The Case of the Clever Clinician With an Eponymous Injury

Albert Lowenfels, MD; Patrick Maisonneuve, Eng

Disclosures

July 08, 2009

What Was the Injury and How Was It Treated?

Some of the details of Pott's injury in January 1756 are well known,[3,4] However, we do not know the exact type of ankle fracture that Pott sustained or even which leg was injured. Several specialists advised amputation, the usual and the safest treatment for a compound fracture in the 18th century and well into the 19th century. However, Edward Nourse, his former teacher, advocated conserving the leg. Amputation was performed to avoid sepsis from various organisms, including tetanus, a deadly infection arising either from contamination at the time of the original injury or introduced by the unwashed hands of the surgeon at the time of examination and treatment. It was not until the second half of the 19th century, after Lister's pioneering work on antisepsis, that limb conservation was considered safe in patients who had sustained a compound fracture. We know only a few of the details about the treatment of Pott's injury. It is probable that the compound fracture would have been reduced and the extremity splinted to begin the slow healing process. A plaster cast would not have been used, because plaster bandages only became available in the 1850s.

In Pott's case, the decision to save the limb proved to be correct, because after a prolonged convalescence, the wound healed satisfactorily, and there is no evidence that he had any limitation of activity or pain with walking during the remainder of his life.

Today the term "Pott's fracture" is often applied loosely to any of several different ankle fractures. In his monograph portraying the treatment of fractures, Pott described a particular type of ankle injury with the following features: (1) a fracture of the fibula at some distance above the ankle, (2) a rupture of the medial (deltoid) ankle ligament, and (3) lateral displacement (subluxation) of the foot.[5] Whether or not Pott actually sustained this exact injury we do not know because his monograph on fractures does not provide details about his own case.

Pott recognized the serious consequences likely to result when both the tibia and fibula are fractured and the ankle dislocated. He wrote:

...although the fibula be a very small and slender bone...when compared with the tibia,…yet the support of...the ankle depends so much on this slender bone, that without it, the body would not be upheld...without hazard of dislocation.[6]

How Would This Injury Be Treated Today?

Because we know so little about the exact type of fracture sustained by Pott, it is difficult to speculate about how his injury would be treated today. However, basic principles for current treatment of an open ankle fracture include:

  • Prompt transport to a local hospital;

  • Antibiotic administration;

  • Accurate radiographic imaging (plain x-rays plus additional imaging procedures, such as a multidetector computed tomographic [MDCT] scan);

  • Copious wound irrigation;

  • Debridement;

  • Open reduction and internal fixation if fracture is unstable; and

  • Delayed primary wound closure for a contaminated wound.

In all likelihood, because there was marked displacement of the foot, Pott's fracture would now be treated with open reduction and fixation. Undoubtedly, the recovery period -- instead of 18 months -- would be only a few weeks.

What Contributions Did Percivall Pott Make to the Field of Medicine and Surgery?

Pott's teachings about bone and joint injuries changed the accepted views on managing fractures. He was one of the first surgeons to recognize the importance of immobilizing the joint above and below the fracture to ensure relaxation of the limb musculature, which is pivotal for proper healing. This concept of proper immobilization is still considered essential for fracture management. Pott also emphasized gentle handling of injured tissue to minimize further tissue damage.

In addition to his many contributions to the diagnosis and management of benign surgical diseases, Pott made a singularly astute observation that has greatly contributed to our understanding of cancer.[6] At that time young children were employed as chimney sweeps because they could work inside the chimney to remove soot and accumulations of tar (Figure 2).

Figure 2.

Young French chimney sweeps.

Among Pott's many patients, he noted that men who had formerly been chimney sweeps had a significantly increased risk of developing what would normally be a rare tumor -- cancer of the scrotum (Figure 3). He wrote:

The fate of these people seems singularly hard; in their early infancy, they are most frequently treated with great brutality and almost starved with cold and hunger; they are thrust up narrow, and sometimes hot chimnies [sic];...and when they get to puberty become peculiarly liable to a most noisome, painful, and fatal disease.[6]

Figure 3.

Cancer of the scrotum. Specimen from the 18th century, St. Bartholomew's Hospital, London, United Kingdom. Courtesy of Robin Cooke, President, International Academy of Pathology.

He believed that the cause was retained soot lodging in the rugae of the scrotum, and because bathing was infrequent, there would have been prolonged contact with benzpyrene, which we now know to be a potent carcinogen contained in the combustion products of coal.

