HEIGHT AND WEIGHT IN RELATION TO ONSET OF PUBERTY IN BOYS BY RICHARD W. B. ELLIS, O.B.E., M.D., F.R.C.P. Professor of Child Life and Health, University of Edinburgh (With the tehnical assistwwe of LUIS SANZ, B.Sc.) The great majority of studies of growth in relation to puberty have been carried out on girls, since the onset of menstruation provides a fixed point which can be accurately recorded, whilst the age of estab- lishment of a regular menstrual cycle can also be determind in most cases within comparatively narrow limits. Although the onset of menstru- ation does not necessarily correspond with the onset of ovulation, and has indeed tended to obscure the fact that puberty is actually a period of trasition from childhood to adolscence rather than a single fixed point, its use for statistical purposes has thrown considerable light on the relationship of growth to early or late maturity. Thus Flory (1935) and others have found that girls who menstruated early showed radiological evidence of more advanced osseous development (e.g. appearance of the sesamoid on the distal end of the first metacarpal) than non-pubescent children of the same age, whilst Stone and Barker (1937) described an early slowing-down of growth in girls who had menstruated early, and found that, after the age of sixteen, girls who had not menstruated were in fact taller than those in whom the menarche had occurred. In the case of boys there is no fixed point corre- sponding to the onset of menstuation which can be accurately determined, and it is probable that spermatogenesis is more gradually established than ovulation. Assays of excretion of 17-ketasteroids (Nathanson et al., 1939, 1941; Talbot et aL, 1943) also suggest that this is of gradual incease, with a wide normal variation, and although excretion of gona- dotrophic hormone in the urine shows a general tendency to increase with increasing maturity (Catch- pole et al, 1938) it cannot as yet be said to provide an accurate index of onset of puberty. The appear- ance of pubic hair, though usually an early sign of pubescence, bears no very constant relationship to genital development, whilst other secondary sexual characters, e.g. skin and voice changes, are all gradual in onset. By considering the various clinical manifestatons of puberty together, however, it is possible even in boys to establish grades of matunty, and to classify groups of boys into these with some degree of accur- acy. Greulic et al. (1942) have described five such maturity-goups. Although the classical mpno- 0 IU graph of these authors was not available when the present study was carried out, it was found subse- quently that closely similar criteria for grading had been established independently; in the present study, however, only three maturity-groups have been compared, the 'prepubcnt' group corre- sponding approximately with Greulich's Grades 1 and 2, the 'pubescnt' with Grade 3, and the 'adolescent' with Grades 4 and 5. The purpose of the present investigation was to determine whether any si nt difference in mean height and weight of boys in the same age-groups but in different maturity-groups could be demonstrated and, if so, how far back these differences were mani- fest. At the same time it was possible to make certain observations on the order of appearance and character of some of the changes associated with puberty. Present Investigatio Clinical mterial. This consisted of two hundred and eight healthy boys between the ages of eleven and sixteen years. All boys who had had prolonged or recent illness likely to have affected their growth were excluded, as were any showing cryptorchidismL No other cases of endocrine diturbance or patho- logical obesity were encountered. The boys were derived from two residential schools, in both cases situated in country surroundings and providing a liberal diet. In all cases, detailed medical records were available. In School A, the boys entered from foster-homes at the age of five, being weighed and masured by trained personnel on entry and thereafter in January of each year, or more fequently. Untl 1945, all the boys had remained at school during the holidays, and had received the same school diet. This group was, therefore, exceptionally well controlled from the point of view of an investigation of this type, and measurements were available in every case from the sixth year. In School B, the boys entered from their homes at various ages from eight years onward, and were weighed and mesured by trained personnel at kast three times a year. They received the same diet at schooL but returned home for the holidays. Although the livmg conditions and diet in the two schools were comparable, it was considered best to compare measurements only of boys fiom the same school. Whilst this renders the indiviual 81 copyright. on June 10, 2020 by guest. Protected by http://adc.bmj.com/ Arch Dis Child: first published as 10.1136/adc.21.108.181 on 1 December 1946. Downloaded from
Transcript
HEIGHT AND WEIGHT IN RELATION TO ONSET OFPUBERTY IN BOYS
BY
RICHARD W. B. ELLIS, O.B.E., M.D., F.R.C.P.
