Metamucil Prescribing
Information
INDICATIONS: For the relief of chronic, atonic, spastic and rectal constipation and for the constipation accompanying pregnancy, convalescence and advanced age. For use in special diets lacking in residue and as adjunctive therapy in the constipation of mucous and ulcerative colitis and diverticulitis. Also useful in the management of hemorrhoids and following anorectal surgery. CONTRAINDICATIONS: Presence of nausea, vomiting, abdominal pain or symptoms of an acute abdomen or fecal impaction. Metamucil instant Mix is contraindicated in patients who must severely restrict their dietary sodium intake. PRECAUTIONS: For patients, such as those suffering from diabetes mellitus, where rigid dietary calorie control is required: Powder - 1 dose furnishes 14 calorIes. Instant Mix - 1 dose furnishes 3 calories.
DOSAGE: Powder - one rounded teaspoonful of powder 1 to 3 times daily depending on the condition being treated, its severity and individual responsiveness. The teaspoonful of powder is stirred into an 8 oz. glass of cool water or other suitable liquid and should be taken immediately. Instant Mix - one packet 1 to 3 times daily depending on the condition being treated, its severity and individual responsiveness. The contents of the packet are poured into an 8 oz. glass to which cool water is then slowly added. The resulting effervescent mixture should be taken immediately. SUPPLIED: Powder - a refined, purified and concentrated vegetable mucilloid, prepared from the mucilaginous portion of Plantago ovata, combined with dextrose as a dispersing agent. Each rounded teaspoonful contains approximately 3.1 g of psyllium hydrophilic mucilloid per dose, a negligible amount of sodium, and furnishes 14 calories. Available in 6 and 12 oz. plastic bottles. Instant Mix - premeasured unit-dose packets. Each unit-dose packet contains 3.6 g of psyllium hydrophilic mucilloid with effervescent and flavouring excipients, 0.25 g of sodium as bicarbonate, and furnishes 3 calories. Available in boxes of 15 unit-dose packets.
NATURAL BOWEL MANAGEMENT THAT BENEFITS MANY KINDS OF PATIENTS,
Complete prescribing information available on request (or in CP*S*).
Searle Pharmaceuticals Oakville. Ontario
Physicians in literature: Part IV: Somerset Maugham, talented but troubled By W.E. Swinton There is no question that the Maugham family was a talented and distinguished one. Willie Maugham's father was in the British diplomatic service in Paris and had a wife renowned for her beauty. Their four sons were highly intelligent and resovrceful, even if one did commit suicide, and the second son, Frederic Hubert Maugham became Lord Chancellor of England and a viscount, being thus a source of envy to his youngest brother, William Somerset Maugham, though the latter become one of the most famous writers of his time and a millionaire. Somerset Maugham, as he called himself as a writer, was a complex character who enjoyed the fame and riches he achieved but felt disowned by the intelligentsia, was disappointed CMAJ continues the series by Dr, Swinton on physicians who have cou.. tributed to literature. The articles, sponsored by the Jason A. Hannah Institute for the History of Medical and Related Sciences, were stimulated by the interest of the CMA committee on archives. IllustratIons are courtesy of the Metropolltau Toronto Library hoard and Indiana Ux*verslty Preuw.
by his life and works and carried the scars of an unhappy youth all his long life. There is some parallel with Dickens here, the bitterness of youth being nurtured and surviving all the apparent successes of later life. Yet Maugham had a fuller life. He was not only a shrewd observer but a brilliant playwright and essayist, and he had in his youth qualified himself for the most honourable of all professions by becoming a doctor of medicine. He was born on British soil, in the British Embassy in Paris, Jan. 25, 1874. There is little doubt that he was attached to his parents, but his mother died of pulmonary tuberculosis when he was 8 years old, and his father died of cancer 2 years later. The loss of his
mother was a great blow from which he never recovered. Her memory was with him, and her photograph by his bedside, for the rest of his life. It may be that this almost cultivated grief was responsible for his odd and cynical view of women - or most women. Deprived of his parents, he went to live with his uncle, the Reverend Henry Macdonald Maugham, at the vicarage of Whitstable, Kent. His uncle seems to have been retiring, somewhat selfish and unused to the ways of children. His German aunt on the other hand, though childless, had the springs of an affection that the boy only realized when it was too late. The coldness, if not austerity, of this life has been told in the autobiographical novel "Of Human Bondage", in which Somerset is Philip Carey and Uncle Carey is located at Blackstable. The circumstances were surely responsible for the boy's shyness, though the stammer which plagued him all his days was an additional burden - how grievous only those who have read the novel and felt Philip's distress over his talipes equinas can know. He went to Kings School in Canterbury in the precincts of the cathedral (Tercanbury in the novel) and, because of his infirmities, was bullied and resentful. Later, through his aunt's influence, he went for a year to study philosophy and literature in the benign academic atmosphere of Heidelberg, an experience he always remembered with appreciation. On his return, like Conan Doyle and Oliver Goldsmith, he found that he was an agnostic and had no wish to enter the church. He attended for a short time the office of a chartered accountant but felt that this was not the life, and then he entered St. Thomas' Hospital, that great, barracklike institution that has stood for so many years by the banks of the historic Thames in London. Here for 5 years he found a new
CMA JOURNAL/JANUARY 10, 1976/VOL. 114 61
.u©w sinemet[ (levodopa and carbidopa combination)
INDICATIONS Treatment of Parkinson's syndrome with exception of drug induced parkinsonism. CONTRAINDICATlONS When a sympathomimetic amine is contraindicated; with monoamine oxidase inhibitors, which should be discontinued two weeks prior to *starting SINEMET*; in uncompensated cardiovascular, endocrine, hematologic, hepatic, pulmonary or renal disease; in narrowangle glaucoma; in patients with suspicious, undiagnosed skin lesions or a history of melanoma. WARNINGS When given to patients receiving levodopa alone, discontinue levodopa at least 12 hours before initiating SINEMET* at a dosage that provides approximately 20% of previous levodopa. Not recommended in drug-induced extrapyramidal reactions; contraindicated in management of intention tremor and Huntington's chorea. Levodopa related central effects such as involuntary movements may occur at lower dosages and sooner, and the 'on and off' phenomenon may appear earlier with combination therapy. Monitor carefully all patients for the development of mental changes, depression with suicidal tendencies, or other serious antisocial behaviour. Cardiac function should be monitored continuously during period of initial dosage adjustment in patients with arrhythmias. Safety of SINEMET* in patients under 18
years of age not established. Pregnancy and lactation: In women of childbearing potential, weigh benefits against risks. Should not be given to nursing mothers. Effects on human pregnancy and lactation unknown.
