to think clearly or even, in many instances, to remember the names of his intimate friends or neighbors. There may be a feeling of numbness or tingling in the tongue or in the arm or hand of the side corresponding to the blind half of the visual field. A marked disturbance of the powers of speech of the sensory aphasic type may now occur in severe attacks, and the symptom complex be highly suggestive of serious central involvement. Cardiac palpitation may come on at this time with a sensation of nausea. The pupillary reflex will be found to be almost normal and, with the ophthalmoscope, the circulation in either fundus oculi will not show any special change. The face may be pale on the side opposite to the blind portion of the visual field.

After about thirty minutes, possibly in a shorter time, the hemianopsia, or half-blindness, will begin to depart, the scintillating wavy lines breaking up, and widening out toward the periphery of the blind side as before mentioned, until they disappear, when the vision will be found to have returned and the power of speech to have been restored, although some degree of mental confusion may still remain. In rudimentary attacks of migraine the seizure may stop at this stage, though in the large majority it continues into the succeeding stage as follows: On the side of the head opposite to the former blurred half of the visual field, the headache, characteristic of the disease, now commences, as a rule, in a circumscribed area of the forehead or temple. The pain is excruciating and of a boring character, and from this starting point it rapidly spreads backward and involves the whole of the affected side of the head, sometimes extending into the neck. The face on this side, at first pale, may now be found to be of a brilliant red, the former condition being due in all likelihood to a primary arterio-spasm, the latter to a secondary relaxation of the walls of the vessels supplying the skin in the region designated, in which respect the facial circulation conforms to the circulatory condition supposed to exist in the brain on the same side. In cases in which the attack is bi-lateral the whole head is, of course, affected. In certain instances of the disease there is an absence of the disturbances of vision and speech. After a longer or shorter period of suffering the patient experiences relief frequently after a spell of vomiting. In severe cases the attack may be assumed to disqualify the victim for at least three days; in other instances it may be over in from twelve to twenty-four hours.

Treatment-In view of what has been stated it may be affirmed as a definite proposition that he will be most success

ful in the treatment of migraine who will diligently and systematically ferret out the various exciting or contributing causes and give them intelligent consideration, while at the same time paying attention to the neurotic state of this unfortunate class of patients.

All sources of reflex irritation must be removed, and in this connection special attention must be directed to the condition of the eyes, nasal passages and accessory cavities, and pelvic organs, as well as to the complex functions connected with assimilation. In spite of what certain authorities would have us believe, it is a positive fact that such causes do excite attacks of migraine in the susceptible, and one actual cure of an undoubted case of this affection by the removal of reflex irritation must be accorded far greater weight in an affirmative way tha should be granted to any amount of denial and carping criticism in a negative sense.

Many such instances of cure are in evidence. Cases caused by auto-intoxication also afford us much food for thought. In instances in which this cause is suspected we must pay careful attention to possible disorders of the gastric, intestinal and hepatic functions. In this connection it should be borne in mind that many cases of hepatic insufficiency have their starting point in intestinal disorders, the toxic products of such disorders being carried directly to the liver through the portal circulation and exercising a most deleterious effect upon that important organ, with a temporary disarrangement of its highly complex functions.

The vaso-motor effects upon the cerebral blood vessels following the entrance into the general circulation of toxic substances, resulting from such derangements, have already been mentioned. The enumeration of the special remedies to be employed in conditions of auto-intoxication, and a discussion of their action, would lead me too far afield and would require more time than could properly be accorded to this paper. I shall simply state in general terms that such treatment should include careful and appropriate regulation of the diet in the several digestive conditions at fault, with the use of drugs to fulfil the following indications, namely: To correct improper gastric or intestinal secretion; to remove the poisonous products of intestinal puterefactive processes by a course of autisepsis; to promote proper daily evacuation of the contents of the bowel tract; to re-establish the normal action of the liver cells, in which connection may be mentioned the valuable results following the administration of the sodium salts of the biliary

acids, and to secure proper elimination of excrementitious bile products.

In the general treatment of the migrainous habit the patient should practice moderation in all things, especially in the matter of the use of alcoholic beverages, which should in reality be rigidly excluded. His diet and daily hygiene should receive careful attention. Seguin, Sinkler and others have strongly advocated the administration of cannabis indiea up to tolerance, a standardized preparation of the fluid extract being the best form of the drug for use. Commencing with eight or ten drops three times a day, the dose may gradually be worked up to as high as thirty or possibly forty drops.

The remedies recommended to relieve the pain of the immediate attack are almost numberless. They are pure palliatives, and in this meeting of scientific physicians it is not necessary to dwell upon them. The occurrence of the attack of migraine may sometimes be aborted by the use of nitroglycerine, or nitrite of amyl, at the very commencement of the initial eye symptoms, with the object of causing relaxation of the spasm of the cerebral vessels, and the course of the individual seizure may be materially shortened, in certain instances, by the use of intestinal eliminative treatment.

