Schizophrenia

SCHIZOPHRENIA (from Greek schizo - I cleave and phren - soul, mind), a mental disease from the group of so-called organic and destructive processes, characterized mainly by the splitting of human mental activity. The problem of schizophrenia as a definite psychosis is among the most difficult in psychiatry. Over the past decades, various questions related to it have been a constant subject of scientific research, reports at society meetings, and even formed program items at special congresses, and at the same time, one must say that each new work on schizophrenia raises more problems than it resolves. The state of affairs in this regard is best characterized by the fact that the authors of a large monograph on schizophrenia, which constitutes the 9th volume of the large manual on psychiatry published under the editorship of the well-known German psychiatrist Prof. Bumke, directly state regarding the essence of schizophrenia: "we know nothing." Such obscurity regarding schizophrenia is undoubtedly explained by the peculiarity of this disease, its complexity, the polymorphism of its picture, and other features due to which it is difficult to resolve even the question of which group it should be assigned to in the general system of psychoses. It can be said that it lies at the junction of various classification groups. Everyone recognizes the role of significant hereditary loading; a number of mental characteristics of individuals who subsequently fall ill with schizophrenia give the right to think in this case of an endogenous disease and raise the question of the possibility of a special schizophrenic constitution. However, the idea of an endogenous disease does not harmonize with the undeniable circumstance that in a number of cases the disease ends in obvious dementia. This brings schizophrenia closer to organic diseases, and a number of authors directly assign it to the group of processes with destructive changes in the nervous system, equating it, for example, to progressive paralysis of the insane. But such an understanding must certainly be considered too simplistic and only to a certain extent bringing one closer to a solution of the question. How can one explain from this point of view that dementia is by no means a rule? One has to reckon even more in this case with the fact that one has to speak of dementia in schizophrenia in a special sense. Although a more or less noticeable general decline in intellect is observed, it gives the right to call the patient demented only in a conventional sense. In any case, this "dementia" differs sharply from what one has to see in organic psychoses in the usual sense. What is more characteristic of schizophrenia is not the decline of intellect as such, but the change in the personality as a whole, considering that the concept of the latter also includes emotional and volitional components. One can speak in schizophrenia of a persistent lowering of the level of the personality, understanding the latter, together with Schertzer, as the degree of its layer-by-layer structure with varying heights of the layers of mental life. Furthermore, it turned out that in some cases a completely typical picture of schizophrenia, admittedly without pronounced dementia, developing directly after an external cause, disappears relatively quickly after the cessation of the latter's action, with the patient returning to the previous mental state. Such cases are particularly difficult to explain from the point of view of endogeny, as well as an anatomical process. With a great variety of manifestations of painful symptoms in individual patients, now one phenomenon, now another dominates the picture. Naturally, various authors, when attempting to generalize the clinical diversity from the point of view of any single idea, place the accent on those groups of phenomena that must be considered pivotal from the point of view of their general views. Of course, this was also reflected in the evolution of scientific views depending on the epoch, with the forefronting of now some, now other leading moments in the general structure of psychosis and its pathogenesis. The first stage in the development of the doctrine of the disease now known under the name of schizophrenia must be seen in Morel's démence précoce and in the doctrine of the French school on degeneration, but its originator must be considered properly Kahlbaum with his works on catatonia as a psychosis of tension. According to his views, this is a disease that goes through a definite cycle of development with a change of phases of excitement with catatonic phenomena, states of stupor, tension, and dementia. As is known, in the history of the development of scientific psychiatry in the early periods, the concepts of Morel and Magnan played a particularly large role. In their systems, psychoses on the soil of degeneration occupied a very large place, and it is undoubtedly true that cases that would now be called schizophrenia were very often referred to the variegated in composition and very large group of degeneration psychoses. Kraepelin, who came forward with his doctrine of the psychosis in question in the 1990s, saw the most essential thing not in heredity and degeneration, but in the course with an outcome in dementia. Compared to the French doctrine of degeneration, this was a significant step forward, because from the collection groups of essentially diverse pictures, cases were singled out by the attribute of a certain unity: no matter how different the manifestations of the disease at the beginning, it ends with one thing—dementia. In accordance with this, Kraepelin referred the disease in question generally to processes, whence comes the name proposed by him for the entire disease—early or premature dementia. Such an anatomical approach to the essence of the disease on the part of a psychiatrist who did not himself work in the field of pathological anatomy is explained to a large extent by the successes of the latter at that time, making it psychologically understandable to be infatuated with what one can generally expect for understanding the essence of psychoses from the dissecting knife and the microscope. Kraepelin's closest associate, also the well-known psychiatrist and anatomist Alzheimer, precisely during the heyday of Kraepelin's doctrine expressed the view that the time was not far off when we would resolutely know the corresponding changes in the brain for absolutely all psychoses and thus manage to explain the essence of the disease. It must be said, however, that over the approximately 30 years that have passed since this proud statement was made, psychiatrists have not only not learned the pathological anatomy of very many psychoses, including schizophrenia, but in accordance with the change in their basic viewpoints, they do not even seek in the pathological anatomy of the nervous system an answer to all their questions about the essence and origin of the disease. To explain the origin of schizophrenia, it turned out to be necessary to take into account, in addition to brain changes, a very large amount of other data—results of the study of internal organs, metabolism, internal secretion. At the same time, it is becoming increasingly clear that pathological deviations in the mental sphere, in particular in schizophrenia, are not only a mechanical reaction of the psyche to stimuli coming from outside and from the organism itself, but are mediated by a living and active personality, as a result of whose work, with the same sum of stimuli, the final results—the mental reaction in general, the psychosis—may present a far from identical picture depending on the general attitudes of the personality. In the general picture of psychosis, the role of structural changes in the brain or other organs thus cannot always be taken into account in a precise manner. Just as in the development of the organism and the nervous system function comes before structure, in other words, this or that function of the organism can become outlined before the differentiation of the corresponding parts of the nervous system with the formation of a special center is achieved, so in pathological deviations disorders can be observed that do not have adequate structural changes even to the slightest degree. Naturally, Kraepelin, singling out his early dementia (dementia praecox) on the basis of only his main principle—outcome in dementia, in other words from the point of view of the process in the brain—could not substantiate even his initial division of the disease into 4 groups: hebephrenic, catatonic, simple—purely demented—and paranoid forms. This division was based on the data of mental observation, which subsequently led Kraepelin himself to the necessity of singling out a much larger number of individual forms of early dementia. In any case, it relatively quickly became clear that on the basis of such signs as dementia, it is impossible not only to demarcate individual forms of early dementia, but also to delimit it from other diseases. The value of outcome in dementia as the cornerstone for building the entire concept of the disease was also shaken by the fact that, according to Kraepelin's own statistics, about 7% of all cases of his early dementia end in recovery. This undoubtedly contradicts the notion of dementia as a persistent, irreversible degradation of the psyche caused by destructive changes in the brain. Therefore, objections naturally arose against the very term "early dementia," since in a significant part of cases it cannot be called dementia in the proper sense. In addition, the terms "early" or "juvenile" and "premature" also turned out to be insufficiently expedient, since it became clear that the disease can develop significantly later than the age of puberty or young age in general, for which alone such an addition would be justified.

