? >


>:> ~>J>

>X> ~>
> » >>
}V»  >3>  » >>

         . >s»  >> ^

>; >> ->  >>  >>»>  »

3 J> »> 3

»>»  21V,


) 3 3 > >
>v 3> d •> :> >> ^
 >a>  >■■> l> 
n-
Surgeon  General's Office

W?f
i-x'ora^
m
ffiQ
\i.
'%
C7cc&cn,........................................
aOOj(JQOaoyOQjGQGQOQ><jQGa&QSJt*Z4
'&&&&& 
 
 

<
EXTRACTS
mm
DR. PERCIVAL.
y
Wt?
PHILADELPHIA:
1823. 
w 
EXTRACTS,  &c.
   I. Physicians and Surgeons should minister
to the sick, with  due impressions  of the import-
ance of their office; reflecting, that the ease, the
health,  and the lives of those committed to their
charge depend on their skill, attention,  and fide-
lity.  They should study,  also, in their deport-
ment, so  to unite tenderness with steadiness, and
condescension with authority, as to inspire the
minds of  their patients with  gratitude, respect,
and confidence.
   II. Every case, committed to  the charge of
a  physician or surgeon, should be  treated with
attention, steadiness, and  humanity: reasonable
indulgence should be granted to the mental imbe-
cility and caprices of the sick.  Secrecy and deli-
cacy, when required by peculiar circumstances,
should be strictly observed: and the familiar and 
4
confidential intercourse, to which the faculty are
admitted  in  their professional visits, should be
used with discretion, and with the most scrupulous
regard to fidelity and honour.
  III. The strictest temperance should be deemed
incumbent on the faculty; as the practice both of
physic and surgery at all times requires the exer-
cise of a clear and vigorous understanding: and
on emergencies, for which no professional man
should be unprepared, a steady  hand,  an acute
eye,  and an  unclouded head may be essential to
the well-being, and even to the life, of a fellow
creature.  Philip of Macedon reposed with entire
security on the vigilance and attention of his gene-
ral Parmenio.  In his hours of mirth and convi-
viality, he was wont to say,  " Let us drink, my
friends; we may do it with safety, for Parmenio
never drinks!" The moral of this story is suffi-
ciently obvious, when applied to the  faculty; but
it should certainly be construed with great limita-
tion by their patients.
  IY.  A physician should not be forward to make
gloomy prognostications; because they savour of
empiricism, by magnifying the importance of his
services in the treatment or cure of the disease.
But  he should not fail, on proper  occasions, to 
5
give to the friends of the  patient timely notice of
danger, when it really occurs, and even to the pa-
tient himself, if absolutely necessary.  This office,
however, is so peculiarly alarming, when executed
by him, that it ought to be declined, whenever it
can  be  assigned to any other person of sufficient
judgment and delicacy. For the physician should
be the minister of hope and  comfort to the sick;
that,  by such cordials to  the drooping spirit, he
may smooth the bed of death, revive expiring life,
and  counteract the depressing influence of those
maladies, which rob the philosopher of fortitude,
and the Christian of  consolation.
  V. Officious interference, in a case under the
charge  of another, should be carefully avoided.
No meddling inquiries should be made concerning
the patient; no unnecessary  hints given, relative
to the nature or treatment of his disorder; nor
any selfish conduct pursued,  that may  directly or
indirectly tend to diminish the trust reposed in the
physician or surgeon employed.  Yet,  though the
character of a professional  busy-body,  whether
from thoughtlessness or craft, is highly reprehen-
sible, there are occasions which not only justify,
but require a spirited interposition.  When artful
ignorance grossly imposes on credulity; when ne-
                       a2 
6
gleet puts to hazard  an important life; or rash-
ness threatens it with still more imminent danger;
a medical neighbour, friend, or relative, apprized
of such facts,  will justly regard his interference
as a duty.  But he ought to be careful, that the
information, on which  he acts, is well  founded;
that his motives  are pure and honourable;  and
that his judgment of  the measures pursued is built
on  experience and practical knowledge,  not on
speculative or theoretical differences of opinion.
The particular circumstances of the case will sug-
gest the most proper mode of conduct.  In general,
however,  a personal  and confidential application,
to the gentlemen of the faculty concerned, should
be the first step taken;  and afterwards, if neces-
sary, the transaction may be communicated to the
patient or to his family.
  VI. When a physician or surgeon  is called to
a patient, who has been before under the care of
another gentleman of the faculty, a consultation
with him should be proposed, even though he may
