often go on beating perhaps for even five minutes longer, and for this reason stimulants are not indicated, although they are nearly always recommended and given at once.
They merely excite the circulation and favour absorption and should only be administered when absolutely required. Treatment.?This is best considered under the two headings, local and constitutional or internal and general treatment. Local.?This is of course by far the most important part of the treatment, for by preventing absorption we avert the constitutional symptoms to a great extent. If the wound be on a limb, as is most frequently the case, apply a ligature made of a piece of cord, or shoe lace, or strip of rag, round the part about 2 inches above the bite, and introduce a bit of stick under this and twist it until tight enough to arrest the circulation. Then apply another about 5 inches higher up the limb in the same way. After the ligature has been applied the part should at once be washed with a solution of common salt, cutting across the punctures to the depth of a quarter of an inch with a lancet or penknife so as to let the wound bleed freely, still washing the part with a strong solution of salt, the more concentrated the better, so as to destroy the poison. If bite be not in a place where ligatures can be applied, it would be best to raise up a portion of skin containing the marks of the fang and cut out a piece as big an a four-anna piece, and thus remove as much as possible of the poison with it, washing the part as before with the solution of salt or permauganate of potash (Condy's fluid) or carbolic lotion. Suction might be applied if means were at hand, a wine glass and match would act in the place of a small cupping glass, but suction by the mouth is rather a risky proceeding on account of cracks on the lips which might give two patients to treat instead of one. As the ligfctu-es cannot be left on much longer than about 20 minutes, for fear of gangrene, it will be necessary to start with the constitutional treatment without delay, as some poison will have been absorbed before the ligatures were applied. Now snake-poison, particularly that of the cobra, causes death from suspension of the respiration, and has little or no effect on the heart. I mention this again because the tendency is to give brandy in quantity which is a mistake,especially in the ea-ly part of the treatment. The next thing to do is to inj ect by means of a hypodermic syringe T^0 S1'- atropia dissolved in ether (it is soluble in 3(1 parts), and repeat this at once in another spot. It may be repeated again later ou. Strychnine also acts as a stimulant to the respiratory centres and has proved of use in some cases where there was embarrassed breathing. Liq. strychnia hydrochlor. (soluble in 1 ?100 of proof spirit) might be given internally after an interval. If at a large civil hospital probably liq. calcii chloride, or a solution of chloride of gold and sodium, might be used as a local application, injected at the seat of the wounds as recommended by Calmette. The chloride of gold and sodium is much cheaper and is soluble 1?2 of water, and therefore readily prepared for If notwithstanding local treatment symptoms of use. poisoning set in, and increase in severity, give 15 drops of liq. ammonite diluted with about half a wine glass of water* and repeat it every J hour for 3 or 4 doses, or longer if necessary, should the patient become faint or nauseated and depressed. Keep the patient warm and endeavour to induce sweating ; do not do this by shutting him up with a lot of people, in a native hut, rather leave him in the fresh air. Do not insist on his walking about, but let him rest, and rouse with hot coffee and stimulants, mustard poultices and ammonia if necessary, but leave him as far as possible quiet and at rest. Iu many cases the prostration is due to fear, and the bite may have been caused by an exhausted or even harmless snake, and the persons thus bitten will of course rapidly
the^
(Eoirapomtciuc. TREATMENT OF SNAKE-BITES. "
Indian Medical Gazette." Editor, Sir,?We all get re-vaccinated as a matter of course to protect ourselves against an attack of small pox, and the To the
time may not be far distant when it will be thought necessary for every one visiting the tropics to go through a series of antitoxin treatment to prevent the risk of an attack of cholera, rabies, or other disease liable to be encountered on one's travels. Professor Fraser of Edinburgh, and Dr. Calmette of Lille, have lately demonstrated to us the possibility of even rendering the system proof against the poison of venomous snakes, such as the cobra, krait, and rattlesuake. However successful this may prove iu the near future, instances will occur in which the anti-venomous serum may not be forthcoming when required, and some other treatment must be resorted to at once. The system moreover after a time may lose its power to resist the effects of the poison and become again susceptible to its potency, or the anti-venomous serum which cannot stand a high temperature for long (as is the case with vaccine lymph) may have lost its efficacy during the hot season or in transit. Some other treatment will ofteu be necessary, and the question naturally arises what is the best treatment to adopt on emergency. Before going on to treatment I think it will be advisable just to review what is known concerning the poison itself, and this will enable us to apply a more rational form of treatment to individual cases. The poison which is of an irritant nature has a twofold action, viz., the local action on the tissues and the blood as it is absorbed into the circulation, and a constitutional or remote action on the nerve centres which is followed by intense congestion of tbe lungs, kidneys, and other internal orgaus. The chief remote action is on the respiratory centres and to a lesser degree on the heart ; and it must be the chief object of our after treatment to counteract this effect. Later on there is a marked and progressive motor paralysis, possibly also convulsions passing iuto total unconsciousness and death from cessation of respiration. The heart will
recover.
