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Toxicology of Androctonus scorpion
British Homoeopathic Journal July 1997, Vol. 86, pp. 142-151
Toxicology of Androctonus scorpion M. S. BONNET, BSC, MB, CHB
Abstract The following paper is a summary of studies of the biology of the Androctonus scorpion and its toxicology. A materia medica based on human envenomation by Androctonus is also provided.
Introduction This paper has been compiled in order to add the biology and human toxicology to the relatively new homoeopathic provings of the 'Scorpion' medicines. In 1939 Azam underwent a hom0eopathic pathogenetic trial using the scorpion Prionurus australis (known at the time as Buthus australis). 1 5 He mentioned experiments, observations and gave a detailed list of several hundred rubrics. In 1985 Jeremy Sherr published a monograph in which he detailed the actions of potentized Androctonus amoreuxi on healthy volunteers. 6, 7 Clarke included Scorpio in his Dictionary of Practical Materia Medica. 8 Gagliardi touched on the possibility of using various scorpion venoms, including that of Androctonus, as medicinal agents. 9 Scorpio became known as Prionurus, then as Buthus and finally Androctonus. 1~It is very likely that the above authors were using the same scorpion. Should not their good work be united in one homoeopathic medicine? Provings are the first step in introducing a new medicine to the homoeopathic materia medica which also takes account of toxicology and observations made in clinical use. In this paper the signs and symptoms experienced by patients unfortunate enough to have been stung by an Androctonus scorpion have been gathered from the scientific press. Medical papers have been consulted in order to extract the relevant rubrics. These have been rearranged in the style of the Synthesis Repertory. 11 Biological data on this scorpion were obtained from scientific publications. It was d e c i d e d to use the t o x i c o l o g y i n f o r m a t i o n f r o m e n v e n o m a t i o n by the genus Androctonus and not to limit the list to the species A. amoreuxi. The symptomatology of envenomation by different species of the genus Androctonus is very similar. 12 Mating between species of A n d r o c t o n u s results in viable progeny. 13
FIGURE1.The Androctonus scorpion. Relatively few of the approximately 1,400 different scorpion species in the world are capable of stinging humans with dangerous consequences. 6 of the 'Old World' genera d a n g e r o u s to h u m a n s are A n d r o c t o n u s , Buthus, Leiurus, Mesobuthus, Parabuthus and Hemiscorpion. 2 notable 'New World' genera are Centruroides and Tityus. TM
Biology of Androctonus scorpion Family A n d r o c t o n u s belongs to the s u p e r f a m i l y Buthoidea, family Buthidae and subfamily Buthinae.15,16 The Buthidae include more than 350 species represented in all continents except Antarctica. It is the largest family of scorpions and includes the most dangerous species of the order. Found in both the Old and New World, the Buthidae family represents almost half the known scorpions of the world 17 and can be represented by Androctonus and Buthus in North Africa and the Middle East; Centruroides in Central and North America; Leiurus in Africa and the Middle East; Parabuthus in South Africa and by Tityus (Subfamily Tityinae) in South America. 18-20
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Species of the genus Androctonus The more common species of Androctonus are A. aeneas el in Tunisia; A. amoureuxi 14 and A. australis14, 21 in the Middle East and North Africa; A. crassicaud 14, as in Turkey, Iran and Iraq; and A. mauritanicus 14, 22 HI North Africa and Morocco. Synonyms The genus Androctonus was first described in 1827 under the name of Scorpio, soon (1829) to be changed to Androctonus, then in 1895 to Prionurus. It was known as Buthus from 1899 until 1948, when the latter genus was split into 2 distinct genera. Since 1948 use of the name Androctonus, designated by Vachon, has been consistent.10 Vernacular
Black scorpion, fat tailed scorpion. Distribution A n d r o c t o n u s has a wide distribution. It is found in North Africa, 23 the Sahara 24 and the entire Middle East including Turkey, 2~ Iran is and the A r a b i a n Peninsula. 25 Its r a n g e extends from India to the Sudan and Senegal in AfricaJ 0 Description A most dangerous, formidable and venomous black scorpion. ~5, 20, 21. 24 Most notorious and most feared scorpion of North Africa responsible for the majority of accidents. 26, 27 Black, thick tailed or very thick tailed, with long dark claws and telson, it can reach a body length of 11 cm or more. The average weight of a scorpion (male or female) is 5-6 g.20, 21, 28 The colour of the adult varies from black to dark chocolate brown, olive or yellow, depending on geographical area. 20, 29 The terminal segments of the legs are lighter. The prosoma ('face') is densely granulated, with distinct crests and a pair of median eyes situated slightly anterior to the middle, plus three small and distinct lateral eyes on the outer anterior corners of the prosoma. 10 The scorpion eye is among the most sensitive of arthropod eyes, more sensitive than the largelens human eye. The lateral eyes of scorpions are more sensitive than the median eyes and are used for orientation in moonless nights, when Androctonus uses astromenotaxy to find its way and prey. 30
143 As a Buthidae, Androctonus has a triangular sternum, an accessory spine on its telson and hairs and bristles on the soles of its feet. ~~20 Habitat The scorpion is particularly abundant in stony soils, cactus hedges, arid mountainous regions and on high plateaux, avoiding moist coastal areas. It is found on steep slopes of drifting sand dunes, in burrows in red sandy soils, or in brown steppe soils. In stony deserts Androctonus favours living under large stones; occasionally dozens of specimens are concentrated in a small stony area surrounded by terrain without stones. ~0,20, 21, 29, 31 Behaviour They are secretive and nocturnal, hiding by day under wood and stones and in crevices in the ground. They are often found near human habitations. A n d r o c t o n u s is more active during the summer months, especially July to September. During the winter months they live quietly in shelters without really hibernating. The winter sting appears to be less dangerous. Androctonus is more active in the evening, when it goes in search of its prey, primarily other arthropods, especially larger insects. 16.21,26 Hunting behaviour Prey is caught by the powerful pedipalp and torn up using the chelicerae. Quiescent prey may not be stung, but struggling prey is quickly overpowered by stinging. The scorpion tears the prey into small pieces which are then partly digested by a secretion emitted from the mouth. The resulting semi-liquid material is ingested. The hunting instinct of the scorpion is less developed than that of other hunting arthropods. Androctonus does not chase its prey but either comes across it by chance or waits for it to cross its path; nor does it follow moving prey visually. Once the scorpion has decided to attack, it does so rapidly and accurately. 16,24,28 Mating behaviour Copulation is a dangerous enterprise. A scorpion approaching another with purely sexual intentions runs a real risk of ending up as a meal rather than a mate. Scorpion mating demands ritualized safeguards and placatory courtship. For scorpions, sexual recognition depends on
144 behavioural responses to each other when they meet, and possibly the emission of an odoriferous response from the female. The mated female appears to lose all attraction immediately after insemination. When a male and a female meet, they stop and 'observe' each other before the male grasps the female by the pedipalps. The tail of the Androctonus m a l e is a l w a y s held straight up during courtship, while the female uses her tail to try and parry him, at least at the beginning of the encounter. Thus 'holding hmads', he proceeds to walk backwards, pulling her forwards. The purpose of this 'promenade gt deux' is to allow him to search for a suitable spot to deposit his spermatophore. The promenade is interrupted by 'kissing' behaviour when the male pulls the female closer to him so that their mouth parts touch. Other interspersed behaviour is 'juddering'. A single bout of juddering consists of several rapid back and forth movements. After the male has deposited his spermatophore, pulled the female over it and made certain that it has been taken into the body of the female, he liberates her and runs away. 32 34
Digging behaviour Androctonus excavates tunnels horizontally just below the surface, in which it hides during the day. It commences by pushing its large chelae into the sand and scraping backwards with the 3 anterior pairs of walking legs. This action is very rapid, resulting in a shower of sand producing a curious rattling sound. 31 Female scorpion This scorpion is viviparous. The reproductive system of the female is a simple ovari-uterus without diverticula. Embryonic development occurs in its lumen and embryonic nutrition is provided by the yolk, supplemented by a diffuse placenta. The female is gravid for 242 days and the litter size varies between 30 and 46 young. Parturition occurs during the months of June to August, taking less than 24 hours, with the neonates randomly orientated at delivery. 29, 35 37 Maternal behaviour Very soon after the birth the newly-born scorpions rid themselves of their embryonic membranes and climb on to the m o t h e r ' s back. She makes sure they do not come in
British Homoeopathic Journal
