fezeszccoesoa] °| , Hew Work State College of Agriculture At Cornell University Ithaca, N. V. = iy I ie i Librarp STATE OF NEW YORK wea STATE HOSPITAL COMMISSION STATISTICAL GUIDE Revised for the Commission by the COMMITTEE ON STATISTICS CHARLES W. PILGRIM, M. D., Ex-offcio, Chairman, R. H. HUTCHINGS, M. D., Chairman, GEORGE H. KIRBY, M. D., ISHAM G. HARRIS, M. D., WALTER G. RYON, M. D., CHARLES G. WAGNER, M. D., HORATIO M. POLLOCK, Ph. D. FIFTH EDITION , UTICA, N, Y. STATE HOSPITALS PRESS 1921 STATE OF NEW YORK STATE HOSPITAL COMMISSION STATISTICAL GUIDE Revised for the Commission by the COMMITTEE ON STATISTICS CHARLES W. PILGRIM, M. D., Ex-officio, Chairman, R. H. HUTCHINGS, M. D., Chairman, GEORGE H. KIRBY, M. D., ISHAM G. HARRIS, M. D., WALTER G. RYON, M. D., CHARLES G. WAGNER, M. D., HORATIO M. POLLOCK, Ph, D. FIFTH EDITION UTICA, N, Y. STATE HOSPITALS PRESS 1921 mW. ca. Ra He] 7 @MLtHY/L INSTRUCTIONS FOR THE PREPARATION OF STATISTICAL DATA REVISED DECEMBER 15, 1920 The statistical data cards adopted in 1909 for use by the State hospitals in reporting facts concerning first admissions, readmissions, discharges, transfers and deaths are continued in slightly modified form. The purpose of this system of reporting and compiling informa- tion concerning the patients treated in our State hospitals is to furnish accurate information to the public and to enable the Commission and the physicians in the State service, as well as psychiatrists and the medical profession generally, to utilize to the fullest extent the knowledge concerning mental diseases that is being gained by the various State hospitals. The statistics already compiled by the Commission have received ‘wide recognition, but it is believed that the scope of the inquiries may be profitably enlarged and that further studies extending over several years may be advantageously made. Too great emphasis can not be placed on the importance of securing full and accurate information in regard to patients and of reporting such information correctly on the cards. The medical data concerning cases should be considered at meetings of the staff. The statistical card should be filled out by the physician into whose service the patient is admitted, or in whose service the discharge or death has occurred, and submitted to the presiding officer of the meeting. All doubtful questions should be freely discussed and a final determination of what is to be accepted should be reached by the staff. Obscure cases should be thoroughly studied before a fina! diagnosis is made. In order that uniformity in the use of terms may be secured the instructions given in this pamphlet should be carefully studied and scrupulously observed. STATISTICAL DATA CARDS General Directions At the end of the fiscal year each hospital should submit to the statistician of the State Hospital Commission at Albany a complete transcript of all statistical cards (Forms 3 to 16 medical). Cards should be sent by express or first-class mail. If changes are made in diagnoses or other data after the cards are sent, the statisti- cian should be notified at once. In reporting a change in diag- nosis, the original as well as the revised diagnosis should be given. Each institution should maintain a complete file of its statistical cards, i. e., duplicates of the cards sent to the statistician. Cards for the two sexes should be kept separate; those for male cases are printed in black and those for female cases in red. First admission cards (Forms 3 and 4 med.) should be submitted for all patients admitted for the first time to any hospital for the treatment of mental diseases, except institutions for temporary care only. Psychopathic wards of army and base hos- pitals should be considered as institutions for temporary care, unless such wards were planned and used for the prolonged care of mental cases. Re-admission cards (Forms 5 and 6 med.) should be submitted for all patients admitted who have been previously under treatment in any hospital or sanitarium wherein mental cases are treated, either public or private, in New York State (exclusive of admissions by transfer) or in other States or in other countries, not including institutions for temporary care only. [See page 47]. Discharge cards (Forms 7 and 8 med.) should be submitted for all patients discharged, including cases discharged as “ not insane” and also cases discharged to the custody of officials of the United States Immigration Service for deportation. Transfer cards (Forms 9 and 10 med.) should be filled out in duplicate for all patients transferred to any other hospital for the. insane, public or private, in New York State, by the hospital from which the patients are transferred, and one copy should be sent to 5 the institution to which the transfer is made, and the other copy to the statistician of the Commission. Death cards (Forms 11 and 12 med.) should be submitted for all patients dying in the hospitals. Patients dying while on parole should be discharged and reported on discharge cards. Filling In Cards Fill in every caption on each card submitted; if full or accurate information can not possibly be obtained enter “+” (symbol for “ facts unascertained ’’). If the information is negative, enter “ none” or “no.” Do not use the interrogation point (?). Do not use the dash (—) for “ unascertained ” or for “ negative.” Do not use the term “ several”; as “ several years”; enter rather “less than one yr.,” “ between 1 and 5 yrs.,” or “ over 10 yrs.,” if exact figures can not be obtained. Avoid round numbers ; accept figures ending with 5 or with 0 with skepticism and only after close questioning. Avoid, e. g., “1 yr.” for 11 mos., 12% mos., etc., and “1 mo.,” for 35 days, ete. Avoid “60 yrs.” for 59 or 61 yrs. Avoid ambiguous abbreviations; as “lob. pneu.” (lobar or lobular?), “par.” (paranoic or paralytic?), etc., and use only standard abbreviations. If the space assigned to any caption of the schedule is too limited to enter all ascertained data, mark the blank “ over” and enter the data on the back of the card. Entries on all cards should be typewritten. Designate items on the cards, by underscoring; as, single. Do not cross out items or use check marks. Identification Number The identification number assigned by the State Hospital Commission should be accurately entered on each card submitted to the statistician. Special attention should be given to transferring to the data cards on file at the hospital all corrections and changes in identification number ordered by the Commission. In case copies vt 6 such cards have been sent to the statistician, advice of such change should be mailed to him. Legal Status The “legal status” should be designated on the admission cards filled out in the State hospitals as of the day of admission and on the discharge and death cards as of the day of discharge and death, respectively, e. g., a patient entering a State hospital voluntarily and later committed should be reported on the admission card as a voluntary case. Psychoses The following classification should be used in diagnosing mental diseases. ‘The psychosis in each case should be designated on the card by the number, and group name; the type should also be given whenever provided for in the classification. CLASSIFICATION OF MENTAL DISEASES ADOPTED BY THE AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION MAY 30, 1917, AND BY THE NEW YORK STATE HOSPITAL COMMISSION JULY;1, 1917 1. Traumatic psychoses. (a) 2) (c) (d) Traumatic delirium. Traumatic constitution. Post-traumatic mental enfeeblement. Other types. 2. Senile psychoses. (a) (b) (ce) (d) (e) (f) (9) Simple deterioration. Presbyophrenic type. Delirious and confused states. Depressed and agitated states in addition to deterioration. Paranoid states. Pre-senile types. Other types. 3. Psychoses with cerebral arteriosclerosis. (This includes psychoses following cerebral softenings or hemorrhage if due to arterial disease). 4. General paralysis. (a) (b) Cerebral type. Tabetic type. 5. Psychoses with cerebral syphilis. 6. Psychoses with Huntington’s chorea. 7. Psychoses with brain tumor. 8. Psychoses with other brain or nervous diseases. (The following are the more frequent of these diseases and should be specified in the diagnosis) : Cerebral embolism. Paralysis agitans. Meningitis, tubercular or other forms (to be specified). Multiple sclerosis. Tabes. Acute chorea. Encephalitis lethargica. Other conditions (to be specified). 