Standards of physical development for reference in clinical appraisement

STANDARDS OF PHYSICAL DEVEI~OP~[ENT FOR RE FE RE N CE IN CLINICAL APPRAISE~[ENT :~~ ~ U G G E S T I O N S F O g TI[EIP~ P R E S E N T A T I O N

AND USE

HAaOLD C. SrruA~T, M.D. BostoN, MASS.

HERE T monly

are two primary purposes for which measurements are comtaken by pediatricians and compared with standards of physical development. The first is in connection with research projects which deal wit.h differences between groups of children, as for example, differences due to age, sex, race, and type of body build, and studies of the effects upon growth of differences in diet, activity, environment, and disease. It is generally conceded that for these research purposes all figures should be s~bjeeted to certain statistical procedures and that a working knowledge of modern biometrie technic is required for the interpretation of group differences. The second purpose in using measuremerits is to assist in the evaluation of individuaI children and in the detection of faulty development. Measurements chosen for these clinical purposes must be few in number, obtained with reasonable accuracy by simple devices, and subject to interpretation without ~ndue mathemathieal complexity. It is also important that the standards used show in proper perspective the attributes of individual measures and throw into relief significant rather than unimportant or nnreal features. It is the purpose of this paper to consider this elinieN use of anthropometrie data, particularly the way they may be thought of and compared with clinical judgments for most useful eonelusions. The simplified standards or rules of thumb formerly adopted for clinical use in examining children have, for the most part, proved too inaccurate for real discrimination. Among the many attempts to refine them and make them more ser~ieeaMe, the use of indices based upon the relation of two or more measurements to each other has received the greatest attention. These have their uses, particularly in the sortJng out of different classes of children by clinically inexperienced perF r o n t t h e D e p a r t m e n t of C h i l d !-Iygiene, H a r v a r d S c h o o l of P u b l i c H e a l t h , a n d t h e D e p a r t m e n t of Pe~tiatrics, I - I a r v a r d M e d i c a l S c h o o l , B o s t o n . :Read b e f o r e t h e A m e r i c a n P e d i a t r i c S o c i e t y , A s h e v i l I e , N . C., M a y 3, 19~4~ * M o s t o f t h e m e a s u r e m e n t s p r e s e n t e d in t h i s p a p e r h a v e b e e n f a l l e n a n d t a b u l a t e d b y ~ q e r n e t t e ~qickers, B . E d . , a n d C o n s t a n c e S h a w , B.S.S., in. c o n n e c t i o n w i t h ~ m o r e c o m p r e h e n s i v e s t u d y of g r o w t h a n d d e v e l o p m e n t b e i n g c o n d u c t e d b y the: D e p a r t m e n t of C h i l d I-Iygiene. T h e y wiIl b e r e p o r t e d in g r e a t e r d e t a i l w h e n t h e s e r i e s h a s b e e n completed. 194

STUART:

