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diff --git a/.gitattributes b/.gitattributes new file mode 100644 index 0000000..6833f05 --- /dev/null +++ b/.gitattributes @@ -0,0 +1,3 @@ +* text=auto +*.txt text +*.md text diff --git a/5069-h.zip b/5069-h.zip Binary files differnew file mode 100644 index 0000000..8798059 --- /dev/null +++ b/5069-h.zip diff --git a/5069-h/5069-h.htm b/5069-h/5069-h.htm new file mode 100644 index 0000000..d51cf64 --- /dev/null +++ b/5069-h/5069-h.htm @@ -0,0 +1,3615 @@ +<?xml version="1.0" encoding="us-ascii"?> + +<!DOCTYPE html + PUBLIC "-//W3C//DTD XHTML 1.0 Strict//EN" + "http://www.w3.org/TR/xhtml1/DTD/xhtml1-strict.dtd" > + +<html xmlns="http://www.w3.org/1999/xhtml" lang="en"> + <head> + <title> + The Project Gutenberg eBook of The Doctor's Dilemma: Preface on Doctors, + by Bernard Shaw + </title> + <style type="text/css" xml:space="preserve"> + + body { margin:5%; background:#faebd0; text-align:justify} + P { text-indent: 1em; margin-top: .25em; margin-bottom: .25em; } + H1,H2,H3,H4,H5,H6 { text-align: center; margin-left: 15%; margin-right: 15%; } + hr { width: 50%; text-align: center;} + .foot { margin-left: 20%; margin-right: 20%; text-align: justify; text-indent: -3em; font-size: 90%; } + blockquote {font-size: 97%; font-style: italic; margin-left: 10%; margin-right: 10%;} + .mynote {background-color: #DDE; color: #000; padding: .5em; margin-left: 10%; margin-right: 10%; font-family: sans-serif; font-size: 95%;} + .toc { margin-left: 10%; margin-bottom: .75em;} + .toc2 { margin-left: 20%;} + div.fig { display:block; margin:0 auto; text-align:center; } + div.middle { margin-left: 20%; margin-right: 20%; text-align: justify; } + .figleft {float: left; margin-left: 0%; margin-right: 1%;} + .figright {float: right; margin-right: 0%; margin-left: 1%;} + .pagenum {display:inline; font-size: 70%; font-style:normal; + margin: 0; padding: 0; position: absolute; right: 1%; + text-align: right;} + pre { font-style: italic; font-size: 90%; margin-left: 10%;} + +</style> + </head> + <body> +<pre xml:space="preserve"> + +The Project Gutenberg EBook of The Doctor's Dilemma: Preface on Doctors, by +George Bernard Shaw + +This eBook is for the use of anyone anywhere at no cost and with +almost no restrictions whatsoever. You may copy it, give it away or +re-use it under the terms of the Project Gutenberg License included +with this eBook or online at www.gutenberg.org + + +Title: The Doctor's Dilemma: Preface on Doctors + +Author: George Bernard Shaw + +Release Date: March 26, 2009 [EBook #5069] +Last Updated: December 10, 2012 + +Language: English + +Character set encoding: ASCII + +*** START OF THIS PROJECT GUTENBERG EBOOK PREFACE TO DOCTOR'S DILEMMA *** + + + + +Produced by Eve Sobol, and David Widger + + + + + + +</pre> + <p> + <br /><br /> + </p> + <h1> + THE DOCTOR'S DILEMMA: <br /><br /><big>PREFACE ON DOCTORS</big> + </h1> + <p> + <br /><br /> + </p> + <h2> + By Bernard Shaw + </h2> + <p> + <br /><br /> + </p> + <h3> + 1909 + </h3> + <p> + <br /> <br /> + </p> + <hr /> + <p> + <br /> <br /> + </p> + <blockquote> + <p class="toc"> + <big><b>CONTENTS</b></big> + </p> + <p> + <br /> + </p> + <p class="toc"> + <a href="#link2H_4_0001"> DOUBTFUL CHARACTER BORNE BY THE MEDICAL + PROFESSION </a> + </p> + <p class="toc"> + <a href="#link2H_4_0002"> DOCTOR'S CONSCIENCES </a> + </p> + <p class="toc"> + <a href="#link2H_4_0003"> THE PECULIAR PEOPLE </a> + </p> + <p class="toc"> + <a href="#link2H_4_0004"> RECOIL OF THE DOGMA OF MEDICAL INFALLIBILITY + ON THE DOCTOR </a> + </p> + <p class="toc"> + <a href="#link2H_4_0005"> WHY DOCTORS DO NOT DIFFER </a> + </p> + <p class="toc"> + <a href="#link2H_4_0006"> THE CRAZE FOR OPERATIONS </a> + </p> + <p class="toc"> + <a href="#link2H_4_0007"> CREDULITY AND CHLOROFORM </a> + </p> + <p class="toc"> + <a href="#link2H_4_0008"> MEDICAL POVERTY </a> + </p> + <p class="toc"> + <a href="#link2H_4_0009"> THE SUCCESSFUL DOCTOR </a> + </p> + <p class="toc"> + <a href="#link2H_4_0010"> THE PSYCHOLOGY OF SELF-RESPECT IN SURGEONS + </a> + </p> + <p class="toc"> + <a href="#link2H_4_0011"> ARE DOCTORS MEN OF SCIENCE? </a> + </p> + <p class="toc"> + <a href="#link2H_4_0012"> BACTERIOLOGY AS A SUPERSTITION </a> + </p> + <p class="toc"> + <a href="#link2H_4_0013"> ECONOMIC DIFFICULTIES OF IMMUNIZATION </a> + </p> + <p class="toc"> + <a href="#link2H_4_0014"> THE PERILS OF INOCULATION </a> + </p> + <p class="toc"> + <a href="#link2H_4_0015"> DOCTORS AND VIVISECTION </a> + </p> + <p class="toc"> + <a href="#link2H_4_0016"> THE PRIMITIVE SAVAGE MOTIVE </a> + </p> + <p class="toc"> + <a href="#link2H_4_0017"> THE HIGHER MOTIVE. THE TREE OF KNOWLEDGE. </a> + </p> + <p class="toc"> + <a href="#link2H_4_0018"> THE FLAW IN THE ARGUMENT </a> + </p> + <p class="toc"> + <a href="#link2H_4_0019"> LIMITATIONS OF THE RIGHT TO KNOWLEDGE </a> + </p> + <p class="toc"> + <a href="#link2H_4_0020"> A FALSE ALTERNATIVE </a> + </p> + <p class="toc"> + <a href="#link2H_4_0021"> OUR OWN CRUELTIES </a> + </p> + <p class="toc"> + <a href="#link2H_4_0022"> THE SCIENTIFIC INVESTIGATION OF CRUELTY </a> + </p> + <p class="toc"> + <a href="#link2H_4_0023"> ROUTINE </a> + </p> + <p class="toc"> + <a href="#link2H_4_0024"> THE OLD LINE BETWEEN MAN AND BEAST </a> + </p> + <p class="toc"> + <a href="#link2H_4_0025"> VIVISECTING THE HUMAN SUBJECT </a> + </p> + <p class="toc"> + <a href="#link2H_4_0026"> "THE LIE IS A EUROPEAN POWER" </a> + </p> + <p class="toc"> + <a href="#link2H_4_0027"> AN ARGUMENT WHICH WOULD DEFEND ANY CRIME </a> + </p> + <p class="toc"> + <a href="#link2H_4_0028"> THOU ART THE MAN </a> + </p> + <p class="toc"> + <a href="#link2H_4_0029"> WHAT THE PUBLIC WANTS AND WILL NOT GET </a> + </p> + <p class="toc"> + <a href="#link2H_4_0030"> THE VACCINATION CRAZE </a> + </p> + <p class="toc"> + <a href="#link2H_4_0031"> STATISTICAL ILLUSIONS </a> + </p> + <p class="toc"> + <a href="#link2H_4_0032"> THE SURPRISES OF ATTENTION AND NEGLECT </a> + </p> + <p class="toc"> + <a href="#link2H_4_0033"> STEALING CREDIT FROM CIVILIZATION </a> + </p> + <p class="toc"> + <a href="#link2H_4_0034"> BIOMETRIKA </a> + </p> + <p class="toc"> + <a href="#link2H_4_0035"> PATIENT-MADE THERAPEUTICS </a> + </p> + <p class="toc"> + <a href="#link2H_4_0036"> THE REFORMS ALSO COME FROM THE LAITY </a> + </p> + <p class="toc"> + <a href="#link2H_4_0037"> FASHIONS AND EPIDEMICS </a> + </p> + <p class="toc"> + <a href="#link2H_4_0038"> THE DOCTOR'S VIRTUES </a> + </p> + <p class="toc"> + <a href="#link2H_4_0039"> THE DOCTOR'S HARDSHIPS </a> + </p> + <p class="toc"> + <a href="#link2H_4_0040"> THE PUBLIC DOCTOR </a> + </p> + <p class="toc"> + <a href="#link2H_4_0041"> MEDICAL ORGANIZATION </a> + </p> + <p class="toc"> + <a href="#link2H_4_0042"> THE SOCIAL SOLUTION OF THE MEDICAL PROBLEM + </a> + </p> + <p class="toc"> + <a href="#link2H_4_0043"> THE FUTURE OF PRIVATE PRACTICE </a> + </p> + <p class="toc"> + <a href="#link2H_4_0044"> THE TECHNICAL PROBLEM </a> + </p> + <p class="toc"> + <a href="#link2H_4_0045"> THE LATEST THEORIES </a> + </p> + </blockquote> + <p> + <br /> <br /> + </p> + <hr /> + <p> + <br /> <br /> + </p> + <p> + It is not the fault of our doctors that the medical service of the + community, as at present provided for, is a murderous absurdity. That any + sane nation, having observed that you could provide for the supply of + bread by giving bakers a pecuniary interest in baking for you, should go + on to give a surgeon a pecuniary interest in cutting off your leg, is + enough to make one despair of political humanity. But that is precisely + what we have done. And the more appalling the mutilation, the more the + mutilator is paid. He who corrects the ingrowing toe-nail receives a few + shillings: he who cuts your inside out receives hundreds of guineas, + except when he does it to a poor person for practice. + </p> + <p> + Scandalized voices murmur that these operations are necessary. They may + be. It may also be necessary to hang a man or pull down a house. But we + take good care not to make the hangman and the housebreaker the judges of + that. If we did, no man's neck would be safe and no man's house stable. + But we do make the doctor the judge, and fine him anything from sixpence + to several hundred guineas if he decides in our favor. I cannot knock my + shins severely without forcing on some surgeon the difficult question, + "Could I not make a better use of a pocketful of guineas than this man is + making of his leg? Could he not write as well—or even better—on + one leg than on two? And the guineas would make all the difference in the + world to me just now. My wife—my pretty ones—the leg may + mortify—it is always safer to operate—he will be well in a + fortnight—artificial legs are now so well made that they are really + better than natural ones—evolution is towards motors and + leglessness, etc., etc., etc." + </p> + <p> + Now there is no calculation that an engineer can make as to the behavior + of a girder under a strain, or an astronomer as to the recurrence of a + comet, more certain than the calculation that under such circumstances we + shall be dismembered unnecessarily in all directions by surgeons who + believe the operations to be necessary solely because they want to perform + them. The process metaphorically called bleeding the rich man is performed + not only metaphorically but literally every day by surgeons who are quite + as honest as most of us. After all, what harm is there in it? The surgeon + need not take off the rich man's (or woman's) leg or arm: he can remove + the appendix or the uvula, and leave the patient none the worse after a + fortnight or so in bed, whilst the nurse, the general practitioner, the + apothecary, and the surgeon will be the better. + </p> + <p> + <br /> <br /> + </p> + <hr /> + <p> + <br /> <br /> <a name="link2H_4_0001" id="link2H_4_0001"> + <!-- H2 anchor --> </a> + </p> + <h2> + DOUBTFUL CHARACTER BORNE BY THE MEDICAL PROFESSION + </h2> + <p> + Again I hear the voices indignantly muttering old phrases about the high + character of a noble profession and the honor and conscience of its + members. I must reply that the medical profession has not a high + character: it has an infamous character. I do not know a single thoughtful + and well-informed person who does not feel that the tragedy of illness at + present is that it delivers you helplessly into the hands of a profession + which you deeply mistrust, because it not only advocates and practises the + most revolting cruelties in the pursuit of knowledge, and justifies them + on grounds which would equally justify practising the same cruelties on + yourself or your children, or burning down London to test a patent fire + extinguisher, but, when it has shocked the public, tries to reassure it + with lies of breath-bereaving brazenness. That is the character the + medical profession has got just now. It may be deserved or it may not: + there it is at all events, and the doctors who have not realized this are + living in a fool's paradise. As to the humor and conscience of doctors, + they have as much as any other class of men, no more and no less. And what + other men dare pretend to be impartial where they have a strong pecuniary + interest on one side? Nobody supposes that doctors are less virtuous than + judges; but a judge whose salary and reputation depended on whether the + verdict was for plaintiff or defendant, prosecutor or prisoner, would be + as little trusted as a general in the pay of the enemy. To offer me a + doctor as my judge, and then weight his decision with a bribe of a large + sum of money and a virtual guarantee that if he makes a mistake it can + never be proved against him, is to go wildly beyond the ascertained strain + which human nature will bear. It is simply unscientific to allege or + believe that doctors do not under existing circumstances perform + unnecessary operations and manufacture and prolong lucrative illnesses. + The only ones who can claim to be above suspicion are those who are so + much sought after that their cured patients are immediately replaced by + fresh ones. And there is this curious psychological fact to be remembered: + a serious illness or a death advertizes the doctor exactly as a hanging + advertizes the barrister who defended the person hanged. Suppose, for + example, a royal personage gets something wrong with his throat, or has a + pain in his inside. If a doctor effects some trumpery cure with a wet + compress or a peppermint lozenge nobody takes the least notice of him. But + if he operates on the throat and kills the patient, or extirpates an + internal organ and keeps the whole nation palpitating for days whilst the + patient hovers in pain and fever between life and death, his fortune is + made: every rich man who omits to call him in when the same symptoms + appear in his household is held not to have done his utmost duty to the + patient. The wonder is that there is a king or queen left alive in Europe. + </p> + <p> + <a name="link2H_4_0002" id="link2H_4_0002"> + <!-- H2 anchor --> </a> + </p> + <div style="height: 4em;"> + <br /><br /><br /><br /> + </div> + <h2> + DOCTOR'S CONSCIENCES + </h2> + <p> + There is another difficulty in trusting to the honor and conscience of a + doctor. Doctors are just like other Englishmen: most of them have no honor + and no conscience: what they commonly mistake for these is sentimentality + and an intense dread of doing anything that everybody else does not do, or + omitting to do anything that everybody else does. This of course does + amount to a sort of working or rule-of-thumb conscience; but it means that + you will do anything, good or bad, provided you get enough people to keep + you in countenance by doing it also. It is the sort of conscience that + makes it possible to keep order on a pirate ship, or in a troop of + brigands. It may be said that in the last analysis there is no other sort + of honor or conscience in existence—that the assent of the majority + is the only sanction known to ethics. No doubt this holds good in + political practice. If mankind knew the facts, and agreed with the + doctors, then the doctors would be in the right; and any person who + thought otherwise would be a lunatic. But mankind does not agree, and does + not know the facts. All that can be said for medical popularity is that + until there is a practicable alternative to blind trust in the doctor, the + truth about the doctor is so terrible that we dare not face it. Moliere + saw through the doctors; but he had to call them in just the same. + Napoleon had no illusions about them; but he had to die under their + treatment just as much as the most credulous ignoramus that ever paid + sixpence for a bottle of strong medicine. In this predicament most people, + to save themselves from unbearable mistrust and misery, or from being + driven by their conscience into actual conflict with the law, fall back on + the old rule that if you cannot have what you believe in you must believe + in what you have. When your child is ill or your wife dying, and you + happen to be very fond of them, or even when, if you are not fond of them, + you are human enough to forget every personal grudge before the spectacle + of a fellow creature in pain or peril, what you want is comfort, + reassurance, something to clutch at, were it but a straw. This the doctor + brings you. You have a wildly urgent feeling that something must be done; + and the doctor does something. Sometimes what he does kills the patient; + but you do not know that; and the doctor assures you that all that human + skill could do has been done. And nobody has the brutality to say to the + newly bereft father, mother, husband, wife, brother, or sister, "You have + killed your lost darling by your credulity." + </p> + <p> + <a name="link2H_4_0003" id="link2H_4_0003"> + <!-- H2 anchor --> </a> + </p> + <div style="height: 4em;"> + <br /><br /><br /><br /> + </div> + <h2> + THE PECULIAR PEOPLE + </h2> + <p> + Besides, the calling in of the doctor is now compulsory except in cases + where the patient is an adult—and not too ill to decide the steps to + be taken. We are subject to prosecution for manslaughter or for criminal + neglect if the patient dies without the consolations of the medical + profession. This menace is kept before the public by the Peculiar People. + The Peculiars, as they are called, have gained their name by believing + that the Bible is infallible, and taking their belief quite seriously. The + Bible is very clear as to the treatment of illness. The Epistle of James; + chapter v., contains the following explicit directions: + </p> + <p> + 14. Is any sick among you? let him call for the elders of the Church; and + let them pray over him, anointing him with oil in the name of the Lord: + </p> + <p> + 15. And the prayer of faith shall save the sick, and the Lord shall raise + him up; and if he have committed sins, they shall be forgiven him. + </p> + <p> + The Peculiars obey these instructions and dispense with doctors. They are + therefore prosecuted for manslaughter when their children die. + </p> + <p> + When I was a young man, the Peculiars were usually acquitted. The + prosecution broke down when the doctor in the witness box was asked + whether, if the child had had medical attendance, it would have lived. It + was, of course, impossible for any man of sense and honor to assume divine + omniscience by answering this in the affirmative, or indeed pretending to + be able to answer it at all. And on this the judge had to instruct the + jury that they must acquit the prisoner. Thus a judge with a keen sense of + law (a very rare phenomenon on the Bench, by the way) was spared the + possibility of leaving to sentence one prisoner (under the Blasphemy laws) + for questioning the authority of Scripture, and another for ignorantly and + superstitiously accepting it as a guide to conduct. To-day all this is + changed. The doctor never hesitates to claim divine omniscience, nor to + clamor for laws to punish any scepticism on the part of laymen. A modern + doctor thinks nothing of signing the death certificate of one of his own + diphtheria patients, and then going into the witness box and swearing a + peculiar into prison for six months by assuring the jury, on oath, that if + the prisoner's child, dead of diphtheria, had been placed under his + treatment instead of that of St. James, it would not have lived. And he + does so not only with impunity, but with public applause, though the + logical course would be to prosecute him either for the murder of his own + patient or for perjury in the case of St. James. Yet no barrister, + apparently, dreams of asking for the statistics of the relative + case-mortality in diphtheria among the Peculiars and among the believers + in doctors, on which alone any valid opinion could be founded. The + barrister is as superstitious as the doctor is infatuated; and the + Peculiar goes unpitied to his cell, though nothing whatever has been + proved except that his child does without the interference of a doctor as + effectually as any of the hundreds of children who die every day of the + same diseases in the doctor's care. + </p> + <p> + <a name="link2H_4_0004" id="link2H_4_0004"> + <!-- H2 anchor --> </a> + </p> + <div style="height: 4em;"> + <br /><br /><br /><br /> + </div> + <h2> + RECOIL OF THE DOGMA OF MEDICAL INFALLIBILITY ON THE DOCTOR + </h2> + <p> + On the other hand, when the doctor is in the dock, or is the defendant in + an action for malpractice, he has to struggle against the inevitable + result of his former pretences to infinite knowledge and unerring skill. + He has taught the jury and the judge, and even his own counsel, to believe + that every doctor can, with a glance at the tongue, a touch on the pulse, + and a reading of the clinical thermometer, diagnose with absolute + certainty a patient's complaint, also that on dissecting a dead body he + can infallibly put his finger on the cause of death, and, in cases where + poisoning is suspected, the nature of the poison used. Now all this + supposed exactness and infallibility is imaginary; and to treat a doctor + as if his mistakes were necessarily malicious or corrupt malpractices (an + inevitable deduction from the postulate that the doctor, being omniscient, + cannot make mistakes) is as unjust as to blame the nearest apothecary for + not being prepared to supply you with sixpenny-worth of the elixir of + life, or the nearest motor garage for not having perpetual motion on sale + in gallon tins. But if apothecaries and motor car makers habitually + advertized elixir of life and perpetual motion, and succeeded in creating + a strong general belief that they could supply it, they would find + themselves in an awkward position if they were indicted for allowing a + customer to die, or for burning a chauffeur by putting petrol into his + car. That is the predicament the doctor finds himself in when he has to + defend himself against a charge of malpractice by a plea of ignorance and + fallibility. His plea is received with flat credulity; and he gets little + sympathy, even from laymen who know, because he has brought the + incredulity on himself. If he escapes, he can only do so by opening the + eyes of the jury to the facts that medical science is as yet very + imperfectly differentiated from common curemongering witchcraft; that + diagnosis, though it means in many instances (including even the + identification of pathogenic bacilli under the microscope) only a choice + among terms so loose that they would not be accepted as definitions in any + really exact science, is, even at that, an uncertain and difficult matter + on which doctors often differ; and that the very best medical opinion and + treatment varies widely from doctor to doctor, one practitioner + prescribing six or seven scheduled poisons for so familiar a disease as + enteric fever where another will not tolerate drugs at all; one starving a + patient whom another would stuff; one urging an operation which another + would regard as unnecessary and dangerous; one giving alcohol and meat + which another would sternly forbid, etc., etc., etc.: all these + discrepancies arising not between the opinion of good doctors and bad ones + (the medical contention is, of course, that a bad doctor is an + impossibility), but between practitioners of equal eminence and authority. + Usually it is impossible to persuade the jury that these facts are facts. + Juries seldom notice facts; and they have been taught to regard any doubts + of the omniscience and omnipotence of doctors as blasphemy. Even the fact + that doctors themselves die of the very diseases they profess to cure + passes unnoticed. We do not shoot out our lips and shake our heads, + saying, "They save others: themselves they cannot save": their reputation + stands, like an African king's palace, on a foundation of dead bodies; and + the result is that the verdict goes against the defendant when the + defendant is a doctor accused of malpractice. + </p> + <p> + Fortunately for the doctors, they very seldom find themselves in this + position, because it is so difficult to prove anything against them. The + only evidence that can decide a case of malpractice is expert evidence: + that is, the evidence of other doctors; and every doctor will allow a + colleague to decimate a whole countryside sooner than violate the bond of + professional etiquet by giving him away. It is the nurse who gives the + doctor away in private, because every nurse has some particular doctor + whom she likes; and she usually assures her patients that all the others + are disastrous noodles, and soothes the tedium of the sick-bed by gossip + about their blunders. She will even give a doctor away for the sake of + making the patient believe that she knows more than the doctor. But she + dare not, for her livelihood, give the doctor away in public. And the + doctors stand by one another at all costs. Now and then some doctor in an + unassailable position, like the late Sir William Gull, will go into the + witness box and say what he really thinks about the way a patient has been + treated; but such behavior is considered little short of infamous by his + colleagues. + </p> + <p> + <a name="link2H_4_0005" id="link2H_4_0005"> + <!-- H2 anchor --> </a> + </p> + <div style="height: 4em;"> + <br /><br /><br /><br /> + </div> + <h2> + WHY DOCTORS DO NOT DIFFER + </h2> + <p> + The truth is, there would never be any public agreement among doctors if + they did not agree to agree on the main point of the doctor being always + in the right. Yet the two guinea man never thinks that the five shilling + man is right: if he did, he would be understood as confessing to an + overcharge of one pound seventeen shillings; and on the same ground the + five shilling man cannot encourage the notion that the owner of the + sixpenny surgery round the corner is quite up to his mark. Thus even the + layman has to be taught that infallibility is not quite infallible, + because there are two qualities of it to be had at two prices. + </p> + <p> + But there is no agreement even in the same rank at the same price. During + the first great epidemic of influenza towards the end of the nineteenth + century a London evening paper sent round a journalist-patient to all the + great consultants of that day, and published their advice and + prescriptions; a proceeding passionately denounced by the medical papers + as a breach of confidence of these eminent physicians. The case was the + same; but the prescriptions were different, and so was the advice. Now a + doctor cannot think his own treatment right and at the same time think his + colleague right in prescribing a different treatment when the patient is + the same. Anyone who has ever known doctors well enough to hear medical + shop talked without reserve knows that they are full of stories about each + other's blunders and errors, and that the theory of their omniscience and + omnipotence no more holds good among themselves than it did with Moliere + and Napoleon. But for this very reason no doctor dare accuse another of + malpractice. He is not sure enough of his own opinion to ruin another man + by it. He knows that if such conduct were tolerated in his profession no + doctor's livelihood or reputation would be worth a year's purchase. I do + not blame him: I would do the same myself. But the effect of this state of + things is to make the medical profession a conspiracy to hide its own + shortcomings. No doubt the same may be said of all professions. They are + all conspiracies against the laity; and I do not suggest that the medical + conspiracy is either better or worse than the military conspiracy, the + legal conspiracy, the sacerdotal conspiracy, the pedagogic conspiracy, the + royal and aristocratic conspiracy, the literary and artistic conspiracy, + and the innumerable industrial, commercial, and financial conspiracies, + from the trade unions to the great exchanges, which make up the huge + conflict which we call society. But it is less suspected. The Radicals who + used to advocate, as an indispensable preliminary to social reform, the + strangling of the last king with the entrails of the last priest, + substituted compulsory vaccination for compulsory baptism without a + murmur. + </p> + <p> + <a name="link2H_4_0006" id="link2H_4_0006"> + <!-- H2 anchor --> </a> + </p> + <div style="height: 4em;"> + <br /><br /><br /><br /> + </div> + <h2> + THE CRAZE FOR OPERATIONS + </h2> + <p> + Thus everything is on the side of the doctor. When men die of disease they + are said to die from natural causes. When they recover (and they mostly + do) the doctor gets the credit of curing them. In surgery all operations + are recorded as successful if the patient can be got out of the hospital + or nursing home alive, though the subsequent history of the case may be + such as would make an honest surgeon vow never to recommend or perform the + operation again. The large range of operations which consist of amputating + limbs and extirpating organs admits of no direct verification of their + necessity. There is a fashion in operations as there is in sleeves and + skirts: the triumph of some surgeon who has at last found out how to make + a once desperate operation fairly safe is usually followed by a rage for + that operation not only among the doctors, but actually among their + patients. There are men and women whom the operating table seems to + fascinate; half-alive people who through vanity, or hypochondria, or a + craving to be the constant objects of anxious attention or what not, lose + such feeble sense as they ever had of the value of their own organs and + limbs. They seem to care as little for mutilation as lobsters or lizards, + which at least have the excuse that they grow new claws and new tails if + they lose the old ones. Whilst this book was being prepared for the press + a case was tried in the Courts, of a man who sued a railway company for + damages because a train had run over him and amputated both his legs. He + lost his case because it was proved that he had deliberately contrived the + occurrence himself for the sake of getting an idler's pension at the + expense of the railway company, being too dull to realize how much more he + had to lose than to gain by the bargain even if he had won his case and + received damages above his utmost hopes. + </p> + <p> + Thus amazing case makes it possible to say, with some prospect of being + believed, that there is in the classes who can afford to pay for + fashionable operations a sprinkling of persons so incapable of + appreciating the relative importance of preserving their bodily integrity, + (including the capacity for parentage) and the pleasure of talking about + themselves and hearing themselves talked about as the heroes and heroines + of sensational operations, that they tempt surgeons to operate on them not + only with large fees, but with personal solicitation. Now it cannot be too + often repeated that when an operation is once performed, nobody can ever + prove that it was unnecessary. If I refuse to allow my leg to be + amputated, its mortification and my death may prove that I was wrong; but + if I let the leg go, nobody can ever prove that it would not have + mortified had I been obstinate. Operation is therefore the safe side for + the surgeon as well as the lucrative side. The result is that we hear of + "conservative surgeons" as a distinct class of practitioners who make it a + rule not to operate if they can possibly help it, and who are sought after + by the people who have vitality enough to regard an operation as a last + resort. But no surgeon is bound to take the conservative view. If he + believes that an organ is at best a useless survival, and that if he + extirpates it the patient will be well and none the worse in a fortnight, + whereas to await the natural cure would mean a month's illness, then he is + clearly justified in recommending the operation even if the cure without + operation is as certain as anything of the kind ever can be. Thus the + conservative surgeon and the radical or extirpatory surgeon may both be + right as far as the ultimate cure is concerned; so that their consciences + do not help them out of their differences. + </p> + <p> + <a name="link2H_4_0007" id="link2H_4_0007"> + <!-- H2 anchor --> </a> + </p> + <div style="height: 4em;"> + <br /><br /><br /><br /> + </div> + <h2> + CREDULITY AND CHLOROFORM + </h2> + <p> + There is no harder scientific fact in the world than the fact that belief + can be produced in practically unlimited quantity and intensity, without + observation or reasoning, and even in defiance of both, by the simple + desire to believe founded on a strong interest in believing. Everybody + recognizes this in the case of the amatory infatuations of the adolescents + who see angels and heroes in obviously (to others) commonplace and even + objectionable maidens and youths. But it holds good over the entire field + of human activity. The hardest-headed materialist will become a consulter + of table-rappers and slate-writers if he loses a child or a wife so + beloved that the desire to revive and communicate with them becomes + irresistible. The cobbler believes that there is nothing like leather. The + Imperialist who regards the conquest of England by a foreign power as the + worst of political misfortunes believes that the conquest of a foreign + power by England would be a boon to the conquered. Doctors are no more + proof against such illusions than other men. Can anyone then doubt that + under existing conditions a great deal of unnecessary and mischievous + operating is bound to go on, and that patients are encouraged to imagine + that modern surgery and anesthesia have made operations much less serious + matters than they really are? When doctors write or speak to the public + about operations, they imply, and often say in so many words, that + chloroform has made surgery painless. People who have been operated on + know better. The patient does not feel the knife, and the operation is + therefore enormously facilitated for the surgeon; but the patient pays for + the anesthesia with hours of wretched sickness; and when that is over + there is the pain of the wound made by the surgeon, which has to heal like + any other wound. This is why operating surgeons, who are usually out of + the house with their fee in their pockets before the patient has recovered + consciousness, and who therefore see nothing of the suffering witnessed by + the general practitioner and the nurse, occasionally talk of operations + very much as the hangman in Barnaby Rudge talked of executions, as if + being operated on were a luxury in sensation as well as in price. + </p> + <p> + <a name="link2H_4_0008" id="link2H_4_0008"> + <!-- H2 anchor --> </a> + </p> + <div style="height: 4em;"> + <br /><br /><br /><br /> + </div> + <h2> + MEDICAL POVERTY + </h2> + <p> + To make matters worse, doctors are hideously poor. The Irish gentleman + doctor of my boyhood, who took nothing less than a guinea, though he might + pay you four visits for it, seems to have no equivalent nowadays in + English society. Better be a railway porter than an ordinary English + general practitioner. A railway porter has from eighteen to twenty-three + shillings a week from the Company merely as a retainer; and his additional + fees from the public, if we leave the third-class twopenny tip out of + account (and I am by no means sure that even this reservation need be + made), are equivalent to doctor's fees in the case of second-class + passengers, and double doctor's fees in the case of first. Any class of + educated men thus treated tends to become a brigand class, and doctors are + no exception to the rule. They are offered disgraceful prices for advice + and medicine. Their patients are for the most part so poor and so ignorant + that good advice would be resented as impracticable and wounding. When you + are so poor that you cannot afford to refuse eighteenpence from a man who + is too poor to pay you any more, it is useless to tell him that what he or + his sick child needs is not medicine, but more leisure, better clothes, + better food, and a better drained and ventilated house. It is kinder to + give him a bottle of something almost as cheap as water, and tell him to + come again with another eighteenpence if it does not cure him. When you + have done that over and over again every day for a week, how much + scientific conscience have you left? If you are weak-minded enough to + cling desperately to your eighteenpence as denoting a certain social + superiority to the sixpenny doctor, you will be miserably poor all your + life; whilst the sixpenny doctor, with his low prices and quick turnover + of patients, visibly makes much more than you do and kills no more people. + </p> + <p> + A doctor's character can no more stand out against such conditions than + the lungs of his patients can stand out against bad ventilation. The only + way in which he can preserve his self-respect is by forgetting all he ever + learnt of science, and clinging to such help as he can give without cost + merely by being less ignorant and more accustomed to sick-beds than his + patients. Finally, he acquires a certain skill at nursing cases under + poverty-stricken domestic conditions, just as women who have been trained + as domestic servants in some huge institution with lifts, vacuum cleaners, + electric lighting, steam heating, and machinery that turns the kitchen + into a laboratory and engine house combined, manage, when they are sent + out into the world to drudge as general servants, to pick up their + business in a new way, learning the slatternly habits and wretched + makeshifts of homes where even bundles of kindling wood are luxuries to be + anxiously economized. + </p> + <p> + <a name="link2H_4_0009" id="link2H_4_0009"> + <!-- H2 anchor --> </a> + </p> + <div style="height: 4em;"> + <br /><br /><br /><br /> + </div> + <h2> + THE SUCCESSFUL DOCTOR + </h2> + <p> + The doctor whose success blinds public opinion to medical poverty is + almost as completely demoralized. His promotion means that his practice + becomes more and more confined to the idle rich. The proper advice for + most of their ailments is typified in Abernethy's "Live on sixpence a day + and earn it." But here, as at the other end of the scale, the right advice + is neither agreeable nor practicable. And every hypochondriacal rich lady + or gentleman who can be persuaded that he or she is a lifelong invalid + means anything from fifty to five hundred pounds a year for the doctor. + Operations enable a surgeon to earn similar sums in a couple of hours; and + if the surgeon also keeps a nursing home, he may make considerable profits + at the same time by running what is the most expensive kind of hotel. + These gains are so great that they undo much of the moral advantage which + the absence of grinding pecuniary anxiety gives the rich doctor over the + poor one. It is true that the temptation to prescribe a sham treatment + because the real treatment is too dear for either patient or doctor does + not exist for the rich doctor. He always has plenty of genuine cases which + can afford genuine treatment; and these provide him with enough sincere + scientific professional work to save him from the ignorance, obsolescence, + and atrophy of scientific conscience into which his poorer colleagues + sink. But on the other hand his expenses are enormous. Even as a bachelor, + he must, at London west end rates, make over a thousand a year before he + can afford even to insure his life. His house, his servants, and his + equipage (or autopage) must be on the scale to which his patients are + accustomed, though a couple of rooms with a camp bed in one of them might + satisfy his own requirements. Above all, the income which provides for + these outgoings stops the moment he himself stops working. Unlike the man + of business, whose managers, clerks, warehousemen and laborers keep his + business going whilst he is in bed or in his club, the doctor cannot earn + a farthing by deputy. Though he is exceptionally exposed to infection, and + has to face all weathers at all hours of the night and day, often not + enjoying a complete night's rest for a week, the money stops coming in the + moment he stops going out; and therefore illness has special terrors for + him, and success no certain permanence. He dare not stop making hay while + the sun shines; for it may set at any time. Men do not resist pressure of + this intensity. When they come under it as doctors they pay unnecessary + visits; they write prescriptions that are as absurd as the rub of chalk + with which an Irish tailor once charmed away a wart from my father's + finger; they conspire with surgeons to promote operations; they nurse the + delusions of the malade imaginaire (who is always really ill because, as + there is no such thing as perfect health, nobody is ever really well); + they exploit human folly, vanity, and fear of death as ruthlessly as their + own health, strength, and patience are exploited by selfish + hypochondriacs. They must do all these things or else run pecuniary risks + that no man can fairly be asked to run. And the healthier the world + becomes, the more they are compelled to live by imposture and the less by + that really helpful activity of which all doctors get enough to preserve + them from utter corruption. For even the most hardened humbug who ever + prescribed ether tonics to ladies whose need for tonics is of precisely + the same character as the need of poorer women for a glass of gin, has to + help a mother through child-bearing often enough to feel that he is not + living wholly in vain. + </p> + <p> + <a name="link2H_4_0010" id="link2H_4_0010"> + <!-- H2 anchor --> </a> + </p> + <div style="height: 4em;"> + <br /><br /><br /><br /> + </div> + <h2> + THE PSYCHOLOGY OF SELF-RESPECT IN SURGEONS + </h2> + <p> + The surgeon, though often more unscrupulous than the general practitioner, + retains his self-respect more easily. The human conscience can subsist on + very questionable food. No man who is occupied in doing a very difficult + thing, and doing it very well, ever loses his self-respect. The shirk, the + duffer, the malingerer, the coward, the weakling, may be put out of + countenance by his own failures and frauds; but the man who does evil + skilfully, energetically, masterfully, grows prouder and bolder at every + crime. The common man may have to found his self-respect on sobriety, + honesty and industry; but a Napoleon needs no such props for his sense of + dignity. If Nelson's conscience whispered to him at all in the silent + watches of the night, you may depend on it it whispered about the Baltic + and the Nile and Cape St. Vincent, and not about his unfaithfulness to his + wife. A man who robs little children when no one is looking can hardly + have much self-respect or even self-esteem; but an accomplished burglar + must be proud of himself. In the play to which I am at present preluding I + have represented an artist who is so entirely satisfied with his artistic + conscience, even to the point of dying like a saint with its support, that + he is utterly selfish and unscrupulous in every other relation without + feeling at the smallest disadvantage. The same thing may be observed in + women who have a genius for personal attractiveness: they expend more + thought, labor, skill, inventiveness, taste and endurance on making + themselves lovely than would suffice to keep a dozen ugly women honest; + and this enables them to maintain a high opinion of themselves, and an + angry contempt for unattractive and personally careless women, whilst they + lie and cheat and slander and sell themselves without a blush. The truth + is, hardly any of us have ethical energy enough for more than one really + inflexible point of honor. Andrea del Sarto, like Louis Dubedat in my + play, must have expended on the attainment of his great mastery of design + and his originality in fresco painting more conscientiousness and industry + than go to the making of the reputations of a dozen ordinary mayors and + churchwardens; but (if Vasari is to be believed) when the King of France + entrusted him with money to buy pictures for him, he stole it to spend on + his wife. Such cases are not confined to eminent artists. Unsuccessful, + unskilful men are often much more scrupulous than successful ones. In the + ranks of ordinary skilled labor many men are to be found who earn good + wages and are never out of a job because they are strong, indefatigable, + and skilful, and who therefore are bold in a high opinion of themselves; + but they are selfish and tyrannical, gluttonous and drunken, as their + wives and children know to their cost. + </p> + <p> + Not only do these talented energetic people retain their self-respect + through shameful misconduct: they do not even lose the respect of others, + because their talents benefit and interest everybody, whilst their vices + affect only a few. An actor, a painter, a composer, an author, may be as + selfish as he likes without reproach from the public if only his art is + superb; and he cannot fulfil his condition without sufficient effort and + sacrifice to make him feel noble and martyred in spite of his selfishness. + It may even happen that the selfishness of an artist may be a benefit to + the public by enabling him to concentrate himself on their gratification + with a recklessness of every other consideration that makes him highly + dangerous to those about him. In sacrificing others to himself he is + sacrificing them to the public he gratifies; and the public is quite + content with that arrangement. The public actually has an interest in the + artist's vices. + </p> + <p> + It has no such interest in the surgeon's vices. The surgeon's art is + exercised at its expense, not for its gratification. We do not go to the + operating table as we go to the theatre, to the picture gallery, to the + concert room, to be entertained and delighted: we go to be tormented and + maimed, lest a worse thing should befall us. It is of the most extreme + importance to us that the experts on whose assurance we face this horror + and suffer this mutilation should leave no interests but our own to think + of; should judge our cases scientifically; and should feel about them + kindly. Let us see what guarantees we have: first for the science, and + then for the kindness. + </p> + <p> + <a name="link2H_4_0011" id="link2H_4_0011"> + <!-- H2 anchor --> </a> + </p> + <div style="height: 4em;"> + <br /><br /><br /><br /> + </div> + <h2> + ARE DOCTORS MEN OF SCIENCE? + </h2> + <p> + I presume nobody will question the existence of widely spread popular + delusion that every doctor is a titan of science. It is escaped only in + the very small class which understands by science something more than + conjuring with retorts and spirit lamps, magnets and microscopes, and + discovering magical cures for disease. To a sufficiently ignorant man + every captain of a trading schooner is a Galileo, every organ-grinder a + Beethoven, every piano-tuner a Hemholtz, every Old Bailey barrister a + Solon, every Seven Dials pigeon dealer a Darwin, every scrivener a + Shakespear, every locomotive engine a miracle, and its driver no less + wonderful than George Stephenson. As a matter of fact, the rank and file + of doctors are no more scientific than their tailors; or, if you prefer to + put it the reverse way, their tailors are no less scientific than they. + Doctoring is an art, not a science: any layman who is interested in + science sufficiently to take in one of the scientific journals and follow + the literature of the scientific movement, knows more about it than those + doctors (probably a large majority) who are not interested in it, and + practise only to earn their bread. Doctoring is not even the art of + keeping people in health (no doctor seems able to advise you what to eat + any better than his grandmother or the nearest quack): it is the art of + curing illnesses. It does happen exceptionally that a practising doctor + makes a contribution to science (my play describes a very notable one); + but it happens much oftener that he draws disastrous conclusions from his + clinical experience because he has no conception of scientific method, and + believes, like any rustic, that the handling of evidence and statistics + needs no expertness. The distinction between a quack doctor and a + qualified one is mainly that only the qualified one is authorized to sign + death certificates, for which both sorts seem to have about equal + occasion. Unqualified practitioners now make large incomes as hygienists, + and are resorted to as frequently by cultivated amateur scientists who + understand quite well what they are doing as by ignorant people who are + simply dupes. Bone-setters make fortunes under the very noses of our + greatest surgeons from educated and wealthy patients; and some of the most + successful doctors on the register use quite heretical methods of treating + disease, and have qualified themselves solely for convenience. Leaving out + of account the village witches who prescribe spells and sell charms, the + humblest professional healers in this country are the herbalists. These + men wander through the fields on Sunday seeking for herbs with magic + properties of curing disease, preventing childbirth, and the like. Each of + them believes that he is on the verge of a great discovery, in which + Virginia Snake Root will be an ingredient, heaven knows why! Virginia + Snake Root fascinates the imagination of the herbalist as mercury used to + fascinate the alchemists. On week days he keeps a shop in which he sells + packets of pennyroyal, dandelion, etc., labelled with little lists of the + diseases they are supposed to cure, and apparently do cure to the + satisfaction of the people who keep on buying them. I have never been able + to perceive any distinction between the science of the herbalist and that + of the duly registered doctor. A relative of mine recently consulted a + doctor about some of the ordinary symptoms which indicate the need for a + holiday and a change. The doctor satisfied himself that the patient's + heart was a little depressed. Digitalis being a drug labelled as a heart + specific by the profession, he promptly administered a stiff dose. + Fortunately the patient was a hardy old lady who was not easily killed. + She recovered with no worse result than her conversion to Christian + Science, which owes its vogue quite as much to public despair of doctors + as to superstition. I am not, observe, here concerned with the question as + to whether the dose of digitalis was judicious or not; the point is, that + a farm laborer consulting a herbalist would have been treated in exactly + the same way. + </p> + <p> + <a name="link2H_4_0012" id="link2H_4_0012"> + <!-- H2 anchor --> </a> + </p> + <div style="height: 4em;"> + <br /><br /><br /><br /> + </div> + <h2> + BACTERIOLOGY AS A SUPERSTITION + </h2> + <p> + The smattering of science that all—even doctors—pick up from + the ordinary newspapers nowadays only makes the doctor more dangerous than + he used to be. Wise men used to take care to consult doctors qualified + before 1860, who were usually contemptuous of or indifferent to the germ + theory and bacteriological therapeutics; but now that these veterans have + mostly retired or died, we are left in the hands of the generations which, + having heard of microbes much as St. Thomas Aquinas heard of angels, + suddenly concluded that the whole art of healing could be summed up in the + formula: Find the microbe and kill it. And even that they did not know how + to do. The simplest way to kill most microbes is to throw them into an + open street or river and let the sun shine on them, which explains the + fact that when great cities have recklessly thrown all their sewage into + the open river the water has sometimes been cleaner twenty miles below the + city than thirty miles above it. But doctors instinctively avoid all facts + that are reassuring, and eagerly swallow those that make it a marvel that + anyone could possibly survive three days in an atmosphere consisting + mainly of countless pathogenic germs. They conceive microbes as immortal + until slain by a germicide administered by a duly qualified medical man. + All through Europe people are adjured, by public notices and even under + legal penalties, not to throw their microbes into the sunshine, but to + collect them carefully in a handkerchief; shield the handkerchief from the + sun in the darkness and warmth of the pocket; and send it to a laundry to + be mixed up with everybody else's handkerchiefs, with results only too + familiar to local health authorities. + </p> + <p> + In the first frenzy of microbe killing, surgical instruments were dipped + in carbolic oil, which was a great improvement on not dipping them in + anything at all and simply using them dirty; but as microbes are so fond + of carbolic oil that they swarm in it, it was not a success from the + anti-microbe point of view. Formalin was squirted into the circulation of + consumptives until it was discovered that formalin nourishes the tubercle + bacillus handsomely and kills men. The popular theory of disease is the + common medical theory: namely, that every disease had its microbe duly + created in the garden of Eden, and has been steadily propagating itself + and producing widening circles of malignant disease ever since. It was + plain from the first that if this had been even approximately true, the + whole human race would have been wiped out by the plague long ago, and + that every epidemic, instead of fading out as mysteriously as it rushed + in, would spread over the whole world. It was also evident that the + characteristic microbe of a disease might be a symptom instead of a cause. + An unpunctual man is always in a hurry; but it does not follow that hurry + is the cause of unpunctuality: on the contrary, what is the matter with + the patient is sloth. When Florence Nightingale said bluntly that if you + overcrowded your soldiers in dirty quarters there would be an outbreak of + smallpox among them, she was snubbed as an ignorant female who did not + know that smallpox can be produced only by the importation of its specific + microbe. + </p> + <p> + If this was the line taken about smallpox, the microbe of which has never + yet been run down and exposed under the microscope by the bacteriologist, + what must have been the ardor of conviction as to tuberculosis, tetanus, + enteric fever, Maltese fever, diphtheria, and the rest of the diseases in + which the characteristic bacillus had been identified! When there was no + bacillus it was assumed that, since no disease could exist without a + bacillus, it was simply eluding observation. When the bacillus was found, + as it frequently was, in persons who were not suffering from the disease, + the theory was saved by simply calling the bacillus an impostor, or + pseudobacillus. The same boundless credulity which the public exhibit as + to a doctor's power of diagnosis was shown by the doctors themselves as to + the analytic microbe hunters. These witch finders would give you a + certificate of the ultimate constitution of anything from a sample of the + water from your well to a scrap of your lungs, for seven-and-sixpense. I + do not suggest that the analysts were dishonest. No doubt they carried the + analysis as far as they could afford to carry it for the money. No doubt + also they could afford to carry it far enough to be of some use. But the + fact remains that just as doctors perform for half-a-crown, without the + least misgiving, operations which could not be thoroughly and safely + performed with due scientific rigor and the requisite apparatus by an + unaided private practitioner for less than some thousands of pounds, so + did they proceed on the assumption that they could get the last word of + science as to the constituents of their pathological samples for a two + hours cab fare. + </p> + <p> + <a name="link2H_4_0013" id="link2H_4_0013"> + <!-- H2 anchor --> </a> + </p> + <div style="height: 4em;"> + <br /><br /><br /><br /> + </div> + <h2> + ECONOMIC DIFFICULTIES OF IMMUNIZATION + </h2> + <p> + I have heard doctors affirm and deny almost every possible proposition as + to disease and treatment. I can remember the time when doctors no more + dreamt of consumption and pneumonia being infectious than they now dream + of sea-sickness being infectious, or than so great a clinical observer as + Sydenham dreamt of smallpox being infectious. I have heard doctors deny + that there is such a thing as infection. I have heard them deny the + existence of hydrophobia as a specific disease differing from tetanus. I + have heard them defend prophylactic measures and prophylactic legislation + as the sole and certain salvation of mankind from zymotic disease; and I + have heard them denounce both as malignant spreaders of cancer and lunacy. + But the one objection I have never heard from a doctor is the objection + that prophylaxis by the inoculatory methods most in vogue is an economic + impossibility under our private practice system. They buy some stuff from + somebody for a shilling, and inject a pennyworth of it under their + patient's skin for half-a-crown, concluding that, since this primitive + rite pays the somebody and pays them, the problem of prophylaxis has been + satisfactorily solved. The results are sometimes no worse than the + ordinary results of dirt getting into cuts; but neither the doctor nor the + patient is quite satisfied unless the inoculation "takes"; that is, unless + it produces perceptible illness and disablement. Sometimes both doctor and + patient get more value in this direction than they bargain for. The + results of ordinary private-practice-inoculation at their worst are bad + enough to be indistinguishable from those of the most discreditable and + dreaded disease known; and doctors, to save the credit of the inoculation, + have been driven to accuse their patient or their patient's parents of + having contracted this disease independently of the inoculation, an excuse + which naturally does not make the family any more resigned, and leads to + public recriminations in which the doctors, forgetting everything but the + immediate quarrel, naively excuse themselves by admitting, and even + claiming as a point in their favor, that it is often impossible to + distinguish the disease produced by their inoculation and the disease they + have accused the patient of contracting. And both parties assume that what + is at issue is the scientific soundness of the prophylaxis. It never + occurs to them that the particular pathogenic germ which they intended to + introduce into the patient's system may be quite innocent of the + catastrophe, and that the casual dirt introduced with it may be at fault. + When, as in the case of smallpox or cowpox, the germ has not yet been + detected, what you inoculate is simply undefined matter that has been + scraped off an anything but chemically clean calf suffering from the + disease in question. You take your chance of the germ being in the + scrapings, and, lest you should kill it, you take no precautions against + other germs being in it as well. Anything may happen as the result of such + an inoculation. Yet this is the only stuff of the kind which is prepared + and supplied even in State establishments: that is, in the only + establishments free from the commercial temptation to adulterate materials + and scamp precautionary processes. + </p> + <p> + Even if the germ were identified, complete precautions would hardly pay. + It is true that microbe farming is not expensive. The cost of breeding and + housing two head of cattle would provide for the breeding and housing of + enough microbes to inoculate the entire population of the globe since + human life first appeared on it. But the precautions necessary to insure + that the inoculation shall consist of nothing else but the required germ + in the proper state of attenuation are a very different matter from the + precautions necessary in the distribution and consumption of beefsteaks. + Yet people expect to find vaccines and antitoxins and the like retailed at + "popular prices" in private enterprise shops just as they expect to find + ounces of tobacco and papers of pins. + </p> + <p> + <a name="link2H_4_0014" id="link2H_4_0014"> + <!-- H2 anchor --> </a> + </p> + <div style="height: 4em;"> + <br /><br /><br /><br /> + </div> + <h2> + THE PERILS OF INOCULATION + </h2> + <p> + The trouble does not end with the matter to be inoculated. There is the + question of the condition of the patient. The discoveries of Sir Almroth + Wright have shown that the appalling results which led to the hasty + dropping in 1894 of Koch's tuberculin were not accidents, but perfectly + orderly and inevitable phenomena following the injection of dangerously + strong "vaccines" at the wrong moment, and reinforcing the disease instead + of stimulating the resistance to it. To ascertain the right moment a + laboratory and a staff of experts are needed. The general practitioner, + having no such laboratory and no such experience, has always chanced it, + and insisted, when he was unlucky, that the results were not due to the + inoculation, but to some other cause: a favorite and not very tactful one + being the drunkenness or licentiousness of the patient. But though a few + doctors have now learnt the danger of inoculating without any reference to + the patient's "opsonic index" at the moment of inoculation, and though + those other doctors who are denouncing the danger as imaginary and opsonin + as a craze or a fad, obviously do so because it involves an operation + which they have neither the means nor the knowledge to perform, there is + still no grasp of the economic change in the situation. They have never + been warned that the practicability of any method of extirpating disease + depends not only on its efficacy, but on its cost. For example, just at + present the world has run raving mad on the subject of radium, which has + excited our credulity precisely as the apparitions at Lourdes excited the + credulity of Roman Catholics. Suppose it were ascertained that every child + in the world could be rendered absolutely immune from all disease during + its entire life by taking half an ounce of radium to every pint of its + milk. The world would be none the healthier, because not even a Crown + Prince—no, not even the son of a Chicago Meat King, could afford the + treatment. Yet it is doubtful whether doctors would refrain from + prescribing it on that ground. The recklessness with which they now + recommend wintering in Egypt or at Davos to people who cannot afford to go + to Cornwall, and the orders given for champagne jelly and old port in + households where such luxuries must obviously be acquired at the cost of + stinting necessaries, often make one wonder whether it is possible for a + man to go through a medical training and retain a spark of common sense. + This sort of inconsiderateness gets cured only in the classes where + poverty, pretentious as it is even at its worst, cannot pitch its + pretences high enough to make it possible for the doctor (himself often no + better off than the patient) to assume that the average income of an + English family is about 2,000 pounds a year, and that it is quite easy to + break up a home, sell an old family seat at a sacrifice, and retire into a + foreign sanatorium devoted to some "treatment" that did not exist two + years ago and probably will not exist (except as a pretext for keeping an + ordinary hotel) two years hence. In a poor practice the doctor must find + cheap treatments for cheap people, or humiliate and lose his patients + either by prescribing beyond their means or sending them to the public + hospitals. When it comes to prophylactic inoculation, the alternative lies + between the complete scientific process, which can only be brought down to + a reasonable cost by being very highly organized as a public service in a + public institution, and such cheap, nasty, dangerous and scientifically + spurious imitations as ordinary vaccination, which seems not unlikely to + be ended, like its equally vaunted forerunner, XVIII. century inoculation, + by a purely reactionary law making all sorts of vaccination, scientific or + not, criminal offences. Naturally, the poor doctor (that is, the average + doctor) defends ordinary vaccination frantically, as it means to him the + bread of his children. To secure the vehement and practically unanimous + support of the rank and file of the medical profession for any sort of + treatment or operation, all that is necessary is that it can be easily + practised by a rather shabbily dressed man in a surgically dirty room in a + surgically dirty house without any assistance, and that the materials for + it shall cost, say, a penny, and the charge for it to a patient with 100 + pounds a year be half-a-crown. And, on the other hand, a hygienic measure + has only to be one of such refinement, difficulty, precision and + costliness as to be quite beyond the resources of private practice, to be + ignored or angrily denounced as a fad. + </p> + <p> + TRADE UNIONISM AND SCIENCE + </p> + <p> + Here we have the explanation of the savage rancor that so amazes people + who imagine that the controversy concerning vaccination is a scientific + one. It has really nothing to do with science. The medical profession, + consisting for the most part of very poor men struggling to keep up + appearances beyond their means, find themselves threatened with the + extinction of a considerable part of their incomes: a part, too, that is + easily and regularly earned, since it is independent of disease, and + brings every person born into the nation, healthy or not, to the doctors. + To boot, there is the occasional windfall of an epidemic, with its panic + and rush for revaccination. Under such circumstances, vaccination would be + defended desperately were it twice as dirty, dangerous, and unscientific + in method as it actually is. The note of fury in the defence, the feeling + that the anti-vaccinator is doing a cruel, ruinous, inconsiderate thing in + a mood of indignant folly: all this, so puzzling to the observer who knows + nothing of the economic side of the question, and only sees that the + anti-vaccinator, having nothing whatever to gain and a good deal to lose + by placing himself in opposition to the law and to the outcry that adds + private persecution to legal penalties, can have no interest in the matter + except the interest of a reformer in abolishing a corrupt and mischievous + superstition, becomes intelligible the moment the tragedy of medical + poverty and the lucrativeness of cheap vaccination is taken into account. + </p> + <p> + In the face of such economic pressure as this, it is silly to expect that + medical teaching, any more than medical practice, can possibly be + scientific. The test to which all methods of treatment are finally brought + is whether they are lucrative to doctors or not. It would be difficult to + cite any proposition less obnoxious to science, than that advanced by + Hahnemann: to wit, that drugs which in large doses produce certain + symptoms, counteract them in very small doses, just as in more modern + practice it is found that a sufficiently small inoculation with typhoid + rallies our powers to resist the disease instead of prostrating us with + it. But Hahnemann and his followers were frantically persecuted for a + century by generations of apothecary-doctors whose incomes depended on the + quantity of drugs they could induce their patients to swallow. These two + cases of ordinary vaccination and homeopathy are typical of all the rest. + Just as the object of a trade union under existing conditions must finally + be, not to improve the technical quality of the work done by its members, + but to secure a living wage for them, so the object of the medical + profession today is to secure an income for the private doctor; and to + this consideration all concern for science and public health must give way + when the two come into conflict. Fortunately they are not always in + conflict. Up to a certain point doctors, like carpenters and masons, must + earn their living by doing the work that the public wants from them; and + as it is not in the nature of things possible that such public want should + be based on unmixed disutility, it may be admitted that doctors have their + uses, real as well as imaginary. But just as the best carpenter or mason + will resist the introduction of a machine that is likely to throw him out + of work, or the public technical education of unskilled laborers' sons to + compete with him, so the doctor will resist with all his powers of + persecution every advance of science that threatens his income. And as the + advance of scientific hygiene tends to make the private doctor's visits + rarer, and the public inspector's frequenter, whilst the advance of + scientific therapeutics is in the direction of treatments that involve + highly organized laboratories, hospitals, and public institutions + generally, it unluckily happens that the organization of private + practitioners which we call the medical profession is coming more and more + to represent, not science, but desperate and embittered antiscience: a + statement of things which is likely to get worse until the average doctor + either depends upon or hopes for an appointment in the public health + service for his livelihood. + </p> + <p> + So much for our guarantees as to medical science. Let us now deal with the + more painful subject of medical kindness. + </p> + <p> + <a name="link2H_4_0015" id="link2H_4_0015"> + <!