SECTION II

THE MEDICAL PROFESSION INCLUDING DENTISTRY

I

MEDICINE AND SURGERY

It may be safely claimed that, although there is still much to be

done, in medicine women have gained as good a position as in any other

branch of labour.

One of the most important considerations in discussing any branch of

women's work is what sort of women are suited for it. The following

are the chief requisites for the medical profession:--

(1) The first and most important qualification is enthusiasm. It is

impossible to follow this profession with success, unless it is

work for which one has not only aptitude but also natural taste. It

necessitates a very strenuous life, and many unpleasant details of

work, which are unimportant to a person to whom the occupation

is acceptable as a whole, but which would be quite insuperably

disagreeable to any one to whom the total idea of life embodied in it

was unattractive.

(2) Another very important qualification is a knowledge of men and

things. A doctor must never forget that she is dealing primarily with

human nature; certainly human nature which may be for a time

unhinged, or the mechanism of which may not be working smoothly, but

nevertheless with the human individual as a whole.

The so-called "bedside" manner which is the butt for so much ridicule

is not so purely ridiculous as one might be tempted to think. Its

basis is to be found in this very knowledge of human nature which is

so essential, although the superstructure is often nothing more than

vapid futility. In addition to this the ideal doctor should possess a

trained scientific mind, and, of the two, the former is infinitely

the more important, although the latter is very valuable, not only for

itself, but for the training which it gives in "tidy" thinking.

(3) Good health. A sick doctor is an anomaly and many people prefer

to be indifferently treated by some one who is cheerful and healthy,

rather than have the most expert advice from a woeful person.

(4) A good general education is essential. This should include a

certain amount of Latin, which is needed throughout medical work.

The student must also possess the necessary capacity for acquiring

knowledge. It is very usual to find among the general public--women in

particular--an idea that a tremendous amount of a vague quality which

they describe as "cleverness" is necessary in order to follow one of

the learned professions. Certainly this is not so in medicine. It is,

however, necessary to be possessed of average intelligence and a

good memory, and it is difficult for people to pass the qualifying

examinations if they have for many years given up "school

work"--_i.e._, the habit of learning large numbers of new facts.

(5) Money. For three reasons: (i.) The training is expensive, (ii.)

It is also strenuous, making a certain amount of margin for suitable

recreation very desirable, (iii.) Earning capacity, although

ultimately high, so far as women are concerned, is much delayed, and

the work itself is one of considerable nerve-strain. It is, therefore,

very important that economic worry should, if possible, be avoided.

Medicine is one of the few professions in which women receive as high

remuneration as men. A very strenuous battle was fought between the

public authorities and medical women on the subject of equal pay for

equal work. All sorts of dodges have been used to get cheap woman

labour, but, so far, the victory has been almost completely on the

side of medical women. By the word "almost" is meant the fact, that

if two or three posts of varying grades and remunerations are created

under a health authority the woman nearly always gets the lowest,

whatever her qualifications and experience. With this exception the

victory has been complete, and this has been entirely due to two

things:--

(1) The very able support given by the British Medical Association,

which practically served as a Trade Union for doctors, stated the

lowest rate of remuneration to be accepted, and kept a black list

of posts which were advertised at salaries below this rate. The

Association has throughout supported with absolute consistency, the

principle of equal pay for equal work for the two sexes, and has

helped us as medical women to fight many battles.

(2) The other factor has been the public spirit of the medical women

concerned, without which nothing could have been done. One of the

forms of public service most essential at the present day and for

which the individual gets neither honour nor even thanks, is that of

refusing "black leg" labour. It is generally admitted by those who

have to deal with the question of salaries and conditions of work

under public authorities, that medical women, as a whole, have shown

at least as great public spirit as men in refusing unsatisfactory

terms. To lose a post which would give one enough for one's own

needs and which would mean so much more in the way of experience and

adequate scope for one's energies, and to refuse it simply because

it would lower the market rate of pay, is a very fine thing to do.

Unless, however, this high tone is maintained the position of medical

women will become as bad as that of some other working women. If, on

the other hand, it can be maintained, the position already gained may

be used as a very powerful lever in raising the rate of pay in other

departments of women's work. There is sufficient support for

us amongst medical men. Everything, therefore, depends upon the

_personnel_ of the women doctors, and, as things become easier for

the students, it becomes more and more difficult to convince the new

recruits of the strenuousness of the fight in earlier years and of the

need for constant vigilance and self-sacrifice at the present time.

Those who fought so nobly in the past have earned the lasting respect

and gratitude of those who come after them. An account of their

labours has been written by Mrs Isabel Thorne, and is called a "Sketch

of the Foundation and Development of the London School of Medicine

for Women."[1] It reads like a romance and shows the absolute

determination and pluck which were needed by the women in order to

gain their point. As one learns of the rebuffs and indignities which

they endured, it reminds one of the struggle which is at the present

time going on for the parliamentary vote. There is one thing which

makes one inclined to "back the women every time," and that is their

stupendous patience. A very short _résumé_ of the facts may not be out

of place here. Miss Elizabeth Blackwell, English by birth but resident

in America, succeeded in 1858 after much difficulty in obtaining the

degree of M.D. of the University of Geneva, United States of America.

She then applied to have her name placed upon the register of duly

qualified medical practitioners of the General Medical Council of

Great Britain and Ireland, and it was discovered to the dismay of the

authorities that she could not be refused. The next step was taken by

Miss Garrett, now Dr Garrett Anderson. She decided to qualify herself

for the medical examinations of the Society of Apothecaries, London,

who also, owing to the wording of their charter, were unable to refuse

her, and in 1865 she successfully passed the required tests. In order,

however, to prevent a recurrence of such "regrettable incidents," the

society made a rule that in future no candidates should be admitted to

their examinations unless they came from a recognised medical school,

and, as no such school would admit women, this closed their doors.

In the meantime Miss Jex-Blake had applied to Edinburgh University

for medical education, but had been refused on the score that it was

impossible to make such alterations "in the interests of one lady."

Mrs Thorne, Miss Chaplin, Miss Pechey, and Mrs de Lacy Evans then

decided to join Miss Jex-Blake, thus making five instead of one. They

were allowed to matriculate, but forced to form separate classes

and to guarantee 100 guineas for each class. They were not, however,

allowed to receive scholarships, to which their work would have

entitled them, on the score that they were women. Mrs Thorne states

that their "success in the examination lists was their undoing," as,

owing to this, and to the fact that they were unjustly debarred from

receiving the distinctions that they had gained, a great deal of bad

feeling was aroused.

As the agitation increased, the efforts of these pioneers to obtain

a qualifying course for women in Edinburgh, were supported by a

committee of sympathisers, which speedily rose to five hundred

members, and, after a severe struggle, the question of clinical

teaching in the Infirmary was settled partially in the women's

favour in 1872. Later, the question of the validity of the original

resolutions admitting women to the University was raised and decided

against them. They had, therefore, been four years at the University

and were finally excluded. This, however, proved to be only temporary

as, in later years, the University reopened its medical degrees to

women; but not in time to allow of the return of these courageous

pioneers.

In the meantime Dr Garrett Anderson, having taken her degree in

Paris, had been steadily working in London, forming the nucleus of the

present New Hospital for Women, and the pioneers from Edinburgh came

to London and helped her to start a school of medicine for women.

This was successfully accomplished owing to the kind help of many

people, both within and without the profession, but no clinical

teaching could be obtained, as all the big London hospitals were

closed to women students. Finally, however, arrangements were made

with the Royal Free Hospital in Gray's Inn Road. It had no men's

medical school attached to it, and the admission of women to

the hospital was due to the kind intervention of the Rt. Hon. J.

Stansfeld, M.P., who met the Chairman of the hospital, Mr James

Hopgood, while away on a holiday, and induced him to persuade the

hospital authorities to give the dangerous experiment a trial. So

seriously was it regarded, that the women students had to guarantee an

indemnity to the hospital of 300 guineas annually in addition to their

fees, as it was felt that the general support might decrease by,

at least, this amount when the public became aware that there were

medical women studying at the hospital! This was soon found not to

be the case, and the yearly indemnity was generously remitted by the

hospital authorities, the students simply paying the usual fees for

instruction. In connection with this subject, it may be of interest

to note that to-day the presence of medical women at the hospital is

evidently found by the authorities to be an important means of

gaining the sympathy of the general public, for appeals for funds may

frequently be seen in London omnibuses stating, as the ground for

an appeal, the fact that this is the only general hospital in London

where women medical students are trained.

The medical school which began in a small Georgian house has now a

fine block of buildings with all modern appliances, and the hospital

is, at the time that this book goes to press, undergoing extensive

alterations and additions, including enlargement of the students'

quarters.

The success of this pioneer work has been sufficiently amazing, but

it is most important that every one should realise that the fight is

still going on. Not a day passes but somebody tries to get medical

women to work either for less pay or under less honourable conditions

than those required by their medical brethren, and one of the most

trying parts of work in this profession at the present time is the

constant alertness required both for detecting and defeating these

attempts. That they should be made is not surprising, when we remember

the lower market value attached to women's work in almost every other

occupation. Practical examples of the sort of attempts made, may be of

service.

