C.—Teleostei.—Physostomi.
This Order is characterised by the presence of a pneumatic duct to the air-bladder. It consists of a large, number of families, only two of which, the Siluridæ and Murænidæ, include venomous species.
1.—Siluridæ.
The majority of the very large number of species belonging to this family live in fresh water, and have the free margin of the lips almost always furnished with barbules (Silurus glanis; [fig. 119]). A few of them possess a poison-apparatus, which, however, attains its greatest development in Plotosus, the only genus of Siluridæ found exclusively in the sea.
The species of Plotosus frequent the shores of the Indian Ocean, and are met with in the Seychelles, Réunion, and Mauritius. In shape they resemble eels, and they bury themselves in the sand or mud, a habit which renders them very dangerous to fishermen.
Fig. 119.—Silurus glanis (Rivers of Central and Eastern Europe).
Plotosus lineatus, which is of a greenish-brown colour, striped with from four to six longitudinal whitish bands, is the most common. By the Creoles of Mauritius and Réunion it is called Machoiran, by the Malays Sambilang, and by the Abyssinians Koomat.
Its poison-apparatus is situated at the base of the dorsal and pectoral spines. These spines are strong, sharp, slightly incurved, and furnished with hooked denticulations, which cause them to remain in the wound, in which they break off. Near their extremity there opens a small canal, which communicates with the culs-de-sac situated at the base of the spiny rays, which produce a venomous secretion. The dorsal spine has only a single cul-de-sac, while the pectoral spines have two.
The contraction of the local muscles, by compressing these culs-de-sac, can cause the venom to make its way into the canal of the spine, but the fluid does not spurt forth in a jet as in the case of Synanceia. The poison-apparatus is therefore passively defensive in character. Plotosus is capable of wounding only when the hand or foot is placed on its dorsal or pectoral spines.
Fishermen who are stung immediately feel an excruciating pain, which is soon accompanied by fever, and lasts for several days. Accidents caused by this fish are of fairly common occurrence in Réunion.
2.—Murænidæ.
Of the fishes belonging to this family, the species of the genus Muræna alone concern us. They have an elongated body, without pectoral fins, and a naked skin, covered with a thick layer of viscid slime, as in the case of the eels. Their dentition is powerful, formed of long, recurved fangs, arranged in one or more rows. These fishes may attain a large size, exceeding 2 metres in length. More than one hundred species are known, all of which live in tropical or subtropical seas. Muræna helena is common in the Mediterranean in the vicinity of Nice and Toulon; M. moringa ([fig. 120]) is found in the Tropical Atlantic.
The species of Muræna live in deep water, and feed upon fishes or crustaceans. In hot countries they frequently venture into fresh water. Their skins are adorned with brightly coloured markings, which vary very greatly according to the species.
The poison-apparatus in Muræna consists of a pouch situated above the membrane of the palate, which may contain ½ c.c. of venom, and three or four conical, curved teeth, with the convex surface in front, as in the fangs of snakes. The teeth are not pierced by a central canal, and the venom flows between them and the mucous membrane of the palate, which forms a sheath. The latter is withdrawn to the base of the teeth, while they are penetrating the tissues. The teeth are mobile; they are articulated with the palatine bone, in which they are inserted in small depressions, and a resistant fibrous tissue serves as the means of union. They can be deflexed backwards against the mucous membrane of the palate; in this position the first, second and fourth tooth (when the latter exists) disappear completely between the folds of the membrane. The third tooth normally remains erect, and it is this by which wounds must in most cases be inflicted. None of these teeth can be protruded beyond the vertical.
Fig. 120.—Muræna moringa (Tropical Atlantic). (After Savtschenko.)
In addition to the palatine teeth there are, among the groups of maxillary teeth, several mobile teeth, which are connected with the poison-reservoir.
Besides its toxic action the venom of Muræna has manifest digestive properties, and, in the case of a fish which has been dead for some little time the gland is no longer to be found, since its walls have undergone a rapid autodigestion.
The venoms of all the fishes of which I have just given a brief description, as regards their physiological action, present a fairly close resemblance to the venom of the Weever, and show scarcely any variation except in the intensity of their effects. They have been but little studied hitherto, and it is desirable that they should be better understood.
CHAPTER XVIII.
VENOMS IN THE ANIMAL SERIES (continued).
3.—BATRACHIANS. LIZARDS. MAMMALS.
A.—Batrachians.
By the ancients the venom of salamanders and toads was dreaded as much as the most terrible poisons. These animals, however, are not very formidable, since they are devoid of inoculatory organs; their poison-apparatus is localised exclusively in the parotids and the skin. It is represented simply by more or less confluent glands in the form of sacs, secreting a viscid mucus, which has a nauseous odour and is highly toxic, even to animals of large size.
The salamander belongs to the Order Urodela, which is characterised by the persistence of the tail. Its body is heavy and thickset, and the flanks and the sides of the tail exhibit a series of glandular crypts, which secrete venom.
“The mucus which flows from the mouth, and resembles milk, eats away human hair,” wrote Pliny; “the spot moistened by it loses its colour, which subsequently returns. Of all venomous animals the salamander is the most terrible; it is capable of annihilating whole nations by poisoning the vegetation over a vast area. When the salamander climbs a tree all its fruit is poisoned, and those who eat of it die as surely as if they had taken aconite. Moreover, if bread be baked with wood touched by the animal, it is dangerous, and may occasion serious disorders. If the naked foot be defiled with the saliva of this creature, the beard and hair soon fall out. Sextius says that a salamander, preserved in honey, after the removal of the entrails, head, and limbs, acts as a stimulant if taken internally.”
In ancient Rome, and also in Mediæval France, it was believed that the most furious fire could be extinguished simply by contact with one of these animals; charlatans sold the inoffensive salamander, which, if cast into the most terrible conflagration, was bound, they declared, to arrest its disastrous progress!
The explanation of this superstition is furnished by Duméril, who writes: “On being placed in the middle of burning charcoal, these victims of so cruel a curiosity, when put to the test, instantly allowed to exude from the many pores with which their skins are riddled a slimy humour, sufficiently abundant to form a viscid layer over that part of the glowing charcoal with which the animals were in contact. Since this surface, being no longer exposed to the air, immediately became quite black, it was supposed to be extinguished; but the salamanders sustained such severe burns that they soon succumbed.”[148]
The principal species of salamanders are:—
Salamandra atra (Black Salamander), which is found in the Alps and the mountains of Central Europe, close to the snow-line, and up to an altitude of 3,000 metres.
Salamandra maculosa (Spotted Salamander, [fig. 121]), distributed throughout almost the whole of Europe, and also found in North Africa.
Triton cristatus (Crested Newt), likewise common all over Europe.
Triton marmoratus (Marbled Newt, [fig. 122]), which is met with in damp and dark places, in Portugal, Spain, South and Central France, and as far north as the Forest of Fontainebleau.
Cryptobranchus japonicus (Great Japanese Salamander, fig. 123), which often exceeds 1 metre in length, and has a clumsy body covered with large warts, and an enormous head, broad behind and flattened in front.
This giant salamander is now confined to a few provinces in the centre of Japan, between long. 34° and 36°, in damp, shady places, from 200 to 800 metres above sea-level. It is eaten by the Japanese, who also use it as a remedy for, or prophylactic against, contagious disorders. By nature it is extremely sluggish, but tries to bite when irritated, and then covers itself copiously with slime.
Fig. 121.—Salamandra maculosa (Europe and North Africa).
Fig. 122.—Triton marmoratus (male). (Europe.)
The venom secreted by salamanders evidently serves to protect these creatures against their enemies. So long ago as 1866, Zaleski[149] isolated from it a substance soluble in alcohol, insoluble in ether, and with a very strong alkaline reaction, to which he gave the name salamandarin. This substance, which is better known to-day as salamandrine, has been studied afresh by A. Dutartre,[150] Phisalix and Langlois,[151] and subsequently by Edwin and S. Faust.[152]
Fig. 123.—Cryptobranchus japonicus (Great Japanese Salamander).
The action of this poison on the frog is characterised by a period of violent convulsions, with general tetanic crises, followed by a period of paralysis, with arrest of respiration and complete muscular relaxation. According to the quantity of poison absorbed, this paralytic period may be followed by death, with arrest of the heart in diastole, or else by return to life, with more or less acute recurrence of convulsions.
S. Faust prepares salamandrine by pounding up whole salamanders in a small quantity of physiological saline solution. The thick pulp obtained in this way is filtered. One cubic centimetre of the filtrate, taken as a unit, contains about 5 decimilligrammes of active substance, which can be purified by treating the filtrate with alcohol, which dissolves the salamandrine and precipitates all the proteic substances that give biuret reaction. The salamandrine thus freed from proteins is saturated with sulphuric or phosphoric acid, when there is formed a crystallisable salt, which is washed and dried. This salt is soluble in alcohol and in water. Its chemical composition is as follows:—
C52H80Az4O2 + H2SO4.
