Dec.,
SNAKEBITE IN CENTRAL PROVINCES.
1915.]
?i[if|inal Hrficlcs. ANALYSIS OF SNAKE-BITE CASES REPORTED IN THE CENTRAL PROVINCES. Bv G. W. P.
DENNYS, e.itE.,
Colonel, i.m.s.,
Inspector-General of
Civil Hospitals, C. P.
It may appear almost a work of supererogation to publish this list of 53 cases of snake-bite, but I am tempted to do so to show, if nothingelse, how difficult it is to form any definite conclusions regarding the merits of the three forms of treatment hitherto generally in use, from the clinical reports of cases treated at medical institutions, because 1. The injection of lethal doses cannot be
proved,
2. In the majority of cases the snake is not identified. 3. In very few cases only is one form of treatment adopted, hence the impossibility of attributing the cure to any particular treatment. These cases also show how easy it is for those who have not studied the subject to jump at false conclusions, and to attribute cures to a particular form of treatment which was probably in no way responsible for the recovery of the
patient.
The list I attach shows 53 cases, of which 51 reported by Medical Officers or subordinates during the period from January 1912 to September 1915. Many of these bites were proved to have been caused by poisonous snakes, while the rest may possibly have been due to the were
same
If were we
cause. we
omit
probably
have 50
(9), (12),
and (35) which from poisonous snakes, to analyse, with 2G deaths, or
cases
not bites
cases
of 52 per cent. One or more of the following three methods of treatment were adopted in these 50 cases. As is well known, the objects aimed at by each were as follows :? a
mortality
Methods
of
Treatment.
A.?Ligature. Object?to arrest the circulation in the bitten part and to prevent thereby absorption of venom into the blood stream. B.?Lauder Brunton's treatment, i.e., incision and rubbing in of permanganate of potassium crystals. Object?to neutralise the venom under the tissues at the bitten part. of intrasubcutaneously venously. Object?to neutralise the venom after its absorption into the general circulation before its fixation in the nerve centres,
C.?Antivenene treatment, i.e., injections
Antivenene
either
or
441
In view of the extreme rapidity with which snake venom is absorbed, as demonstrated long ago by Fayrer, and more lately by Bannerman in his experiments on dogs in the Parel Laboratory, and by Acton and Knowles in their ex-
periments on rats, rabbits, monkeys, and dogs at the Pasteur Institute of India at Kasauli, it may now be taken as 'proved that a ligature applied more than 15 minutes after infliction of a bite is useless, because one or more Minimal Lethal doses of the venom will have been absorbed into the circulation within that time. For similar reasons we may take it that incision and application of permanganate crystals more than 15 minutes after the bite is quite useless. I propose then discussing first, only, the cases in which ligature or Lauder Brunton's treatment or both were applied within 15 minutes after the bite. A. Ligature.?Ligature was applied in 39 of the cases in this list, but in most it was much too late to be of any use. Moreover, most of the reports do not state by what means the
ligatures i.e., string, bandage or rubber tubino-, or their situation. It is probable that some of them were quite useless because of not being tight enough to completely arrest the circulation, or because they were applied on forearms or lower legs in which, owing to the existence of two bones, the circulation cannot be completely arrested by ligature, however tightly applied. We have then, in this list, only 19 cases in which the ligature was applied within 15. minutes of the bite. Of these 19 cases, 3 died, giving a mortality of 15*79 per cent. Cases (8), (30),'and (49) had ligatures applied within five minutes, and all died in spite of Lauder Brunton's treatment or Antivenene or both, in addition to ligature. The snake was not identified in any were
applied,
of the three cases. Of the remaining 16 cases that recovered in only four was the snake
definitely identified, viz.
:?
Case (18)?Echis carinata.
Lauder Brunton's treat-
ment and ligature. No symptoms Case (23)?Cobra. Lauder Brunton s treatment and ligature. No symptoms. Case (24)?Krait. Lauder Brunton s treatment and ligature. No symptoms. Case (31)?Krait. Lauder Brunton's treatment and ligature. Only local symptoms.
Each of these four cases has its interest. In (18) Nitric Acid was applied to the bite
case
immediately. In case (23)
the wound was well sucked, and the man said he had been bitten on two previous occasions and had cured himself by sucking the wounds. In cases (24) and (31) the ligature and Lauder Brunton's treatment were very promptly applied. But in view of the total failure of case
(49)
442
THE INDIAN MEDICAL GAZETTE.
in whicli ligature, Lauder Brunton's treatment and Antivenene were all very promptly applied, the question naturally arises whether these four cases received lethal doses. Of the remaining 12 cases that recovered, I think we may safely eliminate cases (9), (12), and (35), as not cases of bites by poisonous snakes. We are then left with nine cases to
discuss,
viz.,
cases
and
(44), (45), (47),
(13), (22), (29), (33), (41), (48).
Case (13)?Snake described by patient as Cobra. All three treatments applied within reasonable time. Some slight symptoms. No proof of lethal dose. Cure cannot be attributed to any particular treatment. Case (22)?Snake unknown. Slight symptoms. No proof of lethal dose. Cure possibly attributable to ligature and Antivenene. Case (29)?Snake unknown. Lethal dose not proved. Some symptoms. All three treatments applied within reasonable time. Impossible to say which, if any, of the treatments was responsible for the cure. Case (33)?Snake described by patient as Cobra. Slight symptoms. Lethal dose not proved. Cure cannot be attributed to any of the three treatments adopted. Case (41)?If snake had been identified and lethal dose proved, this might be said to be a case of cure by ligature and Lauder Brunton's treatment. Unfortunately/ neither can be proved, and the one puncture seen might have been caused by a thorn. There were no
symptoms. Case
(44)?The
above remarks apply to this case, there were two distinct punctures the is in favour of a snake-bite.
except that
as
probability Case (45)?Snake
unknown. Doubtful if ligature and Lauder Brunton's treatment were applied in time to be of any real use. No distinct symptoms of snake-bite. Doubtful if the Antivenene had anything to do with cure. Case (47)?Snake not known. All three treatments adopted within reasonable time. Distinct symptoms which lasted 12 hours. Impossible to say if lethal dose was injected, and which, if any, of the three treatments was responsible for cure. Case (48)?Snake described by patient as Cobra. No symptoms. Lethal dose not proved. Ligature applied at once, but very loosely. Antivenene treatment applied, 20cc. subcutaneously after 2? hours.
