ANTHROPOMETRY A N D

PHYSICAL EXAMINATION

A B O O K

F O R P R A C T I C A L U S E IN C O N N E C T I O N W I T H G Y M N A S T I C

W O R K A N D P H Y S I C A L E D U C A T I O N .

Instructor in Gymnastics and Lecturer on Practical Hygiene in Yale University. Lecturer on Anatomy, Physiology and Anthropometry in the Chautauqua

School of Physical Education. Ex-Secretary of the American Asso­ciation for the Advancement of Physical Education. Mem­

ber of the Connecticut State Medical Society, etc.

N E W H A V E N , C O N N .

1890

B Y

JAY W . S E A V E R , M.D.,

Copyright, 1890, by Jay W. Seaver.

PRESS OF T U T T U E , MOREHOUSE & T A Y L O R , NEW HAVEN, CONN

CONTENTS.

C H A P T E R I.

T H E USES OF A N T H R O P O M E T R Y AND T H E EXAMINER HIMSELF.

The need of physical training for the young.—The inductive method.—The scientific basis of gymnastic work.—Anthro­pometry furnishes a standard of physical excellence and shows actual changes in condition.—The therapeutic value of gymnastics.—The standard for the examiner and per­sonal advice. 9-22

C H A P T E R II.

A P P A R A T U S TO BE USED AND RECORDS TO BE K E P T .

A list of instruments with illustrations.—Description of new apparatus and simple methods of taking measurements and tests. 23-38

C H A P T E R III .

W H A T TO MEASURE AND H O W TO MEASURE.

The technique of measurement.—The rules and list of items re­commended by the Amer. Assoc. for the A d v . of Phys. Ed.—Criticisms and suggestions. 39S2

C H A P T E R IV.

PERSONAL HISTORY AND EXAMINATION OF SPECIAL SENSES.

The private record.—Family history.—Exercise.—Results.—Ex­amination of the eyes, ears, etc 53-63

6 Contents.

C H A P T E R V.

E X A M I N A T I O N B Y INSPECTION.

Front, side and rear aspects.—Points that the eye must discover. —Table. 64-76

C H A P T E R V I .

EXAMINATION B Y PALPATION.

Methods and results.—Normal movements.—Abnormal condi­tions.—Tumors 77-82

C H A P T E R V I I .

EXAMINATION B Y AUSCULTATION AND PERCUSSION.

Methods.—Areas.—Normal sounds.—Abnormal sounds. . . 83-98

C H A P T E R V I I I .

T H E SIGNIFICANCE OF CERTAIN P H Y S I C A L SIGNS. Discussion of the anatomy of heart sounds, normal and abnor­

mal.—-Tables. 98-106

C H A P T E R I X .

T H E PRESCRIPTION OF EXERCISE.

Methods of getting an idea of a perfect form.—Removal of causes of debility and deformity.—Respiration.—Nervous cases.— Forms of prescription 107-121

C H A P T E R X .

GRAPHIC A N T H R O P O M E T R Y .

Tables, charts, etc 122-128

PREFACE.

The only reason for the appearance of this little book is the desire to meet to some extent the demand that exists for instruction in the great field of physical education, and thus to put a work of the greatest importance on a higher plane. • The organization of schools in this country, for the training of teachers to take charge of the physical education of the people, is a recent development. The demand for competent instructors in this department of work has far outstripped the supply and therefore what­ever will prove a help to instruction is to be welcomed, however meagre and unpretentious it may be.

The only excuse that can be urged for the imperfect and poorly-arranged character of the work is that it has been done in moments between professional cares and college duties.

I wish to express my thanks to Drs. Hitchcock of Amherst, Kellogg, Hitchcock of Cornell, Anderson, Sar­gent, Savage, and others, for the courtesy they have shown me in permitting the use of material that has been pre­pared by them at great expense of time and labor.

JAY W . SEAVER.

N E W H A V E N , CONN. ,

1890.

C H A P T E R I.

T H E U S E S OF A N T H R O P O M E T R Y A N D T H E E X A M I N E R H I M S E L F .

Educational systems are rapidly being broadened by the new standards that have been set by the advance of science or the demands of social organization. At one stage in the history of civilization the great man was the one who over­powered all others by physical strength. Such a man easily gathered around him a retinue of weaker followers, either as subdued competitors or weak dependants who must seek some strong person for protection. This condition of affairs evolved great physical hardihood and endurance but the limitations of development were reached under ignor­ance of physiological laws and the waste caused by impru­dence. Later on the mental activity of the genius gave him a new weapon in competition, and a new force was added to the growth of civilization. This new element was in one respect at least entirely different from the old dominating force, in that it could be shared with others without loss to the original possessor. Any new invention or craft or idea could be taught to others while mere physical strength could only be directly transmitted through hereditary chan­nels.

It is safe to say that for the last three-quarters of a cen­tury the history of civilization must record rapid physical deterioration among the families who have been most act­ive in evolving new ideas for the refinement of life and the amelioration of its hardships. Close application in each department of mental activity and a consequent neglect of the physical basis for life, which depends on muscular ac­tivity, have drawn heavily on the surplus vitality stored up by many generations of healthy and frugal ancestors ; and

2

io The Uses of Anthropometry

in too many cases We find prominent names drop altogether from town records and public lists. France has already reached a point in her history as a people when the natural physical increment barely meets the yearly loss of her pop­ulation, and similar tendencies everywhere are calling the attention of thinking people to the startling limitations that stare civilization in the face.

Medical science has, by the discovery and promulgation of physiological laws and hygienic principles, done much to avert the disaster by eliminating many of the deleterious influences that act with special potency against the weak­ened and delicate. The beneficent influence on humanity has been partly overcome, however, by the rearing of weak­lings whose career would have been short under less intel­ligent care ; but, neglecting this part of the race that is doomed to natural extinction, we find that medical science has done nothing directly to avert the calamity that has menaced civilization from extreme specialization.

It is but natural that the evil effects of excessive mental stimulation without a suitable physical basis for the sup­port and expression of nervous phenomena should have first been noticed by educators and those with training in some scientific pursuit. Ling of Sweden gave his life to the study of the needs of the body, and established a system of exercises that would do for the body what the routine of study would do for the mind. His exercises were graded from light, free movements up to complicated work with apparatus, thus forming a complete system of physical education that has been prescribed by law in all the schools of Sweden. What Ling did for Sweden Jahn did for Ger­many, establishing a system of societies where the practice of bodily exercises was the principal feature of the oraniza-tion, the improvement in physical stamina and the patri­otic zeal that resulted was sufficient to drive Napoleon out in 1810, and since that date there have been efforts to make physical training universal in the German Empire, and with satisfactory results.

and the Examiner Himself. n

In France the establishment of the Republic was the time when public attention was first aroused to the needs of a physical education that should proceed hand in hand with the school work of the children ; but factional dissension and the reorganization of a government have taken so much of the interest of the people that French educational mat­ters have not kept pace with the progress in other countries.

In England there has been no great demand for physical training, for the active outdoor sports that engage old and young have taken the place of the rural occupations and hunting that the early Kelt and Saxon followed—except in the larger cities, and there competent observers like Francis Galton, and Dr. Roth and Mrs. Westlake, of the London School Board, insist that some form of physical education must be adopted.

In America the development of a matchless territory by a population that is heterogeneous, representing all condi­tions of life placed on a common plane, has given free scope to competition. The large return for labor has in­cited to the fullest expenditure of effort. Wealth has grown enormously. The unnatural distribution of indus­tries, caused by legislative interference with supply, has caused an unnatural and unfortunate location of the peo­ple. Twenty years have seen our urban population more than double, while in the older parts of the country the rural population barely holds its own. The rapid development of complicated systems of business in the scramble for sudden wealth has required the outlay of intense energy, and this demand on the vital force of the people has come before they were fully acclimated to the new conditions of the country. The result has been an excess of nervous diseases and premature breaking down of our people. The time when a large majority of our people worked out in the open air has passed, and now the counting-room and the factory shut in the majority during the hours of sun­light. This strain on vitality is beginning to be felt, and a remedy must be sought at once in all the large cities of

12 The Uses of Anthropometry

the country. In some way, artificial though it be, some increase of vitality must be found. The sturdy strength of our fathers, that was gained by an active life in the open air, cutting forests, cultivating land, traveling on horse­back, in the service of society, sailing ships, and kindred pursuits, must now be gained by exercise obtained in an­other way.

In response to this feeling of a need of improving the physical side of our lives there has been a widespread move­ment in the cities of our country toward the formation of clubs for exercise. In the larger cities these clubs have provided large and well equipped gymnasiums for the use of members, and in the smaller towns the Young Men's Christian Associations have been the pioneers in this work of improving the physical status of the young. But in each town where a gymnasium was provided by some organiza­tion there has been an appreciation of imperfect, if not of disastrous, results from the lack of intelligent direction and competent instruction.

A gymnasium has been compared, by some writer, to a drug store—full of good things if intelligently used, but full of evils if taken indiscriminately. The number of men who were fitted to take charge of a gymnasium even ten years ago was exceedingly limited, and these few were mostly Germans who understood German methods and German needs better than they did American.

The question, then, has been and is, What use of the gymnasium will be best for the individual case ? Does he need a large or small dose ?

The physician in treating his patient must recognize every sign and symptom, and then, with whatever histori­cal data he can discover to aid his judgment, he prescribes treatment. It must be so in our management of cases in the gymnasium. We must learn what is the physical pe­culiarity and condition of each pupil. A general system of light exercises can be carried out successfully if the instruc­tor is conservative and careful, without a physical examin-

and the Examiner Himself. 13

ation as the first step ; but, to do the best with the facilities, there must be intelligent discrimination of work, as so few persons have the same physical requirements even if healthy. The director, then, must know what material he would mould and develop, and he must again examine to see if the results of his treatment are satisfactory or such as he expected, and hence the need of a record of the past condi­tion. A statement of a size or strength in black figures is worth a dozen " opinions." For the imperfect the exam­ination will cause a cautionary signal to " go slowly " or " stop " to be hung out before disaster comes and discredit is thrown on the work, or a new method is prescribed that affords relief.

Science has taught us that in living organisms functional activity must be kept up, or there will be no development. A part or group of organs unused will atrophy and become useless. Heredity soon stamps a deformity, that has been developed in two or three generations, as a type and suc­ceeding generations that do not possess that peculiarity are looked upon almost as new varieties. This is especially true of physical defects that impair the vitality of the pa­rents. Notice the stress laid upon this law by life insur­ance companies where business interests have no bias from sentiment. The excellent health of the applicant is not enough, if there be a record going back two or three gen­erations of degenerative diseases that have proved fatal, or if the constitutional vigor has been so- weak as to let the life go out at about forty-five or fifty years of age from any immediate cause.

The first lesson that we must learn from this truth is, that health can not exist if vital organs are seriously undevel­oped.

Health is the condition of harmonious adjustment of all the functional activities. For instance ; a normal pulse rate is from 72 to 76 beats per minute, under ordinary con­ditions of rest, but a pulse-rate of 72 after a half-mile run might be considered abnormal and the ground for solici-

The Uses of Anthropometry

tude,—for health would demand an increased activity of the heart muscle to supply increased blood currents to the ac­tive muscles, that waste products may be eliminated and restorative elements supplied. But further : An adjust­ment of the pulse rate is not all that is to be required in the case cited; for there must be a corresponding increase of respiration for elimination and oxidation. And so the perfect activity of any organ—even the brain—may be shown to be dependent on the healthy activity of other or­gans, while the converse may be stated as a physiological truth, viz : that the imperfect action of any organ impairs the function of all others to some extent. A healthy muscle is, then, dependent on a healthy stomach, heart and brain no less than on good food, air, etc., while the more refined intellectual processes are also based on a normal condition of the physical organs. A person may accom­plish much and be a dyspeptic, and so, too, may a cripple walk a long distance on crutches. A healthy child, then, is better fitted for study than a puny one, and health should be the first thing sought in our schools that are educating children for the duties of life. For the education of the body we may with profit pursue the same pedagogic sys­tem that gives good results in mental training. The teacher must know something of the existing powers and acquisi­tions of the pupil, in order to give proper instruction. In schools the daily recitation is an examination into the re­sults of study and previous instruction, and the mind of the pupil is directed into new channels of thought.

The inductive method of progress (from the simple to the complex), should be followed in the physical as well as the mental training of youth. The body, like the mind, should be taught the simple principles of exercise, and then the complex and intricate movements become easy of mas­tery. Then there will be perfect grace of motion, be­cause there will be perfect control of every muscle and also mental assurance or self-confidence.

To illustrate the command of the body that results from

and the Examiner Himself. 15

systematic physical training, from simple up to complex motions, varying for each hand: I have recently been told by a physician—an accomplished gymnast—that after prac­tising on complex movements with the hands and fingers for some weeks he thought he would try to discover whether or not it had given him any new control of the parts for entirely new work. He had a fair theoretical knowledge of music, and played the piano, but had never attempted to play on a stringed instrument. He procured a violoncello and a book of instruction that showed him the theory of the keyboard, the strings, etc. He began practice in his spare time and in two weeks could play with such ability as to receive and accept a position to play in public with an orchestra each week.

I have repeatedly seen boys, so clumsy and awkward that they could not keep step with a squad, while marching the length of the gymnasium—boys so self-conscious and so lacking in self-control that social life was a burden to them—become fairly graceful and easy in movement and carriage after a few months' work in the development of neglected muscles and the quickening of reflex action by nerve exercise and well-balanced activity.

A clumsy person is, in a certain sense, a sufferer from partial paralysis. There are undeveloped nerve centers or nerve fibres, that, if not quickened into life, will con­tinue to degenerate and in their decay will involve, or, at least, affect other centers. The process may be slow, for the reflex influence of active parts may arrest the degenera­tion to some extent ; but it is not a healthy organism able to resist the encroachments of disease or the strain of pro­longed work and excitement.

So practical a business man as the Hon. Thomas G. Shearman says : " I do not underrate the value of pure mental training, especially as that is nearly all which I have myself received ; but my very lack of training in physical labor has led me to observe the great value which it has not merely with reference to bodily health and

i6 The Uses of Anthropometry

strength but for the very purpose of enlarging the mental faculties." *

The acquisition of new powers over reflex or complica­ted movements is much more rapid in early life than after maturity. The old saying that " It is hard to teach old dogs new tricks " had its origin in this tendency to per­sistency in any habit of body or mind. A system of edu­cation that has in view the symmetrical relations of men­tal and physical qualities, can not ignore the necessity of beginning physical training with the mental. The child should come under the care of an experienced instructor in physical training from the day of entrance to regular school life. A physical examination should be made that should determine the condition of heart, lungs, spine, mus­cles, skin, eyes and ears. Many a case of incipient dis­ease that eventuates in disaster, would be discovered, and put in the care of a physician, if necessary, or a correct regime of diet, sleep, exercise, etc., inaugurated with the aid of the parents, that would counteract the ten­dency to disease or deformity and save the child as a use­ful member of society.

Many parents have no idea that there is serious defor­mity that menaces health in their children, until a stranger points it out to them. The worst case of varicose veins that I ever saw in a young person was found in making examinations for a large school, when a son of a physician came under my eye. The case was referred to parental care and advice, and what was my surprise to learn that the father was entirely ignorant of his son's condition ! It may not be the province of the State to see that each child has medical care ; but, so long as the State takes a child from home for five hours out of the day, it is bound to see that no physical harm comes to the child in that time ; and, if education is for public policy or utility, the care that will produce the best citizen is the care that is demanded.

At the time of this examination a few measurements

Rept. of 3rd annual meeting of Amer. Econ. Assoc. , Philad., 1889.

and the Examiner Himself. 17

should be made and recorded for the direct advantage of instructor and child and the aid that all such material will give to science. The age, weight, height, height sitting; girth of head, neck, chest, depressed and inflated, waist and hips, breadth of shoulders, chest, waist and hips, are all important items. There will be only a very small per cent, of children in the primary grades that can not take the general exercises that will be prescribed, but in higher grades the number will increase, and among advanced students may reach as high as five per cent. Now an advantage of keeping a record of measurements will be, that the actual growth under a given system of exercise can be seen and, if the progress is not satisfactory, the cause may be sought or a new system adopted for these cases. The experienced examiner will be aided in forming an opinion of the needs of a case by seeing the

1 actual measurements and comparing them with an average or standard, while the beginner will rely on them entirely until he gets an ideal or standard of excellence fixed in his own mind. The child will invariably take more inter­est in exercises if he knows what the exercise is for and can see that he needs i t ; or will feel increased pride in keeping ahead of the standard, if he once has passed it.

After the age of puberty the measurements should be more numerous, and should include tests for strength of various parts. This will show any minor defects in time to modify them during the period of growth ; for after this age the boy or girl will have judgment and inter­est enough to carry out any regulations that shall have in view the strength or beauty of their bodies, and a set of measures, or a graphic chart, or both, that will show them where their small records are, will greatly reenforce the directions that may be given them regarding exercise. Again it will help to eradicate from their minds a false standard of beauty and symmetry and give them an intelli­gent basis of judgment of their own shape. It also enables them to see the actual progress that is made under certain

i8 The Uses of Anthropometry

exercises and determines the point of physical maturity when further growth stops.

It will serve as a check to over-development of any part which may be quite as injurious to the health as undevel-opment; in short, there is no other intelligent and sys­tematic way of undertaking physical training than by finding out first, what is needed, and second, prescribing exercise that shall build up the weak parts.

The following simple table has been devised and used by Dr. Anderson. Department of Physical Education of the Adelphi Academy, Brooklyn, N. Y. P H Y S I C A L C O N D I T I O N OF _

G R A D E -

DATE. Age . Height. Weight Lung

Capac­ity.

What it should

be.

AGE 6. 7 . 8. 9. 10. 11. 12. 13. 14. 15.

Height

W e i g h t . .

Lung Capacity.

46.40

47-55

[ 6 4

48.90

56.44

80

5 0 . 1 7

58.09

88

52 .26

63.86

106

54-43

7 1 . 4 2

124

56.86

7 6 . 1 7

144

57 -79

8 1 . 8 1

150

59.92

95-2o

168

62.53

105 -15

188

64.38

1 1 3 . 8 1

205

BO

YS

.

Height . .

W e i g h t . .

Lung Capacity

4 6 . 1 1

46.55

[ 3 5

47-95

50.83

40

49.82

56.37

48

52.03

62.32

65

53-99

7 1 . 5 2

80

57 .06

80.81

106

5 9 . 1 7

90.68

125

60.89

99.61

136

63.38

108 99

150

6 3 . 1 2

1 1 2 . 8 0

i 5 5

GIR

LS

.

[The above figures show the average height, weight, and about the lung capacity of the pupils in a number of the private schools in and near Brooklyn. They are given only for comparison. It cannot be said of them that they indicate just what the aver­ages should be.]

Parents are earnestly requested to notify the Physician in charge of this department, of Physical Defects, if any, that exist in their children, that he may regulate the exer­cises accordingly.

Director Physical Education.

and the Examiner Himself. *9

And now a word in regard to the examiner himself : It is obvious that a medical training is of very great advantage to the person who is to make such physical diagnosis and measurement as shall be strictly scientific and accurate ; but with the thorough knowledge of anatomy and physiology that can be gained in the Normal Schools of Physical Education, and a little prac­tice under the supervision of a physician who can demonstrate abnormal heart and lung sounds, and a great deal of practice on normal sounds, the beginner need not be lacking in confidence or accuracy of work, as he must never be lacking in care. If the examiner has not a medical education, let him always err on the safe side in a doubtful case and require a certificate from a physician before entering on a course of advanced exercise, or athletic work. But first let him study the-case, using all the light that can be thrown on it from books and the history that can be obtained. The examiner must be a student, he must learn, he must study, examin­ing not only the client but books, papers, periodicals. Anything bearing on his subject should be studied and questioned, but not criticised until he is sure of some error ; then let him correct the error by showing its inac­curacy of fact or logic.

Do not take the statement of anybody as infallible. If it clashes with your own idea examine it and decide who is wrong.

Do not run after everything new and think that the new apparatus will make exercise a pleasure and relieve you of your work, or the new idea will save you the trouble of thinking.

Do not go through your work in a perfunctory sort of a way, but be enthusiastic and full of interest in those with whom you come into the relationship of advisor and instructor.

Be earnest, careful and exact, filled with the spirit of hard work, or move on to some less onerous occupation.

20 The Uses of Anthropometry

Do not try to find some fault with each person who comes under your care, nor continually decry habits that you believe to be bad. If you believe, as I do, that the use of tobacco is injurious to the majority of smokers, do not tell every person, whose breath "gives him away," that he is "ki l l ing himself" by smoking, or that he has the " smoker's heart" and must reform at once if he wishes to rob the grave of an early victim ; for in every such case you will be either informed that the smoker has no desire to go into the business of robbing graves or you will be set down as a bigot whose opinion is good for nothing, and whose advice is worth still less. If a person asks you if you think tobacco has hurt him, and you find no indica­tion of injury, be honest enough to tell him so, and your candor will so establish his confidence in you that the sub­sequently expressed opinion, that tobacco has done him no good, will be likely to set him to thinking. At times you are expected to express yourself freely, as when lecturing on any subject, but do not try to pour a lecture into the unwilling ears of everyone who may chance to fall into your hands. You do no good but make yourself ridicu­lous.

Establish a record for honesty and ability, and your advice will be sought. Integrity is the largest factor in influence.

Endeavor to find out the actual condition of each organ and do not be too quick to decide on the cause of any abnormality. If the heart action is imperfect and the person uses tobacco remember that there are occasionally " b a d " hearts in those who have never "used the weed." A lateral curvature of the spine also may be due to no muscular inefficiency or weakness but may indicate good muscular action, as in case of a shorter leg on one side.

Do not be boastful and proudly claim to have discov­ered a new " system " or a " natural " system of exercise because you have by a certain method of life acquired a large biceps or general good physique. Your size of arm

and the Examiner Himself. 21

may have as little relation to any system as your size of hat. Because Dr. Tanner lived forty days without food he did not establish a system of living without food ; and because some " Prof." can live comfortably by breathing only three times a minute it does not follow that he has a " system " all his own ; a turtle can live all winter on one breath.

Be conservative and at the same time progressive. Ex­amine all that is new, but before you adopt it test it by every standard that you can bring into comparison with it. Remember that you will probably not discover a great number of new truths, nor will you undermine and over­throw many of the commonly accepted theories and doc­trines that have been enunciated in the past.

Be modest, then, and learn much from others, claiming very little as entirely new and your own. At the same time it is well to remember that this science and art of Physical Education or Training is in its infancy, in this country at least, and there is much work that is experi­mental and tentative.

Perhaps in no field of scientific research bearing directly on practical medicine is more to be discovered and demon­strated than in kinetic physiology. The influence of exercise on muscle, bone, nerve and connective tissue is not fully understood—in fact we are only working at the alphabet of the science as it will be developed. Much injury to progress has been caused by superficial observa­tion and extravagant claims for " systems " and methods that had produced fair results apparently with a select few and were then loudly proclaimed as a complete scien­tific exposition of the whole subject when they barely rested on a single correct principle or physiological truth. When the enthusiasm of the originator had died out the illumination was found to be meteoric and a general dis­trust was established.

A quack in a community injures the reputation of every honest practitioner in it. Be content, then, to work a

22 The Uses of Anthropometry, etc.

great deal and claim very little. Have a scientific theory as a basis of your work but be ready to amend it at any time. Study your material and you will find so many facts to be classified and arranged that you will have little time to electrify the world by some universal specific. If you have no material and do no work you will have all the more time to invent some startling method that shall make you rich with the money of fools but leave science the poorer by a filching of her name and reputation.

C H A P T E R II.

T H E I N S T R U M E N T S T O BE U S E D A N D T H E R E C O R D S T O B E

K E P T .

For taking the measures of a person several instruments are needed; but the outfit may be very simple. For sev­eral reasons the record should be taken and kept in the metric system : ist. It is the scientific standard in use in all countries, and is in use in every other department of scientific investigation. 2d. It enables one to be very accurate without trouble, as the unit is very nearly one twenty-fifth of an inch. 3d. There are no fractions to complicate compilation, or computations, or records. 4th. It helps to introduce an improved system of weights and measures into general use, and, as the ordinary person has no idea whether his record in English units is large or small, but only judges by comparison with the standard, he will get as good an idea by the metric system.

The record book should be made of the best ledger paper and ruled transversely into spaces enough for all the items to be recorded. The perpendicular ruling can be made to divide the space into six columns, for the records when measurements are repeated. This will enable one to see at a glance what the change has been in any item, from time to time. If the space is economized, there will be plenty of room on the two pages that face together to record the measures of three individuals, six times each, and keep such items of history as should appear in such a book. It is advisable for each examiner to keep a private book for containing information of simply a personal nature, and for the guidance of the instructor in prescribing exercise.

This private record will give him an amount of material

The Instruments to be used

for study and comparison, in a few years. The books should be bound in volumes of about 150 leaves, with heavy leather, as they are handled frequently. A second way of keeping the records, that has advantages in com­piling the figures, or tabulating, has been devised by Dr. F. Swain. It consists of a card, with all the items, and room for two records of measurements. These cards are simply filed in alphabetical order and kept for reference. In tabulating results they are sorted over and placed in piles, according to any' standard that may be taken—as height, or weight, etc. It is not a desirable form for a permanent record but, as the personal property of the examiner, is preferable to a book.

In the form of record book devised by Dr. Gulick, for use in Y. M. C. A. work, the historical data are placed at the top third of the page, the remainder being divided into a column for prescription, and several narrow columns for measures. The number of items measured is smaller than the list prescribed by the American Association for the Advancement of Physical Education.

It would seem that the card system of record could be used profitably in Y. M. C. A. work, as there is no special reason for permanently keeping the data except at some central bureau, where they can be tabulated for scientific purposes. In schools and colleges a permanent record is very important for history and comparison.

A method of duplicating a record for the benefit of the person measured has lately been suggested by Dr. E. Hitchcock, Jr., in connection with his graphic chart de­scribed later, and consists of a duplicate page to be inserted under the record page with a sheet of carbon paper be­tween. By writing the record with a stiff pen the figures are duplicated on the chart page. This method saves much work in copying, and gives each man his record at once on a sheet together with the record of an average of 15,000 college men. This average represents more men of the student class than have ever been tabulated before, and is

and the Records to be kept. 25

therefore the best standard we now have for this class of cases. Another very satisfactory method of recording measures is by the author's anthropometric table bound in book form, and the measures indicated on it by dots and lines ; or the actual record can be written at top or bottom and the graphic indications marked afterward. This gives a person looking over the record for special cases a com­prehensive knowledge of the special form of the subject at a glance, where the examination of a list of measures even by an expert would be long and unsatisfactory. The pri­vate record should contain a careful record of personal peculiarities that may have a bearing on health and devel­opment. Any history of previous disease or accidental injury, even if recovery seems complete, should be recorded. Advice in regard to exercise and the results of the advice should be noted. This book should be a history of the person's physical welfare while he is under observation, and thus correspond to a physician's case-book. The examiner will learn more from this record than from the book recording size and strength.

The following instruments are needed : 1. A set of scales, with high bar for convenience in read­

ing. These are made with metric graduation. 2. A graduated pole, Fig. 1, with a slide moving at right

angles on it for taking heights. The arm of the slide should not be over 125™. long. The pole may have the metric system marked on one side, and the English on the other, like the one shown in the cut. A very convenient method of taking heights is by using two meter sticks, on one of which is fixed at the end an arm of metal, 2 m m . thick and i 8 m m . wide and 125™. long. A slide bearing a similar arm is made to run closely on the stick. The height is readily taken by holding the ends of the sticks together by the left hand while the right lowers the slide to the top of the head. Care must be taken to have the sticks perpen­dicular. The height sitting and the height of pubes and knee are taken with the one stick, which is much lighter

3

26 The Instruments to be used

and more readily handled than the long pole. The meter stick, with slide, can then be used for taking the breadths.

Fig. i.

3. A pair of slide calipers, Fig. 2, for taking breadths. This must have a capacity of 5oo m m .

and the Records to be kept. 27

Fig. 5.

A little device is made by the Narragansett Machine Co., at the suggestion of Dr. Gulick, for attachment to the end of a tape to indicate the proper tension, so that the pres­sure may be always alike. It is a good device for the

4. A tape measure of steel or cotton, Fig. 3. The metal is uncomfortable to the skin, but does not stretch and can be kept clean. A linen tape stretches on being moistened, and many subjects will sweat so freely as to wet a cloth tape. A painted tape is about as unpleasant to the touch as one of steel, and for the above reasons I always use a steel tape.

28 The Instruments to be used

beginner, but useless after practice has given a habit in making the tension.

5. Calipers for taking depths, Fig. 4, and, in some cases, breadth of chest. These may be of wood or metal and should have large extremities, so that a slight variation in pressure will not vary the record greatly by indenting the flesh. An index should be on the instrument, for reading while imposition.

6. A capacity spirometer, Fig. 5, for recording the amount of air that can be inhaled and then exhaled, or the complemental, tidal, and supplemental air of respiration.

Hutchinson's wet spirometer is considered the most reliable»instrument of the kind.

7. A stethometer or pressure spirometer is used by some persons, but is utterly worthless as far as information elicited by it is concerned. A person may blow by means of a rubber tube and suitable mouthpiece into an ordinary steam guage that is made for recording low pressures, or an instrument devised by the author may be used. A piece of glass tubing of 5 m m . diameter is bent into the form of a right-angled triangle, having one angle of about 350. The side adjacent to this angle should be about 4oo m m . long and should be horizontal when the triangle is fixed against a flat wall for support. A rubber tube with a glass mouthpiece is attached to the short side, and mercury is drawn in to fill the horizontal part. Now, by blowing into the mouthpiece, the mercury is forced up the hypothenuse of the triangle.

The graduation is easily made by measuring the perpen­dicular line from the base to any point in the hypothenuse, and affixing a scale to the support back of the tube. The pressure will then be indicated in millimeters of mercury column.

8. A hand dynamometer, Fig. 6, for taking the strength of the flexor muscles of the forearm.

There are several forms of this instrument, the more common ones being the oval (Fig. 6) and the form with

and the Records to be kept.

Fig . 7-

The Instruments to be used

the two sides always parallel—the resistance being two spiral springs. This second form gives all the fingers an equal opportunity to exert their pressure.

9. Dynamometer for lifting with the back and legs, and taking the strength of the pectorals and retractors of the shoulders, Fig. 7. This instrument may be replaced for the first two tests by a lifting machine with spiral spring resistance, and a graduated index applied from actual tests. The advantage of this latter form is the quick adjustment to the height of the person.

10. Parallel bars for testing triceps extensor in " Push up." A short pair of bars, about 75o m m . long, attached to a frame with suitable braces, and made to move up and down against the wall, in being adjusted to any height desired, can be used for this test and also for the " Pull up," or test of flexors of the upper arm. Otherwise a horizontal bar, trapeze bar, or pair of swing rings must be used for this last test.

11. A stethoscope for listening to heart and lung sounds, etc., Fig. 8. Camman's binaural is a suitable instrument. The soft rubber bell (B) is useful at times to secure perfect coaptation to the surface of the chest. It requires some practice to secure all the advantages that a stethoscope can give, as the pressure of the nib in the ear is a distraction of the attention, and any slight movement of the fingers on the instrument causes vibrations that are not understood. If the examiner wishes to hear the valvular sounds of the heart, without the interference of muscular vibration sounds, he can interpose a thin cloth between the bell and skin, but in general the instrument should be placed directly against the surface of the body.

In addition to the above mentioned instruments the following are useful at times and for special work :

12. A sphygmograph, or kymograph, for taking pulse tracings, Dudgeon's instrument is perhaps as satisfactory as any. It is small, easily applied, can be carried in the pocket and used in the gymnasium as well as in the

and the Records to be kept. 31

office. It can not be applied to all pulsating surfaces. Marey's instrument is used to some extent, but the pneu­matic kymograph is employed in all physiological labora­tories, and does very satisfactory work.

13. A laryngoscope, rhinoscope, otoscope and tuning fork, for examining the throat, nose and ears.

14. A Clinical thermometer. 15. A Pleximeter and percussor. Figs. 9, 10. A 16. Microscope of 20™. focal distance for examining

the skin.

Fig. 10.

17. A case of urinary tests for sugar and albumen. 18. Test worsteds, glasses, and charts, for examination

of eyes for color blindness and errors of refraction. These instruments can be obtained of any first-class

dealer in surgical instruments and optical goods except 17 which can be obtained of Parke, Davis & Co., or other manufacturing chemists and druggists.

A universal dynamometer has been invented by Dr. J.

32 Tne Instruments to be used

H. Kellogg, which deserves more than a mere mention for it is destined to be used in modified form by every person practicing anthropometry, and by many physicians in diagnosis and determination of the actual progress of cer­tain cases. Its use will supply the place of all the dyna­mometers mentioned above, while its cost will be compar­atively small.

The instrument may be briefly described in the words of Dr. Kellogg, transcribed from a paper published in the Transactions of the Michigan State Medical Society, 1888 :

" 1. A cistern about two-thirds filled with mercury, the remaining space being filled with water.

" 2. A glass tube of a caliber of about one thirty-second of an inch and six feet in height.

" 3. A rubber bulb connected by a tube with the space above the mercury in the cistern, and both filled with water.

" 4. A bottle partly filled with water, placed two or three feet above the cistern and connected with the upper part of it by a rubber tube. A pinch cock controls the connec­tion between the bottle and the cistern. The purpose of this arrangement is to keep the upper portion of the cistern filled with water, and to raise the height of the column to any desired point before applying pressure to the bulb when it is desirable to do so.

" 5. An adjustable, graduated scale erected beside the glass tube and reaching to the level of the mercury in the cistern.

"6. A framework by which the apparatus is sustained. See Fig. 23, page 36.

" In use compression is made on the rubber bulb by which water is forced into the cistern displacing an equal quantity of mercury which rises in the tube until a height is reached at which the pressure upon the inside of the bulb is equivalent to that upon the outside.

" By means of simple arrangements for the purpose, the strength of every group of muscles in the body, except the

and the Records to be kept. 33

smallest and most inaccessible, can be readily tested by this apparatus."

The following cuts will illustrate the method of using the apparatus for some of the common tests.

Fig. 12. upon an axis in the center, the bulb of the instrument being placed under one end and the toe of the foot under the other end. The test is made by raising the toe.

34- The Instruments to be used

"F ig . 12 shows the method of testing the muscles of the calf. The bulb is placed beneath a bar secured to two uprights, being supported by a flat piece which rests upon the knee. By raising the leg by the toe, the muscles of the calf are brought into action.

Fig. 13. u Fig. 13 shows the method of testing the muscles of the

shoulders.

