Chapter II: Part 2

The notion that its mouth is too small to bite effectively has in some instances resulted in careless disregard for its deadliness. It is true that the head appears very short and the mouth not capable of opening widely. Actually, the skull is rather elongated and the mouth can be opened to a greater degree than might be expected. Even when it bites a relatively flat surface, such as the back of the hand, the snake’s closing mouth will pinch the skin, allowing the fangs to penetrate.

VENOMS

Generally speaking, snake venoms are divided into two broad categories, neurotoxic and hemorrhagic, depending on their destructive actions. Neurotoxic poison is characteristic of cobras and coral snakes and produces considerable pain but little or no swelling and discoloration at the bite. Death from this type of poison is the result of respiratory failure and is preceded by such symptoms as headache, muscular weakness, lethargy and facial paralysis with accompanying difficulty in speech.

Hemorrhagic venom, on the other hand, affects primarily the blood cells and vessels. Local reaction is evident soon after injection of the venom and consists of pain, discoloration, and swelling at the site of the bite. All of these symptoms gradually become more extensive. Weakness, nausea, vomiting and—occasionally—diarrhea may follow in a few hours. In many cases of snake bite, shock is present.

Although every snake’s venom contains both the neurotoxic and hemorrhagic elements, the proportion of these components varies with each kind of poisonous snake. For example, the venom of the coral snake is primarily neurotoxic in action, but produces a small hemorrhagic effect as well. On the other hand, water moccasin venom, although basically hemorrhagic in action, has a greater amount of the neurotoxic element than do the poisons of the copperheads or rattlesnakes. Furthermore, neurotoxic effects are more evident following the bites of the Mojave and massasauga rattlers than they are in poisonings by other Texas rattlesnakes.

Equipment necessary for first aid treatment of snake bite includes a sharp cutting instrument such as a razor blade or sharp knife for making incisions, a constricting band to retard the flow of lymph, iodine or alcohol for sterilizing the knife and bitten area, and a suction device for removing the venom-contaminated lymph. This last item is especially important if you are alone and cannot reach the wound to apply suction by mouth.

Snake bite kits containing the essential items can be purchased at most drug or sporting goods stores at a cost of from two to five dollars, depending upon the make. Anyone who spends much time outdoors should carry a snake bite kit at all times, and he should know how to use it. A smaller kit can be more easily carried and is less likely to be left at home or in the car.

DIAGNOSING THE BITE

To make certain that a poisonous snake has caused the bite, first examine the wound for teeth marks. In a perfect bite by a poisonous snake (excluding the coral snake), the pattern will reveal two distinctly larger holes where the fangs have entered the flesh. There also may be two rows of smaller teeth marks between these punctures.

Furthermore, if the snake engages the lower jaw, two additional rows of small teeth impressions will be seen below the first group.

Frequently the bite pattern is not a clear one. For example, if the snake pulls to one side as it disengages the fangs after a strike, the result is a series of scratch marks instead of punctures. There is also the possibility that the snake will engage only a single fang; or, perhaps, during fang replacement, two fangs are temporarily in position on one or both sides of the upper jaw. Any of these conditions, as well as others, can contribute to an obscure bite pattern.

The bite of a coral snake often is difficult to diagnose by examination of the wound. Because this snake impels its fangs in a sort of chewing motion, the pattern created by its bite may be two groups of closely spaced punctures where the fangs have entered the flesh a number of different times.

A clearly defined harmless snake bite pattern consists of a series of uniformly small punctures (four rows made by teeth in the upper jaw, two rows by teeth in the lower), but always without the large fang holes. More typically, a non-poisonous bite produces several rows of scratches.

Pit-viper poisoning is diagnosed primarily by the presence of _local_ signs and symptoms. The most important of these are:

1. _Pain_ accompanies most poisonous snake bites. Generally intense
and burning in character, it becomes more severe with the passing of
time. This symptom alone is not conclusive because pain can be
imagined following a non-poisonous bite. Occasionally in a severe
bite, the pain is replaced by numbness and tingling.

2. _Swelling_ at the bite area is present in every case of poisoning.
It will appear within five to 30 minutes. In a severe case, the
swelling may continue to spread for 24 hours. There will be no
swelling from a bite by a non-poisonous snake or by a poisonous snake
that injected no venom.

3. _Discoloration_, reddish or bruise-like in appearance, begins around the fang punctures within a half hour and becomes gradually more extensive.

