Percival Pott; Pott's fracture, Pott's disease of the spine, Pott's paraplegia.
Abstract: There is a commonly held belief that Percival Pott sustained that ankle fracture that bears his name. This probably is not true; the injury was more likely a fracture of the tibial shaft, as suggested by careful reading of the account of the accident left to us by his son-in-law.

KEYWORDS Percival Pott / Pott's fracture / Pott's disease of the spine / Pott's paraplegia / ankle fracture
Article Type: Report
Subject: Paraplegia
Fractures
Author: Ellis, Harold
Pub Date: 11/01/2012
Publication: Name: Journal of Perioperative Practice Publisher: Association for Perioperative Practice Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2012 Association for Perioperative Practice ISSN: 1750-4589
Issue: Date: Nov, 2012 Source Volume: 22 Source Issue: 11
Accession Number: 309315447
Full Text: In 1756, on a frosty January morning, Pott was thrown from his horse while riding in Southwark, in South London. He suffered a compound fracture of the leg, 'the bone being forced through the integuments, the fracture at a distance from the skin wound'. Pott, knowing the danger of being transported by coach, where manipulation of the patient into the vehicle and the subsequent jolting of the journey over the cobble stones would aggravate the damage, sent for two chairmen to bring their poles from Westminster, purchased a door from a nearby shop, waited patiently on the icy ground until the chairmen arrived, then had them nail their poles to the chair and transport him on this improvised stretcher over London Bridge to his home near St. Paul's Cathedral. A consultation of surgeons advised immediate amputation, (then fairly standard treatment in those days). The instruments were got ready, when his senior colleague, and old chief, William Nourse, arrived and advised conservative treatment. The leg was splinted and, during his long confinement to his room, Pott wrote his treatises on ruptures, head injuries, fractures and palsies of the lower limbs.

The exact site of the fracture is nowhere mentioned, but was stated to be 'at a distance from the skin wound' and was therefore almost certainly of the tibial shaft rather than its malleolus, which would have torn the immediately adjacent skin.

In his 'Remarks on Fractures and Dislocations' (1769) Pott gives a detailed account, with illustrations, of the fracture of the lateral malleolus of the fibula with dislocation of the ankle and fracture of the tip of the medial malleolus of the tibia and states what is true today, that 'in its most simple state, unaccompanied by any wound, it is extremely troublesome to be put to right, still more to keep in order and, unless managed with address and skill, is frequently productive of both lameness and deformity'.

I am very grateful to my skilful surgeon that the plated fracture of my lateral malleolus has given me no trouble since it was treated some 20 years ago!

In 1779, Pott published his 'Remarks on That Kind of Palsy of the Lower Limbs Which is Frequently Found to Accompany a Curvature of the Spine and is Supposed to be Caused by it, Together with its Method of Cure' - tuberculosis of the spine with paraplegia due to spinal cord or cauda eqina compression. Most of his patients were infants or children, but adults were by no means exempt. However, he had never seen a case beyond 40 years of age. He goes on to give a detailed account of what we now know is tuberculous osteomyelitis, often due to the bovine strain of the organism, and frequently accompanied by abscess formation. Pus arising from the lumbar vertebrae might track into the sheath of the psoas major muscle, on the posterior abdominal wall, and might push its way into the groin. Pressure from the pus and/or the diseased and collapsed bone might compress the spinal cord or the spinal nerve roots, (the cauda equina), to produce paraplegia.

Percival Pott was a cockney, born in Threadneedle Street, London in 1714. His father was one of a family of greengrocers. At the age of 15, Percival was apprenticed to William Nourse, one of the two surgeons on the staff at St. Bartholomew's Hospital, and in 1736, at the age of 22, he obtained his Grand Diploma of the Company of Barber Surgeons of London. In 1744, he was appointed to the staff at Bart's as assistant surgeon, and was promoted to full surgeon five years later. He served his hospital for 40 years.

Pott had a high reputation as a surgical teacher. He was highly intelligent and possessed a friendly personality. He was a skilful and humane surgeon, who strongly preached gentleness in treatment and avoided the use of the cautery, caustics and irritating medicaments. He was a shrewd clinical observer and a prolific author.

As well as his works on fractures and spinal tuberculosis that have already been discussed, he was the first to describe an industrial cancer - the carcinoma of the scrotal skin that occurred in chimney sweeps due to prolonged exposure to the soot and smoke as they climbed up chimneys to clean them. (We now know that this was due to carcinogens in coal tar). Before Pott's work, the condition was regarded as a hereditable affliction. His kind personality comes through in this description of these victims: 'The fate of these people seems singularly hard, in their early infancy they are most frequently treated brutally, and also starved with cold and hunger; they are thrust up narrow and often hot chimneys, where they are bruised, burned and almost suffocated; when they get to puberty, they become peculiarly liable to a most noisome, painful and fatal disease'.

That is not all of his 'Firsts'! He described 'Pott's puffy tumour', the swelling of the scalp over an extradural abscess. He also recognised the lucid period that may precede the coma of an extradural haemorrhage and advised the use of the skull trephine in such cases, as is taught in modern neurosurgery, when an accumulation of blood beneath the skull is suspected.

Truly a remarkable man, who well deserves to be remembered in his eponyms.

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by Professor Harold Ellis

Correspondence address: Department of Anatomy, University of London, Guy's Campus, London, SE1 1UL.

About the author

Professor Harold Ellis

CBE, FRCS

Emeritus Professor of Surgery, University of London; Department of Anatomy, Guy's Hospital, London

No competing interests declared

Provenance and Peer review: Unsolicited contributed; Peer reviewed; Accepted for publication January 2012.
Gale Copyright: Copyright 2012 Gale, Cengage Learning. All rights reserved.