THE FAMILY SYSTEM 
IN PRACTICE. 
A Keport of the Condition of the 
“ Boarded-out ” Insane in 
Massachusetts. 
BY / 
Henry R. Stedman, M. D. 
§frgrintei> 
FROM 
THE TENTH ANNUAL REPORT OP THE 
STATE BOARD OF LUNACY 
AND CHARITY. THE FAMILY SYSTEM IN PEACTICE. 
By HENRY R. STEDMAN, M.D. A REPORT OF THE CONDITION 
or THE 
“ Boakded-out Insane” in Massachusetts. 
Henry R. Stedman, M.D. 
In this paper is presented, as the result of my personal 
inspection of the “ boarded-out” insane under the supervision 
of the State Board of Lunacy and Charity, an account of 
the condition and care of these patients, and the character of 
their surroundings in the different families to which they are 
assigned. As the mere record of a single tour of inspection, 
however detailed, would leave untouched many important 
questions relative to this method of caring for the insane, I 
have added a consideration of other influences which affect, 
favorably or adversely, the successful operation of this system 
in Massachusetts. Recommendations, made with a view 
to securing the full advantages of the system and giving it a 
thorough trial, are also offered, in order that the welfare may 
thereby be promoted, so far as is compatible with the 
best interests of the State, of all patients who are suitable 
cases for such care. The experience of other countries 
in this direction is purposely not considered in this 
paper, and theoretical views are largely avoided.* The 
observations and conclusions reached are drawn, with the 
exception of certain statistics, solely from personal investiga- 
tion, on the spot, of the operation of this system in Massachu- 
setts after a trial of more than three years. Among the 
number of patients whose condition is to be reported upon 
are not included a group previously visited, as a matter of per- 
sonal interest, in Tewksbury, who have since been returned, 
together with thirty others, to the insane department of the 
Tewksbury Almshouse, as patients who did not properly come 
* In a contribution to the Report of the Board of Health, Lunacy and Charity 
for 1884, entitled “ The Family System as an Accessory Provision for Our Insane 
Poor,” the subject is treated from this standpoint. 4 
under the laws regarding “ boarded-out ” patients. They 
were situated, in all essential respects, like the mass of their 
fellow-patients under this system elsewhere in the State, ex- 
cept for the legal question which finally led to their removal 
to their old quarters. The chief bearing that this visit has 
upon the present report is the slight but unavoidable influ- 
ence of the few additional facts and impressions there 
received. The statement is also in place here that, through- 
out this subsequent inspection, made at the request of the 
Board of Lunacy and Charity, there has been the same 
endeavor to unbiased conclusions that led me to 
undertake the unauthorized and unsuggested visit to the 
Tewksbury patients. As an indispensable requisite in 
reaching accurate conclusions is an unprejudiced point of 
view on the part of the inquirer, it should be mentioned 
that these visits were made with many misgivings as to the 
result of the investigation, for, although I had advocated its 
adoption in this State, although, in many particulars, its 
requirements had apparently been fully met, and although 
under lay direction much had been accomplished in spite of 
the many difficulties incident to a new undertaking of this 
nature, the absence of regular expert medical inspection was 
believed to be a serious obstacle to its full success. In 
short, belief in the practicability of the system itself was 
counterbalanced as a prejudicing element in the present 
inquiry by the fear lest its success might have been im- 
perilled through this deficiency. In what follows I hope 
to show how far these opinions have been modified or con- 
firmed by actual observation. It should also be added that, 
while recognizing the value of a natural life for these pa- 
tients under domestic, individualized, non-official care, the 
advantages have also been kept in mind of the routine 
life and regular habits inseparable from institutional care, 
which, however, is necessarily largely of an artificial nature. 
Method of investigation. —With a view to obtaining the 
most accurate and thorough knowledge of the condition of 
these patients, the following method of investigation was 
pursued: Each patient was visited and examined in the 5 
dwelling to which he or she had been assigned by the 
Inspector of Charities. The visits were all made without 
the previous knowledge of the householders or patients. 
