2. Severe acute poisoning is usually due to the bichloride, either from swallowing the tablets or a solution (often with suicidal intent), or from the retention of strong solutions used as uterine or vaginal douches. From mouth doses the dominant lesion is nephritis; from vaginal douches it is generally colitis. Taken by mouth, bichloride gives a strongly metallic and astringent taste. If the swallowed liquid is strong enough there is local corrosion of mouth, esophagus, and stomach, followed by abdominal pain and vomiting. There may be copious serous or bloody stools, albuminous or bloody urine, or suppression of the urine, delirium, coma, collapse and death, or slow recovery. Postmortem examination shows the local corrosion of the upper part of the alimentary tract, and also acute colitis, acute proctitis, and acute nephritis. In the enterocolitis there may be extensive necrosis; in the nephritis there are fatty degeneration and necrosis of the cells of the convoluted tubules. Pericarditis is reported. There is occasionally a period of a day or two before the onset of the symptoms. In a patient that died ten days after taking 225 grains (15 gm.), Rosenbloom found most of the mercury in the liver, but much also in the large and small intestines, heart, kidneys, blood and muscles, and in the stomach and intestinal contents.

If the patient does not die quickly, he may be ill for days or weeks, with marked salivation, inflammatory and gangrenous lesions of the pharynx, cheeks, and hard palate, spongy and broken-down gums, loss of the teeth, gastritis, colitis, and nephritis. He may eventually recover, or may die of uremia or colitis or general prostration. Arterial pressure may be high until collapse sets in. The leucocytes are regularly high (Vogel). Lewis and Rivers report acidosis.

Treatment

Recovery has taken place after nine days of anuria, a fact which indicates the value of vigorous and persistent treatment.

At the outset, after bichloride is swallowed, white of egg or milk should be given to form non-corrosive albuminates; and these should promptly be removed from the stomach by lavage or vomiting to prevent absorption. Bland oils and other demulcents may then be given to soothe damaged membranes. The systemic treatment is eliminant. As the mouth, colon, and kidney symptoms develop, these require vigorous treatment. Potassium chlorate and myrrh make a favorite mouth-wash, and if the mouth is foul, peroxide of hydrogen.

The Lambert-Patter Son Treatment

Perhaps the most highly successful form of treatment is that of S. W. Lambert and H. S. Patterson, of St. Luke's Hospital, New York. They advise immediate administration of the whites of several eggs, followed by lavage. On admission to the hospital they give another thorough lavage and introduce through the tube a pint of milk, following this in one hour by another lavage if the nausea and vomiting continue. As soon as the stomach permits they begin the following routine: (1) Hourly liquid by mouth, 8 ounces (240 c.c.) of milk alternating with 8 ounces (240 c.c.) of a mixture of potassium bitartrate and sugar, each 1 dram (4 gm.), lactose 4 drams (15 gm.), lemon juice, one ounce (30 c.c.), with boiling water, 1 pint (480 c.c.). (2) A continuous rectal drip of a solution of potassium acetate, 3j (4 gm.) to Oj (480 c.c). (3) Lavage of the stomach twice daily. (4) Irrigation of the colon twice daily. (5) A daily hot-pack sweat. The treatment is continued until there is no mercury in the urine on two successive days. In some of the cases received late this stage has not been reached for as much as three weeks. In a number of cases treated by this type of alkali-water therapy, even after anuria for several days the urine had returned to normal in three or four weeks, and the kidneys were apparently permanently restored.

Macnider has shown that alkalies seemed to give the best protection against the development of tubular nephritis in experimental uranium poisoning. A case reported by H. C. Wood illustrates a possible danger from copious water ingestion if the anuria is not overcome. The patient passed only 3 3/4 ounces of urine in seven days and on the four subsequent days 4, 9, 11, and 14 ounces, and on the twelfth day died of pulmonary edema.

Burmeister recommends the substitution of new blood for the mercury-containing blood by repeated copious venesections and transfusions. Wilms uses calcium sulphide intravenously, 1 grain (0.06 gm.) in 1 ounce (30 c.c.) of tap-water filtered hot for each grain of mercury salt ingested. He also gives 1 grain (0.06 gm.) every hour by mouth. Sodium phosphite has been proposed, but it has a reducing value only in the stomach. Halls antidote, consisting of potassium iodide, quinine hydrochloride and water, has been shown by Barbour to be valueless. Decapsulation of the kidneys has overcome the anuria in some cases.

3. Chronic Poisoning

This is seen among makers of mirrors, barometers, thermometers, and felt for felt hats, the hides being impregnated with mercury. It also occasionally results from the mercury treatment of syphilis. The writer saw a case in a man who had used cinnabar (mercuric sulphide) in an Indian make-up. Besides the salivation, the poisoning shows the usual effects of the heavy metals on the nutrition, the alimentary tract, the nervous system, and the blood. These effects are: loss of appetite, nausea, and other derangements of digestion, constipation or diarrhea, colic, anemia, loss of flesh and strength, and aching in bones and joints. There may be a general cachexia. There is no line on the gums, as in lead-poisoning. The effect on the nervous system may be pronounced. There are: a tremor of the hands and lips or the whole body, irritability of temper, fear, hallucinations, loss of memory, mental weakness, loss of will-power, and perhaps a peripheral neuritis (Starr says rare, if occurs at all). The diagnosis is confirmed by finding mercury in the urine or feces.

The treatment is removal of the patient from exposure to the mercury, potassium iodide and free water-alkali therapy to promote elimination, and care for the nervous condition, the malnutrition, the anemia, and the salivation. Oliver thinks iodide is useless.

During the treatment of syphilis a sore throat or mouth due to mercury may sometimes be attributed to the disease, and may persist until the mercury is stopped. Busch says that mercury is contraindicated in Addison's disease.