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Definition:—A disturbance of the complex mechanism of the heart, inducing paroxysms of abnormal action, characterized by increase of rapidity with violent or irregular movement, in which the force of the heart is usually temporarily increased, resulting in weakness, anxiety, difficult breathing, and accompanied in severe cases, with a cold sweat.

Etiology:—The causes of this condition are several; they may be extraneous in character, as from distention of the stomach with gas, thoracic effusions, or by the influence of rarefied air, as in mountain climbing. They may be reflex in character, induced by irritation or pain in any of the other organs or in the intestinal canal; or it may be induced by toxins, or from the excessive use of alcoholic liquors, and tobacco, or from tea and coffee; and also, from autointoxication. It may be due to disease either in the central nervous system, or of the sympathetic apparatus, or very rarely of the heart and arteries. Finally, it is quite common as the result of psychic conditions, as when induced by emotional causes, as distress, anxiety, or fear, or influenced by great sorrow; or by prolonged mental effort, resulting in acute nervous exhaustion. The condition is very common in patients who suffer from neurasthenia.

The mechanism of the heart is exceedingly complex. The intricate motor-apparatus promotes independent motion, but must receive accessions of force from the central nervous system. This nerve influence exercises an inhibiting power upon the heart, to preserve its action at a uniform rate, but the action of the organ is also influenced by certain properties within the blood vessels themselves; by the character and density of the blood; by the proper exercise of the respiratory function, involving or including oxygenation; and by the proper exercise of other important functions of animal life. So intimately is this mechanism concerned in the performance of all of the vital functions that any remote disturbances may readily influence the action of the heart.

Symptomatology:—Palpitation occurs, usually, with no premonitory symptoms. In the milder cases the patient is at once conscious that there is sudden increased violence of the heart's action. This causes alarm, sometimes fear, and there may be precordial oppression, and some dull pain. Rarely, a slight pallor may overspread the countenance, although in most cases the face is flushed. It will be seen that the heart is slower than normal, and that the pulse beats are very full and large, although soft. In many cases there is but little disturbance of the rhythm. In other cases the irregularity of the beat is itself a distressing factor. These attacks occur without regularity, but those that depend upon disturbance of digestion will follow the taking of food, and those which occur from smoking, and the use of alcohol, will be apt to occur following any such excessive indulgence. The character of the beat will in no two cases be alike; it may be said that it is always tumultuous, and also accompanied with great discomfort and anxiety. Usually the patient must occupy a sitting posture, as it is impossible to lie down; soon he becomes weak and faint; there is dizziness and uncertainty of action; the pulse becomes weak, and as time passes, with no cessation of the difficulty, the feebleness increases and it becomes rapid and compressible. Usually, in the advanced stage of the difficulty, the rhythm is disturbed, and the heart is weak.

Auscultation shows no clear symptoms; the different heart sounds cannot be separately distinguished, because of the violence of the movement, and usually there are no valvular sounds apparent. The attack will cease in most cases as suddenly as it occurs; sometimes there will be only a few pulsations before the heart resumes its normal action; at other times the condition may last several hours; at still other times there may be a condition of palpitation, in which there are frequent irregular occurrences of the palpitation, with a complete intermission of a longer or shorter period, varying from half of a minute to four or five minutes. This state may last for several hours, or even for a day or two, to finally abate by a gradual increase in the length of the intermissions.

However occurring, this condition results in temporary weakness, as it causes a shock of greater or less severity to the central nervous system. In the milder cases, the shock is too feeble to be appreciated. In severe cases, the patient may be several days in recovering from it.

Treatment:—A patient subject to attacks of palpitation should receive most careful attention from the physician. If the case is obscure, he should study every condition of that patient's system, until he determines the exact cause. A course of treatment must be laid out which will not only remove the cause, but will remove all factors that contribute to it. The patient must be assured with positiveness that there is no danger from the attacks, as death seldom, if ever, occurs during the period of palpitation, and relief from anxiety will contribute largely to the patient's immediate recovery. So common is the condition due to digestive faults—autotoxemia, and especially from the absorption of gases, which are the product of fermentation of food—that the first attention must be paid to the stomach and digestion. The so-called nervous dyspepsia is a very common cause of palpitation in neurasthenics. In these cases, the nervous system must be built tip with the most positive nerve tonics and restoratives before the condition of the appetite will be greatly improved. The use of coffee, tea, and the ingestion of heavy meat diet with these patients must be proscribed and a vegetable diet substituted often, at least for a few weeks, and an active eliminative treatment adopted in order to rid the system of nitrogenous waste and other toxins. The patient must take an artificial digestive with all food, which must be selected v/ith great care. Patients suffering from sorrow or mental distress, must be removed to an entirely new environment, and brought into contact with conditions, all of which are materially changed from the usual routine. A thorough cleansing of the intestinal tract is sometimes necessary; and when tapeworm is the cause, as it occasionally is, this must be removed.

There are no specifics with which to immediately overcome an attack of palpitation. In severe and protracted cases, accompanied with pain, it may be necessary to administer a hypodermic of one-eighth of a grain of morphin. Usually, in extreme cases, ten drops of the essence of peppermint, with or without one-fourth of a dram of the ginger, given in hot water, will be sufficient. In other cases, a teaspoonfnl of the sodium bicarbonate, given in hot water, will produce immediate relief, especially if the evidences of gastric acidity are pronounced. Fifteen minims of specific eupatorium, repeated every half hour, will be of benefit. In others, an infusion of capsicum will relieve the condition. At times the external application of fifteen minims of chloroform in the palm of the hand, held firmly over the heart, until severe burning is produced, will result in immediate benefit. Where the symptoms are alarming, and there is extreme pallor, an inhalation of amyl nitrate will be sufficient. In others, glonoin, in granules of the one-two-hundredth of a grain each, every fifteen minutes, until four or five are taken, will be sufficient. Some physicians advise swallowing small fragments of ice, or an application of ice over the heart. Others will apply heat to the chest, and advise the patient to drink hot drinks; it is not advisable, however, to distend the stomach with fluids. The palpitation will cease more readily if the stomach be empty. Counter-irritation, or an application of cold over the sympathetic ganglia of the spinal cord, will sometimes give immediate relief. This may be accomplished with the chloroform application above described, or other available measures.

The Eclectic Practice of Medicine with especial reference to the Treatment of Disease, 1910, was written by Finley Ellingwood, M.D.

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