have discontinued his  visits: his practice,  also,
should be treated  with candour, and justified, so
far as probity and truth will permit. For, the want
of success in the primary treatment of a case, is no
impeachment of professional skill or knowledge; 
7
and it often serves to throw light on the nature of
a disease, and to suggest to the subsequent prac-
titioner more appropriate means  of relief.
  VII.  Consultations should be promoted in diffi-
cult or protracted cases, as they  give rise to con-
fidence, energy, and more enlarged views in prac-
tice. On such occasions, no rivalship or jealousy
should be indulged:  candour, probity, and all due
respect should be exercised towards the physician
or surgeon first engaged:  and as he may be pre-
sumed to be best acquainted with the patient and
with his family, he should  deliver all the medical
directions agreed upon, though he may not have
precedency in seniority or  rank.  It should be  the
province, however, of the senior physician first to
propose the necessary questions to the sick, but
without excluding his associate from the privilege
of making  farther inquiries, to satisfy himself, or
to elucidate the case.
  VIII. As circumstances sometimes  occur  to
render  a special  consultation desirable, when  the
continued attendance of another physician or sur-
geon might be objectionable to  the  patient,  the
gentleman  of the faculty,  whose assistance is re-
quired, in such cases, should pay only two or three
visits; and sedulously guard against all future un- 
                       8
solicited interference.  For this consultation,  a
double gratuity may reasonably be expected from
the patient; as it will be found to require an ex-
traordinary portion both of time and attention.
  In medical practice, it is not an unfrcquent oc-
currence, that a physician  is hastily summoned,
through the anxiety of the family, or the solicita-
tion of friends, to visit a patient, who is under the
regular direction of  another physician, to whom
notice of this call has not been given. Under such
circumstances,  no change in the treatment of the
sick person should be made, till a previous consul-
tation with the stated physician has  taken  place;
unless the lateness of the hour precludes meeting,
or the symptoms  of the case are too pressing to
admit of delay.
  IX.  Theoretical discussions should be avoided
in consultations,  as  occasioning perplexity  and
loss of time.  For there may be much diversity of
opinion,  concerning speculative points, with  per-
fect agreement in those modes of practice, which
are founded not on hypothesis, but on  experience
and observation.
  X.  In consultations,  the junior physician  pre-
sent should deliver his opinion first, and the others
in the progressive order of their seniority; and a 
9
majority should be decisive.   But, if the numbers
be equal, the decision should rest with the physi-
cian, under whose care the patient is placed.  No
decision, however, should restrain the acting prac-
titioner from making such variations in the mode
of treatment, as future contingencies may require,
or a further insight into the nature of the disorder
may show to be expedient.   The seniority of a
physician may be determined by the period of his
public and acknowledged  practice as a physician,
and that of a surgeon, by the period of his prac-
tice as a surgeon, in the place where each resides.
This  arrangement,  being clear  and obvious,  is
adapted to remove all grounds of dispute amongst
medical gentlemen; and it secures the regular con-
tinuance of the  order of precedency, established
in every town, which might otherwise be liable  to
troublesome  interruptions by new settlers, per-
haps not long stationary.
   XI. A regular academical education furnishes
the only presumptive evidence of professional abi-
lity, and is so honourable and beneficial, that it
gives a just claim to pre-eminence among physi-
cians, in proportion to the degree, in which it has
been enjoyed and improved:  yet, as it is not in-
dispensably necessary to  the attainment of know- 
10
ledge, skill, and experience, they, who have really
acquired, in a competent measure, such qualifica-
tions, without its advantages, should not be fasti-
diously excluded from the privileges  of fellowship.
In consultations especially, as the good of the pa-
tient is the sole object in view, and is  often depend-
ent on personal confidence, the aid of an intelligent
practitioner ought to be received with candour and
politeness, and his advice adopted, if agreeable to
sound judgment and truth.
  XII. Punctuality should be observed in the visits
of the faculty, when  they are to hold consultation
together.  But as this may not always be practi-
