Household duties, if moderate, are a good regulator. Girls must be taught to endure disappointment, to relish the common ' Overpressure in the High Schools of Denmark. London, 1885.
244 THE PSYCHOLOGY OF ADOLESCENCE homely joys of life, to be content and hopeful as they now rarely are, to avoid extreme fatigue, excitement or exposure, high diet, etc. He concludes by recommending, as better means against threatened decadence, a health report book for each child, such as Hornemann had proposed.
Soon after the first publication of Hertel, the Danish Gov- ernment in 1882 appointed a commission which examined 16,889 boys and 1 1,225 girls, and found 29 per cent of the boys and 41 per cent of the girls sickly, the highest per cent — nearly 50 — being reached at the age of twelve and thirteen.
In 1885 Key published the report of a Swedish commission, of which he was the head,^ and which was chiefly devoted to examining the health of i5,cx)o boys in the Swedish middle schools and 3,000 girls in private schools. Key's studies were made in March and April, and showed a far greater percentage of poor health than in Denmark, where HerteFs data were gath- ered in the fall. At the beginning of the school year, children are more lively, stronger, and more healthful than in winter. Toward spring and near the end of the school year, morbidity reaches its maximum, so that the school is then most detrimen- tal to health.
Eliminating all acute and all chance illness and studying only chronic troubles, states, and feebleness, special curves were constructed by Key for pallor or anemia, headache, near- sightedness, other eye troubles, nosebleed, loss of appetite, scrofula, nervousness, spinal curvature, and other slow diseases. The high percentages of these diseases and their generally rapid increase were alarming. Over 13 per cent of the boys suffered from frequent headache and nearly 13 per cent were anemic. From the first to the second school year, 5 per cent of illness in- creased to 36 per cent, and in the fourth school year reached 40 per cent. There was a great increase in the percentage of ill- ness near the beginning of puberty. As soon as this is well begun, the rate of illness sinks term by term. The increment of weight has closer relation to health than height, for these ^ Laroverkskomit^ns Betankande III. Stockholm, 1885, 2 vols. With elabo- rate tables. This is greatly condensed and most of the elaborate tables are omitted by Burgerstein in a work entitled, Schulhygienische Untersuchungen, 1899. See also Key: Die Pubertats Entwickelung, Verhandl des Internat. Med. Congres zu Berlin. Vol. i, 1890, p. 67 et seq.
DISEASES OF BODY AND MIND 245 diseases decrease almost pari passu with increase of weight. Just when weight is increasing fastest, there is least liability to illness; but as the growth rate declines, the sickness rate rises steadily to a second maximum in the nineteenth or twentieth year. The seventeenth is the healthiest of all years for boys, yet the eighteenth is sickly. When the body grows slowly at an age when it should grow fast, it offers least resistance to disease, and while children are growing fast they are least liable to these illnesses. The weak period just before puberty seems exceptionally liable to disease. While in general the re- sults agree with Hertel's, they still lack confirmation in other lands, although there is no reason to think them peculiar to Sweden and Denmark.
Key's studies of girls were based on those from the upper classes of society, but he found 61 per cent more or less sickly. Of these, 36 per cent were anemic and nearly the same num- ber had habitual headache, 10 per cent had spinal curvature, and 5 per cent scrofula. This illness curve rises to its maximum of nearly 65 per cent in the thirteenth year. Illness of girls con- tinues to increase awhile after the beginning of the period of puberty, but soon slowly ceases to rise and then falls, although at no age under 60 per cent, to rise again after the period of in- crease weight growth is passed. That these girls, whose health is so impaired at the beginning of the increment period, do not decidedly improve during its later stage is a ground for the gravest apprehension, and shows according to Key that modern methods of educating girls are radically and dangerously wrong, perhaps in being too much like the methods applied to boys. It is not safe, however, to reason directly from the pubertal phenomena of one sex to those of the other.
Hertel,^ who later compared the results of the two com- missions in two very suggestive articles, drew many practical conclusions, and found that of children who studied more than the normal time, 7 per cent more were ill than of those who worked less than this time. Key determined the average time devoted to study by 2,000 Stockholm Gymnasium pupils, living under uniform conditions, and found that over 5 per cent more 1 Neure Untersuchungen iiber den allegemeinen Gesundheitszustand der Schuler und Schulerinen. Schulgesundheitspflege, 1888. Nos. 6 and 7, pp.
