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Sir Percivall Pott—Surgeon St. Bartholomew's Hospital
[From Ferneiius’ Universa Medicina, Geneva, 1679.1
BOOKSHELF SIR PERCIVALL
BROWSING
POTT-SURGEON ST. BARTHOLOMEW’S HOSPITAL FELIX CUNHA, SAN
FRANCISCO,
T
M.D. CALIF.
To remove, or even to relieve anv of the miseries to which mankind are liable, ‘is a very satisfactory employment; but to attend on a distemper from its beginning, through a long and painfuI course, to its Iast, fata period,
0 read the origina treatise of Sir Percival1 Pott describing the disease which today bears his name is exceptionaIIy interesting because of the many sidelights it throws on the manner of his reasoning as to etioIogy, as to method of treatment and how this reasoning was arrived at. The number of cures attested to is aIso interesting, aIthough we wouId be incIined to accept them with a bit of reser\;e. Then also the fact that attention was drawn to the disease or the diagnosis onIy after paraIysis from cord pressure due either to destruction of vertebrae or impingement of the cord had set in. As can be seen from the title page of the treatise (Fig. I) the maIady is described as “That kind of palsy of the Lower Limbs which is frequently found to accompany a Curvature of the Spine.” As the entire treatise is short, well worth reading and as copies of the original are scarce, I am quoting the entire article.
without even the hope of being able to do anything which shalI be really serviceable, is of a11 tasks the most unpIeasant. In such cases, an) attempts, however hazardous, provided they were rational, would be justifiable, certainIy then, whatever is not in itself dangerous and affords the smaIIest ray of hope, ought to be embraced. 1 publish therefore an account of the good success which has attended a particular method of’ treating a disease, which has hitherto foiled a11 the efforts of art; and I do it with the principle that by inducing others to make the same experiment, I propagate the benefit. The disease of which I mean to speak is generaII?- caIIed a paIsy, as it consists in a totaI or partra1 aboIition of the power of using and sometimes of even moving the louver limbs, in consequence, as is generaIIy supposed, of a curvature of some part of the spine. To this distemper both sexes and al1 ages are equaIIy Iiable. If the patient be an infant, it becomes an object of constant though unavaiIing distress to its parents; if an aduIt, he is rendered perfectly heIpIess to himself, and useIess to a11 others, which, of a11 possihIe states, is sure1.y the very worst.
Among the \.arious objects of Physick and Surgery, there are unfortunately some in which all the efforts of both, have hitherto been found absolutely ineffectua1, and which therefore have aIways made a very disagreeable and melancholy part of practice. 327
328
American
Journal of Surgery
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PercivaII
When this disease attacks an infant of only a year or two oId, or under, the true cause of it is seIdom discovered unti1 some time after the effect has taken pIace, at least not by parents and nurses, who know not where to Iook for it. The chiId is said to be uncommonIy backward in the use of his Iegs, or it is thought to have received some hurt in its birth. When it affects a chiId who is oId enough to have aIready waIked, and who has been abIe to waIk, the loss of the use of his Iegs is gradua1, though in genera1 not very SIOW. He at first compIains of being soon tired, is Ianguid, Iistless, and unwiIIing to move much, or at a11 briskIy; in no great Iength of time after this he may be observed frequently to trip, and stumbIe, aIthough there be no impedimept in his he attempts to move way; and whenever briskIy, he finds that his Iegs invoIuntariIy cross each other, by which he is frequently thrown down, and that without stumbIing; upon endeavoring to stand stiI1 and erect, without support, even for a few minutes, his knees give way and bend forward. When the distemper is a IittIe farther advanced it wiI1 be found, that he cannot, without much diffIcuIty and deIiberation, direct either of his feet preciseIy to any exact point; and very soon after this, both thighs and Iegs lose a good dea1 of their natura1 sensibiIity, and become perfectIy useIess for a11 the purposes of locomotion. When an aduIt is the patient the progress of the distemper is much the same but rather quicker. Until the curvature of the spine has been discovered, it generaIIy passes for a nervous compIaint; but when the state of the backbone has been adverted to, recourse is almost always had to some previous vioIence to account for it, some pulling, Iifting, carrying, or drawing a heavy body, which is supposed to have hurt the back. In some few instances, this exertion may have been such as might be aIIowed to have been equa1 to the effect, but, in by much the majority, this is so far from being the case, that if it be admitted to have had any share at a11 in it, some predisposing cause, at least, must be Iooked for, in which, (in my opinion) consists the very essence of the disease. I have, in compliance with custom, caIIed the disease a paIsy; but it shouId be observed that notwithstanding the Iower Limbs be rendered almost, or totally useless, yet there are some essentia1 circumstances in which this
Pott
AUGUST.
1935
affection differs from a common nervous palsy; the Iegs and thighs are, I have just said, rendered unfit for a11 the purposes of locomotion, and do aIso Iose much of their natural sensibility, but notwithstanding this, they have neither the flabby feeI, which a truIy paraIytic Iimb has, nor have they that seeming Iooseness at the joints, nor that tota incapacity of resistance, which aIIows the Iatter to be twisted in aImost a11 directions; on the contrary the joints have frequentIy a considerabIe degree of stiffness, particuIarIy the ankIes, by which stiffness the feet of ehiIdren are generaIIy pointed downward, and they are prevented from setting them ffat upon the ground. The curvature of the spine, which is supposed to be the cause of this compIaint, varies in situation, extent and degree, being either in the neck or back, and sometimes (aIthough very seIdom) in the upper part of the Ioins, sometimes comprehending two vertebrae only, sometimes three, or more, by which the extent of the curve becomes necessariIy more or less; but whatever may be the number of vertebrae concerned, or whatever may be the degree or extent of the curvature, the Iower Iimbs onIy fee1 the effect-at Ieast I have never once seen the arms affected by it. This effect is aIso different in different subjects: some are rendered totaIIy and absoIuteIy incapable of waIking in any manner, or with any heIp and that earIy in the course of the distemper; others can make a shift to move about with the heIp of crutches, or by grasping their own thighs with their hands; some can sit in an erect posture, or in a chair, without much troubIe or fatigue, which others are incapabIe of, at Ieast for any Iength of time; some have such a degree of motion in their Iegs and thighs, as to enabIe them to turn and move for their own convenience in bed, others have not that benefit, and are obIiged to lie tiI1 moved by another. When a naturaIIy weak infant is the subject, and the curvature is in the vertebrae of the back, it is not infrequentIy productive of additional deformity, by graduaIIy rendering the whoIe back what is commonIy caIIed humped; and by aIterations which a11 the bones of the thorax sometimes undergo, in consequence of the flexure and weakness of the spine, by which such persons are justIy said to be shortened in their stature; but in al1 cases where this effect has been gradually produced,
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to whatever degree the deformity may extend, or however the alteration made in the disposition of the ribs and sternum may contribute to
Pott
American
329
Journal of Surgery
a variety
of compIaints, dies in an exhausted emaciated state; or, which is still worse, drags on a miserabIe existence, confined to a. great FARTHER
REMARKS ON.
