Nidana Sthana Chapter 8. Diagnosis and etiopathogenesis of seizure disorders
|Section/Chapter||Nidana Sthana Chapter 8|
|Preceding Chapter||Unmada Nidana|
|Other Sections||Sutra Sthana, Vimana Sthana, Sharira Sthana, Indriya Sthana, Chikitsa Sthana, Kalpa Sthana, Siddhi Sthana|
|Translator and commentator||Deole Y. S.|
|Editor||Khandel S.K, Godatwar P.|
|Date of publication||December 17, 2018|
Keywords: apasmara, transient loss of memory, seizure disorders, epilepsy, mind-heart connection, mind-brain connection.
- 1 Introduction
- 2 Sanskrit Text, Transliteration and English Translation
- 2.1 Four types of apasmara
- 2.2 Persons prone to apasmara
- 2.3 Characteristic features of apasmara
- 2.4 Specific types and features of apasmara
- 2.5 Management of apasmara
- 2.6 Manifestation of various diseases
- 2.7 Summary
- 2.8 Diagnostic principles of diseases
- 2.9 Summary
- 3 Tattva Vimarsha (Fundamental Principles)
- 4 Vidhi Vimarsha (Applied Inferences)
- 4.1 History and origin of the disease in ancient medical literature
- 4.2 Definition of apasmara
- 4.3 Impairment of knowledge and coordination
- 4.4 Tattva Sara
- 4.5 Predisposing factors for apasmara
- 4.6 Six stages of pathogenesis of epilepsy (shatkriyakala for apasmara)
- 4.7 Types of apasmara
- 4.8 Premonitory signs of apasmara
- 4.9 Differential diagnosis of apasmara
- 4.10 Prognosis of apasmara
- 4.11 Reasons behind aggressive and dormant stages of apasmara
- 4.12 Management of apasmara
- 4.13 Practical application of principles
- 4.14 Research areas
- 4.15 Research works done on apasmara at post graduate/post doctoral level:
- 4.16 Research papers published
- 4.17 Related Chapters
- 5 References
In this important section dealing with the diagnoses of some common disorders of the body and the mind, this chapter deals with apasmara, a disorder afflicting the mind and sharing similar etiological and pathological factors as unmada (the subject of the preceding chapter). apasmara (Sanskrit for apa (to lose) or leave, and smara (memory)) is a psychosomatic disorder involving memory, intellect and mind and present with cardinal features such as transient loss of memory, abnormal movements of body and blackouts. apasmara is counted, in Ayurvedic texts, among the eight mahagada (most dreadful diseases). The extent of knowledge on the disease indicates that it must have been quite prevalent in antiquity. Ayurvedic scholars have observed that apasmara simulates epilepsy in its features . Epilepsy is a common neuropsychiatric condition involving mainly the brain, nervous system and the psyche. However, Ayurveda emphasizes heart, the abode of consciousness and mind, as its core pathological site while covering diseases of memory, intellect as well as psyche under the umbrella of apasmara.
Causative factors of apasmara can be categorized under dietary, lifestyle, psychological and iatrogenic factors. Vitiated doshas get through the vessels of the heart and when exposed to predisposing psychological factors like excess worry, grief, anger, and fear, move upwards from the heart, the abode of all consciousness, to the brain, afflicting the senses while altering memory. This eventually leads to apasmara. The etiology of the disease and specific features of the dominant doshas involved, and nidanarthakara roga (one disease causing other disease) and its importance in diagnosis and treatment have been described in detail in this chapter, with some important aspects of diagnosis addressed. In some cases, both diseases (the causative and the secondary ones) coexist while in other cases, the causative disease disappears and the new disease remains present. Thus, this chapter, while focusing on apasmara, also talks of complications that lead to secondary conditions and their treatment.
Sanskrit Text, Transliteration and English Translation
अथातोऽपस्मारनिदानं व्याख्यास्यामः ||१||
इति ह स्माह भगवानात्रेयः ||२||
iti ha smāha bhagavānātrēyaḥ||2||
iti ha smAha bhagavAnAtreyaH||2||
Now we shall expound the chapter "Apasmara Nidana" (Diagnosis and etiopathogenesis of seizure disorders). Thus said Lord Atreya. [1-2]
Four types of apasmara
इह खलु चत्वारोऽपस्मारा भवन्ति वातपित्तकफसन्निपातनिमित्ताः ||३||
iha khalu catvārō'pasmārā bhavanti vātapittakaphasannipātanimittāḥ||3||
iha khalu catvAro~apasmArA bhavanti vAtapittakaphasannipAtanimittAH||3||
There are four types of apasmara caused by vata, pitta, kapha and sannipatika (combination of all the three doshas).
Persons prone to apasmara
त एवंविधानां प्राणभृतां क्षिप्रमभिनिर्वर्तन्ते; तद्यथा- रजस्तमोभ्यामुपहतचेतसामुद्भ्रान्तविषमबहुदोषाणां समलविकृतोपहितान्यशुचीन्यभ्यवहारजातानि वैषम्ययुक्तेनोपयोगविधिनोपयुञ्जानानां तन्त्रप्रयोगमपि च विषममाचरतामन्याश्च शरीरचेष्टा विषमाः समाचरतामत्युपक्षयाद्वा दोषाः प्रकुपिता: रजस्तमोभ्यामुपहतचेतसामन्तरात्मनः श्रेष्ठतममायतनं हृदयमुपसृत्योपरि तिष्ठन्ते, तथेन्द्रियायतनानि च | तत्र चावस्थिताः सन्तो यदा हृदयमिन्द्रियायतनानि चेरिताः कामक्रोधभयलोभमोहहर्षशोकचिन्तोद्वेगादिभिः सहसाऽभिपूरयन्ति, तदा जन्तुरपस्मरति ||४||
ta ēvaṁvidhānāṁ prāṇabhr̥tāṁ kṣipramabhinirvartantē; tadyathā- Rajas tamōbhyāmupahatacētasāmudbhrāntaviṣamabahudōṣāṇāṁ samalavikr̥tōpahitānyaśucīnyabhyavahārajātāni vaiṣamyayuktēnōpayōgavidhinōpayuñjānānāṁ tantraprayōgamapi ca viṣamamācaratāmanyāśca śarīracēṣṭā viṣamāḥ samācaratāmatyupakṣayādvā dōṣāḥ prakupitā Rajas tamōbhyāmupahatacētasāmantarātmanaḥ śrēṣṭhatamamāyatanaṁ hr̥dayamupasr̥tyōpari tiṣṭhantē, tathēndriyāyatanāni ca| tatra cāvasthitāḥ santō yadā hr̥dayamindriyāyatanāni cēritāḥ kāmakrōdhabhayalōbhamōhaharṣaśōkacintōdvēgādibhiḥ sahasā'bhipūrayanti, tadā jantur Apasmarati||4||
ta evaMvidhAnAM prANabhRutAM kShipramabhinirvartante; tadyathA-rajastamobhyAmupahatacetasAmudbhrAntaviShamabahudoShANAMsamalavikRutopahitAnyashucInyabhyavahArajAtAni vaiShamyayuktenopayogavidhinopayu~jjAnAnAMtantraprayogamapi ca viShamamAcaratAmanyAshca sharIraceShTA viShamAHsamAcaratAmatyupakShayAdvA doShAH prakupitA rajastamobhyAmupahatacetasAmantarAtmanaHshreShThatamamAyatanaM hRudayamupasRutyopari tiShThante, tathendriyAyatanAni ca| tatra cAvasthitAH santo yadA hRudayamindriyAyatanAni ceritAHkAmakrodhabhayalobhamohaharShashokacintodvegAdibhiH sahasA~abhipUrayanti, tadAjanturapasmarati||4||
Individuals get quickly afflicted with apasmara if:
- the mind of an individual is afflicted by rajas (mental dosha associated with hyperactivity) and tamas (mental dosha associated with hypoactivity);
- the three sharira doshas are imbalanced and excessively aggravated;
- an individual takes food that is impure, untimely, decomposed, possessing antagonistic properties, or touched/cooked by unclean hands
- an individual follows improper methods (of diet and lifestyle, conduct described in Ayurveda) and neglects prescribed rules;
- an individual observes improper techniques (of treatment) and resorts to unhealthy regimen and behavior
- an individual practices improper bodily movements and follows improper postures
- an individual suffers from excessive degeneration or debility.
