snake with back broken in two places was brought to him on the
following day from the exact locality where Rahimudden had been
bitten, gives the following description of it:--Head, large and
triangular; nostrils, large and kidney-shaped; scales, much
imbricate, ventral scales 169, subcaudals 48; confluent, irregular
ring-like, dark brown spots along the back, and with lateral black
patches or rings with white borders. The head marking very
peculiar double V shaped mark, the angle directed between the
nostrils; interstitial coloration, yellowish brown, belly white,
and with brown or amber spots; eyes, large, pupils erect, irides
yellow; body, stout and compressed laterally; poison fangs, large
and recurved, size about half an inch. The length of snake was 3
feet 5 inches, and from these characters it was identified to be
the chain viper (_Duboia Russellii_, _Gray_), the most venomous of
Indian vipers.
The total quantity of the antidote in this case administered was
only 110 minims of a one in 120 solution of strychniae acetas, or
11/12ths of a grain of that drug. Considering the extremely
venomous nature of the snake and the large quantities of
strychnine required in some of the previously reported cases of
echis and bungarus bites, the quantity used seems disproportional,
but this evidently is explained by the fact that only one of the
fangs perforated deeply, and at the back of the foot, probably
struck the bone before entering to its full length, the snake thus
failing to impart the full quantity of venom at its disposal.
The chief interest of Dr. Banerjee's cases centres in the fact
that they are mostly viper-bites. They prove conclusively, as do
Feoktistow's experiments on the lower animals, that the theory of
viper-poison being a blood poison, as asserted in all works on the
subject, is not tenable and must be abandoned. If it effected
changes in the blood, incompatible with life, strychnine, acting
solely on the nerve-centres, could not possibly obliterate these
changes within a few hours or even days. On the other hand the
successful treatment of bungarus bite with strychnine places it
beyond doubt that cobra-poison will also yield to it, if
fearlessly and vigorously applied.
It is most gratifying to the writer to know from good authority
that Sir Joseph Fayrer, the President of the Medical Board at the
India office, has recommended to the English Government the
adoption of the strychnine treatment of snakebite in India, and
that this adoption will not be subject once more to the doubtful
result of experiments on the lower animals, which, according to
newspaper reports, were contemplated at Calcutta as a test. It
would have been deplorable to see more precious time lost in these
experiments, whilst the only proper subjects for experiments, the
unfortunate natives, are perishing by thousands. The step taken by
Sir Joseph Fayrer does honour both to his head and his heart, and
if his recommendation is accepted and vigorously carried out it
will still further increase the debt of gratitude which India owes
to British rule, and with regard to its terrible snake plague, to
the one Englishman who of all others has distinguished himself by
an almost life long study of the subject and indefatigable labours
for its alleviation.
Her Majesty the Queen has also been pleased most graciously to interest
herself in this subject. Memorialised by the writer before Sir J.
Fayrer's recommendation to the British Government, above alluded to, was
known to him, our gracious Sovereign, ever intent on the welfare of her
subjects, has resolved on having the writer's method thoroughly tried in
India, and communicated this her intention to him in a despatch from the
Secretary of State for the Colonies to His Excellency the Governor of
Victoria, dated 11th Nov., 1892, inviting him, at the same time, to
forward any proposals he may have to make direct to the Secretary to the
Government of India in the Home Department; and thus adding one more to
the many noble deeds that mark her benevolent, long, and glorious
reign.
UNSUCCESSFUL CASES.
Considering the newness of the strychnine treatment it would be folly to
expect that the conditions necessary to insure success should have been
observed in every case, and that every practitioner should at once have
made himself familiar with it and the theory on which it is founded.
