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The Classic The Chirurgical Works of Percivall Pott, F.R.S., Surgeon to St. Bartholomew???s Hospital, A New Edition, with his Last Corrections

2002; Lippincott Williams & Wilkins; Volume: 398; Linguagem: Inglês

10.1097/00003086-200205000-00002

1528-1132

Percivall Pott,

Musculoskeletal Disorders and Rehabilitation

Percivall Pott (1714–1798) (Fig 1) was born in London where his father was a business man. Pott was apprenticed to Mr. Edward Nourse, an assistant surgeon at St. Bartholomew’s Hospital, when he was only 15 years old, and he remained in this association for the next 7 years. When he went into practice for himself at the age of 22, he rapidly gained patients. Pott became an assistant surgeon at St. Bartholomew’s Hospital in 1744 and full surgeon in 1749. He resigned his position in 1787, after serving St. Bartholomew’s Hospital “as a man and boy for half a century.” Pott was an excellent teacher and his most important American student was John Jones of New York, the author of the first book on surgery that was published in the United States.Fig 1.: Dr. Percivall Pott (Reprinted from Pott P: The Chirurgical works of Percivall Pott. London, Wood and Innes 1808).In 1757, Pott was thrown from his horse and suffered a “puncture compound,” open fracture of the tibia. On the advice of Mr. Nourse, Pott was spared from an immediate amputation, which was the standard treatment at that time. Instead, his leg was preserved. It was during his long convalescence from this injury that Pott began to write the literary legacy that has preserved his name and reputation. Pott wrote important works on head injuries and on the treatment of fractures. He was the first surgeon to associate smoking (chimneys) to the cause of cancer, in this case, cancer of the scrotum in chimney sweeps. In 1779, Pott published a small monograph. In this monograph Pott made the association between tuberculosis and the disease of the spine. In the same year, Jean-Pierre David also published a monograph in which he made the same observation. 1 Pott’s monograph became the best known and for this reason his eponym has been attached to the condition known as tuberculosis of the spine, or Pott’s disease. The following is an extract from Pott’s monograph taken from his published works. Leonard F. Peltier, MD, PhD REPORTS OF THAT KIND OF PALSY OF THE LOWER LIMBS IN WHICH IS FREQUENTLY FOUND TO ACCOMPANY CURVATURE OF THE SPINE Percivall Pott The disease of which I mean to speak, is generally called a palsy, as it consists in a total or partial abolition of the power of using, and sometimes of even moving the lower limbs, in consequence, as is generally supposed, of a curvature of some part of the spine. To this distemper both sexes, and all ages, are equally liable. If the patient be an infant, it becomes an object of constant, though unavailing distress to its parents; if an adult, he is rendered perfectly helpless to himself, and useless to others, which, of all possible states, is surely the very worst. When this disease attacks an infant of only a year or two old, or under, the true cause of it is seldom discovered until some time after the effect has taken place, at least not by parents and nurses, who know not where to look for it. The child is said to be uncommonly backward in the use of his legs, or it is thought to have received some hurt in its birth. When it affects a child who is old enough to have already walked, and who has been able to walk, the loss of the use of his legs is gradual, though in general not very slow. He at first complains of being very soon tired, is languid, listless, and unwilling to move much, or at all briskly: in no great length of time after this he may be observed frequently to trip, and stumble, although there be no impediment in his way; and whenever he attempts to move briskly, he finds that his legs involuntarily cross each other, by which he is frequently thrown down, and that without stumbling; upon endeavouring to stand still and erect, without support, even for a few minutes, his knees give way and bend forward. When the distemper is a little further advanced, it will be found that he cannot, without much difficulty and deliberation, direct either of his feet precisely to any exact point; and very soon after this, both thighs and legs lose a good deal of their natural sensibility, and become perfectly useless for all the purposes of locomotion. When an adult 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 generally passes for a nervous complaint; but when the state of the back bone has been adverted to, recourse is almost always had to some previous violence to account for it, some pulling, lifting, 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 allowed to have been equal 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 all in it, some predisposing cause, at least, must be looked for, in which (in my opinion) consists the very essence of the disease. I have, in compliance with custom, called the disease a palsy; but it should be observed, that notwithstanding the lower limbs be rendered almost or totally useless, yet there are some essential circumstances in which this affection differs from a common nervous palsy; the legs and thighs are, I have just said, rendered unfit for all the purposes of locomotion, and do also lose much of their natural sensibility; but notwithstanding this, they have neither the flabby feel, which a truly paralytic limb has, nor have they that seeming looseness at the joints, nor that total incapacity of resistance, which allows the latter to be twisted in almost all directions: on the contrary, the joints have frequently a considerable degree of