Fig. 14.

and the Records to be kept. 35

" Fig. 14 shows the method of testing the diaphragm. The apparatus used is seen more distinctly in Fig. 15. It consists simply of a belt carrying two rigid plates, one fixed and the other movable, secured together by rubber bands. The screw which passes through the fixed belt works against another movable plate on the inside of the fixed plate, and furnishes a means of fine adjustment. In use the belt is put around the body so that the movable plate falls just below the ribs. After attaching the belt the screw is turned in until the mercury rises in the column to ten centimeters, then the patient takes a deep abdominal breath. The same instrument may be used for testing the strength of the serratus magnus, by placing it at the side instead of the front.

"F ig . 16 shows the method of testing the pronators and supinators.

"F ig . 17 shows the method of testing the force with which the hands can be pressed together.

Ji Fig. 16.

1

and the Records to be kept. 37

" Fig. 18 shows the method of testing the flexor muscles of the arms. The extensors and flexors of the legs are tested by similar means.

Fig. 17.

" A strap is thrown over the shoulders, with the body bent forward at an angle of 45 degrees for the purpose of testing the strength of the muscles of the back. A similar arrangement attached to the wall is used to test the anterior and lateral muscles of the trunk, also the muscles of the neck. You can readily see how by a simple con­trivance all the principal groups of muscles in the body may be tested. My instrument has a mercurial tube 10 feet long. A much shorter tube will answer the purpose by having the top of the tube closed."

Some modifications of this machine will adapt it to general use. If a closed tube seven or eight feet long be used the top may be doubled on the main part for two feet to save space and make the apparatus more portable. If the calibre of the tube be small there will be no need of the hydraulic pressure from the bottle of water shown in the illustration, Fig. 23. For ordinary tests there will be a record of less than 200 lbs., except for back and legs. To take these heavier tests a system of levers will be required and can be readily arranged.

One point in the working of this machine that must be

The Instruments to be used.

secured before perfect accuracy will be reached is the con­dition of similar pressure surfaces on the bulb for every

Fig. 18.

test. Then the record can be read in a similar unit for each test and will be absolute. This will enable one to compare or tabulate records made on different machines of the same kind, as we now compare weights taken on different scales. The author has devised an arrangement that will apparently meet this requirement for the majority of tests but must have practical experience with the apparatus before announcing a complete machine. Any new device that will enable one to secure accurate tests of strength will assist greatly in practical anthropometry and the prescription of exercise.

C H A P T E R III.

W H A T T O M E A S U R E A N D H O W T O M E A S U R E .

In making a physical examination and measurement it is well to have the subject entirely nude, and consequently the temperature of the room must be kept as high as 75 0 . A good method of procedure is to take the weight and height measurements, then the lengths, then the breadths, then the depths, then the girths, and finally the strength tests. During the measurement the examiner should be alert in noticing any peculiarity or deformity or disease or external indication of disease. The subject may then dress the lower extremities, and the minute examination of the chest be continued.

When the examination is made for an institution, and is to include the measurement of many men, the services of a clerk will save at least half of the time and leave the exam­iner free from merely clerical work, and enable him to give all his attention to the examination in hand. With such assistance the fifty measurements can easily be made, after a little experience, in five or six minutes, and from fifteen to twenty minutes should be devoted to each individual ; the latter amount if advice in regard to methods and forms of exercise, and instruction concerning diet, bathing, sleep, etc., is to be given at the time of the measurement. To economize time the specially weak or undeveloped parts should be pointed out to the subject himself and the sim­plest exercises for developing those parts be recommended and illustrated if possible.

A greater advantage will come from exercise if the ob­ject of the exercise is known than if a routine is simply followed without interest. A muscle will undoubtedly

4.0 What to Measure and Hozv to Measure.

grow faster if watched and made the object of thought dur­ing its activity, and if attention is turned to it during its period of rest. The reason of this is found in the inter­relation of the trophic and voluntary nerves.

A proof of the influence of volition over trophic changes has lately been made by Prof. A. Lehmann of Copenhagen, who has employed a thermometer capable of showing dif­ferences of .02° F. When Lehmann or the person who aided him in his experiments, concentrated his mind on the idea of an increased temperature of the hand, it rose .036° to 0.1080 F. ; but when the attention was concentrated on the idea of a greater warmth of the fingers alone, the temperature of the hand fell 0.7560 to 0.9360 F.—Hospital-stidende, No. 3, 1890. Copenhagen.

The hygienic instruction can be given by lecture to whole classes, and a case needing special care and supervision can be asked to come to your office at some other hour when you will have time to go over the case thoroughly and examine into all the details of his habits, a knowledge of which will alone enable you to give the best advice.

If you are examining many cases in succession, you will need to possess a quick memory of faces and facts, or some notes will have to be taken at the time of examination, that will recall the existing conditions in each case. It is well to train the memory in this matter, but to take careful notes to fall back upon. A client will feel that you re­member him and have given his case thought, if you can show him that you know just what his condition was when you saw him last.

The number of items measured is not of so much impor­tance as the thoroughness of the work done, and the care and judgment displayed in discovering weak parts that can be strengthened, and recommending the proper remedies. But I would advise a strict adherence to the advanced stan­dard of measurements recommended by the American As­sociation for the Advancement of Physical Education and for three reasons : 1st, to take this complete list would re-

What to Measure and How to Measure. 4.1

Report of the Committee on Statistics, appointed by the American Association in 1885, giving the detailed method of securing

measurements, tests, and the condition of the human body.

ANTHROPOMETRIC MEASUREMENTS.

NUMBER. — In order to secure privacy the individual should be entered in the record book by number. As a means of identification the number can be entered in an alphabetical index book opposite the corresponding name, as :

Smith, John H., 526. For further convenience it is advisable to enter the name

in a numerical index book opposite the corresponding number, as :

526, John H. Smith. DATE.—Record the year, month, day and hour, as : Jan.,

'86, 12, 9 A.M. Where perfect accuracy is desired, note should be made of the time that has elapsed since eating, the occupation of previous hours, and of the temperature of the room.

AGE.—Record years and months, as : 21, 9, /. e., twenty-one years and nine months.

4

quire only about two minutes longer time than for the method of twenty items. 2nd, the completeness of the re­cord will be a satisfaction to all parties. 3rd, uniformity of methods is of great importance in giving scientific value to work of this kind. Then, if a person has a special de­sire to ride some hobby of his own and take such measure­ments as the horizental length, the occipito-mental diame­ter of the head and the length of the os calcis, all of which points are of some importance and have a bearing on anthropology and practical anthropometry, he is at liberty to do so.

Below is given in full the report of the committee on statistics appointed by the American Association in 1885.

42 What to Measure and How to Measure.

WEIGHT.—The weight of the body should be taken with­out clothes. Where'this is impracticable the weight of the clothes should be deducted.

HEIGHT.—The height should be taken without shoes and with the head uncovered. The head and figure should be held easily erect, and the heels together. This position is best secured by bringing the heels, the buttocks, the spine between the shoulders and the back of the head, in contact with the measuring rod.

HEIGHT OF KNEE.—The subject should place one foot on a box or chair of such a height that the knee is bent at a right angle. A box about 12 inches high is suitable for adults. Press a ruler upwards with a force of about one pound against the ham string tendons close to the calf of the leg. See that the ruler is held in a position at right angles to the vertical rod, and measure the height of the top of the ruler from the box.

HEIGHT SITTING.—Let the subject sit on a hard, flat sur­face about 12 inches high, such as afforded by a box or chair, with the head and figure easily erect so that the measuring rod will touch the body at the buttocks, between the shoulders, and at the back of the head. Measure the distance from the box to the vertex.

HEIGHT OF PUBES. — With the subject standing easily erect on the box or floor, measure up to the lower edge of the pubic bone.

HEIGHT OF CROTCH.—With the subject standing easily erect on the box or floor facing the vertical rod, press a ruler firmly against the perineum (crotch) and measure the height of the top of the ruler.

HEIGHT OF NAVEL.—With the figure and head of the subject erect, measure the height of the centre of the cicatrix.

HEIGHT OF STERNUM.—With the figure and head of the subject erect, measure the height of the interclavicular notch.

Al l girths should be made on the skin itself at right

What to Measure and How to Measure. 43

angles to the axis of the body or limb at the point of measurement. No oblique measurements are taken.

G I R T H OF HEAD.—This measurement should be taken around the head with the tape at the upper edge of the eye brows, over the supra orbital and occipital prominences.

G I R T H OF NECK.—With the head of the subject erect, pass the tape around the neck half way between the head and body, or just below the "Adam's Apple."

G I R T H OF CHEST.—Pass the tape around the chest so that it shall embrace the scapulae and cover the nipple. The arms of the subject should be held in a horizontal position while the tape is being adjusted and then allowed to hang naturally at the sides. Take the girth here before and after inflation.

Where it is desirable to test the elasticity or extreme mobility of the walls of the chest, a third measurement may be taken after the air has been forced out and the chest contracted to its greatest extent. To test the respira­tory power, independent of muscular development, pass the tape around the body below the pectoral line and the inferior angles of the scapulae, so that the upper edge shall be two inches below the nipples. Take the girth here before and after inflation.

GIRTH OF WAIST.—The waist should be measured at the smallest part after a natural expiration.

GIRTH OF HIPS.—The subject should stand erect with feet together. Pass the tape around the hips above the pubes over the trochanters and the glutei muscles.

G I R T H OF THIGHS.—With the feet of the subject about six inches apart, the muscles set just enough to sustain the equilibrium of the body and the weight distributed equally to each leg, in gluteal fold measure around the thigh just below the nates.

G I R T H OF KNEE.—With the knee of the subject straight and the weight of the body equally supported on both legs, measure over the centre of the patella.

GIRTH OF CALF.—With the heels down and the weight

44 What to Measure and How to Measure.

of the body supported equally on both feet, the tape should be placed around the largest part of the calf.

G I R T H OF INSTEP.—Measure around the instep at right angles with the top of the foot, passing a point at the bot­tom of the foot midway between the end of the great toe and back of the heel.

G I R T H OF UPPER ARM.—With the arm of subject bent hard at elbow, firmly contracting the biceps and held away from the body in a horizontal position, pass the tape around the greatest prominence. If desirable to find the girth of the upper arm when the biceps is not contracted, the arm should be held in a horizontal position and meas­ured around the most prominent part.

G I R T H OF ELBOW.—Taken around the internal condyle of the humerus while the arm of the subject is straight, with the muscles of the forearm relaxed.

G I R T H OF FOREARM.—Taken around the largest part. The fist should be firmly clinched and the palm of the hand turned upward.

G I R T H OF WRIST.—With the hands of the subject open and the muscles of the forearm relaxed, measure between the styloid process and the hand.

BREADTH OF HEAD.—The breadth of head should be taken at the broadest part. In taking the breadth meas­urements, stand behind the subject.

BREADTH OF NECK.—Taken at the narrowest part with the head of the subject erect and the muscles of the neck relaxed.

BREADTH OF SHOULDERS.—With the subject standing in a natural position, elbows at the sides, shoulders neither dropped forward nor braced backward, measure the broad­est part two inches below the acromion processes.

B R E A D T H OF WAIST.—Taken at the narrowest part. BREADTH OF HIPS.—Measure the widest part over the

trochanters, while the subject stands with feet together, the weight resting equally on both legs.

BREADTH OF NIPPLES.—Taken from centre to centre with the chest in a natural position.

What to Measure and How to Measure. 45

DEPTH OF CHEST.—Taken after a natural inspiration. Place one foot of the calipers on the sternum midway between the nipples, and the other foot on the spine at such a point that the line of measurement is at right angles with the axis of the spinal column. When it is desirable to ascertain the extent of the antero-posterior movement of the chest, measurements may be taken from the same points after the fullest inspiration and after the fullest expiration.

DEPTH OF ABDOMEN.—Place one foot of the calipers immediately above the navel, the other on the spine at such a point that the line of measurement is at right angles to the axis of the spinal column.

LENGTH OF SHOULDER TO ELBOW.—With the arm of the subject bent sharply at the elbow and held at the side, measure from the top of the acromion process to the olecranon. Care should be taken that the measuring rod is parallel with the humerus and not with the external surface of the arm.

LENGTH FROM ELBOW TO FINGER TIP.—With the arm of the subject bent sharply at the elbow and the rod resting on back of arm and hand, measure from the olecranon process to the tip of the middle finger.

LENGTH OF FOOT.—Take the extreme length of foot from the end of the first or second toe to the back of the heel, about one inch from the surface upon which the foot rests.

STRETCH OF ARMS.—With the arms of subject stretched out horizontally so that both hands and shoulders are in a line, with one middle finger and the zero end of the meas­uring rod pressed against the wall, note the point to which the other middle finger tip reaches.

HORIZONTAL LENGTH.—With the heels of the subject pressed hard against a perpendicular wall, with arms at the sides and body resting naturally on a horizontal plane, measure the distance of the apex of the head from the wall.

46 What to Measure and How to Measure.

C A P A C I T Y OF LUNGS.—The subject after loosening the clothing about the chest and taking a full inspiration, filling the lungs to their utmost capacity, should blow slowly into the spirometer. Two or three trials may be allowed.

EXPIRATORY STRENGTH.—As before, the subject after loosening the clothing about the chest and filling the lungs completely, should blow with one blast into the manometer. Care should be taken that no air is allowed to escape at the sides of the mouth, and that in expelling the air all the muscles of expiration are brought into play.

STRENGTH OF B A C K . — T h e subject, standing upon the iron foot-rest with the dynometer so arranged that when grasping the handles with both hands his body will be inclined forward at an angle of 6o°, should take a full breath and, without bending the knees, give one hard lift, mostly with the back.

STRENGTH OF LEGS.—The subject while standing on the foot-rest with body and head erect, and chest thrown forward, should sink down, by bending the knees, until the handle grasped rests against the thighs, then taking a full breath, he should lift hard principally with the legs/ using the hands to hold the handle in place.

STRENGTH OF CHEST.—The subject with his elbows ex­tended at the sides until the forearms are on the same horizontal plane and holding the dynamometer so that the dial will face outward and the indicator point upward, should take a full breath and push vigorously against the handles, allowing the back of the instrument to press on the chest.

STRENGTH OF UPPER ARMS, TRICEPS.—The subject, while holding the position of rest upon the parallel bars, sup­porting his weight with arms straight, should let the body down until the chin is level with the bars, and then push it up again until the arms are fully extended. Note the number of times that he can lift himself in this manner.

STRENGTH OF UPPER ARMS, BICEPS.—The subject should

What to Measure and How to Measure. 4-7

grasp a horizontal bar or pair of rings and hang with the feet clear from the floor while the arms are extended. Note the number of times that he can haul his body up until his chin touches the bar or ring.

STRENGTH OF FOREARMS.—The subject, while holding the dynamometer so that the dial is turned inward, should squeeze the spring as hard as possible, first with the right hand then with the left. The strength of the muscles between the shoulders may be tested with the same instru­ment. The subject, while holding the dynamometer on a level with the chest, should grasp it with handles and pull with both arms from the centre outward.

PILOSITY.—Note the amount of hair on the body and limbs, excluding the head, face and pubes.

COLOR OF HAIR.—Light (Very Fair, Fair, Light Brown> Brown), Dark (Dark Brown, Black Brown, Black). Red (Red Brown, Red, Golden).

COLOR OF EYES.—Light (Dark Blue, Blue, Light Blue). Dark (Light Brown, Brown, Dark Brown, Black). Mixed (Gray, Green).

D. A. SARGENT, \ EDW. HITCHCOCK, > Committee. W M . G. ANDERSON, )

The following criticisms of this Report, that now stands as the official list of the Association, are presented, and an effort will be made at the next annual meeting to have the list revised, and the changes here suggested incorporated.

The height of knee should be a bone measurement, and the most convenient point is to top of the fibula, as the subject is sitting, and this record can be taken immediately before or after " height sitting." The present method is very inaccurate and unscientific, because the length will vary from two to five cm., according to the tension of the hamstring muscles, which are not always under the direct control of the will with the leg in the position indicated and can not be relaxed in every case without great care.

4-8 What to Measure and How to Measure.

The head of the fibula can be easily found in nearly every case, and in those where it can not be located, the head of the tibia can be found, and the head of the fibula is about ten mm. shorter. The " height of crotch" need not be taken, for obvious reasons, when we have " height of pubes."

Another height-measurement advised by the Y. M. C. A. committee is the length of trunk which is measured from the buttocks to the point of the seventh spinous process, or vertebra prominens, with the subject in the same posi­tion as for taking the height sitting. It is not always easy to decide with certainty which is the seventh spinous pro­cess ; but it is usually the most prominent one, and of several that seem of equal prominence, it is usually the lowest.

The length of trunk, depth of chest and breadth of chest are three factors, that, multiplied together, may roughly be considered to represent the " vital capacity" of a person. We can get the length of trunk in another way— by subtracting the height of sternum from total height, which will give the length of head and neck ; and, by sub­tracting this remainder from the height sitting we shall have the length of trunk.

I can discover no adequate reason for taking the hori­zontal length. It consumes considerable time, is a difficult measurement to take correctly, and exceedingly awkward for the subject; its average relation to the total height is a matter of anatomical record ; and, in the special case it can easily be estimated by any examiner, of even limited experience, by the amount of lordosis and flexibility of the spine. Each person should take a few measurements of subjects with hollow backs, in order to get an idea of the variation in these cases ; but further than this there is no utility in the recording of this item. In taking girth of elbow the object is to discover the development of the tissues that lie between the muscles measured in the arm girth and those in the forearm girth. The muscles of the

What to Measure and How to Measure. 49

forearm have their origin on the internal and external condyles, without the intervention of tendon. A measure­ment over the condyles is therefore essentially the same as the forearm girth and will in practice differ from it by only about two centimeters. We would discover the con­dition of the whole arm, and the elbow girth taken over the condyle adds nothing to our information. On the contrary, if we measure around the smallest part of the elbow we know how well the tissues are developed between the muscles of the arm and those of the forearm. It is not a muscle girth in the latter case ; in the former it is.

The breadth of shoulders should be a bone measurement as nearly as possible ; for I conceive the object of it to be the determination of the extent of the bone tissue to which the more important muscles of the upper extremities and thorax are attached. If we measure below the acromion, as directed, we give a person credit for broad shoulders simply because he has a thick deltoid muscle and the muscles of the chest and arm add to the record, in such cases, by making the arm hang at an angle instead of per­pendicularly, as expected. It would be nearly as scientific to include the arms in the waist breadth, and then let the subject stand with arms akimbo.

The breadth of chest is of more importance than breadth of nipples and should be taken at full natural inspiration in the axillory regions, on a level with the nipples. For ordinary cases the measurement can be taken with the same instrument as the other breadths ; but in very fat or muscu­lar persons the calipers used in taking depths should be used.

The expiratory strength, as ordinarily taken, is mislead­ing and untrustworthy. The intention is to gain some knowledge of the condition of the accessory muscles of expiration ; for, in ordinary expiration there is little or no activity of muscles but rather a letting go or suspension of muscular effort. (See Foster. Phys. ed. 1883, p. 315.) Now, when the subject is asked to blow as hard as he can into the apparatus, and keep the throat open, as in respira-

50 What to Measure and How to Measure.

tion, he will involuntarily close the pharynx with the back of the tongue and palate, and then bring the muscles of the cheeks and lips into active contraction, and, with a few efforts, acquire such skill as to rival the cornet player in the record secured.

For those who are making a special study of athletes a measurement suggested by Dr. Savage of the Berkeley Lyceum Gym. is worthy of notice, namely ; the length of the os calcis ; this being the lever arm of the muscles that extend the foot; its relation to the metatarsal and phalan­geal portion is doubtless of importance in determining the ability for such exercises as running, walking, jumping, etc.

Some points in minute anthropometry have been sug­gested by various specialists, but obviously such work should be left to those who wish to study some particular phase of the subject.

Dr. F. Swain has proposed to measure the height of ear, girth of ankles and hands, depth of pelvis, neck and head, length of hands. Mr. R. J. Roberts considers the girth around the shoulders at point of shoulder breadth of great importance. Dr. E. Mosher thinks that depth of chest should be a double measurement, showing thickness of right and left chest; and the suggestion is a good one, because, in many cases the sternum is depressed and the record, if made strictly by rule, would be smaller than the subject deserves. In such cases I have put one foot of the calipers on the proper point behind, and brought the other out to a point not quite in line with a ruler laid across the chest. Dr. Mosher's method would show any asym­metry of the chest.

The French police regulations require a minute measure­ment of the ear and middle finger for identification of criminals if they are arrested a second time. These meas­ures help in classifying the photographs that are taken so that they can be readily found among thousands. Some form of anthropometrical tests can no doubt be made more serviceable in establishing identity in a " rogue's gallery "

What to Measure and How to Measure. 5 /

than photography. The physiological picture of a man as shown on a graphic chart is sure to retain some character­istic feature, whatever may be his condition.

Photography may be wisely used as an adjunct of anthropometry. Since Prof. Muybridge made his won­derful pictures of animal locomotion by instantaneous process the value of a photograph to show physical defi­ciencies as well as excellence has been established It makes a record in an artistic way that is made by tape and calipers in a mathematical or scientific way. Already at some of the better equipped gymnasiums, like the Hemen-way in Cambridge, photography is made to assist in pre­serving the record of a man's physical condition.

The strength tests that may be taken are more in number than the muscle girths taken in the above list and a table of strength tests may be made that would correspond to the author's anthropometric table. The quality of the muscles could be graphically shown on this, side by side with the girths. Uniformity of method in testing strength will soon furnish material for such a table. Care must be used to guard against strain and over-exertion in securing data of strength.

The tests for accuracy and strength may be made by the record in a series of athletic exercises and show some­thing of the nerve training that the subject has had ;—in other words, the self-controlled power. In a person we may test the strength of fifty groups of muscles acting separate­ly so far as possible and, while our record may be high, we may still have a very inadequate estimate of the coordi­nated power—the real strength of the individual, which may be small. Probably the best exhibit of a man's power is seen in such games as foot ball where the strength of every muscle is tested both as to its own quality and its adjustment to other muscular groups and to mental stimuli.

An organ may work correctly but slowly. The eye of one person sees at a glance what the eye of a second person would require seconds to reveal, and yet the eye

52 What to Measure and How to Measure.

of the latter may be perfect according to every test of the oculist. It is so with hearing. The time required between hearing and perceiving sounds and giving a signal is .12 to .18 of a second. Higher tones require slightly less time than deeper ones. Noises are heard quickest*

A distinguished teacher recently told me that he had called a certain boy stupid until he discovered that the boy was merely slow in his sense of hearing. Since that time he has studied boys whose perceptive faculties seemed dull and has found that a large percentage of them are deficient mainly in hearing a question that is put rapidly to them. A device that will test the speed of the action of the eye and ear correctly within moderate limits of accu­racy will be of great practical importance in an educa­tional as well as scientific aspect. Physical education must bring up to a higher plane of activity each physical function that is found to be deficient. To do this the examiner must be ever alert to discover undeveloped functions and inventive ability will be frequently required to solve the problems presented.

Another refinement of anthropometry is taking the specific gravity of a man. This may not be a feasible addition to practical anthropometry but for minute study may afford an interesting field of investigation. The record can be taken by immersing the subject to the face or any suitable point in a reservoir of water that is situat­ed on a scale for weighing. From the weights of the reservoir full of water, the displaced water and the im­mersed subject in the reservoir the specific gravity has been calculated. The fact has been often noted that men of small girths often show a weight far above what would be fairly estimated, but as yet there has been no scientific study of this class of cases to discover the relation of high specific gravity to health, strength, endurance or longevity. The specific gravity of any body is represented by the quotient obtained by dividing the weight of the body in air by the loss of weight when weighed in water.

* Kries and Auerbach, quoted by Thompson.

C H A P T E R IV.

P E R S O N A L H I S T O R Y A N D E X A M I N A T I O N O F S P E C I A L S E N S E S .

The historical data that should be gathered at each examination are of varied character, and of the highest importance. It gives the examiner an idea, not only of the immediate weaknesses that are to be met and combated by proper advice and training, but it places the law of heredity in bold relief, and enables the counsel to be far-reaching in its results.

For instance : with a record of tuberculosis, extending through two or more generations, there would seem to be sufficient warrant for advising not only the thorough devel­opment of the chest, but the careful avoidance of excessive exercise, such as would be required in many athletic sports that would seem, at first thought, especially suitable for a person of consumptive diathesis. To know a man well you must know his father and grandfather. This negative side of training and physical education has received very little attention from practical teachers outside of the so-called Delsarte system, where it has run riot. The con­servation of force is the foundation of the Delsarte system, but only profound ignorance of the physiologic* laws of growth and development could excuse the building upon such a principle.

Growth and organic perfection are gained only by a use of all the tissues—but use is one thing and abuse quite another. The eye is developed and improved by a repeated use in distinguishing colors, shapes and sizes ; but a long-continued strain of the eyes over a Greek or German text is not exactly beneficial, as the spectacle-mounted noses of our students, especially the Germans, bear witness. So,

54 Personal History and Examination

while a good run in the open air may be beneficial to a person of sensitive or weakened lung tissue, it does not follow that training for a mile run or a " hare-and-hounds " chase would be.

The condition of the subject during the previous years of his life is valuable in making a prognosis or a judgment of the future history of the case, and in deciding what quality of endurance the subject possesses, for the violent exercise of one man is a mere nothing for another. The boy who comes to school from the farm or workshop may be no better developed than his classmate, who has never known what physical work is, and yet be able to endure twice as much prolonged physical exertion. His life has been spent out of doors, and he takes kindly to outdoor sports, running, foot-ball, boating, etc.; or, if his life has been in a shop where skilled manipulation has engaged his energy, he prefers gymnastic exercises, becomes an adept at club swinging, fencing, etc., or a good performer on the bars, rings and other apparatus.

The city-bred boy has a latent aptitude for anything, and with proper training is a strong competitor with his country classmate in every line of athletics or gymnastics, but his exercise will need to be progressive, or he will suffer from local strains that may affect vital organs.

If, on the other hand, the history discloses a previous life of activity and physical hardship, and the plan of life is directed toward sedentary pursuits, the recommendation must be toward retrogressive exercise. A man with benign hypertrophy of the heart is not in the best condition for sitting at a desk all day—there will be too much local con­gestion for good brain work, or the metamorphosis of muscular tissue in the heart itself will end in fatty degen­eration, or softening, and impaired vitality result. This is undoubtedly the reason for the numerous cases of func­tional and organic diseases of the heart that are found among ex-champions.

The history may also disclose a tendency to disease in

of Special Senses. 55

the subject himself, that will modify the prescription of exercise very materially, if the examiner is alive to the exigencies of the case and informed as to its requirements.

But, without citing further examples of the advantages, nay, necessity of a full history of each case, let us turn to the question of what points in history should be recorded.

On the record book, in connection with the measures, the subject's name and birthplace should be kept—there is no reason for secrecy about these matters.—It is also well to add the birthplace of parents and grandparents to this general record, for it makes the material valuable in study­ing the effect of location or environment in differentiating classes or social groups ; the occupation of the father, the resemblance in physical build to father's or mother's family; past exercise in work and recreation, pulse rate, color of hair and eyes, vision and hearing, use of tobacco and stim­ulants. In the private book should be recorded the cause of death of either parent if not living, any disease that has been common in the family (it is better not to use the word hereditary in this connection) such as lung diseases, heart diseases, rheumatism, neuroses, Bright's disease, cancer, scrofula, varicose veins, dyspepsia, diarrhoea, constipation, catarrh, etc.; also any disease that may be found affecting the subject, as varicocele, rheumatism, synovitis, etc., any deformity and its cause, if discoverable ; any injury in the way of broken bones, surgical operations, strains, etc.; any previous severe illness, such as peritonitis, zymotic fevers, etc.; any tendency to deranged functional activity, as con­stipation, biliousness, indigestion, insomnia, etc.

In this connection it may be well to call attention to the rule that, if a child strongly resembles in physical build the side of the family that has no hereditary taint, the other side having some pathological diathesis or dyscrasia, the probability of his inheriting the disease is diminished.

It is well to record the special kind of athletic or gym­nastic work that has been taken, and whether this has been under the personal direction of a teacher or trainer. If

$6 Personal History and Examination

there is any lesion of the heart or other organs that has been due to or been attributed to athletic or gymnastic work under supervision, look up the instructor and get the previous history of the case. You may find that the so-called instructor or trainer was an ex-prize fighter or dilapidated "bummer," but, if so, use him to discredit the popular trust in ignorance. If he does know his business, he will perhaps be able to enlighten you as to the cause of the trouble.

The record of color-blindness* should be kept, not as a disease, but as a peculiarity that would render the subject unfit for some occupations. In many cases of supposed color-blindness, the sense is probably simply uneducated. Cases of color-blindness among women are very rare (i in 25,000) and are not frequent among men. The eyes should be examined by a specialist in opthalmology if there is the slightest indication of nerve irritation, and the super­ficial examination, such as is indicated here, shows the slightest error of refraction or muscular insufficiency.f

Tests of the hearing may be made, and any dullness or difference in the auditory sense of the two ears should lead to an examination with the otoscope. The channel may be partially or completely occluded with wax or the debris from a previous inflammation or an exostosis of the wall of the meatus. If the opening is normal, the tympanum, or drum, will be seen at a depth of about two centimeters as a smooth, shining, semi-transparent membrane of slightly pinkish-gray color. In cases of inflammation the drum becomes decidedly pink. Slightly below and in front of the center is a white spot as though some white body

* See page 61 for directions for testing special senses. f See the New York Medical Journal for January 7 and 14, 1888, and

the same journal February 27 and March 13, 1886, containing articles by A . L. Ranney, M.D., on The Treatment of Functional Nervous Dis­eases by the Relief of Eye-Strain, etc. A l so the Belgian Prize Essay, by Dr. Stevens, of New York, and the Report of the Stevens Commis­sion, published in The Neurological Journal, 1889.

of Special Senses. 57

pressed the drum slightly forward at that point. This is the end of the bone, the malleus, that conveys the vibra­tions back to the internal ear. In most cases a gray streak can be seen extending upward and forward, which is the body of the bone. Sometimes the drum will appear bulg­ing and convex, from the pressure of serum within, and the vibrations of the drum are prevented, with resulting deafness. Again the drum may appear cupped or concave from the stoppage of the eustachian tube and the subse­quent absorption of air in the middle ear, so that the drum is pushed in by the atmospheric pressure. This is by far the more common condition and only impairment of hear­ing results until the case is of long standing, when com­plete deafness may ensue. Openings in the drum are of frequent occurrence as the result of inflammatory exuda­tion bursting through from the inside, or traumatic punc­ture that has been uncared for. A puncture may not im­pair the hearing to any serious extent. Suppuration of the ear in any part should be the subject of surgical treatment at once, without regard to the whims or prejudices of the person possessing an otorrhcea. The discharge is often looked upon as a necessary affliction, and relief from other woes, but in reality it is a source of debility and impairment of health to the person himself, and a nuisance to others. Cases of impaction require treatment, and the same may be said of the convex drum. The concave drum may be due to catarrh, and if so, that should be treated.

In this connection it may be well to speak of nasal catarrh and its influence on health. The disease may be considered as a condition of mal-nutrition of the part affected, due to irritation of the trophic nerves. It may appear as an inflammation of the upper air passages with an increased secretion of mucous fluid ; or there may be atrophy of the mucous surfaces and of the harder tissues beneath ; or there may be extensive ulceration, and decom­position of secretions.

The first form is due to the action of irritants on a super-5

58 Personal History and Examination

sensitive membrane. The condition can be produced almost instantaneously by the inhalation into the nasal openings of snuff from pulverized tobacco, acrid fumes, dust, etc.; but the hyperaemia is temporary if the irritation is not repeated. The changes of the climate and passing from a warm to a cold atmosphere suddenly do not give the system time for the nice adjustment to environment that enables man to live in every climate where food can be found. The result is a continued irritation of the mucous surfaces of the air passages and a resulting in­flammation with thickening of the superficial tissues until the normal nutrition of the part is lost, and disease be­comes seated. This swelling may close the openings of the eustachian tubes, and impaired hearing is the result. Treatment is usually successful, and hence the importance of examining the nasal chambers if the history discloses any suspicion of defect in this locality. The other forms of catarrh are often quite as distressing without as favora­ble a prognosis, but relief will not be sought in vain.

The sense of smell in the atrophic and erosive forms of catarrh is often entirely lost, and in all cases is deranged. This sense may be tested by inhaling odors that are bland and unconnected with articles of food as musk, attar of roses, etc.

The olfactory nerve is perhaps more intimately con­nected with the brain tissue than any other, being appar­ently a prolongation of the brain through the cribriform plate to the nasal walls. As many cases of headache are due to a bad condition of the surfaces where this nerve is spread out we should examine such cases for ulcerations, tumors, malformations and displacements that may cause occlusion or pressure.

The sense of taste is closely allied with that of smell but is not so important an indication of the condition of the organs with which it is connected. It is a sense with great capacity for education, as it was the boast of Roman epicures that they could tell by the taste of a fish whether

of Special Senses. 59

it was caught above the Bridge or below. A taste may be acquired for the most nauseating substances. Children have been known to cry for cod-liver oil. But while the sense of taste is not important in its relation to health, the condition of the mouth may well occupy our attention in discovering those facts in a man's condition that make for health or debility. A clean tongue indicates good digestion ; while a coating indicates some abnormal con­dition of the stomach, or liver, or pharynx. A cracked tongue means dyspepsia. The tonsils should not protrude beyond the pillars of the fauces ; the general surface of the pharynx should be smooth and of light pink color ; the teeth should be sound or filled ; the vocal cords should be a light, pinkish yellow ; and the tracheal rings below look like white bands, between which pink tissue can be faintly discerned.

The temperature should be taken with the bulb of the thermometer placed under the subject's tongue for five minutes. This should be a record of 98.40 F. without a variation of half a degree. If the temperature is below normal note carefully the* general conditions and repeat the test at some future time. About one or two per cent, of cases have a subnormal temperature. The instrument should be carefully washed in an antiseptic fluid after using and it is well to have a cup of saturated solution of boracic acid into which the mouth-piece of spirometers, etc., can be placed after taking records with them.

The tests of urine for albumen and sugar should be practiced until the examiner is sure of his ability. The simple methods now prepared by leading manufactur­ing chemists and druggists leave little except skillful manipulation to the examiner. The record should be repeated if any abnormality is found and the subject placed under the advice of a physician.

The director of a gymnasium should always recommend some other physician to cases needing medical care.

The following directions are given for testing the re-

6o Personal History and Examination

fractive power of the eye and its color sense and also for determining the auditory power :

Procure of any optician two pairs of spectacles, one with convex glasses, N o . + .75 Dioptric (equal to N o . + .48 in the old or English sys­tem), and the other with concave glasses, N o . + .75 Dioptric. Also obtain a copy of Monoyer's test letters (a card of Dr. Dennett's modifi­cation of Monoyer's test type may be procured of Meyrowitz Bros., opticians, 297 Fourth Ave. , New Y o r k City), to be hung up at 5 meters distance, and a copy of Green's astigmatic lines, in the form of a clock face, to be hung up at the same distance.

