Neurotoxicology

Ramazzini wrote the first comprehensive treatise on the diseases of workers, “De Morbis Artificum Diatriba” [“Dissertation on Workers' Diseases”] (1700). (Source: Wikimedia Commons. Public domain. Edited by Dr. Douglas J Lanska.)

(Source: U.S. National Library of Medicine, Bethesda, Maryland. Public domain.)

(Source: U.S. National Library of Medicine, Bethesda, Maryland. Public domain.)

(Source: U.S. National Library of Medicine, Bethesda, Maryland, and the Schlesinger Library, Radcliffe Institute, Harvard University. Public domain.)

Anonymous woodcut after a design by German Renaissance artist Hans Weiditz (II) (1495-1537), 1514-1532. Ore is being extracted on the back (left) with hammers, chisels, and pickaxes. Metals are being extracted from the ore in the back (center and right). The mined and extracted metal is being worked into metalware in the foreground. (Courtesy of the Rijkmuseum, Amsterdam, The Netherlands. Public domain. Edited by Dr. Douglas J Lanska.)

Anonymous woodcut after a design by German Renaissance artist Hans Weiditz (II) (1495-1537), 1514-1532. Several of the miners have oil headlamps (right of center foreground and background). (Source: Courtesy of the Rijkmuseum, Amsterdam, The Netherlands. Public domain. Edited by Dr. Douglas J Lanska.)

Engraving by Virgilius Solis in Nuremberg (1524-1562). On the left, two men operate a windlass (with a horizontal axis) to lift ore from lower levels of the mine. A rope is wrapped around the barrel in such a manner that a bucket on one end is lowered while the bucket on the other end is raised. Then a foreman directs the extraction of ore by a miner wielding a large hammer and the ore is heated in a furnace to extract the desired metals. (Courtesy of the Rijkmuseum, Amsterdam, The Netherlands. Public domain. Edited by Dr. Douglas J Lanska.)

Engraving by Virgilius Solis in Nuremberg (1524-1562). On the left, ore is being extracted with hammer and chisel. The ore is pushed from the mine in carts, and then sought metals are separated from crushed ore with a panning process. A simple wheelbarrow is sitting on the right. (Courtesy of the Rijkmuseum, Amsterdam, The Netherlands. Public domain. Edited by Dr. Douglas J Lanska.)

Woodcut by Hans Rudolf Manuel Deutsch in Germany (1525-1571), 1556. At the very top, above the mine, a man is using a divining rod to search for precious minerals. In the middle, two men operate a windlass (with a horizontal axis) to lift ore from lower levels of the mine. A rope is wrapped around the barrel in such a manner that a bucket on one end is lowered while the bucket on the other end is raised. At the lower level, miners are using hammers and pickaxes to extract valuable minerals. The ore is then loaded on carts. (Courtesy of the Rijkmuseum, Amsterdam, The Netherlands. Public domain. Edited by Dr. Douglas J Lanska.)

Engraving Dutch engraver Caspar Luyken (1672-1708) in Amsterdam, after a work by his father, Jan Luyken (1649-1712), 1694. A drum with a horizontal axis is being manually turned by a single person in the background with a poor mechanical advantage. A rope is wrapped around the drum so that one end lowers while the other end lifts. The amount lifted per load must have been quite small. In the midground, several miners are pushing carts with ore. In the foreground, a miner is examining the contents of an ore cart that has been emptied. A pickaxe is in the foreground on the left. (Courtesy of the Rijkmuseum, Amsterdam, The Netherlands. Public domain. Edited by Dr. Douglas J Lanska.)

An emblem on mining by Dutch engraver Caspar Luyken (1672-1708), after a work by his father, Jan Luyken (1649-1712), ca. 1700. A drum with a horizontal axis is being manually turned by several people in the background with a poor mechanical advantage. A rope is wrapped around the drum so that one end lowers while the other end lifts. The amount lifted per load must have been quite small. Several miners with pickaxes are headed toward the mine entrance on the right. In the foreground a man pushes a cart with ore. (Courtesy of the Rijkmuseum, Amsterdam, The Netherlands. Public domain. Edited by Dr. Douglas J Lanska.)

Depiction of mining as part of a large, engraved plate concerning Liège, Belgium, by Bohemian graphic artist Wenceslaus Hollar (1607-1677), ca 1657. Horses are turning a capstan (note the vertical axle) to pull up ore from the mine. In early mining, this was called a whim, whim gin, or a horse capstan. A rope is wound around the drum, with both ends traversing several pulleys and hanging down the mine shaft. As the drum is turned around, one end of the rope is lowered, carrying an empty bucket, while the other one is raised, carrying a full load. Early whims were horse-powered, but later they were powered by waterwheels, or by steam engines beginning in the 18th century. (Courtesy of the Rijkmuseum, Amsterdam, The Netherlands. Public domain. Edited by Dr. Douglas J Lanska.)

Depiction of mining as part of a large, engraved plate concerning Liège, Belgium, by Bohemian graphic artist Wenceslaus Hollar (1607-1677), ca 1657. A miner with a pickaxe is walking with two women. One woman carries a large basket of ore on her back, while the other pushes ore in a wheelbarrow. In the background on the left, a man is riding a horse that is pulling a large cart full of ore. (Courtesy of the Rijkmuseum, Amsterdam, The Netherlands. Public domain. Edited by Dr. Douglas J Lanska.)

Design for a painting in the Berlage fair, Amsterdam: "De Industrie," by Dutch painter, draftsman, and lithographer Richard Nicolaüs Roland Holst (1868-1938). In pencil and watercolor. The top portion represents the extraction of metals from ore, whereas the bottom shows the process of mining the ore. (Courtesy of the Rijkmuseum, Amsterdam, The Netherlands. Public domain. Edited by Dr. Douglas J Lanska.)

Pencil and watercolor design for a painting by Dutch painter, draftsman, and lithographer Richard Nicolaüs Roland Holst (1868-1938). (Courtesy of the Rijkmuseum, Amsterdam, The Netherlands. Public domain. Edited by Dr. Douglas J Lanska.)

Etching by Karl Meunier (1864-1894) with plate tone and drypoint, after a work by Belgian painter and sculptor Constantin Emile Meunier (1831-1905). (Courtesy of the Rijkmuseum, Amsterdam, The Netherlands. Public domain. Edited by Dr. Douglas J Lanska.)

Photograph from San Francisco by American photographer Carleton E Watkins (1829-1916), 1871-1891. This was one of a pair of stereophotographs. Watkins focused mainly on landscape photography, and Yosemite Valley was one of his favorite subjects. Notice the stacked piles of large ingots (presumably lead, but possibly silver). (Courtesy of the Rijkmuseum, Amsterdam, The Netherlands. Public domain. Edited by Dr. Douglas J Lanska.)

(Source: National Institute for Occupational Safety and Health (NIOSH). Public domain.)

(Source: Frank AL, Balk S, Resha K. Taking an exposure history: case studies in environmental medicine. ATSDR publication number ATSRD-HE-CS-2001-0002. Atlanta, Georgia. Agency for Toxic Substances and Disease Registry, 2000. In cooperation with National Institute for Occupational Safety and Health.)

(Source: Frank AL, Balk S, Resha K. Taking an exposure history: case studies in environmental medicine. ATSDR publication number ATSRD-HE-CS-2001-0002. Atlanta, Georgia. Agency for Toxic Substances and Disease Registry, 2000. In cooperation with National Institute for Occupational Safety and Health.)

(Source: Frank AL, Balk S, Resha K. Taking an exposure history: case studies in environmental medicine. ATSDR publication number ATSRD-HE-CS-2001-0002. Atlanta, Georgia. Agency for Toxic Substances and Disease Registry, 2000. In cooperation with National Institute for Occupational Safety and Health.)

(Source: Frank AL, Balk S, Resha K. Taking an exposure history: case studies in environmental medicine. ATSDR publication number ATSRD-HE-CS-2001-0002. Atlanta, Georgia. Agency for Toxic Substances and Disease Registry, 2000. In cooperation with National Institute for Occupational Safety and Health.)

Illustration by English illustrator, graphic humorist, and political cartoonist Sir John Tenniel (1820-1914), 1865. (Public domain. Edited by Dr. Douglas J Lanska.)

Illustration by English illustrator, graphic humorist, and political cartoonist Sir John Tenniel (1820-1914), 1865. (Public domain. Edited by Dr. Douglas J Lanska.)

Illustration by English illustrator, graphic humorist, and political cartoonist Sir John Tenniel (1820-1914), 1865. (Public domain.)

Photographic self-portrait of Lewis Carroll, the pen name of Reverend Charles Lutwidge Dodgson. (Source: This was first published in Carroll's biography by his nephew, Stuart Dodgson Collingwood. Collingwood SD. The Life and Letters of Lewis Carroll. London: T Fisher Unwin, 1898:50. Public domain.)

Theophilus Carter (1824-1904), ca 1894, an eccentric British furniture dealer thought to be an inspiration for the illustration by Sir John Tenniel (1820-1914) of the Hatter in Lewis Carroll's "Alice's Adventures in Wonderland" (1866). (Source: Wikimedia Commons. Public domain.)

English author Terence Hanbury "Tim" White, lecturing on his Arthurian fiction at Boston College in 2014. (Courtesy of the Burns Library, Boston College, Boston. Creative Commons Attribution 2.0 Generic [CC BY 2.0] license, creativecommons.org/licenses/by/2.0.)

(Source: Wikimedia Commons. Public domain.)

Daguerreotype photograph of William Makepeace Thackeray (1811-1863), ca. 1855, by Jesse Harrison Whitehurst (1819-1875), New York. (Source: Boston Public Library. Public domain.)

(Source: Read & Co. Engravers & Printers, London, 1851. Public domain. Edited by Dr. Douglas J Lanska.)

From Charles Knight's Pictorial Gallery of the Arts, England, 1858. William Barclay Parsons Collection, New York Public Library Archives. (Public domain. Edited by Dr. Douglas J Lanska.)

From Charles Knight's Pictorial Gallery of the Arts, England, 1858. William Barclay Parsons Collection, New York Public Library Archives. (Public domain. Edited by Dr. Douglas J Lanska.)

(Source: Weigel C. Abbildung Der Gemein-Nützlichen Haupt-Stände Von denen Regenten Und ihren So in Friedens- als Kriegs-Zeiten zugeordneten Bedienten an, biß auf alle Künstler Und Handwercker. Regenspurg, 1698:614. Public domain. Edited by Dr. Douglas J Lanska.)

Red lead (lead[II,IV] oxide, also called minium) is an inorganic compound with the formula Pb3O4. A bright red or orange solid, red lead has been used as pigment for centuries. In more modern times, it has been used in the manufacture of batteries and rustproof primer paints. It is an example of a mixed-valence compound, being composed of both Pb(II) and Pb(IV) in the ratio of two to one. (Source: Oliver T. Lead poisoning in its acute and chronic forms: The Goulstonian Lectures, delivered in the Royal College of Physicians, March 1891. Edinburgh and London: Young J. Pentland, 1891. Public domain.)

"M.W. had entirely lost the blue line on her gums. Circumstances obliged her to return to the lead factory; after working there 1 week, she came to the infirmary suffering from colic." (Source: Oliver T. Lead poisoning in its acute and chronic forms: The Goulstonian Lectures, delivered in the Royal College of Physicians, March 1891. Edinburgh and London: Young J. Pentland, 1891. Public domain.)

(right). Rachael H, at age 35 years. (Source: Oliver T. Lead poisoning in its acute and chronic forms: The Goulstonian Lectures, delivered in the Royal College of Physicians, March 1891. Edinburgh and London: Young J. Pentland, 1891. Public domain.)

(Source: Oliver T. Lead poisoning in its acute and chronic forms: The Goulstonian Lectures, delivered in the Royal College of Physicians, March 1891. Edinburgh and London: Young J. Pentland, 1891. Public domain.)

(x 250) (Source: Oliver T. Lead poisoning in its acute and chronic forms: The Goulstonian Lectures, delivered in the Royal College of Physicians, March 1891. Edinburgh and London: Young J. Pentland, 1891. Public domain.)

(x 250) Case of Barbara R. (Source: Oliver T. Lead poisoning in its acute and chronic forms: The Goulstonian Lectures, delivered in the Royal College of Physicians, March 1891. Edinburgh and London: Young J. Pentland, 1891. Public domain.)

(Source: Oliver T. Lead poisoning in its acute and chronic forms: The Goulstonian Lectures, delivered in the Royal College of Physicians, March 1891. Edinburgh and London: Young J. Pentland, 1891. Public domain.)

Lead poisoning in FG, age 33, a house painter, with paralysis of the finger extensors; the little finger has however escaped. Case of English physician George Hare Philipson (1836-1918), professor of Medicine at Durham University. (Source: Oliver T. Lead poisoning in its acute and chronic forms: The Goulstonian Lectures, delivered in the Royal College of Physicians, March 1891. Edinburgh and London: Young J. Pentland, 1891. Public domain.)

Case of English physician George Hare Philipson (1836-1918), professor of Medicine at Durham University. (Source: Oliver T. Lead poisoning in its acute and chronic forms: The Goulstonian Lectures, delivered in the Royal College of Physicians, March 1891. Edinburgh and London: Young J. Pentland, 1891. Public domain.)

Case of English physician George Hare Philipson (1836-1918), professor of Medicine at Durham University. The patient recovered. (Source: Oliver T. Lead poisoning in its acute and chronic forms: The Goulstonian Lectures, delivered in the Royal College of Physicians, March 1891. Edinburgh and London: Young J. Pentland, 1891. Public domain.)

The posterior interosseous nerve (also called the dorsal interosseous nerve) is the continuation of the deep branch of the radial nerve after it penetrates the supinator muscle. It carries fibers from the C7 and C8 spinal roots and supplies most of the muscles in the posterior compartment of the forearm. (Source: Oliver T. Lead poisoning in its acute and chronic forms: The Goulstonian Lectures, delivered in the Royal College of Physicians, March 1891. Edinburgh and London: Young J. Pentland, 1891. Public domain.)

John FA, a 29-year-old white-lead worker, was admitted on October 30, 1884, for very extensive paralysis involving the arms, shoulders, back, and legs. Case of English physician George Hare Philipson (1836-1918), professor of Medicine at Durham University. (Source: Oliver T. Lead poisoning in its acute and chronic forms: The Goulstonian Lectures, delivered in the Royal College of Physicians, March 1891. Edinburgh and London: Young J. Pentland, 1891. Public domain.)

(Source: Oliver T. Lead poisoning in its acute and chronic forms: The Goulstonian Lectures, delivered in the Royal College of Physicians, March 1891. Edinburgh and London: Young J. Pentland, 1891. Public domain.)

Case of Barbara R. The optic nerve has been cut at an angle. (Source: Oliver T. Lead poisoning in its acute and chronic forms: The Goulstonian Lectures, delivered in the Royal College of Physicians, March 1891. Edinburgh and London: Young J. Pentland, 1891. Public domain.)

Case of Catherine R. On June 20, 1890, the patient was noted to be "perfectly blind." (Source: Oliver T. Lead poisoning in its acute and chronic forms: The Goulstonian Lectures, delivered in the Royal College of Physicians, March 1891. Edinburgh and London: Young J. Pentland, 1891. Public domain.)

Case of Catherine R. On September 20, 1890, the patient had "recovered very considerably her sight." (Source: Oliver T. Lead poisoning in its acute and chronic forms: The Goulstonian Lectures, delivered in the Royal College of Physicians, March 1891. Edinburgh and London: Young J. Pentland, 1891. Public domain.)

Sir Thomas Oliver was an expert on industrial hygiene. He gave the 1891 Goulstonian Lectures on "Lead poisoning in its acute and chronic forms." (Courtesy of the U.S. Library of Congress. Public domain.)

Case of Elizabeth H. On June 28, 1890, the patient was noted to have "permanent blindness." (Source: Oliver T. Lead poisoning in its acute and chronic forms: The Goulstonian Lectures, delivered in the Royal College of Physicians, March 1891. Edinburgh and London: Young J. Pentland, 1891. Public domain.)

Sir George Hare Philipson was professor of Medicine at Durham University. Painting by J Carlton Howard. (Source: Wikimedia Commons. Public domain.)

"The most characteristic (form of lead neuropathy) is the paralysis of the extensors of the hands, producing the well-known wrist-drop. The muscles supplied by the musculo-spiral (radial) nerve are the ones to suffer, although curious exceptions for some unknown reason are seen in the cases of the supinator longus and the extensor of the metacarpal bone of the thumb, both of which invariably escape. The type of paralysis is that of a neuritis. The muscles waste and give the reactions of degeneration.” (Source: Lloyd JH. The diseases of occupations. In: Stedman TL, editor. Twentieth Century Practice: An International Encyclopedia of Modern Medical Practice by Leading Authorities of Europe and America. Volume 3: Occupation Disease, Drug Habits, and Poisons. New York: William Wood and Company, 1895:311-496. Public domain.)

Anterior view. “He has extensive muscular atrophy, involving the muscles of the arms and shoulders, and also, to a less extent, those of the legs. The arms are wellnigh powerless. The muscles have not lost their electro-irritability. Sensation is not involved.” (Source: Lloyd JH. The diseases of occupations. In: Stedman TL, editor. Twentieth Century Practice: An International Encyclopedia of Modern Medical Practice by Leading Authorities of Europe and America. Volume 3: Occupation Disease, Drug Habits, and Poisons. New York: William Wood and Company, 1895:311-496. Public domain.)

Posterior view. “He has extensive muscular atrophy, involving the muscles of the arms and shoulders, and also, to a less extent, those of the legs. The arms are wellnigh powerless. The muscles have not lost their electro-irritability. Sensation is not involved.” (Source: Lloyd JH. The diseases of occupations. In: Stedman TL, editor. Twentieth Century Practice: An International Encyclopedia of Modern Medical Practice by Leading Authorities of Europe and America. Volume 3: Occupation Disease, Drug Habits, and Poisons. New York: William Wood and Company, 1895:311-496. Public domain.)

Dr. Lloyd became an expert in neurologic occupational diseases. (Courtesy of the U.S. National Library of Medicine, Bethesda, Maryland. Public domain. Cropped.)

(Source: Gowers WR. A manual of diseases of the nervous system. 2nd ed. Vol. 2. London: Churchill, 1893. Public domain.)

Theophrastus of Eresos was a Greek philosopher and the successor to Aristotle in the Peripatetic school. Theophrastus described a method of preparing white lead in his brief work, "On Stones or History of Stones" (c. 300 BCE). The statue is in the Palermo Botanical Garden, on the island of Sicily, Italy. (Source: Creative Commons Attribution 2.5 Generic [CC BY 2.5] license, creativecommons.org/licenses/by/2.5. Edited by Dr. Douglas J Lanska.)

(Egyptian 2nd century) (Source: U.S. National Gallery of Art, Washington, D.C. Public domain.)

The Courtauld, London (Samuel Courtauld Trust). The painting exemplifies the use of a priming technique used by Dutch painters that mixed lead white with chalk. (Coremans P, Thissen J. Composition et structure des couches originales [Descente de Croix de Rubens]. Bulletin de l'lnstitut Royal du Patrimoine Artistique 1962;5:119-27. Gettens RJ, Kühn H, Chase WT. Lead white. In: Roy A, editor. Artists' Pigments: A Handbook of Their History and Characteristics. Vol. 2. Washington, DC: National Gallery of Art. London:Archetype, 1993:67-82.) (Source: Onze-Lieve-Vrouwekathedraal [Cathedral of Our Lady in Antwerp]. Public domain.)

(Source: Wikimedia Commons User: Thester11. Creative Commons Attribution 3.0 Unported [CC BY 3.0] license, creativecommons.org/licenses/by/3.0.)

The paint was a combination of white lead (basic lead carbonate) and linseed oil. (Source: Wikimedia Commons User: Thester11. Creative Commons Attribution 3.0 Unported [CC BY 3.0] license, creativecommons.org/licenses/by/3.0.)

White lead or basic lead carbonate (2PbCO3·Pb[OH]2) is a complex salt, containing both carbonate and hydroxide ions. It was formerly used as an ingredient for lead paint and a cosmetic called Venetian ceruse, because of its opacity and the satiny smooth mixture it made with dryable oils. Public domain.)

Red lead is a mixed valence crystalline compound, containing both lead (2) oxide and lead (4) oxide: lead(II,IV) oxide, also called minium. Red lead is an inorganic compound with the chemical formula Pb₃O₄. (Source: BXXXD at German Wikipedia. Creative Commons Attribution 3.0 Unported [CC BY 3.0] license, creativecommons.org/licenses/by/3.0.)

Grey atoms are lead; red atoms are oxygen. (Source: Wikimedia Commons User: Benjah-bmm27. Public domain.)

Grey atoms are lead; red atoms are oxygen. (Source: Wikimedia Commons User: Benjah-bmm27. Public domain.)

X-ray fluorescence elemental maps of the sum of the K or L lines for Iron (Fe), Lead (Pb), Calcium (Ca), Potassium (K), and copper (Cu). X-ray fluorescence is the emission of characteristic "secondary" (or fluorescent) x-rays from a material that has been bombarded with high-energy x-rays or gamma rays. Each element has a unique set of energy levels and emits a pattern of x-rays characteristic of the element with an intensity proportional to the concentration of the corresponding element. (Source: Delaney JK, Dooley KA, Radpour R, Kakoulli I. Macroscale multimodal imaging reveals ancient painting production technology and the vogue in Greco-Roman Egypt. Sci Rep 2017;7[1]:15509. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

Radiocarbon dating of the shaft placed the object within the Late Chalcolithic period, in the late 5th millennium BCE (ca. 4300-4000 BCE). (Source: Yahalom-Mack N, Langgut D, Dvir O, et al. The earliest lead object in the levant. PLoS One 2015;10[12]:e0142948. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

(Source: Yahalom-Mack N, Langgut D, Dvir O, et al. The earliest lead object in the levant. PLoS One 2015;10[12]:e0142948. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

(Source: Yahalom-Mack N, Langgut D, Dvir O, et al. The earliest lead object in the levant. PLoS One 2015;10[12]:e0142948. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

”Portrait of the Artist,” Peter Paul Rubens

Prevalence rate of adults with elevated blood lead levels (BLLs) 10 μg/dL or higher, by state (State Adult Blood Lead Epidemiology and Surveillance programs, United States, 2012).

Notes:
(1) Rate per 100,000 employed adults aged 16 years or older. The state-resident rate might be lower for some states. Data from the Adult Blood Epidemiology and Surveillance Program, National Institute for Occupational Safety and Health. Denominators for 2012 were extracted from the 2013 U.S. Department of Labor, Bureau of Labor Statistics, Local Area Unemployment Statistics.
(2) A total of 41 states submitted data in 2012: Alabama, Alaska, Arizona, California, Colorado, Connecticut, Florida, Georgia, Hawaii, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Montana, Nebraska, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, Utah, Vermont, Washington, Wisconsin, and Wyoming. Kentucky and Illinois submitted BLLs 25 μg/dL or higher and Massachusetts submitted BLLs 15 μg/dL or higher. In 2012, the two states reporting the highest prevalence of elevated blood lead levels were Missouri (106.66) and Kansas (77.32). The national rate in 2012 was 22.5 cases per 100,000 employed adults aged 16 years or older.

(Source: Alarcon WA; State Adult Blood Lead Epidemiology and Surveillance [ABLES] Program Investigators. Elevated blood lead levels among employed adults - United States, 1994-2013. MMWR Morb Mortal Wkly Rep 2016;63[55]:59-65. Public domain.)

National prevalence rate of reported cases of elevated blood lead levels (BLLs), by year (State Adult Blood Epidemiology and Surveillance Programs, United States, 1994-2012).

Notes:
(1) All cases = all reported cases by a state, including adult residents in the reporting state and residents in other states; state residents = adult residents in the reporting state. (2) Rates are per 100,000 employed adults aged 16 years or older. Denominators for 1994-2012 were extracted from the 2013 US Department of Labor, Bureau of Labor Statistics Local Area Unemployment Statistics program.
(2) Since 2009, the case definition for an elevated blood lead level is a BLL of 10 μg/dL or higher. For historical comparisons, prevalence rates at the previous case definition (BLL 25 μg/dL or higher) are provided.
(3) Numbers of states reporting BLLs of 25 μg/dL or higher data are in parentheses. From 2010, numbers of states reporting data for BLLs of 10 μg/dL or higher are also provided. A total of 41 states submitted data in 2012: Alabama, Alaska, Arizona, California, Colorado, Connecticut, Florida, Georgia, Hawaii, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Montana, Nebraska, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, Utah, Vermont, Washington, Wisconsin, and Wyoming.

(Source: Alarcon WA; State Adult Blood Lead Epidemiology and Surveillance [ABLES] Program Investigators. Elevated blood lead levels among employed adults - United States, 1994-2013. MMWR Morb Mortal Wkly Rep 2016;63[55]:59-65. Public domain.)

Prevalence rate of adults with blood lead levels (BLLs) of 10 µg/dL or higher, by state (State Adult Blood Lead Epidemiology and Surveillance programs, United States, 2013).

Notes:
(1) Rate per 100,000 employed adults aged 16 years or older. State-resident prevalence rate might be lower for some states. Data from the Adult Blood Epidemiology and Surveillance Program, National Institute for Occupational Safety and Health. Denominators for 2013 were extracted from the 2015 U.S. Department of Labor, Bureau of Labor Statistics, Local Area Unemployment Statistics program.
(2) The national rate in 2013 was 20.4 cases per 100,000 employed adults aged 16 years or older. A total of 30 states submitted data in 2013: Alabama, Alaska, Arizona, California, Colorado, Connecticut, Florida, Georgia, Illinois, Indiana, Iowa, Kentucky, Louisiana, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Nebraska, New Jersey, New Mexico, New York, North Carolina, Oklahoma, Oregon, Pennsylvania, Vermont, Washington, Wisconsin, and Wyoming. Massachusetts provided data for BLLs 25 µg/dL or higher. In 2013, Missouri (111.8) and Iowa (53.7) reported the highest prevalence rates of elevated blood lead levels.

