Brain (197R) 95, 305-318, MERCURY VAPOUR INTOXICATION! FRED Q. VROOM Axp MELVIN GREER (From the Division of Neurotogy, Univesity of Florida, College of Medicine, Gainessile, Florida) AccieNTAL mercury poisoning in man results from both inorganic and organic mercury compounds. Both affect the nervous system and can cause severe disability and even death. Inorganic mercury is generally less severe; chronic exposure insidiously produces stomatitis, erethism and tremor. Its poisonous properties have been noted for centuries affecting numerous industries, the most famous being the Mad Hatter of “Alice in Wonderland” (Hunter, 1955). Organic mercury produces 4 more severe acute oF subacute disorder manifested by parasthesias, inco-ordina- tion, blindness and dementia or may mimic amyotrophic lateral sclerosis. Epidemics have resulted from ingestion of grain treated for seed purposes and more importantly from fish or animals whose food chain has been contaminated (Nelson et al., 1971). Inorganic mercury has now been demonstrated to cause many of the signs attributed to organic mercury peisoning (Kark ef af., 1971). We here report the neurological impairments resulting from mercury vapour poisoning in nine workers employed bby. local thermometer company and give additional evidence that inorganic mercury can cause abnormalities similar to organic mercury, Parievt Reports ‘in 1969 employees of a mercury thermometer manufacturing company in Flarida developed symptoms of mercury intoxication, The nine patients most severely affected were examined, and they described the working conditions, In the preceding three years, production time was douted, the foreser practice of etching the seale 0m thermonieters was abandoned and decals were Baked 02 thermometers in an annealing oven. In cooling, the aven doors were cracked; there was offen a blue haze around the ovens and throughout the plant, There was inadequate ventilation; work lothes were not changed, and employers ate and smoked in contaminated areas, ‘1a 1968 and early 1969 rany employees involved with work particularly near the ovens developed increasingly severe tremulousness and sporadically complained of difficaly in breathing, bucking ‘et, irritability, amd memory loss such that young mothers would forget to retrieve children tiem Dubyesittrs on the way home from work. Diarrhea occurred, was offen explosive, and occasionally ‘was more marked on first going {0 work in the mornings or developed late in the work week. Finally, drooling, sore gums, and minute ulcerations of the eral mucosa were noted i. many employees. °Thhis work was supported in part by Public Health Service Grant STO! NS 5281-12 and Univer- sity of Florida Grant GRS-6I3.306 FRED Q. VROOM AND MELVIN GREER All patients were simlarly assened (Table . Laboratory stules comstted of bamopram, Iweoy-fourhour urite testing. urine mercury levels (deermiced by Bic Science Labs. Los Angeles, Califora), clecxoencephalograms, electromyogram and acaropsyeholosical ‘Fables, (1, 1¥, and Bg. 1}, The nevropsychologial tats adennirered were the Wechsler Adult Intelligence Scale (Wechsler, 1985), Wechaler Memory (Wecisler and Stone, 1985), Block Rotation Gaz, 1966), Drawings-omcommand (Keita, (864), Facial Recopntion (inet, 198), Bender Gertdht Geer, 1946), Minnesota Mubiphass Personality Inventory, Aphaisa Sesedning, Farm Board Tactile Performance, Halstead Motor Tapping Tes, Astereognostic Tactic and Fingsr Localization, and Agnosia Screening (Rel, 1960). aS Mace ere en toon Deizctne Secale tor tat hen Some oe lute Eee ee sng Hie ink nt ai Ama Scorned dass ® ae {td Geot tm pew soar hase ret hoo = aa! ‘ Pose tahcy = fegro AGA, Tae Yanae Temes ‘tne igs Epicteas 9 call hes imp oy LER go my ton ian a a i Case JID (13-10-58), 4 43yearold man, was employed by a thermomeier company for eight months. His job was to recoveeebercury from defective thermomeles, which be erushed i. manually operued machine, 10 clean out the apnarates whic housed defective thermometers and also to load and unload the annealing overs. "No speial protective respiratory oc skin contact devices were wid. He acknowledged that there was mercury on his Bands ros ofthe ay which be would wash off with soap ard water atthe day's end. He had a transient soce throat and a productive cough thee months before admission, for which he was ieated with 3 Motise as insidiously progressive tremor of his haads. Jk was fist thought fo be nervousness unt tas eventually ream unable 10 eat or deess. He became increasingly istabe. He felt unsteady wealking, almost fling, necesitating the use of a