Another distinction seems to be that corrosive sublimate is more apt than arsenic to cause nervous affections during the first inflammatory stage. The tendency to doze, which sometimes interrupts the inflammatory symptoms caused by arsenic, has been more frequently observed in cases of poisoning with corrosive sublimate.[896] The same may be said of tremors and twitches of the extremities. Sometimes the stupor approaches even to absolute coma;[897] and the twitches occasionally amount to distinct, nay violent convulsions.[898] In other instances paraplegia has been witnessed.[899]
Another difference is, that the effects of mercurial irritants are fully more curable than those of arsenic. Recovery has taken place even after half an ounce was swallowed, with the effect of inducing both bloody vomiting and purging.[900] This may depend in part on the greater solubility of mercurial preparations, so that they are more easily discharged than arsenic, which often remains in the stomach after days of continual vomiting,—and in part on corrosive sublimate and other soluble salts of mercury being converted, in no long time and much more easily, into comparatively innocuous compounds, either by antidotes intentionally given for the purpose, or by animal principles in the secretions and accidental contents of the alimentary canal.
Lastly, deviations from the ordinary course and combination of the symptoms appear to be more rare in the instance of corrosive sublimate than in that of arsenic.
To these general statements, it may be right to add the heads of one or two actual cases, lest an exaggerated idea be conveyed of the combination of the symptoms as they usually occur. For this purpose it will be sufficient to refer to a fatal case related by M. Devergie, to an instance of recovery, without salivation having supervened, which is contained in Orfila’s Toxicology, and to another by Dr. Vautier, presenting the mildest possible symptoms of this variety. In Devergie’s case, the patient, a female, swallowed three drachms of corrosive sublimate in solution, and was soon after seized with vomiting, purging, and pain in the belly. In five hours, when she was first seen by Devergie, the skin was cold and damp, the limbs relaxed, the face pale, the eyes dull, and the expression that of horror and anxiety. The lips and tongue were white and shrivelled; and she had dreadful fits of pain and spasm in the throat whenever she attempted to swallow liquids, also burning and pricking along the course of the gullet, and increase of pain in these parts on pressure. There was likewise frequent vomiting of mucous and bilious matter, with burning pain in the stomach and tenderness of the epigastrium on the slightest pressure. She had farther profuse diarrhœa, with pricking pain and tenesmus. The pulsation of the heart was deep and slow, the pulse at the wrist almost imperceptible, and the breathing much retarded. In eighteen hours these symptoms continued without any material change; but the limbs were also then insensible. In twenty-three hours she died in a fit of fainting, the mind having been entire to the last.[901]—Orfila’s case was that of a gentleman who drank by mistake an alcoholic solution of corrosive sublimate, but fortunately was so much alarmed by its taste while drinking it, that he did not finish the poisonous draught. Nevertheless, he was instantly attacked with a sense of tightness in the throat and burning in the stomach, and then with vomiting and purging. Two hours after the accident Orfila found him with the face very full and red, the eyes sparkling and restless, the pupils contracted, and the lips dry and cracked. There was also acute pain along the whole course of the alimentary canal, particularly in the throat. The belly was swelled, and so tender that he could not bear the weight of fomentation-cloths. The pulse was 112, small and sharp; the skin intensely hot and pungent; micturition scanty, frequent, and difficult; the breathing very much oppressed; the purging bilious. The patient had likewise a tendency to doze, and was affected with occasional convulsive twitches of the face and extremities, and with constant cramps in the limbs. Next morning all the symptoms were sensibly mitigated; and they went on decreasing till convalescence was established in eight days. In the course of a few weeks he recovered his usual health, without suffering salivation.[902]—In Vautier’s case, where sixteen grains had been swallowed, the patient was immediately attacked with pain in the throat and stomach, cold extremities, trembling of the arms and legs, vomiting, paleness of the features, and great feebleness of the pulse. Vomiting being promoted by frequent draughts of warm water, and white of egg given subsequently, no further symptoms ensued, those first excited slowly subsided, and in a few days recovery took place, without any salivation. Yet it was upwards of half an hour before any measures could be taken for his relief.[903]
The only material and common symptom which was wanting in the case now related was blood in the stools and in the matter vomited. In other respects they are good examples of the ordinary train of symptoms in cases of the present variety. For other examples of the same nature the reader may refer particularly to the paper of Mr. Valentine, who has described five cases that happened at one time in the same family, the mother having attempted to poison herself and four children.[904]
It may sometimes be necessary to know the usual duration of this variety of mercurial poisoning, and also the extremes of its duration. On these points I have not hitherto had opportunities of consulting a sufficient number of cases to be able to lay down the general rule with precision. But, so far as my inquiries go, the ordinary duration in fatal cases is from twenty-four to thirty-six hours. It is probable that a few may last three days,[905] but only one instance has come under my notice where the duration was greater; and in that instance, which is described by Dr. Venables, life was prolonged under great agony from pain of the belly, bloody vomiting, diarrhœa and suppression of urine, but without salivation, for no less than eight days.[906] In cases of recovery the symptoms of irritation may continue very long, and nevertheless not pass into the second variety of this kind of poisoning,—a transition, however, which on the whole is uncommon. In the case of which an analysis has been given from Orfila’s narrative, and likewise in one of Mr. Valentine’s patients who recovered, the symptoms all along were those of irritation in the alimentary canal; there was not any ptyalism, or other symptom of proper mercurial erethysm.—The shortest duration yet recorded is two hours and a half. This was in a case related by Dr. Bigsby of Newark-on-Trent, where a tea-spoonful of a concentrated solution of nitrate of mercury was swallowed by a lad sixteen years old, and where the chief symptoms were burning pain from the mouth to the stomach, tenderness of the whole belly, mucous vomiting, and feculent purging.[907] In a case which occurred in London, and which has been published succinctly by Mr. Illingworth, death must have occurred either as soon, or very shortly afterwards. The dose of corrosive sublimate, though not positively ascertained, was large.[908] Next to this the shortest case recorded proved fatal in eleven hours.[909]
2. The second variety of poisoning with mercury comprehends the cases, which begin, like the former, with irritation in the alimentary canal, but in which the symptoms of what is called mercurial erethysm gradually supervene. In fatal cases of this description death sometimes arises from the primary action of the poison, exactly as in the previous variety; but in other instances it is owing to general disturbance of the constitution, or the local devastation, brought on by the secondary effects.
