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 L10,000 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 L200, but an additional sum of at least L100 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 L120 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 L150 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 L80 rising by L2, 10s. yearly to L85, and then by L5 yearly to L105. 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—L120 to L150, with a further rise to L200 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 L19 the first year, with an annual increase of L1 up to L35. 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 L15 rising to L19 in the third year with a bonus of L3 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 L60, which is the minimum, to L120 a year. An Assistant Matron may in some few cases get a salary increasing to L150 or L200. 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 L100 to L250, 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, L305; ordinary Matron, from L75 to L150; Sister, from L50 to L65; Staff Nurse, from L40 to L45, 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 L35 to L40, 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 bona-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 bona-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 L35 to L40 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 L75 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 bona-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 L50 to L100. By the third year a steady connection should be formed, bringing in an income of L150 to L250. 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 L30 to L70 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.]



SECTION IV

WOMEN AS SANITARY INSPECTORS AND HEALTH VISITORS

The introduction of women into the public health service is a modern development, although they have been engaged in it longer than is usually known.

Women who are employed in Public Health Work hold office under Local Sanitary Authorities, and their work must not be confused with that of the Women Home Office Officials, who were first appointed in 1895; these inspect factories and workshops, but their powers and duties are of a different character. For instance, the Women Home Office Inspectors deal, amongst other things, with the cleanliness of factories, but not with the cleanliness of workshops, and with the heating of workshops, while the ventilation of the same workshops is under the control of the local sanitary officials.

Glasgow was the first county borough to utilise the services of Women Health Officials, for in May 1870 four "Female Visitors," afterwards known as Assistant Sanitary Inspectors, were appointed in connection with the Public Health Department. Their duties were: "by persuasion principally, to induce the women householders to keep the interiors of their dwellings in a clean and sanitary condition, and to advise generally how best this can be maintained." They possessed the same right of entry to premises as the men inspectors, and were required to hold the certificate of the Incorporated Sanitary Association of Scotland. They reported certain nuisances, but themselves dealt with others, such as "dirty homes or dirty bedding, clothing, and furnishing."

The work of Women Health Officials in England, dates from the passing of the Factory and Workshops Act of 1891, when certain duties with regard to workshops, which had previously been performed by the Home Office Inspectors, were laid upon Sanitary Authorities.

In the opinion of Dr Orme Dudfield, late Medical Officer of Health for Kensington: "It soon became apparent that, not only was systematic inspection necessary, but also that many of the duties involved were of so special and delicate a nature that they could not be satisfactorily discharged by male inspectors." He therefore recommended the appointment of two Women Inspectors of Workshops in Kensington. In the meantime the city of Nottingham had appointed a Woman Inspector of Workshops in May 1892, and in accordance with Dr Dudfield's recommendation two Women Inspectors were appointed in Kensington in 1893.

These ladies were appointed as inspectors of workshops only. They did not hold Sanitary Certificates, nor had they the status of Sanitary Inspectors. In practice, this entailed a visit by a male inspector every time it was necessary to serve a legal notice for the abatement of any contravention of the Factory and Workshops' Act. Therefore, when these ladies resigned upon their appointment as Factory Inspectors, it was decided to appoint the in-coming ladies as Sanitary Inspectors, with power to deal with these matters themselves. It was, however, Islington which appointed the first woman with the legal status of Sanitary Inspector in 1895.

By 1901, eleven women had been appointed in the Metropolitan area as Sanitary Inspectors, nearly all of them exclusively engaged in the inspection of workshops. Since that time the number of women appointed by Local Sanitary Authorities has increased considerably, both in London and the Provinces. The exact number outside London is only known approximately, as no register exists which is available to the public. It is to be hoped that this information may be obtainable from the last census returns. The figures with regard to London are published annually by the London County Council, and there are now forty-one Women Sanitary Inspectors in the Metropolitan area.

