PRINCIPLES • AND METHODS 
OF— 
EXAMINATION 
—TNT— 
ORTHOPAEDIC PRACTICE. 
By Henry Taylor, M. D., 
OF 
ttf'w yofik:. n 
ItEPRINT FROM THE MARYLAND MEDICAL JOURNAL. 
BALTIMORE: 
Journal Publishing Company Print, 
200 Park Avon up, 
1889, PRINCIPLES AND METHODS OF 
EXAMINATION IN ORTHO- 
PAEDIC PRACTICE.* 
BY HENRY LING TAYLOR, M. D., 
OF NEW YORK. 
The investigation and treatment of 
joint affections and of deformities has 
won for itself a place as a distinct de- 
partment of surgery, having its peculiar 
Sroblems and special methods. The 
ew York Orthopaedic Society—now 
the Section on Orthopaedic Surgery of 
the New York Academy of Medicine— 
founded some five years ago, and the 
American Orthopaedic Association, 
founded two years ago, formally intro- 
duce the specialty into the sisterhood of 
organized medicine. 
Scientific orthopaedy is thus seen to be 
a rather recent arrival; and its princi- 
ples and methods being still to a consid- 
erable extent under discussion, very 
little that is practical or reliable in the 
*Read before the Northwestern Medical and Sur- 
gical Society of N. Y., June 19th, 1889. 2 
matter of methods of examination and 
early diagnosis has found its way into 
surgical teaching or general medical 
literature in such a manner as to become 
the common property of the profession. 
As in several other branches of medi- 
cine the development of orthopaedy has 
been hindered on the one hand by indiff- 
erence, from a sort of surgical fatalism, 
like the common lay notion that in a 
case where only slight symptoms are pres- 
ent no treatment is needed, and when 
they are severe none is of avail; on the 
other hand by too great a willingness, 
not wholly confined to the laity, to en- 
trust the solution of purely scientific 
problems to unscientific and untrained 
minds; one of the numberless varieties 
of that endless problem, how to get 
something out of nothing. The type of 
mind that sees in ophthalmology only a 
question of spectacles, will regard or- 
thopaedy as a question of braces—an 
error encouraged, it must be admitted, 
by much in special literature and prac- 
tice—and as in the one case the peddier, 
the shop-keeper or the optician is ap- 
pealed to, so in the other the blacksmith 
and the instrument-maker are consulted ; 
and with similar results. 
There is however at present a demand 
for the careful and intelligent study of 3 
joint and spinal affections, and it is vi- 
tally important that all should be famil- 
iar with reliable methods of examination 
and diagnosis. 
My present object is to emphasize a 
few principles, which seem to me help- 
ful in the recognition and discrimination 
of the early stages of the more common 
chronic affections of the spine and larger 
joints, especially the hip and knee, rather 
than to present an exhaustive study of 
methods or symptoms. 
There is hardly any class of cases 
where so much good can be accomplished 
or so much evil prevented by an early 
diagnosis as in these affections. Early re- 
cognition of the seat and nature of the 
disease, which in the vast majority of 
cases re-ts with the family physician, 
with employment of treatment adapted 
to meet the indications present, will 
often enable the surgeon to arrest the 
disease, prevent deformity and save life, 
while an error in diagnosis or too much 
reliance on the hope that the beginning 
trouble “will be outgrown,” is as fre- 
quently followed by consequences dis- 
astrous to the patient and distressing to 
the physician. 
As many of the chronic joint and spi- 
nal diseases begin insidiously, and fre- 
quently without pain, or without char- 4 
actcristic pain—a fact Ions: ago pointed 
out by Dr. C. Fayette Taylor*—it is 
easy to understand how the trouble may 
be for a long time overlooked, and when 
discovered its gravity underestimated. 
Unless the symptoms follow directly 
on some traumatism or begin more 
acutely than is usual, we find that the 
attention of friends is generally first at- 
tracted by some peculiarity or awkward- 
ness of gait or attitude, later by lassitude,, 
disinclination to move about as freely as 
usual, restlessness at night, constitutional 
disturbance, and pain ; and each of 
these symptoms calls for careful examin- 
ation on the part of the physician, who 
should never rest satisfied until he has 
traced it to its source. 
