Part 10

4. Cryotherapy--An ice cap over the site of the bite for relief of pain would seem to be permissible, especially prior to the administration of antivenin. It must be remembered that cooling during the administration of the antivenin radically reduces the access of the antiserum to the bite area.

5. Antivenin--Antiserum is the keystone to the therapy of snakebite. Careful evaluation of the severity of the bite and the patient's sensitivity should be made before the use of antivenin. In Grade II (moderate) bites, the intramuscular injection on the side of the bite may suffice. In Grades III (severe) and IV (very severe), shock and systemic effects require intravenous injection. In bites producing symptoms of this severity, antivenin must be given in amounts large enough to produce clinical improvement. Ten to 20 units may be necessary to prevent the relapse that sometimes occurs after small doses of antivenin. Permanent remission of swelling and interruption of necrosis are the therapeutic end point in the clinical use of the antiserum.

In all cases of snakebite where there is any doubt as to the snake's identity, it should be killed if possible and taken to the hospital for positive identification. In many instances of actual bites by poisonous snakes the only treatment needed was an injection of tetanus antitoxin or toxoid and sedation, because physical examination revealed no indication of poisoning (Stimson and Engelhardt, loc. cit.).

Case History of a Bite

On July 29, 1963, at 8:20 a.m., I was treating a nine-month-old cottonmouth for mites. As I dropped the snake into a sink, it twisted its head and bit the tip of my right middle finger with one fang. The fang entered just under the fingernail and was directed downward, the venom being injected about five millimeters below the site of fang penetration. After placing the snake back in its cage, I squeezed the finger once to promote bleeding, wrapped a string around the base of the finger, and drove to Watkins Memorial Hospital on the University of Kansas campus. I began to feel a burning sensation in the tip of the finger almost immediately. Upon my arrival at the hospital, an additional ligature was placed around my wrist. At 8:30 a.m. a small incision was made in the end of the finger, which by this time was beginning to darken at the point of venom deposition. I sucked on the finger until 8:35 a.m., when a pan of ice water that I had requested was brought to me. No pain was felt except that caused by the ice. Fresh ice was added as needed to keep the temperature low. By 9:30 a.m. the finger had swollen and stiffened. At 10:00 a.m. the swelling had progressed to the index finger and back of the hand. I experienced difficulty in opening and closing the hand. Blood oozed slowly from the incision. A dull ache persisted and about every two to four minutes a sharp throb could be felt until nearly 11:00 a.m., when the pain diminished. The rate and intensity of throbbing increased whenever the hand was removed from the ice bath for more than a few seconds. Although only the hand was immersed, the entire forearm was cold. Pain was felt along the lymphatics on top of the arm when it was touched, and by 1:00 p.m. a slight pain could be felt in the armpit. Since swelling and pain were almost nonexistent by 2:00 p.m., I was permitted to leave. After walking to a nearby building, I again felt a burning sensation as the hand warmed. I made another ice bath and again immersed the hand in it until 4:10 p.m., at which time it was removed from the water. The pain and swelling began anew, and the hand was placed back in an ice bath from 5:30 p.m. until about 7:30 p.m. At this time cryotherapy was discontinued. From 10:00 p.m. to 12:00 midnight my legs twitched periodically, and pain could be felt in both armpits. A slight difficulty in breathing also was experienced for a short time. The acute pain and burning sensation remained in the finger until the following morning, but swelling progressed only as far as the wrist. The only discomfort that day was in the finger. The tip was darkened, the entire first digit red and feverish, and the lymphatics still painful when touched. By the third day the swelling had regressed. The incision itself was the main cause of discomfort, and the soreness at the site of the bite persisted for at least four days.

Although the L-C method of snakebite treatment has been vigorously attacked by many, there is still need of much more data before it can be unequivocally condemned or praised. It was preferred in the treatment of this bite because: I knew that envenomation was minimal and that there would be no need for antivenin; only one fang of a snake less than one foot long had entered the tip of the finger; the snake had bitten three frogs in the previous two days and had possibly used up a considerable amount of its venom; the venom was deposited at such a shallow depth that at least a portion of it could be removed by suction; and the wound bled freely even before suction was applied. The ice water was uncomfortably cold but was not cold enough to cause frostbite, a major objection to the L-C method. Ideally, fresh ice should be added little by little to replace that which is melting, and the immersed area should be protected from the water by a plastic bag. Pain and swelling can be minimized by cryotherapy, but I would recommend its use only in cases of mild poisoning such as the one described herein.

