Observations on Pott’s Disease, 
with Reference to the Prin- 
ciples of Treatment and 
their Application. 
BY 
ROYAL WHITMAN,W. D., M. R. C. S., 
Lecturer on Orthopaedic Surgery at the New York 
Polyclinic; Assistant Surgeon to Out Patients, 
Hospital for the Ruptured and Crippled. 
Cte ’Nell) Yorfe i&cfcical Journal 
REPRINTED FROM 
for October 28, 1893. Reprinted from the New York Medical Journal 
for October 28, 1893. 
OBSERVATIONS ON POTT’S DISEASE, 
WITH REFERENCE TO THE 
PRINCIPLES OF TREATMENT AND THEIR APPLICATION.* 
LECTURER ON ORTHOPAEDIC SURGERY AT THE NEW YORK POLYCLINIC ; 
ASSISTANT SURGEON TO OUT PATIENTS, 
HOSPITAL FOR THE RUPTURED AND CRIPPLED. 
ROYAL WHITMAN, Ild., M.R. C.S., 
The principles which govern the treatment of Pott’s 
disease are somewhat as follows : It is tuberculous in char- 
acter ; therefore the general condition of the patient must 
be sustained by the constitutional and therapeutic measures 
that are indicated in other manifestations of tuberculous 
disease. It is a local affection of the bones and joints of 
the spine, accompanied by symptoms of pain and deformity 
that may be relieved or prevented by restraint of motion, 
protection from injury, and removal of superincumbent 
weight. 
The treatment under which the general health is main- 
tained, by which a proper attitude of the entire body is as- 
sured, which relieves pain and prevents deformity, is effect- 
ive ; when these conditions are not fulfilled, treatment is 
ineffective. 
* Read by title at the seventh annual meeting of the American 
Orthopaedic Association. 
COPYBIGHT 1893, BY D. APPLETON AND COMPANY. 2 
OBSERVATIONS ON POTT’S DISEASE. 
The successful treatment of Pott’s disease depends 
upon (1) a knowledge of the functions and relations of the 
different portions of the spine, in order that one may inter- 
pret the early symptoms of disease, because a diagnosis can 
and must be made before the stage of bone deformity if 
the best result is to he attained. 
2. A knowledge of the deformities and complications 
of disease peculiar to the region affected, in order that one 
may foresee and guard against them, for the final deformi- 
ties of Pott’s disease differ very materially with the region 
of the spine involved. 
3. An apprehension of the nature of deformity and of 
the conditions that favor or retard its progress. 
4. An appreciation of the duration and extent of dis- 
ease and deformity, of the quality of the patient and the 
nature of his environment, in order that treatment may he 
applied intelligently or that a necessary compromise may 
be made between what is best and what is possible. The 
treatment of the patient in distinction to the treatment of 
his deformity is one of the more common and difficult 
problems, because patients are not often seen in the early 
stages of disease. The popular idea of Pott’s disease is 
that it causes a hump, that the diagnosis is made because of 
the hump, and that the treatment consists in the applica- 
tion of a brace or plaster jacket without regard to the ex- 
tent or position of the hump or to the symptoms or com- 
plications of disease. Consequently patients are brought 
for treatment in all stages of deformity or suffering, it may 
be from symptoms or complications that may call for spe- 
cial treatment, either because they directly influence the 
course of the affection or indirectly increase the tendency 
to deformity. 
In one, the constitutional depression of the tuberculous 
disease is out of proportion to its local manifestation; in OBSERVATIONS ON POTT’S DISEASE. 
3 
another, great deformity has been acquired with practi- 
cally no effect on the general condition. The complication 
of abscess may from its position endanger life in one in- 
stance, while in others it may increase the tendency to de- 
formity, or interfere with effective support, or remain for a 
time and disappear without symptoms or consequences. 
The treatment which may be most effective in childhood, 
when the danger of deformity is greater than the danger to 
life, may not be applied to the adult, for whom the relative 
danger of the constitutional and local disease is reversed. 
