snakebite with strychnine the ordinary doses must be greatly exceeded,
and that its administration must be continued, even if the total
quantity injected within an hour or two amounts to what in the absence
of snake-poison would be a dangerous if not a fatal dose. Timidity in
handling the drug is fraught with far more danger than a bold and
fearless use of it. The few failures among its numerous successes
recorded during the last four years in Australia were nearly all
traceable to the antidote not having been injected in sufficient
quantity. Even slight tetanic convulsions, which were noticed in a few
cases, invariably passed off quickly. It should be borne in mind that of
the two poisons warring with each other that of the snake is by far the
most insidious and dangerous one, more especially in its effects on the
vaso-motor centres. The latter are wrought very insidiously, and where
they predominate require the most energetic use of the antidote, for
whilst the timid practitioner after injecting as much strychnine as he
deems safe stands idly by waiting for its effects, the snake virus, not
checked by a sufficient quantity of it, continues its baneful work,
drawing the blood mass into the paralysed abdominal veins and finally by
arrested heart action bringing on sudden collapse. In such cases even
some tetanic convulsions are of little danger and may actually be
necessary to overcome the paralysis of the splanchnicus and with it that
of the other vaso-motor centres.
Whilst then it must be laid down as a principle that the antidote should
be administered freely and without regard to the quantity that may be
required to develop symptoms of its own physiological action, the doses
in which it is injected and the intervals between them must be left to
the practitioner's judgment, as they depend in every case on the
quantity of snake-poison absorbed, the time elapsed since its inception
and the corresponding greater or lesser urgency of the symptoms. If the
latter denote a large dose to have been imparted and it has been in the
system for hours, delay is dangerous and nothing less than 16 minims of
liq. strychnine P.B., in very urgent cases even 20 to 25 minims should
be injected to any person over 15 years of age. Even children may
require these large doses, as they are determined by the quantity of the
poison they have to counteract and are kept in check by it. The action
of the antidote is so prompt and decisive that not more than 15 to 20
minutes need to elapse, after the first injection, before further
measures can be decided on. If the poisoning symptoms show no abatement
by that time, a second injection of the same strength should be made
promptly, and unless after it a decided improvement is perceptible, a
third one after the same interval. As the action of strychnine when
applied as antidote is not cumulative, no fear needs to be entertained
of violent effects suddenly breaking out after these large doses
repeated at short intervals. They are, so to say, swallowed up by the
snake-poison and remain latent except in counteracting the latter. This
has now been proven abundantly by scores of qualified observers in all
parts of Australia, and still more by Banerjee in India. No hesitation,
therefore, should be felt by medical men in other snake-infested
countries to adopt the Australian treatment. It is seldom that more than
half a grain of strychnine administered in 16m. doses of liq. strychniae
is required here to effectually counteract the venom and place its
intended victim out of danger. Ligature and excision of the bitten skin
have usually been practised and much of the poison eliminated before the
antidote is applied. Our snakes, however, as already pointed out, with
their shorter and merely grooved fangs, do not perforate the cellular
tissue to such depth nor instil as large a quantity of poison as the
cobras, kraits and vipers of India or the rattlesnake of America, all
having perforated and much longer fangs and much more productive poison
glands. Even if after the bite of a vigorous cobra, for instance, a
ligature has been applied and the bitten part deeply excised, a
comparatively large quantity of poison will probably be absorbed
requiring much larger quantities of the antidote, perhaps grains of it,
to effect a cure.
If under the influence of these large doses the symptoms abate, or if
the latter are comparatively mild from the first, smaller doses of
strychnine should be injected, say from 1/15th to 1/10th of a grain, but
under all circumstances the rule that, distinct strychnia symptoms must
be produced before the injections are discontinued, should never be
departed from. This rule is a perfectly safe one, for its observance
entails no danger, a few muscular spasms or even slight tetanic
convulsions being easily subdued and harmless as compared with that
most insidious condition exemplified in case No. 1, cited below, the
first one treated with strychnine by the writer, who, having no
experience in the treatment, did not administer quite enough strychnine.
The patient, after apparently recovering from a moribund condition and
being able to walk and even to mount a horse, remained partly under the
influence of the poison and succumbed to it during sleep, when,
according to subsequent experience, one more injection would have saved
him.
