OBSERVATIONS ON THE Duties of a Physician, AND THE METHODS OF IMPROVING MEDICINE, ACCOMMODATED TO THE PRESENT STATE OF SOCIETY AND MANNERS IN THE UNITED STATES. DELIVERED IN THE UNIVERSITY OF PENNSYLVANIA, ON THE 7th OF FEBRUARY, 1789, AT THE CONCLUSION OF A COURSE OF LECTURES UPON CHEMISTRY AND THE PRACTICE OF PHYSIC.
I SHALL conclude our course of lectures, by de|livering to you a few directions for the regulation of your future conduct and studies, in the line of your profession.
I SHALL, first, suggest the most probable means of establishing yourselves in business, and of becoming acceptable to your patients, and respectable in life.
Secondly. I SHALL mention a few thoughts which have occurred to me on the mode to be pursued, in the further prosecution of your studies, and for the improvement of medicine.
I. PERMIT me, in the first place, to recommend to such of you as intend to settle in the country, to establish yourselves as early as possible upon farms. My reasons for this advice are as follow.
Page 22 1. IT will reconcile the country people to the li|berality and dignity of your profession, by shewing them that you assume no superiority over them from your education, and that you intend to share with them in those toils, which were imposed upon man in con|sequence of the loss of his innocence. This will pre|vent envy, and render you acceptable to your patients as men, as well as physicians.
2. BY living on a farm you may serve your coun|try by promoting improvements in agriculture. Che|mistry (which is now an important branch of a medi|cal education) and agriculture are closely allied to each other. Hence some of the most useful books upon agriculture have been written by physicians. Witness the essays of Dr. Home of Edinburgh, and of Dr. Hunter of Yorkshire in England.
3. THE business of a farm will furnish you with employment in the healthy seasons of the year, and thereby deliver you from the taedium vitae, or what is worse, from retreating to low or improper company. Perhaps one cause of the prevalence of dram or grog drinking, with which country practitioners are some|times charged, is owing to their having no regular or profitable business to employ them in the intervals of their attendance upon their patients.
4. THE resources of a farm will create such an in|dependence as will enable you to practice with more dignity, and at the same time screen you from the trouble of performing unnecessary services to your pa|tients. It will change the nature of the obligation between you and them. While money is the only means of your subsistence, your patients will feel that they Page 23 are the channels of your daily bread; but while your farm furnishes you with the necessaries of life, your patients will feel more sensibly that the obligation is on their side, for health and life.
5. THE exigencies and wants of a farm, in stock and labor of all kinds, will enable you to obtain from your patients a compensation for your services in those articles. They all possess them; and men part with that of which money is only the sign, much more rea|dily than they do with money itself.
6. THE resources of a farm will prevent your che|rishing, for a moment, an impious wish for the pre|valence of sickness in your neighbourhood. A heal|thy season will enable you to add to the produce of your farm, while the rewards of an unhealthy season will enable you to repair the inconvenience of your necessary absence from it. By these means your pur|suits will be marked by that variety and integrity, in which true happiness is said to consist.
7. LET your farms be small, and let your principal attention be directed to grass and horticulture. These afford most amusement, require only moderate labor, and will interfere least with your duties to your pro|fession.
II. AVOID singularities of every kind in your man|ners, dress, and general conduct. Sir Isaac Newton, it is said, could not be distinguished in company, by any peculiarity, from a common well-bred gentleman. Singularity in any thing, is a substitute for such great or useful qualities as command respect; and hence we find it chiefly in little minds. The profane and in|delicate Page 24 delicate combination of extravagant ideas, improperly called wit, and a formal and pompous manner, whether accompanied by a wig, a cane, or a ring, should all be avoided, as incompatible with the sim|plicity of science and the real dignity of physic. There is more than one way of playing the quack. It is not necessary, for this purpose, that a man should adver|tise his skill, or his cures, or that he should mount a phaeton and display his dexterity in operating to an ignorant and gaping multitude. A physician acts the same part in a different way, who assumes the charac|ter of a madman or a brute in his manners, or who conceals his fallibility by an affected gravity and taci|turnity in his intercourse with his patients. Both characters, like the quack, impose upon the public. It is true, they deceive different ranks of people; but we must remember that there are two kinds of vulgar, viz. the rich and the poor; and that the rich vulgar are often below the poor, in ignorance and credulity.