This was everywhere apparent in circumstances too numerous 
to mention. On reaching the house, the couple who had 
charge of the patients were first questioned on the following 
points : — 
1. Number and names of patients. 
2. Duration of residence, and age of each patient. 
3. Previous experience of guardians among the insane. 
4. The physical health of the patients, and their mental state 
with an account of any morbid propensities. 
5. Nature of the diet. 
6. How far the patients were received into the family. Whether 
they took their meals with the family. 
7. Facts as to bathing and general cleanliness. 
8. Information as to the amount of profit from the board of the 
patients paid by the State. 
9. Amount and kind of work done by them. 
10. Facts as to visits of friends and officials, also physician’s 
visits in case of sickness. 
11. Frequency of elopement of patients. 
An examination was then made of the probable warmth of 
the house in winter, the state of the bedding, arrangement 
of rooms and so far as possible of the food given them. 
Notes were made upon the general appearance of the sur- 
roundings as to cleanliness and upon the character of the 
guardians. Each patient was then examined by himself, 
entirely apart from any other member of the household and 
the facts ascertained, so far as possible, on the following 
points : — 
1. Mental state. 
2. Physical condition. 
3. State of clothing and cleanliness. 
4. Contentment — Whether they preferred their present to an 
asylum life. 
5. Opinion as to food, warmth and other comforts. 
6. Evidences of abuse or neglect on the part of guardians. 6 
This course of inquiry was thought to be best calculated 
to reveal the actual facts as to the care and condition of 
these patients. 
Number and localities of families. — The number of 
“boarded-out” insane on Nov. 3d, was 66.* Of these 21 
were men and 45 were women. They were taken from 
Danvers, Worcester, Northampton and Taunton Lunatic 
Hospitals, the State Almshouse and State Farm. 
The patients are widely scattered throughout the State, 
and in the different localities where they are “ boarded out.” 
They are grouped about the different State institutions men- 
tioned. This arrangement certainly facilitates the removal of 
such patients to and from the asylum in case of placing them 
in families or of removing them therefrom should their con- 
dition require it. The inspector also may save time by com- 
bining his official visits to the hospitals with those to the 
“ boarded-out” patients in the neighborhood. On the other 
hand, if the chief responsible agent can be brought into 
closer communication with his charges without detriment to 
their comfort or that of the community, much would be 
gained. As to individual houses, many are widely separated, 
occasionally two or three miles apart, and in some cases this 
separation is needless, owing to the number of probably 
desirable houses where patients are wanted in the interven- 
ing distance. This criticism is, however, only one of the 
degree of separation that should be practised, as a too close 
grouping would make an undesirable aggregation, which 
would be at variance with one of the main objects of the 
system. 
Selection of patients.—The patients have been selected, 
it is almost needless to say, from the harmless, chronic de- 
mented class which forms so large a part of the population 
of our asylums. The selection has been very largely from 
the State patients. Of the insane who are supported at the 
Lunatic Hospitals by the cities and towns, and comprise the 
* This is not the average number by 43—the number of patients transferred 
from homes to the State Almshouse as illegally “ boarded-out.” 7 
bulk of the inmates, there were found but eight boarded out, 
while there were nine private patients, a class which is 
by far the smallest of the three. Considering, therefore, the 
limited number to draw from, the reasons for which will be 
given later, it is a matter of surprise that the number of 
boarded-out patients should have reached 125, its highest 
mark, during 1888. 
Cases improperly selected. — The number of cases found 
who had been selected improperly in the above respects was 
five. One was a woman with delusions of persecution, who 
was greatly excited at times, and destroyed her bed fre- 
quently, and occasionally wandered away. Another was 
profane and occasionally somewhat violent, in an excellent 
family where there were children. The remaining three 
were men, of whom one was a tramp with a criminal record, 
who was of the imbecile order, one an old man who destroyed 
his clothing and wandered about in inclement weather, and 
the last a feeble creature who neglected himself, was improp- 
erly cared for and frequently ran away. They had remained 
in these families 2 years, 5 months, 7 months, 21 months 
and 3 years respectively. 
