It is self-evident from preceding statements, that in the treatment of snakebite with strychnine the ordinary doses must be greatly exceeded, and that its administration must be continued, even if the total quantity injected within an hour or two amounts to what in the absence of snake-poison would be a dangerous if not a fatal dose. Timidity in handling the drug is fraught with far more danger than a bold and fearless use of it. The few failures among its numerous successes recorded during the last four years in Australia were nearly all traceable to the antidote not having been injected in sufficient quantity. Even slight tetanic convulsions, which were noticed in a few cases, invariably passed off quickly. It should be borne in mind that of the two poisons warring with each other that of the snake is by far the most insidious and dangerous one, more especially in its effects on the vaso-motor centres. The latter are wrought very insidiously, and where they predominate require the most energetic use of the antidote, for whilst the timid practitioner after injecting as much strychnine as he deems safe stands idly by waiting for its effects, the snake virus, not checked by a sufficient quantity of it, continues its baneful work, drawing the blood mass into the paralysed abdominal veins and finally by arrested heart action bringing on sudden collapse. In such cases even some tetanic convulsions are of little danger and may actually be necessary to overcome the paralysis of the splanchnicus and with it that of the other vaso-motor centres.
Whilst then it must be laid down as a principle that the antidote should be administered freely and without regard to the quantity that may be required to develop symptoms of its own physiological action, the doses in which it is injected and the intervals between them must be left to the practitioner's judgment, as they depend in every case on the quantity of snake-poison absorbed, the time elapsed since its inception and the corresponding greater or lesser urgency of the symptoms. If the latter denote a large dose to have been imparted and it has been in the system for hours, delay is dangerous and nothing less than 16 minims of liq. strychnine P.B., in very urgent cases even 20 to 25 minims should be injected to any person over 15 years of age. Even children may require these large doses, as they are determined by the quantity of the poison they have to counteract and are kept in check by it. The action of the antidote is so prompt and decisive that not more than 15 to 20 minutes need to elapse, after the first injection, before further measures can be decided on. If the poisoning symptoms show no abatement by that time, a second injection of the same strength should be made promptly, and unless after it a decided improvement is perceptible, a third one after the same interval. As the action of strychnine when applied as antidote is not cumulative, no fear needs to be entertained of violent effects suddenly breaking out after these large doses repeated at short intervals. They are, so to say, swallowed up by the snake-poison and remain latent except in counteracting the latter. This has now been proven abundantly by scores of qualified observers in all parts of Australia, and still more by Banerjee in India. No hesitation, therefore, should be felt by medical men in other snake-infested countries to adopt the Australian treatment. It is seldom that more than half a grain of strychnine administered in 16m. doses of liq. strychniæ is required here to effectually counteract the venom and place its intended victim out of danger. Ligature and excision of the bitten skin have usually been practised and much of the poison eliminated before the antidote is applied. Our snakes, however, as already pointed out, with their shorter and merely grooved fangs, do not perforate the cellular tissue to such depth nor instil as large a quantity of poison as the cobras, kraits and vipers of India or the rattlesnake of America, all having perforated and much longer fangs and much more productive poison glands. Even if after the bite of a vigorous cobra, for instance, a ligature has been applied and the bitten part deeply excised, a comparatively large quantity of poison will probably be absorbed requiring much larger quantities of the antidote, perhaps grains of it, to effect a cure.
If under the influence of these large doses the symptoms abate, or if the latter are comparatively mild from the first, smaller doses of strychnine should be injected, say from 1/15th to 1/10th of a grain, but under all circumstances the rule that, distinct strychnia symptoms must be produced before the injections are discontinued, should never be departed from. This rule is a perfectly safe one, for its observance entails no danger, a few muscular spasms or even slight tetanic convulsions being easily subdued and harmless as compared with that most insidious condition exemplified in case No. 1, cited below, the first one treated with strychnine by the writer, who, having no experience in the treatment, did not administer quite enough strychnine. The patient, after apparently recovering from a moribund condition and being able to walk and even to mount a horse, remained partly under the influence of the poison and succumbed to it during sleep, when, according to subsequent experience, one more injection would have saved him.
The tendency to relapses is always great when much snake-poison has been absorbed. Apparently yielding to the antidote for a time, the insidious venom, after a shorter or longer interval, during which it appears to have been conquered, all at once re-asserts its presence, and has to be met by such fresh injections, regardless of the quantity of strychnine previously administered, but the amount required in most relapses is not a large one. The writer formerly inclined to the belief that the strain thus put on the delicate nerve-cells would limit the usefulness of the antidote to cases requiring not much above a grain. Knowing the Indian snakes to impart to their victims such comparatively large quantities of venom, he had strong misgivings as to his method standing the severe test of Indian practice; and it was most fortunate for this method that its first practical application in India was made by a gentleman who, whilst thoroughly familiar with its principles and convinced of their correctness, had the courage to apply them fearlessly by injecting what to us Australians appear enormous quantities, ranging as they do up to three and four grains per patient. Dr. Banerjee's eight cases, all successful, and of which the most important one, relating to the much and justly dreaded Duboia Russellii, was published in the November number of the Australasian Medical Gazette, settled the treatment of snakebite in India as well as elsewhere. If the poison of Bungarus coeruleus, Echis carinata, and Duboia Russellii can be successfully counteracted, and if for this purpose four grains of strychnine can be injected with perfect impunity, it may be inferred with certainty that the poison of the cobra, fer-de-lance, and the rattlesnake—in fact, of any snake known to us will be found amenable to the antidote, and that, if four grains can be injected with safety, we may venture on six and eight grains, if they are required. In those cases only where the long fangs of these snakes perforate into a vein, and a large quantity of the venom injected into the blood-stream overpowers the nerve-centres so as to make death imminent, if not almost instantaneous, the subcutaneous injections may be found of little use. Here intravenous injections of half a grain and even one grain doses would appear to be indicated, and might yet fan the flame of life afresh, even when respiration and pulse at wrist have already ceased. We have seen both these functions extinct in Australia and restored by comparatively small doses of the antidote, and can see no reason why a more energetic use of it should not restore them in India.
Considering the terrible mortality from snakebite in India, Dr. Banerjee's merit in being the first to introduce the strychnine treatment there is of a very high order, and his grateful countrymen will ever cherish his memory. When his Excellency the Viceroy had been appealed to in vain by the writer, and the adoption of his method in India urged through two Australian Governors, a native of India has stepped forward and taken the first step towards alleviating an evil that has hurried over two millions of his countrymen in every century to an untimely grave.
The cases as reported by him to the Australasian Medical Gazette are cited below.
