From 1900 to 1940 the theory of focal sepsis was invoked to justify large numbers of dubious surgical procedures. Surgeons believed they were acting rationally. Patrick Watson-Williams advocated suction exploration of the paranasal sinuses for mental patients, claiming to cure criminal insanity by sphenoidectomy. Favourable contemporary reviews show international approval. The rational basis of treatment was emphasised, but there was little systematic evaluation of outcome. Current enthusiasm for functional endoscopic sinus surgery is also based on a rational approach, logical deductions from pathophysiological "facts". Outcome has still not been evaluated scientifically. We should learn from history. Treatment should not be based too readily on what seems to be rational now. Ideas of physiology and pathology change. What seems logical today may appear ridiculous tomorrow. Careful analysis of outcome, preferably by controlled clinical trials, is needed. A rational treatment needs empirical validation just as much as any other treatment.
Human beings, including doctors and scientists, have an extraordinary capacity to repeat the mistakes of their predecessors. To paraphrase Huxley (1960), the main thing that we learn from history is that we learn nothing from history.
Despite this, the value of the study of medical history is not widely appreciated within the profession.
Some believe this to be a modern trend and blame information technology - computerised information searches typically look back only five years, while the oldest papers on Medline are from 1966.
In fact, previous generations were equally dismissive of medical history. Thomas Wakley, founder of the Lancet, wrote in 1842:
" ... antiquarians ... are gentlemen whose business it is to remember what everybody else may forget ... They wear eyes in their polls, in order to see backwards; but men of science require those organs set forward ... If there be one class of men to whom the ancient history of their profession is next to useless, however interesting, it is the medical."
I hope to show that a study of history, particularly of an episode where enthusiasm for the latest scientific advances was allowed to take precedence over careful analysis of the results, can have relevance to modern practice. This critique of the faulty application of science is doubly applicable in today's technology dominated medical world.
Patrick Watson-Williams (Figure 1) was born in Clifton, Bristol in 1863, the son of Dr. E. Williams MD and Margaret Watson.
He was educated at Clifton College, and took his medical degree at University College London.
He practised in Bristol, first as physician to the Bristol Royal Infirmary, and from 1906 as its first Consultant Ear Nose and Throat Surgeon. He was also Lecturer on diseases of the Ear, Nose and Throat in the University of Bristol.
He published extensively, mainly on rhinology, including sections in Allbutt's System of Medicine with Sir Felix Semon (Semon and Watson-Williams, 1908) and three major works of his own. (Watson-Williams, 1901, 1911, 1930)
He achieved national and international recognition. He was President of the Section of Laryngology of the Royal Society of Medicine in 1910-1911, representing the society at the international laryngological conference in Berlin in 1911.
On Guy Fawkes night, 1925 he delivered the Semon Memorial Lecture to the Royal Society of Medicine on
"The toll of chronic nasal focal sepsis on body and mind"(Watson-Williams, 1925). His theme was the causative relation of chronic sinusitis to general medical and psychiatric conditions.
Modern ENT surgeons will be familiar with his name from his sinus instruments, including the frontal rasp (Figure 2) and graduated sphenoidal forceps (Figure 3). His influence was felt far beyond the bounds of otolaryngology, reflecting his general medical background and interest in the relationship between chronic focal infection in the sinuses and general medicine.
He died in 1938 at the age of 75, before the introduction of antibiotics put an end to the widespread use of surgery for focal sepsis.
His influential book, Chronic Nasal Sinusitis and its Relation to General Medicine, based on his Semon Lecture thesis, was published in 1930. It quickly ran to a second edition in 1933, with a foreword by Sir Humphrey Davy Rolleston. Rolleston was the most eminent English physician of the day; his positions included Physician to the King, President of the Royal College of Physicians, President of the Royal Society of Medicine, President of the British Medical Association, and Emeritus Regius Professor of Physic at Cambridge.
The theory of focal sepsis started toward the end of the 19th Century and was well established by the 1930's. It states that chronic, low grade infection in primary sites such as
Miller, a Berlin dentist, wrote a series of articles on the mouth as a focus of infection in 1891. He cites 149 cases, some published, some from private communication, in which sepsis arising from the mouth caused serious disease. Some of these were local complications - abscess formation, osteomyelitis etc - but others were metastatic complications, coming within the definition of focal sepsis. He carried out experiments on bacteria from normal and infected mouths, injecting them into guinea pigs, and concluded that there are pathogenic bacteria even in healthy mouths, but more in those affected by pyorrhoea alveolaris.
William Hunter, pathologist to Charing Cross Hospital (1900a,b) published thirteen cases of septic gastritis and toxic neuritis considered to be due to carious teeth. He stated that a characteristic sallow appearance and languid feelings were due to absorption of toxins. Remote manifestations included
In the United States, Chicago was the major centre for experimental work on focal sepsis. Davis (1912), Billings (1914) and Rosenow (1914) carried out extensive clinical and experimental pathological studies, including the injection of bacteria from supposed foci of infection into animals. The secondary conditions caused were differentiated into those due to direct bacterial embolic phenomena - such as endocarditis, in which the bacteria were identified in the lesions - and those due to toxins, such as chronic arthritis and nephritis, where no bacteria could be recovered from the secondary lesions.
