In 1831 the first epidemic of what came to be known as “Asiatic cholera” bloomed in Britain. The disease, which in previous centuries had been known only in India, was to appear again in Britain in 1848–49, 1853–54, and 1866–67 as pandemics swept around the globe. But it was cholera's first arrival on the shores of Britain in 1831 that struck terror into British hearts. No one knew what disastrous consequences might ensue from this alien plague. Striking down perfectly healthy people, sometimes as they walked in the streets, it could kill within a few hours. So severe was the rapid dehydration caused by violent diarrhea and vomiting, and accompanied by hideously painful cramps, that victims rapidly became semi-comatose and turned blue-white. The Quarterly Review called it “one of the most terrible pestilences which have ever desolated the earth,” and claimed that it had killed fifty million in fourteen years (Morris 14).

Probably the most terrifying aspect of the “horror” of cholera, as Anthony S. Wohl posits, lay in its “foreign, Eastern origin – it had crossed God's ‘moat’ which was supposed to protect England from invasion” (372 n. 5). A “choleraphobia” emerged from the notion, as Dr. William Tennant Gairdner was to put it later, that

The spread of this “shock disease” from the dark territory of colonial India obsessed the British public. Ironically, as post-colonial critics such as David Arnold have recently postulated, it was probably the British themselves who created the first epidemic wave of the disease in India in 1817, by carrying it with them as they marched from Bengal in the east (where cholera had long been endemic) to the west during the most decisive phase of British expansion in India (Arnold 168–69). But this first of the cholera pandemics traveled south to Mauritius and then eastward toward China and Japan. Although it eventually also traveled up the Persian Gulf and as far north as Astrakhan, it never extended to Europe or the Americas. As reports arrived in London in the early summer of 1831 that the second great pandemic had reached Russia and was moving across Europe toward Britain, T. B. Macaulay wrote to his sister, “The great topic now . . . is not, as you perhaps fancy, Reform, but cholera. There is a great panic, as great a panic as I can remember, particularly in the City” (10 June 1831; qtd. in Trevelyan 162).Footnote ¹

In the town of Middlemarch, however, cholera appears not as a “great topic,” but as only one of many topics of discussion, and one that is invariably dropped in favor of some other. First referred to as located in “Dantzic,” cholera's advance to Britain and to Middlemarch itself is so quiet as to be hardly noticed by the reader. Later, the narrator informs us that in Middlemarch “railways were as exciting a topic as the Reform Bill or the imminent horrors of Cholera,” and the remainder of the chapter then focuses on railways (Eliot, Middlemarch 519; ch. 56). References to the disease are so brief and apparently insignificant that the reader, far from imagining the “choleraphobia” of the time, may overlook them completely, perhaps unaware of George Eliot's statement that she intended nothing in the novel to be irrelevant to her design (Eliot, Letters 5: 168). Most striking, the disease is never referred to as “Indian cholera,” despite the predominance of this term at the time of the 1831–32 epidemic.

Yet, the quiet and apparently insignificant appearances of the disease in the narrative parallel and correspond to the exposure of a particular kind of English male pathology: a rootless “cosmopolitanism” that is abhorred by Eliot and exemplified by her “hypochondriacal” character, Nicholas Bulstrode, on whom she inflicts a fiendishly appropriate – that is, imaginary – form of the disease. Eliot's examination of medical knowledge and practice at this time allows her to bring into focus a distinctively nationalized male pathology. Here she provides us with an example of what she called the “abnormal conditions” of the “Natural History,” or “Pathology” of a people – that is, of its men (Eliot, “Natural History” 285). In Middlemarch (1871–72), all the women are healthy, their illnesses being of so minor or temporary a character as to receive only passing mention.Footnote ² But the novel presents a number of case studies of the pathologies of domestic masculinity, and these are far more serious. The worst of these appears to represent “cosmopolitanism” in its most negative nineteenth-century connotation: the “riff-raff” of the world or those who were – like the disease of cholera itself – without local attachment and, therefore, entirely lacking in the capacity for fellow-feeling.

I will argue that Eliot's representation of cosmopolitanisms in the novel circulates through medical discourses, both those of the time of the novel, which is one of reform in medicine as it was of the Reform bill in politics, and those of the 1860s, by which time members of the medical profession were beginning to describe themselves as “cosmopolitan,” but also to class some diseases as “cosmopolitan.” Looking at medical discourses on cosmopolitanism during the nineteenth century suggests not only an emerging sense of the growing interrelatedness of the entire globe and its presumed benefits for humanity, but also of certain disturbing risks incurred by such commingling of diverse populations. Moreover, it provides clues as to why Eliot might have seen a vividly figurative form of cholera – the uncontrollable public purging of the unspeakable contents from “within” Bulstrode's hidden history – as a peculiarly apt narrative equivalent for his moral pathology.

