[534] Mr. Dean, Ladies, and Gentlemen, the pleasing part of this business, so far as I am concerned, is now over, and another portion of the entertainment begins, which I trust may be in some sense satisfactory to you, but which has its difficulties for me. When the authorities of this school were kind enough to honour me by asking me to preside on this occasion, I did not clearly take in and apprehend, as I ought to have done, the notion, that attached to that honour there was a certain responsibility in the shape of an address; but when I found that it was proper and customary that the person who had been favoured with the privilege of awarding these testimonies of merit and desert to young men should say something on his own behoof afterwards, I cast about in my mind for some subject on which I might be able to say something that might be possibly worth hearing, or at any rate that might express my own mature conviction, and might at the same time be of some use to those who are engaged in Medical pursuits. It appeared that on the whole I could not do better than say a few words touching the relations of the physical sciences in general to Medicine and of education in physical science to Medical education; and, indeed, to make some remarks upon the whole subject of Medical education, which is now occupying so many minds and exciting so very large an interest among all the most intelligent members of the Profession.

It is an old and trite observation that medicine is both a science and an art; and if you put what you know about Medicine into a homely phrase–I use the term "Medicine," as applying to the whole range of Physic, whether Surgical, or Medical, or what not–I say, if you endeavour to put into homely phraseology, what the object of the science of Medicine is, I think you will find it to be to ascertain the nature of the disability a diseased or injured person labours under, and in the next place to have a knowledge of the means by which that disability can be removed. And if you look for a definition of the art of Medicine, it has a correlative extent–in other words, the art may be defined as the skilful use of all those means and appliances by which we ascertain what is the matter with a man, and of those further means and appliances by which the wrong thing may be set right again. Now, it hardly needs any remark upon my part to make you perfectly aware that the appliances of the art of Medicine are all of them derived from, or dependent upon, the physical sciences. I need only mention such instruments as the microscope and the ophthalmoscope, and that apparatus by which the chemical qualities of the fluids of the body are ascertained, to make it perfectly obvious that in order to make use of those great and familiar appliances of diagnosis (or finding out what is the matter with people), you must have a knowledge of chemical and physical science. And although a knowledge of the principles of physical science, enough to enable you to use the microscope, and perhaps the ophthalmoscope, with some success may not be very great, yet if you would apply the methods of chemical analysis to the examination of the fluids of the body your knowledge of chemistry must be tolerably practical and tolerably extensive. Further than that, every liberally educated Medical man should know something about the nature of the bodies which he is constantly employing. It is, surely, not compatible with a liberal education that a Medical man should be employing quinine and not know that it is the produce of a plant and what kind of plant that is. It is hardly consistent with liberality of education that a man should employ musk and not even know that it is an animal product. And therefore I think, looking simply to the using of the appliances and means of Medical practice, it may fairly be required that a Medical man should have so much knowledge of botany and zoology as shall simply, for his own credit's sake and for the sake of his position in society, enable him to be on even terms with laymen, and that he shall know so much of botany and zoology as will enable him to give safe opinions upon matters of this kind.

On the other hand, the doctrine which I am now preaching has been pushed by some persons to a very extravagant length. I am quite prepared to admit, and, indeed, I have always had a very strong conviction, that there is something absolutely preposterous in the volume and bulk to which some of our treatises on Materia Medica extend, and the enormous quantity of irrelevant matters with which their pages are crammed. I am not one of those persons who think that because you use spermaceti you are bound to know all about the classification of the Cetacea . I do not clearly see the connexion between those things, nor do I think that a man is bound to be acquainted with physical optics–and I am not talking wildly now, I have a particular case in my mind,–I do not think a student should be dragged through the length and breadth of physical optics, because there are particular substances used in Medicine which affect the polarisation of light or exhibit the phenomena of fluorescence. That appears to be the Scylla we have to escape. The Charybdis we need to avoid, on the other hand, is the knowing nothing about these matters. So much for the relations of physical science to Medicine as an art–that is to say, to Medicine as the use of the implements and appliances which we employ in endeavouring to find out what is the matter with people and in removing their disabilities.

