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The Breasts
THE BREASTS CATHRYN C. HANDELMAN, M.D.
BREAST HYPERPLASIA IN THE NEWBORN Incidence, Degree and Etiology
Breast hyperplasia occurs in the newborn period in both male and female infants. It appears at the third or fourth day of life and reaches a peak at the second or third week. The hyperplastic tissues usually regress and return to normal after the third week, but may persist well into the second month, when gradually the breasts return to normal. I have seen a number persisting well into the second month and occasionally into the third month. The degree of hyperplasia varies widely. It may be barely perceptible, or the affected tissue may be so engorged as to produce profound discomfort and pain. A secretion similar to colostrum may be present, a secretion carrying the age-old name of "witch's milk." Simple physiologic hyperplasia is a response to estrogens from the maternal circulation. The degree of enlargement seems to be related to the sensitivity of the end-organs of the breast tissue to the estrogens. Some have felt that the phenomenon is due to the maternal lactogenic hormone, but this condition occurs as frequently in bottlefed babies. Management
Although this simple, physiologic phenomenon has been observed for centuries, to each mother it poses a personal problem. Through the close relation between mother and physician, it is expedient to prepare the mother for this condition in postpartum instructions on care of the infant. I would include a discussion of this normal newborn variant. The mother is then prepared and will not be unduly alarmed when the breasts enlarge. One should not be complacent and disregard an 337
338
THE BREASTS
insecure mother's calls despite previous instructions. If she needs further reassurance, telephone conversations are usually unsatisfactory and totally impersonal. She needs the personal contact of a house call or an office visit. The time which the physician spends will be rewarding in the future relaxed management of the child and the confidence the mother will feel in subsequent situations. The main points to stress with the mother are as follows: 1. Do not try to express any secretion. The breasts will eventually dry up. 2. Do not rub on any lotions or ointments. These may so soften the tense skin that microscopic breaks permit the entrance of pathogenic bacteria and cause subsequent abscess formation. 3. Cool compresses make the infant more comfortable if there seems to be pain. 4. A mild sedative may be beneficial to reduce the fretfulness (phenobarbital elixir, ~ grain every 4 to 6 hours as needed). 5. Reduce the total fluid intake for 24 hours by about one quarter. In other words, if one can put the point across, "hands off." 6. If the engorgement is extreme, testosterone may be of some value, but is rarely indicated. Some men feel that hormones are of no therapeutic benefit; I personally have never used them. Occasionally the hyperplastic breast tissue may become infected. The breast area will be hot, reddened and under tension. The infant mayor may not have fever. He may have vomiting, diarrhea, anorexia. Therapy should be instituted immediately-antibiotics such as penicillin or possibly a wide-spectrum drug, warm compresses. If the area becomes fluctuant, incision and drainage are indicated. Incision should be made near the periphery in a radiating direction from the nipple and should be as small as possible to prevent scarring and retraction of the nipple and disfiguration, especially in the female child. Whenever possible, the surgeon should be called in consultation for the incision and drainage. BREAST HYPERPLASIA IN EARLY LlFE-"PREMATURE THELARCHE"
Hyperplasia of the immature breast is not uncommon in early life. It is usually unilateral, tender and indurated. The most common age for this condition is three to eight years. It can occur even earlier, however. I am now observing an 8-month-old infant who has bilateral breast development, but is otherwise normal. Parents display concern over this condition. Since malignancy of the breast at this age is practically nonexistent, one must be selective if a consultant is considered. We try to reassure the parents chiefly, since the concern is mainly theirs, and watch the breast carefully at intervals of two to three months, making careful measurements. Removal of the breast should not be considered unless biopsies in a few areas are done. Then, if indicated, operation may be performed. It behooves the referring physician to have a good working relation with his consultant. Too often a referral is made without any pre-
CATHRYN C. HANDELMAN
339
liminary discussion or "meeting of the minds" with the consultant. Too often a child's breast has been removed needlessly. The cause is not known. The treatment is conservative observation over a period of years. Hormonal therapy is of no known benefit. Surgery is done if malignancy is proved. Most cases regress spontaneously. PRECOCIOUS BREAST DEVELOPMENT