Medicine, Cholera, and Cosmopolitanism

Two sharply opposing constructions of “cosmopolitan” emerge around mid-century in the Lancet and other medical journals and books: one triumphantly celebrating medical men as members of a universal brotherhood of cosmopolitan science and the other publishing the terrors of the new “cosmopolitan disease.” As example of the first, an 1856 Lancet article announces that “science is cosmopolitan, men of science form members of one brotherhood all the world over, and they will be as ready to meet and deliberate for the benefit of humanity in Vienna as elsewhere” (“London: Saturday, December 13, 1856” 658). An 1858 article trumpets that “science is cosmopolitan in the most elevated degree: all men are alike interested in its progress; and it is one of the highest privileges of its cultivators that by it they are united in an universal bond of brotherhood” (“Word to Craniographers” 506). Recently deceased medical men are eulogized as having had “cosmopolitan sympathies” or “cosmopolitan importance” (“London: Saturday, May 10, 1856” 520; “London: Saturday, November 5, 1853” 442). Eliot's sole use of the word “cosmopolitan” in Middlemarch – Mr. Brooke's fuzzy conclusion that “certainly a man can only be cosmopolitan up to a certain point” – plays on this elevating connotation, among others (50; ch. 6).

But at about the same mid-point in the century, a starkly contrasting construction of “cosmopolitan” arises in the medical discourse on cholera. “Cholera,” once classed with tropical diseases and thought to be confined to tropical climates, emerges as a “cosmopolitan disease.” It seemed that cholera, like some plants or insects, might be diffused widely over the globe – that it might be able to survive anywhere. As the 1848–49 epidemic spread across the ocean to the United States so did its appellation as a “cosmopolitan” disease. On November 30, 1850, Thomas M. Logan, M.D. wrote in a report on the disease that was then ravaging the gold rush city of Sacramento, California: “Never, perhaps, did pestilence attack a community so little prepared to resist its ravages, and seldom in the history of this cosmopolitan disease, since its first consternating cycle, in 1817, commencing at the Gangetic Delta, and progressing around the globe, which it here spanned, has its visitation of any locality been more destructive and appalling” (Logan 463). Logan's dramatic report was quoted repeatedly all over the United States.Footnote ³ The urgency of its tone suggests the anxiety that colonialism has unleashed forces that may overwhelm the medical powers of the “civilized” world: cosmopolitan disease may be too much for cosmopolitan science.Footnote ⁴

In A Treatise on Fever (Reference Lyons1861), Robert Spencer Dyer Lyons, “Late Pathologist-in Chief to the British Army in Crimea,” addresses medical students on their “high mission”: “as public servants in any of the distant colonies or broad possessions of the British empire, or as adventurers seeking new homes and fortunes in the far west, . . . this cosmopolitan disease meets you in both hemispheres, and on either side of the line . . . you must be prepared to dispute with him each inch of ground . . . to achieve this victory over death” (21–22). This disease-oriented construction of cosmopolitanism underwrites a sinister character to the term: it is to be battled as one battles a secret, invasive force, found everywhere.

This development of opposing constructions of cosmopolitanism in medical discourse contextualizes the opposing medical cosmopolitanisms of Lydgate and Middlemarch's narrator. Lydgate's impassioned belief that the medical profession was “the finest in the world; presenting the most perfect interchange between science and art” (136; ch. 15) is clearly informed by Enlightenment cosmopolitan ideals of utilizing new medical knowledge for the greatest good of the social body, or what Bruce Robbins calls the “old, normative sense,” a “universal ethical ideal” that disavows patriotism or attachment to any specific national or local politics (51). Lydgate identifies with the post-Revolutionary, radical reforms of medicine in France, which did away entirely with the established institutions of medicine and sought to abolish the corruption and favoritism associated with them. Under the new system, all students were trained in the new hospital medical schools, and all patients were admitted on the basis of need and treated free of charge. Since the bodies of all those who died in the hospitals were available for dissection, thus making it possible for actual pathology to be correlated with examination and diagnosis of living patients, medical knowledge expanded dramatically in early nineteenth-century Paris medicine. For a time it was possible for those who had, like Lydgate, studied in Paris to persuade themselves that medicine was advancing rapidly and that it would uniformly promote the “social good.” The advances in pathology made in Parisian medicine, however, not only failed to lead to similar advances in the treatment of disease, but were wholly powerless to stem the tide of new diseases, especially cholera.

The decidedly more critical representation of medicine during these years in England – described as those “heroic times of copious bleeding and blistering” – offered by Eliot's narrator emerges not only from Eliot's research in the medical literature of the 1830s, but also from her own situatedness in the medical knowledge of the late 1860s and her remembered experience of health and disease in England and elsewhere during the forty years or so that follow her fictional surgeon's time (Eliot, Middlemarch 133; ch. 15). The narrator speaks from the standpoint of a skeptical cosmopolitan medical observer, exemplifying what Rebecca Walkowitz calls “critical cosmopolitanism,” or one that develops and examines “new attitudes of cosmopolitanism . . . in the service of a kind of critique” (4). For Walkowitz, “critical cosmopolitanism” is associated with modernist writers of the twentieth century and manifests itself as “a new distrust of civilizing processes,” reflecting “both a desire for and an ambivalence about collective social projects” (4). Eliot's Middlemarch narrator, however, is far closer to this skeptical representation of medicine than to the triumphalist mode common to medical historians of the nineteenth (and much of the twentieth) century. The tale of Lydgate's failure to achieve his ideal of medicine practiced for the “social good” is narrated by an observer skeptical of medical progress. As Peter Melville Logan notes, Middlemarch “questions the basic structure of medical knowledge itself” (5).