_Example 1._--A medical woman went as _locum tenens_ for a

practitioner in a country town during the South African War. The

practitioner himself was at the time absolutely incapacitated by a

severe form of influenza, complicated by ocular neuralgia which made

work absolutely impossible. Owing to the War, he was quite unable to

get a man to act as _locum tenens_. A woman consented to help him in

his extremity, at considerable inconvenience both to herself and to

the people with whom she was working at the time. She carried on the

practice during the depth of the winter, having on some occasions to

go out in the snow-sleigh and frequently to drive in an open trap

at night in the deadly cold. She carried on the work with such

conspicuous success that her "chief" asked her to stay on as his

assistant when he was convalescent. For this he offered her £85 a

year, living in, saying, without any shame, that he knew that this was

not the price that any man would command, but that it was plenty for a

woman. He was bound to admit that he had lost no patient through her,

that he charged no lower fees when she went to a case than when he

did, that she did half the work while acting as his assistant, and

that she had kept his practice together for him while he was ill.

Fortunately, owing to the fact that she had behind her means

of subsistence without her salary, she was able to refuse his

unsatisfactory offer, although at considerable violence to her

feelings, for she had made many friends in the neighbourhood.

_Example 2_.--A husband and wife, both medical, went to settle in a

town in the north of England. They both practised, the qualifications

of both were excellent, but the woman was the more brilliant of the

two, having better degrees and more distinctions. Both applied to

be admitted to the local medical society. The man was, of course,

accepted, the woman refused on the score of her sex, this meaning that

she would be cut off from all opportunity of hearing medical papers

and discussing medical subjects with her colleagues. During the next

few months a local friendly society was anxious to obtain a medical

officer and was offering terms regarded as insufficient by the local

doctors. Among others approached by this society was the medical woman

in question. Directly the officials of the medical society, which had

banned her when her own benefit was concerned, heard that she had been

approached by the friendly society, they elected her without asking

her consent to the very society from which they had previously

excluded her, in order that she might be unable to take the post in

question, whereby they might have financially suffered.

_Example 3_.--The exclusion from medical societies referred to under

Example 2, like many similar actions in life, tends to recoil on its

instigators. For instance, a medical woman in another northern town

applied for and accepted a post which the local men had decided was

unsatisfactory in some particulars, and for which therefore none of

them had applied. They were loud in their denunciations of the woman

in question, but owing to the fact that her men colleagues had not

recognised her professionally in other ways, she was quite unaware of

her offence for several months after undertaking her new duties.

_Example 4_.--Men and women are sometimes appointed on apparently

equal terms and conditions to posts which are not, however, really

equal, in that there is a chance of promotion for the men but none for

the women.

_Example 5_.--In another town in the north of England men and women

appointed to do the work of school medical inspection on equal terms

recently considered that they were not sufficiently remunerated. They

met and decided that they would together apply for better terms. A

rumour was then set abroad that the authority under whom they worked

would certainly not consider such an increase in expenditure. In this

crisis the men on the staff, although they had so far joined with

their women colleagues in sending up their petition, sent up another

of their own, without informing or consulting the women at all, in

which they said that they considered it was time that this equality of

remuneration for both sexes should cease. They begged the authority

to neglect their public appeal, but to grant instead increased

remuneration to the men, and the men only. One of the reasons given

for this suggestion on the part of the men was that their liabilities

were greater. The result of enquiry, however, proved that of the three

men, one only was engaged to be married, the other two had no one

dependent upon them; whereas of the three women, two were supporting

other people--one being a married woman separated from her husband and

with two children to support and educate.

_Example 6_.--The following is an instance of the way in which the

Government is sometimes responsible for encouraging women's "black

leg" labour. Dr Leslie Mackenzie in his evidence given recently before

the Civil Service Commission said that the Treasury refused to allow

the Scottish Local Government Board to have a woman medical inspector

at a medical inspector's salary, but permitted them to engage a woman

with medical qualifications at a woman inspector's salary, which was,

of course, much less. Sad to relate a woman was found to accept this

post.

These examples have been given because it is necessary that a woman

intending to adopt the profession of medicine should know the sort

of work, quite apart from the treatment of her cases, which a medical

woman, worth her salt, has to do. It may be asked how it is, if these

difficulties are still constantly arising, that our pioneers were so

successful? For several reasons: first, because they were in the best

sense women of the world: they understood when to be firm and when

to give way. They understood mankind. Secondly, they had an assured

position. This is probably the most essential condition of all for

success. Before decent terms and conditions of work can be demanded,

the worker must be in such a position financially that she can, if

necessary, refuse the work in question, and if possible the employer

must be aware of this fact. So often women enter the labour market

only when driven by stark necessity, that it is unfortunately the

easiest thing in the world to exploit them. People of either sex faced

by starvation for themselves or those dependent on them must take the

first thing that offers if the conditions be in any way bearable. In

my opinion, next to the parliamentary vote, the most powerful lever

in raising the condition of women will be the entrance into the labour

market of a considerable number of women so trained in Economics that

they will always "play the game," and at the same time sufficiently

remote from want to be able to resist the sweating employer.

Some people discourage women of independent means from entering the

labour market through the mistaken idea that if such women work they

are taking away the chance of some other women who are in need. In

case any reader may be in doubt on this question, I should like

to point out that it is the groups of workers among whom no such

economically independent individuals are to be found, that are always

exploited by the unscrupulous employer; they are such easy prey.

What really makes women workers afraid of their independent sisters is

that extremely pernicious system of payment euphemistically known as

"pocket-money." This should be swept off the face of the earth. Even

the richer woman has some rights, notably the right to work, and

I would suggest that she has this particular, and certainly not

unimportant function of raising the rate of remuneration. From my

knowledge of her, I consider that she is most anxious to do nothing

but good to her fellows. The only thing she needs in order to become

a help instead of a menace to her poorer sisters is knowledge of the

rules that govern the economic labour market.

Owing to the necessary expense and prolonged training for the medical

profession it has probably attracted a larger proportion of working

women who were not subject to immediate economic stress than most

other branches of work, and it is, in my opinion, due to the

presence of such women, that the conditions in it as a whole are so

satisfactory.

Having discussed the sort of woman suitable for the medical

profession, I now pass on to a consideration of the course of training

which must be taken in order to fit her for the work.

Before beginning her training, the student has to decide what medical

qualification she will take. Her choice lies between

(1) A degree of one of the universities, and

(2) A diploma.

It is essential to go to some University or Examining Board which

admits women and not to one, such as Oxford or Cambridge, where women

are denied the degree to which their work entitles them. As a matter

of fact, women medical students are not accepted at Oxford and

Cambridge. It is not possible to practise medicine, in a satisfactory

way unless one is actually in possession of the qualification. Any

one who does so, however well trained, ranks as a quack, and is not

legally entitled to sign death certificates nor to recover fees.

The degrees open to women in medicine, as in other branches of

learning, are those of London, Glasgow, Trinity College, Dublin, and,

in fact, of all the Universities of the United Kingdom except the two

just mentioned.

Qualifying diplomas other than degrees are those granted by:--

(1) The Conjoint Examining Board of the

Royal Colleges of Physicians and

Surgeons of England.

(2) The Royal Colleges of Scotland.

(3) The Royal Colleges of Ireland.

(4) The Society of Apothecaries of London.

The authorities at the Women's Medical School strongly advise students

to take a degree, and that the best open to them, namely, in Great

Britain, that of London for the south, or one of the good Scottish

Universities for the north. Their reason for this advice is that they

feel that it is extremely important that medical women should rank as

high as possible in their profession.

At London University there are no sex restrictions. A woman is

eligible not only to take the examinations on equal terms with a man,

but all the rights and honours (except, of course, the Parliamentary

vote) are also open to her. Women may vote for and sit upon the

Senate, become members of Convocation and take any of the exhibitions,

medals, or scholarships which are offered to candidates at

examinations. For this reason women feel attached and like to belong

to the London University, and to do it honour.

Having decided which qualification she wishes to take, the candidate

applies to be entered as a medical student at a definite school. If

she elects to work in _London_ she must follow the course of study

at the Royal Free Hospital School of Medicine for Women at 8 Hunter

Street, Brunswick Square.

At _Glasgow_ the students are all entered at the Women's College

(Queen Margaret's). The medical course is taken in conjunction with

men students. At the Royal Infirmary some wards are open to women for

clinical instruction.

At _Dublin_ the students are admitted to the degrees and diplomas

in medicine, surgery, and midwifery on the same conditions as men.

A special anatomical department with dissecting room, etc., has been

erected by the Board of Trinity College for them.

At _Edinburgh_ the arrangements for women students are largely

separate from those for the men. The degrees are open to them.

At _Durham_ the degrees are open to women, and most of their work is

done with the men.

The same applies to _Liverpool, Manchester, Leeds, Birmingham,_ and

_Sheffield_.