Conclusions regarding
Though these ing the merits
ligature.
prove very little regardotherwise of ligature as a temporary means of arresting the absorption of snake venom, I think they offer the following
suggestions 1. That the
people
ligature.
19
cases
or
:?
one
cannot
too
strongly impress
on
early application of (8), (30), and (49) show that
necessity
for very
Cases applied within five minutes after the bite, a ligature does not always prevent the absorption of a lethal dose.
a
even
if
2. That the failure of some of these cases may have been due to the ligature not having been applied sufficiently tightly, and that a certain amount of circulation still existed in the limb which permitted the absorption of the poison,
[Dec.,
1915.
3. That the failure of others may have been clue to the ligature being applied on a limb containing two bones such as the leg or forearm, in which the circulation cannot be completely arrested by a ligature.
ligature should consist, if possible, piece of stout indiarubber tubing, as pointed out by Captains Acton and Knowles. But as it is practically impossible to keep a stock of such ligatures in every village and hamlet where a snake-bite may occur, this suggestion can only apply to hospitals and dispensaries, and possibly other public to police stations, schools and 4. That the
of a
institutions. should not be loosened minutes after the intraBut Acton and venous injection of Antivenene. Knowles have pointed out that it is seldom a tight ligature can be tolerated for more than about 20 minutes, owing to the great pain it causes. It is probable, therefore, that many ligatures, even if properly applied in the first place, will not be retained till after the patient has had the opportunity of an intravenous injection of Antivenene. The ligature then is only likely to be of service if applied very tightly within a very few minutes after the bite, on a limb that contains only one bone, and if the patient can get to a medical man for intravenous injection of Antivenene within 20 minutes after the bite. or
5. That the removed till
ligature some
Lauder Brunton's treatment.?This was adopted in 45 cases, but in only 10 was it applied within 15 minutes, so these 10 cases only need be discussed. Of these 10 cases, 9 recovered and only one died, giving a mortality of 10 per cent. Sir Lauder Brunton advocates the incision and permanganate treatment to be used immediately after a ligature has been applied. This was done in most of the cases reported. The exceptions B.
were:? Case (10)?Snake unknown. Lethal dose not proved. No marked symptoms. The husband of patient (a policeman) immediately incised the part and rubbed in permanganate crystals, but applied no ligature. Antivenene injected 45 minutes after bite. Cure cannot with certainty be attributed to Lauder Brunton's treatment.
Case (21)?Snake described by villagers as Bungarus fasciatus (but this cannot be relied on). Lauder Brunton's treatment adopted immediately by villagers. No ligature applied. Case of little value as it was only reported by villagers.
Eight
cases
remain to be
discussed, viz. (23).
(24), (27), (29), (31), (41), (47),
and
(49).
Cuse (23)?Has been discussed under A. Cure cannot with any certainty be attributed to Lauder Brunton's treatment. Case (24)?Snake identified as Bungarus coeruleus. No proof of lethal dose, otherwise cure might be attributed to Lauder Brunton's treatment and ligature Case ment
(27)?Snake unknown. Lauder Brunton's treatwrongly applied. Ligature too late, Probably
Dec.,
FAILURE OF THE PERMANGANATE TREATMENT.
1915.]
not
poisonous close, as some symptoms should have been apparent 50 minutes after bite. Case (29)?Very doubtful if Lauder Brunton's treatment was applied in time to be of any use. If lethal dose was injected, cure may have been due toAntivenene more probably than Lauder Brunton's treatment. Case (31)?Snake definitely identified as Krait. If lethal dose could be proved, cure might fairly be attributed to Lauder Brunton's treatment and ligature.
(41)?Has been discussed under A. (47)?Has been discussed under A. Case (49)?Snake unknown, but little doubt that ltehal dose by poisonous snake had been injected. Case tends to show futility of early ligature and Lauder Brunton's treatment, i.e., five minutes and eight minutes after bite respectively, and also disappointing effects of subcutaneous injection of Antivenene ten minutes after bite. It is difficult to reconcile the statement made by the Sub-Assistant Surgeon that up to 3i hours after bite, Case
Case
no constitutional symptoms had manifested themselves except giddiness, and I doubt extremely if the Sub-
Assistant
Surgeon had really kept the patient under observation, or recorded the facts correctly. Patient is said to have died in a fit," eight hours after bite? probably convulsions as a result of Cobra bite. Case very carelessly and badly reported by Sub-Assistant Surgeon. "
Conclusions
regarding
Lauder Brunton's
Treatment. In not
one
of the
cases
can
the
cure
be defi-
nitely attributed to incision and rubbing in of permanganate crystals, because there is no proof that a lethal dose was injected, and because in In view, howsome, Antivenene was also used. ever, of the elaborate experiments conducted by Captains Acton and Knowles on various animals there can, I think, be little cloubt left in the minds of medical men that this form of treatment is wholly unreliable, and that the use of the Lauder Brunton lancet shoidd be abandoned, as there is experimental proof that other remedies are considerably more efficacious." Of the local remedies they think the best is a subcutaneous injection of 10 to 20 cc. of a 1 per cent, to 5 per cent, solution of Grold Chloride, or, when the bites are on fingers or toes, an injection "
of i to 1 cc. of a concentrated solution of Grold Chloride at several sites in the neighbourhood of the punctures. Captains Acton and Knowles say: The cases of cure by local incision and rubbing in of potassium permanganate some hours after the bite fall into the category of cases where a non-lethal dose was given. ]STo treatment at all would have been attended with equal success." G. Antivenene.?The list shows 41 cases so treated. Cases (9) and (12) might be omitted from consideration as they were probably not cases of bites by poisonous snakes. This then leaves us 39 cases for consideration, with 25 deaths, or a mortality of 64*10 per cent. It is only fair to mention in connection with this high mortality that many cases in which
