THE RELATION OF POSTURE TO HUMAN 
EFFICIENCY AND THE INFLUENCE OF 
POISE UPON THE SUPPORT AND FUNCTION 
OF THE VISCERA * 
The communication which it is my privilege 
to offer to-night is made in the belief that the way 
in which our bodies are used, or the attitudes 
assumed in the performance of all that goes to 
make up the routine of life, is of greater impor- 
tance than is commonly supposed. To stand 
erect, to walk or move easily, to have the various 
parts of the body so perfectly adjusted that easy 
balance and graceful use must result, is to be de- 
sired for reasons of far greater importance than 
the esthetic. Such elements are of absolute im- 
portance for perfect health and the fullest eco- 
nomic efficiency, since use of the body in proper 
poise insures the least friction with consequently 
the greatest amount of energy available for 
whatever may be required of the individual. 
This is of importance not only because of the 
effect upon the framework of the body, but be- 
cause of the effect which it must have upon the 
body as a whole. The human organism resembles 
in many ways a delicately balanced machine 
made up of many parts each related to the others, 
and that which we call perfect health is simply 
BY JOEL E. GOLDTHWAIT, M.D., BOSTON. 
* Read at a meeting of the Boston Medical Library held in con- 
junction with the Suffolk District Medical Society, Dec. 2, 1908, and 
also at the Meeting of the American Orthopedic Association, at 
Hartford, Conn., June 14, 15 and 16, 1909. 
1 the proper correlation of all of these many parts. 
As a machine, it is intended for use, and when 
working rightly there is the minimum of friction, 
and consequently the efficiency of the individual 
is the greatest that is possible. Anything which 
results in a departure from this correlation or 
balance means strain or friction and represents a 
distinct waste of energy so that the efficiency is 
lessened. Under such conditions some one part 
may be, and usually is, strained more than the 
others, but it must be remembered, nevertheless, 
that no one part can be strained without affect- 
ing the whole. 
Not only is the human machine one of ex- 
tremely delicate adjustment or balance, but in its 
use greater variation is demanded in the character 
of the work performed than w'ould be considered 
possible in any other conceivable mechanism. 
Not only are the muscles subjected to varying 
degrees of strain, but all of the visceral functions, 
as well as the higher mental processes, require an 
adjustment of the organism as a whole which 
must make possible wide latitude in the amount 
of energy that each part can reasonably use. Not 
only must the amount of energy to be expended 
vary, but the method of use of any part must also 
vary, since, for example, the body must be used 
not only in one plane, but in any possible plane in 
which it may be placed. The visceral functions, 
as well as the physical activities, must be possible 
whether the body is erect or prone, whether 
straight or flexed, whether in dorsal, dextra, 
2 sinistra or anterior decubitus, and many of the 
functions must go on whether the conscious con- 
trol of the organism, such as exists in the waking 
hours, is present or not. With so much of adjust- 
ment necessary, and with such great diversity in 
the character of the work required, it is obvious 
that all unnecessary friction or strain should be 
eliminated so that the greatest amount of energy 
may be available for the accomplishment of the 
specialtask, and that at the same time the machine 
may not be damaged, or, in other words, that the 
health of the individual may not be impaired. 
In considering the question of the use of the 
body without undue friction or in perfect health, 
the many differing conditions under which the 
body may be used must be recognized, and what- 
ever solution of the problem we may have to offer 
must be offered only after due consideration, not 
of any one part or of any one use, but of the organ- 
ism as a whole with regard to all its functions. 
In the upright position, the poise or attitude in 
which there is the least strain, and consequently 
the correct attitude, is with the body held so that 
it is made as tall as is possible without raising onto 
the toes. In this position the head is erect, the 
shoulders are thrown back so that their center is 
distinctly posterior to the center of gravity, the 
chest is high, the abdomen is flat and the spinal 
curves are slightly convex backward in the dorsal 
region and convex forward in the lumbar region. 
The pelvis is inclined forward so that the axis 
from the promontory of the sacrum to the top of 
3 the pubic bones is downward* and forward 30° 
from the horizontal, the inclination of the sacrum 
being downward and backward so that the axis 
of the pelvis is at right angles with the plane of 
the brim of the pelvis, or about 60° from the 
horizontal. In this position the anterior portion 
of the upper part of the sacrum, together with 
the last lumbar vertebra, is almost directly over 
the top of the great trochanter, or a little posterior 
to the center of the hip-joint. In this position the 
Y ligament is made tense as well as the ilio-psoas 
muscle, these two structures serving to prevent 
the pelvis from lessening its forward inclination. 
In this position the ham-string muscles are tight, 
giving support to the knees as well as preventing 
an increase in the forward inclination of the pelvis. 
The knees are straight and the weight is received 
at the foot upon the astragalus with the posterior 
-calf muscles tight, so that the heel rests lightly, 
and the chief strain is thrown upon the ball of the 
feet. The posterior calf muscles are tense, the 
result being that the posterior tibial and the pero- 
neus longus by their contraction hold the tarsal 
bones in place, the foot thus being in the position 
of greatest strength, while the flexor muscles of 
the toes hold them in contact with the floor, 
giving a stable base and rendering the forward 
propulsion of the body possible with the least 
effort. 
The muscles of the trunk in this position are in 
such balance that while the anterior and posterior 
groups are in slight contraction, neither group is 
4 strained and but few of the ligaments are under 
tension. The shoulder is slightly back of the 
lateral median line of the body so that the weight 
is received largely upon the thorax, none of the 
muscles being in more than slight contraction, 
and the strain upon the posterior muscles which 
must occur when the shoulder is held for- 
ward is absent. The head is held erect and 
so balanced that while all of the muscles, the 
anterior, posterior and lateral, are in slight 
contraction, each group is properly balanced by 
the others and none are subjected to more work 
than they can easily perform. With the body so 
poised, not only is there the least possible expendi- 
ture of energy required for the maintenance of 
the position, but it is from this position that action 
is made most easily. All cf the parts are in bal- 
ance, so that whatever the movement, whether it 
concern chiefly one part or another, the start is 
made with no waste of energy in correcting the 
poise or " gathering oneself " preparatory to the 
action. 
