The accidental ingestion of a preparation containing hexachlorophene (pHisoHex) has been encountered in 10 patients. In most instances the suspension containing it was mistaken for milk of magnesia. This occurred because the disinfectant (meant to be used as a preoperative scrub) was dispensed in a paper cup, without adequate instructions and supervision by the nurse, and because the suspension resembles milk of magnesia in color and viscosity. The major symptoms of toxicity were anorexia, nausea, vomiting, abdominal cramps, and diarrhea. Dehydration was sometimes severe and associated with shock. The water and electrolyte derangement must be treated vigorously. Hexachlorophene is believed to be the primary factor in causing this toxicity. The theoretically fatal dose of hexachlorophene is 2 to 10 gm. and is contained in 67 to 300 cc. of the preparation used.