Should the patient not be seen until some considerable time after the bite has been inflicted, and the symptoms of poisoning are present, the same measures are to be resorted to. Of course they are less likely to be successful, but then nothing else can be done. I have written these remarks chiefly to advocate the use of common salt as a local treatment, combined with atropia subcutaneously, as I believe the treatment will prove the most efficacious, at any rate as good as any other form of treatment and salt is always at hand.
Dec.
1895.]
CORRESPONDENCE.
511
I this raises tlie question whether antivenene will ever be an : aid to practical therapeutics in India. R. H. ELLIOT, M.B., B.S. (Lond.), F.R.C.S., Surgn.-Capt., I.M.s. Nungumbaukum, Madras, 25 th this to found moreover tendency crystalliza- Oct over 189o. common salt and chloride of silver
Some years ago when carrying out experiments in Central India with fresh cobra poison, I noticed a tendency to assume the crystalline form, which varied when treated with different sdts. I attributed this to what has been named
cobric acid. I tion arrested by which had much the same elfect on formic acid of scorpion poison. Salt is a very good local application in scorpion stings, bat although I saw several cases of bites by cobras in natives, I never could get a case recent enough to be able to say that it was a good application, and as I shortly afterwards left India I did not get a good opportunity of trying the chlorides. Carbolic acid applied to the wound in the case of scorpion stings giv
They merely excite the circulation and favour absorption and should only be administered when absolutely required. Treatment.?This is best considered under the two headings, local and constitutional or internal and general treatment. Local.?This is of course by far the most important part of the treatment, for by preventing absorption we avert the constitutional symptoms to a great extent. If the wound be on a limb, as is most frequently the case, apply a ligature made of a piece of cord, or shoe lace, or strip of rag, round the part about 2 inches above the bite, and introduce a bit of stick under this and twist it until tight enough to arrest the circulation. Then apply another about 5 inches higher up the limb in the same way. After the ligature has been applied the part should at once be washed with a solution of common salt, cutting across the punctures to the depth of a quarter of an inch with a lancet or penknife so as to let the wound bleed freely, still washing the part with a strong solution of salt, the more concentrated the better, so as to destroy the poison. If bite be not in a place where ligatures can be applied, it would be best to raise up a portion of skin containing the marks of the fang and cut out a piece as big an a four-anna piece, and thus remove as much as possible of the poison with it, washing the part as before with the solution of salt or permauganate of potash (Condy's fluid) or carbolic lotion. Suction might be applied if means were at hand, a wine glass and match would act in the place of a small cupping glass, but suction by the mouth is rather a risky proceeding on account of cracks on the lips which might give two patients to treat instead of one. As the ligfctu-es cannot be left on much longer than about 20 minutes, for fear of gangrene, it will be necessary to start with the constitutional treatment without delay, as some poison will have been absorbed before the ligatures were applied. Now snake-poison, particularly that of the cobra, causes death from suspension of the respiration, and has little or no effect on the heart. I mention this again because the tendency is to give brandy in quantity which is a mistake,especially in the ea-ly part of the treatment. The next thing to do is to inj ect by means of a hypodermic syringe T^0 S1'- atropia dissolved in ether (it is soluble in 3(1 parts), and repeat this at once in another spot. It may be repeated again later ou. Strychnine also acts as a stimulant to the respiratory centres and has proved of use in some cases where there was embarrassed breathing. Liq. strychnia hydrochlor. (soluble in 1 ?100 of proof spirit) might be given internally after an interval. If at a large civil hospital probably liq. calcii chloride, or a solution of chloride of gold and sodium, might be used as a local application, injected at the seat of the wounds as recommended by Calmette. The chloride of gold and sodium is much cheaper and is soluble 1?2 of water, and therefore readily prepared for If