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George Bernard Shaw.

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house with their fee in their pockets before the patient has recovered
consciousness, and who therefore see nothing of the suffering witnessed
by the general practitioner and the nurse, occasionally talk of
operations very much as the hangman in Barnaby Rudge talked of
executions, as if being operated on were a luxury in sensation as well
as in price.




MEDICAL POVERTY

To make matters worse, doctors are hideously poor. The Irish gentleman
doctor of my boyhood, who took nothing less than a guinea, though he
might pay you four visits for it, seems to have no equivalent nowadays
in English society. Better be a railway porter than an ordinary English
general practitioner. A railway porter has from eighteen to twenty-three
shillings a week from the Company merely as a retainer; and his
additional fees from the public, if we leave the third-class twopenny
tip out of account (and I am by no means sure that even this reservation
need be made), are equivalent to doctor's fees in the case of
second-class passengers, and double doctor's fees in the case of first.
Any class of educated men thus treated tends to become a brigand class,
and doctors are no exception to the rule. They are offered disgraceful
prices for advice and medicine. Their patients are for the most part so
poor and so ignorant that good advice would be resented as impracticable
and wounding. When you are so poor that you cannot afford to refuse
eighteenpence from a man who is too poor to pay you any more, it
is useless to tell him that what he or his sick child needs is not
medicine, but more leisure, better clothes, better food, and a better
drained and ventilated house. It is kinder to give him a bottle of
something almost as cheap as water, and tell him to come again with
another eighteenpence if it does not cure him. When you have done that
over and over again every day for a week, how much scientific conscience
have you left? If you are weak-minded enough to cling desperately to
your eighteenpence as denoting a certain social superiority to the
sixpenny doctor, you will be miserably poor all your life; whilst the
sixpenny doctor, with his low prices and quick turnover of patients,
visibly makes much more than you do and kills no more people.

A doctor's character can no more stand out against such conditions than
the lungs of his patients can stand out against bad ventilation. The
only way in which he can preserve his self-respect is by forgetting
all he ever learnt of science, and clinging to such help as he can
give without cost merely by being less ignorant and more accustomed to
sick-beds than his patients. Finally, he acquires a certain skill at
nursing cases under poverty-stricken domestic conditions, just as women
who have been trained as domestic servants in some huge institution with
lifts, vacuum cleaners, electric lighting, steam heating, and machinery
that turns the kitchen into a laboratory and engine house combined,
manage, when they are sent out into the world to drudge as general
servants, to pick up their business in a new way, learning the
slatternly habits and wretched makeshifts of homes where even bundles of
kindling wood are luxuries to be anxiously economized.