As nearly every degree of thrift and improvidence short 
of prosperity and destitution was found in these homes, and 
as the comfort of the patients varied considerably, but not 
in direct proportion to the state of their surroundings in 
many respects, it will facilitate description to arrange these 
dwellings and their inmates in four groups : — 
1. Homes in which the surroundings were unexceptionable as to 
the housekeeping, the family in charge and the comfort 
and contentment of the patients. 
These numbered seven dwellings, in which there were ten 
patients. The houses were clean, commodious, and kept in 
a neat and orderly fashion. The patients’ bedding was 
ample and comfortable, even spring beds being provided for 
them in tw7o of the houses. Separate bed-rooms were given 
them, and there was usually some means of heating these 8 
rooms in the winter. The diet was of good quality and 
quantity ; meat, fish, eggs and milk forming a generous part 
of the weekly fare. The patients were in excellent bodily 
condition. Their clothing was whole, but shabby and 
patched, in the case of the men, although in two or three 
instances they had other clothing for Sunday. In nearly every 
case they were received as members of the family, sat at 
the same table and occupied the same living rooms. The 
interest in them on the part of the guardians was unmis- 
takable, amounting, in some cases, to actual personal regard. 
The contentment was evident, and all who could give rele- 
vant answers spoke of their pleasure at their situation and 
their desire to remain where they were, with the excep- 
tion of one who wished to return to the asylum on the 
ground that poison was being put into his arms by imaginary 
persecutors, a delusion which he had had for many years 
and which was not affected by any surroundings. None of 
these patients had run away, with the exception of one 
woman, who wandered off a short distance on two or three 
occasions to find an imaginary relative. Most of them 
assisted in the work, usually doing a little every day. The 
men helping in the care of the horses or cattle, chopping 
wood, and doing various light chores. The women, knit- 
ting, mending, etc. There was no evidence of overwork or 
the imposition of drudgery. On the other hand, indications 
in some cases were not wanting, of efforts to awaken their 
interest and to stimulate their sluggishness of mind and body. 
2. Homes reasonably well kept, in which the patients’ comfort and 
content was evident, and where they appeared to be more 
favorably situated in many respects than when in the 
asylums or, probably, in their own homes. 
The dwellings comprised in this group belong to a less 
well-to-do class, although several of them fall little short of 
the merits of that just described, while, on the other hand, a 
few approach the third class to be described. Here there are 
twenty-four patients in thirteen homes, and as the majority 9 
of patients come into this category their situation and con- 
dition will be given in more detail. In six of the thirteen 
houses general disorder and untidiness was apparent on cross- 
ing the threshold, and primitive appliances and domestic 
arrangements spoke either of unthriftiness, or of scanty 
means, or both. The clothing of the men was very poor, 
the bed-rooms seemed to be rather too cold for the winter, 
and bathing appliances were unknown, but here unfavor- 
able comparison ends. These insane persons appeared to 
receive at least all the comforts that the families themselves 
are accustomed to have, and an amount of consideration 
hardly to be expected. The large majority of the house- 
wives who are the care-takers, and practically the sole 
guardians of the patients, are, as a rule, patient, discriminat- 
ing and kindly, and in but two cases did they give the 
impression of taking these patients on sufferance. They 
seemed also anxious to retain them, and more than one 
showed annoyance at being unable to have made comfortable 
certain patients who required to be removed to an asylum 
solely because of their unfitness for “boarding-out” care. 
In but few cases were they denied the freedom of the houses, 
but were accustomed to use freely the day-room occupied by 
the family, which is often the kitchen, as most comfortable. 
The men, apparently, took little part in the actual care of 
the patients, the wife alone attending to their wants. The 
patients were all evidently well fed. Among the few com- 
plaints made, that of poor food found no place. The phys- 
ical condition of the patients was usually sufficient testimony 
on this point without an inspection of the larder. The 
bedding usually consisted of a feather bed and mattress, 
with ample coverings, and sometimes only a well-filled straw 
bed. In but one house did the beds seem uncomfortable. 
