THE 
FAMILY SYSTEM 
AS AN 
ACCESSORY PROVISIONS 
FOR 
OUR INSANE POOR. 
BY 
HENRY R. STEDMAN, M. D., Boston. 
(BE Pill \ Tier; FROM THE SIXTH ANNUAL REPORT OF THE MASSACHUSETTS BOARD OP 
HEALTH, LUNACY, AND CHARITY.] THE 
FAMILY SYSTEM 
AS AN 
ACCESSORY PRO VISION 
FOR 
OUR INSANE POOR, 
BY 
HENRY R. STEDMAN, M. I)., Boston. 
[REPRINTED FROM THE SIXTH ANNUAL REPORT OF THE MASSACHUSETTS BOARD OF 
HEALTH, LUNACY, AND CHARITY.] THE FAMILY SYSTEM 
AS AX 
ACCESSORY PROVISION FOR OUR INSANE POOR. 
Henry R. Stedman, M.D. 
Among the variety of measures which have been proposed 
for the relief of our dependent insane, and of the Common- 
wealth of the burden which their proper care imposes, is 
one which, except for occasional recommendations by om 
Charitable Boards, has never been strongly advocated in tiiis 
State, and has never met with general favor on the part ot 
alienists at large, especially in this country. 
The measure referred to is a system of boarding-out the 
quiet and harmless insane of the dependent class in private 
dwellings under official supervision, for the double purpose 
of relieving the overcrowded state of our lunatic hospitals 
and of improving at the same time the comfort and well- 
being of these patients. 
While there has been the tendency, incident to the propo- 
sal of all novel beneficent schemes of any importance, to 
seek out and magnify their disadvantages, there has not 
been, regarding this measure, a corresponding inclination to 
investigate its merits. It has therefore happened that it has 
had but little justice done it. 
It is taken for granted that the steady and rapid increase 
in the total number of the insane is generally known, and 4 
that the overcrowding which now exists in all our institu- 
tions devoted to their care is appreciated. All who are 
acquainted with the requirements for meeting this state of 
affairs, are agreed that the relief to he afforded in this 
direction when the Weslborough building is completed will 
be but temporary, as the institutions from which it will 
receive patients will soon be overcrowded again unless 
further precautions are taken. Asylum superintendents 
also recognize the importance of “providing for this 
increase as it occurs,” instead of “ repeating the past history 
of injurious overcrowding for years, and then extravagant 
construction for the great accumulation.”* 
It is not so generally known, however, that there is a 
large proportion of cases, both in and outside of lunatic 
hospitals, who do not require to be cared for in such estab- 
lishments, although still in need of care and supervision. 
These are the demented and maniacal cases, who are quiet 
and harmless, and belong to the chronic class, which forms 
the bulk of the inmates of asylums. The number of these 
patients is not small, as will be seen. If they can be 
adequately and economically provided for outside of estab- 
lishments, it follows that more room and better facilities 
will be obtained for the treatment of curable cases, and others 
in asylums, who are more or less dangerous, destructive and 
offensive, and for whom asylums are necessary. It is the 
object of this paper to show that it is practicable for a large 
number of these harmless incurables to be properly provided 
for in suitable families in this State, under systematic expert 
supervision. 
Dr. Fraser, one of the Deputy Commissioners in Lunacy 
for Scotland, who, with his associate, Dr. Lawson, superin- 
tends the care of over eighteen hundred lunatics in private 
dwellings, in speaking of the imperfect knowledge possessed 
even by most asylum officials of the extent to which adequate 
provision for this class can be made in this manner, says : — 
“Further experience has proved to me, however, that no 
* Vide Annual Report Danvers Lunatic Hospital for 1884, p. 22. 5 
mere discussion of the subject can enable a person to appre- 
ciate the capabilities of this scheme of providing for the 
chronic insane, its present extent, and the good results 
which have been obtained from it. I am also convinced 
that a practical insight into its real nature is necessary to 
all concerned in providing for the insane. As it is out of 
the question for any one who has never inspected or studied 
asylums to speak intelligently of the care and treatment of 
the insane in asylums and the capabilities of such institu- 
tions to fulfil their humane purpose, in like manner it 
cannot be expected that the practicability and the advantage 
of domestic care can ever be properly understood by any one 
who has not carefully observed what is going on in those 
localities in which the system is in active working order. I 
would therefore recommend all interested in the question of 
how the ever-increasing number of chronic lunatics is to be 
provided for, and especially I would recommend medical 
officers of those asylums in which overcrowding is beginning 
to be felt, to make themselves, as far as they have the oppor- 
tunity, practically acquainted with the condition of the 
boarded-out insane.” * The writer, having gone over this 
ground after the manner indicated by Dr. Fraser, ventures to 
describe the system in vogue in Scotland, and after wsyds 
to consider the subject in all its important bearings with 
reference to the feasibility of the adoption of a similar sys- 
tem in this State. 
The Belgian Method inferior to the Scottish. 
Of the two representatives of the boarding-out system — 
viz., the Belgian (at Gheel) and the Scottish — there are 
several objections to the former as a model, beside the fact 
that the Scottish organization appears to possess all the 
advantages of the much-described Belgian colony, with none 
of its drawbacks. Among the considerations which would 
seem likely to discourage any would-be imitators of the 
Belgian settlement, and to deter the introduction of any such 
* Twenty-fourth Annual Report of the Board of Commissioners in Lunacy for 
Scotland, p. 142, 6 
system in this country, are : Its development from a popular 
superstition, and the fact that five centuries elapsed before it 
reached its present proportions and efficiency of management. 
Another objection may well have been raised, that so large a 
single community of insane people, although living in sepa- 
rate dwellings, would tend, by its increase, toward a greater 
aggregation than would be desirable. Another tendency to 
be feared from a single increasing community of this kind in 
a State, is the gradual diminution of interests outside of 
families in the way of employment, and the development of 
a race of mere keepers, so to say, in the place of a commu- 
nity interested in other pursuits as well — a result alike disas- 
trous to patient and guardian. But the weightiest reasons 
for preferring the Scotch to the Belgian method, admirable 
though that is in many respects, are that in race, lan- 
guage, religion, characteristics, habits, and social conditions 
generally, the Scotch more nearly resemble our people. 
