, James. Email interview by author, re: Lane and Nichols, June 21, 2010.

Roy and Sherry flew: Lewis, James. Email interview by author, re: Lane and Nichols, June 21, 2010.

Lane and Nichols conducted: Lewis, James. Email interview by author, re: Lane and Nichols, June 21, 2010.

The business address that “Nichols” had given to Lewis: Lewis, James. “The Doctor’s Dilemma - A Collaborative Novel being Co-Authored by: Roy J. Lane, FBI Agent Retired.” January 7, 2009.

From August 2007 through the end of 2008, Nichols and Lane taped 80 hours: Lewis, James. Email interview by author, re: DNA, June 25, 2010.

In 1991, John Orr: “Arson Investigator-Novelist Is Charged With Setting Fires.” The New York Times, December 20, 1991.

“The key to the government’s case”: United States of America, Plaintiff-Appellee, v.John Leonard ORR, Defendant-Appellant. No. 92-10681. United States Court of Appeals, Ninth Circuit, July 21, 1994.

Orr pled guilty to three additional: Wambaugh, John. Fire Lover. New York: HarperCollins Publishers Inc., 2002.

Then, in 1998, Orr was convicted: Wambaugh, John. Fire Lover. New York: HarperCollins Publishers Inc., 2002.

Federal ATF Agent, Mike Matassa: Evan, Thomas. “The scorched earth obsession.” Newsweek, October 27, 2007.

“I used the fires I studied as material for my book”: Grogan, David. “Burning Ambition.” People, April 5, 1993.

“As promised, here are my notes”:  Lane, Roy. “RE: REVISED: Roy and Jim's Lexicon (9:00 AM-Version),” Email, December 9, 2007.

“Sherry, I reviewed your”:  Lane, Roy. “FWD: Tylenol Extortion Letter Motive.” Email, December 26, 2008.

“As you see”:  Lane, Roy. “FWD: Tylenol Extortion Letter Motive.” Email, December 26, 2008.

“After I read”:  Lane, Roy. “RE Chapter 13.” Email, December 31, 2007.

“Chuck’s reconciliation”:  Lane, Roy. “The Doctor’s Dilemma.” Email, March 1, 2008.

“Act of reconciliation”:  Lane, Roy. “The Doctor’s Dilemma.” Email, March 1, 2008.

In the novel that Lewis actually wrote:  Lewis, James Wm. POISON! The Doctor’s Dilemma. 2010.

“According to the logic”:  Lane, Roy. “The Doctor’s Dilemma.” Email, December 13, 2007.

“Results: Chuck is forgiven”:  Lane, Roy. “The Doctor’s Dilemma.” Email, March 1, 2008.

Lewis, to a certain extent: Lewis, James. Email interview by author, re: Lane and Nichols, June 21, 2010.

“Without the either side”: Lewis, James. Email interview by author, re: Lane and Nichols, June 24, 2010.

Roy and Sherry took Jim and LeAnn to dinner: Lewis, James. Email interview by author, re: Lane and Nichols, June 24, 2010.

“No matter how scared: Lewis, James. Email interview by author, re: Lane and Nichols, June 24, 2010.

“I had already read Douglas’s fictional”: Lewis, James. Email interview by author, re: Chuck River and FBI profile, July 5, 2010.

Lewis invited Lane: Lewis, James. Email interview re: Lane and Nichols. Bartz, Scott. June 24, 2010.

“He told me on several occasions”: Lewis, James. Email interview by author, re: Lane and Nichols, June 24, 2010.

Lane also gave out a few clues: Lewis, James. Email interview by author, re: Lane and Nichols, June 21, 2010.

Lane’s interest in a possible India connection: Lewis, James. Email interview by author, re: Aljeev International, July 31, 2010.

“I did character sketches”: Lewis, James. Email interview by author, re: Chuck River and FBI profile, July 5, 2010.

“Believe me,” said Lewis: Lewis, James. Email interview by author, re: Chuck River and FBI profile, July 5, 2010.

“I’ve been on the road”:  Lane, Roy. “Big News.” Email, February 5, 2009.

“Sorry for the delay”:  Lane, Roy. “Fw: DD January 7, 2009 Draft.” Email, February 9, 2009.

Retired FBI agent, Grey Steed: Meyer, Bill; Babwin, Don; Barrett, Devlin. “FBI takes sudden new interest in 'Tylenol Man’.” The Plain Dealer, February 5, 2009.

“Sherry told me”:  Lane, Roy. “Robiatopia Man.” Email, December 20, 2007.

41            A Familiar Pattern

Maurice Possley and Ken Armstrong: Possley, Maurice; Armstrong, Ken. “The Verdict: Dishonor.” The Chicago Tribune, January 10, 1999.

Although the Tribune: Possley, Maurice; Armstrong, Ken. “The Verdict: Dishonor.” The Chicago Tribune, January 10, 1999.

On the afternoon of June 5, 1986: “Bitter Pill.” 48 Hours, CBS News, June 4, 2001

Nearly two weeks after: “Bitter Pill.” 48 Hours, CBS News, June 4, 2001.

As political pressure mounted to get a conviction for these murders: Egan, Timothy. “Victim’s Wife Indicted for Drug Tainting.”  The New York Times, December 13, 1987.

Bruce’s life insurance policy: United Press International. “Poisonings were a plot, Attorney says.” The Daily News, April 21, 1988.

Auburn Detective Mike Dunbar: “Bitter Pill.” 48 Hours, CBS News, June 4, 2001. -- United Press International. “Poisonings were a plot, Attorney says.” The Daily News, April 21, 1988.

“....think things over.”: Farr, Alwin. “U.S.A. vs. Stella M. Nickell Case History & Review.” A.L. Farr Associates Inc. website, Accessed June 30, 2011. http://www.find-em.com/stella/index.html#top

As it turned out: Tibbits, George. “Excedrin Poisoner Sentenced.” Times Union, June 18, 1988.

In 1999, private detectives: Farr, A.L. “Declaration of A.L. Farr.” A.L. Farr Associates Inc. website, Accessed June 30, 2011. http://www.find-em.com/stella/farr_declaration.html

“My belief is that”: “Bitter Pill.” 48 Hours, CBS News, June 4, 2001.

The government claimed: “Bitter Pill.” 48 Hours, CBS News, June 4, 2001.

The Proprietary Association: Associated Press. “O.C. Woman Gets Big Reward in Mom's Conviction.” LA Times, October 06, 1990.

The Proprietary Association paid Stella’s: Associated Press. “O.C. Woman Gets Big Reward in Mom's Conviction.” LA Times, October 06, 1990.

At the request of FBI Agent, Jack: Scott, Sandy. “Declaration of Sandy Scott.” A.L. Farr Associates Inc. website, Accessed June 30, 2011. http://www.find-em.com/stella/sandy_declaration.html

Thomas Noonan, the fish: Associated Press. “O.C. Woman Gets Big Reward in Mom's Conviction.” LA Times: October 06, 1990

When Farr interviewed him later, Noonan: Farr, A.L. Declaration of A.L. Farr.A.L. Farr Associates Inc. website, Accessed June 30, 2011. http://www.find-em.com/stella/farr_declaration.html

“Big business and”:  The “Excedrin Killings.” American Justice. A&E, December 16, 2009.