Test:—Seat the subject at a distance of five meters from the test cards, which should be hung in a good light. Examine each eye sepa­rately, keeping the other covered by a card held in front of, but not touching it. Never press the fingers against the closed lid.

There are ten lines of letters on the test card, numbered from .1, .2, .3, etc., up to ten ioths or 1. If now the subject can read the top line, the smallest letters on the card, with the right eye (R.E.) alone, his vision (V.)is recorded as ten ioths or 1. ( V . R . E . = i ) . If he sees nothing clearly above the fifth line from the bottom, but can read that correctly, then V . R . E . = . 5 . If he cannot read any of the lines, then V .R .E . = .o. (i. e., less than one-ioth). Whatever the vision without glasses may prove to be, always next put on the convex spectacles and again cover the other eye. If now he can still with the right eye see as well or better than with no glasses at all, and can read the same line as before, he is Hypermetropic (H.) in that eye. For example, if without glasses it was found that V . R . E . = . 5 , and now after adding the convex glass his V . is improved to .8, the record would be V . R . E . = .5, + H.=r.8. But if the vision is neither improved nor made worse by the convex glass, the record will be thus : V . R . E . = . 5 , + H.= .5 . If the convex glass can be used at all without decreasing the vision, no further testing with this card is needed ; the subject is hypermetropic in that eye. If it is found that the vision of the right eye equals 1. without glasses, and then the addition of the convex glasses blurs the letters, the eye is Emmetropic, that is, the vision is normal (V .R .E .= i . ) .

If, however, the vision without glasses is less than 1., for instance only .3, and the convex glasses make even that line more indistinct, then put on the concave glasses. If now the vision is improved so that a higher line can be read, for instance the eighth from the bottom, the eye is Myopic, or "near sighted," and the record will be V . R . E . = . 3 , + My.= .8 . Or again, if the vision without glasses in the left eye is found to be .7 and then with the concave glass the top line can be read, the record will stand thus: V . R . E . = .7, + M y . = i . After testing each eye separately, place the record of one above the other, for example thus:

of Special Senses. 61

j V . R . E . = r . 1 V.L.E.==.6, + My.==.9.

This completes the testing for simple hypermetropia, myopia and emmetropia.

After testing the eyes as above, if the vision has not yet been made perfect in either, leave on the proper correcting glass, the convex if there is hypermetropia, or the concave if there is myopia, or use no glass if there is neither; then direct the subject's attention with that eye alone, the other being covered, to the card of radiating black lines. If he sees one or more of the lines running in any direction clearer or blacker than those at right angles to them, he is shown to be astigmatic. Either the perpendicular or the horizontal lines usually appear the blacker to the astigmatic person. If the previous record was V . R . E . = .7 and this defect is found, then it will be V . R . E . = .7, + A s . Or if before it read : V . L . E . = .3, + My.=.6, and astigmatism is found, it will read, V . L . E . = .3,+ My. = .6, + A s . Astigmatism may ex,ist either alone or in combination with My. or H. If alone we might have a record thus : V .R .E .= .6 , + As . ; V . L . E . = 4 , + A s . , or if with hypermetropia thus : V .R.E .= .7 , + H .= .7 , - rAs . ; V . L . E . = .6,-t-H. = .8, + A s .

To recapitulate, in brief: if it is found that V . R . E . = i , then the R.E. is Emmetropic or Hypermetropic. If emmetropic, the convex glass will markedly impair the vision ; if hypermetropic it will not. If the V .R .E .= .9 or less, then the R.E. is either hypermetropic, myopic, astig­matic or amblyopic.

1st. If it is H. the convex glass will not greatly impair the vision. 2nd. If it is My, the concave glass will improve V . yd. If it is A s . one of the radiating lines is blackest. 4tA. If neither of these defects exists and the V . is less than .7 then

Amblyopia or partial blindness may be recorded. It may read thus : V .L .E .= .6 , + A m .

Caution.—Always try the convex glass. Never try the concave unless the convex glass blurs the vision.

In the following cases the subject should be recommended to consult an oculist concerning the advisability of wearing glasses : If the vision without any glasses is less than .4 in either or both eyes ; if he com­plains of weak, watery or painful eyes, especially in reading, and any degree of hypermetropia or astigmatism is found to exist.

D I R E C T I O N S FOR T E S T I N G T H E C O L O R SENSE.

A reliable set of test worsteds of different colors may be procured for $1.25 of N. D . Whitney, 129 Tremont street, Boston. Among these will be found three large test skeins colored light green, purple (pink or rose), and bright red. T o make the examination, spread all the worsteds out on a white cloth placed upon a table. First lay the green

62 Personal History a?td Examination

test skein a little to one side of the others, and then tell the subject to throw out of the pile and lay along side of the test skein all the lighter and darker shades of that color, or all the skeins containing a shade of that color in any degree. Avoid naming the color " g r e e n " to him. If he throws out only shades of green or light blues his color sense is normal (C.S.N.) and the test is completed. But if in addition he throws out light grays, or any other shade of gray, or light yellows, salmons, or pinks, he is color-blind. If he handles or fumbles over those shades a good deal and hesitates, as if in doubt about them, but yet does not throw them out, he probably has " feeble color sense " (C.S.F.). The examiner in these cases must use his judgment in making a certain amount of allowance for the stupidity of some persons in understand­ing what is wanted, especially in the young and uneducated.

If the subject is found to be color-blind, next lay down the purple or rose-colored test skein, in place of the green, in order to determine the nature of the defect. Now tell him to throw out all the different shades of that color. If he only throws out pinks and light reds and shades approaching these he is only partly color-blind. (P.C.B.) But if he throws out decidedly bluish purples, blues, violets, greens, or grays, he is completely color-blind. (C.C.B.) Completely red blind if he throws out the blues, violets, etc., or green blind if the grays or greens.

No further testing is needed, but as a matter of curiosity and to prove the result, the red test skein may next be tried in the same way. If he matches with it browns or greens and grays he is completely color­blind. Dark brown or green if red blind, and light brown or green if green blind.

It is not important to record whether the complete color-blindness is red or green blindness. The following classes may be recorded :— Color sense normal=C.S.N. ; Color sense f eeb le=C.S .F . ; Partial color-b l indness=P.C.B. ; Complete color-bl indness=C.C.B.

Color-blind individuals should be warned against engaging in any occupation where this defect would prove dangerous or inconvenient.

D I R E C T I O N S FOR T E S T I N G T H E A U D I T O R Y SENSE.

Use an ordinary watch and a tuning fork, letter A . or C , as tests. Seat the subject with his right side toward you, and then while the room is perfectly quiet, see how far off he can hear the watch tick. Having previously learned by a few experiments what is the furthest distance at which the tick can be heard by normal ears, make that num­ber of inches the denominator of a fraction, and the hearing distance of each person examined thereafter the numerator. Having found the normal distance (=H.D.) to be, for instance, about sixty inches, and that of the subject now examined to be, say forty inches, his record for the right ear would then be : H .D.R .E .= | | } . If it had been f# or i, the

of Special Senses. 63

ear would be normal. would show an abnormally acute sense of hearing. If the watch could only be heard while in contact with his ear, it would be recorded: H.D.R.E. = 6

C

0 . If not heard at all, then H.D.R.E.=-6%> Next test the left ear in the same way. Voice sounds in talking will often be easily heard by persons quite deaf to the watch tick, so that the latter is not always a reliable practical test.

Suppose we have found H . D . R . E . = f § , H . D . L . E . = i , this implies some deafness in the right ear, and the tuning fork will now help us to decide whether the cause lies in some defect of the auditory nerve or internal ear, or in the external or middle ear or Eustachian tube. Strike the fork against some solid substance, and then place the end of the handle against or between the subject's front teeth. If both ears are normal he will probably seem to hear the ringing of the fork equally well in both ears. But if there is a defect in one ear he will either seem to hear it louder or more feebly in the affected ear. If, as in the case we are examining, the fork is heard best in the deaf ear, this tells us that the deafness is due to some defect in the more external parts of the organ, and it can probably be corrected by appropriate treatment. But if it is heard best in the good ear, it goes to prove that the defect in the other ear is more deeply seated and cannot probably be greatly benefited by treatment. This effect of the tuning fork is contrary to what would ordinarily be expected, and it is- often a matter of surprise to a deaf person to find that he hears with his teeth apparently better on the deaf side.

We may now add to our record in this case : T .F . best R.E. If it had been heard equally well in both ears we would record: T . F . = N . (or normal). Where the defect in hearing is at all marked a specialist in ear diseases should be consulted.

Our record in a normal case might be thus : H . D . R . E . = i , H . D . L . E . = 1., T . F . = N . ; or in an abnormal case it might be thus : H . D . R . E . = i . , H.D.L.E.=- 6%, T.F. best in R.E. This would imply that the subject was so deaf in the left ear as not to be able to hear the watch tick at all, and the fork held between the teeth could be heard best in the good ear, consequently his trouble is probably seated in the deeper structures of the ear, or in the nerve itself, and treatment would not be expected to help him greatly. The tuning fork need not be tried unless the watch tick shows some defect in hearing.

C H A P T E R V.

E X A M I N A T I O N B Y I N S P E C T I O N A N D P A L P A T I O N .

After the measurements of a person have been taken, the work of examination and physical diagnosis should begin. The measurement is mechanical and could be done cor­rectly by any person, after a little practice ; but a physical examination requires the highest product of scientific train­ing backed by sound judgment in order to discover the true condition of organs and determine the real cause of the disordered function or disturbed growth. It may re­quire only a mechanical eye to discover a curved spine, but it must be the mechanical eye, backed by a thorough knowledge of physiology and anatomy, that can discern the fact and the cause.

The suggestion of remedial agents again pre-supposes a knowledge of therapeutics, and this field is as broad as sur­gery, which rests on a knowledge of the same sciences. The therapeutic side of gymnastics has been more thor­oughly worked out by the Swedes, who, following in the footsteps of Ling, have studied exercise, both active and passive, from a medical standpoint, and have developed a system of gymnastics that has been approved and applied by medical men all over the civilized world. Massage as one part of this system is applied in a rudimentary way to a great variety of cases in this country, but with the best success only by practitioners of foreign education. There is a call then for the most extensive preparation in this field of work, and in no line of medical practice is there as broad a field for original scientific research as in this, the prescription of exercise. The following technique is re­commended to all those who are making a physical exam­ination :

Examination by Inspection and Palpation. 65

I . — I n s p e c t i o n s h o u l d b e m a d e w i t h the subject entirely-n u d e a n d s t a n d i n g easily. If a military attitude is a s s u m e d , try to get relaxation into the o r d i n a r y positions. T h i s c a n often b e d o n e b y calling the attention to s o m e trivial matter, as a n y peculiarity of the h a n d s o r feet, or b y h a v i n g the subject step f o r w a r d o r b a c k w a r d a f e w steps, w h e n h e will forget his strained position. F r o m the front notice (1) the general c o u t o u r o r relative b r e a d t h , (2) the position of the h e a d , (3) the position of the s h o u l d e r s a n d a r m s , (4) the c u r v e s of the t r u n k , (5) the m u s c u l a r condition of chest, a b d o m e n , a n d legs, (6) a n y m a l f o r m a t i o n , s u c h as t u m o r s , cicatrices, etc.

F r o m the side notice (7) the antero-posterior o r n o r m a l spinal curves, (8) the d e p t h a n d mobility of the chest a n d a b d o m e n , (9) the position of the shoulders, (10) the relation of the hips to the loins, (11) the relation of the n e c k to the t r u n k , (12) the g e n e r a l attitude of the subject.

F r o m the rear notice (13) a n y lateral or spiral c u r v a t u r e of the spine a n d p r o m i n e n c e of s p i n o u s processes, (14) the condition of the s h o u l d e r a n d scapulae, (15) the waist curves, (16) a n y tipping of the iliac crests d u e to o n e short leg or i m p e r f e c t b o n e d e v e l o p m e n t , (17) the outline a n d position of the legs a n d indications of varicose veins a n d cyanosis, (18) the m u s c u l a r condition, (19) the condition of the skin, a n d (20) a n y t u m o r o r m a l f o r m a t i o n .

O f c o u r s e the e x a m i n e r will n o t l o o k u p e a c h o n e of these points in regular order, b u t h e s h o u l d s t u d y e a c h o n e a n d after a n e x a m i n a t i o n g o o v e r the list a n d see h o w m a n y points there are o n w h i c h h e h a s n o clear, definite k n o w l ­e d g e , a n d t h e n try o n the n e x t case to m a k e the list smaller until h e will take in e v e r y t h i n g at a g l a n c e , as it w e r e . T h e r e are m a n y other m a t t e r s to w h i c h attention m i g h t b e called, b u t t h e y are m o s t l y amplifications of the a b o v e list.

W e include in (1) the b r e a d t h of h e a d as g i v i n g s o m e idea of the t e m p e r a m e n t a n d vitality of the subject. A b r o a d h e a d at the b a s e is believed to indicate a greater vitality

66 Examination by Inspection and Palpation.

t h a n is f o u n d w h e n the h e a d is l o n g a n d "top-heavy." T h e r e is greater p o w e r of resisting disease a n d less liability to n e r v o u s irritability of a pathological character. A thin, w e a k n e c k m e a n s a b a d c u r v e f o r w a r d at the cervical p o r ­tion of the spine, a n d a c o n s e q u e n t flat chest in a large m a ­jority of the cases. T h e voice will b e uncertain a n d the throat surfer f r o m catarrhal diseases o n the slightest p r o v o ­cation.

N a r r o w s h o u l d e r s m e a n c o m p r e s s i o n of the u p p e r part of the t h o r a x , a n d less activity of respiration in the apices of the l u n g s . T h i s , w i t h a history of tuberculosis is u n f o r ­tunate, b e c a u s e tubercular d e g e n e r a t i o n usually b e g i n s at the a p e x of the l u n g s a n d a n inactive part is a n u n h e a l t h y part. T h i s fact h a s led D r . T . J. M a y s to c l a i m in a n ar­ticle p u b l i s h e d in the " T h e r a p e u t i c Gazette," M a y , 1887,* that the w e a r i n g of corsets b y ladies m a y b e a protection against phthisis, b e c a u s e b y c o m p r e s s i n g the a b d o m e n a n d l o w e r part of the t h o r a x costal b r e a t h i n g w i t h a freer u s e of the a p e x of the l u n g w a s necessitated a n d a c o n s e q u e n t i m m u n i t y f r o m tubercular d e g e n e r a t i o n w a s the result. T h e fallacy of this t h e o r y h a s b e e n repeatedly s h o w n b u t b y n o o n e so c o m p l e t e l y d e m o n s t r a t e d as b y D r . J. H . K e l ­l o g g of Battle C r e e k , M i c h . , w h o s e investigations r e g a r d i n g n o r m a l respiration are c o m p l e t e a n d original.f

T h e b r e a d t h of chest is o n e of the three factors in m a k i n g u p the " V i t a l C a p a c i t y , " a n d its relation to the b r e a d t h of waist a n d hips will g i v e a better idea of the natural strength t h a n the size of the biceps. A n y depression of the ribs or s t e r n u m s h o u l d b e noted. I h a v e s e e n a case of severe hepatic disturbance that h a d resisted m e d i c a l t r e a t m e n t for m a n y m o n t h s , r e c o v e r m o r e t h a n o r d i n a r y health u n d e r a series of exercises that t e n d e d to lift t w o d e p r e s s e d ribs o v e r the liver into a m o r e a r c h e d a n d natural position.

N o t i c e a n y elevation of the chest w a l l in the cardiac re­g i o n , a n d a n y transverse d e p r e s s i o n at a b o u t the sixth rib.

*See " Med. News," Nov. 27, 1886. f Transactions of the Mich. State Med. Society, 1888.

Examination by Inspection and Palpation. 6j

T h e elevation m a y b e d u e to e n l a r g e m e n t of the heart o r pericardiac effusion. T h e d e p r e s s i o n is d u e to faulty habits of s i t t i n g — t h e p e r s o n sliding f o r w a r d in his chair a n d sit­ting o n the s a c r u m , instead of o n the b u t t o c k s . T h i s de­pression c a u s e s a p r e s s u r e o n the heart a n d interferes w i t h the circulation a n d also c a u s e s indigestion q u i c k e r t h a n p l u m p u d d i n g b y restraining the m u s c u l a r activity of the s t o m a c h w i c h is v e r y m a r k e d d u r i n g digestion.

U n d e r (2) w e s h o u l d n o t e a n y position of the h e a d that m i g h t d e n o t e a shortness of the s t e r n o m a s t o i d m u s c l e s . A shortness o n o n e side t e n d s to tip the h e a d t o w a r d that side a n d t u r n the face to the other ; if b o t h m u s c l e s are short t h e y t e n d to d r a w the n e c k f o r w a r d a n d tip the face u p . A n a r r o w thin n e c k indicates, generally, p o o r respiratory p o w e r a n d a catarrhal throat w i t h l a r y n g e a l sensitiveness, especially if in (7) w e find the cervical c u r v e v e r y d e e p , o r the n e c k slanting f o r w a r d b e c a u s e of p o o r s u p p o r t f r o m w e a k m u s c l e s . A s t r o n g n e c k is v e r y desirable. It n o t o n l y h o l d s i m p o r t a n t o r g a n s in place a n d insures g o o d circulation in the b r a i n b y m a k i n g the c h a n n e l s direct b u t it gives a n aggressive carriage, a n d indicates d e t e r m i n a t i o n a n d pluck. In (3) w e o b s e r v e the slope of the s h o u l d e r s a n d the relation of the a c r o m i o n s to the s t e r n u m . If a line b e d r a w n f r o m the a c r o m i o n tip to the b a s e of the n e c k , a n d c o n t i n u e d to the spine, it will m a k e a n a n g l e w i t h the ,line of the spine w h i c h s h o u l d a p p r o x i m a t e to 8o°. If the m u s c l e s that s u p p o r t the s h o u l d e r b e w e a k , t h e y p e r m i t the a c r o m i a l tips to sink, m a k i n g the a n g l e less, w h i l e if these m u s c l e s b e o v e r - d e v e l o p e d t h e y d r a w the tips u p a n d g i v e a stiff h u n c h e d a p p e a r a n c e that is u n g r a c e f u l . If the m u s c l e s in front b e better d e v e l o p e d t h a n t h o s e b e h i n d , the s h o u l d e r will b e d r a w n f o r w a r d a n d d o w n , g i v i n g a n a p ­parently flat chest w i t h s l o p i n g shoulders, w h i c h is a m a r k of slack habits a n d lack of all exercise of a v i g o r o u s char­acter. W h e n y o u get h o l d of s u c h cases y o u will feel like t a k i n g t h e m b y the s h o u l d e r s a n d , after g i v i n g t h e m a vio­lent s h a k i n g , telling t h e m to " b r a c e u p . " T h e effect of

68 Examination by Inspection and Palpation.

this p o s t u r e o n respiration will b e evident to e v e r y p e r s o n w i t h a k n o w l e d g e of the e l e m e n t s of a n a t o m y . T h e per­s o n h a s n o e n e r g y or " s a n d " b e c a u s e his b l o o d is n o t p r o p e r l y aerated. T h e a r m s h a n g f o r w a r d , g i v i n g the feeble, helpless attitude assigned b y caricaturists to the in­n o c e n t " d u d e . "

B y (4) w e m e a n the outline c u r v e s of the waist, w h i c h s h o w s o m e t h i n g of the strength of t r u n k that m a y b e e x ­pected, a n d the outlines of m u s c l e s that g i v e the beautiful c u r v e s seen o n the athlete. T h e s e lines m a y n o t b e clearly cut in s o m e cases of w e l l d e v e l o p e d m u s c l e s o n a c c o u n t of the a d i p o s e tissues i m m e d i a t e l y u n d e r the skin. T h i s last point will help u s in estimating m u s c u l a r condition (5)

w h i c h c a n n o t t>e j u d g e d altogether b y size.

It is well to r e m e m b e r that, in (6), w e m u s t n o t o n l y de­cide as to the character of the m a l f o r m a t i o n b u t k n o w w h a t the p r o g n o s i s or p r o b a b l e d e v e l o p m e n t will b e - — w h a t inter­ference w i t h exercise will b e c a u s e d a n d w h a t exercises are c o n t r a - i n d i c a t e d — w h a t will b e the influence o n h e a l t h — w h a t d o e s it indicate as to the physical s t a m i n a o r consti­tutional strength. F o r instance, varicose v e i n s m a y n e v e r h a v e g i v e n a n y trouble a n d m a y n e v e r h a v e b e e n noticed. H o w l o n g c o u l d this condition exist u n n o t i c e d a n d w h a t m a y b e e x p e c t e d f r o m it n o w ? W h a t exercises s h o u l d b e a v o i d e d , etc., etc. ? In s u r g e r y the w o r d t u m o r m e a n s a n y a b n o r m a l e n l a r g e m e n t of a n o r g a n o r tissue.

P e r h a p s the m o s t f r e q u e n t f o r m of t u m o r that-will b e f o u n d is d u e to r u p t u r e o r hernia. A h e r n i a is a t u m o r c a u s e d b y the p a s s a g e of a portion of a n o r g a n t h r o u g h the b o n y m u s c u l a r or t e n d i n o u s w a l l that n o r m a l l y confines it. It m a y b e p r o d u c e d s u d d e n l y b y a severe strain or bruise, o r it m a y b e the result of a g r a d u a l distension of o n e of the natural o p e n i n g s of the wall. C a s e s of intestinal her­nia are frequently f o u n d , a n d a m o n g y o u n g m e n will affect t w o or three p e r cent, of all, w h i l e a m o n g those past m i d ­dle H f e it will affect as h i g h as six p e r cent. A m o n g fe­m a l e s it is m u c h less frequent. T h i s is d u e to the less

Examination by Inspection and Palpation. 6p

p a t u l o u s i n g u i n a l o p e n i n g s in the f e m a l e a n d to less e x ­p o s u r e in the daily a v o c a t i o n s of life. A b d o m i n a l hernias are classed as inguinal, f e m o r a l , umbilical, d i a p h r a g m a t i c , etc., a c c o r d i n g to the place w h e r e the viscus forces its w a y f r o m its natural support.

A n inguinal h e r n i a m a y a p p e a r at the external i n g u i n a l ring as a r o u n d t u m o r of greater or less extent a n d is t h e n called " direct/' w h i l e if it a p p e a r s first at the internal ring a n d passes d o w n the canal it is called " oblique." T h e lat­ter f o r m is m u c h m o r e f r e q u e n t a n d t e n d s to d e v e l o p rap­idly d o w n w a r d , g i v i n g the t u m o r a n e l o n g a t e d f o r m w i t h h i g h e r origin t h a n the direct.

In f e m o r a l o r crural hernia the intestine passes d o w n t h r o u g h the crural ring u n d e r P o u p a r t s ' l i g a m e n t w h e r e it c a u s e s a protrusion of the anterior w a l l in a r o u n d t u m o r that lies in the g r o i n just b e l o w the fold at the s a p h e n o u s o p e n i n g . It is situated farther externally f r o m the m e d i a n line t h a n the direct inguinal a n d if large will h a v e its axis in a horizontal rather t h a n a p e r p e n d i c u l a r direction.

T h e s e three f o r m s of t u m o r m u s t b e readily differentiated f r o m cystic t u m o r s , varices, g l a n d u l a r e n l a r g e m e n t s , etc.

C y s t s h a v e a w e l l - m a r k e d fluctuation. V a r i c e s h a v e fixed relations to the v e n o u s t r u n k s a n d subside o n the subject a s s u m i n g a horizontal position a n d fill a g a i n o n rising if the inguinal rings are s u p p o r t e d . G l a n d u l a r swellings are d u e to s o m e attendant local irritation a n d are painful a n d u n y i e l d i n g to pressure.

T h e antero-posterior c u r v e s of the spine (7) are a c o n ­cavity in t h e cervical a n d l u m b a r r e g i o n s a n d a c o n v e x i t y in the dorsal a n d pelvic. T h e s e c u r v e s m a y all b e e x a g ­g e r a t e d b y disease or o c c u p a t i o n or m u s c u l a r d e v e l o p m e n t . A n y increase in the c u r v e s m u s t shorten the total height. A n y w e a k n e s s of m u s c l e s at the b a c k of the n e c k will per­m i t the h e a d to h a n g f o r w a r d , t h u s increasing the dorsal c o n v e x i t y , p r o d u c i n g r o u n d shoulders, or k y p h o s i s . A n o v e r - d e v e l o p m e n t of the l u m b a r m u s c l e s as c o m p a r e d w i t h those of the a b d o m e n will increase the l u m b a r concavity, c a u s i n g lordosis. T h e s t r o n g b a c k is the straight b a c k .

yo Examination by Inspection and Palpation.

T h e g y m n a s t i c t r e a t m e n t of lordosis, o r a b n o r m a l a n ­terior curvature, is the o n l y satisfactory o n e w h e r e there is n o caries or b r e a k i n g d o w n of b o n e . T h e s a m e is true o f k y p h o s i s , of w h i c h D r . S t e d m a n writes for T h e R e f e r e n c e H a n d b o o k : " A c u r e of adolescent k y p h o s i s , w h e n of slight d e g r e e , m a y b e obtained b y exercise alone, w i t h o u t m e c h a n i c a l s u p p o r t ; b u t it will b e f o u n d a d v a n t a g e o u s to aid the patient in m a i n t a i n i n g a n erect p o s t u r e b y suitable a p p a r a t u s . — T h e t r e a t m e n t b y exercises in this f o r m of k y p h o s i s s h o u l d n e v e r b e omitted, since the fault lies chiefly in a w a n t of tonicity of the m u s c u l a r a n d l i g a m e n t o u s tissues."

If there is e x a g g e r a t e d c u r v e at a n y part of the spine, there will b e m o r e or less c o m p e n s a t o r y c u r v e in the o p p o ­site direction at other parts ; a n d , in prescribing exercise, great care m u s t b e u s e d in d e c i d i n g w h i c h is the p r i m a r y a n d w h i c h the c o m p e n s a t o r y c u r v e , for a n error w o u l d m a k e m a t t e r s w o r s e f r o m the d e v e l o p m e n t of parts already strong, a n d the neglect of parts that are w e a k .

I n o b s e r v i n g the d e p t h of chest a n d a b d o m e n , (8) a n d the m o v e m e n t of e a c h u n d e r respiration w e h a v e a clue to the activity of the p e r s o n . If the chest is d e e p at the sixth rib, b u t thin at the s e c o n d , the s t e r n u m will usually b e f o u n d u n s u p p o r t e d b y the m u s c l e s of the n e c k ; t h o s e b e h i n d b e ­i n g w e a k a n d letting the s p i n e slope f o r w a r d at the u p p e r part so that the sterno-mastoid a n d the scaleni m u s c l e s c a n n o t raise the chest. T h i s t h r o w s all the w o r k of respira­tion o n the d i a p h r a g m , a n d the p e r s o n is unfitted for a n y athletic exercise, a n d w o u l d h a v e a c r a m p in his side if h e w e r e to r u n a n eighth of a mile. It is said that a r o u n d chest of e q u a l girth w i t h a flat o n e will n o t s h o w as g r e a t a l u n g capacity o n the spirometer, b u t m y e x p e r i e n c e d o e s n o t c o r r o b o r a t e the statement.

If the a b d o m e n p r o t r u d e s , o r sags, so that the intestines s e e m to b e h e l d just a b o v e the p u b i c arch, especially if there b e a history of hernia, o r excessive c o r p u l e n c e , or indigestion, the m a t t e r is of s u c h i m p o r t as to call for thor­o u g h instruction a n d earnest advice. M u c h discomfort,

Examination by Inspection and Palpation. 71

ill-health, a n d physical suffering will b e s a v e d s u c h cases, if the a b d o m i n a l m u s c l e s b e d e v e l o p e d b y persistent exer­c i s e — t h e a b d o m i n a l cavity contains quite as i m p o r t a n t or­g a n s of health as the t h o r a x , a n d the c o m p e t e n t instructor will n o t s p e n d all his t i m e a n d talk o n the chest.

In (9), (10) , ( 1 1 ) , ( 1 2 ) , w e h a v e s o m e of the points that g o to m a k e u p the carriage o r g e n e r a l a p p e a r a n c e of the s u b ­ject, a n d t h e y constitute the difference in p h y s i q u e b e t w e e n a W e s t P o i n t cadet a n d a s l o u c h i n g loafer.

O u r rear v i e w of the subject will disclose a n y lateral c u r v a t u r e s ( 1 3 ) of the spine, or scoliosis, a n d w e s h o u l d n o t o n l y see a n y d e f o r m i t y of this character b u t s h o u l d b e able to j u d g e of its nature, a n d d e t e r m i n e its causation. T h e c u r v e m a y b e s i m p l e a n d confined to o n e part of the spine, or it m a y b e multiple. In the latter case o n e of the c u r v e s is usually the p r i m a r y lesion, a n d the others c o m p e n s a t o r y . T h e r e a s o n for the c o m p e n s a t o r y c u r v e is f o u n d in the natural effort to m a i n t a i n a n erect carriage. If there b e a slight c u r v a t u r e to the left in the l u m b a r region, it w o u l d t e n d to tip the s h o u l d e r s to the right b u t the natural effort to straighten the spine h a s m o s t success w h e r e the m u s c l e is s t r o n g e r a n d n o t at the point of greatest w e a k n e s s , to­w a r d w h i c h the c o n v e x i t y lies. T h e result is the b e n d i n g of the u p p e r part into s u c h a position that the w e i g h t is in equilibrium, a n d the s h o u l d e r s fairly level. T h i s effort to b e n d a h i g h e r p o r t i o n of the spine to p r o d u c e a b a l a n c e of w e i g h t usually is the c a u s e of a slighter c u r v e h i g h e r u p in the cervical portion, that restores the h e a d to the erect position. T h i s gives a c u r v e to the left, in l u m b a r region, a n o t h e r h i g h e r u p to the right, in dorsal region, a n d a n ­other still h i g h e r to the left in the cervical portion of the spine. If this e x p l a n a t i o n is correct it is plain that the pre­disposing c a u s e of scoliosis m u s t b e d u e , in a large m a j o r i t y of the cases, to the w e a k n e s s or u n e v e n d e v e l o p m e n t of the m u s c l e s a n d l i g a m e n t s that s u p p o r t the spine. If the m u s ­cular strength a n d activity of o n e side b e greatly in e x c e s s of that of the other, the spine m u s t of necessity b e d r a w n to that side w h i c h will t h r o w the c o n v e x i t y t o w a r d the w e a k -

J2 Examination by Inspection and Palpation.

ness. If this principle obtains in all the a n a t o m i c a l relations — a n d its influence c a n not b e d e n i e d — n o better a r g u m e n t c o u l d b e u s e d in f a v o r of training for bilateral s y m m e t r y .

T h e fact that girls are affected b y spinal c u r v a t u r e m o r e often t h a n b o y s (the p r o p o r t i o n b e i n g 4 to 1) w o u l d s e e m to indicate a n e e d of m o r e robust exercise o u t of d o o r s or in g y m n a s i u m s that shall g i v e a d e v e l o p m e n t of the erector-spinae m a s s a n d all the m u s c l e s a b o v e the hips that shall c o m p a r e f a v o r a b l y w i t h that of b o y s . T h e influence of corsets a n d stays h a s b e e n repeatedly s h o w n to b e the c a u s e of great m u s c u l a r debility in the parts constricted, a n d all m e d i c a l authorities assign a large part of responsibility for c u r v a t u r e s to their use. T h e l u m b a r m u s c l e s of the f e m a l e h a v e a c o m p a r a t i v e l y larger field of origin at the pelvis a n d s h o u l d b e c o r r e s p o n d i n g l y strong, b u t u n d e r the dif­ferentiation of civilization a n d the corset, the f e m a l e waist h a s d e g e n e r a t e d into a b a c k a c h e .

P r e s s u r e o n a m u s c l e t e n d s to drive the b l o o d out, a n d if it b e c o n t i n u o u s , the circulation is i m p a i r e d . T h i s c o n ­dition m e a n s b a d nutrition of the m u s c l e , a n d that leads to i m p e r f e c t d e v e l o p m e n t o r to actual a t r o p h y . Is it a n y w o n d e r t h e n that a physician h e a r s f r o m his f e m a l e clients o n e l o n g c o m p l a i n t of w e a k b a c k s , b a c k - a c h e s a n d g e n e r a l debility !

T h e r e m e d i a l exercises for curvatures n e e d o n l y b e s u g ­gested here, as the o n l y treatment, is forcible straightening a n d p r o p e r exercises. T h e care s h o u l d b e exercised o n the w e a k e s t spot, w h i c h , in s o m e w a y , " m u s t stand the strain." S u s p e n s i o n , as o n the rings a n d bars, a n d the direct exer­cise, either active or passive, of the d e g e n e r a t e m u s c l e , is the g e n e r a l p l a n of treatment.

T h e p r o m i n e n c e of the s p i n o u s p r o c e s s e s are of d i a g n o s ­tic v a l u e in locating w e a k spots. If the interspinous liga­m e n t s h a v e b e e n strained a n d stretched b y lack of m u s c u ­lar s u p p o r t or b a d habits of posture, as sitting b a c k o n the hips, a n d letting the w e i g h t of the t r u n k press the l u m b a r vertebrae b a c k , o r a pernicious habit of letting the h e a d h a n g f o r w a r d , the s a w - t o o t h e d a p p e a r a n c e of the spine, as

Examination by Inspection and Palpation. 73

the subject b e n d s w e l l over, will disclose the fact. N o t i c e the a l i g n m e n t of these processes as the subject is b e n t over, a n d straightens u p . A failure of o n e or t w o , h e r e a n d there, to stand in the line, is n o t a n indication of dis­ease, b u t is d u e to a slight b e n d in the process, as will b e seen o n e x a m i n i n g a l m o s t a n y skeleton. T h e spinal c u r v a ­ture will b e indicated b y a n u m b e r of t h e m a s s u m i n g a general c u r v e d outline.

T h e mobility of the scapulae (14) varies greatly in differ­ent p e o p l e . A m o r e beautiful c o n t o u r exists w h e n the trapezius a n d rhomboi'dei are s t r o n g a n d short h o l d i n g the s c a p u l a e d o w n a n d w e l l b a c k to the spine, b u t the r a n g e of a r m m o v e m e n t is n o t so great. A g o o d d e v e l o p m e n t of these m u s c l e s is v e r y desirable as t h e y p r e v e n t the s h o u l d e r s f r o m rolling f o r w a r d a n d flattening the chest.

