On Snake-Poison: its Action and its Antidote Part 4

CASE 1.--Bhagwan Singh, aged 30, Hindu male, Sepoy, E. T. Force, was bitten by a viperine snake (_echis carinata_) at 4 p.m. 10th June, 1892, in the dorsum of left foot. He was removed to the hospital, tight ligature applied, and with the following symptoms:--Heaviness of both legs, staggered if allowed to walk, giddiness, sense of sinking at the pit of the stomach, bleeding from mucous surfaces and old scars; soon fell swooning.

Treatment.--The punctures incised, and blood let out, one-twelfth of a grain of strychniae; acetas hypodermically injected. Again, the insensibility not gone after 30 minutes, another dose given, and so repeated the third time. The _bleeding stopped_ and the man recovered his senses, but could not raise himself to talk. Many more doses were given under the skin, with hour intervals, and the man recovered the next day; but he was much exhausted and treated for weakness three days, and discharged to duty on the 14th.

Punctures were distinct, symptoms well developed. Took _one and a half grains_ of strychnine to effect cure, leaving no after effects of the drug or poison.

CASE 2.--Sadig Husain, a Mussulman boy, aged 12 years, bitten on the right ankle, just below the inner malleolus, by _echis carinata_ (Khapar) on the 5th August, 1891, brought in with usual symptoms, as before.

Treatment as before. This case took only one-fourth grain of strych. acet. The boy was weak and sickly. He was discharged cured on the third day, _i.e._, 17th August, 1891.

CASE 3.--Nathey Khan, Mussulman, customs peon, aged 35 years, robust and strong, bitten by _echis carinata_ (yellow variety).

Punctures were on the left ankle, over the outer malleolus.

Symptoms as before given.

Treatment as before stated. This case took as much as one and three quarter grains of strych. acet. Was admitted on the 9th August, 1891, and discharged on the 12th August, 1891, cured and fit for duty.

CASE 4.--Musamat Jewai, Hindu female, a labourer, age 40, strong built. Bitten by kerait (_Bungarus coeruleus_), about 2-1/2 feet long, above the left knee joint; ligature below the hip was used, but all the symptoms were present and the patient was insensible.

Cyanotic marks were seen on the arms, abdomen, back and neck. At first all hopes of recovery were given up, but attempts were made to see if anything could do good.

Treatment.--Punctures scarified and cupping applied. Repeated doses of strychnine acetas hypodermically given, but in _quarter grain_ doses. It seemed marvellous. The cyanotic patches in the skin gradually faded away and the body became warmer. It was wondered if the person had expired, but suddenly the woman called for a drink of cold water to bathe her dry and parching mouth.

This was done and she recovered sense. She was admitted on the 3rd September, 1891, and discharged on the 10th. Took _three grains_ of acetate of strychnine to effect a cure.

CASE 5.--Paroati Devi, Hindu female, aged 67 years, healthy const.i.tution. Bitten on big toe of left foot on 10th September, 1891, symptoms were as preceding. The wound was cauterised.

Treatment.--Strychnia was given very cautiously, as the patient was over-aged, the degeneration of the heart kept in view--1/10 grain eventually showed the peculiar strychnine symptoms. The patient was cured in two days and discharged cured on the third day, 14th September, 1891. This patient took in all _one and a half grains_ of acetate of strychnia.

CASE 6.--Maya Swuper, aged 38 years, bitten by echis carinata (without dots) on the lower third of the left leg, on the outside of it. Mucous membrane of the mouth, eyes, nostrils, ears, and urinary pa.s.sages all bled profusely. Urine had clots in it and symptoms resembled those in the first case.

Treated with strychnine and recovered in four days. Was admitted on the 14th September, 1891, and discharged to duty on the 18th September, 1891. Took in all _three grains_ to effect cure.

CASE 7.--Avghunandan, customs semadar, aged 55 years, Hindu male.