Professor of Child Life and Health, University of Edinburgh
(With the tehnical assistwwe of LUIS SANZ, B.Sc.)
The great majority of studies of growth in relationto puberty have been carried out on girls, since theonset of menstruation provides a fixed point whichcan be accurately recorded, whilst the age of estab-lishment of a regular menstrual cycle can also bedetermind in most cases within comparativelynarrow limits. Although the onset of menstru-ation does not necessarily correspond with the onsetof ovulation, and has indeed tended to obscure thefact that puberty is actually a period of trasitionfrom childhood to adolscence rather than a singlefixed point, its use for statistical purposes has thrownconsiderable light on the relationship of growth toearly or late maturity. Thus Flory (1935) and othershave found that girls who menstruated early showedradiological evidence of more advanced osseousdevelopment (e.g. appearance ofthe sesamoid on thedistal end ofthe first metacarpal) than non-pubescentchildren of the same age, whilst Stone and Barker(1937) described an early slowing-down of growth ingirls who had menstruated early, and found that,after the age ofsixteen, girls who had not menstruatedwere in fact taller than those in whom the menarchehad occurred.
In the case of boys there is no fixed point corre-sponding to the onset of menstuation which canbe accurately determined, and it is probable thatspermatogenesis is more gradually established thanovulation. Assays of excretion of 17-ketasteroids(Nathanson et al., 1939, 1941; Talbot et aL, 1943) alsosuggest that this is of gradual incease, with a widenormal variation, and although excretion of gona-dotrophic hormone in the urine shows a generaltendency to increase with increasing maturity (Catch-pole et al, 1938) it cannot as yet be said to providean accurate index ofonset of puberty. The appear-ance of pubic hair, though usually an early sign ofpubescence, bears no very constant relationship togenital development, whilst other secondary sexualcharacters, e.g. skin and voice changes, are allgradual in onset.By considering the various clinical manifestatons
of puberty together, however, it is possible even inboys to establish grades of matunty, and to classifygroups ofboys into these with some degree of accur-acy. Greulic et al. (1942) have described five suchmaturity-goups. Although the classical mpno-
0 IU
graph of these authors was not available when thepresent study was carried out, it was found subse-quently that closely similar criteria for gradinghad been established independently; in the presentstudy, however, only three maturity-groups havebeen compared, the 'prepubcnt' group corre-sponding approximately with Greulich's Grades 1and 2, the 'pubescnt' with Grade 3, and the'adolescent' with Grades 4 and 5.The purpose of the present investigation was to
determine whether any si nt difference in meanheight and weight ofboys in the same age-groups butin different maturity-groups could be demonstratedand, if so, how far back these differences were mani-fest. At the same time it was possible to makecertain observations on the order of appearance andcharacter of some of the changes associated withpuberty.
Present InvestigatioClinical mterial. This consisted of two hundred
and eight healthy boys between the ages of elevenand sixteen years. All boys who had had prolongedor recent illness likely to have affected their growthwere excluded, as were any showing cryptorchidismLNo other cases of endocrine diturbance or patho-logical obesity were encountered. The boys werederived from two residential schools, in both casessituated in country surroundings and providing aliberal diet. In all cases, detailed medical recordswere available.
In School A, the boys entered from foster-homesat the age of five, being weighed and masured bytrained personnel on entry and thereafter in Januaryof each year, or more fequently. Untl 1945, allthe boys had remained at school during the holidays,and had received the same school diet. This groupwas, therefore, exceptionally well controlled from thepoint of view of an investigation of this type, andmeasurements were available in every case fromthe sixth year.