(Source: Alarcon WA; State Adult Blood Lead Epidemiology and Surveillance [ABLES] Program Investigators. Elevated blood lead levels among employed adults - United States, 1994-2013. MMWR Morb Mortal Wkly Rep 2016;63[55]:59-65. Public domain.)

National prevalence rate of reported cases of elevated blood lead levels (BLLs) for adults, by year (State Adult Blood Epidemiology and Surveillance Programs, United States, 1994-2013).

Notes:
(1) Rates are per 100,000 employed adults aged 16 years or older. Denominator data was extracted from the 2015 U.S. Department of Labor, Bureau of labor Statistics Local Area Unemployment Statistics program.
(2) Since 2009, the case definition for an elevated blood lead level is a BLL 10 µg/dL or higher. For historical comparisons, prevalence rates at the previous case definition (BLL 25 µg/dL or higher) are provided.
(3) A total of 30 states submitted data in 2013 (down from 41 states in 2012): Alabama, Alaska, Arizona, California, Colorado, Connecticut, Florida, Georgia, Illinois, Indiana, Iowa, Kentucky, Louisiana, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Nebraska, New Jersey, New Mexico, New York, North Carolina, Oklahoma, Oregon, Pennsylvania, Vermont, Washington, Wisconsin, Wyoming. Massachusetts provided data for BLLs 25 µg/dL or higher. For 2013, the first number is the number of states reporting BLLs 25 µg/dL or higher (ie, 30 states in 2013), and the second number is the number of states reporting BLLs 10 µg/dL or higher (ie, 29 states in 2013).

(Source: Alarcon WA; State Adult Blood Lead Epidemiology and Surveillance [ABLES] Program Investigators. Elevated blood lead levels among employed adults - United States, 1994-2013. MMWR Morb Mortal Wkly Rep 2016;63[55]:59-65. Public domain.)

"These are almost always poorly constructed buildings with old, rough, dirty wooden floors, with accumulations of ground ore in the corners or sometimes covering the whole floor. Still finer dust clings to the walls and all projecting surfaces, and the air is often so dust laden that after a couple of minutes' exposure the leaf of one's note-book is quite gritty with dust." (Source: Hamilton A. Lead poisoning in the smelting and refining of lead. Industrial Accidents and Hygiene Series No. 4. Bulletin of the U.S. Bureau of Labor Statistics 1914a;141:1-97. Public domain.)

"This is protected by a double hood, the flaring outer hood corning over the work plate, but not over the lead well, to the right, nor the car for gray slag, to the left. The photograph was taken purposely during an interval when there was no slag on the work plate, so that fumes would not obscure the view." (Source: Hamilton A. Lead poisoning in the smelting and refining of lead. Industrial Accidents and Hygiene Series No. 4. Bulletin of the U.S. Bureau of Labor Statistics 1914a;141:1-97. Public domain.)

"Not all of the hearths were working, but the presence of fumes is evident enough." (Source: Hamilton A. Lead poisoning in the smelting and refining of lead. Industrial Accidents and Hygiene Series No. 4. Bulletin of the U.S. Bureau of Labor Statistics 1914a;141:1-97. Public domain.)

"The pot is the lower half, the upper half consisting of the great hood and flue which is fitted over the pot during roasting. The windows in the side are opened for raking from time to time. When roasting is complete the hood is lifted off, the pot caught by a crane, tipped over, and the smoking charge dumped and crushed." (Source: Hamilton A. Lead poisoning in the smelting and refining of lead. Industrial Accidents and Hygiene Series No. 4. Bulletin of the U.S. Bureau of Labor Statistics 1914a;141:1-97. Public domain.)

"The roasted cakes have dropped off and the man is chipping off the fragments which still stick to the grates. This is a very much better installation than many, and the man is not so much exposed to the dust as he would be were he standing below." (Source: Hamilton A. Lead poisoning in the smelting and refining of lead. Industrial Accidents and Hygiene Series No. 4. Bulletin of the U.S. Bureau of Labor Statistics 1914a;141:1-97. Public domain.)

"An excellent example of a feed floor, such as is found in five smelters, although only three are as good as this. The openings to the furnaces may be seen in the runway for the cars. The mechanician controls from a distance the discharing of the cars." (Source: Hamilton A. Lead poisoning in the smelting and refining of lead. Industrial Accidents and Hygiene Series No. 4. Bulletin of the U.S. Bureau of Labor Statistics 1914a;141:1-97. Public domain.)

"This is a better hood than average and at times catches the fumes very well, but not when the wind is in the wrong direction, as it was when this photograph was taken. A good feature here is the long rod which the man uses, enabling him to stand outside of the smoky area. However, to close the tap he must approach nearer." (Source: Hamilton A. Lead poisoning in the smelting and refining of lead. Industrial Accidents and Hygiene Series No. 4. Bulletin of the U.S. Bureau of Labor Statistics 1914a;141:1-97. Public domain.)

Tapping floor of a blast furnace in the American Smelting & Refining Co.'s plant at Murray, Utah. "The arrangement In the Midvale plant is exactly the same. Slag is pouring out into the forehearth and overflowing into the slag pot in front. The day being quiet, no fumes are escaping. This is, however, not the case at all times. When the wind blows in toward the furnace the tapping floor seen in the left corner may be thick with fumes. The side of the building facing these furnaces is all open." (Source: Hamilton A. Lead poisoning in the smelting and refining of lead. Industrial Accidents and Hygiene Series No. 4. Bulletin of the U.S. Bureau of Labor Statistics 1914a;141:1-97. Public domain.)

Matte tapping in the American Smelting & Refining Co.'s plant at Murray, Utah. "This is on the other side of the same furnace. It is easy to see that though the hooding protection Is adequate at times a puff of wind could easily scatter the fumes from this matte kettle. These hoods are, however, better than those in any of the other smelters that were visited except those at Midvale." (Source: Hamilton A. Lead poisoning in the smelting and refining of lead. Industrial Accidents and Hygiene Series No. 4. Bulletin of the U.S. Bureau of Labor Statistics 1914a;141:1-97. Public domain.)

"The slag overflows into the second kettle; the lead settings in the first kettle with a small curst of matte on top. The hood can be seen at the top of the picture, too high up to be of any real use." (Source: Hamilton A. Lead poisoning in the smelting and refining of lead. Industrial Accidents and Hygiene Series No. 4. Bulletin of the U.S. Bureau of Labor Statistics 1914a;141:1-97. Public domain.)

"The pigs of bullion come down the closed chute to the charge door. In contrast to this excellent device is the carelessness which allows heaps of dusty dross to lie on the floor near the furnace." (Source: Hamilton A. Lead poisoning in the smelting and refining of lead. Industrial Accidents and Hygiene Series No. 4. Bulletin of the U.S. Bureau of Labor Statistics 1914a;141:1-97. Public domain.)

"The lead drips from the well in front to the lead kettle. There is no hood here at all." (Source: Hamilton A. Lead poisoning in the smelting and refining of lead. Industrial Accidents and Hygiene Series No. 4. Bulletin of the U.S. Bureau of Labor Statistics 1914a;141:1-97. Public domain.)

"The retort is shown with the zinc condenser in place. When this is removed the rich lead or dore runs out. There is no hood to catch the fumes." (Source: Hamilton A. Lead poisoning in the smelting and refining of lead. Industrial Accidents and Hygiene Series No. 4. Bulletin of the U.S. Bureau of Labor Statistics 1914a;141:1-97. Public domain.)

"This lead is red hot and there is no hood." (Source: Hamilton A. Lead poisoning in the smelting and refining of lead. Industrial Accidents and Hygiene Series No. 4. Bulletin of the U.S. Bureau of Labor Statistics 1914a;141:1-97. Public domain.)

"The long brick flues, connected over a gateway by a steel flue, run to the bag house in the left corner of the picture--the building without windows. This is one of the smelters in which there is no mechanical arrangement for shaking the bags." (Source: Hamilton A. Lead poisoning in the smelting and refining of lead. Industrial Accidents and Hygiene Series No. 4. Bulletin of the U.S. Bureau of Labor Statistics 1914a;141:1-97. Public domain.)

Employee in an electric-storage battery plant is cutting the lugs off lead battery plates. Note that the worker was using personal protective equipment consisting of a cap, minimal eye protection, and coveralls. The machine itself was equipped with a ventilator, attached to reduce exposure to lead dust that could easily be inhaled. (Source: CDC/Barbara Jenkins, NIOSH, 1953. Public Health Image Library, Centers for Disease Control and Prevention, Atlanta, Georgia. Public domain.)

Note that the worker was using personal protective equipment (PPE), including a cap, coveralls, and respirator. (Source: CDC/Barbara Jenkins, NIOSH, 1950. Public Health Image Library, Centers for Disease Control and Prevention, Atlanta, Georgia. Public domain.)

Industrial plant employees in a storage battery manufacturing plant, who were using personal protective equipment (PPE) consisting of caps, coveralls, and respirators. (Source: CDC/Barbara Jenkins, NIOSH, 1950. Public Health Image Library, Centers for Disease Control and Prevention, Atlanta, Georgia. Public domain.)

Employee burning lead inside a lead fabrication shop in Oak Ridge, Tennessee. Note that the worker was using personal protective equipment (PPE) consisting of gloves, coveralls, and eye protection. The man manipulating the ventilator was a U.S. Public Health Service employee, who at the time was monitoring occupational safety conditions. (Source: CDC/Barbara Jenkins, NIOSH, 1950. Public Health Image Library, Centers for Disease Control and Prevention, Atlanta, Georgia. Public domain.)

Four industrial plant employees cleaning lead plates in an electric storage battery factory. Note, that while at their workstations, all the workers were using only minimal personal protective equipment (PPE), consisting of dust masks and gloves. (Source: CDC/Barbara Jenkins, NIOSH, 1953. Public Health Image Library, Centers for Disease Control and Prevention, Atlanta, Georgia. Public domain.)

Female employees packaging lead arsenate, which is the lead salt, or ester of arsenic acid. Note that all workers were using personal protective equipment (PPE), which included a cap, a face mask, eye protection, and coveralls over their clothing to guard against workstation contaminants. (Source: CDC/Barbara Jenkins, NIOSH, 1953. Public Health Image Library, Centers for Disease Control and Prevention, Atlanta, Georgia. Public domain.)

Female employees packaging lead arsenate, which is the lead salt, or ester of arsenic acid. Note that all workers were using personal protective equipment (PPE), which included a cap, a face mask, eye protection, and coveralls over their clothing to guard against workstation contaminants. (Source: CDC/Barbara Jenkins, NIOSH, 1953. Public Health Image Library, Centers for Disease Control and Prevention, Atlanta, Georgia. Public domain.)

Female employees processing lead paste. Note that workers were not using respiratory protection, though ventilators were in evidence at their workstations. (Source: CDC/Barbara Jenkins, NIOSH, 1950. Public Health Image Library, Centers for Disease Control and Prevention, Atlanta, Georgia. Public domain.)

Employee in a Cincinnati, Ohio lead smelting plant. Note that the worker was not using respiratory protection, and had lifted his protective face shield, thereby, further exposing himself to lead poisoning, as well as being burnt by any spattering debris. (Source: CDC/Barbara Jenkins, NIOSH, 1950. Public Health Image Library, Centers for Disease Control and Prevention, Atlanta, Georgia. Public domain.)

Employees in an Indiana lead battery manufacturing plant. Note that the workers were not using respiratory protection, although it appears that workstation ventilators were present. (Source: CDC/Barbara Jenkins, NIOSH, 1947. Public Health Image Library, Centers for Disease Control and Prevention, Atlanta, Georgia. Public domain.)

The officer was exposed to lead dust from the bullets and shell casings, due to the enclosed nature of the environment. (Source: This photograph appeared in the December 1951 issue of “Industrial Health Monthly.” CDC/Barbara Jenkins, NIOSH, 1951. Public Health Image Library, Centers for Disease Control and Prevention, Atlanta, Georgia. Public domain.)

Note the down-draft exhaust ventilation for tile fettling by hand in a West Virginia pottery factory. Fettled (ie, finished, polished) ware is placed in saggers (ie, protective fireclay boxes enclosing ceramic ware while it is being fired) at right. (Source: CDC/Barbara Jenkins, NIOSH, 1936. Flinn RH. Neal PA, Reinhart WH, Dallavalle JM. Fulton WB, Dooley AE. Chronic manganese poisoning in an ore-crushing mill. Public Health Bulletin 1940;247:1-77. Public Health Image Library, Centers for Disease Control and Prevention, Atlanta, Georgia. Public domain.)

Wooden racks for the tile are at his left. “The movable die has just been raised exposing newly formed tile. A small bin from which dry, powdered clay is taken is behind the press.” (Source: CDC/Barbara Jenkins, NIOSH, 1936. Flinn RH. Neal PA, Reinhart WH, Dallavalle JM. Fulton WB, Dooley AE. Chronic manganese poisoning in an ore-crushing mill. Public Health Bulletin 1940;247:1-77. Public Health Image Library, Centers for Disease Control and Prevention, Atlanta, Georgia. Public domain.)

Woman working as a remover attends unfired clay tiles on a conveyor equipped with exhaust ventilation in a West Virginia pottery factory. (Source: CDC/Barbara Jenkins, NIOSH, 1936. Flinn RH. Neal PA, Reinhart WH, Dallavalle JM. Fulton WB, Dooley AE. Chronic manganese poisoning in an ore-crushing mill. Public Health Bulletin 1940;247:1-77. Public Health Image Library, Centers for Disease Control and Prevention, Atlanta, Georgia. Public domain.)

A pug mill kneads and extrudes the clay in a West Virginia pottery factory. (Source: CDC/Barbara Jenkins, NIOSH, 1936. Flinn RH. Neal PA, Reinhart WH, Dallavalle JM. Fulton WB, Dooley AE. Chronic manganese poisoning in an ore-crushing mill. Public Health Bulletin 1940;247:1-77. Public Health Image Library, Centers for Disease Control and Prevention, Atlanta, Georgia. Public domain.)

Woman fettling (trimming) greenware (unfired clayware) in a West Virginia pottery factory under uncontrolled conditions. Note the dust produced in the operation. (Source: CDC/Barbara Jenkins, NIOSH, 1936. Flinn RH. Neal PA, Reinhart WH, Dallavalle JM. Fulton WB, Dooley AE. Chronic manganese poisoning in an ore-crushing mill. Public Health Bulletin 1940;247:1-77. Public Health Image Library, Centers for Disease Control and Prevention, Atlanta, Georgia. Public domain.)

Man operating plate jigger, trimming greenware (unfired clayware) in a West Virginia pottery factory. Note the clay thrown against the wall and window by the plate jigger.” (Source: CDC/Barbara Jenkins, NIOSH, 1936. Flinn RH. Neal PA, Reinhart WH, Dallavalle JM. Fulton WB, Dooley AE. Chronic manganese poisoning in an ore-crushing mill. Public Health Bulletin 1940;247:1-77. Public Health Image Library, Centers for Disease Control and Prevention, Atlanta, Georgia. Public domain.)

Man applying glaze by hand to bisqueware (fired-once clayware) in a West Virginia pottery factory by holding the piece of pottery and dipping his hand into the tub of glaze, which contains lead. (Source: CDC/Barbara Jenkins, NIOSH, 1936. Flinn RH. Neal PA, Reinhart WH, Dallavalle JM. Fulton WB, Dooley AE. Chronic manganese poisoning in an ore-crushing mill. Public Health Bulletin 1940;247:1-77. Public Health Image Library, Centers for Disease Control and Prevention, Atlanta, Georgia. Public domain.)

A railroad car unloader shovels finely ground quartz into a wheelbarrow at a West Virginia pottery factory, while a US Public Health Service investigator collects dust samples in his breathing zone with an impringer. (Source: CDC/Barbara Jenkins, NIOSH, 1936. Flinn RH. Neal PA, Reinhart WH, Dallavalle JM. Fulton WB, Dooley AE. Chronic manganese poisoning in an ore-crushing mill. Public Health Bulletin 1940;247:1-77. Public Health Image Library, Centers for Disease Control and Prevention, Atlanta, Georgia. Public domain.)

Man trimming greenware (unfired clay) cups in a West Virginia pottery factory. Note the turnings produced by cup turning which often fall to the floor, dry, and are ground into dust. (Source: CDC/Barbara Jenkins, NIOSH, 1936. Flinn RH. Neal PA, Reinhart WH, Dallavalle JM. Fulton WB, Dooley AE. Chronic manganese poisoning in an ore-crushing mill. Public Health Bulletin 1940;247:1-77. Public Health Image Library, Centers for Disease Control and Prevention, Atlanta, Georgia. Public domain.)

Men placing bisqueware (fired-once clayware) in saggers (ie, protective fireclay boxes enclosing ceramic ware while it is being fired) for a second firing in a West Virginia pottery factory. Note the impinger being used to take an atmospheric dust sample. (Source: CDC/Barbara Jenkins, NIOSH, 1936. Flinn RH. Neal PA, Reinhart WH, Dallavalle JM. Fulton WB, Dooley AE. Chronic manganese poisoning in an ore-crushing mill. Public Health Bulletin 1940;247:1-77. Public Health Image Library, Centers for Disease Control and Prevention, Atlanta, Georgia. Public domain.)

Man putting bisqueware (fired-once clayware) in a sagger (ie, protective fireclay box enclosing ceramic ware while it is being fired) on the “iron horse” for second firing in a West Virginia pottery factory. (Source: CDC/Barbara Jenkins, NIOSH, 1936. Flinn RH. Neal PA, Reinhart WH, Dallavalle JM. Fulton WB, Dooley AE. Chronic manganese poisoning in an ore-crushing mill. Public Health Bulletin 1940;247:1-77. Public Health Image Library, Centers for Disease Control and Prevention, Atlanta, Georgia. Public domain.)

Woman fettling (trimming) greenware (unfired clayware) over down-draft ventilation in a West Virginia pottery factory. Note the dust produced in this operation. (Source: CDC/Barbara Jenkins, NIOSH, 1936. Flinn RH. Neal PA, Reinhart WH, Dallavalle JM. Fulton WB, Dooley AE. Chronic manganese poisoning in an ore-crushing mill. Public Health Bulletin 1940;247:1-77. Public Health Image Library, Centers for Disease Control and Prevention, Atlanta, Georgia. Public domain.)

(Source: CDC/Barbara Jenkins, NIOSH, 1936. Flinn RH. Neal PA, Reinhart WH, Dallavalle JM. Fulton WB, Dooley AE. Chronic manganese poisoning in an ore-crushing mill. Public Health Bulletin 1940;247:1-77. Public Health Image Library, Centers for Disease Control and Prevention, Atlanta, Georgia. Public domain.)

The lunchbox in the foreground was one piece of evidence that they brought food to this room and ate while working. (Source: CDC/Barbara Jenkins, NIOSH, 1936. Flinn RH. Neal PA, Reinhart WH, Dallavalle JM. Fulton WB, Dooley AE. Chronic manganese poisoning in an ore-crushing mill. Public Health Bulletin 1940;247:1-77. Public Health Image Library, Centers for Disease Control and Prevention, Atlanta, Georgia. Public domain.)

The woman attends bisqueware (once-fired clayware) in a sandblasting machine with an enclosed operation and exhaust ventilation, in a West Virginia pottery factory. (Source: CDC/Barbara Jenkins, NIOSH, 1936. Flinn RH. Neal PA, Reinhart WH, Dallavalle JM. Fulton WB, Dooley AE. Chronic manganese poisoning in an ore-crushing mill. Public Health Bulletin 1940;247:1-77. Public Health Image Library, Centers for Disease Control and Prevention, Atlanta, Georgia. Public domain.)

Mind is in Kellogg, Idaho. (Source: Photograph by Arthur Rothstein (1915-1985), 1936. Courtesy of the U.S. Library of Congress, Washington, D.C. Farm Security Administration, Office of War Information Photograph Collection. Public domain.)

Photograph taken late 19th century. (Source: Daylight gelatin silver print. Photographer [attributed to] William Henry Jackson [c. 1860 - c. 1900]. Courtesy of the Rijkmuseum, Amsterdam. Public domain.)

The workman is wearing a respirator but should also protect himself with long-wristed gloves. Lead(II,IV) oxide, also called red lead or minium, is an inorganic compound with the formula Pb₃O₄. A bright red or orange solid litharge is a red lead mineral, one of the natural mineral forms of lead(II) oxide, PbO. Litharge is also a secondary mineral that forms from the oxidation of galena ores. PbO may be prepared by heating lead metal or other lead oxides in air at approximately 600°C (lead melts at 300°C). This is often done with a set of bellows pumping air over the molten lead, causing the oxidized product to slip or fall off the top into a receptacle, where it quickly solidifies in minute scales. (Source: Rosenau MJ. Preventive medicine and hygiene. Third edition. New York: D. Appleton and Company, 1917:1037. Public domain.)

(Source: Massachusetts State Board of Health. Rosenau MJ. Preventive medicine and hygiene. Third edition. New York: D. Appleton and Company, 1917:1045. Public domain.)

(Source: Massachusetts State Board of Health. Rosenau MJ. Preventive medicine and hygiene. Third edition. New York: D. Appleton and Company, 1917:1037. Public domain.)

The worker is ladling molten recycled lead into billets in a lead-acid battery recovery facility. Any manufacturing operation involving lead has the potential for overexposure, and so the elements of a lead program (including the provision of work clothes and personal protective equipment) are in place here. (Source: National Institute for Occupational Safety and Health, 2008. Creative Commons Attribution 2.0 Generic [CC BY 2.0] license, creativecommons.org/licenses/by/2.0.)

Miners who work the lead mines near Creede, Colorado. Creede had been an important lead-producing center in the 19th century but was for many years a "ghost town" until lead mining resumed during World War II to produce metal needed for the war effort. (Source: Photograph by Andreas Feininger [1906-1999], December 1942. U.S. Office of War Information. Courtesy of the U.S. Library of Congress, Washington, D.C.)

Loading lead ore at a mine near Creede, Colorado. Creede had been an important lead-producing center in the 19th century but was for many years a "ghost town" until lead mining resumed during World War II to produce metal needed for the war effort. (Source: Photograph by Andreas Feininger [1906-1999], December 1942. U.S. Office of War Information. Courtesy of the U.S. Library of Congress, Washington, D.C.)

Crushed lead ore at a mine near Creede, Colorado. Creede had been an important lead-producing center in the 19th century but was for many years a "ghost town" until lead mining resumed during World War II to produce metal needed for the war effort. Note that the man is smoking, which involves repeated hand-to-mouth movement in a setting filled with lead dust. (Source: Photograph by Andreas Feininger [1906-1999], December 1942. U.S. Office of War Information. Courtesy of the U.S. Library of Congress, Washington, D.C.)

Zinc smelting operation at the Eagle-Picher plant near Cardin, Oklahoma. (Source: Photograph by Fritz Henle [1909-1993], January 1943. U.S. Office of War Information. Courtesy of the U.S. Library of Congress, Washington, D.C.)

A stream of molten zinc flows from the furnace at a large smelting operation at the Eagle-Picher plant near Cardin, Oklahoma. (Source: Photograph by Fritz Henle [1909-1993], January 1943. U.S. Office of War Information. Courtesy of the U.S. Library of Congress, Washington, D.C.)

A stream of molten zinc flows from the furnace at a large smelting operation at the Eagle-Picher plant near Cardin, Oklahoma. (Source: Photograph by Fritz Henle [1909-1993], January 1943. U.S. Office of War Information. Courtesy of the U.S. Library of Congress, Washington, D.C.)

The operator of a zinc ore leader at a large smelting plant is protected against harmful dust by a mask. From the Eagle-Picher plant near Cardin, Oklahoma. (Source: Photograph by Fritz Henle [1909-1993], January 1943. U.S. Office of War Information. Courtesy of the U.S. Library of Congress, Washington, D.C.)

(Source: Rosenau MJ. Preventive medicine and hygiene. Third edition. New York: D. Appleton and Company, 1917:1058. Public domain.)

Occupational mercury tremor in a 52-year-old woman who worked collecting the rabbit fur that had been removed from the skins by machinery previously treated with preparations of mercury. Case of English surgeon John Fawcett (1866-1944).

(A) Right arm resting quietly. Six tremors per second, of much greater amplitude and regularity than a normal voluntary tremor, which was only four per second.
(B) Voluntary pressure of finger on tambour. Seven tremors per second. Amplitude about seven times as great as A. (E) Normal voluntary tremor.

(Source: Taylor JG. Chronic poisoning, with special reference to the danger in hatters' furriers' manufactories. Guy;s Hospital Reports 1901;55[40, 3rd series]:171-90. Public domain.)

Occupational mercury tremor in a 52-year-old woman who worked collecting the rabbit fur that had been removed from the skins by machinery previously treated with preparations of mercury. Case of English surgeon John Fawcett (1866-1944).

(C) Strong voluntary movement (pressure) of hand not on tambour. Six tremors per second. Amplitude was about twelve times as great as at rest. The excursions very much more regular than any of the others.
(D) Immediate after-effect of C. Five tremors per second. Very regular in amplitude, becoming very small indeed after a short time.

(Source: Taylor JG. Chronic poisoning, with special reference to the danger in hatters' furriers' manufactories. Guy;s Hospital Reports 1901;55[40, 3rd series]:171-90. Public domain.)

Four adults with very high blood lead levels (BLL 40 µg/dL or higher) in multiple years, by year. Adult Blood Lead Epidemiology and Surveillance (ABLES) Program, United States, 2002-2011. (Source: Centers for Disease Control and Prevention. Very high blood lead levels among adults - United States, 2002-2011. MMWR Morb Mortal Wkly Rep 2013;62[47]:967-71. Erratum in: MMWR Morb Mortal Wkly Rep 2014;383[9912]:e3. Erratum in: MMWR Morb Mortal Wkly Rep 2014;62[51]:1053. Public domain.)

Total number of adults tested and whose blood lead levels (BLLs) were 25 µg/dL or higher, by quarter. From 27 states participating in the Adult Blood Lead Epidemiology and Surveillance (ABLES) Program, United States, 1997-1998.