In the posture which has thus far been de- 
scribed, not only is the body in the best position 
for economic function, but the viscera also are 
benefited and are held in the positions most favor- 
able for their function. In the thorax, with the 
erect body, the chest is high and there must be 
the maximum amount of space for the expansion 
of the lungs. Not only are the lungs influenced by 
this position, but with the chest high, the sternum 
is raised so that the antero-posterior diameter of 
5 the upper part of the thorax is considerably 
greater than when the chest is flat, and since the 
heart lies in the space between the sternum and 
the anterior part of the vertebrae (Fig. 1), it is at 
once apparent that with the increased room al- 
lowed by the erect position, the action of the heart 
must be correspondingly more free. Under ordi- 
nary conditions this interference with the free 
heart action is probably of little importance, but 
if disease conditions exist so that the size of the 
heart is increased, such a restriction of the space 
available for its function becomes of practical 
importance. When such a condition is appreci- 
ated, one is not surprised to find that its recog- 
nition and correction is of distinct help in the 
treatment of heart lesions. The article by M. 
Herz, " Interference with Heart Action by Stoop- 
ing," published in Therapie der Gegenwart, June, 
1908, No. 6, p. 241, is of interest in this connection. 
No one would, of course, claim that such mechani- 
cal elements could cause or cure disease conditions 
of the heart, but that their recognition and cor- 
rection will relieve some of the mechanical inter- 
ference with the functions of the organ and make 
its action, although imperfect, nevertheless more 
free, need hardly be emphasized. 
The effect of posture upon the abdominal vis- 
cera is of even greater importance than with the 
viscera of the thorax, since in the abdomen the 
rigid anterior wall of the thorax does not exist 
and the support is furnished largely by soft struc- 
tures which are naturally more easily affected 
6 by strains or weakness. Under normal conditions 
in the erect, well-poised body the lumbar spine 
curves forward to such an extent that opposite 
the fourth and fifth lumbar vertebrae the anterior 
surface of these bones is nearer the front of the 
body than the back. At this level (the fifth lum- 
bar vertebra) the abdominal cavity is much 
narrower in the antero-posterior diameter than is 
commonly supposed, representing hardly more 
than one third of the thickness of the body, and 
the posterior wall is practically straight across on 
a plane with the anterior portion of the vertebra. 
(Fig. 2.) At this level the psoas and quadratus 
muscles with the retroperitoneal fat fill in the 
spaces at the sides of the bodies of the vertebrae 
so that the deepening of the abdominal cavity 
from the opening of these lateral vertebral spaces, 
such as exists higher up, does not occur. This be- 
comes a matter of much importance in connection 
with the understanding of the natural support 
of the viscera. From the level of the fourth or 
fifth lumbar vertebrae the spine inclines upward 
and backward, and with this all of the diameters 
of the abdomen enlarge and sufficient space is 
provided for the viscera, which are practically all 
above this point. That portion of the abdominal 
cavity which lies below this level is naturally 
small and contains for viscera only the loose 
folds of the intestines. Continuous with this is 
the pelvic cavity, which is distinctly posterior, 
with its long axis nearly at a right angle with 
the long axis of the abdominal cavity. The fifth 
7 lumbar vertebra with the promontory of the 
sacrum and the ridge of the ilia, together with the 
superimposed soft structures, forms a distinct 
shelf under which lie the pelvic viscera, shielded 
from the direct pressure of the viscera of the 
abdomen proper. 
The posterior wall of the abdomen is made up 
of the spine, the upper part of the sacrum, the 
wings of the ilia, a portion of the diaphragm, with 
the free portions of the lowrer four or five ribs and 
the muscles of the loin. The sides and anterior 
wall of the abdomen consist practically wholly of 
muscle, the arrangement of the fibers being such 
that the greatest elasticity exists without sacri- 
ficing the element of strength. The proper tone 
of this anterior muscle wall is an important part 
of the support of the abdominal viscera. Besides 
this, the viscera are supported by ligaments, by the 
formation of the bony framework and by the 
arrangement of certain of the structures so that 
definite ridges or shelves exist, upon wThich the 
organs naturally rest. When the body is erect all 
of these elements work to the best advantage. 
All of the abdominal muscles are made tense so 
that the organs are held firmly together with little 
liability to drag out of place. The ligaments are 
subjected to the least strain, and the organs rest 
most securely upon the ridges or shelves, to be 
described more fully later. In this position the 
kidneys cannot become displaced, the stomach 
cannot drag downward nor can the other viscera 
change their normal relations with each other. 
8 Under such conditions there is also the least pos- 
sible interference with the circulation, which, 
together with the freedom from strain of any of 
the structures, would naturally insure the great- 
est efficiency in their function. 
In the consideration of the normal support of 
the abdominal viscera, that part which results 
from the arrangement of the structures so that 
ledges or shelves exist upon which the various 
organs naturally rest has not, it seems to the 
writer, received as much attention as it should. 
Certain work, most notably that of Dr. Martin, of 
Chicago, has referred to this (Visceral Prolapse, 
F. H. Martin, Surgery, Gynecology and Obstetrics, 
December, 1908), but the full significance of this 
part of Nature's plan of construction does not 
seem to have been appreciated, and a more thor- 
ough study seems justified. The writer feels that 
until this element is appreciated many of the 
abdominal conditions will be unsatisfactorily 
treated either by the internist or the surgeon, and 
that with such understanding many of the cases 
which have previously been perplexing will be 
easy of solution. To understand the arrangement 
of the structures for their support the illustra- 
tions which follow, taken from Professor Dwight's 
work on " Frozen Sections," are suggestive. । At 
the level of the fifth lumbar vertebra (Fig. 2) the 
posterior wall of the abdominal cavity is practi- 
cally straight across on a plane with the anterior 
surface of the vertebra. As has already been 
stated, at this level the space On either side of the 
9 vertebrae is almost completely filled by the psoas 
and quadratus muscles, and the total depth of the 
abdominal cavity, while about one third of the 
thickness of the body, is all anterior to the anterior 
surface of the vertebra. 
The rapid change in the shape of and the 
depth of the abdominal cavity is shown in Fig. 3, 
which is a section through the intervertebral 
disk between the third and fourth lumbar verte- 
brae. In this, which is only a little more than the 
thickness of one vertebra above the previous 
illustration, the space available for the abdominal 
viscera has increased markedly. Not only is the 
cavity in front of the vertebra deeper, but the 
space at the sides of the vertebra, instead of being 
occupied by muscle, is occupied by the kidney 
upon the right side, with the colon on the left 
side. It should be noticed that both of these organs 
are almost entirely posterior to the anterior edge of 
the vertebra or the plane of the posterior wall of the 
abdomen as shown in the previous illustration. 
In Fig. 4, a section through the second lumbar 
vertebra, the same thing is shown, only more 
strikingly, the space available for the viscera 
being larger and both kidneys lying well back of 
that which represented the posterior wall of the 
abdomen in Fig. 2. 
In Fig. 5, a section through the twelfth dorsal 
vertebra, both kidneys are shown well back of the 
anterior portion of the body of the vertebra, and 
also the spleen with a considerable portion of the 
liver is also posterior to this line. 
