A CASE OF VENOMOUS BITE BY ECHIS CARIN AT A. By Surgeon
ALCOCK, M. B.,
Indian Medical Service.
The value of tins Preface.
pure record of and addition to the records impaired by the fact
case
symptoms as
an
as
a
and sequela},
of treatment, is greatly that the patient was suffering from chronic Bright's disease. H. R. H., an English, officer of the Public Mr. H. R. Hackmail, Asst. Engineer, P. W. D., Dera Ghazi Khan Divn.
carpo-phalaugeal
Works
Department, aged 25,
of weakly constitution, was bitten on the right index finger, almost over the metajoint by the venomous viperiue
THE INDIAN MEDICAL GAZETTE.
176
snake echis caviuata,
at 4-45 P. M.,
March 1887. The accident took
on
the 27th
on the fort Mnnro in the Suleiman liills, Scene of accident. about a mile-and-a-half from the camp at Khar, in the presence of the writer and two other officers. The moment the patient called out that he was bitten, his hand was firmAccount of accily gripped immediately above dent and of first the bite, which shewed as two treatment. small points of blood about half an inch apart, and the bite excised with free incisions of a small table-knife. At the same time one of the officers, who was standing by, was directed to tie a handkerchief tightly round the wrist to act as a Then in a vessel of warm circular ligature. water, which was fortunately in readiness, the hand was depleted. When the flow of blood had ceased, the wound was carefully sucked, and then repeatedly washed in warm water. After this, compression was made higher up the arm, and the wrist relieved, to allow further bleeding from the wound. The patient was kept in the recumbent position, with the head low, the chest and throat free, and the lower part of the body covered, from the first; and frequent small doses of whisky were given. He was re-assured, and not allowed to know the nature of the snake that had bitten him. The bite was excised almost literally imThe patient was mediately after infliction. kept recumbent on the spot for an hour-aud-ahalf after the infliction of the bite. During this time there was fairly free haemorrhage from the incision; and the only stimulants at hand, namely, whisky in warm tea were administered at frequent intervals. Tlie pulss retained its normal frequency, force, and rhythm all along, the heart sounds were good, and the respiration did not show any signs of impairment. An hour after the accident, the pupils were contracted, both equally, quite First symptom, to the extent of the contracone hour after. tion of opium-poisoning. There were no subjective symptoms, not even local pain or numbness, and all that the patient complained of was a slight feeling of intoxication from the whisky he had been forced to take. At a quarter past six, an hour-and-a-half after he had been bitten, patient said he felt quite well. He was therefore slowly supported home to camp, between two brother officers. Once 011 the road, an hour and three quarters after the accident, lie vomited; Second symptom, but this was the only untoone hour and three ward symptom that occurred quarters. uutil camp was reached. of au hour, quarter Every along the road,
place
ridge,
?
[June,
ammonium carbonate
given
was
in
1888.
spirit
of
ether, these drugs having arrived from The pulse and respiration continued camp. : the pupils were dilating. good After camp was reached, and two hours and a quarter after the accident, patient felt faint, had a shivering fit, and vomited. The pupils were dilated to their very limit, and the pulse a little quickThird symptom, ened (92); but respiration two hours and was quite natural. A hypoquarter. nitrous
a
dermic injection of ether into left arm was given with good effect; and the patient was put to bed. As the whole dorsal surface of the right hand was swollen and very tense, a short longitudinal incision was made to relieve this condition, and the compressing ligature removed from the arm. Both wounds were irrigated with 1-20 carbolic lotion, dredged with iodoform, and bandaged ; and the injured arm elevated on a pillow. Up to 12 o'clock midnight stimulant and eliminant treatment was practised, hot black coffee being frequently given, and every hour small doses of spirit of chloroform and spirit of nitrous ether, in liquor of acetate of ammonia. The state of the patient was noted at regular intervals, and the following is the record :? the
7-30 P.M. pulse 92, respiration 18 r.H. pulse 8S, respiration 18
8 9
P.M.
pulse 7G, respiration
At 9 P.M. were
by
a
nausea
20
]
>
j
Temperature
normal.
and diffuse abdominal pain this was soon relieved
complained of; but turpentine stupe.
At 9-30 p.m. pulse 7G, respiration 18 1 At 10 p.m. pulse 76, respiration 18 > At 10-30p.m.pulse 76, respiration 18 )
Temperature normal.
At this time patient declared himself quite well, and had neither care for the past nor anxiety for the future. At 11 p.m. the pulse and respiration were before. Temperature 99.? At 12 o'clock the wounds on the had previously Haemorrhage.
as
trouble
at
hand, which given 110 all, began to feel
The dressings were removed at once, uneasy. and the wounds were found to be bleeding fast. All night long the bleeding continued, resisting every method of treat2nd day. ment, until at 10 o'clock 011 tlie morning of the 28tli it Avas partially arrestThe whole ed by forci-pressure and elevation. of that day oozing persisted ; but otherwise patient was (airly well, and took plenty of The forearm was swollen, but liquid food. not red or hot, and only slightly painful 011 pressure. There was also a little axillary tenThe temperature was normal, mornderness. and evening, At 6-80 r. M. the oozing ing became profuse hemorrhage, which Avas again not checked until 8 p. m. Oozing still goino011.
CASE OF BITE BY ECHIS CARINATA.
June, 1888.] 29th March.?Patient 3rd
passed Haemorrhage
day.
uncontrollable
a
pood night.
again
became
at 6 A. M.,
and
every means to
stay it were tried, under until 10 A. M., by ligature " en musse" round a tenaculum. Shortly after 10 a. M., an officious servant administered carbolic acid lotion (1-20) for water. Patient swallowed between two and three ounces of this, but called for assistance immediately. Before absorption could have taken place, the stomach was evacuated. Fortunately the stomach was fairly loaded with fluid when the carbolic lotion entered it. And this and the prompt emesis considered, it does not seem probable that the patient took any harm ; or that carbolic acid poisoning became a complicating factor in the case. The wounds continued to ooze throughout the day, and again broke out into violent haemorrhage at 6 p. M. The flow was not arrested until late at night, by a comAt press and strapping. midnight a renewed flow loosened the strapping, which was re-adi justed. On this occasion the Change in colour blood was noticed to be pureof blood. coloured, a character which it retained for several days. The patient's general condition was very satisfactory this day, though lie was weakened by continuous loss of I here was no rise of blood. temperature, and the forearm and hand, though swollen, gave no other pathological indications.
though
was
brought
not
?
