Cases Of Spider Bite

BY G. WILLIAM SEMPLE, M. D., HAMPTON, VA.[J]



[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.



"Spider bites are of rare occurrence in this vicinity, but are generally

productive of grave symptoms. [Isn't it bad taste for doctors to use the

words grave symptoms?] I will report all that have occurred to me in a

practice of forty years:



"CASE I. September 4, 1853. I was called to see Mr. D., at Old Point,

who had been bitten by a small, black spider on the prepuce, whilst on

the privy seat, at 12:30 o'clock. The bite at first caused only itching

of the prepuce, with a little redness of the part, but in less than half

an hour nausea, followed by severe abdominal pains, ensued. A

messenger was dispatched in haste for me to Hampton, three miles off.

Before I reached the patient, at 2:30 o'clock, violent praecordial pains

extending to the axilla, and down the [left] arm and forearm to the

fingers, with numbness of the extremity, had succeeded, attended by

apnaea.



"In consequence of the violence of the symptoms, Dr. Stineca, surgeon of

the post, had been sent for, who had given two doses of Laudanum of

[Latin: ezh]j each, and two of rectified whiskey of [Latin: ezh]ij each,

and, being in ill health and unable to remain, had ordered his steward

to apply four dry cups over the praecordia. This had just been done when

I arrived. I saw the blood, thin and florid, fill the cups like water

oozing through the muslin. When the cups were removed, the blood,

emptied into a basin, did not coagulate; and blood continued to ooze

slightly from the surfaces to which the cups had been applied until the

next morning, though a solution of Tannin was applied.



"I found the patient suffering extremely from the most violent

praecordial pains and from apnaea, and also violent pain in the left

arm, which was almost paralyzed. His pulse was 130 and very

feeble, his skin cold as marble, and his countenance expressive of

the deep anxiety he felt and expressed in words. The laudanum and

whiskey seemed to have produced no effect--the nausea and abdominal

pains having subsided before they were administered. There was no pain,

inflammation, or swelling where the bite was received. Even the itching

of the part had subsided. I gave the patient every half hour for several

hours [Latin: ezh]j of aromatic spirits of ammonia, and as much whiskey

and water as he could be induced to take, and afterwards gave them every

hour; also pediluvia of hot mustard and water, frequently repeated,

until the next night.



"September 5th, 8 A.M.--The symptoms continued unabated; indeed, the

patient grew worse until 2:30 o'clock, twenty-six hours after he was

bitten, for his pulse had then become so frequent that it could not

be counted, and so feeble that it could scarcely be felt. He then

vomited black vomit copiously--a quart or more. Soon afterwards

reaction set in, his pulse gradually gained force, and became less

frequent, the pain subsided and the respiration improved. At 8 P.M., the

pulse had gained considerable force, and the patient slept until some

minutes after 12; his pulse was pretty full at 1:10; his surface warm

and perspirable, and he felt almost free of pain. After a short interval

he again fell asleep, and slept quietly until morning, when he

awoke--his respiration healthy, pulse 80, regular and with sufficient

force, and entirely relieved of pain. He soon afterwards had two pretty

copious evacuations from the bowels, similar to the black vomit he had

vomited. After this he said he felt quite well, and took a light

breakfast and dinner, and returned that evening to his residence in

Portsmouth, and in a few days went to work at his trade.



"In thirty-six hours from the time he was bitten, he took three and a

half quart bottles of the best rectified whiskey--about three quarts

without showing the least symptom of intoxication."



I have cited this case at full length in order to present the evolution

of the symptoms, on which alone depends the resemblance of the action

of the poison to the chief symptoms of an attack of angina pectoris--a

closer resemblance than half a lifetime of somewhat wide reading has

enabled me to find in the effect of any other noxious agent. In fact,

after much searching, I find this case to be unique. In other cases of

spider bite I can find evidence that assures me of its genuineness, but,

to my knowledge, its order of symptom evolution is as solitary as it

is singular and significant. This feature of uniqueness will cause

many to regard it with suspicion. I think they will do wrong; for some

experience in proving work has taught me that one positive result from a

drug out-weighs any number of negative.



In the case of Latrodectus mactans we shall find, from other

poisonings, that, as a rule, it displays an affinity for the praecordial

region as the locus of its chief attack; and having assurance of that

fact, we shall not find it difficult to accept a clue from even a

solitary instance.



Of the remaining cases in Dr. Semple's paper I shall cite only the

symptoms, and be it observed that in all the cases as here given the

italics are my own.



CASE 2. A man "was bitten in the groin, and complained of only a slight

prickling and itching at the spot where he was bitten, but was

complaining [when Dr. S. saw him] of severe abdominal pain, with

nausea, and a sinking sensation at the epigastrium; and his pulse,

in a few minutes after the bite, had already become quick and thready;

and the skin very cold." The man soon recovered under ammonia and

whiskey--two quarts of the latter produced no symptoms of intoxication.



CASE III. A lad of eighteen years of age. "There was no pain, but only

itching and redness at the part bitten at first; but violent pain soon

commenced there [on the back of the left hand] and extended in a short

time up the forearm and arm to the shoulder and thence to the praecordial

region."



CASE IV. "A tawny woman [daughter of a quadroon mulatto woman] about

twenty-two years old, the mother of two children." "Found her

apparently moribund; her skin as cold as marble; violent pain

extending from the bite on the right wrist up the forearm and arm to the

shoulder, and thence up the neck to the back of the head on the right

side; more violent pain in the praecordia, extending thence to the

shoulder and axilla on the left, and down the arm and forearm to the

ends of the fingers, and this extremity partially paralysed; added to

this, apnaea was extreme; the respiration only occasional--gasping; the

pulse could not be felt in the left radial, and I was not sure that I

felt it in the right."



In about fifteen minutes after the intra-venous injection of 13 minims

of undiluted Aqua Ammoniae, the doctor "was astonished at the calm and

painless expression of her countenance, so lately expressive of

anxiety and pain."



CASE V. A healthy young girl of 13. She felt a stinging sensation on the

[right] wrist, accompanied by itching and redness at the spot [bitten].

For several minutes there was but little pain, but in half an hour a

painful sensation began to be felt at the spot, which quickly

extended up the arm to the shoulder, and, in the course of an hour,

along the neck to the back of the head. * * * Pain in the praecordial

region, with apnaea coming on, I was sent for. When I arrived she was

screaming fearfully with pain, and frequently exclaiming she would

lose her breath and die. The pulse had become thready and the

surface cold.



From these data the poison of Latrodectus mactans is suggested for

trial in angina pectoris, in that its physiological action presents

the closest similimum yet found.



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 pain 1 2

III. Countenance anxious 1 4

IV. Pain up arm to shoulder,

thence to back of neck 4 5

V. Praecordial pain extending to

left axilla, and down arm to

finger ends 1 4

VI. Left arm almost paralyzed 1 4

VII. Pain up arm to shoulder,

thence to praecordia 3 4 5

VIII. Apnaea 1 4 5

IX. Praecordial pain 1 3 4 5

X. Pulse feeble, thready 1 2 4 5

XI. Skin cold 1 2 4 5

XII. Sense of impending dissolution 1 4 5

+-----------------------------------------+---------+----------+



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.



Numbness of the arm, 1.

Black vomit, 1.

Alvine evacuations similar to the black vomit, 1.

Sinking sensation at epigastrium, 2.

Respiration only occasional--gasping, 4.



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

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.



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 haemorrhage 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 haemorrhage 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 Homoeopathy, 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 [Latin:

ezh]c 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 Homoeopathic 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.