Science & Education: Essays

by Thomas Henry Huxley

One half of the Johns Hopkins bequest is devoted to the establishment of a hospital, and it was the desire of the testator that the university and the hospital should co-operate in the promotion of medical education. The trustees will unquestionably take the best advice that is to be had as to the construction and administration of the hospital. In respect to the former point, they will doubtless remember that a hospital may be so arranged as to kill more than it cures; and, in regard to the latter, that a hospital may spread the spirit of pauperism among the well-to-do, as well as relieve the sufferings of the destitute. It is not for me to speak on these topics--rather let me confine myself to the one matter on which my experience as a student of medicine, and an examiner of long standing, who has taken a great interest in the subject of medical education, may entitle me to a hearing. I mean the nature of medical education itself, and the co-operation of the university in its promotion.

What is the object of medical education? It is to enable the practitioner, on the one hand, to prevent disease by his knowledge of hygiene; on the other hand, to divine its nature, and to alleviate or cure it, by his knowledge of pathology, therapeutics, and practical medicine. That is his business in life, and if he has not a thorough and practical knowledge of the conditions of health, of the causes which tend to the establishment of disease, of the meaning of symptoms, and of the uses of medicines and operative appliances, he is incompetent, even if he were the best anatomist, or physiologist, or chemist, that ever took a gold medal or won a prize certificate. This is one great truth respecting medical education. Another is, that all practice in medicine is based upon theory of some sort or other; and therefore, that it is desirable to have such theory in the closest possible accordance with fact. The veriest empiric who gives a drug in one case because he has seen it do good in another of apparently the same sort, acts upon the theory that similarity of superficial symptoms means similarity of lesions; which, by the way, is perhaps as wild an hypothesis as could be invented. To understand the nature of disease we must understand health, and the understanding of the healthy body means the having a knowledge of its structure and of the way in which its manifold actions are performed, which is what is technically termed human anatomy and human physiology. The physiologist again must needs possess an acquaintance with physics and chemistry, inasmuch as physiology is, to a great extent, applied physics and chemistry. For ordinary purposes a limited amount of such knowledge is all that is needful; but for the pursuit of the higher branches of physiology no knowledge of these branches of science can be too extensive, or too profound. Again, what we call therapeutics, which has to do with the action of drugs and medicines on the living organism, is, strictly speaking, a branch of experimental physiology, and is daily receiving a greater and greater experimental development.

The third great fact which is to be taken into consideration in dealing with medical education, is that the practical necessities of life do not, as a rule, allow aspirants to medical practice to give more than three, or it may be four years to their studies. Let us put it at four years, and then reflect that, in the course of this time, a young man fresh from school has to acquaint himself with medicine, surgery, obstetrics, therapeutics, pathology, hygiene, as well as with the anatomy and the physiology of the human body; and that his knowledge should be of such a character that it can be relied upon in any emergency, and always ready for practical application. Consider, in addition, that the medical practitioner may be called upon, at any moment, to give evidence in a court of justice in a criminal case; and that it is therefore well that he should know something of the laws of evidence, and of what we call medical jurisprudence. On a medical certificate, a man may be taken from his home and from his business and confined in a lunatic asylum; surely, therefore, it is desirable that the medical practitioner should have some rational and clear conceptions as to the nature and symptoms of mental disease. Bearing in mind all these requirements of medical education, you will admit that the burden on the young aspirant for the medical profession is somewhat of the heaviest, and that it needs some care to prevent his intellectual back from being broken.

Those who are acquainted with the existing systems of medical education will observe that, long as is the catalogue of studies which I have enumerated, I have omitted to mention several that enter into the usual medical curriculum of the present day. I have said not a word about zoology, comparative anatomy, botany, or materia medica. Assuredly this is from no light estimate of the value or importance of such studies in themselves. It may be taken for granted that I should be the last person in the world to object to the teaching of zoology, or comparative anatomy, in themselves; but I have the strongest feeling that, considering the number and the gravity of those studies through which a medical man must pass, if he is to be competent to discharge the serious duties which devolve upon him, subjects which lie so remote as these do from his practical pursuits should be rigorously excluded. The young man, who has enough to do in order to acquire such familiarity with the structure of the human body as will enable him to perform the operations of surgery, ought not, in my judgment, to be occupied with investigations into the anatomy of crabs and starfishes. Undoubtedly the doctor should know the common poisonous plants of his own country when he sees them; but that knowledge may be obtained by a few hours devoted to the examination of specimens of such plants, and the desirableness of such knowledge is no justification, to my mind, for spending three months over the study of systematic botany. Again, materia medica, so far as it is a knowledge of drugs, is the business of the druggist. In all other callings the necessity of the division of labour is fully recognised, and it is absurd to require of the medical man that he should not avail himself of the special knowledge of those whose business it is to deal in the drugs which he uses. It is all very well that the physician should know that castor oil comes from a plant, and castoreum from an animal, and how they are to be prepared; but for all the practical purposes of his profession that knowledge is not of one whit more value, has no more relevancy, than the knowledge of how the steel of his scalpel is made.