notwithstanding local treatment symptoms of use. poisoning set in, and increase in severity, give 15 drops of liq. ammonite diluted with about half a wine glass of water* and repeat it every J hour for 3 or 4 doses, or longer if necessary, should the patient become faint or nauseated and depressed. Keep the patient warm and endeavour to induce sweating ; do not do this by shutting him up with a lot of people, in a native hut, rather leave him in the fresh air. Do not insist on his walking about, but let him rest, and rouse with hot coffee and stimulants, mustard poultices and ammonia if necessary, but leave him as far as possible quiet and at rest. Iu many cases the prostration is due to fear, and the bite may have been caused by an exhausted or even harmless snake, and the persons thus bitten will of course rapidly
the^
(Eoirapomtciuc. TREATMENT OF SNAKE-BITES. "
Indian Medical Gazette." Editor, Sir,?We all get re-vaccinated as a matter of course to protect ourselves against an attack of small pox, and the To the
time may not be far distant when it will be thought necessary for every one visiting the tropics to go through a series of antitoxin treatment to prevent the risk of an attack of cholera, rabies, or other disease liable to be encountered on one's travels. Professor Fraser of Edinburgh, and Dr. Calmette of Lille, have lately demonstrated to us the possibility of even rendering the system proof against the poison of venomous snakes, such as the cobra, krait, and rattlesuake. However successful this may prove iu the near future, instances will occur in which the anti-venomous serum may not be forthcoming when required, and some other treatment must be resorted to at once. The system moreover after a time may lose its power to resist the effects of the poison and become again susceptible to its potency, or the anti-venomous serum which cannot stand a high temperature for long (as is the case with vaccine lymph) may have lost its efficacy during the hot season or in transit. Some other treatment will ofteu be necessary, and the question naturally arises what is the best treatment to adopt on emergency. Before going on to treatment I think it will be advisable just to review what is known concerning the poison itself, and this will enable us to apply a more rational form of treatment to individual cases. The poison which is of an irritant nature has a twofold action, viz., the local action on the tissues and the blood as it is absorbed into the circulation, and a constitutional or remote action on the nerve centres which is followed by intense congestion of tbe lungs, kidneys, and other internal orgaus. The chief remote action is on the respiratory centres and to a lesser degree on the heart ; and it must be the chief object of our after treatment to counteract this effect. Later on there is a marked and progressive motor paralysis, possibly also convulsions passing iuto total unconsciousness and death from cessation of respiration. The heart will
recover.
Should the patient not be seen until some considerable time after the bite has been inflicted, and the symptoms of poisoning are present, the same measures are to be resorted to. Of course they are less likely to be successful, but then nothing else can be done. I have written these remarks chiefly to advocate the use of common salt as a local treatment, combined with atropia subcutaneously, as I believe the treatment will prove the most efficacious, at any rate as good as any other form of treatment and salt is always at hand.
Dec.
1895.]
CORRESPONDENCE.
511
I this raises tlie question whether antivenene will ever be an : aid to practical therapeutics in India. R. H. ELLIOT, M.B., B.S. (Lond.), F.R.C.S., Surgn.-Capt., I.M.s. Nungumbaukum, Madras, 25 th this to found moreover tendency crystalliza- Oct over 189o. common salt and chloride of silver
Some years ago when carrying out experiments in Central India with fresh cobra poison, I noticed a tendency to assume the crystalline form, which varied when treated with different sdts. I attributed this to what has been named
cobric acid. I tion arrested by which had much the same elfect on formic acid of scorpion poison. Salt is a very good local application in scorpion stings, bat although I saw several cases of bites by cobras in natives, I never could get a case recent enough to be able to say that it was a good application, and as I shortly afterwards left India I did not get a good opportunity of trying the chlorides. Carbolic acid applied to the wound in the case of scorpion stings giv
