THE ELEMENTS 
OF THE 
DIFFERENTIAL DIAGNOSIS 
Pott’s Disease in Childhood 
Read before the Orthopedic Section, New York 
Academy of Medicine, April 21st, 1893 
ROYAL WHITMAN, M. D.; M. R. C. S., 
BY 
Lecturer on Orthopedic Surgery at the New York Polyclinic; 
Assistant Surgeon to out Patients’ Hospital 
for Ruptured and Crippled. 
REPRINTED FROM THE NEWYORK POLYCLINIC, MAY, 1893. THE ELEMENTS OF THE DIFFEREN- 
TIAL DIAGNOSIS OF TOTES 
DISEASE IN CHILDHOOD. 
BY ROYAL WHITMAN, M. D., M. R. C. S. 
Lecturer on Orthopedic Surgery at the N. Y. Polyclinic; 
Assistant Surgeon to out Patients; Hospital 
for Ruptured and Crippled. 
Differential diagnosis, in other words the 
early recognition of a group of symptoms pe- 
culiar to a certain disease, implies Knowledge 
of the normal functions of the organ or part 
affected by disease, and knowledge of the 
character of the disease and of its variations 
and modifications, under different circum- 
stances. 
The elements of the differential diagnosis 
of Pott’s disease, should include I appre- 
hend, a description of the norrpal furctions 
of the spine; the character of the disease, and 
the symptoms of the disease, and of its com- 
plications which more often cause errors in 
diagnosis; explaining in logical sequence if 
may be, their causes and significance. 
The spine serves not only as the elastic sup- 
port of the body, but it encloses the spinal 
cord, from which branch the nerves of motion 
and sensation. Although as a whole, it is 
constantly changing its shape, with every 
change in attitude, yet under the influence of 
the force of gravity and the action of the 
muscles in the preservation of the erect 
posture, a certain fixed contour is attained 
known as normal—forward in the upper, back- 2 
ward in the middle and forward again in the 
lower region of the spine. 
Each of these regions has certain move- 
ments and functions peculiar to itself; the 
function of the cervical spine is to support 
the head, and allow free motion; the middle 
portion is made rigid in the formation of the 
thoracic cavity, the lower region is again free 
and movable. 
Pott’s disease is a chronic, tuberculous de- 
structive disease of the spongy substance of 
the bodies of the vertebrae; the partially de- 
stroyed bodies collapse, and the unaffected 
portion of the spine bends to accomodate it- 
self to the irregularity; thus the angular pos- 
terior projection characteristic of Pott’s disease 
is formed. 
Pott’s disease may also be classed as a con- 
stitutional disease, in the sense that tubercle 
in bone implies other and older deposits else- 
where, and because the local affection is 
directly influenced by the condition of the 
patient, as the general condition is at once 
improved by the relief of local irritation or 
pain. 
The symptoms of Pott’s disease may be di- 
vided into three classes: 
ist. Those dependant on the disease as it 
affects the function of the spine as an elastic 
support. 
These are pain, weakness, muscular rigidity 
or distortion, and deformity of bone. 
2nd. Symptoms dependant on the implica- 
tion of the contained spinal cord and its nerves. 3 
These are reflected pain, motor spasm, local 
or general paralysis. 
3rd. Symptoms dependant on the effect of 
inflamation, or abcess on parts adjoining or 
attached to the spine, as seen in obstruction to 
breathing or swallowing in the upper, or mus- 
cular contraction in the lower region of the 
body. 
4th. General constitutional symptoms, as 
anaemia, loss of strength and appetite, or fever 
the effect of local irritation or suppuration. 
The first group of symptoms is primary, 
such as one may expect if the disease is seen 
in the early stage. These early symptoms may 
be entirely overlooked however, and sudden 
weakness or paralysis, the obstruction to breath- 
ing by a retropharyngeal abcess, the limp 
caused by psoas contraction, may be the promi- 
nent symptom for which the patient is brought 
for treatment; such are secondary or compli- 
cating symptoms. 
