previous attacks of insanity is a function of the Immigration and Naturalization Service, the Visa Division of the Department of State, or consular officials. This does not relieve the examining physician of responsibility for inquiring into the possibility of previous illnesses requiring one or more hospitalizations which might indicate such previous attacks. Such information should be reported on form FS-398 at consulates, and in a memorandum to the immigration authority at United States ports. It is the function of the consular or immigration officials to determine from facts available whether such a previous illness occurred. The physician may be requested to render an opinion on the basis of evidence furnished, as to whether a previous illness constituted an attack of "insanity."

6. Constitutional psychopathic inferiority-a. This is a statutory term with no exact counterpart in present medical or psychiatric nosology. However, with certain limitations the term "psychopathic personality" with its various subcategories which appears in the Standard Nomenclature of Disease and Standard Nomenclature of Operations' would seem to have the same meaning. In the classification of conditions under this category the word "constitutional" is important. With the presence of the word "constitutional" the term implies that the psychopathic inferiority was present at birth. It is therefore necessary that the written records of the physician's examination include statements of fact indicating that the condition of psychopathic inferiority, or the symptoms that indicate this diagnosis, were present, and are traceable rather clearly back to the early years of the individual's existence, and therefore could be considered to have been present at birth. If this cannot be accomplished on the basis of the information available at the examination, the condition should not be certified under this category, and should be considered for certification under the category of mental defect to be described later.

1 Copyright 1942 by American Medical Association; published by the Blakiston Co., Philadelphia and Toronto.

b. Some authorities regard the development of a psychosis as evidence that the individual had a psychopathic personality prior to its development. There is some evidence that factors which are not clearly understood cause one person to develop a psychotic reaction under conditions apparently similar to conditions to which other persons have been subjected without undergoing psychotic reactions. It is easy to assume that these factors are hereditary or constitutional. However, such assumptions do not constitute acceptable facts to support a certificate. On the other hand, it is quite possible that the medical examination will reveal enough evidence to indicate that the individual was suffering from mental defects in a relatively minor degree prior to the outbreak of his psychotic reaction. Such defects may then be considered a basis for certification as mentally defective, even though it may not be possible to trace the beginnings of these symptoms back to the time of birth so as to qualify the symptoms as a basis for certification of constitutional psychopathic inferiority.ungo

7. Chronic alcoholism.a. An individual who shows evidence of habitual and excessive use of alcoholic beverages to the extent that it interferes with his interpersonal relationships, or brings him repeatedly into conflict with constituted authority or social customs, is considered a chronic alcoholic. Obviously an individual presenting himself for medical examination in an intoxicated condition should be suspected of being a chronic alcoholic. b. Convulsive seizures following drinking of alcoholic beverages should arouse suspicion of chronic alcoholism.

c. An individual with an alcoholic psychosis, such as delirium tremens, Korsakoff's psychosis, or alcoholic hallucinosis, is certifiable as a chronic alcoholic unless the condition is severe enough to warrant certification as insanity. eg erig

8. Persons who are mentally defective. a. Under this category are certified all persons suffering from a mental abnormality of serious degree that cannot be classified as idiocy, imbecility, feeble-mindedness, epilepsy, insanity, constitutional psychopathic

inferiority, or chronic alcoholism. However, further explanation of this statement is required to enable the physician to classify the alien correctly. The terminology of the law divides afflictions of human beings into two categories, mental and physical. In a broad sense, "physical" is understood to refer to the functions of the organs and tissues of the body while "mental" refers to the function of the individual or his total behavior and interpersonal relations. This behavior of the individual is manifested in his activity as well as in his thought processes.

b. The next phrase to be considered in our discussion of a mentally defective person is the phrase "serious degree." This phrase implies quite correctly that mental disorders vary over a graduated scale from minor and insignificant disorders to major disorders of serious implications. The determination of the existence of a "serious degree" of mental abnormality must be left to the examining physician, but several criteria are given below as an aid to him in exercising his professional judgment:

(1) whether the mental defect is of a hereditary nature;
(2) whether it would require hospitalization; d) {
(3) whether the individual's behavior resulting from the
defect is such as to be likely to bring him into repeated
conflict with social customs, constituted authority, or
the social environment.

