foXtfC^I*-* ^#^w^ / THE ANNUAL DISCOURSE BEFORE THE PHILADELPHIA COUNTY MEDICAL SOCIETY, Delivered February 10,1852, BY THE PRESIDENT, SAMUEL JACKSON, M.D FORMERLY OF NORTHUMBERLAND. PUBLISHED BY THE SOCIETY. * PHILADELPHIA: T, K. AND P. G. COLLINS, PRINTERS, 1852. r At an Adjourned Meeting of the "Philadelphia County Medical Society," held February 10, 1852, it was Resolved, That the thanks of the Society be presented to Dr. Samuel Jackson, for his very able and instructive Address, delivered by him in accordance with a provision of the By-Laws; and that he be requested to furnish a copy of the same for publication. By a second resolution, it was directed that fifteen hundred copies of the Ad- , dress should be printed. D. FRANCIS CONDIE, Secretary of Ph. County Med. Society, I DISCOURSE. Gentlemen : In the second chapter of Ecclesiasticus and the first verse, you may find it thus written : " My son, if thou comest to serve the Lord, prepare thy soul for temptation." This wise admonition of Jesus, the son of Sirach, ought to he strongly impressed on the mind of every young man who is about to enter on the study of Medicine; and if there be any practi- tioners of the healing art who have not learned it, or have un- happily not yet made it a ruling principle in all their intercourse with their patients, let them be assured they have neglected one of the most useful of all lessons, whether human or divine. " My son, when thou comest to serve the Lord, prepare thy soul for temptation.'' It is hardly necessary to remind you, gentlemen, that tempta- tion is the prolific root and the fruitful stock of all the moral, and of nearly all the physical evil, both of the present and the future world; and that every mortal, whether wise or foolish, sinner or saint, is more or less subject to its various charming. Sir Robert Walpole, in speaking of the British Lords and Commons, was accustomed to say that every one of them had his price— meaning that every man of this numerous and august body was open to temptation. Horace, surely one of the greatest masters of practical wisdom, makes it a positive virtue to escape by flight. Homer, whose principal excellence is a just perception and appropriation of character, represents his great pattern of prudence and wisdom as cramming his companions' ears with wax, himself chained to the mast, in order to sail untempted past the Siren's Island. Even the best of men are sometimes overcome. The pious Psalmist, whose sacred songs are yet sung 4 DISCOURSE. in the Jewish and Christian world, could not always resist temptation. Solomon, notwithstanding his shining wisdom, be- came an illustrious victim thereto, even in his old age. St. Peter unhappily yielded on a memorable occasion; and St. Paul was so sensible of his weakness in this respect, that he prepared his own great soul for temptation, lest while he preached to others, he himself, to use his own words, " should become a cast- away." Nor must it be forgotten for a single moment, that the avoiding of temptation, is one of the four good things to which Jesus Christ has limited our prayers. This fact alone is suffi- cient to indicate the importance of our text; but it may be prac- tically inferred from the sincere happiness that a good man must enjoy from every successful resistance. Sir W. Scott even con- siders it as some relief to the blood-stained character of Napo- leon, that he must have resisted many temptations to pour out yet more blood and tears over the countries of Europe. Do you inquire why our text, which would seem applicable to all men, must be assumed particularly by physicians ? Have a little patience with much kindness and I will endeavor to an- swer this question. To serve the Lord, and thereby to encounter much tempta- tion, is the province of the faithful physician far above all other men. He has more frequent opportunities of doing good in a heavenly way than any other man. He it is who comforts the aching breast; who assuages the broken heart; it is he who pours oil and wine into your aching wounds; who banishes or wards off sickness and sorrow from your dwelling ; who rescues you from the grasp of death, restores you to your family, and thus affords you time to prepare for a better world : in all which he is serving in the language of our text, " for it is God that worketh in you both to will and to do of his own good pleasure'' all these heavenly things. Active benevolence, moreover, appears to be the principal dis- tinctive property of the good ; certain it is, there can be no good man in whom this character does not shine conspicuous. Christ says to those on his right hand, " I was an hungered and ye gave me meat; I was thirsty and ye gave me drink ; naked and ye clothed me; sick and in prison, ye visited me." It was said, moreover, of the Roman centurion, though a Pagan, that his DISCOURSE. 5 " alms had gone up for a memorial before God." In neither case is there a word in anticipation of those creeds which have kept the Christian world in a state of irritation for more than fifteen centuries. Where can you find any people who have been as much known for active benevolence, in all its forms, as the physicians ? Dr. Johnson, writing in his seventieth year, and with a most extensive knowledge of the world, bears this testimony:—" Every great man has found in physicians great liberality and dignity of sentiment, very prompt effusions of beneficence, and willingness to exercise a lucrative art where there was no hope of lucre." You must not here object that physicians receive compensation * for at least a part of their services, for to receive pay for good works is an institution of Heaven. The apostle says that the laborer is worthy of his hire. He well knew that gratuitous service could not enter into the divine system of things in the present world; that selfishness is a necessary part of the human mind ; that without this stimulus the world would sink into sloth and indifference; but that antagonizing