TM 8-325 
WAR DEPARTMENT 
TECHNICAL MANUAL 
OUTLINE OF NEUROPSYCHIATRY 
IN AVIATION MEDICINE TM 8-325 
TRAINING MANUAL 1 
No. 8-325 
WAR DEPARTMENT, 
Washington, December 12, 19£Q, 
OUTLINE OF NEUROPSYCHIATRY IN 
AVIATION MEDICINE 
Prepared under direction of tha 
I f Surgeon General a 
Paragraphs 
Section I. General _ 1-3 
II. Descriptive psychology 4-9 
III. Causes and nature of mental disease 10-13 
IV. Dynamics of behavior 14 
V. Mental mechanisms and motives 15 
VI, Psychobiological constitution and reaction types, 16-17 
VII. Classification of mental disorders 18-21 
VIII. Symptoms of mental disease 22-32 
EX. Psychopathic personality 33-34 
X. Minor psychoses 35-38 
XI. Epilepsy 39-54 
XII. Schizophrenia (dementia praecox) 55-62 
XIII, Manic-depressive psychosis 63-73 
XIV. Involutional melancholia 74-78 
XV. Paranoia 79-85 
XVI. General paralysis of the insane 86-99 
XVII. Tabes dorsalis 100-107 
XVIII. Infection exhaustion, toxic, and symptomatic 
psychoses 108-114 
XIX. Psychoses associated with organic diseases of, 
and injury to, the brain 115-118 
XX. Senile psychoses 119-120 
XXI. Epidemic encephalitis 121-133 
XXII. Neurology 134-142 
XXIII. Neuropsychiatric examination 143-157 
Page 
Appendix. Bibliography 162 
Index 165 
•MT5S*—il 1 
1 TM 8-325 
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MEDICAL DEPARTMENT 
Section I 
GENERAL 
Paragraph 
Basic fundamentals 2 
History of mental disease 3 
1. Object.—The objective of this manual is to instruct medical 
officers, Regular, National Guard, Reserve, or those of other Federal 
departments interested in aviation medicine, so that they may attain 
a thorough working knowledge of the psychopathology underlying 
the various forms of mental disease with their symptoms and treat- 
ment ; and a working knowledge of the neurological examination re- 
quired in the examination of candidates for flying training. This 
mission will necessitate a rather thorough course in neuropsychiatry 
as a whole. 
3. Basic fundamentals.—In outlining the basic fundamentals as 
known at present, involving both the so-called normal and abnormal 
conditions of the psyche, it will be necessary to study the develop- 
ment of the mind and its purpose. This will be done from a psy- 
chobiological viewpoint, endeavoring at all times to consider the 
individual as a whole; that is, the behavior of the human organism as 
a unitary system engaged in adjustment to its environment. 
a. The dynamics of behavior and psychic energy, mental mecha- 
nisms and motives, conscious and unconscious processes, all lead up 
to the causes and nature of mental disease. The psychology of men- 
tal disease will be discussed at length. 
h. Border-line conditions will be of more concern than actual psy- 
choses. Actual psychoses are perhaps not as prevalent among appli- 
cants for flying training; however, the percentage is practically the 
same as in any other field of endeavor or profession. 
o. There are three large groups who come into the Air Corps. First, 
those who are apparently highly enthusiastic about flying because of 
flying itself; second, those who would increase their economic standing; 
and third, those who wish to give expression to a compensatory 
superiority developed because of an inherent or acquired inferiority 
which they must counterbalance; that is, demonstrate to society that 
they are really supermen in spite of what society considers them. 
d. Aviation medicine is an interesting specialty but carries with it 
responsibilities that are not to be considered lightly. Aviation is still 
dangerous and will continue to be so at least in this generation. 
Pathologic psychological types cannot be prevented from applying for 
flying training, but applicants can be studied and flight surgeons 
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NETJKOPSYCHTATR Y IK AVTATIOK MEDICTNB 
trained so that these types are recognized at the outset and their initial 
appearance into the Air Corps prevented. Aviation medicine as a 
specialty is comparatively young and those interested in the personality 
as a psychobiological entity find that there is much research that can 
be done to ascertain what that psychobiological entity must have and 
develop in order to produce a military aviator under proper flying 
instruction. 
e. As nearly as possible, the views of the leaders in American 
psychiatry will be presented. 
f. As a nomenclature for the different clinically recognized mental 
diseases, that which has been adopted by the American Psychiatric 
Association will be described. The present tendency in psychiatry is 
to use descriptive terms in the diagnosis of mental diseases, but it is 
believed that this nomenclature will be of more value at the present 
time. 
g. If flight surgeons have any reason for existence, it is that they 
tave been trained to select applicants for flying training, and when 
'. .ese applicants have been selected and trained, to see that their physi- 
cal and mental efficiency is maintained. It is recognized by those in 
actual contact with large groups of patients that at least 60 percent 
of all complaints contacted are of psychogenic origin. Training must 
be given so that these border-line conditions may be recognized. 
h. The strain of flying, which first saps the nervous system because 
it is the most highly organized system of the body, brings out the 
latent tendencies of the individual and it is these latent tendencies 
which must be recognized so that the individual may be properly 
treated. 
3. History of mental disease.—a. A review of history shows 
that mental disease was recorded at the beginning of written time 
of both the Eastern and the Western worlds. The Old Testament 
records Raul’s periods of depression, indicating he was a cyclothymic. 
Nebuchadnezzar is also mentioned, his symptoms being characterized 
by delusions. In Western history are recorded the oracles, which 
were probably hysterical manifestations similar to our present day 
mediums. 
h. To explain these abnormalities at the time they were recorded, 
the thought and knowledge of the period must be considered, and as 
Hart calls them, “conceptions of insanity” were evolved. These con- 
ceptions are continually being evolved, and today the psychological 
conception is perhaps the more universally accepted. 
o. In history is first found the “demonological conceptions.” The 
phenomena at this period were considered as due to demons, and in 
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MEDDOAL DEPARTMENT 
harmony with the religious views of the time, as being due to either 
the devil or the Deity, which naturally developed a religious method 
of treatment, such as ceremonials. 
d. Hippocrates is given credit for evolving the first conception 
which can be considered as logical to present day thinking. He laid 
down the fundamental that the brain was the organ of the mind, and 
that as a sequence, mental disturbances were due to some pathology of 
that organ. This view disappeared during the Dark Ages, as did 
almost every other intellectual development, Scholasticism and mysti- 
cism replacing true science, and the demonological conception again 
prevailing. The result was that those having the various delusions 
and hallucinations were saints and holy men and therefore revered. 
At this time witchcraft flourished, and even today followers of witch- 
craft are found who are classified among the mentally unstable. Dur- 
ing this period many were executed because of these tendencies. Per- 
haps this was an unsatisfactory method of treating these unfortunate 
individuals, but considering these events from a purely biological 
viewpoint, a bettering of biological life should have been the out- 
come. Witness the sterilization of the unfit at the present time. 
However, science and humanitarianism soon flourished again, and 
mental disease was again considered as due to some disturbance of 
the brain. So at the beginning of the nineteenth century, the modern 
physiological conceptions were becoming definitely established, 
e. Prior to this time, a transition period was in vogue. This is termed 
the “political conception.” The mentally diseased at this time were con- 
sidered as having no claim on society. The individual was put away 
so that he did not disturb society. 
/. England was the first to adopt humanitarian methods, about the 
end of the eighteenth century. Since that time, continuous progress 
has been made, and present institutions are model hospitals, with the 
patients considered as mentally ill, instead of lunatics. 
g. Physiological research devoted to the study of the brain, anatomi- 
cally and microscopically, leading to the facts of cerebral topography 
and the discovery that definite portions of the brain controlled definite 
bodily functions, were the important discoveries- This naturally led 
to the conclusion that the nature and causes of mental diseases had been 
found. Disappointment followed, as all mental disease cannot as yet 
be traced to physiological causes. The “psychological conception” 
therefore developed. The corollary basing this conception is that 
mental processes can be directly studied without reference to any ac- 
companying changes which are presumed to occur in the brain and that 
mental disease may therefore be properly attacked from the standpoint 
of psychology. TM 8-325 
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1TBUROPSYCHTATRY IN AVIATION MEDICINE 
h. Even in our time, psychology has been confused with mysticism, 
theology, and ethics. Great progress has been made due to such men 
as Janet, Kraepelin, Freud, Jung, Adler and Bleuler, and the psycho- 
logical conception has become an accomplished fact. There have been 
eras in medicine, but fact has undermined theory in all instances and 
will continue to do so. However, at the present time there are two 
dominating conceptions, the physiological and the psychological, 
which are both founded on scientific fundamentals and which ulti- 
mately will develop into a true conception of mental diseases as to 
nature, cause, and treatment. The psychological conception con- 
siders the mental deviations as states of mind, the physiological as 
due to changes occurring in the brain itself. 
i. The method of acquiring knowledge is the same scientifically no 
matter what the field of research or study. There are certain definite 
steps which are universally followed. First, there is the collection and 
recording of facts; second, the classification of these facts into series 
or consequences; and third, the discovery of a formula or scientific law 
which describes these facts in the most comprehensive and convenient 
manner. These steps are called the “method of science.” These are 
illustrated by Keppler’s formula and Dalton’s formula, and both have 
been found to agree with the facts of experience, and therefore recog- 
nized as scientific law, Dalton’s atomic theory went further, he was 
able to predict and resume facts which is the only justification a scien- 
tific law is required to possess. It was necessary for Dalton to use 
concepts, as his “atom” was, in order to explain the facts of experience. 
Thus we must distinguish between phenomena which are facts that can 
be observed, and concepts which are inventions of the Scientist used to 
explain facts. Both, however, are of scientific value and use. There- 
fore, a complete description of the method of science evolves itself 
into the observation and recording of the phenomena; the classifica- 
tion of the recorded phenomena into groups and series; and the dis- 
covery of a formula which will explain these phenomena. These 
formulae may be altogether conceptual; however, the only test nec- 
essary as to the utility of the devised formula is that it explains the 
facts actually found. Therefore in order to scientifically establish 
research with the cause of mental disease, the foregoing method must 
be followed, 
j. To further distinguish the physiological from the psychological 
conceptions, the physiological admits consciousness involved in the 
phenomena of mental disease, but assumes corresponding changes in 
the brain and therefore devotes all its attention to the brain in an 
endeavor to discover a “law” which will contain nothing but physio- 
logical terms, and which will describe these brain processes in the 
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MEDICAL DEPARTMENT 
shortest and most comprehensive manner. The psychological concep- 
tion, however, regards the conscious processes occurring in mental 
disease as the actual phenomena, and so is in search of a law which 
will comprehensively describe these conscious processes and will nat- 
urally contain nothing but psychological terms. There can be no mix- 
ing of terms, as confusion would result. Any discussion of the connec- 
tion between mind and brain, would lead us into philosophy with which 
this manual is not concerned. Therefore, these steps of the method of 
science must be presented in a logical order, eventually leading to 
definite understanding of the psychological conceptions of mental dis- 
eases and not forgetting the difference between phenomena and 
concepts. 
h. Modern psychology employs conceptions which cannot be dem- 
onstrated, such as complexes, repressions, and unconscious mental proc- 
esses, to explain phenomena which are observed. Phenomenal impos- 
sibilities exist as illustrated by the unconscious mental process, but 
they also exist in physics as illustrated by the weightless, frictionless 
ether. However, in both cases they are justified, because they explain 
in a convenient manner the facts of experience and satisfy the test of 
utility. 
Section IT 
DESCRIPTIVE PSYCHOLOGY 
Paragraph 
Mental processes 4 
Definition of terms — 5 
The fundamental problem of life 6 
Solving of conflict 7 
Fixation of libido 8 
Unconscious emotion 9 
4. Mental processes.—a. General.—The psychiatrist studies the 
mental life of the individual. More particularly, he studies the 
mental life in its abnormal manifestations. Abnormal mental func- 
tioning will be better understood if there is clear comprehension of 
normal mental processes, therefore, before studying disordered mental 
functioning, a brief review is made of normal mental processes and 
understanding had of those psychological terms constantly occurring 
in the study of psychiatry. 
(1) The mental life embraces— 
(a) Consciousness, including all the mental processes concerning 
which there is awareness, distinct or indistinct, at a given moment. 
(h) Fore-consciousness, that region from which material may read- 
ily be recalled. TM 8-325 
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NEUROPSYCHIATRY IN AVIATION MEDICINE 
(c) The rmconscious, a hypothetical region containing material be- 
yond recall; that is, inaccessible to the ordinary processes of memory 
or association and capable of appearing in consciousness only under 
certain special conditions, such as sleep, hypnotism, free association, 
and certain pathological states. 
(2) Consciousness, then, is not the greater but the restricted and 
lesser part of the mental life; fore-consciousness, a wider area; and 
the unconscious, a vastly extended and darkened region inaccessible 
to the ordinary introspective processes. Briefly, consciousness in- 
cludes material within awareness; fore-consciousness, material within 
recall; and the unconscious, material beyond recall. 
b. Consciousness.—(1) Consciousness includes all the mental proc- 
esses concerning which there is awareness, distinct or indistinct, at a 
given moment; that is, consciousness can only be defined in terms of 
itself. Thus sensations, ideas, pains, pleasures, acts of memory, 
imagination, will, etc., are the experiences indicated by the term. 
These, in their entirety, are what is meant by consciousness. Within 
the cortex there is a manifestation of some form of energy, not chemi- 
cal, not electrical, and for a lack of a better term, called “neural” 
which produces consciousness. This energy manifestation is constant. 
Never, during life, does complete quiet reign throughout the organism. 
Always there is a continuous flow of sensations from the organs of the 
body to the brain; an ebb and flow of neural energy in unified series 
of physiological tensions. Consciousness, then, may be regarded as 
the total mass of shifting tensions occurring throughout the cortex at 
a given moment. When the tension is greatest in the occipital region, 
there is awareness of visual qualities. When the tension is greatest in 
the temporal region, consciousness is auditory, etc. Ideational proc- 
esses occur simultaneously. 
(2) In a restricted sense, consciousness obtains whenever physio- 
logical processes are converted into psychological. In this element, 
interruptions occur as in coma and sleep. But in the other element, 
interruptions never occur while life lasts. The two elements which 
make up consciousness are as follows; 
(a) Epiphenomena, made up for the most part of perceptions of 
the outer world of reality which disappear from view in the profundity 
of sleep, as well as in certain other states, and which are erected upon 
the elements given in (b) below. 
(b) Certain permanent phenomena forming the foundation, the 
continuum of consciousness, made up of a continuous flow of sensations 
from all the organs of the body to the brain. This flow is constant 
throughout life and is the continuous, ever present element of con- 
sciousness. TM 8-325 
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MEDICAL. DEPARTMENT 
e. Fore-oonsciousness.—This region, containing material capable of 
ready and spontaneous recall, is not sharply differentiated from con- 
sciousness and the material is of a familiar sort. 
d. The, v/ncomoious.—The unconscious is entirely separated from the 
fore-conscious and the conscious and contains material so completely 
repressed and forgotten as to be absolutely unfamiliar. The concep- 
tion of the unconscious originated with a student of abnormal mental 
processes, Sigmund Freud. It may be defined as an hypothetical 
region of the mind, the content of which is repressed mental material. 
It is that region which constitutes the historical past of the psyche, a 
region of methods of reaction which have been abandoned for some- 
thing better as development proceeded. The unconscious is a concept 
only, a means of explaining psychological and psychopathological 
facts in psychological terms, for the mental life is explainable only 
on the assumption that such a region exists. 
(1) Three current uses of the term, "the unconscious” are as 
follows: 
(а) It is a synonym for nonmentaL This view assumes that no 
mental process can exist that is not accompanied by consciousness or 
awareness. On the contrary, most psychopathologists are convinced 
that processes certainly do occur which present all the attributes of 
mental ones, except that the subject is not aware of them. According 
to the latter accepted view, consciousness is merely an attribute of 
mentality, and not an indispensable one. 
(б) It might be called the “limbo” conception, for in it the un- 
conscious is regarded as an obscure region of the mind, the content of 
which is largely characterized by neglect, oblivion, and decay. It is 
considered to be a lumber room to which various mental processes 
become relegated. These processes then become of quite secondary 
importance having no initiative or dynamic function and remain 
purely passive. 
(c) It is the psycho-analytical conception developed by Freud and 
his school and is the one presented in this manual. Freud arrived at 
this conception without a priori speculative hypothesis through the 
purely inductive method. By technical procedure, he penetrated the 
region beyond the fore-conscious and investigated those mental proc- 
esses inaccessible to the patient’s direct introspection. In so doing, 
he uncovered a buried stratum of mind and found himself in a strange 
mental world, which he named “the unconscious.” 
(2) The origin, content, and significance of the unconscious are— 
(a) Origin.—The unconscious has its beginnings in the earliest part 
of childhood, probably in the first year, and results from the conflict TM 8-325 
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NEUROPSYCHIATRY IN AVIATION MEDICI SR 
between the primitive, instinctive, uncivilized tendencies with which 
the child is born, and the traditional modes of conduct prescribed by 
the society within which he must live and adjust himself. But since 
no part of the mental life ever undergoes annihilation, an inhibiting 
force called “repression,” which is forgetting beyond the power to 
recall, forces the material into that buried stratum of the mind called 
“the unconscious.” This repression takes place without conscious 
effort. If repression were the result of voluntary effort, it would be 
unsuccessful; that is, the experience would become fixed in con- 
sciousness. Further, the experience which tends to be repressed is 
the immediately unpleasant and painful without regard for the con- 
sequences. Nature takes no account as shown in studies of mental 
disorders, of the potentialities for future trouble inherent, because the 
unpleasant or painful experience has merely been buried in the 
unconscious. 
(b) Content.—The unconscious is a storehouse of experience asso- 
ciated with instinctive reactions, and as these latter are essentially 
primitive and infantile in nature, a like coloring is imparted to 
the unconscious of the whole of life. It is that part of the mental 
life standing nearest the crude instincts as inborn, and before sub- 
jection to the refining influence of education. It is commonly not 
realized how extensive is the work performed by these influences, 
nor how violent is the internal conflict they provoke before they finally 
achieve their aim. Without them, the individual would probably 
remain a selfish, jealous, impulsive, aggressive, immodest, cruel 
animal, inconsiderate of the needs of others and unmindful of the 
complicated social and ethical standards that make up a civilized 
society. The primitive tendencies must be repressed and the energy 
diverted into more useful and acceptable channels; it must be sub- 
limated. Yet, according to the findings of psychoanalysis, the results 
of this refining, sublimating process are rarely so perfect as is gen- 
erally supposed; because behind the veneer of civilization there re- 
mains throughout life a mass of crude, primitive tendencies, always 
struggling for expression, and toward which the individual tends 
to relapse whenever suitable opportunity offers. Although experience 
incompatible with the welfare of the individual is repressed (buried 
in the unconscious) it does not remain passive; there is active func- 
tioning and there is unconscious mentation. The experiences re- 
pressed within the unconscious are dynamic in quality and constantly 
strive to again appear in consciousness. They succeed in overcom- 
ing the repressive forces and do appear in dreams, hypnotism, free 
association, and certain pathological states. It follows that the re- TM 8-325 
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MEDICAL. DEPARTMENT 
pressive force must be two-fold in character, on the one hand driving 
material into the unconscious, and on the other, compelling it to 
remain there. The latter force is by far the stronger of the two, 
but neither are invariably successful. Another attribute of the un- 
conscious is that it ignores all logical standards; it is of the emotions, 
not of the reason. Just as the fantasy oversteps the bounds of time 
and space, so does the unconscious ignore all reasonable and logical 
considerations; the primitive and infantile crowd to the fore and 
demand the right of way. Finally, the unconscious is also sexual in 
character. Not sexual, however, in the ordinary acceptation of the 
term, being like other childhood manifestations much more diffuse, 
tentative, and preliminary in nature. To many psychiatrists the 
term biological, or creative, is preferred to sexual, as having a broader 
meaning and more acceptable. Of all the primary instincts, the 
sexual, in this broader sense, is probably the most active, operates 
from early childhood, and is subjected to the greatest intensity of 
repression. The description above may be summarized in a single 
statement: The unconscious is a region of the mind, the content of 
which is characterized by the attributes of being repressed, instinctive, 
primitive, infantile, unreasoning, creative, and dynamic. 
(c) Significance.—Significance of the unconscious for the psycho- 
pathologist may be discussed under four heads: 
i. A knowledge of the content and mode of operation of the 
unconscious furnishes a key for the understanding of 
numerous morbid manifestations that were previously 
incomprehensible; it has given a consistent interpreta- 
tion of them, and has revealed their coherent and intel- 
ligible structure. It has furnished proof that an 
arresting experience, one accompanied by an emotional 
state of the most poignant kind, can lie dormant and 
evade the most searching attempt to bring it into con- 
sciousness by the ordinary processes of memory. It 
has further conclusively shown that an experience, 
though inaccessible to consciousness directly, may yet 
be capable of affecting it indirectly and with disastrous 
consequences. Without this knowledge, no solution can 
be found to such problems as why a given patient has 
developed this or that particular delusion, phobia, or 
other symptom; with this knowledge, the bizarre and 
meaningless which are so familiar in psychopathology 
disappear or are replaced by other problems. 
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2. A knowledge of the unconscious makes clear not only the 
meaning of these symptoms, but their causation as well. 
They are compromise formations produced through con- 
flict between unconscious and conscious tendencies and 
are brought about in the following way: Normally a 
great part of the energy pertaining to the repressed 
trends of the unconscious is diverted to permissible, 
socially useful ends by a process known as “sublima- 
tion.” This denotes a partial renunciation of the crude 
pleasures obtained by indulging in the primitive tend- 
encies that are kept from consciousness, and a replace- 
ment of them by other more or less satisfactory andi 
refined ones. A great number of individuals find it 
by no means easy to achieve this renunciation, and are 
in constant danger of relapsing into the old indulgences 
and gratifications under various circumstances, par- 
ticularly when the attractions of the more refined aims 
flag, as they must do whenever the mental environment 
becomes more painful, difficult, or disagreeable. Then 
the mental interests and energies are apt to regress 
toward older and more primitive modes of functioning. 
This regression, however, is checked by the repressing 
forces on which the original sublimation depended. In 
the resulting conflict, neither set of forces is entirely 
successful; on one hand, the repressing ones manage to 
prevent a complete return to the primitive modes of 
gratification, while on the other hand, they fail in trans- 
forming the energies in question to sublimated activities. 
A compromise is reached whereby both sets of forces 
come to expression, though only in a partial and dis- 
guised way; these compromise formations are clinically 
called symptoms and constitute the various psycho- 
pathological maladies. The actual symptoms do not 
carry their meaning on the surface; they appear sym- 
bolically and must be interpreted and translated into 
the language of the unconscious. This knowledge is 
necessary of the mechanisms by which the distortion is 
brought about, that is, by which the latent material is 
converted into the manifest syptoms. 
2. The knowledge gained by investigation of the unconscious 
bridges over the gap between the normal and the ab- 
normal by demonstrating that similar processes go on 
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MEDICAL DEPARTMENT 
in each, though the control of the one by the other is 
unequal, the unconscious controlling the conscious to a 
far greater degree. 
4- A knowledge of the unconscious furnishes invaluable aid 
in the treatment of mental disorders. While treatment 
has yielded best results in the psychoneuroses, it is hoped 
that there may be gratifying results in the psychoses 
as well. The method of treatment is overcoming, by 
psychoanalysis, the resistances that are interposed 
against making conscious the repressed complexes, freely 
exposing them to view, and gaining a much greater 
control over this pathogenic material by establishing an 
unobstructed flow of feeling from the deeper to the 
more superficial layers of the mind. Thus the energies 
investing the repressed tendencies can be diverted from 
the production of symptoms into more useful and 
socially acceptable channels. 
5. Definitions of terms.—The following are definitions of cer- 
tain terms used in paragraph 4. 
Consciousness.—In a restricted sense, consciousness obtains whenever 
there is transformation of physiological into psychical processes. 
It includes all the mental processes concerning which there is 
awareness, distinct or indistinct, at a given moment It is not 
the greater but the restricted and lesser part of mental life. 
Attention.—Attention means the momentary activity of the mind that 
represents the focal point of consciousness. 
Unconsciousness.—Unconsciousness is that condition in which the 
transformation of physiological into psychical processes is com- 
pletely suspended. 
Fore-consciousness.—Fore-consciousness is that wider region from 
which material may readily be recalled. It contains entirely 
familiar material. 
The unconscious.—The unconscious is an hypothetical, vastly extended, 
and highly potential region of the mind containing material be- 
yond recall. It is the historical past of the psyche. Its content 
is characterized by the attributes of being repressed, instinctive, 
primitive, infantile, unreasoning, creative, and dynamic. 
Conflict.—Conflict is effort at dealing with the discrepancy between 
desire as represented by instinctive, primitive tendencies and 
conduct as prescribed by society. 
Repression.—Repression is the process by which material is forced into 
the unconscious and kept there. 
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Complex.—The complex is a constellation of ideas in the unconscious 
which have an independent existence and growth, a strong emo- 
tional trend, and a tendency to motivate conduct. 
Sublimation.—The word “sublimation,” borrowed from the terminol- 
ogy of chemistry, was introduced by Freud to denote a psycho- 
logical process defined by him as “the capacity to exchange an 
originally sexual aim for another which is no longer sexual, 
though psychically related.” He also defines it as “a process 
which outlet and application in other regions are opened to 
overstrong excitations arising from the individual sources of 
sexuality.” By sublimation, the individual sidetracks his dis- 
appointment, sublimates the energy of the repressed emotion, 
and drafts the interest off to higher, more useful, and socially 
acceptable levels. 
Self-consciousness.—Personality has been called the “riddle of psy- 
chology.” It is the sum total of all the presentations forming 
the complex idea of the physical and mental self. 
Reflex act.—A reflex act is one in which a muscular movement occurs 
in immediate response to a sensory stimulation without the 
interposition of consciousness. Consciousness may take cogni- 
zance of reflex acta but it does not produce them. 
Instincts.—Instincts are racial habits transmitted by heredity to the 
individual through structurally performed pathways in the 
nervous system and stand functionally for effective inherited 
coordinations made in response to environmental demands. 
Difference between reflex acts and mstincts.—The most suggestive 
working distinction seems to be found in the presence or absence 
of some relatively definite though nonconscious end dominating 
a series of acts. If the motor activity is simple and dis- 
charged in response to some objectively present stimulus with- 
out conscious guidance, it is safe to call the act a reflex. If the 
activity involves a number of acts, each one of which consid- 
ered single and alone is relatively useless but all of which taken 
together lead up to some adaptive consequence, such as the 
building of a nest, the feeding of the young, etc., it is safe to 
call the action instinctive. 
Difference between instincts and habits.—Both instincts and habits 
may be defined as complex systems of reflexes functioning la. 
serial order when the child or adult is confronted by the appro- 
priate stimulus. They differ in that instincts are inherited 
while habits are acquired. 
6. The fundamental problem of life.—The fundamental prob- 
lem of all life is that of adjustment to environment. The individual 
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MEDTOAL. nEPAETTMENT 
is a little world set in the midst of a larger world. In no sense does 
he lead an independent existence for his continued welfare depends 
upon a nicely balanced adjustment between his own inner activities 
and the conditions of his environment, some of which are beneficial 
and some harmful. His medium of communication with the environ- 
ment is the peripheral and effector apparatus of his nervous system. 
In general, the nervous system performs two groups of functions; 
the correlation of activities of the several organs of the body among 
themselves and the physiological adjustment of the body as a whole 
to the environment, and the higher functions of the cerebral cortex 
related to the conscious life. The second group cannot be studied 
apart from the first. The psychiatrist must understand each because 
mental and physiological processes are inseparably connected. It 
must be understood that the entire conscious experience depends for 
its materials upon the content of sense; that is, upon the sensory data 
received by the peripheral apparatus and transmitted through the 
lower brain centers to the cortex. 
a. The organism establishes and maintains its relations with the 
environment through the following fields: 
(1) Psychosensory field..—Sensorium; perception. 
(2) Intrapsychic field.—Intellect; thinking. 
(3) Psychomotor field.—Motorium; volition. 
b. The physical basis of mind lies in the neural pathways of the 
cerebral cortex. The functions of these pathways of the cortex are 
so to regulate and control the actions of the individual as to serve 
best his interests in his relations with his environment. 
(1) Three things are necessary for adjustment: ' 
(a) Experience of the environment must be gained. 
(h) This experience must be organized, associated, and brought into 
relation with previous experience, 
(c) The resultant must be transformed into appropriate actions. 
(2) The first is brought about through the group of sensory recep- 
tors and their pathways to the cortex, collectively called the “sen- 
sorium”; the second, by organizing and associating the experiences 
in the intellect; the third, by discharging the energy through the 
motorium as motion or glandular activity. In the language of the 
psychology which considers each of these as faculties of the mind, 
the function of the sensorium is perception; of the intellect, thinking; 
and of the motorium, volition. 
c. Following are definitions of certain terms used above: 
Sensations.—Sensations are the result of stimulation of specialized 
sensory end organs and comprise the mass of material of which 
mental functioning is composed. 
14 THE 8-325 
6 
tfFiUTCOPSYCJHTATBT IN AVIATION MEDICOTK 
Perception.—Perception is the process of forming a mental image 
of an object present to the senses. 
Ide-ation.—Ideation is the process of forming a mental image of an 
object not then present to the senses. The only difference be- 
tween percepts and ideas is the presence of sensory elements 
in the former. 
Thinking.—Thinking is the process of assimilating and rearranging 
materials of knowledge present to the senses with materials 
already present in consciousness. 
Reasoning.—When from the association of two or more ideas there 
issues a new and different idea, the process is reasoning. 
Judgment.—If the reasoning is at all complicated, several judgments 
usually result, each one tending to express itself in appropriate 
action. Ziehen calls this conflict of tendencies the “battle 
motives”. The strongest finally succeeds in expressing itself, 
and volition results. 
Volition.—Volition is the conscious realization in action of the 
strongest motive and is accompanied by a sense of freedom to 
choose which motive shall dominate. 
Conduct.—Conduct is the sum total of the actions of the individual. 
Conduct has social value of the utmost importance because it 
is the basis upon which the community judges the individual. 
He may think as he pleases, but he must act along fairly well- 
defined lines if he expects to be left undisturbed. 
d. The problem of adjustment is clearly set forth by one authority 
as follows: The condition of the baby in its mother’s uterus may 
be described as one of unconditioned omnipotence. Everything is 
performed for it by its mother and no desires can arise because 
everything is furnished before the need of it is permitted to exist. 
At the moment of birth all this is changed. The baby must now 
breathe for itself, eat for itself, and perform many other functions 
for itself. Because it is impossible to furnish everything before the 
need for it exists, desire arises and omnipotence is instantly im- 
periled. However, the watchful household, intent upon serving the 
baby, anticipates most of its needs and desires are few. But as the 
days go by and the baby’s sense organs develop and its relations to 
its environment require more and more complex adjustments, no 
amount of watchfulness can forestall all of its desires. Conse- 
quently, there arises discrepancy between desire and attainment, 
which discrepancy is ever widening as the years go by and the grow- 
ing individual touches reality at more and more numerous points. 
This discrepancy, this conflict between desire and attainment, is at 
15 TM 8-325 
6-8 
MEDTOAL MiPARTM'EOSrr 
the very basis of mental life and the fundamental fact of conscious- 
ness. 
7. Solving of conflict.—a. The conflict may be solved in one of 
two ways; the individual may make things come true by doing 
them, or he may make things come true by thinking them true; that 
is, phantasy them. This is expressed as two types of reaction; reality 
motive and wish fulfillment or pleasure-pain motive, 
h. By these reactions the individual, the child, retains the ability 
to satisfy any desire. Less and less, however, as he grows up he 
realizes immediate satisfaction of desire, and more and more must 
there be relinquishment or repression of desire. This process of 
repression constantly crowds material into the region of the uncon- 
scious, that region which constitutes the historical past of the psyche, 
a region of the greatest interest and importance to the psychiatrist 
because within it lies buried a mass of material so long since re- 
pressed as to be unrecognized when it appears and therefore not 
understood as a motive for conduct. 
c. As the process of development continues with its conflicts, 
repressions, and ever increasing realm of the unconscious, there come 
to be three fundamental and controlling groups of desires as follows: 
(1) Self-preservation, of which hunger is the type. 
(2) Kace preservation, of which the sexual relation is the type. 
(3) Communal or herd instinct, of which tribal grouping is the 
primitive type. 
d. The libido, interest, or craving is the energy driving toward 
these three goals. That component driving toward self-preservation 
is the nutritive libido; that driving toward race preservation is the 
sexual libido; and that driving toward tribal grouping is the com- 
munal libido. Self-preservation, race preservation, and the communal 
interest are in fundamental conflict. The first implies keeping; the 
second giving; and the third subordination of self for the welfare 
of all. 
8. Fixation of libido.—a. The infant’s first interest is in differen- 
tiating itself from its environment (auto-erotism). Next the interest 
goes out indifferently to individuals in its immediate environment, 
hence to its parents, and as there are male and female, to a differentia- 
tion based upon sex. These experiences of love and affection stand as 
types conditioning all subsequent similar experiences. Then follows 
drafting of interest wandering of the libido, first in one direction 
then in another, a characteristic of the young. As the years go by, 
interest tends to become more and more confined to more definite 
directions and objects and with maturer years, becomes still further TM 8-325 
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NBfUBOrSYOHTATBY IN AVIATION MEDICINE 
circumscribed- Increasing restriction of interest is a fundamental 
characteristic of old age. 
b. All mental processes are accompanied by certain physiological 
processes in the cells and fibers of the cerebral cortex, involving changes 
in the energy and substance of these cells and fibers. Therefore, when 
a certain mental process has occurred once, accompanied by its correl- 
ative physiological process, the changes in cells and fibers will have 
left such an impress that a subsequent process of the same sort will occur 
more rapidly. A mental process having occurred once, tends to recur 
in the same way when the same conditions are repeated. This tendency 
is the physiological basis of memory. 
o. Memory is the recurrence to consciousness of a previous experience 
and recognition of it as having occurred before. 
d. All mental processes, conscious or unconscious, have, as a super- 
added mental state, feelings and affections. There is a general tendency 
on the part of the organism to reach out toward the pleasant and to 
withdraw from the unpleasant. This is the whole purpose and nature 
of affection; pleasing things attract and unpleasing things repel the 
organism. In the scheme of evolution affection is the inevitable sequel 
to the development of sensation and movement. 
e. By affects is meant emotions, passions, moods, and temperaments. 
The tone of feeling which attaches to a percept, idea, or concept is of a 
much more complex nature than that which attaches to a simple sensa- 
tion, and it has many more varieties, known as emotions. An emotion, 
then, is the pleasant or unpleasant tore of feeling which accompanies 
sensation. Emotions are also known as feelings compounded of sensa- 
tions which arise in consequence of complex movements reflexly aroused 
by the situation (real or imaginary) in which the individual is placed. 
Each emotion has its corresponding passion and mood, a passion being 
an intense emotion of short duration and a mood a prolonged emotion 
of moderate intensity. Closely allied to the moods are the tempera- 
ments. A temperament is to be regarded as a mood which lasts the 
greater part of a person’s life. It is an individual’s temperament, 
whether sanguine, pessimistic, or suspicious, which is mainly respon- 
sible for the nature of the emotional tone aroused in him by any partic- 
ular incident. 
9. Unconscious emotion.—a. When an individual fails to react 
emotionally to an experience, the emotion is repressed. The reaction 
not having taken place leaves a certain amount of nervous energy 
active but ill-directed and unconscious. 
5. Every civilized human being has innumerable selfish desires 
which he is unwilling to admit even to himself; they are therefore 
274T5S*—*1 3 TM 8-325 
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MEDICAL, DEPARTMENT 
repressed into the unconscious. Whenever a situation or incident 
tends to arouse an emotion which the subject does not consider he 
has a moral right to feel, such emotion is repressed into the uncon- 
scious and replaced in consciousness by its opposite. Thus, the old 
maid refuses to admit, even to herself, the slightest trace of sexual 
passion; it is therefore repressed and converted in consciousness into 
its opposite, prudery. 
c. Another practical point about the psychology of emotion is that 
it is possible for an effect to remain in consciousness although the 
situation or idea which gave rise to it has been repressed; the result 
being that the affect remains unattached, floating free, but ready to 
attach itself to any or every passing incident; or the affect may be- 
come permanently attached to some idea having little association 
with that which originated the emotion. 
d. Affects have a physical basis and depend upon sensations. There 
is evidence that the thalamic region plays an important role in the 
development of an emotion reilexly aroused. If a patient has a 
lesion of one optic thalamus, for example the right, and he hears a 
joke, he smiles on the right side of the face only; the smile does not 
occur on the left side. That this paralysis is not due to a lesion 
of the cortex or pyramidal tract is shown by the fact that the two 
sides of the face act equally when he assumes a smile. If, on the 
other hand, the patient has a lesion of the right Rolandic area, he 
smiles equally on the two sides in response to a joke; but an assumed 
smile occurs on the right side only, volitional acting being paralyzed 
on the left side. 
e. It follows that mental processes are most intimately connected 
and not in any sense separate and distinct from each other. Neither 
barriers nor compartments exist in consciousness; it is a continuum. 
/. Finally, mental processes from their incidence in sensations to 
the release of the motor responses constituting conduct are con- 
ceived to have as their physical substratum a continuous neural 
process. 
Section III 
CAUSES AND NATURE OF MENTAL DISEASE 
Paragraph 
General 10 
Freudian hypothesis 11 
Adler hypothesis 12 
Contributing causes of mental disorders 13 
XO. General.—Psychiatry is an important aspect of medicine, as 
from the psychiatrical viewpoint, the individual is regarded as an TM 8-323 
10 
NEUROPSYCHIATRY IN AVIATION MEDICINE 
entity and not merely the disease is considered. As Euggles states, 
“There is no disease or disorder that in some way does not affect the 
patient’s mental and emotional make-up, nor is there any disease or 
disorder that is not favorably or unfavorably affected by the patient’s 
feeling and thoughts.” 
a. Mental disorders, excluding those of organic origin, are thought 
of as failures to effect harmonious adjustments. The symptoms man- 
ifested, no matter how grotesque, fantastic, or seemingly inexplicable, 
are evolved from materials somewhere in the individual’s mental 
past. Nothing is created. Every mental fact has its efficient cause 
in an antecedent mental state, and every bit of conduct is an end 
product conditioned by what has gone before and out of which it 
issues. This is the law of determinism. Thus the symptoms of a 
psychosis depend for their explanation upon the mental make-up of 
the individual and the character of his psychic trends, and the form 
of reaction begins to be understood when his past is uncovered and 
the history of his development studied. 
h. A psychosis, excluding those of organic origin, is the resultant 
or issue of a conflict. It is the expression on the part of the in- 
dividual of his type of reaction to the conditions of his environment. 
o. In discussing the causes of mental disease, various theories and 
hypotheses, some of which are as yet only such but which have their 
value in explaining mental symptoms are confronted, physical causes 
as well as mental must be considered. Disorders resulting from or 
accompanied by molecular or physiological changes are known as 
“physiogenic.” To those in which the mental symptoms are due to a 
psychological reaction to mental events, the term “psychogenic” is 
applied. 
d. The basic factors involved are heredity and environment; by 
environment is meant the sum of the individual’s conditionings and 
life experiences. How much either of these is a factor cannot be 
established at the present time. The increasing belief is that heredity 
has been overemphasized. The reason for this is that terms have 
been applied loosely, as have statistics. However, it is evident that 
certain forms of mental diseases do injure the germ cell, producing 
an inheritance favorable to the development of mental disease. The 
factor of heredity is still a moot question and knowledge of it is far 
from complete. 
e. The present day opinion is that improper early mental hygiene 
or improper guidance is the cause of many of the psychologic prob- 
lems that were generally held to be of hereditary origin. Thus 
the conclusion which may be drawn is that the symptoms of a 
19 tm 8-aas 
10-11 
MSDICL4.li DBPABTMK5TJ 
psychosis depend upon the mental make-up of the individual, the 
character of his mental trends, and his developmental history. 
f. The fundamental problem of each individual life is that of 
adjustment to environment; but the motivating influence is desire. 
The individual continually strives to satisfy his desires and fulfill 
his wishes. When these are incompatible with social ideals they 
must be repressed, and the energy pertaining to them diverted into 
useful and socially acceptable channels; that is, sublimated. If this 
is accomplished, the intrapsychic conflict has reached favorable issue 
and satisfactory adjustment has been made. When like adequate 
sublimations and adjustments continue throughout life, there is 
mental health. 
g. On the contrary, in numerous instances the intolerable effect of 
an experience looms too large in consciousness; or a body of ex- 
perience, a complex, in the unconscious and antagonistic to conscious 
wishes overrides the repressive forces and disturbs the conscious life. 
Then sublimation has failed, the intrapsychic conflict causes dis- 
harmony, and the individual loses precision of contact with reality; 
maladjustment obtains in varying measure and there is mental ill- 
ness which may range in degree from mere worry, through psycho- 
neurotic manifestations, to the frankly psychotic. 
h. Based on knowledge of the origin, content, and mode of opera- 
tion of the unconscious, two well-known hypotheses have been offered 
in explanation of the causes of mental disorders as well as of the 
mechanisms bringing about the various symptoms. These are the 
hypotheses of Freud and Adler. Freud ascribes all to the sexual 
complex; Adler, to the inferiority complex. Those who accept 
neither hypothesis urge opposing points of view often so evasive that 
the student questions the intellectual honesty of the writers and feels 
that only resistances, conscious or unconscious, block frank accept- 
ance of disputed points. 
11. Freudian hypothesis.—a. This hypothesis has excited a great 
deal of acrimonious discussion and much hostile and abusive crit- 
icism; partly because the compelling primary instinct of sex is 
repressed more than any other and its frank discussion absolutely 
taboo in modem society, and partly because the opposition pushed 
Freud and his followers to the extreme of explaining practically 
every phase of human feeling and activity on the sexual basis. It 
would seem wisest, with unbiased mind, to adopt a compromise view- 
point and deny the sexual instinct primacy in causing mental illness, 
while conceding it due importance as a causative factor. 
h. Freud believes that the tendencies repressed into the unconscious 
are directed by the pleasure-pain motive to conduct and that the TM 8—335 
11-12 
NENBOPSYCHTATBY IN AVIATION MEDICINE 
pleasure sought is of a sexual nature. In the course of development, 
certain forms of pleasure seeking have received undue emphasis; the 
child has for some reason continued to derive pleasure from some ac- 
tivity such as nakedness (exhibitionism); sexual curiosity (peeping); 
inflicting pain on self or others (sadomasochism); pleasure in its own 
sensations (auto-erotism) ; love of children most like itself, of the 
same sex (homosexuality), which should, as a source of pleasure 
seeking have been relegated to its historic past, and therefore the 
necessity for deriving pleasure in this way is greater than normal 
and constantly tends to find expression. Such ways of pleasure 
seeking are incompatible with the conscious ideals, and so can come 
to expression only in some disguise. The ways in which thase ten- 
dencies are satisfied and the disguises they assume produce the 
symptoms of the psychoses. For example, a homosexual man who 
cannot bring himself to consciously think of concrete homosexual 
practices may engage in welfare work among men. The sexual in- 
terest is drafted off to a higher, socially accepted and useful level; it 
is sublimated. When such a man, however, is unable to fully sub- 
limate his homosexual libido, he may take to alcohol because it brings 
him into the company of men and permits a degree of intimacy under 
the guise of intoxication that would not otherwise be possible. If his 
sublimation fails still more completely, h© may develop a psychosis 
with hallucinations of hearing in which the voices accuse him of 
homosexual practices. 
12. Adler hypothesis.—a, Adler emphasizes the self-preservative 
rather than the sexual instinct. He sees in the psychosis a conflict 
due to the desire to dominate which is frustrated by a feeling of 
inferiority based upon some organic defect. For instance, if the 
defect is one of speech, the individual feels it his weak point and 
directs a surplus of energy to overcoming it. If he triumphs, he may 
become a successful public speaker. Or if he fails to overcome the 
defect and cherishes the feeling of inferiority, he may break down 
with a psychosis and show an oversensitiveness concerning the defect 
with ideas of reference; that is, thinking it is noticed, remarked about, 
etc. This hypothesis will occur to the student as resting upon a 
needlessly narrowed basis, only organic defects. If the conception be 
broadened to include feelings of inferiority and self-depreciation 
based on any insufficiency, organic, sexual, or otherwise, it immedi- 
ately assumes deeper significance and lends itself to more general 
application. 
6. Freud and Adler are famous controversialists, and their fol- 
lowers equally so. Their ardor has produced a voluminous litera- 
ture and two great schools of thought with apparently hopelessly TM 8-325 
12-13 
MEDICAL DEPARTMENT 
diverging points of view. On examination, however, their teachings 
do not appear irreconcilable, for while far apart in some respects, 
in others they draw rather closely together, and the student finds an 
acceptable middle ground by broadening the conception of each and 
minimizing the basic contention. 
13. Contributing causes of mental disorders.—a. The study 
of a case of mental disorder is a complex problem because the change 
from the normal usually takes place insdduously; the contributing 
factors are apt to be multiple; and many of the symptoms incompre- 
hensible, unless the underlying mechanisms be understood. 
h. Psychoses are rare until adolescence, at which time the rise is 
sharp and rapid, continuing until the fourth decade. Then the curve 
begins to fall, rising slightly again during the involutional period, 
and again rising during the senium. The marked rise during adoles- 
cence is attributed to the physiological and constitutional changes 
occurring at that period, as well as to the marked increase in conflict 
resulting from the battle between emotional and instinctive life and 
the demands made by society. No other period in life demands such 
an acute change or reorganization of the emotional life. During the 
involutional period occurs the factor of endocrine “underfunction” 
and the psychological results arising from the realization that the 
prime of life has been passed. The highest period of incidence is in 
the fourth decade and is undoubtedly due to the marked prevalence of 
general paralysis. The increase during the senium is due to the 
degeneration changes that occur in the higher cortical neurons at that 
period of life. Mental disease is more common among the single than 
among the married. Not because the married live a more stable or 
regular life, but because the development of mental disease is usually 
more marked before the age of marriage, and therefore decreases the 
prospect of marriage. There is no evidence that abstinence of sexual 
life in itself is a factor in the causation of mental disease from a 
physiological standpoint; however, from a psychological standpoint, 
other factors intervene which have their influence on normal mental 
life. It is no different than that caused by a marriage that does not 
satisfy the biological and emotional expression of the individuals 
concerned. It is interesting to note that mental disease is more preva- 
lent among the divorced per unit of population. For example, the 
rate of first admission in the state of Massachusetts in 1928 was 477 
per 100,000 of divorced in the state population compared with 126 
single, 88 married, and 201 widowed. The cause is perhaps due to 
several factors among which may be personality maladjustment lead- 
ing to psychoses and a fixation at a homosexual development. In other TM 8-325 
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NEUROPSYCHIATRY IN AVIATION MEDICINE 
words, the same mental mechanisms leading to marital maladjustment 
lead also to an active psychosis. 
o. Then there are the psychoses associated with pregnancy, the 
puerperium, toxemia infection, alcohol, focal infection, chemicals and 
drugs, endocrine disturbances, physical anomalies, and trauma. These 
will be further considered in section VII. 
d. There is considerable difference in sex distribution in the vari- 
ous psychoses, although approximately an equal number of men and 
women are admitted to mental hospitals. More men are admitted for 
the alcoholic psychoses, general paralysis, other syphilitic involve- 
ments of the brain, cerebral arteriosclerosis, and schizophrenia. The 
affective psychoses, neuroses, psychoneuroses, and the psychoses due to 
somatic disturbances are more frequent among women. 
e. As yet no one formulation either chemical, physiological, neuro- 
logical, or psychological can explain all the phenomena observed in 
mental disease. 