443
Autivenene was used, arrived in a more or less moribund condition. The serum was used only as a last resort with little or no hope of any benefit being derived. On the other hand, in quite a large number of the cases in which Antivenene was not used, and in which the mortality was comparatively low, no symptoms had manifested themselves some time after the bite, and there was reason, therefore, for thinking either that the bite had not been inflicted by a poisonous snake, or that a non-lethal dose had been injected. It is obviously absurd to inject Antivenene when a patient comes in many hours after the bite, with no symptoms whatever. This then may account for the comparatively high mortality among the cases treated with Antivenene, as compared with those not so treated. Calmette considered the antitoxic effects of Antivenene would manifest themselves almost immediately when injected intravenously, and in two or three hours if injected He thought that two doses of 10 cc. injected subcutaneously, one to three hours after the bite, would be quite sufficient to prevent death from a bite from a venomous snake. He was also of " opinion that the intervention would be very efficacious H hours after the bite in the case of a fall-grown man, if the intoxication has not reached a period too advanced." In otherswords, if subcutaneous injection takes, say, two to manifest its antitoxic effects, and is 1 given h hours after the bite, marked improvement in the symptoms may be expected hours In cases of intravenous bite. the after the improvement should appear immethe symptoms have not advanced if diately too far i.e.. if the venom has not become fixed in the nerve centres. Major (now SurgeonGeneral) Lyons, who submitted a report after visiting the Pasteur Institute at Lille in 1899, thought the benefit would be marked even when H hours had elapsed after the bite, if a o-ood ligature had been immediately applied, and the absorption of venom had thereby been arrested. Let us now see liow far these opinions are borne out in the 39 cases reported to have been treated with Antivenene.
subcutaneously.
hours'
Injection,
more"than
We will first consider only the cases in which Antivenene was injected within two hours of the bite, because it is only in such cases that any benefit from the treatment can be expected. There were 20 such cases with 10 deaths, or a mortality of 50 per cent. We will eliminate cases (1), (2)? (4), (7), (16), (32), and (50) in which there were marked symptoms before the injection of Antivenene. The
disappointing failures then
Case
(8)?Ligature applied immediately. Snake unNo symptoms before Antivenene, Antivenene
known.
were :?
444
THE INDIAN MEDICAL GAZETTE
30 minutes after, viz., 40 cc. subcutaneously, little later 40 ec. intravenously. All symptoms appeared after the injections. Death in 2\ hours. Case (34)?Ligature and Lauder Brunton's treatment too late. No symptoms before Antivenene, which was injected (30 cc.) subcutaneously If hours after bite. Symptoms commenced half an hour after injection. Snake suspected to be Cobra. Death 2i hours after. Patient was a small boy, aged seven.
injected and
Conclusions
a
Case (49)?Snake unknown. Lauder Brunton's treatment 8
Note,?Cases (8) and (49)
are
minutes,
particularly disappoint-
show that even with very early ligature and of Antivenene, a cure cannot be assured.
In none was the snake identified, but in three, viz. (13), (33), and (38) there was reason to think it was a Cobra.
(a)
Cases with
probably
no
not
lethal doses.
symptoms (15) and (27). These poisonous snakes. Certainly not
Cases with slight symptoms (10), (13), (22), (29), and (47). All these presented some sympIn a few they were distinctly indicative of snake toms. In all Antivenene was injected subcutaneously. venom. Unfortunately, there is no proof that lethal doses of venom were injected in any.
(b)
(33), (45),
(c) Case with marked symptoms (38). This is the only really interesting case. It was very carefully treated and reported by an intelligent Military Assistant Surgeon. Ligature and Lauder Brunton's treatment were both applied too late to be of any use (30 minutes after bite). 20 cc. of Antivenene was injected
into each basilic vein two hours after bite, i.e., after very marked symptoms had manifested themselves. SympSnake not identified but toms rapidly disappeared. was probably a Cobra. Unfortunately lethal dose But the rapid disappearance of the was not proved. symptoms after injections intravenously of Antivenene, shows at any rate that, even when marked symptoms have appeared, this treatment may result in cure.
In the
19 cases the Antivenene was than two hours after the bite injected when no benefit from the treatment could be expected. In many the snake was not identified, but distinct symptoms of snake poisoning were present either before or after Antivenene used. Of these 19 cases 15 died, giving a was mortality of 78'95 per cent. This is in marked contrast to the 50 per cent, mortality of cases treated with Antivenene within two hours of the The only case among these deserving bite. special notice is:?
remaining
more
Ca.se
(36)?Snake
Echis.- Marked venene
40
cc.
was.
suspected
of
being Cobra,
1. That
if
injected
intravenously more
The successful cases were (10), (13), (15), (22), (27), (29), (33), (38), (45), and (47).
were
Antivenene
either subcutaneously or than two hours after bite, it is likely to be of little use, especially if symptoms have far advanced. In the 19 cases of this sort there was a mortality of 78'95 per cent., and this would probably have been very much higher had it been possible to prove that lethal doses had been injected in each case.
"
minutes. and Antivenene (20 cc. subcutaneously) 10 minutes after bite. Only slight symptoms before Antivenene. Severe symptoms set in 3|- hours after bite. Death 8 hours after bite.
ing and injection
regarding
1915.
Treatment.
5
Ligature
[Dec.,
or
Anti symptoms before treatment. subcutaneously given 11|- hours after
bite. Severe sloughing and ulceration set in, possibly due to the permanganate, but patient recovered. Little doubt that lethal dose of venom was not injected in this case, and that Antivenene had nothing to do with the cure.
