Stingray Injuries

FINDLAY E. RUSSELL, M.D.

inflicted by stingrays are com¬ the integumentary sheath surrounding the INJURIESmon in several areas of the coastal waters spine is ruptured and the venom escapes into of North America (1-4). Approximately 750 the victim's tissues. In withdrawing the spine, people a year along our coasts are stung by the integumentary sheath may be torn free and these elasmobranchs. The largest number of remain in the wound. stings are reported from southern California, Unlike the injuries inflicted by many venom¬ the Gulf of California, the Gulf of Mexico, and ous animals, wounds produced by the stingray the south Atlantic coast (5). may be large and severely lacerated, requiring Of 1,097 stingray injuries reported over a 5- extensive debridement and surgical closure. A year period in the United States (5, tf), 232 sting no wider than 5 mm. may produce a were seen by a physician at some time during wound 3.5 cm. long (#), and larger stings may the course of the recovery of the victim. Sixty- produce wounds 7 inches long (7). Occasion¬ two patients were hospitalized; the majority of ally, the sting itself may be broken off in the these required surgical closure of their wounds wound. or treatment for secondary infection, or both. The sting, or caudal spine, is a bilaterally ser¬ At least 10 of the 62 victims were hospitalized rated dentinal structure located on the dorsal for treatment for overexuberant first aid care. surface of the animal's tail. The sharp serra¬ Only eight patients were hospitalized for the tions are curved cephalically and as such are treatment of the systemic effects produced by responsible for the lacerating effects as the sting the venom. There were two fatalities. is withdrawn from the victim's flesh. The loca¬ Considerable care should be exercised when tion, size, and number of stings vary with the wading in shallow waters known to be inhabited species, habitat, and age of the fish. The round by stingrays. Stingray injuries usually occur stingray, now designated as Urolophus halleri, when the unwary victim treads upon the fish which is implicated in the majority of injuries while wading in the ocean surf or mud flats along the southern California coast, has one or of a bay, slough, or river. The fish often buries more stings of 1.6 to 5.9 cm. long (8). The itself in the sandy or muddy bottom and may giant stingray of Australia, Bathytoshia, may remain motionless until stepped upon. The possess a caudal spine of 42.0 cm. long (9). pressure of the foot on the dorsum of the fish The greatest portion of venom is contained provokes him to thrust his tail upward and within the two ventrolateral grooves of the forward, driving his sting into the foot or leg sting. In the untraumatized state, the sting is of the victim. As the sting enters the flesh, incased in an integumentary sheath. The ana¬ tomic of the sheath and Dr. Russell is director of the laboratory of neuro¬ relationships sting logical research of the College of Medical Evange¬ have been described elsewhere {10-12). lists and Los Angeles County Hospital. Basic data Chemical and in the report were obtained from studies supported Zootoxicological Properties by the Office of Naval Research, Dazian Foundation The toxic fractions of the venom are soluble for Medical Research, and the Public Health Service. proteins of average molecular weight. They