At the time, the disease was known by the colloquial term "sootwart," and some practitioners believed it to be a venereal disease, common at the time in young men. Pott, who believed it to be a cancer, advocated surgery. Additional evidence for the soot-skin cancer connection came from gardeners who developed cancer of the hand after many years of sprinkling soot on London gardens (Figure 4).

Figure 4.

Cancer of the skin of the hand in a gardener who handled chimney soot. 18th-century specimen from St. Bartholomew's Hospital, London, United Kingdom. Courtesy of Robin Cooke, President, International Academy of Pathology.

The outbreak of scrotal cancer that occurred in the United Kingdom was not observed at the time in other parts of Europe, most likely because coal was substituted for wood earlier in the United Kingdom than in mainland Europe. Also, in many European countries chimney sweeps wore protective clothing and were more concerned about hygiene than in the United Kingdom. As late as the first half of the 20th century, chimney sweepers in the United Kingdom had about a 2% chance of contracting scrotal cancer -- nearly 18 times higher than the risk for scrotal cancer in other male workers.[7] In 1915, Drs. Yamagawa and Ichikawa confirmed the link between smoke, tar products, and cancer by producing skin cancer after painting the skin of a rabbit with coal tar. Pott would have been gratified that scrotal cancer is now rare, only a few cases per million, but he would be dismayed to learn about the global epidemic of lung cancer -- another smoke-related tumor.


Pott had a widespread interest in a great number of illnesses other than fractures and scrotal cancer, as evidenced by the extensive list of eponyms bearing his name (see sidebar). The following are among his contributions:

  • One of his early publications written soon after his leg injury concerned the diagnosis and management of hernia. In it he describes a large sliding bladder hernia where the entire mass disappeared after the patient urinated.

  • Pott developed a special interest in head injuries, a frequent type of accident often afflicting miners who worked with minimal or no protective head gear.

  • He was skilled in using a trephine to successfully evacuate intracranial hematomas.[8]

  • He described "Pott's puffy tumor," a soft swelling of the scalp that Pott ascribed to underlying osteomyelitis of the skull.[9]

  • He wrote about tuberculosis of the spine leading to deformity and often to spasticity or paralysis.

Brief Biography

In 1714, Percivall Pott was born in London, United Kingdom, to a well-established family. He developed an early interest in surgery, and at 15 years of age he became apprenticed to an established London surgeon, Edward Nourse.[2] Apprenticeship with a well-known practitioner was the standard form of training at the time, and Pott paid 200 guineas for the 7-year training period. At that time the average surgical income was about 60-70 guineas, so we can estimate that after his apprenticeship Pott would have had to work for 3-4 years to earn back the cost of his training.

In 1736, upon completion of his period of indenture, Pott received a diploma from the Company of Barber-Surgeons. About 10 years later, when this company dissolved, surgeons formed a new professional organization known as the Corporation of Surgeons. Pott joined the new organization, of which he eventually was elected governor. Near the end of his life, he became the first honorary fellow of the Royal College of Surgeons in Edinburgh.

During his lifetime, Pott was a famous instructor, teaching clinical surgery at St. Bartholomew's Hospital in London, and also at his own home. His teaching attracted many students, of whom the most famous was John Hunter, who eventually became even more well known than Pott. Because of his obvious surgical skills and compassion for his patients, Pott was a busy, respected London surgeon, considered to be the outstanding English surgeon of his era. Among his famous patients were the artist Thomas Gainsborough, the writer Samuel Johnson, and the famous actor David Garrick. Eventually, Pott became wealthy caring for these and many other patients.

Conclusion

At a time when the field of general surgery is rapidly shrinking, Pott's valuable contributions to so many different areas of surgery are truly impressive. Throughout his life he continued to be curious about the causes of and best surgical approaches to many common surgical and medical diseases. He made lasting contributions to the diagnosis and management of patients with orthopaedic problems, tumors, infectious diseases, and hernias.

Working without the benefit of anesthesia or antisepsis, Pott always attempted to be as humane as possible -- recommending surgery cautiously, but never hesitating to operate when a patient's life was at risk. In addition to being a respected surgeon, Pott was an admired, sought-after teacher, and a widely read author.

In 1775 Pott wrote:

Many and great are the improvements which the chirurgic art has received...and much thanks are due to those who have contributed to them: but when we reflect how much still remains to be done, it should rather excite our industry than inflame our vanity.[4]

These words are as valid today as when they were originally written.

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