The Ultimate Poison Legacy: Catastrophes, Accidents, Murder and Suicide
Chapter 14
Catastrophes, Calamities and Accidents
ACCIDENTAL POISONING ON A grand scale has happened as a result of many industrial accidents and numerous natural disasters. Accidents can happen for a wide variety of reasons, including miscalculations, design failures or even – it has to be said – the sheer stupidity of some people. A few of these accidents are recounted here.
The worst industrial disaster in history
This accolade must go to a chemical plant and an explosion in 1984, which is still causing problems today. The disaster occurred at the Union Carbide insecticide manufacturing plant, at Bhopal in Central Northern India. It happened on the night of the 3rd December 1984, following a massive leak of toxic gases.
No accurate record of the total numbers of people killed or injured could be made at the time, such was the scale of the disaster. However, it was estimated that somewhere between 16,000 and 30,000 people were killed, and a further half a million or so injured.
The chemical plant involved was used to make an organophosphate insecticide called carbaryl, for which the Union Carbide brand name was Sevin. The American company Union Carbide was very safety conscious, and when this manufacturing plant first opened at Bhopal in May 1980, there were many safety systems in place, all designed to prevent any leakage.
However, on the fateful night some four and a half years later, not one of these safety systems was still operational. A pressure gauge was broken, the storage tanks were at ambient temperature instead of being cooled down to a temperature of 0oC and a number of other safety systems were out of action due to ongoing maintenance.
As part of the production process, the plant produced the poisonous gas, phosgene, as well as a poisonous liquid called methyl isocyanate, a form of cyanide. This liquid, called MIC for short, was supposed to be maintained at a constant temperature of 0oC (the freezing point of water) to keep it stable. On the night in question, all the safety systems on the MIC tanks were inoperative, and the liquid was at 20oC, the usual nightly temperature in that part of India during the winter. At 20oC, the MIC gave off a number of gases, including hydrocyanic acid, otherwise known as the intensely poisonous Prussic Acid. Of the three storage tanks, one should have been completely empty, for use as a back-up in case of emergency, but on this night it was partly filled with MIC. The problems started when water and chemical debris also got into this back-up tank. This water and debris was the result of cleaning the inside of the pipe work at the plant.
Mixing the MIC, at the ambient temperature, with this chemical debris and water resulted in a number of chemical reactions involving the production of massive amounts of heat. This heating caused a massive pressure build-up in the tank, which then exploded out of its concrete casing, rupturing the pipe work in the process. The explosion released the MIC vapour, and, because it was twice as heavy as air, it formed a gas cloud at ground level. Other lighter gases, such as the poisonous phosgene gas and hydrogen cyanide gas, formed in layers above the MIC, together with yet another gas, monomethylamine, which smelt like ammonia.
Unfortunately the prevailing wind that night blew this toxic collection of gases over the nearby slums, and then over the city of Bhopal itself, killing whoever was in its path – men, women, children and their animals. Chemical breakdown of the methyl isocyanate released hydrogen cyanide, and this gas, when inhaled, instantly destroyed the cellular ability to transport oxygen, of any person in contact with it. This was how the hydrogen cyanide gas killed the majority of the victims that fateful night.
The corpses, when collected later, even smelt of bitter almonds, the characteristic smell of hydrogen cyanide gas. In 1997, 13 years later, it was estimated that at least 150,000 people were still alive and chronically affected by the Bhopal tragedy. Between ten and 15 of these patients still die each month, even now, nearly 25 years later.
These chronically ill survivors suffer from breathing difficulties, persistent coughs, anorexia, fevers, weakness, depression, cataracts, cancer and chronic gynaecological problems. The children born to these survivors suffer from retarded growth at best, but many are stillborn. Union Carbide have never said what they thought was in the toxic cloud – they probably never knew exactly, and no one will ever know for sure now– but this lack of precise information has made treatment of the survivors particularly difficult for the doctors who care for them.
Union Carbide agreed to pay $470 million in damages, but many survivors received little or nothing, and most soon found that any money they were given was quickly consumed by medical bills. Today, the factory is derelict, but toxins from it continue to leak into the water supply and into the soil. Babies are still being born deformed and children still fail to thrive.
Union Carbide is now part of the Dow Chemical Company, of napalm and Agent Orange fame. Dow is the world’s richest chemical corporation but refuses to clean up the derelict factory, claiming that it is not responsible for it. The book Five Past Midnight in Bhopal by Dominique Lapierre and Javier Moro explains this whole sorry story in great detail. And its sales help to fund the charity for the Bhopal survivors.