faculties and mo- tives were given at the same time to restrain its undue force and activity. Does any one say that the profession is often adopted at first from the sordid hope of lucre, or with the ambitious desire of distinction ? Let him be answered, that no young man who examines the history of medicine or contemplates the state of ( human society, would be thus allured by the expectation of riches or fame. In the examples of his predecessors he sees nothing but labor and deprivation, abandonment of home, and of nearly everything which by the English good liver, has been emphati- cally called comfort: and as to the hope of leaving a book be- hind him which may carry his name through a few generations, the view is too distant, at this early period of human life, to make any serious impression. If, then, wealth and fame are the young man's object, the glittering prizes are not seen to shine unless in the very zenith of medicine. No, gentlemen, these are not fascinations for the young and generous and uncorrupted bosom. We sincerely believe that nearly every young man who addicts himself to the regular profession, is evidently or insen- sibly inspired with a spirit of active benevolence. Thus the 6 DISCOURSE. late Dr. Wistar received his first impulse from the pleasure he found, when a boy, in administering to the wounded after the battle of Germantown; and I presume there are very few edu- cated physicians who cannot call to mind a similar impression. This spirit increases with his years and gains strength by use, until it is gradually blunted by ingratitude and other obtund- ing disappointments. These operate with a force proportioned to the sensibility of the unfortunate young man, who has set out in life with the romantic hope of supplying all his own wants by attending to the wants of his afflicted brethren, appealing to his own soul, like the benevolent Chremes to Menedemus—I am a man and no stranger to the cries of humanity.* A youthful spirit, thus nobly endowed, sets out in life with almost unlimited confidence in the honesty and benevolence of man, also with the animating hope of relieving the distresses of grateful patients ; but, alas, too soon he is confounded by every species of dishonesty, prevarication, and falsehood; by the hardheartedness and even cruelty of his fellow man. His observ- ations and collisions continuing from year to year, he must be more than human if he do not gradually lose a portion of his primitive respect for the objects of his youthful kindness. There is a point at which no man, however good and meek he may be, can be goaded and injured without some recalcitration, some feeling of resentment which cannot fail to be swelled by con- tinual repetition. Here, then, I would say to every young man, have your soul prepared for temptation, for you stand on the brink of an awful precipice and of everlasting ruin. Unless you successfully resist temptation, you may be driven insensibly into the broad road of misanthropy, and thus become wretched for life. There is no man so happy as he who loves mankind. To be repeatedly tempted, then, till the mind is perverted in its natural warmth of affection, thus rendered cold and apathetic, is certainly the greatest evil that can happen to any man. This is the very temptation to which physicians, above all other men, are perpetually liable. They witness poor human nature in all its worst and most disgusting phases; they are often unworthily * Homo sum—humani nihil a me alienum puto.—Terent. Heautont. Act I. Sc. 1. DISCOURSE. 7 the victims of her folly or malignity; hence there is perpetual danger of their falling from their first love, from that spirit of active benevolence which animated their youthful bosoms. Na- poleon said, that to pass through so many scenes of human misery, he ought to have acquired a heart of marble; it might be made a question whether he did not attain a heart of ada- mant. But, to use the words of Desgenettes to this adamantine heart, " Our business is to cure and not to kill;" hence it gene- rally happens, in the exercise of our benevolent calling, that, while we lose our respect for men, we do not at the same time lose our desire to serve and relieve them. I have now been student and physician forty-three years, and truly may it be » said, that I have almost uniformly known the regular practi- tioners to find, notwithstanding many temptations, their greatest pleasure and comfort in doing good; hence I cannot fail to look upon our science as an emblem of the waters of Bethesda, which, moved by angels, brought relief or comfort to the afflictions of men. After a long, and, as I believe, an honest contemplation of mankind, I am fully convinced that they do not justly appreciate the hearts and minds of physicians; for if they did, ingratitude would not prevail so rankly. Androcles took a thorn from the lion's paw and thus secured the perpetual favor and even fond- ness of that savage beast; the malignant viper has been con- ciliated by human kindness ; nor is there a wild animal so cruel by nature as not to be overcome and converted by a series of benefits. This cannot be said of those men whose pretended rule of life is, to do unto others as they could wish others to do unto them. You may have faithfully attended a family for many years, have apparently and confessedly saved one or more of them from the untimely grave; you have heartily participated in all their joys and sorrows; you have watched whole nights at their bed-side, your heart torn with anxiety for the fate of a wife, a husband, a parent, or a child; you have freely mingled your tears with theirs, wrhen the cold sweat appeared on your patient's brow; but, alas, a slight offence, merely one unlucky word, and all your long service is forgotten. Here, then, pre- pare your generous soul for temptation; for just in proportion 8 DISCOURSE. to your faithful affection, sorrow now will sink deep and sadden your heart. It often happens that you have attended a