Eliot's writing about cholera, then, represents both the naïve medical cosmopolitanism of Lydgate's story when, as an 1831 Lancet article describes it, immunity from the “frightful evils” of pestilence (i.e., the Black Plague of London in 1665–66) had continued “for a period of nearly double the lifetime of our oldest men,” and the later period in Victorian medicine when it had been recognized that pestilences of various kinds could make themselves right at home in the supposedly safer and cleaner world of England (“History of the Rise” 241). But Eliot also writes from a particular moment in Victorian medicine when the state of Victorian health in general was dismal, worse than it had been earlier in the century. Statistics on mortality gathered by the General Register Office (GRO) since 1837 documented the fact that the death rate for England and Wales, which had stabilized at 22.4 per thousand between 1841–50, actually rose to 22.5 per thousand between 1861 and 1870 (Hardy, Health 5–6). In addition to typhoid fever which, like cholera, was spread by the fecal-oral route, and which caused the death of no less privileged a person than Prince Albert in 1861, typhus fever – spread by the body louse, though Victorians were unaware of this specific effect of infestation with a common vermin – raged in London and also among Lancashire textile workers for most of the 1860s. Continual alarms about increases in venereal disease in the military forces instigated the passage of the Contagious Diseases Acts of 1864, 1866, and 1869 – “medical police” Acts that doubtless increased public paranoia about contagion, especially since these diseases were spread by the alleged increasing hordes of “fallen women,” but were completely powerless to actually reduce the terrible toll of syphilis on children, women, and men. Despite the fact that England had finally made infant smallpox vaccination compulsory in 1853 – long after many other European countries had done so – when smallpox hit the unvaccinated soldiers of the Franco-Prussian War it migrated from them across the Channel in 1870 to produce the severest epidemic of this disease to occur in England in the entire century. And in London, a very serious outbreak of that new disease, diphtheria, which we hear about in the Finale to Middlemarch, only described for the first time by Pierre Bretonneau in 1826 and not observed in England until around 1845, flared from 1858 to 1865 (Hardy, Epidemic Streets 80).Footnote ⁵

Even before the term “cosmopolitan” appears in medical discourse describing cholera, the disease was observed to be a traveler, arriving on the newer and faster modes of transportation and either racing through the newer, bigger, and ever dirtier cities or settling down in them, an undesirable migrant who stayed on. There was no difference between an “Indian” and an “English” cholera, as doctors at first hoped, a domestic version being assumed to be more benign than the foreign one. It was simply a disease that attacked wherever people lived in “filth,” as more privileged, cleaner Victorians put it. But as experience with later epidemics proved, even perfectly clean citizens who happened to drink water that wasn't clean, or to bite into a poisoned apple, could get cholera.Footnote ⁶ Cosmopolitan cholera demolished parochial identities and securities – water could run from poor to privileged neighborhoods, the filthy Thames could overflow on the lawns of the royal residence. Cholera enforced a kind of disastrous globalization – it went everywhere, killed in all countries, infected any and all populations. As an article in the Lancet comments:

Cholera thus figured in nineteenth-century medical discourse as a limitless force that could transform “civilised nations” into “savage hordes” and destroy all social bonds, seeming to attack especially the peaceful and charitable. No more appropriate symbolic vehicle for the “disease” of cosmopolitan riff-raff, people with little or no national, communal, or familial attachment, stereotypically figured as Jews or gypsies or Italians with white mice, or traveling salesmen like Raffles, could be found. But perhaps it would be useful to survey, as Gillian Beer says, what is not in Middlemarch but is in its “stock of common knowledge – that is to say, knowledge common to its first readers and not to us” (Beer 15). What would the writer and her readers have known about cholera that we do not?

Cholera and George Eliot

Many of the readers of Middlemarch in 1871–72, like Eliot herself, would have lived through all four of the British epidemics, and the most recent one, only five years earlier, would be fresh in all readers’ minds. The 1866–67 epidemic, though the smallest one of all, killed about 14,000 people. It would prove to be the last such epidemic in Britain. Although Eliot and her readers could not know that happy bit of future British medical history, they would have known that sanitary measures – especially those safeguarding the cleanliness of drinking water – were clearly effective in controlling the spread of the disease. The “choleraphobia” so prevalent at the time of the 1831–32 epidemic, when Mary Ann Evans was a schoolgirl at Mrs. Wallington's boarding-school in Nuneaton, would have been eradicated for most of the British population by the time of the writing of Middlemarch, because cholera was no longer a new or an “alien” disease but an all too familiar, ongoing threat to the whole world.