-- H2 anchor --> </a> + </p> + <div style="height: 4em;"> + <br /><br /><br /><br /> + </div> + <h2> + DOCTORS AND VIVISECTION + </h2> + <p> + The importance to our doctors of a reputation for the tenderest humanity + is so obvious, and the quantity of benevolent work actually done by them + for nothing (a great deal of it from sheer good nature) so large, that at + first sight it seems unaccountable that they should not only throw all + their credit away, but deliberately choose to band themselves publicly + with outlaws and scoundrels by claiming that in the pursuit of their + professional knowledge they should be free from the restraints of law, of + honor, of pity, of remorse, of everything that distinguishes an orderly + citizen from a South Sea buccaneer, or a philosopher from an inquisitor. + For here we look in vain for either an economic or a sentimental motive. + In every generation fools and blackguards have made this claim; and honest + and reasonable men, led by the strongest contemporary minds, have + repudiated it and exposed its crude rascality. From Shakespear and Dr. + Johnson to Ruskin and Mark Twain, the natural abhorrence of sane mankind + for the vivisector's cruelty, and the contempt of able thinkers for his + imbecile casuistry, have been expressed by the most popular spokesmen of + humanity. If the medical profession were to outdo the Anti-Vivisection + Societies in a general professional protest against the practice and + principles of the vivisectors, every doctor in the kingdom would gain + substantially by the immense relief and reconciliation which would follow + such a reassurance of the humanity of the doctor. Not one doctor in a + thousand is a vivisector, or has any interest in vivisection, either + pecuniary or intellectual, or would treat his dog cruelly or allow anyone + else to do it. It is true that the doctor complies with the professional + fashion of defending vivisection, and assuring you that people like + Shakespear and Dr. Johnson and Ruskin and Mark Twain are ignorant + sentimentalists, just as he complies with any other silly fashion: the + mystery is, how it became the fashion in spite of its being so injurious + to those who follow it. Making all possible allowance for the effect of + the brazen lying of the few men who bring a rush of despairing patients to + their doors by professing in letters to the newspapers to have learnt from + vivisection how to cure certain diseases, and the assurances of the sayers + of smooth things that the practice is quite painless under the law, it is + still difficult to find any civilized motive for an attitude by which the + medical profession has everything to lose and nothing to gain. + </p> + <p> + <a name="link2H_4_0016" id="link2H_4_0016"> + <!-- H2 anchor --> </a> + </p> + <div style="height: 4em;"> + <br /><br /><br /><br /> + </div> + <h2> + THE PRIMITIVE SAVAGE MOTIVE + </h2> + <p> + I say civilized motive advisedly; for primitive tribal motives are easy + enough to find. Every savage chief who is not a Mahomet learns that if he + wishes to strike the imagination of his tribe—and without doing that + he can rule them—he must terrify or revolt them from time to time by + acts of hideous cruelty or disgusting unnaturalness. We are far from being + as superior to such tribes as we imagine. It is very doubtful indeed + whether Peter the Great could have effected the changes he made in Russia + if he had not fascinated and intimidated his people by his monstrous + cruelties and grotesque escapades. Had he been a nineteenth-century king + of England, he would have had to wait for some huge accidental calamity: a + cholera epidemic, a war, or an insurrection, before waking us up + sufficiently to get anything done. Vivisection helps the doctor to rule us + as Peter ruled the Russians. The notion that the man who does dreadful + things is superhuman, and that therefore he can also do wonderful things + either as ruler, avenger, healer, or what not, is by no means confined to + barbarians. Just as the manifold wickednesses and stupidities of our + criminal code are supported, not by any general comprehension of law or + study of jurisprudence, not even by simple vindictiveness, but by the + superstition that a calamity of any sort must be expiated by a human + sacrifice; so the wickednesses and stupidities of our medicine men are + rooted in superstitions that have no more to do with science than the + traditional ceremony of christening an ironclad has to do with the + effectiveness of its armament. We have only to turn to Macaulay's + description of the treatment of Charles II in his last illness to see how + strongly his physicians felt that their only chance of cheating death was + by outraging nature in tormenting and disgusting their unfortunate + patient. True, this was more than two centuries ago; but I have heard my + own nineteenth-century grandfather describe the cupping and firing and + nauseous medicines of his time with perfect credulity as to their + beneficial effects; and some more modern treatments appear to me quite as + barbarous. It is in this way that vivisection pays the doctor. It appeals + to the fear and credulity of the savage in us; and without fear and + credulity half the private doctor's occupation and seven-eighths of his + influence would be gone. + </p> + <p> + <a name="link2H_4_0017" id="link2H_4_0017"> + <!-- H2 anchor --> </a> + </p> + <div style="height: 4em;"> + <br /><br /><br /><br /> + </div> + <h2> + THE HIGHER MOTIVE. THE TREE OF KNOWLEDGE. + </h2> + <p> + But the greatest force of all on the side of vivisection is the mighty and + indeed divine force of curiosity. Here we have no decaying tribal instinct + which men strive to root out of themselves as they strive to root out the + tiger's lust for blood. On the contrary, the curiosity of the ape, or of + the child who pulls out the legs and wings of a fly to see what it will do + without them, or who, on being told that a cat dropped out of the window + will always fall on its legs, immediately tries the experiment on the + nearest cat from the highest window in the house (I protest I did it + myself from the first floor only), is as nothing compared to the thirst + for knowledge of the philosopher, the poet, the biologist, and the + naturalist. I have always despised Adam because he had to be tempted by + the woman, as she was by the serpent, before he could be induced to pluck + the apple from the tree of knowledge. I should have swallowed every apple + on the tree the moment the owner's back was turned. When Gray said "Where + ignorance is bliss, 'tis folly to be wise," he forgot that it is godlike + to be wise; and since nobody wants bliss particularly, or could stand more + than a very brief taste of it if it were attainable, and since everybody, + by the deepest law of the Life Force, desires to be godlike, it is stupid, + and indeed blasphemous and despairing, to hope that the thirst for + knowledge will either diminish or consent to be subordinated to any other + end whatsoever. We shall see later on that the claim that has arisen in + this way for the unconditioned pursuit of knowledge is as idle as all + dreams of unconditioned activity; but none the less the right to knowledge + must be regarded as a fundamental human right. The fact that men of + science have had to fight so hard to secure its recognition, and are still + so vigorously persecuted when they discover anything that is not quite + palatable to vulgar people, makes them sorely jealous for that right; and + when they hear a popular outcry for the suppression of a method of + research which has an air of being scientific, their first instinct is to + rally to the defence of that method without further consideration, with + the result that they sometimes, as in the case of vivisection, presently + find themselves fighting on a false issue. + </p> + <p> + <a name="link2H_4_0018" id="link2H_4_0018"> + <!-- H2 anchor --> </a> + </p> + <div style="height: 4em;"> + <br /><br /><br /><br /> + </div> + <h2> + THE FLAW IN THE ARGUMENT + </h2> + <p> + I may as well pause here to explain their error. The right to know is like + the right to live. It is fundamental and unconditional in its assumption + that knowledge, like life, is a desirable thing, though any fool can prove + that ignorance is bliss, and that "a little knowledge is a dangerous + thing" (a little being the most that any of us can attain), as easily as + that the pains of life are more numerous and constant than its pleasures, + and that therefore we should all be better dead. The logic is + unimpeachable; but its only effect is to make us say that if these are the + conclusions logic leads to, so much the worse for logic, after which curt + dismissal of Folly, we continue living and learning by instinct: that is, + as of right. We legislate on the assumption that no man may be killed on + the strength of a demonstration that he would be happier in his grave, not + even if he is dying slowly of cancer and begs the doctor to despatch him + quickly and mercifully. To get killed lawfully he must violate somebody + else's right to live by committing murder. But he is by no means free to + live unconditionally. In society he can exercise his right to live only + under very stiff conditions. In countries where there is compulsory + military service he may even have to throw away his individual life to + save the life of the community. + </p> + <p> + It is just so in the case of the right to knowledge. It is a right that is + as yet very imperfectly recognized in practice. But in theory it is + admitted that an adult person in pursuit of knowledge must not be refused + it on the ground that he would be better or happier without it. Parents + and priests may forbid knowledge to those who accept their authority; and + social taboo may be made effective by acts of legal persecution under + cover of repressing blasphemy, obscenity, and sedition; but no government + now openly forbids its subjects to pursue knowledge on the ground that + knowledge is in itself a bad thing, or that it is possible for any of us + to have too much of it. + </p> + <p> + <a name="link2H_4_0019" id="link2H_4_0019"> + <!-- H2 anchor --> </a> + </p> + <div style="height: 4em;"> + <br /><br /><br /><br /> + </div> + <h2> + LIMITATIONS OF THE RIGHT TO KNOWLEDGE + </h2> + <p> + But neither does any government exempt the pursuit of knowledge, any more + than the pursuit of life, liberty, and happiness (as the American + Constitution puts it), from all social conditions. No man is allowed to + put his mother into the stove because he desires to know how long an adult + woman will survive at a temperature of 500 degrees Fahrenheit, no matter + how important or interesting that particular addition to the store of + human knowledge may be. A man who did so would have short work made not + only of his right to knowledge, but of his right to live and all his other + rights at the same time. The right to knowledge is not the only right; and + its exercise must be limited by respect for other rights, and for its own + exercise by others. When a man says to Society, "May I torture my mother + in pursuit of knowledge?" Society replies, "No." If he pleads, "What! Not + even if I have a chance of finding out how to cure cancer by doing it?" + Society still says, "Not even then." If the scientist, making the best of + his disappointment, goes on to ask may he torture a dog, the stupid and + callous people who do not realize that a dog is a fellow-creature and + sometimes a good friend, may say Yes, though Shakespear, Dr. Johnson and + their like may say No. But even those who say "You may torture A dog" + never say "You may torture MY dog." And nobody says, "Yes, because in the + pursuit of knowledge you may do as you please." Just as even the stupidest + people say, in effect, "If you cannot attain to knowledge without burning + your mother you must do without knowledge," so the wisest people say, "If + you cannot attain to knowledge without torturing a dog, you must do + without knowledge." + </p> + <p> + <a name="link2H_4_0020" id="link2H_4_0020"> + <!-- H2 anchor --> </a> + </p> + <div style="height: 4em;"> + <br /><br /><br /><br /> + </div> + <h2> + A FALSE ALTERNATIVE + </h2> + <p> + But in practice you cannot persuade any wise man that this alternative can + ever be forced on anyone but a fool, or that a fool can be trusted to + learn anything from any experiment, cruel or humane. The Chinaman who + burnt down his house to roast his pig was no doubt honestly unable to + conceive any less disastrous way of cooking his dinner; and the roast must + have been spoiled after all (a perfect type of the average vivisectionist + experiment); but this did not prove that the Chinaman was right: it only + proved that the Chinaman was an incapable cook and, fundamentally, a fool. + </p> + <p> + Take another celebrated experiment: one in sanitary reform. In the days of + Nero Rome was in the same predicament as London to-day. If some one would + burn down London, and it were rebuilt, as it would now have to be, subject + to the sanitary by-laws and Building Act provisions enforced by the London + County Council, it would be enormously improved; and the average lifetime + of Londoners would be considerably prolonged. Nero argued in the same way + about Rome. He employed incendiaries to set it on fire; and he played the + harp in scientific raptures whilst it was burning. I am so far of Nero's + way of thinking that I have often said, when consulted by despairing + sanitary reformers, that what London needs to make her healthy is an + earthquake. Why, then, it may be asked, do not I, as a public-spirited + man, employ incendiaries to set it on fire, with a heroic disregard of the + consequences to myself and others? Any vivisector would, if he had the + courage of his opinions. The reasonable answer is that London can be made + healthy without burning her down; and that as we have not enough civic + virtue to make her healthy in a humane and economical way, we should not + have enough to rebuild her in that way. In the old Hebrew legend, God lost + patience with the world as Nero did with Rome, and drowned everybody + except a single family. But the result was that the progeny of that family + reproduced all the vices of their predecessors so exactly that the misery + caused by the flood might just as well have been spared: things went on + just as they did before. In the same way, the lists of diseases which + vivisection claims to have cured is long; but the returns of the + Registrar-General show that people still persist in dying of them as if + vivisection had never been heard of. Any fool can burn down a city or cut + an animal open; and an exceptionally foolish fool is quite likely to + promise enormous benefits to the race as the result of such activities. + But when the constructive, benevolent part of the business comes to be + done, the same want of imagination, the same stupidity and cruelty, the + same laziness and want of perseverance that prevented Nero or the + vivisector from devising or pushing through humane methods, prevents him + from bringing order out of the chaos and happiness out of the misery he + has made. At one time it seemed reasonable enough to declare that it was + impossible to find whether or not there was a stone inside a man's body + except by exploring it with a knife, or to find out what the sun is made + of without visiting it in a balloon. Both these impossibilities have been + achieved, but not by vivisectors. The Rontgen rays need not hurt the + patient; and spectrum analysis involves no destruction. After such + triumphs of humane experiment and reasoning, it is useless to assure us + that there is no other key to knowledge except cruelty. When the + vivisector offers us that assurance, we reply simply and contemptuously, + "You mean that you are not clever or humane or energetic enough to find + one." + </p> + <p> + CRUELTY FOR ITS OWN SAKE + </p> + <p> + It will now, I hope, be clear why the attack on vivisection is not an + attack on the right to knowledge: why, indeed, those who have the deepest + conviction of the sacredness of that right are the leaders of the attack. + No knowledge is finally impossible of human attainment; for even though it + may be beyond our present capacity, the needed capacity is not + unattainable. Consequently no method of investigation is the only method; + and no law forbidding any particular method can cut us off from the + knowledge we hope to gain by it. The only knowledge we lose by forbidding + cruelty is knowledge at first hand of cruelty itself, which is precisely + the knowledge humane people wish to be spared. + </p> + <p> + But the question remains: Do we all really wish to be spared that + knowledge? Are humane methods really to be preferred to cruel ones? Even + if the experiments come to nothing, may not their cruelty be enjoyed for + its own sake, as a sensational luxury? Let us face these questions boldly, + not shrinking from the fact that cruelty is one of the primitive pleasures + of mankind, and that the detection of its Protean disguises as law, + education, medicine, discipline, sport and so forth, is one of the most + difficult of the unending tasks of the legislator. + </p> + <p> + <a name="link2H_4_0021" id="link2H_4_0021"> + <!-- H2 anchor --> </a> + </p> + <div style="height: 4em;"> + <br /><br /><br /><br /> + </div> + <h2> + OUR OWN CRUELTIES + </h2> + <p> + At first blush it may seem not only unnecessary, but even indecent, to + discuss such a proposition as the elevation of cruelty to the rank of a + human right. Unnecessary, because no vivisector confesses to a love of + cruelty for its own sake or claims any general fundamental right to be + cruel. Indecent, because there is an accepted convention to repudiate + cruelty; and vivisection is only tolerated by the law on condition that, + like judicial torture, it shall be done as mercifully as the nature of the + practice allows. But the moment the controversy becomes embittered, the + recriminations bandied between the opposed parties bring us face-to-face + with some very ugly truths. On one occasion I was invited to speak at a + large Anti-Vivisection meeting in the Queen's Hall in London. I found + myself on the platform with fox hunters, tame stag hunters, men and women + whose calendar was divided, not by pay days and quarter days, but by + seasons for killing animals for sport: the fox, the hare, the otter, the + partridge and the rest having each its appointed date for slaughter. The + ladies among us wore hats and cloaks and head-dresses obtained by + wholesale massacres, ruthless trappings, callous extermination of our + fellow creatures. We insisted on our butchers supplying us with white + veal, and were large and constant consumers of pate de foie gras; both + comestibles being obtained by revolting methods. We sent our sons to + public schools where indecent flogging is a recognized method of taming + the young human animal. Yet we were all in hysterics of indignation at the + cruelties of the vivisectors. These, if any were present, must have smiled + sardonically at such inhuman humanitarians, whose daily habits and + fashionable amusements cause more suffering in England in a week than all + the vivisectors of Europe do in a year. I made a very effective speech, + not exclusively against vivisection, but against cruelty; and I have never + been asked to speak since by that Society, nor do I expect to be, as I + should probably give such offence to its most affluent subscribers that + its attempts to suppress vivisection would be seriously hindered. But that + does not prevent the vivisectors from freely using the "youre another" + retort, and using it with justice. + </p> + <p> + We must therefore give ourselves no airs of superiority when denouncing + the cruelties of vivisection. We all do just as horrible things, with even + less excuse. But in making that admission we are also making short work of + the virtuous airs with which we are sometimes referred to the humanity of + the medical profession as a guarantee that vivisection is not abused—much + as if our burglars should assure us that they arc too honest to abuse the + practice of burgling. We are, as a matter of fact, a cruel nation; and our + habit of disguising our vices by giving polite names to the offences we + are determined to commit does not, unfortunately for my own comfort, + impose on me. Vivisectors can hardly pretend to be better than the classes + from which they are drawn, or those above them; and if these classes are + capable of sacrificing animals in various cruel ways under cover of sport, + fashion, education, discipline, and even, when the cruel sacrifices are + human sacrifices, of political economy, it is idle for the vivisector to + pretend that he is incapable of practising cruelty for pleasure or profit + or both under the cloak of science. We are all tarred with the same brush; + and the vivisectors are not slow to remind us of it, and to protest + vehemently against being branded as exceptionally cruel and its devisors + of horrible instruments of torture by people whose main notion of + enjoyment is cruel sport, and whose requirements in the way of + villainously cruel traps occupy pages of the catalogue of the Army and + Navy Stores. + </p> + <p> + <a name="link2H_4_0022" id="link2H_4_0022"> + <!-- H2 anchor --> </a> + </p> + <div style="height: 4em;"> + <br /><br /><br /><br /> + </div> + <h2> + THE SCIENTIFIC INVESTIGATION OF CRUELTY + </h2> + <p> + There is in man a specific lust for cruelty which infects even his passion + of pity and makes it savage. Simple disgust at cruelty is very rare. The + people who turn sick and faint and those who gloat are often alike in the + pains they take to witness executions, floggings, operations or any other + exhibitions of suffering, especially those involving bloodshed, blows, and + laceration. A craze for cruelty can be developed just as a craze for drink + can; and nobody who attempts to ignore cruelty as a possible factor in the + attraction of vivisection and even of antivivisection, or in the credulity + with which we accept its excuses, can be regarded as a scientific + investigator of it. Those who accuse vivisectors of indulging the + well-known passion of cruelty under the cloak of research are therefore + putting forward a strictly scientific psychological hypothesis, which is + also simple, human, obvious, and probable. It may be as wounding to the + personal vanity of the vivisector as Darwin's Origin of Species was to the + people who could not bear to think that they were cousins to the monkeys + (remember Goldsmith's anger when he was told that he could not move his + upper jaw); but science has to consider only the truth of the hypothesis, + and not whether conceited people will like it or not. In vain do the + sentimental champions of vivisection declare themselves the most humane of + men, inflicting suffering only to relieve it, scrupulous in the use of + anesthetics, and void of all passion except the passion of pity for a + disease-ridden world. The really scientific investigator answers that the + question cannot be settled by hysterical protestations, and that if the + vivisectionist rejects deductive reasoning, he had better clear his + character by his own favorite method of experiment. + </p> + <p> + SUGGESTED LABORATORY TESTS OF THE VIVISECTOR'S EMOTIONS + </p> + <p> + Take the hackneyed case of the Italian who tortured mice, ostensibly to + find out about the effects of pain rather less than the nearest dentist + could have told him, and who boasted of the ecstatic sensations (he + actually used the word love) with which he carried out his experiments. Or + the gentleman who starved sixty dogs to death to establish the fact that a + dog deprived of food gets progressively lighter and weaker, becoming + remarkably emaciated, and finally dying: an undoubted truth, but + ascertainable without laboratory experiments by a simple enquiry addressed + to the nearest policeman, or, failing him, to any sane person in Europe. + The Italian is diagnosed as a cruel voluptuary: the dog-starver is passed + over as such a hopeless fool that it is impossible to take any interest in + him. Why not test the diagnosis scientifically? Why not perform a careful + series of experiments on persons under the influence of voluptuous + ecstasy, so as to ascertain its physiological symptoms? Then perform a + second series on persons engaged in mathematical work or machine + designing, so as to ascertain the symptoms of cold scientific activity? + Then note the symptoms of a vivisector performing a cruel experiment; and + compare them with the voluptuary symptoms and the mathematical symptoms? + Such experiments would be quite as interesting and important as any yet + undertaken by the vivisectors. They might open a line of investigation + which would finally make, for instance, the ascertainment of the guilt or + innocence of an accused person a much exacter process than the very + fallible methods of our criminal courts. But instead of proposing such an + investigation, our vivisectors offer us all the pious protestations and + all the huffy recriminations that any common unscientific mortal offers + when he is accused of unworthy conduct. + </p> + <p> + <a name="link2H_4_0023" id="link2H_4_0023"> + <!-- H2 anchor --> </a> + </p> + <div style="height: 4em;"> + <br /><br /><br /><br /> + </div> + <h2> + ROUTINE + </h2> + <p> + Yet most vivisectors would probably come triumphant out of such a series + of experiments, because vivisection is now a routine, like butchering or + hanging or flogging; and many of the men who practise it do so only + because it has been established as part of the profession they have + adopted. Far from enjoying it, they have simply overcome their natural + repugnance and become indifferent to it, as men inevitably become + indifferent to anything they do often enough. It is this dangerous power + of custom that makes it so difficult to convince the common sense of + mankind that any established commercial or professional practice has its + root in passion. Let a routine once spring from passion, and you will + presently find thousands of routineers following it passionlessly for a + livelihood. Thus it always seems strained to speak of the religious + convictions of a clergyman, because nine out of ten clergymen have no + religions convictions: they are ordinary officials carrying on a routine + of baptizing, marrying, and churching; praying, reciting, and preaching; + and, like solicitors or doctors, getting away from their duties with + relief to hunt, to garden, to keep bees, to go into society, and the like. + In the same way many people do cruel and vile things without being in the + least cruel or vile, because the routine to which they have been brought + up is superstitiously cruel and vile. To say that every man who beats his + children and every schoolmaster who flogs a pupil is a conscious debauchee + is absurd: thousands of dull, conscientious people beat their children + conscientiously, because they were beaten themselves and think children + ought to be beaten. The ill-tempered vulgarity that instinctively strikes + at and hurts a thing that annoys it (and all children are annoying), and + the simple stupidity that requires from a child perfection beyond the + reach of the wisest and best adults (perfect truthfulness coupled with + perfect obedience is quite a common condition of leaving a child + unwhipped), produce a good deal of flagellation among people who not only + do not lust after it, but who hit the harder because they are angry at + having to perform an uncomfortable duty. These people will beat merely to + assert their authority, or to carry out what they conceive to be a divine + order on the strength of the precept of Solomon recorded in the Bible, + which carefully adds that Solomon completely spoilt his own son and turned + away from the god of his fathers to the sensuous idolatry in which he + ended his days. + </p> + <p> + In the same way we find men and women practising vivisection as + senselessly as a humane butcher, who adores his fox terrier, will cut a + calf's throat and hang it up by its heels to bleed slowly to death because + it is the custom to eat veal and insist on its being white; or as a German + purveyor nails a goose to a board and stuffs it with food because + fashionable people eat pate de foie gras; or as the crew of a whaler + breaks in on a colony of seals and clubs them to death in wholesale + massacre because ladies want sealskin jackets; or as fanciers blind + singing birds with hot needles, and mutilate the ears and tails of dogs + and horses. Let cruelty or kindness or anything else once become customary + and it will be practised by people to whom it is not at all natural, but + whose rule of life is simply to do only what everybody else does, and who + would lose their employment and starve if they indulged in any + peculiarity. A respectable man will lie daily, in speech and in print, + about the qualities of the article he lives by selling, because it is + customary to do so. He will flog his boy for telling a lie, because it is + customary to do so. He will also flog him for not telling a lie if the boy + tells inconvenient or disrespectful truths, because it is customary to do + so. He will give the same boy a present on his birthday, and buy him a + spade and bucket at the seaside, because it is customary to do so, being + all the time neither particularly mendacious, nor particularly cruel, nor + particularly generous, but simply incapable of ethical judgment or + independent action. + </p> + <p> + Just so do we find a crowd of petty vivisectionists daily committing + atrocities and stupidities, because it is the custom to do so. Vivisection + is customary as part of the routine of preparing lectures in medical + schools. For instance, there are two ways of making the action of the + heart visible to students. One, a barbarous, ignorant, and thoughtless + way, is to stick little flags into a rabbit's heart and let the students + see the flags jump. The other, an elegant, ingenious, well-informed, and + instructive way, is to put a sphygmograph on the student's wrist and let + him see a record of his heart's action traced by a needle on a slip of + smoked paper. But it has become the custom for lecturers to teach from the + rabbit; and the lecturers are not original enough to get out of their + groove. Then there are the demonstrations which are made by cutting up + frogs with scissors. The most humane man, however repugnant the operation + may be to him at first, cannot do it at lecture after lecture for months + without finally—and that very soon—feeling no more for the + frog than if he were cutting up pieces of paper. Such clumsy and lazy ways + of teaching are based on the cheapness of frogs and rabbits. If machines + were as cheap as frogs, engineers would not only be taught the anatomy of + machines and the functions of their parts: they would also have machines + misused and wrecked before them so that they might learn as much as + possible by using their eyes, and as little as possible by using their + brains and imaginations. Thus we have, as part of the routine of teaching, + a routine of vivisection which soon produces complete indifference to it + on the part even of those who are naturally humane. If they pass on from + the routine of lecture preparation, not into general practice, but into + research work, they carry this acquired indifference with them into the + laboratory, where any atrocity is possible, because all atrocities satisfy + curiosity. The routine man is in the majority in his profession always: + consequently the moment his practice is tracked down to its source in + human passion there is a great and quite sincere poohpoohing from himself, + from the mass of the profession, and from the mass of the public, which + sees that the average doctor is much too commonplace and decent a person + to be capable of passionate wickedness of any kind. + </p> + <p> + Here then, we have in vivisection, as in all the other tolerated and + instituted cruelties, this anti-climax: that only a negligible percentage + of those who practise and consequently defend it get any satisfaction out + of it. As in Mr. Galsworthy's play Justice the useless and detestable + torture of solitary imprisonment is shown at its worst without the + introduction of a single cruel person into the drama, so it would be + possible to represent all the torments of vivisection dramatically without + introducing a single vivisector who had not felt sick at his first + experience in the laboratory. Not that this can exonerate any vivisector + from suspicion of enjoying his work (or her work: a good deal of the + vivisection in medical schools is done by women). In every autobiography + which records a real experience of school or prison life, we find that + here and there among the routineers there is to be found the genuine + amateur, the orgiastic flogging schoolmaster or the nagging warder, who + has sought out a cruel profession for the sake of its cruelty. But it is + the genuine routineer who is the bulwark of the practice, because, though + you can excite public fury against a Sade, a Bluebeard, or a Nero, you + cannot rouse any feeling against dull Mr. Smith doing his duty: that is, + doing the usual thing. He is so obviously no better and no worse than + anyone else that it is difficult to conceive that the things he does are + abominable. If you would see public dislike surging up in a moment against + an individual, you must watch one who does something unusual, no matter + how sensible it may be. The name of Jonas Hanway lives as that of a brave + man because he was the first who dared to appear in the streets of this + rainy island with an umbrella. + </p> + <p> + <a name="link2H_4_0024" id="link2H_4_0024"> + <!-- H2 anchor --> </a> + </p> + <div style="height: 4em;"> + <br /><br /><br /><br /> + </div> + <h2> + THE OLD LINE BETWEEN MAN AND BEAST + </h2> + <p> + But there is still a distinction to be clung to by those who dare not tell + themselves the truth about the medical profession because they are so + helplessly dependent on it when death threatens the household. That + distinction is the line that separates the brute from the man in the old + classification. Granted, they will plead, that we are all cruel; yet the + tame-stag-hunter does not hunt men; and the sportsman who lets a leash of + greyhounds loose on a hare would be horrified at the thought of letting + them loose on a human child. The lady who gets her cloak by flaying a + sable does not flay a negro; nor does it ever occur to her that her veal + cutlet might be improved on by a slice of tender baby. + </p> + <p> + Now there was a time when some trust could be placed in this distinction. + The Roman Catholic Church still maintains, with what it must permit me to + call a stupid obstinacy, and in spite of St. Francis and St. Anthony, that + animals have no souls and no rights; so that you cannot sin against an + animal, or against God by anything you may choose to do to an animal. + Resisting the temptation to enter on an argument as to whether you may not + sin against your own soul if you are unjust or cruel to the least of those + whom St. Francis called his little brothers, I have only to point out here + that nothing could be more despicably superstitious in the opinion of a + vivisector than the notion that science recognizes any such step in + evolution as the step from a physical organism to an immortal soul. That + conceit has been taken out of all our men of science, and out of all our + doctors, by the evolutionists; and when it is considered how completely + obsessed biological science has become in our days, not by the full scope + of evolution, but by that particular method of it which has neither sense + nor purpose nor life nor anything human, much less godlike, in it: by the + method, that is, of so-called Natural Selection (meaning no selection at + all, but mere dead accident and luck), the folly of trusting to + vivisectors to hold the human animal any more sacred than the other + animals becomes so clear that it would be waste of time to insist further + on it. As a matter of fact the man who once concedes to the vivisector the + right to put a dog outside the laws of honor and fellowship, concedes to + him also the right to put himself outside them; for he is nothing to the + vivisector but a more highly developed, and consequently more + interesting-to-experiment-on vertebrate than the dog. + </p> + <p> + <a name="link2H_4_0025" id="link2H_4_0025"> + <!-- H2 anchor --> </a> + </p> + <div style="height: 4em;"> + <br /><br /><br /><br /> + </div> + <h2> + VIVISECTING THE HUMAN SUBJECT + </h2> + <p> + I have in my hand a printed and published account by a doctor of how he + tested his remedy for pulmonary tuberculosis, which was to inject a + powerful germicide directly into the circulation by stabbing a vein with a + syringe. He was one of those doctors who are able to command public + sympathy by saying, quite truly, that when they discovered that the + proposed treatment was dangerous, they experimented thenceforth on + themselves. In this case the doctor was devoted enough to carry his + experiments to the point of running serious risks, and actually making + himself very uncomfortable. But he did not begin with himself. His first + experiment was on two hospital patients. On receiving a message from the + hospital to the effect that these two martyrs to therapeutic science had + all but expired in convulsions, he experimented on a rabbit, which + instantly dropped dead. It was then, and not until then, that he began to + experiment on himself, with the germicide modified in the direction + indicated by the experiments made on the two patients and the rabbit. As a + good many people countenance vivisection because they fear that if the + experiments are not made on rabbits they will be made on themselves, it is + worth noting that in this case, where both rabbits and men were equally + available, the men, being, of course, enormously more instructive, and + costing nothing, were experimented on first. Once grant the ethics of the + vivisectionists and you not only sanction the experiment on the human + subject, but make it the first duty of the vivisector. If a guinea pig may + be sacrificed for the sake of the very little that can be learnt from it, + shall not a man be sacrificed for the sake of the great deal that can be + learnt from him? At all events, he is sacrificed, as this typical case + shows. I may add (not that it touches the argument) that the doctor, the + patients, and the rabbit all suffered in vain, as far as the hoped-for + rescue of the race from pulmonary consumption is concerned. + </p> + <p> + <a name="link2H_4_0026" id="link2H_4_0026"> + <!-- H2 anchor --> </a> + </p> + <div style="height: 4em;"> + <br /><br /><br /><br /> + </div> + <h2> + "THE LIE IS A EUROPEAN POWER" + </h2> + <p> + Now at the very time when the lectures describing these experiments were + being circulated in print and discussed eagerly by the medical profession, + the customary denials that patients are experimented on were as loud, as + indignant, as high-minded as ever, in spite of the few intelligent doctors + who point out rightly that all treatments are experiments on the patient. + And this brings us to an obvious but mostly overlooked weakness in the + vivisector's position: that is, his inevitable forfeiture of all claim to + have his word believed. It is hardly to be expected that a man who does + not hesitate to vivisect for the sake of science will hesitate to lie + about it afterwards to protect it from what he deems the ignorant + sentimentality of the laity. When the public conscience stirs uneasily and + threatens suppression, there is never wanting some doctor of eminent + position and high character who will sacrifice himself devotedly to the + cause of science by coming forward to assure the public on his honor that + all experiments on animals are completely painless; although he must know + that the very experiments which first provoked the antivivisection + movement by their atrocity were experiments to ascertain the physiological + effects of the sensation of extreme pain (the much more interesting + physiology of pleasure remains uninvestigated) and that all experiments in + which sensation is a factor are voided by its suppression. Besides, + vivisection may be painless in cases where the experiments are very cruel. + If a person scratches me with a poisoned dagger so gently that I do not + feel the scratch, he has achieved a painless vivisection; but if I + presently die in torment I am not likely to consider that his humility is + amply vindicated by his gentleness. A cobra's bite hurts so little that + the creature is almost, legally speaking, a vivisector who inflicts no + pain. By giving his victims chloroform before biting them he could comply + with the law completely. + </p> + <p> + Here, then, is a pretty deadlock. Public support of vivisection is founded + almost wholly on the assurances of the vivisectors that great public + benefits may be expected from the practice. Not for a moment do I suggest + that such a defence would be valid even if proved. But when the witnesses + begin by alleging that in the cause of science all the customary ethical + obligations (which include the obligation to tell the truth) are + suspended, what weight can any reasonable person give to their testimony? + I would rather swear fifty lies than take an animal which had licked my + hand in good fellowship and torture it. If I did torture the dog, I should + certainly not have the face to turn round and ask how any person there + suspect an honorable man like myself of telling lies. Most sensible and + humane people would, I hope, reply flatly that honorable men do not behave + dishonorably, even to dogs. The murderer who, when asked by the chaplain + whether he had any other crimes to confess, replied indignantly, "What do + you take me for?" reminds us very strongly of the vivisectors who are so + deeply hurt when their evidence is set aside as worthless. + </p> + <p> + <a name="link2H_4_0027" id="link2H_4_0027"> + <!-- H2 anchor --> </a> + </p> + <div style="height: 4em;"> + <br /><br /><br /><br /> + </div> + <h2> + AN ARGUMENT WHICH WOULD DEFEND ANY CRIME + </h2> + <p> + The Achilles heel of vivisection, however, is not to be found in the pain + it causes, but in the line of argument by which it is justified. The + medical code regarding it is simply criminal anarchism at its very worst. + Indeed no criminal has yet had the impudence to argue as every vivisector + argues. No burglar contends that as it is admittedly important to have + money to spend, and as the object of burglary is to provide the burglar + with money to spend, and as in many instances it has achieved this object, + therefore the burglar is a public benefactor and the police are ignorant + sentimentalists. No highway robber has yet harrowed us with denunciations + of the puling moralist who allows his child to suffer all the evils of + poverty because certain faddists think it dishonest to garotte an + alderman. Thieves and assassins understand quite well that there are paths + of acquisition, even of the best things, that are barred to all men of + honor. Again, has the silliest burglar ever pretended that to put a stop + to burglary is to put a stop to industry? All the vivisections that have + been performed since the world began have produced nothing so important as + the innocent and honorable discovery of radiography; and one of the + reasons why radiography was not discovered sooner was that the men whose + business it was to discover new clinical methods were coarsening and + stupefying themselves with the sensual villanies and cutthroat's + casuistries of vivisection. The law of the conservation of energy holds + good in physiology as in other things: every vivisector is a deserter from + the army of honorable investigators. But the vivisector does not see this. + He not only calls his methods scientific: he contends that there are no + other scientific methods. When you express your natural loathing for his + cruelty and your natural contempt for his stupidity, he imagines that you + are attacking science. Yet he has no inkling of the method and temper of + science. The point at issue being plainly whether he is a rascal or not, + he not only insists that the real point is whether some hotheaded + antivivisectionist is a liar (which he proves by ridiculously unscientific + assumptions as to the degree of accuracy attainable in human statement), + but never dreams of offering any scientific evidence by his own methods. + </p> + <p> + There are many paths to knowledge already discovered; and no enlightened + man doubts that there are many more waiting to be discovered. Indeed, all + paths lead to knowledge; because even the vilest and stupidest action + teaches us something about vileness and stupidity, and may accidentally + teach us a good deal more: for instance, a cutthroat learns (and perhaps + teaches) the anatomy of the carotid artery and jugular vein; and there can + be no question that the burning of St. Joan of Arc must have been a most + instructive and interesting experiment to a good observer, and could have + been made more so if it had been carried out by skilled physiologists + under laboratory conditions. The earthquake in San Francisco proved + invaluable as an experiment in the stability of giant steel buildings; and + the ramming of the Victoria by the Camperdown settled doubtful points of + the greatest importance in naval warfare. According to vivisectionist + logic our builders would be justified in producing artificial earthquakes + with dynamite, and our admirals in contriving catastrophes at naval + manoeuvres, in order to follow up the line of research thus accidentally + discovered. + </p> + <p> + The truth is, if the acquisition of knowledge justifies every sort of + conduct, it justifies any sort of conduct, from the illumination of Nero's + feasts by burning human beings alive (another interesting experiment) to + the simplest act of kindness. And in the light of that truth it is clear + that the exemption of the pursuit of knowledge from the laws of honor is + the most hideous conceivable enlargement of anarchy; worse, by far, than + an exemption of the pursuit of money or political power, since there can + hardly be attained without some regard for at least the appearances of + human welfare, whereas a curious devil might destroy the whole race in + torment, acquiring knowledge all the time from his highly interesting + experiment. There is more danger in one respectable scientist + countenancing such a monstrous claim than in fifty assassins or + dynamitards. The man who makes it is ethically imbecile; and whoever + imagines that it is a scientific claim has not the faintest conception of + what science means. The paths to knowledge are countless. One of these + paths is a path through darkness, secrecy, and cruelty. When a man + deliberately turns from all other paths and goes down that one, it is + scientific to infer that what attracts him is not knowledge, since there + are other paths to that, but cruelty. With so strong and scientific a case + against him, it is childish for him to stand on his honor and reputation + and high character and the credit of a noble profession and so forth: he + must clear himself either by reason or by experiment, unless he boldly + contends that evolution has retained a passion of cruelty in man just + because it is indispensable to the fulness of his knowledge. + </p> + <p> + <a name="link2H_4_0028" id="link2H_4_0028"> + <!-- H2 anchor --> </a> + </p> + <div style="height: 4em;"> + <br /><br /><br /><br /> + </div> + <h2> + THOU ART THE MAN + </h2> + <p> + I shall not be at all surprised if what I have written above has induced + in sympathetic readers a transport of virtuous indignation at the expense + of the medical profession. I shall not damp so creditable and salutary a + sentiment; but I must point out that the guilt is shared by all of us. It + is not in his capacity of healer and man of science that the doctor + vivisects or defends vivisection, but in his entirely vulgar lay capacity. + He is made of the same clay as the ignorant, shallow, credulous, + half-miseducated, pecuniarily anxious people who call him in when they + have tried in vain every bottle and every pill the advertizing druggist + can persuade them to buy. The real remedy for vivisection is the remedy + for all the mischief that the medical profession and all the other + professions are doing: namely, more knowledge. The juries which send the + poor Peculiars to prison, and give vivisectionists heavy damages against + humane persons who accuse them of cruelty; the editors and councillors and + student-led mobs who are striving to make Vivisection one of the + watchwords of our civilization, are not doctors: they are the British + public, all so afraid to die that they will cling frantically to any idol + which promises to cure all their diseases, and crucify anyone who tells + them that they must not only die when their time comes, but die like + gentlemen. In their paroxysms of cowardice and selfishness they force the + doctors to humor their folly and ignorance. How complete and inconsiderate + their ignorance is can only be realized by those who have some knowledge + of vital statistics, and of the illusions which beset Public Health + legislation. + </p> + <p> + <a name="link2H_4_0029" id="link2H_4_0029"> + <!-- H2 anchor --> </a> + </p> + <div style="height: 4em;"> + <br /><br /><br /><br /> + </div> + <h2> + WHAT THE PUBLIC WANTS AND WILL NOT GET + </h2> + <p> + The demands of this poor public are not reasonable, but they are quite + simple. It dreads disease and desires to be protected against it. But it + is poor and wants to be protected cheaply. Scientific measures are too + hard to understand, too costly, too clearly tending towards a rise in the + rates and more public interference with the insanitary, because + insufficiently financed, private house. What the public wants, therefore, + is a cheap magic charm to prevent, and a cheap pill or potion to cure, all + disease. It forces all such charms on the doctors. + </p> + <p> + <a name="link2H_4_0030" id="link2H_4_0030"> + <!-- H2 anchor --> </a> + </p> + <div style="height: 4em;"> + <br /><br /><br /><br /> + </div> + <h2> + THE VACCINATION CRAZE + </h2> + <p> + Thus it was really the public and not the medical profession that took up + vaccination with irresistible faith, sweeping the invention out of + Jenner's hand and establishing it in a form which he himself repudiated. + Jenner was not a man of science; but he was not a fool; and when he found + that people who had suffered from cowpox either by contagion in the + milking shed or by vaccination, were not, as he had supposed, immune from + smallpox, he ascribed the cases of immunity which had formerly misled him + to a disease of the horse, which, perhaps because we do not drink its milk + and eat its flesh, is kept at a greater distance in our imagination than + our foster mother the cow. At all events, the public, which had been + boundlessly credulous about the cow, would not have the horse on any + terms; and to this day the law which prescribes Jennerian vaccination is + carried out with an anti-Jennerian inoculation because the public would + have it so in spite of Jenner. All the grossest lies and superstitions + which have disgraced the vaccination craze were taught to the doctors by + the public. It was not the doctors who first began to declare that all our + old men remember the time when almost every face they saw in the street + was horribly pitted with smallpox, and that all this disfigurement has + vanished since the introduction of vaccination. Jenner himself alluded to + this imaginary phenomenon before the introduction of vaccination, and + attributed it to the older practice of smallpox inoculation, by which + Voltaire, Catherine II. and Lady Mary Wortley Montagu so confidently + expected to see the disease made harmless. It was not Jenner who set + people declaring that smallpox, if not abolished by vaccination, had at + least been made much milder: on the contrary, he recorded a + pre-vaccination epidemic in which none of the persons attacked went to bed + or considered themselves as seriously ill. Neither Jenner, nor any other + doctor ever, as far as I know, inculcated the popular notion that + everybody got smallpox as a matter of course before vaccination was + invented. That doctors get infected with these delusions, and are in their + unprofessional capacity as members of the public subject to them like + other men, is true; but if we had to decide whether vaccination was first + forced on the public by the doctors or on the doctors by the public, we + should have to decide against the public. + </p> + <p> + <a name="link2H_4_0031" id="link2H_4_0031"> + <!-- H2 anchor --> </a> + </p> + <div style="height: 4em;"> + <br /><br /><br /><br /> + </div> + <h2> + STATISTICAL ILLUSIONS + </h2> + <p> + Public ignorance of the laws of evidence and of statistics can hardly be + exaggerated. There may be a doctor here and there who in dealing with the + statistics of disease has taken at least the first step towards sanity by + grasping the fact that as an attack of even the commonest disease is an + exceptional event, apparently over-whelming statistical evidence in favor + of any prophylactic can be produced by persuading the public that + everybody caught the disease formerly. Thus if a disease is one which + normally attacks fifteen per cent of the population, and if the effect of + a prophylactic is actually to increase the proportion to twenty per cent, + the publication of this figure of twenty per cent will convince the public + that the prophylactic has reduced the percentage by eighty per cent + instead of increasing it by five, because the public, left to itself and + to the old gentlemen who are always ready to remember, on every possible + subject, that things used to be much worse than they are now (such old + gentlemen greatly outnumber the laudatores tempori acti), will assume that + the former percentage was about 100. The vogue of the Pasteur treatment of + hydrophobia, for instance, was due to the assumption by the public that + every person bitten by a rabid dog necessarily got hydrophobia. I myself + heard hydrophobia discussed in my youth by doctors in Dublin before a + Pasteur Institute existed, the subject having been brought forward there + by the scepticism of an eminent surgeon as to whether hydrophobia is + really a specific disease or only ordinary tetanus induced (as tetanus was + then supposed to be induced) by a lacerated wound. There were no + statistics available as to the proportion of dog bites that ended in + hydrophobia; but nobody ever guessed that the cases could be more than two + or three per cent of the bites. On me, therefore, the results published by + the Pasteur Institute produced no such effect as they did on the ordinary + man who thinks that the bite of a mad dog means certain hydrophobia. It + seemed to me that the proportion of deaths among the cases treated at the + Institute was rather higher, if anything, than might have been expected + had there been no Institute in existence. But to the public every Pasteur + patient who did not die was miraculously saved from an agonizing death by + the beneficent white magic of that most trusty of all wizards, the man of + science. + </p> + <p> + Even trained statisticians often fail to appreciate the extent to which + statistics are vitiated by the unrecorded assumptions of their + interpreters. Their attention is too much occupied with the cruder tricks + of those who make a corrupt use of statistics for advertizing purposes. + There is, for example, the percentage dodge. In some hamlet, barely large + enough to have a name, two people are attacked during a smallpox epidemic. + One dies: the other recovers. One has vaccination marks: the other has + none. Immediately either the vaccinists or the antivaccinists publish the + triumphant news that at such and such a place not a single vaccinated + person died of smallpox whilst 100 per cent of the unvaccinated perished + miserably; or, as the case may be, that 100 per cent of the unvaccinated + recovered whilst the vaccinated succumbed to the last man. Or, to take + another common instance, comparisons which are really comparisons between + two social classes with different standards of nutrition and education are + palmed off as comparisons between the results of a certain medical + treatment and its neglect. Thus it is easy to prove that the wearing of + tall hats and the carrying of umbrellas enlarges the chest, prolongs life, + and confers comparative immunity from disease; for the statistics show + that the classes which use these articles are bigger, healthier, and live + longer than the class which never dreams of possessing such things. It + does not take much perspicacity to see that what really makes this + difference is not the tall hat and the umbrella, but the wealth and + nourishment of which they are evidence, and that a gold watch or + membership of a club in Pall Mall might be proved in the same way to have + the like sovereign virtues. A university degree, a daily bath, the owning + of thirty pairs of trousers, a knowledge of Wagner's music, a pew in + church, anything, in short, that implies more means and better nurture + than the mass of laborers enjoy, can be statistically palmed off as a + magic-spell conferring all sorts of privileges. + </p> + <p> + In the case of a prophylactic enforced by law, this illusion is + intensified grotesquely, because only vagrants can evade it. Now vagrants + have little power of resisting any disease: their death rate and their + case-mortality rate is always high relatively to that of respectable folk. + Nothing is easier, therefore, than to prove that compliance with any + public regulation produces the most gratifying results. It would be + equally easy even if the regulation actually raised the death-rate, + provided it did not raise it sufficiently to make the average householder, + who cannot evade regulations, die as early as the average vagrant who can. + </p> + <p> + <a name="link2H_4_0032" id="link2H_4_0032"> + <!