Hence a few failures were unavoidable. Of these a record has been kept,
but for obvious reasons the writer withholds it here. To give names and
dates would be invidious, though the opponents of the treatment have
exultingly pointed to the few deaths that have occurred as palpable
proofs of its uselessness, some of them even going so far as to ascribe
these deaths to the direct action of the antidote. There is, however,
not a single case on record, in which death took place under
strychnine-convulsions. All the patients died under palpable symptoms of
snakebite-poisoning. As these symptoms have now been proven beyond all
doubt to yield to strychnine, when properly administered, the inference
that it was not so administered in the cases referred to becomes not
only justifiable, but unavoidable. In one case only, that of a child of
tender years, blood was vomited so copiously that death may be ascribed
to that cause and the snake-poison combined, but in all the other six
fatal ones, mostly of children, it was undoubtedly due to the
snake-poison not being properly checked by the antidote. The gentlemen
who officiated on these occasions were evidently not Banerjees, but the
very reverse of their Indian confrere. They do not appear to have had
very clear ideas of the absolute antagonism existing between the two
poisons, and entirely disregarded the most important point in the
treatment, namely, the necessity of administering the antidote until it
has completely subdued the snake poison, regardless of the quantity that
may be required for that purpose. In a few instances the treatment was
correct enough at first, but when, as is often the case, a relapse took
place after the patient had apparently recovered, the large quantity of
the antidote already administered appears to have given rise to the
erroneous notion that it would be useless to resort to it a second time,
and thus, through this error and the fear of strychnine-convulsions, the
patients were allowed to die. In most of the six fatal cases collected
by the writer, however, the doses and total quantities given were
altogether inadequate to cope with the poison. They did probably more
harm than good, for the snake-poison when only partially checked by
strychnine seems to renew its onslaught on the nerve-cells even more
insidiously than when not interfered with at all. Convulsions also, as
shown in cases, are sometimes called forth by this timid use of the
antidote.
A few instances will show the correctness of these observations. Thus an
old woman sleeping in a shed is awakened at daylight by a tiger snake
having fastened on to her wrist. She pulls off the snake, alarms the
neighbours, and a doctor, living only a mile away from the place, is
sent for. He appears on the scene four hours afterwards, when complete
coma and collapse has set in, makes two injections of gr. 1/15 each,
which of course had no effect and the patient is allowed to die without
any further effort on the part of her medical attendant. Case 2.--A boy
of 10 years is admitted to a N. S. Wales hospital in a state of complete
collapse, barely alive, having been bitten by a brown snake 22 hours
before admission. Instead of a rousing injection of at least 15 minims
and the same or smaller ones repeated at short intervals, he receives
only 5 minims of liq. strychniae P.B. every twenty minutes, when death
was imminent, and dies 65 minutes after admission. Case 3 is also that
of a boy in an hospital. He is admitted fully conscious and apparently
but slightly under the influence of snake-poison, for a five minims
injection is reported to have removed the symptoms. On the following
day, however, he became comatose, and instead of having the antidote
freely administered, gets only one more injection of five minims and
dies in coma. Case 4 is even worse. A little girl of 3 years, bitten by
a tiger snake, receives three minim injections every half-hour, and
after three of them, whilst in a state of complete coma, gets
convulsions. These are attributed to the strychnine, which thereupon is
withheld, the finale being death in coma.
There can be no doubt that in all these cases life could have been
preserved under a more energetic treatment. Hereafter, when theory and
treatment are better understood, and when officialdom has seen fit to
issue instructions as to the proper treatment of snakebite to medical
practitioners, such cases as those cited will be put down as malpractice
and have to be accounted for. Until then the guardians of the health and
the lives of her Majesty's subjects, and a certain portion of the
medical press of Australia, superciliously and persistently ignoring the
subject, are more responsible for the lives lost than the busy country
practitioner, who may not have had time or opportunity to inform himself
thoroughly on a comparatively new subject, more especially at a period
when Banerjee had not yet taught us that in administering strychnine as
antidote to snake-poison we can venture into grains of it with impunity.