Eliot may not have remembered much about that first epidemic, but as part of her research for Middlemarch, she made notes in her “Quarry for ‘Middlemarch'” on various issues of the Lancet from January 1830 through 1831.Footnote ⁷ Perhaps the lengthiest article on cholera during this period, “History of the Rise, Progress, Ravages, etc. of the Blue Cholera of India,” quoted above, emphasizes what post-colonial critics have recently concluded about the disease: that it traveled with human travelers, especially troops, but also with other migrants. Its irruption in previously uninfected places invariably coincided “with the arrival of ships, of caravans of fugitives or pilgrims, of individuals, and with the progress of armies” (“History of the Rise” 261). In Poland, Prussia, and Austria, for example, “wherever these troops [the Cossacks] went, as they marched through the vast districts of Podolia and Volhynia, the towns and villages were infected in their order of succession from the east to Warsaw” (“History of the Rise” 251). An earlier report by two British physicians, Drs. Russell and Barry, clearly established that the cholera of Russia and that of Jessore were identical: the “Indian pestilence” had proved its power to do something no one had ever expected – to extend its virulence to other climates (253). “Dantzick” [sic] – that unknown locality referred to in wonderment in Middlemarch – was crucial to this conclusion, for until its “irruption” there, “much doubt was entertained in this country and in other European nations respecting the identity of the Russian epidemic with the Indian disease” (252). But the investigations of Dr. Russell, “who had previously witnessed the cholera of the east,” and Dr. Barry proved that the cholera of the east and the cholera that had traveled to Russia and was presently speeding westward were one and the same (252).Footnote ⁸

At the time of the second, and much larger, epidemic of cholera in 1848–49, Evans traveled with her friends the Brays to Geneva in June. In July, the Brays returned to an England in the grip of this most horrific epidemic of cholera. In August Dr. John Snow published the first brief edition of his foundational epidemiological work, On the Mode of Communication of Cholera (Reference Snow1849), in which he argued that cholera was chiefly transmitted by contaminated water. More relevant to the present argument is that Snow too emphasized that the disease moved by means of human travelers. From its first appearance or recognition in India in 1817, he believes, the disease progressed along the channels of “human intercourse” (“On the Mode”). In his much enlarged 1855 edition of this work, he elaborates the “traveling” nature of cholera:

By late in the century, this understanding of how cholera was communicated had become so ubiquitous in medical discourse that Patrick Manson, in his ground-breaking Tropical Diseases: A Manual of the Diseases of Warm Climates (1898) could easily put it into the framework of the increased speed of travel, even for Indian pilgrimages, in these “modern times”:

Mary Ann Evans's awareness of the 1848–49 epidemic and of its appalling impact is demonstrated by letters she wrote to the Brays. On September 20, 1849, she reassures them that “the cholera is not at Geneva – the medical men say it is cholera-proof” (Letters 1: 310). In another letter, written on October 24, 1849, she refers to “these days of cholera and crisis.” (Letters 1: 316). But the Brays, who had returned, found that cholera had arrived before them. The first entry in Mrs. Bray's Diary for September notes briefly, “Cholera in Coventry” (Letters 1: 848).

This epidemic was particularly devastating in England: in comparison to the epidemic of 1831–32, which killed roughly 32,000 people, the 1848–49 epidemic killed 62,000 (Wohl 118). It struck London far more harshly than the earlier epidemic, an incidence that Snow attributed to an effort to abolish cesspools and the “almost universal adoption of water closets in their stead” (OMCC2; “Influence of the Water Supply”). Because water closets emptied their contents through the sewage system into the Thames, and water supply companies at this time drew their water from the same region on the Thames into which the sewage system emptied, the water supply for all London residents was contaminated. (Before this development, cesspools had been emptied by “night soil men,” who carted their contents out of the city to be used as fertilizer.)Footnote ¹⁰

At the beginning of the next epidemic, in 1853, only four years later, Evans – now calling herself Marian Evans – was living in London, the editor in all but name of the Westminster Review and a member of the large and eccentric household of the titular editor, John Chapman. It is possible she felt personally endangered by this epidemic, which again raged in London as well as in the rest of Britain (although this time it killed only a total of about 20,000). On July 20, 1854, Evans and George Henry Lewes left England together for the continent, making public for the first time the scandalous news that she was living with a married man. By this time Harriet Martineau, who was involved with attempting to keep the floundering Review afloat financially, suggested that her brother James Martineau was deliberately trying to ruin it by throwing it onto the market at a time when all London was empty because of the cholera (Haight, George Eliot and John Chapman 77).

In the first week of September 1854, Snow made his famous experiment of removing the handle of the Broad Street pump and thus testifying to the probable accuracy of his earlier hypothesis that cholera was caused by a water-borne organism.Footnote ¹¹ He also proved, in another much more detailed and better-planned study, that families who bought their drinking water from a company that got it from downstream Thames had fourteen times the cholera incidence of those who bought it from companies that got it from the Thames above London, before it had received the discharges of the city's drains and sewers into the river (Bynum, Science 80–81). And although Evans was not in London, she received word that the author of several articles on India – a John Chapman who was known as “the foremost pioneer of railways in western India,” and who was a cousin of the publisher John Chapman, had died suddenly of cholera (Henry, George Eliot and the British Empire 100–01). Ironically, he died in London on September 11, 1854, after having escaped cholera during previous periods of residence in India. Evans wrote to John Chapman (the editor) that “I have been much grieved to hear of Mr. John Chapman's death, which I am sure has affected you deeply, even in the midst of more personal troubles” (Eliot, Letters 2: 175).

