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):