Stridor has been present in all cases, and frequently has drawn our attention to the condition. Holding the breath as described by many mothers, especially when associated with cyanosis and exhaustion, may be due to enlarged thymus. Two of my cases came with this complaint. Spasmophilia is frequently associated with status lymphaticus and is probably part of the general condition. Chvosteck's sign and Trosseau's sign are present. This is usually associated with the convulsive type of the disease. In many cases rickets was present to a more or less degree. The association of congenital cystic thyroid and enlarged thymus was found in one of our very recent cases. This case was first seen through the courtesy of Prof. Slemons. The condition was noted immediately after birth. There was a large thyroid and a thymus extending down to the second rib and well into the right chest. This case has since been referred to the Welfare Station. The thyroid and the thymus are rapidly growing smaller without specific treatment of any sort. This is evidently not a rare condition as Clarke and Farmer recently reported a similar case and to-day Dr. Brayton has also reported one. Two of our cases presenting persistent thymus were mentally retarded. Persistent thymus may occasionally be mistaken for laryngeal diphtheria, especially the intermittent dyspnoeic type. The character of the breathing and the retraction are most similar. Physical examination, however, will show the enlarged thymus. We had a case of this type and it was necessary to do tracheotomy, but without success. Post-mortem examination showed an acute congestion of an already tremendously enlarged thymus. Death took place sixteen hours after the onset of the symptoms. The diagnosis is most easily and positively made by the X-ray. X-ray, or as shown to-day by Dr. Brayton, radium is the ideal treatment for the disease. In three recent cases exposure to the ultra violet ray has reduced the size of the gland and has reduced the severity of the symptoms. I would like to thank Dr. Brayton for his paper and for bringing the subject before this society. DR. BLUMER (New Haven): Mr. Chairman, if it is permissible I should like to say a few words about enlarged thymus in adults because I feel that this is a subject neglected even more than enlarged thymus in infants. In connection with the studies of the Vienna School the whole question was brought before us many years ago, and for some reason the profession has not taken cognizance of its importance. It often is possible by physical examination and without the use of X-rays to detect the presence of status thymicus in a patient. These patients present certain peculiarities in secondary sexual development. In the case of the male there is generally a very sparse distribution of hair. The hair of the beard is often extremely sparse; there is a lack of hair on the chest and on the body generally, and the pubic hair is usually of the female type; instead of tapering up toward the umbilicus in the form of a triangle it is cut sharp across right above the pubes. These patients also are rather gracefully built. Many of them show a distinct outward bowing of the thighs and a fair number of them have rather small testicles and a small tapering glans penis-so it is possible to recognize them even without the use of the X-ray. The importance of the recognition of these cases lies in the bearing which status lymphaticus has in certain diseases. Emerson of New York particularly has called attention to the fact that a great many drug habitués belong to this type, even alcoholic habitués, and particularly he points out that the drug habitués that they see in such large numbers at Bellevue Hospital are very frequently subjects of this status lymphaticus. The second clinical bearing these cases have is that they withstand infectious diseases very much more poorly than normal individuals, and particularly certain infectious diseases such as diphtheria and meningitis. In those diseases the prognosis is very much more grave in them than it is in the ordinary individual. In the third place I think the relation of the enlarged thymus to exophthalmic goiter needs to be emphasized more than it has been, because cases of hyperthyroidism with enlarged thymus present a much graver prognosis than the cases of Graves' disease. If you will look through White's article in the Quarterly Journal on the prognosis of hyperthyroidism in which he details a considerable number of autopsies, you will be surprised to find that a large proportion of those fatal cases showed a considerable enlargement of the thymus gland, and a number of those cases of hyperthyroidism with intense digestive disorders, and extreme toxemias, are cases that have shown by X-ray evidences an enlargement of the thymus gland. So even though it does not exactly bear on the question of thymus enlargement in infancy, I take the liberty of calling attention to the importance of it in adult life. DR. E. H. ARNOLD (New Haven): Since Dr. Blumer has drawn attention to the changes in the skeleton I might invite it to the fact that mild case of this type that persist for some time will undoubtedly furnish one of the causes of deformities of the chest. These deformities are noticed in the young men now coming for examination for military service and have some bearing upon their fitness for service. In the case of young women these deformities represent, besides their influence on health, a great cosmetic blemish. I refer to funnel and chicken breast. If the thymus