THE SUCCESSFUL DOCTOR

The doctor whose success blinds public opinion to medical poverty is
almost as completely demoralized. His promotion means that his practice
becomes more and more confined to the idle rich. The proper advice for
most of their ailments is typified in Abernethy's "Live on sixpence a
day and earn it." But here, as at the other end of the scale, the right
advice is neither agreeable nor practicable. And every hypochondriacal
rich lady or gentleman who can be persuaded that he or she is a lifelong
invalid means anything from fifty to five hundred pounds a year for the
doctor. Operations enable a surgeon to earn similar sums in a couple
of hours; and if the surgeon also keeps a nursing home, he may make
considerable profits at the same time by running what is the most
expensive kind of hotel. These gains are so great that they undo much
of the moral advantage which the absence of grinding pecuniary anxiety
gives the rich doctor over the poor one. It is true that the temptation
to prescribe a sham treatment because the real treatment is too dear for
either patient or doctor does not exist for the rich doctor. He always
has plenty of genuine cases which can afford genuine treatment; and
these provide him with enough sincere scientific professional work to
save him from the ignorance, obsolescence, and atrophy of scientific
conscience into which his poorer colleagues sink. But on the other hand
his expenses are enormous. Even as a bachelor, he must, at London west
end rates, make over a thousand a year before he can afford even to
insure his life. His house, his servants, and his equipage (or autopage)
must be on the scale to which his patients are accustomed, though a
couple of rooms with a camp bed in one of them might satisfy his own
requirements. Above all, the income which provides for these outgoings
stops the moment he himself stops working. Unlike the man of business,
whose managers, clerks, warehousemen and laborers keep his business
going whilst he is in bed or in his club, the doctor cannot earn a
farthing by deputy. Though he is exceptionally exposed to infection, and
has to face all weathers at all hours of the night and day, often not
enjoying a complete night's rest for a week, the money stops coming in
the moment he stops going out; and therefore illness has special terrors
for him, and success no certain permanence. He dare not stop making
hay while the sun shines; for it may set at any time. Men do not resist
pressure of this intensity. When they come under it as doctors they pay
unnecessary visits; they write prescriptions that are as absurd as the
rub of chalk with which an Irish tailor once charmed away a wart from my
father's finger; they conspire with surgeons to promote operations; they
nurse the delusions of the malade imaginaire (who is always really ill
because, as there is no such thing as perfect health, nobody is ever
really well); they exploit human folly, vanity, and fear of death as
ruthlessly as their own health, strength, and patience are exploited
by selfish hypochondriacs. They must do all these things or else
run pecuniary risks that no man can fairly be asked to run. And the
healthier the world becomes, the more they are compelled to live by
imposture and the less by that really helpful activity of which all
doctors get enough to preserve them from utter corruption. For even the
most hardened humbug who ever prescribed ether tonics to ladies whose
need for tonics is of precisely the same character as the need of poorer
women for a glass of gin, has to help a mother through child-bearing
often enough to feel that he is not living wholly in vain.




THE PSYCHOLOGY OF SELF-RESPECT IN SURGEONS

The surgeon, though often more unscrupulous than the general
practitioner, retains his self-respect more easily. The human conscience
can subsist on very questionable food. No man who is occupied in doing
a very difficult thing, and doing it very well, ever loses his
self-respect. The shirk, the duffer, the malingerer, the coward, the
weakling, may be put out of countenance by his own failures and frauds;
but the man who does evil skilfully, energetically, masterfully, grows
prouder and bolder at every crime. The common man may have to found his
self-respect on sobriety, honesty and industry; but a Napoleon needs no
such props for his sense of dignity. If Nelson's conscience whispered to
him at all in the silent watches of the night, you may depend on it it
whispered about the Baltic and the Nile and Cape St. Vincent, and not
about his unfaithfulness to his wife. A man who robs little children
when no one is looking can hardly have much self-respect or even
self-esteem; but an accomplished burglar must be proud of himself. In
the play to which I am at present preluding I have represented an artist
who is so entirely satisfied with his artistic conscience, even to the
point of dying like a saint with its support, that he is utterly selfish
and unscrupulous in every other relation without feeling at the smallest
disadvantage. The same thing may be observed in women who have a genius
for personal attractiveness: they expend more thought, labor, skill,
inventiveness, taste and endurance on making themselves lovely than
would suffice to keep a dozen ugly women honest; and this enables them
to maintain a high opinion of themselves, and an angry contempt for
unattractive and personally careless women, whilst they lie and cheat
and slander and sell themselves without a blush. The truth is, hardly
any of us have ethical energy enough for more than one really inflexible
point of honor. Andrea del Sarto, like Louis Dubedat in my play, must
have expended on the attainment of his great mastery of design and his
originality in fresco painting more conscientiousness and industry
than go to the making of the reputations of a dozen ordinary mayors and
churchwardens; but (if Vasari is to be believed) when the King of France
entrusted him with money to buy pictures for him, he stole it to
spend on his wife. Such cases are not confined to eminent artists.
Unsuccessful, unskilful men are often much more scrupulous than
successful ones. In the ranks of ordinary skilled labor many men are to
be found who earn good wages and are never out of a job because they are
strong, indefatigable, and skilful, and who therefore are bold in a high
opinion of themselves; but they are selfish and tyrannical, gluttonous
and drunken, as their wives and children know to their cost.

