- Email: [email protected]
Pott's puffy tumour
EPONYM
Eponym
Pott’s puffy tumour Rachel Tattersall, Robert Tattersall
A 53-year-old man presented with a 36-h history of drowsiness, increasing confusion, ataxia, and left-sided weakness. His wife attributed these symptoms to an injury sustained 3 weeks earlier, when he had been climbing the stairs and hit his forehead on the ceiling. He had not lost consciousness at the time, but since then had complained of severe frontal headache and swelling on his forehead. He saw his general practitioner a week after the injury and no neurological deficit was noted. The headache continued and had become much worse at the onset of his presenting symptoms. On examination, the most striking finding was a boggy, erythematous swelling over the right frontal bone. His Glasgow coma score was 12/15 and he did not initially have a fever, but subsequently developed a temperature of 38ºC. There was no meningism and fundoscopy was normal. Both ears were examined and no abnormality was seen. He had hypertonicity and hyper-reflexia in the left arm and leg, with an upgoing plantar response and six beats of clonus. Cardiovascular, respiratory, and abdominal examination showed no abnormality. Laboratory tests showed hyponatraemia (120 mmol/L) and leucocytosis of 19·8⫻109 /L (neutrophilia 17·3⫻109/L). Chest radiograph was normal, and he was started on antibiotic and antiviral treatment for presumed intracerebral sepsis. Computed-tomography scan of the head was done urgently and showed soft tissue swelling over both frontal bones, with soft tissue opacity (probable infection) of the frontal sinuses. Initially, the right frontal pole had a region of low density, which did not enhance with contrast. Within 12 h he deteriorated further; his hemiparesis deepened, Glasgow coma score dropped to 9, and he began to have seizures. He was treated with intravenous phenytoin, sedated, and ventilated. Repeat computed-tomography showed extension of the hypodense, nonenhancing area to the left frontal pole, and a 2–3 mm rim of fluid overlying the anterior half of each cerebral hemisphere. He was transferred to the regional neurosurgical centre, where he had a bifrontal craniotomy. The frontal bone was grossly abnormal and osteomyelitic with pus leaking from holes on its surface. A subperiosteal abscess was drained and a 3 mm blackish red membrane (inflamed dura mater) peeled from the cortex. A subdural empyema was then drained and the sinuses washed out. Pus and blood cultures confirmed the causative organism as Streptococcus milleri. Postoperatively, control of intracranial pressure was difficult, and he died after 5 days. The diagnosis of Pott’s puffy tumour—osteomyelitis of the calvarium—was confirmed at necropsy.
The alliteration of the name has probably done more for the prominence of this disorder than its clinical importance. A MEDLINE search showed that only 19 articles on the subject had been published between 1966 and 2000, and only seven cases are thought to have been reported in adults.1 However, these figures undoubtedly give an impression that the disorder is rarer than it is: the ear, nose, and throat surgeons and neurosurgeons to whom these cases present have no reason to write them up. The commonest cause (75% in one series) is frontal sinusitis, with head injury a distant second, and causative organisms include streptococci, staphylococci, Haemophilus influenzae, and anaerobic bacteria. The disorder was first described by Percivall Pott (figure 1), Surgeon to St Bartholomew’s Hospital, London, in Injuries of the Head from External Violence,2 published in 1760 (figure 2). The 43 case histories in this elegant, and still eminently readable, book reveal an extraordinary variety of ways of injuring the head in early Georgian London. One man (case 1) was caught up in a mob who were trying to save someone from being press ganged. About a child (case 2) who was hit on the head by a quoit, Pott wrote “From the symptoms and appearances, I prognosticated no good.”
Rights were not granted to include this image in electronic media. Please refer to the printed journal.
Wellcome Library, London
Case history
Lancet 2002: 359: 1060–63 Correspondence to: Prof Robert Tattersall, Curzon House, Curzon Street, Gotham, NG11 0HQ, UK (e-mail: [email protected])
1060
Figure 1: Percivall Pott, engraving from a picture by Sir Joshua Reynolds
THE LANCET • Vol 359 • March 23, 2002 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet Publishing Group.