The tendency to relapses is always great when much snake-poison has been
absorbed. Apparently yielding to the antidote for a time, the insidious
venom, after a shorter or longer interval, during which it appears to
have been conquered, all at once re-asserts its presence, and has to be
met by such fresh injections, regardless of the quantity of strychnine
previously administered, but the amount required in most relapses is not
a large one. The writer formerly inclined to the belief that the strain
thus put on the delicate nerve-cells would limit the usefulness of the
antidote to cases requiring not much above a grain. Knowing the Indian
snakes to impart to their victims such comparatively large quantities of
venom, he had strong misgivings as to his method standing the severe
test of Indian practice; and it was most fortunate for this method that
its first practical application in India was made by a gentleman who,
whilst thoroughly familiar with its principles and convinced of their
correctness, had the courage to apply them fearlessly by injecting what
to us Australians appear enormous quantities, ranging as they do up to
three and four grains per patient. Dr. Banerjee's eight cases, all
successful, and of which the most important one, relating to the much
and justly dreaded Duboia Russellii, was published in the November
number of the _Australasian Medical Gazette_, settled the treatment of
snakebite in India as well as elsewhere. If the poison of Bungarus
coeruleus, Echis carinata, and Duboia Russellii can be successfully
counteracted, and if for this purpose four grains of strychnine can be
injected with perfect impunity, it may be inferred with certainty that
the poison of the cobra, fer-de-lance, and the rattlesnake--in fact, of
any snake known to us will be found amenable to the antidote, and that,
if four grains can be injected with safety, we may venture on six and
eight grains, if they are required. In those cases only where the long
fangs of these snakes perforate into a vein, and a large quantity of the
venom injected into the blood-stream overpowers the nerve-centres so as
to make death imminent, if not almost instantaneous, the subcutaneous
injections may be found of little use. Here intravenous injections of
half a grain and even one grain doses would appear to be indicated, and
might yet fan the flame of life afresh, even when respiration and pulse
at wrist have already ceased. We have seen both these functions extinct
in Australia and restored by comparatively small doses of the antidote,
and can see no reason why a more energetic use of it should not restore
them in India.
Considering the terrible mortality from snakebite in India, Dr.
Banerjee's merit in being the first to introduce the strychnine
treatment there is of a very high order, and his grateful countrymen
will ever cherish his memory. When his Excellency the Viceroy had been
appealed to in vain by the writer, and the adoption of his method in
India urged through two Australian Governors, a native of India has
stepped forward and taken the first step towards alleviating an evil
that has hurried over two millions of his countrymen in every century to
an untimely grave.
The cases as reported by him to the _Australasian Medical Gazette_ are
cited below.
[Illustration]
CASES.
If the deductions and conclusions set forth in the foregoing chapters
are correct, it may be justly contended that all cases of snakebite
treated with strychnine should invariably end in recovery if the
antidote is properly applied, according to the rules above detailed.
This contention the writer fully and cordially endorses. Given the
largest amount of poison a snake can give off at one bite, strychnine
injected in time and sufficient quantity--either by the hypodermic, or,
if urgent, by the intravenous method--must rouse the dormant nerve-cells
into action, as long as the vital functions are not completely extinct.
Wherever it fails, the fault lies with the operator not injecting it in
sufficient quantity--a fault committed by the writer himself in his
first case.
The following condensed accounts of fifty cases treated in Australia,
and eight in India, the writer has taken mostly from the _Australasian
Medical Gazette_. Two of these only are from his own practice; others
were kindly communicated to him by his colleagues. It is not claimed
that all these cases were rescues from certain death. Some of them
undoubtedly were, others would have recovered under some other treatment
or no treatment at all; but in none of them would recovery have been so
rapid and complete. The two poisons are thrown out together, and no
ill-effects of either are experienced beyond a certain degree of
weakness, which passes off quickly. This is a boon to be appreciated
fully by those only who have gone through the slow, lingering, and
painful process of convalescence from snakebite as formerly treated,
with its deadly languor and weariness, making life itself a burden and
all physical and mental exertion impossible.