The object of treatment is the prevention of deformity ; 
not only because the effect of treatment is estimated by 
the degree of ultimate deformity rather than by the survi- 
val of the patient, but because deformity itself, after com- 
plete recovery from constitutional and local disease, by its 
distortion and compression of vital organs, is a constant 
source of weakness and danger. 
To apprehend the nature of deformity, its causes and 
final results, one must bear in mind the fact that the spine 
is a flexible column, which, balanced under the influence of 
the force of gravity, is constantly changing its shape to 
accommodate itself to the different attitudes and move- 
ments of the body. 
If by disease the function of one portion is interfered 
with, another part must accommodate itself to the change. 
If one section is deformed or thrown out of its true re- 
lation to the weight line, another part must change in the 
opposite direction. 
These compensatory changes, though bearing a neces- 
sary relation to the original cause, may, in the growing 
child, become exaggerated and independent deformities, or 
permanent distortions may be acquired which originally 
were merely symptomatic of disease. The deformities of 
Pott’s disease may thus be divided into two groups, the 4 
OBSERVATIONS ON POTT’S DISEASE. 
essential and the non-essential. The essential deformities 
are those caused by destruction of bone and loss of growth 
—two factors modified to a great extent by early diagnosis 
and efficient treatment. 
Pott’s disease is a destructive process which affects the 
bodies of the vertebrae, the weight supporting portion of 
the spinal column. As the effect of weakness and loss of 
support, the superior section of the spine inclines forward, 
bringing more weight, and thus the influence of attrition, 
to hear on the diseased area. The more rapid the destruc- 
tive process, the more often abscess complicates the condi- 
tion ; this abscess may dissect its way down the spine, in- 
fecting other vertebrae in its progress. It is apparent, then, 
that while the disease causes 
deformity, the deformity may 
increase the disease. 
The non-essential and more 
distinctly preventable deformi- 
ties are those which depend 
upon the symptoms or compli- 
cations of the disease; one of 
these is muscular spasm. In 
disease of the cervical region, 
for example, the head may be 
drawn into a wryneck position, 
which, if allowed to persist, 
becomes a permanent deformi- 
ty, for contracted tissues do not 
grow and the bones of the spine 
quickly accommodate them- 
selves to the changed condition 
of weight and function; or abscess which involves mus- 
cles and fascia may induce a faulty attitude. This is well 
illustrated in disease of the lower region of the spine, in 
Fig. 1. 
Fig. 2. OBSERVATIONS ON POTT’S DISEASE. 
5 
which the compensatory lordosis or overerectness of the 
body is one of the favorable factors in prognosis (Figs. 1 
and 2). When, however, psoas abscess causes flexion of 
the thighs, the erect posture is impossible (Fig. 3) ; thus 
the habitual attitude becomes most unfavorable and, if it is 
allowed to persist, permanent and unnecessary deformity 
may result (Fig. 4). 
Simple weakness is another element of deformity. 
When one sees a child suffering from dorsal disease walk- 
ing about in the squatting attitude of weakness, supporting 
the body by the hands on the knees, it is very evident that 
treatment is ineffective, because a proper attitude is not 
maintained. 
After the cure of the primary disease, the resulting 
deformity and the 
general weakness 
favor secondary 
curvatures of the 
spine, just as weak- 
ness and faulty at- 
titudes may cause 
postural curvatures 
without the influ- 
ence of local dis- 
ease. 
When the spine 
is distorted, the 
thorax must, in a 
certain degree, par- 
ticipate in the 
change; but the ex- 
aggerated pigeon- 
breast deformity of dorsal disease can be prevented by 
efficient treatment. 
Fig. 8, 
Fig. 4. 6 
OBSERVATIONS ON POTT’S DISEASE. 
