for the preservation of the normal "digestion leucocytosis," which is in evidence in the whole circulation, but pre-eminently in the intestinal wall. The role of the leucocytes in attacking invading cells, is well known, and they even segregate arsenic, for instance, in arsenical poisoning.

The liver, along with its other functions, combines that of rendering toxic agencies less noxious. It is estimated that it normally reduces the toxicity of the blood brought to it by one-third, and by how much more in disease, has not been determined.

Animal and vegetable alkaloids are peculiarly subject to its reducing action. Ammonia is there synthetized to harmless urea. A striking example of its reducing power is given by guaiacol. Administered internally, it is not possible to obtain a striking antipyretic effect in fever, but fifteen or twenty drops absorbed by the skin, gives an immediate and powerful effect, notably in the pyrexia of tuberculosis, pneumonia and typhoid fever.

The ductless glands are now credited by all investigators with playing a leading part, not only in the normal metabolism of the body, but in its defense in time of war. Even the littleunderstood thymus is believed to be charged with the duty of reducing catabolic poisons in the blood during foetal life. Up to the present time the deplorable fact remains that we do not sufficiently understand their reciprocal functional relations and their combined effect upon the organism, and the changes of function produced by disease, much less how to meet these changes. Sajous, for instance, claims (on what evidence it does not appear) that at the moment of a convulsive seizure there is an enormous hyper-secretion, whereas there was a hyposecretion precedent to the attack.

The emunctories of the body constitute the line of defense which we best understand and over which we have the most control. Of this we will speak more fully under the head of treatment.

In considering the central causes of convulsions we should not only think of severe traumatism, hemorrhage, tumor, throm

bosis, abscess, meningitis, obvious hydrocephalus, but also of such conditions as concussion, congestion, anaemia, initial hydrocephalus, or transitory change in the amount of cerebrospinal fluid.

A baby two years of age fell from a window sill upon the crown of the head, and had a convulsion. She speedily returned to a normal condition and seemed to be none the worse for her experience. After a few weeks convulsions returned, and she gradually developed a confirmed epilepsy.

Sudden congestion of the brain occurs in fever and in asphyxia, and no doubt contributes to the occurrence of eclampsia. I have observed in a case of apparent death due to postdiphtheritic heart failure, that on the return of the pulse, after artificial respiration, there would occur mild convulsive movements of the muscles of the face and extremities, due to the sudden return of the blood pressure. Immediately after lumbar puncture in a case of prolonged convulsive seizures, I noticed that the attacks became more severe and continuous. In the hydrocephalus of early infant life, every rise of pressure is marked by a series of convulsions, and a subsidence of fluid brings on abatement.

It is possible that some of the cases of convulsions in the beginning of rickets, not characterized by laryngospasm and other marks of tetany, may be due, to a minor degree of hydrocephalus.

Under the head of centripetal causes come the various reflexes that have been brought forward as capable of producing eclampsia: phimosis, dentition, intestinal parasites, foreign bodies, indigestible food, or excessive amounts of food, otitis, calculus, strangulation of intestine, undescended testicle, are all credited with spasmogenic power, on good authority.

It is surprising to see the amount of acrimony injected into the discussion of dentition as a pathogenic agent, especially by the Vienna school. The plea that it is physiological applies with equal force to phimosis and indeed to parturition. In a case seen by W. L. Johnson, convulsions occurred for the first

time accompanied by high fever and double otitis. In spite of all treatment, they persisted, after subsidence of fever and healing of the scars, and only ceased after circumcision. He reports two other cases in which there has not been a return since the operation.

Rachford truly states that a nagging reflex may cause high fever and even degenerative changes in the central nervous system. Jesse Myer has made some very enlightening discoveries in relation to the occurrence of "intestinal sand" after the ingestion of bananas. He finds that it is due to the gum resin and tannin of the tubules. He has requested me to ascertain, if possible, whether the occurrence of convulsions in children after eating bananas may be due to the irritation of this sand. It is possible, although the child has usually gorged itself with the fruit, without the semblance of mastication.

Under the head of centripetal causes comes also the small group due to sudden fright or rage. I have seen a single convulsion occur from the use of the thermometer (no anal fissure). Sometimes a child of uncontrollable temper loses its breath, and has a slight, or severe general convulsion. This recurs so often that it becomes a habit. I would suggest the term "Orgilospasm" for this well defined group of cases. In the few which I have seen there was no sign of tetany.