Sanitary inspectors in London, whether men or women, are required to hold the certificate of the Sanitary Inspectors' Examination Board, the examination for which is the same for men and women.[1] Outside London no definite qualification is required by the Local Government Board, but it is usual in county and municipal boroughs for a sanitary certificate to be demanded from candidates for the position of Inspector of Nuisances (the term used outside London for Sanitary Officials). Men and Women Sanitary Inspectors possess equal rights of entry to premises and equal statutory powers for enforcing compliance with the law.

The duties of Women Sanitary Inspectors have become very varied and numerous during the past ten years; they differ considerably according to locality and to the opinions of the local Medical Officer of Health. Broadly speaking, before 1905 women in London were mainly engaged in the inspection of workshops, whereas in the Provinces (with the exception of Nottingham, Leicester, and Manchester) they were engaged in house-to-house visitation in the poorer parts of the towns, with a view to the promotion of cleanliness, giving advice to mothers concerning the feeding and care of infants and young children, and the detection of sanitary defects. The inspection of workshops in the Provinces was a later development.

These varied duties have called for special qualifications, and, in addition to certificates in sanitation, Women Sanitary Inspectors usually hold qualifications in nursing or midwifery. The general education of the women who take up this profession is, on the whole, superior to that of the men. Most of the women have had a high school education, and many are University graduates, while the men, as a rule, come from the elementary schools.

The duties of a Woman Sanitary Inspector are sufficiently varied to avoid monotony, and may comprise any or all of the following:—

A. (1) The inspection of factories in order to see that suitable and sufficient sanitary accommodation is provided for women, in accordance with the requirements of the Public Health Acts.

(2) The carrying out of the provisions of the Public Health and Factory and Workshops Acts, with regard to the registration and inspection of

(a) laundries, workshops, and workplaces (including kitchens of hotels and restaurants) where women are employed;

(b) Outworkers' premises.

(3) The inspection of tenement houses and houses let in lodgings, and the enforcement of the bye-laws of the Sanitary Authority affecting these.

(4) House-to-house inspection in the poorer parts of the district.

(5) The inspection of public lavatories for women.

(6) The carrying out of duties and inspection concerning

(a) Notifiable infectious diseases, such as scarlet fever.

(b) Non-notifiable infectious diseases such as measles.

(c) The notification of consumption.

(7) Taking samples under the Food and Drugs Acts. (This work is rarely given to women.)

For many of the above duties, women are obviously better fitted than men, but for the following most important group of duties men are practically disqualified by reason of their sex:—

B. Health visiting. Work in connection with the reduction of infantile mortality :—

(1) Notification of Births Act, 1907. Visiting infants and giving advice to mothers about the feeding and general management of young children.

(2) Advising expectant mothers on the management of their health and as to the influence of ante-natal conditions on their infants.

(3) Work in connection with milk depots and infant consultations.

(4) Promotion of general cleanliness in the home and discovery of sanitary defects

remediable under the Public Health Acts.

(5) Investigation of deaths of infants under one year of age.

(6) Lecturing at mothers' meetings.

(7) Organisation of voluntary Health Workers in the district and arrangement of their work.

C. The following duties may also be required in the Provinces:—

(1) Work relating to the administration of the Midwives' Act, 1902 (where the County Council have delegated their powers to the District Council).

(2) The inspection of shops under the Shop Hours Act, 1892-94, and the Seats for Shop-Assistants Act, 1899.

The work described under C. 1 and 2, is performed in London (except in the City) by special inspectors appointed by the London County Council, who also inspect employment agencies where sleeping accommodation is provided and carry out certain duties under the Children's Act.

(3) Work in connection with the medical inspection of school children (performed in London by the London County Council school nurses).

The duties of Men Sanitary Inspectors are very clearly defined, and differ considerably from those of the women. Men are mainly engaged in the inspection and reconstruction of drains, the detection of structural defects in the houses of the working classes, the carrying out of bye-laws with regard to tenement houses, the investigation of cases of notifiable infectious diseases, the inspection of workshops and factories, the enforcement of the law with regard to the sale of foods and drugs and the abatement of smoke nuisances.