More than a decade after the shocking epidemic of 1854, the Rev. Henry Whitehead published two articles in Macmillan's Magazine: the first, “The Broad Street Pump: An Episode in the Cholera Epidemic of 1854,” appeared in December Reference Whitehead1865; the second, “The Influence of Impure Water on the Spread of Cholera,” was published in early 1866. In these two compelling essays he not only details his own work in proving that Snow's theory about the Broad Street pump was correct, but summarizes the content of Snow's two editions of On the Mode of Communication of Cholera (Reference Snow1849 and Reference Snow1855). Whether Eliot or Lewes read these articles is not known, but it is known that Eliot's poems were published in Macmillan's, and that Lewes “read out” to Eliot excerpts from criticism of her work published in the magazine (Eliot, Letters 4: 309).

It was probably during the 1866–67 epidemic, however, when the now established author George Eliot was living with Lewes in their house, the Priory, in London's Regents Park, that she had her closest encounter with epidemic cholera. On July 11, 1866, five people died of cholera in the East End, eleven the next day, and twenty the day after that. Eliot and Lewes were away at the time, vacationing on the Continent after the completion of Felix Holt (1866), but they were back in London by August 1866, by which time the death rate in the East End was over 200 a day (Hempel 268). This epidemic continued throughout the country into 1867, but in East End London, the cause was traced to an old, covered reservoir in use by the East London Waterworks that had become contaminated by the river Lea, itself originally contaminated by sewage.

Cholera and Middlemarch

By the time of her research in the early issues of the Lancet and other medical sources for the writing of Middlemarch, then – about 1869 – Eliot had had personal experience of all four cholera epidemics in Britain, including the 1831–32 epidemic she was studying specifically for the novel. Although the evidence that cholera was transmitted chiefly by polluted water was quite conclusive by then, beliefs that victims of cholera had “predisposed” themselves to it by drunkenness, prostitution, religious laxity, an undisciplined lack of personal cleanliness, or simply fear of the disease remained common. Victorians were in a position somewhat similar to those of us now, looking back on the sudden appearance of that new and alien disease, AIDS, in the early 1980s, when its transmission was blamed on the activities of homosexual men. Cholera, like AIDS, had guilt associations built into it. What is Eliot doing with cholera, burying this by-then infamous disease in a few subtle references? I will argue that cholera stands in for the worst of Eliot's male pathologies – the pathology of a cosmopolitanism that renders Nicholas Bulstrode incapable of “fellow-feeling.”

Bulstrode's medical condition has been strangely neglected, in view of the extensive critical writing on medical practice and theory in Middlemarch. Only a few critics have considered Bulstrode at all, and those who have, such as Alexander Welsh, Ellen Argyros, and Christopher Lane, have paid no attention to his condition as a semi-invalid.Footnote ¹² In fact, the Dissenting banker's “sickly air” is mentioned at his first introduction into the narrative at one of the large parties held at the Grange (86; ch. 10). In a later conversation with Lydgate, Bulstrode refers to his own “imperfect health,” and states that he has “consulted eminent men in the metropolis,” and is therefore “painfully aware of the backwardness under which medical treatment labours in our provincial districts” (117; ch. 13). He appears to be an uncannily precise example of what Maria Frawley explains is the typical “hypochondriac” of the late eighteenth and early nineteenth centuries. Referring to Thomas Trotter's A View of the Nervous Temperament, published in 1807, Frawley notes that “Trotter determined that bankers, vendors, and investors from the rising commercial and bureaucratic branches of the middle class constituted the majority of British hypochondriacs” (74). Frawley also points out that a convergence between medical understanding and Evangelicalism's emphasis on self-examination helped to popularize the confessional form that led to such works as the anonymous Confessions of a Hypochondriac (1849) (Frawley 64–65). Bulstrode – whose career in business has been preceded by his career as a Dissenting preacher, and who continually confesses his utter lack of spiritual health to his god and his lack of physical health to his doctor – could hardly be a more historically authentic representative of that peculiarly masculine pathology referred to by the narrator as “a hypochondriacal tendency” (639; ch. 67).

Bulstrode is also, however, the most “cosmopolitan” of the major characters in the novel in the worst sense of the word: that is, rootless and utterly lacking in the capacity for sympathy. He passes in and out from one metropolitan culture to another, or from the metropolis to the provincial town, as unconcernedly as epidemic cholera. Not only is he a stranger in Middlemarch, but no one knows where he comes from. (We are eventually informed by the narrator that he was raised in an orphanage, a “commercial charity-school,” in London – as rootless and “cosmopolitan,” as you can get [578; ch. 61].) It is significant that both Lydgate and Rosamond, with their mutually poor judgment of others, like him better for being a stranger (116; ch. 13). Like the heroine of Eliot's next novel, Gwendolen Harleth, Bulstrode lacks that rooting “in some spot of a native land, where it may get the love of tender kinship for the face of earth, for the labours men go forth to, for the sounds and accents that haunt it” (Eliot, Daniel Deronda 22; ch. 3).

Yet the narrator hastens to interrupt our assumption that Bulstrode, because he is a stranger and because he is “sickly,” is not English. “Do not imagine his sickly aspect to have been of the yellow, black-haired sort,” we are warned: “he had a pale blond skin, thin grey-besprinkled brown hair, light-grey eyes, and a large forehead” (115; ch. 13). Do not imagine, in other words, that because this man has a “sickly” appearance, he must look like an Indian, or a Chinaman, or perhaps a person of some kind of “mixed blood.” He does not have yellow, but pale blond skin. His hair is not black, but grey-besprinkled brown. He has light grey, not brown or black eyes, and a large forehead, not the low forehead of those human “races” believed at the time to be more primitive. Bulstrode is quintessentially an Englishman.

