Into these wounds was poured a fifteen per cent. solution of permanganate of potassium, and fully half an hour was devoted to kneading this drug into the tissues. In addition I made many hypodermic injections into all portions of the swollen tissue, but particularly about the wound. Since there was no very distinct line of demarkation between the swollen and healthy tissue, I did not, as in other cases, endeavor to prevent the extension of the cellular involvement by a complete circle of hypodermic injections. I employed, in all, about forty grains of the permanganate. In addition to the local treatment I pushed stimulation, employing carbonate of ammonium and whisky. By means of diuretics and laxatives the kidneys and bowels were encouraged to eliminate as much of the poison as possible.

The patient went on to uninterrupted recovery. The wound healed with very little sloughing. The patient returned to his work in about a month. The cure of this case was regarded by the cow boys as most exceptional, since, in their experience, similar cases, even though very freely stimulated, had not recovered.

Some time later I was called to see a girl, aged 14, who was struck by a rattlesnake, fifty-six miles from Fort Fetterman. There was some trouble about procuring relays, and I was compelled to ride the same horse all the way out. This took a little short of five hours. This, together with the time consumed in sending me word, caused an interval of about twenty hours between the infliction of the injury and the time I saw the patient. I found the fangs had entered on either side of the distal joint of the middle metacarpal bone. The arm was enormously swollen, almost to the axilla, and exhibited a bronzed discoloration; this was especially marked about the wound and along the course of the lymphatics. The swollen area was boggy to the touch, and exhibited a distinct line of demarkation between the healthy and diseased tissues, excepting along the course of the brachial vessels, where the indurated discolored area extended as a broad band into the axilliary lymphatics, which were distinctly swollen. The patient was delirious, was harrassed by terror, complained bitterly of pain, and had an exceedingly feeble, rapid heart action. There was marked dyspnoea, and all the signs of impending dissolution. I at once made free multiple incisions into all parts of the inflamed tissue, carrying two of my cuts through the wounds made by the fangs of the snake. In the arm these incisions were several inches long and from one to two inches deep. As in the former case, the bleeding was slight, but there was a free exudation of serum. Into these wounds a fifteen per cent. permanganate of potassium solution was poured, and as much as possible was kneaded into the tissues. In addition multiple hypodermic injections were made, these being carried particularly into the bitten region, and circularly around the arm just at the border of the line of demarkation, thus endeavoring to limit by a complete circle of the antiseptic solution the further extension of the inflammatory process.

In the region of the brachial vessels I hesitated to make my injections as thoroughly as in the rest of the circumference of the arm, fearing lest the permanganate of potassium might injure important vessels or nerves.

This treatment caused very little pain, but immediately after the constitutional symptoms became distinctly aggravated. I stimulated freely, and at once made preparations to take the patient to the Fort Fetterman hospital. She was transported over the fifty-six miles, I riding the same horse back again, and arriving at Fort Fetterman the same evening.

The after treatment of this case was comparatively simple. She was stimulated freely as long as cardiac weakness was manifested. As in the former case, diuretics and laxatives were employed. The arm was wrapped in cloth soaked in a weak permanganate solution, was placed in a splint, and was loosely bandaged. There was some sloughing, but this was treated on general surgical principles. The patient recovered the entire use of her arm, and was turned out cured in about six weeks.

The third case I saw about fourteen hours after he was struck. The patient was a healthy blacksmith, about 30 years of age. The wound was at about the middle of the forearm, the fangs entering toward the ulnar side. When I saw the patient he exhibited comparatively trifling symptoms. His heart action was rapid, and he was suffering from the typical despondency and terror, but I could not note the profound systemic depression characteristic of the great majority of cases. Surrounding the wound and extending up the forearm for several inches there was a boggy swelling, exhibiting a sharp line of demarkation. It was bronzed in color, and was apparently spreading. I at once applied the intermittent ligature just above the elbow, and injected the permanganate of potassium solution freely all through the involved tissues, particularly in the region of the bite and about the periphery of the swelling, surrounding the latter by a complete ring of injections.

The general treatment of this patient was continued on the same general line as described in the former cases, stimulants being employed moderately. He recovered without any bad symptoms. There was no sloughing; the swelling disappeared without any necrosis of tissue. He is still pursuing his trade in Cheyenne, and suffers from absolutely no disability.

I saw but one case shortly after the wound was inflicted. This patient was a healthy young man, who was struck about the middle of the dorsal surface of the hand, the fangs entering on each side of a metacarpal bone, and the poison lodging apparently in the palm of the hand. The patient, when seen, exhibited the characteristic terror and depression, weak, rapid heart action, and agonizing local pain. I made two small incisions in the region of the wound upon the dorsum of the hand, and injected permanganate of potassium freely. This patient ultimately recovered, but only after sloughing and prolonged suppuration. I believe that had I incised freely and at once from the palmar surface, I would have been spared this unpleasant complication.

I have had in all nine cases, and without a single death. The others are in their general features and in the treatment employed quite similar to those given.

The symptoms resulting from snake bite poison are strikingly like those dependent upon the violent septic poison seen in pre-antiseptic times. There is often the same prodromal chill, the high elevation of temperature, the profound effect on the circulation, and the rapid cellular involvement. The tissue disturbance following snake poisoning differs from ordinary cellulitis, however, in the following particulars: The color is bronze, not red; the involved area is boggy, not brawny; and the extension of the process is exceedingly rapid.

The treatment applicable to one condition seems to be equally successful when applied to the other. In cellulitis, free incisions, antiseptic lotions, and active stimulation are the three means upon which the surgeon mainly depends, and in combating the local and general symptoms excited by snake bite poisoning, the same treatment has given me the successful results detailed above. Whether or not permanganate of potassium is more active than other antiseptics in snake bite poisoning I am not prepared to state, but the high authority of S. Weir Mitchell, together with my own experience, does not incline me to substitute any other drug at present.

I would formulate the treatment for poison of the rattlesnake as follows:

1. Free incisions to the bottom of the wound and immediate cauterization; or, if this is not practicable, sucking of the wound.

2. The immediate application of an intermittent tourniquet, that is, one which is relaxed for a moment at a time, so that the poison may gain admission into the circulation in small doses.

3. The free administration of alcohol or carbonate of ammonium.

This might be termed the urgency treatment of snake bite poisoning. The curative treatment requires -

4. Free incisions into all portions of the inflamed tissues, and the thorough kneading into these incisions of a fifteen per cent. solution of permanganate of potassium.

5. Multiple injections of the same solution into all the inflamed regions, but particularly into the region of the wound.

6. The complete surrounding of all the involved tissues, by permanganate of potassium injections placed from half an inch to an inch apart, the needle being driven into the healthy tissue just beyond the line of demarkation, and its point being carried to the deepest part of the border of the indurated area.

7. The permanganate of potassium solution should be used freely in fifteen per cent. solution. I have used one and a half drachms of the pure drug diluted, and would not hesitate to use four times that quantity were it necessary, since it seems to exert no deleterious effect, either locally or generally.

8. The involved area should be dressed by means of lint saturated with fifteen per cent. permanganate of potassium solution. Stimulants should be given according to the indications - i.e., the condition of the pulse. Laxatives, diuretics, and diaphoretics should be administered to aid in the elimination of the poison. The diet should be as nutritious as the stomach can digest. - The Therapeutic Gazette.