Setting the record straight: The real history of Poland’s syndrome

Photo 1: Alfred Poland, Courtesy of the Wellcome Library, London.

Photo 1: Alfred Poland, Courtesy of the Wellcome Library, London.

Few, however, may realize that although Alfred Poland, MD, was an accomplished surgeon, he may not have been the first to describe this anomaly.

Alfred Poland (1822–1872)

Dr. Poland was born in London, England, and as a medical student served as an apprentice in anatomy to Charles Aston Key, MD, at the prestigious Guy’s Hospital in London (see photo 1). He became a demonstrator in anatomy, a fellow of the Royal College of Surgeons, and by 1861 was a designated surgeon at Guy’s Hospital.1

From 1848 to 1861, Dr. Poland served as surgeon to the Royal Ophthalmic Hospital but relinquished this role due to a debilitating infection he contracted while on the ward. He continued at Guy’s Hospital and was considered a popular teacher, good surgeon, and expert orator. His dissertation titled “The Origin, Connection, and Distribution of the Nerves of the Human Eye and its Appendages” won a Triennial prize. His Jacksonian essay titled “Gunshot Wounds and their Treatment” is still retained in the Royal College of Surgeons library. In 1853, Dr. Poland won the Fothergill gold medal for his essay titled Injuries and Wounds of the Abdomen.1

Plagued with poor health and a violent cough, he continued to see patients at Guy’s Hospital until four days before his relatively early death from consumption in 1872.

Photo 2: Tilston’s illustration of Poland’s 1841 dissection.

Photo 2: Tilston’s illustration of Poland’s 1841 dissection.

Poland’s syndrome

As an apprentice in 1841, Dr. Poland dissected a cadaver unlike any he had ever seen. The body was that of a 27-year-old convict named George Elt who was reported to have had difficulty drawing his left arm across his chest. Dr. Poland’s findings would offer an explanation for this condition, and inspire him to ask a friend, Mr. Tilston, to sketch the cadaver’s anatomy (see photo 2).

Dr. Poland’s brief report of this dissection was printed in Guy’s Hospital Reports under the title “Deficiency of the Pectoral Muscles.”2 References to this seminal report are often included in manuscripts regarding Poland’s syndrome. And though this paper generated the eponym, the history of the syndrome actually begins prior to Dr. Poland’s involvement. When he reported his “unusually satisfactory dissection,” as he described it in 1841, there was no syndrome or eponym, only isolated case reports that were largely unknown. Although other reports of similar deformities preceded Dr. Poland’s, these accounts described only the chest wall deficiency without concomitant hand abnormality.3-5 R. Froriep’s account of a woman with unilateral amastia and absence of the sternocostal portion of the pectoralis major muscle illustrates this type of article (see photo 3).5

Photo 3: Illustrations in Friorep’s article of 1839 illustrating the severe form of Poland’s syndrome.

Photo 3: Illustrations in Friorep’s article of 1839 illustrating the severe form of Poland’s syndrome.

Discussion

The value and celebrity accorded to Dr. Poland lies in his meticulous attention to detail, which serves as an example to surgeons and anatomists. Aside from his clear description of the anatomy, he was the first to associate the absence of the sternocostal head of the pectoralis major muscle with an ipsilateral upper extremity deficiency. This association is not as uncommon as it was initially thought to be.

Reviewing Dr. Poland’s description, Mr. Tilston’s illustration, and the appearance of Mr. Elt’s left hand (see photo 4), it is obvious that Mr. Elt had the severe form of the chest wall anomaly as well as brachysyndactyly. This combination still applies to the clinical findings of patients with Poland syndrome and is exactly as the physician described it 171 years ago.6,7

Photo 4. Dr. Seyfer holds the glass-encased specimen of George Elt’s left hand from 1841 at the Gordon Museum, the medical museum of Guy’s Hospital. Keeper of the Museum is William G.J. Edwards, who assisted in locating the specimen.

