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.