9. Alcoholic psychoses. (a) ) (c) (d) (e) (f) (9g) (A) (4) Pathological intoxication. Delirium tremens. Korsakow psychoses. Acute hallucinosis. Chronic hallucinosis. Acute paranoid type. Chronic paranoid type. Alcoholic deterioration. Other types, acute or chronic. 10. Psychoses due to drugs and other exogenous toxins. (a) 2) (c) (d) Opium (and derivatives), cocaine, bromides, chloral, etc., alone or combined (to be specified). Metals, as lead, arsenic, etc. (to be specified). Gases (to be specified). Other exogenous toxins (to be specified). 11. Psychoses with pellegra. 12. Psychoses with other somatic diseases. (a) (b) (c) (d) (e) (f) (9) Delirium with infectious disease (specify). Post-infectious psychosis. Exhaustion-delirium. Delirium of unknown origin. Cardio-renal diseases. Diseases of the ductless glands. Other diseases or conditions (to be specified). 13. Manic-depressive psychoses. (a) (b) (c) (d) (e) (f) Manic type. Depressive type. Stupor. Mixed type. Circular type. Other types. 14. Involution melancholia. 15. Dementia przecox. (a) (b) (c) (d) (e) Paranoid type. Catatonic type. Hebephrenic type. Simple type. Other types. 16. 17. 18. 19, 20. 21. 22. 9 Paranoia or paranoic conditions. Epileptic psychoses. (a) (b) (c) Deterioration, Clouded states. Other conditions (to be specified). Psychoneuroses and neuroses. (a) (b) (c) (d) (e) Hysterical type. Psychasthenic type. Neurasthenic type. Anxiety neuroses. Other types. Psychoses with psychopathic personality. Psychoses with mental deficiency. Undiagnosed psychoses. Without psychosis. (a) (b) (c) (d) (e) (f) Epilepsy without psychosis. Alcoholism without psychosis. Drug addiction without psychosis. Constitutional psychopathic inferiority without psychosis. Mental deficiency without psychosis. Others (to be specified). 10 DEFINITIONS AND EXPLANATORY NOTES The following explanatory notes and definitions of the various clinical groups were prepared for the Committee by Dr. George H. Kirby, Director, Psychiatric Institute, Ward’s Island, New York City. 1. Traumatic Psychoses The diagnosis should be restricted to mental disorders arising as a direct.or obvious consequence of a brain (or head) injury pro- ducing psychotic symptoms of a fairly characteristic kind. The amount of damage to the brain may vary from an extensive destruction of tissue to simple concussion or physical shock with or without fracture of the skull. Manic-depressive psychoses, general paralysis, dementia precox, and other mental disorders in which trauma may act as a contributory or precipitating cause, should not be included in this group. The following are the most common clinical types of traumatic psychosis and should be specified in the statistical record of the hospital : (a) Traumatic delirium: This may take the form of an acute delirium (concussion delirium), or a more protracted delirium resembling the Korsakow mental complex. (b) Traumatic constitution: Characterized by a gradual post- traumatic change in disposition, with vasomotor instability, headaches, fatigability, irritability or explosive emotional reactions ; usually hyper-sensitiveness to alcohol, and in some cases development of paranoid, hysteriod or epileptoid symptoms. (c) Post-traumatic mental enfeeblement (dementia): Varying degrees of mental reduction with or without aphasic symptoms, epileptiform attacks or development of a cerebral arteriosclerosis. (d) Other types. 2. Senile Psychoses A well defined type of psychosis which as a rule develops gradually and is characterized by the following symptoms: Impairment of retention (forgetfulness) and general failure of memory more marked for recent experiences ; defects in orientation 11 and a general reduction of mental capacity: the attention, concentration and thinking processes are interfered with; there is self-centering of interests, often irritability and stubborn opposition; a tendency to reminiscences and fabrications. Accompanying this deterioration there may occur paranoid trends, depressions, confused states, etc. Certain clinical types should therefore be specified, but these often overlap: (a) Simple deterioration: Retention and memory defects, reduction in intellectual capacity and narrowing of interests; usually also suspiciousness, irritability and restlessness, the latter particularly at night. (b) Presbyophrenic type: Severe memory and_ retention defects with complete disorientation; but at the same time preservation of mental aleriness and attentiveness with ability to grasp immediate impressions and conversation quite well. Forget- fulness leads to absurd contradictions and repetitions ; suggestibility and free fabrication are prominent symptoms. (The general picture resembles the Korsakow mental complex). (c) Delirious and confused types: Often in the early stages of the psychosis and for a long period the picture is one of deep confusion or of a delirious condition. (d) Depressed and agitated types: In addition to the underlying deterioration there may be a pronounced depression and persistent agitation. (e) Paranoid types: Well marked delusional trends, chiefly persecutory or expansive ideas, often accompany the deterioration and in the early stages may make the diagnosis difficult if the defect symptoms are mild. (f) Pre-senile types: The so-called “Alzheimer’s disease ” ; an early senile deterioration which usually leads rapidly to a deep dementia. Reported to occur as early as the fortieth year. Most cases show an irritable or anxicus depressive mood with aphasic or apractic symptoms. There is apt to be general resistiveness and sometimes spasticity. (9) Other types. 3. Psychoses with Cerebral Arteriosclerosis The clinical symptoms, both mental and physical, are varied, depending in the first place on the distribution and severity of the 12 vascular cerebral disease and probably to some extent on the mental make-up of the person. Cerebral physical symptoms, headaches, dizziness, fainting attacks, etc., are nearly always present and usually signs of focal brain disease appear sooner or later (aphasia, paralysis, etc.). The most important mental symptoms (particularly if the arteriosclerotic disease is diffuse) are impairment of mental tension, i. e., interference with the capacity to think quickly and accurately, to concentrate and to fix the attention; fatigability and lack of emotional control (alternate weeping and laughing). Often a tendency to irritability is marked; the retention is impaired and with it there is more or less general defect of memory, especially in the advanced stages of the disease, or after some large destructive lesion occurs. Pronounced psychotic symptoms may appear in the form of depression (often of the anxious type), suspicions or paranoid ideas, or episodes of marked confusion. To be included in this group are the psychoses following cerebral softening or hemcrrhage if due to arterial disease. (Autopsies in state hospitals show that in arteriosclerotic cases softening due to occlusion is relatively much more frequent than hemorrhage. ) Differentiation from senile psychosis is sometimes difficult, particularly if the arteriosclerotic disease manifests itself in the senile period. The two conditions may be associated; when this happens preference should be given in the statistical report to the arteriosclerotic disorder. High blood pressuré, although usually present, is not essential for the diagnosis of cerebral arteriosclerosis. 4. General Paralysis The range of symptoms encountered in general paralysis is too great to be reviewed here in detail. As to mental symptoms, most stress should be laid on the early changes in disposition and character, judgment defects, difficulty about time relations and discrepancies in statements, forgetfulness and later on a diffuse memory impairment. Cases with marked grandiose trends are less 13 likely to be overlooked than cases with depressions, paranoid ideas, alcoholic-like episodes, etc. Mistakes of diagnosis are most apt to be made in those cases having in the early stages pronounced psychotic symptoms and rela- tively slight defect symptoms, or in cases with few definite physical signs. Lumbar puncture should always be made if there is any doubt about the diagnosis. A Wassermann examination of the blood alone is not sufficient, as this does not tell us whether or not the central nervous system is involved. 