Notes:
(1) Persons aged 16 to 64 years, categorized according to the highest reported BLL for that person during the given quarter. Second and third quarters of 1998 were not available for New Mexico; the corresponding 1997 quarters were used as estimates.
(2) The reporting threshold varies among the participating states; the value includes persons with BLLs lower than 25 µg/dL. However, the following states do not report persons with BLLs lower than 25 µg/dL: Maryland, Massachusetts, New Jersey, North Carolina, and Oregon. (3) Alabama, Arizona, Connecticut, Iowa, Maine, Maryland, Massachusetts, Minnesota, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, Texas, Utah, Vermont, Washington, Wisconsin, and Wyoming.

(Source: Centers for Disease Control and Prevention. Adult Blood Lead Epidemiology and Surveillance--United States, second and third quarters, 1998, and annual 1994-1997. MMWR Morb Mortal Wkly Rep 1999;48[10]:213-6, 223. Public domain.)

Average state rate (per 100,000 employed persons aged 16 years or older) of adult elevated blood lead levels (BLLs), by year. Adult Blood Lead Epidemiology and Surveillance (ABLES) Program, United States, 1994-2002.

Notes:
(1) Employed persons are according to the Current Population Survey of the Bureau of Labor Statistics. The average is determined by first calculating individual state rates for each year and then calculating the average.
(2) ABLES Program: Alabama, Arizona, California, Connecticut, Florida, Georgia, Hawaii, Illinois, Iowa, Kansas, Kentucky, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Montana, Nebraska, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, Texas, Utah, Washington, Wisconsin, and Wyoming.

(Source: Centers for Disease Control and Prevention. Adult Blood Lead Epidemiology and Surveillance--United States, second and third quarters, 1998, and annual 1994-1997. MMWR Morb Mortal Wkly Rep 1999;48[10]:213-6, 223. Public domain.)

Mean annual rate by state of adults with blood lead levels 25 µg/dL or higher reported by 25 Adult Blood Lead Epidemiology and Surveillance (ABLES) Program states, 1998-2001.

Note: Nebraska 2 years of data; South Carolina 3 years of data.

(Source: Bureau of Labor Statistics, Current Population Survey, 2001. Centers for Disease Control and Prevention. Adult blood lead epidemiology and surveillance--United States, 2002. MMWR Morb Mortal Wkly Rep 2004;53[26]:578-82.)

Mean annual rate by state of adults with blood lead levels 40 µg/dL or higher reported by 25 Adult Blood Lead Epidemiology and Surveillance (ABLES) Program states, 1998-2001.

Note: Nebraska 2 years of data; South Carolina 3 years of data.

(Source: Bureau of Labor Statistics, Current Population Survey, 2001. Centers for Disease Control and Prevention. Adult blood lead epidemiology and surveillance--United States, 2002. MMWR Morb Mortal Wkly Rep 2004;53[26]:578-82.)

Mean annual rate by state for adults with blood lead levels 25 µg/dL or higher in 20 Adult Blood Lead Epidemiology and Surveillance (ABLES) Program states reporting data for 2 or more years in each period.

Note: South Carolina, 3 years of data (1998-2001); Ohio, 2 years of data; Alabama, Iowa, and Minnesota, 3 years of data (1994-1997).

(Source: Bureau of Labor Statistics, Current Population Survey, 2001. Centers for Disease Control and Prevention. Adult blood lead epidemiology and surveillance--United States, 2002. MMWR Morb Mortal Wkly Rep 2004;53[26]:578-82.)

Mean annual rate by state for adults with blood lead levels 40 µg/dL or higher in 20 Adult Blood Lead Epidemiology and Surveillance (ABLES) Program states reporting data for 2 or more years in each period.

Note: South Carolina, 3 years of data (1998-2001); Ohio and Pennsylvania, 2 years of data; Alabama, Iowa, and Minnesota, 3 years of data (1994-1997).

(Source: Bureau of Labor Statistics, Current Population Survey, 2001. Centers for Disease Control and Prevention. Adult blood lead epidemiology and surveillance--United States, 2002. MMWR Morb Mortal Wkly Rep 2004;53[26]:578-82.)

Biopsy with Perls Prussian blue stain (H&E, 50x), ie, blue color staining the erythroid precursor. Abbreviation: H&E, hematoxylin, and eosin. (Source: Stagg MP, Miatech J, Majid B, Polala R. Zinc-containing over-the-counter product causing sideroblastic anemia and neutropenia. Cureus 2024;16(5):e59796. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

(H&E, 100x). Abbreviation: H&E, hematoxylin, and eosin. (Source: Stagg MP, Miatech J, Majid B, Polala R. Zinc-containing over-the-counter product causing sideroblastic anemia and neutropenia. Cureus 2024;16(5):e59796. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

The "flour gold" which is in small, almost powder flakes, will attach itself to the mercury as the water boils away. (Source: Pinos Altos, New Mexico, 1940, by photographer Russell Lee [1903-1986]. Farm Security Administration, Office of War Information Photograph Collection, Library of Congress, Washington, D.C. Public domain.)

(Source: Pinos Altos, New Mexico, 1940, by photographer Russell Lee [1903-1986]. Farm Security Administration, Office of War Information Photograph Collection, Library of Congress, Washington, D.C. Public domain.)

(A) Guacamayo (126519S, 706009W) along the Interoceanic Highway and (B) Colorado-Puquiri (126449S, 706329W) in the buffer zone of the Amarakaeri Communal Reserve. (Source: Swenson JJ, Carter CE, Domec JC, Delgado CI. Gold mining in the Peruvian Amazon: global prices, deforestation, and mercury imports. PLoS One 2011;6(4):e18875. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

(A) December 1986; (B) January 2002; and (C) January 2015. (Source: Images from Google Earth [2015]. Rajaee M, Obiri S, Green A, et al. Integrated assessment of artisanal and small-scale gold mining in Ghana-part 2: natural sciences review. Int J Environ Res Public Health 2015;12[8]:8971-9011. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

Numbers represent key steps in the ASGM process: 1—excavation, 2—crushing and grinding, 3—sifting/shanking, 4—washing/sluicing, 5—amalgamation, and 6—burning. Letters represent key steps in the mercury cycle: A—residual mercury from amalgamation may be discarded in local soil and water; B—volatilization of elemental mercury into the atmosphere; C—oxidation of elemental mercury; D—deposition onto local terrestrial systems; E—deposition onto local aquatic systems; and F—methylation of inorganic mercury to methylmercury. (Source: Rajaee M, Obiri S, Green A, et al. Integrated assessment of artisanal and small-scale gold mining in Ghana-part 2: natural sciences review. Int J Environ Res Public Health 2015;12[8]:8971-9011. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

(Source: Rajaee M, Obiri S, Green A, et al. Integrated assessment of artisanal and small-scale gold mining in Ghana-part 2: natural sciences review. Int J Environ Res Public Health 2015;12[8]:8971-9011. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

(Source: Rajaee M, Obiri S, Green A, et al. Integrated assessment of artisanal and small-scale gold mining in Ghana-part 2: natural sciences review. Int J Environ Res Public Health 2015;12[8]:8971-9011. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

(Source: Museum für Angewandte Kunst à Cologne. Public domain.)

(Source: From the collection of Baron Anthony de Rothschild in London. Hand-colored lithograph from Sauzay A, Delange H. Monographie de l'œuvre de Bernard Palissy, suivie d'un choix de ses continuateurs ou imitateurs. Paris: E Martinet, 1862. Public domain. Edited by Dr. Douglas J Lanska.)

Japanese print shows Palissy, apparently in a frenzy, burning chairs to keep the furnace going as his wife, who is breastfeeding a baby, and a boy run in fear. (Source: Japanese Department of Education [between 1850 and 1900]. Courtesy of the U.S. Library of Congress, Washington, D.C. Public domain. Edited by Dr. Douglas J Lanska.)

By French painter Joseph-Nicolas Robert-Fleury (1797-1890). (Courtesy of the Amsterdam Museum, Amsterdam, The Netherlands. Public domain. Edited by Dr. Douglas J Lanska.)

(Source:"Travailleurs et hommes utiles," avec préface de Léon Chauvin: Librairie nationale d'Education et de Récréation. Limoges: Eugène Ardant et Cie, 1899. Public domain. Edited by Dr. Douglas J Lanska.)

International biweekly gold prices, forest conversion to mining area, and annual mercury imports to Peru (Superintendencia Nacional de Aduanas del Peru). Mercury imports for 2009 were recorded to September and projected for the last quarter. (Source: Swenson JJ, Carter CE, Domec JC, Delgado CI. Gold mining in the Peruvian Amazon: global prices, deforestation, and mercury imports. PLoS One 2011;6[4]:e18875. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

(Source: User: Lincun via Wikimedia Commons. Creative Commons Attribution 3.0 Unported [CC BY 3.0] license, creativecommons.org/licenses/by/3.0.)

(Source: User: Bobo12345 via Wikimedia Commons. Creative Commons Attribution 3.0 Unported [CC BY 3.0] license, creativecommons.org/licenses/by/3.0.)

(Source: User: Bobo12345 via Wikimedia Commons. Creative Commons Attribution 3.0 Unported [CC BY 3.0] license, creativecommons.org/licenses/by/3.0.)

(Source: User: Lincun via Wikimedia Commons. Creative Commons Attribution 3.0 Unported [CC BY 3.0] license, creativecommons.org/licenses/by/3.0.)

(Source: Photographer Carol M Highsmith between 1980 and 2006. Carol M. Highsmith Archive, U.S. Library of Congress, Prints and Photographs Division, Washington, D.C. Public domain.)

(Courtesy of the U.S. Library of Congress, Prints and Photographs Division, Washington, D.C. Public domain.)

(Source: Jet Lowe, 1987. Courtesy of the U.S. Library of Congress, Prints and Photographs Division, Washington, D.C. Public domain.)

Source: Detroit Publishing Co. between 1900 and 1906. Courtesy of the U.S. Library of Congress, Prints and Photographs Division, Washington, D.C. Public domain.)

(Source: Photographer Andreas Feininger [1906-1999] for the U.S. Office of War Information. Courtesy of the U.S. Library of Congress, Prints and Photographs Division, Washington, D.C. Public domain.)

(Source: Detroit Publishing Co between 1900 and 1910. Courtesy of the U.S. Library of Congress, Prints and Photographs Division, Washington, D.C. Public domain.)

The man is facilitating the flow of lead ore. Note that he is smoking; this repetitive hand-to-mouth behavior increases the ingestion and inhalation of lead dust. (Source: Photographer Andreas Feininger [1906-1999] for the U.S. Office of War Information. Courtesy of the U.S. Library of Congress, Prints and Photographs Division, Washington, D.C. Public domain.)

The man is facilitating the flow of lead ore. (Source: Photographer Andreas Feininger [1906-1999] for the U.S. Office of War Information. Courtesy of the U.S. Library of Congress, Prints and Photographs Division, Washington, D.C. Public domain.)

Using a pick axe and shovel to extract lead ore, which is transported out of the mine in metal ore cars. (Source: Photographer Andreas Feininger [1906-1999] for the U.S. Office of War Information. Courtesy of the U.S. Library of Congress, Prints and Photographs Division, Washington, D.C. Public domain.)

(Source: Photographer Andreas Feininger [1906-1999] for the U.S. Office of War Information. Courtesy of the U.S. Library of Congress, Prints and Photographs Division, Washington, D.C. Public domain.)

(Courtesy of the U.S. Library of Congress, Prints and Photographs Division, Washington, D.C. Public domain.)

Five miners in a lead mine, possibly in the Coeur d'Alene region of Idaho. (Courtesy of the U.S. Library of Congress, Prints and Photographs Division, Washington, D.C. Public domain.)

(Courtesy of the U.S. Library of Congress, Prints and Photographs Division, Washington, D.C. Public domain.)

(Source: Keystone View Company,1928. Courtesy of the U.S. Library of Congress, Prints and Photographs Division, Washington, D.C. Public domain.)

In foreground, from left to right, plant dry, slag fuming plant, blast furnace, smelter office, lead and silver refineries are visible. High-velocity flue leads from the lower plant to the bag house and stacks at the top of the smelting facility. (Created by Shauna Hillman, 1993. Courtesy of the U.S. Library of Congress, Prints and Photographs Division, Washington, D.C. Public domain.)

(Courtesy of the U.S. Library of Congress, Prints and Photographs Division, Washington, D.C. Public domain.)

after A R Waud?) Note that Galena, Illinois, is named for the mineral galena, the natural mineral form of lead(II) sulfide. (Source: “Harper's New Monthly Magazine” 1866;32:687. Courtesy of the U.S. Library of Congress, Prints and Photographs Division, Washington, D.C. Public domain.)

Mercury levels increase exponentially up the food web as algae are eaten by small invertebrates which are eaten by larger invertebrates (such as dragonfly larvae) which are eaten by fish and other higher-order predators. (Source: Air Resources Division, U.S. National Park Service. Public domain.)

(Source: MacKenzie E. Jewell, 2020. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

(Source: Wilco Oelen, 2007. Creative Commons Attribution 3.0 Unported [CC BY 3.0] license, creativecommons.org/licenses/by/3.0.)

Gold Placers Incorporated, Coal Creek Dredge, Near Coal Creek & Yukon River, Eagle, Alaska. Note the suspended walkway bridge at right and the control wires and pulleys for controlling the dredge movement. (Source: Todd A Croteau, 2014. Courtesy of the U.S. Library of Congress, Prints and Photographs Division, Washington, D.C. Public domain.)

Gold Placers Incorporated, Coal Creek Dredge, Near Coal Creek & Yukon River, Eagle, Alaska. (Source: Todd A Croteau, 2014. Courtesy of the U.S. Library of Congress, Prints and Photographs Division, Washington, D.C. Public domain.)

Gold Placers Incorporated, Coal Creek Dredge, Near Coal Creek & Yukon River, Eagle, Alaska. (Source: Todd A Croteau, 2014. Courtesy of the U.S. Library of Congress, Prints and Photographs Division, Washington, D.C. Public domain.)

Gold Placers Incorporated, Coal Creek Dredge, Near Coal Creek & Yukon River, Eagle, Alaska. (Source: Jet Lowe, 1984. Courtesy of the U.S. Library of Congress, Prints and Photographs Division, Washington, D.C. Public domain.)

Gold Placers Incorporated, Coal Creek Dredge, Near Coal Creek & Yukon River, Eagle, Alaska. (Source: Jet Lowe, 1984. Courtesy of the U.S. Library of Congress, Prints and Photographs Division, Washington, D.C. Public domain.)

Hydraulic mining for gold in California. (Source: The Century illustrated monthly magazine, January 1883:324. Courtesy of the U.S. Library of Congress, Prints and Photographs Division, Washington, D.C. Public domain.)

Gold miners shoveling sand from stream into sluice while one miner pans for gold in the same stream, small building and mountains in the background. (Published by Currier & Ives, New York. Courtesy of the U.S. Library of Congress, Prints and Photographs Division, Washington, D.C. Public domain.)

(Source: Photographer Russell Lee [1903-1986] for the Office of War Information. Courtesy of the U.S. Library of Congress, Prints and Photographs Division, Washington, D.C. Public domain.)

(Source: Photographer William Henry Jackson [1843-1942]. Courtesy of the U.S. Library of Congress, Prints and Photographs Division, Washington, D.C. Public domain.)

(Source: Lomen Bros. photographer, Nome, between ca. 1900 and ca. 1930. Courtesy of the Frank and Frances Carpenter Collection, U.S. Library of Congress, Prints and Photographs Division, Washington, D.C. Public domain.)

Not all the shiny particles are gold but include mica and a few particles of quicksilver (elemental mercury). The gold usually appears in the pan as a minute shiny upper rim of the dirt in the pan. Source: Photographer Russell Lee (1903-1986), for the Office of War Information. (Courtesy of the U.S. Library of Congress, Prints and Photographs Division, Washington, D.C. Public domain.)

In dry panning the pan is rotated until the dirt is on one side and then with a decisive toss it is thrown into the air, the light dirt being then blown away by the wind and the heavy gold being caught again in the pan. Source: Photographer Russell Lee (1903-1986), for the Office of War Information. (Courtesy of the U.S. Library of Congress, Prints and Photographs Division, Washington, D.C. Public domain.)

In dry panning, the pan is rotated until the dirt is on one side and then with a decisive toss it is thrown into the air, the light dirt being then blown away by the wind and the heavy gold being caught again in the pan. Source: Photographer Russell Lee (1903-1986), for the Office of War Information. (Courtesy of the U.S. Library of Congress, Prints and Photographs Division, Washington, D.C. Public domain.)

(Source: Photographer W.G. Chamberlain, Denver, Colorado. Courtesy of the U.S. Library of Congress, Prints and Photographs Division, Washington, D.C. Public domain.)

(Half of a stereograph published by Lawrence & Houseworth. Courtesy of the U.S. Library of Congress, Prints and Photographs Division, Washington, D.C. Public domain.)

(Half of a stereograph published by Lawrence & Houseworth. Courtesy of the U.S. Library of Congress, Prints and Photographs Division, Washington, D.C. Public domain.)

(Source: Rajaee M, Obiri S, Green A, et al. Integrated assessment of artisanal and small-scale gold mining in Ghana-Part 2: natural sciences review. Int J Environ Res Public Health 2015;12[8]:8971-9011. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

This figure shows some common sources of mercury, the conversion to toxic methylmercury, and the outline of EPA consumption recommendations for certain types of fish based on mercury levels. Mercury from coal-fired power plants and other sources travels through the atmosphere and water. Methylmercury is formed from inorganic mercury by the action of microbes that live in aquatic systems (ie, lakes, rivers, wetlands, and the open ocean), and particularly sediments. Methylmercury can enter the aquatic food chain and is increasingly concentrated (bioaccumulated) at each step on that chain. Large old predators (eg, sharks and pike) or scavengers (eg, halibut), hold the greatest concentrations of mercury. The mercury is particularly problematic during development, so these limits here are designed to protect women, who might become pregnant, and children aged 12 years or younger. (Source: Bretwood Higman, 2009. Creative Commons Attribution 3.0 Unported [CC BY 3.0] license, creativecommons.org/licenses/by/3.0.)

(Source: Dan Polansky, 2024. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

Because most South African Working for Water (WfW) workers hand-washed their personal protective equipment, they had difficulty in properly removing residues and soil from the personal protective equipment. The WfW program is a national government-wide initiative that uses herbicides for the removal of alien invasive plant species and has a policy of hiring unemployed members of poor, marginalized communities. (Source: Pududu BA, Rother HA. Whose jurisdiction is home contamination? Para-occupational 'take-home' herbicide residue exposure risks among forestry workers' families in South Africa. Int J Environ Res Public Health 2021;18[19]:10341. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

South African Working for Water (WfW) workers predominately live in townships that are characterized by low-cost shacks. The space within their homes was limited due to the size of the dwellings and overcrowding from multiple members living together, which likely contributed to their inability to employ protective practices such as storing and washing personal protective equipment separately from household laundry to reduce herbicide exposure risks. (Source: Pududu BA, Rother HA. Whose jurisdiction is home contamination? Para-occupational 'take-home' herbicide residue exposure risks among forestry workers' families in South Africa. Int J Environ Res Public Health 2021;18[19]:10341. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

South African Working for Water (WfW) workers were unaware that residues could remain on washed personal protective equipment and be transferred to household laundry and consequently held the view that drying personal protective equipment together with household laundry did not pose any risk. The WfW program is a national government-wide initiative that hires unemployed members of poor, marginalized communities to use herbicides for the removal of alien invasive plant species. (Source: Pududu BA, Rother HA. Whose jurisdiction is home contamination? Para-occupational 'take-home' herbicide residue exposure risks among forestry workers' families in South Africa. Int J Environ Res Public Health 2021;18[19]:10341. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

The South African Working for Water (WfW) program is a national government-wide initiative that hires unemployed members of poor, marginalized communities to use herbicides for the removal of alien invasive plant species. (Source: Pududu BA, Rother HA. Whose jurisdiction is home contamination? Para-occupational 'take-home' herbicide residue exposure risks among forestry workers' families in South Africa. Int J Environ Res Public Health 2021;18[19]:10341. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

South African Working for Water (WfW) workers were unaware that residues could remain on washed personal protective equipment and be transferred to household laundry and consequently held the view that drying personal protective equipment together with household laundry did not pose any risk. The WfW program is a national government-wide initiative that hires unemployed members of poor, marginalized communities to use herbicides for the removal of alien invasive plant species. (Source: Pududu BA, Rother HA. Whose jurisdiction is home contamination? Para-occupational 'take-home' herbicide residue exposure risks among forestry workers' families in South Africa. Int J Environ Res Public Health 2021;18[19]:10341. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

The South African Working for Water (WfW) program is a national government-wide initiative that hires unemployed members of poor, marginalized communities to use herbicides for the removal of alien invasive plant species. (Source: Pududu BA, Rother HA. Whose jurisdiction is home contamination? Para-occupational 'take-home' herbicide residue exposure risks among forestry workers' families in South Africa. Int J Environ Res Public Health 2021;18[19]:10341. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

The South African Working for Water (WfW) program is a national government-wide initiative that hires unemployed members of poor, marginalized communities to use herbicides for the removal of alien invasive plant species. (Source: Pududu BA, Rother HA. Whose jurisdiction is home contamination? Para-occupational 'take-home' herbicide residue exposure risks among forestry workers' families in South Africa. Int J Environ Res Public Health 2021;18[19]:10341. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

The South African Working for Water (WfW) program is a national government-wide initiative that hires unemployed members of poor, marginalized communities to use herbicides for the removal of alien invasive plant species. (Source: Pududu BA, Rother HA. Whose jurisdiction is home contamination? Para-occupational 'take-home' herbicide residue exposure risks among forestry workers' families in South Africa. Int J Environ Res Public Health 2021;18[19]:10341. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

The South African Working for Water (WfW) program is a national government-wide initiative that hires unemployed members of poor, marginalized communities to use herbicides for the removal of alien invasive plant species. (Source: Pududu BA, Rother HA. Whose jurisdiction is home contamination? Para-occupational 'take-home' herbicide residue exposure risks among forestry workers' families in South Africa. Int J Environ Res Public Health 2021;18[19]:10341. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

The South African Working for Water (WfW) program is a national government-wide initiative that hires unemployed members of poor, marginalized communities to use herbicides for the removal of alien invasive plant species. (Source: Pududu BA, Rother HA. Whose jurisdiction is home contamination? Para-occupational 'take-home' herbicide residue exposure risks among forestry workers' families in South Africa. Int J Environ Res Public Health 2021;18[19]:10341. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

(Public domain.)

(Public domain.)

(Public domain.)

(Source: Dakeishi M, Murata K, Grandjean P. Long-term consequences of arsenic poisoning during infancy due to contaminated milk powder. Environ Health 2006;5:31. Creative Commons Attribution 2.0 Generic [CC BY 2.0] license, creativecommons.org/licenses/by/2.0.)

(Public domain.)

Arsenic (III) trioxide is a white powder that has been mistaken for edible substances with fatal consequences. (Public domain.)

Sir William Thomson, Baron Kelvin "resting on a binnacle and holding a marine azimuth mirror." (Source: Photograph by T. & R. Annan & Sons; restored by Adam Cuerden. National Galleries of Scotland Accession number: PGP 230.1. Public domain.)

Dr. Ernest Septimus Reynolds, Assistant Physician to the Manchester Royal Infirmary and Visiting Physician to the Manchester Workhouse Infirmary, announced "an epidemic of peripheral neuritis amongst beer drinkers in Manchester and district" and attributed this to arsenic poisoning. (Source: Anonymous. Dr. Ernest Septimus Reynolds BMJ 1926;1:969. Public domain.)

General wasting, extensive atrophy of the extremities, and "dropped" hands and feet in a woman poisoned with arsenic-contaminated beer. (Source: Kelynack TN, Kirkby W. Arsenical poisoning in beer drinkers. London: Baillière, Tindall and Cox, 1901. Public domain.)

General muscular atrophy in a woman poisoned with arsenic-contaminated beer. (Source: Kelynack TN, Kirkby W. Arsenical poisoning in beer drinkers. London: Baillière, Tindall and Cox, 1901. Public domain.)

Complete paralysis of the lower extremities with marked atrophy, thickened nails, and mild pigmentation of skin in a woman poisoned with arsenic-contaminated beer. (Source: Kelynack TN, Kirkby W. Arsenical poisoning in beer drinkers. London: Baillière, Tindall and Cox, 1901. Public domain.)

Atrophic paralysis, with marked wasting, and "dropped" feet in a person poisoned with arsenic-contaminated beer. (Source: Kelynack TN, Kirkby W. Arsenical poisoning in beer drinkers. London: Baillière, Tindall and Cox, 1901. Public domain.)

Extensive pigmentation of the body in a woman poisoned with arsenic-contaminated beer. (Source: Kelynack TN, Kirkby W. Arsenical poisoning in beer drinkers. London: Baillière, Tindall and Cox, 1901. Public domain.)

Pigmentation about the arm, axilla, and side of chest and over abdomen in a woman poisoned with arsenic-contaminated beer. (Source: Kelynack TN, Kirkby W. Arsenical poisoning in beer drinkers. London: Baillière, Tindall and Cox, 1901. Public domain.)

Paralyzed lower extremities, with marked muscle wasting and some pigmentation in a person poisoned with arsenic-contaminated beer. (Source: Kelynack TN, Kirkby W. Arsenical poisoning in beer drinkers. London: Baillière, Tindall and Cox, 1901. Public domain.)

"Dropped" hands and feet in a woman poisoned with arsenic-contaminated beer. (Source: Kelynack TN, Kirkby W. Arsenical poisoning in beer drinkers. London: Baillière, Tindall and Cox, 1901. Public domain.)

"Dropped" hands from paralysis of extensors, with marked muscle atrophy in a person poisoned with arsenic-contaminated beer. (Source: Kelynack TN, Kirkby W. Arsenical poisoning in beer drinkers. London: Baillière, Tindall and Cox, 1901. Public domain.)

"Dropped" hands from paralysis of extensors, with marked muscle atrophy in a woman poisoned with arsenic-contaminated beer. (Source: Kelynack TN, Kirkby W. Arsenical poisoning in beer drinkers. London: Baillière, Tindall and Cox, 1901. Public domain.)

Paralysis of lower extremities with wasting of muscles and bilateral foot drop in a person poisoned with arsenic-contaminated beer. (Source: Kelynack TN, Kirkby W. Arsenical poisoning in beer drinkers. London: Baillière, Tindall and Cox, 1901. Public domain.)