PRECAUTIONS General: Periodic evaluations of hepatic, hematopoietic, cardiovascular and renal function recommended in extended therapy. Treat patients with history of convulsions cautiously. Physical Activity: Advise patients improved on SINEMET* to increase physical activities gradually, with caution consistent with other medical considerations. In Glaucoma: May be given cautiously to patients with wide angle glaucoma, provided intraocular pressure is well controlled and can be carefully monitored during therapy. With Anti-
hypertensive Therapy:Assymptomatic postural hypotension has been reported occasionally, give cautiously to patients on antihypertensive drugs, checking carefully for changes in pulse rate and blood pressure. Dosage adjustment of antihypertensive drug may be required. With Psychoactive Drugs: If concomitant administration is necessary, administer psychoactive drugs with great caution and observe patients for unusual adverse reactions. With Anesthetics: Discontinue SINEMET* the night before general anesthesia and reinstitute as soon as patient can take medication orally. ADVERSE REACTIONS Most Common: Abnormal Involuntary Move-
ments-usually diminished by dosage reduction-choreiform, dystonic and other involuntary movements. Muscle twitching and blepharospasm may be early signs of excessive dosage. Other SerIous Reactions: Oscillations in performance: diurnal variations, independent oscillations in akinesia with stereotyped dyskinesias, sudden akinetic crises related to dyskinesias, akinesia paradoxica (hypotonic freezing) and 'on and off' phenomenon. Psychiatric: paranoid ideation, psychotic episodes, depression with or without development of suicidal tendencies and dementia. Rarely convulsions (causal relationship not established). Cardiac irregularities and/or palpitations, orthostatic hypotensive episodes, anorexia, nausea, vomiting and dizziness
Other adverse reactions that may occur: Psychiatric: increased libido with sorious antisocial behavior, euphoria, lethargy, sedation, stimulation, fatiguo and malaise, contusion, insomnia, nightmares, hallucinations and delusions, agitation and anxiety. Neurologic: ataxia, faintness, impairment of gait, headacho, increased hand tremor, akinetic episodes, akinesia paradoxica", increase in tho frequency and duration of the oscillations in performance, torticollis, trismus, tightness of the mouth, lips or tongue, oculogyric crisis, weakness, numbness, bruxism, priapism. Gastrointestinal: constipation, diarrhea, epigastric and abdominal distress and pain, flatulence; eructation, hiccups, sialorrhea; difficulty in swallowing, bitter taste, dry mouth; duodenal ulcer; gastrointestinal bleeding; burning sensation of the tongue. Cardiovascular: arrhythmias, hypotension, nonspecific ECG changes, flushing, phlebitis. Hematologic: hemolytic anemia, leukopenia, agranulocytosis. Dermatologic: sweating, edema, hair loss, pallor, rash, bad odor, dark sweat. Musculoskeletal: low back pain, muscle spasm and twitching, musculoskeletal pain. Respiratory: feeling of pressure in the chest, cough, hoarseness, bizarre breathing pattern, postnasal drip. Urogenital: urinary frequency, retention, incontinence, hematuria, dark urine, nocturia, and one report of interstitial nephritis. SpecialSenses: blurred vision, diplopia, dilated pupils, activation of latent Homer's syndrome. Miscellaneous: hot flashes, weight gain or loss. Abnormalities in laboratory tests reported with levodopa alone, which may occur with SINEMET*: Elevations of blood urea nitrogen, SGOT, SGPT, LDH, bilirubin, alkaline phosphatase or protein bound iodine. Occasional reduction in WBC, hemoglobin and hematocrit. Elevations of uric acid with colorimetric method. Positive Coombs tests reported both with SINEMET* and with levodopa alone, but hemolytic anemia extremely rare. DOSAGE SUMMARY In order to reduce the incidence of adverse reactions and achieve maximal benefit, therapy with SINEMET* must be individualized and drug administration continuously matched to the needs and tolerance of the patient. Combined therapy with SINEMET* hes a narrower therapeutic range then with levodopa alone because of its greater milligram potency. Therefore, titration and adjustment of dosage should be made In small steps and recommended dosage ranges not be exceeded. Appearance of involuntary movements should be regarded as a sign of levodopa toxicity and an indication of overdosage, requiring dose reduction. Treatment should, therefore, aim at maximal benefit without dyskinesias. Therapy In Patients not receiving Levodopa: Initially 1/2 tablet once or twice a day, increase by 1,4 tablet every three days if desirable. An optimum dose of 3 to 5 tablets a day divided into 4 to 6 doses. Therapy in Patients receiving Levedepa: Discontinue levodopa for at least 12 hours, then give approximately 20% of the previous levodopa dose in 4 to 6 divided doses. FOR COMPLETE PRESCRIBING INFORMATION, PARTICULARLY DETAILS OF DOSAGE AND ADMINISTRATION, PLEASE CONSULT PRODUCT MONOGRAPH WHICH IS AVAILABLE ON REQUEST. HOW SUPPLIED Ca8804.TabletsSlNEMET* 250, dapple-blue, oval, biconvex, scored, compressed tablets coded MSD 654, each containing 25 mg of carbidopa and 250 mg of levodopa. Available in bottles of 100. O MERCK *Trademark
I SHARP I & DOHME CANADA LIMITED
Pointe Claire, Quebec
64 CMA JOURNAL/JANUARY 10, 1976/VOL. 114
(MC97.)