2. That
if injected intravenously within two if symptoms have far advanced, it may result in rapid disappearance of symptoms and recovery. (Case 38). 3. That if injected either intravenously or subcutaneously within two hours and before marked symptoms have appeared, even if a good ligature was applied immediately, it does not always save life. (Case 8).
hours,
even
4. That if injected subcutaneously after marked have appeared, it is useless. (Cases 1, 2, 4, 32, 34, 49, and 50). 5. That if injected intravenously more than two hours after bite when marked sypmtoms have appeared, it may sometimes effect a cure and is worth trying.
symptoms
G. That it
is advisable to inject Antivenene intravenously in all cases, if there are distinct fang punctures, no matter if symptoms are present or not, or whether a ligature has been applied immediately or not, provided the patient comes for treatment not more than four hours after the bite. 7. That it is better not to use Antivenene subcutaneously, owing to its slow absorption and the possibility of marked symptoms appearing before it has had time to prevent them. 8. That not less than 40 cc. of Antivenene should be injected intravenously in the case of an adult man. It is doubtful if any smaller dose would be of any use in any case.
Time of Bite.?Captains Acton and Knowles, I.M.S., in their most interesting and instructive " report Studies on the Treatment of Snake Bite" (iSection 1), published in the Indian Journal of Medical Research of July 1914, have pointed " out that during the daytime almost every I strike of the Cobra is a blind one, i.e., one with closed mouth?the snake usually missing its object, grazing its nose on the ground, and recoiling with a good deal of hard swearing. This statement was fully confirmed in a series of operations I conducted in the hot weather of 1897 at Delhi, with the object of procuring large quantities of snake venom for Professor Calmette of Lille, at the request of the Government of India. As these operations were not of a scientific nature, but as they brought to light many interesting facts in connection with the habits "
1915
Dec.,
INDICATIONS FOR TREATMENT OF SNAKE-BITES.
]
extract from my connection :?
snakes, which might be of interest to the general public, I published an account of the of July 1900, same in the Gornhill Magazine Antivenene." The under the nom-de-plume of case however is quite different with Vipers, Kraits and King Cobras, all of which strike at any hour of the day or night with open mouth and elevated fangs. With the object of ascertaining to what extent the above facts may influence the incidence of mortality from snakebite, I have extracted the following information from the list of 51 cases attached to this report, of
which
the
reported :? Day bites (between Total 17.
hour
exact
(Deaths
64-71%.
Night bites (after 7 Total 34. (Deaths
44-12%.
of
the
bite
list is
in
interesting
this
Cases
reported in the hot weather. (1st April to 31st October.)
"
in
445
4
April May
3 6
June
July August September
10
October
2 7
Total
40
8
was
or 78'43% of the Mortality 55%.
total. Deaths 22.
reported, in the cold weathei (1st November to 31st March.)
Cases 7
and 7 11, Cures A.M.
p.m.
15,
p.m.). 6), Mortality
January February
and before 7 a.m.). Cures 19), Mortality
Cobras definitely identified bites 9. Deaths 7.
or
March November December
suspected.
Total
1 5 2 3 0
11
Day
Deaths 4.
Mortality 50%. Total 17.
ment
Season of the Bite.?My snake-bite operations in Delhi were conducted during the hot weather and rains only, because the famous snake-catcher I employed expressed his inability to produce any considerable number of reptiles during the cold weather months. Most of the venomous snakes, I believe, hybernate during the winter. This is the with Colubrine so specially species. During this period, they retire into holes and crevices Delhi snake-catcher and cease to feed. My asserted that during the winter the bites of snake were much less dangerous than in the summer, because they produced very little venom when they were hybernating. The following
Deaths 4.
From these figures we may assume that as a rule the bites of venomous snakes, when they are active and on the feed, are markedly more fatal than when they are hybernating.
Mortality 77*78%. Night bites 8.
These figures then do not confirm the state" that the Cobra during the daytime with because we strikes mouth," open rarely have nine such cases with seven deaths. Nor do the figures show that snake-bites generally the daytime. are less fatal when inflicted during But we have to In fact, they show the contrary. remember that in the majority of the 26 fatal cases in this list, the snake was not identified. It is natural that in the dark, identification It is probable also, judging should be difficult. from the symptoms exhibited in many of these fatal cases, that the bite of the unseen snake was inflicted by a Cobra, and I think we may fairly assume that this snake is responsible for more deaths among human beings than any other, owing to the fact that its common habitat is in and around human dwellings.
or 21*57% of the total. Mortality 36'36%.
! '
!
Site of the Bite.?Captains Acton and Knowles in their report have referred to the many factors that may cause the bite of a certainly venomous snake to be ineffectual, among which they mention the difficulty experienced in closing the lower jaw when the bite is inflicted on large flat surfaces, such as the calf of the leg. In this connection, the following extract from my list is interesting and instructive : Of the 53 cases, 21 bites were inflicted in parts of the body in which the bite was likely to be most effectual, such as the fingers, toes, and eaVs, In such cases the lower jaw can, as a rule, be firmly closed, and a full quantity of venom injected. Of these 21 cases 12 died, giving a 14,/. mortality of In the remaining 31 cases the bites were inflicted on broader surfaces, such as the. thigh, neck, ankle, foot, and leg. There were among these 31 cases only 13 deaths, giving a mortality of 41-94%.
These figures go to show the truth of Captains Acton's and Knowles' statement the regarding enhanced danger of bites on the smaller parts of At the same time, it is the body. just in these kinds of cases that most hope of saving life exists by immediate amputation.
General Conclusions for
1. very
and
Indications
Treatment.
Apply a ligature above the bitten part tightly as soon after the bite as possible.
446
the indiaw Medical gazette.
The ligature should consist preferably of of stout indiarubber tubing, failing which it should be of string or cotton cloth.
[Dec.,
1915.
2.
a
piece
33 fct ?s
Ligatures on fingers, toes or ears should be applied very tightly above the bite, and it is advisable to apply a second ligature above the elbow or knee, as the case may be. 4. It is useless to apply ligatures on limbs between the wrist and elbow, between the ankle 3.
and
knee,
or on
5. The sucked.
the foot
bitten
or
Q
m
o
be
vigorously
7. before
SNAKEBITE IN CENTRAL PROVINCES.