Vol. 74, No. 10, October 1959 855 are extremely labile and rapidly inactivated by the venom show few gross changes. However, heating. Ten amino acids have been identified pulmonary edema, engorgement of the liver in the venom. The total nitrogen, carbohydrate, sinusoids, and vascular congestion with tubular and protein for 100 mg. of the venom has been epithelial necrosis in the loop of Henle are calculated as 3.1 mg., 3.3 mg., and 24.9 mg. seen (IS). respectively. The intravenous LD50 of the lyophilized venom is estimated at 28.0 mg./kg. Diagnosis of body weight (IS). Persons stung by stingrays report having In venom addition to the local effects (12), the received a sharp, painful stab, usually in the produces changes in the cardiovascular, respira¬ foot or leg, while swimming or wading in an tory, nervous, and urinary systems (5, 1^ IS). area where these animals are present. The Low of pain concentrations the toxin give rise to is usually described as intense or excruciating; simple, transient peripheral vasodilatation or it increases in severity during the first 90 min¬ vasoconstriction. The most consistent change utes following the stinging if treatment is not in the eiectrocardiographic pattern of cats when instituted. The pain is out of proportion to small amounts of the venom are injected is that which might be produced by a nonvenom¬ bradycardia with an increase in the PR interval, ous fish or by stepping upon a broken bottle or giving a first degree atrioventricular block with bivalve. "Stingings" by broken bottles, are a but slight change in the blood pressure. Re¬ common occurrence along certain of our coasts, versal of the small dose effect occurs within 30 according to the lifeguard services. seconds following the end of the injection Examination reveals either a puncture or (14,16). a lacerating wound, usually the latter, jagged, Larger amounts produce constriction of the bleeding freely, and often contaminated with arteries and veins as well as the arterioles, and parts of the stingray's integumentary sheath. second or third degree atrioventricular block. The edges of the wound may be discolored, The second degree block is usually followed by though the discoloration is not usually marked sinus arrest. In addition to the PR interval immediately following the injury. However, change, ST, T wave changes indicative of within 2 hours the discoloration may extend ischemia and, in some animals, true muscle in¬ several centimeters from the wound. Subse¬ jury are seen (15,16). Concomitant with these quent necrosis of this area is not uncommon in changes is a fall in systemic arterial pressure. untreated cases. It is apparent that the venom affects the normal Edema is a constant finding following sting¬ pacemaker of the heart. Most of the cardio¬ ings by these animals. The edema is not as vascular changes revert to normal within 24 severe as one sees following a rattlesnake bite, hours (5). but it may persist for several weeks in the un¬ Lethal amounts of the venom cause marked treated case. Syncope, weakness, nausea, vasoconstriction and cardiac standstill of vary¬ nervousness, and sweating are common com¬ ing durations. All degrees of atrioventricular plaints. Vomiting, diarrhea, tremors, general- block as well as defects in intraventricular con¬ duction occur, and if death is not immediate, the rhythm of the normal pacemaker is re¬ placed by one elaborated outside the sino-atrial node. The blood pressure falls rapidly, and the animal dies in complete cardiovascular collapse (5,11},1S). Concomitant with these changes are alterations in the respiratory and central nervous systems (SjlS). The venom has no effect on neuromuscular conduction (17). Postmortem examination of animals which have survived for 4 days following a lethal dose of The round stingray Urolophus halleri 856 Public Health Reports An Early Case History An early stingray victim was Captain John But it chansed our Captaine taking a fish Smith. Walter Russell, "Gentleman, doctor from his sword (not knowing her condition) of physicke," who accompanied Smith as he being much of the fashion of a Thornback. explored Chesapeake Bay in June 1608, de¬ but a long tayle like a ryding rodde, whereon scribed the encounter in chapter 5, "The Acci¬ the middest is a most poysoned sting, of two dents that hapned in the Discovery of the or three inches long, bearded like a saw on Bay of Chisapeack" of The Third Booke of each side, which she strucke into the wrest of The Proceedings and Accidents of the English his arme neere an inch and a halfe: no bloud Colony in Virginia. nor wound was seene, but a little blew spot, but the torment was instantly so extreme, that . . Having finished this discovery (though in foure houres had so swolen his hand, arme our victuall was neere spent) he intended to and shoulder, we all with much sorrow con¬ see his imprisonment-acquaintances upon the cluded his and his in river of called funerall, prepared grave Rapahanock, by many Toppa- an Island by, as himselfe directed: yet it but our bote reason of the hanock, by ebbe, pleased God by a precious oyle Doctor Russell chansing to grownd upon a many shoules at the first applyed to it when he sounded it lying in the entrances, we spyed many fishes with probe, (ere night) his tormenting paine lurking in the reedes: our Captaine sporting was so well asswaged that he eate of the fish himselfe by nayling them to the grownd with to his supper, which gave no lesse joy and his sword, set us all a fishing in that manner: content to us then ease to himselfe. For which thus we tooke more in owne houre then we we called the island Stingray Isle after the

