"THE CHILD."

THE CHILD with this number commences its eighth volume. Never in the history of our nation was there a greater need for the conservation of child life. Child welfare work is now recognized as a most essential form of national service. It is to be studied as a science and practised as an art. THE CHILD exists to further child welfare work in all its departments. We are particularly desirous that this medico-educational journal should be brought to the notice of all engaged in medical, educational and other forms of service for the betterment of child life. We therefore seek the cooperation of our readers in making THE CHILD known. This is not the time when advertisements of the journal and specimen copies can be distributed extensively. We are therefore more than anxious that existing subscribers should assist in making the journal known. THE CHILD has accomplished much good work in the few years of its existence, and in these fateful days its opportunities for service have greatly increased. We are very wishful that a copy of THE CHILD shall reach all schools, orphanages, hospitals and other institutions engaged in educational and medical work for the nation's children, and that every worker for child welfare work may have access to the journal. We hope our readers will do their best to see that THE CHILD has a place in the public libraries of their respective districts. We would also direct attention to the usefulness of the Directories which appear in each issue. It is most desirable that these should be made as complete as possible. Admission is free to all subscribers. Finally, we would again indicate our appreciation of the valuable help of those who as contributors and subscribers have enabled THE CHILD to continue its service in these strenuous and difficult days of war. We gladly welcome suggestions from all sources, and shall continue our endea

vours to make THE CHILD more worthy of the great cause it seeks to serve.

THE PROVISION OF MIDWIVES.

Dr. E. W. Hope, Medical Officer of Health of the City of Liverpool, recently presented an important memorandum on the present and future position of the midwife to the annual meeting of the Association for Promoting the Training and Supply of Midwives. This question is an essential one in its relation to maternity and child welfare. Dr. Hope's exposition of the problem deserves the fullest consideration. The following is an endeavour to present the more imporportant parts of Dr. Hope's suggestive memorandum. A large and increasing proportion of births among the poorer classes-almost three-quarters of the total -are attended by midwives; happily, the vast majority of births take place without any untoward incident, but childbirth, although a perfectly natural process, is, like other natural processes, liable to accidents, perversions, and sudden emergencies, most of which are easily remedied or averted if recognized and taken in time, and provided skilled control is available; but they may be destructive to mother and child alike if the necessary skilled assistance is unavailable, or when meddlesome or ignorant interference is substituted for it. But many of the midwife's patients are under adverse home conditions, and poverty, and all which is implied by privations associated with want of means, add to the responsibilities and difficulties with which the midwife may be confronted. The midwife is an essential factor and of fundamental importance in every scheme affecting the welfare of maternity and infancy; her potentialities must be recognized and applied to the best purpose if beneficent schemes of maternal and infant welfare are to have any measure of success. In the first place there is a large number of perfectly normal births, all, however, requiring

skilled and intelligent care and attention sometimes involving visits and attention for weeks or months before the birth takes place, lest they fall into the category of the abnormal; what we have to ensure is the provision of a standard of midwifery skill which will not only safeguard the ordinary normal cases, but will recognize impending or actual danger, meet it by every means available, and we have also to secure the ready help of the expert in the emergencies which render that help necessary. But it is not merely the present peril which must be guarded against, the ultimate complete recovery of the patient must be ensured; records of gynææcological wards of the various hospitals need only be referred to as evidence of the reality of this need. Another of the series of functions of the midwife involves an attendance upon the mother and the baby for a period of not less than ten days, in order that certain very important duties defined in the Rules of the Central Midwives' Board may be fulfilled. But the midwife has still further functions and opportunities of the highest importance in reference to ante-natal hygiene, which enhance still further the importance of her position. She has, or can obtain, an intimate and confidential knowledge of the condition and circumstances of her patient; the experiences of any difficulties attending previous confinements are known to her, as also the history of miscarriages, stillbirths, and so forth. She possesses, or can possess, influence with the patient which no one else can possibly acquire; it is through her, and only through her, that the benefits of ante-natal welfare schemes can be most easily conferred, and it must always be borne in mind that her influence is of the utmost consequence in obtaining treatment for, and in dealing with sequelæ of venereal disease, and in ensuring that a succession of miscarriages and stillbirths shall give place not only to living but healthy children, by persuading the patient to undergo proper treatment. These reflections open up a wide vista of the benefit the nation will reap from an adequate midwifery service. It is interesting in view of the magnitude of the services which the midwife may render, to consider from what class she is recruited, and what it is that induces her to

