The author wrote a dissertation for the Mmed Sc degree entitled The Clinical Natural History of Snakebite in Southern Africa, which dealt with the epidemiology of snakebite and the clinico-pathological events in snakebite victims. This thesis is a sequel on the management of snakebite victims. Publications on the overall management of snakebite in the Southern African region that include original scientific research are those of F.W. Fitzsimons (1912), F.W. Fitzsimons (1929) (assisted by V.F.M. Fitzsimons), P.A. Christensen (1955, 1966, 1969) and Christensen & Anderson (1967). Subsequent books, pamphlets and journal articles have rehashed this knowledge or advocated methods of treatment developed in other countries. An example of the latter is the pressure immobilisation prehospital measure advocated for snakebites in Australia (Sutherland et aL, 1979, 1981, 1995), which I regard as benefiting less than 1% of snakebite victims here and being deleterious in most cases. In view of the paucity of research done in Southern African in recent years, many questions remain unanswered, and some strongly held views are without logical or scientific foundation. Most of these questions arose prior to the writing of this thesis, and others arose when the data were analysed. The following are some questions on the management of snakebite that have still have to be addressed. Is vaccination against snakebite possible and practical? Are folk and traditional remedies advantageous or deleterious? How commonly are they used? Immobilisation of the bitten part and the patient is an internationally recognised aid measure, but is this relevant to the Southern African situation? Tourniquet use in the case of necrotising venoms is considered to aggravate or precipitate necrosis. Does immediate active movement following a bite ameliorate or prevent necrosis without increasing mortality? The majority of clinicians recommend antibiotic prophylaxis, but is this necessary for all snakebites, against which bacteria should antibiotics be administered, and what is the source of these bacteria? Should antivenom be administered to all snakebite victims: for species-specific bites, only if envenomation is present, for severe envenomation, or not at all? Acute adverse reactions to South African manufactured snakebite antivenom has been variously recorded as less than 1% (Visser & Chapman 1978) up to 76% (Moran et al., 1998). What is the truth? Is syndromic management of snakebite efficacious or is it essential to identify the particular snake species? Is the present liberal use of fasciotomy necessary? Is there an optimum time to debride necrotic areas and is surgery necessary at all? Is paresis or paralysis due to neurotoxic envenomation always the result of a post-synaptic block? Would such a block respond to neostigmine or prostigmine in a similar way to post-synaptic anaesthetic muscle relaxants? Is heparin of value when procoagulant toxins induce a consumption coagulopathy? Do fibrinstabilising agents or fibrinolytics have a role? Does the management of pregnant snakebite patients differ from that of non-pregnant patients? Is snake venom teratogenic? Does snake venom ophthalmia frequently lead to blindness? Are steroids, NSAIDs and antihistaminics, which are commonly used in the management of snakebite, of proven value? This thesis attempts to answer these questions and more, and comprises six sections. The first section deals with pre-hospital management, the second with infection which may occur at the bite site wound, the third with SAIMR snakebite antivenom, the fourth with the three envenomation syndromes, the fifth with snakebite in pregnancy, venom ophthalmia and other treatment modalities, and the sixth section includes a summary, appendix and references. Unless otherwise stated, the materials and methods of each chapter are based on 336 snakebite victims admitted to Eshowe Hospital, KwaZulu-Natal, from January 1990 - July 1993 and other victims treated by the author, the data of which have been prospectively maintained. This has been an ongoing process up to the present time. / Thesis (MMedSc.)-University of Natal, 2000.