could eate in a day. name of the fish. . . . ized cramps, inguinal or axillary pain, and may apply a constriction band directly above respiratory distress are less frequently re¬ the wound site. The extremity should then be ported. Arrhythmias, paresthesias, and con¬ submerged in hot water at as high a tempera¬ vulsions may occur. True paralysis is ex¬ ture as the patient can tolerate without injury tremely rare, if it occurs at all. The "paraly¬ for 30 to 90 minutes. The addition of sodium ses" seen by the author following severe chloride or magnesium sulfate to the hot water stingings were contractures, probably initiated is optional. as flexion reflexes stimulated by the intense In many areas of the United States the life¬ pain. These contractures were relieved with guard services provide the first aid care just meperidine hydrochloride. described, and the victim usually arrives at the hospital emergency room or physician's office in little acute pain and with few, if any, other Treatment complaints. The wound should then be further The standard procedure for treatment of examined for evidence of the integumentary stingray injuries is well established (5). As sheath, debrided, sutured if necessary, and the the chief complaint is immediate, intense, appropriate antitetanus agents administered. localized pain, the treatment will be most suc¬ While infections of these wounds are rare in cessful if the victim initiates it. Injuries to properly treated cases, some physicians rou¬ an extremity should be irrigated with the salt tinely give antibiotics. Elevation of the in¬ water at hand, since much of the venom can jured extremity is advised. be washed from the wound by this step. An Irrigation is contraindicated if the sting has attempt should be made to remove the integu¬ entered the abdominal or thoracic cavity, and mentary sheath if it can be seen in the wound. the patient should be hospitalized. In such If a properly qualified person is available, he cases, the patient should be explored surgically

Vol. 74, No. 10, October 1959 857 for the presence of the ray's integumentary are common complaints. Vomiting, diarrhea, sheath (5). Exploration is indicated if the tremors, generalized cramps, inguinal or axil- sting has pierced the peritoneum or pleura. lary pain, and respiratory distress are less fre- Such exploration may require considerable quently reported. Arrhythmias, parasthesias, time, since the sheath may be torn into several and convulsions may occur. small pieces. The venom is rapidly absorbed Treatment is aimed toward alleviating the in the peritoneal cavity, and should the offend- pain, preventing complications that may be ing ray be a large one, the prognosis is poor evoked by the venom, and preventing second- in the presence of an unremoved sheath. It is ary infections. The following therapy is sug- also possible for the toxin to be expressed from gested. Irrigate the wound thoroughly, re- the venom apparatus without the sheath being moving the animal's integumentary sheath if left in the wound. present. Apply a constriction band directly In severe stings, which provoke systemic above the wound site until hot water can be symptoms, the victim should also be hospital- prepared. Soak affected part in hot water for ized. The primary shock often seen immedi- 30 to 90 minutes. Debride and close wound as ately following these injuries usually responds necessary. Admninister appropriate antitetanus to simple supportive measures. If secondary agent and antibiotic. Keep affected part shock develops as a result of the direct effects elevated. of the venom, the physician must direct his efforts toward maintaining cardiovascular and respiratory tone. Oxygen should always be REFERENCES given. Meperidine hydrochloride has been (1) Gudger, E. W.: Is sting ray's sting poisonous? Historical resum showing development of our found to be effective in controlling the pain knowledge that it is poisonous. Bull. Hist. (5, 6). Experiments with mice have shown Med. 14: 467-504, November 1943. that the drug does not alter the LD.0 of the (2) Halstead, B. W., and Bunker, N. C.: Stingray venom (5). attacks and their treatment. Am. J. Trop. Med. 2: 115-128, January 1953. (3) Russell, F. E.: The stingray. Engineer. & Sc. Summary 17: 15-18, December 1953. Injuries inflicted by stingrays are common in (4) Halstead, B. W.: Dangerous marine animals. Cambridge, Md., Cornell Maritime Press, 1959, several areas of the coastal waters of North pp. 1-146. America. Approximately 750 people a year (5) Russell, F. E., Panos, T. C., Kang, L. W., Warner, along our,coasts are stung by these elasmo- W. M., and Colket, T. C.: Studies of the mech- branchs. About 20 percent of those injured anism of death from stingray venom. A re- are seen by a physician some time during the port of two fatal cases. Am. J. M. Sc. 235: are hos- 566-584, May 1958. course of their recovery; 6 percent (6) Russell, F. E.: Stingray injuries: A review and pitalized. discussion of their treatment. Am. J. M. Sc. In the untraumatized state, the sting is en- 226: 611-622, December 1953. cased in an integumentary sheath. The great- (7) Cleland, J. B.: Injuries and diseases in Australia est portion of the venom is contained within attributable to animals. M. J. Australia 2: the of the sting. 313-320, Oct. 3, 1942. ventrolateral grooves (8) Russell, F. Bl.: Multiple caudal spines in the The toxic fractions of the venom are soluble round stingray, Urobati8 halleri. California proteins of average molecular weight which Fish & Game 41: 213-217, July 1955. are extremely labile and rapidly inactivated (9) Gudger, E. W. Bathytoshia, the giant stingaree by heating. While the venom produces changes of Australia. The largest of the sting-ray tribe in the seven seas. Australian Museum Mag. in the respiratory and central nervous systems, 205-210, April-June 1937. its principal action is on the cardiovascular (10) Ocampo, R. R., Halstead, B. W., and Modglin, system. F. R.: The microscopic anatomy of the caudal The chief complaint following a sting by appendage of the spotted. eagleray, Aetobatu* marinari (Euphrasen) with special reference to one of these animals is severe pain. Syncope, the venom apparatus. Anat. Rec. 115: 87-99, weakness, nausea, nervousness, and sweating January 1953.

