Part 19

Diseases of the Respiratory Organs.

Not uncommonly at this period of life the growth of a goitre is observed. The influence of puberty on the growth of the thyroid body has indeed been asserted by several authors; and Neudörfer maintains that precisely during the period of puberty to this body must be assigned an important regulatory trophic significance for the nourishment and growth of the reproductive organs. Steinberger and Sloan record the observation of cases occurring in young girls in whom, menstruation having first been regular, but having been suddenly suppressed in consequence of external noxious influences, a rapidly growing goitre suddenly appeared.

P. Müller states that in many regions, as for instance in Canton Berne in Switzerland, where the school children exhibit with extraordinary frequency a hereditary tendency to the formation of goitre, during the years of childhood these growths are much less frequent in girls than in boys. At the time of puberty, however, this relation is entirely changed. Whereas in boys from this time onward no further growth of the thyroid body is observed, in girls at puberty the hypertrophy greatly increases, so that very large goitres are formed. The same author recurs to the earlier observations of Heidenreich and Schönlein, as well as to those of Friedreich, by which this influence of puberty is strikingly manifested, and he believes it to be established by experience that sexual excitement can produce a transient swelling of the thyroid body. He alludes also to the remarkable fact that a swelling of the thyroid body, to which a number of animals show a tendency, occurs chiefly at the time of heat or rut; this is especially well known to occur in the case of stags. Similarly, during menstruation, a transient swelling of the thyroid body can sometimes be detected; the swelling is greater if the menstrual discharge fails to occur.

Diseases of the Organs of the Senses.

At the time of the menarche in cases in which there is retardation or some other disturbance in the regular appearance of menstruation, affections of the eye are observed, which are in part functional, dependent on reflex influences proceeding directly from the genital organs without organic changes, and in part are due to circulatory disturbances. Mooren, S. Cohn, and Power have discussed the relations between the uterus and the eyes in general, and also in this especial connection. Of ocular troubles during the menarche, iridochoroiditis, hæmorrhages into the vitreous body, long-continued blindness, and pannous keratitis, are mentioned, which may either disappear with the reestablishment of menstruation (spontaneous or artificially effected), or may exhibit in such circumstances a notable alleviation. Chronic inflammatory states of the conjunctiva, usually of an eczematous nature, which frequently occur at the time of puberty, often exhibit a relation to the menstrual process, a monthly exacerbation of the ocular trouble coinciding with disordered menstruation, and cure taking place only when menstruation has become perfectly regular. Vicarious hæmorrhages into the vitreous body also occur, associated with disturbances of menstruation, the relapses ceasing as soon as menstruation becomes regular; such a case was observed by Courserants in a girl of fourteen years.

Disturbances of hearing have been observed at the time of puberty in young girls addicted to masturbation; the patients complain of subjective noises, rising in intensity till actual hallucinations may be experienced. Lichtenberg reports the case of a strong girl eighteen years of age, in whom the congestion associated with puberty was followed by atrophy of the auditory nerve. The same author, also Ashwell, Law, Puech, Rossi, Stepanow, and Gilles de la Tourette, have published cases of vicarious menstrual hæmorrhage from the external auditory meatus, occurring in girls of ages varying from 14 to 16, 17, 20, and 22 years. Amongst these cases, in some the auditory organ was in a healthy condition, but in others there was associated purulent discharge; the bleeding took place from the ears at the menstrual periods, the proper menstrual discharge being absent or scanty; after the ear trouble was cured, menstruation was normal. Of 200 cases of vicarious menstruation, there were, according to Puech, six in which the vicarious bleeding was from the ears.

Disturbances of the olfactory sense, taking the form, sometimes of diminished acuteness of this sense, sometimes of increased acuteness, and sometimes of perversion, also anomalies in the secretion of the nasal mucous membrane, either abnormal dryness, or greatly increased secretion of mucus, come under observation at this period of life, either as reflex manifestations through the intermediation of vasomotor nerves at the time of the first appearance of menstruation, or in consequence of chronic nasal catarrh, which may be connected with masturbation. In cases in which the menarche is retarded, vicarious epistaxis may also occur, the bleeding sometimes being very profuse, in one case, indeed, reported by Fricke, in a girl seventeen years of age, having a fatal termination. According to Mackenzie, sexual excitement leads to swelling of the nasal mucous membrane, and habitual masturbation to chronic nasal catarrh; the same author asserts that during menstruation, swelling of the turbinate bodies may always be observed, and that in this lies the explanation of the fact that many women complain of a monthly cold in the head as an accompaniment of menstruation.