Bitten at 8 a.m. on the 29th March, 1892, by echis carinata (brown variety) on the right foot near the cuboid bone. The punctures were distinct and the symptoms like those of case 1. Bleeding was profuse in this case.

Treatment.--Strychnine acetas injected _in quarter grain_ doses under the skin and repeated as often as desirable. Patient recovered after the sixth day and took in _all four grains of strych. acet._ in six days. Only the bitten leg had erysipelatous inflammation, which had to be treated afterwards, but the man was quite safe.

Remarks.--In connection with echis bites one peculiar symptom was always noticed, namely, the free oozing of blood from mucous surfaces and old scars of wounds. The power of co-ordination was very much affected from the first setting in of other symptoms.

Usually after 24 hours symptoms showed a relapse. In the treatment with strychnia neither the symptoms of the drug nor of the snake-poison ever showed themselves afterwards. Both seemed to neutralise each other. Bungarus coeruleus, or kerait-bite, had its own peculiar symptoms of cyanotic patches and insensibility, swooning and stertorous breathing. The true comatose state was not present in any, but only a slight one noticed in cases 4 and 5.

The other cases were generally delirious in the beginning.

CASE 8.--Dr. Banerjee communicated this case to the _Australasian Medical Gazette_ separately and quite recently, November, 1892. It is, of all his cases, the most important one. He writes:--"The following case increases my number to eight, and should clear away prejudice and prepossessed ideas, as strychnine saved this case, a bite of _Duboia Russellii_. This snake is admitted by all hands to be virulently poisonous, and the poison is said to be even more virulent than that of the dreaded cobra:"--

_Rahimudden_, aged 43, Mussulman, customs peon, admitted for treatment of snakebite on the 13th September, 1892, at 10.45 p.m., to the North India Salt Revenue Hospital, Pachhadra, Rajputana, India, and put under my treatment.

_History of the Case._--The man is of strong build and healthy const.i.tution. While on duty he went round the salt pit, near his beat. Suddenly he felt a p.r.i.c.k on his foot, and, suspecting snakebite, struck out with a bamboo stick he carried in his hand, and heard the snake make a loud noise. He at once tore a piece of cloth from his turban, and tied it tightly above the right ankle joint round the leg, then tried to kill the snake, but could not do so with certainty, as it was dark. He reported the case to his superiors, and was carried to the hospital. Bitten at 9.30 p.m.; admitted at 10.45 p.m.

_Present Symptoms._--Patient was delirious, and could not understand what was told him; body cold and covered with perspiration; breathing hurried, with a low rattle at the end of expiration; mouth, tongue, and palate all dry; tongue leather-like and cracked, and felt cold; tickling of throat, not exciting vomiting; pupils dilated; conjunctiva congested; pulse 95; patient talked, or rather muttered, with difficulty; could not tolerate strong light or loud noise; the mucous membrane of the mouth showed irregular dark patches of ecchymosed blood.

The right foot was swollen, and in a line between ankle and knuckle of big toe showed two punctures--one deep and bleeding, and surrounded by ecchymosis; the other one below this, more superficial, the blood oozing thin and not coagulating. Received, at 10.45 p.m., 1/12th grain of strychnine in left arm. At 11 p.m., the same dose; breathing the same, but no rattle; stupor rather deepening; incoherency increasing. At 11.15, the same dose; breathing easier; stupor the same; pulse, 85; temp, 97.6; delirious at times, and moaning with inarticulate cries; could not hear when spoken to in loud voice. 11.30 p.m., the same dose; no change in condition. 11.45 p.m., the same dose; stupor now fading away; delirium present; intolerant to light and noise; peculiar grin and cramp in face-muscles when attempting to talk; temp, 95.8; pulse very hard; intense thirst; less bleeding from punctures and blood thicker. 12 p.m., the same dose; no stupor now, but cramps in lower extremities; no incoherency; only occasionally uneasy and senseless for a moment, and then rising suddenly like one startled when sound asleep. 12.30 a.m., no further symptoms; bleeding stopped; great thirst; eyes red and glaring; saccharine drinks given; no injection. 3 a.m., no sleep, but only slight slumber; no pain in foot; no bleeding; temperature, 98.8; thirst unabated; only drinks given.

