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, February 7, 1789, at the conclusion of a course of lectures upon chemistry and the practice of physic. / By Benjamin Rush, M.D. Professor of chemistry in the University of Pennsylvania. ; Published at the request of the class.

GENTLEMEN,

I SHALL conclude our course of lectures, by delivering 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 pa|tients, 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.

1. It will reconcile the country people to the liberality 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 consequence of the loss of his innocence. This will prevent envy, and render you acceptable to your patients as men, as well as physicians.

2. By living on a farm you may serve your country by pro|moting improvements in agriculture. Chemistry (which is now an important branch of a medical 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 York|shire 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 impro|per company. Perhaps one cause of the prevalence of dram or grog drinking, with which country practitioners are so generally 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 independence as will enable you to practice with more dignity, and at the same time screen you from the trouble of performing unnecessary ser|vices to your patients. It will change the nature of the obligati|on between you and them. While money is the only means of your subsistence, your patients will feel that they 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 compen|sation for your services in those articles. They all possess them, and men part with that of which money is only the sign, much more readily than they do with money itself.

6. The resources of a farm will prevent your cherishing, for a moment, an impious wish for the prevalence of sickness in your neighbourhood. A healthy 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 ab|sence from it. By these means your pursuits 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 profession.

II. Avoid singularities of every kind in your manners, 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 indelicate combination of extravagant ideas, improperly called wit, and the 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 pur|pose, that a man should advertise 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 character of a madman or a brute in his manners, or who conceals his fallibility by an affected gravity and taciturnity 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 relaxation, either in princi|ples 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 interfere with acts of public homage to the Supreme Be|ing. Dr. Gregory has observed, that a cold heart is the most fre|quent cause of deism. Where this occurs in a physician, it affords a presumption that he is deficient in humanity. But I cannot ad|mit that infidelity is peculiar to our profession. On the contrary, I believe christianity places among its friends more men of exten|sive abilities and learning than any other secular employment. Stahl, Hoffman, Boerhaave, Sydenham, Haller and Fothergill were all christians. These enlightened physicians were con|sidered 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 inte|rests 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 diffusing knowledge of all kinds. It was in Rome, when medi|cine was practised only by slaves, that physicians were condemn|ed by their profession "mutam exercere artem." But in modern times, and in free governments, they should disclaim an ignoble silence upon public subjects. The history of the American revo|lution has rescued physic from its former slavish rank in society. For the honor of our profession it should be recorded, that some of the most intelligent and useful characters, both in the cabinet and the field during the late war, have been physicians. The il|lustrious Dr. Fothergill opposed faction and tyranny, and took the lead in all public improvements in his native country, with|out suffering thereby the least diminution of that reputation, or business, in which, for forty years, he flourished almost without a rival in the city of London.

V. Let me advise you, in your visits to the sick, never to ap|pear in a hurry, nor to talk of indifferent matters before you have

made the necessary inquiries into the symptoms of your patient's disease.

VI. Avoid making light of any case. "Respice finem" should be the motto of every indisposition. There is scarcely a disorder so trifling, that has not, directly, or indirectly, proved an outlet to human life. This consideration should make you anxious and punctual in your attendance upon every acute disease, and keep you from risking your reputation by an improper or hasty prognosis.

VII. Do not condemn, or oppose, unnecessarily, the simple pre|scriptions of your patients. Yield to them in matters of little consequence, but maintain an inflexible authority over them in matters that are essential to life.

VIII. Preserve, upon all occasions, a composed or cheerful coun|tenance 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 pre|tensions of Mr. Mesmer to the cure of diseases, by what he has absurdly called animal magnetism. But I am willing to derive the same advantages 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 handle 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 certain|ty, of their probable good effects. 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 ac|tion 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 to resolve a spasm, to open an obstruction, or to discharge 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.

IX. 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 patients. 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 immedi|ate application in those chronic diseases which affect the mind. Nothing can be accomplished here, till we produce a new asso|ciation of ideas. For this purpose, a change of place and com|pany are absolutely necessary. But we must sometimes proceed much further. I have heard of a gentleman in South-Carolina who cured his fits of low spirits by changing his clothes. The remedy was a rational one. It produced at once a new train of ideas, and thus removed the paroxysm of his disease.

