Chapter 15

Under one aspect a university is a particular kind of educational institution, and the views which we may take of the proper nature of a university are corollaries from those which we hold respecting education in general. I think it must be admitted that the school should prepare for the university, and that the university should crown the edifice, the foundations of which are laid in the school. University education should not be something distinct from elementary education, but should be the natural outgrowth and development of the latter. Now I have a very clear conviction as to what elementary education ought to be; what it really may be, when properly organised; and what I think it will be, before many years have passed over our heads, in England and in America. Such education should enable an average boy of fifteen or sixteen to read and write his own language with ease and accuracy, and with a sense of literary excellence derived from the study of our classic writers: to have a general acquaintance with the history of his own country and with the great laws of social existence; to have acquired the rudiments of the physical and psychological sciences, and a fair knowledge of elementary arithmetic and geometry. He should have obtained an acquaintance with logic rather by example than by precept; while the acquirement of the elements of music and drawing should have been pleasure rather than work.

It may sound strange to many ears if I venture to maintain the proposition that a young person, educated thus far, has had a liberal, though perhaps not a full, education. But it seems to me that such training as that to which I have referred may be termed liberal, in both the senses in which that word is employed, with perfect accuracy. In the first place, it is liberal in breadth. It extends over the whole ground of things to be known and of faculties to be trained, and it gives equal importance to the two great sides of human activity--art and science. In the second place, it is liberal in the sense of being an education fitted for free men; for men to whom every career is open, and from whom their country may demand that they should be fitted to perform the duties of any career. I cannot too strongly impress upon you the fact that, with such a primary education as this, and with no more than is to be obtained by building strictly upon its lines, a man of ability may become a great writer or speaker, a statesman, a lawyer, a man of science, painter, sculptor, architect, or musician. That even development of all a man's faculties, which is what properly constitutes culture, may be effected by such an education, while it opens the way for the indefinite strengthening of any special capabilities with which he may be gifted.

In a country like this, where most men have to carve out their own fortunes and devote themselves early to the practical affairs of life, comparatively few can hope to pursue their studies up to, still less beyond, the age of manhood. But it is of vital importance to the welfare of the community that those who are relieved from the need of making a livelihood, and still more, those who are stirred by the divine impulses of intellectual thirst or artistic genius, should be enabled to devote themselves to the higher service of their kind, as centres of intelligence, interpreters of Nature, or creators of new forms of beauty. And it is the function of a university to furnish such men with the means of becoming that which it is their privilege and duty to be. To this end the university need cover no ground foreign to that occupied by the elementary school. Indeed it cannot; for the elementary instruction which I have referred to embraces all the kinds of real knowledge and mental activity possible to man. The university can add no new departments of knowledge, can offer no new fields of mental activity; but what it can do is to intensify and specialise the instruction in each department. Thus literature and philology, represented in the elementary school by English alone, in the university will extend over the ancient and modern languages. History, which, like charity, best begins at home, but, like charity, should not end there, will ramify into anthropology, archaeology, political history, and geography, with the history of the growth of the human mind and of its products in the shape of philosophy, science, and art. And the university will present to the student libraries, museums of antiquities, collections of coins, and the like, which will efficiently subserve these studies. Instruction in the elements of social economy, a most essential, but hitherto sadly-neglected part of elementary education, will develop in the university into political economy, sociology, and law. Physical science will have its great divisions of physical geography, with geology and astronomy; physics; chemistry and biology; represented not merely by professors and their lectures, but by laboratories, in which the students, under guidance of demonstrators, will work out facts for themselves and come into that direct contact with reality which constitutes the fundamental distinction of scientific education. Mathematics will soar into its highest regions; while the high peaks of philosophy may be scaled by those whose aptitude for abstract thought has been awakened by elementary logic. Finally, schools of pictorial and plastic art, of architecture, and of music, will offer a thorough discipline in the principles and practice of art to those in whom lies nascent the rare faculty of aesthetic representation, or the still rarer powers of creative genius.

The primary school and the university are the alpha and omega of education. Whether institutions intermediate between these (so-called secondary schools) should exist, appears to me to be a question of practical convenience. If such schools are established, the important thing is that they should be true intermediaries between the primary school and the university, keeping on the wide track of general culture, and not sacrificing one branch of knowledge for another.

Such appear to me to be the broad outlines of the relations which the university, regarded as a place of education, ought to bear to the school, but a number of points of detail require some consideration, however briefly and imperfectly I can deal with them. In the first place, there is the important question of the limitations which should be fixed to the entrance into the university; or, what qualifications should be required of those who propose to take advantage of the higher training offered by the university. On the one hand, it is obviously desirable that the time and opportunities of the university should not be wasted in conferring such elementary instruction as can be obtained elsewhere; while, on the other hand, it is no less desirable that the higher instruction of the university should be made accessible to every one who can take advantage of it, although he may not have been able to go through any very extended course of education. My own feeling is distinctly against any absolute and defined preliminary examination, the passing of which shall be an essential condition of admission to the university. I would admit to the university any one who could be reasonably expected to profit by the instruction offered to him; and I should be inclined, on the whole, to test the fitness of the student, not by examination before he enters the university, but at the end of his first term of study. If, on examination in the branches of knowledge to which he has devoted himself, he show himself deficient in industry or in capacity, it will be best for the university and best for himself, to prevent him from pursuing a vocation for which he is obviously unfit. And I hardly know of any other method than this by which his fitness or unfitness can be safely ascertained, though no doubt a good deal may be done, not by formal cut and dried examination, but by judicious questioning, at the outset of his career.

Another very important and difficult practical question is, whether a definite course of study shall be laid down for those who enter the university; whether a curriculum shall be prescribed; or whether the student shall be allowed to range at will among the subjects which are open to him. And this question is inseparably connected with another, namely, the conferring of degrees. It is obviously impossible that any student should pass through the whole of the series of courses of instruction offered by a university. If a degree is to be conferred as a mark of proficiency in knowledge, it must be given on the ground that the candidate is proficient in a certain fraction of those studies; and then will arise the necessity of insuring an equivalency of degrees, so that the course by which a degree is obtained shall mark approximately an equal amount of labour and of acquirements, in all cases. But this equivalency can hardly be secured in any other way than by prescribing a series of definite lines of study. This is a matter which will require grave consideration. The important points to bear in mind, I think, are that there should not be too many subjects in the curriculum, and that the aim should be the attainment of thorough and sound knowledge of each.

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.

There is not the least reason why this should be so, and, in fact, when elementary education becomes that which I have assumed it ought to be, this state of things will no longer exist. There is not the slightest difficulty in giving sound elementary instruction in physics, in chemistry, and in the elements of human physiology, in ordinary schools. In other words, there is no reason why the student should not come to the medical school, provided with as much knowledge of these several sciences as he ordinarily picks up in the course of his first year of attendance at the medical school.