5. Psychoses with Cerebral Syphilis Since general paralysis itself is now known to be a parenchymatous form of brain syphilis, the differentiation of the cerebral syphilis cases might on theoretical grounds be regarded as less important than formerly. Practically, however, the separation of the non-parenchymatous forms is very important because the symptoms, the course and therapeutic outlook in most of these cases are different from those of general paralysis. According to the predominant pathological characteristics, three types of cerebral syphilis may be distinguished, viz.: (a) Meningitic, (b) endarteritic, and (c) gummatous. The lines of demarcation between these types are not, however, sharp ones. We practically always find in the endarteritic and gummatous types a certain amount of meningitis. The acute meningitic form is the most frequent type of cerebral syphilis and gives little trouble in diagnosis; many of these cases do not reach state hospitals. In most cases after prodromal symptoms (headache, dizziness, etc.) there is a rapid development of physical signs, usually cranial nerve involvement, and a mental picture of dullness or confusion with few psychotic symptoms except those related to a delirious or organic reaction. In the rarer chronic meningitic forms which are apt to occur a long time after the syphilitic infection, usually in the period in which we might expect general paralysis, the diagnostic difficulties may be considerable. In the endarteritic forms the most characteristic symptoms are those resulting from focal vascular lesions. 14 In the gummatous forms the slowly developing focal and pressure symptoms are most significant. In ali forms of cerebral syphilis the psychotic manifestations are less prominent than in general paralysis and the personality is much better preserved as shown by the social reactions, ethical sense, judgment and general behavior. The grandiose ideas and absurd trends of the general paralytic are rarely encountered in these cases. 6. Psychoses with Huntington’s Chorea Mental symptoms are a constant accompaniment of this form of chorea and as a rule become more marked as the disease advances. Although the disease is regarded as being hereditary in nature, a diagnosis can be made on the clinical picture in the absence of a family history. The chief mental symptoms are those of mental inertia and an emotional change, either apathy and silliness or a depressive irritable reaction with a tendency to passionate outbursts. As the disease progresses the memory is affected to some extent, but the patient’s ability to recall past events is often found to be surprisingly weil [reserved when the disinclination to co-operate and give information can be overcome. Likewise the orientation is well retained even when the patient appears very apathetic and listless. Suspicions and paranoid ideas are prominent in some cases. 7. Psychoses with Brain Tumor A large majority of brain tumor cases show definite mental symptoms. Most frequent are mental dullness, somnolence, hebetude, slowness in thinking, memory failure, irritability and depression, although a tendency to facetiousness is sometimes observed. Episodes of confusion with hallucinations are common; some cases express suspicions and paranoid ideas. The diagnosis must rest in most cases on the neurological symptoms, and these will depend on the location, size and rate of growth of the tumor. Certain general physical symptoms due to an increased intra-cranial pressure are present in most cases, viz.: headache, dizziness, vomiting, slowing of the pulse, choked disc and interlacing of the color fields. 15 8. Psychoses with Other Brain or Nervous Diseases This division provides a place for grouping a variety of less common mental disorders associated with organic disease of the nervous system and not included in the preceding larger groups. On the card the special type of brain or nervous diseases should be mentioned after the group name. The following are the diseases most frequently met with: (a) Cerebral embolism (if an incident in cerebral arteriosclerosis it should be placed in group 3.) (b) Paralysis agitans. (c) Meningitis, tubercular or other forms to be specified. (d) Multiple sclerosis. (e) Tabes dorsalis (paresis to be carefully excluded). (f) Acute chorea (Sydenham’s type). Hysterical chorea to be excluded. (g) Encephalitis lethargica. (h) Other diseases (to be specified). 9. Alcoholic Psychoses The diagnosis of alcoholic psychosis should be restricted to those mental disorders arising with few exceptions in connection with chronic drinking and presenting fairly well defined symptom- pictures. One must guard against making the alcoholic group too inclusive. Over-indulgence in alcohol is often found to be merely a symptom of another psychosis, or at any rate may be incidental to another psychosis, such as general paralysis, manic-depressive insanity, dementia przecox, epilepsy, etc. The cases to be regarded as alcoholic psychoses which do not result from chronic drinking are the episodic attacks in some psychopathic personalities, the dipsomanias (the true periodic drinkers) and pathological intoxica- tion, any one of which may develop as the result of a single imbibition or a relatively short spree. The following alcoholic reactions usually present symptoms distinctive enough to allow of clinical differentiation : (a) Pathological intoxication: An unusual or abnormal imme- diate reaction to taking a large or small amount of alcohol. Essentially an acute mental disturbance of short duration characterized usually by an excitement or furor with confusion and hallucinations, followed by amnesia. 16 (b) Delirium tremens: An hallucinatory delirium with marked general tremor and toxic symptoms. (c) Korsakow’s psychosis: This occurs with or without poly- neuritis. The delirious type is not readily differentiated in the early stages from severe delirium tremens but is more protracted. The non-delirious type presents a characteristic retention defect with disorientation, fabrication, suggestibility and tendency to misidentify persons. Hallucinations are infrequent after the acute phase. (d) Acute hallucinosis: This is chiefly an auditory hallucinosis of rapid development with clearness of the sensorium, marked fears, and a more or less systematized persecutory trend. (e) Chronic hallucinosis: This is an infrequent type which may be regarded as the persistence of the symptoms of the acute hallucinosis without change in the character of the symptoms except perhaps a gradual lessening of the emotional reaction accompanying the hallucinations. (f) Acute paranoid type: Suspicions, misinterpretations, and persecutory ideas, often a jealous trend; hallucinations usually subordinate, clearing up on withdrawal of alcohol. (g) Chronic paranoid type: Persistence of symptoms of the acute paranoid type with fixed delusions of persecution or jealousy usually not influenced by withdrawal of alcohol; difficult to differentiate from non-alcoholic paranoid states or dementia przcox. (h) Alcoholic deterioration: A slowly developing ethical, voli- tional and emotional change in the habitual drinker; apparently relatively few cases are committed as the mental symptoms are not usually looked upon as sufficient to justify the diagnosis of a definite psychosis. ‘The chief symptoms are ill humor and irascibility or a jovial, careless, flippant, facetious mood; abusiveness to family, un- reliability and tendency to prevarication; in some cases definite sus- picions and jealousy; there is a general lessening of efficiency and capacity for physical and mental work; memory not seriously im- paired. To be excluded are residual defects due to Korsakow’s psychosis, or mental deterioration due to arteriosclerosis or to trau- matic lesions. (7) Other types, acute or chronic, to be specified. 