Part 6 (1/2)
Macilwaine, in a little book ent.i.tled _Medical Revolution_, again advocated the same changes: the establishment of a Ministry of Health, a medical service on a preventive basis, and the reform of the hospitals which must const.i.tute the nucleus of such a service. It may be said that for medical men no longer engaged in private practice it is easy to view the disappearance of private practice with serenity; but it must be added that it is precisely that disinterested serenity which makes possible also a clear insight into the problems and a wider view of the new horizons of medicine. Thus it is that to-day the dreamers of yesterday are justified.
The great scheme of State Insurance was certainly an important step towards the socialisation of medicine. It came short, indeed, of the complete Nationalisation of Health as an affair of State. But that could not possibly be introduced at one move. Apart even from the difficulty of complete reorganisation, the two great vested interests of private medical practice on the one hand and Friendly Societies on the other would stand in the way. A complicated transitional period is necessary, during which those two interests are conciliated and gradually absorbed. It is this transitional period which State Insurance has inaugurated. To compare small things to great--as we may, for the same laws run all through Nature and Society--this scheme corresponds to the ancient Ptolomaean system of astronomy, with its painfully elaborate epicycles, which preceded and led on to the sublime simplicity of the Copernican system. We need not antic.i.p.ate that the transitional stage of national insurance will endure as long as the ancient astronomy. Professor Moore estimated that it would lead to a completely national medical service in twenty-five years, and since the introduction of that method he has, too optimistically, reduced the period to ten years. We cannot reach simplicity at a bound; we must first attempt to systematise the recognised and established activities and adjust them harmoniously.
The organised refusal of the medical profession at the outset to carry on, under the conditions offered, the part a.s.signed to it in the great National Insurance scheme opened out prospects not clearly realised by the organisers. No doubt its immediate aspects were unfortunate. It not only threatened to impede the working of a very complex machine, but it dismayed many who were not prepared to see doctors apparently taking up the position of the syndicalists, and arguing that a profession which is essential to the national welfare need not be carried out on national lines, but can be run exclusively by itself in its own interests. Such an att.i.tude, however, usefully served to make clear how necessary it is becoming that the extension of medicine and hygiene in the national life should be accompanied by a corresponding extension in the national government. If we had had a Council of National Health, as well as of National Defence, or a Board of Health as well as a Board of Trade, a Minister of Health with a seat in the Cabinet, any scheme of Insurance would have been framed from the outset in close consultation with the profession which would have the duty of carrying it out. No subsequent friction would have been possible.
Had the Insurance scheme been so framed, it is perhaps doubtful whether it would have been so largely based on the old contract system. Club medical practice has long been in discredit, alike from the point of view of patient and doctor. It furnishes the least satisfactory form of medical relief for the patient, less adequate than that he could obtain either as a private patient or as a hospital patient. The doctor, on his side, though he may find it a very welcome addition to his income, regards Club practice as semi-charitable, and, moreover, a form of charity in which he is often imposed on; he seldom views his club patients with much satisfaction, and unless he is a self-sacrificing enthusiast, it is not to them that his best attention, his best time, his most expensive drugs, are devoted. To perpetuate and enlarge the club system of practice and to glorify it by affixing to it a national seal of approval, was, therefore, a somewhat risky experiment, not wisely to be attempted without careful consultation with those most concerned.
Another point might then also have become clear: the whole tendency of medicine is towards a recognition of the predominance of Hygiene. The modern aim is to prevent disease. The whole national system of medicine is being slowly though steadily built up in recognition of the great fact that the interests of Health come before the interests of Disease.
It has been an unfortunate flaw in the magnificent scheme of Insurance that this vital fact was not allowed for, that the old-fas.h.i.+oned notion that treatment rather than prevention is the object of medicine was still perpetuated, and that nothing was done to co-ordinate the Insurance scheme with the existing Health Services.