and formative influence. Everything, from the anatomy dissecting rooms (so well described in "Of Human Bondage" that the familiar odour almost comes through) to the more exciting duties as clerk in various departments, impressed the eager young man. But the obstetric clerkship impressed him most. Called out at any time, his black bag was a passport to the world of slums and forgotten people where even policemen dared not walk alone. Of course London had no prerogative in this. Thirty years later, the slums of Glasgow made the aspiring obstetricians go in pairs into forbidding dwellings, up noisome stairs, past foul landings and appalling lavatories, to doors on which no personal names ever appeared but only cubic footage and permissible human occupancy. Once in the room, the scene was familiar - the boxes for furnitures, the rags on the floor for beds and, in a corner, the tousled woman in labour. In this atmosphere there is neither faith nor hope, and the babies are born into a world of degradation and deprivation. This was the scene that 63 times Maugham saw. A new realism
Those who cry that all men and women are born equal are not obstetricians and have never seen humanity at bay. Here is a world that Victorians, polite novel-reading Victorians, never knew and liked to keep that way. So when Maugham took 2 years to write his slender book, "Liza of Lambeth", and later "Of Human Bondage", he was regarded as something of a pariah. Liza is an inoffensive book that shows the laughter as well as the tears in a London slum; incidentally Maugham records the language better than Dickens or Watson or even Holmes. Perhaps both laughter and tears depended too often on the public house. "Mr. Maugham's story is dirty." "Mr. Maugham has been nosing in the gutters - unpleasant - unhealthy." "Mr. Zola has written dirtily, but he is always more or less artistic - Mr. Maugham never." As Robin Maugham (the second Lord Maugham and Somerset's nephew) has written, "It was the first English novel of any consequence to treat the slums realistically and objectively." It was written by a medical student and it shaped the rest of his life. In 1897 Maugham obtained his MRCS and LRCP. His years in medicine had made an impression on him and on his writing, and after the success of Liza he would be a writer. He had had a sound education in science and medicine, having studied one species in all its aspects for 5 years. He developed a respect for the scientific
St. Thomas'
Hospital, London where Maugham received his medical training
method (compare Conan Doyle, who had a similar experience) and he had discovered "the unaccountability of human nature".
significance He began to see the effects of human evolution to learn that morals and manners did not grow inevitably out of human heads, as hair did, any more than there was one God-given speech that was developed without outside aid, but that all depended on time and place, era and environment. He began to see the Insignificance of Man. "It is not in a cathedral or confronted with any mighty human work that I feel the insignificance of man; then I am impressed rather with his power; his mind seems capable of every feat, and I forget he is an insignificant creature crawling on a speck of mud, the planet of a minor sun. Nature and art, even against one's will, persuade one of the grandeur of man; and it is only science that reveals his utter in¬ significance. Science is the consoler and the healer of troubles, for it teaches how little things matter and how unimportant is life with all its failures" ("A Writer's Notebook", 1949). This note was written in 1896, when he was 22. He soon perceived that medical knowledge was an enormous asset to a writer: he could observe and diagnose the patterns of human behaviour; he could dissect society and an environ¬ ment with the care and enthusiasm he had devoted to the upper extremity or the thorax and abdomen only a few years before. He read and he wrote, his mentors being Swift, Dryden, Voltaire and, of course, Hume, and his careful prose, always simple and to the Man and
irony and disillusionhad more than this, for he was prescient in much that he noted or had to say in his novels. For example, in 1901 he wrote,
point,
shows the
ment of these writers. He
"That which is universal in mankind a fault with many ethical systems that, more or less arbitrarily, they fix upon certain tendencies in man and call them good; and upon others and call them evil. How much greater would human happiness have been if the gratification of the sexual instinct had never been looked upon as wicked. A true system of ethics must find out those qualities which are in all men and call them good." Forty years of experience later he could write, "There is nothing which men lie so much about as their sexual powers. In this at least every man is, what in his heart he would like to be, a cannot be evil: it is
Casanova" ("A Writer's Notebook"). His power as a writer was prodigious and this is no place to attempt a survey. But surprisingly he was many things other than a writer from time to time. World War I
He was living in Paris when the first world war broke out, so he joined a Red Cross ambulance unit in France. His notebook contains some interesting things about this. It was an early dis¬ play of his characteristic nonchalance, but it must be read. Although he had abandoned medicine, he occasionally lent a hand in the field. "I had done no work of this kind for many years and at first felt embarrassed and awk¬ ward, but soon I found I could do the little that it was possible to do clean up the wounds, paint with iodine and .
