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Report of the County Medical Officer—Education
125
with, in advanced cases, a tendency towards ankle and patellar clonus; special liability to fatigue, both
mental and physical, which results in weakness of the muscles of support, leading to scoliosis and
flat feet.
It is easy to see that this description fits, so far as certain of its general particulars are
concerned, almost every case of malnutrition or of "pretuberculosis," just as it fits, also, the
condition which Lane has described under the name of "chronic intestinal stasis." It is possible that
the cases of the latter condition, as seen in children, are primarily cases of asthenia congenita, in
which the pigmentation, the intestinal atony, the slight thyroid enlargement, the gastric disturbances
and the subjective signs are merely the result of the original congenital diathesis.
A consideration of Professor Stiller's views led Dr. Leipoldt to pay some attention at routine
inspections to the question of the costa decima fluctuans, more especially of late, when its value as a
clinical sign of the existence of the asthenic habitus has become clearer. In most children it is
comparatively easy to demonstrate the sign when it exists. The point of the tenth rib is usually
external to the nipple line prolonged downwards. In a normal rib this point cannot be felt as a sharp
end, but is palpated as a smooth cartilaginous prolongation of the rib that joins evenly with the
cartilage of the more oblique ninth rib. This junction, normally, is similar to that of the other ribs,
only differing from the upper costal cartilages in the fact that the cartilage of the tenth rib is thinner
and a trifle more elastic. In a normal child, however, the tenth rib cannot at its end be pushed below
or above the cartilage of the ninth. In a fair percentage of cases there is a varying degree of
downward and upward movement on palpation; these form the first group of cases and are
of comparatively little clinical significance. When the point of the tenth rib can be felt, and its
connection with the ninth costal cartilage made out as a strand which permits of more or less free up
and down movement on pressing it with the fingers, the case belongs to the second group, and the
sigma costale is really present, though its degree has still to be estimated. Practice and experience
can alone enable the examiner to do this. In the third, and much rarer class of cases, the point of the
tenth rib can be grasped between the fingers, and little or no connecting strand of cartilage or ligament
can be made out; this is the costa decima fluctuans in its absolute sense, and is a very valuable sign
of the asthenic condition. In such cases there is an inclination to take the tenth rib for the eleventh.
The only way to avoid this mistake, especially when the twelfth rib, as sometimes is the case,
is rudimentary or absent, is carefully to count the ribs first from above downwards and then from
below upwards. As the children in which both the sigma costale and the floating tenth rib occur are
generally thin, with lax abdominal parietes, and not very resistant musculature, the actual palpation
of the costal margins presents little difficulty if care be taken to carry it out gently, so as not to irritate
the skin and cause the child, involuntarily, to contract the latissimus dorsi and oblique muscles. In a few
cases the exnmination must be carried out with the child lying down, but generally such a procedure
is necessary only in fat, well nourished children, in whom the examination is nearly always negative
so far as the existence of Stiller's sign is concerned.
In most cases in which the existence of this rib abnormality has been shown, Dr. Leipoldt has
taken the chest measurement, and, where the parent has been present, made enquiry into the family
history to find out, if possible, whether there existed any "hereditary tubercular predisposition," or
whether any of the family suffered from gastric or nervous complaints. As the record card did not
afford space for all the data elicited by such examination, additional notes were also made, only the
chest measurement and any findings as to pulmonary, cardiac, or general conditions being noted on
the card. In order to have some definite means of classification, Dr. Leipoldt adopted two record
marks—"S.S (Stiller's sign) in cases in which the tenth rib is absolutely free, and S.C.1 or S.C.2
(sigma costale) when its mobility was marked in greater or less degree.
It is interesting to study the facts elicited by enquiry into the family history and the subsequent
more careful examination of the child in cases in which the sign was found. The
following cases will illustrate this.
J.C. aet. 11. Condition, pale, thin faced, slight, overgrown boy. Height, 139.2 cm.; weight,
28.5 kilograms; chest measurement, 68 cm., expiration, 72 cm. inspiration. Cardiac condition normal.
S.C.2 present. Knee reflexes much increased; no clonus, palpebral or finger tremor. Thyroid
normal. Teeth, class 2. Two small hard glands under left sterno-mastoid; no waxy discharge in ears;
head clean. The boy is said to be "excessively fidgety in school." On his mother's side there is a
strong family history of consumption (uncle, grandmother, two aunts, and two cousins said to have
died of pulmonary phthisis); on his father's side some family history of "paralysis." Two brothers
and one sister suffer from "nervousness and stomach complaints"; one from lung trouble for which
he is being treated at Mount Vernon Hospital. The boy himself is stated by the mother to be healthy
and has had no infectious disease, but suffers from headaches (there is no sign of astigmatism),
dyspepsia, and nervousness; has suffered from incontinence.
J.W. aet. 11. No physical defect found. S.C.2. Height, 132 cm.; weight, 28 kilograms;
chest measurement, 61 cm. expiration, 67 cm. inspiration. Knee jerks normal. On mother's side
strong family history of consumption; on father's side, one uncle suffering from the disease. One
aunt on father's side operated upon for "floating kidney.'' The boy shows at present no chest or
gastric signs, but is a highly strung, nervous lad. Kidneys are not palpable.
A.W. aet. 11. Height, 139 cm.; weight, 30 kilograms; chest measurement, expiration 63 cm.,
inspiration 70 cm. Furred tongue; pallor. Teeth, class 2; slight tenderness on deep pressure in right
iliac fossa. Cardiac condition normal. Expiration sound at both apices prolonged but not rough.
Inguinal and axillary glands markedly palpable; one enlarged cervical gland in left posterior triangle.
Boy has frequent attacks of sick "headache"; vision is 6/9; slight astigmatism is probably present
(treatment card given). Father suffers from "bronchitis and asthma"; mother is healthy; one uncle
on mother's side suffers from consumption; one aunt on father's side died in hospital after" an
operation on her stomach." The boy's knee reflexes are brisk, but he shows no other signs.