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Most of us can recall having a hearty "haw haw" over a story about the antics of some character in one of our present-day bedlams. The fellow who strolls about living the dream that he is Napoleon has always been good for a laugh.
Turn about is fair play. In his lucid moments the latter-day Napoleon is likely to get some belly laughs from the naïve belief held by many of us that all (or, at least most) of the insane and feeble-minded are in the institutions.
It is true that within the past quarter-century we have doubled the case load in our mental hospitals. In 1943, there were more than 600,000 mental cases in our public and private hospitals. It may be that this case load now is pushing on toward the million mark. Even so, we have only begun to scratch the surface. The statistics on this point are not satisfactory. However, there have been a number of sample studies which point in the general direction of the answer.
A study done in Baltimore a few years ago estimated that 1.2% of the population were feeble-minded (i.e. idiots, imbeciles, and morons.) A Tennessee survey, reported in 1943, made an estimate of 1.5% and a South Dakota Commission settled on 1.2%
Here in North Carolina we have set our sights somewhat higher. A state commission studying the problem of feeble-mindedness in 1926 estimated that 2% of all Tar Heels were mentally deficient.
In 1937, another state commission made a sample study in a typical town in Piedmont North Carolina. This committee, after examining 1,188 school children, put the rate of mental deficiency in the public schools at 4.5%. Within the past two years similar studies have been done in Orange County and in Winston-Salem.
Both surveys, presented on this page last week, pegged the incidence of feeble-mindedness among grade school children in the neighborhood of 5%. Other studies made in other sections of the nation arrived at similarly high rates when dealing with children - a result, perhaps, of the abnormal death rates found among mental defectives.
It seems safe to conclude that the rate of mental deficiency in the United States is now running along at something like 1.5% of the entire population. What about the insane?
For the period of April, 1942, through March, 1943, Selective Service boards rejected 5.2% of all men examined on the ground that they suffered from some type of mental disorder. Draft records from World War I reveal that almost 6% of all rejections were on this score. A sample study done in New York City several years ago concluded that "approximately" 4.5% of the persons born in that city will succumb to some sort of mental disease and become patients in mental hospitals.
Accepting these studies for what they are - intelligent guesses based on limited sample case studies - it is probably conservative to peg the combined incidence of insanity and feeble-mindedness at 5% of the total population. This would place the number of insane and feeble-minded persons in the United States today somewhere in the neighborhood of seven million! By any standard, it is a whopping problem.
In the past we have made (and still are making) some half-hearted stabs at correcting the imbalance in our birth rates. The use of contraceptives has been urged to help bring the birth rates into balance. Yet contraceptives have back-fired on us. Generally speaking, they have been accepted only among the class of persons who represent our best mental stock.
Since early times we have used segregation - the technique of herding the mentally unfit into institutions - as one method of dealing with the insane and the least able of the feeble-minded. But segregation has never reached more than a small fraction of the mental cases and, even then, many of the patients drifted in and out of the institutions with clock-like regularity.
It is doubtful if any State has enough hospital beds for mental patients who need treatment, Certainly here in North Carolina it is as difficult to gain admittance to a mental hospital as it is to rise on the waiting list of a fashionable country club.
In many states the mental institutions have been run in a fashion reminiscent of the bedlams of the middle ages. Staffed by under-paid, frequently incompetent, doctors, nurses and attendants, some mental hospitals have racked up a record of inhuman brutality which is unbelievable.
As late as 1944, North Carolina averaged only $200 per patient a year in caring for mental cases. The national average was well over $350. There were 1,500 mental cases on the waiting list of the state-operated hospitals in 1945.
Until 1945, North Carolina did very little in the way of using the mental hospitals as a tool for combating the spread of mental disease. In 1945, the entire administration of our mental hospitals was shaken up. The information now available indicates that we are moving in the direction of an effective use of these facilities. For the present biennium we are spending $4,198,008 for the operation of the mental hospitals. Another $6,732,376 has been ear-marked for permanent improvements and there is the possibility that this sum will be increased by something like $2,500,000 through Federal help in hospital construction, The total budget in 1939-40 was $1,322,049.
But assuming (and this is a bold assumption) that North Carolina will soon have adequate space for the mental cases needing treatment and that the increased patient load will receive the best in curative treatment, you still must face the fact that only a fraction of the mental cases are reached by the hospitals.
Some states have met this problem by declaring that the feeble-minded and insane shall not marry. While they have succeeded in making sex illegal, these states have been singularly unsuccessful in making it unpopular.
In the United States our problem is not more children (the birth rate jumped from 17.1 per 1,000 in 1937 to 28.8 per 1,000 in 1946). Our problem is to produce better children. It is a problem of quality, not quantity.
Because it is confused with castration (a mutilating, barnyard-type of operation in which vital parts are removed) sterilization is much misunderstood. Actually, it is a simple operation in which nothing is removed except the possibility of parenthood.