But there is a perfectly different aspect, and a very much more important one, under which physical science is related to Medicine. The relation to which I now refer is that in which Medical science–the science of Medicine as apart from the art–stands to physical science in general. And this relation is more close and more important and in every way more worthy of consideration than that other of which I spoke just now. Let us consider for a moment one of the simplest cases of disability–I want some word that shall apply both to Medical and Surgical lesions–which can be submitted to a Practitioner. Supposing that a person unable to use his arm, the humerus being dislocated, presents himself to any one for cure, and that this person is no better than what we call in country a bone-setter. The bone-setter knows, from his experience and from the general look of the part, that the arm is out of joint, and he knows very [535] well, from experience also, that a particular mode of pulling that arm will probably get it to go back into its place again; whereupon he applies the pull, and, I suppose, three times out of four, the arm does go back. The fourth time, perhaps, it does not go back, and cannot be got to go back; and the fifth time, it may be, in trying to make it go back, he does something or other which makes the matter very much worse than it was to start with. Now, that is the proceeding of unscientific Medicine.

The scientific Surgeon, such as I hope all those who leave this School will be–and it certainly will not be the fault of their teachers if they are not–pursues a totally different course. The scientific Surgeon who has the same disability presented to him, in the first place calls into his mind the knowledge he has of anatomical science, and which tells him what has become of the head of that dislocated bone, where it is lying, by what obstacles its return to its place is impeded. He calls to his aid his previously acquired physiological knowledge, which tells him what influence muscular contraction is exerting in keeping that bone in its abnormal place–which teaches him to account for all sorts of symptoms –as the result of pressure on nerves, pressure on vessels, and so forth. And lastly, if necessary, he appeals to his knowledge of therapeutics, or in other words, of the influence of medicaments upon the condition of the parts of the body, and he applies them in such a manner as to diminish the obstacles which arise from the contraction of the muscles. In other words, he makes use of the information he has acquired of the physical sciences Anatomy, Physiology, and Therapeutics, to serve as the basis of a series of deductions, by the help of which the internal condition of the injured part becomes visible to the mind's eye. He knows, in virtue of these deductions, on what the bone is resting, what it is touching, what mischief it is doing, what means he ought to apply in order to bring the bone back into its primitive place, and what will be the effect of every measure which he applies for that purpose. In other words, in the case which I have selected, the scientific Surgeon knows precisely the character of the injury; and he knows precisely the kind of preparation which he should perform to remedy that injury; and so far as this particular case is concerned, we may say that scientific Medicine has here attained its perfection–that is to say, the Practitioner may know the whole conditions of the lesion; and he may know exactly what he ought to do to restore the injured part to its healthy condition. And that is exactly the difference between the empiric and the scientific man–that the empiric knows in a coarse, blind sort of way–working in the dark on the doctrine of chances–that if he does certain things it is very likely certain results will follow. The scientific man, on the other hand, makes use of the data of physical science for the purpose of reasoning out the exact conditions of the case which he has before him, and for the purpose of applying the precise measures which are adapted to meet that case. I trust it is not necessary for me to use any argument to show you that it is this latter condition of mind to which the scientific Physician or Surgeon must strive, and that the labours of your teachers here are as much as so much lost if they have not carried you some steps towards that end.