Not only do these talented energetic people retain their self-respect
through shameful misconduct: they do not even lose the respect of
others, because their talents benefit and interest everybody, whilst
their vices affect only a few. An actor, a painter, a composer, an
author, may be as selfish as he likes without reproach from the public
if only his art is superb; and he cannot fulfil his condition without
sufficient effort and sacrifice to make him feel noble and martyred in
spite of his selfishness. It may even happen that the selfishness of
an artist may be a benefit to the public by enabling him to concentrate
himself on their gratification with a recklessness of every other
consideration that makes him highly dangerous to those about him. In
sacrificing others to himself he is sacrificing them to the public he
gratifies; and the public is quite content with that arrangement. The
public actually has an interest in the artist's vices.

It has no such interest in the surgeon's vices. The surgeon's art is
exercised at its expense, not for its gratification. We do not go to the
operating table as we go to the theatre, to the picture gallery, to the
concert room, to be entertained and delighted: we go to be tormented and
maimed, lest a worse thing should befall us. It is of the most extreme
importance to us that the experts on whose assurance we face this horror
and suffer this mutilation should leave no interests but our own to
think of; should judge our cases scientifically; and should feel about
them kindly. Let us see what guarantees we have: first for the science,
and then for the kindness.




ARE DOCTORS MEN OF SCIENCE?

I presume nobody will question the existence of widely spread popular
delusion that every doctor is a titan of science. It is escaped only in
the very small class which understands by science something more than
conjuring with retorts and spirit lamps, magnets and microscopes, and
discovering magical cures for disease. To a sufficiently ignorant man
every captain of a trading schooner is a Galileo, every organ-grinder
a Beethoven, every piano-tuner a Hemholtz, every Old Bailey barrister
a Solon, every Seven Dials pigeon dealer a Darwin, every scrivener a
Shakespear, every locomotive engine a miracle, and its driver no less
wonderful than George Stephenson. As a matter of fact, the rank and file
of doctors are no more scientific than their tailors; or, if you prefer
to put it the reverse way, their tailors are no less scientific than
they. Doctoring is an art, not a science: any layman who is interested
in science sufficiently to take in one of the scientific journals and
follow the literature of the scientific movement, knows more about it
than those doctors (probably a large majority) who are not interested in
it, and practise only to earn their bread. Doctoring is not even the art
of keeping people in health (no doctor seems able to advise you what to
eat any better than his grandmother or the nearest quack): it is the
art of curing illnesses. It does happen exceptionally that a practising
doctor makes a contribution to science (my play describes a very notable
one); but it happens much oftener that he draws disastrous conclusions
from his clinical experience because he has no conception of scientific
method, and believes, like any rustic, that the handling of evidence and
statistics needs no expertness. The distinction between a quack doctor
and a qualified one is mainly that only the qualified one is authorized
to sign death certificates, for which both sorts seem to have about
equal occasion. Unqualified practitioners now make large incomes as
hygienists, and are resorted to as frequently by cultivated amateur
scientists who understand quite well what they are doing as by ignorant
people who are simply dupes. Bone-setters make fortunes under the very
noses of our greatest surgeons from educated and wealthy patients; and
some of the most successful doctors on the register use quite heretical
methods of treating disease, and have qualified themselves solely for
convenience. Leaving out of account the village witches who prescribe
spells and sell charms, the humblest professional healers in this
country are the herbalists. These men wander through the fields on
Sunday seeking for herbs with magic properties of curing disease,
preventing childbirth, and the like. Each of them believes that he is on
the verge of a great discovery, in which Virginia Snake Root will be
an ingredient, heaven knows why! Virginia Snake Root fascinates
the imagination of the herbalist as mercury used to fascinate the
alchemists. On week days he keeps a shop in which he sells packets of
pennyroyal, dandelion, etc., labelled with little lists of the diseases
they are supposed to cure, and apparently do cure to the satisfaction of
the people who keep on buying them. I have never been able to perceive
any distinction between the science of the herbalist and that of the
duly registered doctor. A relative of mine recently consulted a doctor
about some of the ordinary symptoms which indicate the need for a
holiday and a change. The doctor satisfied himself that the patient's
heart was a little depressed. Digitalis being a drug labelled as a
heart specific by the profession, he promptly administered a stiff dose.
Fortunately the patient was a hardy old lady who was not easily killed.
She recovered with no worse result than her conversion to Christian
Science, which owes its vogue quite as much to public despair of doctors
as to superstition. I am not, observe, here concerned with the question
as to whether the dose of digitalis was judicious or not; the point is,
that a farm laborer consulting a herbalist would have been treated in
exactly the same way.