poor family for years, and also their various poor relations; let these miserable people succeed to affluence, and they know you no more. Some physician who has not seen them in their humility, is sure to be called to the rising family; "more certainly, says Dr. Rush, if at any time they have been the objects of your private bene- ficence. This will not surprise us, says the Doctor, when we recollect how forcibly the presence of a physician is calculated to remind them of the wooden hut or small and dirty apartments in which he first visited them." If the children of this poor family rise to affluence, they are certainly far above ordinary mortals if they ever wish to see you again. Their abandonment of their old physician is the more certain, if he remain poor; they throw him off as they do their old houses and furniture, things unsuitable to their new and more brilliant relations in life. Altogether different is the conduct of physicians when they rise into wealthy practice; they never forget or neglect those individuals among the poor who helped them to their early experience. Should any family be unable or unwilling to pay your long- accumulating bills, they suddenly leave you and employ another physician. If a wondering neighbor inquire the reason, they are sure to give you a bad name. Then follows their implacable hatred; for it is justly observed by Tacitus, that men always hate those whom they have injured. The clergy have long been the peculiar objects of the physician's bounty, and yet no people are more deeply stained with ingratitude towards their medical benefactors. You may have assiduously and gratuitously at- tended their families for years, and been thus long their faithful servants by night and by day, but no ties can bind them to you; the silver cords are suddenly broken and you know not why. The clergy, I am sorry to say it, are like children spoiled in the nursery. The great majority of them being poor and sub- sisting, shame to their people, on a beggarly salary, cannot be charged; but it has unfortunately happened that the rich also have had their names recorded on our charity list. How has this DISCOURSE. 9 come to pass? Has it been our fault or theirs? Alas, gentle- men, we must take half the blame to ourselves! Faults lie on either side of the Trojan walls. Iliacos intra muros peccatur et extra. But they have an audacity in demanding and-an ingra- titude in receiving, which may sometimes lead us into irresist- ible temptation. In the Episcopal Recorder, a very popular periodical, edited by a clergyman, physicians have been threat- ened with the loss of public favor if they dare to charge a clergyman whether rich or poor. In the number for January 8, 1848, a clergyman, after much bravado concerning the exemp- tion of his order, and much threatening if we dare to charge them, uses these remarkable and even portentous words: "The » physician who charges any minister whose circumstances are good or bad, is blind to the position he holds in the estimation of the worthy of his church and communion. This is not spoken at random, for often we hear the contemptuous epithet applied to the medical man who has so far forgotten himself and his noble science as to ask pay for the advice he should have gladly and freely given." And in the number for March 4, 1848, he says further: " I believe the time is near when the medical man will scorn to tax him whom God has commissioned to aid in removing the diseases of our spiritual nature. He will view it as a privi- lege to administer to Ms necessities, who has been separated to minister to Mm in holy things." Physicians are greatly to blame for this very troublesome state of their affairs. They have yielded to the temptation of seeking favor from the clergy, and dearly have they paid for what little they have received. Dr. Percival, more than fifty years ago, laid it down as a rule, that "such of the clergy as are qualified, either from their stipends or fortunes, to make a reasonable remu- neration, are not more privileged than any other order of pa- tients." But he says, that "those who experience the res angusta domi, should be visited gratuitously." He alludes to the poor clergy of England, many of whom lived, as Goldsmith says, "passing rich on <£40 a year.'' Dr. Rush says, "the pious clergyman who lives on a scanty salary, and the hired servants in families that we regularly attend, must never know the amount of their obligations to us." Rush 10 DISCOURSE. and Percival entirely agree, and the Kappa Lambda Society copied Percival's very words in their abstract from his ethics. The American Medical Association say, that "no profession is to be exempted from charges," and this was written, to my certain knowledge, in direct allusion to the clergy. Dr. Rush was cer- tainly a bright example of all that is excellent in morals, in reli- gion, in medical ethics, in all the obligations of a gentleman, and would not for any consideration, have been thought deficient in his respect for clergymen, yet he charged the rich clergy; and one of them, I have it from undoubted authority, used to com- plain of the amount of his bills. From those whom we do not charge, we have a right to expect some grateful acknowledg- ments. These we hope for in the name of justice, of gratitude, of common politeness; but let me ask how many of the clergy ever sent you any expression of thanks. I feel much disposed to say more on this subject, but my soul is unprepared for the temp- tation into which it would lead me. In conclusion, I am rejoiced in saying, that of the numerous clergy whom I have attended, there were not wanting a few who proved to be men of the high- est sense of integrity and honor. Great need is there for physicians to have their souls prepared for temptation, when they find their patients are guilty of decep- tion or falsehood. It is almost incredible to the uninitiated, how generally this odious and dangerous vice is practised upon them. It would almost appear, that many people consider it as entirely blameless in their medical conversation with physicians, some- thing excusable, like deception and falsehood in war, as though their lives depended thereupon. They surely do not even sus- pect the danger they incur; they know not how closely our cal- culations are sometimes made as to the congruity and as to the effect of diet and medical regimen. I once left a boy free from fever in his recovery from pneumonia, but at my next visit he had high fever and an irritated pulse. I accused him with hav- ing eaten something forbidden, but he and his mistress both strenu- ously denied it. I bled him till he puked and threw up a large quantity of chicken. Jim, who brought you this? Mistress! Now this was a religious woman, and would probably not have been thus criminal on any other subject. Her husband was a DISCOURSE. 