858 Public Health Reports (11) Halstead, B. W., Ocampo, R. R., and Modglin, F. stingray, Urobati8 halleri. Arch. internat. R.: A study of the comparative anatomy of physiol. 62: 322-333, September 1954. the venom apparatus of certain North Ameri- (15) Russell, F. E., Barritt, W. C., and Fairchild, M. can stringrays. J. Morphol. 97: 1-21, July 1955. D.: Electrocardiographic patterns evoked by (12) Russell, F. B., and Lewis, R. D.: Evaluation of venom of the stingray. Proc. Soc. Exper. Biol. the current status of therapy for stingray in- & Med. 96: 634-635, December 1957. juries. In Venoms, edited by E. E. Buckley (16) Russell, F. E., and van Harreveld, A.: Cardio- and N. Porges. Washington, D.C., American vascular effects of the venom of the round sting- Association for the Advancement of Science, ray Urobati halleri. In Venoms, edited by 1956, pp. 43-53. E. E. Buckley and N. Porges. Washington, (13) Russell, F. Bl., Fairchild, M. D., and Michaelson, D.C., American Association for the Advance- J.: Some properties of the venom of the sting- ment of Science, 1956, pp. 33-41. ray. M. Arts & Sc. 12: 78-86, Second Quarter, (17) Russell, F. E., and Long, T. E.: Effects of venoms 1958. on neuromuscular transmission. Second Inter- (14) Russell, F. E., and van Harreveld, A.: Cardio- national Symposium on Myasthenia Gravis. In vascular effects of the venom of the round press.

Disease Center, Atlanta, Ga.,' by present-day scenes of the polluted films high schools, colleges, youth organi- Potomac. The ugliness of the pollu- zations, and civic groups, as well as tion emanating from the metropoli- health departments, and will be of- tan area is contrasted with the fresh, fered for sale by an independent clear headwaters of the Potomac. The Innocent Party contractor. Scenes include national shrines, Information concerning loan or cherry blossom time at the Tidal 16-mm. film, color, sound, 17 minutes, purchase may be obtained from Dr. Basin, and a long-forgotten bathing 1959. William J. Brown, Chief, Venereal beach in Washington. Audience: Students, parents, educators, Disease Branch, Communicable Dis- The film shows how cities and in- civic groups, health workers, and the ease Center, Public Health Service, dustries can manage their wastes general public. 50 Seventh Street NE., Atlanta 23, and restore the streams for fishing, This film, depicting the problems Ga. boating, swimming, and domestic of teenagers with venereal diseases, and industrial requirements. documents simply, forthrightly, and Film libraries or agencies consid- in good taste the nature, recogni- George Washington's River ering the purchase of a print can obtain a preview copy tion, cure, and control of syphilis. 16-mm. film, color, sound, original music, from the Divi- Suitable for mixed audiences, it 28 minutes, cleared for television, 1959. sion of Water Pollution Control, was shown before release to groups Public Health Service, Washington Audience: Sanitarians, persons interested 25, D.C. Distribution for public of parents, teachers, educators, in conserving natural resources, and the Catholic and Protestant clergy, pub- general public. showings will be made from film lic health officials, and teenagers. service libraries only. The film was produced by the Kan- From a depiction of George Wash- Prints can be purchased, at $95.42 sas State Board of Health in cooper- ington's time when he built his each postpaid, from the Motion Pic- ation with the Public Health Serv- home at Mount Vernon "on the finest ture Service, Office of Information, ice. It may be borrowed from the river in the world," this new water U.S. Department of Agriculture, film library of the Communicable pollution film -takes the audience to Washington 25, D.C.