The course takes from five to six years, but it is wise to allow the

longer time. The preliminary examination in general subjects is taken

before admission to the medical school. After this, the first year

at the medical school is spent in scientific study, such as Biology,

Inorganic Chemistry, etc. Having passed her first scientific

examination, the student proceeds to the study of the human

individual, and deals for the next two years with Anatomy, which

includes dissection, Physiology, the study of drugs in Materia Medica

and Pharmacology, and Organic Chemistry. When the examination in these

subjects has been satisfactorily negotiated, she passes on to medical

work proper, the study of disease and the result of accident in the

living person--in other words, she walks the wards of the hospital and

undertakes duties as clerk to physicians and dresser to surgeons, from

whom she receives instruction in medicine, surgery, and pathology.

Special branches are also studied, such as midwifery, women's

diseases, and affections of the throat, ear, eye, and skin. The

treatment of minor accidents also receives special attention. During

the whole of this time the student also attends regular courses of

lectures on these subjects, and she then takes her final examination.

If this be a degree examination, she becomes, on passing it, Bachelor

of Medicine, or M.B., and Bachelor of Surgery, Ch.B. or B.S. Having

obtained a diploma, she is generally entitled to style herself a

Member or Licentiate of the college of which she has passed the

qualifying examination, for example, M.R.C.S., L.R.C.P. or L.S.A.

On application, she is then placed upon the Medical Register, and is

known as a registered medical practitioner.

The cost of the training is approximately as follows :--

_For a London Degree._

Fee at the Medical School for Women, if paid as a composition fee in

five yearly instalments of £28, £51, £45, £40, and £15; Total:--£179,

or, if the whole sum is paid on entrance to the school, £160. In

addition there is a fee of three guineas for the special study of

fevers. These fees include everything in the way of material, except

books and instruments for which it is wise to allow another £30. The

examination fees of the university are £25. These amounts make no

allowance for any failures, and consequent revision of work, and

re-entry for examination. In reckoning the expense, the necessary cost

of living for the six years must also be included. For those students

whose homes are not in London there are flats and boarding-houses

where it is possible to live very reasonably. Suitable board and

residence can be obtained from about 25s. a week.

_For the Diploma of the Conjoint Board._

The school fees are the same; the examination fees are, however,

higher, namely £42.

For other qualifications, the school fees are £20 less for the course.

Certain scholarships are available for students, of which all

particulars can be obtained from the secretary of each school.

When a woman becomes a registered medical practitioner, she is for

the first time legally entitled to treat patients herself, and is

entrusted with responsibility. As in most other branches of knowledge

in the world, while she has simply been learning and carrying out her

duties under authority, she has had no opportunity of really testing

her own knowledge. It is, therefore, very generally felt amongst newly

qualified medical practitioners that they need more experience before

undertaking quite independent medical work. This experience is

best gained by taking hospital posts. By this is meant positions of

moderate responsibility, such as that of resident house physician or

resident house surgeon in a hospital, where the newly qualified doctor

is under the authority of an experienced visiting "chief," but is

expected to deal with ordinary incidents as they may arise, to realise

the relative importance of different symptoms, and report those that

matter to the visiting physician or surgeon.

It is at this stage that the doctor must decide whether she wishes to

become

(a) a "specialist" in some particular branch

of medicine or surgery,

(b) a general practitioner, or

(c) whether she wishes to work in the public

service.

(a) If she wishes to be a specialist she must so arrange her future

work as to gain experience in the branch which she selects. For

this purpose it is necessary to take posts at special hospitals, and

ultimately to become a member of the staff of some hospital in the

department chosen. Here women find that they are heavily handicapped.

The only hospital of any size in London of which the members of staff

are all women is the New Hospital, Euston Road, and this admits only

of a small staff, giving opportunities to comparatively few women for

special experience.

The Royal Free Hospital, where women take their training as students,

has now two women on its staff in the department for gynaecology. It

has also a woman anaesthetist, and some of the minor posts, such as

clinical assistant to the outpatients, pathologist, etc., are open to

them. All the physicians, the surgeons, and the assistant physicians

and surgeons are, however, men.

Of the hospitals for special ailments in London, none so far admits

women to the staff, and it has only recently become possible for

them even to form part of the medical audience at the outpatients'

department at some of these special hospitals.

No London Hospital for Diseases of Women

and Midwifery (except that of Dr M'Call),

or for Diseases of Children (except one recently

started by women),

or for Diseases of the Eye,

or for Diseases of the Ear, Nose and Throat,

or for Diseases of the Nervous System,

admits women to its staff, although several of them allow women to

take appointments as clinical assistants, pathologists, anaesthetists,

and other minor posts. Their admission to the full staff is, perhaps,

merely a question of time, and of the naturally slow movement of the

British mind towards admitting women to positions of responsibility.

There has, however, been of late years a tendency on the part of

medical women themselves to take this matter into their own hands, and

new women's hospitals are being started about London where the staff

is exclusively composed of women.

(b) If, on the other hand, the newly qualified doctor decides to

become a general practitioner, her course is much simpler. She takes

such posts as are available, which she thinks will aid her general

knowledge of medicine. Then she selects a neighbourhood, puts up a

plate, and waits.

This course also involves delayed earning capacity, as she must be

prepared to face outlay for several years without much return. During

this time she generally augments the income which she gets from her

private practice by other part-time paid work, notably by giving

lectures in first aid, etc., by school inspection, where part-time

officers are appointed, and other such work. She also generally does

a certain amount of voluntary work on that most pernicious system

of giving her services in order to get known. It is in this way that

doctors are everywhere so terribly exploited. When they are _all_ so

busy doing work which they think will bring them into the public view,

this becomes of no particular use to any of them, and the only people

who benefit, and at the same time scoff, are the members of the

general public, who become so used to getting the doctor to work for

nothing or next to nothing, that it comes as a shock when they have

to pay. It is a healthy sign that the long-suffering doctor is at last

beginning to show symptoms of fight, and in the future it may be

hoped that doctors, like lawyers, will not be required to give their

services free to the community. It may be true that if a man will not

work neither shall he eat, but the converse should also be true, that

if a man works he should eat, and at present it is not by any means

always true of the doctor.

(c) Should she decide to enter the public service, she will still

require to take a certain number of posts, especially those dealing

with eyes, ears, and skin, and must also obtain the Diploma of Public

Health. To gain this diploma she will need to devote several months

to post-graduate study in that subject before taking the necessary

examination.

The chief posts at present open in the public service to a woman

are:--

(1) School medical officer, or assistant medical

officer of health.

(2) Assistant medical officer in some asylums

and poor law infirmaries.

There is one woman inspector of prisons who is a medical woman, but

she is not a medical inspector and was not appointed in that capacity.

It is much to be hoped that women prison medical officers will

speedily be appointed on equal terms with their medical colleagues.

The conditions for women prisoners from the standpoint of health are,

at the present time, extremely unsatisfactory.

The tendency is to employ more and more women in the public service,

and therefore the opportunities are likely rapidly to become more

numerous.

The Act, under which medical school inspection was made obligatory,

particularly mentioned the suitability of women for much of this work.

It is therefore becoming usual all over the country to have at least

one woman school doctor, and in some districts there are several on

the staff. This work is not extremely arduous, is free from the heavy

strain of private practice, and, if the school medical officer is

allowed reasonable freedom in her work, may be made of much interest.

It is, however, somewhat monotonous, and has the great disadvantage

that at present the stimulus of promotion is largely absent, as the

higher administrative posts are almost universally in the hands of

men. This is a disadvantage which will also be gradually, perhaps

rapidly removed as the prejudice against women in authority dies down.

After having practised medicine for some years, further degrees

indicating experience are open to the medical practitioner; thus, if

she has taken the Bachelorship of Medicine she may, after the lapse of

three or four years, enter for her Doctorate. This is gained either

by a further examination or by writing a thesis on some subject of

original research. If she has taken the Diploma of the Royal Colleges,

it is open to her to sit for the Fellowship in Surgery or Membership

in Medicine. She is also open to election to the Fellowship in

Medicine.

It is extremely difficult to give anything like an adequate idea

of the remuneration to be obtained in medicine, as it varies

tremendously.

The first posts, which are taken soon after qualification, if really

first-rate in the experience which they give, seldom include any

salary at all, though board and lodging are provided. Posts which rank

as slightly inferior to these, but still give a considerable amount of

experience, are often associated with honoraria varying from about £50

to £150 a year, including board and lodging.

(a) If we turn again to our three sub-divisions we find that a

specialist or consultant cannot expect to earn her working expenses

for a good many years. She must have one room at least in a certain

specialist quarter of the town, known as the consultants' area, and

there the rents are usually high, in London about £150 a year, in the

provinces slightly less.

We have already stated that she requires some hospital post; for this

she will receive no remuneration, but if the hospital where she works

has a medical school attached to it, she may expect to get a certain

number of patients through the recommendation of students whom she

teaches at the hospital. There is generally also some teaching at

the hospitals, for which the students pay definite fees. She may also

augment her income by lectures and work of that description. She will

probably find it necessary to write papers on her special branch of

work and on the cases which come under her observation, but for this

she will very seldom be paid. It is, therefore only possible for a

girl with some monetary resources independent of her work, to take up

successfully a special branch of medicine.

