The psychological side of the situation, how ever, as may be seen is not all. There are cer tain physical changes in the course of the dis ease and certain pathological findings. So far as the observation goes, however, the etiological factors lie almost, if not quite entirely, in the mental sphere, and one must therefore con ceive of the physical changes as superadded. This is a possibility which was well illustrated by the case already quoted of the man who died after a tremendous emotional explosion, during which he killed two people. When the psychic splitting is profound and when it is of considerable duration, it is quite understandable that it should unloose bits of physiological mechanism and thus produce the physical changes found. From the descriptions of the mechanisms in the psychoneuroses, taken in connection with what is known of the vegeta tive nervous system, it may be seen that con stantly operative psychic disturbances are capa ble of producing the physical changes.
Ways of Getting With the concept of the disease process which has been previously elaborated, what is the significance of the three main types of precox which are found clini cally? Bertschinger has recently made an ad mirable study of the process of recovery in dementia precox and his discussion of the nature of the conflict and the ways of adjusting is particularly illuminating. The three clinical types of the disease are the expression of the interplay of the two factors, the conflict and the reaction, the severity of the former and the efficiency of the latter determining the outcome in the individual case. The degree of confusion in the acute onset is an expression of the com pleteness with which the patient is driven back from reality and the dominance of the uncon scious trends. Conditions of moderate confu sion with capacity for adequate reaction to reality at times, or under the special stimuli of, for example, questions, show that the patient still has a certain grip upon the real world and is making an effort at least to retain it. Cer tain other cases of quite clear consciousness with complete orientation show a very adequate grasp upon reality, and these patients, to the casual observer, often seem quite natural. In such patients, however, one will notice inter ference of thought, hesitations in the course of conversations, stutterings and stammerings over certain points, the evidences, in other words, of complex interferences, and the patients will complain that from time to time their minds seem to be absolutely blank. These saltatory associations and thought deprivations are the expressions of reactions to buried com plexes, so that in these patients there is a fairly adequate grasp upon reality for ordinary pur poses at least, with only spasmodic influences from relatively restricted areas. In general, then, the hebephrenic type may be seen to be a reaction to the conflict which is essentially inadequate and inefficient. In the acute stages the patient may be absolutely overwhelmed by the conflict, disoriented and confused. Later on the progressive disintegration and dilapida tion of thought indicates the slowly progressive conquering of the capacity for adjustment to reality by the invasion into consciousness of the unconscious trends. The catatonic type repre sents a somewhat different form of reaction. Here thepatient is oftentimes suddenly over whelmed by the conflict, as under circum stances of accident or sudden and severe shock. No attempt at adjustment is made at first, but the whole situation is actively and definitely shut out. Here there is an active effort on the part of the individual to exclude the offending tendencies, and when this succeeds recovery 'takes place as the result, so tp speak, of the encapsulation of the objectionable material, and its exclusion from consciousness. This form
of the disorder is the most acute, and the re covery is equally most apt to be prompt, and it will be seen from this explanation why this is so. In the paranoid form of the disorder the reaction is much more efficient than in the hebephrenic variety, and in some respects less efficient than in the catatonic. Here the indi vidual takes a flight into a psychosis, and the delusions are the expression of a compromise between the opposing psychic trends. Unable to live in the real world., the patient succeeds in inventing a world in which he can live, and having invented it he succeeds in getting along fairly well without noticeable deterioration. The conflict in these cases tends to become sta tionary after the development of the delusional world. Bertschinger has more especially de fined the ways of getting well by pointing out that the patient in recovering may, as a result of the conflict which he cannot adjust, find a compromise by changing himself and inter preting the world of reality in terms of his morbid phantasy, or by translating the world of his phantasy into terms of external 'experience. And so one would find on the one hand delu sions of grandeur which are a compromise formation and serve to change the individual so that he may be better satisfied with life, and on the other hand one finds delusions of persecution, the delusions of influence from the outer world, that serve to change the outer world in conformity with the patient's com plexes. These outside influences are but the reflections back upon the patient of his failures to get from the world what he wants and they are consequently felt as malign and destructive influences. Another method of getting well is that already described of the catatonic, the shutting out and walling off of the conflict in a circumscribed forgetfulness. In many cases conversions into bodily symptoms, such as are found in hysteria, are found. Another method of getting well is by living• through a series of imaginary experiences which brings the com plex to a logical conclusion. For example: A young Japanese woman was overwhelmed by the sad news that five members of her family had been killed in battle. She passed instantly into a dreamy state of consciousness, went on with the work of the household just as if all five were members of it, made their beds, set their places at table and acted in every way as if they were alive and present. Finally she, so to speak, let one of them die and then another and another until finally she had com passed the death of all five, after which she awoke from her dream-like state and was well. She had succeeded in an efficient reaction to the situation by its attenuation, extending it over a considerable period of time. Finally, a cer tain number of patients get well by the final domination of the reality motive, with a result ing correction of their delusional phantasies.)) These patients are best helped by psychoanaly sis when they are capable of establishing mental contacts with the physician. As a rule they are treated foolishly for bodily diseases too long and the mental disintegration goes too far for possible skilled intervention, They then are left to their own devices. Appendicitis used to be treated in this way for centuries, but now prompt surgical intervention saves thousands of lives. psychoanalytic treatment will help the dementia precox patient. Consult Jelliffe and White, 'Diseases of the Nervous System) (2d ed., 1917) ; Bleuler, 'Die. Schizo phrenie) (1911).