{"collection":"philosophy-ethics","full_text_available":true,"graph_url":"https://unchartedknowledge.5gfusion.net/v2/api/page/gutenberg_5069/graph","html_url":"https://unchartedknowledge.5gfusion.net/v2/page/gutenberg_5069","id":"gutenberg_5069","license":"Public Domain (US)","rights_basis":"gutenberg_metadata_copyright_false","source":"gutenberg","source_url":"https://www.gutenberg.org/ebooks/5069","summary":null,"tags":["Category: Essays, Letters & Speeches","Category: Health & Medicine","Category: Philosophy & Ethics","Nobel Prizes in Literature","Physicians"],"text":"Produced by Eve Sobol\n\n\n\n\n\n\n\n\nTHE DOCTOR'S DILEMMA: PREFACE ON DOCTORS\n\n\nBy Bernard Shaw\n\n\n1909\n\n\n\nIt is not the fault of our doctors that the medical service of the\ncommunity, as at present provided for, is a murderous absurdity. That\nany sane nation, having observed that you could provide for the supply\nof bread by giving bakers a pecuniary interest in baking for you, should\ngo on to give a surgeon a pecuniary interest in cutting off your leg, is\nenough to make one despair of political humanity. But that is precisely\nwhat we have done. And the more appalling the mutilation, the more the\nmutilator is paid. He who corrects the ingrowing toe-nail receives a\nfew shillings: he who cuts your inside out receives hundreds of guineas,\nexcept when he does it to a poor person for practice.\n\nScandalized voices murmur that these operations are necessary. They\nmay be. It may also be necessary to hang a man or pull down a house.\nBut we take good care not to make the hangman and the housebreaker the\njudges of that. If we did, no man's neck would be safe and no man's\nhouse stable. But we do make the doctor the judge, and fine him anything\nfrom sixpence to several hundred guineas if he decides in our favor.\nI cannot knock my shins severely without forcing on some surgeon the\ndifficult question, \"Could I not make a better use of a pocketful\nof guineas than this man is making of his leg? Could he not write as\nwell--or even better--on one leg than on two? And the guineas would\nmake all the difference in the world to me just now. My wife--my pretty\nones--the leg may mortify--it is always safer to operate--he will be\nwell in a fortnight--artificial legs are now so well made that they\nare really better than natural ones--evolution is towards motors and\nleglessness, etc., etc., etc.\"\n\nNow there is no calculation that an engineer can make as to the behavior\nof a girder under a strain, or an astronomer as to the recurrence of a\ncomet, more certain than the calculation that under such circumstances\nwe shall be dismembered unnecessarily in all directions by surgeons\nwho believe the operations to be necessary solely because they want to\nperform them. The process metaphorically called bleeding the rich man\nis performed not only metaphorically but literally every day by surgeons\nwho are quite as honest as most of us. After all, what harm is there\nin it? The surgeon need not take off the rich man's (or woman's) leg or\narm: he can remove the appendix or the uvula, and leave the patient none\nthe worse after a fortnight or so in bed, whilst the nurse, the general\npractitioner, the apothecary, and the surgeon will be the better.\n\n\n\n\nDOUBTFUL CHARACTER BORNE BY THE MEDICAL PROFESSION\n\nAgain I hear the voices indignantly muttering old phrases about the\nhigh character of a noble profession and the honor and conscience of\nits members. I must reply that the medical profession has not a\nhigh character: it has an infamous character. I do not know a single\nthoughtful and well-informed person who does not feel that the tragedy\nof illness at present is that it delivers you helplessly into the hands\nof a profession which you deeply mistrust, because it not only advocates\nand practises the most revolting cruelties in the pursuit of knowledge,\nand justifies them on grounds which would equally justify practising the\nsame cruelties on yourself or your children, or burning down London to\ntest a patent fire extinguisher, but, when it has shocked the public,\ntries to reassure it with lies of breath-bereaving brazenness. That\nis the character the medical profession has got just now. It may be\ndeserved or it may not: there it is at all events, and the doctors who\nhave not realized this are living in a fool's paradise. As to the humor\nand conscience of doctors, they have as much as any other class of men,\nno more and no less. And what other men dare pretend to be impartial\nwhere they have a strong pecuniary interest on one side? Nobody supposes\nthat doctors are less virtuous than judges; but a judge whose salary\nand reputation depended on whether the verdict was for plaintiff or\ndefendant, prosecutor or prisoner, would be as little trusted as a\ngeneral in the pay of the enemy. To offer me a doctor as my judge, and\nthen weight his decision with a bribe of a large sum of money and a\nvirtual guarantee that if he makes a mistake it can never be proved\nagainst him, is to go wildly beyond the ascertained strain which human\nnature will bear. It is simply unscientific to allege or believe\nthat doctors do not under existing circumstances perform unnecessary\noperations and manufacture and prolong lucrative illnesses. The only\nones who can claim to be above suspicion are those who are so much\nsought after that their cured patients are immediately replaced by fresh\nones. And there is this curious psychological fact to be remembered: a\nserious illness or a death advertizes the doctor exactly as a hanging\nadvertizes the barrister who defended the person hanged. Suppose, for\nexample, a royal personage gets something wrong with his throat, or has\na pain in his inside. If a doctor effects some trumpery cure with a wet\ncompress or a peppermint lozenge nobody takes the least notice of him.\nBut if he operates on the throat and kills the patient, or extirpates\nan internal organ and keeps the whole nation palpitating for days whilst\nthe patient hovers in pain and fever between life and death, his fortune\nis made: every rich man who omits to call him in when the same symptoms\nappear in his household is held not to have done his utmost duty to\nthe patient. The wonder is that there is a king or queen left alive in\nEurope.\n\n\n\n\nDOCTOR'S CONSCIENCES\n\nThere is another difficulty in trusting to the honor and conscience of\na doctor. Doctors are just like other Englishmen: most of them have\nno honor and no conscience: what they commonly mistake for these is\nsentimentality and an intense dread of doing anything that everybody\nelse does not do, or omitting to do anything that everybody else\ndoes. This of course does amount to a sort of working or rule-of-thumb\nconscience; but it means that you will do anything, good or bad,\nprovided you get enough people to keep you in countenance by doing it\nalso. It is the sort of conscience that makes it possible to keep order\non a pirate ship, or in a troop of brigands. It may be said that in\nthe last analysis there is no other sort of honor or conscience in\nexistence--that the assent of the majority is the only sanction known to\nethics. No doubt this holds good in political practice. If mankind knew\nthe facts, and agreed with the doctors, then the doctors would be in\nthe right; and any person who thought otherwise would be a lunatic. But\nmankind does not agree, and does not know the facts. All that can\nbe said for medical popularity is that until there is a practicable\nalternative to blind trust in the doctor, the truth about the doctor is\nso terrible that we dare not face it. Moliere saw through the doctors;\nbut he had to call them in just the same. Napoleon had no illusions\nabout them; but he had to die under their treatment just as much as the\nmost credulous ignoramus that ever paid sixpence for a bottle of strong\nmedicine. In this predicament most people, to save themselves from\nunbearable mistrust and misery, or from being driven by their conscience\ninto actual conflict with the law, fall back on the old rule that if you\ncannot have what you believe in you must believe in what you have. When\nyour child is ill or your wife dying, and you happen to be very fond of\nthem, or even when, if you are not fond of them, you are human enough to\nforget every personal grudge before the spectacle of a fellow creature\nin pain or peril, what you want is comfort, reassurance, something to\nclutch at, were it but a straw. This the doctor brings you. You have a\nwildly urgent feeling that something must be done; and the doctor does\nsomething. Sometimes what he does kills the patient; but you do not know\nthat; and the doctor assures you that all that human skill could do\nhas been done. And nobody has the brutality to say to the newly bereft\nfather, mother, husband, wife, brother, or sister, \"You have killed your\nlost darling by your credulity.\"\n\n\n\n\nTHE PECULIAR PEOPLE\n\nBesides, the calling in of the doctor is now compulsory except in cases\nwhere the patient is an adult--and not too ill to decide the steps to\nbe taken. We are subject to prosecution for manslaughter or for criminal\nneglect if the patient dies without the consolations of the medical\nprofession. This menace is kept before the public by the Peculiar\nPeople. The Peculiars, as they are called, have gained their name by\nbelieving that the Bible is infallible, and taking their belief quite\nseriously. The Bible is very clear as to the treatment of illness.\nThe Epistle of James; chapter v., contains the following explicit\ndirections:\n\n14. Is any sick among you? let him call for the elders of the Church;\nand let them pray over him, anointing him with oil in the name of the\nLord:\n\n15. And the prayer of faith shall save the sick, and the Lord shall\nraise him up; and if he have committed sins, they shall be forgiven him.\n\nThe Peculiars obey these instructions and dispense with doctors. They\nare therefore prosecuted for manslaughter when their children die.\n\nWhen I was a young man, the Peculiars were usually acquitted. The\nprosecution broke down when the doctor in the witness box was asked\nwhether, if the child had had medical attendance, it would have lived.\nIt was, of course, impossible for any man of sense and honor to assume\ndivine omniscience by answering this in the affirmative, or indeed\npretending to be able to answer it at all. And on this the judge had to\ninstruct the jury that they must acquit the prisoner. Thus a judge with\na keen sense of law (a very rare phenomenon on the Bench, by the way)\nwas spared the possibility of leaving to sentence one prisoner (under\nthe Blasphemy laws) for questioning the authority of Scripture, and\nanother for ignorantly and superstitiously accepting it as a guide to\nconduct. To-day all this is changed. The doctor never hesitates to claim\ndivine omniscience, nor to clamor for laws to punish any scepticism on\nthe part of laymen. A modern doctor thinks nothing of signing the death\ncertificate of one of his own diphtheria patients, and then going into\nthe witness box and swearing a peculiar into prison for six months\nby assuring the jury, on oath, that if the prisoner's child, dead of\ndiphtheria, had been placed under his treatment instead of that of St.\nJames, it would not have lived. And he does so not only with impunity,\nbut with public applause, though the logical course would be to\nprosecute him either for the murder of his own patient or for perjury\nin the case of St. James. Yet no barrister, apparently, dreams of asking\nfor the statistics of the relative case-mortality in diphtheria among\nthe Peculiars and among the believers in doctors, on which alone any\nvalid opinion could be founded. The barrister is as superstitious as the\ndoctor is infatuated; and the Peculiar goes unpitied to his cell, though\nnothing whatever has been proved except that his child does without\nthe interference of a doctor as effectually as any of the hundreds of\nchildren who die every day of the same diseases in the doctor's care.\n\n\n\n\nRECOIL OF THE DOGMA OF MEDICAL INFALLIBILITY ON THE DOCTOR\n\nOn the other hand, when the doctor is in the dock, or is the defendant\nin an action for malpractice, he has to struggle against the inevitable\nresult of his former pretences to infinite knowledge and unerring skill.\nHe has taught the jury and the judge, and even his own counsel, to\nbelieve that every doctor can, with a glance at the tongue, a touch\non the pulse, and a reading of the clinical thermometer, diagnose with\nabsolute certainty a patient's complaint, also that on dissecting a dead\nbody he can infallibly put his finger on the cause of death, and, in\ncases where poisoning is suspected, the nature of the poison used. Now\nall this supposed exactness and infallibility is imaginary; and to\ntreat a doctor as if his mistakes were necessarily malicious or corrupt\nmalpractices (an inevitable deduction from the postulate that the\ndoctor, being omniscient, cannot make mistakes) is as unjust as to\nblame the nearest apothecary for not being prepared to supply you with\nsixpenny-worth of the elixir of life, or the nearest motor garage for\nnot having perpetual motion on sale in gallon tins. But if apothecaries\nand motor car makers habitually advertized elixir of life and perpetual\nmotion, and succeeded in creating a strong general belief that they\ncould supply it, they would find themselves in an awkward position if\nthey were indicted for allowing a customer to die, or for burning a\nchauffeur by putting petrol into his car. That is the predicament the\ndoctor finds himself in when he has to defend himself against a charge\nof malpractice by a plea of ignorance and fallibility. His plea is\nreceived with flat credulity; and he gets little sympathy, even from\nlaymen who know, because he has brought the incredulity on himself. If\nhe escapes, he can only do so by opening the eyes of the jury to the\nfacts that medical science is as yet very imperfectly differentiated\nfrom common curemongering witchcraft; that diagnosis, though it means in\nmany instances (including even the identification of pathogenic bacilli\nunder the microscope) only a choice among terms so loose that they would\nnot be accepted as definitions in any really exact science, is, even at\nthat, an uncertain and difficult matter on which doctors often differ;\nand that the very best medical opinion and treatment varies widely from\ndoctor to doctor, one practitioner prescribing six or seven scheduled\npoisons for so familiar a disease as enteric fever where another will\nnot tolerate drugs at all; one starving a patient whom another would\nstuff; one urging an operation which another would regard as unnecessary\nand dangerous; one giving alcohol and meat which another would sternly\nforbid, etc., etc., etc.: all these discrepancies arising not between\nthe opinion of good doctors and bad ones (the medical contention is,\nof course, that a bad doctor is an impossibility), but between\npractitioners of equal eminence and authority. Usually it is impossible\nto persuade the jury that these facts are facts. Juries seldom notice\nfacts; and they have been taught to regard any doubts of the omniscience\nand omnipotence of doctors as blasphemy. Even the fact that doctors\nthemselves die of the very diseases they profess to cure passes\nunnoticed. We do not shoot out our lips and shake our heads, saying,\n\"They save others: themselves they cannot save\": their reputation\nstands, like an African king's palace, on a foundation of dead bodies;\nand the result is that the verdict goes against the defendant when the\ndefendant is a doctor accused of malpractice.\n\nFortunately for the doctors, they very seldom find themselves in this\nposition, because it is so difficult to prove anything against them. The\nonly evidence that can decide a case of malpractice is expert evidence:\nthat is, the evidence of other doctors; and every doctor will allow a\ncolleague to decimate a whole countryside sooner than violate the bond\nof professional etiquet by giving him away. It is the nurse who gives\nthe doctor away in private, because every nurse has some particular\ndoctor whom she likes; and she usually assures her patients that all the\nothers are disastrous noodles, and soothes the tedium of the sick-bed\nby gossip about their blunders. She will even give a doctor away for the\nsake of making the patient believe that she knows more than the doctor.\nBut she dare not, for her livelihood, give the doctor away in public.\nAnd the doctors stand by one another at all costs. Now and then some\ndoctor in an unassailable position, like the late Sir William Gull, will\ngo into the witness box and say what he really thinks about the way a\npatient has been treated; but such behavior is considered little short\nof infamous by his colleagues.\n\n\n\n\nWHY DOCTORS DO NOT DIFFER\n\nThe truth is, there would never be any public agreement among doctors if\nthey did not agree to agree on the main point of the doctor being always\nin the right. Yet the two guinea man never thinks that the five shilling\nman is right: if he did, he would be understood as confessing to an\novercharge of one pound seventeen shillings; and on the same ground\nthe five shilling man cannot encourage the notion that the owner of the\nsixpenny surgery round the corner is quite up to his mark. Thus even\nthe layman has to be taught that infallibility is not quite infallible,\nbecause there are two qualities of it to be had at two prices.\n\nBut there is no agreement even in the same rank at the same price.\nDuring the first great epidemic of influenza towards the end of\nthe nineteenth century a London evening paper sent round a\njournalist-patient to all the great consultants of that day, and\npublished their advice and prescriptions; a proceeding passionately\ndenounced by the medical papers as a breach of confidence of these\neminent physicians. The case was the same; but the prescriptions were\ndifferent, and so was the advice. Now a doctor cannot think his own\ntreatment right and at the same time think his colleague right in\nprescribing a different treatment when the patient is the same. Anyone\nwho has ever known doctors well enough to hear medical shop talked\nwithout reserve knows that they are full of stories about each other's\nblunders and errors, and that the theory of their omniscience and\nomnipotence no more holds good among themselves than it did with Moliere\nand Napoleon. But for this very reason no doctor dare accuse another of\nmalpractice. He is not sure enough of his own opinion to ruin another\nman by it. He knows that if such conduct were tolerated in his\nprofession no doctor's livelihood or reputation would be worth a year's\npurchase. I do not blame him: I would do the same myself. But the effect\nof this state of things is to make the medical profession a conspiracy\nto hide its own shortcomings. No doubt the same may be said of all\nprofessions. They are all conspiracies against the laity; and I do not\nsuggest that the medical conspiracy is either better or worse than the\nmilitary conspiracy, the legal conspiracy, the sacerdotal conspiracy,\nthe pedagogic conspiracy, the royal and aristocratic conspiracy, the\nliterary and artistic conspiracy, and the innumerable industrial,\ncommercial, and financial conspiracies, from the trade unions to the\ngreat exchanges, which make up the huge conflict which we call society.\nBut it is less suspected. The Radicals who used to advocate, as an\nindispensable preliminary to social reform, the strangling of the\nlast king with the entrails of the last priest, substituted compulsory\nvaccination for compulsory baptism without a murmur.\n\n\n\n\nTHE CRAZE FOR OPERATIONS\n\nThus everything is on the side of the doctor. When men die of disease\nthey are said to die from natural causes. When they recover (and they\nmostly do) the doctor gets the credit of curing them. In surgery all\noperations are recorded as successful if the patient can be got out of\nthe hospital or nursing home alive, though the subsequent history of the\ncase may be such as would make an honest surgeon vow never to recommend\nor perform the operation again. The large range of operations which\nconsist of amputating limbs and extirpating organs admits of no direct\nverification of their necessity. There is a fashion in operations as\nthere is in sleeves and skirts: the triumph of some surgeon who has at\nlast found out how to make a once desperate operation fairly safe\nis usually followed by a rage for that operation not only among the\ndoctors, but actually among their patients. There are men and women whom\nthe operating table seems to fascinate; half-alive people who through\nvanity, or hypochondria, or a craving to be the constant objects of\nanxious attention or what not, lose such feeble sense as they ever had\nof the value of their own organs and limbs. They seem to care as little\nfor mutilation as lobsters or lizards, which at least have the excuse\nthat they grow new claws and new tails if they lose the old ones. Whilst\nthis book was being prepared for the press a case was tried in the\nCourts, of a man who sued a railway company for damages because a train\nhad run over him and amputated both his legs. He lost his case because\nit was proved that he had deliberately contrived the occurrence himself\nfor the sake of getting an idler's pension at the expense of the railway\ncompany, being too dull to realize how much more he had to lose than\nto gain by the bargain even if he had won his case and received damages\nabove his utmost hopes.