The largest nuclear accident in history so far
Unfortunately, Chernobyl can easily claim this title. The effects of this environmental disaster were not only felt in this city near Kiev, in north-central Ukraine, but eventually reverberated throughout the world.
In April 1986, a series of explosions at the nuclear power station resulted in a serious release of radioactivity into the atmosphere. Because of prevailing winds, it spread quickly to the neighbouring republics of the former Soviet Union and to a number of countries in Europe. Radioactive caesium drifted over Western Europe, including the British Isles. Heavy rain then washed it down to earth, where it was absorbed by plants, through their roots. These plants were then eaten by livestock, including sheep and cattle.
The city of Chernobyl, with a population of about a quarter of a million people, was evacuated. Many died during the explosions or shortly afterwards, while others suffered from exposure to the radioactivity, and died from cancers they developed much later. Even in 1994, half a million sheep in Britain were still classified as affected and could not be sold for slaughter until their meat had been checked for contamination caused by the radioactive caesium, which was released at Chernobyl eight years previously.
Chernobyl happened while it was still part of the Soviet Union, only seven years after the Three Mile Island incident, an accident that occurred at a nuclear power station in the USA. This American incident resulted in damage to the uranium in the reactor core and led not only to a reassessment of safety standards, but also provoked a strong opposition to any future expansion of the nuclear industry in the West. However, Chernobyl, still part of the old communist regime of the USSR at that time, was governed from afar where they preferred to do things the ‘Russian’ way, and so there was no reassessment of their safety standards in those intervening seven years.
The Camelford disaster (detailed in Chapter 11), which poisoned 20,000 people in Cornwall through contaminated water, two years after Chernobyl, is another prime example of a man-made misfortune. And a final example: the rapid growth of industry in China in recent years, with factory owners greedy for profit, has resulted in mass poisonings of many families living close by. Factories and smelters have spewed out pollutants on a massive scale, without carrying out even the most basic environmental monitoring. Thousands of children and their parents have been found to be suffering from lead poisoning as a consequence. At least two regions, Shaanxi and Hunan, have such problems, yet the government’s promises to move villages to safer areas or to control pollution have not been kept. Some of the children’s lead levels are more than ten times the level considered safe in China and public anger is rising fast. Elsewhere in China similar problems near the smelters of other metals, including zinc, cadmium and indium, are causing further public anger and protest.
An African natural disaster
Another example of mass poisoning and mass fatalities on a slightly smaller scale comes from Africa. But this time it was no accident, for this was a natural disaster. On 21st August, 1986, more than 1,700 people died of carbon dioxide poisoning. They all lived within a 15-mile radius of Lake Nyos in Cameroon. Two years earlier, 37 people died in a similar way, at nearby Lake Monoun.
The cause of the problems was the underlying volcanic activity that resulted in the release of a large quantity of carbon dioxide gas from beneath the lakes. This gas is colourless, tasteless and odourless – it is a silent killer that asphyxiates its victims. This is likely to happen again if the lakes are disturbed by further volcanic activity in the future. According to scientists who have studied the problem, the safest solution is to permanently relocate people away from the lakes.
Carbon monoxide is another colourless, tasteless and odourless gas, which is poisonous and highly flammable. Carbon monoxide burns with a characteristic blue flame, combining with the oxygen in the air to produce carbon dioxide. But poorly maintained heating systems result in the incomplete combustion of gas and the production of carbon monoxide instead of carbon dioxide.
As little as one part in a thousand (0.1 per cent) of carbon monoxide in the atmosphere can be fatal. Both inadequate ventilation and incomplete combustion can result in the production or build-up of carbon monoxide. This type of problem is often seen with old and defective heating appliances, which have not been serviced regularly by a suitably qualified heating engineer.
The haemoglobin in our red blood cells binds to the oxygen in the air when we breathe in and carries it around the body for us. Carbon monoxide, when inhaled, takes over and binds to the haemoglobin in the blood in preference to oxygen, resulting in death by asphyxiation and tissues coloured a bright cherry red. This happens because carbon monoxide has a far greater affinity for haemoglobin than oxygen does. As a result it forms carboxyhaemoglobin, in preference to oxyhaemoglobin, fatally depriving the body of the essential oxygen that we all need to sustain life.
