Daily doses of the iodides, nitrates and nitrites have been administered. Practically no bromides have been used. With the exception of the case that died, all have maintained their status during the year, and three have been benefited by presenting with a lessening of vascular tension, a wider spacing of seizure manifestations, and an almost complete disappearance of migrainous symptons.

The Group Classified as Endocrinopathic

There are fourteen cases in this group. Thirteen of these cases are made upon clinical signs, present upon admission, or their clinical history before admission. One was diagnosticated at the autopsy table, a child aged 5 years, with an epilepsy since 2 years of age. This case presented with a much enlarged thymus and the general findings were those of a marked status thymicolymphaticus. Death in this case was due to exhaustion and pulmonary odema following serial petit mal motore.

In this group, the classification has been made only after the exclusion of other possible factors. The writer realizes that when a classification of any epilepsy is made on the basis of endocrine disturbances it is only a starting point for the study, in that particular case, of internal secretions. In this work the classification has been made solely upon clinical evidences and not upon scientific laboratory investigation.

The writer is convinced that there is a large group of the epilepsies due to ductless gland disturbance. Many of the cases, which we in an institution see too late after the onset, have no doubt suffered endocrine upsets at the time of their first seizures. It is not an unreasonable hypothesis that there may be endocrine perversions sufficient to cause epileptic symptoms, without the production of the clinical signs and laboratory findings that we now associate, with our present knowledge, as indicative of these lesions. Especially might this well be so in children who are inferior or neuro-psychopathic in their make-up.

Among these fourteen cases hypophyseal disturbances are represented usually by states of adiposity, etc., associated with hypofunction. No cases of the group have presented with signs indicative of hyperfunction.

There have been practically no clinical evidences of thyroid disturbances.

The case showing the most marked thymus disturbance has already been mentioned.

A hyperfunction of the adrenals may have been possible as a hypertrichosis was seen in one of the cases of the series and a precocious puberty in two others. In the senile cases mentioned before, no doubt, the adrenals were active in assisting to maintain the arterial hypertension.

There are several cases with a history of general body and sexual precocity, occurring at an unusually early age. Some endocrinologists choose to consider these cases as representing a hypofunction of the pineal gland.

Some of these endocrine cases have come to the Colony early in the life of their disorder, others have come when years have elapsed since the signs or symptoms were present. It is easy to understand how cases of epilepsy which in the beginning were dependent upon ductless gland disturbance, readily become chronic after the disturbance has subsided, provided this disturbance was long enough to give the case the so-called, "epileptic habit."

In the cases seen early which suggest endocrine conditions, the course of the epilepsy has generally been erratic. Seizure types greatly varied, there were long remissions, and then again severe serial seizures. The clinical course of their epilepsies, however, did not constitute a clinical entity which might be correlated with this type of gland disturbance.

Under this heading I would mention a case, No. 4531, whose epilepsy began at 18 months following a severe head trauma. Upon admission, at the age of 27 years, he presented as a real acromagelic. The date of the advent of acromagelic changes can not be learned, but the question has been raised, does not the cerebro-pathy which was produced by the head trauma at the age of 18 months stand for both his epilepsy and his acromegaly, or does his epilepsy owe its continuance to the disturbed function of the hypophysis?

Before I leave the discussion of this group of cases, I would call attention to the fact that outside of the group, alleged to be

due to metabolic disturbances, this group of endocrinopathic disturbances are open to much fruitful investigation by laboratory methods.

The Group Following Acute Meningitis or Meningo-encephalitic Processes, the Result of Acute Infectious Disease

In the series there are 15 cases, which give evidence of a cerebro-pathy following inflammation of the meninges, brain or both. Six of these followed acute meningitis, 3 followed scarlet fever, 4 followed measles, 1 followed several acute infectious diseases, which occurred in rapid sequence, and 1 followed pertussis, possibly due to mechanical changes within the brain, incidental to the respiratory spasms. As these cases are reviewed, the truth of Munson's previous statement that, "Permanent brain damage is occurring with unsuspected frequency during the course of the common infectious diseases of childhood," is again emphasized. One of this group, No. 4469, has died. Autopsy confirmed the cerebro-pathy.

