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]]