When your President, Doctor Elijah S. Burdsall, first wrote, inviting me to participate in your meeting, he at the same time asked for the title of my paper, cautioning me to pick a subject that would be interesting to general practitioners. I picked the above title because I feel that focal infection is a most important subject in the practice of medicine today, and one that should be of very vital interest to every physician no matter what his field of medicine may be. The subject of focal infection has grown to be one of so vast a scope that it would be impossible to cover it intelligently in a single paper. Therefore, I will confine myself to focal infection in its relation to the eye, ear, nose and throat, dwelling chiefly upon etiology and diagnosis. I shall strive to deal with the usual rather than with the rare case.
First, let us consider the nasal tract. Nasal focalization, especially that of the non-suppurative variety, is far more prevalent than often considered by many specialists; probably due to the fact that tonsillar and dental infections are easier to detect. The extension of an acute inflammatory process into the accessory cells of the nose is the common occurrence in those nasal infections associated with systemic symptoms loosely called “gripe.”
Unfortunately, the natural drainage from the accessory sinuses is defective. The subsidence of the superficial nasal infection is frequently not accompanied by a similar subsidence within the accessory cells; especially is this true in cases where the swelling of the mucous membrane of the nose due to circulatory disturbances may completely obstruct natural drainage from the air cells.
Nasopharyngeal infection is common in children in the form of infected lymphoid tissue (adenoids). Primary tuberculosis of the adenoids was found in fourteen out of 100 cases by Crowe, who also states that at least 25 per cent. of children with adenoids have defined indication for their removal, the most common being otitis media. Sphenoid infection is commonly associated with adenoids and may persist through adult life. Etiologic nasal focus in acute systemic manifestations has is highest incidence in young adults.
In later life and in the more chronic forms of secondary manifestations, the relative incidence is lower. However, in bronchial asthma, in the recurring headaches of the migraine type or the “indurative or rheumatic” type, in recurring or chronically progressive eye infections, in chronic myositis and in certain cases of chronic arthritis; a chronic sinus focal infection has frequently been found to be the etiologic factor.
The types of organisms usually isolated from nasal focal infections are the members of the streptococcus-pneumococcus group, the diphtheroid organisms, the bacillus influenza, the micrococcus catarrhalis, and the staphylococcus.
Secondly– Foci of infection of the tonsils holds a very foremost place as an etiological site of focal infections. In childhood bacterial invasion of the tonsils is almost universal. The anatomical structure of the tonsil is such that retention of infection is predisposed because of imperfect drainage. Many tonsils may be diseased even though they appear to be innocent. Tonsillar stumps, although atrophied and scarred are frequently seats of chronic infection giving rise to many systemic symptoms.
Here again the infecting agents are generally of the streptococcus-pneumococcus group, including the streptococcus hemolyticus, streptococcus viridans, micrococcus catarrhalis, bacillus influenzae, the diphtheroid organisms and the bacillus tuberculosis. Entamoeba gingivalis has been found in several cases but more frequently where there is an existing pyorrhoea alveolaris.
Thirdly– Bacterial invasion of dental and alveolar tissues with resulting focalization in the dental and predental tissues introduces another phase of etiological focal sites, perhaps more talked of than others, occurring more frequently in adults than in the young. Focal infections of the teeth or tonsils may cause chronic arthritis, arthritis deformans, aortitis, gastric or duodenal ulcers, etc.
Dental foci may exist in various forms, some of which are a periapical abscess, a perimetritis, a pulpitis, a granuloma or an interstitial gingivitis (both suppurative and non- suppurative). The organisms usually offending in these cases are usually a streptococcus of low-grade type (streptococcus viridans). Occasionally, such foci have a high degree of virulence, producing sudden and acute manifestations, the streptococcus possessing mild hemolytic properties.
In passing it is well to remember that there is a possibility of direct extension of bacteria along the ducts of the salivary glands, thereby permitting primary bacterial invasion into the gland. Hematogenous infection of the gland from other foci occurs a great deal more frequently than formerly believed. A continued persistence of the infection in the gland acts as a primary focus from which secondary infections and systemic reactions may arise. Though invasion of most any type of organism may occur in the salivary glands, those of the streptococcus-pneumococcus group are the chief offenders.
Fourthly.– Aural focal infections are not as rare as a great many believe. Middle ear infection by extension through the Eustachian tube is considered a frequent occurrence, but infection may also occur as an hematogenous metastasis. The metastatic complications are not so uncommon and involve venous sinuses and meninges. Aural focal infections often cause acute or chronic mastoiditis, which in turn may give rise to general bacteremia with multiple acute lesions or sinus thrombosis, brain abscess or meningitis.