Intense local pain is symptomatic of coral snake poisoning but, unlike a case of pit-viper poisoning, swelling and discoloration are not pronounced. Diagnosis of coral snake envenomation is difficult and must be based primarily on systemic symptoms: headaches, weakness, lethargy and facial paralysis.

SEVERITY OF THE BITE

Even after the bite has been diagnosed as venomous, it is not immediately possible to predict the course it will follow. The severity of each case of snake poisoning is determined by the speed with which symptoms progress. Although the bite of a large snake is generally more serious than one caused by a small snake, the seriousness of a bite cannot be gauged by snake size alone. Some variable factors that affect the severity of each case include:

1. Age, size and health of the victim.
2. His allergy complex and sensitivity to protein poisoning.
3. His emotional condition immediately after having been bitten.
4. Location of bite on the victim.
5. Amount of fang penetration and venom injection.
6. Number of times the victim was bitten.
7. Kind and size of snake that bit him.
8. Whether or not the snake recently had eaten.
9. Conditions of the snake’s fangs.
10. How soon treatment was administered.

FIRST AID TREATMENT

It is important that every snake bite victim receive first aid treatment as soon as possible. The patient must not exert himself by running, because increased circulation brought on by such physical activity will speed up absorption of the poison. For the same reason, the use of whiskey or other stimulants should be avoided.

The victim’s state of mind is important; he must promptly be convinced that his chances for recovery are good—and, indeed, they are. He should not be terrified by the thought that every snake bite means certain death. Actually, a survey of case histories shows that with prompt and proper treatment, only about one or two per cent of all snake bites in this country are fatal.

There is a considerable difference of opinion about the correct first aid treatment for poisonous snake bite. The Division of Medical Sciences of the National Research Council, a section of the National Academy of Sciences, recently made a study to determine the most effective method of such treatment. It recommended immobilization of the bitten limb, application of a constricting band, and prompt incision and suction.

Based on these recommendations, the following first aid treatment for poisonous snake bite is suggested:

1. IMMOBILIZE THE AFFECTED ARM OR LEG whenever possible. Where this is
not practicable, keep movement of the bitten limb to a minimum.
Muscular activity helps increase the spread of venom. Whenever
feasible, transport the victim by litter to further medical aid.

2. APPLY A CONSTRICTING BAND from two to four inches above the bite,
between the wound and the heart. This will help to limit the spread of
venom until it can be removed by incision and suction or neutralized
by antivenin. A piece of rubber tubing or a strap tourniquet, included
with every snake bite kit, is best for this purpose. When these are
not available, items of clothing may be used. A shoe lace, neckerchief
or a strip of clothing torn from shirt or trousers will do. The
poison, unless injected directly into a major blood vessel or deeply
into a muscle, is absorbed slowly by the lymphatics below the skin.
Therefore, do not restrict the deeper blood circulation by applying
the constricting band too tightly. It should be loose enough for a
finger to be slipped under it with little difficulty. Remember that
during first aid treatment the constricting band must be loosened
every 15 minutes for about two minutes. This precaution may prevent
gangrene. If the bite is on the hand or forearm, take off rings,
bracelets or other jewelry because subsequent swelling may make their
removal difficult.

3. MAKE INCISIONS after sterilizing the cutting instrument and the bite area with iodine or alcohol. If no antiseptic is available, the blade of the cutting instrument can be sterilized by holding it over a flame (a match will do). Make _one_ cut over each fang mark parallel with the long axis of the bitten limb, not across it. Incisions should be one-quarter inch long and one-eighth to one-quarter inch deep, but definitely no longer than the diameter of the suction apparatus being used. This would allow air to enter the suction bulb from the outside and the device would then be unable to work. Incisions are of the utmost importance to first aid treatment; without them little or no poison can be withdrawn from the wound by suction. However, making even a small incision involves some risk and this operation should be done with considerable care. Improper or carelessly applied first aid may actually do more harm than good. Although a physician may later decide to make additional incisions to relieve the pressure of swelling, only the cuts over the fang marks are recommended for first aid.

4. APPLY SUCTION to the cuts. This can best be done with one of the suction devices manufactured for that purpose but, if none is available, suction can be applied by mouth. There is little danger in oral suction unless the lips or inside of the mouth have cuts or abrasions. Contrary to popular opinion, a tooth cavity will not permit passage of venom into the blood. Moreover, snake venom is destroyed by the stomach’s digestive juices, so if some is accidentally swallowed, there is little need to worry if you have a healthy system. Only during the first 30 minutes following the bite can much venom be removed by incision and suction.

