(Correspondence. SNAKE-POISONING AND ITS TREATMENT. To the Editor
"
of the Indian Medical Gazetted kindly permit me to offer a few remarks
ori Sir,?Will you the two cases of snake-bite contained in your issue of the 1st Bull Dr. instant, by Surgeon-General Cornish, C. I. E., and respectively. As regards Dr. Cornish's remark that neither Fayrer nor Ewart in their works dwell on the value of suction in the treatment of snake-bite, I would point out that Dr. Cornish has evidently overlooked that part of the work by the former wherein he distinctly refers to suction (vide Thanatophidia, second edition, pp. 45 and 174). Experiments with an "artificial leech" invented by Sir Joseph Fayrer for the purpose of extracting the poison from the wound have been performed, but it was found to be practically a failure. Seeing how rapidly severe acute local inflammation follows the injection of snake-poison, and the rapidity with which it is absorbed, I do not think it possible to extract any appreciable quantity of the poison by suction. When ill-efiects result to the person sucking the wound, I believe the explanation is to be found in the fact that some of the poison has been lying on the skin around the fang-wounds. I have in unquestionable and fatal cases of snake-poisoning practised continuous suction without experiencing the slightest inconvenience or detecting the presence of the poison in my mouth, but it has been my practice to wash the affected part first. As long as a ligature is applied above the bitten part and suction is employed nothing more than the uncoagnlated blood in the ligatured part is likely to be extracted together with any of the poison which it may happen at the time to contain, but the quantity is not likely to be so great as to materially affect the result. There is no evidence in Dr. Cornish's case, of the man having been poisoned, and as for the merit of the treatment adopted several other cases are on record in modes of treatment were adopted with which varying The severe pain complained an equally apparent success. of was evidently due to the ligature; and it is more than probable that the favorable termination of the case to the fact that the fang merely impinged was owing against the bony projection of the first phalanx and that no poison, or only a small quantity of poison, was ejected, and perhaps none, or next to none, was injected liypodermically. The infliction of a fatal bite involves a series of complex acts which though rapidly executed, follow one another in ordered sequence, and in Dr. Cornish's case (and, indeed, in Dr. Bull's) it is not at all probable that sufficient time elapsed between the strike of the snake and the withdrawal of the hand, for the performance of the several acts which constitute an effective bite. In neither of the above cases was it ascertained whether any poison had been injected, and in Dr. Bull's case, moreover, serious consequences followed the treatment. As regards the_temperature table given by Dr. Bull, I would observe that it is an established fact that cobra snake-poison has_ no influence on either the temperature or circulation. The rise in the temperature and the augmented pulse rate which occurred in that gentleman's case must, therefore, have been due to I notice that Dr. Bull other causes, not far to seek. records that the patient " was not to be allowed to sleep." I am aware that such a line of treatment has the sanction of antiquity, and it is not difficult to understand how its supposed efficacy came to be promulgated, though on physiological grounds it is most desirable in cases of snakepoisoning that the sufferer should be kept as quiet as possible and be allowed to sleep if lie feel so inclined
310
THE INDIAN-MEDICAL GAZETTE.
wliich is most improbable in a serious case. Snake-bite and supposed snake-bite are so frequently confounded with snakepoisoning that one can scarcely be surprised at the numerous remedies and antidotes which have from time to time been discovered. So long as they are of an innocent character not much harm can result from their adoption or administration, but when they involve dangerous or serious consequences to the patient, it becomes necessary that tliey should be had recourse to only after careful consideration, and a satisfactory diagnosis has been completed, or the remedy is likely in nine cases out of ten to prove considerably more formidable than the disease. I am strongly persuaded that in our present state of ignorance we can do nothing to cure snake-poisoning, .and very little (laterally against its prevention save in a very few exceptional cases. Dr. Wall has shown that the local effects of snake-poisoning- become unmistakeably evident in from thirty to sixty seconds after the injection of the poison, and lie has drawn attention to the great diagnostic It is essential in all cases value of these local appearances. of reputed snake-bite to ascertain whether the local characteristic appearances of snake-poisoning exist. What then should be our procedure in cases where interference is likely to be of any benefit? We should first apply a ligature, (Esnjarch's as recommended by Fay re r is the best), make .an incision or cross incisions over the fang-mark completely cutting through the tissues into the areolar tissue to ascertain whether poison has been injected, and if so, to estimate the quantity as may be readily done by the degree of local mischief apparent. If the quantity injected has been large, I have no hesitation in saying that the only remedy is amputation. If 3rtialler, deep scarifications and the application of strong nitric acid may be relied on. When the cauterisation is likely to lead to extensive sloughing, the part might be excised antiseptically, or if a limb be affected, it would, perhaps, be better to remove it?a measure attended with far less risk and certainly much less painful, than cauterisation with prolonged ligation of the limb. This latter causes terrible pain, as I have more than once witnessed (the application of ice around and I may over the ligatured part sometimes affords relief). state that it is possible for a fatal dose of poison to be and in a such a into case the vein, injected directly characteristic local appearances would, of course, be absent. This accident, however, must be exceedingly rare, and So that would be attended with rapidly fatal results. practically such cases may be excluded altogether from consideration as being little likely to come under treatment, or even observation. In certain cases Nitric acid might be rapidly injected beneath the skin all round the bitten part. After cauterisation or amputation a large dose Of Opium or Morphia might be administered with benefit. Vincent Richards, Late Member of the Snake-bite Commission. 12th October 18S0.