Not brought up:  United Press International. “Tampering Found In Anacin Product” Pharos Tribune, June 25, 1986.

FDA spokesperson, Ellen Miller:  Egan, Timothy. “Victim’s Wife Indicted for Drug Tainting.” The New York Times, December 13, 1987.

The Chicago Tribune found: Possley, Maurice; Armstrong, Ken. “The Verdict: Dishonor.” The Chicago Tribune, January 10, 1999.

Rolando Cruz and Alejandro “Alex” Hernandez: Sevener, Donald. “A Capital Blunder.” Chicago Reader, July 27, 1989.

Detective John Sam: Sevener, Donald. “A Capital Blunder.” Chicago Reader, July 27, 1989.

DuPage County prosecutors: Sevener, Donald. “A Capital Blunder.” Chicago Reader, July 27, 1989.

On March 9, 1984, two weeks before: Sevener, Donald. “A Capital Blunder.” Chicago Reader, July 27, 1989.

On December 20, 1984, the Wheaton: Possley, Maurice; Armstrong, Ken. “Prosecution on trial in DuPage.” Chicago Tribune, January 12, 1999.

The trial against Cruz: Possley, Maurice; Armstrong, Ken. “Prosecution on trial in DuPage.” Chicago Tribune, January 12, 1999.

Tim Gabrielsen, one of two: Sevener, Donald. “A Capital Blunder.” Chicago Reader, July 27, 1989

In June 1985, Brian Dugan: Sevener, Donald. “A Capital Blunder.” Chicago Reader, July 27, 1989.

Mueller then hinted: Sevener, Donald. “A Capital Blunder.” Chicago Reader, July 27, 1989.

In November 1985, Brian: Sevener, Donald. “A Capital Blunder.” Chicago Reader, July 27, 1989.

Dugan kicked in: Sevener, Donald. “A Capital Blunder.” Chicago Reader, July 27, 1989.

Cisowski presented his: “Presumed Guilty.” American Justice. A&E, October 22, 2010.

I had the attitude from day one: Sevener, Donald. “A Capital Blunder.” Chicago Reader, July 27, 1989.

On January 19, 1988: Gregory, Ted. ““I’m just very confused why the thing took this long”.” Chicago Tribune, November 30, 2005.

In May of 1988, scientific: Possley, Maurice; Armstrong, Ken. “Prosecution on trial in DuPage.” Chicago Tribune, January 12, 1999.

“The forensic evidence”: Sevener, Donald. “A Capital Blunder.” Chicago Reader, July 27, 1989.

DuPage County prosecutors closed: Bills, Jeffrey. “3rd Murder Trial For Cruz Delayed.” Chicago Tribune, June 19, 1995.

The “vision statement”: Possley, Maurice; Armstrong, Ken. “Prosecution on trial in DuPage.” Chicago Tribune, January 12, 1999.

The verdict was appealed again: Possley, Maurice; Armstrong, Ken. “Prosecution on trial in DuPage.” Chicago Tribune, January 12, 1999.

In September 1995: Possley, Maurice; Armstrong, Ken. “Prosecution on trial in DuPage.” Chicago Tribune, January 12, 1999.

“Let’s look at what the evidence shows”: Frisbie, Thomas; Garrett, Randy. Victims of justice revisited. Northwestern University Press, 2005.

“I as a judge”: Frisbie, Thomas; Garrett, Randy. Victims of justice revisited. Northwestern University Press, 2005.

paid $3.5 million to settle: Houlihan, Kate. “Dugan indicted in Nicarico murder; Birkett looks for `harshest penalty under the law'.” The Sun – Naperville, November 30, 2005.

In November 2009, Birkett: Zorn, Eric. “Who got it right about Brian Dugan?” Chicago Tribune, November 12, 2009.

42            The Judges of DuPage County

“We owe it to the victims’ families”: Coen, Jeff; Marx, Gary. “FBI reopens Tylenol tampering case.” Chicago Tribune, February 5, 2009.

In July 2009, prosecutors: Lewis, James. Email interview by author, re: DNA, June 25, 2010.

“The couple arrived in the front corridor of the courthouse”: Goudie, Chuck. “Cold Case cops hope DNA will crack '82 Tylenol murders.” ABC Chicago website, January 8, 2010. Accessed July 20, 2011. http://abclocal.go.com/wls/story?section=news/iteam&id=7206919

“The FBI used the occasion”: Lewis, James. Email interview by author, re: DNA, June 25, 2010.

“I will have no comment on that”: Goudie, Chuck. “Will smudge on '82 Tylenol bottle be Lewis link?” ABC Local website, January 9, 2010, Accessed July 10, 2011. http://abclocal.go.com/wls/story?section=news/iteam&id=7209493

“Proceedings such as that reported”: Saltzman, Jonathan. “Suspect in ’82 Tylenol case appears at hearing.” The Boston Globe, January 8, 2010.

James Lewis had been fingerprinted: Lewis, James. Email interview by author, re: DNA, June 25, 2010.

More recently, when Lewis: Lewis, James. Email interview by author, re: DNA, June 25, 2010.

Authorities who examined: United Press International. “Cyanide-Extortion Suspect Faces Murder Charge.” Altoona Mirror, October 18, 1982.

DNA typing (profiling): “Interview of the Week: Alec Jeffreys.” MIT Website, June 2004. Accessed July 1, 2011. http://web.mit.edu/invent/iow/jeffreys.html

Police forces can collect DNA: 486 U.S. 35 (1988) CALIFORNIA v. GREENWOOD ET AL. No. 86-684. Supreme Court of United States, May 16, 1988.

On January 12, 2010:  America's Newsroom W/ Bill Hemmer & Megyn Kelly. Fox News, January 12, 2010.

The Huffington Post had reported: The Huffington Post: “James Lewis, Tylenol suspect gives DNA sample, as charges may be brought.” The Huffington Post, January, 9, 2010.

On October 26, 1982, one day after:  United Press International. “Cyanide investigation focused on people full of hate.” Hutchinson News, November 9, 1982.

They apparently meant to say: United Press International. “Cyanide-Extortion Suspect Faces Murder Charge.” Altoona Mirror, October 18, 1982.

Tyrone Fahner had said on November 9, 1982: United Press International. “New Tylenol-Cyanide Mix Found.” Pharos-Tribune: Oct 29, 1982

“What’s going to happen happens”: Gazior, Anne Burris. “Tampering case leaves legacy of distrust for area residents.” Daily Herald, September 27, 1992.

Morgan did not need the Tylenol: Church, George J; Griggs, Lee; Healy, Rita. “Copycats Are on the Prowl.” TIME, November 8, 1982. -- Associated Press: “A narrow miss in taking deadly capsules.” The Register, October 29, 1982.

Morgan claimed to have bought: “Early Cyanide Death Not Tied to Tylenol, Authorities Believe.” New York Times, October 28, 1982.

