N.O. Ophidia. The venom of the rattlesnake, chiefly Crot. horridus, dried or preserved in glycerine.
The venom should be obtained from the living snake by skilled attendants, by snake-charmers or by expressing it from the poison glands of the chloroformed snake, as was done by Dr. J.W. Hayward for his experiments with crotalus.
The articles on snake venoms should be read together. The general effects of snake-bite are described under Lachesis and Crot., and they have all leading features of resemblances, but for therapeutic purposes the points in which they differ are of more importance than those possessed in common.
Lachesis is most extensively used clinically. Giving it on a single symptom, such as “flushings,” or “sore throat,” has often caused disappointment and is always liable to do so.
Students unfamiliar with the subject should read the article on lachesis first, though the articles are given alphabetically for convenience of reference.
CROTALUS: A rattlesnake. ELAPS: The coral-snake of Brazil. LACHESIS: A lance-headed viper. NAJA: A hooded cobra.
The poisons of the various viperine snakes closely resemble one another in their effects, and the reader is recommended to study the article on lachesis before reading this on crotalus. The differences are chiefly those of degree, but there are some differences in kind as well, and these constitute the main points which determine the selection of one or other as a therapeutic agent.
This article, therefore, will not recapitulate the viper poison effects as found under lachesis, but will seek to emphasize those features in which crotalus departs from the lachesis pathogenesy as a standard.
Some symptoms, subjective or objective, not found under lachesis will be given, some which differ from those of lachesis will be noted, and a few will be mentioned which, though occurring from both poisons, are definitely more marked under crotalus. They will, however, not be grouped separately in these classes.
Haemorrhages.-Bleeding and blood changes form the most conspicuous features of viper poisoning and especially of crotalus. When rubbed into a skin abrasion in which blood was not drawn, the poison caused free bleeding from the surface or oozing by minute points almost at once; the bites bleed more freely, caeteris paribus, than do those of lachesis; the oozing is more general. Besides the various orifices (mentioned under lachesis), subcuticular, subconjunctival, submucous and even subserous extravasations-petechiae and ecchymoses-are rapidly induced, not only near the wound but in any and sometimes in every part of the body, including the “pores of the skin” and under the nails. The blood is usually thin, dark and not readily coagulating or altogether fluid. The haemolytic action is most evident round the wound or its vicinity, but may occur in different parts. If a vein is punctured a broad line of discoloration extends centripetally from the site of the bite. A part of the whole of a limb will become swollen, livid and patchy, or mottled from extravasations and staining by blood pigment due to destruction of red corpuscles. So conspicuous is this mottling that it has been likened in some cases to the appearance of the snake inflicting the bite.
Bleeding into cellular tissue, into muscular tissue and into viscera takes place.
Thrombosis, phlebitis and simple varicosis occur.
OEdema is very prominent in crotalus poisoning, shown in its smallest degree by a wheal, like an exaggerated nettle-sting or urticaria round a bite, increasing to oedema of an affected limb, of face and eyelids, of trunk or even of the whole body. The bloated, besotted appearance of the face is due to oedema, retardation of circulation and haemolytic staining.
Vesication.-This is analogous to oedema, but is due to a complete and local transudation of serum under the cuticle in the form of vesicles or blisters, small or large. The fluid is usually dark from blood pigment, and the quantity may be so considerable that the blister bursts spontaneously or from a slight touch or movement. The fluid escaping is of an acrid “scalding” nature.
One-sided Symptoms.-Local lesions due to a bite being right- or left-sided have, of course, no meaning as selective indications. There are, however, enough instances amongst provers of unilateral effects from orally administered doses, and from infinitesimal doses to justify the left-sided indication in lachesis, though it was seen not to be absolute. It is abundantly confirmed right side. The following are instances: (a) lying on the right side induced vomiting in a person accustomed to lying on that side; (b) stitches in right hypochondrium, in right iliac or appendix region; (c) stitches in right chest, near sternum; (d) stitching pain from right shoulder to neck, and down back of neck on right side; (e) between right eye and top of the head; (f) sensitiveness of right half of body; (g) tickling in right auditory meatus. Left-sided symptoms may be present in cases when crotalus is called for,e x. gr., pain from round the heart, extending to left scapula and left arm, and tenderness in cardiac region on lying on left side, but they are definitely less common than in lachesis cases.
Periodicity is more strongly marked in crotalus poisoning than in lachesis cases. It seems undoubted that symptoms may recur at long intervals with considerable regularity, as after three months or a year. Crops of vesicles after a bite have recurred for years, every three months as first, around the site of injury. Symptoms such as neuralgia may recur each spring. This may be due, as with some lachesis cases, to the advent of warm weather after a a long, cold winter. It has been utilized clinically with success in recurring neuralgias and other conditions after malaria and sepsis, and at the climacteric, &c.
Temperature.-The modality aggravation from heat in some form is fairly conspicuous in lachesis; it is strikingly absent in crotalus cases. The chief temperature modality is aggravation from cold air, in the case of cough and other throat and respiratory symptoms. “He hesitates to take his usual cold bath.”