Transverse ridging of fingernails in a woman poisoned with arsenic-contaminated beer. (Source: Kelynack TN, Kirkby W. Arsenical poisoning in beer drinkers. London: Baillière, Tindall and Cox, 1901. Public domain.)

"Dropping" of feet, slight atrophy of muscles, thickened and separating cuticle, and pigmentation in a person poisoned with arsenic-contaminated beer. (Source: Kelynack TN, Kirkby W. Arsenical poisoning in beer drinkers. London: Baillière, Tindall and Cox, 1901. Public domain.)

Pigmentation over abdomen, especially marked along lineae albicantes (whitish marks in the skin, especially of the abdomen and breasts, that often follow pregnancy), in a woman with arsenic-contaminated beer. (Source: Kelynack TN, Kirkby W. Arsenical poisoning in beer drinkers. London: Baillière, Tindall and Cox, 1901. Public domain.)

Pigmentation of skin over breast and slight desquamation about nipple and areola in a woman poisoned with arsenic-contaminated beer. (Source: Kelynack TN, Kirkby W. Arsenical poisoning in beer drinkers. London: Baillière, Tindall and Cox, 1901. Public domain.)

Foot of person poisoned with arsenic contamination of beer, showing keratosis and erythema, with pigmentation. (Source: Kelynack TN, Kirkby W. Arsenical poisoning in beer drinkers. London: Baillière, Tindall and Cox, 1901. Public domain.)

The anhydride form of arsenous acid, arsenic trioxide, is used as a herbicide, pesticide, and rodenticide. (Public domain.)

Key: arsenic (purple), oxygen (red), hydrogen (white). The anhydride form of arsenous acid, arsenic trioxide, is used as a herbicide, pesticide, and rodenticide. (Public domain.)

Dr. John Henry Bell first identified arsenic as the cause of the Bradford sweets mass poisoning (1858). This photograph was included in his newspaper obituary and his obituary in the British Medical Journal in 1906. (Source: Anonymous. John Henry Bell MD MRCS. BMJ 1906;2[2386]:735-6. Public domain. Edited by Dr. Douglas J Lanska.)

Death, the poisonous candy maker, is shown mixing arsenic with a mortar and pestle. A barrel full of arsenic and a wooden box full of plaster of Paris are to either side, and a countertop with candies laid out is behind. Paterfamilias is the male head of a family or household. (Source: By British caricaturist and illustrator John Leech [1817-1864]. First published in Punch [London] on November 20, 1858. Public domain.)

London newspapers accused the Qing governor Ye Mingchen of masterminding the Esing Bakery poisoning incident in 1857. Ye was known for his resistance to British influence in Canton (Guangzhou) in the aftermath of the First Opium War and for his role in the beginning of the Second Opium War. (Source: Cooke GW. China and Lower Bengal. 5th ed. London: Routledge, Warne, and Routledge, 1861. Public domain.)

Examination of Al-Lum Cheong, proprietor of the Esing Bakery, at the Police Office, Victoria, Hong Kong on the charge of poisoning. (Source: Illustrated London News, March 28, 1857:286. Public domain.)

The Chinese-owned Esing Bakery, Hong Kong, 1857, at the time of mass poisoning of between 300 and 500 predominantly European residents of the colony. (Source: Illustrated London News, March 28, 1857:286. Public domain.)

Key: carbon (black), fluorine (green), hydrogen (white), oxygen (red), phosphorus (orange). (Public domain.)

(Public domain.)

(Public domain.)

Key: carbon (black), hydrogen (white), nitrogen (blue), oxygen (red), phosphorus (orange). (Public domain.)

(Source: Wikipedia user: Shaddack, 2006. Public domain.)

Women walking in the Szolnok prison yard between 1929 and 1933. (Source: Bodó B. Tiszazug: A Social History of a Murder Epidemic. Boulder: East European Monographs, 2002b:185-6. Public domain.)

(Source: Wikipedia. Public domain.)

(Source: Wikipedia. Public domain.)

Photo taken in front of the International Hotel in San Francisco. Jones was a white minister who preached socialist and progressive ideas to a predominantly African-American congregation, called the Peoples Temple. (Source: Photo by Nancy Wong. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0. Edited [cropped and dust specks removed] by Dr. Douglas J Lanska.)

(Source: Wikipedia. Edited by Dr. Douglas J Lanska.)

(Source: "Addicted04" using Natural Earth, a public domain map dataset. Creative Commons Attribution 3.0 Unported [CC BY 3.0] license, creativecommons.org/licenses/by/3.0.)

Dr. Elias Elvove is front row, third from left. The photograph was taken on the front steps of the National Institute of Health’s administration building in Washington, DC. In the front row are Dr. W Dayton Maclay, Dr. Ernest L Jackson, Dr. Elias Elvove, Dr. Claude S Hudson, Dr. Raymond M Hann, Dr. Havelock F Fraser, and Dr. Nelson K Richtmyer. In the middle row are Mr. Samuel Dove, Dr. Alice T Merrill, Dr. Allene Jeanes, Dr. Evelyn B Tilden, Dr. Mildred Adams, Miss Edna M. Montgomery, Dr. Willard T Haskins, and Mr. Harry W Diehl. In the back row are Mr. Richard Maggenti, Dr. William S McClenahan, Dr. Frank J McClure, Mr. Charles G Remsburg, Mr. Thomas Collins, Dr. Floyd S Daft, Mr. John T Sipes, and Dr. Albert E Knauf. (Source: Courtesy of the Office of NIH History and Stetten Museum, National Institutes of Health, Bethesda, Maryland.)

The pigment Prussian Blue, ferricyanide, was invented in 1706 and named after the country in which the invention took place (Prussia). (Public domain.)

3D ball-and-stick (left) and space-filling (right) models of ferricyanide (hexacyanoferrate[III]), the anion (Fe[CN]₆)³⁻. Key: Carbon (black), iron (light purple), nitrogen (dark blue). (Public domain.)

2D structural formula of ferricyanide (hexacyanoferrate[III]), the anion (Fe[CN]₆₎³⁻. (Public domain.)

(Source: Wikimedia Commons User: Pok, 2024. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

(Public domain.)

Moments before Rudolf Hoess was put to death for his war crimes at Auschwitz, 1947. (Source: Photograph by press photographer Stanisław Dąbrowiecki, 1947. Public domain.)

War criminal Rudolf Hoess with his executioners walking to his gallows next to a crematorium in the Nazi Auschwitz death camp in Poland (1947). (Source: Photograph by press photographer Stanisław Dąbrowiecki, 1947. Public domain.)

Former German SS officer and commandant of the Auschwitz concentration camp Rudolf Franz Ferdinand Höss (also Höß, Hoeß, or Hoess; 1901-1947), during his trial in Warsaw, Poland, in 1947, after which he was declared guilty then hanged as a war criminal in 1947 in Auschwitz, the place of his crimes. (Source: Polska Agencja Prasowa. Public domain.)

From left to right they are: Richard Baer (Commandant of Auschwitz, 1911-1963), Dr. Josef Mengele (1911-1979), and Rudolf Hoess (the former Auschwitz Commandant, 1901-1947). Hoess was the Commandant when Zyklon B (hydrogen cyanide) was initiated as a means of killing prisoners. From a photograph album found by an unidentified American counterintelligence officer who was billeted in Frankfurt after Germany's surrender in 1945. (Source: U.S. Holocaust Memorial Museum. Public domain.)

Fritzsch was deputy and acting commandant at the Auschwitz concentration camp. According to Rudolf Höss, Fritzsch first suggested using poisonous gas Zyklon B for the purpose of mass murder. Hauptsturmfuehrer was a Nazi Party paramilitary rank that was used in several Nazi organizations including the SS, NSKK, and the NSFK. The rank of Hauptsturmführer was a mid-level commander and had equivalent seniority to a captain in the German Army. (Source: Wikimedia Commons. Public domain.)

Reinforced concrete gas chamber in the Nazi-operated Majdanek concentration camp, designed for killing prisoners by carbon monoxide, which was introduced through a tube, or Zyklon B (hydrogen cyanide), as evidenced by the residual blue coloring on the back wall and portions of the ceiling and side walls. The blue coloring is Prussian blue--iron(III) hexacyanoferrate(II), which has the chemical formula Fe₄[Fe(CN)₆]₃ --a dark blue pigment produced by oxidation of ferrous ferrocyanide salts. (Source: Photograph by Adam Jones PhD, 2013. Creative Commons Attribution 3.0 Unported [CC BY 3.0] license, creativecommons.org/licenses/by/3.0.)

Reinforced concrete gas chamber in the Nazi-operated Majdanek concentration camp, designed for killing prisoners by carbon monoxide, which was introduced through a tube, or Zyklon B (hydrogen cyanide), as evidenced by the residual blue coloring on the back wall and portions of the ceiling and side walls. The blue coloring is Prussian blue--iron(III) hexacyanoferrate(II), which has the chemical formula Fe₄[Fe(CN)₆]₃ --a dark blue pigment produced by oxidation of ferrous ferrocyanide salts. (Source: Photograph by Jolanta Dyr, 2013. Creative Commons Attribution 3.0 Unported [CC BY 3.0] license, creativecommons.org/licenses/by/3.0.)

Empty Zyklon B canisters found by the Allies at Auschwitz-Birkenau Nazi extermination camp in 1945 at the end of World War II. (Source: Wikimedia Commons. Public domain. Cropped and edited by Dr. Douglas J Lanska.)

Photograph taken April 7, 1946, by Alfred H Booth. The first and third panels contain the German Pest Control Company emblem and the brand name Zyklon. The center panel reads "Poison Gas!" "Cyanide Preparation! [skull and crossbones] to be opened and used only by trained personnel." The labels were used as evidence at the International Military Tribunal trial of war criminals at Nuremberg. (Source: U.S. National Archives. Public domain. Edited by Dr. Douglas J Lanska.)

Dr. Elias Elvove, Senior Chemist, Laboratory of Chemistry, National Institute of Health, United States Public Health Service. (Source: Courtesy of the U.S. National Library of Medicine, Bethesda, Maryland. Public domain.)

Dr. Maurice Isadore Smith, Principal Pharmacologist and Chief of the Section on Pharmacology in the Laboratory of Pathology and Pharmacology, Experimental Biology and Medicine Institute (EBMI), National Institute of Health, United States Public Health Service. (Courtesy of the U.S. National Library of Medicine, Bethesda, Maryland. Public domain.)

Dr. Elias Elvove, Senior Chemist, Laboratory of Chemistry, National Institute of Health, United States Public Health Service. (Courtesy of the U.S. National Library of Medicine, Bethesda, Maryland. Public domain.)

(Source: U.S. Food and Drug Administration. Public domain.)

(Source: Wikimedia Commons. Photograph by User: Deltabeignet. Public domain. Edited by Dr. Douglas J Lanska.)

HW Wilson Ltd, St. John, New Brunswick, Canada. (Source: Photograph by Terry Lavigne. Public domain.)

(Courtesy of the Prints and Photographs Division, U.S. Library of Congress, Washington, D.C. Public domain. Edited by Dr. Douglas J Lanska.)

(Courtesy of the Prints and Photographs Division, U.S. Library of Congress, Washington, D.C. Public domain.)

Key: Carbon (grey), hydrogen (white), oxygen (red), and phosphorus (orange). (Source: PubChem, National Institutes of Health, Bethesda, Maryland. Public domain.)

The three forms of cresol (methylphenol) with a methyl group on the 2, 3, and 4 positions on the benzene ring for ortho-, meta-, and para-cresol. (Source: Wikimedia Commons. User: Dr. T., 2009. Creative Commons Attribution 3.0 Unported [CC BY 3.0] license, creativecommons.org/licenses/by/3.0.)

(Source: Wikimedia Commons. Public domain.)

(Source: Wikimedia Commons. Public domain.)

(Source: Wikimedia Commons. Public domain.)

(Source: GBD 2021 Carbon Monoxide Poisoning Collaborators. Global, regional, and national mortality due to unintentional carbon monoxide poisoning, 2000-2021: results from the Global Burden of Disease Study 2021. Lancet Public Health 2023;8[11]:e839-49. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

(Source: GBD 2021 Carbon Monoxide Poisoning Collaborators. Global, regional, and national mortality due to unintentional carbon monoxide poisoning, 2000-2021: results from the Global Burden of Disease Study 2021. Lancet Public Health 2023;8[11]:e839-49. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

GBD=Global Burden of Diseases, Injuries, and Risk Factors Study. (Source: GBD 2021 Carbon Monoxide Poisoning Collaborators. Global, regional, and national mortality due to unintentional carbon monoxide poisoning, 2000-2021: results from the Global Burden of Disease Study 2021. Lancet Public Health 2023;8[11]:e839-49. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

Error bars represent the 95% uncertainty interval. YLLs=years of life lost. (Source: GBD 2021 Carbon Monoxide Poisoning Collaborators. Global, regional, and national mortality due to unintentional carbon monoxide poisoning, 2000-2021: results from the Global Burden of Disease Study 2021. Lancet Public Health 2023;8[11]:e839-49. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

GBD=Global Burden of Diseases, Injuries, and Risk Factors Study. (Source: GBD 2021 Carbon Monoxide Poisoning Collaborators. Global, regional, and national mortality due to unintentional carbon monoxide poisoning, 2000-2021: results from the Global Burden of Disease Study 2021. Lancet Public Health 2023;8[11]:e839-49. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

Global age-standardized mortality rate and number of deaths due to unintentional carbon monoxide poisoning, 2000 to 2021. Shading indicates the upper and lower limits of the 95% uncertainty intervals. (Source: GBD 2021 Carbon Monoxide Poisoning Collaborators. Global, regional, and national mortality due to unintentional carbon monoxide poisoning, 2000-2021: results from the Global Burden of Disease Study 2021. Lancet Public Health 2023;8[11]:e839-49. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

Age-standardized rates of intentional carbon monoxide poisoning hospital admissions by region across all the population (left), and among females (center) and males (right) in England between 2002 and 2016. Standardized using the 2013 European Standard Population. (Source: Roca-Barceló A, Crabbe H, Close R, Fahie H, Leonardi GS, Piel FB. Spatial and temporal trends and risk factors for intentional carbon monoxide poisoning hospitalizations in England between 2002 and 2016. J Affect Disord 2023;329:168-75. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

Distribution of cases of carbon monoxide poisoning by month (%) in Adiyaman, Turkey, from 2012 to 2022. (Source: Öz E, Küçükkelepçe O, Kurt O, Vural A. Carbon monoxide poisoning: beyond survival - mortality, morbidities, and risk factors, a Turkey sample. PeerJ 2023;11:e16093. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

Distribution of cases and deaths from carbon monoxide poisoning by age (%) in Adiyaman, Turkey, from 2012 to 2022. (Source: Öz E, Küçükkelepçe O, Kurt O, Vural A. Carbon monoxide poisoning: beyond survival - mortality, morbidities, and risk factors, a Turkey sample. PeerJ 2023;11:e16093. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

Treatment strategies fall into three categories: gas exchange, carbon monoxide scavenging, and pharmacological mitigation. Normobaric oxygen therapy, hyperbaric oxygen therapy, and isocapnic hyperpnea therapy rely on gas exchange in the lungs with accelerated carbon monoxide clearance driven by increased oxygen partial pressure or ventilation. In addition, extracorporeal membrane oxygenation facilitates carbon monoxide clearance via gas exchange in cases of extreme illness or lung damage, and extracorporeal removal of carbon monoxide with phototherapy facilitates this clearance through carbon monoxide photolysis. Carbon monoxide-scavenging therapeutics, including hemoprotein-based scavengers and small molecule-based scavengers, may directly sequester carbon monoxide from circulating hemoglobin (Hb) or cellular hemoproteins. These scavengers undergo rapid renal clearance to safely eliminate both scavenger molecules and carbon monoxide. Finally, pharmacological compounds are being explored to mitigate pathophysiological damage incurred during acute carbon monoxide poisoning (eg, steroids, anti-inflammatory drugs, and mitochondrial electron transport chain substrates). Abbreviations: ECCOR-P, extracorporeal removal of carbon monoxide with phototherapy; ECMO, extracorporeal membrane oxygenation; HBOT, hyperbaric oxygen therapy; IH, isocapnic hyperpnea; NBOT, normobaric oxygen therapy. (Source: Dent MR, Rose JJ, Tejero J, Gladwin MT. Carbon monoxide poisoning: from microbes to therapeutics. Annu Rev Med 2024;75:337-51. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

In circulating red blood cells, carbon monoxide binds to heme sites in hemoglobin, diminishing oxygen-carrying capacity and stabilizing the high-affinity R-state. In addition to binding hemoglobin in circulation, carbon monoxide may also bind myoglobin, causing a reduction in oxygen availability in tissue. In mitochondria, carbon monoxide may directly bind the heme a₃ site in complex IV of the mitochondrial electron transport chain, inhibiting the reduction of oxygen to water. This inhibition, coupled with reduced oxygen availability, leads to membrane depolarization, reduced ATP output, and accumulation of reducing equivalents in the electron transport chain. These reducing equivalents may react with oxygen to form superoxide (O₂^•−), which may propagate cellular damage directly or through conversion to other reactive oxygen species, such as hydrogen peroxide. Abbreviations: CO, carbon monoxide; CoQ, coenzyme Q/ubiquinone; Cyt c, cytochrome c; ETC, electron transport chain; H2O2, hydrogen peroxide; Hb-R, relaxed-state hemoglobin; Hb-T, tense-state hemoglobin; pO₂, partial pressure of oxygen. (Source: Dent MR, Rose JJ, Tejero J, Gladwin MT. Carbon monoxide poisoning: from microbes to therapeutics. Annu Rev Med 2024;75:337-51. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

A skeletal figure drinking a glass of toxic red chemicals, representing the death of civilization by chemical warfare. Drawn by Dutch painter, caricaturist, and editorial cartoonist Louis Raemakers (1869-1956) for The Century Magazine, Barron Collier Series of Patriotic Cartoons. (Source: U.S. Library of Congress, Prints and Photographs Division, Washington, D.C. Public domain.)

Drawn by Dutch painter, caricaturist, and editorial cartoonist Louis Raemakers (1869-1956) for The Century Magazine, Barron Collier Series of Patriotic Cartoons. (Source: U.S. Library of Congress, Prints and Photographs Division, Washington, D.C. Public domain.)

After a crayon drawing by Dutch painter, caricaturist, and editorial cartoonist Louis Raemakers (1869-1956). (Source: Wellcome Collection, London, UK. Wellcome Library no. 46015i (Photo number: V0018240). Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

Colored chalk by Dutch painter, caricaturist and editorial cartoonist Louis Raemakers (1869-1956), 1916. (Source: Wellcome Collection, London, UK. Wellcome Library no. 46015i (Photo number: V0018240). Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

Dutch painter, caricaturist and editorial cartoonist Louis Raemakers (1869-1956), between ca. 1915 and ca. 1920. (Source: U.S. Library of Congress, Prints and Photographs Division, Washington, D.C. Public domain.)

Pastel by Scottish artist A. Kirkpatrick Maxwell (1884-1975), ca. 1915. (Source: Wellcome Collection, London, UK. Wellcome Library no. 571751i. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

Colored chalks by Dutch painter, caricaturist, and editorial cartoonist Louis Raemaekers (1869-1956), ca. 1918. The print of this composition was "Drawn specially for the Graphic"; it was published in the Graphic on August 3, 1918. (Source: Wellcome Collection, London, UK. Wellcome Library no. 46016i. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

Color halftone printed in two colors after Scottish artist A. Kirkpatrick Maxwell (1884-1975), ca. 1917. The victim died 19 hours after exposure. Most of the pulmonary alveoli are filled with edema fluid, and the walls of the air sacs are ruptured in many places. The rounded edges of these torn walls can be recognized both in the areas of emphysema and in the parts that are flooded with edema fluid. The bronchus also is filled with edema fluid, but its lining is intact, and pus cells have not accumulated in the secretion. The blood vessels of the alveolar network are congested; although intravascular thrombosis is frequently found in these small vessels with phosgene poisoning, it is not present in this section. The main changes in the lung are: (1) congestion, and occasional thrombosis, of the network of pulmonary vessels; (2) abundant outpouring of inflammatory edema fluid both into the tissues and into the airspaces of the alveoli and bronchi; and (3) disruptive emphysema of the weakened lung tissue. The result of these changes is that the blood circulation through the lungs is impeded, and the respiratory exchange of gasses between the blood and the air in the lung is seriously diminished. In this era, before the development of respirators, a gassed man would be in danger of death by asphyxia so long as his lung was drowned in edema fluid. (Source: Wellcome Collection, London, UK. Wellcome Library no. 571919i. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

Color halftone printed in two colors after Scottish artist A. Kirkpatrick Maxwell (1884-1975), ca. 1917. The victim died at the end of the second day (40 hours after exposure). The bronchiole is filled with fibrin and pus cells, and its lining epithelium has been destroyed. The inflammation has caused a characteristic ring of hemorrhage in the tissues around the bronchial tube, and infection is beginning to appear in the alveoli nearest to these inflamed tissues. There is no generalized pulmonary edema. The pathological changes in the bronchioles and in the alveoli are, therefore, in sharp contrast with those caused by phosgene. As infection spreads into the lung tissues, patches of septic bronchopneumonia and small abscesses develop, and these often excite a surrounding inflammatory edema. If the patient lives, his bronchial mucous membrane is slowly regenerated; and during this time, he is subject to reflex spasms of coughing or even to a protracted bronchitis. (Source: Wellcome Collection, London, UK. Wellcome Library no. 571919i. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

Poison gas identification kits were issued to civil defense personnel during World War II. These individuals were usually ARP (Air Raid Precaution) wardens, and the kits trained them to identify a range of dangerous gases. This kit contains eight small, labeled, glass bottles and some sachets of chemicals in a leatherette case. The wider civilian population was issued gas masks as protection against potentially fatal gas attacks. They were also given pamphlets describing characteristic smells of different gases. Gas attacks were to be signaled by air raid wardens using large wooden rattles that produced a loud “clacking” sound. In the post-war period, many of these were used by football (soccer) fans around the country. Poison gases (eg, mustard gas) were used to great effect during World War I (1914-1918). They were outlawed in the Treaty of Versailles, which formally ended the conflict. Nevertheless, because the British expected the Germans to use chemical weapons against civilians during World War II, poison gas identification kits were developed, and the general public was supplied with gas masks. (Source: Courtesy of The Science Museum, London, UK, and the Wellcome Collection, London, UK. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

Note the limited visibility that would be provided through the translucent eye ports and the canister at the end of the protruding snout that was intended to filter airborne chemical weapons. Poison gas was a new weapon during the First World War and was first used by the German Army in 1915. The British and French Armies soon followed suit. Fortunately, although good protective equipment was initially quite slow to develop, masks like this one eventually reduced poison gas to a major annoyance rather than the terrifying killer of the early attacks. Among the chemical weapons used was mustard gas, which caused burns to the skin and blindness. Phosgene gas was also used and was particularly dangerous as it is colorless and almost odorless; this gas affected the lungs and breathing and could also cause heart problems. (Source: Courtesy of The Science Museum, London, UK, and the Wellcome Collection, London, UK. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

Note the limited visibility that would be provided through the translucent eye ports and the canister at the end of the protruding snout that was intended to filter airborne chemical weapons. Poison gas was a new weapon during the First World War and was first used by the German Army in 1915. The British and French Armies soon followed suit. Fortunately, although good protective equipment was initially quite slow to develop, masks like this one eventually reduced poison gas to a major annoyance rather than the terrifying killer of the early attacks. Among the chemical weapons used was mustard gas, which caused burns to the skin and blindness. Phosgene gas was also used and was particularly dangerous as it is colorless and almost odorless; this gas affected the lungs and breathing and could also cause heart problems. (Source: Courtesy of The Science Museum, London, UK, and the Wellcome Collection, London, UK. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

(Source: Chart of war gases. Issued by the Ministry of Home Security. London: H.M. Stationary Office, 1942. Courtesy of the Wellcome Library, London, UK. Reference number: b15316890. Public domain.)

(Source: Waltenburg MA, Larson VA, Naor EH, et al. Notes from the field: botulism type B After intravenous methamphetamine use--New Jersey, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1425-6. Public domain.)

Data are derived from routine, passive national surveillance. Data are presented as one trend line because the incidence and absolute case count trend lines are indistinguishable. (Source: Varma JK, Katsitadze G, Moiscrafishvili M, et al. Signs and symptoms predictive of death in patients with foodborne botulism--Republic of Georgia, 1980-2002. Clin Infect Dis 2004;39[3]:357-62. Public domain.)

The numbers indicated in the period ranges 1875 to 1936, 1940 to 1944, 1956 to 1970, and 1971 to 1977 are the annual mean values. Total cases (blue), type B botulism (green), type A botulism (red), type E botulism (purple), type F botulism (orange arrows). (Source: Rasetti-Escargueil C, Lemichez E, Popoff MR. Human Botulism in France, 1875-2016. Toxins [Basel]. 2020;12[5]:338. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

Cases by epidemiologic week of symptom onset. (Source: Peak CM, Rosen H, Kamali A, et al. Wound botulism outbreak among persons who use black tar heroin - San Diego County, California, 2017-2018. MMWR Morb Mortal Wkly Rep 2019;67[5152]:1415-8. Public domain.)

(Source: Centers for Disease Control and Prevention; Peak CM, Rosen H, Kamali A, et al. Wound botulism outbreak among persons who use black tar heroin - San Diego County, California, 2017-2018. MMWR Morb Mortal Wkly Rep 2019;67[5152]:1415-8. Public domain.)

Botulism cases (n = 31) in a federal correctional facility, by reported date of hooch exposure and symptom onset. Hooch is defined as an illicitly made alcoholic beverage. First exposure is defined as the first exposure to hooch occurring during June 1-19, 2016. Date of exposure was unknown for two inmates. (Source: McCrickard L, Marlow M, Self JL, et al. Notes from the field: botulism outbreak from drinking prison-made illicit alcohol in a federal correctional facility--Mississippi, June 2016. MMWR Morb Mortal Wkly Rep 2017;65[52]:1491-2. Public domain.)

