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(title page) 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
Isaac M. Taylor, M. D.
Jackson & Bell, Steam Power Presses
Call number Cp362.2 N87smt c.1 (North Carolina Collection, University of North Carolina at Chapel Hill)
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Mr. President and Gentlemen of the Medical Society of the State of North Carolina:
When looking about for a subject in the domain of State Medicine upon which to base the Report of this Section, I became interested in the growth of our lunacy laws and their apparent inconsistencies, as a result of this line of investigation, I shall ask your attention to some calculations, and conclusions drawn therefrom, upon the "State Care of all its Insane, from an Economic Stand-point."
Beginning with the establishment of the North Carolina Insane Asylum, the laws of our State show an appreciation by our legislators of the needs of the insane, and a determination on the part of our people to care for all who had been deprived of the proper use of their mental faculties.
So well had our first Asylum promoters studied the question of probable increase in insanity when building the North Carolina Asylum, that the institution was able to meet the demands for accommodation until 1866.
It is probable that this plan had in view gradual extension, as time demonstrated the inadequacy of the provision there made, and that the capacity of the one institution would have been increased, or there would have been other asylums built, but the coming of the war stopped all such philanthropic work, our people found on the several battle-fields those who needed all the comforts which could be spared from their scanty stores, and to provide for the common defence was needed all the public money.
With peace again restored, our people soon found that the provision for the insane made in 1856 had become too small.
The war, fruitful in causes which led to mental disease in those
predisposed thereto, was followed by years of struggle under a load of public and private debts.
Families who had borne the burden of their insane relatives from their private means, were forced to seek relief at the State institution, and the negro race, freed from bondage and protection, and forced to rely on their own efforts in the struggle for existence, proved a fertile field for mental diseases.
Add to these causes the growing acknowledgment by the profession and the laity of the value of hospital care and protection, and the more ready recognition by the profession of cases of incipient mental disease, and we have the reasons for the seeming great increase in the number of the insane and the demand for their reception in the Asylum.
In the face of the depreciated values of taxables and the scarcity of money, recognizing the justice of the demands of this accumulation of chronic insane, our Constitution adopted in these troublous times, accepts for the State, in the fullest measure, the charge of all the insane, as well as the blind and the deaf mutes, and pledges the faith of the State to provide for the idiots and inebriates as soon as practicable.
These pledges were not modified when the State came again into the hands of its lawful sons, but recovery from the direful effects of the war was slow, and, in common with all our people, the insane had to suffer until the funds for their relief were available.
To carry into effect the provisions of the Constitution, and pending the building of other asylums, the first laws provided that all the insane should be cared for from the public Treasury, the Asylum was crowded to its utmost capacity, and those who could not be admitted there were generously supported at their homes.
This policy was soon demonstrated to be too liberal, leaving such an opening for wholesale frauds that, without fear of detection, unscrupulous persons in remote country districts, had those who were deliriously sick, the imbeciles, epileptics, paralytics and dotards adjudged insane that they might receive a share of the public fund.
Such was the rush that, to prevent the bankruptcy of the State, the next Legislature repealed this obnoxious law, and, accepting a policy which had been tried in some of our sister States and by them declared adequate and humane, gave to the care of the counties
all the insane except such recent cases as presented prospect for recovery, those whose malady was accompanied by such violent demonstrations that they seemed dangerous to the community, or those who were adjudged insane when arraigned for crime.
Immediately plans were set on foot for the building of additional asylums to meet the increased demands, but unfortunately, their size was based upon false statistics, and before they were opened the census of 1880 showed the gross errors of that of a decade before, and they afforded only a modicum of the relief needed.
It is probable that the intention of our Legislature when the Eastern Hospital at Goldsboro and the State Hospital at Morganton were projected, was for the State to again assume the direct care of all the insane. Since they have been opened the only increase of capacity has been made at the expense of the comfort of those cared for by the institutions and from funds originally appropriated for their support and saved by judicious economy.
Here beneficent legislation stopped, in disregard of the testimony of all those who had investigated the subject, that our present attitude to our unfortunate brethren was pernicious, and despite the appeals from the friends of the insane emphasized by each succeeding report made by the superintendents of our asylums, our legislators have been deafened by the counter cry for economy, and our people, ignorant of the real condition of affairs, have been contented with a system which is an outrage on humanity. Rude is the awakening to each individual when necessity forces one to seek relief.
Such was the development of our present system, and as each member of this Society must be acquainted with its barbarities, it is needless for me to review what was presented at the last two meetings of this Society in the reports of this Section by Drs. Battle and Hodges.
Our people are conservative, but I believe they are willing to do what is humane and benevolent, and accepting this as their attitude, I have endeavored to calculate the cost of humane provision for our insane in answer to the query:
"Can our State afford to care for all her insane in State institutions?"