246 THE PSYCHOLOGY OF ADOLESCENCE of those who studied over this average were ill than of those who devoted less time to study. In lower classes this difference was between 7 and 8 per cent, for young children have less pow- er to resist disease than pubescents. The injury caused by ex- cessive brain work in the latter class, although less manifest in actual sickness, is probably no less insidious, and is thus very likely greater and its evils more lasting. Rousseau long ago suggested the crude corrective of withholding Emile from study till he was twelve, but surely, says Key, after that age the school is very liable to squander in childhood the vigor of the future man. Key thought younger school children should sleep from eleven to twelve hours, and that in children of all ages, and perhaps especially during puberty, the need of the system for sleep is very rarely met in modern civilized lands. The time spent in bed is by no means the same as that in sleep, although so estimated. The latter decreases in almost exact proportion as the time given to study increases. In- stead of decreasing steadily, as children go up the classes and study harder, the amount of sleep should increase with the growth of mental activity until the body is mature, and should be distinctly augmented at puberty.
In about 2,000 children in Lausanne, Combe ^ found the per- centage of morbidity (chiefly anemia, headaches, catarrhs, indigestion, and respiratory troubles) as follows, from which, comparing annual increase in height, he inferred that mor- bidity and growth increased together. To this we have added, in the lower row of figures, the results of Nesteroff's ^ test of 216 boys in a Moscow gymnasium.
The diseases of the Russian children in the lower row in the order of frequency — ^nervous troubles being excluded — ■ were throat troubles, 15 per cent; general disturbance of di- gestion, 10 per cent; sight, 8; chronic lung trouble, 7; spinal ^ Korperlange u. Wachsthum, etc. Zeits. f. Schulgesundheitspflege, 1896, ' Die moderne Schule u. d. Gesundheit. Zeits. f. Schulgesundheitspflege, DISEASES OF BODY AND MIND 247 curvature, 6 per cent. Of all these children 71 suffered from nervous troubles, which increased very steadily from 8 per cent on entering to 69 per cent at the end of the eighth year. Dur- ing Nesteroff's four years' record he found that each pupil needed a doctor on the average about five times a year, most often for colds and nervous troubles, and that there were two ages of maximal illness, viz., twelve and seventeen.
Zak ^ finds among 4,245 Moscow secondary pupils the fol- lowing percentage of nervousness: Lesgaft found very frequent swelling of the veins of the seminal cord among the St. Petersburg pupils, especially in the- middle and higher grades.
Dr. Schmidt-Monnard,^ a specialist in children's dis- eases, investigated the chronic disorders of 5,100 boys and 3,200 girls as to anemia, chlorosis, headache, nervousness, sleeplessness, defect of appetite, digestive troubles, nosebleed, chronic inflammation of the cornea, and abnormal refraction of the lens. In the middle schools among 2,100 boys, he found nine and twelve the most sickly years, where morbidity from all causes reached 30 and 35 per cent respectively, and that sleep- lessness culminated at the age of twelve. Among 1,900 girls in the same class of schools, the year of maximal sickness for all diseases was thirteen, where it reached nearly 50 per cent; at the same period headaches reached 30 and nosebleed 8 per cent and sleeplessness reached its maximum, while as with the boys morbidity decreased materially the year after its maxi- mum. In higher private schools for girls, sickness increased rapidly from the twelfth to the fifteenth year, when it reached 57 per cent, and slightly increased for the two following years, as did nervous troubles, while sleeplessness at sixteen had reached nearly 10 per cent. In the Real schools and Gymnasia, the maximum of 40 per cent was reached at seventeen for those who had no afternoon session, and the maximum of over 70 per cent was reached at sixteen for those who studied after- ' Die chronische Kranklichkeit in unseren mittleren und hoheren Schulen Zeits. f. Gesundheitspflege, 1897, pp. 593 and 666.
248 THE PSYCHOLOGY OF ADOLESCENCE noons, while headaches alone considered culminated at seven- teen and sleeplessness at eighteen. The differences in all ages were strikingly in favor of those who did no evening work.
Schmidt-Monnard also attempted to compare normal with actual hours of sleep for each age for boys.