“The [eighth] bottle is clearly different”:: Associated Press. “Latest capsule has differences.” The Lethbridge Herald, October 29, 1982.

Furthermore, the adulterated capsules in the eighth bottle: Associated Press. “Latest capsule has differences.” The Lethbridge Herald, October 29, 1982.

“advanced state of deterioration”: Malcolm, Andrew H. “Another poisoned Tylenol bottle is found by Chicago investigators.” The New York Times, October 22, 1982.

On the morning of September 30, 1982, David Collins made a phone call: Moore, Thomas. “The Fight to Save Tylenol.” TIME, November 29, 1982.

It is an amazing coincidence that the only person: Gazior, Anne Burris. “Tampering case leaves legacy of distrust for area residents.” Daily Herald, September 27, 1992.

Paul Noland was sworn: Rodriguez, Alex. “Corporate attorney named DuPage associate judge.” Daily Herald, July 14, 1992.

He retired in 1998: McCoppin, Bob, “In Catch-22, sex offender faces jail.” Daily Herald, May 2, 1998.

A judge in the 18th Circuit Court granted: Gutowski, Christy; Vitello, Barbara. “Tylenol investigators focus on ‘smudge.’” The Daily Herald, January 9, 2010.

On November 23, 2009, Judge Paul Noland was recalled: “M.R. 3033: In re: Recall of Retired Judge.” Order by the State of Illinois Supreme court, November 9, 2009.

On December 23, 2009, a summons was issued: Leone, Gerald Jr. Summons of James Lewis to Superior Court in the County Middlesex, December 23, 2009.

That order required the Lewises: Gutowski, Christy; Vitello, Barbara. “Tylenol case revived with decades-old DNA evidence.” Chicago Daily Herald, January 11, 2010.

The judicial careers: State of Illinois Judicial Inquiry Board. Fiscal Years 2007 and 2008 Report: 2009

After 20 years on the bench, Fawell resigned: Schmeltzer, John. Mount, Charles. “DuPage Judges Get Reprimand.” Chicago Tribune, June 26, 1985.

The Commission said the conduct: Associated Press. “Judges reprimanded for wedding fees.” Alton Telegraph, June 26, 1985.

“The guy lives in Chicago, he should stay in Chicago”: Schmeltzer, John; Mount, Charles. “Ex-judge Off the Hook in Race Case.” Chicago Tribune, August 11, 1987.

“Johnny, you come”:  Schmeltzer, John; Mount, Charles. “Ex-judge Off the Hook in Race Case.” Chicago Tribune, August 11, 1987.

Judge Lewis Morgan, after being accused: Barnum, Art. “Ex-DuPage Judge Faces Legal Charges.” Chicago Tribune, October 25, 1989.

A former DuPage County judge who: Barnum, Art. “Ex-DuPage Judge Faces Legal Charges.” Chicago Tribune, October 25, 1989.

Investigators for the State Commission: Barnum, Art. “Ex-DuPage Judge Faces Legal Charges.” Chicago Tribune, October 25, 1989.

Ed Reiner, following the recommendation of an attorney acquaintance: Reiner, Ed. Personal interview by author. Winfield, IL, May 22, 2010.

“You realize a small town like that has lots of secrets”: Pierce, Victoria: “Wheaton native recalls role in Watergate.” Daily Herald, June 17, 2002.

43            A Reactivated Cover-up

“We generally condone”:  Possley, Maurice; Armstrong, Ken. “Prosecution on trial in DuPage.” Chicago Tribune, January 12, 1999.

Under the federal Freedom of Information Act (FOIA): U.S.C. Title 5, Section 552. “Public information; agency rules, opinions, orders, records, and proceedings.”

Neither Nichols nor Lane responded: Bartz, Scott. Email to Sherry Nichols, re: James Lewis, May 26, 2011. - Bartz, Scott. Email to Roy Lane, re: James Lewis, June 16, 2011.

Sherry Nichols’s phantom Tylenol murders book: Nichols, Sherry. Email to James Lewis, re: book in editing, January 23, 2009.

a decision made easier by the recent death of Roger Arnold: Unites States Department of Veterans Affairs website, “Arnold, Roger Reed.” Accessed July 2010, http://gravelocator.cem.va.gov/j2ee/servlet/NGL_v1

“located no records indicating that your subject”:  Kelso, Wally. FOIA reply, re: Tylenol Murders 1982, August 31, 1999.

Fahner said, “[Lewis] was clearly”: “After 27 years, a break in the Tylenol case?” WMAQ-TV, Chicago, NBC, February 4, 2009.

Dan Webb, the U.S. Attorney: ABC-7 News. ABC, Chicago, February 4, 2009.

The FBI now says that it is actively: Rice, Ross. “Media Advisory on Review of 1982 Tylenol Murders.” FBI website, February 4, 2009. Accessed June 12, 2011. www.FBI.gov . http://www.fbi.gov/chicago/press-releases/2009/feb04_09.htm

The FBI released a statement on February: Rice, Ross. “Media Advisory on Review of 1982 Tylenol Murders.” FBI website, February 4, 2009. Accessed June 12, 2011. www.FBI.gov . http://www.fbi.gov/chicago/press-releases/2009/feb04_09.htm

Human DNA typing: MIT Website. “Alec Jeffreys: DNA Fingerprinting.” June 2004. Accessed July 1, 2011. http://web.mit.edu/invent/iow/jeffreys.html. -- FBI. “Crime and Corruption Across America, 1972-1988.” FBI website. Accessed July 1, 2011 http://www.fbi.gov/about-us/history/a-centennial-history/crime_and_corruption_across_america_1972-1988

Network news video clips taken: Nightly News. NBC, October 8, 1982.

The mishandling of evidence: “County aide sues Ch. 2 reporter for $25 million.” Chicago Sun-Times, March 10, 1986.

“She made statements”: “County aide sues Ch. 2 reporter for $25 million.” Chicago Sun-Times, March 10, 1986.

Zekman responded to: “County aide sues Ch. 2 reporter for $25 million.” Chicago Sun-Times, March 10, 1986.

44            The New Case; Same as the Old Case

Michelle decided to see what: Rosen, Michelle. Telephone interview by author, March 2010.

In 2002, Winfield Police Department: Avila, Oscar. “Tylenol murders linger in shadows.” Chicago Tribune, September 29, 2002.

“To be up front with you”: Avila, Oscar. “Tylenol murders linger in shadows.” Chicago Tribune, September 29, 2002.

The FBI said the case was a murder investigation that falls under: Avila, Oscar. “Tylenol murders linger in shadows.” Chicago Tribune, September 29, 2002.

Frank Bellisario was a rookie: Bellisario, Frank. Rosen, Michelle. Telephone interview by author, March 2010. -- Personal interview by Michelle Rosen, March 12, 2010.

Watkins met with Michelle: Watkins, Scott. Personal interview by Michelle Rosen, March 12, 2010.

Watkins told Michelle that because: Watkins, Scott. Personal interview by Michelle Rosen, March 12, 2010.