_Sept. 14th, 10 a.m._--Better, but talking slightly incoherent; received another injection of 1/12th grain of strychnine. 6 p.m., better; had good appet.i.te; given milk and sago.

_Sept. 15th, 6 a.m._--Better. 6 p.m.--Better; had three motions, rice and milk diet given, slept soundly between 10 a.m. and 2 p.m., no redness in eyes, swelling of foot abated.

_Sept. 16th._--Better, only complaining of heaviness in head. At 9 p.m. had a fit of stupor all of a sudden, became insensible, and commenced to bleed again from the mucous membrane of mouth and nose. The patient became almost insensible, and could only be roused with difficulty. Twenty minims of liq. strychnine, equal to 1/6th grain, were now injected into the right arm.

_At 9.20_ stupor had pa.s.sed away and consciousness was fully restored. From this time onward convalescence was uninterrupted, and patient was discharged cured on the 20th Sept., 1892.

In his remarks on this case Dr. Banerjee, after reporting that the snake with back broken in two places was brought to him on the following day from the exact locality where Rahimudden had been bitten, gives the following description of it:--Head, large and triangular; nostrils, large and kidney-shaped; scales, much imbricate, ventral scales 169, subcaudals 48; confluent, irregular ring-like, dark brown spots along the back, and with lateral black patches or rings with white borders. The head marking very peculiar double V shaped mark, the angle directed between the nostrils; interst.i.tial coloration, yellowish brown, belly white, and with brown or amber spots; eyes, large, pupils erect, irides yellow; body, stout and compressed laterally; poison fangs, large and recurved, size about half an inch. The length of snake was 3 feet 5 inches, and from these characters it was identified to be the chain viper (_Duboia Russellii_, _Gray_), the most venomous of Indian vipers.

The total quant.i.ty of the antidote in this case administered was only 110 minims of a one in 120 solution of strychniae acetas, or 11/12ths of a grain of that drug. Considering the extremely venomous nature of the snake and the large quant.i.ties of strychnine required in some of the previously reported cases of echis and bungarus bites, the quant.i.ty used seems disproportional, but this evidently is explained by the fact that only one of the fangs perforated deeply, and at the back of the foot, probably struck the bone before entering to its full length, the snake thus failing to impart the full quant.i.ty of venom at its disposal.

The chief interest of Dr. Banerjee's cases centres in the fact that they are mostly viper-bites. They prove conclusively, as do Feoktistow's experiments on the lower animals, that the theory of viper-poison being a blood poison, as a.s.serted in all works on the subject, is not tenable and must be abandoned. If it effected changes in the blood, incompatible with life, strychnine, acting solely on the nerve-centres, could not possibly obliterate these changes within a few hours or even days. On the other hand the successful treatment of bungarus bite with strychnine places it beyond doubt that cobra-poison will also yield to it, if fearlessly and vigorously applied.

It is most gratifying to the writer to know from good authority that Sir Joseph Fayrer, the President of the Medical Board at the India office, has recommended to the English Government the adoption of the strychnine treatment of snakebite in India, and that this adoption will not be subject once more to the doubtful result of experiments on the lower animals, which, according to newspaper reports, were contemplated at Calcutta as a test. It would have been deplorable to see more precious time lost in these experiments, whilst the only proper subjects for experiments, the unfortunate natives, are peris.h.i.+ng by thousands. The step taken by Sir Joseph Fayrer does honour both to his head and his heart, and if his recommendation is accepted and vigorously carried out it will still further increase the debt of grat.i.tude which India owes to British rule, and with regard to its terrible snake plague, to the one Englishman who of all others has distinguished himself by an almost life long study of the subject and indefatigable labours for its alleviation.