(rate/100,000 population) (Source: Leclair D, Fung J, Isaac-Renton JL, et al. Foodborne botulism in Canada, 1985-2005. Emerg Infect Dis 2013;19[6]:961-8. Public domain.)

(A) Length of hospitalization, (B) length of time in a special care unit. The box and whiskers represent the data as quartiles; the whiskers (vertical lines) represent the top and bottom values, the box represents the 1st (bottom) to 3rd (top) quartiles of values, and the horizontal line in the middle of the box represents the median. The circles indicate individual data points including outliers. A single outlier for time in special care occurred for serotype E. (Source: Harris RA, Tchao C, Prystajecky N, et al. Foodborne Botulism, Canada, 2006-2021. Emerg Infect Dis 2023;29[9]:1730-7. Public domain.)

(A) Number of cases from 1960 to 2021; (B) detail of number of cases from 2006 to 2021. Inset pie graphs represent the percentage of cases among non-Indigenous and Indigenous persons. (Source: Harris RA, Tchao C, Prystajecky N, et al. Foodborne Botulism, Canada, 2006-2021. Emerg Infect Dis 2023;29[9]:1730-7. Public domain.)

(Source: Centers for Disease Control and Prevention, 2003. Courtesy of Natural Resources Canada. Public domain.)

(Source: Centers for Disease Control and Prevention, 2001. Public domain.)

Postmortem cranial nerve tissue from a patient with asymmetric Type F botulism showing B-cell infiltration of nerve tissue. (Source: Filozov A, Kattan JA, Jitendranath L, et al. Asymmetric type F botulism with cranial nerve demyelination. Emerg Infect Dis 2012;18[1]:102-4. Public domain.)

Postmortem cranial nerve tissue from a patient with asymmetric Type F botulism showing CD68-positive myelinoklastic macrophages (original magnification ×400). (Source: Filozov A, Kattan JA, Jitendranath L, et al. Asymmetric type F botulism with cranial nerve demyelination. Emerg Infect Dis 2012;18[1]:102-4. Public domain.)

Postmortem cranial nerve tissue from a patient with asymmetric Type F botulism showing fragmentation of myelin sheaths and inflammatory infiltration of B and CD3+ T-cells within the nerve tissue (original magnification ×200). (Source: Filozov A, Kattan JA, Jitendranath L, et al. Asymmetric type F botulism with cranial nerve demyelination. Emerg Infect Dis 2012;18[1]:102-4. Public domain.)

(Source: Sobel J, Tucker N, Sulka A, McLaughlin J, Maslanka S. Foodborne botulism in the United States, 1990-2000. Emerg Infect Dis 2004;10[9]:1606-11. Public domain.)

Justinus Kerner published the first description of botulism. Lithograph 1841/1850. (Source: Universitätsbibliothek Leipzig. Public domain.)

Ida Bengtson on January 1, 1848. Dr. Bengtson was the first woman scientist in the Public Health Service. In 1937, she was transferred to Washington, D.C. Her former laboratory in the Public Health Service had become the Division of Infectious Diseases of the National Institute of Health. Bengtson was awarded the Typhus Medal in 1947 by the American Typhus Commission. Dr. Bengtson died in 1952, at the age of 71. (Source: Courtesy of the History Office, U.S. National Institutes of Health, Bethesda, Maryland. Public domain.)

Ida Bengtson was the first woman to be hired as a bacteriologist in the United States Hygienic Laboratory, now known as the National Institutes of Health. Half-length portrait while seated in United States Hygienic Laboratory's sterile room, transferring tissue cultures of Rocky Mountain spotted fever ca. 1938. (Source: Courtesy of the U.S. National Library of Medicine, Bethesda, Maryland. NLM Image ID: B02711 Public domain.)

At her microscope, this historic image depicts bacteriologist Dr. Ida A. Bengtson (1881-1952), while at work in her laboratory. The photograph was taken from the U.S. Public Health Service records. Dr. Bengtson was particularly noted for her studies of bacterial toxins, especially her discoveries concerning the organism Clostridium botulinum. (Source: Public Health Image Library ID# 3606, Centers for Disease Control and Prevention, Atlanta, Georgia. Public domain.)

Belgian bacteriologist Émile van Ermengem discovered the bacterium that causes botulism, later named Clostridium botulinum. (Source: Van Loo, Florimond, Portret Van Emile-Pierre Van Ermengem [1851-1932], Hoogleraar Aan De Faculteit Geneeskunde Te Gent. Gand: Florimond Van Loo, 1897. Creative Commons Attribution-ShareAlike [CC BY-SA 4.0] license, creativecommons.org/licenses/by/4.0.)

(Source: Photograph by Dr. VR Dowell Jr., Centers for Disease Control and Prevention, 1980. Public Health Image Library ID# 16681, Centers for Disease Control and Prevention, Atlanta, Georgia. Public domain.)

The white mouse depicted here was exhibiting neurologic deficits due to botulism toxicity during an in vitro botulism toxicity test. (Source: Photograph by Dr. Hatheway, Centers for Disease Control and Prevention, 1980. Public Health Image Library ID# 16186, Centers for Disease Control and Prevention, Atlanta, Georgia. Public domain.)

Under a low magnification of 1.9x, this image shows a close view of Clostridium botulinum, type-E bacterial colonies, which had formed on the surface of the egg yolk agar growth medium in this Petri dish culture plate, after undergoing a 48-hour incubation period. Note the opaque, opalescent nature exhibited by these characteristic type-E colonies. (Source: Photograph by Dr. Holdeman, Centers for Disease Control and Prevention, 1965. Public Health Image Library ID# 3871, Centers for Disease Control and Prevention, Atlanta, Georgia. Public domain.)

Photomicrograph showing the presence of Clostridium botulinum, type-A bacteria, that had been cultivated in this Gram-stained, thioglycollate broth specimen, having undergone a 48-hour incubation period, at a temperature of 35°C. Note that some of the organisms had entered their endospore phase, assuming the morphological shape of safety pins. (Source: Photograph by Dr. George Lombard, Centers for Disease Control and Prevention, 1978. Public Health Image Library ID# 3870, Centers for Disease Control and Prevention, Atlanta, Georgia. Public domain.)

Under a low magnification (5x), this image shows a close view of a Clostridium botulinum, type-A bacterial colony, which had formed on the surface of the blood agar growth medium in this Petri dish culture plate, after undergoing a 72-hour incubation period. (Source: Photograph by Dr. Holdeman, Centers for Disease Control and Prevention, 1965. Public Health Image Library ID# 3869, Centers for Disease Control and Prevention, Atlanta, Georgia. Public domain.)

Close view of the surface of a blood agar culture plate, which produced these colonies after having been inoculated with Clostridium botulinum, type-A, strain 2 bacteria and incubated for 48 hours. (Source: Photograph by Dr. Holdeman, Centers for Disease Control and Prevention, 1965. Public Health Image Library ID# 3868, Centers for Disease Control and Prevention, Atlanta, Georgia. Public domain.)

Jars containing contaminated Jalapeño peppers preserves, which were involved in an outbreak of botulism in Pontiac, Michigan in April 1977. (Source: Photograph by Dr. Chas Hatheway, Centers for Disease Control and Prevention, 1978. Public Health Image Library ID# 3355, Centers for Disease Control and Prevention, Atlanta, Georgia. Public domain.)

Photomicrograph depicts the presence of numerous Clostridium botulinum, type-A bacteria, which had been highlighted after they were processed using the Gram-stain technique. Note the Cl. botulinum endospores, which appeared shaped like tennis rackets. (Source: Photograph by Dr. George Lombard, Centers for Disease Control and Prevention, 1978. Public Health Image Library ID# 2132, Centers for Disease Control and Prevention, Atlanta, Georgia. Public domain.)

Photomicrograph depicting the presence of numerous Clostridium botulinum, type-A bacteria, which had been highlighted after they were processed using the Gram-stain technique. Note the Cl. botulinum endospores, which appeared shaped like bobby pins. (Source: Photograph by Dr. George Lombard, Centers for Disease Control and Prevention, 1978. Public Health Image Library ID# 2131, Centers for Disease Control and Prevention, Atlanta, Georgia. Public domain.)

Photomicrograph of a gentian violet-stained culture specimen revealing the presence of numerous gram-positive Clostridium botulinum, formerly known as Bacillus botulinus bacteria, and bacterial endospores. (Source: Centers for Disease Control and Prevention, 1979. Public Health Image Library ID# 2107, Centers for Disease Control and Prevention, Atlanta, Georgia. Public domain.)

This 6-week-old infant displayed a posture that was caused by botulinum toxin, which manifested as a marked loss of muscle tone, especially in the region of the head and neck. This toxin is made by the bacterium, Clostridium botulinum, and sometimes Cl. butyricum and Cl. baratii bacteria as well. These bacteria can be spread by food, and sometimes by other means, including potentially in bioterrorism. (Source: Public Health Image Library ID# 1935, Centers for Disease Control and Prevention, Atlanta, Georgia. Public domain.)

Photomicrograph depicting numerous Clostridium botulinum bacteria in their endospore stage, which had been highlighted after being processed using the malachite green staining method. The endospores appear as green spheres, whereas the bacilli themselves stain a purple color. (Source: Photography by Larry Stauffer, Oregon State Public Health Laboratory, 2002. Public Health Image Library ID# 1932, Centers for Disease Control and Prevention, Atlanta, Georgia. Public domain.)

Photomicrograph depicting numerous Clostridium botulinum bacteria in their endospore stage, which had been highlighted after being processed using the malachite green staining method. The endospores appear as green spheres, whereas the bacilli themselves stain a purple color. (Source: Photography by Larry Stauffer, Oregon State Public Health Laboratory, 2002. Public Health Image Library ID# 1931, Centers for Disease Control and Prevention, Atlanta, Georgia. Public domain.)

Close view of a Petri dish, which contained a growth medium of egg yolk agar that had been inoculated with Clostridium botulinum bacteria and subsequently incubated for a 72-hour period. Note the presence of the "lipase reaction," which manifests as a shiny margin that surrounds each colony. (Source: Photography by Larry Stauffer, Oregon State Public Health Laboratory, 2002. Public Health Image Library ID# 1930, Centers for Disease Control and Prevention, Atlanta, Georgia. Public domain.)

A mother is holding off a boa constrictor wrapped around her and her three small children. Flames surround them. A liquor store is in the background on the right. A still is behind them on the right, with the inscription "The worm of the still." (Source: Harper's Weekly 1887;31:760. Courtesy of the U.S. National Library of Medicine, Bethesda, Maryland. Public domain.)

Carleton was the author of "The Serpent of the Still" (1906). (Source: The Magazine of Poetry 1890;2. Public domain.)

(Alcohol addiction) Two old men, one is leaning on a staff and the other is embracing a tankard; their unkempt appearance is indicative of the ravages of alcoholism. (Source: "Human passions delineated in above 120 figures...designed in the Hogarthian style.." by Tim Bobbin [ie, pseudonym of English caricaturist and satirical poet John Collier, 1708-1786] and engraved by Thomas Sanders. London, 1773. Courtesy of the U.S. National Library of Medicine, Bethesda, Maryland. Public domain.)

(Alcohol addiction) Two men, one is happily embracing his tankard of liquor, the other is sad at having none. (Source: "Human passions delineated in above 120 figures...designed in the Hogarthian style.." by Tim Bobbin [ie, pseudonym of English caricaturist and satirical poet John Collier, 1708-1786] and engraved by Thomas Sanders. London, 1773. Courtesy of the U.S. National Library of Medicine, Bethesda, Maryland. Public domain.)

Anti-alcohol poster sponsored by the U.S. National Institute on Alcohol Abuse and Alcoholism. (Source: Courtesy of the U.S. Library of Congress, Washington, D.C. Public domain.)

Huge distillation apparatus; black men, representing the West Indies, distill sugar and molasses. At right representatives of agriculture, holding corn and barley, fall back in fear. Spirits representing the effects of alcohol emanate from a large vat. Artist Samuel De Wilde (1748-1832). Published by S Tipper, England, 1808. (Source: Courtesy of the U.S. National Library of Medicine, Bethesda, Maryland. Public domain.)

Print shows an archway of the nine steps of a drunkard's progress, beginning with a man in fancy dress having "a glass with a friend" and then his gradual decline in society with poverty and disease, criminal activity, becoming a bum, and his eventual "death by suicide"; a weeping woman and child are under the archway. (Source: Lithograph published by N Currier, New York. Courtesy of the U.S. Library of Congress, Washington, D.C. Public domain.)

(Source: Caasis and Lubrecht, New York, c1884. Courtesy of the U.S. Library of Congress, Washington, D.C. Public domain.)

Print shows an archway of the nine steps of a drunkard's progress, beginning with a man in a fancy dress having "a glass with a friend" and then his gradual decline in society with poverty and disease, criminal activity, becoming a bum, and his eventual "death by suicide"; two men, one on horseback and another with sacks, are in foreground. (Source: EB and EC Kellogg, Hartford, Connecticut, c1846. Courtesy of the U.S. Library of Congress, Washington, D.C. Public domain.)

Stereograph showing a studio scene of a policeman intervening in a fight, against a painted backdrop. By GW Edmondson, Plymouth, Richland County, Ohio, c1874? (Source: Courtesy of the U.S. Library of Congress, Washington, D.C. Public domain.)

Illustration by British caricaturist and book illustrator George Cruikshank (1792-1878). A man, ruined by alcohol and placed in an institution, is huddled before a locked cage that protects a stove. He is visited by a son and daughter. Through a doorway, a wide-eyed maniac sits on the floor, and a man holding a key waits outside the door. (Source: Courtesy of the U.S. National Library of Medicine, Bethesda, Maryland. Public domain.)

Two men and a woman are sitting around a small table on which is a large punch bowl; each is holding a glass. On the right is seated a fat man with both feet and his left hand bandaged. In the center, a young woman is holding her stomach. On the left, a man appears to be near death. The fat man with gout on the right claims that "PUNCH cures the GOUT," to which the woman adds "the COLIC," and the sickly man adds "and the TISICK." Note that "tisick" in British English is archaic for a splutter (a short explosive spitting or choking noise) or a cough. Cartoon by British caricaturist and printmaker James Gillray (1756-1815), who was famous for his etched political and social satires. (Source: Courtesy of the U.S. National Library of Medicine, Bethesda, Maryland. Public domain.)

Two men and a woman are sitting around a table drinking to their health; the man on the right suffers from gout. The man on the left, holding a glass of alcohol, claims "This good Appetite gives [sic]." The woman in the middle, holding a glass of alcohol, adds, "Cures the vapors also." The snarling man on the right, also holding a glass of alcohol, asks, "Will it Cure the Cursed Pain I have got in my toe?" Artist William Heath (1795-1840), London, 1810. (Source: Courtesy of the U.S. National Library of Medicine, Bethesda, Maryland. Public domain.)

The bum drinks the alcohol from the cigar lighter. A bowery is a city district known for cheap bars and derelicts. The Strobridge Lithographing Company, Cincinnati and New York. (Source: Courtesy of the U.S. Library of Congress, Washington, D.C. Public domain.)

Two cartoon panels illustrate the effects of overindulging in alcohol. "Night" (left panel) depicts a laughing man with friends seated at a table set with decanters labeled "Port" and "Sherry," holding a goblet of wine in his raised right hand and fruit in his left hand. "Morning" (right panel) depicts the same man lying in bed tormented by two imp-like figures personifying wine; "Sherry" hammers the man's head while "Port" prods his stomach with a red-hot poker. This indicates some of the symptoms of a hangover: headache and nausea. Published by Thomas McLean in London in the 1830s. (Source: Courtesy of the U.S. National Library of Medicine, Bethesda, Maryland. Public domain.)

Designed and engraved by John Warner Barber (1798-1885). Print shows a man identified as "King Alcohol" and a skeleton representing Death standing on barrels labeled "Strong Beer, Wines, Rum, Gin, Brandies, Whiskies, compounded liquors," with "social class" and "moderate drinkers" on the left, as well as the "suicide and murderous fighter," and on the right, the "dead and drunken," their broken families, ruined homes, and their graves. "Hope" at lower left mourns the "60,000 annually in the U.[S.] States." "King Alcohol" holds a tankard in his raised right hand with a snake coiled around his arm; printed above is a reference to Proverbs XXIII 32 ("In the end, it will bite like a snake and poison like a viper."). (Source: Courtesy of the U.S. Library of Congress, Washington, D.C. Public domain.)

Drawing from between 1860 and 1902. Artist Thomas Nast (1840-1902). Forms part of the Cabinet of American illustration (Library of Congress). (Source: Courtesy of the U.S. Library of Congress, Washington, D.C. Public domain.)

Motion picture poster for "Absinthe" shows a man seated, with hand on head, at table with three glasses of absinthe. Metropolitan Division, U.S. Lithograph Company. (Source: Courtesy of the U.S. Library of Congress, Washington, D.C. Public domain.)

Anti-alcohol poster sponsored by the U.S. National Institute on Alcohol Abuse and Alcoholism, 1975. (Source: Courtesy of the U.S. Library of Congress, Washington, D.C. Public domain.)

Painted by Francis William Edmonds (1806-1863) and engraved by Thomas Doney (active 1844-1852). Print showing a man in a woodworking shop sitting in front of a bottle of alcohol resting on a shelf in a window. (Source: Published by R.F. Fraser, New York, c1846. Courtesy of the U.S. Library of Congress, Washington, D.C. Public domain.)

Anti-alcohol poster sponsored by the U.S. National Institute on Alcohol Abuse and Alcoholism, 1973. (Source: Courtesy of the U.S. Library of Congress, Washington, D.C. Public domain.)

Death, appearing as a doctor with a top hat and cane, is standing before a stout man sitting in a chair. The man is holding a glass, and on the table next to him are the remnants of overindulgence. Cartoon by French artist Joseph Guillaume Bourdet (1799-1869), 183-. (Source: Courtesy of the U.S. National Library of Medicine, Bethesda, Maryland. NLM Unique ID: 101393102. Public domain.)

From engraver and publisher Johann Theodor de Bry (1561-1623), after Nicolaas Braeu, after Flemish painter Karel van Mander (1548-1606), 1596. Title: [The epicurians celebrate this rite from a herd of swine]. From: Emblemata Saecularia [Secular emblems], 1596. A drunken young man lies vomiting in a ditch. He is held by his buddy, who points to two men carrying away a large barrel of beer in the background. Two sober barrel carriers are able to carry a full barrel of beer, while a drunkard cannot tolerate anything (anymore). The moral: beware of intemperate drinking with all the bad consequences that entails. Emblem No. 14 in Emblemata Saecularia (1596) and no. 35 in the second edition (1611). (Source: Courtesy of the Rijkmuseum, Amsterdam, The Netherlands. Object number RP-P-BI-5200. Public domain.)

Death is pouring alcohol down the throat of an alcoholic while another man next to him vomits from drinking too much. Copy of a print by German-Swiss painter and printmaker Hans Holbein the younger (c1497-1543) from 1538. First published in: Imagines mortis... (Images of death). Lyon: Johannes Frellon, 1547. (Source: Courtesy of the Rijkmuseum, Amsterdam, The Netherlands. Object number RP-P-OB-21.777[V]. Public domain.)

Anonymous, after George Cruikshank. Print against the abuse of alcoholic beverages, ca 1867-1868. Under a tree composed of liquor barrels and green snakes, all kinds of different people collect the poisonous drink in their glass. In the foreground, victims lie drunk or dead on the ground. In the background, a large laughing devil with the inscription “Strong drink / People's cancer.” (Source: Courtesy of the Rijkmuseum, Amsterdam, The Netherlands. Object number RP-P-1962-352. Public domain.)

People reaching for alcoholic drink falling from a pile of barrels of liquor likened to the upas tree; skeletons litter the ground. Alcohol is compared to the upas tree, a poisonous tree allegedly fatal to approach with sap that is used as arrow poison. Colored etching by British caricaturist and book illustrator George Cruikshank (1792-1878), c1842. (Source: Courtesy of the Wellcome Library, London, UK. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

A large bottle labeled "Absinthe" leans to one side. Death sits on the bottle and pours alcohol into a goblet held by a man while dangling a spider over the man's head. Acts of insanity, murder, and suicide resulting from alcoholism are depicted. (Source: Harper's Weekly 1883;27:592. Courtesy of the U.S. National Library of Medicine, Bethesda, Maryland. Public domain. Figure edited by Dr. Douglas Lanska.)

Sitting under grapevines heavy with fruit is Podagra who, though looking like the wise philosopher, personifies the excess represented by Venus and Bacchus who are sitting beside him. Note the cane for Podagra (gout) and the large glass of alcohol (presumably wine) for Bacchus. (Source: From the frontispiece of Scriptum apologetico-politicum de podagra oder das so benahmte ... Zipperlein (1687) by Johann Andreas Schlegel [fl 1657-1681]. Courtesy of the U.S. National Library of Medicine, Bethesda, Maryland. Public domain. Figure edited and cropped by Dr. Douglas Lanska.)

"Commit him for manslaughter in the greatest degree." Shows an unhappy bottle of rum in a prison yard with a chain on its ankle carrying two buckets of water. (Source: Harper's Weekly 1874;18:264. Courtesy of the U.S. National Library of Medicine, Bethesda, Maryland. Public domain. Figure edited by Dr. Douglas Lanska.)

Experienced Party: "No, it isn't regular drinking that hurts a man; it's this way you fellers have of drinking between drinks." (Source: Harper's Weekly 1865;9:32. Courtesy of the U.S. National Library of Medicine, Bethesda, Maryland. Public domain. Figure edited by Dr. Douglas Lanska.)

(Source: Harper's Weekly 1870;14:344. Courtesy of the U.S. National Library of Medicine, Bethesda, Maryland. Public domain.)

Man with bottle in his back pocket looking at his black eye in mirror. Stereo image by Ingersoll View Company, St Paul, Minnesota, c1902. (Source: Courtesy of the U.S. Library of Congress, Washington, D.C. Public domain.)

Man with a black eye and a bottle in back pocket, in a stuporous condition looking into mirror. Stereo image by Ingersoll View Company, St Paul, Minnesota, c1902. (Source: Courtesy of the U.S. Library of Congress, Washington, D.C. Public domain.)

(A) The sleeve gastrectomy (SG) group included 12 women, and the control group included nine women. (B and D) Area under the curve (AUC) for concentration-time curves for both groups. Whiskers indicate the standard error of the mean. The "a" indicates that the AUC value for the sleeve gastrectomy group was significantly different from the control group at p<.05. (C) Sleeve gastrectomy and control group participants were matched on time-to-peak blood alcohol concentrations (BAC). Analysis was conducted among seven women from each group. (E and F) Individual BAC curves. (Source: Seyedsadjadi N, Acevedo MB, Alfaro R, et al. Site of alcohol first-pass metabolism among women. JAMA Netw Open 2022;5[3]:e223711. Erratum in: JAMA Netw Open 2022;5[4]:e2212773. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

Average annual number of deaths from excessive alcohol use by age group and period among males (A) and females (B). Deaths from excessive alcohol use includes all decedents whose deaths were attributed to conditions that were fully caused by alcohol use, alcohol-related acute causes of death that involved binge drinking, and alcohol-related chronic conditions that involved medium (females: more than one but less than two drinks; males: more than two but less than four drinks) or high (females: more than two drinks; males: more than four drinks) daily average drinking levels. (Source: Esser MB, Leung G, Sherk A, et al. Estimated deaths attributable to excessive alcohol use among U.S. adults aged 20 to 64 years, 2015 to 2019. JAMA Netw Open 2022;5[11]:e2239485. Public domain.)

Estimated percentage of total deaths attributable to excessive alcohol use among adults aged 20 to 49 years, United States, 2015 to 2019. (Source: Esser MB, Leung G, Sherk A, et al. Estimated deaths attributable to excessive alcohol use among U.S. adults aged 20 to 64 years, 2015 to 2019. JAMA Netw Open 2022;5[11]:e2239485. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

Colored etching by British caricaturist George Cruikshank (1792-1878) in 1819, after an illustration by Royal Navy officer and novelist Captain Frederick Marryat (1792-1848). (Source: Wellcome Collection, London, United Kingdom. Public domain.)

Magnified view of period corresponding to tetrodotoxin (TTX) accumulation in bivalves at selected shellfish representative monitoring sites in 2016. The plot shows satellite-derived daily mean sea-surface temperature (SST) values between May and July 2016 at sites with TTX (red dots) and without TTX (blue dots). The dashed vertical lines represent the onset of TTX accumulation on 21st June and when maximum TTX concentrations were recorded (4th July). (Source: Dhanji-Rapkova M, Teixeira Alves M, Triñanes JA, et al. Sea temperature influences accumulation of tetrodotoxin in British bivalve shellfish. Sci Total Environ 2023;885:163905. Creative Commons Attribution [CC BY] license.)

Daily continuous sea-surface temperature (SST) changes at selected shellfish representative tetrodotoxin (TTX) monitoring sites in the United Kingdom where TTX-positive or TTX-negative bivalves were recovered in 2016. Satellite-derived SST from 2016 using (A) daily mean SST and (B) "SST Difference" data sets. "SST Difference" values were determined by subtracting the lowest daily mean SST value from the daily mean SST values at each site. Significant interactions were found between time and TTX status for both data sets. (Source: Dhanji-Rapkova M, Teixeira Alves M, Triñanes JA, et al. Sea temperature influences accumulation of tetrodotoxin in British bivalve shellfish. Sci Total Environ 2023;885:163905. Creative Commons Attribution [CC BY] license.)

Sea-surface temperature characteristics of selected shellfish representative tetrodotoxin (TTX) monitoring sites in the United Kigndom where TTX-positive or TTX-negative bivalves were recovered in 2016. Box and whisker plots showing median (horizontal line), mean (diamond) and 1st and 3rd quartiles for satellite-derived sea surface temperature (SST) from 2016, based on (A) daily mean SST and (B) "SST difference" data sets. "SST difference" values were determined by subtracting the lowest daily mean SST value from the daily mean SST values at each site. (Source: Dhanji-Rapkova M, Teixeira Alves M, Triñanes JA, et al. Sea temperature influences accumulation of tetrodotoxin in British bivalve shellfish. Sci Total Environ 2023;885:163905. Creative Commons Attribution [CC BY] license.)

