inherited neurotic disposition, the convulsive attacks appear much sooner after the advent of the irritative lesion and, as a rule, the epileptic habit is early and fast ingrafted upon the constitution This irritation once relieved or remedied, the habit still persists in these latter cases, and to all intents and purposes the patient has the appearance of suffering with idiopathic epilepsy. When such is the case, the nature and origin of the disease are almost impossible to ascertain and the epilepsy is erroneously classified as spontaneous or inherited.

The question may now be asked: "What shall we look for in deciding the immediate causation of reflex epilepsy?" As a rule, whenever practicable, I have the patient remove all his clothing and examine him thoroughly, beginning with the feet.

Ingrown toe-nails, corns and callouses are not infrequently the cause of epilepsy. Scars about the limbs, disorders of the genitalia, incomplete descent of one or both testes, are some of the causes in youth. In girls, the condition of the clitoris and vulva should be ascertained, also whether there is incontinence of urine, or the presence of oxyurides in the vagina or rectum. Hare, in his monograph on epilepsy, says: "It may be laid down as a fact that in all cases in girls in which epilepsy of unknown cause develops, the the vagina should be examined for the presence of any pin-worms which may have engrafted from the rectum." The condition of the rectum should not be overlooked, but carefully explored, especially for ulcers and irritating hemorrhoids. Coming to the head, we have an extensive field for examination. The mouth, nose, ears, eyes and scalp may all harbor seemingly trivial disturbances, which, under other circumstances, would pass unheeded and unnoticed. Disorders of dentition, such as faulty direction in the growth of the teeth, hidden fangs, caries, neoplasms in and about the buccal cavity, retained foreign bodies in the pharynx, scars-the result of ulcerative or specific processes about the tonsils, tongue and larynx -polypi and foreign bodies in the nose and ears, disorders of refraction; in short, whatever can impinge either directly or indi

rectly upon nerve trunks or nerve filaments, other conditions being equal, may produce reflex symptomatic epilepsy.

These, then, are some of the more common of the external causes, and to discover them is easy-very easy, as compared with the probable internal causes. No doubt you are all well acquainted with the stomach as a very frequent contributor to this subject. Those of us who pay special attention to nerve diseases, receive many cases labelled "Epilepsy, due to Stomach Trouble." The round worms of the intestines are a common cause and have been recognized as one of the most prolific factors in the etiology of this disease. Disturbances of nearly every internal organ have, according to various writers on this subject, been at one time or another, instrumental in precipitating these attacks.

There are two organs, however, in this list of causative agents to which I briefly invite your special attention, namely: the stomach and the urethra-two of the most important canals known to man, lay or professional: the stomach, because it receives not only that which nourishes and sustains the human economy, but nearly everything else that cannot be conveniently sewered in some better way; the urethra, because through it flow little drops of water mixed with little grains of sand, at times another fluid, coming from another gland. In a boy, and not necessarily such a small boy either, what two organs are subject to more use, abuse and refuse, and what two organs call forth more care, repair and despair? Surely none.

The importance of the stomach as a primary etiological factor, is, in my opinion, over-estimated. I will not deny that in some cases the ingestion of indigestible matter invites convulsions, and that after a thorough emesis or purge the spasms disappear. Many patients tell their physician that such was the cause, the starting point of the first attack, and the physician confidingly tells the specialist the same story. They will further testify that they can foretell the onset of an attack by the voracious appetite, peculiar sensations at the pit of the itomach, vomiting of watery fluid and the patient's desire to eat anything and everything that comes within his reach. Put this patient on Put this patient on a bland and exclusive milk

diet and keep him on it for months; give him pepsin, trypsin, papoid and strap-oil until he turns blue in the face and if your experience is similar to mine, he will continue to convulse and froth at the mouth, and you are fortunate, indeed, if his parents do not become similarly affected. I believe that in many of these we are on the wrong trail and must seek the cause elsewhere. The symptoms denoting gastric affinity are not so much epilepto-genic as epileptopathic. These disturbances, as the patients and parents declare, hold a close relations to the paroxysms, and I believe they are only localized epileptic attacks or epileptic equivalents. The increased tension in which the nervous system is held just prior to an attack, stimulates the gastric glandular system through the sympathetic and pneumogastric nerves, calling forth an abnormal secretion of gastric fluids, and the flow of gastric juice means an appetite. The stomach naturally becomes tender and hyperesthetic under such rule long continued, and anything that irritates or demands undue exercise of its function, is rewarded with stern rebuke. I have seen the stomach perform similar antics in hysteria and general paresis, and yet neither you nor I would affirm that the gastric trouble was the cause of these ailments.

