devote themselves to the profession of medicine; and I do not doubt,
from the evidences of ability which have been given to-day, that
I have before me a number of men who will rise to eminence in that
profession, and who will exert a great and deserved influence upon
its future. That in which I am interested, and about which I wish to
speak, is the subject of medical education, and I venture to speak
about it for the purpose, if I can, of influencing you, who may have
the power of influencing the medical education of the future. You may
ask, by what authority do I venture, being a person not concerned in
the practice of medicine, to meddle with that subject? I can only tell
you it is a fact, of which a number of you I dare say are aware by
experience (and I trust the experience has no painful associations),
that I have been for a considerable number of years (twelve or
thirteen years to the best of my recollection) one of the examiners in
the University of London. You are further aware that the men who
come up to the University of London are the picked men of the medical
schools of London, and therefore such observations as I may have
to make upon the state of knowledge of these gentlemen, if they be
justified, in regard to any faults I may have to find, cannot be held
to indicate defects in the capacity, or in the power of application of
those gentlemen, but must be laid, more or less, to the account of the
prevalent system of medical education. I will tell you what has struck
me--but in speaking in this frank way, as one always does about the
defects of one's friends, I must beg you to disabuse your minds of
the notion that I am alluding to any particular school, or to any
particular college, or to any particular person; and to believe that
if I am silent when I should be glad to speak with high praise, it is
because that praise would come too close to this locality. What has
struck me, then, in this long experience of the men best instructed in
physiology from the medical schools of London, is (with the many and
brilliant exceptions to which I have referred), taking it as a whole,
and broadly, the singular unreality of their knowledge of physiology.
Now, I use that word "unreality" advisedly: I do not say "scanty;" on
the contrary, there is plenty of it--a great deal too much of it--but
it is the quality, the nature of the knowledge, which I quarrel with.
I know I used to have--I don't know whether I have now, but I had once
upon a time--a bad reputation among students for setting up a very
high standard of acquirement, and I dare say you may think that the
standard of this old examiner, who happily is now very nearly an
extinct examiner, has been pitched too high. Nothing of the kind, I
assure you. The defects I have noticed, and the faults I have to find,
arise entirely from the circumstance that my standard is pitched too
low. This is no paradox, gentlemen, but quite simply the fact.
The knowledge I have looked for was a real, precise, thorough, and
practical knowledge of fundamentals; whereas that which the best of
the candidates, in a large proportion of cases, have had to give me
was a large, extensive, and inaccurate knowledge of superstructure;
and that is what I mean by saying that my demands went too low,
and not too high. What I have had to complain of is, that a large
proportion of the gentlemen who come up for physiology to the
University of London do not know it as they know their anatomy, and
have not been taught it as they have been taught their anatomy. Now, I
should not wonder at all if I heard a great many "No, noes" here; but
I am not talking about University College; as I have told you before,
I am talking about the average education of medical schools. What I
have found, and found so much reason to lament, is, that while anatomy
has been taught as a science ought to be taught, as a matter of
autopsy, and observation, and strict discipline; in a very large
number of cases, physiology has been taught as if it were a mere
matter of books and of hearsay. I declare to you, gentlemen, that
I have often expected to be told, when I have been asked a question
about the circulation of the blood, that Professor Breitkopf is
of opinion that it circulates, but that the whole thing is an open
question. I assure you that I am hardly exaggerating the state of mind
on matters of fundamental importance which I have found over and over
again to obtain, among gentlemen coming up to that picked examination
of the University of London. Now, I do not think that is a desirable
state of things. I cannot understand why physiology should not be
taught--in fact, you have here abundant evidence that it can be
taught--with the same definiteness and the same precision as anatomy
is taught. And you may depend upon this, that the only physiology
which is to be of any good whatever in medical practice, or in its
application to the study of medicine, is that physiology which a man
knows of his own knowledge; just as the only anatomy which would be
of any good to the surgeon is the anatomy which he knows of his own
knowledge. Another peculiarity I have found in the physiology which
has been current, and that is, that in the minds of a great many
gentlemen it has been supplanted by histology. They have learnt a
great deal of histology, and they have fancied that histology and
physiology are the same things. I have asked for some knowledge of the
physics and the mechanics and the chemistry of the human body, and I
have been met by talk about cells. I declare to you I believe it will
take me two years, at least, of absolute rest from the business of
an examiner to hear the word "cell," "germinal matter," or "carmine,"
without a sort of inward shudder.
