The Industrial Nurse

The industrial nurse is certain to occupy an increasingly useful and responsible position in the general scheme for health promotion in the future. She, like the private nurse, finds herself confronted with situations which no class instruction could possibly anticipate or prepare her for. She must depend largely on her own intuition. and judgment, and it is not to be wondered at, if her judgment does not always meet with the approval of her medical chief.

Most of us in our probation days were taught that "a well-trained nurse never diagnoses and never prescribes." In general, that rule is a good one, but there are exceptions to all rules, and no nurse is long in practice as a graduate nurse without being confronted with cases where the rule cannot be strictly carried out without a good deal of embarrassment.

A nurse visits the home of a workman absent from a factory and finds him slightly ill-coated tongue, headache, constipation, general feeling of lassitude with perhaps some slight elevation of temperature. Is she justified in suggesting some simple remedies that may relieve his condition? Or a child of a workman in a home which she visits may have similar symptoms. He may have an attack of croup or colic or diarrhea. Should she mention what she thinks the trouble is and suggest some simple measures that should be taken, or should she say in effect, "I am a nurse. I am not supposed to even guess what is the matter, nor may I mention anything that might give relief. That would be diagnosing and prescribing.'' This is no new problem. Florence Night

nurse.

ingale met it when she began her work. It will probably always be with us to some degree. Yet it need never be embarrassing if a frank understanding exists between the medical chief in the industrial plant, and his assistant, the industrial It is quite possible to anticipate such instances as we have quoted, and have written orders dealing with them in general. How far a nurse should go in dealing with accidents and emergencies can be covered by a general statement. If a nurse feels the necessities of the case require her to go farther she should certainly notify the doctor at the earliest opportunity. Difficult situations are usually created by difficult or thoughtless people, and evidently in Rhode Island there must have been considerable reason given by industrial nurses, if the State Board of Health was called on to issue a special warning in regard to this practice.

The Rhode Island Medical Journal makes the following comment on the subject:

"The State Board of Health has taken a commendable stand in its potice to nurses employed in large industrial plants for the care of injured employees, calling their attention to what amounts to violation of the Medical Practice Acts in certain instances. These nurses have a great opportunity and are doing a great conservative work, but occasionally and certainly often enough to warrant a warning, they go without their sphere and treat cases which should be handled only under the actual supervision of the physician in charge of the First Aid Room. Her activities should be confined to carrying out the instructions of the physician and too

great latitude in her work should not be given by those physicians who are placed in charge of industrial dispensaries. The prescribing for workmen confined to bed by illness is certainly not within the rightful sphere nor within the professional attainments of an industrial nurse and is capable of more harm than good."

+

More Pay and Less Work

More pay and less work" seems to be the slogan to-day among workers of all kinds. Nurses in the past have given probabiy more generously of their time than workers in most other lines, yet the rising cost of all the necessities of life, which they, in common, with the rest of the world have had to meet, has resulted in a sharp advance in the scale of remuneration demanded. A minimum rate of $6 a day for twelve-hour duty, with $8 for obstetrical patients, and $7 for acute infectious diseases is the new rate which has recently gone into effect in some of the large cities where the housing shortage and the cost of heating have combined to boost rents to a higher level than ever before. Nurses have been sharply criticized for these rates, which however high they may seem, are practically in keeping with the cost of most other things which have to be purchased these days.

The nurses' side of the subject was ably presented in a communication from a Detroit nurse to one of the evening dailies of that city. Her letter is sufficiently interesting to be reprinted. It will be found in the Letter-box Department.

If two nurses happen to be required as they often are on obstetrical cases with twelve-hour duty for each nurse, and the average man will be asked to pay $112 a week or over $400 a month for nursing care in childbirth. We fancy that at these prices babies will be regarded as too expensive a luxury for the average family. If the present perplexing stage of life results in the American women in general

being instructed in how to care for each other in these critical times-safely and efficiently-the end results may be something to be thankful for. It is likely to result in the nurse assuming more and more the position of instructor and organizer of the home forces and marks another step in the general evolution of nursing, that perhaps a dozen years from now we may be looking at with thankfulness. At the present moment, however, the daily problems are too pressing and perplexing for any of us to be absolutely sure whether this stage is an advance in civilization or the opposite.