5. GET TO MEDICAL AID as soon as possible—but keep in mind that unnecessary physical exertion is harmful.

Antivenom may be administered soon after first aid has been started, but this is best left to a doctor. The North American Antisnakebite Serum made by Wyeth, Inc., of Philadelphia 3, Pennsylvania, is effective against pit viper bites but is of less value in the treatment of coral snake poisoning. Because coral snakes cause so few bites in the United States, no serum to neutralize their venom is prepared in this country. In South America, where these snakes are common and may reach a length of five feet, a serum to neutralize the poison is being produced by the Instituto Butantan at Sao Paulo, Brazil. It and other foreign snake bite serums often are available at larger zoos where exotic poisonous species are exhibited.

SUGGESTIONS TO PHYSICIANS

In most areas of Texas, snake bite is an uncommon medical emergency, and one with which few doctors have had experience. For this reason, the following recommendations by the National Research Council’s Division of Medical Sciences are included for the benefit of the physician.

_Statement on Hospital Care Following Bites by Venomous Snakes_
_December 14, 1960_

_Admission Procedures_

The routine admission history and physical examination should provide and record, if possible, the identity and length of the snake, the time of the bite, and the details of all first aid measures employed, including the time lapse for each and the mode of transportation to the hospital. The record should state whether a tourniquet, incision and suction, or the ligature-cryotherapy technique has or has not been used. Inquiry should be made concerning previous bites, allergic manifestations in general, and whether or not the patient had previously received horse serum. The admission examination should provide information from which the severity of the envenomation can be estimated as a guide to the need for the administration of antivenin and other therapy. Sensitivity tests should be instituted promptly during admission if not previously begun.

When the patient enters the hospital, blood should be drawn immediately for typing, matching and coagulation studies.

Although envenomation by one of the snakes of North America may present severe signs and symptoms, death is rare except in children or following envenomation by a large snake. However, permanent damage of an involved extremity is frequent following a bite by certain of the North American venomous snakes; plastic or orthopedic surgical repair to restore function, or amputation, are not unusual consequences. Early and continuing close observation is needed to determine if certain therapeutic measures prevent or promote undesirable results.

_Laboratory Tests_

No rigid set of rules regarding therapy can be justified; the responsible physician must use his best judgment in his choice of tests to be performed as a guide to procedures to be used.

Clinical studies could include items such as repeated hematologic tests, hepatic and renal function studies, serial electrocardiograms, electroencephalograms, and other studies to therapy, depending on the composition of the venom involved and within the limits of personnel, time and equipment available.

_Therapeutic Procedures_

A. Systemic

1. Immobilization. During transportation, admission procedures, and
most of the early hospitalization period, immobilization of the
affected part and absolute rest should be continued. A sedative or
analgesic may be administered to relieve restlessness and anxiety; ice
bags may be applied to alleviate severe pain. The extremity should be
immobilized in the position of function, and active and passive
exercises to prevent contracture started after the third day if
consistent with the patient’s condition.

2. Blood Transfusion. Postmortem examinations have at times revealed
extensive retroperitonial and intraperitonial hemorrhage, and
hemorrhage into the viscera, including the liver and kidney.
Progressive decrease in the total volume of circulating red blood
cells has been attributed to the development of a massive hemolytic
anemia or internal hemorrhage. Blood transfusions may be necessary and
at times have been followed by marked improvement. Studies of the
several factors involved in blood clotting may be useful as guides to
treatment. The first and subsequent specimens of urine should be
especially examined for the presence of red blood cells, hemoglobin,
and protein.

3. Electrolyte Balance. Abnormality of fluid and electrolyte balance
should be detected and corrected on a continuing basis.

4. Antivenin. Polyvalent or specific antivenins prepared from venoms
of snakes in the same geographic area should be administered in
therapeutic quantity as recommended by the manufacturer only with full
realization that the hazard of immediate allergic reaction or delayed
serum sickness are factors to be evaluated in the decision to carry
out this type of treatment. During hospitalization, antivenin should
be given intravenously, provided that sensitivity tests indicate that
the patient is not allergic to the antiserum to be used.
Desensitization, if necessary, should precede the administration of
antivenin by any route. The use of antivenin in such cases should be
carefully evaluated. Injection in normal muscles in other extremities
would be the second choice, since local injections into the deposit
site do not diffuse efficiently into the entire damaged area and would
increase the hazard of pressure ischemia leading to increased tissue
necrosis. Epinephrine should be available for immediate use when
foreign protein is being administered.