It is unnecessary to describe here the several forms of mercurial erethysm which may thus be developed, because they will immediately be considered under the third variety of mercurial poisoning. It is sufficient to state in passing that the leading affection is inflammation of the organs in and adjoining the mouth, and more particularly of the salivary glands.
But it may be right to endeavour in the present place to fix the period of the poisoning at which these secondary affections may and usually do commence. This cannot be done so satisfactorily as might be wished, because the cases already published which I have been able to examine do not form a large enough induction. Among the recorded cases I have hitherto seen, salivation has never been retarded beyond the third day;[910] but in an instance of suicide by corrosive sublimate which happened in the Castle of Edinburgh in 1826, and which was communicated to me by the late Dr. Shortt, the salivation did not begin till the fourth. Salivation seldom comes on sooner than the beginning of the second;[911] and the most usual date of its commencement is towards the close of the second day. There is little doubt that it may be retarded till a period considerably later than I have yet found recorded. It is doubtful whether true mercurial salivation ever begins much sooner than after the first twenty-four hours. Occasionally, however, corrosive sublimate produces salivation of a different kind, which has been mistaken for the specific variety caused by mercury. Thus in a paper on the cure of gonorrhœa by corrosive sublimate in single large doses, communicated by Mr. Addington of West Bromwich to Dr. Beddoes, it is stated that a grain and a half, taken at once in half an ounce of rectified spirit, causes immediately “a great burning in the throat and stomach, and quickly afterwards a copious salivation, lasting between an hour and a half and two hours, and amounting frequently to more than a quart.”[912] These facts have been appealed to by authors in medical jurisprudence as proving the rapid production of mercurial salivation. But the effect produced is not the specific ptyalism of mercury; for its brief duration is scarcely consistent with this supposition. And farther, the author goes on to observe, that, if the dose be taken on going to bed, the latter part of the night is passed quietly, and no inconvenience is felt afterwards, even when the dose is taken five or six times at intervals of three or four days. The effects here observed is a sympathetic phenomenon depending on the topical action of the poison. And such, I have no doubt, has been the nature of the salivation in several cases of poisoning with corrosive sublimate, which have been supposed to be at variance with the general rule, that this affection does not begin till about twenty-four hours have elapsed. Such seems to have been the nature of the salivation in a case published by Dr. Perry,[913] that of a girl who was attacked with swelling of the cheeks and lower lip, burning in the throat, flushed face, feeble pulse, and cold, clammy extremities after swallowing corrosive sublimate, and who had a copious flow of saliva in an hour and a half; for there is no mention made of fetor, and the girl was well enough to leave the hospital in a few days,—which could scarcely happen if she had been affected with ptyalism from the constitutional action of mercury.—In like manner Dr. Alexander Wood has related a case, fatal in fourteen days, in which the patient said salivation came on in seven hours.[914] But, notwithstanding Dr. Wood’s argument in support of the patient’s statement,—for he did not see him till nine days after the poison was taken,—there is no satisfactory evidence that the salivation was the true constitutional salivation of mercury, and not simply the result of its topical action, which seems to have been very severe.—Farther, in an instance related by Dr. H. Anderson of Belfast, where salivation appeared to him to begin in nineteen hours, it seems not improbable that he mistook for mercurial ptyalism the common salivation arising from inability to swallow on account of sore throat; for this patient too was quite convalescent in three days.[915]—Mr. Alfred Taylor alludes to a case in Guy’s Hospital of salivation occurring in four hours; but so briefly, that its true influence on the present question cannot be judged of.[916]—On the whole, then, although it is clear that ptyalism of one kind or another may occur very soon after corrosive sublimate is swallowed, it remains a matter of doubt, whether the true, specific ptyalism, depending on the constitutional action of the poison begins sooner than after an interval of above twenty-four hours.
As to the total duration of this variety in fatal cases, I have found an instance fatal on the fourth day, salivation having begun on the second;[917] and Orfila quotes a case from Degner, in which the gastro-enteritic symptoms were succeeded by ptyalism about the same period, and which proved fatal in fifteen days.[918] These periods, however, probably do not form the extremes; for in such cases as the former death is the consequence of the primary affection, and may therefore ensue immediately after the secondary stage has begun to develope itself; and when death arises from profuse salivation, as in Degner’s patient, or from the ravages committed by ulceration and gangrene, it may be delayed almost as long as in cases of the third variety of mercurial poisoning, in which there is no precursory stage of inflammation in the alimentary canal.
Death may arise, not only from the primary action of the poison, or from the exhaustion caused by mercurial erethysm, but likewise from incidental occurrences. Thus, in Dr. Alexander Wood’s case, referred to above, death arose directly from sudden profuse hemorrhage from the bowels, to the amount of six pounds.
The present variety of poisoning with corrosive sublimate may be concluded with the heads of an excellent example related in the Medical and Physical Journal. The patient, a stout young girl, swallowed soon after supper a drachm of corrosive sublimate dissolved in beer, and in a few minutes she was found on her knees in great torture. All the primary symptoms of this kind of poisoning were present in their most violent form,—burning in the stomach, extending towards the throat and mouth, followed in no long time by violent vomiting of a matter at first mucous, afterwards bilious and bloody; by purging of a brownish, fetid fluid; suppression of urine and much tenderness of the urethra and bladder; small, contracted, frequent pulse, anxious countenance, and considerable stupor, interrupted frequently by fits of increased pain. All these symptoms were developed in four hours. Subsequently the pain in the stomach became much easier, but that in the throat much worse. At length in the course of the second day, the teeth became loose, the gums tender, the saliva more abundant than natural; profuse ptyalism and great fetor of the breath ensued, and the patient expired towards the close of the fourth day.[919]
3. The third variety of poisoning with mercury comprehends all the forms of what is called mercurial erethysm. Without endeavouring to settle the precise meaning of this term, which is now used in rather a vague sense, I shall consider under the present head all the secondary and chronic effects of mercury. These may be caused by any of its preparations, but are most frequently seen as the consequence of its milder compounds, either given medicinally in frequent small doses, or applied continuously to the bodies of workmen who are exposed by their trade to its fumes.
