THE FOLLOWING ARTICLE APPEARED IN THE

FEBRUARY 1999 ISSUE

THE POISON SLEUTHS

DEATH BY POTASSIUM PERMANGANATE

-Dr. Anil Aggrawal

"Good morning doctor. Oh, my God, what are you doing today? You have the dead body of a middle aged man today. The corner of his lips seem to be stained with some dark black substance. What has happened to him? Please tell me."

"Good morning Tarun. The name of this middle aged man is Sagar, and he is about 45 years old. He died in the hospital today morning. Yesterday night, he was having his dinner when suddenly he developed a burning pain in his abdomen. He had nausea and vomiting too, and the vomited material contained some brown material. He complained of intense thirst too. Because of this, the was brought by some of his neighbors to the hospital. But while the doctors were still investigating, he died today morning. Now since the doctors had not arrived at any diagnosis, the police has handed over his body to me. They want me to tell them, how Sagar has actually died."

"So what are you going to do now?"

"I have taken a detailed history from the police. The police tells me that Sagar was a builder, and he was running a very successful business. He however had business rivalry with a person called Nath. Apparently his business endeavors had caused great losses to Nath. Nath however kept visiting him often and posed as if he was his friend. Deep in his heart however, he wanted to get rid of him. Yesterday Nath visited him in his house for the New Year celebrations and gave him a bottle of red wine too for celebrations. Sagar was a sucker for red wine, so immediately after Nath left, he started consuming the red wine. However I am told that before Nath left, Sagar treated him to some very nice champagne from his own stock. But after Nath left, Sagar opened the wine bottle and emptied it in no time. After that he started having his dinner, but soon he started having all those symptoms."

"Oh, I see. Looks like there was something in the red wine, which caused these symptoms. Is it?"

"Probably you are correct Tarun. I became suspicious when I saw these dark stains on Sagar's face. You also noticed these stains, didn't you? Furthermore, the inside of his mouth and foodpipe were also stained. From these and certain other post-mortem findings which I am going to tell you later, I could zero down only on one poison....."

"What is that poison doctor? Please tell me."

"Tarun, it is a very rare poison. You probably never even imagined it is a poison. It is potassium permanganate or KMnO4."

"Really? Yes, I never believed Potassium permanganate could be a poison too. In fact as far as I know, it is used to treat certain poisonings."

"You are right Tarun. In certain poisonings, such as poisoning by Opium, potassium permanganate solution indeed is recommended. Doctors actually wash the stomach with this solution, because potassium permanganate oxidizes the opium. Similarly in many other poisonings, doctors wash the stomach with potassium permanganate solution. But unfortunately permanganate acts as a poison too. In fact about 10-20 g of potassium permanganate is enough to kill a person."

"Is it? Oh, I think, we are on the trail of yet another interesting poison. Doctor please tell me more about Potassium permanganate (KMnO₄)?"

"Tarun, potassium permanganate is a common substance, and it may be acquired without restriction by members of the public. Yet poisoning by it is uncommon and although in the case of Sagar we are probably facing a death due to this substance, in fact fatal poisoning by KMnO4 is rare. This must not cause its danger to be overlooked or underrated. Children in particular must be protected against the ingestion of colored crystals which may be eaten in mistake for sweets. In fact, I am personally aware of a child aged about 22 months who died after eating some permanganate crystals which his father used for gardening. Tablets of KMnO4 are still on sale in the USA and as Condy's tablets in Australia. In India too, this substance is not difficult to acquire. You may be surprised to know that KMnO4 has been used for illegal abortions."

"Really? How??"

"Potassium permanganate is an irritant substance. It irritates the uterus too, and may cause it to expel its contents. This has made the use of KMnO4 very popular in illegal abortions. Some women simply ingest it, while some make its solution and introduce it in their uterus through the vaginal route. Some women simply introduce crystals of KMnO4 in their vagina in order to procure abortion. The insertion of tablets of potassium permanganate into the vagina to procure abortion first came to notice in Spain and Italy during the 1930s. The practice spread to the USA in about 1936. This practice was noticed in England during World War II. It was thought that this 'new way to miscarry' was introduced to England by American servicemen, and indeed the tablets of KMnO4 were being hawked outside the local antenatal clinic of several doctors! You may be surprised to know that the mothers of newly married brides often regarded a box of these tablets as an appropriate gift to their daughters on the eve of their wedding!"

"Oh, that is indeed most interesting. Probably it was because proper methods for abortion had not been developed by then?"