It is well known that the vast majority 
of our acts, movements and vital processes 
are involuntary and automatic,impressed 
upon the individual by his inheritance 
and experience through reflex mechan- 
isms and easily modified by strong or un- 
usual stimuli, whether from the outside 
world or from within the body itself. It is 
just these associated reflex movements 
*1. The Mechanical Treatment of Angular Curva- 
ture or Pott’s Disease of the Spine—New York State 
Medical Society, 186,1: and 
2. On Some of the Elements of Diagnosis in the 
Different Siages of Diseases of the Hip Joint.—The- 
Medical Record, May 8th, 1875. 5 
and the tonicity of special muscular 
groups which require the closest study 
and give us the most valuable informa- 
tion in joint disease. As in health the 
temperament, occupation and even so- 
cial standingf of an individual, and the 
more transient stimuli of heat, hunger, 
fatigue and their opposites, become 
stamped upon his expression, muscular 
tonicity, gait and attitude, so that we 
can tell a sailor from a landsman, a 
craftsman from a headworker, or a tired 
man from one who is fresh, by noticing 
the thousand phases of associated move- 
ments, so disease and particularly disease 
affecting the bony framework or joint 
structure of the body, conditions charac- 
teristic groupings of the ordinary atti- 
tndes and movements. Much that is 
really due to physical disability of one 
kind or another is charged to awkward- 
ness or heedlessness. Joint and spinal 
troubles are a common but by no means 
the only cause of the disturbance. 
A little girl who was always stumbling 
and breaking things and seemed to ex- 
ercise small powers of observation was 
cured at eight years of age by consult- 
+A larty who pass d a season at Carlsbad told me that 
she was able to distinguish the seven or eight nation- 
alities there present by the gait and carriage, Aus- 
trians who tried to imitate the French and Americans 
who aped the English were more easily recognized by 
this test than any other. 6 
ing an oculist and treating a previously 
unsuspected but extreme myopia. 
A young lady was brought ao me for a 
peculiar stiffness or awkwardness of gait. 
After careful examination I found no- 
joint disease or paralytic affection, 
nothing in fact but a slight lateral curv- 
ature and a narrow chest, which did not 
explain the symptom. I treated the 
spinal asymmetry and gave her the 
“Respirator” for chest development, 
but the awkward walking persisted. I 
had previously inquired into the existence 
of uterine symptoms which were denied, 
but I finally urged an examination of 
the pelvic organs by a specialist. He 
found such severe retroflexion that he 
expressed surprise that she could walk 
at all. 
Small tubercular foci in the spongy 
tissue of a vertebra or near the end of a 
long bone may remain comparatively 
quiescent for months or years, or give 
rise only at times to trifling lameness or 
some peculiarity of movement or attitude, 
and afterwards the disease encroach on 
the neighboring joint, and slowly and 
perhaps unconsciously modify muscular 
action and joint mobility, or else more 
JFor description of the’‘Respirator” and its uses 
see an artic'e entitled “The Therapeutic va'ue of Sys- 
tematic Respiratory Movements.’—Medical Record, 
May 4th. 1889. 7 
rapidly produce severe and painful symp- 
toms. Yet it is certain that a careful 
investigation of the causes of the periods 
of slight lameness or other disturbance, 
would in many cases have easily revealed 
the seat and nature of the irritation in 
time to have made possible the preven- 
tion of serious damage. 
With this general idea of what we are 
to look for, how shall we proceed at the 
examination ? 
While the history of the case is being 
taken, the facies, attitude and movements 
of the patient, who ought not to be made 
to feel himself the object of attention, 
should be carefully observed. It will be 
important to notice whether the patient 
is well-nourished, and whether his ap- 
pearance or movements indicate fatigue, 
strain or suffering, for the anxious and 
drawn countenance is often present in 
joint disease when local pain is denied. 
While the patient is undressing—every 
child should be disrobed—any movements 
indicating general irritation or local dis- 
ability or distress should be carefully 
noted. 
The patient should then be made to 
walk, get into and out of a chair, and 
pick something up from the floor. Analy- 
sis of the movements, and especially of 
the gait, will, in the majority of cases, 8 
indicate the correct diagnosis, even be- 
fore the appearance of conscious pain or 
deformity. Indeed the orthopaedic sur- 
geon makes these observations instinct- 
ively as the patient walks into the room, 
and usually has a provisional diagnosis, 
which leads his line of inquiry by the 
time the patient is seated. 
It is not necessary to describe in detail 
the gait and attitude characteristic of 
the various joint, spinal and paralytic 
affections. I merely wish to urge the 
vital importance of close observation of 
everything connected with movement 
and expression, since these will give us 
vastly more definite information than the 
patient’s impressions in regard to his 
own condition, and may be quite as im- 
portant as the results gained from local 
inspection. 
