Acute infectious diseases come with the greatest frequency in ear lier childhood; according to our observations scarlet fever and rheu matism are still striking at the beginning of puberty on account of the relatively higher morbidity. Mumps is noteworthy on account of the inflammatory metastases of the sexual glands (testicles, ovaries) which not infrequently occur, with severe local symptoms. As regards the chronic infectious diseases, the great frequency of tuberculosis at the period of puberty (page 110) has already been considered. Syphilis is infrequently observed either as a fresh infection following premature sexual intercourse or criminal abuse, or as late hereditary syphilis with which the symptoms of the inherited dyscrasia are not always observa ble in earlier childhood. Of the manifold evidences of this are here to be mentioned: hyperplastic periostitis of the tibia or of the head, ster num, etc., gummatous processes and further, obstinate chronic metrical joint affections (suggesting deforming arthritis), destructive processes of the nasal cartilage, of the soft. parts of the lung and of the pharynx with consequent star-shaped cicatrices, indolent glandular infiltration, Hutchinson's triad, from the side of the nervous system in addition to contractions and paralyses, lesions of the cranial nerves, also chronic enlargement of the liver and spleen generally without icterus or marked ascites and finally a retardation of the general and especially of the sexual development (Heubner, Hochsinger).
Of skin affections those that stand in close connection with an in creased activity of the sebaceous glands, comedones, acne and furuncles are to be mentioned as common occurrences in the years of puberty.
Affections of the eyes with the exception of the great frequency of myopia at the time of rapid growth, are not infrequent and are to be considered in connection with the hyperaemia of the retina, optic nerve and brain. Acne of the edge of the lids (hordeolum) is often seen in those at puberty. To be mentioned are the pre-menstrual retinal hypertemias with obscured vision and headache, disturbances in the ehorioid mem brane and retina, which consist of exudation and haemorrhage, but these generally go on to complete recovery. Further to be mentioned are oedema of the head of the optic nerve with immediate improvement after the beginning of menstruation and a periodic return before each menstruation, atrophy of the optic nerve with amenorrhoea and ful minating transitory pre-menstrual amaurosis (Klopstock). In nervous individuals concentric contraction of the field of vision, asthenopia, hemeralopia and flittering scotomata are seen; sometimes there are hemorrhages into the vitreous humour which recur until menstruation is regularly established. Anaemic girls may have a slight inflammation of the whole uveal tract (Gutman).
As has been mentioned above (see page 115) the nervous and men tal life is concerned in a striking manner with the processes character izing puberty. Children who have been previously healthy so far as their nervous system is concerned not infrequently exhibit phenomena at this time which at another time would be considered pathological. A congenital neuropathic disposition may now first become noticeable or irrational hygienic and pedagogic measures at home and in school may give rise to considerable nervous disturbances. First and foremost, headaches are a common occurrence with different localizations, some times recurring periodically, sometimes permanent, so that the ability to pay attention and to perform mental work may be very greatly af fected. Active hyperaemia of the brain is not infrequently the cause of this; this phenomenon is often associated with vertigo, spots before the eyes and ringing in the ears and possibly also hypertemia of the face.
Passive hyperasmia often results from wearing clothes which compress the neck and body, from bending over sharply at work and from inter ference with nasal breathing. Overstraining of the eyes on account of anomalies of refraction is to be considered. Antenna of the brain with anomalies of the blood and insufficient nourishment can give rise to headache which also can be caused by mental overstrain. Other fac tors to be mentioned and which are also to be observed from a prophy lactic standpoint are bad, and overheated air and deficient light while at work; further, dyspepsia and constipation and finally also alcohol and nicotine. The prophylaxis and treatment will be found under the general hygienic and dietetic measures for puberty on page 12S. llemi crania not infrequently appears at this time if it has not previously existed, in which case it may cease. Premonitory symptoms not infre quently precede the typical attacks of headache in the form of weak ness, vertigo, depression and irritability: vomiting generally follows at the height of the attack and at the end quiet sleep comes on. Over filling the stomach often acts as a cause as does the ingestion of alcohol, emotions and physical strain. We not infrequently observe at puberty the symptoms of general nervousness based upon an inher ited tendency and this shows itself in the form of a permanent excita bility with extraordinary sensitiveness to mental impressions and with explosive reactions; on the other hand we frequently meet the ready exhaustion characteristic of neurasthenia, caused by slight or moderate mental or bodily activity in which sensations of pressure in the head, languor, pain in the back and sleeplessness may appear. Especially in the years of puberty, epilepsy, which up to this time not infrequently has evidenced itself by the phenomena of temporary loss of consciousness, or in attacks of vertigo, reaches full development. The expectation often raised by the laity, that epileptic convulsions already developed may disappear at the beginning of puberty, is unfortunately seldom fulfilled; rather more commonly there is an aggravation of them. While the greatest frequency of chorea, especially the so-called rheumatic chorea, occurs in the school years before the time of puberty, chorea, especially in girls, can have its beginning at this time. In addition to the characteristic involuntary movements a psychical alteration is often very striking, in the form of irritability, absent-mindedness, weakness of memory and slight mental exhaustion. As causal factors, emotions (fright and anxiety) come into consideration. The chorea which on the basis of imitation breaks out occasionally in schools almost epidem ically, belongs in the domain of hysteria. The congenital diseased ten dency underlying this expresses itself in early childhood generally in single local symptoms of bodily functional disturbance such as hypo- or hyperkinesia. Accidents, emotions and psychical contagion are effective causes. With progressive bodily development a childish hysteria may disappear or show the characteristic protean and contradictory form of disease in which purely psychical conditions may with extraordinary rapidity take on the most various physical symptoms of disproportionate dimensions and duration. In addition to the typical convulsions, attacks may appear simulating unconsciousness, later stupor, prolonged sleep and somnambulism, but this condition never goes on to dementia.