III. IT has been objected to our profession, that many eminent physicians have been unfriendly to christianity. If this be true, I cannot help ascribing it in part to that neglect of public worship with which the duties of our profession are often incompatible; for it has been justly observed, that the neglect of this religious and social duty generally produces a relaxa|tion either in principles or morals. Let this fact lead you, in setting out in business, to acquire such habits of punctuality in visiting your patients, as shall not in|terfere with acts of public homage to the SUPREME BEING. Dr. Gregory has observed, that a cold heart is the most frequent cause of deism. Where this occurs in a physician, it affords a presumption that he is deficient in humanity. But I cannot admit that in|fidelity Page 25 is peculiar to our profession. On the con|trary, I believe christianity places among its friends more men of extensive abilities and learning, in medi|cine, than in any other secular employment. Stahl, Hoffman, Boerhaave, Sydenham, Haller and Fothergill, were all christians. These enlightened physicians were considered as the ornaments of the ages in which they lived, and posterity has justly ranked them among the greatest benefactors of mankind.
IV. PERMIT me to recommend to you a regard to all the interests of your country. The education of a physician gives him a peculiar insight into the principles of many useful arts, and the practice of physic favours his opportunities of doing good, by dif|fusing knowledge of all kinds. It was in Rome, when medicine was practised only by slaves, that physicians were condemned by their profession
V. STUDY simplicity in the preparation of your medicines. My reasons for this advice are as follow.
Page 26 1. ACTIVE medicines produce the most certain effects in a simple state.
2. MEDICINES when mixed frequently destroy the efficacy of each other. I do not include chemical medicines alone in this remark. It applies likewise to galenical medicines. Nor do I assert that the vir|tues of all these medicines are impaired by mixture; but we can only determine when they are not, by actual experiments and observation.
3. WHEN medicines of the same class, or even of different classes, are given together, the strongest only produces an effect. But what are we to say to a com|pound of two medicines which gives exactly the same degrees of impression to the system? The effect of them will probably be such, if we may judge from analogy, as would have been produced by neither in a simple state.
4. BY observing simplicity in your prescriptions, you will always have the command of a greater num|ber of medicines of the same class, which may be used in succession to each other, in proportion as habit renders the system insensible of their action.
5. BY using medicines in a simple state, you will arrive at an exact knowledge of their virtues and doses, and thereby be able to decide upon the numerous and contradictory accounts, which exist in our books, of the characters of the same medicines.
UNDER this head I cannot help adding two more directions.
Page 27 1. AVOID sacrificing too much to the taste of your patients, in the composition of your medicines. The nature of a medicine may, in some instances, be wholly changed, by being mixed with sweet substances. The Author of nature seems to have had a design in making medicines unpalatable. Had they been more agree|able to the taste, they would long ago have yielded to the unbounded appetites of man, and by becoming ar|ticles of diet or condiments, have lost their efficacy in diseases.
2. GIVE as few medicines as possible in tinctures made with distilled spirits. Perhaps there are but few cases in which it is safe to exhibit medicines prepared in spirits, in any other form than in drops. Many people have been innocently seduced into a love of strong drink, from taking large or frequent doses of bitters infused in spirits. Let not our profession in a single instance be charged with adding to the cala|mities which have been entailed upon mankind by this dreadful species of intemperance.
VI. LET me advise you, in your visits to the sick, never to appear in a hurry, nor to talk of indifferent matters before you have made the necessary inquiries into the symptoms of your patient's disease.
VII. AVOID making 〈◊〉 of any case;
Page 28 VIII. DO not condemn, or oppose, unnecessarily, the simple prescriptions of your patients. Yield to them in matters of little consequence, but maintain an inflexible authority over them in matters that are essen|tial to life.
IX. PRESERVE, upon all occasions, a composed or cheerful countenance in the room of your patients, and inspire as much hope of a recovery as you can, consistent with truth, especially in acute diseases. The extent of the influence of the will over the human body, has not yet been fully ascertained. I reject the futile pretensions of Mr. Mesmer to the cure of dis|eases, by what he has absurdly called animal magne|tism; but I am willing to derive the same advan|tages from his deceptions, which the chemists have derived from the delusions of the alchemists. The facts which he has established, clearly prove the influence of the imagination and will upon diseases. Let us avail ourselves of the aid which these powers of the mind present to us, in the strife between life and death. I have frequently prescribed remedies of doubtful ef|ficacy in the critical stage of acute diseases, but never till I had worked up my patients into a confidence, bordering upon certainty, of their probable good ef|fects. The success of this measure has much oftener answered, than disappointed my expectations; and while my patients have commended the vomit, the purge, or the blister which was prescribed, I have been disposed to attribute their recovery to the vigorous concurrence of the will in the action of the medicine. Does the will beget insensibility to cold, heat, hunger, and danger? Does it suspend pain, and raise the body above feeling the pangs of Indian tortures? Let us not then be surprised that it should enable the system Page 29 to resolve a spasm, to open an obstruction, or to dis|charge an offending humor. I have only time to hint at this subject. Perhaps it would lead us, if we could trace it fully, to some very important discoveries in the cure of diseases.