To Clean or Not to Clean How much, if any, practical work in sweeping, dusting, etc., should a pupil nurse be expected to do? The answer to this question will differ under different conditions, but as far as one can judge by observation, there is little prospect of this part of "domestic science" being dropped from the curriculum or from the program for practice of the modern hospital. A large part of nursing is embodied in the phrase "housekeeping for the sick." The nurse who is not required when in training to pay any attention to the cleaning of the patient's room, is very likely to be the one who when she goes into private practice declines to stoop to anything like menial labor. She is often the one who is allowed to go from the case, and domestic nurse "substituted.

a

There should of course be a limit to the amount of cleaning required. The probationer should be taught how to clean properly. After the first year has passed less cleaning should be required, and in the third year still less.

Those who have doubts about the wisdom or necessity of requiring nurses to clean, would do well to read once again. Florence Nightingale's Notes on Nursing, and observe the emphasis she places on the

part of nursing which comes under the head of "Housekeeping."

Training Nurses for Leadership Miss Laura R. Logan, Principal of the School of Nursing in Cincinnati General Hospital, in her address at one of the section meetings of the Hospital Convention stated that schools of nursing are facing a serious shortage of graduate nurses who are proficient in teaching, in public health service, and in institution management. Many superintendents were distinctly worried because of their difficulty in securing competent head nurses and supervisors. Still others were unable to understand why they had waiting lists of candidates for entrance last year who were eager to enter, and find difficulty this year in keeping the probationers' classes anywhere nearly filled. The shortage seems to be all along the line and apparently few institution heads are entirely satisfied with present conditions at the present moment.

What is the cause and what is the remedy? Undoubtedly the program of the Red Cross to carry nursing to rural districts and small towns and the publicity that has been given to such work has had the result of attracting into this field-for a time at least, a great many capable supervisors and head nurses who have been serving under the Red Cross overseas, while all this means advance, and in the end great gain to every community that is fortunate enough to secure a capable community nurse, it does not relieve the harassed superintendent of a hospital who is facing daily the problem of how to give adequate care to hospital patients.

If the present difficulty in securing com

petent graduate supervisors and head nurses leads hospitals to plan this very season to begin to give senior nurses a definite course of instruction in the principles of institutional management, and of methods to be used in the various departments, and to plan for weekly or fortnightly conferences of head nurses and supervisors to which senior nurses will be admitted, it will prove to be a blessing in disguise.

We have been altogether too indifferent to the matter of training nurses for leadership in institutional work. When we needed a teacher of nurses or an operating room supervisor, we have looked around, hoping that some other institution had developed the kind of worker we were looking for. We have criticized head nurses for not systematically teaching pupil nurses when as a matter of fact in many cases we had never given our own pupil nurses one lecture on how to teach or how to plan for class work. We have expected this teaching ability to blossom out in nurses after graduation without any special effort to cultivate it. A few schools here and there have for years had a definite system for the training of head nurses, but the great majority of schools have depended on filling vacancies in a sort of haphazard way. In the general reorganization that is now going on, this failure should be corrected. No up-to-date business firm would dream of picking up people in such haphazard way and putting them into responsible positions. They "grow" their own department heads and foremen and the sooner hospital people decide to follow the example of the successful business firm, and

Puerperal Eclampsia in Hospital

Practice

In an article read in part before the Medical Society of Bay Ridge, N. Y., Dr. Robert E. Coughlin of Brooklyn stated that the treatment of puerperal eclampsia at the Norwegian Hospital in Brooklyn as advocated by the writer resolves itself into conservative means at the outset with heroic methods at a later period. As soon as a patient is admitted in convulsions with high blood pressure and rapid pulse she is put on the tincture of veratrum viride in fifteen minim doses every fifteen minutes hypodermatically until the pulse shows signs of slowing up perceptibly or the convulsions have discontinued. As a rule, when the pulse has been brought down near the normal rate the convulsions are controlled. At this time observation will show that the pulse has not only become slower, but softer in character. Along with this condition of affairs the blood-pressure has been markedly reduced. At this time the drug may either be discontinued absolutely or given in much smaller doses at infrequent intervals, viz., five minims every four hours. A certain time is allowed to go on (from four to six hours) from the time of the last convulsive seizure when steps are taken to bring on labor. The delay is considered wise as veratrum viride combined with emptying of the uterus may together produce fatal shock. Rapid emptying of the uterus in eclampsia frequently causes a decrease in blood-pressure amounting to 100 mm. Hg, and causes collapse or shock. Veratrum viride given to its full physiological effect may cause a drop of 145 mm. of Hg and produce shock. It seems better for these reasons to allow the sys

of the drug before rapid emptying of the uterus is employed.

