Periodical Sleep Seizures of an 
Epileptic Nature. 
BY 
GEORGE W. JACOBY, M. D. 
REPRINTED FROM 
Etc Nefo ¥orit ^HeUical journal 
for May 20, 1893. Reprinted from the New York Medical Journal 
for May SO, 1893. 
PERIODICAL SLEEP SEIZURES OF AN 
EPILEPTIC NATURE * 
By GEORGE W. JACOBY, M. D. 
There can be no doubt that the study of physiological 
sleep is surrounded by insuperable difficulties, and that no 
great advance in our knowledge of the causes and laws 
which govern this condition has been made. To a certain 
extent this failure must be attributed to the almost exclu- 
sive employment of experimental physiology as a method 
of study, and the neglect of other methods. The subject 
is of so complex a nature that we can not hope to attain 
any results from one method alone, and it would seem natu- 
ral that we should give more attention to the clinical side 
of the question than has hitherto been done. Particularly 
does it seem reasonable that the study of pathological dis- 
orders of sleep should be of service in this regard. The 
production of artificial sleep, known as the hypnotic state, 
has of late years so engrossed the attention of all observers 
that pathological modifications of spontaneous sleep have 
been almost totally disregarded. The appearance of Geli- 
neau's publication on narcolepsy in 1880 for a time caused 
* Read before the Metropolitan Medical Society, February 15, 1893. 
Copyright, 1893. by D. Appleton and Company. 2 
PERIODICAL SLEEP SEIZURES OF 
considerable interest to be taken in these cases of abnormal 
sleep, and they were then studied and classified. 
Under the designation narcolepsy are classed all cases 
in which, from whatsoever cause, an imperative and irre- 
sistible somnolence occurs suddenly, and recurs after more 
or less short intervals. This condition may occur from a 
variety of causes, but the sleeping states known as hys- 
terical are of so interesting a nature, and they have re- 
ceived so much attention, that all other causal agencies 
have been overshadowed by them; it is therefore not sur- 
prising that the majority of practitioners are prone to class 
all cases of periodically recurring sleeping attacks as hys- 
terical : thus, while it has been acknowledged that certain 
of these cases of sleep seizures may be epileptic in nature, 
this characteristic has been entirely lost sight of. These 
cases of epileptic sleeping attacks are undoubtedly of con- 
siderable interest and importance, and they become so from 
the diagnostic difficulties which they present, as well as 
from the medico-legal complications which they may lead 
to ; there can be no doubt that they occur much more fre- 
quently than the scant literature of the subject would in- 
duce us to assume. A careful study of all published cases 
of sleeping attacks, of whatsoever nature, certainly leaves 
the impression that a number of these, even if occurring in 
hysterical patients, are epileptic in nature. It is my inten- 
tion to speak of such cases only as are undoubtedly epilep- 
tic, even though not accompanied by convulsions, and for 
this reason I can not enter upon the cases just referred to, 
which for the most part are described as cases of hystero- 
epilepsy. Personally, I have decided objections to the use 
of this compound designation. That epileptic patients not 
only may, but frequently do, have hysterical attacks I will- 
ingly admit; but in describing these attacks we should 
give them their proper designation-epileptic or hysterical, AN EPILEPTIC NATURE. 
3 
as the case may be-and not create confusion by calling 
them hystero-epileptic. 
A case reported by Sahlmen, which Dana includes under 
those of epileptic somnolence, is one of the few in which 
the author, notwithstanding the marked hysterical symp- 
toms present in the intervals of the attacks, pronounces the 
convulsions and sleep attacks as epileptic, and there can be 
no doubt but that he is correct in this classification. 
Cases of recurrent sleeping attacks unaccompanied by 
convulsions, but probably epileptic, in which the sleep seiz- 
ure constituted the entire palpable attack, have been de- 
scribed by Westphal, Fischer, Mendel, and Putzel (commu- 
nicated by Dana), and very recently by Berkan. Possibly 
the cases of Siemens and Foot also belong to this category. 
The application of the term epilepsy has of late years 
been very much extended, and now this term embraces very 
much more than the train of symptoms described as tonic- 
clonic convulsions with loss of consciousness. We now 
distinguish a variety of epileptic conditions, making use 
of the terms haut mal and petit mat as designations for two 
gross divisions. In this latter category we must class those 
cases which, while they have little or nothing in common 
with the classical epileptic attack, nevertheless present 
symptoms which can not be explained in any other way 
than by the assumption of their epileptic nature. These 
symptoms are, in the main, short disorders and interrup- 
tion of psychic action, followed in all instances by am- 
nesia. 