Tetrodotoxin (TTX) concentrations in bivalves and sea-surface temperature (SST) over multiple years. The data were collected from selected shellfish representative monitoring sites in the United Kingdom. (Source: Dhanji-Rapkova M, Teixeira Alves M, Triñanes JA, et al. Sea temperature influences accumulation of tetrodotoxin in British bivalve shellfish. Sci Total Environ 2023;885:163905. Creative Commons Attribution [CC BY] license.)

A summary of the ecology of tetrodotoxin (TTX) in bivalve mollusks in the United Kingdom. (Source: Dhanji-Rapkova M, Teixeira Alves M, Triñanes JA, et al. Sea temperature influences accumulation of tetrodotoxin in British bivalve shellfish. Sci Total Environ 2023;885:163905. Creative Commons Attribution [CC BY] license.)

(Source:Public domain.)

Several etiopathogenic mechanisms have been proposed to explain the responsiveness of some neonatal seizures to pyridoxine, and particularly to its active form, pyridoxal 5′ phosphate (PLP). PLP acts as a cofactor of several enzymes, such as glutamic acid decarboxylase (GAD), which regulates the synthesis of the inhibitory neurotransmitter gamma-amino butyric acid (GABA) from the excitatory neurotransmitter glutamate (GLUT); consequently, a reduction of PLP may lower GABA and raise GLUT, decreasing the seizure threshold. PLP is also involved in the synthesis of serine and glycine; a reduction of PLP may cause lower levels of these two amino acids, which is associated with epileptic phenotypes. SHMT is involved in the metabolic pathway, eventually leading to the formation of 5-methyltetrahydrofolate (5-mTHF), the main circulating form of folate, a reduction of which has been reported in some patients suffering from pyridoxine-dependent epilepsies. Furthermore, the reduction of 5-mTHF may be associated with oxidative stress, with excessive production of reactive oxygen species (ROS), possibly a consequence of low levels of pyridoxine, an antioxidant. ROS contribute to the peroxidation of several molecules, also affecting ion channels, potentially including KCNQ2. PLP also acts as an antagonist of specific ion channels with a possible anticonvulsant effect, so low pyridoxine levels may have a convulsant effect in part through action on these ion channels: this may apply to KCNQ2 (potassium voltage-gated channel subfamily Q member 2). Finally, some antiepileptic drugs may contribute to the depletion of pyridoxine and, indirectly, hyperhomocysteinemia, which is known to lower the seizure threshold. (Source: Amore G, Butera A, Spoto G, et al. KCNQ2-related neonatal epilepsy treated with vitamin B6: a report of two cases and literature review. Front Neurol 2022;13:826225. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

(Courtesy of the Florida Fish and Wildlife Conservation Commission. Public domain.)

Brevetoxin B, a group of neurotoxins isolated from the marine dinoflagellate Karenia brevis (formerly Gymnodinium breve).

Brevetoxin-2 (PbTx-2) R = -CH2C(=CH2)CHO
Brevetoxin-3 (PbTx-3) R = -CH2C(=CH2)CH2OH
Brevetoxin-5 (PbTx-5) R = -CH2C(=CH2)CH2OH, OH in position 37 is acetylated
Brevetoxin-6 (PbTx-6) like PbTx-2, epoxide in position 27-28
Brevetoxin-8 (PbTx-8) R = -CH2COCH2Cl
Brevetoxin-9 (PbTx-9) R = -CH2CH(CH3)CH2OH

(Source: Public domain.)

Brevetoxin A, a group of neurotoxins isolated from the marine dinoflagellate Karenia brevis (formerly Gymnodinium breve).

Brevetoxin-1 (PbTx-1) R = -CH2C(=CH2)CHO
Brevetoxin-7 (PbTx-7) R = -CH2C(=CH2)CH2OH
Brevetoxin-10 (PbTx-10) R = -CH2CH(-CH3)CH2OH

(Source: Public domain.)

Dr. Mary Broadfoot Walker first demonstrated the effectiveness of physostigmine in the treatment of myasthenia gravis. (Source: Wellcome Institution, London, UK. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0/deed.en.)

(Source: Wellcome Institution, London, UK. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0/deed.en.)

Oil on canvas by George Reid (1841-1913). He introduced physostigmine into ophthalmic practice, and the Argyll Robertson pupil is named after him. (Source: Wikimedia Commons. Public domain.)

(Source: Wellcome Institution, London, UK. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0/deed.en.)

At the time of this photograph, Dr. Ogle was Assistant Physician and Lecturer on Pathology at St. George's Hospital. (Source: U.S. National Library of Medicine. Public domain.)

Sir Robert Christison became an authority on poisons, and his treatise on them was published in 1829. In the course of his research he undertook experiments on himself, such as taking large doses of Calabar bean (physostigmine). (Source: Wellcome Institution, London, UK. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0/deed.en.)

(Photograph by the United Kingdom Government. Public domain.)

Together with Gerhard Peters and Walter Heerdt, Tesch developed a process for manufacturing hydrogen cyanide so it could be used in a solid form as an insecticide: Zyklon B. Tesch was the owner of Tesch & Stabenow (called Testa), a pest control company he co-founded in 1924 with Paul Stabenow in Hamburg, Germany. Tesch became a supporting member of the Nazi party in 1933. During World War II, Tesch & Stabenow sold massive quantities of Zyklon B to the SS. The gas was sold to concentration camps in Auschwitz, Sachsenhausen, Neuengamme, Gross-Rosen, Majdanek, and Ravensbrück. In these camps, the SS used Zyklon B to murder approximately 1.1 million people. Following the end of World War II, Tesch was arrested by the British as a war criminal, tried, and executed. Tesch and his co-executive, Karl Weinbacher, were the only businessmen to be executed for their role in Nazi atrocities in Western Europe. (Photograph by the United Kingdom Government. Public domain.)

Source: Photo by CEphoto, Uwe Aranas, 2017. Used with permission. Photograph edited by Dr. Douglas J Lanska. Cropped and straightened.)

(Source: Organisation for the Prohibition of Chemical Weapons, the implementing body for the Chemical Weapons Convention. Public domain.)

The Battle of Shanghai was the first of the 22 major engagements fought between the National Revolutionary Army of the Republic of China and the Imperial Japanese Army of the Empire of Japan at the beginning of the Second Sino-Japanese War. It was one of the largest and bloodiest battles of the entire war and is often regarded as the battle where World War II started. (Source: Wikimedia Commons. Public domain.)

(Source: U.S. Army Soldier and Biological Chemical Command [SBCCOM]. Public domain.)

The rapid absorption of antidote following automatic injection is enhanced by the degree of tissue dispersion achieved by the autoinjector. The x-ray shows autoinjector doses (on left) compared to standard syringe intramuscular doses (on right). The autoinjector medication is obviously more efficiently diffused into surrounding muscle due to the force with which it is expelled from the injector (as seen in inset photo.) (Source: U.S. Army Soldier and Biological Chemical Command [SBCCOM]. Public domain.)

(Source: U.S. Agency for Toxic Substances and Disease Registry. Case Studies in Environmental Medicine: Cholinesterase Inhibitors: Including Pesticides & Chemical Warfare Nerve Agents, 2007. Public domain. Data source: Sofer S, Tal A, Shahak E. Carbamate and organophosphate poisoning in early childhood. Pediatric Emergency Care 1989;5:222-5.)

(Source: U.S. Agency for Toxic Substances and Disease Registry. Case Studies in Environmental Medicine: Cholinesterase Inhibitors: Including Pesticides & Chemical Warfare Nerve Agents, 2007. Public domain.)

Painting by British portrait painter Héléna Arsène Darmesteter (1854-1923). (Source: Wikimedia Commons. Girton College, University of Cambridge; supplied by The Public Catalogue Foundation. Public domain.)

(Source: U.S. Library of Congress. Public domain. Photograph edited by Dr. Douglas J Lanska.)

(Source: ArbotNet, Centers for Disease Control and Prevention, Atlanta, Georgia. Public domain.)

(Source: ArbotNet, Centers for Disease Control and Prevention, Atlanta, Georgia. Public domain.)

Technical Emergency Response Training students perform a final exercise in Northville, a fictional town at the Chemical, Ordnance, Biological, and Radiological facility. During the exercise, students work with and identify biological materials Ricin and Anthrax and also nerve agents GB and VX. The exercise was conducted in Anniston, Alabama on March 1, 2014. (Source: Photograph by Benjamin Crossley [2014]. Department of Homeland Security. Federal Emergency Management Agency. Public Affairs Division. Unrestricted. National Archives and Records Administration, College Park, Maryland. Public domain.)

Technical Emergency Response Training students perform a final exercise in Northville, a fictional town at the Chemical, Ordnance, Biological, and Radiological facility. During the exercise, students work with and identify biological materials Ricin and Anthrax and also nerve agents GB and VX. The exercise was conducted in Anniston, Alabama on March 1, 2014. (Source: Photograph by Benjamin Crossley [2014]. Department of Homeland Security. Federal Emergency Management Agency. Public Affairs Division. Unrestricted. National Archives and Records Administration, College Park, Maryland. Public domain.)

Technical Emergency Response Training students perform a final exercise in Northville, a fictional town at the Chemical, Ordnance, Biological, and Radiological facility. During the exercise, students work with and identify biological materials ricin and anthrax and also nerve agents GB and VX. The exercise was conducted in Anniston, Alabama on March 1, 2014. (Source: Photograph by Benjamin Crossley [2014]. Department of Homeland Security. Federal Emergency Management Agency. Public Affairs Division. Unrestricted. National Archives and Records Administration, College Park, Maryland. Public domain.)

A United States Army Survey Team member with the 21st Weapons of Mass Destruction-Civil Support Team (WMD-CST), New Jersey National Guard, is placed on a decontamination line during a training exercise at Fort Hancock and Sandy Hook Proving Ground National Historic Landmark, Sandy Hook, New Jersey, on September 25, 2018. The 21st WMD-CST supports civil authorities at man-made or natural disasters by identifying chemical, biological, radiological, and nuclear substances, as well as assessing the consequences, advising on response measures, and assisting in requesting follow-on forces. (Source: New Jersey National Guard photo by Mark C. Olsen/Released. National Archives and Records Administration and the Defense Visual Information Distribution Service. Public Domain Dedication.)

A United States Army Survey Team member with the 21st Weapons of Mass Destruction-Civil Support Team (WMD-CST), New Jersey National Guard, is decontaminated during a training exercise at Fort Hancock and Sandy Hook Proving Ground National Historic Landmark, Sandy Hook, New Jersey, on September 25, 2018. The 21st WMD-CST supports civil authorities at man-made or natural disasters by identifying chemical, biological, radiological, and nuclear substances, as well as assessing the consequences, advising on response measures, and assisting in requesting follow-on forces. (Source: New Jersey National Guard photo by Mark C. Olsen/Released. National Archives and Records Administration and the Defense Visual Information Distribution Service. Public Domain Dedication.)

A United States Army Survey Team member with the 21st Weapons of Mass Destruction-Civil Support Team (WMD-CST), New Jersey National Guard, is decontaminated during a training exercise at Fort Hancock and Sandy Hook Proving Ground National Historic Landmark, Sandy Hook, New Jersey, on September 25, 2018. The 21st WMD-CST supports civil authorities at man-made or natural disasters by identifying chemical, biological, radiological, and nuclear substances, as well as assessing the consequences, advising on response measures, and assisting in requesting follow-on forces. (Source: New Jersey National Guard photo by Mark C. Olsen/Released. National Archives and Records Administration and the Defense Visual Information Distribution Service. Public Domain Dedication.)

A United States Army Survey Team member with the 21st Weapons of Mass Destruction-Civil Support Team (WMD-CST), New Jersey National Guard, is moved down the decontamination line during a training exercise at Fort Hancock and Sandy Hook Proving Ground National Historic Landmark, Sandy Hook, New Jersey, on September 25, 2018. The 21st WMD-CST supports civil authorities at man-made or natural disasters by identifying chemical, biological, radiological, and nuclear substances, as well as assessing the consequences, advising on response measures, and assisting in requesting follow-on forces. (Source: New Jersey National Guard photo by Mark C. Olsen/Released. National Archives and Records Administration and the Defense Visual Information Distribution Service. Public Domain Dedication.)

A Strike Team member with the New Jersey National Guard's 21st Weapons of Mass Destruction-Civil Support Team (WMD-CST), prepares to get scrubbed at a decontamination station by Picatinny Arsenal during a training exercise with the Picatinny Arsenal Fire Department at the New Jersey Homeland Defense Homeland Security Center at Picatinny Arsenal, New Jersey, on March 23, 2017. The 21st WMD-CST is a joint unit comprised of New Jersey National Guard Soldiers and Airmen whose mission is to support civil authorities by identifying chemical, biological, radiological, and nuclear substances in either man-made or natural disasters. (Source: New Jersey National Guard photo by Mark C. Olsen/Released. National Archives and Records Administration and the Defense Visual Information Distribution Service. Public Domain Dedication.)

A Strike Team member with the New Jersey National Guard's 21st Weapons of Mass Destruction-Civil Support Team (WMD-CST), is scrubbed at a decontamination station by Picatinny Arsenal during a training exercise with the Picatinny Arsenal Fire Department at the New Jersey Homeland Defense Homeland Security Center at Picatinny Arsenal, New Jersey, on March 23, 2017. The 21st WMD-CST is a joint unit comprised of New Jersey National Guard Soldiers and Airmen whose mission is to support civil authorities by identifying chemical, biological, radiological, and nuclear substances in either man-made or natural disasters. (Source: New Jersey National Guard photo by Mark C. Olsen/Released. National Archives and Records Administration and the Defense Visual Information Distribution Service. Public Domain Dedication.)

A Survey Team member, 21st Civil Support Team (Weapons of Mass Destruction), New Jersey National Guard, prepares his sample kit at a county facility in Dias Creek, New Jersey, on November 5, 2008. Soldiers and Airmen of the 21st Civil Support Team were evaluated by the 5th Army (ARNORTH) Civil Support Readiness Group-East. (Source: U.S. Air National Guard photo by Tech. Sgt. Mark Olsen/Released. National Archives and Records Administration and the Defense Visual Information Distribution Service. Public Domain Dedication.)

A Chemical, Biological, Radiological, and Nuclear (CBRN) Marine with CBRN platoon, Headquarters Battalion, 3rd Marine Division lies on a table as fellow Marines remove his gear after passing out in the field within a contaminated environment as a simulated casualty during a CBRN training exercise at landing zone Westfield on May 13, 2014. Marines conducted assessment and consequence management training through several scenarios to sustain familiarity with safely conducting research and gathering samples in a contaminated environment. One scenario contained an aircraft leaking chemical agents while the other scenario included locating a chemical agent spill and rescuing multiple casualties in the field. Both scenarios utilized the Rapid Area Sensitive Sight and Reconnaissance robot to investigate the hazardous areas to search for and mitigate potentially harmful substances CBRN personnel may not be aware of. (Source: U.S. Marine Corps photo by Lance Cpl. Matthew Bragg/Released. National Archives and Records Administration and the Defense Visual Information Distribution Service. Public Domain Dedication.)

Chemical, Biological, Radiological, and Nuclear (CBRN) Marines with CBRN platoon, Headquarters Battalion, 3rd Marine Division, clear the area after gathering samples during an aircraft chemical leak training scenario at Westfield on May 13, 2014. Marines conducted assessment and consequence management training through several scenarios to sustain familiarity with safely conducting research and gathering samples in a contaminated environment. One scenario contained an aircraft leaking chemical agents, and the other scenario included locating a chemical agent spill and rescuing multiple casualties in the field. Both scenarios utilized the Rapid Area Sensitive Sight and Reconnaissance robot to investigate the hazardous areas to search for and mitigate potentially harmful substances CBRN personnel may not be aware of. (Source: U.S. Marine Corps photo by Lance Cpl. Matthew Bragg/Released. National Archives and Records Administration and the Defense Visual Information Distribution Service. Public Domain Dedication.)

Chemical, Biological, Radiological, and Nuclear Marines with the 24th Marine Expeditionary Unit search for casualties in a metro line during a course at the Guardian Centers of Georgia in Perry, Ga. October 30, 2020. The course allows Marines to expand their knowledge of procedures and equipment through training in realistic environments. (Source: U.S. Marines Corps photo by Lance Cpl. Nicholas Guevara/Released. National Archives and Records Administration and the Defense Visual Information Distribution Service. Public Domain Dedication.)

Chemical, Biological, Radiological, and Nuclear Marines with the 24th Marine Expeditionary Unit evacuate a casualty in a realistic metro line during a course at the Guardian Centers of Georgia in Perry, Georgia, on October 30, 2020. The course allows Marines to expand their knowledge of procedures and equipment through training in realistic environments. (Source: U.S. Marines Corps photo by Lance Cpl. Nicholas Guevara/Released. National Archives and Records Administration and the Defense Visual Information Distribution Service. Public Domain Dedication.)

Chemical, Biological, Radiological, and Nuclear Marines with the 24th Marine Expeditionary Unit scan a wash rag for contamination during a course at the Guardian Centers of Georgia in Perry, Georgia, on October 22, 2020. The course allows Marines to expand their knowledge of procedures and equipment through training in realistic environments. (Source: U.S. Marines Corps photo by Lance Cpl. Nicholas Guevara/Released. National Archives and Records Administration and the Defense Visual Information Distribution Service. Public Domain Dedication.)

Chemical, Biological, Radiological, and Nuclear Marines with the 24th Marine Expeditionary Unit evacuate a casualty in a realistic metro line during a course at the Guardian Centers of Georgia in Perry, Georgia, on October 30, 2020. The course allows Marines to expand their knowledge of procedures and equipment through training in realistic environments. (Source: U.S. Marines Corps photo by Lance Cpl. Nicholas Guevara/Released. National Archives and Records Administration and the Defense Visual Information Distribution Service. Public Domain Dedication.)

Chemical, Biological, Radiological, and Nuclear Marines with the 24th Marine Expeditionary Unit conduct decontamination procedures on an anatomical donation during a course at the Guardian Centers of Georgia in Perry, Georgia, on October 25, 2020. The course allows Marines to expand their knowledge of procedures and equipment through training in realistic environments. (Source: U.S. Marines Corps photo by Lance Cpl. Nicholas Guevara/Released. National Archives and Records Administration and the Defense Visual Information Distribution Service. Public Domain Dedication.)

A Picatinny Arsenal firefighter, left, checks a New Jersey National Guard 21st Weapons of Mass Destruction-Civil Support Team Strike Team member for contamination during a training exercise with the Picatinny Arsenal Fire Department at the New Jersey Homeland Defense Homeland Security Center at Picatinny Arsenal, New Jersey, on March 23, 2017. The 21st WMD-CST is a joint unit comprised of New Jersey National Guard Soldiers and Airmen whose mission is to support civil authorities by identifying chemical, biological, radiological, and nuclear substances in either man-made or natural disasters. (Source: New Jersey National Guard photo by Mark C. Olsen/Released. National Archives and Records Administration and the Defense Visual Information Distribution Service. Public Domain Dedication.)

A Picatinny Arsenal firefighter, left, checks a New Jersey National Guard 21st Weapons of Mass Destruction-Civil Support Team Strike Team member for contamination during a training exercise with the Picatinny Arsenal Fire Department at the New Jersey Homeland Defense Homeland Security Center at Picatinny Arsenal, New Jersey, on March 23, 2017. The 21st WMD-CST is a joint unit comprised of New Jersey National Guard Soldiers and Airmen whose mission is to support civil authorities by identifying chemical, biological, radiological, and nuclear substances in either man-made or natural disasters. (Source: New Jersey National Guard photo by Mark C. Olsen/Released. National Archives and Records Administration and the Defense Visual Information Distribution Service. Public Domain Dedication.)

(Source: ArbotNet, Centers for Disease Control and Prevention, Atlanta, Georgia. Public domain.)

(Source: U.S. National Archives [1984]. Combined Military Service Digital Photographic Files. Released to the public. Public domain.)

The salsa bar of The Dalles' Taco Time that had been intentionally contaminated as part of the Rajneeshee cult bioterrorism attack in 1983 in The Dalles, Oregon. (Source: Wikimedia Commons. User: Cacophony [2008]. Creative Commons Attribution 3.0 Unported [CC BY 3.0] license, creativecommons.org/licenses/by/3.0/deed.en.)

Four of the restaurants in The Dalles, Oregon, affected by the Rajneeshee cult bioterrorism incident in 1984. (Source: Wikimedia Commons. User: Cacophony [2008]. Creative Commons Attribution 3.0 Unported [CC BY 3.0] license, creativecommons.org/licenses/by/3.0/deed.en.)

(Source: Wikimedia Commons. Image by Sjakkelien Vollebregt [1984]. Nationaal Archief, the Dutch National Archives. Creative Commons CC0 1.0 Universal Public Domain Dedication.)

(Source: Wikimedia Commons. Image by Sjakkelien Vollebregt [1984]. Nationaal Archief, the Dutch National Archives. Creative Commons CC0 1.0 Universal Public Domain Dedication.)

(Source: Wikimedia Commons. Image by Redheylin [1977]. Creative Commons CC0 1.0 Universal Public Domain Dedication.)

Rajneeshee cult members in the summer of 1982, 2 years before cult members perpetrated the largest bioterrorism event in United States history. (Source: © 2003 Samvado Gunnar Kossatz. Available at: web.archive.org/web/20071026130939/http://m31.de/ranch/index.html. Used with permission.)

Rajneeshee cult members in the summer of 1982, 2 years before cult members perpetrated the largest bioterrorism event in United States history. (Source: © 2003 Samvado Gunnar Kossatz. Available at: web.archive.org/web/20071026130939/http://m31.de/ranch/index.html. Used with permission.)

Rajneeshee cult members in the summer of 1982, 2 years before cult members perpetrated the largest bioterrorism event in United States history. (Source: © 2003 Samvado Gunnar Kossatz. Available at: web.archive.org/web/20071026130939/http://m31.de/ranch/index.html. Used with permission.)

The compound of the Rajneeshee cult in The Dalles, Oregon, 1982. (Source: © 2003 Samvado Gunnar Kossatz. Available at: web.archive.org/web/20071026130939/http://m31.de/ranch/index.html. Used with permission.)

Members of the Rajneeshee cult watch their leader, Osho Rajneesh drive by in a car in the summer of 1982, 2 years before cult members perpetrated the largest bioterrorism event in United States history. (Source: © 2003 Samvado Gunnar Kossatz. Available at: web.archive.org/web/20071026130939/http://m31.de/ranch/index.html. Used with permission.)

Histopathologic features from a 5-year-old girl with eastern equine encephalitis in 2005, as part of a study of eastern equine encephalitis in Massachusetts and New Hampshire from 1970 to 2010. The postmortem samples of central nervous system tissue were obtained 10 days after the onset of symptoms. Eastern equine encephalitis virus colocalizes with areas of tissue injury in the brain. Immunohistochemistry with eastern equine encephalitis immune ascites demonstrates eastern equine encephalitis viral antigens in the thalamus. Specificity for Eastern equine encephalitis virus immunoreactivity of this ascites fluid was confirmed by the lack of staining on control brain specimens. (Source: Silverman MA, Misasi J, Smole S, et al. Eastern equine encephalitis in children, Massachusetts and New Hampshire, USA, 1970-2010. Emerg Infect Dis 2013;19[2]:194-201. Public domain.)

Histopathologic features from a 5-year-old girl with eastern equine encephalitis in 2005, as part of a study of eastern equine encephalitis in Massachusetts and New Hampshire from 1970 to 2010. The postmortem samples of central nervous system tissue were obtained 10 days after the onset of symptoms. Eastern equine encephalitis virus colocalizes with areas of tissue injury in the brain. H&E stained section of thalamus (magnification ×100). (Source: Silverman MA, Misasi J, Smole S, et al. Eastern equine encephalitis in children, Massachusetts and New Hampshire, USA, 1970-2010. Emerg Infect Dis 2013;19[2]:194-201. Public domain.)

Histopathologic features from a 5-year-old girl with eastern equine encephalitis in 2005, as part of a study of eastern equine encephalitis in Massachusetts and New Hampshire from 1970 to 2010. The postmortem samples of central nervous system tissue were obtained 10 days after the onset of symptoms. Eastern equine encephalitis virus colocalizes with areas of tissue injury in the brain. Immunohistochemistry of section adjacent to that shown in the previous figure; staining of the basal ganglia with eastern equine encephalitis immune ascites demonstrates foci of eastern equine encephalitis virus (arrow) that correspond with areas of tissue rarefaction in the previous figure (magnification ×12.5). (Source: Silverman MA, Misasi J, Smole S, et al. Eastern equine encephalitis in children, Massachusetts and New Hampshire, USA, 1970-2010. Emerg Infect Dis 2013;19[2]:194-201. Public domain.)

Histopathologic features from a 5-year-old girl with eastern equine encephalitis in 2005, as part of a study of eastern equine encephalitis in Massachusetts and New Hampshire from 1970 to 2010. The postmortem samples of central nervous system tissue were obtained 10 days after the onset of symptoms. Eastern equine encephalitis virus colocalizes with areas of tissue injury in the brain. H&E-stained section of the basal ganglia, demonstrating foci of marked tissue rarefaction (arrow) (magnification ×12.5). (Source: Silverman MA, Misasi J, Smole S, et al. Eastern equine encephalitis in children, Massachusetts and New Hampshire, USA, 1970-2010. Emerg Infect Dis 2013;19[2]:194-201. Public domain.)

Histopathologic features from a 5-year-old girl with eastern equine encephalitis in 2005, as part of a study of eastern equine encephalitis in Massachusetts and New Hampshire from 1970 to 2010. The postmortem samples of central nervous system tissue were obtained 10 days after the onset of symptoms. H&E-stained section of midbrain, showing perivascular inflammation (arrow) (magnification ×400). (Source: Silverman MA, Misasi J, Smole S, et al. Eastern equine encephalitis in children, Massachusetts and New Hampshire, USA, 1970-2010. Emerg Infect Dis 2013;19[2]:194-201. Public domain.)

