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 const.i.tution. 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, circ.u.mstances, 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 a.s.sociation, of which offices are at the Imperial Inst.i.tute, South Kensington.

Salaries vary considerably, according to climate and the nature of the work. In very unhealthy climates, such as the west coast of Africa, the salary is high, and the risks proportionately so.

Private nurses, and those holding subordinate posts in hospitals get salaries varying from 60, which is the minimum, to 120 a year. An a.s.sistant Matron may in some few cases get a salary increasing to 150 or 200. In a large hospital there is the ordinary chance of promotion--a Sister may be made a.s.sistant Matron, or an a.s.sistant 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 pa.s.sage, both out and home, being paid. If, however, there should be a desire on both sides for a renewal of the engagement, the nurse can usually obtain an increase of salary.

A Matron"s salary will vary from 100 to 250, in large Government hospitals in the Colonies where, it must be borne in mind, leave entails a journey to England, and a very expensive pa.s.sage. 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 a.s.sociation 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 a.s.sociation, and serve their country in foreign dependencies, if they were a.s.sured of even a small pension after ten years" hard work in trying climates.

X

NURSING IN THE ARMY AND NAVY

The training required by Army and Navy nurses is that for general work. Additional experience according to the branch of the service which the nurse wishes to enter is also useful. Only fully trained nurses are appointed. Some of the tending of the sick is done by the men themselves, under supervision.

In the _Military Service_ the salaries are as follows: Matron-in-Chief, 305; ordinary Matron, from 75 to 150; Sister, from 50 to 65; Staff Nurse, from 40 to 45, with allowance for board, washing, etc., and arrangements for leave and pension after twenty years" service.

In the _Naval Service _the arrangements are slightly different, but the salaries work out at about the same. Foreign service is obligatory.

There is also a small Army Nursing Reserve, but this is quite inadequate for purposes of defence, and great efforts have recently been made to supplement it by voluntary organisations, such as the British Red Cross Society.

XI

PRISON NURSING

This is, at the present time, carried out by the ordinary staff of prison warders. There are all over England not more than two or three trained nurses among them, and it is most desirable that properly trained women should be in charge of prison infirmary wards, just as much as in the infirmary wards of workhouses. Prisoners are just as likely to suffer from disease as other people, and they surely do not forfeit all claim to expert care, simply because they have, perhaps in a moment of weakness, yielded to temptation. To one form of illness needing specially expert nursing, they are peculiarly liable--mental disease. It is almost impossible to gauge the amount of good which might be done both for the individual and for society by providing trained nurses to attend to these unfortunate people.

XII

MIDWIFERY AS A PROFESSION FOR WOMEN (OTHER THAN DOCTORS)

This is not a paper to discuss the suitability of women for midwifery.

All through the ages it has been done by women, until early in the nineteenth century in England and its colonies, it gradually became customary for men-doctors to attend such cases; apart from this, the work of midwifery has never been in the hands of men, except when abnormal cases have required the a.s.sistance of a doctor with knowledge of anatomy and skilled in instrumental delivery. Even before the pa.s.sing 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 pa.s.sing 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" a.s.sociation, the Midwives"

Inst.i.tute, etc.), now exercises supervision over the midwives of the whole of England and Wales, though local supervising authorities also take cognisance of midwives" work and investigate cases of malpractice and the like. The address of the Central Midwives" Board is Caxton House, Westminster.

The training for the examination of the Central Midwives" Board is based on the method pursued in medical education in English-speaking countries, viz., there is not one uniform course, but each of the training schools attached to hospitals follows out its own plan of training, each hospital having been approved by the Central Midwives"

Board as giving an adequate training for its examination. There are now seven maternity hospitals in London, where women students may train in midwifery. Of these, only one--the Clapham Maternity Hospital (with its training school founded by Mrs Meredith in 1885)--is, and always has been, entirely officered by women. Here the course advised is six months, viz., three months in the hospital (Monthly Nursing), and three months in the hospital and district doing Midwifery proper.

During this time over 200 cases may be seen, and nearly 100 cases attended personally. The cost of this training is 35 to 40, which includes board and residence for twenty-six weeks. Students previously trained elsewhere may take one months" extra training at a cost of ten guineas. Private doctors and midwives may also take pupils if recognised as teachers by the Board.

Midwifery training is now required not only by those who are going to act as midwives, but also by most missionaries, all fully trained nurses (for matrons" posts or colonial posts) and by health visitors and inspectors before obtaining appointments.

But it should be borne in mind, especially in considering the present condition and future prospects of Midwifery as a profession, that even now a large though ever-decreasing proportion of registered midwives are still ignorant women who have never pa.s.sed 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 cla.s.ses--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 35 to 40 for her training, what chance has she of earning a decent living? If she could command 15s. or 17s. 6d. per case afterwards, she could make a decent living, given fairly hard work and the acceptance of real responsibility. If she had 100 cases a year, she would earn 75 at 15s. per case, and so on. This rise in the fees payable to midwives has just been made possible by the National Insurance Act of 1911, the framers of which appear to have recognised the necessary result of the Midwives" Act of 1902. As the _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:--