Basic Emergency First-Aid in Cardiology

Emergency First -Aid

"It would seem that for most of us life comes in phases. ... These are common to all, but there are also phases peculiar to each of us. I am now looking back over the period when I was actively engaged in the work of the Hospital and the teaching carried on there. Thinking of my early days and the difficulties then confronting me I wondered if in any way I could help those starting out on the same road. As a result, I am tempted to offer you this paper on some of the emergencies confronting the beginner in homeopathic general practice.
I think emergencies are one of one's greatest difficulties when beginning to practise Homoeopathy. In an acute emergency one has to do something immediately; we cannot spend time hunting for a drug.
All these emergency cases fall roughly into two main groups - the patient who is dying, and the patient who is in great pain. You sometimes get the two combined. There is a third problem - Is the case medical or surgical ? - and that is always at the back of one's mind. Here it is your general medical skill that comes in; in the other two types it is a question of homoeopathic knowledge. So it is the dangerous case and the case of acute pain that I want to consider here.
In the first instance you will find that the matching of
acute pain is much the more difficult; the cases of acute danger are much easier to tackle. The dangerous cases usually resolve themselves into a question of cardiac failure in one form or another, I think from the homeopathic standpoint one can tackle these cases of incipient cardiac failure very satisfactorily.The simplest way to group the dangerous cases from a drug point of view is to look on them under three headings:

1. The cases with acute cardiac failure

2. The case in which there is a gradual cardiac failure with a tendency to dilation and

3. The case of acute cardiac attack of the anginous type.

Acute Cardiac Failure

For the acute cardiac failures ,I think you will find that most of your cases require one of four drugs,: Arsenic, Antimony tart, Carbo veg., and Oxalic acid. There are various points about these individual drugs which help you in your selection, and you will find that very soon you begin to select your drug almost as quickly as you spot your pathological condition, and by the time you have overhauled your patient you know what to give.
In the Arsenic case, you have the typical Arsenic mental distress, with extreme fear, extreme anxiety, mental and physical restlessness, and with a constant thirst, a desire for small sips of ice-cold water.
So far as the actual local symptoms are concerned the main complaint is of a feeling of extreme cardiac pressure, a sensation of great weight on, or constriction of, the chest, as if the patient cannot get enough breath in, and a fear that he is just going to die.
The patients as a rule are cold, they feel cold, but they may complain of some burning pain in the chest. In appearance they always look extremely anxious and are grey, their lips rather pale, may be a little cyanotic, and they give you the impression of being very dangerously ill. They often have a peculiar pinched, wrinkled, grey appearance.
As a rule in these cases you will get the history that the attack has developed quite suddenly, and the response to Arsenic should be equally quick. If you do not get a response to Arsenic within a quarter of an hour the patient is not an Arsenic one. The first response that you ought to get is a diminution of the patient's mental anxiety and extreme fear; the restlessness beginning to subside, and he begins to feel a little warmer.
In these cases my experience has been that you are wise to administer the highest potency of Arsenic you have with you, and as I now carry all remedies up to the cm. I always give cms. of Arsenic. But whatever potency you have with you, use the highest, because this is the kind of case that will die very rapidly and you gain more by giving whatever potency you have than by wasting time going home to get a higher one. The Arsenic seems to act very much like a temporary cardiac stimulant, and I find that in the majority of these cases you have to repeat the dose, certainly to begin with, about every 15 minutes.
The next thing is that very often one sees a case of that sort which responds perfectly well, the patient is better, everyone feels he is getting over it, and then in three, or four, or six hours the symptoms begin to come back, the patient no longer responds to Arsenic, collapses and dies. That was my experience at one time. Then it began to dawn on me that I had given another drug during the reactive period I could have carried these cases on. I found that when this was done the patients did not get the secondary collapse and were thus saved. To achieve this result, you have to give your secondary drug within four to six hours of the primary collapse while the patient is still responding to the Arsenic, otherwise you are in great danger of having a secondary collapse which you cannot combat. So remember that this is one of the very few instances in which one appears to ride right across the dictum that so long as the patient is improving one carries on with the same drug. In these acute cases if you have set up a reaction at all you have got to take advantage of it, otherwise patient will sink again.
The drugs which as a rule I have found in these Arsenic cases go on to the reactive stage, are Phosphorus or Sulphur, but that is by no means constant. You can quite see that grey; pinched, anxious Arsenic patient responding, getting a little warmer, less pinched and drawn, not so anxious or restless, with a little more colour, and becoming a typical Phosphorous type. Equally you can see them going to the other extreme, where they are too hot, with irregular waves of heat and cold, rather tending to push the blankets off, still with air hunger and going on to Sulphur.
These are the two commonest drugs you will need, but whatever the response is you ought to be able to follow up immediately you get the action well under way.
The Antimony tart. patients have very much the same sort of condition, but mentally they are quite different. In Antimony tart. there is a more definite tendency towards cyanosis than in Arsenic, you never see a patient needing Antimony tart, without very definite cyanotic signs in the finger nails, often extending over the whole of the hands, and the feet may be involved as well.
We do not get the same degree of mental anxiety in Antimony tart, as in Arsenic. The patients are more down and out, much more hopeless and depressed. They are never quite so restless nor so pale. Again, there is none of the thirst you meet with in Arsenic, in fact anything to drink seems to increase the feeling of distress.
Another contrast is that the Antimony tart, patient is very much aggravated by heat, and especially by any stuffiness in the atmosphere. But there is one point to remember here as a contrast between Antimony tart, and Carbo veg.: the Antimony tart, patients do not like a stream of air circulating round them; they want the room fresh, but they like it still.
In most Antimony tart. patients there, is a very early tendency to oedema of the lower extremities. Another point which helps in your Antimony tart. diagnosis is that practically all these patients have a very thickly coated tongue - it is a thick white coat- and a rather sticky, uncomfortable mouth.They have a feeling of fullness in the chest much more than the sensation of acute pressure found in Arsenic. And you are likely to find pretty generalised, diffuse rales in the lower parts of the chest on both sides.
In contrast to Arsenic, the collapse is similar to that after a pneumonic crisis, and if the patient responds to Antimony tart. it will carry him through. You do not have to be on your guard to find the follow-up drug as you have to be in an Arsenic case.
The Carbo veg. case gives the classical picture of the patient with all the symptoms of collapse. They have the cold sweaty skin, are mentally dull, rather foggy in their out look with not a very clear idea of where they are or what is going to happen to them. There is intense air hunger, and in spite of their cold, clammy extremities, they want the air blowing on them; they cannot bear the bedclothes around the neck and they do definitely benefit from the exhibition of oxygen. They are very much paler than the Antimony tart. patients, the lips tend to be pale rather than cyanotic, and there is none of the underlying blueness one associates with Antimony tart.
The next point is that they always have a feeling of great distension, not so much in the chest as in the upper abdomen, and the cardiac distress is always associated with a good deal of flatulence. Like the Antimony tart. patients, any attempt to eat or drink tends to increase the distress, and they have none of the Arsenic thirst.
Another apparent contradiction you come across in Carbo veg. is that, in spite of the desire to be uncovered and the intolerance of the blankets around the upper part of the neck or chest, these patients complain of icy-cold extremities, as if the legs were just lumps of lead, and they cannot get them warm at all. I think in Carbo veg. you have to be careful as to how long you are going to keep up your drug administration when you get the patient responding - sweating less, the surface becoming warmer, and the distress less acute. You are wise then to be thinking of a second drug, because some Carbo veg. patients do relapse although many of them make quite a straight recovery on that remedy. You do have to be careful. If you find the patient has responded up to a point on Carbo veg. do not imagine that a higher potency of Carbo veg. is necessarily going to carry on the improvement. As a rule it does not, and it is much better to look round for a fresh drug to keep up the reaction. In the majority of these cases the drug that follows best has been Sulphur, although Kali carb. should always be considered.