enter upon a calling involving so much work for so little reward. In the first place, there are those with a distinct vocation for midwifery, stimulated maybe by the success achieved by the more highly trained and capable practitioners. Others, some 15 to 20 per cent., have succeeded to a practice from the mother; some again take it as the only prospective means of earning a few pounds, and they know of no other. A fairly large proportion of married women take up midwifery in order to meet increasing domestic expenses caused by additions to their own families; in these cases midwifery is not the only support of the practitioner. The economic result of all this is summarized in a phrase of Dr. Janet Lane-Claypon's, and although her comment is restricted to the County of London, the centre, be it observed, of affluence, it has a much wider application. She says "that it is hardly possible under existing circumstances for a reasonable livelihood to be earned by midwives." In other words, the unfortunate practitioner, who is liable to be called upon at any hour of the day or night, is in fact, from year's end to year's end, never entirely free from her exacting and responsible duties, and unless she has some other means of subsistence, has the added financial anxieties of struggle at or below the border-line of poverty. There can be no doubt that the efforts of the State to improve the position of the midwife, so far as they have gone, through the Midwives Act and Orders of the Local Government Board, and guidance of the Central Midwives' Board, have been rewarded, but they require to go further. The real demand at the present time is for more practising midwives, all of them trained to the highest plane of the present standard. It is clear that neither of these ends will be achieved unless some means are found which will attract a well-educated, good class of practitioner, with a sufficiently long and comprehensive training, who will be ensured such remuneration as will free her life from financial worries and anxieties. Is the need for the midwife likely to diminish? Is it likely that in the future medical practitioners will attend all maternity cases, or that hospital establishments will obviate the

necessity for births taking place in the undesirable homes of the patients? There is not the least possibility of either of these things happening. We may hope that with progressive housing operations, homes will not be so undesirable; but in any case there is no shadow of expectation that hospitals will ever meet the needs; to-day there are whole counties without a single maternity hospital bed other than those provided by the Destitution Authority, and generally, the number is wholly inadequate to justify such an expectation in the centres of population, even were it desirable. With regard to the doctors, there never have been enough to go round, and to the usual wastage must be added the loss of those who have fallen in the War, or have died from wounds and disease; meanwhile the supply of new doctors has unfortunately been cut off at the source, all medical students below four years of study having been called to the colours, an error which our American allies are careful to avoid. The training of a doctor occupies six years; many years must elapse before these additional causes of shortage can be remedied. Finally, after the War a very large increase in the birth-rate may be looked for. Recognizing, then, that the midwife is essential, what scheme can be suggested to ensure not only that a proportion of the women, but all the women taking up the calling shall be sufficiently educated, properly trained, and thoroughly efficient.

The object

sought is a more efficient service, and this can only be attained by enabling a longer and more adequate training to be taken at smaller cost to the student, and also by adopting measures to ensure that the calling shall be rendered less arduous and more attractive. How can these things be achieved? Is there any precedent in any procedure on the part of any Government Department to ensure an adequate preliminary training for any other public service which cannot be provided except by direct Government aid? Two such may be cited; for example, the preservation of trees and forests of India, an essential Imperial question (just as the preservation of the race is an essential Imperial question). The training for the Indian Forestry Service involves as a preliminary the selection of candidates