As will be seen from the duties enumerated above, Women Inspectors, as a general rule, are brought into very close and intimate contact with the homes of the people, and this necessitates the exercise of much tact and patience. The large demands thus made upon their powers of persuasion and teaching capacity, involve a considerable strain upon their nervous energy as well as their physical strength. The work of the Men Inspectors, on the other hand, being of a more official character, does not involve the same strain.

There is no uniformity of practice with regard to hours of work, holidays, remuneration or superannuation, either within or without the metropolitan area. Each Local Authority makes its own arrangements. Many have no superannuation scheme and give no pensions. Men and women working for the same Authority usually work under the same conditions as to hours and holidays: the rate of remuneration, however, is by no means the same. The salaries of Women Sanitary Inspectors within the Metropolitan area range from L100 to L200 per annum, the latter figure being reached only in two boroughs and in the City of London: whilst the salaries of the men range from L150 to L350. The average maximum salary of the women is L150, and the average maximum salary of the men is L205. Outside London, the salaries of both men and women are lower, those of the women ranging from L65 to L100, a few rising to L150. Payments are made monthly, and a month's notice can be demanded on leaving, though it is frequently not enforced. Another unjust distinction frequently made between men and women is that the latter are generally compelled to retire upon marriage, thus enforcing celibacy on some of our most capable women.

The hours of work are usually from 9 A.M. to 5 or 6 P.M. and to 1 P.M. on Saturdays. If we consider the nature of the work, the holidays appear most inadequate—viz.: only from two to three weeks per annum are allowed in London, and from ten to fourteen days in many provincial towns.

The Health Visitor, as a public official, was not known until 1899, when several were appointed by the City Council of Birmingham. The name "Health Visitor" was thought to be more feminine and suitable than that of Inspector, and it was imagined that she would in consequence be better received in the homes of the people. As a private society in Manchester had previously engaged women of an inferior class and education with the title of "Health Visitor," this designation was deprecated by women already in the profession. Many smaller provincial towns, however, followed the example of Birmingham, and appointed Health Visitors instead of Women Sanitary Inspectors. It was not until later that the Health Visitor was introduced into London, and in the following way:—

In the Metropolitan area (exclusive of the City) half of the salary of all Sanitary Inspectors is paid out of the County Rate, and their duties are defined in Sections 107 and 108 of the Public Health (London) Act, 1891. As Medical Officers of Health and the public generally became more and more interested in the question of infant mortality, Women Inspectors were employed to investigate infant deaths, to visit houses where a birth had taken place and advise mothers on infant care, to manage milk depots, to weigh babies, and to assist at infant consultations, and to do a great deal of work which hitherto had not been considered the work of a Sanitary Inspector. There was never any question as to the value of the work done nor of the efficiency with which it was performed, but the Local Government Board Auditor took the view that it did not come within the scope of the order of 1891, defining the duties of a Sanitary Inspector, and he refused to sanction the payment out of the County Rate of half the salary of those women who were engaged in Health Visiting work. In March 1905, the borough of Kensington solved the difficulty for itself by appointing a Health Visitor and paying the whole of her salary out of the Local Rate; but less wealthy boroughs felt unable to do this. It was work which the Sanitary Authorities wanted to undertake; it was work which the London County Council and the Local Government Board were desirous of seeing performed, but this technical difficulty stood in the way. It was overcome by the inclusion in the London County Council General Powers' Act of 1908, of Section 7, which empowered Sanitary Authorities in the Metropolitan area to appoint Health Visitors, and this enabled the London County Council to contribute half their salaries out of the County Rate. As a matter of fact, at the present time (November 1913) the whole of the salary of Health Visitors in London is being paid out of the Local Rate, as the Exchequer contribution account is completely depleted by the payment of the moiety of the salary of Sanitary Inspectors.

The essential difference between a Woman Sanitary Inspector and a Health Visitor is that the Woman Sanitary Inspector is a statutory officer with a legal position, having definite rights of entry and certain statutory powers for enforcing the Public Health Acts, while a Health Visitor is a purely advisory officer, with no legal status or right of entry or power to carry out any of the provisions of the Public Health Acts.