11 poetaster, and she probably remembered in one of his Hudibrastic effusions, this appropriate couplet:— "'Tis only one of those white lies That Dr. Paley justifies." This is one of the most mischievous forms in which falsehood is employed; but there are cases far more odious, requiring the soul to be well prepared for temptation. Patients, in order to escape the payment of at least a portion of their bill, will some- times detract from the merit of your services. You have at- tended a patient through a serious illness and have left him per- fectly restored; some weeks or months elapse before you see him again, when he appears to your gladdened eyes to be in perfect health. Well, my friend, I am glad to see the roses in your cheeks: Yes, doctor, but I have had a poor time of it since you left me; I got no better till these three or four days past, when I began the use of maple sugar, and I think it has done more for me than all your medicine. I once made a most fortunate cure of a compound fracture, having healed the wound without suppuration ; the family soon afterwards moved to a place twenty miles distant. Three years after this, I met the father, and proposed to him the payment of my bill. He said the boy was very lame—that the leg was too short. Amazed and confounded with this story, I began to fear that the broken leg had not grown in proportion to the other. It happened that I had some friends in that neighborhood who instituted a strict inquiry, and even had the legs compared by a physician, when it proved that there was neither lameness nor shortening. Hence the odious culprit was glad to escape with the payment of my bill in full. But patients will not only lie to our injury, but also for the benevolent purpose of doing us the greatest good. They will often tell the most glaring falsehoods for the purpose of advanc- inc the interest of a favorite physician. In my first year at Northumberland, I rJut up, with my own hands, some bundles of tonic powders for a lady. I visited her occasionally, and was told that she was taking the medicine. Her health improved rapidly, and she went abroad among her neighbors to show her returning bloom and to praise the new doctor. About twelve 12 DISCOURSE. months afterward, I had occasion to look into the upper shelf of her chamber closet, when I had the mortification to see all my powders with the strings uncut. Even among many who are desirous of telling the truth, there is an irresistible propensity to exaggeration almost as blamable and mischievous as falsehood itself. They magnify, or diminish, or conceal their diseases and symptoms, to the great injury of themselves and the practice of medicine. Intolerance in religion is often one of the hardest difficulties that a young man has to encounter, and particularly if he has moved to a small town. Each sect would gladly have the village doctor for their fellow worshipper and coadjutor in their cause, hence disappointments and animosities arise. Each desires to have the advantage of his countenance and general influence. Thus, when President Monroe, making a tour through the States, arrived on a Saturday in a respectable city, he was assailed by deputations from various churches to invite him to their worship on the following day. In a small town, there is always to be found a hot-bed of polemic theology. If the doctor be a Catholic, he believes too much; if he be a Unitarian, he believes too little ; if he be a Quaker, he is a Pagan unbaptized. Well might M. De Tocqueville say, that we have more religious persecution in America than is to be found in any nation of Europe. Let the poor village doctor, then, prepare his soul for temptation, for he will not be permitted to love his own church in peace, though Jesus Christ had one disciple whom he particularly loved. To fall under the influence of a patron, is probably one of the greatest evils that can happen to a young physician, or to an old one who has moved into a new situation. The mischief he does you, is generally in proportion to his ardor in serving you; if this be intense, he is sure to make you enemies, and finally to become one himself. A female patron is the more dangerous, inasmuch as her sex are more ardent in all their undertakings, and finally more bitter in all their resentments. Be not tempted then by the allurements of patronage. So sensible Vas Dr. Johnson on this point, that he considered it as one of the greatest evils that could befall a literary man— " Then mark what ills the scholar's life assail, Toil, envy, want, the patron, and the jail." DISCOURSE. 