Convulsions

CONVULSIONS, a series of motor disorders characterized by excessive and involuntary innervation of muscles, causing their contraction. Convulsions can occur not only in striated muscles but also in smooth muscles found in internal organs and not subject to volitional impulses, such as convulsions of bronchial muscles, stomach muscles, intestines, etc. The nature of convulsions, their localization, and etiology vary. Clonic and tonic convulsions are distinguished. The former are convulsions characterized by rapidly alternating brief contractions and relaxations of muscles; the latter are convulsions with more or less prolonged contraction of muscles, due to which the corresponding part of the body remains in a state of contraction for a longer or shorter time. However, there is no sharp boundary between these two types of convulsions, as combinations and transitional forms between them are often observed. According to their distribution, general and partial, or localized convulsions are distinguished; thus, convulsions may affect certain muscles, all muscles innervated by one nerve or root, or all muscles acting synergistically. Convulsions may further spread to an entire limb, half of the body, or the entire skeletal musculature. Clonic convulsions, expressed in intense, voluminous movements of one limb or the entire body, are designated as convulsions. Cramp implies a spreading to one muscle or a limited muscle area of a tonic painful convulsion. Small clonic convulsions appearing during voluntary muscle tension, for example when extending the arms, are called intention clonic convulsions. According to Bekhterev's opinion, it is characteristic of cortical lesions with an excited state, as for example in gunshot wounds in the motor area. Rhythmic convulsions are convulsions in which the affected organ produces for a certain time more or less identical rhythmic movements in tempo. Under tic or convulsive twitching are understood short, very rapid involuntary muscle contractions having the character of a reflex, protective, or expressive movement (see Tics). Tonic convulsions of the masticatory muscles are called trismus; similar convulsions of the trunk with its bending backward in the form of an arc - opisthotonus; tonic convulsions of the trunk with its bending to the side - pleurotonus. Under tremophilia is meant congenital trembling. In nature, this trembling differs in no way from other types of trembling. Under dysnasia (from di-two) are understood convulsions of the upper extremities. This condition is observed in cerebral palsy in children, often in connection with a similar condition of the lower extremities. Böxbüchen's symptom is increased excitability and convulsions of the abdominal muscles. Convulsions are caused directly or reflexively, i.e., the irritation causing muscle movement comes directly from motor centers or conducting pathways, or it occurs in the sensory sphere and is transmitted via sensory pathways to motor centers (reflex convulsions). The question of the occurrence of convulsions due to irritation of the motor nerve innervating the muscle cannot be considered settled. Where convulsions are observed in the corresponding muscles in lesions and diseases of peripheral nerves, the possibility of reflex origin due to irritation of sensory fibers cannot be excluded. Reflex convulsions are very frequent. Any state of irritation in the area of a sensory nerve, such as pain, can cause convulsions, and usually the irritation first spreads from the sensory nerve to the motor nerve of the same side, emerging at the same level. Thus, for example, a lesion of a branch of the trigeminal nerve often causes convulsions in the homonymous facial nerve. However, convulsions are also observed due to irritation of sensory nerves in a distant area, for example convulsions of the facial nerve due to uterine disease, etc. Wounds of the extremities, as well as scars on the face, skull, and perhaps the meninges, can be the cause of reflex epilepsy. Reflex convulsions can also occur due to increased excitability of reflex centers (poisoning by strychnine, tetanus, rabies). The main site of origin of convulsions, especially clonic ones, is the cerebral cortex. Due to organic diseases, poisons, circulatory disorders, the cortex enters a state of irritation causing motor discharges. However, the most frequent cause is functional disorders, finer changes creating and maintaining the irritation of the cortex causing convulsions. The resulting convulsive forms are often characterized by the fact that they can be caused and intensified by emotional excitement. Abnormal mental states can not only be a direct cause of convulsions but also so increase the reflex excitability of centers that ordinary irritations, instead of simple reflex movements, cause convulsions. Tonic convulsions in recent times have been associated with lesions of subcortical formations. According to a number of authors, convulsions in the area of motor cranial nerves can also be caused by irritation of the nuclei of these nerves. Thus, for example, convulsions of the facial nerve are caused by slight changes in the ganglionic elements of its nucleus. Convulsions can be caused by various causes, both exogenous and endogenous. At the same time, one and the same cause can cause various forms of convulsions, and one and the same form of convulsions can be the result of various causes. Convulsions can be divided into organically conditioned, accidental, and convulsions depending on the so-called paroxysmal diseases. Organically conditioned convulsions include convulsions in diseases of the nervous system, both acute and chronic. Thus, convulsions often accompany meningitis, encephalitis, circulatory disorders and diseases of cerebral vessels, brain