he felt should be emulated, and the teachings of Browning "who ever looked above the storm clouds of this lower world to the unsoiled blue of Heaven" should be ever kept in mind. On the contrary every effort should be made to keep in the background the unhealthy pessimism of Leopardi, Thomson, and others of a similar cast of mind. Instead of teaching that

"This little life is all we must endure,

The grave's most holy peace is ever sure."

it is far better, to my mind, even though science may not prove our claims, to endeavor to spread that satisfying spirit of optimism which will enable us to say:

"It is our trust

That there is yet another world to mend

All error and mischance."

FURTHER EXPERIENCE IN FAMILY CARE OF THE

INSANE IN MASSACHUSETTS.'

BY OWEN COPP, M. D.,

Executive Officer, State Board of Insanity, Boston, Mass.

An experience of twenty years in family care of the insane in Massachusetts has just closed. Its teaching is a hopeful augury of the future rather than a record of great achievement. The course of progress has been uneven, beset with difficulties and impeded by the inevitable struggles of a new movement.

Inspired by the example and notable success of the system in Scotland and Europe, Mr. Frank B. Sanborn, Dr. Henry R, Stedman and others made Massachusetts the pioneer of its introduction to this country. Although other States have watched the experiment with quickening interest, Massachusetts still remains its solitary representative here-disappointing, yet, on reflection, not very surprising.

Long before its inception the public had been familiar with another and far different form of community care of the poor and insane. The picture of their distress in poorhouses and shiftless families, as drawn by Miss Dix, in her memorials to State Legislatures, was still vivid in its memory. Even to-day some recall their youthful impressions of the wretchedness of the worthy poor farmed out to the lowest bidder, and the forlornness of the orphan child, underfed, overworked, in but not of the family of its task-master. Naturally in the minds of such was aroused suspicion of mercenary and sinister motives in those willing to receive the insane under the new regime, whose beneficent spirit, appearing in the similitude of the old, could be revealed only by lapse of time. Then there was the unreasoning fear, always prevalent in the community, lest the insane commit some violent act or exert a degrading influence on associates. 'Read at the sixty-second annual meeting of the American MedicoPsychological Association, Boston, June 12-15, 1906.

Their friends also were not always willing to take the risk of renewing old troubles and annoyances against which the institution offered the surer safeguard.

In the endeavor to correct primitive abuses and allay popular apprehension a strong sentiment had been created in favor of institutional care, as the best refuge of the insane and the securest protection of the public, and the current had set strongly in that direction and has continued with accelerating velocity ever since. Accordingly the new order seemed to ignore lessons of the past, and to be a retrogression foredoomed to failure.

Headway against these adverse undercurrents might have been faster had a positive desideratum been obvious, such as the pecuniary saving to the Scotch ratepayer, who is assured a marked reduction in the cost of support of every patient removed from asylum to private family, amounting on the average to about forty per cent. Although such incentive was and is operative in Massachusetts, as will be shown, it did not originally directly touch the parties in control, and was not easily demonstrable until results became apparent.

Prior to inauguration of State care of the insane in 1904, local overseers of the poor determined the disposition of a majority of patients suitable to leave the asylums but destitute of friends. Unless the board rate in the family were less than in the institution, as rarely happened, they saw no advantage in the change, inasmuch as resulting relief to overcrowding and release of space in asylums were benefits accruing, not to them directly but to the Commonwealth; or they would insist, especially in the smaller municipalities, upon the removal of such patients to the cheaper care of the local almshouse. Gradually, however, as they perceived that the initial board rate in a family might be reduced even to self-support, with increasing usefulness of the patient, their cooperation was more readily enlisted, but their initiative never incited.

The institutional effect of family care does not appeal to selfinterest. To be sure, boarding out a patient removes immediately or remotely a floor bed from crowded halls or corridors, but the coincident loss of a comfortable, perhaps helpful inmate, dampens the ardor of active promotion of the cause; while the altruism stimulating to discharge of every patient whose happiness, wel

fare or mental state may allow, easily lies dormant in the busy preoccupation of the medical staff in other more pressing duties. Nevertheless, it is a pleasure to testify to the self-effacement and growing interest in this work among our hospital physicians.

In the last analysis it appears that the State has the only direct and paramount incentive to forward this movement, because it facilitates discharge of patients, tends to prolong their stay outside, reduces the amount of public provision necessary for their care, and does not increase the cost of their maintenance.

These advantages, however, have not always been so clearly manifest as to command aggressive, sustained and organized support.

In spite of these deterrents, considerable advance has been made and foundations laid for better work. A review of the twenty years shows that prejudice against family care of the insane has been dissipated wherever personal contact and knowledge have superseded theoretical preconceptions; that early abuses have been eliminated by seeking the welfare of the patient rather than relief of the public treasury, by insisting upon the suitability of families and careful selection of patients with a view to mutual compatability and the exclusion of morbid characteristics reacting injuriously on associates, by avoiding in the families conditions of poverty so necessitous as to induce undue tolerance of vicious eccentricities of patients, leading to friction and discord, forerunners of ill treatment, by rejecting proposals to make special provision to engage in the work as a vocation and choosing families established in their homes and needing only supplementary incomes, and, finally, by unremitting supervision, alert to detect evidence of neglect, overwork and the like, and quick to respond to discontent or unhappiness of patients by transfer. Human judgment and foresight have never been complete safeguards against violence, self-injury, sexual accidents and lesser mishaps in dealing with the insane, either within or without the institution. The public safety cannot be absolutely insured against them, because insanity develops in the community before admission to the hospital and continues in many cases after discharge. Here, as in determining the suitability of patients for family care, judgment enters as a necessary factor, and equal precaution against error should be taken. The element of risk

is the same in either case, and must be justifiable unless perpetual detention be the inevitable lot of the unrecovered insane.

In the twenty years 762 different patients, chiefly women, have lived in 465 families without doing a serious act of violence and rarely attempting any. At the very outset one man, suffering from recurrent insanity, hung himself within twenty-four hours after leaving the hospital. During the succeeding period of nearly twenty years the record was clean, until May of this year, when an invalid, hypochondriacal woman took her life in the same manner. She had been in four families for four and a half years. No caretaker had ever regarded her as insane. I should have hesitated to commit her as such, and would have discharged her long ago had any other place than the almshouse been open to her. The propriety of caring for her in a family could not be doubted, and the suicidal act seems to have been wholly unforseeable. The only pregnancy occurred twelve years ago in a girl of sixteen, recovering apparently from an acute attack of insanity after boarding three years in a family. She was not feeble-minded, and would properly have been allowed to go home if conditions had been favorable.

On the other hand, patients have been almost universally acceptable to caretakers and their neighbors. Many reveal to them no symptom of insanity, although they are usually described as peculiar." Complaint in any form has been remarkably infrequent. Caretakers have rarely tired of their duties and have not manifested deterioration, moral or otherwise, from their performance. They seem rather to have been spurred to their best endeavor by their responsibilities and the constant visitation of inspectors, not only in keeping up the standard of care of their patients but in improving their homes and surroundings. Generally they have become interested in their wards and sometimes self-sacrificing in befriending them. The process of sifting the good from the bad must be unceasing, but I am satisfied that worthy motives greatly predominate. The community aspect of family care of the insane may be made as benign as any other method and should command cordial approval.

The statistical showing of the last four years is not essentially different in character but more favorable in numerical results than that of the previous sixteen years, as presented to the asso

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