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Isaac M. Taylor
An Appeal for State Care for All the Insane from an Economic Standpoint. The Report of the Chairman of the Section on State Medicine and Medical Jurisprudence Made to the Medical Society of the State of North Carolina, May 28th, 1891
Wilmington, N.C.: Jackson & Bell, Steam Power Presses, 1891.


Items summarized here:

The mid-nineteenth century in North Carolina marked a time of great change in the methods of caring for the mentally ill. The North Carolina Experience collection features several texts which document these changes. Publications by Dorothea L. Dix (in 1848) and Kenneth Rayner (in 1849) appeal to North Carolina's government agencies for the establishment of asylums. A set of 1856 reports issued by the Insane Asylum of North Carolina details the workings and costs of running the newly established asylum, and an 1867 Act passed by the North Carolina General Assembly seeks to streamline the collection of taxes to maintain the relatively new asylums. Finally, an 1891 report demonstrates the accomplishments, failures, and challenges surrounding the fledgling State asylums.

As noted by the North Carolina Center for Public Policy Research, North Carolina relied on "families as caregivers and ad hoc charitable and community-based efforts" to deal with the mentally ill until the mid 1800s (p. v). Despite the push by other states to develop and build asylums, North Carolina hesitated "primarily because the cost of constructing an asylum was considered too high." North Carolina was thus the second-to-last of the original 13 colonies to pass legislation allowing for the construction of a state hospital (p. vi). The efforts of Dorothea L. Dix were of paramount importance in swaying legislators to consider the cost savings (and fundamental humanity) of treating the insane. Dix began as a teacher in New England but upon discovering the plight of the insane while teaching in a prison in Boston, she began a life-long crusade to change the care of the mentally ill.

Dix addresses the North Carolina General Assembly in her 1848 Memorial Soliciting a State Hospital for the Protection and Cure of the Insane. As the North Carolina Division of Mental Health notes in their online biography of Dix, this address was not unique: she traveled from state to state to "try to convince those in authority of the need of improvement in the care of the mentally ill (North Carolina Division of Mental Health)." Speaking as an "advocate of those who cannot plead their own causes," Dix speaks for "hundreds of wailing, suffering creatures, hidden in your private dwellings, and in pens and cabins—shut out, cut off from all healing influences" (p. 3). Chiding North Carolina for being the last state of the original thirteen colonies, "save the small territory of Delaware, to make provisions for the care and cure of her insane citizens," Dix appeals to "liberal and humane hearts" to establish care for the mentally ill (p. 4).

Dix notes that at the time, North Carolina offered "four methods of disposing of her more than one thousand insane, epileptic, and idiot citizens . . . . In the cells and dungeons of the County jails, in comfortless rooms and cages in the county poor-houses, in the dwellings of private families, and by sending the patients to distant hospitals, more seasonably established in sister States" (p. 4). Much of her 48-page Memorial focuses on discussing the inadequacy of each of these methods. Using county prisons to house the ill is "subverting the uses for which these prisons are constructed" and "placing the innocent on a level with the guilty making misfortune and crime, disease and health go hand in hand" (p. 6). Unlike the felon who can look forward to completing his sentence, the mentally ill patient "anticipates no season of liberty" (p. 6). Dix then lists the prisons in North Carolina, noting the conditions and the number of mentally ill persons held there.

Dix argues that North Carolina's poor-houses provide an even worse shelter for the mentally ill, for while a jail might be "well built" and kept in "good order," "[t]he reverse exists" for many poor-houses (p. 13). Dix points out that even the "County poor-house" located "a few miles from Statesville" which stands as a "model of neatness, comfort, and good order" is "no fit place for the insane" (p. 17). Both jails and poor-houses, faced with the challenges of the mentally ill, usually resort to restraint and neglect, which degrades both the human being and the institution.

Like jails and poor-houses, families also struggle with the treatment and care of the insane, as they are "thrown in to sorrow and trouble unequaled through the affliction and sore perplexities arising out of care over the demented, the epileptic, and the maniac" (p. 26). The only remaining option, Dix notes, is removing the ill to other states, making North Carolina "dependent upon other States for her afflicted children, while in possession of ample means to succor and heal their maladies within her own borders" (p. 29). Dix provides several charts displaying specific out-of-state asylums' cure and improvement rates, comparisons of the cost of treating the mentally ill after sustained illnesses versus treating them at the first sign of disease, and the profits from an out-of-state asylum's working farm. Dix aims to show the cost effectiveness of building proper asylums in North Carolina, asylums which can treat—and potentially cure—the mentally ill. She proposes guidelines for proper care, including exercise, proper nursing, and "moderation in all things" (p. 43). Finally, Dix calls upon the legislators to use their "God-like influence" wisely to benefit "the present and future destiny of hundreds, nay of thousands, who pine in want and misery, under privations and sufferings" (p. 48). The decision to establish care, Dix concludes, is the only appropriate response to the demands of "justice," "humanity" and "unquestionable civil obligation" (p. 48).