[November
1, 1880.
"
of the Indian Medical Gazetted kindly permit me to offer a few remarks
ori Sir,?Will you the two cases of snake-bite contained in your issue of the 1st Bull Dr. instant, by Surgeon-General Cornish, C. I. E., and respectively. As regards Dr. Cornish's remark that neither Fayrer nor Ewart in their works dwell on the value of suction in the treatment of snake-bite, I would point out that Dr. Cornish has evidently overlooked that part of the work by the former wherein he distinctly refers to suction (vide Thanatophidia, second edition, pp. 45 and 174). Experiments with an "artificial leech" invented by Sir Joseph Fayrer for the purpose of extracting the poison from the wound have been performed, but it was found to be practically a failure. Seeing how rapidly severe acute local inflammation follows the injection of snake-poison, and the rapidity with which it is absorbed, I do not think it possible to extract any appreciable quantity of the poison by suction. When ill-efiects result to the person sucking the wound, I believe the explanation is to be found in the fact that some of the poison has been lying on the skin around the fang-wounds. I have in unquestionable and fatal cases of snake-poisoning practised continuous suction without experiencing the slightest inconvenience or detecting the presence of the poison in my mouth, but it has been my practice to wash the affected part first. As long as a ligature is applied above the bitten part and suction is employed nothing more than the uncoagnlated blood in the ligatured part is likely to be extracted together with any of the poison which it may happen at the time to contain, but the quantity is not likely to be so great as to materially affect the result. There is no evidence in Dr. Cornish's case, of the man having been poisoned, and as for the merit of the treatment adopted several other cases are on record in modes of treatment were adopted with which varying The severe pain complained an equally apparent success. of was evidently due to the ligature; and it is more than probable that the favorable termination of the case to the fact that the fang merely impinged was owing against the bony projection of the first phalanx and that no poison, or only a small quantity of poison, was ejected, and perhaps none, or next to none, was injected liypodermically. The infliction of a fatal bite involves a series of complex acts which though rapidly executed, follow one another in ordered sequence, and in Dr. Cornish's case (and, indeed, in Dr. Bull's) it is not at all probable that sufficient time elapsed between the strike of the snake and the withdrawal of the hand, for the performance of the several acts which constitute an effective bite. In neither of the above cases was it ascertained whether any poison had been injected, and in Dr. Bull's case, moreover, serious consequences followed the treatment. As regards the_temperature table given by Dr. Bull, I would observe that it is an established fact that cobra snake-poison has_ no influence on either the temperature or circulation. The rise in the temperature and the augmented pulse rate which occurred in that gentleman's case must, therefore, have been due to I notice that Dr. Bull other causes, not far to seek. records that the patient " was not to be allowed to sleep." I am aware that such a line of treatment has the sanction of antiquity, and it is not difficult to understand how its supposed efficacy came to be promulgated, though on physiological grounds it is most desirable in cases of snakepoisoning that the sufferer should be kept as quiet as possible and be allowed to sleep if lie feel so inclined
310
THE INDIAN-MEDICAL GAZETTE.
wliich is most improbable in a serious case. Snake-bite and supposed snake-bite are so frequently confounded with snakepoisoning that one can scarcely be surprised at the numerous remedies and antidotes which have from time to time been discovered. So long as they are of an innocent character not much harm can result from their adoption or administration, but when they involve dangerous or serious consequences to the patient, it becomes necessary that tliey should be had recourse to only after careful consideration, and a satisfactory diagnosis has been completed, or the remedy is likely in nine cases out of ten to prove considerably more formidable than the disease. I am strongly persuaded that in our present state of ignorance we can do nothing to cure snake-poisoning, .and very little (laterally against its prevention save in a very few exceptional cases. Dr. Wall has shown that the local effects of snake-poisoning- become unmistakeably evident in from thirty to sixty seconds after the injection of the poison, and lie has drawn attention to the great diagnostic It is essential in all cases value of these local appearances. of reputed snake-bite to ascertain whether the local characteristic appearances of snake-poisoning exist. What then should be our procedure in cases where interference is likely to be of any benefit? We should first apply a ligature, (Esnjarch's as recommended by Fay re r is the best), make .an incision or cross incisions over the fang-mark completely cutting through the tissues into the areolar tissue to ascertain whether poison has been injected, and if so, to estimate the quantity as may be readily done by the degree of local mischief apparent. If the quantity injected has been large, I have no hesitation in saying that the only remedy is amputation. If 3rtialler, deep scarifications and the application of strong nitric acid may be relied on. When the cauterisation is likely to lead to extensive sloughing, the part might be excised antiseptically, or if a limb be affected, it would, perhaps, be better to remove it?a measure attended with far less risk and certainly much less painful, than cauterisation with prolonged ligation of the limb. This latter causes terrible pain, as I have more than once witnessed (the application of ice around and I may over the ligatured part sometimes affords relief). state that it is possible for a fatal dose of poison to be and in a such a into case the vein, injected directly characteristic local appearances would, of course, be absent. This accident, however, must be exceedingly rare, and So that would be attended with rapidly fatal results. practically such cases may be excluded altogether from consideration as being little likely to come under treatment, or even observation. In certain cases Nitric acid might be rapidly injected beneath the skin all round the bitten part. After cauterisation or amputation a large dose Of Opium or Morphia might be administered with benefit. Vincent Richards, Late Member of the Snake-bite Commission. 12th October 18S0.
[November
1, 1880.
