Percivall Pott

Percivall Pott was born in London, the son of notary Percivall Pott of a well-known Chesire lineage. Fatherless already at the age of four, it was thanks to his mothers care and the support of a distant relative, dr Wilcox, and the bishop of Rochester that he was well brought up. At the age 7 he came to a private school in Kent and, aged 17, after having discarded his original plans of studying for the clergy, he was apprenticed to Edward Nourse jr, a surgeon at the St. Bartholomew's Hospital who taught anatomy and surgery, for the sum of 200 pounds. In addition to his surgical practice, Nourse organized anatomy lessons in his home on Aldersgate Street. Pott served during his 7-years apprenticeship as Nourse’s primary assistant in preparing cadavers for public demonstrations of dissections.

English surgery at the time was hardly more than a craft. It was Pott's luck to become a pupil of Edward Nourse, who, besides teaching anatomy and surgery also let his pupil attend operations at the St. Bartholomew's Hospital. Pott was also a student of William Cheselden (1688-1752) who was said to be the most rapid of the pre-anaesthetic operators, doing a lithotomy in about four minutes.

After a seven year apprenticeship, on September 7, 1736, Pott, 22 years of age, faced the Court of Examiners of the Company of Barber-Surgeons. He passed with flying colours and qualified for the Grand Diploma.

He continued to assist his mentor both at surgical operations and with his private lectures. Pott now established his own surgical practice when he rented a house on Fenchruch Street, where he lived with his mother and half-sister. Three years later, in 1739, he changed his address to Bow Lane.

In 1745 he became assistant-surgeon and in 1749 full surgeon at St. Bartholomew’s Hospital, remaining in that position until his retirement in 1787. In his own words, he had served the institution “as a boy and a man" for half a century". Besides his hospital duties Pott had a busy private practice.

Horses!
When Pott, on a cold January morning in 1756 was making a sick visit on horseback, the horse stalked and threw him off. The fall resulted in an oblique, open compound fracture of the lower part of the fibula and tibia. Realizing the gravity of the injury, Pott refused to let himself be moved until a proper mode of transportation had been secured. He lay on the cold pavement while waiting for the arrival of two “chair men” and their poles. Pott purchased a door, to which the poles were nailed. He reclined on the improvised stretcher and was carried to his home. A multitude of his fellow surgeons were called, all of whom recommended immediate amputation, which was then the accepted treatment for such an injury. Pott agreed, but just as the instruments were being prepared, Nourse arrived and decided to attempt to save the leg by reduction. In time the injury healed properly, and Pott retained his leg without any evidence of disability. The story may be acrophycal, but a lengthy recuperation may have stimulated Pott’s interest in medical writing because from that year on, he produced a steady flow of surgical texts that brought him international recognition. Fractures of this kind are now generally called Pott's fracture - while in France they are designated as Dupuytren's fracture.

Pott was not the first surgeon to experience a fracture of the lower leg while riding to visit a patient. With a couple of friends Ambroise Paré (1510-1590) some time in 1551 was making a visit outside Paris. While he attempted to get the horse to board a boat, the horse kicked Paré in the leg with such force that both the tibia and the tibia of the left lower leg were broken some four fingerbreadths over the foot joint. Immediately afterwards the unfortunate Paré saw the already broken bones stick out through the skin, his trousers and the boot, causing and almost intolerable pain.

Rider turned writer
Forced into a long period of rest, Pott, who had previously published nothing more than a 7 page piece, began recording his experiences as a physician and a surgeon. Already the same year, 1756, appeared A treatise on ruptures, followed by 13 more works during the years 1757-1782. In Pott's lifetime these 14 works were published in a total of 31 editions in England. Besides this he authored the Chirurgical works in 1775, appearing in a new edition in 1783. His works also enjoyed a widespread circulation even abroad and were published in numerous translations into French, Dutch, German, and Italian.

