Popular Science Monthly/Volume 42/November 1892/On Posture and its Indications
IN a former paper I observed that I thought medicine lost a great deal by its practitioners either not recording their experience at all, or not recording it in such a form as to be readily available for their fellow-practitioners, or with sufficient precision to be really useful. As examples of vagueness and precision I instanced a verbal description of a face as commonly given, and a sketch containing all the features more or less precisely drawn. In the present paper I have tried in a very imperfect way to indicate the common postures which one meets with daily, either in patients or others, and to discover the reason why those postures are assumed. I have not attempted to draw the figures, for this would have been beyond my powers, and probably also
|Fig. 1.||Fig. 2.|
beyond the powers of many medical men. I have simply indicated the position by a few simple lines such as anyone can draw. This method is one which was employed with great success by the late Prof. Goodsir more than thirty years ago in illustrating his lectures on anatomy. In a few lines he conveyed the impression of the agility of the cat as compared with the heavy movements of the ox or of the elephant, and the absence of detail fixed the minds of his students all the more firmly on the main facts which he wished them to carry away. As we walk along the streets and notice the difference of attitude in the passers-by, some with head erect and agile steps convey to us at once the idea of energy and activity (Fig. 1), while others with hanging heads and bended knees suggest the ideas of languor, weakness, and depression (Fig. 2). It is a matter of ancient observation that such an attitude as this is associated with weak circulation, and it is probably more than three thousand years ago that the injunction was given: "Strengthen ye the weak hands and confirm the feeble knees; say to them that are of a fearful heart, Be strong, fear not" (Is. xxxv,
|Fig. 3.||Fig. 4.|
3, 4). When the heart is stimulated by joy or hope, the attitude again becomes erect, and the gait brisk and elastic. It is by no means easy to distinguish exactly between the part played in this change by the motor cells of the nerve-centers and by the circulatory apparatus, for the activity of the motor cells on which muscular action depends is itself influenced to an enormous extent by the circulation of blood through the nerve-centers. We find an example of this in the attitude unconsciously assumed by any one engaged in conversation or argument. So long as he takes only a listless interest in the subject under discussion he may lie back
|Fig. 5.||Fig. 6.|
in the chair with his legs crossed and his arms either hanging down or his hands laid loosely in his lap (Fig. 3). As his interest increases his attitude becomes more erect (Fig. 4), and he sits straight up, with his hands folded or laid upon his knees instead of hanging listlessly down (Fig. 5). As the interest increases still further the body is bent forward at an angle and the hand is very probably placed firmly on the thigh (Fig. 6). Fig. 7.If he becomes excited in the heat of argument, the body is bent forward at a somewhat acute angle and the hand is stretched out in front and somewhat upward, as if to help the words which flow from his lips to drive the thoughts which are rapidly evolved from his brain into his opponent's mind (Fig. 7). In this position the flow of blood through the arterial system onward to the brain as well as its return backward through the veins seems to be particularly easy (Fig. 8).
This position is not only assumed during the heat of argument whether the speaker be sitting or standing, but when one is led to assume it unconsciously it seems to give rise to a rapid and sometimes almost uncontrollable flow of ideas. Thus it occasionally becomes a cause of remorse to devout souls, who during the attempt to pray in church in this attitude are sadly distracted by crowds of ideas which at once disappear on the assumption of an easy sitting posture. The circulation in the cerebral vessels and the current of ideas in the brain are very delicate things and may be modified by very slight causes; thus, an attitude with the head drooping slightly more than that indicated in Fig. 6, and with the chin supported upon the hand, is the one frequently assumed in deep thought, with concentration of ideas upon a single subject, and no desire for immediate expression (Fig. 9). The touch of
Fig. 8.—Tracing from the Brain. A, in upright position; B, with head inclined forward.
the hand upon the head seems to have a directing power over the thoughts which one would formerly have been inclined to deny, but such experiments as those of Tesla and Crookes with electric currents of very high tension give a visible illustration of phenomena previously unknown and seemingly incredible. For in these experiments a person who has put himself into the electric field renders vacuum tubes containing various substances fluorescent, and fills them with a glow of colored light by simply waving his hands over them. The tubes, which were previously dark, owe their luminosity only to the approximation of his hand, yet he himself does not feel that any special power has gone out of him. The contact of the hand with the temples seems as if it could hardly by any possibility modify the circulation in the brain or the feelings of the individual, and yet it appears to have
|Fig. 9.||Fig. 10.|
an actually soothing effect and to be a real physical solace in cases of grief and depression (Fig. 10). At the same time the greater droop of the head possibly provides for a better supply of blood to the sensory parts of the brain in the posterior part of the head, and thus to a certain extent counteracts the general weakness of the circulation. In the case of excitement (Fig. 7), the head being more raised, if a straight line were drawn through the axis of the body so as to represent the line of the aorta and carotid arteries, it would come out at the anterior part of the head, and blood driven onward in this line would supply nutriment rather to the motor than to the sensory centers.Fig. 11.In cases where the circulation is exceedingly weak and syncope is threatened, a most useful plan is to make the patient put his head down between his knees (Fig. 11), so that an ample supply of blood shall reach the cerebral centers. Long ago, before the introduction of anæsthetics, a common plan of rendering patients senseless previously to the performance of an operation was to lay the patient flat upon his back and then suddenly hoist him to a standing posture by six strong men who held him by the arms, three on one side, and three on the other. The brain being thus, as it were, lifted away from the blood, became so anæmic that it ceased to act before the circulation could adapt itself to the new posture.