Malign menthol and poisonous peppermint
Many products are peppermint flavoured, but today this is frequently an artificial flavour rather than the naturally occurring peppermint oil, which was widely used in the past. Peppermint oil contains about 50 per cent menthol, so poisoning involving peppermint is generally regarded as being due to its menthol content.
Two patients who became addicted to peppermints about a century ago both suffered from atrial fibrillation, a disorder of the heart’s normal rhythm. Once the peppermint sucking stopped however, the normal cardiac rhythm was restored. An American patient suffered exacerbations of his asthma, with wheezing and difficulty in breathing, which were found to be related to his use of toothpastes containing peppermint, or wintergreen, as flavourings.
In Australia, two patients had recurrent attacks of muscle pain when they consumed large quantities of confectionery flavoured with peppermint oil. A dentist also reported a case where a patient suffered from an acute allergic reaction, affecting the mouth, neck and throat, which was eventually traced to the peppermint oil in toothpaste. And, a few years ago, a baby died after being given peppermint water that was incorrectly prepared, at ten times the strength it should have been.
A 31-year-old woman was found to be hypersensitive to menthol; the symptoms produced were urticaria (hives), flushing and headaches. This woman reacted to a number of products containing peppermint, including a cream, peppermint-flavoured toothpastes and sweets and mentholated cigarettes, and she was so sensitive that she even reacted to mint jelly.
A 13-year-old boy developed ataxia with unsteady gait and uncoordinated movements, confusion, euphoria, rolling eyes and double vision following the inhalation of 5ml of Olbas Oil, instead of the recommended few drops. It was considered probable that the menthol in the preparation was responsible for his symptoms, as the amount of menthol inhaled in this case was about 200mg. The fatal dose in humans is estimated to be about 2g.
Amazing alkaloids
Colchicine is a potent alkaloid, derived from the meadow saffron corm, used in the treatment of gout. The precise details of this are explained in Chapter 17. One tablet is taken every two-three hours, until relief of pain is achieved, or until vomiting and/or diarrhoea occur (because vomiting and diarrhoea are the first signs of toxicity).
Despite using the recommended dosage, some patients have died. In 1966, a patient with obstructive jaundice developed fatal problems with their bone marrow and its production of blood cells. Doctors considered that the liver problems enhanced the toxicity of the drug in this case. Another man who took a 500 microgram tablet daily for three years as a treatment for gout developed fatty stools due to reduced absorption of fat from the diet, as well as a lymphoma, or malignant tumour of the lymph nodes, in part of the intestines called the jejunum, as a result.
In 1947, a 23-year-old woman took a 50mg dose of the alkaloid atropine by mistake. This was 50 times the therapeutic dose but fortunately, because of the prompt treatment given, she recovered. A year earlier, another patient in America, who had taken 1g of atropine by mouth, was successfully treated with a potassium permanganate stomach wash-out, followed by intravenous dextrose and phenobarbitone sedation. In the 1930s, a man who had been taking regular daily doses of belladonna tincture, which contains atropine, for many months with considerable benefit began to lose ground. After a time he suddenly showed great improvement again, which could not be accounted for until he admitted that he had started to take double doses of his medicine.
Aconite is a plant that is very poisonous because of the alkaloids it contains. In the past it was used both internally and externally, but it is now regarded as too dangerous to use and other much safer agents are now available.
In 1911, a patient swallowed enough aconite liniment to kill six people. The treatment given to counteract this overdose included Ipecacuanha Wine as the first antidote, because it acts as a cardiac depressant. Mustard emetic was also given to save the enfeebled heart. The head was kept low and the feet raised, a mustard plaster applied to the heart and hot flannels to the extremities and the abdomen. Strychnine and digitalis were given by injection and brandy was administered as an enema. Artificial respiration was continued unceasingly for six hours, after which this extremely lucky patient recovered.
In 1910, a patient accidentally took a tablespoon of a liniment that contained not only aconite, but also belladonna, chloroform, red pepper and wintergreen oil. The patient fortunately vomited and was then given an injection of strychnine plus an enema of hot, strong coffee, and as a result he made a remarkable recovery, considering that the amount of aconite taken was 35 times the maximum oral dose of the official tincture.
Another case of acute poisoning was reported in India in 1935, where a patient accidentally swallowed about 25ml of A.B.C. Liniment, which contained Aconite, Belladonna and Chloroform. After all the usual treatment measures failed, the poisoning was successfully treated using intravenous saline. All the symptoms abated and recovery was complete within 72 hours. Some 30 years later, a 77-year-old man who drank 60ml of camphorated oil by accident developed vomiting and convulsions. He was treated with haemodialysis using eight litres of soya oil for four and a half hours, during which time 6.56g of camphor was removed. Amazingly, he recovered.