-- H2 anchor --> </a> + </p> + <div style="height: 4em;"> + <br /><br /><br /><br /> + </div> + <h2> + THE SURPRISES OF ATTENTION AND NEGLECT + </h2> + <p> + There is another statistical illusion which is independent of class + differences. A common complaint of houseowners is that the Public Health + Authorities frequently compel them to instal costly sanitary appliances + which are condemned a few years later as dangerous to health, and + forbidden under penalties. Yet these discarded mistakes are always made in + the first instance on the strength of a demonstration that their + introduction has reduced the death-rate. The explanation is simple. + Suppose a law were made that every child in the nation should be compelled + to drink a pint of brandy per month, but that the brandy must be + administered only when the child was in good health, with its digestion + and so forth working normally, and its teeth either naturally or + artificially sound. Probably the result would be an immediate and + startling reduction in child mortality, leading to further legislation + increasing the quantity of brandy to a gallon. Not until the brandy craze + had been carried to a point at which the direct harm done by it would + outweigh the incidental good, would an anti-brandy party be listened to. + That incidental good would be the substitution of attention to the general + health of children for the neglect which is now the rule so long as the + child is not actually too sick to run about and play as usual. Even if + this attention were confined to the children's teeth, there would be an + improvement which it would take a good deal of brandy to cancel. + </p> + <p> + This imaginary case explains the actual case of the sanitary appliances + which our local sanitary authorities prescribe today and condemn tomorrow. + No sanitary contrivance which the mind of even the very worst plumber can + devize could be as disastrous as that total neglect for long periods which + gets avenged by pestilences that sweep through whole continents, like the + black death and the cholera. If it were proposed at this time of day to + discharge all the sewage of London crude and untreated into the Thames, + instead of carrying it, after elaborate treatment, far out into the North + Sea, there would be a shriek of horror from all our experts. Yet if + Cromwell had done that instead of doing nothing, there would probably have + been no Great Plague of London. When the Local Health Authority forces + every householder to have his sanitary arrangements thought about and + attended to by somebody whose special business it is to attend to such + things, then it matters not how erroneous or even directly mischievous may + be the specific measures taken: the net result at first is sure to be an + improvement. Not until attention has been effectually substituted for + neglect as the general rule, will the statistics begin to show the merits + of the particular methods of attention adopted. And as we are far from + having arrived at this stage, being as to health legislation only at the + beginning of things, we have practically no evidence yet as to the value + of methods. Simple and obvious as this is, nobody seems as yet to discount + the effect of substituting attention for neglect in drawing conclusions + from health statistics. Everything is put to the credit of the particular + method employed, although it may quite possibly be raising the death rate + by five per thousand whilst the attention incidental to it is reducing the + death rate fifteen per thousand. The net gain of ten per thousand is + credited to the method, and made the excuse for enforcing more of it. + </p> + <p> + <a name="link2H_4_0033" id="link2H_4_0033"> + <!-- H2 anchor --> </a> + </p> + <div style="height: 4em;"> + <br /><br /><br /><br /> + </div> + <h2> + STEALING CREDIT FROM CIVILIZATION + </h2> + <p> + There is yet another way in which specifics which have no merits at all, + either direct or incidental, may be brought into high repute by + statistics. For a century past civilization has been cleaning away the + conditions which favor bacterial fevers. Typhus, once rife, has vanished: + plague and cholera have been stopped at our frontiers by a sanitary + blockade. We still have epidemics of smallpox and typhoid; and diphtheria + and scarlet fever are endemic in the slums. Measles, which in my childhood + was not regarded as a dangerous disease, has now become so mortal that + notices are posted publicly urging parents to take it seriously. But even + in these cases the contrast between the death and recovery rates in the + rich districts and in the poor ones has led to the general conviction + among experts that bacterial diseases are preventable; and they already + are to a large extent prevented. The dangers of infection and the way to + avoid it are better understood than they used to be. It is barely twenty + years since people exposed themselves recklessly to the infection of + consumption and pneumonia in the belief that these diseases were not + "catching." Nowadays the troubles of consumptive patients are greatly + increased by the growing disposition to treat them as lepers. No doubt + there is a good deal of ignorant exaggeration and cowardly refusal to face + a human and necessary share of the risk. That has always been the case. We + now know that the medieval horror of leprosy was out of all proportion to + the danger of infection, and was accompanied by apparent blindness to the + infectiousness of smallpox, which has since been worked up by our disease + terrorists into the position formerly held by leprosy. But the scare of + infection, though it sets even doctors talking as if the only really + scientific thing to do with a fever patient is to throw him into the + nearest ditch and pump carbolic acid on him from a safe distance until he + is ready to be cremated on the spot, has led to much greater care and + cleanliness. And the net result has been a series of victories over + disease. + </p> + <p> + Now let us suppose that in the early nineteenth century somebody had come + forward with a theory that typhus fever always begins in the top joint of + the little finger; and that if this joint be amputated immediately after + birth, typhus fever will disappear. Had such a suggestion been adopted, + the theory would have been triumphantly confirmed; for as a matter of + fact, typhus fever has disappeared. On the other hand cancer and madness + have increased (statistically) to an appalling extent. The opponents of + the little finger theory would therefore be pretty sure to allege that the + amputations were spreading cancer and lunacy. The vaccination controversy + is full of such contentions. So is the controversy as to the docking of + horses' tails and the cropping of dogs' ears. So is the less widely known + controversy as to circumcision and the declaring certain kinds of flesh + unclean by the Jews. To advertize any remedy or operation, you have only + to pick out all the most reassuring advances made by civilization, and + boldly present the two in the relation of cause and effect: the public + will swallow the fallacy without a wry face. It has no idea of the need + for what is called a control experiment. In Shakespear's time and for long + after it, mummy was a favorite medicament. You took a pinch of the dust of + a dead Egyptian in a pint of the hottest water you could bear to drink; + and it did you a great deal of good. This, you thought, proved what a + sovereign healer mummy was. But if you had tried the control experiment of + taking the hot water without the mummy, you might have found the effect + exactly the same, and that any hot drink would have done as well. + </p> + <p> + <a name="link2H_4_0034" id="link2H_4_0034"> + <!-- H2 anchor --> </a> + </p> + <div style="height: 4em;"> + <br /><br /><br /><br /> + </div> + <h2> + BIOMETRIKA + </h2> + <p> + Another difficulty about statistics is the technical difficulty of + calculation. Before you can even make a mistake in drawing your conclusion + from the correlations established by your statistics you must ascertain + the correlations. When I turn over the pages of Biometrika, a quarterly + journal in which is recorded the work done in the field of biological + statistics by Professor Karl Pearson and his colleagues, I am out of my + depth at the first line, because mathematics are to me only a concept: I + never used a logarithm in my life, and could not undertake to extract the + square root of four without misgiving. I am therefore unable to deny that + the statistical ascertainment of the correlations between one thing and + another must be a very complicated and difficult technical business, not + to be tackled successfully except by high mathematicians; and I cannot + resist Professor Karl Pearson's immense contempt for, and indignant sense + of grave social danger in, the unskilled guesses of the ordinary + sociologist. + </p> + <p> + Now the man in the street knows nothing of Biometrika: all he knows is + that "you can prove anything by figures," though he forgets this the + moment figures are used to prove anything he wants to believe. If he did + take in Biometrika he would probably become abjectly credulous as to all + the conclusions drawn in it from the correlations so learnedly worked out; + though the mathematician whose correlations would fill a Newton with + admiration may, in collecting and accepting data and drawing conclusions + from them, fall into quite crude errors by just such popular oversights as + I have been describing. + </p> + <p> + <a name="link2H_4_0035" id="link2H_4_0035"> + <!-- H2 anchor --> </a> + </p> + <div style="height: 4em;"> + <br /><br /><br /><br /> + </div> + <h2> + PATIENT-MADE THERAPEUTICS + </h2> + <p> + To all these blunders and ignorances doctors are no less subject than the + rest of us. They are not trained in the use of evidence, nor in + biometrics, nor in the psychology of human credulity, nor in the incidence + of economic pressure. Further, they must believe, on the whole, what their + patients believe, just as they must wear the sort of hat their patients + wear. The doctor may lay down the law despotically enough to the patient + at points where the patient's mind is simply blank; but when the patient + has a prejudice the doctor must either keep it in countenance or lose his + patient. If people are persuaded that night air is dangerous to health and + that fresh air makes them catch cold it will not be possible for a doctor + to make his living in private practice if he prescribes ventilation. We + have to go back no further than the days of The Pickwick Papers to find + ourselves in a world where people slept in four-post beds with curtains + drawn closely round to exclude as much air as possible. Had Mr. Pickwick's + doctor told him that he would be much healthier if he slept on a camp bed + by an open window, Mr. Pickwick would have regarded him as a crank and + called in another doctor. Had he gone on to forbid Mr. Pickwick to drink + brandy and water whenever he felt chilly, and assured him that if he were + deprived of meat or salt for a whole year, he would not only not die, but + would be none the worse, Mr. Pickwick would have fled from his presence as + from that of a dangerous madman. And in these matters the doctor cannot + cheat his patient. If he has no faith in drugs or vaccination, and the + patient has, he can cheat him with colored water and pass his lancet + through the flame of a spirit lamp before scratching his arm. But he + cannot make him change his daily habits without knowing it. + </p> + <p> + <a name="link2H_4_0036" id="link2H_4_0036"> + <!-- H2 anchor --> </a> + </p> + <div style="height: 4em;"> + <br /><br /><br /><br /> + </div> + <h2> + THE REFORMS ALSO COME FROM THE LAITY + </h2> + <p> + In the main, then, the doctor learns that if he gets ahead of the + superstitions of his patients he is a ruined man; and the result is that + he instinctively takes care not to get ahead of them. That is why all the + changes come from the laity. It was not until an agitation had been + conducted for many years by laymen, including quacks and faddists of all + kinds, that the public was sufficiently impressed to make it possible for + the doctors to open their minds and their mouths on the subject of fresh + air, cold water, temperance, and the rest of the new fashions in hygiene. + At present the tables have been turned on many old prejudices. Plenty of + our most popular elderly doctors believe that cold tubs in the morning are + unnatural, exhausting, and rheumatic; that fresh air is a fad and that + everybody is the better for a glass or two of port wine every day; but + they no longer dare say as much until they know exactly where they are; + for many very desirable patients in country houses have lately been + persuaded that their first duty is to get up at six in the morning and + begin the day by taking a walk barefoot through the dewy grass. He who + shows the least scepticism as to this practice is at once suspected of + being "an old-fashioned doctor," and dismissed to make room for a younger + man. + </p> + <p> + In short, private medical practice is governed not by science but by + supply and demand; and however scientific a treatment may be, it cannot + hold its place in the market if there is no demand for it; nor can the + grossest quackery be kept off the market if there is a demand for it. + </p> + <p> + <a name="link2H_4_0037" id="link2H_4_0037"> + <!-- H2 anchor --> </a> + </p> + <div style="height: 4em;"> + <br /><br /><br /><br /> + </div> + <h2> + FASHIONS AND EPIDEMICS + </h2> + <p> + A demand, however, can be inculcated. This is thoroughly understood by + fashionable tradesmen, who find no difficulty in persuading their + customers to renew articles that are not worn out and to buy things they + do not want. By making doctors tradesmen, we compel them to learn the + tricks of trade; consequently we find that the fashions of the year + include treatments, operations, and particular drugs, as well as hats, + sleeves, ballads, and games. Tonsils, vermiform appendices, uvulas, even + ovaries are sacrificed because it is the fashion to get them cut out, and + because the operations are highly profitable. The psychology of fashion + becomes a pathology; for the cases have every air of being genuine: + fashions, after all, are only induced epidemics, proving that epidemics + can be induced by tradesmen, and therefore by doctors. + </p> + <p> + <a name="link2H_4_0038" id="link2H_4_0038"> + <!-- H2 anchor --> </a> + </p> + <div style="height: 4em;"> + <br /><br /><br /><br /> + </div> + <h2> + THE DOCTOR'S VIRTUES + </h2> + <p> + It will be admitted that this is a pretty bad state of things. And the + melodramatic instinct of the public, always demanding; that every wrong + shall have, not its remedy, but its villain to be hissed, will blame, not + its own apathy, superstition, and ignorance, but the depravity of the + doctors. Nothing could be more unjust or mischievous. Doctors, if no + better than other men, are certainly no worse. I was reproached during the + performances of The Doctor's Dilemma at the Court Theatre in 1907 because + I made the artist a rascal, the journalist an illiterate incapable, and + all the doctors "angels." But I did not go beyond the warrant of my own + experience. It has been my luck to have doctors among my friends for + nearly forty years past (all perfectly aware of my freedom from the usual + credulity as to the miraculous powers and knowledge attributed to them); + and though I know that there are medical blackguards as well as military, + legal, and clerical blackguards (one soon finds that out when one is + privileged to hear doctors talking shop among themselves), the fact that I + was no more at a loss for private medical advice and attendance when I had + not a penny in my pocket than I was later on when I could afford fees on + the highest scale, has made it impossible for me to share that hostility + to the doctor as a man which exists and is growing as an inevitable result + of the present condition of medical practice. Not that the interest in + disease and aberrations which turns some men and women to medicine and + surgery is not sometimes as morbid as the interest in misery and vice + which turns some others to philanthropy and "rescue work." But the true + doctor is inspired by a hatred of ill-health, and a divine impatience of + any waste of vital forces. Unless a man is led to medicine or surgery + through a very exceptional technical aptitude, or because doctoring is a + family tradition, or because he regards it unintelligently as a lucrative + and gentlemanly profession, his motives in choosing the career of a healer + are clearly generous. However actual practice may disillusion and corrupt + him, his selection in the first instance is not a selection of a base + character. + </p> + <p> + <a name="link2H_4_0039" id="link2H_4_0039"> + <!-- H2 anchor --> </a> + </p> + <div style="height: 4em;"> + <br /><br /><br /><br /> + </div> + <h2> + THE DOCTOR'S HARDSHIPS + </h2> + <p> + A review of the counts in the indictment I have brought against private + medical practice will show that they arise out of the doctor's position as + a competitive private tradesman: that is, out of his poverty and + dependence. And it should be borne in mind that doctors are expected to + treat other people specially well whilst themselves submitting to + specially inconsiderate treatment. The butcher and baker are not expected + to feed the hungry unless the hungry can pay; but a doctor who allows a + fellow-creature to suffer or perish without aid is regarded as a monster. + Even if we must dismiss hospital service as really venal, the fact remains + that most doctors do a good deal of gratuitous work in private practice + all through their careers. And in his paid work the doctor is on a + different footing to the tradesman. Although the articles he sells, advice + and treatment, are the same for all classes, his fees have to be graduated + like the income tax. The successful fashionable doctor may weed his poorer + patients out from time to time, and finally use the College of Physicians + to place it out of his own power to accept low fees; but the ordinary + general practitioner never makes out his bills without considering the + taxable capacity of his patients. + </p> + <p> + Then there is the disregard of his own health and comfort which results + from the fact that he is, by the nature of his work, an emergency man. We + are polite and considerate to the doctor when there is nothing the matter, + and we meet him as a friend or entertain him as a guest; but when the baby + is suffering from croup, or its mother has a temperature of 104 degrees, + or its grandfather has broken his leg, nobody thinks of the doctor except + as a healer and saviour. He may be hungry, weary, sleepy, run down by + several successive nights disturbed by that instrument of torture, the + night bell; but who ever thinks of this in the face of sudden sickness or + accident? We think no more of the condition of a doctor attending a case + than of the condition of a fireman at a fire. In other occupations + night-work is specially recognized and provided for. The worker sleeps all + day; has his breakfast in the evening; his lunch or dinner at midnight; + his dinner or supper before going to bed in the morning; and he changes to + day-work if he cannot stand night-work. But a doctor is expected to work + day and night. In practices which consist largely of workmen's clubs, and + in which the patients are therefore taken on wholesale terms and very + numerous, the unfortunate assistant, or the principal if he has no + assistant, often does not undress, knowing that he will be called up + before he has snatched an hour's sleep. To the strain of such inhuman + conditions must be added the constant risk of infection. One wonders why + the impatient doctors do not become savage and unmanageable, and the + patient ones imbecile. Perhaps they do, to some extent. And the pay is + wretched, and so uncertain that refusal to attend without payment in + advance becomes often a necessary measure of self-defence, whilst the + County Court has long ago put an end to the tradition that the doctor's + fee is an honorarium. Even the most eminent physicians, as such + biographies as those of Paget show, are sometimes miserably, inhumanly + poor until they are past their prime. In short, the doctor needs our help + for the moment much more than we often need his. The ridicule of Moliere, + the death of a well-informed and clever writer like the late Harold + Frederic in the hands of Christian Scientists (a sort of sealing with his + blood of the contemptuous disbelief in and dislike of doctors he had + bitterly expressed in his books), the scathing and quite justifiable + exposure of medical practice in the novel by Mr. Maarten Maartens entitled + The New Religion: all these trouble the doctor very little, and are in any + case well set off by the popularity of Sir Luke Fildes' famous picture, + and by the verdicts in which juries from time to time express their + conviction that the doctor can do no wrong. The real woes of the doctor + are the shabby coat, the wolf at the door, the tyranny of ignorant + patients, the work-day of 24 hours, and the uselessness of honestly + prescribing what most of the patients really need: that is, not medicine, + but money. + </p> + <p> + <a name="link2H_4_0040" id="link2H_4_0040"> + <!-- H2 anchor --> </a> + </p> + <div style="height: 4em;"> + <br /><br /><br /><br /> + </div> + <h2> + THE PUBLIC DOCTOR + </h2> + <h3> + What then is to be done? + </h3> + <p> + Fortunately we have not to begin absolutely from the beginning: we already + have, in the Medical Officer of Health, a sort of doctor who is free from + the worst hardships, and consequently from the worst vices, of the private + practitioner. His position depends, not on the number of people who are + ill, and whom he can keep ill, but on the number of people who are well. + He is judged, as all doctors and treatments should be judged, by the vital + statistics of his district. When the death rate goes up his credit goes + down. As every increase in his salary depends on the issue of a public + debate as to the health of the constituency under his charge, he has every + inducement to strive towards the ideal of a clean bill of health. He has a + safe, dignified, responsible, independent position based wholly on the + public health; whereas the private practitioner has a precarious, + shabby-genteel, irresponsible, servile position, based wholly on the + prevalence of illness. + </p> + <p> + It is true, there are grave scandals in the public medical service. The + public doctor may be also a private practitioner eking out his earnings by + giving a little time to public work for a mean payment. There are cases in + which the position is one which no successful practitioner will accept, + and where, therefore, incapables or drunkards get automatically selected + for the post, faute de mieux; but even in these cases the doctor is less + disastrous in his public capacity than in his private one: besides, the + conditions which produce these bad cases are doomed, as the evil is now + recognized and understood. A popular but unstable remedy is to enable + local authorities, when they are too small to require the undivided time + of such men as the Medical Officers of our great municipalities, to + combine for public health purposes so that each may share the services of + a highly paid official of the best class; but the right remedy is a larger + area as the sanitary unit. + </p> + <p> + <a name="link2H_4_0041" id="link2H_4_0041"> + <!-- H2 anchor --> </a> + </p> + <div style="height: 4em;"> + <br /><br /><br /><br /> + </div> + <h2> + MEDICAL ORGANIZATION + </h2> + <p> + Another advantage of public medical work is that it admits of + organization, and consequently of the distribution of the work in such a + manner as to avoid wasting the time of highly qualified experts on trivial + jobs. The individualism of private practice leads to an appalling waste of + time on trifles. Men whose dexterity as operators or almost divinatory + skill in diagnosis are constantly needed for difficult cases, are + poulticing whitlows, vaccinating, changing unimportant dressings, + prescribing ether drams for ladies with timid leanings towards dipsomania, + and generally wasting their time in the pursuit of private fees. In no + other profession is the practitioner expected to do all the work involved + in it from the first day of his professional career to the last as the + doctor is. The judge passes sentence of death; but he is not expected to + hang the criminal with his own hands, as he would be if the legal + profession were as unorganized as the medical. The bishop is not expected + to blow the organ or wash the baby he baptizes. The general is not asked + to plan a campaign or conduct a battle at half-past twelve and to play the + drum at half-past two. Even if they were, things would still not be as bad + as in the medical profession; for in it not only is the first-class man + set to do third-class work, but, what is much more terrifying, the + third-class man is expected to do first-class work. Every general + practitioner is supposed to be capable of the whole range of medical and + surgical work at a moment's notice; and the country doctor, who has not a + specialist nor a crack consultant at the end of his telephone, often has + to tackle without hesitation cases which no sane practitioner in a town + would take in hand without assistance. No doubt this develops the + resourcefulness of the country doctor, and makes him a more capable man + than his suburban colleague; but it cannot develop the second-class man + into a first-class one. If the practice of law not only led to a judge + having to hang, but the hangman to judge, or if in the army matters were + so arranged that it would be possible for the drummer boy to be in command + at Waterloo whilst the Duke of Wellington was playing the drum in + Brussels, we should not be consoled by the reflection that our hangmen + were thereby made a little more judicial-minded, and our drummers more + responsible, than in foreign countries where the legal and military + professions recognized the advantages of division of labor. + </p> + <p> + Under such conditions no statistics as to the graduation of professional + ability among doctors are available. Assuming that doctors are normal men + and not magicians (and it is unfortunately very hard to persuade people to + admit so much and thereby destroy the romance of doctoring) we may guess + that the medical profession, like the other professions, consists of a + small percentage of highly gifted persons at one end, and a small + percentage of altogether disastrous duffers at the other. Between these + extremes comes the main body of doctors (also, of course, with a weak and + a strong end) who can be trusted to work under regulations with more or + less aid from above according to the gravity of the case. Or, to put it in + terms of the cases, there are cases that present no difficulties, and can + be dealt with by a nurse or student at one end of the scale, and cases + that require watching and handling by the very highest existing skill at + the other; whilst between come the great mass of cases which need visits + from the doctor of ordinary ability and from the chiefs of the profession + in the proportion of, say, seven to none, seven to one, three to one, one + to one, or, for a day or two, none to one. Such a service is organized at + present only in hospitals; though in large towns the practice of calling + in the consultant acts, to some extent, as a substitute for it. But in the + latter case it is quite unregulated except by professional etiquet, which, + as we have seen, has for its object, not the health of the patient or of + the community at large, but the protection of the doctor's livelihood and + the concealment of his errors. And as the consultant is an expensive + luxury, he is a last resource rather, as he should be, than a matter of + course, in all cases where the general practitioner is not equal to the + occasion: a predicament in which a very capable man may find himself at + any time through the cropping up of a case of which he has had no clinical + experience. + </p> + <p> + <a name="link2H_4_0042" id="link2H_4_0042"> + <!-- H2 anchor --> </a> + </p> + <div style="height: 4em;"> + <br /><br /><br /><br /> + </div> + <h2> + THE SOCIAL SOLUTION OF THE MEDICAL PROBLEM + </h2> + <p> + The social solution of the medical problem, then, depends on that large, + slowly advancing, pettishly resisted integration of society called + generally Socialism. Until the medical profession becomes a body of men + trained and paid by the country to keep the country in health it will + remain what it is at present: a conspiracy to exploit popular credulity + and human suffering. Already our M.O.H.s (Medical Officers of Health) are + in the new position: what is lacking is appreciation of the change, not + only by the public but by the private doctors. For, as we have seen, when + one of the first-rate posts becomes vacant in one of the great cities, and + all the leading M.O.H.s compete for it, they must appeal to the good + health of the cities of which they have been in charge, and not to the + size of the incomes the local private doctors are making out of the + ill-health of their patients. If a competitor can prove that he has + utterly ruined every sort of medical private practice in a large city + except obstetric practice and the surgery of accidents, his claims are + irresistible; and this is the ideal at which every M.O.H. should aim. But + the profession at large should none the less welcome him and set its house + in order for the social change which will finally be its own salvation. + For the M.O.H. as we know him is only the beginning of that army of Public + Hygiene which will presently take the place in general interest and honor + now occupied by our military and naval forces. It is silly that an + Englishman should be more afraid of a German soldier than of a British + disease germ, and should clamor for more barracks in the same newspapers + that protest against more school clinics, and cry out that if the State + fights disease for us it makes us paupers, though they never say that if + the State fights the Germans for us it makes us cowards. Fortunately, when + a habit of thought is silly it only needs steady treatment by ridicule + from sensible and witty people to be put out of countenance and perish. + Every year sees an increase in the number of persons employed in the + Public Health Service, who would formerly have been mere adventurers in + the Private Illness Service. To put it another way, a host of men and + women who have now a strong incentive to be mischievous and even murderous + rogues will have a much stronger, because a much honester, incentive to be + not only good citizens but active benefactors to the community. And they + will have no anxiety whatever about their incomes. + </p> + <p> + <a name="link2H_4_0043" id="link2H_4_0043"> + <!-- H2 anchor --> </a> + </p> + <div style="height: 4em;"> + <br /><br /><br /><br /> + </div> + <h2> + THE FUTURE OF PRIVATE PRACTICE + </h2> + <p> + It must not be hastily concluded that this involves the extinction of the + private practitioner. What it will really mean for him is release from his + present degrading and scientifically corrupting slavery to his patients. + As I have already shown the doctor who has to live by pleasing his + patients in competition with everybody who has walked the hospitals, + scraped through the examinations, and bought a brass plate, soon finds + himself prescribing water to teetotallers and brandy or champagne jelly to + drunkards; beefsteaks and stout in one house, and "uric acid free" + vegetarian diet over the way; shut windows, big fires, and heavy overcoats + to old Colonels, and open air and as much nakedness as is compatible with + decency to young faddists, never once daring to say either "I don't know," + or "I don't agree." For the strength of the doctor's, as of every other + man's position when the evolution of social organization at last reaches + his profession, will be that he will always have open to him the + alternative of public employment when the private employer becomes too + tyrannous. And let no one suppose that the words doctor and patient can + disguise from the parties the fact that they are employer and employee. No + doubt doctors who are in great demand can be as high-handed and + independent as employees are in all classes when a dearth in their labor + market makes them indispensable; but the average doctor is not in this + position: he is struggling for life in an overcrowded profession, and + knows well that "a good bedside manner" will carry him to solvency through + a morass of illness, whilst the least attempt at plain dealing with people + who are eating too much, or drinking too much, or frowsting too much (to + go no further in the list of intemperances that make up so much of family + life) would soon land him in the Bankruptcy Court. + </p> + <p> + Private practice, thus protected, would itself protect individuals, as far + as such protection is possible, against the errors and superstitions of + State medicine, which are at worst no worse than the errors and + superstitions of private practice, being, indeed, all derived from it. + Such monstrosities as vaccination are, as we have seen, founded, not on + science, but on half-crowns. If the Vaccination Acts, instead of being + wholly repealed as they are already half repealed, were strengthened by + compelling every parent to have his child vaccinated by a public officer + whose salary was completely independent of the number of vaccinations + performed by him, and for whom there was plenty of alternative public + health work waiting, vaccination would be dead in two years, as the + vaccinator would not only not gain by it, but would lose credit through + the depressing effects on the vital statistics of his district of the + illness and deaths it causes, whilst it would take from him all the credit + of that freedom from smallpox which is the result of good sanitary + administration and vigilant prevention of infection. Such absurd panic + scandals as that of the last London epidemic, where a fee of half-a-crown + per re-vaccination produced raids on houses during the absence of parents, + and the forcible seizure and re-vaccination of children left to answer the + door, can be prevented simply by abolishing the half-crown and all similar + follies, paying, not for this or that ceremony of witchcraft, but for + immunity from disease, and paying, too, in a rational way. The officer + with a fixed salary saves himself trouble by doing his business with the + least possible interference with the private citizen. The man paid by the + job loses money by not forcing his job on the public as often as possible + without reference to its results. + </p> + <p> + <a name="link2H_4_0044" id="link2H_4_0044"> + <!-- H2 anchor --> </a> + </p> + <div style="height: 4em;"> + <br /><br /><br /><br /> + </div> + <h2> + THE TECHNICAL PROBLEM + </h2> + <p> + As to any technical medical problem specially involved, there is none. If + there were, I should not be competent to deal with it, as I am not a + technical expert in medicine: I deal with the subject as an economist, a + politician, and a citizen exercising my common sense. Everything that I + have said applies equally to all the medical techniques, and will hold + good whether public hygiene be based on the poetic fancies of Christian + Science, the tribal superstitions of the druggist and the vivisector, or + the best we can make of our real knowledge. But I may remind those who + confusedly imagine that the medical problem is also the scientific + problem, that all problems are finally scientific problems. The notion + that therapeutics or hygiene or surgery is any more or less scientific + than making or cleaning boots is entertained only by people to whom a man + of science is still a magician who can cure diseases, transmute metals, + and enable us to live for ever. It may still be necessary for some time to + come to practise on popular credulity, popular love and dread of the + marvellous, and popular idolatry, to induce the poor to comply with the + sanitary regulations they are too ignorant to understand. As I have + elsewhere confessed, I have myself been responsible for ridiculous + incantations with burning sulphur, experimentally proved to be quite + useless, because poor people are convinced, by the mystical air of the + burning and the horrible smell, that it exorcises the demons of smallpox + and scarlet fever and makes it safe for them to return to their houses. To + assure them that the real secret is sunshine and soap is only to convince + them that you do not care whether they live or die, and wish to save money + at their expense. So you perform the incantation; and back they go to + their houses, satisfied. A religious ceremony—a poetic blessing of + the threshold, for instance—would be much better; but unfortunately + our religion is weak on the sanitary side. One of the worst misfortunes of + Christendom was that reaction against the voluptuous bathing of the + imperial Romans which made dirty habits a part of Christian piety, and in + some unlucky places (the Sandwich Islands for example) made the + introduction of Christianity also the introduction of disease, because the + formulators of the superseded native religion, like Mahomet, had been + enlightened enough to introduce as religious duties such sanitary measures + as ablution and the most careful and reverent treatment of everything cast + off by the human body, even to nail clippings and hairs; and our + missionaries thoughtlessly discredited this godly doctrine without + supplying its place, which was promptly taken by laziness and neglect. If + the priests of Ireland could only be persuaded to teach their flocks that + it is a deadly insult to the Blessed Virgin to place her image in a + cottage that is not kept up to that high standard of Sunday cleanliness to + which all her worshippers must believe she is accustomed, and to represent + her as being especially particular about stables because her son was born + in one, they might do more in one year than all the Sanitary Inspectors in + Ireland could do in twenty; and they could hardly doubt that Our Lady + would be delighted. Perhaps they do nowadays; for Ireland is certainly a + transfigured country since my youth as far as clean faces and pinafores + can transfigure it. In England, where so many of the inhabitants are too + gross to believe in poetic faiths, too respectable to tolerate the notion + that the stable at Bethany was a common peasant farmer's stable instead of + a first-rate racing one, and too savage to believe that anything can + really cast out the devil of disease unless it be some terrifying hoodoo + of tortures and stinks, the M.O.H. will no doubt for a long time to come + have to preach to fools according to their folly, promising miracles, and + threatening hideous personal consequences of neglect of by-laws and the + like; therefore it will be important that every M.O.H. shall have, with + his (or her) other qualifications, a sense of humor, lest (he or she) + should come at last to believe all the nonsense that must needs be talked. + But he must, in his capacity of an expert advising the authorities, keep + the government itself free of superstition. If Italian peasants are so + ignorant that the Church can get no hold of them except by miracles, why, + miracles there must be. The blood of St. Januarius must liquefy whether + the Saint is in the humor or not. To trick a heathen into being a dutiful + Christian is no worse than to trick a whitewasher into trusting himself in + a room where a smallpox patient has lain, by pretending to exorcise the + disease with burning sulphur. But woe to the Church if in deceiving the + peasant it also deceives itself; for then the Church is lost, and the + peasant too, unless he revolt against it. Unless the Church works the + pretended miracle painfully against the grain, and is continually urged by + its dislike of the imposture to strive to make the peasant susceptible to + the true reasons for behaving well, the Church will become an instrument + of his corruption and an exploiter of his ignorance, and will find itself + launched upon that persecution of scientific truth of which all + priesthoods are accused and none with more justice than the scientific + priesthood. + </p> + <p> + And here we come to the danger that terrifies so many of us: the danger of + having a hygienic orthodoxy imposed on us. But we must face that: in such + crowded and poverty ridden civilizations as ours any orthodoxy is better + than laisser-faire. If our population ever comes to consist exclusively of + well-to-do, highly cultivated, and thoroughly instructed free persons in a + position to take care of themselves, no doubt they will make short work of + a good deal of official regulation that is now of life-and-death necessity + to us; but under existing circumstances, I repeat, almost any sort of + attention that democracy will stand is better than neglect. Attention and + activity lead to mistakes as well as to successes; but a life spent in + making mistakes is not only more honorable but more useful than a life + spent doing nothing. The one lesson that comes out of all our theorizing + and experimenting is that there is only one really scientific progressive + method; and that is the method of trial and error. If you come to that, + what is laisser-faire but an orthodoxy? the most tyrannous and disastrous + of all the orthodoxies, since it forbids you even to learn. + </p> + <p> + <a name="link2H_4_0045" id="link2H_4_0045"> + <!-- H2 anchor --> </a> + </p> + <div style="height: 4em;"> + <br /><br /><br /><br /> + </div> + <h2> + THE LATEST THEORIES + </h2> + <p> + Medical theories are so much a matter of fashion, and the most fertile of + them are modified so rapidly by medical practice and biological research, + which are international activities, that the play which furnishes the + pretext for this preface is already slightly outmoded, though I believe it + may be taken as a faithful record for the year (1906) in which it was + begun. I must not expose any professional man to ruin by connecting his + name with the entire freedom of criticism which I, as a layman, enjoy; but + it will be evident to all experts that my play could not have been written + but for the work done by Sir Almroth Wright in the theory and practice of + securing immunization from bacterial diseases by the inoculation of + "vaccines" made of their own bacteria: a practice incorrectly called + vaccinetherapy (there is nothing vaccine about it) apparently because it + is what vaccination ought to be and is not. Until Sir Almroth Wright, + following up one of Metchnikoff's most suggestive biological romances, + discovered that the white corpuscles or phagocytes which attack and devour + disease germs for us do their work only when we butter the disease germs + appetizingly for them with a natural sauce which Sir Almroth named + opsonin, and that our production of this condiment continually rises and + falls rhythmically from negligibility to the highest efficiency, nobody + had been able even to conjecture why the various serums that were from + time to time introduced as having effected marvellous cures, presently + made such direful havoc of some unfortunate patient that they had to be + dropped hastily. The quantity of sturdy lying that was necessary to save + the credit of inoculation in those days was prodigious; and had it not + been for the devotion shown by the military authorities throughout Europe, + who would order the entire disappearance of some disease from their + armies, and bring it about by the simple plan of changing the name under + which the cases were reported, or for our own Metropolitan Asylums Board, + which carefully suppressed all the medical reports that revealed the + sometimes quite appalling effects of epidemics of revaccination, there is + no saying what popular reaction might not have taken place against the + whole immunization movement in therapeutics. + </p> + <p> + The situation was saved when Sir Almroth Wright pointed out that if you + inoculated a patient with pathogenic germs at a moment when his powers of + cooking them for consumption by the phagocytes was receding to its lowest + point, you would certainly make him a good deal worse and perhaps kill + him, whereas if you made precisely the same inoculation when the cooking + power was rising to one of its periodical climaxes, you would stimulate it + to still further exertions and produce just the opposite result. And he + invented a technique for ascertaining in which phase the patient happened + to be at any given moment. The dramatic possibilities of this discovery + and invention will be found in my play. But it is one thing to invent a + technique: it is quite another to persuade the medical profession to + acquire it. Our general practitioners, I gather, simply declined to + acquire it, being mostly unable to afford either the acquisition or the + practice of it when acquired. Something simple, cheap, and ready at all + times for all comers, is, as I have shown, the only thing that is + economically possible in general practice, whatever may be the case in Sir + Almroth's famous laboratory in St. Mary's Hospital. It would have become + necessary to denounce opsonin in the trade papers as a fad and Sir Almroth + as a dangerous man if his practice in the laboratory had not led him to + the conclusion that the customary inoculations were very much too + powerful, and that a comparatively infinitesimal dose would not + precipitate a negative phase of cooking activity, and might induce a + positive one. And thus it happens that the refusal of our general + practitioners to acquire the new technique is no longer quite so dangerous + in practice as it was when The Doctor's Dilemma was written: nay, that Sir + Ralph Bloomfield Boningtons way of administering inoculations as if they + were spoonfuls of squills may sometimes work fairly well. For all that, I + find Sir Almroth Wright, on the 23rd May, 1910, warning the Royal Society + of Medicine that "the clinician has not yet been prevailed upon to + reconsider his position," which means that the general practitioner ("the + doctor," as he is called in our homes) is going on just as he did before, + and could not afford to learn or practice a new technique even if he had + ever heard of it. To the patient who does not know about it he will say + nothing. To the patient who does, he will ridicule it, and disparage Sir + Almroth. What else can he do, except confess his ignorance and starve? + </p> + <p> + But now please observe how "the whirligig of time brings its revenges." + This latest discovery of the remedial virtue of a very, very tiny hair of + the dog that bit you reminds us, not only of Arndt's law of protoplasmic + reaction to stimuli, according to which weak and strong stimuli provoke + opposite reactions, but of Hahnemann's homeopathy, which was founded on + the fact alleged by Hahnemann that drugs which produce certain symptoms + when taken in ordinary perceptible quantities, will, when taken in + infinitesimally small quantities, provoke just the opposite symptoms; so + that the drug that gives you a headache will also cure a headache if you + take little enough of it. I have already explained that the savage + opposition which homeopathy encountered from the medical profession was + not a scientific opposition; for nobody seems to deny that some drugs act + in the alleged manner. It was opposed simply because doctors and + apothecaries lived by selling bottles and boxes of doctor's stuff to be + taken in spoonfuls or in pellets as large as peas; and people would not + pay as much for drops and globules no bigger than pins' heads. Nowadays, + however, the more cultivated folk are beginning to be so suspicious of + drugs, and the incorrigibly superstitious people so profusely supplied + with patent medicines (the medical advice to take them being wrapped round + the bottle and thrown in for nothing) that homeopathy has become a way of + rehabilitating the trade of prescription compounding, and is consequently + coming into professional credit. At which point the theory of opsonins + comes very opportunely to shake hands with it. + </p> + <p> + Add to the newly triumphant homeopathist and the opsonist that other + remarkable innovator, the Swedish masseur, who does not theorize about + you, but probes you all over with his powerful thumbs until he finds out + your sore spots and rubs them away, besides cheating you into a little + wholesome exercise; and you have nearly everything in medical practice + to-day that is not flat witchcraft or pure commercial exploitation of + human credulity and fear of death. Add to them a good deal of vegetarian + and teetotal controversy raging round a clamor for scientific eating and + drinking, and resulting in little so far except calling digestion + Metabolism and dividing the public between the eminent doctor who tells us + that we do not eat enough fish, and his equally eminent colleague who + warns us that a fish diet must end in leprosy, and you have all that + opposes with any sort of countenance the rise of Christian Science with + its cathedrals and congregations and zealots and miracles and cures: all + very silly, no doubt, but sane and sensible, poetic and hopeful, compared + to the pseudo science of the commercial general practitioner, who + foolishly clamors for the prosecution and even the execution of the + Christian Scientists when their patients die, forgetting the long death + roll of his own patients. + </p> + <p> + By the time this preface is in print the kaleidoscope may have had another + shake; and opsonin may have gone the way of phlogiston at the hands of its + own restless discoverer. I will not say that Hahnemann may have gone the + way of Diafoirus; for Diafoirus we have always with us. But we shall still + pick up all our knowledge in pursuit of some Will o' the Wisp or other. + What is called science has always pursued the Elixir of Life and the + Philosopher's Stone, and is just as busy after them to-day as ever it was + in the days of Paracelsus. We call them by different names: Immunization + or Radiology or what not; but the dreams which lure us into the adventures + from which we learn are always at bottom the same. Science becomes + dangerous only when it imagines that it has reached its goal. What is + wrong with priests and popes is that instead of being apostles and saints, + they are nothing but empirics who say "I know" instead of "I am learning," + and pray for credulity and inertia as wise men pray for scepticism and + activity. Such abominations as the Inquisition and the Vaccination Acts + are possible only in the famine years of the soul, when the great vital + dogmas of honor, liberty, courage, the kinship of all life, faith that the + unknown is greater than the known and is only the As Yet Unknown, and + resolution to find a manly highway to it, have been forgotten in a + paroxysm of littleness and terror in which nothing is active except + concupiscence and the fear of death, playing on which any trader can filch + a fortune, any blackguard gratify his cruelty, and any tyrant make us his + slaves. + </p> + <p> + Lest this should seem too rhetorical a conclusion for our professional men + of science, who are mostly trained not to believe anything unless it is + worded in the jargon of those writers who, because they never really + understand what they are trying to say, cannot find familiar words for it, + and are therefore compelled to invent a new language of nonsense for every + book they write, let me sum up my conclusions as dryly as is consistent + with accurate thought and live conviction. + </p> + <p> + 1. Nothing is more dangerous than a poor doctor: not even a poor employer + or a poor landlord. + </p> + <p> + 2. Of all the anti-social vested interests the worst is the vested + interest in ill-health. + </p> + <p> + 3. Remember that an illness is a misdemeanor; and treat the doctor as an + accessory unless he notifies every case to the Public Health authority. + </p> + <p> + 4. Treat every death as a possible and under our present system a probable + murder, by making it the subject of a reasonably conducted inquest; and + execute the doctor, if necessary, as a doctor, by striking him off the + register. + </p> + <p> + 5. Make up your mind how many doctors the community needs to keep it well. + Do not register more or less than this number; and let registration + constitute the doctor a civil servant with a dignified living wage paid + out of public funds. + </p> + <p> + 6. Municipalize Harley Street. + </p> + <p> + 7. Treat the private operator exactly as you would treat a private + executioner. + </p> + <p> + 8. Treat persons who profess to be able to cure disease as you treat + fortune tellers. + </p> + <p> + 9. Keep the public carefully informed, by special statistics and + announcements of individual cases, of all illnesses of doctors or in their + families. + </p> + <p> + 10. Make it compulsory for a doctor using a brass plate to have inscribed + on it, in addition to the letters indicating his qualifications, the words + "Remember that I too am mortal." + </p> + <p> + 11. In legislation and social organization, proceed on the principle that + invalids, meaning persons who cannot keep themselves alive by their own + activities, cannot, beyond reason, expect to be kept alive by the activity + of others. There is a point at which the most energetic policeman or + doctor, when called upon to deal with an apparently drowned person, gives + up artificial respiration, although it is never possible to declare with + certainty, at any point short of decomposition, that another five minutes + of the exercise would not effect resuscitation. The theory that every + individual alive is of infinite value is legislatively impracticable. No + doubt the higher the life we secure to the individual by wise social + organization, the greater his value is to the community, and the more + pains we shall take to pull him through any temporary danger or + disablement. But the man who costs more than he is worth is doomed by + sound hygiene as inexorably as by sound economics. + </p> + <p> + 12. Do not try to live for ever. You will not succeed. + </p> + <p> + 13. Use your health, even to the point of wearing it out. That is what it + is for. Spend all you have before you die; and do not outlive yourself. + </p> + <p> + 14. Take the utmost care to get well born and well brought up. This means + that your mother must have a good doctor. Be careful to go to a school + where there is what they call a school clinic, where your nutrition and + teeth and eyesight and other matters of importance to you will be attended + to. Be particularly careful to have all this done at the expense of the + nation, as otherwise it will not be done at all, the chances being about + forty to one against your being able to pay for it directly yourself, even + if you know how to set about it. Otherwise you will be what most people + are at present: an unsound citizen of an unsound nation, without sense + enough to be ashamed or unhappy about it. + </p> + <p> + <br /><br /><br /><br /> + </p> +<pre xml:space="preserve"> + + + + + +End of the Project Gutenberg EBook of The Doctor's Dilemma: Preface on +Doctors, by George Bernard Shaw + +*** END OF THIS PROJECT GUTENBERG EBOOK PREFACE TO DOCTOR'S DILEMMA *** + +***** This file should be named 5069-h.htm or 5069-h.zip ***** +This and all associated files of various formats will be found in: + http://www.gutenberg.org/5/0/6/5069/ + +Produced by Eve Sobol, and David Widger + + +Updated editions will replace the previous one--the old editions +will be renamed. + +Creating the works from public domain print editions means that no +one owns a United States copyright in these works, so the Foundation +(and you!) can copy and distribute it in the United States without +permission and without paying copyright royalties. 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You may copy it, give it away or +re-use it under the terms of the Project Gutenberg License included +with this eBook or online at www.gutenberg.org + + +Title: The Doctor's Dilemma: Preface on Doctors + +Author: George Bernard Shaw + +Release Date: February, 2004 [EBook #5069] +Posting Date: March 26, 2009 + +Language: English + +Character set encoding: ASCII + +*** START OF THIS PROJECT GUTENBERG EBOOK PREFACE TO DOCTOR'S DILEMMA *** + + + + +Produced by Eve Sobol + + + + + + + + +THE DOCTOR'S DILEMMA: PREFACE ON DOCTORS + + +By Bernard Shaw + + +1909 + + + +It is not the fault of our doctors that the medical service of the +community, as at present provided for, is a murderous absurdity. That +any sane nation, having observed that you could provide for the supply +of bread by giving bakers a pecuniary interest in baking for you, should +go on to give a surgeon a pecuniary interest in cutting off your leg, is +enough to make one despair of political humanity. But that is precisely +what we have done. And the more appalling the mutilation, the more the +mutilator is paid. He who corrects the ingrowing toe-nail receives a +few shillings: he who cuts your inside out receives hundreds of guineas, +except when he does it to a poor person for practice. + +Scandalized voices murmur that these operations are necessary. They +may be. It may also be necessary to hang a man or pull down a house. +But we take good care not to make the hangman and the housebreaker the +judges of that. If we did, no man's neck would be safe and no man's +house stable. But we do make the doctor the judge, and fine him anything +from sixpence to several hundred guineas if he decides in our favor. +I cannot knock my shins severely without forcing on some surgeon the +difficult question, "Could I not make a better use of a pocketful +of guineas than this man is making of his leg? Could he not write as +well--or even better--on one leg than on two? And the guineas would +make all the difference in the world to me just now. My wife--my pretty +ones--the leg may mortify--it is always safer to operate--he will be +well in a fortnight--artificial legs are now so well made that they +are really better than natural ones--evolution is towards motors and +leglessness, etc., etc., etc." + +Now there is no calculation that an engineer can make as to the behavior +of a girder under a strain, or an astronomer as to the recurrence of a +comet, more certain than the calculation that under such circumstances +we shall be dismembered unnecessarily in all directions by surgeons +who believe the operations to be necessary solely because they want to +perform them. The process metaphorically called bleeding the rich man +is performed not only metaphorically but literally every day by surgeons +who are quite as honest as most of us. After all, what harm is there +in it? The surgeon need not take off the rich man's (or woman's) leg or +arm: he can remove the appendix or the uvula, and leave the patient none +the worse after a fortnight or so in bed, whilst the nurse, the general +practitioner, the apothecary, and the surgeon will be the better. + + + + +DOUBTFUL CHARACTER BORNE BY THE MEDICAL PROFESSION + +Again I hear the voices indignantly muttering old phrases about the +high character of a noble profession and the honor and conscience of +its members. I must reply that the medical profession has not a +high character: it has an infamous character. I do not know a single +thoughtful and well-informed person who does not feel that the tragedy +of illness at present is that it delivers you helplessly into the hands +of a profession which you deeply mistrust, because it not only advocates +and practises the most revolting cruelties in the pursuit of knowledge, +and justifies them on grounds which would equally justify practising the +same cruelties on yourself or your children, or burning down London to +test a patent fire extinguisher, but, when it has shocked the public, +tries to reassure it with lies of breath-bereaving brazenness. That +is the character the medical profession has got just now. It may be +deserved or it may not: there it is at all events, and the doctors who +have not realized this are living in a fool's paradise. As to the humor +and conscience of doctors, they have as much as any other class of men, +no more and no less. And what other men dare pretend to be impartial +where they have a strong pecuniary interest on one side? Nobody supposes +that doctors are less virtuous than judges; but a judge whose salary +and reputation depended on whether the verdict was for plaintiff or +defendant, prosecutor or prisoner, would be as little trusted as a +general in the pay of the enemy. To offer me a doctor as my judge, and +then weight his decision with a bribe of a large sum of money and a +virtual guarantee that if he makes a mistake it can never be proved +against him, is to go wildly beyond the ascertained strain which human +nature will bear. It is simply unscientific to allege or believe +that doctors do not under existing circumstances perform unnecessary +operations and manufacture and prolong lucrative illnesses. The only +ones who can claim to be above suspicion are those who are so much +sought after that their cured patients are immediately replaced by fresh +ones. And there is this curious psychological fact to be remembered: a +serious illness or a death advertizes the doctor exactly as a hanging +advertizes the barrister who defended the person hanged. Suppose, for +example, a royal personage gets something wrong with his throat, or has +a pain in his inside. If a doctor effects some trumpery cure with a wet +compress or a peppermint lozenge nobody takes the least notice of him. +But if he operates on the throat and kills the patient, or extirpates +an internal organ and keeps the whole nation palpitating for days whilst +the patient hovers in pain and fever between life and death, his fortune +is made: every rich man who omits to call him in when the same symptoms +appear in his household is held not to have done his utmost duty to +the patient. The wonder is that there is a king or queen left alive in +Europe. + + + + +DOCTOR'S CONSCIENCES + +There is another difficulty in trusting to the honor and conscience of +a doctor. Doctors are just like other Englishmen: most of them have +no honor and no conscience: what they commonly mistake for these is +sentimentality and an intense dread of doing anything that everybody +else does not do, or omitting to do anything that everybody else +does. This of course does amount to a sort of working or rule-of-thumb +conscience; but it means that you will do anything, good or bad, +provided you get enough people to keep you in countenance by doing it +also. It is the sort of conscience that makes it possible to keep order +on a pirate ship, or in a troop of brigands. It may be said that in +the last analysis there is no other sort of honor or conscience in +existence--that the assent of the majority is the only sanction known to +ethics. No doubt this holds good in political practice. If mankind knew +the facts, and agreed with the doctors, then the doctors would be in +the right; and any person who thought otherwise would be a lunatic. But +mankind does not agree, and does not know the facts. All that can +be said for medical popularity is that until there is a practicable +alternative to blind trust in the doctor, the truth about the doctor is +so terrible that we dare not face it. Moliere saw through the doctors; +but he had to call them in just the same. Napoleon had no illusions +about them; but he had to die under their treatment just as much as the +most credulous ignoramus that ever paid sixpence for a bottle of strong +medicine. In this predicament most people, to save themselves from +unbearable mistrust and misery, or from being driven by their conscience +into actual conflict with the law, fall back on the old rule that if you +cannot have what you believe in you must believe in what you have. When +your child is ill or your wife dying, and you happen to be very fond of +them, or even when, if you are not fond of them, you are human enough to +forget every personal grudge before the spectacle of a fellow creature +in pain or peril, what you want is comfort, reassurance, something to +clutch at, were it but a straw. This the doctor brings you. You have a +wildly urgent feeling that something must be done; and the doctor does +something. Sometimes what he does kills the patient; but you do not know +that; and the doctor assures you that all that human skill could do +has been done. And nobody has the brutality to say to the newly bereft +father, mother, husband, wife, brother, or sister, "You have killed your +lost darling by your credulity." + + + + +THE PECULIAR PEOPLE + +Besides, the calling in of the doctor is now compulsory except in cases +where the patient is an adult--and not too ill to decide the steps to +be taken. We are subject to prosecution for manslaughter or for criminal +neglect if the patient dies without the consolations of the medical +profession. This menace is kept before the public by the Peculiar +People. The Peculiars, as they are called, have gained their name by +believing that the Bible is infallible, and taking their belief quite +seriously. The Bible is very clear as to the treatment of illness. +The Epistle of James; chapter v., contains the following explicit +directions: + +14. Is any sick among you? let him call for the elders of the Church; +and let them pray over him, anointing him with oil in the name of the +Lord: + +15. And the prayer of faith shall save the sick, and the Lord shall +raise him up; and if he have committed sins, they shall be forgiven him. + +The Peculiars obey these instructions and dispense with doctors. They +are therefore prosecuted for manslaughter