contact with the ground by positioning her walking legs as a protective basket and ladder. While they are on her back, the mother protects her young, scoops them back up onto her back, makes sure they do not touch the ground during their first days and feeds them tit-bits. She never uses her sting while she has her brood on her back, neither to defend herself--she will prefer to retreat--nor to hunt she will elect a docile non-struggling prey. After about 25 days the young descend to forage and permanently leave the maternal transport and secnrity. 37
Male scorpion These scorpions exhibit little sexual dimorphism. The male has a hook on its opercular plate; the pectines (a two-comb-like appendage behind the posterior legs, on the under-belly of scorpions) of the male are longer and have more 'teeth' than those of the female. The life span of the male is about one year. This is short compared to that of the female who can survive 3 years and several litters. It is also short considering that it takes at least 242 days to reach maturity. 17, 26, 37 Androctonus v e n o m Androctonus has a most dangerous venom of at least equivalent toxicity to the cobra's. The toxicity varies with the geographical origin of the scorpion and depending on its nutritional state. The longer the fast, the less the quantity but the greater the toxicity. 2~ 26,27.37 Androctonus venom specifically stimulates the acetylcholine receptors throughout the body. Potent neurotoxic, neuromuscular and cardiotoxic venoms provoke spastic paralysis, acting at the voltage-sensitive sodium channel level to induce depolarization of excitable membranes.IS. 21.23,25.38,39The toxins are soluble in water and saline, stable at pH 8-9 and conserve their toxicity at 37 ~ They are denatured at 80 9C. The neurotoxins, each composed of a single polypeptide chain, contain 60 to 70 amino acid residues and are cross-linked by 4 disulphide bridges, but differ in their toxic activity. 4~ The lethal fraction also causes cardiac stimulation, uterine relaxation and increased twitching in the phrenic nerve. Fractions that 'specialize' in uterine relaxation or in causing contraction in skeletal muscle are called alpha and beta toxins. Alpha toxins prolong the action potential of nerves and muscles by
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Volume 86, July 1997 s l o w i n g d o w n i n a c t i v a t i o n of the s o d i u m channel, i.e. the repolarization phase. Beta toxins act on channel activation. 15,38,41, 47 Androctonus toxins are characterized by their action on the sympathetic ganglia (hypertension, peripheral vasoconstriction, lachrymation, s a l i v a t i o n , b r e a t h i n g s p a s m s and i n d i r e c t inotropic effect) and by their direct action on the heart (bradycardia, negative inotropism and arrhythmias leading to fibrillation).4s Scorpion venoms are more complex protein mixtures than snake venoms, and Androctonus venom has a more complex antigen composition than the rest of the Buthidae. Androctonus venom antigen is capable of neutralizing the v e n o m s of other B u t h i d a e genera, but the reverse is not the case. The median lethal dose (LDs0) is 0.3 1-0.32 mg/kg.14, 21 The v e n o m stimulates the postganglionic autonomic nerve fibres by sustained depolari z a t i o n of the r e s t i n g m e m b r a n e . Its dual manifestations on the CNS alternate between sympathetic and parasympathetic stimulation. Lower doses activate the sympathetic nervous system, while higher doses activate predominantly the parasympathetic nervous system. The mechanism is that the v e n o m increases epinephrine and norepinephrine secretion via acetylcholine receptor stimulation.IS, 25 The different toxins in the v e n o m have selective activity on m a m m a l s , vertebrates and invertebrates. The v e n o m also contains biogenic amines causing intense local pain, especially 5-hydroxytryptamine. The toxin that affects m a m m a l s is inactive in arthropods, w h i l e the t o x i n lethal to i n s e c t s is inactive in crustaceans and arachnids. The fraction that affects m a m m a l s is the most potent.21, 50 52,54 Distribution to tissues is very rapid, e l i m i n a t i o n r e l a t i v e l y slow. 39, 53, 54 Antivenin, aspirin and quinine counteract the lethal dose, but must be given quickly. 27,55
Materia medica based on h u m a n envenomation by Androctonus scorpion Toxicology Mind Abnormal behaviour such as agitation, aggression and incoherent speech. 56 Agitation and restlessness, worse at night: 43.5%.57,58 Agitation alternating with somnolence (child). 58 Anxiety and apprehension: 8%. 6o
Cannot survive till morning!'58 Changing position in bed continuously, from lying, to sitting, to standing, to leaving the bed. 56 Confusion: 30.4%. 18 Crying and shouting (adult man and child): 6%.58,60,61 Depression, despondency, lethargy, torpor: marked.2J, 58,66 Distress. 63 Disturbance of consciousness, delirium./8, 2~,58 Dysphoria, incoherent speech: 18%.56,6o Excitement (adult and child), s9,62 Fear with w o r r y . 63-65 Irritability, marked: 87%. 2~,25,66 Loss of orientation as to time, place and person. 56 Restlessness, cannot be confined to bed, for days (adult and child). 56,60,63 State of general excitement. 62
Vertigo Dizziness, drowsiness (adult & child): 1%.59,60 Vertigo (child). 58 Central nervous system Autonomic and CNS functional disorders. J8 Coma, disturbed, loss of consciousness (adult & child): 13%.18, 21,25,29 Convulsions (adult & child): 3-21%. 18,25,58,66 Opisthotonus: 13%.18 Paralysis of the right side of body, persistent. 58 Rigors, tremors, seizures, spastic paralysis (adult & child) generalized. 21,59,6o Head Cephalgia, headaches: 1%; violent.58,6~ Eyes Eyelids myoclonic twitching (child). 62 Eyes, injected, bulging with periorbital swelling.58,60 Haggard. 58 Lachrymation: 15-61%? 8,66 Miosis: 21.7%. 18 Strabismus: 17.4%.57
Nose Nostrils myoclonic twitchings (child). 62 Rhinorrhoea: 52%. 18,21 Sneezing, very violent and uncontrollable, incoercible. 67 Face
Myoclonic twitching (child). 62 Cyanotic faceP 8,63 Face drawn. 58 Flushed face. 63
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146 Formication (child)P s Lips cyanosed (child). 5s Myoclonic twitching (child). 62 Pale face (child). is, 58,62
Urinary retention. 59
Kidneys Bilateral loin pain and tenderness. 59
Mouth
Urine
Dry mouth, dry tongue (adult): 30.4%. 18,58 Difficulty in articulating, in speech, cannot utter a single word: persistent. 58 Excessive salivation & frothing (adult & child). 18,
Microscopic haematuria. 6~ Urine; red & albuminuric. 58
21, 58, 62, 66
Lips cyanosedP 8 Lips myoclonic twitchings (child). 62 Thirst, intense: 30.4%J s, 5s
Male Men and women equally affected. 22 Men affected twice as often as women. 60 Priapism. Adult: 27.4%; child: 8%. TM,25
Female Throat Laryngeal spasm: 8.7%. TM Swallowing difficulty (child). 62
Gastrointestinal system Exocrine glands oversecretion.2S Increased tone and motility of GI tract. 6a
Decreased uterine tone in non-pregnant uterus (experimental). 69 High rate of foetal resorption (experimental). 53 Increase in uterine tone during pregnancy (experimental). 69 Uterine bleeding: 4.3%. TM
Respiratory system Stomach Eating an effort. 62 Hiccoughs. 5s Nausea: 28.6%-60%. TM,2], 25 Thirsty, very (child). 62 Vomiting food all night, repeatedly, abundantly (adult & child): 40%.1s, 22,ss, 60,62 Vomiting saliva; very frequent. 5s Vomiting immediately after hot drinks, including tea and coffee (child). 5s
Breathlessness: 20%. 58, 63,66 Cyanosis: 4.3%? 8,21 Increased bronchial secretion: 60.9%. TM Pulmonary oedema (adult &child), with abnormal ECG recordings. 21,25,70 Respiratory rate decreased accompanied by an increase in depth of respiration (experimental). 69 Respiratory rate increased, hurried, tachypnoeic.2~, 25,62,66 Respiratory distress. 21 Suffocating sensation. 58
Abdomen Abdomen distended, rigid and painful.2S, 58,59 Epigastric pain & tenderness. 5s, 59
Larynx Speech difficult. 6: Stridor. 70
Rectum Constipation. -s9 Gases expulsion very frequent (child). 62 Increased and involuntary defecation: 13%. 18,5s Rectal temperature low: 18%. 66
Respiration Obstructive dyspnoea: 34.8%.1 s Respiration laboured and spastic (child). 6z Respiration (child); panting, stertorous. 58 Respiration; shallow and at 34 breaths per mhmteP8, 59
Stools Diarrhoea & loose stools: abundant.2s, 21, 58
Cough Fits of coughing with rapid breathing. 5s
Urinary system Increased urinary frequency (adult and child). 18,62 Urinary incontinence: 13%. TM Urinary output; less than 20ml/h. 68
Expectoration Bronchorrhoea.lS, 21
Chest Bladder Desire to urinate. 5s
Feeling of oppression. 63 Pain in thorax; very severe. 58
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Volume 86, July 1997 Cardiovascular system 3-phase change in ECG. Acute sinus bradycardia with a gradually increasing atro-ventricular block until it becomes complete, then a phase with hyperexcitability of the myocardium and ventricular extrasystoles and finally a return to a sinus rhythm with secondary bradycardia (experimental).71 Bradycardia, sinus: 4%-13%, down to 40 beats per minute. 18,65 Cardiopulmonary shock: 18%. 25 Cardiovascular collapse. 21 Chest pain, none, despite ECG changes. 21 Cyanosis, peripheral, 68 Heart sounds (child), muffled. 58 M a r k e d c o n g e s t i o n of p e l v i c b l o o d vessels (experimental).53 Murmur, systolic 1/6, best heard at apex. 65 Palpitations.63 Peripheral circulatory failure, with a mean arterial pressure of less than 70 mmHg. 68 Tachycardia > 140/rain.: 49%. 18,21,25,65 Weak heart. 58 Haemodynamics Cardiac i n d e x d i m i n i s h e d s l i g h t l y d e s p i t e increased heart rate: 1.35-2.9 1/min/m2. 6s Left v e n t r i c u l a r c o n t r a c t a b i l i t y m a r k e d l y impaired. 68 Pulmonary arterial occluded pressure (PAOP) increased: 22-28 mmHg. 68 Right ventricular ejection fraction (RVEF) markedly decreased. 72 Stroke volume index (SVI) markedly decreased: 9-34 ml/m2. 68 BP Short-term hypotension followed by pronounced hypertensive response (experimental).69 Arterial hypertension. 21 High BP: 14%. 65,66 Hypertension, majority of children below age 11; up to 160/80. 59 Hypertension (adults and old people), occasionally.59 Low BP: 7%. 66 Significantly low or high blood pressure: 30%. 25 Systolic arterial pressure marked decreased. 68 Systolic pressure 80 m m n g . 73 Pulse Pulse 'miserable' and irregularP 8 Pulse rate 54/rain. 73 Pulse very feeble, unrecordable (adult and child)P 8 Heart/pulse rates increased (adult and child): 120-180 beats/min. 58,59,68
