Abstract

Deliberate self‐harm is a major problem in the developing world, responsible for around 600 000 deaths in 1990. The toxicity of available poisons and paucity of medical services ensure that mortality from self‐poisoning is far greater in the tropics than in the industrialized world. Few data are available on the poisons most commonly used for self‐harm in different parts of the world. This paper reviews the literature on poisoning, to identify the important poisons used for self‐harm in these regions. Pesticides are the most important poison throughout the tropics, being both common and associated with a high mortality rate. In some regions, particular pesticides have become the most popular method of self‐harm, gaining a notoriety amongst both health‐care workers and public. Self‐poisoning with medicines such as benzodiazepines and antidepressants is common in urban areas, but associated with few deaths. The antimalarial chloroquine appears the most significant medicine, self‐poisoning being common in both Africa and the Pacific region, and often fatal. Paracetamol (acetaminophen) is used in many countries but in few has it reached the popularity typical of the UK. Domestic and industrial chemicals are responsible for significant numbers of deaths and long‐term disabilities world‐wide. Self‐poisoning with plant parts, although uncommon globally, is locally popular in some regions. Few of these poisons have specific antidotes. This emphasizes the importance of determining whether interventions aimed at reducing poison absorption actually produce a clinical benefit, reducing death and complication rates. Future research to improve medical management and find effective ways of reducing the incidence of self‐harm, together with more widespread provision of interventions proven to be effective, could rapidly reduce the number of deaths from self‐poisoning in the developing world.

Introduction

Self‐harm has often been thought of as a problem particular to the industrialized world. Recent work has, however, begun to emphasize its importance in the developing world: the Global Burden of Disease study1,2 reported that 593 000 people killed themselves in the developing world during 1990, 75% of the world‐wide total of deaths from self‐harm.3 A recent study demonstrated that 14% of all deaths amongst 10–50‐year‐old women in Bangladesh were due to poisoning, the majority following suicidal ingestion of pesticides.4

Pesticide poisoning from occupational, accidental and intentional exposure is a major developing world public health problem.5 Millions of people are exposed to danger by hazardous occupational practices and unsafe storage.6 However, it is deliberate self‐poisoning that causes the great majority of deaths and the immense strain that pesticides put on hospital services, particularly in Asia.7,8 In 1990, Jeyaratnam estimated that self‐harm resulted in 2 million cases of poisoning each year with 200 000 deaths.5 In contrast, accidental and occupational exposure were estimated to cause 1 million cases with 20 000 deaths. Many studies have shown that deliberate self‐poisoning has a far higher mortality than accidental poisoning.9–12

Poisonings are common among young children as they explore their environment and put new objects into their mouth. In some series, children account for as many as 80% of poisoning cases presenting to hospital.13 Nevertheless, little is normally swallowed and case series (for example references 14–16) show that the mortality rate amongst young children (<10 years old) is generally low in both developing and industrialized nations.

These studies and the World Bank's 1993 World Development Report17 have repositioned mental health in the centre of international public health. The WHO's 1995 World Health Report acknowledged that it had previously been afforded a low priority and called for greater attention to mental health.18 This report coincided with the publication of a book reviewing the problems and priorities in mental health in low‐income countries.19 Together, these publications have generated a wave of interest in suicide in the tropics.20

It is clear from many studies that not all people who die following acts of self‐harm actually wish to die.21–24 Instead, the acts are used to express rage or hostility, or to gain revenge by causing distress to another person. In some cultures, this may be seen as the only means with which to express one's anger with someone (references 25,26 and J Marecek, personal communication). People who do want to kill themselves often do not succeed; in contrast, others with little or no suicidal intent die from their act.27 Many factors affect the outcome, including the degree to which the poison's toxicity was understood, the speed with which the person comes to clinical attention, and the availability of effective medical treatment. It is often difficult to determine whether a person who died actually wished to do so. Therefore, throughout this article, the term ‘deliberate self‐poisoning’ is preferred since it describes the act without presupposing its intention.27

Hanging, self‐immolation and jumping from high buildings are common methods of self‐harm in many Asian cultures and associated with high mortality. However, the toxicity of available poisons7,28 and the paucity of medical services in the developing world ensure that the mortality rate for deliberate self‐poisoning is also high, at 10–20% far higher than the 0.5–1% commonly found in industrialized countries.29–31

Reducing deaths from self‐harm will require interventions to both reduce the incidence of harmful behaviour and to improve medical management of acute poisoning. As a first stage in this latter approach, this paper aims to identify the common poisons used in different regions of the world by reviewing the world‐wide literature on poisoning. By identifying patterns of self‐poisoning world‐wide, it then becomes possible to identify problems that need to be addressed.

Methods

The Medline database was searched for papers reporting hospital‐based surveys of poisoning admissions in the developing world for the years 1980–99. Categorization of countries into developing or industrialized worlds followed the 1993 World Development Report: countries were considered to be part of the developing world if they did not fall into the Established Market Economies (EME) or Former Socialist Economies of Europe (FSE) regions.17

It proved impossible to find developing world papers using MESH or keyword searches. Therefore, the title of every paper selected with the keywords poisoning, suicide, overdose and intoxication was scanned, and papers reporting self‐poisoning selected. Further papers were identified by inspecting references cited in all studies. Regional medical journals not listed on Medline were handsearched at the BMA and London School of Hygiene and Tropical Medicine libraries. Experts associated with the WHO's INTOX project were approached for unpublished studies and hospital patient records handsearched in Sri Lanka and Zimbabwe.

Studies were considered suitable for inclusion in Tables 1–3* if they described a series of (i) patients admitted to hospital (Table 1*); (ii) phone calls to a poison centre (Table 2*), or (iii) post‐mortems. The description had to be sufficiently explicit to allow extraction of data for the tables; the most common reason to exclude a paper was the failure to describe the type of poisons used for overdose. Studies were restricted to the last 20 years to give a recent picture. However, studies from before 1980 were included if they were the only report for a particular region. Studies reporting case series of particular poisons, and not hospital surveys, are cited in the text rather than the tables.

Data on poisoning cases were extracted from relevant papers. Where possible, paediatric cases were excluded, as were cases of alcohol, recreational drug, and carbon monoxide poisoning. Where possible, intentional poisonings were identified in the original paper and presented alone. Otherwise, if this data could not be extracted, an indication of the percent of cases that were intentional is given in the tables. Data on adult cases alone are presented after analysis of the original paper. However, deliberate self‐harm does not only occur in ‘adults’.32,33 In our own work in Anuradhapura and in many of the studies presented here (for example references 14, 34), intentional acts of self‐harm were first noticed in children as young as 7 years old35 and increased in frequency until, by the age of 16, children were harming themselves as often as any age group of adults. The death rate among these adolescents was often high. Unfortunately, these cases will have been excluded if the age range chosen in papers to separate data for adults and children was >16 (e.g. reference 34).

Results

Ninety‐six hospital‐based studies of acute poisonings from across the developing world were identified and are presented in Table 1*. Nine of these studies were ITU‐based; two further studies presented only patients requiring resuscitation or unconscious patients. Five studies restricted themselves to pesticides or medicines, while two presented results of gastric contents screens. These 18 studies, plus three others from Karachi which present the same patients, were excluded from the overall analysis presented in Table 4. Sixteen studies from Poison Control Centres are presented in Table 2* and 28 poisoning autopsy series in Table 3*.

All three sets of studies reveal pesticides to be the most important poisons used for self‐harm world‐wide, with high incidence and fatality rate. Medicines and household products are also common and important causes of morbidity.

Pesticides

Agrochemical pesticides are a major public health problem throughout the developing world.36–41 Many subsistence farming households have stocks of pesticides readily available for impulsive acts. Storage facilities (reference 42 and N. Abeysinghe, MSc thesis, University of Colombo, Sri Lanka) and knowledge of their toxicity are frequently poor.9,28,41,43 However, where toxicity is well recognized, paradoxical increases in the rate of poisoning have also occurred. For example, self‐harm practices have grown up at various times around dimethoate in Zimbabwe (M. Eddleston, unpublished observations), paraquat in Trinidad44 and Samoa,45 malathion in Guyana,46 and parathion in Thailand.47

Organophosphate (OP) pesticides were responsible for the majority of deaths in most series of self‐poisoning cases, particularly those from rural areas (Table 1*). The reported fatality in hospital‐based surveys was as high as 46%. Case series have also been reported from Brasil,48 Chile,49 China,50–52 Costa Rica,10 Ethiopia,53 Guyana,46 India,54–60 Iran,61 Israel,62–64 Kenya,43 South Africa,65,66 Sri Lanka,67 Taiwan,68 Tunisia,69 Turkey,70 and Zimbabwe.66,71

Carbamates are less toxic than OP pesticides.72,73 Series have been recorded in Israel,74 Jordan,75,76 and Brasil,77 the majority occurring following ingestion of rodenticides. Dominicans living in the USA have been poisoned by aldicarb.78 A series of seven deaths due to furathiocarb self‐poisoning was reported from Korea.79

Poisoning with the organochlorines endosulfan and endrin has recently become an important cause of seizures in parts of South Asia.80–83 They cause a status epilepticus that is normally unresponsive to standard treatment, requiring general anaesthesia. The pesticides are rapidly metabolized by the body and therefore, if the patient can be supported through the status epilepticus, prognosis is good with few residual complications.84 Aldrin, dieldrin and lindane have been associated with few cases of self‐harm.85,86

The dipyridyl pesticides paraquat and diquat are highly toxic, although safe after contact with soil. Paraquat has been reported to be a problem in many parts of the world, including Brasil,87 the Caribbean,44,88 Domenica,89 Ecuador (Eddleston, Vargas; unpublished observations), Fiji,90,91 Guadeloupe,92,93 Korea,94–96 Malaysia,97–99 Mexico,100 Nigeria,101 Papua New Guinea,102,103 Reunion,104 Singapore,105 Sri Lanka,9 Surinam,89,106,107 Taiwan,34,108,109 Thailand,110,111 and Western Samoa,45,112–114 in addition to those studies listed in Tables 1–3*.

Aluminium phosphide is toxic after ingestion because contact with water in the stomach liberates phosphine gas.115 It has recently become the commonest means of self‐poisoning in northern India:116 of 720 patients reported in four studies, 439 (61%) died.117–120 A study from Chandigarh, India, showed that it is also a common means of self‐harm amongst 11‐ to 15‐year‐old adolescents, with a mortality rate of 59%.14 A small case series with zinc phosphide has been reported from Poona, India.121 One of four symptomatic patients died from myocarditis; the other three showed marked hepatic toxicity but recovered.

Thallium‐containing rodenticides were banned in the USA during the 1960s after many reports of accidental poisoning. However, they are still used in some tropical countries and accidental poisonings are common.122,123 Poisoning results in abdominal pain, vomiting and diarrhoea, severe limb pain due to neuropathy, mental lethargy, ataxia and alopecia;124,125 severe intoxication results in convulsions and coma. Deliberate self‐poisoning with thallium has been reported from Mexico126 and Thailand.127 The Mexican series was of 50 patients seen over 9 years in one hospital; 21 were deliberate. All but two of the 50 made a complete recovery; one elderly woman died from pneumonia while a 46‐year‐old man was left with bilateral optical atrophy.

Propanil is an aromatic anilide herbicide used for rice farming that produces methaemoglobinaemia if ingested.128 High levels are fatal unless treated with methylene blue. Self‐poisoning cases have been reported from Sri Lanka128; it is currently a significant problem in Kurunegala and Anuradhapura Districts.