Section IV 
DYNAMICS OF BEHAVIOR 
Paragraph 
14. General.—a. There are two vital forces involved which are 
characteristic of life; physical life energy and psychic energy. The 
history of the concept, psychic energy, is interesting. Aristotle called 
it “horme”, Schopenhauer “will”, and Freud the sexual definition of 
“libido.” Jung also uses the term “libido”, but uses it to designate 
psychic energy in whatever form. Adler speaks of it as an urge 
toward superiority, and Jastrow as emotionalized psychic energy. 
Noyes’ definition, perhaps the most practical, is that psychic energy 
is the sum of the vital energy that motivates the life adjustments of 
the individual. He further considers it as the result of the expend- 
iture of nervous energy, which must be discussed in psychological 
terms. He presumes that there is a physico-chemical basis in the 
relation between psychic and nerve energy, which exists in the Nissl 
bodies of nerve cells. 
h. Most psychiatrists agree that this energy is found in the in- 
stincts and manifests itself both potentially and kineticaily; psycho- 
logically, the instincts are characterized as specific forms of energy. 
The theory of instinctive behavior is not accepted by those who do 
not understand biology. They believe that instinctive behavior can 
be nothing but vile, and do not realize that laudable activities may 
also result. Prehuman species down through the periods of evolution 
have efficiently existed by instinctive behavior and it is not for nature 
23 TM 8—335 
14 
MEDICAL DEPARTMENT 
to discard it and create a new principle, which has not been tried, 
in governing behavior. 
e. Some consider behavior to be the result of motive and should 
be so interpreted. However, motives are but instincts which man 
has been able to transform and in some measure conceal. 
d. The function of consciousness in behavior is that of selection 
and inhibition, and perhaps creative. On a somewhat similar basis, 
intelligence determines how the goal of the organism can best be 
reached. 
e. Instincts have been considered from the evolutionary and physi- 
cal and from the psychological viewpoints. The evolutionary view- 
point describes instincts as inherited directors of energy, while psy- 
chologically, they are regarded as urges, drives, or impulsions that 
are utilized for the maintenance of the individual or species, as well 
as for creative purposes in art, philosophy, and science. 
/. Another biomental element which must be considered is emotion. 
‘The conception of emotion is determined by the approach to the sub- 
ject ; it depends upon the particular branch of biology used. Several 
theories are in vogue, such as the James-Lange theory, which considers 
emotion as a physiological phenomenon, Noyes’ definition, as far as 
psychiatrists are concerned, is that it is the agent that transmutes the 
potential energy of the organism into psychic energy, and as a feeling- 
tone that stimulates or facilitates some instinctive tendency, or again 
as the subjective aspect of instinct experienced when instinctive be- 
havior is obstructed. Physiologically, instincts may be considered as 
representing the activities of performed or inherited circuits made up 
of exteroceptors, neurones, and striped muscle fibers, while the emo- 
tions represent the auxiliaries of these. The third concept is the 
psychodynamic agent termed “wish.” Freud introduced this term and 
limited it to sexual longings, especially those that had been repressed. 
However, it will be considered here as a conscious or unconscious striv- 
ing on the part of the organism for the release of its inherent energy 
in forms of instinctive patterns. It is a conveyor of psychic energy. 
Conscious awareness is not necessary as an essential in this factor, 
therefore some prefer the term “inclination.” Its dynamic energy is 
exemplified by the attitudes of anger and hate when a wish is 
frustrated. 
g. Dynamic psychology is based on cause and effect in explaining 
behavior and was made possible by realizing the importance of in- 
stincts, emotions, and wishes. Psychiatry is interested in learning 
how these forces have been misdirected in the abnormal personality. 
24 N EUTiOPSYOHXATRY IN AVIATION MEDIOINB 
TM 8-335 
15 
Section V 
Paragraph 
General- 15 
MENTAL MECHANISMS AND MOTIVES 
15. General.—Mental mechanisms and motives are the mental 
devices, or systems of behavior, with which the individual strives to 
adapt himself to his environment. 
a. Conflict includes the antagonistic tendencies not only of the indi- 
vidual personality, but of those between the individual and the species. 
b. The term “suppression” is distinguished from “repression.” 
Suppression is the conscious attempt to forget what it is desired to 
exclude in contradistinction to repression which is not produced by 
a deliberate and conscious effort of rejection. A point that we must 
continually keep before us is that repression is not always pathological 
nor undesirable, for when repression functions smoothly and without 
undue effort, the result is a well-adjusted life. 
c. A complex is characterized by a strong emotional trend. This 
emotional trend is termed “affect.” It is defined as a feeling-tone 
that tends to color consciousness and outlook on life. In addition, 
the affects with their associated conative tendencies constitute an 
essential and the dynamic element of the complex, that is, the conative 
tendencies are the driving aspect of the personality or that part of 
the complex which motivates conduct. 
d. Sublimation directs the primitive impulses into other activities 
which tend to promote the progress or culture of the individual and 
is one of the most important mechanisms in the formation of sound 
character. However, in the study of disturbed personality symptoms, 
it is found that some outstanding personality trait which the indi- 
vidual interprets as a good sublimation is only a neurotic symptom. 
The transference of energy may be compared to the falls of Niagara. 
The force of gravity of the falls is the primitive biological energy 
and the electrical generator is sublimation which acts without appre- 
hending the nature or meaning of the forces it transforms and renders 
available for utilization. 
e. The internal forces cannot be created any more than can the power 
of gravity, but the motives which are accepted by and are of service 
to the herd can be selected. This power of selection is termed “con- 
scious control.” It is exemplified by the powerhouse switches and 
controls which direct electricity to its various uses for the benefit of 
mankind. 
f. The distinction given between a lie and rationalization is interest- 
ing. The difference between a lie and a rationalization is that in a lie 
25 TM 8-335 
15 
MEDICAL DEPARTMENT 
it is consciously known that the reason is fictitious, whereas rational- 
ization is so thoroughly an unconscious mechanism that it is not realized 
that the reason assigned is fictitious. 
g. Compensation is well illustrated by the comparison of the physi- 
ological and physical with the psychological. The compensating heart 
and compensating scoliosis are examples of the physiological and 
physical. The compensation of the organism as a whole is illustrated 
by the individual of small stature with the loud voice and over-bearing 
manner. These inferiorities may also be of a mental nature, may be 
real, fancied, and various, and the compensatory reactions may be 
equally varied. Physical inferiorities may produce outstanding char- 
acters such as Steinmetz or Edison. In the field of athletics, great 
stars are found who were inferior physically at an earlier age. How- 
ever, all inferiorities do not produce useful compensations. Some 
compensations which do not result so are seen in the neurotic and 
psychotic reactions. Compensated physical or mental inferiorities are 
seen frequently among pilots. The final result which the whole 
organism seeks is security and a method of asserting its superiority. 
This superior feeling is at times attained fictitiously, for example, by 
the recruit who could not assert his superiority in the squad so was 
driven to assert it fictitiously by assuming the rank of a major general. 
However, this did not agree with his environment, so he was removed 
from the group to a hospital, 
h. Symbolization is the representation of an idea, quality, or object 
by another and usually takes the form of symbolic artistry such as 
painting, sculpture, poetry, and music. These are usually symbolic 
portrayals of the artistic individual in which he shows his psychologic 
and often psychiatric status, his problems and unconscious tendencies. 
The expression of the unconscious mind is recognized as being pro- 
duced through symbols, the indirect product of repression. Tics of 
any sort are the product of psychogenic origin, being usually disguised 
expressions of painful mental expressions, or the symbolic representa- 
tion of consciously disowned trends or desires. 
i. Displacement is illustrated by the compulsion “hand-washing.” 
By this mechanism the affect is displaced from a painful complex to 
one that is apparently unrelated, which is, however, invested with 
symbolic significance. This symptom frequently appears in the 
psychotic. 
j. Projection is actually the individual’s motives ascribed to others. 
These projections may be either in the form of ideas or perceptions. 
Ideas project into delusions as illustrated by the “self-inflicted 
wound” type during the World War, Paranoia illustrates further TM 8-325 
15 
2STEUP.0PSYCHIA.TIIY IN AVIATION MEDICINE 
the idea-projection mechanism. Hallucinations illustrate the per- 
ception type of projection, which is the repressed mental material 
taking the form of hallucinated voices accusing the patient of prac- 
tices that represent the rejected aspects. These symptoms commonly 
are seen in mental institutions. 
k. Identification is merely a process of internalization in compari- 
son to projection which is a process of extern alization. Identifica- 
tion brings to use the term “introjection,” which describes the mecha- 
nism involved in incorporating various elements into personality. 
There are two types of identification. First, the type in which the 
individual either transfers or attaches to himself certain qualities or 
properties belonging to other persons or objects, and second, the 
type in which the individual transfers to one person the representa- 
tion he has of a second person. The first type of identification has 
already been discussed. The second type explains why, apparently 
for some unknown reason, like or dislike of individuals with whom 
contact is made is explained by identification of these new acquaint- 
ances with former acquaintances. 
L Freud’s theory of evolution and development of personality is 
based primarily on the evolution of sex interests. He calls the earli- 
est of these the “auto-erotic” stage. In this stage, primitive sex satis- 
faction is gained by irritation of different parts of the body, such as 
the mouth in sucking, and is considered normal at this stage of de- 
velopment. Then the stage of self-consciousness, in which the chief 
interest is in one’s self, and to which Freud gives the term “narcis- 
sism.” This period is marked by phantasy, self-consciousness, and at 
times, conceit. The next change is that in which the individual be- 
comes interested in those of his own sex, and is known as the “homo- 
sexual” stage. It is seen in early adolescence. Little interest is 
shown in the opposite sex, in fact a sort of superior air is shown to- 
ward the opposite sex. Unless perverted sex practices develop, this 
stage is normal for the time involved. From this period, the nor- 
mal stage develops, when the instinctive tendencies trend toward 
those of the opposite sex. Along with this sex development, there 
should be a normal development of mental attributes; however, some 
development may be halted along the time of these different stages 
which results in incompletely matured element or an inharmonious 
integration. This halting of development prior to complete matu- 
rity is known as “fixation.” The simile in physical life is that of the 
blood circulation in the fetal heart. If the formen ovale does not 
close, there is a halt in the maturing of the infant, which condition 
is, however, normal in the intra-uterine development. One concep- 
tion of fixation explains many of the symptoms seen in border-line 
27 TM 8-325. 
15-101 
< MEDICAL DEPARTMENT 
and frank psychoses. A fixation at the homosexual level is a good 
example. This level is maintained by the individual either through 
this stage of development becoming attractive, or through a constitu- 
tional or biological defect in the sexual characteristic. The herd re- 
jects these tendencies as they are contrary to biological law, there- 
fore a conflict is established between the individual and the herd, 
and various psychopathological phenomena are developed. 
m. The personality may lose some of the development it has already 
attained. The mechanism involved has been termed “regression.” 
It is an adjustive mechanism, but adjusts to a lower level and there- 
fore abnormal. It is illustrated by those who when physically ill 
become irritable, defendant, and childish. It is but a reversion to a 
lower stage of development; to an infantile or primitive behavior. 
Where regression occurs, the personality does not return to its pre- 
vious identity on removal of the regression. 
n. If the effect that mental factors have in physical processes are 
not recognized, neither are the exaggerations caused thereby. The 
vegetative nervous system is influenced by mental conflicts and emo- 
tions, and a functional disturbance results therefrom. An organic 
disturbance may be initiated and disturbances already present are 
enlarged. 
Section YI 
PSYCHOBIOLOGICAL CONSTITUTION AND REACTION 
TYPES 
Paragraph 
General — , 10 
Classification-.,— _ _ — . 17 
16. General.—In the psychobiological constitutions, the problem 
of the relation between human form and human nature, or a branch- 
ing out with the general problem of the correlations between physical 
form and psychic nature are considered. It is rather an empirical 
investigation, but it is a grouping of humanity into types and is 
important to the psychiatrist and to all interested in psychology. 
When the common conceptions of various characters, either mytho- 
logical or true, are portrayed, the devil is usually lean with a thin 
beard growing on a narrow chin; the intriguer has a hunch back and a 
slight cough; the old witch has a withered hawk-like face; the gangster 
has a sullen, piercing, antagonistic, hard look. Where there is bright- 
ness, jollity, and good-fellowship, the fat individual with the red 
nose and bald, shining pate is seen. Saints look abnormally lanky, 
pale, long-limbed, of penetrating vision and godly. These conclu- TM 8-335 
16-17 
NEDUOPSYOHIATRY IN AVIATION MEDICINE 
sions are probably objective findings of folk psychology, the results 
of the observations of mankind. 
17. Classification.—a. The anthropological types which Kretsch- 
mer has called attention to are the pyknic, asthenic or leptosome, ath- 
letic, and dysplastic. With these he associated different types of 
temperament and classified temperament into the cyclothymic, and 
schizothymic or schizoid. The cyclothymic temperament is sub- 
divided into the hypomanic, syntonic, and melancholy types. This 
classification involves the physique and temperament of the individual. 
Another classification of reaction types involves the form and direc- 
tion of energy trends. This classification is devised by Jung and 
divides this form and direction of energy trends into two reaction 
types which he called “extroversion” and “introversion.” These 
divisions are as follows: 
(1) Anthropological. 
(a) Pyknic. 
(b) Asthenic or leptosome. 
(o) Athletic. 
(d) Dysplastic. 
(2) Temp&tmrwntaL 
(a) Cyclothymic. 
1. Hypomanic. 
0. Syntonic. 
3. Melancholic. 
(b) Schizothymic or schizoid. 
(3) Direction of energy trends. 
{a) Extroversion. 
(b) Introversion. 
b. The pyknic type is characterized by the pronounced development 
of the head, breast, and stomach, and a tendency to a distribution of 
fat about the trunk with a more graceful construction of the shoulders 
and extremities. An individual of middle height, rounded figure, soft 
broad face on short thick neck, and a fat paunch protruding from a 
deep vaulted chest which broadens out toward the lower part of the 
body. 
c. In the asthenic type we find a general deficiency in thickness with- 
out a corresponding lessening in length. This deficiency in thickness 
development is present throughout all parts of the body. 
d. The male athletic type is recognized by the strong development 
of the skeleton, musculature, and skin. He is middle-sized to tall, 
with a well-formed chest, firm stomach, and a trunk which tapers in 
its lower region, well-shaped pelvis, and strong limbs. TM 8-335 
17 
MEDICAL DEPARTMENT 
e. In the dysplastic type are placed all aberrations, and here are 
classified the biological inverts. The special groups which are recog- 
nized as dysplastic are such as the myxedematous, infantile, eunuch- 
oid, and masculinism in women. 
f. The above classification is devised for more accurate study, espe- 
cially as to their relation to character; and many variations will occur. 
The cranium itself is not important in its relation to the brain; it is 
only a detail in the formation of the entire body. Any morphological 
characteristic must be regarded as being important only as part of the 
framework of the bodily constitution. The size and shape of the skull 
does not reveal what it contains. Psychic disorders are not brain dis- 
orders, they involve the whole physiological development. 
g. The cyclothymic, or the manic-depressive, is associated with the 
pyknic type. In the schizoid, there is a marked preponderance of the 
asthenic, athletic, and dysplastic types. There seems to be a clear 
biological affinity between the psychic disposition of the manic-depres- 
sive and the pyknic body type; a clear biological affinity between the 
psychic disposition of the schizoids and the bodily disposition charac- 
teristic of the asthenics, athletics, and certain dysplastics. The cycloid 
or cyclothymic, on the average, is the good-natured, sociable, friendly, 
realistic individual. In all his reactions and expressions, the person- 
ality tends to function as a unit. He is friendly, well-liked, rarely 
grumbles, has a sense of humor, and enjoys a joke. However, he is 
rather easily moved to tears. He has a soft temperament which can 
swing to great extremes; that is, mood and tempo harmonize. He easily 
oscillates, therefore the name cycloid. These oscillations have been 
classified again with the hypomanic, syntonic, and melancholic groups, 
depending upon the prevalent reaction. The temperament of the 
cycloid alternates between cheerfulness and sadness in what may be de- 
scribed as deep rounded curves. The syntonic is the average, normal 
cyclothyme, the hypomanic is on the upper curve, tl melancholic on 
the lower. The hypomanic is flighty with a tendency +o be carried 
away, confident, aggressive, but has a superficial judgment nd a ready 
excuse for his failures. The melancholics are at the opposite extreme. 
The cycloid is a somewhat uncomplicated being whose feelings rise 
directly, naturally, and undisguised to the surface, so that a correct 
judgment of them may soon be formed. On the contrary, the schizoid 
has a surface and depth; he is a question mark. There are schizoids, 
men and women alike, with whom constant contact may be had for 
years, and yet their feelings may remain unknown; sometimes even 
to themselves. Bleuler calls it “autism,” the living inside one’s self. 
Reality never seems to have a normal value, and he elaborates things 
in phantasy. He shows the contrasting qualities of sensitiveness and TM 8-325 
17 
2TEUB0PSY0HTATEY IN AVIATION MEDICINB 
lack of affective sensibility, in contrast to the cycloid who shows the 
contrasting qualities of cheerfulness and melancholia. The cycloids 
and schizoids have nothing to do with the question of being patho- 
logical or healthy. They are large, general biological types which in- 
clude the great mass of healthy individuals, with the corresponding 
psychotics scattered among them. The cycloids must not necessarily 
be manic-depressives, nor the schizoids schizophrenics. 
h. Extroversion and introversion depend on psychobiological energy. 
All individuals possess both mechanisms, and only the relative pre- 
dominance of one or the other determines the type. This in itself is 
difficult to determine, because the psychological reaction of the human 
being is such a complicated matter. However, this line of demarca- 
tion may be made: In introversion, there is fundamentally an outward 
movement of interest toward the object, and in extroversion there is a 
movement of interest away from the object as regards the individual 
and his psychological processes. Introverts are compensating and 
extroverts compensating, with the result being a combination of both, 
which adds to the difficulty of classification. However, it is a method 
of differentiation of extensive groups of psychological individuals. 
The disguised behavior is of interest in psychiatry. As a further step 
in the study of extroversion and introversion, it is noted that a rhythmi- 
cal alteration of both forms of psychic activity may correspond with 
the normal course of life; but the complicated external conditions 
under which we live, as well as the presumably even more complex 
conditions of individual psychic disposition, seldom permit an undis- 
turbed flow of psychic activity. Jung, who introduced the psycho- 
logical conceptions extroversion and introversion, further added the 
basic psychological functions of thinking, feeling, sensation, and in- 
tuition, and made up types according to these functions, and stated 
also that everyone of these types could be extroverted or introverted. 
The terms “extroverted” and “introverted” were used by Jung to de- 
scribe what he called “general attitude types,” and the special types 
which he based on thinking, feeling, sensation, and intuition, called 
“function types.” The extroverted thinking type belongs to that 
group, if it can be shown that the ideas with which they are engaged 
are to a great extent borrowed from without. They are not what is 
termed “original thinkers.” Therefore they fall into the following 
classification: 
(1) Extroversion. 
Extroverted thinking type. 
Extroverted feeling type. 
Extroverted sensation type. 
Extroverted intuitive type. 
(2) Introversion. 
Introverted thinking type. 
Introverted feeling type. 
Introverted sensation type. 
Introverted intuitive type. 
31 TM 8-325 
17-ai 
MBDTOAIi DEPARTMENT 
This manual is limited to classifying examinees in the two great classes 
of introverts and extroverts. However, it is found that besides the 
conscious main function there is also a relatively unconscious auxiliary 
function and applicants should be classified into these various 
groups, even though the larger groups only are required. 
Section VII 
CLASSIFICATION OF MENTAL DISORDERS 
Taragraph 
Use of term “insanity” 18 
Point of view in studying cases 19 
Classification of the psychoses , 21 
18. Use of term “insanity.”—Insanity is not a disease and 
title word should not be used as a medical term. It is solely a legal 
and sociological concept used to designate those members of society 
who are so far unable to adjust themselves to the ordinary social 
requirements that the community segregates them. “Insane” simply 
means “certifiable” in a legal sense. 
19. Point of view in studying cases.—a. It must be determined 
whether the disorder is organic or psychogenic. Study must be made 
of the life history of the individual. There must be comprehension 
of the— 
(1) Character make-up or trend; as the unstable, hysterical, unre- 
sistive, etc. 
(2) Nature of the etiological factors* 
(3) Mechanism of the reaction. 
h. The type of reaction can only reach its explanation in the type 
of person displaying it. The important consideration is an under- 
standing of the individual, not a labeling of the psychosis. 
20. Psychosis.—A psychosis, excluding those of organic origin, 
is the pathological resultant of a conflict, exhibiting itself in social 
behavior. From the standpoint of disordered mental functioning, it 
is the expression on the part of the individual of his type of reaction 
to the conditions of his environment. 
21. Classification of the psychoses.—Present knowledge of the 
psychoses does not warrant attempts at permanent classification. 
Those classifications in use are therefore tentative and subject to 
change and modification. The tendency in classification is away from 
concrete, definite entities and toward the use of terms indicating symp- 
tom grouping; as, Schizophrenic group, manic-depressive group, 
paranoid group, psychoneurotic group, etc. 
32 NETJEOPSYCHIATEY IN AVIATION MEDICINE 
TM 8-325 
31 
a. With these considerations in mind, and also that other classifica- 
tions are in use, the following list approved by the Council of the 
American Psychiatric Association, compiled by the National Con- 
ference on Nomenclature of Disease, and published by the Common- 
wealth Fund, 1935, is given below: 
(1) Psychoses due to or associated with infection. 
(a) Psychoses with syphilis of the central nervous system. 
1. Meningo-encephalitis type (general paresis). 
0. Meningo-vascular type (cerebral syphilis). 
3. Psychoses with intracranial gumma. 
Jf. Other types (to be specified). 
(5) Psychoses with tuberculous meningitis. 
(c) Psychoses with meningitis. 
(d) Psychoses with epidemic encephalitis, 
(e) Psychoses with acute chorea. 
(/) Psychoses with other infectious disease (to be specified). 
(g) Postinfectious psychoses (infection to be specified). 
(2) Psychoses due to intoxication. 
(a) Psychoses due to alcohol, 
1. Pathological intoxication. 
2. Delirium tremens. 
3. Korsakow’s psychosis. 
4. Acute hallucinosis. 
6. Other types (to be specified), 
(6) Psychoses due to drugs or other exogenous poisons. 
1. Psychoses due to metals (to be specified), 
2. Psychoses due to gases (to be specified). 
3. Psychoses due to opium and derivatives. 
4- Psychoses due to other drugs (to be specified). 
(3) Psychoses due to trauma {traumatic psychoses), 
(a) Traumatic delirium. 
(h) Post traumatic personality disorders. 
(<?) Post traumatic mental deterioration. 
(d) Other types (to bo specified). 
(4) Psychoses due to disturbance of circulation. 
(a) Psychoses with cerebral embolism. 
(5) Psychoses with cerebral arteriosclerosis. 
(<?) Psychoses with cardio-renal disease. 
(d) Other types (to be specified). 
(5) Psychoses due to convulsive disorders (epilepsy). 
(a) Epileptic deterioration. 
(6) Epileptic clouded states. 
37475S*—41 * 
33 TM 8-325 
21 
MEDICAL. KEPAETMELNT 
(c) Other epileptic types. 
(6) Psychoses due to disturbances of metabolism, growth, nutrition, 
or endocrine function. 
(a) Senile psychoses. 
1. Simple deterioration. 
2. Presbyophrenic type. 
S. DeMrious and confused types. 
4.. Depressed and agitated types. 
5. Paranoid types. 
(5) Alzheimer’s disease. 
(c) Involutional psychoses. 
1. Melancholia. 
2. Paranoid types. 
3. Other types (to be specified). 
(d) Psychoses with diseases of the endocrine glands (to be speci- 
fied). 
(e) Exhaustion delirium. 
(/) Psychoses with pellagra. 
(g) Psychoses with other somatic diseases (to b© specified). 
(7) Psychoses due to new growth. 
(a) Psychoses with intracranial neoplasms. 
(b) Psychoses with other neoplasms. 
(8) Psychoses due to unknown or hereditary canses, but associated 
with organic changes. 
(a) Psychoses with multiple sclerosis. 
(b) Psychoses with paralysis agitans. 
(c) Psychoses with Huntington’s chorea. 
(d) Psychoses with other brain or nervous disease (to be specified). 
(9) Disorders of psychogenic origin or without clearly defined 
tangible cause or structural change. 
(a) Manic-depressive psychoses. 
1. Manic type. 
2. Depressive typo, 
3. Circular type. 
4. Mixed type. 
6. Perplexed type. 
6. Stuporous type. 
7. Other types. 
(b) Dementia praecox (Schizophrenia), 
1. Simple type. 
2. Hebephrenic type, 
3. Catatonic type. TM 8-32$ 
si 
irmmoP8TOHXA.TitY m aviation 
£ Paranoid type* 
6. Other types. 
(c) Paranoia. 
(d) Paranoid conditions. 
(e) Psychoses with psychopathic personality, 
(/) Psychoses with mental deficiency. 
(10) Psychoneuroses {hysteria). 
{a) Anxiety hysteria, 
(6) Conversion hysteria, 
(c) Anesthetic type (indicate Symptomatic manifestations). 
(d) Paralytic type (indicate symptomatic manifestations),. 
(e) Hyperkinetic type (indicate symptomatic manifestations). 
(/) Paresthetic type (indicate symptomatic manifestations). 
{g) Autonomic type (indicate symptomatic manifestations). 
(A) Amnesic type (indicate symptomatic manifestations). 
(i) Mixed hysterical psychoneurosis (indicate symptomatic combi- 
nations by using the various symptoms in the categories given above). 
(11) Psychos thenia or compulsive states. 
{a) Obsession (indicate symptomatic manifestations). 
(A) Compulsive tics and spasms (indicate symptomatic manifes- 
tations) . 
(c) Phobia (indicate symptomatic manifestations). 
(d) Mixed compulsive states (indicate symptomatic combinations 
by using the various symptoms in the categories given above). 
(12) Neurasthenia. 
(13) Hypochondriasis. 
(14) Reactive depression {simple situational reaction, others). 
(15) Anxiety stale. 
(16) Mixed psychoneurosis (indicate symptomatic combinations by 
using the various symptoms given above). 
(17) Undiagnosed psychoses. 
(18) 'Without psychosis.—(This diagnosis is to be used only in 
psychiatric and psychopathic hospitals where it is required to account 
for patients submitted for observation or allowed to remain in hos- 
pital for other legitimate reason). 
(19) Epilepsy. 
(20) Alcoholism. 
(21) Drug addiction. 
(22) Mental deficiency. 
(23) Disorders of personality due to epidemic encephalitis. 
(24) Psychopathic personality. 
(a) With pathological sexuality (indicate symptomatic manifesta- 
tions). 
35 TM 8—325 
21 
MEiDlOAL DEPARTMENT 
(5) With pathological emotionality (indicate symptomatic mani- 
festations). 
(0) With asocial or amoral trends (indicate symptomatic manifes- 
tations). 
(d) Mixed types (indicate symptomatic manifestations by using 
the various symptoms in the categories given above). 
(e) Other nonpsychotic diseases or conditions (to be specified). 
(25) Primary behavior disorders.—Simple adult maladjustment. 
(26) Primary behavior disorders in children. 
(a) Habit disturbance (indicate symptomatic manifestations). 
(b) Conduct disturbance (indicate symptomatic manifestations). 
(a) Neurotic traits (indicate symptomatic manifestations). 
b. The following is also listed as involving the “Psychobiological 
unit”; 
(1) Due to prenatal (constitutional) influences. 
(a) Familial mental deficiency. 
(b) Mongolism. 
(o) Mental deficiency with developmental cranial anomalies. 
(d) Mental deficiency with congenital cerebral spastic infantile 
paraplegia. 
(2) Due to infection {lower forms).—Post infectional mental de- 
ficiency. 
(3) Due to trauma. 
(а) Post traumatic mental deficiency, natal. 
(5) Post traumatic mental deficiency, post-natal. 
(4) Due to commlsive disorders.—Mental deficiency due to 
epilepsy. 
(5) Due to disturbances in metabolism, growth, or nutrition. 
{a) Mental deficiency with endocrine disorders. 
(6) Mental deficiency with familian amaurosis. 
(б) Due to new growths.—Mental deficiency with tuberous 
sclerosis. 
(7) Due to causes determinable in the particular case.—Mental 
deficiency, cause undiagnosed. 
(8) Diseases due to prenatal infliLences. 
(a) Prematurity (to be used only in the case of infants admitted 
after birth). 
(6) Congenital hypothyroidism, 
(9) Diseases due to intoxication.—Drug addiction (specify drug). 
(a) Alcohol addiction, 
(b) Alcohol addiction, periodic. 
(c) Ether addiction. 
(d) Chloroform addiction. TM 8-325 
21-33 
NEUROPSYCHIATRY IN AVIATION MEDICO® 
(e) Absinthe addiction. 
(/) Cannabis addiction. 
(g) Cocaine addiction. 
(h) Nicotine addiction. 
(i) Opium (morphine, heroin) addiction. 
(10) Disemes due to disturbances of innervation dr of 'psychic 
control.—Hypertonicity of infancy. 
(11) Diseases due to disorders of metabolism, growth, or nutrition. 
(а) Infantilism. 
(б) Precocity. 
(c) Premature puberty. 
(d) Menopause syndrome. 
{e) Premature menopause. 
If) Senility. 
(g) Pseudocyesis. 
Section VIII 
SYMPTOMS OF MENTAL DISEASE 
Paragraph 
Classification 22 
Disorders of perception 23 
Disorders of content of thought 24 
Disorders of train of thought 25 
Disorders of volition (action) 26 
Disorders of emotion (affectivity, feeling) 27 
Disorders of memory 28 
Disorders of attention 29 
Disorders of personality (disturbances of self-consciousness) 30 
Dreams 32 
22. Classification.—The general symptoms of the psychoses fall 
into eight classifications; these classifications with their subdivisions 
are as follows: 
a. Disorders of perception, comprising— 
(1) Illusion (inaccurate perceptions). 
(2) Hallucination (perceptions without an object). 
(3) Pseudo-hallucinations. 
(4) Hypnagogic hallucinations. 
(5) Auditory hallucinations. 
(6) Visual hallucinations. 
(7) Hallucinations of taste and smell. 
(8) Haptic hallucinations. 
(9) Hallucinations of the organic sensations. 
(10) Kinesthetic or motor hallucinations. PCM 8-335 
22-23 
MED10AI/ DEPARTMENT 
(11) Reflex hallucinations. 
(12) Clouding of consciousness '(insufficiency of perception). 
(13) Dream states. 
(14) Disorientation. 
b. Disorders of content of thought (judgment)— 
(1) Delusion. 
(2) Hyper-quantivalent ideas. 
(3) Fixed ideas. 
(4) Obsessions. 
(5) Autochthonous ideas. 
o. Disorders of train of thought— 
(1) Flight of ideas. 
(2) Circumstantiality. 
(3) Retardation. 
(4) Paralysis of thought. 
d. Disorders of volition (action)— 
(1) Decreased psychomotor activity. 
(2) Increased psychomotor activity. 
(3) Impulsion. 
(4) Compulsion. 
(5) Stereotypy. 
(6) Negativism. 
(7) Suggestibility. 
(8) Stupor. 
«, Disorders of emotion (feeling, affectivity)— 
(1) Exaltation. 
(2) Depression. 
(3) Emotional deterioration. 
(4) Morbid anger, 
/. Disorders of memory— 
(1) Amnesia. 
(2) Hyperamnesia. 
(3) Paramnesia, 
g. Disorders of attention— 
(1) Aprosexia. 
(2) Hyperprosexia. 
h. Disorders of personality— 
(1) Depersonalization. 
(2) Splitting of personality, 
(3) Multiple personality. 
(4) Transformation of personality. 
23. Disorders of perception.—a. Illusion.—An illusion is a false 
perception of an object. It is a perception which alters the qualities of TM 8-325 
23 
NETD'ROPSYOHIATEY IN AVIATION MEDIdNU 
the object perceived and presents it to the consciousness in a form 
other than the real one. The distinguishing feature of an illusion is 
that an actual something in the environment is perceived but the per- 
ception is incorrect and conveys false information to the mind; thus 
a strap on the floor may be perceived as a snake, the sighing of the wind 
as a whispering voice, a bad taste as poison, and so on throughout the 
different sensory realms. 
b. E(dliicmation.—An hallucination is a perception without an 
object. The distinguishing feature of an hallucination is a percep- 
tion without there being anything in the environment to perceive. 
Thus a strap is perceived on the floor when the floor is bare. The 
content of the hallucination is never newly created mental material, 
but is made up of memory pictures. The'congenitally blind never 
have visual hallucinations; the congenitally deaf never have auditory 
hallucinations; they may, however, occur in acquired blindness and 
deafness. In practical use, it is not customary to distinguish between 
illusion and hallucination, the term “hallucination” being understood 
to include the phenomena of illusion. 
o. Pseudo-hallucinations.—These occupy a position midway between 
fully developed hallucinations and imagination, having an objective 
reality less than the former and greater than the latter. Imaginative 
processes do not occur independently of volition as do hallucinations 
and pseudo-hallucinations. In hallucinations, the perceived object 
not only seems external and real, but there is no suspicion that the 
object seen or heard is not actually real and present. In pseudo-hal- 
lucinations there is a background of consciousness which assures the 
victim that the phenomena is after all imaginary and unreal despite 
its genuinely objective appearance. Thus a patient had a pseudo- 
hallucination of a lion which appeared to him and laid its forepaws 
on his shoulders, but he appreciated that he saw the lion only with 
his mind’s eye and was not afraid as he would otherwise have been; 
he merely interpreted the phenomena as signifying his allegiance to 
England. 
d. Hypnagogic hallucmationg.—These are hallucinations occurring 
in the intermediate state between sleeping and waking. They may 
readily be mistaken for genuine hallucinations. 
e. Auditory h/dluoinations.—These are more common than visual 
hallucinations. The “voices” may say pleasant or unpleasant things, 
but disagreeable things are usually heard. Voices may be heard in 
one ear or both ears and may be of any timber. Rarely one voice, 
as of Christ, is heard in one ear and another, as of the devil, is heard 
in the other. The voices may be located externally or as coming from 
the different parts of the body, as the “epigastric voice,” the “pelvic TM 8-325 
23 
MEDICAL, DEPARTMENT 
voice,” etc. More obscurely there may be complaint that the thoughts 
become audible; the patient hears them before speaking them. 
f. Visual hallucinations.—These range all the way from mere 
flashes of light, sparks, colors, to the most complex visions. Hallu- 
cinations of sight are more apt to be pleasant than those of hearing, 
but may also be disagreeable, even terrifying. 
g. Hall/ucinations of taste and small.—These are apt to be associated 
and are almost uniformly disagreeable. 
h. Haptic hallucinations.—These are hallucinations associated with 
the special senses located in the skin; touch, pain, heat, cold. The 
parasthesias come within this class of hallucinations. 
i. Hallucinations of the organic sensations.—These are peculiar and 
often indescribable sensations coming from the internal organs and 
giving rise to such beliefs as the bones are broken, the brain dried 
up, the bowels stopped, that a woman has been violated in her sleep, 
or that a man has had his semen drawn off while he slept. 
j. Kinesthetic or motor hallucinations.—These are sensations com- 
ing from the muscles, tendons, or joints and giving rise to a belief 
that the body has undergone a change in position. Thus a woman 
may complain that men remove her from bed at night, carry her 
away, violate her, and return her to her bed. 
h. Reflex hallucinations.—These are based on. secondary sensations 
arising in one sensory field when the stimulus has been applied in 
another field. 
l. Clouding of consciousness.—The process of perception is de- 
pendent upon sensations coming from without. Stimuli, in order 
to cross the threshold of consciousness, must have a certain force 
(threshold value) in order to fix attention and occupy the focal 
point of consciousness. Stimuli not reaching the focal point of 
consciousness have a marginal value only; their threshold value is 
too low to fix attention. When ordinary and even unusual stimuli 
fail to fix attention, consciousness is said to be clouded; a condition 
representing a fundamental element of many of the psychoses. 
m. Dream states.—These differ from the normal dream because in 
the latter, psychomotor reactions occur corresponding to the con- 
tent of consciousness. In dream states, there is a slight clouding 
so that ordinary stimuli fail to reach consciousness, the patient being 
oblivious of his surroundings while the mind is occupied by dreamy 
ideas and multiform hallucinations. 
n. Disorientation.,—This indicates lack of apprehension of the 
temporal, spatial, and personal aspects of the environment, either 
singly or together. Temporal disorientation indicates failure to 
apprehend time relations; spatial disorientation indicates failure to 
40 TM 8-335 
23-34 
N GUROPSYOHTATEY IN AVIATION TifEDIOTNE 
apprehend relations in space; personal disorientation indicates failure 
to apprehend identity of self as well as others. 
24. Disorders of content of thought.—a. Delusion.—(1) A de- 
lusion is a false belief, but it is not necessarily evidence of psychosis. 
It may be without pathological significance. For example, a man may 
believe today is Thursday when in fact it is Friday, a false belief 
while it lasts but having only the significance of a mistake. 
(2) Delusions present three main characteristics: First, they are 
not true to facts, higlily improbable, even manifestly impossible; 
second, they cannot be corrected by an appeal to reason; third, they 
are out of harmony with the education and surroundings. A sick 
Fijian crying for his soul to return to his body but exemplifies the 
Fijian belief that sickness is due to the soul, or a part of it, leaving 
the body; should an American who had received the customary in- 
struction and training act similarly, there would be reason for con- 
sidering him unbalanced. 
(3) Delusions are classified as systematized and unsystematized. A 
systematized delusion is so firmly established that it motivates con- 
duct and the patient’s whole life becomes centered about and secondary 
to it. Thus the patient who believes all his bones are broken and 
lies in bed because of this belief has a systematized delusion. 
(4) An unsystematized delusion exercises no special control over the 
patient’s conduct. Thus a patient who believes all his bones are 
broken, but goes about his affairs as usual, has an unsystematized 
delusion. 
h. Hyper-quantivalmi ideas.—These will not be discussed here 
because the term “fixed idea” is sufficiently inclusive. 
c. Fixed ideas.—A fixed idea is an idea which attains a degree of 
importance altogether unwarranted. Fixed ideas are felt to be the 
outgrowth or reaction of the normal self and not in any way abnormal 
or an obtrusion from without as are obsessions and autochthonous 
ideas. 
d. Obsessions.—By obsessions is meant ideas, emotion, and im- 
pulses which occupy consciousness persistently and irrespective of 
the desires of the subject, often intruding themselves at inopportune 
times and occupying the field of consciousness to the exclusion of 
other ideas. Obsessions are felt to come from without and are 
often comprehended at their full value. They are often spoken of 
as besetments, and include the phobias or fears, as agoraphobia (fear 
of wide or open spaces), claustrophobia (fear of narrow or closed 
spaces), etc., and the doubts. For example, a person after going to 
bed is obsessed with doubt as to whether he turned the gas cock 
quite shut or put the cat out of doors. He tries to banish the doubt. 
41 TM 8—325 
24-26 
MBDTOAii rxEPARrrMKisrr 
but finally in desperation lie rises, satisfies himself he has done 
these things, returns to bed, and presently falls asleep. Of graver 
import than these trivial doubts are those concerning religious and 
metaphysical matters. These latter doubts (obsessions) may achieve 
a dignity and importance ultimately motivating conduct, in which 
event they are known as imperative ideas or imperative concepts. 
e. Autochthonous ideas.—These are thoughts the patient feels to 
be strange thoughts, not his own, and interprets them as coming 
from without and due to the malevolence of enemies. When acting 
upon these usually bad thoughts, he protests he dislikes acting thus 
and that it is against his will. 
25. Disorders of train of thought.—a. Flight of ideas.—In nor- 
mal thinking, the thought progresses steadily toward an end known 
as the goal idea. In flight of ideas, the train of thought changes 
direction frequently, the goal idea is lost sight of, and the thought 
wanders here and there under the influence of chance association; 
that is, the element of distractibility dominates the goal idea and 
the goal idea is never reached. 
h. Circumstantiality.—This superficially resembles flight of ideas 
but in reality is totally different. Although the train of thought 
changes direction frequently, the goal idea is maintained and ulti- 
mately reached, notwithstanding much circumlocution and narra- 
tion of wearisome but vevertheless related details. In moderately 
developed form, circumstantiality is often encountered and has no 
special significance other than showing a lack of appreciation of the 
relative value of ideas. 
c. Retardation.—This is well expressed by the term “difficulty of 
thinking.” There is a decided slowness in the elaboration of ideas. 
Ideas come slowly, there is difficulty in forming judgments, in com- 
ing to conclusions, and in making decisions. The patient speaks 
very slowly and the retardation may be iniative or executive, or 
both. Thus a patient to count from 1 to 20 may be a long time 
beginning (initial retardation) and a long time in concluding (execu- 
tive retardation). 
d. Paralysis of thought.—This is complete absence of all internally 
initiated conscious processes. Mental life is in abeyance or abolished. 
2(5. Disorders of volition (action).—a. Decreased psychomotor 
activity.—This symptom corresponds in the motor sphere to retarda- 
tion in the psychic sphere and might aptly be called psychomotor 
retardation. Whereas in retardation there is slowness in the elabora- 
tion of ideas, in decreased psychomotor activity there is slowness 
in the liberation of voluntary motor responses. The patient moves 
slowly and deliberately and there is an initial and executive distinc- 2?M S*-325 
23 
ITEnjEOPSYGHTATBY IN AVIATION MEOTCTNB 
tion as in retardation. Decreased psychomotor activity is a promi- 
nent symptom of melancholia. 
b. Increased psychomotor activity.—This symptom is just the op- 
posite of decreased psychomotor activity. There is an abnormally 
facile release of voluntary motor impulses. However, the restless- 
ness, activity, violence, and destructiveness are entirely without pur- 
poseful direction because distractibility controls as in flight of ideas. 
Increased psychomotor activity is a prominent symptom of the manic 
phase of manic-depressive psychosis. 
c. Impulsion.—Impulsions or impulses are tendencies to act which 
are more or less uncontrollable, often absolutely so. This classifica- 
tion includes the manias as kleptomania (a morbid impulse to steal), 
pyromania (a morbid impulse to set things on fire), a dipsomania 
(a morbid impulse to drink), etc. 
d. Compulsion.—This is felt to be an extraneous influence often 
forcing the commission of an act repugnant or even abhorrent to the 
individual. The patient may take elaborate precautions to protect 
others from his compulsive acts, even having himself locked up. If 
impulsions are resisted or interfered with, they give rise to symptoms 
in marked cases constituting a veritable crisis. The patient feels 
weak, trembles, becomes dizzy, perspires, but finds all these symptoms 
promptly disappearing on yielding to the compulsion. 
0. Stereotype.—In this condition, the voluntary impulse once set in 
motion tends to repeat itself in the same way indefinitely. There 
are three forms; stereotypy of attitude, of movement, and of speech. 
In stereotypy of attitude, the patient tends to maintain some peculiar 
position, such as lying on the bed with the head hanging over the side; 
in stereotypy of movement, the patient repeats some meaningless 
movement such as swaying back and forth, nodding, etc., when such 
peculiarities are constant and characteristic of the ordinary con- 
duct, they are called mannerisms; in stereotypy of speech, there is 
constant repetition of senseless phrases commonly called verbigeration. 
Persistence of a motor impulse, whether in action, speech, or writing 
is called perseveration. 
f. Negativism.—This condition presents a three-fold aspect. The 
patient does not do as directed; does nothing (passive negativism); 
does the opposite of what he is directed (active negativism); or ex- 
hibits negativistic tendencies toward the prompting of normal de- 
sires. Thus he refuses to empty the bladder or rectum or retains 
saliva until it undergoes putrefactive changes. 
g. Suggestibility.—This condition is the exact opposite of nega- 
tivism. The patient’s reactions are determined by suggestions or im- TM 8-32*1 
86-29 
MEDICAL DEPARTMENT 
pressions derived from others. Suggestibility is manifested in various 
ways; by repeating words or phrases used by others (echolalia), by 
repeating the actions of others (echopraxia); by a condition in which 
the limbs can be placed in any position as in catalepsy or flexibilitas 
cerea (flexibility); by reactions devoid of all personal initiative (au- 
tomatism) . When the automatic responses are to commands, the con- 
dition is termed automatism. 
h. Stupor.—In this condition consciousness is profoundly disturbed; 
when completely established, stimuli are not perceived. 
27. Disorders of emotion (affectivity, feeling).—a. Exalta- 
tion.—This is a condition of emotional elation, a feeling of happiness 
and well-being not warranted by the patient’s condition or surround- 
ings. It is a prominent symptom of mania. 
b. Depression.—This is a feeling not warranted by the patient’s 
condition or surroundings. It is a prominent symptom of melan- 
cholia. 
o. Emotional deterioration.—A condition of poverty of the emo- 
tions manifesting itself by indifference. It occurs in mental deterio- 
ration, and is seen in dementia praecox, paresis and senility. 
d. Morbid cmger.—This symptom is seen most often in defectives, 
being a marked feature in idiots and imbeciles. 
28. Disorders of memory.—a. Amnesia.—Memory is the recur- 
rence to consciousness of a previous experience and recognition of it as 
having occurred before. The loss of memory is called amnesia. 
When the loss covers a period with a definite beginning and definite 
ending, it is called anterograde amnesia. 
b. Hyperamnesia.—This is an exaggerated degree of retentiveness. 
The condition is often seen in a chronic delusional psychosis, the pa- 
tient seeming to remember every detail of his life bearing on his de- 
lusional system. 
c. Paramnesia.—In this condition, there is a mixture of invention 
and real experience. The gaps resulting from disordered perception 
are filled with fabrications; the patient without awareness thus mak- 
ing good his memory lapses. 
29. Disorders of attention.—a. Aprosexia.—In this condition 
there is inability to fix the attention for any length of time in one 
direction. Consequently perception is inadequate—not clear—mis- 
takes occur, indeed stimuli may not be perceived at all. In this way 
disorientation may occur—as to persons, for instance, because the wan- 
dering attention notes some slight resemblance but is not fixed long 
enough for recognition of actual identity. Inability to fix the atten- 
44 NEUROPSYCHIATRY IN AVIATION MEDICINE 
TM 8-325 
29-31 
tion—enfeeblement of the power of voluntary attention—is one of the 
most fundamental signs of mental deterioration. 
h. Hyperosexia.—In this condition the attention of the patient is 
completely absorbed by some thoughts, usually his delusions. This 
absorption may be so complete that no attention whatever is paid to 
the environment. Perception would, of course, be very inadequate. 
30. Disorders of personality (disturbances of self-conscious- 
ness).—Personality, or self-consciousness, is the sum total of all the 
presentations forming the complex idea of the physical and mental 
self. The four disturbances of self-consciousness all result from an 
intrapsychic conflict. The differences are in degree only. In the first 
two described below the disharmony is of lesser degree than in the 
latter two, although in each the import is equally grave. In deperson- 
alization there is a feeling of unreality; in splitting there is an actual 
division of the component elements; while in multiple personality, new 
entities are added to self-consciousness; and in transformation, the 
explanatory delusional system constructs a new personality upon the 
ruins of the old. 
a. Depersonalization.—This condition is a fragmentation of the per- 
sonality accompanied by a feeling of unreality. There is a disruption 
of the feeling of personal identity. 
b. Splitting of personality.—In individuals exhibiting basic infe- 
riority, the unity of self-consciousness is forever menaced by dynamic 
material buried in the unconscious. Whenever such material, a com- 
plex, breaks through the repressive forces and again appears in con- 
sciousness there exist two distinct and mutually opposed trends of 
thought combating, modifying, or controlling each other and giving 
rise to disturbances in consciousness showing as division or splitting. 