1915.]
?i[if|inal Hrficlcs. ANALYSIS OF SNAKE-BITE CASES REPORTED IN THE CENTRAL PROVINCES. Bv G. W. P.
DENNYS, e.itE.,
Colonel, i.m.s.,
Inspector-General of
Civil Hospitals, C. P.
It may appear almost a work of supererogation to publish this list of 53 cases of snake-bite, but I am tempted to do so to show, if nothingelse, how difficult it is to form any definite conclusions regarding the merits of the three forms of treatment hitherto generally in use, from the clinical reports of cases treated at medical institutions, because 1. The injection of lethal doses cannot be
proved,
2. In the majority of cases the snake is not identified. 3. In very few cases only is one form of treatment adopted, hence the impossibility of attributing the cure to any particular treatment. These cases also show how easy it is for those who have not studied the subject to jump at false conclusions, and to attribute cures to a particular form of treatment which was probably in no way responsible for the recovery of the
patient.
The list I attach shows 53 cases, of which 51 reported by Medical Officers or subordinates during the period from January 1912 to September 1915. Many of these bites were proved to have been caused by poisonous snakes, while the rest may possibly have been due to the were
same
If were we
cause. we
omit
probably
have 50
(9), (12),
and (35) which from poisonous snakes, to analyse, with 2G deaths, or
cases
not bites
cases
of 52 per cent. One or more of the following three methods of treatment were adopted in these 50 cases. As is well known, the objects aimed at by each were as follows :? a
mortality
Methods
of
Treatment.
A.?Ligature. Object?to arrest the circulation in the bitten part and to prevent thereby absorption of venom into the blood stream. B.?Lauder Brunton's treatment, i.e., incision and rubbing in of permanganate of potassium crystals. Object?to neutralise the venom under the tissues at the bitten part. of intrasubcutaneously venously. Object?to neutralise the venom after its absorption into the general circulation before its fixation in the nerve centres,
C.?Antivenene treatment, i.e., injections
Antivenene
either
or
441
In view of the extreme rapidity with which snake venom is absorbed, as demonstrated long ago by Fayrer, and more lately by Bannerman in his experiments on dogs in the Parel Laboratory, and by Acton and Knowles in their ex-
periments on rats, rabbits, monkeys, and dogs at the Pasteur Institute of India at Kasauli, it may now be taken as 'proved that a ligature applied more than 15 minutes after infliction of a bite is useless, because one or more Minimal Lethal doses of the venom will have been absorbed into the circulation within that time. For similar reasons we may take it that incision and application of permanganate crystals more than 15 minutes after the bite is quite useless. I propose then discussing first, only, the cases in which ligature or Lauder Brunton's treatment or both were applied within 15 minutes after the bite. A. Ligature.?Ligature was applied in 39 of the cases in this list, but in most it was much too late to be of any use. Moreover, most of the reports do not state by what means the
ligatures i.e., string, bandage or rubber tubino-, or their situation. It is probable that some of them were quite useless because of not being tight enough to completely arrest the circulation, or because they were applied on forearms or lower legs in which, owing to the existence of two bones, the circulation cannot be completely arrested by ligature, however tightly applied. We have then, in this list, only 19 cases in which the ligature was applied within 15. minutes of the bite. Of these 19 cases, 3 died, giving a mortality of 15*79 per cent. Cases (8), (30),'and (49) had ligatures applied within five minutes, and all died in spite of Lauder Brunton's treatment or Antivenene or both, in addition to ligature. The snake was not identified in any were
applied,
of the three cases. Of the remaining 16 cases that recovered in only four was the snake
definitely identified, viz.
:?
Case (18)?Echis carinata.
Lauder Brunton's treat-
ment and ligature. No symptoms Case (23)?Cobra. Lauder Brunton s treatment and ligature. No symptoms. Case (24)?Krait. Lauder Brunton s treatment and ligature. No symptoms. Case (31)?Krait. Lauder Brunton's treatment and ligature. Only local symptoms.
Each of these four cases has its interest. In (18) Nitric Acid was applied to the bite
case
immediately. In case (23)
the wound was well sucked, and the man said he had been bitten on two previous occasions and had cured himself by sucking the wounds. In cases (24) and (31) the ligature and Lauder Brunton's treatment were very promptly applied. But in view of the total failure of case
(49)
442
THE INDIAN MEDICAL GAZETTE.
in whicli ligature, Lauder Brunton's treatment and Antivenene were all very promptly applied, the question naturally arises whether these four cases received lethal doses. Of the remaining 12 cases that recovered, I think we may safely eliminate cases (9), (12), and (35), as not cases of bites by poisonous snakes. We are then left with nine cases to
discuss,
viz.,
cases
and
(44), (45), (47),
(13), (22), (29), (33), (41), (48).
Case (13)?Snake described by patient as Cobra. All three treatments applied within reasonable time. Some slight symptoms. No proof of lethal dose. Cure cannot be attributed to any particular treatment. Case (22)?Snake unknown. Slight symptoms. No proof of lethal dose. Cure possibly attributable to ligature and Antivenene. Case (29)?Snake unknown. Lethal dose not proved. Some symptoms. All three treatments applied within reasonable time. Impossible to say which, if any, of the treatments was responsible for the cure. Case (33)?Snake described by patient as Cobra. Slight symptoms. Lethal dose not proved. Cure cannot be attributed to any of the three treatments adopted. Case (41)?If snake had been identified and lethal dose proved, this might be said to be a case of cure by ligature and Lauder Brunton's treatment. Unfortunately/ neither can be proved, and the one puncture seen might have been caused by a thorn. There were no
symptoms. Case
(44)?The
above remarks apply to this case, there were two distinct punctures the is in favour of a snake-bite.
except that
as
probability Case (45)?Snake
unknown. Doubtful if ligature and Lauder Brunton's treatment were applied in time to be of any real use. No distinct symptoms of snake-bite. Doubtful if the Antivenene had anything to do with cure. Case (47)?Snake not known. All three treatments adopted within reasonable time. Distinct symptoms which lasted 12 hours. Impossible to say if lethal dose was injected, and which, if any, of the three treatments was responsible for cure. Case (48)?Snake described by patient as Cobra. No symptoms. Lethal dose not proved. Ligature applied at once, but very loosely. Antivenene treatment applied, 20cc. subcutaneously after 2? hours.
