Although a fermenting form it is much less active than B. welchii and its gas production, in cultures and in tissues, where it may be the sole anaerobic infection, is much less. It is a stricter anaerobe than B. welchii. Toxine and antitoxine have been well studied and successfully used. 3. B. oedematiens, an organism discovered by Weinberg and Seguin during the war (1915) but which is closely allied, if not identical, to Novy's bacillus (1894), is a quite frequent cause of gas gangrene and is relatively difficult to isolate from mixtures. It is about the size of vibrion septique, shows a marked tendency to chain formation, is motile, but this is very rapidly lost, and its spores are relatively few. It is a very strict anaerobe and is a fermenting organism with little or no proteolytic power. In animals it gives rise to much edema with very little gas and the same is true in man. The toxine is known and the antitoxine has been prepared and successfully used in human infections. 4. B. tetani isolated by Kitasato (1889) is the anaerobe most feared by the surgeon and rather rarely identified by the bacteriologist. It is present in some 15 per cent. of horse feces and in about 5 per cent. of limited number of human feces especially if the individuals come in contact with horses. It is one of the fermenting anaerobes, has a very meagre proteolytic power which Rettger pointed out some years ago, is long and rather slim, actively motile and its spores are terminal and round. Stock cultures of the tetanus bacillus are rather frequently found to be mixed with other anaerobes more particularly B. sporogenes. Its colonies are quite small. In a concentrated study in the Lister Institute, London, on end spore bearing bacilli it was found that round end spore bearers culturally and morphologically similar to B. tetani but lacking in toxicity are present in the wounds. Harde found the same types in seven of sixty non-tetanic cases. The important points, that with the more general use of antiserum, the incubation period became longer; that repeated doses of antitoxin in the serious wounds and always before secondary operation were necessary; and that, as the antitoxin disappeared from the system in about a week, the symptoms of local tetanus may appear, if the organisms are still growing in the wound, should be here em phasized. The evidence of delayed tetanus in secondary operations weeks and months after the initial injury goes to show that the organism does not develop until its growth and toxine producing requirements are fully met. The symbiotic importance of B. welchii, virbion septique and others in stimulating the infection with B. tetani and the destructive action of B. sporogenes on its toxine are observations which merit further study. 5. B. tertius (Henry, 1917, but previously described by Rodella, von Hibler and others) belongs to a group of anaerobes frequently reported from feces and other sources and given its present name by Henry to indicate that it is the third commonest anaerobe in war wounds. It belongs to the fermentative group, is very slim, usually actively motile, forms end spores in all media which are decidedly oval but which might be confused with B. tetani in young cultures where immature spores are present, its colonies are small and it is believed to be quite harmless. The observation that it flourishes under conditions in media, which are favorable for B. tetani, is important as it is much more readily cultivated, growing well under many anaerobic conditions. 6. B. sporogenes (Metchnikoff, 1908) is the second commonest anaerobe found in wounds. It is a rather small, very actively motile bacillus and forms spores readily which help in its isolation, the spores being subterminal or central and usually distort the bacillus. Motility does not cease with spore formation. It is proteolytic and putrefactive. Supposedly pure cultures often contain other anaerobes such as B. tertius, vibrion septique and others the characters of which are less distinct in cultures, and, therefore, readily overlooked. Its presence in foul smelling wounds and putrefactive cases of gas gangrene as well as its use in treatment make it an important organism in bacteriological study. It is very common, being present in all butcher's meat, as a contaminant in incompletely sterilized media and in many samples of human and animal feces. 7. B. histolyticus (Weinberg and Seguin, 1916) is an active proteolytic form. It is about the size of B. sporogenes but spores are relatively few and the motility is readily overlooked. In animals its destructive action on muscular and other tissues is truly remarkable, no other microorganism showing such active digestion of tissue. Its production of tyrosin* in meat medium is its most striking character in the test tube. Its general distribution has not been determined but it is fortunately rather rare in war wounds. Its use in preparing bone specimens on account of its very complete dissolution of protein matter has been suggested. A great many more anaerobes deserve mention in this connection such as B. aerofetidus, B. fallax and numerous others but I have limited myself to these seven as bringing out the most interesting points of our present knowledge. I wish to emphasize that the clinical classification of gas gangrene cases does not find confirmation in bacteriological study. B. welchii can produce the condition with gas as the predominant feature, or on the other hand, with an outstanding edema and little or no gas. It is also commonly present