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Title: On Snake-Poison: its Action and its Antidote
Author: A. Mueller
Release Date: June 23, 2010 [EBook #32947]
Language: English
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[Illustration]
ON
SNAKE-POISON.
ITS ACTION
AND
ITS ANTIDOTE.
BY
A. MUELLER, M.D.
SYDNEY:
L. BRUCK, MEDICAL PUBLISHER,
13 CASTLEREAGH STREET.
1893.
SYDNEY:
WEBDALE, SHOOSMITH & CO., PRINTERS,
117 CLARENCE STREET.
1893.
PREFACE.
Since the method of treating snakebite-poisoning by hypodermic
injections of strychnine, discovered by the writer and published but a
few years ago, has already been adopted by the medical profession
throughout the Australian colonies, and practised even by laymen in
cases of urgency with much success, it has been repeatedly suggested to
him that the subject calls for further elucidation at his hands; that
the morbid processes engendered by the snake venom and the _modus
operandi_ of the antidote should be explained by him in a manner
satisfying the demands of science, and at the same time within the grasp
of the intelligent, moderately educated layman. When the latter, in a
case of pressing emergency and in the absence of medical aid, is called
upon to administer a potent drug in heroic doses, the aggregate of which
would be attended by serious consequences in the absence of the deadly
ophidian virus, an intelligent insight alone into the process he is
about to initiate will give him that decision and promptitude of action,
on the full exercise of which on his part it may depend whether, within
a few hours, a valuable and to him probably dear life will be saved or
lost.
The foregoing applies, not to Australia only, but to all other countries
infested by venomous snakes. The introduction of the writer's method in
every one of these countries is merely a question of time, for
snake-poison acts everywhere according to one uniform principle, however
different the symptoms it produces may appear to the superficial
observer. The antidote, therefore, that cures snakebite in Australia
will as surely cure it elsewhere if properly and efficiently applied.
To his Australian confrères, more especially to those who adopted his
method but had to practise it more or less empirically, the writer also
owes a more elaborate explanation of his theory of the action of
snake-poison in all its bearings on the various nerve centres than is to
be found in the scattered writings he has from time to time published in
our periodical literature. His warmest thanks are due to them for the
records of cases they have furnished to the _Australasian Medical
Gazette_, and to the Hon. J. M. Creed, its able editor, for the ample
space he has invariably allotted to the subject, and the valuable
support he has given him throughout. By our united efforts we have
reared in a dark and hitherto barren field of research a column of solid
knowledge, and on this column Australia now occupies the highest and
will ever occupy the most prominent place.
Not the least pleasing feature in the history of this discovery is the
fact that it has been made without an elaborate series of experiments on
animals, that it is a peaceful conquest not attained by means of
doubtful justification, and which have hitherto invariably failed in
their object. This object--the discovery of the coveted
antidote--instead of being brought nearer, was, in fact, further removed
by every succeeding series of experiments. However fruitful in results
this mode of research has been in other domains, in this particular one
it has not only been a failure but an actual bar to progress. Nature
invariably refused to yield her secret when thus interrogated. The
tortured animals, like the victims of Torquemada, either did not answer
at all or they answered with a lie, and the baffled experimenter
abandoned his task in despair.
Still, these negative results notwithstanding, the writer is confronted
by a certain class of would-be rigorous scientists, who tell him that
his theory of the action of snake-poison, though it explains all the
phenomena, cannot be accepted as correct until it has been proven so by
strict test experiments on animals, and that the successful
administration of the antidote is proof only of the fact of neither
antidote nor snake-poison having killed the patients, who, probably,
might have recovered if left to themselves. This may be strict logic,
but common sense replies to it that if recovery takes place after proper
administration of the antidote in cases which, according to all our
previous experience, would have ended fatally, it is not illogical to
assume that antidote and recovery stand in the relation of cause and
effect. This sceptical attitude of the scientific mind can justly be
maintained only with regard to cases limited in number and in which the
symptoms left room for doubt as to their final result, but in view of
the formidable and constantly increasing records of cures from snakebite
during the last three years, it is, to say the least of it,
unreasonable.
The demand for experiments on animals, in proof of the correctness of
his theory, the writer does not feel called upon to satisfy, for, apart
from the theory proving itself by explaining all the symptoms the
snake-poison produces, it has also stood the test of practical
application. It is proven to be correct by the success of the antidote
to which it led, and which is the logical outcome of it. After finally
attaining a goal one has striven for, it is quite unnecessary to retrace
one's steps with a view of ascertaining whether the road that has led up
to it is the right and proper one.
By a fortuitous concurrence of circumstances, however, even this demand
for experiments shall be satisfied in these pages. The writer published
his theory of the action of snake-poison in May, 1888, after having
practised the strychnine treatment for some years and thoroughly
satisfied himself of its efficacy. In the latter part of 1888 accounts
of Feoktistow's researches reached this country. His final conclusions
to the effect that snake-poison is solely a nerve poison, that it does
not destroy protoplasm, and has no effect whatever on the blood to which
its destructive potency on animal life can be ascribed, were in
complete harmony with the writer's views, in fact, a re-statement of his
theory. It was a strange coincidence, or whatever it may be called,
that, independent of each other, at almost opposite parts of the globe,
and by opposite methods, we had arrived at almost identical conclusions.
Those of Feoktistow were drawn from 400 elaborate experiments on
animals, both vertebrates and invertebrates, made in the laboratory of
Professor Kobert at the University of Dorpat and in that of Professor
Owsjannikow at the Imperial Academy of Sciences of St. Petersburg. The
writer's conclusions, on the other hand, resulted entirely from a
careful and happy analysis of the symptoms observed at the bedside of
his patients suffering from snakebite. On one point only, but the most
important one, he differs from Feoktistow. The latter shared the fate of
all previous experimenters on animals. Though his experiments with
snake-poison led him to the correct theory of its action, and even to
the correct antidote, his experiments with strychnine and snake-poison
were a failure. The animals experimented on died, and, falling into the
error of his predecessors, mistaking the functional analogy that exists
between the nerve centres of the lower animals and those of man for
absolute identity, which does not exist, especially not when they are
under the influence of the two poisons, he concluded his researches with
the confession that a physiological antidote for snake-poison cannot
even be thought of at the present state of science. Although,
therefore, Feoktistow's labors would have led to no practical result,
they are, nevertheless, a most valuable contribution to science as being
the first to demonstrate the action of snake-poison on a strictly
scientific, experimental basis. For this reason, and with so high an
authority as Professor Kobert vouching for the correctness of the
experiments, they will be frequently quoted hereafter.
[Illustration]
HISTORICAL REVIEW.
Snakebite and its cure have always been the despair of medical science.
On no other subject has our knowledge remained for centuries so
unsatisfactory, fragmentary and empirical. The history of the subject,
in fact, may be summed up briefly as a series of vain and spasmodic
attempts to solve the problem of snakebite-poisoning and wring from
nature the coveted antidote.
Various and contradictory theories of the action of snake-poison have
been propounded, some absolutely erroneous, others containing a modicum
of truth mixed with a large proportion of error, but none but one
fulfilling the indispensable condition of accounting for all the
phenomena observable during the poisoning process and of reducing the
formidable array of conflicting symptoms to order by finding the law
that governs them all. We have the advocates of the blood-poison theory
ascribing the palpable nerve-symptoms to imaginary blood changes
produced by the subtle poison, and alleged to have been discovered by
the willing, but frequently deceiving microscope. Even bacteriology has
been laid under service and innocent leucocytes have been converted
under the microscope into deadly germs, introduced by the reptile,
multiplying with marvellous rapidity in the blood of its victims,
appropriating to themselves all the available oxygen and producing
carbonic acid, as the saccharomyces does in alcoholic fermentation.
Others again, and among them those supposed to be the highest
authorities on the subject now living, divide the honors between nerve
and blood. Some snakes they allege are nerve-poisoners others as surely
poison the blood, but with one solitary exception they assume the
terminations of the motor-nerves and not the centres to be affected.
Thus then with regard to theories we have hitherto had "confusion worse
confounded," and as with theories so it has been with antidotes. They
were proposed in numbers, but only to be given up again, some intended
to decompose and destroy the subtle poison in the system, others to
counteract its action on the system with that action unknown. It is
scarcely too much to assert that there are but few chemicals and drugs
in the materia medica that have not been tried as antidotes in
experiments on animals and dozens upon dozens that have been tried in
vain on man.
The reasons for this somewhat chaotic state of our science on a subject
of so much interest to mankind are various. The countries of Europe, in
which scientific research is most keenly pursued, have but few
indigenous, and these comparatively harmless snakes. The best scientific
talent has, therefore, only exceptionally been brought to bear on the
subject. In those countries on the other hand in which venomous snakes
abound and opportunities for observing the poison-symptoms on man are
more plentiful, the observing element has been comparatively deficient.
A still more potent source of failure must be sought in the faulty
methods of research pursued by most investigators. Experiments on
animals were far too much resorted to, and their frequently misleading
results accepted as final, whilst observations on man did not receive
the attention their importance demanded.
In the investigation of this subject the first desideratum was no doubt
to find the correct theory of the action of snake poison and to define
the law governing that action, assuming as a working hypothesis that
there is but one law for all snake-poison and not several ones, just as
there is one law for the structure of these reptiles, admitting of
variations, but not of absolute divergence from the general plan. The
shortest and surest way to find this law is close observation and
careful analysis of the symptoms produced by the poison on man, and as
the opportunities for such observation are not of frequent occurrence to
the individual, co-operation and careful comparison of notes on the part
of many observers.
This method of investigation, which, during the last few years, has been
pursued in Australia with most satisfactory results, was never practised
anywhere else, not even in America, but instead of it each observer,
with few exceptions, kept his own notes to himself, and if there
happened to be one here and there hungry for more knowledge than his
scanty opportunities for observation on man would supply, his resort
was usually experiments on animals. A few snakes were caught, a few
luckless dogs or other animals procured, and the slaughter of the
innocents began.
As test experiments to confirm observations on man, or made with a view
of finding a correct theory of the action of snake-poison, these
attempts were unobjectionable, although, without an elaborate scientific
apparatus and in other than skilled hands, they were not likely to
produce results of any value. But most of the experimenters were not
content with purely theoretical aims. They were seeking to find the
antidote by a purely empirical method, and had nothing to guide them in
the choice of drugs. A dose of snake-poison was administered to an
animal, and then a dose of some drug or chemical, chosen _ad libitum_,
sent after it. Next day another presumed antidote was tried, another
animal slaughtered, and so on _ad nauseam_, until finally the baffled
antidote-searcher, not one whit the wiser for all his trouble and the
useless tortures inflicted, confessed himself beaten and joined in the
"_non possums_" of his predecessors.
One important point has been completely left out of sight and ignored in
all this experimenting on animals. It is the fact that the action of
snake-poison on the human system and on that of animals, more especially
dogs, though very similar, is not absolutely identical, and that for
this reason alone results of experiments on the latter cannot be
indiscriminately applied to man. As pointed out before, analogy has
been confounded with identity. When a dog, for instance, has been bitten
by a snake he does not usually collapse as quickly as a human being, but
is able to drag himself about much longer before his hind legs refuse
their service and he is unable to walk. This longer duration of the
first stage of the poisoning process is no doubt owing to a higher
organisation and greater functional power of the motor nerve centres of
dogs. The amount of motor force at their disposal is greater, and hence
they offer greater resistance to the invader seeking to turn off this
force. When finally the latter gains the ascendency, irregular
discharges of motor nerve force still take place and find their
expression in convulsions, which in man only exceptionally occur. But
the difference between man and dog becomes more marked yet when
strychnine is administered to a dog suffering from snake-poison. It
counteracts the latter quite as effectually in a dog as in man, but has
to be injected with extreme caution, for whilst in man a slight excess
in the quantity required to subdue the snake-virus is not only harmless,
but actually necessary, any excess of it in a dog will at once produce
violent tetanic convulsions and cause the animal to die even quicker
than the snake-poison would have killed it, if allowed to run its
course. In the face of these facts the judiciousness of the proposal
lately made both here and in India to subject the strychnine treatment
of snakebite once more to a series of test experiments on animals
appears more than questionable.
