# A Discourse upon the Institution of Medical Schools in America/Preface

Preface.
My intention with regard to the latter, having been made known by general conversations only, I find has been often misunderstood. No wonder then, if, in consequence thereof, it has been sometimes greatly misrepresented.
This has, determined me to commit to the press the plan of practice by which I design to regulate myself as much as possible; and to deliver my sentiments very briefly on the expediency of a regular and distinct practice in the several branches of Medicine. The public will then be able to judge more ​clearly of the propriety of those measures, which, from a full persuasion of their great utility I venture to recommend.
First, I purpose to confine myself, in practice, to those cases which belong most immediately to the office of a Physician, that I may prescribe for and attend such cases to greater advantage. I shall therefore avoid, all I can, interfering in the proper business of surgery viz. manual operation.
I do not mean however to refuse to innoculate for the small-pox, where my patients or their friends object to employ another hand to make the incision. This may frequently happen, although there is no more difficulty or art required in it, than in cutting an issue and inserting a pea, or than in cupping and bleeding.
Secondly, I propose, in such cases as shall be required, to attend in consultation with other Physicians, on the same terms as those of character enter into consultation with one another.
​Fourthly, In such cases of surgery as require consultation, or the use of medicines, I am willing to attend, to prescribe, consult, or advise; but not to perform any operation myself, or dress any wound.
In regard to the apothecary and surgeon.
​Mr. Leighton will oblige himself to put up such prescriptions as arc ordered, in the best manner, and with the utmost fidelity and care, as well as at the most moderate rate.
As to fees.
I always mean that these shall be moderate, adapted to the circumstances of this place, of the patient and the attendance he may require.
As a rule of conduct to such as are quite unacquainted with the regular practice of physic, let them inform themselves what is the united expence for Medicines and attendance, as charged by the practitioners of eminence in this place. In such cases as can be exactly ascertained, I shall require no more from them, than they would be obliged to pay to others, as in the case of innoculation and attendance in the small pox; allowance being made for the Medicines. The same rule, as far as it can be observed in fevers and other disorders, might be applyed.
Practitioners in many cases make an advanced charge on their Medicines, so as to include for attendance. This is done to make up for the patients deficiency in fees, than which, when it is willful and not the effect of ignorance in the patient, nothing can be more equitable, or more expedient, ​except charging for attendance under its proper name. For Practitioners must be paid for their time and attendance, as well as for their Medicines, under whatever name they make the charge. Indeed the most extensive practice otherwise would be insufficient to support a family in a becoming manner, as the greatest part of their time is employed in visiting the sick. The paying of a physician for attendance and the apothecary for his Medicines apart is certainly the most eligible mode of practice, both to patient and practitioner. The apothecary then, who is not obliged to spend his time in visiting patients, can afford to make up medicines at a reasonable price; and it is as desirable, as just in itself, that patients should allow fees for attendance, whatever it may be thought to deserve. They ought to know what it is they really pay for Medicines, and what for physical advice and attendance.
Nobody, I believe, will deny that the practice of rating Medicines, at such a price as to include the charge for Medicines and attendance, is liable to gross impositions on the part of ignorant medicasters, too many of whom swarm in every city. Patients who are kept in ignorance of what price Medicines are, considered separately, and what is the value of physical skill and attendance, naturally think the original cost of Medicines, which are comparatively cheap, to be very dear, and undervalue the skill of a physician, ​his toil of study and his expence of time and money in his education, which have often amounted to very large sums and to many years spent abroad in quest of knowledge, as if they were of no consideration.
The levelling of all kind of practitioners so much with illiterate pretenders, who have art enough to gain employ, however ill qualified in that of healing diseases, has a tendency to deter persons, otherwise of just and liberal sentiments, from putting themselves to a further expence to gain knowledge, than what is sufficient to make money. This is to make a vile trade of physic, instead of a noble profession, which as it certainly is, so it ought to be esteemed.
I have been told more than once, upon reasoning on the subject, that people here are used to this method and dont love to change old customs. What is it more than to say,
"Si populus vult decipi, decipiatur
If people choose to be deceived, even let us keep them in their deception."?
