Section B-Types of Certificates in Various Diagnostic Categories II-1-10 Section C-Intelligence, Its Nature and Measurement Section D-References Section A.-Terminology II-1—13 1. General. The purpose of this section is to take up separately various excludable (class A) mental conditions with the object of clarifying the meanings of the terms, and to furnish criteria that will assist the physician in determining the proper classification of mental conditions. It must be emphasized, however, that the law seeks the individual medical examiner's judgment and this material is not in any sense regulatory, nor should it be understood as legally effective interpretation of the statute. 2. Idiocy; imbecility; feeble-mindedness.-a. Idiots.-The term "idiot" is in common use medically and therefore should cause no difficulty. An idiot is considered to be an individual who has a mental age of less than 3 years, if an adult, or, in the case of a child, an intelligence quotient of less than 20. - b. Imbeciles. The term "imbecile" that appears in the law has a uniform medical meaning. An imbecile is considered to be a person having a mental age of 3 to 7 years, inclusive, if an adult, or, if a child, an intelligence quotient of 20 to 49, inclusive. c. Feeble-minded persons.—(1) A certificate of "feeblemindedness" should be considered for all persons who exhibit such a degree of mental deficiency existing from birth or acquired at an early age that their common knowledge, retentiveness of memory, reasoning power, learning capacities, and general mental reactions are severally and distinctly below those normally exhibited by the average of the same age and race living under similar environment. (2) Occasionally in children between the ages of approximately 4 and 12 there will be adequate evidence of abnormally low functioning mental ability, but the question will arise as to whether this lowered performance is the result of a retarded mental development due to unknown reasons or whether it is due to an actual deficiency. In all cases the certificate must be issued on the basis of the findings of facts of the medical examination at the time that it is performed. If there is some question as to the ability of the individual to outgrow this retardation, he should be advised to return for reexamination when he has outgrown his deficiency. (See par. 34 of this chapter.) 2 3. Epilepsy.-a. Two general types of epilepsy are commonly recognized. One type is variously known as essential, idiopathic, or cryptogenic. This is the type in which specific etiological factors cannot be discovered on routine medical examination and which according to accepted medical opinion may be inherited. The other types of epilepsy are considered to be symptomatic. b. Focal seizures that are merely symptoms of other diseases or causes, and commonly classified as "traumatic epilepsy," are not certified as epilepsy. An alien in whom a diagnosis of idiopathic epilepsy can be substantiated is certified for "epilepsy." Such 1In this manual the term "mental deficiency" refers to intellectual capacity and is not to be confused with the term "mental defect" or "mentally defective," discussed in par. 8 of this chapter. 2 See, for example, Diseases of the Nervous System (reference 4, List No. 1, in sec. D of this chapter). certificates include grand mal seizures, petit mal, all psychic equivalent states or fugue states, pyknolepsy, narcolepsy, and catalepsy. c. When an individual suffers from convulsions, but idiopathic epilepsy cannot be substantiated, diagnosis should be deferred pending future observation or examination when the examination is done in a foreign country. If a class B certificate for traumatic epilepsy is issued, a memorandum giving all available information should be sent to the consular officials. Before issuing a class B certificate the examiner must, of course, consider the possibility of associated conditions warranting a class A certificate. d. In this respect it is important that the record of the initial examination abroad contain specific questions and the answers thereto concerning the convulsions as follows: age at onset, frequency, response to therapy, and occurrence of similar conditions in relatives. Particular reference should be made to the history of inflammatory conditions, trauma, birth injury, allergic manifestations, and the effect of drugs, particularly sedatives or alcohol. A history of head injury might be claimed by the alien as the cause of his epilepsy, and when submitted as evidence should receive careful and thorough study to substantiate or refute this etiological factor. The results of this study should be made a matter of record. e. It is advisable to make use of electro-encephalograms whenever there is a question of epilepsy. Although a negative record does not exclude idiopathic epilepsy, a positive record is of distinct value. It is important that such tracings be made at a time when the individual has been free of sedative medications for a period of at least 72 hours. f. The physician should be alert for evidence of scars, especially about the face or on the tongue, and for indications of old or new burns that cannot be explained other than by sudden loss of consciousness. Such scars are good presumptive evidence of epilepsy and require careful and complete examination to exclude or confirm a diagnosis of epilepsy; if necessary, diagnosis should be deferred until there can be a satisfactory explanation of the presence of the scars. g. Various other conditions often referred to as symptomatic epilepsy should be certified on the basis of the condition of which they are symptomatic. For example, convulsive seizures associated with the use of alcohol would probably be certified as chronic alcoholism; convulsions associated with the withdrawal of barbiturates could be certified on the basis of the use of drugs, which would probably fall into the category of a mental defect. In some cases of symptomatic epileptic conditions there will be other associated mental defects which should be considered for certification as "mental defect." See paragraph 8 of this chapter. h. Pyknolepsy, narcolepsy, and catalepsy are considered to be forms of epilepsy, and can be classed as either idiopathic or symptomatic. If idiopathic, the conditions would of course be certified as epilepsy; otherwise, the certificate should be issued on the basis of a causative condition. i. The term "epilepsy" should be used in a certificate only when idiopathic epilepsy has been diagnosed. 4. Insanity.-a. Insanity is a legal term rather than a medical diagnosis. The term has no generally accepted legal definition, largely because the adjudication of insanity is a function of the State courts. In psychiatric practice, a term with which it is most usually identified is commitability, which in many States involves a degree of mental illness that makes a person dangerous to himself or others. In some other States an insane person is considered to be a person afflicted with mental disease to such an extent that he is incapable of managing himself and his affairs, and who for his own welfare, or the welfare of others of the community, requires care and treatment. However, all persons who meet these criteria are not certifiable as insane, because section 34.7 of the regulations states "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." Examples of mental conditions due to physical causes that are usually remediable are: postpartum psychosis, toxic psychosis from an acute infectious disease, psychosis with bromide intoxication, and psychiatric conditions resulting from nutritional deficiencies or physical exhaustion. b. For the sake of clarity, it appears advisable to point out again at this time that any certification must be made on a factual basis and not on speculative opinion. Obviously while the individual is still acutely psychotic, it will be difficult to make a factual statement that the psychosis is of a temporary nature, or that it is due to remediable physical causes. This becomes all the more realistic and true in the case of the medical officers who are examining aliens in foreign countries where extensive facilities for diagnostic determinations are not available as they might be in certain Marine Hospitals within the continental limits of the United States. c. In cases of mental conditions due to senility or to cerebral arteriosclerosis care should be exercised to distinguish between conditions of sufficient severity to be considered certifiable for insanity and those which are not of such severity. In cases certified class A because of advanced mental deterioration, the certification should be "class A, insanity, senile psychosis," or "class A, insanity, psychosis with cerebral arteriosclerosis." Cases with less severe symptoms could be certified as class B on the basis of the physical condition, for example, "class B, senility," or "class B, cerebral arteriosclerosis"; the certification should be accompanied by a memorandum describing the degree of impairment of mental functions and the amount of supervision and care the alien would require without institutionalization. 5. One or more attacks of insanity. Under the law individuals "who have had one or more attacks of insanity at any time previously" are excludable. However, reports of previous attacks of insanity are not submitted as medical notifications or certificates. Determination of excludability on the basis of |