average period of acute illness was 212 days as compared with a period of 82 days when the latter method was employed. The secondary complications, both mild and severe, such as inflammations of the eye and ear, pneumonia, acute rheumatic fever, etc., under the former method were only 12 per cent. as compared with 35 per cent. under the latter. Such treatment consists of evacuating wherever possible localized infections in the nose and throat. In the former, mild shrinkage of the middle turbinate with a solution of adrenalin 1-25,000 or with a solution of cocain hydrochlorid 0.25 per cent. applied with pledgets results in the establishment of free drainage from the accessory cells through the middle meatus. This is followed by the use of a mild stimulant, such as a solution of argyrol 10 per cent. and a vapor of menthol 1 per cent., camphor 1 per cent., in liquid albolene. In tonsillar infections frequent hot normal saline gargles have been found to be more effectual than the more stringent and stimulating preparations.

The general prophylaxis of the nose, throat and teeth should be encouraged from childhood. One of the chief reasons of the low incidence of skin invasion as compared to that of the nose, throat and mouth is the frequent cleansing and the constant cellular desquamation. Similar methods of cleansing the mucous membranes of these cavities should be employed. Routine dental, nasal and pharyngeal supervision in our schools should be encouraged and the laity in general should be educated as to the necessity of these precautions. Detailed description of these methods may be found in chapters dealing with nasal and throat conditions.

Curative Treatment. The treatment of determined foci of infection with or without local symptoms should be their immediate removal. To await until such foci produce secondary results is irrational. It is true that the incidence of primary focalization is much greater than the incidence of local or systemic diseases arising therefrom, but, if the latter are to be prevented, the former are to be eliminated as soon as detected. Radical procedures must be instituted with judgment. The wholesale removal of tonsils without definitely determining the presence of infection is unjustifiable. Radical operations for the correction. of nasal deformities in children to improve aëration is unscientific unless mal-development of the upper maxillæ is considered and, if present, first corrected by orthodontic methods. The persistence of enlarged lymph-nodes following the removal of primary foci requires surgical interference if hygienic measures fail.

The treatment of acute focalized infections complicated by acute systemic diseases in many instances requires conservatism. Surgical procedures during the course of acute rheumatic fever, acute chorea, puerperal sepsis, acute endocarditis or acute pericarditis not only have no effect upon the course of the disease, but are apt to do harm by producing an overwhelming bacteriemia. Prophylactic measures in the treatment of the nose and throat are always indicated. In those cases secondary to an acute nasal infection, the maintenance of continued nasal aëration and drainage by the local treatment just described is a

rational procedure. The removal of persistent foci in such cases should occur ad interim.

In acute nephritis, erythema nodosum, gastric and duodenal ulcer, acute myositis, acute infections of the nervous system, the immediate removal of the etiologic focus is indicated when the general condition of the patient permits.

In the chronic diseases, the chronic focus or foci should be removed radically as soon as detected. It would be just as rational to treat the metastases of carcinoma without removal of the primary growth as it is to treat a chronic cholecystitis or chronic infectious arthritis without removing the primary source of infection.

Therapeutic measures are not confined to the removal of foci of infection, however, for the secondary infections do not disappear immediately with the removal of the feeding focus of infection. In the case of chronic infectious arthritis, for example, the periarticular tissues have been invaded by the bacteria of low virulence which have produced certain proliferative changes, have become focalized at that point and have developed definite elective affinity for joint tissues acting as a constant menace for the production of progressive secondary involvement of other joints. The elimination of this persistent joint infection must be through the natural defenses of the body. Therefore, all of those measures tending to increase bodily resistance are to be employed with the same careful application to the individual as was the custom of clinicians prior to the knowledge of the underlying bacterial etiology of these conditions.

The first and fundamental principle in the treatment of focal infections is the treatment of the patient. There are always two factors involved in an infectious disease, the condition of the host and the species, virulence, number and special pathogenicity of the infecting agent. To ignore the former and deal only with the latter results in disappointment due to the failure to relieve the patient. To remove infected tonsils in a case of chronic gastric ulcer without treating the local gastric condition and the secondary results of disturbed metabolism is as irrational as to employ surgical and medical measures for the relief of the ulcer without removing the primary infecting cause.

It is not always possible to remove the primary focus radically. The strikingly beneficial results obtained following the removal of infected tonsils and the extraction of abscessed teeth are not experienced when dealing with chronically infected accessory sinuses or mastoids, since it is not always possible to remove all of the infected tissue. In such foci the principle is to establish freer drainage in the hope that the relief of tension and the consequent upbuilding of the resistance of the patient may bring about regeneration of tissue with elimination of infection. Too often, however, do we find the remnants of infected granulation tissue remaining in the cell cavities awaiting only the conditions bringing about increased tension, secondary to interference with drainage or acute infection to cause recurrent bacterial invasion.

The use of antibacterial sera, autogenous vaccines, and non-specific

proteins in the treatment of acute and chronic infectious diseases is discussed in detail elsewhere. The value of such measures in the attempt to eradicate the primary etiologic foci of infection is irrational. Their employment in the treatment of the secondary manifestations resulting from such foci should be instituted with judgment only when the primary focus has been removed, since the danger of increased sensitization of tissues may lead to further bacterial invasion.

The hygienic and special therapeutic measures employed in the various acute and chronic diseases are discussed in detail in those chapters devoted to these diseases. In discussing such diseases from the standpoint of focal infections, it is not the purpose of the author to belittle the methods of treatment advised, but rather to emphasize them. But at the same time it is desirable, in applying such therapeutic measures, to keep in mind the importance of the primary etiology of these diseases and the mechanism of secondary infection, rather than to consider alone the end pathological changes.

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