Two case series from Taiwan have described 181 patients with glyphosate‐surfactant herbicide concentrate (‘Round‐up’) poisoning, more than 90% due to self‐poisoning.129,130 The commonest effect was gastrointestinal tract irritation; severe cases showed cardiogenic shock, respiratory and renal failure, and metabolic acidosis. Eighteen patients died.

As for other pesticides, the compounds abamectin and ivermectin (both avermectins) are used for the control of parasite infections in crops and cattle. Out of 19 patients reported to a Taiwanese poison control centre between 1993–97,131 seven showed marked toxicity with coma, respiratory failure, and hypotension. One patient died. Fourteen cases (six severe) were due to self‐poisoning. Pyrethrins are less toxic than other pesticides; a few cases of self‐poisoning have been reported from Sri Lanka (Table 1*) and India.132 Five cases of intentional poisoning with imazapyr have been reported from Taiwan.133 Long‐acting ‘superwarfarin’ compounds such as brodifacoum cause long‐term coagulopathies and have been used for self‐poisoning in Hong Kong.134,135

Medicines

Medicines are used throughout the developing world's cities for self‐harm; outside of the cities they are relatively uncommon, their prominence being displaced by pesticides. In general, they cause few deaths, particularly when compared to pesticides. However, chloroquine is an important and common exception to this rule.

CNS‐acting drugs are the commonest medicines used for self‐harm throughout the developing world's cities. While there are few case series of antiepileptics, benzodiazepines or antidepressants,136,137 barbiturates were an extremely common means of self‐poisoning during the 1970s, and large series exist from this time.48,138–141

Of the analgesic drugs, paracetamol (acetaminophen) is a common poison in some regions of the developing world. Cases have been reported from Bahrain,142 Chile,143 Hong Kong,144–147 Kuwait,148 Israel,149,150 Malaysia,151 Singapore,152,153 South Africa,154,155 and Taiwan.156 Only rarely, however, did its incidence approximate the situation in the UK. Salicylates have been reported as common causes of childhood poisoning (e.g. references 157 and 158) but in many of the urban series were less common means of self‐harm than either barbiturates or benzodiazepines.

Chloroquine causes vasodilatation and myocardial depression that may present with convulsions and respiratory or cardiac arrest.159 It is a common and dangerous toxin160–162 used for self‐poisoning in parts of Africa,163–171 Asia,172 and Pacific.173–177 Its popularity blossomed in Cote d’Ivoire during the 1970s, with the 36 cases reported in Abidjan and Cocody during 1970 increasing to 241 in 1974.

Quinine is an antimalarial drug that causes cinchonism (tinnitus, deafness, nausea and vomiting) in overdose. Severe poisoning results in cardiac arrhythmias, myocardial depression, and/or blindness.178,179 It is a well‐recognized self‐harm poison in Europe.178,179 Reports from the tropics have been few but include cases in Casablanca during the 1960s180 and Thailand in the 1970s (D.A. Warrell, personal communication).

Dapsone is used throughout the tropics for the treatment of leprosy. Acute poisoning causes deep cyanosis due to the formation of methaemoglobinaemia, and neurological complications such as reduced consciousness and convulsions. There have been no large case series reporting its use for self‐harm, although it is a common cause of accidental poisoning in children in India.181 One review reported 32 adult cases published world‐wide between 1950 and 1993,182 mostly published as single case reports. A few cases were of deliberate self‐poisoning.

As regards other medicines, there have been several reports of self‐poisoning with the anti‐TB drug isoniazid,183,184 although it does not appear to be a major problem in any region. Anticonvulsants were reported from many urban areas but were of less importance than other medicines.

Herbal or traditional medicines

African traditional medicines are mostly of plant origin but may incorporate mineral or animal products.13 Examples include extract of the cantharadin beetle (which can be gastrotoxic and nephrotoxic) and the Jatropha curcas plant which produces watery diarrhoea and dehydration.185 Traditional medicines are a common cause of accidental poisoning186 but a rare cause of intentional self‐poisoning. In northern South Africa, a study of 1306 poisoning cases found that traditional medicines accounted for 16% of admissions but 52% of deaths, with a mortality rate of 15%.13 None were due to deliberate self‐harm; however, 50% of cases and deaths in this study were in children <10 years. A study of several hundred admissions in Zimbabwe demonstrated a 13% mortality rate.187

Chinese medications of various forms have been reported to be commonly used for self‐poisoning in Hong Kong and Taiwan.188–191

Margosa oil is an extract of the neem tree (Azadirachta indica) that is widely used by Indians as a traditional medicine. Small amounts are often given orally to children, sometimes producing a toxic encephalopathy similar to Reye's syndrome.192 Intentional poisoning has been reported from Tamil Nadu, India.193

Bird lime thistle is reported to be used for suicide in north Africa.194 An extract of this plant (Atractylis gummifera) is sold in local markets as a medicine for blanching the teeth and inducing abortion.

Household products

There have been few series looking at domestic chemicals, but within some African and Asian communities they are a major problem (see Table 1). Household products include kerosene oil used for lighting, cleaning agents such as Dettol (chloroxylenol) and bleach, and strong acids such as sulphuric acid used for drain clearing.

One study reported 1192 cases from six major Zimbabwe hospitals over 10 years.195 The majority (61%) were accidents in children under the age of 6 years; self‐harm accounted for only 19%. Kerosene oil was by far the most common agent (68%), followed by rodenticides, bleach and NaOH‐containing oven cleaner. There were at least 138 deaths from self‐harm using these products.

A different picture has been reported from Hong Kong. A study of 187 adult patients presenting to hospital in the New Territories showed that 95% of patients took these products (mostly ‘Dettol’ or cleaning products) with the intention of harming themselves.196 Deaths were associated with aspiration of Dettol or detergent in two patients, and the ingestion of sulphuric acid in another. Severe poisoning with Savlon (cetrimide) was also associated with aspiration.197 Another study from Hong Kong showed that nearly 50% of adolescents used dettol, detergent or shampoo.198

In large quantities, dettol may cause coma and cardiorespiratory depression;199,200 renal impairment and GI tract damage are uncommon complications.201,202 The commonest serious complication is pneumonia due to aspiration of dettol directly or following gastric lavage without adequate protection of the airway,200,203,204 Delayed upper‐airway obstruction requiring nasotracheal intubation has also been reported.205

‘Rubigne’ is a domestic cleaning agent that contains hydrofluoric acid and ammonium difluoride.206 It is a common household agent in Cayenne and Guyana; 23 cases of self‐poisoning presented to hospital in Cayenne between 1979 and 1981, with a 21% mortality rate.206

Kerosene and paraffin oils are common household energy sources throughout the developing world. Often kept in unsafe non‐child‐proof containers, these oils are a major problem with accidental poisoning among young children (e.g. references 207 and 208) and to a lesser extent, self‐poisoning by adults. Complications and deaths result from their aspiration; management is symptomatic with preservation of the airway in unconscious patients.

Cosmetics were rarely reported. However, case series from Khartoum209,210 and Casablanca211 have reported 46 cases of hair dye (paraphenylenediamine) poisoning. The majority were deliberate and resulted in 12 deaths. The immediate results were marked facial and neck oedema and decreased consciousness; the high risk of asphyxia had to be managed by tracheotomy. Renal and liver failure occurred in severe cases. Paraphenylenediamine poisoning was the number one cause of poisoning in Morocco during the 1990s;212 a single case of intentional poisoning has been reported from India.213

Traditional hair remover (darou or nezafat) containing arsenic sulphide and calcium oxide has recently become a popular and dangerous method of self‐poisoning in Tehran after a well publicized suicide (M. Balali‐Mood, personal communication). Barium sulphide is another chemical used for removing hair in India that has been used for self‐harm.214

Of other substances, potassium permanganate is a common household disinfectant that has been used for self‐harm in Hong Kong215,216 with fatal hepatorenal complications. Yellow phosphorus is used in Ecuador for the manufacture of cheap fireworks; at the time of street celebrations, such as Easter, self‐poisoning with this chemical becomes common (reference 217 and M. Brito, personal communication). Self‐poisoning with cresol has been reported from Taiwan.218

Corrosives

Corrosive chemicals are used widely in industry and the home. They cause intense damage to the pharynx, oesophagus and stomach, often producing perforations. As a result, gastric lavage and activated charcoal are contraindicated. Patients die from peritonitis or mediastinitis, or from pulmonary complications such as fistula formation and pneumonia.

This type of poisoning is quite unlike other forms of acute poisoning. Pesticides and medicines present with an acute crisis—if survived, the patients will have few complications. In contrast, survivors of acute corrosive poisoning often require extensive surgical follow‐up for their GI complications.219,220 In a series of 110 cases from Sri Lanka,221 14% of patients required complicated bowel replacement surgery; all other patients required regular bouginage, initially at weekly, then at longer intervals over many months. Four patients died during the acute poisoning episode, four as a result of complications of bouginage, and three at surgery.221

Self‐poisoning with hydrochloric and sulphuric acids is a major problem in Taiwan. 274 patients (>75% self‐poisoning; >50% HCl) presenting to two hospitals between 1983 and 1993 had a 12% fatality rate.222,223 Fourteen patients, severely ill on admission, were treated conservatively and died; of the 27 who went to theatre, 19 died. Three hundred and twenty‐five patients presented to a third hospital between 1976 and 1991 with five operative deaths out of 28.224 However, this paper did not make clear how many patients were too ill to go to theatre and were treated with conservative therapy.

A fourth Taiwanese group has reported their results with 75 patients treated for caustic oesophageal strictures or post‐caustic resection over 15 years.225 Most (52 patients) had taken HCl; all adults (62 patients) had taken the corrosive intentionally. 87% of operations were done as an elective procedure; there were no deaths and the outcome after these complicated procedures was described as ‘good’ in 90% of cases.

A large series of 163 patients with mostly intentional HCl poisoning has been reported from Morocco.226 Two died on arrival while three of four taken to theatre died. Two other papers have reported smaller series from Tunisia and Morocco.227,228

`Rubber acids' are the two acids used in rubber manufacture—formic and acetic acids. Self‐poisoning is a problem in regions surrounding rubber plantations. Case series have been reported from India229 and Sri Lanka.221 Of the 53 cases of formic acid poisoning presenting to Trivandrum hospital between 1980 and 1982, 98% were intentional and 15 patients died.229

Vinegar is made from concentrated acetic acid. Before sale of the concentrated acid was banned by the government in 1980, it was an important and dangerous means of self‐poisoning in Surinam.89,230 Acetic acid poisoning was also common in Curacao during the 1970s—one group reported 112 cases in four years.231

Car battery acid poisoning was reported in a case series from Cape Town with 27 adults presenting to hospital over 3 years;232 25 cases were intentional. The acid spared the oropharynx but burnt the oesophagus, stomach, and duodenum, necessitating surgical repair in four cases.233 The majority of patients stated that they used car battery acid because it was readily available in car batteries used as a power source in their unelectrified houses, and also because they were aware of its destructive effects.232 Fatal cases have also been reported from Nigeria234 and Trinidad.235

A large series of domestic chemical patients has been reported from Malaysia of whom the majority had taken NaOH.236 Again complicated bowel replacement procedures were required after patient resuscitation. Ten died acutely, 11 required replacement surgery; all other patients received regular bouginage. Sodium hydroxide was the commonest means of suicide in South Korea during the 1930s and 60s;237 however, it has now been almost completely replaced by other means, in particular potassium cyanide.238

Industrial chemicals

Copper sulphate has long been used for self‐harm in South Asia,140,239–243 although its popularity has fallen since the 1960s and 70s (references 244, 245 and S. Perera, personal communication) and it is now seen rarely in much of South Asia. Unfortunately, it has recently became popular again in the Rajshahi region of southern Bangladesh, where 123 cases were seen over six years.246 Thirty‐one patients died from hepatorenal failure, haemolysis, and GI haemorrhage.