The impossibility, given the current state of knowledge, of obtaining basic criteria for constructing a doctrine on the essence of schizophrenia through clinical observation, the study of the signs of the disease, as well as through anatomical research, even supplemented by the study of metabolism, led to the need to study more deeply the structure of psychosis, to penetrate into the psychology of the schizophrenia patient, in order to find a line of demarcation from other diseases in this way. An attempt at such a psychological conception of schizophrenia was given by Bleuler, who proposed the very name schizophrenia, which became generally accepted. With the new term, he wanted to point out that the most essential thing for this disease is a peculiar change in the entire psychological life with the character of a violation of the unity of psychological functioning, the dissociation of its individual aspects, what Stransky not quite accurately called intrapsychic ataxia. In the most vivid form, this manifests itself in the fact that there is no adequacy of emotional experiences to the content of the intellect, which is characteristic of the normal state. The patient's consciousness may be filled with sensory illusions and delusions of persecution; in his morbid imagination, he may be the object of various kinds of painful influences and remain externally completely impassive; likewise, behavior does not bear the stamp of purposeful representations, but follows some internal impulses often incomprehensible to the patient himself. This splitting extends to all psychological functioning, to the processes of perception and assimilation of the environment, to all thinking, and is especially manifested in disorders of synthetic activity. The tendency to splitting also manifests itself in relation to the environment, to other people, leading to detachment, seclusion in oneself and in one's experiences, to the so-called autism. At the same time, dementia in the proper sense in schizophrenia does not play the role of a decisive sign at all, as it was in Kraepelin, since what is characteristic of schizophrenia is considered not the weakening of the intellect, not its quantitative decrease, but qualitative changes, shifts in the entire psychological personality. With such a psychological understanding of the essence of schizophrenia, it is natural that, compared with Kraepelinian dementia praecox, there was a significant expansion of the framework of the disease. Undoubtedly, the new concept indicates a greater understanding of the psychology of the disease and is a step forward, but it has brought with it a number of new difficulties. The expansion of the framework of the disease led to the inclusion in it of a significant number of mild forms, often those for which even the question of the presence of mental disorder is controversial. This made it difficult to demarcate schizophrenia not only from other mental illnesses, but also from pathological characters, in particular from the so-called schizoid personalities, the concept of which arose approximately together with the concept of schizophrenia itself. Since the decline of the intellect in the proper sense drops out in the new concept, in many cases it has become difficult to demarcate from some cases of more or less short-term psychoses caused by any external factors. The difficulty arises mainly because schizophrenia can also be caused by some external factor and precisely often in these cases gives a picture of recovery. Under such conditions, it is often difficult to decide whether we are talking about true schizophrenia, even if provoked by infections, or about symptomatic psychosis, representing only an external similarity to the psychosis under consideration. The complexity of the situation is also increased by the fact that sometimes external factors, usually under prolonged action, for example, psychological traumatization, tuberculosis, various infections, can, without causing psychosis, lead to significant changes in the psychological personality, hardly distinguishable from what the schizoid represents, if one does not pay attention to the fact that the latter represents a peculiar psychological individuality, the traits of which can be noted even in childhood. The work of psychiatric thought of recent times in the field of studying schizophrenia is concentrated mainly around the issues of demarcation from symptomatic psychoses, from psychopathities, and in particular from schizoid psychopaths. Great attention is also paid to further deepening into the psychology of patients of this kind, since Bleuler's initial characterization turned out to be too crude and could be considered only the first stage in acquainting oneself with the psychology of schizophrenia. In recent years, a great deal of attention has been paid precisely to clarifying the essence of schizophrenic psychology, the question of which was programmatic at the recent congress of German psychiatrists. It was also dealt with by the conference of psychiatrists in Moscow in 1932. It cannot be said that psychiatrists have now solved the task set, but nevertheless they have approached an understanding of its essence. Karl Schneider sees the essential in disorders of thinking, from which he derives not only delusions, but also hallucinations. Gruhle, agreeing with Beringer, sees the most essential in the "insufficiency of the intentional arc in thinking." According to Gruhle, the schizophrenic lacks spontaneity and initiative. The view of Berze deserves the greatest attention, according to which the main disorder (Grundstörung), which in itself is not given in direct observation, but is revealed as underlying all symptoms, must be considered "hypotonia of consciousness." It underlies the active schizophrenic process, causing a decline of the personality, a decrease in psychological activity. According to Minkowski, as well as Kronfeld, schizophrenia is not a morbid process leading to the disorder of the most important functions and the restructuring of the entire personality, but a special form of mental life, a special worldview. This view can hardly be agreed with. According to Minkowski, the main disorder is the loss of vital contact with reality. For the majority of researchers, Bleuler's psychological conception also appears to be too broad. One of the routine tasks of psychiatry in connection with this is to separate in the general mass of schizophrenia cases, in relation to which one can speak of a process leading to dementia, from cases ending in recovery. The ultimate goal of research is to find such moments that could be related to the essence of the disease, which remains unknown for now. Gilyarovsky holds the opinion that the question of the essence of schizophrenia has not yet been resolved, but nevertheless it can be said that schizophrenia is a process, although not always giving a decrease in intellect already in the first periods of the disease. In this regard, Gruhle's thought deserves attention that the current state of studying schizophrenia resembles the position that general paralysis of the insane presented in this respect before the discovery of the Wassermann reaction. Before this, paralysis, although it was clear that it was a process leading to dementia, was difficult to isolate from a group of diseases similar to it, all together constituting one undifferentiated group (les paralysies générales of the French). One must hope that the time is close when criteria will be found for isolating proper schizophrenia from a large number of schizophreniform pictures presenting with it only an external, although sometimes far-reaching similarity. As can be seen from what has been said, in the current position of psychiatry it is difficult to give such a definition of schizophrenia that would indicate precisely the main signs of the disease, capturing its essence in a brief designation. With a certain degree of approximation to the true state of affairs, it can be said that schizophrenia is an endogenous disease based on a hereditary predisposition, developing usually from within, without external jolts, characterized by a general change in the entire psychological personality with the character of a decrease in tone, with a loss of unity, externally manifesting itself in seclusion, detachment from the external world, with a tendency to a decrease in intellect. General psychopathology. The characterization of the disease, generally speaking, cannot be a simple enumeration of its signs. The latter must be given from the point of view of a certain unity. Between them there is an internal cohesion determined by the essence of the disease. Since the latter in schizophrenia is not yet known, here one has to heuristically consider as basic those disorders that most characterize the psychology of this disease. Much in it can still be understood from the point of view of Bleulerian splitting and the peculiar perception of the environment. The loss of internal unity due to the splitting of the psyche and its disintegration into a number of unrelated fragments disturbs the balance of the "ego" and the environment in the sense of lowering the value of the "ego," which cannot resist the environment to the same extent as before. Moreover, by virtue of a peculiar change in psychology, the environment is always experienced by the schizophrenic as having some special relation to him. This leads to a picture of seclusion in oneself, autism, with a clear tendency to put a definite barrier between oneself and the environment. The lack of unity due to the same splitness leads to the fact that there is no necessary synthesis in the evaluation of phenomena experienced by the patient. In every object subject to our assimilation, there are many different sides, each of which in itself determines the positive or negative attitude of the subject. In the norm, however, there is always a resultant that represents the reaction of the psyche as a whole.

In a schizophrenic person, the proper synthesis does not occur, and instead of a unified attitude toward a phenomenon, they produce a series of alternating and contradictory reactions, with one or another reaction taking precedence at any given moment, immediately replaced by another. At the same time, the patient seems to constantly oscillate from one pole to the other. Every phenomenon has a dual, ambivalent meaning for them. It is difficult for them to make any decision because they cannot break out of the vicious circle of contradictory drives, each of which has an equal attractiveness for them (ambitendence). This is also reflected in their behavior, which in pronounced cases consists of alternating movements in both directions: the patient alternately reaches out a hand to the physician and then pulls it back, and so on many times over. Such behavior can sometimes give the impression of complete absurdity and dementia, but in the proper sense, dementia is absent here. The possibility of correctly understanding phenomena and of adequate behavior is not excluded, but it is not manifested due to some internal causes, which can sometimes be treated as a phenomenon of inhibition close to those that bear this name among physiologists. It is not without reason that I. P. Pavlov compares such clinical phenomena to inhibition. It is undoubtedly true, however, that in its main basis the phenomena in schizophrenia are much more complex. One must consider that the German psychiatrist Bumke is closer to the truth, according to whom the most essential thing in schizophrenia is a general decrease in mental activity, due to which existing capabilities are not manifested, and the higher-standing mental forces—in other words, the higher mental abilities—are affected. It is precisely due to the decrease in mental activity, concerning the higher processes, that phenomena become predominant which characterize the life of lower impulses and instinctive drives, which is suppressed in a normal state. However, the state of affairs cannot be represented so simplistically as to be a matter of the disinhibition of impulses coming from the subcortical zone as a consequence of the disinhibition of the cortex, with the activity of which higher mental processes are usually associated. There undoubtedly take place deeper changes in the entire mental personality, a change in consciousness itself and in the understanding of the environment. The self seems to the schizophrenic to be connected to the surroundings by some special relations. In this, there is a certain analogy with the thinking of primitive man, as described by Lévy-Bruhl. These features of schizophrenic thinking give Storch grounds to speak of the arcahestic tendencies of their psyche. Everything surrounding is perceived by the schizophrenic as having a definite relation to them, everything is perceived in a special symbolic manner from the standpoint of some mysterious connections with the environment, of some magical influences of which they and their body are the object. The thinking of the schizophrenic is thus not adequate to the thinking of a normal person, which is why it is often called paralogical, proceeding as if according to its own laws, distinct from all regularities that can be seen in the thinking of a healthy person. One also speaks of the abstractness of the schizophrenic's thinking, which is connected with their detachment from the external, real world and their internal orientation, introversion according to Jung's terminology. The qualitative features that lead one to speak of the great peculiarity of the schizophrenic's thinking and its commensurability with the normal psyche also characterize its individual aspects. A very great weakness of active attention, one must think, is connected with the detachment from the external world, with the patient's autism. From the standpoint of the splitting underlying the disease, it can be understood that the flow of representations does not bear the influence of definite goal-directed sets at all. It is largely chaotic, often completely incoherent, incomprehensible, which is promoted by a large number of completely unexpected ("jumping") associations. Sudden stops in the flow of representations must also be considered characteristic, as if they unexpectedly run into some obstacles which, after a more or less short time, also disappear. This feature is also noticeable in speech, which suddenly, for a few seconds, more rarely longer, stops, exactly as if some kind of blockage (Sperrung) is taking place. For understanding the psychology of schizophrenia, it is also of great importance to become acquainted with those disorders that exist in the sphere of