Текст книги "Pygmalion and Three Other Plays"

Автор книги: George Bernard Shaw

Соавторы: John A. Bertolini
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MEDICAL ORGANIZATION

Another advantage of public medical work is that it admits of organization, and consequently of the distribution of the work in such a manner as to avoid wasting the time of highly qualified experts on trivial jobs. The individualism of private practice leads to an appalling waste of time on trifles. Men whose dexterity as operators or almost divinatory skill in diagnosis are constantly needed for difficult cases, are poulticing whitlows,[131]131
  Infections of the finger or toe.


[Закрыть] vaccinating, changing unimportant dressings, prescribing ether drams for ladies with timid leanings towards dipsomania, and generally wasting their time in the pursuit of private fees. In no other profession is the practitioner expected to do all the work involved in it from the first day of his professional career to the last as the doctor is. The judge passes sentence of death; but he is not expected to hang the criminal with his own hands, as he would be if the legal profession were as unorganized as the medical. The bishop is not expected to blow the organ or wash the baby he baptizes. The general is not asked to plan a campaign or conduct a battle at half-past twelve and to play the drum at half-past two. Even if they were, things would still not be as bad as in the medical profession; for in it not only is the first-class man set to do third-class work, but, what is much more terrifying, the third-class man is expected to do first-class work. Every general practitioner is supposed to be capable of the whole range of medical and surgical work at a moment’s notice; and the country doctor, who has not a specialist nor a crack consultant at the end of his telephone, often has to tackle without hesitation cases which no sane practitioner in a town would take in hand without assistance. No doubt this develops the resourcefulness of the country doctor, and makes him a more capable man than his suburban colleague; but it cannot develop the second-class man into a first-class one. If the practice of law not only led to a judge having to hang, but the hangman to judge, or if in the army matters were so arranged that it would be possible for the drummer boy to be in command at Waterloo whilst the Duke of Wellington was playing the drum in Brussels, we should not be consoled by the reflection that our hangmen were thereby made a little more judicial-minded, and our drummers more responsible, than in foreign countries where the legal and military professions recognized the advantages of division of labor.

Under such conditions no statistics as to the graduation of professional ability among doctors are available. Assuming that doctors are normal men and not magicians (and it is unfortunately very hard to persuade people to admit so much and thereby destroy the romance of doctoring) we may guess that the medical profession, like the other professions, consists of a small percentage of highly gifted persons at one end, and a small percentage of altogether disastrous duffers at the other. Between these extremes comes the main body of doctors (also, of course, with a weak and a strong end) who can be trusted to work under regulations with more or less aid from above according to the gravity of the case. Or, to put it in terms of the cases, there are cases that present no difficulties, and can be dealt with by a nurse or student at one end of the scale, and cases that require watching and handling by the very highest existing skill at the other; whilst between come the great mass of cases which need visits from the doctor of ordinary ability and from the chiefs of the profession in the proportion of, say, seven to none, seven to one, three to one, one to one, or, for a day or two, none to one. Such a service is organized at present only in hospitals; though in large towns the practice of calling in the consultant acts, to some extent, as a substitute for it. But in the latter case it is quite unregulated except by professional etiquet, which, as we have seen, has for its object, not the health of the patient or of the community at large, but the protection of the doctor’s livelihood and the concealment of his errors. And as the consultant is an expensive luxury, he is a last resource rather, as he should be, than a matter of course, in all cases where the general practitioner is not equal to the occasion: a predicament in which a very capable man may find himself at any time through the cropping up of a case of which he has had no clinical experience.