5. Corticosteroids. The use of corticosteroids should be restricted to
the prevention or treatment of late manifestations of allergy
following administration of antivenins.

6. Antibiotics. A broad-spectrum antibiotic should be administered
promptly in appropriate dosage if the reaction to envenomation is
severe. Since the nature of the injury markedly predisposes to
infection, and pathogenic bacteria are found in the wound, this use of
antibiotics seems justified. Laboratory sensitivity tests, if
available, should control the continuing choice of antibiotics to be
used. A massive wound infection with severe systemic reaction could be
mistaken for severe envenomation. Repeated blood and wound cultures
would be of help in making the distinction.

7. Tetanus Prophylaxis. Tetanus toxoid should be administered upon
admission if it has not been given as a first aid measure.

8. Respiratory Paralysis. If respiratory paralysis develops following
envenomation by one of the _Elapidae_ (this family includes the coral
snake), the use of tracheostomy and intermittent positive pressure
artificial respiration is indicated.

9. Renal Shutdown has been an occasional occurrence following massive
envenomation. An awareness of this possible complication can do much
toward the prevention and treatment of secondary effects arising after
its occurrence. Routine daily tests such as B.U.N., CO₂ combining
power, and serum potassium levels are indicated in severe cases.

B. Local Measures During Hospitalization

1. Tourniquet (Constricting band). A tourniquet applied following a
bite by a venomous North American snake should be removed if
envenomation seems mild or after a potent antivenin is given in
therapeutic quantity. The prolonged use of a tourniquet or of a
constricting band would increase local tissue damage due to the action
of venom and might delay the vascular transport of antivenin into
envenomated areas.

2. Incision and Suction. Substantial amounts of venom can be removed
during the first half-hour from subcutaneous deposits by incision and
suction. On the other hand, if the casualty is admitted to the
hospital one hour or more following envenomation, an attempt to remove
venom by incision and suction at the site of the bite would be of
little value. However, if marked subcutaneous pitting edema develops,
interstitial pressure can be relieved by several longitudinal
incisions extending into the subcutaneous tissues. Suction and
fasciotomy may be required at times.

Parrish (1961), using a modification of Wood, Hoback and Green’s (1955) clinical classification of pit viper venenations, has proposed the following guide for determining the severity of a poisonous snake bite. This classification is based upon present signs and symptoms and the clinical course of the patient during the first 12 hours of hospitalization. It will be useful as a guide in treatment.

Grade O (No venenation). Fang or tooth marks present, minimal pain, less
than one inch of surrounding edema and erythema, and no systemic
involvement.

Grade I (Minimal venenation). Fang or tooth marks present, moderate
pain, from one to five inches surrounding edema and erythema in
the first 12 hours after bite, and no systemic involvement.

Grade II (Moderate venenation). Fang or tooth marks present, severe
pain, six to 12 inches of surrounding edema and erythema in the
first 12 hours after bite, with systemic involvement—nausea,
vomiting, giddiness, shock or neurotoxic symptoms present.

Grade III (Severe venenation). Fang or tooth marks present, severe pain,
more than 12 inches of surrounding edema and erythema in the first
12 hours after bite, with systemic involvement (as in Grade II).

BIBLIOGRAPHY

Boys, Floyd and Hobart M. Smith. _Poisonous Amphibians and Reptiles._
Charles C. Thomas Co., Springfield, 1959.

Brown, Bryce C. _An Annotated Check List of the Reptiles and Amphibians
of Texas._ Baylor University Press, Waco, 1950.

Buckley, Eleanor and Nandor Porges (Editors). _Venoms._ Publication No.
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FILMS

A 16 mm. motion picture film in color, entitled, “Poisonous Snakes,” is available from the Texas Parks and Wildlife Department, Reagan State Office Building, Austin, Texas. It deals with snake bite prevention, poisonous snake identification and first aid treatment.

FIELD NOTES

Transcriber’s Notes

—Retained publication information from the printed edition: this eBook
is public-domain in the country of publication.

—Corrected a few palpable typos.

—Collated Table of Contents, and re-ordered entries, or added headings,
to coordinate with the actual contents.

—In the text versions only, text in italics is delimited by
_underscores_.