Conclusions regarding
Though these ing the merits
ligature.
prove very little regardotherwise of ligature as a temporary means of arresting the absorption of snake venom, I think they offer the following
suggestions 1. That the
people
ligature.
19
cases
or
:?
one
cannot
too
strongly impress
on
early application of (8), (30), and (49) show that
necessity
for very
Cases applied within five minutes after the bite, a ligature does not always prevent the absorption of a lethal dose.
a
even
if
2. That the failure of some of these cases may have been due to the ligature not having been applied sufficiently tightly, and that a certain amount of circulation still existed in the limb which permitted the absorption of the poison,
[Dec.,
1915.
3. That the failure of others may have been clue to the ligature being applied on a limb containing two bones such as the leg or forearm, in which the circulation cannot be completely arrested by a ligature.
ligature should consist, if possible, piece of stout indiarubber tubing, as pointed out by Captains Acton and Knowles. But as it is practically impossible to keep a stock of such ligatures in every village and hamlet where a snake-bite may occur, this suggestion can only apply to hospitals and dispensaries, and possibly other public to police stations, schools and 4. That the
of a
institutions. should not be loosened minutes after the intraBut Acton and venous injection of Antivenene. Knowles have pointed out that it is seldom a tight ligature can be tolerated for more than about 20 minutes, owing to the great pain it causes. It is probable, therefore, that many ligatures, even if properly applied in the first place, will not be retained till after the patient has had the opportunity of an intravenous injection of Antivenene. The ligature then is only likely to be of service if applied very tightly within a very few minutes after the bite, on a limb that contains only one bone, and if the patient can get to a medical man for intravenous injection of Antivenene within 20 minutes after the bite. or
5. That the removed till
ligature some
Lauder Brunton's treatment.?This was adopted in 45 cases, but in only 10 was it applied within 15 minutes, so these 10 cases only need be discussed. Of these 10 cases, 9 recovered and only one died, giving a mortality of 10 per cent. Sir Lauder Brunton advocates the incision and permanganate treatment to be used immediately after a ligature has been applied. This was done in most of the cases reported. The exceptions B.
were:? Case (10)?Snake unknown. Lethal dose not proved. No marked symptoms. The husband of patient (a policeman) immediately incised the part and rubbed in permanganate crystals, but applied no ligature. Antivenene injected 45 minutes after bite. Cure cannot with certainty be attributed to Lauder Brunton's treatment.
Case (21)?Snake described by villagers as Bungarus fasciatus (but this cannot be relied on). Lauder Brunton's treatment adopted immediately by villagers. No ligature applied. Case of little value as it was only reported by villagers.
Eight
cases
remain to be
discussed, viz. (23).
(24), (27), (29), (31), (41), (47),
and
(49).
Cuse (23)?Has been discussed under A. Cure cannot with any certainty be attributed to Lauder Brunton's treatment. Case (24)?Snake identified as Bungarus coeruleus. No proof of lethal dose, otherwise cure might be attributed to Lauder Brunton's treatment and ligature Case ment
(27)?Snake unknown. Lauder Brunton's treatwrongly applied. Ligature too late, Probably
Dec.,
FAILURE OF THE PERMANGANATE TREATMENT.
1915.]
not
poisonous close, as some symptoms should have been apparent 50 minutes after bite. Case (29)?Very doubtful if Lauder Brunton's treatment was applied in time to be of any use. If lethal dose was injected, cure may have been due toAntivenene more probably than Lauder Brunton's treatment. Case (31)?Snake definitely identified as Krait. If lethal dose could be proved, cure might fairly be attributed to Lauder Brunton's treatment and ligature.
(41)?Has been discussed under A. (47)?Has been discussed under A. Case (49)?Snake unknown, but little doubt that ltehal dose by poisonous snake had been injected. Case tends to show futility of early ligature and Lauder Brunton's treatment, i.e., five minutes and eight minutes after bite respectively, and also disappointing effects of subcutaneous injection of Antivenene ten minutes after bite. It is difficult to reconcile the statement made by the Sub-Assistant Surgeon that up to 3i hours after bite, Case
Case
no constitutional symptoms had manifested themselves except giddiness, and I doubt extremely if the Sub-
Assistant
Surgeon had really kept the patient under observation, or recorded the facts correctly. Patient is said to have died in a fit," eight hours after bite? probably convulsions as a result of Cobra bite. Case very carelessly and badly reported by Sub-Assistant Surgeon. "
Conclusions
regarding
Lauder Brunton's
Treatment. In not
one
of the
cases
can
the
cure
be defi-
nitely attributed to incision and rubbing in of permanganate crystals, because there is no proof that a lethal dose was injected, and because in In view, howsome, Antivenene was also used. ever, of the elaborate experiments conducted by Captains Acton and Knowles on various animals there can, I think, be little cloubt left in the minds of medical men that this form of treatment is wholly unreliable, and that the use of the Lauder Brunton lancet shoidd be abandoned, as there is experimental proof that other remedies are considerably more efficacious." Of the local remedies they think the best is a subcutaneous injection of 10 to 20 cc. of a 1 per cent, to 5 per cent, solution of Grold Chloride, or, when the bites are on fingers or toes, an injection "
of i to 1 cc. of a concentrated solution of Grold Chloride at several sites in the neighbourhood of the punctures. Captains Acton and Knowles say: The cases of cure by local incision and rubbing in of potassium permanganate some hours after the bite fall into the category of cases where a non-lethal dose was given. ]STo treatment at all would have been attended with equal success." G. Antivenene.?The list shows 41 cases so treated. Cases (9) and (12) might be omitted from consideration as they were probably not cases of bites by poisonous snakes. This then leaves us 39 cases for consideration, with 25 deaths, or a mortality of 64*10 per cent. It is only fair to mention in connection with this high mortality that many cases in which
