Middlemarch
Authors: Vinod Patel, John Morrissey
Journal: BMJ (2007)

George Eliot (real name Mary Ann or Marian Evans) is arguably the greatest of Victorian novelists and Middlemarch is her undisputed masterpiece. Virginia Woolf famously hailed it as “one of the few English novels written for grown-up people.” The events described by this monumental work, which was published in 1871-2, are set 40 years earlier in the fictitious market town of the title. Eliot was born in 1819 in Nuneaton and it is not improbable that Middlemarch was based on nearby Coventry.

The novel has 21 major characters and numerous plots and subplots. At the centre are the parallel stories of a physician, Dr Tertius Lydgate, and the saintly Dorothea Brooke, both of whom in different ways aspire to improve the lot of mankind. Dorothea is an idealist out to change the world and particularly address local social inequalities. Dr Lydgate is passionate about reforming the medical profession and his personal practice. However, both make errors of judgment, in particular in their respective marriages to unsuitable partners, and by the end of the novel their lofty ambitions remain unrealised.

Middlemarch contains several clinical cases, and it is a great tribute to Eliot that the English physician and pathologist Sir James Paget (1814-99) described all the cases as being flawless in clinical detail. In many ways the novel was way ahead of its time, and some of the medical and social areas it covered are still important issues today, as the following examples demonstrate. 

The effect of social inequalities on health: “Life in cottages might be happier . . . if they were real houses fit for human beings.”

Lifestyle and health: “She had brought up her children . . . not to over-eat themselves . . . which . . . habit she considered the chief reason why people needed doctors. Lydgate pleaded for those whose fathers and mothers had over-eaten themselves . . . ”

Holistic care: “He cared not only for ‘cases,' but for John and Elizabeth, especially Elizabeth.”

Continuing education and research: “There must be a systole and diastole in all inquiry” and “a man's mind must be continually expanding and shrinking between the whole human horizon and the horizon of an object-glass.”

Lydgate's research interest is to discover the “primitive tissue” from which all others are derived. Eliot portrays this as a futile and hubristic endeavour, but in retrospect it seems a remarkable anticipation of stem cell research. Lydgate is the first to introduce the stethoscope to Middlemarch.

The potential for a medical school locally: “A fine fever hospital in addition to the old infirmary might be the nucleus of a medical school here . . . and what would do more for medical education than the spread of such schools over the country?” This did happen in June 2007, 135 years later, as Warwick Medical School obtained its charter as an independent medical school. Approximately 25% of the hospital clinical teaching for this medical school now takes place at George Eliot Hospital NHS Trust. Almost all students have a clinical placement at this hospital.

Eliot's final message in Middlemarch is that we must be meliorist in this often tragic world of ours. Ours is to do to whatever we can to make the lot of humankind better.