CASE 1.--A. H., 15 years old, a farm labourer, was bitten on the
right index finger whilst feeling for a rabbit in a burrow. Did
not see the snake nor suspect snakebite, but collapsed helplessly
in a few minutes after returning to his work. The writer saw him
three hours after the accident. He was then completely paralysed
and in deep coma; pupils widely dilated and not reacting to light;
sense of sight and hearing dead; heart action extremely feeble;
pulse small, thread-like, and scarcely countable; respiration
quick and shallow; skin blanched and very cold. Seeing him dragged
along the road between two men, had him quickly carried to the
next house, and injected 20 minims of liq. strychnine. Only a
groan or two and a slight improvement in the pulse, indicating a
change in his condition, gave him a second injection about twenty
minutes after the first one. A change for the better then became
rapidly conspicuous. The pulse gained in strength from minute to
minute, respiration became deeper, and the coma was visibly
reduced to mere sleep, from which there was no difficulty in
rousing him to full consciousness by a vigorous shake of the
shoulders. This marvellous change was brought about within forty
minutes; and this being the first case to which the writer had
applied his theory by injecting strychnine, its unparalleled
success exceeded his most sanguine expectations, but unfortunately
also lulled him into a false sense of security, which proved
disastrous to his patient. Not knowing then as he does now that
the snake-poison after having been subdued by the antidote is not
thrown out of the system as quickly as the strychnine, and is
therefore apt to re-assert itself, he allowed another urgent
engagement to take him away from the lad after watching him for
two hours and actually taking the evening tea with him. His
instructions to the mother not to let her son go to sleep and to
watch him carefully for the slightest sign of the return of
symptoms, were unfortunately disobeyed. Both mother and son went
to sleep, deeming all danger over. During this sleep the lad again
relapsed into coma and was found so at daylight. All attempts to
rouse him were fruitless, and he died before the messenger
intended for me had time to saddle a horse. The death of the
unfortunate lad, however, has saved some lives since. It taught
the writer the lesson never to trust to the apparent success of
the antidote until it shows distinct signs of its own
physiological action, and even then to watch his patients
carefully for the first twenty-four hours, and let them sleep for
short periods only.
CASE 2.--A.H., a vigorous girl of 20 years, bitten above the left
ankle by a snake in some long grass, and therefore not identified.
Had applied two tight ligatures above the bite, ran home and got
her mother to cut out the bitten skin, showing two distinct
punctures. Seen within an hour after the bite the girl presented
distinct, but moderate symptoms, deadly paleness, very cold skin,
small frequent pulse, and a peculiar feeling of agony about the
heart, just able to sit upright, but unable to walk. All symptoms
increased rapidly after writer cut ligatures. She reeled from side
to side, and suddenly fell forward as if in a swoon. Injected
1/6th grain of strychnine and, as she did not lose consciousness,
was able to watch the interesting and rapid effect of the
antidote. It had not been injected more than five minutes when
slight colour returned to the cheeks, naturally very red. Patient
then stated that the distressing feeling about the heart was
getting less and also that of drowsiness. From minute to minute
her condition improved, and in about ten she was able to rise and
walk a few steps. Profiting, however, by the lesson his first case
had given him, the writer did not trust to her apparent recovery,
but seeing that much of the poison had been eliminated by the
prompt measures taken before he saw her, he injected only 1/12th
of a grain, which produced slight muscular spasms. Careful
precautions were taken in this case against a relapse, but none
took place, and when visited next morning the girl declared
herself as well as ever she had been in her life.
The following notes of two cases of tiger snake bite
(_Hoplocephalus curtus_), treated with strychnine, were read by
Dr. Thwaites before the Intercolonial Medical Congress of 1889.
This gentleman, a young practitioner just entering practice, had
the courage to use the antidote according to the writer's
directions in spite of the hostile criticisms of his seniors in
the profession and even his own university teachers, and thereby
not only saved two valuable lives, but also set a praiseworthy
example, which was soon followed by others. The writer gives the
notes abbreviated.
CASE 3.--J. B., a strong, robust labourer, bitten by a tiger snake
on the back of right hand. Killed the snake, which hung on to the
hand and was with some difficulty shaken off. Made slight incision
through the punctures and tied a rag round the wrist, but too
loosely to check circulation; then started for the next
neighbour's house, distant a mile, which he reached with
difficulty, staggering like a drunken man when he arrived. The
bitten skin was here excised, whisky administered and patient sent
on in a buggy, but distance being 30 miles to Dr. Thwaites'
residence, a messenger on horseback galloped ahead to get Dr.