In the situations mentioned above, the doshas get aggravated and affect individuals whose minds are already afflicted by rajas and tamas. The doshas (so aggravated) pervade the heart which is, as mentioned earlier, the abode of consciousness, as well as the sense organs. While there, the doshas get further aggravated by emotions such as passion, anger, fear, greed, attachment, excitement, grief, anxiety, perturbation etc., consequently spreading throughout the heart and the sense organs. The individual is then said to have been afflicted with apasmara. 
Characteristic features of apasmara
अपस्मारं पुनः स्मृतिबुद्धिसत्त्वसम्प्लवाद्बीभत्सचेष्टमावस्थिकं तमः प्रवेशमाचक्षते ||५||
apasmāraṁ punaḥ smr̥ti buddhi sattva samplavādbībhatsacēṣṭamāvasthikaṁ tamaḥ pravēśamācakṣatē||5||
apasmAraM punaH smRutibuddhisattvasamplavAdbIbhatsaceShTamAvasthikaM tamaHpraveshamAcakShate||5||
apasmara is characterized by occasional loss of consciousness associated with aberrant activities (like vomiting of froth and abnormal postures of the body) and behavior, due to perversion of memory, intellect and other psychic faculties. 
तस्येमानि पूर्वरूपाणि भवन्ति; तद्यथा- भ्रूव्युदासः सततमक्ष्णोर्वैकृतमशब्दश्रवणंलालासिङ्घाणप्रस्रवणमनन्नाभिलषणमरोचकाविपाकौ हृदयग्रहः कुक्षेराटोपो दौर्बल्यमस्थिभेदोऽङ्गमर्दो मोहस्तमसो दर्शनंमूर्च्छा भ्रमश्चाभीक्ष्णं स्वप्ने च मदनर्तनव्यधनव्यथनवेपनपतनादीनीति ||६||
tasyēmāni pūrvarūpāṇi bhavanti; tadyathā- bhrūvyudāsaḥ satatamakṣṇōrvaikr̥tamaśabdaśravaṇaṁ lālāsiṅghāṇaprasravaṇamanannābhilaṣaṇamarōcakāvipākau hr̥dayagrahaḥ kukṣērāṭōpō daurbalyamasthibhēdō'ṅgamardō mōhasTamasō darśanaṁ mūrcchā bhramaścābhīkṣṇaṁ svapnē ca madanartanavyadhanavyathanavēpanapatanādīnīti||6||
tasyemAni pUrvarUpANi bhavanti; tadyathA- bhrUvyudAsaHsatatamakShNorvaikRutamashabdashravaNaMlAlAsi~gghANaprasravaNamanannAbhilaShaNamarocakAvipAkau hRudayagrahaH kukSherATopodaurbalyamasthibhedo~a~ggamardo mohastamaso darshanaM mUrcchA bhramashcAbhIkShNaM svapneca madanartanavyadhanavyathanavepanapatanAdInIti||6||
Premonitory symptoms of apasmara include contraction of eyebrows, erratic and constant movement of eyes, auditory hallucinations, excessive salivation, and nasal discharge. There is frequent accompaniment of anorexia, indigestion, and general disinclination towards food, chest congestion, distension of the lower abdomen accompanied with gurgling sound, weakness, cracking pain in bones and malaise, unconsciousness, a feeling of despondency or depression, fainting and giddiness, and frequent dreams of scenes of intoxication, dancing, murdering, aching, shivering and falling. 
These are some common premonitory symptoms of apasmara. 