\n\nThus amazing case makes it possible to say, with some prospect of\nbeing believed, that there is in the classes who can afford to pay\nfor fashionable operations a sprinkling of persons so incapable\nof appreciating the relative importance of preserving their bodily\nintegrity, (including the capacity for parentage) and the pleasure of\ntalking about themselves and hearing themselves talked about as the\nheroes and heroines of sensational operations, that they tempt\nsurgeons to operate on them not only with large fees, but with personal\nsolicitation. Now it cannot be too often repeated that when an operation\nis once performed, nobody can ever prove that it was unnecessary. If I\nrefuse to allow my leg to be amputated, its mortification and my death\nmay prove that I was wrong; but if I let the leg go, nobody can ever\nprove that it would not have mortified had I been obstinate. Operation\nis therefore the safe side for the surgeon as well as the lucrative\nside. The result is that we hear of \"conservative surgeons\" as a\ndistinct class of practitioners who make it a rule not to operate if\nthey can possibly help it, and who are sought after by the people who\nhave vitality enough to regard an operation as a last resort. But no\nsurgeon is bound to take the conservative view. If he believes that an\norgan is at best a useless survival, and that if he extirpates it the\npatient will be well and none the worse in a fortnight, whereas to\nawait the natural cure would mean a month's illness, then he is clearly\njustified in recommending the operation even if the cure without\noperation is as certain as anything of the kind ever can be. Thus the\nconservative surgeon and the radical or extirpatory surgeon may both\nbe right as far as the ultimate cure is concerned; so that their\nconsciences do not help them out of their differences.\n\n\n\n\nCREDULITY AND CHLOROFORM\n\nThere is no harder scientific fact in the world than the fact that\nbelief can be produced in practically unlimited quantity and intensity,\nwithout observation or reasoning, and even in defiance of both, by the\nsimple desire to believe founded on a strong interest in believing.\nEverybody recognizes this in the case of the amatory infatuations of\nthe adolescents who see angels and heroes in obviously (to others)\ncommonplace and even objectionable maidens and youths. But it holds good\nover the entire field of human activity. The hardest-headed materialist\nwill become a consulter of table-rappers and slate-writers if he loses\na child or a wife so beloved that the desire to revive and communicate\nwith them becomes irresistible. The cobbler believes that there is\nnothing like leather. The Imperialist who regards the conquest of\nEngland by a foreign power as the worst of political misfortunes\nbelieves that the conquest of a foreign power by England would be a boon\nto the conquered. Doctors are no more proof against such illusions than\nother men. Can anyone then doubt that under existing conditions a great\ndeal of unnecessary and mischievous operating is bound to go on,\nand that patients are encouraged to imagine that modern surgery and\nanesthesia have made operations much less serious matters than they\nreally are? When doctors write or speak to the public about operations,\nthey imply, and often say in so many words, that chloroform has made\nsurgery painless. People who have been operated on know better.\nThe patient does not feel the knife, and the operation is therefore\nenormously facilitated for the surgeon; but the patient pays for the\nanesthesia with hours of wretched sickness; and when that is over there\nis the pain of the wound made by the surgeon, which has to heal like any\nother wound. This is why operating surgeons, who are usually out of the\nhouse with their fee in their pockets before the patient has recovered\nconsciousness, and who therefore see nothing of the suffering witnessed\nby the general practitioner and the nurse, occasionally talk of\noperations very much as the hangman in Barnaby Rudge talked of\nexecutions, as if being operated on were a luxury in sensation as well\nas in price.\n\n\n\n\nMEDICAL POVERTY\n\nTo make matters worse, doctors are hideously poor. The Irish gentleman\ndoctor of my boyhood, who took nothing less than a guinea, though he\nmight pay you four visits for it, seems to have no equivalent nowadays\nin English society. Better be a railway porter than an ordinary English\ngeneral practitioner. A railway porter has from eighteen to twenty-three\nshillings a week from the Company merely as a retainer; and his\nadditional fees from the public, if we leave the third-class twopenny\ntip out of account (and I am by no means sure that even this reservation\nneed be made), are equivalent to doctor's fees in the case of\nsecond-class passengers, and double doctor's fees in the case of first.\nAny class of educated men thus treated tends to become a brigand class,\nand doctors are no exception to the rule. They are offered disgraceful\nprices for advice and medicine. Their patients are for the most part so\npoor and so ignorant that good advice would be resented as impracticable\nand wounding. When you are so poor that you cannot afford to refuse\neighteenpence from a man who is too poor to pay you any more, it\nis useless to tell him that what he or his sick child needs is not\nmedicine, but more leisure, better clothes, better food, and a better\ndrained and ventilated house. It is kinder to give him a bottle of\nsomething almost as cheap as water, and tell him to come again with\nanother eighteenpence if it does not cure him. When you have done that\nover and over again every day for a week, how much scientific conscience\nhave you left? If you are weak-minded enough to cling desperately to\nyour eighteenpence as denoting a certain social superiority to the\nsixpenny doctor, you will be miserably poor all your life; whilst the\nsixpenny doctor, with his low prices and quick turnover of patients,\nvisibly makes much more than you do and kills no more people.\n\nA doctor's character can no more stand out against such conditions than\nthe lungs of his patients can stand out against bad ventilation. The\nonly way in which he can preserve his self-respect is by forgetting\nall he ever learnt of science, and clinging to such help as he can\ngive without cost merely by being less ignorant and more accustomed to\nsick-beds than his patients. Finally, he acquires a certain skill at\nnursing cases under poverty-stricken domestic conditions, just as women\nwho have been trained as domestic servants in some huge institution with\nlifts, vacuum cleaners, electric lighting, steam heating, and machinery\nthat turns the kitchen into a laboratory and engine house combined,\nmanage, when they are sent out into the world to drudge as general\nservants, to pick up their business in a new way, learning the\nslatternly habits and wretched makeshifts of homes where even bundles of\nkindling wood are luxuries to be anxiously economized.\n\n\n\n\nTHE SUCCESSFUL DOCTOR\n\nThe doctor whose success blinds public opinion to medical poverty is\nalmost as completely demoralized. His promotion means that his practice\nbecomes more and more confined to the idle rich. The proper advice for\nmost of their ailments is typified in Abernethy's \"Live on sixpence a\nday and earn it.\" But here, as at the other end of the scale, the right\nadvice is neither agreeable nor practicable. And every hypochondriacal\nrich lady or gentleman who can be persuaded that he or she is a lifelong\ninvalid means anything from fifty to five hundred pounds a year for the\ndoctor. Operations enable a surgeon to earn similar sums in a couple\nof hours; and if the surgeon also keeps a nursing home, he may make\nconsiderable profits at the same time by running what is the most\nexpensive kind of hotel. These gains are so great that they undo much\nof the moral advantage which the absence of grinding pecuniary anxiety\ngives the rich doctor over the poor one. It is true that the temptation\nto prescribe a sham treatment because the real treatment is too dear for\neither patient or doctor does not exist for the rich doctor. He always\nhas plenty of genuine cases which can afford genuine treatment; and\nthese provide him with enough sincere scientific professional work to\nsave him from the ignorance, obsolescence, and atrophy of scientific\nconscience into which his poorer colleagues sink. But on the other hand\nhis expenses are enormous. Even as a bachelor, he must, at London west\nend rates, make over a thousand a year before he can afford even to\ninsure his life. His house, his servants, and his equipage (or autopage)\nmust be on the scale to which his patients are accustomed, though a\ncouple of rooms with a camp bed in one of them might satisfy his own\nrequirements. Above all, the income which provides for these outgoings\nstops the moment he himself stops working. Unlike the man of business,\nwhose managers, clerks, warehousemen and laborers keep his business\ngoing whilst he is in bed or in his club, the doctor cannot earn a\nfarthing by deputy. Though he is exceptionally exposed to infection, and\nhas to face all weathers at all hours of the night and day, often not\nenjoying a complete night's rest for a week, the money stops coming in\nthe moment he stops going out; and therefore illness has special terrors\nfor him, and success no certain permanence. He dare not stop making\nhay while the sun shines; for it may set at any time. Men do not resist\npressure of this intensity. When they come under it as doctors they pay\nunnecessary visits; they write prescriptions that are as absurd as the\nrub of chalk with which an Irish tailor once charmed away a wart from my\nfather's finger; they conspire with surgeons to promote operations; they\nnurse the delusions of the malade imaginaire (who is always really ill\nbecause, as there is no such thing as perfect health, nobody is ever\nreally well); they exploit human folly, vanity, and fear of death as\nruthlessly as their own health, strength, and patience are exploited\nby selfish hypochondriacs. They must do all these things or else\nrun pecuniary risks that no man can fairly be asked to run. And the\nhealthier the world becomes, the more they are compelled to live by\nimposture and the less by that really helpful activity of which all\ndoctors get enough to preserve them from utter corruption. For even the\nmost hardened humbug who ever prescribed ether tonics to ladies whose\nneed for tonics is of precisely the same character as the need of poorer\nwomen for a glass of gin, has to help a mother through child-bearing\noften enough to feel that he is not living wholly in vain.\n\n\n\n\nTHE PSYCHOLOGY OF SELF-RESPECT IN SURGEONS\n\nThe surgeon, though often more unscrupulous than the general\npractitioner, retains his self-respect more easily. The human conscience\ncan subsist on very questionable food. No man who is occupied in doing\na very difficult thing, and doing it very well, ever loses his\nself-respect. The shirk, the duffer, the malingerer, the coward, the\nweakling, may be put out of countenance by his own failures and frauds;\nbut the man who does evil skilfully, energetically, masterfully, grows\nprouder and bolder at every crime. The common man may have to found his\nself-respect on sobriety, honesty and industry; but a Napoleon needs no\nsuch props for his sense of dignity. If Nelson's conscience whispered to\nhim at all in the silent watches of the night, you may depend on it it\nwhispered about the Baltic and the Nile and Cape St. Vincent, and not\nabout his unfaithfulness to his wife. A man who robs little children\nwhen no one is looking can hardly have much self-respect or even\nself-esteem; but an accomplished burglar must be proud of himself. In\nthe play to which I am at present preluding I have represented an artist\nwho is so entirely satisfied with his artistic conscience, even to the\npoint of dying like a saint with its support, that he is utterly selfish\nand unscrupulous in every other relation without feeling at the smallest\ndisadvantage. The same thing may be observed in women who have a genius\nfor personal attractiveness: they expend more thought, labor, skill,\ninventiveness, taste and endurance on making themselves lovely than\nwould suffice to keep a dozen ugly women honest; and this enables them\nto maintain a high opinion of themselves, and an angry contempt for\nunattractive and personally careless women, whilst they lie and cheat\nand slander and sell themselves without a blush. The truth is, hardly\nany of us have ethical energy enough for more than one really inflexible\npoint of honor. Andrea del Sarto, like Louis Dubedat in my play, must\nhave expended on the attainment of his great mastery of design and his\noriginality in fresco painting more conscientiousness and industry\nthan go to the making of the reputations of a dozen ordinary mayors and\nchurchwardens; but (if Vasari is to be believed) when the King of France\nentrusted him with money to buy pictures for him, he stole it to\nspend on his wife. Such cases are not confined to eminent artists.\nUnsuccessful, unskilful men are often much more scrupulous than\nsuccessful ones. In the ranks of ordinary skilled labor many men are to\nbe found who earn good wages and are never out of a job because they are\nstrong, indefatigable, and skilful, and who therefore are bold in a high\nopinion of themselves; but they are selfish and tyrannical, gluttonous\nand drunken, as their wives and children know to their cost.\n\nNot only do these talented energetic people retain their self-respect\nthrough shameful misconduct: they do not even lose the respect of\nothers, because their talents benefit and interest everybody, whilst\ntheir vices affect only a few. An actor, a painter, a composer, an\nauthor, may be as selfish as he likes without reproach from the public\nif only his art is superb; and he cannot fulfil his condition without\nsufficient effort and sacrifice to make him feel noble and martyred in\nspite of his selfishness. It may even happen that the selfishness of\nan artist may be a benefit to the public by enabling him to concentrate\nhimself on their gratification with a recklessness of every other\nconsideration that makes him highly dangerous to those about him. In\nsacrificing others to himself he is sacrificing them to the public he\ngratifies; and the public is quite content with that arrangement. The\npublic actually has an interest in the artist's vices.\n\nIt has no such interest in the surgeon's vices. The surgeon's art is\nexercised at its expense, not for its gratification. We do not go to the\noperating table as we go to the theatre, to the picture gallery, to the\nconcert room, to be entertained and delighted: we go to be tormented and\nmaimed, lest a worse thing should befall us. It is of the most extreme\nimportance to us that the experts on whose assurance we face this horror\nand suffer this mutilation should leave no interests but our own to\nthink of; should judge our cases scientifically; and should feel about\nthem kindly. Let us see what guarantees we have: first for the science,\nand then for the kindness.\n\n\n\n\nARE DOCTORS MEN OF SCIENCE?\n\nI presume nobody will question the existence of widely spread popular\ndelusion that every doctor is a titan of science. It is escaped only in\nthe very small class which understands by science something more than\nconjuring with retorts and spirit lamps, magnets and microscopes, and\ndiscovering magical cures for disease. To a sufficiently ignorant man\nevery captain of a trading schooner is a Galileo, every organ-grinder\na Beethoven, every piano-tuner a Hemholtz, every Old Bailey barrister\na Solon, every Seven Dials pigeon dealer a Darwin, every scrivener a\nShakespear, every locomotive engine a miracle, and its driver no less\nwonderful than George Stephenson. As a matter of fact, the rank and file\nof doctors are no more scientific than their tailors; or, if you prefer\nto put it the reverse way, their tailors are no less scientific than\nthey. Doctoring is an art, not a science: any layman who is interested\nin science sufficiently to take in one of the scientific journals and\nfollow the literature of the scientific movement, knows more about it\nthan those doctors (probably a large majority) who are not interested in\nit, and practise only to earn their bread. Doctoring is not even the art\nof keeping people in health (no doctor seems able to advise you what to\neat any better than his grandmother or the nearest quack): it is the\nart of curing illnesses. It does happen exceptionally that a practising\ndoctor makes a contribution to science (my play describes a very notable\none); but it happens much oftener that he draws disastrous conclusions\nfrom his clinical experience because he has no conception of scientific\nmethod, and believes, like any rustic, that the handling of evidence and\nstatistics needs no expertness. The distinction between a quack doctor\nand a qualified one is mainly that only the qualified one is authorized\nto sign death certificates, for which both sorts seem to have about\nequal occasion. Unqualified practitioners now make large incomes as\nhygienists, and are resorted to as frequently by cultivated amateur\nscientists who understand quite well what they are doing as by ignorant\npeople who are simply dupes. Bone-setters make fortunes under the very\nnoses of our greatest surgeons from educated and wealthy patients; and\nsome of the most successful doctors on the register use quite heretical\nmethods of treating disease, and have qualified themselves solely for\nconvenience. Leaving out of account the village witches who prescribe\nspells and sell charms, the humblest professional healers in this\ncountry are the herbalists. These men wander through the fields on\nSunday seeking for herbs with magic properties of curing disease,\npreventing childbirth, and the like. Each of them believes that he is on\nthe verge of a great discovery, in which Virginia Snake Root will be\nan ingredient, heaven knows why! Virginia Snake Root fascinates\nthe imagination of the herbalist as mercury used to fascinate the\nalchemists. On week days he keeps a shop in which he sells packets of\npennyroyal, dandelion, etc., labelled with little lists of the diseases\nthey are supposed to cure, and apparently do cure to the satisfaction of\nthe people who keep on buying them. I have never been able to perceive\nany distinction between the science of the herbalist and that of the\nduly registered doctor. A relative of mine recently consulted a doctor\nabout some of the ordinary symptoms which indicate the need for a\nholiday and a change. The doctor satisfied himself that the patient's\nheart was a little depressed. Digitalis being a drug labelled as a\nheart specific by the profession, he promptly administered a stiff dose.\nFortunately the patient was a hardy old lady who was not easily killed.\nShe recovered with no worse result than her conversion to Christian\nScience, which owes its vogue quite as much to public despair of doctors\nas to superstition. I am not, observe, here concerned with the question\nas to whether the dose of digitalis was judicious or not; the point is,\nthat a farm laborer consulting a herbalist would have been treated in\nexactly the same way.