In School B, the boys entered from their homesat various ages from eight years onward, and wereweighed and mesured by trained personnel at kastthree times a year. They received the same diet atschooL but returned home for the holidays.Although the livmg conditions and diet in the two
schools were comparable, it was considered bestto compare measurements only of boys fiom thesame school. Whilst this renders the indiviual
81
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182 ARCHIVEgroups1s , it reduces a numbererrors. Thus the boys in the two sderived from somewhat different stocisocial conditions in the pre-were probably more uniform in the casethan of School B.
Age-groups. The boys were dividedgroups, i.e. 11+ to 12, 12+ to 13, etcfilling on the date of the examinationboy in the younger age-group. InSchool A, where the exact date of eameasurement was known, the ages weithroughout on the basis of years plus 4case of School B, where the month but jdate of the previous examinations w;ages were calculated to the nearest rage-groups examined in the two schofollows:
Ager(yea)11 to 1212 to 1313 to 1414to 1515 to 16
School A263945164
Some of these groups were too small, or idivided on a maturity-grading, to make (possible; the age-groups selected for a12 to 13 (School A), 13 to 14 (Schook14 to 15 (School B), and 15 to 16 (SchoM Heights were measui
boys standing barefoot against a stationwith sliding head-arm, and were recordthe nearest i inch (and converted into crnearest 05 cmL Leg-length was measisteel tape, from the anterior superior iltbh tip of the internal malleolus, andthe nearest 0-5 cm. Weights were meanbalances that had been regularly clxrecorded to the nearest i lb. and convymetric scale. All calclations are banaked weight.
ExanaHuatiom.. A record was made of Iand extent of pubic, axillary, faciaL andthe stage of development of the genitalappearance of the skin, with particularthe presence of comedones or acne and 1
ment of the secous and apocrine s'It was not found practicable to estimate ein the pitch of the voice on a single exawithout special apparatus, though mwhere the voice was obviously ' brokewas recorded. The presec or absenccomastia was noted in all cases.Pumc HUR. This was recorded as P
pubic area showed only the presencebody-hair of early childhood, or the shlnon-pigmented vellus which precedes theof true pubic hair. P1 was used to cappearance of one or more coarse, pignat the base or side of the penis; P2 wherhairs extended across the root of the peniapproximately half the pubis was covermthe area of female distrbution was cihairs extended to the perineal or anal r
P5 when hair was preset on the lineaabdomen, or groins (cf. Godin, 1934).-AxmLay HAIR. This was record
(complete absence), Al (thepence ofcpigmented hairs), A2 (hairs more thailngth and ning over an area apj
S' OF DISEfUSE IN CHILDHOOD-of possble 2 cm in length), or A3 when the growth of axillry
dcols were hair was profiLse.k, whilst the FAcIL mapI_ The signifince of facial hair was-school years found less easy to assess, since the appearance wasof SchoolA greatly in dbycolouring or shaving. Typically
the earliest appearance of fine hair was seen on theI into yearly lateral parts of the upper lip, thence spreading:., a birthday toward the centre. Except in the most hinute boys,placing the it was only found practicable to classify facial hair as
the case of present or absent.ach previous BkDY HAm. The posterior aspects of the fore-re caculated arms were examined for hair-growth, but it wasdays; in the again found that only in the most mature boys werenot the exact the idings unequivocal.as recorded, GENITAiJ Greulich et al. (1942) drew attentionnonth- The to three feitures of the male genitalia at puberty,dlS were as which were also used as criteria of maturity-grading
in the present study. The penis first increases con-School B siderably in length, and then subsequently in girth
with development of the corpora cavernosa. Therapid increase in size of the testicles at puberty is
28 not associated with a corresponding increase in siz28 of the epididymis, with the result that the relative22 proportions ofthe two showa marked alterationfrom