BACTERIOLOGY AS A SUPERSTITION

The smattering of science that all - even doctors - pick up from the
ordinary newspapers nowadays only makes the doctor more dangerous than
he used to be. Wise men used to take care to consult doctors qualified
before 1860, who were usually contemptuous of or indifferent to the germ
theory and bacteriological therapeutics; but now that these veterans
have mostly retired or died, we are left in the hands of the generations
which, having heard of microbes much as St. Thomas Aquinas heard of
angels, suddenly concluded that the whole art of healing could be summed
up in the formula: Find the microbe and kill it. And even that they did
not know how to do. The simplest way to kill most microbes is to throw
them into an open street or river and let the sun shine on them, which
explains the fact that when great cities have recklessly thrown all
their sewage into the open river the water has sometimes been cleaner
twenty miles below the city than thirty miles above it. But doctors
instinctively avoid all facts that are reassuring, and eagerly swallow
those that make it a marvel that anyone could possibly survive three
days in an atmosphere consisting mainly of countless pathogenic
germs. They conceive microbes as immortal until slain by a germicide
administered by a duly qualified medical man. All through Europe people
are adjured, by public notices and even under legal penalties, not to
throw their microbes into the sunshine, but to collect them carefully in
a handkerchief; shield the handkerchief from the sun in the darkness
and warmth of the pocket; and send it to a laundry to be mixed up with
everybody else's handkerchiefs, with results only too familiar to local
health authorities.

In the first frenzy of microbe killing, surgical instruments were dipped
in carbolic oil, which was a great improvement on not dipping them in
anything at all and simply using them dirty; but as microbes are so fond
of carbolic oil that they swarm in it, it was not a success from the
anti-microbe point of view. Formalin was squirted into the circulation
of consumptives until it was discovered that formalin nourishes the
tubercle bacillus handsomely and kills men. The popular theory of
disease is the common medical theory: namely, that every disease had
its microbe duly created in the garden of Eden, and has been steadily
propagating itself and producing widening circles of malignant disease
ever since. It was plain from the first that if this had been even
approximately true, the whole human race would have been wiped out by
the plague long ago, and that every epidemic, instead of fading out as
mysteriously as it rushed in, would spread over the whole world. It was
also evident that the characteristic microbe of a disease might be a
symptom instead of a cause. An unpunctual man is always in a hurry;
but it does not follow that hurry is the cause of unpunctuality: on the
contrary, what is the matter with the patient is sloth. When Florence
Nightingale said bluntly that if you overcrowded your soldiers in dirty
quarters there would be an outbreak of smallpox among them, she was
snubbed as an ignorant female who did not know that smallpox can be
produced only by the importation of its specific microbe.

If this was the line taken about smallpox, the microbe of which
has never yet been run down and exposed under the microscope by the
bacteriologist, what must have been the ardor of conviction as to
tuberculosis, tetanus, enteric fever, Maltese fever, diphtheria, and
the rest of the diseases in which the characteristic bacillus had been
identified! When there was no bacillus it was assumed that, since
no disease could exist without a bacillus, it was simply eluding
observation. When the bacillus was found, as it frequently was, in
persons who were not suffering from the disease, the theory was saved
by simply calling the bacillus an impostor, or pseudobacillus. The same
boundless credulity which the public exhibit as to a doctor's power of
diagnosis was shown by the doctors themselves as to the analytic
microbe hunters. These witch finders would give you a certificate of the
ultimate constitution of anything from a sample of the water from your
well to a scrap of your lungs, for seven-and-sixpense. I do not suggest
that the analysts were dishonest. No doubt they carried the analysis as
far as they could afford to carry it for the money. No doubt also they
could afford to carry it far enough to be of some use. But the fact
remains that just as doctors perform for half-a-crown, without the least
misgiving, operations which could not be thoroughly and safely performed
with due scientific rigor and the requisite apparatus by an unaided
private practitioner for less than some thousands of pounds, so did they
proceed on the assumption that they could get the last word of science
as to the constituents of their pathological samples for a two hours cab
fare.