bandage. I have never seen such wounds. There are great wounds of the shoulder, the bone all shattered, run¬ ning with pus, stinking; there are gap¬ ing wounds in the back; there are the wounds where a bullet has passed through the lungs; there are shattered feet so that you wonder if the limb can possibly be saved." All is touching, for Maugham was an experienced writer who wrote of his experiences, and he saw with words. But he was not to continue in this service. His ability as a writer was good cover for intelligence work and he was recalled from France and sent as an agent to Switzerland (where he wrote the Ashenden stories), then to the South Seas (where he wrote "Rain") and finally, in what now seems a some¬ what hopeless mission, to Russia with the hope that, fortified by British and American money, Kerensky could divert the revolution and have Russia continue as an ally. The money was to be used to buy arms and finance newspapers, and his cover was as a correspondent of the Daily Telegraph. He protested his in¬ ability for this task but he was not believed. Yet he might have had some success had he not stammered. Keren¬ sky gave him a very secret message for Lloyd George to be delivered orally, but Maugham was so afraid of stammering it that he wrote it out and gave it to Lloyd George who was in a hurry and could hardly wait to read it. One can only speculate now as to what might have happened had Maugham (like Conan Doyle) lunched with the fiery but able Welshman. After the war his travels continued, accompanied by a trail of plays and novels. Tahiti yielded "The Moon and
CMA JOURNAL/JANUARY 10, 1976/VOL. 114 65
Sixpence" and the Far East followed. In 1921 there was the Freudian "Trembling of a Leaf" and the plays "East of Suez" in 1922 and "Our Betters.. in 1923. He began to be rich as his plays succeeded in London and New York. He settled in the south of France in 1928 where he lived in luxury at the Villa Mauresque, and with controlled industry led a life that was rudely interrupted in 1940 when he fled in a freighter to America, accompanied by only a suitcase. Here again he found employment as an agent, one for which he was better qualified. For a time he adopted a mysticism that is seen in "The Razor's Edge". When the war was over, he returned to the south of France but made numerous visits to England where he made considerable benefactions to his old school, now more beloved by the passage of time. He virtually retired as an author in 1949, aged 75. He had been offered a knighthood and refused it but accepted a Companionship of Honour (CH) in 1954. Speech therapy
His early life had been marred for him by his stammer, and in later years he had attempted some alleviation with the aid of the same therapist who had helped King George VI. Age seemed to calm him, but the volcano still rumbled underneath, and he was liable to erupt embarrassingly on social occasions. For a time in his younger days he had suffered from tuberculosis; now in his old age he became deaf, and his eyes denied him the pleasures of reading. Robin Maugham recounts that he said, "I've been a horrible and evil man. Every single one of the few people who have got to know me well has ended up by hating me." Rich, he often confusedly thought of himself as financially vulnerable. It is now well known that he was a homosexual and that for a time he thought "he was only 25% homosexual" whereas it was really "75% ". His marriage was thus probably doomed from the start but in 1916 Syrie Wellcome was an attractive woman (and so she remained all her life). She was the daughter of Dr. Barnardo, the famous philanthropist who was a doctor of medicine, and she had been the wife of Sir Henry Wellcome. She married Somerset Maugham in 1916 and they have a daughter, Liza, now Lady Glendevon. Syrie obtained a divorce in 1927, and they met occasionally afterwards. Among the rich rewards of his talents and the product of his industry, where does the voice of the medical man
Somerset Maugham, at age 26 a serious and intent looking youag man.
speak to us9 His agnosticism remained with him all his life, and though this is not a concomitant of the average medical practitioner, it was compounded in his case by his disability and the disillusionment of his travels. Wherever he went he saw diffent mores in different circumstances that appeared to flourish with the approval of different gods. God denied an instant cure to Philip Carey with his club foot and to Somerset Maugham with his stammer. Nonetheless, he was often in tune with nature. In 1901 he writes, "The wind sang to himself like a stronglimbed plough-boy as he marches easily through the country." In 1941, the wind no longer sings, "The moan of the wind [in South Carolina] in the pine trees was like the distant singing of the coloured people, singing their sad song to a heedless or a helpless god." Law of rules For himself he has said, "We are the products of our genes and our chromosomes - we can't change the essential natures we're born with - all we can do is to try and supplement our own deficiencies." Yet in his youth he had thought differently about rules - manmade rules. "One of the commonest errors of the human intelligence is to insist that a rule should be universally applicable. Take an instance in anatomy. Out of 20 cases the branch of an artery in 8 will arise from the second part of the root, in 6 from the first, and in 6 from the third. Though the exceptions surpass it, the rule will be that it rises from the second part" ("A Writer's Notebook", 1896).
As to improving the race, he says (1901), "After all, the only means of improving the race is by natural selection; and this can only be done by elimination of the unfit. All methods which tend to their preservation education of the blind and of deafmutes, care of the organically diseased, of the criminal and of the alcoholic can only cause degeneration." He was still young and not in practice at this time. But there could be hope for some improvements, for in 1902 he writes, "Sorrow is lessened by a conviction of its inevitableness. I suppose one can control many of one's distresses if one can discover a physical cause for them. Kant became a master of his hypochondria, which in his early years bordered on weariness of life, through the knowledge that it resulted from his flat and narrow chest." Summing up for himself, he wrote in 1917: "My native gifts are not remarkable, but I have a certain force of character which has enabled me in a measure to supplement my deficiencies. I have common sense. Most people cannot see anything, but I can see what is in front of my nose with extreme clearness; the greatest writers can see through a brick wall. My vision is not so penetrating. For many years I have been described as a cynic; I told the truth. I wish no one to take me for other than I am, and on the other hand I see no need to accept others' pretences." A good rule on which to end is his, "A good rule for writers: do not explain overmuch." William Somerset Maugham died Dec. 16, 1965 in the 91st year of his life. He had long confessed to the joys of reading, which in his case was over a wide range and included philosophy, religious tracts and anthropology. It may well be that in his last weary years, when he saw the varieties and the vagaries of men and the turning from civilization to barbarism in certain places, as he had long forecast, his mind might have turned to an earlier, even more advantaged person who had said: "Let not your heart be troubled. In my Father's House are many Mansions...
