Monday, 9 March 2009

The Treatment of Bertha Rochester in a True Contemporary Context

People always seem to land in the same position when it comes to interpreting Rochester’s treatment of his wife. Readers of Jane Eyre seem to be biased towards Rochester treating Bertha well, in comparison to the care that was available then, because they presume that care for the mentally ill was the same all through the past up until the invention of medication and modern ways of dealing with psychiatric patients. They seem to think that Bethlem, as it was from the 1800s to the 1830s like Norris described it, was the standard all through the 19th century or that psychiatric patients were not able to be treated, or kept calm at least, without medication (which is of course available now), and so had to be restrained or confined. Yet there have been a number of asylums like the York Retreat that professed ‘non-restraint’ and ‘moral treatment’. Did they never confine or mechanically restrain people? Was this all a sham, as some professors and people in the field claim, or was it serious? And what with really violent people? I will attempt to throw a glance at what were the practices of non-restraint, not only the theory, but what actually went on in the asylums where that was professed.

Firstly it needs to be said that the conditions in which mad people were kept in the early 1900s are not at all the same as the conditions in the 1840s when Jane Eyre was written and to what its initial public was obviously used to hearing (because issues got debated in the press) (Roberts). Roberts writes, on his site dedicated to care for the mentally ill and part of the University of Middlesex, about the 19th century in general: ‘The early period of state asylums was custodial, out of it developed a period of therapeutic optimism that reached its height in the 1840s, and declined into therapeutic pessimism in the second half of the nineteenth century.’ It seems that there was a high in the 1840s of therapeutic optimism, so what did that mean? Roberts writes: ‘The optimistic period in the history of asylums runs from about 1830 to around 1860. It was at its height in the 1840s. Asylums built under the 1808 and 1828 County Asylums Act tended to be left to the management of doctors. As the theories and techniques of managing lunatics in asylums developed, so did the belief that this asylum treatment itself was the correct, scientific way to cure lunacy.’ The only way was up, as it seems. What’s more is that the period 1830s to the 1840s is particularly important to Brontë and her opinions as that was the time of her teenage years in which opinions are formed. It is especially acknowledged in research concerning political participation. (J. Gimpel, J. Lay, J. Schuknecht, Cultivating Democracy). Issues that were debated in the prss must then certainly have found their to Brontë and her perception of lunacy and its proper treatment. About therapeutic pessimism, Roberts writes: ‘The pessimistic period in asylum history developed during the second half of the nineteenth century. Medical theory was strongly influenced by social darwinist beliefs that insanity is the end product of an incurable degenerative disease carried in the victim's inherited biology, and the experience of asylums, and reanalysis of their statistics, undermined the earlier beliefs in their therapeutic value. In the late 19th and early 20th centuries, the pessimistic period in asylum history ran gently into a backwater period. Most progress in mental health policy took place outside the asylums, in specialist hospitals like the Maudsley, or in outpatient departments, and the asylums became the quiet back wards where chronic patients live.’ During the second half of the 19th century social darwinism had taken over. Degeneration was a natural social process and intervening in it (by treating patients in an attempt to cure them f.i.) harms the natural process and is ultimately harmful to society (Roberts). Thus, from an enlightened time of treating the mentally ill, asylum care went backwards, back to the days before treatment. Scientific research in the psychiatric field continued but only in very restricted circles. The reform of humane treatment did not last also partly due to the problem of overcrowding (University of Alabama) as more and more people were admitted to asylums because they were deemed mentally ill (Roberts). Peace could no longer be maintained, keepers were overstretched and as a result reduced to confining patients again. (University of Alabama)

