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Re: Oxygen - how much and why?

Dear Editor,

Mercury: Is it elemental my dear Watson?

CONGRATULATIONS for such a nice, lucid presentation of a case. I just wanted to know with the parameters given "On examination she was alert. The airway was patent. Her pulse was 96, BP 106/71, RR14, oxygen saturations 98% on air." How much oxygen is been given and with what objective parameters as end point?

Regards,

Umesh Chandra Ojha M.D.

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Re: Mad as a Hatter

Dear Editor

I read with interest the case report “Mercury: Is it elemental my dear Watson” by M Poulden. [1] In 1993, Dr Roden and I reported a case of deliberate self injection of mercury resulting in abscess formation and mercuric emboli to the lungs.[2]

In our case a 27-year-old doorman of a local casino presented with a swelling of the arm. (He was a keen body builder 1.90m in height and weighed 107Kgm). On the flexor aspect of his forearm there was a 4 x 5cm fluctuant swelling. The Casualty Officer drained this abscess and out came mercury! A radiograph of the forearm showed the mercury and radiographs of the skull and chest demonstrated micro emboli.

Serial blood and tissue mercury levels were raised but not toxic. We treated him with penicillamine and excised the abscess on the forearm under a general anaesthetic. He remained well. He denied putting the mercury in himself and revelled in any attention.

Three months later he returned complaining of a “head injury”. There was a small wound on his forehead. Radiographs showed a bullet in his skull and CT showed a large frontal haematoma. He was operated on by neurosurgeons and then referred to the psychiatrists.

Deliberate poisoning by self injection of mercury as a suicide attempt was first reported by Umber (1923).[3] There are about 30 such cases in the literature with 3 fatalities reported. However deliberate injection of mercury to obtain strength has also been reported by Celli & Khan ,1976. [4] Our patient admitted eventually that the gunshot wound was a suicide attempt and the injection has been thought to give extra strength to body builders.

These two cases, the ingestion reported in Emergency Medicine and injection reported in Injury, illustrate that the emergency doctor has to be ever vigilant as some of our patients do strange things. In both cases there was a delay in obtaining the blood mercury levels. The patient who ingested mercury had a higher level of mercury than the one who injected himself! There is little correlation between the volume of mercury injected and the outcome. 2cc has been fatal (Johnson & Koumides 1967 [5]) and 20cc non fatal (Celli & Khan 1976 [4]).

The term, “Mad as a hatter” is thought to have derived from madness induced in hatters from contact with mercury. However those who ingest or inject mercury can hardly be termed “normal”.

References

(1) Poulden M. Mercury: Is it elemental my dear Watson? Emerg Med J 2002;19:82-83.

(2) Roden R, Fraser-Moodie A. Self-injection with mercury. Injury 1993; 24(3):191-2.

(3) Umber F Quecksilber. Quecksilber – Embolien des lehender durch intraverose injektion vol metallis chen silber. Med Klin 1923 19.

(4) Celli Bard Khan MA Mercury Embolisation of the lung. N Engl J Med 1976;295:883.

(5) Johnson HRM and Koumides O (1967) Unusual case of mercury poisoning. BMJ 1967;1340.