insufficiently those of childhood; with increase in size the tes-omparisons tides also become softer. Thirdly, the scrotum,alympsis were which in childhood is widest at its proximal end,sA and B) becomes not only pendulous but wider at its distalsl B). end with the increased size of the testicles. (Thise with t last point was found easier to assess clinically thanary mesre rugosity, which was very variable.)led either to In the present study, the stage of development ofm.) or to the the penis and that of the testicles plus scrotum wereuire with a seParately as ' prepubescent,' ' pubescent,'liac spine to or 'adolescent.' (It was found that whereas therecorded to development of the scrotum followed closely thatired on lever Of the testicles, the testicles and penis were notecked, were necessarily developed to an equal extent.)erted to the SRN. The skin of the cheeks, roots of the nose,Lsed -on the and base of the lower lip was examined for come-
dones, and though their presence was found to bethe presence much higher after the onset of puberty, it was notIbody hair- itself taken as a criterion of diagnosis. The groupia; and the as a whole was remarkably free from acne, andreference to though the few cases that were observed were allthe develop- in the more mature boys, its presence or absenceweat glands. was of little help in grading. Development of thearly changes apocrme and -sebaceous glands was also regarded asmination or confirmatory rather than diagnostic.those cases GRADNG. On the basis of the clinical examna-n' the fact tion, irrespective of age and size, each boy wase of gynae- graded as ' prepubescent,' ' pubescent,' or ' adoles-
cent.' The presence of pubic hair and/or pubescent10 when the genital development were taken as the criteria ofof the fine pubescence. The presence of pubic hair, even whenghtly longer, this was profuse, was not by itself taken as a cnterionappearance of adolescence; for this grading, well-markeddescribe the increase in girth as well as length of the penis, andented hain substantial development of the testicles were con-pigmented sidered necessary.
is; P3 when In spite of the inherent difficulties which mustd; P4 when arise over border-line cases (since one stage of)vered, and development will pass gradually and not abruptly toregion; and the next), it appeared that grading on this basis wasalba, lower substantially valid. A second examination of a
hundred and thirty-two of the boys was carried outed as AO one hundred days after the first, and a second assess-)ne or more ment made without reference to the original on
1 cn. in It wasfound that in noinstancewas a boy given aproximtely loweI grading on his second eamination than on his
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HEIGHT AND WEIGHT IN RELATION TO PUBERTYfirst; eleven boys were given a higher grading in
view ofthe advanced development that had occurredduring the interval; and the remainder were placedin the same categories as before.
ResultsMatr in reation to age. The following
analysis of the total number of boys examined (208)shows how the maturity-gradings are related tochronological age (table 1). As would be exPected,the percentage of prepubescent boys steadily falls
from the age of 11 to 15, whilst the percentageof adokscents rises from 13 to 16. The highestpercentage of pubescent boys is seen in the 13- to14-year-old group, which is also the group mostevenly divided between prepubescent and pubescent.
Comparison of height and weight of ailygroups. In each of the age-groups selected, acomparison was made between the mean height andweight of those boys showing a more advanceddegree of maturity with those showing less. Thusin the 12- to 13-year-old group (School A), themean heights andweights of the 25 prepubesent boyswere compared with those of the 14 pubescent boys.In the 13- to 14-year-old groups (Schools A and B),comparison was also made between the prepubescent
boys and the pubescent, whilst in the 14- to 15-year-old and 15- to 16-year-old groups (School B), com-parison was made between the pubescent andadolescent groups. This initial comparison gavethe results shown in table 2.The probable errors were calculated for each
comparison, and it will be seen from table 3 thatthe probability of the lower maturity-group beingof greater height or weight than the higher maturity-group of the same age is in no instance more than1 in 10, whilst in most instances it is considerablyless.