10 In Fig. 6, a section through the eleventh dorsal 
vertebra, the left kidney, together with the spleen, 
is shown posterior to the anterior edge of the 
vertebra, while upon the right side the position 
of the liver with reference to this lateral vertebral 
space is well shown. 
In Fig. 7, a section through the ninth dorsal 
vertebra, the position of the stomach with refer- 
ence to this lateral space is clearly shown. 
From these cross-sections it is apparent that 
the kidneys rest in definite depressions which 
begin at the level of the fourth lumbar vertebra 
upon the right side and a little above this upon 
the left; that the bottom of this depression or 
pocket is made by the psoas and quadratus lum- 
borum muscles together with the retroperitoneal 
fat, and that when the body is erect the kidneys 
rest in these pockets or upon these shelves with 
the long axis of the organs inclined backward at 
the top so that there is no tendency for 
them to sag or to be displaced forward or down- 
ward. 
In this position, also, the major portion of the 
liver is distinctly posterior to the central trans- 
verse line of the body and is supported partly by 
resting upon the right kidney, partly by its liga- 
mentous attachment to the diaphragm, partly by 
the stomach, duodenum, transverse colon and 
other portions of the gastro-intestinal tract, partly 
by the anterior abdominal muscles, and partly by 
the shape of the space at the side of the spine in 
the curve of the lower ribs. This latter element is 
11 appreciated by study of the Figs. 5, 6 and 7, and 
Figs. 8 and 9, in which it is shown that the lower 
ribs are inclined downward and forward, the 
distal ends curling inward, so that the transverse 
diameter of the body is smaller at the level of the 
lowest ribs than at the level of the ninth or tenth 
ribs, the level of the greatest thickness of the 
liver. It is thus seen that if the body is erect the 
liver rests in a cone-shaped space, the base being 
uppermost, formed by the spine and stomach upon 
the median side with the ribs completely encir- 
cling it upon the other sides or surfaces, and that 
in this erect position downward displacement is 
difficult. It should be borne in mind, also, that 
the ligamentous attachment of the liver to the 
diaphragm is well at the back, so that this also 
tends, if the body is erect, to hold the organ in 
the space in which it is most easily supported 
and will interfere the least with the function or 
position of the other viscera. 
With the stomach, similar elements are also 
present, the main portion lying partly in the de- 
pression at the left side of the spine (Fig. 7) and 
supported by the attachment to the diaphragm 
which is well to the back of the center of the body. 
In this position and with these attachments there 
is but little tendency to sag, either downward or 
forward, if the abdominal muscles are of their 
proper tone and they are acting with the body in 
proper poise. Under such conditions the muscle 
wall not only holds the stomach back in its place 
at the side of the spine, but by compressing the 
12 intestines and holding them compactly together 
furnishes a definite support from below. 
This placing of the heavier abdominal viscera 
distinctly posterior to the posterior abdominal 
wall below so that they rest upon ridges or shelves 
or in depressions in which will result the minimum 
of strain upon the various visceral ligaments is 
well shown in the cross-sections, but is equally 
well shown in the longitudinal sections in the 
following illustrations taken from Corning's 
" Lehrbuch fur topographischen Anatomie." 
In Fig. 10 the viscera are shown with the left 
portion of the abdominal wall removed. The 
position of the kidney is well shown, the depres- 
sion or shelf furnished by the retroperitoneal fat, 
which rests in turn upon the psoas and quadratus 
muscles, with the backward inclination of the 
organ at the top, being quite evident. The differ- 
ent depth of the upper and lower portions of the 
abdominal cavity is also well shown, the lower 
being shallow, the upper being deep, so that the 
longitudinal axis of the cavity drawn through the 
middle of the section at the upper portion and 
again through the middle of the section of the 
lower portion is downward and forward about 
20 or 30° from the vertical. Because of this it will 
be seen that the resultant of the force of the down- 
ward thrust of the viscera is received against the 
lower part of the anterior abdominal wall, and the 
appreciation of this gives a new significance to 
the unusually strong arrangement of the fascia) 
in this region. 
13 In Fig. 11 the right abdominal wall has been 
removed and shows the same relative position and 
support of the kidney with the portion of the liver 
still in place. 
In Fig. 9 the view is of the right side, the entire 
liver being in place, and it not only shows the 
organ extending far back at the side of the spine, 
but also suggests the importance which the lower 
ribs represent in its support, a fact that is also 
shown in Fig. 8. The inward inclination of the 
lower four or five ribs, so that they practically 
grasp the liver, is at once apparent. 
The pelvic cavity with its axis at nearly a right 
angle to the axis of the abdominal cavity is well 
shown in Fig. 12, also taken from Corning's 
" Lehrbuch." In this it will be seen that the 
uterus lies almost entirely under the upper part of 
the sacrum and the last two lumbar vertebrae. 
When this is taken into account, together with 
the different axis of the abdominal cavity, and 
when the narrowness of the lower abdomen is 
appreciated, together with the fact that this 
lower portion is entirely filled with omentum and 
folds of intestine which are held in place by their 
mesenteric attachments, the completeness of the 
protection of the pelvic viscera from forces within 
the abdominal cavity becomes apparent. 
The position of the ovaries is still further one of 
protection from pressure from above, since they 
rest in pockets on either side just below the pelvic 
brim, and the bony part of these pockets is still 
further deepened by the psoas muscles which 
14 stretch across the posterior lateral portion of the 
pelvic brim, extending fully half an inch toward 
the center away from the bone. When it is ap- 
preciated that the common iliac arteries rest upon 
these muscles still further toward the median line 
of the body, the definite character of the fossee in 
which these two organs rest is appreciated. 
In studying such a subject after the anatomical 
elements have been appreciated, one naturally 
turns to the direct study of the human family to 
see if the anatomical theories are supported by 
the practical test. Theoretically, the poise that 
has been described should result in the least pos- 
sible waste of energy and would consequently 
leave the greatest amount of energy available for 
expenditure, the form of expenditure, whether 
physical, visceral or mental, being immaterial. 
One naturally turns at once to the Spartans as 
being the people with whom the economic effi- 
ciency of the individual was probably developed to 
as high a degree as has ever been attained by the 
people of any nation. Their principles may not 
be such as would meet the approval of the present 
time, but they were certainly true to their ideals, 
sacrificing the individual for the good of the race, 
and no people were probably ever subjected to 
greater self-discipline than they. The preserva- 
tion of their health with the attainment of the 
highest degree of economic fitness were matters of 
too great importance 'with them to admit of 
question. 