X. 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 irritability of the temper. We are, therefore, to bear the reproaches of our patients with meekness and silence. It is folly to resent injuries at any time, but it is cowardice to resent an injury 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 friend|ship or gratitude. You will sometimes have the mortification 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 excellen|cy, where ever it finds it. I would rather advise 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.—

XI. Avoid giving a patient over in an acute disease. It is im|possible to tell in such cases where life ends, and where death be|gins. Hundreds of patients have recovered, who have been pro|nounced incurable, 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 en|hance the credit of their prescriptions 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.

XII. I shall now give some directions with respect to the me|thod of charging for your services to your patients.

When we consider the expence of a medical education, 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 impor|tant 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 sickness deprives men of the means of ac|quiring money; that it increases all the expences of living; and that high charges often drive patients from regular-bred physici|ans to quacks; I say, when we attend to these considerations, we should make our charges as moderate 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 na|ture of your patient's disease, and his rank in his family or so|ciety, determine the figures in your accounts. It is certainly just to charge more for curing an apoplexy, than an intermitting fever. It is equally just, to demand more for risking your life by visiting a patient in a contagious fever, than for curing a pleurisy. You have a 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 misfortune 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, delica|cy and humanity require, that he should not know the amount of his debt to his physician, till time had bettered his circum|stances.

I shall only add, under this head, that the poor of every de|scription should be the objects of your peculiar care. Dr. Boer|haave used to say,

they were his best patients, because God was their paymaster.

The first physicians that I have known, have found the poor the steps by which they have ascended to bu|siness and reputation. Diseases among the lower class of people are generally simple, and exhibit to a physician the best cases of all epidemics, which cannot fail of adding to his ability of curing the complicated diseases of the rich and intemperate. There is an inseparable connection between a man's duty and his interest. Whenever you are called, therefore, to visit a poor pa|tient, imagine you hear the voice of the good Samaritan sounding in your ears,

Take care of him, and I will repay thee.

I COME now to the second part of this address, which was to point out the best mode to be pursued, in the further prosecu|tion of your studies, and the improvement 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 pos|terity. Preserve, likewise, an account of chronic cases. Re|cord the name, age and occupation of your patient; describe his disease accurately, and the changes produced in it by your re|medies; mention the doses of every medicine you administer to him. It is impossible to tell how much improvement and facility in practice you will find 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, especial|ly in that advanced stage of life when the advice of physicians is supposed to be most valuable.

II. Permit me to recommend to you further, the study of the anatomy (if I may be allowed the expression) of the human mind, commonly called metaphysics. The reciprocal influence of the body and mind upon each other, can only be ascertained by an accurate 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, Butler, 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. 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 useful 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 practice 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 christian charity. By conversing with quacks, we may convey instruction to them, and thereby lessen the mischief 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 diseases which have escaped the most sagacious observers of nature. Even ne|groes and Indians have sometimes stumbled upon discoveries in medicine. Be not ashamed to inquire into them. There is yet one more source of information in medicine which should not be neglected, and that is, to converse with persons who have reco|vered from indispositions without the aid of physicians. Exa|mine 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 in|struction, and have been led to conclude, that if every man in a city, or a district, could be called upon to relate to persons ap|pointed to receive and publish his narrative, an exact account of the effects of those remedies which accident or whim has suggest|ed to him, it would furnish a very useful book in medicine. To preserve the facts thus obtained, let me advise you to record them in a book to be kept for that purpose: it may be called a quack recipe-book. 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 nosology, or in our theories of physic.

IV. Let me recommend to your particular attention, the in|digenous medicines of our country. Cultivate or prepare as many of them as possible, and endeavour 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 strammonium, are but a small part of the medical productions of America. I have no doubt but there are many hundred other plants which now ex|hale invaluable medical virtues in the desert air. Examine, likewise, the mineral waters, which are so various in their im|pregnation, and so common in all parts of our country. Let not the properties of the insects of America escape your investigation. We have already discovered among some of them, a fly equal in its blistering 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 infal|lible 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 decline. 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 nature 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 government; all of which have human happiness for their objects. Let us preserve the unity of truth and happiness, by drawing from the same source, in the present critical moment, a knowledge of an|tidotes to those diseases which are supposed to be incurable.

I have now, Gentlemen, only to thank you for the attention with which you have honoured 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 thou|sands that were ready to perish, be your portion in life, your comfort in death, and your reward in the world to come.

THE END.