Patrick Watson-Williams and the concept of focal sepsis in the sinuses:
An historical caveat for functional endoscopic sinus surgery
Mr James W Fairley BSc MBBS FRCS MS
Consultant ENT Surgeon
Previously published in the Journal of Laryngology & Otology, 1991 Jan;105(1):1-6.
Based on a paper presented to the European Rhinologic Society, London, June 29th 1990.
Recompiled HTML format July 2007
© 1990 – 2016 JW Fairley
- Introduction: Justification of historical research
- Patrick Watson-Williams
- Historical development of the theory of focal sepsis
- Focal sepsis in the sinuses
- Watson-Williams’ method of Suction-exploration
- Contemporary medical press reviews of Watson-Williams’ work
- Similarities between focal sepsis and functional endoscopic sinus surgery
- Rationalism versus empiricism in medicine
Further historical and evidence based medicine pages by JW Fairley
- Hierarchy of Evidence
- Nihilism vs. wisdom
- Has the hierarchy been tested scientifically?
- EBM in Victorian times
- The meta-analyst
- Archie Cochrane
- Cochrane Collaboration
- Popperian logic
- Probability & statistics
- Ignorance & truth
- Randomised Controlled Trials
- The null hypothesis
- Why RCT’s?
- The double blind surgeon
- Why Statisitics? RCT of parachutes
- Conflicts with practice
- Outcome measures
- Surgical skill/preference
- Choice of technique
- Surgeons preference
- RCT results & individual surgical practice
- Professional judgement
- Teamwork & control of the performance environment
- Evolving techniques
- Recognizing advances
- Conclusions & recommendations
Thesis submitted for the degree of Master of Surgery, University of London, 1993.
- Historical review
- Importance of symptoms
- Value and dangers of new techniques
- Development of nasal sinus endoscopy
- Risks of over-interpretation of nasal sinus endoscopy
- Focal sepsis
- Similarities between FESS and focal sepsis
- Notes on diagnostic classification of rhinosinusitis
- The purpose of a classification of disease in clinical research
- Use of symptoms in diagnosis of rhinosinusitis
- Headaches and facial pain of nasal origin
- Sluder’s headache and therapeutic trial of cocaine in diagnosis
- Yankauer’s therapeutic trial of steam inhalations in diagnosis of sinus pain
- Brown Kelly’s therapeutic trial of ephedrine in diagnosis of sinus headache
- General comments of methods and external validity of results from observational studies on patients attending the Nasal Research Clinic
- Correlation of subjective sensation of nasal patency with nasal inspiratory peak flow rate in healthy volunteers
- Nasal pressure probe studies using a new device in healthy volunteers: Pressure applied to middle turbinate causes pain at lower threshold than inferior turbinate or nasal septum (full text)
- Reliability and validity of a nasal symptom questionnaire for use as an outcome measure in clinical research and audit
- The relationship between pain projected on a diagram of the face and systematically documented findings using rigid nasendoscopy
- The relationship between symptom scores on a specially designed questionnaire and corresponding objective measurements: Nasal inspiratory peak flow and subjective sensation of nasal obstruction
- The relationship between symptom scores on a specially designed questionnaire and corresponding objective measurements: Postnasal drip, rhinorrhoea, nasal obstruction, cough and mucociliary clearance time
- The effect on symptoms of facial pain and headache of medical treatment and operations designed to remove endoscopically documented areas of mucosal contact between the turbinates and nasal septum
- A prospective randomized controlled trial of Functional Endoscopic Sinus Surgery: Endoscopic middle meatal antrostomy versus conventional inferior meatal antrostomy. Interim results. (full text)
- Thesis Reference List
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.
Introduction: Justification of historical research
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.
- Although most scientific and medical research papers start with a historical review, it is usually a perfunctory exercise.
- Historical references are often quoted from secondary sources, with the perpetuation of inaccuracies and misconceptions. (Stell, 1987)
- The historical vignette is an interesting appetizer to the main paper, an amusing slide for the beginning of the lecture.
- The idea that we can learn from history is seldom taken seriously.
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.
Mr. Patrick Watson-Williams, 1863 – 1938. Consultant ENT Surgeon to the Bristol Royal Infirmary.
Watson-Williams frontal sinus rasp. This instrument is rarely used as originally intended.
Watson-Williams sphenoidal forceps. Although convinced of the value of endoscopy for diagnostic work, Watson-Williams preferred to open the sphenoid sinus blindly, relying on the correct angulation, measuring the distance on the graduated exploratory cannula, and the sense of touch. He reckoned to be able to open the anterior face of the sphenoid in about one minute, without disturbing the middle turbinate, and claims to have done several thousand of sphenoidectomies in this way without any major complications.
Plates from Watson-Williams’ book showing the presence of cocci in dilated antral mucosal lymphatics. From a patient with a 10 year history of postnasal catarrh and mental depression. Mental symptoms were attributed to local absorption of bacterial toxins. Toxins could also be spread via the bloodstream resulting in widespread ill effects.
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.
Historical development of the theory of focal sepsis
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
- the teeth
- genito-urinary tract
can be responsible for widespread secondary conditions, such as
- stomach ulceration
- atrial fibrillation
- neurological and psychiatric conditions
There are two main mechanisms for such effects
- the action of bacterial toxins
- spread of viable bacteria from primary to secondary sites.
Spread of toxins and bacteria can occur by
- direct tissue invasion
- lymphatic channels
- intraluminal (eg in the case of swallowed organisms acting on the stomach)
- haematogenous routes
Histopathological evidence for such patterns of spread was provided (Figure 4), and correlated with clinical case studies to produce a coherent and convincing thesis.
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
- ulcerative endocarditis
- obscure septicaemia
- purpuric haemorrhages
He was especially interested in pernicious anaemia, which he considered to be due to swallowed bacteria infecting the stomach mucosa. This explanation found wide favour, and removal of the teeth was recommended for pernicious anaemia for many years prior to the introduction of the raw liver diet in 1926.
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.
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).
|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.
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.
- 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.
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
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
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
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.
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