THE SOCIAL SOLUTION OF THE MEDICAL PROBLEM

The social solution of the medical problem, then, depends on that large, slowly advancing, pettishly resisted integration of society called generally Socialism. Until the medical profession becomes a body of men trained and paid by the country to keep the country in health it will remain what it is at present: a conspiracy to exploit popular credulity and human suffering. Already our M.O.H.s (Medical Officers of Health) are in the new position: what is lacking is appreciation of the change, not only by the public but by the private doctors. For, as we have seen, when one of the first-rate posts becomes vacant in one of the great cities, and all the leading M.O.H.s compete for it, they must appeal to the good health of the cities of which they have been in charge, and not to the size of the incomes the local private doctors are making out of the ill-health of their patients. If a competitor can prove that he has utterly ruined every sort of medical private practice in a large city except obstetric practice and the surgery of accidents, his claims are irresistible; and this is the ideal at which every M.O.H. should aim. But the profession at large should none the less welcome him and set its house in order for the social change which will finally be its own salvation. For the M.O.H. as we know him is only the beginning of that army of Public Hygiene which will presently take the place in general interest and honor now occupied by our military and naval forces. It is silly that an Englishman should be more afraid of a German soldier than of a British disease germ, and should clamor for more barracks in the same newspapers that protest against more school clinics, and cry out that if the State fights disease for us it makes us paupers, though they never say that if the State fights the Germans for us it makes us cowards. Fortunately, when a habit of thought is silly it only needs steady treatment by ridicule from sensible and witty people to be put out of countenance and perish. Every year sees an increase in the number of persons employed in the Public Health Service, who would formerly have been mere adventurers in the Private Illness Service. To put it another way, a host of men and women who have now a strong incentive to be mischievous and even murderous rogues will have a much stronger, because a much honester, incentive to be not only good citizens but active benefactors to the community. And they will have no anxiety whatever about their incomes.

THE FUTURE OF PRIVATE PRACTICE

It must not be hastily concluded that this involves the extinction of the private practitioner. What it will really mean for him is release from his present degrading and scientifically corrupting slavery to his patients. As I have already shewn, the doctor who has to live by pleasing his patients in competition with everybody who has walked the hospitals, scraped through the examinations, and bought a brass plate, soon finds himself prescribing water to teetotallers and brandy or champagne jelly to drunkards; beefsteaks and stout in one house, and “uric acid free” vegetarian diet over the way; shut windows, big fires, and heavy overcoats to old Colonels, and open air and as much nakedness as is compatible with decency to young faddists, never once daring to say either “I dont know,” or “I dont agree.” For the strength of the doctor‘s, as of every other man’s position when the evolution of social organization at last reaches his profession, will be that he will always have open to him the alternative of public employment when the private employer becomes too tyrannous. And let no one suppose that the words doctor and patient can disguise from the parties the fact that they are employer and employee. No doubt doctors who are in great demand can be as high-handed and independent as employees are in all classes when a dearth in their labor market makes them indispensable; but the average doctor is not in this position: he is struggling for life in an overcrowded profession, and knows well that “a good bedside manner” will carry him to solvency through a morass of illness, whilst the least attempt at plain dealing with people who are eating too much, or drinking too much, or frowsting[132]132
  Staying in musty rooms.


[Закрыть] too much (to go no further in the list of in temperances that make up so much of family life) would soon land him in the Bankruptcy Court.

Private practice, thus protected, would itself protect individuals, as far as such protection is possible, against the errors and superstitions of State medicine, which are at worst no worse than the errors and superstitions of private practice, being, indeed, all derived from it. Such monstrosities as vaccination are, as we have seen, founded, not on science, but on half-crowns. If the Vaccination Acts, instead of being wholly repealed as they are already half repealed, were strengthened by compelling every parent to have his child vaccinated by a public officer whose salary was completely independent of the number of vaccinations performed by him, and for whom there was plenty of alternative public health work waiting, vaccination would be dead in two years, as the vaccinator would not only not gain by it, but would lose credit through the depressing effects on the vital statistics of his district of the illness and deaths it causes, whilst it would take from him all the credit of that freedom from smallpox which is the result of good sanitary administration and vigilant prevention of infection. Such absurd panic scandals as that of the last London epidemic, where a fee of half-a-crown per re-vaccination produced raids on houses during the absence of parents, and the forcible seizure and re-vaccination of children left to answer the door, can be prevented simply by abolishing the half-crown and all similar follies, paying, not for this or that ceremony of witchcraft, but for immunity from disease, and paying, too, in a rational way. The officer with a fixed salary saves himself trouble by doing his business with the least possible interference with the private citizen. The man paid by the job loses money by not forcing his job on the public as often as possible without reference to its results.

