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 thepersonnelof 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 shortrésuméof 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 aslocum tenensfor 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 aslocum 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 theRoyal Colleges of Physicians andSurgeons 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 inLondonshe must follow the course of study at the Royal Free Hospital School of Medicine for Women at 8 Hunter Street, Brunswick Square.
AtGlasgowthe 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.
AtDublinthe 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.
AtEdinburghthe arrangements for women students are largely separate from those for the men. The degrees are open to them.
AtDurhamthe degrees are open to women, and most of their work is done with the men.
The same applies toLiverpool, Manchester, Leeds, Birmingham,andSheffield.
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 branchof medicine or surgery,(b) a general practitioner, or(c) whether she wishes to work in the publicservice.
(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 Womenand Midwifery (except that of Dr M'Call),or for Diseases of Children (except one recentlystarted 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 totake 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 theBritish 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 areallso 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 medicalofficer of health.(2) Assistant medical officer in some asylumsand 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 alocum 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 isabsolutely identicalwith 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, PortlandPlace, 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.]
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 herlocus 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.
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.