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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
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
u.ses this term tn distinguish all nther constrictions
of the organ from those due to neoplasm, malig-
PITH OF CURRENT LITERATURE.
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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