Instead of making a charge of fees, I willingly leave to the patients themselves to give what ​they please, upon my dismission from further attendance, or as soon after their recovery as shall be thought convenient, without specifying any demand, unless where patients particularly require it. This I look for to prevent the necessity of making a book charge of fees, which is never done in any liberal profession.
By thus leaving the fee in a great measure, or wholly, to the free will and circumstances of the patient, a physician may be employed by the middling class of people as well as the rich.
Many who have no adequate notion of the true Value of attendance, or what rule is observed by others, may wish rather to be directed what fee to. pay for attendance, being desirous on one hand to avoid the appearance of being deficient in generosity, and on the other hand willing to recompence the physician for his care, without unnecessary prodigality. Such persons, upon intimation of their desires, it is to be hoped, will always find themselves fully satisfied in this particular.
As to attending poor patients gratis, and giving them my best advice; I shall chearfully take my share of that kind of practice with my brethern of the faculty. For I shall always esteem it a favourable ​circumstance, that puts it in my power to administer relief to persons, whole indigence forbids them to expect it upon any other terms.
These articles, I presume, will effectually remove the objection which has been most strongly urged, viz. that my method of practice would only suit the wealthy; and will prove that the expence to the patient is not greater, on the plan I have adopted, than in the common method of practice.
​This, and the advice of some judicious friends to endeavour to prevent the ill effects of prejudice, made me resolve to attempt such an alteration as might be better suited, at this time, to the customs and circumstances of the people.
The preceeding plan I have ever since constantly followed, to my entire satisfaction, and I hope to that of my patients. Truth requires of me to acknowledge to the public, that I have always found, as far as my practice has hitherto given me an opportunity of judging, that the insinuation, which has been made to deter me from this mode of practice, viz. that people are too narrow minded here, and show no generosity to a physician, only employing a doctor because he is cheap or lives near to them, is utterly groundless. In most instances I have found their generosity has much exceeded my expectations.
The necessity of regulating the practice of physic.
It will be readily acknowledged by every one that allows himself to reflect upon it, that some regulation in regard to a Physicians attendance upon the sick is now become highly requisite. Formerly, when the city did not occupy much above half the extent, practice was much more manageable than it is at present. Living was then cheap. Within my own memory, every article of expence was less by almost one half. So that what suited the circumstances of the place and people then does not suit them now. Yet we may believe the knowledge of Physic has been cultivated all along with considerable application. A medical education is at least become much more expensive, and a man has little chance, if he keeps free from empiricism, to get a tolerable living by physic now, unless he has spent some years in an expensive education in Europe. Is it not then more equitable to be paid for attendance, than to live by advancing the price of medicines?
I am not urging these as arguments for a more expensive practice, but for an improvement of it, by separating physic from surgery and pharmacy, which ​I think incompatible with them, at least according to the plan of education I have followed, by the advice of some of the most eminent and skillful judges of medical science of any in Great Britain.
What reasonable objection can be then offered against an improvement in the present method of the practice of physic, which, to a man in great business, is by every one allowed to be the most slavish profession known in this part of the world.
Every mechanic has a certain portion of time allotted to him for a relaxation from business, and for the enjoyment of social happiness. Physicians have next to none, but they are obliged to be at the call of the sick, every hour in the night as well as of the day. Were they born slaves to the public and not children? or, for such a voluntary surrender of their liberty and ease as is necessary to practise conscientiously, are they to have no compensation? Is it thought an unreasonable demand to be paid for a toilsome, but necessary attendance, amidst objects of the most moving distress, which deprives them much of the company of their own family and of a number of gratifications, which every other profession allows of without detriment? Where is the encouragement for a man to banish himself from all the endearing tyes of friends and relations, to spend the prime of ​life, and often the bulk of his fortune, to administer more skillful aid to the calamities of his distressed fellow mortals, if he is to be considered as entitled only to the same gratuity with those who employ all their time at home, in getting money, instead of spending it for the public good? or is he to be allowed no more, than if, in acquiring this knowledge, he had been supported at a public expence?—let unbiassed reason and justice determine.