The toxicity of this substance is such that from 7 to 9 decimilligrammes per kilogramme represent the lethal dose for dogs, when injected subcutaneously. The lethal dose for the rabbit is still smaller. It produces convulsive phenomena, followed by arrest of respiration. The administration of chloral to the subjects of the experiment, either preventively or immediately after the poison, prevents the latter from taking effect. Besides salamandrine, S. Faust has isolated a second alkaloid, salamandridine, which, as a sulphate, corresponds to the formula (C20H31AzO)2 + H2SO4, crystallises in rhombic prisms, and is soluble with difficulty in water. The only difference between the two alkaloids is formed by a methylpyridic group, and both are derivatives of quinoline. They must therefore be considered as identical with the exclusively vegetable alkaloids.
S. Faust concludes from his physiological investigations that salamandrine takes effect upon the central nervous system, especially upon the respiratory centres. It is a convulsion-producing poison, comparable to picrotoxin, but its effects differ from those of the latter substance in that the convulsions are accompanied by tetanic spasms.
The venom of the Japanese Salamander (Cryptobranchus japonicus) has formed the subject of studies by Phisalix.[153] This investigator has shown that this venom, which is highly soluble in water and in glycerine, is very unstable; alcohol and heating for twenty minutes at 60° C. are sufficient to destroy it. When inoculated into frogs it produces œdema and hæmorrhage; if injected into warm-blooded animals it causes necrosis. In sufficiently strong doses it kills by arresting respiration. Its effects strongly resemble those produced by Viperine venoms. This venom, if attenuated by being heated at 50° C. and injected into mammals, vaccinates them and leads to the formation in their blood of antitoxic substances, which are capable of preventing intoxication by salamander-venom, and, curiously enough, also confer immunity against viper-venom and the serum of the common snake.
Toads are easy to distinguish from frogs owing to their squat and clumsy shape, and to the mass of glands with which each side of the neck and a more or less extensive portion of the body is furnished in these animals. According to G. A. Boulenger, the number of known species amounts to seventy-six, which are found in the Old and New Worlds, but have no representatives in Australia. The species that are the most common, and most interesting from the point of view of their venoms, are:—
The Common Toad (Bufo vulgaris), in which the skin, which is very thick and rugose, is covered on the back with large rounded tubercles with reddish summits. This species is a great destroyer of insects, and, as such, is very useful to agriculturists.
The Natter-Jack (Bufo calamita), in which the digits are palmate at the base. When irritated it contracts its skin and covers itself with a white frothy exudation, which gives off an odour of burnt powder.
The Green Toad (Bufo viridis), which is especially abundant in Southern Europe, the Levant, and North Africa.
The Musical Toad (Bufo musicus), a species distributed throughout North America as far south as Mexico, and in which the back is covered with pointed conical tubercles resembling spines.
The Brown Pelobates (Pelobates fuscus), common in the neighbourhood of Paris, the skin of which is almost entirely smooth. Although it appears to be nearly destitute of glands, this animal secretes a very active venom, which has a penetrating odour and kills mice in a few minutes, producing vomiting, convulsions, and tetanic spasms of the muscles.
The toxicity of the venom of toads was long ago demonstrated by the experiments of Gratiolet and Cloëz.[154] It is manifest only in the case of small animals, and in man merely produces slight inflammation of the mucous membranes, especially of the conjunctiva.
That this venom preserves its toxic properties for more than a year in the dry state was shown by Vulpian, and satisfactory studies of its composition and physiological action have been made by Fornara,[155] G. Calmels,[156] Phisalix and Bertrand,[157] Schultz,[158] Pröscher,[159] and S. Faust.[160]
Toad-venom was prepared by Phisalix and Bertrand in the following manner: Holding the head of one of these batrachians under water, they expressed the contents of the parotid glands with the fingers or with a pair of forceps. They repeated the same operation with a second, and then with a third toad, until they had sufficiently impregnated the water, which serves to dissolve the venom. In this way they obtained an opalescent, acid liquid, which they filtered with a Chamberland candle under a pressure of from four to five atmospheres. There remained on the filter a yellowish substance, with a highly acid reaction and partly soluble in ether and chloroform, while there passed through the pores a clear, reddish, and slightly acid liquid, which on being evaporated left behind a greyish-white precipitate. This precipitate was separated by filtration, washed in water, and redissolved in absolute alcohol or chloroform. The albuminoid matters were thus separated, and the liquid, after being rendered limpid by filtration, was evaporated away. The substance obtained in this way represents one of the two active principles of the venom. It acts on the heart of the frog, and arrests it in systole. It assumes the appearance of a transparent resin, the composition of which roughly corresponds to the formula C119H117O25. It is the bufotalin of Phisalix and Bertrand, and is probably identical with that obtained by S. Faust, the formula of which, according to the latter author, is said to be C11H23O5.
Bufotalin is readily soluble in alcohol, chloroform, acetone, acetate of ethyl, and acetic acid. When water is added to a solution of it in alcohol it is precipitated, giving a white emulsion, which has a very bitter taste.
From the aqueous extract whence the bufotalin has been separated, it is possible to separate a second poison, which acts on the nervous system and causes paralysis. In order to obtain it in a pure state, the extract is treated with alcohol at 96° C., filtered and distilled; the residue dissolved in water is defæcated with subacetate of lead and sulphuretted hydrogen. The solution thus obtained is successively exhausted with chloroform to extract the cardiac poison, and with ether, which removes almost the whole of the acetic acid. The second neurotoxic principle, called bufotenin, remains in the residue of the solution after being evaporated in vacuo.
Toad-venom, therefore, contains two principal toxic substances: bufotalin, which is of a resinoid nature, soluble in alcohol, but scarcely soluble in water, and is the cardiac poison; and bufotenin, which is readily soluble in those two solvents, and is the neurotoxic poison.[161]
Pröscher, on the other hand, has extracted from the skins of toads a hæmolytic substance, termed by him phrynolysin, which possesses all the properties of a true toxin and is not dialysable. It is obtained by pounding the skins with glass powder in physiological serum.
Phrynolysin dissolves the red corpuscles of the sheep very rapidly, and (in order of sensitiveness) those of the goat, rabbit, dog, ox, fowl, and guinea-pig. The red corpuscles of the pigeon, frog, and toad are scarcely affected. When heated at 56° C. it loses its properties. By the ordinary methods of immunisation it is possible to obtain a very active antilysin.
There is, therefore, a very close analogy between the venoms of toads and salamanders. These highly complex substances are composed of mixtures of poisons, some of which are in all respects analogous to the vegetable alkaloids, while others are closely related to the microbic toxins and snake-venoms.
In the spawning season the cutaneous glands of the male toad are gorged with venom, while those of the female are empty. Phisalix[162] has shown that at this period the venom of the female is accumulated in the eggs, which, if extracted from the abdomen at the moment of oviposition and dried in vacuo, give off in chloroform a product that has all the toxic properties of cutaneous venom (bufotalin and bufotenin). No trace of this poison is to be found in the tadpoles.
B.—Lizards.
The Order Lacertilia includes only a single venomous species, which belongs to the family Lacertidæ, and is known as the Heloderm (Heloderma horridum, [fig. 124]). It is a kind of large lizard, with the head and body covered with small yellow tubercles on a chestnut-brown ground. It sometimes exceeds a metre in length, and its habitat is confined to the warm belt extending from the western slope of the Cordilleras of the Andes to the Pacific. It is met with especially in the vicinity of Tehuantepec, where it inspires the natives with very great dread. It is a slow-moving animal, and lives in dry places on the edges of woods. Its body exhales a strong, nauseous odour; when it is irritated, there escapes from its jaws a whitish, sticky slime, secreted by its highly developed salivary glands. Its food consists of small animals. Its bite is popularly supposed to be extremely noxious, but, as a rule, the wound, though painful at first, heals rapidly. Sumichrast caused a fowl to be bitten in the wing by a young individual, which had not taken any food for a long time. After a few minutes the parts adjacent to the wound assumed a violet hue; the bird’s feathers were ruffled; a convulsive trembling seized its entire body, and it soon sank to the ground. At the end of about half an hour it lay stretched out as though dead, and from its half-open beak there flowed a sanguinolent saliva. There was no movement to give any sign of life, except that from time to time a slight shiver passed through the hinder part of its body. After two hours, life seemed gradually to return, and the bird picked itself up and crouched on the ground, without, however, standing upright, and still keeping its eyes closed. It remained thus for nearly twelve hours, at the end of which time it once more collapsed, and expired.
Fig. 124.—Heloderma horridum.
A large cat which Sumichrast caused to be bitten in the hind leg did not die, but immediately after being bitten the leg swelled considerably, and for several hours the cat continued to mew in a way that showed that it was suffering acute pain. It was unable to stand, and remained stretched out on the same spot for a whole day, unable to get up, and completely stupefied.