The field for differential diagnosis may thus 
include diseases which may cause weakness, 
deformity, abcess, neuralgic pain, motor dis- 
turbances and paralysis. It is always well, 
however, to keep this distinction of symptoms 
clearly in mind; that secondary symptoms are 
not necessary to the diagnosis of Pott’s disease, 
while the primary symptoms, which are always 
present, are necessary to establish the diagnosis, 
and to explain the complicating symptoms. 
The most significant of the early symptoms 
is muscular spasm; the normal range of motion 
is no longer possible in the diseased spine, if 4 
causes pain and is restrained by involuntary 
muscular rigidity. This rigidity of the upper 
spine interferes with the motion of the head; 
in the lower region with stooping and bend- 
ing, while it may cause no marked symptoms 
in the middle region where motion is normally 
so slight. With muscular spasm are combined 
the other symptoms of bone disease, pain, 
weakness, and later, deformity. 
As the contour of the spine is the effect of 
gravity, any deviation in one direction must be 
compensated for by a corresponding change in 
the opposite direction, elsewhere. Again as 
the normal flexible spine is constantly chang- 
ing its shape with every change in attitude, 
or muscular movement, it is evident that pain 
or weakness or muscular rigidity or deformity 
of bone must cause a change in attitude, 
which must be an early and significant symp- 
tom of the disease. It may be merely an 
attitude of restraint, as contrasted with that 
of freedom and health. It may be charac- 
teristic of the disease and of the portion of 
the spine affected. 
Familiarity with the attitudes of the healthy 
child, enables one to detect slight changes 
from the normal standard, and thus to suspect 
Pott’s disease in the early stage. 
Knowledge of the normal contour of the 
spine, the motions, functions and anatomical 
relations of its different parts enables one to 
diagnose Pott’s disease, and to locate it with 
certainty. 
The angular deformity is usually considered the one diagnostic sign of Pott’s disease, and 
until that sign is prominent and aggressive, 
cases are not often referred for special treatment. 
Perhaps the most effective work for early 
diagnosis is done by the relatives of patients, 
who see the disease in its different stages at 
clinics. They are ever ready to recount the 
early symptoms, the progress of the disease, 
and the sufferings of their child, nor do they 
ever forget to condemn the ignorance of the 
doctor who failed to recognize the affection. 
Thus early cases are sometimes brought 
by anxious mothers, because “something is 
wrong,” which perhaps best expresses the 
change from the normal standard of disposition, 
health and activity. The child may be fretful, 
easily fatigued; likes to lie on the floor, re- 
fuses to walk, or cries when lifted suddenly, 
or complains of pain in the abdomen. It may 
be slow or awkward in its movements, or a 
distortion of the head or body, or limp may 
be the prominent symptom in the history 
according to the situation of the disease, or 
the watchfulness of the relatives. In the 
better class any symptom may be considered 
important, in others, pain is almost the only 
symptom that attracts attention. 
Although histories, as obtained from relatives 
are often inaccurate and misleading, one may 
usually ascertain when the child was last per- 
fectly well, if the onset of symptoms was 
sudden or gradual, preceded or not by con- 
tagious disease or injury; injury being of 
significance only when the symptoms followed 6 
immediately upon it and have since continued. 
The child ,is then to be stripped naked and 
its general appearance, attitude and facial ex- 
pression, its movements in walking, rising and 
bending, carefully noted. Attention is this 
called to the suspicious region; that region 
is then to be examined by itself, for change 
in shape, restriction of motion or deformity. 
Failure to make an early diagnosis of Pott’s 
disease, is more often the result of carelessness 
or ignorance on the part of the examiner, than 
of obscurity of symptoms. When symptoms 
are obscure a second examination, with an 
interval for rest of the patient and reflection 
for the examiner, will usually clear up the 
doubtful points. The essential principles of 
early diagnosis having been indicated, their 
application may be illustrated in the different 
regions of the spine. 