Cases of sickness were very rare among them, so far as could 
be learned from their testimony and that of the guardians. 
While the bodily comfort of the patient is quite readily 
appreciated, the amount of contentment is less easily esti- 
mated. Owing to their demented state, many of them, as 10 
might be expected, are apparently unable to appreciate any 
difference, either for better or worse, between their present 
and their former surroundings, and although they seem 
to be sufficiently pleased with their homes, their own 
testimony cannot, therefore, be taken as reliable. Some do 
not reply coherently to any inquiries, and a few make no 
answer at all. While one has extravagantly delusional ideas 
of his former experience in the hospital, another may be 
equally convinced that he is unlawfully kept from his proper 
mission in the institution he has left. Two conflicting 
examples of this kind were represented in one household. 
A dozen patients, out of the twenty in this group who were 
examined as described above, gave reliable answers, and, with 
the exception of one, who wished to return to the asylum for 
the winter, preferred to remain where they were. Through- 
out all the attempts at explaining their feeling on this point 
the sense of greater liberty and independence seemed to be 
the prevailing idea. A few are taken to church by their 
guardians, and not unfrequently to drive. Many are sent 
on errands, etc. It was reported that the growth of interest 
among them in the family concerns was evident in many 
cases. This, of course, could not be substantiated, except 
in two cases, former patients of mine in the Danvers 
Lunatic Hospital, in whom the description given of their 
condition on arriving at the house tallied with my remem- 
brance of them while at the hospital, and in whom the change 
in this respect was noticeable. Those families in which 
there were young children afforded the best examples of 
contentment and awakened interest on the part of the 
patients, as shown in the fondness of the children for them 
and their solicitude in return. In two of these houses the 
patients take their meals apart from the family. But one of 
the examples given of improperly selected cases belongs to 
this group. Very few of the State patients have relatives. 
Some of the fortunate ones in this respect, whether State, town 
or private, were occasionally visited and often written to by 
them. The latter were reported to be pleased with this 11 
arrangement for their insane relatives and their addresses 
were, in several cases, given for corroboration of these state- 
ments. As lack of opportunity has prevented proper inquiry 
on this point nothing more definite was learned. The official 
visits of inspection had been frequent and in excess of the 
regular visits required by law every three months. 
3. Homes more or less squalid and scantily furnished, in which, 
nevertheless, the patients showed little indication of a 
lack of personal attention and were plainly content with 
their surroundings. 
These houses were two in number and contained six 
patients. With regard to the houses in this group it is 
needless to say more than that they were shabby, forlorn 
and not clean, the floors carpetless and the general aspect 
particularly dismal. In one of the two families, however, 
there were five patients who could give a fair account of 
their treatment, and they, to my surprise, were more decided 
in their desire to remain where they were, and in their prefer- 
ence for their present lot to that of institution life, than the 
bulk of patients examined. They seemed attached to the 
housewife. They were well fed, and obliged to bathe reg- 
ularly each week. The house was reported by them to be 
kept sufficiently warm. The other house of a similar de- 
scription had been left, at the time of my visit, to the care of 
two patients, one of whom has since been returned to Tewks- 
bury. One patient, a young woman, gave entirely rational 
answers to all questions touching her history and mental 
state, although a complete examination of the latter was, at 
the time, impossible. She was cheerful and in good con- 
dition and had charge of the baby. In this group was one 
of the improperly selected cases. 
This fact of evident contentment and comfort among 
wretched surroundings was apparently due in great measure 
to the fact that the housewife confined her interest and care- 
taking to the patients rather than to the state of the house, 
which was considered a non-essential. Patients in such sur- 
roundings, whatever their predilections, should be removed 12 
to houses of a better class, if reform in the state of affairs 
is impossible. 
4. Dwellings in which the surroundings were extremely poor, 
and afforded no comfort to the patients, who were also 
neglected by those in charge and in poor condition. 