It is thus clear from table 2 that the more matureboys are si ntly taller and heavier than the lessmature boys in the same age-group. Indeed, themore mature boys in each age-group are found to betaller and heavier than the less mature boys in theage-group immediately above them (e.g. the pubes-cent boys aged 12 to 13 compared to the prepubes-cent boys aged 13 to 14, or the adolescent boys aged14 to 15 compared with the pubescent boys aged 15to 16). Further evidence that these differences in
height and weight between boys of different gradesof maturity in the same age-group cannot be attri-buted to such minor differences in mean age asexisted between the maturity-groups is shown byreference to the growth curves given below, where the
Probability that prepubesent mean Probability that prepubescent meanSchool Age-group height greater than pubescent mean weight greater than pubescent mean
height weight
A 12 to 13 0-015 0-087A 13 to l4 0-094 0-001B 13 to 14 0-000 0-00
Probability that pubescent mean height Probability that pubescent mean weightgreater than adolescent mean height greater than adolescent mean weight
B 15 to 15 O-000 0-005B 15 to 16 0-004 0-034
mean age of the group at the date of each measure-ment is shown graphically.A further point of considerable interest which is
brought out by these figures is that the boys whoshow evidence of the onset of puberty between 13and 14 years ofage (School B), are taller and heavierthan those where puberty is beginning between 14and 15, and these agai are taller and heavier thanthe boys graded as pubescent between 15 and 16years. Although the differences in this instance aresmall, the observation suggests that the smallestboys are in fact those that tend to mature the latest.Growth curve In view of the above findings,
growth curves (height and weight) were constructedfor each group, and compared as before. Thosefor the boys in School A are the more complete, asall boys entered the school in their sixth year. Inthe case of boys from School B, where the age ofentry varied from the eighth to the twelfth year, thecurves have been contucted from the age at which
.C
at
c
tR4
0 7 5 9e0 2
I
/
I
- PUBESCENT
PREPUSESCENT
age years
ols
3t,24
Fa%. 1.-Mean height of boys aged 12 to 13 years at dateof examintion (School A), from the sixth to thiteenthyear.
they may be taken as representative of the completegroup.
It will be seen from these figures that at every agefor which mean values are available, the groups ofboys who matured earler are taller and heavier thantheir later-maturing contemporaries. This is par-ticularly striking in the case of boys from School A(figs. 1 to 4) where the differences are demonstrablein the sixth year. In all cases the curves, particularlythose of weight, tend to diverge with the establish-ment of puberty. Although the individual groupsanalysed are relatively small, the fact that thefindings were similar in every instance tends tosupport their general validity.Rate of growth during puberty. The maturity-
gradings used in the present study include in the' prepubescent' group boys whose developmentis esseptially that of childhood, and also those whomay show the very earliest signs preceding the moremanifest appearances of commencing maturity.
21
26
; 2
32%
a la
ae yeaors
FIG. 2.-Mlean weight of boys aged 12 to 13 yers at dateof examinati (School A), fr the sith to thtnthyear
HEIGHT AND WEIGHT IN RELATION TO PUBERTYThe growth curves of the prepubescent boys can-not, therefore, be expected to demonstrate clearlyany changes in rate of growth which may be asso-ciated with the period imediately preceding themanifestations used in defining the 'pubescent'group. Similarly with the 'adolescent' group,which includes boys in whom maturity is welladvanced but incomplete, and also a few boys inwhom genital development has practically reachedadult proportions, it might reasonably-be objectedthat the grading is too wide to demonstrate changespeculiar to any one phase of development.
In the case of the 'pubescent' group, however,the phase of development is more clearly defined,and probably extends only over a period of six tonine months. Changes in rate of growth peuliarto this period might, therefore, be expected in thegrowth curves immediately before and after the dateof examination. With the exception of the growthin height of the 12- to 13-year-old boys, examinationof the growth curves does in fact suggest that thereis an access of growth (more particularly in weight)in the year preceding the date of examination.Since, however, a somewhat similar increase inannual weight-gain is seen in the prepubescent boysaged 13 to 14 (School A), it was decided to re-examine this age-group approximately three monthsafter the first examination, in order to determinewhether there was any significant difference in theincrease in height and weight of the pubescent andprepubescent boys aged 13 to 14 during this period.The results as shown in table 4 were obtained.Thereare, therefore, substantial differences between
the increase in height and weight of the pubescentand prepubescent boys over the same period, andsince the standard errors are relatively small, thesedifferences can be regarded as significant. (Theprobability that the increase in height is greater forthe prepubescent than for the pubescent boys isapproximately 0-10 and in weight only 0-004.)Since, however, the differences in increase in heightbetween the two groups are not shown to the sameextent in the increases in leg-length, these results areregarded primarily as an indication that furtherstudy along similar lines is likely to be fruitful.