This may occur in infants and small children and is the first sign of precocious sexual development. The breasts seem especially sensitive to estrogens. For this reason they develop both in the young patient and in the maturing child before any other secondary sex characteristics. There are cases on record of a number of children between the ages of two and seven years who had general sexual precocity with breast development. SchaufHer1 cites the case of a 14-month-old girl who had breast development plus periodic vaginal bleeding which began at 12 weeks of age. She had general accelerated precocity. Some of these children have early, cyclic vaginal bleeding plus other well developed secondary sexual characteristics. Others have no menstrual flow, but do have sexual characteristics. The majority have so-called idiopathic or constitutional precocity, to the best of our present knowledge. One must rule out secondary causes for sexual precocity. This is best done by the combined efforts of gynecologic and endocrinologic consultants. I personally would not manage these children except in consultation because the fears and psychic trauma to parents and child are too great to manage without expert advice. I would talk at length with the parents on the rather frequent occurrence of "constitutional precocious breast development." They should know that many of these go on to complete sexual precocity. I would discuss with them the need for normal age activity and companionship for the child, since the mental development does not keep pace with the sexual maturation. GYNECOMASTIA OF THE ADOLESCENT MALE
Male mammary hyperplasia occurs frequently during adolescence. The etiology is not too clear, but it is thought that (1) estrogens may be secreted in excess by the adrenals or testes or (2) there is temporary disproportion between the secretion of the testicular androgen and the hypothetical hormone of seminiferous tubules, "inhibin." Histologically there is little hyperplasia of the ducts, but there is considerable increase in the peri ductal stroma. The hyperplasia may be unilateral or bilateral. The breast enlargement may be slight or considerable and may persist for years. I have not seen any persist beyond two years, at which time there has been a rapid regression in the tissue. I have observed this phenomenon more in the Negro adolescent than in the Caucasian. The usual age of appearance in adolescents that I have observed has been in the 14- to 16-year age groups.
340
THE BREASTS
Boys become somewhat alarmed at this phenomenon and are reticent in consulting their parents. The boy may be brought to the physician's office by the parent without the parent's knowledge of the reason for the visit. The condition may have a psychologically traumatic effect on the adolescent boy. But, if one is patient and discusses maturation with the parents and the boy, they can be reassured and convinced that the future will bring normality. While explaining the complicated process of development I usually tell them about hormones and how they get a little "mixed up" during development and that the body must be given an opportunity to work out its balance. My advice is to "sit tight," no manipulation, prevent trauma, and the condition will regress. The time is variable-from a few months to one to two years. In the 10 years of my work with adolescents I have not had to refer any of my boys to a surgeon. All cases have spontaneously regressed. If the hyperplasia persists beyond two years, surgery for psychological or cosmetic reasons may be considered. Pseudogynecomastia in fat boys is distinguished from true gynecomastia by palpating for breast tissue. Although in the greatest number of cases gynecomastia in the adolescent is benign and one might say physiologic, the other causes must be ruled out. These are: (a) Klinefelter's syndrome, (1) gynecomastia, (2) small testes, (3) hyaline degeneration of seminiferous tubules, (4) azospermia, (5) increase in FSH; (b) hepatic disease; (c) severe malnutrition; (d) feminizing tumor of the adrenal (extremely rare in children and adolescents); (e) testicular neoplasm; (f) paraplegia; (g) exposure to small amounts of estrogens. BREAST DEVELOPMENT IN THE MATURING FEMALE-NORMAL DEVELOPMENTAL PATTERN
Adolescence in the female is generally defined as the transition from childhood into a childbearing woman. Breast development precedes the appearance of all other secondary sexual characteristics by about one year. Adolescent development in the female ranges from 9 to 17 years, breast development appearing from 8 to 16Yz years. If we assume the known average of the menarche as 13 to 15 years, a slight budding of the nipple becomes apparent at around the age of 10. After this, between 10 and 11, the breasts barely bud. At 12 to 13 the breasts fill in and the nipples become pigmented. This is a long-awaited event in the female. Most girls anticipate this development to such an extent that often a brassiere is requested long before the mother notices any changes. I would advise the mother to purchase a beginner's "bra" if her child so desires. The normal sequence of breast development has been briefly outlined. The wide variations that occur are due to such factors as (1) nutritional status, (2) genetics, (3) constitutional variations, (4) race or nationality, (5) endocrine pattern, (6) congenital defects, (7) illness. When a girl begins breast development, despite the fact that she
CATHRYN C. HANDELMAN
341
