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128
Annual Report of the London County Council, 1913.
bruits, disappearing after exertion; in 10 there was slight intermittency of the pulse; in 6 the blood
pressure was markedly low; in 24 it was high. No special note was made of the area of cardiac
dulness.
Lung conditions.—In 8 boys there were signs of slight pulmonary lesions, generally rhonchi,
moist rales, or signs of slight bronchitis; 15 were classed as "pretubercular," mainly on the ground of
deficient expansion, irregularities in the breathing at the apices, or slight crepitations in the upper or
lower lobes; 19 had a prolonged expiration note at the apices; 6 had cough without any pulmonary
signs; none had definite impairment of percussion sound over the lungs; in one a tentative diagnosis
of "enlarged bronchial glands" was made. No child was notified as tuberculous.
It has not been attempted to include in this series any child who was definitely tuberculous,
the intention being to deal with those borderland cases in which the impairment of nutrition was the
main feature. Cases noted as definitely tuberculous or "malnutrition due to some definite defect"
were therefore disregarded, even when S.S. or S.C. was noted against them.
Condition of the mouth.—Bad teeth were noted in 61 cases; in 34 the condition was sufficiently
marked to require treatment (3), the others were placed in class 1. Oral sepsis, apart from bad teeth,
was noted in 23 cases, generally as "furred tongue" or septic tonsils. High palate and long or split
uvula, curiously enough, were only noted in three cases. Enlarged tonsils needing treatment were
noted in 18 cases. Foul breath, not depending on carious teeth or obviously septic tonsils, was
recorded in a fairly large number of cases, 56 or 31.0 per cent.
Gastric and abdominal condition.—Tenderness in the right iliac fossa, chronic catarrhal
appendicitis, and chronic appendicitis were noted in 12 cases out of the 181, a notably high
percentage (6.6 per cent.) Of these, two cases were subsequently operated upon, and three were
medically treated during sub-acute attacks; one had been operated upon before being seen.
Succussion splash or positive evidence of dilatation of the stomach was present in only two cases
(apart from the one already mentioned in the boy who showed Stiller's sign), but slight and recurrent
gastric symptoms, pointing to nervous dyspepsia, were recorded in 19 cases. Constipation, worms,
diarrhœa, and focal incontinence were noted in 33 cases. Protuberant abdomen was noted in three
cases.
Nervous conditions.—Brisk knee jerks were recorded in 114 cases; slight tremor and palpable
tremor in 21; "nervousness" was recorded in 62; subjective neurasthenic symptoms could be
definitely elicited in only two cases. On the other hand signs of fatigue were present in 44 boys,
one of whom was noted as "overstrained," sixteen had "insufficient sleep," three did "work
outside school"; for the rest no cause could be found for the fatigue. One child, who presented
no other signs, was stated to be a somnambulist; nine children suffered from night terrors; sixteen
from nocturnal enuresis; five from enuresis both during the day and when asleep; one child was a
head nodder; eight children had slight habit spasm; five suffered from fits (? epilepsy), two (infants)
were noted as "spasmophilic"; eighteen children had speech defects ranging from slight slurring to
well marked stuttering and stammering. To the psychic phenomena reference has already briefly
been made.
Errors or vision were noted in 23 cases; and in some of these a card was given (although the
vision, as tested by Snellen's types, was normal) because there existed some doubt as to whether or not the
child suffered from eye strain. These slight and doubtful cases were afterwards followed up, and it
was found that with one exception their vision had been declared normal either at an eye hospital or
at the school treatment centre. The symptoms of eye strain in these cases appear therefore to have
been associated with that nervous dyspepsia to which these children, according to Stiller, are so liable.
Curiously enough none of the cases showed any sign of congenital syphilis. The relative
infrequency of Stiller's stigmata in children who show evidence of such hereditary taint in the
shape of eye lesions, Hutchinsonian teeth, or the scaphoid scapula is striking. Similarly only a few
children were found to be rickety.
It was found impossible within the limits of Dr. Leipoldt's report to deal with all the smaller points
noted. It may be mentioned, however, that a fair percentage of the cases had scoliosis, lordosis,
round shoulders, and flat feet. These could usually be classed as postural deformities, due to muscular
weakness and fatigue strain to which asthenic children are strikingly subject. In two children other
stigmata were observed; webbed toes in one, and bilateral enlargement of the pisiform bones in
another: in both the stigma was hereditary.
The most interesting point about these children, and the one to which attention is specially
drawn, is the fact that the largest percentage of them were children in whom the question arose as to
the propriety of referring them to class 3 or class 4 so far as nutrition was concerned. It has already
been stated that some of the children were normal, but it remains a fact that Stiller's stigmata are
found much more frequently in under-nourished than in well-nourished children. While some of the
remainder were not quite bad enough to be classed as 3, comparatively few could at once be assigned to
class 2. The majority were borderland cases, between 3 and 4. Among these were children in whom
could be found no positive sign of tuberculosis, but who had so marked an asthenic appearance that it
was justifiable to class them as "pretubercular." Similar cases had been noted in children who did
not present Stiller's signs, and these served as a standard for comparison with the pretubercular cases
among the 181 boys. In following up the two sets of cases, Dr. Leipoldt was struck by the fact that
children in whom Stiller's sign had not been recorded, generally improved markedly when they had
had the benefit of good food, open air, and tonic treatment; in some cases where the malnutrition
was due to septic absorption through carious teeth, constipation, or gastric disturbance, the improvement
was rapid and quite satisfactory after these defects had been suitably treated. In the children
with the sigma costale, on the other hand, the progress was by no means so satisfactory. Notwithstanding
the fact that these children were put on tonic treatment, sent to the country or the seaside,
and enjoyed the advantage of good homes, excellent food, regular hours of sleep, and adequate
recreation, their progress was apparently nil; they came back, and were found at reinspection, to be
more or less in the same condition as before, pale in colour, with lax musculature, with but little