Michelle also met with Peter Siekmann: Siekmann, Peter. Personal interview by Michelle Rosen, August 2010.

Siekmann, who has been involved in over 10,000 death investigations: Durante, Patrick. Addison Township Republicans, Accessed May 20, 2011. http://addisontwpgop.com/index.php?option=com_content&view=article&id=67&Itemid=68

He is now a judge in the Second Illinois Appellate Court: DuPage County State's Attorney Joe Birkett Appointed to 2nd District Appellate Court, ElmhurstPatch website, November 4, 2010, Accessed June 1, 2011. http://elmhurst.patch.com/articles/dupage-county-states-attorney-joe-birkett-appointed-to-2nd-district-appellate-court-2

Robert Schillerstrom: “Robert Schillerstrom biography.” Ice Miller website, 2011. Accessed May 20, 2011. http://www.icemiller.com/lawyer_detail_popup/id/1087/bioid/838/index.aspx#FullBio

One of Ice Miller’s long-time clients: “Our Clients.” Ice Miller website, 2011. Accessed May 20, 2011. http://www.icemiller.com/our_clients.aspx

On the same day the Tylenol: Ross, Brian. “Tylenol Victim's Daughter Wants Justice.” ABC News: The Blotter website, February 4, 2009. Accessed February 10, 2009.   http://abcnews.go.com/Blotter/story?id=6806499&page=1

Nelson, the co-founder: Ross, Brian. “Tylenol Victim’s Daughter Wants Justice.” ABC News: The Blotter website, February 4, 2009. Accessed February 10, 2009.   http://abcnews.go.com/Blotter/story?id=6806499&page=1

Nelson owes Johnson & Johnson: Nelson Communications, form S-1. April 30, 1999. Accessed, July 10, 2011.  http://www.sec.gov/Archives/edgar/data/1082447/0000950123-99-003962.txt

Johnson & Johnson’s policy of media: Associated Press. “Tylenol comeback.” The Capital, September 24, 1983.

“As Mr. Nelson will explain, this is the first time”: Ross, Warren R. “The view from Nelson's telescope. (interview with Nelson Communications Chairman Wayne Nelson and Pres./CEO Thomas A. Moore).” Medical Marketing & Media, March 1, 1997.

“There were a lot of people who believed”: Ross, Brian. “Tylenol Victim's Daughter Wants Justice.” ABC News: The Blotter website, February 4, 2009. Accessed February 10, 2009.   http://abcnews.go.com/Blotter/story?id=6806499&page=1

ABC news consultant, Brad Garrett: Ross, Brian. “Tylenol Victim's Daughter Wants Justice.” ABC News: The Blotter website, February 4, 2009. Accessed February 10, 2009.   http://abcnews.go.com/Blotter/story?id=6806499&page=1

“Based on an analysis of the stores”: Ross, Brian. “Tylenol Victim's Daughter Wants Justice.” ABC News: The Blotter website, February 4, 2009. Accessed February 10, 2009.   http://abcnews.go.com/Blotter/story?id=6806499&page=1

Nelson never mentioned: Buder, Leonard. “At Time of Tylenol Deaths, Suspects Were in New York.” The New York Times, October 21, 1982. - Saxon, Wolfgang. “Pill Case Suspect Found in New York.” The New York Times, December 14, 1982.

James and LeAnn do not wear: Lewis, James. Personal interview by author. Philadelphia. May 27, 2011.

One person who might: “Volunteer Spotlight.” Winfield Word: January 2011 -- Crane, Marylou. “A Message to the Voters in the 40th House District From Marylou Crane.” Daily Herald, February 27, 1992. -- Crane, Marylou. “DuPage County Application Form for Appointment.” October 3, 1995. – Presecky, William. “Walter Named To DuPage County Board.” Chicago Tribune, January 15, 1986. -- Schillerstrom, Robert. “Reappointment of Marylou Crane to the DuPage County Fair & Exposition Authority.” Resolution CB-0025-08, March 25, 2008.

While president of the Village of Winfield, she even wrote a monthly colum: Crane, Marylou. “Village seeks to attract businesses.” Daily Herald, December 2, 1993.

Marylou is the chairperson of the Winfield Board of Fire & Police Commissioners: “Volunteer Spotlight.” Winfield Word: January 2011 – “Reports of other Village officials.” Village of Winfield Minutes, April 6, 2006. -- Village of Winfield website, Accessed July 10, 2011. http://www.villageofwinfield.com/index.aspx?NID=120

Marylou took on the last name: “Marylou Walter, J. Alan Crane.” Chicago Tribune, September 24, 1989.

But in October of 1982, Marylou Crane, was Marylou Walter: “Chicago lie tests clear 6.” Chicago Sun-Times, October 27, 1982.

Duane Walter had been a Committeeman: Ginnetti, Luisa. “2nd Legislative District – Republican House.” The Herald, March 6, 1976.

Lewis Morgan had been a State Representative: Barnum, Art. “Ex-DuPage Judge Faces Legal Charges.” Chicago Tribune, October 25, 1989.

Lewis Morgan’s father: Van Matre, Lynn. “College photo contest puts face on America’s families.” Chicago Tribune, January 17, 2002.

The Morgans lived in Wheaton: Barnum, Art. “Ex-DuPage Judge Faces Legal Charges.” Chicago Tribune, October 25, 1989.

The Walters lived in Wheaton: Greco, Carmen Jr. “Good Old Days Festival going strong after 26 years.” Daily Herald, September 7, 1995. -- “Volunteer Spotlight.” Winfield Word, January 2011.

It is notable that J&J: Janota, Laura “Tainted Tylenol Civil Case Will Begin.” Daily Herald, May 13, 1991.

An FOIA request was submitted: Bartz, Scott. FOIA request to Winfield, June 16, 2011.

“We no longer have any copies of reports – they were all turned over to the Illinois State Police”: Samuels, Sharon. FOIA request reply, June 16, 2011.

Winfield Police Lieutenant, Bill Rizer, had told: Avila, Oscar. “Tylenol murders linger in shadows.” Chicago Tribune, September 29, 2002.

The case is still being investigated: Sutton, Kerry (ISP FOIA Officer). “Response Denying FOIA Request.” Illinois State Police, July 15, 2011.

The FBI also promptly denied an FOIA request:  Hardy, David M. (FBI Section Chief) Denial of FOIA Request No, 1169091-000, Tylenol Tampering Incident, July 19, 2011.

45     Mens Rea: Guilty Mind

In fact, the FBI had in fact publicly declared: Avila, Oscar. “Tylenol murders linger in shadows.” Chicago Tribun, September 29, 2002.

In 1982, the six lots: Coleman, Brenda. “FDA advises against use of Extra-Strength Tylenol.” Alton Telegraph, October 1, 1982. – United Press International. “Laced Tylenol claims 7th; culprit unknown.” Pacific Stars and Stripes, October 4, 1982. -- Associated Press. “More Poison: 8th tainted bottle found.” New Braunfels Herald-Zeitung, October 26, 1982.