It seems probable that in a Service of State medical officers the solution may ultimately be found. Such a solution would, indeed, immensely increase the value of the Insurance scheme, and, in the end, confer far greater benefits than at present on the millions of people who would come under its operation. For there can be no doubt the Club system is not only unscientific; it is also undemocratic. It perpetuates what was originally a semi-charitable and second-rate method of treatment of the poorer cla.s.ses. A State medical officer, devoting his whole time and attention to his State patients, has no occasion to make invidious distinctions between public and private patients.
A further advantage of a State Medical Service is that it will facilitate the inevitable task of nationalising the hospitals, whether charitable or Poor-law. The Insurance Act, as it stands, opens no definite path in this direction. But nowadays, so vast and complicated has medicine become, even the most skilful doctor cannot adequately treat his patient unless he has a great hospital at his back, with a vast army of specialists and research-workers, and a manifold instrumental instalment.
A third, and even more fundamental, advantage of a State Medical Service is that it would help to bring Treatment into touch with Prevention. The private pract.i.tioner, as such, inside or outside the Insurance scheme, cannot conveniently go behind his patient's illness. But the State doctor would be ent.i.tled to ask: _Why_ has this man broken down? The State's guardians.h.i.+p of the health of its citizens now begins at birth (is tending to be carried back before birth) and covers the school life. If a man falls ill, it is, nowadays, legitimate to inquire where the responsibility lies. It is all very well to patch up the diseased man with drugs or what not. But at best that is a makes.h.i.+ft method. The Consumptive Sanatoriums have aroused enthusiasm, and they also are all very well. But the Charity Organisation Society has shown that only about 50 per cent. of those who pa.s.s through such inst.i.tutions become fit for work. It is not more treatment of disease that we want, it is less need for treatment. And a State Medical Service is the only method by which Medicine can be brought into close touch with Hygiene.
The present att.i.tude of the medical profession sometimes strikes people as narrow, unpatriotic, and merely self-interested. But the Insurance Act has brought a powerful ferment of intellectual activity into the medical profession which in the end will work to finer issues. A significant sign of the times is the establishment of the State Medical Service a.s.sociation, having for its aim the organisation of the medical profession as a State Service, the nationalisation of hospitals, and the unification of preventive and curative medicine. To many in the medical profession such schemes still seem ”Utopian”; they are blind to a process which has been in ever increasing action for more than half a century and which they are themselves taking part in every day.
[1] The result sometimes is that the ambitious doctor seeks to become a specialist in at least one subject, and instals a single expensive method of treatment to which he enthusiastically subjects all his patients. This would be comic if it were not sometimes rather tragic.
XIII
EUGENICS AND GENIUS
The cry is often heard to-day from those who watch with disapproval the efforts made to discourage the reckless procreation of the degenerate and the unfit: You are stamping out the germs of genius! It is widely held that genius is a kind of flower, unknown to the horticulturist, which only springs from diseased roots; make the plant healthily sound and your hope of blossoms is gone, you will see nothing but leaves. Or, according to the happier metaphor of Lombroso, the work of genius is an exquisite pearl, and pearls are the product of an obscure disease. To the medical mind, especially, it has sometimes been, naturally and properly no doubt, a source of satisfaction to imagine that the loveliest creations of human intellect may perhaps be employed to shed radiance on the shelves of the pathological museum. Thus we find eminent physicians warning us against any effort to decrease the vigour of pathological processes, and influential medical journals making solemn statements in the same sense. ”Already,” I read in a recent able and interesting editorial article in the _British Medical Journal_, ”eugenists in their kind enthusiasm are threatening to stamp out the germs of possible genius.”
Now it is quite easy to maintain that the health, happiness, and sanity of the whole community are more precious even than genius. It is so easy, indeed, that if the question of eugenics were submitted to the Referendum on this sole ground there can be little doubt what the result would be. There are not many people, even in the most highly educated communities, who value the possibility of a new poem, symphony, or mathematical law so highly that they would sacrifice their own health, happiness, and sanity to retain that possibility for their offspring. Of course we may declare that a majority which made such a decision must be composed of very low-minded uncultured people, altogether lacking in appreciation of pathology, and reflecting no credit on the eugenic cause they supported; but there can be little doubt that we should have to admit their existence.
