“” AND THE (“MIDDLEMARCH” AND SIR ) By H. A. DEROW, M.D.

BOSTON, MASS.

“ A SK the opinion of a dozen medical men There are few things better worth the pains / upon the novel in which the doctor in a provincial town like this. A fine fever L \\ is best described, and the majority hospital in addition to the old infirmary might / \\ will say ‘Middlemarch.’” be the nucleus of a medical school here, when we Sir William Osler. once get our medical reforms; and what would ’s chief object in “Middle­ do more for medical education than the spread of such schools over the country? march” was to show that “There is no creature whose inward feeling is so strong The extent of the scientific knowledge of that it is not greatly determined by what Lydgate’s colleagues in Middlemarch (the lies outside it, and in obedience to this law, time of the novel is about 1830), as expressed character grows or decays.” Lydgate, the by him, is indicated by the following: physician, is the central figure of special As to the higher questions which determine interest whose career is emblazoned with the starting point of a diagnosis—as to the a great moral for the medical profession. philosophy of medical evidence—any glimmer­ Settling in Middlemarch, a provincial ing of these can only come from a scientific town of England, Lydgate decided to be a culture of which country practitioners have good Middlemarch doctor and by that usually no more notion than the man in the moon. very means keep himself in the track of Copious bleeding and blistering was the far reaching investigations. In his student order of the day and professional practice days, his scientific interest had taken consisted chiefly in giving a great many him to London, Edinburgh and Paris. drugs, the public inferring that it might be He longed to demonstrate the more inti­ better off with more drugs, if they could mate relations of living structure by dili­ only be gotten cheaply, so that a pitiful gent application, not only of the scalpel, deluging of patients with physic resulted. but of the microscope. Such was Lydgate’s Lydgate soon incurred the animosity of plan of his future: to do good small work for his brother- by diagnosing with Middlemarch and great work for the world. the utmost facility conditions that were He determined to keep away from the enigmas to his colleagues. His new methods range of London intrigues, jealousies and of treating fever, according to Louis, of social truckling, and win celebrity, however Paris, met with smarting criticism, and his slowly, as Jenner had done, by the inde­ attempts to discredit the sale of drugs were pendent value of his work. Lydgate was called ungentlemanly. His failure to dis­ ambitious above all to contribute towards pense drugs was considered offensive both enlarging the scientific rational basis of to the physicians whose exclusive distinc­ his profession. tion seemed infringed upon, and to the sur­ I should never have been in any profession geon-apothecaries with whom he ranged that did not call forth the highest intellectual himself. Only a short time before, they strain, and yet keep me in good warm contact might have counted on having the law on with my neighbors. their side against a physician who dared to His zeal toward the establishment of ask for payment except as a charge on drugs I the medical school in the town may be Despite the severe judgment accorded him inferred from: by his fellow-physicians, he tried the expectant theory of treatment in a case of found himself, due to his wife’s extrava­ lobar pneumonia in a robust man, permit­ gances, pressed upon him constantly, and ting Nature to do its share in restoring the cast the blight of irony over all his higher patient’s health, instead of filling him with efforts. shotgun prescriptions. The patient got well. One may easily discern from several The care which he exercised in weighing dialogues between Lydgate and his wife the carefully all items that enter into considera­ state of affairs that existed between them: tion in arriving at a prognosis in a case, and “Why, what can a man do when he takes to a display of that rare virtue in physicians, adoring one of you mermaids? He only neglects i.e. humility, may be gleaned from his his work and runs up bills.” account of a patient who suffered from “I am sure you do not neglect your work. arteriosclerotic heart disease and who had You are always at the Hospital, or seeing poor just sustained a stroke of apoplexy: patients, or thinking about some doctor’s quarrel; and then at home you always want to The first thing that I must impress upon you pore over your microscope