Moreover, he has no bad habits – at least of the bodily sort. He is a teetotaler and at lunch confines himself, to Mr. Vincy's disgust, to what must have been the equivalent of a diet lunch in those days: a sandwich and a glass of water.Footnote ¹³ According to Victorian medical mythology, he is the least likely of individuals to contract cholera, for he stringently limits his appetites and is not only religious, but too religious, in the eyes of some Middlemarchers. It may not be incidental, therefore, that Bulstrode is the only character in the novel who expresses anything remotely comparable to the “choleraphobia” of the time. Bulstrode is never shown to have a real disease, such as other men in the novel manifest: Casaubon's ultimately fatal “fatty degeneration of the heart”; Featherstone's persistent cough and dropsical legs; Fred Vincy's case of typhoid fever; Raffles's alcoholism; and Lydgate's fatal infection with diphtheria, which we hear about only in the Finale (397; ch. 42). Yet he confesses to Lydgate that “a constitution in the susceptible state in which mine at present is, would be especially liable to fall a victim to cholera, if it visited our district” (640; ch. 67). But let us trace the stealthy progress of cholera in Middlemarch, and its relation to Bulstrode's story.

The first mention of cholera compares it to that impressive order of which the significance is entirely hidden, like a statistical amount without a standard of comparison, but with a note of exclamation at the end. The cubic feet of oxygen yearly swallowed by a full-grown man – what a shudder they might have created in some Middlemarch circles! “Oxygen! nobody knows what that may be – is it any wonder the cholera has got to Dantzic? And yet there are people who say quarantine is no good!” (416; ch. 45). Cholera is here mixed in with other information about this newly cosmopolitan world, where one hears about scientific discoveries and epidemics of new diseases which have happened elsewhere, and of which the significance is entirely hidden, precisely because it has no local ground. One such intersection of epidemic and discovery occurs at Stone Court, when John Raffles, visiting his stepson, discovers a piece of folded paper, which he picks up from behind a fender in order to secure his flask (389; ch. 41). No more is heard of cholera for nearly a hundred pages, but then we hear that “in . . . Middlemarch . . . railways were as exciting a topic as the Reform Bill or the imminent horrors of Cholera,” and the narrative promptly turns to the topic of railways, leaving those horrors unelaborated (519; ch. 56). But at this point in the narrative, the vector of Bulstrode's personal horror – Raffles – has reappeared. Having discovered the signature of “Nicholas Bulstrode” on the letter he picked up and stuffed in his flask case, he travels back to Stone Court, planning to get Bulstrode's address from his stepson. However, by this time Bulstrode has purchased Stone Court from Joshua Rigg, so he has no choice but to accommodate his blackmailer there. It may or may not be significant that, on his recent departure from Stone Court after picking up the paper, Raffles traveled by “the new-made railway, observing to his fellow passengers that he considered it pretty well seasoned now it had done for Huskisson” (390; ch. 41). William Huskisson, the Tory statesman, had received fatal injuries when he fell from the platform at the opening of the Manchester and Liverpool Railway on 15 September 1830 (801 n. 390). Raffles's form of travel, in fact, suggests a hidden significance of the apparently unconnected topics of railways and the horrors of cholera, for this human form of moral vermin can now travel faster and farther by means of the railway, just as cholera could. As Manson was to spell out in his later Tropical Diseases, Hindu and Muslim pilgrimages in India were – at the time of the writing of Middlemarch – now being made on the new system of British railways in India, thus spreading cholera more rapidly than ever before. Was Eliot, who had investments in Indian and other colonial railways, aware of this hazard (Henry, Cambridge Introduction 21)? Whether she was or not, she probably did realize that cholera could travel by train in England, and that such improved speed of travel – whether by train or by steamship – was part of the reason for the great pandemics of cholera in the nineteenth century, coinciding with industrialization and the ever larger and faster movements of human populations.

When Raffles accosts Bulstrode at Stone Court, hailing him as his old friend “Nick!,” we are told that the banker's “usual paleness had . . . taken an almost deathly hue” (491; ch. 53). The banker is figuratively “sickened” by the prospect of the public disgrace that Raffles could bring about: “distinct and inmost as the shiver and the ache of oncoming fever when we are discussing abstract pain, was the forecast of disgrace in the presence of his neighbours and of his own wife” (494; ch. 53). When forced to breakfast with Raffles, Bulstrode is even more abstemious than usual, only able to sip tea and not even to nibble at his toast. He feels a “shuddering nausea” (496; ch. 53), and when Raffles won't agree to stay away indefinitely, just for a “dirty annuity,” Bulstrode's “sickly body” is “shattered by the agitations he had gone through since the last evening” (497; ch. 53). He pays Raffles a cash bribe and hopes – wrongly – that he will never encounter the man again.

Raffles is Bulstrode's alter ego in medical terms: where Bulstrode diets, drinks no alcohol, and constantly worries about his health, Raffles worries only about his financial health, eats whatever he can get, and dies of alcoholic poisoning. Raffles, then, is even more “cosmopolitan” in the negative sense than Bulstrode (his name suggests an underhanded allusion to cosmopolitan “riff-raff”), for he has flitted back and forth, not only around England but to the Continent as a traveling salesman.