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of AMPUTATION,
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BEING
AHD U~-~TRCE~ZA~N CIRCUMSTANCES. A
BY PERCIVALL And SURGEON to ST.
POTT, BAKTHOLOMEW’S
VuumquceR ad ipfamcurandirationemnihil quam experientram.
to a former TREATISE
SUPPLEMENT
on that SubjeA.
F. R.S. HOSPITAL.
plusconferre
BY
CELSUS.
PERCIVALL
POTT,
SURGeON t0 ST. BARTHOLOMEW’S
F.R,S. HOSPITAL.
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Printed for J. JOHNSON, No. ,z.
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M,DCC&.XX‘X.
FIG. I. Title page from Pott’s origina disease.
MDCCLXXXII, description of the
such deformity, yet I think that it wiII aIways be found, that the curvature of the spine appeared first, and, if I may so say, singIy and that a11 the rest was consequential. WhiIe the curvature of the spine remains undiscovered or unattended to, the case is generaIly supposed to be nervous, and medicines so caIIed are most frequentIy prescribed, together with warm Iiniments, embrocations and bIisters, to the parts affected; and when the true cause is known, recourse is aIwa?s had to stee1 stays, the swing, the screw chair, and other pieces of machinery, in order to restore the spine to its true and natura1 figure; but aI1, as far as I have observed, to no rea1 or permanent good purpose; the patient becomes unhealthy, and Ianguishing for some time under
FIG.
2.
Title page from his second description three years Iater.
pubIished
chair, or bed, totaIIy deprived of the power of Iocomotion, and useIess both to himself and others. This in an infant is most meIanchoIy to see, in an aduIt most miserabIe to endure. The genera1 health of the patient does not seem at first, to be materiaIIy, if at al1, affected, but when the disease has been sometime, and the curvature thereby increased, many inconveniences and compIaints come on, such as diff<y in respiration, indigestion, pain and what they calI tightness at the stomach, obstinate constipations, purgings, invoIuntary flux of urine and faeces, etc., with the addition of what are caIIed nervous compIaints, some of which are caused by the aIterations made in the form of the cavity of the thorax, others
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seem to arise from impressions made on the abdomina1 viscera. These are different both in kind, and in degree, in different subjects, but seem to depend very much on the consequences of the curvature-that is, in naturaIIy infirm chiIdren, aIthough the curvature of the dorsa1 vertebrae is aIways the first mark of the distemper, by preceding every other, yet it is frequentIy soon foIIowed by such a degree of deformity of the bones of the trunk, as to be, in conjunction with the necessary inactivity and confinement of the patient, productive of a11 the iIIs above mentioned. An affecting instance of this distemper in the person of a very promising youth of fourteen years oId, with whose famiIy I was nearIy connected, induced me to think more of it than perhaps I otherwise shouId have done; and the restoration of the use of his Iimbs, immediateIy after a seemingly accidental abscess near the part, engaged my attention stiI1 more, and became a matter of frequent, though not very satisfactory contempIation; I say unsatisfactory, because it served onIy to increase my doubts, without Ieading me toward a soIution of them. The more I thought upon the subject, the more I was incIined to suspect that we had been misIed by appearances, and that a distempered state of the parts forming, or in the neighborhood of curvature, preceded or accompanied it: in short, that there was something predisposing, and that we had most probabIy mistaken an effect for a cause. For these suspicions, I had the folIowing reasons which appeared to me to have some weight: I. That I had never seen this paraIytick effect on the Iegs from a mal-formation of the crooked such maIformation spine, however might have rendered it, or whether such crookedness had been from time of birth, or had come on at any time afterwards during infancy. 2. That none of those strange twists and deviations, which the majority of European women get in their shapes, from the very absurd custom of dressing them in stays during their infancy, and which put them into a11 directions but the right, ever caused anything of this kind, however great the deformity might be. 3. That the curvature of the spine, which is accompanied by this affection of the Iimbs, whatever may be its degree, or extent, is at first aImost aIways the same, that is, it is
PercivaII
Pott
aIways from within, outward, and seIdom or never to either side. 4. That since I had been particuIarIy attentive to the disorder I had remarked, that neither the degree nor the extent of the curve, made any aIteration in the nature or degree of the symptoms at first, nor for some time after the appearance; or in other words, that the smaIIest curvature, in which onIy two or three of the vertebrae were concerned, was aIways, at first, attended by the same symptoms as the Iargest. 5. That aIthough it sometimes happened that a smart bIow, or a vioIent strain had immediateIy preceded the appearance of the curve, and might be supposed to have given rise to it, yet in many more aduIts it happened that no such cause was fairIy assignabIe, and that they began to stoop, and to faIter in their walking, before they thought at a11 of their back, or of any vioIence offered to it. 6. That exactIy the same symptoms are found in infants, and in young chiIdren, who have not exerted themseIves nor have been injured by others, as in the aduIt, who has strained himself, or received a blow; and that the case was stiI1 the same in those grown peopIe, who have neither done, nor suffered any act of vioIence. 7. That aIthough it must be aIlowed, that a dislocation of any of the vertebrae, wouId most probabIy be attended with the same kind of symptoms from the pressure it must make on the spinal marrow, yet it is aIso most probabIe that such symptoms wouId be immediate, and attended with great pain in the part; neither of which is in genera1 the case here. These considerations appeared to me to have much force; but what confirmed me in my opinion was the state of the parts forming the curvature, and which I had severa fair opportunities of examining after death. By those examinations I found in infants, in young children, and in those who had been affected with the disorder but a smaI1 space of time, that the Iigaments connecting the vertebrae, which from a natura1 state, by being somewhat thickened and reIaxed, and that what are caIIed the bodies of those bones, were paIpabIy spread and enIarged in their texture, just as the bones forming the articuIations are in chiIdren who are caIIed rickety. That those who had Iong Iabored under the distemper, and in whom the symptoms were aggravated, whatever might
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he their age, the ligaments were stiI1 more thickened, relaxed, and altered, the bodies of the f)ones more spread, more enlarged, and more inclined to become carious, and the cartilages between the hodies of the vertebrae much compressed and Iessened in size; and that in :\I1 those who had so Iong Iahored under the disease, as to have been destroyed by it or by its consequences, the corpora vertebrariu m R-ere compIeteIy carious, the intervening cartilages totaIIy destroyed, and a quantity of t’anies lodged between the rotten bones, and the membrane investing the spina marrow. AI1 these circumstances put together, induced me, as I flave aIready said, to suspect, that n-hen N e attribute the whoIe of this mischief to the mere accidental curvature of the spine, in consequence of violence, we mistake an effect for a cause, and that previous both to the paraI,vtick state of the legs, and to the alteration of the figure of the backbone, there is a pre-disposing cause of both, consisting in a distempered state of the ligaments and hones, where the curve soon after makes its appearance. While the subject M-as fresh in my mind, I happened to be at Worcester, and in a conversation on it with the late Doctor Cameron, of that place, I mentioned to him, my opinion, and my doubts; the Doctor concurred with me, and at the same time mentioned a circumstance, Mhich made a strong impression on me. He said, that he remembered some years ago, to have noted a passage in Hippocrates, in which he speaks of a paralysis of the lower limbs being cured by an abscess in the hack or loins, and that taking the hint from this, he, Doctor Cameron, had, in a case of paIsy of the Iegs and thighs, attended by a curvature of the back bone, endeavored to imitate this act of nature, by exciting a discharge near the part, and that it had pro\.etf advantageous. He also referred me to Zlr. Jeft‘rys, a surgeon of eminence at Worcester, for a farther account of the same kind of attempt; this gentIeman confirmed u-hat Doctor Cameron had told me and assured me that he had founci the method equalIy successful. It may easily he supposed, that these accounts from gentlemen of veracity, and of reputation in their profession, stiI1 added to my desire of knobving more on this subject, and determined me to lose no opportunity of getting n Intnrmatlon.