It is obvious that something went on from the end of the 18th century to about the middle of the 19th, this in connection with the Enlightenment which brought a new way of thinking (Edginton). Particularly the case of King George III (of England) who was mad himself, raised awareness for the insane (Roberts), as people did not want to picture their beloved king in a straightjacket. The first to start a more humane approach to asylum care were the Quakers, led by Tuke, who founded the York Retreat in 1796. They decided to found an asylum after the death of one of their members in the conventional York Asylum (Bewley for RCPsych) and speedily took it over by force (Roberts). Bewley writes about their approach: ‘The views of the original promoters of this establishment shed some light on the psychological, moral and medical treatment available to the mentally ill at that time. Although they were aware that abuses existed in many asylums, they expected that there would be people from whose practice they might learn and by whose instructions they might be guided in the main principles of their moral and medical treatment. The system at that time generally adopted relied on the principle of fear to govern the insane. The practical consequence deduced from this was that attendants should initially relate to patients with an appearance of austerity and perhaps the display of personal strength; in some cases of violent excitement, force would be the most suitable method of control. At the beginning the Retreat assented to the general correctness of these views and although they were modified by the good sense and feeling of the management committee, they were acted upon to an extent that we can hardly contemplate without surprise today.’ In other words, the Quakers acknowledged that the mentally ill which they wanted to care for, were usually governed by fear (of their keepers) and their initial approach should be similar. Yet, they moved towards a more humane treatment by modifying the rules. So we can conclude that they did not from one moment to another remove all restraint and hoped for the best, which would be very unrealistic indeed. Beside that, there was the problem for the Quakers that they were the first in England, and that they had to make their own policy and philosophy. On top of that they did not have experience and needed to learn, but renew at the same time. So the likelihood of restraints being removed at once without regard for side-issues is very small indeed and could be a romantic view of it. However, the method of non-restraint when it was finally established should not be taken lightly as it still works today (not least in the York Retreat itself).

Further on in the same article Bewley writes about treatments they used in order to calm people. It shouldn’t be thought that their only ‘therapies’ consisted in cleanliness, order, useful occupation, religious service and education. They did use calming medication (as laudanum), although that was largely limited to agreeable patients before the invention of the injection needle, and they used baths cold and hot. A case note from Thomas Prichard, who managed Northampton Lunatic Asylum from 1838, describes the case of a 31 year old railroad labourer who attacked his wife, bit her and was confined in a pauper asylum and was transferred to Northampton having worn a straightjacket for a week prior to that. Prichard deemed ‘restraint unnecessary’ and advised to have the man treated with ‘digitalis, antimony tartrate and calomel’. He also had to be kept quiet and cool, and should get a ‘low diet’. Digitalis is now used against heart failure and problems with heart rhythm, but due to its toxicity, it causes, in too high doses, ‘nausea, vomiting, anorexia, diarrhea, abdominal pain, wild hallucinations, delirium, and severe headache’ (Lacassie). Admittedly it can cause death, but provided the fact that its medicinal effectiveness was already addressed in 1785 by Erasmus Darwin and William Withering (College of Physicians, An Account of the Successful Use of Foxglove in Some Dropsies and in Pulmonary Consumption, London, 1785), it can be considered that doctors knew which doses were lethal and how much one should give to the patient in order to purge, which was a common practice, and which no doubt had a calming effect (only down to the lack of energy). Antimony tartrate or Antimonium Tartaricum is a substance still used in Homeopathy today (Séror). It causes nausea, headaches, drowsiness, weakness of circulation and is now used for things as bronchitis, but was then used in order to relieve certain symptoms of insanity. (Talcott, Compendium Mental Diseases and their Modern Treatment, 1901). Calomel or mercury chloride was a laxative, used for the same purpose as digitalis. Although it has now been phased out of use because of its toxic nature, back then it was widely used for medicinal purposes, also for pneumonia (University of Alabama). Whatever may have been the merits of the medication the railroad worker admitted to Northampton got, two days after his admission and necessarily the application of his medication, he asked to work in the garden and did that for more than an hour. By the 13th of August 1838, a mere twelve days after his admission on the 1st of that month, he worked in the garden every day from 9 a.m. to 6 p.m.. The same man was discharged ‘recovered’ 2 months after admission. The same man had, as stated above, bitten his wife, but also escaped confinement, knocked down his keeper, scaled two high walls and then banged his head against a bridge. (Thomas Prichard and the non-restraint movement at the Northhampton Asylum, C. Haw and G. Yorston for the Psychiatric Bulletin, 2004). It needs to be asked of course how long the man was ‘recovered’ and how long it was before he was back into care, but by restraining him there would probably have been no way he would ever have ‘recovered’.