Solvents and pickles
Carbon tetrachloride was used as a solvent and dry cleaning fluid for many years. Cases of fatal kidney damage have occurred due to long-term exposure to, and inhalation of, the vapour. In 1946, three patients each took a mixture containing carbon tetrachloride, followed by a dose of Epsom Salts. An hour or so later, they were all vomiting and had diarrhoea, headache, general pains and, in two cases, cramps in the arms and legs. They were treated with a high carbohydrate diet, calcium lactate taken by mouth and calcium gluconate and glucose given intravenously, which led to their eventual recovery.
In 1949, The Lancet carried a report of a 53-year-old man who died after drinking about 50ml of carbon tetrachloride while under the influence of alcohol. Death was delayed for 24 days, and the post-mortem showed that the kidneys suffered the most damage.
Diluted formaldehyde is the liquid used to ‘pickle’ tissues to preserve them for future examination. In 1912, the British Medical Journal reported a case of formaldehyde poisoning. The patient drank about 75ml of a four per cent solution of formaldehyde and lost consciousness within three minutes. The stomach was washed out but the patient died. At the post-mortem examination it was found that the oesophagus and stomach had both been extensively corroded by the formaldehyde.
Fatally cheap ‘alcohol’
Chemicals frequently have more than one name. One such chemical is ethylene glycol, which also goes by the name ethylene alcohol. This substance is commonly used in antifreeze solutions. Unfortunately, it has also been used as a cheap alternative to the similar sounding ethyl alcohol, which is the ‘alcohol’ that we drink in beers, wines and spirits. There have been many cases of accidental poisoning, commonly among students seeking a cheap alternative to the real thing.
A number of such cases have already been recounted in earlier chapters, including the chapters on treatment and food. The problem with drinking ethylene glycol is that it is oxidised to the poisonous oxalic acid by the enzyme alcohol dehydrogenase in the liver, whereas ethyl alcohol is converted to the much safer acetic acid. While the ethylene glycol causes central nervous system depression, the oxalic acid produced causes extensive kidney damage, which follows on later. Similar cases of poisoning have happened time and time again, and each time people are killed trying to get drunk on the cheap.
Oxalic acid and its salts are all extremely poisonous. In 1968, the Pharmaceutical Journal reported the case of a 16-year-old girl who was accidentally given 1.2g of sodium oxalate intravenously. She died five minutes later, but her heart function was restored by cardiac massage and life support was maintained for four days, without any sign of her regaining consciousness. Post-mortem examination showed extensive damage to her kidneys. Ganglion cells throughout her central nervous system were also found to be similarly damaged. Once given that fatal injection, she never had a chance.
Oh my, Spanish Fly
A hundred years ago, Spanish Fly, officially called cantharides, was in use as a medical treatment, but even then it was used sparingly. Many people have heard of the reputed claims of Spanish Fly as an aphrodisiac, but very few have ever personally tried it. However, in 1921, The Lancet carried a report about an inquisitive medical student who, out of misplaced curiosity, decided to give it a try. Unfortunately he used too large a dose and ended up with blood and albumin (a protein) in his urine as a result, which indicated kidney damage, but, happily, he eventually made a full recovery.
Until the 1950s, Spanish Fly was mainly used medicinally on plasters, which were applied to raise blisters on the skin. The size of a blistering plaster was usually about 1 inch (2.5cm) square, and only rarely were larger ones used; such was the power of cantharides. After the 1950s, more modern treatments, such as ointments and rubs, replaced the crushed, dried beetles of Spanish Fly. Today self-heating pain relief pads are available, which will supply up to eight hours of warmth to soothe away the pain.
Having heard of its aphrodisiac reputation, people have still continued to try Spanish Fly on their own. In 1967, a 42-year-old man took a teaspoonful of a preparation which contained about 20mg of cantharidin, the active ingredient in Spanish Fly. He developed symptoms of kidney damage but fortunately responded to treatment, and his badly ulcerated mouth was treated by giving him hydrocortisone pellets to suck.
In 1978, an 18-year-old woman swallowed about 2ml of a preparation containing Spanish Fly. She developed the symptoms of heart damage, as well as direct damage to her mouth, throat and pharynx. She was fortunate that her symptoms all responded to treatment, although in the past there have been fatalities due to cantharides poisoning.