For men the operation is about as serious as a tooth-pulling and can be performed just as quickly and with less pain. The operation (called a vasectomy) is nothing more than the cutting and tying of those tubes traveled by the sperm. With women, the operation (called a salpingectomy) corresponds to the removal of an appendix. Here the fallopian tubes, the route traveled by the egg, are cut and tied.
In neither case are any organs removed. No nerves are cut. The sterilized individual retains every characteristic he (or she) ever possessed with one exception - the ability to have children.
The idea that sterilization interferes with the normal sex life of the individual is entirely incorrect. (For this reason sterilization has little value in dealing with sex delinquents.) As a matter of fact, the so-called Steinach rejuvenation (an operation sometimes performed on men) is nothing more than a simple vasectomy.
Dr. Harry Sharpe, a surgeon connected with the Indiana State Reformatory, began to use the vasectomy as a sterilizing technique in 1889. Since that time, and over the protest of the Roman Catholic clergy, 27 states have adopted laws permitting the sterilization of certain types of insane and mentally deficient individuals. The California law, adopted in 1909 and since amended a number of times, represents the oldest continuous program of sterilization in this country.
The constitutionality of the sterilization laws was settled in the case of Buck vs. Bell in which Justice Oliver Wendell Holmes observed:
"It is better for all the world, if, instead of waiting to execute degenerate off-spring for crime or to let them starve for their imbecility, society can prevent those who are manifestly unfit from continuing their kind. The principle which sustains compulsory vaccination is broad enough to cover cutting the fallopian tubes ... Three generations of imbeciles are enough."
The first North Carolina sterilization law was passed in 1919. It was poorly worded. In 1929, the law was amended and promptly pitched out the window by the courts on the ground it was unconstitutional; it contained no provision for appeal.
The present North Carolina law was passed in 1933. It is a preventive law, nut a punitive measure. In operation it is voluntary, not compulsory.
The law established a state Eugenics Board. The members included the secretary of the State Board of Health, the commissioner of public welfare, the chief medical officers of the State hospitals and the attorney general.
Proceedings are instituted before this board by the heads of the State hospitals and penal institutions or, for those mental cases not in a State institution, by the superintendent of the department of public welfare of the various counties.
The Eugenics Board will order an operation:
1. Where it is to the best interest of the patient, mentally, morally or physically.
2. When the operation is for the public good.
3. Where the operation has been requested by the guardian of a mental case.
4. Where the patient "would be likely, unless operated on, to procreate a child or children who would have a tendency to serious physical, mental or nervous disease or deficiency." (Hemophilia, deaf mutism and hereditary blindness are examples of physical defects which pass by inheritance. Epilepsy is a nervous defect which is passed on by the genes.)
Meeting at least quarterly, the Eugenics Board passes on the cases instituted by the county welfare departments and by the heads of the State hospitals and prisons. Both the patient and his guardian are notified and they may have a say at the hearing.
Where the board orders the operation, the consent of the patient (when he is legally capable) or his guardian is obtained. The board's decision can be appealed to the Superior Court. Because the board selects a case carefully, appeals have been rare. Being voluntary in operation, the North Carolina law can not be attacked on the ground that it is discriminatory.
Although the North Carolina law is a well-drawn piece of legislation, it has not been used widely. As of January 1, 1947, this State had sterilized a total of only 1,827 persons; 1,214 feeble-minded, 385 insane and 228 epileptics and others. This is a 13-year-old total.
During the same period, this state's rate of sterilization on the ground of insanity was only 10 per 100,000. California led all of the states with a rate of 142 per 100,000. The 27-state average was 39 per 100,000.
North Carolina ranked 17th among the 27 states when it came to sterilizing the feeble-minded. The rate for the 13-year period was 32 per 100,000. The 27-state average was 42 feeble-minded persons sterilized for every 100,000 of the population. Delaware led all of the states with a rate of 151.
During 1944, almost 4,000 patients, through death or discharge, left our three mental hospitals. Yet only 79 sterilizations were performed on insane patients during that year.
In 1926, a committee appointed to study the problem of feeble-mindedness in North Carolina in 1926 estimated that we were producing some 1,400 new feeble-minded persons each year. If anything, the estimate should be larger for 1944. Yet in 1944 only 83 feeble-minded persons were sterilized under the state law.
It is a mistake to argue, as some fanatics have done, that unless we launch a vast, mass sterilization program, we will be engulfed in a great wave of insanity and idiocy. On the other hand, it is scarcely any more sensible to turn our back on a tool which has proven value (admittedly limited) in checking a type of birth which is deadly in its unfairness to the parents, to the child and to society.
When you deal with the insane there is a welter of conflicting evidence on the matter of heredity. There are experts who openly question whether heredity is an important factor in explaining the high incidence of some types of insanity in certain families. These men argue that the environment created by the mentally diseased parent is enough to put the children off their mental rockers - especially since these children are likely to have inherited a predisposition to instability. They point out that parents who have one type of insanity not infrequently have children who suffer from another type of mental disorder.