We need not hasten, however, to place the question on this ground. It is first necessary to ascertain what reason there is to suppose that a regard for eugenic considerations in mating would tend to stamp out the germs of genius. Is there any reason at all? That is the question I am here concerned with.
The anti-eugenic argument on this point, whenever any argument is brought forward, consists in pointing to all sorts of men of genius and of talent who, it is alleged, were poor citizens, physical degenerates the prey of all manner of const.i.tutional diseases, sometimes candidates for the lunatic asylum which they occasionally reached. The miscellaneous data which may thus be piled up are seldom critically sifted, and often very questionable, for it is difficult enough to obtain any positive biological knowledge concerning great men who died yesterday, and practically impossible in most cases to reach an unquestionable conclusion as regards those who died a century or more ago. Many of the most positive statements commonly made concerning the diseases even of modern genius are without any sure basis. The case of Nietzsche, who was seen by some of the chief specialists of the day, is still really quite obscure. So is that of Guy de Maupa.s.sant. Rousseau wrote the fullest and frankest account of his ailments, and the doctors made a _post-mortem_ examination. Yet nearly all the medical experts--and they are many--who have investigated Rousseau's case reach different conclusions. It would be easy to multiply indefinitely the instances of great men of the past concerning whose condition of health or disease we are in hopeless perplexity.
This fact is, however, one that, as an argument, works both ways, and the important point is to make clear that it cannot concern us. No eugenic considerations can annihilate the man of genius when he is once born and bred. If eugenics is to stamp out the man of genius it must do so before he is born, by acting on his parents.
Nor is it possible to a.s.sume that if the man of genius, apart from his genius, is an unfit person to procreate the race, therefore his parents, not possessing any genius, were likewise unfit to propagate. It is easy to find persons of high ability who in other respects are unfit for the ends of life, ill-balanced in mental or physical development, neurasthenic, valetudinarian, the victims in varying degrees of all sorts of diseases. Yet their parents, without any high ability, were, to all appearance, robust, healthy, hard-working, commonplace people who would easily pa.s.s any ordinary eugenic tests. We know nothing as to the action of two seemingly ordinary persons on each other in const.i.tuting heredity, how hypertrophied intellectual apt.i.tude comes about, what accidents, normal or pathological, may occur to the germ before birth, nor even how strenuous intellectual activity may affect the organism generally. We cannot argue that since these persons, apart from their genius, were not seemingly the best people to carry on the race, therefore a like judgment should be pa.s.sed on their parents and the germs of genius thus be stamped out.
We only arrive at the crucial question when we ask: Have the characters of the parents of men of genius been of such an obviously unfavourable kind that eugenically they would nowadays be dissuaded from propagation, or under a severe _regime_ of compulsory certificates (the desirability of which I am far indeed from a.s.suming) be forbidden to marry? Have the parents of genius belonged to the ”unfit”? That is a question which must be answered in the affirmative if this objection to eugenics has any weight. Yet so far as I know, none of those who have brought forward the objection have supported it by any evidence of the kind whatever. Thirty years ago Dr. Maudsley dogmatically wrote: ”There is hardly ever a man of genius who has not insanity or nervous disorder of some form in his family.” But he never brought forward any evidence in support of that p.r.o.nouncement. Nor has anyone else, if we put aside the efforts of more or less competent writers--like Lombroso in his _Man of Genius_ and Nisbet in his _Insanity of Genius_--to rake in statements from all quarters regarding the morbidities of genius, often without any attempt to authenticate, criticise, or sift them, and never with any effort to place them in due perspective.[1]
It so happens that, some years ago, with no relation to eugenic considerations, I devoted a considerable amount of attention to the biological characters of British men of genius, considered, so far as possible, on an objective and impartial basis.[2] The selection, that is to say, was made, so far as possible, without regard to personal predilections, in accordance with certain rules, from the _Dictionary of National Biography_. In this way one thousand and thirty names were obtained of men and women who represent the flower of British genius during historical times, only excluding those persons who were alive at the end of the last century. What proportion of these were the offspring of parents who were insane or mentally defective to a serious extent?