THE TECHNICAL PROBLEM

As to any technical medical problem specially involved, there is none. If there were, I should not be competent to deal with it, as I am not a technical expert in medicine: I deal with the subject as an economist, a politician, and a citizen exercising my common sense. Everything that I have said applies equally to all the medical techniques, and will hold good whether public hygiene be based on the poetic fancies of Christian Science, the tribal superstitions of the druggist and the vivisector, or the best we can make of our real knowledge. But I may remind those who confusedly imagine that the medical problem is also the scientific problem, that all problems are finally scientific problems. The notion that therapeutics or hygiene or surgery is any more or less scientific than making or cleaning boots is entertained only by people to whom a man of science is still a magician who can cure diseases, transmute metals, and enable us to live for ever. It may still be necessary for some time to come to practise on popular credulity, popular love and dread of the marvellous, and popular idolatry, to induce the poor to comply with the sanitary regulations they are too ignorant to understand. As I have elsewhere confessed, I have myself been responsible for ridiculous incantations with burning sulphur, experimentally proved to be quite useless, because poor people are convinced, by the mystical air of the burning and the horrible smell, that it exorcises the demons of smallpox and scarlet fever and makes it safe for them to return to their houses. To assure them that the real secret is sunshine and soap is only to convince them that you do not care whether they live or die, and wish to save money at their expense. So you perform the incantation; and back they go to their houses, satisfied. A religious ceremony – a poetic blessing of the threshold, for instance – would be much better; but unfortunately our religion is weak on the sanitary side. One of the worst misfortunes of Christendom was that reaction against the voluptuous bathing of the imperial Romans which made dirty habits a part of Christian piety, and in some unlucky places (the Sandwich Islands[133]133
  Former name of Hawaii.


[Закрыть] for example) made the introduction of Christianity also the introduction of disease, because the formulators of the superseded native religion, like Mahomet, had been enlightened enough to introduce as religious duties such sanitary measures as ablution and the most careful and reverent treatment of everything cast off by the human body, even to nail clippings and hairs; and our missionaries thoughtlessly discredited this godly doctrine without supplying its place, which was promptly taken by laziness and neglect. If the priests of Ireland could only be persuaded to teach their flocks that it is a deadly insult to the Blessed Virgin to place her image in a cottage that is not kept up to that high standard of Sunday cleanliness to which all her worshippers must believe she is accustomed, and to represent her as being especially particular about stables because her son was born in one, they might do more in one year than all the Sanitary Inspectors in Ireland could do in twenty; and they could hardly doubt that Our Lady would be delighted. Perhaps they do nowadays; for Ireland is certainly a transfigured country since my youth as far as clean faces and pinafores can transfigure it. In England, where so many of the inhabitants are too gross to believe in poetic faiths, too respectable to tolerate the notion that the stable at Bethany was a common peasant farmer’s stable instead of a first-rate racing one, and too savage to believe that anything can really cast out the devil of disease unless it be some terrifying hoodoo[134]134
  Superstitious practice using magic and spells.


[Закрыть] of tortures and stinks, the M.O.H. will no doubt for a long time to come have to preach to fools according to their folly, promising miracles, and threatening hideous personal consequences of neglect of by-laws and the like; therefore it will be important that every M.O.H. shall have, with his (or her) other qualifications, a sense of humor, lest (he or she) should come at last to believe all the nonsense that must needs be talked. But he must, in his capacity of an expert advising the authorities, keep the government itself free of superstition. If Italian peasants are so ignorant that the Church can get no hold of them except by miracles, why miracles there must be. The blood of St. januarius[135]135
  Martyr (272? – 205) during the reign of Roman emperor Diocletian; in Naples, a phial thought to contain his dried blood is said to liquefy each year.


[Закрыть] must liquefy whether the Saint is in the humor or not. To trick a heathen into being a dutiful Christian is no worse than to trick a whitewasher into trusting himself in a room where a smallpox patient has lain, by pretending to exorcise the disease with burning sulphur. But woe to the Church if in deceiving the peasant it also deceives itself; for then the Church is lost, and the peasant too, unless he revolt against it. Unless the Church works the pretended miracle painfully against the grain, and is continually urged by its dislike of the imposture to strive to make the peasant susceptible to the true reasons for behaving well, the Church will become an instrument of his corruption and an exploiter of his ignorance, and will find itself launched upon that persecution of scientific truth of which all priesthoods are accused – and none with more justice than the scientific priesthood.