The last of the drugs which I commonly think of for these collapsed conditions is Oxalic acid.Oxalic acid has one or two veiy outstanding symptoms which are a great help in the selection of that drug. The first is that the patients always complain of a feeling of the most intense exhaustion, very often associated with a sensation of numbness. They frequently state that their legs and feet feel numb and paralysed, as if they had no legs at all.The skin surface is just about as cold and clammy as it is in Carbo veg., but there is a peculiar mottled cyanosis in Oxalic acid which you do not get in the other drugs. The finger tips and finger nails and toe nails will be definitely cyanotic, but in addition there is a peculiar mottled appearance of the hands and feet which is quite distinctive of Oxalic acid. There is a somewhat similar mottled, cyanotic appearance in the face, especially over the malar bones.These patients, in contrast to the Arsenic type, want to keep absolutely still, and movement of any kind greatly increases their distress. In addition to the general distress, most of these Oxalic acid patients complain of very definite sharp precordial pains. These pains are not like the typical anginous stab, but more of a sharp pricking sort of pain which usually comes through from the back and may run up the left side of the sternum towards the clavicle, or down the left side of sternum into the epigastrium. The most startling cases giving this picture that I have seen have been in the critical stage of an influenzial pneumonia where the patient was just fading out, having lost all strength, and the heart failing rapidly. I think all the patients of that type that I have seen have been left basal pneumonias. I remember seeing two or three patients who apparently were doing quite well on Natrum sulph. react beautifully to Oxalic acid. But one does get indications for its use in chronic cardiac cases as well.

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The patients are just about as anxious as the Arsenicum patients — in fact all these anginous patients are anxious — but instead of the intense chilliness of the Arsenic they are uncomfortable in heat and in a 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. Then there is yet another type of case in which instead of the complaint being of constriction it is of a progressive sensation of swelling in the heart region. It feels as if the heart gets bigger 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, when the patient feels as if he would nearly choke and it is accompanied by very acute pain.The patients 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 an intense hyperesthesia 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 tig. 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.

- By Dr. Douglas M. Borland

DISCUSSION

Dr. McCrae thought the paper was a masterpiece. There was nothing in it to criticize, there were details of valuable help to everybody which were like the artist sharpening his pencil to produce some line of particular splendour which would make the picture complete. Most had pencils but they were blunt, and the homeopath would always be grateful for these amazingly useful hints.

