Murder and Medicine (Part 2)
Want to know how your organs can turn green? About the controversial start to forensic toxicology evidence? And why our patient isn’t responding to treatment? Listen to find out!
This is the Pick Your Poison podcast. I’m your host Dr. JP and I’m here to share my passion for poisons in this interactive show. Will our patients survive this podcast? It’s up to you and the choices you make. Our episode today is called Murder and Medicine Part 2. It’s a continuation and so is a spoiler for part one. If you haven’t listened yet, I recommend going back and starting there. The King of Poisons is such a fascinating topic it requires two episodes to do it justice.
Want to know how your organs can turn green? About the controversial start to forensic toxicology evidence? And why our patient isn’t responding to treatment? Then stay tuned!
This episode starts in the ICU. At a computer in the nurses station, you review the chart of our 60-year-old-patient. If you remember, he presented with abdominal pain, vomiting and rice water diarrhea. You discovered he’s suffering from arsenic toxicity with a spot urine level of 100,000 mcg/L. You recommended chelation with dimercaprol to treat the poison. Currently his vital signs are as follows: blood pressure 89/62 and heart rate 130 beats per minute. This is not good. His blood pressure is very low, despite the ICU team starting pressors, heavy-duty blood pressure medicines, overnight. This despite the maximum dose of dimercaprol.
How was he exposed to arsenic? Why isn’t he responding to treatment?
There are a number of ways to become poisoned with arsenic. Let’s address the first question by talking about the history of arsenic toxicity because the astonishing prevalence of arsenic in the Victorian era is both interesting and informative.
I love to discuss cases, for me, it makes the poisons vivid and memorable rather than dry and dusty. Rather than confuse ourselves with a new patient– ha-ha- if only the ER worked like this, let’s instead discuss a few historical cases to highlight the history and symptoms of arsenic toxicity.
The first route of exposure we all know about. Murder.
Enter historical case 1 – The trial of Marie LaFarge. It was very, very sensational at the time and remains famous today. Why? It’s the first time forensic toxicology was used in a trial. It was the Marsh Test, invented in 1836, by James Marsh a Scottish chemist, to determine the presence of arsenic postmortem.
Question #1 True or False. The first time this was used in a trial, it definitively proved guilt or innocence of the accused.
A. True
B. False
Answer: B False. There’s no doubt the Marsh test works, if done correctly, so researching the case, I assumed it would be cut and dry with the toxicology results proving the truth beyond a shadow of a doubt. I should’ve known better. Despite what you see on TV, just like in modern times, toxicology evidence is not as definitive and more subject to interpretation than anybody likes.
I’ll share some details, then you decide what you think about the verdict.
Fair? Or biased?
Marie and Charles LaFarge married in Paris in August of 1839. Before the wedding, he advertised himself as a wealthy man with a palatial estate. This was false advertising, in fact he had a pile of debts and needed a wife with a big dowery, which Marie had. When she arrived at this estate, she was shocked to find a ruined former monetary, infested with rats. Her in-laws didn’t trust her, she felt they were little better than peasants.
On her wedding night, Marie locked herself in her room, threatening to commit suicide. With arsenic. Eventually, she and Charles reconciled, promising to will each other their assets. She did will her large dowery to him. He did the same, then secretly changed the will, leaving the estate to his mother.
In December 1839, Charles travelled to Paris for business. Maries sends letters and a Christmas cake, apparently cream puffs. He becomes ill and returns home. He has abdominal pain and diarrhea. His doctor diagnoses cholera and recommends eggnog. While the doctor is there, Marie asks him for an arsenic prescription to kill the rats in Charles’ bedroom.
Charles has ongoing nausea and diarrhea, he develops leg cramps indicating dehydration. He dies on January 13. The family believes Marie poisoned him. A woman staying with them says Marie put white powder into Charles’ eggnog and later into his soup. They become even are more suspicious when they discover Marie obtained arsenic. Marie says she gave the toxin to the gardener. The house is filled with white paste he mixed to kill the rats.
Marie takes Charles’ will to the notary, unaware he changed it. The family calls the justice of the peace. He asks Charle’s doctors if they can perform a new test to detect arsenic, the Marsh test. They lie and say yes.
The LaFarge case captured the attention of the news media worldwide. Questions arose about the “Christmas cake” Marie mailed Charles. Was it poisoned with arsenic? Who knows but honestly, you don’t need poison to kill someone if you’re sending them cream puffs by mail. The media discovered a wealthy classmate and former friend, had accused Marie of stealing her jewels years in the past, prior to her marriage. The accusations, never went anywhere, but now dredged up, a search revealed the jewels in Marie’s house. Marie said she was acting as an intermediary between the friend and a blackmailer. The LaFarge family hated Marie and needed her money. At one point, Marie received an incredible 6,000 letters per week.
