These lapses of memory, which at first seem without content, gain a content by means of accidental auto-suggestion, and this content builds itself up automatically to a certain extent. It achieves no further development, probably on account of the improvement now beginning, and finally it disappears altogether as recovery sets in. Binet and Féré have made numerous experiments on the implanting of suggestions in states of partial sleep. They have shown, for example, that when a pencil is put in the anæsthetic hand of a hysteric, letters of great length are written automatically whose contents are unknown to the patient's consciousness. Cutaneous stimuli in anæsthetic regions are sometimes perceived as visual images, or at least as vivid associated visual presentations. These independent transmutations of simple stimuli must be regarded as primary phenomena in the formation of somnambulic dream-pictures. Analogous manifestations occur in exceptional cases within the sphere of waking consciousness. Goethe,[14] for instance, states that when he sat down, lowered his head and vividly conjured up the image of a flower, he saw it undergoing changes of its own accord, as if entering into new combinations.
In half-waking states these manifestations are relatively frequent in the so-called hypnagogic hallucinations. The automatisms which the Goethe example illustrates are differentiated from the truly somnambulic, inasmuch as the primary presentation is a conscious one in this case; the further development of the automatism is maintained within the definite limits of the original presentation, that is, within the purely motor or visual region.
If the primary presentation disappears, or if it is never conscious at all, and if the automatic development overlaps neighbouring regions, we lose every possibility of a demarcation between waking automatisms and those of the somnambulic state; this will occur, for instance, if the presentation of a hand plucking the flower gets joined to the perception of the flower or the presentation of the smell of the flower. We can then only differentiate it by the more or less. In one case we then speak of the "waking hallucinations of the normal," in the other, of the dream-vision of the somnambulists. The interpretation of our patient's attacks as hysterical becomes more certain by the demonstration of a probably psychogenic origin of the hallucination. This is confirmed by her troubles, headache and teno-synovitis, which have shown themselves amenable to suggestive treatment. The ætiological factor alone is not sufficient for the diagnosis of hysteria; it might really be expected a priori that in the course of a disease which is so suitably treated by rest, as in the treatment of an exhaustion-state, features would be observed here and there which could be interpreted as manifestations of exhaustion. The question arises whether the early lapses and later somnambulic attacks could not be conceived as states of exhaustion, so-called "neurasthenic crises." We know that in the realm of psychopathic mental deficiency there can arise the most diverse epileptoid accidents, whose classification under epilepsy or hysteria is at least doubtful. To quote C. Westphal: "On the basis of numerous observations, I maintain that the so-called epileptoid attacks form one of the most universal and commonest symptoms in the group of diseases which we reckon among the mental diseases and neuropathies; the mere appearance of one or more epileptic or epileptoid attacks is not decisive for its course and prognosis. As mentioned, I have used the concept of epileptoid in the widest sense for the attack itself."[15]
The epileptoid moments of our case are not far to seek; the objection can, however, be raised that the colouring of the whole picture is hysterical in the extreme. Against this, however, it must be stated that every somnambulism is not eo ipso hysterical. Occasionally states occur in typical epilepsy which to experts seem parallel with somnambulic states,[16] or which can only be distinguished by the existence of genuine convulsions.[17]
As Diehl shows,[18] in neurasthenic mental deficiency crises also occur which often confuse the diagnosis. A definite presentation-content can even create a stereotyped repetition in the individual crisis. Lately Mörchen has published a case of epileptoid neurasthenic twilight state.[19]
I am indebted to Professor Bleuler for the report of the following case:—
An educated gentleman of middle age—without epileptic antecedents—had exhausted himself by many years of over-strenuous mental work. Without other prodromal symptoms (such as depression, etc.) he attempted suicide during a holiday; in a peculiar twilight state he suddenly threw himself into the water from a bank, in sight of many persons. He was at once pulled out and retained but a fleeting remembrance of the occurrence.
Bearing these observations in mind, neurasthenia must be allowed to account for a considerable share in the attacks of our patient, Miss E. K. The headaches and the teno-synovitis point to the existence of a relatively mild hysteria, generally latent, but becoming manifest under the influence of exhaustion. The genesis of this peculiar illness explains the relationship which has been described between epilepsy, hysteria and neurasthenia.
Summary.—Miss Elise K. is a psychopathic defective with a tendency to hysteria. Under the influence of nervous exhaustion she suffers from attacks of epileptoid giddiness whose interpretation is uncertain at first sight. Under the influence of an unusually large dose of alcohol the attacks develop into definite somnambulism with hallucinations, which are limited in the same way as dreams to accidental external perceptions. When the nervous exhaustion is cured the hysterical manifestations disappear.
In the region of psychopathic deficiency with hysterical colouring, we encounter numerous phenomena which show, as in this case, symptoms of diverse defined diseases, which cannot be attributed with certainty to any one of them. These phenomena are partially recognised to be independent; for instance, pathological lying, pathological reveries, etc. Many of these states, however, still await thorough scientific investigation; at present they belong more or less to the domain of scientific gossip. Persons with habitual hallucinations, and also the inspired, exhibit these states; they draw the attention of the crowd to themselves, now as poet or artist, now as saviour, prophet or founder of a new sect.
The genesis of the peculiar frame of mind of these persons is for the most part lost in obscurity, for it is only very rarely that one of these remarkable personalities can be subjected to exact observation. In view of the often great historical importance of these persons, it is much to be wished that we had some scientific material which would enable us