In A Treatise on Ruptures (1756) Pott refuted many of the old theories concerning the causes of hernias and methods of treatment. He was the first to describe “congenital hernia” and became embroiled in a bitter academic feud with the Hunters who demanded priority for tracing the anatomy of congenital ruptures. Pott denounced the so-called radical cure of hernia, although he was known to have performed numerous “conservative” operations for strangulations.

In 1760 Pott authored Observations on the Nature . . . . The treatise showcased Pott’s extensive knowledge of surgical literature, which allowed him to systematize the treatment of head injuries. He described the signs by which extradural haematoma can be differentiated from extradural abscesses. One characteristic of the latter is the puffy tumour, a circumscribed swelling of the scalp indicating either an underlying osteitis of the skull or an extradural abscess. Pott explained among other clinical points, the lucid interval that precedes the coma of extradural haemorrhage. In his Practical Remarks . . . (1762) he provided a classic description of hydrocele.

Pott’s methods for treating fractures and dislocations became standard after the publication of Some Few General Remarks . . . (1765). In that work he stressed the necessity for the immediate setting of a displaced fracture and the need for relaxation of the muscles so that the reduction could be successfully performed. Splints’ when used, should immobilize the joints above and below the fracture site and be well padded. From personal experience Pott realized the gravity of the decision to amputate in cases of compound fractures and weighed the chances of saving a limp against the attendant hazard of death from infection. It is in his work on fractures and dislocations that the classic description of Pott’s fracture is found:

When the fibula breaks within two or three inches of its lower extremity, the inferior fractures end falls inwards towards the tibia, that extremity of the bone which forms the outer ankle is turned somewhat outward and upward, and the tibia having lost its proper support is forced off from the astragalus inwards, by which means the weak bursal or common ligament of the joint is violently stretched if not torn, and the strong ones which fasten the tibia to the astragalus and os calcis are always lacerated, thus producing a perfect fracture and a partial dislocation to which is sometimes added a wound in the integuments . . . All the tendons which pass behind or under, or are attached to the extremities of the tibia and fibula or os calcis, have their natural direction so altered that they all contribute to the distortion of the foot and that by turning it outward and upward.
It is extremely troublesome to put to rights, still more so to keep it in order, and unless managed with address and skill is very frequently productive of lameness and deformity ever after . . . but if the position of the limb be changed, if by laying it on the outside with the knee moderately bent, the muscles forming the calf of the leg and those which pass behind the fibula and under the os calcis are all put in a state of relaxation and non-resistance, all this difficulty and trouble do in general vanish immediately, the foot may easily be placed right, the joint reduced, and by maintaining the same disposition of the limb everything will in general succeed very happily.

In his work Pott always sought for the pathogenesis and the anatomical background for the disease or condition, preparing his treatment accordingly. He tried to stem the prevailing busy use of the knife and the burning iron, seeking more humane methods of surgery. This did not, however, stop him from recommending early surgery whenever he found it necessary.

In 1775 Percivall Pott reported a curious prevalence of ragged sores on the scrotums of many chimney sweeps in London. Other doctors might have concluded that the men were afflicted with a venereal disease that was then rampant throughout the city. But Pott was more astute. He realized they were in fact suffering from a type of skin cancer. Pott established that the cause of this form of cancer was "a lodgement of soot in the rugae of the scrotum".

This observation was a medical milestone, and his work Cancer scroti, "chimney sweeper's cancer", is a classic in industrial medicine. By observing that men continually exposed to coal tar were "peculiarly liable" to this form of cancer, he documented for the first time that cancer could be caused by an external agent rather than by internal factors. It was also the first time a specific type of neoplasm being related to a particular occupation. It initiated one of the first epidemiological surveys of coal tar-induced cancer.

In Cancer scroti, he advocates - in forceful wording - an early surgical operation: "If there be any chance of putting a stop to, or preventing this mischief, it must be by the immediate removal of the part affected; I mean that part of the scrotum where the sore is, for if it be suffered to remain until the virus has seized the testicle, it is too late even for castration."

Although the conditions is sometimes called Pott's cancer, the term coined by himself, chimney-sweepers cancer, has replaced a justified eponym.