ECG Any abnormality of ECG tracing returned to normal within a week. 7~ Conduction defects (child). 7~ ST segment either depressed (55.6%) or elevated (44%).21,65, 68 Signs of myocardial ischaemia. 21 Sinus tachycardia (child). 7~ Triphasic E C G rhythm. I n i t i a l l y early sinus bradycardia and AV block, then ventricular hyperexcitability with ventricular extrasystoles, finally return to sinus rhythm with secondary bradycardia. Fibrillation possible (experimental).71 T waves either inverted, tall and peaked, or flat.21, 65, 73
Echocardiography Left v e n t r i c u l a r systolic f u n c t i o n m a r k e d l y impaired with a decreased fractional shortening and ejection fraction. 68 Left ventricular contractability impaired, with a simultaneous involvement of both interventricular septum and left ventricular posterior wall. 68 Mitral regurgitation, mild and transient.68 Peak rapid filling velocity (diastolic) significantly lower at 788 cm/s. ( n o r m a l PRFV: 92 + 14 ClDffS). 68
Peak atrial filling velocity (diastolic) significantly lower at 46 + 7 cm/s (normal PAFV: 59 +_ 16 c m / s ) . 68
Musculoskeletal system General muscle paralysis: 34.8 %. ~8, 21 Intense muscular spasm, affecting both smooth and striated muscles (experimental).74 Muscle function disturbances.IS Muscle twitching, spasms and contractions, local and general. 18.21 Musculoskeletal abnormalities at birth, including flattened and depressed skulls, vertebral defects, ossification defects involving vertebral column, limbs and sternum (experimental).53 Myoclonic twitching in facial muscles (child). 62 Opisthotonos. J8 Spastic paralysis, sustained for hours, with no sequels. 18, 21 Tonic twitchings of all muscles of body (child). 62 Back ShiversP 8 Extremities Athetotic, spontaneous movements in fingers ( c h i l d ) . 62
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148 Carpopedal spasms. TM Cold extremities (adult and child), intense: 58%. 58, 66 Extension of interphalangeal joints.~8 Extremities (upper, lower and head): spasmodic, agitated movements of small amplitude. 58 Feet feel like a block of ice. 58 Flexion of the wrist and carpometacarpal joints.IS Formication in all limbs, fingers and toes (adult and child). 58,62,63 Myoclonic twitchings in muscles of upper and lower extremities (child). 62 Numbness in upper left and lower limbsP 8, 59 Paraplegia of lower limbs with sensation loss. 59 Swelling, local. 65 Tension in limbs. 21 Tenderness, local. 65 Myoclonic twitchings, shivering, especially of hands and feet (child). 62,73
purplish (adult and child). 62,63 Tendemess: 7%. 60
Pain Immediate very severe pain persisting for a long time. 18, 62 Bone ache, continuing for d a y s . 59 Burning pain. 21,76 Crying with pain (adults)9 Intense local pain, radiating proximally.I, 25,59,60,63 Pain accompanied by local numbness and/or slight local hyperthermia. 21 Pain giving way to numbness. 63 Pains persistent. ~8 Pain variable in intensity and duration. May persist for several hours. 21 Pain very severe, lasting a long time. 61 Tenderness, local, common occurrence. 59 Very severe pain (child). 62
Reticuloendothelial system Lymph nodes; tender and enlarged. 63
Sleep Cannot fall asleep (child). 62
Chills Chilly sensation in limbs, progressive. 88 Chilly sensation ascending, starting in l o w e r limbs. 58 Cold sensation all over body, persistent. 58 Cold invading patient despite being well covered and curled up. 58
Fever Fever, mild. 59 Hyperthermia, temperature over 40 ~ 21 Hyperthermia (child), temperature over 40.6 ~ 58 Low rectal temperature: 18%. 66 Rectal temperature (adult and child) > 38 ~ and < 41.6 ~ 58 Rigors and shivers. 21,63,66
Perspiration Icy cold sweats all over body dtLdng mild pyrexia. 58,63 P e r s p i r a t i o n profuse and copious (adult and child).21, 58,62,73 Sweating: 21.7%. 18
Haematology Coagulation abnormalities with low platelet count, prothrombin time. 25,65,70 Eosinophilia of up to 7% in a child. TM Leucocytosis; marked and regularly present up to 20,000 per mm3. 21,70
Biochemistry Alkaline phosphatase plasma levels increased. TM Amylase (serum) markedly elevated. 59 Calcium levels: normal calcium initially followed by hypocalcaemia due to urinary loss and reduced i n t e s t i n a l a b s o r p t i o n of c a l c i u m r e a c h i n g 1.7mmol/1 and less. Hypocalcaemia not detected in ECGs. 21,25,70 Creatinine kinase (CPK) markedly elevated at 150 IU (normal: 80). 59,7o.73 Glucose, hyperglycaemia for a short period, moderate to s e v e r e , as a r e s u l t of e n h a n c e d glycogenolysis, insulin inhibition and glucagon stimulation.21, 39, 59, 70 Hyponatraemia: occasional. 59 Lactic dehydrogenase (LDH) markedly elevated. 59 Phosphorus, serum inorganic, lowered. 25 Potassium serum levels initial increase followed by a decrease. Hyperkalaemia not detected in ECGs. 7~ S o d i u m l e v e l s , initial d e c r e a s e f o l l o w e d by increase. TM
Skin Cold clammy skin. 6~ 66 Erythema, generalized. 59 Redness with swelling (adult and child): 24%. 59, 6o Sweaty skin: 25%. 66 Swelling of part, spreading proximally, turning
Bacteriology Urine cultures: no growth. 59
General AlgeticP 8
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Volume 86, July 1997 General weakness, heaviness exhaustion.59,60,62,63 Looks ill and feels seriously ill. 18,63 Malaise. 59 Tingling 1%.6o
and
total
Amelioration Illness in general better for restriction of fluid intake, down to not more than one third of the normal requirement of fluid for age and weight. 75 Laterality Left side of body affected more frequently than right. 60 Upper left limb numbness.59 Numbness Numbness of limbs, upper left limb; oppressive.58,s9,6o Numbness follows pain.63 Temperature (climate) Occurs more frequently in hot summer months, May to October (76%), especially August and September, with only 6% in December to February.IS, 21,60, 76 Time
Worst between 6 p.m. and 6 a.m., maximally between 8 p.m. and 2 a.m. 60 References 1 Dantas F. How can we get more reliable information from homoeopathic pathogenic trials? Br Hom J 1996; 85: 230-6. 2 Azam Skorpionsgift und pathogenitiit des Prionurus australis. Die Bedeutung der Hom6opathie ftir die ~irztliche Praxis. Proceedings of XIIth Int'l. Homoeopathic Congress, Berlin. 8-15 Aug. 1937; 504-34. 3 Azam Venin de scorpion et pathog~n6sie du Prionurus ou Buthus australis. L ' H o m o e Franfaise 1939; 19: 1, 3-15. 4 Azam Venin de scorpion et pathog6n6sie du Prionums ou Buthus australis. Suite. L'Homoe Franfaise 1939; 19: 2, 91-107. 5 Azam Scorpion venom and the pathogenesis of Buthus australis. J Amer Inst Homeo with Homeo Recorder 1960; Jan-Feb: 7-13. 6 Sherr J. The Homoeopathic Provings o f Scorpion. 2nd edition. The Society of Homoeopaths 1985. 7 ShelT J. The proving of Scorpion. 40th LMHI Congr. Lyon 1985. 8 Clarke JH. A Dictionary of Practical Materia
Medica. Vol. II. part 2. The Homoeo. Pub Co 1902:1126-7. 9 Gigliardi-G. Therapeutic possibilities of the scorpion venoms. JAmer Inst Hom 1939; 32: 6, 332--40. 10 Levy G, Amitai P. Fauna Palaestina. Arachnida I: Scorpiones. IsrAcad Sci Hum 1980; 21-46. 11 Schroyen F. Homeopathicum Repertorium Syntheticum. Ed. 52 Homeopathic Book Pub, 1993. 12Rochat H, Rochat C, Kupeyan C, Miranda F, Lissitzky S, Edman P. Scorpion neurotoxins: a family of Homologous proteins. Fed'n Eur. Biochem Soc 1970; 10: 5, 349-51. 13Dorst MJ. Accouplement interspdcifique suivi de parturition dans le genre Androctonus (Scorpionida, Buthidae). Note de MM. Gilles Le Pape et Max Goyffon. CR. Acad. Sc. Paris, 1975; 280D: 2005-8. 14Watt DD, Simard JM. Neurotoxic proteins in scorpion venom. J Toxicol Toxin Reviews 1984; 3:2 & 3, 181-221. 15Zerrouk H, Bougis PE, C6ard B, Benslimane A, Martin-Eauclaire MF. Analysis by high-performance liquid chromatography of Androctonus mauretanicus mauretanicus (black scorpion) venom. Toxicon 1991; 29: 951-60. 16 Peters W. A colour atlas of arthropods in clinical medicine. London: Wolfe Pub. Ltd. 1990: 228. 17Farzanpay R, Vachon M. Contribution h l'&ude des caract6res sexuels secondaires chez les scorpions Buthidae (Arachnida). Revue Arachnologique 1979; 2: 4, 137-42. 18Radmanesh M. Androctonus crassicauda sting and its clinical study in Iran. J Trop Med Hygiene 1990; 93: 323-6. 19 Levi HW, Levi LR. A guide to spiders and their kin. New York: Golden Press. 1968: 1-160. 20 Keegan HL. Scorpions of medical importance. Mississippi: Univ Press 1980: 43-54. 21Goyffon M, Vachon M, Broglio N. Epidemiological and clinical characteristics of the scorpion envenomation in Tunisia. Toxicon 1982; 20: 1,337-44. 22 Rosso JP, Rochat H. 1982 Characterization from the venom of Androctonus mauretanicus mauretanicus of ten proteins including six neurotoxins. Toxicon 1982; 20: 76-77. 23 Sampieri F, Habersetzer-Rochat C. Structurefunction relationships in scorpion neurotoxins: Identification of the superreactive Lysine residue in toxin-I of Androctonus australis Hector. Biochimica et Biophysica Acta 1978; 535: 100-9.