If she elect to become a surgeon, a hospital post is an absolute

necessity, and her income will, as in the case of the medical

specialist, be delayed. Eventually, however, if she is successful, it

is greater than that to be obtained on the medical side. The fees are

high, and therefore money can be made more speedily in this branch of

the work. People, however, hesitate as a rule to trust a very young

surgeon, so she will at first get her work chiefly as assistant to

her seniors and must be content to wait some years for the much bigger

fees which she will get as principal. Ultimately she should make

£1,000 to £2,000 a year.

(b) If she elect to become a general practitioner, her outlay at first

is probably as great as that of the specialist, if not greater, but

the return is quicker, and a great deal depends upon the choice of a

neighbourhood. If she chooses an upper middle class district she

also, like the specialist, must be content to wait, and in fact she is

ill-advised to choose such a neighbourhood unless she can rely on some

good social introductions.

If she choose a district partly middle and partly lower middle class

her return will be infinitely quicker. She may expect to cover her

expenses in the course of two or three years. The work is, however,

incessant and rather harassing. If she select a working-class

neighbourhood and have a dispensary, her return will be still quicker,

such places frequently paying their expenses in the first or second

year. The people are nice to deal with, and the work is interesting,

but it is apt to be very distressing for two reasons--(1) that owing

to the poverty of the patients they can so seldom be attended under

conditions in which they have a fair chance of recovery, and (2) there

is apt to be an appreciable amount of dirt.

The most varying reports are given as to the incomes to be made in

private practice and it is almost impossible to get at the truth,

because it is obviously to everybody's interest to make them appear

as high as possible. A woman's practice also is admittedly rather a

specialist one. She does not get the general local practice of the

ordinary practitioner, but instead certain selected women who want to

consult a member of their own sex. These often live at considerable

distances, thus making the work more difficult to arrange and the

travelling more expensive than in the case of the ordinary medical

man. It is rare for a woman to be able to buy a practice. She must

generally build it up for herself, as it is of little or no use for

her to buy a man's practice, and there are only very few women's

available.

Generally, it may be stated that a woman covers her expenses by about

the third or fourth year after starting, and she may ultimately make,

according to the district and her success, anything between £400 and

£1,500 a year. Frequently two medical women settle together, which

seems to be a very good arrangement.

(c) If she elect to enter the public service her outlay is very small.

Beyond equipping herself for this work in certain special branches

already described, all that is necessary is that she should be able to

keep herself until she obtains a suitable post. The salary given for

whole time work in the public service should not be less than £250 a

year rising to £400 or £500 a year. In most cases the school doctor

gets the school holidays, including the whole of every Saturday.

English women who go to India, do so generally in connection with

either

(1) a missionary society, or

(2) a hospital under the Dufferin Fund.

(1) Many missionary societies engage medical women to treat the native

women. Salaries, of course, differ, but are, on the whole, low, as the

aim of a missionary is not supposed, primarily, to be financial gain.

Generally somewhere about £110 in English money is given, with

an allowance for carriage and house including the chief items of

furniture. Leave is also granted with second class return fare every

five years--in some missions every three years. The medical experience

is excellent, the opportunities of doing good professional work are

practically unlimited, and the professional position of the doctor

quite untrammelled. She is assisted, usually, by good nurses, under a

proper scheme, these being Indian girls superintended by fully trained

English sisters.

(2) Under the Dufferin Fund[2] things are very different. It is

somewhat difficult to speak of this branch of the work, as it is, at

the present time, the subject of enquiry, and it may be legitimately

expected that it will, before long, be put on a more satisfactory

basis. The fund was originally started by Lady Dufferin as the direct

result of a command by the late Queen Victoria, and it was intended

to provide the services of medical women for the Purdah women of India

who, owing to the strictness of their rules, were not infrequently

debarred from the full benefit of medical treatment by men.

Unfortunately, however, the doctor in charge of most of the Dufferin

Hospitals is under the local senior civil surgeon, who is a man. As

he has the right, if he wishes to exercise it, of seeing any of

the patients, and doing any of the operations or other treatment

necessary, it is obvious that the hospitals are of little or no use to

Purdah women, as they have no guarantee against treatment by a man.

There is also no security of tenure for the doctor who is not allowed

to be present at the meetings of the governing body, and may find

herself dismissed or transferred from a good post to a bad one at

short notice.

The remuneration varies roughly between £250 and £500 a year, with

house but no carriage allowance. The doctor is entitled to add to her

salary by private practice. In some towns this is a considerable

item, whereas in others it is quite negligible. There is no definite

furlough allowance, and the doctor may be removed from her post and

required to keep herself on very little for a considerable period of

time before being appointed to another hospital. All this causes a

severe drain on the resources of doctors without private means. The

staff is also frequently inefficient, and the nursing is sometimes

very indifferent, being undertaken by Eurasian girls under partly

trained women who have never been "home."

In the practice of medicine as in all other branches of women's

labour, the question of the effect of marriage upon work is a very

important and difficult one. In its general aspect it lies at the very

heart of the whole question of the working woman. Its effect on the

medical woman varies according to the branch of her profession which

she selects. If she wishes to become _(a)_ a specialist or _(b)_ a

general practitioner, she has perfect freedom of choice as to what she

will do in the event of marriage; and some women retire while others

continue their work. The latter is a much more desirable course from

the point of view of medical women as a whole. The medical woman who

is married can, better than any one else, render to society certain

services in her profession, and it is desirable that these should not

be lost. In any event no woman need retire from her work on marriage,

though it is, of course, most important that the married medical woman

should not deny to herself and to her husband the normal healthy joy

of having children. To continue in practice, however, while bearing a

child requires a certain amount of expenditure, as such a doctor

will need to retire from practice for at least two or three months,

probably longer, and is therefore put to the expense of engaging a

_locum tenens._ This ought, however, to be possible when both husband

and wife are earning incomes.

From the point of view of society as a whole, it is waste that any one

who has had such a long and arduous training as that required for

the medical profession should not use it in service to the community.

There is a form of selfishness not sufficiently recognised, which

consists not in acquiring goods but in acquiring knowledge without

rendering it again in service to one's fellow men and women.

Should the doctor decide _(c)_ to enter the public service, the

question will probably not be in her own control as there is an

ever-increasing tendency on the part of public authorities to insist

on single women or widows only among the medical women whom they

employ. There is a big fight to be waged here--one of the many that

our pioneers have left for us and our successors. The lack of social

instinct which lies behind this edict is amazing. What can be more

anti-social than that a young, healthy, and highly-trained woman

should have to decide between marriage and executing that public work

for which she has with great labour fitted herself? In at least some

cases of which the writer is aware, the demand that a doctor shall

retire on marriage, has led to a decision against matrimony, and this

is not surprising, although very serious as a general problem. The

great need of society at the present day is that the most healthy and

well-trained young men and women should be induced to found families,

and public authorities by this bar put on the trained woman, are doing

their best to hinder marriage.

Medical women have, for their protection, societies of registered

medical women in London and in the north of England and also in

Scotland, these working more or less in touch with one another. In

common with other medical societies they have meetings at which the

advances in medical science are discussed, and they also act in a

modified way as Trade Unions, Members of these societies can always

gain information from them as to the recognised rate of pay in any

particular branch of the work which they may wish to undertake.

Reference has already been made to the excellent work which has been

done by the British Medical Association in uniting the men and women

of the profession and helping both to keep up the salary rate. Without

this aid the women's associations would have been comparatively

helpless, as they would have erred in ignorance, though certainly

not by intention. The gratitude of medical women to this association

cannot therefore be overstated, and I think I am justified in saying

that the same is true with regard to medical men. If their chief

"Union" had not admitted women we might unwittingly have become a

danger to our medical colleagues as black-leg labour. This has been

almost universally the case in other work which women have taken up,

and one cannot help wishing that men in other branches of labour might

speedily realise the fact that women cannot be stopped from working,

and that the only wise thing, from the men's point of view as well as

from the women's, is to admit all to their unions that they may fight

shoulder to shoulder for better labour conditions, and not against

each other. An example of a case where this was realised has already

been quoted under Example 2, page 144.

With regard to the opportunities for post-graduate study:--At first

all the men's medical societies were closed to women, the provincial

societies being among the first to recognise their women medical

colleagues. London, being in this as in all things conservative, took

many years to move, and did so very grudgingly; but now nearly all

the important medical societies admit women, in this falling into line

with the learned professions generally. The Royal Medical Society,

London, at first admitted women to its separate sections only,

while denying them the Fellowship, with which would have gone that

mysterious power which men so deeply resent our possessing--the power

to vote on matters of its internal economy. The authorities of this

society have, however, recently admitted medical women on perfectly

equal terms with men to their Fellowship--a privilege for which we are

deeply grateful, as post-graduate knowledge of recent investigations

is absolutely essential to good work.

