V.R. Ravi Kumar

One night in August 1973, as the duty paediatric surgeon at the Institute of Child Health at Egmore in Chennai, I was called to see an 18-month-old child facing acute renal failure. A general practitioner had earlier treated the infant for fever. A nephrologist from the government general hospital was then called to see the child. A peritoneal dialysis was tried, but the child did not recover.
Within a week, every day brought one child or two with kidney failure to the institute. So its director, V. Balagopal Raju, convened a meeting of all specialists. By month-end, more than 15 children underwent peritoneal dialysis, but none of them survived and the cause was still not known.
Sometime earlier, a relative of one of my colleagues had started a pharmaceutical company and he met me with his products. Introducing a paracetamol solution with vitamin C labelled Pipmol C, he gave me a couple of bottles as samples, saying the transparent clear solution had a palatable taste. I took one bottle to the clinic. The sample kept at home fell from the cupboard and broke. Next week, a child from my neighbourhood, who had seen me a week earlier, was admitted with acute renal failure.
I went through the history of the illness of the child and the drugs administered. The only new drug was the Pipmol C sample given for fever from the clinic. It struck me like lightning that this solution could be responsible for the renal failure. I ran to the next block in the hospital where another child was undergoing peritoneal dialysis. To my shock, that child also had Pipmol C. I requested A. Peter, the dynamic head of the medical records department of the institute, to get the addresses of all the children who had died.
I visited the house of the first child in a slum at Tondiarpet and requested the parents to show the prescription and the drugs administered before hospitalisation. The mother went to the backyard and brought the empty medicine bottles. One was of Pipmol C. Within 48 hours, after visiting the house of every child who had died, the enquiry revealed that all of them had Pipmol C. Before long, it was proved beyond doubt that all the children who died of renal failure had Pipmol C. Dr. Raju went through all the details and was convinced that Pipmol C was the culprit. He got the samples of Pipmol C brought by us and sent it urgently by a messenger to the State Drugs Controller’s office.
He called up Narasimhan, the Drugs Controller, to analyse the samples and asked him to give the report immediately. At 6 p.m., Narasimhan called to say that all the samples contained diethylene glycol as the solvent, highly toxic to the kidneys.
Dr. Raju immediately drafted a letter to All India Radio to broadcast that Pipmol C was a toxic drug and should not be given to children. He asked me to hurry to the radio station, which broadcast the message immediately and repeated it for the next 48 hours. All the leading dailies carried the report the next day. Investigation by the Drugs Controller revealed that a wholesale company in Chennai which regularly distributed propylene glycol substituted it with diethylene glycol by mistake. Action was taken against its erring chemist. The drug company was closed.
- The Hindu