...I.-
^
30th March.?At 3-30 a. m. I was aroused to attend to very profuse 4 th day. bleeding from the wounds on
Nothing would
the hand. last resort
relays
check
of servants
it,
were
until in the
employed
to
pressure, under an antiseptic on the wounds. At 9 a. m. this was the and bleeding stopped, immediately recommenced. Under fixing the wounds with asceptic needles and the application of a hare-lip suture round these checked the bleeding, for the first time, entirely, though at the cost of some injury to the soft parts round the wounds. At 1 P. M. the patient complained that the mouth and gums felt sore, and it was II pc ra o r r h a ge then found that there was from mouth, phaoozing of blood from the gums, rynx, &c. and tongue, cheeks,
keep
up compress
digital
palate,
This continued for'the
rest of naso-pharynx. the day, and apparently all the following night. The patient's general condition fair; very
weak from loss of blood ; no rises of temperature. Right hand, forearm and lower part of arm swollen and hot, but quite painless.
March.?There 5th p.m. ?urm
clay.
The hand was
was
one
rush of blood
a.m., wliieli was not brought to a stop until 2-30
at
11
was
(edematous
less swollen, but the foreand hot, and slightl}'
Haemorrhage ceased.
tender
177
on
pressure.
lary tenderness.
No axil-
Oozing from
mouth continued all day. There whs a slight sub-conjuuctival haemorrhage in the left eye. The whole body had a dirty icteric tint. And the temperature rose, at
night.
The treatment during these four days was chiefly surgical, and directed to arresting haemorrhage. Continuous attendance on the patient was imperative. Absolute rest and recumbency were insisted 011, the diet was fluid and as nutritious as the circumstances of camp-life in a desert country would permit: the bowels were regulated ; and sleep was procured by potassium bromide. Diffusible stimulants were administered, combined with iron. And ergot and digitalis were given with a view of assisting in staying the haemorrhage. April l.s?.?The aspect of the case now begau to change, and it became Gfch day. apparent that though the direct general action of the viperine poison liad expended itself, the local destructive effect on the tissues of the hand and forearm was to be There was now no bleeding from the asserted. wounds, except wheu they were being dressed. But the whole injured hand and forearm, and lower third of the arm assumed a brawny consistence, and livid hue, with pitting oedema of the more dependent parts, although there was no pain and only slight tenderness on pressure. The skiu of the rest of the body had Commencement of a, local cellulitis. dusky icteric tint, and was very hot. Unfortunately the clinical thermometer had been broken the clay before, and the body-temperature could not be registered. Headache and dyspeptic pains were complained of, but patient explained that he frequently had attacks of these of considerable
severit}'. April 2nd
signs of progressive cellulitis of the right luiud and 7th days, forearm gradually developed Local cellulitis. themselves, but notwithstanding the extreme tension, there wa9 very little pain. The temperature remained over 100?, There was and rose about 2? every evening. still an icteric tint over the whole body, and on the chest some petechias were noticed. The wounds were dressed with all antiseptic care, and some small sloughs were separated. It is certain that there was no septic infection It is probable that free incision at any time. at this time would have been very beneficial; but the late experience of alarming haemorrhage compelled caution. A small incision was made into the most dependent part of the asdematous forearm ; but the blood gushed out so copiously, and shewed so little tendency to coagulate, that the knife was seen to be clearly contra-indicated. On the 2nd, I had leisure for the first time to to 9th
to 4til.?The
THE INDIAN MEDICAL GAZETTE.
178
Albuminuria discovered.
examine the urine. It had been noticed to be abnormally abundant, but as the patient's
diet had been almost entirely fluid, and as diuretics had also been largely given, this did not seem unnatural. Since the appliances of a camp hospital are limited, it was only possible test for the ordinarv to indices -'Ipathological albumen and sugar. Albumin was present to the extent of one-third the amount of urine tested. There was no means of finding the specific gravity. The urine was clear and extremely pale. The condition of the urine was thin, not unnaturally, perhaps, supposed to be a consequence of the change in the blood which had already been so markedly manifested; and it was not considered advisable to alarm the patient by inquiries, after a single examination of his urine. At this period another complication began to give trouble. When the Onset of inflammabite was excised, the patient, tion in right heel. ?who was a nervous and excitable man, relieved his nervous system by repeatedly kicking his right ljeel against a hard immovable rock. As his feet were clad in heelless " chaplis," and as he used great force, his heel was very sorely bruised. Pain now began to be felt on the under-surface of the heel, and the surface-temperature over the calcaneum was raised. April 5tli.?The right hand and forearm o
remained
10th to 12th days. Progressing cellulitis of right forearm.
dusky,
hot,
and
oedematous, and the absence of pain was still a marked There was pitting feature. but 110 fluctuation. 011 The two pressure, 011 the dorsum of the hand diswounds original charged a small quantity of curdy, but quite
inoffensive, pus. The temperature
was, as
before, always about
day,
ami
The condition of the urine was unchanged ; and now it appeared that for Discovery of several years the patient had Bright's disease. been in the habit of passing an abnormal amount of urine of a very pale colour, both day and night; that lie suffered much from thirst; that his skin was habitually dry, and that he did not perspire even in hot weather; that his appetite had been bad for years, and his digestion troublesome, and that he had periodical attacks of very painful dyspepsia; and that from time to time he had been prostrated by severe attacks of headache. The patient was His appetite very weak. was very bad; and it required much pressure and firmness to get him to take food of any kind. rlhe treatment during this time was mainly dietetic and hygienic. The patient was kept at rest in an airy tent. Liquid nourishment was
quantities
at
1888.