If the condition known as haut mat, occurring with or 
without psychic disturbances, is of itself highly interesting, 
that variety just referred to must attract our attention in a 
much wider way. 
One of the most interesting chapters in the study of 
epilepsy is undoubtedly that of sleep, and this state has 4 
PERIODICAL SLEEP SEIZURES OF 
been fully treated of by Siemens. It is well known that 
many epileptics sleep after every convulsive attack, that a 
smaller number do not sleep after their attacks, and that 
there are patients who present no regularity in this regard, 
but who sleep after some attacks but do not sleep after 
others. What, however, is not so well known is that, in 
some patients, attacks of sleep constitute the chief symp- 
tom, and, as stated, it is with cases of this class solely that 
I propose to deal in the present communication. Such 
cases as Reynolds's (that of a young lady who did not sleep 
when she had severe convulsions, but was depressed and 
comatose all day when slight attacks preceded), Nothnagel's 
(that of a lady with otherwise short and light sleep, who 
very shortly before her epileptic attacks fell into a very 
long and deep sleep), and Schultz's (that of an epileptic 
sailor in whom the attacks always occurred about dinner 
time and were announced by tiredness, followed by a sleep 
during which the convulsion occurred), differ from the cases 
which I wish to report, and, although interesting, can not 
be more than mentioned. 
The cases of periodical recurrent sleep seizures of an 
epileptic nature which have come under my own observa- 
tion are the following: 
Case I.-A man, aged twenty-nine (seen in 1887); family his- 
tory neuropathic; mothei- had " nervous spells " all her life; one 
brother was epileptic and died suddenly. Patient himself was 
perfectly well until his twelfth year, when, in consequence of 
fright produced by being chased by a dog, he fell down in a con- 
vulsive attack. He was completely unconscious, bit his tongue 
and frothed at the month. After the attack he slept for sev- 
eral hours. This was the only purely convulsive attack that he 
or his family admit his ever having had. At the age of twenty- 
one be had a peculiar attack described as follows: He was 
walking with a friend, conversing upon ordinary matters, when 
he suddenly wheeled around, completing a full circle, and then be-. AN EPILEPTIC NATURE. 
5 
gan to run at full speed; After running a distance of about five 
hundred feet he fell, and when his friend came to him he found 
him lying upon the ground apparently fast asleep. The asser- 
tions are positive that no convulsions occurred. He slept for 
about fifteen minutes, attempts at arousing him proving futile, 
and awoke as from a normal sleep, with total amnesia as to 
what had occurred from the time he started to run; he. how- 
ever, perfectly remembered the subject of the conversation 
which he was engaged in prior to this occurrence. The next at- 
tack took place under similar circumstances about two months 
later. The attacks gradually grew more and more frequent, so 
that of late years they have occurred almost daily and sometimes 
he has had several in one day. Whenever these attacks have been 
witnessed from their commencement, the reports all agree that 
the first intimation of the attack is the starting off on a run. 
He never runs for a long distance, sometimes only a few yards; 
he never has a convulsion of any kind; and when he ceases 
running is found asleep, generally having fallen, sometimes 
leaning against some support. A complete attack has never 
been witnessed indoors, but he has been found asleep in all 
places and positions. The sleep, as far as known, does not last 
more than fifteen minutes, generally less. Finally, it must be 
noted that the patient is a somnambulist, performing various 
automatic actions of a quiet nature, as walking, talking, etc. As 
a child he was subject to attacks of pavor nocturnu=. I never 
had occasion to witness one of his attacks. 
It is hardly probable that the epileptic nature of this 
case can be doubted. The case belongs to those of pro- 
cursive epilepsy, being made up of the automatic action, 
which here seems to take the place of a convulsion and 
the subsequent sleep. This sleep seems to me to be simi- 
lar to the ordinary sleep of epileptics after a convulsive at- 
tack. For this reason the case hardly belongs to the cate- 
gory to which I intended confining my remarks, but, as the 
patient was often found asleep without any positive knowl- 
edge of preceding occurrences, we are justified in record- 6 
PERIODICAL SLEEP SEIZURES OF 
ing it here. He is totally unconscious from the time he 
starts to run until he awakens from his sleep, so that the 
possibility remains that he actually falls asleep at once and 
that the running is an automatic (somnambulic) action, 
forming part and parcel of this sleeping state. 
Case II.-G. F. W., aged thirty-five (seen in 1890); family 
history unimportant; has had a venereal ulcer without any sec- 
ondary symptoms; professes to have been perfectly well other- 
wise. Ten years ago he began to increase rapidly in weight, so 
that from a hundred and fifty pounds his weight within a 
period of two years increased to two hundred and sixty-seven. 
