CHEMICAL HAZARDS IN THE HOME Roy Goulding
CHEMICAL HAZARDS IN THE HOME ROY GOULDING B.Sc M.D. F.R.C.P. Poisons Unit, Guy's Hospital, London 1 What is poisoning? 2 Statistics 3 Particular poisons met in the household a Gases and vapours b Household products c Garden chemicals d Indoor and garden plants e Medicines / "Borrowed" chemicals g Miscellaneous—and alcohol 4 Prevention 5 Conclusion References
1. What is Poisoning? Thousands of children, so it is declared, have to be admitted to hospital every year because of poisoning contracted in the home. The facts require checking and this leads at once to an appraisal of what is meant by "poisoning". By definition, it occurs whenever a living creature—which in this context refers to a man, a woman or a child—is exposed to a toxic material that finds its way into the body by one route or another, i.e., orally, by inhalation, percutaneously or by any other means, so that it reaches the tissues and damages them structurally or functionally, giving rise to illness or, in extreme cases, death. There must be interference with health or life (Loomis, 1968). Obviously this takes place when, say, someone in an atmosphere of excessive carbon monoxide develops carboxyhaemoglobinaemia with ensuing tissue anoxia. Similarly, if a corrosive substance like formic acid is swallowed there may be ulceration of the mouth, pharynx and oesophagus and, further, there may be acute erosion of the gastric mucosa and perforation of the stomach. Ultimately, cicatrization and stenosis of the upper alimentary tract may ensue. On the other hand, a mouthful of detergent may provoke little more than frothing of the mouth, while the ingestion of a dozen or so fluoride tablets supplied as prophylaxis against dental decay may be totally asymptomatic. In the exercise of medical assessment, therefore, a distinction must be made between "poisoning", which may truly endanger the patient, and "suspected poisoning", or what might be described as "inappropriate ingestion", which is followed by no physical sequelae. The one type of incident calls for prompt and adequate medical intervention, while the other demands no more than confirmation or reassurance. This is not to belittle all the anxiety and alarm that is occasioned whenever poisoning is believed to have come about, but whether it is then excusable to subject the patient to remedial measures, which may be unnecessary, or to commit the patient to a night or more in hospital is doubtful.
Never before in the history of the world has there been such a zest for synthesizing entirely new chemical compounds as that evinced in this second half of the twentieth century. The claim has been made that "More than a million carbon compounds, both natural and synthetic, are known, but billions are possible and the universe probably harbors billions" (Lemmon & Erwin, 1975). What is more, to judge from Chemical Abstracts, some 200000 new compounds, inorganic and organic, are catalogued every year. Yet, no matter how impeccably these substances may be characterized in physicochemical terms, such characterization gives no clue necessarily to their biological activity or toxicity. Since a few of them have been revealed as demonstrably noxious, it is not surprising that all of them have fallen under this suspicion. Such fears have been inflamed by the play of the publicists upon ignorance and, in this way, the numerous chemicals that have been incorporated into the various products widely and advantageously used in the home and elsewhere have been haphazardly identified with all manner of destructive and lethal attributes. A moment's reflection, however, will serve as a reminder that chemical hazards in the home are not a phenomenon confined exclusively to modern times. Until fairly recently, spirits of salt (hydrochloric acid) and lye (caustic soda) were favoured domesticrequisitesfor cleaning lavatories and drains. The household disinfectants were principally of the phenolic type, corrosive sublimate (mercuric chloride) was common as an antiseptic, yellow phosphorus was the preferred rat poison, arsenicals and chlorates figured among the weed-killers, fluoride baits were laid for rodents and cockroaches, thallium was commonly employed to eliminate ants, nicotine was painted on the perches in chicken houses to destroy lice, camphor was the everyday moth suppressant and, among the medicines, digitalis, castor oil, quinine, ergot and quite powerful analgesics abounded. A household in the first half of the twentieth century could thus be a veritable Borgian armoury. Small children then were surely little different in their habits from those of today, so the risk of their gaining access to any
2. Statistics In England and Wales at least, figures have been assembled by which the true incidence of both morbidity and mortality from poisoning can be viewed with some accuracy. The Hospital In-Patient Enquiry conducted jointly by the Office of Population Censuses and Surveys and the Department of Health and Social Security indicates the number of patients admitted to hospital under various diagnostic headings (Keith, 1973). The annual total of admissions for poisoning has risen progressively from 15900 in 1957 to no less than 99800 in 1971 191
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of these highly toxic materials must have been quite high. Yet poisoning from chemicals in the home attracted very little attention and was given scant space in the medical text-books of those days. Perhaps this was because the casualties from this cause were numerically insignificant when compared with the illness and death overtaking the young from trauma and infections. Today, by contrast, the dangers to which children are supposed to be subjected by reason of chemicals make headlines in newspapers and occupy no small part of television screen time. Politicians, too, rampage on this theme and, with appeals more to the emotions than to the facts, champion statutory measures designed to eliminate hazards that still remain properly to be assessed.
CHEMICAL HAZARDS IN THE HOME Roy Goulding bution, extending to 2 % for medicines and 1 % for other chemicals, compared with 35 % from suffocation, 25 % from road accidents, 10% from drowning and 10% from fires (Backett, 1965; Medicines Commission, 1974). While notreflectingthe incidence epidemiologically over the whole country, the records of the National Poisons Information Service are similarly illuminating (R, Goulding, unpublished work). Out of a total of 19133 calls handled at the London centre during 1974, 9919 were queries about medicines and 5738 concerned household products and cosmetics. The remainder were related to supposedly poisonous plants, insect bites, agricultural pesticides, industrial chemicals and a small, ill-defined, miscellaneous group. A follow-up pursued with the doctors initiating the calls yielded a record of 97 deaths, only 10 of which were due to misuse of household products, a gross overdose being taken deliberately by an adult in every instance. 3. Particular Poisons Met in the Household a. Gases and Vapours
Gases, e.g. refrigerants, combustibles like propane, utilized in household equipment may leak into the atmosphere, but these happenings in Great Britain are rare and it is a tribute to the precautions taken in manufacture that the containers so seldom lose their integrity. Vapours may also accumulate from cleaning agents, e.g. perchloroethylenes, or from paints and sprays, e.g. various organic esters, causing drowsiness or even collapse. This, however, is most unusual. The ubiquitous aerosol packsreleasehalogenated hydrocarbons that can have a definite effect on the central nervous system and heart, not so much in the ordinary course of usage as in the deliberate exploitation of this property, usually by young people intent upon getting "high". Fatalities in this connexion more often come about when a plastic bag is improvised for rebreathing and asphyxia also overtakes the subject (Verhulst & Grotty, 1964; Merry, 1967; O'Brien, Yeoman & Hobby, 1971; Aviado, 1975). Some concern has been voiced about the choice of carbon tetrachloride as the active ingredient in dry-cleaning preparations for use in the home. Even following a minimal degree of exposure, liver damage1, sometimes progressive, has been reported. Extremely few cases of this type have been confirmed in Great Britain, but, as a gesture of public health policy, carbon tetrachloride has now been abandoned for this purpose and the negligibly toxic perchloroethylenes are used instead. Putting aside these exceptional hazards, by far the most troublesome of the gases within the home is still carbon monoxide2. So long as it remained a major constituent of "town gas" (coal gas), it was the cause of many deaths, some intentional and many accidental. Old people with advancing anosmia characteristically fell victim to an unignited supply which they could not detect by smell. With the progressive substitution of natural, or North sea, gas for that derived from coal, the deaths so ascribable have fallen dramatically, from 4033 in 1963 to 1263 in 1971—an unintended bonus from a technological advance. Whether this trend will continue to zero is, however, 1 See Judah, Br. Med. Bull. 1969, 25, 274-277.—ED. 3 See Lawther, pp. 256-260 of thi» Bulletin.—ED.