Another cause that has largely contributed to render experiments on
animals so barren of results must be sought in the injudicious selection
of substances intended to serve as antidotes. It is simply impossible to
act on an organic compound like snake-poison, coursing through a living
system, by chemicals that will either combine with it or decompose it in
a manner likely to deprive it of its deadly qualities and render it
innocuous. Yet what do we find? Acids and alkalis, arsenic, bromides and
iodides, chlorine, mercurial preparations, &c., &c., have been poured
into the luckless animals as if they were so many test tubes. A chemical
antidote, a substance possessing special affinity to snake-poison and by
means of this affinity combining with it in some mysterious and
incomprehensible manner, one can hardy imagine to exist. Physiological
antidotes, on the other hand, substances acting on the system in a
manner the exact reverse of, and in direct antagonism to the
snake-poison, though apparently the only feasible ones, have been
strangely neglected and almost despised by experimenters.
In the vast storehouse of Nature the department most likely to furnish
such antidotes is the vegetable kingdom. The untutored human mind has
for centuries past intuitively clung to this idea, and sought among
plants for remedies against the deadly ophidian poison. Hence the great
number of vegetable antidotes that have from time to time been
recommended and the efficacy of some of which at least has been
confirmed by reliable observations. But the hint thus given to science
was not taken. Instead of research being pushed on diligently in the
only direction that promised any chance of success, it was cut short by
the baneful method of experimenting on animals. When it had been
demonstrated that a dog, a cat, or other animal, after having been
saturated with snake-poison, did not recover after the administration of
an alleged antidote, the illogical conclusion was drawn at once that it
could not possibly be of any use to man, whilst, in reality, the only
proof rendered by the experiment, if made properly, was that the
respective antidote could not be relied on in treating animals of the
class experimented on. That some of these despised antidotes are worth a
little further investigation may, in the light of present experience as
to the value of strychnine in snakebite, be inferred from the fact, that
among them is the wood of _Strychnos Colubrina_, and also the well-known
_Huang Noo_, a vegetable extract made from another variety of the
Strychnos family, and largely used by the Chinese, whilst, according to
a letter in the _Australasian Medical Gazette_, July, 1892, the
principal ingredient of a strange compound used by the native snake
doctors of Central America with much success is _Nux Vomica_.
It is superfluous to enter into a criticism of the treatment of
snakebite until recently in vogue, for, with the exception of the local
one by ligature and excision, it stands self-condemned by its complete
inefficiency. It may be summed up as a vain attempt to stem the
collapse invariably attending snakebite by the administration of
stimulants, such as alcohol, ether, ammonia, &c. The attempt is vain,
for a person in collapse from snakebite cannot be stimulated by any of
these remedies, since neither the heart nor the nerve centres respond to
them in the slightest degree, as they do in the absence of snake-poison,
the only one that has any effect at all in slight cases being ammonia.
But the attempt is not only in vain, it is highly injurious, especially
if made with the usual large doses of alcohol, for, in addition to the
latter not having the slightest influence on the snake-poison and its
baneful effects, they act as an anæsthetic and thus add to the existing
depression, besides increasing the tendency to internal hæmorrhage.
It might, under these circumstances, have been expected that any new
method of treating snakebite, based on scientific grounds and holding
out a sure prospect of success, would be hailed with pleasure, and that
conservatism, opposing the new simply on account of its newness, would
refrain from its usual tactics in a case where there was really nothing
to conserve. But this was not to be, and strange, indeed, it would have
been if the writer had escaped the opposition which is almost invariably
offered to the discoverer. It appears to be one of the laws of human
evolution, wisely designed to prevent precipitate advance, that every
new discovery must run the gauntlet of men whose mission it is to act as
brakes on the wheels of progress. Of the opposition which has been
offered to the strychnine treatment it would, therefore, be folly to
complain, but just cause of complaint is furnished by the unscientific
attitude which was assumed from the very first and has been maintained
throughout by its opponents.
Not a single attempt has been made to disprove the correctness of the
theory on which it is founded, yet to leave this theory unquestioned but
object to the conclusion to which it leads, must strike even the lay
mind as a most illogical proceeding. It is self-evident that, when
strychnine is administered as an antidote to snake-poison, the quantity
of it injected must be in proportion to that of snake-venom present in
the system, and that the doses in which we dispense it in ordinary
practice must be entirely left out of sight. Still, in the face of these
obvious conclusions, we have had veterans, grave and grey, arguing
pompously that the heroic doses advocated by the writer could not be
countenanced, and that even medical men could not be entrusted with the
serious task of administering them. Even as late as the last medical
congress at Sydney this absurd objection to large doses of the antidote
was again brought forward. After quantities averaging from half a grain
to a grain have been injected many times in Australia with continuous
success, after Banerjee has even gone as high as three and four grains
in India without a single failure, and without in one single instance
serious strychnine symptoms being evoked, the writer of the paper on
"Snakebite and its Cure" based his principal objection to the treatment
on the alleged ground of there not being sufficient evidence before us
to justify heroic doses and show them to be safe in practice. When
people wilfully shut their eyes against the most conclusive evidence, it
is improbable that any amount of it would satisfy them. Apart, however,
from the fully proven antagonism between the two poisons rendering the
large doses of the antidote, which in all serious cases are
indispensable, perfectly safe, the fear of strychnine is, in itself, a
very strange aberration of judgment on the part of my opponents,
considering how easy it is to counteract any noteworthy excess in its
action, if, perchance, it should occur through unnecessary overdosing,
by appropriate remedies.
All other objections to the treatment require but to be glanced at to
show their absurdity. Certain crude experiments on dogs made many years
ago in India, and put forward as irrefutable at first, have been
abandoned of late, and my learned opponents have now taken up a position
in their stronghold of statistics, supposed to be impregnable, but in
reality only the last refuge of the destitute, a position from which, by
dexterous handling of alleged facts, anything and everything can be
proven, in short, to use a strong expression, not my own, a convenient
and respectable form of lying. By means of these statistics they try to
prove, in the first place, that Australian snake-poison is not at all
the insidious death-dealing agent it is supposed to be, since, according
to statistics, only 126 persons died from it in three colonies within
the last ten years. Further study of these statistics leads them to the
inference that a strong healthy adult will recover from snakebite
_without any treatment_, and thus they finally arrive at the conclusion
aimed at, that persons cured by strychnine injections would probably
have recovered without them. These are the inferences drawn by men, who,
practising in towns, have probably never seen a case of snakebite. How
do they tally with the facts of the case? It is true that the mortality
among those bitten by snakes is small here as compared with India,
though the poison of our snakes, quantity for quantity, has been proven
to be quite as deadly as that of the Indian ones. Our greater immunity
is due to our snakes giving off less poison at a bite, and with their
short and (excepting those of the death adder) merely grooved poison
fangs injecting it very superficially, thus making the process of
elimination of the poison by ligature and incision or excision of the
punctures much more easy and successful. It is to this treatment, which,
as a rule; is immediately adopted in the bush, that our small mortality
is due. Our children are taught it in school, and the most illiterate
bushman knows how to carry it out. Where it is omitted by persons not
knowing that they are bitten until the poison has been absorbed recovery
is as rare as it is with the ox and the horse left to themselves without
any treatment. But it requires a prodigious stretch of the logical
faculty to understand what our small mortality from snakebite has to do
with the intrinsic merits of the strychnine treatment. Even if nobody
died at all its effects in doing away with the misery and suffering,
which, before its introduction, invariably followed snakebite, and often
was never got rid of completely, would still be sufficiently beneficial
to render the senseless opposition to it on the part of a small section
of medical men little short of criminal; for these effects are a matter
of constant observation, and cannot, like the rescues from death, be
called into question.
The statistics brought forward to prove that the treatment has not
reduced the death-rate are also most faulty. Until it is thoroughly
understood and in every instance properly applied it is manifestly
foolish as well as unfair to lay non-success and failures at its door.
When a medical man is called upon to treat a serious case, and instead
of boldly addressing himself to the task of combating the symptoms by
injecting the antidote irrespective of the quantity he may require until
it has conquered the snake-poison, becomes nervous and ceases to inject,
when, after what in ordinary practice would be a dangerous dose, he sees
but little effect, or if from the first he injects small doses at long
intervals, the cause of failure surely lies with him and not with the
antidote, which rarely fails where it is properly applied. The duty of
disseminating a sound knowledge of the principles of the strychnine
treatment unquestionably devolves on our health authorities, who ought,
by this time, to have taken some notice of it. But officialdom remains
obtuse and issues circulars on the treatment of snakebite,
recommending, _inter alia_, the free use of alcohol.
The literature on the subject of snake-poison is very voluminous, but
those who seek for enlightenment in it will be as disappointed as the
writer was after wading through it. The toilers in this barren field of
research were numerous, but with few exceptions, they toiled in vain.
FONTANA may be looked upon as the founder of that hideous
experimentalism by which, in his hands alone, four thousand animals were
tortured to death without a single tangible result except that in his
great work, "Reserche Fisiche sopra il Veneno della Vipera," which he
wrote at the conclusion of his cruel labours, he left us a grotesque
monument of patient, but ill-guided research. Other Italians, following
his method, Redi, Mangili, Metaxa, &c., were equally unsuccessful in
shedding one ray of light on the vexed and obscure problem.
Among the Germans who contributed to the subject may be mentioned:--
WAGNER.--"Erfahrungen über den Biss der gemeinen Otter."
PRINZ MAXIMILIAN VON WIEDD.--"Beiträge zur Geschichte
Brasiliens."
LENZ.--"Schlangenkunde."
HEINZEL.--"Ueber Pelias Berus und Vipera Ammodytes."
Among the French:--
SOUBEIRAN.--"Rapport sur les Vipéres de France."
BULLET.--"Etude sur la Mosure de Vipére."
British and American Workers are the most numerous. Commencing with the
century we have:--
RUSSELL.--"An Account of Indian Serpents, collected on the
Coast of Coromandel." Later on,
S. WEIR MITCHELL.--"Researches upon the Venom of the
Rattlesnake."
HALFORD--"On Australian Snakes, and the Intravenous Injection
of Ammonia, in _British Medical Journal_, _Medical Times_, and
_Australian Medical Journal_."
JONES.--"On Trigonocephalus Contortrix."
NICHOLSON.--"On Indian Snakes."
SIR JOSEPH FAYRER.--"The Tanatophidia of India." Also,
"Researches in conjunction with Richards, Brunton and Eward."
WALL.--"On the Difference in the Physiological Effects produced
by the Poison of Indian Venomous Snakes." Proc. Royal Soc., 1881, vol.
xxxii., p. 333.
Among those enumerated above Wall is the only one who formulated a
correct and thoroughly scientific theory of the action of snake-poison,
which has since been confirmed by Australian research and by
Feoktistow's elaborate experiments. It is strange that, after finding
the theory that explained all the phenomena, he did not follow it up by
applying the antidote to which his theory should have led him.
SNAKE-POISON AND ITS ACTION.
The poison gland of snakes is the analogue of the parotid gland of
mammals, both in position and structure. Its acini or alveoli are lined
with a layer of secretory, columnar, finely granular cells and arranged
with great regularity along the excretory duct, which is straight and
cylindrical and opens with vipers into the hollow poison fang, with our
colubrines into the groove on the anterior surface of it. Snake-poison,
as it leaves this gland, is a thin, albuminoid, yellow liquid of neutral
reaction. On exposure to the air it becomes viscid and slightly acid. Of
its chemical composition we know as yet but little, and it is very
questionable whether the most perfect chemical analysis of its
constituents would ever have given us a clue to its action or will
enrich our present knowledge of it. Like all albuminoid secreta it
becomes putrid after prolonged exposure and then, through ammonia
production, loses its acid, and assumes an alkaline reaction, still,
however, though in a modified degree, retaining its toxic properties,
which are completely lost only after an exposure of many months.
Feoktistow found that freezing at 1° R. caused the poison to separate
into a solid mass and a thin, very yellow liquid, which, even at a
temperature of 4° R., remained liquid, and the poisonous properties of
which greatly exceeded those of the solid mass. Boiling diminishes and,
continued for any length of time, completely destroys the potency of the
poison.
The microscope has done good service in the investigation of
snake-poison. It has, in the first place, informed us with absolute
certainty that there are no micro-organisms or germs of any kind in the
fresh poison immediately after it leaves the gland. But a still more
important revelation we owe to it is the fact that these organisms, when
we introduce them into a 2% solution of the poison, do not die, but
live, multiply, and enjoy their existence most lustily, as they do in
any other non-poisonous albuminoid liquid, whilst animals of a higher
type--say a snail or a frog--soon perish in it. In watching the
movements of the latter we find that they get slower and slower, and
finally cease. We now follow up the interesting research, and take two
frogs. Under the skin of one of them we inject a few drops of the poison
solution, the other one for comparison we leave intact, and place both
into a glass globe partly filled with water. In a very short time we
have no difficulty to identify the poisoned frog. Its hind legs begin to
drop and their movements become sluggish. This difficulty increases from
minute to minute, until at last all motion ceases, and the legs hang
down completely paralysed. At the same time we observe that the animal
shows increasing difficulty of breathing, that, even when taken out of
the water, and placed on the table before us it gasps for breath and is
unable to move. At last respiration ceases altogether and the frog dies.