The secondary and chronic effects of mercury are multifarious enough in reality; but if credit were given to all that has been written, and is still sometimes maintained on this subject, almost every disease in the nosology might be enumerated under the present head; for there is scarcely a disease of common occurrence, which has not been imputed by one author or another to the direct or indirect operation of mercury. The present remarks, however, will be confined as much as possible to what is well ascertained, and bears on the medical evidence of poisoning with mercury, or is important in regard to medical police. With this view, salivation and its concomitants, the most usual of the secondary effects of mercury, will first be treated of. Some observations will then be made on the shaking palsy, or mercurial tremor, which is caused in those who work with mercury. And in conclusion, a short view will be taken of the other diseases which are more indirectly induced by this poison, as well as some which have been ascribed to it on insufficient grounds. This being done, the mode of action of mercurial poisons will be resumed, and a description given of their relative effects when introduced by different channels and in different chemical forms.
Of Mercurial Salivation.—Mercurial salivation may be caused by any of the preparations of mercury, and either by a single dose or by frequently repeated small doses. It may be caused by corrosive sublimate as the secondary stage of a case which commenced with inflammation in the alimentary canal; or it may be the first sign of mercurial action, as in the medicinal mode of administering calomel and blue pill. Even in the latter case a single dose, and that not large, may be sufficient to induce ptyalism of the most violent kind. When induced by a single dose it usually commences between the beginning of the second and end of the third day, rarely within twenty-four hours. But an extraordinary case is mentioned by Dr. Bright, where five grains, put on the tongue in apoplexy and not washed over, excited in three hours most violent salivation, with such swelling of the tongue that scarifications became necessary.[920] It commences with a brassy taste and tenderness of the mouth, swelling, redness, and subsequently ulceration of the gums; peculiar fetor of the breath; and at last an augmentation is observed in the flow of the saliva, commonly accompanied with fulness around the lower jaw. These symptoms increase more or less rapidly. Sometimes they are very mild; nay, this form of the secondary effects of mercury may consist in nothing else than brassy taste, tenderness of the mouth, redness of the gums, and fetor. On the other hand, the symptoms are often very violent, the salivation being profuse, the face swelled so as to close the eyes, and almost fill up the space between the jaw and clavicles, the tongue swollen so as to threaten suffocation, the inside of the mouth ulcerated, nay gangrenous, and at times the gangrene extends over the face. It is not uncommon to observe severe and extensive ulceration without particular increase of the saliva.
These local affections are almost always accompanied with more or less constitutional disorder. If severe, they are attended with the symptomatic fever proper to inflammation and gangrene, from whatever cause they spring. But independently of that, mercurial salivation is accompanied, and indeed commonly preceded, by a constitutional disorder or symptomatic fever of its own, which occasionally exhibits some peculiarities. The mildest affection of the mouth and salivary glands is very generally preceded by some exaltation of the pulse and temperature, and other symptoms of fever. But when the local disorder begins violently, and above all when this takes place by idiosyncrasy from small doses of mild preparations, there is often great rapidity of the pulse, irregular action of the heart, and various nervous disorders possessing the hysteric character,—all of which, except the quick pulse, will sometimes gradually abate or even disappear, when the salivation is fairly established.
The phenomena of ordinary mercurial salivation being familiar to every practitioner, it is unnecessary to quote here any illustrative example; but the following instance may be given to exemplify its most malignant forms. A patient of Mr. Potter of Chipping-Ongar, in Essex, after taking eighteen grains of blue pill in divided doses during three days, was seized with excessive salivation and great constitutional disturbance, indicated by offensive evacuations, copious sweating, bleeding from the nose, purple spots on the skin, dilated pupils, and such severe local disease that the teeth dropped out, and he expired six days after mercurial action set in.[921]
As the phenomena of mercurial salivation have been often known to lead to important evidence and much contrariety of opinion upon trials, it will be necessary to dwell at some length on some parts of the subject.
In the first instance, then, the dose which is required to bring on salivation may be noticed. It is needless to mention the ordinary quantity required in mercurial courses. A more useful object of consideration is the departure from the ordinary rule. One of the most common and important of these deviations is excessive sensibility to the action of mercury, in consequence of which the individuals who have this idiosyncrasy may be profusely salivated by one or two small doses even of the mildest preparations. Three grains of corrosive sublimate divided into three doses have caused violent ptyalism.[922] Fifteen grains of blue pill, taken in three doses, one every night, have excited fatal salivation.[923] Nay, two grains of calomel have caused ptyalism, extensive ulceration of the throat, exfoliation of the lower jaw, and death.[924] Three drachms of mercurial ointment applied externally have caused violent ptyalism and death in eight days. On the other hand, it is well known that some constitutions resist the action of mercurials very obstinately, so as even sometimes to appear incapable of being salivated at all. I have more than once met with cases of the last description, where mercurial courses had been continued for three months and upwards without avail. It may be added, that, except in constitutions naturally predisposed to suffer from a few small doses, a few large doses do not appear apt to excite severe salivation, or even to cause any at all. This has been clearly shown in the course of the practice lately introduced of administering calomel in doses of a scruple. On that subject more will be said by and by. At present I may mention, that, in conformity with the practice alluded to, I have several times, in various diseases, given eight or ten grains of calomel five or six times a day for two or three days together, without observing that ptyalism was apt to ensue.
The next point to be considered is, whether mercurial salivation can be confounded with any other affection. In a very difficult case of poisoning which was tried here in 1817, that of William Patterson for murdering his wife,[925] it appeared probable that he had given her repeatedly large doses of calomel. But the proof of this was circumstantial only, and an important circumstance in the chain of evidence was a deposition to the occurrence of salivation during the woman’s illness. This fact, however, rested on the skill and testimony of a quack doctor only; and the admissibility of such a person to decide on a point of this nature, will depend on the facility with which the true mercurial form of salivation can be recognised. This statement will show the practical object of what is to follow.
Many other causes may excite a preternatural flow of saliva. Several other poisons may have that effect, for example, preparations of gold, preparations of copper, antimony, croton-oil, and foxglove: foxglove has been known to cause violent salivation for three weeks.[926] Opium too has occasionally excited salivation,[927] and also hydrocyanic acid and iodide of potassium.