In (15) notice the size of the l u m b a r m u s c l e s , w i t h the subject b e n t over.

It s h o u l d b e b o r n e in m i n d that a shortness of o n e (16)

leg is c o m p a r a t i v e l y frequent, a n d this deficiency c a u s e s the pelvis to tip w i t h resulting spinal curvature. Distocia, or d e f o r m i t y of the pelvis m a y h a v e the s a m e effect.

T h e b o n e of the legs (17) c a n n o t b e greatly c h a n g e d b y exercise, b u t s o m e t h i n g c a n b e d o n e in early life to relieve o n e of the b u r d e n of b o w legs o r k n o c k - k n e e s . T h e r e f o r e , in the e x a m i n a t i o n of children, d o n o t o v e r l o o k this p o i n t ; n o r needlessly t u r n the attention of the subject to it w h e n there is n o relief, b u t o c c u p y his m i n d w i t h m a t t e r s that c a n b e i m p r o v e d a n d modified. I n o b s e r v i n g the legs, notice a n y c y a n o s i s a b o u t the anjdes, a n d varicose c o n d i ­tion of the veins, especially of the l o w e r leg. I n s o m e p e r s o n s the skin is firm a n d s e e m s to fit the u n d e r l y i n g tissues v e r y closely, t h u s g i v i n g s u p p o r t to the v e n o u s walls ; w h i l e in other cases the skin is relaxed a n d thin, f u r n i s h i n g p o o r s u p p o r t to the superficial vessels. If w e recall the fact that the hydrostatic p r e s s u r e a l o n e in a p e r s o n of o r d i n a r y height, w h i l e standing, w o u l d b e a trifle o v e r t w o lbs. in the vessels of the foot, a n d that the friction of the current a l o n g the vessel wall, the i m p e d i -

6

y/j. Enamination by Inspection and Palpation.

merit f r o m constriction of clothing a n d s p e e d of the current, all a d d to this p r e s s u r e w e c a n readily see w h y certain classes of p e o p l e are specially liable to dilation of the veins, a n d .suffer accordingly. P e r s o n s obliged to stand m u c h of the t i m e w i t h o u t great c h a n g e of position (as clerks, b o o k - k e e p e r s , b e n c h m e c h a n i c s , etc.), a n d v e r y fat people, w h o stand a considerable part of the t i m e , are m o s t often affected. T h e p r e s s u r e o n the external iliac vein in c o r p u l e n t p e o p l e is a p r e d i s p o s i n g cause, as it pre­v e n t s the free return of the b l o o d into the t r u n k ; a n d the s a m e m a y b e said of garters, tight clothing o n the thighs, or elastic t h i g h b a n d s , tight belts a r o u n d the waist, corsets, a n d a n y g a r m e n t or device that p r e v e n t s n o r m a l respira­tion. (See illustrations, C h a p . I X . ) T h e p r o p e r advice in these cases is clear. Restriction s h o u l d b e p l a c e d o n all exercises like j u m p i n g w h e r e the feet strike the g r o u n d h a r d ; r u n n i n g o n p a v e m e n t , floors, etc.; bicycle riding, b e c a u s e of the pressure of the saddle o n the f e m o r a l a n d s a p h e n o u s veins ; violent exercises, like foot ball, etc., etc. L i g h t exercise s h o u l d b e e n c o u r a g e d , for, the better the t o n e of the tissues, the less g i v i n g w a y will there b e to pressure. E x e r c i s e of the skin to k e e p it healthy a n d firm — s u c h as m a s s a g e a n d cold w a t e r baths, to stimulate the contraction of the t i s s u e s — w i l l b e of assistance. In this condition, " f o r e w a r n e d is f o r e a r m e d . " C y a n o s i s is a varicose condition of capillary veins a n d indicates p o o r circulation. In c y a n o s i s a b o u t the t r u n k search carefully for s o m e heart lesion.

T h e condition of the skin (19) will signify m u c h to the careful e x a m i n e r . N o t that e v e r y subject w i t h a c n e s h o u l d b e set d o w n as dyspeptic, b u t in a n a l m o s t intuitive w a y the careful o b s e r v e r will learn to d i a g n o s e m a n y internal a i l m e n t s a n d j u d g e of vices that m i g h t otherwise.be u n ­k n o w n . T h e r e is s o m e t h i n g that c a n n o t b e described in the healthy, firm, velvety skin of a n athlete. It m u s t n o t o n l y b e seen, b u t felt, in o r d e r to b e appreciated. It is better to b e rolled in the dust b y a hearty, h e a l t h y wrestler t h a n to s h a k e the flabby, m o i s t h a n d that is p l a c e d in

Examination by Inspection and Palpation. 75

y o u r s b y s o m e a d v o c a t e of m o r a l suasion a n d intellectual top-heaviness. T h e skin, like the eye, is the m i r r o r of the b o d i l y health, if w e o n l y k n o w h o w to see the i m a g e clearly. Its firmness, its elasticity, its s m o o t h n e s s , its m o i s t u r e , its o d o r , its color, its w a r m t h , all are full of m e a n i n g . P h y s i c i a n s often read the c o m p l a i n t in the c o u n t e n a n c e of the patient, before his m o u t h h a s uttered it. W e h a v e in observation n o t o n l y the facial c o u n ­t e n a n c e b u t the e x p r e s s i o n of the w h o l e b o d y . H o w m u c h , then, s h o u l d Ave rightly j u d g e of the i n n e r m a n ! T h e delicate tint seen o n the skin of the w o m a n w h o h a s exer­cised in the o p e n air, until e v e r y tissue p r o c l a i m s h e r the t y p e of health, is a & superior to the rusty c o v e r i n g of the dyspeptic h o u s e plant, as that is superior to the hide of a p a c h y d e r m . L o c a l diseases m a y d e f o r m the skin, b u t the indications of g e n e r a l health will b e f o u n d , if it exists.

T h e f o l l o w i n g table will present in c o m p a c t f o r m s o m e of the m o r e p r o m i n e n t points o b s e r v e d b y inspection :

GENERAL ASPECT.

Aspect of chest.

f Flat. | Round.

\ Bilateral asymmetry. I Sternum depressed. L Pectoral muscles.

Front View. <

" legs. Knock-knees . Muscles.

(i) Form. - neck. Sterno-mastoid. Lateral muscles.

Poise of head. " thorax. " loins and belly. " hips.

Rear View. - Height of acromions. Line of spinous processes. Scapulae.

v Pelvic crests.

76 Examination by Inspection and Palpation.

r U n d u l y t h i n . { | ^ h / s P f c t - } Atrophy.

(2) Nutrition.

(3) The Skin. -

fat.

Eruptions.

Cicatrices. -

Evenly distributed and firm. Unevenly " and soft. Fatty degeneration.

Acne, furuncles, etc. Eczema. Psoriasis.

( Circinatus. Tinea. •< Versicolor.

( Tricophytosis cruris. Ulcerations. Erysipelas.

f Bruises. ™ .. j Burns. Traumatisms. < ^ u t g

L Lacerations. Carbuncles, variola, etc.

Abscesses. \ * ™

Tumors . -< l 1

1 ( Comedones.

Sebaceous. •< Seborrhcea. ( Sebaceous cysts.

C Ichthyosis. Hypertrophy. •< Goitre.

( Condylomata, callus, etc. C Chicken breast.

Malformation. •< Retained testis. ( Funnel chest, etc.

( Varicocele. Cysts. •< Hydrocele.

( Abscess .

Lentigo. Chloasma. Jaundice.

Discolorations. -{ Erythema. Purpura. Cyanosis. Bruises.

C H A P T E R V I .

PALPATION.

T h e u s e of the sense of t o u c h , or palpation, is of great i m p o r t a n c e in locating t u m o r s a n d d e t e r m i n i n g chest m o v e m e n t s , viz : f r e q u e n c y of respiration, v o c a l fremitus, ronchi, frictions, etc. B y the e y e y o u c a n o n l y imperfectly judge,of size a n d consistency. A n a r m m a y b e large, b u t , if soft a n d flabby, it d o e s n o t indicate health o r strength ; w h i l e if it m e e t s o u r h a n d w i t h a p r o p e r r e s i s t a n c e — n o t too h a r d n o r too s o f t — w e k n o w that it is c a p a b l e of g o o d things, b e it large or small. P a l p a t i o n e n a b l e s u s to s a y h o w m u c h fatty tissue underlies the skin, a n d h o w firm the m u s c l e is u n d e r the fat. It is a m i s t a k e to set e v e r y p e r s o n w i t h a b u n d a n t a d i p o s e tissue in the list of " m u s c l e s u n d e ­veloped." N o r is fat a s u b s t a n c e of n o w o r t h to the physical e c o n o m y a n d to b e avoided. I n certain quanti­ties it is of the greatest a d v a n t a g e to health, a n d is a n indication of h i g h nutrition. It is so m u c h physiological capital stored u p , a n d is so located as to p r e v e n t loss of heat b y radiation, especially o v e r the m o r e sensitive o r g a n s , a n d therefore saves the e n e r g y that w o u l d b e lost in heat. T h i s is nature's w a y of protecting h e r children f r o m the increased severities of the s e a s o n ; for, as a u t u m n b r i n g s p r e s a g e s of w i n t e r b y h e r cooler nights, e v e r y a n i m a l , in health, g r o w s fat, a n d those that are e x p o s e d to c o n t i n u e d l o w t e m p e r a t u r e s , like w h a l e s , seals, bears, etc., lay u p e n o r m o u s stores of it u n d e r n e a t h the skin, w h e r e it will d o the m o s t g o o d , a n d o v e r the a b d o m i n a l o r g a n s a n d heart. If the s u p p l y of f o o d is cut off, the fat is c o n s u m e d to p r o ­vide vital force for l o n g p e r i o d s of time. T h e s a m e is true of m a n , b u t to a less extent. A s civilization h a s relieved

78 Palpation.

h i m of m a n y of the exigencies of nature, it h a s m o d i f i e d his r e q u i r e m e n t s , restricting t h e m in s o m e directions, a n d e n l a r g i n g t h e m in others. T h e m o d e r n civilized m a n n e e d s less fat t h a n the E s q u i m a u x , b e c a u s e h e h a s a m i l d e r climate a n d better facilities for h e a t i n g his h o u s e , b u t h e n e e d s s o m e fat to p r e v e n t the irritation of the n e r v o u s tissues f r o m the a d j u s t m e n t s of h e a t p r o d u c t i o n that are s o rapid in a w e l l - b a l a n c e d b o d y , w h e n w e p a s s f r o m a cold to a w a r m a t m o s p h e r e , a n d the reverse. T h i s strain is t h r o w n o n the i n v o l u n t a r y or s y m p a t h e t i c n e r v o u s sys­t e m , a n d this is the part that b r e a k s d o w n in the so-called " n e r v o u s prostration," or " n e u r a s t h e n i a , " w h i c h is so c o m m o n . N o t that lack of fat stands in causative relation to this disease, b u t that o n e s o u r c e of strain is f o u n d here. S u c h p e r s o n s b e a r the cold b a d l y a n d seek w a r m t h ; their t r e a t m e n t is w a r m t h a n d nutrition. T h e a r g u m e n t , then, is that a fair a m o u n t of fat is c o n d u c i v e to health of the n e r v o u s system. T h e s a m e m a y b e said of all the other o r g a n s . T h e lean m a n h a s n o extra physiological resource to fall b a c k u p o n , if irregularities are forced u p o n h i m , either in the w a y of lessened f o o d s u p p l y , o r sleep, or greater d e m a n d o n his e n e r g y , either physical or m e n t a l , a n d his c o m f o r t a n d health s o o n suffer.

B y palpation w e m a y also j u d g e of the t e m p e r a t u r e a n d m o i s t u r e of the skin, a n d t h u s estimate its activity in ex­cretion. A healthy skin s h o u l d b e firm a n d velvety, e v e n in texture a n d activity, slightly m o i s t u n d e r o r d i n a r y cir­c u m s t a n c e s b u t n o t w e t , c o l o r e d a delicate s h a d e of p i n k , w i t h o u t b e i n g flushed or h a v i n g dilated capillary vessels, as will b e f o u n d c o m m o n in the clavicular or scapular region. If the skin is h o t a n d flushed, it indicates the p r e s e n c e of fever, o r a local d i s t u r b a n c e of circulation, d u e to d e r a n g e d n e r v e activity. If the skin b e dry, a n d t e n d s to f o r m scales, the superficial circulation is insufficient, a n d b a d digestion is a c o m m o n a c c o m p a n i m e n t . F r e e exercise, s h o w e r b a t h i n g , m a s s a g e a n d friction will set t h i n g s to rights if persistently e m p l o y e d , u n l e s s the skin

Palpation. 79

b e affected b y ichthyosis, w h i c h " is a congenital, chronic, h y p e r t r o p h i c disease," a n d h e n c e will b e b u t little b e n e ­fitted. P r o f u s e perspiration is f o u n d frequently, a n d s e e m s injurious o n l y in p r o l o n g i n g b r o n c h i a l i n f l a m m a ­tions a n d g e n e r a l catarrhal conditions, b y k e e p i n g the clothing d a m p a large part of the time. T h e r e is also a n increased liability to Bright's disease f r o m h i g h c o n c e n t r a ­tion of u r i n e a n d chilling of the surface o n slight e x p o s u r e .

H y p e r i d r o s i s will b e f a v o r a b l y influenced b y active exercise, as the circulatory s y s t e m will at that t i m e b e depleted b y the free s w e a t i n g , a n d will give u p less m o i s t ­u r e in a state of rest. A f t e r exercise the d a m p clothes are r e m o v e d , the s w e a t is w a s h e d off in the s h o w e r bath, a n d the skin is dried b y p r o p e r m a s s a g e , leaving slight liability to " c o l d s . " L o c a l hyperidrosis m a y seriously i m p a i r the health b y k e e p i n g the feet d a m p a n d cold a n d t h u s i n d u c e catarrhal, p n e u m o n i c , a n d r h e u m a t i c conditions. M e d i c a l advice is to b e r e c o m m e n d e d in s u c h cases, if h y g i e n i c p r e c a u t i o n s — s u c h as cold baths, frequent c h a n g e of cloth­ing, sensible s h o e s w i t h cloth tops, p r o p e r diet a n d regular e x e r c i s e — d o n o t avail. A t t i m e s the u n d e r a n d i n n e r sur­faces of the toes a n d the outside m a r g i n of the foot f r o m the little toe b a c k to the instep will a p p e a r w h i t e a n d s w o l l e n in these cases. T h i s condition closely r e s e m b l e s large blisters f r o m scalds, b u t is o n l y a w a t e r - s o a k e d , " parboiled," state of the e p i d e r m a l layer, like that seen o n the h a n d s of w a s h e r - w o m e n after t h e y h a v e b e e n in h o t s o a p - s u d s for a half h o u r . T h e a d v a n t a g e of a cloth-top s h o e in these cases is a p p a r e n t w h e n w e think of the c o m ­parative ease w i t h w h i c h m o i s t u r e passes t h r o u g h w o o l e n fabrics as c o m p a r e d w i t h difficulty of e v a p o r a t i o n t h r o u g h leather.

A condition of anidrosis, or t o o scanty perspiration is frequent w i t h o u t evident i m p a i r m e n t of health. T h e skin is apt to get v e r y d r y a n d harsh, especially in cold w e a t h e r , a n d e c z e m a of the h a n d s result. In m a n y of these cases there is n o g e n e r a l s w e a t i n g , e v e n in e x t r e m e l y hot w e a t h e r , a n d perspiration is n o t c o p i o u s .

So Palpation.

It m a y b e w e l l to e x p l a i n that " perspiration " is the t e r m applied to the insensible e x u d a t i o n f r o m the s w e a t g l a n d s that is e v a p o r a t e d as fast as secreted, w h i l e " s w e a t ­i n g " is the appreciable collection of this e x u d a t i o n in d r o p s of greater or less a b u n d a n c e . (See Foster's P h y s i ­o l o g y ) .

I n addition to w h a t w e learn of the i n t e g u m e n t a n d m u s c l e b y palpation, w e detect b y it certain m o v e m e n t s that characterize health or disease. If w e place the h a n d s firmly o n the walls of the chest, letting the fingers press the intercostal regions, there will b e felt a m o v e m e n t of the chest o n e a c h inspiration a n d expiration, if respiration b e n o r m a l . A n y failure in e x p a n s i o n is noticed if there b e interference w i t h the chest action, f r o m m u s c u l a r or m e c h a n i c a l cause, that is unilateral. T h e r e s h o u l d b e bilateral s y m m e t r y of m o v e m e n t , b u t this m a y b e h i n d e r e d b y m u s c u l a r soreness f r o m r h e u m a t i s m , neuralgia, t r a u m a t ­ism, etc.; paresis of a m u s c l e , o r g r o u p of m u s c l e s ; intra­pleural effusions ; n e w g r o w t h s ; o r b y solidification of the l u n g o r a n y considerable part of it. M a l f o r m a t i o n s m a y also interfere w i t h bilateral s y m m e t r y of m o v e m e n t .

If the subject b e a s k e d to repeat s o m e w o r d s u c h as " ninety-nine," or to c o u n t aloud, o n e , t w o , three, w h i l e the h a n d s are o n the chest, as a b o v e described, a peculiar vibration will b e felt, w h i c h is k n o w n as the " v o c a l fremitus." T h i s thrill, o r vibration, is m u c h m o r e p r o m i ­n e n t in p e r s o n s w i t h thin chest w a l l s a n d l o w pitched voices, t h a n w h e r e the w a l l is thickly p a d d e d w i t h fat, a n d the voice in h i g h k e y , o n the s a m e principle that the l o w b a s s strings of a p i a n o , w h e n struck, i m p a r t vibration to solid articles in the r o o m in a n appreciable d e g r e e ; w h i l e the h i g h n o t e s h a v e a less perceptible effect. T h e " v o c a l f r e m i t u s " is s o m e w h a t plainer o n the right side, o n a c c o u n t of the larger size of the right b r o n c h i a l tube. A fremitus m a y b e c a u s e d b y other sources of vibration t h a n the voice, as b y a c o u g h , b y m u c o u s rales, b y pleuritic friction, a n d the s p l a s h i n g of liquid, w h e n the chest contains liquid a n d air.

Palpation, 81

T h e " ronchial fremitus," d u e to m u c o u s in the b r o n c h i a l tubes, is frequently v e r y m a r k e d in bronchitis, a n d felt b y the subject himself ; b u t the area is c i r c u m s c r i b e d in m o s t cases. T h e friction fremitus of pleuritic i n f l a m m a t i o n is faint a n d local in character. I n general, those diseases that p r o d u c e solidification of the air cells of the l u n g s , w i t h o u t obstruction of the b r o n c h i a l tubes, increase the vocal f r e m i t u s ; w h i l e those that interpose m o r e air, like e m p h y s e m a , decrease it. L i q u i d s d i m i n i s h or c h e c k it altogether. T h e scapulae interfere w i t h the f r e m i t u s as d o e s the liver, the latter n o t c o n v e y i n g the vibrations, a n d , if pressing firmly against it, p r e v e n t i n g the chest w a l l f r o m d o i n g so b e l o w the m a r g i n of the l u n g .

P a l p a t i o n is of great service in the diagnosis of t u m o r s . T h e fingers are to b e p l a c e d o n o n e side of the swelling, a n d gentle b u t firm p r e s s u r e m a d e o n the opposite side of it w i t h the fingers of the other h a n d , b y a q u i c k m o v e m e n t of the wrist. If the c o n t e n t s of the t u m o r are liquid a b u l g i n g will b e felt u n d e r the fingers, c a u s e d b y the dis­p l a c e m e n t of the fluid, that passes as a w a v e t h r o u g h the t u m o r , d istending the sac at o n e part to a c c o m m o d a t e the liquid d e p r e s s e d at another. T h i s peculiar w a v e l i k e m o t i o n , called fluctuation, c a n b e w e l l studied b y e x a m i ­nation of a r u b b e r w a t e r b a g u n d e r varied thickness of covering, h a v i n g the b a g distended hard, a n d a g a i n w i t h less w a t e r in it, b u t n o air. In cases of ascites the w a v e i m p u l s e is readily felt across the a b d o m i n a l c a v i t y — a light tap w i t h the e n d of the finger against the side b e i n g suffi­cient to start the w a v e . A close estimate of the a m o u n t of fluid c a n b e f o r m e d in this w a y , as the w a v e s i m p l y c o n ­tinues t h r o u g h the liquid part, a n d is n o t p r o p a g a t e d b y the intestines o r g e n e r a l tissues.

T h e a p e x beat of the heart m a y also b e located b y p a l p a ­tion in a large m a j o r i t y of cases. In m a n y subjects t h e chest w a l l is thin, a n d the heart action strong, so that inspection c a n d e t e r m i n e the a p e x i m p u l s e w i t h tolerable precision ; b u t if it fail to fall in a n intercostal space, o r

82 Palpation.

the chest w a l l b e thick, o r the heart-beat feeble, palpation m u s t b e u s e d . I n this c o n n e c t i o n it m a y b e said, that for this p u r p o s e the ear m a y b e the o r g a n of tactile, as well as of a u d i t o r y i m p r e s s i o n s .

T h e character of acute o r c h r o n i c i n f l a m m a t o r y action c a n often b e d e t e r m i n e d b y palpation, as in swellings a b o u t joints.

C H A P T E R V I I .

PERCUSSION AND AUSCULTATION.

T h e condition of the internal o r g a n s is d e t e r m i n e d in several w a y s . A m o n g the m o s t frequently e m p l o y e d , b e ­c a u s e m o s t satisfactory in results, is b y listening to the passive a n d active s o u n d s so far as t h e y c a n b e secured to the ear. T h e passive s o u n d s are obtained b y percussion, o r striking the surface o v e r a n o r g a n , either w i t h the tips of the fingers or a r u b b e r mallet directly, or b y laying a solid substance, o r the finger, firmly against the surface, a n d striking this. T h e first m e t h o d is called i m m e d i a t e percussion, a n d is s e l d o m used, e x c e p t for hard, b o n y sur­faces. T h e s e c o n d is called m e d i a t e percussion, a n d is applicable to all parts.

T h e s o u n d s o b t a i n e d b y p e r c u s s i o n v a r y in quality, in­tensity a n d pitch. T h e quality of the s o u n d o b t a i n e d o v e r the v a r i o u s o r g a n s c a n o n l y b e r u d e l y described, b u t prac­tice will g i v e skill in distinguishing it. T h e intensity will v a r y a c c o r d i n g to the s u r r o u n d i n g m e d i u m , a n d the pitch will v a r y largely t h r o u g h c h a n g e in the o r g a n s that p r o ­d u c e the s o u n d .

T h e r e g i o n of the b o d y m o s t frequently e x a m i n e d b y percussion is the t h o r a x . T h e a b d o m e n , especially in c o n ­ditions of disease, is often e x a m i n e d b y this m e t h o d (in c o n n e c t i o n w i t h palpation), b u t w i t h o u t the satisfactory a c c u r a c y that is to b e s e c u r e d o v e r the chest, a l t h o u g h it e n a b l e s o n e to distinguish the outline of solid t u m o r s of hepatic, splenic or intestinal origin a n d the area c o v e r e d b y cystic e n l a r g e m e n t s .

T h e m e t h o d of e m p l o y i n g p e r c u s s i o n is generally w i t h the fingers, a l t h o u g h , if m a n y e x a m i n a t i o n s are m a d e daily,

84 Percussion and Auscultation.

it is well to u s e a p l e x i m e t e r a n d p e r c u s s o r (as s h o w n in cut). It s e e m s to the writer that the appreciation of vibrations b y the ringer is of considerable i m p o r t a n c e in assisting the ear, a n d , therefore, that digital p e r c u s s i o n is better t h a n instrumental. T h e act is easily p e r f o r m e d b y laying the ringers of o n e h a n d firmly o v e r the part to b e e x a m i n e d , a n d , w i t h the tips of the first t w o or three fingers of the other h a n d , or the m i d d l e finger alone, striking against o n e of the fingers i m p o s e d o n the part w i t h a firm b l o w , a c c o m ­plished b y a wrist m o v e m e n t of flexion. T h e force of the b l o w m a y b e varied to perceive the difference Jin r e s o n a n c e ,

Fig. 19.

Showing the normal outlines and positions of the heart, lungs, liver, and stomach. The light dotted line shows the outline of the lung at inspiration b. d. and at expiration f. h., and also the lobar divisions at i. k. 1. The heavy continuous line shows the outline of the liver. The light line shows the location and divisions of the heart. The heavy broken line indicates the outline of the stomach. Luschka.

Percussion and Auscultation.

quality, a n d pitch of the s o u n d u n d e r the n e w conditions, a s this m a y h a v e a n i m p o r t a n t b e a r i n g o n o u r d e t e r m i n a ­tion of the case. Forcible p e r c u s s i o n sets in vibration d e e p e r tissues, a n d , if their condition varies greatly f r o m the superficial tissues, there will b e a m i x e d quality to the s o u n d that aids in identifying healthy activity, o r disease, o r a b n o r m a l position. F o r instance, if w e b e g i n at the right clavicle a n d p e r c u s s d o w n w a r d , until w e r e a c h the l o w e r e d g e of the liver, w e shall p a s s o v e r l u n g tissue at first w h e r e the s o u n d elicited u n d e r m i l d or forcible per­cussion is essentially the s a m e ; l o w e r d o w n w e r e a c h a p a r t of the l u n g that contains the large b r o n c h i a l t u b e s w h e n the pitch is l o w e r a n d r e s o n a n c e g o o d , t h e n still l o w e r to a part that is b a c k e d b y the u p p e r c o n v e x i t y of the liver w i t h o n l y the solid d i a p h r a g m a n d l u n g b e t w e e n it a n d the chest wall. H e r e u n d e r m i l d per­cussion the r e s o n a n c e is u n i m p a i r e d ; b u t u n d e r a firmer stroke the r e s o n a n c e is f o u n d to lose its clearness a n d b e c o m e duller, a n d this dullness increases as w e p e r c u s s to the v e r y e d g e of the l u n g , w h e r e the s o u n d is flat. S e e F i g 20. T h e t e r m "flat," as applied to percussion s o u n d s , is s u c h a quality of t o n e as is p r o d u c e d w h e n a n o r g a n c o n ­taining n o free g a s e o u s e l e m e n t is set in vibration b y a n i m p a c t . T h e w o r d " dullness " is c o m p a r a t i v e o n l y a n d d e n o t e s less r e s o n a n c e t h a n s h o u l d b e e x p e c t e d u n d e r n o r m a l conditions.

In u s i n g the p l e x i m e t e r , w e press it firmly against the surface, a n d strike u p o n it w i t h the r u b b e r percussor. T h e r e s o n a n c e of the i n s t r u m e n t is slightly c o n f u s i n g to the p e r s o n w h o h a s b e e n a c c u s t o m e d o n l y to digital percussion, b u t practice s o o n e n a b l e s u s to eliminate this s o u n d , as o n e d o e s the s o u n d s of m e r c a n t i l e life w h i l e listening to a voice in the t e l e p h o n e . Practice a l o n e will g i v e skill in the d e t e r m i n a t i o n of n o r m a l o r a b n o r m a l s o u n d s . It m a y b e r e m e m b e r e d that for a n y individual the r e s o n a n c e of the chest is fairly constant in health, b u t that of the a b d o m e n varies continually ; again, the r e s o n a n c e of the a b d o m e n

86 Percussion and Auscultation.

is a l w a y s t y m p a n i t i c or flat, w h i l e that of the h e a l t h y chest is neither. In m a k i n g a physical e x a m i n a t i o n , p e r c u s s i o n of the a b d o m e n is useless, unless there b e a history of a b ­d o m i n a l disorder, or inspection a n d palpation indicate s o m e t h i n g a b n o r m a l .

F o r c o n v e n i e n c e in describing a n y location o n the anterior aspect of the t r u n k there h a s b e e n a l o n g - c o n t i n u e d c u s t o m of dividing the b o d y into a right a n d left half b y a m e d i a n p e r p e n d i c u l a r line a n d t h e n d e s i g n a t i n g the portion o n either side a b o v e the clavicle as the supraclavicular region, right or left. T h e portion b e l o w the clavicle as far d o w n as the third rib is called the infraclavicular r e g i o n a n d t h e part c o v e r e d b y the clavicle is called the subclavian region. T h e m a m m a r y r e g i o n e x t e n d s f r o m the third rib to the sixth. B e l o w the sixth rib is the i n f r a m a m m a r y region, e x t e n d i n g to the m a r g i n s of the ribs. T h e l o w e r sternal r e g i o n e x t e n d s f r o m the e n s i f o r m cartilage to t h e third costal cartilage, a n d f r o m this p o i n t to the sternal n o t c h is called the u p p e r sternal region. F r o m the t o p of the ster-m i n e to the cricoid cartilage is the suprasternal region. T h e limits o n the right a n d left are p e r p e n d i c u l a r lines d r a w n f r o m the tips of the a c r o m i o n s . A t the side the axillary r e g i o n e x t e n d s f r o m the s u m m i t of the axilla to the sixth rib, a n d b e l o w this is the infra-axillary space, e x ­t e n d i n g to the b o t t o m of the chest.

T h e a b d o m e n is divided into n i n e r e g i o n s for p u r p o s e s of description, as f o l l o w s : D r a w a horizontal line across at the level of the n a r r o w e s t part of the waist a n d a s e c o n d line at the level of the iliac crests. D r a w a p e r p e n d i c u l a r line f r o m the m i d d l e of P o u p a r t ' s l i g a m e n t , o n e a c h side, e x t e n d i n g u p to the chest. O n the outside of these lines will b e f o u n d , a b o v e , the right a n d left h y p o c h o n d r i a c re­g i o n s e x t e n d i n g d o w n to the first horizontal line. B e t w e e n the horizontal lines will b e the l u m b a r r e g i o n s a n d b e l o w these the iliac r e g i o n s b o u n d e d b y P o u p a r t ' s l i g a m e n t . T h e central portion is called the umbilical region. A b o v e this is the epigastric a n d b e l o w the h y p o g a s t r i c regions.

Percussion and Auscultation. 8?

I n e x a m i n i n g a subject b y p e r c u s s i o n it is w e l l to b e g i n o n the supra-clavicular r e g i o n a n d p e r c u s s lightly a n d t h e n forcibly on each side, a n d press the fingers w e l l against the intercostal m u s c l e rather t h a n o v e r the ribs, w h i l e p r o c e e d ­i n g to the l o w e r e d g e of the c h e s t ; t h e n p u r c u s s the right axillary r e g i o n ; t h e n the posterior thoracic, f r o m t o p to b o t t o m , striking o n alternate sides in o r d e r to discover a n y difference in s o u n d that m a y exist, a n d t h e n the left axil­lary space. T h e r e s h o u l d b e e q u a l r e s o n a n c e of s o u n d o n e a c h side b e h i n d , u n l e s s there b e e x t r e m e u n e v e n n e s s of m u s c u l a r d e v e l o p m e n t , w h i c h will slightly dull the s o u n d o n the s t r o n g side ; b u t in front the location of the heart

Fig. 20. Showing the areas of percussion dullness and flatness over heart,

liver, and stomach, i. k. line of beginning dullness around the heart, a. b. d. c. area of flat sound or without pulmonary resonance. p. q. line of dull area over the liver, e. c. m. I. area of flatness over liver. m. n. 0. area of varying resonance over the stomach. Wei l .

Percussion and Auscultation.

to the left of the s t e r n u m , a n d the liver to the right of it, a n d l o w e r d o w n gives a w i d e variation in s o u n d for s i m ­ilar locations o n the t w o sides. O n the right w e usually find the p o i n t of liver dullness b e g i n n i n g a b o u t 2 c m . b e ­l o w the nipple, w h i l e the line of flatness is a b o u t 6 c m .

b e l o w i t — t h e flat area e x t e n d i n g a b o u t the b r e a d t h of the h a n d o r to the e d g e of the ribs, a n d a r o u n d to the spine. S e e Fig. 20. O n the left the area of heart dullness b e g i n s at a b o u t the third intercostal space, n e a r the s t e r n u m a n d e x t e n d s o u t to a point n e a r l y a n i n c h a b o v e the nipple, a n d d o w n for 3 c m . , s h a d i n g off into the flat heart a r e a — t h a t

Fig. 21.

Showing the positions of the kidneys, j . k., and spleen, h ; margin of liver, /. The dotted line, e. f. g., shows the lobar divisions of the lungs. Scheube.

\

Percussion and A uscultation. <$p

is circular a b o v e a b o u t 5 c m . in d i a m e t e r a n d h a v i n g its center at a p o i n t half w a y b e t w e e n the nipple a n d the center of the e n d of the s t e r n u m , a n d r e a c h i n g d o w n ­w a r d to the sixth rib, w h e r e it is m e r g e d in the s t o m a c h i c r e s o n a n c e . S e e fig. 20.

T h e line of s t o m a c h dullness is of variable location a n d m a y n o t b e perceptible at all.

T h e p e r c u s s i o n s o u n d of the a b d o m e n is t y m p a n i t i c o r flat, a c c o r d i n g to the existence of g a s in the intestinal canal. In cases of ascites, a peculiar w a v e i m p u l s e is started b y i m m e d i a t e p e r c u s s i o n that is readily felt b y the other h a n d h e l d against the a b d o m i n a l wall opposite the point of i m ­pact. T h e s a m e is true of cystic t u m o r s in other locations, w h e r e the walls are protected o n l y b y soft tissues, as in effusion into the synovial cavity of the k n e e a n d other joints, as a result of i n f l a m m a t i o n o r h e m o r r h a g e . T h i s w a v e i m p u l s e c o r r e s p o n d s to the fluctuation of palpation. S e e p a g e 81.

T h e area of liver dullness s h o u l d n o t e x t e n d b e l o w the l o w e r e d g e of the ribs, o n the right side, w h i l e the spleen is f o u n d well a r o u n d to the left side, e x t e n d i n g f r o m the line of dullness at n i n t h rib, d o w n w a r d a b o u t eight cm., the b r e a d t h b e i n g a b o u t half this distance. S e e fig. 21. In o r d i n a r y cases the spleen is n o t to b e s o u g h t , as its f u n c ­tion is n o t fully k n o w n , a n d its r e c o g n i z e d a b n o r m a l i t i e s are confined to malarial a n d c o n g e s t i v e fevers, w i t h oc­casional m a l i g n a n t g r o w t h s . T h e l e n g t h of the t h o r a x will b e f o u n d to v a r y greatly in different p e o p l e , a n d , w h e r e the ribs c o m e w e l l t o w a r d the u m b i l i c u s , the liver s h o u l d h a r d l y reach to the l o w e r e d g e of the ribs, e x c e p t in front, w h i l e in the cases of short chest it m a y e x t e n d five or m o r e c. m . b e l o w the free m a r g i n . T h e left lobe e x t e n d s across the m e d i a n line for a b o u t six o r eight c. m., (fig. 19) w h e r e its limits are n o t readily discovered b y percussion, o n a c c o u n t of the area of heart dullness. A t the right side the liver e x t e n d s d o w n to the tenth intercostal space, a n d b e h i n d it reaches to the last rib. S e e fig. 21.