\n\n\n\n\nBACTERIOLOGY AS A SUPERSTITION\n\nThe smattering of science that all--even doctors--pick up from the\nordinary newspapers nowadays only makes the doctor more dangerous than\nhe used to be. Wise men used to take care to consult doctors qualified\nbefore 1860, who were usually contemptuous of or indifferent to the germ\ntheory and bacteriological therapeutics; but now that these veterans\nhave mostly retired or died, we are left in the hands of the generations\nwhich, having heard of microbes much as St. Thomas Aquinas heard of\nangels, suddenly concluded that the whole art of healing could be summed\nup in the formula: Find the microbe and kill it. And even that they did\nnot know how to do. The simplest way to kill most microbes is to throw\nthem into an open street or river and let the sun shine on them, which\nexplains the fact that when great cities have recklessly thrown all\ntheir sewage into the open river the water has sometimes been cleaner\ntwenty miles below the city than thirty miles above it. But doctors\ninstinctively avoid all facts that are reassuring, and eagerly swallow\nthose that make it a marvel that anyone could possibly survive three\ndays in an atmosphere consisting mainly of countless pathogenic\ngerms. They conceive microbes as immortal until slain by a germicide\nadministered by a duly qualified medical man. All through Europe people\nare adjured, by public notices and even under legal penalties, not to\nthrow their microbes into the sunshine, but to collect them carefully in\na handkerchief; shield the handkerchief from the sun in the darkness\nand warmth of the pocket; and send it to a laundry to be mixed up with\neverybody else's handkerchiefs, with results only too familiar to local\nhealth authorities.\n\nIn the first frenzy of microbe killing, surgical instruments were dipped\nin carbolic oil, which was a great improvement on not dipping them in\nanything at all and simply using them dirty; but as microbes are so fond\nof carbolic oil that they swarm in it, it was not a success from the\nanti-microbe point of view. Formalin was squirted into the circulation\nof consumptives until it was discovered that formalin nourishes the\ntubercle bacillus handsomely and kills men. The popular theory of\ndisease is the common medical theory: namely, that every disease had\nits microbe duly created in the garden of Eden, and has been steadily\npropagating itself and producing widening circles of malignant disease\never since. It was plain from the first that if this had been even\napproximately true, the whole human race would have been wiped out by\nthe plague long ago, and that every epidemic, instead of fading out as\nmysteriously as it rushed in, would spread over the whole world. It was\nalso evident that the characteristic microbe of a disease might be a\nsymptom instead of a cause. An unpunctual man is always in a hurry;\nbut it does not follow that hurry is the cause of unpunctuality: on the\ncontrary, what is the matter with the patient is sloth. When Florence\nNightingale said bluntly that if you overcrowded your soldiers in dirty\nquarters there would be an outbreak of smallpox among them, she was\nsnubbed as an ignorant female who did not know that smallpox can be\nproduced only by the importation of its specific microbe.\n\nIf this was the line taken about smallpox, the microbe of which\nhas never yet been run down and exposed under the microscope by the\nbacteriologist, what must have been the ardor of conviction as to\ntuberculosis, tetanus, enteric fever, Maltese fever, diphtheria, and\nthe rest of the diseases in which the characteristic bacillus had been\nidentified! When there was no bacillus it was assumed that, since\nno disease could exist without a bacillus, it was simply eluding\nobservation. When the bacillus was found, as it frequently was, in\npersons who were not suffering from the disease, the theory was saved\nby simply calling the bacillus an impostor, or pseudobacillus. The same\nboundless credulity which the public exhibit as to a doctor's power of\ndiagnosis was shown by the doctors themselves as to the analytic\nmicrobe hunters. These witch finders would give you a certificate of the\nultimate constitution of anything from a sample of the water from your\nwell to a scrap of your lungs, for seven-and-sixpense. I do not suggest\nthat the analysts were dishonest. No doubt they carried the analysis as\nfar as they could afford to carry it for the money. No doubt also they\ncould afford to carry it far enough to be of some use. But the fact\nremains that just as doctors perform for half-a-crown, without the least\nmisgiving, operations which could not be thoroughly and safely performed\nwith due scientific rigor and the requisite apparatus by an unaided\nprivate practitioner for less than some thousands of pounds, so did they\nproceed on the assumption that they could get the last word of science\nas to the constituents of their pathological samples for a two hours cab\nfare.\n\n\n\n\nECONOMIC DIFFICULTIES OF IMMUNIZATION\n\nI have heard doctors affirm and deny almost every possible proposition\nas to disease and treatment. I can remember the time when doctors no\nmore dreamt of consumption and pneumonia being infectious than they\nnow dream of sea-sickness being infectious, or than so great a clinical\nobserver as Sydenham dreamt of smallpox being infectious. I have heard\ndoctors deny that there is such a thing as infection. I have heard them\ndeny the existence of hydrophobia as a specific disease differing from\ntetanus. I have heard them defend prophylactic measures and prophylactic\nlegislation as the sole and certain salvation of mankind from zymotic\ndisease; and I have heard them denounce both as malignant spreaders\nof cancer and lunacy. But the one objection I have never heard from a\ndoctor is the objection that prophylaxis by the inoculatory methods most\nin vogue is an economic impossibility under our private practice\nsystem. They buy some stuff from somebody for a shilling, and inject a\npennyworth of it under their patient's skin for half-a-crown, concluding\nthat, since this primitive rite pays the somebody and pays them, the\nproblem of prophylaxis has been satisfactorily solved. The results are\nsometimes no worse than the ordinary results of dirt getting into cuts;\nbut neither the doctor nor the patient is quite satisfied unless the\ninoculation \"takes\"; that is, unless it produces perceptible illness and\ndisablement. Sometimes both doctor and patient get more value in\nthis direction than they bargain for. The results of ordinary\nprivate-practice-inoculation at their worst are bad enough to be\nindistinguishable from those of the most discreditable and dreaded\ndisease known; and doctors, to save the credit of the inoculation, have\nbeen driven to accuse their patient or their patient's parents of having\ncontracted this disease independently of the inoculation, an excuse\nwhich naturally does not make the family any more resigned, and leads\nto public recriminations in which the doctors, forgetting everything but\nthe immediate quarrel, naively excuse themselves by admitting, and\neven claiming as a point in their favor, that it is often impossible to\ndistinguish the disease produced by their inoculation and the disease\nthey have accused the patient of contracting. And both parties assume\nthat what is at issue is the scientific soundness of the prophylaxis.\nIt never occurs to them that the particular pathogenic germ which they\nintended to introduce into the patient's system may be quite innocent of\nthe catastrophe, and that the casual dirt introduced with it may be at\nfault. When, as in the case of smallpox or cowpox, the germ has not yet\nbeen detected, what you inoculate is simply undefined matter that has\nbeen scraped off an anything but chemically clean calf suffering from\nthe disease in question. You take your chance of the germ being in the\nscrapings, and, lest you should kill it, you take no precautions against\nother germs being in it as well. Anything may happen as the result of\nsuch an inoculation. Yet this is the only stuff of the kind which is\nprepared and supplied even in State establishments: that is, in the\nonly establishments free from the commercial temptation to adulterate\nmaterials and scamp precautionary processes.\n\nEven if the germ were identified, complete precautions would hardly pay.\nIt is true that microbe farming is not expensive. The cost of breeding\nand housing two head of cattle would provide for the breeding and\nhousing of enough microbes to inoculate the entire population of\nthe globe since human life first appeared on it. But the precautions\nnecessary to insure that the inoculation shall consist of nothing else\nbut the required germ in the proper state of attenuation are a very\ndifferent matter from the precautions necessary in the distribution\nand consumption of beefsteaks. Yet people expect to find vaccines\nand antitoxins and the like retailed at \"popular prices\" in private\nenterprise shops just as they expect to find ounces of tobacco and\npapers of pins.\n\n\n\n\nTHE PERILS OF INOCULATION\n\nThe trouble does not end with the matter to be inoculated. There is the\nquestion of the condition of the patient. The discoveries of Sir Almroth\nWright have shown that the appalling results which led to the hasty\ndropping in 1894 of Koch's tuberculin were not accidents, but perfectly\norderly and inevitable phenomena following the injection of dangerously\nstrong \"vaccines\" at the wrong moment, and reinforcing the disease\ninstead of stimulating the resistance to it. To ascertain the right\nmoment a laboratory and a staff of experts are needed. The general\npractitioner, having no such laboratory and no such experience, has\nalways chanced it, and insisted, when he was unlucky, that the results\nwere not due to the inoculation, but to some other cause: a favorite\nand not very tactful one being the drunkenness or licentiousness of\nthe patient. But though a few doctors have now learnt the danger of\ninoculating without any reference to the patient's \"opsonic index\"\nat the moment of inoculation, and though those other doctors who are\ndenouncing the danger as imaginary and opsonin as a craze or a fad,\nobviously do so because it involves an operation which they have neither\nthe means nor the knowledge to perform, there is still no grasp of the\neconomic change in the situation. They have never been warned that the\npracticability of any method of extirpating disease depends not only on\nits efficacy, but on its cost. For example, just at present the world\nhas run raving mad on the subject of radium, which has excited our\ncredulity precisely as the apparitions at Lourdes excited the credulity\nof Roman Catholics. Suppose it were ascertained that every child in the\nworld could be rendered absolutely immune from all disease during its\nentire life by taking half an ounce of radium to every pint of its\nmilk. The world would be none the healthier, because not even a Crown\nPrince--no, not even the son of a Chicago Meat King, could afford\nthe treatment. Yet it is doubtful whether doctors would refrain from\nprescribing it on that ground. The recklessness with which they now\nrecommend wintering in Egypt or at Davos to people who cannot afford to\ngo to Cornwall, and the orders given for champagne jelly and old port in\nhouseholds where such luxuries must obviously be acquired at the cost of\nstinting necessaries, often make one wonder whether it is possible for a\nman to go through a medical training and retain a spark of common sense.\nThis sort of inconsiderateness gets cured only in the classes where\npoverty, pretentious as it is even at its worst, cannot pitch its\npretences high enough to make it possible for the doctor (himself often\nno better off than the patient) to assume that the average income of an\nEnglish family is about 2,000 pounds a year, and that it is quite easy\nto break up a home, sell an old family seat at a sacrifice, and retire\ninto a foreign sanatorium devoted to some \"treatment\" that did not\nexist two years ago and probably will not exist (except as a pretext\nfor keeping an ordinary hotel) two years hence. In a poor practice the\ndoctor must find cheap treatments for cheap people, or humiliate and\nlose his patients either by prescribing beyond their means or sending\nthem to the public hospitals. When it comes to prophylactic inoculation,\nthe alternative lies between the complete scientific process, which can\nonly be brought down to a reasonable cost by being very highly organized\nas a public service in a public institution, and such cheap,\nnasty, dangerous and scientifically spurious imitations as ordinary\nvaccination, which seems not unlikely to be ended, like its equally\nvaunted forerunner, XVIII. century inoculation, by a purely reactionary\nlaw making all sorts of vaccination, scientific or not, criminal\noffences. Naturally, the poor doctor (that is, the average doctor)\ndefends ordinary vaccination frantically, as it means to him the bread\nof his children. To secure the vehement and practically unanimous\nsupport of the rank and file of the medical profession for any sort of\ntreatment or operation, all that is necessary is that it can be easily\npractised by a rather shabbily dressed man in a surgically dirty room in\na surgically dirty house without any assistance, and that the materials\nfor it shall cost, say, a penny, and the charge for it to a patient with\n100 pounds a year be half-a-crown. And, on the other hand, a hygienic\nmeasure has only to be one of such refinement, difficulty, precision and\ncostliness as to be quite beyond the resources of private practice, to\nbe ignored or angrily denounced as a fad.\n\nTRADE UNIONISM AND SCIENCE\n\nHere we have the explanation of the savage rancor that so amazes people\nwho imagine that the controversy concerning vaccination is a scientific\none. It has really nothing to do with science. The medical profession,\nconsisting for the most part of very poor men struggling to keep up\nappearances beyond their means, find themselves threatened with the\nextinction of a considerable part of their incomes: a part, too, that\nis easily and regularly earned, since it is independent of disease,\nand brings every person born into the nation, healthy or not, to the\ndoctors. To boot, there is the occasional windfall of an epidemic,\nwith its panic and rush for revaccination. Under such circumstances,\nvaccination would be defended desperately were it twice as dirty,\ndangerous, and unscientific in method as it actually is. The note of\nfury in the defence, the feeling that the anti-vaccinator is doing a\ncruel, ruinous, inconsiderate thing in a mood of indignant folly: all\nthis, so puzzling to the observer who knows nothing of the economic side\nof the question, and only sees that the anti-vaccinator, having\nnothing whatever to gain and a good deal to lose by placing himself in\nopposition to the law and to the outcry that adds private persecution to\nlegal penalties, can have no interest in the matter except the interest\nof a reformer in abolishing a corrupt and mischievous superstition,\nbecomes intelligible the moment the tragedy of medical poverty and the\nlucrativeness of cheap vaccination is taken into account.\n\nIn the face of such economic pressure as this, it is silly to expect\nthat medical teaching, any more than medical practice, can possibly\nbe scientific. The test to which all methods of treatment are finally\nbrought is whether they are lucrative to doctors or not. It would be\ndifficult to cite any proposition less obnoxious to science, than that\nadvanced by Hahnemann: to wit, that drugs which in large doses produce\ncertain symptoms, counteract them in very small doses, just as in more\nmodern practice it is found that a sufficiently small inoculation with\ntyphoid rallies our powers to resist the disease instead of prostrating\nus with it. But Hahnemann and his followers were frantically persecuted\nfor a century by generations of apothecary-doctors whose incomes\ndepended on the quantity of drugs they could induce their patients to\nswallow. These two cases of ordinary vaccination and homeopathy are\ntypical of all the rest. Just as the object of a trade union under\nexisting conditions must finally be, not to improve the technical\nquality of the work done by its members, but to secure a living wage\nfor them, so the object of the medical profession today is to secure an\nincome for the private doctor; and to this consideration all concern for\nscience and public health must give way when the two come into conflict.\nFortunately they are not always in conflict. Up to a certain point\ndoctors, like carpenters and masons, must earn their living by doing the\nwork that the public wants from them; and as it is not in the nature\nof things possible that such public want should be based on unmixed\ndisutility, it may be admitted that doctors have their uses, real as\nwell as imaginary. But just as the best carpenter or mason will resist\nthe introduction of a machine that is likely to throw him out of work,\nor the public technical education of unskilled laborers' sons to compete\nwith him, so the doctor will resist with all his powers of persecution\nevery advance of science that threatens his income. And as the advance\nof scientific hygiene tends to make the private doctor's visits rarer,\nand the public inspector's frequenter, whilst the advance of scientific\ntherapeutics is in the direction of treatments that involve highly\norganized laboratories, hospitals, and public institutions generally, it\nunluckily happens that the organization of private practitioners which\nwe call the medical profession is coming more and more to represent, not\nscience, but desperate and embittered antiscience: a statement of things\nwhich is likely to get worse until the average doctor either depends\nupon or hopes for an appointment in the public health service for his\nlivelihood.\n\nSo much for our guarantees as to medical science. Let us now deal with\nthe more painful subject of medical kindness.\n\n\n\n\nDOCTORS AND VIVISECTION\n\nThe importance to our doctors of a reputation for the tenderest humanity\nis so obvious, and the quantity of benevolent work actually done by them\nfor nothing (a great deal of it from sheer good nature) so large, that\nat first sight it seems unaccountable that they should not only throw\nall their credit away, but deliberately choose to band themselves\npublicly with outlaws and scoundrels by claiming that in the pursuit of\ntheir professional knowledge they should be free from the restraints of\nlaw, of honor, of pity, of remorse, of everything that distinguishes\nan orderly citizen from a South Sea buccaneer, or a philosopher from\nan inquisitor. For here we look in vain for either an economic or a\nsentimental motive. In every generation fools and blackguards have\nmade this claim; and honest and reasonable men, led by the strongest\ncontemporary minds, have repudiated it and exposed its crude rascality.\nFrom Shakespear and Dr. Johnson to Ruskin and Mark Twain, the natural\nabhorrence of sane mankind for the vivisector's cruelty, and the\ncontempt of able thinkers for his imbecile casuistry, have been\nexpressed by the most popular spokesmen of humanity. If the medical\nprofession were to outdo the Anti-Vivisection Societies in a general\nprofessional protest against the practice and principles of the\nvivisectors, every doctor in the kingdom would gain substantially by the\nimmense relief and reconciliation which would follow such a reassurance\nof the humanity of the doctor. Not one doctor in a thousand is a\nvivisector, or has any interest in vivisection, either pecuniary or\nintellectual, or would treat his dog cruelly or allow anyone else to do\nit. It is true that the doctor complies with the professional fashion of\ndefending vivisection, and assuring you that people like Shakespear and\nDr. Johnson and Ruskin and Mark Twain are ignorant sentimentalists,\njust as he complies with any other silly fashion: the mystery is, how\nit became the fashion in spite of its being so injurious to those who\nfollow it. Making all possible allowance for the effect of the brazen\nlying of the few men who bring a rush of despairing patients to their\ndoors by professing in letters to the newspapers to have learnt from\nvivisection how to cure certain diseases, and the assurances of the\nsayers of smooth things that the practice is quite painless under the\nlaw, it is still difficult to find any civilized motive for an attitude\nby which the medical profession has everything to lose and nothing to\ngain.