To a certain extent the privately managed charitable institutions that the state subsidizes duplicate the services provided by state institutions. This is true in the case of the semi-private asylum at Dixmont, several organizations for combatting tuberculosis, and the institutions for epileptics and the feeble minded. But in these instances the duplication is more apparent than real, since both state and private agencies are not adequate to meet the demands made upon them.

The state institutions are of three classes. In the first class are the asylums for the insane and feeble minded, and the prisons and reformatories. To commit a person to an asylum or to sentence him to prison requires the authority of the state, and that authority is further necessary to restrain, to discipline and to punish criminal offenders. Hence, prisons and reformatories for adults are universally state institutions. *61 In the case of reformatories for children, the same argument applies, but with less force, because these institutions partake largely of the nature of schools and because the guardianship of children is frequently committed to private persons.

61 This includes, of course, county and municipal prisons.

The state is also the logical custodian and guardian of the indigent insane. Here again, restraint and deprivation of liberty are usually necessary. But a more important reason is the indefinite period of care and treatment required. The state is the only agency that can with assurance undertake to provide this in all cases. Finally, the weight of authority now asserts that the indigent insane are likely to receive better care in the larger more elaborate institutions such as the state alone has been able to provide than in smaller local and private asylums. *62 Another class of defectives that requires care and restraint for an indefinite period includes the feeble minded and the epileptics. In the case of these defectives, as in that of those commonly called " insane," the state has a two-fold duty: it is bound by the humanitarian principles for which it stands to alleviate suffering and misery, and it is also bound by principles quite as strong to protect itself.

62 See infra, p. 234. It is not asserted that private asylums, hospitals or sanitoria cannot, or do not provide excellent treatment for all types of mental disease. But these institutions are not usually open to those whose estates or relatives cannot provide ample remuneration. The problem that confronts society is how best to deal with the indigent insane.

That the violent insane should be restrained is a proposition to which all would agree. Public opinion has not as yet, however, given full assent to the equally important proposition that a large proportion of the epileptics and the feeble-minded should be restrained, or at least subjected to custodial care. But such opinion is gaining ground as the heritable character of certain types of feeble-mindedness becomes more fully established. With the growth of the demand for custodial institutional care for a large proportion of the feeble-minded, the state will have a much larger burden of expense to bear. *63 How large an expenditure would be necessary to provide institutional care for this class of defectives cannot at present be estimated since no census of the class has ever been undertaken.

In so far as the state government recognizes responsibility for charitable relief and for correctional institutions, its first duty is to provide reformatories for adults, hospitals and custodial care for the insane, epileptics and feeble-minded, and reformatories and training schools for neglected and delinquent children. These services are vitally important for the entire community, and since no other agency can now be relied upon to undertake the work, the state must do it, if it is to be well done, or, in many cases, at all.

The second class of persons who are likely to require charitable assistance is composed of the sick and mained who, because of their physical disabilities or for other reasons, are unable to pay for treatment. Institutions ministering to this class include hospitals, sanitoria for tuberculosis and homes for those afflicted with disabling, incurable diseases. Institutional and extra-institutional assistance of a permanent or a temporary character is also frequently provided for those who are unable to earn enough to maintain themselves. In general, paupers and indigent cripples and incurables are looked after in Pennsylvania by the local poor authorities. *64 The aged and the incurables are also assisted by private institutions some of which receive state aid. The indigent sick may find free treatment either at the expense of the local governments or in private hospitals. The latter are liberally subsidized by the state.

Moreover, the state supports ten hospitals for persons injured in the coal mines. In 1914 these hospitals reported receipts of $337,662 from state appropriations, and $46,912 from patients and their friends. *65 These hospitals were established because it was asserted that facilities for speedy treatment of those injured in the mines were not adequately provided by private hospitals. The statistics just cited show that in nearly all cases the patients are treated free of charge. The amount appropriated by the state is, however, not large when compared with the total of all its expenditures for charitable relief.

63 One of the principal reasons for confining the feeble-minded in institutions is to prevent them from propagating children, a proportion of whom is likely to inherit some form of insanity or feeble-mindedness. This argument is, of course, strongest in the case of women of child-bearing age.

64 For a statement of the development and present status of poor relief in Pennsylvania, see Heffner's History of Poor Relief Legislation Pennsylvania, 1682-1913.

65 The latter class of payment was presumably for treatment. Board of Public Charities, Report (1914), p. 210.