The same article examined the records of the first 50 cases brought to the asylum. 70% of patients brought in had had a history of violence towards others and 22% had harmed themselves or attempted suicide. 18% of patients had been restrained in a previous institution (it needs to be noted that only 74% of patients came from a ‘previous institution’, namely workhouse or other asylum (68%), infirmary (4%) or gaol (jail) (2%) and that 10% was not indicated and 6% came from home) and 16% was brought to Northampton in restraints. Only In 14% of cases restraints were taken off on admission while 8% over all was temporarily restrained in the asylum. Seen that 70% had a history of violence it is remarkable that only 30% was violent in Northampton and that only 8% was temporarily restrained there (Haw and Yorston). Thomas Prichard said that his system was one ‘of kind and preventative treatment, in which all excitement is as much as possible avoided, and no care omitted’ (Northampton Record Office, 1840). It is imaginable that the more excitement provided, the more risk there is that the patient will get violent. However it needs to be noted that both researchers remarked that it is possible that not all restraint was recorded. But even then there is more than a 50% gap between the patients of those 50 that were restrained before and the people of those 50% that were restrained in Northampton. It seems highly unlikely that in more than 50% of cases the restraint would not have been recorded, while in other cases that was done.

Prichard noted another ‘remarkable’ case, even for his conception:

A servant, 31 years of age, was admitted to Northampton on the 30th of August 1838 with ulcers in the lumbar region, legs and ankles because of being strapped to a bed. After her first attack of insanity she was sent to the local infirmary where they had treated her with bleeding and blisters, but that had not made anything better. She destroyed her clothes. Prichard decided to take restraints away and noted: ‘continued in the state about a week during which time she was very bad destroying her bed continuously, tearing clothes to pieces and talking in a most incoherent manner to herself. [She was] treated with both shower baths and laxatives and bathing the head, under this other improved when tonic mixture was given and she rapidly recovered her reason.’ In February 1839, he wrote on the same case, that ‘it had been a very interesting [one]’ and that she had filled the vacant post of a nurse ‘for the last two weeks’ (!). In March 1839 he discharged her and hired her as a nurse!

Of course not all things went like that. Despite the non-restraint policy, naturally restraint was sometimes necessary. But it was kept to a definite minimum. For controlling aggressive behaviour the man used solitary confinement, low rations and shower baths, however in rare cases he did use restraint. (Robinson, 1859).

Another great man in the movement of non-restraint was John Conolly. In her article John Conolly and the treatment of mental illness in early Victorian England, Haw discusses the possible medication Victorian psychiatrists had at their disposal. It needs to be acknowledged that we are not considering true ‘psychiatric’ medication that tackles the disorders themselves, because those drugs like anti-depressants were 20th century inventions. Also the principles of medicine were totally different at the time. Haw writes: ‘Patients were frequently subjected to a wide variety of drastic purgatives and emetics, such as croton oil, castor oil, extract of rhubarb and aloes (Esquirol, 1845). Constipation was commonly believed to exacerbate insanity, hence alienists were preoccupied with the state of their patients’ bowels and the desirability of producing daily bowel actions (Esquirol, 1845; Rush, 1812).’ Haw argues, like I thought, that ‘dehydration and electrolyte inbalances might have exhausted an excited schizophrenic or manic patient into a state of temporary quietness and thus appear to have alleviated their condition.’ But Conolly was more cautious and did not approve of ‘drastic purgation’. Beside purgation that was considered ‘wholesome’, there were of course also sedatives that could be used: opiates like morphia salts, hyoscyamine, although the latter is extremely poisonous, but it would not be the first extremely toxic medication… Those sedatives were used to make patients sleep when they were excited (Haw). Surprisingly, or maybe not so, Conolly preferred the latter (Haw), but still found ‘a copious draught of cold water often a better sedative than any medicine’ (Report of the Resident Physician at the Hanwell Asylum, 1840). She does conclude that toxic drugs were often used in psychiatry then, but Conolly did have the wariness to remark that antimony and digitalis seemed ‘to lower the strength of the lunatic beyond expectation, but without significant improvement in the mental state (Report, 1840).

