Edward Ellis III, DDS, MS

• Professor and Chair, Department of Oral and
• Maxillofacial Surgery
• University of Texas Health Science Center
• San Antonio, Texas

Chest X-rays are a ly ill bypasses the upper respiratory tract and provides a fundamental part of evaluation of lower respiratory conduit for microbial access directly into the lungs heart attack 3 28 demi lovato heart attack single pop best hydrochlorothiazide 12.5mg. Postero-anterior views are most commonly used hypertension renal disease hydrochlorothiazide 12.5mg online, but a lateral view can provide valuable additional information blood pressure medication od purchase 25 mg hydrochlorothiazide overnight delivery. Blood gas analysis should be performed if there is Learning objectives any suspicion of acute respiratory compromise arteria maxillaris hydrochlorothiazide 12.5 mg otc. The key indicators of disease severity in pneumonia are raised You should: respiratory rate (> 30 beats/min), hypoxia, hypercapnia, q know which features indicate that a specific area of the bilateral or recently enlarging radiographic opacities, respiratory tract is infected shock, renal failure and confusion. So, q know when chemotherapy is indicated infection of the nasopharynx will result in a nasal disq know how to choose the most suitable drug charge, bronchitis in cough and sputum production, and pneumonia in cough and sputum, but also in increased q know how to prevent infection and the spread of infections. Most upper respiratory tract infections are caused by Chemotherapy viruses and are self-limiting. A specific aetiological diagnosis would not alter treatment and would be costly. The antimicrobial therapy of respiratory tract infecthe role of the physician is limited to reassuring the tion depends not only on the likely microbial cause of 72 Diseases and syndromes 7 infection but also on the primary site involved and the worn by staff and other visitors. The commoner upper respiratory covering the mouth when coughing or sneezing is a tract infections are rarely life threatening and in many simple but effective means of preventing the spread of cases are self-limiting. The problem is in knowing who and when to treat with antimicrobial Learning objectives agents. Lower respiratory infections are less of a problem You should: in this respect, since infection is much more likely to cause significant morbidity and mortality. Antibiotics q know the major infections of the respiratory tract should be used as early as possible in the course of q know the factors contributing to their occurrence infection. It is often necessary to make a q understand the basis of their clinical management. The the main infectious diseases of the respiratory tract are initial choice of chemotherapy may have to be sublisted in Table 9. Patients with pneumonia who are ill enough to require hospitalisation usually require parenteral antibiotics. Pharyngitis A syndrome-based choice of therapy has become the preferred approach, since antibiotic choice and deciPharyngitis is an inflammation of the throat, resulting in sions on the need for hospital admission and active pain on swallowing and swollen, red pharyngeal supportive care do not have to wait for a laboratorymucosa. Prevention Aetiological clues include: the ease with which respiratory infections can be spread and their associated morbidity has led to the q conjunctivitis: adenovirus development of specific preventive approaches. Pneumococcal infection can also be preq grey pharyngeal pseudomembrane in unvaccinated vented by vaccination. Infection with Mycobacterium tuberinclude Neisseria gonorrhoeae, Mycoplasma pneumoniae, C. In hospitals, the Transmission is more rapid among groups sharing spread of respiratory infection from known cases of crowded living quarters and is by droplet spread or influenza and pneumonia can be prevented by infecdirect transmission. Filter-type masks and aprons are also not usually require a specific aetiological diagnosis. This is not sensitive in Asians; in this group IgM to viral capsid antigen should be sought. The invesCommon cold tigation most frequently requested for pharyngitis is the common cold is a frequent occurrence, especially in detection of S. The condition is caused mainly nation reaction for group-specific polysaccharide, or by by rhinoviruses. Neither method can distinthe causal role of other respiratory viruses in a minority guish oropharyngeal colonisation from true infection, of common colds, has prevented the development of an but only culture allows antibiotic susceptibility testing. Treatment Influenza An oral penicillin or erythromycin is used to treat streptococcal pharyngitis. Some of the features of a reduce the risk of major non-infective sequelae such common cold may be present, but systemic and resas rheumatic heart disease, poststreptococcal glomerupiratory symptoms are more pronounced. Two major surface been questioned in developed countries, since the nonantigens are used in typing epidemic strains: haemaggluinfective sequelae of streptococcal infection are all rare; tinin and neuraminidase. The different types of influenza but the recent increase in streptococcal infection in virus noted in successive epidemics are the result of Europe and North America may change this view. The other complications of streptococcal pharyngitis Minor changes in antigenic makeup occur between