Now, having this conception of what is meant by scientific Medicine before us, let us consider what has to be done before Medicine will reach this desirable condition. For although it may be possible to adduce instances of what I should call perfect Medical science–that is to say, where you have a complete knowledge of the lesion, and a complete knowledge of the conditions required for the repair of that lesion–yet I need not tell you that these chiefly occur in Surgical practice, and are rarely presented to the Physician; and that in the great majority of purely Medical cases we have, unfortunately, no such complete knowledge either of the lesion which has taken place, or of the steps which should be taken to restore health. In the great majority–I speak under correction here, but I do not think I shall be far wrong–in the great majority of cases the modern Physician, beneficent as his effort are, great as his skill, and unremitting as his attention may be, yet as compared with that which is to be hoped for, and what we may fairly expect one day to attain, it must be confessed is still very much in the condition of the bone-setter. You know there is a wicked and libellous old story–I think some Frenchman invented it–in which it is said, by way of illustration of Medical practice, that in a diseased person Nature and the disease are as two men fighting; while the Doctor is a blind man, who comes with a big club and hits hard, sometimes hitting the disease, and sometimes hitting Nature. Now, there was a time when that description of Medical practice, I fear, was not libellous, but the time has long since passed by when it could have any strict application, and it is not the fault of the cultivators of Medical science if it continues to have any sort of application. But, if I might modify this story and bring it more into accordance with the present state of things, I should say that, in these days, the Physician is not blind; but, on the contrary, is remarkably sharp-sighted, acute, and painstaking: but that he finds himself in a very dim twilight, and having ascertained that the light is very uncertain and very apt to vary, he rather, as a conscientious person, abstains from using his club, and as far as possible confines himself to the position which, if I may say so without offence to the ladies here, is known as that of a "judicious bottle-holder," ready to pick up Nature whenever she gets adrift, and bring her up to time. That, I take it is a fair description of the modern practice of Physic; a statement in the vernacular of what is meant by our Medicine expectante .And no doubt a beneficent change has been brought about, satisfactory to the patient and no less satisfactory to the Physician, who feels that his club is not stained by innocent blood. But, although this may be a vast improvement upon the past condition of affairs, no one who knows what physical science is, or what men of science are thinking about, will imagine for one instant that it is to be a final condition. No one can doubt that the whole purpose of philosophical Medicine and the whole striving of philosophical Physicians must be to approximate Medicine more and more to the plainest kinds of Surgery, and to enable the Physician by-and-by to ascertain as clearly what is the condition of a diseased part, and what must be done to remove that disease; to have as clear a mental picture of that as the skilful Surgeon has of the condition of a dislocated bone, and of what is to be done to remedy the dislocation.

If you come to think of the matter, all disease is, strictly speaking, a dislocation–a something out of place. In the so-called "Medical" lesions, it is not actually bone, and muscle, and viscera, in the gross, it is the atoms of these parts, and the molecules of the fluids, and so forth, which are not what they should be and where they should be, if the patient were in a condition of health. If our senses were so fine and so delicate as to enable us to see the ultimate molecules of the human body acing and interacting, we should discern that they were out of place in every diseased part; and if we had means of reaching them directly, we could put them back again into their right order, so as to produce their right functions, in just the same way as the Surgeon replaces a bone. To do this, the Surgeon uses coarse mechanical power. He knows the bone is out of its place; his eyes give him an indication of where it is, or his hands. Touch and vision teach him what the condition of affairs is, and coarse mechanical methods are sufficient to enable him to bring matters right; but the atomic dislocation of a fever is not to be detected by touch or sight, and cannot be set straight by mechanical forces. The difference between the Surgeon and the Physician, is not that they have different things to do, nor different methods of inquiry nor that their procedure is in any way substantially different; but it is that the something which has gone wrong in Medical lesions requires special means for its discovery, and the forces which are to put that something right again cannot be applied directly and coarsely with our bodily hands, but we must send them to the dislocated atoms upon the shoulders of the atoms of those things which we call medicines, and drugs, and so forth.

To return to my old comparison,–to put the Physician into as favourable a position as the Surgeon, what he wants is simply more light. He wants a better light upon the arena of the fight, so that he may be able to remove the obstacles in the way of Nature, and may be ready, as occasion offers, to deal her opponent a severe blow without the chance of doing herself an injury. And if you will take the trouble to reflect from whence such light may be expected, you will find that there is only one possible channel, and that is from the cultivation and improvement of those sciences which furnish us with our data for deduction. I mean the abstract physical sciences of anatomy, physiology, chemistry, physics, and so forth. Just as the Surgeon's knowledge of the nature of the dislocation of a bone is a deduction from previous anatomical knowledge–as his process of cure is a deduction from other kinds of scientific knowledge–so the discernment of the nature of all morbid processes must consist of a series of deductions from an enlarged physical and anatomical and chemical knowledge, and all our attempts to [536] cure disease must be guided–all the light we get in that direction must be furnished to us–by a more subtle inquiry into the properties of the atoms of matter, and into the forces which they exert. Or, in other words, the whole progress of Medicine depends upon the progress of the physical sciences, from which her great principles are really deductions; and exactly in proportion as physiology, as anatomy, as pathology, as therapeutics are carefully studied and their principles better understood, so will the Physician have placed in his hands more and more powerful implements, on the one hand, for discerning the nature of disease, and, on the other hand, for meeting and conquering that disease.