In studying this part of the subject it has been 
15 possible, through the kindness of Mr. Fairbanks, 
the director of the Museum of Fine Arts in our 
city, for me to have free access to the collections 
of that institution. In the so-called Early Greek 
Room of the old museum, in which were found the 
casts from Greece of the period from 500-600 b.c., 
the time when the Spartans ruled Greece, there was 
not a single cast or reproduction that did not show 
the body so poised that the greatest efficiency of the 
organism would be possible. In Fig. 13 and Fig. 14 
the erect figure is shown, and while the modeling 
may not equal that of the later Greek period, the 
poise is all that could be desired. The head is erect 
and in such balance that all of the muscles must be 
in easy contraction, making possible any move- 
ment, forward, backward, sidewise or with any 
combination, with the greatest ease and with the 
least possible waste of energy. The chest is 
high, allowing the fullest freedom of action of the 
thoracic organs. The shoulders are erect, in which 
position all of the muscles are in easy contraction 
ready for immediate function with the least effort. 
The trunk is so in balance that no group of muscles 
or part is strained, but action with the minimum 
of waste is possible, while the visceral support and 
function is maintained with the least effort. So, 
also, of the legs, there is no strain, but every part 
is ready for full duty with the least waste in 
either time or energy. The greatest amount of 
general fitness is suggested by the figure, and this 
applies not only to that which is physical, but to 
the spirit or the purpose of the individual. In 
16 every part, the body, the mind and spirit, the 
figure suggests readiness and efficiency. 
The same thing is suggested in Fig. 15. The 
ease and balance of the poise is so perfect that it 
requires no effort on the part of the imagination 
to feel sure that the head of the figure must have 
been as well poised as in Fig. 14, as any departure 
from this would have made impossible such per- 
fect poise of the rest of the figure. 
Not only are the standing figures of this period 
worthy of study, but the seated figures are also of 
interest, and in the relief (Fig. 16), not only is the 
standing figure well poised, but the trunk of the 
seated figure is perfectly erect, so that the balance 
of the trunk muscles is not disturbed, and neither 
the thorax nor abdomen is cramped so as to inter- 
fere with the viscera. 
It is naturally not necessary to turn to the early 
Greeks for our types of correct poise, since in all 
ages we have instances which are equally fine, but 
the early Greeks were considered first, as it is 
doubtful if there has ever been a people where all 
were examples of the type, as is true of these 
people of Sparta. Every record that we have of 
them at this time is similar to those which are 
here shown. 
In more modern times it is not difficult to find 
equally satisfactory types, but they are far more 
individualistic and not the universal rule. Noth- 
ing can be finer than the St. Gaudens figure of 
Lincoln (Fig. 17), which is quite remarkable in that 
even though'the figure is depicted in repose, with 
17 one knee relaxed, the trunk is perfectly erect so 
that the poise of the head is free from strain and 
the visceral function, or support, can in no way be 
disturbed. The same thing is also true of Fig. 18, 
the statue at Salzburg of the Empress Elizabeth 
of Austria. In this, also, the figure is depicted in 
repose, yet in the relaxation the trunk is not 
flexed and there is not the slightest suggestion of 
strain or interference with the visceral function. 
Of the seated figures, there is nothing better than 
that of our first President (Fig. 19), in which there 
is not the slightest suggestion of strain or waste of 
energy, the trunk being held perfectly erect. The 
same is also true of the St. Gaudens statue (Fig. 
20) of General Sherman, and in this we have also 
the standing figure ideally poised. 
Of still later time the figure of the athlete 
(Fig. 21) is as finely balanced as any of the early 
Greeks. With him it is evident that not one ounce 
of energy is wasted because of undue strain from 
imperfect posture. It is not to be wondered at 
that such a type is able to win events from less 
well-poised competitors. As a type of physical 
efficiency nothing is left to be desired, and one 
can only hope that such ideals may be more fre- 
quently met in the future, for while many men 
stand fairly well, only those who have studied the 
subject carefully can realize how few stand en- 
tirely well. Since every particle of energy that 
is wasted from imperfect poise, or the faulty use of 
parts, means that much less for reserve when some 
great test comes, no further emphasis should be 
18 needed to make it evident that the attitude as- 
sumed in the performance of any work is of far 
greater importance than the mere esthetic. 
Such illustrations are sufficient to present the 
best type, and while it will probably not be diffi- 
cult to have them accepted as the best, it is, never- 
theless, most regrettable that the type in our 
present civilization is so infrequently seen. Not 
only are the common attitudes less good estheti- 
cally, but the waste of energy which such imper- 
fect use of the body must entail should be a 
sufficient appeal in this age when economic fitness 
is demanded. 
All that has thus far been stated in regard to 
the viscera and the visceral supports has had to 
do with the normal erect figure or with the axes 
of the body in such relation as they are when the 
body is erect. If, now, any departure in these re- 
lations takes place, disturbances in the matter of 
visceral support must take place. If, for instance, 
the body is inclined forward or droops, the ordi- 
nary attitude of weakness or fatigue, the chest is 
flattened at the top, naturally allowing less free 
use of the lungs. The sternum is depressed at the 
top, in which case the space between the sternum 
and the vertebra is narrowed and the action of the 
heart may also be interfered with. 
While the common result when the body 
droops is to depress the sternum so that the an- 
tero-posterior diameter at the upper portion of 
this bone is lessened on an average of from one 
half to three quarters of an inch, the lower portion 
19 may also be depressed or it may be forced forward 
by the flaring of the ribs which may result when 
the body droops. Under this latter condition it 
is evident that the action of the heart would not 
be interfered with mechanically, as it might be if 
the lower portion as well as the upper part of the 
bone were depressed. In estimating the impor- 
tance of the possible changes in the antero- 
posterior diameters of the chest upon the cardiac 
function, caliper measurements are of value, 
since with such an instrument the diameters can 
at once be determined in whatever position may 
be desired. 
With the flattening of the chest, not only is the 
movement or position of the sternum of impor- 
tance, but the effect upon the shape of the upper 
part of the thorax caused by the necessary in- 
crease in the downward inclination of the ribs is 
of much importance, since this frequently is more 
apparent in its effect upon the shape of the chest 
than the sternal positions. The flattening of the 
upper part of the chest at the sides under the 
clavicles is due to this and must necessarily re- 
strict the space normally available for the expan- 
sion of the lungs. By calipers it is possible to 
demonstrate the marked difference between the 
depths of the lateral portions of the chest in the 
erect and in the drooping positions. No argument 
should be required to convince that in the erect 
position the lungs are capable of more perfect 
function than when this space is constricted, as it 
must be when the body droops. 
20 Duct, thorac. 
N. phrenieus 
sin. 