Even a common sore throat, if the swelling and pain are so great as to render swallowing very difficult and distressing, may be accompanied, as every physician must have remarked, with a profuse flow of saliva; and in the ulcerative stage there is also often a fetor that is hardly distinguishable from the mercurial kind. In the ulceration of the mouth called cancrum oris there is some salivation with great fetor of the breath.
Salivation likewise forms an idiopathic disease, and may then be both profuse and obstinate. Mr. Davies has described a case of spontaneous ptyalism which had lasted for a fortnight before he was called to see the patient; and during all that time the quantity of saliva discharged was two or three pints daily. How long it endured afterwards he does not mention; but it must have continued for some time, because during his attendance first one physician and then another were called into consultation with him. Laxatives slowly removed it. Mr. Davies has not described the state of the mouth; but the first physician mistook the salivation for a mercurial one.[928] In the same journal which contains this case another has been related which lasted four months.[929] Another very remarkable case has been recorded by Mr. Power. The patient, a young lady, discharged for more than two years from sixteen to forty ounces of saliva daily. In the last two cases the mouth was not affected.[930] Two other instances have been related by M. Bayle, in one of which the patient was cured after spitting five pounds daily for nine years and a half; while the other continued to be affected after spitting profusely for three years. In neither was there any ulceration of the mouth.[931] An instance has been related by an Italian physician, Dr. Petrunti, where, in the course of various nervous affections of the hysteric character, the patient became affected with heat and tightness in the throat, and so profuse a salivation for two months, that between three and four pounds were discharged daily.[932] A case somewhat similar is related in Rust’s Magazin of a man who suffered upwards of two years from a daily salivation alternating occasionally with a mucous discharge from the bowels or lungs.[933] M. Guibourt describes the case of a lady who had an attack of profuse salivation every thirty, forty, or fifty days, lasting between twenty-four and forty-eight hours, and unaccompanied with any other affection of the mouth or adjoining parts except a sense of tightness in the throat.[934] M. Gorham relates an interesting case of a lady who in three successive pregnancies was attacked soon after impregnation with excessive ptyalism, which continued to the extent of between two and four quarts daily until the period of quickening on two occasions, and on the third till her delivery; but there was never any fetor or any affection of the gums.[935] I have likewise met with a singular case where spontaneous ptyalism accompanied an ulcerated sore throat of the mercurio-syphilitic kind. The patient had taken mercury to salivation about six months before coming under my care, and got completely rid of both the sore throat and salivation. But the sore throat returned, together with the salivation, two months before I saw him, and the salivation continued for two months longer to the extent of twenty or even thirty ounces daily,—the ulcer of the throat during that interval being sometimes healed up, and again returning as severely as ever. In three weeks more the discharge rapidly diminished, and ceased. During all the time he was under my care there was no fetor of the breath, and no redness, ulceration, or sponginess of the gums. A singular account of an epidemic salivation which occurred in connection with a continued tertian fever, has been given in an inaugural dissertation contained in one of Haller’s Collections. The author, Quelmalz, says that the ptyalism sometimes continued for three weeks, that it was in one instance as great in extent as the most violent mercurial salivation, and that it was accompanied by fetor, superficial ulceration of the mouth, pustules on the tongue, relaxation of the gums, and looseness of the teeth.[936]
Salivation may likewise be produced by the influence of the imagination. I have seen a singular example of this. A woman who had a great aversion to calomel was taking it with digitalis for a dropsical complaint. Some one having told her what she was using, she immediately began to complain of soreness of the mouth, salivated profusely, and even put on the expression of countenance of a salivating person, although she had taken only two grains. On being persuaded, however, that she had been misinformed, the discharge ceased gradually in the course of one night. Two days afterwards she was again told on good authority that calomel was contained in her medicines, upon which the salivation began again and was profuse. It did not last above twenty-four hours; but the symptoms during that period resembled a commencing mercurial salivation in every thing but the want of fetor and redness of the gums.
In general, mercurial salivation may be easily distinguished from all the preceding varieties by an experienced practitioner. If its progress has been traced from the first appearance of brassy taste and fetor to the formation of ulcers and supervention of ptyalism, no attentive person can run any risk of mistaking it. Its characters are also quite distinct at the time salivation just begins. The fetor of the breath and sponginess and ulceration of the gums at this stage distinguish it from every other affection. But if the state of the mouth is not examined till the ulcers have existed several days, the characters of the mercurial disorder are much more equivocal. They cannot be distinguished, for example, from some forms of idiopathic ulceration of the mouth connected with unsoundness of the constitution, and characterized by extensive sloughing, ptyalism, and gangrenous fetor.[937] In particular they cannot be distinguished from the effects of the disease called cancrum oris. A few years ago indeed a London physician was charged, in consequence of this resemblance, with having killed, by mercurial salivation, a patient to whom it was proved that he had not given a particle of mercury, and who clearly died of the disease in question;[938] and a similar case, where fatal mercurial salivation was suspected, but which was clearly proved on a Coroner’s Inquest to have been also a case of cancrum oris, has been more lately published by Mr. Dunn.[939]
For distinguishing these and such other affections from mercurial salivation Dr. Davidson of Glasgow has lately proposed a character, the exact scope of which cannot yet be appreciated,—namely, that in true mercurial salivation there is never any sulpho-cyanic acid in the saliva; so that sesquichloride of iron does not render it red. The presence of sulpho-cyanic acid may possibly prove that salivation is not mercurial; but the converse does not hold good, because other causes tend to deprive human saliva of its sulpho-cyanic acid.[940]
The next point to be noticed regarding mercurial salivation is, that a long interval may elapse after the administration of the mercury has been abandoned, before the effect on the salivary glands and mouth begins,—mercury in small doses being what is called a cumulative poison, or a poison whose influence accumulates silently for some time in the body before its symptoms break forth. Swédiaur has met with instances where the interval was several months,[941] Cullerier with a case in which it was three months.[942] It will at once be seen how strongly such facts may bear on the evidence in a criminal case, where the administration of mercury in medicinal doses, which have been long abandoned, is brought forward to account for salivation, appearing weeks or months after, and giving rise, in conjunction with other circumstances, to a suspicion of mercurial poisoning of more recent date.