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(Goulding, 1974). The majority of these patients were adults, most of whom had resorted to deliberate self-poisoning, principally by drug overdose. Children under five years of age, however, accounted for 7400 in 1964, advancing to 16500 in 1969, thereafter fluctuating annually around 15700 and 16700 (Medicines Commission, 1974). One might reasonably conclude that these youngsters, especially as all but a relatively small proportion of them are under three years of age, would not be far from home and that whatever afflicted them toxicologically would most likely have been encountered within the domestic purlieu. This fact prompts closer scrutiny into the nature of the agents responsible. By far the largest number of cases resulted from the misuse of analgesics, mainly aspirin, followed by psychotherapeutic agents and, conspicuously, the barbiturates. Gases and noxious food-stuffs are prominent as causes of poisoning, but other non-medicinal agents are credited with a much larger figure, of the same order as analgesics. So, in general, it may be said that more than half the children taken into hospital nowadays for poisoning have consumed drugs or medicines, and somewhat fewer have been in contact with household products. This represents a heavy load upon the medical services. Further probing, however, discloses that the average length of stay in hospital of each of these children is today as little as 1.4 days, whereas it was 3.3 days in 1964. Expressed in another way, 85 % of these children are currently discharged after just one night, or less, in hospital. There is little evidence to suggest that this state of affairs can be attributed to the promptness and enhanced efficacy of treatment. Rather is the implication that, in the present social atmosphere, people—above all parents and doctors—are poisons-conscious. In previous years a decision about the seriousness or otherwise of an incident would be taken by the mother or father or, at the most, by the general practitioner—if not by the local pharmacist! At the present time anxiety generated by the oft-repeated universal warnings dictates that every child in this predicament should be rushed to hospital where, commonly, caution rules that admission to the ward would be prudent, if only "for observation". Supporting this interpretation are the findings from a survey conducted in Bristol by the Health Education Council's Medical Research Division (Calnan, 1974). This covered 23457 children over about 48000 child-years. During that period 163 children under 15 years of age were seen at hospital because of so-called "poisoning", equally from prescribed medicines, non-prescribed medicines and household products. None died and less than a third of them proclaimed any symptoms at all. Again, the inference is inescapable that the incidence of poisoning, in the exact sense of that diagnosis, and its severity in children are likely to be grossly exaggerated. The mortality figures tend to confirm this. According to the Statistical Reviews published by the Registrar General, the number of children in Great Britain dying from poisoning approaches 200 each year. Of these, between 100 and 150 are overcome by carbon monoxide in some form or another, not necessarily by coal gas itself, but frequently as an atmospheric contaminant liberated by, e.g., ill-functioning oilstoves, or from actual conflagrations in the home. The remaining 50 children are poisoned mainly by analgesics, notably aspirin, followed by psychotrophic drugs and oral iron preparations. Non-medicinal causes of fatal poisoning in children are few. Measured against the total mortality of children under 5 years of age, poisoning offers an almost insignificant contri-
CHEMICAL HAZARDS IN THE HOME Roy Goulding labelled accordingly. Yet the assailing voices are not silenced and the clamouring continues for yet more warning labels, the wide-spread adoption of ostensibly "child-resistant" containers and all manner of other deterrents, firmly backed by ordinances and statutory enforcement. Worse still is the tendency evident in other countries—on the continent of Europe generally and under the aegis of the European Economic Community in particular—to fashion elaborate mathematical formulae by which the practical hazards can, it is assumed, be calculated from the composition of the product. According to this practice there will be a toxicity classification to regulate sale, supply, packaging, and so on, regardless of the fact that objective and exactingfield-workmay have demonstrated that this is unnecessary.
b. Household Products
c. Garden Chemicals
Chemicals that are recognized as poisonous and which find their way on to the market, either in the unsophisticated state or admixed into products, may be listed and scheduled under the Poisons Act 1972, in which event control and restraint may be statutorily exercised over their sale, supply, storage, packaging and labelling. Thus, formic acid as a kettle descaler and phenol as a disinfectant may come into this category. By this means, the more noxious of the household products may be recognized as such and treated with care and respect. Significantly, perhaps, most household products are without these restrictions. They are, in fact, lacking in appreciable intrinsic toxicity. Yet if one examines the detailed composition of many of these wares, refers to the published data on animal toxicity of the separate constituents and, by a process of extrapolation, estimates the toxicity to man, then the resulting calculation can prove quite startling toxicologically. It was along these lines that work proceeded in 1962, when the first index was compiled for the National Poisons Information Service, and the conclusions thus reached theoretically at the desk pointed assuredly to the dangers attendant upon these products in the home. Bleach, for example, suggested itself as a menace, as did the different caustic oven cleaners, many of the detergents designed for dish-washing machines, certain of the polishes and, indeed, a number of the paints and varnishes on ready sale from the "do-it-yourself" stores. Appraising these data uncritically and, presumably, drawing the same "arm-chair" conclusions, the more vociferous of the politicians and agitators can be excused for the rousing campaigns which they inspire or lead, to warn us and protect us from these supposed chemical hazards in the home. Regrettably they probe the facts no further. Over the years 1963 to 1967 inclusive, all 10000 or so inquiries of this nature channelled through the London centre of the National Poisons Information Service were followed up by an inquiry letter to the doctor initiating each call. Validated cases of injury, or disability, from this source amounted to no more than about 25 %, taking into account even the mildest of symptoms, while the deaths under this heading were 14, the majority of them being due to deliberate, if misguided, ingestion among adults rather than to accidental swallowing by children. In short, then, experience has demonstrated that, so far as the UK is concerned, the general run of chemical requisites in the home is innocuous and only a small minority poses any real risk (Goulding & Watkin, 1965; Goulding, 1970). Most of the dangerous ones, moreover, as already mentioned, are recognized under the Poisons Act 1972 and are
Chemical pesticides, many of them being undeniably toxic, that are purveyed expressly for the furtherance of commercial agriculture or horticulture are subject to rigid, if voluntary, control in Great Britain, by a scheme to which industry and government jointly subscribe and which is administered by the Ministry of Agriculture, Fisheries and Food. In so doing there is a corresponding check on the similar pesticides authorized for what is called "home garden use". Except by transgression, these are the only pesticides that should find their way into the ordinary household and, as such, they are all of comparatively low toxicity. Again, through the National Poisons Information Service, it has been shown that the handling of, exposure to and ingestion of these products have very seldom been accompanied by any toxic reactions—apart from a few cases in which adults have wilfully devoured excessive quantities, being intent, if not upon suicide, then certainly upon self-inflicted injury whilst in a disturbed state of mind. Related to the garden pesticides are the domestic fumigants, wood preservatives, rodenticides and such-like requisites. Over some, but not all, of these, an official regulation is exercised. Again, mishaps with them are remarkably exceptional. Many of the insecticides vouchsafed in this way are put up as aerosols, from which it is virtually impossible in ordinary practice to derive a toxic dose—apart from the exploitation of these devices, to which attention has been drawn in section 3a, and which provide a convenient, cheap and un. restricted device for "sniffing". Several of such casualties have come to light. Another object of contention has been the vaporizer, in which a solid-absorbent base is impregnated with an insecticide, commonly of the organophosphorus type, which is gradually evaporated over weeks or months, setting up in the vicinity a chemical atmosphere that is inimical to many forms of hexapod pests. Fears have been expressed that, at the concentration commonly prevailing, human beings might thereby be endangered and, in any event, domestic pets might suffer. Anecdotal reports abound in support of these complaints, and there has been considerable agitation by sections of the press, both lay and para-scientific, the move for which appears to be prompted more by an urge for sensation than a due regard to the facts. Wherever searching and objective studies have been undertaken in domestic and similar environments the findings have firmly indicated that the highest concentrations of chemical reached are below the hazardous threshold, there having been no departure from normal in a wide range of health parameters recorded (Cavagna, Locati & Vigliani, 1969, 1970; Leary et at. 1974). At the same time, probing at 193
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doubtful. Wherever, for lighting or heating, a combustion system exists in the home that is based upon carbon or hydrocarbon and is dependent upon an adequacy of atmospheric oxygen, there is always a risk that the ventilation will prove inadequate or imperfect. The resulting incomplete combustion leads to an accumulation of carbon monoxide from the effects of which coma and death can supervene insidiously. Particularly may this be a hazard for people occupying unsatisfactory accommodation, above all in caravans. Ominously, recent reports indicate that fatalities in these circumstances are actually increasing (Alphey & Leach, 1974). Likewise adjacent to, if not actually within, the home may be the internal combustion engine that is allowed to run in an enclosed garage, the carbon monoxide then reaching lethal levels.