Although muscular spasm and distortion are 
early spmptoms of disease of any portion of the 
cervical region, yet the upper extremity of the 
spine composed of the condyles of the occiput, 
the atlas and axis, differs so materially in 
function and often in the character of symp- 
toms, as to form a region by itself. The tissue 
of the bones is compact, and there is no inter- 
vening disc of cartilage to connect the vertebrae 
with one another, the synovial membrane is 
extensive; the motion of the region is true 
joint motion, with limits defined by special 
ligaments and muscles. As a consequence 
diseases is here more often limited in extent, 
or may be a primary affection of the synovial 7 
membrane and thus more acute and rapid 
in its progress. Pain often confined to one 
side, is reflected upwards instead of down- 
wards, abscess more frequent and from the 
position of the larynx immediately below, may 
cause early symptoms of obstruction. 
In a well marked case, when the special 
movements of nodding and rotation are cut off 
by disease of the joints, in which these move- 
ments are alone possible, the evident stiffness 
of attitude or distortion of the head, the in- 
stinctive seeking of support, the look of appre- 
hension, the scream of pain and voluntary 
resistance whenever an attempt is made to 
raise the chin or rotate the head, the change in 
contour of the neck, the thickening about the 
seat of disease are symptoms only simulated by 
severe traumatism; the history would then 
make the diagnosis clear, and in any event the 
question could be only of prognosis, not of 
treatment. In less well marked cases, or when 
the disease is at a lower level the principal 
symptom may be a distortion of the head by 
muscular contraction; the question then arises 
whether the contraction is symptomatic of bone 
disease, or of a primary affection of muscle, or 
irritation of nerves secondary to inflamation, 
not connected with the spine. 
The various forms of congenital, or acquired 
wry neck when seen in a later stage, show 
simply contraction without pain, the shortened 
tissues stand out as cords on the neck when 
tension is made upon them, and diagnosis is 
simple. The acute rheumatic wry neck is 8 
distinguished by its acute onset, the local pain 
and tenderness and the insignificance of 
general symptoms. Sprains or other injuries 
are to be distinguished by the history of dis- 
tortion and pain, following immediately on the 
injury, because the pain is usually local, com- 
bined with local tenderness. The greatest 
difficulty is experienced in the forms of in- 
flamatory wry neck often following contagious 
diseases, combined with indurated or suppurat- 
ing glands, in which the contraction is partly 
due to irritation of nerves, and partly to direct 
inflamation of muscles. The distinction is 
made on the following points: 
The rigidity and distortion of Pott’s disease 
is a rigidity to restrict painful motion, not in 
one, but in all directions; the contraction 
usually disappears when the muscles are re- 
lieved from this duty—for example, if the 
child is placed on its back, the head supported 
by the hands of the examiner, the contrac- 
tion, distortion and pain will often entirely 
disappear under gentle traction. 
The contraction of inflamatory wry neck 
persists, tension causes pain and is resisted by 
the patient. Motion is limited particularly in 
one direction, that opposed to the contraction, 
and there is an absence of the peculiar con- 
stant apprehensive spasm of bone disease. 
Pain is more often local, combined w.th local 
tenderness and infiltration; that of Pott’s dis- 
ease reflected away from the seat of contrac- 
tion. 
In wry neck, the sterno mastoid is more often the prominent and contracted muscle, in Pott's 
disease the shorter and deeper lateral and 
posterior muscles are more often affected. 
9 
In rare cases of cervical disease, and some- 
times as low as the middle dorsal region, the 
head may be drawn backwards, and this 
attitude or cervical opisthotnos may be simu- 
lated by basilar meningitis or marasmus, or 
it is a temporary symptom in infants without 
explained cause, or may be congenital. The 
history and the appearance of the infant, the 
fact that the head may be replaced in proper 
position without pain, makes diagnosis clear. 