\n\n\n\n\nTHE PRIMITIVE SAVAGE MOTIVE\n\nI say civilized motive advisedly; for primitive tribal motives are easy\nenough to find. Every savage chief who is not a Mahomet learns that if\nhe wishes to strike the imagination of his tribe--and without doing that\nhe can rule them--he must terrify or revolt them from time to time by\nacts of hideous cruelty or disgusting unnaturalness. We are far from\nbeing as superior to such tribes as we imagine. It is very doubtful\nindeed whether Peter the Great could have effected the changes he made\nin Russia if he had not fascinated and intimidated his people by\nhis monstrous cruelties and grotesque escapades. Had he been a\nnineteenth-century king of England, he would have had to wait for some\nhuge accidental calamity: a cholera epidemic, a war, or an insurrection,\nbefore waking us up sufficiently to get anything done. Vivisection helps\nthe doctor to rule us as Peter ruled the Russians. The notion that the\nman who does dreadful things is superhuman, and that therefore he can\nalso do wonderful things either as ruler, avenger, healer, or what not,\nis by no means confined to barbarians. Just as the manifold wickednesses\nand stupidities of our criminal code are supported, not by any general\ncomprehension of law or study of jurisprudence, not even by simple\nvindictiveness, but by the superstition that a calamity of any sort must\nbe expiated by a human sacrifice; so the wickednesses and stupidities\nof our medicine men are rooted in superstitions that have no more to do\nwith science than the traditional ceremony of christening an ironclad\nhas to do with the effectiveness of its armament. We have only to turn\nto Macaulay's description of the treatment of Charles II in his last\nillness to see how strongly his physicians felt that their only chance\nof cheating death was by outraging nature in tormenting and disgusting\ntheir unfortunate patient. True, this was more than two centuries ago;\nbut I have heard my own nineteenth-century grandfather describe the\ncupping and firing and nauseous medicines of his time with perfect\ncredulity as to their beneficial effects; and some more modern\ntreatments appear to me quite as barbarous. It is in this way that\nvivisection pays the doctor. It appeals to the fear and credulity of the\nsavage in us; and without fear and credulity half the private doctor's\noccupation and seven-eighths of his influence would be gone.\n\n\n\n\nTHE HIGHER MOTIVE. THE TREE OF KNOWLEDGE.\n\nBut the greatest force of all on the side of vivisection is the mighty\nand indeed divine force of curiosity. Here we have no decaying tribal\ninstinct which men strive to root out of themselves as they strive to\nroot out the tiger's lust for blood. On the contrary, the curiosity of\nthe ape, or of the child who pulls out the legs and wings of a fly\nto see what it will do without them, or who, on being told that a cat\ndropped out of the window will always fall on its legs, immediately\ntries the experiment on the nearest cat from the highest window in\nthe house (I protest I did it myself from the first floor only), is as\nnothing compared to the thirst for knowledge of the philosopher, the\npoet, the biologist, and the naturalist. I have always despised Adam\nbecause he had to be tempted by the woman, as she was by the serpent,\nbefore he could be induced to pluck the apple from the tree of\nknowledge. I should have swallowed every apple on the tree the moment\nthe owner's back was turned. When Gray said \"Where ignorance is bliss,\n'tis folly to be wise,\" he forgot that it is godlike to be wise; and\nsince nobody wants bliss particularly, or could stand more than a very\nbrief taste of it if it were attainable, and since everybody, by the\ndeepest law of the Life Force, desires to be godlike, it is stupid, and\nindeed blasphemous and despairing, to hope that the thirst for knowledge\nwill either diminish or consent to be subordinated to any other end\nwhatsoever. We shall see later on that the claim that has arisen in this\nway for the unconditioned pursuit of knowledge is as idle as all dreams\nof unconditioned activity; but none the less the right to knowledge must\nbe regarded as a fundamental human right. The fact that men of science\nhave had to fight so hard to secure its recognition, and are still so\nvigorously persecuted when they discover anything that is not quite\npalatable to vulgar people, makes them sorely jealous for that right;\nand when they hear a popular outcry for the suppression of a method of\nresearch which has an air of being scientific, their first instinct is\nto rally to the defence of that method without further consideration,\nwith the result that they sometimes, as in the case of vivisection,\npresently find themselves fighting on a false issue.\n\n\n\n\nTHE FLAW IN THE ARGUMENT\n\nI may as well pause here to explain their error. The right to know\nis like the right to live. It is fundamental and unconditional in its\nassumption that knowledge, like life, is a desirable thing, though any\nfool can prove that ignorance is bliss, and that \"a little knowledge is\na dangerous thing\" (a little being the most that any of us can attain),\nas easily as that the pains of life are more numerous and constant than\nits pleasures, and that therefore we should all be better dead. The\nlogic is unimpeachable; but its only effect is to make us say that if\nthese are the conclusions logic leads to, so much the worse for logic,\nafter which curt dismissal of Folly, we continue living and learning by\ninstinct: that is, as of right. We legislate on the assumption that no\nman may be killed on the strength of a demonstration that he would be\nhappier in his grave, not even if he is dying slowly of cancer and\nbegs the doctor to despatch him quickly and mercifully. To get killed\nlawfully he must violate somebody else's right to live by committing\nmurder. But he is by no means free to live unconditionally. In society\nhe can exercise his right to live only under very stiff conditions. In\ncountries where there is compulsory military service he may even have to\nthrow away his individual life to save the life of the community.\n\nIt is just so in the case of the right to knowledge. It is a right that\nis as yet very imperfectly recognized in practice. But in theory it\nis admitted that an adult person in pursuit of knowledge must not be\nrefused it on the ground that he would be better or happier without\nit. Parents and priests may forbid knowledge to those who accept their\nauthority; and social taboo may be made effective by acts of legal\npersecution under cover of repressing blasphemy, obscenity, and\nsedition; but no government now openly forbids its subjects to pursue\nknowledge on the ground that knowledge is in itself a bad thing, or that\nit is possible for any of us to have too much of it.\n\n\n\n\nLIMITATIONS OF THE RIGHT TO KNOWLEDGE\n\nBut neither does any government exempt the pursuit of knowledge, any\nmore than the pursuit of life, liberty, and happiness (as the American\nConstitution puts it), from all social conditions. No man is allowed\nto put his mother into the stove because he desires to know how long an\nadult woman will survive at a temperature of 500 degrees Fahrenheit,\nno matter how important or interesting that particular addition to the\nstore of human knowledge may be. A man who did so would have short work\nmade not only of his right to knowledge, but of his right to live and\nall his other rights at the same time. The right to knowledge is not\nthe only right; and its exercise must be limited by respect for other\nrights, and for its own exercise by others. When a man says to Society,\n\"May I torture my mother in pursuit of knowledge?\" Society replies,\n\"No.\" If he pleads, \"What! Not even if I have a chance of finding out\nhow to cure cancer by doing it?\" Society still says, \"Not even then.\" If\nthe scientist, making the best of his disappointment, goes on to ask may\nhe torture a dog, the stupid and callous people who do not realize that\na dog is a fellow-creature and sometimes a good friend, may say Yes,\nthough Shakespear, Dr. Johnson and their like may say No. But even those\nwho say \"You may torture A dog\" never say \"You may torture MY dog.\" And\nnobody says, \"Yes, because in the pursuit of knowledge you may do as\nyou please.\" Just as even the stupidest people say, in effect, \"If\nyou cannot attain to knowledge without burning your mother you must do\nwithout knowledge,\" so the wisest people say, \"If you cannot attain to\nknowledge without torturing a dog, you must do without knowledge.\"\n\n\n\n\nA FALSE ALTERNATIVE\n\nBut in practice you cannot persuade any wise man that this alternative\ncan ever be forced on anyone but a fool, or that a fool can be trusted\nto learn anything from any experiment, cruel or humane. The Chinaman who\nburnt down his house to roast his pig was no doubt honestly unable to\nconceive any less disastrous way of cooking his dinner; and the\nroast must have been spoiled after all (a perfect type of the average\nvivisectionist experiment); but this did not prove that the Chinaman\nwas right: it only proved that the Chinaman was an incapable cook and,\nfundamentally, a fool.\n\nTake another celebrated experiment: one in sanitary reform. In the days\nof Nero Rome was in the same predicament as London to-day. If some one\nwould burn down London, and it were rebuilt, as it would now have to be,\nsubject to the sanitary by-laws and Building Act provisions enforced\nby the London County Council, it would be enormously improved; and the\naverage lifetime of Londoners would be considerably prolonged. Nero\nargued in the same way about Rome. He employed incendiaries to set it\non fire; and he played the harp in scientific raptures whilst it was\nburning. I am so far of Nero's way of thinking that I have often said,\nwhen consulted by despairing sanitary reformers, that what London needs\nto make her healthy is an earthquake. Why, then, it may be asked, do not\nI, as a public-spirited man, employ incendiaries to set it on fire,\nwith a heroic disregard of the consequences to myself and others? Any\nvivisector would, if he had the courage of his opinions. The reasonable\nanswer is that London can be made healthy without burning her down; and\nthat as we have not enough civic virtue to make her healthy in a humane\nand economical way, we should not have enough to rebuild her in that\nway. In the old Hebrew legend, God lost patience with the world as Nero\ndid with Rome, and drowned everybody except a single family. But the\nresult was that the progeny of that family reproduced all the vices of\ntheir predecessors so exactly that the misery caused by the flood might\njust as well have been spared: things went on just as they did before.\nIn the same way, the lists of diseases which vivisection claims to have\ncured is long; but the returns of the Registrar-General show that people\nstill persist in dying of them as if vivisection had never been\nheard of. Any fool can burn down a city or cut an animal open; and an\nexceptionally foolish fool is quite likely to promise enormous benefits\nto the race as the result of such activities. But when the constructive,\nbenevolent part of the business comes to be done, the same want of\nimagination, the same stupidity and cruelty, the same laziness and want\nof perseverance that prevented Nero or the vivisector from devising or\npushing through humane methods, prevents him from bringing order out of\nthe chaos and happiness out of the misery he has made. At one time\nit seemed reasonable enough to declare that it was impossible to find\nwhether or not there was a stone inside a man's body except by exploring\nit with a knife, or to find out what the sun is made of without visiting\nit in a balloon. Both these impossibilities have been achieved, but not\nby vivisectors. The Rontgen rays need not hurt the patient; and\nspectrum analysis involves no destruction. After such triumphs of humane\nexperiment and reasoning, it is useless to assure us that there is no\nother key to knowledge except cruelty. When the vivisector offers us\nthat assurance, we reply simply and contemptuously, \"You mean that you\nare not clever or humane or energetic enough to find one.\"\n\nCRUELTY FOR ITS OWN SAKE\n\nIt will now, I hope, be clear why the attack on vivisection is not\nan attack on the right to knowledge: why, indeed, those who have the\ndeepest conviction of the sacredness of that right are the leaders of\nthe attack. No knowledge is finally impossible of human attainment; for\neven though it may be beyond our present capacity, the needed capacity\nis not unattainable. Consequently no method of investigation is the only\nmethod; and no law forbidding any particular method can cut us off\nfrom the knowledge we hope to gain by it. The only knowledge we lose by\nforbidding cruelty is knowledge at first hand of cruelty itself, which\nis precisely the knowledge humane people wish to be spared.\n\nBut the question remains: Do we all really wish to be spared that\nknowledge? Are humane methods really to be preferred to cruel ones? Even\nif the experiments come to nothing, may not their cruelty be enjoyed\nfor its own sake, as a sensational luxury? Let us face these questions\nboldly, not shrinking from the fact that cruelty is one of the primitive\npleasures of mankind, and that the detection of its Protean disguises as\nlaw, education, medicine, discipline, sport and so forth, is one of the\nmost difficult of the unending tasks of the legislator.\n\n\n\n\nOUR OWN CRUELTIES\n\nAt first blush it may seem not only unnecessary, but even indecent, to\ndiscuss such a proposition as the elevation of cruelty to the rank of a\nhuman right. Unnecessary, because no vivisector confesses to a love of\ncruelty for its own sake or claims any general fundamental right to be\ncruel. Indecent, because there is an accepted convention to repudiate\ncruelty; and vivisection is only tolerated by the law on condition that,\nlike judicial torture, it shall be done as mercifully as the nature of\nthe practice allows. But the moment the controversy becomes embittered,\nthe recriminations bandied between the opposed parties bring us\nface-to-face with some very ugly truths. On one occasion I was invited\nto speak at a large Anti-Vivisection meeting in the Queen's Hall in\nLondon. I found myself on the platform with fox hunters, tame stag\nhunters, men and women whose calendar was divided, not by pay days and\nquarter days, but by seasons for killing animals for sport: the fox, the\nhare, the otter, the partridge and the rest having each its appointed\ndate for slaughter. The ladies among us wore hats and cloaks and\nhead-dresses obtained by wholesale massacres, ruthless trappings,\ncallous extermination of our fellow creatures. We insisted on our\nbutchers supplying us with white veal, and were large and constant\nconsumers of pate de foie gras; both comestibles being obtained by\nrevolting methods. We sent our sons to public schools where indecent\nflogging is a recognized method of taming the young human animal. Yet\nwe were all in hysterics of indignation at the cruelties of the\nvivisectors. These, if any were present, must have smiled sardonically\nat such inhuman humanitarians, whose daily habits and fashionable\namusements cause more suffering in England in a week than all the\nvivisectors of Europe do in a year. I made a very effective speech, not\nexclusively against vivisection, but against cruelty; and I have never\nbeen asked to speak since by that Society, nor do I expect to be, as I\nshould probably give such offence to its most affluent subscribers that\nits attempts to suppress vivisection would be seriously hindered. But\nthat does not prevent the vivisectors from freely using the \"youre\nanother\" retort, and using it with justice.\n\nWe must therefore give ourselves no airs of superiority when denouncing\nthe cruelties of vivisection. We all do just as horrible things, with\neven less excuse. But in making that admission we are also making short\nwork of the virtuous airs with which we are sometimes referred to the\nhumanity of the medical profession as a guarantee that vivisection is\nnot abused--much as if our burglars should assure us that they arc too\nhonest to abuse the practice of burgling. We are, as a matter of fact,\na cruel nation; and our habit of disguising our vices by giving\npolite names to the offences we are determined to commit does not,\nunfortunately for my own comfort, impose on me. Vivisectors can hardly\npretend to be better than the classes from which they are drawn, or\nthose above them; and if these classes are capable of sacrificing\nanimals in various cruel ways under cover of sport, fashion, education,\ndiscipline, and even, when the cruel sacrifices are human sacrifices, of\npolitical economy, it is idle for the vivisector to pretend that he is\nincapable of practising cruelty for pleasure or profit or both under\nthe cloak of science. We are all tarred with the same brush; and the\nvivisectors are not slow to remind us of it, and to protest vehemently\nagainst being branded as exceptionally cruel and its devisors of\nhorrible instruments of torture by people whose main notion of enjoyment\nis cruel sport, and whose requirements in the way of villainously cruel\ntraps occupy pages of the catalogue of the Army and Navy Stores.\n\n\n\n\nTHE SCIENTIFIC INVESTIGATION OF CRUELTY\n\nThere is in man a specific lust for cruelty which infects even his\npassion of pity and makes it savage. Simple disgust at cruelty is very\nrare. The people who turn sick and faint and those who gloat are\noften alike in the pains they take to witness executions, floggings,\noperations or any other exhibitions of suffering, especially those\ninvolving bloodshed, blows, and laceration. A craze for cruelty can\nbe developed just as a craze for drink can; and nobody who attempts to\nignore cruelty as a possible factor in the attraction of vivisection and\neven of antivivisection, or in the credulity with which we accept its\nexcuses, can be regarded as a scientific investigator of it. Those who\naccuse vivisectors of indulging the well-known passion of cruelty\nunder the cloak of research are therefore putting forward a strictly\nscientific psychological hypothesis, which is also simple, human,\nobvious, and probable. It may be as wounding to the personal vanity of\nthe vivisector as Darwin's Origin of Species was to the people who\ncould not bear to think that they were cousins to the monkeys (remember\nGoldsmith's anger when he was told that he could not move his upper\njaw); but science has to consider only the truth of the hypothesis,\nand not whether conceited people will like it or not. In vain do the\nsentimental champions of vivisection declare themselves the most humane\nof men, inflicting suffering only to relieve it, scrupulous in the use\nof anesthetics, and void of all passion except the passion of pity for\na disease-ridden world. The really scientific investigator answers that\nthe question cannot be settled by hysterical protestations, and that if\nthe vivisectionist rejects deductive reasoning, he had better clear his\ncharacter by his own favorite method of experiment.\n\nSUGGESTED LABORATORY TESTS OF THE VIVISECTOR'S EMOTIONS\n\nTake the hackneyed case of the Italian who tortured mice, ostensibly to\nfind out about the effects of pain rather less than the nearest dentist\ncould have told him, and who boasted of the ecstatic sensations (he\nactually used the word love) with which he carried out his experiments.\nOr the gentleman who starved sixty dogs to death to establish the fact\nthat a dog deprived of food gets progressively lighter and weaker,\nbecoming remarkably emaciated, and finally dying: an undoubted truth,\nbut ascertainable without laboratory experiments by a simple enquiry\naddressed to the nearest policeman, or, failing him, to any sane\nperson in Europe. The Italian is diagnosed as a cruel voluptuary: the\ndog-starver is passed over as such a hopeless fool that it is impossible\nto take any interest in him. Why not test the diagnosis scientifically?\nWhy not perform a careful series of experiments on persons under the\ninfluence of voluptuous ecstasy, so as to ascertain its physiological\nsymptoms? Then perform a second series on persons engaged in\nmathematical work or machine designing, so as to ascertain the symptoms\nof cold scientific activity? Then note the symptoms of a vivisector\nperforming a cruel experiment; and compare them with the voluptuary\nsymptoms and the mathematical symptoms? Such experiments would be quite\nas interesting and important as any yet undertaken by the vivisectors.\nThey might open a line of investigation which would finally make, for\ninstance, the ascertainment of the guilt or innocence of an accused\nperson a much exacter process than the very fallible methods of our\ncriminal courts. But instead of proposing such an investigation, our\nvivisectors offer us all the pious protestations and all the huffy\nrecriminations that any common unscientific mortal offers when he is\naccused of unworthy conduct.