CHEMICAL HAZARDS IN THE HOME Roy Goulding
d. Indoor and Garden Plants There appears to be a popular assumption that poisonous plants, if not abounding, certainly exist in Great Britain to a significant extent. The walls of doctors' waiting rooms are not infrequently ornamented by colourful posters ominously depicting poisonous species. Yet after 11 years of operating the National Poisons Information Service, during which time
there have been some 11000 inquiries under this heading, none of them has been attended by any serious illness and less still any deaths, with the exception of one fatality from Amanita phalloides in a patient from Guernsey (Standring & Goulding, 1969). What is more, the plants actually within the home—the creepers, the ornamental plants and the rest of contemporary collections—have declared themselves as harmless, apart, possibly, from sensitization reactions from the Primula species. Mistletoe berries, said to be a favourite dish with youngsters about Christmas time, cause little more than a mild loosening of the bowels, notwithstanding the horrifying references in the text-books to the toxins said to be contained therein; and the inviting fruits of the Solanumpseudocapsicum, or winter cherry, also much to the taste of small children, have proved almost totally innocuous. e. Medicines In impressive contrast to the foregoing, the major chemical hazard in virtually every home is the stock of medicines which most people are reluctant to throw away, even when they are no longer required. These encompass both those prescribed by the doctor and, equally, those bought without prescription. Dunnell & Cartwright (1972) in a most revealing survey have demonstrated the immense hoards of medicines in a representative sample of households and many of these are in the attractive form of coloured capsules and tablets, frequently sugar-coated. It must be admitted that these must be voluntarily sought out and consumed, if harm is to ensue. Characteristically these medicines exist in quantities in excess of lethal doses, and are loosely packed in containers with simple and easily manipulated screw, or lift-off, tops. Tragedies consequently ensue in two distinct categories. Modern society is populated by an inordinate number of people mentally depressed, anxious and dejected. Naturally they seek help from their doctors. All too often a time-consuming psychiatric interview yields precedence to the much more deft prescribing of some psychotrophic drug—sedative, hypnotic, tranquillizer, or antidepressant, and commonly the total quantity ordered is in excess of the amount that, on a single occasion, will kill. Approaching 50 million such prescriptions are issued each year in Great Britain (Parish, 1971). Not surprisingly, in those patients for whom these vicarious aids to psychological wellbeing fail to have a prompt effect the temptation to indulge in an overdose, either with determined suicidal intent or simply as a gesture, is too much to resist. No wonder, then, that many unfortunate patients to whomreferencehas already been made in section 2, who have capitulated in this way, are admitted to the hospitals of Great Britain every year. Secondly, these same medicines are irresistible to young children, notably those between the ages of one and three years. This is the stage of human development during which curiosity is paramount and when the environment is explored, above all, orally. Everything within reach is put into the mouth. When the objects of this prying are the common run of household requisites or plants, then, as already explained, calamity seldom ensues. When, on the other hand, medicines are devoured, the outcome can be much more terrifying. Though vitamin capsules or contraceptive pills can be taken by the dozen without ill effect, the majority of medicines are far from harmless. Relatively small doses of hypnotics, antidepressants and aspirin can kill. Fortunately, as tho figures quoted in section 2 make clear, the total mortality rate is low. In England and Wales, of approximately 16000 children
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an experimental level continues, particularly in the demonstration of the alkylating capacity of dichlorovos, the organophosphorus compound employed in so many of these devices, with the implication that this activity, seen both in bacteria and in laboratory mammals, may betoken mutagenic potential for man (Lawley, Shah & Orr, 1974; Lofroth & Wennerberg, 1974; Wennerberg & Lofroth, 1974). Among the wood preservatives, the traditional creosote still enjoys wide popularity. Fortunately, considering its high oral toxicity, few people, adult or child, seem to be induced to drink it. On the skin, however, it can prove extremely irritant, in the vaporous as well as in the liquid form, and above all where the ambient temperature is high. This is not always recognized and precautions can easily be neglected. Creosote derivatives, particularly pentachlorophenol, are more favoured by commercial firms carrying out wood-preserving operations under contract, and this type of chemical is now also to be found in many domestic, wood-preserving preparations. Pentachlorophenol may uncouple oxidative phosphorylation in the tissues and lead to a hypermetabolic state, characterized by weakness, sweating, hyperpyrexia, dyspnoea, exhaustion and collapse (Department of Health and Social Security, 1969). Incidents coming about in this way, some of them fatal, have been reported from various parts of the world, almost entirely in the commercial context (Deichmann & Keplinger, 1963). Domestically, accidents of this kind are most uncommon, though some years ago a child was diagnosed as suffering from pentachlorophenol poisoning, the child having bathed a number of times in, and so absorbed percutaneously, the pentachlorophenol which had found its way into the cold water storage tank of the house after treatment of the roof rafters above it (Chapman & Robson, 1965). The risk, moreover, is greater where the climate is hotter (Bevenue, Haley & Klemmer, 1967). Finally under this heading it needs to be borne in mind that while some vicious rodenticides are still sometimes employed —for example, fluoroacetates, yellow phosphorus and thallium—these are permitted solely in specified industrial surroundings, where their handling can be entrusted to trained and experienced operators. In ordinary residences, the only baits authorized for use against rats and mice are much more benign and comprise anticoagulants like warfarin and stupefying agents such as chloralose. Their efficacy relies on re- , peated ingestion. Adults are unlikely so to regale themselves, whilst children, if tempted, generally consume only a small, single helping. No validated cases of domestic rodenticide poisoning have been recorded in Great Britain over the past 15 years. However, a case has been reported in which some children, espying some sponge cake in the back of an unlocked car, stole and ate portions of it. What they did not know was that the car belonged to a rat-catcher and that the cake was baited with chloralose. Sufficient was devoured for the young thieves subsequently to become stuporous, but they all recovered quickly without treatment and without any lasting stigmata.
