Part 4

Science, however, demands that a theory thus established inductively must also stand the test of practical application or deduction. It says in the present case:--"Granting your theory to be correct, it is but a theory, which, however valuable it may be as a contribution to science, is of little value to mankind if you cannot apply it practically. If snake-poison merely acts as a depressant on motor nerve-cells without interfering with their structure, you must be able to counteract it by administering some drug or substance which acts as a powerful stimulant on these cells, if such a substance can be found."

It is another illustration of that wise adaptation of means to ends which, throughout the domain of nature, denotes the presence and rule of a Supreme Intelligence, that this substance has been provided for us by nature, though we have been long in finding it. Its discovery in strychnine, and its successful application as the long and vainly sought antidote to snake-poison, are glorious triumphs of scientific deduction.

Strychnine is the exact antithesis to snake-poison in its action. Under its influence every motor nerve-cell throughout the system sends forth stronger currents of nerve force than it does in its normal state. These currents run alike from cell to cell, and from cell to peripheral fibre, and act by means of the latter on all contractile, and especially all muscular tissue, causing contractions, which, after poisonous doses of the drug, assume the form of tetanic convulsions, provoked by the slightest touch or even noise in consequence of highly intensified reflex action.

Whilst, then, snake-poison, as we have seen, turns off the motor-batteries and reduces the volume and force of motor-nerve currents, strychnine, when following it as an antidote, turns them on again, acting with the unerring certainty of a chemical test, _if administered in sufficient quantity_. Purely physiological in its action, it neutralises the effects of the snake-poison, and announces, by unmistakable symptoms, when it has accomplished this task, and would, if continued, become a poison itself. Previous to this announcement its poisonous action is completely neutralised by the snake-poison, and the latter would therefore be equally as efficacious in strychnine-poisoning as strychnine is in snake-poisoning. Strychnine, in short, is the antidote _par excellence_ of snake-poison, and cannot be surpassed by any other substance known to us.

With the symptoms following the introduction of the subtle ophidian virus into the human and animal system so markedly pointing to strychnine as the antidote, it appears a matter of surprise that it was not used as such before and that it was left to the writer to discover the antagonism between the two poisons. Misleading experiments with the drug on animals erroneously considered to be final in their results, together with confused and contradictory notions about the action of snake-poison, were the chief factors, already pointed out, that caused research on this important subject to remain for centuries so barren of results, and made even able investigators with more correct views than the rest, postpone the discovery of a physiological antidote to a more advanced state of science, when all the time it was lying ready at their hands.

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.

CASES.

If the deductions and conclusions set forth in the foregoing chapters are correct, it may be justly contended that all cases of snakebite treated with strychnine should invariably end in recovery if the antidote is properly applied, according to the rules above detailed. This contention the writer fully and cordially endorses. Given the largest amount of poison a snake can give off at one bite, strychnine injected in time and sufficient quantity--either by the hypodermic, or, if urgent, by the intravenous method--must rouse the dormant nerve-cells into action, as long as the vital functions are not completely extinct. Wherever it fails, the fault lies with the operator not injecting it in sufficient quantity--a fault committed by the writer himself in his first case.

The following condensed accounts of fifty cases treated in Australia, and eight in India, the writer has taken mostly from the _Australasian Medical Gazette_. Two of these only are from his own practice; others were kindly communicated to him by his colleagues. It is not claimed that all these cases were rescues from certain death. Some of them undoubtedly were, others would have recovered under some other treatment or no treatment at all; but in none of them would recovery have been so rapid and complete. The two poisons are thrown out together, and no ill-effects of either are experienced beyond a certain degree of weakness, which passes off quickly. This is a boon to be appreciated fully by those only who have gone through the slow, lingering, and painful process of convalescence from snakebite as formerly treated, with its deadly languor and weariness, making life itself a burden and all physical and mental exertion impossible.

CASE 1.--A. H., 15 years old, a farm labourer, was bitten on the right index finger whilst feeling for a rabbit in a burrow. Did not see the snake nor suspect snakebite, but collapsed helplessly in a few minutes after returning to his work. The writer saw him three hours after the accident. He was then completely paralysed and in deep coma; pupils widely dilated and not reacting to light; sense of sight and hearing dead; heart action extremely feeble; pulse small, thread-like, and scarcely countable; respiration quick and shallow; skin blanched and very cold. Seeing him dragged along the road between two men, had him quickly carried to the next house, and injected 20 minims of liq. strychnine. Only a groan or two and a slight improvement in the pulse, indicating a change in his condition, gave him a second injection about twenty minutes after the first one. A change for the better then became rapidly conspicuous. The pulse gained in strength from minute to minute, respiration became deeper, and the coma was visibly reduced to mere sleep, from which there was no difficulty in rousing him to full consciousness by a vigorous shake of the shoulders. This marvellous change was brought about within forty minutes; and this being the first case to which the writer had applied his theory by injecting strychnine, its unparalleled success exceeded his most sanguine expectations, but unfortunately also lulled him into a false sense of security, which proved disastrous to his patient. Not knowing then as he does now that the snake-poison after having been subdued by the antidote is not thrown out of the system as quickly as the strychnine, and is therefore apt to re-assert itself, he allowed another urgent engagement to take him away from the lad after watching him for two hours and actually taking the evening tea with him. His instructions to the mother not to let her son go to sleep and to watch him carefully for the slightest sign of the return of symptoms, were unfortunately disobeyed. Both mother and son went to sleep, deeming all danger over. During this sleep the lad again relapsed into coma and was found so at daylight. All attempts to rouse him were fruitless, and he died before the messenger intended for me had time to saddle a horse. The death of the unfortunate lad, however, has saved some lives since. It taught the writer the lesson never to trust to the apparent success of the antidote until it shows distinct signs of its own physiological action, and even then to watch his patients carefully for the first twenty-four hours, and let them sleep for short periods only.