wheelchair. He also complained of insomnia ‘and Poot concentasion. Trassieat pains fa his neck and. arms ware aitributed to deasrerstve jolt disease “The patient was transferred. to the Univenity of Florida Teaching Hospital after a weat-fout- hour urine oniaed £6 mg of mercury (normal: less than 0-2 ma per ee From aloe laboratory).MERCURY VAPOUR INTOXICATION 307 ‘There-was a coarse tnemor of the arma at rest andion intention im addition io truncal tremuloussexs. ‘The specch was halting and staccato in quality. Mastic rigidity on passive movement of the neck and extremities was evident. The gait was millly wide-baced and turning was impaired, The teeth ‘were én a fair state of repair “The patient, @ high school praduate and apparently of norms fotelligense, had a verbal 1Q of 100 and a perfarmeance [0 of 96 on the Wechsler Ineligence Test, The Wethsler Memory score ‘was 7/5 (abaormal), Nioe af 12 feces were idenled correctly on the Faia! Recognition Test (normal, The Form Hoard Test was ended. after treive minutes; there were 7 errars with the referred right Kind aad 3 eraors with the left hand (shnocmal), Minoe ers were sade i tachi recognition (finer localizaiion ercors: right =G,Jefi= 1); astereagnostic errars:right—1, left =) ‘This was more marked inthe left hand, sugscsting a cerebral heriphere lesion mare marked on the right. ‘The tremor added to his poor performance: but, inadditon, aboormalities and occasional ‘omiskions in writing the alphabet and drawing-on-command were eoasisent witha mild perceptual language and memory defect, Anelectroencephaloyrarm was unteadable because of treear artiuct ‘amd other routine laboratory tests inciuding perimetry and sli-timp examination were oormal. [Urine heavy metal screening tert wat negative (Getter and Kaye, 1950). Mercury levels were reported as follows: serurs, 23 wp per cent; cerebeospinal flid, less than | wp per céac; urine, 247 wpitwenty-four hours (Hubbard, 1940), Cerebrospinal uid protein was 37 mg per ee. Hie bad 2 course of -dsity imuramuncular injections of British Au-Lowiste (BAL) 5 m/s pee say for tem days. After two weeks there vias an improvement in his emotional responses, tremor ‘and iii. Taree moths Isler be seluried ta work; he now worked exclusively with glass and Rad ao eontaet with mercury, Follow-up eximiantion eight months later revealed. only mild tremor of the ‘ouistriched right upper exiremiiy. An clectroencephalogrim wis normdl. Urine mercury was 108 ugltweaty-four havrs. The electrompogtam was consistent with denervation (Table IV), ‘Twenty months afier being in hospital the tremor was absent, and the patient said he was normal ‘but he sil had a memory defect. Subimciéon of serial sevens was perdotmed slowly. He could coal recall Eve numbers forward and four numbers backward. There was no changin the Wechsee ‘Memory or the Facial Recognition Test. The Form Board Test was now normal with 39 and 43 rinwies for the preferred right and left has cespectiely. ‘Cases 2 U9 9 are suumarized below and in Tables co LV. Cove 2—AUitiall)' Cerebeospinal fluid protein was 60 mg percent; cerum and vrine merciy levels were 23 ug and 245 ualtwenty-four hoars, Intramuscular BAL vas given, (Eight mons) An electroencephslegracn shewed diffuse thet aetivity and bitemporal sharp waves were peesea. ‘The electromyogram showed excessive polyphasia. and Jong duration high amplitude motar unit potentials, suagestive of denervation (Table TV). Urine mercury was 42 paitwenty-four hours (Twenty months) Verbal and performance 1s were 110 and 96 respectively, Facial recognition wos borderline with # of 12 faces correctly iletiied. The form board was completed slowly rearing 344 and §-5 micutes for the preferred right and left hands (abnormall. Rapid motor tapping was depressed bilaterally (35 sight hand and 25 left hand). ‘Tactile recognition tright 0, lefi=2) aod astereognosis (right 2, lefi=-3) were move abnormal on the left. Case $—{italy) Cerebrospinal uid protein was 22 mg per cent; urine and setum mercury was 249 vestventy-fovr hours and 2 yg per cent, Intramuscular BAL wat given, (To rons) “The Uemor was redused; the patient returned to work, assured the level of mercury vapour wis ‘normal. ne moath inet she developed mouth wlcerasions, increasing tremor and dlarrbsea and verminated her job. (Eight months) An electraencephatogram was abaormal with diffe atosysmal bursts of Uneee Le Ave iesegulas alow wave disaRBes and an clestrompageam. Was foasistent with denervation (Table IV}. Uriae mercury level was 33 ug/tweaty four hours, 4{ ) Indicates time after esporure to mercury is terminated,