From Medical America in the Nineteenth Century: Readings from the Literature. Edited by Gert H. Brieger, Baltimore and London: The Johns Hopkins University Press, 1972. Pp. 90-97.

Editor's Note

Benjamin Rush (1745-1813), one of America's most famous physicians, signer of the Declaration of Independence, medical writer and teacher, needs no introduction. His influence during the first decades of the nineteenth century vas widely felt. Although the lances and calomel purge that he favored so much doubtless caused much harm, his work for education, temperance, and the care of the mentally ill more than balanced the ledger.

Rush, who was active in various religious causes, sometimes sounded more as if he were delivering a sermon than a medical school lecture. The sermonizing is apparent in the following essay, which also nicely illustrates his opinion of the efficacy of active treatment and his contemptuous dismissal of the "ill directed operations of nature." It was partly against views such as Rush's that some of the writers of a later generation reacted. The school of therapy that relied more on nature than on art received a considerable hearing just after the middle of the century.(As Professor Shryock has pointed out, the condemnation of Rush at mid-century also affected the influence of the Paris school on American medical thought.)

Our city has again been afflicted by a malignant bilious fever. Its mortality has been much greater, in a given number of sick people, than in former years. In meditating upon the causes of this extraordinary mortality, I was led to contemplate the causes of death, not only in our late epidemic, but in other diseases which are not incurable, for the malignant bilious or yellow fever is not necessarily a mortal disease. In considering this subject, the first thing that occurred to my mind was the small proportion of people who die of diseases that are acknowledged to be incurable. In examining the bills of mortality, of all countries, how few people do we find die of aneurysms, epilepsy, internal cancers, and casualties, compared with the number of people who perish from fevers and other diseases which are admitted to be under the power of medicine. Perhaps the proportion of deaths from the former, compared with the deaths from the latter diseases, does not amount to more than one in a hundred. Ninety-nine persons, of course, die who might be cured by the proper application of remedies which are within the reach of reason and power of man. The business of the present lecture shall be to point out the various causes which render the means of saving life, that are known or attainable by us, thus abortive. The discovery of these causes will open a wide field for speculative truth, as well as practical virtue and happiness.

 In considering the causes of death in diseases which are not incurable, I shall mention:

 I. those which are derived from physicians;

 II. those which arise from the conduct of sick people; and

 III. those which arise from the conduct of their attendants and visitors.

 1st. Under the first general head, I shall first mention ignorance in a physician, arising from original incapacity or a want of proper instruction in medicine. But where there have been both capacity and instruction, there is sometimes an obliquity in the human understanding which renders it incapable of perceiving truth upon medical subjects. A mind thus formed, may acquire learning without knowledge, and it may even acquire knowledge upon all subjects except in medicine. But where there are talents that are in every respect equal to the profession (and these are by no means so rare as has been commonly supposed), there is often a deficiency in their application. This deficiency extends to reading and observation. Few physicians read after they enter into business, and still fewer profit by their observations. It is from the neglect of these two sources of medical knowledge, that we consider so many cases as new, that have existed a hundred times before, and that we prescribe the same remedies in all countries and seasons for diseases of the same name. No epidemic has the same symptoms or will bear the same treatment in a warm and cold climate. The muslin dresses of the East and West Indies would not be more unsuitable for the citizens of Philadelphia in the autumnal months, than the remedies of a tropical climate are for the diseases of those months in the middle states of America.

But again, epidemics often differ so much in their character in the same mate in different years as to require a difference of treatment. The yellow fevers of 1793, 1794, and 1797 in our city yielded, in most cases, to copious bleeding. They were, moreover, aggravated in those years in every case by bark d laudanum. In the yellow fever of the present year, the lances was used more sparingly, and bark and laudanum were administered in some cases with success. Lastly, the same epidemic differs in the same season in different kinds of weather. This remark was obvious in our late fever. Copious bleeding was forbidden, in almost every case, in the month of August. Emetics at this time had a much happier effect. After the 20th of September, and during the whole month October, copious bleeding, in many instances, supplied the place of emetics, and produced, when properly used, a safe and easy termination of the disease.

 2d. A cause of death in diseases that are not incurable arises from the negligence of physicians. This negligence extends to their delays in not obeying immediately the first call to a patient, to their inattention to all the symptoms and circumstances of a disease in a sick room, and to the time of their visits not being accommodated to those changes in a disease in which remedies of a certain character can be applied with effect. Negligence from the first of those three causes has occasioned the death of many patients. A conduct, the reverse of that which has been mentioned, is happily commended by Dr. Johnson in his friend and physician, Dr. Levet, in an elegant ode to his memory. The talents of this physician were said to be moderate, but his success was considerable in his extensive practice among the poor, owing chiefly to his early and immediate compliance with the calls of his patients.*

*"No summons mock'd by chill delay,

No petty gain disdain'd by pride,

The modest wants of every day,

The toil of every day supply'd."