and phials. Confess is that my conclusions are doubly uncertain— you like these things better than you like me.” uncertain not only because of my fallibility, but “Haven’t you ambition enough to wish that because diseases of the heart are eminently your husband should be something better than difficult to found prediction on. In any case, a Middlemarch doctor?” one can hardly increase appreciably the tremen­ “Still, I do not think it is a nice profession.” dous uncertainty of life. “It is the grandest profession in the world. Lydgate felt sure that if he ever married, To say that you love me without loving the his wife would have that feminine radiance, medical man in me, is the same sort of thing as that distinctive womanhood which must to say that you like eating a peach but don’t like be classed with flowers and music, that sort its flavour.” of beauty which by its very nature is The habits of Lydgate’s profession, his virtuous, being moulded only for pure and home preoccupation with scientific subjects, delicate joys. which seemed to her like a morbid vampire’s I feel sure that marriage must be the best taste, his peculiar views of things which thing for a man who wants to work steadily. had never entered into the dialogue of He has everything at home then—no teasing courtship, all these continually alienating with personal speculations—he can get calmness influences made his presence dull to her. and freedom. To Lydgate it seemed that he had been His marriage with a selfish and socially spending month after month in sacrificing ambitious young provincial marked the more than half of his best intent and best beginning of the sacrifices he was to make power in his tenderness for his wife, bearing subsequently at the expense of his ambi­ her little claims and interruptions without tions and ideals. His wife was wholly at impatience, and above all, bearing without variance with his ideals, and lacked that betrayal of bitterness to look through less sympathy of purpose towards her husband’s and less of interfering illusion at the blank, activities that is so essential in a physi­ unreflecting surface her mind presented to cian’s wife. She harassed his plans and his ardor for the more impersonal ends of thoughts with an obstinacy that produced his profession and scientific study, an ardor its own bitter effect later in his life. Debts, which he fancied that the ideal wife must far in excess of her husband’s income, were somehow worship as sublime, though not incurred by her, handicapping him all the in the least knowing why. Lydgate was more. She tried to interfere with his medical aware that the concessions to his wife were practice, and dictate the course of action often little more than the lapse of slackening for him to follow in treating his patients. resolution, the creeping paralysis apt to The financial indebtedness in which he soon seize an enthusiasm which is out of adjust­ ment to a constant portion of our lives. treatise on Gout. His skill was relied upon Under the first galling pressure of fore­ by many paying patients. His acquaintances seen financial difficulties, and the percep­ thought him enviable in the possession of so tion that his marriage, if it were not to be a charming a wife. yoked loneliness, must be a state of effort Lydgate always regarded himself a fail­ to go on loving without too much care about ure: he had not done what he once meant to being loved, he had once or twice tried a do. His ambitions to carry on the work of dose of opium. It is indeed an easy matter the great Bichat in the quest for the for a physician confronted with such trou­ “primitive tissue” were never realized. bling situations to yield to that most per­ It was regrettable that Lydgate, gifted with nicious and yet soothing mental anodyne, great powers and fired with high ambitions, opium, thereby shirking the reality of his should be brought down by the domestic pressing and immediate responsibilities. But reality of his wife to a very ordinary achieve­ Lydgate had no constitutional craving after ment. The cares which his marriage to a such transient escapes from the hauntings selfish and socially ambitious girl brought of misery. upon him were serious handicaps to the How different a course De Quincey pur­ realizations of his ideals. He called his sued when beset with difficulties of a wife a basil plant once; and when she somewhat dissimilar nature! De Quincey asked for an explanation, said that basil confessed that: was a plant that flourished wonderfully on I cannot face misery, whether my own or not a murdered man’s brains! with an eye of sufficient firmness. . . . O