An experience of my own once showed me how very dependent the brain is upon the supply of blood. I was called upon one night after a long day's work to write an article immediately. I sat down with, pen, ink, and paper before me, but not a single idea came into my head, not a single word could I write. Lying back, I soliloquized: "The brain is the same as it was yesterday, and it worked then; why will it not work to-day?" Then it occurred to me that the day before I was not so tired, and probably the circulation was a little brisker than to-day. I next thought of the various experiments on the connection between cerebral circulation and mental activity, and I concluded that if the blood would not come to the brain the best thing would be to bring the brain down to the blood. I laid my head flat upon the table, and at once my ideas began to flow and my pen began to run across the paper. I thought, "I am getting on so well, I may sit up now," but the moment I raised the head my mind became an utter blank, so I put my head down again flat upon the table and finished my article in that position.
Stimulation of some branch or other of the fifth nerve seems to increase the circulation in the brain, and those who are making their utmost calls upon their mental powers are accustomed to stimulate this nerve in one way or another. The late Lord Derby used to eat brandied cherries, and an experiment of Marey's (Fig. 12) proves that mastication will accelerate the flow of blood through the carotid artery, and serves to show the wisdom of an editor whom I knew who used to eat figs while writing a leading article, and even of those who indulge in the practice so disagreeable to their neighbors of chewing tobacco. Others stimulate the gustatory branches of the fifth nerve by the sweets which they suck, or by the smoke of a cigar or cigarette, while a rustic calledFig. 12.—Tracing of the Rate of Circulation in the Carotid. (After Marey.)upon suddenly to answer a question will probably excite the cutaneous branches of this nerve by scratching his head, and a man of more culture may stroke his mustache or beard, press his forehead or eyes, or, like many Germans, smite his nose with the forefinger.
A similar reason may be given to explain the habit of snuffing, formerly so much in vogue. The gentle titillation of the nasal mucous membrane by the snuff probably serves to stimulate the cerebral circulation, and the increased arterial tension due to the efforts of sneezing so increases the cerebral nutrition that difficulties seem at once to disappear, and obscurities of mental vision are so rapidly removed that snuff is said in popular language to "clear the head." The practice of snuffing has fallen to a great extent into disuse, but it may still be occasionally employed with advantage in cases of severe and persistent headache, where other remedies fail to relieve. Even where such a strong irritant as snuff is not resorted to, smelling salts (sal volatile) or aromatic vinegar may give considerable relief in headache if frequently inhaled.
While stimulation of the fifth nerve as just described tends to keep people awake and increase their mental activity, gentle, rhythmical stroking of the head tends, on the contrary, to make them fall asleep, and brushing the hair has this effect on many people to such an extent that the movements of the hair-dresser's fingers over the scalp, and rhythmical click of the shears, will
|Fig. 13.||Fig. 14.|
send some people to sleep, even at the risk of having their hair shorn to a much greater extent than would be at all pleasing to them on awakening. A gentle rubbing of the scalp, as if to loosen it upon the skull, also tends not only to soothe irritability, but to relieve and to prevent headaches.
External temperature has a powerful effect in determining posture. On a hot summer's day the natural tendency is to lie down with the head slightly raised, the arms hanging loose, and one leg extended, while the other perhaps is drawn up, as in Fig. 13. The physiological reason for this posture is that in it the greatest extent of cooling is attained, for it insures the greatest possible exposure of the largest vascular district in the body—viz., the intestinal vessels—to the cooling influence of the external air. This is aided by the loss of heat due to the evaporation of sweat. By the slight raising of the head and the drawing up of one leg, the abdominal parietes are rendered loose, and the intestines tend to fall sideways, and the abdomen tends to become flattened from before backward. The greatest extent of cooling surface is thus obtained, and the temperature of the body is kept as low as possible.
An entirely opposite attitude is assumed when the external air is cold (Fig. 14). The thin abdominal walls being insufficient to protect the intestinal vessels from the cooling influence of the external air, the legs are drawn up until the thick muscles of the thigh form a warm covering to the abdomen and thus prevent loss of heat from the intestinal vessels. Many people are unable to get to sleep when they are at all cold; and Rosenthal has shown that this attitude is commonly adopted by men, dogs, and other animals when preparing to sleep, so as not only to maintain the bodily temperature during sleep, but to allow the intestinal vessels to dilate and accommodate a mass of blood which would otherwise be driven into the cerebral circulation, stimulating it to functional activity and keeping the person or animal awake.