Moreover, the methods of providing for certain sane pau- 
pers in families, and the insane poor in asylums and alms- 
houses, are theoretically the same in Massachusetts and in 
Scotland. The latter relations will be found to have 
important bearings. 
Anticipating that the following account of the Scotch sys- 
tem may be objected to as far too detailed for the require- 
ments of our subject, the explanation is offered that the 
opposition to the proposed scheme cannot, to our mind, be 
more effectively met than by demonstrating its successful 
operation in each and every particular in which its failure 
was predicted in Scotland, and is now predicted, if it should 
be adopted in this State. This is especially true of the 
matters of guardianship, supervision and expense. 
Statistics. — The average number of insane persons in 
asylums, lunatic wards of poorhouses, and private dwellings 
throughout Scotland during five years immediately preced- 
ing January 1, 1884, was 9,988. These comprise all luna- 
tics under official cognizance. The average number of pau- 
An Account of the Scotch System. 7 
per patients living with relatives or strangers in private 
dwellings during this period was 1,600. 
Distribution of Boarded-out Insane. — The latter are now 
distributed throughout the entire 33 counties of Scotland 
and the islands of Skye and the Hebrides, in nearly 500 par- 
ishes. The number of patients in each parish varies accord- 
ing to its population, size, and policy of its authorities, as 
well as the advantages possessed for the proper care of this 
class. The counties which have more than 100 lunatics dis- 
tributed throughout their parishes are few. Dr. Fraser indi- 
cates the policy of the Lunacy Board in this direction when 
he says, in referring to the localities which are found to be 
most suitable for boarding-out the insane : “ The people of 
these localities have now, I almost regret to say, become too 
eager for the charge of the chronic insane, and consequently 
the increase in the numbers resident in these places is, per- 
haps, leading to the formation of a larger aggregation than 
is desirable, and it may be soon necessary to do something 
in the direction of dispersing these aggregations.”* The 
diversity of sections to which patients are sent, is worthy of 
mention here, as showing that this class may be properly 
cared for in families, in spite of the fact that the physical 
conditions and social characteristics of the localities in which 
they are situated may vary considerably. Not only in the 
rural districts are these homes found for the insane, but 
many are even boarded-out in the heart of the city of Edin- 
burgh, for example. In certain parishes it has long been 
customary to provide for their chronic insane in families, 
and the benefits of this arrangement being readily recog- 
nized, this arrangement soon causes an increase in the num- 
ber of patients thus provided for. Other parishes have no 
such policy, but allow their insane to accumulate in asy- 
lums ; but the number of such parishes is small and is dimin- 
ishing every year, through the exertions of the Lunacy 
Board, and, more particularly, of its deputy commissioners. 
Recent Increase in Numbers Due to Removals from 
Asylums. —There has been a steady increase in the number 
* Twenty-fifth Annual Report of the Board of Commissioners in Lunacy for Scot- 
land, p. 160. 8 
of patients provided for in private dwellings since 1871, which 
has been particularly rapid during the last four years. This 
has been due, in great measure, to the recognition of the 
merits of this method on the part of medical officers of asylums 
and local inspectors of the poor. An instance of this is the 
fact that, in a single year (1882), 142 patients were removed 
from four overcrowded asylums to private dwellings, 
through the co-operation of the superintendents with those 
in charge of this department. They were induced to do this, 
however, only after having investigated the condition of, and 
the means of caring for, other cases in families. The com- 
bined daily average number of patients in these asylums was 
about 1,120, or several hundreds less than the number resi- 
dent in the two largest lunatic hospitals in this State. 
Account of a Number of Oases Boarded-out from the Fife 
and Kinross Asylum. — In this connection the testimony of 
Dr. Turnbull of the Fife and Kinross Asylum, one of the 
superintendents just referred to, is of decided value. After 
a careful and laborious inquiry into the operation of the 
boarding-out system, including visits to various parishes 
with one of the deputy commissioners, he decided to give it 
a trial, with the hope of relieving for the time, at least, the 
overcrowding at the asylum of which he has charge, and 
which contains about 300 inmates. The following extract 
is taken from a letter received recently : — 
“Since March, 1882, there have been discharged as boarded- 
out patients from this asylum, 23 males and 29 females — total, 52. 
Some of these were taken off our books immediately on leaving 
the asylum, others were on trial by being put on pass or probation 
for a longer or shorter period, but all were finally discharged. Of 
this number four men and five women were afterwards sent back to 
the asylum. The reasons for their return were as follows : — In 
three cases it was due to relapse in the mental condition ; that is, 
they did well for several months, then had an access of excitement 
or of acute symptoms, such as happens often enough among the 
cases that are discharged as recovered, and therefore required 
asylum treatment once more. Another is a congenital imbecile 
who ought not to be in an asylum at all. The failure in his case 9 
is due solely to the fact of the inspector and the guardian not 
doing their duty properly by him. He is in the asylum at present, 
but is to go out again very soon, and will I am sure do quite well 
under proper guardianship. The remaining five are classed as 
unsuitable, and in them the more particular causes of failure are as 
follows : —Two were, from the nature of their delusions and their 
general mental state, restless and noisy, refusing to work, and were 
very difficult to manage without skilled attendants. They were 
therefore bad selections. Another, although generally quiet and 
able to be useful, was of uneven temper, irritable, and inclined to 
strike a more demented case that was boarded in the same house 
with him. Another was sent back because, not being usefully 
occupied, he got into the way of riding tOQ often to and fro on the 
engine of a side-line of railway which passed close beside his 
guardian’s house, a rather dangerous habit in his case. The last 
of the five was a case of chronic dementia in a woman, who so far 
as her own mental condition was concerned was in every respect a 
most suitable case for boarding-out, but she had an indiscreet 
husband who visited her too often in her new home, and she was 
accordingly returned to the asylum to avoid any risks from that 
cause. I fear I have been far too diffuse in enumerating the causes 
of the return of the patients in the different instances, but I 
thought it was perhaps the best way of showing the causes ot 
failure in boarding-out, and the conditions which have to be 
guarded against in selecting cases for the purpose.” 