150 24Meglitsch PA. Invertebrate Zoology. Oxford University 1967:711-47. 25E1-Amin EO, Elidrissy A, Hamid HS, Sultan OM, Safar RA. Scorpion sting: a management problem. Annals Trop. Paediatrics 1991; 11: 143-8. 26Barnes RD. Invertebrate Zoology. WB Saunders Co 1963: 340-79. 27Balozet L. Le scorpionisme en Afrique du Nord. Bull Soc Path Exot 1964; 57: 33-38. 28 Mercier-J, Dessaigne-S. Influence exercre par quelques drogues psycholeptiques sur le comportement du scorpion Androctonus australis Hector." CR Soc Bio11970; 164: 341-44. 29 Sampieri-F, Habersetzer-Rochat-C, Astier-JP, Frey-M, Haser-R. PreliminaryX-ray diffraction on a scorpion neurotoxin: Toxin II of Androctonus australis Hector. J Mol Biol 126: 289-91. 30Fleissner G. The absolute sensitivity of the median and lateral eyes of the scorpion, Androctonus australis L. (Buthidae, Scorpiones). J Comp Physiol 1977; BllS: 109-120. 31 Lankester ER. Notes on some habitats of the scorpion Androctonus funestus and Euscorpius italicus. Journ Linn Soc Zool 1883; XVI: 455-62. 32Attenborough D. Life on Earth. London: Collins 1979: 65-69. 33Alexander AJ. Courtship and mating in the Buthid scorpions. Proc Zool Soc London 1959; 133: 145-169. 34Warburg MR. Behavioural patterns of scorpions. Acta Zool Fennica 1990; B190: 387-392. 35 Francke OF. Parturition in scorpions (Arachnida, Scorpiones): a review of ideas. Revue Arachnologique 1982; 4: 27-37. 36Dorst MJ. Accouplement intersprcifique suivi de parturition dans le genre Androctonus (Scorpionida, Buthidae). Note de MM. Gilles Le Pape et Max Goyffon. CR. Acad. Sc. Paris 1975; 2801): 2005-2008. 37 Auber-Thomay M. Croissance et reproduction d'Androctonus australis (L.) (Scorpiones, Buthidrs). Ann Sci Nat Zool Paris 1974; 12: 16, 45-54. 38Ismail M, E1-Asmar MF, Abdul-Rahman AA. I m m u n o l o g i c a l studies with scorpion Androctonus amoreuxi (Aud. &Sav.) venom. Toxicon 1975; 13: 405-408. 39Ismail M, Abdullah ME, Morad AM, Ageel AM. Pharmacokinetics of I(125)-labelled venom from the scorpion Androctonus amoreux. Aud & Sav Toxicon 1980; 18:
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301-308. 40Miranda F, Rochat H, Lissitzky S. Sur les neurotoxines de deux esp~ces de scorpions Nord-Africains. II. Proprirtrs des neurotoxines (scorpamines) d'Androctonus australis (L.) et de Buthus occitanus (Am.). Toxicon 1964; 2: 113-21. 41Zlotkin E. A factor toxic to crustacean in the venom of the scorpion Androctonus australis Hector. Toxicon 1972; 10: 211-16. 42 Kopeyan C, Martinez G, Rochat H. Amino acid sequence of neurotoxin III of the scorpion Androctonus australis Hector. Eur J Biochem 1979; 94: 609-15. 43 Tessier M, Delori P, Bechis G, Rochat H. A sensitive radioimmunoassay of a scorpion neurotoxin. Toxin I of Androctonus australis Hector. Elsevier/North-Holland Biomedical Press 1978; 85: 1,163-66. 44 Rochat C, Rochat H, Miranda F, Lissitzky S. Purification and some properties of the neurotoxins of Androctonus australis Hector. Biochemistry 1967; 6: 2, 578-85. 45 Rochat H, Rochat C, Miranda F, Lissitzky S, Edman P. The amino acid sequence of neurotoxin I of Androctonus australis Hector. Eur J Biochem 1970; 17: 262-6. 46 Kopeyan C, Martinez G, Lissitzky S, Miranda F, Rochat H. Disulfide bonds of toxin II of the scorpion Androctonus australis Hector. Eur J Biochem 1974; 47: 483-9. 47E1-Ayeb M, Martin MF, Delori P, Bechis G, Rochat H. Immunochemistry of scorpion alpha neurotoxins. Determination of the antigenic site number and isolation of a highly enriched antibody specific to a single antigenic site of toxin II of Androctonus australis Hector. Mol Immunology 1983; 20: 7, 697-708. 48Cheymol J, Bourillet F, Roch-Arveiller M, Heckle J. Action cardiovasculaire de trois venins de scorpions Nord Africains (Androctonus australis, Leiurus quinquestriatus, Buthus occitanus) et de deux toxines extraites de l'un d'entre eux. Toxicon 1974; 12: 241-8. 49Tulga T. Cross reaction between anti-scorpion (Buthus quinquestriatus) and anti-scorpion (Prionurus crassicauda) sera. Tiirk Hig Tecr Biol 1960; 20: 191-203. 50Pelhate M, Zlotkin E. Action of insect toxin and other toxins derived from the venom of the scorpion Androctonus australis on isolated giant axons of the cockroach (Periplaneta americana). JExp Biol 1982; 97: 67-77.
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51Zlotkin-E, Miranda-F, Lissitzky-S. A factor toxic to crustacean in the venom of the scorpion Androctonus australis Hector. Toxicon 1972; 10:211-16. 52Bernard P. Effect of a scorpion toxin from Androctonus australis venom on action potential of neuroblastoma cells in culture. Biochem Biophys Res Comm 1977; 77: 2, 782-88. 53Ismail M, Shibl AM, Morad AM, Abdullah ME. Pharmacokinetics of I-labelled antivenom to the venom from the scorpion Androctonus amoreuxi. Toxicon 1983; 21: 1, 47-56. 54Phisalix M. Animaux venimeux et venins. Masson & Co Lib Acad Mgd 1922; 1: 234-255. 55 Guieu R, Kopeyan C, Rochat H. Utilization of aspirin, quinine and verapamil in the prevention and treatment of scorpion venom intoxication. Life Sciences 1993; 53: 26, 1935-46. 56 Radmanesh M. Dept Dermatology. Emam Hosp. Ahwaz. Iran. Personal Communications, 1996. 57Ruhland M, Zlotkin E, Rathmayer W. The effect of toxins from the venom of the scorpion Androctonus australis on a spider nerve-muscle preparation. Toxicon 1977; 15: 157-60. 58 Sergent E. Venin de scorpion et strum antiscorpionique. Arch Inst Pasteur d'Alggrie 1938; 16: 3,257-78. 59 Ismail M, Abd-Elsalam MA, A1-Ahaidin MS. Androctonus crassicauda (Oliver), a dangerous and unduly neglected scorpion--I. Pharmacological and clinical studies. Toxicon 1994; 32: 12, 1599-618. 60Neale JR. Scorpion sting syndrome in eastern Riyadh. Ann Saudi Med 1990; 10: 4, 383-88. 61Ismail MH, Antivenom & Vaccine P r o d ' n Centre. King Fahad Hospital. PO Box 22490. Riyadh. 11426. Saudi Arabia. Personal Communications, 1996. 62 Efrati P. Acute hypothalamic discharge in man due to scorpion stings. Am J Trop Med 1949; 29: 2, 152-67. 63 Pringle G. Notes on the scorpions of Iraq. Bull Endem Dis 1960; 3: 73-87. 64Ismail M, Ellison AC, T i l m i s a n y AK. Teratogenicity in the rat of the venom from the
Address f o r correspondence Dr M. S. Bonnet Avon Prior Durley Park Keynsham Bristol BS18 2AT
151 scorpion androctonus amoreuxi (Aud & Sav). Toxicon 1983; 21: 2, 177-89. 65 Blum A, Lubezki A, Slarovsky S. Black scorpion envenomation: two cases and review of the literature. Clin Cardio11992; 15: 377-278. 66 E1-Amin EO. Issues in management of scorpion sting in children. Toxicon 1992; 30: 1,111-115. 67Sergent E. Etude du venin des scorpions d'Alg~rie. Arch Inst Past d'Alg~rie 1935; 13: 1, 39-41. 68Abroug F, A y a r i M, Nouira S, Gamra H, B o u j d a r i a R, Elatrous S, Ben F a r h a t M, Bouchoucha S. Assessment of left ventricular function in severe scorpion envenomation: combined hemodynamic and echo-Doppler study. Intensive Care Med 1995; 21: 629-35. 69Ghazal A, Ismail M, Abdel-Rahman A, E1A s m a r MF. P h a r m a c o l o g i c a l studies of scorpion (Androctonus amoreuxi Aud. &Sav.) venom. Toxicon 1975; 13: 253-9. 70 E1-Amin EO, U-Din-Khan M. Hematological and biochemical findings in scorpion string children. Ann SaudiMed 1991; 11: 99, 625-27. 71 Roch-Arveiller M, Jaillon P, Heckl6 J, Cheymol G. Effets du venin de scorpion Androctonus mauretanicus sur l'61ectrocardiogramme de rat. CR Soc Biol 1974; 168: 1234-8. 72Nouira S, Abroug F, Haguiga H, Jaafoura M, Boujdaria R, Bouchoucha S. Right ventricular dysfunction following severe scorpion envenomation. Chest 1995; 108: 3, 682-7. 73 Flugelman MY, Naparstek Y, Braverman AJ. Myocardial damage after Androctonus crassicauda crassicauda sting. Isr J Med Sci 1982; 18: 503-4. 74 Tazieff-Depierre F. Propridt~s pharmacologiques des toxines du venin de scorpion Androctonus australis. Notes prrsentres par MJ Trrfou~l. CR Acad Sc Paris. Srrie D, 1968: 240-3. 75E1-Amin EO, Sultan OM, E l i d r i s s y A. Serotherapy in the management of scorpion sting in children in Saudi Arabia. Ann Trop Paed 1994; 14: 21-4. 76 Efrati P. Poisoning by scorpion stings in Israel. Amer J Trop Med Hyg 1949; 29: 2, 249-57.