This is a large subject, one which, in these curt phrases, I can hardly put before you so fully as I could wish; but I hope that you see the bearing of what I have been saying, because it is upon a clear appreciation of this that all our theories of Medical education must eventually turn. If in striving to make Medicine the noble and grand science it should be, all depends upon the perfection of certain other sciences, and if our skill in the use of the means of inquiring into disease and in using the means of cure depends upon our acquaintance with the physical sciences, it must be quite obvious to you that a thorough grounding in physical science is the basis of all Medical education. I believe that is a proposition which cannot be doubted, and which the more we inquire into it will be seen to go more and more completely into the root of the matter.

But how is such a grounding in physical science practicable? Not long ago one of the most experienced Surgeons in these islands raised his voice against the system which is at present pursued in Medical education, in throwing into the system–if I may use a Medical phrase–of a young man an enormous quantity of knowledge of all sorts of remote and theoretical kinds, to the exclusion, as he justly enough observed, of that practical information which could alone in the long run make him a skilful Surgeon. And, so far as I recollect, the argument ran somewhat in this way:–A young man leaves school; he comes to a Medical College, at which he is expected to spend three years; at the end of that time to become a Practitioner, sent forth free to kill or cure, as the case may be. He comes to you perfectly ignorant, without a scintilla of a notion of anything about science, and within that time you expect him to learn physics, or natural philosophy, chemistry, botany, zoology, with comparative anatomy, human anatomy, histology, pathology, therapeutics, Medicine, Surgery, obstetrics, jurisprudence. The thing is absurd. What you run a risk of doing is, to destroy his mental digestion, as you may destroy the physical digestion of a turkey and make a sort of intellectual foie gras of him; but, as for supplying information upon all those subjects of the kind and scope which he ought to have, in that time, and with the current methods, it is out of the question. Consider for a moment: if you take only those branches of Medical study which bear directly upon practice, few persons until they come to try know how vast they are. Take human anatomy, and reflect upon the quantity of work required before a student can possess the sort of knowledge that he ought to have. And no one has a proper knowledge of human anatomy till the man who stands up before him is in a manner transparent, and all the essential organs, bones, nerves, vessels, and muscles are to the mind's eye visible in their places. Consider the knowledge of histology or the minute structure of tissue that is required. Take pathology in itself: the rudiments of it might, if they were studied thoroughly, occupy a very large share of the time. And then physiology is absolutely indispensable, and more especially that experimental physiology which is of more importance than all the rest. I say put these things together, and then superinduce upon them the practical branches of a Medical man's profession–the necessity of becoming dexterous in the use of bandages and the manipulation of instruments–and then all that a student has to learn in the way of theoretical Surgery, and Medicine, and Jurisprudence, and so forth. Why, it will be quite obvious that three years is a most scanty period to devote to all these subjects; it is as much as can be expected if in the three years, by dint of thorough teaching and zealous learning, a young man acquires a notion of the practical branches of his profession. I am not talking, of course, about the way that a man can be taught to pass an examination: anybody can be taught to pass an examination. I was almost going to say that a dog might be taught to pass an examination, or, at least, a good many of the examinations that men go through; but I speak of that kind of information which is alone worthy of being called knowledge–that information which, as I understand, your Professors here are doing their best to give you; that information which is conferred by making men go for themselves, at first hand, to the facts and see them, by leading them not to trust this teacher, or that teacher, but to work out the truth and see it as it is, and carry that away as a thing that they know of yourselves and of their own knowledge. That is the only knowledge that is to be depended upon in your future lives; and if a man is to have that kind of knowledge he cannot spare a minute out of his three years for the subjects I have been speaking of just now.

