Epilepsy

EPILEPSY. —

I. MEDICINE

The crisis of “grand mal” is classically known in the subsequent development of the aura (sensory, sensorial, motor, vascular, neurovegetative, etc.), a prodromal warning sign of the impending seizure; of the tonic phase (contraction of the jaw, biting of the tongue, clenching of the fists, rotation of the eyeballs upward with the eyelids closed, loss of consciousness with a dangerous uncontrolled fall); of the clonic phase (rapid, violent, extensive muscular convulsions); of the neurovegetative disturbances (foaming at the mouth, stertorous breathing, hypertension, pupillary dilation, cyanosis, loss of urine and feces); of the post-epileptic coma (shallow and irregular breathing, pallor), which continues into a more or less prolonged deep sleep, on awakening from which the patient, despite a feeling of severe malaise and the traumatic consequences of the seizure, remembers nothing of what occurred.

Apart from this episode, manifestations with partial symptomatology also fall within the concept of e., in which, however, the characteristic features of sudden onset and disappearance of all memory of what occurred are always present. Thus in petit mal or “epileptic absence” (an attack-like alteration of consciousness, more or less severe and prolonged, without convulsions); in epileptic vertigo (a sudden sensation that one’s body is rotating, with partial clouding of consciousness); in “epileptic syncope” (sudden staggering and falling to the ground unconscious); in Brata’s “affective epilepsy” (sudden onset following violent emotion, frustration, etc.); in the “epileptic equivalents” (various motor, sensory, sensorial, and psychic manifestations) which appear rapidly, followed by total or partial omnesia, during which the patient may commit immoral or criminal acts, even very serious ones, in an apparently coordinated and voluntary manner, of which he loses more or less completely the memory and of which, in his normal state, he would be absolutely incapable given the characteristics of his moral personality; of this nature is the sudden impulse to drink alcoholic beverages (dipsomania) in a person who was previously even asthenic.

“Epileptoidism” is a permanent psychopathic state which may, however, also occur in persons who are not genuinely epileptic; its fundamental traits are impetuosity, impulsiveness, emotional incontinence with a propensity to anger and violence, lack of scruples, a weak, restless, fickle will, egotism, fanaticism, a bigoted degeneration of religious feeling, and a viscous character. In epileptics of long standing, forms resembling dementia readily appear, with a global reduction of the psychic endowment and deviations in practical activity, extending to genuine psychoses (v.), characterized by the onset of states of excitement with hallucinations, impulsiveness, and hostile apperception of the external world, lasting a few weeks. Status epilepticus may develop through the successive repetition of “grand mal” seizures, with a severe state of confusion and danger to life.

Opinions concerning the causes and mechanism of e. are numerous and divergent: spastic circulatory disorders of the brain, allergic crises, alcoholism or syphilis in the parents, neurotropic toxins acting upon a predisposed nervous system, the consequences of cerebral trauma (Jacksonian e.) or of pre- or neonatal encephalitis, disturbances of the water metabolism of the nerve cell, sclerosis of the “Ammon’s horn”; modern “electroencephalography” has proposed new causal hypotheses and has greatly advanced diagnosis, particularly of the equivalent forms.

It is of great importance to distinguish true e. from an attack of hysteria (v.). The treatment of e., insofar as it can be causal or merely symptomatic, falls entirely within the competence of the physician.

From the moral standpoint, the suddenness, involuntariness, abnormality, and often complete absence of consciousness in the epileptic indicate limitations or even the abolition of his legal and religious responsibility, including in the most concealed forms of “equivalents,” which must always be considered in all cases where an unforeseen immoral or criminal action conflicts with the ethical character of the individual. When confronted with “difficult” individuals—impulsive persons whose affective and volitional life is difficult to educate, capricious and fickle, obstinate in some of their attitudes—the educator must consider the possibility of “epileptoidism” and make use of the physician’s assistance.

The hypothesis is far from being confirmed by experience, at least with the frequency necessary to draw ethical and juridical consequences from it, and the absolute relationship between epilepsy and criminality is today commonly rejected.

Nevertheless, one cannot deny in epileptics a diminution and at times an absolute absence of moral responsibility, insofar as the mental integrity of epileptics is more or less profoundly compromised even during the same “free” intervals; and in the most serious forms, psychic disintegration assumes the aspect of dementia. To be precise, moral imputability is completely absent during the epileptic seizure. In determining the moral imputability of acts performed outside the seizure, account must be taken both of the dispositions of character and of the condition of the patient, as well as of the periodicity of the seizures, which, if they recur very frequently, create a habitual condition of semi-mental illness. Broadly speaking, epileptics are to be regarded, in general terms, as having diminished capacity to understand and to will. This diminution must be taken into account both in the administration of the Sacraments and in the assessment of the crime and imposition of penalties.

Given the disturbing manifestations of the disease, at least during the state of seizure, epileptics may not receive certain Sacraments because of the danger of irreverence.

Thus, during an epileptic seizure, Holy Communion may not be administered to them, unless there is danger of death, their prior wish to receive it is established, and the danger of irreverence has been removed (Ritnale Rom., tit. IV, chap. 4, n. 4).

Moreover, in view of the impossibility, or at least the great difficulty, of dispelling the disease, those who were or are epileptic are regarded in the CIC (can. 684, 3°) as irregular by reason of defect (irregulares “ex defectu”) with regard to the sacrament of Holy Orders.

The CIC does not distinguish between prepubertal and postpubertal epilepsy, and since the doctrine preceding the CIC held, at least according to the prevailing opinion, that there was no irregularity in the case of epilepsy with prepubertal manifestations and no subsequent relapse, so that there might be moral certainty of absolute recovery, it may also be held speculatively today that the same applies, on the basis of can. 6, 2°, 4°. (cf. F. M. Cappello, De Ordine, 2ª ed., Torino 1947, n. 483). In practice, however, physicians very rarely pronounce a complete and perfect recovery.

If, on the other hand, the manifestations of epilepsy occur after sacred Ordination, or if there is moral certainty that the disease has been overcome, the Ordinary may permit his subjects to exercise the Orders they have received (can. 684, 3°).

Turning to canon penal law, since criminal responsibility does not arise from physical imputability except through and by means of moral imputability, it is evident that wherever the latter is absent, as during an epileptic seizure, there is incapacity for crime (can. 220: § 1). Even outside seizures, it is necessary that the ecclesiastical judge, in imposing the penalty, take into account the mental condition of the epileptic (can. 2218 §§ 1-2).