where there are no manifestations and mixed infections give a great variety of clinical pictures. I have tried to show in the briefest possible manner the reasons as they appear to me from the bacteriological point of view for the success of a few of the treatments used in this war. These may be summed up by saying that the methods found to be most efficacious depend on 1. depriving the bacteria of the conditions necessary for their growth, largely a question of starvation; 2. the attempt to neutralize their harmful products, the acids by alkaline dressings, the toxines by preventing the production in unfavorable surroundings or by specific antitoxine and 3. very little if at all on antiseptic dressings. The only important exception to this is the sterilization of the edges of the wound to prevent the influx of further bacteria. I cannot finish this brief discussion of war wound bacteriology without saying that I am convinced that hemolytic streptococci are almost, if not equally, as important in the serious infections as are the anaerobic bacteria and that they 2 more difficult to treat by reason of their higher invasive power. Levaditi has particularly studied the importance of streptococci of various types in wounds, especially in connection with early closure. In conclusion I wish to say that the anaerobic bacteria are extremely common and frequently infect man. They find conditions for growth in *I have been informed by Dr. Kendall that the white crystals formed in such abundance in these cultures are not tyrosin. They are, however, the most striking characteristic. regions of the body which at first glance would appear to be strongly aerobic such as in and about the air passages. Microscopic areas may be sufficient to give them a foothold as we have shown. The technical difficulties have prevented their more general study and as these are overcome we may hope for a greater advance. I have not considered the infections with many anaerobic microorganisms such as the spirochaeta pallida, the actinomyces and others but have endeavored to show you that anaerobic bacteria in themselves are of great importance to man and to suggest that their greater importance may be shown in the future when we have developed better methods of study. BIBLIOGRAPHY. Davies: Lancet, 1916, ii, 603. Distaso: Lancet, 1916, i, 74. Donaldson: Lancet, 1917, ii, 445. Harde: Ambulance de l'Ocean-Depage, 1918, ii, 185. Henry: Jour. of Path. and Bact., 1917, xxi, 844. Herter: The Common Bacterial Infections of the Digestive Tract. New York, 1907. Jungano and Distaso: Les Anaerobes. Paris, 1910. Kendall: Amer. Jour. Med. Sci., 1918, clvi. 157 and others. Levaditi: Ambulance de l'Ocean-Depage. 1918, ii, 265. McIntosh: Medical Research Committee National Health Insurance. Special Report, Series No. 12, London, 1917. Rettger: Jour. Biol. Chem., 1906, ii, 71 and others. CYST OF THE THYROGLOSSAL DUCT; A REPORT OF TWO CASES.* OTTO T. FREER, M. D., CHICAGO. The middle lobe of the thyroid gland originates in early fetal life from a pocketing of the epithelium of the anterior pharyngeal wall at the place where the anterior bud or tuberculum impar, which becomes the anterior part of the tongue, is met posteriorly by the two posterior buds which form the base or root of the tongue. From this meeting point the invagination of the epithelium descends, prolonging itself as the thyroid gland moves downward to its normal site in the neck, a narrow, epithelial tube, the thyroglossal duct resulting, whose beginning on the dorsum of the tongue is permanently indicated by the foramen cecum, the little pit that is seen at the apex of the V-formed by the papillæ circumvallatæ. The thyroid duct is a very early fetal structure, being formed and losing its con *Read before the American Laryngological Association, May, 1918. tinuity normally before the creation of the cartilage of the hyoid bone, the duct disappearing at four and one-half weeks, while the cartilage of the hyoid bone does not appear before the end of the fifth week. The lingual part of the thyroglossal duct may remain open throughout life as the lingual duct, a fine canal of varying length that begins at the foramen cecum and may even extend as far as the hyoid bone, a distance of about 212 centimeters. To meet the ductus lingualis the middle lobe of the thyroid gland (called the processus pyramidalis) extends upward from the thyroid isthmus, its continuation in the form of a fibrous band or tube often reaching up underneath the body of the hyoid bone to the level of the hyo-epiglottic ligament. The ductus lingualis and the processus pyramidalis represent the track of the original thyroid embryonic descent. In most individuals the thyroglossal duct vanishes in fetal life, but in thirty per cent of a number of bodies examined by Woglinski remains of the primitive duct were found in the path from the foramen cecum to the thyroid notch, these vestiges remaining unnoticed unless they take the form of separate lobes of thyroid tissue, portions of the duct as a band or tube, cysts or fisctulæ. Where the upper part of the thyroglossal duct fails to disappear it always lies close to the posterior (dorsal) surface of the body of the hyoid bone and may even pass through the bone. Thyroid tissue has been found in the body of the hyoid bone. Thus, while every vestige of the thyroglossal duct usually disappears, the thyroid gland becoming completely detached from its connection with the pharynx, traces of the fetal descent of the gland may be found along the thyroid tract