The natural tendency of Pott’s disease is to cause a 
right-angled deformity at the point of weakness. The op- 
portunity for deformity is greatest when the middle of the 
spine is diseased, because the column is broken in the cen- 
ter. The opportunity for deformity is small when either 
extremity is affected, because the deformed portion is in- 
significant compared to that which remains intact. It is 
evident, then, that it is not the mere angular projection, 
the direct and essential effect of the local disease, which is 
of importance, but that the true measure of deformity is 
the effect of the disease or deformity on the spine as a 
whole. (Contrast Figs. 6 and 7.) 
Each region of the spine, because of its position, func- 
tions, or relations, presents certain peculiarities which in- 
fluence prognosis and treatment. Disease of the occipito- 
axoid section, the region of true joint motion, is not 
infrequently a primary affection of the synovial membrane ; 
consequently, more acute in symptoms and rapid in 
progress. 
Disease of this region is more dangerous because of the 
proximity of the vital centers and because of the possibility 
of sudden displacement and pressure on the cord. 
It is not infrequently complicated by abscess, which, 
unable to find an outlet, dissects its way about the contigu- 
ous vertebrae, or forms a tumor in the throat which may in- 
terfere with breathing and swallowing. 
On the other hand, because of the acute symptoms, an 
early diagnosis is usually made, and, under favorable cir- 
cumstances, the course of the disease is short and the result 
favorable. 
The most disastrous deformity of this region—one not 
infrequently seen in untreated cases—is caused by the fall- 
ing forward of the head so that the chin becomes fixed 
upon the sternum. The indications for treatment are to OBSERVATIONS ON POTT’S DISEASE. 
7 
prevent ultimate displacement of the head by fixing it 
in the line of the normal spine and at a right angle 
to it. 
The prognosis in disease of the middle of the neck is 
favorable from all standpoints, because the special move- 
ments of the head are unaffected and because the opportunity 
for final deformity is slight. Children are often brought for 
treatment in whom the right-angled deformity, concealed 
by the occiput, has never been discovered by the parents or 
physician. Disease of this region is often accompanied by 
painful contraction of muscles and distortion of the head, 
often complicated by enlarged or suppurating glands or 
sinuses. The indications for treatment are therefore the 
removal of the superincumbent weight of the head and re- 
lief of muscular spasm by active extension. 
In disease of the upper and middle dorsal region the 
prognosis is particularly unfavorable as regards deformity. 
The disease is not, as a rule, discovered at an early stage, 
because motion in this region is slight, and the symptoms 
are therefore not pronounced. 
The normal posterior curvature of the spine is marked- 
ly exaggerated by slight deformity, while the compensatory 
lordosis tends to increase rather than to limit the kyphosis. 
The course of the disease is long, and the tendency to in- 
creasing deformity remains after complete cure of the local 
disease. The direct effect of deformity in compressing and 
distorting the thoracic viscera, and thus causing permanent 
weakness, is often very apparent (Fig. 5). A most serious 
and not infrequent complication of disease in this region is 
paralysis from secondary implication of the spinal cord. 
The indications for treatment are to combat all deformities, 
primary or secondary; to prevent the forward inclination 
of the head and neck; to restrain unnecessary movements 
of the arms ; to draw the shoulders backward; to prevent 8 
OBSERVATIONS ON POTT’S DISEASE. 
the secondary deformity of the chest and the compensatory 
lordosis. 
The prognosis in disease of the middle of the spine is- 
favorable if the patient is seen in the early stage, because 
the mechanical conditions are such as to make apparatus 
effective in relieving symptoms and preventing deformity. 
If neglected, disease of this 
region produces the typical 
humpback (Fig. 6), the dwarfed 
stature, the square shoulders, 
the sunken head, and the dis- 
torted back and chest. 