when their children die. + +When I was a young man, the Peculiars were usually acquitted. The +prosecution broke down when the doctor in the witness box was asked +whether, if the child had had medical attendance, it would have lived. +It was, of course, impossible for any man of sense and honor to assume +divine omniscience by answering this in the affirmative, or indeed +pretending to be able to answer it at all. And on this the judge had to +instruct the jury that they must acquit the prisoner. Thus a judge with +a keen sense of law (a very rare phenomenon on the Bench, by the way) +was spared the possibility of leaving to sentence one prisoner (under +the Blasphemy laws) for questioning the authority of Scripture, and +another for ignorantly and superstitiously accepting it as a guide to +conduct. To-day all this is changed. The doctor never hesitates to claim +divine omniscience, nor to clamor for laws to punish any scepticism on +the part of laymen. A modern doctor thinks nothing of signing the death +certificate of one of his own diphtheria patients, and then going into +the witness box and swearing a peculiar into prison for six months +by assuring the jury, on oath, that if the prisoner's child, dead of +diphtheria, had been placed under his treatment instead of that of St. +James, it would not have lived. And he does so not only with impunity, +but with public applause, though the logical course would be to +prosecute him either for the murder of his own patient or for perjury +in the case of St. James. Yet no barrister, apparently, dreams of asking +for the statistics of the relative case-mortality in diphtheria among +the Peculiars and among the believers in doctors, on which alone any +valid opinion could be founded. The barrister is as superstitious as the +doctor is infatuated; and the Peculiar goes unpitied to his cell, though +nothing whatever has been proved except that his child does without +the interference of a doctor as effectually as any of the hundreds of +children who die every day of the same diseases in the doctor's care. + + + + +RECOIL OF THE DOGMA OF MEDICAL INFALLIBILITY ON THE DOCTOR + +On the other hand, when the doctor is in the dock, or is the defendant +in an action for malpractice, he has to struggle against the inevitable +result of his former pretences to infinite knowledge and unerring skill. +He has taught the jury and the judge, and even his own counsel, to +believe that every doctor can, with a glance at the tongue, a touch +on the pulse, and a reading of the clinical thermometer, diagnose with +absolute certainty a patient's complaint, also that on dissecting a dead +body he can infallibly put his finger on the cause of death, and, in +cases where poisoning is suspected, the nature of the poison used. Now +all this supposed exactness and infallibility is imaginary; and to +treat a doctor as if his mistakes were necessarily malicious or corrupt +malpractices (an inevitable deduction from the postulate that the +doctor, being omniscient, cannot make mistakes) is as unjust as to +blame the nearest apothecary for not being prepared to supply you with +sixpenny-worth of the elixir of life, or the nearest motor garage for +not having perpetual motion on sale in gallon tins. But if apothecaries +and motor car makers habitually advertized elixir of life and perpetual +motion, and succeeded in creating a strong general belief that they +could supply it, they would find themselves in an awkward position if +they were indicted for allowing a customer to die, or for burning a +chauffeur by putting petrol into his car. That is the predicament the +doctor finds himself in when he has to defend himself against a charge +of malpractice by a plea of ignorance and fallibility. His plea is +received with flat credulity; and he gets little sympathy, even from +laymen who know, because he has brought the incredulity on himself. If +he escapes, he can only do so by opening the eyes of the jury to the +facts that medical science is as yet very imperfectly differentiated +from common curemongering witchcraft; that diagnosis, though it means in +many instances (including even the identification of pathogenic bacilli +under the microscope) only a choice among terms so loose that they would +not be accepted as definitions in any really exact science, is, even at +that, an uncertain and difficult matter on which doctors often differ; +and that the very best medical opinion and treatment varies widely from +doctor to doctor, one practitioner prescribing six or seven scheduled +poisons for so familiar a disease as enteric fever where another will +not tolerate drugs at all; one starving a patient whom another would +stuff; one urging an operation which another would regard as unnecessary +and dangerous; one giving alcohol and meat which another would sternly +forbid, etc., etc., etc.: all these discrepancies arising not between +the opinion of good doctors and bad ones (the medical contention is, +of course, that a bad doctor is an impossibility), but between +practitioners of equal eminence and authority. Usually it is impossible +to persuade the jury that these facts are facts. Juries seldom notice +facts; and they have been taught to regard any doubts of the omniscience +and omnipotence of doctors as blasphemy. Even the fact that doctors +themselves die of the very diseases they profess to cure passes +unnoticed. We do not shoot out our lips and shake our heads, saying, +"They save others: themselves they cannot save": their reputation +stands, like an African king's palace, on a foundation of dead bodies; +and the result is that the verdict goes against the defendant when the +defendant is a doctor accused of malpractice. + +Fortunately for the doctors, they very seldom find themselves in this +position, because it is so difficult to prove anything against them. The +only evidence that can decide a case of malpractice is expert evidence: +that is, the evidence of other doctors; and every doctor will allow a +colleague to decimate a whole countryside sooner than violate the bond +of professional etiquet by giving him away. It is the nurse who gives +the doctor away in private, because every nurse has some particular +doctor whom she likes; and she usually assures her patients that all the +others are disastrous noodles, and soothes the tedium of the sick-bed +by gossip about their blunders. She will even give a doctor away for the +sake of making the patient believe that she knows more than the doctor. +But she dare not, for her livelihood, give the doctor away in public. +And the doctors stand by one another at all costs. Now and then some +doctor in an unassailable position, like the late Sir William Gull, will +go into the witness box and say what he really thinks about the way a +patient has been treated; but such behavior is considered little short +of infamous by his colleagues. + + + + +WHY DOCTORS DO NOT DIFFER + +The truth is, there would never be any public agreement among doctors if +they did not agree to agree on the main point of the doctor being always +in the right. Yet the two guinea man never thinks that the five shilling +man is right: if he did, he would be understood as confessing to an +overcharge of one pound seventeen shillings; and on the same ground +the five shilling man cannot encourage the notion that the owner of the +sixpenny surgery round the corner is quite up to his mark. Thus even +the layman has to be taught that infallibility is not quite infallible, +because there are two qualities of it to be had at two prices. + +But there is no agreement even in the same rank at the same price. +During the first great epidemic of influenza towards the end of +the nineteenth century a London evening paper sent round a +journalist-patient to all the great consultants of that day, and +published their advice and prescriptions; a proceeding passionately +denounced by the medical papers as a breach of confidence of these +eminent physicians. The case was the same; but the prescriptions were +different, and so was the advice. Now a doctor cannot think his own +treatment right and at the same time think his colleague right in +prescribing a different treatment when the patient is the same. Anyone +who has ever known doctors well enough to hear medical shop talked +without reserve knows that they are full of stories about each other's +blunders and errors, and that the theory of their omniscience and +omnipotence no more holds good among themselves than it did with Moliere +and Napoleon. But for this very reason no doctor dare accuse another of +malpractice. He is not sure enough of his own opinion to ruin another +man by it. He knows that if such conduct were tolerated in his +profession no doctor's livelihood or reputation would be worth a year's +purchase. I do not blame him: I would do the same myself. But the effect +of this state of things is to make the medical profession a conspiracy +to hide its own shortcomings. No doubt the same may be said of all +professions. They are all conspiracies against the laity; and I do not +suggest that the medical conspiracy is either better or worse than the +military conspiracy, the legal conspiracy, the sacerdotal conspiracy, +the pedagogic conspiracy, the royal and aristocratic conspiracy, the +literary and artistic conspiracy, and the innumerable industrial, +commercial, and financial conspiracies, from the trade unions to the +great exchanges, which make up the huge conflict which we call society. +But it is less suspected. The Radicals who used to advocate, as an +indispensable preliminary to social reform, the strangling of the +last king with the entrails of the last priest, substituted compulsory +vaccination for compulsory baptism without a murmur. + + + + +THE CRAZE FOR OPERATIONS + +Thus everything is on the side of the doctor. When men die of disease +they are said to die from natural causes. When they recover (and they +mostly do) the doctor gets the credit of curing them. In surgery all +operations are recorded as successful if the patient can be got out of +the hospital or nursing home alive, though the subsequent history of the +case may be such as would make an honest surgeon vow never to recommend +or perform the operation again. The large range of operations which +consist of amputating limbs and extirpating organs admits of no direct +verification of their necessity. There is a fashion in operations as +there is in sleeves and skirts: the triumph of some surgeon who has at +last found out how to make a once desperate operation fairly safe +is usually followed by a rage for that operation not only among the +doctors, but actually among their patients. There are men and women whom +the operating table seems to fascinate; half-alive people who through +vanity, or hypochondria, or a craving to be the constant objects of +anxious attention or what not, lose such feeble sense as they ever had +of the value of their own organs and limbs. They seem to care as little +for mutilation as lobsters or lizards, which at least have the excuse +that they grow new claws and new tails if they lose the old ones. Whilst +this book was being prepared for the press a case was tried in the +Courts, of a man who sued a railway company for damages because a train +had run over him and amputated both his legs. He lost his case because +it was proved that he had deliberately contrived the occurrence himself +for the sake of getting an idler's pension at the expense of the railway +company, being too dull to realize how much more he had to lose than +to gain by the bargain even if he had won his case and received damages +above his utmost hopes. + +Thus amazing case makes it possible to say, with some prospect of +being believed, that there is in the classes who can afford to pay +for fashionable operations a sprinkling of persons so incapable +of appreciating the relative importance of preserving their bodily +integrity, (including the capacity for parentage) and the pleasure of +talking about themselves and hearing themselves talked about as the +heroes and heroines of sensational operations, that they tempt +surgeons to operate on them not only with large fees, but with personal +solicitation. Now it cannot be too often repeated that when an operation +is once performed, nobody can ever prove that it was unnecessary. If I +refuse to allow my leg to be amputated, its mortification and my death +may prove that I was wrong; but if I let the leg go, nobody can ever +prove that it would not have mortified had I been obstinate. Operation +is therefore the safe side for the surgeon as well as the lucrative +side. The result is that we hear of "conservative surgeons" as a +distinct class of practitioners who make it a rule not to operate if +they can possibly help it, and who are sought after by the people who +have vitality enough to regard an operation as a last resort. But no +surgeon is bound to take the conservative view. If he believes that an +organ is at best a useless survival, and that if he extirpates it the +patient will be well and none the worse in a fortnight, whereas to +await the natural cure would mean a month's illness, then he is clearly +justified in recommending the operation even if the cure without +operation is as certain as anything of the kind ever can be. Thus the +conservative surgeon and the radical or extirpatory surgeon may both +be right as far as the ultimate cure is concerned; so that their +consciences do not help them out of their differences. + + + + +CREDULITY AND CHLOROFORM + +There is no harder scientific fact in the world than the fact that +belief can be produced in practically unlimited quantity and intensity, +without observation or reasoning, and even in defiance of both, by the +simple desire to believe founded on a strong interest in believing. +Everybody recognizes this in the case of the amatory infatuations of +the adolescents who see angels and heroes in obviously (to others) +commonplace and even objectionable maidens and youths. But it holds good +over the entire field of human activity. The hardest-headed materialist +will become a consulter of table-rappers and slate-writers if he loses +a child or a wife so beloved that the desire to revive and communicate +with them becomes irresistible. The cobbler believes that there is +nothing like leather. The Imperialist who regards the conquest of +England by a foreign power as the worst of political misfortunes +believes that the conquest of a foreign power by England would be a boon +to the conquered. Doctors are no more proof against such illusions than +other men. Can anyone then doubt that under existing conditions a great +deal of unnecessary and mischievous operating is bound to go on, +and that patients are encouraged to imagine that modern surgery and +anesthesia have made operations much less serious matters than they +really are? When doctors write or speak to the public about operations, +they imply, and often say in so many words, that chloroform has made +surgery painless. People who have been operated on know better. +The patient does not feel the knife, and the operation is therefore +enormously facilitated for the surgeon; but the patient pays for the +anesthesia with hours of wretched sickness; and when that is over there +is the pain of the wound made by the surgeon, which has to heal like any +other wound. This is why operating surgeons, who are usually out of the +house with their fee in their pockets before the patient has recovered +consciousness, and who therefore see nothing of the suffering witnessed +by the general practitioner and the nurse, occasionally talk of +operations very much as the hangman in Barnaby Rudge talked of +executions, as if being operated on were a luxury in sensation as well +as in price. + + + + +MEDICAL POVERTY + +To make matters worse, doctors are hideously poor. The Irish gentleman +doctor of my boyhood, who took nothing less than a guinea, though he +might pay you four visits for it, seems to have no equivalent nowadays +in English society. Better be a railway porter than an ordinary English +general practitioner. A railway porter has from eighteen to twenty-three +shillings a week from the Company merely as a retainer; and his +additional fees from the public, if we leave the third-class twopenny +tip out of account (and I am by no means sure that even this reservation +need be made), are equivalent to doctor's fees in the case of +second-class passengers, and double doctor's fees in the case of first. +Any class of educated men thus treated tends to become a brigand class, +and doctors are no exception to the rule. They are offered disgraceful +prices for advice and medicine. Their patients are for the most part so +poor and so ignorant that good advice would be resented as impracticable +and wounding. When you are so poor that you cannot afford to refuse +eighteenpence from a man who is too poor to pay you any more, it +is useless to tell him that what he or his sick child needs is not +medicine, but more leisure, better clothes, better food, and a better +drained and ventilated house. It is kinder to give him a bottle of +something almost as cheap as water, and tell him to come again with +another eighteenpence if it does not cure him. When you have done that +over and over again every day for a week, how much scientific conscience +have you left? If you are weak-minded enough to cling desperately to +your eighteenpence as denoting a certain social superiority to the +sixpenny doctor, you will be miserably poor all your life; whilst the +sixpenny doctor, with his low prices and quick turnover of patients, +visibly makes much more than you do and kills no more people. + +A doctor's character can no more stand out against such conditions than +the lungs of his patients can stand out against bad ventilation. The +only way in which he can preserve his self-respect is by forgetting +all he ever learnt of science, and clinging to such help as he can +give without cost merely by being less ignorant and more accustomed to +sick-beds than his patients. Finally, he acquires a certain skill at +nursing cases under poverty-stricken domestic conditions, just as women +who have been trained as domestic servants in some huge institution with +lifts, vacuum cleaners, electric lighting, steam heating, and machinery +that turns the kitchen into a laboratory and engine house combined, +manage, when they are sent out into the world to drudge as general +servants, to pick up their business in a new way, learning the +slatternly habits and wretched makeshifts of homes where even bundles of +kindling wood are luxuries to be anxiously economized. + + + + +THE SUCCESSFUL DOCTOR + +The doctor whose success blinds public opinion to medical poverty is +almost as completely demoralized. His promotion means that his practice +becomes more and more confined to the idle rich. The proper advice for +most of their ailments is typified in Abernethy's "Live on sixpence a +day and earn it." But here, as at the other end of the scale, the right +advice is neither agreeable nor practicable. And every hypochondriacal +rich lady or gentleman who can be persuaded that he or she is a lifelong +invalid means anything from fifty to five hundred pounds a year for the +doctor. Operations enable a surgeon to earn similar sums in a couple +of hours; and if the surgeon also keeps a nursing home, he may make +considerable profits at the same time by running what is the most +expensive kind of hotel. These gains are so great that they undo much +of the moral advantage which the absence of grinding pecuniary anxiety +gives the rich doctor over the poor one. It is true that the temptation +to prescribe a sham treatment because the real treatment is too dear for +either patient or doctor does not exist for the rich doctor. He always +has plenty of genuine cases which can afford genuine treatment; and +these provide him with enough sincere scientific professional work to +save him from the ignorance, obsolescence, and atrophy of scientific +conscience into which his poorer colleagues sink. But on the other hand +his expenses are enormous. Even as a bachelor, he must, at London west +end rates, make over a thousand a year before he can afford even to +insure his life. His house, his servants, and his equipage (or autopage) +must be on the scale to which his patients are accustomed, though a +couple of rooms with a camp bed in one of them might satisfy his own +requirements. Above all, the income which provides for these outgoings +stops the moment he himself stops working. Unlike the man of business, +whose managers, clerks, warehousemen and laborers keep his business +going whilst he is in bed or in his club, the doctor cannot earn a +farthing by deputy. Though he is exceptionally exposed to infection, and +has to face all weathers at all hours of the night and day, often not +enjoying a complete night's rest for a week, the money stops coming in +the moment he stops going out; and therefore illness has special terrors +for him, and success no certain permanence. He dare not stop making +hay while the sun shines; for it may set at any time. Men do not resist +pressure of this intensity. When they come under it as doctors they pay +unnecessary visits; they write prescriptions that are as absurd as the +rub of chalk with which an Irish tailor once charmed away a wart from my +father's finger; they conspire with surgeons to promote operations; they +nurse the delusions of the malade imaginaire (who is always really ill +because, as there is no such thing as perfect health, nobody is ever +really well); they exploit human folly, vanity, and fear of death as +ruthlessly as their own health, strength, and patience are exploited +by selfish hypochondriacs. They must do all these things or else +run pecuniary risks that no man can fairly be asked to run. And the +healthier the world becomes, the more they are compelled to live by +imposture and the less by that really helpful activity of which all +doctors get enough to preserve them from utter corruption. For even the +most hardened humbug who ever prescribed ether tonics to ladies whose +need for tonics is of precisely the same character as the need of poorer +women for a glass of gin, has to help a mother through child-bearing +often enough to feel that he is not living wholly in vain. + + + + +THE PSYCHOLOGY OF SELF-RESPECT IN SURGEONS + +The surgeon, though often more unscrupulous than the general +practitioner, retains his self-respect more easily. The human conscience +can subsist on very questionable food. No man who is occupied in doing +a very difficult thing, and doing it very well, ever loses his +self-respect. The shirk, the duffer, the malingerer, the coward, the +weakling, may be put out of countenance by his own failures and frauds; +but the man who does evil skilfully, energetically, masterfully, grows +prouder and bolder at every crime. The common man may have to found his +self-respect on sobriety, honesty and industry; but a Napoleon needs no +such props for his sense of dignity. If Nelson's conscience whispered to +him at all in the silent watches of the night, you may depend on it it +whispered about the Baltic and the Nile and Cape St. Vincent, and not +about his unfaithfulness to his wife. A man who robs little children +when no one is looking can hardly have much self-respect or even +self-esteem; but an accomplished burglar must be proud of himself. In +the play to which I am at present preluding I have represented an artist +who is so entirely satisfied with his artistic conscience, even to the +point of dying like a saint with its support, that he is utterly selfish +and unscrupulous in every other relation without feeling at the smallest +disadvantage. The same thing may be observed in women who have a genius +for personal attractiveness: they expend more thought, labor, skill, +inventiveness, taste and endurance on making themselves lovely than +would suffice to keep a dozen ugly women honest; and this enables them +to maintain a high opinion of themselves, and an angry contempt for +unattractive and personally careless women, whilst they lie and cheat +and slander and sell themselves without a blush. The truth is, hardly +any of us have ethical energy enough for more than one really inflexible +point of honor. Andrea del Sarto, like Louis Dubedat in my play, must +have expended on the attainment of his great mastery of design and his +originality in fresco painting more conscientiousness and industry +than go to the making of the reputations of a dozen ordinary mayors and +churchwardens; but (if Vasari is to be believed) when the King of France +entrusted him with money to buy pictures for him, he stole it to +spend on his wife. Such cases are not confined to eminent artists. +Unsuccessful, unskilful men are often much more scrupulous than +successful ones. In the ranks of ordinary skilled labor many men are to +be found who earn good wages and are never out of a job because they are +strong, indefatigable, and skilful, and who therefore are bold in a high +opinion of themselves; but they are selfish and tyrannical, gluttonous +and drunken, as their wives and children know to their cost. + +Not only do these talented energetic people retain their self-respect +through shameful misconduct: they do not even lose the respect of +others, because their talents benefit and interest everybody, whilst +their vices affect only a few. An actor, a painter, a composer, an +author, may be as selfish as he likes without reproach from the public +if only his art is superb; and he cannot fulfil his condition without +sufficient effort and sacrifice to make him feel noble and martyred in +spite of his selfishness. It may even happen that the selfishness of +an artist may be a benefit to the public by enabling him to concentrate +himself on their gratification with a recklessness of every other +consideration that makes him highly dangerous to those about him. In +sacrificing others to himself he is sacrificing them to the public he +gratifies; and the public is quite content with that arrangement. The +public actually has an interest in the artist's vices. + +It has no such interest in the surgeon's vices. The surgeon's art is +exercised at its expense, not for its gratification. We do not go to the +operating table as we go to the theatre, to the picture gallery, to the +concert room, to be entertained and delighted: we go to be tormented and +maimed, lest a worse thing should befall us. It is of the most extreme +importance to us that the experts on whose assurance we face this horror +and suffer this mutilation should leave no interests but our own to +think of; should judge our cases scientifically; and should feel about +them kindly. Let us see what guarantees we have: first for the science, +and then for the kindness. + + + + +ARE DOCTORS MEN OF SCIENCE? + +I presume nobody will question the existence of widely spread popular +delusion that every doctor is a titan of science. It is escaped only in +the very small class which understands by science something more than +conjuring with retorts and spirit lamps, magnets and microscopes, and +discovering magical cures for disease. To a sufficiently ignorant man +every captain of a trading schooner is a Galileo, every organ-grinder +a Beethoven, every piano-tuner a Hemholtz, every Old Bailey barrister +a Solon, every Seven Dials pigeon dealer a Darwin, every scrivener a +Shakespear, every locomotive engine a miracle, and its driver no less +wonderful than George Stephenson. As a matter of fact, the rank and file +of doctors are no more scientific than their tailors; or, if you prefer +to put it the reverse way, their tailors are no less scientific than +they. Doctoring is an art, not a science: any layman who is interested +in science sufficiently to take in one of the scientific journals and +follow the literature of the scientific movement, knows more about it +than those doctors (probably a large majority) who are not interested in +it, and practise only to earn their bread. Doctoring is not even the art +of keeping people in health (no doctor seems able to advise you what to +eat any better than his grandmother or the nearest quack): it is the +art of curing illnesses. It does happen exceptionally that a practising +doctor makes a contribution to science (my play describes a very notable +one); but it happens much oftener that he draws disastrous conclusions +from his clinical experience because he has no conception of scientific +method, and believes, like any rustic, that the handling of evidence and +statistics needs no expertness. The distinction between a quack doctor +and a qualified one is mainly that only the qualified one is authorized +to sign death certificates, for which both sorts seem to have about +equal occasion. Unqualified practitioners now make large incomes as +hygienists, and are resorted to as frequently by cultivated amateur +scientists who understand quite well what they are doing as by ignorant +people who are simply dupes. Bone-setters make fortunes under the very +noses of our greatest surgeons from educated and wealthy patients; and +some of the most successful doctors on the register use quite heretical +methods of treating disease, and have qualified themselves solely for +convenience. Leaving out of account the village witches who prescribe +spells and sell charms, the humblest professional healers in this +country are the herbalists. These men wander through the fields on +Sunday seeking for herbs with magic properties of curing disease, +preventing childbirth, and the like. Each of them believes that he is on +the verge of a great discovery, in which Virginia Snake Root will be +an ingredient, heaven knows why! Virginia Snake Root fascinates +the imagination of the herbalist as mercury used to fascinate the +alchemists. On week days he keeps a shop in which he sells packets of +pennyroyal, dandelion, etc., labelled with little lists of the diseases +they are supposed to cure, and apparently do cure to the satisfaction of +the people who keep on buying them. I have never been able to perceive +any distinction between the science of the herbalist and that of the +duly registered doctor. A relative of mine recently consulted a doctor +about some of the ordinary symptoms which indicate the need for a +holiday and a change. The doctor satisfied himself that the patient's +heart was a little depressed. Digitalis being a drug labelled as a +heart specific by the profession, he promptly administered a stiff dose. +Fortunately the patient was a hardy old lady who was not easily killed. +She recovered with no worse result than her conversion to Christian +Science, which owes its vogue quite as much to public despair of doctors +as to superstition. I am not, observe, here concerned with the question +as to whether the dose of digitalis was judicious or not; the point is, +that a farm laborer consulting a herbalist would have been treated in +exactly the same way. + + + + +BACTERIOLOGY AS A SUPERSTITION + +The smattering of science that all--even doctors--pick up from the +ordinary newspapers nowadays only makes the doctor more dangerous than +he used to be. Wise men used to take care to consult doctors qualified +before 1860, who were usually contemptuous of or indifferent to the germ +theory and bacteriological therapeutics; but now that these veterans +have mostly retired or died, we are left in the hands of the generations +which, having heard of microbes much as St. Thomas Aquinas heard of +angels, suddenly concluded that the whole art of healing could be summed +up in the formula: Find the microbe and kill it. And even that they did +not know how to do. The simplest way to kill most microbes is to throw +them into an open street or river and let the sun shine on them, which +explains the fact that when great cities have recklessly thrown all +their sewage into the open river the water has sometimes been cleaner +twenty miles below the city than thirty miles above it. But doctors +instinctively avoid all facts that are reassuring, and eagerly swallow +those that make it a marvel that anyone could possibly survive three +days in an atmosphere consisting mainly of countless pathogenic +germs. They conceive microbes as immortal until slain by a germicide +administered by a duly qualified medical man. All through Europe people +are adjured, by public notices and even under legal penalties, not to +throw their microbes into the sunshine, but to collect them carefully in +a handkerchief; shield the handkerchief from the sun in the darkness +and warmth of the pocket; and send it to a laundry to be mixed up with +everybody else's handkerchiefs, with results only too familiar to local +health authorities. + +In the first frenzy of microbe killing, surgical instruments were dipped +in carbolic oil, which was a great improvement on not dipping them in +anything at all and simply using them dirty; but as microbes are so fond +of carbolic oil that they swarm in it, it was not a success from the +anti-microbe point of view. Formalin was squirted into the circulation +of consumptives until it was discovered that formalin nourishes the +tubercle bacillus handsomely and kills men. The popular theory of +disease is the common medical theory: namely, that every disease had +its microbe duly created in the garden of Eden, and has been steadily +propagating itself and producing widening circles of malignant disease +ever since. It was plain from the first that if this had been even +approximately true, the whole human race would have been wiped out by +the plague long ago, and that every epidemic, instead of fading out as +mysteriously as it rushed in, would spread over the whole world. It was +also evident that the characteristic microbe of a disease might be a +symptom instead of a cause. An unpunctual man is always in a hurry; +but it does not follow that hurry is the cause of unpunctuality: on the +contrary, what is the matter with the patient is sloth. When Florence +Nightingale said bluntly that if you overcrowded your soldiers in dirty +quarters there would be an outbreak of smallpox among them, she was +snubbed as an ignorant female who did not know that smallpox can be +produced only by the importation of its specific microbe. + +If this was the line taken about smallpox, the microbe of which +has never yet been run down and exposed under the microscope by the +bacteriologist, what must have been the ardor of conviction as to +tuberculosis, tetanus, enteric fever, Maltese fever, diphtheria, and +the rest of the diseases in which the characteristic bacillus had been +identified! When there was no bacillus it was assumed that, since +no disease could exist without a bacillus, it was simply eluding +observation. When the bacillus was found, as it frequently was, in +persons who were not suffering from the disease, the theory was saved +by simply calling the bacillus an impostor, or pseudobacillus. The same +boundless credulity which the public exhibit as to a doctor's power of +diagnosis was shown by the doctors themselves as to the analytic +microbe hunters. These witch finders would give you a certificate of the +ultimate constitution of anything from a sample of the water from your +well to a scrap of your lungs, for seven-and-sixpense. I do not suggest +that the analysts were dishonest. No doubt they carried the analysis as +far as they could afford to carry it for the money. No doubt also they +could afford to carry it far enough to be of some use. But the fact +remains that just as doctors perform for half-a-crown, without the least +misgiving, operations which could not be thoroughly and safely performed +with due scientific rigor and the requisite apparatus by an unaided +private practitioner for less than some thousands of pounds, so did they +proceed on the assumption that they could get the last word of science +as to the constituents of their pathological samples for a two hours cab +fare. + + + + +ECONOMIC DIFFICULTIES OF IMMUNIZATION + +I have heard doctors affirm and deny almost every possible proposition +as to disease and treatment. I can remember the time when doctors no +more dreamt of consumption and pneumonia being infectious than they +now dream of sea-sickness being infectious, or than so great a clinical +observer as Sydenham dreamt of smallpox being infectious. I have heard +doctors deny that there is such a thing as infection. I have heard them +deny the existence of hydrophobia as a specific disease differing from +tetanus. I have heard them defend prophylactic measures and prophylactic +legislation as the sole and certain salvation of mankind from zymotic +disease; and I have heard them denounce both as malignant spreaders +of cancer and lunacy. But the one objection I have never heard from a +doctor is the objection that prophylaxis by the inoculatory methods most +in vogue is an economic impossibility under our private practice +system. They buy some stuff from somebody for a shilling, and inject a +pennyworth of it under their patient's skin for half-a-crown, concluding +that, since this primitive rite pays the somebody and pays them, the +problem of prophylaxis has been satisfactorily solved. The results are +sometimes no worse than the ordinary results of dirt getting into cuts; +but neither the doctor nor the patient is quite satisfied unless the +inoculation "takes"; that is, unless it produces perceptible illness and +disablement. Sometimes both doctor and patient get more value in +this direction than they bargain for. The results of ordinary +private-practice-inoculation at their worst are bad enough to be +indistinguishable from those of the most discreditable and dreaded +disease known; and doctors, to save the credit of the inoculation, have +been driven to accuse their patient or their patient's parents of having +contracted this disease independently of the inoculation, an excuse +which naturally does not make the family any more resigned, and leads +to public recriminations in which the doctors, forgetting everything but +the immediate quarrel, naively excuse themselves by admitting, and +even claiming as a point in their favor, that it is often impossible to +distinguish the disease produced by their inoculation and the disease +they have accused the patient of contracting. And both parties assume +that what is at issue is the scientific soundness of the prophylaxis. +It never occurs to them that the particular pathogenic germ which they +intended to introduce into the patient's system may be quite innocent of +the catastrophe, and that the casual dirt introduced with it may be at +fault. When, as in the case of smallpox or cowpox, the germ has not yet +been detected, what you inoculate is simply undefined matter that has +been scraped off an anything but chemically clean calf suffering from +the disease in question. You take your chance of the germ being in the +scrapings, and, lest you should kill it, you take no precautions against +other germs being in it as well. Anything may happen as the result of +such an inoculation. Yet this is the only stuff of the kind which is +prepared and supplied even in State establishments: that is, in the +only establishments free from the commercial temptation to adulterate +materials and scamp precautionary processes. + +Even if the germ were identified, complete precautions would hardly pay. +It is true that microbe farming is not expensive. The cost of breeding +and housing two head of cattle would provide for the breeding and +housing of enough microbes to inoculate the entire population of +the globe since human life first appeared on it. But the precautions +necessary to insure that the inoculation shall consist of nothing else +but the required germ in the proper state of attenuation are a very +different matter from the precautions necessary in the distribution +and consumption of beefsteaks. Yet people expect to find vaccines +and antitoxins and the like retailed at "popular prices" in private +enterprise shops just as they expect to find ounces of tobacco and +papers of pins. + + + + +THE PERILS OF INOCULATION + +The trouble does not end with the matter to be inoculated. There is the +question of the condition of the patient. The discoveries of Sir Almroth +Wright have shown that the appalling results which led to the hasty +dropping in 1894 of Koch's tuberculin were not accidents, but perfectly +orderly and inevitable phenomena following the injection of dangerously +strong "vaccines" at the wrong moment, and reinforcing the disease +instead of stimulating the resistance to it. To ascertain the right +moment a laboratory and a staff of experts are needed. The general +practitioner, having no such laboratory and no such experience, has +always chanced it, and insisted, when he was unlucky, that the results +were not due to the inoculation, but to some other cause: a favorite +and not very tactful one being the drunkenness or licentiousness of +the patient. But though a few doctors have now learnt the danger of +inoculating without any reference to the patient's "opsonic index" +at the moment of inoculation, and though those other doctors who are +denouncing the danger as imaginary and opsonin as a craze or a fad, +obviously do so because it involves an operation which they have neither +the means nor the knowledge to perform, there is still no grasp of the +economic change in the situation. They have never been warned that the +practicability of any method of extirpating disease depends not only on +its efficacy, but on its cost. For example, just at present the world +has run raving mad on the subject of radium, which has excited our +credulity precisely as the apparitions at Lourdes excited the credulity +of Roman Catholics. Suppose it were ascertained that every child in the +world could be rendered absolutely immune from all disease during its +entire life by taking half an ounce of radium to every pint of its +milk. The world would be none the healthier, because not even a Crown +Prince--no, not even the son of a Chicago Meat King, could afford +the treatment. Yet it is doubtful whether doctors would refrain from +prescribing it on that ground. The recklessness with which they now +recommend wintering in Egypt or at Davos to people who cannot afford to +go to Cornwall, and the orders given for champagne jelly and old port in +households where such luxuries must obviously be acquired at the cost of +stinting necessaries, often make one wonder whether it is possible for a +man to go through a medical training and retain a spark of common sense. +This sort of inconsiderateness gets cured only in the classes where +poverty, pretentious as it is even at its worst, cannot pitch its +pretences high enough to make it possible for the doctor (himself often +no better off than the patient) to assume that the average income of an +English family is about 2,000 pounds a year, and that it is quite easy +to break up a home, sell an old family seat at a sacrifice, and retire +into a foreign sanatorium devoted to some "treatment" that did not +exist two years ago and probably will not exist (except as a pretext +for keeping an ordinary hotel) two years hence. In a poor practice the +doctor must find cheap treatments for cheap people, or humiliate and +lose his patients either by prescribing beyond their means or sending +them to the public hospitals. When it comes to prophylactic inoculation, +the alternative lies between the complete scientific process, which can +only be brought down to a reasonable cost by being very highly organized +as a public service in a public institution, and such cheap, +nasty, dangerous and scientifically spurious imitations as ordinary +vaccination, which seems not unlikely to be ended, like its equally +vaunted forerunner, XVIII. century inoculation, by a purely reactionary +law making all sorts of vaccination, scientific or not, criminal +offences. Naturally, the poor doctor (that is, the average doctor) +defends ordinary vaccination frantically, as it means to him the bread +of his children. To secure the vehement and practically unanimous +support of the rank and file of the medical profession for any sort of +treatment or operation, all that is necessary is that it can be easily +practised by a rather shabbily dressed man in a surgically dirty room in +a surgically dirty house without any assistance, and that the materials +for it shall cost, say, a penny, and the charge for it to a patient with +100 pounds a year be half-a-crown. And, on the other hand, a hygienic +measure has only to be one of such refinement, difficulty, precision and +costliness as to be quite beyond the resources of private practice, to +be ignored or angrily denounced as a fad. + +TRADE UNIONISM AND SCIENCE + +Here we have the explanation of the savage rancor that so amazes people +who imagine that the controversy concerning vaccination is a scientific +one. It has really nothing to do with science. The medical profession, +consisting for the most part of very poor men struggling to keep up +appearances beyond their means, find themselves threatened with the +extinction of a considerable part of their incomes: a part, too, that +is easily and regularly earned, since it is independent of disease, +and brings every person born into the nation, healthy or not, to the +doctors. To boot, there is the occasional windfall of an epidemic, +with its panic and rush for revaccination. Under such circumstances, +vaccination would be defended desperately were it twice as dirty, +dangerous, and unscientific in method as it actually is. The note of +fury in the defence, the feeling that the anti-vaccinator is doing a +cruel, ruinous, inconsiderate thing in a mood of indignant folly: all +this, so puzzling to the observer who knows nothing of the economic side +of the question, and only sees that the anti-vaccinator, having +nothing whatever to gain and a good deal to lose by placing himself in +opposition to the law and to the outcry that adds private persecution to +legal penalties, can have no interest in the matter except the interest +of a reformer in abolishing a corrupt and mischievous superstition, +becomes intelligible the moment the tragedy of medical poverty and the +lucrativeness of cheap vaccination is taken into account. + +In the face of such economic pressure as this, it is silly to expect +that medical teaching, any more than medical practice, can possibly +be scientific. The test to which all methods of treatment are finally +brought is whether they are lucrative to doctors or not. It would be +difficult to cite any proposition less obnoxious to science, than that +advanced by Hahnemann: to wit, that drugs which in large doses produce +certain symptoms, counteract them in very small doses, just as in more +modern practice it is found that a sufficiently small inoculation with +typhoid rallies our powers to resist the disease instead of prostrating +us with it. But Hahnemann and his followers were frantically persecuted +for a century by generations of apothecary-doctors whose incomes +depended on the quantity of drugs they could induce their patients to +swallow. These two cases of ordinary vaccination and homeopathy are +typical of all the rest. Just as the object of a trade union under +existing conditions must finally be, not to improve the technical +quality of the work done by its members, but to secure a living wage +for them, so the object of the medical profession today is to secure an +income for the private doctor; and to this consideration all concern for +science and public health must give way when the two come into conflict. +Fortunately they are not always in conflict. Up to a certain point +doctors, like carpenters and masons, must earn their living by doing the +work that the public wants from them; and as it is not in the nature +of things possible that such public want should be based on unmixed +disutility, it may be admitted that doctors have their uses, real as +well as imaginary. But just as the best carpenter or mason will resist +the introduction of a machine that is likely to throw him out of work, +or the public technical education of unskilled laborers' sons to compete +with him, so the doctor will resist with all his powers of persecution +every advance of science that threatens his income. And as the advance +of scientific hygiene tends to make the private doctor's visits rarer, +and the public inspector's frequenter, whilst the advance of scientific +therapeutics is in the direction of treatments that involve highly +organized laboratories, hospitals, and public institutions generally, it +unluckily happens that the organization of private practitioners which +we call the medical profession is coming more and more to represent, not +science, but desperate and embittered antiscience: a statement of things +which is likely to get worse until the average doctor either depends +upon or hopes for an appointment in the public health service for his +livelihood. + +So much for our guarantees as to medical science. Let us now deal with +the more painful subject of medical kindness. + + + + +DOCTORS AND VIVISECTION + +The importance to our doctors of a reputation for the tenderest humanity +is so obvious, and the quantity of benevolent work actually done by them +for nothing (a great deal of it from sheer good nature) so large, that +at first sight it seems unaccountable that they should not only throw +all their credit away, but deliberately choose to band themselves +publicly with outlaws and scoundrels by claiming that in the pursuit of +their professional knowledge they should be free from the restraints of +law, of honor, of pity, of remorse, of everything that distinguishes +an orderly citizen from a South Sea buccaneer, or a philosopher from +an inquisitor. For here we look in vain for either an economic or a +sentimental motive. In every generation fools and blackguards have +made this claim; and honest and reasonable men, led by the strongest +contemporary minds, have repudiated it and exposed its crude rascality. +From Shakespear and Dr. Johnson to Ruskin and Mark Twain, the natural +abhorrence of sane mankind for the vivisector's cruelty, and the +contempt of able thinkers for his imbecile casuistry, have been +expressed by the most popular spokesmen of humanity. If the medical +profession were to outdo the Anti-Vivisection Societies in a general +professional protest against the practice and principles of the +vivisectors, every doctor in the kingdom would gain substantially by the +immense relief and reconciliation which would follow such a reassurance +of the humanity of the doctor. Not one doctor in a thousand is a +vivisector, or has any interest in vivisection, either pecuniary or +intellectual, or would treat his dog cruelly or allow anyone else to do +it. It is true that the doctor complies with the professional fashion of +defending vivisection, and assuring you that people like Shakespear and +Dr. Johnson and Ruskin and Mark Twain are ignorant sentimentalists, +just as he complies with any other silly fashion: the mystery is, how +it became the fashion in spite of its being so injurious to those who +follow it. Making all possible allowance for the effect of the brazen +lying of the few men who bring a rush of despairing patients to their +doors by professing in letters to the newspapers to have learnt from +vivisection how to cure certain diseases, and the assurances of the +sayers of smooth things that the practice is quite painless under the +law, it is still difficult to find any civilized motive for an attitude +by which the medical profession has everything to lose and nothing to +gain. + + + + +THE PRIMITIVE SAVAGE MOTIVE + +I say civilized motive advisedly; for primitive tribal motives are easy +enough to find. Every savage chief who is not a Mahomet learns that if +he wishes to strike the imagination of his tribe--and without doing that +he can rule them--he must terrify or revolt them from time to time by +acts of hideous cruelty or disgusting unnaturalness. We are far from +being as superior to such tribes as we imagine. It is very doubtful +indeed whether Peter the Great could have effected the changes he made +in Russia if he had not fascinated and intimidated his people by +his monstrous cruelties and grotesque escapades. Had he been a +nineteenth-century king of England, he would have had to wait for some +huge accidental calamity: a cholera epidemic, a war, or an insurrection, +before waking us up sufficiently to get anything done. Vivisection helps +the doctor to rule us as Peter ruled the Russians. The notion that the +man who does dreadful things is superhuman, and that therefore he can +also do wonderful things either as ruler, avenger, healer, or what not, +is by no means confined to barbarians. Just as the manifold wickednesses +and stupidities of our criminal code are supported, not by any general +comprehension of law or study of jurisprudence, not even by simple +vindictiveness, but by the superstition that a calamity of any sort must +be expiated by a human sacrifice; so the wickednesses and stupidities +of our medicine men are rooted in superstitions that have no more to do +with science than the traditional ceremony of christening an ironclad +has to do with the effectiveness of its armament. We have only to turn +to Macaulay's description of the treatment of Charles II in his last +illness to see how strongly his physicians felt that their only chance +of cheating death was by outraging nature in tormenting and disgusting +their unfortunate patient. True, this was more than two centuries ago; +but I have heard my own nineteenth-century grandfather describe the +cupping and firing and nauseous medicines of his time with perfect +credulity as to their beneficial effects; and some more modern +treatments appear to me quite as barbarous. It is in this way that +vivisection pays the doctor. It appeals to the fear and credulity of the +savage in us; and without fear and credulity half the private doctor's +occupation and seven-eighths of his influence would be gone. + + + + +THE HIGHER MOTIVE. THE TREE OF KNOWLEDGE. + +But the greatest force of all on the side of vivisection is the mighty +and indeed divine force of curiosity. Here we have no decaying tribal +instinct which men strive to root out of themselves as they strive to +root out the tiger's lust for blood. On the contrary, the curiosity of +the ape, or of the child who pulls out the legs and wings of a fly +to see what it will do without them, or who, on being told that a cat +dropped out of the window will always fall on its legs, immediately +tries the experiment on the nearest cat from the highest window in +the house (I protest I did it myself from the first floor only), is as +nothing compared to the thirst for knowledge of the philosopher, the +poet, the biologist, and the naturalist. I have always despised Adam +because he had to be tempted by the woman, as she was by the serpent, +before he could be induced to pluck the apple from the tree of +knowledge. I should have swallowed every apple on the tree the moment +the owner's back was turned. When Gray said "Where ignorance is bliss, +'tis folly to be wise," he forgot that it is godlike to be wise; and +since nobody wants bliss particularly, or could stand more than a very +brief taste of it if it were attainable, and since everybody, by the +deepest law of the Life Force, desires to be godlike, it is stupid, and +indeed blasphemous and despairing, to hope that the thirst for knowledge +will either diminish or consent to be subordinated to any other end +whatsoever. We shall see later on that the claim that has arisen in this +way for the unconditioned pursuit of knowledge is as idle as all dreams +of unconditioned activity; but none the less the right to knowledge must +be regarded as a fundamental human right. The fact that men of science +have had to fight so hard to secure its recognition, and are still so +vigorously persecuted when they discover anything that is not quite +palatable to vulgar people, makes them sorely jealous for that right; +and when they hear a popular outcry for the suppression of a method of +research which has an air of being scientific, their first instinct is +to rally to the defence of that method without further consideration, +with the result that they sometimes, as in the case of vivisection, +presently find themselves fighting on a false issue. + + + + +THE FLAW IN THE ARGUMENT + +I may as well pause here to explain their error. The right to know +is like the right to live. It is fundamental and unconditional in its +assumption that knowledge, like life, is a desirable thing, though any +fool can prove that ignorance is bliss, and that "a little knowledge is +a dangerous thing" (a little being the most that any of us can attain), +as easily as that the pains of life are more numerous and constant than +its pleasures, and that therefore we should all be better dead. The +logic is unimpeachable; but its only effect is to make us say that if +these are the conclusions logic leads to, so much the worse for logic, +after which curt dismissal of Folly, we continue living and learning by +instinct: that is, as of right. We legislate on the assumption that no +man may be killed on the strength of a demonstration that he would be +happier in his grave, not even if he is dying slowly of cancer and +begs the doctor to despatch him quickly and mercifully. To get killed +lawfully he must violate somebody else's right to live by committing +murder. But he is by no means free to live unconditionally. In society +he can exercise his right to live only under very stiff conditions. In +countries where there is compulsory military service he may even have to +throw away his individual life to save the life of the community. + +It is just so in the case of the right to knowledge. It is a right that +is as yet very imperfectly recognized in practice. But in theory it +is admitted that an adult person in pursuit of knowledge must not be +refused it on the ground that he would be better or happier without +it. Parents and priests may forbid knowledge to those who accept their +authority; and social taboo may be made effective by acts of legal +persecution under cover of repressing blasphemy, obscenity, and +sedition; but no government now openly forbids its subjects to pursue +knowledge on the ground that knowledge is in itself a bad thing, or that +it is possible for any of us to have too much of it. + + + + +LIMITATIONS OF THE RIGHT TO KNOWLEDGE + +But neither does any government exempt the pursuit of knowledge, any +more than the pursuit of life, liberty, and happiness (as the American +Constitution puts it), from all social conditions. No man is allowed +to put his mother into the stove because he desires to know how long an +adult woman will survive at a temperature of 500 degrees Fahrenheit, +no matter how important or interesting that particular addition to the +store of human knowledge may be. A man who did so would have short work +made not only of his right to knowledge, but of his right to live and +all his other rights at the same time. The right to knowledge is not +the only right; and its exercise must be limited by respect for other +rights, and for its own exercise by others. When a man says to Society, +"May I torture my mother in pursuit of knowledge?" Society replies, +"No." If he pleads, "What! Not even if I have a chance of finding out +how to cure cancer by doing it?" Society still says, "Not even then." If +the scientist, making the best of his disappointment, goes on to ask may +he torture a dog, the stupid and callous people who do not realize that +a dog is a fellow-creature and sometimes a good friend, may say Yes, +though Shakespear, Dr. Johnson and their like may say No. But even those +who say "You may torture A dog" never say "You may torture MY dog." And +nobody says, "Yes, because in the pursuit of knowledge you may do as +you please." Just as even the stupidest people say, in effect, "If +you cannot attain to knowledge without burning your mother you must do +without knowledge," so the wisest people say, "If you cannot attain to +knowledge without torturing a dog, you must do without knowledge." + + + + +A FALSE ALTERNATIVE + +But in practice you cannot persuade any wise man that this alternative +can ever be forced on anyone but a fool, or that a fool can be trusted +to learn anything from any experiment, cruel or humane. The Chinaman who +burnt down his house to roast his pig was no doubt honestly unable to +conceive any less disastrous way of cooking his dinner; and the +roast must have been spoiled after all (a perfect type of the average +vivisectionist experiment); but this did not prove that the Chinaman +was right: it only proved that the Chinaman was an incapable cook and, +fundamentally, a fool. + +Take another celebrated experiment: one in sanitary reform. In the days +of Nero Rome was in the same predicament as London to-day. If some one +would burn down London, and it were rebuilt, as it would now have to be, +subject to the sanitary by-laws and Building Act provisions enforced +by the London County Council, it would be enormously improved; and the +average lifetime of Londoners would be considerably prolonged. Nero +argued in the same way about Rome. He employed incendiaries to set it +on fire; and he played the harp in scientific raptures whilst it was +burning. I am so far of Nero's way of thinking that I have often said, +when consulted by despairing sanitary reformers, that what London needs +to make her healthy is an earthquake. Why, then, it may be asked, do not +I, as a public-spirited man, employ incendiaries to set it on fire, +with a heroic disregard of the consequences to myself and others? Any +vivisector would, if he had the courage of his opinions. The reasonable +answer is that London can be made healthy without burning her down; and +that as we have not enough civic virtue to make her healthy in a humane +and economical way, we should not have enough to rebuild her in that +way. In the old Hebrew legend, God lost patience with the world as Nero +did with Rome, and drowned everybody except a single family. But the +result was that the progeny of that family reproduced all the vices of +their predecessors so exactly that the misery caused by the flood might +just as well have been spared: things went on just as they did before. +In the same way, the lists of diseases which vivisection claims to have +cured is long; but the returns of the Registrar-General show that people +still persist in dying of them as if vivisection had never been +heard of. Any fool can burn down a city or cut an animal open; and an +exceptionally foolish fool is quite likely to promise enormous benefits +to the race as the result of such activities. But when the constructive, +benevolent part of the business comes to be done, the same want of +imagination, the same stupidity and cruelty, the same laziness and want +of perseverance that prevented Nero or the vivisector from devising or +pushing through humane methods, prevents him from bringing order out of +the chaos and happiness out of the misery he has made. At one time +it seemed reasonable enough to declare that it was impossible to find +whether or not there was a stone inside a man's body except by exploring +it with a knife, or to find out what the sun is made of without visiting +it in a balloon. Both these impossibilities have been achieved, but not +by vivisectors. The Rontgen rays need not hurt the patient; and +spectrum analysis involves no destruction. After such triumphs of humane +experiment and reasoning, it is useless to assure us that there is no +other key to knowledge except cruelty. When the vivisector offers us +that assurance, we reply simply and contemptuously, "You mean that you +are not clever or humane or energetic enough to find one." + +CRUELTY FOR ITS OWN SAKE + +It will now, I hope, be clear why the attack on vivisection is not +an attack on the right to knowledge: why, indeed, those who have the +deepest conviction of the sacredness of that right are the leaders of +the attack. No knowledge is finally impossible of human attainment; for +even though it may be beyond our present capacity, the needed capacity +is not unattainable. Consequently no method of investigation is the only +method; and no law forbidding any particular method can cut us off +from the knowledge we hope to gain by it. The only knowledge we lose by +forbidding cruelty is knowledge at first hand of cruelty itself, which +is precisely the knowledge humane people wish to be spared. + +But the