stiffness, particularly the ancles, by which stiffness the feet of children are generally pointed downward, and they are prevented from setting them flat upon the ground. The curvature of the spine, which is supposed to be the cause of this complaint, varies in situation, extent, and degree, being either in the neck or back, and sometimes (though very seldom) in the upper part of the loins; sometimes comprehending two vertebræ only, sometimes three, or more, by which the extent of the curve becomes necessarily more or less; but whatever may be the number of vertebræ concerned, or whatever may be the degree or extent of the curvature, the lower limbs only feel the effect—at least I have never once seen the arms affected by it. This effect is also different in different subjects: some are rendered totally and absolutely incapable of walking in any manner, or with any help, and that very early in the course of the distemper; others can make a shift to move about with the help of crutches, or by grasping their own thighs with their hands; some can sit in an erect posture, or in a chair, without much trouble or fatigue, which others are incapable of, at least for any length of time; some have such a degree of motion in their legs and thighs, as to enable them to turn and move for their own convenience in bed; others have not that benefit, and are obliged to lie till moved by another. When a naturally weak infant is the subject, and the curvature is in the vertebræ of the back, it is not infrequently productive of additional deformity, by gradually rendering the whole back what is commonly called humped; and by alterations which all the bones of the thorax sometimes undergo, in consequence of the flexure and weakness of the spine, by which such persons are justly said to be shortened in their stature: but in all cases where this effect has been gradually produced, to whatever degree the deformity may extend, or however the alteration made in the disposition of the ribs and sternum may contribute to such deformity, yet I think that it will always be found, that the curvature of the spine appeared first, and, if I may so say, singly, and that all the rest was consequential. While the curvature of the spine remains undiscovered or unattended to, the case is generally supposed to be nervous, and medicines so called are most frequently prescribed, together with warm liniments, embrocations, and blisters, to the parts affected; and when the true cause is known, recourse is always had to steel stays, the swing, the screw chair, and other pieces of machinery, in order to restore the spine to its true and natural figure; but all, as far as I have observed, to no real or permanent good purpose; the patient becomes unhealthy; and, languishing for some time under a variety of complaints, dies in an exhausted, emaciated state; or, which is still worse, drags on a miserable existence, confined to a great chair, or bed, totally deprived of the power of locomotion, and useless both to himself and others. This in an infant is most melancholy to see, in an adult most miserable to endure. The general health of the patient does not seem at first to be materially, if at all, affected: but when the disease has been some time, and the curvature thereby increased, many inconveniences and complaints come on, such as difficulty in respiration, indigestion, pain, and what they all call tightness at the stomach, obstinate constipations, purgings, involuntary flux of urine and fæces, &c. (sic) with the addition of what are called nervous complaints; some of which are caused by the alterations made in the form of the cavity of the thorax, others seem to arise from impressions made on the abdominal 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 naturally infirm children, although the curvature of the dorsal vertebræ is always the first mark of the distemper, by preceding every other, yet it is frequently soon followed 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 all the ills above mentioned. An affecting instance of this distemper in the person of a very promising youth of fourteen years old, with whose family I was nearly connected, induced me to think more of it than perhaps I otherwise should have done; and the restoration of the use of his limbs, immediately after a seemingly accidental abscess near the part, engaged my attention still more, and became a matter of frequent, though not very satisfactory contemplation; I say unsatisfactory, because it served only to increase my doubts, without leading me toward a solution of them. The more I thought upon the subject, the more I was inclined to suspect that we had been misled by appearances, and that a distempered state of the parts forming, or in the neighbourhood of curvature, preceded, or accompanied it: in short, that there was something predisposing, and that we had most probably mistaken an effect for a cause. For these suspicious, I had the following reasons, which appeared to me to have some wegih (sic): That I had never seen this paralytic effect on the legs from a mal-formation of the spine, however crooked such mal-formation might have rendered it, or whether such crookedness had been from time of birth, or had come on at any time afterwards during infancy. 