frequent regular
much alcoholic stimulant as was considered safe, considering the condition The bowels were regulated, of the kidneys. was incited when necessary, and iron with sleep vegetable bitters and mineral acids administered at appropriate times. Quinine as an antipyretic. The local measures were rest, and fomentation, day and night, of the inflamed arm. And the wounds on the hand were dressed antiseptically The injured heel was elevated twice a day. and fomented.
intervals and
as
April 8th.?Fluctuation
was detected above the wrist in the morninor, and 13th day. Operaiis soon as advisable the patient tion for evacuation was anaesthetized with chloroof pus. form, and a free incision made As there was only ordinary into the forearm. haemorrhage, and as the blood was of normal colour and clotting properly, the incision was upwards for three inches, in order to some masses of away bring sloughed connective
prolonged tissue
As the skin
on
the dorsum of the hand was to be undermined, it
found
13th day. Kemoval of sloughs.
was a
up by cut, which liberated a
thoroughly opened
long
crreat deal of black slouch. Other incisions were made
o
...
higher up the arm for drainage. A certain amount of pus escaped with the sloughs ; it was with
quite
counter-openings sweet.
irrigation
Free
and
syringing'
with
1-20
carbolic lotion was carried out : drainage-tubes inserted: all incisions dredged with iodoform. The tubes
procurable freed wool
were
drained into
antiseptic from
oily
pads
of the
dressing, namely, matter
soap, then
only
cotton-
by boiling with
teased into soft even sheets, and subsequently made antiseptic by slow heating with turpentine This whs found to be ;i very in a closed tin. reliable antiseptic dressing, though not in any way adapted tor permanent contact with a wound (i.e. more than 24 hours). The temperature was 100*3? after the operation, and only rose *2? in the evening. April 9 th.?Morning temperature 99*7?. There was ver)T f ree discharge 14th day. Evacuafrom the tubes. Patient comtion of hypoderplained of pain in the left mic" abscess in left arm. forearm, and 011 examination the site of the hypodermic injection which was made on the evening of the accident, was found to be swollen, but not reel The demonstration of fluctuation was or hot. followed by the introduction of the knife, and Both arms about an ounce of pns escaped. were attended to again in the evening, when temperature was 101 "5?. April 10th.?There was fluctuation over the "
100? in the morning and through the about 102? in the evening.
in small
given
[June,
Turpentine Wool."
"
15th day. Evacuation of abscess at
right lieel. A
ounces
It
absence of redness and heat, again in this instance, was rewas
inserted,
and
of pus evacuated. All wounds were dressed antiseptically twice a day. The temperature morning and evening was 99'5?. ]\th to 20th April.?The patient's condition was unvaried all this time. 16th to 25th. days. The right hand, on its dorsal Line of demarcation region, the right forearm, and of cellulitis. the arm up to well-defined line of demarcation three inches above the elbow, continued to discharge healthy pus; and from time to time big black subcutaneous sloughs There was no element of septiwere removed. city, and above the line of demarcation the arm or was was not healthy. There or tenderness ^ inany the swelling axilla, or ?i-~ ..?o-IUo Superficial burrow- any sign of absorption by the ing of pus?expullymphatics. A pressure-sore sion of sloughs. formed under the internal con'
dyle, notwithstanding padding. the right foot discharged freely
The abscess 111 pus and sloughs,
and showed a tendency to burrow indefinitely. The abscess in the left arm after excavating up to the elbow, healed but slowly, when it was laid open. The temperature was normal on the 11th, remained below 100? for nearly three days, and then gradually rose by zig-ziigs, until 011 the evening of the 20th it had reached 102-6?. The patient was weak but cheerful, and after a very serious remonstrance applied himself to his food with a certain amount of interest. He slept fairly well, and did not need sedatives. The condition of the urine was, 011 the whole,
unchanged. The general
treatment during this time was much as before. The patient was removed from his bed to a well cushioned easy chair in the forenoon, and in the afternoon was carried out to the Government garden, where he was placed in the shade until early evening. He was fed frequently with small quantities of light food, and pressed to eat more solid nourishment. Alcohol, well diluted with soda-water, was thought necessary. Fruit was given when it could be obtained. Preparations of iron and various vegetable bitters were given daily. Antipyrin in 20 grain doses was given to keep down the evening rise of temperature. It certainly did keep down the temperature, but as its effect was very transient, and as there was 110 hyper-pyrexia, it was discarded after a time in favour of quinine. It is worth recording that, although the patient nil all
quite indifferent to the usual diaphoretics, antipyrin asserted its sudorific the local treatment the injured
Diaphoretic effccfc of antipyrin. As to
?*? ??
was
.
kept rested and elevated and drained. well irrigated aud syringed out twice daily with solution of potassium permanganate, and latterly with weak red lotion (lavender and zinc), after which all wounds were dressed with iodoform aud turpentine wool; and latterly with iodoform, wet lint, and salicylic wool. The right foot was dressed in the same manner. Patient did not complain of pain, except during and for about au hour after the dressing of the wounds. 21 st April?Patient complained of severe pain when visited early in the 2Gth day. Deep morning, and the forearm burrowing (pro- was fouud to be very red, bably along extenhot, and tense, and showing sor sheaths.) inflammatory oedema over the supinator and extensor regions. The arm was immovable, and any attempt at flexion caused Examination great pain in the elbow joiut. under chloroform was resolved on, and under this anaesthetic a free incision was made through the inflamed area, liberating pus and sloughs from the intermuscular septa. As it was now apparent that the pus was burrowing deeply, and as, Operation for li- owing to the destruction of of deepberation the sheaths of the extensor seated pus. tendons, and of some of the tendons themselves, the future efficiency of the urm seemed hopelessly impaired, it was feared that amputation above the line of demarcation would be necessary. Such a grave conclusion required confirmation, and the only course was Removal to Dera to take the patient into Dera Grhazi Khan. Ghazi Khan for consultation This course with Surgeon-major Robinson. taken, and the patient was 26th, 27th days. removed in a dandy, after The drainage careful dressing of the wounds. tubes were abandoned, as it was feared the shaking of transport might disturb them, and lead to irritation. The wounds were dressed at the usual times, en route, with iodoform and 28th day. wet lint, under salicylic wool This dressing seemed ami guttapercha tissue. to do good, and when, on the 23rd April Dr. Robinson was consulted, the idea of amputation arm was
right heel, which w:is troubling the patient again. The
Syme's knife
markable. about two
effect.