At a lower point the at- 
titude symptomatic of disease 
tends to prevent great deformi- 
ty, hut in a large proportion 
of cases abscess and psoas con- 
traction change this attitude 
to an unfavorable one. The 
indications for treatment are 
to restrain the awkward atti- 
tude of overerectness and to 
guard against the effect of 
psoas contraction. If this con- 
traction is on one side only, the proper attitude of the spine 
may be maintained by providing the patient with a high 
shoe on the unaffected leg and crutches. If the contrac- 
tion is of both sides, the patient should not be allowed to 
go about, but the irritation must be relieved by complete 
rest, or the abscess treated directly. 
Fig. 5. 
Fig. 6. 
In the two regions of the spine, the upper and lower, 
in which abscess most often makes its appearance, radical 
operation is most often indicated; in the first, because of 
its position; in the second, because of its size and deform- OBSERVATIONS ON POTT’S DISEASE. 
9 
ing influence. In both these regions it is sometimes pos- 
sible to reach and remove the source of suppuration. Ex- 
cept as an imperative necessity, the radical treatment of 
abscesses should not be undertaken unless the proper con- 
ditions for treatment can be assured, unless the source of 
pus can be reached, and unless there is a fair prospect of 
avoiding a suppurating sinus, which is often a source of 
danger and discomfort to the patient or interferes with 
effective support. 
Abscess is a symptom of disease of which the impor- 
tance is estimated by its effects. It may be prevented, and 
its extent and course may be modified by proper treatment 
of the cause of which it is a symptom. The aspiration of 
abscesses, with the injection of antituberculous remedies, is 
the treatment by preference. It is often effective and always 
harmless. 
In the treatment of Pott’s disease, rest and fixation in 
the horizontal position fulfill all the mechanical conditions : 
superincumbent weight is removed ; the function of the 
diseased spine ceases; jars, injury, and overfatigue are im- 
possible. 
On the other hand, this treatment is incomplete in it- 
self, because it must be supplemented by some form of 
mechanical support when the erect positure is again as- 
sumed. 
It necessitates confinement and lack of exercise, the 
constitutional stimulation very essential in the treatment of 
tuberculous disease. The duration of Pott’s disease is esti- 
mated in months and years; thus the moral effect of help- 
lessness and confinement for such a period must be consid- 
ered. In general, this treatment is a last resort, or is a tem- 
porary measure indicated for the relief of pain or threatened 
complications. In certain cases it is the treatment by pref- 
erence ; as in infancy and early childhood, because the 10 
OBSERVATIONS ON POTT’S DISEASE. 
spine is in great part cartilaginous, the effect of disease in 
checking the growth and in the rapid production of de- 
formity is very marked. 
Young children submit very readily to a treatment that 
relieves them of discomfort and pain—that is, in fact, a 
simple prolongation of the helplessness of infancy. 
The treatment is usually indicated for a longer or shorter 
time under the following conditions: In disease of the up- 
per cervical region, because the head may be fixed, the 
danger of abscess lessened, dislocation and deformity pre- 
vented, pain relieved, and the progress of the disease 
checked before joint motion is greatly impaired. In dis- 
ease of the upper dorsal region in young children, because 
progressive deformity is difficult to control, and a proper 
attitude difficult to maintain by apparatus. In disease of 
the middle thoracic region, in which the grunting respira- 
ion and the faulty attitude—the evidences of pain and 
weakness—show that treatment is ineffective. In disease 
of the lumbar region, in which the complication of 
psoas contraction makes the erect posture difficult or im- 
possible. 
This treatment is always indicated when pain is not re- 
lieved by other means; in the acute phases of disease, 
shown by pain, fever, and rapidly increasing deformity ; in 
the complication of paralysis; or for the radical treatment 
of abscess. 
To be effective, the rest treatment must always include 
fixation and often extension, and the apparatus must be en- 
tirely independent for its effectiveness of the bed on which 
it is placed. The most simple and useful appliance is, T be- 
lieve, the frame first recommended by Bradford. The frame 
is made of light steel bars or gas pipe, a little longer and as 
wide as the child’s body. This frame is covered by canvas, 
which is made smooth and rigid by straps or corset lacings OBSERVATIONS ON POTT’S DISEASE. 