And here we come to the danger that terrifies so many of us: the danger of having a hygienic orthodoxy imposed on us. But we must face that: in such crowded and poverty ridden civilizations as ours any orthodoxy is better than laisser-faire. If our population ever comes to consist exclusively of well-to-do, highly cultivated, and thoroughly instructed free persons in a position to take care of themselves, no doubt they will make short work of a good deal of official regulation that is now of life-and-death necessity to us; but under existing circumstances, I repeat, almost any sort of attention that democracy will stand is better than neglect. Attention and activity lead to mistakes as well as to successes; but a life spent in making mistakes is not only more honorable but more useful than a life spent doing nothing. The one lesson that comes out of all our theorizing and experimenting is that there is only one really scientific progressive method; and that is the method of trial and error. If you come to that, what is laisser-faire but an orthodoxy ? the most tyrannous and disastrous of all the orthodoxies, since it forbids you even to learn.

THE LATEST THEORIES

Medical theories are so much a matter of fashion, and the most fertile of them are modified so rapidly by medical practice and biological research, which are international activities, that the play which furnishes the pretext for this preface is already slightly outmoded, though I believe it may be taken as a faithful record for the year (1906) in which it was begun. I must not expose any professional man to ruin by connecting his name with the entire freedom of criticism which I, as a layman, enjoy; but it will be evident to all experts that my play could not have been written but for the work done by Sir Almroth Wright in the theory and practice of securing immunization from bacterial diseases by the inoculation of “vaccines” made of their own bacteria: a practice incorrectly called vaccinetherapy (there is nothing vaccine about it) apparently because it is what vaccination ought to be and is not. Until Sir Almroth Wright, following up one of Metchnikoff‘s[136]136
  The writings of Russian biologist Ilya Metchnikoff ( 1845-I 9 16) include Immunity in Infectious Diseases (1905) and The Nature of Man (1903).


[Закрыть] most suggestive biological romances, discovered that the white corpuscles or phagocytes which attack and devour disease germs for us do their work only when we butter the disease germs appetizingly for them with a natural sauce which Sir Almroth named opsonin, and that our production of this condiment continually rises and falls rhythmically from negligibility to the highest efficiency, nobody had been able even to conjecture why the various serums that were from time to time introduced as having effected marvellous cures, presently made such direful havoc of some unfortunate patient that they had to be dropped hastily. The quantity of sturdy lying that was necessary to save the credit of inoculation in those days was prodigious; and had it not been for the devotion shewn by the military authorities throughout Europe, who would order the entire disappearance of some disease from their armies, and bring it about by the simple plan of changing the name under which the cases were reported, or for our own Metropolitan Asy lums Board,[137]137
  London public-health board established in I867 that operated, among other things, specialist hospitals for infectious diseases and tuberculosis.


[Закрыть] which carefully suppressed all the medical reports that revealed the sometimes quite appalling effects of epidemics of revaccination, there is no saying what popular reaction might not have taken place against the whole immunization movement in therapeutics.

The situation was saved when Sir Almroth Wright pointed out that if you inoculated a patient with pathogenic germs at a moment when his powers of cooking them for consumption by the phagocytes was receding to its lowest point, you would certainly make him a good deal worse and perhaps kill him, whereas if you made precisely the same inoculation when the cooking power was rising to one of its periodical climaxes, you would stimulate it to still further exertions and produce just the opposite result. And he invented a technique for ascertaining in which phase the patient happened to be at any given moment. The dramatic possibilities of this discovery and invention will be found in my play. But it is one thing to invent a technique: it is quite another to persuade the medical profession to acquire it. Our general practitioners, I gather, simply declined to acquire it, being mostly unable to afford either the acquisition or the practice of it when acquired. Something simple, cheap, and ready at all times for all corners, is, as I have shewn, the only thing that is economically possible in general practice, whatever may be the case in Sir Almroth’s famous laboratory in St. Mary’s Hospital. It would have become necessary to denounce opsonin in the trade papers as a fad and Sir Almroth as a dangerous man if his practice in the laboratory had not led him to the conclusion that the customary inoculations were very much too powerful, and that a comparatively infinitesimal dose would not precipitate a negative phase of cooking activity, and might induce duce a positive one. And thus it happens that the refusal of our general practitioners to acquire the new technique is no longer quite so dangerous in practice as it was when The Doctor’s Dilemma was written: nay, that Sir Ralph Bloomfield Bonington’s way of administering inoculations as if they were spoonfuls of squills[138]138
  Medicinal syrup derived from the squill plant, a bulbous herb.