question remains: Do we all really wish to be spared that +knowledge? Are humane methods really to be preferred to cruel ones? Even +if the experiments come to nothing, may not their cruelty be enjoyed +for its own sake, as a sensational luxury? Let us face these questions +boldly, not shrinking from the fact that cruelty is one of the primitive +pleasures of mankind, and that the detection of its Protean disguises as +law, education, medicine, discipline, sport and so forth, is one of the +most difficult of the unending tasks of the legislator. + + + + +OUR OWN CRUELTIES + +At first blush it may seem not only unnecessary, but even indecent, to +discuss such a proposition as the elevation of cruelty to the rank of a +human right. Unnecessary, because no vivisector confesses to a love of +cruelty for its own sake or claims any general fundamental right to be +cruel. Indecent, because there is an accepted convention to repudiate +cruelty; and vivisection is only tolerated by the law on condition that, +like judicial torture, it shall be done as mercifully as the nature of +the practice allows. But the moment the controversy becomes embittered, +the recriminations bandied between the opposed parties bring us +face-to-face with some very ugly truths. On one occasion I was invited +to speak at a large Anti-Vivisection meeting in the Queen's Hall in +London. I found myself on the platform with fox hunters, tame stag +hunters, men and women whose calendar was divided, not by pay days and +quarter days, but by seasons for killing animals for sport: the fox, the +hare, the otter, the partridge and the rest having each its appointed +date for slaughter. The ladies among us wore hats and cloaks and +head-dresses obtained by wholesale massacres, ruthless trappings, +callous extermination of our fellow creatures. We insisted on our +butchers supplying us with white veal, and were large and constant +consumers of pate de foie gras; both comestibles being obtained by +revolting methods. We sent our sons to public schools where indecent +flogging is a recognized method of taming the young human animal. Yet +we were all in hysterics of indignation at the cruelties of the +vivisectors. These, if any were present, must have smiled sardonically +at such inhuman humanitarians, whose daily habits and fashionable +amusements cause more suffering in England in a week than all the +vivisectors of Europe do in a year. I made a very effective speech, not +exclusively against vivisection, but against cruelty; and I have never +been asked to speak since by that Society, nor do I expect to be, as I +should probably give such offence to its most affluent subscribers that +its attempts to suppress vivisection would be seriously hindered. But +that does not prevent the vivisectors from freely using the "youre +another" retort, and using it with justice. + +We must therefore give ourselves no airs of superiority when denouncing +the cruelties of vivisection. We all do just as horrible things, with +even less excuse. But in making that admission we are also making short +work of the virtuous airs with which we are sometimes referred to the +humanity of the medical profession as a guarantee that vivisection is +not abused--much as if our burglars should assure us that they arc too +honest to abuse the practice of burgling. We are, as a matter of fact, +a cruel nation; and our habit of disguising our vices by giving +polite names to the offences we are determined to commit does not, +unfortunately for my own comfort, impose on me. Vivisectors can hardly +pretend to be better than the classes from which they are drawn, or +those above them; and if these classes are capable of sacrificing +animals in various cruel ways under cover of sport, fashion, education, +discipline, and even, when the cruel sacrifices are human sacrifices, of +political economy, it is idle for the vivisector to pretend that he is +incapable of practising cruelty for pleasure or profit or both under +the cloak of science. We are all tarred with the same brush; and the +vivisectors are not slow to remind us of it, and to protest vehemently +against being branded as exceptionally cruel and its devisors of +horrible instruments of torture by people whose main notion of enjoyment +is cruel sport, and whose requirements in the way of villainously cruel +traps occupy pages of the catalogue of the Army and Navy Stores. + + + + +THE SCIENTIFIC INVESTIGATION OF CRUELTY + +There is in man a specific lust for cruelty which infects even his +passion of pity and makes it savage. Simple disgust at cruelty is very +rare. The people who turn sick and faint and those who gloat are +often alike in the pains they take to witness executions, floggings, +operations or any other exhibitions of suffering, especially those +involving bloodshed, blows, and laceration. A craze for cruelty can +be developed just as a craze for drink can; and nobody who attempts to +ignore cruelty as a possible factor in the attraction of vivisection and +even of antivivisection, or in the credulity with which we accept its +excuses, can be regarded as a scientific investigator of it. Those who +accuse vivisectors of indulging the well-known passion of cruelty +under the cloak of research are therefore putting forward a strictly +scientific psychological hypothesis, which is also simple, human, +obvious, and probable. It may be as wounding to the personal vanity of +the vivisector as Darwin's Origin of Species was to the people who +could not bear to think that they were cousins to the monkeys (remember +Goldsmith's anger when he was told that he could not move his upper +jaw); but science has to consider only the truth of the hypothesis, +and not whether conceited people will like it or not. In vain do the +sentimental champions of vivisection declare themselves the most humane +of men, inflicting suffering only to relieve it, scrupulous in the use +of anesthetics, and void of all passion except the passion of pity for +a disease-ridden world. The really scientific investigator answers that +the question cannot be settled by hysterical protestations, and that if +the vivisectionist rejects deductive reasoning, he had better clear his +character by his own favorite method of experiment. + +SUGGESTED LABORATORY TESTS OF THE VIVISECTOR'S EMOTIONS + +Take the hackneyed case of the Italian who tortured mice, ostensibly to +find out about the effects of pain rather less than the nearest dentist +could have told him, and who boasted of the ecstatic sensations (he +actually used the word love) with which he carried out his experiments. +Or the gentleman who starved sixty dogs to death to establish the fact +that a dog deprived of food gets progressively lighter and weaker, +becoming remarkably emaciated, and finally dying: an undoubted truth, +but ascertainable without laboratory experiments by a simple enquiry +addressed to the nearest policeman, or, failing him, to any sane +person in Europe. The Italian is diagnosed as a cruel voluptuary: the +dog-starver is passed over as such a hopeless fool that it is impossible +to take any interest in him. Why not test the diagnosis scientifically? +Why not perform a careful series of experiments on persons under the +influence of voluptuous ecstasy, so as to ascertain its physiological +symptoms? Then perform a second series on persons engaged in +mathematical work or machine designing, so as to ascertain the symptoms +of cold scientific activity? Then note the symptoms of a vivisector +performing a cruel experiment; and compare them with the voluptuary +symptoms and the mathematical symptoms? Such experiments would be quite +as interesting and important as any yet undertaken by the vivisectors. +They might open a line of investigation which would finally make, for +instance, the ascertainment of the guilt or innocence of an accused +person a much exacter process than the very fallible methods of our +criminal courts. But instead of proposing such an investigation, our +vivisectors offer us all the pious protestations and all the huffy +recriminations that any common unscientific mortal offers when he is +accused of unworthy conduct. + + + + +ROUTINE + +Yet most vivisectors would probably come triumphant out of such a series +of experiments, because vivisection is now a routine, like butchering +or hanging or flogging; and many of the men who practise it do so only +because it has been established as part of the profession they have +adopted. Far from enjoying it, they have simply overcome their natural +repugnance and become indifferent to it, as men inevitably become +indifferent to anything they do often enough. It is this dangerous power +of custom that makes it so difficult to convince the common sense of +mankind that any established commercial or professional practice has its +root in passion. Let a routine once spring from passion, and you will +presently find thousands of routineers following it passionlessly for +a livelihood. Thus it always seems strained to speak of the religious +convictions of a clergyman, because nine out of ten clergymen have no +religions convictions: they are ordinary officials carrying on a routine +of baptizing, marrying, and churching; praying, reciting, and preaching; +and, like solicitors or doctors, getting away from their duties with +relief to hunt, to garden, to keep bees, to go into society, and the +like. In the same way many people do cruel and vile things without being +in the least cruel or vile, because the routine to which they have been +brought up is superstitiously cruel and vile. To say that every man +who beats his children and every schoolmaster who flogs a pupil is a +conscious debauchee is absurd: thousands of dull, conscientious people +beat their children conscientiously, because they were beaten themselves +and think children ought to be beaten. The ill-tempered vulgarity that +instinctively strikes at and hurts a thing that annoys it (and all +children are annoying), and the simple stupidity that requires from a +child perfection beyond the reach of the wisest and best adults (perfect +truthfulness coupled with perfect obedience is quite a common condition +of leaving a child unwhipped), produce a good deal of flagellation among +people who not only do not lust after it, but who hit the harder because +they are angry at having to perform an uncomfortable duty. These people +will beat merely to assert their authority, or to carry out what they +conceive to be a divine order on the strength of the precept of Solomon +recorded in the Bible, which carefully adds that Solomon completely +spoilt his own son and turned away from the god of his fathers to the +sensuous idolatry in which he ended his days. + +In the same way we find men and women practising vivisection as +senselessly as a humane butcher, who adores his fox terrier, will cut +a calf's throat and hang it up by its heels to bleed slowly to death +because it is the custom to eat veal and insist on its being white; or +as a German purveyor nails a goose to a board and stuffs it with food +because fashionable people eat pate de foie gras; or as the crew of +a whaler breaks in on a colony of seals and clubs them to death in +wholesale massacre because ladies want sealskin jackets; or as fanciers +blind singing birds with hot needles, and mutilate the ears and tails +of dogs and horses. Let cruelty or kindness or anything else once become +customary and it will be practised by people to whom it is not at all +natural, but whose rule of life is simply to do only what everybody else +does, and who would lose their employment and starve if they indulged +in any peculiarity. A respectable man will lie daily, in speech and in +print, about the qualities of the article he lives by selling, because +it is customary to do so. He will flog his boy for telling a lie, +because it is customary to do so. He will also flog him for not telling +a lie if the boy tells inconvenient or disrespectful truths, because +it is customary to do so. He will give the same boy a present on his +birthday, and buy him a spade and bucket at the seaside, because it is +customary to do so, being all the time neither particularly mendacious, +nor particularly cruel, nor particularly generous, but simply incapable +of ethical judgment or independent action. + +Just so do we find a crowd of petty vivisectionists daily committing +atrocities and stupidities, because it is the custom to do so. +Vivisection is customary as part of the routine of preparing lectures in +medical schools. For instance, there are two ways of making the action +of the heart visible to students. One, a barbarous, ignorant, and +thoughtless way, is to stick little flags into a rabbit's heart and +let the students see the flags jump. The other, an elegant, ingenious, +well-informed, and instructive way, is to put a sphygmograph on the +student's wrist and let him see a record of his heart's action traced +by a needle on a slip of smoked paper. But it has become the custom for +lecturers to teach from the rabbit; and the lecturers are not original +enough to get out of their groove. Then there are the demonstrations +which are made by cutting up frogs with scissors. The most humane man, +however repugnant the operation may be to him at first, cannot do it +at lecture after lecture for months without finally--and that very +soon--feeling no more for the frog than if he were cutting up pieces of +paper. Such clumsy and lazy ways of teaching are based on the cheapness +of frogs and rabbits. If machines were as cheap as frogs, engineers +would not only be taught the anatomy of machines and the functions of +their parts: they would also have machines misused and wrecked before +them so that they might learn as much as possible by using their eyes, +and as little as possible by using their brains and imaginations. Thus +we have, as part of the routine of teaching, a routine of vivisection +which soon produces complete indifference to it on the part even of +those who are naturally humane. If they pass on from the routine of +lecture preparation, not into general practice, but into research work, +they carry this acquired indifference with them into the laboratory, +where any atrocity is possible, because all atrocities satisfy +curiosity. The routine man is in the majority in his profession always: +consequently the moment his practice is tracked down to its source +in human passion there is a great and quite sincere poohpoohing from +himself, from the mass of the profession, and from the mass of the +public, which sees that the average doctor is much too commonplace and +decent a person to be capable of passionate wickedness of any kind. + +Here then, we have in vivisection, as in all the other tolerated +and instituted cruelties, this anti-climax: that only a negligible +percentage of those who practise and consequently defend it get any +satisfaction out of it. As in Mr. Galsworthy's play Justice the useless +and detestable torture of solitary imprisonment is shown at its worst +without the introduction of a single cruel person into the drama, so +it would be possible to represent all the torments of vivisection +dramatically without introducing a single vivisector who had not felt +sick at his first experience in the laboratory. Not that this can +exonerate any vivisector from suspicion of enjoying his work (or her +work: a good deal of the vivisection in medical schools is done by +women). In every autobiography which records a real experience of school +or prison life, we find that here and there among the routineers there +is to be found the genuine amateur, the orgiastic flogging schoolmaster +or the nagging warder, who has sought out a cruel profession for the +sake of its cruelty. But it is the genuine routineer who is the bulwark +of the practice, because, though you can excite public fury against a +Sade, a Bluebeard, or a Nero, you cannot rouse any feeling against +dull Mr. Smith doing his duty: that is, doing the usual thing. He is so +obviously no better and no worse than anyone else that it is difficult +to conceive that the things he does are abominable. If you would see +public dislike surging up in a moment against an individual, you must +watch one who does something unusual, no matter how sensible it may be. +The name of Jonas Hanway lives as that of a brave man because he was the +first who dared to appear in the streets of this rainy island with an +umbrella. + + + + +THE OLD LINE BETWEEN MAN AND BEAST + +But there is still a distinction to be clung to by those who dare not +tell themselves the truth about the medical profession because they are +so helplessly dependent on it when death threatens the household. That +distinction is the line that separates the brute from the man in the old +classification. Granted, they will plead, that we are all cruel; yet the +tame-stag-hunter does not hunt men; and the sportsman who lets a leash +of greyhounds loose on a hare would be horrified at the thought of +letting them loose on a human child. The lady who gets her cloak by +flaying a sable does not flay a negro; nor does it ever occur to her +that her veal cutlet might be improved on by a slice of tender baby. + +Now there was a time when some trust could be placed in this +distinction. The Roman Catholic Church still maintains, with what it +must permit me to call a stupid obstinacy, and in spite of St. Francis +and St. Anthony, that animals have no souls and no rights; so that you +cannot sin against an animal, or against God by anything you may choose +to do to an animal. Resisting the temptation to enter on an argument as +to whether you may not sin against your own soul if you are unjust or +cruel to the least of those whom St. Francis called his little brothers, +I have only to point out here that nothing could be more despicably +superstitious in the opinion of a vivisector than the notion that +science recognizes any such step in evolution as the step from a +physical organism to an immortal soul. That conceit has been taken +out of all our men of science, and out of all our doctors, by the +evolutionists; and when it is considered how completely obsessed +biological science has become in our days, not by the full scope of +evolution, but by that particular method of it which has neither sense +nor purpose nor life nor anything human, much less godlike, in it: +by the method, that is, of so-called Natural Selection (meaning no +selection at all, but mere dead accident and luck), the folly of +trusting to vivisectors to hold the human animal any more sacred than +the other animals becomes so clear that it would be waste of time to +insist further on it. As a matter of fact the man who once concedes +to the vivisector the right to put a dog outside the laws of honor and +fellowship, concedes to him also the right to put himself outside them; +for he is nothing to the vivisector but a more highly developed, and +consequently more interesting-to-experiment-on vertebrate than the dog. + + + + +VIVISECTING THE HUMAN SUBJECT + +I have in my hand a printed and published account by a doctor of how +he tested his remedy for pulmonary tuberculosis, which was to inject a +powerful germicide directly into the circulation by stabbing a vein with +a syringe. He was one of those doctors who are able to command public +sympathy by saying, quite truly, that when they discovered that the +proposed treatment was dangerous, they experimented thenceforth on +themselves. In this case the doctor was devoted enough to carry his +experiments to the point of running serious risks, and actually making +himself very uncomfortable. But he did not begin with himself. His first +experiment was on two hospital patients. On receiving a message from the +hospital to the effect that these two martyrs to therapeutic science +had all but expired in convulsions, he experimented on a rabbit, which +instantly dropped dead. It was then, and not until then, that he began +to experiment on himself, with the germicide modified in the direction +indicated by the experiments made on the two patients and the rabbit. As +a good many people countenance vivisection because they fear that if the +experiments are not made on rabbits they will be made on themselves, +it is worth noting that in this case, where both rabbits and men +were equally available, the men, being, of course, enormously more +instructive, and costing nothing, were experimented on first. Once +grant the ethics of the vivisectionists and you not only sanction the +experiment on the human subject, but make it the first duty of the +vivisector. If a guinea pig may be sacrificed for the sake of the very +little that can be learnt from it, shall not a man be sacrificed for the +sake of the great deal that can be learnt from him? At all events, he is +sacrificed, as this typical case shows. I may add (not that it touches +the argument) that the doctor, the patients, and the rabbit all suffered +in vain, as far as the hoped-for rescue of the race from pulmonary +consumption is concerned. + + + + +"THE LIE IS A EUROPEAN POWER" + +Now at the very time when the lectures describing these experiments +were being circulated in print and discussed eagerly by the medical +profession, the customary denials that patients are experimented on +were as loud, as indignant, as high-minded as ever, in spite of the +few intelligent doctors who point out rightly that all treatments are +experiments on the patient. And this brings us to an obvious but +mostly overlooked weakness in the vivisector's position: that is, his +inevitable forfeiture of all claim to have his word believed. It is +hardly to be expected that a man who does not hesitate to vivisect for +the sake of science will hesitate to lie about it afterwards to protect +it from what he deems the ignorant sentimentality of the laity. When +the public conscience stirs uneasily and threatens suppression, there +is never wanting some doctor of eminent position and high character +who will sacrifice himself devotedly to the cause of science by coming +forward to assure the public on his honor that all experiments on +animals are completely painless; although he must know that the very +experiments which first provoked the antivivisection movement by their +atrocity were experiments to ascertain the physiological effects of +the sensation of extreme pain (the much more interesting physiology +of pleasure remains uninvestigated) and that all experiments in +which sensation is a factor are voided by its suppression. Besides, +vivisection may be painless in cases where the experiments are very +cruel. If a person scratches me with a poisoned dagger so gently that I +do not feel the scratch, he has achieved a painless vivisection; but if +I presently die in torment I am not likely to consider that his humility +is amply vindicated by his gentleness. A cobra's bite hurts so little +that the creature is almost, legally speaking, a vivisector who inflicts +no pain. By giving his victims chloroform before biting them he could +comply with the law completely. + +Here, then, is a pretty deadlock. Public support of vivisection is +founded almost wholly on the assurances of the vivisectors that great +public benefits may be expected from the practice. Not for a moment do I +suggest that such a defence would be valid even if proved. But when +the witnesses begin by alleging that in the cause of science all the +customary ethical obligations (which include the obligation to tell +the truth) are suspended, what weight can any reasonable person give +to their testimony? I would rather swear fifty lies than take an animal +which had licked my hand in good fellowship and torture it. If I did +torture the dog, I should certainly not have the face to turn round and +ask how any person there suspect an honorable man like myself of telling +lies. Most sensible and humane people would, I hope, reply flatly that +honorable men do not behave dishonorably, even to dogs. The murderer +who, when asked by the chaplain whether he had any other crimes to +confess, replied indignantly, "What do you take me for?" reminds us very +strongly of the vivisectors who are so deeply hurt when their evidence +is set aside as worthless. + + + + +AN ARGUMENT WHICH WOULD DEFEND ANY CRIME + +The Achilles heel of vivisection, however, is not to be found in the +pain it causes, but in the line of argument by which it is justified. +The medical code regarding it is simply criminal anarchism at its very +worst. Indeed no criminal has yet had the impudence to argue as +every vivisector argues. No burglar contends that as it is admittedly +important to have money to spend, and as the object of burglary is to +provide the burglar with money to spend, and as in many instances it has +achieved this object, therefore the burglar is a public benefactor +and the police are ignorant sentimentalists. No highway robber has yet +harrowed us with denunciations of the puling moralist who allows his +child to suffer all the evils of poverty because certain faddists think +it dishonest to garotte an alderman. Thieves and assassins understand +quite well that there are paths of acquisition, even of the best things, +that are barred to all men of honor. Again, has the silliest burglar +ever pretended that to put a stop to burglary is to put a stop to +industry? All the vivisections that have been performed since the world +began have produced nothing so important as the innocent and honorable +discovery of radiography; and one of the reasons why radiography was not +discovered sooner was that the men whose business it was to discover +new clinical methods were coarsening and stupefying themselves with the +sensual villanies and cutthroat's casuistries of vivisection. The law of +the conservation of energy holds good in physiology as in other things: +every vivisector is a deserter from the army of honorable investigators. +But the vivisector does not see this. He not only calls his methods +scientific: he contends that there are no other scientific methods. +When you express your natural loathing for his cruelty and your natural +contempt for his stupidity, he imagines that you are attacking science. +Yet he has no inkling of the method and temper of science. The point at +issue being plainly whether he is a rascal or not, he not only insists +that the real point is whether some hotheaded antivivisectionist is a +liar (which he proves by ridiculously unscientific assumptions as to the +degree of accuracy attainable in human statement), but never dreams of +offering any scientific evidence by his own methods. + +There are many paths to knowledge already discovered; and no enlightened +man doubts that there are many more waiting to be discovered. Indeed, +all paths lead to knowledge; because even the vilest and stupidest +action teaches us something about vileness and stupidity, and may +accidentally teach us a good deal more: for instance, a cutthroat learns +(and perhaps teaches) the anatomy of the carotid artery and jugular +vein; and there can be no question that the burning of St. Joan of Arc +must have been a most instructive and interesting experiment to a good +observer, and could have been made more so if it had been carried out by +skilled physiologists under laboratory conditions. The earthquake in San +Francisco proved invaluable as an experiment in the stability of giant +steel buildings; and the ramming of the Victoria by the Camperdown +settled doubtful points of the greatest importance in naval warfare. +According to vivisectionist logic our builders would be justified in +producing artificial earthquakes with dynamite, and our admirals in +contriving catastrophes at naval manoeuvres, in order to follow up the +line of research thus accidentally discovered. + +The truth is, if the acquisition of knowledge justifies every sort of +conduct, it justifies any sort of conduct, from the illumination +of Nero's feasts by burning human beings alive (another interesting +experiment) to the simplest act of kindness. And in the light of that +truth it is clear that the exemption of the pursuit of knowledge +from the laws of honor is the most hideous conceivable enlargement of +anarchy; worse, by far, than an exemption of the pursuit of money or +political power, since there can hardly be attained without some regard +for at least the appearances of human welfare, whereas a curious devil +might destroy the whole race in torment, acquiring knowledge all the +time from his highly interesting experiment. There is more danger in one +respectable scientist countenancing such a monstrous claim than in fifty +assassins or dynamitards. The man who makes it is ethically imbecile; +and whoever imagines that it is a scientific claim has not the faintest +conception of what science means. The paths to knowledge are countless. +One of these paths is a path through darkness, secrecy, and cruelty. +When a man deliberately turns from all other paths and goes down that +one, it is scientific to infer that what attracts him is not knowledge, +since there are other paths to that, but cruelty. With so strong and +scientific a case against him, it is childish for him to stand on +his honor and reputation and high character and the credit of a noble +profession and so forth: he must clear himself either by reason or by +experiment, unless he boldly contends that evolution has retained +a passion of cruelty in man just because it is indispensable to the +fulness of his knowledge. + + + + +THOU ART THE MAN + +I shall not be at all surprised if what I have written above has induced +in sympathetic readers a transport of virtuous indignation at the +expense of the medical profession. I shall not damp so creditable and +salutary a sentiment; but I must point out that the guilt is shared by +all of us. It is not in his capacity of healer and man of science that +the doctor vivisects or defends vivisection, but in his entirely vulgar +lay capacity. He is made of the same clay as the ignorant, shallow, +credulous, half-miseducated, pecuniarily anxious people who call him in +when they have tried in vain every bottle and every pill the advertizing +druggist can persuade them to buy. The real remedy for vivisection is +the remedy for all the mischief that the medical profession and all the +other professions are doing: namely, more knowledge. The juries which +send the poor Peculiars to prison, and give vivisectionists heavy +damages against humane persons who accuse them of cruelty; the +editors and councillors and student-led mobs who are striving to make +Vivisection one of the watchwords of our civilization, are not doctors: +they are the British public, all so afraid to die that they will cling +frantically to any idol which promises to cure all their diseases, and +crucify anyone who tells them that they must not only die when their +time comes, but die like gentlemen. In their paroxysms of cowardice and +selfishness they force the doctors to humor their folly and ignorance. +How complete and inconsiderate their ignorance is can only be realized +by those who have some knowledge of vital statistics, and of the +illusions which beset Public Health legislation. + + + + +WHAT THE PUBLIC WANTS AND WILL NOT GET + +The demands of this poor public are not reasonable, but they are quite +simple. It dreads disease and desires to be protected against it. But it +is poor and wants to be protected cheaply. Scientific measures are too +hard to understand, too costly, too clearly tending towards a rise in +the rates and more public interference with the insanitary, because +insufficiently financed, private house. What the public wants, +therefore, is a cheap magic charm to prevent, and a cheap pill or potion +to cure, all disease. It forces all such charms on the doctors. + + + + +THE VACCINATION CRAZE + +Thus it was really the public and not the medical profession that took +up vaccination with irresistible faith, sweeping the invention out of +Jenner's hand and establishing it in a form which he himself repudiated. +Jenner was not a man of science; but he was not a fool; and when he +found that people who had suffered from cowpox either by contagion in +the milking shed or by vaccination, were not, as he had supposed, immune +from smallpox, he ascribed the cases of immunity which had formerly +misled him to a disease of the horse, which, perhaps because we do not +drink its milk and eat its flesh, is kept at a greater distance in our +imagination than our foster mother the cow. At all events, the public, +which had been boundlessly credulous about the cow, would not have the +horse on any terms; and to this day the law which prescribes Jennerian +vaccination is carried out with an anti-Jennerian inoculation because +the public would have it so in spite of Jenner. All the grossest lies +and superstitions which have disgraced the vaccination craze were taught +to the doctors by the public. It was not the doctors who first began to +declare that all our old men remember the time when almost every face +they saw in the street was horribly pitted with smallpox, and that all +this disfigurement has vanished since the introduction of vaccination. +Jenner himself alluded to this imaginary phenomenon before the +introduction of vaccination, and attributed it to the older practice +of smallpox inoculation, by which Voltaire, Catherine II. and Lady +Mary Wortley Montagu so confidently expected to see the disease made +harmless. It was not Jenner who set people declaring that smallpox, if +not abolished by vaccination, had at least been made much milder: on the +contrary, he recorded a pre-vaccination epidemic in which none of the +persons attacked went to bed or considered themselves as seriously ill. +Neither Jenner, nor any other doctor ever, as far as I know, inculcated +the popular notion that everybody got smallpox as a matter of course +before vaccination was invented. That doctors get infected with these +delusions, and are in their unprofessional capacity as members of the +public subject to them like other men, is true; but if we had to decide +whether vaccination was first forced on the public by the doctors or on +the doctors by the public, we should have to decide against the public. + + + + +STATISTICAL ILLUSIONS + +Public ignorance of the laws of evidence and of statistics can hardly +be exaggerated. There may be a doctor here and there who in dealing +with the statistics of disease has taken at least the first step towards +sanity by grasping the fact that as an attack of even the commonest +disease is an exceptional event, apparently over-whelming statistical +evidence in favor of any prophylactic can be produced by persuading the +public that everybody caught the disease formerly. Thus if a disease is +one which normally attacks fifteen per cent of the population, and if +the effect of a prophylactic is actually to increase the proportion to +twenty per cent, the publication of this figure of twenty per cent will +convince the public that the prophylactic has reduced the percentage by +eighty per cent instead of increasing it by five, because the public, +left to itself and to the old gentlemen who are always ready to +remember, on every possible subject, that things used to be much worse +than they are now (such old gentlemen greatly outnumber the laudatores +tempori acti), will assume that the former percentage was about 100. The +vogue of the Pasteur treatment of hydrophobia, for instance, was due +to the assumption by the public that every person bitten by a rabid dog +necessarily got hydrophobia. I myself heard hydrophobia discussed in +my youth by doctors in Dublin before a Pasteur Institute existed, +the subject having been brought forward there by the scepticism of an +eminent surgeon as to whether hydrophobia is really a specific disease +or only ordinary tetanus induced (as tetanus was then supposed to be +induced) by a lacerated wound. There were no statistics available as to +the proportion of dog bites that ended in hydrophobia; but nobody ever +guessed that the cases could be more than two or three per cent of the +bites. On me, therefore, the results published by the Pasteur Institute +produced no such effect as they did on the ordinary man who thinks that +the bite of a mad dog means certain hydrophobia. It seemed to me that +the proportion of deaths among the cases treated at the Institute was +rather higher, if anything, than might have been expected had there been +no Institute in existence. But to the public every Pasteur patient +who did not die was miraculously saved from an agonizing death by the +beneficent white magic of that most trusty of all wizards, the man of +science. + +Even trained statisticians often fail to appreciate the extent to +which statistics are vitiated by the unrecorded assumptions of their +interpreters. Their attention is too much occupied with the cruder +tricks of those who make a corrupt use of statistics for advertizing +purposes. There is, for example, the percentage dodge. In some hamlet, +barely large enough to have a name, two people are attacked during a +smallpox epidemic. One dies: the other recovers. One has vaccination +marks: the other has none. Immediately either the vaccinists or the +antivaccinists publish the triumphant news that at such and such a place +not a single vaccinated person died of smallpox whilst 100 per cent of +the unvaccinated perished miserably; or, as the case may be, that 100 +per cent of the unvaccinated recovered whilst the vaccinated succumbed +to the last man. Or, to take another common instance, comparisons +which are really comparisons between two social classes with different +standards of nutrition and education are palmed off as comparisons +between the results of a certain medical treatment and its neglect. Thus +it is easy to prove that the wearing of tall hats and the carrying of +umbrellas enlarges the chest, prolongs life, and confers comparative +immunity from disease; for the statistics show that the classes which +use these articles are bigger, healthier, and live longer than the class +which never dreams of possessing such things. It does not take much +perspicacity to see that what really makes this difference is not the +tall hat and the umbrella, but the wealth and nourishment of which they +are evidence, and that a gold watch or membership of a club in Pall Mall +might be proved in the same way to have the like sovereign virtues. A +university degree, a daily bath, the owning of thirty pairs of trousers, +a knowledge of Wagner's music, a pew in church, anything, in short, that +implies more means and better nurture than the mass of laborers enjoy, +can be statistically palmed off as a magic-spell conferring all sorts of +privileges. + +In the case of a prophylactic enforced by law, this illusion is +intensified grotesquely, because only vagrants can evade it. Now +vagrants have little power of resisting any disease: their death rate +and their case-mortality rate is always high relatively to that of +respectable folk. Nothing is easier, therefore, than to prove that +compliance with any public regulation produces the most gratifying +results. It would be equally easy even if the regulation actually raised +the death-rate, provided it did not raise it sufficiently to make the +average householder, who cannot evade regulations, die as early as the +average vagrant who can. + + + + +THE SURPRISES OF ATTENTION AND NEGLECT + +There is another statistical illusion which is independent of class +differences. A common complaint of houseowners is that the Public Health +Authorities frequently compel them to instal costly sanitary appliances +which are condemned a few years later as dangerous to health, and +forbidden under penalties. Yet these discarded mistakes are always made +in the first instance on the strength of a demonstration that their +introduction has reduced the death-rate. The explanation is simple. +Suppose a law were made that every child in the nation should be +compelled to drink a pint of brandy per month, but that the brandy +must be administered only when the child was in good health, with its +digestion and so forth working normally, and its teeth either naturally +or artificially sound. Probably the result would be an immediate and +startling reduction in child mortality, leading to further legislation +increasing the quantity of brandy to a gallon. Not until the brandy +craze had been carried to a point at which the direct harm done by +it would outweigh the incidental good, would an anti-brandy party be +listened to. That incidental good would be the substitution of attention +to the general health of children for the neglect which is now the rule +so long as the child is not actually too sick to run about and play as +usual. Even if this attention were confined to the children's teeth, +there would be an improvement which it would take a good deal of brandy +to cancel. + +This imaginary case explains the actual case of the sanitary appliances +which our local sanitary authorities prescribe today and condemn +tomorrow. No sanitary contrivance which the mind of even the very worst +plumber can devize could be as disastrous as that total neglect for +long periods which gets avenged by pestilences that sweep through whole +continents, like the black death and the cholera. If it were proposed +at this time of day to discharge all the sewage of London crude and +untreated into the Thames, instead of carrying it, after elaborate +treatment, far out into the North Sea, there would be a shriek of horror +from all our experts. Yet if Cromwell had done that instead of doing +nothing, there would probably have been no Great Plague of London. When +the Local Health Authority forces every householder to have his sanitary +arrangements thought about and attended to by somebody whose special +business it is to attend to such things, then it matters not how +erroneous or even directly mischievous may be the specific measures +taken: the net result at first is sure to be an improvement. Not until +attention has been effectually substituted for neglect as the general +rule, will the statistics begin to show the merits of the particular +methods of attention adopted. And as we are far from having arrived +at this stage, being as to health legislation only at the beginning of +things, we have practically no evidence yet as to the value of methods. +Simple and obvious as this is, nobody seems as yet to discount the +effect of substituting attention for neglect in drawing conclusions from +health statistics. Everything is put to the credit of the particular +method employed, although it may quite possibly be raising the death +rate by five per thousand whilst the attention incidental to it is +reducing the death rate fifteen per thousand. The net gain of ten per +thousand is credited to the method, and made the excuse for enforcing +more of it. + + + + +STEALING CREDIT FROM CIVILIZATION + +There is yet another way in which specifics which have no merits at +all, either direct or incidental, may be brought into high repute by +statistics. For a century past civilization has been cleaning away +the conditions which favor bacterial fevers. Typhus, once rife, has +vanished: plague and cholera have been stopped at our frontiers by a +sanitary blockade. We still have epidemics of smallpox and typhoid; and +diphtheria and scarlet fever are endemic in the slums. Measles, which in +my childhood was not regarded as a dangerous disease, has now become +so mortal that notices are posted publicly urging parents to take it +seriously. But even in these cases the contrast between the death and +recovery rates in the rich districts and in the poor ones has led to +the general conviction among experts that bacterial diseases are +preventable; and they already are to a large extent prevented. The +dangers of infection and the way to avoid it are better understood +than they used to be. It is barely twenty years since people exposed +themselves recklessly to the infection of consumption and pneumonia +in the belief that these diseases were not "catching." Nowadays the +troubles of consumptive patients are greatly increased by the growing +disposition to treat them as lepers. No doubt there is a good deal of +ignorant exaggeration and cowardly refusal to face a human and necessary +share of the risk. That has always been the case. We now know that the +medieval horror of leprosy was out of all proportion to the danger +of infection, and was accompanied by apparent blindness to the +infectiousness of smallpox, which has since been worked up by our +disease terrorists into the position formerly held by leprosy. But the +scare of infection, though it sets even doctors talking as if the only +really scientific thing to do with a fever patient is to throw him into +the nearest ditch and pump carbolic acid on him from a safe distance +until he is ready to be cremated on the spot, has led to much greater +care and cleanliness. And the net result has been a series of victories +over disease. + +Now let us suppose that in the early nineteenth century somebody had +come forward with a theory that typhus fever always begins in the +top joint of the little finger; and that if this joint be amputated +immediately after birth, typhus fever will disappear. Had such a +suggestion been adopted, the theory would have been triumphantly +confirmed; for as a matter of fact, typhus fever has disappeared. On +the other hand cancer and madness have increased (statistically) to +an appalling extent. The opponents of the little finger theory would +therefore be pretty sure to allege that the amputations were spreading +cancer and lunacy. The vaccination controversy is full of such +contentions. So is the controversy as to the docking of horses' tails +and the cropping of dogs' ears. So is the less widely known controversy +as to circumcision and the declaring certain kinds of flesh unclean by +the Jews. To advertize any remedy or operation, you have only to pick +out all the most reassuring advances made by civilization, and boldly +present the two in the relation of cause and effect: the public will +swallow the fallacy without a wry face. It has no idea of the need for +what is called a control experiment. In Shakespear's time and for long +after it, mummy was a favorite medicament. You took a pinch of the dust +of a dead Egyptian in a pint of the hottest water you could bear to +drink; and it did you a great deal of good. This, you thought, proved +what a sovereign healer mummy was. But if you had tried the control +experiment of taking the hot water without the mummy, you might have +found the effect exactly the same, and that any hot drink would have +done as well. + + + + +BIOMETRIKA + +Another difficulty about statistics is the technical difficulty +of calculation. Before you can even make a mistake in drawing your +conclusion from the correlations established by your statistics you must +ascertain the correlations. When I turn over the pages of Biometrika, +a quarterly journal in which is recorded the work done in the field of +biological statistics by Professor Karl Pearson and his colleagues, I am +out of my depth at the first line, because mathematics are to me only a +concept: I never used a logarithm in my life, and could not undertake to +extract the square root of four without misgiving. I am therefore unable +to deny that the statistical ascertainment of the correlations between +one thing and another must be a very complicated and difficult technical +business, not to be tackled successfully except by high mathematicians; +and I cannot resist Professor Karl Pearson's immense contempt for, and +indignant sense of grave social danger in, the unskilled guesses of the +ordinary sociologist. + +Now the man in the street knows nothing of Biometrika: all he knows is +that "you can prove anything by figures," though he forgets this the +moment figures are used to prove anything he wants to believe. If he did +take in Biometrika he would probably become abjectly credulous as to all +the conclusions drawn in it from the correlations so learnedly worked +out; though the mathematician whose correlations would fill a Newton +with admiration may, in collecting and accepting data and drawing +conclusions from them, fall into quite crude errors by just such popular +oversights as I have been describing. + + + + +PATIENT-MADE THERAPEUTICS + +To all these blunders and ignorances doctors are no less subject than +the rest of us. They are not trained in the use of evidence, nor +in biometrics, nor in the psychology of human credulity, nor in the +incidence of economic pressure. Further, they must believe, on the +whole, what their patients believe, just as they must wear the sort of +hat their patients wear. The doctor may lay down the law despotically +enough to the patient at points where the patient's mind is simply +blank; but when the patient has a prejudice the doctor must either keep +it in countenance or lose his patient. If people are persuaded that +night air is dangerous to health and that fresh air makes them catch +cold it will not be possible for a doctor to make his living in private +practice if he prescribes ventilation. We have to go back no further +than the days of The Pickwick Papers to find ourselves in a world where +people slept in four-post beds with curtains drawn closely round to +exclude as much air as possible. Had Mr. Pickwick's doctor told him that +he would be much healthier if he slept on a camp bed by an open window, +Mr. Pickwick would have regarded him as a crank and called in another +doctor. Had he gone on to forbid Mr. Pickwick to drink brandy and water +whenever he felt chilly, and assured him that if he were deprived of +meat or salt for a whole year, he would not only not die, but would be +none the worse, Mr. Pickwick would have fled from his presence as from +that of a dangerous madman. And in these matters the doctor cannot cheat +his patient. If he has no faith in drugs or vaccination, and the patient +has, he can cheat him with colored water and pass his lancet through the +flame of a spirit lamp before scratching his arm. But he cannot make him +change his daily habits without knowing it. + + + + +THE REFORMS ALSO COME FROM THE LAITY + +In the main, then, the doctor learns that if he gets ahead of the +superstitions of his patients he is a ruined man; and the result is that +he instinctively takes care not to get ahead of them. That is why all +the changes come from the laity. It was not until an agitation had been +conducted for many years by laymen, including quacks and faddists of all +kinds, that the public was sufficiently impressed to make it possible +for the doctors to open their minds and their mouths on the subject of +fresh air, cold water, temperance, and the rest of the new fashions in +hygiene. At present the tables have been turned on many old prejudices. +Plenty of our most popular elderly doctors believe that cold tubs in the +morning are unnatural, exhausting, and rheumatic; that fresh air is a +fad and that everybody is the better for a glass or two of port wine +every day; but they no longer dare say as much until they know exactly +where they are; for many very desirable patients in country houses have +lately been persuaded that their first duty is to get up at six in the +morning and begin the day by taking a walk barefoot through the dewy +grass. He who shows the least scepticism as to this practice is at once +suspected of being "an old-fashioned doctor," and dismissed to make room +for a younger man. + +In short, private medical practice is governed not by science but by +supply and demand; and however scientific a treatment may be, it cannot +hold its place in the market if there is no demand for it; nor can the +grossest quackery be kept off the market if there is a demand for it. + + + + +FASHIONS AND EPIDEMICS + +A demand, however, can be inculcated. This is thoroughly understood +by fashionable tradesmen, who find no difficulty in persuading their +customers to renew articles that are not worn out and to buy things they +do not want. By making doctors tradesmen, we compel them to learn the +tricks of trade; consequently we find that the fashions of the year +include treatments, operations, and particular drugs, as well as hats, +sleeves, ballads, and games. Tonsils, vermiform appendices, uvulas, even +ovaries are sacrificed because it is the fashion to get them cut out, +and because the operations are highly profitable. The psychology of +fashion becomes a pathology; for the cases have every air of being +genuine: fashions, after all, are only induced epidemics, proving that +epidemics can be induced by tradesmen, and therefore by doctors. + + + + +THE DOCTOR'S VIRTUES + +It will be admitted that this is a pretty bad state of things. And the +melodramatic instinct of the public, always demanding; that every wrong +shall have, not its remedy, but its villain to be hissed, will blame, +not its own apathy, superstition, and ignorance, but the depravity of +the doctors. Nothing could be more unjust or mischievous. Doctors, if no +better than other men, are certainly no worse. I was reproached during +the performances of The Doctor's Dilemma at the Court Theatre in +1907 because I made the artist a rascal, the journalist an illiterate +incapable, and all the doctors "angels." But I did not go beyond the +warrant of my own experience. It has been my luck to have doctors +among my friends for nearly forty years past (all perfectly aware of +my freedom from the usual credulity as to the miraculous powers and +knowledge attributed to them); and though I know that there are medical +blackguards as well as military, legal, and clerical blackguards (one +soon finds that out when one is privileged to hear doctors talking shop +among themselves), the fact that I was no more at a loss for private +medical advice and attendance when I had not a penny in my pocket than I +was later on when I could afford fees on the highest scale, has made it +impossible for me to share that hostility to the doctor as a man which +exists and is growing as an inevitable result of the present condition +of medical practice. Not that the interest in disease and aberrations +which turns some men and women to medicine and surgery is not sometimes +as morbid as the interest in misery and vice which turns some others +to philanthropy and "rescue work." But the true doctor is inspired by +a hatred of ill-health, and a divine impatience of any waste of vital +forces. Unless a man is led to medicine or surgery through a very +exceptional technical aptitude, or because doctoring is a family +tradition, or because he regards it unintelligently as a lucrative and +gentlemanly profession, his motives in choosing the career of a healer +are clearly generous. However actual practice may disillusion and +corrupt him, his selection in the first instance is not a selection of a +base character. + + + + +THE DOCTOR'S HARDSHIPS + +A review of the counts in the indictment I have brought against private +medical practice will show that they arise out of the doctor's position +as a competitive private tradesman: that is, out of his poverty and +dependence. And it should be borne in mind that doctors are expected +to treat other people specially well whilst themselves submitting +to specially inconsiderate treatment. The butcher and baker are not +expected to feed the hungry unless the hungry can pay; but a doctor who +allows a fellow-creature to suffer or perish without aid is regarded as +a monster. Even if we must dismiss hospital service as really venal, +the fact remains that most doctors do a good deal of gratuitous work +in private practice all through their careers. And in his paid work the +doctor is on a different footing to the tradesman. Although the articles +he sells, advice and treatment, are the same for all classes, his fees +have to be graduated like the income tax. The successful fashionable +doctor may weed his poorer patients out from time to time, and finally +use the College of Physicians to place it out of his own power to accept +low fees; but the ordinary general practitioner never makes out his +bills without considering the taxable capacity of his patients. + +Then there is the disregard of his own health and comfort which results +from the fact that he is, by the nature of his work, an emergency man. +We are polite and considerate to the doctor when there is nothing the +matter, and we meet him as a friend or entertain him as a guest; but +when the baby is suffering from croup, or its mother has a temperature +of 104 degrees, or its grandfather has broken his leg, nobody thinks +of the doctor except as a healer and saviour. He may be hungry, +weary, sleepy, run down by several successive nights disturbed by that +instrument of torture, the night bell; but who ever thinks of this +in the face of sudden sickness or accident? We think no more of the +condition of a doctor attending a case than of the condition of +a fireman at a fire. In other occupations night-work is specially +recognized and provided for. The worker sleeps all day; has his +breakfast in the evening; his lunch or dinner at midnight; his dinner or +supper before going to bed in the morning; and he changes to day-work +if he cannot stand night-work. But a doctor is expected to work day and +night. In practices which consist largely of workmen's clubs, and in +which the patients are therefore taken on wholesale terms and very +numerous, the unfortunate assistant, or the principal if he has no +assistant, often does not undress, knowing that he will be called up +before he has snatched an hour's sleep. To the strain of such inhuman +conditions must be added the constant risk of infection. One wonders +why the impatient doctors do not become savage and unmanageable, and the +patient ones imbecile. Perhaps they do, to some extent. And the pay is +wretched, and so uncertain that refusal to attend without payment in +advance becomes often a necessary measure of self-defence, whilst the +County Court has long ago put an end to the tradition that the doctor's +fee is an honorarium. Even the most eminent physicians, as such +biographies as those of Paget show, are sometimes miserably, inhumanly +poor until they are past their prime. In short, the doctor needs our +help for the moment much more than we often need his. The ridicule of +Moliere, the death of a well-informed and clever writer like the late +Harold Frederic in the hands of Christian Scientists (a sort of sealing +with his blood of the contemptuous disbelief in and dislike of doctors +he had bitterly expressed in his books), the scathing and quite +justifiable exposure of medical practice in the novel by Mr. Maarten +Maartens entitled The New Religion: all these trouble the doctor very +little, and are in any case well set off by the popularity of Sir Luke +Fildes' famous picture, and by the verdicts in which juries from time to +time express their conviction that the doctor can do no wrong. The +real woes of the doctor are the shabby coat, the wolf at the door, +the tyranny of ignorant patients, the work-day of 24 hours, and the +uselessness of honestly prescribing what most of the patients really +need: that is, not medicine, but money. + + + + +THE PUBLIC DOCTOR + +What then is to be done? + +Fortunately we have not to begin absolutely from the beginning: we +already have, in the Medical Officer of Health, a sort of doctor who is +free from the worst hardships, and consequently from the worst vices, +of the private practitioner. His position depends, not on the number +of people who are ill, and whom he can keep ill, but on the number of +people who are well. He is judged, as all doctors and treatments should +be judged, by the vital statistics of his district. When the death rate +goes up his credit goes down. As every increase in his salary depends on +the issue of a public debate as to the health of the constituency under +his charge, he has every inducement to strive towards the ideal of a +clean bill of health. He has a safe, dignified, responsible, independent +position based wholly on the public health; whereas the private +practitioner has a precarious, shabby-genteel, irresponsible, servile +position, based wholly on the prevalence of illness. + +It is true, there are grave scandals in the public medical service. The +public doctor may be also a private practitioner eking out his earnings +by giving a little time to public work for a mean payment. There are +cases in which the position is one which no successful practitioner will +accept, and where, therefore, incapables or drunkards get automatically +selected for the post, faute de mieux; but even in these cases the +doctor is less disastrous in his public capacity than in his private +one: besides, the conditions which produce these bad cases are doomed, +as the evil is now recognized and understood. A popular but unstable +remedy is to enable local authorities, when they are too small to +require the undivided time of such men as the Medical Officers of our +great municipalities, to combine for public health purposes so that each +may share the services of a highly paid official of the best class; but +the right remedy is a larger area as the sanitary unit. + + + + +MEDICAL ORGANIZATION + +Another advantage of public medical work is that it admits of +organization, and consequently of the distribution of the work in such +a manner as to avoid wasting the time of highly qualified experts +on trivial jobs. The individualism of private practice leads to an +appalling waste of time on trifles. Men whose dexterity as operators or +almost divinatory skill in diagnosis are constantly needed for difficult +cases, are poulticing whitlows, vaccinating, changing unimportant +dressings, prescribing ether drams for ladies with timid leanings +towards dipsomania, and generally wasting their time in the pursuit of +private fees. In no other profession is the practitioner expected to +do all the work involved in it from the first day of his professional +career to the last as the doctor is. The judge passes sentence of death; +but he is not expected to hang the criminal with his own hands, as he +would be if the legal profession were as unorganized as the medical. The +bishop is not expected to blow the organ or wash the baby he baptizes. +The general is not asked to plan a campaign or conduct a battle at +half-past twelve and to play the drum at half-past two. Even if they +were, things would still not be as bad as in the medical profession; for +in it not only is the first-class man set to do third-class work, but, +what is much more terrifying, the third-class man is expected to do +first-class work. Every general practitioner is supposed to be capable +of the whole range of medical and surgical work at a moment's notice; +and the country doctor, who has not a specialist nor a crack consultant +at the end of his telephone, often has to tackle without hesitation +cases which no sane practitioner in a town would take in hand without +assistance. No doubt this develops the resourcefulness of the country +doctor, and makes him a more capable man than his suburban colleague; +but it cannot develop the second-class man into a first-class one. If +the practice of law not only led to a judge having to hang, but the +hangman to judge, or if in the army matters were so arranged that it +would be possible for the drummer boy to be in command at Waterloo +whilst the Duke of Wellington was playing the drum in Brussels, we +should not be consoled by the reflection that our hangmen were thereby +made a little more judicial-minded, and our drummers more responsible, +than in foreign countries where the legal and military professions +recognized the advantages of division of labor. + +Under such conditions no statistics as to the graduation of professional +ability among doctors are available. Assuming that doctors are normal +men and not magicians (and it is unfortunately very hard to persuade +people to admit so much and thereby destroy the romance of doctoring) +we may guess that the medical profession, like the other professions, +consists of a small percentage of highly gifted persons at one end, +and a small percentage of altogether disastrous duffers at the other. +Between these extremes comes the main body of doctors (also, of +course, with a weak and a strong end) who can be trusted to work under +regulations with more or less aid from above according to the gravity +of the case. Or, to put it in terms of the cases, there are cases that +present no difficulties, and can be dealt with by a nurse or student at +one end of the scale, and cases that