Bearing in mind that systemic disinfection was not possible until prontosil was introduced in 1935 (Domagk) followed by the much more successful penicillin in 1941 (Abraham), these researchers reached the common conclusion that all sources of focal sepsis should be sought out and eliminated.
Watson-Williams developed the concept that focal sepsis in the sinuses could give rise to widespread secondary conditions (Table 1).
|
Optic neuritis |
Endocarditis |
|
Retinal detachment |
Appendicitis |
|
Asthma |
Rheumatoid arthritis |
|
Acne |
Neurasthenia |
|
Boils |
Insanity |
|
Auricular fibrillation |
Criminal behaviour |
He claimed that by searching for and eliminating septic foci in the sinuses, many general medical and psychiatric diseases could be cured. Watson-Williams investigated numerous patients from the mental hospitals, and claimed to have cured cases of criminal insanity by sphenoidectomy. The psychiatrists agreed. (Cotton, 1923; Graves, 1923; French, 1927)
He emphasised the special danger of low grade organisms, which could remain latent for years, causing occult or cryptogenic focal sepsis. Their activities were compared with the
"insidious ravages of the death watch beetle... proceeding unnoticed for generations in the roof of our Westminster Hall".
Watson-Williams did not advocate indiscriminate operation. His diagnostic method was rigid endoscopy of the nose, (Figure 5) looking for any signs of pus or inflammation around the natural ostia.
This was followed by his own technique of suction exploration:
Under local cocaine anaesthesia, and after preliminary disinfection of the vestibule with iodine to avoid contamination from the nose, each individual sinus was cannulated, using specially designed instruments (Figure 6).
The 1930 book received enthusiastic reviews in the medical press, quoted in the second edition. The Practitioner called it
"one of the milestones of medical progress".The Journal of Laryngology described the argument as
"logical and highly convincing".Medical World called it
"an epoch-making work",while the Journal of Mental Science went so far as to state that
"every mental hospital should contain a copy".Reading the work today, paradoxically, most of these sentiments remain valid. It is a closely argued and highly plausible thesis. One wonders whether we have not missed something important in our subsequent rejection of the theory of focal sepsis.
What is missing, however, is a full and complete analysis of the results. There are numerous case reports of successful treatment, but no systematic analysis of overall results. There is no comparison of the results of treatment by suction-exploration of the sinuses with other contemporary treatments.
The lesson we should learn from the focal sepsis debacle is that today's rational treatment may seem ridiculous tomorrow, in the light of further advances.
What is more, the wheel can come full circle, so that the ridiculous old fashioned idea is rehabilitated. For example, the recent re-emergence of the idea that peptic ulcer is due to a bacterial infection, Helicobacter (formerly Campylobacter) pylori. (Goodwin et al, 1986). Peptic ulcer was one of the original conditions blamed on focal sepsis. Who is to say whether Watson-Williams may not have been right - at least part of the time?
For most doctors, the reaction to such bizarre episodes from the past is amusement at the naivety of our predecessors, or incredulity and embarrassment that such things could have gone on in the name of medicine. In fact, we are not so very different today.
There are similarities between the recent introduction of functional endoscopic sinus technique, based on the concept that the ostiomeatal complex is the root of all evil in the sinuses, (Stammberger, 1986; Kennedy, 1985) and Watson Williams' suction exploration for focal sepsis 60 years ago.
The problem here is not one of quantity of information. Surgeons have always been willing to quote their results - especially their successful results. Quite a lot of surgeons have pointed out complications as well - preferably other people's. Unfortunately very few have reported results to the standard required for scientific acceptability.
Out of 364 papers on the surgical treatment of sinusitis between 1966 and 1989 there was only one controlled trial (Arnes et al, 1985), and no studies which met all the standards published by the British Medical Journal for reports on the results of treatment. (Anon, 1988) The lack of controlled trials led Buiter (1988) to conclude that there are no reliable statistics that show any clear advantage for one form of treatment over another.
Despite these considerations, functional endoscopic sinus surgery remains a very attractive concept. It is after all "logical and highly convincing". It is probably a "milestone of medical progress". It may be going too far to say that every mental hospital should have one; in fact before advocating that every ENT department should have one it there should be some evidence, by properly controlled trials, that its enormous promise is borne out by improved results of treatment.
Few doctors nowadays will espouse a treatment just because it is advocated strongly. If Professor Sir Highly-Thoughtof Chappe says one thing, there is usually a Dr. Equal E. Eminent who says the opposite.
There are two types of appeal to reason, however, which have great persuasive force.
The first is to say that our new treatment is quite obviously better, the superiority of this advance is self evident.
The second is to demonstrate that this is a rational treatment, following logically from what we know of the pathology.
When applied to the justification of one form of treatment over another, both of these arguments are false.