The Tylenol from Lot MC2880: “Three Die After Taking Cyanide-Tainted Tylenol.” The Harvard Crimson website, October 1, 1982. Accessed July 1, 2011. http://www.thecrimson.com/article/1982/10/1/three-die-after-taking-cyanide-tainted-tylenol/?print=1. -- 10 p.m. News. WMAQ-TV, NBC, Chicago, October 1, 1982.

The Tylenol from Lot 1910MD: Associated Press. “Poison Found in Another Tylenol Batch.” Winchester Star, October 1, 1982. -- 10 p.m. News. WMAQ-TV, NBC, Chicago, October 1, 1982.

The first bottle of cyanide-laced Tylenol: Brune, Tom; Cose, Larry. “Tylenol scare in N.Y. / Woman dies; food chain pulls drug off shelves.” Chicago Sun-Times, February 11, 1986.

the second bottle cyanide-laced Tylenol recovered in 1986: Herald News Services. “More cyanide found in Tylenol.” The Daily Herald, February 14, 1986.

The Tylenol bottled at the McNeil: “Tylenol Professional Product Information.” Tylenol website, 2010. Accessed June 20, 2011. http://www.tylenolprofessional.com/assets/TYL_PPI.pdf

A drug’s shelf life: CFR Title 21, Sec. 211.166 (Stability testing).

“Under room temperature”: “Tylenol Professional Product Information.” Tylenol website, 2010. Accessed June 20, 2011. http://www.tylenolprofessional.com/assets/TYL_PPI.pdf

The source of this stability data: Fairbrother J. Acetaminophen. New York, NY: Academic Press; 1974.

The three–year shelf life of Tylenol was mentioned in February 1986: Inquirer Wire Service (with contribution from Michael B. Coakley). “Cyanide in Tylenol; Woman Dead.” Inquirer, February 11, 1986.

In October of 1982, Dean Mickelson, a pharmacist at the Revco drugstore: “Pharmacies pull drug,” The Taos News: Oct 7, 1982.

An FOIA request was filed with the FDA: Konigstein, David. Response to FOIA Request, File 2011-4678, July 26, 2011.

In 1973, the DOD: “SLEP - The DoD/FDA Shelf Life Extension Program.” Accessed July 10, 2011. https://slep.dmsbfda.army.mil/portal/page/portal/SLEP_PAGE_GRP/SLEP_HOME_NEW

On July 1, 1975, the FDA: “MOU 224-76-8049: Memorandum of Understanding Between The Veterans Administration and The Food and Drug Administration.” June 12, 1975.

Throughout the 1980s, the DOD: DOD Contract with McNeil Consumer Products Company, Round Rock, Texas, Contract number LA12082 C0776, May 1982. – DOD (Air force) Contract with McNeil Consumer Products Co., Glendale, California, Contract number SA13H 77 50158, Fiscal year 1980.

At the time of the Tylenol murders: United Press International. “Kansans told not to use Tylenol.” Salina Journal, October 3, 1982.

“We’re yanking it.”: Associated Press. “Extra Strength Tylenol off shelves in Kansas.” The Iola Register, October 2, 1982.

Public Affairs Officer, Jane Wray: United Press International. “Kansans told not to use Tylenol.” Salina Journal, October 3, 1982.

Air Force officials discovered: Trimmer, Dwight. “Refunds Offered on Tylenol Products.” Pacific Stars and Stripes, October 15, 1982.

Drug diversion was a big problem: GAO. “FOOD AND DRUG ADMINISTRATION HHS Inspector General Should Be Involved in Criminal Investigations.” Report to the Subcommittee on Oversight and Investigations, Committee on Energy and Commerce, House of Representatives, November 1987. – Associated Press. “7 Ohio drug companies being probed.” Chronicle-Telegram, September 16, 1985.

Diverters actively sought out: Associated Press. “'Drug diversion' is $1B business.” Pacific Stars and Stripes, August 10, 1985. -- Associated Press. “'Shadow' drug market detailed.” 1986. -- Kenyon, Quane. “Drugs Worth $380,000 On Street Missing AtSHS.” Idaho State Journal, October 30, 1977.

I am writing to alert: Patterson, George. “Dear Federal Supply Schedule (FSS) 65 IB Contractor.” VA Acquisition Center, Hines, IL, January 9, 2001.

From 1975 to 1982: GAO. “Fraud in Government Programs: Volume 1.” Report to Congress, May 7, 1981. – GAO. “Inventory Management: Problems in Accountability and Security of DOD Supply Inventories.” Briefing Report to the Honorable Pete Wilson, U.S. Senate, May 1986. – GAO. “More Effective Internal Controls Needed To Prevent Fraud And Waste In Military Exchanges.” Report to the Congress of the United States, December 31, 1980.

“In our opinion, the failure to identify causes and prevent recurrence of reported”: GAO. “Defense’s System for Handling Material Shipping Discrepancies Needs Improvements.” June 10, 1982.

According to a March 19, 1982 GAO report: GAO. “Review of Prices Paid by Military Commissaries on Brand Name Vendor Supply Bulletin Contracts (PLRD-82-55).” March 19, 1982.

Their only valid suspect, Roger Arnold: Nightly News, NBC, October 25, 1982.

In a nine-page synopsis: Marx, Gary; Mills, Steve. Tylenol case revisited. Chicago Tribune, February 8, 2009.

“One of the most”: Bergmann, Joy. “A Bitter Pill.” Chicago Reader, November 3, 2000. http://www.chicagoreader.com/chicago/tylenol-killings-a-bitter-pill/Content?oid=903786

“a soldier of fortune type guy”: United Press. “Cyanide Suspect Released On Bail.” Tyrone Daily, October 14, 1982.

In the 1970s and 1980s, posse comitatus groups: Levitas, Daniel. The Terrorist Next Door. New York: Thomas Dunne Books, 2002.

Arnold’s literature included: Nightly News. NBC, October 13, 1982. -- Associated Press. “Police question ‘chemist’ in cyanide-deaths case.” The New Mexican, October 13, 1982.

In September of 1981: Coates, James. Plot to Poison Water Is Charged.” Chicago Tribune, February 28, 1988.

“Here, you’ll need this.”: “Racists Detail Plot to Form an ‘Aryan Nation.’” New York Times, February 28, 1988.

In June 1982, more than 1,000: Anti-Defamation League. “Paranoia as Patriotism: Far-Right Influences on the Militia Movement.” NCJRS website, 1995. Accessed July 7, 2011. http://www.ncjrs.gov/App/Publications/abstract.aspx?ID=158514 . -- Morrison, Donald. “Festival of the Fed-Up.” TIME website, November 15, 1979. Accessed July 1, 2011. http://www.time.com/time/magazine/article/0,9171,912495-1,00.html

Since 1971, John “Johnny Bob” Harrell had hosted these annual freedom festivals: Morrison, Donald. “Festival of the Fed-Up.” TIME website, November 15, 1979. Accessed July 1, 2011. http://www.time.com/time/magazine/article/0,9171,912495-1,00.html

Just prior to the Tylenol: United Press International. “Police Arrest Suspect in Tylenol Case.” The Progress: October 13, 1982 - Associated Press. “Man Questioned in Cyanide Deaths.” Dispatch, October 13, 1982.

