FOOTNOTES:

[J] Virginia Medical Monthly, Vol. II., No. 9, pp. 633-38, 1875. "He was commissioned surgeon in the Confederate army, July 1, 1861; served until August 1st in the field on the peninsula; then placed in charge of hospital in Williamsburg; afterwards ordered to Richmond and placed in charge of an hospital, and remained until close of war." Failing to find any further trace of him I am led to believe that he has been mustered out of service by the Grand Commander.

II.

It may be well to offer a critical examination of the foregoing cases. If they are genuine effects of the poison of Latrodectus mactans, they must afford a recurrence of corresponding symptoms. They may differ in degree, because the quality of the venom may vary; first, from the season in which the bite occurred (and judging from cases I, IV and V, the poison of Latrodectus mactans is most virulent in the month of September), and, secondly, from the more thorough elaboration of the venom. It is known that the poison of Crotalus horridus differs in intensity according to the frequency with which the snake has bitten in a given period of time; of four successive "strikes" in four different organisms, and at brief intervals, the intensity of the action will vary, so that while the first wound is lethal the last is not—on which fact depends the vaunted reputation of many an antidote to the bite of the rattlesnake. That this may be also true of the spider poison is the only explanation I can offer for the fact that many naturalists have allowed themselves to be bitten by spiders of reputed poisonous species, and with impunity.

Recurrence of Corresponding Symptoms.

(Arabic numerals refer to the Cases.)

I. Nausea 1 2
II. Abdominal pain1 2
III. Countenance anxious1 4
IV. Pain up arm to shoulder,
thence to back of neck 45
V. Præcordial pain extending to
left axilla, and down arm to
finger ends1 4
VI. Left arm almost paralyzed1 4
VII. Pain up arm to shoulder,
thence to præcordia 3 45
VIII. Apnæa 1 45
IX. Præcordial pain1 3 45
X. Pulse feeble, thready1 2 45
XI. Skin cold1 2 45
XII. Sense of impending dissolution1 45

While Dr. Semple's reports do not precisely state it, I think we may safely infer a sense of impending dissolution in cases I, IV and V. The girl exclaimed she "would lose her breath and die;" the man in case I "expressed in words" "the deep anxiety he felt;" the woman in case IV was found "apparently moribund" with "gasping respiration," and therefore incapable of speech, but who can doubt that she had a sense of impending dissolution?

Isolated Symptoms.

It must be admitted that many of our accepted provings cannot as well bear a similar test.

III.

There is another feature that the believer in the law of similars should find no insuperable difficulty in accepting as a criterion of the validity of a proving, namely: the similarity of the drug symptoms to certain disease symptoms. I am not ready to believe that drug symptoms are only the result of a "fortuitous concourse of atoms," nor can I for one moment imagine that they are the product of blind and aimless chance. I plainly discern in them the result of law, and I am wholly unable to conceive of existing law without the absolutely necessary pre-existing law maker. The consequent must have its antecedent. Therefore, in a drug symptom I see a purpose, and by the light of the law of similars I find the purpose of a drug symptom in an analogous disease symptom—they answer to each other as face unto face in the refiner's silver—and behind and beyond them both is another purpose, of wisdom inscrutable, of love unfathomable. In a word, my reader, the problem of the visible universe forces upon me the alternative that weighed upon Marcus Aurelius—"either gods, or atoms." With atoms only I cannot account for law; with God and in God both atoms and law find a meaning and a purpose.

If I were submitting these convictions, or, if you will, this "working hypothesis," to a Sir Thomas Browne, or a William Harvey, or a Thomas Sydenham I should feel no momentary hesitation; as it is, I can only hope that the spirit that filled these worthies is not extinct in days when the "spiritual colic" that disordered an imaginary Robert Elsmere is thought to disturb the eternal Verities. I much doubt if they who mistake an eclipse for an annihilation will get any good from this poor pen of mine.

The resemblance between the symptoms of angina pectoris and the effects of the poison of Latrodectus mactans are so striking as to justify the presentation of a comparison; and it is hoped that physicians of wide reading will pardon what may seem to them a piece of supererogation for the sake of many a humbler practitioner whose opportunities have not been so happy. At the same time, the widest reader must admit that he has not found any one authority who has given a complete picture of angina pectoris. Nor is it essential that such an all-including "composite" shall now be presented; on the contrary, we shall offer only salient points substantiated by observers of the highest order.