3d. Physicians render curable diseases mortal, in many instances, by their connecting the measure of their services to the sick with pecuniary considerations. This is one reason why more of the poor than of the rich die of mortal epidemics. They are in general either deserted by physicians altogether or attended in such a desultory manner that medicine has but a slender chance of doing them any service. Extravagant charges for medical advice and attendance have, in several cases that have come to my knowledge, produced such delays in sending for a physician as have given a curable disease time to advance to its curable stage. These delays, though apparently originating with patients, should be traced wholly to the conduct of physicians.

 4th. Forgetfulness in a physician to visit his patients or to send them medicines at regular and critical hours has occasioned the death of many persons in diseases that might, under other circumstances, have been cured.

 5th. A preference of reputation to the life of a patient has often led physicians to permit a curable disease to terminate in death. This disposition is more general than is known or supposed by the public. The death of a patient, under the ill-directed operations of nature, or of what are called lenient and safe medicines, seldom injures the reputation or business of a physician. For this reason many people are permitted to die who might have been recovered by the use of efficient remedies.

 6th. A sudden indisposition attacking a physician, so as to prevent his regular and habitual visits to his patients, has often been the cause of death, where a favorable issue of a disease would otherwise have taken place. This source of mortality is most obvious in general epidemics, when the disease is dangerous, the patients numerous, and the time of brother physicians so completely occupied as to prevent their affording the persons who have been deserted the least substituted aid.

 7th. Where none of the causes of mortality which have been enumerated have occurred, patients are sometimes lost in curable diseases by fraud and uncertainty in the composition and doses of medicines, by which means they produce greater or less effects than were intended. Many persons have died from an excess in the operation, or from the inertness of a dose of James's powder. The tartarized antimony has as often deceived the hopes of a physician. It was to obviate these evils that Mr. Chaptal expressed a wish that "Those heroic remedies which operate in small doses, should produce constant and invariable effects through all Europe," and wisely proposed that "Governments, which do not apply their stamp of approbation to objects of luxury, until they have passed a rigid inspection, should prohibit traders from circulating, with impunity, products upon which the health of the citizen so essentially depends."* (*Vol. ii, p. 261, 262.)

8th. The prescriptions of physicians, written in a careless and illegible hand, have sometimes produced mistakes in the exhibition of medicines which have been the means of destroying life in diseases that had no tendency to death. Verbal prescriptions have occasionally been followed by the same unfortunate issue. The bare recital of these facts should render perspicuity in writing and speaking an essential part, not only of the learning but of the morality of every physician.
 
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We proceed, in the second place, to mention those causes of death in curable diseases which originate with sick people; and here we must begin, as under our former head, by mentioning ignorance. Medicine has, unhappily for mankind, been made so much a mystery that few patients are judges of the talents or qualifications of physicians; hence the bold and the artful are often preferred to the modest and the skilful. The desire of health, like the love of money, it has been said, levels all ranks and capacities; and, however much what is called a liberal education may enable men to form correct opinions upon certain subjects, it gives them no preeminence in medicine. In this science the rich and the poor, the learned and the illiterate are actuated, in common, by the same vulgar prejudices. Our late epidemic furnished many proofs of the truth of these remarks. An opinion had become current and popular that the disease was aggravated by harsh remedies and that it was to be cured by the operations of nature, aided by the most simple medicines. To the influence of this opinion must be ascribed, in part, its greater mortality than in former years. Patients who suffered by this species of ignorance, not only renounced all knowledge upon other subjects where innumerable analogies suggested the reasonableness of accommodating means to ends, but they rejected the analogy of a practice in diseases which habit had long made familiar to them. What patient is so ignorant as not to use more powerful remedies in a pleurisy than in a common cold? and yet the same patient cannot comprehend that a yellow fever is to a mild remittent, what violent inflammation of the lungs in a pleurisy is to a moderate affection of the same parts in a catarrh.

 2d. Prejudice in patients in the choice of a physician has sometimes rendered diseases mortal which are not incurable. This prejudice is either of a religious or political nature. The former leads men to prefer physicians of their own sect; the latter, of their own party, without any regard to talents or knowledge. It is because our profession is a degraded one, that gentlemen of other professions usurp the right of thinking for us upon political questions. The world does not treat the profession of the law with so much disrespect. Eminent talents at the bar command business from men of all parties. The reason for this difference in he conduct of mankind towards the two professions is that the value and danger of property is better known and more sensibly felt than the value and danger of health and life.

