The Medical Man of Middlemarch

When I finally finished reading Middlemarch, my cousin hailed it as a “life event.” Not for the physical effort of turning over and over its nine-hundred pages, I’m sure, but for its formidable reputation as one of the great English novels. There’s nothing I can say about George Eliot’s masterpiece that hasn’t been said before; all I can do is urge you to read it yourself. Don’t be put off by its size, or occasionally dense prose, because the story you will find underneath is vibrant, profound, and utterly absorbing.

(By the way, spoilers…we all hate them. But they are kind of hard to avoid in an essay about a novel. I’ve done my best not to drop any big ones, so, if you aren’t familiar with the book, nothing you read here should ruin your future reading experience too badly.)

The novel is set in a fictional English town called Middlemarch, in the year 1829, and follows a crowd of its middle-class inhabitants: the families of bankers, clergymen, businessmen, landowners, and of course, doctors. Unsurprisingly, the character that made the deepest impression on me was Dr Lydgate.

Lydgate pitches up in Middlemarch at the start of the novel, having just completed his medical training in Edinburgh and then Paris. He wants to reform medical practice in the town, while working without distraction on his grand unifying theory of the “primitive tissues.” In short, he has a noble dream of doing “good small work for Middlemarch, and great work for the world.” He soon throws himself into the running of a voluntary Fever Hospital and sets up a modest practice, primarily looking after the poorer folk of the town but occasionally providing his services to the wealthier citizens.

Just before entering the room…

I particularly loved one small piece of action, which seems at first glance to be typical of Eliot’s sarcastic wit, but, on reflection, is rather moving in an understated way. Lydgate has just been called to the house of a wealthy man, to see a visitor who has fallen sick. When he arrives, he is given a short summary of events: “I believe he is seriously ill: apparently his mind is affected.” Lydgate is about to go into the room, but pauses:

just before entering the room he turned automatically and said, “What is his name?”—to know names being as much a part of the medical man’s accomplishment as of the practical politician’s.

This tiny, beautiful, true-to-life detail captured my attention because it’s such a vital part of my own routine when seeing a patient. Almost always, the last thing I do outside their room is to glance down at their chart, and ask myself “what is their name,” so I can have it on the tip of my tongue as I go in. And it’s not just me, I’ve had seniors whisper it as we’re walking through a door together, and medical students querying it as we start a simulation session: “what is their name?” In this moment I felt a really strong connection to Lydgate, as if he were a colleague reaching out to me from almost two hundred years ago.

I think it’s important for patients to feel that we acknowledge their individuality, that we keep their own bundle of hopes and fears separate to that of the patient next door. What better way to do it than to know their name from the beginning?

So I was somewhat indignant to find my considered actions being compared to the shenanigans of the “practical politician.” You can see for yourself in the daily coronavirus press briefings what one of those charlatans looks like. Perhaps I’m only flattering myself by looking for a positive spin on this quote, but that is what I set out to find…

The medical man and his accomplishments

Although Dr Lydgate has many personal flaws, Eliot always speaks gushingly of his professional capabilities, especially when compared to the other medical men of Middlemarch. He is an excellent communicator and a patient listener. He has an exquisite emotional intelligence and a strong sense of moral duty. He possesses outstanding clinical acumen, being proficient in all the skills of diagnosis, treatment, and prognostication, and works diligently to keep himself abreast of the latest developments around the world. In other words, he is the one doctor in town you would want to see approaching your bedside if you were sick.

His education underpins this: first London, then Edinburgh, finally Paris, and never Oxford or Cambridge. All these institutions are linked intrinsically to his honourable ambitions.

Paris, for example, was the happening place in medicine at the start of the nineteenth century. French physicians were leading the way in an emerging dogma, in which pathology was catapulted into the limelight. It was the lesion, a physical, visible alteration in the body’s tissues, which was the cause of disease, not some unmeasurable imbalance in the elusive humours. In the huge municipal hospitals sat rows and rows of poor patients who could be poked and prodded exhaustively when alive, and have their bodies dissected thoroughly when dead; thus the lesion causing each different disease could be detected and proven.

A young Paris-trained doctor would become used to a new way of thinking about disease, and a new physical intimacy with his patients in life and in death. He would be a hybrid of the aloof, cerebral physician and the common hands-on surgeon. Many students flocked to France to receive this education and then took their learning back home with them. By giving it to Lydgate, Eliot imbued him with a professional authority beyond his rivals. His compassion is backed up by the most up-to-date training available; he is no mere quack.

As for Edinburgh, it was perhaps the most progressive seat of medical education in the United Kingdom. At the time, healthcare was provided to the public by an unregulated mishmash of practitioners; care supplied by physicians was of the wealthy, by the wealthy, and for the wealthy. Until 1826, with the founding of London University, the only public institutions in England granting medical degrees were Oxford and Cambridge. They were set in their ways and stuffy, even barring Nonconformist Christians until 1854. Eliot was disparaging of the “expensive and highly-rarified” Oxbridge medical training, and many young English doctors agreed, heading north in droves. If you look up the background of any innovative firebrand or provincial voluntary-hospital-running English doctor of the nineteenth century, they probably passed through Edinburgh during their formative years.

Lydgate’s training helps explain his passion for reform, and reform itself is a central theme to the whole novel. Middlemarch is set in 1829 but it was published in 1871-2, so in some ways it’s an origin story for Eliot’s contemporary readership. It describes the makings of the exciting world of progress they could see all around them, such as the 1832 Great Reform Act, Catholic emancipation, and the coming of the railways. It was no different in healthcare; regulatory and political changes in the mid-nineteenth century meant that ordinary people’s experience of formal medicine was about to alter radically. Lydgate is at the vanguard of this change, and here we are transparently invited by Eliot to associate ‘change’ with ‘good.’

The practical politician

What is a “practical politician?” Helpfully, in the novel Eliot gives a perfect example of an unpractical politician for us to draw comparison. Mr Brooke is a wealthy landowner who decides to run for Parliament, and on the big question of the day he decides he ought to be ‘for’ Reform, despite a lack of genuine belief in it. He is a terrible landlord: ignorant of his tenants’ difficulties and negligent in the maintenance of their properties, so he struggles to win their support. Because of this hypocrisy, his opponents find him an easy target to sling mud at.

Middlemarch describes a country gasping for reform; the Great Reform Act is long overdue and too modest in scope. Yet Brooke still struggles to persuade anyone of its merits. By setting him up as an unsteady, fraudulent flag-bearer for Reform, and then skewering him quite savagely, Eliot suggests that the practical politician is of a nobler breed, who believes in a thing and can get it done too.

To know names

I think we can safely say that the honour in Lydgate’s small action is preserved by the comparison to a practical politician. Eliot takes pains to prove his professional integrity and clinical skill, which provide a scientific legitimacy to his demonstrations of compassion. And she would respect an efficient, authentic politician who had the strong intellectual authority to back up their performances of sympathy. Unfortunately, with few of those around to lead us today, it’s not a comparison many people would make favourably.

P.S.

If you are feeling inspired, you can find a free eBook version of Middlemarch here at Project Gutenberg.

My copy of the text (found in a charity bookshop) was: Penguin English Library, 13th reprint 1977, ed. W Harvey.

Some of the homework I did:

• Mullen, J. Middlemarch: reform and change. British Library, 2014, here
• Furst, L. Struggling for medical reform in Middlemarch. Nineteenth Century Literature, 1993, here
• This episode of In Our Time where Melvyn Bragg occasionally lets his expert guests discuss the novel
• All images are used under Creative Commons licence attribution. You can look through the Wellcome Collection catalogue here, and the National Portrait Gallery collection here