As the countenance is apt to bear an 
anxious expression, so the movements 
are exceedingly apt to be cautious and 
protective in these beginning joint trou- 
bles. The patient takes exceeding “care” 
that the back or limb shall not be sub- 
ject to sudden jars or wrenches; he per- 
haps lifts his limb with his hands in 
changing his position, or rests his chin 
on his palms to protect his vertebrae. 
This “ care,” or instinctive effort at pro- 
tection, is usually present in some degree 9 
unless in the earliest and the youngest 
cases, and is exceedingly characteristic, 
but is to be carefully distinguished from 
the conscious apprehensiveness, often 
very extreme, of the hyperaesthetic suf- 
ferer from functional joint troubles. I 
have elsewhere § tried to indicate the 
difference. In joint neurosis “ disability 
of the most varied character and imper- 
fect co-ordination of the neighboring 
muscular reflexes are among the most 
common symptoms, and the most char- 
acteristic one is the visible though often 
unconscious accommodation of the re- 
flexes of the entire body to the condition 
of the disabled member. * * * * 
It is usually more distinct and more 
widely distributed than the secondary 
reflex adjustments in joint disease, and 
somewhat different in character, possibly 
due to greater prominence of the cerebral 
element. If the patient have a lame 
ankle he is, so to speak, “ ankle all over;” 
if it be a young woman with a backache, 
she presents every evidence in her con- 
scious and unconscious life of the para- 
mount influence of that region of the 
body. If we may speak of “care” as 
referring to attitude and movements in 
joint diseases, we may possible charac- 
§“ Hygiene of Reflex Action,” Journal of Nervous 
and Mental Disease, March, 1888. 10 
terize as “ apprehension ” the phenom- 
ena referred to in these functional trou- 
bles. The “ care ” of a diseased joint is 
most distinctly noticed in distant reflexes 
when the joint is hurt or threatened with 
violence. Pain, especially in the earlier 
stages of joint disease, is rather paroxys- 
mal in character and often absent; the 
patient frequently forgets his trouble and 
hurts his joint by too spontaneous move- 
ment In a neurotic joint affection, pain, 
while more constant, is not invariably 
a prominent feature, but, no matter what 
the distractions of the patient, the re- 
motest muscular reflexes of the body are 
in a would-be-protective state of appre- 
hension in a typical case. This influence 
can often be distinctly perceived in the 
expression of the face and the tone of the 
voice, as well as in the peculiar mental 
attitude of the patient; the perceptions, 
emotions, and intellect will frequently 
revolve around a knee or a back for a 
centre as plainly as the muscular re- 
flexes.”- 
Proceeding now to the examination of 
local conditions, our object will be to 
critically estimate the tonicity and re- 
sponsiveness of the muscular groups act- 
ing on the suspected joint, the position 
and mobility of the joint, and the physi- 
cal appearance of the surrounding parts, 11 
as to swelling, wasting and other devia- 
tions from the normal. In testing motion 
we always begin with the sound || limb 
in order to eliminate apprehension and 
active participation as much as possible. 
Suppose the hip is suspected. We 
make gentle movements at the hip, be- 
ginning on the sound side, while the pa- 
tient is seated, and then ask him to cross 
one leg over the other ; this he will be 
rarely able to do on the suspected side, 
if the joint is diseased. 
The patient is then placed on his back 
on the flat examining couch and the 
gentle movements of the joint, always 
beginning on the sound side, are con- 
tinued, one hand being firmly placed on 
the pelvis to ascertain whether it moves 
with the thigh, the object being rather 
to determine the quality than the quan- 
tity of motion. Such tests in various- 
directions will almost infallibly reveal 
the greater or less “ reluctance to relax ” 
(independent of cerebral interference), 
usually with more or less jerk}' spas- 
modic action of certain muscles and lim- 
itation of motion so characteristic of 
joint disease from the earliest stage. The 
crucial test will be to turn the patient 
upon his face and test hyper-extension, 
ilOr. C. Fayette Taylor’s invariable practice so long 
as I can remember. 12 
(sound side first), where limitation will 
invariably be evident if joint trouble is 
present. 
I have said little about pain because 
as a diagnostic sign it is not to be de- 
pended upon. We know that knee pain 
often exists with hip disease, and that it 
is perhaps still more often absent. When 
present the hip should always be ex- 
amined. Cases where all pain is denied 
until the disease u well advanced are 
not rare; and hip or knee pain may 
exist with no joint disease at all. Irrita- 
bility and restlessness at night, with 
cries or night-mare, are much more sug- 
gestive of joint disease in the early stages 
than local pain, and these may be present 
in marked degree without conscious or 
remembered pain. This being the case, 
it is difficult to imagine the object of the 
rough manipulations so cften seen in 
surgical examinations of the joints. 