The extreme manifestation of this condition is seen in dementia 
praecox. 
g. Multiple personality.—In this condition, there is morel or less 
regular alternation of different states in each of which there is 
memory only for the experiences of similar previous states. Thus 
two or more different personalities are dovetailed, each of which has 
at its disposal only a part of the total experience of the individual, 
d. Transformation of personality.—This striking change comes 
about through the operation of a fixed and coherently developed de- 
lusional system. Delusions of self-importance elaborated through 
retrospective falsification more and more obscure and transform the 
consciousness of self until finally a new personality is established, 
31. The complex.—As development proceeds, there is ever widen- 
ing discrepancy between desire and attainment. More and more must 
there be relinquishment of immediate satisfaction of desire and m- 3CM 8-325 
31-32 
MEDICAL DEPARTMENT 
pression of material into the unconscious. When a highly emotional, 
painful, or disagreeable experience is repressed, it tends to become a 
constellation of ideas—a complex functioning independently in the 
unconscious and continually striving to again appear in consciousness. 
Therefore a complex is a constellation of ideas in the unconscious 
which have an independent existence and growth, and a tendency to 
motivate conduct, a strong emotional tone. 
33. Dreams.—The mechanism of dreams is closely related to that 
of phobias, obsessions, delusions, and other psychoneurotic and psy- 
chotic symptoms. Therefore the study of dreams is important in 
psychiatry. In dreams, things are sometimes recalled which are in- 
accessible to memory in the waking state. Dreams are studied, ex- 
plained, interpreted by the psychiatric method. Unconscious men- 
tation goes on ceaselessly during sleep as well as during waking 
hours. The biological aspect of sleep however appears to require 
that we retire from the conflicts and perplexities of our daily lives 
in order to gain strength for the problems of the next day. Thus 
whatever problems are taken to bed are threshed out in the uncon- 
scious during sleep, and we awake refreshed or unrefreshed accord- 
ing tp the ability of the unconscious to properly deal with our 
conflicts. It is conceivable that one whose life is so well ordered 
that his problems are settled from day to day would not dream at 
all, or that he would at least have no recollection of them. However, 
the majority of individuals do dream and preserve some recollection 
of their dreams, fragmentary as it may be. In the scientific analysis 
of dreams, it has been fairly well established that all dreams have a 
meaning; that they are in the nature of wish fulfillments, however 
disguised or symbolically represented they may be; that the main 
actor in the dream is always the dreamer and he too may be sym- 
bolically represented; that the dream will have some definite relation- 
ship to events of the preceding day; and that the dream will, either 
directly, symbolically, or by association, lead to the dominant type 
of complex in the individual’s life about which is centered his chief 
difficulty in making a proper adjustment to everyday life. Thus 
the unconscious conflict goes on ceaselessly, but the individual is at 
least spared a few hours of conscious participation therein. A fair 
knowledge of the individual, gained from a personality study, is 
essential before attempting the interpretation of a dream. Freud 
says, “When the work of interpretation has been completed the dream 
may be recognized as the fulfillment of a wish.” The psychoanalytic 
method brings to light the latent content of the dream. Freud be- 
lieves; that the stimulus for the dream is to be found among the 
46 TM 8-325 
32-33 
NEfUEOPSYCHTATBY IK AYIATIOK MEDICIKB 
experiences “upon which we have not slept,” that is, those of the 
preceding day; but the material may be selected from any time of 
life. Freud says the dream is “the disguised fulfillment of a sup- 
pressed (repressed) wish. The dream is the symbolic expression of 
the repressed wish. The biological purpose of dreams seems to be 
to prevent the interruption of sleep by disturbing sensations or 
thoughts, from whatever source they come. Therefore the dream is 
the guardian of sleep, not the disturber of it.” 
Sectiok IX 
Paragrapu 
General 33 
Classification 34 
PSYCHOPATHIC PERSONALITY 
33. General.—Psychopathic personality as a whole will be con- 
sidered first, then the different entities concerned as noted in the 
classification given in Army Regulations will be discussed. 
a. Psychopathic personality is the term applied to various inade- 
quacies and deviations in the personality structure of individuals who 
are neither psychotic nor feeble-minded, the defect existing particu- 
larly in the conative, emotional, and characterological aspects of the 
personality. These aspects do not operate harmoniously. The term 
“psychopathic personality” is used to define the variant personalities 
that lie between mental health and mental disease, or the borderline 
conditions. 
h. This condition manifests itself usually in the individual’s contact 
with his environment as illustrated by social antagonism and inade- 
quacy, or in the form of deviations in the psychosexual sphere as 
illustrated in the form of deviations of the sexual impulse. 
o. The beginning of the psychopath in childhood is shown in certain 
lines of conduct exhibited at that time and illustrated by the sensitive, 
stubborn child, the one given to outbursts of rage, the petty thief, and 
the sulky, deceitful, obstinate, defiant child. When he arrives at the 
adolescent age, he socializes at a lower level. As he reaches maturity, 
with its concomitant increase of responsibilities and demands, the early 
tendencies which have been noted become outspoken manifestations, 
and the egocentric individual develops who is typical of the psychopath, 
demands much, gives little, and is self-satisfied. His behavior may 
range from queerness to definite social misfits and includes the ex- 
tremists, eccentrics, habitual delinquents, and other types. There is 
no sharply defined dividing line between the normal and the psycho- 
pathic personality. Just where the normal ends and the psychopathic TM 8-325 
33—34 
MEDICAL DEPARTMENT 
personality begins is a matter of individual opinion and not determined 
by definite criteria. There are no definitely fixed types, but as a 
necessity for teaching, descriptive, and classifying purposes, a classifi- 
cation is necessary. 
d. Psychopathic behavior can best be explained by psychological 
conceptions of mental disease. It is the result of intrapsychic con- 
flict which the individual is trying to solve through adjustments that 
are socially inadequate or destructive. His behavior is the expres- 
sion of conflicts, unconscious motives, and strivings. In this way, the 
psychopaths closely resemble the psychoneurotics. Their intrapsychic 
conflicts are probably the same. The psychoneurotic expresses his 
conflicts symbolically through his symptoms, as compared to the psy- 
chopath who expresses these same conflicts through his irrational, 
antisocial, and hostile behavior. Therefore, as Noyes states, “it will 
be seen that it is preferred to look upon the psychopathic personality 
as the product of dynamic psychological forces rather than as the 
result of an innate constitutional condition; that is, in the psycho- 
path these phychological mechanisms lead not to a more or less char- 
acter trait as seen in persons regarded as normal or as a definite symp- 
tom as in the neurotic, but to the establishment of dominant patterns 
of character, temperament, emotion, and conation which lend their 
imprint to the whole personality and its behavior expressions.” 
34. Classification.—The classification given in Army Regulations 
is as follows: 
Constitutional inadequacy 
Nomadism 
Emotional instability 
Pathological lying 
Criminalism 
Paranoid personalities 
Schizoid personalities 
Sexual psychopathies 
a. C\onstituti-onal inadequacy.—Under this are classed those indi- 
viduals who either from lack of initiative, ambition, perseverence, or 
judgment, through shiftlessness or tactlessness, or a planless, improvi- 
dent existence, and often in spite of good educational, social, and 
economic opportunties, make a notorious failure of everything they 
attempt. 
i. Nomadism.—The impulse to wander is inherent in some degree 
in all persons. It is so pronounced in certain races as to govern their 
mode of existence and social organization. Exaggeration of the no- 
48 N EfU'HOPSYOHTATRY IN AVIATION MEDICINE 
TM 8-325 
S4 
madic urge in certain individuals is often turned to useful account by 
their selection of an occupation involving more or less constant travel 
and change of scene. In the pathologic nomad, the urge outweighs 
the ability for such sublimation and the tramp or hobo results. He 
frequently shows a lack of inhibitions in other social directions. He 
may beg, steal, trespass upon private property, or commit other un- 
social acts; but he does these things primarily from necessity rather 
than with criminal intent. 
o. Emotional instability.—The tendency of all individuals under 
everyday stress is to show at certain or irregular periods some variation 
in mood. When these fluctuations are within the so-called normal 
limits, or where they arise in consequence of some unusual physical 
or mental stress but do not contravene conventional limitations, 
they need cause no grave concern. But when an individual shows 
extreme mobility and exaggeration of emotional response, a tendency 
to be at one moment in the depths and the next in the heights as 
the result of ordinary or unusual stimuli, and particularly where 
such emotional excursions are accompanied by rapid changes from 
affection to hatred or from complete egoism to exaggerated gener- 
osity, he can be classed as emotionally unstable. Crimes of violence 
or other unconsidered acts may be carried out by such individuals. 
d. Pathological lying.—(1) The tendency to falsification entirely 
disproportionate to any discernible end in view is the characteristic 
trait of the pathological liar. There appears in these individuals a 
morbid activity of the imagination, an inaccuracy of memory, and a 
certain instability of the emotions and volitions. They apprehend 
easily, comprehend new situations, readily acquire all sorts of infor- 
mation, and converse fluently on the most varied topics. Able to 
convey the impression of being cultured and well-informed, their 
knowledge is nevertheless superficial and made up of incoherent 
scraps; that is, a mixture of details insufficiently comprehended and 
elaborated and at times even falsified. Their thoughts lack system, 
order, and coherence; their judgment is immature; and their con- 
ceptions of life shallow and insincere. 
(2) There is extraordinary mobility of the content of memory. 
-Recollections, moods, wishes, and accidental impulses alter and color 
the experiences of life in various ways so that before long there 
appears an extricable mixture of truth and fiction. A characteristic 
feature of morbid lying is the apparent satisfaction the patient de- 
rives from willful falsification of memory, the “joy of lying.” The 
mazes of misstatements inevitably lead to situations from which there 
is no escape except by the utterance of new falsehoods. The swindler 
274758®—41 4 
49 TM 8-325 
34 
MEDICAL DEPAETMENT 
in many important respects is closely identified with the pathological 
liar. 
e. Criminalism.—This condition finds early expression in perversi- 
ties of conduct and character shown as selfishness, lack of honor, 
cruelty, deceit, and absence of natural affection. Education usually 
fails to modify such natures. They are morally defective and offer 
little resistance to temptation and sudden impulses. There is great 
emotional irritability, vindictiveness, unreliability, and instability. 
Punishment effects no lasting change and the resumption of former 
habits and practices is the rule. 
/. Paranoid 'personalities.—Stubborn adherence to fixed ideas, 
marked conceit, and suspiciousness are the basic traits of these indi- 
viduals, and lie at the root of all their maladjustments. They show 
a contempt for the opinions of others, a distortion of practical values, 
and a tendency to be argumentative. 
g. Schizoid personalities.—Under this are classed the introverts, 
in whom there is an intense self-awareness, a realization of inade- 
quacy, and a feeling of uncertainty toward the outside world which 
produces a peculiar sense of inferiority. Such individuals are either 
unwilling or unable to take cognizance of reality and follow paths 
laid out for them by instincts or emotions. Their contact with 
reality is fragmentary and hazy. Reality to them is unbearable and 
is, therefore, largely eliminated. There is an inability to distinguish 
clearly between reality and fantasy. Thinking is likely to be il- 
logical and at times absurd. 
h. Sexual psychopathies.—Rosanoff discusses anomalies of sexual 
life under anomalies of degree, eroticism and frigidity; anomalies 
of nature, sexual perversion and sexual inversion. 
(1) Anomalies of degree.—Eroticism results in venereal excesses 
and often in indecent acts and attempts of rape. Frigidity consists 
of an indifference and even an aversion of the subject to sexual con- 
nection; at least to normal sexual connection, for frigidity may be 
associated with sexual perversion or inversion. A curious and ap- 
parently paradoxical fact is its frequency among prostitutes. 
(2) Anomalies of nature.—(a) Sexual perversion.—Sexual per- 
version consists of the abnormal character of the conditions necessary 
to excite sexual desire and sometimes its gratification. Its most 
common forms are masturbation, fetishism, exhibitionism, sadism, 
masochism, beastiality, and necrophilia. 
1. Masturbation.—Not only psychiatrists but other physicians 
as well are frequently called upon to discuss with a patient 
the subject of masturbation. According to the best in- 
formation available at this time, masturbation of itself TM 8-325 
34 
jrEUBOT’SYCHIATEy IN AVIATION MNDIGINB 
Is harmless. The habit may arise either from circum- 
stances being adverse to normal gratification of the sexual 
impulse, from repugnance against the normal sexual act, 
or to a persistance into adult life of a childish auto- 
erotism. The practice of the habit usually carries with 
it a feeling of shame and a belief that it is among the 
causes of insanity. Excessive indulgence or the practice 
carried forward into adult life, is rather an expression 
of nervous instability and feeble inhibitions than a 
cause of mental disorder. In the chronic offender, there 
are usually other very definite indications of a constitu- 
tional psychopathic state. 
2. Fetishism.—This sex anomaly is largely confined to the 
male sex. Fetishism is one in which sexual excitement, 
or more rarely gratification, is caused by the sight or 
contact of certain objects or certain parts of the female 
body other than the genital organs. Fetishes may Be 
various objects such as shoes, stockings, handkerchiefs, 
toilet articles, garters, in fact anything used in intimate 
contact with the female body. The choice of the fetish 
is believed to depend upon the impression which was ac- 
cidentally associated with the first genital excitement of 
the individual with a psychopathic disposition. 
3. Exhibitionism.—Sexual perversion may show as an uncon- 
trollable desire to exhibit parts of the body, often the 
genitals only, which are ordinarily clothed. It is usually 
accompanied by sexual excitement and frequently with 
masturbation. 
4. Sadism.—This consists in a sense of voluptuousness derived 
from suffering which the individual witnesses or inflicts 
upon his victim. It is generally associated with a state 
of sexual excitement and is exercised chiefly upon women 
and children. 
5. Masochism.—This anomaly is more frequently encountered 
in women and consists in an abnormal pleasure which the 
subject derives from his or her own suffering or humilia- 
tion. The pleasure is sexual in character. 
6. Bestiality.—This consists in an impulse to copulate with 
animals. Like all genital impulses, it often assumes the 
shape of an imperative idea which the subject only resists 
by a great effort of the wilL 
7. Necrophilia.—This consists of a particular pleasure which 
the subject experiences from the sight or contact with a 
51 TM 8-325 
34-35 
MEDICAL, DEPARTMENT 
cadaver. It is sometimes accompanied by an impulse to 
defile the corpse. 
(h) Sexual inversion.—This anomaly is believed to be congenital 
and consists in a contrast between the physical sex and the psychic 
sex; the subject presents the sexual tendencies of the opposite sex, 
often showing even many of the physical characteristics. In this con- 
dition, there appears to be an actual sexual love for persons of the 
same sex and a feeling of indifference or disgust toward contact with 
the opposite sex. This is particularly true of the frank homosexual 
who is both conscious and proud of his sexual inclinations. He is 
inclined to look upon himself as a superior person, is narcissistic to 
a noticeable degree, and usually of a paranoid personality. Between 
the normal heterosexual person and the invert there exist all grades 
and shadings. There is doubtless a vast army of individuals with 
submerged tendencies to sexual inversion, the only indication of which 
is seen in their choice of occupation and associates. 
Section X 
MINOR PSYCHOSES 
Paragraph 
General 35 
Neurasthenia 36 
Hysteria 37 
Psychasthenias • 38 
35. General.—Under the minor psychoses are grouped the psycho- 
neuroses and neuroses. The term “neurosis” will be used synonymously 
with “psychoneurosis.” 
cl The psychoneuroses comprise a group of disorders in which men- 
tal forces or ideas, of which the subject is either conscious or uncon- 
scious, serve to bring about various mental and physical symptoms. 
A psychoneurosis is an automatic defense of the nervous system through 
which, for the time being, the individual is protected from a succession 
of experiences which tend to weaken him and in the long run, to 
threaten his continued existence. This defense springs from the acti- 
vation of certain instincts into experiences of an abnormal kind which 
take on the appearance of symptoms or symptom groups, presenting 
themselves as disease pictures. According to the mechanism involved, 
such symptoms become organized into stereotyped forms of disease 
which are capable of description and differentiation. The psychoneu- 
roses exhibit those early departures from the normal which, in more 
aggravated form and definite grouping, constitute the psychoses. 
h. The neuroses functionate and fill a real need of the human organ- 
ism for that kind of expression alone. The neurosis may, therefore, be TM 8-325 
35 
NETJBOPSYOHTATBY IN AVIATION MEDICINE 
regarded as a biological necessity expressing reactions that do not 
differ in any important way from those seen under conditions of stress 
and conflict where existence is possible only through overcoming ob- 
stacles. They are adaptive reactions of the nervous system, springing 
from a real or fancied need of the organism. They are protective or 
defense structures which spring into activity when the organism is in 
danger or when the organism finds it more advantageous to substitute 
for its normal environmental reactions something else, which, in this 
instance, takes on this guise of a disease. This is called a “neurosis.” 
The various conflicts arising out of the impact of the human nervous 
system against difficult economic, social, domestic, and traumatic 
stresses give the occasion and the necessity for this defensive reaction. 
If these facts are kept in mind, the understanding of the neuroses both 
clinically and symptomatically will be facilitated. There follows from 
such a conception a great deal of illumination concerning the intricate 
series of questions arising out of a disease picture often psychogeneti- 
cally initiated and somatically presented. 
(1) Whether or not a neurosis is organically founded is of minor 
importance when it is once clearly recognized that a neurosis is per- 
fectly capable of developing on and from an organic condition. In 
such an instance, it can show the identical reactions, structures, and 
mechanism as is the case where no such thing is present. It is by no 
means certain that a neurosis stands out as a pure picture of psycho- 
genic origin when it is possible for all sorts of supplementary mecha- 
nisms to be put into activity through the emotional accompaniment 
of the neurosis structure. For example, the internal secretory glands 
may fulfill the role of causation, of coincident activity, and likewise 
of effect. There must be in any convincing scheme in the explana- 
tion of the neurosis, a place for all the adventitious reactions of the 
total mechanism, whether of so-called organic origin or not. 
(2) In a neurosis, there are certain fundamental facts that must be 
made clear. If this be done, the transition to clinical expression and 
types is readily understood. It is essential to appreciate the fact, 
first of all, that neuroses are fundamental reactions of the organism 
to traumata of various kinds. These traumata are necessary incidents 
to organized life. They are nothing more or less than the contact 
experiences of the individual with his environment, and they arise out 
of the struggle to maintain a place for himself and those dependent 
upon him against the eliminating tendency in all social structures. 
Society protects the individual in this struggle but to pay for that 
protection, the individual must give and surrender himself to the 
necessities of his social environment. This conflict is best expressed 
through th§ awakening of the primitive and essential instinct found TM. 8-325 
35 
MEDICAL DEPARTMENT 
in all living beings, the instinct of self-preservation. This instinct 
is the individualistic impulse, so bound up with life that it cannot be 
divorced from it. It is the essence of the individual continuity as 
the instinct toward species preservation is the essence of communistic 
continuity. Of these two instincts, that of self-preservation is by far 
the more primitive and persuasive. It finds its expression as soon as 
life is manifest and is constant throughout life. The instinct of race 
continuity develops later and becomes at certain periods dominant, 
associated as it then is with many social factors touching the complex 
organization of society. 
(3) The defense that is suggested in the definition is not to be 
regarded as a volitional act, or one that carries with it a state of 
awareness on the part of the individual. It springs from a very 
real need of the organism. In many instances, this need has its 
origin in a mental reaction that suggests to the patient that there is 
something at variance in the normal functioning of his total organ- 
ism. The element of wish or will cannot be totally excluded from 
this formula, as there is a great deal of evidence at hand to suggest 
that in many cases the first conscious manifestation of a beginning 
neurosis is the desire that something might intervene as a protection 
from the conflicts arising out of a particular stress of circumstances. 
As long as the necessities of the occasion are taken into account, 
there is every reason to admit that desire, wish, or will has a place 
in the preliminary state out of which a neurosis is finally developed. 
This wish or will to develop a neurosis is perfectly understandable 
if it is kept in mind that behind the wish is a deep-lying need, in- 
fluencing the patient in that direction. In the development of a 
neurosis, behind the wish, expressed or unexpressed, on the part of 
the patient to be ill, there are the activities of a deeper lying in- 
stinctive appeal which has for its object the safeguarding of the 
total organism. There is no isolated nor abstract desire as far as 
the patient is concerned to become the subject of a neurosis, but a 
requirement of the organism that drives him to want or wish or will 
to be that way. There may be in the neurosis a sense of satisfac- 
tion or contentment in the existence of the diseased condition, but 
this is so because the organism of the patient is insistent that some- 
thing shall stand between him and the conditions which he is forced 
to face, and which are too much for him at the time. The surrender 
is through a compromise, and this compromise is a neurosis. This 
is his protection, and behind it is a feeling of safety no matter how 
disagreeable the process may be through which he is going. That 
there should be some sense of satisfaction in such a mechanism is 
self-evident. 
54 TM 8-325 
35 
IJWIIOPSTCHTATRT IK AYIATIOK MUDTX30TE 
(4) The neurosis therefore is a compromise, the best that the 
patient can devise at the time, and in the protection of this com- 
promise he can manage to keep his place in his environment and, 
what is of greater importance, he is saved from the disrupting 
sensation of utter defeat; the feeling of total inadequacy. In con- 
sidering a neurosis from this standpoint, it is obvious that the de- 
fensive mechanism of the whole organism becomes active so that 
every device commonly energized by such a need comes into the play 
of forces that tend to reach that end. The vasomotor and gland- 
ular systems, etc., become so bound up in the final display that 
often it is with the greatest difficulty that the individual features 
can be separated. 
(5) In a theory that attempts to be as broad as this, almost any 
notion that has proved of value in explanation of the neuroses and 
almost any kind of etiological factor may be included. The various 
causation theories of Freud, the mechanism of Janet, the congenital 
nervous instability of the Charcot school, with its insistence on the 
role of suggestibility, the fatigue theory so much in evidence in 
the writings of S. Weir Mitchell and his students, and a host of 
others can all find a place. It is necessary to find out where they 
play their role, how much importance should be given to each of 
them, and to make use of them so long as they fit in with the notion 
that a neurosis is the crystallized clinical manifestation of the pro- 
tective instinct of the nervous system. 
(6) Freud found the essential cause of every psychoneurosis in 
some disturbance of the sexual function, but dispassionate study of 
the psychoneuroses such as those of warfare shows that there is no 
reason to suppose that the sexual life played any essential part in the 
causation. These disorders have come to be understood as the result 
of the activation of another instinct even more fundamental and 
elementary than the sexual, the instinct of self-preservation, par- 
ticularly that phase of it relating to protection from danger. Ob- 
viously, warfare awakens an instinct which is rarely activated in the 
life of a member of a modem civilized community. In warfare, 
tendencies are awakened which would otherwise lie dormant and 
the instinct of self-preservation is the one most likely to be activated, 
while in time of peace, the sex instinct is probably the most active, 
although instincts less elementary and of later development may be 
the dominant factor. No single etiological factor can be looked 
upon as the essential cause of every neurosis. 
(7) There is much reason to believe that the activity of the glands of 
internal secretion are concerned in activating such emotions as fear TM 8-325 
35-36 
MEDICAL DEPARTMENT 
and in contributing to the habituation of symptoms already established. 
Certain of the internal glands are connected so closely with the defen- 
sive qualities of the organism and their function seems in the main so 
definitely to subserve instinctive reaction in the face of anticipated dan- 
ger or real contact with destructive agencies, that they must be consid- 
ered as definite factors in the chain of positive causation out of which 
the neuroses arise. They are so closely bound up with the primitive 
emotion of fear, for example, that there is no escape from the conclusion 
that they are a vital part of the mechanism which tends to guard the 
organism as a whole. For this same reason, they cannot be separated 
from the defensive mechanism as it is phylogenetically manifested in 
the organization and perpetuation of the neuroses. 
(8) It is necessary to appreciate the fact that both in the formation 
of a neurosis and in its continuation, there is a commingling of many, 
if not all, of the defensive activities of the organism, so that nothing 
short of actual organic changes need be explained away. 
36. Neurasthenia.—The term “neurasthenia” was first introduced 
by Beard in 1868, and up to the present time there is no equanimity of 
opinion nor agreement as to the mechanism and factors involved in neu- 
rasthenia. Beard’s idea was that due to the increased tension of his 
age, nervous anabolism could not keep up with nervous katabolism 
with the resultant being a weakened nerve force. All poorly understood 
neurotic symptoms have been classed as neurasthenia at one time or 
another. Freud believed the etiology of neurasthenia to be somatic, 
however the majority of psychiatrists now believe it to be a psychologi- 
cal disturbance. No one now believes that masturbation is the cause of 
neurasthenia, or that an impaired and exhausted state is an etiological 
factor. The real source, the real etiology is to be found in psychic con- 
flict and therefore is a psychological conception. 
a. Symptoms.—The symptoms may be classified as general and local; 
under local the alimentary system, circulatory system, vasomotor, 
genito-urinary system, respiratory system, nervous system, and mental. 
Under general, is listed first fatigue, which is chiefly manifested when 
the patient’s interest is at a low ebb; then loss of weight, which is usu- 
ally dependent on appetite failure. 
(1) The disturbances related to the alimentary system are capricious 
appetite, anorexia, indigestion, distention, eructation, nausea, vomiting, 
constipation or diarrhea, and mucous colitis. 
(2) Circulatory disturbances show varying degrees of cardiac dis- 
comfort, tachycardia, palpitation, pseudo-anginal sensations, and heart 
irregularities. 
56 TM 8-325 
36 ' 
HEXTROPSYCKTATBY IK AYIATIOK MEDICINE 
(8) Included under vasomotor symptoms are pallor, blushing, 
sweating, coldness, heat, and numerous other phenomena. 
(4) Under the genito-urinary system are found impotence, nocturnal 
emissions, dysmenorrhea, dyspareunia, frequency of micturition, in- 
creased urinary output, ‘doose kidney”, and many other manifestations. 
(5) Related to the respiratory system, neurasthenics are troubled 
with frequent colds, shortness of breath, increased respiratory rate, 
shallow breathing, etc. 
(6) The more important symptoms included under those of the nerv- 
ous system are peculiar sensations in the head or any other part of the 
body. Feelings of swelling of the scalp, tight band around the head, 
bursting and stuffiness of the head, headache especially in the occipital 
region, peculiar uncomfortable or painful sensations in the abdomen, 
rectum, breasts, etc. An almost universal complaint is pain in the 
back. Giddiness, dizziness, and insomnia are common. There may be 
photophobia, muscae volitantes, eye-muscle fatigue, ear noises, and 
intolerance of ordinaiy sounds. 
(7) The prominent mental symptoms are inability to concentrate, 
uncertain memory, fear of insanity, self-consciousness in the presence 
of others, feeling of inferiority, irritability, depressions, phobias, and 
anxieties. There is a state of irritable weakness. There is a subjec- 
tive state of weakness and exhaustion. This instability and irritabil- 
ity affects the vegetative nervous system with resulting disturbances 
as mentioned in the vasomotor and cardiac functions. The basic 
cause is that of psychic conflicts transferred or displaced to an uneasi- 
ness of mind concerning physical organs and their processes. 
h. Differential' diagnosis.—(1) Distinction must be made between 
neurasthenia and the depressed phase of manic-depressive psychosis. 
The prominent differential factors are that in manic-depressive 
psychosis there are definite episodes, while the neurasthenic has pro- 
longed illness. The neurasthenic is concerned regarding his physical 
complaints while the manic-depressive is not. The manic-depressive 
is not concerned with his environment, and shows no response, while 
the neurasthenic is usually all response. 
(2) Differential diagnosis must also be made at times between early 
schizophrenia and neurasthenia. However, the schizophrenic sooner 
or later develops a delusional system and he does not have the variety 
of physical symptoms noted in the neurasthenic. 
(3) A diagnosis of neurasthenia or of any of the neuroses is not 
warranted merely because the physician cannot find a physical cause 
for the patient’s symptoms. A diagnosis of neurosis in any form is 
not justified until an emotional conflict or stress sufficient to explain 
the symptom has been discovered. Neurasthenia is then a disorder of 
57 TM 8—325 
36-37 
MEDTOAL, raSPAKEMENT 
protean physical and mental manifestations associated with a state of 
unusual suggestibility. Furthermore, it is a disorder the manifesta- 
tions of which are primarily and fundamentally instinctive in nature 
and calculated to prevent the organism from continuing a line of 
activity the end of which is material destruction of the organism. 
The growth and development in a clinical way is often slow and im- 
possible to determine until the final stage is reached when the pres- 
ence of the subjective sensation dominates. Depression, helplessness, 
morbid attitude, and subjective interest in his own feelings form a 
symptomatic display easily appreciated and easily recognized. This 
psychical state so dominates that the underlying mechanism may be 
lost sight of entirely and attributed to psychical causes. The par- 
ticular symptoms in a given case likely will show simply as a piling 
up of normal personality trends as in other neuroses. Two general 
types of neurasthenia victims are those individuals with inherited in- 
capacity or early acquired defects in their organism which limit their 
activities this side of fatigue to the minimal, and those who become 
so from the stresses of continuous conflict with environment, or who, 
as a result of some acute experience associated with a marked over- 
load, respond with acute fatigue developing into chronicity which 
gives to the neurasthenic its particular quality of habituation. The 
symptoms indicate an organic defense and a physiological conserva- 
tion. The organism as a whole must defend itself against further 
ravages or submit to destruction. The symptoms therefore in a given 
individual are likely to be those best calculated to erect the best 
possible defense. 
37. Hysteria.—a. General.—In Pierre Janet’s theory of a faulty 
synthesis of the personality resulting in dissociation, cleavage, or 
splitting, and Sigmund Freud’s theory of conversion of the con- 
flict (between desire as represented by the buried complexes and at- 
tainment as combated by attitudes of mind the result of education) 
into a physical symptom or symptoms, are found two of the most 
important contributions to the study of the hysterias. Janet be- 
lieved that through faulty synthesis of the personality, certain groups 
of ideas drop away from association with the main portion of the 
personality into the unconscious, there to exist independently and 
produce results irrespective of correction from the remainder of the 
personality. Therefore he saw the activities of the dissociated or 
split-off personality made manifest in the hysterical symptoms. Freud 
developed the theory of Janet; he perceived that ideas out of har- 
mony (in conflict) with the consciousness of the individual do not 
merely “drop away” from consciousness, but instead, are forced or TM 8-525 
37 
inrcmopsTcmATRT m ayiatvtk MKDroorR 
repressed (with or without awareness) into the unconscious, there 
to function independently and thus bring about dissociation. These 
inacceptable groups of ideas (idea constellations or complexes) 
though buried in the unconscious, continue to act, go on functioning 
independently of awareness, continually striving due to their dynamic 
quality to break through the repressive forces and again appear in 
consciousness. Conflict, repression, and complex formation are nor- 
mal processes. But it is the eruption (breaking through) of these 
over-dynamic, split-off complexes, and the way in which they mani- 
fest themselves that produces the different types of mental disorders; 
the energy of the eruption flows in different directions, the direction 
taken being determined by the personality trends. The peculiarity 
of the hysterical mechanism is that the inacceptable affect of the 
complex is drafted into bodily innervation, thus by conversion pro- 
ducing the physical symptoms of the disorder; that is, conversion 
is the essential feature of the symptomatology of the hysterias and 
all the disturbances, sensory as well as motor, are purely mental in 
origin. 
6. Definition.—Hysteria is a type of reaction adopted unconsci- 
ously, but for a very definite purpose, in order that a problem may 
be solved through a disguise of the symptom. All authorities agree 
that hysteria is a defense or protective mechanism. Moebius defines 
hysteria as “a state in which ideas control the body and produce 
morbid changes in its function.” Janet says, “hysteria is a form of 
mental depression characterized by a retraction of the field of per- 
sonal consciousness and a tendency to the dissociation and emanacipa- 
tion of the systems of ideas and functions that constitute personality.” 
The fundamental trouble is a loose organization; a faulty synthesis 
of the personality. Hysteria may be said to be a type of reaction 
belonging to individuals who in mental organization are still chil- 
dren. He emphasizes the importance of amnesia through which 
certain experiences drop out of the field of consciousneas, with 
resultant changes of personality which eventually may become dou- 
bled or variously fragmented. Babinski says, “hysteria is a special 
psychical state capable of giving rise to certain disturbances which 
can be produced by suggestion or removed by persuasion.” Freud 
explains hysterical manifestations as the result of repression of dis- 
agreeable experiences followed by dissociation, breaking through of 
the complexes, and the conversion of the material into somatic 
symptoms. 
e. Frequency.—The hysterias are among the most common of 
mental disturbances. TM 8-835 
37 
MEDICAL, DEPARTMENT 
d. Time of life.—The majority of cases occur at the age of pu- 
berty and adolescence. After 25 the frequency declines, and occur- 
rence after 45 is rare. It is uncommon before ten, but may develop 
as early as the second or third year. Males and females are affected 
in nearly equal ratio. 
e. Etiology.—The etiology can only be understood in the light of 
explanation of the mechanism. Such influences as trauma, shock, 
profound emotional disturbances incident to situations of unusual 
trial, difficulties and perplexities, toxic substances, and acute and 
chronic illnesses operating upon a background of constitutional psy- 
chopathic inferiority, cause an inability to make the healthy com- 
promises (adjustments) by which the individual must continually 
establish and reestablish his relation to society. 
f. Pathology.—There are no demonstrable pathological lesions. 
g. Symptomatology.—(1) Mental.—The outstanding characteristic 
of the hysterical constitution is instability shown by frequent and 
abrupt changes of the emotional attitude, conduct continually moti- 
vated by fluctuations of feeling, exaggerated self-consciousness, sel- 
fishness, dissatisfaction, insatiable cravings, hypochondriacal 
complaints, vehement expression, lack of uniformity and persistency, 
and susceptibility to all sorts of influences. Many of the patients 
develop a most remarkable attitude toward their condition. They 
believe it confers distinction, become proud of it, and parade their 
invalidism, thoroughly enjoy the “luxury of woe,” tyrannize their 
entire family, and make of their invalidism an asset through which 
to fulfill desire without reacting along the line of normal effort. 
(2) Physical.—These are wholly functional, mental in origin, and 
exceedingly protean because the psychic pressure has all the somatic 
pathways at its disposal. They consist chiefly of different degrees 
of paralyses of a single limb; astasia abasia; choreiform movements; 
contractures; localized and general convulsions; aphonia, impair- 
ment of speech; numerous sensory disturbances, including paraes- 
thesia, anaesthesia, hyperaesthesia, and visual disturbance; globus 
hystericus; singultus; fainting fits; anorexia; obstinate vomiting; 
disturbance of respiration; and anomalies of secretion. Anaesthesia 
of the mucous membrane of the mouth and cornea are regarded as 
characteristic symptoms of hysteria. Disorders of sleep are frequent. 
All these symptoms are dependent in their appearance, persistence, 
and departure upon psychial influence. Often, hemicrania and 
convulsions can be made to disappear by pressure on the eyeballs; 
contractures or paralyses to vanish by firm pressure over the ovaries 
or in the hypogastric region, or by an unexpected dash of cold water. 
Patients bedridden for years, reduced by fasting, secretly inflicting 
60 TM 8-325 
37 
NKUEOPSYOHtATEY IN AVIATION MEDICINE 
wounds to incite sympathy, may be immediately transformed into 
different individuals by a sharp command, new environment, or 
some sudden freakish event. Furthermore, the symptoms sometimes 
disappear when the patients believe themselves unobserved or are 
left alone, only to reappear when their illness is referred to or the 
physician appears. The various physical and mental symptoms de- 
scribed are characteristic of the hysterical personality and constitute 
a groundwork upon which develop other characteristic conditions, 
prominent among which are: 
h. Transitory states.—The transitory hysterical states comprise— 
(1) Befogged states.—These are characterized by a marked cloud- 
ing of consciousness of varying duration and either follow, the 
place of, terminate in, or are interrupted by a convulsion. Or there 
may be a simple attack, with slight clouding of consciousness, sinking 
to the floor without injury, or showing in one way or another external 
influence. 
(2) Conmtlsive attacks.—While complicated, these attacks may be 
purposeful. The patient twists about, groaning and screaming, rolls 
over and straightens out, strikes the feet on the floor, or rolls up like a 
ball; while at the same time, there is a spasm of the diaphragm, slowing 
of the pulse, and rolling of the eyes. Following such an attack, the 
patient may lie quietly and remain irresponsive except to powerful 
stimuli. Such a condition, interrupted by occasional convulsion and 
short lucid intervals during which food is taken, may last from a few 
hours to three weeks. This is termed “hysterical lethargy.” 
i. Course and prognosis.—The course of this psychoneurosis is usu- 
ally protracted; it may extend over many years. Recovery is usually 
possible through proper treatment. 
j. Differential diagnosis.—Hysteria must be differentiated from 
epilepsy, malingering, and schizophrenia. 
(1) Hystec'la.—Consciousness never completely abolished. No sud- 
den involuntary fall, serious injuries, nor biting of tongue. Mani- 
festations diversified and extravagant. Seizures specially induced by 
external influences and may be suddenly aborted by strenuous treat- 
ment. 
(2) Epilepsy.—Consciousness completely abolished. Sudden in- 
voluntary falls, serious injuries, and biting of tongue. Manifestations 
uniform. Independent periodicity. Mental weakness more frequent 
and pronounced. 
(3) Malingering.—The unconscious reaction differentiates hysteria 
from malingering. The malingerer consciously counterfeits some 
physical sign or symptom or some mental disturbance for the purpose TM 8-325 
37 
MEDTGAL DEPARTMENT 
of attaining a particular goal. The motives are the Same in both 
hysteria and malingering. These important facts should be remem- 
bered when examining pilots who for some reason or other, conscious 
or unconscious, develop physical or mental symptoms which excuse 
them from flying. 
(4) Schizophrenia.—Differential diagnosis is at times difficult to 
make with regard to schizophrenia. However, the hysteric shifts his 
emotions more easily, has no disturbances of associations, responds 
more quickly to an emotional reaction, has no desire to be left alone, 
and there is no deterioration as noted in the schizophrenic. 
k. Eapplanation of the Freudian conversion theory.—In the hysteri- 
cal type, disagreeable complexes succeed (consciously or unconsciously) 
in coming to expression symbolically; that is, by what Freud calls 
“conversion,” and achieve expression as physical symptoms. Accord- 
ing to Freud, the complex is due to a psychic conflict of a sexual 
character. The conflict being between desire, as represented by buried 
sexual complexes, and attainment, as opposed by attitudes of mind the 
result of education. The dynamic energy of the inacceptable constella- 
tion of ideas (complexes) breaks through the repressive forces but the 
subject is spared the pain of disagreeable affects by “conversion” of 
the energy into physical symptoms; there is an abnormal compromise 
reaction. This is made clear in the following apt illustration by Dr. 
William A. White, “a patient ought to make a call upon a recently 
bereaved friend. This is recognized as a distinct obligation, but the 
patient’s infantile necessity of escaping reality and seeking pleasure 
makes the duty seem a very onerous affair. Thus arises a conflict be- 
tween duty, bom of conscious appreciation of the social obligation, 
and desire, born of the childish inability to make the necessary sacri- 
fice of personal effort. As a result, the patient develops a headache, 
and so, being ill, does not have to go. The selfish desire is thus gained, 
and at the same time the social demands are satisfied by the illness 
which offers an acceptable excuse, while the painful recognition of the 
patient’s own selfishness is converted into the pain in the head. The 
affect is thus displaced, the whole situation symbolically distorted, and. 
the two opposing tendencies, conscious and unconscious, both satisfied. 
Incidentally, the pain in the head is a self-punishment for not obeying 
the socially useful and unselfish demand and has as a function the tend- 
ency to drive the individual along the path of development, for only 
by following this path can the pain be avoided. An adequate adjust- 
ment by a synthesis at a higher level would result in making the call, 
wanting to make it, and deriving pleasure and satisfaction from hav- 
ing comforted the bereaved person. TM 8-325 
27-38 
NEnCTKlOPSYXlHTATRY IN AVIATION MEDICOTB 
“This is such an example as everyone has constantly presented to 
him by all manner of persons placed in disagreeable circumstances. 
The tendency to develop some minor physical ill as an excuse and an 
escape from a recognized duty is used very widely—one is tempted to 
say, at times by almost everyone. It is the fundamental hysterical 
(conversion) mechanism which throws upon the body, makes it the 
scapegoat of the responsibility for our moral failure. And yet, more 
than this, it produces suffering and pain, which here as elsewhere 
point the way of relief by making the wrong path as unattractive as 
possible.” 
38. Psychasthenias.—a. General.—(1) The psychasthenias com- 
prise a group of disorders characterized by doubt and hesitation, 
obsessions, fears, and impulsive acts. Therefore under the psychas- 
thenias, it is customary to group the conditions variously termed fixed 
ideas, obsessions, imperative conceptions, impulses, morbid scruples, 
phobias, doubts, agitations, mental and motor tics, feelings of strange- 
ness, and feelings of changed personality. 
(2) Always there is clear recognition of the unreasonable nature 
of the act, idea, or condition and a consciousness of defective self* 
control; none of the manifestations, however, either singly or in 
groups, ever influence the intellectual, emotional, or volitional fields 
or color the personality to a degree rising to the frankly psychotic 
level. 
(3) There is a fundamental incapacity to make a choice. It is the 
fear of the consequences of choice, either through expjerience or 
through anticipation of what the choice may bring about, that pro- 
duces the static condition which is the chief characteristic of the psy- 
chasthenic’s attitude toward his environment. The fixed ideas, pho- 
bias, queer conduct anomalies, and stereotyped expressions are the 
result of the primary defect in mental make-up. 
(4) Using obsessions and phobias as broad terms including all the 
above conditions, it is readily seen that they may pertain to nearly 
every phase of human feeling and activity. With Janet may be classi- 
fied the obsessions as those of sacrilege; of crime; of shame of self or 
persons; and those of hypochondriacal nature. For the phobias, the 
Greek language has been searched to find sufficient names; claustro- 
phobia, fear of closed places; agoraphobia, fear of open places; amazo- 
phobia, fear of vehicles; misophobia, fear of dirt; and a hundred 
others testify to the range of human feeling and wealth of the Hel- 
lenic tongue. In many cases, fears are devoid of such definiteness, 
being vague and indefinable. Janet has laboriously tabulated the 
phobias as fear regarding the body; fear of objects; fear of situa- TM 8—325 
38 
MEDIQAli DEPARTMENT 
tions, physical and social; and fear of certain ideas. Under these 
heads, he has meticulously listed oyer 40 different varieties with 
innumerable variations. 
(5) The manifestations of one or more of the above mental symp- 
toms may persist for many years in the same patient, never rising 
however to dignity nor importance, merely ruffling now and then the 
comparative calm of the life current tolerantly and indulgently con- 
strued by the associates as negligible oddities or eccentricities. 
(6) On the contrary, in large numbers of cases, these obsessional 
manifestations definitely color the personality, even motivating con- 
duct. Originating in some emotional shock or striking experience, 
their repetition becomes easily determined by some object, circum- 
stance, sound, smell, or other suggestive factor, and conduct shapes 
itself toward avoiding the recurrence and exhibition of tendencies 
clearly understood by the individual to be incongruous and incon- 
venient. Thus a locality where once was experienced claustrophobia 
is shunned; in dread of contagion, there is refusal to shake hands; 
and fear of poison compels personal supervision of the cooking or 
partaldng only of food first tasted by another. These and similar 
precautions, by continuously narrowing the opportunities and limiting 
the radius of action, may eventually result in self-restriction to the 
house or even to a single room. 
(7) Individuals morbidly impelled to touch certain objects, turn 
in an exact fashion, step in a certain manner, retrace a certain number 
of steps, repeat words or lines when reading, do these things habitually 
and are made extremely uncomfortable, almost frenzied in extreme 
cases, if prevented. Curiously enough, these individuals freely admit 
their behavior is nonsensical but avow they cannot help it. There is 
about it all a laughable incongruity quite apparent to the individual 
and told about in a jocular, shamefaced manner. It is, therefore, an 
emotional and not an intellectual conviction. These obsessive doubts 
represent a defense against self-knowledge. The behavior appears 
meaningless, but when stopped or renounced, a feeling of discomfort 
and anxiety follows. Therefore this behavior should be recognized 
as neurotic ceremonials. 
5. Time of life.—No age is exempt, but most cases occur between 
the ages of 20 and 50, with the maximum at about 30. Females pre- 
ponderate over males in the ratio of three to one. 
o. Etiology.—The psychopathology involved may be summarized 
as follows: These phobias, compulsions, and obsessions originate from 
repressions and are protective and defensive in purpose. A complex 
is repressed, usually instinctive in character, but due to some evok- TM 8-335 
38 
NETTROPSTOHIATBY IN AVIATION MEDICINE 
mg element, is allowed to exert itself in consciousness but is unrecog- 
nized by the consciousness. Consequently the result appears to be a 
fear with no explainable basis. 
d. Course.—The onset is more likely to be insidious than to ap- 
pear suddenly in the wake of an emotional shock. A period of self- 
questioning, of introspection, is commonly crystallized into the par- 
ticular obsession that thereafter has a partial or almost complete 
domination of the individual and may last for the remainder of life. 
Many psychasthenics regain their self-mastery almost completely 
only to relapse on some further provocative occasion. Those indi- 
viduals are fundamentally unstable, and Janet insists that psychas- 
thenia, being a psychological condition, is not foreign to mental 
disease and cites numerous oases ending in definite mental aliena- 
tion. It may readily be admitted, that given stresses sufficiently 
severe, numerous and prolonged, the psychopathic inferior may be 
pushed out of the psychoneurotic borderland into the region definitely 
psychotic. 
e. Diagnosis.—In a typical case, diagnosis is sufficiently simple. 
Neurasthenia, hysteria, and the psychoses must be carefully excluded 
inasmuch as they also exhibit phobias and obsessions. The psychcas- 
thenic nature of the obsession will be strongly indicated if the 
somatic and stigmatic indications of neurasthenia and hysteria are 
absent and the psychoses also excluded, if aside from the obsessions 
there is good physical and mental health and the patient recognizes 
the groundlessness of his morbid idea. 
/. Anxiety neuroses.—Freud separated from the psychoneuroses a 
clinical type he called “anxiety neurosis” in which the symptoms all 
group themselves about the cardinal one of morbid anxiety or anxious 
expectation. The prevailing condition is one of general irritabil- 
ity (or excitability) regularly associated with anxious expectation, 
apprehension, or dread. This general state is disturbed by fluctua- 
tions in intensity and interrupted by exacerbations constituting the 
anxiety attack. These crises or attacks present numerous physical 
symptoms which may be regarded as the bodily accompaniments of 
fear—such as cardiac and respiratory disturbances, profuse sweat- 
ing (often nocturnal), nausea, vomiting, diarrhoea, dizziness, trem- 
bling, shaking, parasthesis, and locomotor disturbances. The loco- 
motor disturbances are noteworthy in that there are sensations, such 
as heaving ground, heavy, shaking, sinking legs, and feeling of im- 
possibility to maintain the upright position, notwithstanding which 
the patient does not fall. 
The quality of anxious expectation is emphasized as the outstand- 
ing feature of the symptomatology aside from the “attacks.” There 
274758°—41 5 TM 8-335 
38-41 
MEDICAL DEPARTMENT 
is a state of continuous uneasiness, concern, trepidation, and fear. 
