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This case takes us to the mid 18th century to jolly ol’ England where a nervous 37 year old male awaits in the examination room to discuss what he feels is something of an embarrassing problem given the sensibilities of the time. He’s unkempt and filthy. He tells the surgeon that he’s noted a lesion on his “privvies” that started as a small bump or wart, perhaps, but now has grown into a 50-pence sized ulceration on the bottom of his scrotum, also medically known as the yambag. Anything you’d like to know about him at this point? The exam is concerning. There is an ulceration extending from the lower yambag with raised edges. No purulence, no infectious smell, mind you. You can’t see into the scrotum but the top tissue layers and underlying fascia seem to be visible. What would you want to do in modern times for this–let’s say in the ER. What about in the 1750’s? The surgeon treating this man will become known for associating this particular disease with the man’s profession. I’d wager that anyone having completed a stint in contemporary medical school will be aware of this surgeon’s name because it’s pasted all over the medical textbooks. This guy collects eponyms like I collect wrestling posters on my walls–fun fact, I have more wrestling pics on the walls of my office than degrees, I realized. Here’s the thing about this case. I didn’t write it quite accurately. The 37 year old patient I’ve made up is fictional. Though he is the average age of diagnosis of this condition at the time, the sad truth is it would be more likely that the patient we’re talking about with this life threatening disease would have been more likely to be a young boy, between the ages of 8 and young teens, likely. He’s filthy because it’s his job to be and that job is very likely to shorten his life, if not by this disease, then by another occupational or health-related hazard. Do you know what we’re talking about today? This is the story of the Chimney Sweep’s Carcinoma, diagnosed by the famous English surgeon, Dr. Percival Pott. This is a tale of occupational medicine at its earliest stages. The association of this cancer with the job of cleaning out chimneys was not accidental. The discovery of this led to sweeping (pun!) changes in social expectations for children and the labor market. Before we get to ol’ Percival Pott himself, let’s talk about what this patient–along with way too many children–would be diagnosed with. Chimney sweep’s carcinoma is really squamous cell carcinoma of the skin of the scrotum. Squamous cell carcinoma is a cancer that arises from the cells of the same name which can be found in your skin or the linings of one’s hollow organs, respiratory and digestive tube structures especially. As with any cancer, the basic problem is that a cell undergoes some sort of genetic change or damage and begins to grow and replicate without stopping. This results in a tumor or growth in many cases, but, with Squamous Cell carcinoma, the initial findings can appear to be an ulcer or wound which does not heal and slowly grows and expands, destroying more tissue around it. This type of cancer is nowadays rare in the “privies” so-to-speak, but very commonly found on skin. This disease would start insidiously for the unfortunate chimney sweeps, often as a mildly irritated sore or pimple-like bump. Might get some bleeding from scratching at it. It would start on the scrotum and, if not treated, the cancer would spread to the other areas of the genitals and, as it destroyed more tissue from the scrotum, would work its way into the testicle and on into the lymph nodes and structures inside the abdomen. Even in the modern era, from what I found, if you can resect–surgically remove–the cancer before it gets into the lymph nodes of the groin, chances are much better. We do chemo and radiation for this as well nowadays. If it makes its way into the inguinal nodes–those in the crease of your hip–there is a 25% 5 year survival rate. If it makes its way into the iliac nodes (deep within the pelvis) there is no survival reported beyond that time. That’s grim. But why were children in Dr. Pott’s heyday being diagnosed with this awful condition so often? Well, it was the beginning of the industrial revolution so that means progress in so many ways–except for those that involve treating children like human beings. You see, from the ages of 4 to prepuberty, the problem was that young boys were just too good at fitting in super dangerous small chimneys where they could do the insanely unsafe job of sweeping a flue for the betterment of society from the 1700’s to the 1800’s. Let’s talk about chimneys. A housing tax in 17th century England had limited the number of fireplaces allowed per house. This meant that houses and buildings were built with a labyrinth of chimneys and flues to get the smoke and soot from one’s fire up and out the top of everyone’s houses to create that soupy fog of carcinogens a person associates with images of London and most other metropolitan centers of the time. Seriously, smog was like a permanent season according to some accounts. Chimneys can collect soot and soot can be flammable if it builds up. Worse yet, if a chimney was plugged, one can imagine how bad that would be inside the house. This meant somehow, someone had to crawl up into the chimney to clean out the soot. That