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The first that offered was in an infant, whose curvature was in the middIe of the neck, and who had Iost the use of its legs for about two or three months. I made an issue h,- incision on one side of the projection, and gave strict charge to the mother to take care that the pea was kept in; the woman, who had no faith in the remedy, did not take the proper care, and consequently the discharge was not equal to what it shouId, and might have heen, but notwithstanding this negIect, at the end of about three weeks or a month the child Leas manifestly hetter, and began to make use of its legs; it was then seized with the small pox and died. The bodies of the vertebrae concerned in the curve, were larger than they should be, and than those above and below were, and their texture much more open and spongy, which difference appeared immediately, before the parts covering them were dissected off. Some time passed before I flat1 another My next patient was a tall thin opportunity. man, about thirty-five years old, ~vho thought that he had hurt himseIf b>- lifting a heavy weight: flis legs and thighs were cold, and what he calIed nummy, but not useless: he could with diffIcuftJ- go about the room with the help of a pair of crutches, hut he could neither rise from his chair, nor get on his crutches without the assistance of another person, nor could he without them waik at all. I made a seton on each side of the curve, which was in his back, about the middle, and having given his wife directions ho\v to dress them, I caIIed on him once in three or four days. At the end of six weeks he had recovered the due degree of sensation in his Iimbs, and found much Iess necessity for the use of his crutches; he could rise from his bed, and from his chair without assistance, and b.y means of one crutch, and an underhand stick, could walk for an hour, or more without resting, and without fatigue. The setons had now, from not having ljecn properly managed, worn their way out, and I woufd have converted each of them into an issue, but as neither the patient nor his wife had beIieved that the discharge had had a11y sflare in his amendment, but on the contrar>- that he would have been better without it, he would not submit to what I proposed, and I Icft him. At the distance of about three weeks from tfle time of my Ieaving him, I met him on tfle street walking very stoutly, with a common cane, of which he made little or no use. I asked him
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PercivaII Pott
what he had done: he told me that the sores had c:ontinued to discharge tilI within a few days, but that he had drank a great dea1 of
Fx.
3.
I believe that the cure of this man wiII, by a11who know anything of medicine, be thoulght to be so unIikeIy to have been affected by the
FIG. 4.
FIG. 6.
FIG. 3.
FIG. 3;-6. Reproduced
from Pott’s
own photographic pIates of post-mortem destructive changes described by him.
confrey-root tea, with isingIass, and he supposed that had cured him.
materia1 iltustrating the exte ,nsive
confrey and isingIass, that my influence in favour of the seton wiI1 not be thought unrea-
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sonabIe, and that my determination to prosecute the method, from what I had heard and seen, was well founded. Within the course of the last ten or twelve months, I have had several fair opportunities of doing this, both in St. BarthoIomew’s hospital, and out of it, and am very happy to be abIe to say, that it has not onIy aIways answered, but in some instances greatIy exceeded my most sanguine expectations, by restoring severa most miserabIe and totaIIy heIpIess people to the use of their limbs, and to a capacity of enjoying life themselves, as well as of being useful to others. I have now in the hospita1 a boy about twelve years old, whose case was so truly deplorable, that I made the experiment mereIy to a\roid the appearance of inhumanity, by discharging him as incurable, without trying something. The curvature n-as in his back, and consisted of three or four vertebrae, but by means of the weakness thereb,y induced, the whole set of dorsal ones had so universaIIy and graduaIIy given way, that he was exceedingly deformed both behind and before: he was so absoIuteIy incapable of motion, that he could neither turn himself, nor sit up in his bed: his feet were pointed downwards, and his ankles so stiff, that when he was held up under the arms, the extremities of his great toes touched the Aoor, nor could his feet be brought fiat to the ground by any means, or force whatever. In short, he was as perfectly and as totalIy helpless as can be supposed, and at the same time in an exceeding general bad state of heaith, from the disorders of the thoracic and abdomina1 viscera. In this state he had been more than a year: it is now about three months since the caustics were applied; he is become healthy, and free from most of his genera1 complaints, has the most perfect use of his Iegs while he is in bed, can walk without the assistance of any body, or anything to hoId by; and from his manner of executing this, will, I make no doubt, in a very short space, recover perfectly the use of his Iegs. To this I ought to add, that notwithstanding a considerable degree of deformity does, and I suppose will, remain, yet the spine in genera1 is so much strengthened, tflat he is some inches taller than he was four months ago. The remedy for this most dreadful disease consists mereIy in procuring a Iarge discharge of matter, by suppuration from underneath the
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membrana adiposa on each side of the curvature, and in maintaining such discharge until the patient shaI1 have perfectly recovered the use of his legs. To accomplish this purpose, I have made use of different means, such as setons, issues made by incision, and issues made by caustic; and although there be no very material difference, I do upon the whoIe prefer the last. A seton is a painfu1 and nasty thing, beside which it frequentIy wears through the skin before the end for which it was made can be accomplished: issues made by if they be large enough for the intended purpose, are apt to become inflamed, and to be very troubIesome before they come to suppuration; but openings made by caustic are not in general IiabIe to any of these inconveniences, at least, not so frequently, nor in the same degree: they are neither so troublesome to make or to maintain. I make the eschars about this size and shape on each side the curve, taking care to leave a sufficient portion of skin between them; in a few days when the eschar begins to loosen and separate, I cut out a11 the middIe, and put into each a Iarge kidney-bean: when the bottoms of the sores are become clean by suppuration, I sprinkle every third or fourth day, a smaI1 quantity of finely powdered cantharides on them, by which the sores are prevented from contracting, the discharge increased, and possibIy other benelit obtained. The issues I keep open unti1 the cure is comthat is, until pIeat, the patient recovers perfectly the use of his legs, or even for sometime longer, and I shouId think that it would be more prudent to hea only one of them first, keeping the other open for some time, that is, not only until the patient can waIk, but until he can walk firmIy, briskly, and \vithout the assistance of a stick; until he can stand quite upright, and has recovered a11 the height, which the habit, or rather the necessity of stooping occasioned by the distemper, had made him lose. I have said that the discharge by means of the issue is all that is requisite for a cure, which is true, as I have experimentaIIy proved by not using any other in cases which have succeeded perfectly; but this fact being established, there is no reason why every assistant means shouId not be appIied at the same time, in order to expedite: such as bark, cold-bathing, frictions, etc. That the patient becomes more upright as his Iegs become stronger, is certain, and there-