 3d. Fashion has a powerful influence in determining sick people in the choice of a physician; and as the leaders in it are generally as ignorant as those who follow them of the true characters of physicians, men are preferred who add by heir ignorance to the mortality of curable diseases. In Europe the common people follow the example of the privileged orders in their choice of a physician. In this country, wealth gives the tone to medical reputation. It is remarkable that the effects of patronage, whether it be derived from titles or money, are as little influenced by success in the treatment of diseases as they are by talents, for it has frequently been observed that the most fashionable physicians are the least successful in their practice. Nor does a general knowledge of this fact affect the business of such physicians while they retain the favor of the great. This imitative disposition in human nature extends to other things as well as to the preservation of health. It discovers itself in acts the most opposite to the common feelings and principles of action in man. It leads man, in some instances, to delight in deformity. The humpback of Alexander was aped by all his officers. It does even more. It leads men to covet diseases and pain. Dionis tells us in his surgery, that after he had cut Lewis XIV, for a fistula in ano, he was called upon by a great number of the nobility of France to examine whether they had not the same loathsome disorder, and he adds that they always appeared to be offended when he informed them they were not affected with it.

 4th. Many patients die of curable diseases by neglecting to apply in due time for medical air. Cancers and consumptions have been called incurable diseases. This is far from being true. If the tumors which precede nearly all cancers were extirpated immediately after they were discovered, and if the premonitory symptoms of consumption were met by proper remedies we should seldom hear of persons dying of either of those diseases. Our newspapers frequently told the public that our late epidemic baffled the skill of our physicians. This assertion was not well founded. Most of our physicians declared that the disease, after the first day, was incurable. In this they discovered a just knowledge of it; and in this knowledge skill consists. It should rather have been said that the disease baffled the hopes of patients who supposed their indisposition was occasioned by a trifling cold and neglected to send for a physician at the only time in which it was under the power of medicine. Few cases proved fatal under any mode of practice where physicians were called in the forming state of the disease.

 5th. The neglect in patients to comply with the prescriptions of their physicians has, in many instances, rendered diseases fatal that might have been cured. It is from disobedience to our prescriptions, whether it be founded in ignorance of the danger of the disease under which sick people labor, or upon the calls of business or pleasure predominating over sickness and pain, or upon the unpalatable nature of certain medicines, or upon a dread of the pain of others that we sometimes discover, after the death of our patients, medicines that would probably have saved them upon a mantlepiece or in the drawers of a dressing table. Patients, who recover sometimes humorously insult their physicians by telling them of the improper and even prostituted use to which they have applied their medicines. Sir Richard Nash was once asked by his physician if he had followed his prescription "If I had," said Sir Richard, "I should certainly have broken my neck, for I threw it out of my window." Fear has prevented, in many instances, the successful application of bloodletting in the cure of diseases. False delicacy, by restraining the use of clysters, has sometimes been attended with the same fatal consequences. The former weakness is the more mischievous, from its disguising itself under the apparent dictates of judgment.

 6th. The neglect in patients to make use of the remedies of their physicians at the time and in the manner in which they were prescribed is a frequent cause of death in curable diseases. In acute indispositions, the cure often turns upon a remedy being used, not only on a certain day, but at a certain hour. Purges, vomits, bleeding, blisters, sweats, and laudanum have all their precise days, hours, and perhaps less divisions in time, of being useful; before or after which they are either ineffectual, or do harm. Our late epidemic furnished many proofs of the truth of this remark, more especially in the use of blood-letting. Few persons died of it where the prescription of the lances was complied with in the early part of the first day of the fever; and few recovered where it was used for the first time on the second or on any other of its subsequent days. Its efficacy was most observable in its paroxysms. In its remissions, bleeding was less proper, and sometimes hurtful. But patients not only injure themselves by neglecting to use remedies at the time, but by using them in a different manner from that in which they are prescribed. They take more or less of their medicines, or they lose more or less blood than was intended, and often at a time when life and leash are perched upon the same beam and when the smallest particle of error gives it a preponderance in favor of the grave....

 Thus have I pointed out the principal causes of death in diseases that are not incurable. If the operation of any one of those causes has been attended with fatal consequences, what must be the combined effects of them all?

 Here gentlemen let us make a pause. Many useful reflections are suggested by the observations which have been delivered. I shall briefly mention such as are obviously connected with the subject of our lecture.

 1. In the first place, let us do homage to the divine goodness. From what has been said, it is evident that our Creator has provided us in the most ample manner with the means of health and life; and if they fail of producing their mended effects it is only because they are rendered ineffectual by the ignorance, folly, and wickedness of man.

