belongs to nursing. The loyalty of silence is an everlasting duty. The law protects the physician in reticence, and it will the nurse. The loyalty of professional secrets should be a matter of course, and especially when poor, sick, and weak human nature is off its guard with physical or mental anguish. No person can be so intimately taken into confidence as the Her office is to listen and not to talk. She receives the confidence as thrust upon her, but is supposed to forget it with cessation of her offices to the patient. She may relate experiences, tell stories of her cases, but without names, and the personal identification of patients must not be revealed. I fear a quiet, skillful physician more than many who talk. A quiet, skillful nurse is worth an army of talking, gossiping

nurses.

A nurse cannot afford to become familiar with a patient any more than a physician can. Familiarity breeds disgust. The nurse can be firm but kind, dignified but helpful, quiet but influential. The nurse must not be familiar with the patient or she cannot impart discipline. She must be firm and distant enough that the prostrated neurotic may help himself. Her helping hand should restore strength and courage to the patient.

A nurse must learn to keep her mouth closed in regard to the physician's relation to the patient. A nurse must not reveal what kind of an operation is to be or has been performed. She should refer all subjects relative to the patient's disease or operation to the physician. She must not inform the patient when the operation is to be performed, nor who was present at the operation. When the patient asks the nurse direct questions in regard to diagnosis, prognosis or treatment or operative procedures, she must refer everything to the attending physician. The nurse must avoid explanations of diseases or operations, all references as to what she saw in the operating rooms, and especially avoid repeating

remarks.

Of course, while in training no recommendation of one physician over another nor the better recovery of patients should be assumed. Physicians in general avoid the nurse who lauds one physician over others, as he will be suspicious

of her. The nurse is frequently an intermediate between a patient or his friends and the physician. Such a position is a delicate one and demands peculiar wisdom.

A wise and discreet nurse does not recommend either remedies or treatment to patients. Neither should she speak of remedies or treatment in the presence of the physician. When the physician requests the nurse for the temperature or pulse it is the wisest plan to show him the record so that the patient will not hear the report. If a misunderstanding arises or the physician wishes to dissent from certain actions of the nurse, he should request a private consultation, so that the confidence of the patient in the nurse will not be disturbed.

The obedience of the nurse to the physician's orders is absolutely necessary, especially in the matter of regular administration of remedies, the exact recording of the pulse, temperature and respiration, as well as the compliance of diet.

It is much more dignified for a nurse to say "I nursed a patient through his sickness" than to say "I pulled or brought him through." It is a discord on my ear to hear a physician say "I cured him."

ÀCUTE INFLAMMATORY EDEMA AND ABSCESS OF THE LARYNX.1

BY DR. LUBET-BARBON,

PARIS.

Translated from the Revue Hebdomadaire de Laryngologie, d'Otologie et de Rhinologie, Vol. 22, No. 30, by Richmond McKinney, M.D., Memphis, Laryngologist to the East End Dispensary; Laryngologist to Presbyterian Hospital.

THE title given to my communication, likewise personal observations elsewhere reported by me, reveal that I have in view those inflammatory or infectious-since inflammation is a result of infection-phenomena which give place to grave symptoms of the larynx, and may terminate by the extreme result of all inflammation, that is to say, by suppuration.

1. A paper read before the French Laryngological Society, May, 1901. NOTE. It is not merely because we feel that this paper will be of interest to laryngologists, but likewise that it contains much information that the general practitioner, who doubtless encounters many cases such as herein reported, may find valuable, that we have translated and reproduced it here.-EDITOR.

All these cases are characterized by sudden development of symptoms, rapid march and dramatic features, and the utility of rational treatment continued during the entire duration of the disease is demonstrated.

Primitive phlegmonous laryngitis is an affection of adults, more frequent in the male than in the female.

We here cite an example in an infant:

Observation 1.2 In an infant 6 years old, which died after eight days illness without appreciable lesion of the viscera, was discovered, on autopsy, a unique lesion, an abscess as large as a hazelnut under the mucous membrane of the vestibule of the larynx. (Obs. No. 24 de la thèse de Jenicot, Paris, 1879).

Traumatism may be one of the etiologic factors in acute edema of the larynx; proof of this is offered in the following observations:

Obs. 2 and 3. Two cases of traumatic edema, unilateral, of the glottis. (Solis-Cohen in Internat. Centralbl. f. Laryngol., 1886). Edema was caused, in these two cases, by a foreign body in the larynx. In one case this was removed with the finger. In the second case the object was not discovered. The wound of the epiglottis, which, each time, was the result of the traumatism, was followed by edema with all of its symptoms: dyspnea, dysphagia, etc. Scarification caused prompt amelioration of all alarming symptoms. There was a disproportion between the dyspnea and edema, which was shown by the mirror (spasm of the abductors).

La grippe appears to predispose to infection of the larynx.