Cephalgic congestion increases with brain-work, and thus causes school headaches, or as Charcot called it cephalgia adolescentiuntj and nosebleed. Key and Becker have shown that this increases in the upper Gymnasia classes, and while there are other etiological factors, overpressure is one, though perhaps not the chief. Both pain and hemorrhage are greatly increased by the neuropathic diathesis.
In a study of the death rates in the school population of Boston, which for the years 1885 and 1890 numbered 70,000 between the ages of five and fifteen when the average annual number of deaths was 471, Dr. HartwelP found that the period from ten to fifteen, which was characterized by the most rapid increase in height and weight, was also that in which the fewest deaths occurred. For girls the year of lowest death rate or power to resist disease was the twelfth; for boys the thirteenth. These years were thus at once the period of ac- celerated growth and of accentuated specific intensity of life, or in other words, this is the period at which Boston school chil- dren attain and pass the flood-tide of growth as measured by their power to resist death. Acceleration of growth and life intensity begin, culminate, and decline about a year earlier for girls than for boys. This result was presented in the table comparing Bowditch's result for weight and height with the specific intensity of life for 1875, 1885, and 1890. For our pur- poses it is compared in the following table with other standards and the age of least mortality, which ranges from eleven to fourteen: ^ See Report of the Director of Physical Training of Boston. School Docu- DISEASES OF BODY AND MIND Acs.
Probability of dy- ing at each age. Farr, 50 years ago. England.
Death rate (England and Wales, Dyingineach year of age (Mass. Life Annual mor- tality per unit at each year of age (Mass. Life Death rates of Boston children, M.
F.
M.
F.
M.
F.
M.
F.
8 IIO III 50 17 Journal of Adolescence, October, 1900, pp. 55-56.
The following table ^ shows the mortality of each age and sex in Prussia on the basis of i,ooo inhabitants: Ybars.
M OS 00 M 1 «oo M 00 00 91 lO.O II2.0 o- II. 2 II. 9 Symonds found for his table of American Life Insurance Societies that mortality is less for girls than for boys in the period preceding and following puberty in the ratio of 1.68 The expectation of life for men at different ages^ ^ Compiled from several tables in the Deutsche Vierteljahrschrift f. off. Ge- sundheitspflege, Bd. 3, 1899. Suppleipent, pp. 50-53.
^ Monatsblatter fur die Vertrauensarzte der Lebensversicherungsbank Gotha I.
THE PSYCHOLOGY OF ADOLESCENCE Completed year of life.
Number of Average dura- Number living.
those dying next year.
Probability of death.
tion of life in years.
25 53 26 54 27 55 28 56 29 57 30 59 In the chart on p. 251, from Engelman/ curve A repre- sents the percentage of morbidity for prepubescent Danish girls from Key and Hertel, as we have no good and comprehensive American data. It is adapted to American girls by giving it the same relation to the period of prepubertal development, here averaging 13.8 years (indicated by the short vertical line near the bottom), that it bears to the time of first menstruation in Denmark, which is ij years later. B is Hartwell's curve of life intensity or the power to resist lethal influences, which is an expression of the nutritive activity of the organism during its period of greatest and most rapid growth, and is based on the ratio of the number living to the number dying. This curiously enough conforms generally to the curve of morbidity. C is the mortality curve, which is almost diametrically opposite that of morbidity, i. e., just during those years from eight or nine to thirteen or fourteen, when American girls are most likely to be sick they are least liable to die. D is the curve of growth in weight, and E represents the percentage of stuttering as indicating augmented nervous excitability.
We now pass to consider the special morbidities of ado- lescence. Very prominent among the physiological disturb- ances of this age are those of indigestion and disorders of the alimentary canal, and especially of the stomach. The rapid bone growth requires more lime, the blood needs iron, the in- creased metabolism more oxygen and more fats for heat, per- haps the brain more phosphorus, the muscles require more protein and muscle work more inogen and myosin to break down, and normally the food supply is increased with height and weight, and the chemical bookkeeping of income and ex- penditure readjusted. Gamgee suggests that the ingesta may * The American Girl of To-day; Pres. Address. Gynecological See, 1900.