443
Autivenene was used, arrived in a more or less moribund condition. The serum was used only as a last resort with little or no hope of any benefit being derived. On the other hand, in quite a large number of the cases in which Antivenene was not used, and in which the mortality was comparatively low, no symptoms had manifested themselves some time after the bite, and there was reason, therefore, for thinking either that the bite had not been inflicted by a poisonous snake, or that a non-lethal dose had been injected. It is obviously absurd to inject Antivenene when a patient comes in many hours after the bite, with no symptoms whatever. This then may account for the comparatively high mortality among the cases treated with Antivenene, as compared with those not so treated. Calmette considered the antitoxic effects of Antivenene would manifest themselves almost immediately when injected intravenously, and in two or three hours if injected He thought that two doses of 10 cc. injected subcutaneously, one to three hours after the bite, would be quite sufficient to prevent death from a bite from a venomous snake. He was also of " opinion that the intervention would be very efficacious H hours after the bite in the case of a fall-grown man, if the intoxication has not reached a period too advanced." In otherswords, if subcutaneous injection takes, say, two to manifest its antitoxic effects, and is 1 given h hours after the bite, marked improvement in the symptoms may be expected hours In cases of intravenous bite. the after the improvement should appear immethe symptoms have not advanced if diately too far i.e.. if the venom has not become fixed in the nerve centres. Major (now SurgeonGeneral) Lyons, who submitted a report after visiting the Pasteur Institute at Lille in 1899, thought the benefit would be marked even when H hours had elapsed after the bite, if a o-ood ligature had been immediately applied, and the absorption of venom had thereby been arrested. Let us now see liow far these opinions are borne out in the 39 cases reported to have been treated with Antivenene.
subcutaneously.
hours'
Injection,
more"than
We will first consider only the cases in which Antivenene was injected within two hours of the bite, because it is only in such cases that any benefit from the treatment can be expected. There were 20 such cases with 10 deaths, or a mortality of 50 per cent. We will eliminate cases (1), (2)? (4), (7), (16), (32), and (50) in which there were marked symptoms before the injection of Antivenene. The
disappointing failures then
Case
(8)?Ligature applied immediately. Snake unNo symptoms before Antivenene, Antivenene
known.
were :?
444
THE INDIAN MEDICAL GAZETTE
30 minutes after, viz., 40 cc. subcutaneously, little later 40 ec. intravenously. All symptoms appeared after the injections. Death in 2\ hours. Case (34)?Ligature and Lauder Brunton's treatment too late. No symptoms before Antivenene, which was injected (30 cc.) subcutaneously If hours after bite. Symptoms commenced half an hour after injection. Snake suspected to be Cobra. Death 2i hours after. Patient was a small boy, aged seven.
injected and
Conclusions
a
Case (49)?Snake unknown. Lauder Brunton's treatment 8
Note,?Cases (8) and (49)
are
minutes,
particularly disappoint-
show that even with very early ligature and of Antivenene, a cure cannot be assured.
In none was the snake identified, but in three, viz. (13), (33), and (38) there was reason to think it was a Cobra.
(a)
Cases with
probably
no
not
lethal doses.
symptoms (15) and (27). These poisonous snakes. Certainly not
Cases with slight symptoms (10), (13), (22), (29), and (47). All these presented some sympIn a few they were distinctly indicative of snake toms. In all Antivenene was injected subcutaneously. venom. Unfortunately, there is no proof that lethal doses of venom were injected in any.
(b)
(33), (45),
(c) Case with marked symptoms (38). This is the only really interesting case. It was very carefully treated and reported by an intelligent Military Assistant Surgeon. Ligature and Lauder Brunton's treatment were both applied too late to be of any use (30 minutes after bite). 20 cc. of Antivenene was injected
into each basilic vein two hours after bite, i.e., after very marked symptoms had manifested themselves. SympSnake not identified but toms rapidly disappeared. was probably a Cobra. Unfortunately lethal dose But the rapid disappearance of the was not proved. symptoms after injections intravenously of Antivenene, shows at any rate that, even when marked symptoms have appeared, this treatment may result in cure.
In the
19 cases the Antivenene was than two hours after the bite injected when no benefit from the treatment could be expected. In many the snake was not identified, but distinct symptoms of snake poisoning were present either before or after Antivenene used. Of these 19 cases 15 died, giving a was mortality of 78'95 per cent. This is in marked contrast to the 50 per cent, mortality of cases treated with Antivenene within two hours of the The only case among these deserving bite. special notice is:?
remaining
more
Ca.se
(36)?Snake
Echis.- Marked venene
40
cc.
was.
suspected
of
being Cobra,
1. That
if
injected
intravenously more
The successful cases were (10), (13), (15), (22), (27), (29), (33), (38), (45), and (47).
were
Antivenene
either subcutaneously or than two hours after bite, it is likely to be of little use, especially if symptoms have far advanced. In the 19 cases of this sort there was a mortality of 78'95 per cent., and this would probably have been very much higher had it been possible to prove that lethal doses had been injected in each case.
"
minutes. and Antivenene (20 cc. subcutaneously) 10 minutes after bite. Only slight symptoms before Antivenene. Severe symptoms set in 3|- hours after bite. Death 8 hours after bite.
ing and injection
regarding
1915.
Treatment.
5
Ligature
[Dec.,
or
Anti symptoms before treatment. subcutaneously given 11|- hours after
bite. Severe sloughing and ulceration set in, possibly due to the permanganate, but patient recovered. Little doubt that lethal dose of venom was not injected in this case, and that Antivenene had nothing to do with the cure.