7

9° Percussion and Auscultation.

It s h o u l d b e r e m e m b e r e d that the l o w e r limits of the liver m a y v a r y greatly w i t h o u t its b e i n g a n indication of e n l a r g e m e n t or disease. In e x a m i n i n g this o r g a n , there­fore, it is well, if a n y a p p a r e n t m a l f o r m a t i o n exists, to d e t e r m i n e b y percussion, a n d m a r k w i t h a flesh pencil the outline of the o r g a n . T h e exact m e a s u r e m e n t s c a n t h e n b e m a d e a n d m a l p o s i t i o n differentiated f r o m h y p e r t r o p h y .

S o m e of the m o r e c o m m o n c a u s e s of m a l p o s i t i o n are tight lacing, pleuritic effusion, c o n g e n i t a l a n d t r a u m a t i c m a l f o r m a t i o n s , pericarditis w i t h effusion, a n d certain ab­d o m i n a l t u m o r s . F o r c o n v e n i e n c e in treating the n o r m a l positions of certain o r g a n s , the f o l l o w i n g points s h o u l d b e fixed in m i n d :

T h e sternal n o t c h is o n a level w i t h the t o p of the s e c o n d dorsal vertebra o r tip of s e v e n t h cervical spine.

T h e spine of the s c a p u l a is o n a level w i t h the third d o r ­sal spine.

T h e l o w e r a n g l e of the s c a p u l a is o n a level w i t h the s e v e n t h dorsal spine.

T h e b a s e of the heart lies at the fourth dorsal spine. T h e a p e x of the heart lies at the level of the eighth d o r ­

sal spine. T h e a p e x of the l u n g lies opposite the s e v e n t h cervical

spine a n d vertebra, a n d f r o m t w o to f o u r c m . a b o v e the t o p of the s t e r n u m .

T h e b a s e of the l u n g is o n the level of the tenth dorsal spine.

T h e spleen lies o n the level of the n i n t h a n d eleventh dorsal spines.

T h e u p p e r c o n v e x i t y of the liver lies o n a level w i t h the eighth dorsal spine o r slightly a b o v e the l o w e r e n d of the s t e r n u m .

T h e n i p p l e usually c o v e r s the f o u r t h intercostal s p a c e at level of sixth s p i n o u s process.

T h e s e locations are all referred to the s p i n o u s processes of the vertebra as fixed points that c a n a l w a y s b e f o u n d . If w e r u b the ball of the t h u m b firmly d o w n the f u r r o w

Percussion and Auscultation.

b e t w e e n the erector spinae m u s c l e s , the tips of the s p i n o u s p r o c e s s e s will s h o w as p i n k spots o n the skin. T h i s m e t h o d is r e c o m m e n d e d b y D r . H o l d e n to d e t e r m i n e the existence of lateral curvatures.

In auscultation w e h a v e the m e t h o d of m o s t precise k n o w l e d g e in diagnosis. B y other m e t h o d s of e x a m i n a ­tion w e m a y learn that there is s o m e t h i n g w r o n g , b u t the ear is the s u p r e m e court to decide the case a n d tell w h a t that " s o m e t h i n g " is. F o r p u r p o s e s of auscultation sev­eral i n s t r u m e n t s h a v e b e e n devised, b u t n o n e better for g e n e r a l u s e t h a n the b i n a u r a l stethoscope of D r . C a m m a n (see F i g . 8), w i t h its i m p r o v e m e n t s for clasping into the ears, w i t h o u t u n d u e pressure. T h e unassisted ear is able to d o all that is required in m o s t cases, as the s o u n d s are equally distinct, b u t the ear c a n n o t b e readily applied to all parts of the chest, a n d to a t t e m p t it in s o m e cases w o u l d b e to affect other parts of the s e n s o r i u m w i t h m o r e p r o ­f o u n d salutations.

T h e stethoscope also e n a b l e s u s to localize s o u n d s closely b y m a k i n g a direct c o u r s e of travel for s o u n d - w a v e s . C o n ­sequently, it readily transmits t h o s e w a v e s that p a s s directly into its bell o r t u b e ; w h i l e those w a v e s that are n o t t h r o w n directly in, are either lost o r b e c o m e o b s c u r e , so that o u r attention is centered o n the s o u n d s p r o d u c e d directly b e ­neath. T h e p r e s s u r e of the aural tips closes the external m e a t u s of the ear, so that foreign s o u n d s are entirely eliminated.

T h e f o l l o w i n g points in the u s e of the i n s t r u m e n t s h o u l d b e b o r n e in m i n d :

1. A p p l y the i n s t r u m e n t to the ears so that the aural tips will p o i n t downward a n d inward, t h u s f o l l o w i n g the direc­tion of the m e a t u s of the ears.

2. H a v e just sufficient p r e s s u r e in the ears to h o l d the i n s t r u m e n t steady a n d m a k e the tips fit perfectly.

3. L e t n o foreign material t o u c h against the stethoscope at a n y part of it d u r i n g use, as friction-vibrations will b e set u p .

9 2 Percussion and A uscultation.

4. P r e s s the bell firmly o v e r the spot to b e auscultated, so that it fits the i n t e g u m e n t ^perfectly all a r o u n d . If the surface is u n e v e n , the soft r u b b e r bell s h o u l d b e used.

5. D o n o t let the fingers m o v e o n the i n s t r u m e n t w h i l e h o l d i n g it in place.

6. A l w a y s a p p l y directly to the skin, as n o t h i n g satisfac­t o r y c a n b e h e a r d t h r o u g h e v e n a thin layer of cloth. (See p a g e 30.)

7. T h e e x a m i n e r s h o u l d k e e p his o w n h e a d as nearly erect as possible to a v o i d cerebral c o n g e s t i o n f r o m v e n o u s constriction.

W h e r e the n a k e d ear is u s e d , a soft cloth c a n b e inter­p o s e d b e t w e e n it a n d the subject.

I n listening to the s o u n d s of the mitral a n d tricuspid v a l v e s w i t h a stethoscope, it is well, s h o u l d there b e d o u b t in diagnosis, to place a thin cloth, like a n a p k i n , o n the chest, a n d auscultate t h r o u g h it. T h e o n l y s o u n d h e a r d t h r o u g h this will b e the valvular c l i c k — t h e first s o u n d b e c o m i n g short a n d u n c o m p l i c a t e d like the s e c o n d s o u n d .

I n auscultation c o n t i n u e d practice m u s t b e g i v e n to l e a r n i n g n o r m a l s o u n d s a n d their relations. If the e x a m ­iner k n o w s e v e r y h e a l t h y s o u n d w i t h its variations, h e will instantly r e c o g n i z e a n a b n o r m a l o n e , e v e n if h e is n o t able to clearly state o r e v e n u n d e r s t a n d the existing lesion. S o m e s o u n d s are so c o m p l i c a t e d as to d e f y e x p e r i e n c e d s u r g e o n s in r e a d i n g their significance.

T h e f o l l o w i n g points are to b e studied : (a) M u s c l e - s o u n d s , b y p l a c i n g the stethoscope o v e r a

m u s c l e like the biceps, d u r i n g its contraction a n d relaxa­tion.

(b) H e a r t - s o u n d s , b y s t u d y i n g the s o u n d at e a c h location in the precordial r e g i o n a n d a l o n g the large arteries.

(c) L u n g - s o u n d s , in e v e r y r e g i o n of the chest. (d) Intestinal-sounds, that are c a u s e d b y the g a s e s of

f e r m e n t a t i o n . (e) S u c c u s s i o n or splashing s o u n d s of fluid in the s t o m ­

a c h (or chest), w h i l e it contains free g a s .

Percussion and A uscultation. 93

(/) T h e " b r u i t " or h u m h e a r d in m a n y cases o v e r the large v e n o u s t r u n k s , especially of the n e c k a n d u p p e r chest, a n d o v e r a n e u r i s m a l sacs.

A m u s c l e s o u n d is of l o w pitch a n d vibratory q u a l i t y — a rapid t h r o b b i n g as it w e r e . Its character is represented in e x a g g e r a t e d f o r m b y m o i s t e n i n g the e n d of the t h u m b a n d t h e n r u b b i n g it a l o n g the surface of a w o o d e n table w i t h a fairly rapid m o v e m e n t . T h e t h u m b will j u m p a l o n g the surface g i v i n g a l o w vibration to the w o o d . T h i s m u s c l e s o u n d is the c a u s e of the peculiar, p r o l o n g e d , " b o o m i n g " s o u n d of the heart d u r i n g its contraction, a n d it modifies the v a l v e s o u n d of closing to s o m e e x t e n t ; therefore the directions o n p a g e 30 s h o u l d b e f o l l o w e d if there is a n a p p a r e n t systolic m u r m u r .

T h e valve s o u n d s are brief in duration, of h i g h pitch a n d clicking o r n o n - r e s o n a n t quality. T h e s e s o u n d s are c o n ­f u s e d m o r e or less b y the m u s c l e s o u n d , b y respiration s o u n d s a n d b y the vibrations of b l o o d currents b o t h n o r ­m a l a n d a b n o r m a l . T h e s e a b n o r m a l s o u n d s are g e n e r a l l y of b l o w i n g quality a n d are called m u r m u r s . T h e y will b e studied m o r e at l e n g t h in C h a p t e r V I I I . T h e s o u n d s of the n o r m a l heart m u s t b e patiently studied w i t h the stetho­s c o p e until its e v e r y peculiarity is familiar ; its r y t h m , its force, its v a r i o u s v a l v e s o u n d s , its points of clearest differ­entiation of c o m p l e x s o u n d s a n d its t r a n s m i s s i o n of s o u n d s , the relation of the p u l s e in v a r i o u s localities to heart i m ­pact, etc. It is o n l y b y a t h o r o u g h a c q u a i n t a n c e w i t h n o r ­m a l conditions that the a b n o r m a l c a n b e recognized.

T h e r e will b e f o u n d f r e q u e n t cases of arterial a n d v e n o u s m u r m u r s o r h u m m i n g s o u n d s that will b e likely to b e m i s t a k e n for heart m u r m u r s . T h e s e h a v e a location o v e r the larger b l o o d vessels a n d the s o u n d is c o n t i n u o u s rather t h a n intermittent, if of v e n o u s origin, a n d if arterial, the s o u n d is usually n o t h e a r d at the heart, b u t at s o m e p o i n t w h e r e a large t r u n k m a k e s a s h a r p t u r n as in the subclavian artery.* T h e v e n o u s m u r m u r m a y v a r y f r o m a l o w h u m

* N. Y . Med. R e c , Nov. 5,1887. " A n undescribed arterial murmur/ ' by H. H. Seelye, M.D.

94 Percussion and Auscultation.

to a whistling s o u n d . T h e j u g u l a r vein is the spot w h e r e the v e n o u s h u m is m o s t frequently heard, a n d in m a n y cases a h u m c a n b e p r o d u c e d b y a n u n e v e n pressure of the stethoscope, m a k i n g a slight constriction in the calibre of the vessel. T u r n i n g the face of the subject to o n e side will s o m e t i m e s p r o d u c e a h u m o n the opposite side. T h i s s o u n d h a s b e e n called b y s o m e writers a n a n a e m i c h u m , b u t its c a u s e c a n h a r d l y b e a s s i g n e d directly to the quality o r quantity of the blood. A n a e m i a m i g h t b e a factor in the p r o d u c t i o n of the s o u n d b y c a u s i n g a softening of the tissues s u p p o r t i n g the vessel, a n d the w a t e r y v e n o u s b l o o d m a y b e s o n o r o u s to a larger extent t h a n arterial b l o o d , a s t a u g h t b y W a l s h e , b u t the direct c a u s e m u s t b e the u n e v e n -n e s s of the calibre of vessels, t h r o u g h w h i c h b l o o d m u s t b e f l o w i n g at a s p e e d b e a r i n g s o m e relation to the size of their l u m e n a .

Arterial m u r m u r s m a y b e d u e to r o u g h n e s s of the i n n e r coat d u e to i n f l a m m a t i o n s o r vegetations, sacculations, or pressures. T h e s e c a u s e s w o u l d p r o d u c e systolic m u r m u r s that w o u l d b e loudest o v e r the site w h e r e t h e y are p r o d u c e d . F r o m similar c a u s e s m u r m u r s m a y b e p r o d u c e d in the cavity of the heart itself. A n o t h e r class of m u r m u r s is f o u n d in e x t r e m e l y n e r v o u s p e o p l e , excessive t o b a c c o users a n d over-trained athletes. It is d u e to irregular m u s c u l a r action of the heart, w i t h c o n s e q u e n t i m p e r f e c t closing of the valves, a n d is therefore systolic a n d h e a r d m o r e c o m m o n l y o v e r the b a s e of the heart. T h e s e m u r ­m u r s are n o t constant, a n d d o n o t frequently, if ever, exist w i t h b e n i g n h y p e r t r o p h y .

H e a r t m u r m u r s d u e to dilatation of the cavities f r o m a n a e m i a d o occur, a n d in t h o s e cases it is difficult to decide w h e t h e r there is aortic obstruction or a s i m p l e d y n a m i c m u r m u r . I n the first case, h o w e v e r , w e w o u l d find a p o w e r f u l heart i m p u l s e f r o m h y p e r t r o p h y , w h i l e in the s e c o n d there w o u l d b e a feeble i m p u l s e f r o m the i m p e r f e c t contractions. A t t i m e s the respiratory s o u n d s m a y c o n ­fuse the heart s o u n d s b y the air b e i n g d r i v e n o u t of a

Percussion and Auscultation. 95

p o r t i o n of the l u n g b y the heart i m p u l s e , g i v i n g rise to a s o u n d that m a y b e m i s t a k e n for a heart m u r m u r . T h i s s o u n d w o u l d b e systolic a n d n o t h e a r d at the a p e x .

It is well, t hen, in e x a m i n a t i o n , to a p p l y the stethoscope to the a p e x of the heart first a n d t h e n o v e r the base, listen­i n g carefully to the valvular s o u n d s a n d a s k i n g the subject to s u s p e n d respiration in expiration for a m o m e n t if a n y a b n o r m a l s o u n d is h e a r d . T h e n listen o v e r the carotid a n d s u b c l a v i a n arteries o n e a c h side. If a h u m m i n g s o u n d is h e a r d that c a n n o t b e u n d e r s t o o d , let the subject t a k e s o m e of the gentler strength tests, a n d after a slight accel­eration of the p u l s e listen again, a n d so p r o c e e d until h e u n d e r s t a n d s the case. T h e case m a y n o t b e o n e to b e d e t e r m i n e d in a f e w m i n u t e s or d a y s .

I n listening to the s o u n d s of the l u n g s w e m u s t also h a v e a fixed idea of the n o r m a l before e n d e a v o r i n g to s t u d y a b n o r m a l s o u n d s . I n perfect health the n o r m a l vesicular m u r m u r of the l u n g s varies w i t h i n quite w i d e limits of force, pitch, quality a n d duration, d u e to the difference in thickness of the chest w a l l a n d the activity of respiration in different individuals, b u t the g e n e r a l character of the s o u n d s r e m a i n s the s a m e .

T h i s s o u n d h a s b e e n likened to the faint rustling of d r y leaves o r straw, b u t the o n l y description that is of h e l p to a student, is the o n e that h e m a k e s to h i m s e l f b y c o n t i n u o u s u s e of the stethoscope a n d n a k e d ear applied to the chest.

T h e f o l l o w i n g points m a y b e b o r n e in m i n d as helpful in e x a m i n a t i o n :

ist. T h e m u r m u r is shorter in expiration t h a n inspira­tion, a n d in s o m e cases the m u r m u r is entirely s u s p e n d e d d u r i n g expiration.

2d. T h e m u r m u r is h a r s h e r o v e r the r e g i o n of the larger b r o n c h i a l tubes, b e c o m i n g m i l d e r as w e p a s s d o w n w a r d to the base.

3d. T h e heart s o u n d s will t e n d to c o n f u s e the l u n g s o u n d s in the front of the left l u n g , b u t o n l y in a f e w cases is it difficult to h e a r o n l y the s o u n d s y o u search for.

96 Percussion and Auscultation.

4th. T h e s o u n d s of bronchial b r e a t h i n g are h e a r d in simple, u n c o m p l i c a t e d f o r m , o v e r the trachea a n d u p p e r sternal region.

5th. the quality of bronchial respiration s o u n d is t u b u l a r a n d h a r s h ; the pitch is high.

6th. T h e expiration s o u n d is l o n g e r t h a n inspiration in the r e g i o n of p u r e b r o n c h i a l breathing.

7th. V e s i c u l a r o r fine respiratory m u r m u r is h e a r d to the l o w e r m a r g i n of the l u n g tissue.

8th. If the m u r m u r e n d s a b r u p t l y at a n y p o i n t a b o v e the natural b o r d e r of the l u n g , a n d the m u r m u r is n o r m a l , suspect a n effusion into the chest cavity.

9th. N o r m a l flatness m a y b e g i n as h i g h as the sixth rib o n the right side, a n d at the s e v e n t h o n the left.

T h e a b n o r m a l respiratory s o u n d s are called rales. T h e y are in g e n e r a l of the bronchial t y p e rather t h a n the vesicu­lar. T h e s o u n d s m a y b e d r y a n d r a s p i n g as w h e n the t u b e s are contracted b y a n i n f l a m m a t i o n at the initial stage o r a s p a s m of the m u s c u l a r fibres of their w a l l s or b y local pres­sure. T h e s o u n d s are called m o i s t w h e n the t u b e s are o b ­structed b y m o r e or less fluid. T h e s e rales m a y b e so l o u d as to o b s c u r e t h e vesicular m u r m u r .

T h e crepitant rale is a fine dry, crackling s o u n d , h e a r d in the last part of inspiration in p n e u m o n i a a n d phthisis, a n d h a s b e e n c o m p a r e d to " the s o u n d p r o d u c e d b y r u b b i n g a s m a l l w i s p of hair b e t w e e n the t h u m b a n d finger n e a r the ear," " p u l l i n g p o s t a g e s t a m p s apart," etc.

T h e subcrepitant rale is h e a r d in bronchitis, p n e u m o n i a , o e d e m a of the l u n g s , phthisis, etc. It is a fine, moist, b u b b l i n g s o u n d , h e a r d in b o t h inspiration a n d expiration.

C o a r s e b r o n c h i a l rales are h e a r d in bronchitis, phthisis, etc., a n d are c a u s e d b y m u c o u s interrupting the flow of air. T h e s e rales m a y b e so l o u d a s to b e h e a r d w i t h o u t a p p l y i n g the ear to the chest a n d if the m u c o u s is v e r y d r y a whist­ling s o u n d will b e p r o d u c e d .

G u r g l i n g rales are s o m e t i m e s h e a r d , especially if the subject is v e r y w e a k a n d c a n n o t e x p e l thin m u c o u s f r o m

Percussion and A uscultation. 97

the larger t u b e s or if there is a cavity in the l u n g f r o m t u b e r c u l a r d e g e n e r a t i o n .

A s i d e f r o m the respiratory s o u n d s the vocal r e s o n a n c e is of i m p o r t a n c e in d e t e r m i n i n g the c o n d i t i o n of the l u n g s .

i . — T h e laryngeal voice is h e a r d o v e r the trachea a n d large bronchial p a s s a g e s , w h i l e in the g e n e r a l area of the chest the s o u n d is m o d i f i e d a n d softened, until the v o c a l e x p r e s ­sion is lost e x c e p t o v e r the right b r o n c h u s , a n d , in thin p e r s o n s , the left.

2 . — T h i s t o n e w i t h " f a r - a w a y " quality is k n o w n as the pulmonary resonance. It c o r r e s p o n d s to the v o c a l f r e m i t u s of palpation.

3 . — I n c r e a s e d r e s o n a n c e indicates s o m e consolidation of the l u n g w i t h o u t closure of the b r o n c h i a l tubes, cavities, pleuritic a d h e s i o n s or c o m p r e s s e d l u n g tissues f r o m effusions.

4 . — D i m i n i s h e d r e s o n a n c e is d u e to obstruction of the b r o n c h i or a layer of fluid b e t w e e n the l u n g a n d chest wall.

5 . — S u p p r e s s e d r e s o n a n c e is c a u s e d b y large effusions in the pleural sac, w i t h c o m p r e s s i o n of the l u n g o r n e w g r o w t h s .

6 . — B r o n c o p h o n y or a d e v e l o p m e n t of the b r o n c h i a l t y p e of r e s o n a n c e in u n u s u a l locations indicates a c o n d e n s a t i o n o r h a r d e n i n g of l u n g tissue, o r cavities.

7 . — A m p h o r i c r e s o n a n c e indicates v e r y large cavities, o r p n e u m o h y d r o t h o r a x . T h e quality of the s o u n d is m u s i c a l a n d metalic ; the pitch is h i g h a n d the r e s o n a n c e h o l l o w a n d w i t h o u t articulation.

8 . — W h i s p e r e d r e s o n a n c e is f o u n d in as m a n y f o r m s as vocal r e s o n a n c e , a n d its modifications are d u e to the s a m e causes. It is a m o r e delicate test of slight consolidation a n d h e n c e s h o u l d b e t h o r o u g h l y studied. I n n o r m a l cases it presents a soft b l o w i n g s o u n d at the u p p e r part of the chest only, w h e r e consolidation usually begins.

9 . — A c o u g h r e s o n a n c e is helpful at t i m e s in s e c u r i n g c u m u l a t i v e e v i d e n c e of a condition suspected f r o m other sources of i n f o r m a t i o n . T h i s is specially true of the diag­nosis of cavities.

C H A P T E R V I I I .

THE SIGNIFICANCE OF CERTAIN PHYSICAL SIGNS.

In c o n s i d e r i n g the s o u n d s of the heart it is well to b e a r in m i n d the a n a t o m i c a l features of the heart, a n d the c o u r s e of the b l o o d as it passes into the heart a n d t h r o u g h it to the aorta. T h e b l o o d f r o m the l o w e r parts of the b o d y is c o n d u c t e d b y the inferior v e n a c a v a to a p o i n t n e a r the heart w h e r e it m e e t s the current b r o u g h t f r o m the u p p e r parts b y the superior v e n a cava, a n d unites w i t h it to f o r m the i n n o m i n a t e vein w h i c h e m p t i e s into the right auricle after a l e n g t h of 30 to 4o m m . T h e r e is n o valve at the m o u t h of this vein, b u t b l o o d c a n flow b a c k w a r d t h r o u g h it u n d e r pressure. T h e right auricle is a p o u c h - l i k e sac w i t h o n l y a s m a l l a m o u n t of m u s c u l a r fibre in its wall. T h i s auricle acts as a reservoir of a fairly steady current w h o s e contents are d i s c h a r g e d at intervals into the v e n ­tricle o r m u s c u l a r c o m p a r t m e n t directly b e l o w it. T h i s act of discharge is e a s y d u r i n g the p e r i o d of diastole o r relaxation of the ventricular m u s c l e , a n d is a c c o m p l i s h e d b y gravity a n d the contraction of the auricular walls. W h e n the ventricle is d i s t e n d e d w i t h b l o o d the m u s c u l a r w a l l s b e g i n to contract, a n d the b l o o d is forced t o w a r d the t w o o p e n i n g s , the p u l m o n a r y artery a n d the auriculo-ventricular p a s s a g e , b u t this latter is fringed b y the tri­c u s p i d v a l v e w h i c h is q u i c k l y closed b y the current a n d the b l o o d sent o n to the l u n g s . A t the o p e n i n g of the ventricle into the p u l m o n a r y artery there is a v a l v e c o m ­p o s e d of three s e m i l u n a r flaps of p o c k e t s h a p e , w h i c h pre­v e n t s a return current after the contraction or systole h a s ceased.

A f t e r p a s s i n g t h r o u g h the p u l m o n a r y tissue the b l o o d c o m e s b a c k to the left side of the heart a n d enters the left

The Significance of Certain Physical Signsx -p^i «' auricle b y the p u l m o n a r y veins w h i c h are u n g a r d e d /by v a l v e s to p r e v e n t a regurgitation. T h e right auricle Ts v e r y similar to the left in function a n d a n a t o m i c a l charac­ter. F r o m it the b l o o d passes d o w n into the left ventricle d u r i n g its p e r i o d of diastole, a n d is p r e v e n t e d f r o m f l o w i n g b a c k d u r i n g the p o w e r f u l contraction of the ventricle b y the mitral or bicuspid valve. T h i s closure of the auricular orifice leaves o n l y the o p e n i n g of the aorta b y w h i c h the b l o o d m u s t b e d r i v e n out, a n d w h i c h t h e n c o n d u c t s it to the g e n e r a l circulation. A t the aortic o p e n i n g are located s e m i l u n a r valves to retain the b l o o d that h a s o n c e p a s s e d into the arterial t r u n k , so that it c a n n o t flow b a c k a n d refill the ventricle d u r i n g its period of receptivity.

It is clear, then, that in n o r m a l heart action w e m u s t h a v e f o u r valvular s o u n d s , a n d these m u s t all originate at points at n o great distance f r o m e a c h other. In fact a circle of 25 m m . radius d r a w n f r o m a center at the sternal e n d of the fourth costal cartilage o n the left will c o v e r the f o u r valves. T h e r e are points, h o w e v e r , w h e r e e a c h s o u n d is h e a r d m o r e plainly, a n d these are for the mitral v a l v e at the a p e x of h e a r t ; for the aortic valves at s e c o n d inter­costal s p a c e just at the right of the s t e r u m , a n d o v e r the right c o m m o n carotid artery ; for the tricuspid v a l v e at m i d d l e of the s t e r n u m at the level of the nipple ; for the p u l m o n a r y v a l v e at the left of the s t e r n u m in the s e c o n d intercostal space. T h e mitral a n d tricuspid s o u n d s m u s t b e at the b e g i n n i n g of the systole, a n d are called the first s o u n d of the heart w h i l e the s e m i l u n a r closings will b e at the e n d of the systole, a n d are called the s e c o n d s o u n d of the heart. T h e first t w o s o u n d s are s y n c h r o n o u s , a n d also the last t w o .

T h e first s o u n d s are p r o l o n g e d b y the m u s c l e vibration into a full b o o m i n g s o u n d , w h i l e the s e c o n d s o u n d s are short a n d clicking. F o s t e r illustrates the difference b y p r o n o u n c i n g the w o r d s loob-diib in the s a m e relative t i m e as the heart s o u n d s . B e t w e e n the s e c o n d a n d first s o u n d s is a n interval that is essentially two-fifths of the t i m e

ioo The Significance of Certain Physical Signs.

required for a c o m p l e t e cycle of heart action. T h i s is called the p e r i o d of rest.

T h e f o l l o w i n g table is a s u m m a r y of n o r m a l heart s o u n d s :

NORMAL HEART-SOUNDS. Sounds.

i . Muscular.

2. Mitral valve.

3. Aortic valve.

4. Tricuspid valve.

5. Pulmonary valve.

Location.

Within boundary limits heart or precordial area.

of

Behind the 3rd left intercostal space and 4th costal car­tilage about 2 o m m . from sternum.

Behind the left edge of the sternum at the level of the 3rd intercostal space.

Behind the sternum at the level of the 4th costal car­tilages.

Behind the junction of the 3rd costal cartilage with the sternum on the left. About in front of the aortic valve.

Where Heard.

Heard best at apex and just above.

Just above apex beat and at 3rd intercostal space on left of ster-

A t 2nd intercostal space on right of sternum, and over the common carotid arteries.

A t lower end of the sternum above the en-siform cartilage.

A t 2nd intercostal space to left of the sternum.

T h e b o u n d a r y limits of the heart as g i v e n b y H o l d e n are as f o l l o w s :

F o r the b a s e d r a w a horizontal line o v e r the third costal cartilages e x t e n d i n g i 2 m m . to the right a n d 25 m m . to the left of the s t e r n u m . F o r the a p e x d r a w a p e r p e n d i c u l a r line 5o m m . l o n g d o w n w a r d f r o m the left n i p p l e a n d f r o m its l o w e r e x t r e m i t y d r a w a horizontal line 25 m m . to the right, w h i c h will b r i n g the pencil o v e r the a p e x to the heart in the fifth intercostal space. T h e n i p p l e is usually located o v e r the fourth intercostal space. F r o m the a p e x d r a w a c u r v e to the e n d of the s t e r n u m , a n d c o n t i n u e it u p m o r e s h a r p l y to the right e d g e of the s t e r n u m , a n d c o n t i n u e it u p w a r d to the right e n d of the b a s e line b y a gentle curve. T h e left side will b e m a r k e d b y a c u r v e of a b o u t 2oom m . radius e x t e n d i n g f r o m the left e n d of the b a s e line to the a p e x . S e e Fig. 19.

T h e part of the heart n o t c o v e r e d b y l u n g tissue is i n c o n -

The Significance of Certain Physical Signs. 101

siderable, a n d is described b y D r . L a t h a m as b e i n g outlined r o u g h l y b y a circle of 25 m m . radius d r a w n f r o m a center half w a y b e t w e e n the nipple a n d l o w e r e n d of the s t e r n u m . F i g . 20.

A b n o r m a l heart s o u n d s are usually called m u r m u r s , a n d result f r o m f o u r c a u s e s :

1. T h e failure of valves to perfectly h o l d the b l o o d f r o m leaking t h r o u g h .

2. T h e n a r r o w n e s s of the o p e n i n g t h r o u g h w h i c h the b l o o d is forced into a t u b e of larger caliber.

3. Friction of the external surface of the heart against a n i n f l a m e d p e r i c a r d i u m .

4. Friction o n e n d o c a r d i u m f r o m vegetations. T h e first c a u s e m a y b e d u e to active i n f l a m m a t i o n of the

valves f r o m endocarditis, etc., that p r o d u c e s vegetations o r u n e v e n t h i c k e n i n g of the valves a n d therefore i m p e r f e c t closure, or the w a l l s of the heart m a y b e c o m e so distended as to p r e v e n t perfect coaptation of the valves. O t h e r c a u s e s also m a y p r o d u c e imperfect closure.

T h e s e c o n d c a u s e usually d e p e n d s o n i n f l a m m a t i o n that h a s c a u s e d a deposit of fibrous tissue a r o u n d the orifice affected.

T h e third c a u s e is m o r e often the result of a n injury o r strain, a n d is f o u n d in s o m e cases after violent exercise.

T h e fourth is f o u n d after fevers, r h e u m a t i s m , etc. T h e character of these a b n o r m a l e n d o c a r d i a l s o u n d s is

hissing or b l o w i n g , a n d for this r e a s o n t h e y are called b y s o m e writers " b e l l o w s m u r m u r s , " w h i l e the friction s o u n d is m o r e s q u e a k i n g o r g r a z i n g in its quality, a n d c a n frequently b e d i a g n o s e d b y the f r e m i t u s discovered b y palpation.

T h e pitch varies in all the s o u n d s f r o m a l o w , g e n t l e m u r m u r to a h i g h whistling n o t e — t h e pitch g i v i n g u s s o m e idea as to the size of the o p e n i n g ; for if the s o u n d b e c a u s e d b y a s t r e a m forced t h r o u g h a s m a l l a p e r t u r e the pitch will b e h i g h e r — t h e surfaces set in vibration b e i n g m u c h shorter t h a n in the large o p e n i n g .

T h e m o s t c o m m o n heart lesion is a failure of the mitral

102 The Significance of Certain Physical Signs.

v a l v e to perfectly close the left auriculo-ventricular p a s ­sage. T h i s is called mitral insufficiency. It is plain, that a n y fault in the closing of this v a l v e w o u l d p e r m i t the b l o o d to flow b a c k into the left auricle d u r i n g systole, a n d that this w o u l d c a u s e increased p r e s s u r e in the auricle a n d p u l m o n a r y veins, t h u s interfering w i t h respiration a n d distending the auricle. A s the heart contraction forces b l o o d into the aortic arch, there is a n effort t o w a r d straight­e n i n g the aortia f r o m the pressure, a n d this b r i n g s the a p e x of the heart against the chest w a l l at a b o u t the fifth inter­costal space. T h i s b r i n g s a c o n t i n u o u s vibratory m e d i u m of solid tissue f r o m the p o i n t of vibration to the external surface w h e r e w e m a y receive it b y the ear o r stethoscope. W e also find that the s o u n d is carried to the left axillary r e g i o n a l o n g the fifth or sixth rib. T h e s o u n d is h e a r d o v e r the valvular r e g i o n at the b a s e of the heart b u t w i t h ­o u t characteristic qualities. T h e t i m e of the m u r m u r is d u r i n g the systole, a n d h e n c e it b e g i n s w i t h the valvular click of the first s o u n d a n d e n d s w i t h the s e c o n d valve closing at the aorta w h i c h gives the s e c o n d s o u n d .

If the heart s o u n d s are so d e r a n g e d that it is difficult to decide w h i c h is the first s o u n d , it m a y b e d e t e r m i n e d b y r e m e m b e r i n g that it is s y n c h r o n o u s w i t h the i m p a c t of the a p e x against the chest wall, a n d also w i t h the p u l s e w a v e in the carotid arteries.

T h e f o l l o w i n g s p h y g m o g r a m s h o w s the typical disturb­a n c e of the arterial p r e s s u r e in mitral regurgitation Fig. 24 :

T h e c u r v e is n o t a b r u p t in the systole, a n d the pressure is n o t sustained to the dicrotic w a v e . If the systole is v e r y energetic the p u l s e w o u l d b e large b u t soft. T h e r h y t h m is irregular. Fig. 25

s h o w s mitral regurgitation w i t h slight aortic insufficiency. I n o r d e r to u n d e r ­s t a n d the m e a n i n g of these curves, let u s s t u d y briefly the n o r ­m a l p u l s e tracing. Fig. 24. Fig. 25.

The Significance of Certain Physical Signs. IOJ

" A l l scientific investigators a g r e e that the line A represents the cardiac contraction, the i m p u l s e b e i n g c o n v e y e d to the n e e d l e t h r o u g h the arteries in the s a m e m a n n e r

Fig. 26. that the i m p u l s e is g i v e n to the last m a r b l e in a r o w of m a r b l e s b y striking the first m a r b l e in the r o w a q u i c k b l o w , the difference b e i n g that the r o w of m a r b l e s d o e s n o t a d v a n c e , w h i l e the b l o o d current does. T h i s ascent w e will call the systolic w a v e .