In the reports of this asylum for the years 1882 and 1883 
he also says of the results of this experiment: 
“ While of unusual service in relieving the pressure on the 
asylum space, the boarding-out system lias also advantages from 
an economic point of view ; . . . . with our present rate of board 
the expense to the parish of boarding-out a lunatic is on the aver- 
age considerably less than that incurred by keeping him in the 
asylum.” .... 
“It is by the removal of these [boarded-out] cases that the 
tendency to accumulate in the asylum can best be combatted 
.... and further experience has confirmed my belief in tlie 
great utility of this system. In the great majority of the cases 
the results are ver}r gratifying In nearly all of them 
the care and guardianship were satisfactory, and when such was 
not the case steps were taken for removal to other guardianship. 10 
In a large number of cases the change of surroundings and mode 
of life with the consequent individualization has had a distinctly 
beneficial effect on the mental condition.” 
Patients from Other Sources. — But it is not alone from 
asylums that insane patients are drawn. A large proportion 
of them have never been committed to any institution, and 
have never required asylum treatment. For example, harm- 
less imbeciles who, from their mental condition and poverty 
in their own families, might, if left to themselves, suffer 
exposure and annoyances, are placed in the homes and 
under the care of guardians of their own social condition, 
who are selected or approved by the Board of Commissioners 
in Lunacy, and come under its supervision. 
Character of Cases Boarded-out.—The kind of cases 
selected for boarding-out are the chronic harmless maniacs 
or dements, and idiots and imbeciles ; and an experience of 
many years shows that these classes are not only best 
adapted for this method of treatment, but in reality that 
they need no other. Of late years the number of cases 
of acquired insanity in private dwellings has considerably 
increased, owing to the discharge of chronic lunatics from 
asylums in greater numbers. 
Availability of Guardians. — The selection of suitable 
guardians, an element of the utmost importance, is now 
a matter of little difficulty. In the first place the people 
are said to have overcome in great measure their distrust 
of the insane, so much so that it is sufficient for a single 
patient to be boarded out in a district to conquer the disin- 
clination to take lunatics under their roofs, and in fact the 
inconveniences which were anticipated are not realized. 
During a visit made b}r the writer to Gartmore, one of these 
parishes, the eagerness of the cotters to obtain patients for 
care was very apparent. Several of the guardians followed 
us to the door to beg the Deputy Commissioner to send them 
another patient, or to prefer the request of some less fortu- 
nate neighbor. In some quarters the reaction in the feeling 
of the inhabitants has been so general that the demand for 11 
lunatic boarders far exceeds the supply. So much for the 
willingness of the residents to receive such boarders. 
As to the proportion of suitable guardians to be found 
among so many applicants, it is enough to mention the ex- 
perience of the inspector of the poor of the city of Edin- 
burgh, according to whom the difficulty lies in supplying 
applicants with suitable patients. He has no difficulty in 
finding suitable persons as guardians, for these come to him 
without seeking. Those whom we had an opportunity of 
seeing evinced great interest in their charges. Their care 
of the patients also seemed to be kindly and intelligent, and 
the patients themselves, in many cases, showed marked 
fondness.for their guardians. 
In most of the houses the insane are cared for by the 
“ gudewife.” This arrangement allows the head of the 
family to keep at his work, and as the majority of these 
patients have no harmful propensities, and many of them 
are aged, not to mention a number who are able to earn 
their living, this division of labor is beneficial in every 
way. 
The majority of the insane in private dwellings reside 
with strangers, and although the attempt is generally made 
to place them with relatives or friends, only a small propor- 
tion are so provided for. It is found where patients have 
long been inmates of asylums that the family tie has been 
broken in the interim, owing, perhaps, to the death of kins- 
folk, poverty, indifference or family quarrels. These patients 
are subject to supervision as well as those who are boarded 
with strangers, but the allowance to the family from the 
parish or from government is restricted to an amount suffi- 
cient to save them-from any loss on the patients’ account. 
Precautions against Pecuniary Gain at the Expense of the 
Patient. — It is hardly necessary to say that only by regular 
supervision, reinforced by the power to enforce the neces- 
sary requirements, that abuses, indifference or neglect on 
the part of the guardians can be prevented. In order, how- 
ever, that the guardian may be less likely to be governed by 
motives of pecuniary gain, it is found best to make it a 12 
requisite for the position that he or she shall be on the same 
social level as the patient. By so doing the patient is more 
readily and completely taken into the family, and becomes 
an object of general interest, care, guidance and watchful- 
ness. This would not be encouraged by a guardian of a 
higher or lower social standing than that of the patient. 
Surroundings of these Patients.—The surroundings of 
the patients in these houses are rude in the extreme, as 
might be expected among a class of people Avhose thrift con- 
sists in living comfortably and decently with what, to the 
visitor, seems the smallest allowance of the necessities. 
To cite again the parish of Gartmore, a fair sample of such 
settlements, there was every evidence during our visit of 
the closest husbandry of small resources, the most meagre 
quarters, a scanty hoard of the most primitive appliances, 
and yet an absence of squalor, and no lack of such comforts 
for sane and insane as are deemed sufficient by that order of 
people and are so. 