Bibliography CURTIS A: The Pattern of Maugham. London, Taplinger, 1974 MAUGHAM R: Somerset and all the Maughams. London, Heinemann, 1966 MAUGHAM ws: A Writer's Notebook. London, Heinemann, 1949 MAUGHAM ws: Liza of Lambeth. London, T Fisher Unwin, 1897 MAUGHAM ws: Of Human Bondage. London, Heinemann, 1915
CMA JOURNAL/JANUARY 10, 1976/VOL. 114 67
Information
INDICATIONS: For the relief of chronic, atonic, spastic and rectal constipation and for the constipation accompanying pregnancy, convalescence and advanced age. For use in special diets lacking in residue and as adjunctive therapy in the constipation of mucous and ulcerative colitis and diverticulitis. Also useful in the management of hemorrhoids and following anorectal surgery. CONTRAINDICATIONS: Presence of nausea, vomiting, abdominal pain or symptoms of an acute abdomen or fecal impaction. Metamucil instant Mix is contraindicated in patients who must severely restrict their dietary sodium intake. PRECAUTIONS: For patients, such as those suffering from diabetes mellitus, where rigid dietary calorie control is required: Powder - 1 dose furnishes 14 calorIes. Instant Mix - 1 dose furnishes 3 calories.
DOSAGE: Powder - one rounded teaspoonful of powder 1 to 3 times daily depending on the condition being treated, its severity and individual responsiveness. The teaspoonful of powder is stirred into an 8 oz. glass of cool water or other suitable liquid and should be taken immediately. Instant Mix - one packet 1 to 3 times daily depending on the condition being treated, its severity and individual responsiveness. The contents of the packet are poured into an 8 oz. glass to which cool water is then slowly added. The resulting effervescent mixture should be taken immediately. SUPPLIED: Powder - a refined, purified and concentrated vegetable mucilloid, prepared from the mucilaginous portion of Plantago ovata, combined with dextrose as a dispersing agent. Each rounded teaspoonful contains approximately 3.1 g of psyllium hydrophilic mucilloid per dose, a negligible amount of sodium, and furnishes 14 calories. Available in 6 and 12 oz. plastic bottles. Instant Mix - premeasured unit-dose packets. Each unit-dose packet contains 3.6 g of psyllium hydrophilic mucilloid with effervescent and flavouring excipients, 0.25 g of sodium as bicarbonate, and furnishes 3 calories. Available in boxes of 15 unit-dose packets.
NATURAL BOWEL MANAGEMENT THAT BENEFITS MANY KINDS OF PATIENTS,
Complete prescribing information available on request (or in CP*S*).
Searle Pharmaceuticals Oakville. Ontario
Physicians in literature: Part IV: Somerset Maugham, talented but troubled By W.E. Swinton There is no question that the Maugham family was a talented and distinguished one. Willie Maugham's father was in the British diplomatic service in Paris and had a wife renowned for her beauty. Their four sons were highly intelligent and resovrceful, even if one did commit suicide, and the second son, Frederic Hubert Maugham became Lord Chancellor of England and a viscount, being thus a source of envy to his youngest brother, William Somerset Maugham, though the latter become one of the most famous writers of his time and a millionaire. Somerset Maugham, as he called himself as a writer, was a complex character who enjoyed the fame and riches he achieved but felt disowned by the intelligentsia, was disappointed CMAJ continues the series by Dr, Swinton on physicians who have cou.. tributed to literature. The articles, sponsored by the Jason A. Hannah Institute for the History of Medical and Related Sciences, were stimulated by the interest of the CMA committee on archives. IllustratIons are courtesy of the Metropolltau Toronto Library hoard and Indiana Ux*verslty Preuw.
by his life and works and carried the scars of an unhappy youth all his long life. There is some parallel with Dickens here, the bitterness of youth being nurtured and surviving all the apparent successes of later life. Yet Maugham had a fuller life. He was not only a shrewd observer but a brilliant playwright and essayist, and he had in his youth qualified himself for the most honourable of all professions by becoming a doctor of medicine. He was born on British soil, in the British Embassy in Paris, Jan. 25, 1874. There is little doubt that he was attached to his parents, but his mother died of pulmonary tuberculosis when he was 8 years old, and his father died of cancer 2 years later. The loss of his
mother was a great blow from which he never recovered. Her memory was with him, and her photograph by his bedside, for the rest of his life. It may be that this almost cultivated grief was responsible for his odd and cynical view of women - or most women. Deprived of his parents, he went to live with his uncle, the Reverend Henry Macdonald Maugham, at the vicarage of Whitstable, Kent. His uncle seems to have been retiring, somewhat selfish and unused to the ways of children. His German aunt on the other hand, though childless, had the springs of an affection that the boy only realized when it was too late. The coldness, if not austerity, of this life has been told in the autobiographical novel "Of Human Bondage", in which Somerset is Philip Carey and Uncle Carey is located at Blackstable. The circumstances were surely responsible for the boy's shyness, though the stammer which plagued him all his days was an additional burden - how grievous only those who have read the novel and felt Philip's distress over his talipes equinas can know. He went to Kings School in Canterbury in the precincts of the cathedral (Tercanbury in the novel) and, because of his infirmities, was bullied and resentful. Later, through his aunt's influence, he went for a year to study philosophy and literature in the benign academic atmosphere of Heidelberg, an experience he always remembered with appreciation. On his return, like Conan Doyle and Oliver Goldsmith, he found that he was an agnostic and had no wish to enter the church. He attended for a short time the office of a chartered accountant but felt that this was not the life, and then he entered St. Thomas' Hospital, that great, barracklike institution that has stood for so many years by the banks of the historic Thames in London. Here for 5 years he found a new
CMA JOURNAL/JANUARY 10, 1976/VOL. 114 61
.u©w sinemet[ (levodopa and carbidopa combination)
INDICATIONS Treatment of Parkinson's syndrome with exception of drug induced parkinsonism. CONTRAINDICATlONS When a sympathomimetic amine is contraindicated; with monoamine oxidase inhibitors, which should be discontinued two weeks prior to *starting SINEMET*; in uncompensated cardiovascular, endocrine, hematologic, hepatic, pulmonary or renal disease; in narrowangle glaucoma; in patients with suspicious, undiagnosed skin lesions or a history of melanoma. WARNINGS When given to patients receiving levodopa alone, discontinue levodopa at least 12 hours before initiating SINEMET* at a dosage that provides approximately 20% of previous levodopa. Not recommended in drug-induced extrapyramidal reactions; contraindicated in management of intention tremor and Huntington's chorea. Levodopa related central effects such as involuntary movements may occur at lower dosages and sooner, and the 'on and off' phenomenon may appear earlier with combination therapy. Monitor carefully all patients for the development of mental changes, depression with suicidal tendencies, or other serious antisocial behaviour. Cardiac function should be monitored continuously during period of initial dosage adjustment in patients with arrhythmias. Safety of SINEMET* in patients under 18
years of age not established. Pregnancy and lactation: In women of childbearing potential, weigh benefits against risks. Should not be given to nursing mothers. Effects on human pregnancy and lactation unknown.
