3rd Edition
If I can ease one life the aching
Or cool one pain
I shall not live in vain
— Emily Dickinson
Medicine in the hands of a fool is poison,
Just as poison becomes medicine in the hands of the wise.
— Giacomo Casanova
3rd Edition
VV PILLAY MD DCL
Chief Department of Analytical Toxicology (Incl. Poison Information Service)
Professor Department of Forensic Medicine and Toxicology Amrita Institute of Medical Sciences and Research Cochin, South India
Jitendar P Vij
Jaypee Brothers Medical Publishers (P) Ltd
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Modern Medical Toxicology (3rd Edition)
© 2005, VV Pillay
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the author and the publisher.
First Edition: 1995
Revised Reprint: 1999
Second Edition: 2001
Reprint: 2003
Third Edition: 2005
9788180615191
Typeset at JPBMP typesetting unit
Printed at Replika Press Pvt. Ltd.
the memory of
my father, Mr PV Pillay
and
my mentor, Prof. ATS Iyengar
7Foreword
With this edition, Modern Medical Toxicology celebrates its 9th year in circulation. When Dr VV Pillay wrote the 1st edition of this book back in 1995, he could not have realised the extent of popularity his book would engender among medical students, faculty and practitioners. MMT has now grown in size, but is still compact enough to be carried in the hand as a handbook.
Although the knowledge of medical toxicology has advanced substantially, the goal of MMT has not changed: to provide useful clinical information on poisons and poisoning to ER physicians, medical students, interns, residents, nurses, pharmacists, and other health care professionals in a concise, complete, and accurate manner. The text continues to cover all the topics expected in a book of this size, with detailed information on corrosives, irritant poisons, neurotoxic agents, cardiovascular drugs and poisons, asphyxiants, and even paediatric and obstetric poisons.
With poisoning cases constituting a significant proportion of hospital admissions, MMT quickly provides information that will help practitioners achieve optimal care. The more specialised the practice of medical toxicology becomes, the more important such information becomes. Specialists as well as generalists must at some time or the other require to quickly access information about various poisons.
The third edition of MMT is the culmination of an arduous but rewarding 10-year enterprise. Every chapter has been updated, and many have, in fact, been completely rewritten. Topics new to this edition include, among others, “Analytical Toxicology” and “Substances of Dependence and Abuse”. Dr Pillay deserves a degree of gratitude that cannot be adequately expressed here, but we know he will feel sufficiently rewarded if his efforts serve your needs.8
I congratulate Dr Pillay for this monumental work, and hope this edition of MMT will serve as an aid to you, compatible with your needs, and worthy of frequent use.
Dr Prem Nair md facp dipab (Gastro)
Medical Director
Amrita Institute of Medical Sciences & Research Centre
Amrita Vishwavidyapeetham (Deemed University)
Cochin, Kerala
Foreword
I deem it a privilege to have been asked to write a foreword to this beautifully written, yet concise textbook Modern Medical Toxicology. Dr VV Pillay, a very popular teacher of Forensic Medicine and Toxicology has definitely proved himself to be a capable author with this maiden venture. Written in lucid style using simple English, the book accomplishes its purpose admirably.
What with the pressure of the present examinations and a host of subjects to study, the student is looking for a book like this which is neither too exhaustive for comprehensive study, nor too small to be a simple guide. The diagrams drawn by the author himself add lustre to the book, as one well conceived diagram can explain a thing better than even a thousand words.
“To learn from books alone is like swimming an uncharted sea, but to learn without books is not going to sea at all”, said Sir William Osler. Dr Pillay's book in my opinion will definitely help the students to learn this rather difficult subject with ease.
References at the end of the chapters enhance the usefulness of the book even to the postgraduate and junior teachers. Textbooks lose their freshness almost immediately after they are published and newer editions are a necessity. This book can be updated easily for future editions.
I wish this beautifully produced book all success that it richly deserves and hope the medical community will be ever grateful to the author.
Dr BM Hegde md frcp (Lond)
frcp (Edin) frcp (Glasg)
facc (USA) ficp (India)
Former Vice Chancellor
Manipal Academy of Higher Education
(a Deemed University)
Manipal, Karnataka
11Preface to the Third Edition
It is nearly 10 years since I first sat down and wrote the first edition of this book, in a fit of intense emotion arising out of my infant daughter's toxic misadventure. Much water (or poison!) has flowed under the bridge since then. In response to the huge success of that initial effort, I have since produced two more books on toxicology, one of them a comprehensive reference work on poisons and poisoning. I have also started a new department of Toxicology in the institute where I am currently working, exclusively dedicated to information resource on poisons, analysis of body fluids of poisoned victims for drugs and toxins, and guidance on all toxicological matters to the doctors and lay public of Kerala State. Plans are afoot to initiate major research projects, and a national Society of Toxicology is being set up to promote the development of this hitherto neglected specialty in India.
In all this, I am grateful to have had the unflagging support and encouragement of all the managing authorities of Amrita Institute of Medical Sciences and Research (AIMS), most particularly the respected Swamijis of Mata Amritanandmayi Math, Dr Prem Nair, the Medical Director of AIMS, Mr Ron Gottsegen, the Administrative Director of AIMS, Mr APS Krishnan, the Vice President of the Math, and Dr DM Vasudevan, the Dean of the AIMS College of Medicine. I owe my thanks also to Mr Sudhakar Jayaram, the General Manager of AIMS and Dr Sanjeev Singh, Medical Administrator of the hospital.