The town, if it may be called one, consists chiefly of a 
long, straggling street of one-story houses, containing, 
from two to three hundred people, and placed at the foot 
of the Grampians* far away from the city of Glasgow, the 
former home of most of these patients. The twenty-nine insane 
persons cared for here in the cotters’ homes bore the aspect 
of content and good health, and participated, to a consider- 
able extent, in the family matters. One melancholy patient, 
removed not long before from an asylum, was devoting her- 
self to a child of her guardian, and manifesting a growing 
interest in her new life. A male patient proudly showed 
the Deputy Commissioner his earnings. Four demented 
women were seated at a table quietly enjoying, with the 
“gudewife,” a simple but substantial and hot dinner, etc., 
etc. The absence of appeals and complaints, so apt to be 
made to officials on a protracted visit among the insane, was 
conspicuous. 
Capacity of the Patients for Usefulness.—The usefulness 
of these patients as a whole is considerable, and is turned 
to good account by all concerned, patient, guardian and 13 
ratepayer, the amount allowed for their support by parlia- 
ment or the parish being regulated by their ability to aid in 
the work of the household or farm, and thus the burden 
of maintenance to the parish is lessened, the guardian has 
an extra “ hand,” and the patient enjoys the increased con- 
sideration of the family. The Commissioners’ report for 
1882 states, under this head, the opinion of Dr. Fraser, as 
follows : — 
“It is common in my experience to note an increase of useful- 
ness among chronic lunatics after the)' have been placed in private 
dwellings. The various duties of home life, the emergencies which 
are apt to arise in a household, and the different interests which a 
piece of land and all its gear possess, tend to wake up such capac- 
ity for work and usefulness as exists, and often produces a desiie 
to help even in the most apathetic and demented.” 
Standard of Health Maintained. — The statistics of phy- 
sical health and mortality are instructive, and speak well for 
the judgment of those engaged in selecting the patients for 
this method of treatment. In the year 1882, out of 758, or 
about one-half of all the boarded-out insane, 79.1) per cent. 
w7ere reported as in good bodily condition, while a little 
under 50 per cent, of the 92 patients above 70 years of age 
were enjoying fair health. 
Hale of Mortality. — The average mortality of the entire 
number for a period of three years was 5.1 per cent., as 
against an average of 8.2 per cent, in asylums ; and the sig- 
nificant fact also appears, that the percentage of deaths from 
pulmonary consumption was 5.6 in private dwellings, as 
against 17.2 in asylums. Moreover, although the average 
number of these patients for this period has been 1,592, no 
suicides and but two accidental deaths have occurred. 
Cost of Maintenance. — The cost of maintaining pauper 
lunatics in private dwellings in Scotland varies greatly ac- 
cording to the locality, the average weekly cost per capita 
ranging in 1883 from 85 cents to $1.60. The computed 
average cost for maintenance in asylums was $2.35 ; in pri- 
vate dwellings, $1.33. This expense, as well as that for 14 
clothes, is met in part from the local poor-rates, but largely 
from a parliamentary appropriation, and is regulated by 
the Board of Lunacy in each case. From the time the 
guardian who receives a patient under his roof applies for 
permission to do so, he is under supervision of the Board 
through one of the deputy commissioners, who, after a pro- 
visional sanction has been granted the guardian, makes a 
preliminary visit, reports to the Board as to the suitability 
of such provision, and afterwards includes him or her, if 
favorably reported upon, in his regular visits of inspection. 
Penalties and Precautions against Neglect of the Pa- 
tient. — Should a local poor-board be negligent, the Lunacy 
Board may compel those authorities to increase the amount 
of payment to the guardian, in case the unsuitability be due 
to parsimoniousness on their part. Moreover, unless the 
patient be comfortably clothed, housed and fed, treated in 
every way as well as the other members of the household, 
and receive such personal care and attendance as will insure 
their comfort and safety, the Board may and does withhold 
the parliamentary grant or appropriation by which the par- 
ishes are aided in supporting the patients. A threat of the 
latter procedure is usually sufficient to insure proper atten- 
tion to the requirements of the Board. As a final resource, 
the Board may direct the removal of any of these patients 
to an asylum, when it becomes evident to them that their 
condition demands it. 
With these penalties as safeguards, and through the care- 
ful supervision to which the guardians are subject, as will be 
shown presently, the opportunity for financial gain at the 
expense of the comfort of the patient would seem to be 
small, and facts might be furnished, would space allow, to 
show that it is so in effect. 
Considerations determining Rate of Board. — The consid- 
erations which fix the rate of board in each case are various 
and refer to “(1) the obligation resting on the guardian to 
maintain the patient; (2) the ability of the patient to do 
useful work; (3) the necessity for providing special diet or 
nursing the patient; (4) the irksomeness of the duties which 15 
the guardian may have to perform; (5) the extent to which 
the patient may interfere with the industrial productiveness 
of the guardian’s household, and (6) the usual cost of living 
of the working classes in the district in which the guardian 
lives.” * 
The Economy of the Method.—An illustration of the 
economy of this method of providing for the chronic insane 
is furnished by a return from the city parish of Edinburgh, in 
which it appears that the average cost, inclusive of supervi- 
sion and every other item of expenditure for the insane 
boarded with strangers, is, in round numbers, $95 per year. 
The asylum rate during the preceding five years was $135 
per year, so the saving during these years was $40 per year 
on each of the thirty-six patients, or a sum of more than 
$8,000 in the expenditure of this parish in the course of five 
years. 
Method of Supervision, Visitation, etc. —As to the vital 
requisite of such a system, adequate supervision, the facts 
are, in brief, as follows : Eveiy pauper and private patient 
is boarded o,ut only upon a permit from the Board, granted 
on two medical certificates of lunacy which also certify that 
the condition of the patient and surroundings generally are 
such as to ensure proper care and treatment in a private 
dwelling. This permit is provisional, and becomes invalid if 
the Deputy Commissioner finds the patient’s condition unsat- 
isfactory and no improvement seems probable. The number 
of patients who can be legally received into a single house is 
but one, unless the occupier holds a special license from the 
Board, in which case four is the limit allowed. It is seldom, 
however, that more than two are thus provided for, usually 
only one. 