Histopathologic features from a 5-year-old girl with eastern equine encephalitis in 2005, as part of a study of eastern equine encephalitis in Massachusetts and New Hampshire from 1970 to 2010. The postmortem samples of central nervous system tissue were obtained 10 days after the onset of symptoms. H&E-stained section of temporal lobe, showing meningeal inflammation (arrow) (magnification ×200). (Source: Silverman MA, Misasi J, Smole S, et al. Eastern equine encephalitis in children, Massachusetts and New Hampshire, USA, 1970-2010. Emerg Infect Dis 2013;19[2]:194-201. Public domain.)

Axial FLAIR from a brain MRI scan of a 3.5-year-old girl with eastern equine encephalitis on hospital day 3. The abnormal T2 hyperintense regions are most prominent in the right parietotemporal gray matter (arrow) and subcortical white matter but are also seen scattered throughout. (Source: Silverman MA, Misasi J, Smole S, et al. Eastern equine encephalitis in children, Massachusetts and New Hampshire, USA, 1970-2010. Emerg Infect Dis 2013;19[2]:194-201. Public domain.)

Axial FLAIR from a brain MRI scan of a 3.5-year-old girl with eastern equine encephalitis on hospital day 3 showing abnormal T2 hyperintense caudate and thalamic nuclei, most prominent on the right (arrow). (Source: Silverman MA, Misasi J, Smole S, et al. Eastern equine encephalitis in children, Massachusetts and New Hampshire, USA, 1970-2010. Emerg Infect Dis 2013;19[2]:194-201. Public domain.)

Axial FLAIR image from a brain MRI scan of a 13-year-old boy with eastern equine encephalitis on hospital day 2 showing abnormal T2 hyperintense regions of the bimesial temporal regions (thick arrows) with accompanying abnormal T2 hyperintense regions of the dorsal pontomesencephalic regions (thin arrows). (Source: Silverman MA, Misasi J, Smole S, et al. Eastern equine encephalitis in children, Massachusetts and New Hampshire, USA, 1970-2010. Emerg Infect Dis 2013;19[2]:194-201. Public domain.)

Noncontrast CT scan of the brain of a 5-year-old girl with eastern equine encephalitis on hospital day 2 showing subtle hypoattenuation of the left caudate head (arrow) and diencephalic region. (Source: Silverman MA, Misasi J, Smole S, et al. Eastern equine encephalitis in children, Massachusetts and New Hampshire, USA, 1970-2010. Emerg Infect Dis 2013;19[2]:194-201. Public domain.)

Gibson was instrumental in recognizing the importance of lead-based paint in the development of childhood lead poisoning from 1897 to 1904. (Source: Gibson JL. A plea for painted railings and painted walls of rooms as the source of lead poisoning amongst Queensland children. 1904. Public Health Rep 2005;120[3]:301-4. Public domain.)

(Top) Distribution of housing age; percentage of houses built before 1973 for the cases’ local area. Values represent for each case, the percentage of housing built before 1973, for the small area (Lower Super Output Area) where the case resides. Data from the Valuation Office Agency (VOA) (2014). (Bottom) Distribution of housing age for Lead Exposure in Children Surveillance System (LEICSS) cases (2014–2020) in England using Ordnance Survey data. (Source: Crabbe H, Verlander NQ, Iqbal N, et al. As safe as houses; the risk of childhood lead exposure from housing in England and implications for public health. BMC Public Health 2022;22[1]:2052. Photography by Rebecca Ingham, Advanced Health Protection Practitioner, Yorkshire and Humber Health Protection Team (HPT), UK Health Security Agency (UKHSA), 2021. Open Government Licence v3.0, www.nationalarchives.gov.uk/doc/open-government-licence/version/3.)

Location of cases, counts per Upper Tier Local Authority (UTLA), UK Health Security Agency (UKHSA) Centre region areas, and percentage of housing built before 1973 per UTLA area (VOA data, 2014). (Source: Crabbe H, Verlander NQ, Iqbal N, et al. As safe as houses; the risk of childhood lead exposure from housing in England and implications for public health. BMC Public Health 2022;22[1]:2052. Photography by Rebecca Ingham, Advanced Health Protection Practitioner, Yorkshire and Humber Health Protection Team (HPT), UK Health Security Agency (UKHSA), 2021. Open Government Licence v3.0, www.nationalarchives.gov.uk/doc/open-government-licence/version/3.)

(Source: Crabbe H, Verlander NQ, Iqbal N, et al. As safe as houses; the risk of childhood lead exposure from housing in England and implications for public health. BMC Public Health 2022;22[1]:2052. Photography by Rebecca Ingham, Advanced Health Protection Practitioner, Yorkshire and Humber Health Protection Team (HPT), UK Health Security Agency (UKHSA), 2021. Open Government Licence v3.0, www.nationalarchives.gov.uk/doc/open-government-licence/version/3.)

(Source: Li M, Shan B, Peng X, Chang H, Cui L. An urgent health problem of indoor air pollution: results from a 15-years carbon monoxide poisoning observed study in Jinan City. Sci Rep 2023;13[1]:1619. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

(Source: Li M, Shan B, Peng X, Chang H, Cui L. An urgent health problem of indoor air pollution: results from a 15-years carbon monoxide poisoning observed study in Jinan City. Sci Rep 2023;13[1]:1619. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

(Source: Li M, Shan B, Peng X, Chang H, Cui L. An urgent health problem of indoor air pollution: results from a 15-years carbon monoxide poisoning observed study in Jinan City. Sci Rep 2023;13[1]:1619. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

(Source: Li M, Shan B, Peng X, Chang H, Cui L. An urgent health problem of indoor air pollution: results from a 15-years carbon monoxide poisoning observed study in Jinan City. Sci Rep 2023;13[1]:1619. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

(Source: Li M, Shan B, Peng X, Chang H, Cui L. An urgent health problem of indoor air pollution: results from a 15-years carbon monoxide poisoning observed study in Jinan City. Sci Rep 2023;13[1]:1619. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

(Source: Li M, Shan B, Peng X, Chang H, Cui L. An urgent health problem of indoor air pollution: results from a 15-years carbon monoxide poisoning observed study in Jinan City. Sci Rep 2023;13[1]:1619. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

Rates per 100,000 inhabitants and age-standardized to the 2013 European Standard Population. Error bars show the 95% confidence intervals. The Carstairs Index is a composite measure of unemployment, household overcrowding, car ownership, and social class. Carstairs scores (a score of 1 corresponding to the least deprived area) were standardized at local geographic levels and categorized into quintiles for the analysis. The local geographic levels were based on British census groupings and comprised between 2000 and 6000 households, with a resident population between 5000 and 15,000 persons. (Sources: Carstairs V, Morris R. Deprivation and mortality: an alternative to social class? Community Med 1989;11[3]:210-19. Roca-Barcelo A, Crabbe H, Close R, Fahie H, Leonardi GS, Piel FB. Spatial and temporal trends and risk factors for intentional carbon monoxide poisoning hospitalizations in England between 2002 and 2016. J Affect Disord 2023;329:168-75. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

Bars show the age-standardized rates (left y-axis). Dashed lines reflect number of cases (right y-axis). Counts under 10 have been suppressed, hence, the interrupted lines. Population standardized to the 2013 European Standard Population. (Source: Roca-Barcelo A, Crabbe H, Close R, Fahie H, Leonardi GS, Piel FB. Spatial and temporal trends and risk factors for intentional carbon monoxide poisoning hospitalizations in England between 2002 and 2016. J Affect Disord 2023;329:168-75. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

The scale is presented on the left y-axis. Shaded areas indicate 95% confidence intervals. Dashed lines present the age-standardized suicide rate, regardless of method, by gender in England with the corresponding scale on the right y-axis. Population standardized to the 2013 European Standard Population. (Source: Roca-Barcelo A, Crabbe H, Close R, Fahie H, Leonardi GS, Piel FB. Spatial and temporal trends and risk factors for intentional carbon monoxide poisoning hospitalizations in England between 2002 and 2016. J Affect Disord 2023;329:168-75. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

The line shows the 3-month moving average. Data include records of visits to any nonfederal hospital facility in Maine, including records of all outpatient and emergency department visits billed through a nonfederal hospital in Maine. (Source: CDC/Graber JM, Smith AE. Results from a state-based surveillance system for carbon monoxide poisoning. Public Health Rep 2007;122[2]:145-54. Public domain.)

The 3D MRI rendering shows a tick (arrow) on the surface of the head. (Source: Sarwar Z, Osborne AF, Shah C, Rathore MH. Neuroimaging in tick paralysis: looking outside the box. Infect Dis Rep 2022;14(6):837-40. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

Sagittal T1-weighted MRI of the brain shows a tick in the occipital region (arrow). (Source: Sarwar Z, Osborne AF, Shah C, Rathore MH. Neuroimaging in tick paralysis: looking outside the box. Infect Dis Rep 2022;14(6):837-40. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

Axial T1-weighted MRI of the brain at the level of the medulla shows a normal appearance of the medulla and the cerebellum. However, on closer inspection, there is a small, isointense area (arrow) seen attached to the skin in the occipital region on the right side. (Source: Sarwar Z, Osborne AF, Shah C, Rathore MH. Neuroimaging in tick paralysis: looking outside the box. Infect Dis Rep 2022;14(6):837-40. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

(Source: Sarwar Z, Osborne AF, Shah C, Rathore MH. Neuroimaging in tick paralysis: looking outside the box. Infect Dis Rep 2022;14(6):837-40. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0. Image cropped from original.)

Coronal section of cerebral MRI FLAIR sequence showing hyperintense signal change of the mammary bodies in a 66-year-old man with Wernicke encephalopathy complicating prolonged parenteral nutrition. (Source: Slim S, Ayed K, Triki W, et al. Gayet-Wernicke's encephalopathy complicating prolonged parenteral nutrition in patient treated for colonic cancer - a case report. BMC Nutr 2022;8[1]:83. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0. Image cropped from original.)

The physico-chemical characterization of the interaction of these chemicals was performed using UV-vis (ultraviolet-visible) spectroscopic techniques in the wavelength range from 190 to 500 nm. UV-vis spectrophotometers use a light source to illuminate a sample with light from across the UV to the visible wavelength range of the electromagnetic spectrum. The UV range normally extends from 100 to 400 nm, with the visible range extending from approximately 400 to 800 nm. In an incubation buffer, the maximum absorbance of vitamin B6 was obtained at 323 nm wavelength. After adding the solution of carboplatin to the solution of vitamin B6 in buffer, the maximum absorbance for the vitamin decreased, reflecting a decrease in vitamin B6 concentration. The decrease of absorbance of pyridoxine hydrochloride is caused by formation of a vitamin B6-carboplatin complex. After 48 hours, the vitamin B6 concentration decreased by 28% relative to the baseline vitamin B6 concentration value. (Source: Szefler B, Czeleń P, Krawczyk P. The affinity of carboplatin to B-vitamins and nucleobases. Int J Mol Sci 2021;22[7]:3634. Creative Commons Attribution License [CC BY], creativecommons.org/licenses/by/4.0.)

EEG showed hypsarrhythmia during frequent cluster seizures in a patient with pyridoxine-dependent epilepsy caused by an ALDH7A1 mutation. The EEG was obtained at the age of 2 years before pyridoxine was used. (Source: Jiao X, Gong P, Niu Y, Zhang Y, Yang Z. A rare presentation characterized by epileptic spasms in ALDH7A1, pyridox[am]ine-5'-phosphate oxidase, and PLPBP deficiency. Front Genet 2022;13:804461. Creative Commons Attribution License [CC BY], creativecommons.org/licenses/by/4.0.)

EEG showed burst suppression in a patient with pyridoxine-dependent epilepsy caused by an ALDH7A1 mutation. The EEG was obtained at the age of 1 month before pyridoxine was used. (Source: Jiao X, Gong P, Niu Y, Zhang Y, Yang Z. A rare presentation characterized by epileptic spasms in ALDH7A1, pyridox[am]ine-5'-phosphate oxidase, and PLPBP deficiency. Front Genet 2022;13:804461. Creative Commons Attribution License [CC BY], creativecommons.org/licenses/by/4.0.)

Bilateral brain atrophy in 3-year-old patient with pyridoxine-dependent epilepsy caused by an ALDH7A1 mutation. The patient had severe intellectual disability and global developmental delay. Seizure types without pyridoxine therapy included infantile spasms, generalized tonic-clonic seizures, focal seizures, and status epilepticus. (Source: Jiao X, Gong P, Niu Y, Zhang Y, Yang Z. A rare presentation characterized by epileptic spasms in ALDH7A1, pyridox[am]ine-5'-phosphate oxidase, and PLPBP deficiency. Front Genet 2022;13:804461. Creative Commons Attribution License [CC BY], creativecommons.org/licenses/by/4.0.)

Schematic diagram showing how a decrease in vitamin B6 (pyridoxine, or its activated form, pyridoxal 5'-phosphate) leads to a decrease in the conversion of the excitatory neurotransmitter glutamic acid to the inhibitory neurotransmitter GABA, which then results in seizures. Glutamic acid decarboxylase is the enzyme that catalyzes the formation of gamma-aminobutyric acid (GABA) from glutamic acid. (Diagram by Dr. Douglas J Lanska.)

MRI of a patient with PLPHP deficiency at 4.5 years of age. A sagittal T1-weighted image (A) demonstrates a thin corpus callosum. Axial views show patchy bilateral increase in T2 (B) and FLAIR (C, D) signal in the deep white matter around the ventricles, especially in the frontal and peritrigonal regions. There is marked cerebral atrophy with prominent CSF spaces, particularly over frontal and Sylvian regions bilaterally (ie, predominant frontotemporal atrophy). (Source: Alsubhi S, Osterman B, Chrestian N, Dubeau F, Buhas D, Srour M. Case report: PLPHP deficiency, a rare but important cause of B6-responsive disorders: a report of three novel individuals and review of 51 cases. Front Neurol 2022;13:913652. Creative Commons Attribution License [CC BY], creativecommons.org/licenses/by/4.0.)

(Source: Image by Buckle AM, Fenalti G, Law RH, Whisstock JC. [2007]. https://www.rcsb.org/structure/2OKJ. Public domain.)

GAD67 active site containing PLP-glutamate complex (shown in green), with Schiff base linkage at Lys405. Side chain residues shown in red. (Source: Image by "OceanicTrees" via Wikipedia. Creative Commons Attribution-Share Alike 4.0 International License, creativecommons.org/licenses/by-sa/4.0/deed.en.)

(Source: United States Public Health Service, 1996. Public domain.)

(Source: User: J4lambert on March 17, 2013, via Wikimedia Commons. Creative Commons Attribution-Share Alike 3.0 Unported License, https://creativecommons.org/licenses/by-sa/3.0/deed.en.)

(Source: User: Torsodog on May 22, 2008, via Wikimedia Commons. Creative Commons Attribution-ShareAlike 3.0 License, https://creativecommons.org/licenses/by-sa/3.0.)

(Source: User: Torsodog on May 22, 2008, via Wikimedia Commons. Creative Commons Attribution-ShareAlike 3.0 License, https://creativecommons.org/licenses/by-sa/3.0.)

(Source: User: Torsodog on May 22, 2008, via Wikimedia Commons. Creative Commons Attribution-ShareAlike 3.0 License, https://creativecommons.org/licenses/by-sa/3.0.)

(Source: User: Torsodog on May 22, 2008, via Wikimedia Commons. Creative Commons Attribution-ShareAlike 3.0 License, https://creativecommons.org/licenses/by-sa/3.0.)

Police, fire, and emergency medical personnel were very quickly on the scene in force. The Japan Defense Force Chemical troops were there within a couple of hours of being notified that they were needed. (Source: United States Public Health Service, 1996. Public domain.)

(Source: United States Public Health Service, 1996. Public domain.)

(Public domain. Illustration edited by Dr. Douglas J Lanska.)

Physostigma venenosum, the Calabar bean or ordeal bean, is a leguminous plant that is endemic to tropical Africa, with a seed poisonous to humans. The Calabar bean contains physostigmine, an alkaloid that is a reversible cholinesterase inhibitor. The people of Old Calabar (also referred to as Callabar, Calabari, Calbari and Kalabar) in Nigeria used Calabar beans or '"E-ser-e" as an ordeal poison administered them to persons accused of witchcraft or other crimes: it was thought to affect only the guilty, so if a person accused of a crime ingested the beans without dying, they were considered innocent. Illustration from Franz Eugen Köhler's Medizinal-Pflanzen (Köhler HA. Köhler's Medizinal-Pflanzen in naturgetreuen Abbildungen mit kurz erläuterndem Texte: Atlas zur Pharmacopoea germanica, austriaca, belgica, danica, helvetica, hungarica, rossica, suecica, Neerlandica, British pharmacopoeia, zum Codex medicamentarius, sowie zur Pharmacopoeia of the United States of America. Band 2. Leipzig: von Ramm & Seemann, 1890).

(The chromolithograph is from Köhler's Medizinal-Pflanzen, a German herbal written principally by German physician and chemist Hermann Adolph Köhler (1834-1879) and originally published in two volumes: the first in 1887, the second in 1890. Illustration edited by Dr. Douglas J Lanska.)

(a) Organophosphate structural backbone of Novichok agents. R=alkyl, alkoxy, aklylamino, or fluorine. X=halogen (F, Cl, Br) or pseudohalogen (CN). (b) Chemical structure of A-234 as described by Mirzayanov (Smithson et al 1995; Mirzayanov 2008). (c) Chemical structure of A-234 as described by Hoenig and Ellison (Hoenig 2006; Ellison 2008).

(Source: Chai PR, Hayes BD, Erickson TB, Boyer EW. Novichok agents: a historical, current, and toxicological perspective. Toxicol Commun 2018;2[1]:45-8. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

References cited:
Ellison DH. Handbook of Chemical and Biological Warfare Agents. 2. Boca Raton, FL: Taylor and Francis Group, 2008.
Hoenig SL. Compendium of Chemical Warfare Agents. New York, NY: Springer, 2006.
Mirzayanov VS. State Secrets: An Insider's Chronicle of the Russian Chemical Weapons Program. Denver: Outskirts Press, 2008.
Smithson AE, Mirzayanov VS, Lajoie R, Krepon M. Chemical Weapons Disarmament in Russia: Problems and Prospects. Report number 17. Washington, DC: The Henry L. Stimson Center; 1995:1-83.

Abbreviations: CW=chemical weapons; CWC=Chemical Weapons Convention; OPCW=Organization for the Prohibition of Chemical Weapons, the international watchdog responsible for overseeing the implementation of the CWC. (Source: Cavalcante SFA, Simas AB, Barcellos MC, et al. Acetylcholinesterase: The "Hub" for Neurodegenerative Diseases and Chemical Weapons Convention. Biomolecules 2020;10[3]:414. Creative Commons Attribution [CC BY] License, http://creativecommons.org/licenses/by/4.0.)

Illustration by Shanata on March 10, 2012. (Creative Commons Attribution-Share Alike 3.0 Unported License, https://creativecommons.org/licenses/by-sa/3.0/deed.en.)

The ribbon shows the overall path and organization of the protein backbone in 3D. Alpha-helices are shown as coiled ribbons or thick tubes, beta-strands as arrows, and nonrepetitive coils or loops as lines or thin tubes. Image by User:ProteinBoxBot on November 7, 2007. (Courtesy of Wikimedia Commons. Released into Public domain.)

1st Lt. Matthew Chau, commander of Border Team 3, 25th Infantry Division, patrols Halabja, Iraq. Buried in the village cemetery are many victims of the 1988 chemical weapons attack, ordered by Saddam Hussein. Photograph by Sgt. Sean Kimmons on February 23, 2005. (This file is a work of a U.S. Army soldier or employee, taken or made as part of that person's official duties. As a work of the U.S. federal government, it is in the public domain in the United States.)

Illustration by Sbolmer on February 26, 2012. (Creative Commons Attribution-Share Alike 3.0 Unported License, https://creativecommons.org/licenses/by-sa/3.0/deed.en.)

Illustration by PyMol on October 28, 2012. (Creative Commons Universal [CC0 1.0]. Public Domain Dedication, https://creativecommons.org/publicdomain/zero/1.0/deed.en.)

The top row shows the normal situation. In the left panel, the nitrogen of acetylcholine is attracted to the anionic site of the acetylcholinesterase enzyme through electrostatic attraction, while an oxygen atom of the carboxyl group links to a hydroxyl group of a serine moiety at the "esteric" or "esteratic" site. Hydrolysis is catalyzed at the esteric site to form choline and acetic acid. The middle row shows the action of a reversible inhibitor of acetylcholinesterase (neostigmine). Reversible cholinesterase inhibitors form a transition state complex with the enzyme, just as acetylcholine does. These compounds are in competition with acetylcholine in binding with the active sites of the enzyme. The bottom row shows the action of an irreversible inhibitor of acetylcholinesterase (the quasi-irreversible organophosphate diisopropyl fluorophosphate, an organophosphorus insecticide). (Illustration by Sbolmer on February 26, 2012. Creative Commons Attribution-Share Alike 3.0 Unported License, https://creativecommons.org/licenses/by-sa/3.0/deed.en. Text by Dr. Douglas J Lanska.)

Nerve agent VX was the agent used in the assassination of Kim Jong-nam on February 13, 2017 at the Kuala Lumpur International Airport in Malaysia. He had been exiled from North Korea in 2003 and had been living abroad. Illustration by Ben Mills on March 17, 2008. (Public domain.)

Illustration by Yikrazuul on April 20, 2014. (Public domain.)

Illustration by Yikrazuul on April 19, 2014. (Public domain.)

The military designation of tabun is GA. Illustration by Amir.ahrls on February 1, 2012. (Public domain.)

"The insidious and deadly gas that creeps noiselessly down toward the foe. Russian trench near Baronvitsky at the moment when it is flooded by the Germans with asphyxiating gas." Exact location unknown. Located in the area of the Eastern Front of WWI. (Source: New York Times, 1919. Courtesy of the U.S. Library of Congress. Public domain. Etching edited by Dr. Douglas J Lanska.)

"The war by fire has proved to be a boomerang to the Germans. ... The Allies are beginning to pay back the Germans in their own coin on the Western front, by means of certain devises [sic] to which, earlier in the war, the Germans trusted as a means of paralysing [sic] resistance in battle. The use of gas both from projectors and in bombs were of German origin. They are now being turned against their originators." National Archives and Records Administration, cataloged under the National Archives Identifier (NAID) 26425078. (This image is a work of a U.S. military or Department of Defense employee, taken or made as part of that person's official duties. As a work of the U.S. federal government, the image is in the public domain in the United States. Photograph edited by Dr. Douglas J Lanska.)

"Protecting horse and man from gas attack. A marked feature in the German attack is the use of poisonous gas. The protection from the gas attack is not limited to man only, but also to the animals they have. Photo shows how the mask is fitted over the horse's nose." Photograph on June 10, 1918, by International Film Service. National Archives and Records Administration, cataloged under the National Archives Identifier (NAID) 26423966. (This image is a work of a U.S. military or Department of Defense employee, taken or made as part of that person's official duties. As a work of the U.S. federal government, the image is in the public domain in the United States. Photograph edited by Dr. Douglas J Lanska.)

United States soldiers “getting the gas out of the trenches” at Camp Upton, New York, on March 9, 1918. "After the gas attack, this soldier protected by his mask and respirator goes into the trench and with a shovel-like contrivance beats the heavy gases out of the trenches. The poisonous gases are heavy and cling to the ground for a considerable period of time before they are sufficiently diluted with air to make the removal of gas masks safe. This is part of the training U.S. soldiers get in combating gas at Camp Upton." Camp Upton was a port of embarkation of the U.S. Army during World War I. It was located in Yaphank, New York in Suffolk County on Long Island, on the present-day location of Brookhaven National Laboratory. Photographer: Underwood & Underwood. National Archives and Records Administration, cataloged under the National Archives Identifier (NAID) 26424052. (This image is a work of a U.S. military or Department of Defense employee, taken or made as part of that person's official duties. As a work of the U.S. federal government, the image is in the public domain in the United States. Photograph edited by Dr. Douglas J Lanska.)

United States Marines in training at Quantico, Virginia, going through drills in June 1918 "for the benefit of Secretary [Josephus] Daniels [Secretary of the Navy, 1862-1948] and other members of the government." Photographer: International Film Service. National Archives and Records Administration, cataloged under the National Archives Identifier (NAID) 26423794. (This image is a work of a U.S. military or Department of Defense employee, taken or made as part of that person's official duties. As a work of the U.S. federal government, the image is in the public domain in the United States. Photograph edited by Dr. Douglas J Lanska.)

Men in the trenches with gas masks on ready to go over the top. Photographer: Charles Feinberg. National Archives and Records Administration, cataloged under the National Archives Identifier (NAID) 26423782. (This image is a work of a U.S. military or Department of Defense employee, taken or made as part of that person's official duties. As a work of the U.S. federal government, the image is in the public domain in the United States. Photograph edited by Dr. Douglas J Lanska.)

Photograph shows the July 7, 1917 attack on the outskirts of Arras, a village that has changed hands several times. This last effort of the Germans to take and hold this place was under cover of a gas cloud after the usually heavy bombardment. Fierce hand-to-hand fighting took place, each man fighting to pull away a German's gas mask. Photographer: Underwood & Underwood. National Archives and Records Administration, cataloged under the National Archives Identifier (NAID) 26423956. (This image is a work of a U.S. military or Department of Defense employee, taken or made as part of that person's official duties. As a work of the U.S. federal government, the image is in the public domain in the United States. Photograph edited by Dr. Douglas J Lanska.)

A class of Army soldiers getting instructions on the use of gas masks on February 26, 1918. U.S. Chemical Warfare Service, World War I. National Archives and Records Administration, cataloged under the National Archives Identifier (NAID) 26423842. (This image is a work of a U.S. military or Department of Defense employee, taken or made as part of that person's official duties. As a work of the U.S. federal government, the image is in the public domain in the United States. Photograph edited by Dr. Douglas J Lanska.)

(Source: Imperial War Museum. This work created by the United Kingdom Government is in the Public domain.)

Behind the masked soldiers, an unmasked superior officer looks on. Ink over graphite on Bristol board by Winsor McCay (1869-1934) circa 1917. (Public domain. Image edited by Dr. Douglas J Lanska.)