Well, now, gentlemen, I am sure my colleagues in this examination will
bear me out in saying that I have not been exaggerating the evils and
defects which are current--have been current--in a large quantity
of the physiological teaching, the results of which come before
examiners. And it becomes a very interesting question to know how all
this comes about, and in what way it can be remedied. How it comes
about will be perfectly obvious to any one who has considered the
growth of medicine. I suppose that medicine and surgery first began
by some savage, more intelligent than the rest, discovering that a
certain herb was good for a certain pain, and that a certain pull,
somehow or other, set a dislocated joint right. I suppose all things
had their humble beginnings, and medicine and surgery were in the same
condition. People who wear watches know nothing about watchmaking. A
watch goes wrong and it stops; you see the owner giving it a shake,
or, if he is very bold, he opens the case, and gives the balance-wheel
a turn. Gentlemen, that is empirical practice, and you know what are
the results upon the watch. I should think you can divine what are the
results of analogous operations upon the human body. And because men
of sense very soon found that such were the effects of meddling with
very complicated machinery they did not understand, I suppose the
first thing, as being the easiest, was to study the nature of the
works of the human watch, and the next thing was to study the way the
parts worked together, and the way the watch worked. Thus, by degrees,
we have had growing up our body of anatomists, or knowers of the
construction of the human watch, and our physiologists, who know how
the machine works. And just as any sensible man, who has a valuable
watch, does not meddle with it himself, but goes to some one who has
studied watchmaking, and understands what the effect of doing this
or that may be; so, I suppose, the man who, having charge of that
valuable machine, his own body, wants to have it kept in good order,
comes to a professor of the medical art for the purpose of having it
set right, believing that, by deduction from the facts of structure
and from the facts of function, the physician will divine what may be
the matter with his bodily watch at that particular time, and what may
be the best means of setting it right. If that may be taken as a
just representation of the relation of the theoretical branches of
medicine--what we may call the institutes of medicine, to use an old
term--to the practical branches, I think it will be obvious to you
that they are of prime and fundamental importance. Whatever tends to
affect the teaching of them injuriously must tend to destroy and
to disorganize the whole fabric of the medical art. I think every
sensible man has seen this long ago; but the difficulties in the way
of attaining good teaching in the different branches of the theory, or
institutes, of medicine are very serious. It is a comparatively
easy matter--pray mark that I use the word "comparatively"--it is a
comparatively easy matter to learn anatomy and to teach it; it is a
very difficult matter to learn physiology and to teach it. It is a
very difficult matter to know and to teach those branches of physics
and those branches of chemistry which bear directly upon physiology;
and hence it is that, as a matter of fact, the teaching of physiology,
and the teaching of the physics and the chemistry which bear upon it,
must necessarily be in a state of relative imperfection; and there is
nothing to be grumbled at in the fact that this relative imperfection
exists. But is the relative imperfection which exists only such as
is necessary, or is it made worse by our practical arrangements? I
believe--and if I did not so believe I should not have troubled you
with these observations--I believe it is made infinitely worse by
our practical arrangements, or rather, I ought to say, our very
unpractical arrangements. Some very wise man long ago affirmed that
every question, in the long run, was a question of finance; and there
is a good deal to be said for that view. Most assuredly the question
of medical teaching is, in a very large and broad sense, a question of
finance. What I mean is this: that in London the arrangements of the
medical schools, and the number of them, are such as to render it
almost impossible that men who confine themselves to the teaching
of the theoretical branches of the profession should be able to make
their bread by that operation; and, you know, if a man cannot make his
bread, he cannot teach--at least his teaching comes to a speedy end.