In actual practice, the title of Inspector has in no way proved an obstacle to successful health visiting, as may be demonstrated by an enquiry into the work now being carried on by Women Sanitary Inspectors in Sheffield, Leeds, Liverpool, Bradford, London, and other places. On the contrary, it has enabled officials to obtain an entry into dirty and insanitary places and to expose cases of neglect, which might otherwise have remained undiscovered.

The Health Visitor is usually paid a lower salary than the Woman Sanitary Inspector; this ranges in London from L100 to L120; in the provinces it may be as low as L65 per annum, and rarely rises above L100. The hours of work and holidays are, as a rule, the same as for Women Sanitary Inspectors. The difference in salary has proved a great temptation to Local Authorities in London to appoint Health Visitors when Women Sanitary Inspectors would have been more useful and efficient officers. Indeed, it is to be deplored that very few members of Local Authorities understood the advantages to be gained by the appointment of the more highly qualified official. The immediate effect of Section 7 was that several boroughs, having no women officials, proceeded to appoint Health Visitors; other boroughs, which possessed Women Sanitary Inspectors, also appointed Health Visitors. Seven or eight boroughs re-appointed their women officials in the dual capacity of Sanitary Inspector and Health Visitor so that the work in those cases went on as before. An indirect effect has been the almost complete cessation of the appointment of Women Sanitary Inspectors and the diminution in their number in some boroughs by the lapse of appointments on resignation or marriage. The inspection of workshops where women are employed has, in several instances, fallen back into the hands of Men Inspectors, whose unsuitability for this work first called women in England into the Public Health Service.

In September 1909 the Local Government Board issued the following order with regard to Health Visitors in London:—

"Art. 1. Qualifications. A woman shall be qualified to be appointed a Health Visitor if she

(a) is a duly qualified medical practitioner ; or

(b) is a duly qualified nurse with three years' training in a hospital or infirmary, being a training school for nurses and having a resident physician or surgeon; or

(c) is certified under the Midwives' Act, 1902; or

(d) has had six months' nursing experience in a hospital receiving children as well as adults, and holds the certificate of the Royal Sanitary Institute for Health Visitors and School Nurses, or the Diploma of the National Health Society; or

(e) has discharged duties similar to those presented in the regulations in the services of a Sanitary Authority and produces such evidence as suffices to prove her competency; or

(f) has a competent knowledge and experience of the theory and practice of nurture, and the care and management of young children, of attendance on women in and immediately after child-birth, and of nursing attendance in cases of sickness or other mental or bodily infirmity.

"Art. 2. Every appointment must be confirmed by the Board.

"Art. 6. Enables a Sanitary Authority to determine the appointment of a Health Visitor by giving her three months' notice, and no woman may be appointed unless she agrees to give three months' notice previous to resigning the office or to forfeit a sum to be agreed.

"Art. 8. Outlines the duties of the Health Visitor but prohibits her from discharging duties pertaining to the position of a Sanitary Inspector (unless with the consent of the Board she holds the dual appointment).

"Art. 9. The Board's approval is required to the salary to be paid to the Health Visitor, and an allowance in respect of clothing, where uniform or other distinctive dress is required, may be made."

The Board in their circular letter state that they consider that, in consideration of the importance of the duties and of the salaries often paid to Women Sanitary Inspectors in London, the salary ought not to be less than L100 per annum.

It will be seen from the above that it is quite possible for a Health Visitor to be appointed practically without any qualification for the position, and with absolutely no knowledge of Public Health Law and sanitation.

It is, therefore, apparent that there are two classes of women officials in connection with Public Health Departments, one on the same footing as the men, with equal powers and responsibilities, but remunerated at a much lower rate, and another with a lower status and a still lower rate of remuneration. The duties of the second class may be performed equally well by the first, but the duties of the first cannot be performed by the second. The introduction of the Health Visitor has therefore lowered the status of the Public Health Service.

The remedy for this state of affairs is for competent woman officials in the future to be appointed in the dual capacity of Sanitary Inspector and Health Visitor at an adequate remuneration, and for the order of 1891 defining the duties of a Sanitary Inspector to be expanded to meet the developments which have been taking place in the Public Health Acts since that date.