We may sharply contrast the character just, subtle, and all conquering opium! that to of Lydgate in “Middlemarch” with that the hearts of rich and poor alike, for the wounds of Doctor Bovary in Flaubert’s “Madame that will never heal, and for the pangs of grief Bovary.” Flaubert tells us that when Dr. that “tempt the spirit to rebel,” bringest an Bovary was a medical student, many assuaging balm; eloquent opium! that with thy hidden things within him came out; he potent rhetoric stealest away the purposes of learned couplets by heart, learned how to wrath. . . . Thou only givest these gifts to make punch, and finally, how to make man; and thou hast the keys to Paradise, O love. Thanks to these preparatory labors, just, subtle and mighty opium! he failed completely in his examinations for Such rapturous praises of opium did not the ordinary degree. He passed a second tempt our Lydgate further. He possessed a examination after undue cramming. Dr. character that was able to cope with these Bovary always regretted that during his precarious financial conditions, but his student days, his purse was never full wife’s obstinacy was not conquerable. Lyd­ enough to treat some little work-girl who gate soon realized the failure that had would have become his mistress. come of his marriage and felt, “I am a Being much afraid of killing his patients, fool. Haven’t I given up expecting any­ Dr. Bovary only prescribed sedatives, thing? I have married care, not help.” and from time to time an emetic, a foot bath He accepted his narrowed lot with sad or leeches. He had no ambition. He was resignation. He had chosen this fragile often humiliated at the bedside of a patient creature and had taken the burden of her by a consultant whom he had called in. life upon his arms. He found that “people still have recourse To his friends, Lydgate was always con­ to novenas, to relics, to the priest, rather sidered a successful man. He had gained an than come straight to the doctor.” excellent practice, alternating according to Dr. Bovary’s marriage was also a dismal the season between London and a Conti­ failure. His wife was completely disillu­ nental bathing-place; and had written a sioned in him. Before marriage, she thought herself in love; but the happiness that should This well-drawn character in George Eliot’s have followed this love did not come. She “Middlemarch” may be studied with advan­ had read Balzac and George Sand, seeking tage by the physician; one of the most important in them imaginary satisfaction for her own lessons to be gathered from it is—marry the right woman! desires. In short, domestic mediocrity drove her to lewd fancies, marriage tenderness Further, in the body of his address to adulterous desires. But Dr. Bovary could Dr. Osler, alluding to the affair of the not have rightfully called his wife a “basil heart that spelled ruination for Lydgate, plant” because the “murdered man” lacked said of the physician who had just entered the brains on which it could flourish! into the realm of internal : “He In the “Physician” by Dr. J. M. T. must put his emotions on ice: there must be Finney (1923), the last chapter is devoted no ‘Amaryllis in the shade,’ and he must be­ to the “Causes of Failure” of physicians. ware of the tangles of ‘Neaera’s hair.’ ” Briefly mentioned, he states them: inherit­ Dr. Harvey Cushing in his “Life of Osler” ance of a fortune by the physician; a rich in commenting upon this address writes: wife exercising a very discouraging influence The address might almost be transcribed as upon the practice of so arduous a profession; an autobiographical sketch, so closely does it acquisition of bad habits upon the part of reflect his [Osier’s] own “modus vivendi.” the doctor; failure to keep abreast of prog­ Visualizing a young Lydgate, who does not get ress in his profession; fatal defect in charac­ entangled in the meshes of specialism and whose ter which may be congenital. But no men­ object it is to become a pure physician, he took tion is made of the “basil plant” wife who him through what Sir Andrew Clark had spoken defeats her husband’s ambitions and ideals. of as the three stages—the dry-bread period, A rich wife, as Dr. Finney says, does not the bread-and-butter period, and the period of necessarily mean the failure of the physi­ cakes-and-ale. . . . Most happily married cian, as there are too many exceptions to himself and knowing how often the tragedy of Lydgate was repeated in the profession, Osler this. It is difficult to evaluate the relative used to reiterate the warning to his young importance of the causes of a physician’s friends to keep their