At present his weight is two hundred and fifty. This increase 
in weight did not trouble him; he felt perfectly well and was 
not obliged to lose a single day's work on account of ill health, 
glis occupation was that of a barber. Four years ago, while 
■shaving a customer, he had what he calls an "attack." This 
attack consisted in his falling asleep; the razor with which he 
was shaving was firmly grasped in his hand and he was bend- 
ing over the occupied barber chair; when he awoke everything 
was in the same position except the customer, whose discretion 
had probably induced a precipitate retreat. Patient felt per- 
fectly well and bright before and after the attack; he him- 
.self says the entire attack came like a rainstorm from a clear 
■sky. The following day, under similar circumstances, he had 
;another attack, and, as was natural, lost his situation. The at- 
tacks, which from the first recurred daily, increased in fre- 
quency so that he would have a number in one day. Mental 
and bodily quietude favored their production, so that sitting 
unoccupied would almost certainly superinduce an attack. At 
present these attacks occur under all circumstances; he has 
fallen asleep while smoking a pipe, and thereby has set fire to 
the carpet; he has often fallen asleep while washing himself; 
-and a few days ago, while seated in a chair near a hot 
:stove, he had an attack during which he fell upon the stove, 
burning his face and forehead intensely. He has also been 
overtaken by this sleep while standing on the front platform of 
a street car, and has then fallen off into the street; further- AN EPILEPTIC NATURE. 
7 
more, he goes to sleep while walking out of doors and continues 
walking until he awakes, having encountered some obstruction 
or having fallen. The longest intermission between the attacks 
is four or five hours, but usually not more than an interval of 
an hour exists. The attacks, which, as stated, are particularly 
frequent when patient is not actively engaged, also occur in the 
midst of hard physical labor. Unable to continue at his trade, 
the patient, in the hope that hard labor might prevent the re- 
currence of the attacks, accepted employment as a longshore- 
man. As a proof of his physical strength, he tells me that he 
is able, unaided, to lift and load upon a wagon objects weigh- 
ing three hundred pounds. Even work of this kind did not 
influence the occurrence of the seizures. As regards the 
character of these seizures, the patient, whose intelligence is 
perfectly normal, can give but little information ; he says that 
his eyes grow heavy and, notwithstanding strenuous efforts to 
prevent it, they close and he sleeps; he has no further premo- 
nition of the approaching attack, and during it is perfectly 
unconscious. I have repeatedly witnessed these attacks, and 
can add that his face becomes intensely congested and his head 
falls forward upon his chest; his pupils during the sleep are con- 
tracted and his respiration and pulse are slower than usual. 
As far as I have been able to observe them, these attacks are of 
two kinds-light and severe ones. The first partake more of 
the character of " absences," but lasting somewhat longer, and 
from these he can be awakened by shaking or addressing him 
roughly. The long attacks are different. In the beginning 
of these it is impossible to arouse him by any kind of irritation ; 
even with a faradaic brush I have failed; but toward the end of 
the attack pricking with a pin causes him to make warding-off 
movements with his hands, and sometimes, but not always, 
awakens him. The attacks which I have witnessed, when not 
interfered with, have all terminated as normal sleep terminates 
in normal persons. The duration of his attacks varies from a 
few minutes to three quarters of an hour. They also occur 
when he is in bed, and his relatives at such times distinguish 
these attacks from normal sleep by their not being able to 
awaken him. Otherwise he is a very light sleeper-in fact, very 8 
PERIODICAL SLEEP SEIZURES OF 
restless, passing the greater part of the night in a semi-wakeful 
condition. Patient has been a somnambulist since childhood, 
his automatic actions usually being of a quiet nature; he has, 
however, had noisy somnambulistic attacks in which he created 
disturbance by shouting and striking about himself with any 
object within his reach. In one of these attacks he struck his 
roommate with a water pitcher, and the following morning 
knew nothing of what he had done. Convulsions of any kind 
are positively denied; nevertheless, an examination of his 
tongue showed scars, and he says that it is often sore and swollen. 
Treatment of various kinds-with bromides, iodides, and reduc- 
tion of weight-all proved unsuccessful in modifying the seizures 
in any way. 
There can, in the light of our present knowledge, hardly 
be any doubt that the nature of this case is epileptic, but 
we are not warranted in classing these sleep attacks in the 
same category as the sleep of epileptics after convulsions; 
neither is it admissible to class them among the somno- 
lent states which are frequently present in gross brain dis- 
ease, as the patient in the intervals between the attacks was 
perfectly bright and wakeful. The case as one of pure 
sleeping attacks is very interesting, and, as will be readily 
acknowledged, differs entirely from those frequent cases of 
epileptic vertigo with momentary loss of consciousness. 