\n\n\n\n\nROUTINE\n\nYet most vivisectors would probably come triumphant out of such a series\nof experiments, because vivisection is now a routine, like butchering\nor hanging or flogging; and many of the men who practise it do so only\nbecause it has been established as part of the profession they have\nadopted. Far from enjoying it, they have simply overcome their natural\nrepugnance and become indifferent to it, as men inevitably become\nindifferent to anything they do often enough. It is this dangerous power\nof custom that makes it so difficult to convince the common sense of\nmankind that any established commercial or professional practice has its\nroot in passion. Let a routine once spring from passion, and you will\npresently find thousands of routineers following it passionlessly for\na livelihood. Thus it always seems strained to speak of the religious\nconvictions of a clergyman, because nine out of ten clergymen have no\nreligions convictions: they are ordinary officials carrying on a routine\nof baptizing, marrying, and churching; praying, reciting, and preaching;\nand, like solicitors or doctors, getting away from their duties with\nrelief to hunt, to garden, to keep bees, to go into society, and the\nlike. In the same way many people do cruel and vile things without being\nin the least cruel or vile, because the routine to which they have been\nbrought up is superstitiously cruel and vile. To say that every man\nwho beats his children and every schoolmaster who flogs a pupil is a\nconscious debauchee is absurd: thousands of dull, conscientious people\nbeat their children conscientiously, because they were beaten themselves\nand think children ought to be beaten. The ill-tempered vulgarity that\ninstinctively strikes at and hurts a thing that annoys it (and all\nchildren are annoying), and the simple stupidity that requires from a\nchild perfection beyond the reach of the wisest and best adults (perfect\ntruthfulness coupled with perfect obedience is quite a common condition\nof leaving a child unwhipped), produce a good deal of flagellation among\npeople who not only do not lust after it, but who hit the harder because\nthey are angry at having to perform an uncomfortable duty. These people\nwill beat merely to assert their authority, or to carry out what they\nconceive to be a divine order on the strength of the precept of Solomon\nrecorded in the Bible, which carefully adds that Solomon completely\nspoilt his own son and turned away from the god of his fathers to the\nsensuous idolatry in which he ended his days.\n\nIn the same way we find men and women practising vivisection as\nsenselessly as a humane butcher, who adores his fox terrier, will cut\na calf's throat and hang it up by its heels to bleed slowly to death\nbecause it is the custom to eat veal and insist on its being white; or\nas a German purveyor nails a goose to a board and stuffs it with food\nbecause fashionable people eat pate de foie gras; or as the crew of\na whaler breaks in on a colony of seals and clubs them to death in\nwholesale massacre because ladies want sealskin jackets; or as fanciers\nblind singing birds with hot needles, and mutilate the ears and tails\nof dogs and horses. Let cruelty or kindness or anything else once become\ncustomary and it will be practised by people to whom it is not at all\nnatural, but whose rule of life is simply to do only what everybody else\ndoes, and who would lose their employment and starve if they indulged\nin any peculiarity. A respectable man will lie daily, in speech and in\nprint, about the qualities of the article he lives by selling, because\nit is customary to do so. He will flog his boy for telling a lie,\nbecause it is customary to do so. He will also flog him for not telling\na lie if the boy tells inconvenient or disrespectful truths, because\nit is customary to do so. He will give the same boy a present on his\nbirthday, and buy him a spade and bucket at the seaside, because it is\ncustomary to do so, being all the time neither particularly mendacious,\nnor particularly cruel, nor particularly generous, but simply incapable\nof ethical judgment or independent action.\n\nJust so do we find a crowd of petty vivisectionists daily committing\natrocities and stupidities, because it is the custom to do so.\nVivisection is customary as part of the routine of preparing lectures in\nmedical schools. For instance, there are two ways of making the action\nof the heart visible to students. One, a barbarous, ignorant, and\nthoughtless way, is to stick little flags into a rabbit's heart and\nlet the students see the flags jump. The other, an elegant, ingenious,\nwell-informed, and instructive way, is to put a sphygmograph on the\nstudent's wrist and let him see a record of his heart's action traced\nby a needle on a slip of smoked paper. But it has become the custom for\nlecturers to teach from the rabbit; and the lecturers are not original\nenough to get out of their groove. Then there are the demonstrations\nwhich are made by cutting up frogs with scissors. The most humane man,\nhowever repugnant the operation may be to him at first, cannot do it\nat lecture after lecture for months without finally--and that very\nsoon--feeling no more for the frog than if he were cutting up pieces of\npaper. Such clumsy and lazy ways of teaching are based on the cheapness\nof frogs and rabbits. If machines were as cheap as frogs, engineers\nwould not only be taught the anatomy of machines and the functions of\ntheir parts: they would also have machines misused and wrecked before\nthem so that they might learn as much as possible by using their eyes,\nand as little as possible by using their brains and imaginations. Thus\nwe have, as part of the routine of teaching, a routine of vivisection\nwhich soon produces complete indifference to it on the part even of\nthose who are naturally humane. If they pass on from the routine of\nlecture preparation, not into general practice, but into research work,\nthey carry this acquired indifference with them into the laboratory,\nwhere any atrocity is possible, because all atrocities satisfy\ncuriosity. The routine man is in the majority in his profession always:\nconsequently the moment his practice is tracked down to its source\nin human passion there is a great and quite sincere poohpoohing from\nhimself, from the mass of the profession, and from the mass of the\npublic, which sees that the average doctor is much too commonplace and\ndecent a person to be capable of passionate wickedness of any kind.\n\nHere then, we have in vivisection, as in all the other tolerated\nand instituted cruelties, this anti-climax: that only a negligible\npercentage of those who practise and consequently defend it get any\nsatisfaction out of it. As in Mr. Galsworthy's play Justice the useless\nand detestable torture of solitary imprisonment is shown at its worst\nwithout the introduction of a single cruel person into the drama, so\nit would be possible to represent all the torments of vivisection\ndramatically without introducing a single vivisector who had not felt\nsick at his first experience in the laboratory. Not that this can\nexonerate any vivisector from suspicion of enjoying his work (or her\nwork: a good deal of the vivisection in medical schools is done by\nwomen). In every autobiography which records a real experience of school\nor prison life, we find that here and there among the routineers there\nis to be found the genuine amateur, the orgiastic flogging schoolmaster\nor the nagging warder, who has sought out a cruel profession for the\nsake of its cruelty. But it is the genuine routineer who is the bulwark\nof the practice, because, though you can excite public fury against a\nSade, a Bluebeard, or a Nero, you cannot rouse any feeling against\ndull Mr. Smith doing his duty: that is, doing the usual thing. He is so\nobviously no better and no worse than anyone else that it is difficult\nto conceive that the things he does are abominable. If you would see\npublic dislike surging up in a moment against an individual, you must\nwatch one who does something unusual, no matter how sensible it may be.\nThe name of Jonas Hanway lives as that of a brave man because he was the\nfirst who dared to appear in the streets of this rainy island with an\numbrella.\n\n\n\n\nTHE OLD LINE BETWEEN MAN AND BEAST\n\nBut there is still a distinction to be clung to by those who dare not\ntell themselves the truth about the medical profession because they are\nso helplessly dependent on it when death threatens the household. That\ndistinction is the line that separates the brute from the man in the old\nclassification. Granted, they will plead, that we are all cruel; yet the\ntame-stag-hunter does not hunt men; and the sportsman who lets a leash\nof greyhounds loose on a hare would be horrified at the thought of\nletting them loose on a human child. The lady who gets her cloak by\nflaying a sable does not flay a negro; nor does it ever occur to her\nthat her veal cutlet might be improved on by a slice of tender baby.\n\nNow there was a time when some trust could be placed in this\ndistinction. The Roman Catholic Church still maintains, with what it\nmust permit me to call a stupid obstinacy, and in spite of St. Francis\nand St. Anthony, that animals have no souls and no rights; so that you\ncannot sin against an animal, or against God by anything you may choose\nto do to an animal. Resisting the temptation to enter on an argument as\nto whether you may not sin against your own soul if you are unjust or\ncruel to the least of those whom St. Francis called his little brothers,\nI have only to point out here that nothing could be more despicably\nsuperstitious in the opinion of a vivisector than the notion that\nscience recognizes any such step in evolution as the step from a\nphysical organism to an immortal soul. That conceit has been taken\nout of all our men of science, and out of all our doctors, by the\nevolutionists; and when it is considered how completely obsessed\nbiological science has become in our days, not by the full scope of\nevolution, but by that particular method of it which has neither sense\nnor purpose nor life nor anything human, much less godlike, in it:\nby the method, that is, of so-called Natural Selection (meaning no\nselection at all, but mere dead accident and luck), the folly of\ntrusting to vivisectors to hold the human animal any more sacred than\nthe other animals becomes so clear that it would be waste of time to\ninsist further on it. As a matter of fact the man who once concedes\nto the vivisector the right to put a dog outside the laws of honor and\nfellowship, concedes to him also the right to put himself outside them;\nfor he is nothing to the vivisector but a more highly developed, and\nconsequently more interesting-to-experiment-on vertebrate than the dog.\n\n\n\n\nVIVISECTING THE HUMAN SUBJECT\n\nI have in my hand a printed and published account by a doctor of how\nhe tested his remedy for pulmonary tuberculosis, which was to inject a\npowerful germicide directly into the circulation by stabbing a vein with\na syringe. He was one of those doctors who are able to command public\nsympathy by saying, quite truly, that when they discovered that the\nproposed treatment was dangerous, they experimented thenceforth on\nthemselves. In this case the doctor was devoted enough to carry his\nexperiments to the point of running serious risks, and actually making\nhimself very uncomfortable. But he did not begin with himself. His first\nexperiment was on two hospital patients. On receiving a message from the\nhospital to the effect that these two martyrs to therapeutic science\nhad all but expired in convulsions, he experimented on a rabbit, which\ninstantly dropped dead. It was then, and not until then, that he began\nto experiment on himself, with the germicide modified in the direction\nindicated by the experiments made on the two patients and the rabbit. As\na good many people countenance vivisection because they fear that if the\nexperiments are not made on rabbits they will be made on themselves,\nit is worth noting that in this case, where both rabbits and men\nwere equally available, the men, being, of course, enormously more\ninstructive, and costing nothing, were experimented on first. Once\ngrant the ethics of the vivisectionists and you not only sanction the\nexperiment on the human subject, but make it the first duty of the\nvivisector. If a guinea pig may be sacrificed for the sake of the very\nlittle that can be learnt from it, shall not a man be sacrificed for the\nsake of the great deal that can be learnt from him? At all events, he is\nsacrificed, as this typical case shows. I may add (not that it touches\nthe argument) that the doctor, the patients, and the rabbit all suffered\nin vain, as far as the hoped-for rescue of the race from pulmonary\nconsumption is concerned.\n\n\n\n\n\"THE LIE IS A EUROPEAN POWER\"\n\nNow at the very time when the lectures describing these experiments\nwere being circulated in print and discussed eagerly by the medical\nprofession, the customary denials that patients are experimented on\nwere as loud, as indignant, as high-minded as ever, in spite of the\nfew intelligent doctors who point out rightly that all treatments are\nexperiments on the patient. And this brings us to an obvious but\nmostly overlooked weakness in the vivisector's position: that is, his\ninevitable forfeiture of all claim to have his word believed. It is\nhardly to be expected that a man who does not hesitate to vivisect for\nthe sake of science will hesitate to lie about it afterwards to protect\nit from what he deems the ignorant sentimentality of the laity. When\nthe public conscience stirs uneasily and threatens suppression, there\nis never wanting some doctor of eminent position and high character\nwho will sacrifice himself devotedly to the cause of science by coming\nforward to assure the public on his honor that all experiments on\nanimals are completely painless; although he must know that the very\nexperiments which first provoked the antivivisection movement by their\natrocity were experiments to ascertain the physiological effects of\nthe sensation of extreme pain (the much more interesting physiology\nof pleasure remains uninvestigated) and that all experiments in\nwhich sensation is a factor are voided by its suppression. Besides,\nvivisection may be painless in cases where the experiments are very\ncruel. If a person scratches me with a poisoned dagger so gently that I\ndo not feel the scratch, he has achieved a painless vivisection; but if\nI presently die in torment I am not likely to consider that his humility\nis amply vindicated by his gentleness. A cobra's bite hurts so little\nthat the creature is almost, legally speaking, a vivisector who inflicts\nno pain. By giving his victims chloroform before biting them he could\ncomply with the law completely.\n\nHere, then, is a pretty deadlock. Public support of vivisection is\nfounded almost wholly on the assurances of the vivisectors that great\npublic benefits may be expected from the practice. Not for a moment do I\nsuggest that such a defence would be valid even if proved. But when\nthe witnesses begin by alleging that in the cause of science all the\ncustomary ethical obligations (which include the obligation to tell\nthe truth) are suspended, what weight can any reasonable person give\nto their testimony? I would rather swear fifty lies than take an animal\nwhich had licked my hand in good fellowship and torture it. If I did\ntorture the dog, I should certainly not have the face to turn round and\nask how any person there suspect an honorable man like myself of telling\nlies. Most sensible and humane people would, I hope, reply flatly that\nhonorable men do not behave dishonorably, even to dogs. The murderer\nwho, when asked by the chaplain whether he had any other crimes to\nconfess, replied indignantly, \"What do you take me for?\" reminds us very\nstrongly of the vivisectors who are so deeply hurt when their evidence\nis set aside as worthless.\n\n\n\n\nAN ARGUMENT WHICH WOULD DEFEND ANY CRIME\n\nThe Achilles heel of vivisection, however, is not to be found in the\npain it causes, but in the line of argument by which it is justified.\nThe medical code regarding it is simply criminal anarchism at its very\nworst. Indeed no criminal has yet had the impudence to argue as\nevery vivisector argues. No burglar contends that as it is admittedly\nimportant to have money to spend, and as the object of burglary is to\nprovide the burglar with money to spend, and as in many instances it has\nachieved this object, therefore the burglar is a public benefactor\nand the police are ignorant sentimentalists. No highway robber has yet\nharrowed us with denunciations of the puling moralist who allows his\nchild to suffer all the evils of poverty because certain faddists think\nit dishonest to garotte an alderman. Thieves and assassins understand\nquite well that there are paths of acquisition, even of the best things,\nthat are barred to all men of honor. Again, has the silliest burglar\never pretended that to put a stop to burglary is to put a stop to\nindustry? All the vivisections that have been performed since the world\nbegan have produced nothing so important as the innocent and honorable\ndiscovery of radiography; and one of the reasons why radiography was not\ndiscovered sooner was that the men whose business it was to discover\nnew clinical methods were coarsening and stupefying themselves with the\nsensual villanies and cutthroat's casuistries of vivisection. The law of\nthe conservation of energy holds good in physiology as in other things:\nevery vivisector is a deserter from the army of honorable investigators.\nBut the vivisector does not see this. He not only calls his methods\nscientific: he contends that there are no other scientific methods.\nWhen you express your natural loathing for his cruelty and your natural\ncontempt for his stupidity, he imagines that you are attacking science.\nYet he has no inkling of the method and temper of science. The point at\nissue being plainly whether he is a rascal or not, he not only insists\nthat the real point is whether some hotheaded antivivisectionist is a\nliar (which he proves by ridiculously unscientific assumptions as to the\ndegree of accuracy attainable in human statement), but never dreams of\noffering any scientific evidence by his own methods.\n\nThere are many paths to knowledge already discovered; and no enlightened\nman doubts that there are many more waiting to be discovered. Indeed,\nall paths lead to knowledge; because even the vilest and stupidest\naction teaches us something about vileness and stupidity, and may\naccidentally teach us a good deal more: for instance, a cutthroat learns\n(and perhaps teaches) the anatomy of the carotid artery and jugular\nvein; and there can be no question that the burning of St. Joan of Arc\nmust have been a most instructive and interesting experiment to a good\nobserver, and could have been made more so if it had been carried out by\nskilled physiologists under laboratory conditions. The earthquake in San\nFrancisco proved invaluable as an experiment in the stability of giant\nsteel buildings; and the ramming of the Victoria by the Camperdown\nsettled doubtful points of the greatest importance in naval warfare.\nAccording to vivisectionist logic our builders would be justified in\nproducing artificial earthquakes with dynamite, and our admirals in\ncontriving catastrophes at naval manoeuvres, in order to follow up the\nline of research thus accidentally discovered.\n\nThe truth is, if the acquisition of knowledge justifies every sort of\nconduct, it justifies any sort of conduct, from the illumination\nof Nero's feasts by burning human beings alive (another interesting\nexperiment) to the simplest act of kindness. And in the light of that\ntruth it is clear that the exemption of the pursuit of knowledge\nfrom the laws of honor is the most hideous conceivable enlargement of\nanarchy; worse, by far, than an exemption of the pursuit of money or\npolitical power, since there can hardly be attained without some regard\nfor at least the appearances of human welfare, whereas a curious devil\nmight destroy the whole race in torment, acquiring knowledge all the\ntime from his highly interesting experiment. There is more danger in one\nrespectable scientist countenancing such a monstrous claim than in fifty\nassassins or dynamitards. The man who makes it is ethically imbecile;\nand whoever imagines that it is a scientific claim has not the faintest\nconception of what science means. The paths to knowledge are countless.\nOne of these paths is a path through darkness, secrecy, and cruelty.\nWhen a man deliberately turns from all other paths and goes down that\none, it is scientific to infer that what attracts him is not knowledge,\nsince there are other paths to that, but cruelty. With so strong and\nscientific a case against him, it is childish for him to stand on\nhis honor and reputation and high character and the credit of a noble\nprofession and so forth: he must clear himself either by reason or by\nexperiment, unless he boldly contends that evolution has retained\na passion of cruelty in man just because it is indispensable to the\nfulness of his knowledge.