X. PERMIT me to advise you to attend to that principle in the human mind, which constitutes the association of ideas, in your intercourse with your pa|tients. A chamber, a chair, a curtain, or even a cup, all belong to the means of life or death, accordingly as they are associated with cheerful or distressing ideas, in the mind of a patient. But this principle is of more immediate application in those chronic diseases which affect the mind. Nothing can be accomplished here, till we produce a new association of ideas. For this purpose, a change of place and company are absolute|ly necessary. But we must sometimes proceed much further. I have heard of a gentleman in South-Ca|rolina, who cured his fits of low spirits by changing his clothes. The remedy was a rational one. It pro|duced at once a new train of ideas, and thus removed the paroxysm of his disease.
XI. A PHYSICIAN in sickness is always a wel|come visitor in a family: hence he is solicited to par|take of the usual sign of hospitality in this country, by taking a draught of some strong drink every time he enters into the house of a patient. Let me charge you to lay an early restraint upon yourselves, by refusing to yield to this practice, especially in the forenoon. Many physicians have been led by it into habits of drunkenness. You will be in the more danger of fall|ing into this vice, from the fatigue and inclemency of weather to which you will be exposed in country prac|tice. Page 30 But you have been taught that strong drink affords only a temporary relief from those evils, and that it tends afterwards to render the body more sen|sible of them.
XII. MAKE it a rule never to be angry at any thing a sick man says or does to you. Sickness often adds to the natural impatience and irritability of the temper. We are, therefore, to submit to the severe and unnecessary toils that are sometimes exacted from us, and to bear even the reproaches of our patients with meekness and silence. It is folly to resent in|juries at any time, but it is cowardice to resent an in|jury from a sick man; since, from his weakness and dependence upon us, he is unable to contend with us upon equal terms. You will find it difficult to attach your patients to you by the obligation of friendship or gratitude. You will sometimes have the mortificati|on of being deserted by those patients who owe most to your skill and humanity. This led Dr. Turner to advise physicians never to chuse their friends from among their patients. But this advice can never be followed by a heart that has been taught to love true excellency, wherever if finds it. I would rather ad|vise you to give the benevolent feelings of your hearts full scope, and to forget the unkind returns they will often meet with, by giving to human nature—a tear. Let us not despair. From the increasing influence of reason and religion in our world, the time must soon come, when even physicians, and the brute cre|ation, shall become the objects of the justice and hu|manity of mankind.
XIII. AVOID giving a patient over in an acute disease. It is impossible to tell, in such cases, where Page 31 life ends and where death begins. Hundreds of pa|tients have recovered who have been pronounced in|curable, to the great disgrace of our profession. I know that the practice of predicting danger and death upon every occasion, is sometimes made use of by physicians, in order to enhance the credit of their pre|scriptions, if their patients recover, and to secure a retreat from blame, if they should die. But this mode of acting is mean and illiberal. It is not necessary that we should decide with confidence at any time, upon the issue of a disease.
XIV. CASES will frequently occur in which you will be exposed to a struggle between a regard for your own reputation, and for the life of a patient. In such cases, let christianity determine what is to be done. That new commandment which directs us to make the measure of our love to our fellow-creatures, the same as the love of the Author of our religion was to the human race, certainly requires that we should at all times risk, and even sacrifice reputation, to preserve the life of a fellow-creature. The pusillanimous, or, as he is commonly called, the safe physician, who, absorbed wholly in the care of his own reputation, views without exertion the last conflict between life and death in a patient, in my opinion will be found hereafter to have been guilty of a breach of the sixth commandment; while the conscientious, or, as he is commonly called, the bold physician, who loses sight of his character, and even of the means of his subsistence, and by the use of a remedy of doubtful efficacy turns the scale in favour of life, performs an act that bor|bers upon divine benevolence. A physician who has only once in his life enjoyed the godlike pleasure that is connected with such an act of philanthropy, will Page 32 never require any other consideration to reconcile him to the toils and duties of his profession.