perception and assimilation of the surroundings, including everything that happens in the organism itself. Due to a peculiar metabolic disorder, with the formation of toxic products poisoning the nervous system (see below), the patient's consciousness is overloaded with various unpleasant sensations, pains in the head and various other places, a feeling of pressure, crawling, the passage of an electric current, and the like. These sensations, acting in a depressing manner on the general well-being, largely determine the attitude toward the surroundings, its understanding as something hostile and full of dangers for the patient. Even more in this regard must one reckon with the influence of illusions and hallucinations, the tendency toward which is considered a very essential element of the disease. Unpleasant sensations in the body are very often perceived illosorily, interpreted as the presence of something superfluous, the movement of something extraneous. Hence the frequent emergence of ideas of possession. In former times, delusions of possession were encountered immeasurably more often, and old psychiatry preserved many special names to designate specific types of zoanthropy (delusions of transformation into one or another animal), e.g., lycanthropy—into a wolf, cynanthropy—into a dog, hippanthropy—into a horse, galeanthropy—into a rooster, and the like. As for hallucinations, which are particularly colorful manifestations of the disease, errors of hearing must be put in the first place. The patient hears themselves called by name, people talking about them, usually various unpleasant things, scolding them, calling them a syphilitic, an onanist, threatening them, and the like; sometimes gunshots, cries, singing are heard. Voices very often bear the character of complete reality, but sometimes they seem to be voiceless, coming from goodness knows where; sometimes voices are heard inside the patient's head, patients speak in this case of inner voices, of "opinions" (pseudohallucinations, according to Kandinsky). Not infrequently, voices repeat the thoughts of the patient themselves: it is enough for them to think about something, and they immediately hear someone loudly repeating their thought, they get the impression as if their thoughts become loud, audible to others, hence the German name for this phenomenon—Gedankenlautwerden. Olfactory hallucinations are also characteristic of the schizophrenic. The patient feels various unpleasant odors—the smell of decay, poisonous gases; it seems to them that the smell of a dead body emanates from them themselves. Such hallucinations also occur in the field of taste; visual hallucinations are also possible, but they do not play a special role. Taking into account everything said regarding the attitudes of the schizophrenic toward the surroundings and the features of their perception, one cannot be surprised that delusions of persecution are extremely frequent in schizophrenia. The patient's consciousness is overloaded with various unpleasant sensations and hallucinations, and given their tendency to perceive everything as having a relation to them, the emergence of the thought is natural that everything delivering such agonizing experiences to them is not the result of the disease, but is connected with hostile influences from the outside, with poisoning, with hypnotic influence on the patient, with the action of an electric current or special machines used by some persons for subversive purposes in relation to the patient. It is understandable in view of what has been said that delusions of physical influence must be considered the most typical for the schizophrenic. The content and greater or lesser elaboration of the delusion vary greatly depending on the experienced era, the patient's education, and the richness of mental functioning, but what remains constant is that it is based on the idea of some hostile influences from the outside. More rarely in schizophrenia are delusions of grandeur observed: some higher mission lies upon the patient; they are called upon to produce a great upheaval, they are the bearer of a higher truth that is brighter than the sun. Becoming acquainted with the content of delusional thoughts, as well as hallucinations, in the schizophrenic is not very easy precisely by virtue of their characteristic withdrawal and distrustfulness. Patients are very reluctant to speak about their experiences, not infrequently directly concealing their delusional attitudes (dissimulating), so that the presence of hallucinations or delusions in them can be judged only by their actions, attitude toward the surroundings, and behavior in general. The result of stubbornly concealed delusions can be unexpected outbursts of hostility, attacks, or even the murder of someone around them. The presence of sensory deceptions is also judged by the so-called objective signs of hallucinations (clutching the nose during olfactory hallucinations, clutching the ears during auditory deceptions, staring fixedly at one point, and the like). The understanding of the schizophrenic's psychology is impossible without a proper assessment of the state of their emotional sphere. The cardinal factor here is also not disorders of a quantitative character, not the decrease and emotional blunting characteristic of the initial stages, but special shifts with a disturbance of equilibrium.

In this sphere, the schizophrenic experiences constant fluctuations from one pole to the other, ranging from a state of excitation and extraordinary sensitivity to complete coldness. At times, exacerbations of sensitivity occur such that the slightest contact with reality seems unbearable ("exposed nerves"), while at other times one must note complete insensitivity and an inability to experience any grief, joy, anger, and so forth. These properties of schizophrenic psychology are designated, at Kretschmer's suggestion, as the aesthetico-psychic proportion. Oscillations of the affective sphere between both poles may occur over a very short time and in various stages of the disease, but if one considers the entire course of the disease from beginning to start, it must be stated that these oscillations do not occur against one and the same emotional background. Schematically, one can say that at the beginning of the disease, the relatively constant mean from which oscillations occur in either direction lies closer to the hyperesthetic pole, whereas with its further course it constantly moves in the opposite direction. Along with this, there is an increasing blunting of the affective sphere in general, reaching complete emotional dullness in the initial stages of the disease. In the first periods of the disease, manifestations of very deep melancholy with thoughts of suicide are possible, which frequently lead to serious attempts to take one's own life. But even in the presence of a capacity for deep feelings, one must note a characteristic feature: like thinking, the emotions of the schizophrenic are somehow barely understandable and barely accessible to the feelings of another person. Given the schizophrenic's low accessibility, which hinders penetration into his inner world, observation of his behavior acquires particularly great importance for acquainting oneself with his psychology. Being a reflection of his intellectual experiences and emotional impulses, it is characterized by the same traits of incomprehensibility, strangeness, and the absence of any unity and consistency whatsoever. Estrangement from the external world with a tendency to adopt a defensive position toward it is the cause of negative attitudes toward others, so-called negativism. To a certain extent, one can attribute to this the striving not to let another person into one's inner world, but usually this name is associated with active resistance to any outside influences: the patient does not answer questions, although he understands them, pulls his hand back when the interlocutor extends his for a greeting, tightly closes his eyes when attempts are made to examine pupillary reactions, and closes his mouth and clenches his teeth in response to a request to show his tongue. Characteristically, one cannot discern in these actions any manifestation of motivated decisions or the influence of emotions. This is especially evident from cases where the patient, like a broken clockwork toy, mechanically does precisely the opposite of what is required: he is offered a hand and he withdraws his, and so on many times, or the patient is repeatedly invited to enter the office, he stubbornly resists, and finally, when he has entered and is asked to leave, he again stubbornly refuses. In view of the fact that resistance is shown here to completely opposite requests, the possibility of interpreting the patient's resistance as the result of some unexpressed considerations or simply fear is excluded, and one has to view it as a purely elemental, convulsive striving for opposition as such. And here, as in other areas, a complete opposite to this convulsive resistance to any influences may take place, namely passive obedience (Befehlsautomatismus), in which the patient immediately and without any resistance performs everything required of him, again regardless of what those requirements are, and performs directly opposite demands with complete readiness. Such passive obedience is, admittedly, observed predominantly in cases with pronounced intellectual weakening, but it can also be encountered in the initial periods when one has to speak of the shutting down of higher psychic mechanisms, turning the patient into an automaton. These or other features of pathological disorders manifest themselves most clearly when the latter are expressed ad maximum. Much of value can therefore be gained by observing an excited schizophrenic. Here, first of all, one's attention is drawn to the compulsive, mechanical nature of the movements. The impression is created that the excitation is not an expression of a general psychic state, and does not testify to any affective experiences standing behind it. It does not even bear the character of performing any purposeful actions. The simplest of the latter presupposes a complex set of individual movements, each of which is performed in a definite order and with a definite degree of intensity and speed. Here, however, one chiefly observes individual movements that in themselves lack any meaning, for example, waving arms, jumping in one place, rotating the entire torso around the longitudinal axis, clicking the tongue, and various grimaces, among which protruding the lips forward in the shape of a snout (Schnauzkrampf) is especially frequent. As a rule, motor excitation is onesided and monotonous. Frequently, the excitation is confined to the bed: the patient does not remain still for a minute, but at the same time does not leave the bed. Often, the very same movement is repeated a large number of times (stereotypy). In contrast to the excitation of a manic patient, one can speak here not of a striving for action (Beschäftigungsdrang), but simply of an elemental, convulsive striving for movement (Bewegungsdrang). It is also understandable that there are cases where the excitation is confined solely to the speech sphere. Lying in bed, patients talk incessantly, and their speech production bears the clear stamp of schizophrenic thinking and generally turns out to be of a completely special property. Its most essential sign is incoherence and incomprehensibility. Sometimes, for a long stretch of time, it consists entirely of some fragments of sentences and individual words having no connection with one another. The impression is created of a kind of word hash, whence the German term Wortsalat. In some cases, incoherent speech bearing all the signs of schizophrenic cleavage comes to the fore due to the fact that other areas are not affected as severely and a certain correctness of behavior is preserved. Such a picture of "schizophasia" has to be observed chiefly in far-advanced cases of the disease. Representing not simply individual words, but precisely speech, and moreover constructed quite correctly grammatically, it has no meaning at all. At best, one can find hints of some fragments of thoughts and expressed delusional ideas, but frequently one has to speak of complete verbal incoherence, which is a reflection of the incoherence of thought. The understanding of a schizophrenic's speech is also hindered by the fact that he often uses the most ordinary words in a completely special sense, sometimes not hesitating to invent completely new words of his own. This feature is generally characteristic not only of schizophrenics, but among them it represents a fairly typical phenomenon. Here it is apparently connected with the formation of some completely new concepts, for which there is a need to form special words as well. However, what has been said does not exhaust everything that characterizes the schizophrenic's speech. Its essential features must also include the fact that it proceeds somehow apart from everything happening around the patient, in particular depending very little on conversations conducted near the patient and even on questions addressed directly to the patient. The schizophrenic with speech excitation, while answering questions put to him, continues to produce his incoherent output, and in the process he often catches up on the question or individual words from it and repeats them, but they do not serve as stimuli for the subsequent train of thought and remain as if outside of it, the patient does not dwell his attention on them and passes them by (Vorbeireden—talking past the point). In some cases, usually unaccompanied by significant speech excitation, the patient mechanically repeats what is said to him or what he hears around him; often only the last word of a phrase is repeated in this process (echolalia). A more or less significant excitation characterizes by no means all cases of schizophrenia, but only some and moreover only separate periods of the disease. The excitation, very pronounced at the beginning of the disease, may subsequently be replaced by general inhibition, stupor, or pass into a state of lethargy and inertia. In the first case, general immobility is observed, as if resulting from the freezing and petrification of the musculature. For a long time, the patient does not change the posture once assumed (catalepsy). Sometimes, in cases with so-called waxy flexibility of the musculature, the patient's body can be given the most varied and awkward positions, and he preserves them for an indefinitely long time. Frequently, states of excitation are replaced by inhibition and vice versa.