It will be well to start from an authority whose scholarship has never been excelled—Copland. Of all our medical writers he may be called the Great Definer—his readers will know what that means.

"Acute constricting pain at the lower part of the sternum, inclining to the left side, and extending to the arm, accompanied with great anxiety, difficulty of breathing, tendency to syncope, and feeling of approaching dissolution."

Copland presents a group of constants, and, for a terse definition, has well covered the principal phenomena. As variants he has omitted the pulse and the surface temperature. He errs on the side of dogmatism in defining the character of the pain as "constricting;" "aching, burning, or indescribable," and "generally attended with a sense of constriction" is more in accordance with the actual condition. Of Copland's seven constants, Case 4 presents an analogue for each in symptoms IX., V., III., VIII., XII., and the "tendency to syncope," which is not included in our table because Dr. Semple did not put the fact in express words. If to this group we add the thready pulse and cold skin, we shall have "covered" nine of the most prominent symptoms of angina pectoris; a pathological "composite" with a most striking pathogenetic similimum.

But all the elements of Copland's group are not of equal importance; two of them, at least, are pathognomonic. "The two constituent elements of the paroxysm," says Latham, are "the sense of dissolution and the pain." "Pain with one awful accompaniment may be everything." "This mixture of the sharpest pain with a feeling of instant death." According to Fothergill "the two prominent subjective phenomena are pain in the chest and a sense of impending death." Eulenburg and Guttmann include another element: "We regard the substernal pain, the feeling of anxiety, and the disturbance of the heart's action, as the essential symptoms of angina pectoris." Romberg notes the companionship of these two elements: "The patient attacked with angina pectoris is suddenly seized with a pain under the sternum in the neighborhood of the heart, accompanied by a sense of anxiety so intense as to induce a belief in the approach of death."

We have laid the emphasis of these various citations on the "essential symptoms" in order to assert, with equal emphasis, that their analogues occur in not only one case of Latrodectus mactans poisoning. The præcordial pain is noted in Cases 1, 3, 4 and 5, and the sense of impending dissolution in Cases 1, 4 and 5. And that disturbance of the heart's action which Eulenburg and Guttmann consider an essential element is found in Cases 1, 2, 4 and 5; so that the tout ensemble presented by Case 4 is corroborated.

Another important element, though it is one subject to variations, is the direction of the extension of the pain. It most generally extends to the left axilla, and down the arm to the fingers; as variations it sometimes affects the right axilla and the back of the head. In Cases 1 and 4 the spider poison followed the direction of the disease, and in Cases 4 and 5 it also affected the back of the head. In Case 1 it produced the numbness of the arm and hand that is sometimes observed in the diseases.

Copland includes "difficulty of breathing" amongst the elements of angina pectoris. Trousseau does not regard this difficulty as real. "Although patients think they are going to be suffocated during a paroxysm, the chest is normally resonant on percussion, and if it be auscultated as they draw in breath again vesicular breathing is heard everywhere." Watson says, "the patient is not necessarily out of breath. It is not dyspnœa that oppresses him; for he can, and generally does, breathe freely and easily." Stokes is decided: "Respiration is secondarily affected; there may be slight dyspnœa or orthopnœa, with lividity of the face, yet by an effort of the will (if the patient dares to encounter the pang this commonly produces) the chest may be pretty freely expanded, and the breathing relieved for a brief space; dyspnœa is not a primary symptom of angina." Eulenburg and Guttmann say, "Our own experience leads us to adopt Parry's conclusion, that the changes in the respiration are principally, perhaps even solely, due to the pain." Bristowe speaks of the sufferer as "fearing to breathe." We can readily see that the "apnæa" observed by Dr. Semple in Cases 1 and 5 had physical origin, but in Case 4 he says "apnæa was extreme; the respiration only occasional—gasping." This shows to what an extreme extent the action of the spider poison had gone—even to implicating the diaphragm; and it is noteworthy that Anstie records a case of angina pectoris (Neuralgia and its Counterfeits, p. 67, London, 1871), in which "there was so marked a catching of the breath as to make it almost certain that there was a diaphragmatic spasm."

Of the changes in respiration accompanying angina pectoris we have, then, both the general, and the rarest, form, produced pathogenetically by the poison of Latrodectus mactans.