There are two organisations which Women Sanitary Inspectors may join:—

(1) The Women Sanitary Inspectors' Association, which includes as members Women Sanitary Inspectors and Health Visitors holding recognised certificates in sanitation. (Health Visitors holding official appointments but without these recognised certificates in sanitation may become associates.)

(2) The Sanitary Inspectors' Association, which is composed of a large number of Men Sanitary Inspectors and a few Women Sanitary Inspectors. This is not open to Health Visitors.

There is no approved society for Sanitary Inspectors under the Insurance Act. The income of the majority of Men Inspectors exempts them from the operation of the Act, but a large number of Men and Women Inspectors receiving less than L160 per annum, have joined the approved society of the National Association of Local Government Officers.

To sum up, we may say that on the whole the life of a Health Official is a healthy and suitable one for a woman of average physique; it demands great activity, with many hours spent out of doors, and whoever undertakes it must be prepared for surprises and difficulties. She may find herself in an office staffed entirely by men, with chief, committee, and council composed entirely of men—indeed everything looked at from the male standpoint. She either works singly or in small groups of two or three, except in a few large towns where the women officials may number from ten to twenty. Thus isolated and scattered, it is extremely difficult for the Women Health Officials to form an effective organisation. What is accomplished under one Authority may have little or no effect upon another.

One condition which presses heavily on many women is the shortness of the holidays. The work is always arduous, particularly in poor districts where one is brought face to face with poverty, disease, and suffering, and from two to three weeks is not sufficient for rest and recuperation, particularly as the years pass on.

The creation of public opinion and the advent of a greater number of women on Municipal Councils and Health Committees is greatly needed to improve the conditions under which women officials work, and to support their reasonable demands.[2]

[Footnote 1: Full particulars of this can be obtained from the Secretary, Sanitary Inspectors' Examination Board, Adelaide Buildings, London Bridge.]

[Footnote 2: The above article considers under the term "Health Visitors" such women only as are serving under public Municipal Authorities. Unfortunately, since it gives rise to confusion, the name is also used in connection with officials privately appointed by various charitable institutions. These have no universally recognised standard of attainments: some of the so-called "Health Visitors" are without any qualifications, others, e.g., those employed by the Jewish Board of Guardians, are fully trained and do excellent work, comparable with that performed by Hospital Almoners. We hope, in a later volume of this series, to publish an article on their duties and position.[EDITOR.]]



SECTION V

WOMEN IN THE CIVIL SERVICE

I

THE HIGHER GRADES: PRESENT POSITION AND PROSPECTS FOR THE FUTURE

The claim that women should be allowed to enter not only the lower but the higher branches of the Civil Service is being freely made at the present time. It is very generally felt that posts in which the holder has to execute judgment and to decide on administrative matters should be open to women as well as to men.

Many reasons are urged for admitting women more freely to a share in the responsible work of the Service, but the true basis of their claim lies in this—that the most successful form of government and the happiest condition for the governed can only be attained, in the State as in the family, when masculine and feminine influences work in harmony.

It is not, perhaps, widely known that women have already made their way into many branches of the Service and have done invaluable work therein. Perhaps the strongest argument that can be urged in favour of their admission into yet other branches of the Service will be found in the following brief survey of the appointments held and the work already done by them in various directions.

The Local Government Boards

The credit of being the first Government Department to appoint a Woman Inspector belongs to the English Local Government Board. As far back as 1873, yielding to the pressure of public opinion, that Board appointed a Woman Inspector, with full powers to inspect workhouses, and district schools. During the short period of her appointment, this lady did excellent work, and called attention to much needed reforms in the education of girls in Poor Law Schools. Unfortunately, owing to a breakdown in health, she was obliged to resign her appointment in November 1874, and the Local Government Board, either repenting of its enlightened action, or not appreciating the aid of a woman even in matters concerning the welfare of women and girls, refrained from appointing a woman to succeed her. It was not until 1885 that another Woman Inspector was appointed, and then her work was restricted to the inspection of Poor Law Children boarded out beyond the Union to which they belonged. In 1896, once more by reason of the pressure of public opinion, a woman was appointed as an Assistant Inspector of Poor Law Institutions in the Metropolis. In 1898 a second Inspector of Boarded-out Children was appointed, and in 1903 the number of Inspectors was increased to three, each Inspector having a district assigned to her.