Thwaites to meet buggy on road. The latter writes: "I met buggy
four miles from my residence. Patient had to be held up on the
seat of the vehicle between two men. He had not spoken for some
time, pulse very weak, pupils greatly dilated, face very pale. I
injected 10 minims of liq. strychnine P.B. at once, and in a few
minutes noticed some improvement. He now answered when spoken to,
his pulse became stronger, and he could walk a few steps. This was
at 5.30 p.m., and he kept up fairly well till 8.15, when he
collapsed completely. I now injected 20 minims of liq. strychniae,
which in a short time brought him round; but at 9.15 another
relapse took place, when a third injection of 15 m. was made.
This was followed by slight twitching about the face and neck,
after which improvement and recovery were uninterrupted."
Dr. Thwaites' second case is even more remarkable and telling.
When the girl, after a journey of 30 miles, was carried into his
surgery, she appeared to be dead, and a second medical man, who
happened to be present, declared her to be so, and all attempts to
revive her useless.
CASE 4.--A. D., aged 15 years, a schoolgirl, bitten by a vigorous
tiger-snake on the outside of left leg, the snake also holding on
for some time. She at once tightened her garter above the knee and
ran home, a distance of three-quarters of a mile. The bitten skin
was at once excised, another firm ligature applied, whisky
administered, and a hurried start made for Dr. Thwaites', distant
30 miles, where she arrived five hours after accident. The latter
writes:--"She was then pulseless at wrists, cold as a stone, and
with pupils insensible to light. I could not perceive any
respiration, but felt the heart yet faintly fluttering. She was to
all appearances just on the point of death. I injected at once 17
minims of liq. strychniae. In about two minutes she sighed, and
then began to breathe in a jerky manner. In about ten minutes, on
my pulling her hair, she opened her eyes and looked around, but
could not recognise any one. Pupils now acted to stimulus of
light. In a short time she could speak when spoken to, but not see
at any distance. Her sight gradually returned completely; she kept
on improving, and in four to five hours after the one injection
she seemed quite well, but rather weak. I gave small doses of
stimulants till morning, and did not let her go to sleep till next
evening. She suffered no relapse, and her recovery was complete."
CASE 5.--This remarkable case was not published in the medical
press, but in many of the papers of Queensland, where it created
much sensation. The writer is indebted for an account of it to Dr.
Thwaites, who vouches for its correctness. It appears that this
gentleman acquainted the well-known explorer of Northern
Queensland, Mr. Johnstone, who is his uncle, and now police
magistrate at Maryborough, Queensland, with his success in
treating snakebite with strychnine. Mr. Johnstone, who during his
explorations had seen much of snakebite and many deaths from it,
wrote rather incredulously in reply, stating that our southern
snakes were innocuous in comparison with those of the north; and
that, having seen twelve persons bitten and die by the deadly
brown snake of the north (_Diemenia superciliosa_), he must
withhold his belief in the new antidote until he had witnessed a
case of brown snakebite cured by it or reported on good authority.
This desire he had quickly gratified, and by a strange fatality in
his own person. Whilst taking his children for a walk in the bush
a few weeks afterwards he stepped aside the path to pluck a flower
from a bush, and in doing so was bitten on the leg by a vigorous
brown snake. He at once applied a ligature, and had the punctures
sucked by an aboriginal, but became comatose before he reached
home. Three medical men were summoned in haste, injected ammonia
into several veins, and finally had to resort to artificial
respiration, declaring the case a hopeless one. In this extremity
Mrs Johnstone rushed to a fourth one, who had seen Dr. Thwaites'
letter, and discussed its contents with her husband in her
presence. This gentleman--Dr. Garde--laid up in bed, quickly
furnished the lady with liq. strychniae, accompanied by the request
to his colleagues to inject it freely. She came back to her
husband's bedside, when artificial respiration was about to be
given up, but the very first injection rendered it no longer
necessary and two more restored Mr. Johnstone completely. Saving
the life of this highly respected and popular functionary, who was
the first in Queensland treated with the antidote, paved the way
for it in that colony, where it is most needed and is now highly
appreciated.