Two problems now present themselves for solution. In the first place we
have to account for the fact of the snake-poison leaving the lower forms
of animal life intact and being fatal to the higher ones. The symptoms
we have observed in the frog point unmistakably to an affection of the
nervous system as their cause. Now we know that the lower forms which
the poison does not affect have no such system, and we are justified to
infer that to the absence of this system they owe their immunity. This
inference leads us on to a second one equally justifiable, namely, that
there is a certain unaccountable attraction between the delicate nerve
tissue and the subtle ophidian poison, which renders the latter a
specific nerve poison.
Our second problem is to ascertain the nature of the change in the
nerves, to find out, if possible, whether it is merely functional or an
actual interference with the structure of either cells or fibres. With
this end in view we once more consult the microscope. We make two
preparations, one of nerve fibres and of nerve cells of the poisoned
frog, and, under the microscope, compare them carefully with an
analogous one from the killed healthy frog. The result is purely
negative as regards structural change. Both present identical and
perfectly normal pictures of apparently healthy cells and fibres. There
being no visible structural change we are driven to the conclusion that
only a functional one has been effected by the poison, and with the
symptoms observed all pointing in that direction, that it is of central
origin.
The writer's theory as to the action of snake-poison, formed, in the
first instance from observations made at the bedside of his patients
only, is thus confirmed by experiments specially instituted by him for
that purpose. Further proof of its correctness we have in the brilliant
results of the strychnine treatment of snakebite in Australia, which is
the outcome and practical application of this theory. In those desperate
cases more especially, reported from all parts of the colonies, in which
death was imminent, and pulse at wrists as well as respiration had
already ceased, the strychnine injections could not possibly have
effected complete recovery within a few hours if the structure of the
nerve centres had been impaired or blood changes brought about
incompatible with life.
Feoktistow's experiments, made with viper poison, fully bear out the
correctness of the writer's theory, besides proving that there is no
essential difference between the action of the viperine and colubrine
poisons. He proved conclusively that snake-poison does not destroy
protoplasm or interfere with infusorial life, that injected into the
heart of a mollusc it causes an almost immediate cessation of its
action, that hypodermic injections of it in fish produce contraction of
the pigment cells and bleaching of the integuments, followed by
asphyxial respiration, general paralysis and death. Similar results were
observed on frogs. In mammals the symptoms were: dyspnoea, asphyxia,
paresis and paralysis of the lower extremities with succeeding general
paralysis, sometimes tonic and clonic convulsions, hæmorrhages from
bowels, lungs, nose and bladder, and finally complete paralysis of
respiration and of heart.
Action of Snake-Poison on Special Nerve Centres.
It must be borne in mind that the symptoms as about to be detailed are
successive only to some extent in the order presented. They commence
generally at the lower part of the spinal cord, but immediately
afterwards, if not simultaneously, are ushered in with great rapidity
from other centres, masking each other and rendering it extremely
difficult to observe and analyse them separately. They are also very
variable through the poison concentrating its action on special centres,
leaving others comparatively intact, and this not only when from
different varieties of snakes, but also from snakes of the same variety.
Another element increasing the difficulties of correct analysis are the
depressing effects of fear, inseparable in all but the strongest minds
from the consciousness of having been bitten, and so similar in
appearance to those of snake-poison, that sometimes it is by no means
easy to decide which of the two is in operation, and that only those
cases are of real value to the observer from which this element of fear
is completely excluded.
A.--Action on the Anterior Cornua of the Spinal Cord.
The anterior cornua are almost invariably the first of the motor-centres
attacked by the snake-poison, the affection (commencing with paresis and
in serious cases generally culminating in paralysis) beginning in the
lumbar ganglia and taking an upward course. The lower extremities feel
unnaturally heavy and a paretic condition of the muscles supervenes
_simultaneously on both sides_. The walk becomes unsteady and
staggering, very similar to that of persons under the influence of large
doses of alcohol. By a powerful effort of the will, however, persons in
this condition are often able to walk and even run for some distance,
especially if by prompt ligature the absorption of the poison has been
checked. As the affection proceeds, though still able to move the legs
in a sitting posture, they are unable to rise again. Ere long even
sitting up becomes impossible and they collapse helplessly. At this
stage sensation is still intact, and reflex action, by pricking the
skin, &c., still takes place. The upper extremities generally retain the
power of voluntary motion, even after the muscles of the neck have
become paretic and the head is held up with difficulty or sinks to one
side.
With birds, according to Feoktistow, the reverse is the case. The wings
are usually first attacked, or paresis comes on in wings and legs at the
same time.
B.--Action on the Medulla Oblongata.
a.--The Vaso-Motor Centre.
Whilst the voluntary muscles are thus brought under the influence of the
poison, symptoms denoting the invasion of the oblongata are rapidly
developing. The first of these is the deadly pallor and ashy hue of the
cold skin, evidently due to the blood receding from the surface, a
condition not unlike that obtaining in extreme anæmia. As persons in
this state complain of an agonising feeling about the heart and of
deadly faintness, a paretic condition of the heart suggests itself as
the most obvious cause, more especially when taken in conjunction with
the small, frequent, and compressible pulse. But though the heart muscle
is no doubt participating in the general paresis, the condition of the
surface of the body is in reality one of anæmia. The blood, even at this
early stage, begins to accumulate in the large veins of the abdomen,
which expand gradually in consequence of the diminishing motor force
supplied by the splanchnicus, keeping them in the normal state of
contraction when intact and having its centre in the medulla oblongata.
When this large vaso-motor nerve is cut in animals anywhere in its
course, the veins of the abdomen become distended enormously. The animal
is, so to say, bled into its own belly.
By a series of most interesting experiments Feoktistow has shown
conclusively that snake-poison has the same effect on the abdominal
circulation as section of the splanchnicus. Even slight intravenous
injections of the poison produced quickly a high degree of paresis of
the nerve and a corresponding engorgement of the veins of the abdomen,
whilst after lethal doses, the paresis culminated in a few minutes in
complete paralysis, followed by rapid collapse, excessive weakness of
the bloodless heart, and death from paralysis of the latter and anæmia
of the nerve-centres. One experiment deserves special record, as it also
shows the untenability of the blood-poison theory.
The whole vascular system of an animal poisoned by intravenous injection
was thoroughly washed out with the warm defibrinised blood of four
animals of the same species, the blood being infused into an external
jugular vein and allowed to flow out of a crural artery. Although blood
exceeding its normal quantity was left in the animal, when the vessels
named were closed, the nerve affection remained unchanged. The blood
pressure raised during the infusion sank at once again to zero, when it
ceased, and the paralysed veins of the abdomen became engorged once
more with the whole, or nearly the whole, of the blood-mass, leaving the
rest of the body anæmic as before. This interesting experiment also
shows how strong a hold the snake-poison has on the nerve-cells when
they are thoroughly under its influence, and how independent this
paralysing action is of the blood, persisting, as it was in this case,
after all the poison had been washed out of the animal.
The heart in vaso-motor paresis and paralysis is weakened in the first
instance by the direct action of the poison on the medulla oblongata and
the intracardiac ganglia. Its pulsations, at first retarded in
frequency, become accelerated soon after the introduction of the poison,
the pulse rate increasing rapidly and the waves becoming smaller and
more easily compressible in proportion to the frequency of the pulse,
which generally counts from 100 to 120 and more per minute at a
comparatively early stage of the poisoning process. But an equally
potent cause of heart failure is its depletion by the simultaneous
stagnation of the blood mass in the veins of the abdomen. Finally, to
complete the mischief, we have not only anæmia of the semi-paralytic
oblongata, but the scanty blood supply this important centre receives
becomes also surcharged with carbonic acid. Oxyhæmaglobin disappears
almost entirely from the blood under the circumstances detailed, as both
pulmonary and internal respiration are greatly interfered with, the
blood tending more and more towards that thin dark condition which it
presents after death, and which has been taken as _prima facie_ evidence
of the direct blood-poisoning action of snake virus by one and all of
previous investigators.
That under the powerful combination of causes, each of which is in
itself sufficient to endanger life, and greatly intensified as paresis
gradually deepens into paralysis, the heart, even of large animals,
succumbs in a comparatively short time, may be readily understood.
The _blood-pressure_, under the circumstances just detailed, must
necessarily be _nil_. Observations by means of the sphygmograph at the
bedside of a person suffering from snake-poison are scarcely feasible,
except, perhaps, in a hospital, and thus far are not on record. We must,
therefore, once more fall back on Feoktistow's experiments, which show
that even the smallest doses (0.02 to 0.04 mllgr.) of the dried poison
_per kilo_ injected into the vein of a cat caused a fall in the
blood-pressure almost immediately, without influencing either pulse or
respiration, but that two to four mgr. were sufficient to reduce the
blood-pressure to zero and bring on collapse, infusions of blood only
raising it temporarily. Of drugs raising the blood-pressure he found
ammonia the most effective, but only after slight doses of the poison;
after lethal ones it had no effect whatever on the blood pressure but
greatly increased the hæmorrhagic process in all internal organs. This
important observation should be kept in mind by those who inject
ammonia in serious snakebite cases, and it probably applies likewise to
_the excessive use of alcohol_.
This leads the writer on to the discussion of this singular hæmorrhagic
process principally characteristic of viperine poisoning, and only very
exceptionally produced by the poison of colubrines. It is among the
symptoms of snakebite poisoning one of the most interesting ones, but
also one most difficult of explanation. There can be no doubt that it is
produced by vaso-motor paresis and paralysis. We further know that it is
preceded by dilatation of the capillaries and small veins, and that it
is effected principally through the process known as diapedesis, or the
passage of both red and white corpuscles with plasma through the
unruptured capillary membrane, and even the thin one of small veins,
which is nearly of the same structure, being composed of endothelial
cells united by cement. This membrane possesses a certain degree of
porosity, which is probably increased by dilatation. In the absence of
plain muscular fibres contraction and dilatation of the capillaries can
only be effected by a corresponding contraction and expansion of the
nuclei of the endothelial cells. As fibrils derived from non-medullated
nerves terminate in small end-butts in connection with the capillary
membrane, we may assume that the nuclei of the endothelial cells are
under the sway of vaso-motor nerve currents, that weak ones will expand,
strong ones contract them. We may further assume that the red and white
corpuscles force their way out of the vessels through pores in the
cement substance, since a passage of cell through cell is not thinkable.
Thus far we see our way fairly clear. But the question now arises: what
causes the solid constituents of the blood to force their way through
the capillary membranes all over the mucous surfaces, even the
conjunctiva, and not these alone, but also through serous membranes such
as the pericardium, and strangest of all, through old scars in the skin?
If the most modern ideas as to the cause of diapedesis being blood
pressure are correct, it is quite incomprehensible how it can take place
in the absence of blood pressure, and take place so extensively. The
theory of blood pressure may apply to diapedesis accompanying the
inflammatory process. In snakebite poisoning it is more likely to be due
to passive engorgement of the capillary system and probably also to
blockage of corpuscles in the finest capillary tubes. In vaso-motor
paresis, and still more paralysis, the arterioles supplying the
capillaries are widely dilated, and at the lowest blood pressure
probably send more blood into the latter than in the normal state. This
circumstance in itself is apt to cause capillary engorgement. In the
finest capillaries permitting only a string of corpuscles, one behind
the other but none abreast, to pass through in the normal state,
dilatation may cause blockage by two or three becoming wedged in abreast
and closing the lumen of the vessel by a sort of embolism. On the
arterial side of this obstruction the crowded corpuscles force their way
through the porous cement substance by what little "vis a tergo" there
may be left yet, whilst in the venous side, in the small veins
corresponding with the closed capillaries, engorgement must necessarily
take place through this "vis a tergo" being entirely absent, and
diapedesis, which here also has been observed, follow in due course. The
writer has always been inclined to take this view, the correctness of
which appears to be borne out by an experiment recorded by Feoktistow.