cable, the physician or surgeon, who first arrives
at the place of appointment, should  wait five mi-
nutes for his associate,  before his introduction to
the patient,  that  the  unnecessary  repetition  of
questions  may be  avoided.   No visits should be
made, but in concert, or by mutual agreement: no
statement or discussion of the case should take
place before the patient or his friends, except in
the presence of each of the attending  gentlemen of
the faculty, and by common consent:  and no prog-
nostications should be delivered, which are not the
result of previous deliberation and concurrence.
  XIII.  Visits to the sick should not be unseason- 
11
ably repeated; because, when too frequent, they
tend to diminish the authority of the physician, to
produce instability in his practice, and to give rise
to such occasional indulgences, as are subversive
of all medical regimen.
   Sir William Temple has  asserted, that " an
honest physician is excused for leaving his patient,
when he finds the disease growing desperate, and
can, by his attendance, expect only to receive his
fees, without any hopes or appearance of deserv-
ing them." But this allegation is not well found-
ed :  for,  the offices of a physician may continue to
be highly useful to the patient, and comforting to
the relatives around him, even in the last period
of a fatal malady, by obviating despair, by alle-
viating pain,  and by soothing mental  anguish.
To decline attendance, under such circumstances,
would be sacrificing, to fanciful delicacy and mis-
taken liberality, that moral duty,  which is inde-
pendent of, and far superior  to, all pecuniary  ap-
preciation.
  XIV.  Whenever a physician  or surgeon offi-
ciates for another, who is sick or absent, during
any considerable length of time, he should receive
the fees  accruing from such additional practice:
but, if this fraternal act be of short  duration, it 
\2
should be gratuitously performed; with an obser-
vance always of the  utmost delicacy towards the
interest and character of the professional gentle-
man previously connected with the family.
  XV.  Some general rules should be adopted by
the faculty, in every town, relative to the pecuni-
ary  acknowledgments of  their patients; and  it
should be deemed a point of honour to adhere to
this rule, with as much  steadiness as varying cir-
cumstances will admit.  For it is obvious, that an
average fee, as suited to the general rank of pa-
tients, must be an inadequate gratuity from the
rich, who often require attendance not absolutely
necessary;  and yet too large to be expected from
that class of citizens, who would feel a reluctance
in calling for assistance, without making some de-
cent and satisfactory retribution.
   But, in the consideration of fees, let it ever be
remembered, that though mean ones from the afflu-
ent  are both unjust  and degrading, yet  the cha-
ractcristical beneficence of the profession is incon-
sistent with sordid views, and avaricious rapacity.
To a young physician, it is of great importance to
have clear and definite ideas of the ends of his
profession; of the means for their attainment;
and of the comparative  value and dignity of each. 
13
Wealth, rank, and independence, with all the be-
nefits resulting from them, are the ends, which he
holds in view; and they are interesting, wise, and
laudable.   But knowledge, benevolence, and ac-
tive virtue, the means to be adopted in their ac-
quisition, are of still higher estimation.  And he
has the privilege and felicity of practising an art,
even more intrinsically excellent in  its mediate
than in its ultimate objects.  The former, there-
fore, have a claim to uniform pre-eminence.
   XVI. All members of the profession, together
with their wives and children, should be  attended
gratuitously by any one or more of the faculty, re-
siding near them, whose assistance  may be re-
quired. For, as solicitude obscures the judgment,
and is  accompanied with  timidity and  irresolu-
tion, medical men, under the pressure of sickness,
either as affecting themselves or their families, arc
peculiarly dependent upon each other.  But visits
should not be obtruded officiously; as such unask-
ed civility may give rise to embarrassment, or in-
terfere with that  choice, on which confidence de-
pends.  Distant  members of the faculty, when
they request attendance, should be expected to de-
fray the charges of travelling.  And, if their cir-
rumstances be affluent, a pecuniary acknowledg-
                      B 
14
incut should  not be  declined: for, no obligation
ought to be imposed, which the party would rather
compensate than contract.
  XVII. When a  physician  attends the wife or
child of a member of the  faculty, or any person
very nearly connected with him, he should mani-