someone had to fit into places as narrow as 9”x9” in some flues so the natural conclusion was to “hire” young boys (again ages 5-11) to strip naked and shimmy their way into the twists and turns of the chimney. You might think the aristocracy of the day gladly offered up one or two of their extraneous progeny for the job, but you might be astonished to hear it was not their kids doing this work. Nope, it was often orphans, street kids, or children from poor families. They were paid badly and took so many risks. Boys might get caught in narrowed spaces and many died of suffocation. Sometimes, the chimneys were still hot or literally on fire from the prior uses. The soot would irritate their eyes to the point that some kids went blind from constant rubbing and scarring of the corneas. The soot also contributed to lung disease. The best case scenario for these kids was surviving to become a master chimney sweep, but that meant making money by exploiting the next generation of unfortunate souls. It was very unlikely for a chimney sweep to live to adulthood, let alone old age. When children would die on the job, the coroners of the time would classify these deaths as “accidental” as opposed to “occupational murder” which is what I’d call it. Speaking of soot–it’s bad. I mentioned the chimney sweep children were naked. This is because it made it easier to squeeze through the nooks and crannies of the passages but, believe it or not, this was part of the problem related to the cancer we are discussing. Soot would cover their bodies and especially collect in the area of the scrotum. Soot contains numerous carcinogenic substances and, with its prolonged contact with the skin, accompanied by the accepted unhygienic conditions of being a poor person in this time in the streets of London, there was high risk of developing cancer of the skin of the scrotum. Let’s return to our friend, the whimsically named Dr. Percival Pott, who lived between 1714 and 1788. He’s an English surgeon, credited with being the first to associate cancer with an occupation related environmental substance. He’s considered to be an occupational health pioneer. Dr. Pott did his surgical apprenticeship at St. Bartholomew’s Hospital over 7 years for a cost of 210 pounds (for all of it). In today’s money that is about $75k USD. He finished that apprenticeship and was hired by the Barbers’ Company, then being licensed to practice surgery. If it seems weird that barbers are licensing surgeons, I’ll refer you to our prior episode #40 to learn more about that whole matter. In 1744 he became an assistant surgeon at St. Bart’s and he went on to be a full fledged surgeon there from 1749 - 1787, the year before his death. I’m pretty sure his career at that one hospital was longer than the average lifespan of a chimney sweep, I’m sad to say. Interestingly, Dr. Pott was not quite the stereotypical surgeon one might expect of this time. He was known as a conservative-minded surgeon who was not quick to rush into a procedure. He was not a fan of “heroic medicine” which can generally refer to the gung-ho, “do something” attitude of the time. Bleed the patient, put leeches on them, make them vomit out the bad bile and amputate, amputate, amputate the problems away! Not for Dr. Pott. Here’s an illustrative example. In 1756, well into his surgical career, Pott was thrown from his horse, landing into the muck of the street, sustaining an open fracture to his tibia. That’s the type of break in the bone where the bone bits peek-a-boo through the skin to see what the outside world is all about. That’s a bad thing because the muck of the streets at this time was chock full of mud and horse manure rich with bacteria which, I should add, Dr. Pott and his colleagues of the time, didn’t even know caused disease. Bacteria and bones don’t mix particularly well and open fractures–especially in the age well before antibiotics, were frequently fatal infections waiting to happen. Pott was able to pay one of his servants to go to a nearby jobsite and buy a door. The door was used as a stretcher to return Dr. Pott home to await the opinions of his surgical colleagues of the time. To nobody’s surprise they voted to amputate his leg, and Dr. Pott was probably all like, “that sounds super fun but I’d rather not,” and he opted to conservatively treat the wound and fracture. This means they cleaned the hell out of it, splinted it, and, in time, Pott avoided dying of both 18th century surgery and infection, going on to a full recovery. So it wasn’t without reservation that he suggested surgery for patients and would be sure it was the only chance. In cases of scrotal cancer, the chimney sweep disease, he was right. If the cancer could be resected before it went to lymph nodes, patients would do well enough. If not, these poor souls would have an untimely end. Pott describes the circumstances of the Chimney Sweepers Carcinoma in, dare I say, empathetic terms especially given the time:: “The fate of these people seems peculiarly hard … they are treated with great brutality … they are thrust up narrow and sometimes hot chimneys [sic], where they are bruised, burned and almost suffocated; and when they get to puberty they become … liable to a most noisome, painful and fatal disease.” That’s downright touchy-feely language given the time. Pott did care about these patients more than most. The