CHEMICAL HAZARDS IN THE HOME Roy Goulding son to believe that poisoning, even in the long term, can overtake the community in this way. Old houses and buildings of a previous age nevertheless exist with coatings of old leadcontaining paints4, whereas the newer types of paint manufactured over the past few decades have, with few exceptions, a much lower content of this metal. Children with a persistent habit of chewing, characteristically those with pica, may over the course of months swallow so much of this old paint that lead poisoning besets them. Finally, while regarded generally as a form of sustenance and delight, there is little denying that alcohol stillfiguresas a toxic chemical hazard in many homes, for adults and children alike.
/. "Borrowed" Chemicals Reasonably, in industry, as in commercial agriculture and horticulture, quite powerful chemicals are employed. The injuries to which workers are thereby exposed are, in the main, recognized beforehand, so that the appropriate precautions and protective measures are adopted and, so far as possible, enforced. So useful are these materials found to be, so difficult to obtain by the ordinary citizen, and, more impressively, so expensive to buy, that the urge to "borrow" them surreptitiously for a job in the home cannot always be suppressed. To be purloined in this way, they must commonly be transferred to a small, easily concealed and unlabelled container. About the home, carelessness leads to such chemicals being left conveniently within reach of the prying child. A small amount then unwittingly put into the mouth can be catastrophic. Many of the poisonings from the herbicide paraquat and from the paint-stripper methylene chloride have come about in this manner. Once more this is an example of a chemical hazard in the home which, by the manner of its perpetration, verges on the culpable.
4. Prevention Over-all, the most effective policy to avert poisoning in the home is to avoid the presence therein of toxic materials. This is a principle to which both industry, in enlightened self-interest, and government, by regulatory measures, are pledged. By continuing and reinforcing these attitudes, the present pattern of a relatively low incidence of household poisoning is most likely to be maintained. The conspicuous blemish on thisotherwise highly creditable record is created by the medicines. The danger therein to children would surely be minimized by the more universal adoption of child-resistant containers, preferably of the strip-pack type. To attack the gross misuse of medicines for self-poisoning in adults calls for a major sociopsychological operation that is as challenging as it is daunting. 5. Conclusion Toxicologically, the danger of chemicals in the home has probably received inordinate and disproportionate attention and publicity, much of it emotively presented. Medicines and drugs nevertheless still present as the major poisoning hazard, as well as carbon monoxide from various sources. By definition, chemicals could also be perilous through fire or explosion but, pyrotechnics apart, this seems to be no great problem.
g. Miscellaneous—and Alcohol
Chemicals, albeit in trace amounts, find their way into the modern diet as food additives3. Most countries regulate this usage in the processing and preparation of food by statutory measures, backed by expert advice. There is little sound rea* See Lloyd & Drake, pp. 214-219 of thi» Bulletin.—ED.
« See Clayton, pp. 236-240 of this Bulletin.—ED.
REFERENCES
Alphey, R. S. & Leach, S. J. (1974) Accidental death in the home (Building Research Establishment Current Paper no. 98/74). Department of the Environment, London Aviado, D. M. (1975) Toxicology, 3, 321-332 Backett, E. M. (1965) Public Health Pap. World Health Organ. no. 26 Bcvenue, A., Haley, T. J. & Klemmer, H. W. (1967) Bull. Environ. Contam. Toxicol. 2, 293-2% Calnan, M. W. (1974) Community Health, 6, 91-101 Cavagna, G., Locati, G. & Vigliani, E. C. (1969) Arch. Environ. Health, 19, 112-123 Cavagna, G., Locati, G. & Vigliani, E. C. (1970) Eur. J. Toxicol. 3,49-57 Chapman, J. B. & Robson, P. (1965) Lancet, 1, 1266-1267 Deichmann, W. B. & Keplinger, M. L. (1963) In: Patty, F. A., ed. Industrial hygiene and toxicology, 2nd revised ed. Vol. II: Toxicology, pp. 1396-1402. Wiley-Interscience, New York & London Department of Health and Social Security (1969) Poisonous chemicals used on farms and gardens: notes for the guidance of medical practitioners. HMSO, London Dunndl, K. & Cartwright, A. (1972) Medicine takers, prescribers and hoarders. Routledge & Kegan Paul, London Goulding, R. (1970) Health Trends, 2, 86-87 Goulding, R. (1974) In: Boyland.E. & Goulding, R.,ed. Modern trends in toxicology—2, pp. 4-5. Butterworths, London
Goulding, R. & Watkin, R. R. (1965) Mon. Bull. Minist. Health, 24, 26-32 Keith, S. (1973) Health Trends, 5, 13-14 Lawley, P. D., Shah, S. A. & Orr, D. J. (1974) Chem.-Biol. Interactions, 8, 171-182 Leary, J. S. et al. (1974) Arch. Environ. Health, 29, 308-314 Lemmon, R. M. & Erwin, W. R. (1975) 5c/. Am. 232, no. 1, pp. 72-79 Lofroth, G. & Wennerberg, R. (1974) Z. Naturforsch. 29, 651 Loomis, T. A. (1968) Essentials of toxicology, pp. 1-12. Kimpton, London Medicines Commission (1974) Report on the presentation of medicines in relation to child safety. Department of Health and Social Security, London Merry, J. (1967) Br. Med. J. 2, 360 O'Brien, E. T., Yeoman, W. B. & Hobby, J. A. E. (1971) Br. Med. J. 2, 29-30 Parish, P. A. (1971) The prescribing of psychotropic drugs in general practice (J. R. Coll. Gen. Pract., vol. 21, suppl. no. 4). Royal College of General Practitioners, London Standring, G. & Goulding, R. (1969) Nurs. Times, August 7 issue, pp.1009-1011 Verhulst, H. L. & Grotty, J. J. (1964) Natl. Clgh. Poison Control Cent. Bull, February-March issue and July-August issue Wennerberg, R. & Lofroth, G. (1974) Chem.-Biol. Interactions, 8,339-348
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admitted to hospital annually with an overdose of medicines, only some 23, on an average, succumb and most of these owe their fate to aspirin. Every one of these deaths is unnecessary and, one might suppose, avoidable. In short, the principal chemical hazard in the home during this latter half of the twentieth century is unquestionably the conserved, but improperly stored, medicine. In passing, the comment might be made that the corresponding veterinary medicaments, purchased in no small quantities for the welfare of domestic pets, are reassuringly of low toxicity.