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 all directions but the right, ever caused any thing of this kind, however great the deformity might be. That the curvature of the spine, which is accompanied by this affection of the limbs, whatever may be its degree or extent, is at first almost always the same, that is, it is always from within, outward, and seldom or never to either side. That since I had been particularly attentive to the disorder, I had remarked, that neither the degree nor the extent of the curve made any alteration in the nature or degree of the symptoms at first, nor for some time after the appearance; or, in other words, that the smallest curvature, in which only two or three of the vertebræ were concerned, was always, at first, attended by the same symptoms as the largest. That although it sometimes happened that a smart blow, or a violent strain, had immediately preceded the appearance of the curve, and might be supposed to have given rise to it, yet in many more adults it happened that no such cause was fairly assignable, and that they began to stoop, and to faulter in their walking, before they thought at all of their back, or of any violence offered to it. That exactly the same symptoms are found in infants, and in young children, who have not exerted themselves, nor have been injured by others, as in the adult, who has strained himself, or received a blow; and that the case was still the same in those grown people, who have neither done nor suffered any act of violence. That although it must be allowed, that a dislocation of any of the vertebræ, would most probably be attended with the same kind of symptoms from the pressure it must make on the spinal marrow, yet it is also most probable that such symptoms would be immediate, and attended with great pain in the part; neither of which is in general the case here. These considerations appear 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 several fair opportunities of examining after death. By these examinations I found, in infants, in young children, and in those who had been afflicted with the disorder but a small space of time, that the ligaments connecting the vertebræ, which formed the curve, were in some degree altered from a natural state, by being somewhat thickened and relaxed, and that what are called the bodies of those bones, were palpably spread and enlarged in their texture, just as the bones forming the articulations are in children who are called rickety. That in those who had long laboured under the distemper, and in whom the symptoms were aggravated, whatever might be their age, the ligaments were still more thickened, relaxed, and altered, the bodies of the bones more spread, more enlarged, and more inclining to become carious, and the cartilages between the bodies of the vertebræ much compressed and lessened in size; and that in all those who had so long laboured under the disease, as to have been destroyed by it, or by its consequences, the corpora vertebrarum were completely carious, the intervening cartilages totally destroyed, and a quantity of sanies lodged between the rotten bones, and the membrane investing the spinal marrow. All these circumstances put together, induced me, as I have already said, to suspect, that when we attribute the whole 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 paralytic state of the legs, and to the alteration of the figure of the back bone, there is a predisposing cause of both, consisting in a distempered state of the ligaments and bones, where the curve soon after makes its appearance. While the subject was fresh in my mind, I happened to be at Worcester, and in a conversation on it with the late Dr. 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, which 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 back or loins; and that taking the hint from this, he, Dr. Cameron, had, in a case of a palsy of the legs and thighs attended by a curvature of the back bone, endeavoured to imitate this act of nature, by exciting a discharge near the part, and that it had proved very advantageous. He also referred me to Mr. Jeffrys, a surgeon of eminence at Worcester, for a further account of the same kind of attempt; this gentleman confirmed what Dr. Cameron had told me, and assured me that he had found the method equally successful. It may easily be supposed, that these accounts from gentlemen of veracity, and of reputation in their profession, still added to my desire of knowing more on this subject, and determined me to lose no opportunity of getting information. The first that offered was in an infant, whose curvature was in the middle of the neck, and who had lost the use of its legs for about two or three months. I made an issue by 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 should, and might have been; but notwithstanding this neglect, at the end of about three weeks or a month the child was manifestly better, and began to make use of its legs; it was then seized with the small-pox, and died. The bodies of the vertebræ 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 had another opportunity. My next patient was a tall thin man, about thirty-five years old, who thought that he had hurt himself by lifting a heavy weight: his legs and thighs were cold, and what he called nummy, but not absolutely useless: he could with difficulty go about the room with the help of a pair of crutches, but he could neither rise from his chair, nor get on his crutches, without the assistance of another person, nor could he without them walk 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 how to dress them, I called on him once in three or four days. At the end of six weeks he had recovered the due degree of sensation in his limbs, and found much less necessity for the use of his crutches; he could rise from his bed and from his chair without assistance; and by 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 been properly managed, worn their way out, and I would have converted each of them into an issue; but as neither the patient nor his wife had ever believed that the discharge had had any share in his amendment, but, on the contrary, that he would have been better without