has been anticipating this development, there is a tendency to stoop. I talk with the mother and the child, pointing out that this is an event for which she has really been waiting. She should be proud to be developing normally as a woman to fulfill her role in life. I discuss this phase of her development along with preparation for the menarche. It is pointed out that each generation must reproduce or our race would die out, and it is each girl's destiny in life to marry and become a mother. God has planned this and made man and woman a wonderful human body which surpasses any machine that we know. So, as we are approaching womanhood, certain parts of our body begin to grow and develop to fulfill their function of motherhood. The breasts are meant by nature to feed the infant. Therefore we should be proud to develop normally. It can be pointed out that a number of women do not develop much breast tissue, and when this happens, women have always used padding to create an illusion of breast tissue. In modern times manufacturers have placed on the market padded brassieres known as "falsies." It is wise to mention this to the child and show her the "falsies," thus doubly impressing upon her the pride she should feel in normal development and how important it is for her to maintain a normal, erect posture, especially at this period when her pelvic organs are developing. Charts and diagrams are useful in this discussion to show the relation of the abdominal organs and the effects of slumping or slouching. "Bras" should be worn as soon as some breast tissue appears. It may really not be necessary, but it supports the girl's insecure feelings about growing up. She identifies herself with other adult females. Also the transition from a beginner's "bra" to one with good support is then a simple matter. The child will feel less embarrassment in being measured and fitted. Two brassieres, one on and one in the wash, are an adequate supply, since the girl's size may change rapidly. All good department stores with teen departments carry an adequate line with women experienced in measuring and fitting. With development of breast tissue an uplift brassiere with good support is essential. They come in different chest sizes and cup sizes for the various types of developed breasts (e.g. T eenform and Maidenform). At times girls fail to develop any degree of normal tissue. This is a psychologic handicap, for as the girl grows into adolescence she feels "different" from other girls. Here, again, a discussion of how girls develop and an explanation that there are individual differences in many areas of the body help relieve the insecurity. Pictures of individual differences in breast development may be of value to impress on her the fact that she is only one of many.2 This fact can be reemphasized again by showing her the "falsies." Since manufacturers place these on the market, there must be an appreciable demand or the item would not be worth producing. Two other strong points to help the girl adjust must be made. First, that with good "falsies" and a pleasing personality she will be as popular with the opposite sex as any other girl; secondly, that although the function of the breast is to suckle the baby, if the breasts do not develop during pregnancy,
342
THE BREASTS
artificial feeding of the infant is adequately developed, even for the severely allergic infant. Chest exercises help produce a fullness. Occasionally one sees a child in whom breast development is extreme with large, pendulous breasts. This condition can be unilateral or bilateral and requires careful psychologic management. One must talk to both the patient and the parent. It can, for their purpose, be explained that the child's breast tissue is sensitive or allergic to the estrogenic hormone which starts circulating in the blood stream at the period of beginning rapid growth. They may be told that as soon as apparent growth ceases surgical intervention may be instituted to remove portions of the breasts and to construct a more normal type of organ. Consultation with a plastic surgeon is planned early, so that the child may see both her physician and the plastic surgeon for reassurance. The child's physician should follow her up every two months with measurements and discussion. The mother should be counseled about the type of clothing the child should wear in order to minimize the appearance of the enlargement. She may have to have these especially designed and made by a dressmaker. Loose hanging dresses without belts, smocks, capes rather than coats, may make the child feel more comfortable. Some type of support must also be designed by you and the dressmaker. The above-mentioned deviations from usual are discussed from the standpoint of normal variations without any associated or causative pathology. We are assuming that these are taken into consideration by the practitioner with the help and advice of an endocrinologist or gynecologist as indicated. As mentioned above, the treatment is purely supportive and psychologic. No hormones are indicated. SUMMARY
It is well to keep in mind that the breast tissue of both the male and the female child is sensitive to estrogens. Normal development in girls should be anticipated and discussed with the child and her parents. Deviations from the expected normal in infancy, childhood and adolescence should be approached as physiologic deviations. Cautious observation, with reassurance of parents and child, seeking consultation as indicated, is the most secure position. Hormones are not indicated in the treatment. REFERENCES 1. SchauffIer, G. C.: Pediatric Gynecology, 3rd ed. Chicago, Year Book Publishers, Inc., 1953, pp. 171-2. 2. Wilkinson, L.: The Diagnosis of Endocrine Disorders in Childhood and Adoles. cence. Springfield, Ill., Charles C Thomas, 1950, pp. 140, 165, 169, 172. 3307 Mt. Rainier Drive R.R. #1 Louisville 7, Ky.