* * * * *
Since the above chapters were put in proof, the writer has seen a fatal
case of tiger snake bite, conveying two lessons of such interest and
importance that it must be placed on record here. It illustrates in an
extraordinary and forcible degree the erratic, capricious, and insidious
course the snake-poison takes at times.
* * * * *
A handsome girl of 17 is bitten in a bathroom on the back of the second
right toe at dusk on a Sunday evening by a half-grown tiger snake,
subsequently caught and killed in the room. She does not suspect
snakebite, and no ligature is applied until the poison has been
absorbed and overpowers her. Instead of sinking into coma, she becomes
unconscious for a short time only. Her brain then clears itself, and all
symptoms seem to disappear so completely that when a medical man of
undoubted ability and skill sees her a few hours after the bite, she
declares herself quite well again, and does not appear to require any
treatment, least of all that by strychnine injections. She passes a good
night, but on Monday morning symptoms denoting paresis of the
respiratory and glosso-pharyngeal centres make their appearance, almost
identical with those described by Indian writers as following
cobra-bite. She has difficulty in breathing and swallowing, but one
injection of 1/10th of a grain removes it completely and speedily, and
once more all danger is thought to be past. On Monday evening, however,
dyspnoea and dysphagia appear again in an aggravated form. The urine
also becomes scanty and loaded with albuminates. Strychnine now is again
resorted to, but it fails to act as before, and from hour to hour the
young lady's condition becomes more critical. When the writer reached
her on Tuesday afternoon, 42 hours after the bite, paralysis of the
centres named was imminent, and her case appeared a hopeless one, unless
a vigorous use of strychnine yet turned the scales in her favour.
One-tenth grain doses were therefore injected every half-hour, and
continued until the physiological action of the drug showed itself. This
took place, but failed to have the least effect on the affected
centres; and complete paralysis ensued 45 hours after the infliction of
the fatal bite.
The first lesson the Australian practitioner should learn from this sad
case is that of extreme care and caution in dealing with any case of
snakebite, no matter how slight it may appear at first sight. It is not
for the first time we have been taught this lesson, though it has
rarely, if ever, been conveyed in so singular a manner. Recent
utterances about the innocuousness of Australian snake-poison find a
fitting answer in this melancholy occurrence.
The second lesson it conveys is a new one, even to the writer. From the
fact of one strychnine injection removing all poison-symptoms early on
Monday, but the free use of the antidote failing entirely to have this
effect on Monday night and on Tuesday, we are warranted to draw the
conclusion that the antidote can only be relied on within the first 24
hours after the bite; and that, after this period, the snake-poison
produces organic changes in the affected nerve-cells, preventing their
depressed functional activity from being restored by the antidote.
Further observations, of course, are required to confirm these
conclusions. Their correctness, however, appears to be borne out by the
fact observed by the writer, that the larger domestic animals, who
sometimes linger on for days after being bitten by a snake, usually
recover under the strychnine treatment if it is applied immediately or
soon after a bite, but die when found and treated in an advanced stage
of the malady.
That the grave kidney complication, checking the elimination of the
poison from the system, militated against recovery in this case, and
greatly influenced the singular course of the poisoning process, cannot
be doubted.
[Illustration]
CONCLUSION.
In the little work submitted herewith to the medical profession and the
general public, for both of whom it is intended, the author may justly
claim to have solved the difficult and long-standing problem of
snake-poison. We have at last a correct theory of its action, and, what
is of more importance to the public, we have an effective antidote.
These facts, being as fully established in these pages as any scientific
facts can be, the most exacting and even captious criticism will not
upset, nor can further research add anything very material to the
writer's deductions and their final result.
In order to show how an obscure Australian country practitioner
succeeded in a discovery, for which all his predecessors in this field
of research had laboured in vain, it will be necessary in conclusion to
give a short history of the discovery as by slow degrees it has
originated and matured in the writer's mind, who during the last 35
years with respect to this subject had followed the advice which
Schiller gives in his grand poem, "Die Glocke:"--
Wer etwas Treffliches leisten will,
Haett' gern was Grossesgeboren,
Der sammle still und unerschlafft
Im kleinsten Punkte die groesste Kraft,
which, translated into English, means that whoever aims at any great
achievement must quietly, but indefatigably, concentrate the highest
force on the smallest point. Now this smallest point has to the writer
been snake-poison from the very commencement of his Australian career.
