The thyroid gland whose connection with puberty has already been mentioned (p. 112) shows not infrequently a strumous degeneration in addition to the temporary or periodic conjestive tumefaction which has been noted. This is sometimes noticed in earliest childhood on the basis of an inherited predisposition but is most commonly observed in the fourteenth or fifteenth year or in the two following years. It is more frequent in females in whom this gland is from the beginning more developed (Demme). While the physiological congestion is transitory in puberty, mechanical causes at this time can give rise to a chronic con gestion; these may be, carrying heavy weights on the head and neck, ex cessive singing exercises, tight bands around the neck; the congestion may also be influenced by pertussis, chronic pneumonia and valvular lesions. For the different forms of goitre see the article by Siegert in Vol. III.
There are no affections of the respiratory system that stand in close connection with puberty. The expectation that has been cherished by some that adenoid vegetations of the nasopharynx will disappear at this time or cause no more symptoms, on account of the increase of the pharynx progressing parallel with the increased bodily growth, is not fulfilled. Operative removal of the growths should be strongly advised in order that their continuance may not interfere with the permanent expansion of the chest.
With the change of voice that has been described on page 111, it frequently happens, more commonly in boys, that the voice is incor rectly developed. It may remain high or crowing, it often fails or cracks. In consequence of the rapidly following changes in the larynx in form and size, the proper sensation for the changing conditions of tension is lost (Bresgen). Relative quiet for the voice (abstinence from singing or shouting) is prophylactically of value, for therapeutic purposes, prac ticing in a moderately loud voice with the deepest tones and possibly with slight compression of the larynx, is effective. In children who previously have had a tendency to diffuse bronchitis possibly with dys pnwa, one may see typical attacks of asthma occur if at the same time with the rapid increase in length that accompanies puberty, a delayed development of the thorax is present. These attacks of asthma can disappear entirely when growth is completed (Miller).
In so far as the digestive system is concerned, frequently recurring attacks of tonsillitis play a considerable part in the morbidity at this time; these attacks occur generally in individuals already predisposed to them. Various dyspeptic complaints are also seen which are charac terized by their periodic recurrence, and in the absence of an irrational diet as a cause they are to be considered as nervous symptoms. Not infrequently gastroptosis and enteroptosis begins in these years, espe cially in females, influenced by constricting clothes, in connection with an irrational and excessive amount of food (Meinert). Ulcer of the stomach, which is almost never found in childhood, occasionally occurs at puberty. Functional motor disturbances of the intestine are decidedly common at this time; especially in girls chronic constipation is noticed and with this one has to contend not only with insufficient exercise and unsuitable food but often with a false sense of modesty. The abnor mally long retention of feces or urine which not infrequently takes place in school girls can cause an ante- or retroflexion of the uterus (llennig).
Occasionally periodic attacks of diarrlicwi are observed that cannot. be explained by errors in diet; less commonly a sudden desire for stool with incontinence occurs, of a temporary congestive or nervous origin. Before the beginning of this period Quincke saw, in an otherwise healthy girl, twelve to fourteen years of age, an ascites slowly develop which disappeared rapidly at the beginning of menstruation.
Diseases of the urinary organs are not common in puberty; still the majority of eases of cyclic or orthostatic albuminuria begin at this period so that one caii speak of albuminuria of puberty. The patients are often pale, tall, and slim individuals easily tired, with swollen eye lids and a tendency to headache, vertigo and dyspeptic complaints. The disturbances of the heart which have been mentioned on page 121, are frequently present. But in otherwise healthy individuals at puberty one finds a periodic excretion of albumin, sometimes more„ sometimes less, in diminishing quantity in the night urine. This occurs often with uneven growth and with a backward general development. The urine shows a high specific gravity; sediment is absent (or a few fatty epithe lial cells and hyaline casts); chemically the demonstration of an albu min precipitable by acetic acid (euglobulin) is important, for this in the chronic nephritis of children is absent or only present in traces (Lang stein). From the standpoint of differential diagnosis one must always consider the exclusion of such nephritides which can begin relatively without symptoms especially in conjunction with infectious diseases and may persist insidiously. The albuminuria of puberty disappears when the organism of the affected individual recovers its balance in con sequence of better formation of blood and better nourishment with the completion of growth (in individuals with a congenital abnormal per viousness of the kidneys, the disposition to an excretion of albumin can remain permanent). Therapeutically a rest cure is not always success ful; in place of this properly graded, systematic exercise with a view to greater general and especially cardiac development should be em ployed. Very exhausting bodily exertion should be rigidly excluded and long periods of rest observed. The food should be nourishing and sometimes the limitation of an excessive. meat diet to a moderate amount is of value. In any event alcohol, coffee and spices are forbidden. Mov able kidneys are found in girls even at puberty possibly from wearing constricting clothes (Rosenthal, HoRedeye!). The majority of cases of Addison's disease observed in childhood occur at puberty corresponding to the common appearance of tuberculosis at this age (Monti). Ogston found in a twelve and in a sixteen year old girl, besides hypoplasia of the internal genitals, greatly enlarged suprarenal glands. As far as the bladder is concerned persistent. enuresis generally ends at puberty with a not infrequent increase in girls up to the beginning of menstruation. In boys this annoyance lasts more commonly into puberty when the prostate gland, which only develops to a considerable extent between the tenth and fourteenth years, gradually provides sufficient obstruc tion during sleep (Dittel, Bokai).