An autopsy case series from Seoul covering 1980–84 reported 121 cases of suicidal potassium cyanide ingestion, 62% of all suicides from poisoning.238 This was reported to be a recent phenomenon, since no cases were reported in either the 1930s or 1960s, the majority of cases in those years being due to sodium hydroxide ingestion.237 Further reports of cyanide self‐poisoning have been reported from Taiwan247 and India.248

Other chemicals that have been used for self‐poisoning include turpentine,249 chromic acid,250 and ethylene bromide251–253 in India, sodium chlorite,254 ferric chloride255 and methylene chloride256 in Taiwan, and xylene in Jordan.257 A paper from Zimbabwe reported a series of 40 patients with acute heavy metal poisoning, mostly via industrial exposure.258 There were nine cases of deliberate self‐poisoning, with arsenic and cyanide, and six deaths (four arsenic, two cyanide).

Plants

Poisonous plants have been used for centuries for homicide, suicide and inducing abortion.259–264 However, they appear to be used in few localities for self‐poisoning now. Some have become locally popular methods for self‐harm, but none compare with the remarkable epidemic of yellow oleander seed poisoning currently occurring in Sri Lanka.265

The sap of the yellow oleander (Thevetia peruviana) contains multiple cardiac glycosides. Although widespread in the tropics, it is only a major self‐harm problem in South Asia. Medicolegal texts indicate that its seeds and leaves have been used in India, particularly the south, for abortions, homicide, and suicide throughout the 20th century.259,260 However, the practice of intentionally ingesting its seeds has recently appeared in Sri Lanka with thousands of cases now occurring each year.265 Severe intoxications result in cardiac arrhythmias and fatal cardiac shock; anti‐digoxin antibodies are effective in treating intoxication.266,267

Although used for self‐harm in the USA, no cases of poisoning have been reported from the tropics with the related common or pink oleander (Nerium oleander). Digitalis purpurea is used for self‐harm in Zaire (J. Dinsmore, personal communication).

Ingestion of oduvan (Clistanthus collinus) leaf preparations is a common self‐harm practice in Tamil Nadu, India.268,269 Over 500 cases were recorded at the Forensic Sciences Dept, Tamil Nadu, between 1976 and 1984.270 The plant contains the glycosides cleistanthin A and B271 which produce marked hypokalaemia and cardiac arrhythmias;268,272 deaths result from sudden cardiac arrest, and in a series of 32 patients, nine died.268 In this case series, ingesting the extract of boiled leaves was associated with significantly higher mortality compared to ingesting fresh leaves.

Both intentional and accidental poisoning with the Superb lily (Gloriosa superba) have been reported from South Asia and Africa.273–276 Its tubers contain multiple alkaloids, including colchicine, which cause persistent diarrhoea and vomiting, dehydration, and shock with profound hypotension. In a Sri Lankan series of six patients, all died.277 There is no specific antidote in use; however, anti‐colchicine antibodies278 will probably be effective if they become affordable. A few cases of colchicine medicine self‐poisoning have been reported from the tropics.279,280

Accidental and homicidal poisoning with alkaloid‐containing thorn apple fruits (Datura stramonium)281 have been reported from the tropics.180,282,283 It appears to be a very rare means of self‐poisoning (one case report from the West284).

World‐wide, a number of cultures use plant preparations to stun or kill fish so that they can easily be picked out of the river. These preparations are also used for self‐poisoning. Examples include the rotenone‐containing derris root of Papua New Guinea285 and Thailand,47 and an unidentified plant used by the Achuar of the Ecuadorean Amazon (D. Holmes, personal communication).

Table 4

Summary table for patients reported in the hospital based poisoning surveys

Region/Poison
 
No. of studies
 
No. of patients
 
Percent of all poisonings
 
Death rate (range)
 
Sub‐Saharan Africa 18   13 819 100  
   Medicines      9970  72 0–14 
   Pesticides      1729  13 0–41 
   Chemicals       939   7 33–48 
   Traditional medicines       148   1 10–13 
   Plants        96 <1 NG 
   Others/Not detailed       937   7 NG 
Middle Eastern Crescent 15     8614 100  
   Medicines      5918  69  0–2 
   Pesticides       955  11  4–5 
   Chemicals       335   4  0–10 
   Others/Not detailed      1406  16 NG 
India  6     3007 100  
   Medicines       459  15  0 
   Pesticides      1777  59 36 
   Chemicals       413  14  0 
   Plants        51 <1  0 
   Others/Not detailed       307  10 NG 
China  1      481 100  
   Medicines       417  87 <1 
   Pesticides        42   9  7 
   Chemicals        18   4  0 
   Traditional medicines         4 <1 25 
   Others/Not detailed         0 NA NA 
Other Asia and islands 30  310 692 100  
   Medicines    33 924  11  0–6 
   Pesticides   170 798  55  7–50 
   Chemicals      1271 <1  0–25 
   Traditional medicines     45 <1 NG 
   Plants      2222 <1  3–13 
   Others/Not detailed   102 432  33 NG 
Latin America and Caribbean  6     2123 100  
   Medicines       773  36 NG 
   Pesticides       575  27 NG 
   Chemicals       433  20 NG 
   Others/Not detailed       342  16 NG 
Region/Poison
 
No. of studies
 
No. of patients
 
Percent of all poisonings
 
Death rate (range)
 
Sub‐Saharan Africa 18   13 819 100  
   Medicines      9970  72 0–14 
   Pesticides      1729  13 0–41 
   Chemicals       939   7 33–48 
   Traditional medicines       148   1 10–13 
   Plants        96 <1 NG 
   Others/Not detailed       937   7 NG 
Middle Eastern Crescent 15     8614 100  
   Medicines      5918  69  0–2 
   Pesticides       955  11  4–5 
   Chemicals       335   4  0–10 
   Others/Not detailed      1406  16 NG 
India  6     3007 100  
   Medicines       459  15  0 
   Pesticides      1777  59 36 
   Chemicals       413  14  0 
   Plants        51 <1  0 
   Others/Not detailed       307  10 NG 
China  1      481 100  
   Medicines       417  87 <1 
   Pesticides        42   9  7 
   Chemicals        18   4  0 
   Traditional medicines         4 <1 25 
   Others/Not detailed         0 NA NA 
Other Asia and islands 30  310 692 100  
   Medicines    33 924  11  0–6 
   Pesticides   170 798  55  7–50 
   Chemicals      1271 <1  0–25 
   Traditional medicines     45 <1 NG 
   Plants      2222 <1  3–13 
   Others/Not detailed   102 432  33 NG 
Latin America and Caribbean  6     2123 100  
   Medicines       773  36 NG 
   Pesticides       575  27 NG 
   Chemicals       433  20 NG 
   Others/Not detailed       342  16 NG 

Data from studies surveying poisoning admissions were grouped and analysed by region. Unfortunately, the large studies dominate these analyses. For example, chemicals are underrepresented in the Other Asia and Islands region since the two huge Sri Lankan studies of 295 000 patients only recorded cases of medicine and pesticide poisoning, listing chemical poisonings as ‘other poisons’. Greater detail of the individual studies can be found in Table 1 with the on-line version of the journal at the Oxford University Press website.

Discussion

Poisoning is a common form of deliberate self‐harm in the developing world. While suicidal intent is often far lower than for self‐immolation and hanging, the mortality rate is high due to the toxicity of the poisons used and poor medical care.

Limitations to this study

The data presented above are very patchy. I have been unable to find studies for many countries, in particular those of South America and Africa. Few countries have more than one study, resulting in a picture of the situation in only one place at one time. Since trends in self‐poisoning change over time and differ between regions, these snapshots may not be representative of the current problems.

Some papers presented few details of the patients, making it difficult to extract data on mortality and the percentage of admissions where poisoning was intentional. There is great scope for further epidemiological studies of self‐poisoning from across the developing world to identify poisons that are of local importance.

There have been many large case series of poisoning with various pesticides, probably reflecting their importance. We do not have the same amount of information for the majority of other poisons. For example, although many plants are said to be used for self‐harm, very little has been published and large case series have only been reported for yellow oleander.

Common poisons

Bearing these caveats in mind, the data presented above indicate that organophosphate pesticides are the predominant problem world‐wide, being responsible for many cases of self‐poisoning and the majority of deaths. Other pesticides such as aluminium phosphide, paraquat and organochlorines are important in specific localities. Pesticides, as would be expected, are particular problems in rural areas where they are freely available.

The mortality rate in urban areas, where pesticides are relatively uncommon, tends to be lower. Here medications are the most commonly used. Fortunately, the majority of these poisons are less toxic than pesticides, although deaths still occur with barbiturates and benzodiazepines. Paracetamol is a significant problem in relatively few regions of the developing world. Traditional medicines appear to be an important cause of accidental but not intentional poisoning.

The most dangerous medicine in the developing world is chloroquine. It is highly toxic and a problem in many parts of Africa and the Pacific. Recent studies from France and West Africa suggest that diazepam and adrenaline may be effective antidotes, however, it is not clear whether they are used in clinical practice world‐wide. The importance of chloroquine in a post‐mortem case series from Mutare, Zimbabwe, compared with its low toxicity in a series of hospital cases (see Tables 1 and 3*; M. Eddleston, unpublished) suggests that it may kill quickly, before the patient gets to hospital.

There have been relatively few studies looking at the use of household and industrial chemicals; most have been surgical case series. Deaths appear to be rare with the majority of household chemicals and often due to ill‐advised gastric lavage without protection of the airway. However, caustic acids and alkalis cause severe damage to the GI tract, requiring complex surgery and causing death in around 10% of cases. The frequency of potassium cyanide in a suicide autopsy series from Seoul, and its absence from a self‐poisoning series appears to confirm this compound's extreme lethality.

In some regions, plants parts are consumed in acts of self‐harm. Antidotes are rarely available, although polyclonal antibodies raised against cardiac glycosides and colchicine, if available, would probably be effective for many types.

Possible interventions

Reducing deaths from self‐poisoning will require multiple approaches.

Banning common poisons, such as particular pesticides,7,286,287 may be effective in particular regions. However, it is difficult to predict the long‐term outcome, since the picture is never constant and new poisons become popular, replacing others.8,245,265,288 Long‐term improvements will come from reducing the incidence of harmful behaviour and improving medical management. In addition, adoption of the integrated pest management scheme with its reduced use of agrochemicals and long term environmental damage289,290 can only be beneficial and should be encouraged. Similarly, improved storage of pesticides and medicines291 together with the requirement for a ‘prescription’ for both medicines and pesticides may reduce the incidence of poisoning.

Hospital‐based interventions after admission for self‐harm have become popular in an attempt to reduce repetition. However, two recent meta‐analyses and a review of these interventions concluded that there was insufficient evidence to recommend a specific intervention with which to reduce further harmful behaviour.292–294 Improved mental health care, particularly at the community level, must be an important part of any strategy to reduce self‐harm.17,286,295

Approaches to primary prevention may include increasing peoples’ skill in coping with problems—perhaps offering coping skill classes at school and counselling in the community.296 An attempt in Sri Lanka during 1997 to study the effects of a community based intervention did reduce the incidence of harmful behaviour, but this was felt to be due simply to increased attention and likely not to be sustained if the workers left (J. Marecek, personal communication).