Four years ago the total number of Women Inspectors was increased to seven, and the scope of their duties somewhat widened, as will be seen below. There is now one Superintendent Inspector at a salary of L400 to L450, and six Inspectors at L250 to L350. Candidates for these inspectorships must have had considerable administrative experience. They must hold a certificate of three years' training as a Nurse, and the Central Midwives' Board's certificate is considered desirable. These qualifications have only been required since 1910.

The duties assigned to the Women Inspectors include (1) the inspection of boarded-out children, both within and beyond the Poor Law Unions to which they belong; and (2) the inspection of Poor Law Institutions—i.e., infirmaries, sick wards of workhouses, maternity wards, and workhouse nurseries: also of Certified Homes, Cottage Homes, and Scattered Homes.

The duties of the Women Inspectors in connection with the boarding-out of Poor Law Children include the visiting of officials of Boarding-Out Committees, and of homes in which children are boarded out; the Inspector visits a sufficient number of children and homes to enable her to satisfy herself that the duties of the Boarding-Out Committee are carried out in a satisfactory manner, and makes a report to the Board thereon. Women Inspectors arrange their own inspections of boarded-out children within a prescribed district.

Each of the fourteen districts into which the country is divided for Poor Law purposes is placed under the care of a General Inspector (male), whilst the half dozen Women Inspectors are available for duty in these districts, but only at the invitation of the General Inspector. If an Inspector omits to arrange for these visits it is possible for his district to remain unvisited by a Woman Inspector for an indefinite period. When it is remembered that there are still 194 Unions without a woman on the Board of Guardians, the present arrangement, by which the Women Inspectors can only inspect Poor Law Institutions on sufferance, is seen to be indefensible and the need for reform in this direction urgent.

There is one Assistant Woman Inspector, who is a highly qualified medical woman, in the Public Health Department of the Board. She has been in office only a few months, but it has been remarked in more than one quarter that the enhanced value of the recent report of the Board's Medical Officer on Infant Mortality is due to her co-operation.

The jurisdiction of the Local Government Board in London is confined to England and Wales—Scotland and Ireland having their own Boards in Edinburgh and Dublin respectively.

The Local Government Board for Scotland appointed a Woman Inspector for the first time about three years ago, at a salary of L200 a year. She is a fully qualified medical woman. Her duties include both Poor Law Work (e.g. the inspection of children in poor-houses or boarded out, enquiries into complaints of inadequate relief to widows) and Public Health Work (e.g. enquiries into any special incidence of disease).

The Local Government Board for Ireland employs two Women Inspectors, one at a salary of L200-10-L300 and the other at a salary of L200, to inspect boarded-out children.

There are no prescribed qualifications for these posts; but they have always been, and still are, held by highly qualified women—distinguished graduates and experienced in social work; one is a doctor of medicine.

Sir Henry Robinson, Vice-President of the Local Government Board for Ireland, said in his evidence before the Royal Commission on the Civil Service that he would like to have one or two women doctors to go round the work-houses and to visit the female wards, but the salaries offered by the Treasury to women doctors seemed to him too low to attract well qualified women.

The Home Office

It was about twenty years ago that the Home Office began to realise that the ever-increasing number of women and girl workers in factories and workshops made it imperative that women as well as men inspectors should be appointed if the Factory Acts intended for the protection of workers were to be effectually enforced. There was no doubt even from the first about the usefulness of these Women Inspectors, but in ten years' time the number appointed for the whole of the United Kingdom had only increased to eight. At the beginning of the present year, 1913, they numbered eighteen, and only within the last few months has this number been increased to twenty.