 2. Let us duly appreciate the difficulties of a physician's studies and labors. He must embrace and control as many objects in contending with a disease, more especially if it be of a dangerous nature, as a general does in arranging his troops and fighting a battle. Death presses upon him from numerous quarters; and nothing but the most accumulated vigor of every sense and faculty, exerted with a vigilance that precludes the abstraction of a single thought or the repose of a moment, can ensure him success in his arduous conflict. It is possible for a patient to reward the mechanical parts of the labor and knowledge of a physician, but no compensation can ever be an equivalent for such paroxysms of solicitude and mental excitement as have been described and which occur at all times, and more especially during the prevalence of great and mortal epidemics.

 3. From what has been said we may learn that medicine is a more certain and perfect science than is commonly supposed. To judge of its certainty by the limited nature of its usefulness is to exclude from our calculations all the circumstances which have been mentioned that militate against successful practice. As well might we deny the fertility of a soil because the owner of it neglected the proper seasons and ways of cultivating it, as deny the certainty of medicine because it does not produce salutary effects in spite of the combination of voluntary ignorance, error, and vice against them.

 4. In contemplating our present want of success in curing diseases that are not necessarily mortal let us apply ourselves with fresh ardour to remove the obstacles which are opposed to the perfection of our science. It was often and well said by the late Dr. Jebb, "that no good effort was lost." The seeds of improvement and certainty in medicine, which are now sown and seem to perish, shall revive at a future day and appear in a large increase in the health and lives of our fellow creatures. Let this reflection console us under the disappointments we meet with in our attempts to extend the usefulness of our profession. The distance occasioned by time between the different generations of mankind will soon be destroyed, and we shall find, with inexpressible comfort, in the final settlement of our account of the good and evil we have done in this life that our abortive labors of love to our contemporaries have not been lost in the total amount of human benevolence.

 5. I have said that the ignorance, folly, and wickedness of man have hitherto defeated the purposes of the divine benevolence to his creatures. The force of human reason has long been tried without effect as a remedy for folly and vice. The true character of this operation of the mind has been discovered, in an eminent degree, in the absurd principles and criminal pursuits which have lately actuated the greatest part of mankind. To remove the folly and vice which obstruct the progress of medical knowledge and assist in rendering curable diseases mortal, the influence of religion must be added to the operations of reason. I once conversed with an ingenious traveller in this city upon the subject of language. He remarked that it would never be perfect while morals continued in their present imperfect state, for words could never have a just and appropriate meaning until a sacred regard to truth regulated their application to qualities and actions. This connection between morals and philology, thus pointed out, is not more intimate and necessary than the connection of morals and medicine. I admit in this place of no mortality but that which is derived from religion. It is this divine principle alone that can subdue all the folly and wickedness which concur in rendering curable diseases incurable. Physical and moral evil begin together. They have constantly kept pace with each other, and they must decline and cease at the same time. It is the business of reason to remove physical evil; moral evil can only be removed by religion; but to ensure the success of the former it must be combined with the latter, for reason without religion is like the clay-formed image of our first parent, before his Creator infused into him the breath of life. It is true, the dictates of right reason and religion are the same, for they both hold out truth and virtue as our supreme good; but they differ in this particularÐreason furnishes the feeble and transitory motives to pursue them, while religion, by its powerful and durable impressions upon the will, disposes us to choose them as the only means of regulating our conduct and ensuring our happiness.

 I shall conclude this lecture by remarking that I have many reasons of a personal nature for being thankful to God for my presentation from death during our late mortal epidemic, but none of them operate with more force upon my mind than the privilege I this day enjoy of again meeting my beloved pupils, in order once more to disseminate among them principles in medicine which I believe to be true and which I know to be useful.

 Bibliographical Note

 Rush's monistic theory of disease causation . . . has been described by Professor Shryock in Medicine and Society in America, 1660-1860, New York: New York University Press, 1960, available in paperback reprint; and in his article "Benjamin Rush from the Perspective of the Twentieth Century," Trans. Studies Coll. Phys. Phila. 14 1946): 113-20, reprinted in Medicine in America, Baltimore: The Johns Hopkins Press, 1966, pp. 233 51. See also Nathan G. Goodman, Benjamin Rush, Physician and Citizen, 1746-1813, Philadelphia: University of Pennsylvania Press, 1934; Letters of Benjamin Rush, L. H. Butterfield, ed., 2 vols., Princeton: Princeton University Press, 1951; and George W. Corner, ed., The Autobiography of Benjamin Rush, Princeton: Princeton University Press, 1948.