Interesting observations on the Heloderm have been made by J. Van Denburgh and O. B. Wight. The saliva of this lizard was found to be highly toxic at certain times, and harmless at others. When injected subcutaneously it produces various effects, such as miction, defæcation, and abundant salivation, with accelerated respiration followed by vomiting. The animal drinks with avidity, and remains lying down, in a very depressed condition. Death finally supervenes, from arrest of respiration and also of the heart’s action. The poison likewise acts upon the arterial tension, which falls very rapidly and very markedly. The sensory nerves are also attacked; irritability is at first increased, then diminished, and at last entirely lost. These changes take place from behind forwards, and from the periphery to the centre. The coagulability of the blood is at first intensified and then lessened, as when acted upon by Viperine venom (H. Coupin).[163]
C.—Mammals.
The only mammal that can be considered to be provided with a poison-apparatus belongs to the Order Monotremata, and is known as the Duck-billed Platypus (Ornithorhynchus paradoxus or O. anatinus, [fig. 125]). The head of this animal is furnished with a kind of flat duck’s bill, armed with two horny teeth in the upper jaw, while the body, which is covered with dense fur, resembles that of a beaver. The tail is broad and flat; the legs are short, and the feet are provided with five toes, armed with strong claws and webbed.
This singular animal is found only in Australia and Tasmania. It lives in burrows near watercourses, entered by holes which it digs in the bank, one above, the other on the water-level. It spends much of its time in the water, and feeds upon worms and small fishes.
In the males the hind feet are armed with a spur, having an orifice at the extremity. At the will of the animal, there is discharged from this spur a venomous liquid secreted by a gland, which lies along the thigh, and is in communication with the spur by means of a wide subcutaneous duct (Patrick Hill).[164]
It has often been proved in Australia that this liquid, when inoculated by the puncture of the spur, may give rise to œdema and more or less intense general malaise. Interesting details with reference to the effects produced by this secretion have been published by C. J. Martin, in collaboration with Frank Tidswell.[165]
Fig. 125.—Ornithorhynchus paradoxus. (After Claus.)
When a dose greater than 2 centigrammes of dry extract of the venom of Ornithorhynchus is injected intravenously into the rabbit, it produces phenomena of intoxication analogous to those observed after inoculation with Viperine venoms.[166] Death supervenes in from twenty-five to thirty minutes, and at the autopsy hæmorrhagic patches are found beneath the endocardium of the left ventricle.
This venom has been studied afresh in my laboratory by Noc, thanks to the acquisition of a small supply kindly forwarded to me by C. J. Martin. Noc proved that it possesses in vitro certain properties of snake-venoms; like the venom of Lachesis lanceolatus, it induces coagulation in citrate-, oxalate-, chloridate-, and fluorate-plasmas. Heating at 80° C. destroys this coagulant power.
Contrary, however, to what is found in the case of the venoms of Vipera and Lachesis, the secretion of Ornithorhynchus is devoid of hæmolytic and proteolytic properties.
Lastly, its toxicity is very slight, at least five thousand times less than that of the venoms of Australian snakes. A mouse is not even killed by 5 centigrammes of dry extract, and in the case of the guinea-pig 10 centigrammes only produce a slight painful œdema.
It has been remarked that the volume and structure of the poison-gland exhibit variations according to the season of the year at which it is observed. It is therefore possible that these variations also affect the toxicity of the secretion (Spicer).[167]
By certain authors the poison of Ornithorhynchus is considered to be a defensive secretion of the males, which becomes especially active in the breeding season, and this hypothesis is plausible. In any case it would seem that as a venom the secretion is but very slightly nocuous.
It will have been seen from the papers quoted above that the chemical nature and physiology of the various venoms, other than those of snakes, are as yet little understood and need further investigation.
The main outlines of this vast subject have scarcely been traced, and the study offers a field of interesting investigations, in which the workers of the future will be able to reap an ample harvest of discoveries, pregnant with results for biological science.
PART V.
DOCUMENTS.
I.—A few Notes and Observations relating to Bites of Poisonous Snakes Treated by Antivenomous Serum Therapeutics.
A.—Naja tripudians (India and Indo-China).
I.—Case published by A. Beveridge, M.B., C.M., Surgeon S. Coorg Medical Fund (British Medical Journal, December 23, 1899, p. 1732).
“A strong coolie, aged 26, was bitten by a cobra on the right ankle, just above the internal malleolus. He was brought to the surgery about one hour after being bitten, in a state of comatose collapse. The pulse was rapid, and the surface of the body cold. He was given an injection of 10 c.c. of Calmette’s antivenene deeply into the right flank. He was kept under observation: the paresis and insensibility were very marked. On visiting him some hours afterwards I found he could walk without assistance, but staggered, and complained of weakness and pains in both legs. Next morning he was much improved, the paresis gradually wore off, and the pulse steadily gained strength. The patient returned to work four days later, quite recovered.
“A few days previously a coolie had died after being bitten by a snake under the same conditions, but without having been treated. Occurrences like these point to the necessity that every Government or private dispensary should be supplied with antivenene, which is certainly the best remedy for snake-bite available.”
II.—Case reported by Robert J. Ashton, M.B., Kaschwa Medical Mission, Mirzapur (N.W.P.).
“A coolie, aged 27, was bitten in the right foot by a cobra at 5.30 a.m., on September 16, 1900. Half an hour later 10 c.c. of antivenomous serum were injected subcutaneously into the left forearm. The patient experienced great pain in the foot, torpor, and great weakness. Recovery, without complications.”
III.—Case reported by Dr. Simond (Saigon).
“Nguyen-Van-Tranc, an Annamese, aged 25, employed in the Botanical Gardens at Saigon, was bitten at 10.30 a.m., on March 11, 1899, by a cobra which had escaped from its cage. The bite was inflicted on the palmar surface of the index finger of the right hand, and the fangs had penetrated deeply.
“This native, to whom a sensible comrade had applied a ligature round the wrist, was brought to the Pasteur Institute three hours later. He was drowsy, with drooping eyelids; his speech was difficult and almost unintelligible. Deglutition was impossible, and ingurgitated liquids caused vomiting. The hand was greatly swollen at the seat of the bite, and the œdema extended to the forearm. There was partial anæsthesia of the skin. As soon as the patient arrived, I gave a single injection, beneath the skin of the flank, of three doses of serum, that is, 30 c.c. In the evening I again injected 10 c.c. of serum. At 10 p.m. the general condition of the patient seemed to be improving. Next morning he was less depressed, spoke more easily, and was able to swallow. Convalescence began from this moment; the œdema and numbness of the hand and arm, however, persisted for several days.
“Recovery was complete on March 20. I have no doubt that in this very serious case the antivenomous serum preserved the life of the patient, since his condition was desperate when I saw him.
“This is the second instance within four months of the successful treatment of snake-bites at Saigon by Calmette’s serum. In the former case two natives were bitten by the same animal. One of them, who permitted the injection of serum, which was performed by Dr. Sartre, recovered; the other, who refused it, died within twenty-four hours.”
IV.—Case reported by the Fathers of the Khurda-Mariapur Mission (India).
“At 1 p.m., on October 31, 1905, a woman, aged 35, who had been bitten by a cobra, was brought to us from Khurda. After being at our dispensary for about an hour she became drowsy; she paid no attention to anything that was said to her, and merely replied that she felt sick. We thereupon injected 10 c.c. of serum. The woman did not even appear to feel the prick when the needle was driven into her calf. Immediately after this was done she dozed and went to sleep. The pulse was feeble, and the entire body cold. We were disposed to give a second injection, but, since we had only two bottles left, we hesitated to sacrifice one of them. At last, after sleeping for about half an hour, the woman awoke of her own accord, sat up, and began to recover her senses. Bodily heat returned almost immediately, and a few moments later the patient asked to be allowed to go home; she was, however, kept at the dispensary. In the evening she continued to complain of headache, but on the following day she was able to walk, and was quite well.”
V.—Case reported by Dr. Brau (Saigon).
“Nhuong, an Annamese agriculturist, on passing through a piece of waste ground beside the barracks, at about 5.30 a.m. on Sunday, September 11, felt himself suddenly bitten behind the right knee. He caught a glimpse of a large blackish snake, with all the characteristics of a cobra, including the raised head and dilated hood, gliding hurriedly away, but was unable to overtake it.
“The seat of the bite merely showed two small blackish punctures. The part soon became painfully swollen, and the patient began to feel giddy. Other natives came to his help; he was lifted into a Malabar cart and brought to the Military Hospital, whence he was sent to my house, where he arrived about a quarter past six.
“I entered the vehicle, and immediately drove with the patient to the Pasteur Institute. The only treatment that he had received was a ligature round the middle of the right thigh. The lower leg was enormously swollen, and the swelling was not stopped by the slight barrier formed by the ligature, but had already extended to the base of the limb.
“The patient lay stretched out between the two seats of the vehicle, with head thrown back and eye-balls turned up and ghastly. His skin and extremities were cold, and his pulse was scarcely perceptible. In order not to lose time, he was not even taken up to the first floor of the Institute, but was carried to an inoculating table. He was then made to swallow black coffee and rum, and was given an injection of as much as six doses of antivenomous serum, which had just been received from the Pasteur Institute at Lille.
