The Doctor’s Dilemma/The Latest Theories

Medical theories are so much a matter of fashion, and the most fertile of them are modified so rapidly by medical practice and biological research, which are international activities, that the play which furnishes the pretext for this preface is already slightly outmoded, though I believe it may be taken as a faithful record for the year (1906) in which it was begun. I must not expose any professional man to ruin by connecting his name with the entire freedom of criticism which I, as a layman, enjoy; but it will be evident to all experts that my play could not have been written but for the work done by Sir Almroth Wright in the theory and practice of securing immunization from bacterial diseases by the inoculation of "vaccines" made of their own bacteria: a practice incorrectly called vaccinetherapy (there is nothing vaccine about it) apparently because it is what vaccination ought to be and is not. Until Sir Almroth Wright, following up one of Metchnikoff's most suggestive biological romances, discovered that the white corpuscles or phagocytes which attack and devour disease germs for us do their work only when we butter the disease germs appetizingly for them with a natural sauce which Sir Almroth named opsonin, and that our production of this condiment continually rises and falls rhythmically from negligibility to the highest efficiency, nobody had been able even to conjecture why the various serums that were from time to time introduced as having effected marvellous cures, presently made such direful havoc of some unfortunate patient that they had to be dropped hastily. The quantity of sturdy lying that was necessary to save the credit of inoculation in those days was prodigious; and had it not been for the devotion shown by the military authorities throughout Europe, who would order the entire disappearance of some disease from their armies, and bring it about by the simple plan of changing the name under which the cases were reported, or for our own Metropolitan Asylums Board, which carefully suppressed all the medical reports that revealed the sometimes quite appalling effects of epidemics of revaccination, there is no saying what popular reaction might not have taken place against the whole immunization movement in therapeutics.

The situation was saved when Sir Almroth Wright pointed out that if you inoculated a patient with pathogenic germs at a moment when his powers of cooking them for consumption by the phagocytes was receding to its lowest point, you would certainly make him a good deal worse and perhaps kill him, whereas if you made precisely the same inoculation when the cooking power was rising to one of its periodical climaxes, you would stimulate it to still further exertions and produce just the opposite result. And he invented a technique for ascertaining in which phase the patient happened to be at any given moment. The dramatic possibilities of this discovery and invention will be found in my play. But it is one thing to invent a technique: it is quite another to persuade the medical profession to acquire it. Our general practitioners, I gather, simply declined to acquire it, being mostly unable to afford either the acquisition or the practice of it when acquired. Something simple, cheap, and ready at all times for all comers, is, as I have shown, the only thing that is economically possible in general practice, whatever may be the case in Sir Almroth's famous laboratory in St. Mary's Hospital. It would have become necessary to denounce opsonin in the trade papers as a fad and Sir Almroth as a dangerous man if his practice in the laboratory had not led him to the conclusion that the customary inoculations were very much too powerful, and that a comparatively infinitesimal dose would not precipitate a negative phase of cooking activity, and might induce a positive one. And thus it happens that the refusal of our general practitioners to acquire the new technique is no longer quite so dangerous in practice as it was when The Doctor's Dilemma was written: nay, that Sir Ralph Bloomfield Boningtons way of administering inoculations as if they were spoonfuls of squills may sometimes work fairly well. For all that, I find Sir Almroth Wright, on the 23rd May, 1910, warning the Royal Society of Medicine that "the clinician has not yet been prevailed upon to reconsider his position," which means that the general practitioner ("the doctor," as he is called in our homes) is going on just as he did before, and could not afford to learn or practice a new technique even if he had ever heard of it. To the patient who does not know about it he will say nothing. To the patient who does, he will ridicule it, and disparage Sir Almroth. What else can he do, except confess his ignorance and starve?

But now please observe how "the whirligig of time brings its revenges." 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 at the hands of its own restless discoverer. I will not say that Hahnemann may have gone the way of Diafoirus; for Diafoirus 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. 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 another 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.