anywhere from the foramen cecum to the thyroid isthmus. The highest of these traces is an accessory thyroid gland in the tongue in the region of the foramen cecum, verying from cherry size to that of a hen's egg and it has even been found that all of the thyroid tissue in the body was collected in this locality, the fetal descent of the thyroid gland never having taken place. The next remnant of the thyroglossal duct is the ductus lingualis mentioned. Still lower may be found a processus pyramidalis. In other cases there is no thyroid tissue in the track of the thyroglossal duct, a fibrous cord being found as a remnant of the duct. This may reach from the upper border of the body of the hyoid bone, lying against its dorsal surface, to the isthmus of the thyroid gland, or a portion of the open duct may remain, ending in a fistula in the median line of the neck or beside it, or the fibrous remains of the duct may be found to descend only a short way, ending in a median cyst or the duct may expand to a cyst somewhere in its length. Case I. In October, 1914, the patient, a man, aged 57 years, began to have difficulty in swallowing and at the same time noticed a swelling in the region of the thyro-hyoid space. When first seen, April 19, 1915, the swelling had increased and there was an increase in the difficulty in swallowing, so that to the hyoid bone when the patient swallowed, that is the cyst became pinched between the two structures. Operation on June 17, 1915. After dissecting off the superficial fascia and platysma muscle from a vertical median incision a strong, tendinous layer of fascia was exposed that was attached to the lower border of the hyoid bone above and to the border of the thyroid notch below, so firmly binding down the cyst between itself in front, the median thyro-hyoid ligament behind and the thyro-hyoid membrane laterally, the cyst being unable to escape from the compartment in which it was confined when pinched during swallowing. When exposed by removing the fascia described the wall of the semitransparent cyst (Fig. 1) was found to be so frail that it could not be seized lest it tear. This made the dissection tedious as only the tissue surrounding the cyst could be held with tissue forceps the cyst being held aside with dull retractors. The cyst was removed unhurt from its bed and was found to end above in a fibrous pedicle that lay against the posterior surface of the body of the hyoid bone and could be followed as high up as its superior border at the level of the hyo-epiglottic ligament. Removal of the cyst exposed the median thyro-hyoid ligament to view, this ligament forming the posterior wall of the compartment in which the cyst had been confined. Microscopic section of a part of the cyst wall showed it to be composed of fibrous tissue lined with a layer of leucocytes intermingled with numerous, evenly distributed giant cells. There was no epithelium. The cyst contained a clear fluid. The removal of the cyst enabled the patient to swallow normally. Case 2. The second patient was a woman, aged 32 years. First seen November 8, 1916. She had a swelling over the larynx since her tenth year. Iodine was injected into this swelling during the summer and since this was done the swelling had gradually increased in size. Examination showed a spindle-shaped cystic tumor of the size of a walnut in the prelaryngeal region. The upper pole of the cyst could be felt to dive under the centre of the body to the hyoid bone; its lower pole dwindled to a cord that could be felt to reach the region of the thyroid isthmus. Operation under cocaine on Nov. 17, 1916. It took two hours to dissect out the cyst, as only the most delicate handling could prevent its rupture and inflammatory changes caused by the iodine injection had made the cyst wall grow to its surroundings, so that the thyro-hyoid and sterno-hyoid muscles were firmly joined to it in front. The upper end of the cyst ended in a cord that extended upward under the body of the hyoid bone to its upper border where it was lost in the hyo-epiglottic ligament. Below, the cyst ended in a similar cord that joined the isthmus of the thyroid gland. When freed from its bed just before removal, the cyst ruptured, thick pus escaping, a cold abscess caused by the iodine injection. After the cyst was taken away, the thyroid and cricoid cartillages, upon which it had lain, were bared to view. In the first case the possibility of the cyst being one derived from a subhyoid bursa might come into question. However, the pedicle which formed a cord passing up under the body of the hyoid bone in the location of the thyro-glossal duct showed the thyroid origin of the cyst. In the second case the entire thyro-glossal duct, expanded to a cyst in its middle, was present to prove the correctness of the diagnosis. Related to this subject is a report by Dr. T. W. Lewis of Chicago, presented to the Chicago Medical Society some years ago, but not yet published, of obstinate cough caused by suppuration of the ductus lingualis, pus discharging from the foramen cecum. Dr. Lewis also described a large lingual thyroid gland that he showed to me and which had led to repeated severe hemorrhages. THE UNWARRANTED SACRIFICE OF H. M. HARRISON, M. D. QUINCY, ILLINOIS. In presenting this subject for your consideration, I do not do it with a view of antagonizing real progress in medicine and surgery, for I am an optimist, and quite an enthusiast concerning the achievements of our profession, but feel it incumbent to help sound the alarm against the