Toxicology of Androctonus scorpion M. S. BONNET, BSC, MB, CHB
Abstract The following paper is a summary of studies of the biology of the Androctonus scorpion and its toxicology. A materia medica based on human envenomation by Androctonus is also provided.
Introduction This paper has been compiled in order to add the biology and human toxicology to the relatively new homoeopathic provings of the 'Scorpion' medicines. In 1939 Azam underwent a hom0eopathic pathogenetic trial using the scorpion Prionurus australis (known at the time as Buthus australis). 1 5 He mentioned experiments, observations and gave a detailed list of several hundred rubrics. In 1985 Jeremy Sherr published a monograph in which he detailed the actions of potentized Androctonus amoreuxi on healthy volunteers. 6, 7 Clarke included Scorpio in his Dictionary of Practical Materia Medica. 8 Gagliardi touched on the possibility of using various scorpion venoms, including that of Androctonus, as medicinal agents. 9 Scorpio became known as Prionurus, then as Buthus and finally Androctonus. 1~It is very likely that the above authors were using the same scorpion. Should not their good work be united in one homoeopathic medicine? Provings are the first step in introducing a new medicine to the homoeopathic materia medica which also takes account of toxicology and observations made in clinical use. In this paper the signs and symptoms experienced by patients unfortunate enough to have been stung by an Androctonus scorpion have been gathered from the scientific press. Medical papers have been consulted in order to extract the relevant rubrics. These have been rearranged in the style of the Synthesis Repertory. 11 Biological data on this scorpion were obtained from scientific publications. It was d e c i d e d to use the t o x i c o l o g y i n f o r m a t i o n f r o m e n v e n o m a t i o n by the genus Androctonus and not to limit the list to the species A. amoreuxi. The symptomatology of envenomation by different species of the genus Androctonus is very similar. 12 Mating between species of A n d r o c t o n u s results in viable progeny. 13
FIGURE1.The Androctonus scorpion. Relatively few of the approximately 1,400 different scorpion species in the world are capable of stinging humans with dangerous consequences. 6 of the 'Old World' genera d a n g e r o u s to h u m a n s are A n d r o c t o n u s , Buthus, Leiurus, Mesobuthus, Parabuthus and Hemiscorpion. 2 notable 'New World' genera are Centruroides and Tityus. TM
Biology of Androctonus scorpion Family A n d r o c t o n u s belongs to the s u p e r f a m i l y Buthoidea, family Buthidae and subfamily Buthinae.15,16 The Buthidae include more than 350 species represented in all continents except Antarctica. It is the largest family of scorpions and includes the most dangerous species of the order. Found in both the Old and New World, the Buthidae family represents almost half the known scorpions of the world 17 and can be represented by Androctonus and Buthus in North Africa and the Middle East; Centruroides in Central and North America; Leiurus in Africa and the Middle East; Parabuthus in South Africa and by Tityus (Subfamily Tityinae) in South America. 18-20
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Species of the genus Androctonus The more common species of Androctonus are A. aeneas el in Tunisia; A. amoureuxi 14 and A. australis14, 21 in the Middle East and North Africa; A. crassicaud 14, as in Turkey, Iran and Iraq; and A. mauritanicus 14, 22 HI North Africa and Morocco. Synonyms The genus Androctonus was first described in 1827 under the name of Scorpio, soon (1829) to be changed to Androctonus, then in 1895 to Prionurus. It was known as Buthus from 1899 until 1948, when the latter genus was split into 2 distinct genera. Since 1948 use of the name Androctonus, designated by Vachon, has been consistent.10 Vernacular
Black scorpion, fat tailed scorpion. Distribution A n d r o c t o n u s has a wide distribution. It is found in North Africa, 23 the Sahara 24 and the entire Middle East including Turkey, 2~ Iran is and the A r a b i a n Peninsula. 25 Its r a n g e extends from India to the Sudan and Senegal in AfricaJ 0 Description A most dangerous, formidable and venomous black scorpion. ~5, 20, 21. 24 Most notorious and most feared scorpion of North Africa responsible for the majority of accidents. 26, 27 Black, thick tailed or very thick tailed, with long dark claws and telson, it can reach a body length of 11 cm or more. The average weight of a scorpion (male or female) is 5-6 g.20, 21, 28 The colour of the adult varies from black to dark chocolate brown, olive or yellow, depending on geographical area. 20, 29 The terminal segments of the legs are lighter. The prosoma ('face') is densely granulated, with distinct crests and a pair of median eyes situated slightly anterior to the middle, plus three small and distinct lateral eyes on the outer anterior corners of the prosoma. 10 The scorpion eye is among the most sensitive of arthropod eyes, more sensitive than the largelens human eye. The lateral eyes of scorpions are more sensitive than the median eyes and are used for orientation in moonless nights, when Androctonus uses astromenotaxy to find its way and prey. 30
143 As a Buthidae, Androctonus has a triangular sternum, an accessory spine on its telson and hairs and bristles on the soles of its feet. ~~20 Habitat The scorpion is particularly abundant in stony soils, cactus hedges, arid mountainous regions and on high plateaux, avoiding moist coastal areas. It is found on steep slopes of drifting sand dunes, in burrows in red sandy soils, or in brown steppe soils. In stony deserts Androctonus favours living under large stones; occasionally dozens of specimens are concentrated in a small stony area surrounded by terrain without stones. ~0,20, 21, 29, 31 Behaviour They are secretive and nocturnal, hiding by day under wood and stones and in crevices in the ground. They are often found near human habitations. A n d r o c t o n u s is more active during the summer months, especially July to September. During the winter months they live quietly in shelters without really hibernating. The winter sting appears to be less dangerous. Androctonus is more active in the evening, when it goes in search of its prey, primarily other arthropods, especially larger insects. 16.21,26 Hunting behaviour Prey is caught by the powerful pedipalp and torn up using the chelicerae. Quiescent prey may not be stung, but struggling prey is quickly overpowered by stinging. The scorpion tears the prey into small pieces which are then partly digested by a secretion emitted from the mouth. The resulting semi-liquid material is ingested. The hunting instinct of the scorpion is less developed than that of other hunting arthropods. Androctonus does not chase its prey but either comes across it by chance or waits for it to cross its path; nor does it follow moving prey visually. Once the scorpion has decided to attack, it does so rapidly and accurately. 16,24,28 Mating behaviour Copulation is a dangerous enterprise. A scorpion approaching another with purely sexual intentions runs a real risk of ending up as a meal rather than a mate. Scorpion mating demands ritualized safeguards and placatory courtship. For scorpions, sexual recognition depends on
144 behavioural responses to each other when they meet, and possibly the emission of an odoriferous response from the female. The mated female appears to lose all attraction immediately after insemination. When a male and a female meet, they stop and 'observe' each other before the male grasps the female by the pedipalps. The tail of the Androctonus m a l e is a l w a y s held straight up during courtship, while the female uses her tail to try and parry him, at least at the beginning of the encounter. Thus 'holding hmads', he proceeds to walk backwards, pulling her forwards. The purpose of this 'promenade gt deux' is to allow him to search for a suitable spot to deposit his spermatophore. The promenade is interrupted by 'kissing' behaviour when the male pulls the female closer to him so that their mouth parts touch. Other interspersed behaviour is 'juddering'. A single bout of juddering consists of several rapid back and forth movements. After the male has deposited his spermatophore, pulled the female over it and made certain that it has been taken into the body of the female, he liberates her and runs away. 32 34
Digging behaviour Androctonus excavates tunnels horizontally just below the surface, in which it hides during the day. It commences by pushing its large chelae into the sand and scraping backwards with the 3 anterior pairs of walking legs. This action is very rapid, resulting in a shower of sand producing a curious rattling sound. 31 Female scorpion This scorpion is viviparous. The reproductive system of the female is a simple ovari-uterus without diverticula. Embryonic development occurs in its lumen and embryonic nutrition is provided by the yolk, supplemented by a diffuse placenta. The female is gravid for 242 days and the litter size varies between 30 and 46 young. Parturition occurs during the months of June to August, taking less than 24 hours, with the neonates randomly orientated at delivery. 29, 35 37 Maternal behaviour Very soon after the birth the newly-born scorpions rid themselves of their embryonic membranes and climb on to the m o t h e r ' s back. She makes sure they do not come in
British Homoeopathic Journal
