The demarcation of hysteria and certain borderline cases of epilepsy from congenital and acquired psychopathic mental deficiency likewise presents the greatest difficulties. The symptoms of one or other disease everywhere invade the neighbouring realm, so violence is done to the facts when they are split off and considered as belonging to one or other realm. The demarcation of psychopathic mental deficiency from the normal is an absolutely impossible task, the difference is everywhere only "more or less." The classification in the region of mental deficiency itself is confronted by the same difficulty. At best, certain classes can be separated off which crystallise round some well-marked nucleus through having peculiarly typical features. Turning away from the two large groups of intellectual and emotional deficiency, there remain those deficiencies coloured pre-eminently by hysteria or epilepsy (epileptoid) or neurasthenia, which are not notably deficiency of the intellect or of feeling. It is essentially in this region, insusceptible of any absolute classification, that the above-named conditions play their part. As is well known, they can appear as part manifestations of a typical epilepsy or hysteria, or can exist separately in the realm of psychopathic mental deficiency, where their qualifications of epileptic or hysterical are often due to the non-essential accessory features. It is thus the rule to place somnambulism among hysterical diseases, because it is occasionally a phenomenon of severe hysteria, or because mild so-called hysterical symptoms may accompany it. Binet says: "Il n'y a pas une somnambulisme, état nerveux toujours identique à lui-même, il y a des somnambulismes." As one of the manifestations of a severe hysteria, somnambulism is not an unknown phenomenon, but as a pathological entity, as a disease sui generis, it must be somewhat rare, to judge by its infrequency in German literature on the subject. So-called spontaneous somnambulism, resting upon a foundation of hysterically-tinged psychopathic deficiency, is not a very common occurrence and it is worth while to devote closer study to these cases, for they occasionally present a mass of interesting particulars.
Case of Miss Elise K., aged 40, single; book-keeper in a large business; no hereditary taint, except that it is alleged a brother became slightly nervous after family misfortune and illness. Well educated, of a cheerful, joyous nature, not of a saving disposition, always occupied with some big idea. She was very kind-hearted and gentle, did a great deal both for her parents, who were living in very modest circumstances, and for strangers. Nevertheless she was not happy, because she thought she did not understand herself. She had always enjoyed good health till a few years ago, when she is said to have been treated for dilatation of the stomach and tapeworm. During this illness her hair became rapidly white, later she had typhoid fever. An engagement was terminated by the death of her fiancé from paralysis. She had been very nervous for a year and a half. In the summer of 1897 she went away for change of air and treatment by hydropathy. She herself says that for about a year she has had moments during work when her thoughts seem to stand still, but she does not fall asleep. Nevertheless she makes no mistakes in the accounts at such times. She has often been to the wrong street and then suddenly noticed that she was not in the right place. She has had no giddiness or attacks of fainting. Formerly menstruation occurred regularly every four weeks, and without any pain, but since she has been nervous and overworked it has come every fourteen days. For a long time she has suffered from constant headache. As accountant and book-keeper in a large establishment, the patient has had very strenuous work, which she performs well and conscientiously. In addition to the strenuous character of her work, in the last year she had various new worries. Her brother was suddenly divorced. In addition to her own work, she looked after his housekeeping, nursed him and his child in a serious illness, and so on. To recuperate, she took a journey on the 13th September to see a woman friend in South Germany. The great joy at seeing her friend from whom she had been long separated, and her participation in some festivities, deprived her of her rest. On the 15th, she and her friend drank half a bottle of claret. This was contrary to her usual habit. They then went for a walk in a cemetery, where she began to tear up flowers and to scratch at the graves. She remembered absolutely nothing of this afterwards. On the 16th she remained with her friend without anything of importance happening. On the 17th her friend brought her to Zürich. An acquaintance came with her to the Asylum; on the way she spoke quite sensibly, but was very tired. Outside the Asylum they met three boys, whom she described as the "three dead people she had dug up." She then wanted to go to the neighbouring cemetery, but was persuaded to come to the Asylum.
She is small, delicately formed, slightly anæmic. The heart is slightly enlarged to the left, there are no murmurs, but some reduplication of the sounds, the mitral being markedly accentuated. The liver dulness reaches to the border of the ribs. Patella-reflex is somewhat increased, but otherwise no tendon-reflexes. There is neither anæsthesia, analgesia, nor paralysis. Rough examination of the field of vision with the hands shows no contraction. The patient's hair is a very light yellow-white colour; on the whole she looks her age. She gives her history and tells recent events quite clearly, but has no recollection of what took place in the cemetery at C. or outside the Asylum. During the night of the 17th-18th she spoke to the attendant and declared she saw the whole room full of dead people—looking like skeletons. She was not at all frightened, but was rather surprised that the attendant did not see them too. Once she ran to the window, but was otherwise quiet. The next morning, while still in bed, she saw skeletons, but not in the afternoon. The following night at four o'clock she awoke and heard the dead children in the neighbouring cemetery cry out that they had been buried alive. She wanted to go out to dig them up, but allowed herself to be restrained. Next morning at seven o'clock she was still delirious, but recalled accurately the events in the cemetery at C. and those on approaching the Asylum. She stated that at C. she wanted to dig up the dead children who were calling her. She had only torn up the flowers to free the graves and to be able to get at them. In this state Professor Bleuler explained to her that later on, when in a normal state again, she would remember everything. The patient slept in the morning, afterwards was quite clear, and felt herself relatively well. She did indeed remember the attacks, but maintained a remarkable indifference towards them. The following nights, with the exception of those of the 22nd and the 25th September, she again had slight attacks of delirium, when once more she had to deal with the dead. The details of the attacks differed, however. Twice she saw the dead in her bed, but she did not appear to be afraid of them, she got out of bed frequently, however, because she did not want "to inconvenience the dead"; several times she wanted to leave the room.
After a few nights free from attacks there was a slight one on the 30th Sept., when she called the dead from the window. During the day her mind was clear. On the 3rd of October she saw a whole crowd of skeletons in the drawingroom, as she afterwards related, during full consciousness. Although she doubted the reality of the skeletons, she could not convince herself that it was a hallucination. The following night, between twelve and one o'clock—the earlier attacks were usually about this time—she was obsessed with the idea of dead people for about ten minutes. She sat up in bed, stared at a corner and said: "Well, come!—but they're not all there. Come along! Why don't you come? The room is big enough, there's room for all; when all are there, I'll come too." Then she lay down with the words: "Now they're all there," and fell asleep again. In the morning she had not the slightest recollection of any of these attacks. Very short attacks occurred in the nights of the 4th, 6th, 9th, 13th and 15th of October, between twelve and one o'clock. The last three occurred during the menstrual period. The attendant spoke to her several times, showed her the lighted street-lamps, and trees; but she did not react to this conversation. Since then the attacks have altogether ceased. The patient has complained about a number of troubles which she had had all along. She suffered much from headache the morning after the attacks. She said it was unbearable. Five grains of Sacch. lactis promptly alleviated this; then she complained of pains in both fore-arms, which she described as if it were a teno-synovitis. She regarded the bulging of the muscles in flexion as a swelling, and asked to be massaged. Nothing could be seen objectively, and no attention being paid to it, the trouble disappeared. She complained exceedingly and for a long time about the thickening of a toenail, even after the thickened part had been removed. Sleep was often disturbed. She would not give her consent to be hypnotised for the night-attacks. Finally on account of headache and disturbed sleep she agreed to hypnotic treatment. She proved a good subject, and at the first sitting fell into deep sleep with analgesia and amnesia.
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