\n\n\n\n\nTHOU ART THE MAN\n\nI shall not be at all surprised if what I have written above has induced\nin sympathetic readers a transport of virtuous indignation at the\nexpense of the medical profession. I shall not damp so creditable and\nsalutary a sentiment; but I must point out that the guilt is shared by\nall of us. It is not in his capacity of healer and man of science that\nthe doctor vivisects or defends vivisection, but in his entirely vulgar\nlay capacity. He is made of the same clay as the ignorant, shallow,\ncredulous, half-miseducated, pecuniarily anxious people who call him in\nwhen they have tried in vain every bottle and every pill the advertizing\ndruggist can persuade them to buy. The real remedy for vivisection is\nthe remedy for all the mischief that the medical profession and all the\nother professions are doing: namely, more knowledge. The juries which\nsend the poor Peculiars to prison, and give vivisectionists heavy\ndamages against humane persons who accuse them of cruelty; the\neditors and councillors and student-led mobs who are striving to make\nVivisection one of the watchwords of our civilization, are not doctors:\nthey are the British public, all so afraid to die that they will cling\nfrantically to any idol which promises to cure all their diseases, and\ncrucify anyone who tells them that they must not only die when their\ntime comes, but die like gentlemen. In their paroxysms of cowardice and\nselfishness they force the doctors to humor their folly and ignorance.\nHow complete and inconsiderate their ignorance is can only be realized\nby those who have some knowledge of vital statistics, and of the\nillusions which beset Public Health legislation.\n\n\n\n\nWHAT THE PUBLIC WANTS AND WILL NOT GET\n\nThe demands of this poor public are not reasonable, but they are quite\nsimple. It dreads disease and desires to be protected against it. But it\nis poor and wants to be protected cheaply. Scientific measures are too\nhard to understand, too costly, too clearly tending towards a rise in\nthe rates and more public interference with the insanitary, because\ninsufficiently financed, private house. What the public wants,\ntherefore, is a cheap magic charm to prevent, and a cheap pill or potion\nto cure, all disease. It forces all such charms on the doctors.\n\n\n\n\nTHE VACCINATION CRAZE\n\nThus it was really the public and not the medical profession that took\nup vaccination with irresistible faith, sweeping the invention out of\nJenner's hand and establishing it in a form which he himself repudiated.\nJenner was not a man of science; but he was not a fool; and when he\nfound that people who had suffered from cowpox either by contagion in\nthe milking shed or by vaccination, were not, as he had supposed, immune\nfrom smallpox, he ascribed the cases of immunity which had formerly\nmisled him to a disease of the horse, which, perhaps because we do not\ndrink its milk and eat its flesh, is kept at a greater distance in our\nimagination than our foster mother the cow. At all events, the public,\nwhich had been boundlessly credulous about the cow, would not have the\nhorse on any terms; and to this day the law which prescribes Jennerian\nvaccination is carried out with an anti-Jennerian inoculation because\nthe public would have it so in spite of Jenner. All the grossest lies\nand superstitions which have disgraced the vaccination craze were taught\nto the doctors by the public. It was not the doctors who first began to\ndeclare that all our old men remember the time when almost every face\nthey saw in the street was horribly pitted with smallpox, and that all\nthis disfigurement has vanished since the introduction of vaccination.\nJenner himself alluded to this imaginary phenomenon before the\nintroduction of vaccination, and attributed it to the older practice\nof smallpox inoculation, by which Voltaire, Catherine II. and Lady\nMary Wortley Montagu so confidently expected to see the disease made\nharmless. It was not Jenner who set people declaring that smallpox, if\nnot abolished by vaccination, had at least been made much milder: on the\ncontrary, he recorded a pre-vaccination epidemic in which none of the\npersons attacked went to bed or considered themselves as seriously ill.\nNeither Jenner, nor any other doctor ever, as far as I know, inculcated\nthe popular notion that everybody got smallpox as a matter of course\nbefore vaccination was invented. That doctors get infected with these\ndelusions, and are in their unprofessional capacity as members of the\npublic subject to them like other men, is true; but if we had to decide\nwhether vaccination was first forced on the public by the doctors or on\nthe doctors by the public, we should have to decide against the public.\n\n\n\n\nSTATISTICAL ILLUSIONS\n\nPublic ignorance of the laws of evidence and of statistics can hardly\nbe exaggerated. There may be a doctor here and there who in dealing\nwith the statistics of disease has taken at least the first step towards\nsanity by grasping the fact that as an attack of even the commonest\ndisease is an exceptional event, apparently over-whelming statistical\nevidence in favor of any prophylactic can be produced by persuading the\npublic that everybody caught the disease formerly. Thus if a disease is\none which normally attacks fifteen per cent of the population, and if\nthe effect of a prophylactic is actually to increase the proportion to\ntwenty per cent, the publication of this figure of twenty per cent will\nconvince the public that the prophylactic has reduced the percentage by\neighty per cent instead of increasing it by five, because the public,\nleft to itself and to the old gentlemen who are always ready to\nremember, on every possible subject, that things used to be much worse\nthan they are now (such old gentlemen greatly outnumber the laudatores\ntempori acti), will assume that the former percentage was about 100. The\nvogue of the Pasteur treatment of hydrophobia, for instance, was due\nto the assumption by the public that every person bitten by a rabid dog\nnecessarily got hydrophobia. I myself heard hydrophobia discussed in\nmy youth by doctors in Dublin before a Pasteur Institute existed,\nthe subject having been brought forward there by the scepticism of an\neminent surgeon as to whether hydrophobia is really a specific disease\nor only ordinary tetanus induced (as tetanus was then supposed to be\ninduced) by a lacerated wound. There were no statistics available as to\nthe proportion of dog bites that ended in hydrophobia; but nobody ever\nguessed that the cases could be more than two or three per cent of the\nbites. On me, therefore, the results published by the Pasteur Institute\nproduced no such effect as they did on the ordinary man who thinks that\nthe bite of a mad dog means certain hydrophobia. It seemed to me that\nthe proportion of deaths among the cases treated at the Institute was\nrather higher, if anything, than might have been expected had there been\nno Institute in existence. But to the public every Pasteur patient\nwho did not die was miraculously saved from an agonizing death by the\nbeneficent white magic of that most trusty of all wizards, the man of\nscience.\n\nEven trained statisticians often fail to appreciate the extent to\nwhich statistics are vitiated by the unrecorded assumptions of their\ninterpreters. Their attention is too much occupied with the cruder\ntricks of those who make a corrupt use of statistics for advertizing\npurposes. There is, for example, the percentage dodge. In some hamlet,\nbarely large enough to have a name, two people are attacked during a\nsmallpox epidemic. One dies: the other recovers. One has vaccination\nmarks: the other has none. Immediately either the vaccinists or the\nantivaccinists publish the triumphant news that at such and such a place\nnot a single vaccinated person died of smallpox whilst 100 per cent of\nthe unvaccinated perished miserably; or, as the case may be, that 100\nper cent of the unvaccinated recovered whilst the vaccinated succumbed\nto the last man. Or, to take another common instance, comparisons\nwhich are really comparisons between two social classes with different\nstandards of nutrition and education are palmed off as comparisons\nbetween the results of a certain medical treatment and its neglect. Thus\nit is easy to prove that the wearing of tall hats and the carrying of\numbrellas enlarges the chest, prolongs life, and confers comparative\nimmunity from disease; for the statistics show that the classes which\nuse these articles are bigger, healthier, and live longer than the class\nwhich never dreams of possessing such things. It does not take much\nperspicacity to see that what really makes this difference is not the\ntall hat and the umbrella, but the wealth and nourishment of which they\nare evidence, and that a gold watch or membership of a club in Pall Mall\nmight be proved in the same way to have the like sovereign virtues. A\nuniversity degree, a daily bath, the owning of thirty pairs of trousers,\na knowledge of Wagner's music, a pew in church, anything, in short, that\nimplies more means and better nurture than the mass of laborers enjoy,\ncan be statistically palmed off as a magic-spell conferring all sorts of\nprivileges.\n\nIn the case of a prophylactic enforced by law, this illusion is\nintensified grotesquely, because only vagrants can evade it. Now\nvagrants have little power of resisting any disease: their death rate\nand their case-mortality rate is always high relatively to that of\nrespectable folk. Nothing is easier, therefore, than to prove that\ncompliance with any public regulation produces the most gratifying\nresults. It would be equally easy even if the regulation actually raised\nthe death-rate, provided it did not raise it sufficiently to make the\naverage householder, who cannot evade regulations, die as early as the\naverage vagrant who can.\n\n\n\n\nTHE SURPRISES OF ATTENTION AND NEGLECT\n\nThere is another statistical illusion which is independent of class\ndifferences. A common complaint of houseowners is that the Public Health\nAuthorities frequently compel them to instal costly sanitary appliances\nwhich are condemned a few years later as dangerous to health, and\nforbidden under penalties. Yet these discarded mistakes are always made\nin the first instance on the strength of a demonstration that their\nintroduction has reduced the death-rate. The explanation is simple.\nSuppose a law were made that every child in the nation should be\ncompelled to drink a pint of brandy per month, but that the brandy\nmust be administered only when the child was in good health, with its\ndigestion and so forth working normally, and its teeth either naturally\nor artificially sound. Probably the result would be an immediate and\nstartling reduction in child mortality, leading to further legislation\nincreasing the quantity of brandy to a gallon. Not until the brandy\ncraze had been carried to a point at which the direct harm done by\nit would outweigh the incidental good, would an anti-brandy party be\nlistened to. That incidental good would be the substitution of attention\nto the general health of children for the neglect which is now the rule\nso long as the child is not actually too sick to run about and play as\nusual. Even if this attention were confined to the children's teeth,\nthere would be an improvement which it would take a good deal of brandy\nto cancel.\n\nThis imaginary case explains the actual case of the sanitary appliances\nwhich our local sanitary authorities prescribe today and condemn\ntomorrow. No sanitary contrivance which the mind of even the very worst\nplumber can devize could be as disastrous as that total neglect for\nlong periods which gets avenged by pestilences that sweep through whole\ncontinents, like the black death and the cholera. If it were proposed\nat this time of day to discharge all the sewage of London crude and\nuntreated into the Thames, instead of carrying it, after elaborate\ntreatment, far out into the North Sea, there would be a shriek of horror\nfrom all our experts. Yet if Cromwell had done that instead of doing\nnothing, there would probably have been no Great Plague of London. When\nthe Local Health Authority forces every householder to have his sanitary\narrangements thought about and attended to by somebody whose special\nbusiness it is to attend to such things, then it matters not how\nerroneous or even directly mischievous may be the specific measures\ntaken: the net result at first is sure to be an improvement. Not until\nattention has been effectually substituted for neglect as the general\nrule, will the statistics begin to show the merits of the particular\nmethods of attention adopted. And as we are far from having arrived\nat this stage, being as to health legislation only at the beginning of\nthings, we have practically no evidence yet as to the value of methods.\nSimple and obvious as this is, nobody seems as yet to discount the\neffect of substituting attention for neglect in drawing conclusions from\nhealth statistics. Everything is put to the credit of the particular\nmethod employed, although it may quite possibly be raising the death\nrate by five per thousand whilst the attention incidental to it is\nreducing the death rate fifteen per thousand. The net gain of ten per\nthousand is credited to the method, and made the excuse for enforcing\nmore of it.\n\n\n\n\nSTEALING CREDIT FROM CIVILIZATION\n\nThere is yet another way in which specifics which have no merits at\nall, either direct or incidental, may be brought into high repute by\nstatistics. For a century past civilization has been cleaning away\nthe conditions which favor bacterial fevers. Typhus, once rife, has\nvanished: plague and cholera have been stopped at our frontiers by a\nsanitary blockade. We still have epidemics of smallpox and typhoid; and\ndiphtheria and scarlet fever are endemic in the slums. Measles, which in\nmy childhood was not regarded as a dangerous disease, has now become\nso mortal that notices are posted publicly urging parents to take it\nseriously. But even in these cases the contrast between the death and\nrecovery rates in the rich districts and in the poor ones has led to\nthe general conviction among experts that bacterial diseases are\npreventable; and they already are to a large extent prevented. The\ndangers of infection and the way to avoid it are better understood\nthan they used to be. It is barely twenty years since people exposed\nthemselves recklessly to the infection of consumption and pneumonia\nin the belief that these diseases were not \"catching.\" Nowadays the\ntroubles of consumptive patients are greatly increased by the growing\ndisposition to treat them as lepers. No doubt there is a good deal of\nignorant exaggeration and cowardly refusal to face a human and necessary\nshare of the risk. That has always been the case. We now know that the\nmedieval horror of leprosy was out of all proportion to the danger\nof infection, and was accompanied by apparent blindness to the\ninfectiousness of smallpox, which has since been worked up by our\ndisease terrorists into the position formerly held by leprosy. But the\nscare of infection, though it sets even doctors talking as if the only\nreally scientific thing to do with a fever patient is to throw him into\nthe nearest ditch and pump carbolic acid on him from a safe distance\nuntil he is ready to be cremated on the spot, has led to much greater\ncare and cleanliness. And the net result has been a series of victories\nover disease.\n\nNow let us suppose that in the early nineteenth century somebody had\ncome forward with a theory that typhus fever always begins in the\ntop joint of the little finger; and that if this joint be amputated\nimmediately after birth, typhus fever will disappear. Had such a\nsuggestion been adopted, the theory would have been triumphantly\nconfirmed; for as a matter of fact, typhus fever has disappeared. On\nthe other hand cancer and madness have increased (statistically) to\nan appalling extent. The opponents of the little finger theory would\ntherefore be pretty sure to allege that the amputations were spreading\ncancer and lunacy. The vaccination controversy is full of such\ncontentions. So is the controversy as to the docking of horses' tails\nand the cropping of dogs' ears. So is the less widely known controversy\nas to circumcision and the declaring certain kinds of flesh unclean by\nthe Jews. To advertize any remedy or operation, you have only to pick\nout all the most reassuring advances made by civilization, and boldly\npresent the two in the relation of cause and effect: the public will\nswallow the fallacy without a wry face. It has no idea of the need for\nwhat is called a control experiment. In Shakespear's time and for long\nafter it, mummy was a favorite medicament. You took a pinch of the dust\nof a dead Egyptian in a pint of the hottest water you could bear to\ndrink; and it did you a great deal of good. This, you thought, proved\nwhat a sovereign healer mummy was. But if you had tried the control\nexperiment of taking the hot water without the mummy, you might have\nfound the effect exactly the same, and that any hot drink would have\ndone as well.\n\n\n\n\nBIOMETRIKA\n\nAnother difficulty about statistics is the technical difficulty\nof calculation. Before you can even make a mistake in drawing your\nconclusion from the correlations established by your statistics you must\nascertain the correlations. When I turn over the pages of Biometrika,\na quarterly journal in which is recorded the work done in the field of\nbiological statistics by Professor Karl Pearson and his colleagues, I am\nout of my depth at the first line, because mathematics are to me only a\nconcept: I never used a logarithm in my life, and could not undertake to\nextract the square root of four without misgiving. I am therefore unable\nto deny that the statistical ascertainment of the correlations between\none thing and another must be a very complicated and difficult technical\nbusiness, not to be tackled successfully except by high mathematicians;\nand I cannot resist Professor Karl Pearson's immense contempt for, and\nindignant sense of grave social danger in, the unskilled guesses of the\nordinary sociologist.\n\nNow the man in the street knows nothing of Biometrika: all he knows is\nthat \"you can prove anything by figures,\" though he forgets this the\nmoment figures are used to prove anything he wants to believe. If he did\ntake in Biometrika he would probably become abjectly credulous as to all\nthe conclusions drawn in it from the correlations so learnedly worked\nout; though the mathematician whose correlations would fill a Newton\nwith admiration may, in collecting and accepting data and drawing\nconclusions from them, fall into quite crude errors by just such popular\noversights as I have been describing.\n\n\n\n\nPATIENT-MADE THERAPEUTICS\n\nTo all these blunders and ignorances doctors are no less subject than\nthe rest of us. They are not trained in the use of evidence, nor\nin biometrics, nor in the psychology of human credulity, nor in the\nincidence of economic pressure. Further, they must believe, on the\nwhole, what their patients believe, just as they must wear the sort of\nhat their patients wear. The doctor may lay down the law despotically\nenough to the patient at points where the patient's mind is simply\nblank; but when the patient has a prejudice the doctor must either keep\nit in countenance or lose his patient. If people are persuaded that\nnight air is dangerous to health and that fresh air makes them catch\ncold it will not be possible for a doctor to make his living in private\npractice if he prescribes ventilation. We have to go back no further\nthan the days of The Pickwick Papers to find ourselves in a world where\npeople slept in four-post beds with curtains drawn closely round to\nexclude as much air as possible. Had Mr. Pickwick's doctor told him that\nhe would be much healthier if he slept on a camp bed by an open window,\nMr. Pickwick would have regarded him as a crank and called in another\ndoctor. Had he gone on to forbid Mr. Pickwick to drink brandy and water\nwhenever he felt chilly, and assured him that if he were deprived of\nmeat or salt for a whole year, he would not only not die, but would be\nnone the worse, Mr. Pickwick would have fled from his presence as from\nthat of a dangerous madman. And in these matters the doctor cannot cheat\nhis patient. If he has no faith in drugs or vaccination, and the patient\nhas, he can cheat him with colored water and pass his lancet through the\nflame of a spirit lamp before scratching his arm. But he cannot make him\nchange his daily habits without knowing it.