Focal sepsis in the sinuses
Watson-Williams developed the concept that focal sepsis in the sinuses could give rise to widespread secondary conditions (Table 1).
Table 1. Conditions said to be caused by focal sepsis in the sinuses
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' method of Suction-exploration
Watson-Williams used the rigid nasendoscope for diagnostic precision. He first used the endoscope in 1919.
Figure 5.
Watson-Williams used the rigid nasendoscope for diagnostic precision. He first used the endoscope in 1919.
Watson-Williams cannulae for sphenoid and posterior ethmoid suction-exploration
Figure 6.
Watson-Williams cannulae for sphenoid and posterior ethmoid suction-exploration. He designed separate cannulae for each sinus.
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).
Sterile water was injected, and the contents withdrawn for bacteriological study.
A disinfectant solution was then injected.
A separate cannula, syringe and bottle was used for each sinus.
Subsequent management of the patient was determined by the results of bacteriological culture.
The presence of bacteria was all important. Clear fluid, without pus cells, but growing organisms, was regarded as highly significant. The absence of white blood cells in the washings meant that the patient had impaired defences against toxic absorption and tissue invasion, and was therefore at greater risk than in cases where pus had formed.
Contemporary medical press reviews of Watson-Williams' work
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?
Similarities between focal sepsis and functional endoscopic sinus surgery
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.
Both introduced a rational form of treatment, based on logical deduction from pathophysiological concepts.
Both offered the prospect of relieving relatively major disease by eliminating a relatively minor focal cause.
Both used the latest technology, and relied on endoscopes for diagnostic precision.
Neither has been subject to a controlled trial of efficacy.
What is missing from Watson-Williams' book, and missing from practically all other reports on treatment of sinusitis up to and including the present day, is a full presentation and critical analysis of the results.
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.
Rationalism versus empiricism in medicine
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.
The argument of obviousness is immediately quashed by the very fact that there is disagreement.
If something was genuinely obvious there would be no argument about it.
And even where there is no disagreement, whole populations can be wrong collectively, for instance in the belief that the world is flat.
Before it was known that cilia beat toward the natural ostia, it was obvious that a drainage hole should be at the lowest point of a sinus. Now it seems obvious that it should be at the natural ostium, but who knows what future developments might bring?
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
support the existing body of knowledge
or, more likely,
suggest that something has been missed.
The questions that arise when a rational treatment doesn't work will often lead to new knowledge, because the underlying hypothesis is then questioned and may be falsified. (Popper, 1959) This is the true raison d'etre for rationalism in medicine.
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.
Conclusions
In comparatively recent medical history, an apparently rational treatment was used without adequate trials of outcome.
The practices which resulted now appear bizarre.
The pathophysiological basis of focal sepsis was later discredited.
We should not repeat the same error with functional endoscopic sinus surgery, nor with any other advance in rational treatment.
We should beware of over-interpretation of clinical findings.
No treatment, even when supported by the finest rationale, should be accepted without proper controlled trials of outcome.
References
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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.
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Huxley A. (1960) Collected Essays. Chatto and Windus, London.
Kennedy DW. (1985) Functional endoscopic sinus surgery technique. Archives of Otolaryngology 111: 643-649
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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.
Acknowledgements
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".
Further EBM pages authored by JW Fairley
Evidence based medicine - historical perspective and critique
Philosophical, scientific and statistical basis of Evidence based medicine
Limitations of evidence based medicine - should Cochrane reviews of surgical interventions concluding "no evidence of benefit" come with a health warning?
Footnote 2007: Biofilms - Focal sepsis rediscovered?
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.
http://entkent.com/patrick-watson-williams/