fest peculiar attention to his opinions, and tender-
ness even to his prejudices.  For the dear and im-
portant interests, which the one has at stake, su-
persede every consideration of rank or seniority
in the other; since the mind of a husband,  a fa-
ther, or a friend, may receive a deep and lasting
wound, if  the disease terminate fatally, from the
adoption of means he could  not approve, or the
rejection of those  he wished to be tried.  Under
such delicate circumstances, however, a conscien-
tious physician will not lightly sacrifice his judg-
ment; but  will urge, with proper confidence, the
measures he deems to be expedient, before  he
leaves the  final decision concerning them to his
more responsible coadjutor.
  XVIII.  Clergymen, who experience the res an-
gusta domi, should be visited  gratuitously by the
faculty:  and this exemption should be an acknow-
ledged general rule, that the feeling  of individual
obligation  may be  rendered less oppressive.  But 
15
such of the clergy, as are qualified, either from
their stipends or fortunes, to make a reasonable
remuneration for medical  attendance,  are not
more privileged than any other order of patients.
Military or  naval subaltern officers, in narrow
circumstances, are also proper objects of profes-
sional liberality.
  XIX.  As the first consultation by letter imposes
much more trouble and attention than a personal
visit, it is reasonable, on such an occasion, to ex-
pect a gratuity of double the usual amount: and
this  has long  been the established  practice of
many respectable physicians.  But a subsequent
epistolary correspondence,  on the further  treat-
ment of the same disorder, may justly be regarded
in the  light of ordinary attendance, and may be
compensated as such, according to the circum-
stances of the case, or of the patient.
  XX. Physicians and surgeons are occasionally
requested to furnish certificates, justifying the
absence of persons, who hold situations of honour
and trust in the army, the navy, or the civil depart-
ments of government.  These testimonials,  unless
under particular circumstances, should be  consi-
dered as acts due to the public, and therefore, not to
be compensated by any gratuity.  But they should 
16
never be given without an accurate and  faithful
scrutiny into the case; that truth and probity may
not be violated, nor the good of the community
injured, by the unjust pretences  of its servants.
The same conduct is to he observed by medical
practitioners, when they are solicited  to  furnish
apologies for non-attendance on juries; or  to state
the valetudinary incapacity of persons appointed
to execute the business of constables, churchwar-
dens, or overseers of the poor.  No fear of giving
umbrage, no view to present or future emolument,
nor any motives of friendship, should incite to a
false, or even  dubious declaration.  For the ge-
neral weal  requires, that  every  individual, who
is properly qualified, should deem himself  obliged
to execute, when legally called upon, the  juridi-
cal and  municipal employments of the body politic.
And to  be accessary, by untruth or prevarication,
to the evasion of this duty, is at once a high mis-
demeanour against social order,  and a breach of
moral and professional honour.
   XXI. The  use  of quack medicines  should  be
discouraged by the faculty, as disgraceful to the
profession, injurious to health, and  often destruc-
tive even of life.  Patients, however, under lin-
gering disorders, are sometimes obstinately bent 
17
on having recourse to such as they see advertised,
or hear recommended, with a boldness and confi-
dence, which no intelligent physician dares  to
adopt with respect to the means that he prescribes.
In these cases, some  indulgence seems  to be re-
quired to a credulity  that is insurmountable: and
the patient should neither incur the displeasure of
the physician, nor be entirely deserted by him.
He may be apprized  of the fallacy of his expecta-
tions, whilst assured, at the same time, that dili-
gent attention should be paid to the process of the
experiment, he is so unadvisedly making on him-
self, and the consequent mischiefs, if any, obviated
as timely as possible.  Certain  active prepara-
tions, the nature, composition, and effects of which
are well known, ought not  to be proscribed as
quack medicines.
   XXII.  No  physician or surgeon  should dis-
pense a secret nostrum, whether it  be his inven-
tion, or exclusive property.   For, if it be of real
efficacy, the concealment of it is inconsistent with
beneficence  and  professional liberality:  and,  if
mystery alone give it value and importance, such
craft implies either disgraceful ignorance, or frau-
dulent avarice.
                      B 2 
18
