THE DOCTOR'S DILEMMA: PREFACE ON DOCTORS

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 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.