excesses committed in the many unnecessary removals of the tonsils, especially in the young. I am quite aware that I am not in full accord with the present time professional dictum in the presentation of this subject, but believe this to be an opportune time for its thoughtful consideration and discussion. We must admit that fads obtain in our profession, as with other aggregations of the human family, and many have been the votaries, as evidenced by the voluminous discards, in our literature of the past. So may not the pendulum of excess, or faddism, be again swinging far beyond the rational middle ground of conservatism in the present day removal of the tonsils. May we not anticipate, that when agreed and true his *Read at the sixty-ninth annual meeting of the Illinois State Medical Society at Peoria, May 22, 1919. tologic interpretations of the tonsillar bodies are had, safe and sane rules will obtain and govern those engaging in this line of work, as has been the case in other procedures, so rife in the past? In the construction of the complex human machine, the Great Creative Genius placed within that structure all the elements and parts seemingly for some purpose and as a whole it was pronounced good. Whilst we have to do with the degeneracies of that perfect organism, we should be very circumspect in our surgical meddling, lest there follow undesirable functional entailments, some of which are being pointed out of late, even through the channel of legal prosecutions. The histology of the tonsil, at the present time, seems almost an anomaly, for we find a great array of talent on both sides of the question as to just how and through what channels the infections travel. The earlier writers believed that the ducts of the mucous glands opened into the tonsillar crypts, and some of the text-books reiterate that today, but others, like Labbe, Serugne, Von Levinstein, Frankel and Maclachlan, have shown that they open at the periphery of the tonsil. Wright says that with our present knowledge it is not accurate or proper to attempt a discussion of the physiology or function of the tonsil. He enshrouds the process of infection with the obscuring theory that it is of a physicochemical nature, which does not clarify the subject as to how, where or through what channels the bacteria enter and travel, in their infectious course, leaving only the inference that the tonsils are subject to infections the same as all other organized bodies having the ordinary chains of lymphatics and subject to the same local and constitutional influences. Stöhr, and others, have defined a peculiar arrangement of the epithelial lining of the tonsillar crypts whereby dehisences occur, which are believed to permit the entrance of micro-organisms, which is only another way of explaining the solution of continuity so favorable to infection. A multitude of authorities might be cited, pro and con, but they do not help us to get anywhere in the solution of this intricate problem. As a matter of fact all mucous membranes are especially susceptible to infection from the myriads of bacteria that find lodgment on their surfaces, if the conditions are favorable. So why pick out the tonsil as the chief offender and extirpate it, normal or abnormal, right or wrong, and perpetuate the habit, which Fetterolf says represents practice only, not principle. The faucial tonsils that are left still have an entity and we wish to describe them grossly ́as being deeply located between the anterior and posterior pillars of the fauces. They are composed largely of lymphoid tissue, said to be closed lymphatics, having no large afferent or efferent lymphatic sinuses, as have lymph nodes. The faucial surfaces are covered with a mucous membrane that lines even the crypts and dips well down in the sulci of their lobulated structure. They possess the same lymphatics as any other organ, and are encased within a dense fibrous capsule. The position and environments the faucial tonsils occupy, enter into their being so frequently involved in inflammatory attacks and offer a mechanical difficulty in their safe removal; being located in a muscular trigon or fossa, composed of the palato-glossus anteriarly, palatopharyngeus posteriorly and the superior constrictor muscle externally, or at their base, rendering it difficult to separate them from this muscular environment without injury. Then in a large percentage of throats we find the remains of an embryologic membrane in evidence over and about the tonsil and pillars. This membrane, called the plica-triangularis, is attached at its base to the side of the tongue and extends over a part or all of the tonsil to be attached to the anterior pillar and some times to the posterior pillar. This whole, or partial, encompassing of the tonsil presents a perfect picture of faulty drainage that most surgeons would certainly correct were their attention called to it. We believe that this faulty drainage is the most important thing we have to reckon with in abnormal tonsils. The normal action of this muscular trigon around the tonsil in each effort at swallowing, is to seize it and squeeze or express out the contents of the crypts, mucous follicles and peritonsillar spaces, a massaging in other words, that tends to clear it of all offending detritus, etc., and the massaging helps in its retrogression after childhood. Take the tonsil and muscles crippled by this plica and we have the anterior pillar sweeping over the tonsil by reason of the attachments of this membrane to the pillar and side of the |