\n\n\n\n\nTHE REFORMS ALSO COME FROM THE LAITY\n\nIn the main, then, the doctor learns that if he gets ahead of the\nsuperstitions of his patients he is a ruined man; and the result is that\nhe instinctively takes care not to get ahead of them. That is why all\nthe changes come from the laity. It was not until an agitation had been\nconducted for many years by laymen, including quacks and faddists of all\nkinds, that the public was sufficiently impressed to make it possible\nfor the doctors to open their minds and their mouths on the subject of\nfresh air, cold water, temperance, and the rest of the new fashions in\nhygiene. At present the tables have been turned on many old prejudices.\nPlenty of our most popular elderly doctors believe that cold tubs in the\nmorning are unnatural, exhausting, and rheumatic; that fresh air is a\nfad and that everybody is the better for a glass or two of port wine\nevery day; but they no longer dare say as much until they know exactly\nwhere they are; for many very desirable patients in country houses have\nlately been persuaded that their first duty is to get up at six in the\nmorning and begin the day by taking a walk barefoot through the dewy\ngrass. He who shows the least scepticism as to this practice is at once\nsuspected of being \"an old-fashioned doctor,\" and dismissed to make room\nfor a younger man.\n\nIn short, private medical practice is governed not by science but by\nsupply and demand; and however scientific a treatment may be, it cannot\nhold its place in the market if there is no demand for it; nor can the\ngrossest quackery be kept off the market if there is a demand for it.\n\n\n\n\nFASHIONS AND EPIDEMICS\n\nA demand, however, can be inculcated. This is thoroughly understood\nby fashionable tradesmen, who find no difficulty in persuading their\ncustomers to renew articles that are not worn out and to buy things they\ndo not want. By making doctors tradesmen, we compel them to learn the\ntricks of trade; consequently we find that the fashions of the year\ninclude treatments, operations, and particular drugs, as well as hats,\nsleeves, ballads, and games. Tonsils, vermiform appendices, uvulas, even\novaries are sacrificed because it is the fashion to get them cut out,\nand because the operations are highly profitable. The psychology of\nfashion becomes a pathology; for the cases have every air of being\ngenuine: fashions, after all, are only induced epidemics, proving that\nepidemics can be induced by tradesmen, and therefore by doctors.\n\n\n\n\nTHE DOCTOR'S VIRTUES\n\nIt will be admitted that this is a pretty bad state of things. And the\nmelodramatic instinct of the public, always demanding; that every wrong\nshall have, not its remedy, but its villain to be hissed, will blame,\nnot its own apathy, superstition, and ignorance, but the depravity of\nthe doctors. Nothing could be more unjust or mischievous. Doctors, if no\nbetter than other men, are certainly no worse. I was reproached during\nthe performances of The Doctor's Dilemma at the Court Theatre in\n1907 because I made the artist a rascal, the journalist an illiterate\nincapable, and all the doctors \"angels.\" But I did not go beyond the\nwarrant of my own experience. It has been my luck to have doctors\namong my friends for nearly forty years past (all perfectly aware of\nmy freedom from the usual credulity as to the miraculous powers and\nknowledge attributed to them); and though I know that there are medical\nblackguards as well as military, legal, and clerical blackguards (one\nsoon finds that out when one is privileged to hear doctors talking shop\namong themselves), the fact that I was no more at a loss for private\nmedical advice and attendance when I had not a penny in my pocket than I\nwas later on when I could afford fees on the highest scale, has made it\nimpossible for me to share that hostility to the doctor as a man which\nexists and is growing as an inevitable result of the present condition\nof medical practice. Not that the interest in disease and aberrations\nwhich turns some men and women to medicine and surgery is not sometimes\nas morbid as the interest in misery and vice which turns some others\nto philanthropy and \"rescue work.\" But the true doctor is inspired by\na hatred of ill-health, and a divine impatience of any waste of vital\nforces. Unless a man is led to medicine or surgery through a very\nexceptional technical aptitude, or because doctoring is a family\ntradition, or because he regards it unintelligently as a lucrative and\ngentlemanly profession, his motives in choosing the career of a healer\nare clearly generous. However actual practice may disillusion and\ncorrupt him, his selection in the first instance is not a selection of a\nbase character.\n\n\n\n\nTHE DOCTOR'S HARDSHIPS\n\nA review of the counts in the indictment I have brought against private\nmedical practice will show that they arise out of the doctor's position\nas a competitive private tradesman: that is, out of his poverty and\ndependence. And it should be borne in mind that doctors are expected\nto treat other people specially well whilst themselves submitting\nto specially inconsiderate treatment. The butcher and baker are not\nexpected to feed the hungry unless the hungry can pay; but a doctor who\nallows a fellow-creature to suffer or perish without aid is regarded as\na monster. Even if we must dismiss hospital service as really venal,\nthe fact remains that most doctors do a good deal of gratuitous work\nin private practice all through their careers. And in his paid work the\ndoctor is on a different footing to the tradesman. Although the articles\nhe sells, advice and treatment, are the same for all classes, his fees\nhave to be graduated like the income tax. The successful fashionable\ndoctor may weed his poorer patients out from time to time, and finally\nuse the College of Physicians to place it out of his own power to accept\nlow fees; but the ordinary general practitioner never makes out his\nbills without considering the taxable capacity of his patients.\n\nThen there is the disregard of his own health and comfort which results\nfrom the fact that he is, by the nature of his work, an emergency man.\nWe are polite and considerate to the doctor when there is nothing the\nmatter, and we meet him as a friend or entertain him as a guest; but\nwhen the baby is suffering from croup, or its mother has a temperature\nof 104 degrees, or its grandfather has broken his leg, nobody thinks\nof the doctor except as a healer and saviour. He may be hungry,\nweary, sleepy, run down by several successive nights disturbed by that\ninstrument of torture, the night bell; but who ever thinks of this\nin the face of sudden sickness or accident? We think no more of the\ncondition of a doctor attending a case than of the condition of\na fireman at a fire. In other occupations night-work is specially\nrecognized and provided for. The worker sleeps all day; has his\nbreakfast in the evening; his lunch or dinner at midnight; his dinner or\nsupper before going to bed in the morning; and he changes to day-work\nif he cannot stand night-work. But a doctor is expected to work day and\nnight. In practices which consist largely of workmen's clubs, and in\nwhich the patients are therefore taken on wholesale terms and very\nnumerous, the unfortunate assistant, or the principal if he has no\nassistant, often does not undress, knowing that he will be called up\nbefore he has snatched an hour's sleep. To the strain of such inhuman\nconditions must be added the constant risk of infection. One wonders\nwhy the impatient doctors do not become savage and unmanageable, and the\npatient ones imbecile. Perhaps they do, to some extent. And the pay is\nwretched, and so uncertain that refusal to attend without payment in\nadvance becomes often a necessary measure of self-defence, whilst the\nCounty Court has long ago put an end to the tradition that the doctor's\nfee is an honorarium. Even the most eminent physicians, as such\nbiographies as those of Paget show, are sometimes miserably, inhumanly\npoor until they are past their prime. In short, the doctor needs our\nhelp for the moment much more than we often need his. The ridicule of\nMoliere, the death of a well-informed and clever writer like the late\nHarold Frederic in the hands of Christian Scientists (a sort of sealing\nwith his blood of the contemptuous disbelief in and dislike of doctors\nhe had bitterly expressed in his books), the scathing and quite\njustifiable exposure of medical practice in the novel by Mr. Maarten\nMaartens entitled The New Religion: all these trouble the doctor very\nlittle, and are in any case well set off by the popularity of Sir Luke\nFildes' famous picture, and by the verdicts in which juries from time to\ntime express their conviction that the doctor can do no wrong. The\nreal woes of the doctor are the shabby coat, the wolf at the door,\nthe tyranny of ignorant patients, the work-day of 24 hours, and the\nuselessness of honestly prescribing what most of the patients really\nneed: that is, not medicine, but money.\n\n\n\n\nTHE PUBLIC DOCTOR\n\nWhat then is to be done?\n\nFortunately we have not to begin absolutely from the beginning: we\nalready have, in the Medical Officer of Health, a sort of doctor who is\nfree from the worst hardships, and consequently from the worst vices,\nof the private practitioner. His position depends, not on the number\nof people who are ill, and whom he can keep ill, but on the number of\npeople who are well. He is judged, as all doctors and treatments should\nbe judged, by the vital statistics of his district. When the death rate\ngoes up his credit goes down. As every increase in his salary depends on\nthe issue of a public debate as to the health of the constituency under\nhis charge, he has every inducement to strive towards the ideal of a\nclean bill of health. He has a safe, dignified, responsible, independent\nposition based wholly on the public health; whereas the private\npractitioner has a precarious, shabby-genteel, irresponsible, servile\nposition, based wholly on the prevalence of illness.\n\nIt is true, there are grave scandals in the public medical service. The\npublic doctor may be also a private practitioner eking out his earnings\nby giving a little time to public work for a mean payment. There are\ncases in which the position is one which no successful practitioner will\naccept, and where, therefore, incapables or drunkards get automatically\nselected for the post, faute de mieux; but even in these cases the\ndoctor is less disastrous in his public capacity than in his private\none: besides, the conditions which produce these bad cases are doomed,\nas the evil is now recognized and understood. A popular but unstable\nremedy is to enable local authorities, when they are too small to\nrequire the undivided time of such men as the Medical Officers of our\ngreat municipalities, to combine for public health purposes so that each\nmay share the services of a highly paid official of the best class; but\nthe right remedy is a larger area as the sanitary unit.\n\n\n\n\nMEDICAL ORGANIZATION\n\nAnother advantage of public medical work is that it admits of\norganization, and consequently of the distribution of the work in such\na manner as to avoid wasting the time of highly qualified experts\non trivial jobs. The individualism of private practice leads to an\nappalling waste of time on trifles. Men whose dexterity as operators or\nalmost divinatory skill in diagnosis are constantly needed for difficult\ncases, are poulticing whitlows, vaccinating, changing unimportant\ndressings, prescribing ether drams for ladies with timid leanings\ntowards dipsomania, and generally wasting their time in the pursuit of\nprivate fees. In no other profession is the practitioner expected to\ndo all the work involved in it from the first day of his professional\ncareer to the last as the doctor is. The judge passes sentence of death;\nbut he is not expected to hang the criminal with his own hands, as he\nwould be if the legal profession were as unorganized as the medical. The\nbishop is not expected to blow the organ or wash the baby he baptizes.\nThe general is not asked to plan a campaign or conduct a battle at\nhalf-past twelve and to play the drum at half-past two. Even if they\nwere, things would still not be as bad as in the medical profession; for\nin it not only is the first-class man set to do third-class work, but,\nwhat is much more terrifying, the third-class man is expected to do\nfirst-class work. Every general practitioner is supposed to be capable\nof the whole range of medical and surgical work at a moment's notice;\nand the country doctor, who has not a specialist nor a crack consultant\nat the end of his telephone, often has to tackle without hesitation\ncases which no sane practitioner in a town would take in hand without\nassistance. No doubt this develops the resourcefulness of the country\ndoctor, and makes him a more capable man than his suburban colleague;\nbut it cannot develop the second-class man into a first-class one. If\nthe practice of law not only led to a judge having to hang, but the\nhangman to judge, or if in the army matters were so arranged that it\nwould be possible for the drummer boy to be in command at Waterloo\nwhilst the Duke of Wellington was playing the drum in Brussels, we\nshould not be consoled by the reflection that our hangmen were thereby\nmade a little more judicial-minded, and our drummers more responsible,\nthan in foreign countries where the legal and military professions\nrecognized the advantages of division of labor.\n\nUnder such conditions no statistics as to the graduation of professional\nability among doctors are available. Assuming that doctors are normal\nmen and not magicians (and it is unfortunately very hard to persuade\npeople to admit so much and thereby destroy the romance of doctoring)\nwe may guess that the medical profession, like the other professions,\nconsists of a small percentage of highly gifted persons at one end,\nand a small percentage of altogether disastrous duffers at the other.\nBetween these extremes comes the main body of doctors (also, of\ncourse, with a weak and a strong end) who can be trusted to work under\nregulations with more or less aid from above according to the gravity\nof the case. Or, to put it in terms of the cases, there are cases that\npresent no difficulties, and can be dealt with by a nurse or student at\none end of the scale, and cases that require watching and handling by\nthe very highest existing skill at the other; whilst between come\nthe great mass of cases which need visits from the doctor of ordinary\nability and from the chiefs of the profession in the proportion of, say,\nseven to none, seven to one, three to one, one to one, or, for a day\nor two, none to one. Such a service is organized at present only\nin hospitals; though in large towns the practice of calling in the\nconsultant acts, to some extent, as a substitute for it. But in the\nlatter case it is quite unregulated except by professional etiquet,\nwhich, as we have seen, has for its object, not the health of the\npatient or of the community at large, but the protection of the doctor's\nlivelihood and the concealment of his errors. And as the consultant is\nan expensive luxury, he is a last resource rather, as he should be, than\na matter of course, in all cases where the general practitioner is not\nequal to the occasion: a predicament in which a very capable man may\nfind himself at any time through the cropping up of a case of which he\nhas had no clinical experience.\n\n\n\n\nTHE SOCIAL SOLUTION OF THE MEDICAL PROBLEM\n\nThe social solution of the medical problem, then, depends on that large,\nslowly advancing, pettishly resisted integration of society called\ngenerally Socialism. Until the medical profession becomes a body of men\ntrained and paid by the country to keep the country in health it will\nremain what it is at present: a conspiracy to exploit popular credulity\nand human suffering. Already our M.O.H.s (Medical Officers of Health)\nare in the new position: what is lacking is appreciation of the change,\nnot only by the public but by the private doctors. For, as we have seen,\nwhen one of the first-rate posts becomes vacant in one of the great\ncities, and all the leading M.O.H.s compete for it, they must appeal to\nthe good health of the cities of which they have been in charge, and not\nto the size of the incomes the local private doctors are making out of\nthe ill-health of their patients. If a competitor can prove that he has\nutterly ruined every sort of medical private practice in a large city\nexcept obstetric practice and the surgery of accidents, his claims are\nirresistible; and this is the ideal at which every M.O.H. should aim.\nBut the profession at large should none the less welcome him and set\nits house in order for the social change which will finally be its own\nsalvation. For the M.O.H. as we know him is only the beginning of that\narmy of Public Hygiene which will presently take the place in general\ninterest and honor now occupied by our military and naval forces. It is\nsilly that an Englishman should be more afraid of a German soldier than\nof a British disease germ, and should clamor for more barracks in the\nsame newspapers that protest against more school clinics, and cry out\nthat if the State fights disease for us it makes us paupers, though\nthey never say that if the State fights the Germans for us it makes us\ncowards. Fortunately, when a habit of thought is silly it only needs\nsteady treatment by ridicule from sensible and witty people to be put\nout of countenance and perish. Every year sees an increase in the number\nof persons employed in the Public Health Service, who would formerly\nhave been mere adventurers in the Private Illness Service. To put it\nanother way, a host of men and women who have now a strong incentive\nto be mischievous and even murderous rogues will have a much stronger,\nbecause a much honester, incentive to be not only good citizens but\nactive benefactors to the community. And they will have no anxiety\nwhatever about their incomes.\n\n\n\n\nTHE FUTURE OF PRIVATE PRACTICE\n\nIt must not be hastily concluded that this involves the extinction of\nthe private practitioner. What it will really mean for him is release\nfrom his present degrading and scientifically corrupting slavery to his\npatients. As I have already shown the doctor who has to live by pleasing\nhis patients in competition with everybody who has walked the hospitals,\nscraped through the examinations, and bought a brass plate, soon finds\nhimself prescribing water to teetotallers and brandy or champagne jelly\nto drunkards; beefsteaks and stout in one house, and \"uric acid free\"\nvegetarian diet over the way; shut windows, big fires, and heavy\novercoats to old Colonels, and open air and as much nakedness as is\ncompatible with decency to young faddists, never once daring to say\neither \"I don't know,\" or \"I don't agree.\" For the strength of the\ndoctor's, as of every other man's position when the evolution of social\norganization at last reaches his profession, will be that he will always\nhave open to him the alternative of public employment when the private\nemployer becomes too tyrannous. And let no one suppose that the words\ndoctor and patient can disguise from the parties the fact that they are\nemployer and employee. No doubt doctors who are in great demand can be\nas high-handed and independent as employees are in all classes when a\ndearth in their labor market makes them indispensable; but the average\ndoctor is not in this position: he is struggling for life in an\novercrowded profession, and knows well that \"a good bedside manner\"\nwill carry him to solvency through a morass of illness, whilst the\nleast attempt at plain dealing with people who are eating too much, or\ndrinking too much, or frowsting too much (to go no further in the list\nof intemperances that make up so much of family life) would soon land\nhim in the Bankruptcy Court.\n\nPrivate practice, thus protected, would itself protect individuals, as\nfar as such protection is possible, against the errors and superstitions\nof State medicine, which are at worst no worse than the errors and\nsuperstitions of private practice, being, indeed, all derived from it.