It is only after this encounter with Raffles that we hear the details of Bulstrode's past history, beginning with his employment as a banker in London and followed by his passage through various aspects of London society, from a Dissenting religious sect to a pawnshop business (which is really a fencing operation) to a “sleeping partner” in a business that obtains raw materials cheaply (as in the dyes that rotted Mr. Vincy's silks) (581; ch. 61). Meanwhile, Lydgate is making preparations for the possible appearance of cholera (he is preparing a special ward just for cholera victims in the New Fever Hospital). Bulstrode calls in Lydgate for consultation, as he is so tormented by insomnia that he sees it “as a sign of threatening insanity” (639; ch. 67). The unsympathetic narrator intervenes with the chilly comment that the insomnia is “really only a slight exaggeration of an habitual dyspeptic symptom” and that Bulstrode is now showing his “hypochondriacal tendency” (639; ch. 67). But at this point Bulstrode confesses to the young doctor his fear that, should cholera come to town, he would be a likely victim. Lydgate reassures him that “the town has done well in the way of cleansing, and finding appliances; and I think that if the cholera should come, even our enemies will admit that the arrangements in the New Hospital are a public good” (640; ch. 67).

Cholera appears in the text just three more times, the first of these as Lydgate and Bulstrode ride back to town after Raffles's death. The two men “talk[ ] of many things – chiefly cholera and the chances of the Reform Bill in the House of Lords, and the firm resolve of the Political Unions” (669; ch. 70). If cholera troubles Bulstrode personally at this point, the fact goes unmentioned: Raffles's death seems to have relieved him of his fear of cholera, not to mention of insanity. But not long after, a meeting is held at the Town Hall to deal with “a sanitary question which had risen into pressing importance by the occurrence of a cholera case in the town” (681; ch. 71). There has been only one case of cholera in Middlemarch but, as the narrator tells us, there had been a Board for the superintendence of measures of “cleansing and preparation” since the passage of the Act of Parliament of 1828, authorizing assessments for sanitary measures (681; ch. 71). Now, with the occurrence of a “cholera case,” the Board meets to decide whether a burial-ground outside the town should be secured by assessment or by private subscription (682; ch. 71). It was commonly thought that the decomposing bodies of cholera victims might produce poisonous effluvia.

At this meeting, Bulstrode finds himself suddenly called upon to “deny and confute the scandalous statements made against him by a man now dead, and who died in his house – the statement that he was for many years engaged in nefarious practices, and that he won his fortune by dishonest procedures – or else to withdraw from positions which could only have been allowed him as a gentleman among gentlemen” (683; ch. 71). Bulstrode suffers a “disgusting agony” as the shameful filth of his dishonest past is poured out before the town.Footnote ¹⁴ In a slyly wicked narrative joke, this imaginary invalid suffers what might be seen as an imaginary attack of cholera. He totters out, with the help of his doctor's unwilling but compassionate arm.

As Mr. Brooke reports to Dorothea, “we have just come from a meeting – a sanitary meeting, you know” (686; ch. 71). But how and where did the other “gentlemen” of Middlemarch find out about Bulstrode's “nefarious practices”? Oddly enough, it comes about through a conversation staged with Bambridge, the horse-dealer with whom young Fred Vincy had unfortunate dealings. As Bambridge tells Hawley about the gig-horse he picked up at the Bilkley horsefair, he also passes on the “fine story” he heard about Bulstrode from an “old chum” of Bulstrode's whom he ran into there (673; ch. 71). The old chum, of course, is Raffles, who blabbed the whole story about Bulstrode's truly disgusting business in the past, in which he had kept his first wife, Will Ladislaw's grandmother, from ever having known her daughter's whereabouts or the fact that there was a grandson.

But what does this have to do with cholera, or the fact that Bulstrode and his filthy business is “purged” at a “sanitary meeting”? It was through such not-quite-clean horse-dealings with the “vicious” Bambridge that Fred Vincy found that he had not only bought a vicious horse but had picked up a nasty case of typhoid fever, for Bambridge's friend's stable is reached through a back street where, the narrator tells us, “you might as easily have been poisoned without expense of drugs as in any grim street of that unsanitary period” (225; ch. 23). As typhoid, like cholera, is a “filth disease,” contracted by swallowing water or food contaminated by typhoid bacteria, one is especially liable to contract the disease in areas heavily populated by horses and the disease-carrying flies that are especially numerous near horse manure. Fred gets an appropriate punishment for his not-too-clean financial dealings. He picks up a case of typhoid fever from which, thanks to Lydgate's enlightened notions of treatment and care, he is saved. But Bulstrode's punishment for his many crimes – ranging from complicity in Raffles's death, to dishonest business practices, to keeping a mother and daughter estranged in order to inherit what rightfully belonged to the daughter and her son – is that his own secrets are publicly exposed. It is an equivalent, but perhaps rather worse, punishment than the “little white parcels” sent by Mr. Wrench for Fred's treatment, which had “black and drastic contents” (244; ch. 26).