Unfortunately the results of the eleventh census as to the number of insane in our State are not yet available for the calculations
of this paper, and the basis used must still be the census of 1880, accepting the ratio therein established as still existing, and calculating the number of insane now in the State on the total population as shown by the census of 1890.
It is safe to assume that the results thus reached will be nearly correct, as the statistics of the tenth census have been proved, and the ratios there shown are in accord with those previously determined, and it is probable that the ratio will hold good for the ten years just past, there has been little change in the character of our population. No horde of pauper immigrants from Europe have found a settlement in our borders; there has been a healthy growth, the natural increase of our own people augmented in the main by native Americans from our sister States northward.
Nor have there been causes to greatly disturb the ratio between the producing and dependent classes--no war or great financial crisis and no famine or widespread epidemic.
So, without a material increase in the proportion of those who must share the public charity, there has been a considerable advance in the value of taxables, and on every hand is evidence of more positive recovery from the financial disasters following the civil war.
There were in North Carolina in 1880 white insane 1,591, and colored insane 437, making a total of 2,028; of these 269 were in the one Asylum then open, 218 were in poor houses and 23 were confined in jails, leaving those cared for at home 1,518.
The ratio of increase in population, as shown by the eleventh census is, for whites, 20.98 per cent., and for colored, 6.76 per cent.; so, if the proportion is preserved, there are now in the State white insane 1,925, colored insane 448--a total of 2.373.
The increase in Asylum room since 1880 has been, at the State Hospital 500, at the Eastern Hospital 250, and the North Carolina Asylum has, by over-crowding, been caring for 300 patients, though constructed for only 204. Taking a mean number, 250, as its capacity, we have the total hospital room now available as 1,000--an increase since 1880 of 784. This leaves the total number of insane in our State and unprovided for at the hospitals 1,373.
That we may have an outside figure, for ease in calculation, and to leave some margin for increase, I will assume that we are to provide for 1,400 insane.
Assuming that the hospitals now opened are ample for the care
and treatment of the acute cases, the violent and the convalescent, we have before us the problem of caring for 1,400, all of the misnamed harmless and incurable class. The first consideration is the provision of a plant suitable for their reception.
The estimated cost of the hospitals for the insane in the United States shows an average of about $1,000 for each patient accommodated; this average embraces much money wastefully spent for elaborate and needless architectural ornamentation and fittings and a good round sum spent in political jobbery. The costliest construction is not needed for the class of insane who are now unprovided for, however essential it may be in hospitals ready to receive all classes.
In our State, where land, materials and labor are cheap, and where there are no extremes of temperature to be guarded against, 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, and advantage is thus taken of the provision there made in excess of their needs; this would make an aggregate cost of $420,000.
Provide for this by an issue of bonds at 6 per cent., which would leave a liberal margin for a sinking fund, and we would have an annual interest account of $25,000, but the construction is necessarily slow, and an annual appropriation sufficient for the amount of building possible to be economically done, could be made with out increasing the public debt or oppressing the tax-payers.
The cost of maintainance is more difficult to approximate, the average cost per capita for maintainance in our three institutions is estimated at $167.78. This shows a steady yearly reduction of expense per capita since 1871, when it was $303.73, in spite of the fact that year by year our hospitals have been caring for a greater proportion of acute cases necessarily the most expensive class.
This reduction is due to a number of factors--the lower prices of the necessaries of life, a more economical administration of the affairs of our institutions, but more largely to the increased number of insane cared for and a consequent reduction in the cost to each individual of the expenses of administration.
This cost by further extension of asylum accommodation is capable of much greater reduction than is contemplated in the provision for those needing asylum care now in the State.
The cost for the class of harmless and incurables probably would be not far from $130 per capita--a total annual cost of $182,000, or, if we include the interest account, at an annual cost of $207,200.
Considering only the maintainance account, we have before us the fact that for $352,700 all the insane of our State could be cared for within the walls of our hospitals. This would necessitate an increase of State tax of about four and a half cents on each hundred dollars worth of taxable property.
It must be borne in mind that this is not a new expense, each idle individual consumes his proportion of the public wealth, and the charge is only transferred, in some cases from the counties, in some from private families to the State, and it is probable that, with the economies of wholesale provision, there is a saving effected rather than an increase of expense.
Dr. Hodges has calculated that the average per capita cost of maintainance in the county poor houses is $85.78, so for the increased amount of $44.22 would be given such comfort as would be sumptuous in comparison, food plentiful and wholesome, medical attention and supervision in sickness and in health, cleanliness and such occupation and amusement as would be best suited to each individual capacity.
This I conceive to be a true statement of the cost of suitable provision for all our insane with the estimates made in excess rather than below the actual cost, the only argument now urged against such provision is on the ground of expense, and while the aggregate is large, the cost to each individual is small, and to balance this are manifest advantages. These naturally group themselves into three divisions--to the Insane, to the Community, to Posterity.