contact with the ground by positioning her walking legs as a protective basket and ladder. While they are on her back, the mother protects her young, scoops them back up onto her back, makes sure they do not touch the ground during their first days and feeds them tit-bits. She never uses her sting while she has her brood on her back, neither to defend herself--she will prefer to retreat--nor to hunt she will elect a docile non-struggling prey. After about 25 days the young descend to forage and permanently leave the maternal transport and secnrity. 37
Male scorpion These scorpions exhibit little sexual dimorphism. The male has a hook on its opercular plate; the pectines (a two-comb-like appendage behind the posterior legs, on the under-belly of scorpions) of the male are longer and have more 'teeth' than those of the female. The life span of the male is about one year. This is short compared to that of the female who can survive 3 years and several litters. It is also short considering that it takes at least 242 days to reach maturity. 17, 26, 37 Androctonus v e n o m Androctonus has a most dangerous venom of at least equivalent toxicity to the cobra's. The toxicity varies with the geographical origin of the scorpion and depending on its nutritional state. The longer the fast, the less the quantity but the greater the toxicity. 2~ 26,27.37 Androctonus venom specifically stimulates the acetylcholine receptors throughout the body. Potent neurotoxic, neuromuscular and cardiotoxic venoms provoke spastic paralysis, acting at the voltage-sensitive sodium channel level to induce depolarization of excitable membranes.IS. 21.23,25.38,39The toxins are soluble in water and saline, stable at pH 8-9 and conserve their toxicity at 37 ~ They are denatured at 80 9C. The neurotoxins, each composed of a single polypeptide chain, contain 60 to 70 amino acid residues and are cross-linked by 4 disulphide bridges, but differ in their toxic activity. 4~ The lethal fraction also causes cardiac stimulation, uterine relaxation and increased twitching in the phrenic nerve. Fractions that 'specialize' in uterine relaxation or in causing contraction in skeletal muscle are called alpha and beta toxins. Alpha toxins prolong the action potential of nerves and muscles by
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Volume 86, July 1997 s l o w i n g d o w n i n a c t i v a t i o n of the s o d i u m channel, i.e. the repolarization phase. Beta toxins act on channel activation. 15,38,41, 47 Androctonus toxins are characterized by their action on the sympathetic ganglia (hypertension, peripheral vasoconstriction, lachrymation, s a l i v a t i o n , b r e a t h i n g s p a s m s and i n d i r e c t inotropic effect) and by their direct action on the heart (bradycardia, negative inotropism and arrhythmias leading to fibrillation).4s Scorpion venoms are more complex protein mixtures than snake venoms, and Androctonus venom has a more complex antigen composition than the rest of the Buthidae. Androctonus venom antigen is capable of neutralizing the v e n o m s of other B u t h i d a e genera, but the reverse is not the case. The median lethal dose (LDs0) is 0.3 1-0.32 mg/kg.14, 21 The v e n o m stimulates the postganglionic autonomic nerve fibres by sustained depolari z a t i o n of the r e s t i n g m e m b r a n e . Its dual manifestations on the CNS alternate between sympathetic and parasympathetic stimulation. Lower doses activate the sympathetic nervous system, while higher doses activate predominantly the parasympathetic nervous system. The mechanism is that the v e n o m increases epinephrine and norepinephrine secretion via acetylcholine receptor stimulation.IS, 25 The different toxins in the v e n o m have selective activity on m a m m a l s , vertebrates and invertebrates. The v e n o m also contains biogenic amines causing intense local pain, especially 5-hydroxytryptamine. The toxin that affects m a m m a l s is inactive in arthropods, w h i l e the t o x i n lethal to i n s e c t s is inactive in crustaceans and arachnids. The fraction that affects m a m m a l s is the most potent.21, 50 52,54 Distribution to tissues is very rapid, e l i m i n a t i o n r e l a t i v e l y slow. 39, 53, 54 Antivenin, aspirin and quinine counteract the lethal dose, but must be given quickly. 27,55
Materia medica based on h u m a n envenomation by Androctonus scorpion Toxicology Mind Abnormal behaviour such as agitation, aggression and incoherent speech. 56 Agitation and restlessness, worse at night: 43.5%.57,58 Agitation alternating with somnolence (child). 58 Anxiety and apprehension: 8%. 6o
Cannot survive till morning!'58 Changing position in bed continuously, from lying, to sitting, to standing, to leaving the bed. 56 Confusion: 30.4%. 18 Crying and shouting (adult man and child): 6%.58,60,61 Depression, despondency, lethargy, torpor: marked.2J, 58,66 Distress. 63 Disturbance of consciousness, delirium./8, 2~,58 Dysphoria, incoherent speech: 18%.56,6o Excitement (adult and child), s9,62 Fear with w o r r y . 63-65 Irritability, marked: 87%. 2~,25,66 Loss of orientation as to time, place and person. 56 Restlessness, cannot be confined to bed, for days (adult and child). 56,60,63 State of general excitement. 62
Vertigo Dizziness, drowsiness (adult & child): 1%.59,60 Vertigo (child). 58 Central nervous system Autonomic and CNS functional disorders. J8 Coma, disturbed, loss of consciousness (adult & child): 13%.18, 21,25,29 Convulsions (adult & child): 3-21%. 18,25,58,66 Opisthotonus: 13%.18 Paralysis of the right side of body, persistent. 58 Rigors, tremors, seizures, spastic paralysis (adult & child) generalized. 21,59,6o Head Cephalgia, headaches: 1%; violent.58,6~ Eyes Eyelids myoclonic twitching (child). 62 Eyes, injected, bulging with periorbital swelling.58,60 Haggard. 58 Lachrymation: 15-61%? 8,66 Miosis: 21.7%. 18 Strabismus: 17.4%.57
Nose Nostrils myoclonic twitchings (child). 62 Rhinorrhoea: 52%. 18,21 Sneezing, very violent and uncontrollable, incoercible. 67 Face
Myoclonic twitching (child). 62 Cyanotic faceP 8,63 Face drawn. 58 Flushed face. 63
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146 Formication (child)P s Lips cyanosed (child). 5s Myoclonic twitching (child). 62 Pale face (child). is, 58,62
Urinary retention. 59
Kidneys Bilateral loin pain and tenderness. 59
Mouth
Urine
Dry mouth, dry tongue (adult): 30.4%. 18,58 Difficulty in articulating, in speech, cannot utter a single word: persistent. 58 Excessive salivation & frothing (adult & child). 18,
Microscopic haematuria. 6~ Urine; red & albuminuric. 58
21, 58, 62, 66
Lips cyanosedP 8 Lips myoclonic twitchings (child). 62 Thirst, intense: 30.4%J s, 5s
Male Men and women equally affected. 22 Men affected twice as often as women. 60 Priapism. Adult: 27.4%; child: 8%. TM,25
Female Throat Laryngeal spasm: 8.7%. TM Swallowing difficulty (child). 62
Gastrointestinal system Exocrine glands oversecretion.2S Increased tone and motility of GI tract. 6a
Decreased uterine tone in non-pregnant uterus (experimental). 69 High rate of foetal resorption (experimental). 53 Increase in uterine tone during pregnancy (experimental). 69 Uterine bleeding: 4.3%. TM
Respiratory system Stomach Eating an effort. 62 Hiccoughs. 5s Nausea: 28.6%-60%. TM,2], 25 Thirsty, very (child). 62 Vomiting food all night, repeatedly, abundantly (adult & child): 40%.1s, 22,ss, 60,62 Vomiting saliva; very frequent. 5s Vomiting immediately after hot drinks, including tea and coffee (child). 5s
Breathlessness: 20%. 58, 63,66 Cyanosis: 4.3%? 8,21 Increased bronchial secretion: 60.9%. TM Pulmonary oedema (adult &child), with abnormal ECG recordings. 21,25,70 Respiratory rate decreased accompanied by an increase in depth of respiration (experimental). 69 Respiratory rate increased, hurried, tachypnoeic.2~, 25,62,66 Respiratory distress. 21 Suffocating sensation. 58
Abdomen Abdomen distended, rigid and painful.2S, 58,59 Epigastric pain & tenderness. 5s, 59
Larynx Speech difficult. 6: Stridor. 70
Rectum Constipation. -s9 Gases expulsion very frequent (child). 62 Increased and involuntary defecation: 13%. 18,5s Rectal temperature low: 18%. 66
Respiration Obstructive dyspnoea: 34.8%.1 s Respiration laboured and spastic (child). 6z Respiration (child); panting, stertorous. 58 Respiration; shallow and at 34 breaths per mhmteP8, 59
Stools Diarrhoea & loose stools: abundant.2s, 21, 58
Cough Fits of coughing with rapid breathing. 5s
Urinary system Increased urinary frequency (adult and child). 18,62 Urinary incontinence: 13%. TM Urinary output; less than 20ml/h. 68
Expectoration Bronchorrhoea.lS, 21
Chest Bladder Desire to urinate. 5s
Feeling of oppression. 63 Pain in thorax; very severe. 58
147
Volume 86, July 1997 Cardiovascular system 3-phase change in ECG. Acute sinus bradycardia with a gradually increasing atro-ventricular block until it becomes complete, then a phase with hyperexcitability of the myocardium and ventricular extrasystoles and finally a return to a sinus rhythm with secondary bradycardia (experimental).71 Bradycardia, sinus: 4%-13%, down to 40 beats per minute. 18,65 Cardiopulmonary shock: 18%. 25 Cardiovascular collapse. 21 Chest pain, none, despite ECG changes. 21 Cyanosis, peripheral, 68 Heart sounds (child), muffled. 58 M a r k e d c o n g e s t i o n of p e l v i c b l o o d vessels (experimental).53 Murmur, systolic 1/6, best heard at apex. 65 Palpitations.63 Peripheral circulatory failure, with a mean arterial pressure of less than 70 mmHg. 68 Tachycardia > 140/rain.: 49%. 18,21,25,65 Weak heart. 58 Haemodynamics Cardiac i n d e x d i m i n i s h e d s l i g h t l y d e s p i t e increased heart rate: 1.35-2.9 1/min/m2. 6s Left v e n t r i c u l a r c o n t r a c t a b i l i t y m a r k e d l y impaired. 68 Pulmonary arterial occluded pressure (PAOP) increased: 22-28 mmHg. 68 Right ventricular ejection fraction (RVEF) markedly decreased. 72 Stroke volume index (SVI) markedly decreased: 9-34 ml/m2. 68 BP Short-term hypotension followed by pronounced hypertensive response (experimental).69 Arterial hypertension. 21 High BP: 14%. 65,66 Hypertension, majority of children below age 11; up to 160/80. 59 Hypertension (adults and old people), occasionally.59 Low BP: 7%. 66 Significantly low or high blood pressure: 30%. 25 Systolic arterial pressure marked decreased. 68 Systolic pressure 80 m m n g . 73 Pulse Pulse 'miserable' and irregularP 8 Pulse rate 54/rain. 73 Pulse very feeble, unrecordable (adult and child)P 8 Heart/pulse rates increased (adult and child): 120-180 beats/min. 58,59,68