T h e arteries t h u s s u d d e n l y filled b e g i n i m m e d i a t e l y b y virtue of their elasticity to contract a n d the n e e d l e d e s c e n d s to the point B . N e x t w e h a v e a w a v e , the c a u s e of w h i c h is n o t definitely settled. It is g e n e r a l l y believed that the w a v e B - C , called the tidal w a v e , is d u e to a r e b o u n d of the b l o o d f r o m the t e r m i n a l vessels o r capillaries, for the fol­l o w i n g r e a s o n s :

T h e tidal w a v e is m o r e perceptible n e a r e r the capillaries. T h e b a s e of tidal w a v e a p p r o a c h e s the systolic line a n d

systolic a p e x the farther the tracing is t a k e n f r o m the heart.

S w e a t i n g r e n d e r s the tidal w a v e less perceptible a n d the b a s e n e a r e r the dicrotic n o t c h .

F r o m C the artery a g a i n contracts till the n e e d l e reaches point D . T h e rise at D is g e n e r a l l y c o n c e d e d to b e d u e to the r e b o u n d of b l o o d f r o m the closed aortic valves a n d is usually t e r m e d the dicrotic w a v e . T h e r e m a i n d e r of the cycle represents the diastole o r rest of the heart."*

Fig. 27 s h o w s a n o r m a l p u l s e /] i\

of h i g h tension a n d Fig. 28 a -U^^J ^

Fig. 27. n o r m a l p u l s e of l o w tension. Fig . 28.

T h e lesion that s t a n d s s e c o n d in f r e q u e n c y is obstruc­tion at the aortic o r i f i c e — a n y n a r r o w i n g of this o p e n i n g that m a k e s its caliber less t h a n that of the aorta will p r o ­d u c e a m u r m u r a n d t e n d to increase the w o r k of the v e n ­tricle w i t h resulting h y p e r t r o p h y . It o b v i o u s l y d o e s n o t

*See an article on the Use of the Sphygmograph, by Dr. J. G. Smith, in the Annual Report of the Amer. Assoc. for the A d v . of Phy. Ed. , 1888.

10//. The Significance of Certain Physical Signs.

F i g . 29 illustrates the typical p u l s e trac­i n g in this lesion. T h e systolic c u r v e is

Fig. 29. n o t a b r u p t n o r h i g h , b u t the p r e s s u r e is w e l l sustained past the dicrotic notch. T h e p u l s e is s m a l l a n d u s u a l l y regular.

T h e third lesion in f r e q u e n c y is a regurgitation of b l o o d t h r o u g h the s e m i l u n a r valves f r o m the aorta into the left ventricle. E v i d e n t l y this c a n o n l y o c c u r d u r i n g the dias­tole of the heart. It s h o u l d b e h e a r d in the s a m e locations a s the m u r m u r of aortic stenosis, a n d also d o w n a l o n g the s t e r n u m . T h e lesion is t e r m e d aortic insufficiency.

1 T h e interference w i t h the p u l s e is s h o w n b y F i g . 30. Its characteristics are m a r k e d . T h e

\ ^ systolic c u r v e is h i g h a n d a b r u p t . T h e fall is Fig- 3°- a b r u p t . T h e dicrotic w a v e is small. T h e p u l s e

is q u i c k a n d s t r o n g ; t h e " bullet " pulse. T h e fourth lesion p r o d u c i n g a characteristic s o u n d is

mitral obstruction d u e to stenosis of the left auriculo-ven-tricular p a s s a g e . T h i s w o u l d interfere w i t h the p a s s a g e of b l o o d f r o m the auricle to the ventricle in the period of diastole. T h e m u r m u r b e i n g started d u r i n g the stage of auricular contraction a n d e n d i n g w i t h the b e g i n n i n g of the first s o u n d ; it is called presystolic. It is h e a r d o v e r the mitral v a l v e a n d at the a p e x of the heart, b u t is n o t transmitted o v e r a large area. T h i s lesion leads to m u c h p u l m o n a r y disturbance o n a c c o u n t of the increased b l o o d p r e s s u r e in the l u n g s .

m e n a c e life a n d health to the s a m e extent as mitral insuffi­ciency. T h e s o u n d b e i n g p r o d u c e d b y the current forced o u t b y the contraction of the ventricle it m u s t b e s y n c h r o ­n o u s w i t h the systole a n d e n d w i t h the s e c o n d s o u n d of the heart. Its location b e i n g at the b a s e of the heart, w e w o u l d e x p e c t to find the s o u n d clearest at the b e g i n n i n g of the aorta. It is in fact h e a r d m o s t distinctly o v e r the s t e r n u m at level of the s e c o n d rib or just to the right of the s t e r n u m , a n d is also h e a r d o v e r all the large arterial t r u n k s of the u p p e r t h o r a x a n d n e c k . It is called aortic stenosis.

The Significance of Certain Physical Signs. IOJ

T h e fifth lesion is obstruction of the p u l m o n a r y orifice f r o m stenosis. T h i s w o u l d place extra w o r k o n the right ventricle, w h i c h h y p e r t r o p h i e s b y natural a c c o m m o d a t i o n . T h e m u r m u r m u s t b e systolic a n d h e a r d o v e r the s e c o n d cartilage to left of the s t e r n u m . It is p r o l o n g e d u p w a r d a n d to left of the s t e r n u m for o n l y a short distance as the artery s o o n divides into s m a l l b r a n c h e s to r a m i f y t h r o u g h the l u n g s .

T h e sixth lesion is a regurgitation t h r o u g h the tricuspid valves d u e to insufficiency of the closure. It is systolic a n d c a u s e s great increase of v e n o u s pressure b y the current forced b a c k into the auricle a n d t h r o u g h it into the v e n o u s t r u n k s c a u s i n g a v e n o u s pulse. It is h e a r d at junction of e n s i f o r m cartilage w i t h the s t e r n u m a n d to the a p e x .

T h e s e v e n t h lesion is a n obstruction of the right auriculo-ventricular o p e n i n g b y n a r r o w i n g , a n d h e n c e the m u r m u r m u s t b e presystolic.

It is h e a r d o v e r the m i d d l e of the s t e r n u m at level of fourth cartilage, a n d is n o t transmitted e x c e p t to a slight extent d o w n w a r d to the e n d of s t e r n u m . It is called tri­c u s p i d stenosis.

T h e eighth lesion is a regurgitation t h r o u g h the valves ( s e m i l u n a r ) at the o p e n i n g of the p u l m o n a r y artery, a n d is t e r m e d p u l m o n a r y insufficiency. It t e n d s to e n l a r g e m e n t of the right ventricle, a n d interferes w i t h the p u l m o n a r y circulation a n d aeration o f b l o o d . In t i m e it m u s t b e dias­tolic, a n d is h e a r d at the r e g i o n of the s e c o n d left costal cartilage. T h e s o u n d is carried a l o n g the s t e r n u m faintly.

A m u r m u r is transmitted, in general, b y the b l o o d a n d h e n c e in the direction of the current.

If these lesions b e tabulated in the o r d e r of their fre­q u e n c y , it will b e o b s e r v e d at o n c e that the left side of the heart is m o s t frequently affected—all possible a b n o r m a l ­ities h a v i n g representation before the m o s t frequent m u r ­m u r of the right side. T h e r e a s o n for this is clear w h e n w e consider the vastly greater extent of tissues to b e supplied b y the left side of the heart c o m p a r e d w i t h t h e p u l m o n a r y circulation supplied b y the right.

8

io6 The Significance of Certain Physical Signs.

TABLE OF ABNORMAL HEART SOUNDS. Condition.

1. Mitral regurg.

2 . Aortic obstruct.

regurg.

Mitral obstruct.

5. Pulmon. obstruct.

6. Tricusp. regurg.

obstruct.

8. Pulmon. regurg.

Heart Sound. 1st sound.

After 2 d sound.

1st sound.

After 2 d sound.

With 2 d sound.

Heart Action. Systolic.

Diastolic.

Systolic.

Diastolic.

Where Heard. Mitral area and

apex.

2 d rt. cost, car-til, at sternum.

2 d rt. cost, car-til, at sternum.

Mitral area and apex.

2 d left cost, car­tilage.

Just above ensi-form cart.

Sternum at head of 4th rib.

2 d left costal cartilage.

Transmitted. Along 6th rib to

axilla.

To top of ster­num and arterial trunks.

Down along ster­num.

Not transmitted.

Up a short dist., ends abruptly.

Down a short dis­tance.

Not transmitted.

Up a short dis­tance.

Lesion. Mitral insuf.

Aortic stenosis

Aortic insufficiency

Mitral stenosis

Pulmonary stenosis

Tricuspid insufficiency

Tricusp. stenosis

Pulmonary insufficiency

T h e exocardial m u r m u r is d u e to the m o v e m e n t of the heart r u b b i n g t w o i n f l a m e d a n d r o u g h e n e d surfaces to­gether. T h e pitch is usually h i g h a n d quality s q u e a k i n g . It h a s n o c o n n e c t i o n w i t h the v a l v e s o u n d s in t i m e o r l o c a t i o n — i s n o t transmitted in a n y particular direction, a n d if loud, m a y b e felt as a fremi t u s at the a p e x beat. It h a s n o influence o n the p u l s e curve.

The Pulse of Mitral regurgitation: (a) Compensated, is soft and often large. (b) Uncompensated, is soft and short (celer.)

" " " " stenosis is small and soft (sometimes frequent and often irregular).

" " " Aortic regurgitation is quick, large, " shotty pulse" (and regular).

" " " " stenosis is small and long (tardus). " " " Tricuspid regurgitation is venous.

T h e r e is a n o r m a l v e n o u s pulse. I n t i m e it p r e c e d e s the arterial pulse, a n d m a y b e said to alternate w i t h it. It is c a u s e d b y the auricular systole a n d the c o n s e q u e n t stop­p i n g of the free current t o w a r d the heart.

T h e a b n o r m a l v e n o u s p u l s e is di s c o v e r e d m o s t easily at the l o w e r part of the j u g u l a r vein, a n d is s y n c h r o n o u s w i t h the arterial pulse, b e i n g d u e to the s a m e cause, n a m e l y , the systole of the ventricles. T h i s indirect current c a n b e forced into the veins o n l y w h e n there is insufficiency of the tricuspid valve.

C H A P T E R I X .

PRESCRIPTION OF EXERCISE.

T h e m a i n object of a physical e x a m i n a t i o n is to learn as m a n y facts c o n c e r n i n g the physical n e e d s a n d t e n d e n c i e s of the subject as possible in o r d e r to b e able to advise h i m p r o p e r l y r e g a r d i n g his exercise a n d p e r s o n a l h y g i e n e . W i t h o u t b e i n g able to give exactly the m e a s u r e s of a per­fect m a n or w o m a n w e m u s t h a v e a s t a n d a r d of f o r m a n d d e v e l o p m e n t that is derived f r o m a k n o w l e d g e of a n a t o m y a n d e x p e r i e n c e in o b s e r v i n g the individuals that present the highest e v i d e n c e of perfect health a n d p o w e r . W e learn also in a n e g a t i v e w a y b y a s t u d y of pathological cases. T h e p e r s o n s of i m p a i r e d health c a n usually b e so classified in g r o u p s w i t h c o m m o n s y m p t o m s that certain physical signs will b e f o u n d c o m m o n to n e a r l y all in the g r o u p . T h e n b y a s t u d y of the history of these cases w e c a n j u d g e w i t h s o m e correctness w h e t h e r the physical sign s t a n d s in the relation of c a u s e o r effect to the a b n o r m a l s y m p t o m s . F o r instance, if w e g r o u p together all cases of o r g a n i c l u n g diseases s u c h as tuberculosis, c h r o n i c bronchitis, recurrent attacks of p n e u m o n i a , p u l m o n a r y c o n g e s t i o n , e m p h y s e m a , etc., a n d find that a v e r y large p e r cent, of the cases h a v e in c o m m o n p o o r l y d e v e l o p e d respiratory muscles,flat chests, s a g g i n g shoulders, etc., w i t h n o other c o m m o n feature, w e m a y p r o p e r l y c o n c l u d e that a chest of this t y p e is n o t a n ideal in the sense of b e i n g a m o d e l t o w a r d w h i c h w e s h o u l d e n d e a v o r to c o n f o r m the flexible chests of o u r p e o p l e .

B u t o u r inference m i g h t b e v e r y far f r o m truth a n d u n ­t r u s t w o r t h y if w e did n o t also a p p r o a c h the subject f r o m a different line of s t u d y a n d r e a c h the o p i n i o n in a positive w a y . W e d o this b y g r o u p i n g the individuals that h a v e

Prescription of Exercise.

p r o v e d their ability for e n d u r i n g p r o l o n g e d m e n t a l a n d physical strain, the superior individuals of society like B i s m a r k , G l a d s t o n e , G r e e l e y , W e b s t e r , etc. If w e find in this g r o u p the physical c o n f o r m i t y of chest exactly o p p o ­site to o u r other g r o u p , w e h a v e a d d e d to o u r k n o w l e d g e of w h a t s h o u l d b e a v o i d e d , a t y p e that m a y wisely b e fol­l o w e d .

It is often a q u e s t i o n h o w far the aesthetic sense m a y g u i d e u s in d e c i d i n g a s to a physical standard. T h e e y e will ordinarily b e pleased w i t h the f o r m that h a s scientific perfection. A w e l l r o u n d e d a n d d e v e l o p e d b o d y is m o r e pleasing t h a n a lax, u n t r a i n e d o n e , b u t there m a y b e senti­m e n t s a n d u n j u s t s t a n d a r d s of criticism, the result of faulty training in y o u t h , that bias e v e n o u r j u d g m e n t s of b e a u t y .

T h i s is seen e v e r y w h e r e in the w o r l d of fashion. A h e a d of hair that is c o n s i d e r e d beautiful a n d b e c o m i n g o n e sea­s o n m u s t b e b l e a c h e d o r d y e d to s o m e other color in o r d e r to b e " perfectly lovely " the next. T h i s d e p r a v e d taste that a p p r o v e s of a pale face a n d c r o o k e d spine in a student, a n d a n a r r o w waist w i t h constricted chest a n d pelvic dis­p l a c e m e n t s in a w o m a n , m u s t b e e d u c a t e d u p to the scien­tific a n d artistic standard. W e m u s t s h o w in the g y m n a ­s i u m s that increased health m e a n s n o t o n l y increased ability, b u t increased b e a u t y , a n d that health is o n l y a correct b a l a n c e of functional activities. It c a n n o t exist in perfection if o n e part is u n d e r - d e v e l o p e d o r over-developed.

T h i s b r i n g s u s to the first p o i n t in prescription. If w e discover a n a b n o r m a l i t y of s h a p e d u e to e x t r a n e o u s c a u s e s w e s h o u l d first prescribe the r e m o v a l of these c a u s e s w h e n possible. T o forget this w o u l d b e to g i v e m e d i c i n e to c o u n t e r a c t a p o i s o n w h i l e p e r m i t t i n g the patient to ingest the d e a d l y substance. I n w o r k w i t h b o t h sexes the m a t t e r of dress s h o u l d b e i n q u i r e d into w h e r e w e find a n y suspi­cious a b n o r m a l i t y of s h a p e . T h i s is especially true of c o n ­strictions of the t r u n k . B o y s will often w e a r a belt in i m ­itation of s o m e n o t e d " s l u g g e r " or local " t o u g h , " o r for other r e a s o n s k n o w n o n l y to t h e m s e l v e s . T h e injurious

Prescription of Exercise. iog

effects are the s a m e as m a y b e seen in the case of corset-afflicted w o m e n ; w e a k l u m b a r m u s c l e s , n a r r o w loins, p e n d e n t a b d o m e n , varicose veins, costal respiration, diges­tive ailments, etc.

T h e m u s c u l a r w e a k n e s s c a n n o t b e c u r e d w h i l e circula­tion is i m p e d e d b y pressure o n the fibres ; the n a r r o w waist c a n n o t b e b r o u g h t o u t into correct outline, to g i v e r o o m for a p r o p e r location of the digestive o r g a n s , that w o u l d relieve the s u p r a p u b i c distention, w h i l e e v e r y force is c r o w d i n g t h e m d o w n into the pelvis.

T h e respiratory act s h o u l d b e u n i m p e d e d o r imperfect o x i d a t i o n will result a n d this m e a n s virtually a n e n f o r c e d vitiated a t m o s p h e r e . A reduction of waist-girth b y 5o m m . is s h o w n b y D r . S a r g e n t to r e d u c e the l u n g capacity t w e n t y p e r cent. A n u m b e r of p e r s o n s w i t h a n a v e r a g e l u n g ca­pacity of 2.70 litres, a n d waist girth of 7 i o m m . w e r e f o u n d to h a v e a l u n g capacity of o n l y 2.15 liters w h e n the waist girth w a s r e d u c e d to 66om m .

A r e d u c t i o n of the o x y g e n in the air b y diluting it w i t h n i t r o g e n o r c a r b o n d i o x i d e to the extent of one-fifth (20

p e r cent.) w o u l d s o o n b e disastrous to active life. A g a i n , constriction of the waist calls for a n entirely artificial m e t h o d of respiration, as h a s b e e n conclusively s h o w n b y D r . K e l l o g g , t h r o u g h w h o s e courtesy the f o l l o w i n g illus­trations of n o r m a l a n d a b n o r m a l respiration are g i v e n o n p a g e s n o , i n , 112.

A f t e r l o o k i n g at these illustrations, that e x p l a i n t h e m ­selves, t w o q u e s t i o n s m i g h t b e s u g g e s t e d b y a n y p e r s o n n o t fully a c q u a i n t e d w i t h A n a t o m y a n d P h y s i o l o g y : 1st,

D o e s n o t the amplification of the costal c u r v e s d u r i n g c o m ­pression s h o w that the respiratory act is fairly c o m p l e t e — o n e set of m u s c l e s acting w h e n the other is i m p e d e d ? T h i s v i e w h a s b e e n p r e s e n t e d in articles b y D r . M a y s , to w h i c h reference h a s a l r e a d y b e e n m a d e , w h o a t t e m p t s to s h o w that this m e t h o d of b r e a t h i n g m a y t e n d to p r e v e n t tuber­culosis b y c a u s i n g a better action of the apices of the l u n g s w h e r e that disease usually locates. T h e o n l y s u p p o r t b r o u g h t to this t h e o r y w a s the fact that m o r e m e n t h a n

P L A T E I.

Costal. Abdominal* Fig. 1. Man.

Costal. Abdominal . Fig. 2. Civilized Woman (Unmarried, age 33 years).

Costal. Abdominal . Fig. 3. Chinese Woman. *

Costal. Abdominal . Fig. 4. Indian Man (Chickasaw).

Costal. Abdominal* Fig. 5. Indian Woman (Chickasaw).

Costal. Abdominal . Fig. 6. Chippeway Indian Woman.

P L A T E I I .

Costal. Abdominal . Fig, T. A Scotch Woman, who has never worn a corset (age 45, unmarried).

A v ' v A

v v. v. mx-m Costal. Abdominal .

Fig. 8. A Reformed Corset-wearer (ordinary respiration)

Costal. Abdominal* Fig. 9. Reformed Corset-wearer (forced respiration).

Costal. Abdominal . Fig. 10. Young Woman in Corset.

Costal. Abdominal . Fig. 11. Man in Corset.

Costal. Abdominal . Fig. 12. Male Dog.

Postal. Abdominal Fig. 18. Female Dog.

P L A T E I I I .

Costal. Abdominal . Costal. Abdominal ,

Fig. 14, Woman at Seventh Month of Pregnancy. Fig. 15. Woman, a Week Before Confinement.

Costal. Abdominal.

Fig. 16. Man with Enlarged Spleen.

Ordinary, Forced. Fig. IT. Respiratory Tracing (Vaginal).

Ordinary. Forced. Fig. 18. Vaginal Tracing, with Corset.

Without Corset. Tightening With Corset. Corset.

Fig. 19. With and Without Corset.

Prescription of Exercise. ii3

w o m e n die of p u l m o n a r y tuberculosis ; b u t w h e n w e re­m e m b e r that this disease is largely d u e to climatic influences of w h i c h w i d e a n d s u d d e n variations are the chief feature, a n d that m e n are m o r e e x p o s e d to these variations t h a n w o m e n , the a r g u m e n t s e e m s worthless.

B u t e v e n if w e c o n c e d e a possible s a f e g u a r d against tub­erculosis in tight lacing w e m u s t still l o o k u p o n it as a case w h e r e the r e m e d y is w o r s e t h a n the disease, or a dis­g u i s e d blessing of the k i n d described b y " J o s h Billings," w h o r e m a r k e d that " tight b o o t s are a blessing, i n a s m u c h as t h e y c a u s e a m a n to forget all his other miseries."

2nd, If costal respiration is prejudicial to health w h y d o w e n o t h a v e a larger death-rate f r o m acute l u n g diseases a n d other diseases directly traceable to interference w i t h respiration ?

T h e reply is r e a d y that the i m p a i r e d activity of o n e o r g a n rarely gives e v i d e n c e in physical signs of its a b n o r m a l i t y . E v e n as sensitive a n o r g a n as the brain m a y disclose its disordered function, n o t b y p a i n in the h e a d , b u t b y a n a b ­n o r m a l secretion in s o m e r e m o t e o r g a n ; o r a disease of the k i d n e y b e discovered b y its c a u s i n g a n o r g a n i c c h a n g e in the heart. T h e l u n g s are ordinarily c a p a b l e of e n d u r i n g great h a r d s h i p . T h e i r flexibility e n a b l e s t h e m to c o n f o r m to a n y s h a p e of the t h o r a x o r to b e c o m p r e s s e d for a l o n g t i m e b y a pleuritic effusion, o r other cause, w i t h o u t per­m a n e n t injury, as is frequently seen in cases of e x t r e m e k y p h o s i s . A c c o r d i n g to the statistics of the N e w Y o r k M u t u a l Life I n s u r a n c e C o . , c o n s u m p t i v e s a v e r a g e o n e a n d a half i n c h e s less in chest girth t h a n n o n - c o n s u m p t i v e s . B u t m e a n w h i l e h o w fare the o r g a n s that are d e p e n d a n t o n g o o d b l o o d ? T h e brain c a n n o t act w e l l f r o m the in­stant u n o x i d i z e d b l o o d w h i c h flows in to s u p p l y it. L o w ­ered vitality is the result w i t h a yielding to acute diseases of e v e r y k i n d . M a n y a d e a t h is r e c o r d e d as d u e to t y p h o i d fever, peritonitis, malaria, etc., that is really d u e to a defi­cient respiration w h e n the s y s t e m requires the m o s t active oxidation. T h e respiratory p o w e r is r e c o g n i z e d as of the highest i m p o r t a n c e in all a c u t e diseases.

11/f. Prescription of Exercise. -

W e m u s t see to it, then, that n o article of clothing inter­fere w i t h the free action of e v e r y o r g a n .

T h e s a m e care m u s t b e exercised in j u d g i n g w h e t h e r o r n o t a b a d f o r m is d u e to faulty habits of posture. If the respiration is c h e c k e d b y a position that b r i n g s a b e n d in the t r u n k w i t h a d e p r e s s i o n across the u p p e r part of the a b d o m e n , as is the case w h e n o n e slides f o r w a r d in his seat until the s a c r u m instead of the ischia b e a r s the w e i g h t of the b o d y , the s a m e ill results will b e f o u n d that are noticed in tight lacing.

T h e horizontal d e p r e s s i o n d u e to the a b o v e c a u s e will s o m e t i m e s b e f o u n d a s h i g h as the fifth rib a n d w e c a n readily u n d e r s t a n d the interference w i t h circulation that m u s t exist in s u c h cases. I n all there will b e m o r e o r less disturbance of the hepatic function, i m p a i r e d digestion, constipation a n d a t r o p h y of the l u m b a r m u s c l e s .

T h e m u s c u l a r condition of the loins a n d a b d o m i n a l w a l l c a n tell u s m u c h a b o u t the digestion a n d nutritive p o w e r s . If these m u s c l e s are w e a k w e m u s t p o i n t o u t the fact w i t h e m p h a s i s a n d o r d e r s u c h exercises as shall t e n d to g i v e strength a n d activity to t h e m . T h e s m a l l size of a m a n ' s biceps o r g a s t r o c n e m i u s often troubles h i m w h e n his real a n x i e t y s h o u l d b e r e g a r d i n g his erector s p i n a e or rectus a b d o m i n a l i s .

It is the essentials that w e m u s t lay stress u p o n in o u r prescriptions, for the other parts will g e t incidental exer­cise in a l m o s t e v e r y case. A person's a r m will a l w a y s b e large e n o u g h for the o r d i n a r y d e m a n d s of life u p o n i t — h i s heart m a y n o t b e ; his leg will a l w a y s b e s t r o n g e n o u g h to fill e v e r y r e q u i r e m e n t — h i s s t o m a c h m a y fail utterly. A m a n m a y h a v e life a n d fair health w i t h c o m p l e t e loss of s o m e m u s c l e s , w h i l e others act at the seat of life itself.

A class of cases will c o m e u n d e r the care of the instruct­ors in the g y m n a s i u m s of S c h o o l s a n d C o l l e g e s that will b e rarely m e t b y the Directors of other g y m n a s i u m s ; a set of b o y s a n d girls w h o h a v e b e e n o v e r w o r k e d m e n t a l l y a n d u n d e r w o r k e d physically, until the n e r v o u s side of

Prescription of Exercise.

their lives is far in the a s c e n d a n t . T h e w h o l e idea of physical exercise h a s b e c o m e repulsive to t h e m b e c a u s e their m u s c u l a r tissue is so w e a k that a n y fair activity b e g e t s great w e a r i n e s s , a n d s o m e t i m e s e v e n l a m e n e s s . B r a i n w o r k is easy for t h e m b e c a u s e it h a s b e c o m e the habit of their lives ; t h e y c a n generally a c c o m p l i s h great feats in the w a y of b e a r i n g severe strains of short duration, b o t h m e n t a l a n d physical. T h e y c a n sit u p all night pre­p a r i n g for a n e x a m i n a t i o n , a n d the n e x t d a y are bright a n d r e a d y for g o o d w o r k , or, at the t i m e of physical e x a m ­ination t h e y s h o w a surprisingly h i g h record in strength tests, b u t c o m e in the n e x t d a y to tell of a strained b a c k o r l a m e s h o u l d e r as the result of their lifting. T h e y m a k e g o o d athletes, b u t are continually getting over-trained. T h e y invariably d o t o o m u c h .

Is g y m n a s t i c w o r k advisable for s u c h p e r s o n s ? A n affirmative a n s w e r c a n o n l y b e g i v e n w h e n there is to b e p e r s o n a l supervision of the w o r k . T h e b o y of h i g h nerv­o u s o r g a n i z a t i o n n e e d s exercise quite as m u c h as o n e w r h o h a s n o t e n d e n c y to a b n o r m a l n e r v e activity, b u t it m u s t b e of a different character, for the results s o u g h t are dissimi­lar. T h e n e r v o u s p e r s o n d o e s n o t live e n o u g h in his m u s c l e s . H i s habit is to m a k e e x c u r s i o n s o u t into his extremities, a n d after stirring t h e m u p a n d m a k i n g e v e r y tissue tingle h e retires, to leave e a c h m u s c l e e x h a u s t e d a n d e v e r y e n e r g y depleted. T h e exercise prescribed for these cases, a n d e n f o r c e d b y p e r s o n a l supervision, m u s t b e light, a n d c o n t i n u e d o v e r a l o n g p e r i o d of e a c h d a y . T o satisfy the m e n t a l r e q u i r e m e n t of the case the w o r k m u s t b e m a d e attractive, either as a g a m e o r a p e r s o n a l contest b e t w e e n individuals. I n a f e w cases s u c h a n interest in the physical w e l f a r e c a n b e excited in the subject as to t a k e the place of this m e n t a l interest that is stimulated b y g a m e s , a n d a p e r s o n will d o routine w o r k that is laid o u t s i m p l y f r o m the e n j o y m e n t that h e gets f r o m visible i m ­p r o v e m e n t .

Athletic w o r k , o n the other h a n d , is t o o stimulating to

n6 Prescription of Exercise.

the n e r v e centers to b e advisable for s u c h cases. T h e e x ­c i t e m e n t of contests will leave a p e r s o n e x h a u s t e d , for it will continually lead h i m to over-exertion. T h i s objection d o e s n o t a p p l y to those contests w h e r e skill rather t h a n great strength is the s o u r c e of excellence.

M a n y of these p e r s o n s , if u n c a r e d for in the g y m n a s i u m , w o u l d shortly fall into the h a n d s of a physician as typical cases of neurasthenia, a n d rest m u s t often b e prescribed instead of exercise. T h e S w e d i s h s y s t e m of passive m o v e ­m e n t s , or m a s s a g e , gives u s a n o p p o r t u n i t y to d e v e l o p m u s c u l a r tissue e v e n w h i l e the patient is resting, for the passive m o t i o n of the m u s c l e s t e n d s to stimulate the circu­lation in the s a m e w a y as active exercise, a n d c o n s e q u e n t l y the nutrition a n d g r o w t h of the part is actively p r o m o t e d .

C o m p a r a t i v e l y f e w p e o p l e u n d e r s t a n d w h a t is m e a n t b y c o m p l e t e rest. T h e c o m p l e t e relaxation of e v e r y tissue is a requisite of rest, a n d a habit of relaxation b y a n act of will c a n s o o n b e secured. T h e r e are m a n y n o t e d cases of this ability to e v e n sleep b y a n act of sheer will p o w e r . O n e of the m o s t useful features of the Delsarte s y s t e m lies in the attention that is paid to this idea of physiological rest. T h e effect of sunlight o n these N e u r a s ­thenic cases is a l m o s t a l w a y s favorable, a n d c o n s e q u e n t l y o u t d o o r w o r k s h o u l d b e prescribed in preference to i n d o o r w o r k .

In m a r k e d contrast to the cases m e n t i o n e d the athlete m a y b e placed. A d v i c e in r e g a r d to exercise will b e s o u g h t , a n d s u c h exercise m u s t b e prescribed* as will t e n d to secure a d e v e l o p m e n t of the m u s c l e s that are least u s e d in the particular f o r m of exercise in w h i c h the athlete en­g a g e s . A g a i n , after a severe c o u r s e of training for a n y athletic event, m a n y cases will find d i s c o m f o r t f r o m local c o n g e s t i o n s o n a c c o u n t of a n over-activity of the heart d u r i n g the period w h e n there is n o great physiological " w e a r a n d t e a r " to require a v e r y active circulation. T o m e e t these cases a c o u r s e of training m u s t b e laid o u t that shall b e g r a d u a t e d f r o m h e a v y w o r k d o w n to light, so that

Prescription of Exercise. 117

the p e r s o n m a y s l o w l y a c c u s t o m h i m s e l f to the n e w c o n ­ditions u n d e r w h i c h h e m u s t live. T h e heart of a n athlete, w h o h a s b e e n p r o p e r l y trained, is usually in g o o d c o n d i ­tion, a n d a v e r y s m a l l p e r c e n t a g e d e v e l o p a n y heart lesion d u r i n g their training, b u t a large s t r o n g heart m a y b e a n actual d i s a d v a n t a g e to a m a n l e a d i n g a s e d e n t a r y life, as a p u n y , feeble heart surely is.

T h e e x a m i n e r will find m a n y cases of debility a n d n e r ­v o u s irritability. A m o n g m e n a large p e r cent, of these cases will b e inordinate users of t o b a c c o . T h e v e r y first g l a n c e will betray to the e x p e r i e n c e d e y e the " s o m e t h i n g w r o n g , " b u t w e m u s t a l w a y s r e m e m b e r that s o m e of the m o s t persistent users of t o b a c c o are s t r o n g a n d hearty w h i l e a f e w of t h o s e w h o d o n o t u s e it are w e a k a n d ner­v o u s . H o w t h e n shall w e s a y to a p e r s o n w h o a s k s o u r advice w h e t h e r h e is suffering f r o m nicotine p o i s o n i n g o r n o t ?

In the first place the heart action u n d e r c o n t i n u e d in­fluence of nicotine is peculiar a n d attention is called to

" t o b a c c o heart,'' f r o m the R e f e r e n c e H a n d b o o k of the M e d i c a l Sciences. It will b e noticed that the first t w o beats are essentially n o r m a l w i t h the tidal w a v e as m a r k e d as the dicrotic. T h e interval b e t w e e n the s e c o n d a n d third w a v e s is l o n g e r t h a n the first w h i c h m a y b e c o n s i d e r e d the n o r m a l for this case. T h e third interval is short a n d the dicrotic n o t c h d e e p w h i l e the systolic w a v e is n o t h i g h . T h e fourth interval is n o r m a l ; the fifth l o n g e r a n d fol­l o w e d b y a v e r y faint i m p u l s e after w h i c h the heart a g a i n rallies, a n d so o n .

T h e character of this p u l s e as felt at the wrist is irreg­ular a n d t r e m u l o u s . A beat or t w o of h i g h tension fol­l o w e d b y o n e of l o w , o r there m a y b e n o r y t h m discover­able.

Fig. 31. of a typical p u l s e o f a

n8 Prescription of Exercise.

T h e s e cases s h o u l d b e studied carefully a n d c a n readily b e distinguished f r o m the f r e q u e n t p u l s e of n e r v o u s e x ­c i t e m e n t o r the palpitation a n d irregularity of c h r o n i c indigestion. I n p e r h a p s three-fourths of the cases there will b e s o m e n e r v o u s e x c i t e m e n t attendant o n the n e w e x p e r i e n c e s of a t h o r o u g h e x a m i n a t i o n b u t this influence o n the p u l s e m a y b e either q u i c k e n i n g o r depressing, a n d these c h a n g e s c o m e n o t for single beats b u t d u r i n g cycles c o v e r i n g m a n y pulsations.

A n intermittent p u l s e m a y n o t b e a n indication of serious interference w i t h health o r l o n g e v i t y a n d m a y n o t b e d u e to a n y appreciable cause. T h e o m i s s i o n is t h e n u s u a l l y f o u n d at stated intervals n o t v e r y short, b u t f r o m ten to a h u n d r e d beats apart.

O f c o u r s e the e x a m i n e r ' s d u t y is clear in e a c h discovered case of s m o k e r s ' irritable heart, a n d it is o n l y s u g g e s t e d that other narcotic stimulants, like tea a n d coffee, will p r o ­d u c e effects that are nearly similar. In these cases the exercise r e c o m m e n d e d m u s t b e light, a n d s u c h as t e n d s to relieve the circulation.

The following form of blank prepared by Mr. C. M. Williams of the St. Louis Y . M. C. A . Gym. is the best of the many that have come under the author's notice where personal explanations can accompany the directions:

Apparatus. Move­ments. Times.

I. 2. 3-4-5. 6. 7. 8.

18. 39-

9. 10. 11 . 12. 13. 14. 16. 17. 19. 20. 21. 22.