Lastly, a sustained attempt to improve management and reduce the appallingly high death rates associated with self‐poisoning should have both immediate and long term benefits.297 The WHO's IPCS/INTOX project has successfully promoted the development of high‐quality poison information services in the developing world. However, in parts of Asia, it is not poisons information in the Western sense that is required. Physicians in rural areas see hundreds of cases of OP or aluminium phosphide poisoning and are extremely familiar with the problem. It is the lack of evidence‐based guidelines to aid management that is important, together with a lack of resources—drugs, ITU, and staff.

The management of the forms of poisoning seen in the tropics is not well developed, with few specific antidotes and few evidence‐based protocols. For example, the efficacy of immunosuppression in paraquat‐induced lung fibrosis has never been properly assessed. In addition, the recent recommendations for OP poisoning are based on theoretical studies, not on clinical trials. Since the developing world has little money to waste, the efficacy of interventions has to be proven to their satisfaction before they can be incorporated into clinical practice. It is, for example, this lack of evidence that prevents the more widespread use of pralidoxime in Asia.

Attitudes amongst physicians faced with severely poisoned patients are often of hopelessness, and sometimes simple delusion—one consultant physician in Zimbabwe confidently told me that no patients had died from OP poisoning during his 15 years at the hospital. This contrasted strongly with a simple review of case notes which revealed 9 deaths in the previous 16 months and a case mortality of around 50%.

Hardly any of the poisons listed in the tables have specific antidotes. This emphasizes the importance of establishing whether cheap non‐specific therapies such as multiple‐dose activated charcoal regimens298 save lives. The debate surrounding the efficacy of activated charcoal has raged for decades with little change299–302—we are still desperately short of high‐quality clinical trials. Until they are designed and run, we will be forced to rely on the current European and American consensus that activated charcoal cannot be recommended due to a complete lack of evidence for its efficacy.303

Address correspondence to Dr M. Eddleston, Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, John Radcliffe Hospital, Oxford OX3 9DU. e‐mail: EddlestonM@aol.com

*

The supporting tabular material is available with the on‐line version of the Journal at the Oxford University Press website.

I thank the long suffering librarians at the Sussex Postgraduate Medical Centre, Brighton, Royal Alexandra Hospital, Paisley, and BMA library, London, for their extreme patience with me as we chased yet another obscure paper. I also thank K. Hawton, J. Ryan and R. Ferner for critical comments on this paper, the members of WHO's INTOX, especially John Haines, Mike Ruse and Ligia Fruchten‐garten, for their help, Drs Damodaran and Dewan for sending information on poisoning in India, and all the physicians who took the time to tell me about their experiences managing poisoned patients in the developing world. I am greatly indebted to David Warrell for his immense patience and support over the last five years and to the Foulkes Foundation for their financial support.

References

1
Murray CJL, Lopez AD. The global burden of disease: a comprehensive assessment of mortality and disability from diseases, injuries and risk factors in 1990 and projected to 2020. [Global Burden of Disease and Injury Series. Volume 1]. Cambridge MA, Harvard School of Public Health,
1996
.
2
Murray CJL, Lopez AD. Global Burden of Disease Study—Summary.
Lancet
 
1997
;
349
:
1269
–76.
3
Murray CJL, Lopez AD. Global health statistics.
A compendium of incidence, prevalence and mortality estimates for over 200 conditions
 . [Global burden of disease and injury series. Volume II]. Cambridge MA, Harvard School of Public Health and WHO,
1996
.
4
Yusuf HR, Akhter HH, Rahman MH, Chowdhury MK, Rochat RW. Injury‐related deaths amongst women aged 10–50 years in Bangladesh, 1996–97.
Lancet
 
2000
;
355
:
1220
–4.
5
Jeyaratnam J. Acute pesticide poisoning: a major global health problem.
Wld Hlth Statist Quart
 
1990
;
43
:
139
–44.
6
Karalliedde L, Eddleston M, Murray V. Epidemiology of organophosphate insecticide poisoning. In: Karalliedde L, Marrs T, Feldman F, Henry JA (eds),
Organophosphate Pesticides and Human Health
 . London: Imperial College; in press.
7
van der Hoek W, Konradsen F, Athukorala K, Wanigadewa T. Pesticide poisoning: a major health problem in Sri Lanka.
Soc Sci Med
 
1998
;
46
:
495
–504.
8
Eddleston M, Sheriff MHR, Hawton K. Deliberate self‐harm in Sri Lanka: an overlooked tragedy in the developing world.
Br Med J
 
1998
;
317
:
133
–5.
9
Hettiarachchi J, Kodithuwakku GCS. Pattern of poisoning in rural Sri Lanka.
Int J Epidemiol
 
1989
;
18
:
418
–22.
10
Ingianna J, Herrero R, Albertazzi C. Estudio comparativo de casos de intoxicaciones por insecticidas organofosforados en diferentes zonas de Costa Rica.
Revista Biol Trop
 
1983
;
31
:
139
–44.
11
Abdollahi M, Jalali N, Sabzevari O, Hoseini R, Ghanea T. A retrospective study of poisoning in Tehran.
Clin Toxicol
 
1997
;
35
:
387
–93.
12
Sinitox. Revisao da estatistica de 1997. Casos de intoxicacao e envenenamento. Brasil, 1997. http://www.fiocruz.br
13
Joubert PH. Poisoning admissions of black South Africans.
Clin Toxicol
 
1990
;
28
:
85
–94.
14
Singh S, Singhai S, Sood NK, Kumar L, Walia BNS. Changing pattern of childhood poisoning (1970–1989): experience of a large north Indian hospital.
Indian Pediatr
 
1995
;
32
:
331
–6.
15
Pearn J, Nixon J, Ansford AJ, Corcoran A. Accidental poisoning in childhood: 5 year urban population study with 15 year analysis of fatality.
BMJ
 
1984
;
288
:
44
–6.
16
Singh M, Hessam MY, Azamy S, Arya LS. Spectrum of poisonings among children in Afghanistan.
Indian J Pediatr
 
1984
;
51
:
313
–16.
17
World Bank.
World Development Report 1993: investing in health
 . New York, Oxford University Press,
1993
.
18
World Health Organisation.
World Health Report 1995
 . Geneva, WHO,
1995
.
19
Desjarlais R, Eisenberg L, Good B, Kleinman A.
World mental health: problems and priorities in low‐income countries
 . New York, Oxford University Press,
1997
.
20
Brown P. No way out.
New Scientist
 
1997
, 22 March 1997:
34
–7.
21
Hawton K. Deliberate self‐harm.
Medicine
 
1997
;
24
:
77
–80.
22
Hawton K, Catalan J.
Attempted suicide: a practical guide to its nature and management
 . Oxford, Oxford Medical Publications,
1987
.
23
Abu Al‐Ragheb S, Qaryoute S, el‐Muhtaseb H. Mortality of burn injuries in Jordan.
Burns, including Thermal Injury
 
1984
;
10
:
439
–43.
24
Williams H, Buchan T. A preliminary investigation into parasuicide in Salisbury, Zimbabwe–1979/1980.
Central Afr J Med
 
1981
;
27
:
129
–35.
25
Maracek J. Psychological approaches to understanding suicide. In: De Silva P, ed.
Suicide in Sri Lanka
 . Kandy, Institute of Fundamental Studies,
1989
:
16
–24.
26
De Silva P. The logic of attempted suicide and its linkage with human emotions. In: De Silva P, ed.
Suicide in Sri Lanka.
  Kandy, Institute of Fundamental Studies,
1989
:
25
–40.
27
Kessel N. Self‐poisoning.
Br Med J
 
1965
;
ii
:
1265
–70, 1336–40.
28
Hettiarachchi J, Kodithuwakku GCS. Self‐poisoning in Sri Lanka: factors determining the choice of the poisoning agent.
Human Toxicol
 
1989
;
8
:
507
–10.
29
Jacobsen D, Frederichsen PS, Knutsen KM, Sorum Y, Talseth T, Odegaard OR. Clinical course in acute self‐poisoning: a prospective study of 1125 consecutively hospitalised adults.
Hum Exp Toxicol
 
1984
;
3
:
107
–16.
30
Pond SM, Lewis‐Driver DJ, Williams GM, Green AC, Stevenson NW. Gastric emptying in acute overdose: a prospective randomised controlled trial.
Med J Aust
 
1995
;
163
:
345
–9.
31
Bailas MC, Reid PG, Beck P, et al. Changing patterns of self‐poisoning in a UK health district.
Q J Med
 
1996
;
89
:
893
–901.
32
Hawton K.
Suicide and attempted suicide among children and adolescents
 . Developmental clinical psychology and psychiatry series, vol. 5. Newbury Park CA, Sage Publications,
1986
:
9
–157.
33
Lawson GR, Craft AW, Jackson RH. Changing pattern of poisoning in children in Newcastle, 1974–81.
Br Med J
 
1983
;
287
:
15
–17.
34
Yang CC, Wu JF, Ong HC, et al. Taiwan National Poison Centre: epidemiologic data 1985–1993.
J Toxicol Clin Toxicol
 
1996
;
34
:
651
–63.
35
Hincal F, Hincal A, Sankayalar F, Cevik N, Kinik E. Self‐poisoning in children: a ten year survey.
Clin Toxicol
 
1987
;
25
:
109
–20.
36
Wiese IH. Pesticides and the South African population.
S Afr Med J
 
1976
;
50
:
1801
–5.
37
Singh PDA, West ME. Acute pesticide poisoning in the Caribbean.
West Indian Med J
 
1985
;
34
:
75
–83.
38
Keir N, Whiting N.
A study of pesticide‐related suicide
 . London, Befrienders International,
1997
.
39
Forget G. Pesticides and the third world.
J Toxicol Env Health
 
1991
;
32
:
11
–31.
40
Garcia JE. Intoxicaciones agudas con plaguicidas: costos humanos y economicos.
Pan Am J Public Health
 
1998
;
4
:
383
–7.
41
Wesseling C, McConnell R, Partanen T, Hogstedt C. Agricultural pesticide use in developing countries: health effects and research needs.
Int J Health Services
 
1997
;
27
:
273
–308.
42
Haynes IH. Problems of pesticide storage in developing countries.
Chem Ind
 
1985
; September
16
:
621
–3.
43
Kimani VN, Mwanthi MA. Agrochemical exposure and health implications in Githunguri location, Kenya.
East Afr Med J
 
1995
;
72
:
531
–5.
44
Hutchinson G, Daisley H, Simmons V, Gordon AN. Suicide by poisoning.
West Indian Med J
 
1991
;
40
:
69
–73.
45
Bowles JR. Suicide in Western Samoa: an example of a suicide prevention program in a developing country. In: Diekstra R, ed.
Preventative strategies on suicide
 . Leiden, Brill,
1995
:
173
–206.
46
Nalin DR. Epidemic of suicide by malathion poisoning in Guyana.
Trop Geogr Med
 
1973
;
25
:
8
–14.
47
Eungprabhanth V. Suicide in Thailand.
Forensic Sci
 
1975
;
5
:
43
–51.
48
da Silva OA, Lopez M. Tratamento intensivo das intoxicacoes exogenas agudas.
Rev Assoc Med Brasil
 
1980
;
26
:
4
–6.
49
Delgado M, Suazo M. Intoxicacion por insecticidas organofosforados.
Rev Med Chile
 
1981
;
109
:
837
–40.
50
He F, Xu H, Qin F, Xu L, Huang J, He X. Intermediate myasthenia syndrome following acute organophosphate poisoning—an analysis of 21 cases.
Hum Exp Toxicol
 
1998
;
17
:
40
–5.
51
Si FZ, Wang DX, Yang GQ. [Atropine dependence during treatment of acute organophosphorus pesticides poisoning].
Chinese J Int Med
 
1994
;
33
:
540
–2.
52
Zhao DL, Li LJ. [The emergency treatment of organophosphorus pesticides poisoning].
Chinese J Int Med
 