There is a sense in which the basal will to live is simply the will to eat and in which this latter is the basis of psychology. Nearly three-fourths of the total energy of the body, expressed kinetically, probably goes to digestion and half the struggle of life is for food. The very cells of our embryo, as they grow large so that their surface diminishes relatively to their content, must divide or die of starvation. Most of the movements of every form of life that has ceased to be sessile are to get food; organs of locomotion are to get to it or to escape being eaten by enemies. In the primitive struggle for survival, when two hos- tile creatures meet, one is destined to be the food of the other. The first fear is that of being devoured; the first form of prop- erty is accumulated food. Almost every living being is the food for some other, even the organs of our body struggle in rivalry for the food which the blood brings, and every form of disease and death itself is caused by cutting ofif the food supply from some group of cells. Sleep is to feed and build up again the nuclei of cells, which under the microscope are seen to have been worn away by activity, and to remove the chip pile of dead mat- ter. Fungoid growths are low level metabolisms, where the excreta or clinkers in the human furnace are not removed. What we call hunger is the massed and unconscious desire of every cell for the food it needs, and death in every form may be in a sense said to be due to progressive local or general starvation.
These general considerations, which I conceive to be the basis of the new genetic psychology of the future, may serve to give us due appreciation of the special importance for adoles- cence of the general law that there is a trophic or nutritive background to everything and to suggest that the profound metamorphoses of puberty involve adjustments far more radi- cal than are usually imagined. Almost all returns to our food questionnaires, to be elsewhere more fully reported on, show that the appetite, which, if natural, is like a compass point- ing to the true pole of our somatic needs, is often gravely dis- turbed at this period. Nearly all report changed appetite. Foods, very prominent in the habitual dietaries before, are now DISEASES OF BODY AND MIND ^53 neglected and new favorites arise. This change is especially marked with regard to sweets, acids, fruits, meats, and stimu- lants. There is a new tendency to experiment, not only with new dishes, but often with things strange and even offensive. Boys dare each other to taste, eat, or swallow offensive and sometimes harmful things, or force their mates to do so, some- times with disastrous results, not infrequently suggesting the nauseous anthropological chapter of scatology. Boys some- times affect or boast of their achievements in eating, and girls affect daintiness, become exceedingly discriminating in sweet- meats, bonbons, summer drinks, etc. Boys have eating and drinking matches and duels, and intemperance very generally takes its rise here. Lancaster reported ninety-one spontaneous reconstructions of appetite in his returns. It is irregular, fast- ing and feasting perhaps alternate, strange whims or picse arise with sometimes extreme dislike of some one and passion- ate fondness for other kinds of foods. Taste seems to acquire a more inward and independent quality of its own, and junkets dainty-mouthed and perhaps stealthily, on titbits. Girls in particular become squeamish, fastidious, and lickerish, and per- haps develop a sweet tooth of disproportionate dimensions. It is never so hard to establish a well-balanced dietary, and yet this is the nascent period for it. Perverse tastes may grievous- ly interfere with health, and the rectification of appetite may be hard just in proportion as plasticity of this age passes into settled bad eating habits of later life.
I am convinced that one of the causes of diseased cravings, which may lead to wrong food habits and to intemperance, is due to the fact that the normal changes of appetite for both quality and quantity of food are perversions of normal appe- tite so often unnoticed and unmet. Now judicious oversight, perhaps eked out by a little wholesome authority, does more to push the psycho-physic organism on to pass safely over the immature stages and dangers of arrest and to come to full ma- turity with a real maximum of utilized nutrition, than almost any other influence. Very many of the failures of middle and later life are due to avoidable errors of diet, and the arrest thus caused. We know that many larvae and embryos of the lower forms stop at various stages of immaturity, if food is not abun- dant and fit, taken properly at due intervals, etc. Not malaria, 254 THE PSYCHOLOGY OF ADOLESCENCE as Morel thought, but perverted appetites, sometimes aided by adulterations and bad cooking, are one of the causes of human degeneration, because man, who ought to be polyphagous and can only with increased difficulty adopt a new food after the period of sex development, is really not fed according to his physiological needs. This is not only the cause of many break- downs among pupils and students, anemias and most of the maladies of malnutrition so common at adolescence, but of that disquiet, weakness, and lust for stimulants, which in part di- rectly and in part indirectly causes the appetite for drink, by producing either the extreme fatigue under only normal strain, that often has recourse to it, or else this craving is due to lack of proper exercise which so strongly prompts to the quest of arti- ficial excitement.