affections on ice. His advice failure, but I feel that of prime considera­ was not always taken. tion is the wife who is in collision with her husband’s purpose in life. Among Osler’s notes for an intended Sir William Osler often referred to Lyd­ Introduction to the “Litteraria” section of gate’s ambitions and marriage in his addres­ his library catalogue there is a long one ses and letters to medical students and which reads in part as follows: young celibate physicians on the subject of Ask the opinion of a dozen medical men upon the advisability of marriage for a young the novel in which the doctor is best described physician who has just been launched into and a majority will say “Middlemarch.” the Anfang of his career. In Dr. Osier’s Lydgate is at once an example and a warning. address on “Physic and Physicians as . . . An unmitigated calamity, his marriage Depicted in Plato,” (1892) he said: ruined his intellectual life in a soul-wasting struggle with worldly annoyances. . . . Writers of our times, like George Eliot, have George Eliot was happy in her relations with told for future generations in a character such as the profession, and we owe her a deep debt for Lydgate, the little everyday struggles and this Early Victorian sketch of it in a provincial aspirations of the profession of the nineteenth town. It is often said that my Brother Regius century. of Cambridge, Sir Clifford Allbutt, was the original Lydgate. Nothing in their careers is in In the only footnote to his address on common, save the training and the high aspira­ “Internal Medicine as a Vocation” (1897) tions. There is a basis for the statement. When in referring to Lydgate, Dr. Osler wrote: Dr. Bastian lived at Hanwell, one Sunday afternoon, he had just returned from a visit to younger, earthly Aphrodite, daughter of Zeus George Eliot, and the conversation turned on and Dione, she will whistle you off and let you “Middlemarch” which had recently appeared. down the wind to be a prey, perhaps to the He said that the matter had been discussed in examiners, certainly to the worm regret. In her house that afternoon, and she confessed plainer language, put your affections in cold that Dr. Allbutt’s early career at Leeds had storage for a few years, and you will take them given her suggestions. out ripened, perhaps a bit mellow, but certainly A young medical graduate, who had less subject to those frequent changes which perplex so many young men. Only a grand pas­ sought Dr. Osler’s advice on the subject of sion, an all-absorbing devotion to the elder marriage, and had married despite the goddess can save the man with a congenital contrary admonition, subsequently received tendency to philandering.1 the following letter from Dr. Osler: During the “dry-bread period” of which “Dear------, Osler spoke, it may not be unwise to give Do not worry, you could not offend me, nor did you fool me altogether. Although I did not special thought to Bacon’s essay on “Mar­ refer to it, I had a feeling that you had made up riage and Single Life,” from which I quote: your mind. Long experience has taught me that He that hath wife and children hath given in these cases, advice is sought to confirm a hostages to fortune; for they are impediments to position already held. In the affairs of the heart, great enterprises, either of virtue or mischief. in which I have had a long and curious experi­ Certainly the best works, and of greatest merit ence, I do not remember an instance in which for the public, have proceeded from the unmar­ my adverse counsel was taken. . . . ried or childless men, which both in affecta­ Of course, I know you love her, or think you tion and means, have married and endowed do, which at this stage of the game is the same the public. thing. Only remember that the blind bow-boy “Marry the right woman.” Who is she? plays the devil with us sometimes. I tried to warn you against what I felt was an indiscreet What are her attributes and virtues? In marriage. his letter to the medical graduate that was You have a career ahead of you which the mentioned before, Dr. Osler tries to define right woman will help and the wrong woman her. I doubt whether any description else­ wreck. A level-headed fellow can do anything he where compares with that given in the Book wishes with a wife if love blossom into trust, of Proverbs in the last chapter beginning gentleness and consideration. A doctor needs a at the tenth verse. Here we find a superb woman who will look after his house and rear his delineation of the ideal woman as wife and children, a Martha whose first care will be for mother, especially applicable to the wife