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fore appears taIIer as we11 as straighter in proportion, as the whoIe spine strengthens; hut whether the curvature wiI1 aIways and totaIIy disappear I am not yet abIe to say with certainty. In two Iate instances both adults, it has, but the deformity, which in weak infants and chiIdren, is often the consequence of the curvature, and of the state of the spine at that pIace, must in some degree, I fear, be expected to remain; but of this I am not yet abIe to speak with absoIute certainty. There are a few other circumstances, of no great moment perhaps, but which will require more time to ascertain than I thought shouId be sufEced to pass, before mankind were made acquainted with the great means of reIief, in so distressing, and SQ dreadfu1 a maIady: for the reader wiII
be pIeased to remember what I told him in the beginning of this tract, which was, that my motive for pubIishing this account sooner than might. appear in genera1 to be right, or indeed than I otherwise shouId have done, was a desire that as IittIe time as possible might be Iost,, in conveying to the profession in particular, and to mankind in generaI, the means of reIief under an affection, which tiI1 these were known, has not admitted of any: and this I was &II more incited to do, because the remedy is as harmIess, and as void of hazard, as it is efficacious. And thus ends Sir Percival1 Pott’s description of a disease which apparentIy was recognized onIy when extensive vertebra1 destruction had taken place, with kyphosis-compression of the cord and paraIysis-partia1 or compIete of the legs. It is interesting to note that aIthough mention is made of the frequent invoIvement of the thoracic viscera, association of that with the vertebra1 lesion was not thought of. A perusaI of his pIates shows that his onIy conception of the condition advanced state-when was in a very extensive bony destruction had taken pIace. Figures 3-6 iIIustrate this weI1. However, his deductions, seven in number-differentiating this as a separate disease entity and not due to trauma or congenita1 defect are certainIy compIete and descriptive. His aIIusion to its presence in infants who had never had trauma of any sort to cIinch his arguments.
PercivaII
Pott
One is at a Ioss, however, to expIain his cures with their recovery of motion in the Iegs, disappearance of the deformity and attainment of former height. LocaI weakening of the structures about a coId abscess so that it might more readiIy rupture externaIIy as he might have accompIished with his seton might account for a recovery of motion in the Iegs due to reIease of pressure upon the cord, but hardIy the exceIIent resuIts reported. However due credit must be awarded Sir PercivaII for recognizing the condition, taking it out of the reahn of ignorance in which it had rested, actually Iooking at post-mortem materia1 and describing it and at Ieast suggesting some therapeutic procedure so that it is onIy befitting that it shouId bear his name as the pioneer in ai this work. His expIanation and defense of his tract foIIows: In the preceding tract I have reIated the appearance which the parts constituting the seat of the distemper make upon examination after death, or to speak more properly, the different states of these parts in different persons, and at different periods of this disease. These, though necessariIy subject to considerabIe variety, may, I think, be reduced to three genera1 ones. I. A smaI1 degree of an increase of size in the bodies of the vertebrae, forming the curve, with an apparent laxity in their texture, and reIaxed state of the connecting ligaments, by which they seem to have lost part of their power of hoIding the bones together. II. A more considerabIe, and more apparent enIargement of the same parts of the vertebrae, whose spongy texture becomes more visibIy spread through their whole substance, and tending towards a caries, with an apparentIy distempered state, both of the ligaments, and of the intervening cartiIages. III. A truIy carious state of the bodies of the bones, a dissoIution or destruction of the cartiIaginous substance between them, and a Iodgment of sanies on the surface of the membrane enveIIoping the spina marrow. These are I think the most particuIarIy different states or stages of the disorder, and
Nrw
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are such as, in my opinion, decisiveIy mark the true nature of it. Between these in different persons, and under different circumstances, there must be a considerable variety, but the material difference will be only in degree. From the whole, the few foIIowing practica1 inferences seem fairly deducible: I. That the disease does not originaIIy consist in a displacement of the vertebrae, made by violence, the bones and ligaments being previously in a sound and uninjured state; but in such a morbid alteration of the texture of both, as wiI1, if not timely prevented, produce curvature and caries, with all their consequences. 2. That the proper remedies for this disease cannot be applied too soon. 3. That the restoration of the spine to its normal figure, depends much on the early administration of the heIp proposed. 4. That although the distemper may be so far cured, that the patient may perfectIy recover the use of his Iegs, yet such an aIteration may have taken pIace in the bodies of the vertebrae, as to render it impossibIe for the spine to become straight again. 4. That when three or four, or more vertebrae, are concerned in the curve, the trunk of the body will have so IittIe support from that part of the spine which is not distempered, that no degree of deformity can be wondered at; nor can it be expected that such deformity shouId be removed, whatever other benefit such patient may receive. 6. That if from inattention, from Iength of time, or from any other circumstances, it happens that the bodies of the vertebrae become compIeatl!carious, and the intervening car-
PercivaII
Pott
American
Journal
of Surgrry
335
tilages are destroyed, no assistance is to be expected from the proposed remedy. To these I will take the Iiberty of adding that it appears to me we11 worth while, to try what a Large and free discharge, made for a length of time from the vicinity of the distempered part, might be capable of doing in the very beginning of what are commonly caIIed scrophuIous joints; which when arrived to a certain point, bafHe a11 our art, and render a painfu1 and hazardous operation, absoIuteIy necessary.
The description of the bone pathoIogy was not strictIy correct but from further study of postmortem material is made quite compIete and detailed in treatise II pubIished three years Iater. This shortcoming, however, is expIained in his statement that he realized the paper a bit premature but that he considered the advancement of a simple remedy for a hopeIess disease as sufficient justification. In reading between the Iines one can obtain a gIimpse of the idealism of the man, such Iines as “To remove, or even to reIieve any one of the miseries to which mankind are IiabIe, is a very satisfactory empIoyment.” Again, “I made the experiment merely to avoid the appearance of inhumanity.” And thus Sir PercivaII Pott and the origina description of the disease bearing his name.* * From the author’s coIIection of oId medical books and medica incunabula.
BOOKSHELF SIR PERCIVALL
BROWSING
POTT-SURGEON ST. BARTHOLOMEW’S HOSPITAL FELIX CUNHA, SAN
FRANCISCO,
T
M.D. CALIF.