Diseases of the skin are not uncommon in young girls at the time of the menarche, and later as an accompaniment of each successive menstruation. It is a well-known fact that at puberty girls sometimes lose a hitherto beautiful complexion, and suffer from various disfigurements of the skin of the face. These are produced especially by the profuse secretion of sweat, and by the excessive secretion of the sebaceous glands, which so often results in acne, an inflammation of these glands. Ecchymoses also, effusions of blood into the skin, are observed, especially, as a form of vicarious menstruation, in cases in which menstruation is irregular. When actual bleeding occurs from the intact skin, the blood finds its way out through the sudoriferous ducts—hæmatidrosis occurs; in some cases, however, the hæmorrhage takes place from areas of skin altered and injured by disease, from wounds or other injuries, from ulcers, or from excrescences. Hæmorrhage into the skin occurs also in the so-called stigmatization, in which condition also an etiological role has been assigned to menstruation.

In the skin, remark Spietschka and Grünfeld, a new life begins at the time of the development of puberty, and it is this which first gives to human beings the external characteristics of sexual maturity. In certain regions which have hitherto been covered only by fine downy hairs, thick, strong hairs develop, and at the same time the general growth of hair becomes more active. These regions are, the genital region, and the axillæ. This increased growth of hair is accompanied by a stronger secretion of the sebaceous glands, which very often is in excess of actual requirements, and may thus lead to cosmetic disturbances and to various diseases of the skin. Thus arise the various forms of seborrhœa. The commonest of these is the formation of comedones, which, at the time of puberty, may make their appearance especially on the nose, the forehead, and below the corners of the mouth, but also on other parts of the face or on the back and the breast; in those regions, that is to say, in which the sebaceous glands attain a considerable size. The retention of the sebum may give rise to inflammation, which the access of micro-organisms converts into suppuration. Thus arises acne vulgaris. In another form of seborrhœa, the secretion is more fluid in consistence, and collects on the surface of the skin, furnishing this with an oily covering—seborrhœa oleosa. This most commonly occurs on the face; if the fatty layer is removed, the skin remains dry for a brief period only, and soon becomes greasy and shiny once more. Dust readily adheres to the greasy surface, and this gives the face a dirty appearance. Seborrhœa faciei is readily converted into eczema.

With the puberal development of the external genital organs is associated an increase in the sebaceous secretion of these regions. On the clitoris and its prepuce, and on the folds and in the furrows of the vulva, in consequence of insufficient cleanliness, an accumulation of sebum and cast-off epidermic scales readily occurs; such an accumulation may become rancid, may irritate the skin, and may thus give rise to erosions and to purulent secretion.

In chlorotic girls at the time of puberty, on account of the anæmic condition of the blood, eczema is not uncommon, especially on the hands and the face. On the face, or on the forehead, red papules appear on circumscribed areas, and become vesicular; raw, weeping spots are thus formed, and have a very disfiguring appearance. Such eczema may occur also in connection with disturbances of menstruation, when the menses are scanty and pale, or when dysmenorrhœa is present.

At the time when menstruation ought to appear, but fails to do so, sometimes also, when menstruation is regular, with each successive period, an eruption of urticaria takes place; it usually disappears quickly, but in some cases is more persistent; owing to the intense itching it is always an extremely distressing complaint. Sometimes it takes the form of urticaria factitia, in which the skin reacts to every kind of mechanical stimulation, such as rubbing, scratching, or pressure, all of which alike lead to the formation of weals, which may be diffused all over the body. Less often in association with disturbances of menstruation, acute œdema or erythema are observed.

Finally, we must mention herpes progenitalis, a rather uncommon acute condition in which, with violent itching and burning sensation, intense redness and œdematous swelling of the skin, vesicles form on the præputium clitoridis, the nymphæ, and the inner surface of the labia majora.

Hygiene During the Menarche.

It is the object of rational hygiene to increase the resisting power of the organism, which has been depressed by the processes of the menarche, in order that the increased demands made by the awakened sexual life may be adequately met.

The principal means for this purpose are, suitable diet, a suitable mode of life, and the employment of physical therapeutic measures, among which strengthening and hardening measures are to be preferred.

The diet should be at once as richly albuminous as possible and readily digestible, there should be several, four or five, meals every day; in chlorotic patients food should be taken at regular intervals of two to three hours. Meat should be a predominant article in the diet, but fresh vegetables should also be eaten in abundance for the sake of the nutritive salts they contain; the vegetables rich in compounds of iron, such as spinach, oats, beans, and lentils, are to be recommended; fruit, raw or cooked, should also be taken in considerable quantities. The evening meal should not be too succulent or too plentiful; it may best consist of soft-boiled eggs, an omelette, or milk. Alcoholic beverages should be avoided or taken in minimal quantities; only as a stomachic may a glass of beer or of light wine be recommended.

Chlorotic patients should even at their first breakfast have a meal rich in albumin, such as a considerable helping of meat, or a beefsteak, with rolls, butter, and tea or coffee. Milk should be taken in small quantities only, not more than a pint to a pint and a half daily; only when solid food cannot be tolerated should milk be given freely. Beer and wine are often of value in chlorotic girls from their stimulant action on digestion and circulation. Half an hour’s rest before and after meals is useful.