Pott's disease, tuberculous spondylitis, was no new discovery. Tuberculosis has been one of the scourges of mankind for thousands of years, a fact which is amply witnessed by grave findings from all over the world. Tuberculosis of the spine was well known even to Hippocrates, and after him the condition has been described by several others. Pott gave a very good description of the disease in 1779. In 1782 he completed his description of the disease and corrected some errors. His description has become a classic.

Pott was one of the busiest and most famous surgeons in England during the middle of the eighteenth century. He had probably the largest surgical practice in London and was an extremely pleasant person who attracted many foreign students to St. Bartholomew's. He made careful post mortem examinations, although some of his advice seems rather rough and ready. In head injuries the treatment was always "phlebotomy and an open belly"!. He advocated trephine and removal of bone for suppuration beneath the bone and concluded that symptoms from head injuries were due to brain damage and not to a fracture of the skull per se.

Pott always remained active in the organizational affairs of the Company of Surgeons. In 1753 he was elected one of the first masters of anatomy; 3 years later he was appointed to the court of assistants; and eventually he was named to the Court of Examiners. In 1765 he succeeded Robert Young as governor of the company.

Pott was elected member of the Royal Society in 1764.

Returning in foul weather from a sick call about 32 km from London on December 11 1788, Percivall Pott complained of having caught cold. On the day for his return call, the 14th, he was persuaded by his son in law, James Earle, also a physician, to stay home and let his son in law do the call. During James Earle's absence Pott made a sick round of London. His condition deteriorated, and on December 21 he made his last diagnosis: "My lamp is almost extinguished: I hope it has burned for the benefit of others." The next day Pott died of pneumonia.

We thank Professor ES Flamm for correcting an error.

• Treatise on Ruptures. London, 1756, 1766.
• An Account of a Particular Kind of Rupture frequently attended upon New Born Children.
  London, 1757, 1765, 1775.
• Observations on that disorder of the corner of Eye Commonly Called Fistula Lacrymalis.
  London, 1758, 1762, 1765, 1769, 1775. German translation, Dresden, 1771.
• Observations on the Nature and Consequences of Wounds and Contusions of the Head, Fractures of the Skull, Concussions of the Brain.
  London, Hitch & Lowes, 1760. Later editions 1760, 1768. German translation, Nürnberg, 1768.
• Practical Remarks on the Hydrocele or Watery Rupture.
  London, 1762, 1767. German translation, Copenhagen 1770.
• Remarks on the Disease Commonly Called Fistula in Ano.
  London, 1765, 1767, 1771, 1775. German translation, Wien, 1768.
• Some Few General Remarks on Fractures and Dislocations.
  London, 1769. French translation, Paris, 1788; Italian translation, Venice, 1784.
• Chirurgical Observations Relative to the Cataract, the Polypus of the Nose, and the Cancer of the Scrotum, the Different Kinds of Ruptures, and the Mortification of the Toes and Feet.
  London, 1775. German translation, Berlin, 1776.
  Describing gangraene senilis and the chimney sweeper’s disease.
• 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...
  London, J. Johnson, 1779.
  German translation by by K. H. Spohr, Leipzig, 1786.
  Dutch translation, Leiden, 1779; French, Paris, 1783.
• Farther Remarks on the Useless State of the Lower Limbs, in Consequence of a Curvature of the Spine: Being a Supplement to a Former Treatise on that Subject.
  London, 1782.
• The chirurgical works of Percivall Pott. A complete edition.
  First edition in 4 volumes, London, 1771; 2nd edition, 1775.
  3rd edition in three volumes, London, printed for T. Lowndes, J. Johnson . . . and S. Hayes, 1779. Later editions 1783, 1790, and 1808.
  Dublin, 1778.
  German translation in two volumes, Berlin, 1787-1788;
  French translation, Paris, 1777; 3 volumes, 1792.
  Italian translation by Bassano, 3 volumes, 1794.
  Pott's writings were popular in America and an edition of the present work appeared in Philadelphia as late as 1819.