Valvula mi- 
trails und 
Ventric. sin. 
Art. mamma,ria int. 
Margo ant. pulm. sin. 
Fig. 1, Corning: Lehrbuch fur topographischen Anatomie. 
Aorta thor. und 
N. vagus sin. 
Valvula 
tricusp, 
u. Ventric. dexter 
Oesophagus und 
N. vagus dext. 
Atrium dextr. 
Margo ant. pulm. dextr. 
M. teres maj. 
N. phrenic, dexter 
M. latiss. dorsi 
Serratus int.- 
maj. 
Mm. inter- 
costales 
Costa IV 
Mm. pectorales 
maj. et min. Fig. 2. (Dwight.) 
Fig. 3. (Dwight.) Fig. 4. (Dwight.) 
Fig. 5. (Dwight.) Fig. 6. (Dwight.) 
Fig. 7. (Dwight.) Fig. 8. (Sobotta's Anatomy.) Lobus dext. hepatis mit Impressiones costales 
Diaphragma 
Peritoneum 
parlet. 
Costa, IX 
Costa XII 
Fascia lumbo- 
dors. (Lamina 
superficialis) 
XI. latiss. dorsi 
-Colon aseendens 
Peritoneum 
pariet. 
Trista iliaca 
Fig. 9. Corning: Lehrbuch fur topographischen Anatomie. Omentum majus 
JAiaphragma 
Bursa omentalis 
Mesocolon 
Cauda 
Colon transvers. 
Ran. sin. 
Capsula adip. 
rents 
Omentum majus 
Pent, parted, und 
Aste d. A. und 
V. colica sin. 
Mesenterium 
Fettpfropf d. Cap- 
sula adip. rents 
Ansae intest, ilei 
Colon.descendens 
Fig. 10. Corning: Lehrbuch fur topographischen Anatomie. Hepar 
Diaphragma 
Vesicajellea 
Beginn des 
Mesocolon 
Margo ant. 
hepat. 
Facies colica rents 
dextri 
Colon trans- 
vers. 
Costa XII 
Duodenum 
Fettpfropf dev 
Capsula adip. 
rents 
Umschlag des 
Pent, auf das 
Colon ascend. 
Intestinum 
ileum 
Fig. 11. Corning: Lehrbuch fur topographischen Anatomie. Sacrum 
M. rectus ab- 
dom. 
Pars amr 
pullaris 
recti 
Excava- 
tio recto- 
■ uterina 
Vesica ~ 
_Fornix 
~vaginae 
Orificium 
urethrae int. 
Septum 
-rectovag- 
inale 
Corpus caver- 
nosum clitor. 
idis 
Orificium 
urethrae 
ext. 
Canalis 
analis 
Fig. 12. Corning: Lehrbuch fur topographischen Anatomie 
Perineum Fig. 13. 
Fig. 14. Fig. 15. Fig. 16. 
Fig. 17. Ftg. 18. 
Fig. 19. Fig. 20. 
Fig. 21. 
Fig. 22. Fig. 23. 
Fig. 24. 
Fascia lumbo- 
dors. (Lamina 
superfic.) 
Fascia lumbo- 
dors.) Lam. prof.} 
Colon descen- 
dens 
Colon ascendens - 
M. transversus - 
M. obliq. int. 
M. obliq. ext. 
Periton. parlet. 
Aorta 
Art. lumb. 
Gangl. 
trunci sympatic. 
Ram. vtsceralls 
Fig. 25. Corning: Lehrbuch fur topographischen Anatomie. Fig. 26. 
Fig. 28. (Scudder.) 
Fig. 27. (Scudder.) 
Fig. 29. Fig. 30. 
Fig. 31. Fig. 32. 
Fig. 33. Fig. 34. 
Fig. 35. 
Fig. 36. Fig. 37. 
Fig. 38. Fig. 39. 
Fig. 40. With the lower or abdominal portion of the 
trunk the changes of posture become of even 
greater importance than is the case with the upper 
or thoracic portion, for the anatomical reasons 
which have already been described. In the 
changes of the general posture which concern the 
lower portion of the body, two distinct types are 
met with and must be appreciated if the results of 
such conditions are to be understood. 
With the first of these in the forward bend of 
the upper body or the consequent increase of the 
anterior curve of the dorsal spine there is a com- 
pensatory increase in the lumbar curve, lordosis, 
with the protrusion of the lower abdomen forward. 
(Fig. 22.) In this change the pelvis maintains 
its normal position and relation to the legs, but 
as the upper part of the lumbar spine moves back- 
ward, as it must in the position of lordosis, the 
depressions into which the posterior viscera rest 
are consequently deepened, and as far as this 
feature alone is concerned there is less liability of 
the organs becoming displaced downward than 
is normal. Since, however, this feature is only 
one part of the support of the viscera, and since 
the anterior abdominal wall is of much importance 
in this support, it is evident that as this position 
necessarily means relaxation of the abdominal 
muscles, a definite portion of the normal support 
is lost. It is also evident that as in this position 
the abdominal cavity as well as the entire length 
of the trunk is shortened, the viscera are neces- 
sarily crowded downward. In this shortening 
21 of the trunk the antero-posterior diameter of the 
abdomen is necessarily increased, and with this 
increase of the diameter the diaphragm must be 
stretched antero-posteriorly, with the result that 
it becomes flatter and the upper part of the dome 
is lowered. Since at the back the diaphragmatic 
attachment extends down to the last rib, and 
since the liver rests directly against this posterior 
portion of the diaphragm, if the dome of the 
diaphragm is flattened it must result in forcing 
the liver and stomach forward and downward, 
lifting them out of their normal positions in the 
spaces at the sides of the spine in the curve of the 
ribs. This naturally results in an increased pres- 
sure upon the kidneys and other viscera, with 
varying degrees of disturbance. 
With the kidneys the pressure must naturally 
result in the gradual absorption of the retro- 
peritoneal fat upon which they rest, with a weak- 
ening of this natural support so that even though 
the depression in which the organs rest is deep- 
ened, the fat tissue may be so much absorbed that 
together with the lack of tone of the abdominal 
muscles an undue mobility may result. 
In this position, except as the supporting 
structures would be weakened by the bad mechan- 
ical use of the body, the organs of the pelvis 
would not be subjected to any increase of strain 
or disturbance of function. 
The other abdominal type met with in these 
departures from the normal posture is that which 
results from an absence of the compensatory in- 
22 crease of the lumbar curve or its entire oblitera- 
tion. (Figs. 23 and 24.) When this occurs, not 
only is the axis of the abdominal cavity changed, 
but the axis of the pelvis is also changed, the 
angle between these two being materially lessened. 