For the bill of fare of these patients I recommend especially: Roast beef and veal, underdone beefsteak à l’Anglaise, ham; roasted venison, hare, partridge, grouse, fieldfare, hazel-hen, ptarmigan, pheasant, chicken, pigeon, turkey, oysters; asparagus, cauliflower, and spinach. For variety, fish or shellfish may occasionally be taken. Sweetbread in soup or with sauce forms a very delicious and easily digestible dish.

Kahane recommends for chlorotic patients the systematic use of Bavarian beer, to the amount of about two pints daily; it should, he says, be a beer rather dark in tint, full-brewed, rich in malt, but containing a comparatively small proportion of hops, alcohol, and carbonic acid. Jaworski has recommended a dietetic iron-beer, containing 4.7 per cent. of alcohol and from 0.0317 to 0.0644 per cent. of iron.

When girls are at the same time anæmic and very thin, fat-containing foods must be taken in abundance, such as milk, butter, and cream; also large quantities of carbohydrates. Farinaceous foods, rice, potatoes, arrowroot, sago, tapioca, oatmeal, barley meal, carrots, turnips, sweet fruits, grapes, dates, pippins, plums, pears, and preserved fruits—all these must appear at table more frequently than usual; beverages, in addition to milk, that are suitable are chocolate and cocoa, Bavarian beer, and sweet, heavy wines.

The diet-table of such thin chlorotic patients should be as follows:

First breakfast, 7.30 to 8 A. M.: Coffee or cocoa with milk, or a pint of milk, white bread and butter, honey. Second breakfast, 10 A. M.: Half a pint to a pint of milk, egg and bread and butter, or sandwiches of sausage, ham, or roast meat. Mid-day dinner, 1 P. M.: Soup, roast meat with vegetables and potatoes, or fish may take the place of the soup, sweets to follow. Afternoon, 4 P. M.: Coffee with milk, or a pint of milk, with bread and butter. Supper, 7.30 P. M.: A plate of meat with accessories. Evening, 9 P. M.: A glass of milk.

In the treatment of the anæmic form of obesity, to which chlorotic patients of the better classes are subject, in consequence of sedentary habits and overfeeding, the diet must be so arranged that albumins predominate, whilst carbohydrates should be given sparingly, and as little fat as possible. As the average quantities of the food elements required in such cases, I suggest, 200 grammes of albumin, 12 grammes of fat, and 100 grammes of carbohydrate.

The quantity of fluid taken must be as small as possible, since the deprivation of water may result in a proportionate increase in the solid constituents of the blood, and thus increase its hæmoglobin-richness.

The amount of physical exercise taken by young girls at this period of life must vary according to the circumstances of each individual case. In general, we may recommend for them much active movement, especially in the open air, in order to counteract the effects of sedentary habits and confinement in close rooms. Chlorotic patients must, however, be careful to avoid overdoing their exercise, and in some cases it will be necessary to limit the amount of this very strictly. In severe cases of chlorosis, Nothnagel, Hayem, and other authorities recommend complete rest in bed for from four to six weeks. This rest-cure can be carried out as far as possible in the open air, and can be combined with systematic massage and the use of passive movements.

I have drawn up the following diet-table for obese chlorotic patients:

┌───────────────┬────────────┬────────────────────────────────────────┐ │ │Quantity in │ CONTAINS OF │ │ │ Grammes. │ │ ├───────────────┼────────────┼────────────┬────────────┬──────────────┤ │ „ │ „ │ Albumin. │ Fat. │Carbohydrates.│ ├───────────────┼────────────┼────────────┼────────────┼──────────────┤ │ Morning: │ │ │ │ │ │Beefsteak │ 100│ 38.2│ 1.7│ ——│ │A cup of tea │ 150│ 0.45│ ——│ 0.9│ │White bread │ 30│ 2.9│ 0.2│ 18.0│ │ │ │ │ │ │ │ Mid-day: │ │ │ │ │ │Meat soup │ 100│ 1.1│ 1.5│ 5.7│ │Roast meat │ 200│ 76.4│ 3.4│ ——│ │Vegetables │ 50│ 0.8│ 0.2│ 4.2│ │White bread │ 50│ 4.8│ 0.4│ 30.0│ │Light wine │ 150│ ——│ ——│ 1.0│ │ │ │ │ │ │ │ Afternoon: │ │ │ │ │ │A cup of coffee│ 120│ 0.2│ 0.67│ 1.7│ │White bread │ 25│ 2.4│ 0.2│ 15.0│ │ │ │ │ │ │ │ Evening: │ │ │ │ │ │Roast meat │ 200│ 46.4│ 3.4│ ——│ │Vegetables │ 25│ 0.4│ 0.1│ 2.1│ │Wine │ 150│ ——│ │ ——│ │White bread │ 30│ 2.9│ 0.2│ 18.0│ ├───────────────┼────────────┼────────────┼────────────┼──────────────┤ │ Total│ 1380│ 206.97│ 11.92│ 97.6│ ├───────────────┼────────────┼────────────┼────────────┼──────────────┤ │Contains about │ │ │ │ │ │1300 calories. │ │ │ │ │ └───────────────┴────────────┴────────────┴────────────┴──────────────┘