That is a matter of physiology. Anatomy is fairly well taught, because
it lies in the direction of practice, and a man is all the better
surgeon for being a good anatomist. It does not absolutely interfere
with the pursuits of a practical surgeon if he should hold a Chair
of Anatomy--though I do not for one moment say that he would not be a
better teacher if he did not devote himself to practice. (Applause.)
Yes, I know exactly what that cheer means, but I am keeping as
carefully as possible from any sort of allusion to Professor Ellis.
But the fact is, that even human anatomy has now grown to be so large
a matter, that it takes the whole devotion of a man's life to put the
great mass of knowledge upon that subject into such a shape that it
can be teachable to the mind of the ordinary student. What the student
wants in a professor is a man who shall stand between him and the
infinite diversity and variety of human knowledge, and who shall
gather all that together, and extract from it that which is capable
of being assimilated by the mind. That function is a vast and an
important one, and unless, in such subjects as anatomy, a man is
wholly free from other cares, it is almost impossible that he can
perform it thoroughly and well. But if it be hardly possible for a man
to pursue anatomy without actually breaking with his profession, how
is it possible for him to pursue physiology?
I get every year those very elaborate reports of Henle and
Meissner--volumes of, I suppose, 400 pages altogether--and they
consist merely of abstracts of the memoirs and works which have been
written on Anatomy and Physiology--only abstracts of them! How is
a man to keep up his acquaintance with all that is doing in the
physiological world--in a world advancing with enormous strides every
day and every hour--if he has to be distracted with the cares of
practice? You know very well it must be impracticable to do so. Our
men of ability join our medical schools with an eye to the future.
They take the Chairs of Anatomy or of Physiology; and by and by they
leave those Chairs for the more profitable pursuits into which they
have drifted by professional success, and so they become clothed,
and physiology is bare. The result is, that in those schools in which
physiology is thus left to the benevolence, so to speak, of those
who have no time to look to it, the effect of such teaching comes
out obviously, and is made manifest in what I spoke of just now--the
unreality, the bookishness of the knowledge of the taught. And if this
is the case in physiology, still more must it be the case in those
branches of physics which are the foundation of physiology; although
it may be less the case in chemistry, because for an able chemist a
certain honourable and independent career lies in the direction of
his work, and he is able, like the anatomist, to look upon what he
may teach to the student as not absolutely taking him away from his
bread-winning pursuits.
But it is of no use to grumble about this state of things unless
one is prepared to indicate some sort of practical remedy. And I
believe--and I venture to make the statement because I am wholly
independent of all sorts of medical schools, and may, therefore, say
what I believe without being supposed to be affected by any personal
interest--but I say I believe that the remedy for this state of
things, for that imperfection of our theoretical knowledge which keeps
down the ability of England at the present time in medical matters,
is a mere affair of mechanical arrangement; that so long as you have
a dozen medical schools scattered about in different parts of the
metropolis, and dividing the students among them, so long, in all the
smaller schools at any rate, it is impossible that any other state of
things than that which I have been depicting should obtain. Professors
must live; to live they must occupy themselves with practice, and
if they occupy themselves with practice, the pursuit of the abstract
branches of science must go to the wall. All this is a plain and
obvious matter of common-sense reasoning. I believe you will never
alter this state of things until, either by consent or by _force
majeure_--and I should be very sorry to see the latter applied--but
until there is some new arrangement, and until all the theoretical
branches of the profession, the institutes of medicine, are taught in
London in not more than one or two, or at the outside three, central
institutions, no good will be effected. If that large body of men, the
medical students of London, were obliged in the first place to get a
knowledge of the theoretical branches of their profession in two or
three central schools, there would be abundant means for maintaining
able professors--not, indeed, for enriching them, as they would be
able to enrich themselves by practice--but for enabling them to make
that choice which such men are so willing to make; namely, the choice
between wealth and a modest competency, when that modest competency
is to be combined with a scientific career, and the means of advancing
knowledge. I do not believe that all the talking about, and tinkering
of, medical education will do the slightest good until the fact
is clearly recognized, that men must be thoroughly grounded in the
theoretical branches of their profession, and that to this end the
teaching of those theoretical branches must be confined to two or
three centres.