In conclusion, the general position of medical women at present may be

shortly summarised as follows:--

Their legal status is _absolutely identical_ with that of men in

every respect, by which is meant that by being placed upon the Medical

Register they have every privilege, duty, and responsibility which

they would have if they were men. In obtaining this and allowing many

other things to be settled by their successors our pioneers showed

their tremendous wisdom.

We have in the medical profession, what women are now claiming in the

State, the abolition of legal sex disqualification. With this firm

platform upon which to stand, it entirely depends upon medical women

themselves what position they will gain in their profession. All other

disabilities and disqualifications are minor and remediable.

This absolute equality of medical men and women before the law

includes the rights to

(1) Practise in any department of medicine in

which their services may be demanded.

(2) Recover fees if necessary.

(3) Sign death certificates.

(4) Sign any certificates for which a medical

signature is essential.

Under this latter heading a curious anomaly arises. If a man is signed

up as a lunatic, he is, for so long as he remains a lunatic, debarred

from using his Parliamentary vote, and, as may be seen from the above,

a medical woman's signature is as valid as that of a man for this

disfranchising certificate of lunacy. The State, therefore, at the

present time allows that a medical woman may be sufficiently learned

and reliable to disfranchise a man, though she be not sufficiently

learned and reliable to vote herself.

The Insurance Act concerned medical women only in the same way that

it affected their men colleagues. The sole reason, therefore, for

mentioning it in this paper is that it affords an indication of two

things:--

(1)that the Government therein makes no sex distinction in the

profession;

(2)that the bogey of sex cleavage, so often mentioned by the timorous

in the political world, is here, as always where it is put to the

test, proved to be without foundation.

Unfortunately, the Insurance Act divided the medical profession into

two parties; women, no more than men, were unanimous on the subject

and some were to be found on either side.

Women are still debarred from the full use of their medical powers in

the following ways:--

(1) The demand for their services from the general public is at

present not so great nor so universal as that for men. This is not

surprising when it is realised for how short a time there have been

medical women; however, the demand on the part of the public is very

rapidly increasing, naturally, of course, amongst their own sex.

(2) As in other work the tendency is to restrict women to the

lower branches of public work, or to the so-called "blind alley"

occupations. This can only be cured by public demand, and some

improvement is to be noted in this respect. There is, however, no

doubt that general practice affords at present the most unrestricted

field for a medical woman's activity, because there she suffers from

no limitations except those of her own personality in relation to

society. Any patients who are inclined to trust her are absolutely

free to do so, and it is open to her to demand what fees her services

are found to be worth.

If, on the other hand, she enters the public service she may

admittedly qualify herself in every way by attainments and experience

in the lower ranks for one of the higher administrative posts and be

barred simply by sex disqualification. This also will no doubt in time

improve, and the pioneer work that it implies may attract many, but

the progress is necessarily slower.

(3) She is still debarred from full opportunity for specialist work.

(See efforts being made by women themselves to obviate this by the

starting of women's hospitals, p. 149.)

Finally, then, the medical profession should attract women of good

average capacity and general education, good health and certain, even

if moderate, means. Above all do they need public spirit, which will

make them anxious to maintain and improve the excellent position

medical women have so far obtained. It is a very widely interesting

life, bringing those who adopt it out of the study into direct touch

with human affairs.

[Footnote 1: Publisher, G. Sharrow, 28A Devonshire Street, Portland

Place, W.]

[Footnote 2: Quite recently the outline of a new scheme was put

before a meeting at the Women's Medical School in London by the

Director-General of the Indian Medical Service. Under this scheme the

Women's Medical Service in India would not be upon the same footing

as the Indian Medical Service (I.M.S.) for men, but would remain as

at present, a Dufferin Association. It would, however, receive a

Government grant of £10,000 yearly, and proper arrangements would be

made for pay, furlough, promotion, and security of tenure. The scheme

is open to criticism on some points, but, as a whole, it marks a

considerable advance on the previous conditions of service in this

department of women's work, and may be welcomed as a genuine if

somewhat belated attempt on the part of the Government to deal fairly

with an urgent question.]

II

DENTAL SURGERY

It is not sufficiently well-known that dental surgery as a profession,

opens up a practically unexplored and lucrative work for women.

The training in the British Isles can be carried out in London,

Edinburgh, Glasgow, and Dublin, each of these cities granting their

Licentiate of Dental Surgery. In London, the National Dental Hospital,

and the London School of Medicine for Women (Royal Free Hospital) have

special facilities for women students, including special bursaries

and scholarships, while dental and medical studies can be carried

on concurrently. The course of study includes the passing of a

Professional Preliminary Examination or Matriculation, followed by two

years' mechanical work, and two years' hospital practice. The student

can be articled to a qualified dental practitioner for mechanics, or

can obtain tuition at the Dental Hospital. This branch includes the

preparation of models, vulcanite and metal dentures, crowns, and

bridges, etc.

The Dental Hospital course for two years includes lectures on Physics

and Chemistry, Dental Anatomy and Surgery, Metallurgy and Materia

Medica. At the same time practical work is done--extractions,

fillings, crowns, bridges, dentures, and the regulation of children's

teeth. At the medical school and hospital, lectures on Anatomy,

Physiology, Surgery, and Medicine must be attended, and dissections on

the human body, and clinics in the ward must be completed. At the end

of each year examinations in the subjects are taken, the whole course

covering a minimum time of four years. The qualification of the

Licentiate of Dental Surgery of the Royal College of Surgeons of

England is now open to women. The composite fee for training extending

over four years, is about £200, but an additional sum of at least £100

is required for incidental expenses. Should the woman student desire

to confine herself to dental mechanics this would materially lessen

the expense. The average wage for a good male mechanic is £120 per

annum. Hospitals can be joined at the age of nineteen, and it is

advisable to begin study soon after leaving school or college.

If it is possible, a woman should obtain a medical qualification as

well as the L.D.S. Much of the work can be taken at the same time as

the dental course. A medical degree enlarges a dentist's sphere of

usefulness and interest and adds to her _locus standi_: on the other

hand, it necessitates two or three years' extra study, and the fees

are increased by several hundred pounds.

The woman dentist will probably find it necessary to start practice on

her own account as soon as she is qualified, as it is not likely she

will be able to obtain an assistantship with men practitioners, but

there are an increasing number of posts open to women, such as dental

surgeon to school clinics or to factories. These posts offer the same

salaries to men and women. Smaller part-time appointments, with an

honorarium attached, can be obtained, and are especially useful to the

newly qualified practitioner who is building up a practice.

It is essential for the woman who intends to succeed in this

profession to have excellent physical and mental health, though

great muscular strength is not necessary. During student life and in

practice, every care should be taken of the general health--exercise

in the open air being especially necessary, though this should not be

too energetic in character. It is a well-known fact that male dentists

doing careful and conscientious work, cannot, as a rule, stand the

strain for many hours daily after they have reached middle age, and

the intending student should consider this point.

The prolonged hours of standing in a cramped position, the confined

space, the exactitude required for minute and painful operations, are

some of the causes of this overstrain. Great self-control and will

power must be exercised as the patients, especially children, are

frequently nervous, and confidence must be imparted to them if the

work is to be well done.

The British Dental Association and the Odontological Society are both

open to women, and male practitioners have always displayed the utmost

courtesy though some prejudice must be expected. The general public

apparently welcome the advent of women dentists as the few qualified

women in London and the Provinces have excellent practices. It is

curious, however, to note that few Englishwomen have taken up the

profession, there being about twelve practising in the United Kingdom,

though in Germany, Russia, and the United States there are great

numbers of women practitioners.

With regard to restrictions from which women at present suffer, one

dental hospital only is open to women in London, and, until recently,

no posts could be obtained. But as more women qualify, these

disadvantages will probably be removed. It is also extremely difficult

to obtain mechanical work in private work-rooms. Women should bear in

mind that they require exactly the same facilities for study as men,

and try to get admittance to all hospitals and posts on an equal

basis--_i.e._, the salary should be equal for equal work, and a

smaller fee should not be accepted.

In deciding whether a practice should be started in London or a

provincial town, the question of capital must be carefully considered,

as it is improbable that the expenses will be met during the first

year of practice. The upkeep necessarily varies with the locality

chosen, and a minimum capital of £150 is desirable.

Pioneer women must be prepared to do their work conscientiously, and

to the utmost of their ability, and they must always remember that

their work will be very severely criticised.

This necessitates frequent inspection of both the clothing and persons

of the children. Certain cases which are found to need attention are

also visited in their homes. The school nurse is so much alone in

her work that she requires to be very experienced and her powers of

observation to be highly trained in order to enable her to detect

signs of ill-health in its early stages. Firmness and kindness

are constantly required in dealing with parents, and tact and

consideration in her dealings with all with whom her work brings her

in contact.

In the London area the salary begins at £80 rising by £2, 10s.

yearly to £85, and then by £5 yearly to £105. Uniform and travelling

expenses, within the county, are provided. The nurse is required to

contribute to the superannuation fund from which she can ultimately

draw a pension if she remains all her working life in the service of

the Council.

The hours of work are from 9 A.M. to 4.30 P.M. five days weekly, and

from 9 to 12.30 on Saturdays. Clerical work must be done out of school

hours. Holidays are arranged during the school holidays.