Another question which has been made the subject of discussion is the duration of mercurial ptyalism. The medical witness may be required to give his opinion how long this affection may last after the administration of mercury has been abandoned. The present question may be cut short by stating, that there appears to be hardly any limit to its possible duration. Linnæus met with an instance of its continuing inveterately for a whole year;[943] Swédiaur says he has known persons languish for months and years from its effects;[944] and M. Colson knew an individual who had been salivated for six years.[945] These, however, are very rare incidents. After an ordinary mercurial course the mouth and salivary glands generally return to the healthy state in the course of a fortnight or three weeks.
A fifth question, whether the ptyalism, or, speaking in general terms, the erethysm of mercury, is susceptible of a complete intermission, formed a material subject of inquiry, and the cause of much contradictory statement on a noted criminal trial, that of Miss Butterfield in 1775 for the murder of her master, Mr. Scawen. She was accused of administering corrosive sublimate; and it was alleged in her defence, that the salivation and consequent sloughing of which he died might have arisen, without the fresh administration of mercury, from the renewal of a previous ptyalism, which had been brought on by a common mercurial course, and had ceased two months before the second salivation began. It appeared that Mr. Scawen was salivated with a quack medicine from the beginning till the middle of April; and that about the middle of June he was again seized with violent salivation, of which he died. It was rendered very improbable, that during the interval between the two salivations any more mercury had been taken medicinally. The question then was, whether the original ptyalism could have reappeared after so long an interval, without the fresh administration of mercury? The witnesses for the prosecution, gentlemen in extensive practice, said it could not. But one of the prisoner’s witnesses, Mr. Bloomfield of the London Lock Hospital, said he had repeatedly known salivation reappear after a long intermission; that it was quite common for hospital patients to have a second salivation, when thought well enough to go out the next dismissal day;[946] that in one case the interval was three months; and that one of his patients was attacked periodically with salivation at intervals of six weeks or a month for a whole year. Mr. Howard, another surgeon of the Lock Hospital, deposed to the same effect; and the prisoner was acquitted, apparently upon their evidence.[947]
Notwithstanding what was said by these gentlemen, I believe the recurrence of mercurial salivation after so long an interval, without the repetition of mercury, is exceedingly rare. Dr. Gordon Smith, in alluding to the trial of Miss Butterfield, has mentioned a case which occurred to the late Dr. Hamilton of this University, and used to be related by him in his lectures. The interval was so great as four months.[948] Mr. Green of Bristol has lately described another unequivocal case, where the interval was six weeks.[949] Dr. Mead says he met with an instance where the interval was six months;[950] and Dr. Male mentions another where mercury brought on moderate salivation in March, and after a long interval excited a fresh salivation in October, of which his patient died in a few weeks.[951] M. Louyer-Villermé met with a case, where, in consequence of exposure to cold, a sudden attack of salivation was caused a twelvemonth after the removal of syphilis by mercury.[952] Some other cases not less wonderful have been recorded by M. Colson in his paper on the effects of mercury. He quotes Dr. Fordyce for the case of a man who had repeated attacks of salivation, with metallic taste, which lasted for three weeks, although mercury had not been taken for twelve years; and Colson himself knew a surgeon who had a regular and violent attack of all the symptoms of mercurialism eight years after he had ceased to take mercury.[953] It is impossible to attach credit to such marvellous stories as the last two. Granting the ptyalism to be really mercurial, it would require much better evidence than any practitioner could procure, to determine the fact that mercury had not been given again during the supposed interval. This objection indeed will apply more or less even to the instances where the alleged interval did not exceed a few months.
The last point to be noticed regarding mercurial salivation is the manner in which it proves fatal. Death may ensue from the mildest preparations, and from the smallest doses, in consequence of severe salivation being produced by them in peculiar habits. Two instances have been already mentioned which illustrate both of these statements, and others might easily be referred to were the fact not familiar.
Death may be owing to a variety of causes. Some of those which have been assigned are direct and unquestionable in their operation; others indirect and more doubtful.
The most direct and obvious manner is by extensive spreading gangrene of the throat, mouth, face, and neck. The late happy changes, introduced into the treatment of syphilis and other diseases which are benefited by mercury, render this mode of death rare in the present day. Yet I may mention that I have seen an example of it in a woman who was salivated to death, because her medical attendant, a firm believer in the powers of mercury as an antidote, forgot that the antidote is itself a poison, if not given in moderation. In general, when gangrene is the cause of death, it begins within the mouth or in the throat, and spreads from that till it even reaches the face. But sometimes it begins at once on the external surface, at a distance from the primary ulcers. An example of such a progress of the symptoms has been related by Dr. Grattan. A child ten years old was violently salivated by twenty grains of calomel given in six days. On the fifth day of the salivation, a little vesicle appeared on the skin near the mouth on each side, and was the commencement of a gangrenous ulcer, which spread over the whole cheek, and proved fatal eight days after its appearance.[954]
Another cause of death appears to be exhaustion from profuse and protracted discharge of saliva, without material injury of the mouth or adjoining organs.
A third manner of death which I have witnessed is exhaustion from laryngeal phthisis; and from the circumstances of the case, I have little doubt but, in the state to which patients are then sometimes reduced, death may also take place suddenly from suffocation. My patient had undergone before I saw him five long salivations for a venereal complaint, and had latterly been attacked with symptoms of ulceration of the glottis. This affection went on slowly increasing, and he died of exhaustion after many weeks of suffering. During this period he was repeatedly attacked with alarming fits of suffocation, which were relieved by the hawking of mucous flakes. The symptoms were explained on dissection by the appearance of extensive ulceration and thickening of the glottis, and almost total destruction of the epiglottis.
The other causes of death are more indirect, and will be mentioned presently. They depend on the pre-existence of other diseases, on which mercury acts deleteriously during the state of erethysm excited by it in the constitution.
Of Mercurial Tremor.—The second division of the secondary effects of mercury comprehends the palsy or tremor, with the collateral disorders induced in miners, gilders, and other workmen, whose trade exposes them to the operation of this poison. Under the present head, which might be treated at considerable length as an important branch of medical police, I shall confine myself chiefly to an analysis of an interesting essay by Mérat on the Tremblement Metallique, and to some remarks by Jussieu on the health of the quicksilver miners of Almaden in Spain.