These were fortunately but two in number and contained 
four patients. It was here that the majority of the improp- 
erly selected cases mentioned were found. The question 
immediately arises whether their present situation and not 
the nature of their insanity might account for the wretched 
state in which they were found. It would be, however, 
unfair to attribute their condition largely to their surround- 
ings, as they were, obviously, unfit cases for “ boarding-out ” 
care. Their associates who were suitable cases for family 
care showed the same neglect on the part of their guardians. 
In one house the patients were kept in a small L, separated 
from the rest of the house by a wood shed. There was no 
furniture to speak of, and the beds, which were untidy in the 
extreme, were made up carelessly on the floor when not 
destroyed by one of the patients who had attacks of 
excitement. They were reported by the guardian to 
wander away not infrequently. There appeared to be 
little solicitude felt by their guardians, who evidently 
regarded them as a necessary burden. In the second 
house was a small, thin man of the imbecile type, in 
delicate health, extremely dirty. His clothing was of the 
poorest, shabbiest description, and his long nails and gen- 
erally uncared-for condition spoke of unpardonable neglect. 
When asked details as to his cleanliness and bathing the only 
statement made by the man in charge was that they “ took 
him down to the brook once last summer and put him in.” 
He was offensive to them chiefly in ways which a little care 
might have improved. The other patient was a worker, an 
inoffensive man who had little to say. He was very dirty 
and poorly clad and seemed to be under-fed. It may be 
said with no exaggeration that one or two neglected cases of 13 
the latter type make a more powerful impression upon the 
observer than a dozen of the better class. Just as one 
example of ill-usage in a lunatic hospital throws into the 
shade for a time the numerous beneficial results of well- 
directed care. 
Apart from these groups was one woman in her home, 
but still under the supervision of your Board. She was 
living apparently in bodily comfort, but more or less 
influenced by delusions as to her husband’s identity and 
his treatment of her, as well as other delusional ideas. Her 
home seemed less comfortable than the majority of the 
houses visited. 
Former attendants as guardians. —Among the points not 
confined to any particular class is the former experience of 
the guardians as affecting the care of the patients. In five 
of the families, one of the guardians, at least, had had experi- 
ence as an attendant among the insane at a hospital and 
four in almshouses. Although in some of these families 
the advantage of training of the kind learned at the asylums 
appeared to some extent, many of the housewives who had 
had no experience of the sort proved quite as competent 
and rather more interested in their charges. With notable 
exceptions, those who had lived in institutions, having had 
less domestic experience, made rather too plainly evident 
the official nature of their relations, and restricted their 
intercourse with their patients; unnecessarily so, viewed 
from the standpoint of the practice and general sentiment 
in the families on this point. For example, while the large 
majority of them take their meals with the patients, in 
certain cases to the decided improvement in the habits of 
the latter, it is apt to be among the “ experienced ” guar- 
dians that, as one of them (who, by the way, had patients 
who were inoffensive in this respect) remarked, they “will 
not have them come to their table at any price.” 
Proportion of foreign-born patients. — The proportion of 
foreign-born patients,—more than one-half, —who are willing- 
ly cared for as stated, indicates either a remarkable sacrifice of 14 
prejudice on the part of many of the guardians, or its repres- 
sion for the sake of the consideration of the pecuniary profit 
from the allowance, $3.25 a week, or perhaps both, in part. 
Amount of work done by patients.—It was impossible to 
acquire any information of value as to the actual amount of 
work done by these patients during a single visit of inspec- 
tion. The impression left as the result of close inquiry 
was that the amount done was comparatively slight. In two 
of the houses, however, it was impossible to avoid the sus- 
picion that additional profit was made from the labor of the 
patients by obliging them to assist in other than the house- 
hold or farm work of the family. But objectionable as 
this might be, evidences that the labor required was pushed 
to the extent of drudgery or overwork were wanting. 
Young to omen unsuitable cases for care in families. — A 
number of young women were found who, although in other 
respects most suitable for such care, were, from their youth 
and feeble-minded condition, likely to be taken advantage 
of, and on that account should have the closer protection 
that institutional supervision affords. 
