A medical classic: Liza of Lambeth

William Somerset Maugham was extremely prolific in his writing of novels, short stories and plays. Maugham was perhaps one of the most successful medical writers of the twentieth century, alongside other notable doctors such as the 1881 Edinburgh medical graduate Arthur Conan Doyle and 1884 Moscow medical graduate Anton Chekhov. Maugham's first novel, Liza of Lambeth,¹ was published in 1897, the year he became a doctor. The vivid observations of society portrayed in the novel suggest that perhaps the complex relationships of the local people he found in Lambeth, London, during his training there, and their challenging living conditions, captivated his imagination and inspired him to focus on writing rather than medicine. Maugham described the squalid living conditions of factory workers, involving long hours and little pay, in a close, inner-city community. More than 100 years later, many of these conditions persist in the borough and other areas of the UK. Maugham's stark portrayal of his, and to some extent our, society should catch our imaginations today.

One of Maugham's more recent books, The painted veil (1925), was made into a film and was reviewed as a ‘medical classic’ due to its description of the terror and horror of a cholera outbreak in the 1920s.² Similarly, Liza of Lambeth¹ can also be viewed as a classic, as it captures his outlook on life as a medical student of St Thomas' Hospital, who was working on his obstetric attachment in the slums of Lambeth and seeing life as it really was, complete with promiscuity, alcoholism and domestic violence.

Maugham completed his studies at St Thomas' Hospital Medical School in 1897 by successfully passing licentiate examination diplomas to become a member of the Royal College of Surgeons (MRCS) and licentiate of the Royal College of Physicians (LRCP). His medical registration with the General Medical Council (GMC) is cited in its medical register, and he maintained this until his death in 1965, when his residence in France was given as Villa Mauresque, St Jean Cap Ferrat.

In Liza of Lambeth,¹ it is apparent that Maugham was struck by the rapid birth rate in Lambeth. He wrote:

The number of babies was prodigious; they sprawled about everywhere, on the pavement, round the doors, and about their mothers' skirts. The grown-ups were gathered round the open doors; there were usually two women squatting on the doorstep, and two or three more seated on either side on chairs; they were invariably nursing babies, and most of them showed clear signs that the present object of the maternal care would be soon ousted by a new arrival.

The main character of the novel, Liza, ‘a young girl of about eighteen’, seems destined to follow in the footsteps of the parents of Lambeth. Using the language of the time, Maugham wrote of one mother: ‘I've ‘ad twelve, ter sy nothin' of two stills an' one miss.’¹

Pregnancy rates were high despite the high maternal and neonatal mortality associated with midwifery at the time. Mortality has reduced dramatically over the past 100 years and contraceptives are now widely available. However, in 2010, Lambeth NHS stated that the borough had ‘the second highest rate of teenage conceptions in England’.³ This should not be interpreted as a constant trend though as, encouragingly, a 28% reduction in the rate was seen between 2003 and 2007.³

Maugham's work suggests that alcohol abuse was widespread at the time, despite the aspirations of the temperance movement and the depictions of alcohol abuse a few years earlier by Thomas Hardy in his novel The mayor of Casterbridge.⁴ In Maugham's Liza of Lambeth, Liza's mother spends everything she has to get a drink, including Liza's factory wages: ‘She mikes yer slave awy ter pay the rent, an' all the money she earns she boozes.’¹ Alcohol as a cause of domestic violence is uncovered as Liza witnesses the injuries inflicted by the husband of her newly married best friend Sally: ‘“It wasn't ‘is fault”, put in Sally; amidst her sobs; “it's only because ‘e's ‘ad a little drop too much. ‘E's arright when ‘e's sober.”‘¹ This remains a huge problem a century later. In 2003 a study by the Home Office of a cohort of 336 male domestic violence offenders showed that alcohol had been consumed prior to 73% of cases.⁵

It is commonly believed that Victorian society had strict views on sex and marriage. The church had a considerable influence, but, judging by Maugham's writing, this is likely far from the reality he perceived. Liza's love was for Jim, a married man, who asked Liza to move away with him. She replied, worried about what her mother might think: ‘Not when I'm not married. I shouldn't like ‘er ter know as I'd – as I'd gone wrong.”¹

Liza suffered a traumatic miscarriage following a beating by Jim's angry wife. The description of Liza's subsequent death from the moment of her miscarriage is a perfect case study that encapsulates both the then untreatable medical emergency and the overwhelming sadness of this tragic situation. The doctor who is called gives no room for hope. One is left thinking that if only an intravenous infusion to rehydrate Liza and antibiotics to treat her infection had been available, she might have been discharged 24 hours later from a gynaecology ward. The following deathbed scene must have been so commonplace then, given a doctor's lack of treatment options. Maugham portrayed it with reality and solemnity:

Suddenly a sound was heard – a loud rattle. It was from the bed and rang through the room, piercing the stillness. The doctor opened one of Liza's eyes and touched it, then he laid on her breast the hand he had been holding, and drew the sheet over her head.

In contrast to the other aspects of society described by Maugham, great advances have been made in medical care over the past 100 years. Furthermore, the benefits of these advances in the UK are now freely available to all, regardless of their place in society. However, challenges remain in the distribution of this medical care. Julian Tudor Hart, a London-born and-trained GP, went on to practise for three decades in Glyncorrwg, West Glamorgan, Wales. In 1971, 74 years after the publication of Liza of Lambeth, he published in The Lancet his observation ‘The inverse care law’.⁶ This was the observation that those patients who have the greatest health need, eg those in inner cities, seem to receive the poorest quality healthcare, and so medical care tends to be inversely related to the needs of the population. Perhaps Maugham's observation of this trend motivated him in his writing. It remains one of the greatest challenges to healthcare today.

• © 2012 Royal College of Physicians