The wisdom teeth too are now forming, and the chin and lower jaw and the muscles of mastication are growing. Biting sticks, toothpicks, pencils, etc., is an automatism, the curve of which now undergoes a marked rise. The propensity for gum chewing, which partially gratifies this instinct, may contribute to digestive troubles by provoking salivary secretions, which are not utilized for digestion, and which thus introduce an ele- ment of discord into the manifold symphony of these processes.
Dr. Pitt^ describes slight cardiac failure, shortness of breath, dyspnoea, palpitation, and other symptoms of cardiac dilation at puberty. The languor and feeble pulse, discomfort, and other symptoms which attend it rarely last long and ought soon to be compensated by growth. The heart, as we saw, nearly or quite doubles in size during the development of puberty, and this increase may all be within a year or may be extended over several. Dr. Pitt's tables of the normal volume of the heart at different ages and its rate of growth are of great value. The area of the pulmonary artery grows from 52 c. mm. at the age of thirteen to 61 c. mm. at fourteen, and the volume of the heart from 120 to 215 c. cm. during the same years. While the heart during its most rapid growth in the first year of life increases only 15-16 c. cm., during puberty it increases » On Cardiac Dilation at Puberty and its Frequent Occurrence in Girls* Brit- ish Medical Journal, 1886.
DISEASES OF BODY AND MIND ^55 Dr. E. Kisch, of Prague, in a valuable article describes the heart troubles of pubescent girls somewhat as follows: The most common form is nervous palpitation, w^hich often and sometimes in violent form precedes by a few weeks or months the first menstruation, and generally ceases as these periods be- come well established. Diminution of appetite, indigestion, constipation, flatulence, irritability, inertia, and sleeplessness often occur, due in part to reflex excitation from the uterus and in part to oversensitiveness of the psyche. Another form of heart distortion is seen in cases of great delay of first menstru- ation or in long continued irregularity of this function, and seems to be due to the chlorotic composition of the blood. A third and far rarer form is seen where unusually rapid growth has just preceded menstruation, and in girls who are not anemic or nervous, but strikingly lean and slender. It goes with a sense of fulness, short breath, and hypertrophy of the left ventricle, and this is due to a circulatory storm incident to puberty, which obliges the heart to act against increased resist- ance. These cases are most frequent among the non-labor- ing classes, and are aggravated by garments in the least degree tight about the waist.
Irregularity of heart action or arhythmia is far more common among children than was previously supposed. It is usually transient and may be due to many causes; it be- comes serious only as senescence approaches.* It is most frequent in anemic children who are growing rapidly at puberty and seems often due to relatively narrow arteries and overpressure, and hypertrophy may follow. Chronic heart troubles often begin in insufficiency of action, while arrhythmia appears only late in valvular diseases. Nervous heart troubles are due to imperfect development of the neural regulative ap- paratus. Idiopathic heart irregularities seem more common among boys than among girls. Sometimes the pulse at puberty is exceptionally slow, and sometimes very rapid for a season. Loss of a beat by deep inspiration may occur. Irregularity may be for a time habitual during sleep, while fright, worms, bowel trouble, a cold bath, nausea, etc., may produce this same effect. Guidi ^ has called special attention to the frequency of * O. Heubner. Herzarythmia im Kindesalter. Zeit. f. Klin. Med., 1894, p. 492. ^ Arch, Ital. di Pediatria, 1892.
256 THE PSYCHOLOGY OF ADOLESCENCE palpitation in growing school children between fifteen and eighteen.
Very many children now become morbidly conscious of their heart, anxiously feel their pulse, count the beats, and not a few in our returns work themselves into a state of high tension, fearing that they are doomed to die and that the heart may cease to pulsate at any moment. This might almost be called a characteristic phobia of adolescence. In extreme cases for months, and even years, the fingers are on the wrist on every occasion, and ingenious methods of concealing this watch from others are invented. Especially at night, when after reclining its beats are slightly feebler and at longer intervals, this chronic solicitude may occasionally reach a sudden panic that the end has come, and this starts it bounding again. Some read medical books, devise pretexts for comparing rate and intensity with that of their friends, imagine twingings, gurgles, stoppages, and obstructions, dread violent exercise, modify their regi- men, all this perhaps without betraying their fears to any one, and entirely outgrowing them later. One boy of four- teen never dared lie on his back or left side; another feared to take a deep breath and felt it necessary for his safety to assume a peculiar bending attitude in sitting or standing. Usually, however, these solicitudes, although very common, are slight