179
CASE OF BITE BY ECHIS CARINATA.
June, 1888.]
was
was
abandoned.
On the 2?th 29th
in
the Professor of Surgery at Lahore, met Dr. Robinson and the writer
April.?Dr. Perry,
day.
consultation, and
amputation.
The notes of
his
was
also
against _
the case are by Dr. Robinson, into whose charge the patient was delivered; and they have been abridged
the_rest
'
Robinson's Dr. account of termination of case.
as
25th
opinion or
follows:?
April.?Wounds
011
light
hand and
arm
?
180
THE INDIAN MEDICAL GAZETTE.
looking well: some counteropenings necessary to liberate Temperature, morning 100*8?, evening
30th day.
pus. 101 7?.
Patient in a clean bare -ventilated by openings and punkah. 26th
room,
well
99*8?. About 5 drachms of laudable 31st day. pus from the whole right arm. Bed-sore over inner condyle stationary. About 2| drachms of pus from the right foot, from which also a slough was detached. Patient removed into the fresh air on a sofa, in the evening, when the temperature wsis 101*2?. 27th April. Morning temperature 99'4?. Wounds looking well, and 32nd day. discharging less. Evening
April.
?
Morning temperature
temperature 101*2?; complains of headache. 28th April.?A pocket of pus evacuted above the wrist. Headache and dys-
33rd day. Slight pulmonary compli-
pepsia prominent.
temperature 11020.
Morning
Wound of foot verv well. Evening Examination of cheat temperature 99'80. reveals impairment of vesicular murmur. 2(Jth April.?Morning temperature 10040. A pocket of pus discovered along 34th day. extensors of thumb, opened and drained. Evening temperature, 100-6?. 3Oth April.?Morning temperature 100'2? 2b drachms of pus from the 35th day. Onset the arm, about li drachm of diarrhoea. from the foot. Appetite very bad, three loose motions passed last night. Evening temperature 101?. lsf May.?Morning 99"6?. temperature ?Wounds all looking well. 36th day. Appetite bad. Complained of diarrhoea with griping and tenesmus ; two evacuations examined; these were of a dirty grey colour, with clots of blood. 2nd May.?Patient'sbowelsmoved three times cation.
J
37th
during
day.
the
o
night.
Morning
temperature 100?. All the ?wounds on the arm looking well, and discharging but little. The foot'is also looking well,
though there
is
a
small
the os calcis. three times
ot dead bone in still bad. Defecated
piece
Appetite during the morning. Evening
perature 101-4?. 3rd
38th
May.?Morning day.
temperature
tem-
OO'S0.
Bowels acted twice during the night. The -wounds on
the arm fairly well; some exuberant gianula A small pocket ot tions touched with caustic. bone. pus opened over the fifth metacarpal 4th May.?Bowels still loose, and the evacuations mixed with fluid blood. 39th day. Collapse About 2 drachms of pus came threatening. from the arm, and only a few drops from the foot. Patient apathetic and somnolent; and unwilling to take food. Pupils
dilated.
[June,
1888.
was disturbed by the frequent action of the 40th day, Pulse bowels. weak and and skin Surface of tlie cold, body thready. weak and apathetic. Patient freely. perspiring Sphincter and relaxing. Towards eveninga griping, loose, bloody motion was passed. The wounds were looking: well, and discharging O O very little. His 6th May.?Patient had a bad night. wounds were dressed in the 41st on Death day. morning and were clean and The asthenia increased hour by hour, healthy. and patient died unconscious shortly afternoon. The treatment under Dr. Robinson was conducted on much the same principles ns before. The patient was kept in a clean, bare room, recumbent, and was daily removed into the fresh air. He was pressed with small quantities of nutritious food at frequent intervals, and was allowed plenty of appropriate fluids for thirst. The dysenteric complication was treatThe Avounds were dressed much as before, ed. but the sinuses in the arm and foot were drained with carbolized horse hair, which was without doubt an improvement on the india-rnbber-
bth
May.?Patient's sleep
?
i
tubing.
Dr. Robinson examined the urine.
It was three and limes between two Examination of greater in quantity than the urine. The specific normal flow. was 1002 to 1004. The amount of al-
gravity
bumin was unchanged Jrd to -|th. Microscopic examination of the sediment showed pus, epithelium, hyaline cast, and many granular casts. Conclusion.?The fatal result in this case was almost undoubtedly due to Conclusion. Bright's disease, and it seems correct to regard the snake-bite as merely an accelerating cause. I do not think that the powers of the patient
were equal to the of expenditure any serious illphysiological ness, far less equal to recuperative requirements.
reserve
Dr. Robinson concurs in this opinion. The history of the patient rather indicated that the form of the kidney disease was waxy, jxikI perhaps the presence of epithelium and in the urine pus cells supports this view. Also that the formation of the " hypodermic " fact the abscess in the left arm was preceded by the development of small tubercular like nodules Dr. Robinson has in the subcutaneous tissue. the flux from the not stated whether he
regards
bowels as a consequence of tubercular ulceration. This unfortunate co-existence of Blight's
disease also detracts from the value of the case from the desirable point of view of snake-bite treatment. Overlooking this for the moment, the marked symptom of the bite of echis carinata seems to be the fluidity of the blood after the absorption of the poison?a well-known effect
of
viperiue
venom.
CASE OF FOREIGN BODY IN THE WINDPIPE.
June, 1888.]
It seems to me that this liquefaction of the blood rather contra-indicates the too reckless use of the knife in cases of echis-bite. In this case, if the means of performing amputation had been at hand, it would have been necessary to remove the index-finger, so low was it bitten, through its metacarpal bone. This would have left a large incised surface, from which, judging by the terrific bleeding from the comparatively small incisions actually made, I fully believe that the haemorrhage might have been fatal. If a second case of echis-bite were to occur in my practice, I should, I think, run all the risks of the tightest possible circular ligature, and then destroy the venom-injected tissues with fire or escharotics. Camp Khar, 14th June, 1887.