When it comes to rational treatment, what we are doing is applying deductive logic to an incompletely understood system. This is an excellent method for predicting what should work. Finding whether something actually does work will either
It is wrong to usurp rationalism to justify one treatment over another. It is logically wrong because to do so is a tautology, and scientifically wrong because the empirical basis is ignored.
What counts with treatment is results - the results, all the results and nothing but the results.
Abraham AE et al. (1941) Further observations on penicillin. Lancet 2: 177-189
Anonymous (1988) Guidelines for writing papers. British Medical Journal, 296: 48-50
Arnes E, Anke IM, Mair IWS. (1985) A comparison between middle and inferior meatal antrostomy in the treatment of chronic maxillary sinus infection. Rhinology, 23: 65-69
Billings F. (1914) Focal Infection: Its broader application in the etiology of general disease. Journal of the American Medical Association 63: 899-903.
Buiter CT. (1988) Nasal Antrostomy. Rhinology, 26: 5-18
Cotton H. (1923) The relations of chronic sepsis to the functional psychoses. Journal of Mental Science 69: 434-465.
Davis DJ. (1912) Bacteriological and experimental observations on focal infections. Archives of Internal Medicine 505-514
Domagk G. (1935) Ein Beitrag zur Chemotherapie der bakteriellen Infektionen. Deutsche medizinische Wosenschrift. 61: 250-253
French JG. (1927) Infection of the nasal sinuses in relation to insanity. Lancet 2: 13
Goodwin CS, Armstrong JA, Marshall BJ. (1986) Campylobacter pyloridis, gastritis and peptic ulceration. Journal of Clinical Pathology 39: 353-365.
Graves TC. (1923) The relation of chronic sepsis to mental disorder. Journal of Mental Science 69: 465-471.
Hunter W. (1900a) Further observations on pernicious anaemia (seven cases): A chronic infectious disease; its relation to infection from the mouth and stomach; suggested serum treatment. Lancet 1: 221-224 and 371-377
Hunter W. (1900b) Oral sepsis as a cause of septic gastritis, toxic neuritis and other septic conditions. Practitioner 65: 611-638
Huxley A. (1960) Collected Essays. Chatto and Windus, London.
Kennedy DW. (1985) Functional endoscopic sinus surgery technique. Archives of Otolaryngology 111: 643-649
Miller WD. (1891) The human mouth as a focus of infection. Dental Cosmos, 33: 689-713
Popper KR. (1959) The logic of scientific discovery. Hutchinson, London.
Rosenow EC. (1914) The newer bacteriology of various infections as determined by special methods. Journal of the American Medical Association 63: 903-912
Semon F and Watson-Williams P. (1908) in Allbutt C and Rolleston HD. A system of medicine by many writers. Vol 4 part 2: Diseases of the nose, pharynx and ear. 2nd Edn. Macmillan, London.
Stammberger H. (1986) Endoscopic nasal surgery - Concepts in treatment of recurring sinusitis. Part 1. Anatomic and pathophysiologic considerations. Otolaryngology Head and Neck Surgery, 94(2): 143-156
Stell PM (1987) Epithelial tumours of the external auditory meatus and middle ear in Kerr AG (Ed) Scott-Brown's Otolaryngology 5th Edition Vol 5 Otology 534 Butterworths London
Wakley T. (1842) Editorial reply to a letter "Old Medical Books" from Branson F. Lancet 2: 197
Watson-Williams P. (1901) Diseases of the Upper Respiratory Tract, the Nose, Pharynx and Larynx. 4th Edn. John Wright, Bristol.
Watson-Williams P. (1910) Rhinology: A text-book of diseases of the nose and the nasal accessory sinuses. Longmans, London.
Watson-Williams P. (1925) The toll of chronic nasal focal sepsis on body and mind. The Semon Lecture. Journal of Laryngology and Otology 40: 765-780
Watson-Williams P. (1930) Chronic nasal sinusitis and its relation to general medicine. John Wright, Bristol.
Watson-Williams P. (1933) Chronic nasal sinusitis and its relation to general medicine. 2nd Edition. John Wright, Bristol.
I would like to thank Mr Richard Maw, Consultant ENT Surgeon to the Bristol Royal Infirmary, for the photograph of Patrick Watson Williams, and Butterworth Scientific Publishers for permission to reproduce figures 2,3,4,5 and 6, from the 1933 edition of Watson-Williams' book "Chronic nasal sinusitis and its relation to general medicine".
Evidence based medicine - historical perspective and critique
Philosophical, scientific and statistical basis of Evidence based medicine
Recent interest in the clinical importance of biofilms bears striking resemblance to ideas of focal sepsis. Biofilms in humans are now thought to pose that same special danger of low grade organisms, which can remain latent for years, causing occult or cryptogenic focal sepsis. Watson-Williams was probably right to compare their activities with
"insidious ravages of the death watch beetle... proceeding unnoticed for generations in the roof of our Westminster Hall".He did not use the terrorist / guerilla warfare / safe base analogy, even though terrorist / guerilla tactics would have been known because of the Boer war.
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Mr James W. Fairley BSc MBBS FRCS MS (Lond)
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