In the final mention of cholera in the text, Mrs. Bulstrode hopes there will be no more cases of cholera, as it has been “an awful visitation” (704; ch. 74). Still unaware of her husband's perfidy, she adds that she has always thought of Middlemarch as “a very healthy spot” (704; ch. 74). Even her friend Mrs. Plymdale cannot bear to tell her that Middlemarch has become a most unhealthy spot for her husband.

Cholera and Cosmopolitanism Today

In a recent pmla article, Lauren M. E. Goodlad asks, “Can criticism of nineteenth-century literature illuminate our globalizing world in the first decade of the twenty-first century?” And further, “does cosmopolitanism provide a useful framework for this critical endeavor?” (Goodlad 437). Does Eliot's medical cosmopolitanism – both detached from and situated in the late 1860s medical world of the British Empire – provide a useful framework for illuminating our present, globalizing world? Eliot's presentation of the distinctive pathologies of English men reflects not only what U. C. Knoepflmacher has described as “the perversions of a social structure of relationships based on male power and male prerogative” (53, 80), but an anxiety about the loss of national rootedness in an age of cosmopolitan travel of all kinds – not only of migrating men, but of “cosmopolitan disease.” Amanda Anderson, referring most specifically to Eliot's later novel Daniel Deronda (Reference Eliot and Cave1876), comments that “George Eliot laments the ‘cosmopolitan indifference’ promoted by the rootless condition of the Jew, an indifference that threatens to afflict modern ‘migratory Englishmen’ as well” (64). But a closer look at the diseases suffered by the men of Middlemarch suggests not only that they are “slyly symbolic,” as Jeremy Tambling has argued, but that Eliot is preoccupied with the “new” diseases of the newly cosmopolitan medicine of Reform England (948). Casaubon, who seems never to have had much heart or passion to begin with, dies of a “fatty degeneration of the heart,” a condition first described in Paris medicine, where Laennec taught students how to auscultate it with his new instrument, the stethoscope.Footnote ¹⁵ Fred Vincy contracts typhoid, another disease first described in the late 1820s. Lydgate knows about Pierre Louis's studies of typhoid, but the disease was also identified as a new fever in London between 1826 and 1830, though it was still being confused in the 1860s with other fevers, especially cholera (Middlemarch 154; ch. 16; Hardy, Epidemic Streets 152). One can certainly speculate that the author's choice of diphtheria as the instrument of Lydgate's death arises from her knowledge that diphtheria causes death by a “primary web” of thickening tissue that grows into the throat and suffocates the victim – a metaphoric equivalent for the choking off of Lydgate's medical idealism by the web of provincial medical politics – but it is also significant in its status as a new disease in this time of the proliferation of new “cosmopolitan” diseases (138; ch. 15).

Bulstrode's “disease” can be recognized as a scrupulously conscientious, deadpan reconstruction of the “hypochondriac” as described in medical texts of the early nineteenth century, but his medical condition also mimics the rootlessness of contemporary cosmopolitan disease. Carefully contextualized with the apparently inconsequential references to cholera, Bulstrode's imaginary form of cholera manifests at precisely the moment the contents of his hidden history are humiliatingly exposed to public view.Footnote ¹⁶ We are not told how or where Bulstrode dies, perhaps because, as Middlemarchers conjecture, he will go abroad somewhere, continuing his sad and rootless brand of “cosmopolitanism.” We can certainly say, however, that Bulstrode has died a thousand deaths as a consequence of a sanitary meeting to prepare for cholera.

What can we learn from Eliot's anxiety about cosmopolitan disease? Perhaps that, like Mr. Brooke, we are only “cosmopolitan” – that is, aware of the needs of other cultures – to a certain point. Cholera still infests the globe, but we hardly notice it. If we shudder at the details of what it was like to have cholera in the nineteenth century, we comfort ourselves that pandemics of this particular disease, at least, are past. However, the latest WHO Fact Sheet on cholera, dated November 2008, states that “the seventh pandemic, which is still ongoing, started in 1961 in South Asia, reached Africa in 1971 and the Americas in 1991. The disease is now considered to be endemic in many countries and the pathogen causing cholera cannot currently be eliminated from the environment” (“Cholera”). A BBC news report dated January 30, 2009 states that 60,000 cases of cholera and 3,000 deaths from cholera had been reported in Zimbabwe.Footnote ¹⁷ These internet reports are just blips on our screens, incidental bits of information comparable to the seemingly passing references to cholera in the detail-filled text of Middlemarch. Eliot, however, is not constrained by a Kantian, or in this case, Lydgatian, vision of a medicine that will promote either intellectual progress or the “social good.” As she writes about the provincial region that imagines itself as a “very healthy spot” situated in the “middle” of a world that will be increasingly improved by the advances of a beneficently cosmopolitan medicine, she copyedits this narrative, so to speak, with apparently marginal references to instances of the new diseases that were in fact criss-crossing the globe as they were the fictional town of Middlemarch. By the time of Eliot's writing of Middlemarch, cosmopolitan disease had constituted a new and dangerous form of “primary web” in which the very healthiest people could succumb to illnesses that rendered the most cosmopolitan physicians helpless. What we can learn from this tracing out of Eliot's subtle references to cholera, both real and imaginary, is that she inhabited a world of globalizing disease without remedy, and that we are not as distanced from that world as we commonly believe.