Dr. John Paterson said that they had listened to a real clinical paper. There was not much which one could criticize, but one might add a little. With regard to the cardiac cases, Arsenic and Sulphur his experience was that Arsenic was often the acute of Sulphur and on the mental side they were the exact opposite. One found that a Sulphur patient swung in an acute condition to Arsenic and Dr. Boland had brought out that point. He was interested in the question of Aconite acting in the first attack but not in the second. There had been many discussions about covering the totality of the symptoms and here was evidence that the homeopathic remedy could be prescribed on the mental symptoms which worked in the first instance but it did not cover the whole of the case. It was possible to prescribe homeopathically without covering the whole of the case, only covering a phase because obviously on the next occasion the pain was present but not the fear, the Aconite had removed one phase of the case — mental fear. Aconite came out very strongly in the air raids. Another remedy was Natrum Mur.
He wondered if any orthodox practitioners were surprised that there was no mention of Digitalis but Digitalis was quite useful in these slightly relaxing hearts in homeopathic doses, not in the massive doses given in allopathic medicine.

Dr. Stonham said that the paper was excellent and the sort of paper which would appeal to the general practitioner, who was always coming up against acute cases. To have such cases so plainly stated with the drug indications for them was valuable. There were one or two points he would like to mention with regard to Aconite which, as Dr. Borland had , was very useful in many cases. The case which he did not mention was the acute pulmonary oedema. He had given. Aconite 30 in such cases and it quickly calmed the patient in that distressing and somewhat dangerous condition and he had found it valuable not only in the first case but also in cases when the attack has been repeated. Dr. Borland said he gave Laurocerasus in acute heart complaints. He had had an acute case with Cheyne-Stokes respiration, it looked as if the patient would die, he gave Hydrocyanic Acid and he recovered very nicely. Many people would substantiate the value of Dr. Borland's paper.

Dr. G. R. Mitchell said that a clinical paper was most useful. He wanted to criticize something Dr. Paterson said when he took the Aconite example as not prescribing on the totality. He would have thought it was an example of prescribing on that procedure because in the first case, on all the manifestations, Aconite was the drug, and it worked and on the second occasion there was a different totality, and the Aconite did not work. That was the way he would have regarded the matter.

Dr. Hardy added her grateful thanks to Dr. Borland for his paper. With regard to medicines for heart complaints she agreed with Dr. Paterson that Digitalis 200, one dose, was very effective in the semi-chronic or chronic case of the right sided congestion, blue face and blue nails, but not in the acute patient. She also used mother tincture Crataegus for heart patients because it was specific for the cardiac muscle. Another drug which was used in Russia was Adonis mother tincture, five drops to a dose. ..the wonderful collection of details on which indications had been given and which were of the greatest possible value. The paper would require a great deal of study, so that these indications could be taken for future use.
He was rather in favour of trying to keep the remedies which were very definitely specific for particular conditions because in cases where there was an emergency there was no time to seek for all the exact indications which might help, but he was rather surprised that Dr. Borland did not make more use of the Snake Poisons in heart cases because he must admit he would not be without Lachesis. If there was any suggestion of heart failure he would give Lachesis and would be surprised if it did not answer. There was one rather interesting point from the homeopathic point of view with regard to Snake Poisons and that was to think of the first thing which an individual felt when he was bitten by a snake, which was death, and when death threatened the patient ,the prescriber should think of the Snake Poisons. He mentioned this in a paper he read on Snake Poisons in Berlin just before the war and it attracted the attention of reporters who were present. In the Berliner Tageblatte there appeared in headlines, "When death threatens, think of the Snake Poisons."..

Dr. Alva Benjamin said that with regard to the collapse cases one would have thought that Dr. Borland would have mentioned Veratrum Album for cases of great coldness and excessive sweating. With regard to heart cases he had had a lot of help from Chamomilla, particularly when the pain was very severe. ..

Dr. W. Lees Templeton said that most of them felt that they had been back at school and he felt not only humbled but humiliated, for he must admit that he did not get such good results, possibly because one did not always get the symptoms. Most of the emergencies he saw were unable to give symptoms and one had to judge on appearances. He was glad, therefore, that Dr. Borland had elaborated on the appearance of the patient, because that was important. With regard to drugs, he did not find Ant. Tart, useful in heart cases because he believed the pathology was different. He thought Ant. Tart, had a pulmonary pathology, not cardiac. Carbo Veg. had a great and justifiable reputation as the "corpse reviver" and it did work when the appropriate symptoms were present. Cold sweat he looked upon as a guiding symptom for Verat. Alb. and he had verified its value in collapse. He was sorry that Dr. Borland was not more specific in his diagnoses, e.g. if pain was due to coronary thrombosis he doubted if the high potency alone would ease this particular pain in a matter of minutes.
The wait with the patient for four or five hours for the second presentation was a serious matter when one was called out in the middle of the night, and like confinements many of these emergencies did occur at night. Why was this, he wondered?

Excerpt from : The British Homoeopathic journal, March 1946

Dr.FHLew

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