Gynaecomastia The presence of a small noduleof mammary tissue attached to the nipple (whichcould readily be distinguished on palpation fromsubcutaneous fat) was observed in twenty-six cases.In the great majority this was bilateral and painlessor only very slightly tender. In no case couldcolostrum be expressed. In most cases where themammary tissue was more than 2 cm. in diameter,
or where the chest was poorly covered, the swellingwas visible as wel as palpable, but no very markedcase of breast enlargement was observed. Theoccurrence of gynaecomastia in relation to maturity-grading in the whole group was as follows:
PrepubescentPubescent . .
Adolescent
Total No. with Per cent.gynaecomasta.
85 0 070 9 12-953 17 32-1
This would suggest that breast-development is morecharacteristic of the latter stages of puberty than theearlier, and is unlikely to be observed before othermanifestations ofsexual development. It is probablethat gynaecomastia at puberty is due, as Weber(1946) expresses it, to 'a temporary burst of endo-crine activity in the testes and possibly in the adrenalcortex' and that the secretions of these organscontain not only adrogenic but some oestrogenicelements. These latter may be sufficient to producetemporary gynaecomastia in boys who are constitu-tionally so predisposed.
Rehtionship of tminal hair to genital develop-ment. In general, it was found that the appearanceof pubic hair corresponded roughly with the stage ofgenital development classified as pubescent, thougheither might precede or follow the other; thataxillary hair appeared relatively late, i.e. correspond-ing with the grading of adolescence; and that hairon the linea alba was very late in appearance, beingobserved once only in the whole series. Whilst anexact analysis of the order of appearance of primaryand secondary sexual characters could only beattempted by serial examinations of the same boysover a period of five or six years, the single examina-tion, particularly of the pubescent boys, yieldedcertain information.Of the boys classified as pubescent, 52 per cent.
showed pubic hair (P1 to P3) and pubescent genitaldevelopment, but no axillary hair; 12 per cent.showed the same signs plus axillary hair (Al or A2);10 per cent. showed pubic hair with genitalia gradedas prepubescent; and 23 per cent. showed pubes-cent genitalia with absence of both pubic and axillaryhair. In two cases, moderately profuse axillaryhair was present in the absence of pubic hair, andwith genitalia showing only the earliest signs ofpubescence.The adolescent group was almost evenly divided
between those in which axillary hair was present andthose in which it was absent. In all cases pubic hairwas present, though this varied from P2 to P5. In
TABLE 4MEAN INCREASE IN HEIGHT, LEG-LENGTH, AND WEIGHT OF PREPUBESCENT AND PUBESCENT
BOYS AGED 13 TO 14 YEARS (SCHOOL A) OVER A PERIOD OF 100 DAYS
1ARCHIVES OF DISE4SE IN CHILDHOODthree cases, the growth of axilary hair apredmore advanced than that of pubic hair.No relationship could be demonstrated between
the occurrence of gynaecomastia and the presenceof axillary hair.Ski chages. It is generaly recognized that the
occurrence of comedones, acne, and possibly folli-cular keratosis are, or may be, related to the actionofandrogenic hormones. As already indicated, acnewas seen in only a very small percentage of cases,whilst follicular keratosis appeared too variable inrelation to season and exposure to be accuratelycorrelated with puberty.Comedones occurring on the facial area were,
however, noted in 197 per cent. of the prepubescentgroup, 41-O per cent. of the pubescent group, and76-2 per cent. of the adolescent group.