Arnold was four days away from leaving the country: United Press. “Cyanide Suspect Released On Bail.” Tyrone Daily, October 14, 1982.

Under Title 21 of the U.S. Code of Federal Regulations: CFR Title 21 PART 211

“Either capsules were missing, or some other medication was mixed in or there were foreign objects”: Associated Press. “Families of poisoning victims can sue Tylenol, judge rules.” Syracuse Herald-Journal, September 13, 1990.

46            The Madman

Just days before the deaths: Moore, Thomas. “The Fight to Save Tylenol.” TIME, November 29, 1982. -- “New Hall of Fame Members” Fenwick Magazine, Spring 2003, p. 12.

Also in September of 1982, Johnson & Johnson: Aguilar, Francis J.; Bhambri, Arvind: “Johnson & Johnson (B): Hospital Services.” Harvard Business School Publishing, 1983.

a longtime proponent of decentralization: Aguilar, Francis J.; Bhambri, Arvind: “Johnson & Johnson (A): Philosophy and Culture.” Harvard Business School Publishing, 1983.

“We had been marveling”: Moore, Thomas. “The Fight to Save Tylenol.” TIME, November 29, 1982.

“I did worry”: Cimons, Marlene; Jackson, Robert L. “Latest Tylenol Poisoning: A Nightmare Comes True.” LA Times, February 23, 1986.

FDA Commissioner, George Larrick”: Associated Press. “Cites Firm’s Secrecy on Drug’s Harm.” The Des Moines Register, April 29, 1964.

When Johnson & Johnson executives took: Weiser, Benjamin; Walsh, Elsa. “Drug Firm’s Strategy: Avoid Trial, Ask Secrecy.” The Washington Post, October 25, 1988.

A study that J&J was conducting: Mintz, Morton. “Drug fiends: even inside Johnson & Johnson, public safety can take a back seat to profits.” Washington Monthly, December 1991.

More recently, Johnson & Johnson knew: Willman, David. “How a New Policy Led to Seven Deadly Drugs.” LA Times, December, 20, 2000.

J&J executives said the Tylenol involved in the 1982: Beck, Melinda; Hagar, Mary; LaBreque, Ron; Monroe, Sylvester; Prout, Linda. “The Tylenol Scare.” Newsweek, October 11, 1982. -- Associated Press. “Cyanide Madman Sought.” The Titusville Herald, October 2, 1982. -- Associated Press. “Sixth Victim Claimed By Cyanide Pills.” Bedford Gazette, October 2, 1982.

Larry Foster said J&J: Associated Press. “Cyanide Found in Tylenol.” Wisconsin State Journal, October 2, 1982.

“They were principally interested”: ABC World News Tonight. ABC, October 6, 1982.

“People started calling yesterday”: Maroney, David.  “Logan Shelves Being Emptied.” Pharos Tribune, October 1, 1982.

When McNeil executives made those urgent: Beck, Melinda; Hagar, Mary; LaBreque, Ron; Monroe, Sylvester; Prout, Linda.“The Tylenol Scare.” Newsweek. October 11, 1982 -- Nenni, Pete; Van Wye, Joann. “5 dead after taking Tylenol capsules filled with cyanide.” The Daily Herald, October 1, 1982. -- Flock, Jeff. CNN-News. September 30, 1982.

The FDA and the FBI confirmed: Associated Press. “FDA: Don’t Take Tylenol.” Maryville Journal-Tribune, February 14, 1986. - Norman, Michael. “FBI Finds No Tampering with Packaging of Tylenol.” The New York Times, February 19, 1986. - Washington Post. “A Puzzle for Investigators.” The Post Standard, February 15, 1986.

Following the 1986 tampering incident: Norman, Michael. “FBI is assigning Tylenol inquiry ‘highest priority.’” The New York Times, February 15, 1986. -- Associated Press. “Cyanide Madman Sought.” The Titusville Herald, October 2, 1982. -- Washington Post. “A Puzzle for Investigators.” The Post Standard, February 15, 1986. -- McFadden, Robert D. “Two bottles of poisoned Tylenol were shipped by same distributor.” New York Times, February 16, 1986. -- “FDA Witnesses Destruction of Drug Products.” FDA website, June 28, 2001. Accessed July 20, 2011. http://www.fda.gov/ICECI/EnforcementActions/EnforcementStory/EnforcementStoryArchive/ucm107058.htm

The FBI put an end to Carl Vergari’s investigation: Norman, Michael. “Bottle Tampering Found.” The New York Times, February 27, 1986.

He pled guilty on January 22, 1998: “Guilty Plea of Unabomber Theodore Kaczynski Court document SACRAMENTO, CALIFORNIA. Eskimo.com website, January 22, 1998. Accessed July 1, 2011. http://www.eskimo.com/~rarnold/guilty.htm

In a Motion for Retention: “Motion for retention of evidence.” Case 2:96-cr-00259-GEN-GGH Document 806. Eastern District of California, May 9, 2011.

FBI spokesperson Ross Rice: Savage, Charlie. “FBI is looking at Unabomber in Tylenol case.” The New York Times, May 19, 2011.

Whoever, with reckless: Federal Anti-Tampering Act, U.S.C. TITLE 18 Section 1365

The FBI’s search for a patsy: Saltzman, Jonathan. “Suspect in ’82 Tylenol case appears at hearing.” The Boston Globe, January 8, 2010.

“If you had to pick somebody”: Martinez, Edecio. “Unabomber Theodore "Ted" Kaczynski probed in 1982 Tylenol poisonings.” CBS-News website, May 20, 2011. Accessed July 1, 2011. http://www.cbsnews.com/8301-504083_162-20064603-504083.html

“I suppose the case can now be labeled a random act of terrorism”: Sneed, Michael. “The Tylenol Case,” in “Daleys Selling House.” Chicago Sun-Times, September 20, 2011. Accessed July 21, 2011. http://www.suntimes.com/news/sneed/5454095-452/daleys-selling-house.html

“I’m surprised none of us thought of this [making Kaczynski a suspect] before”: Sneed, Michael. “The Tylenol Case,” in “Daleys Selling House.” Chicago Sun-Times, September 20, 2011. Accessed July 21, 2011. http://www.suntimes.com/news/sneed/5454095-452/daleys-selling-house.html

It’s been at least a dozen years since I’ve heard any updates on the case”: Sneed, Michael. “The Tylenol Case,” in “Dalys Selling House.” Chicago Sun-Times, September 20, 2011. Accessed July 21, 2011. http://www.suntimes.com/news/sneed/5454095-452/daleys-selling-house.html

“It [the testing of Kaczynski’s DNA] is a good”: CBS-News. WBBM, Chicago, May 19, 2011.