1994
;
33
:
630
–2.
53
Abebe M. Organophosphate pesticide poisoning in 50 Ethiopian patients.
Ethiop Med J
 
1991
;
29
:
109
–18.
54
Adlakha A, Philip PJ, Dhar KL. Organophosphorous and carbamate poisoning in Punjab.
J Assoc Physicians India
 
1988
;
36
:
210
–12.
55
Singh S, Batra YK, Singh SM, Wig N, Sharma BK. Is atropine alone sufficient in acute severe organophosphate poisoning? Experience of a North West Indian hospital.
Int J Clin Pharmacol Ther
 
1995
;
33
:
628
–30.
56
Shailesh KK, Pais P, Vengamma B, Muthane U. Clinical and electrophysiological study of intermediate syndrome in patients with organophosphorous poisoning.
J Assoc Physicians India
 
1994
;
42
:
451
–3.
57
Agarwal SB. A clinical, biochemical, neurobehavioural, and sociopsychological study of 190 patients admitted to hospital as a result of acute organophosphate poisoning.
Environ Res
 
1993
;
62
:
63
–70.
58
Malik GM, Mubarik M, Romshoo GJ. Organophosphorus poisoning in the Kashmir Valley, 1994 to 1997 [Letter].
N Engl J Med
 
1998
;
338
:
1078
.
59
Goswamy R, Chaudhuri A, Mahashur AA. Study of respiratory failure in organophosphate and carbamate poisoning.
Heart Lung
 
1994
;
23
:
466
–72.
60
Dagli AJ, Shaikh WA. Pancreatic involvement in malathion anticholinesterase insecticide intoxication—a study of 75 cases.
Br J Clin Prac
 
1983
;
37
:
270
–2.
61
Balali‐Mood M, Shariat M. Treatment of organophosphate poisoning. Experience of nerve agents and acute pesticide poisoning on the effects of oximes.
J Physiol (Paris)
 
1998
;
92
:
375
–8.
62
Finkelstein Y, Kushnir A, Raikhlin‐Eisenkraft B, Taitelman U. Antidotal therapy of severe acute organophosphate poisoning: a multihospital study.
Neurotoxicol Teratol
 
1989
;
11
:
593
–6.
63
Lerman Y, Hirshberg A, Shteger Z. Organophosphate and carbamate pesticide poisoning: the usefulness of a computerized clinical information system.
Am J Med
 
1984
;
6
:
17
–26.
64
Zamir DL, Novis BN. Organophosphate poisoning and necrotizing pancreatitis.
Israel J Med Sci
 
1994
;
30
:
855
–6.
65
Bardin PG, van Eeden SF, Joubert JR. Intensive care management of acute organophosphate poisoning. A 7‐year experience in the Western cape.
S Afr Med J
 
1987
;
72
:
593
–7.
66
Hayes MM, van der Westhuizen NG, Gelfand M. Organophosphate poisoning in Rhodesia. A study of the clinical features and management of 105 patients.
S Afr Med J
 
1978
;
54
:
230
–4.
67
Karalliedde L, Senanayake N. Acute organophosphorus insecticide poisoning in Sri Lanka.
Forensic Sci Int
 
1988
;
36
:
97
–100.
68
Jang SW, Lin JL, Chuang FR. Electrocardiographic findings of organophosphate intoxication in emergency department as predictors of prognosis: a retrospective analysis.
Chang‐Keng i Hsueh Tsa Chih
 
1995
,
18
:
120
–5.
69
Nouira S, Abroug F, Elatrous S, Boujdaria R, Bouchoucha S. Prognostic value of serum cholinesterase in organophosphate poisoning.
Chest
 
1994
;
106
:
1811
–14.
70
Ozturk MA, Kelestimur F, Kurtoglu S, Guven K, Arslan D. Anticholinesterase poisoning in Turkey—clinical, laboratory, and radiological evaluation of 269 cases.
Hum Exp Toxicol
 
1990
;
9
:
273
–9.
71
Nhachi CF. A study of organophosphate poisoning at one rural and one urban hospital.
Central Afr J Med
 
1988
;
34
:
180
–5.
72
Ballantyne B, Marrs TC. Overview of the biological and clinical aspects of organophosphates and carbamates. In: Ballantyne B, Marrs TC (eds),
Clinical and Experimental Toxicology of Organophosphates and Carbamates
 . Oxford, Butterworth Heinemann
1992
;
3
–14.
73
Hayes WJ.
Pesticides studied in man
 . Baltimore MD, Williams & Wilkins,
1982
.
74
Lifshitz M, Shahak E, Bolotin A, Sofer S. Carbamate poisoning in early childhood and adults.
J Toxicol Clin Toxicol
 
1997
;
35
:
25
–7.
75
Saadeh AM, al‐Ali MK, Farsakh NA, Ghani MA. Clinical and sociodemographic features of acute carbamate and organophosphate poisoning: a study of 70 adult patients in north Jordan.
J Toxicol Clin Toxicol
 
1996
;
34
:
45
–51.
76
Saadeh AM, Farsakh NA, al‐Ali MK. Cardiac manifestations of acute carbamate and organophosphate poisoning.
Heart
 
1997
;
77
:
461
–4.
77
Lima JS, Reis CA. Poisoning due to illegal use of carbamates as a rodenticide in Rio de Janeiro.
J Toxicol Clin Toxicol
 
1995
;
33
:
687
–90.
78
Centers for Disease Control and Prevention. Poisonings associated with illegal use of aldicarb as a rodenticide—New York City, 1994–1997.
MMWR
 
1997
;
46
:
961
–3.
79
Lee SK, Ameno K, In SW, et al. Acute fatal poisoning cases due to furathiocarb ingestion.
Forensic Sci Int
 
1999
;
101
:
65
–70.
80
Bhaskara Reddy D, Edward VD, Abraham GJS, Venkateswara Rao K. Fatal endrin poisoning. A detailed autopsy, histopathological and experimental study.
J Indian Med Assoc
 
1966
;
46
:
121
–4.
81
Rowley DL, Rab MA, Hardjotanojo W, et al. Convulsions caused by endrin poisoning in Pakistan.
Pediatrics
 
1986
;
79
:
928
–34.
82
Singh N, Singh CP, Kumar H, Brar GK. Endosulfan poisoning: a study of 22 cases.
J Assoc Physicians India
 
1992
;
40
:
87
–8.
83
Sood AK, Yadav SP, Sood S. Endosulphan poisoning presenting as status epilepticus.
Indian J Med Sci
 
1994
;
48
:
68
–9.
84
World Health Organization. Environmental health criteria #130. Endrin. Geneva: World Health Organization,
1992
.
85
Konje JC, Otolorin EO, Sotunmbi PT, Ladipo OA. Insecticide poisoning in pregnancy. A case report.
J Reprod Med
 
1992
;
37
:
992
–4.
86
Agapejev S, Vassilieff I, Lima MMF, Silva SMG. Poisoning by chemical non‐medicinal products in Brazil: clinical and laboratory findings in 132 patients.
Human Toxicol
 
1986
;
5
:
369
–72.
87
Povoa R, Maciel FM, Orlando JM, et al. Lesao cardiaca secundaria ao paraquat.
Arq Bras Cardiol
 
1992
;
59
:
95
–8.
88
Addo E, Poon‐King T. Leucocyte suppression in treatment of 72 patients with paraquat poisoning.
Lancet
 
1986
;
i
:
1117
–20.
89
Anon. Paraquat poisoning in the Caribbean.
PAHO Bulletin
 
1986
;
20
:
406
–9.
90
Haynes RH. Suicide and social response in Fiji: a historical survey.
Br J Psychiatr
 
1987
;
151
:
21
–6.
91
Ram P, Roa U. Paraquat poisoning in Fiji.
Fiji Med J
 
1983
; Jan‐Feb:
12
–16.
92
Ragoucy‐Sengler C, Pileire B, Daijardin JB. Survival from severe paraquat intoxication in heavy drinkers [Letter].
Lancet
 
1991
;
338
:
1461
.
93
Ragoucy‐Sengler C, Pileire B. A biological index to predict patient outcome in paraquat poisoning.
Hum Exp Toxicol
 
1996
;
15
:
265
–8.
94
Lee SH, Lee KS, Ahn JM, Kim SH, Hong SY. Paraquat poisoning of the lung: thin‐section CT findings.
Radiology
 
1995
;
195
:
271
–4.
95
Im JG, Lee KS, Han MC, Kim SJ, Kim IO. Paraquat poisoning: findings on chest radiography and CT in 42 patients.
Am J Roentgenol
 
1991
;
157
:
697
–701.
96
Lee SK, Ameno K, In SW, et al. Levels of paraquat in fatal intoxications.
Int J Legal Med
 
1999
;
112
:
198
–200.
97
Ng TS, Thong KW. Paraquat poisoning.
Med J Malaysia
 
1978
;
32
:
278
–81.
98
Chan KW, Cheong Izham KS. Paraquat poisoning: a clinical and epidemiological review of 30 cases.
Med J Malaysia
 
1982
;
37
:
227
–30.
99
Wong KT, Ng TS. Alleged paraquat poisoning in Perak.
Med J Malaysia
 
1984
;
39
:
52
–5.
100
Tinoco R, Parsonnet J, Halperin D. Paraquat poisoning in southern Mexico: a report of 25 cases.
Arch Environ Health
 
1993
;
48
:
78
–80.
101
Akang EE, Adeyami FA, Bamidele RW, et al. A fatal case of paraquat poisoning in a Nigerian.
Afr J Med Med Sci
 
1994
;
23
:
401
–3.
102
Wohlfahrt DJ. Paraquat poisoning in Papua New Guinea.
PNG Med J
 
1981
;
24
:
164
–8.
103
Mowbray DL. Pesticide poisoning in Papua New Guinea and the South Pacific.
PNG Med J
 
1986
;
29
:
131
–41.
104
Chong MF, Harms JD, Peretout H, Genin R. Intoxicatioins aigues au paraquat. Une seule therapeutique: la prevention.
Presse Med
 
1983
;
12
:
2187
.
105
Fock KM. Clinical features and prognosis of paraquat poisoning: a review of 27 cases.
Singapore Med J
 
1987
;
28
:
53
–6.
106
Perriens J, van der Stuyft P, Chee H, Benimadho S. The epidemiology of paraquat intoxications in Suriname.
Trop Geogr Med
 
1989
;
41
:
266
–9.
107
van der Stuyft P. Paraquat poisoning.
Lancet
 
1999
;
353
:
322
–3.
108
Lin J‐L, Liu L, Leu ML. Recovery of respiratory function in survivors with paraquat intoxication.
Arch Environ Health
 
1995
;
50
:
432
–9.
109
Talbot AR, Fu CC, Hsieh MF. Paraquat intoxication during pregnancy: a report of 9 cases.
Vet Hum Toxicol
 
1988
;
30
:
12
–17.
110
Soontornniyomkij V, Bunyaratvej S. Fatal paraquat poisoning: a light microscopic study in eight autopsy cases.
J Med Assoc Thai
 
1992
;
75
(Suppl
1)
:98–105.
111
Tungsanga K, Sitprija V, Suvanpha R, et al. Paraquat poisoning: experience in fourteen patients.
J Med Assoc Thai
 
1981
;
64
:
215
–22.
112
Paksoy N. Problems in paradise: pattern of coroner's autopsies in Western Samoa [Letter].
Med J Aust
 
