476 REPORT OF NATIONAL MUSEUM, 1893. 



A similar treatment also seems advisable iu such cases of slow poison- 

 ing in wbicli the patient has already reached a stage of collapse, or 

 coma, before assistance can be rendered, provided not more than 

 twenty four hours have elai^sed since the bite was inflicted, in which 

 case injections of strychnine seem inaijplicable. 



If in case of slow poisoning help can be administered very soon after 

 the infliction of the wound and the venom has been localized by liga- 

 tures and minimized by incision of the wound, sucking, or, better, cup- 

 ping of the blood, the treatment next to be applied depends upon 

 whether the ottending snake is a Pit Viper (Orotalid)or an Ulaps, for if 

 it was a rattlesnake, a copperhead, or a water moccasin, attention 

 should at once be directed to the local lesion, unless the state of the 

 patient imperatively demands an immediate stimulant, in which case 

 small doses of alcohol may be useful. Apparently the best treatment 

 of the local lesion is an 1 to 100 solution of chromic acid injected into 

 the incised wound, the punctures of tlie fangs, and into the surrounding 

 swelling, as quickly as the circumstances will allow, since the success 

 of this treatment depends upon the chemical reaching and destroying 

 the venom before it is absorbed into the circulation. Kneading of the 

 tissues surrounding the wound in order to bring the venom and chemi- 

 cal in close contact may be useful. If chromic acid is not at hand, 

 chloride of gold, permanganate of i^otassa, etc., may be substituted. 



There does not seem to be any necessity for amputation in a case 

 where hypodermic injection of any of these chemicals can be applied. 

 It can only be recommended in such extreme cases in which these 

 remedies are not to be had, and the danger great. But even in this 

 case the amputation must follow quickly or not at all. 



The local lesion having been attended to, the general systemic treat- 

 ment may connuence, as by this time the venom has probably already 

 entered the circulation, it being necessary occasionally to loosen the 

 ligatures for a moment to prevent mortification. Alcohol in small 

 doses and washing out of the stomach may now be in order, as well as 

 the administration of sudorific and diuretic remedies, preferably 

 extract of jaborandi. Hypodermic injections of 15 to 20 minims of 

 liqu. strychnine repeated every twenty minutes until slight tetanic 

 spasms appear, seem to be warranted. Constant watching for relapses 

 and attention to the local lesion will do the rest. 



The action of the venom of the elapid snakes being so much more 

 rapid and the local changes so insignificant as not to cause any great 

 alarm, the chances are that when the patient asks for help and treat- 

 ment the venom has already entered the circulation, and that attempt 

 to destroy any appreciable quantity of the poison in the wound would 

 be futile. However, whenever possible this should not be neglected. 

 The usual first treatment would nevertheless be general, viz, the 

 administration of stimulants, sudorifics and diuretics as instanced 

 above, since the danger from a quick paralysis of the nerve centers is 

 so much greater in these cases. 