Drugs were of course not the only means of treatment. There were a number of other methods that were applied like bleeding, blisters, calming in general, the whirling chair, warm baths and giant rocking horses in the courtyard. Because physicians were obsessed with physical causes of mental illness, they bled certain areas that were deemed the cause of mental discomfort. Blisters, moxas (burns caused by a Japanese burning herb) and setons (the application of a thread through a fold of skin) were applied with the aim of counter-irritation (Haw), Conolly did use blisters occasionally, but never moxas or setons (Haw). Depression was thought to result from a debility in the gastric system and so small blisters and leeches were applied to the epigastrium and a bland diet was prescribed (Haw). Furthermore Conolly and Esquirol asserted that madness was the result of an over-excited brain and they believed that shaving the head and applying a paste containing antimony or cold packs (bladders with powdered ice) was wholesome. Shower baths were also deemed calming and Conolly reported that patients were calm for days or even months after one (Haw). Morison used the douche, but Conolly did not like it as it was too much of a punishment (Haw). While he disapproved of the whirling chair which rotated at high speed so as to shock people out of their delusions, Conolly calmed patients down with warm baths in order to soothe them to sleep. Equally sleep-inducing were supposed to be the giant rocking horses for the patients in the courtyards on which several patients at the time could take place. (Haw)

When Conolly visited the Lincoln Asylum in 1839, where non-restraint was already practiced by Hill, he decided to do away with all restraint in Hanwell as well and managed that in three months (Haw). However, the ideal situation that was present in Lincoln with its mere 150 patients, was not there in Hanwell as that was an asylum with 800 inmates. To achieve his goal he increased the number of keepers from 1 per 25 patients to 1 for 18 patients and increased the wages to £25 a year. (Haw)

In order to calm patients down, Conolly decided on seclusion which would remove all irritating sources from an excited brain. To prevent misuse by the attendants he ordered them to meticulously record any use of the padded rooms, which he had specially constructed, and they at all times had to inform a member of the medical staff (Haw). He noted about the absence of restraint that ‘the wards are less noisy, frantic behaviour and manic paroxysms are less frequent, patients are more cheerful and cleaner.’ (Conolly, reprinted 1973)

There were of course patients who were not correctible in their violence or destructiveness. Women who were continually destroying their clothes, he did not restrain, however, but just supplied them with stronger dresses and a leather belt with a lock (Haw). For epileptic patients that were fastened to their beds at night for fear of fits - he did not continue practicing that because he found it unsafe - he made their beds lower and padded the rooms (Haw). But it did not stop with non-restraint and moral management. He improved the wards’ hygiene, lighting and heating in winter. He kept the patients equally hygienic and warm. The food was of better quality and of a bigger amount. Employment was provided. Even leisure activities were supplied in the form of dances, dinners, tea parties and seasonal activities (on a grand scale, for several hundreds of patients!). He also trained the nurses in order to improve their care to his patients and ended up (after some doubt on their part) with a loyal workforce (Haw). Nevertheless, even he could not fail to see that a large number of patients never recovered: ‘the consequences [of non-restraint] may not be that a much greater number of perfect recoveries are effected, for recovery is impossible in a majority of cases of insanity, but the actual number of the insane thus kept in the living and intellectual world, and enjoying a great share of happiness, is immensely increased.’ In the end Conolly was saddled with a lot of chronic patients that indeed did not recover. Though Haw does comment on the ‘occupational therapy’ being certainly in a modern view exploiting, she does put it in its Victorian context of literal ‘usefulness’. She concludes further: ‘We can usefully apply Conolly’s healthy scepticism over physical and drug remedies for mental illness to today’s treatments, although we now have the benefit of the double-blind technique by which to judge a treatment’s efficacy.’