1990
;
152
:
612
.
113
Bowles J.
Suicide—Samoa
 . Mimeographed. Apia, Western Samoa,
1982
.
114
Bowles J.
Suicide and attempted suicide
 . Mimeographed. Apia, Western Samoa,
1983
.
115
World Health Organization.
Environmental health criteria #73. Phosphine and selected metal phosphides.
  Geneva: World Health Organization,
1988
.
116
Gupta S, Ahlawat SK. Aluminium phosphide poisoning—a review.
J Toxicol Clin Toxicol
 
1995
;
33
:
19
–24.
117
Singh S, Dilawari JB, Vashist R, Malhotra HS, Sharma BK. Aluminium phosphide ingestion.
Br Med J
 
1985
;
290
:
1110
–11.
118
Chugh SN, Dushyant, Ram S, Arora B, Malhotra KC. Incidence and outcome of aluminium phosphide poisoning in a hospital study.
Indian J Med Res
 
1991
;
94
:
232
–5.
119
Khosla SN, Handa R, Khosla P. Aluminium phosphide poisoning.
Trop Doct
 
1992
;
22
:
155
–7.
120
Singh S, Singh D, Wig N, Jit I, Sharma BK. Aluminium phosphide ingestion—a clinicopathological study.
J Toxicol Clin Toxicol
 
1996
;
34
:
703
–6.
121
Sangle SA, Thomas A, Verma S, Wadia RS. Zinc phosphide poisoning.
J Assoc Physicians India
 
1987
;
35
:
591
–4.
122
Pai V. Acute thallium poisoning. Prussian blue therapy in nine cases.
West Indian Med J
 
1987
;
36
:
256
–8.
123
Anon. Thallium poisoning in Guyana—a national crisis [Editorial].
Lancet
 
1987
;
i
:
604
.
124
Reed D, Crawley J, Faro SN, Pieper SJ, Kurland LT. Thallotoxicosis. Acute manifestations and sequelae.
JAMA
 
1963
;
183
:
96
–102.
125
Moore D, House I, Dixon A. Thallium poisoning.
Br Med J
 
1993
;
306
:
1527
–9.
126
Rangel‐Guerra R, Martinez HR, Villareal HJ. Intoxicacion por talio. Experiencia con 50 pacientes.
Gaceta Medica de Mexico
 
1990
;
126
:
487
–94.
127
Kunarutanapruk S, Kurathong S. Thallium intoxication.
J Med Assoc Thai
 
1978
;
61
:
175
–8.
128
De Silva WAS, Bodinayake CK. Propanil poisoning.
Ceylon Med J
 
1997
;
42
:
81
–4.
129
Tominack RL, Yang GY, Tsai WJ, Chung HM, Deng JD. Taiwan National Poison Center Survey of glyphosate‐surfactant herbicide ingestions.
Clin Toxicol
 
1991
;
29
:
91
–109.
130
Talbot AR, Shiaw MH, Huang JS, et al. Acute poisoning with a glyphosate‐surfactant herbicide(‘Round‐up’): a review of 93 cases.
Hum Exp Toxicol
 
1991
;
10
:
1
–8.
131
Chung K, Yang CC, Wu ML, Deng JF, Tsai WJ. Agricultural avermectins: an uncommon but potentially fatal cause of pesticide poisoning.
Ann Emerg Med
 
1999
;
34
:
51
–7.
132
Peter JV, John G, Cherian AM. Pyrethroid poisoning.
J Assoc Physicians India
 
1996
;
44
:
343
–4.
133
Lee HL, Chen KW, Wu MH. Acute poisoning with a herbicide containing imazapyr (arsenal): a report of six cases.
J Toxicol Clin Toxicol
 
1999
;
37
:
83
–9.
134
Hui CH, Lie A, Lam CK, Bourke C. ‘Superwarfarin’ poisoning leading to prolonged coagulopathy.
Forensic Sci Int
 
1996
;
78
:
13
–18.
135
Chong LL, Chau WK, Ho CH. A case of ‘superwarfarin’ poisoning.
Scand J Haematol
 
1986
;
36
:
314
–15.
136
Thabet H, Brahmi N, Zagdoudi I, et al. Acute self‐poisoning with carbamazepine.
Presse Med
 
1999
;
28
:
955
–8.
137
Khan MM, Reza H. Benzodiazepine self‐poisoning in Pakistan: implications for prevention and harm reduction.
J Pak Med Assoc
 
1998
;
48
:
293
–5.
138
Agarwal SK, Tiwari SC, Dash SC. Spectrum of poisoning requiring haemodialysis in a tertiary care hospital in India.
Int J Artif Organs
 
1993
;
16
:
20
–2.
139
Kuo TL, Chen WY, Fong JM, How SW. Studies on serum barbiturate levels of acute intoxication.
J Formosan Med Assoc
 
1984
;
83
:
135
–41.
140
Singh S, Sharma BK, Wahi PL, Anand BS, Chugh KS. Spectrum of acute poisonings in adults (10 year experience).
J Assoc Physicians India
 
1984
;
32
:
561
–3.
141
Gupta SK, Grover JK, Bhardwaj SL, Sahak T, Basu N. Blood barbiturate levels in 175 suspected suicide patients.
J Assoc Physicians India
 
1984
;
32
:
340
–2.
142
Al‐Ansari AMS, Hamadeh RR, Matar AM, Buzaboon B, Marhoon H, Raees AG. Overdose among youth in Bahrain: psycho‐social characteristics, contact with helping agencies, and problems.
J Roy Soc Health
 
1997
;
117
:
366
–71.
143
Brahm J, Silva G, Palma R. Sobredosis de paracetamol: una neuva forma de suicidio en Chile y el valor de la administracion de N‐acetilcisteina.
Rev Med Chile
 
1992
;
120
:
427
–9.
144
Chan TYK, Critchley JAJH. Hospital admissions due to acute poisoning in the New Territories, Hong Kong.
Southeast Asian J Trop Med Public Health
 
1994
;
25
:
579
–81.
145
Chan TYK. The epidemiology of acetaminophen (paracetamol) poisoning in Hong Kong.
Vet Hum Toxicol
 
1996
;
38
:
443
–4.
146
Chan TY, Critchley JA, Chan AY. Renal failure is uncommon in Chinese patients with paracetamol (acetaminophen) poisoning.
Vet Hum Toxicol
 
1995
;
37
:
154
–6.
147
Chan TY, Chan AY, Critchley JA. Factors responsible for continuing morbidity after paracetamol poisoning in Chinese patients in Hong Kong.
Singapore Med J
 
1996
;
37
:
275
–7.
148
Fido AA, Al Mughaiseeb A. Consultation liaison psychiatry in a Kuwaiti general hospital.
Int J Social Psychiatr
 
1988
;
35
:
274
–9.
149
Levy M, Oren R. Paracetamol overdosage in Jerusalem.
Israel J Med Sci
 
1985
;
21
:
36
–9.
150
Oren R, Levy M. Paracetamol overdose in Jerusalem 1984–89.
Israel J Med Sci
 
1992
;
28
:
795
–6.
151
Maniam T. Suicide and parasuicide in a hill resort in malaysia.
Br J Psychiatr
 
1988
;
153
:
222
–5.
152
Chee YC, Teo LH. Self‐poisoning: a study of male patients hospitalised in a general medical department in one year.
Singapore Med J
 
1984
;
25
:
67
–9.
153
Chee YC, Teo LH. Self‐poisoning: a study of female patients hospitalised in a general medical department in one year.
Singapore Med J
 
1984
;
25
:
240
–3.
154
Monteagudo FS, Folb PI. Paracetamol poisoning at Groote Schuur Hospital. A five year experience.
S Afr Med J
 
1987
;
72
:
773
–6.
155
Spearman CW, Robson SC, Kirsch RE, Pillans P. Paracetamol poisoning.
S Afr Med J
 
1993
;
83
:
825
–6.
156
Wang K, Huang YS, Deng JF, et al. Characteristics and risk factors of acetaminophen‐induced hepatitis in Taiwan.
Chinese Med J
 
1999
;
62
:
369
–75.
157
Whitehall J. Fatal salicylate poisoning. Report on three fatal cases.
Central Afr J Med
 
1973
;
19
:
25
–7.
158
McDonald R. Accidental poisoning in children in Cape Town, with special reference to kerosene and salicylates.
S Afr Med J
 
1961
;
35
:
21
–5.
159
Don Michael TA, Aiwazzadeh S. The effects of acute chloroquine poisoning with special reference to the heart.
Am Heart J
 
1970
;
79
:
831
–42.
160
Good MI, Shader RI. Lethality and behavioural side effects of chloroquine.
J Clin Psychopharmacol
 
1982
;
2
:
40
–7.
161
Clemessy J‐L, Taboulet P, Hoffman JR, et al. Treatment of acute chloroquine poisoning: a 5‐year experience.
Crit Care Med
 
1996
;
24
:
1189
–95.
162
Meeran K, Jacobs MG. Chloroquine poisoning.
Br Med J
 
1993
;
307
:
49
–50.
163
Ndiaye PD, Ayessou V, Boye I. Intoxication volontaire mortelle a la nivaquine en milieu dakarois au Senegal. A propos de 22 cas.
Dakar Med
 
1983
;
28
:
159
–65.
164
N'Dri KD, Palis R, Saracino E, Nyouma A, Bondurand A. A propos de 286 intoxications a la chloroquine.
Afr Med
 
1976
;
15
:
103
–5.
165
Bondurand A, N'Dri KD, Coffi S, Saracino E. L’intoxication a la chloroquine au C.H.S.Abidjan.
Afr Med
 
1980
;
19
:
239
–42.
166
Vitris M, Aubert M. Intoxications a la chloroquine: notre experience a propos de 80 cas.
Dakar Medical
 
1983
;
28
:
593
–602.
167
Singh M, Patel BC, Pillai VRR, Madundo WK. Fatal suicidal chloroquine poisoning [Letter].
East Afr Med J
 
1979
;
??
:
294
–5.
168
McKenzie AG. Intensive therapy for chloroquine poisoning. A review of 29 cases.
S Afr Med J
 
1996
;
86
:
597
–9.
169
Mondain J, Gras G, Ndiaye PD. Repartition tissulaire de la chloroquine dans dix‐huit cas d’intoxication volontaire.
Bull Soc Pathol Exot
 
1979
;
72
:
86
–92.
170
Demaziere J, Saissy JM, Vitris M, et al. Effects du diazepam sur la mortalite des intoxications aigues par la chloroquine.
Ann Fr Anesth Reanim
 
1992
;
11
:
164
–7.
171
Queen HF, Tapfumaneyi C, Lewis RJ. The rising incidence of serious chloroquine overdose in Harare, Zimbabwe: emergency department surveillance in the developing world.
Trop Doct
 
1999
;
29
:
139
–41.
172
Kiel FW. Chloroquine suicide.
JAMA
 
1964
;
190
:
398
–400.
173
Pridmore S. Suicidal behaviour in the Solomon Islands.
Med J Aust
 
1995
;
162
:
614
–15.
174
Cooke RA, Wilkey IS, Aiken GH, Murthy P, Sengupta K. Forensic pathology in Papua New Guinea 1962–1989.
Med J Aust
 
1992
;
157
:
826
–8.
175
Wilkey IS. Chloroquine suicide.
Med J Aust
 
1973
;
i
:
396
–7.
176
Korinihona A, Laurenson IF, Naraqi S. Chloroquine overdose in adults: a practical approach to management.
PNG Med J
 
1992
;
35
:
311
–18.
177
Sengupta SK, Purohit RC, Buck AT. Chloroquine poisoning.
PNG Med J
 
1986
;
29
:
143
–7.
178
Boland ME, Brennand Roper SM, Henry JA. Complications of quinine poisoning.
Lancet
 