STANDARDS OF P H Y S I C A L D E V E L O P M E N T

195

sons. Many of t h e m seem very abstract and impractical. F o r pediatricians or those clinically trained and experienced in the examination of children, the time spent arriving at the mathematical expression of a relationship would often seem better spent in making direct comparisons, one measurement with another, and eaeh with clinical observations and with the child's history. W h a t seems most needed is some sbnple method of assembling and presenting in reasonably comparable form, d a t a derived from different sources and by different technics.. One would like to have the m a i n features of this data visualized, or at least as free f r o m figures and unessential details as possible. Measurements should be used to reinforce and imp~'ove clinical judgments, not to replace them. They should fit in logically with clinical methods of thought, for their usefulness is in large measure dependent upon the way in which they are analyzed and interpreted. The clinician is constantly comparing one c h i l d with a composite picture of children of similar age. This picture includes a wide range of variations which he has come to expect on the basis of experience. The w a y any one physician will interpret a child will depend both upon the accuracy of his observations and upon the extent and t y p e of his personal experience. The physician uses measurements p r i m a r i l y to confirm or refute his impressions of size and proportion and to call attention to unusual features which he has overlooked; in short to assist in making his interpretations as objective as possible. Norms should therefore be so assembled and presented as to allow direct comparison between subjective ratings and the implications of measurements. Since the consideration of an individuM's relation to the usual range of occurrences offers a most helpful approach to an u n d e r s t a n d i n g of him and since all measurable attributes show wide variations at any given age, it would seem most helpful if norms made it possible to determine the place an individual holds in relation to the usual distribution of measurements. One should also be able through the use of norms to compare a child's r a n k in one measurement with t h a t in another. The interpretation to be placed on any one measurement depends to a considerable extent u p o n the general position of others. One also wishes to be able t o compare a child's position at one time with previous periods, to see whether his progress has been satisfactory. A n y single figure chosen to represent the s t a n d a r d or usual measure of an attribute u n d u l y emphasizes one point in a range and attaches tO it a suggestion of normality not shared by other figures. Experience with the average weight figure in the use of height-weight-age tables is a n o t a b l e example. The estimation of the percentage of deviation f r o m this average is a crude a t t e m p t to measure the degree of variation which the individual exhibits, but the figure obtained is meaningless

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THE

J O U R N A L OF PE,DIATt~ICS

unless one remembers the frequency with which different devias are n o r m a l l y found. F u r t h e r m o r e , negative deviations inevitably c a r r y with them the implication of inferiority. One can introduce the coneept of "range" by giving the two figures which supposedly limit normal findings. However, the actual ranges f o u n d in large series include such extreme and unusual deviations t h a t it becomes necessary, if they are to have practical significance, to include only those figures which are of fairly common occurrence. P a b e r 1 has p r e p a r e d modifications of the height-weight-age tables which give t h e range rather t h a n the average, but his tables eliminate the top and bottom 10 per cent f r o m each group as too unusual to be included. These tables are undoubtedly m o r e use"FIGURE 1

THE NORMALCURVE FITTEDTO THE FREQUENCY DISTRIBUTIONOF LENGTHS OF38BOYS AT 12 MONTHS

///// ///// ///// ///// ///// /////

////% I / / / /

1/1// I / / / / / / / / /

CMg,

700- 7L9 72.0-7~ 74.0-75,9 760-779 780-79,9 8Q0~81.9 CNI~.

ful t h a n those giving averages, but they do not indicate, except in the extremes, how common or how unusual a specific measurement really is. There are various methods of setting up standards based u p o n measurements obtained on large groups of comparable children, b y which the frequency of occurrence of p a r t i c u l a r measurements m a y be shown. One method is to lay off eolmnns representing" given intervals of measurements and indicating in each column the n u m b e r of children falling in that p a r t i c u l a r interval. This is the method usually adopted in the reports of the Children's B u r e a u and used by Eliot 2 in her recent report on P o r t o Riean children. I n t e r p r e t a t i o n of these tables involves a comparison of a series of different numbers, a disadvantage which may. be avoided by plotting the numbers u n d e r each measure as a graph. Fig.

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STANDARDS OF P H Y S I C A L D E V E L O P M E N T

