A Fatal Form of Contentment

A Fatal Form of Contentment

 

Catherine Hickie, MBBS

Spring 2009 - Volume 13 Number 2

https://doi.org/10.7812/TPP/09-007

The medical humanities can be relevant to clinical practice in unexpected ways. While researching an essay on mass tourism in Victorian England, I read about the Grand Tour of Europe, a travel experience for the select few, mostly upper class young men who travelled from England officially to complete their education with exposure to the great cultural experiences of Europe, but unofficially to let loose away from home. I identified with those young men and their freedom away from scrutiny. Studying medical humanities was supposed to broaden a narrow scientific education and reinvigorate my work as a psychiatrist but it was tempting to take courses as far removed from medicine as possible. The history of travel seemed remote from 21st-century medicine but as a virtual tourist to the study of history, I found some surprising links.

The medical humanities can be relevant to clinical practice in unexpected ways. While researching an essay on mass tourism in Victorian England, I read about the Grand Tour of Europe, a travel experience for the select few, mostly upper class young men who travelled from England officially to complete their education with exposure to the great cultural experiences of Europe, but unofficially to let loose away from home. I identified with those young men and their freedom away from scrutiny. Studying medical humanities was supposed to broaden a narrow scientific education and reinvigorate my work as a psychiatrist but it was tempting to take courses as far removed from medicine as possible. The history of travel seemed remote from 21st-century medicine but as a virtual tourist to the study of history, I found some surprising links.

In 19th century England with the Industrial Revolution and the subsequent rise of the middle class, travel opened up. People flooded to Italy, France, Switzerland, and further afield to Egypt and other exotic destinations. In contrast to the Grand Tour, where ample money and time allowed a young man to spend months in Florence or Venice, many of the Victorian middle-class travellers were on brief vacations from work. They came to Europe on package tours that had been organized for them and travelled in groups along a beaten tourist track. There were criticisms of these new tourists who flooded the art galleries of Italy and trekked the mountains of Switzerland clutching newly printed guidebooks. One name was singled out for praise and blame in regard to mass travel, Thomas Cook.

Thomas Cook—Mass Travel

On the Internet there are thousands of references to Mr Cook and his tours, but one stands out because of its medical linkage: an obituary in The Lancet, published in July 1892.1 Every issue of The Lancet from 1823 till the present day is now available online.2 The early issues are fascinating with their mix of London medical politics and medical progress. But why would a man who pioneered mass travel be eulogized in a prominent medical journal? The obituary of Thomas Cook reads, in part: “The death of Mr Thomas Cook of Leicester, … the originator of excursions by land and sea over the world, calls for a word of deep respect and regret. We sometimes complain of the restlessness of the age and its locomotive tendencies. … His [Thomas Cook’s] is the credit of having reduced the evils and the discomfort of travel and of having enormously contributed to the width of men’s ideas of the world and of their fellow creatures.”1

Thomas Cook came from a working class background. His father died before he was ten and he was apprenticed to a gardener and later to a wood turner, both men were alcoholics. Mr Cook became a committed member of the temperance movement. He was a Baptist minister and preached against alcohol. A medical journal might eulogize a man who had crusaded against the harms of alcohol, but there is no mention of this in The Lancet obituary. Cook is remembered as “the originator of excursions by land and sea over the world ….”1

The first excursion Cook organized was to a temperance rally in 1841. He made a deal with the railway company for cheap tickets; he had meals provided and a pamphlet printed. Five hundred and seventy temperance campaigners travelled by train to a rally eleven miles away.3 He organized a similar event the next year and the year after that. The railways made it possible for large groups to travel but Mr Cook saw the greater potential. In 1845, he took a group from Leicester to Liverpool and made a small profit. The next year he took a group from Leicester for a tour around Scotland. Within ten years he was arranging trips to France, Switzerland, and further afield.3 What is the connection between The Lancet (and the Victorian medical fraternity) and the rise of mass travel?

Thomas Wakely—The Lancet

The Lancet is one of the world’s most respected scientific medical journals. The founder and first editor, Thomas Wakely, was a London-based physician with a political axe to grind. He believed medicine was held at the throat by the Royal Colleges, dominated by privilege and nepotism and lacking in standards. When Dr Wakely founded The Lancet in 1823, he used the journal to attack the medical leadership—particularly the College of Surgeons—and to agitate for reform.4 He wanted a voice for ordinary practitioners within the medical profession. He also wanted medical information to be in plain language so that anyone could keep up with changes in medical knowledge. In the preface of the first edition he set out the target audience for the journal: London specialists, country practitioners colonial practitioners and “every individual in these realms.”5 To make The Lancet as accessible as possible, Dr Wakely determined that his journal would not use the “semibarbarous phraseology of the schools … [but] we will adopt … plain English diction.”5