But you may turn round upon me and say, "This is excessively inconsistent; for you have been preaching to us up to this time the enormous importance of abstract physical science, and telling us we can understand nothing unless we are well grounded in the principles of physics, in the principles of chemistry, and in the principles of biology." No, I have been guilty of no inconsistency. I hold absolutely to that position. I hold that no man can have a proper knowledge of physiology, no man can understand what the Scotch well call the "Institutes of Medicine," unless he has gone back still further, and unless he has acquainted himself with the general laws of the physical forces and with the general powers of matter as revealed by chemistry and biology.

The fact is, that you ought to have this general knowledge of physical science before you approach the study of Medicine. I fully concur with the distinguished Surgeon to whom I refer that these are not the matters with which a man ought to be occupied when he is busy with his practical Professional education. In other words, if we could arrange things as they ought to be, all this general knowledge of physical science, all this acquaintance with the principles of physics, and chemistry, and biology, ought to have been acquired by you in the course of your ordinary education. If those who regulate education in this country had a right conception of what their duties are, or of the purpose of education and the conditions of the progress of mankind at this present time are, you would get that knowledge. And those who wish to improve Medical education must, to my mind, throw all their energies into the attempt to compel those who give us primary education to make physical science a very large constituent portion of that education. I thoroughly sympathise with those who groan over the present chaotic condition of affairs. I do not see how, for some time, we are to escape the attempt to force upon young men who come to learn Physic too much knowledge and too various knowledge. Perhaps, even, it is better they should have the kind of chaotic training they have now than that they should be altogether free from a tincture of physical science; therefore I do not in the smallest degree blame the existing system of instruction in Medical schools. I think the attempts which are being made in all the great schools of London to make physical science an integral part of Medical teaching are necessary so long as physical science is ignored in ordinary education. The effort is good; the evils which attend it must be met as they may. But I repeat once more, the great effort of all Medical reformers must be to make such a pressure upon those who have the charge of education in the country that physical science shall be made an integral part of it. If that were the case,–if men came to their Medical studies trained not only in the facts of physical science, for that is only half the battle, but if the precious time which is now wasted in gerund grinding at school were even partially employed in accustoming them to the methods of scientific inquiry, the task of the Medical teacher would be infinitely lightened. If a knowledge of classical literature, or an appreciation of literary excellence, were really given at our schools, I should be the last person in the world to cry out against it, for I yield to no man in my respect and love for literature. But let any one of us turn back to his school-days, and let him try to call to mind what enduring result he obtained from all the Greek and Latin teaching he got at school. What was the whole effect? It was a pervading sense of nominative cases, and verbs, and so forth, to the end of the chapter. We read our Virgil, and Horace, and the rest of it, and when we had done, all that we knew was they were made up of verbs and substantives which had certain quantities and were packed together in accordance with certain rules; and as to what the whole thing meant, unless you were more fortunate than I, we had not the smallest notion of it.

It is the duty of every man to life up his voice against this [537] strange waste of human time and perversion of human ability; and it is the especial duty of everyone of us who has the cause of Medical education at heart to endeavour, as far as possible, to exercise such an influence upon the general education of the country as shall relieve Medical education from three-fourths of the difficulties under which it at present labours; and to bring about the great result that, when the Medical teacher begins his work, he shall not have to commence that work upon a mere tabula rasa , a mere raw material which has been used for no better purposes than gerund grinding. Conceive how different the case would be if the young men who come up for Medical education had been accustomed to handle physical experimental apparatus. Suppose that they had been accustomed to acquaint themselves with chemical formulæ, with chemical reactions; suppose they had learned, and there is no difficulty in learning these things, the great distinguishing characters of the different forms of life, and the great broad facts of physiology, which (I speak from experience) may be taught perfectly well to boys of from ten to fourteen years old; I say, supposing they had done this, and that they came to the study of Medicine with their minds stored with important truths, accustomed to go back to facts at first hand, and trained and disciplined in the methods of inductive and deductive reasoning, how much easier the task would be, not only for the learner, but for the teacher, and how vastly greater would be the stride made by every man towards that great goal I have already indicated–the establishment of a scientific Medicine.

THE HUXLEY FILE

C. Blinderman & D. Joyce
Clark University