Now turn to the urethra, such as is controlled by a boy from his eighth to his eighteenth year. He may live high or live low, be a street urchin or a mother's pride, a country lad or a city tough; it matters little; he is for all that a boy, and as dogs will be dogs, so boys will be boys. The same old story-he has eaten green apples and had fits; he has been doctored for his stomach and, strangely enough, the fits still persist. As he comes into your cffice you notice that his head hangs, his eyes are dull and sunken, his gait heavy and labored, and his answers are backward and evasive. You put the questions direct and with force, and he admits that he has occasionally masturbated-but that he learnt it from the other boys. Now, instead of upbraiding and threatening him, you do your duty and examine his genital organs, inside as well as outside, and in nine cases out of ten you will find some irritation, seated most generally in connection with the penis. The prepuce may be too long

or too short, adherent or constricted; the frenulum may be too short, causing a mild form of hypospadia; or the prepuce has never been everted and large accumulations of smegma are present. Supposing that none of these conditions are found, you have still the most important examination to make the exploration of the urethra and how many times it is undertaken in these cases? The boy has never had connection and hence, you infer, no gonorrhea with its attending inflammations and strictures, and why waste time in such an absurd procedure? But try to introduce a No. 12 or 15 French Benas catheter, and although they glide along so nicely at other times, you are beset with obstacles in passing through constrictions, evading the boy's hands, and in convincing him that his urethra is anesthetic and that he does not feel any pain.

I am thoroughly satisfied that there are many disturbances present in a good boy's urethra which prompt him to vicious habits, and they in turn, if his constitution is impressionable, lead to serious nervous disorders, such as chorea, epilepsy and neurasthenia. Vegetations, polypi, cysts or other neoplasms in the walls of the urethra, creating strictures, hyperesthetic areas, low forms of inflammation, etc., are translated by such symptoms as priapism, spasm of the urethral muscles, frequent micturition, spermatorrhea, masturbation and sexual excesses. The influence of these morbific agencies upon the central nervous system is too well known to be here reviewed.

The more a boy's urethra is examined, the more I am convinced that it's not what it is cracked up to be; further, that a virgin urethra may be as full of strictures as his pockets are of marbles in the spring; still further, that by virtue of the morbid processes present, he may have an urethral discharge which is as innocent and. innocuous as are the conditions giving rise to it.

In a short period of time I have treated six boys with reflex neuroses, five of which were reflex epilepsy, due unquestionably to disturbances along the urethral canal. In some of these cases I have found the meatus urinarius surrounded by a red border or ring, indicating, perhaps, the congested state of the urethral lining. An

urethroscopic examination should never be omitted, for by its revelations the exact nature of the lesion can be determined.

My treatment of these patients has consisted, besides the administration of the bromides, in the use of a mild galvanic current or from one to five miliamperes, each treatment lasting about three minutes, three times weekly. In the employment of the ordinary urethral electrode I have been annoyed by several inconveniences. The olive point electrode is more or less inflexible; besides, having a metallic point, its introduction in many cases becomes difficult, owing to the fact that a contraction of the urethral walls is produced through the stimulus imparted to the mucus membrane by the metal. Then, too, in cases of stricture, vegetations, etc., where the electrolytic action is desired, the metallic point is liable to produce injury in its passsge, or when the olive is in close proximity to the sphincter vesica a strong current may produce unpleasant suquellæ.

To overcome these drawbacks, Messrs. George Tiemann & Co. have made for me an electrode possessing lightness, flexibility and a non-metallic bulbous point. A Benas catheter or bougie is encircled with a narrow steel band about one to one and one-half inches from its bulbous extremity. This band is connected with the attachment end by means of a soft copper wire extending through the interior of the catheter. The electrode is made in two sizes, Nos. 15 and 20 of the French scale. In all cases thus far in which it has been used, it has given perfect satisfaction.

In conclusion, I wish to report what to me is a typical case of reflex epilepsy:

Bessie B.; aged 3 years and 9 months; weight, 31 pounds; height, 37 inches; constitution, rather delicate; complexion, fair; hair, brown; eyes, blue. Antecedents: Parents, both living and healthy, offering no hereditary taint of any kind, no history of syphilis or tuberculosis.