XV. I SHALL now give some directions with re|spect to the method of charging for your services to your patients.
WHEN we consider the expence of a medical edu|cation, and the sacrifices a physician is obliged to make of ease, society, and even health, to his profession; and when we add to these, the constant and painful anxiety which is connected with the important charge of the lives of our fellow-creatures, and above all, the inestimable value of that blessing which is the object of his services, I hardly know how it is possible for a patient sufficiently and justly to reward his physician. But when we consider, on the other hand, that sick|ness deprives men of the means of acquiring money; that it increases all the expences of living; and that high charges often drive patients from regular-bred physicians to quacks; I say, when we attend to these considerations, we should make our charges as mode|rate as possible, and conform them to the following state of things.
AVOID measuring your services to your patients by scruples, drachms, and ounces. It is an illiberal mode of charging. On the contrary, let the number and the time of your visits, the nature of your patient's disease, and his rank in his family or society, deter|mine the figures in your accounts. It is certainly just to charge more for curing an apoplexy, than an in|termitting fever. It is equally just to demand more for risking your life by visiting a patient in a contagi|ous fever, than for curing a pleurisy. You have a Page 33 right likewise to be paid for your anxiety. Charge the same services, therefore, higher to the master or mistress of a family, or to an only son or daughter, who call forth all your feelings and industry, than to less important members of a family and of society. If a rich man demands more frequent visits than are necessary, and if he imposes the restraints of keeping to hours by calling in other physicians to consult with you upon every trifling occasion, it will be just to make him pay accordingly for it. As this mode of charging is strictly agreeable to reason and equity, it seldom fails of according with the reason and sense of equity of our patients. Accounts made out upon these principles, are seldom complained of by them. I shall only remark further upon this subject, that the sooner you send in your accounts after your patients recover, the better. It is the duty of a physician to inform his patient of the amount of his obligation to him at least once a year. But there are times when a departure from this rule may be necessary. An unexpected mis|fortune in business, and a variety of other accidents, may deprive a patient of the money he had allotted to pay his physician. In this case, delicacy and hu|manity require, that he should not know the amount of his debt to his physician, till time has bettered his cir|cumstances.
I SHALL only add, under this head, that the poor of every description should be the objects of your pe|culiar care. Dr. Boerhaave used to say,
I COME now to the second part of this address, which was to point out the best mode to be pursued, in the further prosecution of your studies, and the im|provement of medicine.
I. GIVE me leave to recommend to you, to open all the dead bodies you can, without doing violence to the feelings of your patients, or the prejudices of the common people. Preserve a register of the weather, and of its influence upon the vegetable productions of the year. Above all, record the epidemics of every season; their times of appearing, and disappearing, and the connection of the weather with each of them. Such records, if published, will be useful to foreigners, and a treasure to posterity. Preserve, likewise, an account of chronic cases. Record the name, age and occupation of your patient; describe his disease accu|rately, and the changes produced in it by your reme|dies; mention the doses of every medicine you admi|nister to him. It is impossible to tell how much im|provement and facility in practice you will derive from following these directions. It has been remarked, that physicians seldom remember more than the two or three last years of their practice. The records which have been mentioned, will supply this deficiency of memory, especially in that advanced stage of life when the ad|vice of physicians is supposed to be most valuable.
Page 35 II. PERMIT me to recommend to you further, the study of the anatomy (if I may be allowed the expres|sion) of the human mind, commonly called metaphy|sics. The reciprocal influence of the body and mind upon each other, can only be ascertained by an accu|rate knowledge of the faculties of the mind, and of their various modes of combination and action. It is the duty of physicians to assert their prerogative, and to rescue the mental science from the usurpations of schoolmen and divines. It can only be perfected by the aid and discoveries of medicine. The authors I would recommend to you upon metaphysics, are, But|ler, Locke, Hartly Reid, and Beattie. These ingenious writers have cleared this sublime science of its technical rubbish, and rendered it both intelligible and useful.
III. Do not confine your studies and attention only to extraordinary cases. The most frequent outlets of human life are through the channels of common diseases. A late professor in the college of Glasgow, when a student in one of the London hospitals, was observed to be busy in examining the pulse of a patient in a fever, while all his fellow students were employed in examining with uncommon attention the case of a child with two heads that had just been brought into the hospital. Upon being condemned by his compani|ons for neglecting to profit by the examination of so new a case, he answered, "I never expect in the whole course of my life to see, or hear, of another child with two heads: but I expect to meet with fevers in my practice, every day of my life." This sensible answer admits of extensive application to the advancement of medicine. Could we eradicate fevers only from our bills of mortality, how much more should we add to the population and happiness of our country, than by discovering remedies for polypi and aneurisms?