When yet a new-chum, a vigorous tiger snake gave him the first lesson on
the action of the insidious venom which nearly cost him his life, but
afforded some valuable glimpses into the mystery of snakebite--in fact,
gave him the key to unlock that mystery. On analysing the horrid
sensations he had experienced before he lost consciousness, and even
after regaining it, he saw "depressed nerve-action, emanating from the
central nervous system," written on the face of every one of them, so
much so that this became the foundation and corner stone of his present
structure, which, however, it took him a quarter of a century to erect;
for the material he required, namely, cases of snakebite observed from
an early stage, and from which all disturbing elements were excluded,
did not occur very frequently in his practice. Though he lived all the
time among mountains, the beautiful Australian Alps, on the rivers and
creeks of which snakes are abundant, and though these creatures and
anything connected with them had an almost fascinating interest for him,
years sometimes elapsed without adding one single good case to his
notes. Sometimes his patients were dead when he reached them, and all
his entreaties for an autopsy were in vain with the relatives. More
frequently he found that they were not bitten at all, and only suffered
from the effects of fear or of enormous doses of alcohol. On persons
really bitten, but completely paralysed and comatose, observations were
also unsatisfactory, as they had to be supplemented by second-hand
evidence obtained from those who had been with them before they became
unconscious. Thus within 25 years the author did not see more than
half-a-dozen really instructive cases; and frequently his desire for
more evidence overcame his reluctance to inflict on animals the agony of
snakebite he had himself endured, and he made a few experiments, but
soon gave them up again as unsatisfactory. All the evidence, however, he
had thus far collected tended to confirm the correctness of his ideas as
to the action of snake-poison. At last, some ten years ago, he obtained
absolute certainty, and this, strange to relate, by a case of spider
bite.
He was called early one morning to visit a little boy, two years old,
and on examination found that he presented symptoms almost identical
with those of snakebite poisoning. Although there was no evidence of the
child having come in contact with a snake, the writer naturally
concluded that during the night a snake had obtained access to the
bedroom through the open door or window, and after biting the child
sleeping in its low cot, had escaped again. He therefore searched most
carefully for the usual two punctures, but they were not to be found.
The child evidently laboured under the effect of some poison, and
spiderbite suggested itself, but the symptoms were so much more
aggravated than anything the writer had frequently seen of spiderbite
that he hesitated to accept it as the cause, although it appeared almost
the only possible one. A careful inquiry into the history of the case
elicited from the mother the important fact that on the previous
afternoon the little fellow, just able to toddle about, had gradually
lost the use of his legs, and also become very peevish, and that
suspecting nothing but a little temporary indisposition, she had put him
to bed, to find him in the morning all but dead. He was scarcely
breathing when the writer saw him, and only the stethoscope gave
evidence of the heart still beating feebly. His body was very cold,
pupils widely dilated, and the sight even apparently gone, the eyes wide
open, staring fixedly upwards and not noticing a lighted match in
closest proximity to them. Consciousness also appeared extinct, as
liquids introduced into the mouth were not swallowed. Examining once
more for traces of spiderbite in the skin, the writer noticed faint red
stripes extending up the arm from a little cut on the right index finger
near the nail, and on inquiry it was ascertained at last from an elder
brother that he had seen the child pick up a little black spider with a
red back, hold it for some time between thumb and index finger, and then
throw it away. This was evidently the Katipo (_Latrodectus icelio_), the
poison of which acts on the same principle as snake-poison, but
generally much milder. The greater severity of its action in this case
was accounted for by the mandibles having been inserted into the cut,
and the insect, being squeezed by the child, having emptied the whole
available contents of its poison gland into the cellular tissue exposed
in the cut, whence it was quickly absorbed. This also accounted for the
absence of all irritation and of the neuralgic pains usually
accompanying spiderbite, when the mandibles merely perforate the
epidermis and the poison is deposited in the upper cutis, where
absorption is slow and local irritation consequently greater.