To remove, or even to relieve anv of the miseries to which mankind are liable, ‘is a very satisfactory employment; but to attend on a distemper from its beginning, through a long and painfuI course, to its Iast, fata period,
0 read the origina treatise of Sir Percival1 Pott describing the disease which today bears his name is exceptionaIIy interesting because of the many sidelights it throws on the manner of his reasoning as to etioIogy, as to method of treatment and how this reasoning was arrived at. The number of cures attested to is aIso interesting, aIthough we wouId be incIined to accept them with a bit of reser\;e. Then also the fact that attention was drawn to the disease or the diagnosis onIy after paraIysis from cord pressure due either to destruction of vertebrae or impingement of the cord had set in. As can be seen from the title page of the treatise (Fig. I) the maIady is described as “That kind of palsy of the Lower Limbs which is frequently found to accompany a Curvature of the Spine.” As the entire treatise is short, well worth reading and as copies of the original are scarce, I am quoting the entire article.
without even the hope of being able to do anything which shalI be really serviceable, is of a11 tasks the most unpIeasant. In such cases, an) attempts, however hazardous, provided they were rational, would be justifiable, certainIy then, whatever is not in itself dangerous and affords the smaIIest ray of hope, ought to be embraced. 1 publish therefore an account of the good success which has attended a particular method of’ treating a disease, which has hitherto foiled a11 the efforts of art; and I do it with the principle that by inducing others to make the same experiment, I propagate the benefit. The disease of which I mean to speak is generaII?- caIIed a paIsy, as it consists in a totaI or partra1 aboIition of the power of using and sometimes of even moving the louver limbs, in consequence, as is generaIIy supposed, of a curvature of some part of the spine. To this distemper both sexes and al1 ages are equaIIy Iiable. If the patient be an infant, it becomes an object of constant though unavaiIing distress to its parents; if an aduIt, he is rendered perfectly heIpIess to himself, and useIess to a11 others, which, of a11 possihIe states, is sure1.y the very worst.
Among the \.arious objects of Physick and Surgery, there are unfortunately some in which all the efforts of both, have hitherto been found absolutely ineffectua1, and which therefore have aIways made a very disagreeable and melancholy part of practice. 327
328
American
Journal of Surgery
Cunha-Sir
PercivaII
When this disease attacks an infant of only a year or two oId, or under, the true cause of it is seIdom discovered unti1 some time after the effect has taken pIace, at least not by parents and nurses, who know not where to Iook for it. The chiId is said to be uncommonIy backward in the use of his Iegs, or it is thought to have received some hurt in its birth. When it affects a chiId who is oId enough to have aIready waIked, and who has been abIe to waIk, the loss of the use of his Iegs is gradua1, though in genera1 not very SIOW. He at first compIains of being soon tired, is Ianguid, Iistless, and unwiIIing to move much, or at a11 briskIy; in no great Iength of time after this he may be observed frequently to trip, and stumbIe, aIthough there be no impedimept in his he attempts to move way; and whenever briskIy, he finds that his Iegs invoIuntariIy cross each other, by which he is frequently thrown down, and that without stumbIing; upon endeavoring to stand stiI1 and erect, without support, even for a few minutes, his knees give way and bend forward. When the distemper is a IittIe farther advanced it wiI1 be found, that he cannot, without much diffIcuIty and deIiberation, direct either of his feet preciseIy to any exact point; and very soon after this, both thighs and Iegs lose a good dea1 of their natura1 sensibiIity, and become perfectIy useIess for a11 the purposes of locomotion. When an aduIt is the patient the progress of the distemper is much the same but rather quicker. Until the curvature of the spine has been discovered, it generaIIy passes for a nervous compIaint; but when the state of the backbone has been adverted to, recourse is almost always had to some previous vioIence to account for it, some pulling, Iifting, carrying, or drawing a heavy body, which is supposed to have hurt the back. In some few instances, this exertion may have been such as might be aIIowed to have been equa1 to the effect, but, in by much the majority, this is so far from being the case, that if it be admitted to have had any share at a11 in it, some predisposing cause, at least, must be Iooked for, in which, (in my opinion) consists the very essence of the disease. I have, in compliance with custom, caIIed the disease a paIsy; but it shouId be observed that notwithstanding the Iower Limbs be rendered almost, or totally useless, yet there are some essentia1 circumstances in which this
Pott
AUGUST.
1935
affection differs from a common nervous palsy; the Iegs and thighs are, I have just said, rendered unfit for a11 the purposes of locomotion, and do aIso Iose much of their natural sensibility, but notwithstanding this, they have neither the flabby feeI, which a truIy paraIytic Iimb has, nor have they that seeming Iooseness at the joints, nor that tota incapacity of resistance, which aIIows the Iatter to be twisted in aImost a11 directions; on the contrary the joints have frequentIy a considerabIe degree of stiffness, particuIarIy the ankIes, by which stiffness the feet of ehiIdren are generaIIy pointed downward, and they are prevented from setting them ffat upon the ground. The curvature of the spine, which is supposed to be the cause of this compIaint, varies in situation, extent and degree, being either in the neck or back, and sometimes (aIthough very seIdom) in the upper part of the Ioins, sometimes comprehending two vertebrae only, sometimes three, or more, by which the extent of the curve becomes necessariIy more or less; but whatever may be the number of vertebrae concerned, or whatever may be the degree or extent of the curvature, the Iower Iimbs onIy fee1 the effect-at Ieast I have never once seen the arms affected by it. This effect is aIso different in different subjects: some are rendered totaIIy and absoIuteIy incapable of waIking in any manner, or with any heIp and that earIy in the course of the distemper; others can make a shift to move about with the heIp of crutches, or by grasping their own thighs with their hands; some can sit in an erect posture, or in a chair, without much troubIe or fatigue, which others are incapabIe of, at Ieast for any Iength of time; some have such a degree of motion in their Iegs and thighs, as to enabIe them to turn and move for their own convenience in bed, others have not that benefit, and are obIiged to lie tiI1 moved by another. When a naturaIIy weak infant is the subject, and the curvature is in the vertebrae of the back, it is not infrequentIy productive of additional deformity, by graduaIIy rendering the whoIe back what is commonIy caIIed humped; and by aIterations which a11 the bones of the thorax sometimes undergo, in consequence of the flexure and weakness of the spine, by which such persons are justIy said to be shortened in their stature; but in al1 cases where this effect has been gradually produced,
NEW SERVES VOL
XXIX,
Cunha-Sir
NW z
Pe rcivaI1
to whatever degree the deformity may extend, or however the alteration made in the disposition of the ribs and sternum may contribute to
Pott
American
329
Journal of Surgery
a variety
of compIaints, dies in an exhausted emaciated state; or, which is still worse, drags on a miserabIe existence, confined to a. great FARTHER
REMARKS ON.
THAT
A
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KIND
REMARKS
OF
L
S
y ON
OF
LOWER WHICH1s
LIMBS,
FREVENTLY
FOUND
CURVATURE
A
AND
STATE
ACCOMPANY
OF
SPINE,
TO BE CAUSED
TOCBTHER
ITS
USELESS
TO
OF THE
IS SUPPOSED
THE
THE
BY IT.
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0
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THB
R
L
I
M
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S,
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METHOD
OF
CURE.
IN
CONSSLQJBNCE
OF A
90 WXICIlAREIDDEP. OBSERVATIONS PROPRIETY
on the
and
NECEWTY
CURVATURE
OF
THE
SPINE:
of AMPUTATION,
Ih. CERTAIN CASES.