Page 36 IV. LET me remind you, that improvement in medicine is not to be derived, only from colleges and universities. Systems of physic are the productions of men of genius and learning; but those facts which constitute real knowledge, are to be met with in every walk of life. Remember how many of our most use|ful remedies have been discovered by quacks. Do not be afraid, therefore, of conversing with them, and of profiting by their ignorance and temerity in the prac|tice of physic. Medicine has its Pharisees, as well as religion. But the spirit of this sect is as unfriendly to the advancement of medicine, as it is to chri|stian charity. By conversing with quacks, we may convey instruction to them, and thereby lessen the mis|chief they might otherwise do to society. But further. In the pursuit of medical knowledge, let me advise you to converse with nurses and old women. They will often suggest facts in the history and cure of disea|ses which have escaped the most sagacious observers of nature. Even negroes and Indians have sometimes stumbled upon discoveries in medicine. Be not a|shamed to inquire into them. There is yet one more means of information in medicine which should not be neglected, and that is, to converse with persons who have recovered from indispositions without the aid of physicians. Examine the strength and exertions of nature in these cases, and mark the plain and home|made remedy to which they ascribe their recovery. I have found this to be a fruitful source of instruction, and have been led to conclude, that if every man in a city, or a district, could be called upon to relate to persons appointed to receive and publish his narrative, an exact account of the effects of those remedies which accident or whim has suggested to him, it would fur|nish a very useful book in medicine. To preserve the Page 37 facts thus obtained, let me advise you to record them in a book to be kept for that purpose. There is one more advantage that will probably attend the inquiries that have been mentioned; you may discover diseases, or symptoms of diseases, or even laws of the animal oeconomy, which have no place in our systems of no|sology, or in our theories of physic.
V. IN dangerous cases that are plain and common, let me caution you against having recourse to consulta|tions. They relax exertion, suspend enterprise, and lessen responsibility in a physician. They moreover add, unnecessarily, to the expences of a patient. But in difficult and obscure cases let me advise you to an|ticipate the fears of your patients, by requesting as|sistance. Such candor begets subsequent confidence and business, for truth is the universal interest of man|kind. There are few instances in which any solid ad|vantages have been derived from more than two phy|sicians consulting together. Where a greater number are employed, the prescriptions are generally the re|sult of neutralized opinions, and are of course often unsuccessful. The epitaph of Pliny, viz.
VI. LET me recommend to your particular attenti|on, the indigenous medicines of our country. Cul|tivate or prepare as many of them as possible, and en|deavour to enlarge the materia medica, by exploring the untrodden fields and forests of the United States. The ipecacuana, the Seneka and Virginia snake roots, the Carolina pink-root, the spice-wood, the sassafras, the butter-nut, the thoroughwort, the poke, and the Page 38 strammonium, are but a small part of the medicinal productions of America. I have no doubt but there are many hundred other plants which now exhale in|valuable medicinal virtues in the desart air. Examine, likewise, the mineral waters, which are so various in their impregnation, and so common in all parts of our country. Let not the properties of the infects of Ame|rica escape your investigation. We have already dis|covered among some of them, a fly equal in its blister|ing qualities to the famous fly of Spain. Who knows but it may be reserved for America to furnish the world, from her productions, with cures for some of those diseases which now elude the power of medicine? Who knows but what, at the foot of the Allegany mountain there blooms a flower that is an infallible cure for the epilepsy? Perhaps on the Monongahela, or the Potowmac, there may grow a root that shall supply, by its tonic powers, the invigorating effects of the savage or military life in the cure of consumptions. Human misery of every kind is evidently on the de|cline. Happiness, like truth, is an unit. While the world, from the progress of intellectual, moral and political truth, is becoming a more safe and agreeable abode for man, the votaries of medicine should not be idle. All the doors and windows of the temple of na|ture have been thrown open by the convulsions of the late American revolution. This is the time, therefore, to press upon her altars. We have already drawn from them discoveries in morals, philosophy, and govern|ment, all of which have human happiness for their object. Let us preserve the unity of truth and hap|piness, by drawing from the same source, in the present critical moment, a knowledge of antidotes to those diseases which are supposed to be incurable.
Page 39 I HAVE now, gentlemen, only to thank you for the attention with which you have honored the course of lectures which has been delivered to you, and to assure you, that I shall be happy in rendering you all the services that lie in my power, in any way you are pleased to command me. Accept of my best wishes for your happiness, and may the blessings of hundreds and thousands who were ready to perish, be your por|tion in life, your comfort in death, and your reward in the world to come.