It may be said there is a quantum of “freely floating” anxiety which 
controls ideation by expectation and is forever ready to unite itself 
with any suitable idea. Freud, in distinguishing the anxiety neu- 
roses from the obsessive compulsive states, says that the latter de- 
pend on repressed sexual episodes in early childhood, but that the 
anxiety neuroses depended on the conflict between sexual excitation 
and sexual satisfaction. The unsatisfied excitation expressing itself 
in the various physical and mental symptoms noted in the anxiety 
states. 
Section XI 
Paragraph 
Distribution 40 
Frequency of attacks 42 
Season and time 43 
Sex and age 44 
Definition 45 
Etiology 46 
Pathological anatomy 47 
Symptomatology 48 
Epileptic character 49 
Clinical varieties 50 
Sequelae 51 
Prognosis 52 
Diagnosis 53 
Differential diagnosis 54 
EPILEPSY 
39. History.—Epilepsy is frequently mentioned in the earliest 
medical literature. The term is derived from the Greek word meaning 
“to take or seize upon”, and was originally spelled “epilency.” The 
ancients knew it as the disease of Hercules. The Romans called it 
“morbus caducus” or “falling sickness”; and the Egyptians “morbus 
lunatious et astralis” because they thought it due to the influence of 
the moon and stars. 
40. Distribution.—Epilepsy occurs in all countries, in all races, 
and at all cultural levels. It probably occurs in all vertebrate animals; 
certainly in the horse, ox, pig, dog, cat, rabbit, in poultry and birds. 
41. Prevalence.—Epilepsy is very common. There is no other 
disease so widely spread in time and space. It is estimated that there 
are from 300,000 to 500,000 epileptics in the United States, of whom 
less than 5 percent are in institutions. From statistical studies, it has 
been stated that epilepsy is becoming less frequent in the United States. 
66 TM 8-325 
41-45 
NENROPSYCHIATRY IN AVIATION MEDICINE 
The indicence is stated as follows for other countries: Switzerland, 1 
to 750; Russia, 1 to 1,500; Scotland, 1 to 750; and France, 1 to 1,000. 
There must be a host of petit mals, as well as those who have the even 
less obtrusive minor equivalents and go unrecognized. 
42. Frequency of attacks.—Some patients have attacks very 
frequently while others may have but two or three during a life- 
time. Some have attacks at irregular intervals, in others they occur 
with considerable regularity; in fact, the regularity of occurrence 
may be very striking. One author reports a patient all of whose 
attacks occurred at 6 a. m.; another had all between 2 and 4 p. m.; 
and another between 7 and 10 a. m. The regularity may assume a 
definite periodicity. A case is reported as having had five attacks, 
one each June for 5 successive years. A patient may have a series 
of attacks known as serial epilepsy; or a series of hundreds may 
occur without restoration to consciousness, status epilepticus; these 
cases are likely to terminate fatally. The attacks are apt to be more 
frequent in petit mal than in grand mal. A case of petit mal is 
reported with 26,124 attacks in 5 years without mental impairment; 
and a case of grand mal with 619 attacks in 49 hours. 
43. Season and time.—There is no seasonal incidence. The 
attacks may occur at any time of the day or night. Nocturnal 
epilepsy is by no means infrequent and its occasional occurrence 
may go undetected for years especially if the patient sleeps in a room 
by himself, or if the significance of bed wetting, blood on the pillow, 
bitten tongue, and feeling sore and fatigued in the morning are not 
understood. 
44. Sex and age.—The syndrome epilepsy is more frequent in 
males than in females, the incidence being about 60 to 40 percent re- 
spectively, according to Noyes. The first attack may occur at any 
age, but in 75 percent of the cases it is before the twentieth year. 
The greatest incidence is before the fifth year with an increase in 
frequency at about the seventh year and again at puberty. The in- 
cidence of epilepsy after the thirtieth year should arouse suspicion 
of organic disease, particularly paresis. In order to establish the 
“idiopathic” form, in infancy, trauma to the head from forceps de- 
livery or any other cause; in childhood, trauma and syphilis; after 
30, alcoholism, syphilis conditions, and brain tumor; and in old age, 
arteriosclerosis, chronic nephritis, senile involution, apoplexy, etc.. 
must be eliminated. 
45. Definition.—a. In the course of time, the conception “epi- 
lepsy” has had varying definitions and today there is no certainty 
where the boundary line should be fixed. Epileptoid occurrences TM 8-335 
45 
MEDICAL DEPARTMENT 
are among the most widespread of symptoms and have been observed 
in some 100 different conditions. In view of this, those seizures ap- 
pearing, without characteristic background, and merely as a symptom 
in various diseases and disorders, are distinguished as “symptomatic” 
epilepsy. On the other hand, a disease characterized by seizures 
of a like nature but arising upon a definite personality background 
without discoverable cause other than the psychopathological is dis- 
tinguished as “genuine or idiopathic.” Yet despite closest scrutiny 
of the clinical pictures, it will often be difficult to decide whether one 
is dealing with a symptomatic or genuine epilepsy. 
b. In the Lumleian Lectures of 1928, Dr. Collier says, “the occur- 
rence of epilepsy in connection with every conceivable variety of local 
disease of the cerebral hemispheres is a difficulty in the conception of 
a fundamental factor for epilepsy in a disordered metabolic state. 
The organic epilepsy has for the most part been considered as some- 
thing quite separate and apart from idiopathic epilepsy, and as having 
a different clinical aspect and etiology, and requiring a separate de- 
scription, and as amenable to surgical methods of treatment. This 
opinion, which is still widely held, has, I am sure, impeded the progress 
of our knowledge of epilepsy, for there is in reality no difference what- 
soever between the clinical manifestations of epilepsy resulting from 
organic disease of the nervous system and those of idiopathic epilepsy.” 
o. Epilepsy may ba defined as a symptom complex characterized by 
a tendency toward mental infantilism, with symptomatic manifesta- 
tions occurring as occasional, sudden, excessive, rapid, local discharges 
from some center, sensory or motor. The discharges occur independ- 
ently of volition and are accompanied by interference, partial or com- 
plete, with the stream of consciousness. 
(1) Certain of the statements require explanation. Naturally “the 
tendency toward mental infantilism” will be most striking in those 
pronounced epileptics whose development has been interrupted so fre- 
quently by seizures that they are reduced to a condition of semi-inva- 
lidism. Obviously, also, the native endowment will largely influence 
the extent to which the subject regressively expresses infantile re- 
actions. If there was defect with respect to ability to acquire knowl- 
edge and react normally to situations, then so much the more will such 
an individual under the convulsive handicap tend to react primitively 
and instinctively. Such defect of acquisitiveness and adaptability may 
be acquired owing to the limitations concerning opportunity imposed 
by the disease. In either case, the psyche undergoes a change of a 
distinctive stamp, resulting in what has come to be called the epileptic 
character. Even in those numerous milder cases in which the inter- 
ruptions to development are less frequent and in which the greater 
68 NEXTROPS'YOHIATRY IN AVIATION ME3>ICTNE 
TM S—335 
45 
manifestations of this peculiar character are lacking, its finer shadings 
are none the less discernible on careful analysis. In the symptomatic 
forms, the mental picture will be that of the disease in which the seizure 
has the value of a symptom only, for in such cases one is not dealing 
with the disease epilepsy which has psychic features peculiar to itself. 
It should be borne in mind that an epileptic in whom the first attack 
appeared after the completion of schooling, and in whom the attacks 
are few and far between, may reach a high order of accomplishment; 
for example, Julius Caesar, Mahomet, Peter the Great, Swedenborg, 
Napoleon, Flaubert, etc. 
(2) Anyone familiar with epileptic seizures will admit that the 
discharges are sudden, excessive, and rapid. The word “occasional” 
is introduced in order to exclude discharges not of this order; for 
instance, the interrupted continuous discharges of the chorea. The 
word “local” is justified by the fact that while the features of an 
epileptic attack differ in different cases, they are similar in the same 
case. Thus each individual patient invariably experiences the same 
kind of aura, falls on the same part of his body, bites the tongue in 
the same place, and utters the same sort of cry in successive attacks. 
And it is of peculiar interest to the student of mental disorders that 
if the individual exhibits mental disturbance either before or after a 
fit, it is of the same character with successive attacks. 
(3) With respect to all that is implied by “discharges from some 
center, sensory or motor” there has been much discussion. The con- 
vulsion is said to be a form of cortico-motor release. So long as the 
organism functions normally, the cortico-motor release flows as & 
rhythmic energy tide. In the epileptic attack, there is interference 
with this rhythmic release; an inhibition of release showing as an 
impairment or interruption. Much has been written concerning the 
precise nature of what occurs. 
(4) Foster Kennedy states, “It is a simpler task, however, to say 
what epilepsy is not, than what it is. It has already been described 
as an occasional paroxysmal discharge of a nerve center or group of 
centers occurring apart from volition and accompanied by interfer- 
ence with consciousness. Perhaps ‘impairment’ might be a better 
word than ‘discharge’, for many of the minor manifestations have 
such negative characteristics as to preclude the use of so positive a 
descriptive title. Even in the major seizure, the sequence of events 
can be most readily understood as a sudden cutting out of the highest 
level, the cortex, allowing the lower neuronic levels to pour down an 
ungoverned stream of tonic postural impulses; in fact, an abrupt 
rigidity of the decerebrate type. The subsequent convulsions which 
69 TM 8-325 
45 
JOOIOAL IXErAETTMENT 
have secured, by their dramatic quality and their greater duration, 
more attention than I think they deserve, probably represent the 
gradual return of cortical control, incapable at first of ordered voli- 
tional action. I suggested at the beginning of this paper that many 
diverse causative conditions must operate through a common mecha- 
nism to produce so constant a result, and that the differences in the 
various manifestations of epilepsy, from the major seizure through 
petit mal, to migraine, to recurrent syncope and periodic endogenous 
emotional tempests, comprise nothing less than a qualitative and 
quantitative unity. And in the gamut I should include, without 
equivocation, the voluminous mental states of unreality, and those 
prolonged and terrifying experiences known now as vasovagal attacks 
in which the patient is suddenly terror stricken, suffers mediastinal 
oppression, has a feeling of tingling and swelling of the limbs, a 
sense of impending death, and losing precision of contact with his 
surroundings, experiences an acute transient seizure of cardiac 
hurry.” 
(5) One authority believed “idiopathic epilepsy far too difficult a 
subject for precise investigation unless we approach its consideration 
from the bases supplied by the principles deduced from the less 
complex kinds of cases. Probably the mechanism of the major 
attacks will be revealed by a study of the manifestations of the minor 
attacks which will be found, I think, to be fragments of the fully 
developed seizure—just as we have fragments of the decerebrate 
posture produced by imperfect mesencephalic block, so we may have 
fragments of the great fit produced when abnormal conditions, prob- 
ably of a vascular nature, are not sufficiently violent to unseat the 
entire cortical function. The vasovagal attack which I have just 
described, if condensed in point of time, would be the same as the 
phenomena of many of the petit mal attacks.” 
(6) That the discharges occur independently of volition must be 
granted even in those psychopathological cases in which the individ- 
ual defensively expresses such abhorrence of reality as to obliterate 
it and regressively react along the lowest levels of organic response. 
No one will question that the interference with the stream of con- 
sciousness is absolute in grand mal. But in petit mal and the minor 
equivalents this interference may range from a momentary “absence”, 
through a transient diminution in the form of twilight thinking, to 
a fleeting disturbance seen as the obtrusion of an irrelevant thought. 
(T) Since the epileptic problem is entirely unsettled it may be 
helpful to quote other definitions. One authority says, “epilepsy is a 
disease in which there occur repeated transient attacks of either a 
psychic, sensory, or motor nature, with a loss or impairment of con- 
70 TM 8-325 
45-46 
ITHUBOPSYCJHIATBY IN AVTATIOttT Mm>I05ENB 
sciousness. The essential feature of epilepsy is a repeated and sudden 
loss of consciousness with or without a convulsion, and without 
apparent immediate cause.” Gaupp says, “by epilepsy we under- 
stand a chronic, usually progressive disease of the brain, the main 
symptom of which is a disturbance of consciousness, appearing sud- 
denly and in the form of attacks. Motor and other irritation phe- 
nomena are common but by no means present in all cases. Besides 
the transitory attacks symptoms which often, but not always, occur 
periodically, there appears in the majority of cases a gradual transr 
formation of the entire psychic being, which sometimes chiefly affects 
the character, in other cases the intelligence as well of the patient 
(epileptic degeneration), and in the severer form of the disease ends 
in terminal dementia of a high degree and peculiar coloring.” Noyes 
states that the term “epilepsy” is applied to various symptom com- 
plexes of a recurring paroxysmal nature, usually involving disturb- 
ances of kinesis, particularly in the form of convulsions. 
46. Etiology.—a. Some authorities think the term “genuine epi- 
lepsy” should be abandoned. They regard it as an organic cerebral 
disease, the morbid anatomy of which is not yet understood. One 
says, “in considering the epilepsies there is no ground for defining 
‘genuine epilepsy’ as an isolated group except that in the other groups, 
causative factors have been already discovered.” Others believe there 
is a genuine epilepsy without discoverable cause other than the psy- 
chogenic, and that it is a form of degeneration having its roots in the 
congenital constitution. In any event there must be an inherent in- 
stability of nerve centers unduly favoring release of a mechanism 
permitting “the pouring downward of an ungoverned stream of pos- 
tural impulses.” The evidences of such release may range from the 
“dramatic gesture of the major seizure, through the less intrusive 
features of petit mal, to the most unobstrusive and momentary minor 
manifestations.” And it is concluded the releasing mechanism is the 
same whether the cause is organic or psychogenic because the mani- 
festations are similar and it is impossible in many instances to dis- 
tinguish between the “symptomatic” end “genuine” convulsive attack, 
short of weighing all considerations and making careful study of the 
personality make-up. However heterogeneous and elusive the provoc- 
ative conditions may seem to be, it is vital to recognize the essential 
unity of all attacks of loss or impairment of consciousness, with or 
without convulsions, or as has been stated, “The initial and essential 
event in every epileptic attack is a cessation and loss of function. All 
positive phenomena such as hallucinations and convulsions being re- 
ferred to as ‘release phenomena’ occurring in lower levels of the 
nervous system no longer under control.” TM 8-325 
46 
MEDICAL DEPARTMENT 
b. If a “genuine epilepsy” is conceded, then it must be admitted 
little is known about its cause although much importance attaches 
to a burdening psychopathic heredity which expresses itself along 
lines of degenerative modification by way of the epileptic convulsive 
aptitude. However, the present tendency is to lay less emphasis than 
formerly on heredity. It probably plays a part in about 25 percent 
of cases, although epileptic persons may have normal children while 
entirely healthy parents may have progeny afflicted with epilepsy. 
c. Factors noted in the ancestors of epileptics have been alcoholism, 
the vague term “neuropathic diasthesis”, parental syphilis, influence 
of mother’s health on intra-uterine life, endocrine disturbances, and 
nervous and mental disorders. In such offspring, physical and mental 
stigmata of degeneration are common. Abnormal skull; asymmetries 
of the cranium and face; abnormalities of the palate; broad, heavy 
nose, and thick lips; visual anomalies; dilated, unequal, and irregular 
pupils; strabismus; abnormal ears; and anomalies of the teeth and 
growth of hair are frequent. Some are definitely retarded while in 
others the psychopathic personality is apparent before attacks occur. 
In fact, there are epileptics who never have an attack within the 
ordinary meaning of the term. On the other hand, the distinctive 
personality changes may be acquired in organic cases because of the 
limitations in the way of development and opportunity imposed by 
the disease. 
d. Acting upon the inborn predisposition, secondary predetermin- 
ing factors operate to produce the attacks. Among these are trauma 
to the head or any part of the body, although only 5 percent of those 
who received gun shot wounds of the head in the last war developed 
epileptic reactions. Others are noted as due to the influence of endo- 
genous or exogenous toxins, anaphylactic reactions, the glands of in- 
ternal secretion, circulatory disturbances especially anemia of the 
brain, hyperpnea, and the hydrogen-ion concentrations of the blood. 
Finally, the psychoanalytic theory should be mentioned as advanced 
by one authority, that the attack represents a flight from reality in 
response to an unconscious conflict, and is a regression to an infantile 
level or even the intra-uterine pleasurable state. 
e. The difficulty of establishing the cause of epilepsy has been tersely 
stated as follows: “Anybody who is looking for one cause of epilepsy 
might as well stop looking.” It would be informative if it could be 
known what actually takes place in the brain during an attack. When 
it is considered that these causes involve anatomical, physiological, 
physiochemical, and psychopathological processes, it may be con- 
cluded, as do a large group of psychiatrists, to consider epilepsy as 
the psychobiol ogical life reaction of an inadequately equipped indi- 
72 TM 8-335 
46-48 
NEU RO PSYCHIATRY IN AVIATION MEDICINE 
vidual to psychic stresses within and to psychosocial strains or en- 
vironmental realities without, an adjustmental psychobiological re- 
action which becomes habitual with the personality tending to suffer 
a permanent deterioration. (Noyes.) 
47. Pathological anatomy.—a. While anatomic changes are 
demonstrable in the brains of epileptics, none has been found which 
is uniformly characteristic. Alzheimer concluded epilepsy to be a 
group of various diseases; that a variety of conditions were capable 
of releasing the convulsive mechanism. He differentiates six groups 
of different processes. The first group comprises genuine epilepsy, 
the causes of which are not yet known; the second, he ascribes to 
external poisons and finds corresponding anatomic changes; the third, 
is syphilitic epilepsy dependent on endarteritis syphilitica of the 
smallest cortical vessels; the fourth, is arterio-sclerotic late epilepsy; 
the fifth, is found in focal diseases, especially encephalitis; and the 
sixth, is epilepsy in case of inhibition of the development of the brain. 
5. Dr. Collier’s latest contribution in the Lumleian Lectures for 
1928 is as follows: “So far as the so-called ‘idiopathic’ epilepsy which 
thus affects man and animals is concerned, no pathological changes 
have been found upon which any hypothesis as to the nature of 
epilepsy can be built up. The findings have been for the most frankly 
negative, or such changes as have been found in severe and long- 
standing cases as may be reasonably attributed to long-lasting dis- 
order of function. Attention has therefore turned to the possibility 
of finding an explanation of epilepsy in some perversion of the 
chemistry of life—some metabolic dyscrasia which may lead to the 
presence of substances within the system which act upon the nervous 
system as do the convulsant poisons and which may further, by de- 
priving the nervous system of its customary activators, cause in some 
cases, a progressive impairment of the higher functions of the nervous 
system.” However, the pathology and pathogenesis of the convulsive 
state are only a little less understood than its etiology. 
c. Sclerosis of the cornu ammonis is found in about 50 percent of 
epileptic brains, but whether due to cause or effect has not been 
determined. Vascular changes have been noted in the cortex as have 
arachnitis, thickening of the pia, and thickening of the skull, but 
again whether due to cause or effect is not known. 
48* Symptomatology.—Four groups of phenomena must be con- 
sidered ; those preceding the attack; comprising the attack; following 
the attack; and occurring between attacks which embrace the episodic 
occurrences known as “epileptic equivalents” and the permanent per- 
sonality changes forming the “epileptic character.” TM 8-325 
48 
MEDTOAIi DEPARTMENT 
a. Phenomena ‘preceding the attack.—(1) These include the pro- 
dromata or more “distant heralds”, lasting from a few hours to a 
few days; and the real aura or “signal symptom” lasting only a few 
seconds, or from 1, to 2, or 3 minutes. The more distant heralds con- 
sist chiefly of changes in mood and behavior, showing as irritability, 
unsociability, depression, excitement, euphoria, delusions, and disin- 
clination to do any work. These prodromata may appear with such 
regularity that relatives, associates, or attendants know an attack is 
imminent. The aura may occur as a sensory hallucination which may 
be auditory, visual, olfactory, gustatory, cutaneous, or visceral; or it 
may be motor, psychic, vasomotor, or secretory. The sensory halluci- 
nation may be of any variety capable of being aroused in the par- 
ticular field or fields involved. Motor, psychic, vasomotor, and secre- 
tory aurae require more detailed description. The motor aura usually 
starts as a twitching of a single muscle or group of muscles gradually 
extending to other muscles; or there may be merely a tonic contrac- 
tion of a muscle or group of muscles; in either event, usually not 
extending beyond a portion of a limb or one whole limb before con- 
sciousness is lost. Sometimes the head is rotated to one side, or the 
eyeballs turned to one side, or there is mere fluttering of the lids. 
It is rare for bilateral motor irritation to precede the attack. There 
may be dysarthria, aphasia, moistening of the lips, swallowing move- 
ments, yawning, singultus, crying, singing, whistling, etc. The 
patient may turn around rapidly, or run forward, backward, or in a 
circle. Not infrequently children will run to their mothers crying 
as if for protection. Psychic aurae are exceedingly varied and may 
be either vivid or vague. They occur as a depression, a fervor, a 
doubt; an impulse, as gaiety, rage, or quarrelsomeness; as a sudden 
recollection or instantaneous review of a lifetime; a vague, dreamy 
state, or feeling of strangeness and unreality. Vasomotor aurae occur 
as flushing or pallor; erythema, urticaria, ischemia, or angioneurotic 
edema. Secretory aurae may occur as profuse perspiration, saliva- 
tion, or more rarely gastrosuccorrhoea. 
(2) The attack may or may not be preceded by prodromata or by 
an aura. No statistics are available concerning the former, but the 
latter occurs in about 60 percent of cases although not in 50 percent 
of attacks. It is an interesting fact that attacks may often be 
aborted by assault upon the aura if it is sufficiently prolonged, espe- 
cially if located distally. It must, therefore, be clear that an epileptic 
attack instead of invariably occurring with lightning-like abruptness 
as is popularly believed may be announced by prodromata, an aura, 
or both. Since an aura may last from a few seconds to as long as 
3 minutes, it follows that epileptics, experienced concerning their 
74 TM 8-325 
48 
N KUHOi^YOHJrATE.Y IN AVIATION MEDICINE 
attacks, may have time to lie down and avoid injury. Just as the 
hysteric falls without injury, so may an epileptic, under the condi- 
tions described, ease to the floor or go and lie on the bed. Thus a 
mother might place her baby in the crib and then lie down in any 
convenient place before consciousness is lost Gowers says, “Swift- 
ness is an essential element of ordinary epilepsy, but this does not 
preclude the possibility of deliberation.” 
5. Phenomena comprising the attach.—These include grand mal 
or the major attack; petit mal or the minor attack; and in a sense, 
abortive or larval attacks; the latter is described in d below, in con- 
nection with epileptic equivalents. Some patients have only major, 
others only minor, attacks, but frequently they have both; or major 
attacks may be replaced by minor attacks, or vice versa; or either 
become abortive, and grade downward into the less obtrusive mani- 
festations. 
(1) Gramd mal or major attachsi.—These attacks exhibit three dis- 
tinct stages; the tonic, the clonic, and the stertorous. The latter 
stage properly belongs with phenomena following attack which is 
described in c below. 
(a) The tonic stage lasts from a few seconds to 1 minute and 
because of the very short duration may go unrecognized. It sets in 
abruptly, with or without apparent cause, with or without prodro- 
mata, premonition, or aura, and consciousness is instantly lost. 
(Consciousness is completely lost during the whole of the attack in 
most grand mals, at least for a part of the attack in all.) Since all 
the muscles of the body are thrown into tetanic rigidity, the patient 
not only falls, but frequently is flung down violently. Simultane- 
ously, but after consciousness is lost, occurs the characteristic cry, 
shriek, or respiratory guttural sound due to the sudden tetanic muscu- 
lar grasp of the thoracic and fixation of the laryngeal apparatus. 
The cry is not verbal, nor does it occur in all cases nor in all attacks. 
The face is pale, then congested, then cyanotic. Occasionally the 
pallor persists throughout the attack. The eyelids are usually open 
(but may be closed); the eyes fixed, turned up, or to one side; the 
pupils at first miotic, then mydriatic, with no reaction to light; and 
the conjunctival reflex lost. The inner surface of the cheeks or tongue 
or both may be caught between the teeth and lacerated. Instead of 
all the muscles being in tetanic rigidity, there may be only flexion 
of the fingers or toes, or fixation of a single muscle or groups of 
muscles, or of one-half of the body. Usually, however, the entire 
musculature is involved; the thumbs are adducted across the palms 
and grasped by the flexed fingers, the hands and elbows flexed, the TM 8-325 
48 
MEDICAL DEPARTMENT 
head retracted, the back arched, and the legs rigidly extended, or 
the more powerfully contracted muscles of one side may draw the 
body, head, and eyes toward that side. While the above is the usual 
position, exceptions occur. The fingers may be extended, the elbows 
flexed, and the arms raised; or the body may be flexed, with head 
forward and chin on chest, one arm and one leg flexed, the other arm 
across the chest, and the other leg extended. There may be almost 
any variation from the classical position. Spasm of the abdominal 
muscles may expel the contents of the bladder and rectum. A thrill 
or vibratory impulse can be detected by placing the hand on the 
tonically contracted muscles. Often minute vascular ruptures occur 
in the skin, mucous membranes, and conjunctivae, and it is probable 
that similar vascular accidents take place in the viscera and brain. 
It should be remembered all the above occurrences are condensed in 
point of time from a few seconds to 1 minute, and may be entirely 
overlooked by the casual observer. 
(h) The clonic stage usually lasts from 1 to 5 minutes, and some- 
times as long as 15 minutes. The tetanic rigidity is replaced by 
trembling, advancing to clonic movements increasing to rapidity, then 
becoming more powerful but slower and slower until finally they 
cease and the body lies in full relaxation. The eyelids will now 
likely close, but during the convulsive movements, they may alter- 
nately open and close. The clonic movements are not always of the 
same character; in general there is flexion and extension of the 
limbs, the head and trunk are tossed about with violence, the eyes 
roll, the face grimaces, and the tongue and inner surfaces of the 
cheeks may be bitten. Respiratory movements, momentarily inter- 
rupted in the tonic stage, now resume, diminishing the cyanosis, but 
are rapid and noisy and often accompanied by groaning or moaning 
noises. The increased saliva, instead of being swallowed or expec- 
torated, is churned and forced between the teeth as bloody foam. 
Urine, feces, and semen may be expelled. Cardiac action momen- 
tarily interrupted in the tonic stage, now is rapid. The pupils are 
mydriatic and immobile, the cutaneous and deep reflexes absent, and 
ankle clonus and Babinski often present. The body and face are 
covered with perspiration but the temperature remains normal. (In 
status epilepticus, the temperature may rise to 107°. When status 
takes place, it usually does so as a continuation of a grand mal). 
(2) Petit mcH or the minor attack.—These fractional epileptic at- 
tacks last from a second to half a minute. They appear suddenly 
and occur in great variety, with or without falling, with or without 
motor twitching. Gowers mentions 70 different manifestations of 
petit mal. The constant factor is a momentary loss of consciousness 
76 TM 8-335 
48 
NEUROPSYCHIATRY IN AVIATION MEDICINE 
but this does not preclude subsequently concluding something unusual 
had occurred. While an attack may occur after an aura, it is very 
rare for an aura to precede. In the commonest form, the face sud- 
denly pales (rarely flushes), the palpebral fissures widen, the pupils 
dilate, and the “gap” in consciousness shows as an interruption in 
conversation or whatever is being done, followed by immediate re- 
sumption without the subject realizing the “absence” or those around 
perhaps even noticing it. Or, in addition to the above facial changes, 
there may be slight twitching of the facial muscles, of the eyelids or 
lips, smacking, tasting, or sucking movements; spitting; dropping 
whatever is in the hands; twitching of one or more extremity; dis- 
charge of urine; or giving way of the knees and falling. Events such 
as these clearly indicate release of some deeply seated mechanism, 
but there is no real convulsion. Perhaps the slight jerks occurring 
while dropping off to sleep have similar significance. One must also 
think of attacks of “dizziness” and so-called fainting spells as not 
infrequently related to petit mal. 
g. Phenomena following the attach.—The patient lies inert just as 
the convulsion left him, unconscious and breathing stertorously. 
Within a few minutes he opens his eyes, but appears dreamlike and 
confused. Presently consciousness is fully restored, but he is likely 
to be cross, irritable, and complain of a headache. Barely there is 
abrupt restoration to consciousness and feeling of being as well as 
usual, or of feeling unusually well. More commonly the patient opens 
his eyes, without seeming to be conscious, and then falls into a deep 
sleep lasting for hours. The sleep is apt to be long after severe 
and short after mild attacks. If roused from the sleep (often im- 
possible), he may get up and do apparently purposive acts, such as 
undressing movements, or be violent, without knowledge of it after- 
ward. Vomiting may occur during and after an attack. Polyuria or 
nycturia may follow the attack. The blood and urine may be toxic. 
There may be transitory blindness, aphasia, stuttering, paraplegia, 
and various other disturbances. The mental state is apt to be one of 
dullness and stupidity due to exhaustion of the cortical centers; but 
the patient may appear bright as usual. There is complete amnesia 
for at least a part of an epileptic attack, and this may extend over a 
period preceding, but the patient usually at least remembers the aura 
and knows something unusual occurred because of feeling sore, 
strained, fatigued; the sore mouth, injury due to falling or the con- 
vulsive movements, urine, feces, etc. Only because of such experi- 
ences may there be reason for suspecting a night attack has occurred. 
Ankle clonus and Babinski persist for a while after the attack and 
the knee-jerk remains in abeyance. 
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MEDTOAIi DEPARTMENT 
(L Phencnrhena occurring between attacks.—These embrace the oc- 
currences known as epileptic equivalents and the permanent person- 
ality changes forming the epileptic character. 
(1) There are a number of striking disturbances which occur 
between, or in relation to, either major or minor attacks, called 
“epileptic equivalents”. Some are abortive and transitory in the 
sense of their not being a complete convulsive manifestation; while 
others occurring as protracted mental disturbances are more strictly 
substitutive in character and of extreme legal and sociological im- 
portance. Others, as sleep talking or muttering, narcolepsy, mi- 
graine, momentary absences, fainting spells, vasovagal attacks, and 
attacks of dizziness are scientifically interesting to the psychiatrist 
as indices for epilepsy even in the absence of attacks within the ordi- 
nary meaning of the term. They form an ensemble, with or without 
the characteristic personality changes, making possible the diagnosis 
of epilepsy without history of convulsive seizure, as there are epi- 
leptic organisms which never “gesture” in dramatic fashion. 
(2) Both abortive and protracted disturbances may precede, in- 
terrupt, take the place of, or follow an attack; or occur independ- 
ently of anything strictly resembling a convulsive seizure. The 
amnesia for these disturbances may be partial or complete. No hard 
and fast line can be drawn between the abortive or transitory and 
tlie protracted disturbances; the former may be classed as those last- 
ing from a few seconds to a few hours and the latter as those 
lasting days, weeks, or even months. The terms, “psychic epilepsy”, 
“epileptic twilight states”, “epileptic automatism”, and “epileptic 
fugues” are generalizations somewhat loosely used to include practi- 
cally all the conditions. In evaluating the abortive disturbances 
those transitory changes are seen as unmotivated ill-humor, anger, 
depression, excitement, euphorism, or confusion related to attacks 
in time as preconvulsive or postconculsive; or more obscurely taking 
their place in masked or rudimentary fashion—additional proof of 
relation in fact resting upon observed or unobserved motor twitch- 
ings or other rudiments. In this connection, petit mal is a frag- 
mentary seizure, abortive in the sense of its relationship to grand 
mal, the two conditions frequently occurring interchangeably or by 
gradation from one to the other in the same individual. Certain 
other transitory disturbances consist of impulsive acts of a violent, 
often criminal nature. They are— 
(a) Epilepsia procursiva, in which the patient automatically per- 
forms movements of walking or running, often ending by running 
forward even several miles as if impelled by an irresistible force, 
perhaps striking any body happening in his way. 
78 NEUROPSYCHIATRY IN AVIATION MEDICINE 
TM 8-325 
48 
(6) Epilepsia retropulsiva, in which the patient performs move- 
ment of walking or running, often ending by running backward. 
(<?) Epileptic furor, in which there is an ungovernable asocial 
impulse leading to indecent exposure, assault, theft, arson, rape, 
or murder; in connection with the last two, acts of revolting brutality 
are often committed all absolutely unmotivated and without distinc- 
tion as to time, place, or person. 
(3) Protracted disturbances last for days, weeks, or even as long as 
2 or 3 months. No hard and fast line can be drawn between the 
transitory and protracted disturbances for the difference is practically 
that of duration only. Hence when prolonged beyond a few hours 
they become states of— 
(a) Epileptic depression or ill-humor, in which the subject is irrita- 
ble, querulous, complaining, and antagonistic; nothing pleases, nor does 
any one understand or sympathize; he is very hypochondriacal, and 
threatens or attempts suicide. Some authorities teach that real dipso- 
mania is an epileptic manifestation because it arises in a peculiar mood 
of depression; and that the dipsomania attack under the influence of 
alcohol gradually passes into a severe twilight condition from which 
the patient awakes with total or partial amnesia. 
(h) Epileptic excitement, in which the subject laughs immoderately, 
strips, somersaults, declaims, speaks irrationally to bystanders, or 
addresses inanimate objects; or the aspect becomes forbidding and 
there arises passionate fury and violence expending itself in wanton 
destructiveness; or in criminal acts, as assault, theft, arson, rape, mur- 
der often with revolting brutality or bestiality, “Ripper” crimes, or 
epileptic furor. 
(c) Epileptic confusion, with imperception and disorientation, and 
aimless wanderings or purposeless movements of the arms and legs. 
Stoddard mentions one such case in which there was remarkable sug- 
gestibility. The patient was in a London hospital, but said she was 
near the sea because she heard the sound of the waves which was in 
reality the noise of traffic. The patient’s suggestibility had doubtless 
been heightened by being demonstrated to a class of students. In any 
event, Stoddard impressively told her that in one week she would hear 
a crack in her head, and suddenly recover. Exactly one week later she 
did hear a crack in her head and returned to her normal condition. 
Says Stoddard: “the kudos I had obtained for remarkably clear in- 
sight into the patient’s malady was ill-deserved. The result was 
probably due to the patient’s unsuspected suggestibility; it could 
hardly have been a coincidence.” 
(d) Epileptic delirium, in which the subject has terrifying halluci- 
nations and the delusion of a hostile environment. Or the halluci- 
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MEDICAL DEPARTMENT 
nations and delusions may have religious import. Celestial beings 
appear and perhaps speak, so that the patient sings or kneels in prayer. 
(0) Epileptic stupor, often called “epileptic catatonia” because of 
its resemblance to catatonic stupor. 
!(/) Epileptic automatism, consideration of which introduces 
many interesting questions concerning double or alternate conscious- 
ness, because the manifestations may range from a single automatic 
act to the ambulatory fugue lasting days or weeks during which the 
behavior is so apparently normal and natural that the unusual state 
is unsuspected. The single automatic act often consists of undress- 
ing movements in public. Gowers explained this “as due to some 
vague sense of indisposition and the propriety of going to bed.” 
Stoddard sees it “as the gratification of an unconscious desire to 
expose the body to public gaze.” All these conditions begin and 
end suddenly and are most common after petit mal. The amnesia 
may be partial or complete. Several striking illustrations of epilep- 
tic automatism are as follows: “Without mishap a man drove a 
dray through crowded thoroughfares, across London, and found 
himself 6 miles from the place where he was, as it seemed to him, 
a moment before.” (Gowers.) “A bank clerk was sent with a 
message to another bank, having entered which, he knocked a clerk 
off his stool, disarranged some papers but removed none, and left 
the bank. Subsequently he remembered nothing of the incident ex- 
cept experiencing his usual epileptic aura on ascending the bank 
steps.” (Stoddard.) “There is the classical case of the French 
judge, who, after an attack of petit mal which occurred during a 
trial, micturated in a comer of his court before the public gaze, an 
incident of which he could subsequently remember nothing. (Stod- 
dard.) Occasionally, however, these post epileptic states are remem- 
bered by the patient. “A man who worked in a shipyard and had 
for some years been subject to attacks of giddiness with increasing 
frequency, went to the yard as usual one morning, did some work, 
and then went and sat down on a piece of timber. His comrades 
spoke to him but could get no answer, so he was taken to a hospital. 
While there he would say nothing except the Lord’s prayer, in 
reciting which he showed some difficulty in articulation. After a 
sojourn of a few days he was transferred to an asylum where he 
became almost immediately his normal self, and was able to recount 
all that had happened to him in the hospital, knew the names of the 
doctors there and related incidents which occurred during demon- 
strations of his case to students. After a few days he relapsed and 
became an ordinary case of epileptic insanity.” (Stoddard.) “A 
patient was sitting before me, and just as I was about to make an 
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48 
NEUHOPSYCHIATRY IN AVIATION MEDICINE 
ophthalmological examination, the pupils suddenly dilated, the face 
became expressionless, the palpebral fissures widened, while the 
patient suddenly unbuttoned his vest and trousers, put his hand in 
his pocket and withdrew his knife, opened the large blade, and 
grasped it as if with the intention of stabbing. His muscles then 
gradually relaxed, his shoulders dropped, he folded his knife and 
put it back in his pocket, and he had no knowledge of having had 
the attack when questioned about it.” (Block.) “One of my pa- 
tients walked 40 miles to a neighboring town and on recovery from 
the attack, knew of only two facts which he could associate with 
the trip; on entering the hotel of his home town to keep an appoint- 
ment, consciousness ceased at the door of the hotel and it had re- 
turned while he was standing on the doorstep of a house in the 
neighboring town, his hat in his hand, while a lady instructed him 
how to reach some point in the town, although he knew nothing of 
what he had asked her. He had suffered from frequent epileptic con- 
vulsions, and this one was replaced by psychical epilepsy.” (Block.) 
Professor James of Harvard University, recites the remarkable 
case of the Reverend Ansel J. Bourne. This man, a carpenter and 
itinerant preacher, then 60 years of age, disappeared from his home 
in Rhode Island on January 17, 1887. With abrupt restoration to 
normal consciousness on March 14, he found himself keeping a con- 
fectioner’s shop, under the name of A. J. Brown, in Norristown, 
Pennsylvania. No one who had known him in Norristown had sus- 
pected there was anything wrong with him. There was absolute 
amnesia for the whole period, and vice versa, during the period for 
the whole of his past life. His history showed him to have been of 
average endowment and of unblemished character. There had been 
a significant episode in his thirtieth year, interpreted by himself 
and friends as a visitation of Providence. One day while walking 
in the open country he heard a voice saying, “Go to the chapel!” 
He inquired, “What chapel?” The voice said, “To the Christian 
chapel.” But the carpenter was on unfriendly terms with the pastor 
of the chapel and exclaimed, “Before I go to that place I hope God 
may strike me deaf, dumb, and blind.” Whereupon he fell to the 
ground, enveloped in darkness and silence, and without the power 
of speech. Presently he was restored to his senses and the matter 
culminated in his conversion and becoming an itinerant preacher for 
the next 25 years. One wonders with what embellishments the 
preacher narrated this tale in after years to his audiences. Professor 
James repeatedly hypnotized the Rev. Ansel J. Bourne and each 
time got a detailed account of the doings of A. J. Brown. In addi- 
tion, he recalled having been apprehensive concerning some sort 
274758°—41——6 
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MEDICAL DEPARTMENT 
of trouble at borne, having drawn money from the bank and going 
away. He spent a night at the Grand Union Hotel, New York 
City; next day went to Philadelphia, was at a boarding house on 
Filbert Street for two days; saw the advertisement of a store for 
sale in Norristown, went there, purchased it and set himself up in 
business. All of which was duly verified. Professor James stated 
that his Brown personality was a weak, insipid, diluted extract of 
his normal self. After being hypnotized many times, his hypnotic 
memory grew more and more feeble until finally he could recollect 
only the faintest outlines of his abnormal state. 
49. Epileptic character.—a. In addition to being a serious 
physical disease, it must be emphasized that genuine epilepsy is like- 
wise a mental disease. In those cases with but few and isolated at- 
tacks, and in which the first did not appear until after the completion 
of schooling, assuming also an average original endowment, there may 
be little or no effect upon the mental life. Under such circumstances, 
epilepsy is not incompatible with full mental vigor and usual or even 
exceptional accomplishment. Certain famous men were epileptics. 
In explanation, it has been urged that the consciousness of insufficiency 
aroused a defense reaction spurring them on to greater endeavor, 
culminating in brilliant compensation. However this may be, the 
picture has its darker side. Since the greatest incident is in the 
earliest years, and since the majority of epileptics begin life under a 
burdening psychopathic inferiority, they are inevitably handicapped 
by the three-fold factors—disease, inherent defect, and limited oppor- 
tunity. These unfortunates illustrate the damaging influence of the 
uncompensated inferiority complex, for most epileptics gradually 
relinquish the struggle and accept defeat, becoming idle, dependent, 
and deteriorated. 
h. It is to be expected that the chronic changes in personality will 
show variously in different subjects. Nor are all the peculiarities 
seen in epileptics to be interpreted as epileptic symptoms: other con- 
tributing factors may be operating. Neverthless the disease seems, 
in typical cases, to cause specific changes in the psyche. The char- 
acter deteriorates. The patient becomes irritable, stubborn, spiteful, 
quarrelsome, pedantic, petty, untractable, untruthful; is taciturn or 
loquacious, moody or euphoric; has hypochondriacal ideas, is given to 
fawning politeness, and gradually becomes more and more egotistic. 
He is boastful, praises himself and family, notwithstanding he is apt 
to be quarrelsome and a most disturbing element in the family life, 
disposed to make trouble for others and get sympathy for himself. 
In some, the ethical and esthetic sense dulls; in others there is a sort TM. 8-325 
49-50 
NEUROPSYCHTATRY IN AVIATION MEDICINE 
of religious emphasis, a kind of “righteousness”, in reality, however, 
a superficiality, a vapid piety. 
o. With respect to the intellectual content, epileptic thinking has 
something unclear and indefinite about it. The mental stream is 
retarded and runs heavily. He is verbose, clumsy, and vague in speech, 
fails to get anywhere in his talking, depicts all trivialities in repeti- 
tion and in manifold expression of the same idea in different forms. 
He dwells on the simple and the present and what immediately con- 
cerns himself, has gormandizing habits, is careless, indifferent, and 
notoriously unreliable. There is poverty of ideation, with small 
vocabulary and word reactions of the infantile sort; memory defect, 
diminished impressibility and comprehension, and impaired judg- 
ment. The patient evinces peculiar slowness, ceremoniousness, men- 
tal backwardness, and dearth of thoughts. The whole tendency is 
regressive and the picture a curious composite of adultism and infan- 
tilism. The affectivity is morbid. The patients are clinging in their 
attachments, given to emotional oscillations; resentful if unnoticed; 
like children joyful if praised, heartbroken if rebuked; they busy 
themselves about the wards without getting much done and their 
clumsy readiness often becomes a nuisance. They are self-centered, 
egotistic, auto-erotic and narcissistic; often showing exaggeration or 
perversion of the sexual impulse. 
d. When it is remembered that epileptics lead an interrupted school 
life, are restricted in their social contacts, have difficulty in holding 
positions, suffer inhibitions concerning marriage, and are apt to be 
pitied, just tolerated or even shunned, it is inevitable that personality 
changes such as the above should occur in varying degrees and ex- 
tent in accordance with the severity of the case and associated factors, 
inherent as well as environmental. 
50. Clinical varieties.—In addition to symptomatic and genuine 
idiopathic epilepsy; grand mal and petit mal; serial epilepsy and 
status epilepticus; epileptic equivalents, including psychic epilepsy, 
twilight states, automatism, and fugues; epilepsia procursiva and 
retropulsiva; abortive or larval forms; nocturnal epilepsy; and porio- 
mania or wandering epilepsy, there are several other varieties, prin- 
cipal among which are— 
a. Uncinate fits, in which there are smell or taste sensations with 
smacking or chewing movements, associated with a dreamy, confused 
state, and often a sense of fear. 
b. Narcolepsy, suddenly falling into a deep and prolonged sleep 
during the day with amnesia for the period immediately preceding. 
Usually classed with the equivalents. 
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MEDICAL DEPARTMENT 
c. Jacksonian epilepsy, in which there is a localized spasm at times 
associated with a loss or impairment of consciousness and at times 
developing into a general convulsion. 
51. Sequelae.—The most common and important of the sequelae 
is mental deterioration. Its degree usually is in direct proportion to 
the frequency of attacks. Mental enfeeblement is more often associ- 
ated with petit mal than with grand mal, and the prognosis is worse. 
The extreme of mental deterioration is seen in epileptic dementia 
which may become as complete as the terminal dementia of paresis, 
existence being purely vegetative. 
52. Prognosis.—There is a general impression that epilepsy is 
incurable or at least cured but rarely. Perhaps this is due to “one 
method” forms of treatment and failure in all cases to make system- 
atic search for cause. The disease is due to an unstable nervous 
system plus a cause. Ten percent is usually given as the proportion 
of cures. It is preferable to speak of the disease as arrested rather 
than cured, because of the liability of recurrence even after a long inter- 
val. The prognosis is better if treatment is begun soon after the first 
attack in cases preceded by an aura, if the attacks are severe and far 
apart, and if they occur only during sleep or only while awake. The 
attacks often cease during pregnancy and the infectious diseases, 
usually reappearing after convalescence. One well-known author 
feels that “if, after a patient is treated for 2 years without the occur- 
rence of a fit, and the treatment is then gradually reduced and no 
fits occur for a year after treatment is stopped, the patient may be 
considered cured. It is not, however, claimed that the patient now 
has a perfectly stable nervous system and that he will never again be 
subject to any of the various functional nervous diseases, for in 
reality he will be more subject to them than a normal person as long 
as he lives, and among these diseases he will be subject to epilepsy. 
The prognosis naturally carries out the general hygienic measures, 
diet, and treatment.” Death often occurs through vascular accident, 
by suffocation or other physical mishaps attending a fit. Status epi- 
lepticus is apt to terminate fatally. Pronounced epileptics are short- 
lived. Only about 3 percent reach their fiftieth year. 
53. Diagnosis.—a. Since some epileptics never make the dramatic 
convulsive gesture, the diagnosis must often rest on evidence pre- 
sented by less intrusive manifestations such as equivalents and per- 
sonality changes. Even when there is history of a seizure or seizures, 
the physician may not have opportunity for observing one, and the 
patient’s statements are of no value for presumably he was uncon- 
scious. If he relates anything, not hearsay, as having occurred 
during a fit, then it was not epileptic. However, this is not to be 
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NEUROPSYCHIATRY IN AVIATION MEDICINE 
held conclusive with respect to some equivalents, notably a fugue, as 
there might be islets of memory. While it would be unwise to be- 
little the importance of a convulsion, yet it has the value of a 
symptom only, occurring as it does in some 100 different conditions. 
More significance attaches to the momentary and less insistent ges- 
tures, to the more obscure equivalents, and to the character changes. 
In occurrence (isolated, repeated, or in ensemble) they are presump- 
tive for the disease epilepsy and have the weight of proof despite 
absence of attacks. 
b. Age is an important diagnostic factor inasmuch as three-fourths 
of genuine epilepsies occur before the twentieth year, with the greatest 
incidence during infancy. Hence a first occurrence toward 30 or 
later should arouse suspicion of organic disease; if in the thirties, of 
syphilis; in the forties or later, of alcoholism, lead poisoning, or 
arteriosclerosis. There remain many obscure cases, however, in 
which diagnosis is difficult, even impossible, unless the patient be in 
the ward under observation. Even then the case may be atypical 
and the symptom complex confusing because in its spectrum lie 
colors belonging elsewhere. The epilepsies are not so poor in re- 
source that they disdain appropriating manifestations from related 
disorders. 