is slightly enlarged and acts as a valve it will hinder respiration and you will get malformation of the thorax. If it hinders inspiration you will get a cumulative minus pressure in the thorax as compared with outer atmospheric pressure. The greater outside pressure will push the thorax in at the points of least resistance, i. e. at the site of the costal cartilages and you will get a funnel breast. Conversely where the thymus hinders expiration you will get a progressive plus pressure in the thorax which will make the thorax bulge in the same place, chicken breast resulting. These deformities come to the orthopedist when the child is becoming a youth and when it is much too late to do anything for them. These deformities can and should be prevented. Greater care, then, should be taken of the condition treated of in this paper in infancy to remove one possible and probable cause of the deformity. Dr. Osborne (New Haven): I would like to emphasize what Dr. Blumer says in regard to the thymus in relation to hyperthyroidism. It has not been shown that thymus feeding can do any real harm unless the dose is very large. Why the thymus so many times is enlarged when the thyroid is enlarged and hypersecreting, we do not know, but it may be that it tries to overcome some of the toxic effects of the thyroid. At any rate, using Radium or X-ray to diminish the size of the thymus in hyperthyroidism has, in my experience, done no good to that condition. Also, many times I have found that in hyperthyroidism feeding thymus has seemed to aid in combination with other proper treatment in the reduction of the toxemia and in the reduction of the hypersecretion. Now, just what this gland does has not been shown. A child seems to require this gland and at puberty he is through with it, and the other glands take up its work, notably the increased activity of the thyroid and possibly other glands, but the greatest difference between the child and the adult is his bone growth. Therefore, it has been thought that this gland, which is rich in nucleins and phosphorous radicals, and possibly in calcium, has to do with the bone growth as well as has the thyroid and the pituitary glands. We must recognize that the rapidity with which this gland when it is enlarged becomes normal under radium and X-ray, probably shows that it is simply normal hypertrophy. Surely it is not a tumor or pathologic growth. Certainly the whole story is exceedingly interesting and we are all very grateful to the writer of the paper for presenting the subject to us. DR. BRAYTON (Hartford): I wish to thank Dr. Linde for leading the discussion. Dr. Linde has done pioneer work in the treatment of this condition in Connecticut. Our knowledge of the intricate subject of internal gland function is still in its infancy. We do know, however, that there is a close relationship between the thyroid and the thymus. This is shown by the fact that certain cases of hyperthyroidism which do not improve after thyroidectomy are helped by removal of a portion of the thymus. The last case I reported also suggests this inter-relation of the two glands: in this infant the thymus and thyroid were both enormously enlarged and both shrunk synchronously after radium treatment. Only recently has experimental work on excision of the thymus been of value, for the early workers apparently failed to completely remove all gland substance. When totally extirpated, fatal nutritional disturbance invariably follows. The question of thymus function in adults and especially its relation to secondary sex characteristics I did not touch upon and do not feel qualified to discuss. Laws Governing the Commitment of the Insane. The Importance of Early Hospital Treatment for Manic-Depressive Cases. WHITEFIELD N. THOMPSON, M.D., HARTFORD. The laws governing the commitment of the insane were revised and amended at the 1917 session of the Legislature, with the result that the operations through which a person mentally ill may reach hospital care and treatment were very much simplified. My purpose in presenting a review of these laws is to call the attention of members of the Society to their more liberal provision, to the end that patients may be brought more promptly under hospital care. Some of you have heard an able psychiatrist, a member of this Society, say that the worst place in which to attempt the care of an insane person is the home. No one can gainsay this, for it means the employment of drugs, the attention of nurses not skilled in the care of mental cases, and the ready expression of sympathy on the part of the family, all of which are bad, when not actually pernicious. Heretofore when question has existed as to whether or not a patient's condition warranted commitment, the committing authorities have had no option but to await the development of symptoms marking the case as unmistakably insane. This period has not infrequently been spent under most unfavorable conditions for the patient, as in an almshouse, a lock-up, or jail. Consider, if you please, the situation of a person sick in body and mind, unable to think, feel or judge normally, out of harmony with his environment, in need of nursing and medical attention, shut away to await the break of the storm. Such a situation ought never to be tolerated except in an extreme emergency. The laws designed to protect the patient's interests have had the effect to permit the opening of hospital doors only by a court order. The patient's rights have been duly protected while his chief interests have been sorely |