THE TREATMENT OF SNAKE BITE BY

CALMETTE'S ANTIVENENE.

By A. SCOTT REID, M.B.,

COLONEL,

Admiiislrativc Medical Officer, Central Provinces.

Although the efficiency of Calmette's anti- venene, as an antidote to the venom of snakes, has been proved up to the hilt by physiological experiments on animals conducted in the Pasteur Institute at Lille and elsewhere, the number of clinical cases reported in which the remedy has been used with success in man, have been, up to date, comparatively few, and, in all,or nearly all, there has been some doubt as to the identity of the snake which inflicted the bite, or as to the fact of a lethal dose of poison having been received. It was therefore primarily with the object of obtaining more accurate data in these respects, that, towards the end of 3 809, I caused each of the police and charitable hospitals and dis-

pensaries (branch as-well as main) in the Central Provinces to be furnished with the necessary ap- paratus and a small stock of the antitoxin, while

I, at the same time, circulated full instructions

regarding the administration of the latter, my ultimate hope being to establish a case strong enough to enable me to recommend a more

extended application of the treatment through the agency of Police, Forest and other officials, whose duties call them into regions far removed from medical aid, and where opportunities for using the serum are liable to be met with at any moment. Although not Utopian enough in my ideas to anticipate that the final results would, under the most favourable auspices, make any appreciable difference in the total provincial aggregate of deaths from snake-bite, I could conceive nothing in the way of treatment more satisfactory to medical or laymen (for the

hypodermic method of injection is simple enough to be learnt by any one of ordinary intelli-

gence) than to possess the means of, here and

there, saving a human life otherwise doomed ; and nothing more calculated to make a favour- able impression 011 the native mind. No one, however, who has not tried can realise the diffi-

culty of collecting reliable and accurate data when one has to rely for such on the assistance of subordinates imperfectly trained in methods of observation, and many of whom hardly pos- sess even the literary ability of recording, in an intelligible form, what they have actually seen. There is besides the vis inertice opposed to the introduction of new measures to be overcome, and a riotous tendency of the Oriental imagina- tion to contend with.

The first case to come to my notice was the one which was published in the January number of tlio Indian Medical Gazette .for 1901, and for the particulars of which I was indebted to Mr. Hogan, Civil Medical Officer of Mandla, in which district tlio occurrence took

place, .and under whoso care the patient was finally placed. There the usual difficulty existed as to the identification of the snake, and also, as I pointed out, a doubt as to whether the man had received a lethal

quantity of venom, in view of the length of time he had survived before the specific treatment was commenced. At page 12, paragraph 47 of my Annual Sanitary lie-

port for 1900, I briejly alluded to six other cases which had been reported to 1110 as having been treated by Cal- mette's method during that year, but of which the history was also incomplete as regarded the identification of the snake, and in which many other po:nts, which ought to have been noted, were neglected. Had the reports baen submitted to me at the time, as requested, instead of being held over to the end of the year, I might have been able to elicit more satisfactory information. From a perusal of tlio data which reached me, I havo, however, little doubt that all the cases were genuine ones. Four recovered and two proved fatal, and a possible expla- nation of the failure of the serum in the latter is sug- gested by the Civil Surgeon in the probable fact that the persons had been bitten by Russell's viper, a very common snake at the time, and whoso venom is said not

to be amenable to the action of the antitoxin, vide Allbutt's System of Medicine, Volume II. In connec- tion with this point I observe that, according to the report issued by Major II. W. Lyons, i.M.s., of the results of his visit to the Pasteur Institute at Lille, Dr. Cal- mette does not appear to make uso of tlio Daboia iu

preparing his mixed venom for immunising the horses from which the serum is obtained.

Oct. 1901.] SNAKE-BITE CURED BY ANTIVENENE. 373

I will now proceed to give the details of a recent case which I venture to consider is, in essential particulars, one of the most complete yet published. The informa- tion was forwarded to ma by Dr. T. W. Qainn, Civil Medical Officer of Damoh, at the head quarters of which district the incident occurred, but who himself was not

present on the occasion :?