epiinclude scarlet fever (less common than in the past in demics. Antigenic developed countries), streptococcal toxic shock synshift results in influenza epidemics because it renders 74 Diseases and syndromes 7 pre-existing specific immunity to influenza virus antiDiagnosis is by culture of fungus from exudate. High mortality rates have been recorded Aural toilet and treatment with a topical agent such during influenza epidemics as a result of cardioas aluminium acetate may be sufficient. Topical antibiotrespiratory failure or secondary bacterial pneumonia ic preparations should be avoided. Therapy with agents effective against Pseudomonas Diagnosis is usually clinical, with serology reserved for spp. Treatment Acute sinusitis Treatment is aimed at symptomatic relief and at complications if they occur. However, amantidine treatment Infection of the axillary, frontal, ethmoid or sphenoidal may be of benefit if commenced early during infection sinuses with bacteria from the nasopharynx follows with epidemic type A strains. Infection causes the sinus to fill up A vaccine is available, but it is only effective against with mucopus, which alters the resonance of the voice previously isolated strains. Treatment It is most frequent in the younger child, whose eustaTreatment is with decongestants to improve drainage. It is also more Surgical procedures may be required in more severe or prone to blockage by hypertrophic lymphoid tissue at persistent cases. Some authorities argue that oral antibithe proximal end, as a result of prior respiratory tract otics. Much rarer and is a self-limiting condition of hoarseness and loss of complications are meningitis and mastoiditis. Bronchitis Aetiological diagnosis is possible only if purulent exuThere are three related conditions: acute bronchitis (in date from the middle ear is cultured, either following disthe strict sense), tracheobronchitis and acute exacerbacharge via the eardrum or following tympanocentesis. This condition involves a cough, Antimicrobial treatment is with an antibacterial agent sputum production (which is usually white to cream in. Here, acute bouts of coughing are not accompanied by significant sputum production. Infection is caused by influenza virus, and features of sysOtitis externa temic infection such as fever and myalgia may be present. Inflammation of the external auditory meatus is most often Acute exacerbation of chronic bronchitis. Some authorities recommend culture only when q interstitial pneumonia there is no response to treatment after 48 hours. Acute pneumonia has its onset either prior to or immediately after admission to hospital. It is one of the most Aetiological clues common infectious causes of death worldwide. Patients the causative organism can be suggested by the type of with acute pneumonia usually have a cough, chest signs symptom observed (Table 10). Chest signs are variable and prone the choice of presumptive therapy may be narrowed by to subjective interpretation. Culture and antibiotic susof consolidation, fluid in the air spaces or even the ceptibility results take too long to affect the initial choice presence of an effusion or cavity. The most important of treatment but may be reason for subsequent modificaconsequence of acute pneumonia is impairment of tion, particularly if the response to initial therapy has respiratory function, which should be assessed as a first been poor. The identity of the likely infective agent will the minimum of contamination by oral flora. A careful hiscough sputum specimen collected first thing in the morntory, thorough examination and appropriate chest X-rays ing is best.

The occurrence of migraine or pathogenetic and from a therapeutic point of view blood pressure chart 13 year old order 12.5mg hydrochlorothiazide with amex. Relaxation and biofeedback migraine arrhythmia electrophysiology order discount hydrochlorothiazide on-line, are factors of crucial importance in distintreatment help arrhythmia hyperkalemia cheap hydrochlorothiazide amex. The ergotamine effect (and ally be avoided since some patients become depressed probably also the sumatriptan effect) is also clearly more and others develop dependence arrhythmia untreated discount 25 mg hydrochlorothiazide with mastercard. Page 70 splints and psychotherapy, has not been shown to be Temporomandibular Pain and superior to placebo. Long-term outcome Aching in the muscles of mastication, sometimes with an studies are unavailable. However, small sample studies occasional brief severe pain on chewing, often associindicate that many experience symptoms indefinitely. Complications Possible degenerative joint disease, depression and anxiSite ety, drug dependence. In some intractable cases wideTemporomandibular, intra-auricular, temporal, occipital, spread diffuse aching facial pain develops. Social and Physical Disability System Interference with mastication and social and vocational Musculoskeletal system. Disk displacement shown that up to 10% of people between the ages of 15 with or without reducibility appears in some cases. Sex Ratio: most patients are feare widely believed to be contributory factors, although male. Trauma is known to be remandibular pain and dysfunction have an age range of 5lated to a minority of cases. Pain Quality: the pain is usually described as intermittent, unilateral, dull, and aching, but can be conSummary of Essential