The duty of superintending the condition of these patients is 
mainly confided by the Board of Commissioners in Lunacy to 
the two Deputy Commissioners (not members of the Board), 
who receive salaries of £600 each. These gentlemen are 
physicians trained in the specialty of mental disease, and were 
* Twenty-fifth Report of the Board of Commissioners in Lunacy for Scotland, p. 
xxxviii. 16 
formerly successful superintendents of important asylums. 
These officials visit each patient under their charge once a 
year, although their visits to special cases are much more fre- 
quent. Moreover it has become a practice of the Deputy 
Commissioner to visit various asylums where the greatest 
need of room is felt, and to select, with the superintendent’s 
advice and assistance, suitable cases for boarding out. 
In addition to the inspection by the Deputy Commissioner, 
at least four visits a year must also be made by a medical 
man, appointed for that purpose by the parochial Board of 
the parish to which the lunatic is chargeable. It is also his 
duty at every visit to enter in a “ Visiting Book for Pauper 
Patients in Private Dwellings,” prescribed by the Lunacy 
Board and kept in every such house, a report of the condition 
of the patient, and any suggestions he may deem necessary. 
Still further supervision is exercised by the inspectors of 
the poor, who are obliged to visit, at least twice a year, every 
patient in their respective parishes where they hold office, 
and to record their visits in the book just mentioned. 
Unsatisfactory Cases.—It is acknowledged there are a 
number of such cases who are not satisfactorily cared for in 
this manner, but they are thought to be growing fewer, and 
the last report of the Board states that the improvement of 
their condition in general is steadily progressive, and is con- 
sidered to be quite abreast of what is taking place in the care 
and treatment of the insane in the asylums. 
Indications of the Success of this System in Scotland. — 
Before leaving this part of the subject, attention is called 
to the facts which indicate the success of the Scotch system, 
viz. : The large increase in the number of licensed houses, 
the evident content of the patients, and finally the growing 
sentiment among asylum physicians favorable to this mode of 
treatment, and the efforts now being made on all sides to 
take advantage of it. 
Dr. Clouston’s Views.—The eminent alienist, Dr. Clous- 
ton, superintendent of the foremost asylum in Scotland, who 
was, at one time, hardly to be counted among the advocates 
of the system, says, in a letter just received : — 17 
“ One of the parishes in Edinburgh has about one-fourth of all 
its insane boarded out with benefit to the patients and to the rate- 
pa}rers. When the disease is acute, the patients are sent here. 
As they become quiet and chronic I select them and send their 
names to the Inspector of Poor, who finds suitable guardians. 
Some of those I select are sent back to the asylum, but no great 
harm is done. Of late years, since it (the boarding-out 
system) was better understood, better organized and better super- 
vised, the results have been good on the whole, and very good in 
some cases. Money has been saved, the patients have been suffi- 
ciently well cared for, and in many cases made happier, and asy- 
lums have been relieved from overcrowding, prevented from grow- 
ing unmanageable in size, and have been left more to their proper 
work of treating the curable and recent cases. The rich, quiet 
insane have always been boarded out largely here and elsewhere. 
Why should not the poor have the same chance? I cannot imag- 
ine any country where a certain proportion and a certain kind of 
chronic and quiet lunatics and imbeciles should not be boarded 
out in private houses. Asylum life is, at best, an unnatural and 
an expensive thing, and, in my opinion, its undoubted benefits to 
most cases of insanity do not apply to certain of the more quiet 
and manageable patients.” 
English Opinion of the System. —Further evidence of the 
success of the Scotch in this direction is found in the opinion 
in which their organization is held by some of their brother 
alienists in England. A reviewer in a recent number of the 
“ Journal of Mental Science,” in the course of a criticism 
of this feature of the Scottish lunacy administration, makes 
reference to the Parliamentary Grant before mentioned, and 
its beneficial influence in helping to maintain the boarded- 
out cases, while in England only the patients in asylums 
profit by it. This difference is thought to result in a very 
obvious benefit to the rate-payers in Scotland and, probably, 
advantage to a certain class of patients, and the conclusion 
is reached that it is difficult to suggest any very practical 
objection to the extension of the Scotch system to England. 
This is also a fitting place to refer to an objection which is 
sometimes made to the adoption of the boarding-out system 18 
for the insane elsewhere, viz. : That it has been tried in 
England, and found to be impracticable, and of doubtful 
advantage to the patients. If the preceding criticism of the 
plan is not a sufficient answer, one may be found in the fact 
that pauper patients in private dwellings do not appear on the 
registers of the English Board of Lunacy, that there is no 
direct supervision of them by the commissioners, and that 
the visitation of them does not fall within their duties. There 
is, consequently, no system in selecting guardians to take 
care of boarded-out cases, and no proper oversight of them 
after they are boarded out. It seems needless, therefore, 
in the face of these facts, to claim that any “ system” of the 
sort has yet been developed in England. 
Consideration of the Chief Objections to the 
System. 
The objections to the method are of two kinds: — 
I. General ones, condemning its employment under any 
circumstances. 
2. Those referring only to its applicability to this 
State. 
The more important of these will be considered, although 
some are included which may seem trivial, except, perhaps, to 
the general public, who would justly require to be satisfied 
of the merits of any scheme which so closely concerns them, 
and without whose sympathy and assistance little can be 
achieved. 
The Effect on the Families Themselves. — The success of 
such a course has been doubted by some on the ground 
of its bad influence on the families themselves in which 
these patients are placed. It is admitted that in some 
instances the arrangement is of mutual benefit; but it is 19 
thought that in the majority of cases it may be of more 
than dubious advantage to the family, whatever it may be 
to the patient and the taxpayers. Without discussing this 
question in its wider aspects as a social and philosophical 
problem, but applying the test of practice, analogy and 
every-day experience, it will, I think, be seen that the 
grounds for any such misgivings are more apparent than 
real. 