He found on sprinkling a two per cent. solution of snake-poison over the
mesentery of an healthy animal, that wherever a drop of the solution
fell, almost immediately the capillaries and small veins became dilated
and small point-like effusions of blood appeared, gradually enlarging
and ultimately becoming confluent with adjoining ones. Large hæmorrhagic
surfaces were thus formed in a comparatively short time. Here paralysis
of the nerve-cells interspersed in the vaso-motor nerve-ends was
evidently the first effect, followed by dilatation of the capillaries
and immediately afterwards by effusion. Without some obstruction within
the capillaries, like that above described, effusion in this purely
local poisoning process appears unexplainable.
The special preference which the viper-poison has for the vaso-motor
sphere will hereafter be referred to. Hæmorrhages from Australian
snake-poison are comparatively rare. Even at the bitten place there is
as a rule very little swelling and effusion and frequently none at all.
When it occurs it quickly disappears after strychnine injections. Only
a few cases have been reported as yet of blood-vomiting. In one of these
the hæmorrhage took place soon after the bite and was so considerable
that it must have arisen from actual rupture of vessels consequent on
abdominal engorgement and not from mere diapedesis. It is very doubtful
whether the latter ever takes place here as it does after viper-bite in
India and elsewhere. Even the death-adder, although half a viper, and
producing more swelling and effusion locally than any other one of our
snakes, is not known to have ever produced the extensive effusions from
mucous surfaces in pericardium, lungs, &c., described above. More
research however is necessary, especially more carefully conducted
autopsies. Since Australia has taken the lead in this hitherto so
obscure department, every practitioner should make it his object and
special ambition to contribute his quota towards the elucidation of the
subject, not only by reporting successful cases, but also the
post-mortem appearances in unsuccessful ones, wherever it is
practicable. It is not by experiments on animals but by a hearty
co-operation of Australian practitioners that we can ever hope to
supplement our knowledge on this subject.
b.--The Respiratory Centre.
Paresis of this centre does not play as important a part here as it does
in India, more especially after cobra-bite. The peculiar, and as yet
unexplained, tendency of snake-poison to act with special virulence on
some centres, passing others by comparatively little disturbed, is
markedly shown by the cobra poison of India as compared with that of our
Australian cobra (_hoplocephalus curtus._) The unfortunate victims of
the former are tortured by an ever-increasing dyspnoca, and finally die
from asphyxia, under what are supposed to be carbonic acid convulsions.
They retain their consciousness more or less unclouded to the last, the
poison spending all its force on the respiratory centre, and leaving the
brain intact. Here we hardly ever see actual dyspnoca after the bite of
hoplocephalus or any other Australian snake. Respiration becomes quicker
at an early stage, and then, from hour to hour, shallower; but our
patients soon pass from sleep into coma, and suffer no respiratory
distress even when, in consequence of general paralysis, the respiratory
muscles cease to act, which usually takes place a few minutes before the
heart stands still.
Feoktistow records the following observations on cats with reference to
the respiratory centre:--Small intravenous injections of the fresh
poison (0.07-0.13 mllgr.) produced a great increase in frequency of
respirations (280-360 per minute). Section of both vagi at once reduced
this frequency, from which he infers that small doses act as an irritant
to the respiratory centre. When small doses were repeated several times,
the respiratory movements were gradually retarded, and asphyxia set in
through paralysis of the centre. Large doses produced this effect at
once, without any previous acceleration. Very large ones paralysed
respiration, heart, and vaso-motors almost simultaneously, and caused
the blood pressure to fall to 0. By the kymograph respirations were
found to become shallower in proportion to their frequency. As the
latter was reduced, they became at first deeper, but ere long shallower
again, and were occasionally interrupted by spasmodic inspirations.
Artificial respiration prolonged life for a short time only.
C.--Action on Centres of Cranial Nerves.
Among the symptoms denoting paresis of motor-centres of cranial nerves,
together with sympathetic ganglia, the first and most noteworthy is the
early dilatation of the pupil. This truly pathognomic condition is never
absent, and becomes intense when paresis becomes intensified into
paralysis. The most glaring light, in immediate proximity to the
eyeball, has then no effect whatever on the pupil. If it remains dilated
after strychnine injections have restored consciousness and the power to
walk, it is a sure sign that the snake-poison is not completely
counteracted, and will in all probability re-assert itself,
necessitating another injection, whilst a pupil restored to its normal
condition justifies the conclusion that the patient is safe.
Another symptom denoting paresis of the cranial nerve-centres is a
marked change in the expression of the face. The features become
relaxed, and lose their mimetic play. The cornea is dull, and, together
with the anterior surface of the eyeball, becomes dry, as the eyelids
are moved imperfectly, if at all, and the tears in consequence are not
properly distributed over the conjunctiva. The nostrils become more or
less immovable, and the naso-labial fold is obliterated, whilst the
lower lip hangs down. The lips are apart, as the lower jaw is not held
up by the muscles. When paralysis supervenes it drops entirely, and the
tongue protrudes.
Deglutition, somewhat difficult in paresis, is completely suspended in
the paralytic stage, through paralysis of the soft palate, the pharynx,
and oesophagus. Liquids forced on the patient in this extremity may
partly flow down the oesophagus, but will also enter the larynx, and
their administration should be carefully avoided.
D. Action on motor-centres of Cerebellum and Basal Ganglia.
Of this action little if anything is patent to observation. A certain
want of co-ordination in the movements has been noticed in the early
stage of paresis, and the peculiar staggering walk of persons in this
stage is probably owing to an affection of the motor-centres of the
cerebellum. That they do not escape the action of the subtle poison,
when symptoms denoting the invasion of all the other motor-centres
throughout the body are in evidence, we have every reason to assume.
The co-ordination and automatic regulation of the lower motor-centres
must necessarily escape observation when the function of these centres
is partially suspended, and when, moreover, the powerful currents of
nerve force the cerebellum and basal ganglia receive from the motor
cortical centres of the cerebrum are partially if not wholly withdrawn.
E. Action of the Motor Cortical Centres of the Cerebrum.
In all but the very lightest cases of snakebite-poisoning there are
always symptoms manifested that cannot be referred to any other cause
than an invasion of the centres now under consideration. They range from
mere stupor, confusion of thought and delirium to the deepest coma, with
complete extinction of consciousness and insensibility to all external
impressions. Coma is a frequent and in serious cases an almost
invariable symptom in Australia. After the bite of our death adder only
we find persons sometimes collapse and expire suddenly, when still
conscious and able to answer questions rationally. Coma invariably
develops from sleep. It is, in fact, sleep intensified. An almost
irresistible desire to sleep is one of the first symptoms to be
observed. If the dose of poison imparted by the snake has been small,
the desire may pass off or the sleep may not assume the form of coma,
but in all serious cases it quickly assumes that form. _Vice versa_ the
deepest coma becomes sleep again, when the suspended function of the
cortical centres is roused by strychnine injections. The insensible and
completely paralysed patient usually announces the gradual return of
consciousness by a few groans and uneasy movements and not unfrequently
begins to snore, as in ordinary sleep, when a smart shake at the
shoulder will rouse him into full consciousness. At other times this
transition from coma back to sleep does not take place and consciousness
returns quite suddenly, the persons opening their eyes and looking
around them, dazed and bewildered, but perfectly conscious at once. When
coma is fully established and the largest and most powerful
motor-centres have succumbed to the insidious poison, general paresis
becomes general paralysis and all the motor-centres of the body are in a
condition of more or less suspended functional activity. This and this
only is the condition of the centres, the whole secret of snake-poison,
that has puzzled the human mind for ages and yet appears so simple when
discovered at last. It is beautifully and strikingly illustrated in the
phenomena before us. We have coma and complete general paralysis, every
motor-nerve cell, from the highest psycho-motor one downwards, is thrown
into a state of torpor and has ceased to discharge the life force that
regulates every process of life and the entire absence of which
inevitably must be death. Only weak, lingering currents are sent forth
yet and put off the inevitable finale for a time. But the strychnine is
injected and mark the change. It courses quickly to every one of the
sleepers, for whom it also has an affinity, but the direct opposite to
that of the deadly venom that has overpowered them. It touches them as
if with the wand of a magician and orders them to awake and do their
work. There is no disobeying the mandate, for it is founded on one of
nature's unchangeable laws. Almost immediately the cells begin their
work again, the life streams flow afresh, coma and paralysis vanish and
within a very short time the subject of this beautiful experiment is
snatched from the brink of the grave and restored to life and health.
The phenomena of sleep and coma as the result of a poison acting as a
depressant of motor nerve force afford food for some interesting
speculations, which, however, as more concerning the psychologist, the
writer can only glance at here. It is evident that in the highest of
psycho-motor centres, the organs of thought and of consciousness, the
paresis of the lower centres assumes the form of sleep, and paralysis
that of coma. Sleep, as a partial, and coma, as a complete, obliteration
of thought and consciousness must, therefore, be intimately connected
with motor nerve function, sleep being a reduction, coma a suppression
of the function, or a suspension of thought. Ideation, to use J. S.
Mill's very appropriate term for the thought process, appears to be
effected by motor nerve currents or, at all events, to be accompanied by
them and suspended with their suspension. The thinking principle, the
nous within us, is no doubt more than mere nerve action, but it can,
apparently, not manifest its presence without motor nerve cells in
healthy action. Every thought, though not synonymous, is evidently
synchronous with a current of motor nerve force, and it is not
improbable that, by means of these currents, that silent transference of
thought is effected from brain to brain, which modern psychology has
demonstrated to be not only possible but actual under certain
conditions. But further speculation on these interesting mysteries it
would be out of place here to indulge in.
F. Action on Sensory Centres and the Reflexes.
The sensory sphere remains comparatively unaffected in mild cases, and
in the early stages of more serious ones, but when paresis has deepened
into paralysis, sensation becomes ever more blunted, and with the advent
of coma, of course, quite extinct. Reflexes, both superficial and deep
ones, are also completely abolished at this period of the poisoning
process, and the nerves of special sense do not react against any, even
the strongest possible stimulation. The eye stares vacantly into a
glaring light held close before it, and the widely dilated pupil shows
no sign of reaction. The ear also appears deaf to any noise, and strong
ammonia vapour is inhaled through the nose like the purest air, whilst
pricking, beating, and even burning the skin elicit not a quiver of a
muscle.
Feoktistow's experiments with regard to reflexes, more especially their
restoration by strychnine, differ in their results entirely from
Australian observations. Whilst we have no difficulty in restoring them
with the drug on man as well as the domestic animals, his experiments on
frogs were a failure, and merely showed a decided antagonism between the
two poisons. He did not succeed in restoring the reflexes, and, instead
of following up with experiments on the higher animals, he trusted
implicitly to his results on frogs, and thus lost his opportunity.
G. Irregularities in the Action of Snake-poison.
There is in the whole range of toxicology not a single condition known
to us in which the symptoms, both in chronological order and in their
strength and relation to each other, show as much variety as those of
snake-poison. Experienced observers will agree with the writer that it
is but rarely we find two cases of snakebite exactly alike in the
symptoms they present. Some of these puzzling variations have already
been alluded to, but it is necessary to consider them a little more in
detail. Apart from quantitative differences in the poison imparted, they
arise principally from the strange capriciousness with which the poison
concentrates its action on special nerve centres and leaves others
comparatively intact.
The nearest approach to regularity and orderly sequence of the symptoms,
as described in the foregoing pages, we find in Australia after the bite
of the tiger snake (_Hoplocephalus curtus_) and the brown snake
(_Diemenia superciliosa_), more especially that of Queensland. Here we
can trace the action of the poison distinctly from centre to centre,
from the lowest part of the anterior cornua up to the cortex cerebri,
and even throughout the sympathetic ganglia as far as they are patent to
observation. The poison of these snakes is extremely diffusible and
quickly absorbed. It spreads with rapidity and nearly equal force over
all the motor centres, the symptoms following each other so quickly as
almost to appear simultaneous, though, in reality, successive. But even
the poison of these snakes leaves the arms only slightly paretic, when
paralysis in all the other voluntary muscles is well pronounced, and
does not paralyse them until coma has set in. It also touches the
respiratory centre but slightly. Sometimes coma is light and the
patients can be roused for a little while, at other times it is deep and
lasts till death. But even greater variations are observed occasionally.
In one very extraordinary case of tiger snakebite, the patient, a child
of 9 years, remained conscious to the last, and after vomiting blood
freely died under symptoms of heart failure. In rare cases the symptoms
resemble those of cobra poison.
