The revolution which at the time of puberty attacks especially the sexual organs, often affects the male breasts. The atrophy of these generally takes place at this time without symptoms. Nevertheless, a sensitive swelling of one or both breasts may sometimes occur with red dening and pigmentation of the nipple accompanied by first dull and later sharper pain. These sensations are often referred to trauma, and disappear spontaneously in the course of a few weeks. They may however recur, but the breasts rarely remain enlarged (gyntecomastia) in which case a deficient growth of the genitals would also be noticed. In both sexes at puberty a circumscribed nodular swelling of the breasts can be caused by a growth of interstitial connective tissue but this also disappears later on and seldom is it the point of origin of a new NV growth.
In the male genitals unpleasant sensations sometimes occur because of an incomplete descensus testiculi which up to that time had not been observed. With retentio testis inguinalis (less commonly with the abdominal or perineal variety) boys complain sometimes of drawing pains in the testicle (or spermatic cord). Sharper pains during puberty are caused especially by inflammatory irritation which occurs readily after injuries (gymnastic) or after mumps, etc., in consequence of the confined position of the retained testicle. As retained testicles not in frequently become atrophic and further show a tendency to malignant degeneration, removal of the testicles is to be considered provided a hernia pad especially constructed and to be worn without intermission does not hold the testicle constantly pressed below it (Heidenhein). Analogous to the displaced testicles of boys changes in position of the ovaries (ovarian hernias) are apparent in girls especially at puberty, through periodic swelling of this organ (Hennig). At puberty not in frequently cases of pseudohermaphroditism can be determined as to sex, as retained testicles pass into the sides of the scrotum separated by an extreme liypospadias and in addition changes follow in the charac teristics of the child which up to that time seemed to be feminine. Phimosis also can give rise at puberty- to manifold disturbances. At this time especially, a quantity of readily decomposing smegma is produced whose retention leads to balanitis and ga]anopQSthitis with a foul smelling discharge which can simulate gonorrhoea. A microscopical examination of the secretion for gonococci prevents error. Successful treatment is only possible after operative removal of the phimosis; this is further to be considered when with a narrow prepuce enuresis or masturbation comes on at puberty.
The chief development of a systematic practice of onanism occurs (according to Fiirbringer) at puberty. Provided that this had habit has not already been practiced, a local irritation of the genital nerves (through eczema, prurigo, phimosis or vulvitis with an accumulati ii of smegma, oxyurides, stone in the bladder, constipation) plays the part of an exciting cause in connection with the awakening sexual passion (see page 114). This complaint is more often the outcome of a neuro pathic disposition with hereditary weakness of will than the result of an excessive hereditary sexual desire (Lowenfeld). Idiots, those men tally deficient, and epileptics often show a decided tendency to onanism. In hoarding schools (occasionally breaking out epidemically in conse quence of living with certain depraved scholars) the evil is commoner in boys than in girls. Provided there is no excessive practice of this evil habit, striking symptoms on the side of the nervous system are not to be found in otherwise healthy individuals. But one sees in habitual masturbators in addition to anaemia and an exhausted appearance not infrequently the signs of general nervousness with migraine, sense of pressure in the head or of cardiac neuroses, with palpitation and sense of pressure or spinal symptoms (exhaustion, parfesthesia in the legs, sacral pains and other annoying sensations in the back). The associa tion during the period of development of intense mental effort with excessive onanism injures the brain in its power of resistance and accom plishment; beside loss of energy, lack of memory, indisposition and incapacity to work, absent-mindedness is often a striking symptom.
Sexual neurasthenia not infrequently begins at puberty. The evil re sults of masturbation can be completely overcome by early and rational opposition. Positive local signs in the genitalia, apart from slight evi dences of irritation, are not to be determined. For the purpose of pro phylaxis the above-mentioned bodily anomalies that lead to irritation of the genital organs are to be removed; of importance also is food causing as little irritation as possible (especially the avoidance of alcohol). Reading and companions should be overseen, often severe bodily exer cise out of doors is of advantage and further the awakening of a mental interest sometimes by travelling. If the evil persists the moral influence of parents and teachers is often of value in addition to these other measures; there is less to be accomplished by severe punishment than there is by kindly explanation, if necessary with the assistance of the physician. If on the one hand as can be seen by the foregoing descrip tion, sexual development gives rise to most manifold disturbances, so on the other hand at puberty occasional functional disturbances occur in almost all the organs which may often have sweeping and enduring consequences, and the general health at this time is subject to great variations. A consideration of the ratio of disease during this age of development gives us the following striking facts. We gather from the statements of Axel Key, Hansen, Hertel and others which claim the greatest possible accuracy, that in the middle grade schools the general sickness of boys reaches nearly 40 per cent. and of girls GO per cent. and over. While by the latter alumina amounts to 40 per cent., by the former myopia occupies the first place. Sixteen per cent. of boys suffer from chronic headache, 36 per cent. of girls, of the latter 10 per cent. have spinal curvature. Of chronic diseases it has been determined, that those of the lungs amount to per cent., of the heart 3 per cent., and of the gastrointestinal tract 2.1 per cent. From personal observations of 2500 cases observed in the last four years in the pediatric polyclinic and of 500 from private practice, 260 suffered from acute infectious diseases, 354 from tuberculosis, 7 from syphilis, 325 from ancemia and chlorosis, .350 from diseases of the respiratory organs, 5S1) from diseases of diges tion, 90 from diseases of the urogenital organs, 2S0 from skin diseases and 60 from organic heart disease. Disturbances were found in 600 eases which could be brought into more or less close connection with Of these 22 per cent. had general evidences of menstruation, drawing and other kinds of pains in the breasts or abdomen without objective physical signs; 16 per cent. had cardiac neuroses, 16 per cent. goitre, 16 per cent. periodic headaches, 15 per cent. neurasthenia, 15 per cent. hysteria, 7 per cent. epilepsy, 4 per cent. chorea and 6 per cent. the albuminuria of puberty. Of the chronic infectious diseases, tuberculosis at this critical period is of the utmost significance on ac count of its great frequency and its often fatal result. According to Kirchner, between the ages of ten and fifteen, the deaths from tubercu losis in males increase from ten to sixteen in a hundred deaths and in females from eighteen to twenty-six in a hundred. After tuberculosis the anomalies of the blood—especially chlorosis—take the first place. As far as the diseases of the single organs are concerned those of the respiratory and digestive tract are not infrequent and affections of the skin still show a great frequency. Functional disturbances are found in 20 per cent. of children at puberty according to my observations and these are to be referred to the processes of development; three-fifths of these affect females and two-fifths affect males.