(Source: United States Army Chemical Corps, 1918. Photograph edited by Dr. Douglas J Lanska.)

(Source: Deutsches Bundesarchiv [German Federal Archives]. Attribution: Bundesarchiv, Bild 183-F0313-0208-007 / CC-BY-SA 3.0. Creative Commons Attribution-Share Alike 3.0 Germany License, https://creativecommons.org/licenses/by-sa/3.0/de/deed.en. Photograph edited by Dr. Douglas J Lanska.)

American soldiers of the 42nd division in presence of gas in Essey, France, on September 20, 1918. Chemical gases were broadly used during World War I to cause incapacitation, harm, or death to opposing troops. The types of chemicals ranged from agents like tear gas to lethal gases, such as phosgene, mustard gas, and chlorine. Their effectiveness diminished in the later stages of the war due to countermeasures, such as gas masks. The use of poison gas in this era constituted a war crime. (Source: National Museum of Health and Medicine. Photo ID: Reeve 037283. Creative Commons Attribution 2.0 Generic License, https://creativecommons.org/licenses/by/2.0/deed.en. Photograph edited by Dr. Douglas J Lanska.)

U.S. Chemical Warfare Service drills, World War I (1918). (Source: War Department. Army War College. Historical Section. National Archives and Records Administration, cataloged under the National Archives Identifier (NAID) 55163715. This image is a work of a U.S. military or Department of Defense employee, taken or made as part of that person's official duties. As a work of the U.S. federal government, the image is in the public domain in the United States. Photograph edited by Dr. Douglas J Lanska.)

(Source: War Department. Army War College. Historical Section. National Archives and Records Administration, cataloged under the National Archives Identifier (NAID) 55163709. This image is a work of a U.S. military or Department of Defense employee, taken or made as part of that person's official duties. As a work of the U.S. federal government, the image is in the public domain in the United States. Photograph edited by Dr. Douglas J Lanska.)

(Source: War Department. Army War College. Historical Section. National Archives and Records Administration, cataloged under the National Archives Identifier (NAID) 55162745. This image is a work of a U.S. military or Department of Defense employee, taken or made as part of that person's official duties. As a work of the U.S. federal government, the image is in the public domain in the United States. Photograph edited by Dr. Douglas J Lanska.)

(Source: War Department. Army War College. Historical Section. National Archives and Records Administration, cataloged under the National Archives Identifier (NAID) 55162641. This image is a work of a U.S. military or Department of Defense employee, taken or made as part of that person's official duties. As a work of the U.S. federal government, the image is in the public domain in the United States. Photograph edited by Dr. Douglas J Lanska.)

Recruits of Mike Company, 3rd Recruit Training Battalion, test the seal on their gas masks while in the gas chamber on July 22, 2014 at Parris Island, S.C. The recruits proved they learned the basics of biological and chemical warfare defense by properly using gas masks while being exposed to tear gas. U.S. Marine Corps photograph by Cpl. Caitlin Brink. (This image was released by the United States Marine Corps with the ID 140722-M- FS592-101. This file is a work of a sailor or employee of the U.S. Navy, taken or made as part of that person's official duties. As a work of the U.S. federal government, it is in the public domain in the United States.)

Recruits of Charlie Company, 1st Recruit Training Battalion, shake their heads during chemical warfare defense training June 3, 2014, on Parris Island, S.C. The recruits shook their heads and performed other exercises to prove their gas masks worked despite vigorous activity. Later, each recruit had to temporarily break the airtight seal, exposing himself to nonlethal tear gas used to simulate the stresses of a chemically contaminated environment. Recruits then resealed their masks and cleared the gas. U.S. Marine Corps photograph by Cpl. Octavia Davis, released. (This image was released by the United States Marine Corps with the ID 140603-M- RV272-298. This file is a work of a sailor or employee of the U.S. Navy, taken or made as part of that person's official duties. As a work of the U.S. federal government, it is in the public domain in the United States.)

United States soldiers with the 44th Chemical Company, 2nd Chemical Battalion, 48th Chemical Brigade, based at Fort Hood, Texas, prepare to enter and clear a building of opposing forces during a simulated chemical attack at Fort McCoy, Wisconsin, on May 12, 2014. Soldiers with the 44th Chemical Company were participating in an annual combat support training exercise involving 7,000 soldiers and joint military personnel. U.S. Army photo by Spc. Robert Farrell, released. (This image was released by the United States Army with the ID 140512-A-TW638-080. This file is a work of a sailor or employee of the U.S. Navy, taken or made as part of that person's official duties. As a work of the U.S. federal government, it is in the public domain in the United States.)

Cpl. Brandon Dockery, a chemical and biological warfare defense instructor, fans tear gas in the gas chamber on November 27, 2013, on Parris Island, S.C., as recruits of Mike Company, 3rd Recruit Training Battalion, prove their gas masks hold an air-tight seal despite vigorous activity. This training ensures recruits can use the masks and trust them to work in a chemically or biologically contaminated area. Photo by Cpl. Caitlin Brink, released. (This image was released by the United States Marine Corps with the ID 131127-M- FS592-170. This file is a work of a sailor or employee of the U.S. Navy, taken or made as part of that person's official duties. As a work of the U.S. federal government, it is in the public domain in the United States.)

United States Navy photo by Hospital Corpsman 3rd Class Raolito M Pambid, released. (This image was released by the United States Navy with the ID 030626-N- 0000R-001. This file is a work of a sailor or employee of the U.S. Navy, taken or made as part of that person's official duties. As a work of the U.S. federal government, it is in the public domain in the United States.)

Military trainees don their chemical warfare gear prior to entering the Nuclear, Biological, Chemical, Conventional Training Facility at Lackland Air Force Base, San Antonio, on September 16, 2002. The NBCC is part of week five of Basic Military Training's Warrior Week. U.S. Air Force photo by Robbin Cresswell, released. (Public domain photograph from defenseimagery.mil. This image was released by the United States Air Force with the ID 020916-F-LS942-004. This file is a work of a sailor or employee of the U.S. Navy, taken or made as part of that person's official duties. As a work of the U.S. federal government, it is in the public domain in the United States.)

Troops in NBC (nuclear biological and chemical) outfits with a “wounded” soldier on a stretcher during an exercise before the start of operations in Kuwait. (This image is a work of a U.S. military or Department of Defense employee, taken or made as part of that person's official duties. As a work of the U.S. federal government, the image is in the public domain in the United States.)

Soldier in full NBC (nuclear biological and chemical) equipment is taking cover in a foxhole during a live-firing exercise prior to the start of operations in Kuwait. (This image is a work of a U.S. military or Department of Defense employee, taken or made as part of that person's official duties. As a work of the U.S. federal government, the image is in the public domain in the United States.)

Photograph captured at the Palace of Westminster, London, between 1939 and 1945. (Source: Ministry of Information, Second World War Press Agency Print Collection. Public domain.)

Color lithography. (Public domain.)

The Makassar or Makassarese people are an ethnic group that inhabits the southern part of the South Peninsula, Sulawesi (formerly Celebes), in what is now Indonesia. (Source: Churchill A. A collection of voyages and travels, some now first printed from original manuscripts, others now first published in English. To which is prefixed, an introductory discourse [supposed to be written by the celebrated Mr. Locke] intitled, the whole history of navigation from its original to this time/Illustrated with maps and cuts, curiously engraved. Third edition. Vol. 2. London: Messrs. Churchill for Henry Lintot and John Osborn, 1744. Courtesy of the Wellcome Collection, London, England. Creative Commons Attribution 4.0 International [CC BY 4.0] License, https://creativecommons.org/licenses/by/4.0.)

(Source: Tropenmuseum, part of the National Museum of World Cultures, http://www.tropenmuseum.nl. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0.)

The latex of the upas tree (Antiaris toxicari) contains intensely toxic cardenolides, including a cardiac glycoside named antiarin that is used as a toxin for arrows, darts, and blowdarts in Southeast Asian cultures. The concentrate is applied by dipping the darts used in sumpit blowguns employed for hunting and warfare, sometimes mixed with Strychnos ignatii for arrow poison. The Kenyah people are indigenous, Austronesian-speaking people of Borneo. Sarawak, a Malaysian state on Borneo, stretches along the island’s northwest coast, including many beaches on the South China Sea. (Courtesy of the Wellcome Collection, London, England. Creative Commons Attribution 4.0 International [CC BY 4.0] License, https://creativecommons.org/licenses/by/4.0. Photograph edited by Dr. Douglas J Lanska.)

(Source: Tropenmuseum, part of the National Museum of World Cultures, http://www.tropenmuseum.nl. Creative Commons Attribution-Share Alike 3.0 Unported License, https://creativecommons.org/licenses/by-sa/3.0/deed.en.)

(Source: User: A2-33 on December 3, 2013. Courtesy of Wikimedia Commons. Creative Commons Attribution 3.0 Unported [CC BY 3.0] license, creativecommons.org/licenses/by/3.0.)

(Source: ArboNET, Arboviral Diseases Branch, Centers for Disease Control and Prevention. Public domain.)

When assessing the likelihood of botulism, consider clinical criteria and available epidemiologic data. Classify patients into a botulism likelihood category by clinical judgment. Additional information on clinical criteria is available. (Source: Rao AK, Sobel J, Chatham-Stephens K, Luquez C. Clinical guidelines for diagnosis and treatment of botulism, 2021. MMWR Recomm Rep 2021;70[2]:1-30. Public domain.)

When assessing the likelihood of botulism, consider clinical criteria and available epidemiologic data. Classify patients into a botulism likelihood category by clinical judgment. Additional information on clinical criteria is available. (Source: Rao AK, Sobel J, Chatham-Stephens K, Luquez C. Clinical guidelines for diagnosis and treatment of botulism, 2021. MMWR Recomm Rep 2021;70[2]:1-30. Public domain.)

(Source: Centers for Disease Control and Prevention. Botulism in the United States, 1899-1996. Handbook for Epidemiologists, Clinicians, and Laboratory Workers. Atlanta, Georgia: CDC, 1998. Public domain.)

(Source: Centers for Disease Control and Prevention. Botulism in the United States, 1899-1996. Handbook for Epidemiologists, Clinicians, and Laboratory Workers. Atlanta, Georgia: CDC, 1998. Public domain.)

(Source: Centers for Disease Control and Prevention. Botulism in the United States, 1899-1996. Handbook for Epidemiologists, Clinicians, and Laboratory Workers. Atlanta, Georgia: CDC, 1998. Public domain.)

(Source: Centers for Disease Control and Prevention. Botulism in the United States, 1899-1996. Handbook for Epidemiologists, Clinicians, and Laboratory Workers. Atlanta, Georgia: CDC, 1998. Public domain.)

* Multistate outbreaks are added to each involved state's total. (Source: Centers for Disease Control and Prevention. Botulism in the United States, 1899-1996. Handbook for Epidemiologists, Clinicians, and Laboratory Workers. Atlanta, Georgia: CDC, 1998. Public domain.)

* Multistate outbreaks are added to each involved state's total. (Source: Centers for Disease Control and Prevention. Botulism in the United States, 1899-1996. Handbook for Epidemiologists, Clinicians, and Laboratory Workers. Atlanta, Georgia: CDC, 1998. Public domain.)

* Multistate outbreaks are added to each involved state's total. (Source: Centers for Disease Control and Prevention. Botulism in the United States, 1899-1996. Handbook for Epidemiologists, Clinicians, and Laboratory Workers. Atlanta, Georgia: CDC, 1998. Public domain.)

* Multistate outbreaks are added to each involved state's total. (Source: Centers for Disease Control and Prevention. Botulism in the United States, 1899-1996. Handbook for Epidemiologists, Clinicians, and Laboratory Workers. Atlanta, Georgia: CDC, 1998. Public domain.)

Abbreviations: BoNT/A-G=botulinum toxin A-G, TeNT=tetanus toxin. (Source: Y tambe on June 26, 2007. Creative Commons Attribution 3.0 Unported [CC BY 3.0] license, creativecommons.org/licenses/by/3.0.)

(Source: Wikimedia Commons. Created on October 4, 2008. See also: Lacy DB, Tepp W, Cohen AC, DasGupta BR, Stevens RC. Crystal structure of botulinum neurotoxin type A and implications for toxicity. Nat Struct Biol 1998;5[10]:898-902. Released into Public domain.)

Synaptobrevin on the synaptic vesicle must interact with syntaxin and SNAP (synaptosomal-associated protein)-25 on the neuronal membrane for fusion to occur, which allows the nerve impulse to be delivered across the synaptic junction. The botulinum neurotoxin serotypes cleave the peptide bonds at specific sites on the three cellular proteins, as indicated. Cleavage of any one of these cellular proteins prevents vesicle membrane docking and nerve impulse transmission. (Source: Barr JR, Moura H, Boyer AE, et al. Botulinum neurotoxin detection and differentiation by mass spectrometry. Emerg Infect Dis 2005;11[10]:1578-83. Public domain.)

The schematic representation is colored from N-terminal end (red) to C-terminal end (blue). Disulfide bonds are shown in gold. (Source: Created by Fvasconcellos on June 29, 2008. Released into Public domain.)

Cartoon representation. (Source: Jawahar Swaminathan and MSD staff at the European Bioinformatics Institute. Released into public domain. Figure edited by Dr. Douglas J Lanska.)

The schematic representation is colored from N-terminal end (blue) to C-terminal end (red). Disulfide bonds are shown in yellow. (Source: Created by Fvasconcellos on June 26, 2008. Released into Public domain.)

A μ-conotoxin (μ-CTX) mutant does not completely block the sodium current. The sodium ion can escape through the incompletely sealed outer pore and vacate the cation-attractive central cavity for binding of QX-222, which is a lidocaine derivative and a sodium channel blocker. (Source: Tikhonov DB, Zhorov BS. Predicting structural details of the sodium channel pore basing on animal toxin studies. Front Pharmacol 2018;9:880. See also: Bruhova I, Tikhonov DB, Zhorov BS. Access and binding of local anesthetics in the closed sodium channel. Mol Pharmacol 2008;74[4]:1033-45. Creative Commons Attribution [CC BY] license.)

When the outer pore is blocked by tetrodotoxin (TTX), the sodium ion is trapped in the central cavity and prevents binding of QX-222. QX-222, a lidocaine derivative, is a sodium channel blocker. (Source: Tikhonov DB, Zhorov BS. Predicting structural details of the sodium channel pore basing on animal toxin studies. Front Pharmacol 2018;9:880. See also: Bruhova I, Tikhonov DB, Zhorov BS. Access and binding of local anesthetics in the closed sodium channel. Mol Pharmacol 2008;74[4]:1033-45. Creative Commons Attribution [CC BY] license.)

In the schematic, the permanently charged QX-222 reaches the inner pore via III/IV repeat interface and displaces the resident ion that leaves the central cavity through the selectivity filter. QX-222, a lidocaine derivative, is a sodium channel blocker. (Source: Tikhonov DB, Zhorov BS. Predicting structural details of the sodium channel pore basing on animal toxin studies. Front Pharmacol 2018;9:880. See also: Bruhova I, Tikhonov DB, Zhorov BS. Access and binding of local anesthetics in the closed sodium channel. Mol Pharmacol 2008;74[4]:1033-45. Creative Commons Attribution [CC BY] license.)

Repeats I, II, III, and IV are green, yellow, cyan, and magenta, respectively. The outer carboxylates are shown as sticks. (Source: Tikhonov DB, Zhorov BS. Predicting structural details of the sodium channel pore basing on animal toxin studies. Front Pharmacol 2018;9:880. See also: Tikhonov DB, Zhorov BS. Architecture and pore block of eukaryotic voltage-gated sodium channels in view of NavAb bacterial sodium channel structure. Mol Pharmacol 2012;82[1]:97-104. Creative Commons Attribution [CC BY] license.)

Shown is Arg13 in μ-conotoxin GIIIA, which is critical for the channel block. (Source: Tikhonov DB, Zhorov BS. Predicting structural details of the sodium channel pore basing on animal toxin studies. Front Pharmacol 2018;9:880. Creative Commons Attribution [CC BY] license.)

Positions of toxin-interacting residues are shown by red circles. In eukaryotic voltage-gated sodium channels, the selectivity filter DEKA ring, which contains D, E, K, and A residues, borders the extracellularly exposed outer pore and the inner pore that is exposed to the cytoplasm in the open channel. Abbreviations: TTX (tetrodotoxin), STX (saxitoxin), and μ-CTX (μ-conotoxin). (Source: Tikhonov DB, Zhorov BS. Predicting structural details of the sodium channel pore basing on animal toxin studies. Front Pharmacol 2018;9:880. Creative Commons Attribution [CC BY] license.)

Positions of the selectivity filter "DEKA residues" and the outer carboxylates, which interact with TTX (tetrodotoxin), STX (saxitoxin), and μ-CTX (μ-conotoxin), are marked by red dots. (Source: Tikhonov DB, Zhorov BS. Predicting structural details of the sodium channel pore basing on animal toxin studies. Front Pharmacol 2018;9:880. Creative Commons Attribution [CC BY] license.)

The normal condition is depicted in the top image, and the tetrodotoxin blockade (black blobs on the outer surface of the voltage-gated sodium channels) is depicted in the lower image. TTX=tetrodotoxin. (Source: Campos-Ríos A, Rueda-Ruzafa L, Herrera-Pérez S, Rivas-Ramírez P, Lamas JA. Tetrodotoxin: a new strategy to treat visceral pain? Toxins (Basel) 2021;13[7]:496. Creative Commons Attribution 4.0 International [CC BY 4.0] license, creativecommons.org/licenses/by/4.0. This figure was modified and edited by Dr. Douglas J Lanska; the original emphasis on pain transmission in bipolar sensory neurons was changed to schematically depict a generic neuron.)

The diagram illustrates the membrane topology of a voltage-gated sodium channel protein. Binding sites for different neurotoxins are indicated by color. Abbreviations: TTX, tetrodotoxin; STX, saxitoxin. Image by Kathleen Cusick and Gary Sayler on April 11, 2013. (See: Cusick KD, Sayler GS. An overview on the marine neurotoxin, saxitoxin: genetics, molecular targets, methods of detection and ecological functions. Mar Drugs 2013;11[4]:991-1018. Creative Commons Attribution 3.0 Unported [CC BY 3.0] license, creativecommons.org/licenses/by/3.0.)

(Public domain.)

Eastern equine encephalitis virus is maintained in a cycle between C. melanura mosquitoes and avian hosts in freshwater hardwood swamps. C. melanura is not an important vector of Eastern equine encephalitis virus to people because it feeds almost exclusively on birds. Transmission to people requires another mosquito species to create a “bridge” between infected birds and uninfected mammals (eg, people and horses). Most of the bridge species are within the Aedes, Coquillettidia, and Culex genera. Photograph credit: CDC/The Connecticut Agricultural Experiment Station in 2019. (Source: Public Health Image Library, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia. Image 24558. Public domain.)

This image depicts a Uranotaenia sapphirina mosquito, along with an accompanying inset of its right wing from a superior perspective, detailing its venation pattern. Known as the sapphire-lined mosquito, U. sapphirina gets its name due to the iridescent sapphire-blue markings displayed on its head and thoracic regions. This mosquito does not feed on human beings but instead seems to feed exclusively on amphibians and reptiles. However, this mosquito has been found amongst mosquito pools from which the West Nile virus and the Eastern equine encephalitis virus have been isolated. Image by CDC/ Dr. Darsie in 1975. (Source: Public Health Image Library, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia. Image 6908. Public domain.)

The diagram illustrates characteristics that include a long, curved proboscis, a dark-scaled abdomen, and slightly enlarged, dark scales on the outer wing. This mosquito is a vector of the eastern equine encephalitis virus in bird populations. (Source: Public Health Image Library, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia. Image 2077. Public domain.)

In this transmission electron microscopic image, note the numerous Eastern equine encephalitis virions in various stages of development, from the precursor particles through the mature virus. Image by CDC, 1969. (Source: Public Health Image Library, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia. Image 17438. Public domain.)

Culex tarsalis mosquito is a vector of many mosquito-borne diseases. The epidemiologic importance of C. tarsalis lies in its ability to spread Western equine encephalitis, St. Louis encephalitis, and California encephalitis. At one point, it was the main vector of West Nile virus in the western United States. (Source: Public Health Image Library, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia. Image 6338. Public domain.)

In this photograph, the Culex tarsalis mosquito is about to begin feeding after landing on the skin of what would become its human host. Note the light-colored band wrapped around its dark-scaled proboscis (A), the multiple, similarly light-colored bands wrapped around the distal appendages (ie, the tibia and femur) of its forelegs and middle pair of legs (B), and the presence of one of the two silver markings on its dorsal scutum (C). The epidemiologic importance of C. tarsalis lies in its ability to spread Western equine encephalitis, St. Louis encephalitis, and California encephalitis. When this image was created in 2005, C. tarsalis was the main vector of West Nile virus in the western United States. Photograph by CDC/James Gathany in 1976. (Source: Public Health Image Library, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia. Image 7957. Public domain.)

This diagram illustrates the methods by which the arbovirus Western equine encephalitis virus reproduces and amplifies itself in both avian and rodent populations and is subsequently transmitted by the Culex tarsalis mosquito to dead-end hosts, including humans and horses. Image by CDC/Dr. Thomas Monath in 1976. (Source: Public Health Image Library, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia. Image 14996. Public domain.)

Note the characteristic head droop. Photograph by CDC/James Stewart, Fort Collins in 1976. (Source: Public Health Image Library, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia. Image 2625. Public domain.)

As in humans, under natural conditions (as opposed to the artificial condition of bioweapons use), the etiologic pathogens responsible for equine encephalitic diseases are transmitted to horses by mosquito vectors, with various bird species serving as reservoirs. Photograph by CDC/James Stewart in 1976. (Source: Public Health Image Library, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia. Image 2809. Public domain.)

This negatively stained, transmission electron microscopic image revealed Venezuelan equine encephalitis virus virions in the tissue specimen, which had been fixed using phosphotungstic acid. Phosphotungstic acid is very electron-dense and, due to electrostatic forces of attraction, clings to the capsid surface of each viral particle or virion, thereby highlighting the presence of such pathogens. Venezuelan equine encephalitis is a Togaviridae family member and a member of the genus Alphavirus. Photomicrograph by CDC/Dr. Fred Murphy and Sylvia Whitfield in 1975. (Source: Public Health Image Library, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia. Image 10266. Public domain.)

This photomicrograph of a mouse brain tissue sample collected after the mouse had succumbed to Venezuelan equine encephalitis reveals histopathologic changes indicative of neural necrosis and edema (magnification x 300). Photomicrograph by CDC/Dr. Fred A Murphy in 1971. (Source: Public Health Image Library, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia. Image 2809. Public domain. Figure cropped from original by Dr. Douglas J Lanska.)

This photomicrograph of a mouse brain tissue sample collected after the mouse had succumbed to Venezuelan equine encephalitis reveals histopathologic changes indicative of neural necrosis and edema (magnification x 300.) Photomicrograph by CDC/Dr. Fred A Murphy in 1971. (Source: Public Health Image Library, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia. Image 2808. Public domain. Figure cropped from original by Dr. Douglas J Lanska.)

This photomicrograph of a mouse brain tissue sample collected after the mouse had succumbed to Venezuelan equine encephalitis reveals histopathologic changes indicative of neural necrosis and edema (magnification x 300). Photomicrograph by CDC/Dr. Fred A Murphy in 1971. (Source: Public Health Image Library, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia. Image 2807. Public domain. Figure cropped from original by Dr. Douglas J Lanska.)

This photomicrograph of a mouse brain tissue sample collected after the mouse had succumbed to Venezuelan equine encephalitis reveals histopathologic changes indicative of neural necrosis and edema (magnification x 300). Photomicrograph by CDC/Dr. Fred A Murphy in 1971. (Source: Public Health Image Library, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia. Image 2806. Public domain. Figure cropped from original by Dr. Douglas J Lanska.)

This photomicrograph of a mouse brain tissue sample collected after the mouse had succumbed to Venezuelan equine encephalitis reveals histopathologic changes indicative of neural necrosis and edema. Photomicrograph by CDC/Dr. Fred A Murphy in 1971. (Source: Public Health Image Library, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia. Image 2805. Public domain. Figure cropped from original by Dr. Douglas J Lanska.)

In this digitally colorized transmission electron microscopic image, the viral particles have been colorized red (magnification x 83,900) Photomicrograph by CDC/Dr. Fred Murphy and Sylvia Whitfield in 1975. (Source: Public Health Image Library, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia. Image 7057. Public domain.)

Transmission electron microscopic image reveals Eastern equine encephalitis virus virions in this tissue specimen. Photomicrograph by CDC/Dr. Fred Murphy and Sylvia Whitfield in 1975. (Source: Public Health Image Library, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia. Image 10252. Public domain.)

Transmission electron microscopic image reveals numerous Eastern equine encephalitis virus virions in this specimen of central nervous system tissue. Photomicrograph by CDC/Dr. Fred Murphy and Sylvia Whitfield in 1975. (Source: Public Health Image Library, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia. Image 10253. Public domain.)

Transmission electron microscopic image reveals numerous Eastern equine encephalitis virus virions in this specimen of central nervous system tissue. Photomicrograph by CDC/Dr. Fred Murphy and Sylvia Whitfield in 1975. (Source: Public Health Image Library, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia. Image 10265. Public domain.)

Negatively stained transmission electron microscopic image reveals Eastern equine encephalitis virus virions in this tissue specimen. Photomicrograph by CDC/Dr. Fred Murphy and Sylvia Whitfield in 1975. (Source: Public Health Image Library, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia. Image 10267. Public domain.)

Transmission electron microscopic image reveals numerous Eastern equine encephalitis virus virions in this central nervous system tissue specimen. Photomicrograph by CDC/Dr. Fred Murphy and Sylvia Whitfield in 1975. (Source: Public Health Image Library, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia. Image 10268. Public domain.)

Transmission electron microscopic image reveals numerous Eastern equine encephalitis virus particles harbored in this mosquito salivary gland tissue specimen. Photomicrograph by CDC/Dr. Fred Murphy and Sylvia Whitfield in 1975. (Source: Public Health Image Library, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia. Image 1868. Public domain.)