If we turn from these to the black snake (_Pseudechis porphyriacus_) a
different picture presents itself. Its poison does not produce so deep a
coma and often none at all. The patients generally feel drowsy and fall
asleep, but are easily roused and sometimes awake spontaneously. There
is also not the same amount of muscular paralysis. They are frequently
able to walk a few steps with assistance and can move in bed, the arms
especially being almost free from paresis. But the insidious poison none
the less does its work, though its effects are less patent. It
concentrates its action on the vaso-motor centre. The victims from hour
to hour become more anæmic in appearance through increasing engorgement
of the abdominal veins. Anæmia of the nerve-centres hastens the
collapse, and from the combined effects of this and heart failure death
takes place suddenly and quickly as if in a fainting fit. Here then we
have an approach to the effects of viper poison which is also shown in
the greater amount of swelling and effusion around the bite and in the
bitten limb.
This approach is still closer in the poison of the death adder
(_Acantophis antarctica_). There is generally much extravasation of
blood locally. Muscular paralysis is also less pronounced, but sudden
collapse from vaso-motor paralysis not unfrequently takes place, when
the patients fully conscious are still able to sit up. That leading
feature of viper poison, diapedesis with hæmorrhage, does not occur with
either.
If we turn from Australian to Indian snakes, the peculiar tendency of
the poison to concentrate its action on special nerve-centres becomes
still more marked. The predilection of the cobra poison for the
respiratory centre has already been dwelt on. More remarkable and
strange is the action of the Indian viper-poison on the minute ganglia
in the vaso-motor nerve ends, which control the capillary circulation,
and by their paralysis bring about extensive hæmorrhage through
diapedesis.
It is quite impossible for us with our present scanty knowledge to
account for these peculiarities and irregularities in the action of a
poison, which we know now to accomplish its destruction of animal life
by one uniform design and principle of action. That the protean forms
under which the poison-symptoms present themselves are one and all the
result of reduction and suspension of motor nerve currents may now be
accepted as a well proven and fully established scientific fact. But why
the effects of one and the same cause are so varying in their
appearance, why the poison of different varieties of snakes, and even
that of the same variety under different circumstances, make such a
capricious selection among the various motor nerve-centres we can not
explain and probably never will. Chemical analysis of the dead poison,
no matter how minutely and elaborately it may be effected, will probably
never throw much light on the "why" of this strange puzzle, for the
subtle phenomena of life are apt to elude the grasp of the analyst. We
have to do with a poison transferred from one living organism into
another one and modified in its action by the condition of the giver and
the constitution and peculiarities of the recipient quite as much
probably as by slight variations in its chemical composition. Accepting
the "why" of these phenomena like that of many other ones, simply as a
fact not to be accounted for at present, we must be content to know
"how" they are effected, and, what is of more immediate and paramount
importance to know, that we now have an antidote that will deal
successfully with them all, that the convulsions and hæmorrhages of the
Indian viper-poison and the asphyxia of that of the cobra will yield as
readily to strychnine, when properly and boldly applied, as the coma and
general paralysis following the bite of the deadly tiger snake.
[Illustration]
THE ANTIDOTE.
The theory of the action of snake-poison as that of a specific
nerve-poison, depressing and more or less suspending the function of the
motor nerve-centres throughout the body, has in the foregoing pages
received a double proof of its correctness.
In the first place, all the symptoms the snake-poison produces have been
passed in review, and shown to be fully explainable by this theory. On
this ground alone it may be claimed to have been fully established; for
it is an axiom in science that a theory on any subject must be accepted
as correct, if it accounts satisfactorily for all the phenomena
observable in connection with that subject by showing them to result
from the operation of one law. The second inductive proof of the
correctness of the writer's theory has been rendered by the experiments
of Feoktistow on animals.
Science, however, demands that a theory thus established inductively
must also stand the test of practical application or deduction. It says
in the present case:--"Granting your theory to be correct, it is but a
theory, which, however valuable it may be as a contribution to science,
is of little value to mankind if you cannot apply it practically. If
snake-poison merely acts as a depressant on motor nerve-cells without
interfering with their structure, you must be able to counteract it by
administering some drug or substance which acts as a powerful stimulant
on these cells, if such a substance can be found."
It is another illustration of that wise adaptation of means to ends
which, throughout the domain of nature, denotes the presence and rule of
a Supreme Intelligence, that this substance has been provided for us by
nature, though we have been long in finding it. Its discovery in
strychnine, and its successful application as the long and vainly sought
antidote to snake-poison, are glorious triumphs of scientific deduction.
Strychnine is the exact antithesis to snake-poison in its action. Under
its influence every motor nerve-cell throughout the system sends forth
stronger currents of nerve force than it does in its normal state. These
currents run alike from cell to cell, and from cell to peripheral fibre,
and act by means of the latter on all contractile, and especially all
muscular tissue, causing contractions, which, after poisonous doses of
the drug, assume the form of tetanic convulsions, provoked by the
slightest touch or even noise in consequence of highly intensified
reflex action.
Whilst, then, snake-poison, as we have seen, turns off the
motor-batteries and reduces the volume and force of motor-nerve
currents, strychnine, when following it as an antidote, turns them on
again, acting with the unerring certainty of a chemical test, _if
administered in sufficient quantity_. Purely physiological in its
action, it neutralises the effects of the snake-poison, and announces,
by unmistakable symptoms, when it has accomplished this task, and would,
if continued, become a poison itself. Previous to this announcement its
poisonous action is completely neutralised by the snake-poison, and the
latter would therefore be equally as efficacious in strychnine-poisoning
as strychnine is in snake-poisoning. Strychnine, in short, is the
antidote _par excellence_ of snake-poison, and cannot be surpassed by
any other substance known to us.
With the symptoms following the introduction of the subtle ophidian
virus into the human and animal system so markedly pointing to
strychnine as the antidote, it appears a matter of surprise that it was
not used as such before and that it was left to the writer to discover
the antagonism between the two poisons. Misleading experiments with the
drug on animals erroneously considered to be final in their results,
together with confused and contradictory notions about the action of
snake-poison, were the chief factors, already pointed out, that caused
research on this important subject to remain for centuries so barren of
results, and made even able investigators with more correct views than
the rest, postpone the discovery of a physiological antidote to a more
advanced state of science, when all the time it was lying ready at their
hands.
It is self-evident from preceding statements, that in the treatment of
snakebite with strychnine the ordinary doses must be greatly exceeded,
and that its administration must be continued, even if the total
quantity injected within an hour or two amounts to what in the absence
of snake-poison would be a dangerous if not a fatal dose. Timidity in
handling the drug is fraught with far more danger than a bold and
fearless use of it. The few failures among its numerous successes
recorded during the last four years in Australia were nearly all
traceable to the antidote not having been injected in sufficient
quantity. Even slight tetanic convulsions, which were noticed in a few
cases, invariably passed off quickly. It should be borne in mind that of
the two poisons warring with each other that of the snake is by far the
most insidious and dangerous one, more especially in its effects on the
vaso-motor centres. The latter are wrought very insidiously, and where
they predominate require the most energetic use of the antidote, for
whilst the timid practitioner after injecting as much strychnine as he
deems safe stands idly by waiting for its effects, the snake virus, not
checked by a sufficient quantity of it, continues its baneful work,
drawing the blood mass into the paralysed abdominal veins and finally by
arrested heart action bringing on sudden collapse. In such cases even
some tetanic convulsions are of little danger and may actually be
necessary to overcome the paralysis of the splanchnicus and with it that
of the other vaso-motor centres.
Whilst then it must be laid down as a principle that the antidote should
be administered freely and without regard to the quantity that may be
required to develop symptoms of its own physiological action, the doses
in which it is injected and the intervals between them must be left to
the practitioner's judgment, as they depend in every case on the
quantity of snake-poison absorbed, the time elapsed since its inception
and the corresponding greater or lesser urgency of the symptoms. If the
latter denote a large dose to have been imparted and it has been in the
system for hours, delay is dangerous and nothing less than 16 minims of
liq. strychnine P.B., in very urgent cases even 20 to 25 minims should
be injected to any person over 15 years of age. Even children may
require these large doses, as they are determined by the quantity of the
poison they have to counteract and are kept in check by it. The action
of the antidote is so prompt and decisive that not more than 15 to 20
minutes need to elapse, after the first injection, before further
measures can be decided on. If the poisoning symptoms show no abatement
by that time, a second injection of the same strength should be made
promptly, and unless after it a decided improvement is perceptible, a
third one after the same interval. As the action of strychnine when
applied as antidote is not cumulative, no fear needs to be entertained
of violent effects suddenly breaking out after these large doses
repeated at short intervals. They are, so to say, swallowed up by the
snake-poison and remain latent except in counteracting the latter. This
has now been proven abundantly by scores of qualified observers in all
parts of Australia, and still more by Banerjee in India. No hesitation,
therefore, should be felt by medical men in other snake-infested
countries to adopt the Australian treatment. It is seldom that more than
half a grain of strychnine administered in 16m. doses of liq. strychniæ
is required here to effectually counteract the venom and place its
intended victim out of danger. Ligature and excision of the bitten skin
have usually been practised and much of the poison eliminated before the
antidote is applied. Our snakes, however, as already pointed out, with
their shorter and merely grooved fangs, do not perforate the cellular
tissue to such depth nor instil as large a quantity of poison as the
cobras, kraits and vipers of India or the rattlesnake of America, all
having perforated and much longer fangs and much more productive poison
glands. Even if after the bite of a vigorous cobra, for instance, a
ligature has been applied and the bitten part deeply excised, a
comparatively large quantity of poison will probably be absorbed
requiring much larger quantities of the antidote, perhaps grains of it,
to effect a cure.
If under the influence of these large doses the symptoms abate, or if
the latter are comparatively mild from the first, smaller doses of
strychnine should be injected, say from 1/15th to 1/10th of a grain, but
under all circumstances the rule that, distinct strychnia symptoms must
be produced before the injections are discontinued, should never be
departed from. This rule is a perfectly safe one, for its observance
entails no danger, a few muscular spasms or even slight tetanic
convulsions being easily subdued and harmless as compared with that
most insidious condition exemplified in case No. 1, cited below, the
first one treated with strychnine by the writer, who, having no
experience in the treatment, did not administer quite enough strychnine.
The patient, after apparently recovering from a moribund condition and
being able to walk and even to mount a horse, remained partly under the
influence of the poison and succumbed to it during sleep, when,
according to subsequent experience, one more injection would have saved
him.
The tendency to relapses is always great when much snake-poison has been
absorbed. Apparently yielding to the antidote for a time, the insidious
venom, after a shorter or longer interval, during which it appears to
have been conquered, all at once re-asserts its presence, and has to be
met by such fresh injections, regardless of the quantity of strychnine
previously administered, but the amount required in most relapses is not
a large one. The writer formerly inclined to the belief that the strain
thus put on the delicate nerve-cells would limit the usefulness of the
antidote to cases requiring not much above a grain. Knowing the Indian
snakes to impart to their victims such comparatively large quantities of
venom, he had strong misgivings as to his method standing the severe
test of Indian practice; and it was most fortunate for this method that
its first practical application in India was made by a gentleman who,
whilst thoroughly familiar with its principles and convinced of their
correctness, had the courage to apply them fearlessly by injecting what
to us Australians appear enormous quantities, ranging as they do up to
three and four grains per patient. Dr. Banerjee's eight cases, all
successful, and of which the most important one, relating to the much
and justly dreaded Duboia Russellii, was published in the November
number of the _Australasian Medical Gazette_, settled the treatment of
snakebite in India as well as elsewhere. If the poison of Bungarus
coeruleus, Echis carinata, and Duboia Russellii can be successfully
counteracted, and if for this purpose four grains of strychnine can be
injected with perfect impunity, it may be inferred with certainty that
the poison of the cobra, fer-de-lance, and the rattlesnake--in fact, of
any snake known to us will be found amenable to the antidote, and that,
if four grains can be injected with safety, we may venture on six and
eight grains, if they are required. In those cases only where the long
fangs of these snakes perforate into a vein, and a large quantity of the
venom injected into the blood-stream overpowers the nerve-centres so as
to make death imminent, if not almost instantaneous, the subcutaneous
injections may be found of little use. Here intravenous injections of
half a grain and even one grain doses would appear to be indicated, and
might yet fan the flame of life afresh, even when respiration and pulse
at wrist have already ceased. We have seen both these functions extinct
in Australia and restored by comparatively small doses of the antidote,
and can see no reason why a more energetic use of it should not restore
them in India.