197

1 shows the lengths of the one-year-old boys in our series plotted by intervals a n d fitted to a hypothetical " n o r m a l distribution c u r v e . " Measurements are only a means to an end, and we wish, as quickly as possible a f t e r taking them, to forget the actual figures and to think r a t h e r of their implications. W h e n using a. graphic representation of a distribution of figures, as a norm or s t a n d a r d of reference, we focus attention u p o n the position which a p a r t i c u l a r child adopts in relation to a s t a n d a r d group and upon the n u m b e r of children like him, rather than upon the m e a s u r e m e n t itself. I t is, however, cumbersome to deal with g r a p h s and preferable t6 use Some expression to show these relationships. One w a y is to use the mean (average) a n d the s t a n d a r d deviations (sigmas) f r o m this mean. The position of the mean and One to three positive and negative s t a n d a r d deviations are indicated in a " n o r m a l distribution c u r v e " in Fig. 2. This method of expression is generally conceded to be most useful in research projects, in dealing with figures which have a relatively " n o r m a l " or symmetrical distribution. and is the method adopted by G r a y and Ayres2 Another method of expressing position in a distribution is to use the percentile scale. This can be applied to any set of figures regardless of whether or not they follow closely a " n o r m a l " distribution. U n d e r this system the n u m b e r of cases in any series is divided into succeeding percentage divisions according to increasing measurements. The 25 percentile (first quartile) indicates t h a t 25 per cent or one-quarter of the measurements fall below and three-quarters above this figure. The 50 .percentile is the median of the group, which means that an equal n u m b e r fall below a n d above this figure. Similarly half of the cases fall within the range limited b y the 25 .and 75 percentiles. A v e r y simple and practical scale uses the 10, 25, 50, 75, and 90 percentiles, thus dividing any series into six intervals or ranks: u n d e r 10, 10 to 25, 25 to~50, 50 to 75, 75 to 90, and over 90. These divisions of a " n o r m a l distribution c u r v e " are shown in Fig. 3. W h e n norms are distributed in this way, one m a y readily place any child in one of the six r a n k s in respect to each of the m e a s u r e m e n t s taken. This scale has been adopted for reporting our measurements in the tables and figures which follow, although in plotting the growth curves of individual children we have used the smaller 5 per cent ranks for purposes of more detailed study. F o r clinical use more accurate placement t h a n in one of the six ranks shown in our norms h a r d l y seems justified by knowledge of the significance o f measurable differences. All a physician is really interested in is to determine about where a p a r t i c u l a r child would stand if lined up with a healthy group of comparable children in ascending order of magnitude, first of one measure and then of another, a n d to be able to

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FIGURE Z

/

OB' P E D I A T R I C S

(

NORMAL CURVE SHOWING MEANAND STANDARD DEVIATIONS

+ t~

MEAN

FIGURE 3

..~

2~

~

+36-

NORMAL CURVE SHOWING PERCENTILES

/I\

I0~

+26-

7~

9ffL

Figs. 2 and 3.--The type of curve which is closely approximated by piotting measurements of normal individuals although most measurements p r o d u c e slightl}r a s y m metrical curves, :~'ig'. 2 i n d i c a t e s t h e s e g m e n t s of the distribution included between v a r i o u s s i g m a v a l u e s , a n d F i g . 3, t h e s e g m e n t s included between various l~ercentile values. In perfectly normal distributions the mean and the median are seen to be the same ~nd to fall at the height of the curve, but the sigma lines include different proportions of the total from the percentiles. The range of plus and minus one sigma i n c l u d e s 67 p e r c e n t a n d p l u s o r m i n u a t w o s i g m a , 95 p e r c e n t .

STUAI~T:

STANDARDS OF P H Y S I C A L D E V E L O P M E N T

_199

make comparisons between the different positions adopted. I t makes no difference which method one uses for expressing this position provided it is suff• accurate and provided one understands what the expression means. Position expressed in percentile r a n k would seem to be more readily understood and to be a more f a m i l i a r concept for physicians t h a n when expressed ill terms of s t a n d a r d deviations. I t clearly indicates the position a child holds in relation to his group. This is the information which is desired in the i n t e r p r e t a t i o n of his status, and it is the maintenance of this position or the recognition of shifts in position over intervals of time which one wishes to recognize in the observation of progress. Given norms distributed in percentile ranks for all common m e a s u r e m e n t s for each sex at each successive age one would be in a position to gain a n u m b e r of useful impressions regarding the physical characteristics of a particular child by m e a s u r i n g him and relating his measures to these scales. The physician could then record his subjective evaluations in a way which would allow rough comparison with these objective findings. Another a d v a n t a g e of thus focusing attention u p o n the implications of figures r a t h e r t h a n the figures themselves, is that ill considering progress f r o m period to period the actual measurements ~sed do not have to remain the same. F o r example, if one is following the progress of a child f r o m infancy onward, he must use recumbent length in the early years but would p r e f e r to use standing height or stature in the later years. W h e n curves are plotted on the basis of actual measures, the shift from recumbent length to stature destroys the significance of the curve. If, however, the place in the percentile distribution is being followed, one m a y legitimately use recumbent length at one period and stature at another and compare the place of the two in relation to the distribution of each as f o u n d in groups of comparable children. I n mental testing, for example, one would not think of applying the same test to a oneyear-old child as to a school child, and if this were a requirement, no comparisons could be made. Measurements other t h a n weight are notably difficult to obtain accurately during the first three years of life, and m a n y of the measurements adopted for s t a n d a r d use b y anthropologists are totally inapplicable during these years. The I n t e r n a t i o n a l Agreement 4 as to the technic to be used in measuring m a n totally ignores the difficulties of m e a s u r i n g during the years of noncooperation. I t is therefore necessary in measuring infants to depart f r o m these s t a n d a r d technics, and in the absence of generally accepted technics to work out m e a s u r e m e n t s of one's own. The group connected with the growth study at the H a r v a r d School of Public H e a l t h are, among other things, involved in the consecutive measurement of children during the early years and are t r y i n g to answer

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OF

TABLE

I~ORMS FOg MEAS ~ URE-

AGE

qO.

I~r

MEDIAN

AND

D•162

PERCENTILES

io%

25% 5 0 %

Head Birth eircum- 2 wk. t e r e n c e 3 mo. 6 too. 9 too. 12 me. 18 mo. 24 mo.

50 33 50 45 41 37 34 26

32.4 33.9 38.6 41.8 43.6 45.1 47.0 47.8

33.7 35.0 39.2 42.5 44.4 45.6 47.4 48.2

34.5 35.5 40.1 43.3 45.1 46.5 48.1 49.1

Chest Birth eireum~ 2 w k . t e r e n c e 3 mo. 6 too. 9 mo. 12 too. 18 too. 24 mo.

50 34 50 45 42 38 34 26

29.2 30.0 37.0 40.4 42.0 42.3 45.8 48.2

30.6 31.6 38.8 42.1 43.7 44.9 47.1 48.9

31.6 32.7 39.5 42.9

InterBirth s p i n o u s 2 wk. 3 mo. 6 mo. 9 too. 12 too. 18 mo. 24 mo.

50 34 50 45 42 38 34 26

6.9 7.2 8.7 10.0 10.8 11.2 12.2 13.1

7.3 7.5 9.6 10.5 11.2 11.5 12.7 13.2

Length

Birth 2 wk. 3 mo. 6 mo. 9 mo. 12 mo. 18 mo. 24 too.

50 33 50 44 42 38 34 26

45.0 47.0 57.2 62.3 68.0 71.8 78.9 83.5

47.7 49.2 58.2 64.4 68.8 72.4 79.1 84.6

Birth 2 wk. 3 too. 6 too. 9 too. 12 too. 18 mo.] 24 mo.!