“Under the stimulus of this injection, somewhat drastic I admit, an absolute resurrection took place in the sick man. The pulse became strong and bounding, bodily heat returned, and, although the swelling did not at once diminish, its progressive extension seemed to be sharply arrested, while the pain was also greatly lessened. The patient was able to sit up without assistance, and relate the incidents of his misadventure.
“In a few minutes time I thought it possible to have him taken to the Choquan Hospital, the Director of which Institution, First-class Surgeon-Major Angier, has been good enough to furnish me with a note of the subsequent history of this case.
“’The Annamese Nhuong, who entered the Choquan Hospital on September 11, suffering from snake-bite, was discharged on September 20.
“’On admission, heat and puffiness were observed in the calf and thigh. Slight dyspnœa, severe fever, tendency to coma. September 12, temperature 38°, 39·2° C. September 13, temperature 37·3°, 37·6° C. September 17, temperature 36·8°, 37° C.
“’On discharge, slight œdema and puffiness in the region of the bite. General condition good.’”
VI.—Case recorded by Dr. Robert Miller, Bengal-Nagpur Railway Company (Advocate of India, Bombay, January 15, 1902).
“On the evening of October 23 I was called to a coolie woman, who had been bitten by a large cobra about 7 o’clock; some two hours had already elapsed since the accident. The woman was, so to speak, moribund, unconscious, and suffering from paralysis of the throat, after having exhibited all the characteristic symptoms of poisoning by cobra-venom. I immediately injected 10 c.c. of Calmette’s serum, without any hope of a successful result, however, so desperate did the condition of the patient appear. The effect of the serum was marvellous; fifteen minutes later she regained consciousness. I gave a fresh injection of 10 c.c., and three hours after the first the patient was out of danger. Dr. Sen, my assistant-surgeon, was present. I have forwarded a note of this case to Dr. L. Rogers, Professor of Pathology at the Calcutta Medical College.”
VII.—Case recorded by Captain H. A. L. Howell, R.A.M.C. (British Medical Journal, January 25, 1902).
“Shortly before 4 p.m. on November 17, 1901, Lance-Corporal G., Royal Scots, was bitten on the right forefinger by a snake. On being brought to hospital, Assistant-Surgeon Raymond tied a tight ligature round the finger, scarified the wound, and applied a strong solution of calcium chloride. On my arrival I found the patient apparently quite well, and not at all alarmed. As I could get no information as to the nature of the snake, I injected into the patient’s flank at 4.30 p.m. 3 c.c. of Calmette’s serum, and sent for the snake, which was the property of one of the men in barracks. The snake was brought to me just before 6 p.m., and I found it to be a cobra about 3½ feet long, of the pale-coloured variety that natives call Brahmini cobra. I at once injected 7 c.c. of Calmette’s serum into the other flank. The patient thus received one full dose of serum. The ligature was removed from the finger, which was swollen and very painful.
“Up to half an hour after the bite the patient, a healthy and powerful man, presented no abnormal symptoms: pulse, respiration, pupils, temperature, and general appearance, all were normal. His pulse and respiration began to increase in frequency, and the pulse became very compressible, but quite regular. After the first injection of serum his temperature was 98° F., pulse full, high tension, regular, 88, and respirations greatly increased in frequency. He now became very drowsy, and had to be roused when the second injection of serum was given. Soon after this the patient’s general condition and pulse improved.... He had complete loss of sensation in the bitten finger, in the part terminal to the site of the puncture, for some days.... The injection of Calmette’s serum gave rise to no local reaction, and caused no pain. It did not affect the temperature, but was followed in half an hour by perspiration, which was very profuse four hours after the injection.... The patient made a complete recovery.... The serum used in this case was fresh, having been prepared at Lille in July, 1901.”
VIII.—Note of case treated by Major Rennie, R.A.M.C., transmitted by M. Klobukowski, French Consul-General at Calcutta, September 5, 1899:—
“A remarkable cure effected by Major Rennie, by means of Calmette’s method, has just taken place at Meerut. Since the introduction of this remedy three years ago, its efficacy has been abundantly proved, but the present case is especially interesting, since it seems to show that the serum can be successfully employed even in cases apparently desperate. The well-known symptoms of poisoning by cobra-venom were already so advanced that the patient, who was insensible, was kept alive by artificial respiration in order to give time for the serum to be absorbed and to take effect.
“The truth of the above statements is attested by six doctors, and is also vouched for by the Commissioner and Magistrate of the military cantonment, who, although not medical men, have, nevertheless, had long experience of Indian matters.”
IX.—Case recorded by Binode Bihari Ghosal, Assistant-Surgeon, Jangipur (“A Case of Snake-bite [Cobra?].—Recovery,” Indian Medical Gazette, January, 1905, p. 18).
“While fastening her door about 10 o’clock one night a Hindu woman was bitten by a cobra in the left foot, about 1 inch above the metatarso-phalangeal joints of the second and third toes. About ten minutes after the bite natives applied three strong ligatures, one above the ankle, one below, and one above the knee-joint. Four hours later ‘Fowl’ treatment was applied, which it appears gives marvellous results. The author arrived about nine hours after the accident, during the ‘Fowl’ treatment, for which nineteen chickens had already been sacrificed. In spite of this the patient was pulseless (no radial pulse—the brachial pulse was thready and flickering); respiration about six per minute. An injection of strychnine improved her condition for a few minutes. When the incision, which had been made over the bite, was crucially enlarged, large quantities of dark blood were withdrawn by cupping. In spite of this the patient’s condition grew worse, and her respiration fell to three a minute; she then received an injection of 10 c.c. of Calmette’s serum in the left buttock. The pulse immediately became stronger, and respiration increased to ten per minute. About half an hour after the first, a fresh injection of 10 c.c. of serum was given in the same place. Within five minutes the appearance of the patient, who had seemed to be dying, became normal. The pulse grew stronger, and respiration was about fifteen per minute. One hour after the injections the patient was practically cured.
“The ‘Fowl’ treatment consists in applying directly to the wound, after the latter has been slightly enlarged by means of an incision, the anal apertures of living fowls, from which the surrounding feathers have been removed. The fowl immediately becomes drowsy, its eyes blink, and its head falls on its breast with the beak open, after which the bird rapidly succumbs. Twenty fowls had been employed in the present case, but in vain.” (The author does not appear to have troubled himself to ascertain whether the fowls were really dead, or had merely fallen into a hypnotic condition.)
X.—Case reported by Major G. Lamb, I.M.S., Plague Research Laboratory, Parel, Bombay, October 18, 1900.
“Ten days ago I was bitten by a large cobra, from which I was collecting venom. I had only some very old serum in the laboratory, but I immediately gave myself an injection of 18 c.c. Three hours after being bitten I felt faint, my legs became paralysed, and I was seized with vomiting. In the meantime, fresh serum had been obtained at a chemist’s, and I received an injection of 10 c.c. The symptoms improved very rapidly, and an hour later I felt perfectly well. I applied no local treatment, relying altogether upon the serum.”
XI.—Case reported by Dr. Angier, of Pnom-Penh (Cambodia).
“At 11.30 one night in April, 1901, His Majesty, the second King of Cambodia brought to me in a carriage one of his wives who, when crossing the courtyard of the palace at about 8 o’clock, was bitten by a snake, which she said was a cobra (in Cambodian Povek).
“The bite was situated in the lower third of the leg, in front of the internal malleolus. The patient complained continually; she was suffering greatly from the leg, which was swollen as high as the knee. Great lassitude. An injection of 10 c.c. of antivenomous serum was given, half in the leg and half in the flank. The wound was washed, squeezed and dressed. Twenty minutes later the pain had ceased, and the patient went away, feeling nothing more than a slight dulness in the injured limb.”
B.—Naja haje (Tropical Africa).
XII.—Cases reported by Dr. P. Lamy, of the Houdaille Expedition.
“Lamina, a Senegalese, bitten on the outside of the left thigh, on February 18, 1898. Treated with serum. Recovery.
“Momo Bolabine, bitten in the heel on April 20, 1898. Ten c.c. of serum. Recovery.”
XIII.—Case reported by Dr. Deschamps, of Thiès (Senegal).
“In the month of October, 1898, I was called to a native, a local constable, who had just been bitten by a Naja. The Ouoloffs of Senegal are much afraid of the bites of this reptile, since they are generally fatal. In this case the man had been bitten in the forehead by a snake, which was coiled up in his bed, as he was placing his head on the pillow. Being in the dark, he got up greatly frightened, lit a candle, and saw the snake glide from his bed and escape through the half-open door. I arrived a few minutes after the accident; the constable already felt very weak, and complained of nausea and of pains in the head and back of the neck. In the middle region of the forehead I found two adjacent wounds, around which the tissues were œdematous. I washed the wounds with a solution of permanganate of potash, and had a telegram sent to St. Louis asking for antivenomous serum. Half an hour after the bite, the patient was seized with vomiting and cold sweats. At 6 a.m. on the following day there was considerable œdema of the face and dyspnœa, while the pulse was small and intermittent. The patient, who had not slept, was dull and depressed. He vomited a little milk which I tried to make him take. Forty hours after the bite the patient, who was already paralysed, became comatose; the face and neck were enormously swollen. The dyspnœa had increased; it was difficult to hear the respiratory murmur; the pulse was thready, slow, and intermittent; the skin was cold; the temperature, taken in the axilla, was 35·8° C. At this moment the serum asked for arrived from St. Louis. I injected into the buttock the only dose that I possessed, 10 c.c. The coma persisted throughout the evening and during part of the night; at 6 a.m. on the following day, fourteen hours after the injection, the patient awoke and said that he felt quite well. The œdema of the face and neck had diminished, that of the eyelids had disappeared. Three days later the constable returned to duty.”