Dissection of the Buried Tonsil in Children.

*By H. L. ARNOLD, M. D., Omaha.

The writer has been asked to present a paper to this society along some line of general interest to the section, and in persuance of this request the complete enucleation of the buried tonsil in children will be considered.

In the first place, tonsillectomy is unqualifiedly a hospital operation, from the fact that some complications may arise, such as hemorrhage, which demand quick and adequate attention. Moreover, the work cannot be successfully done without the aid of assistants, and last, for the sake of the patient and physician, the operation should never be undertaken at the home or in the office.

As to the length of time that the child should remain in the hospital depends, of course, upon what, if any, untoward condition arises; but as a rule, if no hemorrhage or oozing has occurred, the patient is allowed to go home the evening of the day after the operation. The writer has dismissed patients on

*Read before the Ophthalmological Section of the Omaha-Douglas County Medical Soc'y, Dec. 22, 1911.

the evening of the same day and had trouble with bleeding after they had been up and ridden on the street cars. So from experience it is advisable to keep them until the evening of the second day.

The ordinary protruding tonsil is reasonably easy to remove, but the class of cases to which this paper refers are those whose free surface is in the same plane as the inner edge of the pillars, where no protrusion exists and the body of the gland is completely hidden or submerged.

These tonsils, when pathological, demand removal; they are by far the most difficult to remove and a complete extirpation gives an unboundedly good result.

In dealing with these buried tonsils the writer has used many of the various dissecting instruments, which are exploited for this work, with varying degrees of success and some well fixed opinions.

To begin with, a dull or semi-dull dissector has not found very much favor in my hands, because to start the operation the mucous membrane must be torn or lacerated in order to reach the capsule and in carrying on these manipulations the tonsil may be more or less torn, which makes it difficult to snare, also causes more bleeding and unless very careful the capsule is liable to be punctured. Again, in separating the tonsil from its bed, preparatory for the snare, the surrounding tissues are necessarily roughly handled, causing the wound to be longer in healing and more susceptible to an infection.

On the other hand, a cutting instrument opens the mucous membrane, exposing the capsule, with practically little or no tugging at the tonsil, and especially the surrounding muscles; but some of these cutting instruments were found to be so large as to obstruct the view of the field. In fact, some were larger than the tonsil to be removed.

A cue was finally taken from Ballenger's description of the Kyle knife, which, as you know, has a small shaft and a short right angled cutting edge. With this knife the mucous membrane is slit from two to three millimetres from the free surface of the tonsil, which is drawn inwardly only enough to dislodge the gland from under the anterior pillar and at no time using extra tension with the forceps. Many descriptions in books say to insert the upper blade of the forceps in the supra tonsillar fossa. This is quite impossible with these buried tonsils, as the supra tonsillar fossa is filled with the tonsil and the mucous membrane falls or folds over onto the gland; moreover if this procedure were insisted upon, the blade of the forceps

would grasp the very tissue we want exposed and free to dissect from the gland. If a distinction were made as to the kind. of a tonsil being worked upon, where the fossa is more exposed, it is well and good.

To go on with the description, the knife should be held with its cutting edge on the flat, with the point entered just under the mucous membrane (and this is most particular and important), then withdrawn, cutting from the tonsil, when, if done properly, the capsule will jump into view. The knife is repeatedly entered and withdrawn until the mucous membrane is detached from the entire circumference of the tonsil, which becomes unlocked, as it were, and can then be drawn inward from its bed.

The natural tendency is to make the first incision so deep as to include the capsule, which, of course, destroys our only landmark in the dissection and the tonsil becomes a haggled mass, with no head or tail to further procedure.

What might be a golden rule in tonsil dissection is to get on the outside of the capsule and stay there, which sounds much easier than it is to do, because if it can always be done, then every tonsil shells out readily.

After the membrane is cut from the circumference of the tonsil and the beginning of the capsule well exposed, all that remains is to keep up a gentle pull and the knife, hugging the tonsil, severs all attachments until the equator is well passed and especially the upper pole well out of the supra tonsillar fossa, when the snare does the rest by peeling out the tonsil with its capsule complete.

It sometimes happens that the wire snare makes a short cut at the lower pole of the tonsil, leaving a portion behind, so to obviate such a mishap the tonsil is lifted up and a cross cut incision made below the tonsil, connecting the lower ends of the incisions, which were previously extended around the tonsil, thus giving the wire a chance to bite and follow the outside of the capsule.

In using the Kyle knife one soon obtains a touch or feel when in contact with the fibrous capsule, or rather it should be said, when cutting into the capsule, so in doing the dissection after this fashion little tugging or pulling is done on the tonsil and the surrounding musculature is not mutilated to any extent, which gives a kindly healing wound, without the usual soreness attendant upon a blunt dissection.

In regard to the position of the child upon the table, it seems to be purely a matter of choice, for whether one prefers the Rose position or the patient on its back or side, blood comes