At 8-45 p.m of the 4th July 1901, Mossummi Chanhoo, male, aged 20, sweeper in the employment of Mr. R ,

Sub-divisional Officer, Public Works Department, brought to his master a dead pigeon he had just then found lying under the cot in the compound, and which is said to have been at the time warm and bleeding slightly from a wound in the head. As three other birds had been found dead in the same spot that morning, having appprently fluttered out during the night and died, the man was told to remove the survivors at once, which he proceeded to do. The sweeper, however, immediately returned holding out a bleeding left fore- finger, and saying that, while carrying out (lie order, he had been bitten by a snake which he had seen. He was at once hurried off to the Main Dispensary, distant 600 yards, by Mr. B?.Head-quarters Police Inspector, who happened to be present, and who, on the way, bound the injured finger with a pocket handkerchief, and, while passing the quarters of the Hospital Assistant, shouted to him to come immediately, as there was a case of snake bite to be treated. The medical subordinate, on

examining the patient, found two punctured wounds on the terminal phalanx of the left index finger which was swollen and covered with blood. He then placed a

ligature, which was retained for 24 hours, above the bite and scarified the part, rubbing powdered permanganate of potassium into the original and additional wounds thus made. Next 1C c. c of Calmette's antitoxin was injected into the subcutaneous cellular tissue of the

flank, with antiseptic precautions, viz., washing the skin with soap and water followed by boric lotion, while the syringe was at the same time sterilised with boiling water and similar solution, the time which had elapsed between the bite and moment of injection having been 33 minutes as calculated from the distance and necessary delays. The patient had complained of a sense of giddi- ness on admission, but this symptom subsided after

treatment, and no further sign of constitutional poison- ing manifested itself, although the case was carefully Avatclied until four the next morning. The man was

discharged after three days' detention. Sharply demarcated sloughing followed at the site of the bite

extending in area to the size of a four-anna piece and in

depth almost to the bone. The subsequent ulcer took a long time to assume a healthy action, and at the date of my latest information, 4th August (a month after the

bite), had not quite healed, notwithstanding repeated applications of Cupri Sulph. I feel sure from the

circumscribed nature of the sloughing that it was not due to strangulation by the ligature, although the latter was kept on for an unnecessary time. The figures on the box containing the serum, and indicating the date on which it had been drawn from the horse were 7th March 1900. It was obtained from Messrs. Kemp & Co., Bombay, on the 10th March 1901, but how long previous- ly it had been kept in this country I cannot say. While the operations described above were in pro-

gress, Mr. It proceeded to the pigeon cot with a

lantern, and inside it found the snake, which he shot. It had since then been sent to me in spirits, with a young pigeon which had been found in the stomach, and proved to be the non spectacled variety of the

Nuja Tripudians, measuring 3? feet (probably a little more when alive as the body had been cut in two by the shot and part of it blown away) with the glands and fangs intact. The only possible unfavourable criticism which I can

see as to the efficiency of Calmette's antivenene in this case is that the snake may have partially or completely exhausted its venom on the last pigeon killed, for the

bird had apparantly died within the previous two hours, as the sweeper stated that he had examined the cot at

about 7 p.m. and found all correct. The warmth of the

body in an atmospheric temperature of about 100?, and the oozing of blood from the wounds do not count for

much. The fact of the three pigeons having been killed in succession the previous night, however, goes against this theory, and a much stronger incident with the same

import recurs to my mind. In 1874, while I acted as

Honorary Secretary to the Mess of my regiment, the

hhansamah, who kept a moorghi-khana, containing fowls of every description, one day brought for my inspection a large basketful of dead birds, certainly not less than a dozen, and comprising, as far as I can recollect, one or two turkeys and sevaral guinea-fowl. His

story was that during the night he had heard a great commotion in the moorghi-khma, and on opening the

doors in the morning found the catastrophe I have de-

scribed, his theory being that the unfortunate birds had been blown upon by a cobra which had been seen several times in the compound and whose habitat in a hole was known. I had several of the fowls plucked, and in each discovered the characteristic punctured wounds with a

surrounding area of extravasated blood Probably the snake had gone in search of eggs or young birds, and being attacked by the parents had struck out all

round. It is thus obvious that a venomous snake does

not always exhaust all its venom in one bite, and it would seem to have the power of regulating the quanti- ty ejected with relation to the object it^ attacks. Had a

human being been bitten after the first fowl, I havo little doubt that he would have received a lethal dose.