1985
;
i
:
384
–5.
179
Dyson EH, Proudfoot AT, Prescott LF, Heyworth R. Death and blindness due to overdose of quinine.
Br Med J
 
1985
;
291
:
31
–3.
180
Dezoteux H, Vinceneux Ph. Statistiques des intoxications aigues dans un service de reanimation medicale de Casablanca entre 1963 et 1969.
Maroc Med
 
1970
;
??
:
201
–11.
181
Nair PM, Philip E. Accidental dapsone poisoning in children.
Ann Trop Paediatr
 
1984
;
4
:
241
–2.
182
Tracqui A, Gutbub AM, Kintz P, Mangin P. A case of dapsone poisoning: toxicological data and review of the literature.
J Anal Toxicol
 
1995
;
19
:
229
–35.
183
Tai DY, Yeo JK, Eng PC, Wang YT. Intentional overdosage with isoniazid: case report and review of the literature.
Singapore Med J
 
1996
;
37
:
222
–5.
184
Su L. Clinical analysis of 40 cases with acute toxicosis of isoniazid.
Chung Hua Chieh Ho Ho HuHsi Hsi Chi Ping Tsa Chih
 
1983
;
6
:
174
–6.
185
Joubert PH, Mathibe L. Acute poisoning in developing countries.
Adverse Drug React Acute Poisoning Rev
 
1989
;
8
:
165
–78.
186
Stewart MJ, Steenkamp V, Zuckerman M. The toxicology of African herbal remedies.
Ther Drug Monitor
 
1998
;
20
:
510
–16.
187
Nyazema NZ. Herbal toxicity in Zimbabwe.
Trans R Soc Trop Med Hyg
 
1986
;
80
:
448
–50.
188
Chan TY, Lee KK, Chan AY, Critchley JA. Poisoning due to Chinese proprietary medicines.
Hum Exp Toxicol
 
1995
;
14
:
434
–6.
189
Chan TY, Chan JC, Tomlinson B, Critchley JA. Poisoning by Chinese herbal medicines in Hong Kong: a hospital based study.
Vet Hum Toxicol
 
1994
;
36
:
546
–7.
190
Chan TH, Wong KC, Chan JC. Severe salicylate poisoning associated with he intake of Chinese medicinal oil (‘red flower oil’) [Letter].
Aust New Zeal J Med
 
1995
;
25
:
57
.
191
Deng JF, Lin TJ, Kao WF, Chen SS. The difficulty in handling poisonings associated with Chinese traditional medicine: a poison control center experience for 1991–1993.
Vet Hum Toxicol
 
1997
;
39
:
106
–14.
192
Sinniah D, Baskaran G. Margosa oil poisoning as a cause of Reye's syndrome.
Lancet
 
1981
;
i
:
487
–9.
193
Sivashanmugham R, Bhaskar N, Banumathi N. Ventricular fibrillation and cardiac arrest due to neem leaf poisoning.
J Assoc Physicians India
 
1984
;
32
:
610
–11.
194
Capdevielle P, Darracq R. L’intoxication par le chardon a glu (Atractylis gummifera L.).
Med Trop
 
1980
;
40
:
137
–42.
195
Nhachi CFB, Kasilo OMJ. Household chemical poisoning admissions in Zimbabwe's main urban centres.
Hum Exp Toxicol
 
1994
;
13
:
69
–72.
196
Chan TYK, Leung KP, Critchley JAJH. Poisoning due to common household products.
Singapore Med J
 
1995
;
36
:
285
–7.
197
Chan TY. Poisoning due to Savlan (cetrimide) liquid.
Hum Exp Toxicol
 
1994
;
13
:
681
–2.
198
Chung SY, Luk SL, Mak FL. Attempted suicide in children and adolescents in Hong Kong.
Soc Psychiatry
 
1987
;
22
:
102
–6.
199
Joubert P, Hundt H, Du Toit P. Severe Dettol (chloroxylenol and terpineol) poisoning.
Br Med J
 
1978
;
i
:
890
.
200
Chan TYK, Lau MSW, Critchley JAJH. Serious complications associated with Dettol poisoning.
Q J Med
 
1993
;
86
:
735
–8.
201
Chan TY, Critchley JA. Is chloroxylenol nephrotoxic like phenol? A study of patients with Dettol poisoning.
Vet Hum Toxicol
 
1994
;
36
:
250
–1.
202
Chan TY, Sing JJ, Critchley JA. Chemical gastro‐oesophagitis, upper gastrointestinal haemorrhage and gastroscopic findings following Dettol poisoning.
Hum Exp Toxicol
 
1995
;
14
:
18
–19.
203
Chan TY, Critchley JA. Pulmonary aspiration following Dettol poisoning: the scope for prevention.
Hum Exp Toxicol
 
1996
;
15
:
843
–6.
204
Chan TY, Critchley JA, Lau JT. The risk of aspiration in Dettol poisoning: a retrospective cohort study.
Hum Exp Toxicol
 
1995
;
14
:
190
–1.
205
Joynt GM, Ho KM, Gomersall CD. Delayed upper airway obstruction. A life‐threatening complication of Dettol poisoning.
Anaesthesia
 
1997
;
52
:
261
–3.
206
Hulin A, Presles P, Desbordes J‐M. Les intoxications volontaires dans l’ile de Cayenne en 1979, 1980 et 1981.
Medecine d'Afrique Noire
 
1983
;
30
:
267
–71.
207
Ellis JB, Krug A, Robertson J, Hay IT, MacIntyre U. Paraffin ingestion—the problem.
S Afr Med J
 
1994
;
84
:
727
–30.
208
St. John MA. Kerosene poisoning in children in Barbados.
Ann Trop Paediatr
 
1982
;
2
:
37
–40.
209
Yagi H, El Hind AM, Khalil SI. Acute poisoning from hair dye.
East Afr Med J
 
1991
;
68
:
404
–11.
210
El‐Ansary EH, Ahmed MEK, Clague HW. Systemic toxicity of para‐phenylenediamine.
Lancet
 
1983
;
i
:
1341
.
211
Bourquia A, Jabrane AJ, Ramdani B, Zaid D. Toxicite systemique de la paraphenylene diamine. Quatre observations.
Presse Med
 
1988
;
17
:
1798
–800.
212
Benslama A, Moutaouakkil S, Mjahed K, El Moknia M, Lahbil D, Fadel H. Syndrome intermediaire lors d’une intoxication aigue par le malathion.
Presse Med
 
1998
;
27
:
713
–15.
213
Sood AK, Yadav SP, Sood S, Malhotra RC. Hair dye poisoning.
J Assoc Physicians India
 
1996
;
44
:
69
.
214
Agarwal SK, Bansal A, Mani NK. Barium sulfide poisoning.
J Assoc Physicians India
 
1986
;
34
:
151
.
215
Young RJ, Critchley JA, Young KK, Freebairn RC, Reynolds AP, Lolin YI. Fatal acute hepatorenal failure following potassium permanganate ingestion.
Hum Exp Toxicol
 
1996
;
15
:
259
–61.
216
Ong KL, Tan TH, Cheung WL. Potassium permanganate poisoning—a rare cause of fatal self poisoning.
J Accident Emerg Med
 
1997
;
14
:
43
–5.
217
Brito MA, Reyes RM, Arguello JR, Spiller HA. Principal causes of poisoning in Quito, Ecuador: a retrospective epidemiology study.
Vet Hum Toxicol
 
1998
;
40
:
40
–2.
218
Wu ML, Tsai WJ, Yang CC, Deng JF. Concentrated cresol intoxication.
Vet Hum Toxicol
 
1998
;
40
:
341
–3.
219
Chaudhary A, Puri AS, Dhar P, et al. Elective surgery for corrosive‐induced gastric injury.
World J Surg
 
1996
;
20
:
703
–6.
220
Gupta S. Surgical management of corrosive strictures following acid burns of upper gastrointestinal tract.
Eur J Cardiothoracic Surg
 
1996
;
10
:
934
–40.
221
Ganeshananthan.
Poisoning by corrosives in Sri Lanka—a unique experience
 . Oration to the Sri Lankan Medical Association, January
1999
.
222
Lai KH, Huang BS, Huang MH, et al. Emergency surgical intervention for severe corrosive injuries of the upper digestive tract.
Chinese Med J
 
1995
;
56
:
40
–6.
223
Su JM, Hsu HK, Chang HC, Hsu WH. Management for acute corrosive injury of upper gastrointestinal tract.
Chinese Med J
 
1994
;
54
:
20
–5.
224
Wu MH, Lai WW. Surgical management of extensive corrosive injuries of the alimentary tract.
Surg Gynecol Obstet
 
1993
;
177
:
12
–16.
225
Wu MH, Lai WH. Esophageal reconstruction for esophageal strictures or resection after corrosive injury.
Ann Thorac Surg
 
1992
;
53
:
798
–802.
226
Abi F, El Fares F, El Moussaoui A, Laaroussi H, Touzani K, Zerouali N. Les lesions caustiques du tractus digestif superieur. A propos de 191 observations.
J Chir (Paris)
 
1986
;
123
:
390
–4.
227
Jebira A, Daoues A, Ben Younes MA, Fourati M. Les oesophagites caustiques: considerations diagnostiques et therapeutiques. A propos de 16 cas.
Tunis Med
 
1985
;
63
:
601
–8.
228
Tounsi A, Hamdouch Z, Halhal A, M’Jahed A. Oesophagoplastie pour stenose caustique (a propos de 21 cas).
Chirurgie
 
1980
;
106
:
654
–8.
229
Rajan N, Rahim R, Kumar SK. Formic acid poisoning with suicidal intent: a report of 53 cases.
Postgrad Med J
 
1985
;
61
:
35
–6.
230
de Vries RR, Sitalsing AD, Schipperheyn JJ, Sedney MI. Klinische aspecten van azijnzuurintoxicatie.
Ned Tijdschr Geneeskd
 
1977
;
121
:
862
–6.
231
Nossent JD, Vismans FJFE. Azijnzuurintoxicatie op Curacao.
Ned Tijdschr Geneeskd
 
1982
;
126
:
1180
–3.
232
Wilson DAB, Wormald PJ. Battery acid—an agent of attempted suicide in black South Africans.
S Afr Med J
 
1994
;
84
:
529
–531.
233
Wormald PJ, Wilson DAB. Battery acid ingestion: a South African phenomenon.
Clin Otolaryngol
 
1993
;
18
:
112
–14.
234
Egigbo PO, Aghaji MAC, Obiako MN. Battery acid intake as a method of suicide attempt in Nigeria—family and social antecedents.
Int J Fam Psych
 
1987
;
8
:
375
–85.
235
Daisley H, Simmons V. Forensic analysis of acute fatal poisonings in the southern districts of Trinidad.
Vet Hum Toxicol
 
1999
;
41
:
23
–5.
236
Balasegaram M. Early management of corrosive burns of the oesophagus.
Br J Surg
 
1975
;
62
:
444
–7.
237
Lee JB, Chi JG, Ahn YO, et al. Comparative study on the structure of underlying cause of death among Koreans in autopsy cases between 1930s and 1960s.
Seoul J Med
 
1984
;
25
:
517
–26.
238
Lee JB, Hwang JJ. Analysis of suicide in legal autopsy during the period of 1981–1984.
Seoul J Med
 
1985
;
26
:
325
–30.
239
Chuttani HK, Gupta PS, Gulati S, Gupta DN. Acute copper sulphate poisoning.
Am J Med
 
1965
;
39
:
849
–54.
240
Wahal PK, Lahiri B, Mathur KS, Wahi PN. Acute copper sulphate poisoning.
J Assoc Physicians India
 