Even contact with just one Spanish Fly blister beetle or 1mg of cantharidin can produce distressing symptoms; for example, even brief skin contact can lead to the formation of blisters.
In the past, many substances have been regarded as aphrodisiacs and sold as such, but for most of them these effects are largely in the mind of the user, and have rarely been proven scientifically. Some are downright dangerous: indeed, one of the victims described in Chapter 2, James Maybrick, took small doses of arsenic, which he considered to be an aphrodisiac, with fatal results. Strychnine in small doses was also regarded as an aphrodisiac by the Victorians, and old habits die hard: it was only in 1989 that the American FDA put strychnine on their list of banned aphrodisiacs.
More myths dispelled
Word of mouth is a powerful thing. Myths may be based on no true fact at all, but they spread and wreak havoc when people believe them to be true.
During the 1950s in Puerto Rico, there were a number of accidental deaths caused by people eating rat poison containing phosphorus. They chose to eat it in the misguided belief that it had brain-enhancing effects or that it was an aphrodisiac – both untrue urban myths.
Two other chemicals involved in myths are dinitrocresol and dinitrophenol, which were used in the past as insecticides and to kill mites and ticks. They are both equally dangerous to use and are no longer in use because of adverse effects to agricultural workers. However, in the past, they were thought to speed up metabolism, and this possible quick fix for burning fat could not be ignored by some.
In the 1930s, dinitrocresol was used medicinally to speed up a patient’s metabolism in the treatment of obesity. In 1934, a young dancer sought to reduce her weight by way of a course of treatment which included taking a single capsule of dinitrocresol daily. Her death from an overdose occurred within a few days. At the post-mortem the drug was found in both her stomach and her intestine. In her eagerness to lose weight, she had taken 17 of the 50mg capsules in a period of only three days, instead of one daily.
Dinitrophenol is still available today, sold by disreputable traders heedless of its dangers. In 2003, the Food Standards Agency (FSA) issued urgent advice, to the bodybuilding community in particular, about the dangers of consuming products containing 2,4-dinitrophenol (DNP). DNP has even been available on the Internet, sold as ‘fat-burner’ capsules.
This chemical is known to have both very serious short-term and long-term adverse effects. As few as three or four of the capsules, if taken as a single dose, could be fatal. Smaller amounts, even less than one capsule per day, if taken long term can have serious side effects, such as blindness, due to the formation of cataracts in the eyes.
Sometimes word of mouth, like Chinese Whispers, can cause dangerous confusion. In 1936, a fatal case of poisoning occurred in Malaya when Japanese star anise was taken in mistake for a different species, Chinese star anise. Chinese star anise, also called Aniseed Stars, is used in the East as a remedy for colic and rheumatism, and in China for seasoning dishes, especially sweets, with aniseed. The distinction between the toxic and the harmless species is not very marked, but the taste of the toxic species is pungent and bitter and its odour resembles that of oil of cajuput or cardamom. The poisonous Japanese star anise is smaller and less regular in appearance than the non-toxic version, and contains a poisonous principle called sikimin. In China, Japan and the Philippines, the poisonous variety, being much cheaper, is often sold and used as a substitute for the non-toxic variety, resulting in many cases of poisoning.
Some skin problems
In America in 1936, a fisherman was found to have developed blood poisoning, with jaundice, of unknown origin. He began suffering from generalised itchiness because of the jaundice, and to treat it he was given a number of injections of ergotamine tartrate, one of the ergot alkaloids. This unfortunately resulted in him developing gangrene of the feet, which eventually necessitated amputation of his legs. A total of 19ml of the ergotamine had been injected within one week. This was a massive overdose.
Today his itchiness would have been easily treated using an antihistamine, but, at that time, antihistamines had yet to be synthesised. Piriton, one of the earliest antihistamines, was first marketed in the United Kingdom in 1954, and is still widely used today.
Pyrogallol is not used internally, as it is known to be toxic to the liver. However, it was used externally for many years in the past to treat a number of dermatological complaints, despite the known possibility of poisoning if sufficient absorption of pyrogallol through the skin occurred. A fatal case of pyrogallol poisoning occurred in America in 1925. The patient was badly affected by the chronic skin disease psoriasis, which was affecting his whole body. He was given an ointment containing pyrogallol to treat it. Within five minutes of covering about two-thirds of his body with the ointment, he collapsed and died due to pyrogallol poisoning caused by skin absorption. It was estimated that the patient had probably absorbed a total of about 10g of pyrogallol.