EPONYM
A drunk drayman (case 11) fell off his cart and his head was squeezed between the wheel and a post. Others included a woman whose husband had hit her on the head with a broom, a lunatic who threw himself out of a window, a child who was hit on the head by a cricket bat, and a fireman who fell through the roof of a burning building. Pott clearly described the symptoms of various forms of intracranial haemorrhage, and distinguished between subdural and extradural haematomas.2
Rights were not granted to include this image in electronic media. Please refer to the printed journal.
“If the symptoms of pressure; such as stupidity, loss of sense, voluntary motion etc appear some few days after the head has suffered injury from external mischief, they do most probably imply an effusion of a fluid somewhere; this effusion may be in the substance of the brain, in its ventricles, between its membranes, or on the surface of the dura mater.”2
He pointed out the difficulty of distinguishing between these disorders except that
Wellcome Library, London
“Inflammation of the dura mater, and the formation of matter between it and the skull, in consequence of contusion, is generally indicated and preceded by one [sign] I have hardly ever known to fail; I mean a puffy, circumscribed, indolent tumour of the scalp . . . these appearances therefore following a smart blow on the head, and attended with langour, pain, restlessness, watching, quick pulse, head-ach [sic], and slight, irregular shiverings, do almost infallibly indicate an inflamed dura mater, and pus, either forming or formed between it and the cranium.”2
Figure 2: Frontispiece of Pott’s book on head injuries, 1760
In general, Pott thought the best way of preventing “mischief” after a head injury was phlebotomy, but accepted that it was difficult to persuade people who had had “only a knock on the pate” to undergo it. Once the puffy tumour had formed, he stressed that perforation should be done immediately, and that usually the procedure is delayed for too long. Several openings might have to be
Wellcome Library, London
Rights were not granted to include this image in electronic media. Please refer to the printed journal.
Figure 3: Pott’s apparatus for raising depressed fractures of the skull
THE LANCET • Vol 359 • March 23, 2002 • www.thelancet.com
1061
For personal use. Only reproduce with permission from The Lancet Publishing Group.
EPONYM
Wellcome Library, London
Rights were not granted to include this image in electronic media. Please refer to the printed journal.
Figure 4: Pott’s concern for chimney sweeps who developed cancer of the scrotum
made, according to Pott (figure 3), and the operation must be followed up with—as was usual for the time—supportive treatment of blood letting, cooling laxative medicines, antiphlogistic remedies, and strict control of diet.2
Percivall Pott3 Percivall Pott (1714–88) was born in London, but his father died when he was 3 years old, leaving the family poorly provided for. However, the Bishop of Rochester, who was his mother’s relative by a previous marriage, paid for his education. At the age of 15, he was apprenticed to Edward Nourse, one of the two surgeons at St Bartholomew’s Hospital, for a fee of 200 guineas. One of Pott’s duties as an apprentice was to dissect preparations for the anatomy demonstrations at Nourse’s home in Aldersgate street in east London, and this was probably where he developed his substantial surgical skills. At 22, he was admitted into the freedom of the Company of the Barber Surgeons, and then went into practice in Fenchurch Street were he lived with his mother and stepsister. In 1739, he applied for the post of assistant surgeon at St Bartholomew’s, but was turned down. But when his former master, Edward Nourse, was made surgeon at the hospital in 1745, Pott became assistant surgeon, and was promoted to full surgeon in 1749. In early life he was described as “a spare man, not very tall, of a lively disposition, fond of talking, fond of society and fond of his family”.3 Later he began to turn up at the hospital in a red coat, sometimes wearing a sword. He became very successful and rich, and his patients included Samuel Johnson, David Garrick, and Thomas Gainsborough. The most significant event of Pott’s life was when he was riding to see a patient in Southwark on a frosty morning in 1756 and fell off his horse, thereby sustaining a compound fracture of the tibia. He sent to Westminster for two bearers and lay on the frozen ground until they turned up. He then bought a door (presumably while still lying on the ground) and this was nailed to the bearer’s poles and Pott was carried to his home on this improvised stretcher. The
1062
surgeons who were called advised amputation and Pott agreed, despite the fact that he later described amputation as “terrible to bear and horrible to see”.2 However, when Nourse arrived, he reduced the fracture and it eventually healed by first intention. During his convalescence, Pott wrote A treatise on ruptures,4 which established his reputation, even though it was initially criticised by John Hunter who wrote that it “bore strong marks of second hand observations, and of time-serving hurry in the composition”.5
Other eponymous diseases Carcinoma of the scrotum In addition to his puffy tumour, Pott was the first to describe an industrial disease: cancer of the scrotum in chimney sweeps (figure 4). Pott’s fracture of the ankle Pott’s fracture is not, as is said in some books of eponyms, the one which he had in 1756, but a fracture dislocation of the ankle. This was usually caused by leaping or jumping, with the fibula breaking at its narrowest part. The tibia was then forced outwards and all the tendons which pass behind, under, or are attached to the extremities of the tibia and fibula, or os calcis, have their natural direction and disposition so changed, that instead of acting normally, they all contribute to the distortion of the foot, by turning it outward and upward.6 Pott’s disease of the spine (tuberculosis) This disease is, in Pott’s own words “what is in general called the scrophula; that is, that same kind of indisposition as occasions the thick upper lip, the tedius obstinate ophthalmy [persisent inflammation of the eye], the indurated glands under the chin and in the neck, the obstructed mesentery, the hard dry cough, the glairy [albumin-like] swellings of the wrist and ancles, the thickened ligaments of the joints, the enlargement and caries of the bones, etc. etc. etc.”7
THE LANCET • Vol 359 • March 23, 2002 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet Publishing Group.