Localized diptheritic paresis of the muscles of 
the neck, affecting more particularly the tra- 
pezius, may allow the head to fall forward 
In addition there may be contraction of one 
sterno-mastoid combined with local tenderness. 
Such appearances are confusing until a history 
has been obtained, when corresponding paral- 
ysis of parts supplied by the spinal accessory, 
the paralysis of the fauces or accomodation of 
the eyes, clear up the doubtful points. Several 
cases have been seen, in which diagnosis of 
Pott’s disease had been previously made. 
Abcess appearing as a tumor in the pharynx, 
interfering with breathing and swallowing, 
may be a relatively early symptom, mistaken 
for croup, adenoid vegetation or enlarged ton- 
sils. Palpation and inspection will show the 
cause of the symptoms—the symptoms of Pott’s 
disease, the source of the pus. 
In general then, the distinguishing features 
between the distortions of Pott’s disease and those due to local irritation, inflamation or 
injury, are these: 
10 
Such distortion is but one of the symptoms 
of a serious, protracted and constitutional 
affection—when the contraction is overcome, 
treatment is but begun.—In the other forms 
of contraction with which it is likely to be 
confused, the cure of the local distortion is a 
cure of the disease. 
Disease of the middle or thoracic region, 
where motion is so limited, is not often seen 
in the earliest stage, and I am inclined to 
think that early symptoms are not as signifi- 
cant here as elsewhere. 
In young children the most characteristic 
attitude is one of weakness, a forward stoop 
of the body, while the head hangs backward 
or on one shoulder. This attitude combined 
with the grunting respiration or expiratory 
sigh caused by the effort to restrain the motion 
of the ribs on the weakened spine, are often 
early and constant symptoms. 
In disease of a lower point, as the lumbar 
region is approached, the attitude may change 
to one of erectness and rigidity, there is an 
elevation of the shoulders, and a balancing 
attitude of the arms. It is in disease of this 
region that the sudden cry of pain is noticed 
when the child is lifted, that it instinctively 
seeks support by clinging to the mother’s dress 
or other objects, or sits supporting the body 
with the hands on the seat of the chair. In 
older and more robust children, the symp- 
toms of weakness and pain may be much less marked, and the slowly increasing deformity 
is thought to be round shoulders, or a lateral 
deviation thought to be simple rotary lateral 
curvature. The most characteristic of all the 
rational symptoms of Pott’s disease, is pain 
reflected along the intercostal nerves to the 
sides and front of the body; it may bp an 
occasional complaint, it may be almost con- 
stant, emphasized by the so called night cry. 
In the upper dorsal region the pain is referred 
to the chest, and is often accompanied by an 
irritating cough, or by irregularity in the 
rythm of respiration. At a lower region the 
pain is referred to the abdomen. 
Thus patients may be treated for asthma, 
bronchitis or bowel disturbances long after the 
deformity of the spine is apparent. As such 
mistakes imply a neglect of proper examina- 
tion, they need only be mentioned. 
Marked weakness, and the so called loss of walk 
are symptoms which cannot be overlooked, 
and seem to be considered as especially signifi- 
cant of Pott’s disease; Thus children who remain 
weak after contagious or other exhausting 
disease, or as the effect of marasmus or rachitis 
or cerebral deficiency, are brought for braces 
on the supposition that they are suffering from 
spinal disease. It is only necessary to mention 
the fact, that simple weakness may cause a gen- 
eral postural curve of the spine, which is more 
or less rigid according to the time it has per- 
sisted. The absence of pain, the appearance of 
the patient, the history of the case, will readily 
exclude all these affections except rachitis, in which pain may be a prominent symptom com- 
bined with a rigid curvature. The examination, 
however, will show the existence of general dis- 
ease, in the enlarged epiphyses, and beaded ribs. 