BEING
AHD U~-~TRCE~ZA~N CIRCUMSTANCES. A
BY PERCIVALL And SURGEON to ST.
POTT, BAKTHOLOMEW’S
VuumquceR ad ipfamcurandirationemnihil quam experientram.
to a former TREATISE
SUPPLEMENT
on that SubjeA.
F. R.S. HOSPITAL.
plusconferre
BY
CELSUS.
PERCIVALL
POTT,
SURGeON t0 ST. BARTHOLOMEW’S
F.R,S. HOSPITAL.
-
L
0
N
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0
Printed for J. JOHNSON, No. ,z.
t.OND6N:
N: St. Paul’s Church-Yazd.
M,DCC&.XX‘X.
FIG. I. Title page from Pott’s origina disease.
MDCCLXXXII, description of the
such deformity, yet I think that it wiII aIways be found, that the curvature of the spine appeared first, and, if I may so say, singIy and that a11 the rest was consequential. WhiIe the curvature of the spine remains undiscovered or unattended to, the case is generaIly supposed to be nervous, and medicines so caIIed are most frequentIy prescribed, together with warm Iiniments, embrocations and bIisters, to the parts affected; and when the true cause is known, recourse is aIwa?s had to stee1 stays, the swing, the screw chair, and other pieces of machinery, in order to restore the spine to its true and natura1 figure; but aI1, as far as I have observed, to no rea1 or permanent good purpose; the patient becomes unhealthy, and Ianguishing for some time under
FIG.
2.
Title page from his second description three years Iater.
pubIished
chair, or bed, totaIIy deprived of the power of Iocomotion, and useIess both to himself and others. This in an infant is most meIanchoIy to see, in an aduIt most miserabIe to endure. The genera1 health of the patient does not seem at first, to be materiaIIy, if at al1, affected, but when the disease has been sometime, and the curvature thereby increased, many inconveniences and compIaints come on, such as diff<y in respiration, indigestion, pain and what they calI tightness at the stomach, obstinate constipations, purgings, invoIuntary flux of urine and faeces, etc., with the addition of what are caIIed nervous compIaints, some of which are caused by the aIterations made in the form of the cavity of the thorax, others
330
American Journal of Surgery
Cunha-Sir
seem to arise from impressions made on the abdomina1 viscera. These are different both in kind, and in degree, in different subjects, but seem to depend very much on the consequences of the curvature-that is, in naturaIIy infirm chiIdren, aIthough the curvature of the dorsa1 vertebrae is aIways the first mark of the distemper, by preceding every other, yet it is frequentIy soon foIIowed by such a degree of deformity of the bones of the trunk, as to be, in conjunction with the necessary inactivity and confinement of the patient, productive of a11 the iIIs above mentioned. An affecting instance of this distemper in the person of a very promising youth of fourteen years oId, with whose famiIy I was nearIy connected, induced me to think more of it than perhaps I otherwise shouId have done; and the restoration of the use of his Iimbs, immediateIy after a seemingly accidental abscess near the part, engaged my attention stiI1 more, and became a matter of frequent, though not very satisfactory contempIation; I say unsatisfactory, because it served onIy to increase my doubts, without Ieading me toward a soIution of them. The more I thought upon the subject, the more I was incIined to suspect that we had been misIed by appearances, and that a distempered state of the parts forming, or in the neighborhood of curvature, preceded or accompanied it: in short, that there was something predisposing, and that we had most probabIy mistaken an effect for a cause. For these suspicions, I had the folIowing reasons which appeared to me to have some weight: I. That I had never seen this paraIytick effect on the Iegs from a mal-formation of the crooked such maIformation spine, however might have rendered it, or whether such crookedness had been from time of birth, or had come on at any time afterwards during infancy. 2. That none of those strange twists and deviations, which the majority of European women get in their shapes, from the very absurd custom of dressing them in stays during their infancy, and which put them into a11 directions but the right, ever caused anything of this kind, however great the deformity might be. 3. That the curvature of the spine, which is accompanied by this affection of the Iimbs, whatever may be its degree, or extent, is at first aImost aIways the same, that is, it is
PercivaII
Pott
aIways from within, outward, and seIdom or never to either side. 4. That since I had been particuIarIy attentive to the disorder I had remarked, that neither the degree nor the extent of the curve, made any aIteration in the nature or degree of the symptoms at first, nor for some time after the appearance; or in other words, that the smaIIest curvature, in which onIy two or three of the vertebrae were concerned, was aIways, at first, attended by the same symptoms as the Iargest. 5. That aIthough it sometimes happened that a smart bIow, or a vioIent strain had immediateIy preceded the appearance of the curve, and might be supposed to have given rise to it, yet in many more aduIts it happened that no such cause was fairIy assignabIe, and that they began to stoop, and to faIter in their walking, before they thought at a11 of their back, or of any vioIence offered to it. 6. That exactIy the same symptoms are found in infants, and in young chiIdren, who have not exerted themseIves nor have been injured by others, as in the aduIt, who has strained himself, or received a blow; and that the case was stiI1 the same in those grown peopIe, who have neither done, nor suffered any act of vioIence. 7. That aIthough it must be aIlowed, that a dislocation of any of the vertebrae, wouId most probabIy be attended with the same kind of symptoms from the pressure it must make on the spinal marrow, yet it is aIso most probabIe that such symptoms wouId be immediate, and attended with great pain in the part; neither of which is in genera1 the case here. These considerations appeared to me to have much force; but what confirmed me in my opinion was the state of the parts forming the curvature, and which I had severa fair opportunities of examining after death. By those examinations I found in infants, in young children, and in those who had been affected with the disorder but a smaI1 space of time, that the Iigaments connecting the vertebrae, which from a natura1 state, by being somewhat thickened and reIaxed, and that what are caIIed the bodies of those bones, were paIpabIy spread and enIarged in their texture, just as the bones forming the articuIations are in chiIdren who are caIIed rickety. That those who had Iong Iabored under the distemper, and in whom the symptoms were aggravated, whatever might
NEW SERIES VOL. XXIX,
No.