It should also be mentioned that animals were used in a therapeutic way! The first to introduce them was Tuke (again). By 1813 be had put in his airing courts rabbits, hawks, poultry and seagulls (although it is not clear what the rabbits actually thought about that). Conolly had ‘various tame animals’ in his wards and ducks and ‘other aquatic fowl’ in his yards by 1847. In Bethlem, by 1860 they had birds, cats, canaries, squirrels and greyhounds. (Allderidge)

In connection with non-restraint, there was the moral management-approach which tried to ‘increase the conscience and will of patients and thus to combat insanity by increasing self-control’ (Haw). In his article The Well-Ordered Body: The Quest for Sanity through nineteenth-century Asylum Architecture, Edginton makes a link between the philosophy of the day concerning curing insanity and the architecture of the asylums that had to provide a space for it, as Tuke said it. Moral management could not be applied without a place that allowed such things as Classification, Routine, Discipline and Contact with the Landscape, without which moral management was non-existent. Classification, Routine and Discipline were needed to make a copy of the normal and natural (the sane) in order to put the abnormal (the insane) in it. The cheerful, agreeable aspect, the wholesomeness of the site, the sense of space, the temperature and the comfort would be able to pass from the outside, where it was sensed, to the inside (the mind). Thus a well-ordered asylum would produce well-ordered minds (Edginton). Patients were classified according to class, gender, behaviour, type of insanity: ‘Those who are violent, require to be separated from the more tranquil, and to be prevented, by some means, from offensive conduct, towards their fellow sufferers. Hence, the patients are arranged according to classes, as much as may be, according to the degree in which they approach rational or orderly conduct.’ (Tuke, Practical Hints on the Construction and Economy of Pauper Lunatic Asylums, W. Alexander, 1815). That is as far as the importance of classification goes. The healing aspects of nature, though, were present in the construction of the places themselves: great window space, verandas, large day rooms, gardens, sports facilities as bowls, tennis and cricket and a farm. Edginton remarked that from all windows one had a view of the landscape/nature. Even when there were walls around the airing courts, the places where the windows were were elevated enough so as to look over them. Windows were cleverly constructed so people would not jump out of them: they only opened 6 inches top and bottom, they consisted out of little panes and they were four feet from the floor. They were always directed south and they had an uninterrupted view of the landscape. The asylums did not have fences, but instead a ditch with a wall on the other side so the lunatics could not escape (a so-called ha-ha), but did have an uninterrupted view of the landscape and did not feel ‘locked in’ by a fence or wall. (Sennett) That design was an effect of the ways people wanted to cure insanity and it was apparent in the design of lunatic asylums by the 1840s. While Wakefield (1818) and Cornwall (1820) were built like the asylums installed in buildings that were not purpose-built (prisons or similar buildings like convents) with a few alterations as to view and space, by the 1880s asylums were built according to gaiety (Edginton, a view also shared by Roberts and Rutherford who examined the influence of Moorfields Bethlem built in 1815 with a corridor plan ending in two pavilions). The concept of moral management had first been identified in the Retreat of Tuke: the realisation of the humanity of the insane or their incompleteness as rational individuals; the need for non-medical or the psychological aspects of treatment; the treatment of the insane as children and the asylum organisation as a family; the use of nature as a means of calming insanity. (Edginton) Thus, together with the classification, routine and discipline provided, the design of the asylum itself became a therapy to make the insane sane. (Edginton)

The Audit of Violence of the National Healthcare Commission between 2003 and 2005 in the UK asked about violence on psychiatric wards. 50% of staff of all levels of 203 wards was questioned and for each ward there were 20 patients asked their opinion. The examined wards were mainly acute wards, but also included elderly, learning disability and secure wards. 35% of patients claimed that they were ‘winded up’ by staff or nurses. In the same audit, patients and visitors were asked what they felt ‘triggered’ violence on the ward. Amongst the most common were: substance misuse: the use of alcohol, illegal drugs, or withdrawal from them; staff: (low) staff levels, skills, experience, but also attitudes (patronising), over custodial, interaction with patients, nature or absence of intervention; space and over-crowding: bed numbers, ward/unit layout, proximity of other people, lack of privacy; medication and treatment: side effects, compliance, changes to regimen; frustration: lack of activities, noise levels, being away from family and friends, lack of visitors; smoking: lack of cigarettes, overcrowded smoking areas, annoyance about smoking behaviour of others; excessive noise: radios, shouting people, squeaking doors, ringing door bells, noises made by others late at night; intimidation by other patients; theft; temperature. It is obvious that the same problems existed in the asylums in the 19th century: patronising staff, not enough staff, too many people, lack of privacy, too much noise, squeaking doors, ringing bells etc… Although the medication and treatment should be left to one side as that is not comparable. If all these are kept to a minimum by the layout of the building, the organisation of the asylum, and the training of the staff, it seems totally plausible to me to be able to keep violence to a minimum. The question about what triggers violence is particularly important if we acknowledge that no patient (or visitor, because they were also asked) puts it down to themselves (or the patients). Of course, people are not aware of the fact that a squeaking door should not irritate you that much that you should become violent, but in eradicating the squeaking door one takes away the cause of the violence in the first place which would be a lot harder if one were to try to take away the irritation at once. Conolly and the others of the non-restraint movement tried to diminish causes of irritation so much by achieving quietness, kind nurses, and low numbers of patients, that it can indeed become credible that non-restraint did work without medication. That is at least what the audit was partly concerned with as they did not ask the staff what triggered the violence but the patients and visitors.