Mérat’s account of the shaking palsy induced by mercury is very interesting.[955] The disease, he states, may sometimes begin suddenly; but in general it makes its approaches by slow steps. The first symptom is unsteadiness of the arms, then quivering, finally tremors, the several movements of which become more and more extensive till they resemble convulsions, and render it difficult or impossible for the patient to walk, to speak, or even to chew. All voluntary motions, such as carrying a morsel to the mouth, are effected by several violent starts. The arms are generally attacked first and also most severely. If the man does not now quit work, loss of memory, sleeplessness, delirium, and death ensue. But as the nature of the disease soon renders working almost impossible, he cannot well continue; and in that case death is rare. The concomitant symptoms of the trembling are a peculiar brown tint of the whole body, dry skin, flatus, but no colic, no disorder of respiration, and, except in very old cases, no wasting or impaired digestion. The pulse is almost always slow.—This description agrees with a somewhat later account of the disease by Dr. Bateman, as he observed it in mirror-silverers;[956] and also with some interesting cases recently published by Dr. Bright.[957]
In general the tremors are cured easily, though slowly, several months being commonly required. One of Dr. Bright’s patients got almost well in little more than a fortnight under the use of sulphate of zinc. Sometimes, however, the trembling is incurable.[958] I have said the disease is rarely fatal. Mérat quotes three cases only, in one of which death was owing to profuse salivation and gangrene, in the others to marasmus. On the whole, those who are liable to the shaking palsy do not appear liable to salivation. Yet the two affections are sometimes conjoined, as in three of the cases described by Dr. Bright, and in some noticed by Mr. Mitchell among the mirror-silverers of London.[959] Gilders, miners, and barometer-makers are all subject to the disease. Even those who undergo mercurial frictions may have it, according to Mérat; and M. Colson, who confirms this statement, quotes Swédiaur as another authority for it.[960] It is not merely long-continued exposure to mercurial preparations that causes the shaking palsy: a single strong exposure may be sufficient; and the same exposure may cause tremor in one and salivation in another. Professor Haidinger of Vienna some time ago mentioned to me an accident a barometer-maker of his acquaintance met with, which illustrates both of these statements. This man and one of his workmen were exposed one night during sleep to the vapours of mercury from a pot on a stove, in which a fire had been accidentally kindled. They were both most severely affected, the latter with salivation, which caused the loss of all his teeth, the former with shaking palsy, which lasted his whole life.
In regard to all such workmen, it is exceedingly probable that with proper care the evils of their trade may be materially diminished. This appears at least to be the result of the observations made long ago by Jussieu on the miners of Almaden in La Mancha. Most quicksilver mines are noted for great mortality among the workmen. But Jussieu maintains that the trade is not by any means so necessarily or so dreadfully unhealthy as is represented, or as it really is in some places. The free workmen at Almaden, he says, by taking care on leaving the mine to change their whole dress, particularly their shoes, preserved their health, and lived as long as other people; but the poor slaves, who could not afford a change of raiment, and who took their meals in the mine, generally without even washing their hands, were subject to swelling of the parotids, aphthous sore throat, salivation, pustular eruptions, and tremors.[961]
Of the indirect effects of mercurial erethysm.—The last division of the secondary effects of mercury relates to its indirect action when concurring with other diseases or predispositions to disease.
Of these effects there are some of which the poison appears to be the chief, if not even the sole cause. Thus, during the symptomatic fever which precedes salivation there are sometimes remarked imitative inflammations, or coma, or affections of the heart, which go off as salivation is established.
Other effects require the distinct co-operation of collateral causes. Many inflammatory diseases, not easily excited in ordinary circumstances, arise readily from improper exposures during salivation, for example dropsy, pneumonia, phrenitis, iritis, erysipelas, and various chronic eruptions.
Other effects again require the co-operation of disease, such as sloughing gangrene supervening on ordinary ulcers during the action of mercury,—a not uncommon accident. This appears most likely to happen when the ulcers are constitutional.
Lastly, in conjunction with other diseased morbid actions, either going on at the same time, or immediately preceding mercurial erethysm, this poison is apt to occasion some modifications of disease which are rarely otherwise witnessed. Modifications of the kind have already been traced in the instances of lues venerea and scrofula; but there is reason to believe that the same singular property may also exist in relation to other constitutional disorders.
These observations conclude the inquiry into the symptoms caused in man by mercurial poisons generally. Returning now to its mode of action, we have to examine its relative effects through the different animal textures, and in its various chemical forms.
The result of the previous remarks as to its action on animals, it will be remembered, was, that its soluble preparations cause when swallowed corrosion of the stomach, and in whatever way it enters the body irritation of the stomach and rectum, inflammation of the lungs, depressed action and perhaps inflammation of the heart, oppression of the functions of the brain, and inflammation of the salivary glands. All of these effects have likewise been mentioned in the preceding sketch, as occurring in a greater or less degree in consequence of its operation on man.
Mercury acts as a poison on man in whatever way it is introduced into the body,—whether it be swallowed, or inhaled in the form of vapour, or applied to a wound, or even simply rubbed or placed on the sound skin. But the kind of action excited differs according to the channel by which it is introduced.
The most ordinary and dangerous cases of poisoning arise from the introduction of corrosive sublimate into the stomach. The poison then kills by corroding or inflaming the alimentary canal, or by causing salivation and its concomitants.