In these shifts, it is impossible to notice any regularity in the sense of greater or lesser equal duration of excitation, depression, or states of lethargy and calm indifference. Against the background of a completely calm state, sudden bursts of very great excitation may unexpectedly arise, sometimes individual impulsive acts, jumping out of bed, shouting, attacking someone among those around. Suicide attempts can be just as impulsive, which are generally not uncommon in schizophrenics. The mechanisms that lead to such attempts are not always the same. Suicide attempts by schizophrenics are especially frequent at the beginning of the disease in a state of lowered well-being, when the ability to observe oneself with a critical evaluation is not yet lost and when the patient is entirely absorbed by experiences of profound changes caused by the disease. Sometimes such attempts are associated with delusional ideas of persecution and are to a certain extent a means to escape from the oppressive state of anguish and fear of impending doom. There are cases when suicide attempts have to be regarded as the result of imitation. On the other hand, delusional ideas of persecution, arousing in the patient the thought of the necessity of defense, can lead to attacks on their imaginary enemies, to murders. Their victims are often people who had no relation to the patient whatsoever. Usually these are persons occupying a greater or lesser prominent position, the murder of which naturally attracts general attention, and this in turn can give the patient the opportunity to declare to everyone and in particular to the judicial authorities about the persecutions to which the patient is subjected, about the persecutions of which he has become a victim. For the behavior of schizophrenics, at least in some cases, obsessive and compulsive actions are also typical. Apart from the tendency to suicide, which can also have an obsessive character, one should include here the urge to inflict injuries on oneself, to scratch oneself, to pick at the skin until ulcers form, to pull out one's hair (trichotillomania). Sometimes some sexual experiences lie at the base of such an urge to self-torture, since it is directed at the genitals; very rarely, such facts as tearing out the genitals and self-castration are encountered. Phenomena such as squeezing out one's own eyeball and biting off the tip of the tongue are also possible. Compulsiveness is sometimes manifested in the tendency to pronounce cynical or some indecent words, and sometimes phrases having some symbolic and defensive meaning for the patient. One should similarly look sometimes at the patient's performance of some special action, a movement of the hand or the entire torso, wherein the patient clearly strives in such a way to rid himself of some hostile influences. State of consciousness in schizophrenia. As we have seen, the impossibility of entering into contact with the patient, which is sometimes manifested very sharply, the absence of reaction to verbal irritation, depend on special attitudes toward the environment and do not indicate a disorder of consciousness. The latter is not grossly disrupted from the formal side in the sense, at least, as happens in amebic, epileptic psychoses, and certain other diseases, and as a rule, the schizophrenic is satisfactorily oriented in time and the surrounding environment. At the same time, however, upon closer examination, one has to state very significant disorders of consciousness and moreover very peculiar ones, perhaps even most characterizing the psyche of the schizophrenic. Their essence can be understood proceeding from the schizophrenic lowering of activity and splitting, which also extend to the consciousness of the "ego". The latter generally has a very complex structure. A fully developed consciousness is characterized by a distinct differentiation of the "ego" and the environment. The former is presented as a certain activity, which is opposed by the environment, subject as it were to conquest, to mastering. The "ego" of the schizophrenic is devoid of this activity, unity, and, what is very significant, is characterized by a completely different attitude toward the environment. Even in a healthy person, there are states in which higher forms of consciousness yield to those that characterize more primitive forms of mental functioning, when the boundaries between the "ego" and the non-"ego" lose their clarity. Such hyponotic states occur during dozing, sleep, but can be expressed particularly sharply in morbid states and above all in schizophrenia. In the schizophrenic, not only a decrease in mental activity is observed, but also a special state that can be characterized as a lowering of consciousness. Berze speaks of the hypotonia of consciousness. The "ego" itself seems altered to the patient himself. In this personality change, depersonalization, the loss of activity and unity of the "ego" plays a particularly large role. In connection with this, individual complexes of experiences that previously entered as a part into a harmonious whole acquire great independence. Individual experiences or whole groups of them seem alien, extraneous to the patient himself; hence he often gets the idea that these are not his thoughts, but are "made" for him, suggested from the outside. As a consequence of the disorder of the bodily "ego", it seems to the patient that his whole self has changed, his body has become different, in some cases it seems to the patient that his body is growing and filling the whole room. The typhophrenic state also affects the nature of the perception of the environment. Here, too, there is no integrity and unity, and, most importantly, everything is perceived from the angle of some special relation to the patient's "ego". For the ambivalent psyche of the schizophrenic, who has lost the ability to synthesize disparate experiences into a single whole, everything has a dual meaning. Becoming acquainted with any new phenomenon, he is able to assimilate its actual content, but gives everything his own evaluation. Upon entering the hospital, he knows that others consider it precisely a medical institution, but for him it is a place for testing or torment. Similarly, he thinks that the patients surrounding him are fictitious, dummy persons, only passed off as patients. Thus, not only a double orientation arises—understanding the environment from the point of view of others and from his own personal point of view—but also a picture of splitting of personality and double thinking. On the one hand, the patient lives in the surrounding real world, as it were admitting that he is indeed what others pass him off as; on the other hand, in his own world of dream-like experiences (see also Psychic duality). Taking into account the above-described features of the schizophrenic psyche, it is easy to understand that the patient reluctantly admits others into this special world of his, especially since others, as he knows, evaluate everything differently. This peculiar double bookkeeping sometimes leads to what is called condensation (Verdichtung): for the patient, for example, the doctor treating him is indeed a doctor, but at the same time his deceased relative. If one takes into account the complexity of the structure of consciousness and the entire personality, in which higher forms of consciousness normally dominate, suppressing lower layers of experiences, then the predominance of the latter in schizophrenia is understandable. The above-mentioned inclination toward magical, mystical experiences, often with a relapse into a peculiar religiosity, is understandable. Grosser disorders of consciousness with the subsequent loss of memories in schizophrenics occur only as an exception and moreover in states in the development of which some external moments, e.g., infections, played a role. It is typical for schizophrenics in general that upon the passing of a state of severe stupor, when the patient did not react to the environment with anything, or a picture of excitation with the same inaccessibility, upon the establishment of the possibility of contact, patients can give an account of their experiences, as well as report in general terms what was happening around at that time. Clinic of schizophrenia. The data just set forth regarding the psychology of schizophrenia and its individual manifestations relate to the disease as a whole. They represent a summary of observations on a large number of cases, in each of which only a small part of the described symptomatology can be stated and moreover in a peculiar combination. The latter cannot be regarded as a mechanical mixture of symptoms; there is undoubtedly an internal connection between them, and they are grouped around certain elements that are leading. The above-described features of psychology are characteristic of all cases of schizophrenia, but at the same time, each case represents something of its own precisely because the principal, leading factor is not always one and the same. The determining moments for the structure of schizophrenia, like any other psychosis, must be considered heredity, the totality of innate personality traits entering into the concept of constitution, one or another warehouse of organization and in particular somatic types, changes on the part of internal organs, and external influences. In each individual case, one or two of these moments come to the fore, which mainly explains the variety of the clinical picture. Hereditary burden is something inherent in schizophrenia in general, but sometimes it is expressed particularly sharply and imprints a special stamp on the clinic. This group of cases is characterized by the fact that the disease begins without any external additional moments whatever.

