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?