It is evident that under these conditions the 
smaller this angle becomes the more direct will 
the downward thrust of the abdominal viscera be 
received upon the viscera of the pelvis. Not only 
this, but since, with such flattening of the back, the 
upper body must be inclined forward more 
markedly than is normal, the long axis of the 
body becomes more nearly vertical and the atti- 
tude naturally tends to increase the downward 
sag of the viscera and make displacement more 
easy of occurrence. 
Whenever this flattening of the back occurs 
there must also be a tipping of the pelvis back- 
ward and consequently downward. In the erect 
poise the anterior part of the sacrum as well as 
the anterior part of the fifth lumbar vertebra is 
almost directly over the top of the trochanter, 
the hip-joint being slightly anterior to this. In 
this position the upper surface of the sacrum, 
which articulates with the fifth lumbar vertebra, 
faces forward from the horizontal about 30°. 
From this articulation the lumbar spine inclines 
upward and forward with a gradual change to a 
backward inclination as the dorsal region is 
reached. If for any reason this lumbar curve is 
flattened, the upper part of the sacrum must at 
the same time move backward at the top, the 
23 plane of the lumbo-sacral articulation more 
nearly approaching the horizontal. Since, how- 
ever, the top of the sacrum is practically at the 
top of the pelvic circle, if the sacrum moves back- 
ward it must also move downward, with the result 
that the long axis of the pelvis looks upward more 
than normal. It is at once evident that as the 
upper part of the sacrum moves downward under 
such conditions, and that as this represents the 
base upon which the spine rests, the height of the 
body is lessened. In the simple change from the 
erect position with the normal spinal curves to 
the simple flattening of the lumbar spine, with the 
average individual there is a difference in height 
of between one half and three quarters of an 
inch. In the other type of posture in which the 
curves of the spine are increased, as shown by 
the lordosis, the shortening of the trunk is due, 
of course, to simply an increase of the spinal 
curves and has nothing to do with the position of 
the pelvis, since this is not changed. 
Another important element in connection with 
the attitude in which the back is flattened is that 
the Y ligament is naturally tense when the body 
is held erect; if the upper part of the pelvic girdle 
drops downward and backward, this can only 
take place with at the same time the thigh flexing 
forward. Since the Y ligament naturally cannot 
yield, the flexion of the thigh forward is the only 
thing that can result and this in standing natur- 
ally must be associated with flexion of the knees. 
(Fig. 23.) 
24 The effect which this flattening of the back 
must have upon the abdominal viscera is of much 
importance, since in such a position the lower part 
of the lumbar spine is moved backward, while the 
upper part of the lumbar spine is moved forward, 
with the natural result that the depressions or 
pockets in which, or the shelves or ridges upon 
which, the viscera rest become more shallow. At 
the same time the plane of the floor of these de- 
pressions or ridges necessarily changes so that 
they shelve forward and downward, making 
displacement more easy. With this the fact that 
the whole upper part of the body is carried for- 
ward so that the natural center of weight of all of 
the viscera is more anterior than normal, to- 
gether with the fact that in this position the 
anterior abdominal muscles are necessarily re- 
laxed, makes the importance of attitude in the 
treatment of the displacements of the abdominal 
viscera, and the various enteroptoses, easily ap- 
preciated. 
Since also in this position, with the body droop- 
ing and with the back flattened, the upper part of 
the longitudinal axis of the abdomen is moved 
forward so that the axis more nearly approaches 
the perpendicular, and since also the axis of the 
pelvis moves farther away from the horizontal 
toward the perpendicular, the two axes more 
nearly converge, the two cavities become more 
nearly one, and any force or pressure exerted by 
the abdominal contents must be more directly 
transmitted to the viscera of the pelvis than could 
25 possibly result under the normal conditions with 
the axes of the two cavities at nearly right angles 
with each other. 
Another feature which is less easy of anatomical 
demonstration, but the truth of which is borne 
out by clinical observations, has to do with the 
nervous phenomena, and offers an explanation of 
the common association of the functional nervous 
disorders with spinal symptoms. Whenever the 
body is used so that the center of gravity is for- 
ward of the normal plane, the posterior or spinal 
muscles are subjected to greater use or strain than 
is normal, and if this is continued the muscles 
weaken, with the result that the ligaments are 
strained, causing the common back pains or points 
of tenderness. If the muscles weaken, their blood 
supply will naturally be less abundant than nor- 
mal, and as the lumbar arteries (Fig. 25) and the 
intercostal arteries supply the muscles and send 
a branch into the spinal canal on the level of each 
vertebra, furnishing part of the blood supply of 
the spinal cord, it would seem probable that, if 
the flow of blood to the muscles were less active 
than normal, the amount of blood received in the 
branch which supplies the spinal cord will also be 
less. Whether this is the explanation of the com- 
mon association of neurasthenic symptoms with 
the conditions of spinal weakness, or whether as 
the result of the weakness of the spinal muscles 
the motions of the spine are made less freely and 
thus lead to venous stasis, is entirely problem- 
atical. Certain it is, however, that these two 
26 groups of symptoms are commonly met with in 
the same individual, and that the rapid improve- 
ment in the nervous symptoms which so often 
follows the relief of spinal strain with the correc- 
tion of the spinal weakness would suggest some 
such explanation. 
Not only are such departures from the normal 
poise or proper balance of the body, as have been 
shown in Figs. 22, 23 and 24, seen commonly, but 
there are many variations of these met with which 
demand consideration if anything approaching 
normal health is the standard desired in the treat- 
ment of these individuals. The simple round or 
stoop shoulder attitude (Fig. 26) so common in 
childhood, the bad postures assumed with such 
frequency by the children when sitting, especially 
during the school periods (Figs. 27 and 28), the 
stooping habits associated with disease of the re- 
spiratory tract (Figs. 29 and 30), the attitudes 
with sprung knees and flexed thighs resulting 
from flat feet, to say nothing of the faulty atti- 
tudes which result from definite disease of the 
framework of the body, such as disease of the hip 
(Fig. 31), disease of the spine (Fig. 32), all must 
be given proper consideration if the maximum 
amount of improvement that it is possible to offer 
to the patient is to be achieved. 