DisWhilst accurate maturity-grading of boys should
include not only olinical examination but also radio-logical assessment of ossification and estimation ofhormone-excretion, the present study indicates thatgrading on clinical grounds alone may serve to bringout certain differences in mean height and weightbetween the groups studied; and that such differencesare present long before puberty is reached. If, asseems probable, there are also changes in rate ofgrowth peculiar to the onset and duration of puberty,it follows that standard height and weight curvescompiled without reference to the stage of maturityof the children measured will be deceptive whencompared with the growth curves of an individualchild; thus although the 13- to 14-year-old groupcontained the greatest number of pubescent boys, itwas clear that the age of onset of puberty variedconsiderably in different subjects, and that instandard curves based on chronological age only,' puberty-growth 'will not be as clearly demonstrableat any one age-period as it may be in the individual.The relationship of puberty to increase in weighthas also a practical importance when mean weightcurves are used in the assessment of nutrition ofcommunities of children in their teens, and it haspreviously been suggested (Ellis, 1945) that severemalnutrition may itself be responsible for a generaldelay in the onset of puberty, reflected in the shapeof the mean weight curve of the affected groups.
Since the present study is concerned only withboys up to the age of sixteen, it gives no informationwith regard to the mean adult height and weight ofthose who mature early as compared with those whomature late. Studies made on girls and on adultwomen, in whom the age of onset of menstruationwas known, indicated that the pyknic type tends tomature earLier (Pryor, 1936) and that the adult heightof those who menstruated late tends to be greaterthan that of girls in whom the menarche occusearly. In order to obtain comparable informationin the case of adult males, it would be necessary tofollow up boys who had been examine and gradedduring their teens, since the age of onset of pubertyis seldom accurately remembered or noted in theirschool medical records. However, if clinical assess-ment of maturity were included in the routine
medical examination of boys, it would be possible tosee whether adult height and weight showed anysignficant correlation with early or late maturity inthe male. Whilst improvement on the clinicalcriteria employed in the present study could nodoubt be made, it is suggested that they provide asimple, if rough, guide to maturity-grading whichwould serve this purpose.Another possible application of maturity-grading
is in relation to education and physical performance.Since education is based very largely on groupingby chronological age, it-follows that most classesduring the early and middle teens will contain boysvarying from physically imature children to thosewho are well advanced in adolescence. Whilstintellctual development is obviously not commen-surate with physical development, there are certaindisadvantages in educating together boys of verydifferent physical, and often emotional, stages ofmaturity. When large numbers have to be cateredfor, and classes have in any case to be subdivided onother than strictly intellectual grounds, it has beensuggested that maturity-grading might be used as abasis of division, boys of roughly the same maturitythen being educated together. With regard to phys-ical performance, a natural division into maturityplus individual aptitude is more likely to establishitself automatically in athletics and organizedgames, but in the case of boys in employment, theburden may fall very unequally on the mature andthe immature. Legislation with regard to juvenileemployment ofboys is entirely based on age, whereasin fact maturity is a better basis for deciding thephysical demands that can be made on the individual.The raising of the school leaving-age to fifteen willhave, amongst other advantages, the result that theproportion of prepubescent boys entering employ-ment will be substantially reduced.