require watching and handling by +the very highest existing skill at the other; whilst between come +the great mass of cases which need visits from the doctor of ordinary +ability and from the chiefs of the profession in the proportion of, say, +seven to none, seven to one, three to one, one to one, or, for a day +or two, none to one. Such a service is organized at present only +in hospitals; though in large towns the practice of calling in the +consultant acts, to some extent, as a substitute for it. But in the +latter case it is quite unregulated except by professional etiquet, +which, as we have seen, has for its object, not the health of the +patient or of the community at large, but the protection of the doctor's +livelihood and the concealment of his errors. And as the consultant is +an expensive luxury, he is a last resource rather, as he should be, than +a matter of course, in all cases where the general practitioner is not +equal to the occasion: a predicament in which a very capable man may +find himself at any time through the cropping up of a case of which he +has had no clinical experience. + + + + +THE SOCIAL SOLUTION OF THE MEDICAL PROBLEM + +The social solution of the medical problem, then, depends on that large, +slowly advancing, pettishly resisted integration of society called +generally Socialism. Until the medical profession becomes a body of men +trained and paid by the country to keep the country in health it will +remain what it is at present: a conspiracy to exploit popular credulity +and human suffering. Already our M.O.H.s (Medical Officers of Health) +are in the new position: what is lacking is appreciation of the change, +not only by the public but by the private doctors. For, as we have seen, +when one of the first-rate posts becomes vacant in one of the great +cities, and all the leading M.O.H.s compete for it, they must appeal to +the good health of the cities of which they have been in charge, and not +to the size of the incomes the local private doctors are making out of +the ill-health of their patients. If a competitor can prove that he has +utterly ruined every sort of medical private practice in a large city +except obstetric practice and the surgery of accidents, his claims are +irresistible; and this is the ideal at which every M.O.H. should aim. +But the profession at large should none the less welcome him and set +its house in order for the social change which will finally be its own +salvation. For the M.O.H. as we know him is only the beginning of that +army of Public Hygiene which will presently take the place in general +interest and honor now occupied by our military and naval forces. It is +silly that an Englishman should be more afraid of a German soldier than +of a British disease germ, and should clamor for more barracks in the +same newspapers that protest against more school clinics, and cry out +that if the State fights disease for us it makes us paupers, though +they never say that if the State fights the Germans for us it makes us +cowards. Fortunately, when a habit of thought is silly it only needs +steady treatment by ridicule from sensible and witty people to be put +out of countenance and perish. Every year sees an increase in the number +of persons employed in the Public Health Service, who would formerly +have been mere adventurers in the Private Illness Service. To put it +another way, a host of men and women who have now a strong incentive +to be mischievous and even murderous rogues will have a much stronger, +because a much honester, incentive to be not only good citizens but +active benefactors to the community. And they will have no anxiety +whatever about their incomes. + + + + +THE FUTURE OF PRIVATE PRACTICE + +It must not be hastily concluded that this involves the extinction of +the private practitioner. What it will really mean for him is release +from his present degrading and scientifically corrupting slavery to his +patients. As I have already shown the doctor who has to live by pleasing +his patients in competition with everybody who has walked the hospitals, +scraped through the examinations, and bought a brass plate, soon finds +himself prescribing water to teetotallers and brandy or champagne jelly +to drunkards; beefsteaks and stout in one house, and "uric acid free" +vegetarian diet over the way; shut windows, big fires, and heavy +overcoats to old Colonels, and open air and as much nakedness as is +compatible with decency to young faddists, never once daring to say +either "I don't know," or "I don't agree." For the strength of the +doctor's, as of every other man's position when the evolution of social +organization at last reaches his profession, will be that he will always +have open to him the alternative of public employment when the private +employer becomes too tyrannous. And let no one suppose that the words +doctor and patient can disguise from the parties the fact that they are +employer and employee. No doubt doctors who are in great demand can be +as high-handed and independent as employees are in all classes when a +dearth in their labor market makes them indispensable; but the average +doctor is not in this position: he is struggling for life in an +overcrowded profession, and knows well that "a good bedside manner" +will carry him to solvency through a morass of illness, whilst the +least attempt at plain dealing with people who are eating too much, or +drinking too much, or frowsting too much (to go no further in the list +of intemperances that make up so much of family life) would soon land +him in the Bankruptcy Court. + +Private practice, thus protected, would itself protect individuals, as +far as such protection is possible, against the errors and superstitions +of State medicine, which are at worst no worse than the errors and +superstitions of private practice, being, indeed, all derived from it. +Such monstrosities as vaccination are, as we have seen, founded, not on +science, but on half-crowns. If the Vaccination Acts, instead of being +wholly repealed as they are already half repealed, were strengthened by +compelling every parent to have his child vaccinated by a public officer +whose salary was completely independent of the number of vaccinations +performed by him, and for whom there was plenty of alternative public +health work waiting, vaccination would be dead in two years, as the +vaccinator would not only not gain by it, but would lose credit through +the depressing effects on the vital statistics of his district of the +illness and deaths it causes, whilst it would take from him all the +credit of that freedom from smallpox which is the result of good +sanitary administration and vigilant prevention of infection. Such +absurd panic scandals as that of the last London epidemic, where a fee +of half-a-crown per re-vaccination produced raids on houses during +the absence of parents, and the forcible seizure and re-vaccination of +children left to answer the door, can be prevented simply by abolishing +the half-crown and all similar follies, paying, not for this or that +ceremony of witchcraft, but for immunity from disease, and paying, too, +in a rational way. The officer with a fixed salary saves himself trouble +by doing his business with the least possible interference with the +private citizen. The man paid by the job loses money by not forcing his +job on the public as often as possible without reference to its results. + + + + +THE TECHNICAL PROBLEM + +As to any technical medical problem specially involved, there is none. +If there were, I should not be competent to deal with it, as I am not a +technical expert in medicine: I deal with the subject as an economist, a +politician, and a citizen exercising my common sense. Everything that I +have said applies equally to all the medical techniques, and will hold +good whether public hygiene be based on the poetic fancies of Christian +Science, the tribal superstitions of the druggist and the vivisector, or +the best we can make of our real knowledge. But I may remind those +who confusedly imagine that the medical problem is also the scientific +problem, that all problems are finally scientific problems. The notion +that therapeutics or hygiene or surgery is any more or less scientific +than making or cleaning boots is entertained only by people to whom +a man of science is still a magician who can cure diseases, transmute +metals, and enable us to live for ever. It may still be necessary for +some time to come to practise on popular credulity, popular love and +dread of the marvellous, and popular idolatry, to induce the poor +to comply with the sanitary regulations they are too ignorant +to understand. As I have elsewhere confessed, I have myself been +responsible for ridiculous incantations with burning sulphur, +experimentally proved to be quite useless, because poor people are +convinced, by the mystical air of the burning and the horrible smell, +that it exorcises the demons of smallpox and scarlet fever and makes it +safe for them to return to their houses. To assure them that the real +secret is sunshine and soap is only to convince them that you do not +care whether they live or die, and wish to save money at their expense. +So you perform the incantation; and back they go to their houses, +satisfied. A religious ceremony--a poetic blessing of the threshold, for +instance--would be much better; but unfortunately our religion is weak +on the sanitary side. One of the worst misfortunes of Christendom was +that reaction against the voluptuous bathing of the imperial Romans +which made dirty habits a part of Christian piety, and in some unlucky +places (the Sandwich Islands for example) made the introduction of +Christianity also the introduction of disease, because the formulators +of the superseded native religion, like Mahomet, had been enlightened +enough to introduce as religious duties such sanitary measures as +ablution and the most careful and reverent treatment of everything +cast off by the human body, even to nail clippings and hairs; and our +missionaries thoughtlessly discredited this godly doctrine without +supplying its place, which was promptly taken by laziness and neglect. +If the priests of Ireland could only be persuaded to teach their flocks +that it is a deadly insult to the Blessed Virgin to place her image in a +cottage that is not kept up to that high standard of Sunday cleanliness +to which all her worshippers must believe she is accustomed, and to +represent her as being especially particular about stables because +her son was born in one, they might do more in one year than all the +Sanitary Inspectors in Ireland could do in twenty; and they could hardly +doubt that Our Lady would be delighted. Perhaps they do nowadays; for +Ireland is certainly a transfigured country since my youth as far as +clean faces and pinafores can transfigure it. In England, where so +many of the inhabitants are too gross to believe in poetic faiths, too +respectable to tolerate the notion that the stable at Bethany was a +common peasant farmer's stable instead of a first-rate racing one, and +too savage to believe that anything can really cast out the devil of +disease unless it be some terrifying hoodoo of tortures and stinks, the +M.O.H. will no doubt for a long time to come have to preach to fools +according to their folly, promising miracles, and threatening hideous +personal consequences of neglect of by-laws and the like; therefore it +will be important that every M.O.H. shall have, with his (or her) other +qualifications, a sense of humor, lest (he or she) should come at last +to believe all the nonsense that must needs be talked. But he must, in +his capacity of an expert advising the authorities, keep the government +itself free of superstition. If Italian peasants are so ignorant that +the Church can get no hold of them except by miracles, why, miracles +there must be. The blood of St. Januarius must liquefy whether the +Saint is in the humor or not. To trick a heathen into being a dutiful +Christian is no worse than to trick a whitewasher into trusting himself +in a room where a smallpox patient has lain, by pretending to exorcise +the disease with burning sulphur. But woe to the Church if in deceiving +the peasant it also deceives itself; for then the Church is lost, and +the peasant too, unless he revolt against it. Unless the Church works +the pretended miracle painfully against the grain, and is continually +urged by its dislike of the imposture to strive to make the peasant +susceptible to the true reasons for behaving well, the Church will +become an instrument of his corruption and an exploiter of his +ignorance, and will find itself launched upon that persecution of +scientific truth of which all priesthoods are accused and none with more +justice than the scientific priesthood. + +And here we come to the danger that terrifies so many of us: the danger +of having a hygienic orthodoxy imposed on us. But we must face that: in +such crowded and poverty ridden civilizations as ours any orthodoxy +is better than laisser-faire. If our population ever comes to consist +exclusively of well-to-do, highly cultivated, and thoroughly instructed +free persons in a position to take care of themselves, no doubt they +will make short work of a good deal of official regulation that is now +of life-and-death necessity to us; but under existing circumstances, I +repeat, almost any sort of attention that democracy will stand is better +than neglect. Attention and activity lead to mistakes as well as +to successes; but a life spent in making mistakes is not only more +honorable but more useful than a life spent doing nothing. The one +lesson that comes out of all our theorizing and experimenting is that +there is only one really scientific progressive method; and that is the +method of trial and error. If you come to that, what is laisser-faire +but an orthodoxy? the most tyrannous and disastrous of all the +orthodoxies, since it forbids you even to learn. + + + + +THE LATEST THEORIES + +Medical theories are so much a matter of fashion, and the most fertile +of them are modified so rapidly by medical practice and biological +research, which are international activities, that the play which +furnishes the pretext for this preface is already slightly outmoded, +though I believe it may be taken as a faithful record for the year +(1906) in which it was begun. I must not expose any professional man to +ruin by connecting his name with the entire freedom of criticism which +I, as a layman, enjoy; but it will be evident to all experts that my +play could not have been written but for the work done by Sir Almroth +Wright in the theory and practice of securing immunization from +bacterial diseases by the inoculation of "vaccines" made of their own +bacteria: a practice incorrectly called vaccinetherapy (there is nothing +vaccine about it) apparently because it is what vaccination ought to be +and is not. Until Sir Almroth Wright, following up one of Metchnikoff's +most suggestive biological romances, discovered that the white +corpuscles or phagocytes which attack and devour disease germs for us do +their work only when we butter the disease germs appetizingly for them +with a natural sauce which Sir Almroth named opsonin, and that our +production of this condiment continually rises and falls rhythmically +from negligibility to the highest efficiency, nobody had been able +even to conjecture why the various serums that were from time to time +introduced as having effected marvellous cures, presently made such +direful havoc of some unfortunate patient that they had to be dropped +hastily. The quantity of sturdy lying that was necessary to save the +credit of inoculation in those days was prodigious; and had it not been +for the devotion shown by the military authorities throughout Europe, +who would order the entire disappearance of some disease from their +armies, and bring it about by the simple plan of changing the name +under which the cases were reported, or for our own Metropolitan Asylums +Board, which carefully suppressed all the medical reports that revealed +the sometimes quite appalling effects of epidemics of revaccination, +there is no saying what popular reaction might not have taken place +against the whole immunization movement in therapeutics. + +The situation was saved when Sir Almroth Wright pointed out that if you +inoculated a patient with pathogenic germs at a moment when his powers +of cooking them for consumption by the phagocytes was receding to its +lowest point, you would certainly make him a good deal worse and perhaps +kill him, whereas if you made precisely the same inoculation when the +cooking power was rising to one of its periodical climaxes, you would +stimulate it to still further exertions and produce just the opposite +result. And he invented a technique for ascertaining in which phase the +patient happened to be at any given moment. The dramatic possibilities +of this discovery and invention will be found in my play. But it is one +thing to invent a technique: it is quite another to persuade the medical +profession to acquire it. Our general practitioners, I gather, simply +declined to acquire it, being mostly unable to afford either the +acquisition or the practice of it when acquired. Something simple, +cheap, and ready at all times for all comers, is, as I have shown, the +only thing that is economically possible in general practice, whatever +may be the case in Sir Almroth's famous laboratory in St. Mary's +Hospital. It would have become necessary to denounce opsonin in the +trade papers as a fad and Sir Almroth as a dangerous man if his practice +in the laboratory had not led him to the conclusion that the customary +inoculations were very much too powerful, and that a comparatively +infinitesimal dose would not precipitate a negative phase of cooking +activity, and might induce a positive one. And thus it happens that the +refusal of our general practitioners to acquire the new technique is +no longer quite so dangerous in practice as it was when The Doctor's +Dilemma was written: nay, that Sir Ralph Bloomfield Boningtons way of +administering inoculations as if they were spoonfuls of squills may +sometimes work fairly well. For all that, I find Sir Almroth Wright, +on the 23rd May, 1910, warning the Royal Society of Medicine that "the +clinician has not yet been prevailed upon to reconsider his position," +which means that the general practitioner ("the doctor," as he is called +in our homes) is going on just as he did before, and could not afford +to learn or practice a new technique even if he had ever heard of it. +To the patient who does not know about it he will say nothing. To the +patient who does, he will ridicule it, and disparage Sir Almroth. What +else can he do, except confess his ignorance and starve? + +But now please observe how "the whirligig of time brings its revenges." +This latest discovery of the remedial virtue of a very, very tiny +hair of the dog that bit you reminds us, not only of Arndt's law of +protoplasmic reaction to stimuli, according to which weak and strong +stimuli provoke opposite reactions, but of Hahnemann's homeopathy, which +was founded on the fact alleged by Hahnemann that drugs which produce +certain symptoms when taken in ordinary perceptible quantities, will, +when taken in infinitesimally small quantities, provoke just the +opposite symptoms; so that the drug that gives you a headache will +also cure a headache if you take little enough of it. I have already +explained that the savage opposition which homeopathy encountered from +the medical profession was not a scientific opposition; for nobody seems +to deny that some drugs act in the alleged manner. It was opposed simply +because doctors and apothecaries lived by selling bottles and boxes of +doctor's stuff to be taken in spoonfuls or in pellets as large as peas; +and people would not pay as much for drops and globules no bigger than +pins' heads. Nowadays, however, the more cultivated folk are beginning +to be so suspicious of drugs, and the incorrigibly superstitious people +so profusely supplied with patent medicines (the medical advice to take +them being wrapped round the bottle and thrown in for nothing) that +homeopathy has become a way of rehabilitating the trade of prescription +compounding, and is consequently coming into professional credit. At +which point the theory of opsonins comes very opportunely to shake hands +with it. + +Add to the newly triumphant homeopathist and the opsonist that other +remarkable innovator, the Swedish masseur, who does not theorize about +you, but probes you all over with his powerful thumbs until he finds out +your sore spots and rubs them away, besides cheating you into a little +wholesome exercise; and you have nearly everything in medical practice +to-day that is not flat witchcraft or pure commercial exploitation of +human credulity and fear of death. Add to them a good deal of vegetarian +and teetotal controversy raging round a clamor for scientific eating +and drinking, and resulting in little so far except calling digestion +Metabolism and dividing the public between the eminent doctor who tells +us that we do not eat enough fish, and his equally eminent colleague +who warns us that a fish diet must end in leprosy, and you have all that +opposes with any sort of countenance the rise of Christian Science with +its cathedrals and congregations and zealots and miracles and cures: +all very silly, no doubt, but sane and sensible, poetic and hopeful, +compared to the pseudo science of the commercial general practitioner, +who foolishly clamors for the prosecution and even the execution of the +Christian Scientists when their patients die, forgetting the long death +roll of his own patients. + +By the time this preface is in print the kaleidoscope may have had +another shake; and opsonin may have gone the way of phlogiston at the +hands of its own restless discoverer. I will not say that Hahnemann may +have gone the way of Diafoirus; for Diafoirus we have always with us. +But we shall still pick up all our knowledge in pursuit of some Will o' +the Wisp or other. What is called science has always pursued the Elixir +of Life and the Philosopher's Stone, and is just as busy after them +to-day as ever it was in the days of Paracelsus. We call them by +different names: Immunization or Radiology or what not; but the dreams +which lure us into the adventures from which we learn are always at +bottom the same. Science becomes dangerous only when it imagines that +it has reached its goal. What is wrong with priests and popes is that +instead of being apostles and saints, they are nothing but empirics +who say "I know" instead of "I am learning," and pray for credulity and +inertia as wise men pray for scepticism and activity. Such abominations +as the Inquisition and the Vaccination Acts are possible only in the +famine years of the soul, when the great vital dogmas of honor, liberty, +courage, the kinship of all life, faith that the unknown is greater than +the known and is only the As Yet Unknown, and resolution to find a +manly highway to it, have been forgotten in a paroxysm of littleness and +terror in which nothing is active except concupiscence and the fear of +death, playing on which any trader can filch a fortune, any blackguard +gratify his cruelty, and any tyrant make us his slaves. + +Lest this should seem too rhetorical a conclusion for our professional +men of science, who are mostly trained not to believe anything unless it +is worded in the jargon of those writers who, because they never really +understand what they are trying to say, cannot find familiar words for +it, and are therefore compelled to invent a new language of nonsense +for every book they write, let me sum up my conclusions as dryly as is +consistent with accurate thought and live conviction. + +1. Nothing is more dangerous than a poor doctor: not even a poor +employer or a poor landlord. + +2. Of all the anti-social vested interests the worst is the vested +interest in ill-health. + +3. Remember that an illness is a misdemeanor; and treat the doctor as an +accessory unless he notifies every case to the Public Health authority. + +4. Treat every death as a possible and under our present system a +probable murder, by making it the subject of a reasonably conducted +inquest; and execute the doctor, if necessary, as a doctor, by striking +him off the register. + +5. Make up your mind how many doctors the community needs to keep +it well. Do not register more or less than this number; and let +registration constitute the doctor a civil servant with a dignified +living wage paid out of public funds. + +6. Municipalize Harley Street. + +7. Treat the private operator exactly as you would treat a private +executioner. + +8. Treat persons who profess to be able to cure disease as you +treat fortune tellers. + +9. Keep the public carefully informed, by special statistics and +announcements of individual cases, of all illnesses of doctors or in +their families. + +10. Make it compulsory for a doctor using a brass plate to +have inscribed on it, in addition to the letters indicating his +qualifications, the words "Remember that I too am mortal." + +11. In legislation and social organization, proceed on the principle +that invalids, meaning persons who cannot keep themselves alive by their +own activities, cannot, beyond reason, expect to be kept alive by +the activity of others. There is a point at which the most energetic +policeman or doctor, when called upon to deal with an apparently drowned +person, gives up artificial respiration, although it is never possible +to declare with certainty, at any point short of decomposition, that +another five minutes of the exercise would not effect resuscitation. The +theory that every individual alive is of infinite value is legislatively +impracticable. No doubt the higher the life we secure to the individual +by wise social organization, the greater his value is to the community, +and the more pains we shall take to pull him through any temporary +danger or disablement. But the man who costs more than he is worth is +doomed by sound hygiene as inexorably as by sound economics. + +12. Do not try to live for ever. You will not succeed. + +13. Use your health, even to the point of wearing it out. That is +what it is for. Spend all you have before you die; and do not outlive +yourself. + +14. Take the utmost care to get well born and well brought up. This +means that your mother must have a good doctor. Be careful to go to +a school where there is what they call a school clinic, where your +nutrition and teeth and eyesight and other matters of importance to you +will be attended to. Be particularly careful to have all this done at +the expense of the nation, as otherwise it will not be done at all, the +chances being about forty to one against your being able to pay for it +directly yourself, even if you know how to set about it. Otherwise +you will be what most people are at present: an unsound citizen of an +unsound nation, without sense enough to be ashamed or unhappy about it. + + + + + + + + + + +End of the Project Gutenberg EBook of The Doctor's Dilemma: Preface on +Doctors, by George Bernard Shaw + +*** END OF THIS PROJECT GUTENBERG EBOOK PREFACE TO DOCTOR'S DILEMMA *** + +***** This file should be named 5069.txt or 5069.zip ***** +This and all associated files of various formats will be found in: + http://www.gutenberg.org/5/0/6/5069/ + +Produced by Eve Sobol + +Updated editions will replace the previous one--the old editions +will be renamed. + +Creating the works from public domain print editions means that no +one owns a United States copyright in these works, so the Foundation +(and you!) can copy and distribute it in the United States without +permission and without paying copyright royalties. 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But that is precisely what we have done. And +the more appalling the mutilation, the more the mutilator is paid. +He who corrects the ingrowing toe-nail receives a few shillings: +he who cuts your inside out receives hundreds of guineas, except +when he does it to a poor person for practice. + +Scandalized voices murmur that these operations are unnecessary. +They may be. It may also be necessary to hang a man or pull down a +house. But we take good care not to make the hangman and the +housebreaker the judges of that. If we did, no man's neck would be +safe and no man's house stable. But we do make the doctor the +judge, and fine him anything from sixpence to several hundred +guineas if he decides in our favor. I cannot knock my shins +severely without forcing on some surgeon the difficult question, +"Could I not make a better use of a pocketful of guineas than this +man is making of his leg? Could he not write as well--or even +better--on one leg than on two? And the guineas would make all the +difference in the world to me just now. My wife--my pretty ones-- +the leg may mortify--it is always safer to operate--he will be +well in a fortnight--artificial legs are now so well made that +they are really better than natural ones--evolution is towards +motors and leglessness, etc., etc., etc." + +Now there is no calculation that an engineer can make as to the +behavior of a girder under a strain, or an astronomer as to the +recurrence of a comet, more certain than the calculation that +under such circumstances we shall be dismembered unnecessarily in +all directions by surgeons who believe the operations to be +necessary solely because they want to perform them. The process +metaphorically called bleeding the rich man is performed not only +metaphorically but literally every day by surgeons who are quite +as honest as most of us. After all, what harm is there in it? The +surgeon need not take off the rich man's (or woman's) leg or arm: +he can remove the appendix or the uvula, and leave the patient +none the worse after a fortnight or so in bed, whilst the nurse, +the general practitioner, the apothecary, and the surgeon will be +the better. + + +DOUBTFUL CHARACTER BORNE BY THE MEDICAL PROFESSION + +Again I hear the voices indignantly muttering old phrases about +the high character of a noble profession and the honor and +conscience of its members. I must reply that the medical +profession has not a high character: it has an infamous character. +I do not know a single thoughtful and well-informed person who +does not feel that the tragedy of illness at present is that it +delivers you helplessly into the hands of a profession which you +deeply mistrust, because it not only advocates and practises the +most revolting cruelties in the pursuit of knowledge, and +justifies them on grounds which would equally justify practising +the same cruelties on yourself or your children, or burning down +London to test a patent fire extinguisher, but, when it has +shocked the public, tries to reassure it with lies of breath- +bereaving brazenness. That is the character the medical profession +has got just now. It may be deserved or it may not: there it is at +all events, and the doctors who have not realized this are living +in a fool's paradise. As to the humor and conscience of doctors, +they have as much as any other class of men, no more and no less. +And what other men dare pretend to be impartial where they have a +strong pecuniary interest on one side? Nobody supposes that +doctors are less virtuous than judges; but a judge whose salary +and reputation depended on whether the verdict was for plaintiff +or defendant, prosecutor or prisoner, would be as little trusted +as a general in the pay of the enemy. To offer me a doctor as my +judge, and then weight his decision with a bribe of a large sum of +money and a virtual guarantee that if he makes a mistake it can +never be proved against him, is to go wildly beyond the +ascertained strain which human nature will bear. It is simply +unscientific to allege or believe that doctors do not under +existing circumstances perform unnecessary operations and +manufacture and prolong lucrative illnesses. The only ones who can +claim to be above suspicion are those who are so much sought after +that their cured patients are immediately replaced by fresh ones. +And there is this curious psychological fact to be remembered: a +serious illness or a death advertizes the doctor exactly as a +hanging advertizes the barrister who defended the person hanged. +Suppose, for example, a royal personage gets something wrong with +his throat, or has a pain in his inside. If a doctor effects some +trumpery cure with a wet compress or a peppermint lozenge nobody +takes the least notice of him. But if he operates on the throat +and kills the patient, or extirpates an internal organ and keeps +the whole nation palpitating for days whilst the patient hovers in +pain and fever between life and death, his fortune is made: every +rich man who omits to call him in when the same symptoms appear in +his household is held not to have done his utmost duty to the +patient. The wonder is that there is a king or queen left alive in +Europe. + + +DOCTOR'S CONSCIENCES + +There is another difficulty in trusting to the honor and +conscience of a doctor. Doctors are just like other Englishmen: +most of them have no honor and no conscience: what they commonly +mistake for these is sentimentality and an intense dread of doing +anything that everybody else does not do, or omitting to do +anything that everybody else does. This of course does amount to a +sort of working or rule-of-thumb conscience; but it means that you +will do anything, good or bad, provided you get enough people to +keep you in countenance by doing it also. It is the sort of +conscience that makes it possible to keep order on a pirate ship, +or in a troop of brigands. It may be said that in the last +analysis there is no other sort of honor or conscience in +existence--that the assent of the majority is the only sanction +known to ethics. No doubt this holds good in political practice. +If mankind knew the facts, and agreed with the doctors, then the +doctors would be in the right; and any person who thought +otherwise would be a lunatic. But mankind does not agree, and does +not know the facts. All that can be said for medical popularity is +that until there is a practicable alternative to blind trust in +the doctor, the truth about the doctor is so terrible that we dare +not face it. Moliere saw through the doctors; but he had to call +them in just the same. Napoleon had no illusions about them; but +he had to die under their treatment just as much as the most +credulous ignoramus that ever paid sixpence for a bottle of strong +medicine. In this predicament most people, to save themselves from +unbearable mistrust and misery, or from being driven by their +conscience into actual conflict with the law, fall back on the old +rule that if you cannot have what you believe in you must believe +in what you have. When your child is ill or your wife dying, and +you happen to be very fond of them, or even when, if you are not +fond of them, you are human enough to forget every personal grudge +before the spectacle of a fellow creature in pain or peril, what +you want is comfort, reassurance, something to clutch at, were it +but a straw. This the doctor brings you. You have a wildly urgent +feeling that something must be done; and the doctor does +something. Sometimes what he does kills the patient; but you do +not know that; and the doctor assures you that all that human +skill could do has been done. And nobody has the brutality to say +to the newly bereft father, mother, husband, wife, brother, or +sister, "You have killed your lost darling by your credulity." + + +THE PECULIAR PEOPLE + +Besides, the calling in of the doctor is now compulsory except in +cases where the patient is an adult--and not too ill to decide the +steps to be taken. We are subject to prosecution for manslaughter +or for criminal neglect if the patient dies without the +consolations of the medical profession. This menace is kept before +the public by the Peculiar People. The Peculiars, as they are +called, have gained their name by believing that the Bible is +infallible, and taking their belief quite seriously. The Bible is +very clear as to the treatment of illness. The Epistle of James; +chapter v., contains the following explicit directions: + +14. Is any sick among you? let him call for the elders of +the Church; and let them pray over him, anointing him with +oil in the name of the Lord: + +15. And the prayer of faith shall save the sick, and the +Lord shall raise him up; and if he have committed sins, they +shall be forgiven him. + +The Peculiars obey these instructions and dispense with doctors. +They are therefore prosecuted for manslaughter when their children +die. + +When I was a young man, the Peculiars were usually acquitted. The +prosecution broke down when the doctor in the witness box was +asked whether, if the child had had medical attendance, it would +have lived. It was, of course, impossible for any man of sense and +honor to assume divine omniscience by answering this in the +affirmative, or indeed pretending to be able to answer it at all. +And on this the judge had to instruct the jury that they must +acquit the prisoner. Thus a judge with a keen sense of law (a very +rare phenomenon on the Bench, by the way) was spared the +possibility of leaving to sentence one prisoner (under the +Blasphemy laws) for questioning the authority of Scripture, and +another for ignorantly and superstitiously accepting it as a guide +to conduct. To-day all this is changed. The doctor never hesitates +to claim divine omniscience, nor to clamor for laws to punish any +scepticism on the part of laymen. A modern doctor thinks nothing +of signing the death certificate of one of his own diphtheria +patients, and then going into the witness box and swearing a +peculiar into prison for six months by assuring the jury, on oath, +that if the prisoner's child, dead of diphtheria, had been placed +under his treatment instead of that of St. James, it would not +have lived. And he does so not only with impunity, but with public +applause, though the logical course would be to prosecute him +either for the murder of his own patient or for perjury in the +case of St. James. Yet no barrister, apparently, dreams of asking +for the statistics of the relative case-mortality in diphtheria +among the Peculiars and among the believers in doctors, on which +alone any valid opinion could be founded. The barrister is as +superstitious as the doctor is infatuated; and the Peculiar goes +unpitied to his cell, though nothing whatever has been proved +except that his child does without the interference of a doctor as +effectually as any of the hundreds of children who die every day +of the same diseases in the doctor's care. + + +RECOIL OF THE DOGMA OF MEDICAL INFALLIBILITY ON THE DOCTOR + +On the other hand, when the doctor is in the dock, or is the +defendant in an action for malpractice, he has to struggle against +the inevitable result of his former pretences to infinite +knowledge and unerring skill. He has taught the jury and the +judge, and even his own counsel, to believe that every doctor can, +with a glance at the tongue, a touch on the pulse, and a reading +of the clinical thermometer, diagnose with absolute certainty a +patient's complaint, also that on dissecting a dead body he can +infallibly put his finger on the cause of death, and, in cases +where poisoning is suspected, the nature of the poison used. Now +all this supposed exactness and infallibility is imaginary; and to +treat a doctor as if his mistakes were necessarily malicious or +corrupt malpractices (an inevitable deduction from the postulate +that the doctor, being omniscient, cannot make mistakes) is as +unjust as to blame the nearest apothecary for not being prepared +to supply you with sixpenny-worth of the elixir of life, or the +nearest motor garage for not having perpetual motion on sale in +gallon tins. But if apothecaries and motor car makers habitually +advertized elixir of life and perpetual motion, and succeeded in +creating a strong general belief that they could supply it, they +would find themselves in an awkward position if they were indicted +for allowing a customer to die, or for burning a chauffeur by +putting petrol into his car. That is the predicament the doctor +finds himself in when he has to defend himself against a charge of +malpractice by a plea of ignorance and fallibility. His plea is +received with flat credulity; and he gets little sympathy, even +from laymen who know, because he has brought the incredulity on +himself. If he escapes, he can only do so by opening the eyes of +the jury to the facts that medical science is as yet very +imperfectly differentiated from common curemongering witchcraft; +that diagnosis, though it means in many instances (including even +the identification of pathogenic bacilli under the microscope) +only a choice among terms so loose that they would not be accepted +as definitions in any really exact science, is, even at that, an +uncertain and difficult matter on which doctors often differ; and +that the very best medical opinion and treatment varies widely +from doctor to doctor, one practitioner prescribing six or seven +scheduled poisons for so familiar a disease as enteric fever where +another will not tolerate drugs at all; one starving a patient +whom another would stuff; one urging an operation which another +would regard as unnecessary and dangerous; one giving alcohol and +meat which another would sternly forbid, etc., etc., etc.: all +these discrepancies arising not between the opinion of good +doctors and bad ones (the medical contention is, of course, that a +bad doctor is an impossibility), but between practitioners of +equal eminence and authority. Usually it is impossible to persuade +the jury that these facts are facts. Juries seldom notice facts; +and they have been taught to regard any doubts of the omniscience +and omnipotence of doctors as blasphemy. Even the fact that +doctors themselves die of the very diseases they profess to cure +passes unnoticed. We do not shoot out our lips and shake our +heads, saying, "They save others: themselves they cannot save": +their reputation stands, like an African king's palace, on a +foundation of dead bodies; and the result is that the verdict goes +against the defendant when the defendant is a doctor accused of +malpractice. + +Fortunately for the doctors, they very seldom find themselves in +this position, because it is so difficult to prove anything +against them. The only evidence that can decide a case of +malpractice is expert evidence: that is, the evidence of other +doctors; and every doctor will allow a colleague to decimate a +whole countryside sooner than violate the bond of professional +etiquet by giving him away. It is the nurse who gives the doctor +away in private, because every nurse has some particular doctor +whom she likes; and she usually assures her patients that all the +others are disastrous noodles, and soothes the tedium of the sick- +bed by gossip about their blunders. She will even give a doctor +away for the sake of making the patient believe that she knows +more than the doctor. But she dare not, for her livelihood, give +the doctor away in public. And the doctors stand by one another at +all costs. Now and then some doctor in an unassailable position, +like the late Sir William Gull, will go into the witness box and +say what he really thinks about the way a patient has been +treated; but such behavior is considered little short of infamous +by his colleagues. + + +WHY DOCTORS DO NOT DIFFER + +The truth is, there would never be any public agreement among +doctors if they did not agree to agree on the main point of the +doctor being always in the right. Yet the two guinea man never +thinks that the five shilling man is right: if he did, he would +be understood as confessing to an overcharge of one pound +seventeen shillings; and on the same ground the five shilling man +cannot encourage the notion that the owner of the sixpenny +surgery round the corner is quite up to his mark. Thus even the +layman has to be taught that infallibility is not quite +infallible, because there are two qualities of it to be had at +two prices. + +But there is no agreement even in the same rank at the same +price. During the first great epidemic of influenza towards the +end of the nineteenth century a London evening paper sent round a +journalist-patient to all the great consultants of that day, and +published their advice and prescriptions; a proceeding +passionately denounced by the medical papers as a breach of +confidence of these eminent physicians. The case was the same; +but the prescriptions were different, and so was the advice. Now +a doctor cannot think his own treatment right and at the same +time think his colleague right in prescribing a different +treatment when the patient is the same. Anyone who has ever known +doctors well enough to hear medical shop talked without reserve +knows that they are full of stories about each other's blunders +and errors, and that the theory of their omniscience and +omnipotence no more holds good among themselves than it did with +Moliere and Napoleon. But for this very reason no doctor dare +accuse another of malpractice. He is not sure enough of his own +opinion to ruin another man by it. He knows that if such conduct +were tolerated in his profession no doctor's livelihood or +reputation would be worth a year's purchase. I do not blame him: +I would do the same myself. But the effect of this state of +things is to make the medical profession a conspiracy to hide its +own shortcomings. No doubt the same may be said of all +professions. They are all conspiracies against the laity; and I +do not suggest that the medical conspiracy is either better or +worse than the military conspiracy, the legal conspiracy, the +sacerdotal conspiracy, the pedagogic conspiracy, the royal and +aristocratic conspiracy, the literary and artistic conspiracy, +and the innumerable industrial, commercial, and financial +conspiracies, from the trade unions to the great exchanges, which +make up the huge conflict which we call society. But it is less +suspected. The Radicals who used to advocate, as an indispensable +preliminary to social reform, the strangling of the last king +with the entrails of the last priest, substituted compulsory +vaccination for compulsory baptism without a murmur. + + +THE CRAZE FOR OPERATIONS + +Thus everything is on the side of the doctor. When men die of +disease they are said to die from natural causes. When they +recover (and they mostly do) the doctor gets the credit of curing +them. In surgery all operations are recorded as successful if the +patient can be got out of the hospital or nursing home alive, +though the subsequent history of the case may be such as would +make an honest surgeon vow never to recommend or perform the +operation again. The large range of operations which consist of +amputating limbs and extirpating organs admits of no direct +verification of their necessity. There is a fashion in operations +as there is in sleeves and skirts: the triumph of some surgeon +who has at last found out how to make a once desperate operation +fairly safe is usually followed by a rage for that operation not +only among the doctors, but actually among their patients. There +are men and women whom the operating table seems to fascinate; +half-alive people who through vanity, or hypochondria, or a +craving to be the constant objects of anxious attention or what +not, lose such feeble sense as they ever had of the value of +their own organs and limbs. They seem to care as little for +mutilation as lobsters or lizards, which at least have the excuse +that they grow new claws and new tails if they lose the old ones. +Whilst this book was being prepared for the press a case was +tried in the Courts, of a man who sued a railway company for +damages because a train had run over him and amputated both his +legs. He lost his case because it was proved that he had +deliberately contrived the occurrence himself for the sake of +getting an idler's pension at the expense of the railway company, +being too dull to realize how much more he had to lose than to +gain by the bargain even if he had won his case and received +damages above his utmost hopes. + +Thus amazing case makes it possible to say, with some prospect of +being believed, that there is in the classes who can afford to +pay for fashionable operations a sprinkling of persons so +incapable of appreciating the relative importance of preserving +their bodily integrity, (including the capacity for parentage) +and the pleasure of talking about themselves and hearing +themselves talked about as the heroes and heroines of sensational +operations, that they tempt surgeons to operate on them not only +with large fees, but with personal solicitation. Now it cannot be +too often repeated that when an operation is once performed, +nobody can ever prove that it was unnecessary. If I refuse to +allow my leg to be amputated, its mortification and my death may +prove that I was wrong; but if I let the leg go, nobody can ever +prove that it would not have mortified had I been obstinate. +Operation is therefore the safe side for the surgeon as well as +the lucrative side. The result is that we hear of "conservative +surgeons" as a distinct class of practitioners who make it a rule +not to operate if they can possibly help it, and who are sought +after by the people who have vitality enough to regard an +operation as a last resort. But no surgeon is bound to take the +conservative view. If he believes that an organ is at best a +useless survival, and that if he extirpates it the patient will +be well and none the worse in a fortnight, whereas to await the +natural cure would mean a month's illness, then he is clearly +justified in recommending the operation even if the cure without +operation is as certain as anything of the kind ever can be. Thus +the conservative surgeon and the radical or extirpatory surgeon +may both be right as far as the ultimate cure is concerned; so +that their consciences do not help them out of their differences. + + +CREDULITY AND CHLOROFORM + +There is no harder scientific fact in the world than the fact +that belief can be produced in practically unlimited quantity and +intensity, without observation or reasoning, and even in defiance +of both, by the simple desire to believe founded on a strong +interest in believing. Everybody recognizes this in the case of +the amatory infatuations of the adolescents who see angels and +heroes in obviously (to others) commonplace and even +objectionable maidens and youths. But it holds good over the +entire field of human activity. The hardest-headed materialist +will become a consulter of table-rappers and slate-writers if he +loses a child or a wife so beloved that the desire to revive and +communicate with them becomes irresistible. The cobbler believes +that there is nothing like leather. The Imperialist who regards +the conquest of England by a foreign power as the worst of +political misfortunes believes that the conquest of a foreign +power by England would be a boon to the conquered. Doctors are no +more proof against such illusions than other men. Can anyone then +doubt that under existing conditions a great deal of unnecessary +and mischievous operating is bound to go on, and that patients +are encouraged to imagine that modern surgery and anesthesia have +made operations much less serious matters than they really are? +When doctors write or speak to the public about operations, they +imply, and often say in so many words, that chloroform has made +surgery painless. People who have been operated on know better. +The patient does not feel the knife, and the operation is +therefore enormously facilitated for the surgeon; but the patient +pays for the anesthesia with hours of wretched sickness; and when +that is over there is the pain of the wound made by the surgeon, +which has to heal like any other wound. This is why operating +surgeons, who are usually out of the house with their fee in +their pockets before the patient has recovered consciousness, and +who therefore see nothing of the suffering witnessed by the +general practitioner and the nurse, occasionally talk of +operations very much as the hangman in Barnaby Rudge talked of +executions, as if being operated on were a luxury in sensation as +well as in price. + + +MEDICAL POVERTY + +To make matters worse, doctors are hideously poor. The Irish +gentleman doctor of my boyhood, who took nothing less than a +guinea, though he might pay you four visits for it, seems to have +no equivalent nowadays in English society. Better be a railway +porter than an ordinary English general practitioner. A railway +porter has from eighteen to twenty-three shillings a week from +the Company merely as a retainer; and his additional fees from +the public, if we leave the third-class twopenny tip out of +account (and I am by no means sure that even this reservation +need be made), are equivalent to doctor's fees in the case of +second-class passengers, and double doctor's fees in the case of +first. Any class of educated men thus treated tends to become a +brigand class, and doctors are no exception to the rule. They +are offered disgraceful prices for advice and medicine. Their +patients are for the most part so poor and so ignorant that good +advice would be resented as impracticable and wounding. When you +are so poor that you cannot afford to refuse eighteenpence from a +man who is too poor to pay you any more, it is useless to tell +him that what he or his sick child needs is not medicine, but +more leisure, better clothes, better food, and a better drained +and ventilated house. It is kinder to give him a bottle of +something almost as cheap as water, and tell him to come again +with another eighteenpence if it does not cure him. When you have +done that over and over again every day for a week, how much +scientific conscience have you left? If you are weak-minded +enough to cling desperately to your eighteenpence as denoting a +certain social superiority to the sixpenny doctor, you will be +miserably poor all your life; whilst the sixpenny doctor, with +his low prices and quick turnover of patients, visibly makes much +more than you do and kills no more people. + +A doctor's character can no more stand out against such +conditions than the lungs of his patients can stand out against +bad ventilation. The only way in which he can preserve his self- +respect is by forgetting all he ever learnt of science, and +clinging to such help as he can give without cost merely by being +less ignorant and more accustomed to sick-beds than his patients. +Finally, he acquires a certain skill at nursing cases under +poverty-stricken domestic conditions, just as women who have +been trained as domestic servants in some huge institution with +lifts, vacuum cleaners, electric lighting, steam heating, and +machinery that turns the kitchen into a laboratory and engine +house combined, manage, when they are sent out into the world to +drudge as general servants, to pick up their business in a new +way, learning the slatternly habits and wretched makeshifts of +homes where even bundles of kindling wood are luxuries to be +anxiously economized. + + +THE SUCCESSFUL DOCTOR + +The doctor whose success blinds public opinion to medical poverty +is almost as completely demoralized. His promotion means that his +practice becomes more and more confined to the idle rich. The +proper advice for most of their ailments is typified in +Abernethy's "Live on sixpence a day and earn it." But here, as at +the other end of the scale, the right advice is neither agreeable +nor practicable. And every hypochondriacal rich lady or gentleman +who can be persuaded that he or she is a lifelong invalid means +anything from fifty to five hundred pounds a year for the doctor. +Operations enable a surgeon to earn similar sums in a couple of +hours; and if the surgeon also keeps a nursing home, he may make +considerable profits at the same time by running what is the most +expensive kind of hotel. These gains are so great that they undo +much of the moral advantage which the absence of grinding +pecuniary anxiety gives the rich doctor over the poor one. It is +true that the temptation to prescribe a sham treatment because +the real treatment is too dear for either patient or doctor +does not exist for the rich doctor. He always has plenty of +genuine cases which can afford genuine treatment; and these +provide him with enough sincere scientific professional work to +save him from the ignorance, obsolescence, and atrophy of +scientific conscience into which his poorer colleagues sink. But +on the other hand his expenses are enormous. Even as a bachelor, +he must, at London west end rates, make over a thousand a year +before he can afford even to insure his life. His house, his +servants, and his equipage (or autopage) must be on the scale to +which his patients are accustomed, though a couple of rooms with +a camp bed in one of them might satisfy his own requirements. +Above all, the income which provides for these outgoings stops +the moment he himself stops working. Unlike the man of business, +whose managers, clerks, warehousemen and laborers keep his +business going whilst he is in bed or in his club, the doctor +cannot earn a farthing by deputy. Though he is exceptionally +exposed to infection, and has to face all weathers at all hours +of the night and day, often not enjoying a complete night's rest +for a week, the money stops coming in the moment he stops going +out; and therefore illness has special terrors for him, and +success no certain permanence. He dare not stop making hay while +the sun shines; for it may set at any time. Men do not resist +pressure of this intensity. When they come under it as doctors +they pay unnecessary visits; they write prescriptions that are as +absurd as the rub of chalk with which an Irish tailor once +charmed away a wart from my father's finger; they conspire with +surgeons to promote operations; they nurse the delusions of the +malade imaginaire (who is always really ill because, as there is +no such thing as perfect health, nobody is ever really well); +they exploit human folly, vanity, and fear of death as ruthlessly +as their own health, strength, and patience are exploited by +selfish hypochondriacs. They must do all these things or else run +pecuniary risks that no man can fairly be asked to run. And the +healthier the world becomes, the more they are compelled to live +by imposture and the less by that really helpful activity of +which all doctors get enough to preserve them from utter +corruption. For even the most hardened humbug who ever prescribed +ether tonics to ladies whose need for tonics is of precisely the +same character as the need of poorer women for a glass of gin, +has to help a mother through child-bearing often enough to feel +that he is not living wholly in vain. + + +THE PSYCHOLOGY OF SELF-RESPECT IN SURGEONS + +The surgeon, though often more unscrupulous than the general +practitioner, retains his self-respect more easily. The human +conscience can subsist on very questionable food. No man who is +occupied in doing a very difficult thing, and doing it very well, +ever loses his self-respect. The shirk, the duffer, the +malingerer, the coward, the weakling, may be put out of +countenance by his own failures and frauds; but the man who does +evil skilfully, energetically, masterfully, grows prouder and +bolder at every crime. The common man may have to found his self- +respect on sobriety, honesty and industry; but a Napoleon needs +no such props for his sense of dignity. If Nelson's conscience +whispered to him at all in the silent watches of the night, you +may depend on it it whispered about the Baltic and the Nile and +Cape St. Vincent, and not about his unfaithfulness to his wife. A +man who robs little children when no one is looking can hardly +have much self-respect or even self-esteem; but an accomplished +burglar must be proud of himself. In the play to which I am at +present preluding I have represented an artist who is so entirely +satisfied with his artistic conscience, even to the point of +dying like a saint with its support, that he is utterly selfish +and unscrupulous in every other relation without feeling at the +smallest disadvantage. The same thing may be observed in women +who have a genius for personal attractiveness: they expend more +thought, labor, skill, inventiveness, taste and endurance on +making themselves lovely than would suffice to keep a dozen ugly +women honest; and this enables them to maintain a high opinion of +themselves, and an angry contempt for unattractive and personally +careless women, whilst they lie and cheat and slander and sell +themselves without a blush. The truth is, hardly any of us have +ethical energy enough for more than one really inflexible point +of honor. Andrea del Sarto, like Louis Dubedat in my play, must +have expended on the attainment of his great mastery of design +and his originality in fresco painting more conscientiousness and +industry than go to the making of the reputations of a dozen +ordinary mayors and churchwardens; but (if Vasari is to be +believed) when the King of France entrusted him with money to buy +pictures for him, he stole it to spend on his wife. Such cases +are not confined to eminent artists. Unsuccessful, unskilful men +are often much more scrupulous than successful ones. In the ranks +of ordinary skilled labor many men are to be found who earn good +wages and are never out of a job because they are strong, +indefatigable, and skilful, and who therefore are bold in a high +opinion of themselves; but they are selfish and tyrannical, +gluttonous and drunken, as their wives and children know to their +cost. + +Not only do these talented energetic people retain their self- +respect through shameful misconduct: they do not even lose the +respect of others, because their talents benefit and interest +everybody, whilst their vices affect only a few. An actor, a +painter, a composer, an author, may be as selfish as he likes +without reproach from the public if only his art is superb; and +he cannot fulfil his condition without sufficient effort and +sacrifice to make him feel noble and martyred in spite of his +selfishness. It may even happen that the selfishness of an artist +may be a benefit to the public by enabling him to concentrate +himself on their gratification with a recklessness of every other +consideration that makes him highly dangerous to those about him. +In sacrificing others to himself he is sacrificing them to the +public he gratifies; and the public is quite content with that +arrangement. The public actually has an interest in the artist's +vices. + +It has no such interest in the surgeon's vices. The surgeon's art +is exercised at its expense, not for its gratification. We do not +go to the operating table as we go to the theatre, to the picture +gallery, to the concert room, to be entertained and delighted: we +go to be tormented and maimed, lest a worse thing should befall +us. It is of the most extreme importance to us that the experts +on whose assurance we face this horror and suffer this mutilation +should leave no interests but our own to think of; should judge +our cases scientifically; and should feel about them kindly. Let +us see what guarantees we have: first for the science, and then +for the kindness. + + +ARE DOCTORS MEN OF SCIENCE? + +I presume nobody will question the existence of widely spread +popular delusion that every doctor is a titan of science. It is +escaped only in the very small class which understands by science +something more than conjuring with retorts and spirit lamps, +magnets and microscopes, and discovering magical cures for +disease. To a sufficiently ignorant man every captain of a +trading schooner is a Galileo, every organ-grinder a Beethoven, +every piano-tuner a Hemholtz, every Old Bailey barrister a Solon, +every Seven Dials pigeon dealer a Darwin, every scrivener a +Shakespear, every locomotive engine a miracle, and its driver no +less wonderful than George Stephenson. As a matter of fact, the +rank and file of doctors are no more scientific than their +tailors; or, if you prefer to put it the reverse way, their +tailors are no less scientific than they. Doctoring is an art, +not a science: any layman who is interested in science +sufficiently to take in one of the scientific journals and