When applied to a wound or ulcer corrosive sublimate does not often occasion dangerous symptoms. Yet it is sometimes a hazardous remedy. It is not a convenient escharotic even in a concentrated state; for its escharotic action is not incompatible with its absorption; at all events it certainly sometimes acts constitutionally through the surface of wounds and ulcers, and the symptoms brought on in this way are generally violent. They are the symptoms of mercurial salivation, accompanied at times with well-marked inflammation of the alimentary canal. When applied to sores in a diluted state it has also been known to cause dangerous effects if too long persevered in. A case of the kind has been related by Mr. Robertson, an army-surgeon. After anointing an itchy eruption of the arms for seven days with a solution of corrosive sublimate containing five grains to the ounce, his patient was attacked with fever, inflammation of the stomach and bowels, and in two days more with violent salivation.[962] A case of the same nature has been related by Mr. Sutleffe.[963] His patient, a child, in consequence of having an eruption of the head washed with a solution of corrosive sublimate, was attacked with violent salivation, which proved fatal in a few days. Pibrac has recorded three fatal cases from the free application of corrosive sublimate to ulcerated surfaces. One of these proved fatal in five days, another in twenty-four hours, and a third during the night after the poison was applied. The symptoms generally indicated violent action on the alimentary canal.[964] In an instance mentioned by Degner, fatal in twenty-five days, there was also violent irritation of the stomach; but the chief affection was excessive swelling of the face and throat, together with profuse ptyalism.[965]
One of the readiest modes of bringing the system under the poisonous action of mercury is by introducing its preparations into the lungs. It appears from some experiments by Schlöpfer that the fluid preparations act rapidly through the lining membrane of the air-passages. Six grains of corrosive sublimate in solution will thus kill a rabbit in five minutes.[966] But the effects of mercury through this channel are much better exemplified when its preparations are inhaled in the form of vapour. Corrosive sublimate when incautiously sublimed in chemical experiments has been known to cause serious effects. Dr. Coldstream of Leith informs me, that while subliming about twenty-four grains of it with the blowpipe when a student, he and several of his fellow-apprentices were seized with painful constriction of the throat, several had headache, and one had sickness and vomiting. The phenomena produced by the various preparations of mercury in more violent cases, are sometimes protracted tremors,[967] sometimes severe ptyalism and tedious dysentery,[968] sometimes salivation and gangrene of the mouth ending fatally.[969] This last form was produced remarkably in a chimney-sweeper, after cleaning a gilder’s chimney, during which operation he felt a disagreeable sense of tightness in the throat.
Several extraordinary instances have happened of poisoning from long-continued inhalation of the vapours which arise from metallic mercury. That vapours do arise from metallic mercury of the ordinary temperature of the atmosphere has been fully proved by Mr. Faraday; who found, that when a bit of gold was suspended from the top of a phial, the bottom being covered with a little mercury, the gold soon became amalgamated.[970] The vapours thus discharged may produce the worst species of mercurialism, if they are diffused through an apartment insufficiently ventilated. One of the most striking examples known of the baneful effects of mercury thus gradually insinuated into the system, occurred in a well-known accident which befel the ships Triumph and Phipps. These vessels were carrying home in 1810 a large quantity of quicksilver saved from the wreck of a ship near Cadiz, when by some accident several of the bags were burst and the mercury spilled. On the voyage home the whole crews of both vessels were more or less severely salivated, two died, many were dangerously ill, all the copper articles on board became amalgamated, all the rats, mice, cockroaches, and other insects, as well as a canary-bird and several fowls, and all larger animals, such as cats, dogs, goats, and sheep were destroyed.[971]
The action of mercury is often violently excited when it is applied to the skin even not deprived of the cuticle. The effects of mercurial inunction form a well-known and satisfactory proof of this. Even without the aid of infriction, the soluble preparations of mercury will excite mercurial action by being put simply in contact with the skin. Thus it has been shown by a German physician, Dr. Guérard, that ptyalism may be induced by a warm bath of corrosive sublimate in the proportion of an ounce to 48 quarts of water, and that the effect commonly begins after the third bath with an interval of three days between them.[972] It is not so generally known that the more active preparations, such as corrosive sublimate or nitrate of mercury, may, like arsenic, cause through the sound skin effects almost as violent as through the alimentary canal. The following pointed illustration is related by Dr. Anderson. A gentleman affected with rheumatism, was persuaded by a friend to use a nostrum, which was nothing else than a solution of half a drachm of corrosive sublimate in an ounce of rum. This was rubbed on the affected part for several minutes before going to bed. Ere the friction was ended, he felt a sensation of heat in the part, to which, however, he paid little attention. But during the night he was attacked with pain in the stomach, sickness, and vomiting, and soon after with purging and tenesmus. In the morning Dr. Anderson found him very weak and vomiting incessantly. The arm up to the shoulder was prodigiously swelled, red, and blistered. Next day he complained of brassy taste and tenderness of the gums, and regular salivation soon succeeded.[973] Another case of much interest has been described by my colleague, Professor Syme, where a solution of the nitrate was rubbed by mistake upon the hip and thigh instead of camphorated oil. Intense pain immediately followed, and afterwards shivering; the urine was suppressed for five days, without any insensibility, and during its suppression urea was detected in the blood; ptyalism appeared on the third day, became very profuse, and was followed by exfoliation of the alveolar portion of the lower jaw, but recovery nevertheless slowly took place.[974]
The mere carrying of mercurial preparations for a length of time near the skin, though not in direct contact with it, may be sufficient to induce the peculiar effects of the poison, as the following example will show. A man applied to a German physician, Dr. Scheel, affected with violent salivation evidently mercurial which proved fatal, but which it was impossible to trace to its real cause till after death, when a little leathern bag containing a few drachms of mercury was found hanging at his breast; and it was then discovered that he had been in the practice of carrying this bag for six years as a protection against itch and vermin, and during that period had frequent occasion to renew the mercury.[975]
The effects of mercury as a poison differ with the chemical form in which it is introduced into the system.
In its metallic state it is probably inactive. This fact is a material one for the medical jurist to determine precisely; for running quicksilver has been given with a criminal intent. A case of the kind forms the subject of a medico-legal report in Pyl’s Repertory;[976] and another is mentioned in Klein’s Annals.[977]
It is well ascertained that large quantities of fluid mercury have been repeatedly swallowed, without any injury or peculiar effect having followed. In neither of the German cases now referred to was any bad effect produced; and it has proved equally harmless when given medicinally to remove obstruction in the intestines. Farther, M. Gaspard mentions in his paper quoted in a former page, that he has left large quantities shut up for many hours in the various cavities of the body in animals, without observing any other result than at times inflammation, which was evidently owing to the mere presence of a foreign body, and not to the action of an irritant poison.[978]
It has been already stated, however, that the vapours of metallic mercury, even at the temperature of the air, produce mercurialism when inhaled. But then, in all likelihood, some of the metal is oxidated before being inhaled. At least the chemist knows that the surface of a mercurial trough soon tarnishes, especially when the mercury is not pure.