The FBI does of course: Stanton, Sam. “FBI: Unabomber Ted Kaczynski is suspect in 1982 Tylenol deaths.” The Denver Post, May 20, 2011. Accessed July 1, 2011. http://www.denverpost.com/nationworld/ci_18101709#ixzz1RSZ1fKoG

Then, when Kaczynski dies: “AMERITHRAX INVESTIGATIVE SUMMARY.” The United States Department of Justice, February 19, 2010. -- Maugh, Thomas H. II; Serrano, Richard A. “Evidence linking anthrax to Bruce Ivins ‘not as definitive as stated,’ panel says.” Los Angeles Times, February 16, 2011.

“A person who would put”: Cimons, Marlene. “Tylenol Chief Says Seals Can Be Replaced.” LA Times, February 20, 1986.

“Big business and big government”: “The Excedrin Killings.” American Justice. A&E, December 16, 2009.

Jay Mitchell died: Malcolm, Andrew H. “Wyoming cyanide death investigated.” The New York Times, October 9, 1982.

There were also three deaths: “Drug death probes reopened.” The Daily Herald: January 13, 1983.

In February of 1986, FDA: Kerr, Peter Tylenol is Linked to a Cyanide Death in Yonkers.” The New York Times, February 11, 1986.

James Cope, of the Proprietary: “The Proprietary Association offers reward up to $300,000 for the arrest and conviction of person or persons responsible for Excedrin Extra-Strength capsule poisonings in Seattle.” PR Newswire, June 19, 1986.

After the seven deaths: “The Proprietary Association offers reward up to $300,000 for the arrest and conviction of person or persons responsible for Excedrin Extra-Strength capsule poisonings in Seattle.” PR Newswire, June 19, 1986.

The term “self-regulation”: Braithwaite, John. “Enforced Self-Regulation: A New Strategy for Corporate Crime Control.” Michigan Law Review, Vol. 80, No. 7, June 1982, pp. 1466-1507.

“Who will protect America”: “Underground is Proposed for Those Making Atomic Products.” The Norwich Sun, January 6, 1947.

In 2004, the Medicaid program alone paid more than $2.8 billion for J&J drugs: “Government Contracting and Pricing Compliance Program.” Pg 3, 2005.

The anonymous leaders: Ross, Brian. “Tylenol Victim’s Daughter Wants Justice.” ABC News: The Blotter website, February 4, 2009. Accessed February 10, 2009.   http://abcnews.go.com/Blotter/story?id=6806499&page=1

Former Illinois Attorney General: “After 27 years, a break in the Tylenol case?”  NBC-News. NBC, Chicago, February 4, 2009.

Former FBI Agent, Brad Garret: Ross, Brian. “Tylenol Victim’s Daughter Wants Justice.” ABC News: The Blotter, February 4, 2009. Accessed February 10, 2009.   http://abcnews.go.com/Blotter/story?id=6806499&page=1

Former U.S Attorney, Dan Webb: ABC-7 News. ABC, Chicago, February 4, 2009.

The FBI announced: Saltzman, Jonathan. “Suspect in ’82 Tylenol case appears at hearing.” The Boston Globe, January 8, 2010.

The FBI said that the 25th anniversary: “Media Advisory on Review of 1982 Tylenol Murders.” FBI website, February 4, 2009. www.FBI.gov . http://www.fbi.gov/chicago/press-releases/2009/feb04_09.htm

James Lewis was in New York City: “Tylenol Suspect in N.Y. During Killings?” Pharos-Tribune, October 21, 1982. -- Buder, Leonard. “At Time of Tylenol Deaths, Suspects were in New York.” The New York Times, October 21, 1982. -- Saxon, Wolfgang. “Pill Case Suspect Found in New York.” New York Times: December 14, 1982 -- Doyle, Pat. “Lewis arraignment on extortion plot today.” The Daily Herald, December 28, 1982.

the Tylenol task force never considered Lewis: Associated Press. “Report says investigators know identity of Tylenol murderer.” Alton Telegraph, March 10, 1983. -- Nightly News. NBC, October 8, 1982. -- United Press International. “Police Arrest Suspect in Tylenol Case.”The Progress, October 14, 1982. -- Associated Press. “Tylenol victim's relative a suspect.” Register, October 25, 1982. -- United Press International. “More Cyanide-Laced Tylenol Found; Colorado Incidents Investigated.” The Progress, October 26, 1982. – Nightly News. NBC, October 25, 1982. -- United Press International. “Philadelphia Cyanide Link Not Solid: Top Investigator.” Pharos-Tribune:, October 7, 1982. -- Beck, Melinda; Foote, Donna; Michael, Renee; Shannon, Elaine. “The Tylenol Manhunt.” Newsweek, November 1, 1982. -- Buder, Leonard. “At Time of Tylenol Deaths, Suspects were in New York.” The New York Times, October 21, 1982. -- United Press International. “Chicago Officials Closer To Tylenol Case Arrest.” Pharos Tribune, Oct 27, 1982. -- United Press International. “Tylenol poisoning probe narrowed to 4 suspects.” Pacific Stars and Stripes, October 11, 1982. -- Associated Press. “Cyanide probe narrowed down to just a few leads.” Wisconsin State Journal, October 11, 1982. -- Malcolm, Andrew H. “Tylenol Maker Recalls Capsules After Strychnine Incident in West” The New York Times, October 6, 1982.

the Tylenol task force spent the first month: Associated Press. “Report says investigators know identity of Tylenol murderer.” Alton Telegraph: March 10, 1983 – Nightly News. NBC, October 8, 1982. -- Associated Press. “Tylenol victim's relative a suspect.” Register, October 25, 1982. -- Nightly News. NBC, October 25, 1982. -- Reiner, Ed. Personal interview by author. Winfield, IL, May 22, 2010. -- “Chicago lie tests clear 6.” Chicago Sun Times, October 27, 1982.

authorities in DuPage County planted: Associated Press. “Woman Who Turned in Tainted Tylenol is Sought.” The New York Times, October 27, 1982. -- United Press International. “New Tylenol-Cyanide Mix Found.” Pharos-Tribune, Oct 29, 1982. -- United Press International. “FBI Can't Match Fingerprint on Tylenol Bottle.” Altoona Mirror, October 29, 1982. -- Gazior, Anne Burris. “Tampering case leaves legacy of distrust for area residents.” Daily Herald, September 27, 1992. -- United Press International. “Fingerprint discovered on poison Tylenol.” Hutchinson News, October 28, 1982. -- Associated Press. “Official: More than one may be responsible for poisonings.” The Register, October 29, 1982. -- Associated Press. “More Tainted Tylenol Found in Chicago.” Syracuse Post-Standard, October 26, 1982. -- Associated Press. “Coupon Company Hired for Tylenol Swap.” Gazette, October 8, 1982. -- Associated Press. “8th poisoned Tylenol bottle found.” Galveston Daily News, October 26, 1982. -- United Press International. “8th Tylenol Bottle Found” - Pharos Tribune, October 26, 1982 -- Associated Press. “Latest capsule has differences.” The Lethbridge Herald: October 29, 1982. -- Watkins, Scott. Personal Interview by author, August 19, 2010.