54. Differential diagnosis.—The principal problem is that of 
differentiating genuine epilepsy from hysteria. A thorough knowl- 
edge of each disorder should make this positive in practically all 
instances, although some authors say there occur those in which it 
is impossible. There are instances in which it is practically im- 
possible to decide whether the seizure is epileptic or hysteric. It 
has been claimed there is a “hystero-epilepsy”; and further, that there 
occur attacks which should be considered “intermediate” between the 
epileptic and the hysteric. Obviously, a hysteric eventually might, 
because of trauma or disease, present symptomatic epileptic attacks. 
Conversely, an epileptic might exhibit certain hysterical symptoms. 
Or the manifestation may be so indeterminate as to seem a com- 
posite standing midway between the two. A knowledge of epilepsy, 
particularly with respect to the momentary “absences” and other 
minor equivalents, as well as amnesic states following head trauma, 
is of vital importance to the flight surgeon. While these phenomena 
interest every physician, their occurrence on the ground may not 
involve special hazard. In the air, however, it may cost a life, or 
lives; and the responsibility will rest directly upon the flight surgeon 
who failed to discover the defect. Further, the potentiality for 
momentary “absences” and automatisms lurks in every individual 
85 TM 8-325 
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MEDICAL DEPARTMENT 
who has sustained a severe head trauma and the examiner must 
have this possibility in mind before again qualifying for flying duty 
the pilot who has sustained such injury. Nor is it safe to disregard 
a possible latency in this direction which may become a manifest 
symptom, even months afterward. There is increasing interest in 
the so-called equivalents, migraine, narcolepsy, pyknolepsy, vaso- 
vagal attacks, syncopal attacks and tetany, which, it is becoming 
more and more the belief, are caused by the same condition—a 
metabolic dyscrasia, now considered by most authorities on the sub- 
ject as responsible for the epilepsies, and which flight surgeons should 
constantly be on their guard to recognize in the original examina- 
tion of applicants for flying training, in order that they may be 
rejected. 
cl Epilepsy.—(1) Usually arises without any demonstrable cause, 
psychological or otherwise. 
(2) Consciousness completely lost for the whole of the attack in 
most instances, at least for a part of the attack in all. 
(3) Sudden involuntary falls, injuries, and bitten tongue. 
(4) The self injuries are unfortunate accidents. 
(5) Makes no sound after the initial respiratory cry, although they 
make moaning or groaning sounds during clonic stage, 
(6) Eyelids open, or alternately open and shut; eyes fixed, turned 
upward, or to side; pupils at first miotic, then mydriatic, no reaction to 
light; conjunctival reflex lost. 
(7) Cutaneous and deep reflexes lost; ankle clonus and Babinski toe 
reflex present; both persist for short time after attack 
(8) Face pale, then suffused, then cyanotic; pallor may persist 
throughout. 
(9) Tonic-clonic stages; in general, the movements are those of re- 
flection and extension and they are continuous, not interrupted by rest 
periods. 
(10) Occasional involuntary micturition and defecation. 
(11) Not induced by external stimuli, nor can the course be influ- 
enced by interference. As to the latter, however, some attacks can be 
aborted by interference with the aura; when it occurs in one of the 
limbs, by constricting or manipulating it; swallowing a pinch of salt, 
startling the psyche, etc. 
(12) Manifestations uniform in successive attacks in the same indi- 
vidual, but different in different subjects. 
(13) Duration rarely more than 15 minutes; subsequent headache, 
somnolence, muscular fatigue, and amnesia. 
(14) Falls in convulsion whether observed or unobserved, even 
where conditions threaten life. 
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KEUROPSTGHTATBY IN' AVIATION MEDICINE 
(15) Epileptic character wholly different from the hysteric. 
(16) Characteristic mental deterioration in typical cases. 
(17) Never simulates any other form of disease. 
b. Hysteria.—(1) Reaction to a psychic excitement; psychic proc- 
esses are responsible for its excitation and further development. 
(2) Consciousness rarely completely lost. 
(3) No sudden involuntary falls, injuries, or bitten tongue, unless 
accidental or by way of demonstration. 
(4) Self injuries, when occurring, are intentional, but this does not 
preclude an accidental injury. 
(5) Often there is talking from time to time, or even crying or 
laughing. 
(6) Eyelids usually tightly closed (may be open), but may covertly 
open them and look around; if lids are forcibly separated, eyes will be 
found rolled upward. 
(7) No reflexes lost; ankle clonus may be present, Babinski never. 
(8) Face pale, unchanged, or suffused; never cyanosed. 
(9) No tonic-clonic stages; sometimes tonic rigidity throughout; 
more frequently a tumult of emotion. In general, movements of ex- 
pression coordinated in character. The patients pound, hammer, push, 
tread, often quite rhythmically. They struggle, toss the arms and legs 
about; opisthotonos; periods of rest, then more convulsions, biting of 
the lips, hands, bed clothing, bystanders, but not the tongue. Urination 
and defecation do not occur except intentionally. 
(10) Emotionalism arising either internally or because of external 
influences. Attacks are usually susceptible to external influences so 
that the physician may place himself in contact with the patient during 
the attack and influence the course of the individual phases. Attacks 
may be abruptly terminated by strenuous treatment. 
(11) Manifestations diversified and extravagant, and without uni- 
formity in successive attacks. 
(12) Attack may last for hours, and patient be surprisingly alert 
and well immediately afterward. Amnesia for attack very rare, but 
it may be claimed. 
(13) Tendency to pose, play a role, and incite sympathy causes him 
to stage a fit where there is an audience, not necessarily a conscious 
theatricalism. 
(14) Hysteric character wholly different from the epileptic. 
(15) Hysteria never leads to mental dullness. 
(16) Hysterics are great imitators and may simulate various forms 
with such perfection as to make detection extremely difficult. This is 
not necessarily conscious imitation. TM 8-325 
55 
MEDICAL DEPARTMENT 
Section XII 
SCHIZOPHRENIA (DEMENTIA PRAECOX) 
Paragraph 
General 55 
Etiology 56 
Pathology . 5f7 
General symptomatology 58 
Characteristic symptoms 59 
Types 60 
Course and prognosis 61 
Differential diagnosis 62 
55. General.—Schizophrenia has perhaps excited more interest 
and speculation than any other form of mental disease, largely be- 
cause it constitutes about 20 percent of first admissions to State 
hospitals and comprises about 60 percent of their population, 
a. The onset may occur at any time from late childhood to the 
late middle age although the most frequent age incidence is found 
to be during adolescence. This is readily explained, as at this time 
the most perplexing life problems, as sex, religion, vocational and 
social life are met with, and those inadequately equipped have the 
difficult task of successfully emerging from this period. 
b. To Kraepelin, in 1896, belongs the credit for separating this 
disease as a psychosis distinct from other allied forms of mental dis- 
order and giving it the name “dementia praecox.” Additional ex- 
perience with this psychosis has led to the conclusion that the title 
“dementia praecox” is somewhat misleading, as the term itself indi- 
cates a disturbance or change of tissue which may be either structural 
or toxic. Again, the term does not indicate the outcome of the 
disease as it does not always lead to dementia but to deterioration in 
interests and habits, and an unfavorable outcome or prognosis is not 
always the result. (Noyes.) 
c. Attacking the subject from the interpretative point of view, 
Bleuler introduced the term “schizophrenia,” as he considers a split- 
ting of the psyche the essential element, and its characteristic fea- 
tures to be due to a combination of psychic changes affecting the 
emotions, the will, and association of ideas, prominent among which 
is a dissociation of the affect, leading to withdrawal from contact 
and reality. It is an introversion psychosis and its roots are found 
in personality traits which are ordinarily manifest from early child- 
hood and show as a tendency to be seclusive with small capacity for 
becoming emanicipated from childish methods of reacting. 
88 NEUROPSYCHIATRY IN AVIATION MEDICINE 
TM 8—335 
56-57 
56. Etiology.—a. Schizophrenia develops in individuals probably 
predisposed constitutionally with a special personality make-up man- 
ifested by a personality disorganization occurring in response to the 
stresses of their life situations, the forms of which are determined in 
part by their innate psychological inadequacy, in part by their pro- 
gressively faulty responses and unhealthful habits of thinking and 
feeling, and in part by psychological events and experiences. These 
psychological events and experiences include emotionally determined 
complexes and mental conflicts; forces which have long tended to dis- 
organize personality. 
h. In accord with Noyes, schizophrenia is considered as a person- 
ality disorganization occurring in response to the stresses of life 
situations in individuals probably predisposed constitutionally with 
a special personality make-up. With this observation in mind, there 
remain other less fundamental factors that may precipitate or con- 
tribute to the development of this psychosis. These may be classed 
as the so-called exciting causes and include such factors as age, sex, 
physiological epochs, environmental conditions, climate, civilization, 
toxaemias, bodily diseases, head traumas, physical and mental ex- 
haustion, and emotional stresses. These are stresses common to all 
mankind. The mentally fit survive, while the mentally unfit make 
adjustments on levels increasingly lower until the stage of a definite 
psychosis is reached, depending upon the degree of constitutional 
defect and the severity of the precipitant. 
o. These contributing factors are peculiarly significant to the thera- 
peutist for they furnish valuable indications for bringing about an 
adjustment on a higher level than could otherwise be reached. These 
observations are predicated upon the assumption that an organism 
cannot function beyond its inherent capacity. 
d. One authority believed in an inherent lack of vitality in the 
fertilized ovum. Another authority believes there are associated 
organic changes in the brain, however he admits that his findings 
are not definite enough to make a diagnosis. Because of the close 
association with puberty, the puerperium and the climacteric, em- 
phasis has been laid on a possible toxic factor, probably some secre- 
tion of the gonads. Disturbances of acid-base equilibrium has also 
been accused, as has a decrease in the number of ganglion cells. 
57. Pathology.—a. There is no general agreement as to whether 
or not brain pathology is present. Lewis calls attention to the aplas- 
tic circulatory system and a polyglandular sclerosis of the endocrine 
glands seen in a large number of cases. Authorities have found 
products of nerve-cell degeneration within nerve cells, in the clear 
spaces around them, and especially in the pervascular spaces. Eos- TM 8-335 
57-58 
MEDICAL DEPARTMENT 
anoff, observing the relationship between cranial capacity and brain 
weight, has found close correlation between the degree of mental 
deterioration observed clinically and that of atrophy found at au- 
topsy in cases of schizophrenia; from this he has drawn the conclusion 
that “dementia praecox is associated in some way with changes in 
the brain which lead to atrophy.” Another authority has also ob- 
served, in cases of clinical deterioration, reduction in brain weight 
and, by careful microscopic measurements, thinning of the second, 
third, and fifth cortical layers, especially in the prefrontal region. 
h. Present day psychiatrists are of the opinion that there is no 
definite pathology that can be adequately ascribed as being the cause 
of schizophrenia. Noyes states that the causes must be found in 
complicated psychobiological forces such as intrapsychic conflicts, 
rejected demands of the instinctive urges, feelings of guilt, and other 
frustrated purposes usually found in individuals who easily give 
up the struggle with reality and find satisfaction in phantasy, hallu- 
cinations, and delusions. 
58. General symptomatology.—a. (1) Physical.— 
Circulatory appartus.—Vasomotor disorders causing edema, cyanosis 
of the extremities, and dermographia; localized sweating and 
dilated pupils are frequently present. 
Digestive system.—Anorexia, boulimia, indigestion, constipation, and 
disordered metabolism may be present. 
Motility.—Epileptiform and especially hysteriform attacks are fre- 
quently observed in the early stages. Contractures are as a rule 
the consequence of negativism. 
Tendon reflexes.—Usually exaggerated. 
Sensorium.—Often unilateral anaesthesia as in hysteria, 
(2) Mental.—The schizophrenic patient creates in the mind of the 
observer an impression peculiar, distinct, and radically different from 
that of any other psychosis. Constrained, cold, passive, apathetic, and 
indifferent; remote, inaccessible, introverted, shut in; sufficient unto 
himself, yet without insight; he is withdrawn from reality into an 
isolation baffling approach. 
Perception.—Inadequate and unclear. 
HdPiwGifnations.—Numerous and fleeting. In order of frequency, audi- 
tory, visual, haptic. Auditory most frequent at first, simple 
noises, then voices in quality disagreeable, disturbing, pleasant 
or nonsensical. 
Consciousness.—Clear, except in excited and stuporous states. 
Orientation.—Seldom disturbed. 
Content of thought.—Shallow, showing intellectual enfeeblement. 
90 imjiWyPSYXTHTATBY HT AVSATIOW MXDICENE 
TM 8-305 
56 
Delusions.—Fantastic, grotesque, changeable; at first, depressive; later, 
expansive and grandiose. In character may be hypochondri- 
acal, of sinfulness, persecutic influence, reference, exaltation, 
sexual matters, but never systematized. The delusions seem a 
contradiction of the emotional indifference. They ultimately 
fade as the mental activity decreases and the emotional indif- 
ference becomes more marked. 
Train of thought.—A looseness and desultoriness superficially resem- 
bling flight of ideas. The thought is incoherent. Ideas entirely 
disconnected are associated. Pass without any connection from 
one subject to another. No logical ordering of the train of 
thought. Retardation or difficult thinking, a slowness in the 
elaboration of ideas. 
Emotion.—Apathy, indifference, and lack of interest are among the 
earliest symptoms. There may be depression, sometimes alter- 
nating with exaltation. There is always in some degree emo- 
tional deterioration seen as lack of coordination between the 
intellectual and emotional reactions. Stransky calls this an 
“intrapsychic ataxia.” There is a peculiar emotional dullness 
with uncertainty and senselessness of emotional response. This 
uncertainty and senselessness show in either of two ways: as an 
inadequate reaction, the patient merely simpers or smiles when 
the occasion calls for hearty laughter; or as a contrasted re- 
action, he fatuously laughs when he should be sad. Emotions 
appear to dominate ideas. Patients are apt to cry with the eyes 
and laugh with the mouth. Stransky calls this “April weather 
behavior.” These are aptly called paradoxical emotional states. 
On the other hand, there may be emotional neutrality; no grief 
and no joy, total loss of sympathy, no delicacy of feeling, no 
shame. Patients seldom worry, for owing to inadequate per- 
ceptions, no emotions are aroused. 
M&mory.—Not commonly affected except in advanced cases in which 
it becomes poor for recent events, good for events antedating 
onset of disease. This failure of memory for recent events is 
due to enfeeblement of powers of attention, to aprosexia. 
Attention.—Failure of power of voluntary attention, there is marked 
indifference and lack of interest. Patients seem able to under- 
stand what is going on about them, without being able to show 
any real interest. 
Personality.—Splitting, molecular instead of massive as in hysteria; 
more a fragmentation. There is a peculiar destruction of 
the internal connections of the psychic personality, the effects 
showing especially in the emotional and volitional fields. 
91 TM 8-325 
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MEDICAL DEPARTMENT 
Volition.—Disappearance of voluntary activity. There is loss of 
incentive to normal behavior; the patient sits idly about, negli- 
gent of person, dress, and the demands of nature. 
Stereotypy of attitude.—Tends to maintain a particular, 
usually peculiar position. 
Stereotypy of movement.—Exhibits mannerisms, such as 
repetition of same movement, usually meaningless. 
Stereotypy of speech.—Manifests itself as verbigeration; the 
repetition of the same, usually senseless, words and phrases. 
Negativism.—Passive, active, and auto. 
Suggestibility.—Manifests itself as echolalia, echo- 
praxia, automatism, and flexibilitas cerea. 
b. The description in a above of the general symptomatology of 
schizophrenia suggests, in some respects, particularly on the volitional 
side, such absolute withdrawal from reality as to practically exclude 
awareness of the environment. Such a conclusion is erroneous, for 
an extremely negativistic subject will often surprise attendants and 
physicians by recalling occurrences that took place when, according 
to the most competent observers, his withdrawal from reality seemed 
so absolute as to preclude the possibility of noting occurrences about 
him. 
59. Characteristic symptoms.—These symptoms consist of emo- 
tional and intellectual deterioration, splitting of the personality, 
grotesque and changeable delusions, introversion, indifference, inac- 
cessibility, lack of insight, disappearance of voluntary activity, stereo- 
typy, negativism, and suggestibility. 
60. Types.—The schizophrenic group has been subdivided into 
five smaller groups; heboidophrenia or the simple type, hebephrenia, 
catatonia, paranoid forms, and mixed forms. Each differs in the 
grouping, prominence, and course of the fundamental symptoms, but 
it should be borne in mind that transition from one form to another 
and intermingling of forms are very common. Clinical experience 
continually demonstrates the artificiality of these groupings and the 
impractibility, in numerous cases, of making sharply drawn differ- 
entiations. 
a. Heboidophrenia or the simple type.—This is an impoverishment 
and devastation of the whole psychic life, developing insidiously as a 
deterioration, with few if any of the symptoms abundant in other 
forms. The boy or girl hitherto apparently normal, begins to show 
lack of interest, seclusiveness, listlessness, and failing ability to ac- 
quire knowledge. There may be fleeting hallucinations, transitory 
delusions, and slight peculiarities of conduct, such as scarcely notice- 
able mannerisms or suggestions of negativism. These are the cases so 
92 Tiff 8-325 
60 
NBXJEOPSYOHIATBY IN AVIATION MEDICINE 
mild as to be unrecognized, or in which the so-called recovery is an 
adjustment on a lower level with a residuum of peculiarities construed 
to be inherent character anomalies. Could the history of many a 
criminal, hobo, prostitute, crank, and eccentric be traced, there would 
he disclosed an episode of schizophrenic coloring which separated a 
period of relative efficiency from a following period of relative in- 
efficiency. It would be seen there had been inability to adjust to the 
ordinary social requirements, that responsibilities had been evaded, 
and refuge found on a lower level. On the contrary, many heboido- 
phrenics stop short of regression to so low a level, and adjust themselves 
after a fashion in some humbler calling, where with the simplest duties 
and slightest responsibilities they manage to earn a livelihood. While 
in these cases recovery may he said to he final, it is nevertheless in- 
completef, and a hlight rests thereafter upon the whole of the psychic 
life. Numerous other cases, however, withdraw more and more from 
reality and finally regress to those lowest of all praecox levels, those 
graver forms requiring institutional care. In the heboidophrenic, 
there is neither clouding of consciousness nor disorientation. But the 
mental activity diminishes, there is emotional deterioration and gen- 
eral apathy, memory and attention defect, and decreased psychomotor 
activity with lack of insight dominating the clinical picture. 
h. Hebephrenia.—The onset of this type is usually more abrupt. 
Hallucinations are numerous and fleeting, involving especially the 
auditory and visual fields. Consciousness may show little clouding, 
and orientation be only slightly disturbed. Delusions are fantastic 
and changeable, apt to be disagreeable, and from being depressive 
become expansive in character. In the train of thought, there is a 
looseness and desultoriness superficially resembling flight of ideas. In 
conduct and behavior, there is childish silliness and senseless laughter. 
Silly laughter, with complaint of feeling sad, is a very characteristic 
symptom. The voluntary activity is inconsistent and lacks independ- 
ence ; at one moment the patient is headstrong, at the next, tractable. 
The personal appearance is neglected and all sorts of foolish and 
outlandish deeds performed; or the time frittered away in listlessly 
lounging about without evidence of real interest in anything. There 
is some stereotypy of attitude, movement, and speech. The latter 
abounds in stilted phrases, stale witticisms, obsolete words, and neo- 
logisms. Letter writing is characterized by frequent repetitions, lack 
or superfluity of punctuation, and copious underlining. 
Memory for recent events decreases as the power of attention 
diminishes; and for remote events also, in proportion, as the increas- 
ing mental deterioration more and more erases memory pictures. TM 8-325 
60 
MEDICAL. DEPARTMENT 
Aprosexia is characteristic. This enfeeblement of the power of 
voluntary attention is an outstanding feature of schizophrenia. 
0. Catatonia.—In this form, volitional disturbances predominate. 
The onset is usually subacute or chronic but it may be very sudden, 
the patient becoming either profoundly stuporous or greatly excited. 
The typical symptoms group themselves into two stages, catatonic 
stupor and catatonic excitement, which irregularly alternate. 
(1) Catatonic stupor.—The principal symptoms are stupor, stereo- 
typy, negativism, and suggestibility. Stupor, in the sense her© 
implied, does not signify a profound disorder of consciousness. The 
patients seem to know what is going on about them (they may be 
observed furtively noting occurrences), and the immobility is merely 
a form of negativism. Voluntary activity decreases to the vanishing 
point and stupor is manifested by lying perfectly still without move- 
ment or reaction to stimuli, and remaining absolutely mute. In many 
cases, however, the patient can observe, remember, and carry out 
complicated trains of thought if provided with the necessary stimulus. 
Negativism is shown in its three forms; doing nothing, the opposite 
of what told to do, or as negativistic opposition to physiological 
promptings. Stereotypy occurs as attitudinizing, mannerisms, and 
verbigeration. Suggestibility shows as reaction in accordance with 
impressions or suggestions derived from others. There may be repe- 
tition of words or phrases used by others (echolalia); repetition of 
the actions of others (echopraxia) ; a condition permitting molding 
of the limbs in any position (flexibilitas cerea); or reaction devoid of 
all personal initiative (automatism). 
Perhaps behavior so utterly foreign to the normal individual is 
atavistic; regression toward those distant race beginnings when rea- 
son but glimmered and blind instinct ruled. 
(2) Catatonic excitement.—In this phase, increased psychomotor 
activity predominates. Marked cases are constantly talking, shout- 
ing, and throwing themselves about on the bed. The actions, how- 
ever, tend toward absurdity and are without purposeful direction. 
Nor is the noisy, incoherent talk to be mistaken for flight of ideas; 
there is no suggestion of a goal or idea, and the element of distract- 
ibility does not enter because little or no attention is paid to what is 
being said or done by others. Impulsive acts are common. Without 
warning, patients commit some violence, as tearing clothing, breaking 
a window, or assaulting another patient. In catatonia there is some 
clouding of consciousness and disturbance of orientation in phases of 
marked stupor or marked excitement. The delusions are fantastic 
and changeable. Thought is loose and desultory and reasoning diffi- TM 8—325 
60 
INTBOTBOTSTOHTATKY I*T AVIATION MEDTOTN* 
cult. Memory for the remote past remains surprisingly good. In 
emotional attitude these patients are at first sad, dejected, and com- 
plaining; later they become indifferent and contented; still later 
cheerful and even ecstatic. Catatonic excitement bears a superficial 
resemblance to the manic phase of manic-depressive psychosis. The 
two conditions, however, differ in important particulars. The an- 
swers of catatonic patients are absolutely irrelevant, but insistence 
will usually cause the manic to give momentary heed and a rational 
reply. The increased psychomotor activity of catatonia is more apt 
to be static; that is, he remains in the same place and the motor 
activity involves chiefly small joint movements; in the manic the 
activity is more apt to be dynamic, that is, large joint movements also 
come into play and he moves from place to place. Again, the move- 
ments of the catatonic are sudden, impulsive, violent, and restless, 
and the destructiveness seems merely a desire to be objectionable; it 
is a form of negativism. The motor excitement of the manic is less 
apt to show these interruptions; it is continuous, and the destruc- 
tiveness instead of seeming intentional, merely expresses complete 
loss of control. Physical symptoms are more pronounced in catatonia 
than in any other form. There may be hippus, mydriasis, the phe- 
nomenon of Pilz, and differences in size of pupils. Tendon reflexes 
are usually exaggerated, cutaneous sensibility lowered, and vaso- 
motor disturbances common. Loss of weight is common in the active 
stages. 
d. Paranoid forme.—In both the hebephrenic and catatonic forms, 
delusions are characteristic but grotesque and changeable, of no par- 
ticular type, and tend to ultimately fade. They are not persistent. 
On the other hand, the paranoid forms are characterized by the rapid 
development of fantastic and changeable delusions of the persecutory 
and expansive type, but not harmonized with events nor coherently 
developed. They are, however, persistent. Associated with this is 
a total lack of insight; that is, no appreciation of the abnormality of 
the condition nor attempt at explanation. The emotional attitude is 
changeable in harmony with the delusional content. Usually, also, 
there are hallucinations, chiefly auditory in character, although they 
may involve any sensory field. 
&. Mixed forms.—The several forms described are not always clean 
cut. Mixed forms are very common. The heboidophrenic, hebe- 
phrenic, and paranoid forms often present symptoms that are more 
characteristically developed in the catatonic forms. 
/. Unrecorded and unclassified cases.—Without doubt numerous 
cases of schizophrenia are never recorded. Either they are undiag- 
nosed, or are mild in type and make an adjustment on a lower level, 
95 TM 8-325 
60-61 
MEDTCLAL DEPARTMENT 
earning a livelihood in some humble calling under supervision; or 
they regress to the still lower level of the hobo, prostitute, or petty 
criminal. Many a dull, listless, odd, or wayward boy or girl with a 
poor school and vocational record is an undiagnosed schizophrenia. 
Numerous bright and highly regarded students who suddenly lapse in 
their work, become mediocre and unaccountably change, never again 
displaying the former intelligence and interest, and remaining con- 
tent with a performance utterly belying the earlier promise. It is 
also a matter of ordinary clinical experience to meet with cases seem- 
ingly able to earn a living after a fashion but none the less bearing 
indelibly the stamp of the disease, although without an aggregate of 
manifestations permitting definite classification in any one of the 
different forms. 
61. Course and prognosis.—a. Schizophrenia is no longer con- 
sidered to result in a permanent disorganization of the personality. 
This was formerly considered to be the rule, and also as part of the 
requirements of the definition of schizophrenia, and a favorable out- 
come merely showed that a mistake had been made in diagnosis. 
Recovery does not always indicate that the personality will assume 
its prepsychotic integrity and level. The episodes may be remissions. 
No doubt the psychosis leaves its marks on personality, a trauma to 
the conscious which will leave its scar as will traumata to organic 
structure, but a social recovery is frequent with the individual doubt- 
less less poorly endowed. Prognosis falls into three groups: first, 
those in which complete recovery is made; second and more frequently, 
those in whom periods of adjustment occur at a lower level for a con- 
siderable period of time; and the third group, which is the largest 
group, in which are f oimd those who suffer permanent disorganization 
of the personality resulting in mental deterioration. 
b. It is difficult to prognosticate what the final outcome will be 
in any given case of schizophrenia. However, there are certain 
facts which may act as guides in the formation of an opinion. It 
has been found that the more introverted the prepsychotic history 
the worse the prognosis. If we find the psychosis to be a gradual 
revolution of the previous personality, the prognosis is unfavorable. 
The more rapid the onset and the more acute the symptoms, the 
more probable is the occurrence of intermissions and remissions, 
although deterioration does occur following an acute attack. If 
the psychosis has been precipitated by environmental factors which 
can be remedied, the outcome is favorable. If there is found a marked 
affective element the outcome is favorable. If hallucinations persist, 
the outcome is unfavorable. If the psychosis has persisted more than JTErUIlOPSY<3HTATRY IN' AVIATION MEDICINE 
TM 8-325 
61-63 
a year, the outcome is again unfavorable. Previous remissions indi- 
cate that the episode will be followed by improvement. 
c. As to prognosis in the different types, the prognosis in catatonia 
is relatively good; perhaps 25 percent are restored to their prepsycho- 
tic level for varying periods of time. The prognosis of the simple 
form is bad, though these do not necessarily require institutional care. 
They are found touring the country as petty criminals and hobos. 
The hebephrenic type usually continues on to a final disorganization 
of the personality, although in some cases remissions do occur. Oc- 
casionally the paranoid type makes a social recovery, but complete 
recovery in this type is doubtful. But, as Bleuler states, “The treat- 
ment undoubtedly is the governing factor as to prognosis. The treat- 
ment will decide in more than one-third of schizophrenic cases 
whether they can become social men again or not.” 
62. Differential diagnosis.—a. The prodromal stage of heboido- 
phrenia and hebephrenia must be differentiated from neurasthenia. 
(1) Heboidophrenia and hebephrenia.—Sixty percent of cases 
occur before the twenty-fifth year. Grotesque and changeable de- 
lusions. Emotional apathy and indifference concerning symptoms. 
Lack of insight. Conduct disorders of a bizarre nature; mentally ill 
though not necessarily in a certifiable sense. Little or no improve- 
ment under appropriate treatment. 
(2) Neurasthenia.—Most cases occur between the twenty-fifth and 
forty-fifth years, rarely before 20 or after 50. No delusions. Over- 
emotional and intensely interested in symptoms. Introspective 
without insight. It is essentially a fatigue neurosis. Probability of 
improvement with appropriate treatment. 
b. Paranoid forms from pure paranoia. 
(1) Paranoid forms.—Rapid development of fantastic and change- 
able delusions of persecutory and expansive types, not harmonized 
with events nor woven into a coherent whole, but tending to persist. 
Lack of insight, inability to explain condition and conduct. Emo- 
tional attitude changeable and demeanor abnormal. 
(2) True paranoia..—Insidious development of delusions of perse- 
cution largely based on morbid interpretations of actual events, 
woven into a coherent whole, and very persistent. Contradictions 
and improbabilities in the fabric of the delusional system appre- 
hended and explained. Many exhibit such formally correct conduct 
and adequate emotional reactions as to more or less mask the true 
condition, so that when finally the delusional formation no longer 
gathers new material and loses much of the old, they are merely 
considered less odd and peculiar than formerly. Many others, how- 
474758*—41 T TM 8-325 
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MEDICAL DEPARTMENT 
ever, become so abnormal in conduct and behavior as to be definitely 
asocial and to require institutional care. 
c. Schizophrenia of middle life from paresis. Paresis may be estab- 
lished by examination of the blood and spinal fluid. In paresis, the 
mental deterioration is apt to be more rapid and profound. However, 
the diagnosis may be extremely difficult in those cases in which 
physical symptoms of paresis have not yet appeared. 
d. Schizophrenia from manic-depressive psychosis. This is prob- 
ably the most difficult differential diagnosis to make which is in part 
due to the fact that mixtures of the schizoid and cycloid types are 
found in individuals. However, the onset of schizophrenia is more 
insidious, the excitement more paroxysmal, the delusions more bizarre 
and the patient less distressed by them. Further, there is no harmony 
between the emotions, ideational content, and the behavior. 
Section XIII 
MANIC-DEPRESSIVE PSYCHOSIS 
Paragraph 
History —— 63 
Definition 64 
Frequency 65 
Time of life and sex 66 
Etiology 67 
General symptomatology 68 
Onset, course, duration, and remissions 69 
Prognosis 70 
Pathology 71 
Differential diagnosis 72 
Summary and interpretation 73 
63. History.—a. Mania and melancholia were described in the 
Hippocratic era; somewhat later by Celcus, Galen, Sydenham, and 
Morgagni; and more recently by Fleming, Ealret, Kahlbaum, Sankey, 
Sclmle, Ziehen, and various others, including Kraepelin. These in- 
dustrious classifiers have described over 50 varieties of mania, and 
about 30 of melancholia. 
b. Often there had been mentioned some relation between the dis- 
orders, but Kraepelin demonstrated, between 1896 and 1899, the very 
frequent occurrence of these contrasted disorders in the same indi- 
vidual, showed the conditions to be one and the same disease entity, 
and named the disorder “manic- depressive psychosis.” While it had 
been recognized that the manias and melancholias together with cer- 
tain seemingly allied conditions appeared to represent diverging 
forms of disturbance, on the one hand emotional and in a sense re- 
coverable, on the other, deteriorating and unrecoverable, Kraepelin 
98 TM 8-325 
63-65 
NEUROPSYCHIATRY IN AVIATION MEDICINE 
with one authoritative pronouncement cleared the situation by naming 
the former “manic-depressive psychosis” and the latter, “dementia 
praecox.” When in 1899 Kraepelin placed the manias and melan- 
cholias of other writers in his manic-depressive group, he continued to 
regard involutional melancholia as a distinct disease entity and as set 
apart from other melancholias by the age incidence (presenile 
period), absence of previous attacks, anxious depressions, sense of 
impending danger, delusions of sinfulness, greater frequency of 
suicidal impulses, and the comparatively unfavorable prognosis. Be- 
sides these considerations, there was the uncertain factor of the 
influence of arteriosclerotic changes. 
o. In 1907, Dreyfus, then an assistant of Kraepelin, published the 
results of an elaborate study of 79 cases previously diagnosed as in- 
volutional melancholia at the Heidelberg clinic. Because two-thirds 
of these made complete or nearly complete recoveries, only 8 percent 
showed mental deterioration and more than half had had -previous 
attacks (usually depressions); he concluded all could be explained on 
the basis of manic-depressive psychosis, chiefly mixed type. In his 
introduction to this book, Kraepelin accepted these views and has 
maintained them in subsequent writings. 
d. Many leading psychiatrists accept this conclusion but others dis- 
sent, so that opinion remains divided. The statistical committee of the 
American Psychiatric Association, while holding the matter under 
consideration, decided for the present to retain involutional melan- 
cholia in its classification as a separate entity and it will be so treated in 
this manual. 
64. Definition.—Manic-depressive psychosis is a disorder, appar- 
ently not ending in mental deterioration but characterized by the 
recurrence of groups of reactions, essentially emotional, throughout 
the life of the individual. Mental deterioration may occur in atypical 
forms in which the attacks are so close together as to practically exclude 
normal life. The manic phase illustrates the extroversion type of 
reaction. 
65. Frequency.—The psychosis furnishes about 15 percent of all 
admissions to mental hospitals. Of 70,987 first admissions to 48 hos- 
pitals in 16 states, there were 12,152 manic-depressives or a trifle over 
15 percent. About 8,000 new cases are admitted to public mental 
hospitals yearly. The type incidence was as follows: 
this manual. 
reaction. 
Type: Number Percentage 
Manic * 5, 480 45. 09 
Depressive 4, 676 38. 47 
Mixed 1, 312 10. 79 
Circular 348 2.87 TK 8-325 
66-68 
MEDTOAL DEPARTMENT 
66. Time of life and sex.—Sixty percent of the cases develop 
before the twenty-fifth year and less than 10 percent after the fortieth; 
but the first attack may occur as early as the tenth or as late as the 
seventieth year. With sucli late occurrence, there must always arise 
the question of unrecorded previous attacks. Two-thirds of the cases 
occur in women, and in many instances the first attack coincides with 
the first menstruation or with the first childbearing, recurrence being 
associated with subsequent childbearing periods. It is a fact, however, 
that in many of these instances recurrences do not cease with the 
climacterium. 
67. Etiology.—The cause of the manic-depressive psychosis is at 
present unknown. Psychobiological and psychogenic factors and 
forces are involved. Many theories have been suggested which involve 
metabolic, endocrine, and other physiological disturbances. Also no 
histological, biochemical, or biophysical disturbances have ever been 
demonstrated in the brain. There is a personality make-up of irritabil- 
ity and instability with proneness to excitements and depressions with- 
out adequate cause. On such a predisposing background, any exciting 
factor, one perhaps not unduly disturbing to the normal individual, is 
sufficient to produce psychotic disturbance. A familiar psychoneurotic 
or psychopathic taint has been shown to exist in from 75 to 90 percent 
of cases. 
68. General symptomatology.—Manic-depressive psychosis is 
essentially an affective disorder. It is strikingly characterized by 
emotional oscillations with subsidences and recurrences. The symp- 
toms broadly express qualitative disturbances of the normal mental 
processes and their effects either in increased psychogenic activity 
(mania), decreased psychogenic activity (depression), or fusion of 
the components of mania and depression in the same patient (mixed 
type). In the manic phase there is exaltation of emotional tone with 
rapidity of thought and action; in the depressive stage, depression of 
emotional tone with retardation of thought and action; and in the 
mixed types, fusion of these fluid components; in each instance in 
varying degree with respect to an hypothetical emotional normal. 
The attempted adjustments of the manic-depressive, therefore, differ 
in degree only from those of normal individuals. The disorder mani- 
fests itself in three principal phases; manic, depressive, and mixed. 
In addition, there occur other manifestations such as recurrent manic, 
recurrent depressive, alternating manic and depressive, alternating 
double phase, circular, and various other forms. 
cl Manic 'phase.—This phase exhibits three degrees of fluctuation 
above the hypothetical normal reaction tone level, that is, three de- 
grees of mania; hypomania, acute mania, and hyperacute mania, each 
100 TM 8-325 
68 
NETJBOPSYOHTATRY IN AVIATION MEDICINE 
presenting in proportional or disproportional degrees of severity, 
three cardinal symptoms; flight of ideas, emotional excitement, and 
increased, psychomotor activity. These three degrees of manic may 
be diagrammatically illustrated as follows: 
Base line—normal. 
1 —hypomania. 
2 —acute mania. 
3 —hyperacute mania. 
As the mania mounts, the three cardinal symptoms augment in severity, 
but not necessarily in proportionate degree. 
(1) Hypomcmia.—This is the mildest of the three grades of manic 
excitement. There is no clouding of consciousness nor is the patient 
disorientated but there is clear manifestation of the three cardinal 
symptoms; flight of ideas, emotional excitement, and increased psycho- 
motor activity. The typical patient rises early, bustles noisily about 
from one matter to another, showing great good humor or flying into a 
rage if thwarted, exhibiting throughout the unproductive day a maxi- 
mum of effort and minimum of accomplishment. These patients char- 
acteristically show increased busyness, but decreased capacity for 
accomplishing worth-while things. They do unnecessary and foolish 
things. 
(2) Acute mania.—This is the second grade of manic excitement. 
There may be some clouding of consciousness and some disorientation, 
with fleeting hallucinations and changeable delusions of a grandiose 
nature. Flight of ideas with distractibility is so marked that the 
train of thought may become incoherent and dwindle to strings of 
words, merely similar in sound (clang-association). Emotional excite- 
ment and exaltation is shown by boisterous laughter and exaggerated 
ideas of self-esteem and personal prowess. The increased psychomotor 
activity is constant. The patient seems absolutely unable to keep 
quiet (pressure of activity); he runs, jumps, somersaults, tears his 
clothing, breaks furniture, howls and yells the night long, does not even 
take time to eat, and frequently shows extreme sexual excitement. 
(3) Hyperacute mania.—This is the severest grade of manic excite- 
ment and is merely an aggravated form of acute mania (a deliri- 
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MEIDTCIAL DEPARTMENT 
ous mania). Consciousness is more clouded, disorientation more com- 
plete, flight of ideas so great as to reach incoherence, emotional excite- 
ment intense, and psychomotor activity unremitting, a condition 
inevitably leading to great exhaustion and physical depletion. 
h. Depressive phase.—This phase exhibits three degrees of fluctua- 
tion below the hypothetical normal reaction tone level, that is, three 
degrees of depressions; simple retardation, acute depression, and stu- 
porous depression, each presenting in proportionate or dispropor- 
tionate degrees of severity three cardinal symptoms, each the opposite 
of the corresponding cardinal symptom of the manic phase; retarda- 
tion, emotional depression, and decreased psychomotor activity. These 
three degrees of depression may be diagrammatically illustrated as 
follows; 
Base line—normal. 
1 —simple retardation. 
2 —acute depression. 
S —stuporous depression. 
As the depression deepens, the three cardinal symptoms deepen in 
severity but not necessarily in proportionate degree. 
(1) Simple retardation.—This is the mildest grade of depression. 
Consciousness is not clouded nor orientation disturbed. Retardation, 
or difficulty in thinking, is expressed by the patient answering in 
monosyllables, slowly and in a low tone, or j ust above a whisper. Emo- 
tionally he is depressed, but not to a marked degree, the facial expres- 
sion perhaps not even indicating it. Decreased psychomotor activity 
is shown by moving slowly, speaking slowly, abandonment of volun- 
tary effort, and sitting about with folded hands, doing nothing. 
(2) Acute depression.—This is the second and severer grade of 
depression, with the three cardinal symptoms more pronounced but 
with consciousness usually clear and the patient fully oriented. Hal- 
lucinations of the organic sensations and self-accusatory delusions 
with hypochondriacal ideas are the rule. Delusions are less frequent 
in acute and hyperacute mania because the racing thought moves too 
rapidly for their formation. Emotional depression is profound and 
indicated by an attitude of extreme dejection; the position is one of 
flexion with hands limp in lap, chin on breast, and shoulders bent 
forward, suggesting regression to situation, simulating that in utero. 
Retardation, including both difficulty in thinking and decreased 
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KBUm>PSY€HXATRY IN AVIATION MEDIGENE 
psychomotor activity, is shown by the almost inaudible, slow, mono- 
syllable speech and very slow deliberate movements. 
(3) Stuporous depression.—This is the third and most severe grade 
of depression. Consciousness is considerably clouded and orientation 
much disturbed. Dreadful hallucinations and delusions harass the 
patient, and all the symptoms of the phase of acute depression obtain 
in aggravated form. The patient does not even speak, but lies in bed 
absolutely inert, requiring to be fed and administered to in every 
way. 
g. Mixed types.— (1) Mixed and atypical forms are of special im- 
portance because they occupy a middle ground between the classical 
manic-depressive types and the schizophrenic. In the mixed types, 
the three cardinal symptoms of the manic and depressive phases are 
so intermingled that the resulting state is neither the one nor the 
other, but a mixture of the two. The following mixed types are 
recognized; 
(a) Manic stupor.—Emotional exaltation, decreased psychomotor 
activity, difficulty of thinking. 
(fb) Agitated degression.—Emotional depression, increased psy- 
chomotor activity, flight of ideas. 
(c) Unproductive mania.—Emotional exaltation, increased psycho- 
motor activity, difficulty of thinking. 
(6?) Depressive mania.—Emotional depression, difficulty of think- 
ing, increased psychomotor activity. 
(e) Depresssion with -flight of ideas.—Emotional depression, flight 
of ideas, decreased psychomotor activity. 
(/) Akinetic mania.—Emotional exaltation, flight of ideas, de- 
creased psychomotor activity. 
(2) So protean, however, are the manifestations that the above 
classifications by no means exhaust the possibilities. Additional 
combinations occur. Some of the combinations of the manic and 
depressive phases and quiescent periods are as follows: 
(a) Recurrent mania.—Here there are recurrent attacks of manic 
phases separated by quiescent periods. 
(b) Recurrent depression.—Here there are recurrent attacks of 
depressive phases separated by quiescent periods. 
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MESDTOAIi DEPARTMENT 
(e) Alternating forms.—Here there are manic and depressive 
phases, each followed by a quiescent period. 
(d) Alternating double phase.—Here there are cycles of mania and 
depression, each followed by a quiescent period. 
(8) Still other types have been described, inasmuch as the manic 
and depressive phases may be variously combined. 
69. Onset, course, duration, and remissions.—a. There may 
be a prodromal period extending over days, weeks, months, or even 
years; or the condition may develop very suddenly. In the latter 
instance, however, there may have been prodromal indications which 
escaped observation. Statistics show that the first attack is apt to 
be a depressive phase. 
&. The course presents manifold variations; in many cases the lack 
of uniformity is so marked and the diversity of manifestations so 
great, that doubt arises as to the form occurring. 
c. The duration also is subject to wide fluctuations. It may last 
only a few days, weeks, months, or years, even 10, 20, or more. A 
single phase has lasted 20 years. 
d. Remissions may be of any duration, ranging from hours or days 
to many years. There is a record of a remission lasting 44 years. 
Or there may be but one attack in a lifetime. However, in such an 
instance, there may have been unrecorded mild attacks. 
70. Prognosis.—Recovery from single attacks is the rule, but 
recurrence is quite certain. Prognosis is therefore good concerning 
separate attacks, but unfavorable as to ultimate recovery. Recovery 
is only so-called, merely an adjustment on the background which 
perhaps is in reality the disorder itself. Noyes presents some inter- 
esting figures as to course and prognosis. In the 8,000 manic-de- 
pressive cases admitted or readmitted to New York State hospitals, 
there were no readmissions in more than half of that number. The 
most frequent age for the first manic episode was between the ages 
of 15 and 25. The average age for the first depressive episode was 
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NEDEOPSYCHIATEY IN AVIATION MEDICINE 
found to be about 10 years later, or 26 to 85. If either episode was 
found to occur in early life, the prognosis was bad. As age increased, 
the tendency was more to depressive episodes. The average duration 
of the manic episode was 6 months, and of the depressive 9 months, 
also as age increased, the psychotic periods tended to become longer 
and the normal intervals shorter. 
71. Pathology.—There is no demonstrable pathological anatomy. 
72. Differential diagnosis.—The mixed and atypical forms 
occupy a middle ground between the classical manic-depressive types 
and schizophrenic reactions, so the diagnosis may be extremely 
difficult. 
cl The manic phase is differentiated from catatonic excitement as 
follows: The answers of catatonic patients are absolutely irrelevant, 
but insistence will usually cause the manic to give momentary heed 
and a rational reply. The increased psychomotor activity of the 
catatonic is more apt to be static, that is, he remains in the same 
place and the motor activity involves chiefly small joint movements; 
in the manic, the activity is more apt to be dynamic, that is, large 
joint movements also come into play and he moves from place to 
place. The movements of the catatonic are sudden, impulsive, vio- 
lent, restless, and the destructiveness seems merely a desire to be 
objectionable; it is a form of negativism. The motor excitement of 
the manic is less apt to show these interruptions; it is continuous 
and the destructiveness, instead of appearing intentional, merely 
suggests complete loss of control. 
b. The depressive phase of manic-depressive psychosis presents 
fluctuating cardinal symptoms and absence of mental deterioration, 
with usually a history of previous attacks; the stuporous stage of 
catatonia the so-called stupor, with stereotypy, negativism, sugges- 
tibility, and mental deterioration. 
73. Summary and interpretation.—Manic-depressive psychosis 
is extroversion reaction. The patient endeavors to solve his conflict 
by a flight into reality, by extroversion. This flight is the manic 
phase, during which he seems to be at the mercy of his environment, 
attention being diverted by every passing stimulus. The stream of 
diverting activities is a defense mechanism and the effort to cover 
every possible approach to the complex by rushing wildly from every 
danger of disclosure. In the depressive phase, the defense mech- 
anism breaks down and the patient is overwhelmed by his conflict. 
The flight of the manic phase is a lesser failure than the submission 
of the depressive, but is still a failure. The psychosis reveals not as 
much the nature of the conflict as the manner of dealing with it% The 
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MEDICAL DEPARTMENT 
benign character of the manic-depressive group is explained on the 
ground of their extroverted mechanism. Reality is the normal direc- 
tion for the libido, and because the direction is normal, they more 
readily tend toward recovery. Viewing the disorder as issuing from 
a background of predisposing psychopathic inability to cope with 
reality, certain of the phases may be interpreted somewhat as follows: 
The manic, as an attempt to conceal the complex by a diverting 
stream of activity; the depressive, as open confession of failure by 
abandonment of effort; the intermingling of symptoms in the mixed, 
as an increased futility of effort; the alternating and circulating as 
oscillations between flight and defeat; the atypical, as psychic rout; 
and the remissions, adjustments at best precarious because of the 
continuing psychopathic predisposition. The admitted background 
may be considered as the disorder itself, and the manifestation as 
grades of disturbance ranging from mild exaggeration of the indi- 
vidual normal reaction type to the asocial extreme. 
Section XIV 
INVOLUTIONAL MELANCHOLIA 
Paragraph 
General 74 
Symptomatology 75 
Prognosis 76 
Differential Diagnosis 77 
Treatment 78 
74. General.—a. Much controversy exists concerning whether or 
not involutional melancholia should be considered a clinical entity. 