Now let me add one other word, and that is, that if I were a despot, I
would cut down these branches to a very considerable extent. The next
thing to be done beyond that which I mentioned just now, is to go
back to primary education. The great step towards a thorough medical
education is to insist upon the teaching of the elements of the
physical sciences in all schools, so that medical students shall not
go up to the medical colleges utterly ignorant of that with which they
have to deal; to insist on the elements of chemistry, the elements of
botany, and the elements of physics being taught in our ordinary
and common schools, so that there shall be some preparation for
the discipline of medical colleges. And, if this reform were once
effected, you might confine the "Institutes of Medicine" to physics
as applied to physiology--to chemistry as applied to physiology--to
physiology itself, and to anatomy. Afterwards, the student, thoroughly
grounded in these matters, might go to any hospital he pleased for
the purpose of studying the practical branches of his profession. The
practical teaching might be made as local as you like; and you
might use to advantage the opportunities afforded by all these
local institutions for acquiring a knowledge of the practice of the
profession. But you may say: "This is abolishing a great deal; you are
getting rid of botany and zoology to begin with." I have not a doubt
that they ought to be got rid of, as branches of special medical
education; they ought to be put back to an earlier stage, and made
branches of general education. Let me say, by way of self-denying
ordinance, for which you will, I am sure, give me credit, that I
believe that comparative anatomy ought to be absolutely abolished.
I say so, not without a certain fear of the Vice-Chancellor of the
University of London who sits upon my left. But I do not think the
charter gives him very much power over me; moreover, I shall soon come
to an end of my examinership, and therefore I am not afraid, but shall
go on to say what I was going to say, and that is, that in my belief
it is a downright cruelty--I have no other word for it--to require
from gentlemen who are engaged in medical studies, the pretence--for
it is nothing else, and can be nothing else, than a pretence--of a
knowledge of comparative anatomy as part of their medical curriculum.
Make it part of their Arts teaching if you like, make it part of their
general education if you like, make it part of their qualification for
the scientific degree by all means--that is its proper place; but to
require that gentlemen whose whole faculties should be bent upon
the acquirement of a real knowledge of human physiology should
worry themselves with getting up hearsay about the alternation of
generations in the Salpae is really monstrous. I cannot characterize
it in any other way. And having sacrificed my own pursuit, I am sure I
may sacrifice other people's; and I make this remark with all the
more willingness because I discovered, on reading the name-of your
Professors just now, that the Professor of Materia Medica is not
present. I must confess, if I had my way I should abolish Materia
Medica[1] altogether. I recollect, when I was first under examination
at the University of London, Dr. Pereira was the examiner, and you
know that "Pereira's Materia Medica" was a book _de omnibus rebus_. I
recollect my struggles with that book late at night and early in the
morning (I worked very hard in those days), and I do believe that I
got that book into my head somehow or other, but then I will undertake
to say that I forgot it all a week afterwards. Not one trace of a
knowledge of drugs has remained in my memory from that time to this;
and really, as a matter of common sense, I cannot understand the
arguments for obliging a medical man to know all about drugs and
where they come from. Why not make him belong to the Iron and Steel
Institute, and learn something about cutlery, because he uses knives?
[Footnote 1: It will, I hope, be understood that I do not include
Therapeutics under this head.]
But do not suppose that, after all these deductions, there would not
be ample room for your activity. Let us count up what we have left. I
suppose all the time for medical education that can be hoped for is,
at the outside, about four years. Well, what have you to master in
those four years upon my supposition? Physics applied to physiology;
chemistry applied to physiology; physiology; anatomy; surgery;
medicine (including therapeutics); obstetrics; hygiene; and medical
jurisprudence--nine subjects for four years! And when you consider
what those subjects are, and that the acquisition of anything beyond
the rudiments of any one of them may tax the energies of a lifetime,
I think that even those energies which you young gentlemen have
been displaying for the last hour or two might be taxed to keep you
thoroughly up to what is wanted for your medical career.