The trigger for the development of schizophrenia is frequently infectious diseases (influenza, pneumonia, one or another form of typhus), physical exhaustion, or psychic trauma, but in these cases the disease begins without any external causes whatsoever, as if from within. The psychosis, as with other forms of this disease, begins with general indefinite nervous phenomena. Patients exhibit irritability, mood instability, complain of headaches, increased fatigue, and the like. All these phenomena strongly resemble the familiar complex of nervous phenomena observed in individuals with nervous system exhaustion, but the fact of the matter is that in this case there are no such conditions present that would make nervous exhaustion understandable. The main thing, however, is that these indefinite nervous symptoms are a prelude to an increasingly clearly designated decline of the intellect and the entire psychic personality. The latter is manifested in a decrease in working capacity and intellectual productivity. At the same time, psychic activity is increasingly lost, interests in anything whatsoever disappear, and lethargy and apathy usually set in. As generally with schizophrenia, no matter what form it takes, one can also note here withdrawal and autistic attitudes, but there may be a complete absence of any phenomena of irritation, hallucinations, or excitement. Likewise, the mistrust characteristic of all schizophrenics does not turn into persecutory delusions. This is the so-called simple form of schizophrenia. With it, there is a gradual progression and accumulation of dementia phenomena. This form is characteristic predominantly of youth. During puberty, the hebephrenic form is frequently observed, which is characterized by a peculiar cheerful excitement, with silliness, with the senseless stringing of one word to another (verbigeration) without the noticeable participation of hallucinations or delusional ideas. In the subsequent course of the disease, there is a calming with the development of ever-increasing dementia. In youth, one has to encounter forms that are conventionally designated as catatonic (see Catatonia). The course of these catatonic cases is comparatively favorable, which corresponds to a greater preservation of the formal abilities of the intellect and the external correctness of behavior. With this form, there are convulsive seizures of a predominantly tonic character, bearing the character of attacks that usually proceed without loss of consciousness and without biting the tongue, but convulsive seizures not distinguishable from true epilepsy are possible in schizophrenia in general; essentially, apparently, they belong to symptomatic epilepsy. Cases of the combination of schizophrenia with true epilepsy are described. The course of those cases which, in view of a certain similarity to circular psychosis, received the name of circular schizophrenia must be considered comparatively favorable. The similarity here is expressed not only in the tendency to produce more or less isolated attacks, followed by intervals of a relatively good condition, but also in the fact that individual phases from the external side sometimes present a rather far-reaching similarity to the picture of a manic or depressive state. Behind these symptoms, which give the entire picture of the psychosis a certain similarity to circular psychosis, one can always discern that fundamental element which is characteristic of schizophrenia in general, and in particular the tendency to progression. The tendency to periodic repetition is sometimes also discovered in cases in which the attacks themselves do not present a great similarity to mania or melancholia (remitting type). In middle age, and sometimes earlier, a form develops in the picture of which delusional ideas of persecution, partly also of grandeur, stand in the foreground, with a more sluggish development and with a very sharply expressed tendency to the development of dementia. Such cases are conventionally called paranoid schizophrenia (dementia paranoides). Delusions here develop in connection with the appearance of special sensations in the body, the realization within oneself of certain changes, the cause of which the patient sees not in the disease, but in malicious influences from the outside. The tendency to perceive actual impressions under a special angle of view also has significance. Delusions are often subjected to a certain processing, as a result of which they reveal a certain systematization; it seems to the patient that he is the victim of some secret of conspirators, counter-revolutionaries, wreckers; agents of a special organization are constantly tracking him, and moreover, even in the hospital he is surrounded by some double agents passing themselves off as patients. In some cases, persecutory delusional ideas are intertwined with ideas of grandeur. Although some improvement is possible even with this form, pronounced remissions do not occur, however, and a progressive course must be considered typical. In terms of prognosis, this form must be considered unfavorable. The enumerated items do not exhaust all the diversity of the course of schizophrenia, in which a significantly greater number of individual forms could be isolated, as some authors do. However, such a division, based on external features, cannot be given special significance. A more essential division must be considered Berze's division into active and inactive forms. Sometimes the disease proceeds with such insignificant changes and develops so slowly that the true nature of the disease is revealed significantly later. These are the so-called mild, or more accurately mildly proceeding, forms of schizophrenia. In some cases, the disease debuts with sharply expressed and short-lived flare-ups ending so favorably that the patients are considered recovered. However, the repetition of the disease in the same form, but with a clearer picture of schizophrenia, indicates that the first flare-up was not something independent, but the first attack of the same disease. It is conventionally considered that in the intervals between attacks, schizophrenia was in a hidden, latent state. It happens rarely that the first clear attack of schizophrenia develops for the first time at a late age (late onset of schizophrenia). It has already been mentioned above that sometimes schizophrenia at the beginning of its course is difficult to distinguish from the picture of nervous exhaustion. There are, on the other hand, cases that debut with hysterical seizures, and for a long time patients are considered "degenerative hysterics"; and in these cases, the gradual decline of the personality points to the true nature of the disease. There are cases of slowly developing schizophrenia when complaints of disorders on the part of internal organs play a dominating role in the picture of the disease. Patients apply with them to therapists who find some somatic disorders, and sometimes organ neuroses, and for a long time no assumption arises that it is a question of mental illness. Sometimes the onset of schizophrenia is connected with one or another external trigger. Thus, it can be noted that it develops after some typhus, influenza, in connection with a postpartum illness or alcoholism. In these cases, even in the very picture of the disease, the stamp of exogeny can be noted in the form of mass hallucinations of the type that is characteristic of infections or alcohol illnesses, so that at the beginning the disease resembles an infectious or alcohol delirium. Later, however, these exogenous layers are erased, and the disease goes its own way. Schizophrenia in childhood also presents significant differences. Schizophrenia developing in the pubertal period and later does not present special differences from what is observed in adults, but there are cases when a picture appears in a 3-4-year-old child that by its structure must be attributed to schizophrenia; the further course is convincing of the correctness of such a classification of these cases. With a small tendency to produce delusional ideas, childhood schizophrenia is characterized by a comparative abundance of catatonic phenomena. A feature of childhood schizophrenia must also be considered the fact that here, apart from that intellectual weakening which enters into the very essence of the disease, there is also a growth retardation characterizing the development of the child. Naturally, the earlier the age at which schizophrenia begins, the heavier this stamp of developmental lag, and the more difficult the distinction from the picture of imbecility or idiocy. What has been said almost exhausts everything essential regarding the course of schizophrenia. It is generally extremely diverse. At one pole, one must place cases ending in recovery, at the other, those rapidly leading to profound dementia. We saw that even in relation to the so-called dementia praecox of Kraepelin, the possibility of recovery was allowed in a decent percentage. With the modern broader understanding of schizophrenia, the percentage of possible recoveries must be considered even more significant. More frequently, however, there are such cases when one can speak only of the arrest of the disease, and patients again acquire the ability to live in society and even engage in independent labor. As for the lethal outcome, schizophrenia itself does not lead to death, and patients suffering from it can live indefinitely long. The decrease in activity, however, concerns not only psychic experiences. Patients have little activity in general, move little, have few drives for anything whatsoever, eat poorly, and frequently refuse food altogether. All this leads to physical exhaustion and makes the development of various somatic diseases easier, from which patients ultimately perish. The danger of tuberculosis is especially great for them. Somatic constitutional types and somatic changes.