When there is reasonable evidence to support the conclusion that
a mental defect meets any of these criteria, it would seem to be
of a degree sufficient to warrant certification as mental defect,
class A.
Jack sine is to no oigaro can

c. It is well to quote here, again, paragraph (d) of section 34.7 of the regulations: "A mental defect not enumerated in paragraph (c) of this section; Provided, however, That a class A certificate or class A notification shall in no case be issued with respect to an alien having only mental shortcomings due to ignorance, or suffering only from a mental condition attributable to remediable physical causes, or from a psychosis of a temporary nature caused by a toxin, drug, or disease." 22 bobahasol boot

(1) A number of mental conditions are attributable to remediable causes. There There may be doubt as to whether a mental defect can be attributed to a physical cause, or whether the physical cause is remediable. In such cases the regulations would require that the. alien be "held over for such observation and further examination as may be reasonably necessary to determine his physical or mental condition" (sec. 34.10 (a)).

(2) If paresis is so far advanced that treatment obviously would not relieve the mental symptoms, the proviso in section 34.7 (d) quoted in paragraph c above regarding remediable causes would of course not be applicable.

d. In unusual cases not clearly covered by this manual the physician should assemble the pertinent data and forward them, with a request for advice, to the Surgeon General, Public Health Service, Washington 25, D. C., Attention: Division of Foreign Quarantine. Meanwhile the diagnosis should be deferred.

e. Aliens having epileptiform convulsions due to brain trauma with associated mental deterioration of a severe degree should be considered as having a mental defect, class A.

f. A number of psychotic conditions are certifiable under the category "mental defect." To illustrate, there are many patients with schizophrenia who cannot properly be certified as insane, but the existence of a clinical diagnosis of schizophrenia constitutes a serious degree of mental illness and warrants certification as a mental defect.

g. Individuals with psychopathic personality in whom it is not possible to demonstrate the constitutional nature of their symptoms are also certifiable in class A for "mental defect."

h. Individuals suffering from psychoneuroses are certifiable in class A only upon determination of the serious degree of the mental illness in accordance with the criteria outlined above.

i. Many organic diseases of the brain produce symptoms of mental illness. These mental symptoms should be evaluated in accordance with the above criteria, and if they are considered to be of a serious degree the individual should be certified in class A.

j. Drug addicts should be certified in class A regardless of the specific drugs used.

Section B.-Types of Certificates in Various
Diagnostic Categories

1

9. As an aid to the examining physician, all of the most common diagnostic categories of nervous and mental conditions. taken from the Standard Nomenclature of Disease1 are listed in this section with an alphabetical symbol opposite each diagnosis. These alphabetical symbols indicate the types of certificates that should be considered in each diagnostic condition, Symbol

ia

a-Certify as a mental defect unless criteria for other types of class A certificates are present,

b-Certify as mental defect unless criteria for insanity (par. 4, this chapter) are present.

c-Certify as feeble-mindedness, imbecility, or idiocy, depending upon the La degree. ut sub

d-Certify as chronic alcoholism.

e-Certify as mental defect unless it is determined that the mental condition is attributable to a remediable physical cause or of a temporary nature, caused by a toxin, drug, or disease.

f-Certify as chronic alcoholism unless severe enough to be certified as

A

h-Certify as epilepsy if idiopathic, as insanity or mental defect if criteria 2. kamu to s

are present.

i-Certify as constitutional psychopathic inferiority when constitutional factors are apparent, otherwise as mental defect.

j-Certify as mental defect if condition meets criteria for severity outlined in paragraph 8 of this chapter; otherwise consider as anoncertifiable condition.

k-Certify as epilepsy if idiopathic, as insanity or mental defect if criteria are present, otherwise as class B.