THE NECESSITY OF THOR- 
OUGH EXAMINATION IN 
SUSPECTED POTT'S 
DISEASE. 
BY REGINALD H. SAYRE, M. D., NEW YORK. 
Read before the Orthopedic Section of the N. Y. 
Academy of Medicine. 
REPRINT FROM THE 
New England Medical Monthly 
For April, 1893. 
Danbury, Conn., 
THE DANBURY MEDICAL PRINTING COMPANY. THE NECESSITY OF THOR- 
OUGH EXAMINATION IN 
SUSPECTED POTT'S 
DISEASE. 
REGINALD H. SAYRE, M. D., NEW YORK. 
Read before the Orthopedic Section of the N. Y. 
Academy of Medicine. 
REPRINT FROM THE 
New England Medical Monthly 
For April, 1893. 
Danbury, Conn., 
THE DANBURY MEDICAL PRINTING COMPANY. 
1893. THE NECESSITY OF THOR- 
OUGH EXAMINATION IN 
SUSPECTED POTT'S 
DISEASE. 
REGINALD H. SAYRE, M. D., NEW YORK. 
Read before the Orthopedic Section'of the N. Y. 
Academy of Medicine. 
IN the old "Daniel Webster"primer 
there is a picture of two women, 
•one erect, stout and hearty; the other 
bent forward, flat-chested, emaciated 
and feeble, the very counterpart of 
hundreds of underfed, over-worked 
farmers' wives throughout the coun- 
try. These pictures served to point 
the moral that attention must be paid 
to sitting upright in school if the pu- 
pil wished to look like the buxom 
dame instead of her consumptive 
companion. 
The look and attitude of the cadav- 
erous woman were exactly those 
which I have often seen in women 
suffering from various uterine dis- 
orders. There is a careful tread, a 4 
position that suggests a constant 
colic, a general uneasy look about 
the whole figure, and a stoop that re- 
sembles rather closely that of com- 
mencing Pott's disease in the mid- 
dorsal region, and when this is ac- 
companied, as it is at times, by a 
spasm of certain fibers of the abdomi- 
nal muscles, giving the appearance 
of a girdle tied around the waist, and 
also spasm of the erecta spinae, the 
similarity to Pott's disease becomes 
marked enough to deceive even those 
of experience; and as I have happened 
to see several such cases, I have 
thought the matter worth bringing 
before you this evening. 
Case I.-In June, 1888, Miss B., 
aged 26, consulted me for supposed 
disease in the spine. She was a tall, 
fairly well nourished girl, and gave 
a history of having fallen twelve 
years before, and of having pain and 
inability to walk gradually increas- 
ing since that time. At the time 
that she first consulted me her spine 5 
was markedly curved,but not with the 
usual- sharp projection of spinal ca- 
ries. She walked with great difficulty, 
complained of pain on the slightest 
jar, was unable to step without great 
pain, could not lie down or arise with- 
out aid, and when lying down was 
unable to turn over without assistance 
on account of pain. On rising from 
a chair she was obliged to put her 
hands on her knees to aid her. The 
left lower extremity was much 
smaller than the right, and sensation 
in it was markedly diminished. At 
the time of visiting me she was wear- 
ing a plaster jacket, which had been 
applied by an eminent surgeon in 
this city. After careful examination 
of the case I came to the conclusion 
that, although there was marked pain 
around the abdomen, pains down the 
legs, very great sensitiveness on the 
slightest movement, and marked 
rigidity of the spinal muscles, her 
symptoms were more attributable to 
a uterine disturbance than to ostitis 6 
of the vertebrae, and requested va- 
ginal examination. I found the 
uterus markedly retro-flexed and 
firmly bound down in the pelvis, and 
told her that when her uterus was 
replaced and held in its normal po- 
sition, her symptoms would subside, 
and that I did not believe there was 
any disease of the vertebrae. It was 
not until some time after this that I 
learned from the patient her history, 
which she was very unwilling to give 
me at the beginning of the examina- 
tion. About the age of fourteen she 
had a fall, striking her right hip on 
the curbstone. She did not feel any 
effects for a few days, but afterward 
began to have pain on certain move- 
ments of the limb and body, when it 
seemed to "catch her," as she ex- 
pressed it, and caused her intense 
pain. Several physicians examined 
her thinking that she had displaced 
the joint, but found that it was sound. 