13 When, therefore, you find any one disposed to make himself busy in your behalf, running about among sick people to recom- mend you, and to decry your brethren—then consider your path as beset with briers and thorns, snares and pitfalls, all which may lie concealed by the most alluring and deceitful temptations. Even an excessive warmth of friendship, is often a very dan- gerous thing and difficult to manage in any position of life, but particularly so between a patient and his medical adviser. More is expected on either side than human nature can accord, and dis- appointment follows. I have known an eminent physician who would not attend his relations for this very reason ; and I have known persons who would not employ a physician who was their intimate friend, because they might not find it convenient to dis- miss him as necessity or caprice might suggest. For the same reason, Dr. Turner advises physicians never to choose their friends from among their patients. This advice, says the good Dr. Rush, can never be followed by a heart that loves true ex- cellence. I would rather, he says, "advise you to give your benevolent feelings their full scope, and to forget the unkind re- turns you will often meet with, by giving to human nature a tear." Alas, gentlemen, as many tears as Heraclitus poured forth in the streets of Ephesus, would not suffice to relieve your saddened hearts. Physicians frequently spend much labor, time and money in disinterested acts of public beneficence, such as the prevention of disease and crime, the founding of asylums for human misery, or the enacting of laws to prevent it; they call upon the people for co-operation, but they call in vain; their appeals remain un- answered. The people will spend neither time, labor, nor money, by the advice of those who are suspected to be wiser than them- selves. They will sometimes do something in their own way; they will even ask the advice of physicians, but they will seldom adopt it—witness the Preston Retreat, and the deplorable con- struction of that unfortunate fabric on the banks of the Schuyl- kill. In this public contempt of our knowledge, we suffer no little temptation, for we have in view the great good that is denied to suffering humanity, by the waywardness and folly of impudent arrogance. Quackery has ever been a deformed and odious feature in so- 14 DISCOURSE. ciety, but still it was not wholly abominable as long as it kept its appropriate place and pretensions. As it existed in former times, it was a thing to be expected and therefore it did not startle us; it excited neither surprise nor wonder; it was the mere pseudo- progeny of the regular profession. But it has come forward, of late, under the imposing and sacred name of science, a new phi- losophy, now patronized by lawyers and ministers of religion. From all this I cannot say that we suffer much temptation. It will all soon pass away, and leave the next generation to wonder why their fathers regarded it. We deplore the mischief that is done to our fellow-creatures, but we cannot prevent it, except by the slow process of improving our profession and ourselves. It will sometimes happen, even among your friends, that you are secretly defrauded of your just praise. You have struggled laboriously and anxiously through a most difficult and dangerous case, and while you secretly glory in the success of the Hippo- cratic art, you find the cure is imputed to the sly interference of a busy neighbor. Sometimes, when a dangerous case is unex- pectedly cured, the friends will gravely observe, that the patient was not so ill as he was supposed to be, as though death was the only criterion of danger, or, as though no fatal case could be saved by medicine. If you have been particularly successful in an epidemic fever, if there have been fewer deaths in your village than in those of neighboring doctors, your very friends will gravely tell you, that the disease has been less violent. In this there is much tempta- tion, but you cannot say nay without reflecting on the merits of your brethren. What can you do? Nothing, nothing, but follow the advice the gaoler gave Socrates a few minutes before sending him the poison: " try to bear this unavoidable evil as lightly as possible.*" It has been well observed by Dr. Johnson, that " the misery of man proceeds not from any single crush of overwhelming evil, but from small vexations continually repeated.''! This observa- tion holds good with respect to both body and mind. As Lucre- tius observes: " the rings on your fingers are attenuated by use; * -----Xat?e Te Xs" wrilfai aif 'ea-j-Ttt <}>sc£i» t« avayitaia.—Phaid. sub fin. f Life of Pope. DISCOURSE. 15 mere drops of water excavate stone; the hard ploughshare se- cretly diminishes; the flinty pavement is worn away by the tra- veller's feet."* Thus it must be with respect to the integrity of the body and the placidity of the mind ; a single case of violence to either may be resisted or recovered from, but slow and unap- preciated irritations, long continued, will show their melancholy effects on the constitution of either body or mind. Now, it is to these that the physician, above all other men, is most unhappily exposed; hence his tenure of longevity, as ascertained by Cas- per of Berlin, is shorter than that of the minister, merchant, soldier, lawyer, artist, or literary man. When he visits his pa- tients, he is detained by their fretfulness in taking his medicines; by long stories of diseases and cures and deaths; hydropathia and homceopathia; what their grandmothers could cure with herbs; what uncle John had been reading and aunt Polly dream- ing. If, in addition to all this, and much more of the same kind, he find his patient worse; that his means have not been judi- ciously used; that some dissatisfaction is seen in the countenance of the sick or his friends, then—farewell to all comfort in the pre- sent case. But it would be a toil for you to hear, and for me to relate, the many " petty annoyances" which are peculiar to our profession. There is no physician who may not justly incur some blame. In the confidence which he reposes in his medical experience, he will often promise, for the comfort of his patient, more than he can finally perform; and when the failure is apparent, the pa- tient is disappointed, the physician confounded, and no little tact is required to unravel the unfortunate tissue of irritation on one side, and suffering on the other. Here let us resist tempta- tion, for the fault, if kindness can be called by this name, has been our own; and we must bear, like Socrates, the unavoidable evil as lightly as possible. We must remember, too, that we have often been praised when we did not deserve to be; and, as Dr. Priestly said in his own case, " Too much praise may go against too much blame." Among the petty annoyances may be considered the unseason- able calls that patients make upon their physician. You have- * L. i. 313. 