BREAST HYPERPLASIA IN THE NEWBORN Incidence, Degree and Etiology
Breast hyperplasia occurs in the newborn period in both male and female infants. It appears at the third or fourth day of life and reaches a peak at the second or third week. The hyperplastic tissues usually regress and return to normal after the third week, but may persist well into the second month, when gradually the breasts return to normal. I have seen a number persisting well into the second month and occasionally into the third month. The degree of hyperplasia varies widely. It may be barely perceptible, or the affected tissue may be so engorged as to produce profound discomfort and pain. A secretion similar to colostrum may be present, a secretion carrying the age-old name of "witch's milk." Simple physiologic hyperplasia is a response to estrogens from the maternal circulation. The degree of enlargement seems to be related to the sensitivity of the end-organs of the breast tissue to the estrogens. Some have felt that the phenomenon is due to the maternal lactogenic hormone, but this condition occurs as frequently in bottlefed babies. Management
Although this simple, physiologic phenomenon has been observed for centuries, to each mother it poses a personal problem. Through the close relation between mother and physician, it is expedient to prepare the mother for this condition in postpartum instructions on care of the infant. I would include a discussion of this normal newborn variant. The mother is then prepared and will not be unduly alarmed when the breasts enlarge. One should not be complacent and disregard an 337
338
THE BREASTS
insecure mother's calls despite previous instructions. If she needs further reassurance, telephone conversations are usually unsatisfactory and totally impersonal. She needs the personal contact of a house call or an office visit. The time which the physician spends will be rewarding in the future relaxed management of the child and the confidence the mother will feel in subsequent situations. The main points to stress with the mother are as follows: 1. Do not try to express any secretion. The breasts will eventually dry up. 2. Do not rub on any lotions or ointments. These may so soften the tense skin that microscopic breaks permit the entrance of pathogenic bacteria and cause subsequent abscess formation. 3. Cool compresses make the infant more comfortable if there seems to be pain. 4. A mild sedative may be beneficial to reduce the fretfulness (phenobarbital elixir, ~ grain every 4 to 6 hours as needed). 5. Reduce the total fluid intake for 24 hours by about one quarter. In other words, if one can put the point across, "hands off." 6. If the engorgement is extreme, testosterone may be of some value, but is rarely indicated. Some men feel that hormones are of no therapeutic benefit; I personally have never used them. Occasionally the hyperplastic breast tissue may become infected. The breast area will be hot, reddened and under tension. The infant mayor may not have fever. He may have vomiting, diarrhea, anorexia. Therapy should be instituted immediately-antibiotics such as penicillin or possibly a wide-spectrum drug, warm compresses. If the area becomes fluctuant, incision and drainage are indicated. Incision should be made near the periphery in a radiating direction from the nipple and should be as small as possible to prevent scarring and retraction of the nipple and disfiguration, especially in the female child. Whenever possible, the surgeon should be called in consultation for the incision and drainage. BREAST HYPERPLASIA IN EARLY LlFE-"PREMATURE THELARCHE"
Hyperplasia of the immature breast is not uncommon in early life. It is usually unilateral, tender and indurated. The most common age for this condition is three to eight years. It can occur even earlier, however. I am now observing an 8-month-old infant who has bilateral breast development, but is otherwise normal. Parents display concern over this condition. Since malignancy of the breast at this age is practically nonexistent, one must be selective if a consultant is considered. We try to reassure the parents chiefly, since the concern is mainly theirs, and watch the breast carefully at intervals of two to three months, making careful measurements. Removal of the breast should not be considered unless biopsies in a few areas are done. Then, if indicated, operation may be performed. It behooves the referring physician to have a good working relation with his consultant. Too often a referral is made without any pre-
CATHRYN C. HANDELMAN
339
liminary discussion or "meeting of the minds" with the consultant. Too often a child's breast has been removed needlessly. The cause is not known. The treatment is conservative observation over a period of years. Hormonal therapy is of no known benefit. Surgery is done if malignancy is proved. Most cases regress spontaneously. PRECOCIOUS BREAST DEVELOPMENT