ECG Any abnormality of ECG tracing returned to normal within a week. 7~ Conduction defects (child). 7~ ST segment either depressed (55.6%) or elevated (44%).21,65, 68 Signs of myocardial ischaemia. 21 Sinus tachycardia (child). 7~ Triphasic E C G rhythm. I n i t i a l l y early sinus bradycardia and AV block, then ventricular hyperexcitability with ventricular extrasystoles, finally return to sinus rhythm with secondary bradycardia. Fibrillation possible (experimental).71 T waves either inverted, tall and peaked, or flat.21, 65, 73
Echocardiography Left v e n t r i c u l a r systolic f u n c t i o n m a r k e d l y impaired with a decreased fractional shortening and ejection fraction. 68 Left ventricular contractability impaired, with a simultaneous involvement of both interventricular septum and left ventricular posterior wall. 68 Mitral regurgitation, mild and transient.68 Peak rapid filling velocity (diastolic) significantly lower at 788 cm/s. ( n o r m a l PRFV: 92 + 14 ClDffS). 68
Peak atrial filling velocity (diastolic) significantly lower at 46 + 7 cm/s (normal PAFV: 59 +_ 16 c m / s ) . 68
Musculoskeletal system General muscle paralysis: 34.8 %. ~8, 21 Intense muscular spasm, affecting both smooth and striated muscles (experimental).74 Muscle function disturbances.IS Muscle twitching, spasms and contractions, local and general. 18.21 Musculoskeletal abnormalities at birth, including flattened and depressed skulls, vertebral defects, ossification defects involving vertebral column, limbs and sternum (experimental).53 Myoclonic twitching in facial muscles (child). 62 Opisthotonos. J8 Spastic paralysis, sustained for hours, with no sequels. 18, 21 Tonic twitchings of all muscles of body (child). 62 Back ShiversP 8 Extremities Athetotic, spontaneous movements in fingers ( c h i l d ) . 62
British HomoeopathicJournal
148 Carpopedal spasms. TM Cold extremities (adult and child), intense: 58%. 58, 66 Extension of interphalangeal joints.~8 Extremities (upper, lower and head): spasmodic, agitated movements of small amplitude. 58 Feet feel like a block of ice. 58 Flexion of the wrist and carpometacarpal joints.IS Formication in all limbs, fingers and toes (adult and child). 58,62,63 Myoclonic twitchings in muscles of upper and lower extremities (child). 62 Numbness in upper left and lower limbsP 8, 59 Paraplegia of lower limbs with sensation loss. 59 Swelling, local. 65 Tension in limbs. 21 Tenderness, local. 65 Myoclonic twitchings, shivering, especially of hands and feet (child). 62,73
purplish (adult and child). 62,63 Tendemess: 7%. 60
Pain Immediate very severe pain persisting for a long time. 18, 62 Bone ache, continuing for d a y s . 59 Burning pain. 21,76 Crying with pain (adults)9 Intense local pain, radiating proximally.I, 25,59,60,63 Pain accompanied by local numbness and/or slight local hyperthermia. 21 Pain giving way to numbness. 63 Pains persistent. ~8 Pain variable in intensity and duration. May persist for several hours. 21 Pain very severe, lasting a long time. 61 Tenderness, local, common occurrence. 59 Very severe pain (child). 62
Reticuloendothelial system Lymph nodes; tender and enlarged. 63
Sleep Cannot fall asleep (child). 62
Chills Chilly sensation in limbs, progressive. 88 Chilly sensation ascending, starting in l o w e r limbs. 58 Cold sensation all over body, persistent. 58 Cold invading patient despite being well covered and curled up. 58
Fever Fever, mild. 59 Hyperthermia, temperature over 40 ~ 21 Hyperthermia (child), temperature over 40.6 ~ 58 Low rectal temperature: 18%. 66 Rectal temperature (adult and child) > 38 ~ and < 41.6 ~ 58 Rigors and shivers. 21,63,66
Perspiration Icy cold sweats all over body dtLdng mild pyrexia. 58,63 P e r s p i r a t i o n profuse and copious (adult and child).21, 58,62,73 Sweating: 21.7%. 18
Haematology Coagulation abnormalities with low platelet count, prothrombin time. 25,65,70 Eosinophilia of up to 7% in a child. TM Leucocytosis; marked and regularly present up to 20,000 per mm3. 21,70
Biochemistry Alkaline phosphatase plasma levels increased. TM Amylase (serum) markedly elevated. 59 Calcium levels: normal calcium initially followed by hypocalcaemia due to urinary loss and reduced i n t e s t i n a l a b s o r p t i o n of c a l c i u m r e a c h i n g 1.7mmol/1 and less. Hypocalcaemia not detected in ECGs. 21,25,70 Creatinine kinase (CPK) markedly elevated at 150 IU (normal: 80). 59,7o.73 Glucose, hyperglycaemia for a short period, moderate to s e v e r e , as a r e s u l t of e n h a n c e d glycogenolysis, insulin inhibition and glucagon stimulation.21, 39, 59, 70 Hyponatraemia: occasional. 59 Lactic dehydrogenase (LDH) markedly elevated. 59 Phosphorus, serum inorganic, lowered. 25 Potassium serum levels initial increase followed by a decrease. Hyperkalaemia not detected in ECGs. 7~ S o d i u m l e v e l s , initial d e c r e a s e f o l l o w e d by increase. TM
Skin Cold clammy skin. 6~ 66 Erythema, generalized. 59 Redness with swelling (adult and child): 24%. 59, 6o Sweaty skin: 25%. 66 Swelling of part, spreading proximally, turning
Bacteriology Urine cultures: no growth. 59
General AlgeticP 8
149
Volume 86, July 1997 General weakness, heaviness exhaustion.59,60,62,63 Looks ill and feels seriously ill. 18,63 Malaise. 59 Tingling 1%.6o
and
total
Amelioration Illness in general better for restriction of fluid intake, down to not more than one third of the normal requirement of fluid for age and weight. 75 Laterality Left side of body affected more frequently than right. 60 Upper left limb numbness.59 Numbness Numbness of limbs, upper left limb; oppressive.58,s9,6o Numbness follows pain.63 Temperature (climate) Occurs more frequently in hot summer months, May to October (76%), especially August and September, with only 6% in December to February.IS, 21,60, 76 Time
Worst between 6 p.m. and 6 a.m., maximally between 8 p.m. and 2 a.m. 60 References 1 Dantas F. How can we get more reliable information from homoeopathic pathogenic trials? Br Hom J 1996; 85: 230-6. 2 Azam Skorpionsgift und pathogenitiit des Prionurus australis. Die Bedeutung der Hom6opathie ftir die ~irztliche Praxis. Proceedings of XIIth Int'l. Homoeopathic Congress, Berlin. 8-15 Aug. 1937; 504-34. 3 Azam Venin de scorpion et pathog~n6sie du Prionurus ou Buthus australis. L ' H o m o e Franfaise 1939; 19: 1, 3-15. 4 Azam Venin de scorpion et pathog6n6sie du Prionums ou Buthus australis. Suite. L'Homoe Franfaise 1939; 19: 2, 91-107. 5 Azam Scorpion venom and the pathogenesis of Buthus australis. J Amer Inst Homeo with Homeo Recorder 1960; Jan-Feb: 7-13. 6 Sherr J. The Homoeopathic Provings o f Scorpion. 2nd edition. The Society of Homoeopaths 1985. 7 ShelT J. The proving of Scorpion. 40th LMHI Congr. Lyon 1985. 8 Clarke JH. A Dictionary of Practical Materia
Medica. Vol. II. part 2. The Homoeo. Pub Co 1902:1126-7. 9 Gigliardi-G. Therapeutic possibilities of the scorpion venoms. JAmer Inst Hom 1939; 32: 6, 332--40. 10 Levy G, Amitai P. Fauna Palaestina. Arachnida I: Scorpiones. IsrAcad Sci Hum 1980; 21-46. 11 Schroyen F. Homeopathicum Repertorium Syntheticum. Ed. 52 Homeopathic Book Pub, 1993. 12Rochat H, Rochat C, Kupeyan C, Miranda F, Lissitzky S, Edman P. Scorpion neurotoxins: a family of Homologous proteins. Fed'n Eur. Biochem Soc 1970; 10: 5, 349-51. 13Dorst MJ. Accouplement interspdcifique suivi de parturition dans le genre Androctonus (Scorpionida, Buthidae). Note de MM. Gilles Le Pape et Max Goyffon. CR. Acad. Sc. Paris, 1975; 280D: 2005-8. 14Watt DD, Simard JM. Neurotoxic proteins in scorpion venom. J Toxicol Toxin Reviews 1984; 3:2 & 3, 181-221. 15Zerrouk H, Bougis PE, C6ard B, Benslimane A, Martin-Eauclaire MF. Analysis by high-performance liquid chromatography of Androctonus mauretanicus mauretanicus (black scorpion) venom. Toxicon 1991; 29: 951-60. 16 Peters W. A colour atlas of arthropods in clinical medicine. London: Wolfe Pub. Ltd. 1990: 228. 17Farzanpay R, Vachon M. Contribution h l'&ude des caract6res sexuels secondaires chez les scorpions Buthidae (Arachnida). Revue Arachnologique 1979; 2: 4, 137-42. 18Radmanesh M. Androctonus crassicauda sting and its clinical study in Iran. J Trop Med Hygiene 1990; 93: 323-6. 19 Levi HW, Levi LR. A guide to spiders and their kin. New York: Golden Press. 1968: 1-160. 20 Keegan HL. Scorpions of medical importance. Mississippi: Univ Press 1980: 43-54. 21Goyffon M, Vachon M, Broglio N. Epidemiological and clinical characteristics of the scorpion envenomation in Tunisia. Toxicon 1982; 20: 1,337-44. 22 Rosso JP, Rochat H. 1982 Characterization from the venom of Androctonus mauretanicus mauretanicus of ten proteins including six neurotoxins. Toxicon 1982; 20: 76-77. 23 Sampieri F, Habersetzer-Rochat C. Structurefunction relationships in scorpion neurotoxins: Identification of the superreactive Lysine residue in toxin-I of Androctonus australis Hector. Biochimica et Biophysica Acta 1978; 535: 100-9.