Specific types and features of apasmara
Vata dosha dominant apasmara
तत्रेदमपस्मारविशेषविज्ञानं भवति; तद्यथा-
अभीक्ष्णमपस्मरन्तं, क्षणेन सञ्ज्ञां प्रतिलभमानम्, उत्पिण्डिताक्षम्, असाम्नाविलपन्तम्, उद्वमन्तं फेनम्, अतीवाध्मातग्रीवम्, आविद्धशिरस्कं, विषमविनताङ्गुलिम्, अनवस्थितपाणिपादम्, अरुणपरुषश्यावनखनयनवदनत्वचम्, अनवस्थितचपलपरुषरूक्षरूपदर्शिनं, वातलानुपशयं, विपरीतोपशयं च वातेनापस्मरन्तं विद्यात् ||८||
tatrēdamapasmāraviśēṣavijñānaṁ bhavati; tadyathā-
abhīkṣṇamApasmarantaṁ, kṣaṇēna sañjñāṁ pratilabhamānam, utpiṇḍitākṣam, asāmnā vilapantam, udvamantaṁ phēnam, atīvādhmātagrīvam, āviddhaśiraskaṁ, viṣamavinatāṅgulim, anavasthitapāṇipādam, aruṇaparuṣaśyāvanakhanayanavadanatvacam, anavasthitacapalaparuṣarūkṣarūpadarśinaṁ, vātalānupaśayaṁ, viparītōpaśayaṁ ca vātēnāpasmarantaṁ vidyāt (1)||8||
tatredamapasmAravisheShavij~jAnaM bhavati; tadyathA-
abhIkShNamapasmarantaM, kShaNena sa~jj~jAM pratilabhamAnam, utpiNDitAkSham, asAmnA vilapantam, udvamantaM phenam,atIvAdhmAtagrIvam, AviddhashiraskaM, viShamavinatA~ggulim, anavasthitapANipAdam,aruNaparuShashyAvanakhanayanavadanatvacam, anavasthitacapalaparuSharUkSharUpadarshinaM,vAtalAnupashayaM, viparItopashayaM ca vAtenApasmarantaM vidyAt (1)||8||
More frequent episodes of apasmara, episodes of instant loss of consciousness and regain it quickly, bulging or rolling up of eyes, incoherent speech, frothy vomit, excessive stiffness of neck, drooping of the head to one side, irregular contraction of fingers, unstable upper and lower limbs, redness, dryness and grayish tint in the nails, eyes, face and skin, apparent vision or perception of unstable, fickle, coarse and dry objects, conditions associated with consuming vata-aggravating diets and alleviation of ailments when subjected to vata-pacifying diets.[8-1]
अभीक्ष्णमपस्मरन्तं क्षणेन सञ्ज्ञां प्रतिलभमानम्, अवकूजन्तम्, आस्फालयन्तं भूमिं, हरितहारिद्रताम्रनखनयनवदनत्वचं,रुधिरोक्षितोग्रभैरवादीप्तरुषितरूपदर्शिनं, पित्तलानुपशयं,विपरीतोपशयं च पित्तेनापस्मरन्तं विद्यात् ||८||
abhīkṣṇamapasmarantaṁ kṣaṇēna sañjñāṁ pratilabhamānam, avakūjantam, āsphālayantaṁ bhūmiṁ, haritahāridratāmranakhanayanavadanatvacaṁ, rudhirōkṣitōgrabhairavādīptaruṣitarūpadarśinaṁ, pittalānupaśayaṁ,viparītōpaśayaṁ ca pittēnāpasmarantaṁ vidyāt (2)||8||
abhIkShNamapasmarantaM kShaNena sa~jj~jAM pratilabhamAnam, avakUjantam, AsphAlayantaMbhUmiM, haritahAridratAmranakhanayanavadanatvacaM,rudhirokShitograbhairavAdIptaruShitarUpadarshinaM, pittalAnupashayaM,viparItopashayaM capittenApasmarantaM vidyAt (2)||8||
Frequent episodes of apasmara, instant loss of consciousness and regaining it quickly, stertorous breathing, abnormal, dragging-like movement, green, yellow or coppery tint of nails, eyes, face and skin, apparent vision or perception of bleeding, terrifying, horrible, burning and angry looking objects, conditions associated with pitta-aggravating diets and alleviation of ailments when subjected to pitta-pacifying diets [8-2]
चिरादपस्मरन्तं, चिराच्च सञ्ज्ञां प्रतिलभमानं, पतन्तम्, अनतिविकृतचेष्टं, लालामुद्वमन्तं, शुक्लनखनयनवदनत्वचं,शुक्लगुरुस्निग्धरूपदर्शिनं, श्लेष्मलानुपशयं, विपरीतोपशयं च श्लेष्मणाऽपस्मर-न्तं विद्यात् ||८||
cirādapasmarantaṁ, cirācca sañjñāṁ pratilabhamānaṁ, patantam, anativikr̥tacēṣṭaṁ, lālāmudvamantaṁ, śuklanakhanayanavadanatvacaṁ, śuklagurusnigdharūpadarśinaṁ, ślēṣmalānupaśayaṁ, viparītōpaśayaṁ ca ślēṣmaṇā'pasmarantaṁ vidyāt (3)||8||
cirAdapasmarantaM, cirAcca sa~jj~jAM pratilabhamAnaM, patantam, anativikRutaceShTaM,lAlAmudvamantaM, shuklanakhanayanavadanatvacaM, shuklagurusnigdharUpadarshinaM,shleShmalAnupashayaM, viparItopashayaM ca shleShmaNA~apasmarantaM vidyAt (3)||8||
Less frequent episodes of apasmara, gradual loss and regain of consciousness, frequently falling down, less pronounced abnormalities in movement, dribbling of saliva, whitish discoloration of nails, eyes, face, and skin, apparent vision or perception of white, heavy and unctuous objects, and conditions associated with consuming kapha-aggravating diets and alleviation of ailments when subjected to kapha-pacifying diets [8-3]
Sannipatika apasmara with dominance of all dosha
समवेतसर्वलिङ्गमपस्मारं सान्निपातिकं विद्यात्, तमसाध्यमाचक्षते इति चत्वारोऽपस्मारा व्याख्याताः ||८||
samavētasarvaliṅgamapasmāraṁ sānnipātikaṁ vidyāt, Tamasādhyamācakṣatē ||
iti catvārō'pasmārā vyākhyātāḥ||8||
samavetasarvali~ggamapasmAraM sAnnipAtikaM vidyAt, tamasAdhyamAcakShate (4)
iti catvAro~apasmArA vyAkhyAtAH||8||
Sannipatika apasmara (caused by the simultaneous vitiation of all the three doshas) shares the symptoms of all the three doshas (described above). This condition is incurable.
Thus, four types of apasmara are explained. [8-4]
apasmara with extrinsic factors
तेषामागन्तुरनुबन्धो भवत्येव कदाचित्, तमुत्तरकालमुपदेक्ष्यामः |
तस्य विशेषविज्ञानं यथोक्तलिङ्गैर्लिङ्गाधिक्यमदोषलिङ्गानुरूपं च किञ्चित् ||९||
tēṣāmāganturanubandhō bhavatyēva kadācit, tamuttarakālamupadēkṣyāmaḥ|
tasya viśēṣavijñānaṁ yathōktaliṅgairliṅgādhikyamadōṣaliṅgānurūpaṁ ca kiñcit||9||
teShAmAganturanubandho bhavatyeva kadAcit, tamuttarakAlamupadekShyAmaH|
tasya visheShavij~jAnaM yathoktali~ggairli~ggAdhikyamadoShali~ggAnurUpaM ca ki~jcit||9||
Sometimes these conditions are associated with extrinsic causative factors described later (in Cikitsa10:53). The symptoms that manifest in such cases, though, are not the same as those caused by vitiated doshas. 