EPONYM
He noted that the caries was always confined to the bodies of the vertebrae and never affected the articular processes. Destruction of the vertebrae produced a curvature of the spine and a “useless state of the limbs”.7 However, there was controversy about Pott’s treatise on this disease of the spine, because a dissertation on the same theme had been presented in 1778 by the French surgeon, Jean-Pierre David, for a prize offered by the Royal Academy of Surgery in Paris. The dissertation was published the year after, and, although there is no evidence that Pott had read it, people pointed out that in the 19th century, it was very unjust that David’s name was forgotten in France, where the disease was called le mal vertébral de Pott.5
References 1
2 3 4 5 6 7
Verbon A, Husni RN, Gordon SM, Lavertu P, Keys TF. Pott’s puffy tumour due to Haemophilus influenzae: case report and review. Clin Infect Dis 1996; 23: 1305–07. Pott P. Injuries of the head from external violence. 1st edn. London: C Hitch and L Hawes, 1760: 47–48. Medvei V C, Thornton J L, eds The Royal Hospital of St Bartholomew 1923–1973. London: St Bartholomew’s Hospital, 1974: 206–09. Pott P. A treatise on ruptures. London: C Hitch and L Hawes, 1756: 232. Dobson J, Percivall Pott. Ann R Coll Surg Eng 1972; 50: 54–65. Pott P. Some few general remarks on fractures and dislocations. London: Clarke, Hawes, and Collins, 1769: 126. Pott P. Remarks on that kind of palsy of the lower limbs, which is frequently found to accompany a curvature of the spine, and is supposed to be caused by it. London: J Johnson, 1779: 84.
Uses of error Ambylopia and arrogance Theodore B Schwartz The year was 1943. I was interning at the Osler Clinic of the Johns Hopkins Hospital, unarguably an arduous undertaking, incomprehensible to today’s medical residents. We were on duty every other night and, for the month’s rotation through the emergency room (ER), we were on duty for 34 h, then off for the subsequent 14. It was in this setting that I saw a patient, a robust black male in his early 20’s, complaining of headache, malaise and a low-grade fever. As was usual, the ER was busy that night; there was “flu going around”. Anxious to get to other waiting patients, I performed a perfunctory examination, decided that he, too, had the flu, and prescribed an analgesic. I assured him that he would improve before long. He thanked me and walked to the door of my small cubicle. As he was leaving, I said, “Listen, if you don’t feel better or if you feel worse, come on back.” He turned back to me and said, “OK, thanks” and left. I thought that there was something vaguely disquieting about his behaviour but my unease soon dissolved in the ongoing bustle of activity. 8 h later he was returned to the ER, dead on arrival. I was upset and apprehensive, searching my mind for what I had missed. At necropsy, he was found to have suffered an overwhelming meningococcal infection. It was then that I recalled what had struck me as unusual as he walked to the door. When he turned around to respond to my comment he did not turn his neck; rather, he turned his whole body, signalling a cardinal sign of meningitis. He had had a stiff neck! I was devastated and inconsolable. Ignoring the fact that no one was aware of my lapse, I told my story to everyone I encountered, hoping that my confession, in some way, would expiate my sin. I have never forgotten that it is not enough to look; you must be able to see. Fast-forward to 1960. I was now in Chicago and, bursting with self-confidence, convinced that I had mastered my trade. One day, accompanied by a resident, I