Considering the terrible mortality from snakebite in India, Dr.
Banerjee's merit in being the first to introduce the strychnine
treatment there is of a very high order, and his grateful countrymen
will ever cherish his memory. When his Excellency the Viceroy had been
appealed to in vain by the writer, and the adoption of his method in
India urged through two Australian Governors, a native of India has
stepped forward and taken the first step towards alleviating an evil
that has hurried over two millions of his countrymen in every century to
an untimely grave.
The cases as reported by him to the _Australasian Medical Gazette_ are
cited below.
[Illustration]
CASES.
If the deductions and conclusions set forth in the foregoing chapters
are correct, it may be justly contended that all cases of snakebite
treated with strychnine should invariably end in recovery if the
antidote is properly applied, according to the rules above detailed.
This contention the writer fully and cordially endorses. Given the
largest amount of poison a snake can give off at one bite, strychnine
injected in time and sufficient quantity--either by the hypodermic, or,
if urgent, by the intravenous method--must rouse the dormant nerve-cells
into action, as long as the vital functions are not completely extinct.
Wherever it fails, the fault lies with the operator not injecting it in
sufficient quantity--a fault committed by the writer himself in his
first case.
The following condensed accounts of fifty cases treated in Australia,
and eight in India, the writer has taken mostly from the _Australasian
Medical Gazette_. Two of these only are from his own practice; others
were kindly communicated to him by his colleagues. It is not claimed
that all these cases were rescues from certain death. Some of them
undoubtedly were, others would have recovered under some other treatment
or no treatment at all; but in none of them would recovery have been so
rapid and complete. The two poisons are thrown out together, and no
ill-effects of either are experienced beyond a certain degree of
weakness, which passes off quickly. This is a boon to be appreciated
fully by those only who have gone through the slow, lingering, and
painful process of convalescence from snakebite as formerly treated,
with its deadly languor and weariness, making life itself a burden and
all physical and mental exertion impossible.
CASE 1.--A. H., 15 years old, a farm labourer, was bitten on the
right index finger whilst feeling for a rabbit in a burrow. Did
not see the snake nor suspect snakebite, but collapsed helplessly
in a few minutes after returning to his work. The writer saw him
three hours after the accident. He was then completely paralysed
and in deep coma; pupils widely dilated and not reacting to light;
sense of sight and hearing dead; heart action extremely feeble;
pulse small, thread-like, and scarcely countable; respiration
quick and shallow; skin blanched and very cold. Seeing him dragged
along the road between two men, had him quickly carried to the
next house, and injected 20 minims of liq. strychnine. Only a
groan or two and a slight improvement in the pulse, indicating a
change in his condition, gave him a second injection about twenty
minutes after the first one. A change for the better then became
rapidly conspicuous. The pulse gained in strength from minute to
minute, respiration became deeper, and the coma was visibly
reduced to mere sleep, from which there was no difficulty in
rousing him to full consciousness by a vigorous shake of the
shoulders. This marvellous change was brought about within forty
minutes; and this being the first case to which the writer had
applied his theory by injecting strychnine, its unparalleled
success exceeded his most sanguine expectations, but unfortunately
also lulled him into a false sense of security, which proved
disastrous to his patient. Not knowing then as he does now that
the snake-poison after having been subdued by the antidote is not
thrown out of the system as quickly as the strychnine, and is
therefore apt to re-assert itself, he allowed another urgent
engagement to take him away from the lad after watching him for
two hours and actually taking the evening tea with him. His
instructions to the mother not to let her son go to sleep and to
watch him carefully for the slightest sign of the return of
symptoms, were unfortunately disobeyed. Both mother and son went
to sleep, deeming all danger over. During this sleep the lad again
relapsed into coma and was found so at daylight. All attempts to
rouse him were fruitless, and he died before the messenger
intended for me had time to saddle a horse. The death of the
unfortunate lad, however, has saved some lives since. It taught
the writer the lesson never to trust to the apparent success of
the antidote until it shows distinct signs of its own
physiological action, and even then to watch his patients
carefully for the first twenty-four hours, and let them sleep for
short periods only.
CASE 2.--A.H., a vigorous girl of 20 years, bitten above the left
ankle by a snake in some long grass, and therefore not identified.
Had applied two tight ligatures above the bite, ran home and got
her mother to cut out the bitten skin, showing two distinct
punctures. Seen within an hour after the bite the girl presented
distinct, but moderate symptoms, deadly paleness, very cold skin,
small frequent pulse, and a peculiar feeling of agony about the
heart, just able to sit upright, but unable to walk. All symptoms
increased rapidly after writer cut ligatures. She reeled from side
to side, and suddenly fell forward as if in a swoon. Injected
1/6th grain of strychnine and, as she did not lose consciousness,
was able to watch the interesting and rapid effect of the
antidote. It had not been injected more than five minutes when
slight colour returned to the cheeks, naturally very red. Patient
then stated that the distressing feeling about the heart was
getting less and also that of drowsiness. From minute to minute
her condition improved, and in about ten she was able to rise and
walk a few steps. Profiting, however, by the lesson his first case
had given him, the writer did not trust to her apparent recovery,
but seeing that much of the poison had been eliminated by the
prompt measures taken before he saw her, he injected only 1/12th
of a grain, which produced slight muscular spasms. Careful
precautions were taken in this case against a relapse, but none
took place, and when visited next morning the girl declared
herself as well as ever she had been in her life.
The following notes of two cases of tiger snake bite
(_Hoplocephalus curtus_), treated with strychnine, were read by
Dr. Thwaites before the Intercolonial Medical Congress of 1889.
This gentleman, a young practitioner just entering practice, had
the courage to use the antidote according to the writer's
directions in spite of the hostile criticisms of his seniors in
the profession and even his own university teachers, and thereby
not only saved two valuable lives, but also set a praiseworthy
example, which was soon followed by others. The writer gives the
notes abbreviated.
CASE 3.--J. B., a strong, robust labourer, bitten by a tiger snake
on the back of right hand. Killed the snake, which hung on to the
hand and was with some difficulty shaken off. Made slight incision
through the punctures and tied a rag round the wrist, but too
loosely to check circulation; then started for the next
neighbour's house, distant a mile, which he reached with
difficulty, staggering like a drunken man when he arrived. The
bitten skin was here excised, whisky administered and patient sent
on in a buggy, but distance being 30 miles to Dr. Thwaites'
residence, a messenger on horseback galloped ahead to get Dr.
Thwaites to meet buggy on road. The latter writes: "I met buggy
four miles from my residence. Patient had to be held up on the
seat of the vehicle between two men. He had not spoken for some
time, pulse very weak, pupils greatly dilated, face very pale. I
injected 10 minims of liq. strychnine P.B. at once, and in a few
minutes noticed some improvement. He now answered when spoken to,
his pulse became stronger, and he could walk a few steps. This was
at 5.30 p.m., and he kept up fairly well till 8.15, when he
collapsed completely. I now injected 20 minims of liq. strychniæ,
which in a short time brought him round; but at 9.15 another
relapse took place, when a third injection of 15 m. was made.
This was followed by slight twitching about the face and neck,
after which improvement and recovery were uninterrupted."
Dr. Thwaites' second case is even more remarkable and telling.
When the girl, after a journey of 30 miles, was carried into his
surgery, she appeared to be dead, and a second medical man, who
happened to be present, declared her to be so, and all attempts to
revive her useless.
CASE 4.--A. D., aged 15 years, a schoolgirl, bitten by a vigorous
tiger-snake on the outside of left leg, the snake also holding on
for some time. She at once tightened her garter above the knee and
ran home, a distance of three-quarters of a mile. The bitten skin
was at once excised, another firm ligature applied, whisky
administered, and a hurried start made for Dr. Thwaites', distant
30 miles, where she arrived five hours after accident. The latter
writes:--"She was then pulseless at wrists, cold as a stone, and
with pupils insensible to light. I could not perceive any
respiration, but felt the heart yet faintly fluttering. She was to
all appearances just on the point of death. I injected at once 17
minims of liq. strychniæ. In about two minutes she sighed, and
then began to breathe in a jerky manner. In about ten minutes, on
my pulling her hair, she opened her eyes and looked around, but
could not recognise any one. Pupils now acted to stimulus of
light. In a short time she could speak when spoken to, but not see
at any distance. Her sight gradually returned completely; she kept
on improving, and in four to five hours after the one injection
she seemed quite well, but rather weak. I gave small doses of
stimulants till morning, and did not let her go to sleep till next
evening. She suffered no relapse, and her recovery was complete."
CASE 5.--This remarkable case was not published in the medical
press, but in many of the papers of Queensland, where it created
much sensation. The writer is indebted for an account of it to Dr.
Thwaites, who vouches for its correctness. It appears that this
gentleman acquainted the well-known explorer of Northern
Queensland, Mr. Johnstone, who is his uncle, and now police
magistrate at Maryborough, Queensland, with his success in
treating snakebite with strychnine. Mr. Johnstone, who during his
explorations had seen much of snakebite and many deaths from it,
wrote rather incredulously in reply, stating that our southern
snakes were innocuous in comparison with those of the north; and
that, having seen twelve persons bitten and die by the deadly
brown snake of the north (_Diemenia superciliosa_), he must
withhold his belief in the new antidote until he had witnessed a
case of brown snakebite cured by it or reported on good authority.
This desire he had quickly gratified, and by a strange fatality in
his own person. Whilst taking his children for a walk in the bush
a few weeks afterwards he stepped aside the path to pluck a flower
from a bush, and in doing so was bitten on the leg by a vigorous
brown snake. He at once applied a ligature, and had the punctures
sucked by an aboriginal, but became comatose before he reached
home. Three medical men were summoned in haste, injected ammonia
into several veins, and finally had to resort to artificial
respiration, declaring the case a hopeless one. In this extremity
Mrs Johnstone rushed to a fourth one, who had seen Dr. Thwaites'
letter, and discussed its contents with her husband in her
presence. This gentleman--Dr. Garde--laid up in bed, quickly
furnished the lady with liq. strychniæ, accompanied by the request
to his colleagues to inject it freely. She came back to her
husband's bedside, when artificial respiration was about to be
given up, but the very first injection rendered it no longer
necessary and two more restored Mr. Johnstone completely. Saving
the life of this highly respected and popular functionary, who was
the first in Queensland treated with the antidote, paved the way
for it in that colony, where it is most needed and is now highly
appreciated.
These five cases, thoroughly typical of the effects of strychnine
in snakebite, are almost in themselves sufficient to bear out the
correctness of the writer's deductions, but for the benefit of a
certain class of rigorously incredulous scientists, who would not
be satisfied with five cases, the writer submits 45 more and in
addition to these--last but not least--Dr. Bannerjee's eight
Indian cases. They are all well authenticated, being mostly taken
from the _Australasian Medical Gazette_ or from private notes, but
to avoid useless repetition the greater part of them will be
merely cited and only the more remarkable ones be given in detail.
Whether in the face of this formidable array of evidence that
blind incredulity and senseless opposition, usually blocking the
way of every new discovery, will at last give way, remains to be
seen. The writer has had his full share of them, and but for the
valuable aid he received from the Hon. Dr. Creed, the able editor
of the _A. M. Gazette_, would probably be struggling yet for the
introduction of his antidote. When it is considered that, in spite
of such evidence as here produced, his discovery has as yet
received no official recognition from any of the Australian
medical authorities, and that even now there are medical men who
can write such effusions as that of Dr. T. L. Bancroft, of
Brisbane, beginning with the words: "It is deplorable to still see
recorded cases of snakebite treated with strychnine, &c.," (see
_Gazette_ for July, 1892)--the attitude assumed from the first by
Dr. Creed and his unfailing advocacy of the antidote can not be
too highly appreciated and lay both the writer and the public
under a debt of deep gratitude to him. But for his early
recognition of the soundness of the writer's theory and treatment
of snakebite many valuable lives now saved would have been lost.
As early as June, 1889, Dr. Creed wrote in an editorial: "We
desire to call the special attention of the profession to Dr.
