Nevertheless, a slight œdema began to appear round the bite. The injured man seemed to be suffering a little, but the pain did not extend above the wrist; a slight trembling appeared in the other arm. From time to time Coupin gently massaged the affected limb with his left hand from above downwards, in order, he said, to lessen the pain, and perhaps also with a view to checking the diffusion of the venom. A slight perspiration broke out over the body; the pulse was regular, 92, twenty minutes after the bite.
Towards 6.15, or about an hour and a half after the experiment, the man, refusing an injection of serum, prepared to go home, but we insisted that he should remain at the hospital for at least two hours longer, so as to enable us to watch his condition. He consented to this, and asked for something to eat. At this time the back of the hand was somewhat more swollen, but Coupin seemed to be little disturbed by it; he even declared that the swelling would increase still further on the following day, and that, in two or three days, he would make an incision in order to let out the impure blood collected at the spot; also that the trouble was now localised, and would not extend higher. He merely complained of acute thirst, and of a certain difficulty in swallowing, which was due, he declared, to the extreme bitterness of the leaves that he had just masticated. Temperature 36·8° C.; pulse 36. After the brief reaction at the outset, there was a certain amount of hypothermia, but the general condition seemed satisfactory, and the man remained perfectly calm. We therefore left him under the supervision of the resident student and the male attendants, giving orders that we should be sent for immediately in case of any serious symptoms arising.
At 7.15 we received a note from the student to the effect that Coupin had vomited, that his pulse was small, there was difficulty in breathing, and that he had just received an injection of antivenomous serum. We hastened to the hospital, where we were speedily joined by Drs. Cordier and Lhomme.
On our arrival we found Coupin in a rather prostrate condition. The pupils were fixed, he was foaming slightly at the mouth, respiration was regular, the pulse was strong and quite rhythmical at 96; the man was somewhat chilly. The patient was unable to speak, but had not lost consciousness, for, when we asked him how he was, he indicated by signs that he felt very ill. We subsequently learnt, from the student on duty, that towards 6.45 the condition of the patient became suddenly worse, after his companion had administered to him some medicine, the nature of which we have been unable to discover; on swallowing this drug Coupin was seized with vomiting, and became collapsed. We thought it more likely, however, that this was a mere coincidence, rather than the result of a poison adding its effects to those produced by the bite of the snake.
While waiting for our arrival a ligature had been applied to the injured arm, and near the bite there had been made two deep incisions, from which some dark blood escaped. At the same time the patient received hypodermically a first injection of 10 c.c. of Dr. Calmette’s antivenomous serum, and two injections of ether and caffeine. As the result of this treatment we found a marked increase in pulse-rate. After a subcutaneous injection of 500 grammes of artificial serum, there appeared to be a further distinct improvement until about 8.45 (four hours after the bite). From this moment, however, the patient gradually sank. A second dose of antivenomous serum was injected beneath the skin,[171] and, since the respiratory movements gradually became slower, artificial respiration by Sylvester’s method was resorted to, while the tongue was rhythmically drawn forward. From time to time these proceedings were interrupted for a few moments, in order to observe the condition of the respiration; at the base of the thorax and in the flanks abrupt, jerky, tetaniform undulations were observable, but there was no free respiratory movement. The abdominal aorta, the pulsations of which were visible behind the navel, raising the anterior wall of the abdomen, was somewhat misleading, simulating the rhythmical oscillations of the abdominal respiratory type. The heart, however, continued to beat regularly, without any appreciable weakness. The radial pulse persisted, although weak and slow: rate 48.
The patient was kept alive by repeated injections of ether and artificial serum (1¼ litres in three doses). About 8.30 there appeared to be a slight improvement; the patient was warmer, and showed some degree of sensation in the region of the bite. On pinching the vasculo-nervous bundle in the left axilla reflex movements were produced in the fingers, which closed convulsively. The pulse, which had momentarily disappeared in the radial artery, could again be felt, weak but regular. At the same time, when the epigastric region was examined, a few faint respiratory movements were just perceptible. A third injection of antivenomous serum was given and artificial respiration was continued.
This factitious amelioration, however, was not maintained, and after a few scarcely visible movements of the thorax the end soon came. The eyes were fixed and insensible, the pupils slightly dilated; no sweats, no urine passed. The body slowly grew cold; the pulse disappeared from the femoral and carotid arteries, and diminished in the aorta. The contractions of the heart were once or twice irregular, and its beats became weaker and gradually lower. The reflexes had disappeared. There were still a few slight muscular contractions near the base of the chest, and the patient quietly passed away at 11.5 p.m., as the result of the progressive arrest of the heart’s action, respiration itself having virtually disappeared two hours before the heart had ceased to beat.
Case III.—A week after this sad occurrence, another snake-charmer, Kingilien by name, aged 25, was bitten in the first phalanx of the right forefinger, when taking hold of a cobra in the courtyard of the Pondicherry Hospital. Refusing an injection of antivenomous serum, the man ran off as fast as he could go, after having a simple ligature applied to his wrist. Scarcely had he reached his dwelling, when he fell into a deep coma, in which condition he was carried to Cottacoupom, to the abode of one Souraire Kramani, a kind of sorcerer, who administered to him a certain medicament in a betel leaf. After having vomited a large quantity of bile he was taken home. At this time, according to the summary investigation that we caused to be made, the patient was unable to utter a single word; he could only open his mouth with difficulty, and his eyelids remained closed. Kingilien, who had partially regained consciousness, seemed to be suffering from continuous attacks of vertigo; his head, if pushed to one side, drooped, and the man was incapable of voluntary movement. Respiration was fairly easy, swallowing painful. The entire hand was greatly swollen; poultices of leaves were applied to it, after a few incisions had been made with a knife in the back of the hand, in order to reduce the congestion. The arm was rubbed from above downwards with the very bitter leaves of the Vëmbou, or mango-tree, and prayers were recited. This is all the information that I have been able to obtain with reference to this man, who, after a prolonged convalescence, is said to have recovered (?).
Case IV.—One Latchoumanin, aged 25, also a snake-charmer, of Caradicoupom, was bitten at the Hospital at 10 a.m., on August 2, while handling a cobra. The bite was situated in the second joint of the right thumb. After it had bitten the man, ten drops of venom were extracted from the reptile’s glands.
A ligature was immediately applied, and the wound was made to bleed by hard squeezing. Refusing all other treatment, especially injection of serum, although we repeatedly urged it, the man made off home with all speed, but on arrival failed to find the specific on which he was relying. All that was then done was to recite a few prayers over him, and a Brahmin priest was called to bless him. About 11.30, after acute suffering, Latchoumanin sank into a comatose condition. At 12.30 respiration became stertorous, and the patient succumbed at 2 p.m., four hours after being bitten. Just as the medical officer, deputed by us, reached the dying man, two chatties containing live snakes were deposited at his bedside, to ward off ill-luck!