After listening to my most recent podcast on toxicology an anaesthetist friend reflected that his job essentially involves poisoning people with potent toxins.
He could have made a fine living as a Royal Poisoner in the Middle Ages, except for his soft spot for administering antidotes towards the end of the operation.
Scheming royals traditionally considered that sort of thing a character flaw.
The ancients liked their poisons irreversible. Anyone who accidentally woke up in the recovery room was given a pillow, but not in the modern sense. Let’s call it airway management.
When Therapeutic Guidelines: Toxicology approached me to do a podcast I jumped at the chance.
I had always been fascinated by those Russian spies who could drink enough vodka to kill a bear yet die soon after sipping a cup of tea.
So, imagine my disappointment once I discovered the book was all about managing accidental poisonings rather than being a Soviet instruction manual.
Useful as a GP reference, but as a bedtime read? Very putdownable.
Ancient druids used to take years to learn how to craft a decent poison, but these days multinational companies pump out thousands of ampoules a day. They are called medicines, not poisons of course; but there’s quite an overlap.
My anaesthetist friend probably dishes out more ‘nerve agent’ per year than the KGB. Happily, he is also considerably more likely to follow the product’s safety leaflet instructions.
Getting your hands on a neurotoxin may be easy these days, but imagine all the trouble Socrates’ assassins had to go to 3000 years ago, to bump him off with hemlock.
A full day gathering the white flowers then picking out enough seeds to kill a Greek philosopher (around half the Russian dose).
Grind the seeds, boil them, sieve the sludge with your toga cloth, and remember not to lick your fingers.
No ampoules back then, so the use-by dates were probably rubbish, too.
If you couldn’t slip it into their wine by Sunday drinks at the agora, you’d have to spend all Monday out in the meadows starting again.
By the time of Shakespeare, toxicology had advanced to the point where it started to intersect with Therapeutic Guidelines.
Ophelia’s “long purples” were her foxglove flowers, later described as “dead men’s fingers”, on the riverbank where she died.
Digitalis poisoning didn’t kill Ophelia — she drowned.
And oddly enough, digoxin’s first medicinal use was to stop people ‘drowning’ from massive heart failure.
Coincidence, I ask you?
Well, yes, obviously. Shakespeare was a poet, not an oracle. Not unless someone discovers a missing, rather tedious scene where Hamlet spends all Monday collecting purple flowers and distilling their toxin.
No, he was too busy bumping off Polonius. Possibly with polonium.
The Bard’s most famous poisonous brew was burned and bubbled (twice, apparently) in a witch’s cauldron at the start of Macbeth.
Hemlock makes it into the ingredients list, as does salt-sea shark — a prescient reference to those cartilage-based arthritis products that have proved so lucrative and useless ever since.
None of the other cauldron additives ever made it onto an anaesthetic trolley, at least once the pharmaceutical companies abandoned their phase II trials for eye-of-newt.
Too hard to catch the slippery little blighters. They’d see you coming before you could enucleate them.
The modern toxicology text outlines the management of evenomations from eight-legged spiders to no-legged snakes.
Yet it turns out that by far the most dangerous creature is the two-legged doctor: All drugs are poisons; the devil is in the dosage.
Half of the toxicology information is about therapeutics gone rogue: accidental or deliberate overdosage, pharmaceutical miscalculations or simply the human body doing what we GPs know it does so reliably — buggering up for no apparent reason.
One of my female patients recently clocked an INR of eight, and I have no idea why.
She could have killed a rat by sneezing on it.
My working theory is that someone distilled ‘dicoumarol’ from sweet clover flowers and slipped it into her tea.
The coroner, more pragmatically, might have questioned my warfarin order.
Toxicology guidelines are about trying to mop up the mess. (A quiet vitamin K infusion to get you out of a tight spot).
I like to imagine the mess is created by redback spiders, bluebottle jellyfish and grey-suited Israeli assassins.
But nope…it’s mainly just us.
Plain old doctors, doing our thing, playing with dangerous toys.
This article was first published in Medical Observer, Oct 2020