cyanide did not cause the gel-based: Litke, James. “Cyanide kills Philadelphian.” The Gettysburg Times, October 7, 1982. -- United Press International. “Suspect List Cut to Four.” Pharos-Tribune, October 11, 1982. -- Tifft, Susan; Lee, Griggs. “Poison Madness in the Midwest.” TIME, October 11, 1982. -- “Suspects Studied in Cyanide Deaths.” Casa Grande Dispatch, October 4, 1982. -- Norman, Michael. “FBI is assigning Tylenol inquiry ‘highest priority.’” The New York Times, February 15, 1986.

the FBI did not have probable cause: “County aide sues Ch. 2 reporter for $25 million.” Chicago Sun-Times, March 10, 1986. – Nightly News. NBC, October 25, 1982. -- Coroner’s inquest, re: Mary McFarland. Direct examination by DuPage County Coroner Richard Ballinger, December 14, 1982. -- O’Connor, Phillip J. “Lewis wife harassed by FBI, lawyer says.” Chicago Sun-Times, February 15, 1986. -- 797 F.2d 358 21 Fed. R. Evid. Serv. 225 USA, Plaintiff-Appellee, v. James William Lewis, Defendant-Appellant. No. 84-2011. US Court of Appeals, Seventh Circuit, May 31, 1985. -- Associated Press. “Tylenol makers report $1 million extortion plot.” Alton Telegraph, October 8, 1982. -- Buder, Leonard. “At Time of Tylenol Deaths, Suspects were in New York.” The New York Times, October 21, 1982. -- Saxon, Wolfgang. “Pill Case Suspect Found In New York.” The New York Times, December 14, 1982. -- Doyle, Pat. “A year after Tylenol killings: sorrow lingers, answers elude.” The Sunday Herald, September 25, 1983. -- Slania, John, “Two years later, Tylenol murders haunt task force.” The Daily Herald, September 30, 1984.

the FBI has no DNA evidence: “County aide sues Ch. 2 reporter for $25 million.” Chicago Sun-Times, March 10, 1986. -- Lewis, James. Personal interview by author. Philadelphia, May 27, 2011. – Nightly News. NBC, October 8, 1982.

the 25th anniversary did not generate: Avila, Oscar. “Tylenol murders linger in shadows.” Chicago Tribune, September 29, 2002. -- Bellisario, Frank. Personal interview by Michelle Rosen, March 2010. -- Watkins, Scott. Personal interview by Michelle Rosen, March 12, 2010. -- Siekmann, Peter. Personal interview by Michelle Rosen, Michelle, August 2010. -- Lewis, James. Personal interview by author. Philadelphia, May 27, 2011. -- Sneed, Michael. “The Tylenol Case,” in “Dalys Selling House.” Chicago Sun-Times, September 20, 2011. Accessed July 21, 2011. http://www.suntimes.com/news/sneed/5454095-452/daleys-selling-house.html

and the FBI and Illinois officials are not: Avila, Oscar. “Tylenol murders linger in shadows.” Chicago Tribune, September 29, 2002. -- Bellisario, Frank. Personal interview by Michelle Rosen, March 2010. -- Watkins, Scott. Personal interview by Michelle Rosen, March 12, 2010. -- Siekmann, Peter. Personal interview by Michelle Rosen, August 2010 -- Lewis, James. Personal interview by author. Philadelphia, May 27, 2011. -- Bartz, Scott. FOIA request to Winfield, June 16, 2011.

In 1982, the disclosures by Cook County: United Press International. “Suspect List Cut to Four.” Pharos-Tribune, October 11, 1982. -- Tifft, Susan; Lee, Griggs. “Poison Madness in the Midwest.” TIME, October 11, 1982. -- “Suspects Studied in Cyanide Deaths.” Casa Grande Dispatch, October 4, 1982.

In 1986, West Chester District Attorney: Norman, Michael. “FBI is assigning Tylenol inquiry ‘highest priority.’” The New York Times, February 15, 1986. -- Associated Press. “Poisoned Tylenol: no time limit.” Sunday Intelligencer/Montgomery County Record, February 16, 1986. -- McFadden, Robert D. “Two bottles of poisoned Tylenol were shipped by same distributor.” New York Times, February 16, 1986. -- “Tests Link Poisons in Two Tylenol Bottles.” The Post-Standard, February 15, 1986.

knowingly selling drugs that contain contaminants: FDA. “FDA 483 Inspection Observations.” April 4, 2010.

From 2008 through 2010, the FDA apparently: FDA. “FDA 483 Inspection Observations.” January 8, 2010 -- FDA. “FDA 483 Inspection Observations.” April 4, 2010.

J&J also had to shut down the McNeil: “Tylenol plant in Ft. Washington closed in wake of recall.” ABC Action News Philadelphia website, May 5, 2010. Accessed July 1, 2011. http://abclocal.go.com/wpvi/story?section=news/health&id=7396607

yet the company’s handling of the 1982 Tylenol murders is still portrayed in the media as the gold standard: Singer, Natasha. “In Recall, a Role Model Stumbles.” The New York Times, January 17, 2010. – Adubato, Steve. “At Johnson & Johnson, humility helps salvage a reputation.” Star Ledger website, May 1, 2011. Accessed July 1, 2011. http://www.nj.com/business/index.ssf/2011/05/at_johnson_johson_humility_hel.html

J&J convinced the judge:  Szymczak, P. Davis. “Settlement Reached In Tylenol Suit.” Chicago Tribune, May 14, 1991.

A federal judge dismissed the 1986: John Elsroth as Administrator of the Estate of Diane Elsroth v. Johnson & Johnson et al. 87 Civ. 1524, US District Court for the Southern District of New York, November 15, 1988.

“When a corporation”: Mintz, Morton. “Drug fiends: even inside Johnson & Johnson, public safety can take a back seat to profits.” Washington Monthly, December 1991.

Table of Contents

PART 1

A Curious Discovery

The Tylenol Murders

Who Will Protect America?

The Tylenol Crisis

All of Burke’s Men

The Developing Investigation

We Will Be Completely Honest

J&J and the FBI

Above the Law

The Madman Myth

Handling the Evidence

Selling the Myth

Rack Jobbers

The Vanishing Evidence

A Reluctant Recall

The Other Cyanide Murders

A Poisoned Investigation

The Tylenol Institution

The Louis Zahn Drug Company

We Know Who did It

The Closet Chemist

A Conspiracy Theory

The Eighth Bottle

The Conspiracy

The Last Suspect

Project Chatham

Death is a Manageable Side Effect

PART 2

The 1986 Tylenol Murder

We Never Said It Is Tamper Proof

The Great Capsule Debate

Burke’s Nightmare

The Puerto Rican Diversion

Our Credo

The Vergari Problem

Revisionist History

Big Jim’s Boys

PART 3

The Manhunt

How Do You Solve A Problem Like James Lewis?

A Second Look

A Novel Approach

A Familiar Pattern

The Judges of DuPage County

A Reactivated Cover-up

The New Case; Same as the Old Case

Mens Rea : Guilty Mind

The Madman

About the Author

Endnotes