Management of apasmara
हितान्यपस्मारिभ्यस्तीक्ष्णानि संशोधनान्युपशमनानि च यथास्वं, मन्त्रादीनि चागन्तुसंयोगे ||१०||
hitānyapasmāribhyastīkṣṇāni saṁśōdhanānyupaśamanāni ca yathāsvaṁ, mantrādīni cāgantusaṁyōgē||10||
hitAnyapasmAribhyastIkShNAni saMshodhanAnyupashamanAni ca yathAsvaM, mantrAdInicAgantusaMyoge||10||
Strong elimination and alleviation therapies are effective in alleviating and curing apasmara. When extrinsic causative factors are involved, then mantras etc., are considered useful. 
Manifestation of various diseases
तस्मिन् हि दक्षाध्वरध्वंसे देहिनां नानादिक्षु विद्रवतामभिद्रवणतरणधावनप्लवनलङ्घनाद्यैर्देहविक्षोभणैः पुरागुल्मोत्पत्तिरभूत्, हविष्प्राशात् प्रमेहकुष्ठानां, भयत्रासशोकैरुन्मादानां, विविधभूताशुचिसंस्पर्शादपस्माराणां, ज्वरस्तु खलुमहेश्वरललाटप्रभवः , तत्सन्तापाद्रक्तपित्तम्, अतिव्यवायात् पुनर्नक्षत्रराजस्य राजयक्ष्मेति ||११||
tasmin hi dakṣādhvaradhvaṁsē dēhināṁ nānādikṣu vidravatāmabhidravaṇataraṇadhāvanaplavanalaṅghanādyairdēhavikṣōbhaṇaiḥ purā gulmōtpattirabhūt, haviṣprāśāt pramēhakuṣṭhānāṁ, bhayatrāsaśōkairunmādānāṁ, vividhabhūtāśucisaṁsparśādapasmārāṇāṁ, jvarastu khalu mahēśvaralalāṭaprabhavaḥ , tatsantāpādraktapittam, ativyavāyāt punarnakṣatrarājasya rājayakṣmēti||11||
tasmin hi dakShAdhvaradhvaMse dehinAM nAnAdikShuvidravatAmabhidravaNataraNadhAvanaplavanala~gghanAdyairdehavikShobhaNaiH purAgulmotpattirabhUt, haviShprAshAt pramehakuShThAnAM, bhayatrAsashokairunmAdAnAM,vividhabhUtAshucisaMsparshAdapasmArANAM, jvarastu khalu maheshvaralalATaprabhavaH ,tatsantApAdraktapittam, ativyavAyAt punarnakShatrarAjasya rAjayakShmeti||11||
As per vedic legends, in the aftermath of destruction of Daksha’s yajna (holy sacrifice), gulma (disease similar to lumps in abdomen) was manifested first in human beings due to stress induced as a result of fleeing, swimming, running, flying, etc. in all directions. Prameha (disease of obstinate urinary disorders) and kushtha (obstinate skin diseases including leprosy) were manifested due to excess intake of ghee. Various types of unmada (insanity/psychosis) were manifested due to fear, apprehension and grief. apasmara (epilepsy) set in due to coming in contact with various types of unclean objects. Jwara came out of the forehead of Lord Shiva, and raktapitta was manifested (a condition characterized by bleeding from different parts of the body) due to jwara’s heat. Moon was afflicted with rajayakshma due to excessive sexual indulgence. 
अपस्मारो हि वातेन पित्तेन च कफेन च |
चतुर्थः सन्निपातेन प्रत्याख्येयस्तथाविधः ||१२||
साध्यांस्तु भिषजः प्राज्ञाः साधयन्ति समाहिताः |
तीक्ष्णैः संशोधनैश्चैव यथास्वं शमनैरपि ||१३||
यदा दोषनिमित्तस्य भवत्यागन्तुरन्वयः |
तदा साधारणं कर्म प्रवदन्ति भिषग्विदः ||१४||
apasmārō hi vātēna pittēna ca kaphēna ca|
caturthaḥ sannipātēna pratyākhyēyastathāvidhaḥ||12||
sādhyāṁstu bhiṣajaḥ prājñāḥ sādhayanti samāhitāḥ|
tīkṣṇaiḥ saṁśōdhanaiścaiva yathāsvaṁ śamanairapi||13||
yadā dōṣanimittasya bhavatyāganturanvayaḥ|
tadā sādhāraṇaṁ karma pravadanti bhiṣagvidaḥ||14||
bhavanti cAtra- apasmAro hi vAtena pittena ca kaphena ca|
caturthaH sannipAtena pratyAkhyeyastathAvidhaH||12||
sAdhyAMstu bhiShajaH prAj~jAH sAdhayanti samAhitAH|
tIkShNaiH saMshodhanaishcaiva yathAsvaM shamanairapi||13||
yadA doShanimittasya bhavatyAganturanvayaH|
tadA sAdhAraNaM karma pravadanti bhiShagvidaH||14||
From the preceding verses, it can be said that apasmara manifests itself due to the vitiation of vata, pitta and kapha and sannipata (combined vitiation of all the three doshas). The sannipata variation is incurable. 
The curable types of apasmara should be carefully treated by a physician possessing extensive knowledge and experience of administering elimination and alleviation therapies associated with the dosha(s) causing the specific variant of apasmara. 
When apasmara is caused by the vitiation of doshas associated with extrinsic causative factors, then general therapies addressing both (doshic equilibrium and extrinsic causes) are advised by the best of physicians. 
भिषक् सर्वामयान् हन्ति न च मोहं निगच्छति ||१५||
bhiṣak sarvāmayān hanti na ca mōhaṁ nigacchati ||15||
bhiShak sarvAmayAn hanti na ca mohaM nigacchati ||15||
An able physician, well versed in the specific characteristics of all diseases and the properties of all medicines, cures all (curable) diseases and does not get confused. 
इत्येतदखिलेनोक्तं निदानस्थानमुत्तमम् |१६|
This concludes the (excellent section titled) Nidana Sthana. 
Diagnostic principles of diseases
Nidanarthakara roga (disease specific causes)
निदानार्थकरो रोगो रोगस्याप्युपलभ्यते ||१६||
nidānārthakarō rōgō rōgasyāpyupalabhyatē||16||
nidAnArthakaro rogo rogasyApyupalabhyate||16||
Diseases can act as causative factors of other diseases as well 
रक्तपित्ताज्ज्वरस्ताभ्यां शोषश्चाप्युपजायते ||१७||
raktapittājjvarastābhyāṁ śōṣaścāpyupajāyatē ||17||
raktapittAjjvarastAbhyAM shoShashcApyupajAyate ||17||
For example, elevated temperature in jwara can cause raktapitta and raktapitta can cause jwara. Both the diseases (i.e jwara and raktapitta) may lead to shosha (depletion of dhatus). 