\ J
]8i
ALCOCK, M. B.,
Indian Medical Service.
The value of tins Preface.
pure record of and addition to the records impaired by the fact
case
symptoms as
an
as
a
and sequela},
of treatment, is greatly that the patient was suffering from chronic Bright's disease. H. R. H., an English, officer of the Public Mr. H. R. Hackmail, Asst. Engineer, P. W. D., Dera Ghazi Khan Divn.
carpo-phalaugeal
Works
Department, aged 25,
of weakly constitution, was bitten on the right index finger, almost over the metajoint by the venomous viperiue
THE INDIAN MEDICAL GAZETTE.
176
snake echis caviuata,
at 4-45 P. M.,
March 1887. The accident took
on
the 27th
on the fort Mnnro in the Suleiman liills, Scene of accident. about a mile-and-a-half from the camp at Khar, in the presence of the writer and two other officers. The moment the patient called out that he was bitten, his hand was firmAccount of accily gripped immediately above dent and of first the bite, which shewed as two treatment. small points of blood about half an inch apart, and the bite excised with free incisions of a small table-knife. At the same time one of the officers, who was standing by, was directed to tie a handkerchief tightly round the wrist to act as a Then in a vessel of warm circular ligature. water, which was fortunately in readiness, the hand was depleted. When the flow of blood had ceased, the wound was carefully sucked, and then repeatedly washed in warm water. After this, compression was made higher up the arm, and the wrist relieved, to allow further bleeding from the wound. The patient was kept in the recumbent position, with the head low, the chest and throat free, and the lower part of the body covered, from the first; and frequent small doses of whisky were given. He was re-assured, and not allowed to know the nature of the snake that had bitten him. The bite was excised almost literally imThe patient was mediately after infliction. kept recumbent on the spot for an hour-aud-ahalf after the infliction of the bite. During this time there was fairly free haemorrhage from the incision; and the only stimulants at hand, namely, whisky in warm tea were administered at frequent intervals. Tlie pulss retained its normal frequency, force, and rhythm all along, the heart sounds were good, and the respiration did not show any signs of impairment. An hour after the accident, the pupils were contracted, both equally, quite First symptom, to the extent of the contracone hour after. tion of opium-poisoning. There were no subjective symptoms, not even local pain or numbness, and all that the patient complained of was a slight feeling of intoxication from the whisky he had been forced to take. At a quarter past six, an hour-and-a-half after he had been bitten, patient said he felt quite well. He was therefore slowly supported home to camp, between two brother officers. Once 011 the road, an hour and three quarters after the accident, lie vomited; Second symptom, but this was the only untoone hour and three ward symptom that occurred quarters. uutil camp was reached. of au hour, quarter Every along the road,
place
ridge,
?
[June,
ammonium carbonate
given
was
in
1888.
spirit
of
ether, these drugs having arrived from The pulse and respiration continued camp. : the pupils were dilating. good After camp was reached, and two hours and a quarter after the accident, patient felt faint, had a shivering fit, and vomited. The pupils were dilated to their very limit, and the pulse a little quickThird symptom, ened (92); but respiration two hours and was quite natural. A hypoquarter. nitrous
a
dermic injection of ether into left arm was given with good effect; and the patient was put to bed. As the whole dorsal surface of the right hand was swollen and very tense, a short longitudinal incision was made to relieve this condition, and the compressing ligature removed from the arm. Both wounds were irrigated with 1-20 carbolic lotion, dredged with iodoform, and bandaged ; and the injured arm elevated on a pillow. Up to 12 o'clock midnight stimulant and eliminant treatment was practised, hot black coffee being frequently given, and every hour small doses of spirit of chloroform and spirit of nitrous ether, in liquor of acetate of ammonia. The state of the patient was noted at regular intervals, and the following is the record :? the
7-30 P.M. pulse 92, respiration 18 r.H. pulse 8S, respiration 18
8 9
P.M.
pulse 7G, respiration
At 9 P.M. were
by
a
nausea
20
]
>
j
Temperature
normal.
and diffuse abdominal pain this was soon relieved
complained of; but turpentine stupe.
At 9-30 p.m. pulse 7G, respiration 18 1 At 10 p.m. pulse 76, respiration 18 > At 10-30p.m.pulse 76, respiration 18 )
Temperature normal.
At this time patient declared himself quite well, and had neither care for the past nor anxiety for the future. At 11 p.m. the pulse and respiration were before. Temperature 99.? At 12 o'clock the wounds on the had previously Haemorrhage.
as
trouble
at
hand, which given 110 all, began to feel
The dressings were removed at once, uneasy. and the wounds were found to be bleeding fast. All night long the bleeding continued, resisting every method of treat2nd day. ment, until at 10 o'clock 011 tlie morning of the 28tli it Avas partially arrestThe whole ed by forci-pressure and elevation. of that day oozing persisted ; but otherwise patient was (airly well, and took plenty of The forearm was swollen, but liquid food. not red or hot, and only slightly painful 011 pressure. There was also a little axillary tenThe temperature was normal, mornderness. and evening, At 6-80 r. M. the oozing ing became profuse hemorrhage, which Avas again not checked until 8 p. m. Oozing still goino011.
CASE OF BITE BY ECHIS CARINATA.
June, 1888.] 29th March.?Patient 3rd
passed Haemorrhage
day.
uncontrollable
a
pood night.
again
became
at 6 A. M.,
and
every means to
stay it were tried, under until 10 A. M., by ligature " en musse" round a tenaculum. Shortly after 10 a. M., an officious servant administered carbolic acid lotion (1-20) for water. Patient swallowed between two and three ounces of this, but called for assistance immediately. Before absorption could have taken place, the stomach was evacuated. Fortunately the stomach was fairly loaded with fluid when the carbolic lotion entered it. And this and the prompt emesis considered, it does not seem probable that the patient took any harm ; or that carbolic acid poisoning became a complicating factor in the case. The wounds continued to ooze throughout the day, and again broke out into violent haemorrhage at 6 p. M. The flow was not arrested until late at night, by a comAt press and strapping. midnight a renewed flow loosened the strapping, which was re-adi justed. On this occasion the Change in colour blood was noticed to be pureof blood. coloured, a character which it retained for several days. The patient's general condition was very satisfactory this day, though lie was weakened by continuous loss of I here was no rise of blood. temperature, and the forearm and hand, though swollen, gave no other pathological indications.
though
was
brought
not
?