I shall be failing in my duty if I do not acknowledge the invaluable contributions of Dr R Krishnaprasad and Mr RR Rajesh, in helping me set up an analytical toxicological facility of such high standards that we have come in for special praise by Mr Alexander von Hildebrand, the Regional Adviser (Chemical Safety), of the World Health Organisation, Regional Office, New Delhi. In fact, the WHO has been actively supporting the growth 12of our modest department from its very inception, a fact that we gratefully acknowledge.
The third edition of Modern Medical Toxicology (MMT) is a rebirth of sorts for the handbook that started it all for me. It is completely revised, revamped, and refurbished. Every chapter has been extensively modified, some in fact being completely rewritten. References have been updated, new tables have been incorporated, and all obsolete information has been thrown out of the window. Two new chapters are included “Analytical Toxicology” and “Substances of Dependence and Abuse.” All this has been accomplished without substantially increasing the size of the book, nor changing the basic format. I sincerely hope that the users of MMT will continue to find this handbook suited to their needs. Suggestions and criticism are always welcome to further improve the quality of content and presentation in subsequent editions.
In closing I must place on record my eternal gratitude to my wife, Dr Minnie Pillay and my daughter Roshni (the unwitting inspiration!), for their incredible patience in putting up with my obsessive style of working, replete with odd hours and late nights.
And most of all to Her Holiness, Mata Amritanandmayi Devi, for inspiring me to greater heights of success and satisfaction in all my endeavours.
Vijay Vasudev Pillay
13Preface to the First Edition
The desire to write this book originated from a near catastrophic occurrence about three years ago. One evening, my daughter (then aged 8 months) swallowed some cockroach bait accidentally. We rushed her to the hospital where a stomach wash was carried out. Following this, none of the doctors present (including myself) had an inkling as to what further must be done. We did not even know the exact ingredients of the bait that my daughter had swallowed. Though it later transpired that the substance, which happened to be a newly introduced insecticide, while being poisonous to cockroaches was relatively non-toxic to humans, my wife and I spent a sleepless night observing our child's condition with great anxiety.
This incident brought me face to face with the dismal reality of ignorance and apathy on the part of the medical profession in our country in matters relating to poisoning. Though toxicology is today an important part of clinical medicine in the West, it is largely neglected in India. This, despite the well known fact that cases of poisoning constitute a significant proportion of hospital admissions. There is an urgent need for doctors in India as in other Third World countries to realise the importance of toxicology in clinical medicine. This book is a humble contribution towards generating such an interest and towards providing practical guidelines in the treatment of poisoning. Though emphasis is on the clinical and pharmacological aspects, the book nevertheless deals extensively with forensic implications. After all, almost every case of poisoning has medicolegal overtones! Also, while the stress is on important fundamental information on commonly encountered poisons, an attempt has been made to enhance readability by including fascinating trivia (as Accessory Points), and landmark case histories involving the use or misuse of poisonous substances.
I have consulted innumerable journals and treatises for modern concepts in toxicology and have in addition corresponded with all 14major pharmaceutical companies and forensic science laboratories in India for information relating to various aspects. I hope all this has been worthwhile. If this book is found to be genuinely useful by medical students, doctors and all others concerned with toxicological matters, my efforts would have been vindicated. Suggestions and criticism for improving this book (which by no means is flawless) in subsequent editions would be particularly welcome.
Vijay Vasudev Pillay
15Some Opinions on this Book
This is the first book on medical toxicology written by an Indian author. The book has definite overtones of Forensic Toxicology, but the author has done an excellent job by making it concise and lucid…………….. The clinical, pharmacological, and forensic aspects of all types of poisoning have been given due coverage. The author has also taken care to mention the toxicological problems in paediatrics and pregnancy. All chapters are well supported by up to date references……..
The book will not only be popular with medical students but will also serve as a much needed information source for emergency room physicians.
Dr SK Kashyap
(Occupational Health)
Indian Journal of Medical Research
The book under review comes as a whiff of fresh air. It is written by a forensic expert of eminence, and is exclusively devoted to toxicology……. It strives to break established myths and superstitions. The author has shown boldness in treating the subject entirely from a new and fresh angle……. It should adorn the personal library of every one who is interested in toxicology in any way.
Prof Anil Aggrawal
(Forensic Medicine)
Invention Intelligence
16Modern Medical Toxicology is a well brought out handy book that documents adequately, information about poisons. The inclusion of actual cases in the text makes it topical and relevant…….
Prof KP Ganesan
(Medicine)
Journal of Karnataka Medicolegal Society
The author deserves full compliments for presenting data on various chemicals and drugs in a systematic, precise, and lucid manner………. Some of the special features of the book include toxicity rating of poisons, and a comprehensive review of general principles of diagnostic methods and management of poisoning. The inclusion of real life stories makes the book interesting, and the simplicity of language enhances its readability.
Prof Gurumadhva Rao
(Pharmacology)
Manipal Linq.