Mueller's papers on the pathology and cure of snakebite, published
in our issues for Nov., Dec., Feb, April and May last, and to
press upon them the justice and, we submit, the necessity of
extremely careful consideration of his theory and of the results
shown in the cases in which, acting on it, he has used hypodermic
injections of strychnine for the treatment of snakebite. We
formerly expressed our concurrence in the opinion of Sir Joseph
Fayrer, who wrote: 'I do not say that a physiological antidote is
impossible, all I assert is, that it is not yet found.' We are
indeed pleased to state that we believe such an antidote is now
found and that Dr. Mueller is the happy discoverer. We are of
opinion that his theory as to the pathological changes set up in
the human system by the injection of snake-poison is a sound one
and that the treatment he has suggested and used is correct and
proper, and the one likely to avert death in cases of snakebite,
which would otherwise in all probability prove fatal. We therefore
press the use of hypodermic injections of strychnia in the manner
described by him upon the attention of practitioners who may have
to treat cases in which the symptoms present are the result of
snake or dangerous insect poison, and think that, should the
patients die without its having been used, all will not have been
done to save life that might have been." Without such utterances
repeated from time to time and without the ample space always
allowed in the _Gazette_ to the subject, a record like that now
submitted would not have been possible.
CASE 6.--P. Evans, a girl of 20 years, bitten on wrist by a brown
snake. Symptoms--Staggering gait, drowsiness, &c. Only 1/16th
grain in four injections. Notes furnished by Drs. Mahoney and
Kennedy, of Albury.
CASE 7.--W. Thiplin, a labourer, bitten on hand by brown snake.
Three injections. Notes by Dr. Baird of Healesville.
CASE 8.--Luke Dewhurst, labourer, bitten on hand by tiger snake.
Cured by one injection of m. xv. liq. strychniæ after ammonia had
failed. Notes by Dr. Dutton, of Lillydale.
CASE 9.--P. Moroney, labourer, bitten on thigh at night, snake not
identified. Cured by three injections of 1/12th grain each. Notes
by Dr. Pardey, of Myrtleford.
CASE 10.--Mrs. Skinner, bitten on thigh, at Carrum. Treated by Dr.
Verity.
CASE 11.--Child of Mr. Weeks, aged three years. Treated by Dr.
Degner, of Myrtleford.
CASE 12.--Annie Rankin, servant, at Corowa. Treated by local
chemist.
CASE 13.--Child of Mr. F. Daniels, of Mount Kent, Queensland,
_only two years old_, bitten by a death adder on fourth finger of
left hand, the snake found clinging to finger. Ligature applied
and finger chopped off, but condition of child very precarious
when admitted to Toowoomba Hospital, after a night's journey, at
daylight, in complete collapse. Pronounced out of danger by Dr.
Hunt, the house-surgeon, at 10.30 and taken home in the afternoon.
Notes not furnished.
CASE 14.--Reported by Dr. Pain, of Allora, Queensland. Symptoms
serious. Four injections of m. xv., x., viii. and vii.
CASE 15.--Reported by Dr. Garde, of Maryborough, Queensland, girl
of 13 years, bitten by brown snake, requiring only two injections
of m. xv. and x.
CASE 16.--Reported by Dr. St. George Queely, of Maytown,
Queensland, lad of 19 years, bitten by black snake, symptoms
serious. Four injections of m. xv., xv., xx., and xv., total 65
minims of liq. strych. P.B. injected within less than two hours,
muscular spasms appearing after last injection. Patient made rapid
recovery, riding home, a distance of 16 miles, within a few hours
after treatment.
CASE 17.--Reported by Dr. Ray, of Seymour, severe bite of a tiger
snake. Within six hours 4/5th of a grain administered
subcutaneously, besides a considerable quantity given by the
mouth. Patient made a good recovery. "Every injection after the
second one," Dr. Ray reports, "having a distinct effect within
three or four minutes, and lasting from one to one and a half
hours before tendency to coma returned."
CASE 18.--Very remarkable. Read by Dr. Forbes, medical officer of
hospital, Charters Towers, Queensland, before the North Queensland
Medical Society. Boy, 6 years old, was admitted to hospital at 9
p.m. on 27th October, 1890, bitten on foot by a death adder, which
was killed and identified. Dr. Forbes reports: When seen by me,
two hours after the accident, he was sitting on his mother's knee
with his head hanging on one side, but quite conscious, and
answering questions rationally, pupils widely dilated with almost
no reaction to light, pulse very fast and soft, &c. Thinking his
condition might be due to fear I hesitated to use strychnine. So,
ordering strong coffee, I hurried to attend an accident case just
admitted with severe hæmorrhage, and left the boy in charge of a
nurse, with orders to call me at once if she saw any change. I had
scarcely been away 15 minutes when the father rushed in saying his
boy was dead, and indeed his statement seemed but too true. The
child was lying quite limp, face blue, eyes half shut, extremities
very cold, no pulse perceptible, no respiration visible. I at once
injected m. x. of liq. strychniæ P.B. and made artificial
respiration. He soon began to improve, and in about 20 minutes was
able to speak. He was watched all night, but suffered no relapse,
and was discharged on the next day.
CASES 19 TO 21, reported by Dr. Weekes, of Lithgow, N.S.W. Dr.
Weekes writes:--"Within the last year I have had three cases under
my care, all bitten by black snakes, and all in about the same
place, on the outside of the calf of the leg. The patients were
all comatose, exhibiting all the usual symptoms of
snakebite-poisoning, and in one, my last case, _the patient had
convulsions_. In all of them I made hypodermic injections of m.
xv. liq. strych., and the effects were most marked, the patients
being completely roused and becoming quite sensible and rational
each time," &c.
CASE 22.--Mrs. Ryan, of Oberon, N.S.W., bitten on leg by tiger
snake, comatose and nearly pulseless after three hours, treated by
Dr. Kingsburry, amount of strychnine not stated.
CASE 23.--Benjamin Childs, bitten on finger by death adder,
treated by Dr. Campbell, of Grafton, N.S.W.
CASE 24.--Rather remarkable. Reported by Dr. Lloyd Parry, of
Emmaville, N.S.W., in _Gazette_ of March, 1891, and further
particulars in private correspondence with writer. A Chinese
miner, aged 30 years, was bitten on the back of the foot by a
death adder. His mates, deeming medical aid useless, did not send
for Dr. Parry until death was imminent, and then only with a view
of getting a certificate of death, and avoiding autopsy and
inquest. When seen, three hours after infliction of bite, the man
was deeply comatose and pulseless, skin icy cold, pupils dilated
and insensible to light, lower jaw hanging down and tongue
protruding, respiration scarcely perceptible. He was in fact so
near death that this event was expected to take place from minute
to minute. In order to task the antidote to the utmost, Dr. Parry
cut the tight ligature without excising the bitten skin and then
injected xv. of liq. st. P.B. To his surprise in a few minutes the
man began to groan and very soon afterwards became conscious. Dr.
Parry then watched him carefully and in about an hour found coma
returning, when another injection was made and roused him for
good. There was much swelling and effusion in the leg, but no ill
effects followed.
In this case, judging from the comparatively small quantity of the
antidote required, only a small amount of poison had been
imparted, the bite being on the back of the foot, where the fangs
cannot penetrate deeply. Still there can be no doubt that even
this small quantity of the justly dreaded death adder poison would
have proved fatal, if it had not been counteracted by the
antidote.
CASE 25, reported from Tasmania by Dr. Holmes, of Launceston,
presents different features, showing the very large quantity of
the antidote sometimes required. After describing the condition of
his patient, a Mrs. Frazer, of St. Leonards, Dr. Holmes
writes:--"From her desperate condition I thought it too late for
the ammonia treatment and decided on injecting liq. strychniæ. At
12.30 p.m. injected m. xv, at 1.40, m. xv., at 2.10, m. xv., at
2.40, m. xv., and 3.10, m. xv., at 4 p.m., m. x., and at 5, m. x.
A few minutes after the last dose I noticed the physiological
action of the drug and desisted from injecting. At 8 p.m. she
seemed almost well, pupils normal in size and reacting well, was
not sleepy and could swallow easily. The patient made a good
recovery."
This is the largest quantity of strychnine that has been required
in Australia, namely, 126 minims of liq. strych., or 1-1/9th gr.
injected in less than five hours, with the most beneficial result.
Surely the most cynical scepticism must give in to such facts.
CASE 26.--Reported by Dr. MacDonald, of Murwillumbah, N.S.W. Mr.
S., bitten on leg by a black snake. Coma, complete paralysis,
chin hanging down to sternum, pupils dilated, &c. An injection of
m. xv. had no effect; one of m. xx. very little. After a third one
of m. x. patient suddenly became conscious, could walk without
assistance, and in half an hour was sent to bed perfectly
recovered.
CASE 27.--Reported by Dr. Yeatman, of Auburn, South Australia. Mr.
D., a farmer, aged 45 years, bitten on thumb; snake not named;
cured by three injections of only m. v. each. Convulsions lasting
for an hour came on three hours after treatment--a very rare
occurrence--by Dr. Yeatman erroneously ascribed to the strychnine,
which in so small a dose would not have produced them in the
absence of snake-poison.
CASE 28.--Reported by officer in charge of police at Grenfell. Boy
of 6 years, bitten by brown snake, and treated by Dr. Rygate.
CASE 29.--W. Toomer, aged 19, bitten by tiger snake on thumb and
index finger, and not treated until 9-1/2 hours after bite, having
a long distance to travel. Recovery very slow through timid use of
antidote, five injections of 1/30th grain having but little
effect, until one of 1/10th restored him. Treated by Dr. Stokes,
of Echuca.
CASE 30.--Reported by Dr. Bennett, surgeon, Gulgong Hospital,
N.S.W. Mrs. Mears admitted to hospital comatose and pulseless,
nothing having been done to check absorption. The intravenous
injection of ammonia failing to rouse her, m. xv. of liq. strych.
were injected, when pulse returned, but coma continued. After a
second injection of m. xv. she suddenly became quite conscious,
and in an hour was fully restored.
CASE 31.--Reported by Dr. Mead, of Quirindi, N.S.W. John Simson,
aged 15 years, bitten by a death adder on forefinger of right
hand. Dr. Mead living 50 miles away, and the lad collapsing, a
layman, Mr. Robert Simson, had to undertake treatment, and
injected during the night m. 150 of a one in 240 solution of
strychnine, equal to 5/8ths of a grain. Dr. Mead, finding the lad
conscious and only a little drowsy, did not inject any more
strychnine until 2 p.m., when a relapse took place. He then
injected m. viii. of liq. str. P. B., and in half an hour m. vii.
more. The last injection produced slight muscular twitchings, and
subdued the snake-poison effectually, the lad making a good
recovery. The total quantity used in 13 injections was over
three-quarters of a grain within 18 hours.
CASE 32.--This case is another instance of the successful use of
the antidote by a layman, and can be verified by the writer, who
saw the patient, a girl of 14 years, after her father had carried
out the treatment successfully. The girl had been bitten by a
large brown snake whilst walking through a paddock, and very soon
afterwards lost the use of her legs, and for a time also her
eyesight. The symptoms being so very alarming, and the girl at a
distance of 35 miles from the writer's residence, the father at
once injected 1/12th of a grain of strychnine, and in a very short
time another 1/12th. The child then rallied somewhat, and a start
was made to bring her in, the father taking the precaution of
bringing the antidote-case with him. This was fortunate, for the
child collapsed several times, and each time had to be roused by
an injection before reaching the writer. When finally she
presented herself, walking into the writer's surgery with a firm
step, not a trace could be discovered either of the strychnine, of
which nearly half a grain had been injected, nor of the
snake-poison, also imparted no doubt in a fatal dose. The two
punctures on her leg, testifying to the size of the snake that had
bitten her, were the only tokens of the ordeal she had gone
through; and the only task remaining for the writer was to
congratulate her father (Mr. James Trebilcock, a farmer, of
Tawanga), on the plucky manner in which he had carried out the
treatment, and see to the child being properly watched during the
night in case of a relapse taking place. None, however, occurred,
and she left next morning perfectly well. Cases of this kind, in
which no doctor is called in, are frequently reported to the
writer, who finds that laymen are even more successful because
less timid than many medical men.
CASE 33.--Joseph Cartledge, bitten on calf of leg by a black
snake, was treated by Dr. Browne, of Sale, five hours after
accident. Two injections of 1/8th grain each used.
CASE 34.--Miss Davie, teacher, at Nerung, Queensland, treated by
Dr. Hannah, of Southport. Particulars not given.
CASE 35.--Mrs. Rogers, of Bulu Bulu, Gippsland, bitten on finger
by tiger snake, and treated by Dr. Trampy, first with intravenous
injections of ammonia, which had no effect, and when sinking with
strychnine injections, which had almost immediate effect, and in a
few hours placed her out of danger.