tumors, etc. Accidental, or symptomatic convulsions do not depend on brain lesions and are caused mainly by external causes independent of the nervous system. These include various poisonings, intoxications, such as uremia, eclampsia, poisons such as strychnine, santonin, etc. Paroxysmal diseases or idiopathic convulsions include epilepsy, hysteria, tetany, tics, etc. The latter diseases also include the so-called convulsive neuroses; these include professional convulsions, under which are understood the convulsions described especially by Duchenne and Benedict, developing in certain muscles as a result of overfatigue due to their constant tension, corresponding to the peculiarities of the profession of the given patient. A characteristic feature of professional convulsions is that they manifest with particular force only at the moment when the patient begins to perform the movements usual for his profession, whereas in the resting position of the extremities no convulsive movements are observed in the patient. All movements that do not resemble in their mechanism the professional movements of the patient are performed by him, with rare exceptions, without any difficulty, despite the fact that the affected muscles also participate in their execution. A convulsive attack often begins with clonic contractions of one muscle or a whole series of muscles, greatly hindering the smoothness of movements. When passing into a tonic convulsion, the patient loses all possibility of continuing the movements necessary for his work. Professional convulsions can be observed in both upper and lower extremities. The mechanism of origin of convulsions cannot be considered fully clarified. It is assumed that it is a matter of functional disease, of exhaustion neurosis affecting the coordination center regulating the correct activity of the muscles necessary for a given work. Centrifugal and centripetal irritations accompanying movements and usually not felt now reach consciousness, causing an unpleasant sensation, and the more the patients pay attention to them, the more significant the convulsions become. It should be noted that these diseases mostly develop in people with not quite a complete nervous system. Most of these patients belong to neuropaths. The course of the disease is almost always prolonged, it can continue for years, and sometimes does not pass at all. Relapses often occur; the longer the disease lasts, the less hope for recovery. Patho-anatomical changes in the cases hitherto examined have not been established.-TREATMENT. It is necessary to completely abandon the activity causing convulsions. Further, massage, Swedish gymnastics, baths, galvanization, strengthening treatment are applied. Prevention and proper choice of profession are of great importance. The most common form of these convulsions is writer's cramp (see). Besides this cramp, however, there exists a large number of others. It can be said in general that they are as numerous and diverse as the professions. For example, convulsions of pianists, violinists, telegraphists, shoemakers, tailors, milkmaids, ballerinas, etc., are known. In convulsions of pianists, one or several fingers involuntarily rise from the keys or press on them, as a result of which playing becomes impossible. In violinists, convulsions and pains spread to the muscles of both the left and right hands. In milkmaids, a tonic convulsion occurs in the flexors and extensors of the wrist and fingers. In tailors, the thumb and index finger are especially affected.

In ballerinas, when walking on their toes, a tonic painful convulsion of the calf muscles occurs. Among local convulsions, the most frequent are convulsions in the muscles innervated by the facial nerve (tic convulsii, spasmus facialis). Sometimes isolated convulsions of some muscle innervated by the facial nerve are observed, for example, convulsions of the platysma muscle. In this case, clonic convulsions occur, affecting these muscles on one side or simultaneously or successively both of these muscles. Among convulsions in the area of the motor branch of the trigeminal nerve, the most frequent are convulsions of the masticatory muscles (see Trismus). Convulsions are also observed in the area of the hypoglossal nerve—convulsions of the tongue (glossospasmus), convulsions of the pharynx (pharyngismus). Furthermore, convulsions in the area of the neck muscles are quite frequently observed, especially those innervated by the accessory nerve (see Torticollis). Clonic convulsions of the diaphragm are also often encountered, sometimes in connection with convulsions of the swallowing musculature (see Hiccups). Localized or idiopathic convulsions in the area of the trunk and limb muscles are observed comparatively rarely. They occur, however, in almost all muscles, affecting one muscle or an entire group of them. Thus, convulsions of the rhomboid, deltoid, and broad back muscles are noted, convulsions of the muscles that elevate the scapula, pectoral muscles, muscles of the arm, forearm, and hand. Of the muscles of the lower extremities, the calf muscles are particularly often subjected to brief tonic painful convulsions (crampi). Convulsions are also observed in the extensors of the foot and toes, as well as in the muscles of the sole, in the tensor muscle of the fascia lata, in the quadriceps, etc. These convulsions are often caused by intoxications and abnormalities in metabolism. Thus, they are observed in alcoholics, diabetics, in saturnism, cholera, typhus, diarrhea, after long marches, etc.; often in neuropaths and hysterics. More rarely, convulsions may affect the greater or lesser part of the musculature, especially the calf, quadriceps, and gluteal muscles. These cases, named by Wernicke convulsive neurosis (Crampusneurose), are characterized