responded to an urgent request for consultation from the closed psychiatric unit. The patient, a 27-year-old postpartum female, had hyperemesis gravidum. She had begun intractable vomiting some weeks before the birth of her baby and, following its delivery, she refused to take any notice of it. She also refused to take any nourishment. On examination, she had obvious signs of inanition and dehydration. We administered intravenous fluids and I asserted that the patient must be transferred to a medical floor; her emotional problems could wait. There, I engaged her in some straight talk. “Your continued vomiting,” I said, “has threatened your health and has prevented you from caring for your baby. It is my responsibility to see that you become better nourished so we are going to feed you through a stomach tube.” She acquiesced quietly and the tube was inserted. The resident told me at this juncture, that, when he percussed her chest, he had found that her cardiac dullness was increased. I dismissed his finding with good-tempered tolerance, suggesting that, perhaps, her anaemia had led to cardiac dilatation. The next day the patient obstinately persisted in vomiting; indeed, she was vomiting up around the gastric tube. I instructed the resident to advance the tube through the pylorus into the duodenum so that she could absorb the administered nutrients. He complied but, unconvinced by my easy explanation for the patient’s enlarged heart, he obtained a chest radiograph. When we looked at the film the diagnosis was obvious. The patient had achalasia, a hugely dilated, fluid-filled oesophagus with the gastric tube lying in coils inside it. From that moment, I changed from an arrogant pontificator to a lifelong practitioner of humility. Anyone my age has a store, hopefully modest, of such “horror stories” but the two provided here should suffice to convince young physicians that learning from the errors of others is preferable to suffering through one’s own.
Rush Medical College, Chicago, Illinois, USA (Prof T B Schwartz MD)
THE LANCET • Vol 359 • March 23, 2002 • www.thelancet.com
1063
For personal use. Only reproduce with permission from The Lancet Publishing Group.
Eponym
Pott’s puffy tumour Rachel Tattersall, Robert Tattersall
A 53-year-old man presented with a 36-h history of drowsiness, increasing confusion, ataxia, and left-sided weakness. His wife attributed these symptoms to an injury sustained 3 weeks earlier, when he had been climbing the stairs and hit his forehead on the ceiling. He had not lost consciousness at the time, but since then had complained of severe frontal headache and swelling on his forehead. He saw his general practitioner a week after the injury and no neurological deficit was noted. The headache continued and had become much worse at the onset of his presenting symptoms. On examination, the most striking finding was a boggy, erythematous swelling over the right frontal bone. His Glasgow coma score was 12/15 and he did not initially have a fever, but subsequently developed a temperature of 38ºC. There was no meningism and fundoscopy was normal. Both ears were examined and no abnormality was seen. He had hypertonicity and hyper-reflexia in the left arm and leg, with an upgoing plantar response and six beats of clonus. Cardiovascular, respiratory, and abdominal examination showed no abnormality. Laboratory tests showed hyponatraemia (120 mmol/L) and leucocytosis of 19·8⫻109 /L (neutrophilia 17·3⫻109/L). Chest radiograph was normal, and he was started on antibiotic and antiviral treatment for presumed intracerebral sepsis. Computed-tomography scan of the head was done urgently and showed soft tissue swelling over both frontal bones, with soft tissue opacity (probable infection) of the frontal sinuses. Initially, the right frontal pole had a region of low density, which did not enhance with contrast. Within 12 h he deteriorated further; his hemiparesis deepened, Glasgow coma score dropped to 9, and he began to have seizures. He was treated with intravenous phenytoin, sedated, and ventilated. Repeat computed-tomography showed extension of the hypodense, nonenhancing area to the left frontal pole, and a 2–3 mm rim of fluid overlying the anterior half of each cerebral hemisphere. He was transferred to the regional neurosurgical centre, where he had a bifrontal craniotomy. The frontal bone was grossly abnormal and osteomyelitic with pus leaking from holes on its surface. A subperiosteal abscess was drained and a 3 mm blackish red membrane (inflamed dura mater) peeled from the cortex. A subdural empyema was then drained and the sinuses washed out. Pus and blood cultures confirmed the causative organism as Streptococcus milleri. Postoperatively, control of intracranial pressure was difficult, and he died after 5 days. The diagnosis of Pott’s puffy tumour—osteomyelitis of the calvarium—was confirmed at necropsy.