XIV.—Case reported by Professors H. P. Keatenje and A. Ruffer (Cairo).
“A girl named Hamida, aged 13, while picking cotton on October 7, 1896, at Ghizeh, near Cairo, was bitten in the left forearm by a large Egyptian cobra, which measured 3 feet in length. She cried out, and her brother and others who were working with her ran up. She was brought to hospital by the police at 7 p.m. in a state of complete collapse. She was almost cold, with upturned eyeballs and imperceptible pulse. The forearm had been bandaged with a dirty cloth, and the entire arm was covered with a thick layer of Nile mud (a favourite remedy among the Fellahîn). Above the wrist two deep punctures were clearly visible, evidently corresponding to the fangs of the reptile. The patient, whose condition seemed absolutely desperate, had no longer any reflexes; she was completely insensible; the moderately dilated pupils scarcely reacted at all to luminous impressions. Dr. Ruffer injected, with the customary antiseptic precautions, 20 c.c. of Calmette’s antivenomous serum beneath the skin of the abdomen. The child gave a groan while this was being done; this was at 7.30 p.m. At 11 o’clock at night her condition improved; the pulse was 140, and bodily heat returned; the patient replied to questions that were put to her. A second injection of 10 c.c. of serum was given in the flank. She slept for the remainder of the night, and passed her water four times under her. At 8 a.m. on October 8 she appeared to be out of danger. She took food, and dozed throughout the day. On the 9th she was convalescent. There were no complications resulting from the injection, neither eruptions nor pains in the joints.”
XV.-Case reported by Dr. Maclaud, of Konakry (French Guinea).
“At 7.30 p.m., on June 22, 1896, there was brought to the Konakry Hospital a native soldier, named Demba, who had just been bitten by a snake. This man, who was employed in the bakery, was stacking firewood, when he felt an extremely acute pain in the left foot; simultaneously he saw a large snake making off; he succeeded in killing it, and found it to be a black Naja. After having applied a stout ligature to the limb, the injured man hastened to the hospital, where, immediately afterwards, he fell into a condition verging on coma. The body was bathed with cold sweat; the temperature was subnormal; the pulse, which was small and thready, was 140. There was difficulty in breathing, and severe vomiting. At intervals the patient was aroused by spasms, and excruciating pains in the injured limb, which exhibited considerable œdema above and below the ligature. Tendency to asphyxia. I washed the wounds with 1 per cent. solution of permanganate of potash, and injected a dose of antivenomous serum into the subcutaneous cellular tissue of the left flank. In view of the severity of the symptoms I gave two other injections of serum, an injection of 3 c.c., followed by one of 2 c.c. The patient dozed all night. Next day the general symptoms had entirely disappeared. Two days later Demba returned to duty.”
C.—Bungarus fasciatus.
XVI.—Case reported by Surgeon-Captain Jay Gould (Nowgong, Central India, British Medical Journal, October 10, 1896, p. 1025).
“On June 11, 1896, a punkah coolie was bitten on the dorsum of the left foot, between the second and third toes. He had only the distinct mark of an incisor, a very slight prick, with a stain of blood which marked the spot. Within ten minutes we had injected 20 c.c. of Calmette’s serum into the abdominal wall, after which we made a local injection of a 1 in 60 solution of hyperchlorite of calcium. Two hours after the injection the temperature was subnormal, the pulse full and slow. Twelve hours later the patient was perfectly well and walking about.
“The snake was a Bungarus, full grown, measuring 28 inches. Unfortunately the syces killed it; it died the very moment I arrived, so that I was unable to test its virulence.”
D.—Bungarus cæruleus.
XVII.—Case reported by Major S. J. Rennie, R.A.M.C., Meerut, N.W.P., India.
“A twelve-year old Hindu boy, named Moraddy, was brought to me at 6 p.m., on July 10, in a semi-comatose condition, with commencing paralysis of the respiratory muscles. I was told that the child was sleeping on the ground, when he was bitten in the left hand. He immediately felt very great pain and giddiness, and his arm began to swell. Two small wounds were clearly visible, corresponding to the marks of the fangs of a krait, or Bungarus cæruleus.
“The child had salivation, and ptosis of both eyelids. Respiration was difficult, and deglutition impossible; the pulse was 110 and dicrotic. The patient’s breathing was of an abdominal character; the surface of the body was covered with cold sweat. The child soon became lethargic and collapsed; his condition appeared absolutely desperate. I gave a subcutaneous injection of 12 c.c. of antivenomous serum, and commenced artificial respiration, which I continued for half an hour in order to give the serum time to take effect. In forty-eight hours the symptoms gradually disappeared, and the child became quite well. Diplopia of the left eye persisted for a few days, but this also entirely passed away.
“This case shows that, in Calmette’s antivenomous serum, we have a very powerful remedy against snake-bites, which may take effect even in desperate cases. It further proves that the serum will keep for a very long time, even when exposed to all the vicissitudes of the Indian climate, for the serum employed by me had been in my possession for nearly four years.”
E.—Sepedon hæmachates (Berg-Adder).
XVIII.—Case reported by Mr. W. A. G. Fox, Table Mountain, Cape of Good Hope.
“On February 9, 1898, I was summoned to the Town Council’s Camp to treat a native who had been bitten by a berg-adder in the left leg, just below the knee. I immediately injected a dose of Calmette’s antivenomous serum in the left flank, and the wounds were washed. The injection was given two and a quarter hours after the accident. The patient was already very ill when I saw him, and I have no doubt that, without the antivenomous serum, he would have died.
“On the following day he had recovered, and I saw him again three months later; since then he has not experienced any functional trouble.”
F.—Hydrophiidæ (Sea-Snakes).
XIX.—Case recorded by Mr. H. W. Peal, Indian Museum, Calcutta (Indian Medical Gazette, July, 1903, p. 276).
“On April 1, 1903, at 7.30 p.m., a man was bitten at Dhamra, in Orissa, by a sea-snake which had been caught in a fishing net. He was not brought to me until 2.30 the next day, when he was in a state of collapse, semi-unconscious, and unable to speak, with eyes dull and almost closed. The bite was on the third finger of the left hand, just above the first joint. The finger was swollen, tense, and stiff. I gave the man an injection of 5 c.c. of antivenene ten minutes after he was brought to me. Three or four minutes after the injection the man with some assistance was able to sit up, and said he felt much better. He complained of great pain at the back of the neck and also in the lumbar region. He was able to speak fairly coherently after a little time. His eyes were brighter and he seemed to be aroused from his lethargy.
“I had about one hundred living sea-snakes with me, belonging to the three genera Enhydrina, Hydrus, and Distira. He identified Enhydrina valakadien as being the snake which bit him; so did the men who were with him. The snake was said to be about 3½ to 4 feet long.
“The antivenene did the man so much good, that he himself asked me to give him a second injection. This I gave him at 2.25 p.m. (5 c.c.).
“Date on bottle used, May 8, 1900.
“The pains in the joints had disappeared on the second injection (which was given in opposite flank). At 5 o’clock the man walked away with assistance. He was quite well a couple of hours after the second injection, and when I saw him again on May 8 he was in perfect health.”
G.—European Vipers (Pelias berus and Vipera aspis).
XX.—Case published by Dr. Marchand, of des Montils, Loir-et-Cher (Anjou médical, August, 1897).
“About 11 a.m., on Friday, July 23, Jules Bellier, aged 26, was mowing in a damp spot, when he was bitten in the heel by a large viper (Vipera berus). The bite, which was deep, was situated on the outside of the foot, 1 cm. behind the malleolus and 3 cm. above the plantar margin; at this point there were two punctures in the skin, 1 cm. apart. Directly after the accident the patient left his work, tied his hankerchief tightly round the lower third of his leg, made the wound bleed, and came to me with all speed, hopping on one foot for about a kilometre. When I saw him scarcely twenty minutes had elapsed since the accident; his general appearance was altered, and his pulse rapid. The patient had vomited twice; he complained of pains in the head, and of general weakness, and ’was afraid,’ he said, ‘of fainting.’ The foot and leg were painful under pressure; a slight tumefaction was visible in the peri-malleolar region, around the bites, which bled a little. Forthwith, after washing the wound freely with a solution of permanganate of potash, I injected 10 c.c. of Calmette’s serum into the antero-external region of the middle part of the thigh; then I enveloped the leg in a damp antiseptic dressing as high as the knee. The patient breathed more freely and plucked up his spirits. After lying down for quarter of an hour he went home on foot (he lives a hundred yards from my house).
