The arrival at maturity shows itself in children by various manifes tations that are noticeable in part subjectively and in part objectively and of these some can periodically recur. First of all cardiac palpita tion is commonly noticed, and besides this, vertigo, a sense of oppression, shortness of breath, nose bleed and headache are not infrequently seen. (This will be more particularly dealt with under the relation of puberty to the circulation.) Especially in girls one sees premonitorily as an expression of a congestion toward the genital organs an occasional sense of pressure, weight and twinges in the lower abdomen, tender ness in the region of the ovaries and spasmodic pain in the abdomen and lumbar regions, the former radiating toward the epigastrium and the latter toward the thighs. Transient and even painful pricking or tension in the breasts and twinging pains along the ribs are common symptoms present oftener in girls than boys. Besides the bodily trans formations that indicate puberty, mental changes make their appear ance. New sensations develop. Boys learn from emissions the specific sexual sensations out of which an impulse to attain such a sensation can develop. The awakening of the sexual impulse is dependent, irre spective of the progress of bodily development, upon the exciting in fluences of environment (persuasion), education (sensual excitation from had literature, immoral pictures), and food (too nourishing food, the use of alcohol). We will speak in the chapter on masturbation of the effect of an abnormal, hereditary predisposition and of the irritation of the genital nerves by phimosis and other local bodily anomalies on the one hand and of early provocation of the sexual sensation on the other. Under normal circumstances the sexual impulse of boys first shows it self only in occasional erections and likewise in a friendly affection for girls, provided that the company of girls is not at first despised. Emis sions and such acts do not take place in normal girls and to them at first sexual sensations are still foreign (Lowenfeld); on the other hand specific female characteristics show themselves, such as solicitude for younger brothers and sisters and tenderness for strange children. In addition young girls, as is well known, readily idealize a teacher, an officer, favorite actors, etc. In general the mental changes in maturing girls take place more quietly than in boys in whom the growing sense of manhood often finds expression in an increased sense of importance and an arrogant disposition (Emminghaus). In consequence of this change of disposition we notice more often in boys than in girls a pecu liar transformation of the mental and bodily power that characterizes these years. This shows itself in chaffing and teasing of those younger and weaker, derision of the infirm, cruelty to animals and foolish acts of all kinds. Also against parents and teachers a sense of superiority is felt; their warnings are laughed at and the reaction against them amounts to insubordination and even rising animosity. Falsehood and bragging, sentimentality and extravagance are evidences of the fre quent mental variations. Depression and buoyancy abruptly alternate. This unsteadiness of mind is evidenced by the often clumsy, awkward and clownish movements of the rapidly growing body. The rapidity of the mental growth is subject to great variations, sometimes the intelli gence develops more rapidly, at other times the emotions alone. Bodily and mental progress do not take place throughout in parallel lines, it is more common for the mental development to stand still when bodily growth is accelerated. The psychical changes mentioned above con tinue beyond the time of bodily development and only in the eighteenth year or later is the boy relieved of this disturbing experience. It must be confessed, however, that from this time permament psychical distur bances may date.
may be premature or delayed. the head of premature development we see an early mental and bodily development going hand in hand or independently following one an other. The early bodily development usually consists in a more rapid growth of the body without corresponding involvement of the sexual organs but less frequently sexual maturity is independent of and pre cedes bodily development (Kussmaul). There are numerous observa
tions of menstruatio prvecox (before the tenth year) upon record even in children during the first year, in whom in addition to a dispropor tionate development of the breasts and outer genitalia regular bleeding took place usually at considerable intervals. Menstruation in these cases is however rare. Pregnancies progressing in a relatively normal manner have also been recorded as early as the eighth or ninth year This early menstruation is referred to congenital errors in development with premature bodily growth as its result, to excessive maternal pro ductiveness, to diseased conditions in the ova, to irritation of the trophic centres (hydrocephalus, shock) and to sexual excitation. In those who mature early, bodily growth generally ends with complete sexual maturity. Early maturity is sometimes combined with enormous fat formation which latter can appear early by itself or can accompany a precocious bodily growth without early sexual power. Girls may show a sexual prematurity alone; but in boys this early sexual development generally goes hand in hand with an early development of the whole body. Emissions of semen have been noticed in such boys very early, from the second year on. The mental growth does not progress parallel with the bodily development in those early matured, it seldom precedes it, usually it takes place later.
Amenorrhoea can be simulated by atresia of the uterovaginal canal; in consequence of the collection of blood behind the atresia with distention of the vagina, uterus and tubes, hannatocolpus, lnematometra or hcematosalpinx may arise In consequence of congenital heart disease (pulmonary stenosis) there may be a deficient develop ment of the genitalia. With congenital aplasia of the ovaries, the uterus is also insufficiently developed and ovulation and menstruation are absent. Menstruation can hardly take place if functionating ovaries are combined with a rudimentary uterus but it may evidence itself in the form of pains and nervous disturbances recurring periodically and with intensity. A foetal uterus can be suspected if the breasts do not develop or if the pubic hair fails to appear at the proper time. Errors in the de velopment of the inner genitalia in girls are first clinically noticeable at the time of puberty, but even before this deficient development of the ova causes a retardation of bodily growth. Functional amenorrhcea in . the years of development is not infrequently noticed after a sudden change of social or climatic conditions and further, in consequence of constitutional anomalies such a chlorosis, amemias of all kinds, after acute infectious diseases, in tuberculosis, severe syphilis, nephritis, neuroses. psychoses, diabetes, leuklumia, Basedow's disease, alcoholism and morphinism. When menstrual bleeding fails or is deficient in quan tity even at the age of puberty the appearance of periodically recurring, vicarious bleeding, from the nose, gums, lungs, stomach, hemorrhoids, nipples and ears is sometimes seen.
Independent of the local premonitory disturbances that have been previously mentioned (p. 11.1) we sometimes find even at the first men struation prodromal, concomitant or succeeding cramp-like abdominal pains (especially in the case of nervous or chlorotic girls or with hypo plasia of the uterus). In connection with the nervous system, vertigo or intense headache may be noticed; functional stomach and intestinal disturbances (such as regurgitation. vomiting, cardialgia, diarrhcea, constipation or flatulence) can appear. The congestive sacral pains are sometimes accompanied by a desire for urination or defecation. At the age of puberty reflex angioncuroses are also found. Besides the pre menstrual sensations of heat and cold, erythemata, urticaria, eruptions of herpes are noticed prodromally or concomitantly and further as a forerunner periodic painful oedema of the extremities may be found.