It probably needs but little argument to show 
that use of the body in any of these ways must 
result in a much low'er standard of efficiency than 
should be our ideal, or than is suggested by the 
type pictured in Figs. 13 to 21. If the body is 
27 held erect and well poised, there must be the 
greatest amount of energy available for whatever 
function the individual may choose or be forced to 
perform. The muscular forces are used with least 
waste, the viscera are most favorably situated for 
function, the circulation in the spinal cord as well 
as in the rest of the body is subjected to the least 
interference, so that there is the least possible 
waste of either mental, nervous or physical energy, 
and the spirit of the individual has its greatest 
potential. Any departure from this use of the 
body means waste, and when we realize that the 
types depicted in Figs. 22, 23, 24, 29 and 30 are 
not rare, but exist in varying degrees in a very 
large number of individuals, irrespective of age 
or sex or of social position or occupation, a slight 
idea of the great waste in human energy can be 
formed. How unfair the problem of the struggle 
for existence becomes when in addition to the 
regular work it is necessary to expend a consider- 
able portion of energy in overcoming the strain 
resulting from such imperfect postures. It would 
take but slight thought to decide which of the 
two types, Fig. 21 or Fig. 22, or Fig. 18 or Fig. 24, 
would be able to best meet the task which life 
makes necessary, and whether the task be physi- 
cal or mental is immaterial. Not only from the 
simple viewpoint of health is such a consideration 
of importance, but at this time when subjects 
such as the conservation of the nation's resources, 
the conservation of energy, the utilization of 
waste, the elimination of friction, are being so 
28 seriously considered, it seems only appropriate 
that that which concerns the preservation and 
most perfect utilization of the energy of the human 
being, upon which all of these other questions 
must depend, should be given full consideration. 
Under such conditions as are here shown, there 
must be strain of the muscles and ligaments or a 
waste of energy; the viscera, neither the thoracic 
nor the abdominal, can be normally used, and the 
general circulation must be less free than normal, 
so that the whole body suffers and the energy 
that can be delivered in case of any stress is far 
less than that which exists in potential. It is to 
prevent this waste, as well as to relieve the more 
distinct conditions of disease, that should be the 
effort of the medical profession. It is preventive 
medicine which has come to be so large a part 
of the work for which our profession is held 
responsible. 
The recognition of the many problems suggested 
in such a paper as this means that the physician 
has a higher function than the mere treatment of 
local conditions, however commendable this may 
be. It means at once that our work must be 
judged upon the bases of the ultimate cure or 
general efficiency rather than simply the immedi- 
ate relief of some local lesion. This oftentimes 
represents only the beginning of our work. The 
flat foot, the tuberculosis of the lungs or what- 
ever the special lesion may be should, of course, 
be corrected or relieved in so far as it is possible 
so to do, but our care should not stop until the 
29 highest degree of physical efficiency for that in- 
dividual is obtained. 
It means that with pulmonary tuberculosis the 
simple insistence on good hygiene with fresh air 
and food is not all that the physician is called upon 
to perform. The Figs. 29 and 30 were taken at 
random by the director of the class in one of the 
best supervised of the tuberculosis classes in our 
city at the request of the writer, but without any 
selection by him. They show how imperfect the 
posture is and how imperfectly the respiratory 
functions must be performed, and suggest the 
waste of energy which there must be from the 
back strain at just the time when all the forces 
should be conserved. Such persons may get well 
from the good care they receive, but how much 
easier and surer it would be if the body could be 
held erect so that the thorax could be thrown wide 
open and the fresh air that is so insistently urged 
could be taken in in full measure instead of with 
so much stint. Not only would the possibility of 
relief of the local condition be greater, but the 
energy which is now wasted in the unnatural 
strain of the spinal muscles, with the interference 
with the function of the other structures, could 
then be used for recuperation. Repair under such 
conditions must take place more rapidly and be 
more enduring when complete. 
It means that in the treatment of disturbances 
or displacements of the pelvic organs, it is only 
half doing the work if the condition is simply 
treated locally, while an imperfect posture which 
30 may have been largely responsible for the trouble 
is allowed to go uncorrected. It needs little argu- 
ment to show that a cure of such a lesion in a 
person poised as in Fig. 18 must be much simpler 
than when such an attitude exists as is pictured 
in Fig. 24. 
It means that in the various abdominal visceral 
ptoses there is more to do than treat locally a 
stomach which may have sagged out of place by 
irrigation or drugs, or' to even suture a kidney 
in place because it too has sagged. Operations, 
stomach washing and the various forms of local 
treatment for all such conditions are undoubtedly 
necessary and may give temporary relief, but 
none of these can be expected to really cure the 
lesion until the whole body can be used in such a 
way that there is the least possible tendency to 
visceral displacement and there is the greatest 
amount of energy available for the proper nutrition 
and function of all the structures of the body. 
Until the question is approached in some such 
way as this, and the body is considered first with 
the local condition second, or at least with due 
regard to the first, until then this large class of 
abdominal disturbances will be unsatisfactorily 
treated, either by the internist or the surgeon, and 
our profession will be reproached for that for 
which, judging from many of the results obtained 
in such cases, reproach seems deserved. 
Our responsibility with our patients not only 
concerns the attitude assumed or the condition 
present at the time of examination, but we must 
31 also know the way in which the body is used in 
the routine of life, with the correction of the errors 
in so far as this is possible. In other words, the 
contributive factors to imperfect poise should be 
studied and remedied. It is foolish, for instance, 
to treat the weakly child that stands with the 
chest flat, with the shoulders drooping forward 
and with the abdomen relaxed by simply giving 
tonics. These have their place, of course, but 
the causes of such attitudes should be investi- 
gated, and of these the costume, because most 
often at fault, should be looked at first. If the 
underwaist to which the clothing as well as the 
stocking straps is usually attached is supported 
by straps which cross over the outer or movable 
part of the shoulders, this must be changed so 
that the support is received upon the more stable 
part of the shoulder near the base of the neck. 
So also, if we leave the habit of standing with the 
hands in the low trousers pockets (Figs. 33 and 34) 
uncorrected, our treatment of the round shoulder 
will avail little, because in this position the shoul- 
ders must drag forward and the chest must be 
flattened. Again, if we try to correct the poise 
of the woman without considering the costume 
our treatment will often avail but little. In 
this the corsets are, of course, the element of 
chief importance, and the types pictured (Figs. 
35 and 36) show the extremes which must be 
met. The types pictured are of the old straight 
front corset and the present long, flat-back pat- 
tern. The former, although seemingly the more 
32 radical, is, however, less harmful than the latter 
because it causes less spinal strain and less inter- 
ference with the position or function of the 
viscera. The normal lordosis is increased and 
with this the forward inclination of the pelvis is 
increased. This inclination of the pelvis forward 
relatively shortens the ham-string muscles and 
makes the easiest standing position with the 
knees slightly flexed and with the heels raised. 
