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 two-penny 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 Abernathy‘s[96] “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) ^{35} 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[97] (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,[98] 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 church-wardens; 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.