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Report of the County Medical Officer—Education.
127

These averages agree fairly well with the table of Guttmann, although the physique of his
children is generally a trifle below that of the average normal London child. In both tables it is
shown that the chest capacity markedly increases in children above 135 centimetres in height.
Measurements of the chest in young children (entrants) are not very reliable, and the first three
rows of figures are therefore merely approximate averages.
Taking the series of 181 boys who showed the sigma costale, it was found that 101 or 55.8 per
cent. had a pulmonary capacity below the average for their height, 92 or 50.8 were below the
average weight for their height, 84 or 46.4 per cent. were above the average height for their age,
and only three were normal in respect to average height, weight, and chest expansion. It was
unfortunately impossible to work out the average chest measurements for the girls, for a comparison
of which, in these cases, reliance was placed entirely upon Guttmann's tables.
Of the 181 boys, 72 or 39.3 per cent. were noted as "normal," that is to say they presented
no obvious defects. In the majority of cases, however, their family history showed that these
children were "burdened" with nervous, asthenic, or tuberculous "predispositions." Sixteen of
them had a well-marked family history of consumption on mother's or father's side; twelve had
a father or mother suffering from gastric complaints; three had evidences of insanity in the family;
five had a paralytic family history; two had brothers or sisters suffering from what was evidently
neurasthenic dyspepsia; one had a mother suffering from visceroptosis for which she had been an
inmate in a London hospital. In none of these normal cases was the habitus asthenicus well
marked ; in a few it was not present at all, the children being well nourished, strong, muscular, and
florid complexioned. Particular stress is laid on these normal cases since they appear to support
Stiller's view that the asthenic condition may be latent in childhood, giving rise to no symptons
until physical stress has to be endured or some infectious process supervenes. To all intents and
purposes these children are normal; the closest investigation into their history does not elicit any
evidence of gastric, nervous, or tubercular trouble; that very valuable help to the school doctor
in investigating the nervous condition of a child, the master's report, gives no aid in their cases; the
boys are average normal school boys, neither good enough nor bad enough to cause them to be
prominently noticed by their class master. Yet, in many cases, they have these curious family
antecedents. It would be well, therefore, to follow them up and see what happens to them in later life.
This, of course, it has been impossible to do. Two cases, however (not included in the above series of
normal children), have some bearing on this point and may be summarised here.
At one school, in the course of a routine inspection, a little boy was seen who presented
costal sign in a marked degree, but was otherwise normal. Some months later the same boy was
brought up for presumed chorea. He then had tremor of the fingers and forearms, nystagmus,
marked increased knee reflexes, slight ankle clonus, but no cardiac signs. He was excluded, and an
advice card was given. On reinspection three months later he was found to have considerably
improved, but he still showed nervous signs of which he had had no indication at the time of the
first inspection. A little girl in Holmes Road school, who showed the sigma costale in an equally
marked degree, but who was also malnourished with a very evident habitus asthenicus, was later on
specially examined for "general ill-health." Her nutrition was found much below the average; she
was profoundly anaemic, with basal and apical systolic murmurs, brisk knee jerks, and slight tremor
of the fingers. She was put on milk feeding and tonic treatment, but during the holidays she was
taken to hospital and subsequently died at home, the cause of death being certified as " gastritis."
The point on which Stiller lays particular stress is that children who show these costal stigmata
are congenitally weaker than normal children; they resist infection less well than do the latter; they
are more prone to nervous diseases and diseases of nutrition; and they are, generally speaking,
less stable than other children of a similar age. Dr. Leipoldt has been specially struck with the
number of "only children" in his series who show this costal sign. Out of his 181 boys he notes
that 29 were only children, who presented characteristic mannerisms, among which psychical
phenomena such as idioglossia, nervousness, phobia in various forms, and even melancholia,
were noted.
Out of the 181 cases in the series, a family history of tuberculosis was obtainable in 53, or
29.3 per cent.; of nervousness or neurasthenia—a much more difficult matter to investigate—in only
15, or 82 per cent.; of gastric trouble in 32, or 17.6 per cent.; of paralysis in only 3, or 1.6 percent.;
of visceroptosis in only 12, or 6.6 per cent. In the others either no information could be obtained
about the family history or the investigation was negative.
Other results.—Anmiæ a and pallor; 84, or 46.4 per cent. of the boys were pale or anæmic; in
29 this anæmia was sufficiently grave to call for treatment; in 22 there were hæmic murmurs; in 4
there were mitral systolic murmurs not traceable into the axilla; in 11 there were apical presystolic