[Закрыть] may sometimes work fairly well. For all that, I find Sir Almroth Wright, on the 23rd May, 1900, warning the Royal Society of Medicine that “the clinician has not yet been prevailed upon, to reconsider his positon,” which means that the general practitioner (“the doctor,” as he is called in our homes) is going on just as he did before, and could not afford to learn or practice a new technique even if he had ever heard of it. To the patient who does not know about it he will say nothing. To the patient who does, he will ridicule it, and disparage Sir Almroth. What else can he do, except confess his ignorance and starve?

But now please observe how “the whirligig of time brings its revenges.”[139]139
  hus Feste gloats over Malvolio’s humiliation in Shakespeare’s Twelfth Night (act 5,cene I ) .


[Закрыть] This latest discovery of the remedial virtue of a very, very tiny hair of the dog that bit you reminds us, not only of Arndt’s law of protoplasmic reaction to stimuli, according to which weak and strong stimuli provoke opposite reactions, but of Hahnemann’s homeopathy, which was founded on the fact alleged by Hahnemann that drugs which produce certain symptoms when taken in ordinary perceptible quantities, will, when taken in infinitesimally small quantities, provoke just the opposite symptoms ; so that the drug that gives you a headache will also cure a headache if you take little enough of it. I have already explained that the savage opposition which homeopathy encountered from the medical profession was not a scientific opposition; for nobody seems to deny that some drugs act in the alleged manner. It was opposed simply because doctors and apothecaries lived by selling bottles and boxes of doctor’s stuff to be taken in spoonfuls or in pellets as large as peas; and people would not pay as much for drops and globules no bigger than pins’ heads. Nowadays, however, the more cultivated folk are beginning to be so suspicious of drugs, and the incorrigibly superstitious people so profusely supplied with patent medicines (the medical advice to take them being wrapped round the bottle and thrown in for nothing) that homeopathy has become a way of rehabilitating the trade of prescription compounding, and is consequently coming into professional credit. At which point the theory of opsonins comes very opportunely to shake hands with it.

Add to the newly triumphant homeopathist and the opsonist that other remarkable innovator, the Swedish masseur, who does not theorize about you, but probes you all over with his powerful thumbs until he finds out your sore spots and rubs them away, besides cheating you into a little wholesome exercise; and you have nearly everything in medical practice to-day that is not flat witchcraft or pure commercial exploitation of human credulity and fear of death. Add to them a good deal of vegetarian and teetotal controversy raging round a clamor for scientific eating and drinking, and resulting in little so far except calling digestion Metabolism and dividing the public between the eminent doctor who tells us that we do not eat enough fish, and his equally eminent colleague who warns us that a fish diet must end in leprosy, and you have all that opposes with any sort of countenance the rise of Christian Science with its cathedrals and congregations and zealots and miracles and cures: all very silly, no doubt, but sane and sensible, poetic and hopeful, compared to the pseudo science of the commercial general practitioner, who foolishly clamors for the prosecution and even the execution of the Christian Scientists when their patients die, forgetting the long death roll of his own patients.

By the time this preface is in print the kaleidoscope may have had another shake; and opsonin may have gone the way of phlogiston[140]140
  Hypothetical substance thought to be released through burning, a theory disproved by French chemist Antoine Lavoisier (1743– 1794).