Snakebite in the United States

Many estimates have been made of the number of bites of poisonous snakes that occur annually in the United States. The occurrence of poisonous snakebite has been nearly as badly underestimated as fatal results of their envenomations have been overrated. For important data on number of persons bitten by poisonous snakes in the United States, see the following: Allen and Swindell (1948:15); Githens (1935:172); Klauber (1956:811); Parrish (1963); Sowder and Gehres (1963:973); Stimson and Engelhardt (1960:153); Swaroop and Grab (1956:441); Swartzwelder (1950:579); Willson (1908:530); and Wood (1954b:937).

Judging from estimates made in several states, the number of poisonous snakebites in the United States would be about 5000 per year. In the region where the cottonmouth occurs there are approximately 2000 persons bitten annually by poisonous snakes. Of these approximately 39 per cent are copperhead bites, 30 per cent each are cottonmouth and rattlesnake bites, and I per cent are coral snake bites. These percentages vary considerably from place to place, because of the distribution and abundance of the eight species of poisonous snakes whose ranges overlap that of the cottonmouth.

According to Parrish (1963), about 14 people die of snakebite each year in the United States. Of these deaths, about 6.6 per cent are attributable to cottonmouths, 77.0 per cent to rattlesnakes, and 1.6 per cent to coral snakes; 14.8 per cent are unidentified. Almost half of the fatalities are in persons less than 20 years of age, the high mortality rate being partially due to the greater ratio of venom to body weight.

SUMMARY

In my study, 306 living and preserved cottonmouths were examined. This species occurs throughout the coastal plains of the southeastern United States, usually at altitudes of less than 500 feet but occasionally up to altitudes of more than 2000 feet.

Two subspecies are recognized: the eastern cottonmouth, A. p. piscivorus, occurring from extreme eastern Mississippi to southeastern Virginia and Florida; and the western cottonmouth, A. p. leucostoma, occurring from eastern Mississippi northward to southern Illinois and Missouri and westward to central Texas. Intergradation occurs in eastern Mississippi.

The northern edge of the range is probably limited by low temperatures in winter, and the western edge by lack of available habitat resulting from insufficient precipitation. Old records of occurrence indicate that the range has decreased in the last 100 years. The species inhabits mostly areas where water is found, but at times wanders a mile or more from the nearest water.

The ground color is predominantly a brown, but varies from a brownish-green to almost black with a pattern of 10 to 17 irregular bands of a darker shade of brown. The pattern is better defined in the eastern subspecies than in the western.

The scutellation resembles that of other species of Agkistrodon. In the specimens examined supralabials ranged from 7 to 9, and infralabials from 8 to 12. The number of dorsal scale rows on the neck, at mid-body, and immediately anterior to the anus is relatively constant at 27-25-21, respectively. Ventral scales of 34 males averaged 134.4 (128 to 139), and those of 48 females 133.5 (128 to 137). The number of caudal scales showed some degree of sexual dimorphism; the average was 45.4 (41 to 50) in 34 males and 42.6 (39 to 49) in 44 females. In general, caudal scales on the basal half of the tail are undivided, whereas those on the distal half are divided. No marked geographical variation was found in any scale character.

The poison fangs vary in length from 1.3 per cent of snout-vent length in juveniles to 1.0 per cent in large adults. Fangs of captive cottonmouths were shed and replaced at intervals of about 21 days, but the interval was variable. Relationships in distance between the base of fangs and between fang punctures in an actual bite indicate that examination of the wound does not provide a good basis for judging accurately the size of the snake that inflicted the bite.

In general, females less than 450 millimeters in snout-vent length were juveniles; those more than 450 millimeters were classified as post partum or reproductive on the basis of sizes of ovarian follicles. Since about half the adult females were fecund, it was concluded that a biennial reproductive cycle occurs in this species. An annual cycle may occur in areas where temperature permits year-round activity. It was estimated that females become sexually mature at an age of approximately two and one-half years. Mating is probably most concentrated in early spring at about the time when females ovulate, but copulation is not a stimulus for ovulation. Sperm retention and delayed fertilization allow young to be produced without copulation occurring in each breeding season. The testes increase in size gradually rather than rapidly at maturity or in each breeding season, but seasonal cycles in sperm production occur.