16 DISCOURSE. struggled through a day of hard labor and have retired with the hope of some refreshing sleep, when you are suddenly called, for the first time, to a patient who has been ill since morning, and whose door you have recently passed. If you are a village phy- sician, you may be obliged to ride for miles through mud and storms and darkness. Prepare your soul for temptation, lest angry passions arise and contribute more to your discomfort than mud and storms with darkness and loss of sleep. Dr. Rush reprobates the great unkindness of patients in not sending for their physician in the early part of the day. They ought, moreover, to write, whether an immediate visit is required. It often happens that the message is sent by a servant who mis- takes the words of his master, and thinks to do him a service by urging a hasty visit. Another petty annoyance arises from the various falsehoods which you hear concerning physicians' charges. This irritation will continue forever, for the causes can never cease. We can- not measure our services, as Dr. Rush says, by scruples, drachms, and ounces; we cannot render items in our bills; we cannot con- descend to become shopkeepers. We try to accommodate our bills to the abilities of our patients; but we cannot tell the rich man that we have charged him generously and according to the fee-bill because he is rich and would be called a gentleman ; we cannot tell a poor man that we charged him almost nothing be- cause he is poor; hence, on comparing their bills, there appears to ignorant and ungenerous minds, some cause for dissatisfaction. What is to be done ? For my own part, I have always permitted the poor man, for his comfort, to consider his bill as a full charge, but this is attended by so many evils that I can hardly propose myself as a good example in this matter. I believe you are all agreed with me, that our services to the rich are made too cheap. To a wealthy man and a gentleman, either real or pretended, you pay ten or twenty anxious visits in a year—will any one say that a dollar a visit is a suitable com- pensation for this man to make ? A rich man pays his accou- cheur twenty dollars every two years, or perhaps only once in his whole life. A surgeon amputates the rich man's leg, heals the wound, restores him to his family, then holds out his hand for seventy-five dollars. A rich man's only child lies ill of a DISCOURSE. 17 dangerous fever, which keeps you uneasy and unhappy and almost sleepless night and day for five or six weeks—for this you receive one dollar a visit. Now, in such cases as these, and many others, it ought to be known to the public that we expect a bountiful compensation and a liberal present in addition thereto. But if you are mad enough to magnify your bill or expect a present, then prepare your soul for temptation and fall back on the old proverb, " blessed is he that expecteth nothing, for he shall not be disappointed." I cannot leave this subject without observing that the citizens of Philadelphia have become sadly corrupted or perverted, with respect to our charges. I have heard more complaints in one month by physicians in Philadelphia, than I heard during twenty-five years spent in Northumberland. I have heard from old people much concerning the low charges of Rush, Physick, and Wistar. Now one reason of this may be that a great por- tion of the wealthy people of Philadelphia have risen from the low or the middle class, who were charged according to their ability to pay. A physician who charges a rich man below what is just, hoping to gain popularity, or to appear noble and contemptuous of money, or to secure his own ease, injures his brethren and dis- honors his profession. Those physicians do very wrong who would persuade us that medical attendance is not a saleable article, but still you must not turn shopkeeper, and endeavor to undersell your neighbors ; you must not, to use an Irish pro- verb, have the meanness to throw out a herring to catch a cod, since you would thereby break the laws of the profession, and injure your brethren. There is one thing which the public ought to know and feel—it is that physicians are not shopkeepers, and ought not to be expected to send their bills unless to families which they regularly attend. To send a bill unasked is a hate- ful task ; to send or ask for the money is an abomination, and not consistent with the dignity of our profession. No man can even imagine Hippocrates or Sydenham sending for money, but it is our unhappy fate to undergo this hateful burden, or die like the horse of Scholasticus. There is one way in which those who cannot pay and those who do not intend to pay, might render us the greatest service. 2 18 DISCOURSE. Let them call or write and tell us so, make their apology, and tender their thanks. This is surely not too much to expect: it would prove a great comfort, and relieve us of all further trouble and of much temptation. Gratitude thus expressed pays your bill, and gives you good impressions of human nature: these may often prove of more value than money. The present author has thus mentioned a few of the discom- forts of a medical life. He has experienced them all, with many others too tedious to name, and he is sorry to say that he en- countered them with a soul by no means prepared for tempta- tion. He would, therefore, warn his younger brethren, as suc- ceeding voyagers down the stream of life, by what means they may avoid the rocks and shallows upon which his frail bark has often been wrecked. To prepare the soul for temptation, two conspicuous means, Philosophy and Religion, have been provided ; and, happily for mankind, they mutually assist and support each other. It was a maxim of the Stoics, that a wise man has all the means of happiness within himself; hence the paradox of Epictetus, that external circumstances do not trouble you, but merely the opinion you form concerning them.