Throat and Respiratory Symptoms.-Crot. poisoning may produce very considerable swelling of the cellular tissue of the neck, of the submucous and mucous tissue of the throat, and of the lymphatic salivary glands in and about the neck and throat. This would account for difficulty of breathing and of swallowing. Though the swelling is more with crotalus cases, the feeling of constriction, of tightness, the intolerance of neck bands, and of any object impeding access of air are not so marked as under lachesis. In so far as dyspnoea and dysphagia exist, they seem to be more definitely mechanical and less spasmodic or nervous than with Lachesis. This will explain the symptomatic difference between the two poisons as to swallowing. The crotalus victim swallows solids with great difficulty or not at all, the lachesis patient swallows solids better than fluids and fluids better than nothing at all, i.e., than “empty” swallowing. This is an important guiding symptom. The head is thrown backwards to assist breathing. The breath is described as having “a mouldy smell,” and if this is noticed it might be an item in favour of crotalus, especially with dysphagia and a scarlet-red tongue. A dry, smooth, shining or glazed tongue is met with in crotalus poisoning, and may be a valuable indication in some septic and zymotic fevers. It may be enormously swollen, and usually is so to some extent, interfering with articulation.
Aphonia may be present from local causes or from exhaustion, due, ex. gr., to diarrhoea.
Cough.-A dry, nervous cough, from breathing cold dry air, from deep breathing, from external pressure or from talking, is a crotalus symptom; also a paroxysmal cough like whooping-cough. It has indeed been beneficial in pertussis accompanied with great blueness of face during a paroxysm, followed by puffiness of face, blood-strained expectoration (see ipecac.) and by subcuticular and subconjunctival petechiae. A suffocating feeling without much local change has been induced, though the bite was on the hand.
A very instructive case is married in the M.M.P.A. of a severe snake bite which happened while the victim was in the midst of a bad attack of whooping-cough. When the effects of the venom passed off no cough was left.
Perspiration.-Sweating is common to lachesis and CROTALUS, but it is more often cold in crotalus; the whole body may be bathed in cold sweat. Of more clinical value is axillary perspiration, staining the clothing reddish. Definitely blood- stained perspiration may be produced.
Sleep.-The general lachesis features are present also in crotalus cases. The dreams are more distressing-“frightful,” as of “murders, death, dead people, of associating with the dead,of dead bodies-corpses-of being in graveyards, even the smell of the cadaver is dreamt of.” These seem to be clinical symptoms (Kent, Mat. Me., p. 468). A few crotalus symptoms are worse in the morning on waking, such as headache (soon passing off), but the sleep aggravation of lachesis is not so definitely present under crotalus.
Mental Condition.-The fear of death and anxiety associated with snake bite may sometimes be purely psychological. It has been absent where the pain of the bite was believed to be due to the scratch of a cat, and has been present where the injury was believed to be a snake bite and was not. Sadness and dwelling on death (while awake) are induced. Inability to collect thoughts or pursue a train of thought; making mistakes in spelling (in a good speller), thinking of the proper letter or word and writing a wrong one; dull and stupid feeling and faulty “perception” (or judgment,) “in crossing a street would have been run over but for watchfulness of sister,” and loss of memory,”could not remember what she had gone into shop to buy.” These were experiences of healthy experimenters. They form valuable clinical guides in mild crotalus cases. Provers and patients develop a weepy mood-are easily moved to tears during conversations, &c.
In fevers the delirium is predominantly of a low type, mumbling, incoherent speech, going on to stupor; movements slow and hesitating.
Head.-The crotalus headaches vary a little. The head feels too large, feel full to bursting. Waves of pain come and on recur; they are liable to be brought on by moving, such as turning over or rising up in bed or any changing of position, or by a jar. A sudden disabling pain, as if struck on the back of the head with a hammer, is a well-known characteristic head pain of crotalus, valuable as a clinical indication. Rest relieves the headaches. The head feels so heavy that the muscles seem too weak to hold it up, and it requires the support of the hand. The headaches are usually worse in the morning, except pains centering in the orbits, which are usually worse in the evening. The morning headaches soon go off after moving about. A frontal headache is common, worse after each meal. Vertigo is a frequent occurrence: it comes in sudden attacks, on the slightest movement.
Eyes.-Crot. causes yellowness of the conjunctiva, and is used to clear up keratitis and iritis.
The face looks puffy, livid, bloated, stupid or mottled, after snake bites, and these features characterize many cases of low toxaemic disorders requiring crotalus; if the disease has come on suddenly, as in choleraic diarrhoea, a haggard expression, with the body bathed in cold perspiration, would be an item in favour of crotalus. Sneezing and nasal catarrh come on without any special characteristics. Epistaxis is common, especially in diphtheria and whooping cough.