Like Dix, North Carolina General Assembly Representative Kenneth Rayner believed in the importance of proper care for the mentally ill. Addressing the North Carolina House of Commons in 1848 (the speech was published the following year), Rayner argues that "the Representative of a confiding and generous people can perform no more welcome task, that that of providing for a mitigation of one of the most awful calamities visited upon our race" (p. 3). Stating that "inductive experience" and "statistical data" prove that "in most cases, insanity proceeds from physical disease," Rayner calls for the proper care of the ill (pp. 4-5). Since proper care usually involves "paternal and domestic" aid, along with "[g]enial air, cheerful prospects, and healthful exercise," and because such care is "beyond the reach of private enterprise," Rayner advocates government-supported facilities (p. 5). Such facilities would benefit the ill and the sane, according to Rayner: "Government owes it not only to the destitute maniac, to provide for his sufferings, but it owes it to the more fortunate, to protect them, from the horrifying spectacle of an aberration of intellect in their fellow beings" (p. 6).

Rayner urges members of the House to heed the requests for aid of Dorothea Dix, "who comes among us as the friend of the unfortunate" and "who is an ornament, not only to her sex, but to human nature itself" (p. 9). Like Dix, Rayner sees a failure to act as a blemish upon the state of North Carolina, although Rayner employs a more dramatic approach, arguing that "[t]heir dismal cries and awful groans will haunt us in our slumbers, and their ghastly visages will freeze our hearts with terror, even to our dying day," should North Carolina fail to act (p. 9). Arguing that the counties in the state already pay for the indigent mentally ill through the cost of prisons, poor-houses, or familial loss, Rayner sees a small tax as not "bear[ing] more heavily on people than the charge already existing" (p. 11). Rayner sees no other option than the construction of an institution "to which our posterity can point with pride, whenever they mention our names" (p. 16).

North Carolina finally did begin constructing an asylum in Raleigh around 1854. The Reports of the Board of Directors and Superintendent of the Asylum for the Insane of North-Carolina, written in 1856 and published in 1857, details the establishment and early management of the asylum. The Reports open with a brief statement from the four directors. They note their appointment of Dr. Edward C. Fisher to the position of superintendent of the institution; they also request the modification of several sections of the act that allowed for the construction and management of the asylum, including those that limited the number of persons from each North Carolina county and those that classified who could be admitted to the facility. The directors also "beg leave to tender their resignation" after having "discharged the very onerous and responsible duties confided to them in connection with the asylum" (p. 2).

The superintendent's report dominates much of the remainder of the document. Noting the folly of an 1854 report in which "the conjecture was hazarded that a space of twelve months would be sufficiently long for the completion of so much of the remainder as to justify the directors in putting the institution into operation, Fisher acknowledges that, by 1856, "sufficient progress has been made" (p. 3).

At the time of the Report, the Asylum had been open "eight months and nine days" and the Asylum had admitted "fifty-one males and thirty-nine females," who had been "laboring under insanity for periods varying from one to thirty years" (p. 6). Fisher notes problems in the Asylum, including an outbreak of dysentery and the death of two inmates, including one by suicidal "abstinence from food" and another from epilepsy (p. 7). But Fisher also stresses the positive developments from the Asylum's first year, including patients who had "learned to appreciate the privileges of companionship" and those who "gladly embrace the opportunity afforded them of performing manual labor" (p. 8). One of the greatest challenges faced by the Asylum is the filling of the "offices of attendants upon the patients; a position, which, though of inferior grade to others, is hardly second to any position in the asylum in its importance and responsibility" (p. 8). Fisher recognizes that other institutions have faced similar problems in finding suitable staff, a problem exacerbated by the "strictly agricultural" location of the North Carolina Asylum (p. 8).

Fisher also discusses problems arising from insufficient funding, including a well that fails to provide adequate water for the Asylum. He contends that the only viable solution requires machinery to pump water from a nearby stream, a set-up that would cost approximately four thousand dollars. Fisher also regrets that "it has been found impracticable, from the want of funds, to go on with the construction of the gas works," which forces the Asylum to less reliable lighting alternatives (p. 13). Fisher expresses similar frustrations with missing buildings, insufficient gardening grounds, and the lack of an enclosed grounds to allow free patient movement. After thanking those who assisted the Asylum in its foundational years, Fisher ends the Report with several tables, detailing various elements related to the Asylum, including suspected causes of insanity ("Religious excitement, Blow on the head, Masturbation, Pecuniary embarrassment" and other causes), the counties from which the residents have come, and the funds received and spent by the Asylum (p. 20).

The law titled An Act to Revise and Consolidate the Various Acts Relating to the Collection and Return of Taxes for the Support of the Indigent Insane, passed in 1867, sought to streamline the intake and distribution of funds for the Asylum. Drafted by the North Carolina General Assembly, the Act suggests changes such as allowing the Superintendent of the Insane Asylum to submit a "list showing the amounts due by each County in this State, for the support of the indigent patients in the Insane Asylum" (p. 1). The Act also proposes methods for dispensing the lists to the counties, for levying county taxes in response to the list, and for taking appropriate actions should a county default on its payments. The end of the document is partially missing due to a tear in the document.