50 52 51 44 42 38 34 26

5-6 5-14 10- 6 12-12 16- 0 18- 0 20- 9 23-14

Weight

I

~MALL EST

M.ENT

DIRECT

PEDIATRICS

6-

4

6-5 10-14 15- 2 17- 3 19- 2 21-11 25- 9

45.0

46.5 48.1 49.9 7.7 7.8 9.9

ii.0 11.6 ]1.9 13.1 13,6 49,2 51.1 59.1 65.6 70.1

73.7 80.5 86.2 84

90%

RAN(}E OF • r

47.3 48.9 50.1

34.1-36.7 35.1-37.5 39.7-42.3 43.8-46.0 44.9-47.1 46.2-48.2 47.9-50.3 48,7-51.3

32.9 33.7 40.7 44.3 45.9 47.6 49.5 50.9

31.2-35.0 32.1-35.9 39.1-42.5 43,5-47.5 44.4-48.8 45.5-50.1 47.1-52.1 49.4-53.0

8.1 8,2 10,3 11,4 12.0 12.4 13.3 13.9

7.5- 8.7 7.6- 8.8 9.8-11.0 11.2-12.6 11.4-12.6 11.6-13.2 12.8-14.0 13.5-14.7

50,7 52.3 60.6 66.9 71.2 75.5 82.2 88.9

48.4-52.6 50.1-54.1 58.8-62.8 65.1-69.1 69.4-73.6 73.1-78.3 79.8-85.0 85.7-91.3

35.4 36.3 41.0 44.2 46.1

6-15 7-8 7-9 17-0 11-12 12-10 15-14 19- 0 20- 9 23-12 26- 8

75%

7-0 19-14

22- 0 25- 2 27- 9

6- 8- 8-12 6-10- 8-10 11- 3-14- 9 15- 5-18-13 18- 1-22- 1 19-13-24- 9 22-12-27- 8 25-10-30-12

Footnote to Tables and II: All measurements reported at consecutive age periods have been taken on the same group of children, sick or clinically abnormal children having been excluded. Only white children (of American or North European parentage), Weighing over 5 pounds at birth and receiving reasonably good feeding and care have been included. Birth refer~ to measurements taken within the first forty-eight hours, and all subsequent measurements have been taken within one week of the age specified. The two weeks' examination is done on the twelfth, thirteenth, or fourteenth day. "V~rious members of the study staff ha~e measured at birth, b~/t there has been consistency of observers at later ages. All children are measured by two observers at each examination. If the measurements agree within 0.5 era., the median is taken. If there is a discrepancy of more than 0.5 cm., a second reading by each measurer is required, and the median of the total measurements is recorded. Jill measurements are taken with the child stripped and lying on a table, .and, excepting at the lying-in period. between 2 and 4 in the afternoon. Lengths are taken with a )/[artin anthropometer attached at its base to a specially devised metal plane which guarantees o~ fixed right angle between it-

STUART:

TABLE i~Ol~MS FOI~ DIRECT IV[EASURE:ME,NT

Head circumference

Chest circumference

Interspinous

Length

Weight

~{EDIAN

II

~EASUREMENTS--~]R.LS AND

PERCENTILES

I~IEAN A N D

I 25% 150% I 75%] 9O%

ES~:

ES~

10%

32.8 38.2 41.0 42.3 43;6 44.8 46.2

33.7 38.5 41.4 42.9 44.1 45.7i 46.5

34.6 39.1 42.1 43.8 44.9 46.4 47.2

35.6 40.2 43.0 44.7 45.9 47.3 48.0

29.9

30.4

3]..5

32.8

34.1 } 34.9 ] 37.0

30.0 I 35.4 38.3

31.0 38.0 41.1

32.4 38.8

34.8/35.6 41.1142.7 45.0 145.7

36.5 45.5 49.2

41.8 43.2 45.0 I 45.4

43.1 44.7 46.4 48.6

42.4 44.6 46.3 48.0 49.5

33.9 40.2 43.5 45.7 47.7 49.5 50.7

46.9 147.8 48.5 ] 4 9 . 5 50.8 51.9 52.4 54.3

50.4 I

7.5 9.5 10.3 11.1 11.3 12.1

7.7 9.8 10.7 11.3 11.9 12.4

8.1 10.2 11.2 11.8 12.4 13.1

8.5 10.5 11.6 12.3 12.9 13.4

9.8 11.8 ]3.1 13.9 14.0 14.4

36.5 41.1 43.9 45.8 46.9 48.0 49.2

5-9 5- 6 9- 5 ]2- 0 14- 4 16- 2 18-15 , 20-12

I t / / /

1 2 . 7 1 13.4 1 3 . 9 1 4 . 3 I 47.2 48.8 ] 48.5 49.9 56.4 57.8 62.4 i 63.8 67.0 68.4 70.3 72.3 77.6 79.5 82.0 84.6 6- 0 / 6 4 1 5-10{ 6- 6 10- 5 ]i- 6 14- 4 ]5- 5 16- 9 17-10 18- 3 20- 3 2 2 : 0 23- 0 24- 0 25- 6