Kraepelin first introduced involutional melancholia as an entity dis- 
tinguishable from the depressive phase of manic-depressive psy- 
chosis. It seems that Kraepelin has changed his opinion and now 
agrees that involutional melancholia is to be regarded as manic- 
depressive psychosis of late occurrence. However, it is believed with 
Noyes that there are special physiological and psychological factors 
of such dynamic importance and so peculiar to that period of the indi- 
vidual’s life during which this mental disturbance occurs that sep- 
arate consideration is justified. 
b. As the name implies, this disease occurs during the involutional 
period of life and as such is found most frequently in women during 
the late forties and in men during the late fifties. The Chinese have 
a proverb in which they state that the productive period as to age 
is seven times seven in women and eight times eight in men. During 
this period, the endocrine and reproductive glands are suffering a 
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NBURO PSYCHIATRY IN AVIATION MEDICINE 
decrease in functional activity with concomitant changes in the chem- 
ical, metabolic, and vegetative activities of the body. 
c. It is difficult to determine how much etiological value to place on 
these physiological changes, but as the soma and psyche are consid- 
ered as one, the conclusion is that they are important. The pre- 
psychotic history is again of importance, as in a large number of 
cases there seems to be found a certain general type of personality 
make-up. It will be found that this type of personality is the inhib- 
ited type of individual, the overconscientious with a lack of humor, 
the plodder, the ideal servant, the morbidly disposed. Women seem 
more inclined to the disease than men. Life has not brought to these 
individuals the success and happiness that they have consciously or 
unconsciously striven for, and now at the turning point of life they 
realize that it is too late to achieve new successes or ambitions and the 
transition to another stage of life is not easily made. 
d. The ebbing potency in the male, as Noyes states it, and the 
realization on the part of the female that she cannot now bear chil- 
dren, which she probably has intentionally kept from doing in her 
early life, is to the patient more than the loss of these functions; 
it is a symbol, a sense of failure that both the sources and ends of 
energy have failed. Humans lay special stress on the reproductive 
organs as being the source and criterion of manly and womanly 
strength, and physiologically such is the case. To the extent this 
instinctive urge or striving influences the individual, on the proper 
background, determines the reaction at the menopausal age. As 
physical strength decreases, old conflicts and complexes become 
stronger. Retiring from business or from the military service, or 
breaking up home ties are means of precipitating this psychosis. It 
may be regarded as the morbid expression of the feeling of growing 
inadequacy, and those who are morbidly disposed by nature become 
melancholic most easily, and women seem mare inclined to the disease 
than men. 
75. Symptomatology.—The characteristic feature of this disease 
is an apprehensive depression with delusions of sinfulness (an un- 
pardonable sin), often merging into a definite anxiety state (anxiety 
neuroses are common at this period). The manifestations range from 
a profound depression through an agitated melancholia to a confused 
state, according as there is an intense apprehensive depression, a 
similar condition with agitation, or an exaggeration of these symp- 
toms reaching confusion with clouding of consciousness, hallucina- 
tions, and disorientation. In addition to delusions of sinfulness, there 
may be those of an hypochondriacal nature; of persecution; of 
poverty, of possession; or of grandeur. It should always be remem- 
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MEDICAL, DEPARTMENT 
bered that the danger from suicide is greater in this psychosis than 
in any other. Every case of melancholia is a potential suicide. 
76. Prognosis.—Forty percent of patients recover from this dis- 
ease, although they are frequently ill for 2 or 3 years. The prognosis 
naturally depends on the extent of the melancholia and the extent of 
deterioration of personal habits. 
77. Differential diagnosis.—In differential diagnosis, manic- 
depressive psychosis, cerebral arteriosclerosis, and the anxiety states 
seen in the psychoneuroses must be considered. The age factor should 
first be given consideration between manic-depressive psychosis and 
involutional melancholia, as the latter need not be considered unless 
the age factor is favorable. Also in manic-depressive psychosis, there 
is usually a history of previous attacks and there is not the fear and 
apprehensive depression noted in melancholia. In differentiating 
cerebral arteriosclerosis, there is usually a memory loss in this disease, 
and a lessening of initiative. 
Fear is not present in the psychoneuroses as in melancholia. They 
have no delusions or hallucinations and their interest in the outside 
world is maintained, while in melancholia the relations with reality 
is disturbed. 
78. Treatment.—Treatment first involves the taking of every 
precaution to prevent suicide. The general physical upbuilding is 
important together with intelligent nursing and occasionally a drug 
to relieve agitation. 
Section XV 
Paragraph 
General * 79 
Types 80 
Stages 81 
Diagnosis 82 
Differential diagnosis 83 
Prognosis 84 
Treatment 85 
PARANOIA 
79. General.—a. Paranoia of itself is not important from a statis- 
tical standpoint, for true Kraepelinian paranoia, as Noyes states, is 
much less frequent than are paranoid reactions which are frequently 
seen in all sorts of conditions. There is extreme paranoia on the 
one hand and paranoid schizophrenia on the other, with many vari- 
ations, which is to be expected since personalities cannot be classified 
in distinct categories any more than the mental mechanisms with 
which each individual meets his life experiences can be classified. 
108 KEUROrSYCHTATKY IN AVIATION MEDICINE 
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79-80 
b. Kraepelin in his original theses on paranoia, looked upon para- 
noia as a fixed type of disease due exclusively to internal causes and 
characterized by persistent, systematized delusions, the perseveration 
of clear orderly thinking and acting, and by the absence of hallu- 
cinations. He also recognized a disease entity which he termed 
“paraphrenia,” classified between the true paranoia and paranoid 
schizophrenia, and which had as its characteristic features the pres- 
ence of hallucinations, the delusional system more marked than in 
true paranoia, and mental deterioration. 
c. Noyes gives the following definition for paranoia and the par- 
anoid conditions: “A type of personality reaction characterized by 
the mechanisms of projection or of compensation or by both acting 
simultaneously, not precipitated by toxic or organic states, and not 
accompanied by dilapidation of affect, of conations, or of associative 
processes.” 
d. The processes involved in this condition are again only exagger- 
ations of those found in the apparently normal. All persons have 
weaknesses which they tend to rationalize in some way or other. True 
paranoia is so rare that Dr. White, in St. Elizabeths Hospital, on 
one occasion stated that out of the 4,000 or more patients who were 
at that time in that institution he could not present what he called 
a good case of paranoia. Paranoiacs are usually too smart to stay 
in institutions. With their energy and apparent intelligence, it is 
difficult to convince a jury or court that they are psychotic. The old 
school of psychiatrists said that it took a man of brains to be a 
paranoiac. 
80. Types.—Three types of paranoia may be considered; true 
paranoia, paraphrenia, and paranoid type of schizophrenia. 
In this paranoid group is found, as a prepsychotic history, indi- 
viduals who have an exaggerated tendency to place responsibility 
for their failures on others, those who repudiate the aspects of their 
personalities that do not measure up to the goal which they have 
set for themselves, thereby gaining a sense of security which does not 
exist. The mental mechanism involved is that of projection. The 
paranoiac uses this mechanism to protect that part of his personality 
which he recognizes as weak, to gain recognition greater than he 
is able to acquire, and to meet his conflicts whether they be from 
within or from without. In true paranoia, there is no deterioration. 
By deterioration in these conditions is not meant actual destruction 
of brain substance. This brings to attention the term “deterioration.” 
Deterioration is here considered to designate gradual inability of the 
individual to cope with his environment at the social level, that is, 
to adjust himself to the common herd. In discussing the symptoms 
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MEDICAL DEPARTMENT 
of paranoia, the prepsychotic manifestations which are found in the 
individual’s history are of interest. The patient as a child was a 
stubborn, suspicious, sullen youngster who was resentful of parental 
and school discipline, given to sulking and unable to get along with 
his playmates. As he passed through adolescence into adult life, 
these characteristics continued with rigidity of opinion becoming more 
marked and an apparent self-confidence. This show of self-confidence 
being nothing more, however, than an assumed characteristic used to 
cover his sensitiveness and self-consciousness. As these character- 
istics develop, there is a tendency to morose abstraction in which the 
individual endeavors to analyze his failures and in his attempt co 
fix a blame for his failures, he develops his delusions, and ideas of 
reference. He develops a feeling of resentment toward others. He 
rationalizes with great affective energy which is one of the character- 
istics of paranoid reactions. This stage may be termed the “stage 
of persecution.” From this stage there may be a transformation 
of personality into a stage of grandiosity. The patient assumes 
the role to which his grandiose ideas have placed him. This external 
behavior may be as variant as the different ideas developed by the 
patient. 
81. Stages.—The symptoms of paranoia are classified into the 
stages of self-analysis, persecution, and grandiosity. 
a. During the stage of persecution, common findings in paranoid 
conditions are illustrated by the individual believing that someone 
is tampering with his mail; large organizations, usually fraternal, 
are conspiring against him; agents, such as secret service, are prying 
into his business affairs; in fact, he notes connivances against him 
on every hand and in various disguises. This delusional theme is 
characteristically illogical. Any event, however irrelevant, is con- 
nected to his delusional theme and supports his dominant idea, which 
carries with it marked effect. Not content with present events, he 
revives incidents of the past to support his delusional theme. He 
gives them a new interpretation. This process is termed “retro- 
spective falsification.” As his delusional theme or system continues 
to expand, almost any incident however trivial has an overvalued 
significance, and no amount of argument can change his attitude, 
as is typical of paranoid patients, he knows that he is right because 
his inner sense of security, as Noyes terms it, does not permit him 
to do otherwise. 
b. The grandiose type of paranoia may appear at the beginning of 
the psychosis or may be a long time in establishing itself after the 
period or stage of persecution. A typical and frequent form of this 
grandiose period is that of ideas of invention. The patient works 
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NETUROPSYCITTATRY IN’ AVIATION" MEBIOTN’E 
continually on some invention which is usually in itself an im- 
possibility, such as machines of perpetual motion. Also character- 
istic of this type of patient is that he is so engrossed with his in- 
vention or dominant idea, that he does not consider his livelihood. 
When he does construct his models or invention, foreign and secret 
agents steal them or are hindering in securing their patents. 
g. Quite common is the religious paranoiac. Those who have vis- 
ited wards in mental hospitals have noted patients who were Christs 
and chosen ones of God. They usually have supernatural powers. 
Some are so successful as to establish new religious sects; while 
others are so bizarre in their beliefs and behaviors that they cannot 
convince even notoriety and sensation-seeking moronic individuals. 
d. Then again is found the erotic form. Examples of this type of 
paranoia are frequently seen in the daily newspapers. Movie stars 
are being annoyed by love epistles; heiresses are pestered with so- 
called “cranks” who are in love with them, and if they are not 
successful in their attempts at love-making, the recipient is merely 
testing the individual’s love. Movie fan mail is evidence of paranoid 
erotic tendencies of the writers who really wish to be these so-called 
“stars” but can only attain satisfaction to the extent of the letters. 
This is an illustration of projection. 
e. Freud’s theory as to the origin of paranoia is that there is 
incomplete evolution of the personality, a fixation at the homosexual 
level; that these individuals consciously will not admit, as Noyes 
states, “I love him.” They change it to “I do not love him; I hate 
him.” This is not acceptable to the personality so the mechanism 
of projection is brought into play and the reaction is that “He 
hates me,” which is further elaborated into “I am persecuted by 
him,” and the result is a paranoid reaction. 
f. The true paranoiac is usually a person of superior intelligence 
and may be explained by the method in which he deals with his 
reactions. He uses rationalization, and to be able to explain his, 
at times, very complicated dominant idea or delusional theme, re- 
quires an almost uncanny intelligence. This is in itself one of the 
distinguishing characteristics in differentiating true paranoia from 
the paranoid schizophrenic. The schizophrenic gives up his struggle 
for self-esteem, resumes a passive attitude, and has a tendency to 
regress rather than to rationalize. 
g. Attempts have been made to classify paranoia as to different 
forms, especially as related to the delusional systems involved, 
therefore in some textbooks are described litiginous paranoia, reli- 
gious paranoia, political paranoia, and erotic paranoia. While these 
forms of paranoia are the most usual, the descriptions are not so im- 
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MEDTOAL DEPARTMENT 
portant as determining the causes of distress of the patient and asceiV 
taining the mechanisms he is using to effect a compromise with these 
causes. 
i In a typical case history is found the inability of the patient 
to secure for himself a satisfactory adjustment to his repressed feel- 
ings of inadequacy and to his other complexes as well as his homo- 
sexuality. In many paranoiacs, evidences of sexual inadequacy is 
found in some form or other, either physical or psychical. Impo- 
tence is frequently met with and as a compensatory reaction, the 
individual usually accuses his wife of dissatisfaction on her part 
and that she is obtaining sexual pleasures from other men, therefore 
he is released from his humiliating feeling of inferiority. From 
the physical standpoint, genital maldevelopments are quite frequently 
noted in paranoiacs. 
82. Diagnosis.—The essential features of this condition may be 
summarized as follows: 
cl There is a dominant or fixed idea, delusional in nature, consti- 
tuting the basis of the psychosis. 
h. There is progressive development of a plausible and logically 
coherent system of false interpretations, delusions, and retrospective 
falsifications around this fundamental fixed idea. 
c. Hallucinations are either absent or rare. 
d. The patient’s emotional tone and reactions are in harmony ■with 
his delusional system. 
e. The course of the disease is chronic but not deteriorating. 
83. Differential diagnosis.—Stress must be given to differentia- 
tion between paranoia and the paranoid form of schizophrenia. The 
outstanding differential characteristic is the extent to which the 
patient’s contact with reality has been disturbed. The more this is 
disturbed, the more it approaches paranoid schizophrenia. Other 
points of differentiation are that in schizophrenia is found an in- 
ability to explain conduct and the emotional attitude is inadequate. 
84. Prognosis.—It is doubtful whether any true paranoiac ever 
recovers. A larger percentage of paranoiacs die from degenerative 
circulatory diseases than in any other group of psychoses. This may, 
as Noyes states, show a somatic association in that the cardio-vascular 
system cannot compensate for the demands made upon it, or an evi- 
dence of djmamic unity of the organism. 
85. Treatment.—Treatment depends on the individual patient. 
When the behavior becomes sufficiently disorganized, commitment is 
necessary. All interferences and restraints usually extend his delu- 
sional system. It is far better, unless the patient is dangerous, to 
allow him to remain in his environment. 
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NETJTvOPSYCHIATRY IN AVIATION MEDICINE 
Section XVI 
GENERAL PARALYSIS OF THE INSANE 
Paragraph 
History 86 
Definition 87 
Frequency 88 
Time of life 89 
Etiology 90 
Other causal factors 91 
Pathological anatomy 92 
Onset, course, duration, and remissions 93 
Prognosis 94 
Symptomatology 95 
Tabetic forms 96 
Summary of mental symptoms 97 
Differential diagnosis 98 
Treatment 99 
86. History.—General paralysis is not described in the old medical 
literature; its exact description dates back only about 100 years. The 
first account of the physical and mental symptoms as constituting a 
single disease process was by Bayle in 1822. It was described by 
Calmeil in 1826 and again by Baillarger in 1846, who proposed the 
name “paralytic dementia.” That it was due to syphilis was first 
advocated by Esmarch and Jessen in 1857. In 1858, the French 
Medico-Psychological Society agreed the disorder should be regarded 
as a distinct disease entity. In 1904, Alzheimer and Nissl demon- 
strated the histopathology of the disease, and in 1913, Moore and 
Noguchi demonstrated the treponema pallidum in paretic brains. 
Because the disorder seems to belong especially to modern life, Kraft- 
Ebing termed it a “disease of civilization and syphilization.” 
87. Definition.—General paralysis is a psychosomatic disorder 
produced by a progressive syphilitic meningo-encephalitis leading to 
a degeneration of the parenchyma with an infiltration of interstitial 
elements and manifesting itself in a comprehensive but variable syn- 
drome of neurological and mental disturbances with fairly constant 
serological changes. (Noyes.) 
88. Frequency.—This disease furnishes about 8 percent of all first 
admissions to asylums. About four to five times as many males as 
females are affected. Paresis appears to affect syphilitic brain workers 
and intelligent persons more frequently than manual laborers and the 
illiterate. It seems to be of varying frequency in different races and 
to be practically unknown among uncivilized peoples. Not over 5 
percent of syphilitics develop paresis. 
*74768*—U. 8 
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MEDICAL. DEPARTMENT 
89. Time of life.—General paralysis is preeminently a disease of 
middle life, the majority of cases occurring between the thirty-fifth 
and forty-fifth years. It is rare before 25 or after 55, but may occur 
at any age. Late cases, those of about 60 and after, are often called 
senile paresis. Paresis appears in from 2 to 30 years after the luetic 
infection, usually within 10. Juvenile cases seldom develop before 
the tenth year, usually from the thirteenth to the eighteenth years, and 
appear to last slightly longer than adult forms, or about 4 to 7 years. 
Paresis appears to occur earlier in men than in women, perhaps because 
women are apt to contract syphilis later than men. 
90. Etiology.—The cause of general paralysis is syphilis. The 
spirocheta pallida has been found in the cortex, spinal fluid, and cord. 
An attempt to produce syphilitic symptoms by inoculating paretics 
with chancre virus failed. A certain physician inoculated nine paret- 
ics who were in the last stages of the disease and in whom syphilis 
had not been demonstrated, but with negative result. It is of interest 
that no pathologist, physician, or attendant has ever contracted the 
disease from a patient. The occurrence of paresis seems entirely 
without relation to the severity of the original syphilitic infection. In 
many instances, the history shows the infection to have been accom- 
panied by few and mild symptoms. 
91. Other causal factors.—The question of causal factors other 
than syphilis arises in view of the fact that not over 5 percent of 
syphilitics develop paresis; that it is practically unknown among 
uncivilized peoples, notwithstanding they have much syphilis; and 
that it affects brain workers and intelligent persons more frequently 
than manual laborers and illiterates. 
o. Why, in not more than 5 percent of syphilitics, do the spirochetes 
attack the parenchyma of the cortex? Are there strains of special 
virulence ? Are there strains possessing localizing powers for certain 
situations, with special predilection for certain forms of nervous 
tissue? Are there different races of spirochetes, and if so, is there a 
spirochete specific for paresis? In other words, is paresis a separate 
venereal infection? (There is a record of five men contracting the 
disease from the same woman.) Further, are paretics who exhibit 
also the manifestations of ordinary syphilis (a rare combination), 
patients who contracted two separate specific diseases at the same time ? 
Does the paretic, because there is a specific paretic infection, have the 
disease whether or not he ever had ordinary syphilis? Should the 
latter assumption be correct, it would raise the question whether the 
development of paresis is in reality delayed for so long as 10 years 
after infection. None of the above questions has as yet been answered. TM 8-325 
91-92 
NEUROPSYCHIATRY IN AVIATION MEDICINE 
h. Where the spirochetes are during the years elapsing between 
the initial infection and the development of the disease is as yet un- 
answered. They may have halted along the way or even have reached 
the cortex, in either case remaining inactive in intracellular granule 
form, due either to increased tissue resistance, diminished virulence, or 
the naturally unfavorable soil offered by the cortical tissues for 
development of the parasite. The ultimate incidence of the disease 
might be due to some condition or combination of conditions, such as 
debilitating illness, head trauma, meningitis, toxaemia, alcohol, mental 
or physical overwork, or worry, lowering resistance to a point per- 
mitting resumption of activity. How the spirochetes gain entrance 
to the parenchyma of the cortex has not been fully answered; certainly 
not from the meningeal coverings, since the limiting membrane of the 
outer zone of the cortex acts as an impenetrable barrier between the 
latter and the innermost layer of the pia. It has been shown, however, 
that the spirochetes may travel from an initial luetic lesion along 
the peripheral nerves. Spirochetes have been found in the lymph 
spaces of the perineurium and between the nerve fibres. It has been 
shown further that the perineural lymph sheaths of the spinal roots 
and nerves do act as afferent channels to the central nervous system. 
In view of the fact that some syphilitics have liver lesions, others bone 
lesions, others interstitial brain lesions, and others lesions of the cortical 
neuronic elements, it might be worth bearing in mind that the dis- 
tribution and destination of an organism, which is carried by the 
blood and lymph and which is itself actively motile, might vary some- 
what in different cases according to the element of chance. 
c. There is little evidence for assumption that there is a special 
predisposition or an inherent neuropathic defect which renders an 
individual more liable following luetic infection to develop paresis. 
On the contrary, psychopathic predisposition is almost certain to find 
expression in reckless exposure to syphilitic infection and thus multiply 
the probabilities for paresis. 
93. Pathological anatomy.—Although only a person who has 
had syphilis can become a paretic, the disease nevertheless is not a 
form of tertiary syphilis, for the anatomic changes are not typical 
syphilitic tissue changes. Paresis is a mixed degenerative and inflam- 
matory disease; the primary condition is a degeneration of the 
cortical neuronic elements with inflammatory changes in neuroglia, 
meninges, and vessels as secondary occurrences, although the two sets 
of changes may proceed simultaneously. While other syphilitic brain 
diseases are also degenerative and inflammatory, the primary changes 
are interstitial with degenerative changes in the neuronic elements 
secondary. No one finding is pathognomonic of this disease, although 
115 TM 8-335 
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MEDICAL. DEPARTMENT 
a combination of certain changes is suggestive. The pathological 
anatomy will be considered under two heads; macroscopic and 
microscopic. 
a. Macroscopic changes.—The dura is usually partially adherent to 
the calvarium; the pia is thickened, whitish, and translucent along 
the vessels except over the occipital lobes, and adherent, tearing on 
removal. The convolutions, especially of the frontal lobes, are 
atrophied, and the pia over these atrophied convolutions contains blebs 
filled with serum. The ventricles are dilated and the choroid plexuses 
contain cysts. The ependyma, especially of the fourth and lateral 
ventricles, presents granulations composed of increased glia cells, 
causing the usual glistening surface to have a frosted appearance. 
The weight of the brain is regularly below normal, and may be reduced 
to 900 grams. 
h. Microscopic changes.—Cell changes of varying degree are found 
in the cortex but few are pathognomonic for paresis. These cell 
changes lead to destruction but there is least involvement of the 
occipital lobe, especially the calcarine area; and of the central con- 
volutions, especially the precentral. In a given diseased area, normal 
cells are found lying side by side with diseased cells and these degen- 
erative changes in cells and processes result in atrophy of the cortex, 
which in extreme cases, may shrink to one-half its normal width. A 
common finding in paresis are the rod-shaped cells of Nissl, the distor- 
tion or turning of cells in all directions (architectonic changes), and 
infiltration of the perilymph spaces with lymph, plasma, and mast 
cells. Vascular lesions in the cortex are prominent. The vessels are 
increased in number, their walls thickened, and some show small 
aneurisms. In addition to the finer microscopic changes in the cortex, 
there are small areas of softening but gross focal lesions are rarely 
seen. The basal ganglia, central gray matter, and cerebellum also 
present degenerative changes in the nerve cells and fibre tracts. In 
the spinal cord, there is degeneration of the tracts in the posterior 
and lateral columns. Vascular changes in the internal organs occur 
so frequently as to seem to bear a distinct relationship to the disease 
process, the most prominent being atheroma of the aorta and arteritis 
of the vessels of the liver and kidneys. Special points to be remem- 
bered are: almost no change in the dura, but important changes in 
the pia; very few changes in the occipital lobe, but many in the frontal; 
Nissl cells, distortion of cells, degeneration of cells, infiltration of 
perilymph spaces. A moderate internal hydrocephalus, and dilated 
ventricles; vascular changes; atrophy of convolutions with reduction 
in brain weight. 
116 TM 8-325 
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NEUROPSYCHIATRY IN AVIATION MEMCTNE 
93. Onset, course, duration, and remissions.—a. The onset is 
insidious, often quite neurasthenic in character. Like the neuras- 
thenic, the paretic complains during the prodromal period of not 
feeling well. Later, when the disease is well established, he exhibits 
marked indifference concerning his condition, protests there is nothing 
the matter with him, and shows total lack of insight. 
b. In a study of 74 male paretics at the New York Psychiatric In- 
stitute, reported in the American Journal Medical Science, March 1926, 
it was found that the earliest symptoms which may occur in patients 
who later develop outspoken general paralysis to be as follows: 
(1) Irritability holds first rank since it occurred as the earliest ab- 
normality in 42 cases, or 57 percent of the 74 cases. 
(2) The character change whereby an individual is reduced in 
activity and spontaneity, loses some of his interests, tends to withdraw 
into himself, and is often described as having become “quiet”, is like- 
wise a common early symptom, occurring in 28 cases, or 38 percent. 
(3) Loss of weight ranks third. It occurred, often very early, in 22 
cases, or 30 percent of the series. 
(4) An increased tendency to sleep, somewhat more suggestive in 
itself than any of the foregoing symptoms, was an early manifestation 
in 15 cases, or 20 percent. 
(5) Speech defect, memory defect, and judgment defect have con- 
siderable diagnostic value in themselves; they were found in this series 
among the earliest symptoms in only 11 cases, 15 cases, and 7 cases, 
respectively. 
(6) Visual impairment, digestive disturbance, insomnia, fatiga- 
bility, headaches, tremor, and rheumatoid pains were present as the 
earliest manifestations in a few cases. 
c. The course is frequently interrupted by spontaneous remissions 
lasting weeks, or from 5 to 6 years. During those interludes, there may 
be remarkable amelioration of symptoms chiefly on the mental side. 
It is difficult, therefore, to determine the permanence of the modern 
treatment of general paralysis. It would be preferable to designate 
these cases as being in full or complete remission. Following remis- 
sions, patients usually are worse and the course more rapid. 
94. Prognosis.—The prognosis in untreated paresis is extremely 
unfavorable, most cases terminating in death within from 3 to 5 years. 
95. Symptomatology.—The clinical picture is exceedingly varied 
because the physical and psychical disturbances not only occur in mani- 
fold combinations, but also differ greatly in degree in different 
subjects. 
117 I’M 8-335 
95 
MEDTOAIi DEPARTMENT 
a. The disease is best studied in three periods; period of onset, fully 
developed period, and terminal period. 
(1) Period of onset.-^The period of onset is considered to date 
from that time when the clinician detects, either singly or in combina- 
tions, those physical and psychical disturbances which establish the 
diagnosis. It is preceded by a prodromal period, perhaps of months 
or years, during which there occur neurasthenoid-like changes in dis- 
position, character, and judgment; a period during which the laity 
consider the patient only nervous and excitable; not physically or 
mentally ill, but merely less efficient. Because of the grave questions 
likely to arise concerning the degree of mental impairment and extent 
to which it affects responsibility for conduct and ability to transact 
business, this has often been called the medico-legal period. Similar 
questions may arise during periods of remission. The symptoms 
are physical and mental. There is no rule concerning the order in 
which symptoms appear. Physical and mental may appear simul- 
taneously, either may predominate, or the two sets be variously com- 
bined. It is well to bear in mind that arrangement of the develop- 
ment into three periods is somewhat arbitrary, for the progression 
of symptoms from mild to severe and their intermingling and diversity 
as well, are subject to wide variations throughout the disease. 
(a) Physical symptoms.—About this time, the appearance begins 
to undergo significant changes; the patient looks wearied, older, and 
loses weight; while the relaxing facial muscles and flattening naso- 
labial folds begin that wiping away of expression which eventually 
leaves only a vacant, wooden countenance, the paretic “ironed-out 
facies.’r Among the most important physical symptoms are loss of 
the sympathetic light reflex; loss of the consensual light reflex; and 
slowing, weakening, or loss of the direct light reflex (Argyll-Robert- 
son pupil) which occurs in about 50 percent of cases. The latter may 
occur in one or both eyes, and be in different degree. (Such anomalies 
are peculiar to paresis; not often seen in tabes.) In outline, the 
pupils may be irregular; and in size, one normal, the other miotic 
or mydriatic; both miotic or mydriatic; or one miotic and the other 
mydriatic. When miotic, the pupil may be so small as to form the 
paretic “pinhole pupil.” In certain individuals a light pupillary 
irregularity or inequality may be normal, and in some few paretics 
the pupils are without change throughout the disease. The most 
important tendon reflex is the knee jerk. It may be normal, exag- 
gerated, diminished, or lost; on one, or both sides. The exaggerated 
is the most common. Unequal knee jerks are a frequent and im- 
portant sign. Other helpful diagnostic signs on the physical side 
118 TM 8-325 
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NEUROPSYCHIATRY IN AVIATION MEDICINE 
may be defective innervation of one side of the face; transitory ocular 
palsies (more common in tabes); and tremors either fibrillary, fine, 
or coarse. The tremors are extremely significant. They appear in 
connection with voluntary movements as fibrillary of the tip and 
margins of the tongue when it is protruded; of the lips, angles of 
the mouth, and maso-libial folds in showing the teeth; and as flash- 
like twitchings flitting across the cheeks, orbital regions, and forehead 
in smiling. Frequently, however, the fibrillary tremors do not range 
so broadly, for the paretic tremor is apt to involve the lower face, 
and the alcoholic, the upper. Fine tremors may be seen in the fingers 
when the subject extends the hands and tries to separate the fingers. 
In the later stages, the defective innervation of all the muscles shows 
as a general trembling, or as coarse tremors particularly of the hands 
and tongue; in attempting to protrude the latter, to and fro move- 
ments occur. More gross motor disturbances show as adiadokokinesis, 
awkwardness and heaviness of gait, and clumsiness in doing ordinary 
things. Difficulties of articulation, while heard in this stage, are 
more pronounced in the fully developed period and are described in 
h below. 
(b) Mental symptoms.—The neurasthenoid symptoms of the pro- 
dromal stage now become more pronounced. Complaint is made of 
insomnia or somnolence, great weariness, and frequently of a vise- 
like headache. The patient is apt to be depresesd and free with com- 
plaints about his ill health and inability to accomplish things as for- 
merly; in sharp contrast with the later tendency to be euphoric, he 
may overestimate his possessions and powers and engage in foolish 
and ruinous enterprises. The initial mental changes should be re- 
garded as the beginning of a deterioration certain to progress rapidly 
toward a fatal dementia. Because the degenerative changes involve 
chiefly the frontal convolution, the first symptoms show as a deteriora- 
tion of those functions which were the latest to be acquired. Conse- 
quently, accomplishments are not up to the former standard; the 
business man is less efficient, the artist does not paint as well, the 
musician’s performance is less brilliant, etc. Interest in work dimin- 
ishes, comprehension, reasoning, and judgment are impaired, and the 
ethical and esthetic sense dulled. There is a change in disposition, 
character, habit of thought and action, with alteration of the finer 
feelings and lowering of the whole moral tone. Delusions which later 
become so enormously expansive and grandiose, at this period are 
apt to be disturbing and depressive. Memory defects are prominent, 
but less for events than for resolutions, that is, the patient forgets what 
he has to do; post a letter, catch a train, lock the safe, etc. Accord- 
119 Til 8-325 
95 
MEDTOAL, DEPARTMENT 
ingly, as significant indications of mental deterioration, there appear 
little faults of memory, errors in speech and writing, growing indif- 
ference to higher sentiments, loss of critical faculty, small lapses in 
the proprieties, and failing interest in the more important affairs of 
life. As these mental features become more and more pronounced, 
the patient loses and mislays things; makes mistakes in money mat- 
ters; errs in appointments; confuses persons and objects; forgets his 
way; is negligent in dress; shows extravagance in the use of money; 
evinces distinct loss of ethical feeling; and exhibits proclivities toward 
sexual and alcoholic excesses. 
(2) Fully developed period.—Because of the tendency to become fat, 
proneness to fatuously protest he is quite well, and the frequency of 
fits, this has been named the “fat, fatuous, and fitty” period. In a 
typical case, all the symptoms previously mentioned, together with the 
additional ones enumerated below, will be clearly in evidence. 
(a) Physical symptoms.—The chief physical symptoms are peculiar 
articulation and writing (the “paretic speech” and “paretic writing”); 
tremors; pupillary disorders; lost or exaggerated tendon reflexes; 
muscular weakness; apoplectiform or epileptiform seizures; emacia- 
tion ; trophic disorders; and disturbances of the special senses. 
1. Paretic speech is slow, hesitating, drawling, or scanning and 
the tone hard and monotonous. Labials and certain con- 
sonants are most difficult to enunciate, and the typical 
speech is shown in prolonged reading or in attempting 
to pronounce such words as “electricity”, “artillery”, 
“brigade”, “Methodist Episcopal”, “truly rural”, etc., in 
which the consonants may be left out, drawled over, or 
misplaced thus: “electericity”, “artillililery”, “brigrade”, 
“Methist Pispal”, etc. Or test sentences like the follow- 
ing may be used: “Around the rugged rock the ragged 
rascal ran his truly rural race”; “She stood at the door of 
Burgess’s fish-sauce shop”; “She sells sea shells and shav- 
ing soap”. Sentences such as these are also memory tests. 
The paretic handwriting becomes puerile and shows let- 
ters and words elided and reduplicated, large and sepa- 
rated letters, (a half dozen words may cover a page), 
undulating and widely spaced lines, tremors on the up 
strokes, and blots and smudges; these manifestations to 
be interpreted as associations of like phenomena on the 
intellectual side, that is, lapses of words, etc. 
2. In this stage, the tremors previously mentioned, especially 
those of the fingers, tongue, and lips are much more in 
evidence. 
120 TM 8-325 
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NEUROPSYCHIATRY IN AVIATION MEDICINE 
3. In order of importance, the pupillary abnormalities are the 
Argyll-Robertson pupil; extreme miosis; variable inequal- 
ity ; and irregularity of outline. 
J. The tabetic forms show diminished or lost knee jerks, while 
in other forms they are strikingly exaggerated or mark- 
edly unequal. 
6. A progressive weakening of the muscles of the whole body, 
with occasional atrophy, is one of the most important 
physical symptons of paresis. It is rather an enfeeble- 
ment than a paralysis. The weakening especially in- 
volves the lower limbs and the gait becomes shuffling like 
that of an old man, then tottering and falling, so that 
finally the patient takes to his bed. 
6. The apoplectiform seizures resemble true apoplexy but the 
resulting paralysis is apt to be less permanent; in fact, it 
may disappear in a few days. Epileptiform seizures are 
apt to last longer than true epileptic attacks and con- 
sciousness may be retained. Sometimes there is status 
epilepticus. Local or Jacksonian convulsions also occur, 
said to be most frequent in thumb and index finger of 
right hand, apposition of these being the most, recently 
evolved, most voluntary, and least stable motor function 
of the cortex. The seizures are believed to be due to ac- 
cumulation of toxic materials to a point exceeding elimi- 
native capacity. They occur in about one-half the cases 
and usually in the fully developed period, but may occur 
in the initial or terminal stage. The patient is usually 
worse afterward. 
7. Rapid emaciation is the rule after the disorder is well 
established, and is followed in this period by gain in 
weight, 
8. Among trophic disorders are bedsores, a striking fragility 
of the bones, hematoma of the cartilage of the ear sup- 
posedly due to trauma, and graying of the hair. 
9. The chief special sense disturbances are deafness and visual 
defects, the former of central origin, and the latter due 
to optic atrophy. 
(5) Mental symptoms.—The chief mental symptoms are halluci- 
nation (auditory); disorientation; delusions (marked by enormous 
exaggeration whether exsdted or depressed); irritability or change- 
ability; depressed, agitated, or exalted moods; diminishing number 
of ideas; failure of memory for both recent and old events; loss of 
ethical and esthetic sense; moral obtuseness; and total lack of insight 
121 TM 8-335 
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MEDICAL DEPARTMENT 
1. Only the typical case presents such orderly combination 
and progression of symptoms as here set forth. How- 
ever, the average case will exhibit many of the symptoms 
in varying degree. Especially evident, on the mental 
side, will be a change in disposition and character, im- 
pairment of judgment, loss of the ethical and esthetic 
sense, and moral obtuseness, the latter in particular show- 
ing utter disregard of the proprieties and flagrant im- 
moralities; for example, a deacon of the church brought 
a prostitute into his home and insisted his wife give her 
the guest chamber. 
2. In paresis, the delusions show a combination of childish- 
ness and grandiosity not seen in any other psychosis. 
Their triviality and fantastic enormity suggest regres- 
sion to childish make-believe and wish-fulfillment, for the 
patient playfully remarks “I am a Spanish onion”, and 
then explains he is president, czar, king, God, at one and 
and the same time, will bring the Pacific ocean over the 
Andes to make the greatest waterfall in the world; has 
lost billions, been committed to prison for thousands of 
years, and weeps because unable to do his duty by the 
nations he governs. However, the delusions may be and 
not infrequently are depressive, nihilistic, accusatory, and 
persecutory. 
3. Remissions, lasting weeks or months, often occur during 
the fully developed period. Amelioration of symptoms 
is chiefly on the mental side, but some of the physical 
symptoms may also show a change for the better. The 
improvement may be phenomenal, and the patient change 
from a state of almost total mental dilapidation to ap- 
parent lucidity. Following remissions, the patient is 
apt to grow worse rapidly. 
(3) Terminal 'period.—This is the stage of rapid progression to- 
ward complete dementia. The remains of old grandiose delusions 
may still be noted in the scarcely comprehensible mumblings of the 
paretic dement, but usually the mind becomes completely vacuous, 
the patient speechless, filthy in habit, and helpless as an infant. 
Paralysis of the muscles of deglutition makes tube feeding necessary 
to prevent strangling; and he lies in bed, wetting and soiling him- 
self, and requiring much care lest contractures and bedsores develop. 
Like a decerebrate animal, he grunts or snarls when disturbed, and 
the merely vegetative existence is prolonged solely through the 
lower cerebral and bulbar neuronic mechanisms until death supervenes. 
122 TM 8-335 
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NEUROPSYCHIATRY IN AVIATION MEDICINE 
5. Some authors, instead of describing the development in three 
periods, describe four clinical varieties; demented, expansive, mani- 
acal, and depressive. In each, the physical symptoms run the usual 
course with steady progression toward dementia, the essential feature 
on the mental side. In the demented type, there is progressive mental 
deterioration without great excitement, exaltation, or depression; in 
the expansive type, delusions of exaltation predominate in either mod- 
erate or exaggerated degree; in the maniacal, the manifestations so 
resemble those of the manic phase of manic-depressive psychosis as 
to require special care in diagnosis; and in the depressive, hypochon- 
driacal and self-accusatory delusions predominate sometimes with per- 
secutory trends, creating a resemblance to the depressive phase of 
manic-depressive psychosis. The individual’s personality organiza- 
tion has underlying complexes, problems, and experiences which influ- 
ence and color the patient’s mental reaction. Stuporous, circular, and 
convulsive forms also have been described. In the latter, convulsive 
seizures are the outstanding clinical feature. The occurrence of con- 
vulsive seizures after the age of 30 and without a history of previous 
attacks, should arouse suspicion of paresis. 
96. Tabetic forms.—Tabetic signs, such as loss of reflexes, ataxia, 
positive Romberg, paralysis of rectum and bladder, lancinating pains, 
and girdle symptoms, occur in from 16 to 21 percent of cases. These 
cases are called taboparesis and seem not to be precisely the same 
as either tabes or paresis, but a composite with variations from 
type in each component; that is, an ill-defined tabes and a modified 
paresis. In fact tabes has been called “spinal paresis,” and paresis, 
“cerebral tabes.” 
97. Summary of mental symptoms.—a. Clouding of conscious- 
ness and disorientation occur in varying degree throughout the dis- 
ease, being very marked in the terminal period. 
h. Delusions may be hypochondriacal, depressive, self-accusatory, 
persecutory, or expansive; the fantastic enormity of the latter ex- 
ceeds that seen in any other psychosis. 
c. Flight of ideas occurs in periods of excitement while diminish- 
ing ideation reaches complete paralysis of thought in the terminal 
period. 
d. The mood is one of irritability and changeability in conformity 
with the ideational content and delusional formation, complaining 
in the period of onset, euphoric in the fully developed period, and 
depressive in the terminal period, 
e. Memory and attention defects keep pace with the mental deter- 
ioration ; memory in particular suffers from the beginning, and finally 
is completely lost. 
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MEDICAL DEPART ME3STT 
f. Impairment of reasoning and judgment early manifests itself 
in uncertainties and contradictions, develops rapidly, and culminates 
in absurd business transactions and ruinous undertakings. 
g. Character, personality, conduct, and behavior are disastrously 
affected. There is a profound change in disposition, habit of thought 
and action, with dulling of the finer feelings and degradation of the 
whole moral nature. 
98. Differential diagnosis.—a. It is a cardinal principle that 
every case of neurasthenia must be proved not to be paresis. The 
early stages of paresis are differentiated from neurasthenia as 
follows: 
Paresis 
Neurasthenia 
Pupils.. 
Reflexes 
Insight 
At first complains, later protests is 
not ill, lacks insight. 
At first mentioned, later minimized.. 
Never has insight but introspective- 
ness persists throughout illness. 
Always exaggerated. 
Symptoms 
Spinal fluid 
Effect of rest and quiet 
count, increased globulin, positive 
colloidal gold test. 
Improvement probable. 
None. 
Mental and moral deteriora- 
Noticeable.. . 
tion.' 
h. The differentiation from cerebral syphilis is often quite difficult. 
Paresis 
Cerebral syphilis 
Speech disturbances 
If present, is true aphasia due to 
focal lesions. 
If present, are permanent. 
Inconstant, slight or absent, en- 
darteritic and gummatous types. 
Usually extremely marked in 
meningitic types, 100 to 1,500 cells. 
Under 30. 
Very anxious concerning condition. 
Nocturnal and common. 
Rare. 
Luetic curve. 
Paralyses 
Lymphocytosis 
Age 
Invariably present, 15 to 50 per 
cubic millimeter. 
Symptoms, _ 
Headache 
Childish make-believe and fantastic 
enormity. 
Colloidal gold tests. 
c. From tabes dorsalis, the differentiation may be impossible and 
it may be necessary to await developments. However, a tentative 
diagnosis of paresis is in order if there is retention of knee jerks 
associated with mental deterioration. 
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NEUROPSYCHIATRY IN AVIATION MEDICINE 
d. Cerebral tumor presents focal symptoms, choked disk, severe 
and localized headaches, slow pulse, and usually attacks of protracted 
stupor. 
e. Schizophrenia usually may be differentiated by the presence of 
catatonic features, tendency of consciousness to remain unclouded 
and orientation undisturbed, mental deterioration to develop more 
slowly and by the absence of the characteristic paretic physical signs. 
/. The manic and depressive phases of manic-depressive psychosis 
are differentiated from the maniacal and depressive phases of paresis 
by the absence of mental deterioration and by serological examina- 
tion of spinal fluid. 
99. Treatment.—a. Malaria is still the most popular form of 
treatment for general paralysis in spite of the numerous attempts 
which have been made to supersede it by other forms of pyrexial 
therapy. Its popularity with clinicians is derived not so much from 
the high measure of complete recoveries achieved as from its relative 
immunity to serious accidents. In thus combining a moderate degree 
of success with comparative safety, it has proved itself superior to 
and generally more acceptable than any of its rival methods of 
treatment. It was first used by Wagner von Jauregg of Vienna in 
1917, for which he received the Nobel Prize in Medicine in 1927. 
h. Malaria fever is produced in the patient either by direct in- 
oculation by the mosquito or by transferring active blood from one 
patient to another. Technique varies with the individual. However, 
from 5 cc. to 10 cc. of activated blood have been inoculated directly 
into the vein of the recipient. The incubation period after intra- 
venous injection is about 10 days. An average of ten paroxysms is 
allowed, after which quinine therapy is used to halt the fever. Thirty 
grains of quinine hydrochloride daily for 3 days followed by fifteen 
grains daily for 3 weeks have been found sufficient in the average 
patient to stop paroxysms. It has been the practice to give some 
form of bismuth following malaria therapy, which seems to act as a 
tonic as well as having specific value. Tryparsamide is being used 
to a certain extent as a follow-up treatment. The majority of ma- 
laria deaths can be eliminated if care is taken in controlling the ma- 
laria paroxysms and treating concurrent conditions, such as cardio- 
renal complications. 
c. Benefit from malaria treatment becomes apparent in from 2 to 
6 months. An average of between 30 to 40 percent of patients show 
complete remission from 1 to 2 years after treatment, while 25 to 
30 percent show a partial remission. After 10 years, the average 
for remission is about 15 percent although many more maintain 
improvement. 
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MEDICAL DEPARTMENT 
d. More than one course of malaria therapy has no effect. There 
is no similarity that is proportionately between the clinical improve- 
ment and the serological. Usually there is no change in serological 
findings. 
e. The mechanism by which malaria operates is unknown. How- 
ever, it is recognized that there is something besides the fever that 
is active in destroying the spirochetes. The most common theory 
is that malaria influences the reticulo-endothelial system, increasing 
the inflammatory reaction of the cells, and promoting phagocytosis. 
/. Tryparsamide is now in common use and the results are almost 
as satisfactory in the treatment of ncurosyphilis as they are with 
malaria therapy. Here serological improvement is noted as well. 
It is a good rule that if no serological improvement is noted after 
1 year of intensive treatment, no clinical improvement is to be ex- 
pected from its use. Tryparsamide seems to pass the blood-brain 
barrier and it has a special affinity for the cells of the nervous system. 
For this reason, it sometimes causes amblyopia. However, this com- 
plication appears early if at all, and usually during the first five 
to ten injections. If the drug is stopped immediately, recovery is 
the rule. The dosage is not the determining factor in the production 
of eye symptoms. 
g. Typhoid, paratyphoid, rat-bite fever, milk, diathermy, radio- 
therapy, etc., have been used to produce pyrexia, but malaria seems 
to be the most efficient. 
Section XVII 
TABES DORSALIS 
Paragraph 
Definition 100 
Etiology 101 
Differential diagnosis 105 
Prognosis 106 
(Locomotor ataxia and posterior spinal sclerosis) 
100. Definition.—Tabes dorsalis is a chronic, more or less pro- 
gressive disease of the central nervous system, exhibiting its chief 
morbid changes in the spinal ganglia and in the posterior roots and 
posterior columns of the spinal cord; it is characterized clinically 
by a very definite senes of symptoms, among which the Argyll- 
Hobertson pupil, the lightning pains, the girdle sensations, the loss 
126 TM 8-335 
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NEUROPSYCHIATRY IN AVIATION MEDICINE 
of deep reflexes, the hypotonia, and the ataxic gait are the most 
prominent. 
101. Etiology.—In the great majority of cases a history or symp- 
toms of a syphilitic infection can be obtained and syphilitic infection 
is the almost universal cause of the disease. Pseudotabetic syn- 
dromes are known to occur in multiple sclerosis, in tumor, in caries, 
from accident, gun-shot woimds, in poisoning, by alcohol, pellagra, 
hypothyroid states, diabetes, ergot, and various other etiological 
factors. However, in true tabes dorsalis, syphilitic infection is the 
etiological factor. Tabes appears as a rule 5 to 20 years after the 
initial infection. Sachs, in Osier’s Modern Medicine, records a case 
of a man of 55 in whom the first symptoms of tabes, including optic 
atrophy, appeared within 1 year of the initial infection and states 
that when syphilis is acquired late in life, syphilitic forms of spinal 
disease may appear within a very few years. 
102. Pathology.—The chief anatomical change is a degeneration 
of the posterior columns of the cord. This change usually begins 
in the columns of Burdach at the level of the upper lumbar segment. 
At higher levels, the columns of Goll are also involved at a very early 
period of the disease. At a later stage, the entire posterior columns 
of the lumbar and dorsal segments are completely degenerated. The 
disease is not strictly limited to the posterior columns; the columns 
of Clarke and the posterior horns are frequently involved. The 
morbid process may extend into the medulla oblongata involving 
certain cranial nerves. Especially frequent is the degeneration of 
the optic nerve (simple white atrophy). 
103. Symptoms.—With the possible exception of general paresis, 
there is no disease presenting such a great number of symptoms and 
it is doubtful whether any one patient presents even a bare majority 
of them. Sachs describes two distinct groups of symptoms; the 
ataxic and the ophthalmic. The ataxic group represents the classical 
type. In this group, the optic nerve symptoms are developed very 
late or not at all, while all the ataxic and sensory symptoms attain 
fullest development. In the ophthalmic group, optic nerve atrophy is 
one of the earliest and most profound features, leading to early blind- 
ness, while the ataxic symptoms are imperfectly exhibited. It has 
been the rule to divide the symptoms into those of the prodromal 
stage and those of the ataxic stage. The prodromal stage may last 
for months or years and yet the final diagnosis cannot be safely 
established until several of the cardinal symptoms have appeared. 