The curvature is seen to be postural by observing 
the child as it sits in its habitual attitude, or as it 
is held on the mother's arm. The curvature is 
rounded, and if the child is placed on its face the 
legs raised and gentle massage applied to the pro- 
jection, it may be partially or entirely effaced; 
such would not be the case in a corresponding 
deformity the result of Pott’s disease. 
12 
It is in disease of the upper dorsal region 
that one of the complications of Pott’s disease 
more often occurs, paralysis—from implication 
of the spinal cord. This may be a relatively 
early symptom; it may precede deformity, but is 
always accompanied by pain and local rigidity. 
The character of the paralysis is spastic para- 
plegia, that is, increased reflexes or stiffness 
of the limbs—it could not therefore be con- 
founded with the other form of paralysis, most 
often seen in children, resulting from anterior - 
polio-myelitis, which is sudden in onset often 
confined to one limb—a flaccid paralysis with 
loss of reflexes and not accompanied by the 
symptoms of Pott’s disease: The spastic para- 
plegia of cerebral origin, although similar in 
character, as a rule implies semi-idiocy, and 
need only be mentioned to exclude it. 
There then remains only the deformity, 
which in very mild cases, may be mistaken for 
round shoulders, but in Pott’s disease in ad- 
dition, there is always more rigidity, more pain and more weakness. 
The same distinction applies to the differen- 
tiation from rotary lateral curvature. A slight 
deviation of the spine may be an early symp- 
tom of Pott’s disease of the middle region, but 
it is a deformity always accompanied and over- 
shadowed by the symptoms of pain and rigidity. 
The simple postural rotation is not accom- 
panied by such symptoms; it is for the relief 
of deformity that patients are brought, not for 
the relief of pain and weakness. 
As a patient suffering from acute empyema, 
was recently referred for treatment on the sup- 
position that the pain and deformity were the 
result of Pott’s disease, it may be mentioned 
that acute or chronic affections of the thoracic 
viscera, may distort the spine. 
Disease of the lower dorsal and lumbar 
region is early shown in the peculiar attitude 
of over erectness or exaggerated lordosis. As 
this attitude is only simulated by such rare 
affections as congenital dislocation of the hips, 
pseudo hypertrophic muscular paralysis or by 
paralysis of the spinal or abdominal muscles 
diagnosis sometimes can be made at a glance. 
As this region is the elastic portion of the 
spine, constantly changing its shape in bend- 
ing, walking, or in the sitting posture, the 
other symptoms of Pott’s disease are very 
evident in the rigidity, the awkwardness and 
peculiar waddling gait. The patient is stiff and 
slow in changing a position once assumed, and 
may be even unable to turn in bed withour as- 
sistance. Examination of the part shows the 
rigidity, the limitation of special motion by 
muscular spasm, the inability to stoop, and the 
evident weakness. The secondary symptoms, or complications, 
are those which cause the difficulty in diag- 
nosis—of these, the most important is abcess, 
which involving the psoas and iliacus muscles, 
flexes the thigh making extension painful—; 
this complication immediately causes a change 
in attitude, there is a forward stoop and well 
marked limp. This is so frequent as to be one 
of the characteristic attitudes of disease in this 
region. In this stage cases are almost always 
referred for hip disease. 
Differential diagnosis may be perhaps best 
illustrated, by certain typical cases of disease 
in this region. In order of frequency they are: 
ist. The uncomplicated cases—characterised 
by the diagnostic attitude, of over-erectness, the 
rigidity, the inability to bend or the evident 
weakness in attempting to rise again— the pain 
referred to the inguinal region or buttocks. 
2nd. The cases mistaken for hip-disease be- 
cause of the limp—ordinarily the diagnosis is 
simple. The limp of hip-disease is a limp 
caused by pain, weakness or contraction of 
muscles; movements of the hip are limited in 
all directions, and when the limit is passed, 
pain and muscular spasm are evident. The 
limp of psoas contraction is a limp caused 
by shortening, the leg is drawn towards the 
body, and the body towards the leg, an at- 
titude not usually seen in hip-disease. Motion 
is limited only in one direction, that opposed 
by the contracted muscles. The rigidity of 
the spine, or deformity at the seat of disease, 
and a tumor in the pelvic fossa, will usually 
make the cause of the symptoms clear. 