* This was to push philosophy to madness, and the man who would propose this sentiment in these times would surely be sent to Bedlam. Yet there is certainly a possibility of subduing our natural or acquired irritability, so as to enable us to pass with tolerable comfort through the various irritations of a medical life. I heard a respectable physician complain to the American Medical Association that his profes- sional path had been infested with briars and thorns. Alas, we have all been torn by these, for they often hear beautiful flowers and tempting fruit, in the plucking of which we may often suffer many and grievous wounds ; but let us not forget that it will depend greatly on the mental attemperament whether these shall kindly heal, or whether they shall fester and mortify. I am constrained to say, however, that the task of healing them is hard in proportion to the honesty and nobility of your mind; for if you have one spark of heavenly fire in your soul, you cannot hear falsehood, deceit, corruption, oppression, bad principles, * Manual. Cap. IV. DISCOURSE. 19 without expressing or showing your disapprobation; nor can you patiently tolerate the various impositions in your professional capacity. Be careful then that your own soul is prepared for such temptation, and your wounds will heal with the greater kind- ness. Do not suppose that I am proposing to throw off the dig- nity of man, and become, like Shakspeare's Polonius, a mere echo. Nay, gentlemen, if there is any man whose supple nature it is, to smile and bow and submit himself when he hears what he cannot approve, he is utterly beneath our notice or advice, and we leave him to the contempt of his own soul; but let him be assured that respect, or gratitude, or self-approbation he will never know ; and that, like Juvenal's Pacuvius, he can love no man nor can any man ever love him. He will steal on gently through life, he will escape the thorns but he will never pluck a rose. He is one of those of whom all men speak well, and of these the New Testament says, woe betide you. The pleasures and comforts of a medical life I have not men- tioned, because they do not come into the tenor of the present I discourse. They have been set forth by Dr. Rush with almost irresistible eloquence. They are very many, incomprehensible to the little vulgar and the great, almost incredible to ourselves, while it is consolatory to know that very few of our discomforts and disappointments are necessary attendants of the profession itself. Many of them have their origin in the ignorance or wickedness of men, very many in our own imprudence, and not » a few in those debilities from which human nature can never be free. Man is necessarily an erring being from youth to old age; such he was intended to be, so long as he may sojourn in this world of probation; such were all the good men of old; such will be every mortal to the end of time. This is necessary to the forming of that state of mind upon which his ultimate happiness must depend; necessary to the evolution of cardinal virtues. If mankind did not vex and persecute each other, there would be no such virtues as patience, fortitude, or charity—no forgiveness of injuries, no loving of enemies.* * The author goes on the principle that after you have done all in your power to avoid temptation, there will be enough left to try and to perfect the man: hence the propriety of the prayer, lead us not into temptation. Those people who 20 DISCOURSE. Be consoled, gentlemen, for in the practice of our divine art there is found every species of temptation which is necessary to the formation of a perfect character, and happy will it be for that physician who has prepared his soul therefor. In old age, the natural irritability of both soul and body is so much increased, that Solomon says, the very grasshopper is then a burden. Will any of us believe that Hippocrates or Sydenham, Boerhaave or Rush, was so easily fretted, or was ever driven into any inde- corum by the greatest irritation from patients or their friends ? The grasshopper was to them no burthen in their old age. The names of these venerable men bring into mind the saying of one of the ancients, I believe it was Plutarch, that every young man should propose some excellent character for his per- petual imitation. This precept, however, will admit, like most other ancient things, of much improvement. Better for us to take for model something from many, e pluribus unum, as did the framers of our good Constitution, and as Demosthenes did from the various great orators who preceded him. But could we superinduce upon these examples a few verses from the Sermon on the Mount, and put them fairly into practice, nothing further would be wanting to enable us to convert temptation into a mere trial of patience, and finally into a blessing. Does any one say that these verses are alone sufficient ? Let him be answered that he is greatly mistaken, for the contemplation of good examples is necessary in proving that precept can be brought into practice. This frequent view of the honestum in others will, moreover, teach what good men do in casualties similar to our own. It may act like the beau-ideal of Demosthenes, who must have formed himself, says Cicero, upon an imaginary model of collective excellencies. Do not presume that I am proposing a state of mind that is unattainable. But suppose this to be the fact, and that a phy- sician shall aim at such a state, may not the shining vision act upon him as Cicero says it did in forming the character of his own great prototype ? Whatever may be the cause thereof, no profession or state in life, as I believe, affords so many examples would court temptation in order to prepare themselves for future trials, seem to differ greatly from the author of this prayer. DISCOURSE. 