"No, proper methods for abortions were there, but unfortunately abortion was not legal in most countries at that time. For instance in India, abortion became legal only as late as 1971. Before this time, if any married or unmarried woman became pregnant, the only way for her to have an abortion was to resort to such dangerous "household" methods. Although abortion has become legal in most countries, yet this practice has not yet have been abandoned in most of the countries. The reason is that most unmarried girls - for fear of society's censure - still don't want to disclose they have fallen pregnant. They prefer to do it themselves by these dangerous methods. They learn of these methods from their friends, acquire KMnO4 from somewhere and then try it out on their own. This has caused several deaths too. Douching with potassium permanganate is also very common..."

"What is douching doctor?"

"Women make a solution of KMnO4 and then with the help of an appropriate instrument, push this solution into their uterus. The douching may be done with intent to procure an abortion or only for hygienic reasons as KMnO4 is supposed to be an antiseptic. If however, the solution is too concentrated, it can have dangerous and probably fatal consequences."

"Oh, I see. Has it been used for some other illegal activities too?"

"Yes, potassium permanganate has been used to produce fictitious injuries. A trick is often employed by soldiers to simulate the lesions of tertiary syphilis by applying a tablet of permanganate to the skin for 10 to 20 minutes..."

"Doctor what is tertiary syphilis? And what do you mean by lesions?"

"Tarun, syphilis is a venereal disease which spreads by sexual contact. It affects the victim in several stages. Tertiary syphilis is the last stage of this disease, which commences several years after the sexual contact with an affected partner. By lesions, I simply mean the various abnormal and harmful changes which occur because of disease. A peculiar lesion in tertiary syphilis is a perforating ulcer of the feet. Such a lesion can be produced by applying potassium permanganate on the feet for several minutes..."

"But why would a person want to produce such a lesion?"

"Many persons want to simulate disease in order to get medical leaves. This trend is very common in the Army, where getting leaves is very difficult. Such people who pose that they are ill, yet are not, are called malingerers. A case of a soldier has been described who swallowed a solution of permanganate to simulate 'coffee ground' vomit. Such kind of vomit is usually seen in gastric ulcers. So probably this soldier wanted leave on this ground."

"Oh, that is most interesting. Has it been used for other illegal activities too?"

"Well, not for illegal activities, but certainly for some dangerous activities. For instance potassium permanganate solution was used at one time, notably during and after World War I, as an irrigant of the urethra and bladder in the treatment of gonorrhoea. The reasoning behind it was the same - it acts as an antiseptic."

"Doctor, you told earlier that KMnO₄ is used for stomach wash in certain poisonings. Does it not kill the patient then?"

"Tarun, when KMnO₄ is used for stomach wash, it is used in a solution of the strength 1:5000. It acts as an irritant in higher concentrations - about 1:1000. I may tell you that from the color of the KMnO4 solution, a rough idea can be made about the concentration. When the solution has a faint pink colour, the concentration is about one part per million. When the concentration rises to 1 part in 76,000 (65 mg/4.5 l) the fluid becomes purple. Because of its color, the solution has been used for staining also. Those who use the chemical as a stain for flooring and woodwork, working with a concentrated solution, must exercise care. Deep staining of the skin of the hands is immediate and prolonged contact can cause damage to the skin. There was a time when permanganate was used to dye white hair a chestnut brown."

"Oh really?"

"Yes, and I can tell you certain other interesting facts about permanganates too. Permanganates are normally stable in crystalline form but zinc permanganate can become explosive. In fact, storing it in tightly stoppered bottles can be highly dangerous. When handling these containers one should exercise utmost caution."

"Doctor, do you think Nath mixed Potassium permanganate in something which he gave to Sagar?"

"Yeah, looks like. Remember he gave a bottle of Red wine which Sagar immediately consumed after he left. Potassium permanganate can be easily dissolved in red wine because the colors of both are similar. Moreover the taste of red wine would mask the taste to potassium permanganate. Furthermore, Nath ensured that Sagar was not completely in his senses by having some drinks with him in his house. He knew that after he left his house Sagar would consume the red wine, and he would get severely poisoned."

"Doctor, has Potassium permanganate been used for homicide often?"

"Not really. It has more often been used for suicidal purposes, but accidental poisoning also occurs, notably in children under the age of four years, who usually mistake the red colored crystals for sweets. Adults, however, have taken the poison by mistake. A solution of permanganate may easily be mistaken for wine. And as I already told you, in the past it occasionally caused poisoning when taken orally as an abortifacient."