The body is hyperextended, the chest must be 
elevated, the lumbar spine must be curved for- 
ward more sharply so that the thorax and the 
abdomen are held in such a way as to favor the 
proper support and the free function of the vis- 
cera. As awkward as such a figure must appear, 
the effect upon the visceral support and function, 
as well as the effect upon the pelvic joints and the 
spinal ligaments, is much less harmful than the 
flat-back type. With this type (Fig. 36) the effect 
is largely reversed, the lumbar spine is flattened, 
which necessarily means the tilting of the pelvis 
backward and downward, and the upper part of 
the body being thrown forward, the shoulders are 
at the same time pushed upward. Such an atti- 
tude must mean strain to the sacro-iliac joints 
and the spinal muscles and also results in ab- 
dominal, pelvic and thoracic positions unfavor- 
able to the proper support and function of the 
viscera. 
It means that if our full duty is to be performed 
that duty has not been fulfilled until we have at 
least explained to the patient the importance of 
33 these elements in their health, and if the emphasis 
is put upon the health entirely apart from the 
esthetic side, the majority will be willing to listen 
to and heed our advice. 
It means also that we should study the habits 
of the patients in their occupations, and harmful 
features be eliminated in so far as is possible, 
explaining that the erect position in standing, 
once it is learned, is the easiest position; that the 
relaxed position, which is an attitude of fatigue, 
causes still further fatigue; that the sitting posi- 
tion with the body erect, inclining slightly back- 
ward, is not only the best position, because the 
abdominal and thoracic cavities are not con- 
stricted, but because also the muscles are the 
least strained; that if the body must be used in- 
clined forward that the trunk should be kept 
straight and not flexed, as is the common posi- 
tion; that in walking the trunk should be straight, 
not flexed, and that if the body is inclined for- 
ward it should be from the hips and not by flexing 
the trunk itself. 
Not only does our function as physicians extend 
into these details of life, but it concerns the posi- 
tions of the body during the resting or recumbent 
periods. We must remember that when lying 
upon the back, if the bed or supporting structure 
is hard so that the buttocks cannot settle into it, 
that the lumbar spine must sag downward, and if 
the buttocks are large or the waist small, the 
amount of this sag may be enough to cause pain- 
ful strain upon the interspinous ligaments or upon 
34 the sacro-iliac joints. So, also, the position upon 
the side must mean sag of the middle or unsup- 
ported portion of the body as the muscles tire, and 
results in strain of the spinal ligaments. In both 
these positions the muscle strain with the result- 
ing strain to the joints may indirectly weaken 
the visceral supports and exaggerate existing 
symptoms or be a factor in developing fresh symp- 
toms. If these conditions exist, the use of a small 
pillow' or roll of clothing under the lumbar spine 
in the hollow of the back, or in the hollow above 
the hip, if the side position be the one for con- 
sideration, will often not only relieve distinct 
symptoms of strain, such as backache with the 
referred legache, but will prevent the weakening 
of the ligaments that would result from the con- 
tinuance of such positions. 
The importance of these positions during re- 
cumbency is of particular importance at the time 
of operations and during the course of acute febrile 
disturbances. In the former the unyielding 
character of the operating table, together with 
the temporary paralysis of the muscles, makes the 
maximum amount of strain of the joints possible. 
In the latter, as a part of the febrile disturbance, 
the severe narcosis, together with the general 
dulling of the reflexes, makes possible spinal sag 
and strain that would not occur in ordinary health, 
even if the positions were favorable for such strain. 
This means that in planning operations we 
have responsibilities other than those which have 
to do with the purely local lesion. At such times, 
35 if the whole body is considered, the strained sacro- 
iliac joints with the distressing backaches and 
with the not infrequent disability which results 
from this will not occur. The patient will not 
be put upon the table, as shown in Fig. 37, since 
in this position the thighs are hyperextended, the 
axis of the pelvis must be drawn forward, thereby 
raising the upper part of the sacrum and the lum- 
bar spine. There being no support for the spine, 
however, it must sag back again, and with this 
the sacrum must be dragged downward, the two 
influences necessarily resulting in definite strain 
of the sacro-iliac joints, with subsequent back- 
ache. Not only this, but as the result of the 
hyperextension of the thighs and the tilting down- 
ward of the anterior part of the pelvis the ab- 
dominal muscles must be stretched, making un- 
necessarily difficult the separation of these muscles 
during abdominal operations. With the slight 
support under the back to prevent the sag of the 
spine and also under the knees so that hyper- 
extension is prevented (Fig. 38), all of these unde- 
sirable features can be overcome without in any 
way interfering with the important elements of 
the position. 
With the lithotomy position, also, there is a 
right and a wrong way of obtaining this. If the 
thigh is sharply flexed (Fig. 39) and at the same 
time abducted, and if, as is so commonly seen with 
this, the assistant rests upon the leg as he reaches 
over to assist the operator, the ilium must be 
strained downward and backward, with resulting 
36 sacro-iliac strain and weakness. If, however, the 
thigh is flexed to the position shown in Fig. 40, 
and if a bandage or strap is attached about the 
knees to prevent the marked separation of the 
knees, the position can be maintained indefi- 
nitely without harm and without sacrificing the 
essential features of the position. 
In conclusion, the writer feels that both the 
medical profession and the laity should realize 
that there is a certain definite amount of energy 
available for expenditure with each individual; 
that this energy can be expended in many differ- 
ent ways, but that if expended for one thing it 
no longer is available for other efforts, except 
after periods of recuperation. The form of the 
expenditure, whether in mental or physical ex- 
pression, is immaterial, and the waste of this 
energy is not only undesirable, but is usually 
harmful. It is our great function as physicians to 
show in every way possible how the human organ- 
ism is to conserve this energy so that when ex- 
pended it shall yield to the world the largest 
possible return. If used rightly the physical 
functions will be more perfectly performed, the 
mental powers will be greater, and the spirit of 
the individual must be finer if expressed through 
a body properly formed and used. It has caused 
no surprise to find Washington and Lincoln 
poised so that there could be no waste from the 
improper use of the physical frames with which 
they were endowed. We unconsciously expected 
to find them so poised, and we expect such types 
37 to measure up to a very high standard when the 
great tests are given. It is our duty, however, to 
recognize that the types which have been de- 
picted as departures from the best have in them 
the potential of the finest and that we can have 
no higher function than that of making it possible 
for some of these poor creatures to so live that 
they, or their children, may approach more nearly 
to the standard that it should be the aim of every 
human being to reach, which, when reached, 
must mean a high degree of efficiency of all the 
elements of the body, the physical, the mental 
and the spiritual.1 
1 In the preparation of the anatomical parts of this paper I am 
indebted to Professor Dwight and Professor Warren of the Harvard 
Medical School for much valuable assistance. 
38