प्लीहाभिवृद्ध्या जठरं जठराच्छोथ एव च |
अर्शोभ्यो जठरं दुःखं गुल्मश्चाप्युपजायते ||१८||
plīhābhivr̥ddhyā jaṭharaṁ jaṭharācchōtha ēva ca|
arśōbhyō jaṭharaṁ duḥkhaṁ gulmaścāpyupajāyatē||18||
plIhAbhivRuddhyA jaTharaM jaTharAcchotha eva ca|
arshobhyo jaTharaM duHkhaM gulmashcApyupajAyate||18||
Pleeha (enlargement of spleen) causes jathara (abdominal diseases including ascitis), which leads to shotha (generalized edema). Arsha (hemorrhoids) causes jathara (abdominal diseases including ascitis) that leads to gulma (abdominal lumps). 
प्रतिश्यायाद्भवेत् कासः कासात् सञ्जायते क्षयः |
क्षयो रोगस्य हेतुत्वे शोषस्याप्युपलभ्यते ||१९||
pratiśyāyādbhavēt kāsaḥ kāsāt sañjāyatē kṣayaḥ|
kṣayō rōgasya hētutvē śōṣasyāpyupalabhyatē||19||
pratishyAyAdbhavet kAsaH kAsAt sa~jjAyate kShayaH|
kShayo rogasya hetutve shoShasyApyupalabhyate||19||
Pratishyaya (rhinitis) leads to kasa (cough) which further leads to kshaya (depletion of dhatu), consequently resulting in sosha (emaciation). 
ते पूर्वं केवला रोगाः पश्चाद्धेत्वर्थकारिणः |
उभयार्थकरा दृष्टास्तथैवैकार्थकारिणः  ||२०||
tē pūrvaṁ kēvalā rōgāḥ paścāddhētvarthakāriṇaḥ|
ubhayārthakarā dr̥ṣṭāstathaivaikārthakāriṇaḥ  ||20||
te pUrvaM kevalA rogAH pashcAddhetvarthakAriNaH|
ubhayArthakarA dRuShTAstathaivaikArthakAriNaH ||20||
Conditions in their primary stages or forms manifest themselves as diseases and subsequently act as causative factors for other diseases. They thus play a dual role - as a disease and as a causative factor. Some of these play just one role as well– either as a disease or as a causative factor. 
कश्चिद्धि रोगो रोगस्य हेतुर्भूत्वा प्रशाम्यति |
न प्रशाम्यति चाप्यन्यो हेत्वर्थं कुरुतेऽपि च ||२१||
kaściddhi rōgō rōgasya hēturbhūtvā praśāmyati|
na praśāmyati cāpyanyō hētvarthaṁ kurutē'pi ca||21||
kashciddhi rogo rogasya heturbhUtvA prashAmyati|
na prashAmyati cApyanyo hetvarthaM kurute~api ca ||21||
Some diseases subside after causing another disease, while some do not subside even after causing another disease. 
एवं कृच्छ्रतमा नॄणां दृश्यन्ते व्याधिसङ्कराः |
प्रयोगापरिशुद्धत्वात्तथा चान्योन्यसम्भवात् ||२२||
ēvaṁ kr̥cchratamā nr̥̄ṇāṁ dr̥śyantē vyādhisaṅkarāḥ|
evaM kRucchratamA nRUNAM dRushyante vyAdhisa~gkarAH|
Combinations of diseases in human beings are usually very difficult to treat, owing to the complexity of the line of treatment, and their serving as causative factors of each other. 
Ideal therapy without adverse effects
प्रयोगः शमयेद्व्याधिं योऽन्यमन्यमुदीरयेत् |
नासौ विशुद्धः, शुद्धस्तु शमयेद्यो न कोपयेत् ||२३||
prayōgaḥ śamayēdvyādhiṁ yō'nyamanyamudīrayēt|
nāsau viśuddhaḥ, śuddhastu śamayēdyō na kōpayēt||23||
prayogaH shamayedvyAdhiM yo~anyamanyamudIrayet|
nAsau vishuddhaH, shuddhastu shamayedyo na kopayet||23||
A therapy that alleviates one disease condition but provokes another disease is not shuddha (or is an impure or incorrect therapy). The ideal therapy is that which pacifies a disease without provoking any other disease. 
Diagnostic aspect of etiological factors
एको हेतुरनेकस्य तथैकस्यैक एव हि |
व्याधेरेकस्य चानेको बहूनां बहवोऽपि च ||२४||
ēkō hēturanēkasya tathaikasyaika ēva hi|
vyādhērēkasya cānēkō bahūnāṁ bahavō'pi ca||24||
eko heturanekasya tathaikasyaika eva hi|
vyAdherekasya cAneko bahUnAM bahavo~api ca||24||
One causative factor may cause one or many diseases. Many causative factors may result in a single disease or may cause several diseases. 
ज्वरभ्रमप्रलापाद्या दृश्यन्ते रूक्षहेतुजाः |
रूक्षेणैकेन चाप्येको ज्वर एवोपजायते ||२५||
jvarabhramapralāpādyā dr̥śyantē rūkṣahētujāḥ|
rūkṣēṇaikēna cāpyēkō jvara ēvōpajāyatē||25||
jvarabhramapralApAdyA dRushyante rUkShahetujAH|
rUkSheNaikena cApyeko jvara evopajAyate||25||
It is seen that a single causative factor, ruksha (dry) can cause many diseases such as jwara (fever), bhrama (vertigo) and pralapa (delirium) etc., while the same single factor (ruksha) may cause just one disease (jwara) 
हेतुभिर्बहुभिश्चैको ज्वरो रूक्षादिभिर्भवेत् |
रूक्षादिभिर्ज्वराद्याश्च व्याधयः सम्भवन्ति हि ||२६||
hētubhirbahubhiścaikō jvarō rūkṣādibhirbhavēt|
rūkṣādibhirjvarādyāśca vyādhayaḥ sambhavanti hi||26||
hetubhirbahubhishcaiko jvaro rUkShAdibhirbhavet|
rUkShAdibhirjvarAdyAshca vyAdhayaH sambhavanti hi||26||
Jwara alone may be caused by a combination of several causative factors including but not limited to ruksha(dry) etc. and many causes like, ruksha (dry, rough) etc. may lead to several diseases. 