17 10. Psychoses Due to Drugs and Other Exogenous Toxins The clinical pictures produced by drugs and other exogenous poisons are principally deliria or states of confusion; although sometimes hallucinatory and paranoid reactions are met with. Certain poisons and gases appareritly produce special symptoms, e. g., cocaine, lead, illuminating gas, etc. Grouped according to the toxic etiological factors the following are to be differentiated: (a) Opium (and derivatives), cocaine, bromides, choral, etc., alone or combined (to be specified). (6) Metals, as arsenic, lead, etc. (to be specified). (c) Gases (to be specified). (d) Other exogenous toxins (to. be specified). 11. Psychoses with Pellagra The relation which various mental disturbances bear to the disease pellagra is not yet settled. Cases of pellagra occurring during the course of a well-established mental disease such as dementia pracox, manic-depressive insanity, senile dementia, etc., should not be included in this group. The mental disturbances which are apparently most intimately connected with pellagra are certain delirious or confused states (toxic-organic-like reactions) arising during the course of a severe pellagra. These are the cases which for the present should be placed in the group of psychoses with pellagra. 12. Psychoses with Other Sematic Diseases Under this heading are brought together those mental disorders which appear to depend directly upon some physical disturbance or somatic disease not already provided for in the foregoing groups. In the types designated below under (a) to (e) inclusive, we have essentially deliria or states of confusion arising during the course of an infectious disease or in association with a condition of exhaustion or a toxemia. The mental disturbance is apparently the result of interference with brain nutrition or the unfavorable action of certain deleterious substances, poisons or toxins, on the central nervous system. ‘The clinical pictures met with are extremely varied. The delirium may be marked by severe motor excitement and incoherence B 18 of utterance, or by multiform hallucinations with deep confusion or a dazed, bewildered condition; epileptiform attacks, catatonic-like symptoms, stupor, etc., may occur. In classifying these psychoses a difficult problem arises in many cases if attempts are made to distinguish between infection and exhaustion as etiological factors. For statistical reports the following differentiations should be made: Under (a) “ Delirium with infectious diseases,” place the initial deliria which develop during the prodromal or incubation period or before the febrile stage as in some cases of typhoid, small-pox, malaria, etc.; the febrile deliria which seem to bear a definite relation to the rise in temperature; the post-febrile deliria of the period of defervescence including the so-called “ collapse delirium.” Under (0) “ Post-infectious psychosis” are to be grouped deliria, the mild forms of mental confusion or the depressive, irritable, suspicious reactions which occur during the period of convalescence from infectious diseases. Physical asthenia and prostration are undoubtedly important factors in these conditions and differentiation from “exhaustion deliria’”’ must depend chiefly on the history and obvious close relationship to the preceding infectious disease. (Some cases which fail to recover show a peculiar mental enfeeblement.) In this group should be classed the “ cerebropathica psychica toxemica” or the non-alcoholic polyneuritic psychoses following an infectious disease as typhoid, influenza, septicemia, etc. Under (c) “ Exhaustion delirium” are to be classed psychoses in which physical exhaustion, not associated with or the result of an infectious disease, is the chief precipitating cause of the mental disorder, e. g., hemorrhage, severe physical over-exertion, deprivation of food, prolonged insomnia, debility from wasting disease, etc. Of the psychoses which occur with diseases of the ductless glands, the best known are the thyroigenous mental disorders. Disturbance of the pituitary or of the adrenal function is often associated with mental symptoms. According to the etiology and symptoms the following types should therefore be specified under “ Psychoses with other Somatic Diseases”: (a) Delirium with infectious disease (specify). 19 (b) Post-infectious psychosis (specify). (c) Exhaustion delirium. (d) Delirium of unknown origin. (e) Cardio-renal disease with psychoses. (f) Diseases of the ductless glands (specify). (g) Other diseases or conditions (to be specified). 13. Manic-Depressive Psychoses This group comprises the essentially benign affective psychoses: mental disorders which fundamentally are marked by emotional oscillations and a tendency to recurrence. Various psychotic trends, delusions, illusions and hallucinations, clouded states, stupor, etc., may be added. ‘To be distinguished are: The manic reaction with its feeling of well-being (or irascibility), flight of ideas and over-activity. . The depressive reaction with its feeling of mental and physical insufficiency, a despondent, sad or hopeless mood and in severe depressions, retardation and inhibition; in some cases the mood is one of uneasiness and anxiety, accompanied by restlessness. The stupor reaction with its marked reduction in activity depression, ideas of death, and often dream-like hallucinations ; sometimes mutism, drooling and muscular symptoms suggestive of the catatonic manifestations of dementia przcox, from which, however, these manic-depressive stupors are to be differentiated. The mixed reaction, a combination of manic and depressive symptoms appearing at the same time. An attack is called circular when as is often the case, one phase is followed immediately by another phase, e. g., a manic reaction passes over into a depressive reaction or vice versa. Cases formerly classed as allied to manic-depressive should be placed here rather than in the undiagnosed group. In the statistical reports the following should be specified : (a) Manic type. (b) Depressive type. (c) Stuporous type. (d) Mixed type. (e) Circular types. (f) Other types. 20 14. Involution Melancholia These depressions are probably related to the manic-depressive group; nevertheless the symptoms and the course of the involution cases are sufficiently characteristic to justify us in keeping them apart as special forms of emotional reaction. To be included here are the slowly developing depressions of middle life and later years which come on with worry, insomnia, uneasiness, anxiety and agitation, showing usually the unreality and sensory complex, but little or no evidence of any difficulty in thinking. ‘The tendency is for the course to be a prolonged one. Arteriosclerotic depressions should be excluded. When agitated depressions of the involution period are clearly superimposed on a manic-depressive foundation with previous attacks (depression or excitement) they should, for statistical purposes, be classed in the manic-depressive group. 15. Dementia Przcox This group cannot be satisfactorily defined at the present time as there are still too many points at issue as to what constitute the essential clinical features of dementia preecox. A large majority of the cases which should go into this group may, however, be recognized without special difficulty, although there is an important smaller group of doubtful, atypical, allied or transitional cases which from the standpoint of symptoms or prognosis occupy an uncertain clinical position. The term “schizophrenia” is now used by many writers instead of dementia precox. Cases formerly classed as allied to dementia przcox should be placed in the dementia precox group rather than in the undiagnosed group. The following-mentioned features are sufficiently well established to be considered most characteristic of the dementia precox type of reaction: A seclusive type of personality or one showing other evidences of abnormality in the developmen: of the instincts and feelings. Appearance of. defects of interest and discrepancies between thought on the one hand and the behavior-emotional reactions on the other. 