Features and Diagnostic stant. Combinations of Muscle tenderness; temporomandibular joint clicking; aching and severe exacerbations may also occur. Time difficulty in opening the jaw and sometimes deviation on Pattern: the pain may be continuous by day or brief. It is opening; a dull ache or severe episodes associated with often worse on waking. Differential Diagnosis Clicking of the joint or popping noises in the ears are Degenerative joint disease, rheumatoid arthritis, traufrequently present. Limitations of opening, deviation of matic arthralgia, temporal arteritis, otitis media, parotithe jaw on opening, and a feeling that the teeth do not tis, mandibular osteomyelitis, stylohyoid process meet together properly are common. Signs Restricted mandibular opening with or without deviation Code of the jaw to the affected side on opening; tenderness to 034. X8a palpation of the muscles of mastication; clicking or popping at the joint on auscultation or palpation; changes in References the ability to occlude the teeth fully. The clinical significance of disk displacement and its relationship to the syndrome are not established. Psychosocial factors risk factors for temporomandibular pain and dysfunction synaccount for a significant portion of the outcome. The drome: psychosocial, health behavior, physical illness and injury, effectiveness of common treatments. Page 71 Osteoarthritis of the TemporomanRelief Heat, joint physiotherapy, anti-inflammatory agents. X6 Social and Physical Disability Mastication impairment, associated orthopedic restrictions. Multiple joint involvement, radiographic joint space loss and condylar deformation, positive lab findings. Differential Diagnosis Includes degenerative joint disease, traumatic arthritis, Main Features inflammatory arthritis, myofascial pain dysfunction. Prevalence: Caucasian, approximately 50% occurrence with general rheumatoid arthritis. Dystonic Disorders, Facial Dyskinesia (111-6) Signs Preauricular erythema, crepitus, tenderness of external Code acoustic meatus, restriction and deformation of other 003. Laboratory and Radiological Findings Positive latex fixation, radiographic joint space narrowCrushing Injury of Head or Face ing. X1 joint restriction and ankylosis; responsive to condyloplasty without recurrence. Intensity: mild to Shortlasting diffuse orofacial pain due to dentino-enamel severe. The illness develops when swelling of the nasal mucosa blocks the ostium so that drainage can no longer occur Site into the nose. Dental cases System arise from infection associated with the apex of one of Musculoskeletal system. They may also be associated with operative procedures including a tooth root Main Features being pushed accidentally into the sinus during extracPrevalence: extremely common. In chronic cases there may be no pain or stimulus evoked, not spontaneous, heat, cold, mechanionly mild, diffuse discomfort from time to time. Signs Tenderness of upper molar and premolar teeth and over Dental caries, fracture, crack, or lost restoration. Laboratory and Radiological Findings Laboratory Findings Radiographic evidence of caries. In chronic cases radiographic examination reveals a sinus Usual Course more opaque than normal. If neglected, there may be mineralization within the dentine, resulting in less frequent pain or no pain; or Usual Course pulpal involvement. Page 73 Diagnostic Criteria Pathology Visually observed defects, or defects palpated with a Histopathological examination of the pulp reveals acute probe, plus radiographic examination. X2b Differential Diagnosis Other forms of dental disease, rarely can mimic trigemiOdontalgia: Toothache 2. X2c Definition Orofacial pain due to pulpal inflammation, often evoked by local stimuli. Definition System Orofacial pain due to the causes named and having a Musculoskeletal system. In severe cases may be System spontaneous (no external stimulus needed) but is exacerMusculoskeletal. Occurrence: with meals in milder cases; daily Deep dental caries, seen both directly and on radiograin severe cases. Laboratory and Radiological Findings Signs Radiologic evidence of caries usually extending to pulp Ten days from onset, radiography may show resorption chamber. Usual Course Laboratory Findings If untreated, the pulp dies and infection spreads to the Various microorganisms from the exudate. Death of the pulp ends pain from this source, if untreated, pain may cease because of drainage but but by then pain may already have started from the acute there are, in many cases, recurrences with further attacks periapical periodontitis. Relief Relief By analgesics, sometimes by cold fluids, extirpation of By analgesics, drainage by pulp canal therapy, extraction the dental pulp; extraction of the tooth. Complication Complications Spread of infection to the periodontal tissues, jaws, Cellulitis, facial sinus, lymphadenitis, sinusitis, spread lymph glands. Page 74 Pathology Relief Rarefying osteitis about apex of the tooth, abscess forAntidepressants. Possibly hyperalgesia of pulp and periodontal pain receptors due to persistent vasodilation. Summary of Essential Features and Diagnostic Criteria Code Continuous throbbing pain in the tooth, hypersensitive to 031. Patient with history of tooth pain associated with endodontic therapy and/or extractions. Definition Burning pain in the tongue or other oral mucous memMain Features branes.