Accidents with antiseptics
Phenol used to be known as carbolic acid, and was widely used as an antiseptic for many years. It has been a long time now since it was superseded by far more effective, less toxic agents.
In 1922, a large glass bottle called a Winchester, containing about two litres of carbolic acid solution, was dropped. It smashed, releasing its contents all over the floor. A boy began to mop it up with a cloth and could not help but inhale the fumes of the carbolic acid. This quickly resulted in symptoms of severe poisoning. The boy’s life was only saved by prompt treatment; his breathing improved once he was given oxygen, and then two pints (about a litre) of normal saline solution with added sodium bicarbonate were given intravenously. He made a full recovery.
Mercurochrome was another toxic antiseptic and disinfectant widely used in the past. There have been many reports in the medical literature of deaths attributed to its use. In 1979, a 59-year-old woman, who had previously had surgery for an oesophageal stricture, had a two per cent aqueous mercurochrome solution applied to her surgical wounds and bedsores. By Day 22, the mercury level in her blood was very high and she died the following day of therapy-resistant shock. Aplastic anaemia was confirmed at the autopsy and tentatively ascribed to the mercurochrome treatment she had received. Mercurochrome will be mentioned again in Chapter 17 on Potent Potions.
Eating arsenic and other unfortunate errors
In the early years of the twentieth century, the British Medical Journal reported a strange death caused by arsenic poisoning. It was known that the body could tolerate a certain amount of arsenic if taken regularly – if it was started at a low dose and gradually increased – but it was not realised that once such tolerance was achieved, in order to stop safely, a slow decrease in dose was also required. A man working in an arsenic factory was in the habit of eating 20 grains (about 1.3g) of coarse powdered arsenic each day. Wishing to give it up, the man simply stopped eating it, rather than cutting his consumption down gradually, and as a result he quickly developed stomach pains and diarrhoea, before he collapsed and died.
Zinc sulphate has, for very many years, been used in astringent lotions for the skin. In 1947, a woman requiring a laxative mistakenly swallowed about 25g of zinc sulphate instead of Epsom Salts (magnesium sulphate). Vomiting and purging occurred, and were then followed by acute collapse and restlessness. Treatment with soothing liquids, morphine for pain and nikethamide, a stimulant for the central nervous system, produced a marked improvement within 12 hours. Progress was maintained until the sixth day, when the patient became semi-comatose, with symptoms of diabetes. Insulin therapy was tried but the unfortunate lady died.
In 1967, a married couple both developed chronically sore skin on their wedding ring fingers, but nowhere else. Investigation revealed that the gold used to make their wedding rings contained radioactive impurities with half-lives of over 20 years. If they continued to wear the rings, the soreness would persist, and they would be exposed to a continuous, though slowly reducing, dose of radioactivity. As a result of this case, it was recommended that all gold for either jewellery or dental use should be routinely screened for radioactive impurities.
Allergy to gold is rare, but it does happen. One woman developed persistent, small spotty sores on both her earlobes, which only appeared after she had her ears pierced and started wearing gold earrings. She subsequently developed hypersensitivity to gold. And an unfortunate jeweller developed necrotising inflammation of the blood vessels in his fingers, induced by prolonged exposure to gold during his work.
Insect powders containing fluoride became popular in the mid-twentieth century because they had the advantage over those containing arsenic in that they were cheaper, quicker acting and effective against a wide range of insects. There have been a number of fatalities resulting from people taking insect powder that contained either sodium fluoride or sodium silicofluoride by mistake, instead of their indigestion powder. Even half a teaspoonful taken in error for sodium bicarbonate has caused death within ten hours.
In 1936, a patient intending to take flowers of sulphur, an old-fashioned laxative, took a dose of insect powder containing sodium fluoride. Nausea, vomiting, diarrhoea, pains in the arms and legs, problems swallowing and ocular paralysis with double vision were the symptoms exhibited. Oxygen and stimulants were used to treat the symptoms and later nikethamide, strychnine, atropine and radiant heat were all needed to cure the patient.
In The Lancet in 1949, there was an interesting case of accidental lead poisoning. The patient had applied dressings soaked in Strong Lead Acetate Solution BP to areas of his body for some 16 weeks, which had resulted in a generalised shedding of the skin with mild lead intoxication. This was considered to be very rare as cutaneous absorption of non-volatile lead compounds was thought to be minimal until this case was reported.