I see parallels between Mr Cook’s opening up of travel and Dr Wakely’s dissemination of medical knowledge. Whatever their personal agendas both men were pioneers in loosening the upper-class grip on learning and education: Mr Cook saw a way to make travel accessible to large numbers and was vocal in defending against elitist attitudes that “places of rare interest should be excluded from the gaze of common people.”3 The Lancet made medical science more accessible but Dr Wakely also used the journal to air his strong political views.6 He argued against the status and power of the London Corporations who charged licensing fees of the small practitioners for the benefit of their own cliques.4

The Evils of Travel

One sentence in the obituary holds a clue to the link between Mr Cook and the medical fraternity: “His is the credit of having reduced the evils and the discomfort of travel.”1 The word “evils” is striking. Although The Lancet evolved as a scientific medical journal, science cannot be separated from the prevailing experiences, fears, and beliefs of its practitioners. Train travel was new in the 18th century; there were concerns about safety. Early trains had frequent accidents and poor suspension. With the introduction of signals and improvements in vehicle technology accidents became progressively less frequent. But it was not just the accidents that were a focus of concern. Comforts were minimal in the third class carriages where people sat on wooden benches, initially in carriages that had no roofs. Physicians were concerned about the effects of this rough travel especially for vulnerable people who were already sick or weak.

In 1861, The Lancet commissioned its own inquiry into train travel, “Editors note: Influence of Railway Travelling upon Public Health.”7 Submissions were sought from “interested parties” from individual specialists, often London based, reporting on observations they had made of their patients. In general, they reflected concerns about the body as a fragile machine: the motion of the train being seen as a source of harm. For example, on February 15th 1862, a London obstetrician wrote: “I would wish to draw attention to one very important point … the danger of excessive railway travelling to newly married women,”8 attributing miscarriages to the new habit of train travel. And further, “But I should expect, from the impressionable state of the nervous system in women, that whatever is found to affect this system in man, will do so to a higher degree [in women] ….”8 And this submission from a surgeon, Samuel Solly, MD: “I was visited by a patient, aged 62, who had been suffering from congestion of the brain, which had been completely relieved by medicine and 24 leeches to the temples …. He told me he had felt perfectly well … until he travelled up this morning by rail. … a brain disturbed by congestion is injuriously affected by motion on the rail.”9

Not all the observations concerned injuries, some wrote of protective factors: “… the stout, easy-going, lethargic traveller, I notice, bears continuous locomotion far better than the spare, nervous, irritable man.”10 This author postulated a connection between temperament and vulnerability to the effects of physical motion.

Many of the submissions viewed the motion of the train, the shaking and the vibrations, as a source of harm. And some parts of the body, such as the uterus and the brain, were seen as more sensitive than others. Pregnant women and sick people were thought to be at greatest risk. Submissions made to The Lancet can be read as an attempt to make sense of these anxieties. What beliefs and anxieties cloud our current scientific vision? One example from my own clinical practice seems relevant.

A Train Ride

During the last four years I have worked in the psychiatric service of a rural district hospital in a town on the main railway line between Sydney and Melbourne. More than once a man has alighted from the train (or been put off because of odd behaviour), found the police station or the hospital Emergency Department and announced that he has a mental illness and wishes to be admitted to the psychiatry unit. He gives a sketchy account of recent travels, he has just come from the outback or the coast where he has been for several months. If pressed he will give a slim account of a long psychotic history with bursts of treatment and long gaps with no medical care. He has been in other country psychiatric units. He may name a friend or a family member, but probably not. The impression is of persistent psychotic symptoms and a desire to keep moving.

I recall one of these men in particular—he had many years of psychotic symptoms and had been in the ward for a week or more when he slipped out the door of the hospital, got himself to the railway station and rode the train to Sydney. At the Sydney terminus, he approached a station guard, announced that he was a “mental patient” and asked to be taken to the hospital. When the overstretched inner-city Emergency Department discovered he had a hospital bed waiting for him in the country, transport was quickly arranged. The round trip was complete within 12 hours and the man was very pleased with his day. When I asked him why he had gone to all that trouble to end up where he started he said he just wanted to ride the train.

Patients who prefer to be itinerant present a problem to physicians. When we treat patients who have chronic conditions we emphasize the benefits of wholistic care. For patients with enduring mental illness we want to do more than prescribe medications; we aim for improvements in social function and work, establishing accommodation and building social networks. We can’t do our best work when people are itinerant. Concerns about illness and itinerants have a long history: a particular concern at the turn of the 20th century was the rapid spread of infectious diseases. Unemployed people could travel widely on foot and by catching free rides on the trains; it was feared that these people spread diseases like smallpox; concerns were also for a perceived moral problem: enjoying the pleasure of travel without having earned it through work. The Lancet ran a number of articles on vagrancy at the beginning of the 20th century. There was particular interest in those who chose to move freely from town to town and refused to engage in the work schemes that were established. The Lancet was critical of the charitable organizations that made this not only possible “but pleasant and attractive. They enabled the idle to live either by mendicancy or by crime or by both without any need to work and the example of men and women leading indolent, self-indulgent lives without responsibility or restraint is a constant temptation to others to adopt the same course.”11 An editorial in The Lancet, in a report on an inquiry into vagrancy, called this “a fatal form of contentment.”12

I wonder if contentment is the motivation to leave town soon after hospital discharge, opting to ride the train rather than to accept accommodation and community treatment. Or is it to be in control, coming for treatment, then slipping away. Do the trains symbolize freedom? Adventure? Or is it something about the movement of the train itself? Were the Victorians right about the rocking and the vibrations but wrong in their conclusions? Could it be soothing or even therapeutic?