There are 128 nurses working under one Superintendent,

two Assistant-Superintendents, and four Divisional

Assistant-Superintendents.

_B_. There are 42 nurses attached to schools for the physically

defective whose special duties are concerned with the care of the

crippled and delicate children who attend these schools. Certain

special precautions against injury and strain are necessary for these

children, and the nurse receives instructions concerning these from

the visiting doctor. The salary is the same as that mentioned above,

and the nurses get the school holidays. At open-air schools the

nurse's work is somewhat similar to that in the schools for the

physically defective.

_C_. There are 8 nurses now working under the Infant Life Protection

Act.

All women who undertake the care of an infant for payment have to be

registered. Of such children, a large proportion is illegitimate. It

is the duty of the nurses to visit every such case. Each nurse has

an area allotted to her; the work is arduous and responsible as the

visitor has full powers under an Act of Parliament summarily to remove

the child if the conditions required by the Act are not complied

with. The nurse who undertakes this work should have been trained

in maternity work (and if possible have been examined by the Central

Midwives' Board). She should also have her certificate from the

Sanitary Institute as she is expected to report on the sanitation

of the premises as well as on the condition of the child. There is a

considerable amount of clerical work in connection with these posts.

The salary of these nurses is good, compared with the usual salaries

for nurses--£120 to £150, with a further rise to £200 after ten years

of service.

The superannuation fund, which is compulsory for all permanent

officers, yields a provision of not less than one-third of the average

rate of pay in a case of complete breakdown in health after ten or

more years in the service of the council. The retiring age, apart from

breakdown, is sixty-five years.

The conditions of work in the Provinces are much the same in general

outline as those described above, which prevail in London, except that

in the country the nurse often undertakes in addition the work done in

London by Care Committees and Attendance Officers. This, although it

increases her work also increases its variety.

VIII

NURSING IN HOSPITALS FOR THE INSANE

Mental nursing as a profession for educated women has much to

recommend it. It is of absorbing interest to those of a sympathetic

nature and of a scientific turn of mind, and it develops all the finer

qualities, self-control, patience, tact, and common-sense. It gives

scope for originality and accomplishments of every kind. The work

itself is difficult, and is the one of all the many branches of

nursing which demands the closest personal devotion and service, great

as is the necessity for these in all forms of a nurse's work.

Mental nurses are employed in (1) county asylums, (2) mental

hospitals, (3) private work.

(1) _County Asylums_--These may take from 1,000 to 2,000 patients

each. They are usually situated in the country with healthy

surroundings and large grounds, and they are generally placed within

reasonable access to some town.

Probationer nurses are received for training from twenty-one years

of age. They must be of good health and physique. A nurse who is

successful in this branch of work should be able to obtain her

certificate from the Medico Psychological Board at the end of three

years' training. The salary is £19 the first year, with an annual

increase of £1 up to £35. Free board, lodging, washing, medical

attendance, are also supplied and uniform after three months' trial.

The hours on duty are from 6 A.M. to 8 P.M., with two hours off for

meals. Nurses get leave from 8 P.M. to 10 P.M. daily and one day

weekly; they also have fourteen days' holiday after the first twelve

months, increasing subsequently to three weeks a year.

The duties of the nurse in an asylum consist of the care of the

patients, the supervision of the cleanliness of the wards and

linen, and also of the work done by the patients in the various

departments--the needleroom, laundry, kitchen, corridors, etc. It is

obvious that in view of the number of patients, individual attention

is practically impossible. Entertainments of all kinds are provided

for the help and amusement of the patients, and nurses are expected to

assist in arranging these. Consequently any one with a gift for music,

acting, singing, or other accomplishment is an acquisition to the

staff.

(2) _Registered Mental Hospitals_.--These, owing to their different

circumstances, vary much in their conditions of service. Most of them

are training-schools and receive probationers of good education, from

twenty-two years of age, for a course of training. This consists of

lectures by the Medical Staff and Matron, the subjects receiving most

attention being Elementary Anatomy, Physiology, and Psychology; and

there is, of course, practical training in the nursing of mental

cases: in some hospitals a course of Massage and Swedish Drill are

added in the fourth year.

Salaries are on the whole lower than in the County Asylums, beginning

at anything from £15 rising to £19 in the third year with a bonus of

£3 on passing the final examination of the Medico-Psychological Board.

There must, however, be set against this lower rate of remuneration,

the fact that these mental hospitals are often situated more centrally

than the county asylums, thus making less expenditure necessary for

travelling to and from the hospital when out on leave. The usual free

board, lodging, washing, medical attendance, and uniform are also

given after three months' satisfactory service.

The hours of duty are from 7 A.M. to 8 P.M. with two hours off for

meals, etc. Leave during a month varies with the different hospitals,

but is usually two whole days, three half days, four evenings from 6

P.M. to 10 P.M., and four evenings from 8 P.M. to 10 P.M.: there is

also annual leave of fourteen days after the first twelve months,

increasing to three weeks after three years' service.

The work in a mental hospital is totally different from that in large

asylums. As there are fewer patients, individual treatment is the

rule, and the nurse gets more intimate knowledge of her patients'

condition, which she may thus do much to ameliorate. Owing to the

homelike freedom allowed, nurses need to be specially patient

and tactful. In return for this, however, by their much closer

companionship with their patients they gain the opportunity of

thoroughly knowing and therefore sympathising with and guiding them,

and on this, successful treatment largely depends. The majority of

the patients in these hospitals are suffering from acute forms of

insanity, and this adds both to the strenuousness and to the interest

of the nursing work: the fact that such patients frequently recover,

acts as a great incentive to the work.

Private asylums are on a different basis and do not as a rule offer

training.

A trained nurse may hope for promotion to posts as Sister of a ward,

Night Superintendent, Assistant Matron, or Matron. These posts demand

personal attributes in addition to good training--_e.g._, powers of

organisation and administration, a knowledge of housekeeping, laundry

work, etc. For the higher posts, training in general nursing is

essential. In all forms of mental nursing it is undoubtedly a great

advantage if the nurse has had a preliminary general training before

entering on the special branch of the work.

The conditions for private mental cases are the same as those

described under private nursing for general work (see page 184). The

fees, however, compare very favourably with those obtained for general

work, being almost universally higher. The great disadvantage is that

the hours are very long and the work necessarily exhausting.

Much has been done of recent years to improve the conditions of

service for workers in institutions, and there is still room for

amelioration. Particularly is this so with regard to the long hours

on duty and insufficient leave, due, chiefly, to shortage of staff.

Increase is also urgently needed in the salaries in every department

so that the nurses may be able to make provision for old age. When, as

now, so many of them are dependent on a pension as the only provision

for their old age, they are bound to stay at one institution for the

whole or nearly the whole of their lives--an arrangement which is not

to the benefit of either party, for "change is necessary to progress,

and the tendency is, from long years of service in one place, to

narrow and lose the adaptability of earlier years."

More arrangements are needed for the recreation of the nurses when

off duty, especially in institutions situated in the country. Swimming

baths would be a real boon; the beneficial effects of this form

of exercise upon both nerves and body being too well known to need

further comment. Its value also in promoting mutual helpfulness is

by no means negligible. Reading-rooms, apart from the general

common-room, are very valuable, as are also tennis courts where they

can be arranged. All these, of course, mean expense, but, if the

better class woman is to be attracted to the work, her interests

must be considered. Moreover, healthful recreations, apart from their

benefit to the nurse herself, must re-act favourably on the patients.

IX

NURSING IN THE COLONIES

Colonial nursing is usually undertaken by those who possess the spirit

of adventure, and do not mind the prospect of pioneering work. Love of

novelty, strong interest in fresh scenes and peoples, a desire to make

more money than can in most cases be made in England, help a nurse in

colonial work, provided that work really means her life, and she loves

it. But let it be emphatically stated that the nurses who are _not_

wanted in the colonies, in any capacity, are those who are failures

in their work in England, or who simply leave the dull work of the old

country with the object of having a good time abroad. Such women may

do immense harm in countries where it is essential to the Empire that

English people should be looked up to with respect and admiration,

and where almost the most important part of an English nurse's work

(_quite_ the most important _if_ she is working in a hospital), is to

make the native nurses, of whatever race they may happen to be, see

the dignity and possibilities of their profession, and be stirred with

the desire to become proficient themselves.

No special training is required for colonial work. A thorough

all-round training, including midwifery, a high standard of nursing

ethics, a knowledge of hospital organisation, and good business

abilities are needed. The rest is chiefly a matter of temperament

and constitution. It goes without saying that a nurse for foreign

climates, whether tropical, as in the majority of colonial posts,

or subject to extremes of heat and cold, such as in Canada, must

be physically strong; she should also be of an even temper and

philosophical disposition, easily adaptable to climate, conditions,

circumstances, and racial peculiarities.

The nature of the work will vary greatly with the locality and the

kind of post undertaken. The colonial nurse who does private work will

find patients and their needs much the same all the world over; she

must, however, be prepared for anything, and ready to make the best of

all things in emergencies.