3rd. A type seen in young infants—who cry 
when lifted, or when the diapers are changed, 
who scream when undressed, and contract 
every muscle of the body when manipulated. 
The symptoms usually may be localized in the 
lower region of the body, but it is sometimes 
14 impossible at the first examination to decide 
whether the lumbar spasm is due to hip-disease, 
or the contraction of the thigh to spinal 
disease. In such cases the application of a 
plaster spica bandage, to rest both hip and 
spine, may make the diagnosis clear at the 
next examination. 
4th. Patients, often accompanied by ignorant 
relatives bent over, supporting the body with 
the hands on the knees, or unable to stand 
showing evidence of pain and exhaustion, who 
resist examination, who scream when the leg is 
moved, or the abdomen palpated. When a his- 
tory is obtained, it wi:l be usually found that 
the onset of the affection was sudden, accom- 
panied by pain and fever and that the atti- 
tude was assumed from the beginning. 
Such symptoms are usually those of acute 
intra-abdominal inflamation, such as peri- 
typhlitis or perinephritis. The latter affection 
is sometimes much less acute in its onset, and 
psoas contraction and rigidity of the back are 
the prominent symptoms. The psoas contraction 
of Pott’s disease is, however, always preceded 
by certain symptoms, peculiar to the disease, 
while the distortion of the spine from these 
other causes, is sudden in its onset, and ac- 
companied by the symptoms more or less char- 
acteristic of the special organ involved. 
sth. Cases of disease of the lowest region of 
the spine, accompanied by symptoms pointing 
to the hip, pain reflected to the thigh: The 
child limps, or refuses to support the weight 
on the leg, or contracts the muscles when the 
limb is moved. If, however, the pelvis is 
steadied the hip may be moved without pain. 
There is often the peculiar lordosis, and a 
lateral deviation of the spine, but rigidity is 
much less marked, and the patients may be 
able to bend without appreciable difficulty. 
In such cases the pain reflected down the leg is mistaken for sciatica, but pain is usually 
in both legs, and is relieved often completely 
by rest on the back, thus differing from sciatica. 
Again, sciatica is very rare in children, as is 
the chronic lumbago, the strains of the lumbar 
region or rheumatic deformity of the spine. 
Nor is it necessary to consider displacements 
of the uterus, or inflamation of its appendages, 
which in the adult, may cause symptoms simu- 
lating somewhat those of Pott’s disease. 
As a sequel of infectious diseases, the joints 
of the spine are sometimes affected, the symp- 
toms being explained by the preceding history. 
The so called neurotic spine, rarely an affec- 
tion of childhood, is characterised by the ex- 
aggeration of the symptoms of local tender- 
ness, and the irregularity and want of corre- 
spondence of groups of symptoms, which 
characterise local Pott’s disease. 
It only remains to call your attention to the 
fact, that Pott’s disease, does not confer an 
immunity from other affections, and that the 
plaster jacket, or brace, may cover a variety 
of diseases, which are sometimes overlooked 
and untreated, or thought to be complications 
of a disease, of which they are independent, 
I cannot hope to have done more than to 
indicate some of the affections, for which Pott’s 
disease may be mistaken, but I hope that at- 
tention has been called to the principle of 
diagnosis by exclusion, resting on careful 
history, grouping of symptoms, general ob- 
servation of the attitude and appearance of 
the patient; finally on the examination of the 
special region to which these symptoms point. 
In other words, on the logical explanation of 
the symptom complex of Pott’s disease, which 
varies with the character and duration of the 
disease, with the function and anatomical re- 
lations of the part involved, and with the age, 
inheritance, and surroundings of the patient.