by examination as to their previous education; if found suitable, such candidates undergo a preliminary training, at the cost of the Government Department, the subsequent special training which may extend over one or two years is also at departmental cost, and when qualified a post is entrusted to them. The same principles, more or less, apply to the student interpreterships in certain branches of the Consular and Diplomatic Service, viz., preliminary examination and selection, subsidized training, and subsequent employment upon terms, on proof of fitness. The analogy with midwives is plain. After an entrance examination to test the general fitness of the candidate, free or subsidized professional training of perhaps two years, as in France, Denmark, and elsewhere (amplified in such directions as may be thought expedient), would be provided existing facilities, such as those at the disposal of this Association being availed of-and at its close a professional examination would give evidence of fitness to practise. But, it will then be asked, is the midwife to be assured of a practice? It may not be necessary to assure her of a practice; indeed, it may be impossible, but an assurance of quite another character can be given to stimulate her interest andthis is most important--her industry, and, to preserve freedom of choice to the patient, by means of a payment over and above the fee which she receives from each patient, of such amount as may be deemed equitable and necessary. For example, at relatively small cost an arrangement by which every midwife should be assured of a fee not less than one guinea for each birth attended could be quite easily brought into operation, and safeguarded from imposition, just, in fact, as is done in Liverpool in the case of the doctor's emergency fee. In this case a fee of one guinea has for many years been assured by the City Council to the doctor if the patient is not able to pay; if the patient is able to pay a part the balance is made up by the City Council, and now one-half of this is repaid to the Council by the Local Government Board. An exactly similar arrangement could be made with equally good results, and with equally simple administrative machinery, to make up the midwife's

fee to one guinea for every birth she attended. This arrangement could, of course, apply to all midwives now on the register, if it were thought expedient. If it were thought desirable to supervise midwives direct from a Government Department nothing would be simpler, and the midwife would lose the apprehension -well founded, no doubt, in some localities of the possibility of inquisitorial inspection by persons less qualified than herself, and of being made a scapegoat in difficulties which could neither be foreseen nor controlled, a system which can only be discouraging and likely to rouse a feeling of resentment towards her supervisor, not to say a spirit of revolt. Many of the difficulties connected with the midwifery problem will then be solved. The needs cannot be fully met by philanthropic effort or by effort of bodies such as county nursing associations, admirable as they are. The plan appeals to me as more likely to succeed than any other, for example, adding to the amount of the maternity benefit, with a view to enabling the patient to pay more to the midwife; increased maternity benefit payment may be desirable on quite other grounds, but may not meet the present need. It might be thought that as other professions are self-supporting and independent of State aid, so ought the calling of the midwife to be. The answer at once is that none of the professions is independent of State aid, in one way or another, direct or indirect; with scarcely an exception they are all of them aided, generally by scholarships or by University grants for research purposes and so on; moreover, all of them, whether law, physic, divinity, science, or art, have their prizes. No comparison can be instituted between them and a struggling body like the 40,000 registered midwives, not one-half of whom, however, are in actual practice. The subsidized and trained midwife would be expected to undertake practice wherever she was sent, but by the method of subsidizing she would still be unfettered, and, as in the case of panel doctors, a free choice would be left to her patients, whilst there would be no inducement to her to shirk nor to undersell, she would have greater security, and she would have no bad debts.

The cost of such schemes to the

Imperial Exchequer, so far as can be roughly gauged, would approximate to something between £80,000 and £100,000 per year, a sum which cannot be considered large in view of the advantages which would accrue.

THE BOY SCOUTS.

The Boy Scouts Movement, founded by Lieut.-General Sir Robert Baden-Powell, K.C.B., K.C.V.O., in 1908, was incorporated by Royal Charter in 1912 as the Boy Scouts Association, and now, in the summer of 1917, it has entered into the possession of specially designed and excellently constructed new headquarters at 25, Buckingham Palace Road, and close to Buckingham Palace. "Be Prepared" is the grand motto of the Scouts, and the great test of war has proved that they have lived up to their ideal and precept. The general feeling of national pride in our Boy Scouts has been finely expressed by the Prime Minister. Mr. Lloyd George's letter deserves reproduction here: "I feel much encouraged to think that any words I may have spoken should be the means of helping on the Boy Scout movement. It is perhaps only since the beginning of the War, during these three years of constant drain upon the manhood of our nation, that we have come to realize the great value of the movement which your Chief inaugurated six years before. We all now see the meaning of the motto represented by the initials B. P., and which the Association has lived up to with such sincerity and success. I do not think I am exaggerating when I say that the young boyhood of our country, represented by the Boy Scouts' Association, shares the laurels for having been prepared with the old and trusted and tried British Army and Navy. For both proved their title to make the claim when the great War broke upon us like a thief in the night. It is no small matter to be proud of that the Association was able within a month of the outbreak of war to give the most intelligent and energetic help in all kinds of service. When the boyhood of a nation can give such practical proofs of its honour, straightness, and loyalty, there is not much danger of that nation going under, for those boys are in training to render service to their country as leaders in all

