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
praecordial 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 dyspnoea that oppresses him; for he can, and generally does,
breathe freely and easily." Stokes is decided: "Respiration is
_secondarily_ affected; there may be slight dyspnoea or orthopnoea,
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;
dyspnoea 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 "apnaea" observed by Dr. Semple in Cases 1 and 5
had physical origin, but in Case 4 he says "apnaea 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_.