by their dependence on emotional factors, as well as on voluntary innervation of the muscles, especially during unusual movements. Forster attributes these cases to striatal diseases. Under palmospasmus (Schüttel-krampf) is understood a tremor with large amplitude, affecting the limbs and trunk and often making walking and standing impossible. Such convulsions are observed in tabes, in alcoholism, especially during the period of withdrawal, as well as in hysteria. Saltatory, or static convulsions (sal-tatorischer Reflexkrampf), first described by Bamberger, represent a special type of convulsion of the lower extremities, expressed in the fact that in the patient, as soon as the soles touch the floor, movements begin, resembling jumping or dancing and caused by clonic convulsions in the muscles of the lower extremities, especially in the calf muscles. In mild cases, the patient can stand on tiptoe, while the heels are convulsively raised upward. In the supine position, convulsions cease, but in some cases they can be caused by touching the soles. Tendon and skin reflexes are mostly increased. There are no other phenomena besides symptoms of general nervousness and hysteria. The disease can develop at any age in both sexes, suddenly or after excitement, sometimes after infection. Apparently, it is a matter of a rare form of hysteria or psychasthenia. Sometimes these convulsions are observed as a professional neurosis in ballerinas. During the war, they were observed in various forms of dysbasia. The prognosis is favorable. After several weeks or months, the disease ends with complete recovery. Treatment consists of various types of suggestion, electrization, and sedatives. Substances causing convulsions. Poisons causing convulsions differ from each other both in nature and in the place of action. Some of them act primarily on the brain, others on the spinal cord. In this case, some directly excite the cerebral cortex or lower-lying areas of the central nervous system, for example, caffeine; others increase the excitability of the reflex apparatus, for example, strychnine. To the poisons that primarily excite the brain belong caffeine, santonin, cocaine, picrotoxin, coriamyrtin, tutin, cicutoxin, apomorphine, ammonia, urea, phenol, camphor, atropine, hyoscyamine, nicotine, mescaline, Cannabis, ephedrine, Secale cornutum, mushroom poison. To the substances acting primarily on the spinal cord belong strychnine, fuchsin C, tetanus toxin. To the anticonvulsive poisons that paralyze the central nervous system belong morphine, scopolamine, coniine, cocaine (after preliminary excitation, especially with direct action on the central nervous system), colchicine, nicotine (after preceding excitation), hydrocyanic acid, bromine and magnesium salts. Convulsions in childhood. The number of children suffering from convulsions is comparatively large, especially in the first 2-3 years of life. This unusual predisposition of children of this age to convulsions is connected not only with functional but also with anatomical immaturity, with incomplete development of the brain. In view of the fact that the latter is a physiological phenomenon, one speaks of the physiological predisposition of children to convulsions. This by no means means that convulsions in a child represent a physiological phenomenon, but only that all pathological irritations that could cause seizures in a child more easily lead to them. Among the diseases causing convulsions in childhood are both acute and chronic diseases of the central nervous system. Among acute ones, special importance is attached to various forms of meningitis, especially cerebrospinal and serous meningitis, as well as hemorrhagic pachymeningitis, mainly at the beginning of the disease. General convulsions are also an important symptom in some encephalitides, especially those that sometimes develop after measles, smallpox vaccination or other infectious diseases. The causes of convulsions can also be circulatory disorders and diseases of the blood vessels of the central nervous system, such as stagnation in heart defects, whooping cough, hemorrhages in severe infections, syphilis, thrombosis of the sinuses in otitis, sepsis and severe nutritional disorders in infants, injuries. The latter include in the vast majority of cases convulsions of newborns, caused by hemorrhages into the brain that occurred during childbirth. Less frequently than in acute diseases, convulsions appear in chronic, congenital or acquired organic diseases of the brain. These include seizures in severe congenital or acquired defects of the brain at birth, such as porencephaly, pseudomicrocephaly, further diffuse sclerosis of the brain, cerebral infantile paralysis, brain tumors. In the latter, in infancy, due to the soft skull that easily yields to slowly increasing pressure on the brain, convulsions are rare. Symptomatic convulsions are of great importance. Some infants are particularly predisposed to such occasional convulsions, so that all sorts of diseases are accompanied by convulsions in them. Sometimes the cause of such predisposition is a neuropathic constitution; hereditary factors can also play a certain role: families are observed in which infants from generation to generation suffer from convulsions with any rise in temperature, without harm to their health later. The cause of occasional convulsions can be a rise in temperature, to which some infants react with convulsions every time. Usually such convulsions accompany the first rise in temperature, convulsions cease when the temperature, having reached a certain height, becomes constant. Especially well-known are initial convulsions in lobar pneumonia, further in inflammation of the bladder, influenza, measles, but they can also occur with any other infectious