Chest Weights Giant Pul l . " Low Chest " _. Split H'dle Giant . Intercost. Mach. Abd . Giant P u l l . . . Quarter Circle _. Rowing Machine . ScullingMachine . Paddl 'g Mach. _. Chest E x p a n d e r . . Leg Developer Leg Developer _. Neck Machine _. Forearm Devel. _. Abdominal Stool . B ' k & L o i n P u l l . _. Finger Machine _. Paral. Bar Mach. . . Parallel B a r s . . _. Horizontal Bar Vault ing B a r . . _

Weight. Apparatus. 23. Vertical Bar 24. Floor Bars 15. Incl. Chest Bars 26. Ver . Chest Bars 27. Susp. Par. Bars 25. Vault ing Horse 28. Vault ing Buck 29. Inclined Ladder 30. Horizont'l Lad. 31. Climbing Ropes 32. Peg Pole 33. Climbing Pole 34. Striking B a g . -35. Kick ing Appar. 36. Jumping Stand. 37. Flying R ings . 38. Traveling Rings 40. Spring Table __

Bar Bells Dumb B e l l s . . . Indian Clubs _

Move­ments. Times. Weight.

Prescription of Exercise.

The following directions prepared by Dr. J. G . Smith a i ^ m o r e intel­ligible where the person has no direct supervision in his worlcj-' /

1. F O R G R I P A N D F O R E A R M — O p e n i n g and shutting fingers^^itjiicfej without resistance, (a) wrist roller : (b) clubs ; (c) bells ; {d) horizontals bar and (e) rings.

2. F R O N T A R M — A n y exercise bending the elbow joint against resist­ance especially while rotating the thumb outwards ; such as (a) curling dumb bells ; (b) the pull up ; (c) the rings ; (d) the horizontal bar; (<?) the high parallels ; ( / ) the pulley weights ; (g) climbing ropes and ladders.

3 . B A C K A R M — A n y exercise straightening elbow against resistance ; (a) pushing up dumb bells ; (b) dip on parallels ; (c) traveling parallels ; (d) pulley weights ; (e) striking bag ; ( / ) chest bars, either straight or inclined ; (g) work on horse or buck.

4. S H O U L D E R S — A n y exercise carrying the arm from the body against resistance, either front, back or out, with (a) bells ; (b) clubs ; (c) pulley weights ; (d) wands, etc.

5. N E C K — B e n d i n g head back, front or sideways against resistance of the hand or neck machine.

6. C H E S T M U S C L E S — A n y exercise tending to bring the arms across the body, whether front or back, or raising the body when arms are fixed, as (a) pulley weights ; (b) parallels ; (c) horizontal bar ; (d) travel­ing parallels ; (<?) high parallels ; ( / ) ladders ; (g) chest expanders ; (h) giant pulleys ; (1) rings ; (J) quarter circle.

7. A B D O M I N A L M U S C L E S — A n y exercise tending to bend the body forward against resistance ; such as (a) quarter circle ; (b) abdominal mat and stool ; (c) raising from a reclining to a sitting posture ; (d) pul­ley weights ; (e) giant pulleys ; ( / ) the " L " on ladders, rings, horizontal and parallels.

8. B A C K — A n y exercise straightening or bending the body back against resistance, such as (a) rowing ; (b) low pulleys ; (c) dumb bells ; (d) free-hand and setting up dril ls , (e) wands.

9. F R O N T T H I G H — A n y exercise bending the hip or straightening the knee against resistance ; (a) leg work of free-hand and dumb bell drills ; (b) running ; {c) hurdling ; (d) jumping ; (<?) leaping ; ( / ) rowing ; (g) leg machine.

10. B A C K T H I G H — A n y exercise bending knee or straightening hip against resistance, (a) Second motion of West Point Setting Up Dr i l l ; (b) leg work of pulley weight drills ; {c) free-hand and dumb bell drills ; (d) striking bag.

1 1 . F R O N T OF L E G . — A n y exercise raising toes, or tending to carry body forward with bent knee against resistance ; (a) pulley weights with back towards them ; (b) leg work of dumb-bell and free-hand drills ; (c) ankle machine.

12. B A C K OF L E G — A n y exercise raising the body on the toes. A l l exercises for front of thigh ; ankle machine.

120 Prescription of Exercise.

For all around development with light apparatus no better work has ever been devised than the dumbbell drill of R. J. Roberts.

ROBERTS' GYMNASIUM DUMBBELL DRILL N o . i.

Div . i — F R E E W O R K .

1 Open and shut fingers. 2 Wrist shakes. 3 Wrist extensions. 4 Small circles. 5 Arm quivers. 6 Y a w n stretch. 7 Windmill down in front of face.

8 Same down through sides horizontals. 9 Milkman's slap.

10 Back neck exercise. 11 Sternum expression. 12 Out-door breathing work. 13 In-door breathing extensions. 14 Massage.

Div . 2 — L E G W O R K . 5 Spread eagle. 6 Raise on toes and roll the shoulders

back and down.

1 Raise high on tip-toes. 2 Raise sharp on heels. 3 Combine one and two. 4 Ank le cradle rock.

Div . 3 — T H I G H W O R K .

1 Squat half way down. 6 4 count side pull the string. 2 Squat all the way down. 7 Spring board jump, 3 Combine one and two. 4 Front hammer. 5 Side hammer, No. 2.

1 Side push. 2 Sternum elevator. 3 Cradle rock. 4 The chop—vocal. 5 Shoulder raiser. 6 The cut—vocal. 7 The cut—stretch. 8 Liver squeezer. 9 The flip.

10 Yawn stretch.

1 Biceps—up hard. 2 Triceps—down hard. 3 Combine two and one. 4 Triceps, vocal—Hello. 5 " " — A h .

8 Jump rope. 9 Stationary run with X > M turns and

arm expressions.

Div . 4 — B O D Y W O R K . 11 Forward push—vocal. 12 " A " walls. (Jump feet together on

last count.) 13 Push to sides horizontals. 14 Muscular chest. 15 Vertical push (pull the string.) 16 Dry land swim (forward hammer.) 17 Same side hammer, No. 2. 18 The 32 count, Nos. 1 ,4 ,6 ,9 ,11 ,13 , i5«

Div. 5 — A R M W O R K . 6 Triceps, vocal—Sh. 7 Tricep swing (st. exp.) 8 Wrist twists. 9 Wrist curls.

10 Yawn stretch.

D i v . 6 — E X T E N S I O N W O R K .

1 Forward sweeps. 2 Side sweeps. 3 Strike, hard, behind heels and under

chin and over head. 4 Clavicular exercise. 5 Trapezius squeeezer. 6 Strike behind thighs and under chin

7 Strike over head and under chin. 8 Combine six and seven. 9 2 count side pull the string.

10 Repeat No. 7 and pull the string. 11 The scoop, (do slowly.) 12 The toe yawn stretch.

Prescription of Exercise. 121

F o r c a r d s o r prescription b l a n k s to b e furnished to the individual e x a m i n e d m a n y devices h a v e b e e n originated, the principal o n e s , c o n t a i n i n g a list of the m e a s u r e m e n t s of the p e r s o n , o n w h i c h is m a r k e d the parts that especially n e e d d e v e l o p m e n t , w h i l e o n a n o t h e r part of the c a r d is a reference either to a p p a r a t u s or to the f o r m of exercises that will specially t e n d to d e v e l o p those parts. T h e standard that is c o m m o n l y u s e d o n these c a r d s is a n a v e r a g e m a d e u p f r o m the m e a s u r e m e n t s of a large n u m ­b e r of individuals. T h e question of w h a t is a typical or ideal m a n is still a n o p e n o n e , h o w e v e r , b u t p e r h a p s n o better idea of s u c h a m a n c a n b e g a i n e d at present t h a n the m e a s u r e m e n t s illustrated in the chart of D r . E . H i t c h ­c o c k , Jr., as s h o w n in A p p e n d i x 4.

W e s h o u l d h a v e a standard of m a r k i n g physical excel­lence or deficiency in a n u m e r i c a l w a y that shall in s o m e w a y c o r r e s p o n d w i t h the m a r k that is g i v e n o n e x a m i n a t i o n for intellectual a c c o m p l i s h m e n t s . F r a n c i s G a l t o n , in a p a ­p e r p r e p a r e d for the A m e r i c a n Association, s u g g e s t s that attention b e g i v e n to this point, a n d says : " I w o u l d a s k to b e p e r m i t t e d to s u g g e s t a subject, or rather a v e r y interest­i n g class of subjects, that fall u n d e r this h e a d ; it is to in­vestigate the best m e t h o d of a s s i g n i n g m a r k s for physical efficacy b a s e d o n a n t h r o p o m e t r i c tests. T h e colleges of A m e r i c a w o u l d greatly h e l p in a g o o d c a u s e b y w o r k i n g o n the g e n e r a l lines s u g g e s t e d in this p a p e r . I see n o r e a s o n w h y a m a n ' s physical efficacy s h o u l d n o t b e v a l u e d in t e r m s s i m p l y of the n u m b e r of m a r k s a w a r d e d o n a well u n d e r s t o o d s y s t e m , n o r d o I see a n y r e a s o n w h y a n e m p l o y e r , m a k i n g his selection a m o n g m a n y candidates, s h o u l d n o t hereafter, at s o m e n o t distant time, b e in­fluenced in f a v o r of that c a n d i d a t e w h o possessed a certifi­cate of h a v i n g b e e n a w a r d e d h i g h m a r k s . M a n is a m a c h i n e of flesh a n d b o n e , a n d a g o o d m a c h i n e of a n y k i n d is w o r t h m o r e t h a n a b a d m a c h i n e . "

9

C H A P T E R X .

GRAPHIC ANTHROPOMETRY.

W i t h i n the last six y e a r s v a r i o u s devices for a p p l y i n g the principles of g r a p h i c m a t h e m a t i c s to the m e a s u r e s a n d tests of m e n h a v e b e e n invented. T h e s e h a v e b e e n the o u t g r o w t h of the g r a p h i c m e t h o d of Q u e t e l e t for s h o w i n g the m e a n of a n y part, as chest girth o r height, a n d the tables of a v e r a g e s a n d m e a n s p u b l i s h e d f r o m t i m e to t i m e d u r i n g the last twenty-five y e a r s b y D r . H i t c h c o c k of A m h e r s t a n d the tables of p e r c e n t a g e s p u b l i s h e d b y F r a n c i s G a l t o n a n d other students of a n t h r o p o l o g y .

T h e oldest record of a n t h r o p o m e t r i c a l data in a n y col­lege in the c o u n t r y is to b e f o u n d at A m h e r s t , w h e r e f r o m 1861-2 to this date the students h a v e h a d the a d v a n t a g e of a physical e x a m i n a t i o n , a n d advice r e g a r d i n g exercise a n d a r e c o r d of their g e n e r a l size h a s b e e n secured. I n 1881

D r . D . A . S a r g e n t p r o p o s e d a m o r e extensive list of i t e m s for m e a s u r e m e n t after the p l a n of D r . W . T . B r i g h a m of B o s t o n a n d the E u r o p e a n studies in a n t h r o p o m e t r y . I n the f o l l o w i n g y e a r this p l a n w a s a d o p t e d at A m h e r s t , a n d in 1883 at Y a l e .

T h e o r d e r of i t e m s as originally a r r a n g e d b y D r . S a r g e n t h a s b e e n r e a r r a n g e d in a better o r d e r for g r a p h i c represen­tation if n o t a m o r e logical o r d e r b y the a u t h o r in his a n ­t h r o p o m e t r i c table a n d the recent record b o o k s of Yale. T h i s list of i t e m s w i t h o n l y slight modifications is n o w in g e n e r a l u s e in all educational institutions w h e r e there is a n a i m at c o m p l e t e m e t h o d s a n d the highest results.

T h e i t e m s g i v e n o n D r . H i t c h c o c k ' s table p a g e 126 are e x t e n d e d in the r e c o r d b o o k of Y a l e b y the addition of a g e , b r e a d t h of chest, d e v e l o p m e n t , condition, exercise, vision, hearing, color of hair a n d eyes, p u l s e rate, a n d u s e of to­b a c c o . T h e horizontal l e n g t h is omitted. It m a y b e said in further e x p l a n a t i o n of these tables of D r . H i t c h c o c k that

Graphic Anthropometry. 123

the record of e a c h student is transcribed for h i m o n a table that is c o m p i l e d f r o m the m e a s u r e m e n t s of m e n of the s a m e height as the s u b j e c t — t h e table h e r e s h o w n b e i n g the o n e that w o u l d b e g i v e n to the m a n of a v e r a g e height or i725 m m .

In 1878 D r . D . A . S a r g e n t of H a r v a r d b e g a n a s y s t e m ­atic record of m e a s u r e m e n t s of students e x a m i n e d b y h i m ­self, a n d w i t h the e n t h u s i a s m w h i c h h e excited in the e d u ­cational w o r l d b y his a b u n d a n t p r e p a r a t i o n for the w o r k , his natural ability a n d his u n e q u a l e d field for observation, h e s o o n established a school for training teachers in the t h e o r y a n d practice of g y m n a s t i c s , a n d sent o u t m a n y able instructors i m b u e d w i t h his ideas a n d r e a d y to assist h i m in the d e v e l o p m e n t of a p l a n for the d e t e r m i n a t i o n of s o m e physical s t a n d a r d for A m e r i c a n college students that s h o u l d b e derived f r o m a tabulation of all the m e a s u r e m e n t s that c o u l d b e secured. T h e w o r k w a s v e r y c o m p r e h e n s i v e in s c o p e a n d the m a i n results h a v e n o t yet b e e n g i v e n to the public, b u t a partial result h a s b e e n seen in the g r a p h i c chart that w a s p r e p a r e d in 1886 (see a p p e n d i x I.) b y w h i c h D r . S a r g e n t w a s able to g i v e a p e r s o n a n idea of h o w h e c o m p a r e d w i t h the w h o l e b o d y of students w h o s e m e a s u r e s h a d b e e n tabulated. A s e c o n d result w a s seen in the J u l y a n d O c t o b e r n u m b e r s of " Scribner's M a g a z i n e " for 1887,

w h e r e , in a n article o n " T h e P h y s i c a l Characteristics of the Athlete," certain w e l l - k n o w n m e n w e r e pictured graphically as well as literally, a n d t h u s t he application of the m e t h o d w a s m o r e clearly i m p r e s s e d b y D r . S a r g e n t o n the m i n d s of p e r s o n s e n g a g e d in physical e d u c a t i o n .

M e a n w h i l e D r . H i t c h c o c k of A m h e r s t C o l l e g e , w h o h a d p u b l i s h e d tables of a v e r a g e m e a s u r e m e n t s of A m h e r s t stu­dents of all ages , f r o m fifteen u p to t w e n t y - e i g h t years, a n d tables of a v e r a g e s w h e r e height instead of a g e w a s the basis of tabulation, issued a table in w h i c h the latter a v e r a g e s w e r e a r r a n g e d o n a sheet in o r d e r f r o m shortest to tallest, b y g r a d a t i o n of o n e centimeter, a n d the records of a n or­din a r y p e r s o n , c o u l d b e indicated o n this n e w table in a g r a p h i c w a y . I n 1887 a n " a d j u s t e d a v e r a g e s " table w a s

12/f. Graphic Anthropometry.

p r e p a r e d as a s i m p l e a c k n o w l e d g m e n t that the tables w e r e c o m p i l e d f r o m so f e w records in m a n y cases that there w a s considerable irregularity, a n d therefore after d e t e r m i n i n g the a p p a r e n t l a w of variation, the table w a s m a d e to c o n ­f o r m m o r e o r less closely to this l a w , a n d a better sheet for g r a p h i c illustration w a s p r o d u c e d . T h e n u m e r i c a l c o m ­p a r i s o n m e t h o d that h a s b e e n in u s e at A m h e r s t for o v e r twenty-five y e a r s is still the favorite o n e there. S e e p a g e 126. T h e tables c o m p i l e d b y D r . H i t c h c o c k are the m o s t c o m p l e t e in existence in this c o u n t r y , the records all h a v i n g b e e n t a k e n b y o n e m a n .

In 1888 the m e a s u r e m e n t s of Y a l e students for five years, that h a d b e e n t a k e n b y the a u t h o r a n d that i n c l u d e d e v e r y m a n in the u n d e r g r a d u a t e d e p a r t m e n t s for three y e a r s a n d of t w o other a c a d e m i c a l classes, e x c e p t three m e n , for f o u r y e a r s ; altogether o v e r 2,200 m e n w e r e c o m p i l e d a n d ar­r a n g e d in tabular f o r m a c c o r d i n g to the m e t h o d of M r . G a l t o n . S e e a p p e n d i x II.

T h i s h a s f u r n i s h e d a table for g r a p h i c illustration a n d p e r s o n a l i n f o r m a t i o n that is fairly c o m p l e t e . It c o m b i n e s the c o m p a r i s o n of a m a n ' s r e c o r d w i t h the w h o l e m a s s of students ; a c o m p a r i s o n w i t h the mean ; the s t a t e m e n t of the actual n u m e r i c a l size of e a c h part of a n individual, a n d its relation to e v e r y other part.

D r . F r e m o n t S w a i n of B r o o k l y n also, in 1888, devised a chart for g r a p h i c illustration, u s i n g the figures of D r . Sar­g e n t as a basis.

In 1889 D r . W . L . S a v a g e of S a v a g e ' s G y m n a s t i c Institute, 308 W e s t 59th Street, N e w Y o r k City, devised a chart for u s e in plotting the m e a s u r e s of b o y s a n d y o u t h s . S e e a p ­p e n d i x III. T h e s c h e m e is v e r y i n g e n i o u s a n d will b e f o u n d g e n e r a l l y useful w h e n the table o n w h i c h it is b a s e d is p l a c e d in the h a n d s of instructors. T h e chart c a n b e u s e d for a n y a g e a n d gives absolute record of a v e r a g e s rather t h a n c o m ­parative. F o r b o y s the m e t h o d of a v e r a g e s is p r o b a b l y the best, as the m e t h o d of m e a n s c a n n o t b e scientifically u s e d in c o m p i l i n g data derived f r o m all a g e s as is b e i n g d o n e at present b y s o m e p r o m i n e n t teachers a n d a n t h r o p o m e -trists, the material n o t b e i n g h o m o g e n e o u s .

Graphic A nthropometry. ™5

I n the present y e a r u n d o u b t e d l y the m o s t c o m p l e t e l y g r a p h i c m e t h o d that h a s yet b e e n devised w a s c o m p l e t e d b y D r . E . H i t c h c o c k , Jr., of C o r n e l l University. S e e a p p e n ­dix I V . It is b a s e d o n the tabulation of 15,000 sets of m e a s u r e m e n t s — a l l m a d e b y physicians w h o are experi­e n c e d in the w o r k . T h e figure is d r a w n f r o m the a v e r a g e of the various m e a s u r e s , a n d lines to right a n d left s h o w in a perfect m a n n e r the relation of girths as t h e y are actually f o u n d to exist. T h e relation in size of l i m b girths to s e m i -girths of the t r u n k h a v e n e v e r b e e n so clearly d e m o n s t r a t e d before, a n d therefore the chart is a n i m p o r t a n t contribution to artistic a n a t o m y . T h i s chart h a s b e e n the p r o d u c t of a larger c o m p i l a t i o n of m e a s u r e m e n t s t h a n h a s ever before b e e n m a d e of the s a m e class in the c o m m u n i t y .

" T h e T a b l e first f o l l o w i n g , w h i c h is called the A v e r a g e A n t h r o p o m e t r i c T a b l e , exhibits, u n d e r fifty-five items, the a v e r a g e m e a s u r e m e n t s of b o d i l y p r o p o r t i o n s a n d tests of strength w h i c h w e r e o b t a i n e d d u r i n g the college years 1861-2 to 1888-9 f r o m the s t u d y of nearly eight t h o u s a n d A m h e r s t C o l l e g e students s e v e n t e e n to t w e n t y - s i x years of a g e .

T h e T a b l e is so a r r a n g e d that it m a y b e u s e d to r e c o r d the m e a s u r e m e n t s of a n y y o u n g m a n , affording'him a r e a d y c o m p a r i s o n of h i m s e l f w i t h the n o r m a l or a v e r a g e y o u n g m a n as represented b y the printed c o l u m n s of figures.

T o record the results of a n e x a m i n a t i o n : if the i t e m is less t h a n the s t a n d a r d as represented in these central col­u m n s , p u t it in the left b l a n k s p a c e ; if the s a m e o r greater, p u t it in the right. In this w a y , w h e n the e x a m i n a t i o n is fully recorded, the p e r s o n c a n ascertain at a g l a n c e , b y s i m p l e addition o r subtraction, h o w m u c h h e varies f r o m the m e a s u r e m e n t s of a y o u n g m a n of 1725 millimetres, o r 67.9

i n c h e s stature, w h i c h is r e g a r d e d as the s t a n d a r d for the students of A m h e r s t College. S h o u l d h e desire to k n o w the p e r c e n t a g e of difference b e t w e e n h i m s e l f a n d the stan­dard, a s i m p l e division will i n f o r m h i m , a n d its result, w h e t h e r less o r greater, c a n b e r e c o r d e d o n the outer b l a n k space."

126 Graphic Anthropometry.

AVERAGE ANTHROPOMETRIC TABLE.

1725 millimeters, or 6j.<p inches being the standard.

Items. per | Below Cent. 1 A v e r ~

i age. Metric English

System. System. At or above

A verage. Per

Cent.

WE I G H T , Kilos. Pounds. 6 1 . 2 *34«6

STATURE, M. M. Inches.

1 7 2 5 67 .9

3 f

ft {

1 4 1 0 55-S 1030 40.6

860 33 .9 903 35-5 476 1 8 . 7

3 f

ft {

Navel, 1 4 1 0 55-S 1030 40.6

860 33 .9 903 35-5 476 1 8 . 7

3 f

ft {

1 4 1 0 55-S 1030 40.6

860 33 .9 903 35-5 476 1 8 . 7

3 f

ft {

1 4 1 0 55-S 1030 40.6

860 33 .9 903 35-5 476 1 8 . 7

3 f

ft { Knee, -

1 4 1 0 55-S 1030 40.6

860 33 .9 903 35-5 476 1 8 . 7

| G

irth

s.

1

Head, 572 22 .5 349 13 .8 880 34.6 927 36.5 724 28.4 893 35- i 5 i 7 20.3 5 1 2 20.2 361 1 4 . 3 359 M-2 359 T 4-2 349 J 3 - 8 245 9-5 242 9.4 257 10 .0

253 9-9 295 1 1 . 6 251 9-8 247 9 .7 267 10 .5 261 10 .2 T66 6.5 165 6.5 |

Gir

ths.

1

Neck, 572 22 .5 349 13 .8 880 34.6 927 36.5 724 28.4 893 35- i 5 i 7 20.3 5 1 2 20.2 361 1 4 . 3 359 M-2 359 T 4-2 349 J 3 - 8 245 9-5 242 9.4 257 10 .0

253 9-9 295 1 1 . 6 251 9-8 247 9 .7 267 10 .5 261 10 .2 T66 6.5 165 6.5 |

Gir

ths.

1

572 22 .5 349 13 .8 880 34.6 927 36.5 724 28.4 893 35- i 5 i 7 20.3 5 1 2 20.2 361 1 4 . 3 359 M-2 359 T 4-2 349 J 3 - 8 245 9-5 242 9.4 257 10 .0

253 9-9 295 1 1 . 6 251 9-8 247 9 .7 267 10 .5 261 10 .2 T66 6.5 165 6.5 |

Gir

ths.

1

Chest, full,

572 22 .5 349 13 .8 880 34.6 927 36.5 724 28.4 893 35- i 5 i 7 20.3 5 1 2 20.2 361 1 4 . 3 359 M-2 359 T 4-2 349 J 3 - 8 245 9-5 242 9.4 257 10 .0

253 9-9 295 1 1 . 6 251 9-8 247 9 .7 267 10 .5 261 10 .2 T66 6.5 165 6.5 |

Gir

ths.

1

Belly,

572 22 .5 349 13 .8 880 34.6 927 36.5 724 28.4 893 35- i 5 i 7 20.3 5 1 2 20.2 361 1 4 . 3 359 M-2 359 T 4-2 349 J 3 - 8 245 9-5 242 9.4 257 10 .0

253 9-9 295 1 1 . 6 251 9-8 247 9 .7 267 10 .5 261 10 .2 T66 6.5 165 6.5 |

Gir

ths.

1

Hips,

572 22 .5 349 13 .8 880 34.6 927 36.5 724 28.4 893 35- i 5 i 7 20.3 5 1 2 20.2 361 1 4 . 3 359 M-2 359 T 4-2 349 J 3 - 8 245 9-5 242 9.4 257 10 .0

253 9-9 295 1 1 . 6 251 9-8 247 9 .7 267 10 .5 261 10 .2 T66 6.5 165 6.5 |

Gir

ths.

1

572 22 .5 349 13 .8 880 34.6 927 36.5 724 28.4 893 35- i 5 i 7 20.3 5 1 2 20.2 361 1 4 . 3 359 M-2 359 T 4-2 349 J 3 - 8 245 9-5 242 9.4 257 10 .0

253 9-9 295 1 1 . 6 251 9-8 247 9 .7 267 10 .5 261 10 .2 T66 6.5 165 6.5 |

Gir

ths.

1

572 22 .5 349 13 .8 880 34.6 927 36.5 724 28.4 893 35- i 5 i 7 20.3 5 1 2 20.2 361 1 4 . 3 359 M-2 359 T 4-2 349 J 3 - 8 245 9-5 242 9.4 257 10 .0

253 9-9 295 1 1 . 6 251 9-8 247 9 .7 267 10 .5 261 10 .2 T66 6.5 165 6.5 |

Gir

ths.

1 Right Knee,

572 22 .5 349 13 .8 880 34.6 927 36.5 724 28.4 893 35- i 5 i 7 20.3 5 1 2 20.2 361 1 4 . 3 359 M-2 359 T 4-2 349 J 3 - 8 245 9-5 242 9.4 257 10 .0

253 9-9 295 1 1 . 6 251 9-8 247 9 .7 267 10 .5 261 10 .2 T66 6.5 165 6.5 |

Gir

ths.

1

Left Knee,

572 22 .5 349 13 .8 880 34.6 927 36.5 724 28.4 893 35- i 5 i 7 20.3 5 1 2 20.2 361 1 4 . 3 359 M-2 359 T 4-2 349 J 3 - 8 245 9-5 242 9.4 257 10 .0

253 9-9 295 1 1 . 6 251 9-8 247 9 .7 267 10 .5 261 10 .2 T66 6.5 165 6.5 |

Gir

ths.

1

Right Calf, . . . . . .

572 22 .5 349 13 .8 880 34.6 927 36.5 724 28.4 893 35- i 5 i 7 20.3 5 1 2 20.2 361 1 4 . 3 359 M-2 359 T 4-2 349 J 3 - 8 245 9-5 242 9.4 257 10 .0

253 9-9 295 1 1 . 6 251 9-8 247 9 .7 267 10 .5 261 10 .2 T66 6.5 165 6.5 |

Gir

ths.

1

Left Calf, -

572 22 .5 349 13 .8 880 34.6 927 36.5 724 28.4 893 35- i 5 i 7 20.3 5 1 2 20.2 361 1 4 . 3 359 M-2 359 T 4-2 349 J 3 - 8 245 9-5 242 9.4 257 10 .0

253 9-9 295 1 1 . 6 251 9-8 247 9 .7 267 10 .5 261 10 .2 T66 6.5 165 6.5 |

Gir

ths.

1

Right Instep,

572 22 .5 349 13 .8 880 34.6 927 36.5 724 28.4 893 35- i 5 i 7 20.3 5 1 2 20.2 361 1 4 . 3 359 M-2 359 T 4-2 349 J 3 - 8 245 9-5 242 9.4 257 10 .0

253 9-9 295 1 1 . 6 251 9-8 247 9 .7 267 10 .5 261 10 .2 T66 6.5 165 6.5 |

Gir

ths.

1

Left Instep,

572 22 .5 349 13 .8 880 34.6 927 36.5 724 28.4 893 35- i 5 i 7 20.3 5 1 2 20.2 361 1 4 . 3 359 M-2 359 T 4-2 349 J 3 - 8 245 9-5 242 9.4 257 10 .0

253 9-9 295 1 1 . 6 251 9-8 247 9 .7 267 10 .5 261 10 .2 T66 6.5 165 6.5 |

Gir

ths.

1

R. U. Arm, . . .

572 22 .5 349 13 .8 880 34.6 927 36.5 724 28.4 893 35- i 5 i 7 20.3 5 1 2 20.2 361 1 4 . 3 359 M-2 359 T 4-2 349 J 3 - 8 245 9-5 242 9.4 257 10 .0

253 9-9 295 1 1 . 6 251 9-8 247 9 .7 267 10 .5 261 10 .2 T66 6.5 165 6.5 |

Gir

ths.

1

L. U. Arm,

572 22 .5 349 13 .8 880 34.6 927 36.5 724 28.4 893 35- i 5 i 7 20.3 5 1 2 20.2 361 1 4 . 3 359 M-2 359 T 4-2 349 J 3 - 8 245 9-5 242 9.4 257 10 .0

253 9-9 295 1 1 . 6 251 9-8 247 9 .7 267 10 .5 261 10 .2 T66 6.5 165 6.5 |

Gir

ths.

1

R. U. A., cont.,

572 22 .5 349 13 .8 880 34.6 927 36.5 724 28.4 893 35- i 5 i 7 20.3 5 1 2 20.2 361 1 4 . 3 359 M-2 359 T 4-2 349 J 3 - 8 245 9-5 242 9.4 257 10 .0

253 9-9 295 1 1 . 6 251 9-8 247 9 .7 267 10 .5 261 10 .2 T66 6.5 165 6.5 |

Gir

ths.

1

Right Elbow,

572 22 .5 349 13 .8 880 34.6 927 36.5 724 28.4 893 35- i 5 i 7 20.3 5 1 2 20.2 361 1 4 . 3 359 M-2 359 T 4-2 349 J 3 - 8 245 9-5 242 9.4 257 10 .0

253 9-9 295 1 1 . 6 251 9-8 247 9 .7 267 10 .5 261 10 .2 T66 6.5 165 6.5 |

Gir

ths.

1

Left Elbow,

572 22 .5 349 13 .8 880 34.6 927 36.5 724 28.4 893 35- i 5 i 7 20.3 5 1 2 20.2 361 1 4 . 3 359 M-2 359 T 4-2 349 J 3 - 8 245 9-5 242 9.4 257 10 .0

253 9-9 295 1 1 . 6 251 9-8 247 9 .7 267 10 .5 261 10 .2 T66 6.5 165 6.5 |

Gir

ths.

1

Right Forearm,

572 22 .5 349 13 .8 880 34.6 927 36.5 724 28.4 893 35- i 5 i 7 20.3 5 1 2 20.2 361 1 4 . 3 359 M-2 359 T 4-2 349 J 3 - 8 245 9-5 242 9.4 257 10 .0

253 9-9 295 1 1 . 6 251 9-8 247 9 .7 267 10 .5 261 10 .2 T66 6.5 165 6.5 |

Gir

ths.

1

Left Forearm,

572 22 .5 349 13 .8 880 34.6 927 36.5 724 28.4 893 35- i 5 i 7 20.3 5 1 2 20.2 361 1 4 . 3 359 M-2 359 T 4-2 349 J 3 - 8 245 9-5 242 9.4 257 10 .0

253 9-9 295 1 1 . 6 251 9-8 247 9 .7 267 10 .5 261 10 .2 T66 6.5 165 6.5 |

Gir

ths.

1

Right Wrist,

572 22 .5 349 13 .8 880 34.6 927 36.5 724 28.4 893 35- i 5 i 7 20.3 5 1 2 20.2 361 1 4 . 3 359 M-2 359 T 4-2 349 J 3 - 8 245 9-5 242 9.4 257 10 .0

253 9-9 295 1 1 . 6 251 9-8 247 9 .7 267 10 .5 261 10 .2 T66 6.5 165 6.5 |

Gir

ths.

1

. Left Wrist,

572 22 .5 349 13 .8 880 34.6 927 36.5 724 28.4 893 35- i 5 i 7 20.3 5 1 2 20.2 361 1 4 . 3 359 M-2 359 T 4-2 349 J 3 - 8 245 9-5 242 9.4 257 10 .0

253 9-9 295 1 1 . 6 251 9-8 247 9 .7 267 10 .5 261 10 .2 T66 6.5 165 6.5

* f Head, ' . . . 155 6 .1

108 4.2 430 1 6 . 9 198 7.8 250 9.8 323 1 2 . 7

* Neck, 155 6 .1 108 4.2 430 1 6 . 9 198 7.8 250 9.8 323 1 2 . 7

* Shoulders,

155 6 .1 108 4.2 430 1 6 . 9 198 7.8 250 9.8 323 1 2 . 7

* Nipples,

155 6 .1 108 4.2 430 1 6 . 9 198 7.8 250 9.8 323 1 2 . 7

* Waist, . . .

155 6 .1 108 4.2 430 1 6 . 9 198 7.8 250 9.8 323 1 2 . 7

*

L Hips,

155 6 .1 108 4.2 430 1 6 . 9 198 7.8 250 9.8 323 1 2 . 7

* • Chest, * • Abdomen,

| L

en

gth

s. 1

1

R. Shoulder Elbow,.. 373 *4-7 3 7 1 1 4 . 6 461 1 8 . 1 459 18.0 260 10 .2 259 10 .2

1780 70 .1 1732 68.1 |

Len

gth

s. 1

1

Left Shoulder Elbow, Right Elbow Tip,

373 *4-7 3 7 1 1 4 . 6 461 1 8 . 1 459 18.0 260 10 .2 259 10 .2

1780 70 .1 1732 68.1 |

Len

gth

s. 1

1

Left Shoulder Elbow, Right Elbow Tip,

373 *4-7 3 7 1 1 4 . 6 461 1 8 . 1 459 18.0 260 10 .2 259 10 .2

1780 70 .1 1732 68.1 |

Len

gth

s. 1

1

Left Elbow Tip,

373 *4-7 3 7 1 1 4 . 6 461 1 8 . 1 459 18.0 260 10 .2 259 10 .2

1780 70 .1 1732 68.1 |

Len

gth

s. 1

1

Right Foot,

373 *4-7 3 7 1 1 4 . 6 461 1 8 . 1 459 18.0 260 10 .2 259 10 .2

1780 70 .1 1732 68.1 |

Len

gth

s. 1

1

Left Foot,

373 *4-7 3 7 1 1 4 . 6 461 1 8 . 1 459 18.0 260 10 .2 259 10 .2

1780 70 .1 1732 68.1 |

Len

gth

s. 1

1

Stretch of Arms,

373 *4-7 3 7 1 1 4 . 6 461 1 8 . 1 459 18.0 260 10 .2 259 10 .2

1780 70 .1 1732 68.1 |

Len

gth

s. 1

1

L Horizontal Length,...