CASE 2.--A.H., a vigorous girl of 20 years, bitten above the left ankle by a snake in some long grass, and therefore not identified. Had applied two tight ligatures above the bite, ran home and got her mother to cut out the bitten skin, showing two distinct punctures. Seen within an hour after the bite the girl presented distinct, but moderate symptoms, deadly paleness, very cold skin, small frequent pulse, and a peculiar feeling of agony about the heart, just able to sit upright, but unable to walk. All symptoms increased rapidly after writer cut ligatures. She reeled from side to side, and suddenly fell forward as if in a swoon. Injected 1/6th grain of strychnine and, as she did not lose consciousness, was able to watch the interesting and rapid effect of the antidote. It had not been injected more than five minutes when slight colour returned to the cheeks, naturally very red. Patient then stated that the distressing feeling about the heart was getting less and also that of drowsiness. From minute to minute her condition improved, and in about ten she was able to rise and walk a few steps. Profiting, however, by the lesson his first case had given him, the writer did not trust to her apparent recovery, but seeing that much of the poison had been eliminated by the prompt measures taken before he saw her, he injected only 1/12th of a grain, which produced slight muscular spasms. Careful precautions were taken in this case against a relapse, but none took place, and when visited next morning the girl declared herself as well as ever she had been in her life.

The following notes of two cases of tiger snake bite (_Hoplocephalus curtus_), treated with strychnine, were read by Dr. Thwaites before the Intercolonial Medical Congress of 1889. This gentleman, a young practitioner just entering practice, had the courage to use the antidote according to the writer's directions in spite of the hostile criticisms of his seniors in the profession and even his own university teachers, and thereby not only saved two valuable lives, but also set a praiseworthy example, which was soon followed by others. The writer gives the notes abbreviated.

CASE 3.--J. B., a strong, robust labourer, bitten by a tiger snake on the back of right hand. Killed the snake, which hung on to the hand and was with some difficulty shaken off. Made slight incision through the punctures and tied a rag round the wrist, but too loosely to check circulation; then started for the next neighbour's house, distant a mile, which he reached with difficulty, staggering like a drunken man when he arrived. The bitten skin was here excised, whisky administered and patient sent on in a buggy, but distance being 30 miles to Dr. Thwaites' residence, a messenger on horseback galloped ahead to get Dr. Thwaites to meet buggy on road. The latter writes: "I met buggy four miles from my residence. Patient had to be held up on the seat of the vehicle between two men. He had not spoken for some time, pulse very weak, pupils greatly dilated, face very pale. I injected 10 minims of liq. strychnine P.B. at once, and in a few minutes noticed some improvement. He now answered when spoken to, his pulse became stronger, and he could walk a few steps. This was at 5.30 p.m., and he kept up fairly well till 8.15, when he collapsed completely. I now injected 20 minims of liq. strychniæ, which in a short time brought him round; but at 9.15 another relapse took place, when a third injection of 15 m. was made. This was followed by slight twitching about the face and neck, after which improvement and recovery were uninterrupted."

Dr. Thwaites' second case is even more remarkable and telling. When the girl, after a journey of 30 miles, was carried into his surgery, she appeared to be dead, and a second medical man, who happened to be present, declared her to be so, and all attempts to revive her useless.

CASE 4.--A. D., aged 15 years, a schoolgirl, bitten by a vigorous tiger-snake on the outside of left leg, the snake also holding on for some time. She at once tightened her garter above the knee and ran home, a distance of three-quarters of a mile. The bitten skin was at once excised, another firm ligature applied, whisky administered, and a hurried start made for Dr. Thwaites', distant 30 miles, where she arrived five hours after accident. The latter writes:--"She was then pulseless at wrists, cold as a stone, and with pupils insensible to light. I could not perceive any respiration, but felt the heart yet faintly fluttering. She was to all appearances just on the point of death. I injected at once 17 minims of liq. strychniæ. In about two minutes she sighed, and then began to breathe in a jerky manner. In about ten minutes, on my pulling her hair, she opened her eyes and looked around, but could not recognise any one. Pupils now acted to stimulus of light. In a short time she could speak when spoken to, but not see at any distance. Her sight gradually returned completely; she kept on improving, and in four to five hours after the one injection she seemed quite well, but rather weak. I gave small doses of stimulants till morning, and did not let her go to sleep till next evening. She suffered no relapse, and her recovery was complete."