Let us now turn to the diseases of the special organs or systems in so far as they are made evident during puberty by special symptoms or by great frequency. In the increased general bodily growth which accompanies puberty the bony and muscular systems are chiefly involved and the diminished resistance (insufficient firmness of the skeleton and relative weakness of the muscles) which occurs in consequence of this gives rise to the most various disturbances. In the first place, curva tures of the spine—especially lateral curvatures—occur at this time in consequence of customary but improper attitudes at school and in housework; further, in consequence of unilateral muscular exercise (for example violin playing and tennis) and in consequence of unilateral loading of the body (the carrying at the side of heavy school bags, etc.). Gann valgum can also develop at this age by reason of prolonged stand ing. The changes that have been mentioned are the more easily pro duced according as bodily exercise has been disregarded in consequence of an education devoted too exclusively to mental improvement and further when by reason of improper food at this critical time the composition of the blood becomes deficient or was deficient from the beginning. The possibility of late rickets has recently been emphasized from the surgical side (Roos, II. Curschmann) as a cause for gene valgum and also for curvatures of the spine or for flattening of the pelvis in so far as these anomalies develop during puberty. With the increased processes of ossification that go on at this time analogous to those at the infantile period of bony formation a special disposition to rachitic disease is supposed to exist. At this stage of rapid growth a slight amount of bodily fatigue easily occurs and forced exertion undertaken concurrently with stronger comrades, especially in sports, gives rise to overexhaustion. This shows itself generally in addition to a general weakness in a somewhat diminished motility of the joints and in pain on pressure over the epiphyses chiefly involved in growth without other objective changes. These are the upper epiphyses of the humerus and tibia and the lower epiphyses of the radius and femur. The pains which generally disappear rapidly are described as growing pains (espe cially in France by Poncet, Botany, Comby) and growing fever is also described. These are statetnents which we should accept with caution. Certain it is that at this time pain in the extremities results from slight trauma or overexertion and also with rheumatic and other febrile in fections following which as is well known a more rapid growth often occurs (poussee de croissance).
Finally the multiple cartilaginous exostoses developing only on bones still in the process of growth and which occur from an inherited source, should be mentioned in this place. These generally appear as symmetrical, hard, painless indurations and rough tumors in the neigh borhood of the epiphyses from which they may be separated in the process of growth.
Of the myopathic muscular atrophies the infantile muscular dys trophy with psendohypertrophy (of the calves, thighs, glutcal and deltoid muscles) and the infantile muscular hypertrophy (without psendohypertrophy) with involvement of the muscles of the face are likely to develop before puberty. During the period of puberty the so-called juvenile form of muscular atrophy appears with the initial in volvement of the shoulder-girdle muscles and later the muscles of the .upper arm (with the exception of the deltoid, supra- and infraspinatus and coracobrachialis) and filially the muscles of the back and pelvis.
Anomalies of the blood are a decidedly common phenomenon at the age of puberty. These, so far as the anemias are concerned, date from some previous time or occur very easily in consequence of severe acute infectious diseases, protracted fevers following irrational methods of life (improper food, athletic exhaustion) or unhygienic living or work ing conditions. Tuberculosis, kidney affections, constipation and entozoa
are always to be thought of. An absolute predisposition for chlorosis exists in the female sex, the blood of which is from the beginning poorer in red blood cells by nearly half a million per mini. but besides this (according to Jones following Grawitz) it shows especially at puberty a relatively smaller hemoglobin content. The number of leucocytes is higher at puberty, 9-12000 per cmm. (Bayer). For a further considera tion of chlorosis see the chapter on blood diseases.
In the circulatory system-, disturbances frequently arise at puberty in the form of cardiac palpitation, sensations of pressure, vertigo, syncope and shortness of breath. Only when alcohol, nicotine, kidney disease and overexertion can be excluded as causes, is a direct connec tion with puberty to be considered. Objectively one finds an enlargment of the right or left side of the heart (sometimes both sides) with a soft pulse and an apex beat which may be exaggerated without an evident increase in size of the heart and this generally with an accentuated second aortic sound and often with an accentuated second pulmonic sound. Sometimes the sounds are ringing in character. The tension is seldom increased and the arteries rarely tortuous. Systolic murmurs at the apex or in the second left intercostal space are heard with and with out an accentuated second pulmonic sound. The pulse is increased in frequency and may sometimes be irregular. An excited heart action at the time when various organs show an increased excitability can be simply evidence of irritation (Krehl) but generally there is an actual disproportion between the development of the chest and the size of the heart, a decided increase in the cardiac volume and a relative narrowness of the blood vessels; a further disproportion can also occur between the rapid expansion of the blood vessels in consequence of a sudden growth in length (especially after afebrile diseases) and an undeveloped heart which cannot meet the increased demands made upon it. An insuffi cient growth of the heart generally goes hand in hand with a retarded growth of the whole body and especially of the sexual organs: hypo plasia of the heart is generally congenital as is also an especial narrow ness of the large blood vessels, but this nevertheless frequently manifests itself only at puberty (Berg). The subjective and objective phenomena which have been mentioned begin without any apparent outward ca'ise, continue for a long time with more or less regularity or may periodically increase, especially the subjective symptoms. A complete disappearance of the cardiac symptoms generally follows the completion of puberty, by virtue of a readjustment of the equilibrium. Not so very infre quently an exaggerated apex beat remains permanent and this may also be true of a functional weakness which shows itself later on in frequent attacks of weakness, of syncope, etc., following slight exertion or excite ment. The prognosis of the cardiac disturbances at puberty is to be made with caution, as transient changes in the size of the heart are not always to be distinguished from definite changes in the muscle. Pro phylactically and therapeutically, caution is to be exercised against the influences which can injure the heart, such as excessive meat eating, alcohol, nicotine, coffee, tea, sexual excitement and especially against athletic overexertion. When on account of the increased growth of the body, the heart must. accomodate itself to increased demands, a nutri tious non-irritating diet is necessary as well as sufficient bodily rest and exercise corresponding to the patient's present condition. This can best be accomplished by moderate out-of-door exercise, walking, etc. Chil dren with valvular disease not infrequently show at puberty extreme car diac disturbances on account of the association of functional disorders with the valvular lesions.