IV.

In its physiological action the poison of Latrodectus mactans resembles angina pectoris vasomotoria—a purely functional derangement. The similitude of the physiological action to pure angina pectoris corroborates the accepted pathology of the latter condition, because the phenomena of Latrodectus poisoning were educed from previously healthy organisms, and in pure angina pectoris there is no pre-existent organic change occasioning the attack. According to the accepted pathology, we have in angina pectoris vasomotoria, sudden spasms of the arterioles; from this an increase of the arterial tension; to overcome this is more forcible and rapid action of the heart; as the arteriole spasm persists and doubtless deepens in intensity, distension of the left ventricle follows, and from overdistension the agonizing breast-pang, and even death from stoppage of the heart's diastole. But we must include another element—spasm of the coronary vessels. "When there is a sudden rise in the blood-pressure in the arteries, due to vasomotor spasm of the peripheral systemic arterioles, and the heart-walls are strong and well nourished, palpitation is evoked; when the coronary branches are involved in the vasomotor spasm then angina is produced, and the heart-walls, acutely distended with blood, can scarcely contract in the face of the opposition presented to their contraction by the high arterial tension. When this sudden systemic arteriole spasm extends to the coronary vessels in a heart whose walls are diseased, a fatal attack of angina with the heart full of blood may be induced. The danger increases with the extent of the structural degeneration of the heart-walls. Sudden rises of blood-pressure in the arteries will tax hearts in their textural integrity, and lead to painful distension; such sudden demands on decayed hearts lead to agonizing angina pectoris, and the sense of impending dissolution is frequently followed by sudden death."

Spasm of the arterioles and coronary vessels, rise of blood-pressure in the arteries, embarrassed action of the heart, and painful distension are just so many consecutive links in the phenomena produced by the poison of Latrodectus mactans, as Cases I and IV amply testify.

The spider poisons are akin to the serpent poisons in their property of producing a disorganization of the blood. In Case I, thin and florid non-coagulable blood continued to ooze from the cut surface despite the application of tannin. It may be a question whether this condition of the blood is directly toxicological, or a pathological result of stasis in the peripheral vessels. I incline to regard it as due to the latter condition, and I believe this explanation also holds good in the case of serpent poisoning.

The hæmorrhage recorded in Case I was of gastric origin; splenic congestion existed, and the vasa brevia—branches of the splenic artery—gave way under the pressure. I once met a similar hæmorrhage in a case of intermittent fever in a child, and I recorded the fact as a possible hint for the applicability of Latrodectus mactans in a similar condition.

In all the year that the stray copy of the old magazine was in my possession I felt it a duty to write up this remedy. I have done it lamely, but as well as I was able. Reader, where my duty ends yours begins. May you discharge it more worthily than I.

(There have been a number of cases reported in which Latrodectus mac. acted as Dr. Jones predicted; from them we select the following by Dr. E. H. Linnell, North American Journal of Homœopathy, December, 1890):

S. L. G., a man fifty years old, of bilious temperament, a dentist by profession, had slight attacks of angina after severe exposure and overexertion during "the blizzard" in March, 1888. He did not consider them of sufficient importance to consult a physician about them, but some months later he had a suppurative prostatitis, which was followed by considerable prostration, and the attacks of angina became very severe. I never could get a satisfactory description of the character of the pain, and I never saw him during a paroxysm. The pain was brought on by exertion of any kind, and was especially frequent soon after dinner. The pain was sometimes felt in the left arm, but was usually confined to the cardiac region. I once or twice detected a slight aortic obstruction sound, but aside from this failed to find any evidence of organic disease. The usual remedies gave no relief, but Latrodectus ʒc was of great benefit. Under its use the attacks gradually became less frequent and less severe. He has taken no medicine now for at least six months, and he tells me that although he occasionally has a little reminder of his former trouble, the attacks are so slight that he pays no attention to them. I have given the remedy in another similar case, with even more gratifying success. The attacks were very promptly arrested and have not returned, although nearly a year has elapsed. I think we have in this remedy, to which Dr. S. A. Jones directed attention in one of the issues of the Homœopathic Recorder, a very valuable remedy in this painful affection. It is probably, as Dr. Jones suggests, in angina pectoris vasomotoria that it will be found especially serviceable.