50.1 51.5 59.6 65.5 69.8 73.6 81.2 85.9 7- 8 712- 4 16- 0 18-15 21-10 24- 9 26-12

51.0 52.8 60.7 66.8 71.8 75.8 83.1 88.1

I I I [

MEAN

I o"

RANGE OF

_+1 ~ 34.4 35.5 40.2 43.1 44.8 46.0 47.4 48.2

1.4 33.0-35.8 1.2 34.3-36.7 1.2 39.0-4] .4 1.3 41.8-44.4 1.4 43.4-46.2 1.4 44.6-47.4 1.4 i 46.0-48.8 1.3 46.9-49.5

32.8 33.5 40.2 43.5 45.6 47.5 49.4 50.9

1.8 ] .6 1.8 ].9 3.2 ].9 2.0 2.2

3] .0-34.6 3].9-35.1 38.4-42.0 41.6-45.4 44.4-46.8 45.6-49.4 47.4-5] .4: 48.7-53.]

1 4 . 7 15.4

7.8 8.2 ].0.2 ].].2 1].9 12.4 ]3,1 13.8

0.5 0.6 0.7 0.6 0.7 0.8 0.7 0.8

7.3- 8.3 7.6- 8.8 9.5-:10.9 10.6-]].8 ]].2-]2.6 ]1,6-]3.2 ]2.4-]3.8 13.0-]4.6

52.9 ] 55.6 54"0 I 58.6 61.8 65.0 68.2 69.8 73.2 75.0 77.8 79.0 85.0 87.0 89.7 92.2

50.0 2.0 51.5 2.3 59.2 2.0 65.3 2.] 70.0 2.2 73.9 I 2.6 81.2 2.8 8 6 . 1 2.9

I 37.2 [ 41,8 I 44.8 14.6.8 I 47.9 49.5 50.0

38.0 42.6 46.2 47.9 49.] 50.1 50.5

52.2 53.2 54.6

64I717 79r838j8

45.6 46.8 54.4 59.4 64.8 68.6 74.0 80.0

_+ I

LARG-

~MALL-

7.0 8.9 ]0.2 10.6 10.8 11.6 11.9

201

STANDARDS OF PHYSICAL DEVELOPMENT

9.0 11.0 12.0 ]2.7 13.3 13.9

I

I

]

48.0-52.0 49.2-53.8 57.2-61.2 63.2-67.4 67.8-72.2 71.3-76.5 78.4-84.0 83.2-89.0

7-7 1-0 6-7-8-7 7- 5 1- ] 6- 4- 8- 6 12- 311- 6 ]0-]3-]3- 9 16- 5 1-13 14- 8-18- 2 19- 4 1-].4 17- 6-21- 2 28-12 I 21-13 2- 9 19- 4-24- 6 32- 0 24-15 ] 3- 0121-15-27-15 31- 2 27- 1 2-12 24- 5-29-13 8-14 9-11 16- 2 23-10 25-14

self and both a n t h r o p o m e t e r and table. All breadths are taken with a spreading metal caliper, and all circumferences with a tape, frequently checked a g a i n s t the anthropometer. The n u m b e r of cases upon which each distribution is based is given in the left-hand column of the tables. Head Circumference: Circumference through supraorbital ridges anteriorly and greatest occipital prominence posteriorly. Chest Uireumr Circumference in plane of ensiforrn cartilage in midrespiration. Interspinous: T r a n s v e r s e diameter of pelvis between anterosuperior spines of ilia, (The intercristal diameter, comparable to the biaristal of the International Agreement, is also being" taken and is preferred, but the numbers are not yet adequate f o r setting up a distribution,) Total Length: Recumbent vei'tex-sole length, Weight: Taken in pounds and ounces and converted into grams. Distribution of figures as given in Tables I and I I are also available for the following: head breadth, head length, chest breadth, chest depth, abdomen, t r u n k length, and sitting length.