1963
;
11
:
93
–9.
241
Thirumalaikolundusubramanian P, Chandramohan M, Johnson ES. Copper sulphate poisoning.
J Indian Med Assoc
 
1984
;
82
:
6
–8.
242
Mehta A, Patney NL, Bhati DPS, Singh SP. Copper sulphate poisoning—its impact on kidneys.
J Indian Med Assoc
 
1985
;
83
:
108
–10.
243
Chugh KS, Sharma BK, Singhal PC, Das KC, Datta BN. Acute renal failure following copper sulphate intoxication.
Postgrad Med J
 
1977
;
53
:
18
–23.
244
Ahmed SH, Zuberi H. Changing pattern of suicide and parasuicide in Karachi.
J Pak Med Assoc
 
1981
;
??
:
76
–8.
245
Singh D, Tyagi S. Changing trends in acute poisoning in Chandrigah zone. A 25‐year autopsy experience from a tertiary care hospital in northern India.
Am J Forensic Med Pathol
 
1999
;
20
:
203
–10.
246
Ahasan HAMN, Chowdhury MAJ, Azhar MA, Rafiqueuddin AKM. Copper sulphate poisoning.
Trop Doct
 
1994
;
24
:
52
–3.
247
Yen D, Tsai J, Wang LM, et al. The clinical experience of acute cyanide poisoning.
Am J Emerg Med
 
1995
;
13
:
524
–8.
248
Borgohain R, Singh AK, Radhakrishna H, Rao VC, Mohandas S. Delayed onset generalised dystonia after cyanide poisoning.
Clin Neurol Neurosurg
 
1995
;
97
:
213
–15.
249
Pande TK, Pani S, Hiran S, Rao VVB, Shah H, Vishwanathan KA. Turpentine poisoning: a case report.
Forensic Sci Int
 
1994
;
65
:
47
–9.
250
Varma PP, Jha V, Ghosh AK, Joshi K, Sakhuja V. Acute renal failure in a case of fatal chromic acid poisoning.
Renal failure
 
1994
;
16
:
653
–7.
251
Singh S, Chaudhry D, Garg M, Sharma BK. Fatal ethylene dibromide ingestion.
J Assoc Physicians India
 
1993
;
41
:
608
.
252
Prakash MS, Sud K, Kohli HS, Jha V, Gupta KL, Sakhuja V. Ethylene dibromide poisoning with acute renal failure: first reported case with non‐fatal outcome.
Renal failure
 
1999
;
21
:
219
–22.
253
Saraswat PK, Kandara M, Dhruva AK, Malhotra VK, Jhanwar RS. Poisoning by ethylene dibromide—six cases: a clinicopathological and toxicological study.
Indian J Med Sci
 
1986
;
40
:
121
–3.
254
Lin JL, Lim PS. Acute sodium chlorite poisoning associated with renal failure.
Renal failure
 
1993
;
15
:
645
–8.
255
Chen MR, Lin JL, Liaw SJ, Bullard MJ. Acute iron intoxication: a case report with ferric chloride ingestion.
Chinese Med J
 
1993
;
52
:
269
–72.
256
Chang YL, Yang CC, Deng JF, et al. Diverse manifestations of oral methylene chloride poisoning: report of six cases.
J Toxicol Clin Toxicol
 
1999
;
37
:
497
–504.
257
Abu Al‐Ragheb S, Salhab AS, Amr SS. Suicide by xylene ingestion.
Am J Forensic Med Pathol
 
1986
;
7
:
327
–9.
258
Kasilo OMJ, Nhachi CFB. Survey of chemical (mostly metals) poisoning cases as reflected in hospital admissions in urban Zimbabwe.
Bull Environ Contam Toxicol
 
1993
;
50
:
260
–5.
259
Modi NS.
Modi's Textbook of Medical Jurisprudence and Toxicology
 . Bombay, N.M. Tripathi Private Limited,
1988
;
277
.
260
Parikh CK.
Parikh textbook of medical jurisprudence and toxicology
 . Bombay, Medical Publication,
1989
:
912
–14.
261
Schvartsman S (ed).
Plantas venenosas e animais peconhentos
 . Sao Paulo, Brasil, Sarvier,
1992
.
262
Saravanapavananthan T. Plant poisoning in Sri Lanka.
Jaffna Med J
 
1985
;
20
:
17
–22.
263
Fernando R, Fernando D. Poisoning with plants and mushrooms in Sri Lanka: a retrospective hospital based study.
Vet Hum Toxicol
 
1990
;
32
:
579
–81.
264
Pronczuk de Garbino J, Laborde A. Plants that poison in Uruguay.
J Toxicol Clin Toxicol
 
1984
;
22
:
95
–102.
265
Eddleston M, Ariaratnam CA, Meyer PW, et al. Epidemic of self‐poisoning with seeds of the yellow oleander tree (Thevetia peruviana) in northern Sri Lanka.
Trop Med Int Health
 
1999
;
4
:
266
–73.
266
Eddleston M, Rajapakse S, Rajakanthan, et al. Anti‐digoxin Fab fragments in cardiotoxicity induced by ingestion of yellow oleander: a randomised controlled trial.
Lancet
 
2000
;
355
:
967
–72.
267
Eddleston M, Ariaratnam CA, Sjostrom L, et al. Acute yellow oleander (Thevetia peruviana) poisoning—cardiac arrhythmias, electrolyte disturbances and serum cardiac glycoside levels on presentation to hospital.
Heart
 
2000
;
83
:
301
–6.
268
Thomas K, Dayal AK, Gijsbers A, Seshadri MS, Cherian AM. Oduvanthalai leaf poisoning.
J Assoc Physicians India
 
1987
;
35
:
769
–71.
269
Aleem HMA, Thomas K. Oduvan leaf poisoning [Letter].
J Assoc Physicians India
 
1991
;
39
:
973
–4.
270
Annapoorani KS, Damodaran C, Chandra Sekharan P. A promising antidote to Cleistanthus collinus poisoning.
J Forensic Sci Soc India
 
1986
;
2
:
3
–6.
271
Annapoorani KS, Periakali P, Ilangovan S, Damodaran C, Chandra Sekharan P. Spectrofluorometric determination of the toxic constituents of Cleistanthus collinus.
J Anal Toxicol
 
1984
;
8
:
182
–6.
272
Thomas K, Dayal AK, Narasimhan, et al. Metabolic and cardiac effects of Clistanthus collinus poisoning.
J Assoc Physicians India
 
1991
;
39
:
312
–14.
273
Dunuwille R, Balasubramanian K, Bibile SW. Toxic principles of Gloriosa superba.
Ceylon J Med Sci
 
1968
;
17
:
1
–6.
274
Angunawela RM, Fernando HA. Acute ascending polyneuropathy and dermatitis following poisoning by tubers of gloriosa superba.
Ceylon Med J
 
1971
;
??
:
233
–4.
275
Aleem HM. Gloriosa superba poisoning.
J Assoc Physicians India
 
1992
;
40
:
541
–2.
276
Mendis S. Colchicine cardiotoxicity following ingestion of Gloriosa superba tubers.
Postgrad Med J
 
1989
;
65
:
752
–5.
277
Nagaratnam N, De Silva DPKM, De Silva N. Colchinine poisoning following ingestion of Gloriosa superba tubers.
Trop Geogr Med
 
1973
;
25
:
15
–17.
278
Baud FJ, Sabouraud A, Vicaut E, et al. Brief report: treatment of severe colchicine overdose with colchicine‐specific Fab fragments.
N Engl J Med
 
1995
;
332
:
642
–5.
279
Cummins RR, Allwood CW. Suicide attempts or threats by children and adolescents in Johannesburg.
S Afr Med J
 
1984
;
66
:
726
–9.
280
Usalan C, Altun B, Ulusoy S, et al. Hypernatraemia and polyuria due to high‐dose colchicine in suicidal patient.
Nephr Dial Transplant
 
1999
;
14
:
1556
–7.
281
Gowdy JM. Stramonium intoxication.
JAMA
 
1972
;
221
:
585
–7.
282
Ali Taha S, Mahdi AH. Datura intoxication in Riyadh.
Trans Roy Soc Trop Med Hyg
 
1984
;
78
:
134
–5.
283
Khan NI, Sen N, al‐Haque N. Poisoning in a medical unit of Dhaka Medical College Hospital in 1983.
Bangladesh Med J
 
1985
;
14
:
9
–12.
284
Simmat G, Robert R, Gil R, Lefevre JP. Tentative d’autolyse par absorption de graines de Datura stramonium.
Presse Med
 
1983
;
12
:
2399
.
285
Parker N, Burton‐Bradley BG. Suicide in Papua and New Guinea.
Med J Aust
 
1966
;
ii
:
1125
–9.
286
Ad Hoc Committee on Health Research Relating to Future Intervention Options.
Investing in health research and development
 . Geneva, World Health Organisation (Document TDR/Gen/96.1),
1996
.
287
Daisley H, Hutchinson G. Paraquat poisoning.
Lancet
 
1998
;
352
:
1393
–4.
288
Proudfoot AT, Park J. Changing patterns of drugs used for self‐poisoning.
Br Med J
 
1978
;
i
:
90
–3.
289
Gunn DL. Alternatives to chemical pesticides. In: Gunn DL, Stevens JGR, eds.
Pesticides and human welfare
 . Oxford, Oxford University Press,
1976
:
241
–55.
290
Swezey SL, et al.
Getting off the pesticides treadmill in the developing world: Nicaragua's revolution in pesticide policy
 . Leon, University of Nicaragua,
1984
.
291
Matthew H. Acute poisoning.
Community Health
 
1970
;
2
:
18
–22.
292
van der Sande R, Buskens E, Allart E, van der Graaf Y, van Engeland H. Psychosocial intervention following suicide attempt: a systematic review of treatment interventions.
Acta Psychiatr Scand
 
1997
;
96
:
43
–50.
293
Hawton K, Arensman E, Townsend E, et al. Deliberate self harm: systematic review of efficacy of psychosocial and pharmacological treatments in preventing repetition.
Br Med J
 
1998
;
317
:
441
–7.
294
House A, Owens D, Patchett L. Deliberate self‐harm.
Effective health care
 
1998
;
4(6)
:
1
–12.
295
Patel V, Sumathipala A. Methods used for suicide vary between regions in the developing world [Letter].
Br Med J
 
1999
;
318
:
259
.
296
Ellawela NS. Strategies of suicide prevention. In: De Silva P, ed.
Suicide in Sri Lanka.
  Kandy, Institute of Fundamental Studies,
1989
:
69
.
297
Eddleston M. Deliberate self‐poisoning in Sri Lanka—improving medical management through clinical research (Editorial).
J Ceylon Coll Physicians
 
1997
;
30
:
11
–17.
298
Chyka PA. Multiple‐dose activated charcoal and enhancement of systemic drug clearance: summary of studies in animals and human volunteers.
J Toxicol Clin Toxicol
 
1995
;
33
:
399
–405.
299
Todd JW. Do measures to enhance drug removal save life?
Lancet
 
1984
;
i
:
331
.
300
Henry JA, Volans GN, Widdop B. Do measures to enhance drug removal save life? [Letter].
Lancet
 
1984
;
i
:
561
.
301
Vale JA, Proudfoot AT. How useful is activated charcoal?
Br Med J
 
1993
;
306
:
78
–9.
302
Henry JA, Hoffman JR. Continuing controversy on gut decontamination.
Lancet
 
1998
;
352
:
420
–1.
303
Chyka PA, Seger D. Position statement: single‐dose activated charcoal. American Academy of Clinical Toxicology and European Association of Poison Centres and Clinical Toxicologists.
J Toxicol Clin Toxicol
 
1997
;
35
:
721
–41.