[Закрыть]at the hands of its own restless discoverer. I will not say that Hahnemann may have gone the way of Diafoirus;[141]141
  In Moliere’s play The Imaginary Invalid (1673) a doctor who disdains such new fangled theories as circulation of the blood.


[Закрыть] for Di afoirus we have always with us. But we shall still pick up all our knowledge in pursuit of some Will o’ the Wisp or other. What is called science has always pursued the Elixir of Life and the Philosopher’s Stone, and is just as busy after them to-day as ever it was in the days of Paracelsus.[142]142
  Sixteenth-century German alchemist and physician.


[Закрыть] We call them by different names: Immunization or Radiology or what not; but the dreams which lure us into the adventures from which we learn are always at bottom the same. Science becomes dangerous only when it imagines that it has reached its goal. What is wrong with priests and popes is that instead of being apostles and saints, they are nothing but empirics who say “I know” instead of “I am learning,” and pray for credulity and inertia as wise men pray for scepticism and activity. Such abominations as the Inquisition and the Vaccination Acts are possible only in the famine years of the soul, when the great vital dogmas of honor, liberty, courage, the kinship of all life, faith that the unknown is greater than the known and is only the As Yet Unknown, and resolution to find a manly highway to it, have been forgotten in a paroxysm of littleness and terror in which nothing is active except concupiscence and the fear of death, playing on which any trader can filch a fortune, any blackguard gratify his cruelty, and any tyrant make us his slaves.

Lest this should seem too rhetorical a conclusion for our professional men of science, who are mostly trained not to believe anything unless it is worded in the jargon of those writers who, because they never really understand what they are trying to say, cannot find familiar words for it, and are therefore compelled to invent a new language of nonsense for every book they write, let me sum up my conclusions as dryly as is consistent with accurate thought and live conviction.

1. Nothing is more dangerous than a poor doctor: not even a poor employer or a poor landlord.

2. Of all the anti-social vested interests the worst is the vested interest in ill-health.

3. . Remember that an illness is a misdemeanor; and treat the doctor as an accessory unless he notifies every case to the Public Health authority.

4. Treat every death as a possible and under our present system a probable murder, by making it the subject of a reasonably conducted inquest; and execute the doctor, if necessary, as a doctor, by striking him off the register.

5. Make up your mind how many doctors the community needs to keep it well. Do not register more or less than this number; and let registration constitute the doctor a civil servant with a dignified living wage paid out of public funds.

6. Municipalize Harley Street.

7. Treat the private operator exactly as you would treat a private executioner.

8. Treat persons who profess to be able to cure disease as you treat fortune tellers.

9. Keep the public carefully informed, by special statistics and announcements of individual cases, of all illnesses of doctors or in their families.

10. Make it compulsory for a doctor using a brass plate to have inscribed on it, in addition to the letters indicating his qualifications, the words “Remember that I too am mortal.”

11. In legislation and social organization, proceed on the principle that invalids, meaning persons who cannot keep themselves alive by their own activities, cannot, beyond reason, expect to be kept alive by the activity of others. There is a point at which the most energetic policeman or doctor, when called upon to deal with an apparently drowned person, gives up artificial respiration, although it is never possible to declare with certainty, at any point short of decomposition, that five minutes of the exercise would not effect resuscitation. The theory that every individual alive is of infinite value is legislatively impracticable. No doubt the higher the life we secure to the individual by wise social organization, the greater his value is to the community, and the more pains we shall take to pull him through any temporary danger or disablement. But the man who costs more than he is worth is doomed by sound hygiene as inexorably as by sound economics.

12. Do not try to live for ever. You will not succeed.

13. Use your health, even to the point of wearing it out. That is what it is for. Spend all you have before you die; and do not outlive yourself.

14. Take the utmost care to get well born and well brought up. This means that your mother must have a good doctor. Be careful to go to a school where there is what they call a school clinic, where your nutrition and teeth and eyesight and other matters of importance to you will be attended to. Be particularly careful to have all this done at the expense of the nation, as otherwise it will not be done at all, the chances being about forty to one against your being able to pay for it directly yourself, even if you know how to set about it. Otherwise you will be what most people are at present: an unsound citizen of an unsound nation, without sense enough to be ashamed or unhappy about it.