The alliteration of the name has probably done more for the prominence of this disorder than its clinical importance. A MEDLINE search showed that only 19 articles on the subject had been published between 1966 and 2000, and only seven cases are thought to have been reported in adults.1 However, these figures undoubtedly give an impression that the disorder is rarer than it is: the ear, nose, and throat surgeons and neurosurgeons to whom these cases present have no reason to write them up. The commonest cause (75% in one series) is frontal sinusitis, with head injury a distant second, and causative organisms include streptococci, staphylococci, Haemophilus influenzae, and anaerobic bacteria. The disorder was first described by Percivall Pott (figure 1), Surgeon to St Bartholomew’s Hospital, London, in Injuries of the Head from External Violence,2 published in 1760 (figure 2). The 43 case histories in this elegant, and still eminently readable, book reveal an extraordinary variety of ways of injuring the head in early Georgian London. One man (case 1) was caught up in a mob who were trying to save someone from being press ganged. About a child (case 2) who was hit on the head by a quoit, Pott wrote “From the symptoms and appearances, I prognosticated no good.”
Rights were not granted to include this image in electronic media. Please refer to the printed journal.
Wellcome Library, London
Case history
Lancet 2002: 359: 1060–63 Correspondence to: Prof Robert Tattersall, Curzon House, Curzon Street, Gotham, NG11 0HQ, UK (e-mail: [email protected])
1060
Figure 1: Percivall Pott, engraving from a picture by Sir Joshua Reynolds
THE LANCET • Vol 359 • March 23, 2002 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet Publishing Group.
EPONYM
A drunk drayman (case 11) fell off his cart and his head was squeezed between the wheel and a post. Others included a woman whose husband had hit her on the head with a broom, a lunatic who threw himself out of a window, a child who was hit on the head by a cricket bat, and a fireman who fell through the roof of a burning building. Pott clearly described the symptoms of various forms of intracranial haemorrhage, and distinguished between subdural and extradural haematomas.2
Rights were not granted to include this image in electronic media. Please refer to the printed journal.
“If the symptoms of pressure; such as stupidity, loss of sense, voluntary motion etc appear some few days after the head has suffered injury from external mischief, they do most probably imply an effusion of a fluid somewhere; this effusion may be in the substance of the brain, in its ventricles, between its membranes, or on the surface of the dura mater.”2
He pointed out the difficulty of distinguishing between these disorders except that
Wellcome Library, London
“Inflammation of the dura mater, and the formation of matter between it and the skull, in consequence of contusion, is generally indicated and preceded by one [sign] I have hardly ever known to fail; I mean a puffy, circumscribed, indolent tumour of the scalp . . . these appearances therefore following a smart blow on the head, and attended with langour, pain, restlessness, watching, quick pulse, head-ach [sic], and slight, irregular shiverings, do almost infallibly indicate an inflamed dura mater, and pus, either forming or formed between it and the cranium.”2
Figure 2: Frontispiece of Pott’s book on head injuries, 1760
In general, Pott thought the best way of preventing “mischief” after a head injury was phlebotomy, but accepted that it was difficult to persuade people who had had “only a knock on the pate” to undergo it. Once the puffy tumour had formed, he stressed that perforation should be done immediately, and that usually the procedure is delayed for too long. Several openings might have to be
Wellcome Library, London
Rights were not granted to include this image in electronic media. Please refer to the printed journal.
Figure 3: Pott’s apparatus for raising depressed fractures of the skull
THE LANCET • Vol 359 • March 23, 2002 • www.thelancet.com
1061
For personal use. Only reproduce with permission from The Lancet Publishing Group.
EPONYM
Wellcome Library, London
Rights were not granted to include this image in electronic media. Please refer to the printed journal.