21 A gradual blunting of the emotions, indifference or silliness with serious defects of judgment and often hypochondriacal complaints, suspicions or ideas of reference. Development of peculiar trends, often fantastic ideas, with odd, impulsive or negativistic conduct not accounted for by any acute emotional disturbance or impairment of the sensorium. Appearance of autistic thinking and dream-like ideas, peculiar feelings of being forced, of interference with the mind, of physical or mystical influences, but with retention of clearness in other fields (orientation, memory, etc.). According to the prominence of certain symptoms in individual cases the following four clinical forms of dementia praecox may be specified, but it should be borne in mind that these are only relative distinctions and that transitions from one clinical form to another are common: (a) Paranoid type: Cases characterized by a prominence of delusions, particularly ideas of persecution or grandeur, often connectedly elaborated, and hallucinations in various fields. (b) Catatonic type: Cases in which there is a prominence of negativistic reactions or various peculiarities of conduct with phases of stupor or excitement, the latter characterized by impulsive, queer or stereotyped behavior and usually hallucinations. (c) Hebephrenic types: Cases showing prominently a tendency to silliness, smiling, laughter, grimacing, mannerisms in speech and action, and numerous peculiar ideas usually absurd, grotesque and changeable in form. (d) Simple type: Cases characterized by defects of interest, gradual development of an apathetic state, often with peculiar behavior, but without expression of delusions or hallucinations. (e) Other types. 16. Paranoia or Paranoic Conditions From this group should be excluded the deteriorating paranoic states and paranoic states symptomatic of other mental disorders or of some damaging factor such as alcohol, organic brain disease, etc. The group comprises cases which show clinically fixed suspicions, persecutory delusions, dominant ideas or grandiose trends logically 22 elaborated and with due regard for reality after once a false interpretation or premise has been accepted. Further characteristics are formally correct conduct, adequate emotional reactions, clearness and coherence of the train of thought. Hallucinations may occur although not usually prominent. 17. Epileptic Psychoses In addition to the epileptic deterioration, transitory psychoses may occur which are usually characterized by a clouded mental state followed by an amnesia for external occurrences during the attack. (The hallucinatory and dream-like experiences of the patient during the attack may be vividly recalled.) Various automatic and secondary states of consciousness may occur. According to the most prominent clinical features the epileptic mental disorders should therefore be specified as follows: (a) Epileptic deterioration: A gradual development of mental dullness, slowness of association and thinking, impairment of mem- ory, irritability or apathy. (b) Epileptic clouded states: Usually in the form of dazed reactions with deep confusion, bewilderment and anxiety or excite- ments with hallucinations, fears and violent outbreaks; instead of fear there may be ecstatic moods with religious exaltation. (c) Other epileptic types. (To be specified. ) 18. Psychoneuroses and Neuroses The psychoneurosis group includes those disorders in which mental forces or ideas of which the subject is either aware (conscious) or unaware (unconscious) bring about various mental and physical symptoms—in other words these disorders are essentially psychogenic in nature. The term neurosis is now generally used synonymously with psychoneurosis although it has been applied to certain disorders in which, while the symptoms are both mental and physical, the primary cause is thought to be essentially physical. In most instances, however, both psychogenic and physical causes are operative and we can assign only a relative weight to the one or the other. 23 The following types are sufficiently well defined clinically to be specified : (a) Hysterical type: Episodic mental attacks in the form cf delirium, stupor or dream states during which repressed wishes, mental conflicts or emotional experiences detached from ordinary consciousness break through and temporarily dominate the mind. The attack is followed by partial or complete amnesia. Various physical disturbances (sensory and motor) occur in hysteria, and these represent a conversion of the affect of the repressed disturbing complexes into bodily symptoms or, according to another formulation, there is a dissociation of consciousness relating to some physical function. (b) Psychasthenic type: This includes the compulsive and obsessional neuroses of some writers. The main clinical character- istics are phobias, obsessions, morbid doubts and impulsions, feelings of insufficiency, nervous tension and anxiety. Episodes of marked depression and agitation may occur. There is no disturbance of consciousness or amnesia as in hysteria. (c) Neuwrasthenic type: This should designate the fatigue neuroses in which physical as well as mental causes evidently figure ; characterized essentially by mental and motor fatigability and irritability ; also various hyperesthesias and paresthesias, hypochon- driasis and varying degrees of depression. (d) Anxiety neuroses: A clinical type in which morbid anxiety or fear is the most prominent feature. A general nervous irritability (or excitability) is regularly associated with the anxious expectation or dread; in addition there are numerous physical symptoms which may be regarded as the bodily accompaniments of fear, particularly cardiac and vasomotor disturbances: the heart’s action is increased, often there is irregularity and palpitation; there may be sweating, nausea, vomiting, diarrhoea, suffocative feelings, dizziness, trembling, shaking, difficulty in locomotion, ete. Fluctuations occur in the intensity of the symptoms, the acute exacerbations constituting the “anxiety attack.” (e) Other types. 24 19. Psychoses with Psychopathic Personality Under the designation of psychopathic personality is brought to- gether a large group of pathological personalities whose abnormality of make-up is expressed mainly in the character and intensity of their emotional and volitional reactions. To meet the demands of current usage, the term for this group has been shortened from the older one “psychoses with constitutional psychopathic inferior- ity” with which it is synonymous. Individuals with an intellectual defect (feeblemindedness) are not to be included in this group. Several of the preceding groups, in fact all of the so-called constitutional psychoses, manic-depressive, dementia precox, paranoia, psychoneuroses, etc., may be considered as arising on a basis of psychopathic inferiority or constitution because the previous mental make-up in these conditions shows more or less clearly abnor- malities in the emotional and volitional spheres. These reactions are apparently related to special forms of psychopathic make-up now fairly well differentiated, and the associated psychoses also have their own distinctive features. There remain, however, various other less well differentiated types of psychopathic personalities, and in these the psychotic reactions (psychoses) also differ from those already specified in the preceding groups. It is these less well differentiated types of emotional and volitional deviation which are to be designated, at least for statistical purposes, as psychopathic personality. The type of behavior dis- order, the social reactions, the trends of interests, etc., which psycho- pathic personalities may show give special features to many cases, €. g., criminal traits, moral deficiency, tramp life, sexual perversions and various temperamental peculiarities. The pronounced mental disturbances or psychoses which develop in psychopathic personalities and bring about their commitment are varied in their clinical form and are usually of an episodic character. Most frequent are attacks of irritability, excitement, depression, paranoid episodes, transient confused states, etc. True prison psychoses belong in this group. In accordance with the standpoint developed above, a psychopathic personality with a manic-depressive attack should be classed in the 25 manic-depressive group, and likewise a psychopathic personality with a schizophrenic psychosis should go in the dementia pracox group. Psychopathic personalities without an episodic mental attack or any psychotic symptoms should be placed in the without psychoses group under the appropriate sub-heading. 