follow +the literature of the scientific movement, knows more about it +than those doctors (probably a large majority) who are not +interested in it, and practise only to earn their bread. +Doctoring is not even the art of keeping people in health (no +doctor seems able to advise you what to eat any better than his +grandmother or the nearest quack): it is the art of curing +illnesses. It does happen exceptionally that a practising doctor +makes a contribution to science (my play describes a very notable +one); but it happens much oftener that he draws disastrous +conclusions from his clinical experience because he has no +conception of scientific method, and believes, like any rustic, +that the handling of evidence and statistics needs no expertness. +The distinction between a quack doctor and a qualified one is +mainly that only the qualified one is authorized to sign death +certificates, for which both sorts seem to have about equal +occasion. Unqualified practitioners now make large incomes as +hygienists, and are resorted to as frequently by cultivated +amateur scientists who understand quite well what they are doing +as by ignorant people who are simply dupes. Bone-setters make +fortunes under the very noses of our greatest surgeons from +educated and wealthy patients; and some of the most successful +doctors on the register use quite heretical methods of treating +disease, and have qualified themselves solely for convenience. +Leaving out of account the village witches who prescribe spells +and sell charms, the humblest professional healers in this +country are the herbalists. These men wander through the fields +on Sunday seeking for herbs with magic properties of curing +disease, preventing childbirth, and the like. Each of them +believes that he is on the verge of a great discovery, in which +Virginia Snake Root will be an ingredient, heaven knows why! +Virginia Snake Root fascinates the imagination of the herbalist +as mercury used to fascinate the alchemists. On week days he +keeps a shop in which he sells packets of pennyroyal, dandelion, +etc., labelled with little lists of the diseases they are +supposed to cure, and apparently do cure to the satisfaction of +the people who keep on buying them. I have never been able to +perceive any distinction between the science of the herbalist and +that of the duly registered doctor. A relative of mine recently +consulted a doctor about some of the ordinary symptoms which +indicate the need for a holiday and a change. The doctor +satisfied himself that the patient's heart was a little +depressed. Digitalis being a drug labelled as a heart specific +by the profession, he promptly administered a stiff dose. +Fortunately the patient was a hardy old lady who was not easily +killed. She recovered with no worse result than her conversion to +Christian Science, which owes its vogue quite as much to public +despair of doctors as to superstition. I am not, observe, here +concerned with the question as to whether the dose of digitalis +was judicious or not; the point is, that a farm laborer +consulting a herbalist would have been treated in exactly the +same way. + + +BACTERIOLOGY AS A SUPERSTITION + +The smattering of science that all--even doctors--pick up from +the ordinary newspapers nowadays only makes the doctor more +dangerous than he used to be. Wise men used to take care to +consult doctors qualified before 1860, who were usually +contemptuous of or indifferent to the germ theory and +bacteriological therapeutics; but now that these veterans have +mostly retired or died, we are left in the hands of the +generations which, having heard of microbes much as St. Thomas +Aquinas heard of angels, suddenly concluded that the whole art of +healing could be summed up in the formula: Find the microbe and +kill it. And even that they did not know how to do. The simplest +way to kill most microbes is to throw them into an open street or +river and let the sun shine on them, which explains the fact that +when great cities have recklessly thrown all their sewage into +the open river the water has sometimes been cleaner twenty miles +below the city than thirty miles above it. But doctors +instinctively avoid all facts that are reassuring, and eagerly +swallow those that make it a marvel that anyone could possibly +survive three days in an atmosphere consisting mainly of +countless pathogenic germs. They conceive microbes as immortal +until slain by a germicide administered by a duly qualified +medical man. All through Europe people are adjured, by public +notices and even under legal penalties, not to throw their +microbes into the sunshine, but to collect them carefully in a +handkerchief; shield the handkerchief from the sun in the +darkness and warmth of the pocket; and send it to a laundry to be +mixed up with everybody else's handkerchiefs, with results only +too familiar to local health authorities. + +In the first frenzy of microbe killing, surgical instruments were +dipped in carbolic oil, which was a great improvement on not +dipping them in anything at all and simply using them dirty; but +as microbes are so fond of carbolic oil that they swarm in it, it +was not a success from the anti-microbe point of view. Formalin +was squirted into the circulation of consumptives until it was +discovered that formalin nourishes the tubercle bacillus +handsomely and kills men. The popular theory of disease is the +common medical theory: namely, that every disease had its microbe +duly created in the garden of Eden, and has been steadily +propagating itself and producing widening circles of malignant +disease ever since. It was plain from the first that if this had +been even approximately true, the whole human race would have +been wiped out by the plague long ago, and that every epidemic, +instead of fading out as mysteriously as it rushed in, would +spread over the whole world. It was also evident that the +characteristic microbe of a disease might be a symptom instead of +a cause. An unpunctual man is always in a hurry; but it does not +follow that hurry is the cause of unpunctuality: on the contrary, +what is the matter with the patient is sloth. When Florence +Nightingale said bluntly that if you overcrowded your soldiers in +dirty quarters there would be an outbreak of smallpox among them, +she was snubbed as an ignorant female who did not know that +smallpox can be produced only by the importation of its specific +microbe. + +If this was the line taken about smallpox, the microbe of which +has never yet been run down and exposed under the microscope by +the bacteriologist, what must have been the ardor of conviction +as to tuberculosis, tetanus, enteric fever, Maltese fever, +diphtheria, and the rest of the diseases in which the +characteristic bacillus had been identified! When there was no +bacillus it was assumed that, since no disease could exist +without a bacillus, it was simply eluding observation. When the +bacillus was found, as it frequently was, in persons who were not +suffering from the disease, the theory was saved by simply +calling the bacillus an impostor, or pseudobacillus. The same +boundless credulity which the public exhibit as to a doctor's +power of diagnosis was shown by the doctors themselves as to the +analytic microbe hunters. These witch finders would give you a +certificate of the ultimate constitution of anything from a +sample of the water from your well to a scrap of your lungs, for +seven-and-sixpense. I do not suggest that the analysts were +dishonest. No doubt they carried the analysis as far as they +could afford to carry it for the money. No doubt also they could +afford to carry it far enough to be of some use. But the fact +remains that just as doctors perform for half-a-crown, without +the least misgiving, operations which could not be thoroughly and +safely performed with due scientific rigor and the requisite +apparatus by an unaided private practitioner for less than some +thousands of pounds, so did they proceed on the assumption that +they could get the last word of science as to the constituents of +their pathological samples for a two hours cab fare. + + +ECONOMIC DIFFICULTIES OF IMMUNIZATION + +I have heard doctors affirm and deny almost every possible +proposition as to disease and treatment. I can remember the time +when doctors no more dreamt of consumption and pneumonia being +infectious than they now dream of sea-sickness being infectious, +or than so great a clinical observer as Sydenham dreamt of +smallpox being infectious. I have heard doctors deny that there +is such a thing as infection. I have heard them deny the +existence of hydrophobia as a specific disease differing from +tetanus. I have heard them defend prophylactic measures and +prophylactic legislation as the sole and certain salvation of +mankind from zymotic disease; and I have heard them denounce both +as malignant spreaders of cancer and lunacy. But the one +objection I have never heard from a doctor is the objection that +prophylaxis by the inoculatory methods most in vogue is an +economic impossibility under our private practice system. They +buy some stuff from somebody for a shilling, and inject a +pennyworth of it under their patient's skin for half-a-crown, +concluding that, since this primitive rite pays the somebody and +pays them, the problem of prophylaxis has been satisfactorily +solved. The results are sometimes no worse than the ordinary +results of dirt getting into cuts; but neither the doctor nor the +patient is quite satisfied unless the inoculation "takes"; that +is, unless it produces perceptible illness and disablement. +Sometimes both doctor and patient get more value in this +direction than they bargain for. The results of ordinary private- +practice-inoculation at their worst are bad enough to be +indistinguishable from those of the most discreditable and +dreaded disease known; and doctors, to save the credit of the +inoculation, have been driven to accuse their patient or their +patient's parents of having contracted this disease independently +of the inoculation, an excuse which naturally does not make the +family any more resigned, and leads to public recriminations in +which the doctors, forgetting everything but the immediate +quarrel, naively excuse themselves by admitting, and even +claiming as a point in their favor, that it is often impossible +to distinguish the disease produced by their inoculation and the +disease they have accused the patient of contracting. And both +parties assume that what is at issue is the scientific soundness +of the prophylaxis. It never occurs to them that the particular +pathogenic germ which they intended to introduce into the +patient's system may be quite innocent of the catastrophe, and +that the casual dirt introduced with it may be at fault. When, as +in the case of smallpox or cowpox, the germ has not yet been +detected, what you inoculate is simply undefined matter that has +been scraped off an anything but chemically clean calf suffering +from the disease in question. You take your chance of the germ +being in the scrapings, and, lest you should kill it, you take no +precautions against other germs being in it as well. Anything may +happen as the result of such an inoculation. Yet this is the only +stuff of the kind which is prepared and supplied even in State +establishments: that is, in the only establishments free from the +commercial temptation to adulterate materials and scamp +precautionary processes. + +Even if the germ were identified, complete precautions would +hardly pay. It is true that microbe farming is not expensive. The +cost of breeding and housing two head of cattle would provide for +the breeding and housing of enough microbes to inoculate the +entire population of the globe since human life first appeared on +it. But the precautions necessary to insure that the inoculation +shall consist of nothing else but the required germ in the proper +state of attenuation are a very different matter from the +precautions necessary in the distribution and consumption of +beefsteaks. Yet people expect to find vaccines and antitoxins and +the like retailed at "popular prices" in private enterprise shops +just as they expect to find ounces of tobacco and papers of pins. + + +THE PERILS OF INOCULATION + +The trouble does not end with the matter to be inoculated. There +is the question of the condition of the patient. The discoveries +of Sir Almroth Wright have shown that the appalling results which +led to the hasty dropping in 1894 of Koch's tuberculin were not +accidents, but perfectly orderly and inevitable phenomena +following the injection of dangerously strong "vaccines" at the +wrong moment, and reinforcing the disease instead of stimulating +the resistance to it. To ascertain the right moment a laboratory +and a staff of experts are needed. The general practitioner, +having no such laboratory and no such experience, has always +chanced it, and insisted, when he was unlucky, that the results +were not due to the inoculation, but to some other cause: a +favorite and not very tactful one being the drunkenness or +licentiousness of the patient. But though a few doctors have now +learnt the danger of inoculating without any reference to the +patient's "opsonic index" at the moment of inoculation, and +though those other doctors who are denouncing the danger as +imaginary and opsonin as a craze or a fad, obviously do so +because it involves an operation which they have neither the +means nor the knowledge to perform, there is still no grasp of +the economic change in the situation. They have never been warned +that the practicability of any method of extirpating disease +depends not only on its efficacy, but on its cost. For example, +just at present the world has run raving mad on the subject of +radium, which has excited our credulity precisely as the +apparitions at Lourdes excited the credulity of Roman Catholics. +Suppose it were ascertained that every child in the world could +be rendered absolutely immune from all disease during its entire +life by taking half an ounce of radium to every pint of its milk. +The world would be none the healthier, because not even a Crown +Prince--no, not even the son of a Chicago Meat King, could afford +the treatment. Yet it is doubtful whether doctors would refrain +from prescribing it on that ground. The recklessness with which +they now recommend wintering in Egypt or at Davos to people who +cannot afford to go to Cornwall, and the orders given for +champagne jelly and old port in households where such luxuries +must obviously be acquired at the cost of stinting necessaries, +often make one wonder whether it is possible for a man to go +through a medical training and retain a spark of common sense. +This sort of inconsiderateness gets cured only in the classes +where poverty, pretentious as it is even at its worst, cannot +pitch its pretences high enough to make it possible for the +doctor (himself often no better off than the patient) to assume +that the average income of an English family is about 2,000 +pounds a year, and that it is quite easy to break up a home, sell +an old family seat at a sacrifice, and retire into a foreign +sanatorium devoted to some "treatment" that did not exist two +years ago and probably will not exist (except as a pretext for +keeping an ordinary hotel) two years hence. In a poor practice +the doctor must find cheap treatments for cheap people, or +humiliate and lose his patients either by prescribing beyond +their means or sending them to the public hospitals. When it +comes to prophylactic inoculation, the alternative lies between +the complete scientific process, which can only be brought down +to a reasonable cost by being very highly organized as a public +service in a public institution, and such cheap, nasty, dangerous +and scientifically spurious imitations as ordinary vaccination, +which seems not unlikely to be ended, like its equally vaunted +forerunner, XVIII. century inoculation, by a purely reactionary +law making all sorts of vaccination, scientific or not, criminal +offences. Naturally, the poor doctor (that is, the average +doctor) defends ordinary vaccination frantically, as it means to +him the bread of his children. To secure the vehement and +practically unanimous support of the rank and file of the medical +profession for any sort of treatment or operation, all that is +necessary is that it can be easily practised by a rather shabbily +dressed man in a surgically dirty room in a surgically dirty +house without any assistance, and that the materials for it shall +cost, say, a penny, and the charge for it to a patient with 100 +pounds a year be half-a-crown. And, on the other hand, a hygienic +measure has only to be one of such refinement, difficulty, +precision and costliness as to be quite beyond the resources of +private practice, to be ignored or angrily denounced as a fad. + +TRADE UNIONISM AND SCIENCE + +Here we have the explanation of the savage rancor that so amazes +people who imagine that the controversy concerning vaccination is +a scientific one. It has really nothing to do with science. The +medical profession, consisting for the most part of very poor men +struggling to keep up appearances beyond their means, find +themselves threatened with the extinction of a considerable part +of their incomes: a part, too, that is easily and regularly +earned, since it is independent of disease, and brings every +person born into the nation, healthy or not, to the doctors. To +boot, there is the occasional windfall of an epidemic, with its +panic and rush for revaccination. Under such circumstances, +vaccination would be defended desperately were it twice as dirty, +dangerous, and unscientific in method as it actually is. The note +of fury in the defence, the feeling that the anti-vaccinator is +doing a cruel, ruinous, inconsiderate thing in a mood of +indignant folly: all this, so puzzling to the observer who knows +nothing of the economic side of the question, and only sees that +the anti-vaccinator, having nothing whatever to gain and a good +deal to lose by placing himself in opposition to the law and to +the outcry that adds private persecution to legal penalties, can +have no interest in the matter except the interest of a reformer +in abolishing a corrupt and mischievous superstition, becomes +intelligible the moment the tragedy of medical poverty and the +lucrativeness of cheap vaccination is taken into account. + +In the face of such economic pressure as this, it is silly to +expect that medical teaching, any more than medical practice, can +possibly be scientific. The test to which all methods of +treatment are finally brought is whether they are lucrative to +doctors or not. It would be difficult to cite any proposition +less obnoxious to science, than that advanced by Hahnemann: to +wit, that drugs which in large doses produce certain symptoms, +counteract them in very small doses, just as in more modern +practice it is found that a sufficiently small inoculation with +typhoid rallies our powers to resist the disease instead of +prostrating us with it. But Hahnemann and his followers were +frantically persecuted for a century by generations of +apothecary-doctors whose incomes depended on the quantity of +drugs they could induce their patients to swallow. These two +cases of ordinary vaccination and homeopathy are typical of all +the rest. Just as the object of a trade union under existing +conditions must finally be, not to improve the technical quality +of the work done by its members, but to secure a living wage for +them, so the object of the medical profession today is to secure +an income for the private doctor; and to this consideration all +concern for science and public health must give way when the two +come into conflict. Fortunately they are not always in conflict. +Up to a certain point doctors, like carpenters and masons, must +earn their living by doing the work that the public wants from +them; and as it is not in the nature of things possible that such +public want should be based on unmixed disutility, it may be +admitted that doctors have their uses, real as well as imaginary. +But just as the best carpenter or mason will resist the +introduction of a machine that is likely to throw him out of +work, or the public technical education of unskilled laborers' +sons to compete with him, so the doctor will resist with all his +powers of persecution every advance of science that threatens his +income. And as the advance of scientific hygiene tends to make +the private doctor's visits rarer, and the public inspector's +frequenter, whilst the advance of scientific therapeutics is in +the direction of treatments that involve highly organized +laboratories, hospitals, and public institutions generally, it +unluckily happens that the organization of private practitioners +which we call the medical profession is coming more and more to +represent, not science, but desperate and embittered antiscience: +a statement of things which is likely to get worse until the +average doctor either depends upon or hopes for an appointment in +the public health service for his livelihood. + +So much for our guarantees as to medical science. Let us now deal +with the more painful subject of medical kindness. + + +DOCTORS AND VIVISECTION + +The importance to our doctors of a reputation for the tenderest +humanity is so obvious, and the quantity of benevolent work +actually done by them for nothing (a great deal of it from sheer +good nature) so large, that at first sight it seems unaccountable +that they should not only throw all their credit away, but +deliberately choose to band themselves publicly with outlaws and +scoundrels by claiming that in the pursuit of their professional +knowledge they should be free from the restraints of law, of +honor, of pity, of remorse, of everything that distinguishes an +orderly citizen from a South Sea buccaneer, or a philosopher from +an inquisitor. For here we look in vain for either an economic or +a sentimental motive. In every generation fools and blackguards +have made this claim; and honest and reasonable men, led by the +strongest contemporary minds, have repudiated it and exposed its +crude rascality. From Shakespear and Dr. Johnson to Ruskin and +Mark Twain, the natural abhorrence of sane mankind for the +vivisector's cruelty, and the contempt of able thinkers for his +imbecile casuistry, have been expressed by the most popular +spokesmen of humanity. If the medical profession were to outdo +the Anti-Vivisection Societies in a general professional protest +against the practice and principles of the vivisectors, every +doctor in the kingdom would gain substantially by the immense +relief and reconciliation which would follow such a reassurance +of the humanity of the doctor. Not one doctor in a thousand is a +vivisector, or has any interest in vivisection, either pecuniary +or intellectual, or would treat his dog cruelly or allow anyone +else to do it. It is true that the doctor complies with the +professional fashion of defending vivisection, and assuring you +that people like Shakespear and Dr. Johnson and Ruskin and Mark +Twain are ignorant sentimentalists, just as he complies with any +other silly fashion: the mystery is, how it became the fashion in +spite of its being so injurious to those who follow it. Making +all possible allowance for the effect of the brazen lying of the +few men who bring a rush of despairing patients to their doors by +professing in letters to the newspapers to have learnt from +vivisection how to cure certain diseases, and the assurances of +the sayers of smooth things that the practice is quite painless +under the law, it is still difficult to find any civilized motive +for an attitude by which the medical profession has everything to +lose and nothing to gain. + + +THE PRIMITIVE SAVAGE MOTIVE + +I say civilized motive advisedly; for primitive tribal motives +are easy enough to find. Every savage chief who is not a Mahomet +learns that if he wishes to strike the imagination of his tribe-- +and without doing that he can rule them--he must terrify or +revolt them from time to time by acts of hideous cruelty or +disgusting unnaturalness. We are far from being as superior to +such tribes as we imagine. It is very doubtful indeed whether +Peter the Great could have effected the changes he made in Russia +if he had not fascinated and intimidated his people by his +monstrous cruelties and grotesque escapades. Had he been a +nineteenth-century king of England, he would have had to wait for +some huge accidental calamity: a cholera epidemic, a war, or an +insurrection, before waking us up sufficiently to get anything +done. Vivisection helps the doctor to rule us as Peter ruled the +Russians. The notion that the man who does dreadful things is +superhuman, and that therefore he can also do wonderful things +either as ruler, avenger, healer, or what not, is by no means +confined to barbarians. Just as the manifold wickednesses and +stupidities of our criminal code are supported, not by any +general comprehension of law or study of jurisprudence, not even +by simple vindictiveness, but by the superstition that a calamity +of any sort must be expiated by a human sacrifice; so the +wickednesses and stupidities of our medicine men are rooted in +superstitions that have no more to do with science than the +traditional ceremony of christening an ironclad has to do with +the effectiveness of its armament. We have only to turn to +Macaulay's description of the treatment of Charles II in his last +illness to see how strongly his physicians felt that their only +chance of cheating death was by outraging nature in tormenting +and disgusting their unfortunate patient. True, this was more +than two centuries ago; but I have heard my own nineteenth- +century grandfather describe the cupping and firing and nauseous +medicines of his time with perfect credulity as to their +beneficial effects; and some more modern treatments appear to me +quite as barbarous. It is in this way that vivisection pays the +doctor. It appeals to the fear and credulity of the savage in us; +and without fear and credulity half the private doctor's +occupation and seven-eighths of his influence would be gone. + + +THE HIGHER MOTIVE. THE TREE OF KNOWLEDGE. + +But the greatest force of all on the side of vivisection is the +mighty and indeed divine force of curiosity. Here we have no +decaying tribal instinct which men strive to root out of +themselves as they strive to root out the tiger's lust for blood. +On the contrary, the curiosity of the ape, or of the child who +pulls out the legs and wings of a fly to see what it will do +without them, or who, on being told that a cat dropped out of the +window will always fall on its legs, immediately tries the +experiment on the nearest cat from the highest window in the +house (I protest I did it myself from the first floor only), is +as nothing compared to the thirst for knowledge of the +philosopher, the poet, the biologist, and the naturalist. I have +always despised Adam because he had to be tempted by the woman, +as she was by the serpent, before he could he induced to pluck +the apple from the tree of knowledge. I should have swallowed +every apple on the tree the moment the owner's back was turned. +When Gray said "Where ignorance is bliss, 'tis folly to be wise," +he forgot that it is godlike to be wise; and since nobody wants +bliss particularly, or could stand more than a very brief taste +of it if it were attainable, and since everybody, by the deepest +law of the Life Force, desires to be godlike, it is stupid, and +indeed blasphemous and despairing, to hope that the thirst for +knowledge will either diminish or consent to be subordinated to +any other end whatsoever. We shall see later on that the claim +that has arisen in this way for the unconditioned pursuit of +knowledge is as idle as all dreams of unconditioned activity; but +none the less the right to knowledge must be regarded as a +fundamental human right. The fact that men of science have had to +fight so hard to secure its recognition, and are still so +vigorously persecuted when they discover anything that is not +quite palatable to vulgar people, makes them sorely jealous for +that right; and when they hear a popular outcry for the +suppression of a method of research which has an air of being +scientific, their first instinct is to rally to the defence of +that method without further consideration, with the result that +they sometimes, as in the case of vivisection, presently find +themselves fighting on a false issue. + + +THE FLAW IN THE ARGUMENT + +I may as well pause here to explain their error. The right to +know is like the right to live. It is fundamental and +unconditional in its assumption that knowledge, like life, is a +desirable thing, though any fool can prove that ignorance is +bliss, and that "a little knowledge is a dangerous thing" (a +little being the most that any of us can attain), as easily as +that the pains of life are more numerous and constant than its +pleasures, and that therefore we should all be better dead. The +logic is unimpeachable; but its only effect is to make us say +that if these are the conclusions logic leads to, so much the +worse for logic, after which curt dismissal of Folly, we continue +living and learning by instinct: that is, as of right. We +legislate on the assumption that no man may be killed on the +strength of a demonstration that he would be happier in his +grave, not even if he is dying slowly of cancer and begs the +doctor to despatch him quickly and mercifully. To get killed +lawfully he must violate somebody else's right to live by +committing murder. But he is by no means free to live +unconditionally. In society he can exercise his right to live +only under very stiff conditions. In countries where there is +compulsory military service he may even have to throw away his +individual life to save the life of the community. + +It is just so in the case of the right to knowledge. It is a +right that is as yet very imperfectly recognized in practice. But +in theory it is admitted that an adult person in pursuit of +knowledge must not be refused it on the ground that he would be +better or happier without it. Parents and priests may forbid +knowledge to those who accept their authority; and social taboo +may be made effective by acts of legal persecution under cover of +repressing blasphemy, obscenity, and sedition; but no government +now openly forbids its subjects to pursue knowledge on the ground +that knowledge is in itself a bad thing, or that it is possible +for any of us to have too much of it. + + +LIMITATIONS OF THE RIGHT TO KNOWLEDGE + +But neither does any government exempt the pursuit of knowledge, +any more than the pursuit of life, liberty, and happiness (as the +American Constitution puts it), from all social conditions. No +man is allowed to put his mother into the stove because he +desires to know how long an adult woman will survive at a +temperature of 500 degrees Fahrenheit, no matter how important or +interesting that particular addition to the store of human +knowledge may be. A man who did so would have short work made not +only of his right to knowledge, but of his right to live and all +his other rights at the same time. The right to knowledge is not +the only right; and its exercise must be limited by respect for +other rights, and for its own exercise by others. When a man says +to Society, "May I torture my mother in pursuit of knowledge?" +Society replies, "No." If he pleads, "What! Not even if I have a +chance of finding out how to cure cancer by doing it?" Society +still says, "Not even then." If the scientist, making the best of +his disappointment, goes on to ask may he torture a dog, the +stupid and callous people who do not realize that a dog is a +fellow-creature and sometimes a good friend, may say Yes, though +Shakespear, Dr. Johnson and their like may say No. But even those +who say "You may torture A dog" never say "You may torture MY +dog." And nobody says, "Yes, because in the pursuit of knowledge +you may do as you please." Just as even the stupidest people say, +in effect, "If you cannot attain to knowledge without burning +your mother you must do without knowledge," so the wisest people +say, "If you cannot attain to knowledge without torturing a dog, +you must do without knowledge." + + +A FALSE ALTERNATIVE + +But in practice you cannot persuade any wise man that this +alternative can ever be forced on anyone but a fool, or that a +fool can be trusted to learn anything from any experiment, cruel +or humane. The Chinaman who burnt down his house to roast his pig +was no doubt honestly unable to conceive any less disastrous way +of cooking his dinner; and the roast must have been spoiled after +all (a perfect type of the average vivisectionist experiment); +but this did not prove that the Chinaman was right: it only +proved that the Chinaman was an incapable cook and, +fundamentally, a fool. + +Take another celebrated experiment: one in sanitary reform. In +the days of Nero Rome was in the same predicament as London to- +day. If some one would burn down London, and it were rebuilt, as +it would now have to be, subject to the sanitary by-laws and +Building Act provisions enforced by the London County Council, it +would be enormously improved; and the average lifetime of +Londoners would be considerably prolonged. Nero argued in the +same way about Rome. He employed incendiaries to set it on fire; +and he played the harp in scientific raptures whilst it was +burning. I am so far of Nero's way of thinking that I have often +said, when consulted by despairing sanitary reformers, that what +London needs to make her healthy is an earthquake. Why, then, it +may be asked, do not I, as a public-spirited man, employ +incendiaries to set it on fire, with a heroic disregard of the +consequences to myself and others? Any vivisector would, if he +had the courage of his opinions. The reasonable answer is that +London can be made healthy without burning her down; and that as +we have not enough civic virtue to make her healthy in a humane +and economical way, we should not have enough to rebuild her in +that way. In the old Hebrew legend, God lost patience with the +world as Nero did with Rome, and drowned everybody except a +single family. But the result was that the progeny of that family +reproduced all the vices of their predecessors so exactly that +the misery caused by the flood might just as well have been +spared: things went on just as they did before. In the same way, +the lists of diseases which vivisection claims to have cured is +long; but the returns of the Registrar-General show that people +still persist in dying of them as if vivisection had never been +heard of. Any fool can burn down a city or cut an animal open; +and an exceptionally foolish fool is quite likely to promise +enormous benefits to the race as the result of such activities. +But when the constructive, benevolent part of the business comes +to be done, the same want of imagination, the same stupidity and +cruelty, the same laziness and want of perseverance that +prevented Nero or the vivisector from devising or pushing through +humane methods, prevents him from bringing order out of the chaos +and happiness out of the misery he has made. At one time it +seemed reasonable enough to declare that it was impossible to +find whether or not there was a stone inside a man's body except +by exploring it with a knife, or to find out what the sun is +made of without visiting it in a balloon. Both these +impossibilities have been achieved, but not by vivisectors. The +Rontgen rays need not hurt the patient; and spectrum analysis +involves no destruction. After such triumphs of humane experiment +and reasoning, it is useless to assure us that there is no other +key to knowledge except cruelty. When the vivisector offers us +that assurance, we reply simply and contemptuously, "You mean +that you are not clever or humane or energetic enough to find +one." + +CRUELTY FOR ITS OWN SAKE + +It will now, I hope, be clear why the attack on vivisection is +not an attack on the right to knowledge: why, indeed, those who +have the deepest conviction of the sacredness of that right are +the leaders of the attack. No knowledge is finally impossible of +human attainment; for even though it may be beyond our present +capacity, the needed capacity is not unattainable. Consequently +no method of investigation is the only method; and no law +forbidding any particular method can cut us off from the +knowledge we hope to gain by it. The only knowledge we lose by +forbidding cruelty is knowledge at first hand of cruelty itself, +which is precisely the knowledge humane people wish to be spared. + +But the question remains: Do we all really wish to be spared that +knowledge? Are humane methods really to be preferred to cruel +ones? Even if the experiments come to nothing, may not their +cruelty be enjoyed for its own sake, as a sensational luxury? Let +us face these questions boldly, not shrinking from the fact that +cruelty is one of the primitive pleasures of mankind, and that +the detection of its Protean disguises as law, education, +medicine, discipline, sport and so forth, is one of the most +difficult of the unending tasks of the legislator. + + +OUR OWN CRUELTIES + +At first blush it may seem not only unnecessary, but even +indecent, to discuss such a proposition as the elevation of +cruelty to the rank of a human right. Unnecessary, because no +vivisector confesses to a love of cruelty for its own sake or +claims any general fundamental right to be cruel. Indecent, +because there is an accepted convention to repudiate cruelty; and +vivisection is only tolerated by the law on condition that, like +judicial torture, it shall be done as mercifully as the nature of +the practice allows. But the moment the controversy becomes +embittered, the recriminations bandied between the opposed +parties bring us face-to-face with some very ugly truths. On one +occasion I was invited to speak at a large Anti-Vivisection +meeting in the Queen's Hall in London. I found myself on the +platform with fox hunters, tame stag hunters, men and women whose +calendar was divided, not by pay days and quarter days, but by +seasons for killing animals for sport: the fox, the hare, the +otter, the partridge and the rest having each its appointed date +for slaughter. The ladies among us wore hats and cloaks and head- +dresses obtained by wholesale massacres, ruthless trappings, +callous extermination of our fellow creatures. We insisted on our +butchers supplying us with white veal, and were large and +constant consumers of pate de foie gras; both comestibles being +obtained by revolting methods. We sent our sons to public schools +where indecent flogging is a recognized method of taming the +young human animal. Yet we were all in hysterics of indignation +at the cruelties of the vivisectors. These, if any were present, +must have smiled sardonically at such inhuman humanitarians, +whose daily habits and fashionable amusements cause more +suffering in England in a week than all the vivisectors of Europe +do in a year. I made a very effective speech, not exclusively +against vivisection, but against cruelty; and I have never been +asked to speak since by that Society, nor do I expect to be, as I +should probably give such offence to its most affluent +subscribers that its attempts to suppress vivisection would be +seriously hindered. But that does not prevent the vivisectors +from freely using the "youre another" retort, and using it with +justice. + +We must therefore give ourselves no airs of superiority when +denouncing the cruelties of vivisection. We all do just as +horrible things, with even less excuse. But in making that +admission we are also making short work of the virtuous airs with +which we are sometimes referred to the humanity of the medical +profession as a guarantee that vivisection is not abused--much as +if our burglars should assure us that they arc too honest to +abuse the practice of burgling. We are, as a matter of fact, a +cruel nation; and our habit of disguising our vices by giving +polite names to the offences we are determined to commit does +not, unfortunately for my own comfort, impose on me. Vivisectors +can hardly pretend to be better than the classes from which they +are drawn, or those above them; and if these classes are capable +of sacrificing animals in various cruel ways under cover of +sport, fashion, education, discipline, and even, when the cruel +sacrifices are human sacrifices, of political economy, it is idle +for the vivisector to pretend that he is incapable of practising +cruelty for pleasure or profit or both under the cloak of +science. We are all tarred with the same brush; and the +vivisectors are not slow to remind us of it, and to protest +vehemently against being branded as exceptionally cruel and its +devisors of horrible instruments of torture by people whose main +notion of enjoyment is cruel sport, and whose requirements in the +way of villainously cruel traps occupy pages of the catalogue of +the Army and Navy Stores. + + +THE SCIENTIFIC INVESTIGATION OF CRUELTY + +There is in man a specific lust for cruelty which infects even +his passion of pity and makes it savage. Simple disgust at +cruelty is very rare. The people who turn sick and faint and +those who gloat are often alike in the pains they take to witness +executions, floggings, operations or any other exhibitions of +suffering, especially those involving bloodshed, blows, and +laceration. A craze for cruelty can be developed just as a craze +for drink can; and nobody who attempts to ignore cruelty as a +possible factor in the attraction of vivisection and even of +antivivisection, or in the credulity with which we accept its +excuses, can be regarded as a scientific investigator of it. +Those who accuse vivisectors of indulging the well-known passion +of cruelty under the cloak of research are therefore putting +forward a strictly scientific psychological hypothesis, which is +also simple, human, obvious, and probable. It may be as wounding +to the personal vanity of the vivisector as Darwin's Origin of +Species was to the people who could not bear to think that they +were cousins to the monkeys (remember Goldsmith's anger when he +was told that he could not move his upper jaw); but science has +to consider only the truth of the hypothesis, and not whether +conceited people will like it or not. In vain do the sentimental +champions of vivisection declare themselves the most humane of +men, inflicting suffering only to relieve it, scrupulous in the +use of anesthetics, and void of all passion except the passion of +pity for a disease-ridden world. The really scientific +investigator answers that the question cannot be settled by +hysterical protestations, and that if the vivisectionist rejects +deductive reasoning, he had better clear his character by his own +favorite method of experiment. + +SUGGESTED LABORATORY TESTS OF THE VIVISECTOR'S EMOTIONS + +Take the hackneyed case of the Italian who tortured mice, +ostensibly to find out about the effects of pain rather less than +the nearest dentist could have told him, and who boasted of the +ecstatic sensations (he actually used the word love) with which +he carried out his experiments. Or the gentleman who starved +sixty dogs to death to establish the fact that a dog deprived of +food gets progressively lighter and weaker, becoming remarkably +emaciated, and finally dying: an undoubted truth, but +ascertainable without laboratory experiments by a simple enquiry +addressed to the nearest policeman, or, failing him, to any sane +person in Europe. The Italian is diagnosed as a cruel voluptuary: +the dog-starver is passed over as such a hopeless fool that it is +impossible to take any interest in him. Why not test the +diagnosis scientifically? Why not perform a careful series of +experiments on persons under the influence of voluptuous ecstasy, +so as to ascertain its physiological symptoms? Then perform a +second series on persons engaged in mathematical work or machine +designing, so as to ascertain the symptoms of cold scientific +activity? Then note the symptoms of a vivisector performing a +cruel experiment; and compare them with the voluptuary symptoms +and the mathematical symptoms? Such experiments would be quite as +interesting and important as any yet undertaken by the +vivisectors. They might open a line of investigation which would +finally make, for instance, the ascertainment of the guilt or +innocence of an accused person a much exacter process than the +very fallible methods of our criminal courts. But instead of +proposing such an investigation, our vivisectors offer us all the +pious protestations and all the huffy recriminations that any +common unscientific mortal offers when he is accused of unworthy +conduct. + + +ROUTINE + +Yet most vivisectors would probably come triumphant out of such a +series of experiments, because vivisection is now a routine, like +butchering or hanging or flogging; and many of the men who +practise it do so only because it has been established as part of +the profession they have adopted. Far from enjoying it, they have +simply overcome their natural repugnance and become indifferent +to it, as men inevitably become indifferent to anything they do +often enough. It is this dangerous power of custom that makes it +so difficult to convince the common sense of mankind that any +established commercial or professional practice has its root in +passion. Let a routine once spring from passion, and you will +presently find thousands of routineers following it passionlessly +for a livelihood. Thus it always seems strained to speak of the +religious convictions of a clergyman, because nine out of ten +clergymen have no religions convictions: they are ordinary +officials carrying on a routine of baptizing, marrying, and +churching; praying, reciting, and preaching; and, like solicitors +or doctors, getting away from their duties with relief to hunt, +to garden, to keep bees, to go into society, and the like. In the +same way many people do cruel and vile things without being in +the least cruel or vile, because the routine to which they have +been brought up is superstitiously cruel and vile. To say that +every man who beats his children and every schoolmaster who flogs +a pupil is a conscious debauchee is absurd: thousands of dull, +conscientious people beat their children conscientiously, because +they were beaten themselves and think children ought to be +beaten. The ill-tempered vulgarity that instinctively strikes at +and hurts a thing that annoys it (and all children are annoying), +and the simple stupidity that requires from a child perfection +beyond the reach of the wisest and best adults (perfect +truthfulness coupled with perfect obedience is quite a common +condition of leaving a child unwhipped), produce a good deal of +flagellation among people who not only do not lust after it, but +who hit the harder because they are angry at having to perform an +uncomfortable duty. These people will beat merely to assert their +authority, or to carry out what they conceive to be a divine +order on the strength of the precept of Solomon recorded in the +Bible, which carefully adds that Solomon completely spoilt his +own son and turned away from the god of his fathers to the +sensuous idolatry in which he ended his days. + +In the same way we find men and women practising vivisection as +senselessly as a humane butcher, who adores his fox terrier, will +cut a calf's throat and hang it up by its heels to bleed slowly +to death because it is the custom to eat veal and insist on its +being white; or as a German purveyor nails a goose to a board and +stuffs it with food because fashionable people eat pate de foie +gras; or as the crew of a whaler breaks in on a colony of seals +and clubs them to death in wholesale massacre because ladies want +sealskin jackets; or as fanciers blind singing birds with hot +needles, and mutilate the ears and tails of dogs and horses. Let +cruelty or kindness or anything else once become customary and it +will be practised by people to whom it is not at all natural, but +whose rule of life is simply to do only what everybody else does, +and who would lose their employment and starve if they indulged +in any peculiarity. A respectable man will lie daily, in speech +and in print, about the qualities of the article he lives by +selling, because it is customary to do so. He will flog his boy +for telling a lie, because it is customary to do so. He will also +flog him for not telling a lie if the boy tells inconvenient or +disrespectful truths, because it is customary to do so. He will +give the same boy a present on his birthday, and buy him a spade +and bucket at the seaside, because it is customary to do so, +being all the time neither particularly mendacious, nor +particularly cruel, nor particularly generous, but simply +incapable of ethical judgment or independent action. + +Just so do we find a crowd of petty vivisectionists daily +committing atrocities and stupidities, because it is the custom +to do so. Vivisection is customary as part of the routine of +preparing lectures in medical schools. For instance, there are +two ways of making the action of the heart visible to students. +One, a barbarous, ignorant, and thoughtless way, is to stick +little flags into a rabbit's heart and let the students see the +flags jump. The other, an elegant, ingenious, well-informed, and +instructive way, is to put a sphygmograph on the student's wrist +and let him see a record of his heart's action traced by a needle +on a slip of smoked paper. But it has become the custom for +lecturers to teach from the rabbit; and the lecturers are not +original enough to get out of their groove. Then there are the +demonstrations which are made by cutting up frogs with scissors. +The most humane man, however repugnant the operation may be to +him at first, cannot do it at lecture after lecture for months +without finally--and that very soon--feeling no more for the frog +than if he were cutting up pieces of paper. Such clumsy and lazy +ways of teaching are based on the cheapness of frogs and rabbits. +If machines were as cheap as frogs, engineers would not only be +taught the anatomy of machines and the functions of their parts: +they would also have machines misused and wrecked before them so +that they might learn as much as possible by using their eyes, +and as little as possible by using their brains and imaginations. +Thus we have, as part of the routine of teaching, a routine of +vivisection which soon produces complete indifference to it on +the part even of those who are naturally humane. If they pass on +from the routine of lecture preparation, not into general +practice, but into research work, they carry this acquired +indifference with them into the laboratory, where any atrocity is +possible, because all atrocities satisfy curiosity. The routine +man is in the majority in his profession always: consequently the +moment his practice is tracked down to its source in human +passion there is a great and quite sincere poohpoohing from +himself, from the mass of the profession, and from the mass of +the public, which sees that the average doctor is much too +commonplace and decent a person to be capable of passionate +wickedness of any kind. + +Here then, we have in vivisection, as in all the other tolerated +and instituted cruelties, this anti-climax: that only a +negligible percentage of those who practise and consequently +defend it get any satisfaction out of it. As in Mr. Galsworthy's +play Justice the useless and detestable torture of solitary +imprisonment is shown at its worst without the introduction of a +single cruel person into the drama, so it would be possible to +represent all the torments of vivisection dramatically without +introducing a single vivisector who had not felt sick at his +first experience in the laboratory. Not that this can exonerate +any vivisector from suspicion of enjoying his work (or her work: +a good deal of the vivisection in medical schools is done by +women). In every autobiography which records a real experience of +school or prison life, we find that here and there among the +routineers there is to be found the genuine amateur, the +orgiastic flogging schoolmaster or the nagging warder, who has +sought out a cruel profession for the sake of its cruelty. But it +is the genuine routineer who is the bulwark of the practice, +because, though you can excite public fury against a Sade, a +Bluebeard, or a Nero, you cannot rouse any feeling against dull +Mr. Smith doing his duty: that is, doing the usual thing. He is +so obviously no better and no worse than anyone else that it is +difficult to conceive that the things he does are abominable. If +you would see public dislike surging up in a moment against an +individual, you must watch one who does something unusual, no +matter how sensible it may be. The name of Jonas Hanway lives as +that of a brave man because he was the first who dared to appear +in the streets of this rainy island with an umbrella. + + +THE OLD LINE BETWEEN MAN AND BEAST + +But there is still a distinction to be clung to by those who dare +not tell themselves the truth about the medical profession +because they are so helplessly dependent on it when death +threatens the household. That distinction is the line that +separates the brute from the man in the old classification. +Granted, they will plead, that we are all cruel; yet the tame- +stag-hunter does not hunt men; and the sportsman who lets a leash +of greyhounds loose on a hare would be horrified at the thought +of letting them loose on a human child. The lady who gets her +cloak by flaying a sable does not flay a negro; nor does it ever +occur to her that her veal cutlet might be improved on by a slice +of tender baby. + +Now there was a time when some trust could be placed in this +distinction. The Roman Catholic Church still maintains, with what +it must permit me to call a stupid obstinacy, and in spite of St. +Francis and St. Anthony, that animals have no souls and no +rights; so that you cannot sin against an animal, or against God +by anything you may choose to do to an animal. Resisting the +temptation to enter on an argument as to whether you may not sin +against your own soul if you are unjust or cruel to the least of +those whom St. Francis called his little brothers, I have only to +point out here that nothing could be more despicably +superstitious in the opinion of a vivisector than the notion that +science recognizes any such step in evolution as the step from a +physical organism to an immortal soul. That conceit has been +taken out of all our men of science, and out of all our doctors, +by the evolutionists; and when it is considered how completely +obsessed biological science has become in our days, not by the +full scope of evolution, but by that particular method of it +which has neither sense nor purpose nor life nor anything human, +much less godlike, in it: by the method, that is, of so-called +Natural Selection (meaning no selection at all, but mere dead +accident and luck), the folly of trusting to vivisectors to hold +the human animal any more sacred than the other animals becomes +so clear that it would be waste of time to insist further on it. +As a matter of fact the man who once concedes to the vivisector +the right to put a dog outside the laws of honor and fellowship, +concedes to him also the right to put himself outside them; for +he is nothing to the vivisector but a more highly developed, and +consequently more interesting-to-experiment-on vertebrate than +the dog. + + +VIVISECTING THE HUMAN SUBJECT + +I have in my hand a printed and published account by a doctor of +how he tested his remedy for pulmonary tuberculosis, which was to +inject a powerful germicide directly into the circulation by +stabbing a vein with a syringe. He was one of those doctors who +are able to command public sympathy by saying, quite truly, that +when they discovered that the proposed treatment was dangerous, +they experimented thenceforth on themselves. In this case the +doctor was devoted enough to carry his experiments to the point +of running serious risks, and actually making himself very +uncomfortable. But he did not begin with himself. His first +experiment was on two hospital patients. On receiving a message +from the hospital to the effect that these two martyrs to +therapeutic science had all but expired in convulsions, he +experimented on a rabbit, which instantly dropped dead. It was +then, and not until then, that he began to experiment on himself, +with the germicide modified in the direction indicated by the +experiments made on the two patients and the rabbit. As a good +many people countenance vivisection because they fear that if the +experiments are not made on rabbits they will be made on +themselves, it is worth noting that in this case, where both +rabbits and men were equally available, the men, being, of +course, enormously more instructive, and costing nothing, were +experimented on first. Once grant the ethics of the +vivisectionists and you not only sanction the experiment on the +human subject, but make it the first duty of the vivisector. If a +guinea pig may be sacrificed for the sake of the very little that +can be learnt from it, shall not a man be sacrificed for the sake +of the great deal that can be learnt from him? At all events, he +is sacrificed, as this typical case shows. I may add (not that it +touches the argument) that the doctor, the patients, and the +rabbit all suffered in vain, as far as the hoped-for rescue of +the race from pulmonary consumption is concerned. + + +"THE LIE IS A EUROPEAN POWER" + +Now at the very time when the lectures describing these +experiments were being circulated in print and discussed eagerly +by the medical profession, the customary denials that patients +are experimented on were as loud, as indignant, as high-minded as +ever, in spite of the few intelligent doctors who point out +rightly that all treatments are experiments on the patient. And +this brings us to an obvious but mostly overlooked weakness in +the vivisector's position: that is, his inevitable forfeiture of +all claim to have his word believed. It is hardly to be expected +that a man who does not hesitate to vivisect for the sake of +science will hesitate to lie about it afterwards to protect it +from what he deems the ignorant sentimentality of the laity. When +the public conscience stirs uneasily and threatens suppression, +there is never wanting some doctor of eminent position and high +character who will sacrifice himself devotedly to the cause of +science by coming forward to assure the public on his honor that +all experiments on animals are completely painless; although he +must know that the very experiments which first provoked the +antivivisection movement by their atrocity were experiments to +ascertain the physiological effects of the sensation of extreme +pain (the much more interesting physiology of pleasure remains +uninvestigated) and that all experiments in which sensation is a +factor are voided by its suppression. Besides, vivisection may be +painless in cases where the experiments are very cruel. If a +person scratches me with a poisoned dagger so gently that I do +not feel the scratch, he has achieved a painless vivisection; but +if I presently die in torment I am not likely to consider that +his humility is amply vindicated by his gentleness. A cobra's +bite hurts so little that the creature is almost, legally +speaking, a vivisector who inflicts no pain. By giving his +victims chloroform before biting them he could comply with the +law completely. + +Here, then, is a pretty deadlock. Public support of vivisection +is founded almost wholly on the assurances of the vivisectors +that great public benefits may be expected from the practice. Not +for a moment do I suggest that such a defence would be valid even +if proved. But when the witnesses begin by alleging that in the +cause of science all the customary ethical obligations (which +include the obligation to tell the truth) are suspended, what +weight can any reasonable person give to their testimony? I would +rather swear fifty lies than take an animal which had licked my +hand in good fellowship and torture it. If I did torture the dog, +I should certainly not have the face to turn round and ask how +any person there suspect an honorable man like myself of telling +lies. Most sensible and humane people would, I hope, reply flatly +that honorable men do not behave dishonorably, even to dogs. The +murderer who, when asked by the chaplain whether he had any other +crimes to confess, replied indignantly, "What do you take me +for?" reminds us very strongly of the vivisectors who are so +deeply hurt when their evidence is set aside as worthless. + + +AN ARGUMENT WHICH WOULD DEFEND ANY CRIME + +The Achilles heel of vivisection, however, is not to be found in +the pain it causes, but in the line of argument by which it is +justified. The medical code regarding it is simply criminal +anarchism at its very worst. Indeed no criminal has yet had the +impudence to argue as every vivisector argues. No burglar +contends that as it is admittedly important to have money to +spend, and as the object of burglary is to provide the burglar +with money to spend, and as in many instances it has achieved +this object, therefore the burglar is a public benefactor and the +police are ignorant sentimentalists. No highway robber has yet +harrowed us with denunciations of the puling moralist who allows +his child to suffer all the evils of poverty because certain +faddists think it dishonest to garotte an alderman. Thieves and +assassins understand quite well that there are paths of +acquisition, even of the best things, that are barred to all men +of honor. Again, has the silliest burglar ever pretended that to +put a stop to burglary is to put a stop to industry? All the +vivisections that have been performed since the world began have +produced nothing so important as the innocent and honorable +discovery of radiography; and one of the reasons why radiography +was not discovered sooner was that the men whose business it was +to discover new clinical methods were coarsening and stupefying +themselves with the sensual villanies and cutthroat's casuistries +of vivisection. The law of the conservation of energy holds good +in physiology as in other things: every vivisector is a deserter +from the army of honorable investigators. But the vivisector does +not see this. He not only calls his methods scientific: he +contends that there are no other scientific methods. When you +express your natural loathing for his cruelty and your natural +contempt for his stupidity, he imagines that you are attacking +science. Yet he has no inkling of the method and temper of +science. The point at issue being plainly whether he is a rascal +or not, he not only insists that the real point is whether some +hotheaded antivivisectionist is a liar (which he proves by +ridiculously unscientific assumptions as to the degree of +accuracy attainable in human statement), but never dreams of +offering any scientific evidence by his own methods. + +There are many paths to knowledge already discovered; and no +enlightened man doubts that there are many more waiting to be +discovered. Indeed, all paths lead to knowledge; because even the +vilest and stupidest action teaches us something about vileness +and stupidity, and may accidentally teach us a good deal more: +for instance, a cutthroat learns (and perhaps teaches) the +anatomy of the carotid artery and jugular vein; and there can be +no question that the burning of St. Joan of Arc must have been a +most instructive and interesting experiment to a good observer, +and could have been made more so if it had been carried out by +skilled physiologists under laboratory conditions. The earthquake +in San Francisco proved invaluable as an experiment in the +stability of giant steel buildings; and the ramming of the +Victoria by the Camperdown settled doubtful points of the +greatest importance in naval warfare. According to vivisectionist +logic our builders would be justified in producing artificial +earthquakes with dynamite, and our admirals in contriving +catastrophes at naval manoeuvres, in order to follow up the line +of research thus accidentally discovered. + +The truth is, if the acquisition of knowledge justifies every +sort of conduct, it