ing it necessary to have them recommitted. The question as to why so large a percentage of cases relapsed after discharge from the state hospitals will be considered in detail in another chapter.

VII. MARITAL CONDITION

In the following table (Table 10) the marital condition of the patients is presented. There were almost twice as many single as married males; whereas, of female patients, there were actually fewer single than married. The large percentage of single persons among the insane enumerated by the United States Census of 1910, showing 63.5 per cent male and 41.7 per cent female, compared to 60.3 per cent male and 44.5 per cent female in Table 10, should not be interpreted as indicating that the single are more liable to become insane than the married. It means rather, that the insane as compared with the normal are less likely to marry. That the percentage of single persons is smaller for females than for males, both among the insane and the general population, is due to the fact that women marry at a younger age than men. The psychoses which are largely responsible for the majority of cases of insanity do not as a rule develop until after the eighteenth year, except in the cases of dementia praecox, hebephrenic form. By this time in many cases, the females are married and for that reason psychoses were found to have developed in an unduly large number of young women whose marriage was a matter of but a short time. The added burdens of household care, of gestation, pregnancy, and lactation, have caused the onset of psychoses in persons as to whose good mental condition there was no question prior to marriage; at least the nearest relatives knew of no mental abnormality, indicated or latent.

The comparatively large number of married men and

women, many of them with dependent children, presents an important social problem. The majority of these patients were between the ages of 20 and 40 years, and the commitment of a father or mother to an institution for the insane left a family, in many cases, in straightened circumstances.

With but very few exceptions, the social status of nearly all the patients was that of working people whose only source of income was what they themselves earned from week to week, or what relatives contributed out of meagre incomes. Under such conditions, the commitment of an unmarried young man or woman has in many cases meant a reduction in the family income, whereas in cases of married persons more serious adjustments have to be made, this often being possible only through the financial aid of a social or relief agency. The kind and amount of assistance to be rendered to such families depends on whether the father or the mother has been committed; the number and age of the children, if any; the financial resources of the family, and the assistance to be expected from relatives. Often the most important factor is the matter of the diagnosis of the patient; if a recovery may reasonably be expected within a few weeks or months, emergency assistance will usually be sufficient to keep the family together;

otherwise a more definite program of relief must be outlined and carried out.

VIII. NATIVITY

In the United States, and especially in New York State, the question of immigration in relation to insanity presents a problem of great magnitude. Of the total number of inmates of insane asylums on January 1, 1910, according to the enumeration of the Thirteenth Census, 28.8 per cent were whites of foreign birth, and of the persons admitted to such institutions during the year 1910, 25.5 per cent were of this class.1 Of the total population of the United States in 1910 the foreign-born whites constituted 14.5 per cent.2 The number of foreign born admitted to the New York State Hospitals for the year 1918 was 44.5 per cent of the total admissions; those of foreign parentage constituted 59.8 per cent and those of mixed parentage 11.0 per cent.* From this it seems that for the country as a whole and for New York State in particular the foreign born have an unduly large representation in insane asylums. However, it should be remembered that most cases of insanity occur after the eighteenth year, and that the difference in age distribution which exists between the native and foreignborn parts of the population accounts largely, but not wholly, for the difference in the proportion of insane hospital admissions.*

1Insane and Feebleminded in Institutions, U. S. Census, 1914, p. 48. * Ibid., p. 25.

'S. H. C., 30th A. R., p. 282.

*Rosanoff, A. J., "Some Neglected Phases of Immigration," Amer. Jo. of Ins., July, 1915, p. 47; points out the apparent shortcomings in computing percentages without considering age distribution.

An unusually large number of the immigrants, especially the Jews, settle in the urban districts, more often in the larger cities. It is an established fact that an urban environment brings to the surface neuropathic tendencies of a community far more fully than a rural environment. Considering this factor together with the difference in age distribution, and making some allowance for the heavy stress entailed in the migration and in the subsequent process of adjustment to new conditions and more exacting standards of living, there is found to be but little difference, if any, between the native and foreign-born parts of the population in the incidence of certified insanity."

Table II indicates that 820 or 72.7 per cent of the total

1 De Fursac and Rosanoff, p. 19.

Jewish admissions under consideration were of foreign birth, and 307 or 27.3 per cent were native born. Russia contributed more than half of the foreign born, 284 males and 188 females, a total of 472; from Austria-Hungary came 127 males and 115 females, a total of 242; Roumania contributed a total of 38, Germany 35, England 17, Turkey 6, Belgium 2, France 2, and I each from Arabia, Greece, Palestine, Persia, Spain and Switzerland. The figures of admissions to the psychopathic wards indicate approximately the proportion of Jewish immigration from the various countries during recent years, especially the last 20 to 30 years prior to 1914. In view of what has been said on the matter of age distribution among immigrants and the fact that 72.7 per cent of admissions in one year were foreign-born, any seeming disproportion of insanity among Jews in the United States, particularly in New York, where most Jews live, must be discounted.1 The further fact that nearly all Jewish immigrants settle in the cities, especially in the congested sections of the large seaboard communities, should render judgment still more cautious. From all available facts, the only conclusion that can be drawn indicates that there is no greater proneness toward mental disease in the foreign-born than in the native population and that the excessive proportion of hospital admissions furnished by the foreign-born is due to other causes.

IX. AGE DISTRIBUTION

Table 12 indicates the age distribution of the patients admitted. In interpreting the figures it should be remembered that the several clinical groups differ widely with respect to age distribution on admission. The senile and arterioscler

'U. S. Census, Population, vol. i, p. 826, gives the foreign-born population in New York City in 1910 as 40.8 per cent of the total population; for the Borough of Manhattan, 47.9 per cent.