20. Psychoses with Mental Deficiency This group includes the psychoses with various types of intellect- ual deficiency or feeblemindedness. The degree of mental deficiency should be determined by the history and the use of standard psycho- metric tests. The intellectual level may be denoted in the statistics by specifying borderline, moron, imbecile, idiot. Acute, usually transient, psychoses of various forms occur in mentally deficient persons and commitment to a hospital for the insane may be necessary. The most common mental disturbances are episodes of excitement or irritability, depressions, paranoid trends, hallucinatory attacks, etc. Mentally deficient persons may suffer from manic-depressive attacks or from dementia precox. When this occurs the diagnostic grouping should be manic-depressive or dementia precox as the case may be. Mental deficiency cases without psychotic disturbances should go into the without psychoses group under the appropriate sub-heading. 21. Undiagnosed Psychoses In this group should be placed the cases in which a satisfactory diagnosis can not be made and the psychosis must therefore be regarded as an unclassified one. The difficulty may be due to lack of information or inaccessibility of the patient; or the clinical picture may be obscure, the etiology unknown, or the symptoms unusual. Cases placed in this group during the year should be again reviewed before the annual diagnostic tables are completed. Cases of the type formerly placed in one of the allied groups should not be put in the undiagnosed group except for some special reason. Most of the cases hitherto called allied should be placed in the main group to which they seem most closely related. 26 22. Without Psychosis This group should receive the occasional case which after investigation and observation gives no evidence of having had a psychosis. ‘The only difficulty likely to be encountered in the statistical reports will arise in the grouping of patients who have recovered from a psychosis prior to admission. In such cases, if the history, the commitment papers or the patient’s retrospective account shows that a psychosis actually existed immediately before admission, that is, at the time of commitment, then the case should be considered as having suffered from a mental disorder, and classification under the appropriate heading should be made. If it is determined that no psychosis existed, then the condition which led to admission should be specified. The following come most frequently into consideration: (a) Epilepsy without psychosis. (6b) Alcoholism without psychosis. (c) Drug addiction without psychosis. (d) Psychopathic personality without psychosis. (e) Mental deficiency without psychosis. (f) Other conditions (to be specified). Nativity The state or territory of birth of those born in the United States should be given; enter “ U.S.” only when the state of birth can not be ascertained. The data of nativity of those of foreign birth should be based on the classification used by the United States Census Bureau, a condensed copy of which is given herewith. Care should be taken to ascertain definitely the country of birth of every patient. Here- after nativity should be reported in accordance with a new map of Europe established by the Peace Congress. at Modified Form of United States Africa Asia* of Nativity Atlantic Islands Australia Austria Belgium Bohemi a Canadat Central China Cuba America Czecho-Slovakia Denmark England Europe* Finland France Germany Greece Hawaii Holland Hungary India * Not otherwise specified. { Includes Newfoundland. ¢ Except Cuba and Porto Rico. Census Classification Ireland Italy Japan Jugo-Slavia Mexico Norway Philippine Islands Poland Porto Rico Portugal Roumania Russia Scotland South America Spain Sweden Switzerland Turkey in Asia Turkey in Europe Wales West Indiest Other countries Born at sea 28 Citizenship The citizenship of the patient and of the father of the patient should be definitely reported as “American” or “ foreign.” Foreign-born persons (with few exceptions) are aliens unless naturalized, and their citizenship should be reported as foreign if evidence of their naturalization can not be produced. Aliens may be naturalized in several ways, as follows: 1. By making required declarations and receiving final naturalization Papers from a court of competent jurisdiction. 2. A woman, by the naturalization of her husband or by marriage to a citizen. 3. Minors, by the naturalization of their parents. All persons (with few exceptions) born in the United States are citizens regardless of parentage. A woman loses her citizenship by marriage to an alien. A declaration of intention does not confer rights of citizenship; a foreigner is an alien until actually naturalized. An alien, to be eligible for citizenship, must have resided in the United States continuously for five years. The provision in regard to period of residence in the United States does not apply to foreign-born soldiers and sailors who served in the army or navy of the United States in the recent World War. Such soldiers and sailors must be naturalized, however, by a court of competent jurisdiction in order to become citizens of the United States. Race The race of the patients admitted should be designated by the terms given in the list of races printed below: Condensed Form of List of Races Adopted by United States Immigration Service African (black) American Indian Armenian Bulgarian Chinese Cuban Dutch and Flemish East Indian English Finnish French German Greek Hebrew Trish Italian (includes “ north ” and “ south ”) Japanese Korean { Includes Lett race. Lithuanianf Magyar Mexican Pacific Islander Portugese Roumanian Scandinavian (Norwegians, Danes and Swedes) Scotch Slavonic* Spanish Spanish-American Syrian Turkish Welsh West Indian (except Cuban) Mixed Race unascertained * “ Slavonic ” includes Bohemian, Bosnian, Croatian, Dalmatian, Herzegovinian, Montenegrin, Moravian, Polish, Russian, Ruthenian, Servian, Slovak, Slovenian. The “Dictionary of Races” prepared by the Immigration Commission should be used as a guide for the determination of race. The following suggestions may be found helpful : African. ‘This term should be applied to all negroes of pure or mixed blood, whether coming from Africa, Cuba or other West Indian Islands, Europe or North or South America. Armenian. Care should be taken not to confuse Armenians with Syrians. 30 Bulgarian. The Bulgarians who came to the United States before the World War are all from Bulgaria but hereafter it will not always be possible to identify Bulgarians by their starting place in Europe. The language should identify them in all cases. Cuban, Care must be taken not to include negroes and Spanish-Americans among “ Cubans.” Dutch and Flemish. Nearly all the Dutch who come to the United States come from Holland. They call themselves “ Hollanders.” The Flemish are the people inhabiting Belgium. East Indian. This term refers to the natives of the East Indies, including Hindus and is a very loose term, ethnologically. This is a matter of smail importance, however, as very few immigrants come to the United States from the East Indies. English. Care must be taken to exclude Hebrews who are born in England. English speaking persons of mixed race should also be excluded. Finnish. All natives of Finland are not Finns: many of them are Swedes. Of the Finns living in Europe, more than 1,000,000 live outside of Finland. German. Care must be taken to classify Germans from Russia as Germans. Hebrew. No difficulty will be experienced in identifying Hebrews and they should be so classified without regard to the country from which they come. Italian. Very few Italians come to the United States from any country except Italy, although some come from Brazil and the Argentine Republic. Care must be taken not to confuse these with Spanish-Americans, Lithuanian, Lithuanians in the United States are quite likely to be confused with Poles or Slovaks. They are quite distinct from the “ Slavonic” people and should be enumerated separately. Magyar. Magyars are often called “Hungarians,” “Huns” or “Hunyaks” in popular language in this country. Roumanian. In reporting patients born in Roumania, the only chance for error is the failure to exclude Hebrews and Gypsies. There are about hali as many Roumanians in Hungary as there are in Roumania and so it is necessary to consider them in reporting the race of natives of Hungary. Slavonic. This is a very important racial