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Cunha-Sir
he their age, the ligaments were stiI1 more thickened, relaxed, and altered, the bodies of the f)ones more spread, more enlarged, and more inclined to become carious, and the cartilages between the hodies of the vertebrae much compressed and Iessened in size; and that in :\I1 those who had so Iong Iahored under the disease, as to have been destroyed by it or by its consequences, the corpora vertebrariu m R-ere compIeteIy carious, the intervening cartilages totaIIy destroyed, and a quantity of t’anies lodged between the rotten bones, and the membrane investing the spina marrow. AI1 these circumstances put together, induced me, as I flave aIready said, to suspect, that n-hen N e attribute the whoIe of this mischief to the mere accidental curvature of the spine, in consequence of violence, we mistake an effect for a cause, and that previous both to the paraI,vtick state of the legs, and to the alteration of the figure of the backbone, there is a pre-disposing cause of both, consisting in a distempered state of the ligaments and hones, where the curve soon after makes its appearance. While the subject M-as fresh in my mind, I happened to be at Worcester, and in a conversation on it with the late Doctor Cameron, of that place, I mentioned to him, my opinion, and my doubts; the Doctor concurred with me, and at the same time mentioned a circumstance, Mhich made a strong impression on me. He said, that he remembered some years ago, to have noted a passage in Hippocrates, in which he speaks of a paralysis of the lower limbs being cured by an abscess in the hack or loins, and that taking the hint from this, he, Doctor Cameron, had, in a case of paIsy of the Iegs and thighs, attended by a curvature of the back bone, endeavored to imitate this act of nature, by exciting a discharge near the part, and that it had pro\.etf advantageous. He also referred me to Zlr. Jeft‘rys, a surgeon of eminence at Worcester, for a farther account of the same kind of attempt; this gentIeman confirmed u-hat Doctor Cameron had told me and assured me that he had founci the method equalIy successful. It may easily he supposed, that these accounts from gentlemen of veracity, and of reputation in their profession, stiI1 added to my desire of knobving more on this subject, and determined me to lose no opportunity of getting n Intnrmatlon.
PercivaIl
Pott
American
Journal
of Surgery
33’
The first that offered was in an infant, whose curvature was in the middIe of the neck, and who had Iost the use of its legs for about two or three months. I made an issue h,- incision on one side of the projection, and gave strict charge to the mother to take care that the pea was kept in; the woman, who had no faith in the remedy, did not take the proper care, and consequently the discharge was not equal to what it shouId, and might have heen, but notwithstanding this negIect, at the end of about three weeks or a month the child Leas manifestly hetter, and began to make use of its legs; it was then seized with the small pox and died. The bodies of the vertebrae concerned in the curve, were larger than they should be, and than those above and below were, and their texture much more open and spongy, which difference appeared immediately, before the parts covering them were dissected off. Some time passed before I flat1 another My next patient was a tall thin opportunity. man, about thirty-five years old, ~vho thought that he had hurt himseIf b>- lifting a heavy weight: flis legs and thighs were cold, and what he calIed nummy, but not useless: he could with diffIcuftJ- go about the room with the help of a pair of crutches, hut he could neither rise from his chair, nor get on his crutches without the assistance of another person, nor could he without them waik at all. I made a seton on each side of the curve, which was in his back, about the middle, and having given his wife directions ho\v to dress them, I caIIed on him once in three or four days. At the end of six weeks he had recovered the due degree of sensation in his Iimbs, and found much Iess necessity for the use of his crutches; he could rise from his bed, and from his chair without assistance, and b.y means of one crutch, and an underhand stick, could walk for an hour, or more without resting, and without fatigue. The setons had now, from not having ljecn properly managed, worn their way out, and I woufd have converted each of them into an issue, but as neither the patient nor his wife had beIieved that the discharge had had a11y sflare in his amendment, but on the contrar>- that he would have been better without it, he would not submit to what I proposed, and I Icft him. At the distance of about three weeks from tfle time of my Ieaving him, I met him on tfle street walking very stoutly, with a common cane, of which he made little or no use. I asked him
332
American
Journal
Cunha-Sir
of Surgery
PercivaII Pott
what he had done: he told me that the sores had c:ontinued to discharge tilI within a few days, but that he had drank a great dea1 of
Fx.
3.
I believe that the cure of this man wiII, by a11who know anything of medicine, be thoulght to be so unIikeIy to have been affected by the
FIG. 4.
FIG. 6.
FIG. 3.
FIG. 3;-6. Reproduced
from Pott’s
own photographic pIates of post-mortem destructive changes described by him.
confrey-root tea, with isingIass, and he supposed that had cured him.
materia1 iltustrating the exte ,nsive
confrey and isingIass, that my influence in favour of the seton wiI1 not be thought unrea-
NEW
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VOL. XXIX,
No.
2
Cunha-Sir
sonabIe, and that my determination to prosecute the method, from what I had heard and seen, was well founded. Within the course of the last ten or twelve months, I have had several fair opportunities of doing this, both in St. BarthoIomew’s hospital, and out of it, and am very happy to be abIe to say, that it has not onIy aIways answered, but in some instances greatIy exceeded my most sanguine expectations, by restoring severa most miserabIe and totaIIy heIpIess people to the use of their limbs, and to a capacity of enjoying life themselves, as well as of being useful to others. I have now in the hospita1 a boy about twelve years old, whose case was so truly deplorable, that I made the experiment mereIy to a\roid the appearance of inhumanity, by discharging him as incurable, without trying something. The curvature n-as in his back, and consisted of three or four vertebrae, but by means of the weakness thereb,y induced, the whole set of dorsal ones had so universaIIy and graduaIIy given way, that he was exceedingly deformed both behind and before: he was so absoIuteIy incapable of motion, that he could neither turn himself, nor sit up in his bed: his feet were pointed downwards, and his ankles so stiff, that when he was held up under the arms, the extremities of his great toes touched the Aoor, nor could his feet be brought fiat to the ground by any means, or force whatever. In short, he was as perfectly and as totalIy helpless as can be supposed, and at the same time in an exceeding general bad state of heaith, from the disorders of the thoracic and abdomina1 viscera. In this state he had been more than a year: it is now about three months since the caustics were applied; he is become healthy, and free from most of his genera1 complaints, has the most perfect use of his Iegs while he is in bed, can walk without the assistance of any body, or anything to hoId by; and from his manner of executing this, will, I make no doubt, in a very short space, recover perfectly the use of his Iegs. To this I ought to add, that notwithstanding a considerable degree of deformity does, and I suppose will, remain, yet the spine in genera1 is so much strengthened, tflat he is some inches taller than he was four months ago. The remedy for this most dreadful disease consists mereIy in procuring a Iarge discharge of matter, by suppuration from underneath the
Percival1
Pott
American
Journal
of Surgery
333