...I.-
^
30th March.?At 3-30 a. m. I was aroused to attend to very profuse 4 th day. bleeding from the wounds on
Nothing would
the hand. last resort
relays
check
of servants
it,
were
until in the
employed
to
pressure, under an antiseptic on the wounds. At 9 a. m. this was the and bleeding stopped, immediately recommenced. Under fixing the wounds with asceptic needles and the application of a hare-lip suture round these checked the bleeding, for the first time, entirely, though at the cost of some injury to the soft parts round the wounds. At 1 P. M. the patient complained that the mouth and gums felt sore, and it was II pc ra o r r h a ge then found that there was from mouth, phaoozing of blood from the gums, rynx, &c. and tongue, cheeks,
keep
up compress
digital
palate,
This continued for'the
rest of naso-pharynx. the day, and apparently all the following night. The patient's general condition fair; very
weak from loss of blood ; no rises of temperature. Right hand, forearm and lower part of arm swollen and hot, but quite painless.
March.?There 5th p.m. ?urm
clay.
The hand was
was
one
rush of blood
a.m., wliieli was not brought to a stop until 2-30
at
11
was
(edematous
less swollen, but the foreand hot, and slightl}'
Haemorrhage ceased.
tender
177
on
pressure.
lary tenderness.
No axil-
Oozing from
mouth continued all day. There whs a slight sub-conjuuctival haemorrhage in the left eye. The whole body had a dirty icteric tint. And the temperature rose, at
night.
The treatment during these four days was chiefly surgical, and directed to arresting haemorrhage. Continuous attendance on the patient was imperative. Absolute rest and recumbency were insisted 011, the diet was fluid and as nutritious as the circumstances of camp-life in a desert country would permit: the bowels were regulated ; and sleep was procured by potassium bromide. Diffusible stimulants were administered, combined with iron. And ergot and digitalis were given with a view of assisting in staying the haemorrhage. April l.s?.?The aspect of the case now begau to change, and it became Gfch day. apparent that though the direct general action of the viperine poison liad expended itself, the local destructive effect on the tissues of the hand and forearm was to be There was now no bleeding from the asserted. wounds, except wheu they were being dressed. But the whole injured hand and forearm, and lower third of the arm assumed a brawny consistence, and livid hue, with pitting oedema of the more dependent parts, although there was no pain and only slight tenderness on pressure. The skiu of the rest of the body had Commencement of a, local cellulitis. dusky icteric tint, and was very hot. Unfortunately the clinical thermometer had been broken the clay before, and the body-temperature could not be registered. Headache and dyspeptic pains were complained of, but patient explained that he frequently had attacks of these of considerable
severit}'. April 2nd
signs of progressive cellulitis of the right luiud and 7th days, forearm gradually developed Local cellulitis. themselves, but notwithstanding the extreme tension, there wa9 very little pain. The temperature remained over 100?, There was and rose about 2? every evening. still an icteric tint over the whole body, and on the chest some petechias were noticed. The wounds were dressed with all antiseptic care, and some small sloughs were separated. It is certain that there was no septic infection It is probable that free incision at any time. at this time would have been very beneficial; but the late experience of alarming haemorrhage compelled caution. A small incision was made into the most dependent part of the asdematous forearm ; but the blood gushed out so copiously, and shewed so little tendency to coagulate, that the knife was seen to be clearly contra-indicated. On the 2nd, I had leisure for the first time to to 9th
to 4til.?The
THE INDIAN MEDICAL GAZETTE.
178
Albuminuria discovered.
examine the urine. It had been noticed to be abnormally abundant, but as the patient's
diet had been almost entirely fluid, and as diuretics had also been largely given, this did not seem unnatural. Since the appliances of a camp hospital are limited, it was only possible test for the ordinarv to indices -'Ipathological albumen and sugar. Albumin was present to the extent of one-third the amount of urine tested. There was no means of finding the specific gravity. The urine was clear and extremely pale. The condition of the urine was thin, not unnaturally, perhaps, supposed to be a consequence of the change in the blood which had already been so markedly manifested; and it was not considered advisable to alarm the patient by inquiries, after a single examination of his urine. At this period another complication began to give trouble. When the Onset of inflammabite was excised, the patient, tion in right heel. ?who was a nervous and excitable man, relieved his nervous system by repeatedly kicking his right ljeel against a hard immovable rock. As his feet were clad in heelless " chaplis," and as he used great force, his heel was very sorely bruised. Pain now began to be felt on the under-surface of the heel, and the surface-temperature over the calcaneum was raised. April 5tli.?The right hand and forearm o
remained
10th to 12th days. Progressing cellulitis of right forearm.
dusky,
hot,
and
oedematous, and the absence of pain was still a marked There was pitting feature. but 110 fluctuation. 011 The two pressure, 011 the dorsum of the hand diswounds original charged a small quantity of curdy, but quite
inoffensive, pus. The temperature
was, as
before, always about
day,
ami
The condition of the urine was unchanged ; and now it appeared that for Discovery of several years the patient had Bright's disease. been in the habit of passing an abnormal amount of urine of a very pale colour, both day and night; that lie suffered much from thirst; that his skin was habitually dry, and that he did not perspire even in hot weather; that his appetite had been bad for years, and his digestion troublesome, and that he had periodical attacks of very painful dyspepsia; and that from time to time he had been prostrated by severe attacks of headache. The patient was His appetite very weak. was very bad; and it required much pressure and firmness to get him to take food of any kind. rlhe treatment during this time was mainly dietetic and hygienic. The patient was kept at rest in an airy tent. Liquid nourishment was
quantities
at
1888.
frequent regular
much alcoholic stimulant as was considered safe, considering the condition The bowels were regulated, of the kidneys. was incited when necessary, and iron with sleep vegetable bitters and mineral acids administered at appropriate times. Quinine as an antipyretic. The local measures were rest, and fomentation, day and night, of the inflamed arm. And the wounds on the hand were dressed antiseptically The injured heel was elevated twice a day. and fomented.