Diagnostic aspect of symptoms
लिङ्गं चैकमनेकस्य तथैवैकस्य लक्ष्यते |
बहून्येकस्य च व्याधेर्बहूनां स्युर्बहूनि च ||२७||
liṅgaṁ caikamanēkasya tathaivaikasya lakṣyatē|
bahūnyēkasya ca vyādhērbahūnāṁ syurbahūni ca||27||
li~ggaM caikamanekasya tathaivaikasya lakShyate|
bahUnyekasya ca vyAdherbahUnAM syurbahUni ca||27||
Similarly, one symptom may be common to many diseases, one symptom may be related to only one disease, many symptoms may be associated with only one disease, and many symptoms may be common to many diseases. 
विषमारम्भमूलानां लिङ्गमेकं ज्वरो मतः |
ज्वरस्यैकस्य चाप्येकः सन्तापो लिङ्गमुच्यते ||२८||
viṣamārambhamūlānāṁ liṅgamēkaṁ jvarō mataḥ|
jvarasyaikasya cāpyēkaḥ santāpō liṅgamucyatē||28||
viShamArambhamUlAnAM li~ggamekaM jvaro mataH|
jvarasyaikasya cApyekaH santApo li~ggamucyate||28||
One symptom i.e. jwara can be considered common to many diseases that have irregular onset, while santapa (elevated temperature) is considered a symptom of only one disease i.e. jwara.
विषमारम्भमूलैश्च ज्वर एको निरुच्यते |
लिङ्गैरेतैर्ज्वरश्वासहिक्काद्याः सन्ति चामयाः ||२९||
viṣamārambhamūlaiśca jvara ēkō nirucyatē|
liṅgairētairjvaraśvāsahikkādyāḥ santi cāmayāḥ||29||
viShamArambhamUlaishca jvara eko nirucyate|
li~ggairetairjvarashvAsahikkAdyAH santi cAmayAH||29||
Irregular onset (and similar other symptoms) appear in the case of jwara, while similar symptoms also occur in shwasa (dyspnea), hikka (hiccups), and other similar diseases. 
एका शान्तिरनेकस्य तथैवैकस्य लक्ष्यते |
व्याधेरेकस्य चानेका बहूनां बह्व्य एव च ||३०||
ēkā śāntiranēkasya tathaivaikasya lakṣyatē|
vyādhērēkasya cānēkā bahūnāṁ bahvya ēva ca||30||
ekA shAntiranekasya tathaivaikasya lakShyate|
vyAdherekasya cAnekA bahUnAM bahvya eva ca||30||
A single therapy can subside many diseases as well as a single disease. Multiple therapies may be needed to subside many diseases, whereas one disease could require multiple therapies to cure. 
शान्तिरामाशयोत्थानां व्याधीनां लङ्घनक्रिया |
ज्वरस्यैकस्य चाप्येका शान्तिर्लङ्घनमुच्यते ||३१||
śāntirāmāśayōtthānāṁ vyādhīnāṁ laṅghanakriyā|
jvarasyaikasya cāpyēkā śāntirlaṅghanamucyatē||31||
shAntirAmAshayotthAnAM vyAdhInAM la~gghanakriyA|
jvarasyaikasya cApyekA shAntirla~gghanamucyate||31||
The diseases originating from amashaya are cured by langhana (fasting), only whereas only a single disease entity jwara also can be treated by the single therapy of langhana (fasting). 
तथा लघ्वशनाद्याश्च ज्वरस्यैकस्य शान्तयः |
एताश्चैव ज्वरश्वासहिक्कादीनां प्रशान्तयः ||३२||
tathā laghvaśanādyāśca jvarasyaikasya śāntayaḥ|
ētāścaiva jvaraśvāsahikkādīnāṁ praśāntayaḥ||32||
tathA laghvashanAdyAshca jvarasyaikasya shAntayaH|
etAshcaiva jvarashvAsahikkAdInAM prashAntayaH||32||
For treating a single disease like jwara, multiple therapies like light diet, etc. are needed and the same multiple therapies like light diet etc. are needed to subside many diseases like jwara(fever), shwasa(dyspnea), hikka(hiccups) etc. 
Prognostic aspect in therapy
सुखसाध्यः सुखोपायः कालेनाल्पेन साध्यते |
साध्यते कृच्छ्रसाध्यस्तु यत्नेन महता चिरात् ||३३||
याति नाशेषतां व्याधिरसाध्यो याप्यसञ्ज्ञितः |
परोऽसाध्यः क्रियाः सर्वाः प्रत्याख्येयोऽतिवर्तते ||३४||
नासाध्यः साध्यतां याति साध्यो याति त्वसाध्यताम् |
पादापचाराद्दैवाद्वा यान्ति भावान्तरं गदाः ||३५||
sukhasādhyaḥ sukhōpāyaḥ kālēnālpēna sādhyatē|
sādhyatē kr̥cchrasādhyastu yatnēna mahatā cirāt||33||
yāti nāśēṣatāṁ vyādhirasādhyō yāpyasañjñitaḥ|
parō'sādhyaḥ kriyāḥ sarvāḥ pratyākhyēyō'tivartatē||34||
nāsādhyaḥ sādhyatāṁ yāti sādhyō yāti tvasādhyatām|
pādāpacārāddaivādvā yānti bhāvāntaraṁ gadāḥ||35||
sukhasAdhyaH sukhopAyaH kAlenAlpena sAdhyate|
sAdhyate kRucchrasAdhyastu yatnena mahatA cirAt||33||
yAti nAsheShatAM vyAdhirasAdhyo yApyasa~jj~jitaH|
paro~asAdhyaH kriyAH sarvAH pratyAkhyeyo~ativartate||34||
nAsAdhyaH sAdhyatAM yAti sAdhyo yAti tvasAdhyatAm|
pAdApacArAddaivAdvA yAnti bhAvAntaraM gadAH||35||
Easily curable diseases can be managed in a short time by simple measures. Diseases which are difficult to cure may require more effort and time to cure. The palliable variety of incurable diseases can never be cured, but can be alleviated. Incurable diseases are not amenable to any type of treatment.
Conversely, incurable diseases never become curable, while the curable varieties may become incurable due to factors like incompetence of the four components of health management (the physician, the medicine, the attendant and the patient) and/or misfortune. The easily curable kinds may also become difficult to cure, if not incurable, while diseases that are difficult to cure may become palliable and palliable variety may become incurable. [33-35]
Examination of stages of disease
वृद्धिस्थानक्षयावस्थां रोगाणामुपलक्षयेत् |
सुसूक्ष्मामपि च प्राज्ञो देहाग्निबलचेतसाम् ||३६||
vr̥ddhisthānakṣayāvasthāṁ rōgāṇāmupalakṣayēt |
susūkṣmāmapi ca prājñō dēhāgnibalacētasām||36||
vRuddhisthAnakShayAvasthAM rogANAmupalakShayet |
susUkShmAmapi ca prAj~jo dehAgnibalacetasAm||36||
A wise physician should carefully observe the subtle changes in the state of diseases (aggravated, normal and diminished) while properly assessing the patient’s body strength, digestive power and mental ability. 