CHEMICAL HAZARDS IN THE HOME ROY GOULDING B.Sc M.D. F.R.C.P. Poisons Unit, Guy's Hospital, London 1 What is poisoning? 2 Statistics 3 Particular poisons met in the household a Gases and vapours b Household products c Garden chemicals d Indoor and garden plants e Medicines / "Borrowed" chemicals g Miscellaneous—and alcohol 4 Prevention 5 Conclusion References
1. What is Poisoning? Thousands of children, so it is declared, have to be admitted to hospital every year because of poisoning contracted in the home. The facts require checking and this leads at once to an appraisal of what is meant by "poisoning". By definition, it occurs whenever a living creature—which in this context refers to a man, a woman or a child—is exposed to a toxic material that finds its way into the body by one route or another, i.e., orally, by inhalation, percutaneously or by any other means, so that it reaches the tissues and damages them structurally or functionally, giving rise to illness or, in extreme cases, death. There must be interference with health or life (Loomis, 1968). Obviously this takes place when, say, someone in an atmosphere of excessive carbon monoxide develops carboxyhaemoglobinaemia with ensuing tissue anoxia. Similarly, if a corrosive substance like formic acid is swallowed there may be ulceration of the mouth, pharynx and oesophagus and, further, there may be acute erosion of the gastric mucosa and perforation of the stomach. Ultimately, cicatrization and stenosis of the upper alimentary tract may ensue. On the other hand, a mouthful of detergent may provoke little more than frothing of the mouth, while the ingestion of a dozen or so fluoride tablets supplied as prophylaxis against dental decay may be totally asymptomatic. In the exercise of medical assessment, therefore, a distinction must be made between "poisoning", which may truly endanger the patient, and "suspected poisoning", or what might be described as "inappropriate ingestion", which is followed by no physical sequelae. The one type of incident calls for prompt and adequate medical intervention, while the other demands no more than confirmation or reassurance. This is not to belittle all the anxiety and alarm that is occasioned whenever poisoning is believed to have come about, but whether it is then excusable to subject the patient to remedial measures, which may be unnecessary, or to commit the patient to a night or more in hospital is doubtful.
Never before in the history of the world has there been such a zest for synthesizing entirely new chemical compounds as that evinced in this second half of the twentieth century. The claim has been made that "More than a million carbon compounds, both natural and synthetic, are known, but billions are possible and the universe probably harbors billions" (Lemmon & Erwin, 1975). What is more, to judge from Chemical Abstracts, some 200000 new compounds, inorganic and organic, are catalogued every year. Yet, no matter how impeccably these substances may be characterized in physicochemical terms, such characterization gives no clue necessarily to their biological activity or toxicity. Since a few of them have been revealed as demonstrably noxious, it is not surprising that all of them have fallen under this suspicion. Such fears have been inflamed by the play of the publicists upon ignorance and, in this way, the numerous chemicals that have been incorporated into the various products widely and advantageously used in the home and elsewhere have been haphazardly identified with all manner of destructive and lethal attributes. A moment's reflection, however, will serve as a reminder that chemical hazards in the home are not a phenomenon confined exclusively to modern times. Until fairly recently, spirits of salt (hydrochloric acid) and lye (caustic soda) were favoured domesticrequisitesfor cleaning lavatories and drains. The household disinfectants were principally of the phenolic type, corrosive sublimate (mercuric chloride) was common as an antiseptic, yellow phosphorus was the preferred rat poison, arsenicals and chlorates figured among the weed-killers, fluoride baits were laid for rodents and cockroaches, thallium was commonly employed to eliminate ants, nicotine was painted on the perches in chicken houses to destroy lice, camphor was the everyday moth suppressant and, among the medicines, digitalis, castor oil, quinine, ergot and quite powerful analgesics abounded. A household in the first half of the twentieth century could thus be a veritable Borgian armoury. Small children then were surely little different in their habits from those of today, so the risk of their gaining access to any
2. Statistics In England and Wales at least, figures have been assembled by which the true incidence of both morbidity and mortality from poisoning can be viewed with some accuracy. The Hospital In-Patient Enquiry conducted jointly by the Office of Population Censuses and Surveys and the Department of Health and Social Security indicates the number of patients admitted to hospital under various diagnostic headings (Keith, 1973). The annual total of admissions for poisoning has risen progressively from 15900 in 1957 to no less than 99800 in 1971 191
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of these highly toxic materials must have been quite high. Yet poisoning from chemicals in the home attracted very little attention and was given scant space in the medical text-books of those days. Perhaps this was because the casualties from this cause were numerically insignificant when compared with the illness and death overtaking the young from trauma and infections. Today, by contrast, the dangers to which children are supposed to be subjected by reason of chemicals make headlines in newspapers and occupy no small part of television screen time. Politicians, too, rampage on this theme and, with appeals more to the emotions than to the facts, champion statutory measures designed to eliminate hazards that still remain properly to be assessed.
CHEMICAL HAZARDS IN THE HOME Roy Goulding bution, extending to 2 % for medicines and 1 % for other chemicals, compared with 35 % from suffocation, 25 % from road accidents, 10% from drowning and 10% from fires (Backett, 1965; Medicines Commission, 1974). While notreflectingthe incidence epidemiologically over the whole country, the records of the National Poisons Information Service are similarly illuminating (R, Goulding, unpublished work). Out of a total of 19133 calls handled at the London centre during 1974, 9919 were queries about medicines and 5738 concerned household products and cosmetics. The remainder were related to supposedly poisonous plants, insect bites, agricultural pesticides, industrial chemicals and a small, ill-defined, miscellaneous group. A follow-up pursued with the doctors initiating the calls yielded a record of 97 deaths, only 10 of which were due to misuse of household products, a gross overdose being taken deliberately by an adult in every instance. 3. Particular Poisons Met in the Household a. Gases and Vapours
Gases, e.g. refrigerants, combustibles like propane, utilized in household equipment may leak into the atmosphere, but these happenings in Great Britain are rare and it is a tribute to the precautions taken in manufacture that the containers so seldom lose their integrity. Vapours may also accumulate from cleaning agents, e.g. perchloroethylenes, or from paints and sprays, e.g. various organic esters, causing drowsiness or even collapse. This, however, is most unusual. The ubiquitous aerosol packsreleasehalogenated hydrocarbons that can have a definite effect on the central nervous system and heart, not so much in the ordinary course of usage as in the deliberate exploitation of this property, usually by young people intent upon getting "high". Fatalities in this connexion more often come about when a plastic bag is improvised for rebreathing and asphyxia also overtakes the subject (Verhulst & Grotty, 1964; Merry, 1967; O'Brien, Yeoman & Hobby, 1971; Aviado, 1975). Some concern has been voiced about the choice of carbon tetrachloride as the active ingredient in dry-cleaning preparations for use in the home. Even following a minimal degree of exposure, liver damage1, sometimes progressive, has been reported. Extremely few cases of this type have been confirmed in Great Britain, but, as a gesture of public health policy, carbon tetrachloride has now been abandoned for this purpose and the negligibly toxic perchloroethylenes are used instead. Putting aside these exceptional hazards, by far the most troublesome of the gases within the home is still carbon monoxide2. So long as it remained a major constituent of "town gas" (coal gas), it was the cause of many deaths, some intentional and many accidental. Old people with advancing anosmia characteristically fell victim to an unignited supply which they could not detect by smell. With the progressive substitution of natural, or North sea, gas for that derived from coal, the deaths so ascribable have fallen dramatically, from 4033 in 1963 to 1263 in 1971—an unintended bonus from a technological advance. Whether this trend will continue to zero is, however, 1 See Judah, Br. Med. Bull. 1969, 25, 274-277.—ED. 3 See Lawther, pp. 256-260 of thi» Bulletin.—ED.