I am sorry that the objections, which have been made to my proposed method of practice, have laid me under the disagreeable necessity of mentioning the kind of education I have had to qualify me for my profession, and to afford me a reasonable expectation of a living from my advice and attendance.
It is now more than fifteen years since I began the study of medicine in this city, which I have prosecuted ever since without interruption. During the first six years I served an apprenticeship with Dr. John Redman, who then did, and stills continues to enjoy a most justly acquired reputation in this city for superior knowledge and extensive practice in physic. At the same time I had an opportunity of being acquainted with the practice of other eminent physicians in this place, particularly of all the ​physicians to the hospital, whose prescriptions I put up there above the space of one year. The term of my apprenticeship being expired, I devoted myself for four years to a military life, principally with a view to become more skillful in my profession; being engaged, the whole of that time, in a very extensive practice in the army, amongst diseases of every kind. The last five years I have spent in Europe, under the most celebrated masters in every branch of Medicine, and spared no labour or expence to store my mind with an extensive acquaintance in every science, that related any way to the duty of a physician; having in that time expended, in this pursuit, a sum of money, of which the very interest would prove no contemptible income. With what success this has been done others are to judge, and not myself.
Thus I have arrived at the middle age of life, in endeavouring to lay up treasures of useful knowledge, before I commence a settled practice; and yet I have been told, that to expect to gain a support here by my medical advice and attendance only, without becoming a surgeon and apothecary too in order to help out, is to forget that I was born an American. I am very happy that my country has always discovered too much of a laudable ambition to excell in every branch of polite literature, and has taken too much pleasure in the reputation of her sons, to fill ​me with apprehension that an education in physic will be accounted too expensive, such as I have thought necessary to qualify myself for practicing my profession with ease of mind to myself and with benefit to the community.
As far as I can learn, every body approves of my plan for instituting medical schools, and I have the honour of being appointed a public professor for teaching physic in the college here. Can any man, the least acquainted with the nature of that arduous task, once imagine it possible for me to acquit myself in that station, in an honourable or useful manner, and yet be engaged in one continued round of practice in surgery and pharmacy, as well as physic?
On the advantages of a separate and regular practice of Physic, Surgery and Pharmacy.
In the more laborious occupations of life, as in building a house or a ship, a great variety as well as a great number of artizans are employed, but all in different departments.
In the less laborious callings we observe the like prudent regulations, thus in making a pipe, a button or a pin, a variety of hands, no less commonly than five, six, or seven different artists unite their industry. By this means they finish more work in a limited time, and can afford to sell it at a cheaper rate, than they could, if every individual was employed in all the separate branches. But each having a particular province assigned to himself, while all conspire in one uniform plan, they become more skillful and dextrous in their respective parts, and all more usefullly subservient to one end. Are the good qualities of accuracy, dispatch and cheapness, not to speak of the greater perfection of the work, no recommendation to the manner of doing it?
Why should the more difficult, but more ingenious and liberal arts, scorn to be taught wisdom from their example? Is it easier to understand the ​intricate structure of the animal frame, the work of God, than to learn the construction of any machine, as a watch or clock, the work of human invention? Or are the springs and movements of the former, so divinely adjusted, more easily managed and put to rights when in disorder, than the wheels of the latter? or does the preservation of this in a sound state require less study, knowledge, and conduct?
The human body is certainly one of the most compound machines in nature. Medicine is one of the noblest and most difficult of arts, made up of a number of sciences different from each other. The practice of physic requires deliberation, reasoning, judgement, and experience. Surgery calls for different powers and qualifications rarely uniting in one man. Are these then all to be blended with the apothecary, the botanist, and chymist, which ought to be, and are each of them separate and distinct in their very nature? Whilst we labour amidst such a variety of pursuits, all improvement must be at a stand. Whereas, let each cultivate his respective branch apart, the physician, surgeon, apothecary &c. the knowledge of medicine will be then daily improved, and it may be practiced with greater accuracy and skill as well as a less expence.
Prejudice may here ask, how can a physician practice with advantage, if he does not equally ​pursue every branch of his profession? or how shall he know that the Medicines are good, which he orders if he does not prepare them himself?