Whether or not pain or tenderness is 
elicited by these procedures no informa- 
tion of value is derived, and they are not 
free from danger. I remember very well 
a young man shown at a medical meet- 
ing, who seemed to be suffering from a 
diseased hip, of whom a noted surgeon 
then present stated that he was sure 
that when he first examined him some 
months previous no joint disease existed, 13 
but admitted the possibility of the start- 
ing up of the disease from his rough ma- 
nipulations. "When such results are pos- 
sible from methods not rarely employed, 
is it not time to call a halt, even if the 
use of violence were not as stupid as it 
is dangerous ? I have seen other patients 
who have been frightened and cruelly 
hurt at examinations; any approach to 
roughness defeats the object of the exam- 
ination and should not be tolerated. 
In the knee we have a joint very often 
affected and admirably fitted by its size 
and accessibility for investigation, but 
mistakes in diagnosis, especially as be- 
tween functional and organic disease, 
are exceedingly common. We test here 
also the tonicity and activity of the mus- 
cles, and if bone enlargement or synovial 
distension is present these can hardly es- 
cape close observation. Too much at- 
tention to pain and tenderness about the 
joint will only distract our attention 
from the really diagnostic features. 
There will be no organic disease of the 
joint without reflex muscular spasm, or 
without some limitation of extension at 
the knee. No matter how painful the 
joint, if complete extension without vio- 
lence is possible, disease of the joint can 
hardly be present; and it is to be remem- 
bered that functional knee trouble, which 14 
is often accompanied by pain and limita- 
tion of motion, is exceedingly common, 
whether as a primary affection or fol- 
lowing in the wake of some slight injury. 
These patients will sometimes relate a 
history not inconsistent with that of 
joint disease, but I have learned to take 
a patient’s estimate of appearances and 
conditions with considerable allowance. 
They will often relate that swelling has 
existed or still exists, when measurements 
show the affected limb to be the smaller 
of the two. Restraint of a limb will 
usually cause an appreciable wasting 
with a change of contour, which the pa- 
tient, fearing inflammation, takes for 
swelling ; and it is also true that actual 
swelling, especially a boggy relaxation of 
the tissues, may exist, and that a state of 
local malnutrition and consequent or- 
ganic disability may follow. 
Some of these cases have a habit of 
keeping the knee stiffly extended while 
sitting, a position impossible to the suf- 
ferer from joint disease. Careful analysis 
of the facts developed by the general and 
local examinations should make the 
diagnosis clear. 
In many of these cases the functional 
nature of the trouble has been clearly 
recognized, but either it has been aggra- 
vated by local treatment, which is un- 15 
certain and sometimes harmful in its 
effects, or the sufferer has lost confidence 
from being told that “ there is nothing 
the matter,” a statement which besides 
being untrue adds a new difficulty to the 
management of the case. 
Many get well without being diag- 
nosed, under the routine treatment of 
iodine, blisters, firing, local applications, 
bandages, etc., but many prove exceed- 
ingly obstinate until their real nature is 
recognized and indicated treatment 
adopted, wdien an apparently hopeless 
deformity or disability often clears up 
like magic. 
In suspected caries of the vertebrae a 
careful study of attitude and movements, 
alone suffices to enable us to make 
the diagnosis with great certainty, and 
in most cases before the appearance of 
deformity. 
“There is a peculiar carefulness in the 
step; an instinctive poising of the body 
to avoid all shocks; an indescribable 
expression of the whole person and 
every attitude and motion, which exists 
in this disease, and in this disease alone. 
The toes are turned slightly inward; 
the shoulders and elbows are drawn 
backward; the chin is thrown upward; 
the gait is sliding; the patient catches 
hold of objects in passing them, and 16 
when lie stops, he leans heavily on his 
mother’s lap or whatever object may be 
near him. All this indicates the pres- 
ence ot the disease as clearly as a pecu- 
liar eruption indicates the measles.”* 
The back muscles are rigid and the 
sufferer reaches the h and down by the 
side in picking an object from the floor 
to avoid stooping. If to these symptoms 
pain in the side or bowels, restlesssnees 
at night and a careworn look are added 
the presence of deformity! is hardly 
needed to complete the picture. 
“And we should always bear in mind, 
when this disease is suspected, that to 
wait for the projection to appear is to 
wait for the destruction of the vertebrae. 
It is to throw away the golden moment 
for arresting the disease in its incipiency. 
We must remember that the curvature 
is the result of the disease and not the 
disease itself.” 