An involvement of the lymphatic drainage of these parts usually occurs, resulting in a secondary lymphadenitis. Staphylococcus, the bacillus influenza or the diphtheroid organisms are usually found to be the predominant infecting agents in these cases; occasionally the pneumococcus and bacillus coli act as causative agents.
Fifthly.– The eye can become directly infected by direct invasion of the invading organism but more frequently suffers as a result of a focus of infection elsewhere in the body, especially in teeth, tonsils, gall bladder, appendix, gastro- intestinal tract. Any or all of the following eye conditions may be caused by a focus infection:.
Uveitis Corneal ulcers.
Keratitis Optic neuritis.
Iritis Optic atrophy.
Retinitis Affections of eye muscles.
Choroiditis Chronic glaucoma.
In diagnosing a case of focal infection, clinical history is valuable. Repeated occurrence of nasal and throat infections, of acute sinusitis, of peritonsillitis, of otitis media, of mastoiditis, or acute lymphadenitis, of alveolar abscess is always significant as indicating portals of entry and possible chronic foci of infection. Devitalized dental root canals and unerupted teeth are guides toward possible foci.
The history of jaundice as indicating an acute cholecystitis or the eliciting of the symptom-complex of appendicitis indicates the possibility of persistent secondary foci of infection, which may be the primary cause of the systemic symptoms under observation. Various metabolic disturbances, neurasthenia, chloranemia are signs of a possible persistent feeding focus of infection, either primary or secondary. Of less importance but not to be disregarded is the history of such acute bacterial invasion as the acute exanthemata, pneumonia, typhoid fever and puerperal infections.
Special attention should be given to the presence of septal deflections, septal spurs, hypertrophied turbinates, all of which interfere with the normal drainage of the nasal passages thus predisposing sinus infection. Persistent sinus infection is usually suppurative when acute but not necessarily however, in the chronic form it is usually non-suppurative in type with an absence of discharge.
Hypertrophied granular middle turbinates, polypoid degeneration of the turbinates, or protrusion of polypus into the nasal cavity from the middle meatus, or the closure of the middle meatus with a sticky exudate indicates chronic sinus disease. Enlargement of deep cervical glands may indicate persistent nasal infection. Roentgenography assists in the diagnosis of those diseased cells containing pus. Positive findings in the roentgenogram are conclusive; negative findings do not exclude the accessory sinuses as locations of focal infections. Transillumination is also of value in diagnosis.
In patients giving an indefinite history with sudden loss of vision, let us consider the sinus. I am sure we are all giving them the attention they deserve if we dont forget that every suppurating sinus is a menace to his life and best results are only to be expected from early intervention.
Hypertrophied tonsils per se do not always indicate disease according to some authorities, but I feel that the hypertrophy is a pathological state and should be watched very closely. However, when cheesy material can be expressed from the follicles, local disease is present. Liquid pus is positive proof of surface infection and usually indicated bacterial invasion and the formation of an abscess in the lymphoid tissue of the tonsil. Localized abscesses are frequently found between the tonsils and the pillars.
Congested and granular anterior pillars indicate deep-seated tonsillar infection. The small fibroid imbedded tonsil, even though the surface is free from evidence of disease, must always be looked upon with suspicion. Tonsils in which scar tissue formation has partially or wholly occluded the orifices of the crypts are particularly dangerous. Tenderness and enlargement of the superficial or deep cervical lymph glands are important signs in determining the presence of chronic tonsillar infection. Enlargement of the lymphatic gland at the angle of the jaw often spoken of as the “tonsillar gland,” is particularly suggestive of infection.
The determination of chronic middle ear or mastoid infection depends upon the history of the case, the results of visual otoscopic examination, and the roentgenographic findings. In the absence of chronic suppuration, enlarged lymph-nodes in the posterior cervical chain are indicative of chronic infection in this area.
In determining dental foci of infection, it is well to follow a routine method of diagnosis:.
1. Make a thorough clinical and visual examination to determine the presence of pyorrhea, ulcerations, suppurating sinuses, swellings, enlarged lymph-nodes.
2. Determine the response of each tooth to the faradic current.
3. Roentgenologic examination of each devitalized or suspicious tooth, but better X-ray all the teeth.
The blood picture is of real value in determining the presence of foci of infection. I feel that too frequently we fail to make use of the laboratory; perhaps because we may inconvenience our patient a little bit, but if we could only realize the kindness we are doing them, we would insist more often upon blood analysis as well as X-ray pictures.
Assuming that in the average adult we find a normal red count of 4,500,000 to 5,00,000 with hemoglobin 90 to 100 per cent. and a white count averaging 7500 with a range of from 6500 to 8500 and a differential of polymorphonuclear neutrophils 60 to 75 per cent., average 70 per cent.; small lymphocytes 20 per cent. (20- 25 per cent.), large lymphocytes 5 per cent., eosinophils 0.5 per cent., basophiles 0.1 to 0.5 per cent. and transitionals 4 per cent.