Figure 4: Pott’s concern for chimney sweeps who developed cancer of the scrotum
made, according to Pott (figure 3), and the operation must be followed up with—as was usual for the time—supportive treatment of blood letting, cooling laxative medicines, antiphlogistic remedies, and strict control of diet.2
Percivall Pott3 Percivall Pott (1714–88) was born in London, but his father died when he was 3 years old, leaving the family poorly provided for. However, the Bishop of Rochester, who was his mother’s relative by a previous marriage, paid for his education. At the age of 15, he was apprenticed to Edward Nourse, one of the two surgeons at St Bartholomew’s Hospital, for a fee of 200 guineas. One of Pott’s duties as an apprentice was to dissect preparations for the anatomy demonstrations at Nourse’s home in Aldersgate street in east London, and this was probably where he developed his substantial surgical skills. At 22, he was admitted into the freedom of the Company of the Barber Surgeons, and then went into practice in Fenchurch Street were he lived with his mother and stepsister. In 1739, he applied for the post of assistant surgeon at St Bartholomew’s, but was turned down. But when his former master, Edward Nourse, was made surgeon at the hospital in 1745, Pott became assistant surgeon, and was promoted to full surgeon in 1749. In early life he was described as “a spare man, not very tall, of a lively disposition, fond of talking, fond of society and fond of his family”.3 Later he began to turn up at the hospital in a red coat, sometimes wearing a sword. He became very successful and rich, and his patients included Samuel Johnson, David Garrick, and Thomas Gainsborough. The most significant event of Pott’s life was when he was riding to see a patient in Southwark on a frosty morning in 1756 and fell off his horse, thereby sustaining a compound fracture of the tibia. He sent to Westminster for two bearers and lay on the frozen ground until they turned up. He then bought a door (presumably while still lying on the ground) and this was nailed to the bearer’s poles and Pott was carried to his home on this improvised stretcher. The
1062
surgeons who were called advised amputation and Pott agreed, despite the fact that he later described amputation as “terrible to bear and horrible to see”.2 However, when Nourse arrived, he reduced the fracture and it eventually healed by first intention. During his convalescence, Pott wrote A treatise on ruptures,4 which established his reputation, even though it was initially criticised by John Hunter who wrote that it “bore strong marks of second hand observations, and of time-serving hurry in the composition”.5
Other eponymous diseases Carcinoma of the scrotum In addition to his puffy tumour, Pott was the first to describe an industrial disease: cancer of the scrotum in chimney sweeps (figure 4). Pott’s fracture of the ankle Pott’s fracture is not, as is said in some books of eponyms, the one which he had in 1756, but a fracture dislocation of the ankle. This was usually caused by leaping or jumping, with the fibula breaking at its narrowest part. The tibia was then forced outwards and all the tendons which pass behind, under, or are attached to the extremities of the tibia and fibula, or os calcis, have their natural direction and disposition so changed, that instead of acting normally, they all contribute to the distortion of the foot, by turning it outward and upward.6 Pott’s disease of the spine (tuberculosis) This disease is, in Pott’s own words “what is in general called the scrophula; that is, that same kind of indisposition as occasions the thick upper lip, the tedius obstinate ophthalmy [persisent inflammation of the eye], the indurated glands under the chin and in the neck, the obstructed mesentery, the hard dry cough, the glairy [albumin-like] swellings of the wrist and ancles, the thickened ligaments of the joints, the enlargement and caries of the bones, etc. etc. etc.”7
THE LANCET • Vol 359 • March 23, 2002 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet Publishing Group.
EPONYM
He noted that the caries was always confined to the bodies of the vertebrae and never affected the articular processes. Destruction of the vertebrae produced a curvature of the spine and a “useless state of the limbs”.7 However, there was controversy about Pott’s treatise on this disease of the spine, because a dissertation on the same theme had been presented in 1778 by the French surgeon, Jean-Pierre David, for a prize offered by the Royal Academy of Surgery in Paris. The dissertation was published the year after, and, although there is no evidence that Pott had read it, people pointed out that in the 19th century, it was very unjust that David’s name was forgotten in France, where the disease was called le mal vertébral de Pott.5
References 1
2 3 4 5 6 7
Verbon A, Husni RN, Gordon SM, Lavertu P, Keys TF. Pott’s puffy tumour due to Haemophilus influenzae: case report and review. Clin Infect Dis 1996; 23: 1305–07. Pott P. Injuries of the head from external violence. 1st edn. London: C Hitch and L Hawes, 1760: 47–48. Medvei V C, Thornton J L, eds The Royal Hospital of St Bartholomew 1923–1973. London: St Bartholomew’s Hospital, 1974: 206–09. Pott P. A treatise on ruptures. London: C Hitch and L Hawes, 1756: 232. Dobson J, Percivall Pott. Ann R Coll Surg Eng 1972; 50: 54–65. Pott P. Some few general remarks on fractures and dislocations. London: Clarke, Hawes, and Collins, 1769: 126. Pott P. Remarks on that kind of palsy of the lower limbs, which is frequently found to accompany a curvature of the spine, and is supposed to be caused by it. London: J Johnson, 1779: 84.