“In the evening I saw my patient again. He was in bed, with a temperature of 37·2° C.; pulse 60; no malaise, no headache, no further vomiting; he had taken a little soup, and a small quantity of alcoholic infusion of lime-tree flowers. He complained of his leg, which was swollen as high as the knee; the pain was greater in the calf than at the malleolus. I applied a damp bandage. The patient had a good night, and slept for several hours, but still had pain in the leg. On the following morning, July 24, I found him cheerful, with no fever, and hungry. Around the bite the œdema had become considerable, and had extended to an equal degree as high as the instep; the calf and thigh were swollen, but to a much less extent. I gave a second injection of 10 c.c. of antivenomous serum in the cellular tissue of the abdominal wall. The day was good; indeed, the patient had no fever at any time; the spots at which the injections were made were but very slightly sensitive on pressure. In the evening the general condition of the patient was satisfactory; he complained most of his calf. Thinking that a contraction was possible, due to his having hopped along quickly on one leg after the accident, I ordered him a bath.
“On July 25, the second day after he was bitten, the only symptom still exhibited by the patient was a somewhat considerable amount of œdema in the peri-malleolar region and lower third of the leg. This œdema was slowly and gradually absorbed on the following days.
“Remarks.—(1) At this season of the year viper-bites are both frequent and dangerous in this district of the Loir-et-Cher. A year never passes without several cases occurring, and it has very often happened that deaths have had to be recorded in spite of the most careful treatment.
“(2) The therapeutic effect of Calmette’s serum was rapid and efficacious; the injections did not cause any pain or febrile reaction.
“(3) The œdema resulting from the bite was a long time in being absorbed; this, indeed, was the only remarkable symptom after the injection of the serum.”
XXI.—Case recorded by Dr. D. Paterne, of Blois (Anjou médical, September, 1897).
“My confrère and friend Dr. Marchand (des Montils) published in last month’s Anjou médical an interesting case of viper-bite, cured by Calmette’s serum. May I send you particulars of another case, which can only increase the interest of the one that you have already published? The facts are as follows:—
“Léon Bertre, aged 55, living at 17, Rue du Puits-Châtel, Blois, professes to be a snake-charmer, and really catches and destroys large numbers of dangerous reptiles in the vicinity of Blois.
“On Sunday, the 30th of last May, he went among the rocks of the Chaussée Saint-Victor on his favourite quest, and soon returned with ten large female vipers, and amused himself by exhibiting them to a group of interested spectators in an inn. A dog came up and began to bark. Bertre, whose attention was momentarily distracted, ceased to fix his gaze on the vipers, one of which, being no longer under the influence of its fascination, bit him on the back of the right hand, between the metacarpals of the thumb and index-finger. (I here reproduce the account of the occurrence as I received it from the snake-charmer’s own lips.) Bertre immediately felt an acute pain; his hand swelled up almost suddenly, and, since he was perfectly aware of the seriousness of what had happened, he ran with all speed in the direction of my consulting-room. The unfortunate man, however, had hardly gone 200 metres, when he fell insensible on the highway. He was brought to me, and Dr. Moreau, of Paris, locum tenens for Dr. Ferrand, of Blois, who was away, rendered first aid. He washed the wound, dressed it with perchloride of mercury, and injected 10 c.c. of Calmette’s serum into the right flank. The accident took place a little before 5 p.m., and the injection was given about 6 o’clock.
“Dr. Moreau, who was interested in the case, asked me to take charge of it, which I gladly consented to do. The patient’s general condition was very grave, since he remained two days and two nights without regaining consciousness.
“On Tuesday, June 1, about 11 o’clock, Dr. Moreau gave a second injection of 20 c.c. Considering the condition of the patient, we hardly hoped for a successful result. To our great surprise, however, the patient regained consciousness about 3 p.m., and the improvement progressed rapidly.”
XXII.—Case recorded by Dr. Thuau, of Baugé (Anjou médical, September, 1897).
“X., a young man of Volandry, a parish 10 kilometres from Baugé, was bitten in the heel at 10 a.m. on the 6th of last August, by an aspic, about 50 cm. in length, while engaged in harvesting. He at once had himself taken to Baugé, knowing that there was an antivenomous serum dispensary there, and about noon he arrived at the house of my confrère and friend Dr. Boell. The latter, in view of the grave symptoms exhibited by the patient (nausea, vertigo almost amounting to syncope, pain in the chest, profuse sweating, &c.), gave him, with all the customary precautions, a first injection of 10 c.c. of Calmette’s serum in the flank. After about half an hour, since the alarming symptoms did not appear to diminish, he did not hesitate to give a second injection of 10 c.c., and then had him sent to the Baugé Civil Hospital, where he came under my care about 3 p.m. I then found that this young man had been bitten in the left foot, a little below the external malleolus, midway between the latter and the plantar margin. The snake’s fangs had penetrated rather deeply; the two little wounds were about a centimetre apart. About this time the patient experienced great relief, and his general condition continued rapidly to improve. The axillary temperature was 37·8° C.
“Locally the patient complained of somewhat acute pain in the entire foot; the latter was purple and greatly swollen, and the swelling had affected the whole of the lower leg and extended to a little above the knee. I made a slight incision in the region of the two wounds caused by the bite, made the place bleed a little, and washed it with a solution of permanganate of potash, advising that the dressing should be changed several times a day. In the evening the temperature was 37° C., and never varied again from the normal until recovery was complete on August 25.
“The two injections of antivenomous serum did not produce any painful or inflammatory reaction.”
XXIII.—Case reported by Dr. Clamouse, of Saint-Epain, Indre-et-Loire.
“Léonie C., a servant at a farm, aged 19, bitten on June 1, 1900, by a red viper on the dorsal face of the left ring-finger. Somewhat serious symptoms of intoxication. In default of serum, injection of Labarraque’s fluid, 1 in 12. Serum obtained from Tours was injected at 11 p.m. on June 2, thirty-eight hours after the accident.
“On the morning of June 3, very marked improvement. On June 7, general condition excellent. Recovery.”
XXIV.—Case reported by Dr. G. Moreau, of Neung-sur-Beuvron, Loir-et-Cher.
“A. B., aged 12, living at Villeny, in the canton of Neung-sur-Beuvron (Loir-et-Cher), was bitten on June 23, 1900, on the left external malleolus. The parents contented themselves with applying a ligature above the wound, and did not bring the child to me until 12.15 p.m.
“Tumefaction of the entire foot. Ecchymosis of the skin extending half-way up the leg. General condition excellent. I gave antiseptically an injection of 10 c.c. of antivenomous serum in the right flank, followed by a draught of acetate of ammonia and syrup of ether. Damp bandage applied to wound and swollen part.
“I saw the child again on the following day. Generalised œdema and tumefaction of the bitten limb. Heart excellent; no vomiting, no fever. I again gave an injection of 20 c.c. of serum, and ordered a continuance of damp phenic dressings to be applied to the entire limb. Condition very good.
“On June 25, no fever at the time of my visit. Pulse irregular. Ordered treatment to be continued.
“I did not see the patient for four days, when I was summoned by telegram. I found that the child had fever, 39° C. Complete tumefaction of the left leg, abdomen, and trunk, with ecchymosed patches. Prescribed quinine. Arhythmia of pulse and heart. Prescribed digitalis and Jaccoud’s tonic. The febrile condition was due to congestion of the base of the right lung. I ordered cupping and sinapisms alternately.
“I saw the child again two days later. The congestion still continued. Temperature 39° C., but the general tumefaction showed a tendency to diminish.
“On July 4 I again saw the child. Now only slight œdema. General condition very satisfactory. Temperature normal. The child was making rapid strides towards recovery. The leg was doing well, and the wound was almost healed.
“Summary: A very serious bite and, above all, great delay in injecting serum (injection not given until four hours after the accident); unforeseen complications in the lung, by which recovery was delayed.”
XXV.—Case reported by Mons. H. Moindrot, Assistant to Dr. Martel, of Saint-Étienne (Loire).
“Claude L., aged 8, living at Ricamarie, was brought, on May 26, 1904, to the Bellevue Hospital. The parents stated that about 10 o’clock the same morning, while playing near a stack of faggots, the child was bitten by a snake in the third finger of the right hand. Since the wound caused by the bite seemed to them of little importance, they contented themselves with squeezing the injured finger in order to make it bleed a little. A few moments later, however, the child began to complain of a feeling of distension in the region of the bite, caused by œdema, which soon increased to an alarming extent. A doctor, who was called in, carefully washed the wound, applied an aseptic dressing, and at once sent the little sufferer to the Hospital.
“On admission, enormous œdema, including fingers, hand, entire right arm, cervical region on the same side, and the anterior face of the thorax, nearly as far as the inner margin of the false ribs. This œdema was not very painful, though fairly tense, yielding but slightly to pressure. In the affected region the skin was cold, of a dull livid colour, with a few ecchymosed patches. In the bitten finger, a small wound with no special characteristics.