Some medical mistakes
Accidents can happen anywhere, and every year drug errors even occur in hospitals for a multitude of reasons: drugs are administered by the wrong route or not prepared correctly before administration; the dose may be wrong; even similar looking packaging and similar sounding names can cause errors.
In January 2001, a young man who had received some 18 months of treatment for leukaemia and whose cancer was now considered to be in remission was given an injection of vincristine, a potent anti-cancer drug, to complete his course of treatment, but unfortunately it was injected by the wrong route. The drug should have been injected intravenously, but it was injected intrathecally instead – directly into the spinal fluid, even though the syringe was clearly labelled that it should never be injected by that route. Although the error was realised within minutes of the injection being given, it was too late. There was nothing that could be done to save this patient’s life. The injection led to an agonising creeping paralysis, with multiple organ failure, until the young man eventually died a month later. Sadly this traumatic incident was not unique; there had been at least 13 similar cases since 1985, all which had left patients either dead or permanently paralysed.
Drugs are frequently added to bags of intravenous fluids, such as those containing half or one litre of normal saline – that is, an isotonic solution of sodium chloride (ordinary salt) in water. This method is chosen so that any added drugs will be delivered slowly to the patient, and in dilute solution, over a period of several hours. However, if the bag of saline is not manipulated after the addition to ensure that the added drug is thoroughly mixed throughout the saline, the patient may receive the added drug in too concentrated a form. One nurse was seen to inject a concentrated solution of the antibiotic vancomycin into a patient’s infusion bag of saline and not mix it in. Fortunately someone else noticed and fixed the problem, but if this error had gone unnoticed the patient would have received this antibiotic far too rapidly, which could have caused shock and even cardiac arrest.
In 1997, a man died when the anticonvulsant syrup that he should have been given to swallow was injected into him instead. There was even a case where a nurse tried to administer Calpol, the well-known children’s paracetamol medicine, intravenously. Fortunately this was spotted in the intravenous-drip tubing before it entered the child’s bloodstream.
Medical mistakes are not a new problem. There have been many incidents, in the past as well as in more recent years, of fatal errors, and no doubt many mistakes have caused death without anyone ever realising. But sometimes, the mistake is well known: in the churchyard at Hillswick on Shetland is a gravestone carrying the following epitaph:
Donald Robertson.
Born 14th January 1785, died 4th June 1848.
He was a peaceful quiet man,
and to all appearances a sincere Christian.
His death was much regretted,
which was caused by the stupidity of Laurence Tulloch,
who sold him nitre instead of epsom salts
by which he was killed in the space of five hours
after taking a dose of it.
Nitre was the old name for potassium nitrate, which was used in very small doses as a diuretic over 80 years ago, while Epsom Salts are magnesium sulphate, and are used in much larger doses as a laxative. The poor man probably died of heart failure.
A massive arsenic overdose
Sometimes doctors get carried away with a treatment. In 1961, a 28-year-old woman was the victim of an acute and fatal poisoning due to arsenic. Her doctor was treating her for a resistant vaginal infection caused by an organism called trichomonas, a sexually transmitted disease. Other than this infection, she was perfectly healthy when they took her to the operating theatre to administer a general anaesthetic, prior to packing her vagina with no less than 18 acetarsol vaginal tablets.
This arsenic-containing drug had been used for many years by the hospital without any serious problems. The usual starting dose was between one and four vaginal tablets, which were inserted twice a day for the first few days and then at lengthening intervals for a period of up to two months. Why 18 were inserted to start this unlucky woman’s treatment, we do not know.
By the next day, the poor lady was very ill, so the medical team gave her some chlorpromazine, a major tranquilliser which is also an anti-nauseant. On the third day, they inserted a further 12 of the vaginal tablets, making 30 in total, containing some seven grams of arsenic. The last 12 were inserted without the benefit of an anaesthetic, as the doctors were of the opinion that her illness might have been due to the earlier anaesthetic.
On the fourth day, she had a fit, her pulse was rapid and she appeared to be confused. The nurses washed out her vagina and found that all the vaginal tablets had been absorbed. She then had several more fits before falling into a coma. Towards the end, somebody finally realised that she was suffering from arsenic poisoning and administered an antidote, but by then it was far, far too late and she died.
Awful handwriting pays the price
Many medical mistakes simply come down to bad penmanship or careless haste. Errors commonly occur because of the position of the decimal point, and milligrams are frequently confused with micrograms. And sometimes, the prescriber’s handwriting is all but illegible.