Os acidentes causados por serpentes peçonhentas são considerados um problema de saúde pública no Brasil, e é muito importante que sejam feitos mais estudos para um melhor conhecimento desse agravo. O objetivo deste trabalho é descrever as características clínicas e epidemiológicas que foram observados no Hospital de Doenças Tropicais de Araguaína, Estado do Tocantins, Brasil, que é uma unidade de saúde que cuida de pacientes que sofrem de doenças tropicais, no período de 2007 a 2009. Foram estudados 556 indivíduos e as características mais comuns observadas foram: sexo masculino, idade entre 19-40 anos, picada em membros inferiores e os ferimentos causados por serpentes do gênero Bothrops. Os sinais e sintomas mais freqüentes foram dor, edema e hemorragia. A manifestação sistêmica mais observada foi alteração da coagulação sanguínea. As complicações mais freqüentes foram abscesso, insuficiência renal aguda, necrose e infecção bacteriana. Os principais microorganismos identificados foram Morganela morganii (17,1%), Pseudomonas aeruginosa (14,6%) e Staphylococcus epidermidis (4,9%). Esta flora bacteriana foi semelhante às descritas no veneno e na boca das serpentes por outros pesquisadores. Com base nos resultados dos testes de suscetibilidade sugere-se a continuidade no uso de ciprofloxacin para o tratamento desses abscessos que não respondem à simples drenagem. O conjunto dos resultados obtidos representa um completo levantamento da atual situação dos acidentes envolvendo serpentes no estado do Tocantins e arredores e certamente contribuirá para o aprimoramento das ações de combate aos problemas de Saúde Pública da região Norte. / Accidents caused by venomous snakes are considered a public health problem in Brazil, and it is very important that more studies be done to a better understanding of this injury. The aim of this paper is to describe the clinical and epidemiological characteristics that were observed in the patients at the Hospital for Tropical Diseases in Araguaina, Tocantins State, Brazil, during the last three years. We have studied 556 individuals and the most common features were: male, aged 19-40 years, stinging in his legs and injuries caused by Bothrops snakes. Signs and symptoms were pain, swelling and bleeding. The most observed systemic manifestation was alteration of blood coagulation. The most frequent complications were abscess, acute renal necrosis and bacterial infection and the main microorganisms identified were Morganela morganii (17.1%), Pseudomonas aeruginosa (14.6%) and Staphylococcus epidermidis (4.9%). The bacterial flora was similar to those described in the mouth of snakes by other researchers. The susceptibility tests results suggest the continuity in the use of ciprofloxacin for the treatment of abscesses that do not respond to simple drainage. The set of results represents a complete survey of the current situation of accidents involving snakes in the state of Tocantins and the surrounding area and will certainly contribute to the improvement of actions to combat public health problems in the North region of Brazil.

Os acidentes causados por serpentes peçonhentas são considerados um problema de saúde pública no Brasil, e é muito importante que sejam feitos mais estudos para um melhor conhecimento desse agravo. O objetivo deste trabalho é descrever as características clínicas e epidemiológicas que foram observados no Hospital de Doenças Tropicais de Araguaína, Estado do Tocantins, Brasil, que é uma unidade de saúde que cuida de pacientes que sofrem de doenças tropicais, no período de 2007 a 2009. Foram estudados 556 indivíduos e as características mais comuns observadas foram: sexo masculino, idade entre 19-40 anos, picada em membros inferiores e os ferimentos causados por serpentes do gênero Bothrops. Os sinais e sintomas mais freqüentes foram dor, edema e hemorragia. A manifestação sistêmica mais observada foi alteração da coagulação sanguínea. As complicações mais freqüentes foram abscesso, insuficiência renal aguda, necrose e infecção bacteriana. Os principais microorganismos identificados foram Morganela morganii (17,1%), Pseudomonas aeruginosa (14,6%) e Staphylococcus epidermidis (4,9%). Esta flora bacteriana foi semelhante às descritas no veneno e na boca das serpentes por outros pesquisadores. Com base nos resultados dos testes de suscetibilidade sugere-se a continuidade no uso de ciprofloxacin para o tratamento desses abscessos que não respondem à simples drenagem. O conjunto dos resultados obtidos representa um completo levantamento da atual situação dos acidentes envolvendo serpentes no estado do Tocantins e arredores e certamente contribuirá para o aprimoramento das ações de combate aos problemas de Saúde Pública da região Norte. / Accidents caused by venomous snakes are considered a public health problem in Brazil, and it is very important that more studies be done to a better understanding of this injury. The aim of this paper is to describe the clinical and epidemiological characteristics that were observed in the patients at the Hospital for Tropical Diseases in Araguaina, Tocantins State, Brazil, during the last three years. We have studied 556 individuals and the most common features were: male, aged 19-40 years, stinging in his legs and injuries caused by Bothrops snakes. Signs and symptoms were pain, swelling and bleeding. The most observed systemic manifestation was alteration of blood coagulation. The most frequent complications were abscess, acute renal necrosis and bacterial infection and the main microorganisms identified were Morganela morganii (17.1%), Pseudomonas aeruginosa (14.6%) and Staphylococcus epidermidis (4.9%). The bacterial flora was similar to those described in the mouth of snakes by other researchers. The susceptibility tests results suggest the continuity in the use of ciprofloxacin for the treatment of abscesses that do not respond to simple drainage. The set of results represents a complete survey of the current situation of accidents involving snakes in the state of Tocantins and the surrounding area and will certainly contribute to the improvement of actions to combat public health problems in the North region of Brazil.