After about a year her feet began to 
swell, and the soles, particularly the 7 
heels, became sore, swollen and pain- 
ful. Then the left hip became af- 
fected as the right had been, and she 
was said to have sciatica, and for a 
number of years was obliged to use 
hypodermic injections of morphine 
to quiet the pain. The pain was 
worse while lying down, and often 
after going to bed she would be 
obliged to get up, and stand in a cer- 
tain position for hours. 
Five years before the patient con- 
sulted me, her back began to ache. 
Three months after the onset of this 
symptom she went to Philadelphia 
and was examined by a very promi- 
nent physician, who pronounced it 
disease of the spine and ordered a 
leather jacket. Up to this time she 
had always been able to go about, 
and even walked quite well, but 
after the application of the jacket 
she became, as she describes it, per- 
fectly "helpless," her arms becom- 
ing so weak that she could hardly 
lift them. Her physician then re- 8 
moved the jacket and advised her to 
remain in bed until the spine had 
become consolidated. This advice 
she did not follow, because she suf- 
fered so much pain while lying down 
that she was unable to do so. She 
then visited New York, and while 
here was seen by a professor m one 
of the colleges, who pronounced her 
trouble Pott's disease, and called 
another gentleman in consultation, 
who agreed with him in diagnosis, 
and said that unless she would wear 
a support she would become hump- 
backed. He first applied a brace of 
his own, and finding this gave no re- 
lief, applied a Taylor brace. The 
latter failing to give comfort, he 
tried a plaster jacket, which she was 
enabled to "endure" for some three 
years. About this time the left 
lower extremity began to diminish 
in size. This history I did not learn 
from the patient until a number of 
months after first seeing her, her 
answers to my inquiries at that time 9 
being most vague and unsatisfac- 
tory. Having discovered the retro- 
flection of the uterus, I endeavored 
to replace the uterus and hold it in 
position by boro glyceride tampons, 
with some slight improvement. I 
then advised the patient to consult 
Dr. Lusk as to the advisability of 
performing "Alexander's operation" 
of shortening the round ligaments. 
This operation was performed by 
Dr. Lusk and held the uterus in 
very satisfactory position, although 
there was some doubt at the time 
whether it might not be necessary 
to stitch the uterus fast to the ante- 
rior abdominal walls. The old pain 
in the back and legs began to dimin- 
ish immediately after the operation, 
but the patient was restless and in- 
sisted upon going around too soon, 
and part of the old pain returned. 
As this pain persisted to some de- 
gree after the application of a suita- 
ble pessary, I attributed it to neu- 
ralgia of the sacral plexus and ap- 10 
plied intra-pelvic galvanism with re- 
lief. I also directed the patient to 
take regular and systematic gymnas- 
tic exercise and massage to 
straighten her curved spine and re- 
lax the contracted muscles of the 
entire anterior part of her trunk. 
She speedily became more upright 
in carriage and has had steady dimi- 
nution of her aches and pains. She 
writes me under date of December 
20, 1890: 
"Since my operation I have never 
once felt the slightest return of 
those attacks in my hip I suffered 
with so long. I am quite straight 
and can keep myself up better. My 
health is excellent, and it would be 
impossible for me to tell you how 
well I am. I have neither ache or 
pain. All troubles have vanished 
entirely. My muscular strength is 
much improved also." 
Case II.-Miss S., aged 16, sent 
to me at the Out Door Department 
of Bellevue Hospital, by Dr. C. S. 11 
Allen, who had treated her for 
chronic laryngitis for some time. 
Patient was pale and anaemic though 
rather stout and pasty looking; had 
frequent cough and a husky voice, a 
marked stoop and a cautious tread; 
said it hurt her to ride in street cars; 
had pain in her back which some- 
times ran into her legs; at times had 
pain in lower part of abdomen, 
which was much distended with gas. 
A rather sharp knuckle was to be 
seen at the first and second lumbar 
vertebrae, so prominent in fact that 
her corsets had rubbed a discolored 
callous spot here. Menstruation 
had been absent a number of months. 