Hereditary relationships in schizophrenia. Essence of the disease. The described picture of mental changes is naturally a reflection of the processes occurring throughout the entire organism and primarily in the brain. We have seen that in the clinical picture, despite all its diversity, one can single out certain variants and types of course, which are naturally not accidental. Repeating themselves with a certain regularity, they correspond to certain regularities, to certain variants in somatic and cerebral changes and in the very types of somatic constitution. Schizophrenia very often develops against the background of a specific pre-psychotic personality—a number of characterological traits (withdrawal, distrust, etc.) included in the concept of the schizoid. Kretschmer established correlations between this schizoid, as well as schizophrenia, and the leptosomatic (asthenic), sometimes giant type of constitution. Numerous verification studies in various countries have generally confirmed the correctness of Kretschmer's observations, although these correlations cannot be considered a regularity in the proper sense. Schmidt's data concerning the distribution of 200 schizophrenics by somatic types (in %) deserve attention: leptososomes (asthenics) - 40.5, leptosomatic - 10.5; mixed types: giant (muscular) type - 7.5, dysplastic types - 2.0, indefinite types - 27.0, pyknic mixed types - 9.0, pyknic type - 3.5. From these data it is evident that with the undeniable predominance of leptososomes, other types are also significantly represented, in particular, pure pyknic types are not such a rarity. Although constitutions, the concept of which also includes somatic structural types, do not determine the entire picture of diseases developing against their background, nevertheless, certain correlations between the two are undeniable. Somatic types can be considered as one of the factors grouping symptomatology in certain directions. These or other variants of the clinical picture correspond with a certain degree of constancy to certain somatic types. As a known regularity, it can be accepted that the presence of pyknic components coincides with a more favorable course, and one can speak of schizophrenia with a pyknic constitution as a special type, close in course and structure to circular psychosis and giving a more favorable prognosis (Mautz's type - schizophrenia with pyknic constitution). In the presence of leptosomatic constitution, the course can, conversely, take on a catastrophic character with a rapid outcome in dementia ("schizokara" of Mautz). Other, more detailed features of somatic organization do not remain without reflection in the mental picture of the disease. These include the insufficient development of the cardiovascular system, a small, drop-shaped heart, a narrow, hollow chest, which explains the easy development of tuberculosis. Of even greater importance is low sexual hormonality, which makes it understandable that in the sexual life of schizophrenics, which is generally not particularly active, there is little concrete in the sense of rapprochement with persons of the opposite sex, which is usually replaced by masturbation and more sexual fantasies with a touch of sexual perversions. The reduced activity of schizophrenics in the sphere of metabolism corresponds to insufficient energy of respiratory movements, a decrease in basal metabolism, a decrease in oxidative processes, a decrease in the percentage of nitrogen in relation to sulfur, and an increase in neutral sulfur. Metabolism in schizophrenia is disturbed, and moreover in the direction that toxic substances accumulate in the organism, poisoning the nervous system, and this poisoning leaves a special imprint on the clinical picture. In particular, the catatonia series of phenomena must be compared precisely with the processes of auto-intoxication, but the latter may also have significance for the entire clinical picture. This is supported by the possibility of the reverse development of morbid phenomena, and it is not accidental that this occurs especially often in relation to cases with catatonic syndrome. De Jong's experiments also deserve attention in this regard; he obtained catalepsy, negativism, and vegetative disorders by injecting bulbocapnine into animals. It is not accidental that such syndromes can also be caused by certain hormones circulating in normal human blood. It is noteworthy that mescaline, which produces a schizophrenia-like picture in experiments, is very close to adrenaline, and this is all the more interesting because, according to a number of studies (done, it is true, with not entirely impeccable methodology), the amount of adrenaline in the blood in schizophrenia decreases, and this makes possible the appearance in the blood of some derivatives acting in a toxic manner. The essence of schizophrenia is undoubtedly connected with some toxic processes. From this point of view, it is easiest to understand the changes found in the brains of schizophrenics at autopsy. A fact of capital importance is that properly atrophic changes are found only in cases of comparatively long duration of the disease, when mental decline clearly strikes the eye during clinical observation. In far-advanced cases, atrophic changes in the convolutions, most pronounced in the frontal regions, are noticeable to the naked eye in the brain. Upon microscopic examination, one can note a decrease in the number of cells and nerve fibers, especially in layers 2, 3, and 5. The absence of inflammatory changes must be considered typical in this regard. At the same time, in the brains of schizophrenics who died for one reason or another at the beginning of the disease, one can state phenomena of edema and especially swelling due to the binding of water thanks to changed chemistry. This once again indicates that the basis of the disease is phenomena of auto-intoxication, which subsequently lead to changes in the brain with the character of a destructive process. The localization of the greatest changes in certain parts of the brain is also a factor influencing the formation of symptomatology. The lesion of the frontal lobes in itself is easy to invoke to explain the symptom complex entering into the picture of the simple, demented, sluggish form of schizophrenia. It is believed that in catatonic cases there are the most changes in the subcortical zone. As thought, the lesion of the vegetative centers located here has the closest relation to the metabolic disorder, the result of which is autointoxication. The predominant lesion of certain psychosensory departments can lead to the appearance of hallucinatory syndromes in the picture of the disease. However, the role of local changes in the brain in the structure of the disease cannot be exaggerated, since they are always the result of damage to the brain as a whole, and moreover as an organ closely connected with the entire organism. What significance does hereditary burdening have in the pathogenesis of the disease, the role of which, generally speaking, must be recognized as very significant? The point is not only that the hereditary burden here is as great as in no other psychosis, with the exception of circular psychosis, but also in its qualitative features. Genealogical studies of Rüdin, Hoffmann, Luxenburger, and others have shown that in the families of schizophrenics, mainly along collateral lines (in uncles and aunts, brothers, sisters, uncles, cousins), schizophrenics and schizoid personalities are also often found. One can therefore think that the brain of a schizophrenic is already deficient at birth, especially in certain systems. The latter therefore fall ill more easily and are more frequently affected by toxic substances developing as a result of disordered metabolism. Brain changes in the initial periods of the disease are toxic in nature and essentially reversible. Prolonged poisoning, however, produces persistent changes of a destructive nature. That schizophrenia is a cerebral process is evident from neurological data, of which enough has accumulated to speak of the neurology of schizophrenia. From the side of the cranial nerves, one can note phenomena of asymmetry, e.g., a difference in the pupils, depending on unequal innervation on the right and left sides. The absence of pupil dilation during painful skin stimuli (Bumke's symptom) is often noted. One can often note sluggishness of facial expression, but the most characteristic disorders from the side of the latter—paramimia, inadequacy of facial expression to mental experiences—are essentially an expression of general splitting. A decrease in reflexes from the skin and mucous membranes and an increase in tendon reflexes must be classified among constant phenomena. Sometimes one can state pathological reflexes—Gordon, Oppenheim, Babinski—usually not sharp and transient. Various vasomotor disorders are very often observed: cyanosis and cooling of the extremities, dermographism, tendency to edema. Attention is drawn to headaches, noted with great constancy at the beginning of the disease; often they have a special character of bursting, pressure from the inside on the forehead and back of the head. The cited data indicate with great certainty that the essence of schizophrenia is connected with cerebral changes, but their nature remains unclear. Further research must show whether we are talking only about the congenital weakness of certain systems falling ill as a result of various poisonings, or whether special processes giving toxic substances exhibiting selective affinity for certain parts lie at the basis.

