Let us look now at the cases with definite anginous attacks. For these cases you must give the patient relief very speedily. It is a little difficult to pick out of Materia Medica the most commonly indicated drug for it, but I think one can limit the choice to about one of half a dozen Aconite, Cactus, Arsenic, Iodine, Spongia, Spigelia and Lilium tigrinum
The outstanding characteristic of the majority of these cases in their first attack is an absolutely overwhelming fear. The patient is certain he is going to die, and that very speedily, and he is terrified. He is quite unable to keep still, and yet any movement seems to aggravate his distress. Here a dose of Aconite in high potency will give relief almost instanteously.
I have seen a case of that sort and put a dose of Aconite on the tongue and almost before the remedy could be swallowed that patient was feeling better. I usually carried 10 m as my highest potency in general practice and I gave Aconite 10 m.
The man had a similar attack at a later date, and the anxiety the distress, and the fear were nothing like so marked because he had come through one attack before and Aconite had no effect at all. That has been my experience. where you are dealing with the first attack and the patient is quite certain he is going to die. Aconite does relieve him right away but does not act in a second or attack. So if you get a man with his first attack, a dose of Aconite and you will probably find in no time he is feeling more more comfortable. But if he had a previous attack Aconite will not be helpful.
For the patient who is having a subsequent attack much the most likely drug to help is Cactus. Cactus has a good deal of anxiety and fear but it is quite different from that of Aconite. It is not a fear that the immediate attack will be fatal it is more a conviction that he has an absolutely incurable condition which will eventually kill him.
That is one point about the Cactus indication. Another is the type of the actual distress of which the patient complains. He feels as if he had tight band round the chest which was gradually becoming tighter and tighter and that if this constriction did not let up soon the heart would be unable to function. It is that feeling of increasing tension which gives you the Cactus indication.
In addition you may get stabbing radiating pains from the precordium, but they are not so characteristic of Cactus as the intense constricting feeling, which is of course, just exactly how the majority of your anginous patients describe it.
In these acute conditions I always give the drug in high potency because it acts much more quickly and one wants instant relief.
The you will get an occasional patient having an anginous attack with very similar constricting feelings not quite so intense but a definite feeling of constriction. The patient has been ailing for some time, is rather anxious and worried, very chilly, and accompanying this feeling of constriction there is an acute, distressing burning sensation in the chest. These anginous patients respond very well to a dose of Arsenic I have never seen Arsenic do anything in an anginous attack except in the rather broken down, ill-looking patient who is a bit pale, rather withered looked very definitely anxious, fearful with that sense of constriction accompanied by the burning discomfort in the chest. And Arsenic does relieve these cases quickly.
There is another type of case which is very similar to that with very much the same sensation but the feeling of constriction the feeling of tension is described but the feeling of actually in the heart it self rather than involving the whole of the side of the chest.
The patient are just about as anxious as the Arsenicum patients in fact al these anginous patients are anxious but instead of the intense chilliness of the Arsenic they are uncomfortable in heat and in stuffy atmosphere. They are just about as restless, but instead of the pale, drawn appearance which you get in Arsenic they tend to be rather flushed and as a rule they are dark haired, dark-complexioned people. They are rather underweight in spite of the fact that they have always been pretty good livers and very often have an appetite above the average although they have not been putting on weight. These cases respond exceedingly well to Iodine.
The three is yet another type of case in which instead of the complaint being of constriction it is a progressive sensation of swelling in the heart in the heart region. It feels as if the heart gets and bigger until it would finally burst and this sensation of fullness spreads up into the neck.
This sensation of fullness and swelling is very much aggravated by lying down the patient feels as if he would nearly choke and it is accompanied by very acute pain.
The patient themselves are chilly and any draught of air increases their distress.
In addition to the feeling of distension they usually complain of more or less marked numbness, particularly of the left arm and hand, though very frequently there is numbness of the hand only without any involvement of the arm, and not infrequently they complain of numbness of the lower extremities too.
As a rule the face and neck give you the impression of being some what congested; they do not have the pale, drawn, wrinkled Arsenicum appearance.
And these cases respond well to spongia.
Another drug which you will find useful in a condition which is somewhat similar though not an angina at all, but which you meet with in hysterical women. You will fail to find any cardiac lesion, but they will produce a symptom picture difficult to distinguish from a true anginous attack. They have the very marked stabbing, radiating pains and often and intense hyperaesthesia of the chest wall. They are very depressed, frightened, and intensely irritable. They are sensitive to heat, and their distress is aggravated by any movement.
In addition to the stabbing pains they have the anginous sense of constriction tightness, of the chest wall.
These cases are usually associated with some kind of pelvic lesion, or a history of having had some gynaecological illness.
I have seen quite a number of these cases now in which an electro-cardiogram shows no lesion at all. And all the symptoms have cleared up entirely with Lilium tigrinum
So you see when you are confronted with one of these very distressing conditions where you have to make a quick decision, it is fairly easy to individualize and get something which will give almost instantaneous relief.