ECONOMIC DIFFICULTIES OF IMMUNIZATION

I have heard doctors affirm and deny almost every possible proposition
as to disease and treatment. I can remember the time when doctors no
more dreamt of consumption and pneumonia being infectious than they
now dream of sea-sickness being infectious, or than so great a clinical
observer as Sydenham dreamt of smallpox being infectious. I have heard
doctors deny that there is such a thing as infection. I have heard them
deny the existence of hydrophobia as a specific disease differing from
tetanus. I have heard them defend prophylactic measures and prophylactic
legislation as the sole and certain salvation of mankind from zymotic
disease; and I have heard them denounce both as malignant spreaders
of cancer and lunacy. But the one objection I have never heard from a
doctor is the objection that prophylaxis by the inoculatory methods most
in vogue is an economic impossibility under our private practice
system. They buy some stuff from somebody for a shilling, and inject a
pennyworth of it under their patient's skin for half-a-crown, concluding
that, since this primitive rite pays the somebody and pays them, the
problem of prophylaxis has been satisfactorily solved. The results are
sometimes no worse than the ordinary results of dirt getting into cuts;
but neither the doctor nor the patient is quite satisfied unless the
inoculation "takes"; that is, unless it produces perceptible illness and
disablement. Sometimes both doctor and patient get more value in
this direction than they bargain for. The results of ordinary
private-practice-inoculation at their worst are bad enough to be
indistinguishable from those of the most discreditable and dreaded
disease known; and doctors, to save the credit of the inoculation, have
been driven to accuse their patient or their patient's parents of having
contracted this disease independently of the inoculation, an excuse
which naturally does not make the family any more resigned, and leads
to public recriminations in which the doctors, forgetting everything but
the immediate quarrel, naively excuse themselves by admitting, and
even claiming as a point in their favor, that it is often impossible to
distinguish the disease produced by their inoculation and the disease
they have accused the patient of contracting. And both parties assume
that what is at issue is the scientific soundness of the prophylaxis.
It never occurs to them that the particular pathogenic germ which they
intended to introduce into the patient's system may be quite innocent of
the catastrophe, and that the casual dirt introduced with it may be at
fault. When, as in the case of smallpox or cowpox, the germ has not yet
been detected, what you inoculate is simply undefined matter that has
been scraped off an anything but chemically clean calf suffering from
the disease in question. You take your chance of the germ being in the
scrapings, and, lest you should kill it, you take no precautions against
other germs being in it as well. Anything may happen as the result of
such an inoculation. Yet this is the only stuff of the kind which is
prepared and supplied even in State establishments: that is, in the
only establishments free from the commercial temptation to adulterate
materials and scamp precautionary processes.

Even if the germ were identified, complete precautions would hardly pay.
It is true that microbe farming is not expensive. The cost of breeding
and housing two head of cattle would provide for the breeding and
housing of enough microbes to inoculate the entire population of
the globe since human life first appeared on it. But the precautions
necessary to insure that the inoculation shall consist of nothing else
but the required germ in the proper state of attenuation are a very
different matter from the precautions necessary in the distribution
and consumption of beefsteaks. Yet people expect to find vaccines
and antitoxins and the like retailed at "popular prices" in private
enterprise shops just as they expect to find ounces of tobacco and
papers of pins.




THE PERILS OF INOCULATION

The trouble does not end with the matter to be inoculated. There is the


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Online LibraryGeorge Bernard ShawThe Doctor's Dilemma: Preface on Doctors → online text (page 2 of 7)