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Un das symboias sulvanta apparattra sur la damiAra imaga da chaqua microflcha, salon la caa: la symbols —»> signifia "A SUIVRE", la symbols y signifia "FIN". Mapa, plates, charts, ate. may ba filmad at diffarant reduction ratios. Thoaa too large to be entirely included in one expoeure are filmed beginning in the upper left hand corner, left to right and top to bottom, as many framea as required. The following diagrams illustrate the method: Lee cartas, planches, tableaux, etc., peuvent Atre fiimAa A das taux da rAduction diff Arents. Lorsque ie document est trop grand pour Atre reproduit en un seul clichA, ii est filmA A partir da I'angle aupAriaur gauche, de gauche A droite, et de haut an baa, an prenant la nombra d'images nAcessaire. Las diagrammes suivants illustrent la mAthode. rrata :o 3elure, Yd 3 32X 12 3 1 2 3 4 5 6 P\c M 0-y^ \LKf^/vy^ n^.T ^/ 7' \^. ^>:.. THE ACCURATE MEASUREMENT OF SPINAL CURVATURES WITH THE DESCRIPTION OF A NEW INSTRUMENT FOR THE PURPOSE. BY R. TAIT MACKENZIK, M.D., Demonstrator of Anutoiiiy, Medical Exaniiuer and Instructor in GyninasticH, McGill University, Montreal. {Reprintfd from Montreal Medical Journal, Fehrvary, 1898 ) THE ACCURATE MEASUREMENT OF SPINAL CURVATURES, VVITII THE DESCRIPTION OF A NEW INSTRU- MENT FOR THE PURPOSE. BY R. Tait McKknzik, M.D. Demonstrator of Anatomy, Medical Examiner and Instructor in Gymnastics, McGill University, Montreal. Almost thoiirst difficulty that confronts the surgeon in dealing with a case of scoliosis is the obtaining of definite date on which to base a diagnosis and prognosis, a fixed starting point from which he can fol- low its progress ; a standard by which he can test his course of treat- ment with a reasonable degree of accuracy. Mere opinion as to the exact condition present in a patient is notori- ously unscientific and inaccurate, especially in this disease, and a few figu'-os in black and white, or an accurate chart, are worth pages of surmise or supposition. In the measurement of curvatures we must obtain a record of the general asymmetry of the figure, as well as of the details of the deformity. One wants some quick and accurate way of getting at the difference in height of the acromia, of the points of the scapulae, some graphic record of the deviation of the spinous processes from the straight line, of the differences in outline and level of the hips and iliac crest=. And, again, the record will not be complete unless the rotation of the vertebras is shown, both in the dorsal and lumbar regions. In angular curvature the nature and extent of the kyp-iosis must be displayed to give a clinical picture of the case. Many methods have been used to get some of these results, and some plans have been used to get many of them, but I have not yet seen any practical scheme by which a complete picture such as I have just described has been obtained. I need not enter into a detailed description of all the ways by which this subject has been attacked, but, among them, photography has cer- tainly been the most popular. Perhaps the most fatal objections to its use as a routine practice are its expense, both in time and money, and its liability to mislead the observer by indistinctness, or other imperfections in the process of lighting the figure, or the developing of the plates. Many plans have been described in which plumb lines are dropped and deviations from thcni notod at different levels. The shoulder levels have been measured from the j^round.and various other isolated facts have been taken. These methods an; all imperfect and cumber- some., and, above all, lack that uniformity so necessary if such obser- vations are to be of permanent vahie. For recordiu},' the rotation which is totally neglected by the above- mentioned plans, Mr., Bernard Roth describes a method winch is both rapid and accurate. The complete de.scription of it is found in his text-book on the .subject. Briefly, it is by moulding a strip of pure tin to the back at the desired level and making a tracing from this on paper. Mary Putman Jacobi elaborates this method by using a hinged tape and encircling the whole chest or abdomen. This tape is removed, placed on a table, and plaster is run in, forming on accurate cross- section of the body at the level selected. This, although accurate, is imperfect, and its inconvenience in private practice will at once suggest itself. Dr. Geo. W. Fitz, in Boston Medical and Sur(iical Journal, recom- mends, in measurements of the spine, to spot with a black-flesh pencil, the spinous processes frotn the seventh cervical vertebra down to the .sacrum, together with the posterior iliac spines ; to place the patient behind a screen consisting of a rectangular frame with threads strung vertically and horizontally, cutting the entire surface in inch s(iuares to measure the amount of rotation of the spine ; he uses the method described by Mr. Roth. In the Cyclopedia of Diseases of Children, Dr. R. E. Roth describes a small instrument for recording rotation, which merits description. A long pointer, with a pencil attached, moves freely by a swivel joint on a stand placed on the back of the patient, who bends well for- ward. Attached to the stand is a curved sheet of paper on which the pencil marks the movement of the pointer, the tracing being of course reversed , by varying the pi'oportion of the two sections of the pointer the tracing can be made to any scale. J. A. Weegel describes a graphic method of showing a cross-section (natural size) of the prone figure. This is open to the serious objec- tion that the scapuhio and attached muscle.