For more than 100 years following Dr. Poland’s description, the condition existed without an eponym, although other authors seemed to recognize the unusual anatomy of Poland syndrome, which was always unilateral.8,9 Then, in 1962, Patrick Clarkson, MD, a plastic and hand surgeon at Guy’s Hospital, described three patients with breast hypoplasia and syndactyly.10 According to Dr. Clarkson’s son, the physician rediscovered Dr. Poland’s earlier article and gave the syndrome its eponym, Poland’s syndactyly, and published his article in the same journal as Dr. Poland’s original article.11 Five years later, Baudinne and colleagues first referred to Poland’s syndactyly as Poland’s syndrome—a trend that continues to this day.7,12 Sporadic reports have continued to focus on chest wall defects, hand deformities, and other variations, and some have classified the problems according to the degree of deformity in order to guide surgical repairs.6,7,13-16

Interestingly, Mark Ravitch, MD, FACS, a pediatric surgeon, was critical of attributing the syndrome to Dr. Poland. And Frank McDowell, MD, a plastic surgeon, referring to the chest-hand association, commented that “Poland hadn’t the foggiest notion” that the two deformities constituted a syndrome.18 Such critiques appear to be unfounded since Dr. Poland not only described the condition with amazing detail, but had a colleague illustrate the chest wall and had his subject’s hand preserved for posterity (see photos 2 and 4).

Mr. Tilston’s exclusion of the extremity in his illustration is odd, although Dr. Poland’s role in this is unclear and it must have taken some effort to have Mr. Elt’s left hand preserved as a specimen. As Dr. Poland’s footnote stated, “The hand has been deposited in the museum of Guy’s Hospital” —where it resides to this day (see photo 4).

On surgical rounds and in the operating room, eponyms can be entertaining and colorful. They are common in clinical practice and credit earlier and observant physicians for their identification of a disease, deformity, or association of findings. The syndrome ascribed to Dr. Poland, a gifted surgeon, relates to the accuracy and detail with which he recorded the deformity and his awareness of its uniqueness. His foresight in adding an illustration of the dissection and his preservation of the subject’s hand has earned him the eponym, Poland’s syndrome.


References

  1. Power D, ed. Pharr’s Lives of the Fellows of the Royal College of Surgeons of England, Alfred Poland (1822–1872). Bristol, United Kingdom: John Wright & Sons Ltd; 1930: 184.
  2. Poland A. Deficiency of the pectoral muscles. Guy’s Hosp Rep. 1841;VI:191–193.
  3. Lallemand LM. Éphémérides Médicales de Montpellier. 1826;1:144-147.
  4. Leinveber. Lahmung und Atrophie des linken grossen Brustmusckels. Med Ztg Berl. 1837;vi:143.
  5. Froriep R. Beobachtung eines Falles von Mangel der Brustdrüse. Notizen aus dem Gebiete der Natur- und Heilkunde. 1839;10:9-14.
  6. Seyfer AE, Icochea R, Graeber GM. Poland’s anomaly: Natural history and long-term results of chest wall reconstruction in 33 patients. Ann Surg. 1988;208(6):776-782.
  7. Seyfer AE, Fox JP, Hamilton CG. Poland’s syndrome: Evaluation and treatment of the chest wall in 63 patients. Plast Reconstr Surg. 2010;126(3):902-911.
  8. Thomson J. On a form of congenital thoracic deformity. Teratologia, 2: 1-12, Plates I-V, 1895.
  9. Clarke E. Congenital variation of the pectoral muscles, with report of a case. J Anat and Physiol. 1915;49:155.
  10. Clarkson P. Poland’s syndactyly. Guys Hosp Rep. 1962;111: 335-346.
  11. Clarkson JH, Harley OJ, Kirkpatrick JJ. Alfred Poland’s syndrome: A tidy little controversy. J Plast Reconstr Aesthet Surg. 2006;59(9):1006-1008.
  12. Baudinne P, Bovy GL, Wasterlain A. Un cas de syndrome de Poland. Acta Paediat. Belg. 1967;32:407-410.
  13. Ireland DC, Takayama N, Flatt AE. Poland’s syndrome: A review of forty-three cases. J Bone Joint Surg. 1976;58(1):52–58.
  14. Sugiura Y. Poland’s syndrome: Clinico-roentgenographic study on 45 cases. Cong Anom. 1976;16(1):17-28.
  15. Gausewitz SH, Meals RA, Setoguchi Y. Severe limb deficiency in Poland’s syndrome. Clin Orthop Relat Res. 1984;185:9-13.
  16. Al-Qattan MM. Classification of hand anomalies in Poland’s syndrome. Br J Plast Surg. 2001;54:132-136.
  17. Ravitch, MM. Poland’s syndrome—a study of an eponym. Plast Reconstr Surg. 1977;59(4):508-512.
  18. McDowell F. On the propagation, perpetuation, and parroting of erroneous eponyms such as “Poland’s Syndrome.” Plast Reconstr Surg. 1977;59(4):561-563.

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