The presence of three of the cardinal symptoms is sufficient for this 
purpose, and among those cardinal symptoms subjective as well as 
127 TM 8-325 
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MEDICAL. DEPARTME3ST 
objective must be ranked. The cardinal symptoms of tabes dorsalis 
given approximately in their order of importance are— 
a. Lancinating pains, according to Erb, in 90 percent of cases. 
h. Argyll-Robertson pupil, in 80 to 90 percent of all cases. 
c. Loss of deep reflexes, particularly of the knee jerks and Achilles 
tendon reflex, in 95 percent of all cases. 
d. Romberg symptom. 
e. Girdle sensation in various forms. 
f. Hypotomia of the muscles. 
g. Bladder disturbances. 
A, Ataxic movements of the lower extremities. 
i. Sexual weakness. 
j. Cranial (more particularly ocular) nerve palsies, strabismus, 
double vision, etc. 
k. Optic nerve atrophy, simple white or primary white atrophy. 
l. Visceral crises. 
m. Trophic disorders, perforating ulcers, etc. 
n. Special mention should also be made of the laryngeal and car- 
diac crises. 
104. Diagnosis.—In the fully developed forms, it is hardly pos- 
sible to mistake tabes for any other disease of the nervous system. If 
three or more of the cardinal symptoms are present, the diagnosis 
should be made without hesitation, but it is well to keep in mind 
that the disease may begin with one or the other of the more unusual 
symptoms, with visceral crises, laryngeal crises, or with visceral 
and rectal disturbances. These symptoms may precede the cardinal 
symptoms for months or years. In the recognition of the earlier 
stages, evidence furnished by the serological and cytological find- 
ings of the blood and spinal fluid will be of the greatest importance. 
105. Differential diagnosis.—Some of the symptoms of tabes 
may occur in tumors of the cord invading first the posterior half 
of the cord, and in multiple sclerosis, if the sclerotic areas happen 
to involve the posterior columns and the posterior gray matter 
rather than the pyramidal tracts in which they generally occur. 
However in doubtful cases, the occurrence of nystagmus, of altered 
speech, and the ataxic tremor will help to indicate the disease. 
Greater difficulty will be encountered in differentiating between a 
syphilitic meningomyelitis invading the posterior half of the cord 
and genuine tabes dorsalis. Here complete immobility of the pupils, 
paralysis associated with the ataxia at an early stage of the disease, 
marked remissions and exacerbations of the symptoms, would help 
to indicate an active luetic process rather than a typical posterior 
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NEUROPSYCHIATRY IN AVIATION MEDICINE 
spinal sclerosis. The ataxic paraplegia of combined sclerosis may 
offer even more difficulty if at some stage of the disease the ataxia 
may predominate to such an extent that the patient may present 
so few of the spastic and paralytic symptoms that there is little 
reason to suspect anything else than tabes dorsalis. If the ataxic 
symptoms are associated with increase of reflexes and if the pupillary 
phenomena are not typical of tabes, the diagnosis of combined 
sclerosis may safely be made. The greatest difficulty will be in 
differentiating tabes from alcoholic multiple neuritis, or as formerly 
called, alcoholic pseudo-tabes. The resemblance to tabes lies in the 
ataxic movements of the lower extremities and in the absence of 
the deep reflexes, also in the occurrence every now and then of marked 
sensory disturbances. The differentiating points are that in alcoholic 
pseudo-tabes the pupillary phenomena are not so constant although 
there is often a sluggish reaction to light; there is almost invariably 
a considerable degree of paralysis with the ataxia, often also some 
muscular wasting; lancinating pains and girdle sensations are 
not the rule in multiple neuritis due to alcoholism and the entire 
development of the symptoms is more rapid than in tabes. 
106. Prognosis.—As far as a cure is concerned, the prognosis is 
hopeless. There are, however, so-called benign cases and the possi- 
bility of the degenerative changes coming to a standstill at any period 
of development must not be overlooked in prognosticating. Many 
cases are very slow in progressing and many a patient is able to attend 
to his routine duties and live a fairly comfortable life for many years. 
The more hopeless cases are those developing an early amaurotic type 
of tabes, and where an early complication with a cystitis or a pyelo- 
nephritis occurs. The average duration is from 10 to 15 years. 
107. Treatment.—Treatment of the individual case is the method 
to be sought for. The following is quoted from the Year Book of 
Neurology, Psychiatry, Endocrinology for 1934: “The abundant litera- 
ture of the year 1934 has not produced universally accepted conclusions 
as to the therapy of choice in regard to general paresis, tabes dorsalis, 
meningovascular or asymptomatic forms of syphilis. The consensus 
of opinion seems to be that an individual approach should be made to 
the given case, scrutinizing the constitution, the reaction type, and the 
physical condition before the most promising method of therapeutic 
endeavors is instituted. The use of antisyphilitic drugs, particularly 
arsphenamine, tryparsamide, bismuth, mercury, and iodides affords 
an opportunity for the arrest and finally for the cure of various types 
of syphilis of the central nervous system. Nonspecific therapy with 
malaria, relapsing fever, typhoid vaccine, sodoku, pyrifer or sulphur 
274758'— 9 
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MEDICAL. DEPARTMENT 
injections, and diathermy are the newer methods of combating and 
arresting the pathologic processes of neurosyphilis. Both methods, 
singly or combined, have given excellent results. The scientific dispute 
over the pathogenetic problems leading to neurosyphilis is not settled 
as yet. The formerly accepted division of the spirochete into a neuro- 
tropic and dermotropic type has been discarded since subsequent re- 
searches on this question have not supported such a simple working 
thesis. It is much more plausible to assume variable reactive defense 
mechanisms in individuals for the developmental course in syphilis, 
conditioned by such important factors as environment with its physical 
and emotional strain and trauma, the biological reactions of the skin, 
vascular and nervous system upon insufficient antisyphilitic therapy, 
or defective forces in the tissue immunity against the spirochetes. 
The clinical plus the serological syndrome, the elapsed time of the 
latent infection, the previous and last methods of therapy, and espec- 
ially the present physical-mental status determine in each case the 
antisyphilitic procedures to be followed.” 
Section XVIII 
INFECTION EXHAUSTION, TOXIC, AND SYMPTOMATIC 
PSYCHOSES 
Paragraph 
General 108 
Etiology 109 
Infection exhaustion psychoses 110 
Symptomatology 111 
Differential diagnosis 112 
Toxic psychoses 113 
Symptomatic psychoses 114 
108. General.—Because of the close relationship and for conven- 
ience of description, the psychoses are grouped together for discussion. 
There is no group of mental reactions more important to all medical 
men than the toxic psychoses. Considered from a broad standpoint, 
it is clear that in this field there is no division or demarcation between 
internal medicine and psychiatry. It must be realized that in any 
physical disease, infection, cardiac disease, metabolic disorder, or 
glandular disfunction may be abruptly transformed into mental dis- 
ease. In other words, it must be anticipated that in the course of any 
physical disease, such phenomena as disturbance of consciousness, hal- 
lucinosis, hyperactivity, and other symptoms may appear. These 
symptoms are simply a part of and a continuation of the same condition 
which a short time ago may have been a simple uncomplicated case of 
lobar pneumonia, typhoid fever, myocarditis, or similar disease. It is TM 8-325 
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NEUROPSYCHIATRY IN AVIATION MEDICINE 
obvious that the infective exhaustive and the toxic psychiatric reac- 
tions are extraordinarily common. Naturally the majority of these 
cases are not committed to mental hospitals so there is a discrepancy 
between the statistics from mental hospitals and the actual number 
of cases. 
109. Etiology.—One of the cardinal and distinguishing traits of 
these psychoses is the definite etiology. A wide range is covered, but 
usually the cause is ascertainable. It may be strictly exogenous, and 
in this connection alcohol, opium and its derivatives, and the entire 
class of hypnotic and narcotic drugs, the metals and gases used in 
the industries, etc., are considered. When attention is turned to 
endogenous agents, the host of acute infectious diseases such as 
typhoid fever, influenza, and pneumonia is thought of at once. Here 
the mental equilibrium may be upset by the fever primarily, or by 
the toxin. Usually both are operative. Then the effect of more 
chronic infections, notably tuberculosis, must be reckoned with. 
Heart disease, particularly in the stage of decompensation, exerts a 
decided influence on metal functioning. Again, there is a whole 
series of chemical alterations, blood dyscrasias, metabolic disturb- 
ances and deprivations, and endocrine imbalances which are ex- 
pressed not solely in terms of organic disfunctions but often and 
sometimes predominantly as psychic disorders. As Noyes states, 
“Unless the organism is intact at physical, chemical, and physiologi- 
cal levels, its operation at the psychobiological level or level of per- 
sonality functioning, may be impaired to a varying degree.” 
110. Infection exhaustion psychoses.—a. Individual resistive- 
ness and stability of nervous organization seem to be the factors 
determining the presence, absence, or degree of mental disturbance 
in conditions of infection and exhaustion. In some individuals, con- 
sciousness remains clear notwithstanding a temperature as high as 
106° F., while others become delirious with only a slight rise above 
normal. In the one case, resistance is very marked, in the other, 
lack of resistance is very evident. In conditions of infection and 
exhaustion, the hallucinatory and delusional manifestations as well 
as the disorientation and clouding of consciousness vary widely, are 
disproportionate to the etiological factors and lack of fixity, and 
are extremely multiform and changeable. Concerning mental dis- 
turbances in the infections the following differentiations are made: 
(1) Initial delirium.—Developing during the prodromal or incu- 
bation period or before the febrile stage. 
(2) Febrile delirium.—Having a definite relation to the febrile 
stage. 
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MEDICAL. DEPARTMENT 
(3) Post febrile delirium.—Developing during the period of de- 
fervescence and convalescence (collapse delirium included). 
b. Under mental disturbances attending exhaustion are included 
these manifestations resulting from exhaustion from any cause, as 
hemorrhage, starvation, severe physical overexertion, severe mental 
shock, wasting diseases, prolonged insomnia, prolonged worry, and 
prolonged convalescence from infections. 
111. Symptomatology.—The symptom-complex is a delirium. 
Following a few days of insomnia and restlessness, there develops very 
rapidly a condition of motor excitement with clouding of conscious- 
ness, dreamy hallucinations, and delusions. Orientation is quickly 
lost; the patients become noisy and talkative; the contents of speech 
show great incoherence, sometimes with a flight of ideas. In emotional 
attitude there is much exhaltation as a rule though occasionally 
depression with anxiety may predominate the emotional tone. The 
motor excitement is very pronounced. The patients remove their cloth- 
ing, race about the room, overturn furniture, pound the door, and 
attempt to escape. Physically, following the onset and during the 
height of the disease, there is great insomnia. They take little nour- 
ishment and therei is marked loss of flesh and physical weakness. 
Many cases require mechanical feeding. The course is short, the con- 
dition rarely lasting over 2 weeks. The return to consciousness is 
usually sudden and relapses are rare. 
112. Differential diagnosis.—The condition must be differenti- 
ated from epileptic dazedness, delirium tremens, catatonic excitement, 
paresis, and the acute mania of manic-depressive psychoses. 
113. Toxic psychoses.—Under this classification will be consid- 
ered the mental disturbances resulting from alcohol, which includes 
ordinary intoxication, pathological intoxication, delirium tremens, 
Korsakow’s psychosis, acute hallucinosis, chronic hallucinosis, acute 
paranoid type, chronic paranoid type, alcoholic deterioration (in the 
chronic drinker), and dipsomania; and drugs and other exogenous 
poisons. 
a. Alcohol.—Over-indulgence in alcohol may be a symptom of or 
incidental to some psychosis not alcoholic. Excepting ordinary in- 
toxication, all the psychoses described below are precipitated by 
chronic drinking. At the present time, the tendency is to consider 
acute alcoholic hallucinosis as a symptom-complex which is libera- 
ted by the alcoholic excess, and a psychogenic reaction rather than a 
reaction due to the toxic action of the alcohol. 
(1) Ordinary intoxication.—The higher psychic centers are in- 
hibited, resulting in apparent stimulation; then follows paralysis of 
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NEUROPSYCHIATRY IN AVIATION MEDICINE 
the centers controlling muscular coordination; then sensory disturb- 
ances; followed in extreme cases by coma and death. The mood is 
either exalted or depressed. 
(2) Pathological intoxication.—There is an unusual or abnormal 
immediate reaction to taking a large or small amount of alcohol. It 
is essentially an acute mental disturbance of short duration charac- 
terized usually by an excitement or furor with hallucinations and 
delusions, followed by amnesia. 
(3) Delirium tremens.—This is an acute hallucinatory condition 
with marked general tremor and toxic symptoms. It may occur as 
the result of a prolonged debauch in connection with a traumatism 
or as the initial symptom of an acute illness, in each instance the 
subject being a chronic alcoholic. The hallucinations are auditory, 
visual, haptic, and disagreeable. Disorientation is apt to be com- 
plete and psychomotor activity marked. Obviously, the above mani- 
festations are accompanied in the emotional sphere by a mood of con- 
stant apprehension and fear concerning the terrifying environment. 
On the contrary, some patients may remain calm, even finding 
interest and amusement in their delirious experience. 
(4) Korsakov?s psychosis.—This is often called a chronic alcoholic 
delirium in contradistinction from delirium tremens which is an 
acute alcoholic delirium. This disorder is the mental state accom- 
panying polyneuritis and is usually of alcoholic origin, but may be 
induced by various other poisons, the polyneuritis being very slight. 
In the alcoholic type, an ordinary delirium tremens merges into a 
protracted delirium known as Korsakow’s psychosis with anterograde 
amnesia, paramnesia, and disorientation. There is composure of 
manner and apparent lucidity while paramnesia is manifested by 
filling in the gaps resulting from disordered perception with falsifi- 
cations of memory, aptly called “opportune confabulation.” 
(5) Acute hallucinosis.—This is chiefly an auditory hallucinosis of 
rapid development with clearness of the sensorium, but with marked 
fears and a more or less systematized persecutory trend. 
(6) Chronic hallucinosis.—This is an infrequent type which may be 
regarded as the persistence of the acute hallucinosis without change 
in the character of the symptoms except perhaps a gradual lessening 
of the emotional reaction accompanying the hallucinations. 
(7) Acute paranoid type.—This type has suspicions, misinterpre- 
tations, persecutory ideas, and often a jealous trend; the hallucina- 
tions are usually subordinate, and the condition clears up on the 
withdrawal of alcohol. 
(8) Chronic paranoid type.—This type is characterized by per- 
sistence of symptoms of the acute paranoid type with fixed delusions 
133 TM 8-325 
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MEDTOAL department 
of persecution or jealousy, usually not influenced by withdrawal of 
alcohol; difficult to differentiate from nonalcoholic paranoid states or 
dementia praecox. 
(9) Alcoholic deterioration.—This is a gradual and progressive 
intellectual, moral, esthetic, emotional, and volutional deterioration 
in the chronic drinker; relatively few cases are admitted to insti- 
tutional care because the mental symptoms are not apt to be con- 
sidered sufficient to warrant the diagnosis of a definite psychosis. 
On the psychical side the chief symptoms are insidious but pro- 
gressive intellectual enfeeblement; flagrant immoralities; indifference 
concerning inefficiency; misery and humiliation of family, and com- 
prised honor; loss of the esthetic sense; ill humor, irascibility or 
a jovial, careless, facetious mood; diminished inclination and capacity 
for mental application with disinclination to undertake new work 
and tendency to continue in the same course. These diverse mani- 
festations, in range, degree, fluctuation, and course, variously but 
none the less unmistakably, indicate lessening efficiency and moral 
decay. The physical changes are equally disastrous, involving as 
they do the stomach, pancreas, liver, kidneys, spleen, blood vessels, 
and nervous system, central as well as peripheral. 
(10) Dipsomania.—This is a periodic impulse to drink and is to 
be interpreted as evidence of a deep-seated constitutional inferiority, 
b. Drugs and other exogenous poisons.—(1) Opium.—A single 
dose causes mild stimulation of the mental faculties, followed by a 
quiet, half-waking, half-sleeping period interrupted by multiform 
pleasant hallucinations (predominating visual). The prolonged 
use produces a train of somatic disturbances and results in mental 
and moral deterioration. 
(2) Cocaine.—A single dose produces marked stimulation but the 
effects are fleeting and the dose must be frequently renewed. The 
prolonged use produces, as with opium, a train of somatic disturb- 
ances and results in mental and moral deterioration. Opium caues 
miosis; cocaine, mydriasis. In neither are there apt to be found 
the degenerative tissue changes seen in alcoholic habitues. The 
cocaine habit is more difficult to overcome than addiction to either 
alcohol or morphine, because the effects are more dominating and 
disintegrating. 
(3) Other drugs.—Various other drugs, as bromine, chloral, canna- 
bis indica, hyocyamus, belladonna, etc.; metals, as arsenic and lead; 
and gases produce psychotic symptoms and should be kept in mind 
in making diagnosis. 
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NETJ710 PSYCHI ATEY IN AVIATION MEDICINE 
114. Symptomatic psychoses.—Under this classification will be 
considered those mental disorders, either associated with or symp- 
tomatic of, certain bodily diseases. Auto-toxic psychoses, thy- 
roigenous psychoses, and psychoses with certain nervous diseases are 
described below. 
a. Auto-toxic psychoses.—(1) Urerrda.—The uremic convulsion can- 
not be distinguished in its outward manifestations from the ordinary 
epileptic attack. Acute uremic conditions may present hallucinations, 
delusions, dream states, disorientation, disturbances of the sensorium, 
and increased psychomotor activity. Usually in chronic uremia there 
are marked mental symptoms. There is apt to be a general stupidity, 
irritability, tremor, ocular palsies, speech disturbances, pupillary 
differences, and sluggish or failing light reactions. If along with 
these symptoms there are Jacksonian attacks followed by monoplegia 
or hemiplegia with aphasia and visual disturbances, the similarity to 
paresis on the one hand, or to brain tumor on the other, may be very 
great. The mood may be depressed or euphoric. Some cases of 
uremic psychosis resemble dementia praecox presenting negativism 
and catatonic symptoms. 
(2) Diabetes.—In this disease there is often a mild depression with 
ideas of ruin or sin, or paranoid ideas may develop. The clinical pic- 
ture may create the impression of paresis. 
(3) Oastro-mtestinal conditions.—The mood in these conditions is 
usually one of depression, with psychoneurotic rather than psychotic 
symptoms. 
h. Thyroigenous psychoses.—These psychoses may be divided into 
two classes, those due to deficient secretion (the hypothyreoses) in 
eluding myxoedema and cretinism; and those due to increased glandu- 
lar action (the hyperthyreoses) represented by exophthalmic goitre. 
(1) Myxoedema.—The thyroid gland atrophies, or becomes diseased 
during adolescence or later. There are pronounced indications on the 
mental side, usually those of defect. There is defect of memory, atten- 
tion is diminished, thinking and speech slow with poor apprehension, 
loss of initiative, motor reluctance, and emotional dullness. The whole 
picture is one of advancing stupidity, going on, if there is no relief, to 
dementia. On the physical side, there are characteristic integumentary 
and nervous symptoms. The skin is thickened, dry, rough, inelastic, 
particularly in the supravicular region, over the upper arms and the 
abdominal wall, and the facial lines of expression are obliterated, pro- 
ducing a physiognomy expressing immobility and stupidity. The nose 
is broad, the lips thick, the tongue thick and unwieldy, and the speech 
rough and monotonous, the hairy growths are scanty, the hairs dry 
135 TM 8-325 
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MEDTOAL DEPAKTMENT 
and brittle, the nails deformed and brittle, and the hands and fingers 
misshapen. The skin and mucous membranes become anaemic, very 
sensitive to cold, the menses cease, and the temperature becomes sub- 
normal. The nervous symptoms are headache, vertigo, fainting, 
convulsive attacks, and fine tremors. 
(2) Cretinism.—This appears during the first and second years of 
childhood and there is an arrest of somatic and psychic development 
dependent generally upon a goitre and more rarely upon atrophy of 
the thyroid gland. The child is dull, stupid, indifferent, sleepy, not 
learning to walk or talk, and slow and awkward in movement. The 
patients continue indifferent and phlegmatic, fail to develop mentally, 
and remain at about the 5-year level. 
The long bones thicken and do not increase in length, the head is 
large, the neck short and thick, nose broad, ears prominent, and the 
skin thickened as though padded, and in places, especially the neck, 
hanging in folds. The characteristic physiognomy with the pudgy 
legs, scanty hair, defective teeth, coarse inarticulate speech sounds, 
and the unwieldly cumbersome gait, presents a picture quite unmis- 
takable. 
(3) Exophthalmic goitre.—The prevailing mental tone is that of 
fear and apprehension. There is emotional irritability and change- 
ability, there may be manic phases or profound depressions. There is 
some tendency to ally the hyperthyreoses with the manic-depressive 
group and to separate certain manic-depressives as largely conditioned 
by hyperthyroid activity. 
c. Psychosis with certain nervous diseases.— (1) Sydenham’s cho- 
rea.—In addition to the adiodokokinesis and asynergia on the physical 
side, there is on the mental side, irritability, fretfulness, and emotional 
instability. Some cases develop terrifying dreams and hallucinations. 
Korsakow’s psychosis may appear as a result of polyneuritis from over- 
treatment with arsenic. 
(2) Huntingdon’s chorea.—There is a tendency to mental deteriora- 
tion with depression and suspiciousness. 
(3) Paralysis agitens.—This is often characterized by a mild degree 
of mental deterioration. As this is a disease of later life, it should 
be remembered that arteriosclerosis and senile changes may contribute 
toward the mental enfeeblement. Occasionally patients develop a 
well-marked psychosis of a depressive hypochondriacal character with 
paranoid coloring. 
(4) Multiple sclerosis.—There may be slight mental impairment, but 
the principle manifestations are in the emotional sphere shown by 
instability. 
(5) Korsakovas psychosis.—See paragraph 112a (4). 
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NEUROPSYCHIATRY IN AVIATION MEDICINE 
(6) Encephalitis lethargical—There is no psychosis peculiar to this 
infection. The mental changes observed are usually of an emotional 
nature and show as behavior disorders or regressions to earlier methods 
of reacting. 
Section XIX 
PSYCHOSES ASSOCIATED WITH ORGANIC DISEASES OF, 
AND INJURY TO, THE BRAIN 
Paragraph 
General 115 
Phychoses with cerebral syphilis 116 
Psychoses with brain tumor 117 
Traumatic psychoses 118 
115. General.—Psychoses associated with organic disease of, and 
injury to, the brain are epilepsy, described in section XI; psychoses 
with cerebral syphilis; psychoses with brain tumor; and traumatic 
psychoses. 
116. Psychoses with cerebral syphilis.—General paresis is a 
parenchymatous form of brain syphilis; cerebral syphilis is an inter- 
stitial form. Differentiation between paresis and cerebral syphilis is 
important because of the difference in symptomatology, course, and 
prognosis. 
a. Types.—In accordance with the predominating pathological char- 
acteristics, three types of cerebral syphilis are distinguished; endar- 
teritic, meningitic, and gummatous. In none of the forms are psy- 
chotic symptoms as manifest as in paresis, and the personality is much 
better preserved as shown by the social reactions, ethical sense, judg- 
ment, and general behavior. The grotesque and grandiose delusions 
of the paretic are rarely shown by the victim of cerebral syphilis. 
(1) The endarteritic type is the most common. It is difficult to 
distinguish from cerebral arteriosclerosis, the clinical manifestations 
being essentially the same. 
(2) The meningitic type is next in frequency. It usually develops 
within 5 years after the initial lesion and reaches complete develop- 
ment in two or three weeks. 
(a) Physical symptoms.—In order of importance these are head- 
ache, dizziness, vomiting, convulsions, and evidences of cranial nerve 
involvement. The Argyll-Eobertson sign is generally absent, but the 
pupillary reaction to light and distance is likely to be sluggish. A 
spastic and partly paralytic condition of the lower extremities with 
increased knee jerks and bilateral and unilateral Babinski is often 
found. 
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MEDICAL DE PARTME'NT 
(&) Mental symptoms.—These are very important. The patients 
very characteristically present a lethargic, typhoid, or semicomatose 
condition, with a purposeless, hazy motor delirium. From this con- 
dition, they may be roused to answer questions in a slow, drawling, 
dreamy, sleepy manner and may even perform complex acts in 
response to requests or demands, the while remaining unable to re- 
spond to the calls of nature. However in cerebral syphilis, there 
is no such alteration of the personality as occurs in paresis. The 
critical faculties are well preserved and the patient remains conscious 
of his intellectual deficiencies, nor is he by any means indifferent con- 
cerning his condition. 
(3) The gummatous type is infrequent. It is characterized ana- 
tomically by one or more gummata originating in the meninges and 
extending into the brain substance. The physical symptoms resemble 
those of brain tumor, together with hemianopsia, aphasia, convul- 
sions, hemiplegia, etc., according to the location of the gummata. 
The mental symptoms resemble those of the meningitic type. 
5. Prognosis.—Early and prompt treatment may produce marked 
improvement and sometimes a cure. The meningitic cases are most 
amenable to treatment; the gummatous the most resistant; while the 
endarteritic, though often showing a change for the better, are least 
favorable owing to tissue destruction. For differential diagnosis be- 
tween paresis and cerebral syphilis see study of paresis (sec. XVI). 
117. Psychoses with brain tumor.—The cause, pathology, or 
neurological signs of brain tumor will not be considered. Mental 
symptoms due to brain tumor are not frequently found, however they 
have been divided into three groups; those due to increased intra- 
cranial pressure, those due to site of tumor and the structures injured 
by it, character changes based on individual personality. Noyes adds 
a fourth, the depressive and anxious reactions, noted following paral- 
yses, disturbances of vision, headache, vomiting, or epileptic attacks. 
Increased pressure affects practically all of the mechanisms of the 
mind because of its interference with the arteriovenous and cerebro- 
spinal circulation. Tumors do not produce characteristic psycho- 
logic disturbances because of their locality, as they do produce 
characteristic neurologic signs. Tumors in the prefrontal and tem- 
poral lobes in their early stages produce mental symptoms as well 
as those in the corpus callosum which takes the form of a childlike 
dementia. One authority reports 21 of 25 patients with frontal 
tumors having mental changes, and states that the most constant 
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NEUROPSYCHIATRY IN AVIATION MEDICINE 
symptoms are a peculiar indifference and failure of the patient to 
realize the seriousness of his condition, a loss of sense of responsibility, 
impairment of attention, loss of memory for recent events, and of 
interest and enthusiasm in his usual vocation. In some cases, the 
symptoms of frontal lobe tumor resemble those of dementia para- 
lytica. Briefly, the most common findings in other parts of the 
brain are: in temporal lobe involvement are noted visual hallucina- 
tions; in the occipital lobe mistakes in calculation; disorientation in 
tumors of the parietal region; in tumors of the cerebellum, giddi- 
ness, ataxia, asynergia and a tendency to fall. Tumors of the brain 
stem show no mental symptoms. Alterations in personality occur1 
most frequently in tumors of the frontal lobe, but may occur regard- 
less of the site of the tumor and may be manifested in various expres- 
sions of personality disorganization. Noyes believes that these per- 
sonality changes are due to a disturbance of integrating functions 
and are of psychological rather than of focal significance, and prob- 
ably merely defensive reactions. 
These various mental symptoms noted in brain tumor have been 
described in detail in order to emphasize their importance, especially 
in a differential diagnosis between them and the various organic and 
functional psychoses as well as the minor psychoses. 
118. Traumatic psychoses.—Here will be considered those psy- 
chotic symptoms of a fairly characteristic type, arising as a direct 
or obvious consequence of trauma to the head. The amount of dam- 
age to the brain may range all the way from extensive tissue destruc- 
tion to simple concussion or physical shock with or without fracture. 
The three following classifications comprise the fairly characteristic 
psychotic manifestations: 
a. Traumatic delirium.—Occurs either as an acute (concussion) 
delirium or as a more protracted delirium resembling the Korsakow 
complex. 
b. Traumatic constitution.—Shown as a gradual post-traumatic 
change in disposition with vasomotor instability, headaches, fatig- 
ability, irritability, or explosive emotional reactions; usually hyper- 
sensitiveness to alcohol, and in some cases development of paranoid, 
hysteroid, or epileptoid symptoms. 
c. Post-tramnatic mental enfeeblement.—Showing varying degrees 
of mental reduction with or without aphasic symptoms, epileptiform 
attacks, or development of a cerebral arteriosclerosis. 
139 TM 8-325 
119-120 
MEDICAL DEPARTMENT 
Section XX 
SENILE PSYCHOSES 
Paragraph 
General 119 
Types . 120 
119. General.—There is nothing more inevitable than old age, 
and although the active flying personnel of the Air Corps does not have 
the same opportunity of attaining this state as do others in the Army, 
flight surgeons will have a certain proportion who reach senility to 
contend with. As Noyes states, the essential features of the senile 
psychoses are a progressive impoverishment of mental resources and 
a gradual regression of the personality incident to an advancing 
dissolution of the highly specialized nerve tissue during the senile 
period. The reason this occurs is not known, but it is supposed that 
it is due to an innate inadequacy in durability of neurones. The 
pathology is interesting. There is a general reduction in brain volume, 
and the concomitant dementia is proportionate to this reduction. The 
white matter and gray matter are both diminished in size, as are the 
basal ganglia, the convolutions are atrophied, especially in the frontal 
region, with consequent widening of the fissure. The ventricles are 
dilated, and there is an increased amount of fluid in the subarachnoid 
spaces. The brain macroscopicallt gives the appearance of being 
worn out. There is a reduction of parenchymatous cells and in the 
numbers of fibers. There are also two types of amorphous deposits 
found in these brains; one type is known as corpora amylacea, and 
the other type as senile plaques. In connection with these senile 
changes in the brain, sclerosis of the cerebral arteries may also be 
found, and clinically it is difficult to tell, as Noyes states, which of 
the two findings is producing the symptoms in a given case. The 
diagnosis of senile dementia is not difficult. Rarely does senile de- 
mentia occur before 60, and retirement is not mandatory until the 
age of 64. The earliest signs noted are a loss of memory for recent 
events and a tendency to reminesce, the theme being characteristically 
personal. Orientation becomes defective, judgment impaired, hal- 
lucinations are not uncommon, and at times delusions are apparent. 
The physical findings are those of senility; thin, atrophied, wrinkled 
skin, with general bodily deterioration. 
120. Types.—Clinical types have been divided into simple deterio- 
ration, delirious and confused, depressed and agitated, paranoid, and 
presenile. TM 8-335 
120 
FEU'R'OPSYOHIATRY IN AVIATION MEDICINE 
a. The simple deteriorating type is the most commonly noted in 
senile psychoses; a gradual lessening of contact with the environment 
until a vegetative, stuporous stage results. 
h. The delirious, confused type is as designated. The onset is acute 
with the patient becoming restless, resistive, and may die of exhaustion. 
c. In the depressed and agitated type is found not only memory 
loss and intellectual impoverishment, but also a persistent agitation 
with melancholic, hypochondriacal, and nihilistic delusions. 
d. The paranoid type is characterized by persecutory delusions. 
This type of psychosis is again influenced by the prepsychotic life 
history. With loss of judgment, the delusions become more absurd, 
hallucinations and illusions are prominent, in fact more than in any 
of the other types although consciousness and orientation are not 
disturbed. 
e. Presenile psychoses derive their name because of their occurrence 
between the ages of 40 and 60, or what is termed the presenile period. 
There are several types which are determined by their difference in 
histopathology; those usually recognized are Alzheimer’s disease, 
Pick’s disease, and presbyophrenia. 
(1) In Alzheimer’s disease the clinical findings vary, but in general 
there is fairly rapid mental deterioration, disorientation, memory 
defect, delirium, disturbances of speech, such as incoherence, aphasia, 
inability to understand spoken language, disturbances in writing, 
apraxia, and agnosia. It is a precocious form of senile dementia. The 
histopathological findings are characterized by tangled thread-like 
structures occupying much or all of the body of the cortical ganglion 
cells. These were first noted by Alzheimer, therefore the name 
“Alzheimer’s disease.” 
(2) Pick’s disease is characterized histopathologically by premature 
focal and extreme atrophy in individuals under 60 years of age. The 
clinical findings are dependent upon the diffuse and focal processes 
in the brain. It is an uncommon form of organic mental disease. 
The microscopic findings are those of degeneration. The white mat- 
ter atrophies early. The mental symptoms develop rapidly, becoming 
well established within a year. The most common findings are those 
of echolalia, alexia, agraphia, and aphasia; the characteristic of the 
aphasia being that it comes on gradually in comparison to the sudden- 
ness noted in vascular disease. The patient usually dies in from 2 to 4 
years of some intercurrent infection. Dementia is extreme and cachexia 
becomes marked. Some believe this condition to be merely senile 
dementia, others that it is a distinct entity. 
141 TM 8-335 
120 
MEiDTQAL. DGPAKTM'E'NT 
(3) Presbyophrenia becomes apparent typically in the presenile 
stage and usually during the involutional period. It is characterized 
by confabulation and defect of retention. There is no distinct pathol- 
ogy in presbyophrenia. Some consider it a stage of Alzheimer’s dis- 
ease, and others just an early senile dementia. It is more common in 
women than in men. Memory is greatly impaired, but the patient 
covers this impairment by confabulation and these are unnoticed by 
the patient. This is suggestive of Korsakow’s psychosis, the distin- 
guishing feature being the age of the patient as well as the gradual 
deterioration and onset and absence of neuritic symptoms. Prognosis 
is hopeless, the course progressive. The diagnosis of simple senile 
dementia is comparatively easy when we consider the outstanding 
findings which are first the age, then the characteristic memory loss, 
and the progressive egocentricity. Differentiation must be made as to 
involutional melancholia. The points to consider here are the age and 
the presence or absence of mental deterioration. The question as to 
cranial arteriosclerosis or senility being present is difficult to deter- 
mine in some cases. They are at times both present. In considering 
this differentiation, the presence of exacerbation of mental symptoms, 
apoplectic attacks, aphasias and neurological findings should be noted. 
Treatment involves the individual. Patients are usually better satis- 
fied in their accustomed surroundings. However, at times it becomes 
necessary to institutionalize these patients for the safety and good 
of the family. It is a foregone conclusion that in the first evidence of 
any of these signs and symptoms in Air Corps personnel, steps should 
be taken immediately to remove them from military responsibility. 
This is of special importance in the event of senile paranoids. They 
have usually been the defensive paranoid type, and it is difficult to 
state when the psychotic line is passed. They will compensate the 
threat to their personality by rendering decisions detrimental to their 
juniors, because of belief that they are conspiring their downfall. This 
should be prevented and can only be so done by intelligent medical 
officers. 
Section XXI 
EPIDEMIC ENCEPHALITIS 
Paragraph 
General— 121 
History' 123 
Relation to other diseases 124 
Etiology 125 
Pathology 126 
Symptoms * 127 
142 TM 8-335 
131-124 
imjEOPSYCHTATRY IN’ AYIATICOT MEDICINE 
Paragraph 
Duration and course 128 
Sequelae 130 
Diagnosis 131 
Prognosis 132 
Treatment 133 
121. General.—Because medical officers are brought into contact 
with large groups of individuals in early adult life, especially during 
mobilization and war, and as epidemic encephalitis is more prevalent 
in this age group, it is advisable to give a brief outline and discussion 
of this disease. 
122. Definition.—Epidemic encephalitis is an acute inflammatory 
infection of the central nervous system, with a special predilection for 
the gray matter of the brain-stem and basal ganglia. It occurs in 
epidemic form and presents a variety of clinical types. Sequelae are 
numerous and there is a marked tendency to recurrence. In its clas- 
sical form, the disorder is characterized by cranial nerve palsies, a pecu- 
liar somnolence or lethargy and symptoms referable to the extrapy- 
ramidal system of motility. 
123. History.—From the standpoint of modern medicine, this 
affection must be regarded as a new disease. The first description was 
given by von Economo in May 1917, based upon the observation of a 
small epidemic which had occurred in Vienna during the previous 
winter. He called the affection “encephalitis lethargica.” In April 
of the same year, the French medical men recorded a similar group 
of cases in France which they termed “subacute encephalomyelitis.” 
The disease represents a new clinical and pathological entity, and while 
its appearance in epidemic form is new, its occurrence in sporadic form 
has been observed from time to time in the past. For more than 200 
years, the occurence of lethargy and asthenia as prominent symptoms 
of an epidemic disease having some of the features of influenza has 
been noted by medical waiters. One such an epidemic occurred in 
Germany in 1712, to which the name “sleeping sickness” was given; and 
the disease called “Nona,” which appeared in 1890 and 1892, were 
closely related to this affection. Both of these disorders were asso- 
ciated with epidemics of influenza. Of even greater significance is 
the electric chorea which appeared in Northern Italy in 1846 and was 
first observed by Dubini. The resemblance of this group of cases to 
the myoclonic form of epidemic encephalitis is very striking. 
124. Relation to other diseases.—The exact relation which this 
affection bears to certain other diseases has played an important role 
in recent investigations. Considerable emphasis has been laid by some 
143 TM 8-325 
124-125 
observers on tbe simultaneous appearance of epidemics of influenza 
with those of epidemic encephalitis. No constant relationship, how- 
ever, in the occurrence of the two disorders has been shown to exist. 
In certain epidemics, encephalitis has been the first to appear, as in 
the Vienna outbreak in 1916, while at other times influenza preceded 
the occurrence of encephalitis. However, there has been enough im- 
portance given to the association of influenza so that the Veterans’ 
Administration has ruled that encephalitis lethargica is a sequelae of 
influenza, and therefore a compensable condition. One condition that 
has occurred frequently, epidemic hiccough, seems more closely related 
to epidemic encephalitis, if not actually identical with it. In the 
early history of epidemic encephalitis, certain resemblances to the cere- 
bral forms of poliomyelitis were noted. Both disorders are inflamma- 
tory in nature and both have certain epidemiological features in 
common. There is a difference, however, in seasonal incidence, age 
susceptibility, mortality, and the localization of the virus. Certain 
differences in pathological changes are also present. In poliomyelitis, 
for example, while round cells do occur, it is the polymorphonuclear 
leukocyte which plays the most conspicuous role. The meninges also 
show greater involvement and neuronophagocytosis is more common. 
125. Etiology.—Among the predisposing causes are overwork and 
worry, the lowering of resistance by infectious disease, and especially 
influenza. Social conditions and occupation appear to play but a 
minor role. The comparative infrequency of the disease among nurses 
and medical men exposed to the infection is worthy of mention. 
<7. Age.—Epidemic encephalitis is most common in early adult life, 
but may occur at any age from infancy to old age. It has been ob- 
served as early as the second week of life and cases of encephalitis neo- 
natorum have been recorded in which the disease appeared immediately 
after birth, probably by placental infection. 
h. Sex.—The distribution is about equally divided between the two 
sexes. In Smith’s series, GO percent were males and 40 percent females. 
c. Injectivity.—One source of the virus is the nasopharynx. The 
evidence also suggests that the infectious agent is carried through the 
air and not conveyed by biting insects, water or food. The disease 
is not highly infectious and the evidence in favor of personal con- 
tagion is very slight. Multiple cases in families and small outbreaks 
in institutions were observed during the epidemic, as well as infection 
of the newborn by the mother through nursing or placental transmis- 
sion. In hospitals and institutions, the instances of direct contagion 
are very few. Carriers also play a role in dissemination. These may 
be convalescents or those who have suffered a mild or abortive attack. 
MEDTOALi HEPABTTMENT 
144 T3VE 8-325 
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NEUROPSYCHIATRY IN AVIATION MEDICINE 
Once the infection is established, there is a decided tendency to chronic- 
ity and recurrence. An interval of months or even years may elapse 
between the acute and chronic stage, and like disseminated sclerosis 
and syphilis, the virus of the disease may remain quiescent in the 
central nervous system for long periods of time. 
d. Incubation period.—This is difficult to determine with accuracy. 
The evidence indicates that it may vary from 1 day to 2 weeks or even 
longer. 
126. Pathology.—The brain is congested and oedematous, and the 
seat of numerous inflammatory foci. These are particularly well- 
marked in the gray matter of the pons and basal ganglia. Inflam- 
matory lesions are also found in the cerebral cortex, in the medulla, and 
rarely in the cerebellum. They are also rare in the spinal cord. Hem- 
orrhages are often absent but hemorrhagic extravasations, both small 
and large, may occur. Numerous minute hemorrhages have been found. 
A group of cases with hemorrhages in the cerebral cortex has been 
described. In the inflamed areas, there is more or less extensive round- 
cell infiltration of the gray matter and of the perivascular lymphatic 
sheaths consisting of large and small mononuclear lymphocytes, poly- 
blasts, and plasma cells. The ganglion cells, unlike poliomyelitis, 
are not especially involved except in the affected areas, where 
they may be swollen and show diffuse changes in the chromatin. 
Neuronophagia is rare. The glia cells sometimes show proliferation. 
As a rule there are no marked meningeal changes. A mild leptomen- 
ingitis has been found. In the chronic stage, evidences of atrophy of 
the neural structures, both cells and nerve fibres, are manifest. Spe- 
cial medullary stains often reveal a more or less well-defined funicular 
degeneration in pyramidal tracts, posterior columns, and crus cerebelli. 
In relapsing cases, evidences of acute and chronic lesions are encoun- 
tered side by side (von Economo). Some authorities found inflamma- 
tory and degenerative changes in the spinal nerve roots and similar 
changes were found in the trigeminal nerve roots by other authorities. 
Minute bodies have been reported both within and without the ganglion 
cells, and suggests a possible relationship to the virus of the disease, 
they playing the same role in encephalitis as Negri’s bodies in rabies. 
The inflammatory lesions may be very slow in developing and in fatal 
cases may be absent even after a week’s illness. 
127. Symptoms.—The clinical manifestations of epidemic enceph- 
alitis cover a very wide range in both the acute and chronic stages. 
There are great variations, both in virulence and localization, so that 
a large array of clinical types is presented. The sequelae are fre- 
quent and many are of unusual character. There is no other acute 
274758°—£1—■—10 TM 8—325 
127 
MEiDIOAL. D'BPAROI'ENT 
inflammatory affection of the central nervous system which is more 
grave in its immediate effects and more serious in its later conse- 
quences. The onset may be either acute or gradual. Tilney states 
that 6 to 12 percent of the cases have an acute onset; 88 to 94 percent 
have a gradual onset. The initial symptoms in order of frequency 
are headache (present in nearly half the cases) ; lethargy; vomiting; 
diplopia; change in character; fever; vertigo; general malaise, etc. 
Thirty-seven symptoms are listed by Tilney, ranging from nearly 
50 percent for headache to about 2 percent for speech changes, fits, 
and conjunctivitis. Rarely the attack may come on so suddenly with 
loss of consciousness that an apoplectiform seizure is simulated. The 
general symptomatology is indicative of an infectious process. In a 
great majority of cases there is moderate fever in the early stage 
which continues usually for a fortnight and gradually subsides. 
a. Tilney gives the following table on “Parts of nervous system 
involved and resulting focal symptoms.” 
1. Oculomotor nucleus. 
Palsies of extrinsic and intrinsic 
eye muscles. 
2. Basal ganglia—including striatum, 
thalamus and red nucleus. 
Paralysis agitans. 
Athetosis. 
Chorea, 
Choreoathetosis. 
Mobile spasm. 
Cataleptic rigidity. 
Myorhythmic movements. 
Emotional imbalance, 
3. Pons varolii. 
Facial paralysis. 
Abducens paralysis. 
4. Cerebral cortex. 
Delirium. 
Hallucinosis. 
Confusion and mania. 
Behavior perversions. 
Hypersomnia. 
Insomnia. 
Aphasia. 
Anesthesia. 
Convulsions. 
Astereognosis. 
5. Spinal cord. 
Myoclenic spasms. 
Flaccid paralysis. 
6. Dorsal roots. 
Radicular pains. 
7. Medulla oblongata. 
Vertigo and tinnitus. 
Nausea and vomiting. 
Dyspnea and tachycardia. 
Dysphagia. 
Respiratory and cardiac. 
Death. 
8. Internal capsule. 
Hemiplegia. 
9. Optic nerve. 
Amblyopia. 
©ptic neuritis. 
Choked disk. 
10. Dorsal root ganglia. 
Herpes Zoster. 
b. J. Ramsey Hunt, in Osier’s Modern Medicine, quoting A. C. 
Parson’s study of 1,275 cases in Great Britain, lists three great clinical 
groups, dependent upon the virulence of the infection and localization 
of the virus in the various nerve centers and pathways to the brain 
and spinal cord. TM 8-325 
127-1S9 
3STETJR0PSYCHIATRY IN AVIATION MEDICINE 
I. There is a general disturbance of the functions of the central nervous system 
without evidences of focal involvement. This type was observed in 6.7 percent 
of the cases. The general symptoms consist of lethargy, asthenia, and mental 
dullness; these may be severe in some cases and in others comparatively mild, 
grading off into the abortive type. In this group, transient ocular palsies were 
occasionally present. 
II. With general disturbances of function there is distinct evidence of focal 
involvement in the central nervous system. This type comprised 90 percent 
of the cases distributed as follows: 
a. Involvement of the oculomotor nerves—this group corresponds to the clas- 
sical description of the disease and is characterized by fever, lethargy, and 
ocular palsies. 
b. Involvement of the pons and medulla—in this series all of the cranial nerves 
may show involvement, but more especially the facial nerve. 
c. Involvement of the pyramidal and extra-pyramidal systems—in the former 
giving rise to hemiplegia, monoplegia, and paraplegia, and in the latter to Parkin- 
sonism, chorea, and athetosis. 
d. Ataxic type—this is rare and indicates an involvement of the cerebellar 
mechanism. 
e. Cerebral cortex—in 40 cases, motor symptoms referable to the cerebral 
cortex were present, including convulsive seizures, Jacksonian epilepsy, and 
speech disturbances. 
f. Spinal cord—the spinal mechanism is rarely involved. In three cases 
flaccid paralysis of the extremities and in two cases wasting of the arm and leg 
muscles were noted. 
g. Polyneuritic type—this is quite rare. In some cases, there was symmetrical 
involvement as in multiple neuritis with bilateral foot-drop. 
III. This is composed of mild abortive cases. There were 81 cases in this 
series, with a duration of 2 to 3 weeks, all terminating in complete recovery. 
This group is characterized by slight fever, sore throat, and gastro-intestinal 
symptoms with slight or negligible nervous symptoms. Some cases were so 
mild that their recognition was only possible during the active period of an 
epidemic. The ambulatory cases belong to this group and are often not recognized 
before the appearance of transient diplopia. 
138. Duration and course.—Of the cases that recover, the dura- 
tion of the primary disease is from 4 to 8 weeks, somewhat longer 
in children than in adults. Of the recognized cases, probably less 
than 20 percent make a complete recovery. Remissions and exacerba- 
tions extending over a period of months or years are frequently seen. 
Recovery with residuals is the rule. In about 60 percent there remain 
serious and progressive disabilities. Some authorities estimate that 
fully 90 percent suffer some mental impairment as a result of the 
disease. 
129. Recurrences.—It is well established that there is a well- 
marked tendency to recurrence. An ominous feature of this tendency 
is the long interval of time which may elapse between the initial 
infection and the relapse. In some instances, this has been 2, 3, and 
even 10 years. Often the original infection was slight and attracted TM 8-335 
129-131 
MEDICAL DEPARTMENT 
but little attention. More than one relapse may also occur and in 
this respect the disorder resembles disseminated sclerosis and syphilis 
of the central nervous system. 