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(Goulding, 1974). The majority of these patients were adults, most of whom had resorted to deliberate self-poisoning, principally by drug overdose. Children under five years of age, however, accounted for 7400 in 1964, advancing to 16500 in 1969, thereafter fluctuating annually around 15700 and 16700 (Medicines Commission, 1974). One might reasonably conclude that these youngsters, especially as all but a relatively small proportion of them are under three years of age, would not be far from home and that whatever afflicted them toxicologically would most likely have been encountered within the domestic purlieu. This fact prompts closer scrutiny into the nature of the agents responsible. By far the largest number of cases resulted from the misuse of analgesics, mainly aspirin, followed by psychotherapeutic agents and, conspicuously, the barbiturates. Gases and noxious food-stuffs are prominent as causes of poisoning, but other non-medicinal agents are credited with a much larger figure, of the same order as analgesics. So, in general, it may be said that more than half the children taken into hospital nowadays for poisoning have consumed drugs or medicines, and somewhat fewer have been in contact with household products. This represents a heavy load upon the medical services. Further probing, however, discloses that the average length of stay in hospital of each of these children is today as little as 1.4 days, whereas it was 3.3 days in 1964. Expressed in another way, 85 % of these children are currently discharged after just one night, or less, in hospital. There is little evidence to suggest that this state of affairs can be attributed to the promptness and enhanced efficacy of treatment. Rather is the implication that, in the present social atmosphere, people—above all parents and doctors—are poisons-conscious. In previous years a decision about the seriousness or otherwise of an incident would be taken by the mother or father or, at the most, by the general practitioner—if not by the local pharmacist! At the present time anxiety generated by the oft-repeated universal warnings dictates that every child in this predicament should be rushed to hospital where, commonly, caution rules that admission to the ward would be prudent, if only "for observation". Supporting this interpretation are the findings from a survey conducted in Bristol by the Health Education Council's Medical Research Division (Calnan, 1974). This covered 23457 children over about 48000 child-years. During that period 163 children under 15 years of age were seen at hospital because of so-called "poisoning", equally from prescribed medicines, non-prescribed medicines and household products. None died and less than a third of them proclaimed any symptoms at all. Again, the inference is inescapable that the incidence of poisoning, in the exact sense of that diagnosis, and its severity in children are likely to be grossly exaggerated. The mortality figures tend to confirm this. According to the Statistical Reviews published by the Registrar General, the number of children in Great Britain dying from poisoning approaches 200 each year. Of these, between 100 and 150 are overcome by carbon monoxide in some form or another, not necessarily by coal gas itself, but frequently as an atmospheric contaminant liberated by, e.g., ill-functioning oilstoves, or from actual conflagrations in the home. The remaining 50 children are poisoned mainly by analgesics, notably aspirin, followed by psychotrophic drugs and oral iron preparations. Non-medicinal causes of fatal poisoning in children are few. Measured against the total mortality of children under 5 years of age, poisoning offers an almost insignificant contri-
CHEMICAL HAZARDS IN THE HOME Roy Goulding labelled accordingly. Yet the assailing voices are not silenced and the clamouring continues for yet more warning labels, the wide-spread adoption of ostensibly "child-resistant" containers and all manner of other deterrents, firmly backed by ordinances and statutory enforcement. Worse still is the tendency evident in other countries—on the continent of Europe generally and under the aegis of the European Economic Community in particular—to fashion elaborate mathematical formulae by which the practical hazards can, it is assumed, be calculated from the composition of the product. According to this practice there will be a toxicity classification to regulate sale, supply, packaging, and so on, regardless of the fact that objective and exactingfield-workmay have demonstrated that this is unnecessary.
b. Household Products
c. Garden Chemicals
Chemicals that are recognized as poisonous and which find their way on to the market, either in the unsophisticated state or admixed into products, may be listed and scheduled under the Poisons Act 1972, in which event control and restraint may be statutorily exercised over their sale, supply, storage, packaging and labelling. Thus, formic acid as a kettle descaler and phenol as a disinfectant may come into this category. By this means, the more noxious of the household products may be recognized as such and treated with care and respect. Significantly, perhaps, most household products are without these restrictions. They are, in fact, lacking in appreciable intrinsic toxicity. Yet if one examines the detailed composition of many of these wares, refers to the published data on animal toxicity of the separate constituents and, by a process of extrapolation, estimates the toxicity to man, then the resulting calculation can prove quite startling toxicologically. It was along these lines that work proceeded in 1962, when the first index was compiled for the National Poisons Information Service, and the conclusions thus reached theoretically at the desk pointed assuredly to the dangers attendant upon these products in the home. Bleach, for example, suggested itself as a menace, as did the different caustic oven cleaners, many of the detergents designed for dish-washing machines, certain of the polishes and, indeed, a number of the paints and varnishes on ready sale from the "do-it-yourself" stores. Appraising these data uncritically and, presumably, drawing the same "arm-chair" conclusions, the more vociferous of the politicians and agitators can be excused for the rousing campaigns which they inspire or lead, to warn us and protect us from these supposed chemical hazards in the home. Regrettably they probe the facts no further. Over the years 1963 to 1967 inclusive, all 10000 or so inquiries of this nature channelled through the London centre of the National Poisons Information Service were followed up by an inquiry letter to the doctor initiating each call. Validated cases of injury, or disability, from this source amounted to no more than about 25 %, taking into account even the mildest of symptoms, while the deaths under this heading were 14, the majority of them being due to deliberate, if misguided, ingestion among adults rather than to accidental swallowing by children. In short, then, experience has demonstrated that, so far as the UK is concerned, the general run of chemical requisites in the home is innocuous and only a small minority poses any real risk (Goulding & Watkin, 1965; Goulding, 1970). Most of the dangerous ones, moreover, as already mentioned, are recognized under the Poisons Act 1972 and are
Chemical pesticides, many of them being undeniably toxic, that are purveyed expressly for the furtherance of commercial agriculture or horticulture are subject to rigid, if voluntary, control in Great Britain, by a scheme to which industry and government jointly subscribe and which is administered by the Ministry of Agriculture, Fisheries and Food. In so doing there is a corresponding check on the similar pesticides authorized for what is called "home garden use". Except by transgression, these are the only pesticides that should find their way into the ordinary household and, as such, they are all of comparatively low toxicity. Again, through the National Poisons Information Service, it has been shown that the handling of, exposure to and ingestion of these products have very seldom been accompanied by any toxic reactions—apart from a few cases in which adults have wilfully devoured excessive quantities, being intent, if not upon suicide, then certainly upon self-inflicted injury whilst in a disturbed state of mind. Related to the garden pesticides are the domestic fumigants, wood preservatives, rodenticides and such-like requisites. Over some, but not all, of these, an official regulation is exercised. Again, mishaps with them are remarkably exceptional. Many of the insecticides vouchsafed in this way are put up as aerosols, from which it is virtually impossible in ordinary practice to derive a toxic dose—apart from the exploitation of these devices, to which attention has been drawn in section 3a, and which provide a convenient, cheap and un. restricted device for "sniffing". Several of such casualties have come to light. Another object of contention has been the vaporizer, in which a solid-absorbent base is impregnated with an insecticide, commonly of the organophosphorus type, which is gradually evaporated over weeks or months, setting up in the vicinity a chemical atmosphere that is inimical to many forms of hexapod pests. Fears have been expressed that, at the concentration commonly prevailing, human beings might thereby be endangered and, in any event, domestic pets might suffer. Anecdotal reports abound in support of these complaints, and there has been considerable agitation by sections of the press, both lay and para-scientific, the move for which appears to be prompted more by an urge for sensation than a due regard to the facts. Wherever searching and objective studies have been undertaken in domestic and similar environments the findings have firmly indicated that the highest concentrations of chemical reached are below the hazardous threshold, there having been no departure from normal in a wide range of health parameters recorded (Cavagna, Locati & Vigliani, 1969, 1970; Leary et at. 1974). At the same time, probing at 193
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doubtful. Wherever, for lighting or heating, a combustion system exists in the home that is based upon carbon or hydrocarbon and is dependent upon an adequacy of atmospheric oxygen, there is always a risk that the ventilation will prove inadequate or imperfect. The resulting incomplete combustion leads to an accumulation of carbon monoxide from the effects of which coma and death can supervene insidiously. Particularly may this be a hazard for people occupying unsatisfactory accommodation, above all in caravans. Ominously, recent reports indicate that fatalities in these circumstances are actually increasing (Alphey & Leach, 1974). Likewise adjacent to, if not actually within, the home may be the internal combustion engine that is allowed to run in an enclosed garage, the carbon monoxide then reaching lethal levels.
