The appearance of conspicuous mental weakness is an early symp tom of hebephrenia; this stands in close connection with the rapid and total change of the bodily and mental development and always appears in connection with puberty (Hecker, Kahlbaum). Generally the patients are individuals already backward in their bodily and mental development in consequence of previous illness, in whom, often appa rently after an emotional shock, mental depression is first noticed (with delusions and impression of persecution); then excitement alternates with causeless mirth and a tendency to foolish speaking, in speech and in writing a delight in arbitrary imagery appears, often with a striking tendency to take up a subject over and over again; a sentimental method of expression, a forced tone full of meaningless phrases and affected speech are typical phenomena. An exaggerated impulse to be doing something is made evident by aimless actions, such as littering things about. These patients may remain for a long time at the mid-point of mental decay and during this time periods of excitement amounting to delirium may come on in consequence of outward causes such as men struation or hallucinations. Generally the termination in a state of extreme mental weakness follows in the course of a few- months often with destruction of the mind. If on the one hand the phenomena of hebephrenia in the initial stages are often merely the same that we meet in healthy individuals as transitory appearances at puberty, on the other hand, nevertheless, victims of dementia praecox often show cer tain peculiarities much earlier; these arc a reticent, sly manner, whim sicalness, unruliness, irritability and moral instability.
In addition to the hebephrenic form of dementia prwcox described above, other forms may begin at puberty and lead to marked mental weakness; the catatonic form for instance, in which, after an initiaL stage of depression, states of stupor alternate with excitement, and there appear characteristic phenomena of motor spasm and motor retardation; then the form similating paranoia, characterized by hallu cinations and illusions as well as by rapid mental decay. Other psy choses may now and then be observed at the time of puberty, and it may be worthy of note that paralytic dementia not infrequently has its. beginning at this period. attacking both sexes with about equal fre quency. According to Alzheimer the majority of such cases may he traced to syphilis, the later manifestations of which appear about this time. The disease runs its course with many epileptiform and apoplec tiform attacks, with choreic disturbances and especially with paralytic phenomena, and ends rapidly in complete dementia. During the course of the disease, states of excitement and of confusion are (but rarely) to be observed while optic atrophy is common.
The great frequency of diverse pathological processes is indicated by the above consideration; but it must also be remembered that the physio logical sexual development a critical period, requiring inncit insight and con sideration from parents and teachers. In the following pages will be given merely the principles of a rational hygiene for the periods of puberty.
So far as nutrition is concerned. the rapidly growing children at the age of puberty require an increased quantity of food. more than the amount necessary for adults. The latter have only to preserve their equilibrium by supplying the material that is used up; the corporal development of puberty, on the other hand, a great acceleration as it is over the growth in preceding years, which is shown by the gain of 10 Gm. instead of 5 Gm. daily, calls for an increased supply of food. Accord ing to Voit, Uffelmann and 01111110er, the average of food required daily consists of 70-90 Gm. of proteids, 20-50 Gm. of fats, and 500-250 Gm. of carbohydrates. Even though the capacity of the digestive apparatus at this time does not place any restriction upon the quantity or quality of the food-stuffs. Yet special consideration must be exercised in ref erence to the composition of the food. Of the special indications, the body weight is to be considered more than the age; moreover, abundant. exercise in the fresh air is required with a diet that is mostly vegetarian. This fact is especially to be considered with those children that may have previously been accustomed to an abundant supply of proteids and fats, while for poorly nourished individuals a diet especially rich in fats is sometimes advisable. In all cases such animal food-stuffs as are rich in easily assimilated proteids, for example, milk, eggs, and cheese, are never to be placed too much in the background, especially in the diet of girls inclined to chlorosis. With boys, on the other hand, a diet too abundant in meats shows, at certain periods unfavorable effects upon their state of nervous excitability. To avoid this excitability it is advised that both sexes should abstain from sharp and stimulating articles of diet, such as mustard, large quantities of vinegar, strong coffee, tea, spices, and alcoholic beverages of any kind. Tobacco, of course, belongs also to the group of forbidden articles. It must be in sisted upon that sufficient time be allowed for meals, especially in the ease of school children. ;o far as evacuation of the bowels is concerned, children at puberty are of course to be trained in regular habits, if such habits have not been acquired at the proper time. A rational nutrition