intervals and
as
April 8th.?Fluctuation
was detected above the wrist in the morninor, and 13th day. Operaiis soon as advisable the patient tion for evacuation was anaesthetized with chloroof pus. form, and a free incision made As there was only ordinary into the forearm. haemorrhage, and as the blood was of normal colour and clotting properly, the incision was upwards for three inches, in order to some masses of away bring sloughed connective
prolonged tissue
As the skin
on
the dorsum of the hand was to be undermined, it
found
13th day. Kemoval of sloughs.
was a
up by cut, which liberated a
thoroughly opened
long
crreat deal of black slouch. Other incisions were made
o
...
higher up the arm for drainage. A certain amount of pus escaped with the sloughs ; it was with
quite
counter-openings sweet.
irrigation
Free
and
syringing'
with
1-20
carbolic lotion was carried out : drainage-tubes inserted: all incisions dredged with iodoform. The tubes
procurable freed wool
were
drained into
antiseptic from
oily
pads
of the
dressing, namely, matter
soap, then
only
cotton-
by boiling with
teased into soft even sheets, and subsequently made antiseptic by slow heating with turpentine This whs found to be ;i very in a closed tin. reliable antiseptic dressing, though not in any way adapted tor permanent contact with a wound (i.e. more than 24 hours). The temperature was 100*3? after the operation, and only rose *2? in the evening. April 9 th.?Morning temperature 99*7?. There was ver)T f ree discharge 14th day. Evacuafrom the tubes. Patient comtion of hypoderplained of pain in the left mic" abscess in left arm. forearm, and 011 examination the site of the hypodermic injection which was made on the evening of the accident, was found to be swollen, but not reel The demonstration of fluctuation was or hot. followed by the introduction of the knife, and Both arms about an ounce of pns escaped. were attended to again in the evening, when temperature was 101 "5?. April 10th.?There was fluctuation over the "
100? in the morning and through the about 102? in the evening.
in small
given
[June,
Turpentine Wool."
"
15th day. Evacuation of abscess at
right lieel. A
ounces
It
absence of redness and heat, again in this instance, was rewas
inserted,
and
of pus evacuated. All wounds were dressed antiseptically twice a day. The temperature morning and evening was 99'5?. ]\th to 20th April.?The patient's condition was unvaried all this time. 16th to 25th. days. The right hand, on its dorsal Line of demarcation region, the right forearm, and of cellulitis. the arm up to well-defined line of demarcation three inches above the elbow, continued to discharge healthy pus; and from time to time big black subcutaneous sloughs There was no element of septiwere removed. city, and above the line of demarcation the arm or was was not healthy. There or tenderness ^ inany the swelling axilla, or ?i-~ ..?o-IUo Superficial burrow- any sign of absorption by the ing of pus?expullymphatics. A pressure-sore sion of sloughs. formed under the internal con'
dyle, notwithstanding padding. the right foot discharged freely
The abscess 111 pus and sloughs,
and showed a tendency to burrow indefinitely. The abscess in the left arm after excavating up to the elbow, healed but slowly, when it was laid open. The temperature was normal on the 11th, remained below 100? for nearly three days, and then gradually rose by zig-ziigs, until 011 the evening of the 20th it had reached 102-6?. The patient was weak but cheerful, and after a very serious remonstrance applied himself to his food with a certain amount of interest. He slept fairly well, and did not need sedatives. The condition of the urine was, 011 the whole,
unchanged. The general
treatment during this time was much as before. The patient was removed from his bed to a well cushioned easy chair in the forenoon, and in the afternoon was carried out to the Government garden, where he was placed in the shade until early evening. He was fed frequently with small quantities of light food, and pressed to eat more solid nourishment. Alcohol, well diluted with soda-water, was thought necessary. Fruit was given when it could be obtained. Preparations of iron and various vegetable bitters were given daily. Antipyrin in 20 grain doses was given to keep down the evening rise of temperature. It certainly did keep down the temperature, but as its effect was very transient, and as there was 110 hyper-pyrexia, it was discarded after a time in favour of quinine. It is worth recording that, although the patient nil all
quite indifferent to the usual diaphoretics, antipyrin asserted its sudorific the local treatment the injured
Diaphoretic effccfc of antipyrin. As to
?*? ??
was
.
kept rested and elevated and drained. well irrigated aud syringed out twice daily with solution of potassium permanganate, and latterly with weak red lotion (lavender and zinc), after which all wounds were dressed with iodoform aud turpentine wool; and latterly with iodoform, wet lint, and salicylic wool. The right foot was dressed in the same manner. Patient did not complain of pain, except during and for about au hour after the dressing of the wounds. 21 st April?Patient complained of severe pain when visited early in the 2Gth day. Deep morning, and the forearm burrowing (pro- was fouud to be very red, bably along extenhot, and tense, and showing sor sheaths.) inflammatory oedema over the supinator and extensor regions. The arm was immovable, and any attempt at flexion caused Examination great pain in the elbow joiut. under chloroform was resolved on, and under this anaesthetic a free incision was made through the inflamed area, liberating pus and sloughs from the intermuscular septa. As it was now apparent that the pus was burrowing deeply, and as, Operation for li- owing to the destruction of of deepberation the sheaths of the extensor seated pus. tendons, and of some of the tendons themselves, the future efficiency of the urm seemed hopelessly impaired, it was feared that amputation above the line of demarcation would be necessary. Such a grave conclusion required confirmation, and the only course was Removal to Dera to take the patient into Dera Grhazi Khan. Ghazi Khan for consultation This course with Surgeon-major Robinson. taken, and the patient was 26th, 27th days. removed in a dandy, after The drainage careful dressing of the wounds. tubes were abandoned, as it was feared the shaking of transport might disturb them, and lead to irritation. The wounds were dressed at the usual times, en route, with iodoform and 28th day. wet lint, under salicylic wool This dressing seemed ami guttapercha tissue. to do good, and when, on the 23rd April Dr. Robinson was consulted, the idea of amputation arm was
right heel, which w:is troubling the patient again. The
Syme's knife
markable. about two
effect.