CHEMICAL HAZARDS IN THE HOME Roy Goulding
d. Indoor and Garden Plants There appears to be a popular assumption that poisonous plants, if not abounding, certainly exist in Great Britain to a significant extent. The walls of doctors' waiting rooms are not infrequently ornamented by colourful posters ominously depicting poisonous species. Yet after 11 years of operating the National Poisons Information Service, during which time
there have been some 11000 inquiries under this heading, none of them has been attended by any serious illness and less still any deaths, with the exception of one fatality from Amanita phalloides in a patient from Guernsey (Standring & Goulding, 1969). What is more, the plants actually within the home—the creepers, the ornamental plants and the rest of contemporary collections—have declared themselves as harmless, apart, possibly, from sensitization reactions from the Primula species. Mistletoe berries, said to be a favourite dish with youngsters about Christmas time, cause little more than a mild loosening of the bowels, notwithstanding the horrifying references in the text-books to the toxins said to be contained therein; and the inviting fruits of the Solanumpseudocapsicum, or winter cherry, also much to the taste of small children, have proved almost totally innocuous. e. Medicines In impressive contrast to the foregoing, the major chemical hazard in virtually every home is the stock of medicines which most people are reluctant to throw away, even when they are no longer required. These encompass both those prescribed by the doctor and, equally, those bought without prescription. Dunnell & Cartwright (1972) in a most revealing survey have demonstrated the immense hoards of medicines in a representative sample of households and many of these are in the attractive form of coloured capsules and tablets, frequently sugar-coated. It must be admitted that these must be voluntarily sought out and consumed, if harm is to ensue. Characteristically these medicines exist in quantities in excess of lethal doses, and are loosely packed in containers with simple and easily manipulated screw, or lift-off, tops. Tragedies consequently ensue in two distinct categories. Modern society is populated by an inordinate number of people mentally depressed, anxious and dejected. Naturally they seek help from their doctors. All too often a time-consuming psychiatric interview yields precedence to the much more deft prescribing of some psychotrophic drug—sedative, hypnotic, tranquillizer, or antidepressant, and commonly the total quantity ordered is in excess of the amount that, on a single occasion, will kill. Approaching 50 million such prescriptions are issued each year in Great Britain (Parish, 1971). Not surprisingly, in those patients for whom these vicarious aids to psychological wellbeing fail to have a prompt effect the temptation to indulge in an overdose, either with determined suicidal intent or simply as a gesture, is too much to resist. No wonder, then, that many unfortunate patients to whomreferencehas already been made in section 2, who have capitulated in this way, are admitted to the hospitals of Great Britain every year. Secondly, these same medicines are irresistible to young children, notably those between the ages of one and three years. This is the stage of human development during which curiosity is paramount and when the environment is explored, above all, orally. Everything within reach is put into the mouth. When the objects of this prying are the common run of household requisites or plants, then, as already explained, calamity seldom ensues. When, on the other hand, medicines are devoured, the outcome can be much more terrifying. Though vitamin capsules or contraceptive pills can be taken by the dozen without ill effect, the majority of medicines are far from harmless. Relatively small doses of hypnotics, antidepressants and aspirin can kill. Fortunately, as tho figures quoted in section 2 make clear, the total mortality rate is low. In England and Wales, of approximately 16000 children
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an experimental level continues, particularly in the demonstration of the alkylating capacity of dichlorovos, the organophosphorus compound employed in so many of these devices, with the implication that this activity, seen both in bacteria and in laboratory mammals, may betoken mutagenic potential for man (Lawley, Shah & Orr, 1974; Lofroth & Wennerberg, 1974; Wennerberg & Lofroth, 1974). Among the wood preservatives, the traditional creosote still enjoys wide popularity. Fortunately, considering its high oral toxicity, few people, adult or child, seem to be induced to drink it. On the skin, however, it can prove extremely irritant, in the vaporous as well as in the liquid form, and above all where the ambient temperature is high. This is not always recognized and precautions can easily be neglected. Creosote derivatives, particularly pentachlorophenol, are more favoured by commercial firms carrying out wood-preserving operations under contract, and this type of chemical is now also to be found in many domestic, wood-preserving preparations. Pentachlorophenol may uncouple oxidative phosphorylation in the tissues and lead to a hypermetabolic state, characterized by weakness, sweating, hyperpyrexia, dyspnoea, exhaustion and collapse (Department of Health and Social Security, 1969). Incidents coming about in this way, some of them fatal, have been reported from various parts of the world, almost entirely in the commercial context (Deichmann & Keplinger, 1963). Domestically, accidents of this kind are most uncommon, though some years ago a child was diagnosed as suffering from pentachlorophenol poisoning, the child having bathed a number of times in, and so absorbed percutaneously, the pentachlorophenol which had found its way into the cold water storage tank of the house after treatment of the roof rafters above it (Chapman & Robson, 1965). The risk, moreover, is greater where the climate is hotter (Bevenue, Haley & Klemmer, 1967). Finally under this heading it needs to be borne in mind that while some vicious rodenticides are still sometimes employed —for example, fluoroacetates, yellow phosphorus and thallium—these are permitted solely in specified industrial surroundings, where their handling can be entrusted to trained and experienced operators. In ordinary residences, the only baits authorized for use against rats and mice are much more benign and comprise anticoagulants like warfarin and stupefying agents such as chloralose. Their efficacy relies on re- , peated ingestion. Adults are unlikely so to regale themselves, whilst children, if tempted, generally consume only a small, single helping. No validated cases of domestic rodenticide poisoning have been recorded in Great Britain over the past 15 years. However, a case has been reported in which some children, espying some sponge cake in the back of an unlocked car, stole and ate portions of it. What they did not know was that the car belonged to a rat-catcher and that the cake was baited with chloralose. Sufficient was devoured for the young thieves subsequently to become stuporous, but they all recovered quickly without treatment and without any lasting stigmata.