This may occur in infants and small children and is the first sign of precocious sexual development. The breasts seem especially sensitive to estrogens. For this reason they develop both in the young patient and in the maturing child before any other secondary sex characteristics. There are cases on record of a number of children between the ages of two and seven years who had general sexual precocity with breast development. SchaufHer1 cites the case of a 14-month-old girl who had breast development plus periodic vaginal bleeding which began at 12 weeks of age. She had general accelerated precocity. Some of these children have early, cyclic vaginal bleeding plus other well developed secondary sexual characteristics. Others have no menstrual flow, but do have sexual characteristics. The majority have so-called idiopathic or constitutional precocity, to the best of our present knowledge. One must rule out secondary causes for sexual precocity. This is best done by the combined efforts of gynecologic and endocrinologic consultants. I personally would not manage these children except in consultation because the fears and psychic trauma to parents and child are too great to manage without expert advice. I would talk at length with the parents on the rather frequent occurrence of "constitutional precocious breast development." They should know that many of these go on to complete sexual precocity. I would discuss with them the need for normal age activity and companionship for the child, since the mental development does not keep pace with the sexual maturation. GYNECOMASTIA OF THE ADOLESCENT MALE
Male mammary hyperplasia occurs frequently during adolescence. The etiology is not too clear, but it is thought that (1) estrogens may be secreted in excess by the adrenals or testes or (2) there is temporary disproportion between the secretion of the testicular androgen and the hypothetical hormone of seminiferous tubules, "inhibin." Histologically there is little hyperplasia of the ducts, but there is considerable increase in the peri ductal stroma. The hyperplasia may be unilateral or bilateral. The breast enlargement may be slight or considerable and may persist for years. I have not seen any persist beyond two years, at which time there has been a rapid regression in the tissue. I have observed this phenomenon more in the Negro adolescent than in the Caucasian. The usual age of appearance in adolescents that I have observed has been in the 14- to 16-year age groups.
340
THE BREASTS
Boys become somewhat alarmed at this phenomenon and are reticent in consulting their parents. The boy may be brought to the physician's office by the parent without the parent's knowledge of the reason for the visit. The condition may have a psychologically traumatic effect on the adolescent boy. But, if one is patient and discusses maturation with the parents and the boy, they can be reassured and convinced that the future will bring normality. While explaining the complicated process of development I usually tell them about hormones and how they get a little "mixed up" during development and that the body must be given an opportunity to work out its balance. My advice is to "sit tight," no manipulation, prevent trauma, and the condition will regress. The time is variable-from a few months to one to two years. In the 10 years of my work with adolescents I have not had to refer any of my boys to a surgeon. All cases have spontaneously regressed. If the hyperplasia persists beyond two years, surgery for psychological or cosmetic reasons may be considered. Pseudogynecomastia in fat boys is distinguished from true gynecomastia by palpating for breast tissue. Although in the greatest number of cases gynecomastia in the adolescent is benign and one might say physiologic, the other causes must be ruled out. These are: (a) Klinefelter's syndrome, (1) gynecomastia, (2) small testes, (3) hyaline degeneration of seminiferous tubules, (4) azospermia, (5) increase in FSH; (b) hepatic disease; (c) severe malnutrition; (d) feminizing tumor of the adrenal (extremely rare in children and adolescents); (e) testicular neoplasm; (f) paraplegia; (g) exposure to small amounts of estrogens. BREAST DEVELOPMENT IN THE MATURING FEMALE-NORMAL DEVELOPMENTAL PATTERN
Adolescence in the female is generally defined as the transition from childhood into a childbearing woman. Breast development precedes the appearance of all other secondary sexual characteristics by about one year. Adolescent development in the female ranges from 9 to 17 years, breast development appearing from 8 to 16Yz years. If we assume the known average of the menarche as 13 to 15 years, a slight budding of the nipple becomes apparent at around the age of 10. After this, between 10 and 11, the breasts barely bud. At 12 to 13 the breasts fill in and the nipples become pigmented. This is a long-awaited event in the female. Most girls anticipate this development to such an extent that often a brassiere is requested long before the mother notices any changes. I would advise the mother to purchase a beginner's "bra" if her child so desires. The normal sequence of breast development has been briefly outlined. The wide variations that occur are due to such factors as (1) nutritional status, (2) genetics, (3) constitutional variations, (4) race or nationality, (5) endocrine pattern, (6) congenital defects, (7) illness. When a girl begins breast development, despite the fact that she
CATHRYN C. HANDELMAN
341