Obs. 4. Two cases of laryngeal edema of grippal origin. (Cartax in Rev. de laryngol., No. 12, 1893). A groom, of good habitual health, was taken with symptoms of la grippe, which reigned epidemic at the time. He was admitted to the Necker Hospital on account of experiencing very marked difficulty in breathing, with a sensation of constriction of the neck and hoarseness. Inspiration was painful, wheezing, and mildly labored; expi

2. In reviewing the literature I have found a number of cases of inflammatory edema of the larynx reported. From these I have reserved a limited number where the condition was first located in the larynx. I have thus, for example, rejected all of those edemas consecutive to a phlegmonous process of the mouth and pharynx (various anginas, abscess of the faucial or lingual tonsils, lateral and retropharyngeal abscesses). In the cases reported I have also in condensation retained merely the most characteristic features, referring the reader to the original papers for more complete details.

ration was fairly free. In the laryngoscope it was seen that the redness and inflammation of the entire mucous membrane, with the left ventricular band, formed a voluminous swelling that partially hid the cords. During the next twenty-four hours the difficulty in breathing gave rise to apprehension of the necessity of tracheotomy. Treatment consisted in placing leeches in front of the larynx, and in treating the grippe. Several days later recovery was complete.

Obs. 5. A woman, aged 26 years, entered the hospital on account of symptoms following grippe identical with the previous case. Inspiration painful and noisy, expiration easy, voice almost normal. On laryngoscopy the epiglottis was seen to be red without tumefaction, but there was a large infiltration of the left arytenoid, which attained the volume of a small nut. Leeches, cold compresses, etc. Recovery in a few days.

But the indirect cause the more evident is refrigeration. I do not care to again enter into a discussion of those affections considered as due to cold. The process is said to be, and it is actually admitted, that all inflammatory processes have as an immediate cause a microbic infection. But it is certain that sudden cooling is one of the morbid conditions which permit most organisms an opportunity to occasion infection. In particular the inflammatory states of the pharyngo-laryngeal tract, and of first importance, those which we here have in view, appear in a close relationship with refrigeration, and we discover an attack of cold in the history of almost all of the patients. Here, in this connection, is a typical case:

Tra

Obs. 6. Acute edema of the larynx from refrigeration. cheotomy. Recovery. (Oulmont, Méd. moderne, June 12, 1890.) Male, adult, cabinet maker; was admitted to the Tenon Hospital in a state of asphyxiation requiring urgent tracheotomy. This man had descended into a cave in a perspiration, rapidly cooled off, and was suddenly taken with shivering and mild dysphagia. The next day the disease of the throat was augmented, and the patient was taken with a dyspnea which rapidly grew worse and necessitated his removal to a hospital.

After tracheotomy the patient's condition speedily improved; his temperature, which at that time was 40°C., descended to 38°. A laryngoscopic examination was made three days after the operation; this revealed a red and edematous epiglottis; the ary-epiglottic folds were likewise uniformly reddened and

tumefied. The tracheotomy tube was removed the nineteenth day afterward, and at the end of the third week the larynx was normal.

This patient was a man of good physique, and without the least pathologic blemish.

The infectious agent which may directly cause suppuration is variable. It may be one of the various microbes which we habitually encounter in the oro-pharynx - staphylococcus, streptococcus or pneumococcus.

Obs. 7. (Personally observed). Abscess of the larynx. Tracheotomy. Recovery. A young man presented himself on the evening of April 29 at the Cochin Hospital with a difficulty in respiration that necessitated immediate tracheotomy. He said that bis condition had developed several hours before he came to the hospital. On April 20 Dr. Netter, in whose service the patient was, examined the pus which came through the canula, and discovered pneumococci and staphylococci aureus (culture). April 29 I opened an abscess of the larynx situated in the right glosso-epiglottic fold; creamy pus was obtained. Microscopic examination of this pus revealed: "the cocci in bunches were colored by the Gram method; the culture gave a development exclusively of staphylococcus pyogenes aureus." There was here an abscess due to staphylococcic infection; the presence of pneumococci in the pus obtained from the canula were nothing contrary to this opinion; pneumococci are found on the buccal and bronchial mucous membrane. The patient was relieved of the canula, quitted the hospital cured, and was later seen in perfect health by Dr. Netter.

Streptococci in the pure state were the cause in the following case:

Obs. 8. Phlegmonous streptococcic laryngitis. (Prieur et Claoue, Soc. Franc. de laryngol., session of May, 1899.) This observation concerned a soldier who, suddenly, was taken with a violent shivering and dysphagia. Examination revealed congestion of the pharynx, hard and purple colored edema of the epiglottis and ary - epiglottic folds, especially of the right side; the ventricular bands were slightly swollen, nothing else; the splanchnic organs being healthy; no albumin in the urine. The next day the patient was admitted to the hospital. He was dyspneic, and anticipating an aggravation of this symptom, preparation was made that evening to do a tracheotomy, but the patient died under the eyes of the physicians without presenting an approach of suffocation.