373 *4-7 3 7 1 1 4 . 6 461 1 8 . 1 459 18.0 260 10 .2 259 10 .2

1780 70 .1 1732 68.1

Str

en

gth

s. 1

1

Lungs Kilos. Pounds.

1 . 5 3-3o 1 3 7 3 ° i 1 6 6 365

4 1 . 5 9 i . 3 38.1 83.8

No. of times. 6 9

Str

en

gth

s. 1

1

Back, *".\\V-V.\\\\\V-

Kilos. Pounds. 1 . 5 3-3o 1 3 7 3 ° i 1 6 6 365

4 1 . 5 9 i . 3 38.1 83.8

No. of times. 6 9

Str

en

gth

s. 1

1

Legs, .

Kilos. Pounds. 1 . 5 3-3o 1 3 7 3 ° i 1 6 6 365

4 1 . 5 9 i . 3 38.1 83.8

No. of times. 6 9

Str

en

gth

s. 1

1

^ Right Forearm,

Kilos. Pounds. 1 . 5 3-3o 1 3 7 3 ° i 1 6 6 365

4 1 . 5 9 i . 3 38.1 83.8

No. of times. 6 9

Str

en

gth

s. 1

1

Kilos. Pounds. 1 . 5 3-3o 1 3 7 3 ° i 1 6 6 365

4 1 . 5 9 i . 3 38.1 83.8

No. of times. 6 9

Str

en

gth

s. 1

1

j Left Forearm, . . . . 1 Din

Kilos. Pounds. 1 . 5 3-3o 1 3 7 3 ° i 1 6 6 365

4 1 . 5 9 i . 3 38.1 83.8

No. of times. 6 9

Str

en

gth

s. 1

1

1 ^ ' P I I Pull Up,

Kilos. Pounds. 1 . 5 3-3o 1 3 7 3 ° i 1 6 6 365

4 1 . 5 9 i . 3 38.1 83.8

No. of times. 6 9

LUNG CAPACITY, Litres. Cub. In.

3 . 7 7 230

PlLOSITY, Tenths of Body.

2.25

* Depths.

Graphic Anthropometry. 12J

T h e n u m e r i c a l m e t h o d of c o m p a r i s o n h a s b e e n the o n e in m o s t g e n e r a l u s e b e c a u s e the data n e c e s s a r y for m a k i n g a g r a p h i c picture of a person's a n a t o m i c a l p r o p o r t i o n s h a s o n l y recently b e e n m a d e public. T h e a d v a n t a g e of a g r a p h i c illustration of physical p r o p o r t i o n s is as great as the ad­v a n t a g e of that m e t h o d in a n y d e p a r t m e n t of scientific w o r k . It discloses at a g l a n c e w h a t is discovered o n l y after considerable t i m e s p e n t in s t u d y of figures. It w o u l d s e e m that the u n i o n of the g r a p h i c a n d n u m e r i c a l m e t h o d s of stating the p r o p o r t i o n s of a n individual m u s t b e m o r e c o m p r e h e n s i v e t h a n either m e t h o d alone, a n d m o r e satis­factory to b o t h instructor a n d student.

T h e u s e of p h o t o g r a p h y is a legitimate application of g r a p h i c principles a n d it will s o o n b e e m p l o y e d in all g y m ­n a s i u m s w h e r e scientific s t u d y a n d accurate w o r k is a c c o m ­plished. It gives a n idea of the f o r m of a m a n that c a n n o t b e derived f r o m figures o r g r a p h i c lines, a n d will therefore s h o w results of exercise that figures c a n n o t express.

Ago... WeigM... H e i g h t S t a n d i n g .

•' S i t t i ng

•• Knee . ,

" Pubic Arch

S t e r n u m .

Girth Head ••• Neck

" C h e s t

<• Ful l .

W a i s t . . . .

" H . p s

Thigh R . .

•t • » L . . M Knee R - .

C a l f R

I

" I n s t e p R...

»

•• U p Arm R . .

•• L . .

Elbow R . . .

L . . .

" Foro Arm R . .

*• t .

Wrist R . . .

Oepth C h e s t

" A b d o m e n . .

Breadth H e a d . . .

N e c k . . .

" S h o u l d e r s

W a v s t . . . .

H i p s . . . . ,

Shou ldc r - t ibow R'.

" " t. Clbow-Tip R

" '• L

Leng th Foot R . . . .

** Hort ' ionta l .

S t r e t ch of Arms . .

Capac i ty L u n g s . . .

S t r e n g t h L o n g s . .

B a c » . „ .

" L e g s . . . .

/ ' C h e s t , . .

'* Upper Arms.

" f o r e Arms.. T o t a l .

D e v e l o p m e n t . . ,

Vision

Hearing . . . . . .

95 00 80 70 60 50 40 30 S O 10

\ - 7 -

*• 1

!

1 - )

-

-

-- - T •

> 1 i l

_ i . _ j

" I f s

1 > i

j

- - i t

... T~ ... T r

p ' i - !

\ - -/ -

1

s - -- -

Z - - *

\ ---

-- r - —

1 hi

A N P 1

C o m p i l e d f r o m t h e m e a s u r e m e n t s o f Y a l e £

i n d i c a t e d a t t h e l e f t . T h e b l a e l

HEIGHT. LENGTH.

a a

w >

.2 Oo o o X?o te 03 S 3 P2T

P3 H3

03 o

' H R O P O M E T R I C i T A B L f

S t u d e n t s f o r five y e a r s e n d i n g J u n e A t , 1 8 8 8 , A

c f i g u r e s r e p r e s e n t m i l l i m e t e r s a n d l | o g r a m s ; th<

it

r r a n g e d a c c o r d i n g t o t h e p e r c e n t a g e s

3 r e d , i n c h e s a n d p o u n d s .

.a .q 3 Br

Is

J H4

.2

GIRTHf. L_.

Eh EH H4

BREADTH. D e p t h .

c3 •s T—I

44 O to A .2

6 G £

| * ! s i s ! * !

! § s s"s N <1 o m m m

1 27. 86.1 1876 1546 1146 956 986 494 412 410 513 513 1950 380 280 600 397 1005 1060 857 1046 363 315 MIL) 3 7 3 \m 3H5 IKl 183 616 614 404 403 406 407 360 360 166 131 457 \m £*3~ m 363 335 325 5.70 339 272 82

2 . 5 35.5 81.1 1849 1534 1125 936 971 486 404 403 505 504 1930 377 276 596 386 970 1035 833 1000 348 3HH 31M ami :5Hfi 180 178 593 586 394 394 395 397 356 356 164 119 418 3 3 3 235 3H7 3 5 5 315 214 5.40 330 261 75

5 34. 77. 1837 1506 1110 925 960 477 398 396 497 497 1894 374 273 593 379 951 1005 810 974 337 390 2H4 3«VI mi 3hh 3M0 176 175 577 70 385 385 386 388 353 353 163 115 413 311 330 3*1 319 305 304 5.16 211 247 70

1 0 33.6 74.4 1805 1490 1096 910 952 472 393 390 490 488 1873 270 269 588 372 ' 930 980 790 953 327 3M3 3"i r» 3IW 5JMB 3 7 5 173 172 560 54 3T9 379 377 177 347 348 161 113 4W 306 316 374 3 4 4 Hit) 3111 4.94 105 281 ,67

1 5 31.10 73.1 1790 1476 1084 900 944 467 388 386 483 483 1854 266 266 583 368 915 966 779 943 321 270 3 7 0 y 4 A sill Y, m 911 171 170 551 44 373 373 373 173 343 344 160 113 438 39H 313 370 ;uo 197 IOM 4.76 186 m 66 \

2 0 31.4 69.4 1775 1464 1074 891 938 463 384 382 480 479 1840 264 264 580 365 905 955 769 934 315 a » :m 3»IH 170 169 544 &8 368 37J 368 J68 341 342 159 111 434 393 .'.•OH 3H7 il!»7 lu.% MM 4 (III W tt 2 5 30.11

68.5 1765 1453 10ti5 884 932 459 381 378 477 476 1836 262 262 578 362 895 946 761 934 311 36H 2113 '•SM SJV4 »v. 161) 168 538 5̂ 3 365 167 364 :i64 339 340 158 111 43 f 388 305 2HI :tu MM l»H 4 VI in in «l

3 0 30.7 67.6 1754 1443 1057 877 927 456 378 376 474 473 1814 260 260 575 360 888 938 754 918 308 2415 359 '.fill villi m 16* 167 ~534~ 537 363 (65 361 361 • 338 339 157 110 418 383 303 3<»2 ;UI I'.'l \m 4 Vk i?i m • i

3 5 30.3 65.8 1746 1435 1051 871 923 453 37» 373 471 470 1804 259 259 573 357 881 930 747 912 304 363 35n t i l «*w» m\ ID, Kill 529 523 360 363 358 358 336 337 156 109 415 379 301 359 IU> \m km n r • 1

4 0 30. 64.9 1737 1437 1045 866 917 450 373 372 468 467 1795 358 357 571 354 875 923 741 906 301 359 263 AM WW *uj Iftfl nr. 524" 519 3)8 359 3.4.2

355 355 334 335 156 108 413 376 199 357 3 3 7 |MU 1*4 4 mi M l m • ir 4 5 19.9 63.5 1730 1430 1039 860 913 448 370 369 464 463 1786 356 355 569 352 868 916 735 900 298 256 3 5 0 •si I *jw *»» %w m 164 5lT 514 2)6 357

14. 353

R 352 333 334 155 107 410 373 196 355 ;t!f» |MH IKl kii w Mr

• ir

5 0 19.7 63.1 1734 1415 1033 855 910 446 368 366 462 461 1278 354 354 568 350 861 910 730 893 295 3 5 \ 31H 3 M ??i T T Mi Im 16 i 5M 509 354 355 350 , J50 331 332 155 106 407 370 194 253 xxi IH7 |H| 4.H II !• •

4 5 19.6 61.7 1717 1410 1037 850 907 444 366 364 460 459 1768 353 253 567 348 \ 854 1 ' '"

904 725 891 292 351 :tu\ I F (tut tit:? 511 505 a5: a53 348 1 347 3:30

9 • 1

331 155 105 405 368 193 351 mi 186 179 4.(r} IU I I • 4 0 19.4 60.8 1710 1403 1022 844 903 443 364 362 457 456 1759 352 251 565 346 i 848 898 719 885 288 24H 343 " ! • 'Ml IN' Uil wr 501 3K. 351 345 1

1 344 339 330 154 105 403 365 190 349 319 184 17H 4.00 146 17V m

3 5 19.1 59.4 1703 1396 1017 840 899 439 361 359 455 454 1749 350 350 564 343 842 892 713 880 285 245 240 m Mil KM) m 497 348 349 343 I 341 337 338 153 104 400 363 188 347 317 18.3 177 ».i« 140 176 at

3 0 18.10 58.5 1695 1388 1010 835 895 436 359 357 453 451 1739 249 248 562 341 836 884 707 874 282 243 3: rv •fjii m m »»!) 1 HI 498 492 345 346 339~ 338 336 337 153 103 397 361 186 345 315 180 175 3.82 186 171 51

60" 2 5 18.6 57.6 1687 1380 1004 839 890 433 357 355 449 447 1739 347 246 560 339 828 877 701 867 278 3 3 9 :su » * m m \r# 485 342 343 335 335 335 336 153 103 394 359 184 243 m 178 174 3.78 " 180 166

51

60"

2 0 18.3 57. 1676 1371 997 823 884 430 354 352 446 444 1715 346 244 558 337 819 868 695 860 273 236 331 Hi m M m 480" 3'59 340 331 '331 333 224 151 103 391 257 181 340 310 176 173 3.62 "125" ~159~ ~49~

1 5 18. 55.4 1664 1360 986 815 876 426 350 348 442 443 1700 344 342 555 333 810 858 686 852 268 3JJ3 237 •i ? -JIM m m m m 480 476" mt 337 337 327 331 333 150 101 387 354 178 337 307 173 170 3.48 120 151 47

1 0 17.8 53.5 1645 1345 974 806 868 422 346 344 437 437 1687 240 240 550 329 800 846 677 841 262 227 — *H m m m 474 466 m 334 333 333 318 219 149 98 383 347 175 334 303 170 167 3.35 113 144 45

5 17.3 51.3 1626 1335 958 794 854 418 340 338 431 431 1658 336 335 545 324 784 8.26 661 828 255 323 317 h i H*l m m m tAI 463 465 327 316 316 316 316 147 98 375 340 170 230 397 167 163 3.13 104 136 4 3 .

2 . 5 17.1 49.4 1605 1314 947 780 842 414 334 333 435 435 1630 333 232 540 318 766 812 644 814 247 217 313 it* *

w m w 144* 4A|> 444 330 %

322 310 310 312 212 145 96 368 333 164 335 392 164 159 2.90 95 125 41

1 16.7 45.4 1576 1390 931 765 826 403 338 327 418 418 1600 326 326 53£ 311 740 787 595 794 240 310 305 IUI 1*1 m m m UI 4tr 482 M 315 304 304 308 308 143 94 361 I . ; . -'

338 160 330 386 160 153 2.65 84 114 38

f I •* '• ' V : .^w/ifc

PRESS OF TUTTLE, MOREHOUSE A TAYLOR.

Also the measures of Mr. 1 8 8 b y J a y W . S b a v e r , M . D .

A N T H R O P O M E T R I C

C H A R T F O R B O V S .

S& ioo <4So MOO iSc joo Ifo loc ,jp iqv Sp ,<U> aoo zip ipn iSo HSO SOO

ANTHROPOMETRIC TABLE DEPARTMENT OF PHYSICAL TRAINING, WELLESLEY COLLEGE.

Arranged according to the percentages at the left, from the measurements of fifteen hundred Wcllcsley students. The black figures indicate millimeters and kilograms; the red, inches and pounds. "Lung Capacity" is given in litres and cubic inches.

M E A S U R E M E N T S T A K E N A N D C O M P I L E D BY M . A N N A W O O D , Wellesley Col lege , Welles ley, Mass.

H E I G H T . G I R T H . D E P T H . B R E A D T H . L E N G T H . I S T R E N G T H .

Si u 1 5 j AG

E.

WE

IG

HT

l H

eig

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Sit

tin

g.

Kn

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Pu

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|

Na

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l.

I S

tern

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.

j H

ead

.

Neck

.

Ch

est.

Ch

est

full

.

Nin

th R

ib.

Nin

th R

ib

full

.

Wais

t.

Hip

s.

Th

igh R

.

Th

igh L

.

Kn

ee R

.

Kn

ee L

.

Calf

R.

Calf

L

.

An

kle

R.

An

kle

L

.

Inste

p R

.

Inste

p L

.

Up

.arm

R.

Up

.arm

L..

Elb

ow

R.

Elb

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L.

Fo

rearm

R.

Fo

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Wri

st

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Wi is

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.

Ch

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Ab

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me

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Head

.

Ne

ck

.

Sh

ou

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Wais

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Hip

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Nip

ple

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Sh

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lder-

Elb

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r E

lbo

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.

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T

ip R

.

Elb

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T

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.

Fo

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Fo

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Str

etc

h o

f A

rms.

Back

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.... i h 1 i 1 | | I j : • . i ! j i . - ; - !

i 2 7 . 6 75-3 |; 1725 l 6 6 . ; ' 6 7 . 9

9 1 7 1 45S 3 6 . 1 ,s.

S72 1060

34-3 4 ' - 7

1 4 1 S ! 593

5 5 - S : 2 3 - 3

34S! S49 J 3 - 7 3 3 - 4

9041 7 5 5

35-* 29-7

S07

3 ' - *

7421 1060

29-2 4 1 . 7

659J 656J 4 2 1 4 1 6 3 9 6 ! 394I 236 237, 2.|6

2 5 . 9 25.s 1 6 . 6 ! 1 6 . 4 15.6 15 .5 : 9 . 3 9 . 3 ' 9 - 7 243 327| 32Ij 259 2 5 ^ 256 254 1 7 0 l 69 2)4; 228

9.6 ' 1 2 . 9 :1 2 .6 j 10.2 .10 . i j i o . i '10. ! 0 . 7 ' 6 . 7 ! : S-4 . 0.

168 6.6

I 19 4 - 6

404 261! 3S3 1 5 . 9 ! 1 0 . 3 ; 1 5 . I

249 9 - S ;

3 7 7 3 7 S 466 1 4 . 8 1 4 . 9 1 S . 3

460 1 S . 1

265! 264 1 7 6 1 1 0 . 4 j i o . 4 | 6 9 . 3

i o i i 170' 40 2 2 2 . 6 : 3 7 4 . 7 , SS.2

3 * 3S| 8 3 . 8 7 7 - ' '

3 -45 2 1 1 .

2 . 5 7 1 . 4 ! : 1710 905 451 854 1049; 1 4 0 4 5S6J 339 .S30 8 8 3 , 731 j 7S3

is7-.V ' 6 7 . 3 3 5 . 6 1 7 . 8 33.6 4 1 . 3 ' 5 5 . 3 ; 23.1 13.3 32 .7 ! 3 » - 8 2S.4I 3 ° - *

7 l 6 ; I025 j 6371 634 2.8. I : 40.4' 25 .I 25.

4(17

16.

402 366 1 5 . S . 5 . 2

383

' 5 - '

230 230) 240

9 . 1 0.1 , 0-4 239 3 ' 5

"•4 ' 2 . 4 309

1 2 . 2 254

10. 250

9 - S

249I 248 9.8 9 .S

169

6 . 7

168

6 . 6

206 2 1 7

i S . i j 8 . 5

165

6-5

Il6

4 - 5

39SJ 254] 370

1 5 . 7 ' , I O - 1 ' 4 - 6

243I 9 . 6

3 7 ' | 370 1 459 1 4 . 6 1 1 4 . 6 ; 1 S . 1

457 i S .

259; 2591 1 7 4 6 1 0 . 2 j 1 0 . 2 | 6 S . 7

9 5 1 '55l 3S 209.4I 3 4 1 . 6 , S 3 . 8

36! 3 3 1 7 9 - 3 7 2 - 7

3 . 2 S 200.6

5 24 . 3 6 7 , 4 i' 1 6 9 4 S ° 5 < 4441 841 1036; 13S9J. 5 7 9 | 3351 S131 S67! 700) 761

1 ! i 4 S . 6 : 6 6 . 7 35 .2 17 .5 3 3 • ' 4(-»-S 54.7 22.S 13-2 ' 33- ! 34 - ' • 2 7 . 6 1 3 ° -

69S1 997 6 2 3 | 621 2 7 - S 39-3 24.5: 24.4

396

. 5 . 6 392! 3 7 7

1 5 . 4 1 4 . S 3 7 5

1 4 . 8

227 227! 237 ; 8.<,, 9 . 3

235 3<*> o - \ \ 1 2 .

300

1 1 . 8

249

<;.S 247

0 . 7 245

9 . 6 242

9-5 io^i

6 . 5 164

6 . 5

199! 207

7-9 ' S . i

160

6 - 3

1 1 2 4 . 4

39 ' j 24SI 363 15 .4 : 9 .SJ 1 4 . 3

23S 9 . 4

366| 36d 455 1 4 . 4 ; 1 4 . 4 ; 1 7 . 9

452 1 7 . 8

257 10 .1

256 1 0 . 1

1 7 2 6 6 8 .

90 146J 36 1 9 S . 4 ; 3 2 1 . S j 7 9 . 3

351 3 ' ! 77.1 6 8 . 3 !

3 . 1 2 190 . 7

1 0 2 2 _ 7

6 3 - 7 i, 1674 8S5 435; S2S 10211 1374 j 5 7 4 ! 3 2 9 | 796 S 5 1 ! 6 $ o j 7431 679 j 9 7 1 606 603J 3 S 4

' 140.4" 6^.Q ^ . . S 1 7 - 1 33.6 40.3 5 4 . 1 ! ' 22 .6 13 . 3 1 . 3 3 S - 5 26.8; 29.3I 2 6 . 7 : 3 S . 2 ! 23 .9 ; 2 3 . 7 ; 15 .1 381 3r>7

•5- ' 4 -5

366

1 4 . 4

222 223 231

S . 7 1 K.S ; 9 . 1

230 290

0 . 1 : 1 1 • 7

290

1 1 . 4 245

9.6

240

9-4

239 9 .4

237 162! 160

0 - 3 i 6 . 4 ! 6 . 3 193! ' 9 7

j 7 - 6 | 7 - S

' 5 9

6 - 3

109

4 - 3

386) 242] 354

15 .21 9 - 5 1 i 3 -9 23 ' |

9 - 1 !

360 360; 44S 14.2j I4.2 I7.6

446 1 7 . 6

2 5 ' 9 . 9

250 9 -S

1706 6 7 . 2

81

: ' 7 8 . 5 ' 35 33

2 9 7 - 5 : 7 2 . 7 33| 29|

7 2 - 7 ! 6 3 . 9 : 2.96

1 S 0 . 6

1 5 2 1 . 1 0 6 1 . 5 1661 S 7 S 429! S 1 9 1011 1361 5 7 0 ! 326 783 840! 0 6 8 733 i 666j 956

1 3 ^ 5 6 5 . 4 u - 6 16.9 ^2.2 39 .8 22 .4 12 .8 }o- s ^ - ' l 2 ^ } 28.9 2 6 . 2 37.6 5 9 5

2.5-4

593 | 377

23-3 ' 4 - 8

3 7 5 1 363 14.8 14.3

301 14.2

2 1 9 | 2 1 9 229

8 . 6 ! 8 . 6 j 0 .

228: 290

9 - " • »

2S5 11 . 2

240

9 - 4

238

9-4

235 9 - 3

233| 160I 159

0.2 1 6.3' 6 . 3 i 'S9i ' 9 '

1 7 - 4 I 7-5

'5S| 6 . 2

10c

4-3

380 23il 34J 1 5 . : 9 . 4 1 3 . 7

2271

8 . 9 : 357 350 44^

1 4 . i ; 1 4 - : ' 7 - 5 44-

1 7 . 4 24c

9 . 8 ' 24S

9 - S i6Sc

6 6 . 5 1 6 9 . 7 124! 32

2 7 3 - 3 : 7 o - 5

31 j 2 S | | 2.S2 6 8 . 3 ! 6 1 . 7 ! j 172 . 3

2 0 2 1 . 4 6 0 . 1653 8721 426; SiO| 1 0 0 3 1 1 3 5 2

1\2.2-} 9 5 - j 34.V 1 6 . S ' 3 1 . Q 39-5' 5%-2 568 322 i 7 7 3 j S31J 659 7261 657 9431 5 S 6

' 2 2 . 4 12.7: 30.4 3^-7 2 5 . 9 : 2 8 . 6 2 5 . 9 3 7 . 1 ( 2 3 . 1 533

23-

372 14.6

3 7 o ! 3 5 3 1 4 . 6 1 4 . 1

3 5 7 2 1 7 ! 2 ' 7 ' 227

1 4 . i j 8.5 ; 3-5 ! K.„ 226 286

s . , / , , . 3

2S1

1 1 . 1

233

0 . 4 236

9-3

232'i 229J 1591 158

0 . 1 j w. ! 6 . 3 ! 6 . 2

• 187 1S8

1 7-4 ' 7 - 4

' 5 7 6 . 2

10S

4-2 37S| 2 3 6 |

' 4 - 9 9-3

344

' 3 -5

222!

8.7 3S4( 353i 440

•3-9 ! ' 3 - 9 . ' 7 - 3

43S 1 7 . 2

247

9 - 7

247 j 1 6 7 7 9 . 7 1 66 .

741 " 7 | 3 ' 1 6 3 - 1 j 257-9] o S - 3

30 6 6 . 1 - 2 7 l

5 9 - 5

2.79 170.2

2 5 20.11 ss-s j I2Q.6;

1642 867

6 4 . 6 1 1 4 . 1

422j S04 997j 1344

1 6 . 6 ; 3 1 . 7 3 9 - 3 K2.Q 1 566 320

1 2 . 6

765 S24

3 0 . I 1 32.4

650

25 •

7 i 3

2 S . 3

650

25.6 933 j 5 7 3

3 6 . 7 22 .8

5 7 7 2 2 . 7

368

•4-5

3601 354 14.4! 1 3 . 9

353

•3-9

2141 215

8.4 8 . 5

225 S . o

224' 282

S . S j 1 1 . 1 277

10.9

236

9 - 3

234 9 . 2

229 227 157 iSC 9- 8 . 9 ! 6 . 2 I 6 . 1

| '35 j 1S5

7-3 ; 7-3

' 5 7 6 . 2

107

4 . 2 375 | 233

1 4 . S ( 9 -2 3 4 °

' 3 - 4

2 1 9

S.6 | 3 5 ' 1 3501 437

1 3 . S | 1 3 . 8 ; 1 7 - 2 435

1 7 . 1

246

9-7

245 j 1666 9.6 | 6 5 . 6 j

7 ' '56-5

i n 2 4 4 . 6

30 66 .1

29

6 3 - 9

26

5 7 - 3

2.71

' » S - 7

3 0 2 0 . S 5 7 - 3

1 2 7 . 4

i ° 3 4

6 4 . 3

862

3 3 . 0

419 79S l 6 - 5 | 3 ' - 4

9 9 1

3 9 -

' 3 3 7

52.6 1 563

22.2

3 i S

1 2 . 5

757 3 i S

29.8 32-2

644

2 , v 4

7 1 2

28. 645

25-4

923

36.3

5 7 2 22.5

5 7 ' 22.5

3^4 1 1 -3

36 i j 3 5 '

1 4 . 2 1 3 . S 35o

1 3 . 8

212 3-3

213 8.4

22 t

s.s 222 279' 274

S . 7 In. 1 0 . 8 234

0 . 2

2 3 ' 9 . 1

226

S . y 224! ' 5 7

8 - S | 9.2 ' 55

6 . 1

182 j 182

7 . 2 ! 7 - 2

i S 6

6 . 1

106

4 . 2

3 7 2 230

1 4 . 6 ! 9 - '

337

' 3 -3

216 j 8-5 !

34S j 34SJ 434 432 1 3 . 7 ! 1 3 . 7 . 1 7 . i | 17 .

244

9 . 6 243 9 . 6

'6571 6 5 . 2

6 9

152.1 '05

2 3 1 . 4 29

6 3 . 9

29

6 3 - 9 25

5 5 - i

2 . 6 3 160.S

3 5 2 0 . 5 5 6 . s 1627

6 4 . 1

S5S

33. s 4 ' 7 793

16.41 ^ 1 . 2

9S5 38 .8

' 3 3 o

52 .4

5 6 l

22. I

3 1 6

12.4

7 5 o

2 9 . 5

Si 2

3 2 -

639 2 5 . 2

706

2 7 . S

639 2 5 . 2

9 1 4

3 M -

567 565 3 6 0

1 4 . 2 358 347

14.1 1 .3 .7

346

1 3 . 0

310

8-3

211

S-3

222

S . 7

2 3 u l /2t> 271

S . 7 10.7

2 1 2

9.1

220

o-

22 1 S.s

222 1 K() 154

S . 7 O . i 6 . 1

;180 1 1 7 9

i 7 - 1 : 7 -

155 6 . 1

105

4 . 1

370 i 2 2 8 ! 3 . u

1 4 . 6 : 9 . ! 13 .1

214: S.4

3 f 6 346 | 4321 429

13..61 1 3 . 6 ' 17 . j . 1 6 . 9

242( 242 9 - 5 9-5

1640

6 4 . 9 66

' 4 5 - 5

101 2 2 2 . 6

2S

6 1 . 7

2 S i 24 6 1 . 7 ! 5 2 . 9

2.62

1 5 9 . S

4 0 20.2 5 5 - 9

I23'I 1620

6 3 . S

S54

33-6

4 « S

1 6 . ^

7 3 7

l i .

9S0

3 S . 6

1324

52.1

559

22.

3 '4

12 .4

743

2Q • 3

807

3 1 . S

634

25 •

701j 6 3 1

27.0; 25.

907) 501

35.7 22.1 559 357

1 4 . 1 355 j 344

' 4 -

343 | 209

1 3 . 5 S . 2

209

' S . 2

2 2 0

8.7

2 1 9 ^ T ^ f 268

S . 6 ! 10.S 10.6

230

9.1

228 222 220. i 5 5 ( . 53

0. , 8.7 1 s. 7 ,,.,! 6 .

1 1 7 9 1 7 7

' 7 . 1 7 -

' 5 4

6 . 1

104

4 . 1

36S1 226 . 330

1 4 - 5 : . s - 9 j ' 3 -

2 1 2

8.3

34 f : 344 429 1 427 1 3 . 5 ! 1 3 . 5 1 1 6 . 9 ! 16.8

2 4 1 | 2 4 0 ! 1 6 3 9

9 - 5 9 -4 ' 6 4 . 5 63

1 3 8 . 9 9s

2 1 6 . 2S

6 1 . 7

27 | 24

59 -5 i 5 2 - 9

2-53.

' 5 4 - 7

4 5 20. 54 -9

1 2 1 . 1

1 6 1 2 850 4 ' 3

16.3

7S3

3 0 . S

974

3-S-3

1 3 1 8

5 1 - 9

5 5 3

2 2 .

3 l * | 7 3 7

1 2 . 3 29.

802

3 1 . 6

6 2 9

24 .8

69L) 629

27.4 24.s

901

35-5

555 2 1 . 9

553

21 .s 354

' 3 - 9

352 i 34 '

•3 -9 ' 3 -4

340

' 3 -4

207 | 2o8

8.1 ! 8.2

219 j 218J 271 '< 266

S . o i 8 . 6 10.7 j 1 0 . 5

229

9.

226J 220 218; 151-1 152

S . o ' S . 7 ! S . o • ( ) > ,i f,. 1 • 7 7 ' 7 5

7- 6 - 9

' 5 3

6 .

104

4 . 1

3 6 6 224I 327 I.,..,' S.Sj w.9

2(x;

S.2

342 j 342 427 425 1 239

. 3 . 5 ! 13 .5 1 6 . 8 , 10.7! 9.4

2 3 9 | 1 6 3 0

9 . 4 : 6 4 . 2

6 i

' 3 4 - 4

95 209 .4

37

5 9 - 5

26) 231

5 7 - 3 ' 50 .7!

2.47

1 5 0 . 8

5 0 19 . 10 54-2 1 1 9 . 4

l605

6 3 . 2

846

3 3 - 3

4 1 0 1 6 . 1

7 7 S 30 .6

96S

3 S . 1

1313 5 i - 7

5 5 * 21 .9

3 1 0 732 798

1 2 . 2 ; - 8 . S | 31 .4

624

2 4 . 6

691 ; 624 27.2: 24.6

S93 35-2

549 1 543

21 . 0 ! 21.6 3 5 ' ,3.8

349 | 333 1 3 -7" j ' 3 -3

337 J 3 - 3

206 ! 206 S . i | S . i

217 j 2 1 6 i 269 1 264

8.5 1 S .5 ' 1 0 . 6 ' 1 0 . 4

2 2 7 8.0

225 218 ; 216 153 : 151 ' 7 5 | ' 7 3

| " - s

'531 103

6 . ! 4.

3 6 ^ 222I 324 1 1 . 3 , S . 7 ! 1 2 . s

207 340 | 3 4 0 | 425! 423 2381 237 1621 1 3 . 4 1 1 3 . 4 ' 10.7 10.7! . , . 4 . 9 .3 6 3 . S

I 5 9 9 ' 1 1 3 0 . ; 2 0 0 . 6

26 5 7 - 3

261 22j 5 7 - 3 ! 4 3 - 5

2.46 1 5 0 - 3

4 5 1 9 . 8 5 3 - 3 i i 7 - 5

159S 6 2 . 9

S42

33 - i 7 7 3

30-4 9^3

37-9 1306 S» -4

554 | 30S | 7 3 5 2 1 . S , 12. ll 2b.5

793 3 ' -2

6 1 9 24.4

6S7 27-

619 24.4

SS5 34-3

544 542 i 343 21-4! 2 1 . 3 , 13-7

346" J 335 13.0; 13 .2

334 | 204 j 205 1 3 . 1 8 . ! 8 . 1

2 1 6 ! 2 1 5 1 2 6 6 i 261

S . 5 S.5 ! 1 0 . 5 ; 10.3

226 8 . 9

223 I 216 S . S S . ^

1 2 l f 152 i 150

1 s. , , 5.,^

T 312 1 1.51 I49 , s - 3 v o 5 . 0

j '.._! ' 1 173 1 0 . ;

, f . .V - 7

1 5 1 1 1 0 1 5 . 0 \ 4 .

3 6 2 ! 220 1 321 I4.3, 8 .7 12.0 8.1

33S 333 422 421 1 237 M - 3 ; ' 3 - 3 '"•'• '"-5 9 - . i

236 i 1611 o-3 6 3 . 4 1 2 3 . 4

SS 1 9 4 . 25

5 5 - ' 251 21 i

5 5 - ^ ; 4 6 - 3 ; 1

4 0 i 9 - 5 5 2 . 4 i i 5 -5

1592 6 2 . 7

S3S

33-405 1 5 . 0

7 6 9 3°-3

9 5 7 3 7 - 7

1300 5 1 . 2

553 2 1 . S

307 12.1

788 3 1 •

6 1 4 2 4 . 2

682 26 .9

614 ; 2 4 . 2

8 7 S 34-f'»

5 3 3 2 1 . 2

537 1 345, 2 1 . 1 ; 1 3 . 6

344 i 333 I 333| 2 0 3 | 2 0 3 | 215 214 j 263 250 13.5 1 3 . 1 ; 1 3 . 1 ; S . ! 8 . { S.5 S.4 I 1 0 . 4 10.2

232 2 I t s. 7 s.,

1 2 l f 152 i 150

1 s. , , 5.,^

T 312 1 1.51 I49 , s - 3 v o 5 . 0

j '.._! ' 1 173 1 0 . ;

, f . .V - 7

1 5 1 1 1 0 1 5 . 0 \ 4 .

3'JO 217 3 1 8 1 4 . 3 s.5, 12.5

203 33'̂ » ' 3 3 ^ 420 ! 418 1 235 1 3 . 2 ; 1 3 . 2 \ o . 5 10.ij 9.3 1 A 4

5 5 ? ' 4 ^ - 3 !

"I ' 2. \2

3 5 j 1 9 - 3 5 1 . 6

i i 3 - 7 ! i 5 S 3

6 2 . 3 S34

3 2 . S 403 1 5 . 9

764 30.1

9 5 i 3 7 - 4

1293 5° -9

5 5 1

21.7 305 7 » 4 i 783

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Also the measures of Miss , taken , 189 , by