by means of a simple yet not monotonous diet is a necessary condition for normal development. Important for the attainment of the last named end is the exclusion in dress of all articles of clothing that may interfere with the function of the respiratory, circulatory and digestive organs, such as narrow collars, belts, corsets and skirt-strings. The weight of the clothes is to be evenly distributed upon shoulders and hips. Both the skeleton, that is not vet perfectly firm, and the muscles, not yet completely developed in strength, react very readily to injuries of any sort, with the production of such deformities as we have described above (page 120). Attention is to be paid to correct posture while writing, as well as sufficient light during work in the school or at home. Sitting down for long periods of time occupied with work requiring men tal effort is an injurious factor of first importance at the time of puberty; and to combat this the temporary freedom from all work is often more rational than additional tasks that seem to suit the mental progress of the child. Increase of work requiring mental effort is to be regulated in this period solely by the progress of bodily development. Rational division of lime between work, relaxation, and rest, with thorough use of the periods allotted to each, is very important in each case. While in general almost all the hours at school are devoted to the mental edu cation, the attention to the physical development is relegated almost exclusively to the parental home, where private studies of all sorts in addition to the required school tasks lead to overwork of the brain, that is so sensitive during this period. In order that a race healthy in body and nerves may be raised, it is necessary to make changes in the above arrangement. The school must assign more time to compulsory physical exercise, while the requirements in mental work are to he cor respondingly diminished, yet the fact must not be lost sight of, that systematic physical exercise is not necessarily equivalent to relaxation in all individuals. The various sports that have become so popular at the present time are valuable factors in opposing the injury done by the school, provided they are regulated according to individual capaci ties, and are not allowed to obtain complete hold of the sphere of men tal interests. Excessive physical exercise can easily do harm in the period of puberty. While systematic gymnastic exercise strengthens the muscles, and exercise especially in the fresh air, by such means as rowing, swimming, cycling, skating, tennis and ball games produces good effect upon the capacity of the thorax by the increased expan sion of the lungs, as well as upon the various groups of muscles and the general bodily agility, yet overfatigue may result with grave sequels in its train. Accordingly the duration and intensity of exercise is always to he carefully limited; this is especially true of cycling, which like other too strenuous exercises easily leads to overstraining the heart, ready as the latter is to break down at this period of development. Too prolonged a stay in cold water is especially to be forbidden to growing girls inclined to be chlorotie. Often not enough importance is attached to the hygienic value of a daily prolonged walk in the fresh air. The rational exercise of the body leads to a wholesome fatigue, which is made up for in the period of sound sleep. The latter is an especial necessity for individuals at the time of puberty, and care must be taken that its duration be perfectly sufficient and extend from 9 to 10 hours.
If we remember the necessity for sufficient sleep, and the various injuries that may be produced by nervous excitement, sensual stimula tion, alcoholic excesses and the like, it becomes clear that individuals at the age of puberty are best prevented from taking part in the so called social pleasures of any sort, unless, of course, the latter are made suitable, from every standpoint, to the stage_ of development of their age. In the sphere of education especial consideration is to be given to the nervous and mental life of such individuals. Individualized loving care and handling by considera-te parents and teachers lead most chil dren more easily and smoothly through this critical period, than the adoption of a strict routine, although at tittles energy and insistence ought to be displayed. It is important to keep guard over the reading matter, the amusements and the social intercourse of the child, while one of the tasks of a rational education nowadays is to furnish informa tion in regard to the natural sexual processes. This may best be done by the parents themselves, with the use of examples taken from the life of plants and animals (Siebert). If the parents or teachers of the child are nervous themselves, very grave conflicts may occur at this time.. In order to prevent such conflicts and to remove the harm that may be done by such bad example to the already sensitive nervous organism of the growing child, it is often advisable, from the physician's standpoint, to remove children, endangered in such fashion, from the or from their home, or even from life in the city, unfavorable as the latter often is in other conditions. In such cases, the boarding schools in the country are best suited to guide the child correctly in passing through the period of puberty.