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is probably an aetiological factor. These operations should be, as a rule, performed in a quiescent pe- riod, especially in the case of rheumatism, when the nervous shock and the additional sepsis should both be avoided in the acute stage. The existence of endocarditis in a more online blackjack free or less chronic state need not necessarily be regarded as a contraindication for operation. The tonsils should be thoroughly enucleated in all cases of repeated circumtonsillar abscess. The tonsils should not be removed where they are of moderate size, that is projecting not over a quarter of an inch beyond the anterior and posterior pillars. They should also not be removed under the promise to the parents that their removal" will relieve the child of best online blackjack reviews cold in the head or ear trou- ble. This may seem a self evident proposition, but his experience is that the parent is frequently as- sured that the operation will relieve both of these troubles, which is a result not to be expected. In online blackjack reviews adults we occasionally see one or both tonsils very large, almost filling the pharyngeal cavity, with a history of repeated throat trouble in childhood, but with no throat infection for many years. Such a case, and it is a blackjack betting trigger free fairly common one, would be any- thing but benefited by an operation. It should be remembered that the operative shock to the adidt is very considerable. There is also the danger of hjemorrhagc. which is certainly a more considerable one in adults than in children. There is also the possibility in cases of persons with a well developed musical voice that the voice may be permanently injured or they may have to change the whole mu- sical method to obtain the same good results, so that even although some super blackjack download freeware tonsils are distinctly pathologi- cal, he does not advise their removal. With this exception his position is the same, as far as indi- cations go. both for children and adults. Me is sure that in doing an adenoid operation a great majority of operators remove all the tonsil online blackjack for money legal tissue free blackjack with side bets in the throat regardless whether it is normal or abnormal in amount best free blackjack app for ipad at the time the adenoid is removed. This is contrary to good surgical procedure. It virtual blackjack machines for sale adds a irreat deal tr) the nmnnnt i.f -hock which the patient receives and does not add anything to the success of the operation, although materially increasing the danger. The mere fact that the child is under ether for an adenoid operation should not be con- sidered justification for the removal of tonsils if the}^ are of normal size and the case has no history of their infection. If the case presents a clear his- tory of infectious process such as circumtonsillar ab- scess, acute articular rheumatism or tuberculous in- fection online blackjack reviews uk of the neck, beyond question the whole ton- sil should be enucleated and removed as completely as possible. This should be done by blunt dissection rather than sharp dissection. In an ordinary case of simple hypertrophy devoid of symptoms, the most common type in children, it is not necessary to remove the base of the tonsil, but a perfect re- sult may be obtained by removing enough of the tonsil to bring it down to a normal size so as not to project beyond the pillars. This may be done with a snare or punch online blackjack free game or with the tonsi'llotome, if the operator is skillful in the use of that instrument. We should, however, guard ourselves against fu- ture trouble by warning the parents that'it is pos- sible for the child to have an acute infection of the nasopharynx without the existence of any demon- strable amount of tonsil tissue, although 'the child is free blackjack apps for android very much less liable to such infections than be- fore the tonsils were rem.oved. We should also after this type of tonsil operation keep the child quite quiet for several days, and particularly in cases of adults warn the family that there is going to be a very sore throat. 4. Secondary Efforts to Hasten Healing after Mastoidectomy.— Reik observes that mastoid fistula; do not ordinarily online blackjack strategy guide require elaborate plastic operations, with the formation and transposition of skin flaps, but may be closed by repeating what was or should have been done at the time blackjack 21 game free download for pc of the original mastoid operation, and primary union will almost surely follow the closure of such wounds. If one fears to attempt primary imion after mastoidectomv, or if attempts in that direction are attended online blackjack free multiplayer by fail- ure, this method of secondary closure oft'ers an alternative or a corrective. The wound may be packed at the time of operation in the ordinary way, and at some later date, when sure that the local infection has been controlled, if not eliminated, and that the patient is satisfactorily convalescing, then one can recleanse and close the wound with ever\' assurance of safety and speedv healing. The ad- vantages to be gained are : The saving of at least a month in the time required for healing; the sav- ing of much discomfort for the patient and trouble for the surgeon; and the substitution of a small linear scar for a rather unsightly one with more or less depression. March 30, igji. 1. The Nurse and the Public Health, _., ^ . , By Annie \\'. Goodrich. 2. tibrous Stricture of the Rectum, „ , . ^. By James P. Tuttle. 3. Haemorrhagic Disease of the Newborn, By Robert M. Green and John B. Swht, Jr. 4- Medical Inspection of Schools in Boston. - c- , r^ • , , r, By S. H. Ayer. .1. simple, Quickly Removable ?Iead Bandage. By Eren C. Hill. 2. Fibrous Stricture of the Rectum.— Tuttle this term tn distinguish all nther constrictions of the organ from those due to neoplasm, malig- 6q2 PITH OF CURRENT LITERATURE. [Xew York Medical Jour.- nant or benign. They have their origin in some previous intrarectal injury, irritation, or ulceration. Muscular spasm may cause temporary stricture. Sometimes a stricture is a congenital deformity. There are circumrectal strictures caused by very fine adhesions or plastic bands in online blackjack casino reviews Douglas's cul-de- sac, which are postoperative in women. They may follow improperly done operations for blackjack slot machines in vegas hsemor- rhoids, Whitehead's ligature, or excision. Pelvic abscesses may give rise to blackjack free download stricture. Amoebic dysentery is a cause, also syphilis, in which case systemic treatment is of no avail. Gonorrhoea is a very doubtful cause ; tuberculosis is a great factor. Strictures are valvular, annular, and tubular. Diag- nosis is easy with the finger or pneumatic speculum. Treatment comprises gradual dilatation, partial or complete proctostomy, followed by dilatation, and extirpation of the strictured area. Colostomy is sometimes successful ; in long, tubular strictures, patients should be persuaded to permit the forma- play blackjack online for money ipad tion of an artificial anus. 3. Haemorrhagic Disease of the Newborn. — Green and Swift have studied 51 cases; their ob- servations are carefully tabulated and their conclu- sions are as follows: i. The parity and civil status of the mother, the foetal presentation, the duration

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