At the trial, local physicians declared there was no arsenic in Charles’ body though they did find it in the eggnog and other food. Interestingly, analysis of the white paste around the house, untouched by rats, revealed only flour, water and soda, no arsenic. In truth, they didn’t know how to perform the Marsh test.
Faced with contradictory evidence, and vociferous factions of the media and public both for and against Maria, a famous chemist was called to definitively perform the test. His name was Mathieu Orfila, and using the Marsh test, proved high levels of arsenic were present in Charle’s body and the food Marie had given him.
Do you think Marie LaFarge is guilty? Yes or No?
She was pronounced guilty and sentenced to life in prison with hard labor on the basis of this evidence, the first forensic toxicology evidence in history.
You’d think that was the end of the story, but no. Another expert called in said Orfila did the test wrong, however this man arrived too late to testify, four hours after LaFarge was pronounced guilty. The Marsh test itself works, so that wasn’t in question. How it was performed in this case was the issue. During the trial, both the New York Times and the British Medical Journal doubted the evidence against Marie. Orfila did the Marsh test three times, the first two, with local reagents, was negative. The third test, after an assistant was sent to his lab in Paris, was positive.
Now do you think she was guilty? Yes or No?
Questions remain and I doubt we will ever know the truth. It’s fascinating the controversy surrounding the first use of forensic toxicology isn’t much different than questions which arise in modern trials.
The case occurred at the height of what’s been called the Poison Panic in Victorian England. Newspapers published dramatic headlines, fanned the flames of sensationalism. In addition, arsenic was everywhere and in everything at this time.
Who wrote in his journal, “It is clear the favorite poison with us is arsenic.” Question #2.
A. Charles Dickens
B. Emily Bronte
C. Aurther Conan Doyle
D. Oscar Wilde
Answer: A. Charles Dickens.
Why arsenic for murder? It was easy to obtain as it was readily available over the counter as rat poison. It’s tasteless and colorless, easy to conceal. And speaking of easy to conceal, poisoning looked like cholera, super common at the time. So death was easily attributed to natural causes.
Murder wasn’t the only way back then to develop arsenic toxicity. It wasn’t just in rat poison, but also in medicine. I mentioned last week it was in powders, pills and even enemas. Fowler’s solution 1% arsenic, invented in 1786 was used until the 1950s to treat a variety of ailments including psoriasis, syphilis, malaria and cancer. Charles Darwin used it, leading to speculation about the role of arsenic toxicity in his death.
It was also found in cosmetics and hair dye. Dr. Campbell’s Safe Arsenic Wafers promised a clear complexion. Remarkably boxes said “guaranteed safe and absolutely harmless to anybody.” At a time when everyone knew about arsenic toxicity. Users hoped to achieve a “milk and roses completion” with pale skin and pink cheeks. The pink cheeks were damaged capillaries. People even went to arsenic hot springs, for example in the Czech Republic, promising transparent skin.
When I say arsenic was everywhere, I mean it literally. It even reached the Artic, on expeditions. Charles Francis Hall, an Artic explorer may’ve been murdered on his last trip. He fell ill after drinking coffee, suffered vomiting and delirium, accusing other members of his party of poisoning him. An investigation in 1968 on his exhumed body, revealed high arsenic levels. Was it murder or medicine? No one knows.
Question #3. Poisoning wasn’t only via ingestion. Where was arsenic found in the 1800s?
A. Clothing
B. Wallpaper
C. Cosmetics
D. All of the above
Answer: all of the above.
Unintentional poisoning by environmental exposure was so common, it was literally part of everyday life. Why? In 1814 Paris green dye was developed. It was a beautiful color, very popular and very expensive. It was used everywhere from wallpaper to clothing. Beautiful and expensive, also poisonous.
Historical Case 2 also captured the attention of the media. In contrast to the LaFarge case, there was no doubt as to the culprit in this tragedy. Mathilda Scheurer died in 1861. She was a 19 yo woman employed as an artificial flower maker. Newspapers described her death in lurid detail. The whites of her eyes and fingernails were green. She vomited green waters, convulsed and foamed from the mouth eyes, and nose.
At autopsy, her organs were green. Arsenic was found in her lungs, liver and bowels. The patient’s sister had died under similar circumstances.
Matilda worked in a factory making flower crowns. Her job was to dust the leaves of the artificial flowers with powder containing green pigment. 1/8th a teaspoon of this powder is a fatal dose, workers were exposed to it by the pound. Newspapers later reported each flower she’d dusted contained enough arsenic to kill 20 people.
Cases like these established the toxicity of green pigment in flowers, fabric and wallpaper. While arsenic toxicity was well known, was wasn’t initially common knowledge arsenic was part of the dye and, no surprise symptoms were dismissed by those in power. William Morris, manufacturer of famously beautiful wallpaper still admired today said the victims were bitten by Witch Fever, suggesting they were faking.
