Demetriades, Andreas K.

West, Charles T.

West, Stephen C.

English

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 Vol 7. No 1. February 2014                   South Sudan Medical  Journal    15SHort ItEmSIntroductionDiaries spanning three decades (1943-1964) have been discovered that tell the story of  the life of  missionary nurses, doctors and surgeons working at the Lui and Leer Hospitals in South Sudan (then known as Southern Sudan). The medical facility at Leer during this period covered a 300 miles radius serving approximately 60,000 of  the Nilotic Western Nuer tribe [1]. It was among these records that the following case description was found. The puff  adder (Bitis arietans) is one of  the commonest African snakes, causing more bites in animals and humans than all other species of  snake put together in sub-Saharan regions. It commonly inhabits the banks of  the Nile [2].  The venom of  the puff  adder causes specific cytotoxic, fibrinolytic, platelet-inhibiting, pro-thrombotic, vasodilating, cardiodepressant, and neurotoxic effects [3-8]. When envenomation occurs in a human tissue necrosis, coagulopathy, hypotension, thrombocytopenia and spontaneous bleeding have all been reported [9]. Case ReportIn 1954 a Nuer boy presented to Leer Hospital with a large wound on his lower right leg. The injury was such that the fibula was exposed and the foot gangrenous with necrosis spreading halfway to the knee. The injury arose from a puff  adder bite while walking on the bank of  the Nile. The father took four days to transport the patient in a basket to the hospital downriver in a canoe (see Figure 1). There was no anti-venom available at Leer and no records of  any drugs being administered. There was access to penicillin. The child underwent a below knee amputation from which he recovered (see Figure 2). He remained at the hospital to work. The procedure that was performed is summarised below from the operative textbook used at the time.“Below-knee amputations should leave a stump 6-7½ inches long in a man; longer stumps only increase the risk of  circulatory troubles. The patient is in the dorsal position with a tourniquet applied to the thigh. A single anterior flap Medicine in the 1950s in South Sudan:Amputation for a puff adder (Bitis arietans) envenomation in a child - 1954 Charles T Westa, Stephen C Westb  and Andreas K Demetriadesca FY1, St Mary’s Hospital, Isle of Wight PO30 5TG, UK. ctimothyw@gmail.com b Frenchay Hospital, Bristol BS16 1LE, UK. Stephenwest@doctors.org.ukc Consultant Neurosurgeon, Western General Hospital, Edinburgh EH4 2XU, UK, A.Demetriades@nhslothian.scot.nhs.ukis marked out at the appropriate level and its length made equal to the diameter of  the limb and its width half  the circumference at the point of  bone section. The corners of  the flap are rounded and the skin reflected proximally. A transverse incision across the back of  the limb at the level of  the base of  the flap cuts everything down to bone. The muscles and interosseous membrane are divided and the tibia bared of  periosteum for 1 inch before being cut transversely with a saw. The tibia is rounded anteriorly and the fibula cut 1 inch above the tibia. Vessels and nerves are treated as already described, but the muscles are not sutured and the skin is closed. Messrs. Desoutter recommend a course of  exercises with an elastic accumulator and advise a crepe bandage applied to the stump from above downwards. Muscular development is thus encouraged, and a firm, tapered stump made ready for the permanent limb in six to eight weeks from the date of  uncomplicated amputation [10].”DiscussionEnvenomations from puff  adder bites remain an important presentation for African medical centres and there are a few reported cases in Europe and the USA [11-15]. Warrell et al [16] recommend 80ml of  South Figure 1. Dr. James West (Grandfather of Charles and Stephen West) examining the child (West family photograph). South Sudan Medical Journal                                                                                           Vol 7. No 1. February 2014 16SHort ItEmSAfrica polyvalent antivenom  intravenously. This results in an 80% survival among patients with dangerous envenomations. It relieves hypotension and bradycardia reduces the degree of  necrosis. The successful