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PEDIATRICS

BOYS I0

LEAST ~""

MATURE

25 .

.

.

.

.

50 .

-

9

Fig', 4.

OSSI FICATION OF /5

.~,

90 ~

MOST ....

MATURE

STUART:

STANDARDS OF P I [ Y S T C A L D E V E L O P ~ E N T

IST A ND HA ND AGE LEAST MATURE +

10

25

203

GIRLS 50

75 ~.*"

+.

.

.

90 . .

MOST .MATURE

~'~o.

BI RTH

3MOS

6 MOS 40

9MOS 27

12MOS 47

Fig. 4.

204

THE

J0:UICNAL OF PEDIATRICS

OSSIFICATION BOYS LEAST MATURE §

I0

25

5O

75

90 +*~..~

46

)

35

35

42

?? ~ i g . 5.

.,-,-'--

MOST MATURE

STUART:

STANDARDS OF P ~ I Y S I C A L D E V E L O P M E N T

205

OF FOOT GIRLS

AGE LEAST MATURE+

I0

25 **

50 "" . . . .

75

90

MOST ++,++MATURE

BIRTH

3 IviOS

6MOS

~N

N

g MOS 28

i2MOS 4?

18MOS

\t.i./ F i g . 5.

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THE

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OF P E D I A T R I C S

the question as to what measurements, if any, may be of practical value to the pediatrician in appraising" the child. Our material is not as yet extensive enough to recommend any particular measurements. Our present feeling is that the n u m b e r of measurements which can be taken with sufficient accuracy at this age to serve such a purpose is exceedingly small. The very attempt to secure and interpret a few simple measurements, however, seems to improve clinical judgment. It brings to our attention physical characteristics which would otherwise be missed and undoubtedly helps to cultivate and make more accurate the clinical powers of observation. Tables I and I I give the percentile distributions, the limits of the ranges, and the means and sigmas of a few of the measures we have been using' and have found helpful. We have similar distributions for other measurements as indicated in the footnote to the tables. The drawings in Pigs. 4 and 5 show reproductions of hand and foot roentgenograms from. our series, representing the percentile distributions of bone and epiphyseal development by sex and age. They indicate how epiphyseal maturation may be interpreted in much the same way as measurements. The appropriate drawing to represent the different percentiles has been chosen after arranging by inspection all x-rays in the order of advancing maturation. X-rays of individual children may be compared with these drawings and their relative position in respect to them determined by similar inspection. The numbers in most age periods in the tables and charts are still too small to be accepted as tinal, but there is no reason to believe that the distributions will be very greatly altered when they are revised with the addition of more cases. Examples of curves plotted from the norms for the different pereentiles of two measurements at successive age intervals are shown in Fig. 6. In considering progress, it is possible to plot any measure against such norms, just as we are accustomed to plotting weight against the average weight curve. However, a series of such charts becomes cumbersome. The technic can be greatly simplified if one makes a straight line out of each percentile. All. that is lost in so doing" is the visual picture of the changing extent of range at different periods. We have been recording' in this way on a single chart all of the measurements of a child, making curves out of succeeding measurements, and have found that they bring into striking relief many interesting characteristics of individual children. This kind of record offers an excellent opportunity not only to recognize spurts and rests in general growth, but also to visualize changing proportions or localized arrests of growth. Examples of two. such charts are shown in Figs. 7 and 8, but for simplicity only a few of the more important measurements are given. Fig. 7 shows a consistently small child, while Fig. 8 indicates both unusual