Submitted by admin tede (tede@pucgoias.edu.br) on 2018-05-29T13:32:18Z No. of bitstreams: 1 CLEITON JOSÉ COSTA SANTOS 1.pdf: 1693805 bytes, checksum: 73acf521014b6d3136d8e759744648f7 (MD5) / Made available in DSpace on 2018-05-29T13:32:18Z (GMT). No. of bitstreams: 1 CLEITON JOSÉ COSTA SANTOS 1.pdf: 1693805 bytes, checksum: 73acf521014b6d3136d8e759744648f7 (MD5) Previous issue date: 2018-03-14 / Recently the World Health Organization reclassified the snakebites as Neglected Tropical Disease. This problem mainly affects economically active age groups of rural populations in poor or in developing countries in tropical regions. Despite the low mortality rate associated with this type of accident in Brazil, one of the largest estimates of occurrence was attributed to the country. The epidemiological profile is widely known in several Brazilian regions, but little was inferred about factors associated with the occurrence of snakebites in the country. In order to analyze the spatial distribution of snakebites caused by snakes of the Elapidae and Viperidae families in the Brazilian municipalities between 2007 and 2015, we associate the number of snakebites with variables related to human factors (Area of the Municipality, Population, Agricultural Production, Municipal Human Development Index and Gross Domestic Product) and environmental factors (Species Richness, Remnant Area of Native Vegetation, Altitude and Climate). The records of notifications were obtained from the database of the Ministry of Health's Information and Notification System of Injuries. The average annual incidence rate for the time series analyzed was calculated. The association between the number of snakebites and factors analyzed was tested through Multiple Linear Regression Analysis by an OLS (Ordinary Least Square) model, evaluating the spatial autocorrelation in the model residues by the Moran Index. The variance partition was performed to evaluate the isolated effect of the different factors (environmental, human and spatial) on the variation of the accident data. Data were analyzed at national and regional scales. The average annual incidence for the period was 12.1/100,000 inhabitants. The North and Midwest regions presented the highest incidence, followed by the Northeast, South and Southeast regions, respectively. The OLS model indicated association more than 50% between snakebites data and variables tested, with the highest contribution of human factors followed the spatial effect and lower contribution of environmental factors in all scales. The model showed higher suitability especially for regions with the highest incidence rate, indicating differences in the composition of the most important variables in each region. However, it is possible to infer that in the analysis period, human factors contributed most heavily to the occurrence of snakebites in Brazil, followed by the spatial effect on the distribution of these snakebites and minor contribution of environmental factors. Clearly, the demographic density linked to type of occupation and climatic conditions may favor the increase of snakebites in the country, and different regional characteristics can clarify the disparity in the incidence rate among the Brazilian regions. / Recentemente os acidentes ofídicos foram reclassificados pela Organização Mundial da Saúde como Doença Tropical Negligenciada. Esse problema atinge principalmente grupos etários economicamente ativos de populações rurais em países pobres ou em desenvolvimento nas regiões tropicais. Apesar do baixo índice de mortalidade associado a esse tipo de acidente no Brasil, uma das maiores estimativas de ocorrência foi atribuída ao país. O perfil epidemiológico é amplamente conhecido nas diversas regiões brasileiras, porém, pouco se inferiu sobre fatores associados à ocorrência de acidentes ofídicos no país. Assim, com o objetivo de analisar a distribuição espacial dos acidentes causados por serpentes das famílias Elapidae e Viperidae, registrados para os municípios brasileiros entre os anos de 2007 e 2015, associamos o número de acidentes