  XXIII. The Esprit du Corps is a principle ot
action founded in human nature,  and, when duly
regulated, is both rational and laudable.  Every
man, who enters into a fraternity, engages, by a
tacit compact, not only to submit  to the laws, but
to promote the honour and interest of the associa-
tion, so far as they are consistent with morality,
and the general good of mankind.  A physician,
therefore, should cautiously guard against what-
ever may injure the general respectability of his
profession;  and should avoid all contumelious re-
presentations of the faculty at large; all general
charges  against  their selfishness or improbity;
and the indulgence of an affected  or jocular scep-
ticism,  concerning  the  efficacy and utility of the
healing art.
   XXIV. As diversity of opinion and opposition
of  interest  may, in  the medical, as in other pro-
fessions, sometimes occasion controversy, and even
contention; whenever such cases unfortunately oc-
cur, and cannot be immediately terminated, they
should be referred to the arbitration of a sufficient
number of physicians or of surgeons, according to
the nature of the dispute; or to the two orders
collectively, if belonging both to medicine and
 surgery.   But neither the subject matter of such 
19
references, nor the adjudication, should be com-
municated to the public; as they may be person-
ally injurious to the  individuals concerned,  and
can hardly fail to  hurt  the  general credit of the
faculty.
  XXV.  A wealthy  physician  should not give
advice gratis to the affluent; because it is an in-
jury to his professional  brethren.  The office of a
physician can never be  supported but as a lucra-
tive one;  and it is defrauding,  in some degree,
the common funds for its support, when fees are
dispensed with, which might justly be claimed.
  XXVI. It frequently happens, that a physician,
in his incidental communications with the patients
of other physicians,  or with their friends, may
have their cases stated to him in so direct a man-
ner, as not to admit of his declining to pay atten-
tion to them.  Under such circumstances, his ob-
servations should be delivered with the most deli-
cate propriety and reserve.  He should not inter-
fere in the  curative  plans  pursuedj and should
even"recommend a steady adherence to them, if
they appear to merit approbation.
  XXVII. A physician, when visiting a sick per-
son in  the country, may be desired to see a neigh-
bouring patient, who  is under the regular direc- 
20
 tion of another physician, in consequence of some
 sudden change or aggravation of symptoms.  The
 conduct  to  be pureued on  such an  occasion  is
 to give advice adapted to present circumstances;
 to interfere no farther than is  absolutely neces-
 sary with the general plan of treatment; to as-
 sume no  future direction, unless it be expressly
 desired;  and, in this case,  to request an imme-
 diate consultation with  the practitioner antece-
 dently employed.
   XXVIII. At the close of every interesting and
 important case, especially when it hath terminated
 fatally, a physician should trace back, in calm re-
 flection,  all the steps, which he had taken in the
 treatment of it.   This review of the origin, pro-
 gress, and conclusion of the malady; of the whole
 curative plan pursued; and  of the particular ope-
 ration of  the several remedies employed, as well
 as of the  doses and periods of time in which they
 were administered;—will furnish the most authen-
 tic documents, on which individual experience can
 be formed.   But it  is in a moral view, that the
practice  is here  recommended;  and it should be
performed with the most scrupulous impartiality.
 Let no self-deception be permitted in the retro-
spect;  and,  if errors, either of omission or com. 
21
mission, are discovered,  it  behoves,  that  they
should be brought fairly and fully to the mental
view.  Regrets  may follow,  but  criminality will
thus be obviated.  For, good intentions and the
imperfection of human skill, which cannot antici-
pate the knowledge that events alone disclose, will
sufficiently justify what is past, provided the fai-
lure be made conscientiously subservient to future
wisdom and rectitude in professional conduct.
  XXIX. The opportunities, which a physician
not  unfrequently enjoys,  of  promoting  and
strengthening the good  resolutions  of his pa-
tients, suffering under the consequences of vicious
conduct, ought never  to be neglected.  And his
councils, or even remonstrances, will give satis-
faction, not  disgust, if they be conducted with po-
liteness, and evince a genuine love of virtue, ac-
companied by a sincere interest in the welfare of
the person to whom they are addressed.
  XXX.  The  observance of the Sabbath  is  a