Had worn a plaster of Paris jacket 
about a year previous, with partial 
relief of her pain. 
Although I could get no signs ex- 
cept those of bronchitis from exami- 
nation of the lungs, I was at first in- 
clined to treat the case as one of 
vertebral tuberculosis, the cough, 
laryngitis, and absence of menstrua- 12 
tion helping to lead me to this con- 
clusion. I found that by manipula- 
tion I could remove the knuckle ab- 
solutely, and concluded it was due to 
spasm of the spinal muscles and not 
to erosion of the anterior part of the 
bodies of the vertebrse. The clinical 
appearance of the case did not satis- 
fy this diagnosis completely, but the 
fact that she said she had worn a 
plaster of Paris jacket before with 
benefit decided me to treat her as a 
case of Pott's disease, which I did. 
After watching the case for a few 
weeks, I concluded I was mistaken 
in my diagnosis, or at any rate that 
there was trouble in the pelvis as 
well as the back. 
Vaginal examination showed small 
pin hole, os and anti-flexed uterus 
with very tender ovaries on both 
sides. I referred patient to another 
gentleman for relief of these condi- 
tions, but she did not consult him. 
Tonics, cod liver oil, passing uter- 
ine sound, faradism in the back and 13 
abdomen improved the patient's con- 
dition from time to time. She has 
at times lost her cough and hoarse- 
ness, has fewer pains, and can walk 
further and better. Menstruation 
has returned and is growing less and 
less painful. I have seen her occa- 
sionally during the past two years, 
and the back unsupported has made 
no progress towards developing a 
hump. Her supposed Pott's disease 
has grown better without any treat- 
ment directed to it, and she is be- 
coming straighter and stronger. 
Case III.-Miss I. consulted me on 
supposed disease of the back in 1888 
in a London hospital. A gentleman 
of large experience had seen her in 
consultation with her family physi- 
cian, and had ordered an iron brace 
which she wore without benefit for a 
number of months. After this a 
gentleman in Paris had ordered a 
kind of orthopedic corset. She felt 
tired; could not ride in cars; had 
aches in abdomen, and down her 14 
legs, imagined there was a knuckle 
in the mid-dorsal region. Every 
now and then would have cramp like 
pains in abdomen which were so 
severe she could not stand upright. 
Examination revealed nothing the 
matter with the spine, but a vaginal 
exploration showed a retroflexed 
uterus with a prolapsed and enlarged 
ovary. With the uterus replaced 
and held in position with post-gly- 
ceride tampons the pains and aches 
disappeared. 
Case IV.-Miss H. consulted me 
in 1888 for a supposed disease of her 
spine. She said that her chest had 
become very flat and her back very 
round; that she was incapable of 
making any exertion without subse- 
quent aches and pains. Had a very 
tender spot between the shoulder 
blades where the spine had become 
prominent. Had for a number of 
months been under the charge of a 
prominent French orthopedist who 
had referred her to my father. While 15 
under treatment there she had worn 
a curious kind of spinal corset. 
On examination I could not find 
anything the matter with the spinal 
column except a marked endosis and 
an exaggerated dorsal curvature 
with a flattening of the anterior 
thoracic walls, the counterpart of the 
woman in the "Daniel Webster" 
primer. 
Vaginal examination revealed a 
retroverted uterus and a prolapsed 
ovary, and at the present time, when 
her pelvic viscera are in position,she 
feels well; when they are out of 
place, she is sick. The supposed 
Pott's disease has not progressed. 
It may be said that these cases 
were too plain to be mistaken, and I 
would concur in this if it were not 
for the fact that they were all treat- 
ed by men of experience for Pott's 
disease. In one of these cases I was 
myself in doubt as to the diagnosis 
for some time, and I feel sure that 
the conditions present in the first 16 
case were such as might mislead any 
man who was not on his guard. 
I often see cases that have been 
treated for rheumatism, neuralgia or 
indigestion where there is present a 
disease of the vertebrae, and it is 
rare to meet with cases such as I 
have described this evening. Still I 
wish to call attention to the fact 
that there are reflex pains of uterine 
and ovarian origin which may at 
times simulate Pott's disease so 
closely as to be taken for it by men 
of experience.