In the case under report I regard the giddi- ness which was complained of as an indication of constitutional poisoning, for I find it given as one of the first symptoms in several of the other cases referred to in the beginning of this article. Dr. Quinn states that the sweeper is by no means a nervous individual, but that, on the

contrary, he was quite cool and collected after being bitten. The swelling of the linger was, in my opinion, due to local action, for the

handkerchief used by Mr. B as a ligature could hardly have entirely impeded the circula- tion. Further evidence in this direction was afforded by the circumscribed and deep slough- ing, a feature which was noted also in the case published by Mr. W. Hanna, M.B., and Captain George Lamb, in the Lancet of 5th

January, 1901. P.S.?Since writing the above I have received

from Captain G. Lamb, i.M.s., of the Plague Research Laboratory at Bombay, the following reports of the standardisation ot a sample from the batch of serum which was used in the Danioh case, and of the result of an examination which he kindly made of the poison glands of the cobra concerned. It is interesting to note that, if the conclusion arrived at be correct, the snake had apparently injected all its available stock of venom into the man.

" 1. Standardisation of a sample of Calmettes serum received from Mr. J. W. Quinn, L.R.C.P Civil Surgeon, Damoh, C. P. The serum was dated 7th March 1900: it

arrived in Bombay on 11th December 1900, and had been sent to the Central Provinces on the 10th March 1901.

374 THE INDIAN MEDICAL GAZETTE. [Oct. 1901.

The method adopted for the standardisation of this serum was the method described in the Lancet of the loth June 1901. The test dose employed was ten lethal doses,

for a rat, of pure unheated cobra venom, viz., 0 4 milligramme. Rats of 115 to 118 grammes were used. The

venom and serum were mixed in vitro and allowed to stand at the laboratory temperature for half an hour. All injections were made

subcutaneously in the hind leg. The following was the result obtained :?

Animal.

Eat 1

? 2

? 8

? i

? 5

,, 6

? 7

Amount of venom in milll

grammes.

0-4 0-4 0-4 0*4

04 0-4 0'4

Amount of serum in cubic centimetres.

0T> 0-fi 0-7

0-8

09 ro ML

Result.

Died 4? hours. Died in 20 hours. Ill, but recovered. ?Slightly ill, but re-

covered. No symptoms.

Do. Died I4- hours.

From this series of experiments we can con- clude that 07 c.c. of the serum neutralised

0"4?0035 milligramme of venom. In other

words, one cubic centimetre was able to neutra- lise 052 milligramme of pure cobra venom.

In the paper mentioned above it was shown

that 1 c. c. of fresh serum could neutralise 0'73

milligramme of cobra venom. There has, there- fore, been only a slight deterioration of the

sample of serum which was examined now. 2. Examination of poison glands of cobra

sent by Colonel Scott Iicid, I.M.S., as to the pre- sence or not of active venom. The snake was killed on the 4th July 1901. It

was at once placed in a large excess of methy- lated alcohol. The glands were examined by me on the 4th September. They had, therefore, been in alcohol for exactly two months. This treat- ment with an excess of alcohol would have the effect of precipitating all proteids present in the glands; and, further, of rendering the globulins and albumins insoluble 011 further treatment with water. Now cobra venom owes its toxicity main- ly, if not wholly, to an albumose. It was there- fore possible to ascertain if there was still left any toxic element in the glands of this snake. The

glands were carefully dissected out from their cap- sules. They were then cut up into small pieces and well pounded with distilled water. This material was thrown on a filter. The clear filtrate was caught in a weighed platinum basin. The filter paper was well washed with distilled water.

The filtrate was then evaporated over a water bath at 00?c. By this means G'3 milligrammes of material which had been dissolved in the water was recovered.

The following rats were injected with varying quantities of this residue:?

Animals.

Rat 1

. i 2

? 3

91 4

.. 6 6

Amount of resi- due iu

milligrammes.

O'O.- 01 0'5 1 2

Result.

)

i } No symptoms, i

J

We can therefore conclude, in view of the fact that the minimum lethal dose of cobra venom for a rat of the size used in this series of

experiments is 0'04< milligramme, that the glands of this snake contained no venom at the time of its death."