Having seen the types of treatment doctors used in an attempt to cure and calm patients, and having seen the non-restraint policy, we should consider Bertha’s position. Non-restraint and moral management were not a hoax as it seems. It can be said that it is written about seriously in psychiatric magazines, and not least the Royal College of Psychiatrists does not see it as a hoax, but as a system that worked though not cured. Although we can make objections to some of its methods, we should acknowledge, in this context, that that was the best they could do with the knowledge and medication available to them. If there was such an emphasis on healthy wards, kind attendants and non-restraint (which apparently did work due to organisation and diminishing of the causes of irritation), even if it did not cure, is it then to be considered that Rochester did the best he could in confining his wife in the half dark for 10 years, 24 hours a day, and restraining her with a rope under the eyes of Wood, Briggs, Mason and Jane? In my view the non-restraint asylums were definitely better than the ones criticised by the Commisioners and Bethlem which chained people to the floor, although that was largely over by the time Brontë wrote Jane Eyre. Restraint in Bethlem had largely been abolished in the 1840s and was totally abandoned in the 1850s (source: Bethlem itself). What is better? To sit 24 hours a day in the same place with nothing to occupy you and maybe still have blisters applied, be leeched and even beaten, or to occasionally be made calm by (from a modern point of view unorthodox) treatment after which you sleep, become (temporarily) better and can get usefully occupied? Even from a modern point of view the non-restraint policy is just that slight bit better than the conventional way of handling lunatics, because it at least supplied them freedom. In the 19th century, from 1830 on, it was the best that was possible. Harriet Martineau’s article in The Lancet of June 1834 can be considered as a little too romantic in feel, but not as untrue. In that context it is obvious that Rochester did not care. He paid Grace Poole about the tenfold of Conolly’s attendants that were very well paid, in order to keep his wife a secret, not to give her good care.

The intriguing question still remains, however, which was the actual ‘retreat’ Brontë based the name ‘Grimsby Retreat’ on. The Guardian and the Rowntree organisation both claim it is the York Retreat, and Stanford University puts the same on its fact sheet for Jane Eyre and moral madness, basing its factsheet on Showalter (1985) and Sutherland (1997). Yet, there was another non-restraint asylum in Lincoln, the capital of Lincolnshire, the same county as Grimsby is in and 34 miles from there.


Thomas Bewley, Madness to Mental Illness, A History of the Royal College of Psychiatrists, 2008, a publication of the RCPsych

Camilla Haw & Graeme Yorston, Thomas Prichard and the Non-Restraint movement at the Northampton Asylum, 2004 for the Psychiatric Bulletin

Camilla Haw, John Conolly and the treatment of mental illness in early Victorian England, 1989 for the Psychiatric Bulletin

The National Audit of Violence, 2003-2005, Royal College of Psychiatrists and Healthcare Commission.

Barry Edginton, The Well-Ordered Body: The Quest for Sanity through nineteenth-century Asylum Architecture, 1993, for the Canadian Society for the History of Medicine and the European Society for the History of Psychiatry

Patricia H. Allderidge, A cat, surpassing in beauty, and other therapeutic animals, 1991, for the Psychiatric Bulletin

Selden Harris Talcott, Compendium Mental Diseases and their Modern Treatment, 1901

Factsheet Jane Eyre and Moral Madness, Stanford University

Andrew Roberts, Mental Health History Timeline, for Middlesex University

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