The medical men of Middlemarch.

There must be two dozen books on my shelves that I’ve never read, but recently, after coming across a couple references to how dauntingly unreadable Middlemarch is, I decided to verify my hazy impression that I’d found it absorbing from the start.

Maybe “absorbing” is the wrong word. Victorian novels demand sifting, extracting, unpacking. Many sentences need to be double-read: once through to sort out how the clauses relate to each other and again to determine how they relate to the story. You’d think I’d find it tedious. I’m not enchanted with complexity for its own sake. My eyelids tend to droop when I read poetry, for instance, even stuff I know I should admire, like Shakespeare. George Eliot begins each chapter with an epigraph, usually poetical; I skim them. But the story is interesting enough that I don’t mind unravelling the prose when it gets knotty. Clive James once disparaged another literary pretzel-twister, Edward Gibbon, for “the kind of stylistic difficulty which leads its admirers to admire themselves, for submitting to the punishment.” Perhaps liking Middlemarch is a kind of masochism.

The other day, awaiting the inevitable callback from my garage to upsell me from a routine oil-and-lube to major repairs, I found myself wondering why mechanics can’t operate the way Mr. Lydgate does in Middlemarch. I know that sounds unbearably pretentious but it’s what I was thinking.

Most readers remember Middlemarch for the thwarted romance of widowed Dorothea Casaubon and the passionate but aimless Will Ladislaw. Mr. Lydgate is the hero of what a screenwriter would call the “B-plot”; to quote the rear cover copy on my Signet Classic paperback, Lydgate is “an ambitious young doctor who is betrayed by his wife’s egoism and his own inner weakness.” The rather haughty surgeon-apothecary, newly arrived in Middlemarch, offends local custom by acting on the principle that a doctor should “simply prescribe, without dispensing drugs or taking percentage from druggists.” He explains that,

it must lower the character of practitioners and be a constant injury to the public if their only mode of getting paid for their work was by their making out long bills for drafts, boluses, and mixtures.

This explanation gets rather muddled in third-hand transmission to a competitor:

The next day Mr. Gambit was told that Lydgate went about saying physic was of no use.

“Indeed!” said he, lifting his eyebrows with cautious surprise. (He was a stout, husky man with a large ring on his fourth finger.) “How will he cure his patients, then?”

“That is what I say,” returned Mrs. Mawmsey, who habitually gave weight to her speech by loading her pronouns. “Does he suppose that people will pay him only to come and sit with them and go away again?”

This business about Lydgate and his rivalry with the town’s other “practitioners” is one of those subtle questions of class and custom that gets lost on the modern reader. On first reading Middlemarch I failed to notice that Lydgate is referred to as “Mr.”, never as “Dr.” The latter honorific is reserved to those, like the town physicians, Dr. Minchin and Dr. Sprague, who have “been to either of the English universities and enjoyed the absence of anatomical and bedside study there”. In other words they have been more expensively though not more comprehensively educated. Mr. Lydgate, by contrast, after his apprenticeship to a country apothecary, has studied at Edinburgh, Paris, and London, there picking up numerous progressive and unsettling ideas.

Middlemarch is set just before and after the accession of William IV in 1830, a time of much reformist ferment. A decade and a half earlier, Parliament had made a stab at straightening out the chaotic system of medical accreditation which then prevailed in the United Kingdom. As S.W.F. Holloway explained in the July 1966 issue of the journal Medical History (“The Apothecaries’ Act, 1815: A Reinterpretation: Part II“) , the new system effectively defined nearly all medical practitioners as apothecaries, and regulated them as such. Traditionally apothecaries had filled a role roughly analogous to pharmacists today, but the lines between the different classes of medical practitioners had become blurred. As Holloway quotes a contemporary source:

In London, and some of our other great towns, there are physicians and surgeons who do not compound or vend medicines; but in the country this distinction of the three branches of the profession does not exist. Except in a few of our largest towns, every man who practises medicine at all, likewise deals in drugs, and must do so … If he were not to supply [patients] with medicines, there is nobody else from whom they could procure them. The consequence is … that over all England the medical practitioners are also apothecaries, within the meaning of this act.

Physicians were an exalted class who could afford to forgo the unseemly necessity of seeking licensure as apothecaries, which required a five-year apprenticeship as an apothecary. Men of substance who could afford a degree from Oxford or Cambridge, physicians attended the sickbeds of the titled and propertied; the customary fee for a consultation was one guinea. All other medical men, known inclusively as general practitioners, were traditionally forbidden to charge an attendance fee. Their sole source of income was the “drafts, boluses, and mixtures” they peddled. As Holloway explains:

This system led not only to [the general practitioner] being considered a tradesman in an age when trade was regarded as a debased occupation: it also exposed him to the accusation of over-charging and over-prescribing. The apothecary, it was said in 1703, “makes the deluded Patient pay very extravagant Fees by the intolerable Prices he puts on all the cheap Medicines, and by passing upon him very many more Doses than the Disease requires or the Constitution can bear”.

(You can see why my mind ran to Lydgate as I sat awaiting the call from my mechanic, to pass upon me a Dose my Constitution could not bear.)

By charging for doctoring and not for drugs, Lydgate is offensive not only to the physicians on whose exclusive prerogative he is trespassing, but to his fellow general practitioners Mr. Wrench and Mr. Toller, to whom he appears to be trying to overreach his station:

“I say the most ungentlemanly trick a man can be guilty of is to come among the members of his profession with innovations which are a libel on their time-honoured procedure. That is my opinion, and I am ready to maintain it against anyone who contradicts me.”

“My dear fellow,” said Mr. Toller, striking in pacifically and looking at Mr. Wrench, “the physicians have their toes trodden on more than we have. If you come to dignity it is a question for Minchin and Sprague.”

“Does medical jurisprudence provide nothing against these infringements?” said Mr. Hackbutt with a disinterested desire to offer his lights. “How does the law stand, eh, Hawley?”

“Nothing to be done there,” said Mr. Hawley. “I looked into it for Sprague. You’d only break your nose against a damned judge’s decision.”

What decision is this? Holloway again:

The first step came in 1829 when Chief Justice Best, in Towne v. Gresley, held that an apothecary might charge for his attendance, provided he made no charge for the medicines furnished. But in the following year Lord Tenterden ruled that an apothecary might recover for reasonable attendance as well as for medicines.

Per this judgement, there’s nothing stopping Mr. Lydgate from charging a consulting fee and also pushing lucrative potions on his patients. But he refrains as a matter of principle.

Perhaps an idealistic thinker of the Lydgate type will one day reform the automotive repair industry so that garages are no longer incentivized, as apothecaries once were, to over-prescribe service. A consulting mechanic would examine our car and determine which fluids really needed flushing, which gaskets really needed replacing, then write out a prescription which we’d take to a practicing mechanic up the road, who’d actually carry out the repairs. I’m sure the first such practitioner would arouse much resentment and resistance among his fellow tradespeople. It would make good drama for a novel. Not the main story, probably. A B-plot.

M.

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