In the first place, patients with tendencies of obviously 
harmful nature are, or should be, sent to asylums. Cases 
of idiocy and dementia, also, of very repulsive habits and ap- 
pearance, and who are included among those known in asy- 
lum parlance as “harmless,” are, nevertheless, plainly unfit 
for family life. Moreover, the interest and solicitude, per- 
haps also the self-sacrifice and pride, which the care of suita- 
ble patients may awaken in a household, whether the interest 
be due to kindly or pecuniary motives, are certainly bene- 
ficial influences, and would seem to more than counteract any 
demoralizing tendencies springing from the insanity of the 
patient. 
Again, the practice of placing in families sane dependents 
among whom are depraved vicious children, “juvenile 
offenders,” and female convicts, has long been extensively 
employed. Such inmates of a household surely might have 
a bad effect on it, if any ; but it has been found to be inap- 
preciable. 
Finally, Dr. Lawson’s opinion, drawn from an oversight 
of about eight hundred patients so situated, is as follows. 
He says : — 
“ While in some cases the question of the effect upon the fami- 
lies themselves may be regarded as an open one, there can, I 
think, be little doubt that, in the majorit}7 of cases in which insane 
persons are neither dangerous nor of indecent tendencies, their 
presence amongst sane associates is either productive of no harm 
or is actually beneficial.” 
Danger of Neglect or Abuse of Patients. — This objec- 
tion is due in great measure to reports of occasional cases 20 
of extreme neglect or other ill-treatment of insane persons 
at home by their relatives. In their ignorance perhaps, 
they conceal and shamefully neglect or even abuse these 
unfortunates, rather than endure the supposed stigma of hav- 
ing an insane relative.in an asylum, or in order to keep the 
patient from asylum treatment and its imagined cruelties, or 
from various other motives. Such wrongs (which occur for 
want of official oversight) naturally create a sensation and 
excite just indignation. On the other hand, properly treated 
cases, which might illustrate the advantages of domestic care, 
seldom come to the surface, from a desire of concealment on 
the part of relatives, etc. Thus it happens that a calm ex- 
amination of the value of domestic care and its humanizing 
influences is sometimes set aside, the possibility of utilizing 
these advantages under a system of official supervision is 
scouted, and the unwarrantable conclusion is reached that a 
reckless abandonment of the insane to private care is advo- 
cated. 
To the second class of objections belong the following : — 
The Difference between Scotland and this State in Social 
Conditions and Methods of Lunacy Administration. —Most 
of the arguments advanced against the project under con- 
sideration refer solely to its applicability to our own in- 
stitutions. By far the strongest of these relate to the 
differences in social conditions, national characteristics, and 
method of lunacy administration. Any one who has closely 
investigated the subject will admit that the respectable fami- 
lies among our poorer class of working people, in which 
might be found the best guardians for such cases, are too 
well-to-do to be influenced by the pittance from the Govern- 
ment, which is a considerable assistance to the Scotchman in 
like station. The latter has long been inured to laboring 
hard for small results, and cannot afford to neglect any op- 
portunity for gain. Moreover, it often happens that his 
position, as a paid guardian, raises him in social importance 
among his neighbors. For the American, however, other 21 
and more congenial employment is more available, and fear 
of losing caste with his neighbors is a more potent influence 
in the other direction. Again, the rigor of class distinctions 
in Great Britain tends to keep the lower orders as a class at 
one level of life, causing their occupations to change vastly 
less than with us, and their ambitions to be fewer. Conse- 
quently a family system of the kind advocated would seem 
more likely to have stability and to flourish in such a soil than 
when planted among a more shifting and restless people, who 
are less content with a little. These views seem, in theory, 
unassailable. As a matter of fact, however, sane dependents, 
as we have just indicated, have long been “placed out” in 
families in this and other States, and in countries differing 
widely in the characteristics alluded to. The recompense to 
the guardian has often been surprisingly small, and the care 
of many of their charges has been trying in the extreme. 
Nevertheless, this method has proved so advantageous that 
it is being daily more and more fully acted upon. Again, it 
seems probable that guardians receiving into their families 
young women who have been “ placed out” from a reforma- 
tory prison would not be less likely to suffer in their neigh- 
bors’ good opinion than others taking charge of boarded-out 
patients from an asylum. 
With regard to the methods of lunacy administration em- 
ployed in the two countries, it may be said that it is chiefly 
the difference between wise and imperfect legislation that 
places the condition of the insane in private dwellings in 
Scotland far in advance of that of the same class in England. 
So also in Massachusetts, judicious legislation is vital to the 
success of our scheme, and should be joined to competent 
and thorough management from the outset of its establish- 
ment. 
Number of Cases Likely to be Small and Room for 
Improvement Slight. — There is every variety of opinion 
as to the number of insane persons available for this kind 
of care. The view of the Illinois Board of Commissioners, 
as expressed in their last Report, is that the number of 
insane people in that State who might be properly cared 22 
for in private dwellings is comparatively small. The cases 
referred to, however, are those whose condition would allow 
them to be taken into families without systematic official 
supervision. The legislature is warned of the danger of 
“ leaving the insane to the uncontrolled and often misdi- 
rected impulses and ideas of their friends.” Under such 
conditions the number boarded out would necessarily be 
small. Dr. Quinby, of the Worcester Asylum, in a recent 
paper devoted to a careful consideration of the best methods 
of providing for our chronic insane, disapproves of the sys- 
tem here proposed, advancing, among other reasons, the 
opinion that, although “ it would not be very difficult to find 
places in desirable families [in this State] for a certain 
limited number of quiet, cleanly dements, capable of par- 
tially paying for their support by their labor, such patients 
could not,” he thinks, “well be spared from the hospital, 
for they contribute largely toward reimbursing the State for 
their support by the work which they perform; while, on 
the other hand, their condition would not be materially 
improved by the proposed change, as most such inmates 
of our hospitals are but little restricted in personal liberty.” 