\nSuch monstrosities as vaccination are, as we have seen, founded, not on\nscience, but on half-crowns. If the Vaccination Acts, instead of being\nwholly repealed as they are already half repealed, were strengthened by\ncompelling every parent to have his child vaccinated by a public officer\nwhose salary was completely independent of the number of vaccinations\nperformed by him, and for whom there was plenty of alternative public\nhealth work waiting, vaccination would be dead in two years, as the\nvaccinator would not only not gain by it, but would lose credit through\nthe depressing effects on the vital statistics of his district of the\nillness and deaths it causes, whilst it would take from him all the\ncredit of that freedom from smallpox which is the result of good\nsanitary administration and vigilant prevention of infection. Such\nabsurd panic scandals as that of the last London epidemic, where a fee\nof half-a-crown per re-vaccination produced raids on houses during\nthe absence of parents, and the forcible seizure and re-vaccination of\nchildren left to answer the door, can be prevented simply by abolishing\nthe half-crown and all similar follies, paying, not for this or that\nceremony of witchcraft, but for immunity from disease, and paying, too,\nin a rational way. The officer with a fixed salary saves himself trouble\nby doing his business with the least possible interference with the\nprivate citizen. The man paid by the job loses money by not forcing his\njob on the public as often as possible without reference to its results.\n\n\n\n\nTHE TECHNICAL PROBLEM\n\nAs to any technical medical problem specially involved, there is none.\nIf there were, I should not be competent to deal with it, as I am not a\ntechnical expert in medicine: I deal with the subject as an economist, a\npolitician, and a citizen exercising my common sense. Everything that I\nhave said applies equally to all the medical techniques, and will hold\ngood whether public hygiene be based on the poetic fancies of Christian\nScience, the tribal superstitions of the druggist and the vivisector, or\nthe best we can make of our real knowledge. But I may remind those\nwho confusedly imagine that the medical problem is also the scientific\nproblem, that all problems are finally scientific problems. The notion\nthat therapeutics or hygiene or surgery is any more or less scientific\nthan making or cleaning boots is entertained only by people to whom\na man of science is still a magician who can cure diseases, transmute\nmetals, and enable us to live for ever. It may still be necessary for\nsome time to come to practise on popular credulity, popular love and\ndread of the marvellous, and popular idolatry, to induce the poor\nto comply with the sanitary regulations they are too ignorant\nto understand. As I have elsewhere confessed, I have myself been\nresponsible for ridiculous incantations with burning sulphur,\nexperimentally proved to be quite useless, because poor people are\nconvinced, by the mystical air of the burning and the horrible smell,\nthat it exorcises the demons of smallpox and scarlet fever and makes it\nsafe for them to return to their houses. To assure them that the real\nsecret is sunshine and soap is only to convince them that you do not\ncare whether they live or die, and wish to save money at their expense.\nSo you perform the incantation; and back they go to their houses,\nsatisfied. A religious ceremony--a poetic blessing of the threshold, for\ninstance--would be much better; but unfortunately our religion is weak\non the sanitary side. One of the worst misfortunes of Christendom was\nthat reaction against the voluptuous bathing of the imperial Romans\nwhich made dirty habits a part of Christian piety, and in some unlucky\nplaces (the Sandwich Islands for example) made the introduction of\nChristianity also the introduction of disease, because the formulators\nof the superseded native religion, like Mahomet, had been enlightened\nenough to introduce as religious duties such sanitary measures as\nablution and the most careful and reverent treatment of everything\ncast off by the human body, even to nail clippings and hairs; and our\nmissionaries thoughtlessly discredited this godly doctrine without\nsupplying its place, which was promptly taken by laziness and neglect.\nIf the priests of Ireland could only be persuaded to teach their flocks\nthat it is a deadly insult to the Blessed Virgin to place her image in a\ncottage that is not kept up to that high standard of Sunday cleanliness\nto which all her worshippers must believe she is accustomed, and to\nrepresent her as being especially particular about stables because\nher son was born in one, they might do more in one year than all the\nSanitary Inspectors in Ireland could do in twenty; and they could hardly\ndoubt that Our Lady would be delighted. Perhaps they do nowadays; for\nIreland is certainly a transfigured country since my youth as far as\nclean faces and pinafores can transfigure it. In England, where so\nmany of the inhabitants are too gross to believe in poetic faiths, too\nrespectable to tolerate the notion that the stable at Bethany was a\ncommon peasant farmer's stable instead of a first-rate racing one, and\ntoo savage to believe that anything can really cast out the devil of\ndisease unless it be some terrifying hoodoo of tortures and stinks, the\nM.O.H. will no doubt for a long time to come have to preach to fools\naccording to their folly, promising miracles, and threatening hideous\npersonal consequences of neglect of by-laws and the like; therefore it\nwill be important that every M.O.H. shall have, with his (or her) other\nqualifications, a sense of humor, lest (he or she) should come at last\nto believe all the nonsense that must needs be talked. But he must, in\nhis capacity of an expert advising the authorities, keep the government\nitself free of superstition. If Italian peasants are so ignorant that\nthe Church can get no hold of them except by miracles, why, miracles\nthere must be. The blood of St. Januarius must liquefy whether the\nSaint is in the humor or not. To trick a heathen into being a dutiful\nChristian is no worse than to trick a whitewasher into trusting himself\nin a room where a smallpox patient has lain, by pretending to exorcise\nthe disease with burning sulphur. But woe to the Church if in deceiving\nthe peasant it also deceives itself; for then the Church is lost, and\nthe peasant too, unless he revolt against it. Unless the Church works\nthe pretended miracle painfully against the grain, and is continually\nurged by its dislike of the imposture to strive to make the peasant\nsusceptible to the true reasons for behaving well, the Church will\nbecome an instrument of his corruption and an exploiter of his\nignorance, and will find itself launched upon that persecution of\nscientific truth of which all priesthoods are accused and none with more\njustice than the scientific priesthood.\n\nAnd here we come to the danger that terrifies so many of us: the danger\nof having a hygienic orthodoxy imposed on us. But we must face that: in\nsuch crowded and poverty ridden civilizations as ours any orthodoxy\nis better than laisser-faire. If our population ever comes to consist\nexclusively of well-to-do, highly cultivated, and thoroughly instructed\nfree persons in a position to take care of themselves, no doubt they\nwill make short work of a good deal of official regulation that is now\nof life-and-death necessity to us; but under existing circumstances, I\nrepeat, almost any sort of attention that democracy will stand is better\nthan neglect. Attention and activity lead to mistakes as well as\nto successes; but a life spent in making mistakes is not only more\nhonorable but more useful than a life spent doing nothing. The one\nlesson that comes out of all our theorizing and experimenting is that\nthere is only one really scientific progressive method; and that is the\nmethod of trial and error. If you come to that, what is laisser-faire\nbut an orthodoxy? the most tyrannous and disastrous of all the\northodoxies, since it forbids you even to learn.\n\n\n\n\nTHE LATEST THEORIES\n\nMedical theories are so much a matter of fashion, and the most fertile\nof them are modified so rapidly by medical practice and biological\nresearch, which are international activities, that the play which\nfurnishes the pretext for this preface is already slightly outmoded,\nthough I believe it may be taken as a faithful record for the year\n(1906) in which it was begun. I must not expose any professional man to\nruin by connecting his name with the entire freedom of criticism which\nI, as a layman, enjoy; but it will be evident to all experts that my\nplay could not have been written but for the work done by Sir Almroth\nWright in the theory and practice of securing immunization from\nbacterial diseases by the inoculation of \"vaccines\" made of their own\nbacteria: a practice incorrectly called vaccinetherapy (there is nothing\nvaccine about it) apparently because it is what vaccination ought to be\nand is not. Until Sir Almroth Wright, following up one of Metchnikoff's\nmost suggestive biological romances, discovered that the white\ncorpuscles or phagocytes which attack and devour disease germs for us do\ntheir work only when we butter the disease germs appetizingly for them\nwith a natural sauce which Sir Almroth named opsonin, and that our\nproduction of this condiment continually rises and falls rhythmically\nfrom negligibility to the highest efficiency, nobody had been able\neven to conjecture why the various serums that were from time to time\nintroduced as having effected marvellous cures, presently made such\ndireful havoc of some unfortunate patient that they had to be dropped\nhastily. The quantity of sturdy lying that was necessary to save the\ncredit of inoculation in those days was prodigious; and had it not been\nfor the devotion shown by the military authorities throughout Europe,\nwho would order the entire disappearance of some disease from their\narmies, and bring it about by the simple plan of changing the name\nunder which the cases were reported, or for our own Metropolitan Asylums\nBoard, which carefully suppressed all the medical reports that revealed\nthe sometimes quite appalling effects of epidemics of revaccination,\nthere is no saying what popular reaction might not have taken place\nagainst the whole immunization movement in therapeutics.\n\nThe situation was saved when Sir Almroth Wright pointed out that if you\ninoculated a patient with pathogenic germs at a moment when his powers\nof cooking them for consumption by the phagocytes was receding to its\nlowest point, you would certainly make him a good deal worse and perhaps\nkill him, whereas if you made precisely the same inoculation when the\ncooking power was rising to one of its periodical climaxes, you would\nstimulate it to still further exertions and produce just the opposite\nresult. And he invented a technique for ascertaining in which phase the\npatient happened to be at any given moment. The dramatic possibilities\nof this discovery and invention will be found in my play. But it is one\nthing to invent a technique: it is quite another to persuade the medical\nprofession to acquire it. Our general practitioners, I gather, simply\ndeclined to acquire it, being mostly unable to afford either the\nacquisition or the practice of it when acquired. Something simple,\ncheap, and ready at all times for all comers, is, as I have shown, the\nonly thing that is economically possible in general practice, whatever\nmay be the case in Sir Almroth's famous laboratory in St. Mary's\nHospital. It would have become necessary to denounce opsonin in the\ntrade papers as a fad and Sir Almroth as a dangerous man if his practice\nin the laboratory had not led him to the conclusion that the customary\ninoculations were very much too powerful, and that a comparatively\ninfinitesimal dose would not precipitate a negative phase of cooking\nactivity, and might induce a positive one. And thus it happens that the\nrefusal of our general practitioners to acquire the new technique is\nno longer quite so dangerous in practice as it was when The Doctor's\nDilemma was written: nay, that Sir Ralph Bloomfield Boningtons way of\nadministering inoculations as if they were spoonfuls of squills may\nsometimes work fairly well. For all that, I find Sir Almroth Wright,\non the 23rd May, 1910, warning the Royal Society of Medicine that \"the\nclinician has not yet been prevailed upon to reconsider his position,\"\nwhich means that the general practitioner (\"the doctor,\" as he is called\nin our homes) is going on just as he did before, and could not afford\nto learn or practice a new technique even if he had ever heard of it.\nTo the patient who does not know about it he will say nothing. To the\npatient who does, he will ridicule it, and disparage Sir Almroth. What\nelse can he do, except confess his ignorance and starve?\n\nBut now please observe how \"the whirligig of time brings its revenges.\"\nThis latest discovery of the remedial virtue of a very, very tiny\nhair of the dog that bit you reminds us, not only of Arndt's law of\nprotoplasmic reaction to stimuli, according to which weak and strong\nstimuli provoke opposite reactions, but of Hahnemann's homeopathy, which\nwas founded on the fact alleged by Hahnemann that drugs which produce\ncertain symptoms when taken in ordinary perceptible quantities, will,\nwhen taken in infinitesimally small quantities, provoke just the\nopposite symptoms; so that the drug that gives you a headache will\nalso cure a headache if you take little enough of it. I have already\nexplained that the savage opposition which homeopathy encountered from\nthe medical profession was not a scientific opposition; for nobody seems\nto deny that some drugs act in the alleged manner. It was opposed simply\nbecause doctors and apothecaries lived by selling bottles and boxes of\ndoctor's stuff to be taken in spoonfuls or in pellets as large as peas;\nand people would not pay as much for drops and globules no bigger than\npins' heads. Nowadays, however, the more cultivated folk are beginning\nto be so suspicious of drugs, and the incorrigibly superstitious people\nso profusely supplied with patent medicines (the medical advice to take\nthem being wrapped round the bottle and thrown in for nothing) that\nhomeopathy has become a way of rehabilitating the trade of prescription\ncompounding, and is consequently coming into professional credit. At\nwhich point the theory of opsonins comes very opportunely to shake hands\nwith it.\n\nAdd to the newly triumphant homeopathist and the opsonist that other\nremarkable innovator, the Swedish masseur, who does not theorize about\nyou, but probes you all over with his powerful thumbs until he finds out\nyour sore spots and rubs them away, besides cheating you into a little\nwholesome exercise; and you have nearly everything in medical practice\nto-day that is not flat witchcraft or pure commercial exploitation of\nhuman credulity and fear of death. Add to them a good deal of vegetarian\nand teetotal controversy raging round a clamor for scientific eating\nand drinking, and resulting in little so far except calling digestion\nMetabolism and dividing the public between the eminent doctor who tells\nus that we do not eat enough fish, and his equally eminent colleague\nwho warns us that a fish diet must end in leprosy, and you have all that\nopposes with any sort of countenance the rise of Christian Science with\nits cathedrals and congregations and zealots and miracles and cures:\nall very silly, no doubt, but sane and sensible, poetic and hopeful,\ncompared to the pseudo science of the commercial general practitioner,\nwho foolishly clamors for the prosecution and even the execution of the\nChristian Scientists when their patients die, forgetting the long death\nroll of his own patients.\n\nBy the time this preface is in print the kaleidoscope may have had\nanother shake; and opsonin may have gone the way of phlogiston at the\nhands of its own restless discoverer. I will not say that Hahnemann may\nhave gone the way of Diafoirus; for Diafoirus we have always with us.\nBut we shall still pick up all our knowledge in pursuit of some Will o'\nthe Wisp or other. What is called science has always pursued the Elixir\nof Life and the Philosopher's Stone, and is just as busy after them\nto-day as ever it was in the days of Paracelsus. We call them by\ndifferent names: Immunization or Radiology or what not; but the dreams\nwhich lure us into the adventures from which we learn are always at\nbottom the same. Science becomes dangerous only when it imagines that\nit has reached its goal. What is wrong with priests and popes is that\ninstead of being apostles and saints, they are nothing but empirics\nwho say \"I know\" instead of \"I am learning,\" and pray for credulity and\ninertia as wise men pray for scepticism and activity. Such abominations\nas the Inquisition and the Vaccination Acts are possible only in the\nfamine years of the soul, when the great vital dogmas of honor, liberty,\ncourage, the kinship of all life, faith that the unknown is greater than\nthe known and is only the As Yet Unknown, and resolution to find a\nmanly highway to it, have been forgotten in a paroxysm of littleness and\nterror in which nothing is active except concupiscence and the fear of\ndeath, playing on which any trader can filch a fortune, any blackguard\ngratify his cruelty, and any tyrant make us his slaves.\n\nLest this should seem too rhetorical a conclusion for our professional\nmen of science, who are mostly trained not to believe anything unless it\nis worded in the jargon of those writers who, because they never really\nunderstand what they are trying to say, cannot find familiar words for\nit, and are therefore compelled to invent a new language of nonsense\nfor every book they write, let me sum up my conclusions as dryly as is\nconsistent with accurate thought and live conviction.\n\n1. Nothing is more dangerous than a poor doctor: not even a poor\nemployer or a poor landlord.\n\n2. Of all the anti-social vested interests the worst is the vested\ninterest in ill-health.\n\n3. Remember that an illness is a misdemeanor; and treat the doctor as an\naccessory unless he notifies every case to the Public Health authority.\n\n4. Treat every death as a possible and under our present system a\nprobable murder, by making it the subject of a reasonably conducted\ninquest; and execute the doctor, if necessary, as a doctor, by striking\nhim off the register.\n\n5. Make up your mind how many doctors the community needs to keep\nit well. Do not register more or less than this number; and let\nregistration constitute the doctor a civil servant with a dignified\nliving wage paid out of public funds.\n\n6. Municipalize Harley Street.\n\n7. Treat the private operator exactly as you would treat a private\nexecutioner.\n\n8. Treat persons who profess to be able to cure disease as you\ntreat fortune tellers.\n\n9. Keep the public carefully informed, by special statistics and\nannouncements of individual cases, of all illnesses of doctors or in\ntheir families.\n\n10. Make it compulsory for a doctor using a brass plate to\nhave inscribed on it, in addition to the letters indicating his\nqualifications, the words \"Remember that I too am mortal.\"\n\n11. In legislation and social organization, proceed on the principle\nthat invalids, meaning persons who cannot keep themselves alive by their\nown activities, cannot, beyond reason, expect to be kept alive by\nthe activity of others. There is a point at which the most energetic\npoliceman or doctor, when called upon to deal with an apparently drowned\nperson, gives up artificial respiration, although it is never possible\nto declare with certainty, at any point short of decomposition, that\nanother five minutes of the exercise would not effect resuscitation. The\ntheory that every individual alive is of infinite value is legislatively\nimpracticable. No doubt the higher the life we secure to the individual\nby wise social organization, the greater his value is to the community,\nand the more pains we shall take to pull him through any temporary\ndanger or disablement. But the man who costs more than he is worth is\ndoomed by sound hygiene as inexorably as by sound economics.\n\n12. Do not try to live for ever. You will not succeed.\n\n13. Use your health, even to the point of wearing it out. That is\nwhat it is for. Spend all you have before you die; and do not outlive\nyourself.\n\n14. Take the utmost care to get well born and well brought up. This\nmeans that your mother must have a good doctor. Be careful to go to\na school where there is what they call a school clinic, where your\nnutrition and teeth and eyesight and other matters of importance to you\nwill be attended to. Be particularly careful to have all this done at\nthe expense of the nation, as otherwise it will not be done at all, the\nchances being about forty to one against your being able to pay for it\ndirectly yourself, even if you know how to set about it. Otherwise\nyou will be what most people are at present: an unsound citizen of an\nunsound nation, without sense enough to be ashamed or unhappy about it.","title":"The Doctor's Dilemma: Preface on Doctors","tradition":"philosophy-ethics","translated_text":null,"word_count":28271}