It wasn’t just workers who were sickened. Wearers of dresses dyed with Paris green developed malaise and fatigue, skin ulcers and hair loss in addition to systemic poisoning from arsenic absorbed into the blood stream. The British Medical Journal wrote “a woman carries in her skirts poison enough to slay the whole of the admirers she may meet within a half a dozen ballrooms.” It wasn’t an exaggeration. Dresses were estimated to contain 200x the lethal dose of arsenic.
Wallpaper with Paris green sickened family members after exposure inside their homes. Humidity and interestingly, fungus, are believed to affect the paper, releasing toxic arsine gas. You may’ve heard speculation about Napolean dying from arsenic poisoning. It’s true he had very high levels on postmortem testing. However, his prison wallpaper contained arsenic and hair testing, revealed very high levels even in childhood, making unintentional exposure much more likely than murder.
As late as 1950, Claire Luce Booth, the American ambassador to Italy developed arsenic toxicity from paint chips falling from the ceiling of her 17th century villa into her coffee. There are still concerns about arsine gas release with artifacts, wallpaper, dresses and books, in museums.
What finally stopped the Victorian Poison Panic? I assumed it was the Marsh test but, in fact, cases in British courts increased in the years following it’s development. Awareness of the toxicity of Paris green helped. What finally seems to have stemmed the tide is the Sale of Arsenic Regulation Act in 1851, requiring registration of sales by sellers. This act started our modern system of pharmacies and drug regulation. It didn’t restrict the sale, but rather required keeping a register of sales.
Some complained asking why only arsenic. The Poisons and Pharmacy Act 1868 addressed this, adding 15 poisons and detailing a system of pharmacy qualification and education. Side note, this act was incredibly important. Pediatric opium deaths dropped from about 20 per million in 1867 to 7 per million in the 1880s thanks to the legislation.
Anyway, I could literally go on forever with nefarious tales of arsenic poisoning and murder.
Back to our patient. Is this an occupational exposure? Jewelers, semiconductor manufacturing and Chinese fireworks manufacturing use arsenic. He’s an account, so doubtful. He’s not getting any arsenicals as medicine and fortunately it’s no longer in cosmetics. Leaving us with murder. The ICU team called the police after you made the diagnosis a few days ago.
It’s time for rounds. So let’s get to his bedside. You don’t need a physical exam, a glance is enough to tell you he’s deathly ill. His skin is pale and sweaty. The nurse just changed his soiled sheets, nevertheless liquid stool is leaking out of his diaper onto the clean linens. He has a breathing tube down his throat and a feeding tube snaking down one nostril. His arms are bruised from dimercaprol injections.
His wife is at his bedside. She dips a syringe into a Tupperware container on the bedside table, sucking up a thick white liquid. She squirts it down his feeding tube.
“He just loves my milkshakes,” she says with a smile. This is the first time you’ve ever seen a milkshake used as tube feeds. “Thank you for taking such good care of my husband.”
It doesn’t feel like we are taking good care of him. He’s not getting better despite treatment. She squirts another syringeful down the tube.
Uh oh.
You figured out why our patient is not improving. You grab the syringe out of her hand, the Tupperware container from the bedside and run down the hall. She chases you. You swipe your badge to enter the med room and slam the door shut behind you. She pounds on the door while you call the police.
They police charge her with attempted murder. Our patient, free of the poisoned milkshakes recovers. Barely. But he does, his arsenic levels rising before finally dropping, as the exposure stops and dimercaprol does its job.
This is a fictional case as are all our cases to protect the innocent, but it is based on real poisonings. In this case, a woman convicted of poisoning several husbands, including one while in the hospital, is the oldest woman on death row.
Did Arsenic poison residents after the 2007 meteorite impact event in Peru? I was very excited when I saw this headline. Poisoning from contact with outer space? Yes! After the meteor struck, about 200 residents complained of nausea, vomiting and headaches. One theory suggested naturally occurring arsenic in the groundwater liberated by the crater caused the symptoms. Sadly, others noted arsenic levels were the same as drinking sources, casting this theory in doubt. You can’t believe everything you read, especially true about suspected poisoning and toxins.
Last question in today’s podcast. What book describes the death of a main character by arsenic poisoning? And is recorded in such great detail the author said they vomited twice while writing it?
A. And then there were none – Agatha Christie
B. A Study in Scarlet – Arther Conan Doyle
C. Madam Bovary – Gustave Flaubert
D. Hamlet – Shakespeare
Follow the Twitter and Instagram feeds both @pickpoison1 and you’ll see the answer when I post it. Remember, never try anything on this podcast at home or anywhere else.
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While I’m a real doctor this podcast is fictional, meant for entertainment and educational purposes, not medical advice. If you have a medical problem, please see your primary care practitioner. Thank you. Until next time, take care and stay safe.