These five cases, thoroughly typical of the effects of strychnine
in snakebite, are almost in themselves sufficient to bear out the
correctness of the writer's deductions, but for the benefit of a
certain class of rigorously incredulous scientists, who would not
be satisfied with five cases, the writer submits 45 more and in
addition to these--last but not least--Dr. Bannerjee's eight
Indian cases. They are all well authenticated, being mostly taken
from the _Australasian Medical Gazette_ or from private notes, but
to avoid useless repetition the greater part of them will be
merely cited and only the more remarkable ones be given in detail.
Whether in the face of this formidable array of evidence that
blind incredulity and senseless opposition, usually blocking the
way of every new discovery, will at last give way, remains to be
seen. The writer has had his full share of them, and but for the
valuable aid he received from the Hon. Dr. Creed, the able editor
of the _A. M. Gazette_, would probably be struggling yet for the
introduction of his antidote. When it is considered that, in spite
of such evidence as here produced, his discovery has as yet
received no official recognition from any of the Australian
medical authorities, and that even now there are medical men who
can write such effusions as that of Dr. T. L. Bancroft, of
Brisbane, beginning with the words: "It is deplorable to still see
recorded cases of snakebite treated with strychnine, &c.," (see
_Gazette_ for July, 1892)--the attitude assumed from the first by
Dr. Creed and his unfailing advocacy of the antidote can not be
too highly appreciated and lay both the writer and the public
under a debt of deep gratitude to him. But for his early
recognition of the soundness of the writer's theory and treatment
of snakebite many valuable lives now saved would have been lost.
As early as June, 1889, Dr. Creed wrote in an editorial: "We
desire to call the special attention of the profession to Dr.
Mueller's papers on the pathology and cure of snakebite, published
in our issues for Nov., Dec., Feb, April and May last, and to
press upon them the justice and, we submit, the necessity of
extremely careful consideration of his theory and of the results
shown in the cases in which, acting on it, he has used hypodermic
injections of strychnine for the treatment of snakebite. We
formerly expressed our concurrence in the opinion of Sir Joseph
Fayrer, who wrote: 'I do not say that a physiological antidote is
impossible, all I assert is, that it is not yet found.' We are
indeed pleased to state that we believe such an antidote is now
found and that Dr. Mueller is the happy discoverer. We are of
opinion that his theory as to the pathological changes set up in
the human system by the injection of snake-poison is a sound one
and that the treatment he has suggested and used is correct and
proper, and the one likely to avert death in cases of snakebite,
which would otherwise in all probability prove fatal. We therefore
press the use of hypodermic injections of strychnia in the manner
described by him upon the attention of practitioners who may have
to treat cases in which the symptoms present are the result of
snake or dangerous insect poison, and think that, should the
patients die without its having been used, all will not have been
done to save life that might have been." Without such utterances
repeated from time to time and without the ample space always
allowed in the _Gazette_ to the subject, a record like that now
submitted would not have been possible.
CASE 6.--P. Evans, a girl of 20 years, bitten on wrist by a brown
snake. Symptoms--Staggering gait, drowsiness, &c. Only 1/16th
grain in four injections. Notes furnished by Drs. Mahoney and
Kennedy, of Albury.
CASE 7.--W. Thiplin, a labourer, bitten on hand by brown snake.
Three injections. Notes by Dr. Baird of Healesville.
CASE 8.--Luke Dewhurst, labourer, bitten on hand by tiger snake.
Cured by one injection of m. xv. liq. strychniae after ammonia had
failed. Notes by Dr. Dutton, of Lillydale.
CASE 9.--P. Moroney, labourer, bitten on thigh at night, snake not
identified. Cured by three injections of 1/12th grain each. Notes
by Dr. Pardey, of Myrtleford.
CASE 10.--Mrs. Skinner, bitten on thigh, at Carrum. Treated by Dr.
Verity.
CASE 11.--Child of Mr. Weeks, aged three years. Treated by Dr.
Degner, of Myrtleford.
CASE 12.--Annie Rankin, servant, at Corowa. Treated by local
chemist.