justifies any sort of conduct, from the +illumination of Nero's feasts by burning human beings alive +(another interesting experiment) to the simplest act of kindness. +And in the light of that truth it is clear that the exemption of +the pursuit of knowledge from the laws of honor is the most +hideous conceivable enlargement of anarchy; worse, by far, than +an exemption of the pursuit of money or political power, since +there can hardly be attained without some regard for at least the +appearances of human welfare, whereas a curious devil might +destroy the whole race in torment, acquiring knowledge all the +time from his highly interesting experiment. There is more danger +in one respectable scientist countenancing such a monstrous claim +than in fifty assassins or dynamitards. The man who makes it is +ethically imbecile; and whoever imagines that it is a scientific +claim has not the faintest conception of what science means. The +paths to knowledge are countless. One of these paths is a path +through darkness, secrecy, and cruelty. When a man deliberately +turns from all other paths and goes down that one, it is +scientific to infer that what attracts him is not knowledge, +since there are other paths to that, but cruelty. With so strong +and scientific a case against him, it is childish for him to +stand on his honor and reputation and high character and the +credit of a noble profession and so forth: he must clear himself +either by reason or by experiment, unless he boldly contends that +evolution has retained a passion of cruelty in man just because +it is indispensable to the fulness of his knowledge. + + +THOU ART THE MAN + +I shall not be at all surprised if what I have written above has +induced in sympathetic readers a transport of virtuous +indignation at the expense of the medical profession. I shall not +damp so creditable and salutary a sentiment; but I must point out +that the guilt is shared by all of us. It is not in his capacity +of healer and man of science that the doctor vivisects or defends +vivisection, but in his entirely vulgar lay capacity. He is made +of the same clay as the ignorant, shallow, credulous, half- +miseducated, pecuniarily anxious people who call him in when they +have tried in vain every bottle and every pill the advertizing +druggist can persuade them to buy. The real remedy for +vivisection is the remedy for all the mischief that the medical +profession and all the other professions are doing: namely, more +knowledge. The juries which send the poor Peculiars to prison, +and give vivisectionists heavy damages against humane persons who +accuse them of cruelty; the editors and councillors and student- +led mobs who are striving to make Vivisection one of the +watchwords of our civilization, are not doctors: they are the +British public, all so afraid to die that they will cling +frantically to any idol which promises to cure all their +diseases, and crucify anyone who tells them that they must not +only die when their time comes, but die like gentlemen. In their +paroxysms of cowardice and selfishness they force the doctors to +humor their folly and ignorance. How complete and inconsiderate +their ignorance is can only be realized by those who have some +knowledge of vital statistics, and of the illusions which beset +Public Health legislation. + + +WHAT THE PUBLIC WANTS AND WILL NOT GET + +The demands of this poor public are not reasonable, but they are +quite simple. It dreads disease and desires to be protected +against it. But it is poor and wants to be protected cheaply. +Scientific measures are too hard to understand, too costly, too +clearly tending towards a rise in the rates and more public +interference with the insanitary, because insufficiently +financed, private house. What the public wants, therefore, is a +cheap magic charm to prevent, and a cheap pill or potion to cure, +all disease. It forces all such charms on the doctors. + + +THE VACCINATION CRAZE + +Thus it was really the public and not the medical profession that +took up vaccination with irresistible faith, sweeping the +invention out of Jenner's hand and establishing it in a form +which he himself repudiated. Jenner was not a man of science; but +he was not a fool; and when he found that people who had suffered +from cowpox either by contagion in the milking shed or by +vaccination, were not, as he had supposed, immune from smallpox, +he ascribed the cases of immunity which had formerly misled him +to a disease of the horse, which, perhaps because we do not drink +its milk and eat its flesh, is kept at a greater distance in our +imagination than our foster mother the cow. At all events, the +public, which had been boundlessly credulous about the cow, would +not have the horse on any terms; and to this day the law which +prescribes Jennerian vaccination is carried out with an anti- +Jennerian inoculation because the public would have it so in +spite of Jenner. All the grossest lies and superstitions which +have disgraced the vaccination craze were taught to the doctors +by the public. It was not the doctors who first began to declare +that all our old men remember the time when almost every face +they saw in the street was horribly pitted with smallpox, and +that all this disfigurement has vanished since the introduction +of vaccination. Jenner himself alluded to this imaginary +phenomenon before the introduction of vaccination, and attributed +it to the older practice of smallpox inoculation, by which +Voltaire, Catherine II. and Lady Mary Wortley Montagu so +confidently expected to see the disease made harmless. It was not +Jenner who set people declaring that smallpox, if not abolished +by vaccination, had at least been made much milder: on the +contrary, he recorded a pre-vaccination epidemic in which none of +the persons attacked went to bed or considered themselves as +seriously ill. Neither Jenner, nor any other doctor ever, as far +as I know, inculcated the popular notion that everybody got +smallpox as a matter of course before vaccination was invented. +That doctors get infected with these delusions, and are in their +unprofessional capacity as members of the public subject to them +like other men, is true; but if we had to decide whether +vaccination was first forced on the public by the doctors or on +the doctors by the public, we should have to decide against the +public. + + +STATISTICAL ILLUSIONS + +Public ignorance of the laws of evidence and of statistics can +hardly be exaggerated. There may be a doctor here and there who +in dealing with the statistics of disease has taken at least the +first step towards sanity by grasping the fact that as an attack +of even the commonest disease is an exceptional event, apparently +over-whelming statistical evidence in favor of any prophylactic +can be produced by persuading the public that everybody caught +the disease formerly. Thus if a disease is one which normally +attacks fifteen per cent of the population, and if the effect of +a prophylactic is actually to increase the proportion to twenty +per cent, the publication of this figure of twenty per cent will +convince the public that the prophylactic has reduced the +percentage by eighty per cent instead of increasing it by five, +because the public, left to itself and to the old gentlemen who +are always ready to remember, on every possible subject, that +things used to be much worse than they are now (such old +gentlemen greatly outnumber the laudatores tempori acti), will +assume that the former percentage was about 100. The vogue of the +Pasteur treatment of hydrophobia, for instance, was due to the +assumption by the public that every person bitten by a rabid dog +necessarily got hydrophobia. I myself heard hydrophobia discussed +in my youth by doctors in Dublin before a Pasteur Institute +existed, the subject having been brought forward there by the +scepticism of an eminent surgeon as to whether hydrophobia is +really a specific disease or only ordinary tetanus induced (as +tetanus was then supposed to be induced) by a lacerated wound. +There were no statistics available as to the proportion of dog +bites that ended in hydrophobia; but nobody ever guessed that the +cases could be more than two or three per cent of the bites. On +me, therefore, the results published by the Pasteur Institute +produced no such effect as they did on the ordinary man who +thinks that the bite of a mad dog means certain hydrophobia. It +seemed to me that the proportion of deaths among the cases +treated at the Institute was rather higher, if anything, than +might have been expected had there been no Institute in +existence. But to the public every Pasteur patient who did not +die was miraculously saved from an agonizing death by the +beneficent white magic of that most trusty of all wizards, the +man of science. + +Even trained statisticians often fail to appreciate the extent to +which statistics are vitiated by the unrecorded assumptions of +their interpreters. Their attention is too much occupied with the +cruder tricks of those who make a corrupt use of statistics for +advertizing purposes. There is, for example, the percentage +dodge. In some hamlet, barely large enough to have a name, two +people are attacked during a smallpox epidemic. One dies: the +other recovers. One has vaccination marks: the other has none. +Immediately either the vaccinists or the antivaccinists publish +the triumphant news that at such and such a place not a single +vaccinated person died of smallpox whilst 100 per cent of the +unvaccinated perished miserably; or, as the case may be, that 100 +per cent of the unvaccinated recovered whilst the vaccinated +succumbed to the last man. Or, to take another common instance, +comparisons which are really comparisons between two social +classes with different standards of nutrition and education are +palmed off as comparisons between the results of a certain +medical treatment and its neglect. Thus it is easy to prove that +the wearing of tall hats and the carrying of umbrellas enlarges +the chest, prolongs life, and confers comparative immunity from +disease; for the statistics show that the classes which use these +articles are bigger, healthier, and live longer than the class +which never dreams of possessing such things. It does not take +much perspicacity to see that what really makes this difference +is not the tall hat and the umbrella, but the wealth and +nourishment of which they are evidence, and that a gold watch or +membership of a club in Pall Mall might be proved in the same way +to have the like sovereign virtues. A university degree, a daily +bath, the owning of thirty pairs of trousers, a knowledge of +Wagner's music, a pew in church, anything, in short, that implies +more means and better nurture than the mass of laborers enjoy, +can be statistically palmed off as a magic-spell conferring all +sorts of privileges. + +In the case of a prophylactic enforced by law, this illusion is +intensified grotesquely, because only vagrants can evade it. Now +vagrants have little power of resisting any disease: their death +rate and their case-mortality rate is always high relatively to +that of respectable folk. Nothing is easier, therefore, than to +prove that compliance with any public regulation produces the +most gratifying results. It would be equally easy even if the +regulation actually raised the death-rate, provided it did not +raise it sufficiently to make the average householder, who cannot +evade regulations, die as early as the average vagrant who can. + + +THE SURPRISES OF ATTENTION AND NEGLECT + +There is another statistical illusion which is independent of +class differences. A common complaint of houseowners is that the +Public Health Authorities frequently compel them to instal costly +sanitary appliances which are condemned a few years later as +dangerous to health, and forbidden under penalties. Yet these +discarded mistakes are always made in the first instance on the +strength of a demonstration that their introduction has reduced +the death-rate. The explanation is simple. Suppose a law were +made that every child in the nation should be compelled to drink +a pint of brandy per month, but that the brandy must be +administered only when the child was in good health, with its +digestion and so forth working normally, and its teeth either +naturally or artificially sound. Probably the result would be an +immediate and startling reduction in child mortality, leading to +further legislation increasing the quantity of brandy to a +gallon. Not until the brandy craze had been carried to a point at +which the direct harm done by it would outweigh the incidental +good, would an anti-brandy party be listened to. That incidental +good would be the substitution of attention to the general health +of children for the neglect which is now the rule so long as the +child is not actually too sick to run about and play as usual. +Even if this attention were confined to the children's teeth, +there would be an improvement which it would take a good deal of +brandy to cancel. + +This imaginary case explains the actual case of the sanitary +appliances which our local sanitary authorities prescribe today +and condemn tomorrow. No sanitary contrivance which the mind of +even the very worst plumber can devize could be as disastrous as +that total neglect for long periods which gets avenged by +pestilences that sweep through whole continents, like the black +death and the cholera. If it were proposed at this time of day to +discharge all the sewage of London crude and untreated into the +Thames, instead of carrying it, after elaborate treatment, far +out into the North Sea, there would be a shriek of horror from +all our experts. Yet if Cromwell had done that instead of doing +nothing, there would probably have been no Great Plague of +London. When the Local Health Authority forces every householder +to have his sanitary arrangements thought about and attended to +by somebody whose special business it is to attend to such +things, then it matters not how erroneous or even directly +mischievous may be the specific measures taken: the net result at +first is sure to be an improvement. Not until attention has been +effectually substituted for neglect as the general rule, will the +statistics begin to show the merits of the particular methods of +attention adopted. And as we are far from having arrived at this +stage, being as to health legislation only at the beginning of +things, we have practically no evidence yet as to the value of +methods. Simple and obvious as this is, nobody seems as yet to +discount the effect of substituting attention for neglect in +drawing conclusions from health statistics. Everything is put to +the credit of the particular method employed, although it may +quite possibly be raising the death rate by five per thousand +whilst the attention incidental to it is reducing the death rate +fifteen per thousand. The net gain of ten per thousand is +credited to the method, and made the excuse for enforcing more of +it. + + +STEALING CREDIT FROM CIVILIZATION + +There is yet another way in which specifics which have no merits +at all, either direct or incidental, may be brought into high +repute by statistics. For a century past civilization has been +cleaning away the conditions which favor bacterial fevers. +Typhus, once rife, has vanished: plague and cholera have been +stopped at our frontiers by a sanitary blockade. We still have +epidemics of smallpox and typhoid; and diphtheria and scarlet +fever are endemic in the slums. Measles, which in my childhood +was not regarded as a dangerous disease, has now become so mortal +that notices are posted publicly urging parents to take it +seriously. But even in these cases the contrast between the death +and recovery rates in the rich districts and in the poor ones has +led to the general conviction among experts that bacterial +diseases are preventable; and they already are to a large extent +prevented. The dangers of infection and the way to avoid it are +better understood than they used to be. It is barely twenty years +since people exposed themselves recklessly to the infection of +consumption and pneumonia in the belief that these diseases were +not "catching." Nowadays the troubles of consumptive patients are +greatly increased by the growing disposition to treat them as +lepers. No doubt there is a good deal of ignorant exaggeration +and cowardly refusal to face a human and necessary share of the +risk. That has always been the case. We now know that the +medieval horror of leprosy was out of all proportion to the +danger of infection, and was accompanied by apparent blindness to +the infectiousness of smallpox, which has since been worked up by +our disease terrorists into the position formerly held by +leprosy. But the scare of infection, though it sets even doctors +talking as if the only really scientific thing to do with a fever +patient is to throw him into the nearest ditch and pump carbolic +acid on him from a safe distance until he is ready to be cremated +on the spot, has led to much greater care and cleanliness. And +the net result has been a series of victories over disease. + +Now let us suppose that in the early nineteenth century somebody +had come forward with a theory that typhus fever always begins in +the top joint of the little finger; and that if this joint be +amputated immediately after birth, typhus fever will disappear. +Had such a suggestion been adopted, the theory would have been +triumphantly confirmed; for as a matter of fact, typhus fever has +disappeared. On the other hand cancer and madness have increased +(statistically) to an appalling extent. The opponents of the +little finger theory would therefore be pretty sure to allege +that the amputations were spreading cancer and lunacy. The +vaccination controversy is full of such contentions. So is the +controversy as to the docking of horses' tails and the cropping +of dogs' ears. So is the less widely known controversy as to +circumcision and the declaring certain kinds of flesh unclean by +the Jews. To advertize any remedy or operation, you have only to +pick out all the most reassuring advances made by civilization, +and boldly present the two in the relation of cause and effect: +the public will swallow the fallacy without a wry face. It has no +idea of the need for what is called a control experiment. In +Shakespear's time and for long after it, mummy was a favorite +medicament. You took a pinch of the dust of a dead Egyptian in a +pint of the hottest water you could bear to drink; and it did you +a great deal of good. This, you thought, proved what a sovereign +healer mummy was. But if you had tried the control experiment of +taking the hot water without the mummy, you might have found the +effect exactly the same, and that any hot drink would have done +as well. + + +BIOMETRIKA + +Another difficulty about statistics is the technical difficulty +of calculation. Before you can even make a mistake in drawing +your conclusion from the correlations established by your +statistics you must ascertain the correlations. When I turn over +the pages of Biometrika, a quarterly journal in which is recorded +the work done in the field of biological statistics by Professor +Karl Pearson and his colleagues, I am out of my depth at the +first line, because mathematics are to me only a concept: I never +used a logarithm in my life, and could not undertake to extract +the square root of four without misgiving. I am therefore unable +to deny that the statistical ascertainment of the correlations +between one thing and another must be a very complicated and +difficult technical business, not to be tackled successfully +except by high mathematicians; and I cannot resist Professor Karl +Pearson's immense contempt for, and indignant sense of grave +social danger in, the unskilled guesses of the ordinary +sociologist. + +Now the man in the street knows nothing of Biometrika: all he +knows is that "you can prove anything by figures," though he +forgets this the moment figures are used to prove anything he +wants to believe. If he did take in Biometrika he would probably +become abjectly credulous as to all the conclusions drawn in it +from the correlations so learnedly worked out; though the +mathematician whose correlations would fill a Newton with +admiration may, in collecting and accepting data and drawing +conclusions from them, fall into quite crude errors by just such +popular oversights as I have been describing. + + +PATIENT-MADE THERAPEUTICS + +To all these blunders and ignorances doctors are no less subject +than the rest of us. They are not trained in the use of evidence, +nor in biometrics, nor in the psychology of human credulity, nor +in the incidence of economic pressure. Further, they must +believe, on the whole, what their patients believe, just as they +must wear the sort of hat their patients wear. The doctor may lay +down the law despotically enough to the patient at points where +the patient's mind is simply blank; but when the patient has a +prejudice the doctor must either keep it in countenance or lose +his patient. If people are persuaded that night air is dangerous +to health and that fresh air makes them catch cold it will not be +possible for a doctor to make his living in private practice if +he prescribes ventilation. We have to go back no further than the +days of The Pickwick Papers to find ourselves in a world where +people slept in four-post beds with curtains drawn closely round +to exclude as much air as possible. Had Mr. Pickwick's doctor +told him that he would be much healthier if he slept on a camp +bed by an open window, Mr. Pickwick would have regarded him as a +crank and called in another doctor. Had he gone on to forbid Mr. +Pickwick to drink brandy and water whenever he felt chilly, and +assured him that if he were deprived of meat or salt for a whole +year, he would not only not die, but would be none the worse, Mr. +Pickwick would have fled from his presence as from that of a +dangerous madman. And in these matters the doctor cannot cheat +his patient. If he has no faith in drugs or vaccination, and the +patient has, he can cheat him with colored water and pass his +lancet through the flame of a spirit lamp before scratching his +arm. But he cannot make him change his daily habits without +knowing it. + + +THE REFORMS ALSO COME FROM THE LAITY + +In the main, then, the doctor learns that if he gets ahead of the +superstitions of his patients he is a ruined man; and the result +is that he instinctively takes care not to get ahead of them. +That is why all the changes come from the laity. It was not until +an agitation had been conducted for many years by laymen, +including quacks and faddists of all kinds, that the public was +sufficiently impressed to make it possible for the doctors to +open their minds and their mouths on the subject of fresh air, +cold water, temperance, and the rest of the new fashions in +hygiene. At present the tables have been turned on many old +prejudices. Plenty of our most popular elderly doctors believe +that cold tubs in the morning are unnatural, exhausting, and +rheumatic; that fresh air is a fad and that everybody is the +better for a glass or two of port wine every day; but they no +longer dare say as much until they know exactly where they are; +for many very desirable patients in country houses have lately +been persuaded that their first duty is to get up at six in the +morning and begin the day by taking a walk barefoot through the +dewy grass. He who shows the least scepticism as to this practice +is at once suspected of being "an old-fashioned doctor," and +dismissed to make room for a younger man. + +In short, private medical practice is governed not by science but +by supply and demand; and however scientific a treatment may be, +it cannot hold its place in the market if there is no demand for +it; nor can the grossest quackery be kept off the market if there +is a demand for it. + + +FASHIONS AND EPIDEMICS + +A demand, however, can be inculcated. This is thoroughly +understood by fashionable tradesmen, who find no difficulty in +persuading their customers to renew articles that are not worn +out and to buy things they do not want. By making doctors +tradesmen, we compel them to learn the tricks of trade; +consequently we find that the fashions of the year include +treatments, operations, and particular drugs, as well as hats, +sleeves, ballads, and games. Tonsils, vermiform appendices, +uvulas, even ovaries are sacrificed because it is the fashion to +get them cut out, and because the operations are highly +profitable. The psychology of fashion becomes a pathology; for +the cases have every air of being genuine: fashions, after all, +are only induced epidemics, proving that epidemics can be induced +by tradesmen, and therefore by doctors. + + +THE DOCTOR'S VIRTUES + +It will be admitted that this is a pretty bad state of things. +And the melodramatic instinct of the public, always demanding; +that every wrong shall have, not its remedy, but its villain to +be hissed, will blame, not its own apathy, superstition, and +ignorance, but the depravity of the doctors. Nothing could be +more unjust or mischievous. Doctors, if no better than other men, +are certainly no worse. I was reproached during the performances +of The Doctor's Dilemma at the Court Theatre in 1907 because I +made the artist a rascal, the journalist an illiterate incapable, +and all the doctors "angels." But I did not go beyond the warrant +of my own experience. It has been my luck to have doctors among +my friends for nearly forty years past (all perfectly aware of my +freedom from the usual credulity as to the miraculous powers and +knowledge attributed to them); and though I know that there are +medical blackguards as well as military, legal, and clerical +blackguards (one soon finds that out when one is privileged to +hear doctors talking shop among themselves), the fact that I was +no more at a loss for private medical advice and attendance when +I had not a penny in my pocket than I was later on when I could +afford fees on the highest scale, has made it impossible for me +to share that hostility to the doctor as a man which exists and +is growing as an inevitable result of the present condition of +medical practice. Not that the interest in disease and +aberrations which turns some men and women to medicine and +surgery is not sometimes as morbid as the interest in misery and +vice which turns some others to philanthropy and "rescue work." +But the true doctor is inspired by a hatred of ill-health, and a +divine impatience of any waste of vital forces. Unless a man is +led to medicine or surgery through a very exceptional technical +aptitude, or because doctoring is a family tradition, or because +he regards it unintelligently as a lucrative and gentlemanly +profession, his motives in choosing the career of a healer are +clearly generous. However actual practice may disillusion and +corrupt him, his selection in the first instance is not a +selection of a base character. + + +THE DOCTOR'S HARDSHIPS + +A review of the counts in the indictment I have brought against +private medical practice will show that they arise out of the +doctor's position as a competitive private tradesman: that is, +out of his poverty and dependence. And it should be borne in mind +that doctors are expected to treat other people specially well +whilst themselves submitting to specially inconsiderate +treatment. The butcher and baker are not expected to feed the +hungry unless the hungry can pay; but a doctor who allows a +fellow-creature to suffer or perish without aid is regarded as a +monster. Even if we must dismiss hospital service as really +venal, the fact remains that most doctors do a good deal of +gratuitous work in private practice all through their careers. +And in his paid work the doctor is on a different footing to the +tradesman. Although the articles he sells, advice and treatment, +are the same for all classes, his fees have to be graduated like +the income tax. The successful fashionable doctor may weed his +poorer patients out from time to time, and finally use the +College of Physicians to place it out of his own power to accept +low fees; but the ordinary general practitioner never makes out +his bills without considering the taxable capacity of his +patients. + +Then there is the disregard of his own health and comfort which +results from the fact that he is, by the nature of his work, an +emergency man. We are polite and considerate to the doctor when +there is nothing the matter, and we meet him as a friend or +entertain him as a guest; but when the baby is suffering from +croup, or its mother has a temperature of 104 degrees, or its +grandfather has broken his leg, nobody thinks of the doctor +except as a healer and saviour. He may be hungry, weary, sleepy, +run down by several successive nights disturbed by that +instrument of torture, the night bell; but who ever thinks of +this in the face of sudden sickness or accident? We think no more +of the condition of a doctor attending a case than of the +condition of a fireman at a fire. In other occupations night-work +is specially recognized and provided for. The worker sleeps all +day; has his breakfast in the evening; his lunch or dinner at +midnight; his dinner or supper before going to bed in the +morning; and he changes to day-work if he cannot stand night- +work. But a doctor is expected to work day and night. In +practices which consist largely of workmen's clubs, and in which +the patients are therefore taken on wholesale terms and very +numerous, the unfortunate assistant, or the principal if he has +no assistant, often does not undress, knowing that he will be +called up before he has snatched an hour's sleep. To the strain +of such inhuman conditions must be added the constant risk of +infection. One wonders why the impatient doctors do not become +savage and unmanageable, and the patient ones imbecile. Perhaps +they do, to some extent. And the pay is wretched, and so +uncertain that refusal to attend without payment in advance +becomes often a necessary measure of self-defence, whilst the +County Court has long ago put an end to the tradition that the +doctor's fee is an honorarium. Even the most eminent physicians, +as such biographies as those of Paget show, are sometimes +miserably, inhumanly poor until they are past their prime. +In short, the doctor needs our help for the moment much more than +we often need his. The ridicule of Moliere, the death of a well- +informed and clever writer like the late Harold Frederic in the +hands of Christian Scientists (a sort of sealing with his blood +of the contemptuous disbelief in and dislike of doctors he had +bitterly expressed in his books), the scathing and quite +justifiable exposure of medical practice in the novel by Mr. +Maarten Maartens entitled The New Religion: all these trouble the +doctor very little, and are in any case well set off by the +popularity of Sir Luke Fildes' famous picture, and by the +verdicts in which juries from time to time express their +conviction that the doctor can do no wrong. The real woes of the +doctor are the shabby coat, the wolf at the door, the tyranny of +ignorant patients, the work-day of 24 hours, and the uselessness +of honestly prescribing what most of the patients really need: +that is, not medicine, but money. + + +THE PUBLIC DOCTOR + +What then is to be done? + +Fortunately we have not to begin absolutely from the beginning: +we already have, in the Medical Officer of Health, a sort of +doctor who is free from the worst hardships, and consequently +from the worst vices, of the private practitioner. His position +depends, not on the number of people who are ill, and whom he can +keep ill, but on the number of people who are well. He is judged, +as all doctors and treatments should be judged, by the vital +statistics of his district. When the death rate goes up his +credit goes down. As every increase in his salary depends on the +issue of a public debate as to the health of the constituency +under his charge, he has every inducement to strive towards the +ideal of a clean bill of health. He has a safe, dignified, +responsible, independent position based wholly on the public +health; whereas the private practitioner has a precarious, +shabby-genteel, irresponsible, servile position, based wholly on +the prevalence of illness. + +It is true, there are grave scandals in the public medical +service. The public doctor may be also a private practitioner +eking out his earnings by giving a little time to public work for +a mean payment. There are cases in which the position is one +which no successful practitioner will accept, and where, +therefore, incapables or drunkards get automatically selected for +the post, faute de mieux; but even in these cases the doctor is +less disastrous in his public capacity than in his private one: +besides, the conditions which produce these bad cases are +doomed, as the evil is now recognized and understood. A popular +but unstable remedy is to enable local authorities, when they are +too small to require the undivided time of such men as the +Medical Officers of our great municipalities, to combine for +public health purposes so that each may share the services of a +highly paid official of the best class; but the right remedy is a +larger area as the sanitary unit. + + +MEDICAL ORGANIZATION + +Another advantage of public medical work is that it admits of +organization, and consequently of the distribution of the work in +such a manner as to avoid wasting the time of highly qualified +experts on trivial jobs. The individualism of private practice +leads to an appalling waste of time on trifles. Men whose +dexterity as operators or almost divinatory skill in diagnosis +are constantly needed for difficult cases, are poulticing +whitlows, vaccinating, changing unimportant dressings, +prescribing ether drams for ladies with timid leanings towards +dipsomania, and generally wasting their time in the pursuit +of private fees. In no other profession is the practitioner +expected to do all the work involved in it from the first day of +his professional career to the last as the doctor is. The judge +passes sentence of death; but he is not expected to hang the +criminal with his own hands, as he would be if the legal +profession were as unorganized as the medical. The bishop is not +expected to blow the organ or wash the baby he baptizes. The +general is not asked to plan a campaign or conduct a battle at +half-past twelve and to play the drum at half-past two. Even if +they were, things would still not be as bad as in the medical +profession; for in it not only is the first-class man set to do +third-class work, but, what is much more terrifying, the third- +class man is expected to do first-class work. Every general +practitioner is supposed to be capable of the whole range of +medical and surgical work at a moment's notice; and the country +doctor, who has not a specialist nor a crack consultant at the +end of his telephone, often has to tackle without hesitation +cases which no sane practitioner in a town would take in hand +without assistance. No doubt this develops the resourcefulness of +the country doctor, and makes him a more capable man than his +suburban colleague; but it cannot develop the second-class man +into a first-class one. If the practice of law not only led to a +judge having to hang, but the hangman to judge, or if in the army +matters were so arranged that it would be possible for the +drummer boy to be in command at Waterloo whilst the Duke of +Wellington was playing the drum in Brussels, we should not be +consoled by the reflection that our hangmen were thereby made a +little more judicial-minded, and our drummers more responsible, +than in foreign countries where the legal and military +professions recognized the advantages of division of labor. + +Under such conditions no statistics as to the graduation of +professional ability among doctors are available. Assuming that +doctors are normal men and not magicians (and it is unfortunately +very hard to persuade people to admit so much and thereby destroy +the romance of doctoring) we may guess that the medical +profession, like the other professions, consists of a small +percentage of highly gifted persons at one end, and a small +percentage of altogether disastrous duffers at the other. Between +these extremes comes the main body of doctors (also, of course, +with a weak and a strong end) who can be trusted to work under +regulations with more or less aid from above according to the +gravity of the case. Or, to put it in terms of the cases, there +are cases that present no difficulties, and can be dealt with by +a nurse or student at one end of the scale, and cases that +require watching and handling by the very highest existing skill +at the other; whilst between come the great mass of cases which +need visits from the doctor of ordinary ability and from the +chiefs of the profession in the proportion of, say, seven to +none, seven to one, three to one, one to one, or, for a day or +two, none to one. Such a service is organized at present only in +hospitals; though in large towns the practice of calling in the +consultant acts, to some extent, as a substitute for it. But in +the latter case it is quite unregulated except by professional +etiquet, which, as we have seen, has for its object, not the +health of the patient or of the community at large, but the +protection of the doctor's livelihood and the concealment of his +errors. And as the consultant is an expensive luxury, he is a +last resource rather, as he should be, than a matter of course, +in all cases where the general practitioner is not equal to the +occasion: a predicament in which a very capable man may find +himself at any time through the cropping up of a case of which he +has had no clinical experience. + + +THE SOCIAL SOLUTION OF THE MEDICAL PROBLEM + +The social solution of the medical problem, then, depends on that +large, slowly advancing, pettishly resisted integration of +society called generally Socialism. Until the medical profession +becomes a body of men trained and paid by the country to keep the +country in health it will remain what it is at present: a +conspiracy to exploit popular credulity and human suffering. +Already our M.O.H.s (Medical Officers of Health) are in the new +position: what is lacking is appreciation of the change, not only +by the public but by the private doctors. For, as we have seen, +when one of the first-rate posts becomes vacant in one of the +great cities, and all the leading M.O.H.s compete for it, they +must appeal to the good health of the cities of which they have +been in charge, and not to the size of the incomes the local +private doctors are making out of the ill-health of their +patients. If a competitor can prove that he has utterly ruined +every sort of medical private practice in a large city except +obstetric practice and the surgery of accidents, his claims are +irresistible; and this is the ideal at which every M.O.H. should +aim. But the profession at large should none the less welcome him +and set its house in order for the social change which will +finally be its own salvation. For the M.O.H. as we know him is +only the beginning of that army of Public Hygiene which will +presently take the place in general interest and honor now +occupied by our military and naval forces. It is silly that an +Englishman should be more afraid of a German soldier than of a +British disease germ, and should clamor for more barracks in the +same newspapers that protest against more school clinics, and cry +out that if the State fights disease for us it makes us paupers, +though they never say that if the State fights the Germans for us +it makes us cowards. Fortunately, when a habit of thought is +silly it only needs steady treatment by ridicule from sensible +and witty people to be put out of countenance and perish. Every +year sees an increase in the number of persons employed in the +Public Health Service, who would formerly have been mere +adventurers in the Private Illness Service. To put it another +way, a host of men and women who have now a strong incentive to +be mischievous and even murderous rogues will have a much +stronger, because a much honester, incentive to be not only good +citizens but active benefactors to the community. And they will +have no anxiety whatever about their incomes. + + +THE FUTURE OF PRIVATE PRACTICE + +It must not be hastily concluded that this involves the +extinction of the private practitioner. What it will really +mean for him is release from his present degrading and +scientifically corrupting slavery to his patients. As I have +already shown the doctor who has to live by pleasing his patients +in competition with everybody who has walked the hospitals, +scraped through the examinations, and bought a brass plate, soon +finds himself prescribing water to teetotallers and brandy or +champagne jelly to drunkards; beefsteaks and stout in one house, +and "uric acid free" vegetarian diet over the way; shut windows, +big fires, and heavy overcoats to old Colonels, and open air and +as much nakedness as is compatible with decency to young +faddists, never once daring to say either "I don't know," or "I +don't agree." For the strength of the doctor's, as of every other +man's position when the evolution of social organization at last +reaches his profession, will be that he will always have open to +him the alternative of public employment when the private +employer becomes too tyrannous. And let no one suppose that the +words doctor and patient can disguise from the parties the fact +that they are employer and employee. No doubt doctors who are in +great demand can be as high-handed and independent as employees +are in all classes when a dearth in their labor market makes them +indispensable; but the average doctor is not in this position: he +is struggling for life in an overcrowded profession, and knows +well that "a good bedside manner" will carry him to solvency +through a morass of illness, whilst the least attempt at plain +dealing with people who are eating too much, or drinking too +much, or frowsting too much (to go no further in the list of +intemperances that make up so much of family life) would soon +land him in the Bankruptcy Court. + +Private practice, thus protected, would itself protect +individuals, as far as such protection is possible, against the +errors and superstitions of State medicine, which are at worst no +worse than the errors and superstitions of private practice, +being, indeed, all derived from it. Such monstrosities as +vaccination are, as we have seen, founded, not on science, but on +half-crowns. If the Vaccination Acts, instead of being wholly +repealed as they are already half repealed, were strengthened by +compelling every parent to have his child vaccinated by a public +officer whose salary was completely independent of the number of +vaccinations performed by him, and for whom there was plenty of +alternative public health work waiting, vaccination would be dead +in two years, as the vaccinator would not only not gain by it, +but would lose credit through the depressing effects on the vital +statistics of his district of the illness and deaths it causes, +whilst it would take from him all the credit of that freedom from +smallpox which is the result of good sanitary administration and +vigilant prevention of infection. Such absurd panic scandals as +that of the last London epidemic, where a fee of half-a-crown per +re-vaccination produced raids on houses during the absence of +parents, and the forcible seizure and re-vaccination of children +left to answer the door, can be prevented simply by abolishing +the half-crown and all similar follies, paying, not for this or +that ceremony of witchcraft, but for immunity from disease, and +paying, too, in a rational way. The officer with a fixed salary +saves himself trouble by doing his business with the least +possible interference with the private citizen. The man paid by +the job loses money by not forcing his job on the public as often +as possible without reference to its results. + + +THE TECHNICAL PROBLEM + +As to any technical medical problem specially involved, there is +none. If there were, I should not be competent to deal with it, +as I am not a technical expert in medicine: I deal with the +subject as an economist, a politician, and a citizen exercising +my common sense. Everything that I have said applies equally to +all the medical techniques, and will hold good whether public +hygiene be based on the poetic fancies of Christian Science, the +tribal superstitions of the druggist and the vivisector, or the +best we can make of our real knowledge. But I may remind those +who confusedly imagine that the medical problem is also the +scientific problem, that all problems are finally scientific +problems. The notion that therapeutics or hygiene or surgery is +any more or less scientific than making or cleaning boots is +entertained only by people to whom a man of science is still a +magician who can cure diseases, transmute metals, and enable us +to live for ever. It may still be necessary for some time to come +to practise on popular credulity, popular love and dread of the +marvellous, and popular idolatry, to induce the poor to comply +with the sanitary regulations they are too ignorant to +understand. As I have elsewhere confessed, I have myself been +responsible for ridiculous incantations with burning sulphur, +experimentally proved to be quite useless, because poor people +are convinced, by the mystical air of the burning and the +horrible smell, that it exorcises the demons of smallpox and +scarlet fever and makes it safe for them to return to their +houses. To assure them that the real secret is sunshine and soap +is only to convince them that you do not care whether they live +or die, and wish to save money at their expense. So you perform +the incantation; and back they go to their houses, satisfied. A +religious ceremony--a poetic blessing of the threshold, for +instance--would be much better; but unfortunately our religion is +weak on the sanitary side. One of the worst misfortunes of +Christendom was that reaction against the voluptuous bathing of +the imperial Romans which made dirty habits a part of Christian +piety, and in some unlucky places (the Sandwich Islands for +example) made the introduction of Christianity also the +introduction of disease, because the formulators of the +superseded native religion, like Mahomet, had been enlightened +enough to introduce as religious duties such sanitary measures as +ablution and the most careful and reverent treatment of +everything cast off by the human body, even to nail clippings and +hairs; and our missionaries thoughtlessly discredited this godly +doctrine without supplying its place, which was promptly taken by +laziness and neglect. If the priests of Ireland could only be +persuaded to teach their flocks that it is a deadly insult to the +Blessed Virgin to place her image in a cottage that is not kept +up to that high standard of Sunday cleanliness to which all her +worshippers must believe she is accustomed, and to represent her +as being especially particular about stables because her son was +born in one, they might do more in one year than all the Sanitary +Inspectors in Ireland could do in twenty; and they could hardly +doubt that Our Lady would be delighted. Perhaps they do nowadays; +for Ireland is certainly a transfigured country since my youth as +far as clean faces and pinafores can transfigure it. In England, +where so many of the inhabitants are too gross to believe in +poetic faiths, too respectable to tolerate the notion that the +stable at Bethany was a common peasant farmer's stable instead of +a first-rate racing one, and too savage to believe that anything +can really cast out the devil of disease unless it be some +terrifying hoodoo of tortures and stinks, the M.O.H. will no +doubt for a long time to come have to preach to fools according +to their folly, promising miracles, and threatening hideous +personal consequences of neglect of by-laws and the like; +therefore it will be important that every M.O.H. shall have, with +his (or her) other qualifications, a sense of humor, lest (he or +she) should come at last to believe all the nonsense that must +needs be talked. But he must, in his capacity of an expert +advising the authorities, keep the government itself free of +superstition. If Italian peasants are so ignorant that the Church +can get no hold of them except by miracles, why, miracles there +must be. The blood of St. Januarius must liquefy whether the +Saint is in the humor or not. To trick a heathen into being a +dutiful Christian is no worse than to trick a whitewasher into +trusting himself in a room where a smallpox patient has lain, by +pretending to exorcise the disease with burning sulphur. But woe +to the Church if in deceiving the peasant it also deceives +itself; for then the Church is lost, and the peasant too, unless +he revolt against it. Unless the Church works the pretended +miracle painfully against the grain, and is continually urged by +its dislike of the imposture to strive to make the peasant +susceptible to the true reasons for behaving well, the Church +will become an instrument of his corruption and an exploiter of +his ignorance, and will find itself launched upon that +persecution of scientific truth of which all priesthoods are +accused and none with more justice than the scientific +priesthood. + +And here we come to the danger that terrifies so many of us: the +danger of having a hygienic orthodoxy imposed on us. But we must +face that: in such crowded and poverty ridden civilizations as +ours any orthodoxy is better than laisser-faire. If our +population ever comes to consist exclusively of well-to-do, +highly cultivated, and thoroughly instructed free persons in a +position to take care of themselves, no doubt they will make +short work of a good deal of official regulation that is now of +life-and-death necessity to us; but under existing circumstances, +I repeat, almost any sort of attention that democracy will +stand is better than neglect. Attention and activity lead to +mistakes as well as to successes; but a life spent in making +mistakes is not only more honorable but more useful than a life +spent doing nothing. The one lesson that comes out of all our +theorizing and experimenting is that there is only one really +scientific progressive method; and that is the method of trial +and error. If you come to that, what is laisser-faire but an +orthodoxy? the most tyrannous and disastrous of all the +orthodoxies, since it forbids you even to learn. + + +THE LATEST THEORIES + +Medical theories are so much a matter of fashion, and the most +fertile of them are modified so rapidly by medical practice and +biological research, which are international activities, that the +play which furnishes the pretext for this preface is already +slightly outmoded, though I believe it may be taken as a faithful +record for the year (1906) in which it was begun. I must not +expose any professional man to ruin by connecting his name with +the entire freedom of criticism which I, as a layman, enjoy; but +it will be evident to all experts that my play could not have +been written but for the work done by Sir Almroth Wright in the +theory and practice of securing immunization from bacterial +diseases by the inoculation of "vaccines" made of their own +bacteria: a practice incorrectly called vaccinetherapy (there is +nothing vaccine about it) apparently because it is what +vaccination ought to be and is not. Until Sir Almroth Wright, +following up one of Metchnikoff's most suggestive biological +romances, discovered that the white corpuscles or phagocytes +which attack and devour disease germs for us do their work only +when we butter the disease germs appetizingly for them with a +natural sauce which Sir Almroth named opsonin, and that our +production of this condiment continually rises and falls +rhythmically from negligibility to the highest efficiency, nobody +had been able even to conjecture why the various serums that were +from time to time introduced as having effected marvellous cures, +presently made such direful havoc of some unfortunate patient +that they had to be dropped hastily. The quantity of sturdy lying +that was necessary to save the credit of inoculation in those +days was prodigious; and had it not been for the devotion shown +by the military authorities throughout Europe, who would order +the entire disappearance of some disease from their armies, and +bring it about by the simple plan of changing the name under +which the cases were reported, or for our own Metropolitan +Asylums Board, which carefully suppressed all the medical reports +that revealed the sometimes quite appalling effects of epidemics +of revaccination, there is no saying what popular reaction might +not have taken place against the whole immunization movement in +therapeutics. + +The situation was saved when Sir Almroth Wright pointed out that +if you inoculated a patient with pathogenic germs at a moment +when his powers of cooking them for consumption by the phagocytes +was receding to its lowest point, you would certainly make him a +good deal worse and perhaps kill him, whereas if you made +precisely the same inoculation when the cooking power was rising +to one of its periodical climaxes, you would stimulate it to +still further exertions and produce just the opposite result. And +he invented a technique for ascertaining in which phase the +patient happened to be at any given moment. The dramatic +possibilities of this discovery and invention will be found in my +play. But it is one thing to invent a technique: it is quite +another to persuade the medical profession to acquire it. Our +general practitioners, I gather, simply declined to acquire it, +being mostly unable to afford either the acquisition or the +practice of it when acquired. Something simple, cheap, and ready +at all times for all comers, is, as I have shown, the only thing +that is economically possible in general practice, whatever may +be the case in Sir Almroth's famous laboratory in St. Mary's +Hospital. It would have become necessary to denounce opsonin in +the trade papers as a fad and Sir Almroth as a dangerous man if +his practice in the laboratory had not led him to the conclusion +that the customary inoculations were very much too powerful, and +that a comparatively infinitesimal dose would not precipitate a +negative phase of cooking activity, and might induce a positive +one. And thus it happens that the refusal of our general +practitioners to acquire the new technique is no longer quite so +dangerous in practice as it was when The Doctor's Dilemma was +written: nay, that Sir Ralph Bloomfield Boningtons way of +administering inoculations as if they were spoonfuls of squills +may sometimes work fairly well. For all that, I find Sir Almroth +Wright, on the 23rd May, 1910, warning the Royal Society of +Medicine that "the clinician has not yet been prevailed upon to +reconsider his position," which means that the general +practitioner ("the doctor," as he is called in our homes) is +going on just as he did before, and could not afford to learn or +practice a new technique even if he had ever heard of it. To the +patient who does not know about it he will say nothing. To the +patient who does, he will ridicule it, and disparage Sir Almroth. +What else can he do, except confess his ignorance and starve? + +But now please observe how "the whirligig of time brings its +revenges." This latest discovery of the remedial virtue of a +very, very tiny hair of the dog that bit you reminds us, not only +of Arndt's law of protoplasmic reaction to stimuli, according to +which weak and strong stimuli provoke opposite reactions, but of +Hahnemann's homeopathy, which was founded on the fact alleged by +Hahnemann that drugs which produce certain symptoms when taken in +ordinary perceptible quantities, will, when taken in +infinitesimally small quantities, provoke just the opposite +symptoms; so that the drug that gives you a headache will also +cure a headache if you take little enough of it. I have already +explained that the savage opposition which homeopathy encountered +from the medical profession was not a scientific opposition; for +nobody seems to deny that some drugs act in the alleged manner. +It was opposed simply because doctors and apothecaries lived by +selling bottles and boxes of doctor's stuff to be taken in +spoonfuls or in pellets as large as peas; and people would not +pay as much for drops and globules no bigger than pins' heads. +Nowadays, however, the more cultivated folk are beginning to be +so suspicious of drugs, and the incorrigibly superstitious people +so profusely supplied with patent medicines (the medical advice +to take them being wrapped round the bottle and thrown in for +nothing) that homeopathy has become a way of rehabilitating the +trade of prescription compounding, and is consequently coming +into professional credit. At which point the theory of opsonins +comes very opportunely to shake hands with it. + +Add to the newly triumphant homeopathist and the opsonist that +other remarkable innovator, the Swedish masseur, who does not +theorize about you, but probes you all over with his powerful +thumbs until he finds out your sore spots and rubs them away, +besides cheating you into a little wholesome exercise; and you +have nearly everything in medical practice to-day that is not +flat witchcraft or pure commercial exploitation of human +credulity and fear of death. Add to them a good deal of +vegetarian and teetotal controversy raging round a clamor for +scientific eating and drinking, and resulting in little so far +except calling digestion Metabolism and dividing the public +between the eminent doctor who tells us that we do not eat enough +fish, and his equally eminent colleague who warns us that a fish +diet must end in leprosy, and you have all that opposes with any +sort of countenance the rise of Christian Science with its +cathedrals and congregations and zealots and miracles and cures: +all very silly, no doubt, but sane and sensible, poetic and +hopeful, compared to the pseudo science of the commercial general +practitioner, who foolishly clamors for the prosecution and even +the execution of the Christian Scientists when their patients +die, forgetting the long death roll of his own patients. + +By the time this preface is in print the kaleidoscope may have +had another shake; and opsonin may have gone the way of +phlogiston at the hands of its own restless discoverer. I will +not say that Hahnemann may have gone the way of Diafoirus; for +Diafoirus we have always with us. But we shall still pick up all +our knowledge in pursuit of some Will o' the Wisp or other. What +is called science has always pursued the Elixir of Life and the +Philosopher's Stone, and is just as busy after them to-day as +ever it was in the days of Paracelsus. We call them by different +names: Immunization or Radiology or what not; but the dreams +which lure us into the adventures from which we learn are always +at bottom the same. Science becomes dangerous only when it +imagines that it has reached its goal. What is wrong with priests +and popes is that instead of being apostles and saints, they are +nothing but empirics who say "I know" instead of "I am learning," +and pray for credulity and inertia as wise men pray for +scepticism and activity. Such abominations as the Inquisition and +the Vaccination Acts are possible only in the famine years of the +soul, when the great vital dogmas of honor, liberty, courage, the +kinship of all life, faith that the unknown is greater than the +known and is only the As Yet Unknown, and resolution to find a +manly highway to it, have been forgotten in a paroxysm of +littleness and terror in which nothing is active except +concupiscence and the fear of death, playing on which any trader +can filch a fortune, any blackguard gratify his cruelty, and any +tyrant make us his slaves. + +Lest this should seem too rhetorical a conclusion for our +professional men of science, who are mostly trained not to +believe anything unless it is worded in the jargon of those +writers who, because they never really understand what they are +trying to say, cannot find familiar words for it, and are +therefore compelled to invent a new language of nonsense for +every book they write, let me sum up my conclusions as dryly as +is consistent with accurate thought and live conviction. + +1. Nothing is more dangerous than a poor doctor: not even a poor +employer or a poor landlord. + +2. Of all the anti-social vested interests the worst is the +vested interest in ill-health. + +3. Remember that an illness is a misdemeanor; and treat the +doctor as an accessory unless he notifies every case to the +Public Health authority. + +4. Treat every death as a possible and under our present system a +probable murder, by making it the subject of a reasonably +conducted inquest; and execute the doctor, if necessary, as a +doctor, by striking him off the register. + +5. Make up your mind how many doctors the community needs to keep +it well. Do not register more or less than this number; and +let registration constitute the doctor a civil servant with a +dignified living wage paid out of public funds. + +6. Municipalize Harley Street. + +7. Treat the private operator exactly as you would treat a +private executioner. + +8. Treat persons who profess to be able to cure disease as you + treat fortune tellers. + +9. Keep the public carefully informed, by special statistics and +announcements of individual cases, of all illnesses of doctors +or in their families. + +10. Make it compulsory for a doctor using a brass plate to have +inscribed on it, in addition to the letters indicating his +qualifications, the words "Remember that I too am mortal." + +11. In legislation and social organization, proceed on the +principle that invalids, meaning persons who cannot keep +themselves alive by their own activities, cannot, beyond +reason, expect to be kept alive by the activity of others. +There is a point at which the most energetic policeman or +doctor, when called upon to deal with an apparently drowned +person, gives up artificial respiration, although it is never +possible to declare with certainty, at any point short of +decomposition, that another five minutes of the exercise would +not effect resuscitation. The theory that every individual +alive is of infinite value is legislatively impracticable. No +doubt the higher the life we secure to the individual by wise +social organization, the greater his value is to the +community, and the more pains we shall take to pull him +through any temporary danger or disablement. But the man who +costs more than he is worth is doomed by sound hygiene as +inexorably as by sound economics. + +12. Do not try to live for ever. You will not succeed. + +13. Use your health, even to the point of wearing it out. That is +what it is for. Spend all you have before you die; and do not +outlive yourself. + +14. Take the utmost care to get well born and well brought up. +This means that your mother must have a good doctor. Be +careful to go to a school where there is what they call a +school clinic, where your nutrition and teeth and eyesight and +other matters of importance to you will be attended to. Be +particularly careful to have all this done at the expense of +the nation, as otherwise it will not be done at all, the +chances being about forty to one against your being able to +pay for it directly yourself, even if you know how to set +about it. Otherwise you will be what most people are at +present: an unsound citizen of an unsound nation, without +sense enough to be ashamed or unhappy about it. + + + + + + +End of the Project Gutenberg EBook of The Doctor's Dilemma: Preface on +Doctors, by George Bernard Shaw + +*** END OF THE PROJECT GUTENBERG EBOOK THE DOCTOR'S DILEMMA: PREFACE *** + +This file should be named dcprf10.txt or dcprf10.zip +Corrected EDITIONS of our eBooks get a new NUMBER, dcprf11.txt +VERSIONS based on separate sources get new LETTER, dcprf10a.txt + +This etext was produced by Eve Sobol, South Bend, Indiana, USA + +Project Gutenberg eBooks are often created from several printed +editions, all of which are confirmed as Public Domain in the US +unless a copyright notice is included. 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