In view of as yet unclarified but undoubtedly existing correlations between certain nerve centers and systems of internal organs, it can be assumed that the essence of schizophrenia reduces to a disease of entire systems developing on the basis of hereditary predisposition, which include both nerve centers and internal organs functionally dependent on them, as well as endocrine glands. Diagnosis of the disease. The definition of the disease must be made chiefly on the basis of the presence of characteristic features of schizophrenic psychology and above all the phenomena of splitting and reduction of mental activity. In contrast to schizoid psychopathies, it is natural that these features are not permanent properties of the personality, but develop and continue to develop starting from a certain period of life. It is also characteristic that mental changes develop without any external push, as if from within. When diagnosing schizophrenia, which often presents difficulties at the beginning of the disease, one must keep in mind the possibility of schizoidization of the personality, its change in the sense of convergence with schizoids as a result of purely external causes—beginning tuberculosis, psychological traumatization. The recognition of schizophrenia in the initial periods can be hindered due to the fact that, as a result of additional etiological factors, neurotic overlays, exhaustion symptoms, or hysterical reactions appear, which may obscure the true face of the disease. The decisive factor here must be the clarification of the question whether there is a general decline of the personality, its degradation with a weakening of activity, interests, and intellectual productivity. These same considerations have to guide one in differentiating schizophrenia from schizoid psychopathies. It must be remembered that mildly progressing schizophrenia with monotonous complaints about various disorders may present not as a mental disorder, but as a picture of neurosis or even a somatic disease. In the case of acute phenomena of excitement, according to its features in the majority of cases it is not difficult to make a correct diagnosis, but there exists a group of cases in which, as a result of one or another external influence, usually infection, pictures develop that are extremely close to schizophrenia; most often in this case, excitement is observed with negativism, catatonic phenomena in general, and with hallucinations. These states pass relatively quickly, leaving behind no mental changes of any kind, and likewise no schizoid traits are often noted in the patient's character before the disease. The impression is created that these outbreaks of the disease with a picture of schizophrenia arise exclusively as a result of an exogenous factor and, upon its removal, pass without a trace. Such cases are usually called exogenous or symptomatic schizophrenias, separating them from proper schizophrenia. Their development is explained in accordance with Popper's conception of the schizophrenic type of reaction, which is an exogenous form of reaction—typical, able to develop with various etiological factors, and non-specific for schizophrenia. In France, in accordance with Claid's proposal, in contrast to schizophrenia they are called schizomanies. The position of these cases remains insufficiently defined. It must be agreed that some of them present only an external similarity to schizophrenia and have no relation to it, but it is undoubtedly true that frequently here we are dealing with the first, as it were, signal outbursts of schizophrenia, which later reveals itself with complete certainty. The exact demarcation of schizophreniform pictures of purely exogenous origin from genuine schizophrenia is connected with the resolution of the core question of the essence of schizophrenia and at present can be carried out only tentatively. The recognition of schizophrenia in cases with pronounced delusional ideas usually does not present difficulty in view of the characteristic nature of the delusion itself and the mechanisms of its development. When it is necessary to demarcate from paranoia, it is taken into account that in this disease the delusion arises as a result of a peculiar interpretation of actual facts by a personality inclined by its features to delusional interpretations. Demarcation from so-called paraphrenias is of no special significance, since Kraepelin himself, who created this concept, recently included them together with premature dementia in one group (endogene Verblödungen). In cases with clearly manifested dementia in the absence of sufficient anamnestic data, demarcation from congenital dementia is sometimes not easy. The occasion for diagnostic errors can be given in particular by those cases of schizophrenia that develop against the background of some intellectual deficiency (Propfschizophrenie). The decisive importance belongs to the proof of the growth of phenomena from a certain time. The prognosis must be based on the fact that the diagnosis of schizophrenia itself does not doom the patient to the development of dementia and the loss of working capacity and social value. Apart from the possibility of recovery or an improvement close to it, the decline of the mental personality, if it nevertheless occurs, can be so insignificant and slowly developing that the patient can continue his previous work for a long time and even go forward. The prognosis is better in those cases that are close in form to circular psychosis, as well as in cases in the development of which any external factors played a role. The prognosis is comparatively better in the catatonic form. The worst prognosis is warranted by forms with a progressively developing delusion (paranoid forms). In prognosis, one must also keep in mind the possibility of suicide and the development of tuberculosis. Treatment and prophylaxis. In the acute period of the disease, stationary treatment is indicated, which is dictated by the necessity of a more complete study and greater opportunities to apply various special methods of treatment. The hospital is indicated in cases of refusal of food or persistent striving for suicide, as well as in cases of great excitement with danger to others due to active delusion formation. In treatment, it is necessary to pay attention to the general condition and raising nutrition. As for drug treatment, in sluggish forms intravenous infusions of calcium, protein therapy, oxygen insufflation, the use of extracts from genital organs, injections of spermin, organolysates of Tushnov, Kazakov, gravidan (not in excited patients), lipocerebrin of Lifshits are useful. Theoretically, transplantation of genital glands is indicated, especially from a person, if they must for some reason be removed, but in practice this method has given very little so far. Steinach's operation has not justified itself at all. Ligatures of the vessels of the cervico-vertebral region and extirpation of the upper cervical nodes of the sympathetic nerve were also proposed. Theoretical indications seem to exist for the second method (better blood supply to the brain is achieved). In general, surgical methods of treatment are still poorly developed. General light baths are useful. In all acute cases, especially with excitement, warm and hot baths (37, 38°) are indicated; one has to resort to narcotics (codeine, heroin); in excited patients it is useful to systematically apply small doses of hypnotics. The latter are also given in usual doses (0.5–1.0 veronal) in cases with persistent insomnia and excitement. Kleist recommended intravenous infusion of 3.0–5.0 somnifen to induce prolonged sleep, after which not only calming but also the restoration of contacts with surroundings is said to occur. The remedy is not indifferent and has not found wide application. Hyperthermic methods can bring benefit, which must include, besides subcutaneous administration of sodium nucleinate, also the introduction of sulfosin under the skin. Malaria has been repeatedly recommended. The benefit from it in any case is not as great as in general paralysis of the insane. A stay in the hospital, no matter how much it guarantees the possibility of more complete treatment, is not, however, such a universal measure that is applicable to all cases and throughout the course of the disease. Even in relation to acute periods, it must be limited to the most necessary time. As we saw, the schizophrenic even in the acute period of the disease constantly fluctuates between inclusion in his imaginary world and the surrounding reality. Immersion in the deep layers of the psyche with dream-like experiences (hypnoid of Kretschmer) is connected with biological changes in the organism and is physiological to a certain extent. The subsiding of acute phenomena marks a decrease in the intensity of painful experiences, and in this period precisely one can expect that inclusion in the real world will turn out to be possible to a greater extent than it was before, and here in particular the application of active occupational therapy can have significance. Only in recent years have psychiatrists clearly realized the importance of timely, as early as possible, active intervention, although earlier they drew attention to the fact that patients as a result of a long stay in the hospital with doing nothing give a picture of rapid mental decay ("hospital dementia"), and pointed out the necessity of as early discharge as possible. Until recently, occupational therapy was understood in the sense of occupying the patient's attention with something, but not with work as such.

Now the emphasis is placed on ensuring that patients are engaged in labor and that this labor appears useful and socially valuable in the eyes of the patient himself. It is not always easy to draw a schizophrenic into occupational therapy, but much can be done along this path in terms of treatment. After discharge, patients must be under medical supervision and, if necessary, receive outpatient treatment. In this way, it is possible to continue and deepen the results of treatment and timely notice deterioration requiring interning. Remembering the importance of labor, one should not rush to transfer the patient to disability status. In cases of remissions, even deep ones, intense intellectual work should not be permitted, e.g., continuation of studies in a higher educational institution, and it is better to transfer the patient to physical labor. From a preventive point of view, one must first of all keep in mind the major role of hereditary burden in the disease of schizophrenia. The fight against defective conceptions can be successful both along the lines of sanitary education and by registering all schizophrenics along with other mental patients. Patients who are constantly treated in the outpatient clinic and are under supervision naturally have less chance of producing offspring, for whom there is a great danger of being born with an unstable nervous system. One should combat the prejudice according to which mental illness in young people is the result of sexual abstinence, which is why uncultured parents have a tendency to treat such patients through marriage. But even if it were possible through some, even radical measures, to deprive all schizophrenics of the opportunity to have children (which is essentially impossible), this alone would contribute very little to the goal, since the predisposition to schizophrenia is transmitted not by parents, who usually remain healthy, but through collateral lines. Nevertheless, one should strive to limit the number of children in families where there are many schizophrenics and mentally ill people in general. Likewise, if the question of interrupting pregnancy arises at all, the presence of hereditary burden in the family is an extra reason for its positive decision. In general, it must be borne in mind that the influx of a healthy stream from unburdened families greatly lowers the danger for the offspring. Marriages where schizophrenics are present on both sides must be considered especially dangerous; if this is not the case, the number of schizophrenics in subsequent generations tends to come to naught. It must be kept in mind that not only the presence of genes transmitted according to Mendel's laws, but also mutations are of significance for the occurrence of schizophrenia. In families where there is generally a burden of schizophrenia, pathological mutations can arise more easily under unfavorable influences on the germ plasm. In the presence of a congenital predisposition, such external moments as infection, intoxication, overwork, and psychic trauma are thought to be of significance. Schematically speaking, they translate the latent form into an overt one. The prophylaxis of schizophrenia thus coincides to a significant extent with neuropsychic prophylaxis in general. In the sense of individual prophylaxis, medical and educational measures in relation to children from families with a high hereditary burden are of primary importance. Such children are often physically weak, sometimes develop very young, and exhibit fair abilities, even talent, usually of a one-sided nature. Real child prodigies can be found in such families, but this premature development is an expression not of strength, but of weakness. For such children, who, moreover, are usually intensively developed and stuffed with various kinds of knowledge, there is a great danger of a pathological breakdown, manifested in the subsequent disease of schizophrenia. Such children should be the object of care in the sense of physical strengthening and release from excessive tension in school years and during the transitional age, which is especially dangerous for them. A similar attitude should be directed toward persons who have undergone a schizophrenic attack more or less safely. Social significance of schizophrenia. Here one must first of all reckon with the high frequency of this disease. It accounts for approximately one third of all mental patients. At the same time, it must be taken into account that the figures characterizing the spread of schizophrenia refer only to fully expressed cases, and there are many more of them than initial and mild forms. At the same time, it is important that schizophrenia strikes mainly at a young age. The great social significance of schizophrenia must also be seen in the fact that large sums are spent on the treatment and maintenance of numerous cadres of patients of this kind. It must also be borne in mind that schizophrenics present a greater danger than any other patients. If the correlations between criminality and mental illness are very great in general, this is largely due to schizophrenia. The percentage of schizophrenics among mental patients in psychiatric hospitals undergoing compulsory treatment, i.e., who committed one crime or another in a state of mental illness and were placed in a hospital because of their social danger, is very large. But it would be unfair to think that humanity only suffers from schizophrenics and receives nothing from them. Mental disease does not, of course, create any values by itself, but the situation with schizophrenia is somewhat different precisely because it is not necessarily a process leading to dementia, but qualitative shifts in psychic functioning. Without producing dementia proper, it sometimes intensifies and emphasizes certain aspects of the psyche that exist in every person; it sharpens perception in certain directions and therefore allows one, especially in cases where an gifted, talented personality falls ill with schizophrenia, to see more than is accessible to a healthy, "sober-minded person." Recently, there has been talk of a special trend in literature and art—ultraism—among the representatives of which one can also find persons with schizophrenic thinking. V. CXXIV, 1930; Handbuch der Geisteskrankheiten, hrsg. v. O. Bumke, B. IX, B., 1932 (lit.; abridged translation—O. Bumke, Shizofreniya [Schizophrenia], M., 1933); Mauz F., Der kompensierte u. dekompensierte schizophren. Defekt, seine Prognose u. Psychotherapie, B., 1929; Müller M., Über Heilungsmechanismen in der Schizophrenie, B., 1930; Storch A., Das archaisch-primitive Erleben und Denken der Schizophrenen, B., 1922.