"What is an abortifacient doctor?"

"Tarun, abortifacient is a drug which causes abortion. Another popular - although wrong - belief is that it is a remedy for amenorrhoea. Amenorrhoea means absence of menstruation. Normally a girl should start menstruation at about the age of 13 years, but if the menstrual cycle does not start, the condition is known as amenorrhoea. Ideally when faced with such a symptom, a woman should contact a doctor, but many women prefer to treat themselves by folk remedies, and potassium permanganate is one of the folk remedies for amenorrhoea. Pills containing 65-130 mg of potassium permanganate, taken shortly before the expected period are supposed to cure the condition."

"Doctor, what symptoms does the person get when he ingests potassium permanganate?"

"Tarun, the symptoms are exactly as seen in Sagar's case. Staining of the tissues is very obvious. Some patients may have brown stains on the face, in linear form running down from an angle of the mouth on to the chin as you have seen in Sagar's case. The eyes and face may be stained if crystals fall on to the face. It is more usual to find discoloration of the interior of the mouth. If seen soon after poisoning the colour is purple-brown, but within minutes this changes to brown or dark brown and, later, following the formation of manganese dioxide, it may be coal black. A slight metallic lustre may also be apparent. I have seen Sagar's food pipe and it is coal black from the inside. This is a very clear indication that he had ingested potassium permanganate. I may tell you that potassium hydroxide is a product of the action of permanganate on the tissues, so corrosion of the foodpipe and stomach may be present. It is however superficial. The lips, gums, teeth, tongue, tonsils, pharynx, and the upper end of the larynx are all likely to be discoloured, inflamed and superficially corroded. This is especially severe at points where any crystals may lodge inside the mouth or throat. Occasionally, crystals may be seen on the lips, inside the cheeks or at the back of the throat and in the piriform fossae, especially when unusually deep."

"What are the piriform fossae doctor?"

"Tarun, the word piriform comes from the Latin pirum which means a pear. These are deep pear shaped pockets on either side of the pharynx. They are present at just the point where the pharynx ends and oesophagus starts. These pockets are at the sides. In fact any swallowed object - like pins for instance - is likely to get entangled in these pockets. If crystals of KMnO4 get lodged in piriform fossae, they can corrode these areas. Burning pain from the mouth to the pit of the stomach occurs soon after the ingestion of permanganate. Nausea and vomiting are not long delayed and the latter may become intractable. The vomit contains purple-brown or brown material which may be mistaken for altered blood from a bleeding peptic ulcer, i.e. 'coffee ground' vomit. Fluid loss by vomiting may cause intense thirst. A number of the patients experience difficulty in speaking or swallowing; this may persist for several days. About half of the patients complain of epigastric pain and tenderness. This may be accompanied and exaggerated by distension of the abdomen. The stools are black due to manganous sulphide. Potassium permanganate can come in contact with the air passages and when it does that, it provokes severe swelling of the air passages. Irritation of the trachea and bronchi leads to difficulty in respiration, and a persistent, spasmodic cough. Any sputum produced may contain dark flecks. A lethal dose, e.g. about 20g, usually kills in from 20 to 90 hours. When potassium permanganate is introduced into the uterus death may occur in only 12 hours."

"Doctor, I have known enough about potassium permanganate to interact intelligently with you. Now tell me how you are going to convince the court positively that Nath killed him by giving KMnO4 in red wine?"

"Tarun, I have got the wine bottle seized, and I have analyzed its washings. It has shown traces of KMnO4. How could KMnO4 come in a wine bottle? Obviously someone had put it there. And who else except the one who gave the bottle to him, and that too his business rival. Moreover I have found all the changes in Sagar's body, which are found in deaths due to KMnO4. As I told you, the changes produced by potassium permanganate are essentially those produced by an irritant and mildly caustic poison, but distinguished by brown-black staining of the tissues. I have found the staining of tissues in Sagar's case all over - over his face, inside his mouth, foodpipe and stomach. All these organs show congestion too, which is seen in ingestion of irritant poisons like KMnO4. I have also analyzed the contents of his stomach and I have found KMnO4 there as well. This is enough evidence to nail Nath. Come, let us tell the police to arrest Nath at once. He should not escape the legal net."

"Very clever doctor. This was a most interesting discussion doctor. Without your masterly deduction, Nath could never have been caught. People might have thought, it was an accidental or perhaps a natural death. Tell me what are you going to tell me the next time?"

"Tarun, next time, I would tell you about death by diesel fumes." "