In acute focalization there is usually a polymorphonuclear neutrophilic leukocytosis associated with erythrocytic destruction. In persistent focalization of the sub-acute and chronic types there is usually a low color index with a moderate decrease in the erythrocytic count. The majority of cases show a moderate decrease in the hemoglobin even as low as 35 per cent. and a decrease in red cell count, one case of frontal sinus as low as 1,760,000.
A moderate increase in total white count rarely above 13,000, occasionally as high as 20,000, with a relative decrease in the per cent. of leucocytes average somewhere below 60 per cent,. with a relative increase of lymphocytes to about 38 per cent.; while the small lymphocytes show a greater increase relatively than the large.
One of the most frequent diseases complicating the diagnosis of focal infection is syphilis. This infection is often associated with focal infection, giving us a mixed infection. The blood picture in syphilis shows a slight leucocytosis rarely as high as 15,000, with a distinct lymphocytosis as high as 6.5per cent. Generally speaking, focal infections are unilateral, while syphilis is nearly always bilateral. The Wassermann reaction and other clinical findings well known to all of us aid in the differential diagnosis which I will not attempt to discuss at this time.
As regards treatment of the foci of teeth, tonsils, sinuses, etc., I feel that the modern dentist of today is in a situation to help our patients, and it behooves us to give this subject more attention, but at the same time we must ward against the unjustifiable removal of teeth without carefully weighing all the symptoms. Too many teeth have been sacrificed– but when disease warrants it, the sacrifice is amply repaid. Remove all dead teeth, dead roots, fixed bridges, whether abscessed or not.
It is well accepted fact as to the importance of tonsils as a point of entry for numerous organisms, and their removal will aid materially in controlling such disease. The complete removal is the only procedure. However, I would like to say a word of caution against the apparent wholesale removal of tonsils without due consideration of the consequences. Remember, that a patient “has tonsils” is not enough of an indication that they are the cause of infection. Careful study will have a tendency to prove or disprove them as the factor in focal infection.
In the correction of diet, pyorrhea and teeth, careful regulation of sugars, which is one of the important factors in fermentation, we have fundamentals upon which we can hope to eliminate some of the factors which cause disturbance of the alimentary tract. Dr. George Huston Bell of New York City is an ardent advocate of diet with other treatment. He divides food substances into two classes:.
1. Heavy starches — Bread of all kinds, potatoes, macaroni, corn, lima beans, rice, dry beans and sugar.
2. Heavy proteids– Meats of all kinds, fish, shell fish, chicken, duck, turkey, eggs and cheese.
A patient may pick only from list (1) heavy starches, for a singe meal with nothing else but fresh vegetables, salads, and fruits for desserts; or from the heavy proteid list, with the addition of fresh vegetables, salads, and fruit for desserts. This is done in order to prevent fermentation in the stomach and to prevent putrefaction in the intestines. The starches are digested in the mouth and intestines and if they are detained in the stomach with proteid food, the starches ferment and fight with the proteins.
So eat starches when they wont be delayed, since when meat is eaten, it causes a flow of gastric juice. In hyperchlorhydria, carbohydrate digestion is checked by hydrochloric acid and therefore interferes with the digestion of carbohydrates. For that reason, take heavy carbohydrates when heavy proteids are not eaten, so that they can get out of the stomach immediately.
In ear conditions, free drainage should be maintained by opening drumhead if necessary. Simple mastoid or radical mastoid operation should be performed when indicated. Local treatment maintained to keep ear clean and draining freely.
In eye conditions the treatment is simple. Remove focus of infection.
The question will no doubt arise as to the case where there is more than one focus of infection which should be removed. It is the consensus of opinion of the majority of authorities on the subject that where time and condition allows, foci should be removed in the following order: First, teeth and mouth, tonsils, sinuses, gall bladder, etc.
In cases where the pathology is caused by a focal infection associated with some other condition, for instance diseased tonsils with a gastric ulcer, it must be remembered that with the removal of the focus of infection ( the tonsils), the gastric ulcer will not cure itself. It is therefore very important to follow up the complete removal of the focus of infection with a conscientious indicated treatment, medical, hydrotherapy, corrective diet or whatever may be deemed advisable, until the patients entire body has been returned to a state of health.
In conclusion, I will summarize by calling your attention to the importance of looking for a focus of infection as a causative agent in disease of the eye, ear, nose and throat.
First.– Find the focus of infection, (teeth, tonsils, sinuses, appendix, gall bladder, or wherever it may be).
Second.– Cure the disease by removing the cause (focus) in the quickest and safest manner.
Third.– Remove any contributing cause, and lastly dont forget the three Ts.