The child presented two additional times with increasing symptoms and in each case responded well blood pressure 210120 proven hydrochlorothiazide 12.5 mg. After leaks were corrected and damaged areas with copious fungal growth removed one direction heart attack 12.5 mg hydrochlorothiazide amex, the child returned home and the pattern of emergency respiratory events ceased arterial blood gas test trusted 25 mg hydrochlorothiazide. She lived with her parents and 56-month-old asthmatic brother in a suburban single family house blood pressure chart record cheap hydrochlorothiazide. The patient had been afebrile, but after her cough had worsened over 4 days, her mother took her to her pediatrician for evaluation. She was transferred in respiratory distress to the regional pediatric hospital by helicopter and admitted to the intensive care unit. An admission chest X-ray was read as clear, and she was treated with antibiotics and did well. Multiple laboratory investigations, obtained in the emergency room as well as during her hospitalization, remained negative for bacteria, respiratory syncytial virus, pertussis, and chlamydia. She was discharged home after 5 days on a 7-day course of an oral cephalosporin. She did well at home for about 3 weeks, but then again developed an upper respiratory tract syndrome with rhinorhea, cough, and intermittent fevers. She was seen by her pediatrician on two occasions over the next 2 weeks and then on a subsequent weekend at the local hospital emergency room. The emergency room workup had included a negative chest X-ray, blood tests, and cultures. Over the next week, 12 the cough worsened, and the family again returned to the emergency room, where the chest X-ray and blood work were again negative. The next morning, the patient was taken for an office visit with her pediatrician, was diagnosed with otitis media, and treated with amoxicillin. She was again taken to the local hospital emergency room, where she was afebrile but had a respiratory rate in the mid-80s and an oxygen saturation of 60 percent on room air, which improved to 98 percent after 100 percent oxygen and suctioning. After she was stabilized, she again was transferred by helicopter to the regional pediatric hospital. There, the physical exam revealed retractions with inspiratory crackles over the right lung fields and no wheezes. The admission testing included a chest X-ray that showed right middle and upper lobe infiltrates, and a white blood count of 35. She was admitted to the intensive care unit and rapidly recovered, not requiring intubation. She was treated intravenously with a second generation cephalosporin and transferred to the floor after about 18 hours. Again, laboratory investigations for pathogens (including bacterial, atypical, and viral agents) were negative, and her quantitative immunoglobulins were within normal limits. At time of transfer from the intensive care unit, she had decreased breath sounds at the right base and harsh wheezes that cleared over the next 2 days. At that point she was discharged home, alert, smiling, afebrile, and breathing comfortably, but with an occasional cough. Then, after about 24 hours at home, she returned to the local emergency room, again after developing cough, tachypnea at about 80/min, increased work of breathing, and respiratory distress. She was documented to have oxygen saturation of about 80 percent, which improved to 90 percent on supplemental oxygen. Her chest X-ray showed patchy infiltrates in the right upper and left lower lobes. She was again transferred to the pediatric hospital and admitted to the intensive care unit. During this hospitalization, concerns developed about water damage in the home environment. One week after discharge, the patient returned to the pediatric hospital for bronchoscopy and lavage by her pulmonologist. The bronchoscopy was reported as unremarkable, and the lavage provided scant fluid. No differential cell count was reported, and only 4 lipid-laden macrophages, with no evidence of intracellular hemosiderin accumulation, were noted. This impression was confirmed by cultures of bulk and wipe samples from environmental surfaces in the home, from chronically damp areas of the basement recreation room and downstairs bathroom. The dominant species isolated in the cultures were Stachybotrys chartarum and Aspergillus versicolor (from the lower wall of the downstairs bathroom, and the baseboard and carpet in the basement recreation room), and Aspergillus alone in the ceiling tiles of the downstairs bathroom. The family was advised to correct the problems with water leakage in the home, and remove and replace any mold-contaminated building materials, before allowing their daughter back into the house. This was done, and the child did not develop any further episodes of respiratory distress. The only triggers for exacerbations identified during this follow-up period were viral illnesses. About Fungus and Mold n appreciation of fungi and their ecological A role will help the healthcare provider guide patients who express concern 1 over indoor mold. Mushrooms produced on hardwood floor where there has been long-term water Many atopic patients incursion. Yang of P&K experience allergic symptoms Microbiology Services) related to molds commonly encountered outdoors. The presence of mold spores in the indoor environment is not in itself a problem when the source is the normal interchange of outside air and the amount and types of