PRECAUTIONS General: Periodic evaluations of hepatic, hematopoietic, cardiovascular and renal function recommended in extended therapy. Treat patients with history of convulsions cautiously. Physical Activity: Advise patients improved on SINEMET* to increase physical activities gradually, with caution consistent with other medical considerations. In Glaucoma: May be given cautiously to patients with wide angle glaucoma, provided intraocular pressure is well controlled and can be carefully monitored during therapy. With Anti-
hypertensive Therapy:Assymptomatic postural hypotension has been reported occasionally, give cautiously to patients on antihypertensive drugs, checking carefully for changes in pulse rate and blood pressure. Dosage adjustment of antihypertensive drug may be required. With Psychoactive Drugs: If concomitant administration is necessary, administer psychoactive drugs with great caution and observe patients for unusual adverse reactions. With Anesthetics: Discontinue SINEMET* the night before general anesthesia and reinstitute as soon as patient can take medication orally. ADVERSE REACTIONS Most Common: Abnormal Involuntary Move-
ments-usually diminished by dosage reduction-choreiform, dystonic and other involuntary movements. Muscle twitching and blepharospasm may be early signs of excessive dosage. Other SerIous Reactions: Oscillations in performance: diurnal variations, independent oscillations in akinesia with stereotyped dyskinesias, sudden akinetic crises related to dyskinesias, akinesia paradoxica (hypotonic freezing) and 'on and off' phenomenon. Psychiatric: paranoid ideation, psychotic episodes, depression with or without development of suicidal tendencies and dementia. Rarely convulsions (causal relationship not established). Cardiac irregularities and/or palpitations, orthostatic hypotensive episodes, anorexia, nausea, vomiting and dizziness
Other adverse reactions that may occur: Psychiatric: increased libido with sorious antisocial behavior, euphoria, lethargy, sedation, stimulation, fatiguo and malaise, contusion, insomnia, nightmares, hallucinations and delusions, agitation and anxiety. Neurologic: ataxia, faintness, impairment of gait, headacho, increased hand tremor, akinetic episodes, akinesia paradoxica", increase in tho frequency and duration of the oscillations in performance, torticollis, trismus, tightness of the mouth, lips or tongue, oculogyric crisis, weakness, numbness, bruxism, priapism. Gastrointestinal: constipation, diarrhea, epigastric and abdominal distress and pain, flatulence; eructation, hiccups, sialorrhea; difficulty in swallowing, bitter taste, dry mouth; duodenal ulcer; gastrointestinal bleeding; burning sensation of the tongue. Cardiovascular: arrhythmias, hypotension, nonspecific ECG changes, flushing, phlebitis. Hematologic: hemolytic anemia, leukopenia, agranulocytosis. Dermatologic: sweating, edema, hair loss, pallor, rash, bad odor, dark sweat. Musculoskeletal: low back pain, muscle spasm and twitching, musculoskeletal pain. Respiratory: feeling of pressure in the chest, cough, hoarseness, bizarre breathing pattern, postnasal drip. Urogenital: urinary frequency, retention, incontinence, hematuria, dark urine, nocturia, and one report of interstitial nephritis. SpecialSenses: blurred vision, diplopia, dilated pupils, activation of latent Homer's syndrome. Miscellaneous: hot flashes, weight gain or loss. Abnormalities in laboratory tests reported with levodopa alone, which may occur with SINEMET*: Elevations of blood urea nitrogen, SGOT, SGPT, LDH, bilirubin, alkaline phosphatase or protein bound iodine. Occasional reduction in WBC, hemoglobin and hematocrit. Elevations of uric acid with colorimetric method. Positive Coombs tests reported both with SINEMET* and with levodopa alone, but hemolytic anemia extremely rare. DOSAGE SUMMARY In order to reduce the incidence of adverse reactions and achieve maximal benefit, therapy with SINEMET* must be individualized and drug administration continuously matched to the needs and tolerance of the patient. Combined therapy with SINEMET* hes a narrower therapeutic range then with levodopa alone because of its greater milligram potency. Therefore, titration and adjustment of dosage should be made In small steps and recommended dosage ranges not be exceeded. Appearance of involuntary movements should be regarded as a sign of levodopa toxicity and an indication of overdosage, requiring dose reduction. Treatment should, therefore, aim at maximal benefit without dyskinesias. Therapy In Patients not receiving Levodopa: Initially 1/2 tablet once or twice a day, increase by 1,4 tablet every three days if desirable. An optimum dose of 3 to 5 tablets a day divided into 4 to 6 doses. Therapy in Patients receiving Levedepa: Discontinue levodopa for at least 12 hours, then give approximately 20% of the previous levodopa dose in 4 to 6 divided doses. FOR COMPLETE PRESCRIBING INFORMATION, PARTICULARLY DETAILS OF DOSAGE AND ADMINISTRATION, PLEASE CONSULT PRODUCT MONOGRAPH WHICH IS AVAILABLE ON REQUEST. HOW SUPPLIED Ca8804.TabletsSlNEMET* 250, dapple-blue, oval, biconvex, scored, compressed tablets coded MSD 654, each containing 25 mg of carbidopa and 250 mg of levodopa. Available in bottles of 100. O MERCK *Trademark
I SHARP I & DOHME CANADA LIMITED
Pointe Claire, Quebec
64 CMA JOURNAL/JANUARY 10, 1976/VOL. 114
(MC97.)