11 
on the under surface; between the two layers a thin hair 
mattress may be inserted if desirable. 
For older children it is well to apply the canvas cover 
n three sections, the narrow middle sheet to be removed 
for the use of the bed pan. This is unnecessary when 
diapers are used, the middle portion being protected by 
rubber sheeting. 
Two or more sets of covers (sheets) are necessary, in or- 
der that the apparatus may be perfectly clean, for an unclean 
child is always neglected. 
The patient must be fixed to the frame ; the child who 
can raise the head or turn the body is uncomfortable and 
unhappy because he can not sit up, but when motion is 
impossible he quickly accustoms himself to restraint. To 
fix the patient, the shoulders and the head are the two 
points of advantage. If the shoulders are fixed, he can not 
turn over; and if the head is held, he will not attempt to 
sit up. The patient is usually attached to the frame in the 
following manner: A broad swathe surrounds the body 
and the frame, and straps attached to the frame are passed 
over the shoulders and through the axillae, while a band 
across the chest prevents displacement. 
Traction is indicated in cervical disease, and may be 
applied with advantage in disease of the upper dorsal 
region, with the aim of reducing deformity. Traction is 
easily accomplished by the ordinary halter attached to a 
slightly flexible steel upright, screwed to the brace after 
the manner of the jury mast. The amount of traction is 
regulated by raising the head of the frame ; this allows the 
child to look about and is often as effective as the weight 
and pulley. Pillows beneath the head are not often indi- 
cated ; in fact, it is sometimes necessary to loosen the upper 
part of the canvas so that the occiput may fall back, and 
to place a pad beneath the dorsal region if effective trac- 12 
OBSERVATIONS ON POTT’S DISEASE. 
tion is to be applied in disease of that region; by this 
means in young children it is sometimes possible to reduce 
what is apparently deformity of bone. In the treatment of 
cervical disease, particularly in those cases in which the 
displaced bone projects forward, it may be necessary 
to place a pillow beneath the head as a temporary sup- 
port. 
Psoas contraction, even if complicated with abscess 
often disappears under the influence of rest. If, however, 
this position has long been maintained, it may be necessary 
to apply traction to the legs, as in the treatment of the de- 
formities of hip disease. 
The rest treatment is not often indicated in cases of 
great deformity, or in half-grown children or adults, except 
to meet certain indications, some of which have been men- 
tioned ; but it may be applied, and almost always with 
advantage, in the treatment of any region of the spine in 
infancy or early childhood. The patients may be taken 
into the open air daily, pain is relieved, the condition of the 
patient improves, while growth is often very rapid. Strong 
objection to the treatment is often made by the parents, 
but, once applied, its effects are so apparent that it may be 
continued without protest until other indications call for 
change. 
If the essential conditions can be fulfilled by treatment 
which does not confine the patient to the bed or house—in 
other words, does not make an invalid of him—this is the 
treatment by preference. 
The principle of support in the erect posture is this: If 
the body is inclined forward, the weight or pressure is sup- 
ported by the bodies of the vertebra}. When the body is 
inclined backward or held in the upright position, more 
weight is supported by the articular processes. This is 
what is meant by relief from superincumbent weight as OBSERVATIONS ON POTT’S DISEASE. 
13 
effected by a spinal support; in addition, it fixes the spine 
and protects it from the injury of motion. 
If the point of disease is above the thoracic section, 
superincumbent weight may be actually lifted ; the body 
support then acts primarily as a base of support for the 
attachment which fixes or lifts the head. 
The two types of appliance used are the plaster jacket 
and the spinal brace. Each of these has advocates who 
seem to base their conclusions on the failures of the one 
rather than on a personal comparison of the merits of the 
two; the desirability of interchanging the two methods of 
treatment is not often considered in the discussion or writ- 
ings on this subject. 
The jacket is brought into disrepute because it can be 
so easily and is so often applied by those who have a 
blind faith in its efficacy as a specific for humpback; the 
because of a lack of knowledge of the principles of 
its construction or application. 