Epilepsy is a disease of the brain cortex, and is caused 
by a temporary affection or abolition of the central pro- 
cesses of inhibition. It is probable that the clinical pic- 
tures of all epileptic phenomena are modified by the topi- 
cal distribution of this inhibitory interference; that epilep- 
tic vertigo is due to a disorder in the cerebral hemispheres 
and the typical general convulsion is dependent upon an 
extension of the disorder to the medulla and convulsive 
center here situated, or to the cortical centers. If we are 
right in these assumptions, it follows that cases of epilep- 
tic psychic equivalents are due to an affection of the AN EPILEPTIC NATURE. 
9 
psychic centers. We are therefore warranted in classing 
these cases of epileptic sleep as cases of psychic epilepsy, 
and in attributing their causation to a disorder of these 
psychic centers. 
Siemens believes in the existence of a sleep center, 
probably situated in the medulla not far from the convul- 
sive center, with which it is supposed to possess certain 
analogies. Such an assumption would materially aid us in 
understanding the mechanism of production of these cases 
of sleep seizures as well as of all epileptic sleeping states, 
but, unfortunately, we have no reason to take the existence 
of such a center for granted. 
The great corpulence of our patient can not fail to 
cause remark, and the first question which forces itself 
upon us is whether there is not some connection between 
the corpulence and these attacks. We well know that fat 
people, particularly when they are seated, easily become 
drowsy ; and Dickens's fat boy Joe, whose every appearance 
is greeted by the remark, " Damn that boy, he's asleep 
again," is familiar to us all. 
That there is some connection between the corpulence 
and the sleep attacks I firmly believe, but I do not think 
that these attacks are due to the corpulence, but consider 
it more likely that in this corpulence we must recognize a 
state of perverted nutrition due to the pathological con- 
dition in the psychic centers. A case of marked somno- 
lence extending over years, with psychic and physical 
characteristics of such a nature as to raise a suspicion 
of epilepsy, described by Morrison, weighed two hun- 
dred and fifty-nine pounds, and "his whole physique was 
gross." 
Finally, as an example of the medico-legal relations 
which such sleep seizures may have, I will briefly report the 
following case: 10 
PERIODICAL SLEEP SEIZURES OF 
W. B. W., seen in prison in October, 1889, for the purpose of 
giving an opinion in regard to his sanity. The prisoner, whose 
wife had left him on account of his violent temper and irregulari- 
ties of life, purchased a butcher knife, and, seeking her out in her 
own dwelling, attempted to murder her, and nearly succeeded 
in so doing. He was arrested, and professes to have total 
amnesia for all occurrences from a time prior to the purchase of 
the knife until he found himself in the station house-a period 
of over two hours. 
It is needless here to enter upon the details of the case or 
upon the reasons which led me to consider him sane and a ma- 
lingerer. Suffice it to say that he professed to have had three 
attacks of unconsciousness during his life, each of which lasted 
for several hours. In one of these attacks he says he traveled 
from Buffalo to Niagara Falls without knowing that he had done 
so. He gave no history of convulsions, of tongue biting, etc., 
but my notes contain the following: "Patient says that he falls 
asleep easily during the day; that he falls asleep during impor- 
tant conversations and under circumstances which should make 
him wakeful; he furthermore says that he passes restless nights, 
and he has been a somnambulist since childhood." 
To-day, were I to give an opinion upon the same case, I 
think that, in view of the notes last cited, I should be more 
than inclined to consider the subject an epileptic. Whether 
such a decision would have influenced my opinion as re- 
gards his sanity and as to his malingering is, however, an 
entirely different question. Westphal enters fully upon 
the forensic import of these sleeping attacks and refers to 
the case of von Zastrow (detailed in Casper and Liman, 18*76, 
vol. i, p. 509), in which he carefully sought for a history of 
epileptic attacks, but was unable to find any; Westphal, 
however, remembers that von Zastrow said that he frequently 
fell asleep during the day. 
This much is certain: that, medico-legally, a history of 
such sleeping attacks merits quite as much attention as 
does a history of absence, or even of marked epileptic con- AN EPILEPTIC NATURE. 