The gestation period is three and one-half to four months. Determination of sex in the embryos is possible by late June, because the hemipenes of males are evaginated until the time of birth. Parturition generally occurs in August or September, but captivity may delay birth for a month or more. From one to 16 young per litter are born, depending on size of the mother and other factors; but the average is between six and seven. Mortality rate at birth is high in captive individuals but has not been determined in natural populations. The sex ratio in embryos and adults examined revealed about 53 per cent females. Because sufficient information on population composition is not available, an estimate of the percentage of adults in a natural population was based upon the number found in my study. The reproductive potential was estimated from these figures.

Normal young at birth are 230 to 240 millimeters in snout-vent length, but their size is influenced by the condition of the mother. Comparison of newborn young with those captured in spring indicates that little growth occurs during winter. Early growth is largely dependent upon feeding before winter quiescence.

The umbilical cord is broken at birth and the navel closes within a few days, but the scar remains throughout life. Sexual dimorphism in the position of the scar is characteristic of some snakes but is minimal in cottonmouths.

In those snakes more than 700 millimeters in length, males outnumber females three to one. The maximum age of cottonmouths in nature is unknown, but one has been kept in captivity for more than 18 years.

Allometric growth is striking in cottonmouths. The head and tail are proportionately longer in young individuals than in adults; and in males the tail is, on the average, slightly longer than in females of the same size.

Shedding of the skin provides for growth and wear in snakes. The young shed within a few days after birth and generally shed more frequently than adults. Frequency of shedding depends mostly on amount of food consumed, and there is some evidence that injuries on the head and neck increase the frequency of shedding. Before shedding, the eyes become cloudy for about five and one-half days, then clear up again for about four days before the skin is shed.

The food of cottonmouths consists mainly of small vertebrates and occasionally invertebrates that are found near water. Fish, amphibians, and reptiles make up nearly 70 per cent of the diet. Carrion is also eaten and cannibalism occurs occasionally. Food is obtained by lying in ambush or by active searching. The young are known to lure their prey within striking range by waving their yellow tails in a manner suggestive of writhing grubs. The method of obtaining prey differs according to the kind of prey. Generally, cottonmouths retain their hold on fish or frogs but release mice and larger prey after delivering a bite.

The major causes of mortality of cottonmouths are obscure. Predators are known to include alligators, indigo snakes, king-snakes, largemouth bass, and blue herons; there are probably numerous others. Heavy parasitic infestations were found among the snakes examined. Snake mites, Ophionyssus natricus, became increasingly abundant on almost all captive snakes in April and May of 1963. Lung flukes (Ochetosoma sp.) were in 16 of 20 captive snakes, and many preserved specimens contained nematodes (Kalicephalus sp.) in the stomach and/or tapeworms (Ophiotaenia sp.) in the intestine. Although parasitic infestation causes discomfort and may lower resistance to other detrimental factors, it is difficult to attribute death to the effect of any particular kind of parasite. Miscellaneous causes of death of some captive snakes also were discussed.

The maximal body temperatures tolerated by four cottonmouths were between 38 deg. and 40 deg. C., but a temperature of 38 deg. was lethal to a fifth individual. Cottonmouths have been found on occasion when other snakes were inactive because of low temperatures, but minimal temperatures tolerated by this species are not known. The annual cycle of activity is dependent upon temperature and thus varies from north to south. Cottonmouths generally migrate inland in autumn, usually to dry forested hillsides, where they den along with other species of snakes. After a few warm days in spring they migrate back to the water's edge. The diel activity cycle likewise depends upon temperatures but is influenced by other factors as well. In spring and autumn, the snakes are active mostly on warm, sunny days, whereas in summer they are active mostly at night. In order to maintain adequate internal temperatures, much time is spent basking mostly in a characteristic flat, resting coil either beside a body of water or above water on limbs of dead trees. In this position the snake is ready either for a short strike or a hasty getaway.

Juveniles appear particularly aggressive and strike repeatedly when approached, a behavioral pattern definitely favoring survival. Adults vary in disposition, usually appearing sluggish and lazy, but they are capable of striking rapidly when disturbed. The typical threat display consists of lying in a coiled position with the mouth opened widely, exposing the white interior, and with the tail vibrating rapidly. The striking posture resembles the resting coil except that the anterior part of the body is raised off the ground and the mouth is sometimes opened. Musk is often ejected in a fine spray from glands in the tail as a further defensive action.