But it may be said that the blue ointment, which is made with running quicksilver, will not act as a mercurial when rubbed upon the skin. Here too, however, some oxidation takes place in the making of the ointment. Mr. Donovan endeavoured to prove that some of the mercury is always oxidated;[979] and I have generally found a sufficient quantity of oxide to account for the effects.[980]
It has been farther said, in proof of the poisonous action of quicksilver in its metallic state,—that patients, who have taken it for obstructed bowels, have sometimes been salivated. This accident has, I believe, happened in a few instances where the mercury was retained long in the body. But such cases are undoubtedly very rare. Zwinger mentions the case of a man, who took four ounces for colic, and was seized in seven days with salivation.[981] Laborde relates the particulars of another instance where seven ounces taken in fourteen days excited ptyalism, ulceration of the mouth, and great feebleness of the limbs.[982] In the days of Dr. Dover, when the administration of large doses of fluid mercury was a fashionable practice for a variety of purposes, it was alleged to have even sometimes proved fatal; and the case of an actor is specially mentioned, to whom, when convalescent from ague, Dover gave mercury to the amount of two pounds in five days, and who at the close of that period was seized with headache, colic, restlessness, and costiveness, proving fatal in two days; and the whole lower intestines were found black and lined with minute metallic globules.[983] Perhaps then it must be admitted that fluid mercury is not altogether inactive, speaking medicolegally. But this admission is no argument in favour of the metal being physiologically a poison; because in the course of the cases referred to, a part is in all likelihood oxidated by the oxygen in the intestinal gases. It is said to have been taken in the dose of an ounce daily for nine months, without either good or harm resulting.[984]
The question regarding the poisonous qualities of running quicksilver was carefully investigated some years ago by the Berlin College of Physicians in a report on the case in Pyl’s Repertory.[985] They observe that the opinion of Pliny, Galen, Hippocrates, Dioscorides, and many of the earlier moderns, including even Zacchias, had led to the popular belief in the deadly properties of fluid mercury; but that this belief is erroneous; for many surgeons, and among the rest Ambrose Paré, had given without injury to their patients several pounds of it to cure obstructed bowels; and in 1515 the Margrave of Brandenburg, over-heated on his marriage night with love and wine, and rising to quench his thirst, drank by mistake a large draught of quicksilver without suffering any harm. Fallopius mentions that he had known instances of women swallowing pounds of mercury, for the purpose of procuring miscarriage, and who did not suffer any injury.[986]
The sulphurets of mercury, like the metal, are not possessed of any deleterious action on the animal body. Orfila found that half an ounce of the sulphuret, formed in a solution of corrosive sublimate by sulphuretted-hydrogen, and half an ounce or six drachms of cinnabar, had no effect whatever on dogs.[987] The sulphurets which have appeared injurious in the hands of Smith[988] and other previous experimentalists must therefore have been impure.
Of the compounds of mercury, the red-precipitate and Turbith-mineral act as irritants, besides possessing the property common to all mercurial compounds, of causing mercurial erethysm. But they are not escharotics, though generally termed such. That is, they do not chemically corrode the animal textures. The effects of red-precipitate have been variable. Mr. Allison relates the case of a girl who in a fit of jealousy swallowed thirty grains of it. Being immediately detected, an emetic was given, which operated freely, and subsequently the stomach-pump was used; but on neither occasion was any red powder brought away. She was attacked with burning pain in the stomach, which was removed by opium, and for a week she had a distaste for food, but no other symptom of consequence.[989] Mr. Brett has described a case, in which the symptoms were occasional vomiting, stupor, languid pulse, cold clamminess of the skin, afterwards severe cramps of the legs, tenderness of the abdomen, dysuria, and some purging, and on the third day ptyalism; but the patient recovered.[990] M. Devergie has given a case somewhat similar, but without any ptyalism having followed the irritant effects of the poison.[991] In 1840 I was consulted on the part of the Crown in the case of a girl, who, there was every reason to suppose, had been killed in twelve hours by red-precipitate. The symptoms towards the close were pain in the throat, inability to swallow, vomiting, and excessive prostration; extensive red patches were found on the villous coat of the stomach after death; and I detected mercury in the solid contents and likewise in the inner coat of the stomach. The case did not go to trial, because, although a man by whom she was pregnant came under some suspicion, it rather appeared that the deceased had herself swallowed the poison with the view of inducing miscarriage. Dr. Sobernheim has given the particulars of the case of a young man who died from swallowing an ounce of red-precipitate. He suffered for some hours from vomiting, diarrhœa, pain in the stomach, tenderness of the belly, and colic; next day he had no pain, but coldness, lividity, stiffness, and an imperceptible pulse; and he expired in thirty-three hours. The poison was found abundantly in the stomach and duodenum after death, and some grains of it rested upon little ulcers.[992] As to Turbith-mineral, two scruples will kill a cat in four hours and a half; and several instances of violent and even fatal poisoning with it are mentioned by the older modern authors.[993]
The white precipitate or chloride of mercury and ammonia is probably also irritant, though inferior in power to the preparations just mentioned. Two scruples given to a dog occasion vomiting, pain, and some diarrhœa; and cases are recorded of death in the human subject from less doses.[994] But there are no recent facts as to the activity of this compound, and the older cases, which would assign to it very great energy, are open to the objection that this preparation was in former times often impure.
The bichloride or corrosive sublimate is a powerful corrosive or irritant, according to the dose and state of concentration; and it also excites mercurial erethysm in a violent degree. The nitrates too are corrosive, and not inferior in activity to the bichloride, as may be inferred from Dr. Bigsby’s case, noticed at page 314.
The bicyanide or prussiate of mercury, from the researches of Ollivier, and an interesting case he has published of poisoning with it in the human subject, appears to resemble corrosive sublimate closely in all its effects, except that it does not corrode chemically. Twenty-three grains and a half proved fatal in nine days.[995] M. Thibert has described a case in which ten grains caused death in the same period of time.[996] The symptoms in both instances were those of severe irritation of the stomach, extensive inflammation of the organs in the mouth, and suppression of urine; and in Thibert’s case a small quantity of albuminous fluid was discharged from the bladder instead of urine.