11 
vulsions. That attacks of petit mat in which the patient, 
while in the midst of any occupation, suddenly loses con- 
sciousness, if only for a few moments, may present medico- 
legal relations of a complicated nature, is well known; 
that psychic equivalents, psychic disorders which take the 
place of convulsions, are even of more importance is seen 
from the fact that theft, arson, sexual crimes, and murder 
have all been committed during such a state, and have be- 
come the subject of medico-legal inquiry. All that I wish 
here is to emphasize the well-known fact that in all dubi- 
ous cases, of whatsoever nature, in which amnesia is alleged, 
we should carefully search for corroborative data of an epi- 
leptic character. 
One more question I desire to touch upon before con- 
cluding, and that is the value of somnambulism as a cor- 
roborative symptom in the diagnosis of the epileptic nature 
of any trouble. In the three cases which I have here re- 
ported the patients were all subject to somnambulic attacks. 
Of Westphal's case it is said that the woman suffered from 
nocturnal insomnia, and could sleep only a small portion of 
the night, and in Fischer's case there was insomnia when 
the condition first came on ; there was restlessness at night; 
the patient had bad dreams, during which she saw people, 
etc. The sister relates that the patient often sleeps with 
open eyes ; that she often speaks in her sleep and answers 
questions. Of these nocturnal occurrences Fischer says: 
" Often she got up at night and imagined that some one 
was in front of her door who wanted to kill her; but she 
never left her room. She says that she sees these people 
in her dreams." It is probable that both these patients 
were somnambulists. Of Berkan's cases, two of the three 
which I consider typical cases of sleep seizures also pre- 
sented somnambulic phenomena. Of the nocturnal condi- 
tion in the few other published cases nothing is said. 12 
PERIODICAL SLEEP SEIZURES OF 
While it is true that somnambulism (non artificial) may 
be due to a variety of causes, we know that foremost 
among these, beyond a doubt, stands epilepsy. It is also 
well known that epileptics are particularly subject to vivid 
and exciting dreams. So it happens that somnambulism 
is frequently the first symptom which may attract our at- 
tention to the possible epileptic nature of an affection, and 
that especially in patients suffering from recurring sleep 
seizures the presence of somnambulism is of diagnostic 
value. 
Diagnostically, these cases will have to be distinguished 
from cases of narcolepsy, so called, and from cases of hys- 
terical sleep. In narcolepsy there is always consciousness 
of what is going on during the attacks, the patient is never 
obtuse when awakened, and he at once has full possession 
of all his intellectual faculties; sensibility and motility are 
normal, and the attack can be cut short by any severe 
stimulus. Hysterical cases, even if presenting no other 
stigmata of hysteria, will generally show a complete or in- 
complete hemianaesthesia or a retraction of the visual field ; 
the attacks occur in consequence of psychic influence, and 
are prolonged, lasting several hours or more. 
All in all, I would formulate the diagnosis as follows: 
Sleeping attacks occurring alone or in combination with 
other symptoms, if of brief duration and followed by am- 
nesia, are probably epileptic in character. If somnambu- 
lism, particularly of a noisy kind, is present, this probabil- 
ity becomes a certainty. 
Literature. 
1. Berkan, O. Eigenthumliche mit Einschlafen verbundene 
Anfiille. Deutsche Zeitschrift fur NervenheUkunde, Leipsic, 
1892. 
2. Dana, C. L. On Morbid Drowsiness or Somnolence. 
Journal of Nervous and Mental Disease, 1884, pp. 153-176. AN EPILEPTIC NATURE. 
13 
3. Fischer, F. Epileptoide Schlafzustande. Archiv fur Psy- 
chiatric, vol. viii, p. 200. 
4. Foot, A. Wynne. Narcolepsy; Sudden Periodical Sleep 
Seizures. Dublin Journal of Medical Sciences, 1886, vol. Ixxxii, 
p. 465. 
5. G61ineau. De la narcolepsie. Gaz. des hopitaux, 1880, 
pp. 626, 635. 
6. Mendel. Ueber Anfalle von Einscblafen. Deutsche med. 
Wochenschrift, 1880, p. 266. 
7. Morrison, Alexander. Somnolence with Cyanosis. 
Practitioner, 1889, p. 277. 
8. Nothnagel. Cited by Siemens. 
9. Reynolds. Cited by Siemens. 
10. Sahlmen. Berl. khn. Wochenschrift, 1881, p. 95. 
11. Schultz. Cited by Siemens. 
12. Siemens, F. Zur Lehre vom epileptischen Schlaf und 
vom Schlaf uberhaupt. Archiv fur Psychiatric, 1879, vol. ix, 
p. 72. 
13. Westphal, C. Eigenthumliche mit Einschlafen verbun- 
dene Anfalle. Archivfur Psychiatrie, vol. viii, p. 200. © a REASONS WHY 
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