In tropical hospitals it is altogether another matter. If the nurse

taking a Matron's post in such a hospital is the first European

to have occupied that post, she will probably have every detail to

organise and put in order, from providing dusters for use in the

wards, to arranging off-duty time for the nurses. She will mostly

likely see at once that everything wants altering, and yet she

will have to "make haste slowly," _very_ slowly, or she will have

everything in a ferment, and every one in open rebellion against her.

If she is working in the East, she will have the endless complications

of caste and race and religion to deal with, and will have for some

time, to learn vastly more than she teaches. Her success or failure

will depend very largely upon how she gets on with the medical

department--in other words, upon her own tact and common-sense, and

whether she can so approve herself to the various medical officers

that they will loyally back her up in her attempts at reform. Once

things are established in working order, it is a question of constant

supervision, day by day, for in no tropical hospital is it possible to

expect that native nurses will do their work well and conscientiously,

without the constant example and supervision of their trained Matron

and Sisters.

Colonial posts are chiefly to be obtained through the Colonial Nursing

Association, of which offices are at the Imperial Institute, South

Kensington.

Salaries vary considerably, according to climate and the nature of the

work. In very unhealthy climates, such as the west coast of Africa,

the salary is high, and the risks proportionately so.

Private nurses, and those holding subordinate posts in hospitals get

salaries varying from £60, which is the minimum, to £120 a year. An

Assistant Matron may in some few cases get a salary increasing to

£150 or £200. In a large hospital there is the ordinary chance of

promotion--a Sister may be made Assistant Matron, or an Assistant

Matron become Matron; but most colonial posts are simply for a certain

term of years, at the expiration of which the nurse seeks fresh

fields, her passage, both out and home, being paid. If, however, there

should be a desire on both sides for a renewal of the engagement, the

nurse can usually obtain an increase of salary.

A Matron's salary will vary from £100 to £250, in large Government

hospitals in the Colonies where, it must be borne in mind, leave

entails a journey to England, and a very expensive passage. In

colonial posts there is usually six weeks leave yearly (which may be

taken as three months together in the second year), but in most places

there is no bracing climate within a reasonable distance. This, of

course, does not apply to India and Ceylon, where the hills are easily

accessible.

Each Government has its own arrangements with regard to pensions; some

posts include pensions, but not all. The retiring age is usually

sixty years. There is, unfortunately, no pension obtainable from the

Colonial Nursing Association itself. This is certainly one respect

in which it would be well if an alteration could be made; it is

a question of funds and has already been brought forward for

consideration. There would be vastly more inducement for really

capable nurses, no longer very young (the age limit for joining is

thirty-five) to join the Colonial Nursing Association, and serve their

country in foreign dependencies, if they were assured of even a small

pension after ten years' hard work in trying climates.

X

NURSING IN THE ARMY AND NAVY

The training required by Army and Navy nurses is that for general

work. Additional experience according to the branch of the service

which the nurse wishes to enter is also useful. Only fully trained

nurses are appointed. Some of the tending of the sick is done by the

men themselves, under supervision.

In the _Military Service_ the salaries are as follows:

Matron-in-Chief, £305; ordinary Matron, from £75 to £150; Sister, from

£50 to £65; Staff Nurse, from £40 to £45, with allowance for board,

washing, etc., and arrangements for leave and pension after twenty

years' service.

In the _Naval Service _the arrangements are slightly different,

but the salaries work out at about the same. Foreign service is

obligatory.

There is also a small Army Nursing Reserve, but this is quite

inadequate for purposes of defence, and great efforts have recently

been made to supplement it by voluntary organisations, such as the

British Red Cross Society.

XI

PRISON NURSING

This is, at the present time, carried out by the ordinary staff of

prison warders. There are all over England not more than two or three

trained nurses among them, and it is most desirable that properly

trained women should be in charge of prison infirmary wards, just as

much as in the infirmary wards of workhouses. Prisoners are just as

likely to suffer from disease as other people, and they surely do not

forfeit all claim to expert care, simply because they have, perhaps

in a moment of weakness, yielded to temptation. To one form of illness

needing specially expert nursing, they are peculiarly liable--mental

disease. It is almost impossible to gauge the amount of good which

might be done both for the individual and for society by providing

trained nurses to attend to these unfortunate people.

XII

MIDWIFERY AS A PROFESSION FOR WOMEN (OTHER THAN DOCTORS)

This is not a paper to discuss the suitability of women for midwifery.

All through the ages it has been done by women, until early in the

nineteenth century in England and its colonies, it gradually became

customary for men-doctors to attend such cases; apart from this, the

work of midwifery has never been in the hands of men, except when

abnormal cases have required the assistance of a doctor with knowledge

of anatomy and skilled in instrumental delivery. Even before

the passing of the Midwives Act in 1902, statistics proved that

three-quarters of all confinements in this country were attended by

women.

Continental countries have been alive to the need for training the

women who did this work. For instance, in the great General Hospital

in Vienna with its 3,000 beds, 550 beds were kept apart for maternity

wards, and of these, 200 were reserved for the State training of

midwives--a course of _one_ year's duration being obligatory, with

_daily_ lectures on every detail in midwifery from the Professor of

Obstetrics. The present writer attended these lectures daily for six

months in 1885, and was made to feel the importance in teaching of

"hammering" at essentials and of questioning, so that the lecturer

might discover whether he were talking above the head of the least

clever of the audience.

England's population increased so steadily and rapidly during the

nineteenth century, that it seemed to trouble no one that countless

lives of mothers and babies were lost during the perils of

child-birth; it remained the only civilised country of Europe where a

woman could practise as a midwife without any training at all.

For nearly twenty years before the passing of the Midwives Act in

1902, a small band of devoted women laboured in season and out of

season urging on Parliament the need of a bill requiring a _minimum_

of three months' theoretical and practical training and an examination

before trusting a woman with the lives of mother and child.

This historical fact alone is a sufficiently cogent reason for the

now ever-increasing demand on the part of women for the parliamentary

vote.

The Central Midwives Board (C.M.B.), a body of eight members (experts

elected by various bodies, such as the Royal Colleges of Physicians

and Surgeons, the British Nurses' Association, the Midwives'

Institute, etc.), now exercises supervision over the midwives of the

whole of England and Wales, though local supervising authorities also

take cognisance of midwives' work and investigate cases of malpractice

and the like. The address of the Central Midwives' Board is Caxton

House, Westminster.

The training for the examination of the Central Midwives' Board is

based on the method pursued in medical education in English-speaking

countries, viz., there is not one uniform course, but each of the

training schools attached to hospitals follows out its own plan of

training, each hospital having been approved by the Central Midwives'

Board as giving an adequate training for its examination. There are

now seven maternity hospitals in London, where women students may

train in midwifery. Of these, only one--the Clapham Maternity Hospital

(with its training school founded by Mrs Meredith in 1885)--is, and

always has been, entirely officered by women. Here the course advised

is six months, viz., three months in the hospital (Monthly Nursing),

and three months in the hospital and district doing Midwifery proper.

During this time over 200 cases may be seen, and nearly 100 cases

attended personally. The cost of this training is £35 to £40, which

includes board and residence for twenty-six weeks. Students previously

trained elsewhere may take one months' extra training at a cost of

ten guineas. Private doctors and midwives may also take pupils if

recognised as teachers by the Board.

Midwifery training is now required not only by those who are going

to act as midwives, but also by most missionaries, all fully trained

nurses (for matrons' posts or colonial posts) and by health visitors

and inspectors before obtaining appointments.

But it should be borne in mind, especially in considering the present

condition and future prospects of Midwifery as a profession, that even

now a large though ever-decreasing proportion of registered midwives

are still ignorant women who have never passed the Central Midwives'

Board or any other examination, and have had no teaching from any

one more experienced or better informed than themselves. For when

the Midwives' Act came into force in 1903, it was necessary to move

slowly, and so a clause was inserted, permitting women who had been

in _bonâ-fide_ practice for more than one year before 1902 to continue

their work under inspection and supervision (with many attempts at

teaching them by means of simple lectures and demonstrations). This

plan, or some similar one, was necessary, not only in the interests

of the midwives themselves, a set of decent and kindly, if ignorant

women, who would have been ruined by too sudden a change, but also

because a large number of mothers in England would have been left with

no one to help them in their time of need unless they were prepared

to run the risk of breaking the law. This, until recently, respectable

English women disliked to do.

It is important to remember this fact, when considering the present

and future prospects of the midwife. The untrained woman used to

charge 5s. or 7s. 6d. for her services, and the fact that her name had

been enrolled on the Government Register, that she was subject to

the supervision of an inspector, without having spent anything on her

change of status beyond the 10s. registration fee, did not suggest the

need of any particular change in her scale of charges. Thus 7s.

6d. per case, unfortunately still remains the very common fee for

midwifery, though this now involves, under the rules of the Midwives'

Board, not only the long hours of watchful care at the birth, but ten

days of daily visits to supervise both mother and baby, with careful

records of pulse and temperature, etc., kept in a register. Naturally,

the general public who employ midwives--viz., the poorer classes--do

not differentiate between the trained certificated midwife and the

untrained _bonâ-fide_ midwife whose name is on the register, and thus

the scale of charges remains very low and the profession, as one for

educated women, is thereby greatly injured.