There is one Woman Inspector of Prisons at a salary of L300-15-L400. (The lowest salary received by Men Inspectors is L600-20-L700.)

There is also one Woman Assistant Inspector of Reformatories and Industrial Schools. Her salary is L200-10-L300, whilst that of Men Assistant Inspectors is L250-15-L400.

Women Factory Inspectors are appointed in the same way as men. A register of candidates is kept in the office, in which the name of every applicant is entered. When a vacancy occurs a selection is made from the list, and the best qualified candidates are interviewed by a Committee of Selection, consisting of the Parliamentary Under-Secretary, the Private Secretary, the Chief Inspector of Factories and the Chief Woman Inspector. Generally speaking, about one half of the candidates interviewed are selected to sit for an examination in general subjects. At the end of two years' probation a qualifying examination in Factory Law and Sanitary Science must be passed.

The Principal Woman Inspector is responsible to the Chief Inspector of Factories for the administration of the Women Inspectors' work throughout the United Kingdom. Women Inspectors are stationed at Manchester, Birmingham, Glasgow, and Belfast. The work of the Women Inspectors is so organised as to be entirely separate from that of the Men Inspectors, although they cover the same ground. The nature and scope of the women's work is so generally known that it is perhaps unnecessary to describe it in much detail. Investigations into cases of accident affecting women and girl workers or into complaints as to the conditions under which they work are promptly made by the Women Inspectors. Women Inspectors (equally with men) have power to enter and inspect all factory and workshop premises where women and girls are employed. They are empowered to enforce the provisions of the Factory and Truck Acts and to prosecute in cases of breach of the law. They conduct their own prosecutions.

The reports of the Women Inspectors evoked much appreciative comment during a recent debate in the House of Commons. Some interesting remarks on their work are also to be found in the evidence given before the Royal Commission on the Civil Service by Sir Edward Troup, K.C.B., Permanent Under-Secretary of the Home Office.

The number of Women Inspectors at present employed is not nearly large enough to cope with the work that needs to be done. It must be remembered that the staff enumerated above is responsible for the inspection of factories and workshops in Scotland and Ireland as well as in England, and that the number of women engaged in industrial work has increased during the last five years from about one and a half millions to two millions. The necessity of increasing the number of Women Inspectors has frequently been urged upon the Government in the House of Commons and in the press, and it seems probable that the Government must soon yield to this pressure.

The following extract from the Women's Trade Union League Quarterly Review, July 1913, may be of interest in this connection:—

"That the Women Inspectors' staff in particular is far below the numerical strength which would enable it to cope adequately—we do not say completely—with the task presented to it, has long been patent to every one who knows anything of the industrial world and the part taken in it by the woman worker. But in 1912 promotions and resignations left gaps in the already meagre ranks which for some time were not filled even by recruits, with the result that the number of inspections was necessarily reduced in proportion. To those who realise, as we do, the importance of the women inspectors' visits, both in detecting infringements of the law and in making clear its provisions and their value to the employer and worker alike, this decrease, even for a time, of the opportunities which Miss Anderson's staff enjoy of exercising their beneficent and educative influence seems altogether deplorable. The recent promise of the Home Secretary to increase that staff by two is very welcome, but we cannot pretend to think that such an increase will meet the need which these pages reveal."

There is one Woman Inspector of Prisons, a qualified medical woman, who acts also as Assistant Inspector of State and Certified Inebriate Reformatories. Her salary is L300-15-L400, whilst the lowest salary received by Men Inspectors is L600-20-L700.

There is one Woman Assistant Inspector of Reformatories and Industrial Schools in Great Britain. Her salary is L200-10-L300, whilst that of Men Assistant Inspectors is L250-15-L400.

The Board of Trade

The first woman to be admitted to the higher branches of the Board of Trade was appointed as a Labour Correspondent in 1893. In 1903 she became the Senior Investigator for Women's Industries, the salary of the post being fixed at L450. A Senior Investigator's Assistant was also appointed at a salary of L120-10-L200, but the salary has now been increased to L200-L300. These posts are open only to University women with high honours.