Her Majesty the Queen has also been pleased most graciously to interest herself in this subject. Memorialised by the writer before Sir J.

Fayrer's recommendation to the British Government, above alluded to, was known to him, our gracious Sovereign, ever intent on the welfare of her subjects, has resolved on having the writer's method thoroughly tried in India, and communicated this her intention to him in a despatch from the Secretary of State for the Colonies to His Excellency the Governor of Victoria, dated 11th Nov., 1892, inviting him, at the same time, to forward any proposals he may have to make direct to the Secretary to the Government of India in the Home Department; and thus adding one more to the many n.o.ble deeds that mark her benevolent, long, and glorious reign.

UNSUCCESSFUL CASES.

Considering the newness of the strychnine treatment it would be folly to expect that the conditions necessary to insure success should have been observed in every case, and that every pract.i.tioner should at once have made himself familiar with it and the theory on which it is founded.

Hence a few failures were unavoidable. Of these a record has been kept, but for obvious reasons the writer withholds it here. To give names and dates would be invidious, though the opponents of the treatment have exultingly pointed to the few deaths that have occurred as palpable proofs of its uselessness, some of them even going so far as to ascribe these deaths to the direct action of the antidote. There is, however, not a single case on record, in which death took place under strychnine-convulsions. All the patients died under palpable symptoms of snakebite-poisoning. As these symptoms have now been proven beyond all doubt to yield to strychnine, when properly administered, the inference that it was not so administered in the cases referred to becomes not only justifiable, but unavoidable. In one case only, that of a child of tender years, blood was vomited so copiously that death may be ascribed to that cause and the snake-poison combined, but in all the other six fatal ones, mostly of children, it was undoubtedly due to the snake-poison not being properly checked by the antidote. The gentlemen who officiated on these occasions were evidently not Banerjees, but the very reverse of their Indian confrere. They do not appear to have had very clear ideas of the absolute antagonism existing between the two poisons, and entirely disregarded the most important point in the treatment, namely, the necessity of administering the antidote until it has completely subdued the snake poison, regardless of the quant.i.ty that may be required for that purpose. In a few instances the treatment was correct enough at first, but when, as is often the case, a relapse took place after the patient had apparently recovered, the large quant.i.ty of the antidote already administered appears to have given rise to the erroneous notion that it would be useless to resort to it a second time, and thus, through this error and the fear of strychnine-convulsions, the patients were allowed to die. In most of the six fatal cases collected by the writer, however, the doses and total quant.i.ties given were altogether inadequate to cope with the poison. They did probably more harm than good, for the snake-poison when only partially checked by strychnine seems to renew its onslaught on the nerve-cells even more insidiously than when not interfered with at all. Convulsions also, as shown in cases, are sometimes called forth by this timid use of the antidote.

A few instances will show the correctness of these observations. Thus an old woman sleeping in a shed is awakened at daylight by a tiger snake having fastened on to her wrist. She pulls off the snake, alarms the neighbours, and a doctor, living only a mile away from the place, is sent for. He appears on the scene four hours afterwards, when complete coma and collapse has set in, makes two injections of gr. 1/15 each, which of course had no effect and the patient is allowed to die without any further effort on the part of her medical attendant. Case 2.--A boy of 10 years is admitted to a N. S. Wales hospital in a state of complete collapse, barely alive, having been bitten by a brown snake 22 hours before admission. Instead of a rousing injection of at least 15 minims and the same or smaller ones repeated at short intervals, he receives only 5 minims of liq. strychniae P.B. every twenty minutes, when death was imminent, and dies 65 minutes after admission. Case 3 is also that of a boy in an hospital. He is admitted fully conscious and apparently but slightly under the influence of snake-poison, for a five minims injection is reported to have removed the symptoms. On the following day, however, he became comatose, and instead of having the antidote freely administered, gets only one more injection of five minims and dies in coma. Case 4 is even worse. A little girl of 3 years, bitten by a tiger snake, receives three minim injections every half-hour, and after three of them, whilst in a state of complete coma, gets convulsions. These are attributed to the strychnine, which thereupon is withheld, the finale being death in coma.