2. That
if injected intravenously within two if symptoms have far advanced, it may result in rapid disappearance of symptoms and recovery. (Case 38). 3. That if injected either intravenously or subcutaneously within two hours and before marked symptoms have appeared, even if a good ligature was applied immediately, it does not always save life. (Case 8).
hours,
even
4. That if injected subcutaneously after marked have appeared, it is useless. (Cases 1, 2, 4, 32, 34, 49, and 50). 5. That if injected intravenously more than two hours after bite when marked sypmtoms have appeared, it may sometimes effect a cure and is worth trying.
symptoms
G. That it
is advisable to inject Antivenene intravenously in all cases, if there are distinct fang punctures, no matter if symptoms are present or not, or whether a ligature has been applied immediately or not, provided the patient comes for treatment not more than four hours after the bite. 7. That it is better not to use Antivenene subcutaneously, owing to its slow absorption and the possibility of marked symptoms appearing before it has had time to prevent them. 8. That not less than 40 cc. of Antivenene should be injected intravenously in the case of an adult man. It is doubtful if any smaller dose would be of any use in any case.
Time of Bite.?Captains Acton and Knowles, I.M.S., in their most interesting and instructive " report Studies on the Treatment of Snake Bite" (iSection 1), published in the Indian Journal of Medical Research of July 1914, have pointed " out that during the daytime almost every I strike of the Cobra is a blind one, i.e., one with closed mouth?the snake usually missing its object, grazing its nose on the ground, and recoiling with a good deal of hard swearing. This statement was fully confirmed in a series of operations I conducted in the hot weather of 1897 at Delhi, with the object of procuring large quantities of snake venom for Professor Calmette of Lille, at the request of the Government of India. As these operations were not of a scientific nature, but as they brought to light many interesting facts in connection with the habits "
1915
Dec.,
INDICATIONS FOR TREATMENT OF SNAKE-BITES.
]
extract from my connection :?
snakes, which might be of interest to the general public, I published an account of the of July 1900, same in the Gornhill Magazine Antivenene." The under the nom-de-plume of case however is quite different with Vipers, Kraits and King Cobras, all of which strike at any hour of the day or night with open mouth and elevated fangs. With the object of ascertaining to what extent the above facts may influence the incidence of mortality from snakebite, I have extracted the following information from the list of 51 cases attached to this report, of
which
the
reported :? Day bites (between Total 17.
hour
exact
(Deaths
64-71%.
Night bites (after 7 Total 34. (Deaths
44-12%.
of
the
bite
list is
in
interesting
this
Cases
reported in the hot weather. (1st April to 31st October.)
"
in
445
4
April May
3 6
June
July August September
10
October
2 7
Total
40
8
was
or 78'43% of the Mortality 55%.
total. Deaths 22.
reported, in the cold weathei (1st November to 31st March.)
Cases 7
and 7 11, Cures A.M.
p.m.
15,
p.m.). 6), Mortality
January February
and before 7 a.m.). Cures 19), Mortality
Cobras definitely identified bites 9. Deaths 7.
or
March November December
suspected.
Total
1 5 2 3 0
11
Day
Deaths 4.
Mortality 50%. Total 17.
ment
Season of the Bite.?My snake-bite operations in Delhi were conducted during the hot weather and rains only, because the famous snake-catcher I employed expressed his inability to produce any considerable number of reptiles during the cold weather months. Most of the venomous snakes, I believe, hybernate during the winter. This is the with Colubrine so specially species. During this period, they retire into holes and crevices Delhi snake-catcher and cease to feed. My asserted that during the winter the bites of snake were much less dangerous than in the summer, because they produced very little venom when they were hybernating. The following
Deaths 4.
From these figures we may assume that as a rule the bites of venomous snakes, when they are active and on the feed, are markedly more fatal than when they are hybernating.
Mortality 77*78%. Night bites 8.
These figures then do not confirm the state" that the Cobra during the daytime with because we strikes mouth," open rarely have nine such cases with seven deaths. Nor do the figures show that snake-bites generally the daytime. are less fatal when inflicted during But we have to In fact, they show the contrary. remember that in the majority of the 26 fatal cases in this list, the snake was not identified. It is natural that in the dark, identification It is probable also, judging should be difficult. from the symptoms exhibited in many of these fatal cases, that the bite of the unseen snake was inflicted by a Cobra, and I think we may fairly assume that this snake is responsible for more deaths among human beings than any other, owing to the fact that its common habitat is in and around human dwellings.
or 21*57% of the total. Mortality 36'36%.
! '
!
Site of the Bite.?Captains Acton and Knowles in their report have referred to the many factors that may cause the bite of a certainly venomous snake to be ineffectual, among which they mention the difficulty experienced in closing the lower jaw when the bite is inflicted on large flat surfaces, such as the calf of the leg. In this connection, the following extract from my list is interesting and instructive : Of the 53 cases, 21 bites were inflicted in parts of the body in which the bite was likely to be most effectual, such as the fingers, toes, and eaVs, In such cases the lower jaw can, as a rule, be firmly closed, and a full quantity of venom injected. Of these 21 cases 12 died, giving a 14,/. mortality of In the remaining 31 cases the bites were inflicted on broader surfaces, such as the. thigh, neck, ankle, foot, and leg. There were among these 31 cases only 13 deaths, giving a mortality of 41-94%.
These figures go to show the truth of Captains Acton's and Knowles' statement the regarding enhanced danger of bites on the smaller parts of At the same time, it is the body. just in these kinds of cases that most hope of saving life exists by immediate amputation.
General Conclusions for
1. very
and
Indications
Treatment.
Apply a ligature above the bitten part tightly as soon after the bite as possible.
446
the indiaw Medical gazette.
The ligature should consist preferably of of stout indiarubber tubing, failing which it should be of string or cotton cloth.
[Dec.,
1915.
2.
a
piece
33 fct ?s
Ligatures on fingers, toes or ears should be applied very tightly above the bite, and it is advisable to apply a second ligature above the elbow or knee, as the case may be. 4. It is useless to apply ligatures on limbs between the wrist and elbow, between the ankle 3.
and
knee,
or on
5. The sucked.
the foot
bitten
or
Q
m
o
be
vigorously
7. before