The attitude of the body may be altered permanently by occupation or disease in such a way that one accustomed to pay attention to this subject can frequently make out, with a little trouble, a good deal regarding the patient's history and illnesses. Thus, a chronic cough has the effect of inflating the chest and rounding the back, so that one might almost guess from the figure (15) that the person so shaped was liable to chronic bronchitis. The more tightly a bladder is blown up with air the more tense does it become
|Fig. 15.||Fig. 16.|
and the more does it take a circular form. In the same way the more an alveolus of the lung is blown up by the efforts of coughing the more does it resemble the inflated bladder. What is true of a single alveolus is true of the chest as a whole. It tends as nearly as possible to become globular, with a circular outline not only in the transverse but in the longitudinal direction. The sternum and vertebræ prevent it from becoming completely globular, notwithstanding all efforts, and it thus assumes the barrel shape so characteristic of emphysema, as being the nearest possible approach to a globe. In going through a hospital ward one sees here and there patients who are constantly sitting up in bed and do not lie down at all; these are for the most part people who have great difficulty of breathing. The reason for this position has no doubt been often given, but I do not recollect coming across it in print and I can not say whether
the reason that I now give has been evolved from my own brain or whether I have learned it from others.
When a man is sitting upright the diaphragm moves up and down during respiration (Fig. 16). At each inspiration it descends and displaces the intestines and the abdominal walls outward.Fig. 17.During each expiration the diaphragm ascends and the intestines and abdominal wall return back to their former position. In the upright posture the diaphragm moves vertically, but the abdominal walls and intestines move in a horizontal plane and there is no lifting work for the diaphragm to do. The case is quite different when a man is lying on his back, for then the diaphragm moves in a horizontal plane and the abdominal walls and intestines in a vertical one. During inspiration as the diaphragm encroaches on the abdomen for the purpose of enlarging the thorax (Fig. 17) it has actually to raise the intestines and the abdominal walls instead of merely moving them in a horizontal plane. As the diaphragm returns into the thorax during inspiration its progress will be accelerated by the weight of the descending intestines, and thus the recumbent posture may be sometimes useful in cases of bronchitis with emphysema, and so such cases may be seen sometimes lying down although there is considerable interference with the aëration of the blood. In cases of cardiac disease no benefit of this kind is obtained, and therefore we find that a large proportion of those whom we see sitting upright in bed in a hospital ward are suffering from disease of the heart.
When a patient lies upon his side the intestines also move in a horizontal plane, and this is the position usually assumed during healthy sleep, for in it there is no interference with expiration any more than when the patient is sitting upright, while at the same time the rest obtained is much more complete. The side upon which one lies is immaterial to most healthy persons, and they frequently lie first upon one and then on another, turning over perhaps several times in the course of the night; but in cardiac disease or cardiac irritability without organic disease patients frequently are unable to lie upon the left side because the heart beats against the ribs with such force as to cause physical discomfort. At the same time the heart itself appears to be stimulated by the blows which it gives itself against the thoracic walls and to palpitate more violently than before. The patient is therefore obliged to lie upon the right side. A similar result may occur if the liver is enlarged or congested, for then it seems to drag upon the suspensory ligaments when the patient lies upon the left side, and thus he is obliged to turn round that the liver may be supported by the ribs. If a heavy meal has been taken shortly before retiring to rest the person may be unable to lie upon his left side because the stomach drags upon its pyloric end. On the other hand, if the stomach is distended by flatulence, the gases sometimes will not escape while the patient is lying on his right side, and he must either be raised into a sitting posture or be turned on his left side to allow the gas to eructate by the œsophagus and the tension in the stomach to be relieved, for the œsophagus joins the stomach at such an angle that when the patient is on his right side the gases appear to accumulate and not to find an exit through the oesophagus, but when he is on his left side they pass upward with comparative ease. This, of course, is a matter of very slight moment to patients who are able to move readily, because they adjust their own position at will and soon find out which is the most easy one for them. But when a patient is so weak that he is unable to move himself he is frequently allowed to lie flat on his back and to suffer much from abdominal distention and even from difficulty of breathing, due to the diaphragm being pushed upward, when he might be relieved by simply sitting him up for a few minutes or turning him over on his left side.
In this short paper I have made no reference to many other postures in disease, neither have I attempted to discuss the postures due to trade, nor have I attempted to make the paper complete. I have merely tried to give an illustration of an easy method of recording posture in a tolerably precise and easily understood way, and have attempted to connect external signs with physiological conditions as an illustration of the method of tracking which I mentioned in a former paper in the hope of inducing others to prosecute the same line of work.—London Lancet.
- On the Method of Zadlig in Medicine. The Lancet, January 2, 1892.
- Also, "Lift up the hands which hang down, and the feeble knees, and make straight paths for your feet " (Heb. xii, 12).
- I have found this practice useful. The explanation I have given of its utility was, I think, suggested to me several years ago by John Haddon, M. A., M. D.