« mask to a great extent all sections taken in the upper dorsal region, an objection surmounted by having the patient stooping well forward. Raymond Sainton took up this subject very fully in the Revue d'Orthopedie some years ago and described a hinged\collar or belt of steel, in which the patient is encircled. Set in it at regular intervals are pointers like wheel spoke.s. The.se are shoved in till they touch the skill, clamped, and the collar reinoved. A tracinj; from these pointers will show the l)ody in cross-section. ITo also fij^ures an adaptation of the pantoj,'raph for taking full-sized tracinj^'s of tlu; spinous processes. Many instrunient-i have lieen devised, all more or less complicated and expensive, for takiiiff such tracin{,'s. The most elaborate I have seen, that of Hchultliess, thou<,'h accurati;, ^dvcs a tracing life size, and too liig for convenience!. It is not adajjted to reconl rotation. Its size and expense would make its ifidieral introduction impossil)le. Beehrini^'s uses a <.,dass plate (m which the silhouette is traced, Imt I could multiply example on example till one is tempted to cry that of makinj,' many devices tlusre is no end, and yet one mu.st agree with the author in a recent work on Orthopoedic Surgery when he .says that " An inexpensive and efficient scoliosiameter is yet t(j he invented." An efficient instrument should record in inches or centimeters the dirterenco in levels, of the shoulders, of the points of the scapulio, and of the iliac crests. It should measure the deviation of the spinous processes at all levels. It should show the outline of the hips and shoulders that differences may be noted, and, lastly, it should measure the amount and show the nature of rotation when present. In this instrument an attempt has been made to fulfil tlie.se condi- tions. It consists of a fixed horizontal iron stand, into which a rigid upright rod is screwed firmly. To this rod two arms are attached by collars that can be moved up and down or clamped by thumb .screws. The lower arm passes behind the patient and clamps the hips, prevent- ing any sidewise movement. The upper arm passes in front of the patient and fixes the shoulders. To the collar of the upper arm is attached, by a hinge, a plate, to which a pantograph is .screwed, set .so as to make a tracing reduced to one in four. The paper, which is stretched over this plate and held by clips behind, is ruled in eighth inch squares. Hence, a line passing vertically through eight sq ares or one inch, would represent a distance of four inches covered by the pointer. It is more accurate and convenient to use a reversible pointer, a short arm for the spine and scapula?, and a longer for the outline of the shoulders and hip.s. To take a tracing the spinous processes are first marked with a flesh pencil and the patient is placed upon the stand. The hips ai'e first clamped at the level of the trochanters, the shoulder arm is then moved up or down, adjusted and clamped, after the patient has settled into the habitual position. The spine is followed by the pointer, the gluteal cleft and the points of the scapuhe noted, and then an outline of the shoulders and hips is rapidly traced. In taking cross-soctiojis to show the; rotatiuM, tlio imticnt stainlH ht'tit over, atiing 2A inches, taken when stand- ing with heels together, and in his habitual position. In Fig II. the cause of the curvature is shown in the ditferenct; t)f height of tho iliac crests and tilting of the pelvis, duo in this case to shortening of tho left leg. Tho cross-section taken at the level of the third lumbar vertebra shows a projection of tho right side and a cor- responding depression of the left. Fig. III. shows a very extreme deformity, duo to infantile paralysis The projection of the left hip is very noticeable. Fig. IV. .shows two tracings plotted on the sanie chart, the iliac crests being laken as the starting points. It will be seen from this how improvement under treatment can be clearly demonstrated. If we could select some standard set of measurements instead of continuing in tho present haphazard way, every man having a system which may servo for himself, but is a sealed book to his neighl)()r, there would be a chance of comparing our work one with an(»ther, and arriving at results in tho treatment of scoliosis that would be at once definite, intelligible and scientific. I f I AX i