CHEMICAL HAZARDS IN THE HOME Roy Goulding son to believe that poisoning, even in the long term, can overtake the community in this way. Old houses and buildings of a previous age nevertheless exist with coatings of old leadcontaining paints4, whereas the newer types of paint manufactured over the past few decades have, with few exceptions, a much lower content of this metal. Children with a persistent habit of chewing, characteristically those with pica, may over the course of months swallow so much of this old paint that lead poisoning besets them. Finally, while regarded generally as a form of sustenance and delight, there is little denying that alcohol stillfiguresas a toxic chemical hazard in many homes, for adults and children alike.
/. "Borrowed" Chemicals Reasonably, in industry, as in commercial agriculture and horticulture, quite powerful chemicals are employed. The injuries to which workers are thereby exposed are, in the main, recognized beforehand, so that the appropriate precautions and protective measures are adopted and, so far as possible, enforced. So useful are these materials found to be, so difficult to obtain by the ordinary citizen, and, more impressively, so expensive to buy, that the urge to "borrow" them surreptitiously for a job in the home cannot always be suppressed. To be purloined in this way, they must commonly be transferred to a small, easily concealed and unlabelled container. About the home, carelessness leads to such chemicals being left conveniently within reach of the prying child. A small amount then unwittingly put into the mouth can be catastrophic. Many of the poisonings from the herbicide paraquat and from the paint-stripper methylene chloride have come about in this manner. Once more this is an example of a chemical hazard in the home which, by the manner of its perpetration, verges on the culpable.
4. Prevention Over-all, the most effective policy to avert poisoning in the home is to avoid the presence therein of toxic materials. This is a principle to which both industry, in enlightened self-interest, and government, by regulatory measures, are pledged. By continuing and reinforcing these attitudes, the present pattern of a relatively low incidence of household poisoning is most likely to be maintained. The conspicuous blemish on thisotherwise highly creditable record is created by the medicines. The danger therein to children would surely be minimized by the more universal adoption of child-resistant containers, preferably of the strip-pack type. To attack the gross misuse of medicines for self-poisoning in adults calls for a major sociopsychological operation that is as challenging as it is daunting. 5. Conclusion Toxicologically, the danger of chemicals in the home has probably received inordinate and disproportionate attention and publicity, much of it emotively presented. Medicines and drugs nevertheless still present as the major poisoning hazard, as well as carbon monoxide from various sources. By definition, chemicals could also be perilous through fire or explosion but, pyrotechnics apart, this seems to be no great problem.
g. Miscellaneous—and Alcohol
Chemicals, albeit in trace amounts, find their way into the modern diet as food additives3. Most countries regulate this usage in the processing and preparation of food by statutory measures, backed by expert advice. There is little sound rea* See Lloyd & Drake, pp. 214-219 of thi» Bulletin.—ED.
« See Clayton, pp. 236-240 of this Bulletin.—ED.
REFERENCES
Alphey, R. S. & Leach, S. J. (1974) Accidental death in the home (Building Research Establishment Current Paper no. 98/74). Department of the Environment, London Aviado, D. M. (1975) Toxicology, 3, 321-332 Backett, E. M. (1965) Public Health Pap. World Health Organ. no. 26 Bcvenue, A., Haley, T. J. & Klemmer, H. W. (1967) Bull. Environ. Contam. Toxicol. 2, 293-2% Calnan, M. W. (1974) Community Health, 6, 91-101 Cavagna, G., Locati, G. & Vigliani, E. C. (1969) Arch. Environ. Health, 19, 112-123 Cavagna, G., Locati, G. & Vigliani, E. C. (1970) Eur. J. Toxicol. 3,49-57 Chapman, J. B. & Robson, P. (1965) Lancet, 1, 1266-1267 Deichmann, W. B. & Keplinger, M. L. (1963) In: Patty, F. A., ed. Industrial hygiene and toxicology, 2nd revised ed. Vol. II: Toxicology, pp. 1396-1402. Wiley-Interscience, New York & London Department of Health and Social Security (1969) Poisonous chemicals used on farms and gardens: notes for the guidance of medical practitioners. HMSO, London Dunndl, K. & Cartwright, A. (1972) Medicine takers, prescribers and hoarders. Routledge & Kegan Paul, London Goulding, R. (1970) Health Trends, 2, 86-87 Goulding, R. (1974) In: Boyland.E. & Goulding, R.,ed. Modern trends in toxicology—2, pp. 4-5. Butterworths, London
Goulding, R. & Watkin, R. R. (1965) Mon. Bull. Minist. Health, 24, 26-32 Keith, S. (1973) Health Trends, 5, 13-14 Lawley, P. D., Shah, S. A. & Orr, D. J. (1974) Chem.-Biol. Interactions, 8, 171-182 Leary, J. S. et al. (1974) Arch. Environ. Health, 29, 308-314 Lemmon, R. M. & Erwin, W. R. (1975) 5c/. Am. 232, no. 1, pp. 72-79 Lofroth, G. & Wennerberg, R. (1974) Z. Naturforsch. 29, 651 Loomis, T. A. (1968) Essentials of toxicology, pp. 1-12. Kimpton, London Medicines Commission (1974) Report on the presentation of medicines in relation to child safety. Department of Health and Social Security, London Merry, J. (1967) Br. Med. J. 2, 360 O'Brien, E. T., Yeoman, W. B. & Hobby, J. A. E. (1971) Br. Med. J. 2, 29-30 Parish, P. A. (1971) The prescribing of psychotropic drugs in general practice (J. R. Coll. Gen. Pract., vol. 21, suppl. no. 4). Royal College of General Practitioners, London Standring, G. & Goulding, R. (1969) Nurs. Times, August 7 issue, pp.1009-1011 Verhulst, H. L. & Grotty, J. J. (1964) Natl. Clgh. Poison Control Cent. Bull, February-March issue and July-August issue Wennerberg, R. & Lofroth, G. (1974) Chem.-Biol. Interactions, 8,339-348
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admitted to hospital annually with an overdose of medicines, only some 23, on an average, succumb and most of these owe their fate to aspirin. Every one of these deaths is unnecessary and, one might suppose, avoidable. In short, the principal chemical hazard in the home during this latter half of the twentieth century is unquestionably the conserved, but improperly stored, medicine. In passing, the comment might be made that the corresponding veterinary medicaments, purchased in no small quantities for the welfare of domestic pets, are reassuringly of low toxicity.