CASE 36.--Son of Mr. J. Beveridge, squatter, of Glengower, treated
successfully by Dr. Andrew, of Clunes, with strychnine injections.
CASE 37.--Theresa Byrne, aged 14 years, bitten whilst bathing,
snake not seen. Treated by Dr. Cuppaidge, of Normanby, Queensland.
Only 18 minims of L. S. required.
CASE 38.--Mr. Bullock, of Tenterfield, N.S.W., bitten by black
snake and treated by Dr. Morice.
CASE 39.--A boy, J. Taylor, bitten at Mount Keat, agricultural
settlement, Queensland, by a black snake, and treated successfully
by a layman, Mr. James Daniels.
CASE 40.--George Neilson, a Danish miner, bitten by a tiger snake
whilst bathing. Case reported by Dr. Gamble, of Walhalla. Forty
minims of liq. strych. required; recovery complete next morning.
CASES 41 AND 42, reported by Dr. Helsham, of Richmond, N.S.W. In
one of these where, judging from the symptoms, a large dose of
snake-poison had been absorbed, but very small doses of strychnine
were injected, convulsions set in, _whilst coma was still
present_, and lasted for two hours. Though semi-tetanic in
appearance they were erroneously ascribed to m. xxvi. of liq.
strychniæ, which at the time of their appearance had not removed
the symptoms of snake-poison. They were evidently produced by the
latter and quite on a par with those occasionally occurring in man
before the strychnine is administered, and almost invariably in
dogs. As long as coma is present with other symptoms denoting the
snake-poison to be in active operation, such convulsions rather
call for the antidote, than contra indicate its use, for the
strychnine never produces them until it has completely conquered
the snake-poison, and even then they are always preceded by local
spasms and never set in suddenly. Timid medical men, when
administering the antidote and anxiously watching for the dreaded
strychnine effects, are too apt to see them in the slightest
irregular muscular action.
CASE 43, reported by Dr. Johnson, of Avoca, patient bitten by a
tiger snake, was comatose, pulseless, with very shallow
respiration, &c., and restored by three injections of m. xvi., xv.
and x. within less than three hours.
CASE 44.--Reported in _Australian Journal of Pharmacy_, from
Tasmania, treated by Dr. Tofft, of Campbell Town. The report
concludes: We have had some fatal cases of snakebite already this
season, and the successful treatment in the above case has created
a strong feeling in favour of strychnine in such emergencies.
CASES 45 TO 49.--Reported by Dr. Alex. Barber to _A.M. Gazette_.
He writes: "During the last year I treated four cases of snakebite
successfully with strychnine. In one of these, a bite of a brown
snake, I injected three doses of m. xx. each of liq. strych. P.B.,
in all over half a grain, in one hour."
CASE 50.--Reported by Dr. Barrington, of Benalla (Vic.), bite of
tiger snake, symptoms moderate. Completely removed in three hours
by 57 minims of liq. strych. P.B.
_Notes of eight cases as reported to the "Australasian Medical
Gazette" for July and November, 1892, by R. P. Banerjee,
B.A., G.B.M.S.L., Medical Officer, Salt Mines, Pachhadra,
Rajputana, India_:--
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 strychniæ; 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
constitution. 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 passages 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
constitution. While on duty he went round the salt pit, near his
beat. Suddenly he felt a prick 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 appetite; 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 passed 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; interstitial 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 quantity of the antidote in this case administered was
only 110 minims of a one in 120 solution of strychniæ acetas, or
11/12ths of a grain of that drug. Considering the extremely
venomous nature of the snake and the large quantities of
strychnine required in some of the previously reported cases of
echis and bungarus bites, the quantity 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 quantity 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 asserted 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 perishing 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 gratitude 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 noble 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 practitioner 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 confrère. 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 quantity 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 quantity 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 quantities 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. strychniæ 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
practitioners, 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
practitioner, 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 illustrates 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 passes 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 albuminates. 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 practitioner 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.
[Illustration]
CONCLUSION.
In the little work submitted herewith to the medical profession and the
general public, for both of whom it is intended, the author may justly
claim to have solved the difficult and long-standing problem of
snake-poison. We have at last a correct theory of its action, and, what
is of more importance to the public, we have an effective antidote.
These facts, being as fully established in these pages as any scientific
facts can be, the most exacting and even captious criticism will not
upset, nor can further research add anything very material to the
writer's deductions and their final result.
In order to show how an obscure Australian country practitioner
succeeded in a discovery, for which all his predecessors in this field
of research had laboured in vain, it will be necessary in conclusion to
give a short history of the discovery as by slow degrees it has
originated and matured in the writer's mind, who during the last 35
years with respect to this subject had followed the advice which
Schiller gives in his grand poem, "Die Glocke:"--
Wer etwas Treffliches leisten will,
Hätt' gern was Grossesgeboren,
Der sammle still und unerschlafft
Im kleinsten Punkte die grösste Kraft,
which, translated into English, means that whoever aims at any great
achievement must quietly, but indefatigably, concentrate the highest
force on the smallest point. Now this smallest point has to the writer
been snake-poison from the very commencement of his Australian career.
When yet a new-chum, a vigorous tiger snake gave him the first lesson on
the action of the insidious venom which nearly cost him his life, but
afforded some valuable glimpses into the mystery of snakebite--in fact,
gave him the key to unlock that mystery. On analysing the horrid
sensations he had experienced before he lost consciousness, and even
after regaining it, he saw "depressed nerve-action, emanating from the
central nervous system," written on the face of every one of them, so
much so that this became the foundation and corner stone of his present
structure, which, however, it took him a quarter of a century to erect;
for the material he required, namely, cases of snakebite observed from
an early stage, and from which all disturbing elements were excluded,
did not occur very frequently in his practice. Though he lived all the
time among mountains, the beautiful Australian Alps, on the rivers and
creeks of which snakes are abundant, and though these creatures and
anything connected with them had an almost fascinating interest for him,
years sometimes elapsed without adding one single good case to his
notes. Sometimes his patients were dead when he reached them, and all
his entreaties for an autopsy were in vain with the relatives. More
frequently he found that they were not bitten at all, and only suffered
from the effects of fear or of enormous doses of alcohol. On persons
really bitten, but completely paralysed and comatose, observations were
also unsatisfactory, as they had to be supplemented by second-hand
evidence obtained from those who had been with them before they became
unconscious. Thus within 25 years the author did not see more than
half-a-dozen really instructive cases; and frequently his desire for
more evidence overcame his reluctance to inflict on animals the agony of
snakebite he had himself endured, and he made a few experiments, but
soon gave them up again as unsatisfactory. All the evidence, however, he
had thus far collected tended to confirm the correctness of his ideas as
to the action of snake-poison. At last, some ten years ago, he obtained
absolute certainty, and this, strange to relate, by a case of spider
bite.
He was called early one morning to visit a little boy, two years old,
and on examination found that he presented symptoms almost identical
with those of snakebite poisoning. Although there was no evidence of the
child having come in contact with a snake, the writer naturally
concluded that during the night a snake had obtained access to the
bedroom through the open door or window, and after biting the child
sleeping in its low cot, had escaped again. He therefore searched most
carefully for the usual two punctures, but they were not to be found.
The child evidently laboured under the effect of some poison, and
spiderbite suggested itself, but the symptoms were so much more
aggravated than anything the writer had frequently seen of spiderbite
that he hesitated to accept it as the cause, although it appeared almost
the only possible one. A careful inquiry into the history of the case
elicited from the mother the important fact that on the previous
afternoon the little fellow, just able to toddle about, had gradually
lost the use of his legs, and also become very peevish, and that
suspecting nothing but a little temporary indisposition, she had put him
to bed, to find him in the morning all but dead. He was scarcely
breathing when the writer saw him, and only the stethoscope gave
evidence of the heart still beating feebly. His body was very cold,
pupils widely dilated, and the sight even apparently gone, the eyes wide
open, staring fixedly upwards and not noticing a lighted match in
closest proximity to them. Consciousness also appeared extinct, as
liquids introduced into the mouth were not swallowed. Examining once
more for traces of spiderbite in the skin, the writer noticed faint red
stripes extending up the arm from a little cut on the right index finger
near the nail, and on inquiry it was ascertained at last from an elder
brother that he had seen the child pick up a little black spider with a
red back, hold it for some time between thumb and index finger, and then
throw it away. This was evidently the Katipo (_Latrodectus icelio_), the
poison of which acts on the same principle as snake-poison, but
generally much milder. The greater severity of its action in this case
was accounted for by the mandibles having been inserted into the cut,
and the insect, being squeezed by the child, having emptied the whole
available contents of its poison gland into the cellular tissue exposed
in the cut, whence it was quickly absorbed. This also accounted for the
absence of all irritation and of the neuralgic pains usually
accompanying spiderbite, when the mandibles merely perforate the
epidermis and the poison is deposited in the upper cutis, where
absorption is slow and local irritation consequently greater.
Minuteness of detail in relating this case must be excused on account of
the extreme interest and importance attached to it. Being brought about
under such peculiar and almost unique circumstances it presented the
effects of spider-poison in a superlative degree and showed them to be
identical with those of snake-poison. But whilst the latter ushers in
the symptoms with such rapidity that they cover each other and are
difficult of separate analysis, in this case the highly significant
paresis of the lower extremities, evidently of central origin, remained
separate for some time. Taking this symptom for his guide and
interpreting the formidable array of the others, developed during the
night, on the same principle, the writer's diagnosis of the case, as it
presented itself to him, was paralysis of the motor and vaso-motor
nerve-centres. This, he found, and this alone could explain all the
symptoms, and he therefore determined to put its correctness to a
practical test. There was but one remedy to make this test with and this
had to be applied without delay, for the child was rapidly sinking and
had almost ceased to breathe. _One twelfth of a grain_ of strychnine was
therefore injected in the arm, a bold dose for so young a child, but, as
the result showed, exactly the one that was required. The test was
eminently successful. Having to leave the child immediately after the
injection, the writer on returning in half an hour found his little
patient sitting up in bed, perfectly restored, with both poisons so
completely neutralising each other, that not a trace of either could be
detected. Thus the writer's structure was at last completed, and an
insignificant spider furnished the last material required for an
important discovery.
There are a few hypothetical points yet in the explanation of some of
the symptoms of snakebite-poisoning by the writer's theory, but these
imperfections are more those of science than of the theory. The whole
subject of vaso-motor paralysis for instance, and of the pathological
changes that follow it, is more or less a _terra incognita_. Diapedesis
is now supposed to be the result of blood pressure, but it occurs in
snakebite, where blood pressure is at zero. Feoktistow, we have seen,
produced it locally on the mesentery of animals with normal blood
pressure, whilst Banerjee arrested by strychnine-injections profuse
hæmorrhages from all the mucous surfaces, which were no doubt the result
of diapedesis. We know that neither snake-poison nor strychnine affect
the nerve ends but only the nerve cells. There must therefore be nerve
cells at or near the terminations of the nerves regulating the
capillary circulation in the mucous membranes, but microscopical anatomy
has yet to find them, for minute ganglia have only been discovered at
present in sympathetic nerve ends of the abdomen.
On other subjects also, besides that of vaso-motor paralysis, the
strychnine treatment of snakebite has thrown an unexpected light. We did
not know before it was demonstrated by this treatment that sleep is
merely a reduced discharge of motor-nerve force, a partial turning off
of the motor-batteries, by which, through rest, they are invigorated for
fresh action during the waking hours, and that the degrees of this
reduction range in their effects from sleep, more or less deep, down to
coma, and can be raised again from coma to sleep, and from sleep to
complete wakefulness. We knew that every movement and action is brought
about by a discharge of this force, but we did not know that even the
silent thought must be carried on the wings of it, and cannot take place
without it, at least not in our present state of existence. All these
important revelations are now the property of science, and it will be
well for science to take note of them.
* * * * *
In conclusion, the writer may be permitted to express his joy and
thankfulness for having been made the instrument, by Divine Providence,
to confer a boon on humanity that will prevent much suffering and
thousands of premature, untimely deaths.
+-----------------------------------------------+
| Transcriber's Note: |
| |
| Inconsistent hyphenation and spelling in the |
| original document have been preserved. |
| |
| Typographical errors corrected in the text: |
| |
| Page 23 intracardial changed to intracardiac |
| Page 69 Banarjee changed to Banerjee |
| Page 73 ease changed to case |
+-----------------------------------------------+
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