notch during inspiration, but even in the most extreme cases we have been unable to duplicate their findings.

Percussion (Slide 2) generally reveals an area of dullness extending either side of and continuous with the usual hyporesonence of the upper sternum. This dullness, as a rule, is more pronounced on the left, but unless very light percussion is employed the entire area will be obscured by the transmitted resonance of the underlying lung.

(Slide 3.) Often, when dyspnoea, supraclavicula and epigastric retraction are slight, they may be accentuated, or when absent may be produced, by forcibly extending the head over the edge of a table or pillow. This procedure should never be resorted to, however, in extreme cases for fear of sudden death.

A condition (Slide 4) often simulating thymic dyspnoea may be found in certain marasmic infants in whom the throat muscles are so poorly developed that an excessively long palate is allowed to drop down upon the dorsum of the tongue. This gives rise to fits of choking and coughing and at times considerable stridor.

The one diagnostic means which stands above all others and the only one which is infallible is the X-ray (Slide 5). By its use the contour of the gland may be seen normally projecting but little either side of the sternum, and continuous with the heart shadow-compared often to the neck of a flask extending up to the clavicles. Normally the sides of the shadow are concave (Slide 6), while the enlarged gland gives an outline the sides of which are both displaced laterally and bent convexly. The left lobe of the gland is usually enlarged more than the right, which corresponds with the percussion findings. Great care must be exercised in placing the child flat on the back during the exposure for otherwise the mediastinal structures will be projected obliquely, with a resulting worthless negative.

The treatment of enlarged thymus is simple and specific:-it consists solely in radiotherapy.

Although for over a decade the X-ray had been employed to decrease the size of the gland, the method did not come into general use until about three years ago. Even then the technique of treatment varied so in the hands of different workers that

contradictory reports arose as to its efficacy. The matter was finally clearly defined in July of last year when Friedlander of Cincinnati published a series of over a hundred cases in only four of which X-ray therapy was not successful. He attributes his good results partly to his standardized method of treatment which consists in using a tube of known penetration, a constant target-skin distance, a filter of certain thickness, a definite length of exposure and repeated treatments.

Last year the writer was asked to see an infant who was suffering from extreme thymic asthma. Roentgen ray treatment was advised and the case referred to Dr. Heublein, who suggested that, owing to the severity of the symptoms, radium be substituted in the hope that its effect might be more prompt. The results of this substitution were so satisfactory that ever since radium has been used exclusively in both hospital and private cases.

(Slide 7.) The technique as formulated by Dr. Heublein is as follows: 100 millegrammes of radium element, still in its silver capsule, is wrapped in sufficient gauze so that when strapped to the chest by a strip of adhesive, it will lie a half inch from the skin surface. With a pencil dipped in ink four marks are made in the form of a rectangle over the thymic area and the nurse is instructed to allow the package of radium to remain two hours over each spot. This makes a total exposure of 800 millegrammehours.

Judged solely from the end results, there is little choice between radium and X-ray. By both methods a cure is effected, provided the child survives the effects of thymic pressure until the radiotherapy has had opportunity to reduce the gland. As yet we have had too small a number of cases to be able to state definitely which method produces the prompter amelioration of symptoms in severe cases. It is probable, however, that the effect of radium is noticeable about twenty-four hours earlier than that of the Roentgen ray, although from the fact that control experiments are impossible this view must be taken merely as an impression. Radium does have certain advantages over the X-ray, which may be summarized as follows:-With radium

one treatment alone suffices to effect a cure, even in the severest forms of the disease; radium is portable, thus obviating the difficulty of transporting the patient, often a considerable distance, to a Roentgen laboratory; the application of radium is simple, thus eliminating the dangerous element of fear from the mind of the patient, and at the same time rendering unnecessary the use of an elaborate X-ray equipment and highly-skilled operator.

The following illustrative cases are taken from the Children's Service of Dr. Goodrich at the Hartford Hospital and from certain cases my friends have kindly allowed me to see:

Case 1. (Slide 8.) A male child of eleven months entered the hospital because of convulsions, vomiting and diarrhoea. Physical examination at entrance was not remarkable except for eczema, malnutrition and rales in the chest. Lumbar puncture was negative. A few days after admission attacks of cough accompanied by cyanosis and dyspnoea developed. X-ray showed an enlarged thymus. Before treatment could be instituted the child suddenly died as the nurse was changing its napkin.

Case 2. (Slide 9.) A male infant, six weeks old, entered the hospital as a boarder during the illness of its mother. Physical examination negative. The baby was an ideal feeding case, gaining consistently on an increasing formulae, and showing no abnormal symptoms. Four weeks after admission was found dead in its basinette. Autopsy being refused, post-mortem X-ray negative was taken with the finding of enlarged thymus.