spores inside are the same or less than outside. However, mold actively growing on an indoor substrate may affect the quality of the environment by degrading the surrounding materials (weakening the structure) and, more important, by potentially adding unhealthy chemicals and bioaerosols to the indoor air. The next section discusses health effects that may be associated with fungi in the indoor environment. Although all can contaminate buildings, the most common fungi that colonize the quality of the environment by building materials belong to the Ascomycetes degrading the surrounding group (Burge 1997). This section presents a brief discussion of the morphology and ecology of fungus in the indoor environment. They share characteristics of both plants and animals and are classified in a unique kingdom. Most fungi are saprophytes, and saprophytic fungi thrive by first exuding enzymes and acids that act on surrounding dead and decaying materials and then by absorbing nutrition from the breakdown, fulfilling a critical ecological role by degrading waste material. Fungi exist in many forms: single-celled yeasts, microscopic filaments (termed hyphae), large visible mats of mycelium (an aggregate of hyphae), and visible spore-producing fruiting bodies known as basidiomycetes, which include common mushrooms. Different fungi are associated with different health effects, and specific components of fungi (such as glucans in the cell walls) or forms of the fungi (spores) are thought to be agents associated with illness. Other Microbial Agents Indoors It is important to note that bacteria also grow on building materials and are likely contributors with fungi of bioaerosols to the indoor environment. In a water-damaged environment, environmental bacteria such as gram-negatives and actinomycetes may amplify along with molds.

Syndromes

• Fruity-smelling breath
• This surgery is done through a cut on the left side of the chest, which may reach to the abdomen.
• Cranial MRI
• Intravenous pyelogram
• Releasing hormones and other chemicals
• Coma
• Disk problems
• 8 years

He had so little confidence in his ability to write that he sneaked out and mailed his first manuscript in the dead of night so nobody would laugh at him blood pressure numbers for seniors order 12.5 mg hydrochlorothiazide overnight delivery. He was so thrilled that he wandered aimlessly around the streets with tears rolling down his cheeks arteria meningea media cheap hydrochlorothiazide 25mg visa. After two years blood pressure medication glaucoma buy cheap hydrochlorothiazide on-line, he could stand it no longer arrhythmia online purchase hydrochlorothiazide 25 mg, so he got up one morning and, without waiting for breakfast, tramped fifteen miles to talk to his mother, who was working as a housekeeper. Then he wrote a long, pathetic letter to his old schoolmaster, declaring that he was heartbroken, that he no longer wanted to live. His old schoolmaster gave him a little praise and assured him that he really was very intelligent and fitted for finer things and offered him a job as a teacher. That praise changed the future of that boy and made a lasting impression on the history of English literature. For that boy went on to write innumerable best-selling books and made over a million dollars with his pen. This great contemporary psychologist has shown by experiments with animals and with humans that when criticism is minimized and praise emphasized, the good things people do will be reinforced and the poorer things will atrophy for lack of attention. John Ringelspaugh of Rocky Mount, North Carolina, used this in dealing with his children. And, as in so many cases, the children became a little worse rather than better after each such session and so did the parents. Ringelspaugh determined to use some of the principles he was learning in our course to solve this situation. We managed to find something, and within the first day or two some of the really upsetting things they were doing quit happening. Keith Roper of Woodland Hills, California, applied this principle to a situation in his company. Some material came to him in his print shop which was of exceptionally high quality. The printer who had done this job was a new employee who had been having difficulty adjusting to the job. His supervisor was upset about what he considered a negative attitude and was seriously thinking of terminating his services. Roper was informed of this situation, he personally went over to the print shop and had a talk with the young man. He told him how pleased he was with the work he had just received and pointed out it was the best work he had seen produced in that shop for some time. He told several of his co-workers about the conversation and how someone in the company really appreciated good work. Because he had singled out a specific accomplishment, rather than just making general flattering remarks, his praise became much more meaningful to the person to whom it was given. Everybody likes to be praised, but when praise is specific, it comes across as sincere not something the other person may be saying just to make one feel good. Remember, we all crave appreciation and recognition, and will do almost anything to get it. Let me repeat: the principles taught in this book will work only when they come from the heart. If you and I will inspire the people with whom we come in contact to a realization of the hidden treasures they possess, we can do far more than