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is a second factor, producing the contracted alveo- lar process and irregularity of the teeth. Hence, the immense importance of unrelaxed ef- fort on the part of physician, and especially parents, to induce children from infancy up to keep the mouth closed and make every eiTort to breathe through the nose, even if obstruction exists in the form of temporary swelling of the nasal membrane or permanent obstruction. Breathe through the nose, and the air pressure will prevent the excessive growth of adenoid tis- sue. Remove adenoid growths if they form an online sports gambling legal in california ob- struction, but if nasal breathing is not persisted in after their removal the excess of adenoid growth will again take place. Besides repeated remonstrance on the part of physician, teacher, and parents, or others in the home, nasal breathing can be enforced during sleep by closing the lips by means of skin plaster. When this is done sleep is more peaceful and the head rests in its normal position. The child accustomed to the sensation of nasal breathing at night can be so much more readily prevailed upon to persist in nasal breathing throughout the day. So, also, much of the harm done by neglect during the waking hours can be mitigated by the online sports gambling legal normal breathing during sleep. Not only can all the ill effects of mouth breath- ing be prevented, but after they have existed a num- ber of years they can be corrected by the changed mode of breathing, i. is online sports gambling legal in canada e., normal nasal breathing. The oftentimes hideous physiognomy of the former can gambling online casino be remodeled and changed into a normal, gambling machine games online free some- times even a handsome type, if the error is cor- rected before the firmer bones have hardened to too great a degree. 123 East Sixtieth Street. THE ROLE OF ACUTE BRONCHITIS, EX.ACERB.ATIONS, AND REMISSIONS IN PUL- MOXARY TUBERCULOSIS.* Bv 1 1. J. Hartz, M. D., Philadelphia. (From the Oiitfalient Medical Department of the Jefferson Medical College Hospital.) The frequency with which patients present them- '^elves at the medical dispensaries for the treatment ■ f self diagnosticated colds, bronchitidcs, pleurisies, -lomach troubles, and muscular pains when in real- ity they are suffering from tuberculosis of the lungs is well known. It is not as well known, however, that a large percentage of these same patients have been under the care of physicians before coming to the dispensaries and that the physicians have con- curred real gambling online usa in the self made diagnosis of the patient without having made a sufificiently thorough exam- ination of the patient. To a physician who attends a medical dispensary there soon comes the knowledge that thfe greatest difficulty in making a diagnosis of lung disease lies •Read before the Philadelphia County Medical Society, .\pril 5, in having the patient properly prepared for the ex- amination, that is, stripped to the waist in a warm room and facing the light. It is one thing, however, to make a correct diag- nosis of the disease present and quite another to be equally sure of the extent and chronicity of the lesion. When one takes the time necessary to elicit a satisfactory recital of the past medical history of such individuals as have been found to have lung lesions, one is immediately impressed with the knowledge online sports gambling sites reviews that for weeks, months, and often for years the patient, being questioned, has suffered the inconvenience of more or less frequent colds with an occasional "touch of fever." When such a his- tory has been elicited subsequently to having made a diagnosis of online sports gambling canada incipient tuberculosis, the diagnos- tician IS quite likely to change his mind online sports gambling legal us regarding the considered incipiency of the disease. Even in children and young adults this holds true, and the lesions that at nj online gambling sites real money first we are inclined to believe are incipient have actually existed for a much longer time. This is borne out time and again gambling online sports in the dispensary when a physician who has not previously seen the patient makes an examination and states that the condition is incipient tuberculosis, and is much sur- prised to learn that the patient has been under free online casino gambling play ob- servation for months and often for years and that the condition was diagnosticated incipient tubercu- losis months or years before. The interesting ques- tion naturally arises, "How long did the lesion ex- ist before it was first discovered ?" This is of course very difficult to answer, but the more experience one has with pulmonary tuber- culosis the more one is inclined to feel that the im- best online gambling games plantation and incipient changes occurred years be- fore the patient sought aid at the dispensary. The cases studied in this series were from a clini- cal point of view, the observations having been made in the outpatient medical department of the Jeft'er- son Medical College Hospital. That possibly pre- existing chronic lung affections might influence the present conditions for which the patient is seeking relief led me to select only the cases of older chil- dren and those of adults under twenty years of age. For in this class of cases chronic lung affections other than offshore sports betting-online gambling sport tuberculosis online sports gambling legal florida arc met with less frequently than leading european online gambling and sports betting in older persons. A careful history was elicited from each patient as to the chief complaint, family history, personal history, and, onset and duration of the present illness. The patient was then directed to remove all clothing down to the waist, thus fa- cilitating a more accurate physical examination of the chest. Rv having the patient fold the arms on his chest and place the hands on the opposite shoulders and lean forward, thereby widening the interscapular area, a greater amount of lung surface becomes available for examination. The most frequent sites for manifestations of lo- calized lung involvement arc the supraclavicular and infraclavicular fossre. the interscapular region, and at times the axillary s]iaces. The examiner is standing in front of the patient, who is facing the light, and notes anv difference in the expansion of the two sulcs. With the patient in the sitting pnsi- "34 HARTZ: ACUTE BRONCHITIS IX TUBERCULOSIS. tion, while the examiner is looking over his shoul- ders from behind, the latter will often notice dif- ferences in the expansibility of the apices, the apex involved being greatly restricted in expansion. Palpation will also n.j. senate approves online gambling bill elicit restricted expansions of either side and detect increased tactile fremitus, nba sports betting and gambling odds online suggesting an infiltration or consolidation. Occa- sionally a pleural friction rub is thus detected. Per- cussion aids us gambling online games free in determining impaired resonance

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