There can be no doubt that in all these cases life could have been preserved under a more energetic treatment. Hereafter, when theory and treatment are better understood, and when officialdom has seen fit to issue instructions as to the proper treatment of snakebite to medical pract.i.tioners, such cases as those cited will be put down as malpractice and have to be accounted for. Until then the guardians of the health and the lives of her Majesty's subjects, and a certain portion of the medical press of Australia, superciliously and persistently ignoring the subject, are more responsible for the lives lost than the busy country pract.i.tioner, who may not have had time or opportunity to inform himself thoroughly on a comparatively new subject, more especially at a period when Banerjee had not yet taught us that in administering strychnine as antidote to snake-poison we can venture into grains of it with impunity.

Since the above chapters were put in proof, the writer has seen a fatal case of tiger snake bite, conveying two lessons of such interest and importance that it must be placed on record here. It ill.u.s.trates in an extraordinary and forcible degree the erratic, capricious, and insidious course the snake-poison takes at times.

A handsome girl of 17 is bitten in a bathroom on the back of the second right toe at dusk on a Sunday evening by a half-grown tiger snake, subsequently caught and killed in the room. She does not suspect snakebite, and no ligature is applied until the poison has been absorbed and overpowers her. Instead of sinking into coma, she becomes unconscious for a short time only. Her brain then clears itself, and all symptoms seem to disappear so completely that when a medical man of undoubted ability and skill sees her a few hours after the bite, she declares herself quite well again, and does not appear to require any treatment, least of all that by strychnine injections. She pa.s.ses a good night, but on Monday morning symptoms denoting paresis of the respiratory and glosso-pharyngeal centres make their appearance, almost identical with those described by Indian writers as following cobra-bite. She has difficulty in breathing and swallowing, but one injection of 1/10th of a grain removes it completely and speedily, and once more all danger is thought to be past. On Monday evening, however, dyspnoea and dysphagia appear again in an aggravated form. The urine also becomes scanty and loaded with alb.u.minates. Strychnine now is again resorted to, but it fails to act as before, and from hour to hour the young lady's condition becomes more critical. When the writer reached her on Tuesday afternoon, 42 hours after the bite, paralysis of the centres named was imminent, and her case appeared a hopeless one, unless a vigorous use of strychnine yet turned the scales in her favour.

One-tenth grain doses were therefore injected every half-hour, and continued until the physiological action of the drug showed itself. This took place, but failed to have the least effect on the affected centres; and complete paralysis ensued 45 hours after the infliction of the fatal bite.

The first lesson the Australian pract.i.tioner should learn from this sad case is that of extreme care and caution in dealing with any case of snakebite, no matter how slight it may appear at first sight. It is not for the first time we have been taught this lesson, though it has rarely, if ever, been conveyed in so singular a manner. Recent utterances about the innocuousness of Australian snake-poison find a fitting answer in this melancholy occurrence.

The second lesson it conveys is a new one, even to the writer. From the fact of one strychnine injection removing all poison-symptoms early on Monday, but the free use of the antidote failing entirely to have this effect on Monday night and on Tuesday, we are warranted to draw the conclusion that the antidote can only be relied on within the first 24 hours after the bite; and that, after this period, the snake-poison produces organic changes in the affected nerve-cells, preventing their depressed functional activity from being restored by the antidote.

Further observations, of course, are required to confirm these conclusions. Their correctness, however, appears to be borne out by the fact observed by the writer, that the larger domestic animals, who sometimes linger on for days after being bitten by a snake, usually recover under the strychnine treatment if it is applied immediately or soon after a bite, but die when found and treated in an advanced stage of the malady.

That the grave kidney complication, checking the elimination of the poison from the system, militated against recovery in this case, and greatly influenced the singular course of the poisoning process, cannot be doubted.

[Ill.u.s.tration]