Painjrcferrcd to the terminal filaments 
of the intercostal and lumbar nerves in 
the side and abdomen is frequently an 
early and always a suggestive symptom 
but is not rarely absent. But the spinal 
tenderness so sedulously sought for by 
many is never present unless from the 
*1. Op. cit. 1. 
t2. It should he remembered that an angular lateral 
deformity sometimes appears early in this disease. 17 
too frequent or tx> vigorous efforts of 
the examiner, or other adventitious cause. 
Pain in the back is seldom complained 
of and never characteristic of this con- 
dition. The only case of disease of the 
spine in which 1 saw it marked!}" devel- 
oped, proved to be a cancer of the verte- 
brae. 
For purposes of record rather than of 
diagnosis the patient should be placed on 
the examining couch, face down, and the 
spinal contour taken by means of a flex- 
ible lead strip, which is afterwards traced 
on pasteboard and kept for reference. 
The minutest changes in outline during 
the progress of the case can thus be 
readily recognized. These children 
should always be lifted by placing one 
hand under the seat, the other in front 
of the chest, and all the manipulations of 
the examiner should be of the gentlest; 
any rough handling is cruel, unnecessary 
and harmful. 
The-cases most easy to overlook are 
those that cannot walk. In a case of 
pressure paraplegia without marked de- 
formity, seen some years ago, the verte- 
bral disease escaped the notice of the at- 
tending physician and house staff, in- 
cluding myself, during six months of 
hospital treatment. 
Lateral curvature of the spine, being 
a deformity due to loss of equilibrium, 18 
not to bone disease, is not characterized 
by the special modifications of associated 
movements due to inflammatory pro- 
cesses, and the preliminary examination 
is relatively of less importance; but 
here, as in all orthopaedic eases, the gait 
and attitude should be carefully studied. 
The history, especially as bearing on the 
temperament, mental habits, schooling, 
etc., of the patient should be thoroughly 
inquired into, and will often in early 
cases furnish the key to the causes and 
cure of the affection. 
In making the examination, the back 
and hips of the patient should be exposed 
and the patient seated on a low stool be- 
fore the examiner. In this position the 
contours of the body, hip3, spine and 
shoulders can be observed, spinal mobil- 
ity tested, and chest expansion measured. 
The patient then stands up, the back 
being still turned to the examiner, and 
while the patient stands squarely on the 
feet, the knees being straight, the hori- 
zontal hands of the examiner are forced 
inward over the iliac crests to ascertain 
any pelvic obliquity that may exist. 
After this has been done, if the patient 
bends forward at the hips until the body 
makes a right angle with the legs, the 
arms hanging, any rotation will be 
plainly shown. It is of less importance 19 
to ascertain the exact line of the spinous 
processes than to study the lateral con- 
tours of the body, any fulness or flat- 
ness at the side of the spine, the position 
of the hipB, and spinal mobility. 
Too much stress should not be laid on 
backache or spinal tenderness ; these are 
undoubtedly present in a certain propor- 
tion of cases but there is no necessary 
connection between them and ordinary 
lateral curvature, which, indeed, has no 
rational symptoms until rotation is so 
great as to cramp the viscera. 
Spinal tenderness, usually superficial 
and often severe, and “backache” are 
nearly always referable to general causes 
or to the condition of the nervous system. 
In states of ansemia, nervous depression 
and brain-tire, backache and spinal 
tenderness are a characteristic symptom. 
These cases of “backache” may be 
exceedingly obstinate and distressing, 
but are usually amenable to hygienic 
and tonic treatment after the removal of 
the predisposing causes. Systematic 
active and passive movements are of 
great value and assist in that regulation 
of the psycho-physical life which is often 
essential to a cure. 
Leaving aside round-shoulders, the 
diagnosis of which is obvious, nearly all 
the back cases which present themselves 20 
will be found to fall into these three 
classes of spinal caries, lateral curvature 
and “ backache,” which it is of the ut- 
most importance to clearly discriminate 
from the start, as the treatment is radi- 
cally divergent. 
I call particular attention in closing to : 
1. The necessity for the critical analy- 
sis of any deviation from the normal car- 
riage or locomotion, especially during 
the growing period, and for a careful 
study of expression and movement in its 
widest sense, as revealing the effect of 
general strain and local irritation. 
2. The value of specially testing the 
tonicity of the muscle groups, acting 
upon a joint where disease is suspected. 
3. The unreliability of pain and ten- 
derness as a diagnostic sign in the early 
stages of joint disease, and the inadmis- 
sibility of rough manipulations to elicit 
them. 
201 West 54th Street.