21 of various goodness as that of medicine. So long and so tho- roughly have I been convinced of this, that I always consider a physician as a good man till the contrary is doubly shown. I would trust myself with a stranger in greater confidence from knowing him to be a regular physician. In justice to human nature, moreover, and to sound reasoning, we are bound to sup- pose that the multiplicity of circumstances which necessarily attend a medical life, all tending to mollify and improve the heart, have had their proper effect. When we are deceived, the greater is the deception. We must not, however, be too hasty to condemn, but must remember that pravity in a practitioner of medicine appears more conspicuous and detestable because of the purity that is therein expected and required. "'Tis like a stain upon a vestal's robe The worse for what it stains." But let us leave this disgusting paragraph and pursue the subject of our concluding pages. So great are the pleasures and I comforts of a medical life, that I once heard an aged physician, one of our own number, declare in the Medical Society of Penn- sylvania, that a physician, who was truly such, would be happy in his good works, though he had nothing better than a crust of bread and a cup of water. Here there was certainly some want of experience in this destitution; but it is not necessary to sup- pose this extreme case, for such are not to be found. Yet, if \ examples of virtue and contentment in humble life strike you with the greatest force, take the meek and lowly physician whose shining virtues secured the perpetual friendship of Dr. Johnson:— " Well tried through many a varying year See Levet to the grave descend, Officious, innocent, sincere, Of every friendless name the friend." It was the active, unwearied benevolence of this obscure philan- thropist that drew upon him the friendship and favor of that great man, whose heart was always open to humanity's impulse. He saw him going continually among the poor, bearing relief or comfort wherever he went, receiving with gratitude the most trifling compensation, often nothing more than a frugal meal. 22 DISCOURSE. For twenty years he had a gratuitous apartment in his pro- tector's house, and thence he sallied forth, comparing small with great, an humble Howard on his missions of humanity: — "No summons mocked by chill delay, No petty gains disdained by pride, The modest wants of every day The toil of every day supplied." Such a man steals gently through life without arrogance or pride, temptation or want, going from house to house by night and by day, in the faithful discharge of his many but not unim- portant duties. We have all had a portion of this humble practice, and perhaps there is nothing we can look back upon with more satisfaction. "Inmisery's darkest caverns known His ready help was ever nigh, Where hopeless anguish poured his groan, And lonely want retired to die." If his heart was as pure as his works were good, he lives now where sickness and poverty are never known. Do not presume, however, that I propose this good man as a universal example. There must be men of a higher rank in the science and practice—to study, to observe, to experiment, and to write, for the improvement of the art. But there is no physi- cian, however exalted, who may not carry into his more polite sphere of usefulness, a portion of those shining virtues and saint- like habits that drew upon the humble Levet the notice, and secured the perpetual friendship of the great Coryphaeus of lite- rature. Now, if we ourselves have not been equally contented and happy in the practice of medicine, if we have been torn by briers and thorns, which tempted us by their flowers and fruit, let us look back and survey the years that are past, to see whether the fault has not been our own, whether there has not been some want of application to those means, without which contentment and happiness are never found. It is an old say- ing, that fortune favors the brave; Hercules is represented in the fable as helping those who laid their own shoulders to the wheel; the great Frederic told our ambassador, that Providence always favored well-drilled battalions; in the New Testament we DISCOURSE. 23 are taught to watch and pray, lest we enter into temptation. Thus, it is remarkable in how many different ways the duties of man are urged upon him. But they must be fulfilled by care and labor, without which there can be no laudable success. In medicine, whatever there be in theology, there is no predestina- tion, there is no irresistible saving grace—the physician must predestine and save and grace himself. Finally, gentlemen, I am thoroughly convinced, there is no profession, no business, no condition of life so propitious to vir- tue and happiness as that of medicine. External comforts will often be rather deficient, but the serene soul, prepared for temp- tation, has but few wants, and these he well knows will soon find \ an end. I am not proposing a stoical contempt of circumstances, but merely that the soul should be attempered from youth to old age to the caprices of fortune, the stings of enemies, the neglect of friends, and to all the various temptations of a medical life. The physician thus fortified and prepared, goes cheerful and happy down the hill of life, his path not beset by briers and fc thorns, but embowered and bordered by flowers and fruits, his feeble heart rejoicing in the hope, and his dim eyes delighting in the view of an honorable grave, now seen, as it were, in the milder beams of his setting sun; and though unadorned by any costly marble, which even the wild fig tree, as the poet says, may break down and scatter, the humble mound will not soon be for- gotten—it will be honored both in heaven and in earth; it will be i enshrouded in the love both of God and man.