the house. Make her feel she is your partner of the physician: arranging a side of the business in which she should have her sway and way. Keep the two Who can find a virtuous woman? for far above separate. Consult her and take her advice pearls is her value. about house and children, but keep to yourself, The heart of her husband doth safely trust in as far as possible, the outside affairs relating to her, and he will not see his gain diminish. the practice. She treateth him well not ill, all the days of her life. . . . Osler’s remarks on the “affairs of the She spreadeth out wide her open palm to the heart” of medical students may be advan­ poor; yea, her hand she stretcheth forth to the tageously included here: needy. The mistress of your studies should be the She openeth her mouth with wisdom, and the heavenly Aphrodite, the motherless daughter of law of kindness is on her tongue. Uranus. Give her your whole heart, and she will She Iooketh well to the ways of her household, be your protectress and friend. A jealous and the bread of idleness she doth not eat. creature, brooking no second, if she finds you 1 Master-word in medicine, Johns Hopkins Hosp. trifling and coquetting with her rival, the Bull., Balt., 1904, xv, 1. Her children rise up, and call her blessed: week-end. Dr. Osler called it a “gushing her husband, also, and he praiseth her: letter—so true!” It is a tribute to the ideal “Many daughters have done virtuously; but wife of the ideal physican. The letter, in thou excellest them all!” part, is as follows: In reading “The Book on the Physician I cannot tell you how much I enjoyed my week­ Himself and the Things that Concern His end with you. I have inherited from some Reputation and Success” by Dr. D. W. miserable Anglo-Saxon ancestor the unfortunate Cathell,2 I had expected to find some allu­ quality of being too shy to express my apprecia­ sion to the physician’s wife as a possible tion, face to face. But from this distance I can factor, and found that mention was only tell you frankly what I feel, and that is, that made of the “meddling” wife of the doctor: you are simply wonderful. You keep open house; you are always “en evidence” as it were. There is no end to mortifications, compro­ You are always the same, welcoming them in mises and estrangements into which a physi­ and speeding the parting guest, whether they cian’s prying and babbling wife may lead him by are maids, matrons or children. You do the her tittle-tattle, about “The Doctor’s Patients.” right thing always. You must be tired, bored, at A little volume, “The Physician’s Wife times sick to death of it, but you never appear to and the Things that Pertain to Her Life” be. You spend your life looking after other by Mrs. Ellen M. Firebaugh, made its people, looking after the sick and the afflicted, helping the lame dogs over the stile. Your whole appearance in 1894, after the publication of life is lived for others and the fact that you get a the 9th edition of Dr. Cathell’s treatise. certain amount of unselfish pleasure out of being By depicting the daily trials and tribulations able to do it doesn’t alter in the least that you of a country physician, she illustrates how are “wonderful.” I tell you candidly, there is no the practitioner’s wife may serve her hus­ woman that I have as great an admiration for as band best. This little book should be read I have for you. My mother, Aunt------, and by the wives of physicians as an example of you are the three that make my ideal. And none how much a wife may mean in the life of of you ask for praise or applause, or expect it. a doctor. You probably think I am ridiculous to write Dr. W. S. Thayer, in his paper on “Osler, like this, but I mean it, and I think that we all the Teacher”3 spoke of Sir William Osier’s make a mistake sometimes in not expressing wife: “If you can select a wife with a heart appreciation. I love the artistic side of your as big as your own, whose generous welcome house—the garden, the roses, the ease, the comfort, the blue carpet on the stairs, though makes your tea-table a Mecca . . . . ” it may be worn; the birds in the morning, the In Dr. Cushing’s “Life of William Osler” comfortable bed, the towels worked in blue! is printed a portion of a letter that was sent the writing table with everything on it, the to Lady Osler by one who sojourned at books. All is perfect, but behind it all, I appreci­ Sir William Osier’s home in Oxford for a ate you, and the organizing power. Other people, 2 Ed. 12, Phila, 1913. many of them, appreciate this but they don’t 3 Johns Hopkins Hosp. Bull., Balt., 1919, xxx, 198. know why. I do—it is YOU!