The cases due to acute meningitis at an early age, usually present with evidences of permanent brain damage. They are usually inferior to a marked degree.

The cases of this series in which the lesions arose during scarlet fever, appear to have suffered the greater damage than those arising during the other infectious diseases.

Two cases of the series, one with an acute meningitis at 18 months, the other with meningitis at 9 years, both appear at this time to have their seizures lessening in frequency and severity. The former patient is recovering from a retardation, and at 13 years of age approaches practically a normal mental

status.

From an epileptic standpoint, the prognosis of cases in which there is an apparent causal relation between the meningoencephalitic changes and the epilepsy, varies according to the severity of the infection, and the original endowments of the individual. The later in life the cerebro-pathy is acquired, the better the prognosis. This applies especially to the resulting mental

status.

The treatment of this group has been that of proper care. The

low grade cases have received wholesome custodial care, while the retarded cases have been given special scholastic training and instruction in social behavior.

Developmental Defect

Eight cases present with primary organic defectiveness. Three are at the lowest vegetative levels of life, and 5 range from imbecility to high grade feeblemindedness. Their history is that of amentia in varying degrees. Not only in this group are the developmental defects confined to the central nervous system, but are distributed throughout the bodies, as congenital hernias, congenital heart disease, marked gross asymmetries, etc. None of the cases of this classification have died since their admission.

Birth, or Subsequent Head Trauma

Thirteen cases after the exclusion of other obvious or ascertainable factors presented in the series with a definite history of head trauma, associated with the beginning of their seizures. It is interesting to note, that of all the causes ascribed to the production of seizures by the relatives, head trauma is foremost. In this series of 131 cases, head trauma after birth, was ascribed to be the exciting factor in 41 cases, whereas careful analysis of the alleged traumatic conditions, allowed only 10 such claims to stand. On the 13 cases ascribed to trauma, 3 are birth traumas, all severe instrumentations with marked external injuries. Spasms in these cases followed rapidly after birth, and recurred at varying intervals throughout the life of the individual. One of these birth trauma cases had died during the year and autopsy confirmed the alleged lesion.

Of the 10 acquired traumatic cases, 5 show definite focality in grandmal attacks. Three have a large destruction of bone tissue in the skull and have been operated upon by surgical methods prior to their coming to the Colony. Only one of these 3 was operated upon before the onset of convulsions, and although seizures have persisted for the past 15 years, they are less severe and less frequent than others in the group, and there has been a better general mental upkeep. One of the traumatic cases in this classification, which received a severe head trauma

at 18 months of age, with the immediate occurrence and persistence of seizures since, has already been referred to in regard to an accompanying acromegaly (see paragraph on endocrine disturbance). As these traumatic cases deteriorated, irritability appears to be especially marked. This irritability may be associated with the fact that the majority of traumatic cases are frequently given to severe headaches. None of the acquired trau

matic cases have died.

Syphilitic Group

In this group there are classified 4 cases, 3 acquired and 1 congenital. Of the three acquired, one represented a case of cerebral lues rather than that of epilepsy. In this particular case the clinical history prior to admission was practically unknown, and the mental picture was so typically that of an advanced state of cerebral lues that the patient could supply little information. The patient died after a residence of six months, and the gross examination of the brain at autopsy established the authenticity of the diagnosis. The blood serum during life gave a 4x positive Wassermann.

The case of congenital lues is a boy aged 8, with seizures for 2 years. Blood serum gives a positive 2x Wassermann, saturation with iodides is followed by a remission of 5 months in seizures, which formerly occurred in series of from 5 to 20 per day. Salvarsan was not given as it was not available.

Patient No. 4624 gives a positive Wassermann 4x, seizures occurring about 2 years after infection. Salvarsan has been administered several time during the past 18 months prior to admission, with lessening of seizures. Still under anti-syphilitic treatment outside of the Institution.

Patient No. 4652, several time a patient at the Colony, contracted syphilis at 14 and epilepsy at 20. Alcoholic, dissolute, wanderer and at shortly after the onset of his epilepsy an injury to head brought out a right hemiplegia. Death from pneumonia after serial seizures gave occasion for autopsy, the report of which was syphilis, vascular lesion, large destructive lesion left hemisphere.

To summarize this group to date, all of the three acquired