Case 3. (Slide 10.) A male child, seven and a half months of age, entered the hospital with a history of convulsions and cough for three months. The convulsions had occurred at intervals of about two weeks, each one lasting approximately twenty minutes. Physical examination revealed a child with cyanotic skin, stertorous breathing, and retraction of the chest during inspiration. A definite thymic dullness was demonstrable but at the left of the sternum only. This corresponded to the X-ray findings which showed an enlargement of the left lobe of the gland, with practically no change in the right lobe. The child promptly improved after the excitement of the examination had passed but nevertheless the parents were informed of the severity of the condition and arrangements were made to apply radium the next day. Early the next morning the infant suddenly died in the arms of the nurse, before an interne could be summoned.

Case 4. (Slide 11.) Male, 14 months of age, with a history of eczema, weakness and convulsions since birth. On close questioning these convulsive seizures were found to consist of the following sequence of events:—

sudden asphyxia, cyanosis, retraction of the neck, general clonic contractions, syncopy and exhaustion. Examination showed a flabby, eczematous child with bulging of the upper chest and well defined (Slide 12) thymic dullness, particularly to the left. X-ray corroborated these findings. (Slide 13.) Radium was applied. (Slide 14.) One week later the child was in much better general condition, having had no respiratory symptoms, and the skiagram showed a marked diminution in the size of the gland.

Case 5. (Slide 15.) Female, seven and a half months old, who had always breathed "as though she had a cold." For three months there had been an increasing frequency of general clonic convulsions. Dysphagia was present to a marked degree, the child choking, vomiting, and becoming cyanotic at each feeding. Again, examination showed retraction of the chest, cyanosis and stertorous breathing. X-ray confirmed the percussion findings of thymic enlargement and radium was applied. Within twentyfour hours there was marked improvement and at the end of a week the infant was practically well except for the fact that respiration was slightly more audible than normal. (Slide 16.) Another skiagram at the end of three weeks showed a radical change in the appearance of the gland.

Case 6. (Slide 17.) A female of eleven months who presented much the same symptoms as the preceding case, though to a much milder degree. The Roentgen plates before treatment with radium and one week after (Slide 18) demonstrate well the rapid effect of radiotherapy.

Case 7. (Slide 19.) This male infant, twelve pounds in weight, was seen one hour after birth. The labor had been easy but with the first cry the obstetrician had noticed that the child's breathing was decidedly abnormal. The patient presented the most unusual appearance; the skin, nails and lips were intensely cyanotic and the inspiratory stridor was distinctly audible in the adjoining room, while the epigastric retraction was equal to that accompanying the severest forms of laryngeal diphtheria. Percussion and X-ray both detected the presence of a thymus filling nearly one-half the chest cavity, while inspection, palpation and X-ray all revealed the presence of an enormous thyroid occupying the entire front of the neck as far back as the lobes of the ears. Radium was applied the following day and within 48 hours the baby showed decided improvement which continued until, at the end of a week, he was nearly normal in appearance. It was interesting to note that the thyroid disappeared coincidently with the shrinkage of the thymus. Repeated X-ray plates showed a steady diminution in the size of the gland shadow. (Slide 20.) Two months after discharge from the hospital the gland was again skiagraphed, this time showing an approximately normal outline.

From these illustrative cases it will be seen how varied are the symptoms of thymic enlargement. The severer types, which are comparatively rare, are easy of diagnosis, but the milder forms of

the disease, which go to make up the great majority, are readily overlooked.

Over half of our series of thirty-one cases have occurred during the past year. This is not coincidence, but is to be explained solely by the fact that the proper diagnosis in many cases have been missed. The more one sees of this condition the more careful he is to look for it in each new patient. Every infant who has inexplicable convulsions, who has "queer spells," who has habitual attacks of coughing, choking, rattling respirations, or blueness should have an X-ray of its chest in the hope of finding a condition which is so easily and satisfactorily cured.

DISCUSSION.

DR. LINDE (New Haven): The subject just presented is a most important one and Dr. Brayton is to be congratulated for presenting it in such an excellent manner. The results which he and Dr. Heublein have obtained with radium in this condition are really remarkable and to say the least, most encouraging.

In considering the subject of enlarged thymus gland in children we must remember that except for primary enlargement of the gland which may either be tuberculous, specific or neoplastic, the enlargement is usually the major pathological condition of status lymphaticus. There are certain things in the symptomology of the disease which I think should be emphasized.

The fact that there are two general types of symptoms, the first convulsive, the cause of which the Doctor has pointed out to be general in character, and the local symptoms, which are usually respiratory. These symptoms are dyspnoea, which may either be continuous or intermittent.

The continuous type is the common one in young infants, the respiratory difficulty in this type leading to suffocation and intense cyanosis. Dyspnoea continues between the suffocative attacks.

In the intermittent form the child is usually quite normal between attacks. Stridor is a most important symptom and while every case of stridor in young infants is not necessarily due to thymic enlargement it should make us suspicious.

Briefly from our twenty-four cases of this condition we can say the following:

All the usual types have been represented.

The majority of our cases have been Italian.