Granted an intelligent woman is willing to give six months' work and

study and £35 to £40 for her training, what chance has she of earning

a decent living? If she could command 15s. or 17s. 6d. per case

afterwards, she could make a decent living, given fairly hard work and

the acceptance of real responsibility. If she had 100 cases a year,

she would earn £75 at 15s. per case, and so on. This rise in the

fees payable to midwives has just been made possible by the National

Insurance Act of 1911, the framers of which appear to have recognised

the necessary result of the Midwives' Act of 1902. As the _bonâ-fide_

midwife, who has received no training, gradually dies out, it becomes

necessary to provide the means of paying trained midwives, whom the

people are obliged to employ in place of the old ones, but who would

soon be non-existent were the means of paying them not also provided

by the State.

A 30s. maternity benefit is now given for every confinement of an

insured person or the wife of an insured person. As the patient may

have free choice of doctor or midwife, it seems possible, now that it

has been established that the benefit shall go direct to the mother or

her nominee, that hereafter the greater part of it may be paid over to

the person who can supply that most necessary item of the treatment,

i.e., good and intelligent midwifery with nursing care of mother and

child. Therefore, it is the right moment for the careful, well-trained

popular midwife definitely to raise her fees to all "insured"

patients, being still willing to help the poor at a low fee as before.

It should be remembered that in about one-tenth of all her cases,

medical help will be required, but this case could probably be guarded

against by an insurance fund, if properly organised.

We frankly admit that as things now stand--apart from the possibility

of the maternity benefit being made to help her--midwifery is

financially but a poor profession. But to an enthusiastic lover of

her kind, who has other means or prospects for her future than the

proceeds of her profession, there is much that is attractive in this

most useful calling.

Now let us turn to a consideration of the poor mother. Dr Matthews

Duncan in 1870 put the puerperal mortality at 1 in 100 for in-patients

and 1 in 120 for patients in their own homes--shocking figures for

a physiological event! Miss Wilson, a member of the Central Midwives

Board, stated in 1907 that the average mortality of English women,

from puerperal fever, a preventable disease, is 47 in 10,000 or _1 in

213_, but that in three of the best lying-in hospitals this figure has

been reduced to less than _1 in 3,000_. To quote Miss Alice Gregory

in her article on this subject in _The Nineteenth Century_ for January

1908: "We feel there is something hopelessly wrong somewhere. It

becomes indeed a burning question: By what means have the Maternity

Hospitals so marvellously reduced their death rate?"

The answer is not now far to seek in the opinion of the writer,

who has worked continuously at Midwifery since 1st May 1884. It is

probably wholly contained in the three following points:--

(1) All that makes for scrupulous asepsis in

every detail for the surroundings of the

mother.

(2) The absence of "Meddlesome Midwifery."

(3) Pre-maternity treatment, a factor which

the writer considers to be of great importance,

and of which she would like

to have much more experience.

By this is meant the building up of the future mother's health by

improved hygiene and careful, wise dieting and exercising and bathing

during the last three months of pregnancy, which enables many a

stumbling-block to be removed out of the way. Hence, the utility of

pre-maternity wards wisely used. This is, one knows, a "counsel of

perfection"; but every expectant mother should and could be taught how

to treat herself wisely at this time.

These three points are all in favour of the well-trained midwife.

(1) _Scrupulous Asepsis_, if intelligently taught, can be learned in

six months' training, though one feels bound to add it requires moral

"grit" in the character to make one unswervingly faithful in observing

it. The midwife, too, should run no risk of carrying infection from

others, as a doctor might do.

(2) "Meddlesome Midwifery" is not so much a temptation for the midwife

as the doctor, though she also may want to do too much. Patience

combined with accurate knowledge when interference is urgently needed,

is part of her training.

(3) The midwife who becomes a wise friend to her patients will be just

the one to whom the mother will gladly apply early, and who will know

if it is advisable to send for skilled medical advice. Contracted

pelvis, threatened eclampsia, and antepartum haemorrhage are typical

cases, which lose half their terror if diagnosed and treated early.

If ever it is recognised that good midwifery is at the root of the

health of the nation and the new maternity benefit is made to help

in obtaining it, it will at once become worth while for educated and

intelligent women to take to the profession seriously. A practice

could then be worked by sets of two or three midwives in co-operation,

and with proper organisation as regards an insurance fund for securing

operative midwifery from medical practitioners when necessary.

There is ample room for a much larger body of trained midwives than

exists at present, if the health and welfare of the nation are to be

secured, while the women themselves could, under these conditions,

earn a sufficient livelihood.

Trained nurses also specialise in midwifery. They take the full course

of training described above, completing this by passing the Central

Midwives' Board Examination. They do not practise for themselves,

but work only under doctors, thus replacing the monthly nurse. The

improvement in health and comfort of both mother and child, when

nursed by some one thoroughly competent, is very marked.

The fees which they receive for this work are usually 12 to 14 guineas

for the month, and in some cases may rise to 18 guineas.

XIII

MASSAGE

This work demands a healthy body and cheerful mind, a love of the

work, endurance, and much tact in dealing with the nervous cases for

which this form of treatment is found to be beneficial.

It may be undertaken either

(1) As a separate profession, or

(2) As an additional qualification by trained nurses.

The training must be good and adequate to ensure any success as a

masseuse, so great care should be exercised in the choice of a

school. The many training schools advertised are of varying degrees

of efficiency, and those prepared to train in a few weeks, or by

correspondence only, are obviously unsatisfactory.

On application to the secretary of the Incorporated Society of Trained

Masseuses, information can be obtained with regard to the training

schools in London and the Provinces where a course of instruction in

massage is given, which is accepted by the society as adequate.

The society itself is an independent examining body which insists on

a satisfactory standard for massage workers. It holds two examinations

yearly and grants a certificate to successful candidates. No one may

enter for the examination unless she can show that she has received

her training at one of the schools approved by the society.

Adequate training in massage includes a course of not less than six

months in Elementary Anatomy and Physiology, the Theory and Practice

of Massage and a course of bandaging. Students usually attend the

classes from 10 A.M. to 4 P.M., lectures being given in the morning,

demonstrations and practical work on "model patients" in the afternoon

hours.

Sufficiently advanced students are allowed to attend at hospitals or

infirmaries to see--and themselves to carry out under the teacher's

supervision--the treatment ordered for the patients by the doctor. In

this way all students have opportunity during their training of seeing

and giving treatment to the various cases which they may have to deal

with as qualified masseuses when working under private doctors.

Some training schools give their own certificate after training,

and this is useful as a guarantee of the training taken. It is not,

however, such an assurance of efficiency to the medical profession or

the general public as the certificate gained after examination by an

independent examining body.

There is also a further examination held by the society once yearly

in Medical Gymnastics. The minimum time to expend on this is a further

six months after qualifying as a masseuse, so that it takes a year to

gain the double qualification.

In addition to supplying the independent examination in these

subjects, the society watches over the interests of the masseuses. All

its members are bound to observe the rules of the society. The result

of this is threefold.

(1) The doctor is assured that the masseuse

will not undertake cases on her own

diagnosis, but work only under qualified

direction.

(2) The public is assured that the masseuse

is a trustworthy woman as well as an

efficient worker.

(3) The masseuse herself is protected from

undesirable engagements. This is of

considerable importance.

The training for the examination previously

mentioned is from 10 to 15 guineas for those taking

the course. There is generally some reduction

made for nurses. The further course in Medical

Gymnastics costs from 20 guineas.

From this it will be seen that the whole training is comparatively

inexpensive; it is, however, not a profession to be entered lightly.

London is already overstocked and the better openings at the present

time are to be found in the Provinces, in Scotland and the Colonies.

It is well to start, if possible, in a town where the masseuse is

already known either to the doctors, or to some influential residents.

Much depends on the individuality of the masseuse, and one who is

prepared to give all her time to the work, taking every call that

comes, may reasonably expect to make in her first year from £50 to

£100. By the third year a steady connection should be formed, bringing

in an income of £150 to £250. This cannot, however, be expected unless

the masseuse has some introductions to start her in her work.

Fees in the country vary from 3s. 6d. to 7s. a visit, and in London

and some other places they rise to 10s. 6d. for an hour or less.

Hospital and nursing-home appointments are most useful as experience

for the masseuse in her first year; they should be tried before

she finally decides where to start work. Such appointments are

residential, and the salaries offered vary from £30 to £70 a year.

It must not be forgotten that, owing to the short and comparatively

inexpensive training, very many women take up this work,

so that the above excellent results are not realised unless the

masseuse has good introductions. The value of a thoroughly reliable

society such as that mentioned cannot be over-estimated, not only

for its certificate, but also on account of the information it can

give as to the respectability of posts advertised for masseuses.

Many of these are unfortunately merely blinds for undesirable houses.

[SUB-EDITOR.]