179
CASE OF BITE BY ECHIS CARINATA.
June, 1888.]
was
was
abandoned.
On the 2?th 29th
in
the Professor of Surgery at Lahore, met Dr. Robinson and the writer
April.?Dr. Perry,
day.
consultation, and
amputation.
The notes of
his
was
also
against _
the case are by Dr. Robinson, into whose charge the patient was delivered; and they have been abridged
the_rest
'
Robinson's Dr. account of termination of case.
as
25th
opinion or
follows:?
April.?Wounds
011
light
hand and
arm
?
180
THE INDIAN MEDICAL GAZETTE.
looking well: some counteropenings necessary to liberate Temperature, morning 100*8?, evening
30th day.
pus. 101 7?.
Patient in a clean bare -ventilated by openings and punkah. 26th
room,
well
99*8?. About 5 drachms of laudable 31st day. pus from the whole right arm. Bed-sore over inner condyle stationary. About 2| drachms of pus from the right foot, from which also a slough was detached. Patient removed into the fresh air on a sofa, in the evening, when the temperature wsis 101*2?. 27th April. Morning temperature 99'4?. Wounds looking well, and 32nd day. discharging less. Evening
April.
?
Morning temperature
temperature 101*2?; complains of headache. 28th April.?A pocket of pus evacuted above the wrist. Headache and dys-
33rd day. Slight pulmonary compli-
pepsia prominent.
temperature 11020.
Morning
Wound of foot verv well. Evening Examination of cheat temperature 99'80. reveals impairment of vesicular murmur. 2(Jth April.?Morning temperature 10040. A pocket of pus discovered along 34th day. extensors of thumb, opened and drained. Evening temperature, 100-6?. 3Oth April.?Morning temperature 100'2? 2b drachms of pus from the 35th day. Onset the arm, about li drachm of diarrhoea. from the foot. Appetite very bad, three loose motions passed last night. Evening temperature 101?. lsf May.?Morning 99"6?. temperature ?Wounds all looking well. 36th day. Appetite bad. Complained of diarrhoea with griping and tenesmus ; two evacuations examined; these were of a dirty grey colour, with clots of blood. 2nd May.?Patient'sbowelsmoved three times cation.
J
37th
during
day.
the
o
night.
Morning
temperature 100?. All the ?wounds on the arm looking well, and discharging but little. The foot'is also looking well,
though there
is
a
small
the os calcis. three times
ot dead bone in still bad. Defecated
piece
Appetite during the morning. Evening
perature 101-4?. 3rd
38th
May.?Morning day.
temperature
tem-
OO'S0.
Bowels acted twice during the night. The -wounds on
the arm fairly well; some exuberant gianula A small pocket ot tions touched with caustic. bone. pus opened over the fifth metacarpal 4th May.?Bowels still loose, and the evacuations mixed with fluid blood. 39th day. Collapse About 2 drachms of pus came threatening. from the arm, and only a few drops from the foot. Patient apathetic and somnolent; and unwilling to take food. Pupils
dilated.
[June,
1888.
was disturbed by the frequent action of the 40th day, Pulse bowels. weak and and skin Surface of tlie cold, body thready. weak and apathetic. Patient freely. perspiring Sphincter and relaxing. Towards eveninga griping, loose, bloody motion was passed. The wounds were looking: well, and discharging O O very little. His 6th May.?Patient had a bad night. wounds were dressed in the 41st on Death day. morning and were clean and The asthenia increased hour by hour, healthy. and patient died unconscious shortly afternoon. The treatment under Dr. Robinson was conducted on much the same principles ns before. The patient was kept in a clean, bare room, recumbent, and was daily removed into the fresh air. He was pressed with small quantities of nutritious food at frequent intervals, and was allowed plenty of appropriate fluids for thirst. The dysenteric complication was treatThe Avounds were dressed much as before, ed. but the sinuses in the arm and foot were drained with carbolized horse hair, which was without doubt an improvement on the india-rnbber-
bth
May.?Patient's sleep
?
i
tubing.
Dr. Robinson examined the urine.
It was three and limes between two Examination of greater in quantity than the urine. The specific normal flow. was 1002 to 1004. The amount of al-
gravity
bumin was unchanged Jrd to -|th. Microscopic examination of the sediment showed pus, epithelium, hyaline cast, and many granular casts. Conclusion.?The fatal result in this case was almost undoubtedly due to Conclusion. Bright's disease, and it seems correct to regard the snake-bite as merely an accelerating cause. I do not think that the powers of the patient
were equal to the of expenditure any serious illphysiological ness, far less equal to recuperative requirements.
reserve
Dr. Robinson concurs in this opinion. The history of the patient rather indicated that the form of the kidney disease was waxy, jxikI perhaps the presence of epithelium and in the urine pus cells supports this view. Also that the formation of the " hypodermic " fact the abscess in the left arm was preceded by the development of small tubercular like nodules Dr. Robinson has in the subcutaneous tissue. the flux from the not stated whether he
regards
bowels as a consequence of tubercular ulceration. This unfortunate co-existence of Blight's
disease also detracts from the value of the case from the desirable point of view of snake-bite treatment. Overlooking this for the moment, the marked symptom of the bite of echis carinata seems to be the fluidity of the blood after the absorption of the poison?a well-known effect
of
viperiue
venom.
CASE OF FOREIGN BODY IN THE WINDPIPE.
June, 1888.]
It seems to me that this liquefaction of the blood rather contra-indicates the too reckless use of the knife in cases of echis-bite. In this case, if the means of performing amputation had been at hand, it would have been necessary to remove the index-finger, so low was it bitten, through its metacarpal bone. This would have left a large incised surface, from which, judging by the terrific bleeding from the comparatively small incisions actually made, I fully believe that the haemorrhage might have been fatal. If a second case of echis-bite were to occur in my practice, I should, I think, run all the risks of the tightest possible circular ligature, and then destroy the venom-injected tissues with fire or escharotics. Camp Khar, 14th June, 1887.
\ J
]8i