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walks of life in the future. I can only say to all sections of the movement, Old Scouts and New Scouts, Scout Officers and patrol leaders, go forward; stick to it to the end." Although the Boy Scout is now a familiar figure in our national life, and although his services have been invaluable, and his spirit and purpose have invigorated the patriotism of us all, there is still much ignorance regarding the fundamental principles and essential practices governing the movement. We hope all our readers will secure a copy of the last and eighth edition of "Scouting for Boys: A Handbook for Instruction in Good Citizenship," published by C. Arthur Pearson, Ltd., Henrietta Street, Covent Garden, W.C. (price 2s. 6d. net). It has been written by Sir Robert BadenPowell, and provides a complete exposition of the whole movement. The Scout's promise is this: "On my honour I promise that I will do my best. To do my duty to God and the King. To help other people at all times. To obey the Scout Law." And here are the elements of the Scout Law (1) A Scout's honour is to be trusted. (2) A Scout is loyal to the King and his officers, and to his parents, his country, and his employers or employees. (3) A Scout's duty is to be useful and to help others. (4) A Scout is a friend of all, and a brother to every other Scout, no matter to what social class the other belongs. (5) A Scout is courteous. (6) A Scout is a friend to animals. (7) A Scout obeys orders of his parents, patrol leader, or Scoutmaster without question. (8) A Scout smiles and whistles under all difficulties. (9) A Scout is thrifty. (10) A Scout is clean in thought, word, and deed. Here, indeed, is the whole duty of a boy to God and man. It may be well to enunciate the first rule of the Association "The aim of the Association is to develop good citizenship among boys by forming their character; training them in habits of observation, obedience and selfreliance; inculcating loyalty and thoughtfulness for others; teaching them services useful to the public and handicrafts useful to themselves; promoting their physical development and hygiene." A copy of the "Policy, Organization, and Rules" (price 3d.) may be obtained on application to headquarters. To those desirous of understanding the real char

acter-building work of the Scouts movement we commend the perusal of a striking booklet : "The Two Ideals," effectively illustrated, and having as frontispiece Bernard Partridge's great cartoon of Christ and the Kaiser. The booklet has been written by Mr. H. Geoffrey Elwes, Editor of the Boy Scouts' Headquarters Gazette (published monthly at 18, Henrietta Street, W.C.2, price 2d. each issue). To those anxious to establish the Scout movement in their own district or in connection with their own church, school, club, works or other organization or institution, it will afford just the information desired. We are particularly desirous of commending the Scout movement to all readers of THE CHILD and, indeed, to all medicals and educationists throughout the country. Sir Robert Baden-Powell is desirous of securing the loyal co-operation of all medical practitioners and teachers, men and women in both professions. We believe that many doctors will be glad to render assistance in so far as they are able in these difficult days. Women medicals could render invaluable aid in connection with the Wolf Cubs. The Boy Scout Association is a body of which every Britisher may justly be proud, and medico-educationists will not be slow to render such service as may be possible in furthering the great aims of this truly national enterprise.

RELIGION AND THE CHILD.

Religion occupies a foremost place among influences which make or mar the development of the child. At the present time there is great need for guidance. The rôle of religion in the mental and moral evolution of the child cannot be denied or neglected without permanent prejudice. The most lasting influences in the establishment of a person's outlook on religion and the exercises of the religious life are those which are brought to bear on the child in its early years by parents and teachers. To those desirous of direction in this perplexing problem of religion and the child we commend a study of "The Religious Difficulties of Children," by Mrs. Edith E. Read Mumford, M.A., recently issued by the Sunday School Union, 57 and 59, Ludgate Hill, E.C.4 (price 2s. net). The book