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Mad as a hatter
  1. A Fraser-Moodie
  1. Department of Accident and Emergency, Derbyshire Royal Infirmary, Derby, UK; alistair.fraser-moodiesdah-tr.trent.nhs.uk

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    I read with interest the case report by 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 1.90 m in height and weighed 107 kg). On the flexor aspect of his forearm there was a 4×5 cm fluctuant swelling. The casualty officer drained this abscess and out came mercury! A radiograph of the forearm (fig 1 in the case report) 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 computed tomography 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.3 There are about 30 such cases in the literature with three fatalities reported. However, deliberate injection of mercury to obtain strength has also been reported.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 MedicineJournal 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 concentrations. 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—2 cc has been fatal5 and 20 cc non-fatal.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”.

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