All knowledge is good. It is impossible to say that any fragment of knowledge, however insignificant or remote from one's ordinary pursuits, may not some day be turned to account. But in medical education, above all things, it is to be recollected that, in order to know a little well, one must be content to be ignorant of a great deal.

Let it not be supposed that I am proposing to narrow medical education, or, as the cry is, to lower the standard of the profession. Depend upon it there is only one way of really ennobling any calling, and that is to make those who pursue it real masters of their craft, men who can truly do that which they profess to be able to do, and which they are credited with being able to do by the public. And there is no position so ignoble as that of the so-called "liberally-educated practitioner," who may be able to read Galen in the original; who knows all the plants, from the cedar of Lebanon to the hyssop upon the wall; but who finds himself, with the issues of life and death in his hands, ignorant, blundering, and bewildered, because of his ignorance of the essential and fundamental truths upon which practice must be based. Moreover, I venture to say, that any man who has seriously studied all the essential branches of medical knowledge; who has the needful acquaintance with the elements of physical science; who has been brought by medical jurisprudence into contact with law; whose study of insanity has taken him into the fields of psychology; has ipso facto received a liberal education.

Having lightened the medical curriculum by culling out of it everything which is unessential, we may next consider whether something may not be done to aid the medical student toward the acquirement of real knowledge by modifying the system of examination. In England, within my recollection, it was the practice to require of the medical student attendance on lectures upon the most diverse topics during three years; so that it often happened that he would have to listen, in the course of a day, to four or five lectures upon totally different subjects, in addition to the hours given to dissection and to hospital practice: and he was required to keep all the knowledge he could pick up, in this distracting fashion, at examination point, until, at the end of three years, he was set down to a table and questioned pell-mell upon all the different matters with which he had been striving to make acquaintance. A worse system and one more calculated to obstruct the acquisition of sound knowledge and to give full play to the "crammer" and the "grinder" could hardly have been devised by human ingenuity. Of late years great reforms have taken place. Examinations have been divided so as to diminish the number of subjects among which the attention has to be distributed. Practical examination has been largely introduced; but there still remains, even under the present system, too much of the old evil inseparable from the contemporaneous pursuit of a multiplicity of diverse studies.

Proposals have recently been made to get rid of general examinations altogether, to permit the student to be examined in each subject at the end of his attendance on the class; and then, in case of the result being satisfactory, to allow him to have done with it; and I may say that this method has been pursued for many years in the Royal School of Mines in London, and has been found to work very well. It allows the student to concentrate his mind upon what he is about for the time being, and then to dismiss it. Those who are occupied in intellectual work, will, I think, agree with me that it is important, not so much to know a thing, as to have known it, and known it thoroughly. If you have once known a thing in this way it is easy to renew your knowledge when you have forgotten it; and when you begin to take the subject up again, it slides back upon the familiar grooves with great facility.

Lastly comes the question as to how the university may co-operate in advancing medical education. A medical school is strictly a technical school--a school in which a practical profession is taught--while a university ought to be a place in which knowledge is obtained without direct reference to professional purposes. It is clear, therefore, that a university and its antecedent, the school, may best co-operate with the medical school by making due provision for the study of those branches of knowledge which lie at the foundation of medicine.

At present, young men come to the medical schools without a conception of even the elements of physical science; they learn, for the first time, that there are such sciences as physics, chemistry, and physiology, and are introduced to anatomy as a new thing. It may be safely said that, with a large proportion of medical students, much of the first session is wasted in learning how to learn--in familiarising themselves with utterly strange conceptions, and in awakening their dormant and wholly untrained powers of observation and of manipulation. It is difficult to over-estimate the magnitude of the obstacles which are thrown in the way of scientific training by the existing system of school education. Not only are men trained in mere book-work, ignorant of what observation means, but the habit of learning from books alone begets a disgust of observation. The book-learned student will rather trust to what he sees in a book than to the witness of his own eyes.