change people. Then listen to these sage words from William James, one of the most distinguished psychologists and philosophers America has ever produced: Compared with what we ought to be, we are only half awake. Yes, you who are reading these lines possess powers of various sorts which you habitually fail to use; and one of these powers you are probably not using to the fullest extent is your magic ability to praise people and inspire them with a realization of their latent possibilities. Henry Henke, a service manager for a large truck dealership in Lowell, Indiana, had a mechanic whose work had become less than satisfactory. Yet, of late, the time you take to complete each job has been increasing and your work has not been up to your own old standards. Because you have been such an outstanding mechanic in the past, I felt sure you would want to know that I am not happy with this situation, and perhaps jointly we could find some way to correct the problem. Henke had given him to live up to , how could he do anything else but turn out work comparable to that which he had done in the past. Give them a fine reputation to live up to , and they will make prodigious efforts rather than see you disillusioned. Georgette Leblanc, in her book Souvenirs, My Life with Maeterlinck, describes the startling transformation of a humble Belgian Cinderella. She simply went back to the kitchen and repeated what I had said, and such is the force of faith that no one made fun of her. Believing she was the tabernacle of unseen marvels, she began taking care of her face and body so carefully that her starved youth seemed to bloom and modestly hide her plainness. Bill Parker, a sales representative for a food company in Daytona Beach, Florida, was very excited about the new line of products his company was introducing and was upset when the manager of a large independent food market turned down the opportunity to carry it in his store. Bill brooded all day over this rejection and decided to return to the store before he went home that evening and try again. I have respected the fact that you are always willing to listen and are big enough to change your mind when the facts warrant a change. Martin Fitzhugh, a dentist in Dublin, Ireland, was shocked when one of his patients pointed out to him that the metal cup holder which she was using to rinse her mouth was not very clean. True, the patient drank from the paper cup, not the holder, but it certainly was not professional to use tarnished equipment. Fitzhugh retreated to his private office to write a note to Bridgit, the charwoman, who came twice a week to clean his office. Fitzhugh reported, "My desk had been polished to a mirror-like finish, as had my chair, which I nearly slid out of. When I went into the treatment room I found the shiniest, cleanest chrome-plated cup holder I had ever seen nestled in its receptacle. I had given my char-woman a fine reputation to live up to , and because of this small gesture she outperformed all her past efforts. Ruth Hopkins, a fourth-grade teacher in Brooklyn, New York, looked at her class roster the first day of school, her excitement and joy of starting a new term was tinged with anxiety. He was not just mischievous; he caused serious discipline problems in the class, picked fights with the boys, teased the girls, was fresh to the teacher, and seemed to get worse as he grew older. His only redeeming feature was his ability to learn rapidly and master the-school work easily. If you want to excel in that difficult leadership role of changing the attitude or behavior of others, use. She said I was all wrong; I would just have to forget everything and begin all over again. But use the opposite technique be liberal with your encouragement, make the thing seem easy to do, let the other person know that you have faith in his ability to do it, that he has an undeveloped flair for it and he will practice until the dawn comes in the window in order to excel. Lowell Thomas, a superb artist in human relations, used this technique, He gave you confidence, inspired you with courage and faith. Thomas; and on Saturday night, I was asked to sit in on a friendly bridge game before a roaring fire. All because I was told I had a natural flair for it and the game was made to seem easy. Speaking of bridge reminds me of Ely Culbertson, whose books on bridge have been translated into a dozen languages and have sold more than a million copies. Then he tried selling coal, and he failed at that Then he tried selling coffee, and he failed at that, too. He had played some bridge, but it had never occurred to him in those days that someday he would teach it. He asked so many questions and held so many post-mortem examinations that no one wanted to play with him. Then he met a pretty bridge teacher, Josephine Dillon, fell in love and married her. She noticed how carefully he analyzed his cards and persuaded him that he was a potential genius at the card table. It was that encouragement and that alone, Culbertson told me, that caused him to make a profession of bridge. Jones, one of the instructors of our course in Cincinnati, Ohio, told how encouragement and making faults seem easy to correct completely changed the life of his son. In 1958 his head was cut open in a car accident, leaving a very bad scar on his forehead. In 1960 his mother and I were divorced and he moved to Dallas, Texas, with his mother.

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