Less frequent than such attacks of palpitation recurring at irregular intervals are paroxysmal attacks of tachycardia, in which the frequency of the heart and pulse is increased to an enormous extent. This disorder manifests itself a little time before the first appearance of menstruation, thenceforward recurring regularly every three or four weeks, accompanying menstruation, or occurring at the proper menstrual period if menstruation is in abeyance; the attacks last several days. This trouble also disappears a few months after the establishment of menstruation.
Associated with these cardiac troubles are, not constantly indeed, but in the majority of cases, disturbances of the digestive organs.
From the heart-troubles already described, another group of cases must be distinguished, which are also observed at the time of the menarche. They occur in girls in whom the first appearance of menstruation is strikingly delayed, not having yet begun at the ages of 18, 19, or 20 years, or in whom considerable irregularities have occurred in connection with the commencement of menstruation. In such girls, in whom menstruation has appeared late and been irregular, or who are perhaps entirely amenorrhoeic, cardiac troubles may be so pronounced that the physician may be led to suspect the presence of organic disease of the heart. The most prominent symptom is frequent and violent palpitation, with strong pulsation in the carotids, respiratory distress, and feeling of anxiety, on continued exertion or even on very slight occasion. On percussion, the heart is not found to be enlarged; on auscultation, the heart-sounds are found to be very loud, often with a systolic murmur in the mitral region, whilst over the lower end of the internal jugular vein, the humming-top murmur (_bruit de diable_) is audible. The pulse is increased in frequency, at times arhythmical, and easily compressible. The sphygmographic tracing usually shows a subdicrotic or dicrotic character. The upstroke is not high; the downstroke descends low, almost to the lowest level of the curve, before the enlarged dicrotic elevation begins. The skin is always strikingly pale, pale also are the visible mucous surfaces, the hæmoglobin-richness and the corpuscular richness of the blood are considerably diminished, a feeling of fatigue and various other nervous manifestations are constantly present—in short, in all cases we have to do with the well-known chlorotic disposition, sometimes in association with the manifestations of the anæmic form of lipomatosis universalis. In several such cases, skin affections were also present. Some suffered from acne vulgaris of the face with the usual comedones; others perspired profusely from the palms of the hands and the soles of the feet; others exhibited a bluish coloration of the nose and the ears.