Answer, It is not only expedient, but necessary that a physician should have a general and extensive knowledge of the whole art, and be acquainted with the principles of every branch of his profession Thus the general of an army should be acquainted with every part of military science, and understand the whole detail of military duty, from that of colonel down to a private centinel. But there is no need that he should act as a pioneer and dig in a trench. Where a proper subordination is wanting, there is a perversion of all practical knowledge. No more then is a physician obliged, from his office, to handle a knife with a surgeon; to cull herbs with the botanist; to distill simples with the chymist; or compound drugs with the apothecary. Can he be more sure however that his Medicines are genuine, if he does not collect his own herbs and roots as a botanist, or distill with the chymist, than he can, if, omitting these, he should stick to the plaister-pan and spatula, or the pestle and mortar?
But practitioners in great business never do, or can do the business of an apothecary in this place, themselves. They have apprentices for ​the purpose. After visiting the sick, do not their apprentices make up their prescriptions? I would ask, is not an apothecary thoroughly acquainted with the art of compounding and making up Medicines as skillful in it as an apprentice? Is not a man educated in the profession to be trusted in preference to one who is only learning that business? or has the master, who may be called from place to place to attend other cases of surgery, or see other patients, always time to wait for medicines to be made up under his eye?
These queries are easy enough for every one to decide upon, without being brought up to the study of physic. Will he not therefore do a worthy action, whoever shall steadily apply himself to remove the difficulties which are in the way of regular practice? Will he not do real service to his country and mankind, for the good effects of which posterity may thank him? Who then would hesitate to rank himself amongst the foremost class of those who shall be concerned in a work of such real benefit to the public?
Having thus fully explained the method I propose for practising physic in this place, I appeal to the impartial judgment of the public to decide upon the question. Is. it to be deemed an idle innovavation, or is it not rather an improvement of practice in Philadelphia, to adopt a plan conformable to what is observed in great Britain and all polished countries, ​as far as the circumstances of this place admit? I profess myself open to conviction, and shall allow due weight to every reasonable argument that may be opposed to my plan. When I am rationally convinced that I have been in an error, I shall readily acknowledge and retract my sentiments, which I hope, till then, I may be allowed to continue, without being charged with an innovating spirit.
What remains yet to be done is to endeavour to elucidate a few passages, which have been thought exceptionable in the discourse by particular persons.
In some paragraphs, the opinions and practice of the faculty of physic in this place have been thought to have been too indiscriminately condemned.
​I doubt not that every practitioner here of education, experience and integrity, has pursued the plan which, in his opinion, was best suited to the place and people. But as circumstances alter, so does the propriety of particular established customs, which gradually give way to others better suited to those changes which happen in a course of years. May I not hope to meet with the same candour that I show to others, and be admitted to act from the same honest principles, in recommending what I think an improvement of practice, that I allow those who have pursued a plan different from mine?
Wherever there is the least appearance of being particular, or wherever I have spoken expressly of the pracitioners of this town, it has been in the most becoming manner and without the least censure, well knowing how much I myself need the indulgence of others.
"Mecum habito et novi quam sit mihi curta suppellex."
In confirmation hereof, I shall adduce a few instances to which the reader may refer. Thus I have said, p. 18. "and here we may congratulate ourselves, that in this, and some of the large neighbouring towns, we have a number of skillful physicians ​and expert surgeons, qualified by genius, education and experience to take charge of the health of their fellow creatures." And p. 30. "The city of Philadelphia, adorned with a set of eminent practitioners, draws to it a great number of pupils, from the neighbouring parts, to learn the arts of physic and surgery." Indeed the only part in which I have been particular, and there it was unavoidable, is in speaking of the physicians of the hospital, which I have done in terms of the highest respect. p. 31.
It is true, I have endeavoured, as well as I was able, to describe the mischievous effects that ensue from ignorance and presumption, when young men enter upon the practice of Medicine before they are duly instructed in the important duties of the profession. See p. 23. 24.