Uses of error Ambylopia and arrogance Theodore B Schwartz The year was 1943. I was interning at the Osler Clinic of the Johns Hopkins Hospital, unarguably an arduous undertaking, incomprehensible to today’s medical residents. We were on duty every other night and, for the month’s rotation through the emergency room (ER), we were on duty for 34 h, then off for the subsequent 14. It was in this setting that I saw a patient, a robust black male in his early 20’s, complaining of headache, malaise and a low-grade fever. As was usual, the ER was busy that night; there was “flu going around”. Anxious to get to other waiting patients, I performed a perfunctory examination, decided that he, too, had the flu, and prescribed an analgesic. I assured him that he would improve before long. He thanked me and walked to the door of my small cubicle. As he was leaving, I said, “Listen, if you don’t feel better or if you feel worse, come on back.” He turned back to me and said, “OK, thanks” and left. I thought that there was something vaguely disquieting about his behaviour but my unease soon dissolved in the ongoing bustle of activity. 8 h later he was returned to the ER, dead on arrival. I was upset and apprehensive, searching my mind for what I had missed. At necropsy, he was found to have suffered an overwhelming meningococcal infection. It was then that I recalled what had struck me as unusual as he walked to the door. When he turned around to respond to my comment he did not turn his neck; rather, he turned his whole body, signalling a cardinal sign of meningitis. He had had a stiff neck! I was devastated and inconsolable. Ignoring the fact that no one was aware of my lapse, I told my story to everyone I encountered, hoping that my confession, in some way, would expiate my sin. I have never forgotten that it is not enough to look; you must be able to see. Fast-forward to 1960. I was now in Chicago and, bursting with self-confidence, convinced that I had mastered my trade. One day, accompanied by a resident, I
responded to an urgent request for consultation from the closed psychiatric unit. The patient, a 27-year-old postpartum female, had hyperemesis gravidum. She had begun intractable vomiting some weeks before the birth of her baby and, following its delivery, she refused to take any notice of it. She also refused to take any nourishment. On examination, she had obvious signs of inanition and dehydration. We administered intravenous fluids and I asserted that the patient must be transferred to a medical floor; her emotional problems could wait. There, I engaged her in some straight talk. “Your continued vomiting,” I said, “has threatened your health and has prevented you from caring for your baby. It is my responsibility to see that you become better nourished so we are going to feed you through a stomach tube.” She acquiesced quietly and the tube was inserted. The resident told me at this juncture, that, when he percussed her chest, he had found that her cardiac dullness was increased. I dismissed his finding with good-tempered tolerance, suggesting that, perhaps, her anaemia had led to cardiac dilatation. The next day the patient obstinately persisted in vomiting; indeed, she was vomiting up around the gastric tube. I instructed the resident to advance the tube through the pylorus into the duodenum so that she could absorb the administered nutrients. He complied but, unconvinced by my easy explanation for the patient’s enlarged heart, he obtained a chest radiograph. When we looked at the film the diagnosis was obvious. The patient had achalasia, a hugely dilated, fluid-filled oesophagus with the gastric tube lying in coils inside it. From that moment, I changed from an arrogant pontificator to a lifelong practitioner of humility. Anyone my age has a store, hopefully modest, of such “horror stories” but the two provided here should suffice to convince young physicians that learning from the errors of others is preferable to suffering through one’s own.
Rush Medical College, Chicago, Illinois, USA (Prof T B Schwartz MD)
THE LANCET • Vol 359 • March 23, 2002 • www.thelancet.com
1063
For personal use. Only reproduce with permission from The Lancet Publishing Group.