130. Sequelae.—It is difficult to draw a distinct line between the 
long-continued symptoms of the disease and sequelae. It is becoming 
more and more common to speak of chronic epidemic encephalitis 
rather than of conditions present being sequelae of the disease. The 
most common conditions present in these chronic forms are Parkin- 
sonian syndrome, mental impairment, psychic changes (especially in 
children), various ocular defects, etc. The most dramatic form is 
the Parkinsonian syndrome which closely resembles paralysis agitans 
with its rigidity of expression, fixed stare, and paresis of the facial 
muscles particularly marked on mimetic innervation and therefore 
suggestive of thalamic pathology. There is inability to show the 
teeth properly, difficulty in protruding the tongue, dysarthria, sial- 
orrhoea, champing movements of the lower jaw, and generalized 
muscular rigidity with Parkinsonian attitude and gait. Intention 
tremor is often present. 
131. Diagnosis.—a. Any disease showing the diversity of clinical 
types and the numerous sequelae of epidemic encephalitis must also 
present corresponding diagnostic difficulties and uncertainties. Many 
of the cases, especially those of mild prodromal type, can only be 
detected during the actual progress of an epidemic. The diagnosis 
is readily made when the chronic stage follows immediately or soon 
after the acute phase. It is very difficult, however, if the febrile state 
was slight or poorly defined or occurred years previously. In the 
classical form with fever, lethargy, and cranial nerve palsies, and 
the type characterized by Parkinsonism, the diagnosis is relatively 
easy. 
h. In the early stage symptoms as apathy, drowsiness, headache, 
and diplopia associated with the general symptoms of infection are 
very suggestive, and during the course of an epidemic, are almost 
pathognomonic. Later, when the infection is well established, stupor, 
alternating with delirium, extreme asthenia, muscular rigidity, cra- 
nial nerve palsies, a mask-like expression of face, spontaneous stupor, 
chorea, or myoclonus may occur and give a characteristic stamp to 
the disorder. A peculiarity of the cranial nerve palsies is a tend- 
ency to amelioration in one distribution as the paralysis appears in 
another. Optic neuritis is comparatively rare and its absence in the 
presence of other nerve cerebral symptoms has a certain diagnostic 
value. 
c. In an important group, the mild initial symptoms are not recog- 
nized and it is only with the recurrence of the disorder when symp- 
148 TM 8-335 
131 
NEUROPSYCHIATRY IN AVIATION MEDICINE 
toms of paralysis agitans or chorea-athetosis appear that the diag- 
nosis is established. In rare instances, an apoplectic onset has been 
observed with stupor and paralysis simulating very closely cerebral 
hemorrhage. 
d. Tuberculous and meningococcus meningitis, cerebral tumor and 
cerebral hemorrhage are the conditions with which this disease is 
most readily confused. 
(1) In meningitis, the examination of the cerebrospinal fluid and 
the preponderance of meningeal symptoms are important. In the 
early stage of tuberculous meningitis, the cerebrospinal fluid may 
be similar to that of lethargic encephalitis. In other forms of men- 
ingitis, the spinal fluid changes are usually diagnostic. 
(2) In cerebral tumor, the slow progressive course and swelling of 
the optic nerves usually serve to differentiate but fundus changes 
resembling those of tumor may occur in the later stages. Encephali- 
tis shows a great tendency to remission and exacerbation and is more 
polymorphous in its clinical manifestations. In cerebral abscess, 
there is usually a previous history of trauma or infection of otogenic 
or rhinogenic origin. 
e. Cerebrospinal syphilis is distinguished by the history of infection 
and the serological reactions. In early life, poliomyelitis may come 
up for consideration but it has a different seasonal incidence, occur- 
ring in warm weather, and the paralysis is of the atrophic flaccid 
type. 
/. The disorder has also been confused with botulism and the early 
cases of the first epidemic in England were so regarded. Poisoning 
by narcotic drugs, barbital luminal, chloral, and morphine may also 
simulate the clinical picture. 
g. In many disorders of the central nervous system, the question 
of a previous attack of encephalitis is of great importance and in 
cases of paralysis agitans, chorea, athetosis, dystonia musculorum 
deformans, and myoclonus multiplex the previous history should be 
carefully scanned for evidences of a previous attack of encephalitis. 
This is also true in the psychoses, and especially in children, many 
obscure psychopathic states and sexual aberrations are sequelae of a 
previous attack of encephalitis. 
h. The classical paralysis agitans appears spontaneously and is 
not related to a previous infection. It is of gradual onset and 
progresses very gradually. 
i. The clinical field covered by encephalitis is so wide and so varied 
that the most careful history, physical and mental examination, to- 
gether with laboratory tests are required to solve the obscure diagnostic 
problems presented by this disorder. 
149 TM 8—335 
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MEDTOAL DEPARTMENT 
133. Prognosis.—This should always be guarded. Compara- 
tively mild cases frequently have a severe recurrence and a chronic 
condition results. The average mortality is given by Tilney as about 
25 percent and complete recovery at about 12 percent. 
133. Treatment.—No specific treatment for epidemic encephalitis 
has yet been discovered. Many drugs have been advocated, but only 
temporary relief has been obtained from any. Kest during the acute 
period should be strongly emphasized. Also during the convalescent 
period the treatment is rest. In view of the possibility of contagion, 
however slight, the patient should be isolated. Further than this, 
treatment is symptomatic. 
Section XXII 
NEUROLOGY 
Paragraph 
General 134 
Cranial nerves 135 
Trigeminal nerve 136 
Lesions of the facial nerve 138 
Glosso-pharyngeal and the pneumogastric nerves 139 
Accessorius 140 
Hypoglossus 141 
Articulation 142 
134. General.—a. It is impossible to do more than give a few 
suggestions in such a broad subject as neurology, but the brief outline 
given may be of value as a review of some cardinal points. The 
anamnesis should cover the essential points in the patient’s history, his 
previous life, and the history of his present illness. Allow the patient 
to tell his own story in his own words. Listen patiently and avoid 
making suggestions. To complete the history, a few leading questions 
may have to be asked, particularly about the following symptoms: 
Headache.—Constant or intermittent, diffuse or localized; hemicrania. 
Vomiting.—With or without a subjective feeling of nausea; projectile; 
any relation to the taking of food. 
Vertigo.—More pronounced in the dark than in the light; tendency 
to fall to one side; any subjective sensation of rotation. 
Disturbance of vision.—First and foremost diplopia (temporary 
diplopia very frequent in disseminated sclerosis and in syphilitic 
brain lesions, and in the early stages of encephalitis lethargica). 
Pain and paresthesias.—Location, character, radiation, etc., “cushion 
sensation,” “girdle sensation,” in tabes, etc. 
Disturbances of consciousness.—Loss of consciousness, clouding of 
consciousness, automatism, petit mah 
150 TJVE 8-325 
134-136 
NEUROPSYCHIATRY IN AVIATION MEDICINE 
Convulsive fits.—Tonic or clonic, general or localized, followed by 
localized paresis or paralysis. 
Bladder trouble.—Precipitate micturition (frequent in disseminated 
sclerosis); retention; incontinence (ischuria paradoxa). 
Constipation.—There is no doubt that many neurotic complaints are 
accentuated by constipation. 
Disorders of sleep.—Insomnia, hypersomnia. In insomnia is it the 
process of going to sleep that is impeded by pains, by persever- 
ing thought, or by anxiety ? Does the patient wake up with any 
peculiar sensation? How many hours does the patient sleep 
during the day or during the night ? 
b. It is of great importance to ascertain whether the illness started 
suddenly (a certain day or a certain hour; this generally indicates a 
vascular “catastrophe” as hemorrhage, embolism, thrombosis); or grad- 
ually (tumors, degenerative lesions); and if there have been remissions 
(as in disseminated sclerosis). 
c. Inquiries about syphilitic infection should always be made, if 
not directly, then indirectly, such as questions about abortions, still- 
births, rash, etc. Intemperance with regard to alcohol and tobacco or 
other drugs should be noted, and the quantity consumed should be 
stated as accurately as possible. 
135. Cranial nerves.—a. Test the olfactory nerve for anosmia by 
the use of peppermint, camphor, and asafetida. Avoid the use of 
irritating substances. Anosmia may be due to— 
(1) Tumor of the frontal lobe. 
(2) Cerebellar tumors. v 
(3) Atrophy of the olfactory nerves (tabes). 
(4) Hysteria. 
(5) Local lesions (rhinitis). 
b. The optic, oculomotor, trochlearis, abducens, and auditory nerves 
are fully discussed in TM 8-300, 
136. Trigeminal nerve.—a. Motor division.—Innervating all 
muscles of mastication is tested by having the patient clench his teeth 
as hard as he can and at the same time the maseeter and temporal 
muscles are tested by palpation. The patient is then directed to open 
his mouth wide, and any deviation of the lower jaw is noted. In 
affections of the motor part of the trigeminal, the lower jaw deviates 
to the side of the lesion because of the deficient action of the 
pterygoidei muscles. 
b. /Sensory division.—(1) Sensation of the face and a varying por- 
tion of scalp has to be tested by means of— 
(a) A piece of paper or cotton wool (touch). 
(6) Pinpricks (pain). TM 8-325 
136-137 
MEDICAL DEPARTMENT 
(<?) Test tubes filled with hot and cold water (temperature). 
(2) The sensory part of the trigeminal nerve is connected with the 
contralateral hemisphere only; the motor part with both. The points 
of exit of the chief sensory nerves are also tested for tenderness (frontal, 
supraorbital, infraorbital, and mental nerves). In trigeminal neu- 
ralgia, these are often excessively tender even between the neuralgic 
attacks. 
137. Facial nerve.—a. If the patient’s face has a one-sided 
appearance, this may be due to paresis or paralysis of the one side, to 
contracture of the other, to a developmental asymmetry, or to unilateral 
facial atrophy. Test in the following manner; 
(1) The patient is asked to raise his eyebrows. 
(2) To frown. 
(3) To shut his eyes and screw them up as tightly as he can; by then 
trying to open them against the patient’s efforts to keep them closed, an 
impression of the power of the orbiculares oculi is obtained. 
h. The above tests are for the muscles of the upper facial portion 
which has a bilateral cortical innervation and which consequently is 
not affected in supranuclear lesions, for example, the ordinarily cap- 
sular hemiplegia, or at least not to the same extent as the lower part of 
the facial muscles. These are tested in the following manner: 
(1) The patient is asked to show his teeth. 
(2) To blow out his cheeks. 
(3) To whistle. 
(4) To smile. 
c. Many patients, mostly females, smile spontaneously after the 
effort of whistling. It is important to take note of this as well as of 
the patient’s spontaneous emotional expressions in general. 
d. In thalmic lesions, it is often found that there is deficiency or 
loss of the movements of emotional expression on the opposite side 
of the face while the above tests (all carried out on the examiner’s 
command and having nothing to do with emotional expression) 
betray no disturbance. 
e. On the other hand, it is commonly found in organic lesions 
(example, hemiplegia), which have affected the pyramidal fibres to 
the facial nucleus, that while the patient’s voluntary movements (as 
evidenced to his response to tests 3, 4, and 5) are decidedly paretic 
yet the emotional innervation, as evidenced by the spontaneous smile, 
does not betray any paresis. The stiff, mask-like expression in paral- 
ysis and in the Parkinson syndrome of encephalitis lethargica is 
characteristic. 
f. Uncontrolled attacks of laughing and crying occur in many nerv- 
ous diseases, notably in disseminated sclerosis. Characteristic also TM 8-335 
137-138 
NEUROPSYCHIATRY IN AVIATION MEDICINE 
is the absolutely blank expression which is encountered in schizo- 
phrenia, interrupted now and again by smiles for no apparent reason, 
probably in response to hallucinations. 
g. In the foregoing tests, it is important to note not only any de- 
ficiency of movement but also if the movements are accompanied by 
any tremor. Perioral fibrillary tremor is a sign that is frequently and 
typically found in dementia paralytica, often very early in the devel- 
opment of the disease. Tremor palpebrarum is a frequent finding 
also in purely “functional” conditions and has not the same signifi- 
cance as the perioral tremor. Any overaction of the facial move- 
ments should also be noted. 
138. Lesions of the facial nerve.—a. Lesion peripheral to the 
chorda tympani’s leaving the facial trunk produces a paralysis of 
the whole corresponding side of the face, the upper facial portion 
included. 
b. Lesion central to the departure of the chorda tympani but periph- 
eral to the ganglion geniculi produces paralysis to the whole cor- 
responding side of the face and besides, loss of taste in the anterior 
two-thirds of the corresponding side of the tongue. 
c. Lesion between the ganglion geniculi and pons produces paralysis 
of the whole corresponding1 side of the face; no disturbance of 
taste, but as a rule some deafness, as the acoustic nerve is generally 
affected. If the acoustic nerve is intact, hyperacusis as a rule obtains 
on account of the stapedius paralysis, thus in any case a disturbance 
of hearing. 
d. Lesion in the pons itself, nuclear or infra-nuclear, produces 
paralysis of the whole corresponding half of the face but without 
any disturbance of taste or hearing. However, as the fibres of the 
facial nerve come into close relationship to the nucleus and the fibres 
of the sixth nerve, a facial paralysis of pontine origin is as a rule 
accompanied by abducens paralysis. 
e. In supranuclear lesions the paralysis is never complete and is 
chiefly or exclusively confined to the lower portion of the face, the 
upper portion being either intact or much less affected. As the lesion 
is nearly always situated above the decussation of the pyramidal fibres 
of the seventh nucleus, the paralysis is found on the opposite side of 
the lesion. 
/. The examination of taste should always be carried out in a case 
of facial paralysis. The patient is asked to put out his tongue and 
keep it out dunng the test. A little powdered sugar, salt, citric acid, 
and quinine are then placed successively on the tongue and rubbed 
in with a corner of a towel. The patient must then indicate the sen- 
sation he gets by pointing to one of the following words which have 
153 TM 8-335 
138-141 
MEDICAL. DEPARTMENT 
been written up for him; sweet; salt; sour; bitter. Only the anterior 
two-thirds of the tongue, that portion innervated by the chorda tym- 
pani, can be tested in this way. The posterior third, innervated by the 
glosso-pharyngeus is tested by the use of a wire electrode of copper 
and a weak galvanic current which elicits a peculiar acid taste. 
139. Glosso-pharyngeal and the pneumogastric nerves.— 
These are generally recorded together as their areas of innervation 
seem to overlap, or at least cannot be clearly distinguished. 
cl The patient is made to open his mouth and say “Ah.” In cases 
of one-sided paresis, the raphe palati deviates to the nonparalyzed 
side. 
h. The patient is made to swallow and the power with which the 
larynx is pulled upward during the act of deglutition is tested. A 
convenient method is to let the patient sip from a glass of water. 
Notice if any regurgitation through the nose takes place and if 
accompanied by coughing. 
c. Any peculiarities of heart and respiratory functions should also 
be noted. 
d. The posterior third of the tongue is tested for taste as described 
in paragraph 138f. 
140. Accessorius (motor nerve for the sterno-cleido-mastoid, and 
upper part of the trapezius).— 
cl The patient is asked to turn his head to the right and to the 
left; this movement is carried out chiefly by the action of the sterno- 
cleido-mastoid on the opposite side. The movement is opposed by 
placing one hand against the patient’s chin while the contracting 
sterno-mastoid is palpated by the other. 
h. The upper portion of the trapezius is tested by making the patient 
shrug his shoulder against resistance. 
c. When the upper fibers of the trapezius are paralyzed, the scapula 
alters position, the upper part of the scapula falling away laterally 
from the vertebral column. 
141. Hypoglossus (motor nerve of the tongue).—The patient is 
asked to open his mouth and put out his tongue. Note if any devia- 
tion takes place on protrusion, if any atrophy, if there are any 
wrinkles on the tongue, and if they are confined to one side. Note 
if the tongue fills the whole space inside the lower jaw. In some 
cases, the tongue cannot be protruded at all (as in advanced bulbar 
paralysis or myasthenia), or only for a moment (as in myasthenia). 
If one side is paretic or paralyzed, the tongue will deviate to that side 
on protrusion. The patient is also asked to move his tongue sideways 
and to press it against the inside of either cheek, while the strength 
154 TM 8—335 
141-143 
NEUROPSYCHIATRY IN AVIATION MEDICINE 
of this pressure is tested with the finger on the outside of the patient’s 
cheek. 
143. Articulation.—This is a complex coordinated function in- 
volving the cooperation of a number of cranial nerves (fifth, seventh, 
ninth, twelfth). It is most conveniently tested after the examination 
of the cranial nerves just described. If there is a striking peculiarity 
of the patient’s speech, it probably will have made itself manifest 
during the patient’s narrative of the history. In order to detect latent 
disturbances of articulation, the patient is asked to pronounce certain 
test words, as “West Register Street,” “British Constitution,” “Royal 
Artillery,” “Righteous retribution,” “Methodist Episcopal,” “Irish 
Constabulary,” “hippopotamus,” etc. In bulbar and pseudo-bulbar pa- 
ralysis, the speech is found to be indistinct; in dementia paralytica, 
the speech is blurred and hesitating with repetitions and omissions 
of one or more syllables; in desseminated sclerosis, an explosive stac- 
cato speech; and in myasthenia, a speech disturbance which on pro- 
longed effort increases from a light dysarthria to complete anarthria. 
Section XXIII 
SURVEY OF THE NEUROPSYCHIATRIC EXAMINATION 
Paragraph 
General 143 
Classification of tremors 144 
Psychomotor tension 145 
Peripheral circulation 146 
Knee-jerk 147 
History of applicant 148 
Use of tobacco, alcohol and medicine 149 
Epileptic equivalents 150 
Insomnia 151 
Memory 152 
Anxiety 154 
Cycloids and schizoids 155 
Extroversion and introversion 156 
Selection of candidates for flying 157 
143. General.—a. That the value of the neuropsychiatric exami- 
nation of the applicant for flying training as well as of the pilot in 
his annual and semiannual examinations is of utmost importance is 
recognized by all flight surgeons. 
h. In many instances, an applicant has arrived at the Air Corps 
training center, both in the cadet group and in the sudent officer 
group, having disqualifications which should have precluded his being 
accepted for flying training. In some instances, a pilot has been TM 8-325 
143-144 
MEDICAL DEPARTMENT 
allowed to fly in spite of disqualifying neuropsychic findings, which 
either had not been recognized by the examining flight surgeon or 
the importance of these findings had not been properly evaluated. 
c. Under the neurological examination, factors involved such as 
tic, tremor, psychomotor tension, peripheral circulation, and disturb- 
ances of the reflexes are considered as having psychic importance. 
Spasmodic tic or habit spasm is designated as an “involuntary repeti- 
tion of some ordinary coordinated purposive act.” The characteristic 
of spasmodic tic is that it can be controlled by mental effort, is in- 
creased by emotion, and ceases during sleep. The psychological mech- 
anisms involved will not be entered into. Spasmodic tic or habit 
spasm is indicative of psychical weakness; however, single spasmodic 
contractions may develop in normal individuals as a result of great 
fatigue, nervous exhaustion, or overwork. These usually do not 
last more than a second, and disappear entirely on removal of the 
cause. Therefore, any habit spasm or spasmodic tic is disqualifying 
for flying training, as it is either due to psychical weakness or an 
organic lesion. 
144. Classification of tremors.—Tremors occur when the nor- 
mally uniform tone of a muscle at rest is replaced by a succession of 
separately perceptible muscular twitches. They are the most common 
of all abnormal movements and must be distinguished from fibrillations 
which are slow vermicular twitchings of individual muscle-fibres or 
bundles, which may occur anywhere, but do not produce movements 
of muscles or joints. They are essentially evidence of an organic 
lesion, usually in the anterior horn cells. 
a. Tremors are usually classified as to being slow, moderate, rapid, 
coarse, medium or fine, regular or irregular. A further classification 
is that of being fine, unilateral fine, coarse, intention, and toxic. It is 
impossible to give a definite clinical classification of tremors j however, 
the more important may be listed as follows: 
(1) Fine tremor. 
(a) Minor psychoses. 
1. Hysteria. 
2. Neurasthenia. 
3. Neurosis, occupational. 
(h) Organic. 
1. Paralysis agitans. 
2. Paresis. 
3. Graves’ disease. 
% Uremia. 
i£. Exophthalmic goitre. 
156 TM 8-325 
144-145 
NEUROPSYCHIATRY IN AVIATION MEDICINE 
(o) Muscular fatigue or weakness. 
(d) Senile tremor. 
(e) High fever. 
(/) Convalescence. 
(2) Unilateral fme tremor. 
(a) Hysteria. 
(b) Hemiplegia. 
(c) Brain tumor. 
(d) Chorea. 
(3) Coarse tremor. 
(a) Exaggerated fine tremors. 
(b) Hereditary and familial ataxias. 
(c) Hemiplegia. 
(4) Intention tremor.— 
(a) Hysteria. 
(b) Disseminated sclerosis. 
(c) Some brain lesions. 
(5) Toxic tremor.—Various states of toxic poisoning, as— 
(a) Tobacco. 
(b) Alcohol. 
(c) Various drugs. 
(d) Metals. 
b. Fine, unilateral fine, coarse, and intention tremors are found in 
various types of the minor psychoses and as such are evidences of 
psychical Emotional nervousness also produces a fine 
tremor, and is occasionally found when a raw applicant is examined. 
This should be seriously considered in the general estimate of the 
individual, 
145. Psychomotor tension.—This is an observable indication of 
the amount of psychomotor activity which results from the action of 
the psycho-sensory and intrapsychic fields. It interprets the apti- 
tude or inaptitude of the individual to adjust himself to his environ- 
ment. The perception of the individual as influenced by his intellect 
is being demonstrated by the tension produced. It demonstrates the 
ease with which the nervous system is functioning. Therefore, an 
appreciable increased tension in the applicant should be studied as to 
cause. In the pilot it is termed “staleness.” The test of unexpectedly 
dropping the examinee’s arm, which has been held in a state of relax- 
ation in the examiner’s hand, is satisfactory, although a genera,! ob- 
servation of the examinee during the examination should indicate 
whether or not there is increased tension present. 
157 TM 8-335 
146-148 
MEDICAL DEPARTMENT! 
146. Peripheral circulation.—Disturbances of the peripheral 
circulation may be noted in the presence of localized sweating, mot- 
tling, and cyanosis of the face, trunk, and extremities. They are 
themselves evidence of neurocirculatory instability and should be 
considered as important factors for disqualification. 
147. Knee-jerk.—A normal knee-jerk cannot be defined. Nor- 
malcy of the knee-jerk is dependent on the type of individual being 
examined and on the opinion of the examiner. A suitable percussion 
hammer is essential. The attempt to elicit a patellar response with 
the lingers or hand is unsatisfactory. The most satisfactory manner 
of eliciting this important sign is to place the examinee’s feet as far 
away as it is possible for him to do so and still keep the soles of his 
feet in contact with the floor. In this manner, the various responses 
are more easily and accurately determined. Enforcement may be 
necessary at times and is usually produced by having the examinee 
pull his grasped hands while looking at the ceiling or in performing 
some other voluntary act. The knee-jerk may be absent, diminished, 
exaggerated, or unequal. Absent and unequal responses are to be re- 
garded as signs of organic pathology, especially if associated with 
other reflex changes. The same may be said of the truly diminished 
response. A sluggish response should not b confused with one that 
is diminished. The natural variations should be taken into considera- 
tion. The exaggerated knee-jerk may be due either to psychogenic 
or organic conditions and occurs when the reflex arc to the quadriceps 
is insufficiently controlled by the higher nerve centers. Exaggerated 
knee-jerks may be considered to be of psychogenic origin when asso- 
ciated with normal abdominal and plantar reflexes. The abnormal re- 
flex findings are to be expected more in those of the older age group 
than in those of the cadet and student officer group. 
148. History of applicant.—Of great importance is the family 
history of the applicant and perhaps of greater importance is the per- 
sonal history. The present day opinion is that many of the psychologic 
problems which are met are due to improper mental hygiene or im- 
proper guidance. It is also believed that heredity has been over- 
emphasized. Basic factors involved are considered to be heredity and 
environment, but how much either of these is a factor cannot be estab- 
lished at this time. As to heredity, it is evident that the germ cell 
is injured in certain types of mental disease and will perhaps progenate 
organisms favorable to the development of mental disease. 
a. In studying the personal history, the individual’s conditionings 
and his life experiences, that is, his environment, must be studied. In 
the applicant, a family history of direct heredity involving mental 
disease is a disqualifying factor; knowledge of the factor of heredity 
158 TM 8-335 
148-150 
NEUROPSYCHIATRY IN AVIATION MEOICTNE 
is far from complete, and it is not necessary, with the amount of ma- 
terial from which to choose, to be placed in jeopardy as to the outcome 
of any applicant. This is well illustrated from two cases selected at 
random: 
(1) Family history; brother an idiot; patient committed suicide. 
(2) Family history: father committed suicide, grandmother in hos- 
pital for mental diseases. Present illness: schizophrenia; attempted 
suicide. 
6. As to the study of the personal history, paragraph 32a (2) AR 
40-110, is quoted in full: “The personal history will be searched on 
the points below mentioned in order to develop and complete the 
balance of the examination. The infantile period will be searched 
for evidences of retardation, and particular study made of the factors 
which obtained during the formative years and determined the per- 
sonality trend. To this end study will be made of the family life, 
play life, sex life, school and college life, trends of thought, athletic 
tendencies, degree of manual dexterity, personal and family attitude 
toward flying, reactions concerning the ordinary stresses of life, and 
particularly the probable reactions under the special stresses incident 
to flying.” If this instructional paragraph is carried out in detail, 
many of the pitfalls encountered would be avoided. Pilots are not 
eliminated from flying training nor “grounded” merely because of 
having schizoid or cycloid personality. It is when these personalities 
develop psychotic manifestations that elimination and “grounding” 
are necessary. 
149. Use of tobacco, alcohol, and medicine.—a. When consid- 
ering the use of tobacco in its various forms, especially in the appli- 
cant, attention should be given as to the excessiveness of its use. Its 
use may be an outlet for excessive nervous energy or an outlet for 
repressed tendencies. 
h. The use of alcohol should be given careful study. Alcoholism 
cannot be excused in the applicant, nor should it be in the pilot. Its 
use is an artificial retreat from reality and reality must be met 
actively by those engaged in flying. 
o. The habitual use of medicines of any sort falls into somewhat 
the same category. Usually the ailment for which the medicine is 
used is fancied, which again is evidence of an unstable individual. 
150. Epileptic equivalents.—It is the opinion, as substantiated 
by the findings presented, that a history of any of the so-called epilep- 
tic equivalents should be sufficient to disqualify any applicant. Under 
these epileptoid equivalents are listed enuresis, severe headaches, diz- 
ziness, fainting, stammering or stuttering, somnambulism, pavor noc- TM 8-325 
150-152 
MEDICAL DEPARTMENT 
turnus, and migraine. More consideration should be given fainting 
than is probably accorded at the present time. Given two indi- 
viduals, one who faints having a temperature of 102° F., and another 
who does not with a temperature of 104° or more, it is preferable to 
accept the latter as an applicant. In fact, the first individual would 
be disqualified. Somewhat the same conclusion is warranted as to 
those who faint at the sight of blood or disagreeable sights of one 
type or another. The manner in which pain, is borne is also a good 
criterion of the stability of the individual. 
151. Insomnia.—Insomnia includes besides sleeplessness, broken 
and interrupted sleep. The diagnosis of insomnia should be made with 
care as the normal amount for different individuals varies and de- 
pends usually on the age and habit. Most psychoneurotics do not show 
the physical effects of sleeplessness. Insomnia is a symptom, not a 
disease. 
a. Insomnia has been classified as— 
(1) Toxic insomnia, such as due to excessive use of tobacco, coffee, 
tea, and alcohol. 
(2) Extrinsic insomnia, such as following mental traumata. Actual 
physical causes. 
b. Insomnia of either type disqualifies the applicant and grounds the 
flyer. 
Example: 
Lieut. “X.” Unable to sleep. Paced the floor at night. 
Eesult: One of the “crashes” ascribed to the Air Mail. 
152. Memory.—Memory is of concern insofar as defects may be 
uncovered. The type of applicant and student officer who reports 
for training is of such educational caliber that memory of itself should 
approximate “an hypothetical norm.” An injury or illness severe 
enough to produce memory defect of an extended period of time is 
surely sufficient ground for disqualification. Sequelae must have re- 
sulted from the injury or illness that will have left its scar on the brain 
itself as well as the personality. It is not believed a safe procedure 
to allow anyone who is not a rated pilot or observer to continue with 
his flying who has complete amnesia of his accident or injury, or of 
a considerable period of time prior to and following the occasion. 
Examples: 
a. Cadet “A”. Automobile accident. Has no "memory of events 
occurring from the time he left his post, of his accident, nor for a 
period of 3 days following. 
b. Cadet “B”. Automobile accident. Complete amnesia of events 
leading up to his accident, of the death of the other two occupants of 
his car, and for a period of 14 days following. Of further interest in 
160 TM 8-335 
152-156 
ITEnjSOPSYOITTATRY IK AVIATION MEDICINE 
this case is the fact that the patient will not be convinced that deaths 
did occur in his accident. 
Neither of these cadets should be allowed to continue their training. 
In the case of rated pilots and observers, a guarded and studied opinion 
as to their continuing flying is required. It is, perhaps, better for 
them that they have amnesia of the events of their “crash.” However, 
if any personality changes or defects are noted, permanent grounding 
is obligatory. 
153. Phobias.—Phobias represent specific fears containing the 
elements of conversion, and stimulate obsessive ideas. Anxiety is a 
constant component of phobias. Phobias are therefore expressions of 
fundamental instability. When phobias are elicited, disqualification 
for flying training should be imperative. 
154. Anxiety.—Manifest anxiety, due to any cause whatsoever, 
is disqualifying. Anxiety is closely related to fear. Fear is a defen- 
sive reaction of the organism from dangers in the environment; while 
in anxiety, on the other hand, the danger is represented in a mental 
image. Panic is not far distant from either fear or anxiety. Any of 
these symptoms show an underlying sense of insecurity, and as such 
have no place in flying of any sort. 
155. Cycloids and schizoids.—Cycloids must not necessarily be 
manic-depressives nor the schizoids, schizophrenics. The terms have 
nothing to do with the question of being pathological or healthy. They 
are large biological types which include the great mass of healthy 
individuals with the corresponding psychotics scattered among them. 
Elation and depression are characteristic of the cycloid group, and 
irritability and apathy are found among the schizoids, although found 
in other conditions as well. In any event, an appreciable disturbance 
in any of these findings should be sufficient grounds for the cessation 
of all flying activities of the individual involved and permanent dis- 
qualification of the cadet or student officer. 
Paragraph 326 (26), AR 40-110, states that “in the study of the 
examinee a review is made of his total experience. Each candidate 
will be found to have met with situation difficulties requiring solution. 
The extent and type of these difficulties will vary with the individual. 
The manner in which he has met worries, handled conflicts, and subli- 
mated complexes is an indication of the degree to which he can adjust 
himself to his environment. The study should determine whether he 
is inherently stable or unstable. 
156. Extroversion and introversion.—Extroversion and intro- 
version have to do with the energy trends. They have reference to 
psychobiological energy. All individuals possess both mechanisms and 
874758°—41-—U 
161 TM. 8-325 
156-157 
MEDICAL DEPARTMENT 
it is only the predominance of one or the other which determines the 
type. They are, as Jung termed them, “general-attitude types.” 
157. Selection of candidates for flying.—It is being taught 
in the Department of Neuropsychiatry that insofar as the candidate is 
being classified, it first be determined whether he shows a predomi- 
nance of extrovertive or introvertive tendencies and then add to this 
classification the various psychological mechanisms involved in his ad- 
justment to his environment or reality. The degree of facility of ad- 
justment may be a criterion of the individual’s aptitude to meet a new 
environment such as is encountered in flying. Such has not been 
proved, although it is reasonable to believe that those with a greater 
degree of facility of adjustment should adjust themselves more readily. 
The important factor is to believe that the inherently stable individual 
makes the ideal military pilot, and endeavor to determine whether or 
not the applicant is herently stable or unstable. Perhaps too mucli 
prominence has been given to these opinions without adequate research 
work to justify the conclusions arrived at. However, flight sur- 
geons can perhaps determine whether the applicant for fly- 
ing has a proper sensory, central and motor nervous system, whether 
or not he has an adequate memory function, whether he sublimates 
or symbolizes, whether or not he is an inherently stable or unstable 
individual, whether he is an introvert or extrovert, but cannot deter- 
mine that he will or will not learn to fly. However, flight surgeons 
can pass upon and present for flying instruction the best material 
available, those individuals who do not show the various factors, both 
physical and mental, that have been found detrimental to the success- 
ful development of a military pilot, insofar as the present knowledge 
of successful material is limited. 
Appendix 
BIBLIOGRAPHY 
References which have been freely drawn upon throughout this 
manual, and to whom acknowledgment is made, are as follows: 
ADLER: The Practice and Theory of Individual Psychology, and 
other writings. 
BLEULER: Text Book of Psychiatry. 
BRINK: Morbid Fears and Compulsions. 
BRILL: Psychoanalysis and other writings. 
CHURCH AND PETERSON: Nervous and Mental Diseases. 
COLLIER; The Lumleian Lectures, 1928, The Lancet, March 24, 31, 
and April T, 1928. 
162 TM 8-335 
STEXTROPSTCHTATBY IN AVIATION MUDIGTNB 
DEIFENDORF; Clinical psychiatry. 
FREUD: Various writings. 
GOWERS: Faints and Fainting, The Lancet, March 2,1907, Vagal 
and Vaso-Vagal Attacks. The Lancet, June 8, 1907. 
HART; The Psychology of Insanity. 
HERRICK: Introduction to Neurology. 
HINKLE: The Re-creating of the Individual. 
HUNT: Diagnostic Symptoms in Nervous Diseases. 
JANET: Various writings. 
JELLIFFE: The Hysteria Group. 
JELLIFFE and WHITE: Diseases of the Nervous System. 
JENSEN: Epileptic Equivalents Associated with Airplane “Crashes”, 
The Journal of Aviation Medicine, March 1934. 
JONES: Psychoanalysis and other writings. 
JUNG: Various writings. 
KEMPF: Various writings. 
KENNEDY: Fits, Medical Clinics of North America, July 1924. 
KRAEPELIN: Various writings. 
LEWIS: The Constitutional Factors in Dementia Praecox. 
NOYES: Modern Clinical Psychiatry, 
OSLER: Modern Medicine, Volume VI. 
PRINCE: The Unconscious, and other writings. 
RIVERS: Instinct and the Unconscious. 
ROSANOFF: Manual of Psychiatry. 
SINGER: Neurasthenia and Psychasthenia. 
STEKEL: Various writings. 
STEW ART: The Diagnosis of Nervous Diseases. 
ST ODD ART: Mind and Its Disorders. 
TICE: Practice of Medicine. 
TILNEY and RILEY: The Form and Functions of the Nervous 
System. 
WHITE: Various writings. 
WILSON: The Narcolepsies, Brain, Part 1,1928. 
163 TM 8-335 
Paragraphs Pages 
Accessorius 140 154 
Action disorders 26 42 
Adler hypothesis 12 21 
Afftectivity of emotional disorders 27 44 
Age, epilepsy 44 67 
Anatomy of epilepsy, pathological 47 73 
Anxiety 154 161 
Articulation 142 155 
Attacks, epilepsy, frequency 42 67 
Attention disorders 29 44 
Basic fundamentals, mental 2 2 
Behavior, dynamics 14 23 
Bibliography App, 162 
Brain tumor, psychoses with 117 138 
Candidates for flying, selection 157 162 
Casual factors, paralysis of insane 91 114 
Cerebral syphilis, psychoses with 116 137 
Character of epilepsy 49 82 
Characteristic symptoms, schizophrenia (dementia praecox) 69 92 
Circulation, peripheral 146 158 
Classification: 
Mental disorders 18-21 32 
Psychopathic personality , 34 48 
Psychoseas 21 32 
Tremors 144 156 
Clinical varieties of epilepsy 50 83 
Complex 31 45 
Conflict, solving 7 16 
Constitution types, psychobiological 17 29 
Content of thought disorders 24 41 
Cranial nerves 135 151 
Cycloids 155 161 
Definitions: 
Epidemic encephalitis 122 143 
Epilepsy 45 67 
Mental process terms 5 12 
Minor psychoses 35 52 
Manic-depressive psychosis 64 99 
Paralysis of insane 87 113 
Psychopathic personality 33 47 
Tabes dorsalis 100 126 
Dementia praecox (schizophrenia) 55-62 88 
Descriptive psychology 4-9 6 
Diagnosis: 
Differential: 
Epilepsy 154 161 
Infection exhaustion 110 131 
Involutional melancholia 77 108 
Manic-depressive psychosis 72 105 
INDEX 
165 TM 8-335 
LNuiii 
Diagnosis—Continued. 
Differential—Continued. Paragraphs Pages 
Paranoia 83 112 
Paralysis of insane 98 124 
Psychosis 112 132 
Schizophrenia (dementia praecox) 62 97 
Tabes dorsalis 105 128 
Epidemic encephalitis 131 148 
Epilepsy 63 84 
Paranoia 82 112 
Tabes dorsalis 104 128 
Disease, mental: 
History 3 3 
Symptoms 22-32 37 
Disorders, mental: 
Action 26 42 
Affectivity of emotional disorders 27 44 
Attention 29 44 
Complex 31 45 
Content of thought 24 41 
Dreams 32 46 
Emotion 27 44 
Feeling 27 44 
Insanity, use of term 18 32 
Memory 28 44 
Personality 30 45 
Perception 23 38 
Point of view 19 32 
Psychosis, classification 20, 21 82 
Train of thought 25 42 
Volition 26 42 
Distribution of epilepsy 40 66 
Disturbance of self-consciousness 30 46 
Dreams 32 46 
Dynamics of behavior 14 23 
Emotion: 
Unconscious 9 17 
Disorders 27 44 
Epidemic encephalitis 121-133 143 
Course 128 147 
Definition 122 143 
Diagnosis 131 148 
Duration 128 147 
Etiology 125 144 
History 123 143 
Pathology 126 145 
Prognosis 132 160 
Recurrences 129 147 
Relation to other diseases 124 143 
Sequelae 130 148 
Treatment 133 160 
166 TM 8-325 
XAiDikX 
Paragraphs Pages 
Epilepsy 39—54 66 
Age 44 67 
Clinical varieties 50 83 
Definition 45 67 
Diagnosis 53, 54 84, 85 
Distribution 40 66 
Epileptic character 49 82 
Etiology 46 71 
Frequency of attack 42 67 
History 39 66 
Pathological anatomy 47 73 
Prevalence 41 66 
Prognosis 62 84 
Season 43 67 
Sequelae 51 84 
Sex 44 67 
Symptomatology 48 73 
Time 43 67 
Epileptic equivalents 150 159 
Etiology: 
Epidemic encephalitis 125 144 
Epilepsy 46 71 
Manic-depressive psychosis 67 100 
Paralysis of insane 90 114 
Psychoses 109 131 
Schizophrenia (dementia praecox) 56 89 
Tabes dorsalis 101 127 
Extroversion 156 161 
Facial nerve, paralysis and lesions 137, 138 152, 153 
Feeling disorders 27 44 
Fixation of libido 8 16 
Frequency: 
Epilepsy attacks 42 67 
Manic-depressive psychosis 65 99 
Paralysis of insane 88 113 
Freudian hypothesis 11 20 
Fundamental problem of life 6 13 
Fundamentals, basic, mental 2 2 
Glosso-pharyngeal nerve 139 154 
History: 
Epidemic encephalitis 121-133 143 
Epilepsy 39 66 
Mental disease 3 3 
Paralysis of insane 86 113 
Hypoglossus 141 154 
Hypothesis: 
Adler 12 21 
Freudian 11 20 
Hysteria 37 58 
Infection exhaustion psychoses 110 131 TM 8-325 
INDEX 
Paragraphs Pages 
Injury to the brain 115 137 
Insane, paralysis 86-99 113 
Insantiy, use of term 18 32 
Insomnia 151 160 
Interpretation, manic-depressive psychosis 73 105 
Introversion 156 161 
Involutional melancholia 74 106 
Knee-jerk 147 158 
Lesions of facial nerve 138 153 
Libido, fixation 8 16 
Life problem, fundamental 6 13 
Manic-depressive psychosis: 
Course 69 104 
Definition 64 99 
Differential diagnosis 72 105 
Duration - 69 104 
Etiology 67 100 
Frequency 65 99 
History 63 98 
Interpretation 73 105 
Onset 69 104 
Pathology. 71 105 
Prognosis 70 104 
Remissions 69 104 
Sex 66 100 
Summary 73 105 
Symptomatology 68 100 
Time of life 66 100 
Melancholia, involutional: 
Definition 74 106 
Differential diagnosis 77 108 
Prognosis 76 108 
Symptomatology 75 107 
Treatment 78 108 
Memory 162 160 
Mental disease: 
Causes 10-13 18 
Dreams 32 46 
History. 3 3 
Nature 10-13 18 
Symptoms 22 37 
Mental disorders: 
Action . 26 42 
Affectivity 27 44 
Attention 29 44 
Causes 13 22 
Classification, types 17 29 
Content of thought 24 41 
Contributing causes 13 22 
Emotion 27 44 
168 TM 8~&25 
INDEX 
Mental disorders—Continued. Paragraphs Pages 
Feeling 27 44 
Memory 28 44 
Perception 23 38 
Personality 30 45 
Train of thought 25 42 
Volition 26 42 
Mental mechanisms and motives 15 25 
Mental processes 4, 5 6, 12 
Minor psychoses: 
Definition 35 52 
Hysteria 37 58 
Neurasthenia 36 56 
Psychasthenias 38 63 
Nature of mental disease 10-13 18 
Nerves; 
Accessorius 140 154 
Cranial 135 151 
Facial, paralysis and lesions 137, 138 152, 153 
Glosso-pharyngeal 139 154 
Hypoglossus 141 154 
Pneumogastric 139 154 
Trigeminal 136 151 
Neurasthenia 36 56 
Neurology 134-142 150 
Articulation 142 155 
Description 134 150 
Nerves 135-141 151 
Neuropsychiatric examination 143-157 155 
Organic diseases of the brain 115 137 
Paranoia: 
Definition 79 108 
Diagnosis 82, 83 112 
Prognosis 84 112 
Stages 81 110 
Treatment 85 112 
Types 80 109 
Paralysis of insane: 
Casual factors 91 114 
Course 93 117 
Definition 87 113 
Diagnosis, differential 98 124 
Duration 93 117 
Etiology 90 114 
Frequency 88 113 
History 86 113 
Onset 93 117 
Pathological anatomy 92 115 
Prognosis 94 117 
Remissions 93 117 
Summary, mental symptoms 97 123 TM 8-325 
INDEX 
Paralysis of insane—Continued. Paragraphs Pages 
Symptomatology 95 117 
Tabetic forms 96 123 
Time of life 89 114 
Treatment 99 125 
Pathological anatomy: 
Epilepsy 47 73 
Paralysis of insane — 92 115 
Pathology: 
Epidemic encephalitis 126 145 
Manic-depressive psychosis 71 105 
Tabes dorsalis 102 127 
Phobias 153 161 
Pneumogastric nerves 139 154 
Point of view in studying cases 19 32 
Prevalence of epilepsy 41 66 
Problem of life, fundamental 6 13 
Processes, mental 4, 5 6, 12 
Prognosis: 
Epidemic encephalitis 132 150 
Epilepsy 52 84 
Manic-depressive psychosis 70 104 
Melancholia 76 108 
Paranoia 84 112 
Paralysis of insane 94 117 
Tabes dorsalis 106 129 
Psychobiological constitution and reaction types; 
Extroversion 16, 17 28, 29 
Introversion 16, 17 28, 29 
Psychasthenias 38 63 
Psychopathic personality 33, 34 47, 48 
Psychoses: 
Brain tumor 117 138 
Classification 21 32 
Cerebral syphilis 116 137 
Diseases, organic of the brain 116 137 
Infection exhaustion 108-110 130 
Differential diagnosis 112 132 
Symptomatology 111 132 
Injury to the brain 115 137 
Symptomatic 108, 109, 114 130, 
131, 136 
Senile, types 119, 120 140 
Toxic 108, 109, 113 130, 
131, 132 
Traumatic 118 139 
Psychosis 20,108 32, 130 
Reaction types, psychobiological 17 29 
Recurrence of epidemic encephalitis 129 147 
Relation of epidemic encephalitis to other diseases 124 143 
170 TM 8-325 
INDEX 
Remissions: Paragraphs Pages 
Manic-depressive psychosis 69 104 
Paralysis of insane 93 117 
Schizophrenia (dementia praecox): 
Course 61 96 
Diagnosis, differential 62 97 
Etiology 66 89 
Pathology 57 89 
Prognosis 61 96 
Symptomatology 58 90 
Symptoms, characteristic 69 92 
Types 60 92 
Schizoids 155 161 
Season, epilepsy 43 67 
Selection of candidates for flying 157 162 
Self-consciousness, disturbances 30 45 
Sequelae: 
Epidemic encephalitis 130 148 
Epilepsy 51 84 
Sex: 
Epilepsy 44 67 
Manic-depressive psychosis 66 100 
Solving of conflict 7 16 
Stages of paranoia 81 110 
Survey of neuropsychiatric examination 143-167 155 
Anxiety 154 161 
Classification of tremors 144 166 
Cycloids 155 161 
Description 143 155 
Epileptic equivalents 150 159 
Extroversion 156 161 
History of applicant 148 158 
Insomnia 151 160 
Introversion 166 161 
Knee-jerk 147 158 
Memory. 152 160 
Peripheral circulation 146 158 
Phobias 153 161 
Psychomotor tension 145 157 
Schizoids 155 161 
Symptoms: 
Mental disease; 
Classification 22 37 
Disorders: 
Action 26 42 
Affectivity 27 44 
Attention 29 44 
Complex 31 45 
Content of thought 24 41 
Dreams 32 46 
Emotion 27 44 
Feeling 27 44 
171 TM 8-325 
INDEX 
Symptoms—Continued. 
Mental disease—Continued. 
Disorders—Continued. Paragraphs Pages 
Memory 28 44 
Perception 23 38 
Personality 30 45 
Train of thought 25 42 
Volition 26 42 
Tabes dorsalis 103 127 
Symptomatology; 
Epilepsy 48 73 
Manic-depressive psychosis 68 100 
Paralysis of insane 95 117 
Psychoses 111 132 
Schizophrenia (dementia praecox) 58 90 
Syphilis, cerebral, psychoses with 116 137 
Tabes dorsalis: 
Definition 100 126 
Diagnosis 104, 105 128 
Etiology. 101 127 
Pathology 102 127 
Prognosis 106 129 
Symptoms 103 127 
Treatment 107 129 
Tabetic forms, paralysis of insane 96 123 
Time, epilepsy 43 67 
Time of life; 
Manic-depressive psychoses 66 100 
Paralysis of the insane 89 114 
Toxic psychoses r 113 132 
Train of thought disorders 25 42 
Treatment: 
Epidemic encephalitis 133 150 
Melancholia, involutional 78 108 
Paranoia 85 112 
Paralysis of insane 99 125 
Tabes dorsalis 107 129 
Unconscious emotion 9 17 
Use of alcohol, medicine, and tobacco, neuropsychiatrics 149 159 
Varieties of epilepsy, clinical 50 83 
Volition, disorders 26 42 
[A. G. 062.11 (8-26-40).] 
By order of the Secretary of War: 
G. C. MARSHALL, 
Official ; Chief of Staff. 
E. S. ADAMS, 
Major General, 
The Adjutant General. 
172