Summary. — To summarize our observations, then, these 
patients were generally found to be comfortable and contented 
and in good bodily condition in the houses visited. Except 
in the instances mentioned, no evidence of undue neglect was 
found, and no case of abuse or injury could be detected 
on the closest inquiry possible under the circumstances. 
The supply of food of good quality was abundant. The 
bedding was everywhere sufficient. The guardians of these 
insane, i.e., the housewives, impressed one as, without 
doubt, desirable persons for this work in the great majority 
of the families. Their character, capabilities and interest 
in their charges were, so far as could be judged in a single 
visit, all that could be required. The defects that were most 
apparent were the poor state of the clothing worn by the 
men, and, to a less extent, by the women. In this respect 
there was generally a noticeable difference between them 
and the rest of the household. A few minor discomforts 15 
were shared by sane and insane alike. The houses them- 
selves, as a rule, afford less proportionate comfort than the 
personal care on the part of the guardians, and it seemed 
probable that more homes of the first group above described 
might be found among the number of families said to desire 
patients. Moreover, a number of the more desirable class 
were without a fair complement of patients, while poorer 
houses had the full number allowed. Those insane were 
relatively least comfortable who were in the least accessible 
part of the State and among the least prosperous families. 
Here also the patients ran away rather more than elsewhere. 
There were several instances of patients being given 
repeated trials in different houses, whose propensities made 
them evidently unfit for such care ; also originally unsuitable 
cases left too long out of the asylum and occasionally not in 
the best hands. There seemed also to be a lack of definite 
instruction as to the duties of the guardian toward the 
patient, which was fortunately in many cases made good by 
their common-sense and sympathy. In spite of these defects, 
the well-being of the mass of the patients, in the cardinal 
points of care as above described, appeared to be in advance 
of what they would receive in a lunatic hospital, and immeas- 
urably superior to the condition of many similar cases now 
in town poor-houses throughout the State. 
Facts as to improvement in the condition of the patients. — 
Among the facts which bear more directly upon the gen- 
eral results of this method in practice is the amount of 
improvement recorded. This can best be ascertained by 
a glance at the following statistics : — 
State and Town Patients Supported by Relatives or by their 
Own Labor, from Oct. 1st, 1887, to Oct. 1st, 1888. 
S elf-supporting. 
I). R., .... 1 year. 
B. C., . . . . 807 clays. 
E. C., . . . . 243 “ 
M. M., . . . . 194 “ 
M. M 122 “ 
C. L., . . . . 170 “ 
,J. J. J., 
F. K., . . . .9# clays. 
E. F., . . . . 77 “ 
D. M., . . . . 48 “ 
S. M., . . . . 25 “ 
H. B., . . . . 17 “ 
M. W., ... 55 “ 
122 days. 16 
Supported by Relatives. 
C. S., . . . . 1 year. 
A. W., .... 319 days. 
Y. D., . . . . 315 “ 
W.L., . . . . 183 “ 
C. L., 
S. H., .... 93 days. 
R. P., . . . .44 “ 
J. R. S 41 “ 
E. II., . . . . 360 “ 
183 days. 
IIow tlie guardians find profit in the arrangement. — 
These details lead naturally to the economic aspect of the 
subject. Let us tirst consider the direct pecuniary profit 
to the guardians. The man or men of the family are, for 
the most part, farmers of small means, who raise vegetables, 
eggs, milk, etc., and make butter, which they usually 
exchange for flour and other groceries and meat. The 
patients, however, as one farmer expressed it, create a home 
market for much of their produce, which, for various rea- 
sons, they had been unable to sell, and which their own 
family did not require. The knowledge that they have 
more to provide for also stimulates them to raise larger 
quantities, in which they are, in some cases, helped by the 
labor of the patients. Thus, without additional outlay of 
money, they are able to furnish an abundant supply of food 
for their larger households, and to save out of the allow- 
ance of $3.25 a week a sufficient sum as an incentive to 
proper care of their charges. 
Considerations of the expense of these charges to the State. 