Interested scholars should note that only two other insane asylums were approved and built before the turn of the twentieth century in North Carolina: Broughton Hospital in Morganton and Cherry Hospital in Goldsboro. Cherry Hospital, which opened in 1880, was designated the "Asylum for the Colored Insane" and remained the only mental hospital available to African Americans in North Carolina "[u]ntil the implementation of the Civil Rights Act 85 years later" ("Reforming Mental Health Reform," p. vi).

The final document summarized here, Dr. Isaac M. Taylor's An Appeal for State Care for All the Insane from an Economic Standpoint. The Report of the Chairman of the Section on State Medicine and Medical Jurisprudence Made to the Medical Society of the State of North Carolina, May 28th, 1891, notes the difficulties still faced by the relatively new asylums. Taylor was an Assistant Physician for the State Hospital in Morganton, North Carolina. His report, addressed to the "President and Gentlemen of the Medical Society of the State of North Carolina," examines "the growth of our lunacy laws and their apparent inconsistencies" (p. 1). Acknowledging that the "laws of our State show an appreciation by our legislatures of the needs of the insane, and a determination on the part of our people to care for all who had been deprived," Taylor nonetheless finds that the current state of the asylums fails to live up to expectations (p. 1).

From the time of their creation until 1866, says Taylor, North Carolina's asylums served the state well, but as the need for space increased, the asylums did not expand to meet that need. While the Civil War understandably "stopped all such philanthropic work" and diverted state funds elsewhere, both during and after the conflict, the war also forced many families into debt and made them thus unable to sustain the "burden of their insane relatives from their private means" (pp. 1, 2).

With an increase in patients and a decrease in funding, North Carolina attempted to care for its insane "from the public Treasury" by filling the Asylum to capacity and "generously" supporting others "at their homes" (p. 2). Such a plan was quickly recognized as an "opening for wholesale fraud" and "the next Legislature repealed" the law (p. 2). Taylor notes that the State then took the right steps in the "building of additional asylums," but due to "false statistics," the new locations "afforded only a modicum of the relief needed" (p. 3). And yet, Taylor alleges, "Here beneficent legislation stopped" (p. 3). Assuming the existing facilities could somehow complete their mission despite their insufficient size and funding, "our legislators . . . . have been contented with a system which is an outrage on humanity" (p. 3).

Taylor thus explores what the state can do to care for its insane more responsibly. Using the 1880 census, he determines the "ratio of increase in population" and the subsequent expected number of insane persons (p. 4). Taylor projects that there are approximately 1,400 uncared-for psychiatric patients in North Carolina. And while the "estimated cost for the hospitals or the insane in the United States shows an average of about $1,000 for each patient," Taylor argues that that number reflects "elaborate and needless architectural ornamentation and fittings and a good sum spent in political jobbery" (p. 5). Instead, in North Carolina, where "land, materials and labor are cheap," Taylors suggests that "provision could be made for all at a per capita cost not to exceed $300, provided, of course, that such extension is made in connection with the hospitals already established" (p. 5). Such expansion would cost the state $420,000 (p. 5). Taylor suggests paying for the expansions slowly through the sale of "an issue at bonds at 6 per cent," which would allow for the changes without "increasing the public debt or oppressing the tax-payers" (p. 5).

Maintenance of the hospitals and the patients, however, necessitates a tax increase of "about four and a half cents on each hundred dollars worth of taxable property" (p. 6). Such expansions and changes would allow for the care of all patients, ending the trend of "classing one portion as harmless and incurable, and for that reason denying them a chance for recovery" in the name of space and funding (p. 6). It would also offer "protection from the sane in the community" who can be cruel and "wicked" (p. 7). Taylor notes that this protection is especially pertinent to the "female element" who are "easily the victims of the most vicious of the community" (p. 7). Expansion and care would allow the insane to "no longer be brought in contact with paupers and criminals" while providing "suitable employment to each one" (p. 7).

In terms of the community, proper growth and maintenance of the asylums would offer "an assurance to each one of high or low degree" that his family would be cared (p. 7). Proper asylums also offer "freedom from a troublesome or dangerous element in the community," "a grateful reduction of expenses by the utilization of the labor of the better class of insane," as well as "a sense of duty properly done and a knowledge that the demands of humanity are fully met" (p. 8). Taylor ends his piece with a sentiment that can be seen in each of the documents found here: "State care is the only solution of the problem which meets every objection— it is benevolent, it is humane, it is economical" (p. 9).

Works Consulted: North Carolina Center for Public Policy Research, "Reforming Mental Health Reform: The History of Mental Health Reform in North Carolina"; North Carolina Division of Mental Health, Developmental Disabilities and Substance Abuse Services, "Biography of Dorothea Lynde Dix," accessed 25 April 2010.

Meredith Malburne-Wade

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