व्याध्यवस्थाविशेषान् हि ज्ञात्वा ज्ञात्वा विचक्षणः |
तस्यां तस्यामवस्थायां चतुःश्रेयः प्रपद्यते ||३७||
vyādhyavasthāviśēṣān hi jñātvā jñātvā vicakṣaṇaḥ|
tasyāṁ tasyāmavasthāyāṁ catuḥśrēyaḥ prapadyatē||37||
vyAdhyavasthAvisheShAn hi j~jAtvA j~jAtvA vicakShaNaH|
tasyAM tasyAmavasthAyAM catuHshreyaH prapadyate||37||
The physician, who is keenly observing variations in disease stages in the patient, should know it (the disease) well and prescribe such a treatment that would be helpful in attaining the fourfold effect of therapeutics. 
प्रायस्तिर्यग्गता दोषाः क्लेशयन्त्यातुरांश्चिरम् |
तेषु न त्वरया कुर्याद्देहाग्निबलवित् क्रियाम् ||३८||
प्रयोगैः क्षपयेद्वा तान् सुखं वा कोष्ठमानयेत् |
ज्ञात्वा कोष्ठप्रपन्नांस्तान् यथासन्नं हरेद्बुधः ||३९||
prāyastiryaggatā dōṣāḥ klēśayantyāturāṁściram|
tēṣu na tvarayā kuryāddēhāgnibalavit kriyām||38||
prayōgaiḥ kṣapayēdvā tān sukhaṁ vā kōṣṭhamānayēt|
jñātvā kōṣṭhaprapannāṁstān yathāsannaṁ harēdbudhaḥ||39||
prAyastiryaggatA doShAH kleshayantyAturAMshciram|
teShu na tvarayA kuryAddehAgnibalavit kriyAm||38||
prayogaiH kShapayedvA tAn sukhaM vA koShThamAnayet|
j~jAtvA koShThaprapannAMstAn yathAsannaM haredbudhaH||39||
Generally, doshas that are spread over obliquely (in the transverse direction) afflict the patient for a longer time. In that condition, treatment should not be initiated in a hurry without proper assessment of body strength and digestive power. These doshas should be alleviated first by treatment, or they should be carefully be drawn to the koshtha (bowel). After knowing their status in koshtha, the wise physician should eliminate them through the nearest route. [38-39]
ज्ञानार्थं यानि चोक्तानि व्याधिलिङ्गानि सङ्ग्रहे |
व्याधयस्ते तदात्वे तु लिङ्गानीष्टानि नामयाः ||४०||
jñānārthaṁ yāni cōktāni vyādhiliṅgāni saṅgrahē|
vyādhayastē tadātvē tu liṅgānīṣṭāni nāmayāḥ||40||
j~jAnArthaM yAni coktAni vyAdhili~ggAni sa~ggrahe|
vyAdhayaste tadAtve tu li~ggAnIShTAni nAmayAH||40||
In the Nidana Sthana, a compendium of symptomatology has been provided as a reckoner for the Ayurveda practitioner to gain adequate knowledge of some of the major classes of diseases and diagnose them effectively. But these symptoms may independently develop into diseases and create emergency situations. 
विकारः प्रकृतिश्चैव द्वयं सर्वं समासतः |
तद्धेतुवशगं हेतोरभावान्नानुवर्तते ||४१||
vikāraḥ prakr̥tiścaiva dvayaṁ sarvaṁ samāsataḥ|
vikAraH prakRutishcaiva dvayaM sarvaM samAsataH|
Everything can be categorized into being in a normal or an abnormal state. Both of these categories depend upon causes. Nothing can happen without a cause. 
हेतवः पूर्वरूपाणि रूपाण्युपशयस्तथा |
सम्प्राप्तिः पूर्वमुत्पत्तिः सूत्रमात्रं चिकित्सितात् ||४२||
ज्वरादीनां विकाराणामष्टानां साध्यता न च |
पृथगेकैकशश्चोक्ता हेतुलिङ्गोपशान्तयः ||४३||
हेतुपर्यायनामानि व्याधीनां लक्षणस्य च |
निदानस्थानमेतावत् सङ्ग्रहेणोपदिश्यते ||४४||
hētavaḥ pūrvarūpāṇi rūpāṇyupaśayastathā|
samprāptiḥ pūrvamutpattiḥ sūtramātraṁ cikitsitāt||42||
jvarādīnāṁ vikārāṇāmaṣṭānāṁ sādhyatā na ca|
hētuparyāyanāmāni vyādhīnāṁ lakṣaṇasya ca|
hetavaH pUrvarUpANi rUpANyupashayastathA|
samprAptiH pUrvamutpattiH sUtramAtraM cikitsitAt||42||
jvarAdInAM vikArANAmaShTAnAM sAdhyatA na ca|
hetuparyAyanAmAni vyAdhInAM lakShaNasya ca|
To sum up this chapter, etiological factors, premonitory symptoms, signs and symptoms, therapeutic relief, pathogenesis, historical origins and brief line of treatment of apasmara have been described in this section. Since this is the concluding chapter of the Nidana Sthana, a summary to the entire section has also been provided here, stating that starting from jwara all eight diseases have been dealt with separately in eight chapters, each with etiological factors, symptomatology, prognosis and brief line of management.
A compendium of diseases with etiological factors, their synonyms, symptoms of the diseases have been provided as an epilogue to the chapter. [42-44]
इत्यग्निवेशकृते तन्त्रे चरकप्रतिसंस्कृते निदानस्थाने अपस्मारनिदानं नामाष्टमोऽध्यायः |
निदानस्थानं समाप्तम् ||८||
ityagnivēśakr̥tē tantrē carakapratisaṁskr̥tē nidānasthānē
iti carakasaṁhitāyāṁ dvitīyaṁ nidānasthānaṁ samāptam|
Thus, ends the eighth chapter on the ‘diagnosis of apasmara” of the section “Diagnosis of diseases” (Nidana Sthana) of Agnivesha , as redacted by Charak.
Tattva Vimarsha (Fundamental Principles)
- Apasmara is a disease due to vitiation of three sharira doshas and two manas doshas.
- The causative factors of apasmara mainly include consuming unhygienic, impure, decomposed food and encountering inauspicious things that are not compatible with one’s sensibilities.
- Diet is important for sustaining physical and psychological health. Improper dietary habits can lead to various psychosomatic disorders associated with apasmara.