In 1988, a patient visited his doctor to get his regular prescription for inhalers and tablets, and because he had a chest infection his doctor prescribed an antibiotic as well. Unfortunately this doctor’s writing was so appalling that the pharmacist misread the prescription and dispensed Daonil, a drug taken by diabetics, instead of Amoxil, an antibiotic. The patient suffered irreversible brain damage as a result and was later awarded £139,000 in damages, with the pharmacist to pay 75 per cent and the doctor 25 per cent. This is just one example of many where drug brand names are similar or can be confused due to poor handwriting on the part of the prescriber.
When doctors make a prescribing error, the pharmacist will normally spot the error and then contact the prescriber to sort the problem out. Rarely do such errors go unnoticed and cause harm. However, sometimes errors do slip through. In 1982, a woman suffering from migraines ended up requiring excessive surgery for gangrene in both feet – all because of a prescribing error that was not spotted.
The doctor had written a prescription for Migril tablets to treat the woman’s migraine. These tablets contain ergotamine, one of the ergot alkaloids. Ergotamine is so potent that there is both a daily and a weekly limit to the dose that can be taken. Unfortunately the doctor had incorrectly prescribed a dose that was to be taken several times every day, a dose much higher than the limit.
The pharmacist dispensed the prescription complete with the incorrect dosage instructions, just as the doctor had written, with disastrous results. The lady far exceeded the manufacturer’s recommended maximum dose, and by the time the overdose was discovered, several days later, she had developed gangrene. The owner of the pharmacy was deemed to be 45 per cent at fault and the doctor 55 per cent when the case came to court, and £100,000 damages were awarded to the lady.
In 1995, a handwritten prescription for the angina drug Isordil was misread as Plendil, which is a blood pressure drug. Plendil has a maximum daily dose of ten mg while the dose for Isordil can be up to 120mg when used for angina. The Plendil was dispensed complete with the dosage instructions for Isordil. The resulting overdose resulted in the patient’s death following a massive heart attack. This was a tragedy for the patient’s family, and was followed by some very expensive lawsuits.
In July 2000, the heart drug Amrinone was renamed Inamrinone in the USA. This change was made because the name Amrinone was being confused with Amiodarone, also a heart drug, but an anti-arrhythmic, used for totally different heart problems. There were a number of cases of serious illness, and at least three deaths, due to the confusion caused by these similar names.
Similar errors have occurred with one of the newer non-steroidal anti-inflammatory drugs called Celebrex. Originally the manufacturers had planned to call it Celebra, but this was vetoed due to the similarity with an anti-depressant called Celexa in the USA (fortunately called Cipramil in the UK). So the manufacturers decided on Celebrex instead, and the new drug was duly launched. However, it still caused errors, due to confusion with another quite different drug, an anti-convulsant called Cerebryx, which is used in Canada and the USA. This confusion was somewhat surprising, as this anti-convulsant drug is only available as an injection and Celebrex was a capsule to be swallowed.
Some years ago a woman was taking Plavix, an anti-platelet drug used to prevent future heart attacks. Unfortunately on her admission to hospital, when a doctor asked her what medication she was taking, she got the name wrong and said not Plavix, but Plaxil. There is no drug of this name so the doctor assumed that she meant the similar sounding Paxil, an antidepressant marketed under that name in Canada and the USA. In Britain, this drug has the brand name Seroxat. There followed severe disorientation for this patient, who was given the wrong medication for several days before the mistake was sorted out.
Another instance of error due to similar product names occurred when no less than five women were given injections of a steroid preparation normally used for rheumatic disease and other inflammatory conditions. This was the anti-inflammatory injection Depo-medrone, which was injected into these women in error for another drug, Depo-provera, which is a three-monthly contraceptive injection. Both preparations were long-acting (also called depot) injections, which were administered intramuscularly; both were made by the same company; they were packaged in the same company livery, in the same size of package; even the ampoules enclosed were of identical size. Before administering a drug to a patient, the label must be read – on the box and on the glass ampoule inside – and checked by someone else. Checking afterwards is too late. Some would say that this was an accident waiting to happen.
A doctor of my acquaintance was instructed, very early in his career, to write all his prescriptions in capital letters as his handwriting was so appalling. But his capitals deteriorated rapidly too and within a short space of time they also became virtually illegible. Fortunately, today, most prescriptions are printed out by computer, and pharmacists no longer have to try to second-guess what the doctor has written, apart from the few prescriptions that may be handwritten on emergency home visits.