division as a very large number of Slavonic immigrants have come to the United States in recent years. It is believed that the use of this term will solve a great many difficulties as it makes it unnecessary to distinguish between Poles, Slovaks, etc. The only 31 danger to guard against is that of including Lithuanians, Finns, Magyars or Roumanians. Spanish, Care should be taken not to apply this term to Spanish- Americans. Spanish-Americans. This term refers only to “the people of Central and South America of Spanish descent.” Turkish. Care should be taken not to include Armenians and Syrians under this designation. West Indians. Care should be taken to exclude negroes, Cubans and Spanish-Americans. Only a very small number of West Indians, not negroes, are admitted to the United States. Mixed. This term should be used to designate the race of a patient whose ancestors were of two or more races. The terms “American,” “Swiss” and “Austrian” should not be used to designate race. (See discussion of these terms in the “Dictionary of Races.’’) Marital Condition The term “ separated ” as here used indicates undivorced married persons who live apart through estrangement, whether by legal decree or otherwise. Education Report education as “none” if patient or inmate can neither read nor write in any language. If he has attended common school, high school or college, indicate on the card the grade of scholastic work completed in the institution of highest rank among those attended. Give also age at which this grade was completed. Schools of law, medicine, dentistry or pharmacy are included under the term “collegiate”. Business schools may rank as common school, high school or collegiate in accordance with the course of instruction given. If education has been obtained outside of school, the grade attained should be reported on the card. 32 Occupation The occupation assigned a patient should be based on the United States Census “Index to Occupations”, a copy of which should be procured by each institution. Each occupational designation should give the kind of work the person performs and the business, industry or establishment in which the person works. An abbreviated list of principal occupations in this State classified by industries is ap- pended hereto. Occupations not exactly assignable to any of those given in the list or in which further particulars are of importance should be entered specifically; as, “operator on pearl buttons” (sawyer), “train solicitor for baggage transfer,” etc. “Indicate in every case the kind of work done or character of service rendered. Do not state merely the article made or worked upon, or the place where the work is done. For example, the reply ‘carriage builder,’ or ‘works in a carriage factory,’ is unsatisfactory, because men of different trades, such as blacksmiths, joiners, wheelwrights, painters, upholsterers, work together in building carriages. Such an answer, therefore, does not show what kind of work the person performs. “Return every person according to his own occupation, not that of his employer. For example: Describe a blacksmith employed by a manufacturer of carriages as a carriage blacksmith and not as a carriage builder; or a cooper, employed by a brewery as a cooper and not a brewer, etc. “Do not confound a clerk with a salesman, as is often done, especially in dry goods stores, grocery stores, and provision stores. Generally speaking, a person so employed is to be considered as a salesman, unless most of his service is in the office on the books and accounts; otherwise he should be returned as salesman—dry goods; salesman—groceries, etc. A stenographer, typewriter, accountant, bookkeeper or cashier should be reported as such and not as a clerk. “Distinguish a traveling salesman from a salesman in a store, return the former as a ‘ commercial traveler,’ and state the kind of goods sold by him. “Do not accept ‘ maker’ of an article, or ‘ works in’ mill, shop or factory, but strive always to find out the particular work done. 33 “Do not say ‘finisher,’ ‘molder,’ ‘polisher,’ etc., but describe the work done, as brass finisher, iron molder, steel polisher, etc. “Distinguish between a person who tends machines and the unskilled workman or laborer in mills, factories and workshops.”’* Report a person who operates a farm as owner, tenant, renter or cropper, as a farmer; a person who manages a farm for some one else for wages or salary, as a farm overseer; and a person who works on a farm for someone else, as a farm laborer. Do not describe a person in a printing office as a printer where a more specific term can be used, as compositor, pressman, linotypers and typesetters. Distinguish between an expressman, teamster, driver, and carriage and hack driver. When any of these terms are used be careful tu state definitely the industry in which the service was performed, as driver—bakery wagon; driver—delivery wagon; driver—ambulance, etc. In reporting semi-skilled operatives precisely specify the industry as weaver—carpet mill; spinner—cotton mill, etc. Carefully discriminate between butchers employed in slaughter houses and butchers who are meat dealers. Do not use the word “laborer” alone, but indicate the kind of labor performed, as farm laborer, building laborer, railroad laborer, laborer paper mill, etc. The entry own income should be made in case of all persons who followed no specific occupation, but have an independent income upon which they were living. All females engaged in a gainful occupation (exclusive of housekeeping in their own families or assisting in the house work at home, where a regular wage is not received and the relationship of employer and employee not maintained) should be reported as doing such work, but all females dependent on another should be reported as wife, sister, daughter, etc., of the member of the family on whom they are dependent, e. g.: a farmer’s daughter engaged in teaching school should be reported as “public school teacher,” a second daughter employed as saleswoman in a dry goods store as *Extracts from the instructions concerning the reporting of occupations issued the enumerators employed on tho Twelfth Census. Q 34 “saleswoman—dry goods,” a third daughter assisting in the housework at home as “farmer’s daughter.” Return as “housekeepers ” only those receiving a regular wage for such work. Do not report a married woman as a “ housewife.” If a woman in addition to doing housework in her own home regularly earns money by some other occupation, that occupation should be reported. For instance, a woman who regularly takes in washing should be reported as,—laundress at home. Distinguish between cloakmaker, dressmaker, seamstress and tailoress. Distinguish between teachers of art and music, of dancing, and teachers in schools, public or private. If a patient has had two or more occupations, report only the most important one, that is the one from which he derived the greater part of his income. For instance, return a man as a farmer if he obtained most of his living from farming, although he may have followed the occupation of carpenter or painter when not engaged in farm work. If a patient had changed his occupation before the onset of the psychosis, the facts should be stated. For example, book agent one month, formerly farmer. CONDENSED LIST OF OCCUPATIONS Taken from United States Census “Index to Occupations,” Prepared February, 1915 Agriculture, Forestry and Animal Husbandry: Farmers. Farm laborers. Fishermen and oystermen. Foresters. Gardeners, florists, fruit growers and nurserymen, Garden, greenhouse, orchard and nursery laborers. Landscape gardeners. Lumbermen, raftsmen and woodchoppers. Apiarists. Poultry raisers. Extraction of Minerals: Mine operators, officials and managers. Mine foreman and inspectors. Mine operatives. Quarry operatives. Oil, gas and salt well operatives. Manufacturing and Mechanical Industries: Apprentices. Bakers. Blacksmiths. Boiler makers. Brick and stone masons. Builders and building contractors. Butchers (slaughter house). Cabinet makers. Carpenters. Compositors, linotypers and typesetters. Coopers. Coppersmiths. Dressmakers and seamstresses (not in factory). Dyers. Electricians and electrical engineers. Electrotypers and stereotypers. Engineers (mechanical). Engincers (stationary). Engravers. 