“General condition bad; the child was unable to stand. He was indifferent to what was passing around him, merely groaning a little when examined. The pulse was feeble, thin, and easily compressible; it was also very irregular. The extremities were cold. Lungs: nothing abnormal on auscultation, rapidly performed, it is true. Respiration, however, was distinctly accelerated, 30 per minute. Temperature not taken on admission. No urine passed since the accident.
“The patient’s condition being so alarming, not to say desperate, we thought it almost useless to have recourse to Calmette’s method, more especially since at least seven hours had already elapsed since the child was bitten. Nevertheless we gave a hypodermic injection of 20 c.c. of Calmette’s serum. At the same time the wound was crucially incised, and bathed with a 1 in 1,000 solution of permanganate of potash, after which a damp dressing was applied to the whole of the swollen limb. The patient was put to bed, and kept warm. He was given an injection of 50 centigrammes of caffeine, and 300 grammes of artificial serum. In the evening the temperature was 36·8° C.
“May 27.—General condition more satisfactory; pulse still weak, but less irregular. Persistence of dyspnœa, explained by a series of small râles at the bases of both lungs. This morning the little patient passed his urine, about 200 grammes. He is more lively, and replies better to any questions addressed to him.
“May 28.—The improvement continues; the dyspnœa has almost entirely disappeared; only a few râles are still heard at the extreme base. The pulse is stronger and remains regular. The secretion of urine gradually reappears. The temperature of the extremities has become normal.
“On May 29 and following days the œdema continued to diminish, and had totally disappeared eight or ten days later.
“Recovery was complete by about June 15. The child was discharged on June 23, 1904.
“It seemed to us worth while to report this case, in order to emphasise the conclusion that forces itself upon us, namely that in all cases of bites from poisonous snakes an injection of Calmette’s serum should be given, without considering the efficacy of this therapeutic agent as being rendered doubtful by the length of time that may have elapsed since the bite was inflicted.
“In the present case, as we have seen, there was extensive intoxication, which had seriously affected the functions of the various organs, since we found cardiac arhythmia and pulmonary œdema, and that the patient was threatened with collapse, algidity, hypothermia, and anuria. Impregnation by the virus having continued for seven hours, we might have felt ourselves justified, on the one hand in merely employing the proper means for the relief of the general condition, on the other hand in treating the local condition, without having recourse to the serotherapeutic method, that seems to us in this case, in so far as it is permissible to make such a statement, to have been the determining factor in the recovery.”
XXVI.—Case recorded by Dr. Lapeyre, of Fontainebleau (from L’Abeille de Fontainebleau of June 27, 1902).
“M. X., who arrived at Fontainebleau on Sunday morning with a friend, keeps grass snakes at home, in Paris; he finds his hobby as good a means as any other to remind him of the forest and its charms. Human nature includes all kinds of tastes, so that this particular one need not be further discussed.
“The journey, therefore, had a twofold object: firstly to spend a whole day in sunshine and in the open air, and secondly to catch grass snakes to add to the collection.
“On leaving the train, our Parisian walked up the Amélie Road, and saw a snake under a rock. Never doubting that it was one of the kind that he knew so well, to kneel down, pass his left arm into the hole, and seize the snake, was the work of a moment; he quickly succeeded, even better than he intended, for instead of his seizing a grass snake, the viper bit him so hard in the left forefinger, that he could only make it let go by pulling it off with his other hand. Well knowing that he had been dangerously bitten, he went down to the Station Road to get the wound dressed, after which, thinking that all necessary precautions had been taken he returned to the forest, but soon felt uncomfortable. His arm and then his body swelled up, and he was seized with vomiting. It was time to go to Fontainebleau to seek medical assistance, for he had acute pain in the abdomen and stomach, his tongue was swollen, and his body was turning black.
“Accompanied by his friend he reached the town. His condition becoming more serious every moment; the injured man was carried into a hotel, where Dr. Lapeyre administered injections of antivenomous serum. After three hours—the same period as had elapsed between the accident and the first treatment—the general condition of the patient, which had never ceased to be alarming, showed marked improvement. By the end of the day he appeared to be out of danger, and left for Paris on Tuesday evening, delighted at having got off so cheaply.”
H.—Echis carinata.
XXVII.—Case recorded by Lieutenant C. C. Murison, I.M.S. (Indian Medical Gazette, May, 1902, p. 171).
“G. W. R., a Mahomedan, aged about 12, was admitted into hospital on March 10, 1902, at 9.30 p.m., having been bitten by a snake on the dorsum of the right foot an hour and a half previously. The snake was killed by his sister, and was subsequently identified at the Research Laboratory, Bombay, as an Echis carinata (Phoorsa).
“I saw the patient at about 9.45. The dorsum of the foot was swollen, and the swelling extended above the ankle-joint. The knee reflexes were very exaggerated, and the boy was somewhat drowsy. Since he was gradually getting worse, I decided to inject 5 c.c. of Calmette’s antivenene. I got the hospital assistant under my supervision to inject it into the right calf, to cauterise the bite with silver nitrate, and to apply a 1 in 40 carbolic poultice. Very soon (fifteen minutes) after this the pain in the thigh, which had reached to the right groin, began to disappear. During the night the patient was very sleepy, and the attendants had great difficulty in keeping him awake.
“March 12.—This morning the patient is much better; there is still considerable swelling of the foot, but the pain is much less. All other symptoms are gone.”
XXVIII.—Case reported by Surgeon-Captain Sutherland I.M.S., Saugor, C.P., India.
Case of a woman bitten on the finger on July 22, 1898, by an Echis carinata. Treated six hours later with 10 c.c. of serum. Recovery.
I.—Cerastes.
XXIX.—Case reported by Dr. Moudon, of Konakry, French Guinea.
“On December 9, 1898, a Foulah woman, eight months pregnant, was collecting wood when she was bitten in the heel, behind the internal malleolus of the right foot, by a snake which, from the description given, must have been a Horned Viper. When I saw her, four hours after the accident, the whole of the lower leg was swollen and painful. The swelling extended to the groin, and the patient complained of vertigo and nausea. I immediately gave her an injection of 10 c.c. of antivenomous serum in the right flank, followed by a second injection at 10 p.m. Ten days later, with the Commandant of the Fulton, I saw her again at her village; she had no symptom of malaise, and the pregnancy was taking its normal course.”
XXX.—Case of a bite from a Horned Viper reported by Dr. Mons, in charge of the Military Hospital of Laghouat, Algeria.
“Mohamed ben Naouri, a day labourer, aged 26, during the summer catches Horned Vipers, which he stuffs and sells.
“On August 3 a Cerastes, which he was holding down on the sand with a forked stick, disengaged itself and fastened on his hand. The snake was a large one, about 50 cm. in length.
“The accident happened at 6.30 a.m., 6 kilometres from Laghouat, and the man was bitten on the joint between the second and third phalanges of the third finger of the right hand. He applied a ligature to his wrist, and started to run as fast as he could towards the Military Hospital, where he arrived an hour later.
“He was immediately given an injection of antivenomous serum, in accordance with the instructions, and, around the bite, five or six injections of permanganate of potash, 1 in 20. On the next and following days, tense œdema of the arm and left side of the chest. Extensive purplish ecchymosis of the inner face of the arm; no fever. The phenomena gradually diminished, and, on August 17, there was merely a trifling wound where the bite had been inflicted. The patient was discharged at his own request.
“Like Dr. Marchand (des Montils), we can certify that the action of Calmette’s serum was rapid and efficacious. The injection did not cause any pain or febrile reaction.”
XXXI.—Case reported by Dr. Blin, of Dahomey.
“On March 5, 1906, native hospital attendant C., while gathering vegetables in the hospital garden, was bitten in the right hand by a Cerastes. The bite was inflicted in the tip of the index finger. Ten minutes later a ligature was applied to the base of the finger and another to the upper arm, and as soon as we saw the man, which was after the lapse of about an hour, he was given an injection of 10 c.c. of antivenomous serum. The patient complained of feeling cold and vomited. The axillary temperature was 36·1° C.; the pulse was weak, irregular, and rapid. The finger and hand were swollen. A few minutes later we gave a second injection of serum. Until evening (the accident took place at 11 a.m.) the patient suffered from nausea, but sweating set in, and at 7 o’clock the temperature had risen to 36·7° C. The feeling of depression was much less. On the following day the symptoms had disappeared, and forty-eight hours afterwards the patient returned to duty.”
K.—Bitis arietans (Puff Adder).
XXXII.—Case reported by Dr. P. M. Travers, Chilubula Mission, North-eastern Rhodesia.
“On Thursday, September 6, 1906, information was brought to me that a child, aged 7 or 8, in inserting his hand into a mole’s hole had been bitten by a lifwafwa (’Death-Death,’ i.e., Puff Adder). I set off in all haste on my bicycle. An accident obliged me to leave the road when half-way, and, to complete the series of mishaps, I went to a village with a similar name, a good half-hour distant from that where the patient lived. The result was that by the time I arrived I should say that about two hours had elapsed since the child had been bitten. The snake had been killed, and was, indeed, a puff adder. It had bitten the child in the middle finger of the right hand, and half the arm was greatly swollen, and as hard as stone. As quickly as possible I gave an injection of 10 c.c. of antivenomous serum, and then vainly endeavoured to make the wound bleed. In a very short time the serum was absorbed. On the following morning the child was still ill, with wild eyes resembling those of an epileptic. He yawned continually, and did not seem altogether conscious; the inflammation, however, had greatly diminished. A few days later recovery was complete, but a large abscess formed on the forearm, and the hand became necrosed. I was obliged to amputate all the phalanges. The natives said the child was going to die during the night. In my opinion the serum saved the child’s life, and recovery would have been more rapid had I not been so late in arriving.”