To the insane the advantages are:
1. The removal of the necessity for classing one portion as harmless and incurable, and for that reason denying them a chance for recovery.
Probably no single cause has been so productive of harm as this necessity, forced upon us by our present system. There is no alienist so skilled that he is able to pronounce with certainty upon any case of insanity as harmless; fed, clothed, kept clean, amused, his slighest ailment considered and treated, the patient may be tractable and inoffensive, under other conditions, half starved, uncleanly and brutally treated, the dormant fires of insanity leap into flame and
the docile patient becomes a dangerous maniac. Nor are there those so skilled as to pronounce one incurable; the records of all hospitals contain accounts of unlooked-for recoveries--patients, after long years of chronic mental disease, recovering their reason and remaining perfectly well.
But even if the classification could be made, it does not remove the necessity for the tenderest care; because one is harmless does not mean that he is cleanly, or that he is quiet, or that he is willing to remain at one place and be protected from storm and cold.
2. Their protection from the sane in the community. This is a condition which is not met in the poor-house care of our unfortunates; it is a positive need; they are the victims of the gravest wrongs, from the jeers of the thoughtless to the cruelties of the wicked.
Especially is this protection needed by the female element, unrestrained by the higher moral impulses which are the accompaniments of a sound intellect, often with erotic tendencies as a symptom of their mental disease, they are easily the victims of the most vicious of the community. It is appalling to know how many of these helpless ones have been debauched.
3. They would no longer be brought in contact with paupers and criminals.
It must be remembered in this connection that the insane, dependent wholly for support upon the public, are not properly paupers, until brought low by disease they were producers and tax payers, contributing their proportion to the care of their unfortnnate fellows; less than 5 per cent. come from the pauper class. A still smaller per centage are from the criminal class, and many have a keen sense of the degradation of being confined in the poor houses and jails.
4. It would give suitable employment to each one. All well-conducted institutions seek to keep the patients constantly employed at work suited to their mental and physical capacity, and though many protest against being so employed, it is a great help in keeping them contented and in preserving health and strength.
The advantages to the community are:
1. An assurance to each one of high or low degree in the event that such a misfortune should befall any one of his family, no matter what the form of the malady, proper care would be taken
of the unfortunate, and every chance for recovery would be given under the guidance of those acquainted with the needs of the case, a safe conduct to health, if possible, and careful protection in the event of incurability.
2. Freedom from a troublesome or dangerous element in the community.
3. A grateful reduction of expense by the utilization of the labor of the better class of insane in productive work.
The amount of work which can be done by such persons is large, while never enough to be self-supporting, each little helps, and just so much is the burden lightened on the shoulders of the tax-payers.
4. A sense of a duty properly done and a knowledge that the demands of humanity are fully met.
To posterity some of the advantages are:
1. A gradual reduction of the ratio between the dependent classes and the producers.
There is no factor in the production of insanity and mental defects more persistently present than heredity. Dormant in one generation, it is rife in the next. Necessarily if the progeny of the insane are born during such insanity the defect is more likely to be transmitted, so, while it would be impossible to prevent the marriage of those who have an hereditary tendency to mental disease, the sequestration of those actually insane will greatly reduce the number of their descendants.
Already the Commission in Lunacy of the State of New York announce that there is an apparent reduction in the annual increase of insanity, and attribute it, in part, to efforts in this direction.
2. A reduction in the ratio of the criminal classes. This would be in consequence of the same supervision.
Students of sciology are every day more clearly showing that the criminal classes are the results of degenerated physical and mental powers. Says Maudsley, in speaking of criminals: "Other important facts disclosed by their family histories are that a considerable proportion of them are weak-minded, or epileptic, or become insane, or that they spring from families in which insanity, epilepsy, or some other neurosis exists, and that the diseases from which they suffer and of which they die, are chiefly tubercular diseases and diseases of the nervous system. Crime is a sort of outlet in which their unsound tendencies are discharged; they
would go mad if they were not criminals, and they do not go mad because they are criminals."
In addition to the consideration here given to the needs of the chronic insane, I had hoped to ask your attention to some of the claims of the imbeciles. Although their number is large and many are deserving of some relief, there has been no effort in any direction toward the amelioration of their condition, and there is not available any data upon which to argue for their betterment. Reluctantly I abandon the whole theme to some other who may be able to direct the public attention to these unfortunates and hasten the time when it is practicable to establish institutions for their education and protection.
In conclusion, I have but to say that the time will come when the State must assume the care of all its insane--the longer it is delayed the greater must be the first outlay for their accommodation and the annual charge for their support.
The present system has had a long and fair trial and has proved barbarous; any effort to reform it short of its total abolition is practically hopeless.
State care is the only solution of the problem which meets every objection--it is benevolent, it is humane, it is economical.