Whilst clinical maturity-grading applied to groupsallows certain generalizations with regard to meanheight and weight, it should, however, be emphasizedthat anthropometric measurements alone are anureliable guide in the prediction ofonset and durationof puberty in the individual. (Thus Flory (1935) inthe case of girls found that anthropometric measure-ments were much inferior to radiological assessmentof maturity in predicting the onset of menstruation.)It cannot be assumed that an individual child who isbelow the mean height and weight for his age willnecessarily mature late rather than early. Similarlythe rapidity with which individuals pass from onematurity-grade to the next is likely to vary consider-ably, and it follows that any application of maturitygrading to educational grouping or employment canhave only a limited and temporary value. Thefollowing example (not included in the presentseries) is quoted in detail, as it illustrates the earlymaturation of a small child and also the extremelyrapid increase in height and weight which may takeplace at puberty.M. J. was born prematurely at seven months,
weighing 3j lb. (l 59 kg.). At two months heweighed 6 lb. (2-73 kg.), at one year 19 lb. (8-6 kg.),
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hild: first published as 10.1136/adc.21.108.181 on 1 Decem
HEIGHT AND WEIGHT IN RELATION TO PUBERTY 189at two years 24 lb. (10-9 kg.), and at four years 33 lb.7 oz. (15 2 kg.). He was examined at the age ofeleven years five months, when he was graded asprepubescent; he then weighed 68 lb. (30 9 kg.)and measured 4 ft. 6 in. (137-2 cm.) in height. Attwelve years two months he showed the presence ofpubic hair (P2) and early genital development, andwas graded as pubescent. At twelve years fivemonths he had reached 'established adolescence ';the voice was broken, pubic hair was profuse,axillary hair was present, and the 'adolescentmoustache' was appearing on the upper lip. Hisheight was 5 ft. 14 in. (156-2 cm.) and weight 1054lb. (48-0 kg.). He had, therefore, not only maturedearly (receiving a higher maturity-grading at twelveyears five months than any of the boys in the 12- to13-year-old group), but had passed from prepubertyto adolescence in the space of one year, during whichtime he had increased 71 in. (19 cm.) in height and374- lb. (17 kg.) in weight. Apart from vasovagalattacks, coincident with the onset of puberty, heappeared healthy, and no pathological cause for hisrapid growth and development was found.
Summary and Concusions1. Two hundred and eight boys, aged eleven to
sixteen years, from two residential schools, weregraded on a basis of clinical assessment into threematurity-groups viz. prepubescent, pubescent, andadolescent. Comparison was made between themean heights and weights of boys from the sameschool who fell into the same yearly age-groups butinto different maturity-groups.
2. It was found that not only were boys of thehigher maturity-group heavier and taller than theircontemporaries in the lower maturity-group, butthat differences between the growth curves could bedemonstrated as far back as the sixth year (in thecase of boys from School A, where records wereavailable to this time).
3. The growth curves suggested that there was anincreased annual gain in weight, and to a lesser
extent in height, which could be related to the onsetand duration of puberty.
4. This was confirmed by the re-examination ofone age-group after a period of one hundred days,when it was found that increase in height and weightof pubescent boys was significantly greater than thatof prepubescent boys in the same school.
5. Gynaecomastia was observed in none of theprepubescent group; in 12 9 per cent. of thepubescent group; and in 32-1 per cent. of theadolescent group.
6. Observations were made on the relationship ofcertain primary and secondary sexual charactersduring puberty.
I wish to thank the Governing Bodies and Head-masters of the Thomas Coram School and the RoyalMerchant Navy School for facilities in carrying outthis investigation, which was undertaken from theDepartment of Child Health, Guy's Hospital. Ialso wish to thank the Medical Officers and NursingStaffs of the two schools for their help and co-operation.
REFERENCESCatchpole, H. R., Greulich, W. W., and Sollenberger, R.
T. (1938). Amer. J. Phvsiol., 123, 32.Ellis, R. W. B. (1945). Arch. Dis. Childh., 20, 97.Flory, C. D. (1935). Child Development, 6, 1.Godin, P. (1934). Quoted by Laroche, G. (1938).
La Pubertd. Paris.Greulich, W. W., Doriman, R. I., Catchpole, H. R.,
Solomon, C. I., and Culotta, C. S. (1942). Somaticand Endocrine Studies of Puberal and AdolescentBoys. Nat. Res. Council, Washington.
Nathanson, I. T., Towne, L. E., and Aub, J. C. (1939).Endocrinol., 24, 335.
(1941). Ibid.,28,851.Pryor, H. B. (1936). J. Pediat., 8, 52.Stone, C. P. and Barker, R. G. (1937). Human Biol.,
9, 1.Talbot. N. B. Butler, A. M., Berman, R. A., Rodriguez,
P. M., and MacLechann, E. A. (1943). Amer. J.Dis. Child., 65, 364.
Weber, F. P. (1946). Rare Diseases and some DebatableSubjects. London.
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