I have likewise urged the necessity of joining study with practice, and availing ourselves of the medical discoveries and improvements made by others. On the authority of a very learned society, I have also disapproved of the conduct of those, who, from prejudice affecting a simplicity, (which might often mislead them) disdain those persons who divide their time between study and practice. I have likewise added, on the same authority, that novices enlightened by the discoveries, which these practitioners shut ​their eyes against, would in their turn with reason despise them, when grown old in their errors," see p. 42 and 47.
But I have no where intentionally aimed the shaft of censure at any one, or attempted the character of a particular man; much less have I dared to attack indiscriminately a whole body of men. As far as I have engaged in painting the errors or faults of any, I have endeavoured to represent general actions of men, such as they are, and not the picture of individuals. Yet, as Le Sage has justly remarked, there are some persons who cannot read, and I say there are others who cannot hear, without making an application of those vicious or ridiculous characters which they learn from an author. With him I declare to all who have such a malicious propensity, that they are in the wrong to apply the portraits which they may find here exhibited; nor let any reader take for his own what may equally belong to another, otherwise he will foolishly expose himself, as Phædrus says,
"Stulté nudabit animi conscientiam."
​Some, it is said, have thought, that I have described the difficulties of attaining to the knowledge of physic in too strong terms, and have enumerated so many qualifications as requisite to acquire any considerable knowledge of the medical art, that I rather deter students, than encourage them in attempting to compleat their studies and to become skillful in their profession.
To these I reply, that I have been far from exaggerating, matters, and have left much unsaid, on purpose to avoid discouraging their eager pursuit. If we cannot arrive at absolute perfection in science, let us not abandon ourselves to a criminal indolence, but strive to approach that degree of knowledge which is attainable by industry, and we cannot fail of being eminently skillful in the healing art and highly useful to mankind.
Others, I am informed, as if they were afraid of engaging in too great an expence, have said that I have insisted too much on the necessity of students attending lectures in every different branch of medicine. They seem to imagine if they hear lectures upon Anatomy only, the branch which I have first mentioned in my discourse, that they can easily make themselves masters of all the other branches of medicine by reading. I blush for those who thus ​expose either their ignorance or their avarice. Why are they not equally contented with such a share of knowledge in anatomy, as they can gain from books, since this science can be better painted to the eye, than some of the other branches of medicine, which are altogether as necessary to be known by a physician? Are not anatomical plates and descriptions as intelligible to a student, as the philosophical studies of chymistry, physiology, and pathology are, from a mere course of reading? or is it of less consequence to gain a systematic knowledge of the materia medica, or practice of medicine, than of anatomy, which is of no other use to a physician than as it contributes its share towards explaining what diseases are? The others furnish him with the means and manner of performing the cure, and require, at least, as much labour and explanation as anatomy itself demands.
The worthy and learned Doctor Lewis is of opinion, "that the medicinal history, or the knowledge of the powers and effects of medicine in the human body, though apparently a most essential branch of the healing art, has been far more incuriously cultivated, and still perhaps continues less cleared from the errors of former ages than any other science." Another writer on the same subject says, "it is an idle supposition to set out upon, that there are the ​works of good chymists and good naturalists extant, and that from those a sufficient system of information on this important head may be compiled. To compile with judgement requires as much knowledge of the subject as to write well upon it. No man is qualified to execute this to advantage, who is not able to have written what he borrows. Even the best and most authentic books on these subjects have their errors, most of them too many; and while he who is himself deficient in the knowledge of the subject, cannot but be liable to take in these with the rest, it is evident what sort of dependance ought to be placed on his collections."
Whatever anatomical skill a man may boast, yet if he is ignorant of the virtues of Medicines, or of their changes from differently compounding them together, or knows not what are the true indications in the cure, or relief of diseases, he may value himself for expertness in dissection, but every sensible man will hold him cheap as a physician.
Nobody, who is anxious to be skillful in the divine art of healing, will be a niggard of the necessary trouble and expence of rendering himself intelligent in every thing his profession requires he should know. Whoever is sparing of these has no cause of complaint, if he is rewarded only according to his merit, unless ​he would invert scripture and the laws of reason, and casting his eyes on those who have sowed plentifully in knowledge and reaped but little pecuniary advantage from thence, think, from sowing sparingly, he has a better title to expect that his ignorance should be rewarded with a bountiful harvest.