L.—Lachesis ferox (known as the Grage, in French Guiana).
XXXIII.—Case reported by Dr. Lhomme.
“In May, 1898, A., aged 48, a European convict undergoing sentence, was admitted to the Penitentiary Infirmary, of Roches de Kouvous (French Guiana), suffering from a poisonous bite.
“The man had been bitten while engaged in felling timber, at the place called Passouva. The locality is one that is infested with snakes, especially at the end of the wet season. Two venomous species in particular are found there in considerable numbers, the rattle-snake and another called the Grage by the blacks, which appears to be a Lachesis.
“The patient arrived at the Infirmary in the evening, about twelve hours after the accident. We endeavoured to obtain precise details, but, owing to special circumstances, A., who was alone, had been unable to see what animal had bitten him. The clinical signs, however, pointed to a venomous snake; inflammatory phenomena and pain set in soon after the wound was inflicted, and in a very short time became acute.
“Clinical Signs.—On examining the patient we found that the whole of the right arm was swollen. The skin, which was of a dark red colour, was acutely inflamed. The slightest touch or the least movement caused the patient to cry out. The hand showed traces of the bite, in the shape of two small red marks, each surrounded by a bluish areola. The general condition was good. The thermometer, however, indicated a slight rise of temperature, and the pulse seemed a little soft. The urine on being examined on the day after the accident contained a small quantity of albumin. Organs normal. General health before the accident excellent. Nothing worth mentioning in the previous history.
“Progress.—The conditions that we have just described disappeared very quickly, once the treatment was applied. The pain soon ceased, the temperature fell, and the patient was able to get a few hours sleep. By the following day the inflammatory phenomena had noticeably diminished. The œdema of the forearm and hand, however, persisted for some time, though there was no formation of pus. On the third day after the accident the albumin had completely disappeared from the urine. Finally, after the lapse of a fortnight, the condition became normal, and the convict, who had recovered the entire use of his arm, was able to resume work.
“Treatment.—On admission to the Infirmary, A. received a hypodermic injection in the thorax of the contents of a bottle of antivenomous serum. At the same time he was given tonics (alcoholised coffee). The injured limb was placed in a hot phenic arm-bath. These baths were continued on the following days, alternately with damp dressings. Milk diet, and daily aperients.
“We saw the patient again more than a year after the accident; his recovery had been complete; there was no loss of power in the arm whatsoever, and he had never suffered from the nervous troubles mentioned by some authors as a complication ensuing after a long interval, and attributed by them to the antitoxic serum.”
XXXIV.—Case reported by M. Jean, Veterinary Surgeon of Artillery in Martinique.
“C., a negro, aged 26, employed in the artillery quarters at the Rivière d’Or, was bitten in the right leg by a snake measuring about 1 metre in length, which he declared was a Trigonocephalus. The patient came to me twenty minutes after the accident. The marks of the bite were clearly visible a hand’s breadth above the external malleolus. The wounds were inflamed, and appeared as two small red spots 1·5 cm. apart, from which a few drops of serum were exuding. I did not notice any congestion. The patient, however, complained of a feeling of weight in the leg, and supported himself upon the sound one. After making the man lie down upon a bed, I applied a tight ligature above the bitten part, and, with a penknife passed through a flame, I endeavoured to incise the wounds. The instrument, however, was blunt and I obtained but little blood.
“The treatment prescribed in Dr. Calmette’s directions was then strictly followed. With the usual antiseptic precautions, I made several hypodermic injections of the solution of hypochlorite of calcium round the bite, and injected the dose of serum indicated in two places in the abdominal wall. The patient was then vigorously rubbed and covered with woollen blankets. He was made to take two cups of a strong infusion of black coffee. Since he could not be induced to go to hospital, he was carried half an hour later to his home, where he placed himself in the hands of a ‘dresser.’
“According to information furnished by Captain Martin, who lived on the spot and was able to follow the course of the case, the patient remained throughout the day in a state of profound prostration, and had several attacks of syncope. The injured limb was greatly swollen, and the swelling, which extended to above the knee, produced a mechanical difficulty in using the joint, leading to a belief that paralysis was setting in. During the first five days the condition of the patient was so alarming as to cause a fatal issue to be apprehended. By degrees these symptoms diminished, until they disappeared about the fifth day.
“On the twentieth day, C. returned to his work. I saw him again a month later, when he was in perfect health; his leg had returned to its normal size, and all that remained were two small fibrous nodules showing where the bite had been inflicted.”
XXXV.—Case reported by Dr. Gries, Fort-de-France, Martinique.
“On June 21, 1896, a young black, who had just been bitten in the foot by a Bothrops of large size, was brought to the Fort-de-France Hospital. The entire limb was swollen and benumbed.
“Two hours after the accident I gave an injection of 10 c.c. of serum in the abdomen, and the patient was taken back to his family. I saw him again ten days later, and found that he was quite cured. His friends stated that recovery had taken place much more quickly than could have been hoped after so serious a bite, and without the usual complications.”
XXXVI.—Case reported by Dr. Gries, Fort-de-France, Martinique.
“About 7 a.m., on November 25, 1896, G., aged 23, a fusilier belonging to the disciplinary battalion, was bitten by a Bothrops at Fort Desaix under the following circumstances. One of his comrades had just caught the snake, and was holding its head down on the ground by means of a forked stick applied to the neck. G. passed a running noose round the reptile’s neck, but, his comrade having withdrawn the fork too soon, the snake had time to dart at him and bite him in left thumb. At the moment when he was bitten the man was squatting, but he quickly stood up, carrying with him the snake, which remained for a few seconds suspended from the thumb by its fangs, and did not let go until its victim had struck it on the head with his fist. G. immediately ran to one of his officers, who applied a tight ligature to the base of his thumb, and sent him off to the hospital, where he arrived on foot and quite out of breath, ten or twelve minutes after the accident. He was at once given a hypodermic injection of 10 c.c. of antivenomous serum in the left flank; the thumb was washed with a 1 in 60 solution of hypochlorite of calcium, after which the ligature was removed. A few moments later, thinking the case a serious one, I caused a second injection of 10 c.c. of serum to be given in the right flank.
“Immediately after being bitten the patient experienced complete loss of sensation in the limb, as far as the middle of the arm. About 9 a.m. he complained of acute shooting pains in the hand. At 11 o’clock the limb was still benumbed, but by degrees sensation returned. Profuse sweating.
“On November 26 sensation was restored in the whole limb; no inflammatory phenomena. The patient was perfectly well.
“The Bothrops on being brought to the hospital measured 1 metre 47 cm. in length.”
XXXVII.—Case reported by Dr. Lavigne, Colonial-Surgeon at Fort-de-France.
“At 7 a.m. on January 19, 1897, G., aged 22, was going along a footpath near Trouvaillant, when he was bitten in the left external malleolus by a Trigonocephalus which was rutting (a circumstance which, according to the natives, aggravates the character of the bite).
“After killing one of the reptiles (the other having escaped), the young man made his way to the detachment of gendarmery stationed close by. The officer in command applied a ligature to the upper part of the leg, cupped the man a few times, and sent information to us at the Military Hospital. On reaching the spot at 9.15 we found, on the postero-inferior surface of the left external malleolus, two small wounds resembling those caused by the bite of a snake. The leg was swollen and painful, and the patient could hardly put his foot to the ground.
“At 9.30, after taking the usual antiseptic precautions, we gave an injection of Calmette’s antivenomous serum, from a bottle dated December 26, 1896. Not having any hypochlorite of calcium at our disposal, we washed the wound with a 1 in 60 solution of hyposulphite of soda, and applied a dressing of carbolic gauze. An hour later the patient was taken to Saint Pierre in a carriage. Temperature 37·2° C. No vomiting, or tetanic phenomena. In the afternoon the pain was less acute, and the œdema seemed to have diminished a little. Mercurial ointment rubbed in.
“Four days later the patient, being cured without having had the least rise of temperature, proceeded to the country.
“This case is interesting, since a single dose of antivenomous serum (20 grammes), injected two hours and a half after the accident, sufficed to cure a young man bitten by a Trigonocephalus measuring 1 metre 20 cm. in length.”
M.—Crotalus horridus.
XXXVIII.—Case recorded by Dr. P. Renaux, of Piriapolis, Uruguay (La Tribuna popular, Piriapolis, December 14, 1898).
Silverita, aged 20, bitten in the ankle by a Crotalus, on December 7, 1898. Symptoms of serious intoxication. Treated with a dose of antivenomous serum, injected half in the right flank, half in the left. Recovery.