— The economic question of vital interest, however, is the 
public expense of this provision as compared with asylum 
and almshouse care. 
Insane in Families who remained under State Supervision during Year 
ending Oct. 1st, 1888. 
Average of State cases, 
. 93.3 
Averag# of Town cases, 
. 10.7 
104.0 
Cost to the State, board, 
$14,222 
47 
Cost to the Towns, board, 
1,422 
33 
Clothing and medical attendance, 
693 
49 17 
Removal and return, 
$208 
69 
Visitation (approximately), 
600 
00 
Total cost, 
$17,146 
98 
Average yearly cost per capita, 
$164 
87 
Average weekly cost per capita, 
3 
17 
Average weekly cost per capita, including private patients, 
2 
92 
Comparative weekly cost per capita of different means of providing for 
Insane during Year ending Oct. 1st, 1888. 
For all classes of Insane.* 
Northampton Lunatic Hos- 
pital, . . . .$3 39 
Worcester Lunatic Hospital, 3 79 
Taunton “ “ 3 52 
Danvers “ “ 3 91 
Westboro’ “ “ 4 79J 
For Chronic Insane.* 
Worcester Insane Asylum, $3 12 
State Farm, . . . 2 23 
State Almshouse, . 2 23 
In Families, . . . 2 92 
Explanation of statistics as to economy of the method. 
— The above statistics require explanation. The total ex- 
pense incurred by the State for the visitation and inspection 
of the insane in families cannot be given accurately, as there 
is no separate statement of this item in the account rendered 
of the general expense for visitation and inspection of 
all the insane. Accordingly, the amount has been roughly 
estimated, by the best judges, after careful calculation, 
at $600 or a little more than $5 per patient, as nearest the 
actual expense. No account, however, is taken of minor 
expenses incurred in the way of correspondence and other 
clerical work. The difference between the average weekly per 
capita cost of these patients, $2.92, and the amount allowed 
by the State, $3.25, is due to the number of patients in the 
list just given who were self-supporting or were supported 
by relatives for varying portions of the year, but who were 
still visited and inspected and under the general oversight of 
the Board until discharged from its supervision or returned 
to families. Although these patients are nominally similar, 
in this respect, to those who are allowed to leave the hospitals 
* The figures are taken from the Financial Statements of the different Institutions 
for 1888. 18 
on “ trial visits,” they come of a class who were not allowed 
that liberty while in the institutions, and, what is more to 
the point, they continue, as “ boarded-out ” patients, to re- 
main under the supervision of the Board, while all public care 
ceases when hospital patients are even temporarily absent. 
These patients can also be legitimately compared to those 
chronic patients in the hospitals who require little care, and 
contribute not a little (by the fact of not needing special 
accommodations and by assisting largely in the work) 
toward lessening the average expense. The private 
patients (the average number of whom was nine) have 
been included in the comparative statement of expense, 
as the same reason for including them in computing 
hospital averages seemed to hold good in the case of this 
department, where they are also under supervision by the 
State authorities, but of a different form. On the other 
hand, it must be remembered that a little less than one- 
half of these patients were taken from the State Almshouse, 
where the rate is considerably less than in the hospitals, as 
appears above. 
Private patients of proper class and small means as 
objects of this provision. — The relatively large number 
of private patients seems to point to the possibility of 
utilizing this system largely in this direction throughout 
the State. The lack of separate and suitable provision 
for patients of this class who are able to pay, but whose 
means are quite limited, is well known as a crying 
need in the Commonwealth. Does not a family system 
meet these demands so far as the quiet chronic class is 
concerned ? The houses in which most of the private patients 
were quartered, and the care they received, are facts which, 
to my mind, instantly answer this question in the affirmative. 
Should this be found to be practicable, a slight charge in the 
rate for supervising such patients, above that allowed for 
pauper lunatics, would do much to diminish the cost to the 
State of this department. 