Vol. 74, No. 10, October 1959 859 The government of East Pakistan has contracted with 220 small contractors, each with 2 or 3 crews of 4-man gangs, to dig new tube wells or put clogged wells back into service. Most of the wells are less than 200 feet deep. In the Dacca area, 2,294 out of the scheduled 3,370 wells were finished in 30 days. The village water supply project required nearly 350 miles of 1^2-inch galvanized iron pipe, 10,000 Medical Center hand pumps, 1,000 deep-well hand pumps, and quantities of pipe fittings, strainers, well points, A national medical center for Korea opened Oc¬ for the and hand tools. modern medi¬ spare parts clogged wells, tober 2, 1958, in Seoul. The largest .Anthony health ad¬ cal in the Far the center has 465 beds Donovan, M.D., chief public facility East, viser U.S. Mission, Pakistan. and was financed with $2.4 million from UNKRA physician, Operations funds and $2 million contributed by Norway, Sweden, and Denmark. For its first 5 years of op¬ Tuberculosis in Israel eration the center will have approximately 80 The number of tuberculosis cases in Israel has Scandinavian staff an an¬ members, supported by dropped so that 750 beds are sufficient for hospital¬ nual $1.5 million contribution from the three coun¬ ized tuberculous patients. Other tuberculosis facil¬ tries. The entire facility will be turned over to ities have been converted into general wards, homes Korea in 1963. for the aged, and mental hospitals. .Alfred S. Lazarus, chief, Health and Sanitation Ten years ago, when 1,000 immigrants were ar¬ Division, U.S. Operations Mission, Korea. riving daily, 12 out of 1,000 had signs of the disease. Through efforts of the Ministry of Health, trade unions' sick funds, and philanthropic organizations, Ojos de Agua the number of beds for tuberculosis patients in¬ The Ministries of Agriculture, Education, and creased from 348 in 1948 to 2,200 by 1953. Health joined forces in a new rural development at Malben, a philanthropic organization, took on the task of Ojos de Agua, a small community in southeastern rehabilitating discharged patients, totaling in 1958 alone. El Salvador. An earth-cement brick-making ma¬ 7,000 chine, used here for the first time, manufactures bricks for a new school, houses, and water supply Malaria in Southeast Asia units. The water units consist of laundries, showers, To coordinate malaria eradication, 40 officers and for drinking fountains, watering troughs animals, technicians from Laos and Thailand met at a border and vats. The is food-washing community building conference at Thailand, latrines for each of 420 houses. Nongkhai, February 2-6, approved 1959. In 1959 eradication efforts will serve 14 mil¬ .Lamar A. Byers and W. C. James, chief and lion Thai and 700,000 Lao, an increase of 2 million acting chief, Health and Sanitation Division, U.S. persons in Thailand and 300,00 in Laos. Operations Mission, El Salvador. In large areas of Thailand the malaria eradication program is almost complete, and less than half of the The Well Diggers operational areas require spraying this year. Laos Twelve thousand new or rehabilitated wells will will continue spraying in all operational areas and start surveillance activities areas be put into operation in East Pakistan this year. The in of 175,000 wells will provide a safe source of water. Villagers population. customarily use open tanks for bathing and launder¬ .Melvin E. Griffith, acting chief, public health ing as well as for drinking water. division, U.S. Operations Mission, Thailand.

860 Public Health Reports