No matter what the period of uterogestation, the bringing about of labor is indicated, the idea always being kept in mind that the longer the patient is left in a condition of toxemia of the convulsive type tendency, the slighter are her chances for life with each convulsion. Likewise the child, for the more convulsions the greater are the risks to the life of the fetus. Labor is induced by means of the catheter and if necessary forcible dilatation. Once there is full dilatation the delivery is accomplished as rapidly as possible, instruments being used if the progress shows a tendency to be slow.

The anesthetic used is ether preceded by a hypodermic injection of morphine, oneeighth of a grain. Ether does not cause as much kidney congestion as chloroform and appears to be the safer anesthetic.

Ca

To relieve the condition of the kidney diuretin and potassium citrate are the diuretics employed. etics employed. Aconite is also given at times for its diuretic action. Ten-gallon rectal irrigations of normal saline solution are also employed along with a retaining rectal injection of about four ounces. thartics are given and the patient is kept in a hot pack. For failing heart conditions consequent upon the toxemia we have to fall back on strychnine and tincture of strophanthus. For extreme nervousness bromide of sodium is given in almost all cases. The diet consists of milk diluted in different forms, cereals, gruels, toast, oatmeal, jelly, rice, and prepared buttermilk.

In desperate cases or when there is pulmonary edema atropine sulphate in one seventy-fifth grain doses is administered

Creeping Sickness

Tamura (Japanese Journal of Dermatology and Urology) describes a case of creeping sickness" in a Japanese woman who had lived for ten years in China. The lesion consisted of hard, red swelling on the right breast. The origin of the tumor Iwas about five cm. below the axilla between the axillary and pre-axillary line, and ran from this point obliquely upwards. The subjective symptoms were intermittent lancinating pains, worse at night.

On cutting open the swollen area, the author found a worm-like animal 5 mm. long by 1 mm. broad which was classified as a species of gnathostomum not hitherto described. The author is of the opinion that there are several different kinds of animalcules beside gastrophilus and gnathostostomum which cause creeping sickness.

Castor Oil in Dermatology Montgomery praises (Jour. Cut. Dis.) castor oil for its value in dermatological practice. He points out that the oil is very heavy and resistant to changes of temperature; thus it withstands heating better than most oils, and only solidifies when a very low temperature is reached. Some features of importance to dermatologists are: (1) Its solubility in alcohol. Various medicated alcoholic lotions are frequently employed in the treatment of the scalp, and without the addition of a small quantity of oil the spirit would in a dry scalp dissolve out an excessive quantity of sebum. For this purpose castor oil is the oil which is usually chosen. (2) This oil also facilitates the solution of salicylic acid in oils and ointments, and thus renders it less irritating to the skin. The salicylic acid The salicylic acid must first be mixed with a little hot castor oil, and then added to the other ingredients. (3) Lastly, the internal administration of the oil acts particularly on the ascending colon, and as many of the more active skin reactions are caused by poisons

ization for the anaerobic proteolytic bacteria, it thus produces a clean alimentary canal, which in turn conduces to a clean cutaneous surface.

+

The Teeth and Arthritis Deformans in Children

A writer in New York Medical Journal calls attention to the tendency to sacrifice the teeth (needlessly in many cases) because of the belief that rheumatoid arthritis is due to infection of the gums and teeth, and states that signs are in evidence of a reaction against this practice. In children, the tonsils, adenoid growths, and the accessory sinuses of the nose should be looked upon as the seat of the infection. If after the tonsils and adenoids are removed, and there still remains elevation of temperature, leucocytosis and poor appetite, surgical treatment of the nasal sinuses should be undertaken.

What Should Be Taught About
Prevention

Tuberculous infection is peculiarly malignant in infants and young children. Therefore, writes W. J. Dobbie of the Toronto Free Hospital, Western Ontario, the young child must be absolutely protected against infection; to such an extent, indeed, that he would advocate the following two radical measures: (1) A tuberculous mother must not be allowed to come in contact with her child during its first three years, and (2) if the father is tuberculous he should not live in the house so long as there is in the house an infant under three years of age. While immunity is being developed, older children should be carefully protected against disease. We should adopt a more rational attitude toward attitude toward the adult consumptive. Needy consumptives should be provided with maintenance assistance, not only in institutions, but also at home. The incorrigibly careless patients should be detained