Obstacles to success of the system.—Turning now from 
the favorable aspect of the situation, let us consider 19 
the obstacles to the success of the system. It may 
be said at once that the great impediment is the un- 
willingness of the overseers of the poor in the towns to 
co-operate. Although families may be found where, for 
different reasons, a lower rate might be required than the 
towns are paying for their charges at the hospitals, it is 
argued that if they are able to live in families they can just 
as well go to the town almshouse where the expense would 
be much less. Considering that the wretched state of the 
insane in many of our town almshouses is notorious, that 
the comfort of the insane in lunatic hospitals is, as a rule, 
directly proportionate to the amount of overcrowding (which 
even now is considerable), the picture is certainly a forbid- 
ding one. Supposing, however, that aroused public senti- 
ment, revised legislation, and other means, if employed, 
should fail to relieve the asylums of their surplus of chronic 
insane of this class who are now removed from time to 
time to town almshouses, it is an open question whether a 
very gradual “ boarding out” from State, town and private 
patients, even at the present rate of accumulation (125 in 
about three years), is not a reason for the continuance of 
the system, if its operation be successful in other respects, 
until the numerical limit of an asylum population is reached. 
In order to secure the full and permanent efficiency of 
the system, a revision of the laws regarding this class is 
essential. I therefore offer the following 
Suggestions for complete efficiency of the system in Massa- 
chusetts.—(a) An amendment of the statutes whereby all 
State patients who are insane, and who are suitable cases for 
care in families shall be allowed the privilege of such provision. 
(b) Legislation directed toward the removal of any insane 
persons in city or town almshouses who are abused, neglected 
or otherwise improperly cared for, and their disposal in fami- 
lies under supervision of the State Board of Lunacy and Char- 
ity, provided they are suitable cases for such care, (c) An 
amendment of section 3, chapter 385 of the General Stat- 
utes, to the effect that the condition of the patients in fami- 
lies shall be inspected at least once in six months by a 20 
medical man practised in the care and treatment of the 
insane; also that the number of patients in one family shall 
not exceed four. 
As minor improvements within the immediate control of 
the State Board of Lunacy and Charity I would offer the 
following 
Recommendations. 
1. That the most accessible groups of the insane in 
families should be the first to be developed where practicable. 
2. That the number of patients in any house should be 
regulated by the standard of care maintained, the best 
families in this respect being allowed the full complement 
where accommodations warrant it. 
3. That all young women of the imbecile or weak- 
minded type now living in these families be gradually 
replaced by men or older women from asylums. 
4. That there be placed in each house a visiting-book 
prescribed by the State Board, which shall contain general 
instructions as to the care of such patients, in which a report 
of the condition of each patient, together with any sugges- 
tions deemed necessary, shall be entered at each visit of 
inspection. 
5. That extended publicity be given to the advantages 
of this provision for patients of the private class, of moderate 
means, through the facilities of the Board for selecting 
suitable homes. 
Conclusions. 
1. The defects in the operation of this means of provi- 
sion for the chronic insane in Massachusetts have been largely 
due to the difficulties inseparable from the introduction of 
any new and extended system of public charity. 
2. As regards good guardianship and care, a more 
natural life, increased comfort to the insane who enjoy its 
privileges, and economy to the State, this method of caring 
for the insane has been in the main a successful provision 
but for a relatively small number of patients. Until, how- 21 
ever, it has stood a longer test, it cannot be said to have 
passed the experimental stage, and only when it has become 
a thoroughly organized institution with fully developed re- 
sources can it be pronounced an established success. 
3. As a means of relief to the lunatic hospitals from 
overcrowding the value of this method is at present incon- 
siderable. 
4. Under the present restrictions it serves as a useful, 
humane and economical accessory provision for the insane, 
which may ultimately take rank with the Lunatic Hospitals, 
in point of numbers cared for, thereby precluding the neces- 
sity of constructing other accommodations for the insane. 
5. Should the town authorities generally throughout the 
State consent to the transfer to family care of their charges 
in the lunatic hospitals, who are suitable cases for such 
outside care, the family system, rightly conducted, cannot 
fail to be a valuable means of delaying the over-accumula- 
tion of the insane in the hospitals.