Heredity is a well known factor in the etiology of eclampsia. Every member of a large family has been known to be subject to it. Sometimes the neuropathic diathesis in the ancestors is dissimilar. Drunkenness is peculiarly prone to be transmitted into convulsions, resulting in epilepsy.

It would be interesting to know whether prematurity contributes, to any appreciable extent, to the occurrence of eclampsia. I have in mind a very neurotic mother who lost her first two children in difficult labor, and was delivered of the next two at eight months. They both died of convulsions under one year of age, the one in the course of whooping cough and the other in the initial fever of measles.

Tetany and rickets seem to be almost synonymous in the treatment of this subject. The general weakness and small

ness of the cartilages may affect the structure of the larynx, and be in part responsible for the laryngospasm. If the convulsion is inaugurated with a crowing sound, we may at once divine the nature of the case. It is well to remember that the list of drugs capable of producing convulsions in infants is a long one. Balsam of Peru applied to the nipple has produced them in the nursling. Likewise diachylon ointment, and acetanilid applied to the umbilicus. Phenacetine and antipyrin have caused severe cutaneous eruption with eclampsia. Carbonic acid gas and acetone are universally credited with this power, but on no adequate evidence. Acetone is feebly anesthetic and not convulsivant. CO, is nature's anesthetic. Physiology teaches that CO, poisoning, slowly induced, ends in coma and not in convulsions. If however, the supply of oxygen be rapidly cut off, convulsions occur. The significance of this fact will be brought out later. The Germans are particularly insistent that alcohol should not be allowed to the nursing woman. I would remark in passing that Bunge attributes the failure of modern women to nurse their infants largely to this cause. Intoxication is a convenient word. coined by Combé, the meaning of which is apparent: At first sight it might seem useless to distinguish between this and pyrexia as causative agents. But I wish here to make a point. Just as it is unscientific to credit CO, and acetone with spasmogenic power, when all the evidence is to the contrary, so I hold that no toxine should be listed as a cause of convulsions, until it is proved that it, and nothing else, is the guilty party. The toxine of tetanus is undoubtedly spasmogenic, but the unknown toxine of measles would seem to be soporific. That the sudden onset of measles is sometimes accompanied by convulsions, is capable of quite another interpretation.

Of all the factors entering into the causation of eclampsia, initial pyrexia seems to be the most prolific and the most dangerous. This is, no doubt, largely due to the fact that the infections which give rise to fever with convulsions, are more or less virulent, but pyrexia due to heat stroke with no exogenous infection is even more fatal. However, one fact strikes us as very sin

gular in this connection, namely, that the convulsions in the vast majority of cases are initial only. If the child comes out victorious in the contest, after a day or two, there is no tendency to return, even though the high temperature may continue for a long time. A recurrence late in the course of the infection almost invariably means death, due to organic changes in the kidneys and other organs.

If then the specific toxines, most of them, cannot be credited with direct spasmogenic power, and if fever has not that power throughout the whole course of the infection, it behooves us to search for some other link in the chain of causes. We find it in the wide domain of autointoxication.

In advanced organic disease of the kidney, we see the clearest type of convulsions due to retention-toxicosis. Likewise in the onset of fever we have all the conditions requisite to autotoxemia-dry skin, dry mucous membranes, suppression of oral and gastrointestinal secretions, renal insufficiency, hepatic insufficiency and most probably disturbance of the function of the ductless glands. The urine first voided may be colorless and of very low specific gravity, as low as 1002; the next contains urates in abundance. The specific gravity, registering the output of solids, furnishes a good index of the progress of the retention-toxicosis toward recovery.

These initial convulsions more often come on during sleep, and this reminds us of the fact that epilepsy in its first manifestations nearly always begins in the early hours of the morning. In sleep during the first stages of fever the temperature rises and the respiration becomes much more rapid.

Bouchard's theory was that the normal catabolic products of the tissues during sleep were spasmogenic, whilst those of the waking hours were soporific. Certain it is that sleep is apt to bring on convulsions, where the conditions are ripe for their

Occurrence.

Whilst the urine betrays an hepatic insufficiency, it is impossible in the present state of our knowledge, to know just what the ductless glands are doing in initial high fever. Shaw says (not referring, however, to febrile diseases) "it is possible