36 Filers, grinders, buffers and polishers (metal). Firemen (except locomotive and fire department). Foremen and overseers (manufacturing). Furnace men. Glass blowers. Goldsmiths and silversmiths. Jewelers and watchmakers (factory). Jewelers and watchmakers (not in factory). Laborers (specify industry). Lithographers. Loom fixers. Machinists and millwrights. _ Managers and superintendents (manufacturing). Manufacturers and officials. Millers (grain, flour, feed, etc.). Milliners and millinery dealers. Molders, founders and casters (brass). Molders, founders and casters (iron). Oilers of machinery. Painters, glaziers and varnishers (building). Painters, glaziers and varnishers (factory). Paper hangers. Pattern and model makers. Piano and organ tuners. Plasterers. Plumbers and gas and steamfitters. Pressmen (printing). Rollers and roll hands (metal). Roofers and slaters. Sawyers. Semi-skilled operatives (specify industry). Automobile factories. Bakeries. Blast furnaces and rolling mills. Brass mills. Breweries. Brick, tile and terra cotta factories. Broom and brush factories. Butter and cheese factories. Button factories, Candy factories. Car and railroad shops. Carpet mills— Weavers. Other occupations. 37 Cigar and tobacco factories. Clock and watch factories. Cotton mills— Spinners. Weavers. Other occupations. Electric light and power plants. Electrical supply factories. Furniture, piano and organ factories. Gas works. Glass factories. Glove factories. Gold and silver and jewelry factories. Harness and saddle industries. Hat factories (felt). Iron foundries. Knitting mills— Spinners. Other occupations. Lace and embroidery makers. Leather belt, leather case and pocketbook factories. Lime, cement and gypsum factories. Marble and stone yards. Paint factories. Paper and pulp mills. Paper box factories. Potteries. Printing and publishing. Rubber factories. Saw and planing mills. Ship and boat building. Shirt, collar and cuff factories. Shoe factories. Silk mills— Weavers. Other occupations. Slaughter and packing houses. Soap factories. Suit, coat, cloak and overall factories. Tanneries. Textile dyeing, finishing, and printing mills. Tinware and enamelware factories. Trunk factories. Wagon and carriage factories. Woolen and worsted mills— Weavers. Other occupations. 38 Sewers and sewing machine operators (factory). Shoemakers and cobblers (not in factory). Stonecutters. Structural iron workers (building). Tailors and tailoresses, Tinsmiths. Tool makers, diesetters and sinkers. Upholsterers. Wheelwrights. Wood carvers. Transportation: Water transportation. Boatmen, canal men and lock keepers. Captains, masters, mates and pilots. Longshoremen and stevedores. Sailors and deck hands. Road and street transportation. Carriage and hack drivers. Chauffeurs. Draymen, teamsters, expressmen and drivers. Foremen of livery and transfer companies. Garage keepers and managers. Hostlers and stable hands. Livery stable keepers and managers. Proprietors and managers of transfer companies, Railroad transportation. Baggagemen and freight agents (steam railroad). Brakemen. Conductors (steam railroad). Conductors (street railroad). Foremen and overseers. Railroad laborers. Locomotive engineers. Locomotive firemen. Motormen. Officials and superintendents. Switchmen and flagmen. Ticket and station agents. Yardmen. Express, post, telegraph and telephone agents. Agents (express companies). Express messengers and railway mail clerks. Mail carriers. Telegraph and telephone linemen. 39 Telegraph messengers. Telegraph operators. Telephone operators. Other transportation pursuits. Foremen and overseers, road and street construction. Inspectors. Laborers. Proprietors, officials and managers. Trade: Auctioneers. Bankers and bank officials. Butchers (meat dealers). Clerks in stores. Commercial travelers. Commercial brokers and commission men. Decorators, drapers and window dressers. Deliverymen. Floorwalkers and foremen in stores. Inspectors, gaugers and samplers. Insurance agents and officials. Laborers in coal and lumber yards, warehouses, etc. Laborers, porters and helpers in stores. Meat cutters. Newsboys. Pawnbrokers. Proprietors, officials and managers (warehouses). Real estate agents and officials. Retail dealers (specify). Salesmen and saleswomen. Stockbrokers. Undertakers. Wholesale dealers, importers and exporters. Others (specify). Public Service (Not Elsewhere Classified): Firemen (fire department). Guards, watchmen and doorkeepers. Laborers (public service). Garbage men and scavengers. Other laborers. Marshals, sheriffs, detectives, etc. Officials and inspectors (city and county). Officials and inspectors (State and United States). Policemen. Soldiers, sailors and marines. 40 Other pursuits. Life-savers, lighthouse keepers. Other occupations (specify). Professional Service: Actors. Architects. Artists, sculptors and teachers of art. Attendants and helpers (professional service). Authors, editors and reporters. Chemists, assayers and metallurgists. Civil engineers and surveyors. Clergymen. College presidents and professors. Dentists. Designers, drafismen and inventors. Lawyers, judges and justices. Musicians and teachers of music. Photographers. Physicians and surgeons. Religious and charity workers. Showmen. Teachers (school). Trained nurses. Veterinary surgeons. Other professional pursuits (specify). Domestic and Personal Service: Barbers, hairdressers and manicurists. Bartenders. Billiard room, dance hall, skating rink, etc., keepers. Boarding and lodginghouse keepers. Bootblacks. Charwomen and cleaners. Cleaners and renovators (clothing, etc.). Elevator tenders. Hotel keepers and managers. Housekeepers and stewards. Janitors and sextons. Laborers (domestic and professional service). Launderers and laundresses (not in laundry). Laundry operatives. Laundry owners, officials and managers. Midwives and nurses (not trained). Porters (except in stores). 41 Restaurant and lunch room keepers. Saloon keepers. Servants. Bell boys, chore boys, etc. Chambermaids. Coachmen and footmen. Cooks. Waitresses. Others (specify). Umbrella menders and scissors grinders. Waiters. Clerical Occupations: Agents, canvassers and collectors. Bookkeepers, cashiers and accountants. Clerks (except clerks in stores). Messenger, bundle and office boys and girls. Stenographers and typists. 42 Religion Care should be taken to designate the particular sect whenever it can be acertained, e. g., Methodist, Presbyterian, etc., instead of Protestant ; Roman Catholic, or Greek Catholic instead of Catholic; Orthodox Hebrew or Reformed Hebrew instead of Hebrew. The religion of a patient of Protestant leaning but without definite denominational affiliations may be entered as “ Independent Protestant,” of a patient of a Catholic family who does not attend church as “Catholic—noncommunicant,” of a Hebrew not connected with any congregation as “Independent Hebrew.” Environment Under “ environment ” in general, report as “ urban” places with a population of 2,500 or more and all other places as “rural.” Care must be taken to classify properly legal residents of a city who live in sparsely settled portions of the city (e. g., Staten Island) where their environment and mode of life may be actually those of rural residents; also rural residents whose homes are some distance from a compactly settled neighborhood but who claim to live in the nearby city or village. Economic Condition This item refers to the economic status of the patient at the time of onset of the psychosis. The standard terms printed on the admission cards are defined as follows: Dependent: Wacking in the necessities of life or receiving aid from public funds or persons outside the immediate family. Marginal: Living on earnings but accumulating little or nothing ; being on the margin between self-support and dependency. Comfortable: Having accumulated resources sufficient to main- tain self and family for at least four months. Patients should not be classed as “ dependent” because they are unable to reimburse the hospital for their maintenance, provided they were previously able to maintain themselves. Minors and aged people cared for by their families should not be classed as “ dependent ;” their economic condition should be considered as that 43 of their family. A pensioner who has no accumulated resources should be classed as “ marginal.”