STUART:

STANDARDS

OF

PHVSICAI~

207

I)EVELOPMENT

shifts in position from time to time and differences in position in different measurements at the same time. A record sheet which groups together the various evaluations of a child at a p a r t i c u l a r time is also LE N(IT BCY

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presented in Fig. 9 to show the way comparisons may be made between different kinds of data. The items u n d e r " o t h e r e v a l u a t i o n s " in this chart are only suggestions as to what may be recorded in this way, and

208

TIlE

JOURNAL

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fewer measurements may be used if desired. These charts are intended to suggest a method for using measurements in attempting to arrive at judgments regarding the physical fitness and progress of different ehil-

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F i g . 7 . - - I n d i v i d u a l p e r c e n t i l e r a n k c h a r t of m e a s u r e m e n t s . These era'yes s h o w a c o n s i s t e n t l y s m a l l child t h r o u g h o u t t h e p e r i o d r e c o r d e d . Her health has always seemed excellent and her musculature and nutrition have at each examination been considered perfectly satisfactory. ( H i s t o r y 2go. 33.) I/~GTH

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l~ig. 8 . - - I n d i v i d u a l p e r c e n t i l e r a n k c h a r t of m e a s u r e m e n t s . T h i s c h a r t s h o w s s t r i k i n g c o n s i s t e n c y in t h e p o s i t i o n of d i f f e r e n t m e a s u r e m e n t s a t t h e s a m e t i m e , b u t v e r y d i f f e r e n t p o s i t i o n s a t succeeding- p e r i o d s , T h e s e u ~ u s u a l s h i f t s w e r e o b v i o u s l y d u e to c h a n g i n g r a t e s of g r o w t h . T h e e a r l y r a p i d g r o w t h w a s a s s o c i a t e d w i t h s u c c e s s f u l b r e a s t f e e d i n g a n d good h e a l t h . :Following this, t h e r e w a s a p p a r e n t l y c o m p e n s a t o r y a c c e l e r a t i o n of g r o w t h . T h e e n d - r e s u l t shows, a m u c h s h o r t e r c h i l d t h a n w o u l d h a v e b e e n p r e d i c t e d a t b i r t h , b u t in o t h e r r e s p e c t s h e r p o s i t i o n w a s m u c h t h e s a m e . (Hist o r y No. 6.)

dren, but are not urged for adoption in their present form, without modification to meet individual practice and needs. The limitations to the practical usefulness of measurements are recognized, both because of technical inaccuracies and because of difficulties

STUART:

STANDARDS OF PHYSICAL DEVELOPMENT

~09

in determining their significance. The number o~ measurements which can be taken with profit is small, particularly during the years covered by the accompanying tables. It is believed, however, that the very attempt to secure and interpret a few simple measurements improves clinical judgment and brings to one's attention physical characteristics NA~:: F. R.

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GOOD Fig. 9 . - - I n d i v i d u a l ~ developmental appraisal form. Single a p p r a i s a l of an u n u s u a l l y s m a l l but well-proportioned and h e a l t h y one-year-old infant.

which would otherwise be overlooked. Their usefulness is, in large measure, dependent upon the way in which they are compared with standards and related to clinical data. REFERENCES 1'. F a b e r , H . K . : A m . J. Dis. Child. 38: 758, 1929. 2. Eliot, M. M. : The E f f e c t o f T r o p i c a l S u n l i g h t on t h e D e v e l o p m e n t of B o n e s of Children in P u e r t o Rico, C h i l d r e n ' s B u r e a u , P u b l i c a t i o n No. 217. 3. Gray, H., a n d Ayres, J. G.: Growth in P r i v a t e School Children, Chicago, 1931, Univ. Chicago P r e s s . 4. Hrdlicka, A : : A n t h r o p o m e t r y ( T h e W i s t a r I n s t i t u t e o f A n a t o m y a n d Biology,

1920). 55

SHATTUCK

STREET