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

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 who have neither nor suffered any of That although it must be that a of any of the most probably be attended with the same kind of symptoms from the it must make on the yet it is also most that such symptoms be and attended with great in the neither of which is in general the case These to me to have much but what me in my was the state of the parts the curvature, and which I had of after these I found, in infants, in young children, and in those who had been with the but a small of time, that the the which the curve, were in some degree from a natural by being and and that what are called the of those were and in their just as the bones the are in children who are called That in those who had long under the distemper, and in the symptoms were whatever might be their the were still more and the of the bones more more and more to become and the between the of the vertebræ much and in and that in all those who had so long under the as to have been by it, or by its the were the totally and a of between the and the the these circumstances put induced as I have already said, to that when we the whole of this to the accidental curvature of the spine, in consequence of we an effect for a and that previous both to the paralytic state of the legs, and to the alteration of the of the back there is a predisposing cause of in a distempered state of the and where the curve soon after its While the was in my I happened to be at and in a on it with the Dr. of that place, I to my and my the with and at the same time a which made a on He said, that he some years to have a in in which he of a of the lower limbs being by an abscess in the back or loins; and that the from this, Dr. in a case of a of the legs and thighs attended by a curvature of the back to this of by a near the part, and that it had very He also me to Mr. a surgeon of at for a further account of the same kind of this what Dr. had and me that he had found the equally It may be supposed, that these from of and of in their still to my of more on this subject, and me to lose no of The first that offered was in an infant, whose curvature was in the of the and who had the use of its legs for about two or three I made an by on of the and to the to that the was the who had no in the not the and the was not equal to what it and might have but notwithstanding this at the of about three or a the child was and began to make use of its it was with the and The of the vertebræ in the curve were than they should be, and than those above and and their much more open and which appeared before the parts them were time before I had next patient was a about years old, who thought that he had hurt himself by a heavy his legs and thighs were and what he called but not absolutely he with difficulty about the with the help of a of crutches, but he neither rise from his chair, nor get on his crutches, without the of nor he without them at I made a on each of the curve, which was in his back, about the and given his directions to I called on once in three or the of he had the degree of in his limbs, and found much for the use of his he rise from his and from his without and by of and an for an or more, without and without The had from not been their way and I have each of them into an but as neither the patient nor his had ever that the had had any share in his but, on the contrary, that he have been without it, he not to what I and I the of about three from the time of my I in the walking very with a common of which he made little or no I what he had he me that the had to till a few but that he had a great deal of with and he supposed that had I that the of this man by all who know any thing of be thought to be so to have been by the and that my in of the will not be thought and that my to the from what I had and was the course of the or I have had of this, both in St. Bartholomew’s and of and very to be able to say, that it has not only always but in some my most by most miserable and totally helpless to the use of their limbs, and to a of themselves, as as of being to others. I have in the a boy about years old, whose case was so truly that I made the to the appearance of by as without The curvature was in his back, and of three or but by of the weakness thereby the whole of dorsal had so and gradually given that he was both and he was so absolutely incapable of that he neither turn himself, nor sit in his his feet were pointed and his so that when he was under the the of his great the nor his feet be flat to the by any or In short, he was as perfectly and as totally helpless as can be and at the same time in an general state of from of the and abdominal viscera. In this state he had been more than a it is about three since the were he is become and from most of his general complaints, has the most use of his legs he is in bed, can without the of any body, or any thing to and from his of this, I make no in a very perfectly the use of his this I to that notwithstanding a considerable degree of deformity and I yet the spine in general is so much that he is some than he was The for this most disease consists in a of by from the on each of the curvature, and in such until the patient have perfectly the use of his To this I have made use of different such as made by and made by and although there be no very I do upon the whole the is a and a which, it frequently the before the for which it was made can be made by if they be enough for the are to become and to be very before they come to but made by are not in general to any of these at least not so nor in the same they are neither so to make or to I make the about this and on each the curve, to a of between in a few when the to and I all the and put into each a When the of the are become by I every or a small of on by which the are prevented from the increased, and other The I open until the is that is, until the patient perfectly the use of his legs, or even for some time and I should think that it be more to only of them first, the other open for some time; that is, not only until the patient can walk, but until he can briskly, and without the of a until he can stand and has all the with the or rather the of by the distemper, had made I have said that the by of the is all that is for a which is as I have by not any other, in cases which have but this being there is no reason every assistant should not be at the same time, in order to such as That the patient becomes more as his legs become is and as as in as the whole spine but whether the curvature will always and totally I not yet able to say with In two instances, both it but the deformity which, in weak and children, is the consequence of the curvature, and of the state of the spine at that place, must in some degree, I be to but of this I not yet able to with are a few other of no great but which will more time to than I thought should be suffered to before were made with the great of in so so and so a for the will be to what I at the of this which that my for this account than might in general to be right, or than I otherwise should have was a that as little time as possible might be in to the in and to in the of under an which, till these were known, has not admitted of and this I was still more to because the is as and as of as it is