administration of  anti-venom is not always straight forward. Warrell et al [16] also describe a case where no anti-venom was available and amputation was refused by the patient’s family. They presented only three hours after the bite and received dextrose saline to maintain blood pressure. Two days later the limb was cold, anaesthetic and pulseless below the knee. Amputation was eventually attempted on the twenty-third day but the patient died post-operatively. Lavonas et al [9] report a case where a bite to the right ring finger eventually caused necrosis, despite administration of  anti-venom. The finger was amputated and the patient’s condition improved markedly afterwards. Bey et al [17] published a case from the USA where administration of  anti-venom was delayed due to difficulty identifying the exotic nature of  the bite and logistical issues locating and transporting anti-venom from a zoo 950 miles away. This resulted in a 20 hours delay and the patient developed necrosis around the bite site on their right index finger. Debridement of  the affected area was carried out and viable tissue was found underneath, so amputation avoided.Necrosis is more likely to occur when anti-venom is either unavailable, its administration delayed or envenomation too severe for it to be effective. If  necrosis occurs then wide surgical debridement should be performed [16]. If  the tissue is not viable amputation should then be considered urgently. The case reported here demonstrates that even in the most difficult situations it is still possible to preserve life. ReferencesPollock E. Christ’s Globe-Trotter. Providence House 1. Publishers, Franklin, Tennessee, 2005.FitzSimmons VFM. Snakes of  Southern Africa; 2. MacDonald: London, 1962.Homma M, Tu AT. Morphology of  Local Tissue Damage 3. in Experimental Snake Envenomation. Br J Exp Pathol. 1971;52:538-542.Brink S, Steytler JG. Effects of  Puff-Adder Venom on 4. Coagulation, Fibrinolysis, and Platelet Aggregation in the Baboon. S Afr Med J. 1974; 1205-1213.Calvete JJ, Scharader M, Raida M et al. The Disulfide 5. Bond Pattern of  Bistatin, a Disintegrin Isolated from the Venom of  the Viper Bitis arietans. Fed Eur Biochem Soc Lett. 1997;416:192-202.Jennings BR, Spearman CWN, Kirsvh RE, et al. A Novel 6. High Weight Fibrinogenase from the Venom of  Bitis arietans. Biochim Biophys Acta. 1999;1999:82-91.Nikai T, Momose M, Okumura Y et al. Kallidin-Releasing 7. Enzyme from Bitis arietans (Puff  Adder) Venom. Arch Biochem Biophys. 1993;307:304-310.Nikai T, Suzuki J, Komori Y et al. Primary Structure 8. of  the Lectin from the Venom of  Bitis arietans (Puff-Adder). Biol Pharm Bull. 1995; 18:1620-1622.Lavonas EJ, Tomaszewski CA, Ford MD. Severe Puff  9. Adder (Bitis areitans) Envenomation with Coagulopathy. Journal of  Toxicology. 2002 vol 40, no 7, pp 911-918Barrington-Ward L, Saner FD, Walker K, et al. Royal 10. Northern Operative Surgery, H.K. Lewis & Co Ltd, London, 1939.Mugti GI, Maramba AWCT. Snake Bites in Zimbabwe: A 11. Clinical Study with Emphasis on the Need for Antivenom. Cent Afr J Med. 1994;40:80-83.Takahashi WY, Tu AT. Puff  adder snakebite. 12. J Am Med Assoc. 1970;211:1857.Reid HA. Bites by foreign venomous snakes in Britain. 13. Br Med J. 1978;1:1598-1600.Sigel H, Rasche H, Kinzl L. Therapie und verlauf  eines 14. exotischen giftschlangenbisses (Afrikanische puffotter). Deutsche Med Wochenzeitschr. 1980;32:1128-30.Rainer PP, Kaufmann P, Smolle-Juettner FM et al. Case 15. report: Hyperbaric oxygen in the treatment of  puff  adder (Bitis areitans) bite. Undersea and Hyperbaric Medicine. 2010;37(6):395-398.Warrell DA, Ormerod LD, McD Davidson N. Bites 16. by puff-adder (Bitis arietans) in Nigeria, and value of  antivenom. BMJ. 1975;4:697-700.Bey TA, Boyer LV, Walter FG, et al. Exotic Snakebite: 17. Envenomation by an African Puff  Adder (Bitis arietans). J Emerg Med. 1997; 15: 827-831.Figure 2. The child after the operation with hospital orderlies and father (West family photograph)

Medicine in the 1950s in South Sudan: Amputation for a puff adder (Bitis arietans) envenomation in a child - 1954

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Medicine in the 1950s in South Sudan: Amputation for a puff adder (Bitis arietans) envenomation in a child - 1954

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