They also argue that any family, even the most superior, likely has some insanity in its background. In the case of the dementia praecox patients (split personality) the disease, most often incurable, begins early in life and is marked by a slow, progressive mental breakdown. The experts who emphasize heredity (rather than environment) cite studies which indicate that one parent suffering from dementia praecox will pass the disease on to 8 or 10% of his children. Of the others, these experts say, roughly 50% will not be affected (though they may be carriers of the fatal genes) and the remaining 40% may show a predisposition towards the disease. Where both parents have dementia praecox, the incidence of the disease among the children is said to be far higher.
With the manic depressives (marked by great swings from hysterical elation to bottomless depression) the incidence of the disease among children appears to be even higher. The men who argue in favor of heredity say that, where one parent is affected, it is likely one third of the children will inherit the defect. Where both parents are manic depressives, the rate is reported to increase to something like 60 or 70%. In 1943, patients suffering from dementia praecox and the manic depressives accounted for 30% of the first admissions in the mental hospitals in the United States.
It is absurd to believe that these two mental diseases can be wiped out by simply sterilizing the hospital cases. For our purposes it is not important whether we accept the arguments of these psychiatrists who believe in heredity or, instead, join forces with the scientists who use environment to explain the peculiar tendency of these disease to crop out in certain families.
The important fact is that there does seem to be a tendency of certain types of insanity to flow among family lines. Whether this is gene-produced or a product of an unhealthy environment is immaterial, If we can curb, even to a limited extent, the spread of these types of mental disorders by the effective use of selective sterilization our failure to do this is not mercy. It represents the sort of brutality which frequently results from teary-eyed sentimentality.
In the case of the feeble-minded the need for a more effective application of selective sterilization is even more apparent.
Oddly enough, sterilization is not ordinarily necessary among the feeblest of the feeble-minded. The great majority of the idiots never mature sexually. To a lesser degree, this is true of the imbeciles. In the case of both the idiots and imbeciles physical abnormalities prevent them from offering particularly stiff competition in the fight for mates. The danger is in the moron group which includes a host of physically attractive individuals whose IQ's are lower than a January thermometer reading. Among other things, they breed like mink.
Family studies (we all remember the Jukes, the Kallikaks and the Nams) indicate that certain types of feeble-mindedness appear to be hereditary. The doctors, providing they have an adequate family history to guide them, can come close to spotting the hereditary types. It is here that selective sterilization, again no cure-all, can be made to pay dividends. One state hospital in California is said to have saved the taxpayers more than $600,000 a year by an effective use of sterilization.
A child born of defective or insane parents has two strikes on him from the beginning. If the child has inherited a predisposition toward the defects or diseases which mar his parents then the mental atmosphere in which he lives serves to fan that smoldering predisposition alive. One defective adult in the family is like a bad apple in a barrel.
A superior child born to mentally inferior parents is as rare as a dodo. To a considerable extent, intelligence is an inherited characteristic. The mental defectives have little to pass on and most of what they do pass on is bad. These people, particularly the morons, tend to marry among themselves. They produce large families which show an abnormal rate of mental deficiency and a general sub-normal IQ. Their children are a burden on themselves, on their parents, and on society.
Sterilization must not be used lightly. It removes forever the possibility of parenthood. But as a technique of preventive medicine it has values which, as yet, we have not begun to realize.
To use selective sterilization effectively requires, above all else, some public understanding of what sterilization is, what it seeks to do, and what in can accomplish.
Backed by an intelligent sort of public support, it is likely that the heads of the State hospitals and the county welfare departments will begin to use the North Carolina law as they have not used it in the past.
The medical profession is awakening to the magnitude of the problem of mental health. More and more doctors, working quietly and with the consent of their patients, are performing sterilizations. Eugenics, for many generations an empiric proceeding in which men bred their best animals because they knew the results were good, is now emerging as an important science. Wake Forest's Bowman Gray School of Medicine was the first medical school in the United States to launch a department of genetics. Some 20 to 25 schools have followed suit.
Swede, the nation which has led the world in the field of eugenics, has profited from detailed, accurate family histories running back 250 years. Working with information of that type, it has been possible for doctors to trace hereditary mental defects and diseases from generation to generation, identifying the carriers and using sterilization in those instances where there is a probability of defective or diseased children, or where the birth of a child will be savagely unfair to the parents of the child.
We do not have records like these in the United States today. We desperately need such records. They are as much a part of an effective sterilization program as the operation itself. It seems likely that the public health services will begin to move into this field before too long.
When William Penn observed "Men are generally more careful of the breed of their horses and dogs than of their children," his readers smiled an nodded, "How true! How true!"
In the past two centuries we have come to learn just how true this observation is. We continue to quote William Penn and nod our heads but we no longer can afford to smile.