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Of human bondage
  1. John Launer
  1. Correspondence to Dr John Launer, Faculty Development, Health Education England, Stewart House, 32 Russell Square, London WC1B 5DN, UK: ejohn.launer{at}londondeanery.nhs.uk

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One of the wealthiest and most popular authors of the twentieth century was a doctor. His best known book included some vivid accounts of his experiences as a medical student. It is a masterpiece, but also provides the richest first-hand description we have of medicine in late Victorian London and is worth reading for that reason alone. William Somerset Maugham was born in 1874 into a family of lawyers, but decided to study medicine at St Thomas' Hospital, qualifying in 1897. He had already published his first novel and had decided to give up medicine. By the time he was 40, he had published ten books, while ten of his plays had been produced on the London stage. After working as a British spy in Switzerland and Russia during the First World War, he continued as a prolific writer of novels and short stories, mainly describing colonial life in Asia and the Pacific. By the 1930s, his earnings from writing, together with shrewd investments in the stock market and paintings, made him the richest author in the world. At the height of his fame, virtually every literate person in Britain would have read his works and known about his flamboyant life style.1

Although Maugham was an active homosexual, he had an affair with the wife of Henry Wellcome, the pharmaceuticals magnate. When Wellcome divorced her, Maugham entered into a ruinous marriage with her. After its dissolution, he moved to the south of France, where he set up a lavish household and literary salon with his lover, Gerald Haxton. After Haxton's death, Maugham remained there with another lover, Alan Searle, for the rest of his life. At one point he employed thirteen staff at his villa on the Riviera. Yet even in his sixties, he looked back with appreciation at his years at medical school, believing that contact with the poor and destitute of south London had given him an understanding of life that laid the foundations of his career. Maugham's most famous book, where he described his time as a medical student, is called ‘Of Human Bondage.’2 The title refers to the philosopher Spinoza, who examined why human beings can follow their worst instincts, in spite of knowing they can behave in other ways. Maugham made little attempt to disguise the book's autobiographical nature. Its hero, Philip Carey, is orphaned and put into the care of a self-centred uncle, just as Maugham was. Philip is bullied at school for a club foot, in the same way that Maugham was savagely lampooned for his stammer. He leaves school to study in Germany, and then tries his hand at accountancy before changing to medicine, just as the author did.

Sexual theme

The central theme of the book is sexual. At the time, its account of sexual feelings was daring, and shocked many readers. The plot traces Philip's relationships with women, and in particular his infatuation with a working class girl called Mildred, to whom he remains devoted in spite of her infidelities and—eventually—her descent into prostitution. His generosity towards her leads to penury and his enforced departure from medical school for a while. Although the attitudes of the era did not allow Maugham to depict homosexual relationships, the accounts of his male friendships hint strongly at these. Philip's infatuation with Mildred echoes the life of another gay writer, Oscar Wilde, whose affair with Alfred Douglas and entanglement with male prostitutes were the greatest sexual scandal of the time. In the end of the book, Philip's uncle dies, leaving a small inheritance that enables him to complete his studies. On the last page, Philip proposes marriage to the daughter of a cheerful Dickensian family who fed him during his period of poverty. The episode is not very convincing: Maugham may have been over-compensating for his own lack of conviction about heterosexuality and marriage. His sexuality may well have been a factor in his decision to leave medicine, reminding us how recently people have begun to accept doctors who are gay.

The portrait of Philip's life as a medical student shows how vastly the social context of medicine has changed. Philip's early days at medical school are spent on dissection and studying anatomy. There is the usual nervous banter over the anatomy room cadaver, but Maugham uses this to highlight the brutal realities of Victorian London. ‘Ripping to have him so thin’, one of Philip's fellow students says about the dead body. ‘The blighter can't have had anything to eat for a month.’ One recent student has died of septicaemia, following a cut with a dissecting scalpel—recalling Maugham's own brush with death from the same cause. Other students take many years to complete their exams, needing to take periods off for family or financial reasons. Among the men of Philip's year are an ex-Navy man in his thirties, allegedly discharged for drunkenness, and a married man with children bowed down with debts from a legal case. Some students leave altogether, to take up ‘the White Man's Burden’ as administrators overseas.

Philip manages to struggle through his pre-clinical years, but he is kept going by the same motives that any doctor might have today. ‘I have an idea I am more interested in people than anything else in the world’, he tells one of his friends. ‘And as far as I can seem it's the only profession in which you have your freedom. You carry your knowledge in your heart; with a box of instruments and a few drugs you can make your living anywhere.’ He imagines himself as a ship's doctor in the East, something that Maugham later regretted not having tried. As Philip moves into his clinical years, he earns money by practising bandaging in out-patients, and prepares for his pharmacology exams by concocting mixtures, rolling pills and making ointments. He becomes an out-patient clerk, working alongside a jovial and condescending consultant called Dr Tyrell. ‘He made the patient feel like a boy confronted by a jolly schoolmaster; his illness was an absurd piece of naughtiness which amused rather than irritated.’

Curious thrill

Although Philip is appalled by seeing the illnesses of the poor and destitute of south London, he also feels a ‘curious thrill’ in observing them. The most common ailments he sees among the men are due to the excessive use of alcohol. The women are anaemic, and ‘aged prematurely by frequent confinements.’ Maugham describes the despair of patients who are told they have tuberculosis—invariably fatal in those days—and of those whose chronic illnesses were an economic death sentence: ‘the death which was inevitable because the man was a little wheel in the great machine of a complex civilisation, and had as little power of changing the circumstances as an automaton.’ Philip's final year at medical school includes doing midwifery in the slums of south London. The scenes from this time are the most vivid in the book.

Philip visits filthy courtyards in dingy streets to deliver babies. ‘The people who dwelt here lived from hand to mouth. Babies were unwelcome, the man received them with surly anger, the mother with despair.’ Twins were a catastrophe, especially if both lived. Accidents might then occur, with mothers ‘overlaying’ their babies. For the mothers themselves, death following childbirth was common, and Philip attends a pretty sixteen year old girl as she bleeds to death before his eyes. Yet the greatest tragedy in a household was not death, but loss of work. Philip comes to understand that many of the efforts of the well-meaning rich to alleviate slum conditions were misdirected. All that the poor really wanted was employment, and to be left alone.

After qualifying, Philip carries out locum work in Dorset, and comes close to entering a career in general practice. Maugham's portrait of country practice is a sympathetic one. The general practitioner he is attached to is eccentric, irascible and old-fashioned, but considerate with the fishermen and their families whom he attends. He is scornful towards the young and arrogant hospital doctors who normally come down to assist him, but identifies Philip as a man who can get on with working people, and offers him a partnership. For the remainder of the book, Philip vacillates about whether to accept this, although in the end he declines. There is no evidence that Maugham had direct experience of general practice, or ever carried out locum work, but his decision to include these elements in the story suggests he found the idea attractive, just as he was tempted by becoming a ship's doctor. It raises an intriguing possibility. Had his novels not become such a huge success, one of the most successful writers of the twentieth century might well have ended up as general practitioner on the south coast of England.

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