duty, to which medical men are bound,  so far as
is compatible with the urgency of the cases under
their charge. Visits may often be made with suffi-
cient convenience and benefit, either before the
hours of going to church, or during the intervals
of public  worship. And,  in  many chronic ail- 
22
ments, the sick,  together with their attendants.
are qualified to participate in the social offices of
religion; and should not be induced to forego this
important privilege, by the expectation of a call
from their physician or surgeon.
  XXXI. A physician who is advancing in years,
yet unconscious of any decay in his faculties, may
occasionally experience some change in the wont-
ed confidence of his friends. Patients, who before
trusted solely to his care and  skill, may now re-
quest that he will join in consultation, perhaps
with a younger coadjutor.  It behoves him to ad-
mit this change without dissatisfaction or fastidi-
ousness ; regarding it as no mark of disrespect,
but as the exercise of a just and reasonable privi-
lege in those by whom he is employed. The junior
practitioner may well  be supposed to have  more
ardour, than he possesses, in the treatment of dis-
eases ; to he bolder in the exhibition of new medi-
cines ; and disposed to administer old ones in doses
of  greater efficacy.  And this union of enterprise
with caution, and of fervour with coolness, may
promote the  successful management  of a  difficult
and protracted case.  Let the  medical  parties,
therefore, be studious to conduct themselves to-
wards each other with candour and impartiality; 
23
co-operating, by mutual concessions, in the bene-
volent discharge of professional duty.
  XXXII. The commencement of that period of
senescence, when it becomes incumbent on a phy-
sician to decline the offices of his profession, it is
not easy to ascertain; and the decision on so nice
a point must be left to the moral discretion of the
individual.  Because, one grown old in the useful
and honourable exercise of the healing  art  may
continue to enjoy, and  justly to enjoy,  the  una-
bated confidence of the public.  And whilst ex-
empt, in a considerable degree, from the priva-
tions and infirmities of age, he is under indispen-
sable obligations to apply his  knowledge and ex-
perience, in the most efficient way, to the  benefit
of mankind:  for, the possession of  powers is  a
clear indication  of the will of our Creator, con-
cerning their practical  direction.  But, in the or-
dinary course of nature,  the  bodily and  mental
vigour must  be  expected to decay progressively,
 though perhaps slowly, after the meridian of life
 is past.  As age advances, therefore, a physician
 should, from  time to time, scrutinize impartially
 the state of his faculties; that he may determine,
 bona fide, the precise degree, in which he is quali-
 fied to execute the active and multifarious  offices 
24
of his profession.   And whenever he  becomes
conscious, that his memory presents to him with
faintness those analogies, on which medical  rea-
soning and the treatment of diseases are founded;
that diffidence of the measures to be pursued per-
plexes his  judgment;  that, from a deficiency in
the acuteness of his senses, he finds himself less
able to  distinguish signs, or  to  prognosticate
events;—he should at once resolve, though others
perceive  not the changes which have taken place,
to sacrifice every consideration of fame or fortune,
and to retire from the engagements of business.
To the surgeon under  similar circumstances, this
rule of conduct is still more necessary; for  the
energy of the understanding often subsists much
longer than the quickness of eye-sight, delicacy
of touch, and steadiness of hand, which are essen-
tial to the skilful performance of operations.  Let
both the physician and surgeon never forget, that
their professions are public trusts, properly ren-
dered lucrative whilst  they fulfil them; but which
they are bound, by honour and probity, to relin-
quish, as soon as they find themselves unequal to
their adequate and faithful execution.
Clark & Raser. Printer , 33 Carter's Alley,
         Philad t+1■: <a. 
 
NATIONAL LIBRARY OF MEDICINE
C< Cmx
NLM  DDTflflTD5  3
       c<*  •:< <■ cc"  <-.•»?.: cccc  <:•
       ccc *;<•  c<t  «■«:_ c«<< c  '~

esc  «r< ccr ccc <sr  cc: c<r c~. _

tc« V.CV  <.  c«T

c<(i  <: cc c«ic«c co
 c_ «<  cot. <;  <c  <_ *~ < JgL <-C
 ^,  «t <:  <c  ce,' SF ,'A
 C«  <C  C cc ce< «L C

  <:« <«  <  c  < «» c-


  <_ « <$.c_ < cc  C <£ \
' <mr  <*  «  c <r  <r < c««:s
'C  CC  <C c C  C4( <c:ca.i' -

     C <  ,«L  c c  cc c «[<c<
. c c  <X c c «£«■
mm
m


C CC CjfSL c «

"Cv C «B -
<• C «§.'.'

CC<f:

_c«  <:c

C( recce-       _
<(CC. c cc*c   ccc

    V c  cc«c>  cc C
c  c  Cj^r -
C '< C c «
NLM009889053