Minuteness of detail in relating this case must be excused on account of
the extreme interest and importance attached to it. Being brought about
under such peculiar and almost unique circumstances it presented the
effects of spider-poison in a superlative degree and showed them to be
identical with those of snake-poison. But whilst the latter ushers in
the symptoms with such rapidity that they cover each other and are
difficult of separate analysis, in this case the highly significant
paresis of the lower extremities, evidently of central origin, remained
separate for some time. Taking this symptom for his guide and
interpreting the formidable array of the others, developed during the
night, on the same principle, the writer's diagnosis of the case, as it
presented itself to him, was paralysis of the motor and vaso-motor
nerve-centres. This, he found, and this alone could explain all the
symptoms, and he therefore determined to put its correctness to a
practical test. There was but one remedy to make this test with and this
had to be applied without delay, for the child was rapidly sinking and
had almost ceased to breathe. _One twelfth of a grain_ of strychnine was
therefore injected in the arm, a bold dose for so young a child, but, as
the result showed, exactly the one that was required. The test was
eminently successful. Having to leave the child immediately after the
injection, the writer on returning in half an hour found his little
patient sitting up in bed, perfectly restored, with both poisons so
completely neutralising each other, that not a trace of either could be
detected. Thus the writer's structure was at last completed, and an
insignificant spider furnished the last material required for an
important discovery.
There are a few hypothetical points yet in the explanation of some of
the symptoms of snakebite-poisoning by the writer's theory, but these
imperfections are more those of science than of the theory. The whole
subject of vaso-motor paralysis for instance, and of the pathological
changes that follow it, is more or less a _terra incognita_. Diapedesis
is now supposed to be the result of blood pressure, but it occurs in
snakebite, where blood pressure is at zero. Feoktistow, we have seen,
produced it locally on the mesentery of animals with normal blood
pressure, whilst Banerjee arrested by strychnine-injections profuse
haemorrhages from all the mucous surfaces, which were no doubt the result
of diapedesis. We know that neither snake-poison nor strychnine affect
the nerve ends but only the nerve cells. There must therefore be nerve
cells at or near the terminations of the nerves regulating the
capillary circulation in the mucous membranes, but microscopical anatomy
has yet to find them, for minute ganglia have only been discovered at
present in sympathetic nerve ends of the abdomen.
On other subjects also, besides that of vaso-motor paralysis, the
strychnine treatment of snakebite has thrown an unexpected light. We did
not know before it was demonstrated by this treatment that sleep is
merely a reduced discharge of motor-nerve force, a partial turning off
of the motor-batteries, by which, through rest, they are invigorated for
fresh action during the waking hours, and that the degrees of this
reduction range in their effects from sleep, more or less deep, down to
coma, and can be raised again from coma to sleep, and from sleep to
complete wakefulness. We knew that every movement and action is brought
about by a discharge of this force, but we did not know that even the
silent thought must be carried on the wings of it, and cannot take place
without it, at least not in our present state of existence. All these
important revelations are now the property of science, and it will be
well for science to take note of them.
* * * * *
In conclusion, the writer may be permitted to express his joy and
thankfulness for having been made the instrument, by Divine Providence,
to confer a boon on humanity that will prevent much suffering and
thousands of premature, untimely deaths.
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| Transcriber's Note: |
| |
| Inconsistent hyphenation and spelling in the |
| original document have been preserved. |
| |
| Typographical errors corrected in the text: |
| |
| Page 23 intracardial changed to intracardiac |
| Page 69 Banarjee changed to Banerjee |
| Page 73 ease changed to case |
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