The digestive symptoms may be merged in the toxic picture in febrile and septic cases. Burning thirst with inability to swallow what has been taken is an example of this.
In slighter cases,thirst, retching, a faint sinking or hungry feeling in the epigastrium, with trembling and weakness, may be present. The same intolerance of constriction and of clothing round the waist in common to crotalus and lachesis. Attempts at walking are liable to bring on the retching.
Swelling of the abdomen, with pain and tenderness on pressure, when combined with the toxic symptoms have led to its successful use in peritonitis.
If an icteric tinge is present this would confirm the selection of the drug. Lying on the right side in hepatic cases is liable to bring on vomiting of a bilious nature (“dark green vomiting”) or of “coffee-grounds” when crotalus is indicated.
Diarrhoea, of offensive, watery, dark stools may occur from some forms of poisoning, as from high game. If blood is passed as such it is dark and does not coagulate. In toxic cases the evacuations will frequently be involuntary. In catarrhal jaundice with toxic features the stools would be white.
A rather striking symptom, noticed first in a teetotaller and repeatedly verified, is intense craving for alcohol, especially for urine. In some cases of delirium tremens in broken-down subjects crotalus may be called for, and this feature would confirm its selection. Apart from delirium tremens, chronic alcoholism may require this remedy.
Circulatory and Respiratory Systems.-Aphonia and trembling where the patient has been weakened by illness, acute or chronic, ex. gr., diarrhoea, is found in the milder crotalus cases, with quickened compressible pulse. Palpitation, with a feeling as if the heart turned over, may accompany almost any stage of illness requiring this remedy. A spasmodic cough, with cardiac embarrassment, blue face, epistaxis and great weakness has led to the use of crotalus in whooping-cough. In toxic cases, bronchitis, pleurisy, and pneumonia, with puffed face, lividity, haemoptysis of dark thin blood or bloody mucus, form part of the crotalus complex. The chest pains are mostly left-sided, and if the right lung be affected there may be hepatic symptoms and some jaundice. The venom has caused and may be indicated in pericarditis with effusion.
Urinary System.-The urine, especially in fever, contains albumin and is smoky from transuded blood, or when the liver is attacked it may be green-yellow from the pressure of bile.
Sexual Sphere.-Crot. is not much used for disorders of the reproductive system unless associated with other symptoms also requiring its use. It would be indicated if there were excessive and premature menstruation, preceded by weight in the head and by pains before the flow, extending from the hypogastrium and back down the thighs. The flow is likely to be intermittent, and may be accompanied by pain in the region of the heart, palpitation and cold feet. In men there may be pain in the glans, diurnal sexual excitement but actual impotence.
The pains of crotalus remit and recur with great frequency; pain in one part may alternate rapidly with pain in another, or with other symptoms. Except as regards headache, the pains have a tendency to appear and disappear somewhat suddenly.
Dr. J. W. Hayward, by whom crotalus was made prominent as a remedy in this country, summarizes its uses as follows: (1) In septic and zymotic diseases it plays a large and important part, ex. gr., in typhus, diphtheria, enteric, malignant smallpox and malignant scarlet fever. While he was himself experimenting with the drug he affected a dramatic cure in the last-named disease in a member of his own family. (2) In yellow fever, in South America and the southern U.S.A. States, it has been regarded as the prime remedy, especially where the haemorrhagic features are prominent. The diluted venom has been injected as a prophylactic.
Recalling the vomitings, purgings and cramps, with the cold surface and shrunken countenances, Dr. Hayward suggests its use in “malignant cholera.”
For acute tubular nephritis,the characteristic urinary conditions with general Oedema, somnolency and convulsions suggest the drug.
The symptoms of acute alcoholism and delirium tremens are sometimes fairly well reproduced in crotalus poisoning.
Tetanic features are also represented in the pathogenesis, and in the Medical Times and Gazette of 1874 it was recommended for hydrophobia (by “inoculation”).
Chorea, epilepsy convulsions (exanthematic and puerperal), haemorrhages, malignant jaundice, hysteria, neuralgia, “dropsy,” and other conditions are mentioned by Hayward as calling for the consideration of this remedy.
Altogether the viper poisons must rank among our most important polychrest remedies.
(1) Consult those of lachesis.
(2) Note that its right-sided symptoms are more numerous than its left.
(3) Note that the “empty swallowing” difficulty (lach.) is replaced in crotalus by difficulty in swallowing solids.
(4) Intense flushings at the menopause with heavy perspiration.
(5) Skin cold and dry; boils, carbuncles, vesicles, pemphigus, with blue or mottled surrounds, peliosis rheumatica.
(6) Haemolytic and septic conditions, with dark, thin blood from many orifices and surfaces.
(7) Dissecting wounds, bites of insects, scorpions, &c.
(8) Cellulitis, sloughing, gangrene; anthrax; carbuncle.
Lying on right side (vomiting), cold air (throat and respiratory), morning and waking, constrictive clothing, right side (many symptoms), after a meal (frontal headache), touch and pressure.