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301-308. 40Miranda F, Rochat H, Lissitzky S. Sur les neurotoxines de deux esp~ces de scorpions Nord-Africains. II. Proprirtrs des neurotoxines (scorpamines) d'Androctonus australis (L.) et de Buthus occitanus (Am.). Toxicon 1964; 2: 113-21. 41Zlotkin E. A factor toxic to crustacean in the venom of the scorpion Androctonus australis Hector. Toxicon 1972; 10: 211-16. 42 Kopeyan C, Martinez G, Rochat H. Amino acid sequence of neurotoxin III of the scorpion Androctonus australis Hector. Eur J Biochem 1979; 94: 609-15. 43 Tessier M, Delori P, Bechis G, Rochat H. A sensitive radioimmunoassay of a scorpion neurotoxin. Toxin I of Androctonus australis Hector. Elsevier/North-Holland Biomedical Press 1978; 85: 1,163-66. 44 Rochat C, Rochat H, Miranda F, Lissitzky S. Purification and some properties of the neurotoxins of Androctonus australis Hector. Biochemistry 1967; 6: 2, 578-85. 45 Rochat H, Rochat C, Miranda F, Lissitzky S, Edman P. The amino acid sequence of neurotoxin I of Androctonus australis Hector. Eur J Biochem 1970; 17: 262-6. 46 Kopeyan C, Martinez G, Lissitzky S, Miranda F, Rochat H. Disulfide bonds of toxin II of the scorpion Androctonus australis Hector. Eur J Biochem 1974; 47: 483-9. 47E1-Ayeb M, Martin MF, Delori P, Bechis G, Rochat H. Immunochemistry of scorpion alpha neurotoxins. Determination of the antigenic site number and isolation of a highly enriched antibody specific to a single antigenic site of toxin II of Androctonus australis Hector. Mol Immunology 1983; 20: 7, 697-708. 48Cheymol J, Bourillet F, Roch-Arveiller M, Heckle J. Action cardiovasculaire de trois venins de scorpions Nord Africains (Androctonus australis, Leiurus quinquestriatus, Buthus occitanus) et de deux toxines extraites de l'un d'entre eux. Toxicon 1974; 12: 241-8. 49Tulga T. Cross reaction between anti-scorpion (Buthus quinquestriatus) and anti-scorpion (Prionurus crassicauda) sera. Tiirk Hig Tecr Biol 1960; 20: 191-203. 50Pelhate M, Zlotkin E. Action of insect toxin and other toxins derived from the venom of the scorpion Androctonus australis on isolated giant axons of the cockroach (Periplaneta americana). JExp Biol 1982; 97: 67-77.
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51Zlotkin-E, Miranda-F, Lissitzky-S. A factor toxic to crustacean in the venom of the scorpion Androctonus australis Hector. Toxicon 1972; 10:211-16. 52Bernard P. Effect of a scorpion toxin from Androctonus australis venom on action potential of neuroblastoma cells in culture. Biochem Biophys Res Comm 1977; 77: 2, 782-88. 53Ismail M, Shibl AM, Morad AM, Abdullah ME. Pharmacokinetics of I-labelled antivenom to the venom from the scorpion Androctonus amoreuxi. Toxicon 1983; 21: 1, 47-56. 54Phisalix M. Animaux venimeux et venins. Masson & Co Lib Acad Mgd 1922; 1: 234-255. 55 Guieu R, Kopeyan C, Rochat H. Utilization of aspirin, quinine and verapamil in the prevention and treatment of scorpion venom intoxication. Life Sciences 1993; 53: 26, 1935-46. 56 Radmanesh M. Dept Dermatology. Emam Hosp. Ahwaz. Iran. Personal Communications, 1996. 57Ruhland M, Zlotkin E, Rathmayer W. The effect of toxins from the venom of the scorpion Androctonus australis on a spider nerve-muscle preparation. Toxicon 1977; 15: 157-60. 58 Sergent E. Venin de scorpion et strum antiscorpionique. Arch Inst Pasteur d'Alggrie 1938; 16: 3,257-78. 59 Ismail M, Abd-Elsalam MA, A1-Ahaidin MS. Androctonus crassicauda (Oliver), a dangerous and unduly neglected scorpion--I. Pharmacological and clinical studies. Toxicon 1994; 32: 12, 1599-618. 60Neale JR. Scorpion sting syndrome in eastern Riyadh. Ann Saudi Med 1990; 10: 4, 383-88. 61Ismail MH, Antivenom & Vaccine P r o d ' n Centre. King Fahad Hospital. PO Box 22490. Riyadh. 11426. Saudi Arabia. Personal Communications, 1996. 62 Efrati P. Acute hypothalamic discharge in man due to scorpion stings. Am J Trop Med 1949; 29: 2, 152-67. 63 Pringle G. Notes on the scorpions of Iraq. Bull Endem Dis 1960; 3: 73-87. 64Ismail M, Ellison AC, T i l m i s a n y AK. Teratogenicity in the rat of the venom from the
Address f o r correspondence Dr M. S. Bonnet Avon Prior Durley Park Keynsham Bristol BS18 2AT
151 scorpion androctonus amoreuxi (Aud & Sav). Toxicon 1983; 21: 2, 177-89. 65 Blum A, Lubezki A, Slarovsky S. Black scorpion envenomation: two cases and review of the literature. Clin Cardio11992; 15: 377-278. 66 E1-Amin EO. Issues in management of scorpion sting in children. Toxicon 1992; 30: 1,111-115. 67Sergent E. Etude du venin des scorpions d'Alg~rie. Arch Inst Past d'Alg~rie 1935; 13: 1, 39-41. 68Abroug F, A y a r i M, Nouira S, Gamra H, B o u j d a r i a R, Elatrous S, Ben F a r h a t M, Bouchoucha S. Assessment of left ventricular function in severe scorpion envenomation: combined hemodynamic and echo-Doppler study. Intensive Care Med 1995; 21: 629-35. 69Ghazal A, Ismail M, Abdel-Rahman A, E1A s m a r MF. P h a r m a c o l o g i c a l studies of scorpion (Androctonus amoreuxi Aud. &Sav.) venom. Toxicon 1975; 13: 253-9. 70 E1-Amin EO, U-Din-Khan M. Hematological and biochemical findings in scorpion string children. Ann SaudiMed 1991; 11: 99, 625-27. 71 Roch-Arveiller M, Jaillon P, Heckl6 J, Cheymol G. Effets du venin de scorpion Androctonus mauretanicus sur l'61ectrocardiogramme de rat. CR Soc Biol 1974; 168: 1234-8. 72Nouira S, Abroug F, Haguiga H, Jaafoura M, Boujdaria R, Bouchoucha S. Right ventricular dysfunction following severe scorpion envenomation. Chest 1995; 108: 3, 682-7. 73 Flugelman MY, Naparstek Y, Braverman AJ. Myocardial damage after Androctonus crassicauda crassicauda sting. Isr J Med Sci 1982; 18: 503-4. 74 Tazieff-Depierre F. Propridt~s pharmacologiques des toxines du venin de scorpion Androctonus australis. Notes prrsentres par MJ Trrfou~l. CR Acad Sc Paris. Srrie D, 1968: 240-3. 75E1-Amin EO, Sultan OM, E l i d r i s s y A. Serotherapy in the management of scorpion sting in children in Saudi Arabia. Ann Trop Paed 1994; 14: 21-4. 76 Efrati P. Poisoning by scorpion stings in Israel. Amer J Trop Med Hyg 1949; 29: 2, 249-57.