membrana adiposa on each side of the curvature, and in maintaining such discharge until the patient shaI1 have perfectly recovered the use of his legs. To accomplish this purpose, I have made use of different means, such as setons, issues made by incision, and issues made by caustic; and although there be no very material difference, I do upon the whoIe prefer the last. A seton is a painfu1 and nasty thing, beside which it frequentIy wears through the skin before the end for which it was made can be accomplished: issues made by if they be large enough for the intended purpose, are apt to become inflamed, and to be very troubIesome before they come to suppuration; but openings made by caustic are not in general IiabIe to any of these inconveniences, at least, not so frequently, nor in the same degree: they are neither so troublesome to make or to maintain. I make the eschars about this size and shape on each side the curve, taking care to leave a sufficient portion of skin between them; in a few days when the eschar begins to loosen and separate, I cut out a11 the middIe, and put into each a Iarge kidney-bean: when the bottoms of the sores are become clean by suppuration, I sprinkle every third or fourth day, a smaI1 quantity of finely powdered cantharides on them, by which the sores are prevented from contracting, the discharge increased, and possibIy other benelit obtained. The issues I keep open unti1 the cure is comthat is, until pIeat, the patient recovers perfectly the use of his legs, or even for sometime longer, and I shouId think that it would be more prudent to hea only one of them first, keeping the other open for some time, that is, not only until the patient can waIk, but until he can walk firmIy, briskly, and \vithout the assistance of a stick; until he can stand quite upright, and has recovered a11 the height, which the habit, or rather the necessity of stooping occasioned by the distemper, had made him lose. I have said that the discharge by means of the issue is all that is requisite for a cure, which is true, as I have experimentaIIy proved by not using any other in cases which have succeeded perfectly; but this fact being established, there is no reason why every assistant means shouId not be appIied at the same time, in order to expedite: such as bark, cold-bathing, frictions, etc. That the patient becomes more upright as his Iegs become stronger, is certain, and there-
334
American Journal of Surgery
Cunha-Sir
fore appears taIIer as we11 as straighter in proportion, as the whoIe spine strengthens; hut whether the curvature wiI1 aIways and totaIIy disappear I am not yet abIe to say with certainty. In two Iate instances both adults, it has, but the deformity, which in weak infants and chiIdren, is often the consequence of the curvature, and of the state of the spine at that pIace, must in some degree, I fear, be expected to remain; but of this I am not yet abIe to speak with absoIute certainty. There are a few other circumstances, of no great moment perhaps, but which will require more time to ascertain than I thought shouId be sufEced to pass, before mankind were made acquainted with the great means of reIief, in so distressing, and SQ dreadfu1 a maIady: for the reader wiII
be pIeased to remember what I told him in the beginning of this tract, which was, that my motive for pubIishing this account sooner than might. appear in genera1 to be right, or indeed than I otherwise shouId have done, was a desire that as IittIe time as possible might be Iost,, in conveying to the profession in particular, and to mankind in generaI, the means of reIief under an affection, which tiI1 these were known, has not admitted of any: and this I was &II more incited to do, because the remedy is as harmIess, and as void of hazard, as it is efficacious. And thus ends Sir Percival1 Pott’s description of a disease which apparentIy was recognized onIy when extensive vertebra1 destruction had taken place, with kyphosis-compression of the cord and paraIysis-partia1 or compIete of the legs. It is interesting to note that aIthough mention is made of the frequent invoIvement of the thoracic viscera, association of that with the vertebra1 lesion was not thought of. A perusaI of his pIates shows that his onIy conception of the condition advanced state-when was in a very extensive bony destruction had taken pIace. Figures 3-6 iIIustrate this weI1. However, his deductions, seven in number-differentiating this as a separate disease entity and not due to trauma or congenita1 defect are certainIy compIete and descriptive. His aIIusion to its presence in infants who had never had trauma of any sort to cIinch his arguments.
PercivaII
Pott
One is at a Ioss, however, to expIain his cures with their recovery of motion in the Iegs, disappearance of the deformity and attainment of former height. LocaI weakening of the structures about a coId abscess so that it might more readiIy rupture externaIIy as he might have accompIished with his seton might account for a recovery of motion in the Iegs due to reIease of pressure upon the cord, but hardIy the exceIIent resuIts reported. However due credit must be awarded Sir PercivaII for recognizing the condition, taking it out of the reahn of ignorance in which it had rested, actually Iooking at post-mortem materia1 and describing it and at Ieast suggesting some therapeutic procedure so that it is onIy befitting that it shouId bear his name as the pioneer in ai this work. His expIanation and defense of his tract foIIows: In the preceding tract I have reIated the appearance which the parts constituting the seat of the distemper make upon examination after death, or to speak more properly, the different states of these parts in different persons, and at different periods of this disease. These, though necessariIy subject to considerabIe variety, may, I think, be reduced to three genera1 ones. I. A smaI1 degree of an increase of size in the bodies of the vertebrae, forming the curve, with an apparent laxity in their texture, and reIaxed state of the connecting ligaments, by which they seem to have lost part of their power of hoIding the bones together. II. A more considerabIe, and more apparent enIargement of the same parts of the vertebrae, whose spongy texture becomes more visibIy spread through their whole substance, and tending towards a caries, with an apparentIy distempered state, both of the ligaments, and of the intervening cartiIages. III. A truIy carious state of the bodies of the bones, a dissoIution or destruction of the cartiIaginous substance between them, and a Iodgment of sanies on the surface of the membrane enveIIoping the spina marrow. These are I think the most particuIarIy different states or stages of the disorder, and
Nrw
Sm,ns
VOL.
XXIX.
No.
2
Cunha-Sir
are such as, in my opinion, decisiveIy mark the true nature of it. Between these in different persons, and under different circumstances, there must be a considerable variety, but the material difference will be only in degree. From the whole, the few foIIowing practica1 inferences seem fairly deducible: I. That the disease does not originaIIy consist in a displacement of the vertebrae, made by violence, the bones and ligaments being previously in a sound and uninjured state; but in such a morbid alteration of the texture of both, as wiI1, if not timely prevented, produce curvature and caries, with all their consequences. 2. That the proper remedies for this disease cannot be applied too soon. 3. That the restoration of the spine to its normal figure, depends much on the early administration of the heIp proposed. 4. That although the distemper may be so far cured, that the patient may perfectIy recover the use of his Iegs, yet such an aIteration may have taken pIace in the bodies of the vertebrae, as to render it impossibIe for the spine to become straight again. 4. That when three or four, or more vertebrae, are concerned in the curve, the trunk of the body will have so IittIe support from that part of the spine which is not distempered, that no degree of deformity can be wondered at; nor can it be expected that such deformity shouId be removed, whatever other benefit such patient may receive. 6. That if from inattention, from Iength of time, or from any other circumstances, it happens that the bodies of the vertebrae become compIeatl!carious, and the intervening car-
PercivaII
Pott
American
Journal
of Surgrry
335
tilages are destroyed, no assistance is to be expected from the proposed remedy. To these I will take the Iiberty of adding that it appears to me we11 worth while, to try what a Large and free discharge, made for a length of time from the vicinity of the distempered part, might be capable of doing in the very beginning of what are commonly caIIed scrophuIous joints; which when arrived to a certain point, bafHe a11 our art, and render a painfu1 and hazardous operation, absoIuteIy necessary.
The description of the bone pathoIogy was not strictIy correct but from further study of postmortem material is made quite compIete and detailed in treatise II pubIished three years Iater. This shortcoming, however, is expIained in his statement that he realized the paper a bit premature but that he considered the advancement of a simple remedy for a hopeIess disease as sufficient justification. In reading between the Iines one can obtain a gIimpse of the idealism of the man, such Iines as “To remove, or even to reIieve any one of the miseries to which mankind are IiabIe, is a very satisfactory empIoyment.” Again, “I made the experiment merely to avoid the appearance of inhumanity.” And thus Sir PercivaII Pott and the origina description of the disease bearing his name.* * From the author’s coIIection of oId medical books and medica incunabula.