and formative influence. Everything, from the anatomy dissecting rooms (so well described in "Of Human Bondage" that the familiar odour almost comes through) to the more exciting duties as clerk in various departments, impressed the eager young man. But the obstetric clerkship impressed him most. Called out at any time, his black bag was a passport to the world of slums and forgotten people where even policemen dared not walk alone. Of course London had no prerogative in this. Thirty years later, the slums of Glasgow made the aspiring obstetricians go in pairs into forbidding dwellings, up noisome stairs, past foul landings and appalling lavatories, to doors on which no personal names ever appeared but only cubic footage and permissible human occupancy. Once in the room, the scene was familiar - the boxes for furnitures, the rags on the floor for beds and, in a corner, the tousled woman in labour. In this atmosphere there is neither faith nor hope, and the babies are born into a world of degradation and deprivation. This was the scene that 63 times Maugham saw. A new realism
Those who cry that all men and women are born equal are not obstetricians and have never seen humanity at bay. Here is a world that Victorians, polite novel-reading Victorians, never knew and liked to keep that way. So when Maugham took 2 years to write his slender book, "Liza of Lambeth", and later "Of Human Bondage", he was regarded as something of a pariah. Liza is an inoffensive book that shows the laughter as well as the tears in a London slum; incidentally Maugham records the language better than Dickens or Watson or even Holmes. Perhaps both laughter and tears depended too often on the public house. "Mr. Maugham's story is dirty." "Mr. Maugham has been nosing in the gutters - unpleasant - unhealthy." "Mr. Zola has written dirtily, but he is always more or less artistic - Mr. Maugham never." As Robin Maugham (the second Lord Maugham and Somerset's nephew) has written, "It was the first English novel of any consequence to treat the slums realistically and objectively." It was written by a medical student and it shaped the rest of his life. In 1897 Maugham obtained his MRCS and LRCP. His years in medicine had made an impression on him and on his writing, and after the success of Liza he would be a writer. He had had a sound education in science and medicine, having studied one species in all its aspects for 5 years. He developed a respect for the scientific
St. Thomas'
Hospital, London where Maugham received his medical training
method (compare Conan Doyle, who had a similar experience) and he had discovered "the unaccountability of human nature".
significance He began to see the effects of human evolution to learn that morals and manners did not grow inevitably out of human heads, as hair did, any more than there was one God-given speech that was developed without outside aid, but that all depended on time and place, era and environment. He began to see the Insignificance of Man. "It is not in a cathedral or confronted with any mighty human work that I feel the insignificance of man; then I am impressed rather with his power; his mind seems capable of every feat, and I forget he is an insignificant creature crawling on a speck of mud, the planet of a minor sun. Nature and art, even against one's will, persuade one of the grandeur of man; and it is only science that reveals his utter in¬ significance. Science is the consoler and the healer of troubles, for it teaches how little things matter and how unimportant is life with all its failures" ("A Writer's Notebook", 1949). This note was written in 1896, when he was 22. He soon perceived that medical knowledge was an enormous asset to a writer: he could observe and diagnose the patterns of human behaviour; he could dissect society and an environ¬ ment with the care and enthusiasm he had devoted to the upper extremity or the thorax and abdomen only a few years before. He read and he wrote, his mentors being Swift, Dryden, Voltaire and, of course, Hume, and his careful prose, always simple and to the Man and
irony and disillusionhad more than this, for he was prescient in much that he noted or had to say in his novels. For example, in 1901 he wrote,
point,
shows the
ment of these writers. He
"That which is universal in mankind a fault with many ethical systems that, more or less arbitrarily, they fix upon certain tendencies in man and call them good; and upon others and call them evil. How much greater would human happiness have been if the gratification of the sexual instinct had never been looked upon as wicked. A true system of ethics must find out those qualities which are in all men and call them good." Forty years of experience later he could write, "There is nothing which men lie so much about as their sexual powers. In this at least every man is, what in his heart he would like to be, a cannot be evil: it is
Casanova" ("A Writer's Notebook"). His power as a writer was prodigious and this is no place to attempt a survey. But surprisingly he was many things other than a writer from time to time. World War I
He was living in Paris when the first world war broke out, so he joined a Red Cross ambulance unit in France. His notebook contains some interesting things about this. It was an early dis¬ play of his characteristic nonchalance, but it must be read. Although he had abandoned medicine, he occasionally lent a hand in the field. "I had done no work of this kind for many years and at first felt embarrassed and awk¬ ward, but soon I found I could do the little that it was possible to do clean up the wounds, paint with iodine and .