ofídicos, obtidos na base de dados do Sistema de Informação e Notificação de Agravos do Ministério da Saúde, com variáveis ligadas a fatores humanos e ambientais considerando o efeito espacial na distribuição dos dados. A taxa de incidência média anual foi calculada para elaboração do mapa de distribuição nacional e regional da incidência no período analisado. A associação entre o número de acidentes e fatores analisados foi testada através de Análise de Regressão Linear Múltipla OLS (Ordinary Least Square), avaliando a autocorrelação espacial nos resíduos do modelo pelo Índice de Moran. A partição de variância foi realizada para avaliar o efeito isolado dos diferentes fatores sobre a variação do número de acidentes. A incidência média anual para o período foi de 12,1/100.000hab. As regiões Norte e Centro-Oeste apresentaram as maiores incidências, seguidas pelas regiões Nordestes, Sul e Sudeste, respectivamente. O modelo OLS indicou associação superior a 50% entre dados de acidentes e variáveis testadas, com maior contribuição dos fatores humanos seguidos do efeito espacial e menor contribuição dos fatores ambientais em todas as escalas analisadas. O modelo mostrou maior adequação principalmente para as regiões com maior taxa de incidência, indicando diferenças na composição das variáveis mais importantes em cada região. Contudo, é possível inferir que no período analisado, fatores humanos contribuíram mais fortemente para a ocorrência de acidentes ofídicos no Brasil, seguidos do efeito espacial sobre a distribuição desses acidentes e menor contribuição dos fatores ambientais. Especialmente, o adensamento demográfico ligado ao tipo de ocupação e condições climáticas podem favorecer o aumento de acidentes ofídicos no país e diferentes características regionais podem esclarecer a disparidade na taxa de incidência entre as regiões brasileiras.

Bibliography: leaves 515-531 / The Brooklyn Papyrus (47.218.48 and 47.218.85) is the handbook of the Priests of Serqet who were called upon to treat snakebite victims in ancient Egypt. The first part of the Brooklyn Papyrus describes various snakes encountered by the ancient Egyptians, and the effects of the bites of these snakes. The second part of the Papyrus contains the numerous treatments that were used to treat the snakebite victims. The primary question of the thesis is to address how the ancient Egyptians treated snakebite victims; and if it is possible to identify the snakes that they encountered, as treatment often hinges on this identification. Additional questions are addressed, namely: What is the Brooklyn Papyrus exactly and what is its background? How does the Brooklyn Papyrus compare to the well-known ancient Egyptian medical papyri? How does the snakebite treatment of the ancient Egyptians compare to that of today’s treatment protocol? In order to answer these questions, this thesis provides my transliteration of the hieroglyphic writing into Latin script, and my translation into English, based on the hieratic to hieroglyphic transliteration done by Serge Sauneron in the late 1960s, and published in 1989 as Un Traité Egyptien d’Ophiologie. The primary aim of this thesis is to provide a transliteration and full English translation of the Brooklyn Papyrus, as none is currently available. It is clear that from the translation that one can discover exactly how snakebite was treated in ancient Egypt: what medicinal ingredients were used and how the patient was treated. Furthermore, from the text describing the snakes and the effects of their bites, one can indeed attempt to identify the species of snakes. It is also apparent from the Brooklyn Papyrus that the ancient Egyptians did recognise and accurately describe many effects of snakebite on the human body, as well as the different types of bite wounds: and they also understood the importance of being able to identify a species of snake as it very often impacted on the treatment to be prescribed—exactly as snakebite treatment is considered in medicine today / Biblical and Ancient studies / D. Litt. et Phil. (Ancient Near Eastern Studies)