Dr. Goldsmith, of the Danvers Hospital, on the other hand, 
in the Report of that Institution for 1884, advocates a 
system of boarding-out certain of the insane, and he thinks 
that “in a few years several hundred would be found thus 
cared for economically on the part of the State and com- 
fortably for themselves, if the cases should be carefully 
selected and the system judiciously pushed.” The class of 
patients he would select would be chiefly women, and pref- 
erably those who, being advanced in years, would probably 
be kept nearer their home by their physical infirmity. He 
also considers it probable that the practice would spread 
from family to family. 
This element of elasticity is one of the great advantages 
of such a system, as will be seen. 
Three hundred and eighty inmates of the Taunton Lunatic 
Hospital, 150 at Worcester, 100 at Danvers and 89 at North- 
ampton, a total of 719 in a combined hospital population of 23 
about 2,575, are considered “harmless” by the superin- 
tendents of those institutions. The number of quiet, cleanly 
demented patients in these hospitals, whose liberty is but 
little restricted, and who do what might be called remunera- 
tive work for those institutions, is quite small. Conse- 
quently, leaving such patients out of the category, it is 
reasonable to suppose that among the entire number (3,250) 
of the insane inmates of the establishments in our State, 
500 or 600 suitable cases might be found among, we will say, 
900 of the harmless, chronic patients, who would answer the 
requirements of such a provision. 
However much acute insanity may vary in different coun- 
tries in the activity of its symptoms, the chronic insane are 
pretty much the same everywhere. At all events, the char- 
acteristics of the chronic lunatics seen by us at the Fife and 
Kinross Asylum, and afterwards successfully boarded out, as 
before mentioned, differed in no respect from the class 
designated “harmless” who are now at the Danvers Hos- 
pital in this State. 
A further contingent ought justly to be furnished from 
among the insane in certain of our city and town almshouses, 
in some of which they are subject to the evils of overcrowd- 
ing, or suffer serious discomfort, to say the least, owing to 
the ignorance of the superintendents of the requirements of 
the insane. 
.Nor should the possibility of improving by this means the 
condition of this class of the insane be ignored. Any 
radical change is of course out of the question, but there can 
be no doubt that domestic treatment frequently results in 
increased intelligence, usefulness and bodily health through 
the individualization which it makes possible. The fact that 
more “attendant-power,” as it has been aptly termed, is 
available in private dwellings than in asylums, would lead 
one to expect better results in the former. Thus, instead 
of thirty or forty patients, under the care of two or three 
attendants, as is the case in many of our asylum wards, 
single patients in private dwellings would each be under the charge of one or more members of the household, and among 
vastly more natural surroundings. 
The Impossibility of Obtaining Suitable Guardians. — 
This has been found to be the main argument against the 
movement in whatever country or locality it has been 
attempted. In practice it has been found to be a groundless 
objection. As might reasonably be expected, the introduc- 
tion of a few quiet and but little objectionable insane patients 
into families in any well-selected locality, is not a difficult mat- 
ter, and this footing, once gained, has opened the way for a few 
others demanding more attention. The popular distrust, 
which is due to ignorant fear of the insane, is soon dispelled 
by slight acquaintance with the disposition and conduct of a 
class of the insane in whom loss of mental and bodily activity 
are leading characteristics. Although there is little enough 
to attract one in such cases, it is a mistake to give the im- 
pression, as do some objectors, that patients of this class 
retain enough mental vigor “to call forth the exercise of 
most if not all of the Christian virtues.” This criticism 
should be applied to asylum cases only. 
The Large Amount of Supervision Required.—Those 
who are only acquainted with the oversight and care of the 
insane as it exists in asylums, tind it difficult to understand 
how anything short of an equally large amount of supervision 
and the most unremitting vigilance can ensure the well- 
being of insane people in private dwellings. With a full 
appreciation of the value of careful supervision, and realizing 
that the success of any such organization as the one proposed 
would largely turn upon the efficiency of this part of its 
mechanism, it is yet conceivable that there is danger of over- 
doing in this direction from an exaggerated idea of the 
requirements of this class of patients. The endeavor should 
be to resist the tendency that is shown in this demand for 
constant and rigorous inspection to gradually introduce the 
wholly official administration, of which the asylum is the 
type, in the place of a domestic administration officially 
supervised, which is the essential merit of private-dwelling 25 
care. The object of the latter is to have the patient received 
into a family on as nearly equal terms as his or her condition 
will allow, to share, as far as possible, in the domestic inter- 
ests and comforts. This end would be defeated, should the 
guardian and charge come to occupy merely the positions of 
attendant and patient, as in asylums. Consequently, it 
would seem that the interests of such patients might be suffi- 
ciently guarded by a system of central and local visitation, 
through which the condition of each one of them should be 
inspected once a month, and oftener in cases demanding 
special attention. 
Undue Expense to the State.—Unless the public and its 
representatives can be convinced that any proposal for pro- 
viding for its insane will not involve great expense, it wovdd 
be folly to advocate it. The day of costly establishments has 
passed, and lavish outlay in that direction has not been found 
productive of the hoped-for results to the patient, while the 
effect upon the community has been to arouse distrust, and 
to bring more strongly to the front purely economical con- 
siderations. In the matter under consideration, indications 
point to a decided saving in the cost of the support of the 
State’s insane, should such a system be adopted. The 
expense of supporting the boarding-out insane in Scotland, 
is, in itself, no criterion ; but some idea of the probable cost 
in this State may be obtained by comparing the rate, per 
capita, of patients in asylums and of those in private dwell- 
ings in that country. The average yearly cost will then be 
found to average, at the least, a third less in favor of the latter- 
class. Why, in this State, the weekly rate for boarded-out 
patients should be higher than that which the towns are 
obliged to pay for their charges in asylums ($3.25), remains 
unexplained. 