The jacket is in fact a simple circular plaster bandage, 
which, like any other plaster bandage, depends for its effi- 
ciency on the size and irregularities of the surface to which 
it is applied and on the distance to which it extends on 
either side of the point to be fixed; for example, a plaster 
bandage applied to the knee of an adult may be an effective 
support, yet is useless on the leg of an infant. So the 
plaster jacket may be admirably effective when applied 
under proper conditions, and absolutely ineffective under 
others. 
The plaster jacket provides a general support for the 
trunk as a whole; solid at the sides, front, and back; less 
accurately adjusted than the brace at the seat of disease. 
The abdomen is supported and counterpressure applied to 
the chest without uncomfortable tension. The jacket is 
most effective as a support in disease of the middle of the 14 
OBSERVATIONS ON POTT’S DISEASE. 
back, less effective at a lower point, because the unyielding- 
plaster does not allow the accurate adjustment to the pelvis 
that may he afforded by the brace. The brace, which is 
more effective in the lower region, is also more effective in 
the middle and upper dorsal region, because, by an appli- 
ance that I have elsewhere described (Transactions of the 
Orthopaedic Association, vols. iv and v, and Philadelphia 
Medical Mews, November 19, 1892), backward traction may 
be applied to the shoulders, the leverage of the brace 
increased, and greater fixation assured by restraint of 
unnecessary forward-reaching movements of the arms, 
which act directly on the weakened spine to increase the 
deformity. 
The jacket is admirably effective as a support in disease 
of the middle region in adults. It is a better support than 
the brace in cases of marked deformity and in cases of lat- 
eral distortion of the spine. When the neck region is in- 
volved the choice between the brace and jacket is more often 
one of relative comfort than of other importance. The jury 
mast is usually associated with the plaster jacket, but may 
equally well be used with the brace. In disease of the 
occipito-axoid region greater fixation of the head than is 
afforded by the jury mast is usually indicated; while in 
the painful distortion of the neck, associated it may be with 
suppurating sinuses or inflamed glands, the active traction 
afforded by the jury mast and halter is more comfortable 
and effective than the simple fixation of the metallic head 
supports. A disadvantage of the jury mast is that it is a 
very noticeable and rather offensive support. This is a 
matter of some importance, because head or chin supports 
are oftener indicated in disease of the dorsal region than is 
usually taught, not for the relief of pain, but to check the 
tendency to slowly increasing deformity. In such cases an 
inoffensive chin rest maybe used when the jury mast would OBSERVATIONS ON POTT’S DISEASE. 
15 
not be tolerated. One may conclude, then, that while the 
brace and its attachments has a wider range of application, 
under certain conditions the jacket is more comfortable and 
more elfective. 
The faults of the jacket, as it is often applied, are that 
it is made too short below to support the abdomen, but 
allows it to bulge out beneath—thus it fails in support and 
predisposes to hernia; that it is not carried high enough to 
cover the chest and assure efficient counterpressure; that 
jury masts are not applied when they are indicated, are not 
strong enough to support the weight of the head, and that 
traction is not properly applied. 
Most of the spinal braces sold in shops 
are useless; others are not properly fitted or 
the aprons are too short or made of yielding 
material which allows uneven and uncomforta- 
ble tension. While either method, properly 
carried out, may meet all the ordinary indi- 
cations in treatment, there are occasions when 
one is distinctly preferable to the other, or 
when the appliances may be interchanged 
with advantage. 
The object of mechanical treatment is to 
free the spine from the influence of local de- 
formity (Fig. V) and from the deforming in- 
fluence of the symptoms and complications 
of disease; to distribute the compensation 
which is necessary and to limit that which is 
unnecessary. 
Fig. 7. 
The test of an appliance is its efficiency in meeting 
these indications; the test of treatment is its effect upon 
the patient. The New York Medical Journal. 
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