has been anticipating this development, there is a tendency to stoop. I talk with the mother and the child, pointing out that this is an event for which she has really been waiting. She should be proud to be developing normally as a woman to fulfill her role in life. I discuss this phase of her development along with preparation for the menarche. It is pointed out that each generation must reproduce or our race would die out, and it is each girl's destiny in life to marry and become a mother. God has planned this and made man and woman a wonderful human body which surpasses any machine that we know. So, as we are approaching womanhood, certain parts of our body begin to grow and develop to fulfill their function of motherhood. The breasts are meant by nature to feed the infant. Therefore we should be proud to develop normally. It can be pointed out that a number of women do not develop much breast tissue, and when this happens, women have always used padding to create an illusion of breast tissue. In modern times manufacturers have placed on the market padded brassieres known as "falsies." It is wise to mention this to the child and show her the "falsies," thus doubly impressing upon her the pride she should feel in normal development and how important it is for her to maintain a normal, erect posture, especially at this period when her pelvic organs are developing. Charts and diagrams are useful in this discussion to show the relation of the abdominal organs and the effects of slumping or slouching. "Bras" should be worn as soon as some breast tissue appears. It may really not be necessary, but it supports the girl's insecure feelings about growing up. She identifies herself with other adult females. Also the transition from a beginner's "bra" to one with good support is then a simple matter. The child will feel less embarrassment in being measured and fitted. Two brassieres, one on and one in the wash, are an adequate supply, since the girl's size may change rapidly. All good department stores with teen departments carry an adequate line with women experienced in measuring and fitting. With development of breast tissue an uplift brassiere with good support is essential. They come in different chest sizes and cup sizes for the various types of developed breasts (e.g. T eenform and Maidenform). At times girls fail to develop any degree of normal tissue. This is a psychologic handicap, for as the girl grows into adolescence she feels "different" from other girls. Here, again, a discussion of how girls develop and an explanation that there are individual differences in many areas of the body help relieve the insecurity. Pictures of individual differences in breast development may be of value to impress on her the fact that she is only one of many.2 This fact can be reemphasized again by showing her the "falsies." Since manufacturers place these on the market, there must be an appreciable demand or the item would not be worth producing. Two other strong points to help the girl adjust must be made. First, that with good "falsies" and a pleasing personality she will be as popular with the opposite sex as any other girl; secondly, that although the function of the breast is to suckle the baby, if the breasts do not develop during pregnancy,
342
THE BREASTS
artificial feeding of the infant is adequately developed, even for the severely allergic infant. Chest exercises help produce a fullness. Occasionally one sees a child in whom breast development is extreme with large, pendulous breasts. This condition can be unilateral or bilateral and requires careful psychologic management. One must talk to both the patient and the parent. It can, for their purpose, be explained that the child's breast tissue is sensitive or allergic to the estrogenic hormone which starts circulating in the blood stream at the period of beginning rapid growth. They may be told that as soon as apparent growth ceases surgical intervention may be instituted to remove portions of the breasts and to construct a more normal type of organ. Consultation with a plastic surgeon is planned early, so that the child may see both her physician and the plastic surgeon for reassurance. The child's physician should follow her up every two months with measurements and discussion. The mother should be counseled about the type of clothing the child should wear in order to minimize the appearance of the enlargement. She may have to have these especially designed and made by a dressmaker. Loose hanging dresses without belts, smocks, capes rather than coats, may make the child feel more comfortable. Some type of support must also be designed by you and the dressmaker. The above-mentioned deviations from usual are discussed from the standpoint of normal variations without any associated or causative pathology. We are assuming that these are taken into consideration by the practitioner with the help and advice of an endocrinologist or gynecologist as indicated. As mentioned above, the treatment is purely supportive and psychologic. No hormones are indicated. SUMMARY
It is well to keep in mind that the breast tissue of both the male and the female child is sensitive to estrogens. Normal development in girls should be anticipated and discussed with the child and her parents. Deviations from the expected normal in infancy, childhood and adolescence should be approached as physiologic deviations. Cautious observation, with reassurance of parents and child, seeking consultation as indicated, is the most secure position. Hormones are not indicated in the treatment. REFERENCES 1. SchauffIer, G. C.: Pediatric Gynecology, 3rd ed. Chicago, Year Book Publishers, Inc., 1953, pp. 171-2. 2. Wilkinson, L.: The Diagnosis of Endocrine Disorders in Childhood and Adoles. cence. Springfield, Ill., Charles C Thomas, 1950, pp. 140, 165, 169, 172. 3307 Mt. Rainier Drive R.R. #1 Louisville 7, Ky.