If the view of Maudsley--that there is ”hardly ever” a man of genius who is not the product of an insane or nervously-disordered stock--had a basis of truth, we should expect that in one or other parents of the man of genius actual insanity had occurred in a very large proportion of cases; 25 per cent. would be a moderate estimate. But what do we find? In not 1 per cent. can definite insanity be traced among the parents of British men and women of genius. No doubt this result is below the truth; the insanity of the parents must sometimes have escaped the biographer's notice. But even if we double the percentage to escape this source of error, the proportion still remains insignificant.
There is more to be said. If the insanity of the parent occurred early in life, we should expect it to attract attention more easily than if it occurred late in life. Those parents of men of genius falling into insanity late in life, the critic may argue, escape notice. But it is precisely to this group to which all the ascertainably insane parents of British men of genius belong. There is not a single recorded instance, so far as I have been able to ascertain, in which the parent had been definitely and recognisably insane before the birth of the distinguished child; so that any prohibition of the marriage of persons who had previously been insane would have left British genius untouched. In all cases the insanity came on late in life, and it was usually, without doubt, of the kind known as senile dementia. This was so in the case of the mother of Bacon, the most distinguished person in the list of those with an insane parent. Charles Lamb's father, we are told, eventually became ”imbecile.” Turner's mother became insane. The same is recorded of Archbishop Tillotson's mother and of Archbishop Leighton's father. This brief list includes all the parents of British men of genius who are recorded (and not then always very definitely) as having finally died insane. In the description given of others of the parents of our men of genius it is not, however, difficult to detect that, though they were not recognised as insane, their mental condition was so highly abnormal as to be not far removed from insanity. This was the case with Gray's father and with the mothers of Arthur Young and Andrew Bell. Even when we allow for all the doubtful cases, the proportion of persons of genius with an insane parent remains very low, less than 2 per cent.
Senile dementia, though it is one of the least important and significant of the forms of insanity, and is entirely compatible with a long and useful life, must not, however, be regarded, when present in a marked degree, as the mere result of old age. Entirely normal people of sound heredity do not tend to manifest signs of p.r.o.nounced mental weakness or abnormality even in extreme old age. We are justified in suspecting a neurotic strain, though it may not be of severe degree.
This is, indeed, ill.u.s.trated by our records of British genius. Some of the eminent men of genius on my list (at least twelve) suffered before death from insanity which may probably be described as senile dementia.
But several of these were somewhat abnormal during earlier life (like Swift) or had a child who became insane (like Bishop Marsh). In these and in other cases there has doubtless been some hereditary neurotic strain.
It is clearly, however, not due to any intensity of this strain that we find the incidence of insanity in men of genius, as ill.u.s.trated, for example, by senile dementia, so much more marked than its incidence on their parents. There is another factor to be invoked here: convergent morbid heredity. If a man and a woman, each with a slight tendency to nervous abnormality, marry each other, there is a much greater chance of the offspring manifesting a severe degree of nervous abnormality than if they had married entirely sound partners. Now both among normal and abnormal people there is a tendency for like to mate with like.
The attraction of the unlike for each other, which was once supposed to prevail, is not predominant, except within the sphere of the secondary s.e.xual characters, where it clearly prevails, so that the ultra-masculine man is attracted to the ultra-feminine woman, and the feminine man to the boyish or mannish woman. Apart from this, people tend to marry those who are both psychically and physically of the same type as themselves. It thus happens that nervously abnormal people become mated to the nervously abnormal. This is well ill.u.s.trated by the British men of genius themselves. Although insanity is more prevalent among them than among their parents, the same can scarcely be said of them in regard to their wives. It is notable that the insane wives of these men of genius are almost as numerous as the insane men of genius, though it rarely happens (as in the case of Southey) that both husband and wife go out of their minds. But in all these cases there has probably been a mutual attraction of mentally abnormal people.