I entertain a very strong conviction that any one who adds to medical
education one iota or tittle beyond what is absolutely necessary, is
guilty of a very grave offence. Gentlemen, it will depend upon the
knowledge that you happen to possess,--upon your means of applying it
within your own field of action,--whether the bills of mortality of
your district are increased or diminished; and that, gentlemen, is a
very serious consideration indeed. And, under those circumstances, the
subjects with which you have to deal being so difficult, their extent
so enormous, and the time at your disposal so limited, I could not
feel my conscience easy if I did not, on such an occasion as this,
raise a protest against employing your energies upon the acquisition
of any knowledge which may not be absolutely needed in your future
career.
IV.
YEAST.
IT has been known, from time immemorial, that the sweet liquids which
may be obtained by expressing the juices of the fruits and stems
of various plants, or by steeping malted barley in hot water, or
by mixing honey with water--are liable to undergo a series of very
singular changes, if freely exposed to the air and left to themselves,
in warm weather. However clear and pellucid the liquid may have been
when first prepared, however carefully it may have been freed, by
straining and filtration, from even the finest visible impurities, it
will not remain clear. After a time it will become cloudy and turbid;
little bubbles will be seen rising to the surface, and their abundance
will increase until the liquid hisses as if it were simmering on
the fire. By degrees, some of the solid particles which produce the
turbidity of the liquid collect at its surface into a scum, which
is blown up by the emerging air-bubbles into a thick, foamy froth.
Another moiety sinks to the bottom, and accumulates as a muddy
sediment, or "lees."
When this action has continued, with more or less violence, for
a certain time, it gradually moderates. The evolution of bubbles
slackens, and finally comes to an end; scum and lees alike settle at
the bottom, and the fluid is once more clear and transparent. But
it has acquired properties of which no trace existed in the original
liquid. Instead of being a mere sweet fluid, mainly composed of sugar
and water, the sugar has more or less completely disappeared, and it
has acquired that peculiar smell and taste which we call "spirituous."
Instead of being devoid of any obvious effect upon the animal economy,
it has become possessed of a very wonderful influence on the nervous
system; so that in small doses it exhilarates, while in larger it
stupefies, and may even destroy life.
Moreover, if the original fluid is put into a still, and heated for a
while, the first and last product of its distillation is simple water;
while, when the altered fluid is subjected to the same process, the
matter which is first condensed in the receiver is found to be a
clear, volatile substance, which is lighter than water, has a pungent
taste and smell, possesses the intoxicating powers of the fluid in
an eminent degree, and takes fire the moment it is brought in contact
with a flame. The alchemists called this volatile liquid, which
they obtained from wine, "spirits of wine," just as they called
hydrochloric acid "spirits of salt," and as we, to this day, call
refined turpentine "spirits of turpentine." As the "spiritus," or
breath, of a man was thought to be the most refined and subtle part
of him, the intelligent essence of man was also conceived as a sort
of breath, or spirit; and, by analogy, the most refined essence of
anything was called its "spirit." And thus it has come about that we
use the same word for the soul of man and for a glass of gin.
At the present day, however, we even more commonly use another name
for this peculiar liquid--namely, "alcohol," and its origin is not
less singular. The Dutch physician, Van Helmont, lived in the latter
part of the sixteenth and the beginning of the seventeenth century--in
the transition period between alchemy and chemistry--and was rather
more alchemist than chemist. Appended to his "Opera Omnia," published
in 1707, there is a very needful "Clavis ad obscuriorum sensum
referandum," in which the following passage occurs:--
"ALCOHOL.--Chymicis est liquor aut pulvis summè subtilisatus,
vocabulo Orientalibus quoque, cum primis Habessinis,
familiari, quibus _cohol_ speciatim pulverem impalpabilem ex
antimonio pro oculis tin-gendis denotat ... Hodie autem, ob
analogiam, quivis pulvis teuerior, ut pulvis oculorum cancri
summe subtilisatus _alcohol_ audit, hand aliter ac spiritus
rectificatissimi _alcolisati_ dicuntur."