Possibly at the outset a larger allowance might be necessary 
in order to overcome the prejudice which might arise against 
caring for the insane in this way. It may, however, be pre- 
dicted with confidence that the ease of dealing with them 
would, before long, become generally recognized. In this 26 
case, it is probable, in view of what has been stated, especially 
with regard to the character of many other dependents now 
boarded out in the State, that suitable guardians might be 
found to whom three dollars a week for each patient would 
be an object, especially where it should be found expedient 
to board two patients in one family. 
By far the greatest financial advantage to the State, and it 
is one that is generally recognized, lies in the fact that no 
expense in the way of construction would be necessary by 
this method of provision. Moreover, a successful organiza- 
tion of this kind would result in postponing the erection of 
additional buildings, a step which seems inevitable from the 
rapid accumulation of insane persons in the State. This re- 
sult might be expected from a system by which the quiet and 
harmless insane may be, at the time such change becomes 
necessary, taken from overcrowded asylums and distributed 
throughout the State in families. In other words, it is an 
institution of unlimited capacity in its particular direction if 
rightly conducted. 
Further Evidence in the Condition of Certain De- 
partments of Our State Charities of the Feasi- 
bility of Adopting this System. 
If in spite of the foregoing facts and opinions the system 
should still fail to recommend itself, the success of certain 
organized methods of charitable administration which are 
in operation in this State ought to have great weight, with the 
most sceptical, in its favor, for the reasons which will appear. 
In its Second Annual Report the Board of Charities of this 
State, through its Chairman, the late Dr. Samuel G. Howe, 
made an earnest and forcible plea for the separation and dif- 
fusion of the dependent classes of the State Institutions, and 
advocated, among other remedial agencies, the use of the 
family for this purpose. 
Youthful offenders in the Industrial School and Reforma- 
tories, dependent children in almshouses, and harmless in- 
curables in asylums, were alike suggested as proper subjects 
for family care. The success, also, of any such undertaking 27 
was predicted on the ground that it was based on natural 
principles. Since that time, nearly twenty years ago, this 
means of provision for the sane dependents above mentioned 
has been adopted, and the practice of placing in families these 
children and youths, of ages varying from three to eighteen 
years, has become most extensive. So far, therefore, as the 
sane poor are concerned the prediction may be said to have 
been fulfilled, as the plan has been found to be highly advan- 
tageous to the dependent and the State. On the other hand, 
the proposal then made for a similar disposal of the harmless 
insane has met with little or no encouragement. The reason 
for this, it will be said, lies in the want of parallelism be- 
tween poor children and poor lunatics as to their care and 
treatment. Let us see if this argument is well grounded in 
fact. In the following year the same Board called attention 
to the exertions being made by the Commissioners of Lunacy 
in Scotland toward boarding out the insane, and the probable 
success of the scheme in prospect. It has been shown how 
widely that practice has since been extended in that country 
and how thoroughly have been realized the expectations con- 
cerning it. Now it is a well-established fact that for more 
than thirty years previously the boarding out of pauper 
children of the lowest classes had been customary in Scot- 
land and that it led to a trial of a similar procedure, by cer- 
tain inspectors of the poor, with quiet and harmless lunatics. 
This experiment proved satisfactory ; the organization became 
more and more extensive and efficiently administered, until 
now it is a most valuable adjunct. Here, therefore, is a case 
in point of the rise of a system of boarding out the insane 
from a similar method of dealing with sane paupers. 
Method of Administration. 
Considering it now established that the conditions are 
favorable for the initiation of our scheme, there remains to 
be discussed the means by which the system may be suc- 
cessfully administered. Any recommendations giving all 
the details of legislation and administration necessary to its 
furtherance would be of little value, as the various minor 28 
complications likely to arise touching legal enactments and 
prevailing methods of management in different departments 
cannot be foreseen. The main requirements, however, in 
these directions are, first, that such a system should be con- 
trolled by the Central Board; and secondly, that it should 
be under expert supervision. This is indispensable. To 
be more explicit, the supervision should be intrusted to one 
or more physicians skilled in dealing with the insane, and 
practically acquainted with their requirements. The reason 
for this will be obvious when we recall the early experi- 
ence at Gheel, and many other places, wdiere the attempt 
has been made to care for the chronic insane without that 
precaution. In Gheel, abuses were rife until the colony was 
placed under systematic medical and expert supervision. 
Then, only, did it begin to properly serve its useful pur- 
pose in the novel manner which made it famous. Again, 
the care of the insane in almshouses throughout this 
country has been a chapter of evils, from first to last, 
wherever it has lacked expert oversight. Further explana- 
tion of the necessity of this safeguard would be superfluous, 
although the reasons for it are numerous and weighty. 
Iii addition to the direction of the organization through ex- 
pert agency under the control of the central Board, regular, 
local visitation by a medical practitioner, living near each col- 
lection of cases, would be of great advantage for obvious 
reasons. Other visits could be entrusted to reliable non- 
professional individuals willing to engage in such work, or, 
where practicable, to local overseers of the poor. As a final 
requisite the Board should have, beside the necessary appro- 
priation for the provision proposed, the aid of statutory enact- 
ments in enforcing its requirements. These might take the 
form of penalties in the way of withdrawing pecuniary aid 
from those in charge of patients, and of removing the latter 
to asylums. 29 
Summary and Conclusions. 
It follows from the foregoing observations, especially in 
view of the great need that exists of additional provision for 
the chronic insane poor of the State in lunatic hospitals, 
that:— 
1. A large proportion of these patients do not require 
asylum treatment, who, nevertheless, cannot for various 
reasons be suitably provided for among their relatives or 
friends. 
2. Experience, both in this country and abroad, justifies 
the belief that suitable families can be found in this State to 
undertake the care of these cases. 
3. If placed in these families under systematic expert 
supervision and regular and competent visitation, these 
patients would be more comfortable than they now are ; those 
who need it most could receive more effective treatment in 
the lunatic hospitals ; and the expense to the State and the 
towns for the harmless insane would be considerably 
lessened. 
Finally, the early adoption, on a small scale, of the method 
proposed is earnestly advised, trusting to judicious manage- 
ment for its rapid extension.