disease. Convulsions during fever do not indicate the special severity of the underlying disease and can be quite prognostically favorable. Unilateral convulsions do not yet indicate a focal disease. In infants during convulsions, the fontanelle bulges, but, unlike in meningitis, it flattens out after a convulsive seizure. During the course of febrile diseases, convulsions occur significantly less frequently. A frequent cause of convulsions are also acute and chronic disorders of the digestive tract. Convulsions caused by intestinal disease always occur in groups and repeat after 1-2 days; later they may repeat again. These convulsions also include convulsions caused by oversaturation of the blood with carbon dioxide. This explains convulsions in congenital defects, convulsions in attacks of whooping cough. Further, convulsions are observed in uremia, acetonemia, in stenosis of the larynx, in burns, etc. Sometimes apparently worms, especially ascarids, can also cause convulsions. Exogenous toxicoses can also be a cause of convulsions. This includes a whole series of poisons introduced into the body in excessive amounts, such as various medicines—santonin, strychnine, etc. To occasional convulsions also belong the so-called terminal convulsions, occurring in the last stages of severe diseases, after which recovery rarely occurs. A very frequent cause of convulsions in childhood are also convulsive diseases (idiopathic convulsions). Special importance is attached to tetany, epilepsy, as well as hysteria. Convulsions of an epileptic nature should also include the so-called secousses and salaam convulsions.

(from the Arabic word 'salaam' - a ritual greeting), incorrectly classified by some authors as spasmus nutans. Both for salaam convulsions and for secousses, the characteristic feature is convulsive contraction of extensive muscle groups, as if of a coordinated nature. At the same time, there occurs a rapid, jerky forward bending of the head and torso. Simultaneously, the upper limbs are abducted and then adducted. Sometimes blinking of the eyes and shaking of the entire body are noted. All these movements in secousses are performed with lightning speed, while in salaam convulsions they are slower. In the former case, the movements are often limited to a single jerky motion, while in the latter, a whole series of such movements (10-20-40 or more) may occur. These movements may repeat several times during the day and appear regardless of the environment and emotional states: at rest, during play, walking, and occasionally even during sleep. Consciousness during these convulsions is only slightly impaired. Both of these forms are characteristic of early childhood and are prognostically very unfavorable. They are observed almost exclusively in organic brain diseases, later being replaced by major seizures and leading to severe dementia. A special place among childhood convulsions is occupied by the seizures described by Friedman, or pyknolepsy (see). It is also necessary to mention here the so-called affective-epileptic seizures (Bratz), which clinically present a picture of an epileptic major seizure and are observed in children under the influence of pain or other mental experiences. They usually occur in severe neuropaths. Respiratory affective convulsions are also classified as convulsive diseases. They occur predominantly in small children, approximately from 2 to 4 years of age. By these convulsions are meant seizures associated with sudden cessation of breathing during crying, due to anger or fright of the child. In this case, children hold their breath for so long that they do not have time to inhale in a timely manner. They turn blue, lose consciousness for several seconds, and fall. These seizures pose no danger, but for children they often serve as a way to get all their desires fulfilled by those around them. To prevent seizures, energetic parental intervention is necessary. Quick distraction before the child turns blue definitely leads to a sigh and prevents the seizure.

To convulsive diseases also belongs jactatio capitis nocturna. It consists of movements of the head and torso that continue for hours. These movements cease during deep sleep and resume if it becomes more superficial. The movements are of diverse character, very extensive and strong. During this time, the child sleeps very well and in the morning remembers nothing about these movements. If they are interfered with, the child wakes up. Children suffering from these movements are usually neuropaths. After some time, the phenomena disappear, but they may last for one or two years. A special form of minor but very frequent convulsions, belonging to the earliest age, are the so-called S taupe hen. In many newborns, and especially in premature infants, usually in connection with feeding, but also in the intervals between feedings, nystagmoid jerking of the eyeballs, clonic jerking of the eyelids and lips, and even clonic jerking of the upper limbs occur, lasting for several minutes or even seconds and sometimes occurring in series for half an hour. They have no special significance and apparently represent irritations caused by circulatory disorders in the area of the nuclei of the eye muscles and other muscles. Due to the variety of causes that provoke convulsions in children, and in view of the far from uniform significance of these convulsions for the further development of the child, their correct diagnosis acquires particularly great importance. It must however be pointed out that it is very often impossible to attribute convulsive seizures to a specific disease due to the complete absence of any differential diagnostic signs. Therefore, one must be very cautious in evaluating convulsions and predicting them in children, especially in early childhood.