it, he would not submit to what I proposed, and I left him. At the distance of about three weeks from the time of my leaving him, I met him in the street walking very stoutly, with a common cane, of which he made little or no use. I asked him what he had done: he told me that the sores had continued to discharge till within a few days; but that he had drank a great deal of comfrey-root tea, with isinglass, and he supposed that had cured him. I believe that the cure of this man will, by all who know any thing of medicine, be thought to be so unlikely to have been effected by the comfrey and isinglass, that my inference in favour of the seton will not be thought unreasonable, 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. Bartholomew’s hospital, and out of it; and am very happy to be able to say, that it has not only always answered, but in some instances greatly exceeded my most sanguine expectations, by restoring several most miserable and totally helpless 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 hospital a boy about twelve years old, whose case was so truly deplorable, that I made the experiment merely to avoid the appearance of inhumanity, by discharging him as incurable, without trying something. The curvature was in his back, and consisted of three or four vertebræ; but by means of the weakness thereby induced, the whole set of dorsal ones had so universally and gradually given way, that he was exceedingly deformed both behind and before: he was so absolutely incapable of motion, that he could neither turn himself, nor sit up in his bed: his feet were pointed downwards, and his ancles so stiff, that when he was held up under the arms, the extremities of his great toes touched the floor, nor could his feet be brought flat to the ground by any means, or force whatever. In short, he was as perfectly and as totally helpless as can be supposed; and at the same time in an exceeding general bad state of health, from disorders of the thoracic and abdominal 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 general complaints, has the most perfect use of his legs while he is in bed, can walk without the assistance of any body, or any thing to hold by; and from his manner of executing this, will, I make no doubt, in a very short space recover perfectly the use of his legs.—To this I ought to add, that notwithstanding a considerable degree of deformity does, and I suppose will, remain, yet the spine in general is so much strengthened, that he is some inches taller than he was four months ago. The remedy for this most dreadful disease consists merely in procuring a large discharge of matter, by suppuration, from underneath the membrana adiposa on each side of the curvature, and in maintaining such discharge until the patient shall 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 whole prefer the last. A seton is a painful and a nasty thing; besides which, it frequently wears through the skin before the end for which it was made can be accomplished: issues made by incision, if they be large enough for the intended purpose, are apt to become inflamed, and to be very troublesome before they come to suppuration; but openings made by caustic are not in general liable 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 all the middle, and put into each a large kidney-bean. When the bottoms of the sores are become clean by suppuration, I sprinkle, every third or fourth day, a small quantity of finely powdered cantharides on them, by which the sores are prevented from contracting, the discharge increased, and possibly other benefit obtained. The issues I keep open until the cure is complete; that is, until the patient recovers perfectly the use of his legs, or even for some time longer; and I should think that it would be more prudent to heal only one of them first, keeping the other open for some time; that is, not only until the patient can walk, but until he can walk firmly, briskly, and without the assistance of a stick; until he can stand quite upright, and has recovered all the height, with 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 experimentally 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 should not be applied at the same time, in order to expedite: such as bark, cold-bathing, frictions, &c (sic). That the patient becomes more upright as his legs become stronger, is certain, and therefore appears taller, as well as straighter in proportion as the whole spine strengthens; but whether the curvature will always and totally disappear, I am not yet able to say with certainty. In two late instances, both adults, it has; but the deformity which, in weak infants and children, is often the consequence of the curvature, and of the state of the spine at that place, must in some degree, I fear, be expected to remain; but of this I am not yet able to speak with absolute certainty. There are a few other circumstances, of no great moment perhaps, but which will require more time to ascertain than I thought should be suffered to pass, before mankind were made acquainted with the great means of relief, in so distressing, so melancholy, and so dreadful a malady: for the reader will be pleased to remember what I told him at the beginning of this tract, which was, that my motive for publishing this account sooner than might appear in general to be right, or indeed than I otherwise should have done, was a desire that as little time as possible might be lost, in conveying to the profession in particular, and to mankind in general, the means of relief under an affliction, which, till these were known, has not admitted of any; and this I was still more incited to do, because the remedy is as harmless, and as void of hazard, as it is efficacious.