association between this cancer, soot, and the awful life of a young chimney sweep did eventually lead to changes, albeit way slower than you’d like to imagine. Pott’s work was foundational in changing the social consideration for this job. It took an absurd amount of legislative baby steps to finally stop legally stuffing orphans into chimneys. The first was the Chimney Sweepers Act in 1788 (the year Pott died) which aimed to “protect” child workers. It did this by ensuring the minimum working age was raised to a far more respectable eight years old. In 1803, societies were formed to bring awareness to this problem. Succinct names for things had not been invented yet, so the English of the time came up with the following organization: The Society for Superseding the Necessity of Climbing Boys by Encouraging a New Method of Sweeping Chimeys and for Improving the Condition of Children and Others Employed by Chimney Sweepers. (which could go by the unpronounceable acronym, the SSNCBENMSCICCOECS). Acronyms were probably new then, too? In 1834, British parliament passed the “Act for the Better Regulation of Chimney Sweepers and their Apprentices” as well as the “Act for Safer Construction of Chimneys and Flues”. This raised the minimum working age to a double digit, ten years old! In 1840, legislators were all like, “FINE” and raised the working age to 16 years old with the kind recommendation that nobody under 21 should work in the chimney sweeping industry. As almost rational as this sounds, apparently nobody bothered to enforce all of these laws to this point. A commission at this time actually found that all of these bills and acts and whatnot somehow contributed to an INCREASE in child labor so that wasn’t good. Finally in 1875, almost 100 years post Pott’s death, an Act of Parliament forbade children of any sort of working in the chimney sweeping industry. What do you know? The rates of scrotal carcinoma dropped off precipitously. In the 1940’s, St. Bart’s, Pott’s old hospital, reported one single case in 5000 new cancers diagnosed. It turns out that preventing children from laboring in an actual slurry of carcinogens was a good thing. You might wonder, as I did, why it took so long to see the light on this one? Well, have you considered that some people were Pro-Dangerous-Child-Labor at the time? Who was in that camp? More people than there should have been. Insurance companies of the time defended the child labor practices because they did such a good job of sacrificing themselves for cleaner chimneys. There were some mechanical devices suggested to do the job instead of kids, but the companies felt more fires resulted in the chimneys NOT cleaned by children so this was a hit to their bottom line. And have you considered the problematic but lucrative partnerships between the orphanages, parishes, and master chimney sweeps of the time? Master sweeps were paid to take on “local strays” and give them gainful employment and often sourced their employees from orphanages and parishes. I can only imagine the world of horrors that unfolded in those relationships. Lastly, there was some description of public perception that, while shortening the life spans of many of the youngest and most vulnerable members of society was regrettable, it had to be weighed against the dangers to society of having chimneys catch fire more often. I can almost respect the cold logic of that position, but I have to say I’m firmly in the camp of looking for solutions that don’t involve increasing child mortality, I don’t know about you guys. Finally, I wanted to wrap up with a brief tour of Pott’s other contributions to medicine. I mentioned that he has many, many things named after him. I wonder if you guys remember some of them? Pott’s eponym collection Pott’s Spine (aka Pott’s disease) - Tuberculosis infection of the spine and all the associated complications such as “cold abscesses” Pott’s Fracture - Ankle fracture of distal fibula that allows subluxation of the talus laterally since medial ligaments are wrecked. We’ve probably all treated this. He’s considered to be a father of orthopedics as well. Pott’s Gangrene - Basically gangrene caused chronically by end artery disease of the legs. Pott’s Puffy Tumor - Not a tumor but rather the word for swelling. Subperiosteal abscess due to frontal skull osteomyelitis. Sinusitis complication. Forehead swelling, fever, headaches, nasal discharge, possible increased ICP. Apparently wrestling is listed as a risk factor due to punches to the head? Sources: -https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1037746/?page=1 -http://www.whonamedit.com/doctor.cfm/1103.html -https://en.wikipedia.org/wiki/Percivall_Pott -https://en.wikipedia.org/wiki/Worshipful_Company_of_Barbers -https://en.wikipedia.org/wiki/Chimney_sweeps%27_carcinoma -https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1008067/figure/F2/ (Chimney Sweep Pic) -https://www.historic-uk.com/CultureUK/History-Boy-Chimney-Sweep/ -https://www.ncbi.nlm.nih.gov/books/NBK538331/ (Pott’s Disease) -https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5531910/ (Pott’s Fracture) -https://jdc.jefferson.edu/cgi/viewcontent.cgi?article=1008&context=dacosta_modernsurgery (Pott’s gangrene) -https://www.ncbi.nlm.nih.gov/books/NBK560789/ (Pott’s Puffy Tumor) Dr. Max Doctor with a mustache
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