Or perhaps it is the anonymity of the train, where a traveller can be in company without pressure to communicate. Where a person who lives with schizophrenia can step out of the persona of patient and become a traveller like everybody else. Trains can offer a social mixing that is both exciting and threatening.

In the 21st century, we have our own new technology that takes us on anonymous rides, mixes up the social order, and challenges the establishment. The Internet has come with anxieties and fears just as the trains did a century and a half ago. We are all familiar with the concerns: the speed at which a child can be on a pornography site; the anonymous chat rooms as a place of social intercourse; ciber bullying and stalking. And, like The Lancet of the 19th century, the Internet presents an information revolution for health. Knowledge is no longer the exclusive domain of the expert, up-to-the-minute medical facts can be found on the Internet in plain language for all to read. Any amateur can set up a Web site. In some ways we are back in the unregulated age, where quacks are flourishing. This makes us nervous. We warn of the dangers of unregulated Web sites, false information, and global cons. The Internet is changing our relationships as health professionals. We may have a looser hold on knowledge but there are benefits. There are good Web sites hosted by reliable providers; and Web-based therapies may offer some solutions to unmet needs in mental health care.13

In the university library, a virtual tourist to the study of history, I wondered if our hopes for new technology were so different from the hopes of the Victorians. Perhaps The Lancet eulogized Thomas Cook for the same reason that people set aside their fears and embraced the train, the opening up of possibilities (risks and all) to people who were previously shut out. This, after all, was one of The Lancet’s original aims. As our anxieties subside we are embracing information technology to improve health care as well as for pleasure and private exploration. An essay on mass travel in the 19th century proved far from irrelevant to a 21st century psychiatrist.

Disclosure Statement

The author(s) have no conflicts of interest to disclose.

Acknowledgment

My thanks to Megan Hickie for her thoughtful reading and comments on an early draft of this paper.

References
1. Obtituary. Death of Mr Thomas Cook. Lancet 1892 Jul 23;140(3595):215.
2. Hutchinson M. How The Lancet made medical history [monograph on the Internet]. London: BBC News. 2003 Oct 6 [cited 2009 Mar 7]. Available from: http://news.bbc.co.uk/2/hi/health/3168608.stm.
3. Feifer M. Tourism in history. Briarcliff Manor (NY): Stein and Day; 1986.
4. Peterson MJ. The medical profession in mid-Victorian London. Berkeley: University of California Press; 1978.
5. Wakely T. Preface. Lancet 1823 Oct 5;1(1):2.
6. Loudon J, Loudon I. Medicine, politics and the medical periodical 1800-50. In: Bynum WF, Lock S, Porter R (editors). Medical journals and medical knowledge. New York: Routledge; 1992. p 49-69.
7. Editors note. The influence of railway travel on public health. Lancet 1861 Dec 14;1998:584.
8. Ellis R. Letter. The influence of railway travelling on public health: The effects of railway travelling upon uterine disease. Lancet 1862 Feb 15;79(2007):184.
9. Solly S. Letter. The influence of railway travelling on public health: congestion of the brain resulting from railway travelling. Lancet 1862 Feb 15;79(2007):184.
10. Acton W. Letter. The influence of railway travelling on public health: personal experiences of an habitual traveller. Lancet 1862 Feb 22;79(2008):210-1.
11. Small pox and vagrancy. Lancet 1904 Apr 30;163(4209):1215-6.
12. Editorial. The report on vagrancy. Lancet 1906 Mar 24;167(4308):841-3.
13. Titov N, Andrews G, Schwencke G, Drobny J, Einstein D. Shyness 1: distance treatment of social phobia over the Internet. Aust N Z J Psychiatry 2008 Jul;42(7):585-94.

The Permanente Journal

Sponsored by the eight Permanente Medical Groups, The Permanente Journal advances knowledge in scientific research, clinical medicine, and innovative health care delivery.

Reprint Permissions

The Permanente Journal welcomes requests for reprints and reproduction. Use of any and all material published in The Permanente Journal is copyrighted and protected.

The Permanente Press

The Permanente Press publishes The Permanente Journal and books related to healthcare. Journal subscriptions are entered for the calendar year. Advance payment in US dollars is required.


ISSN 1552-5775 Copyright © 2018 thepermanentejournal.org.

The Permanente Press. All Rights Reserved.