bandage. I have never seen such wounds. There are great wounds of the shoulder, the bone all shattered, run¬ ning with pus, stinking; there are gap¬ ing wounds in the back; there are the wounds where a bullet has passed through the lungs; there are shattered feet so that you wonder if the limb can possibly be saved." All is touching, for Maugham was an experienced writer who wrote of his experiences, and he saw with words. But he was not to continue in this service. His ability as a writer was good cover for intelligence work and he was recalled from France and sent as an agent to Switzerland (where he wrote the Ashenden stories), then to the South Seas (where he wrote "Rain") and finally, in what now seems a some¬ what hopeless mission, to Russia with the hope that, fortified by British and American money, Kerensky could divert the revolution and have Russia continue as an ally. The money was to be used to buy arms and finance newspapers, and his cover was as a correspondent of the Daily Telegraph. He protested his in¬ ability for this task but he was not believed. Yet he might have had some success had he not stammered. Keren¬ sky gave him a very secret message for Lloyd George to be delivered orally, but Maugham was so afraid of stammering it that he wrote it out and gave it to Lloyd George who was in a hurry and could hardly wait to read it. One can only speculate now as to what might have happened had Maugham (like Conan Doyle) lunched with the fiery but able Welshman. After the war his travels continued, accompanied by a trail of plays and novels. Tahiti yielded "The Moon and
CMA JOURNAL/JANUARY 10, 1976/VOL. 114 65
Sixpence" and the Far East followed. In 1921 there was the Freudian "Trembling of a Leaf" and the plays "East of Suez" in 1922 and "Our Betters.. in 1923. He began to be rich as his plays succeeded in London and New York. He settled in the south of France in 1928 where he lived in luxury at the Villa Mauresque, and with controlled industry led a life that was rudely interrupted in 1940 when he fled in a freighter to America, accompanied by only a suitcase. Here again he found employment as an agent, one for which he was better qualified. For a time he adopted a mysticism that is seen in "The Razor's Edge". When the war was over, he returned to the south of France but made numerous visits to England where he made considerable benefactions to his old school, now more beloved by the passage of time. He virtually retired as an author in 1949, aged 75. He had been offered a knighthood and refused it but accepted a Companionship of Honour (CH) in 1954. Speech therapy
His early life had been marred for him by his stammer, and in later years he had attempted some alleviation with the aid of the same therapist who had helped King George VI. Age seemed to calm him, but the volcano still rumbled underneath, and he was liable to erupt embarrassingly on social occasions. For a time in his younger days he had suffered from tuberculosis; now in his old age he became deaf, and his eyes denied him the pleasures of reading. Robin Maugham recounts that he said, "I've been a horrible and evil man. Every single one of the few people who have got to know me well has ended up by hating me." Rich, he often confusedly thought of himself as financially vulnerable. It is now well known that he was a homosexual and that for a time he thought "he was only 25% homosexual" whereas it was really "75% ". His marriage was thus probably doomed from the start but in 1916 Syrie Wellcome was an attractive woman (and so she remained all her life). She was the daughter of Dr. Barnardo, the famous philanthropist who was a doctor of medicine, and she had been the wife of Sir Henry Wellcome. She married Somerset Maugham in 1916 and they have a daughter, Liza, now Lady Glendevon. Syrie obtained a divorce in 1927, and they met occasionally afterwards. Among the rich rewards of his talents and the product of his industry, where does the voice of the medical man
Somerset Maugham, at age 26 a serious and intent looking youag man.
speak to us9 His agnosticism remained with him all his life, and though this is not a concomitant of the average medical practitioner, it was compounded in his case by his disability and the disillusionment of his travels. Wherever he went he saw diffent mores in different circumstances that appeared to flourish with the approval of different gods. God denied an instant cure to Philip Carey with his club foot and to Somerset Maugham with his stammer. Nonetheless, he was often in tune with nature. In 1901 he writes, "The wind sang to himself like a stronglimbed plough-boy as he marches easily through the country." In 1941, the wind no longer sings, "The moan of the wind [in South Carolina] in the pine trees was like the distant singing of the coloured people, singing their sad song to a heedless or a helpless god." Law of rules For himself he has said, "We are the products of our genes and our chromosomes - we can't change the essential natures we're born with - all we can do is to try and supplement our own deficiencies." Yet in his youth he had thought differently about rules - manmade rules. "One of the commonest errors of the human intelligence is to insist that a rule should be universally applicable. Take an instance in anatomy. Out of 20 cases the branch of an artery in 8 will arise from the second part of the root, in 6 from the first, and in 6 from the third. Though the exceptions surpass it, the rule will be that it rises from the second part" ("A Writer's Notebook", 1896).
As to improving the race, he says (1901), "After all, the only means of improving the race is by natural selection; and this can only be done by elimination of the unfit. All methods which tend to their preservation education of the blind and of deafmutes, care of the organically diseased, of the criminal and of the alcoholic can only cause degeneration." He was still young and not in practice at this time. But there could be hope for some improvements, for in 1902 he writes, "Sorrow is lessened by a conviction of its inevitableness. I suppose one can control many of one's distresses if one can discover a physical cause for them. Kant became a master of his hypochondria, which in his early years bordered on weariness of life, through the knowledge that it resulted from his flat and narrow chest." Summing up for himself, he wrote in 1917: "My native gifts are not remarkable, but I have a certain force of character which has enabled me in a measure to supplement my deficiencies. I have common sense. Most people cannot see anything, but I can see what is in front of my nose with extreme clearness; the greatest writers can see through a brick wall. My vision is not so penetrating. For many years I have been described as a cynic; I told the truth. I wish no one to take me for other than I am, and on the other hand I see no need to accept others' pretences." A good rule on which to end is his, "A good rule for writers: do not explain overmuch." William Somerset Maugham died Dec. 16, 1965 in the 91st year of his life. He had long confessed to the joys of reading, which in his case was over a wide range and included philosophy, religious tracts and anthropology. It may well be that in his last weary years, when he saw the varieties and the vagaries of men and the turning from civilization to barbarism in certain places, as he had long forecast, his mind might have turned to an earlier, even more advantaged person who had said: "Let not your heart be troubled. In my Father's House are many Mansions...
Bibliography CURTIS A: The Pattern of Maugham. London, Taplinger, 1974 MAUGHAM R: Somerset and all the Maughams. London, Heinemann, 1966 MAUGHAM ws: A Writer's Notebook. London, Heinemann, 1949 MAUGHAM ws: Liza of Lambeth. London, T Fisher Unwin, 1897 MAUGHAM ws: Of Human Bondage. London, Heinemann, 1915
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