V. Gilyarovsky.

SCHISTOSOMIASIS (bilharziasis), a group of helminthiases caused by trematodes (see) of the genus Schistosoma, fam. Schistosomatidae. Characteristics of the genus Schistosoma Weinland, 1858. Gonochoric trematodes with weak suckers and without a pharynx. The male has a ventral groove, capable of closing, in which the female is housed (see separate plate, fig. 1). The intestine initially divides into two trunks, which run parallel and then merge into a single trunk. They parasitize the blood vessels of mammals. Eggs (see separate plate, fig. 2), lacking the operculum usual for trematodes, are armed with 1 or 2 stylets, by means of which they pave their way from the closed vascular bed into the external environment, traumatizing the underlying tissues (they exit either through the walls of the bladder into its cavity and are excreted in the urine, or penetrate through the mucosa of the large and rectums into the lumen of the intestine and are excreted with feces). The cycle of development takes place through an intermediate host—freshwater mollusks, without the participation of an additional host. Emerging from the body of mollusks into water, cercariae have the ability to actively penetrate the blood, burrowing into the host's body through undamaged skin (while bathing, working, e.g., in rice plantations with bare feet, etc.). 6 representatives of the fam. Schistosomatidae have been registered in humans, among which 3 species are of great importance in tropical pathology. The attached table shows the differential diagnosis of these three species. Definitive hosts... Geography...

Characters of Schistosoma haematobium Bilharz, 1852; Schistosoma Mansoni Sambon, 1907; Schistosoma japonicum Katsurada, 1901. Male: length ... width. Female: length ... width. Cuticle of the male: Number of testicles ..... Eggs: length ... width. Spine on the egg. Eggs exit to the outside .... Mollusks: intermediate hosts ..... 10–15 mm, 0.8–1.0 mm, 20 mm, 0.25 mm. With small tubercles. 0.120–0.180 mm, 0.040–0.060 mm. Terminal. As a rule—with urine, rarely with feces. Bullinus contortus, Physopsis africana, etc. Man. Africa and Western Asia (Palestine, partly Arabia). In the USSR not yet found. 10–12 mm, 1.0–1.2 mm, 12–16 mm, 0.16 mm. Large. With bumps. 0.140–0.165 mm, 0.060–0.070 mm. Lateral. As a rule—with feces, rarely with urine. Planorbis boissyi, Planorbis olivaceus, etc. Man. Africa, America (Brazil, Porto Rico). In the USSR not yet found. 12–20 mm, 0.5–0.55 mm, 15–26 mm, 0.3 mm. Smooth. 0.070–0.100 mm, 0.055–0.065 mm. Lateral. Only with feces. Katayama nosophora, Oncomelania hupensis, etc. Man, dog, pig, sheep, horse. Southeast Asia (Japan, Korea, Philippines). In the USSR, several imported cases have been found. In the USSR, two species of Schistosomiasis have been ascertained in animals: 1) Schistosoma turkestanicum Skrjabin, 1913, widely distributed in Kazakhstan, 156 and 2) Sch. bomfordi Montgomery, 1906, ascertained in sheep in the Far East (Skrjabin and Schulz, 1928). Both of these species have been separated by modern systematists into a special genus, Ornithobilharzia Odhner. The pathogenesis of schistosomiasis is combined with the following biological moments. Cercariae emerging from the body of mollusks swim in water, actively penetrating through human skin into blood vessels. At this moment, they lose their tail appendage, transforming into the stage of so-called schistosomulum, which head towards the arterial system of the abdominal organs, where after 30–35 days they grow to the sexually mature stage. This period, corresponding to the so-called first stage of the disease, is characterized by its symptomatology and pathological anatomy. When the mature female begins to lay eggs, and the latter, by means of their spine, carve a way for themselves from the closed circulatory system through tissue elements into the external environment either into the intestinal lumen or into the urinary tracts, this period of the cycle marks the second stage of the disease, the most severe in its course. Finally, the third stage of schistosomiasis, having a very heterogeneous course depending on the intensity of invasion, the presence of repeated infections, and similar moments, is characterized by the predominance of chronic hyperplastic processes, phenomena of cirrhosis, ascites, and the complex of those phenomena that characterize schistosomatomatous intoxication. Intensive invasion can lead the patient to death. Depending on the causative agent, 3 main types of human schistosomiasis are distinguished: Japanese schistosomiasis, urinary schistosomiasis, and Manson's schistosomiasis. 1. Japanese schistosomiasis is caused by Schistosoma japonicum. The intestines and liver are mainly involved in the pathological process. The first stage of the disease is characterized by acute intestinal disorders (diarrhea) and the appearance of edema. Gradually, diarrhea with tenesmus becomes more frequent, blood appears in the feces, the patient noticeably loses weight, and an enlargement of the liver and spleen is observed. The walls of the large intestines at this stage appear unusually thickened, with all their tissue saturated with a multitude of parasite eggs in the amount of millions of specimens. As a result of prolonged mechanical irritation caused by strings of eggs migrating through the intestinal wall, papillomatous growths on the mucosa of the colon and rectum are generally observed (see separate table, Fig. 3), which in individual cases can also turn into carcinomas. As the disease progresses, liver cirrhosis develops, ascites appears, limb edema occurs, and the patient dies in a state of exhaustion. In individual cases, the disease may be characterized by severe damage to the central nervous system (cerebral form of schistosomiasis), extreme enlargement of the spleen, atypically proceeding fever, phenomena of urticaria, and the like. The diagnosis is made by finding characteristic eggs in the feces. 2. Urinary schistosomiasis is caused by S. haematobium. The urinary and reproductive organs are involved in the pathological process, since the females lay eggs in the vessels of the urinary bladder, ureters, and much less often the rectum. After a 1¹/₂–2-month incubation, symptoms of urticaria, edema, fever appear, and then phenomena of cystitis and hematuria. In severe cases, purulent cystitis, pyelitis, and nephritis are observed. The disease is frequently accompanied by the formation of urinary stones, in the center of which the parasite's egg can be found. With a mild invasion, spontaneous recovery can occur within 2–3 years. The diagnosis is made by finding characteristic eggs in the urine. Cystoscopy and fluoroscopy can likewise provide valuable indications. In 1919, Fairley successfully applied the complement fixation test, taking as an antigen an extract of the organs of mollusks infected with schistosomes. 3. Manson's schistosomiasis is caused by Schistosoma Mansoni. The large intestine and liver are mainly involved in the pathological process. The symptomatology is very similar to Japanese schistosomiasis: bloody diarrhea, tenesmus, prolapse of the rectum, papillomatous growths on the mucosa. The disease is complicated by liver cirrhosis, general intoxication, and frequently leads to death. Therapy of all types of schistosomiasis: Tartarus stibiatus in the form of intravenous injections is considered the most specific remedy. A 1% solution in physiological saline, sterilized in an autoclave or passed through a Chamberland filter, is used. Treatment begins with a dose of 0.05, then proceeds to 0.075, and finally 0.1, with injections given at intervals of every other day, calculated so that the total dose for the entire course reaches 0.75. Prophylaxis is carried out by: 1) dehelminthization of patients with an emphasis on the careful protection of the external environment from contamination by urine and feces; 2) destruction of mollusks—intermediate hosts—by chemical methods (spraying basins with a copper sulfate solution); 3) reclamation works in infected areas; and 4) protection of the skin from contact with water infected with cercariae.