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124
Annual Report of the London County Council, 1913.
Dr. Leipoldt's
inve stigation
into the
presence of
Stiller's signs
in cases of
malnutrition.
associated with malnutrition, pp. 50-55. Several of the school doctors have pursued independent
investigations into the causation and concomitants of malnutrition; see, for instance, Dr. Palgrave on
faulty home management, p. 30; Dr. Norman on the comparison of breast fed and bottle fed children,
p. 31; and Dr. Mabel Russell on the sufficiency of sleep, p. 31.
Dr. Leipoldt, too, has investigated the usefulness of certain signs in the recognition of cases
of malnutrition, and in view of its importance extended reference will now be made to this subject.
There is a class of child vaguely recognised by all who have had experience in school inspection,
which will be described by one observer as "congenitally debilitated," by another as "the nervous
type," and by yet another as presenting the "pretubercular condition." The children so described,
often exceptionally intelligent, and not infrequently of striking beauty, are constantly brought to
notice by reason of their frequent absences from school, their tendency to suffer from manifold
ailments, particularly night terrors and chorea, their inability to withstand the slightest pressure
with their lessons and the frequency with which they eventually fall victims to tuberculosis. The
indefiniteness of the characteristics ascribed to this class of children has, however, led many observers
to express doubts as to the reality of their existence, and even to those who pinned their belief upon
the existence of such a type of child, recognition has hitherto been much easier than description.
Any common physical sign or stigma which will aid in giving definition to this class of child is
therefore to be looked upon as exceedingly valuable.
Dr. C. Louis Leipoldt has investigated in this connection the occurrence in school children,
suffering from malnutrition, of certain signs first described by Professor Stiller, of Buda Pesth.
Dr. Leipoldt's observations appear to be of sufficient importance to warrant their being published in
detail. He points out that every school doctor, in his routine examination of children in the various
age-groups, comes across a certain percentage of children who, while not obviously suffering from any
gross physical defect that calls for treatment, arc yet below a certain standard of health and nutrition
which he has in mind as the normal. At present there is no criterion which will serve as a means of
properly classifying such children.
In 1898 Professor Berthold Stiller, of Budapesth, published the results of an investigation which
he had made into the incidence of visceral displacements in patients under his charge. His data led
him to the conclusion that a fairly constant phenomenon in these patients was the occurrence of a
skeletal abnormality, a floating tenth rib. He further came to the conclusion that this "stigma
of physical degeneration" is found not only in patients with visceroptosis, but also in those
who present the "habitus phthisicus" of Rokitanski. In his book on the subject, published
in 1907, Stiller definitely commits himself to the view that those who present the various typical
signs, which may be conveniently styled "Stiller's syndrome," are sufferers from a specific congenital
asthenia or habitus asthenicus, to which he has given the name "Asthenia universalis congenita."
Before proceeding further it is necessary to describe this syndrome and to make clear the significance
which Professor Stiller attaches to certain variations to which reference must be made.
Normally, the tenth rib is joined to the sternum by its costal cartilage, which runs smoothly
upward to join the costal cartilage of the much more oblique ninth rib. The eleventh and twelfth
ribs are not so joined, but their anterior ends are free, and can easily be felt by palpating the hypochondriac
regions below the costal margin. The point of the tenth rib, corresponding with the
prolongation downwards of the line drawn through the nipple, can usually be easily felt and its
junction with the ninth costal cartilage easily traced. In a very small percentage of persons, however,
the tenth rib is loose, or floating, corresponding, so far as its want of anterior attachment is
concerned, with the eleventh and twelfth ribs. This is the "costa decima fluctuans" of Stiller, which
he regards as a conclusive sign of the habitus asthenicus. In a much larger percentage of cases it is
not floating, but is fairly moveable, its junction to the ninth costal cartilage being represented merely
by a thin strand of cartilage which allows its point to be pushed upwards or downwards by the
examiner. This is the "sigma costale" of Stiller, by whom it is regarded as strong accessory proof
of the existence of the habitus asthenicus, its value as a clinical sign, according to Stiller, depending
largely upon the range and extent of its moveableness.
Stiller bases his supposition that asthenia congenita universalis is a well-marked clinical entity
upon a series of other signs to which attention had already been directed by older observers. In fact,
the description which Stiller gives of his typical "habitus asthenicus" is one closely resembling that
already given by Rokitanski. "Thin boned, a gracile skeletal system, a narrow and shallow thorax
with wide intercostal spaces, and a sharp epigastric angle, weakly developed musculature, transparent
dry skin, well-marked reflexes—this constitutes the habitus asthenicus." If the descriptions given by
various authors be combined, the following picture, which very fairly details the main features
observable in the so-called "pretubercular" child, is obtained.—Thin, slight figure, with
marked slenderness of the limbs, long, slender hands and feet; narrow, oval face, with a
proportionately greater development of the cranium than of the facial bones; smooth, transparent,
dry skin, with the surface veins well-marked on arms, thorax, hands, feet, and temples; long eyelashes,
and generally long smooth hair, with, in many cases, well-grown downy hair on the arms and
back; markedly paie complexion, without definite anaemia; slight cardiac signs, such as respiratory
irregularity, basal and apical bruits after exertion, and intermittent pulse; relatively long, shallow
and narrow thorax; an abdomen small in proportion to the thorax; a sharp epigastric angle; a short
and stiffened first costal cartilage (Freund's sign), and a marked flattening of the angulus Ludovici
(Rothschild's sign); costa decima fluctuans or sigma costale (Stiller's sign); deficient chest expansion
and limited pulmonary capacity; tendency to atony of the stomach and intestines, leading eventually
to dyspepsia, habitual constipation, and intestinal stasis, with gradual pigmentary changes in the
skin ; tendency to glandular enlargement, and physiological stigmata of physical degeneration, such as
achylia gastrica or orthostatic albuminuria; want of co-ordination, slight choreic or athetotic movements,
nystagmus, and twitching of the facial muscles; markedly excitable, neurasthenic temperament,
accompanied with considerable variations in the blood pressure; increased knee and ankle reflexes,