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Report of the County Medical Officer—Education
129
adipose tissue, under normal weight, and with deficient chest expansion. These facts seem to
justify the conclusion that the sigma costale is a reliable sign in estimating the prognosis in a case of
malnutrition; if it is present the probabilities are that the child will benefit but little from ordinary
tonic and open-air treatment so far as immediate results are concerned. Such children will have to
be kept under observation throughout their school life, and also later on, for while it is perhaps too
sweeping a deduction to make, as Stiller does, that these children are all potential neurasthenics,
consumptives, and enteroptotics, the fact remains that they are suffering from a congenital
constitutional weakness which places them in an inferior position so far as resistance to the factors
that establish ill-health is concerned.
Girls.—The results of the investigation so far as girls are concerned were even more striking
than with the boys. It would be superfluous to give here all the details entered in Dr. Liepoldt's
notes; the enumeration of a few salient points alone is therefore attempted.
Altogether 2,105 girls were examined; among these 382 or 18.1 per cent. had the costal sign
in a more or less pronounced form, while 14 or 0.6 per cent. showed Stiller's sign. These percentages
are higher than for the boys, and agree closely with those given by Stiller, Moritz, and, so far as
nephroptosis is concerned, with those of Blum. Dr. Leipoldt's impression, however, is that the percentage
is too high, since a slight fluctuation of the tenth rib is very common in girls—certainly
much more so than in boys—and undoubtedly, in the earlier cases, from which these data were
taken, Dr. Leipoldt states that he took these slight degrees of moveability as abnormal and classed
them as sigma costale 1. Making allowance for these errors, the percentage of girls is probably
very close to that of the boys. It is usually stated that enteroptosis is much more common in
females, but this is perhaps one of these statements often copied in the text books that will not bear
the test of investigation.
Out of the 382 girls noted as possessing the sigma costale, 48 or 12.5 per cent. were normal,
using the word in the sense in which it has been employed in dealing with the boys. 189 out of the
382, a percentage of 49.4, were below the average weight for their height; 110 or 28.7 per cent. had
chest expansion below the average for their height (using Guttmann's tables). In 102, a percentage of
26.7, a family history of tuberculosis was obtained; in 19 a family history of enteroptosis; in 64 of
nervousness or psychical disorder and nervous disease, including paralysis; in 45 of gastric disease;
in six (not included under the nervous cases) of diabetes; in 17 of tumour or cancer. In 129
children no adequate family predisposition to any of these diseases could be ascertained.
The fourteen cases which showed Stiller's sign—absolute moveability of the tenth rib—presented
interesting features. Well marked family history of tuberculosis, 9 cases. History of enteroptosis
in parent or relative, 2 cases (1 doubtful). History of nervous or gastric trouble, either
alone or combined with tuberculosis, 6 cases. No history of hereditary disposition elicitable, 2
cases. Normal, 2 cases. Defects of teeth, oral sepsis, 4 cases. Defects of nutrition: Three girls
were markedly malnourished, and put down as 4; five were below the normal average weight for
their heights. Two were above the average weight. With one exception all were pale; this exception
was a girl with malar flush, high blood pressure, and slightly pigmented skin. Evidence of
fatigue was marked in six cases. Nervous defects: with one exception all had increased knee
reflexes; none had ankle clonus or tremor. One had well marked vaso-motor signs of nervous
irregularity; in three the pulse was intermittent; one had cardiac irregularity of the respiratory
type. Ten had nervous psychic disturbances, fidgetiness, night terrors, fits of temper, &c. One
was psychasthenic; one had incontinence. In four the kidneys were palpable; in one, an entrant,
the liver and spleen were easily palpable, four had enlargement of the thyroid, one with rather
prominent eyes but with no cardiac signs or tremor. In six there was evidence of gastric or intestinal
atony (constipation; dilated stomach). Eight were typically asthenic in appearance and build.
These findings justify the conclusion that the graver degree of moveability of the tenth rib
is to some extent an index of the asthenic condition of the child. Unfortunately it was impossible
to follow up these children in detail. It may be said, however, that at least two of these cases would
not now be classed as S.S., but rather as S.C. 2. Illustrative cases have already been given to show
the general condition found in a child presenting the sigma costale in the second degree; the third
degree, S.S. is really a rare sign, and in two recent cases it seems to be associated with the absence
or under development of the twelfth rib. Nervous signs in the girls were less prominent than
among the boys; yet a relatively large percentage of them had gastric symptoms, which could
legitimately be classed as nervous in origin. Such were frequent bilious attacks—eye strain being
excluded—precordial uneasiness in some cases amounting to oppression and pain, headache, hiccough,
furred tongue, and in a few cases epigastric tenderness. Definite evidence of dilatation in the form of
succussion splash was obtained in only three cases. It should be borne in mind that such a sign shows
the existence of a relatively large degree of dilatation of the stomach in a child, and that its
importance is, therefore, far greater in these children than it would be in adult patients. In cases
with marked gastric or intestinal signs, the asthenic habitus was well developed and the family history
usually showed evidence of hereditary tuberculous disposition.
Among the girls a far larger percentage of children showed two defects, enlarged thyroid and
lateral curvature, than the boys. The enlargement of the thyroid was in most cases entirely
unaccompanied by any other signs indicating Basedow's disease, and appeared to be associated chiefly
with septic absorption either from carious teeth or from constipation. Two such children
presented, most markedly, signs of so-called "chronic intestinal stasis," with pigmentation of the
skin, a high blood pressure, and symptoms of fatigue. Yet in both cases it seemed clear that their
condition was accounted for by the state of the mouth; under the dental treatment they rapidly
improved although their intestinal atony was still noticeable in the irregularity of the bowels. It is
needless to point out that such conditions, as Stiller observes with justice, may be accounted for by
assuming the existence of a congenital asthenic state in which atony of the intestines and stomach is
a well marked feature.
23610 s