- Apasmara originates from the heart, which is the center of consciousness and emotions per Vedic texts. The clinical presentation includes impaired heart-brain coordination leading to transient loss of memory, erratic movements, and blackouts. Analysis of the heart-brain connection is very important in the pathology of apasmara.
- Psychological stressors like excessive passion, anger, fear, greed, attachment, excitement, grief, anxiety, worry, perturbation etc. precipitate episodes of apasmara in a person afflicted with excessively aggravated dosha.
- apasmara, depending upon the predominant dosha, can be diagnosed on the basis of frequency of episodes, duration of loss of consciousness, pattern of abnormal movements, and types of objects perceived (in aura phase) prior to the occurrence of an actual episode.
- Purification therapies using strong medicines, observing a healthy diet and lifestyle are considered the primary forms of treatment of apasmara. Non-pharmacological measures like mantra (holy chants) and sattvavajaya chikitsa (mind training for restraint, such as cognitive behavior therapy) aid in the treatment of apasmara.
- There can be one causative factor for many diseases or multiple causative factors for single disease.
- Similarly one symptom can be common in many diseases and one symptom can be seen in a single disease alone.
- There could be a single treatment for many diseases or many treatments for a single disease.
- The duration of treatment depends upon prognosis of the disease. A disease at the onset may be curable but if not treated, could worsen into a palliable or incurable variant.
- The subtle changes in dosha, and the three states of a disease (aggravated, normal, or diminished) should be carefully observed along with proper assessment of body strength, digestive power and mental ability .
- The doshas that spread obliquely (in the transverse direction) afflict patient for a longer time. These doshas should be managed first, or they should be carefully drawn to koshtha (bowel) by proper measures. After analyzing them in koshtha, the physician should eliminate them through the nearest route.
Vidhi Vimarsha (Applied Inferences)
The chapter on apasmara is sequenced after the one on unmada. The sequence is due to similarities of clinical origin as well as causative and pathophysiological factors, since both diseases are psychosomatic in nature.
History and origin of the disease in ancient medical literature
The origin of various diseases is narrated in the eleventh verse of the chapter. apasmara originates from physical and mental contact with various unclean and unwholesome exogenous factors leading to imbalance at physical and psychological levels. The words ashuchi samsparsha literally mean direct contact of body and mind with unwholesome things. This is further supported by apasmara’s etiology which points at improper diet and lifestyle as a major causative factor.
Review of ancient medical literature confirms that epilepsy was initially called sacred, because of the belief for its divine origin. A chapter on epilepsy in Babylonian texts on medicine comprising 40 tablets dating as far back as 1067 BC accurately recorded many of the different seizure types recognized today. It emphasizes upon the supernatural nature of epilepsy, with each seizure type associated with a divinity, spirit or deity (usually evil). It was believed, in antiquity, that if a person comes in contact with things that are supernatural and evil, he/she would suffer from epilepsy. This view is consistent with those in ancient Greek, British, and Indian (Vedic) literature as well. The Ayurvedic theory of origin of epilepsy mentions contact with evil, unwholesome and unclean objects or experiences as key causative factors. References of grahas (celestial bodies) as a causative factor of apasmara, specifically in children, can be found in vedic texts with terms such as ‘skanda’ and ‘skandapasmara. Though there are references of exogenous variants of epilepsy (agantu apasmara) in Charak Samhita, a detailed description of these is not found. This indicates two things:
- Epilepsy originates from exposure to unwholesome, unclean and evil things either at a physical or at a psycho-spiritual plane.
- Management of the disease may include adhyatmik chikitsa (psycho-spiritual therapy) for better treatment.
Definition of apasmara
apasmara is defined as the occasional loss of consciousness due to deterioration of smriti (memory), buddhi (intellect) and sattva (mind), characterized by tamahpravesha (entering darkness/ blackouts) and bibhatsa cheshta (abnormal movements).
As explained by Sushruta, smriti in context of apasmara is bhutarha vijnana i.e. orientation of external world and consciousness. Dhi-buddhi (intellect) is karya-akarya vibhaga karini i.e. discriminating power between right and wrong. Sattva is referred as mana (mind) and dhairya (temperance, patience). A patient of apasmara suffers from deterioration of all these three important mental faculties (dhi, buddhi and smriti).
The first cardinal sign of this deterioration is tamapravesha , i.e., jnana abhava or loss of knowledge and the ability to acquire new knowledge. The second cardinal sign, bibhatsa cheshta, indicates involuntary movements of body due to lack of brain’s control or improper coordination. Sushruta narrated that due to these features of apasmara, the disease often leads to death (antakrita). Dallhana comments that the dreadfulness of this disease is due to the fact that an afflicted person may fall into water or fire due to lack of orientation.
Impairment of knowledge and coordination
According to Ayurveda, knowledge of external objects is processed through sense organs , to the mind-intellect, culminating in the spirit. This chain or sequence for attainment of knowledge is important for proper functioning of memory (encoding, storage and retrieval) and intellect (cognition) [Fig.1]. Occasional impairment of coordination in the sequence consisting of sense organs-intellect-mind-spirit is seen in apasmara. This may lead to decrease in cognitive performance of an individual.[Fig. 1: Faculty involved in attainment of knowledge]
In conventional medicine, three major factors that cause disturbance in cerebral neurotransmission leading to blackouts and epilepsy viz. hypo-perfusion, hypo-metabolism, and hypoxia have been described in relevant medical texts. These disturbances lead to abnormal discharges, improper signal transduction in the neurotransmitter channels, and seizures. As a consequence, cellular dysfunctions in the brain, disruptions of the memory mechanism, and disturbed coordination of movements may occur causing the clinical manifestation of apasmara. The role of these three factors and its impact on memory and cellular dysfunction in the pathogenesis of epilepsy need to be elucidated. The three pathological effects are comparable to the changes created by vitiation of kapha, pitta and vata. Differentiation between these three types of manifestations is described further.
Per Ayurveda, smriti is atmaja (originated from the soul) and sattvaja (originated from the mind). This means that smriti (memory) of a person is essentially related with soul and mind. The Bhagavad Gita describes the consequences of excessive indulgence in sensory activities leading to excessive affliction resulting in an increase in passion, then anger, and then lack of knowledge. This further leads to deterioration of smriti and then affecting the intellect. This sequence lays the ground for apasmara.
Three factors of mind, memory, intellect and consciousness are impaired in apasmara. Due care should be taken to protect and manage these three. Herbs like medhya rasayana and treatment modalities like sattvajaya chikitsa are known to promote activities of mind, intellect and consciousness.
Predisposing factors for apasmara
The susceptible individuals and conditions for epilepsy are described in detail:
The first factor, rajas - tamas affliction, signifies the role of mind in etio-pathology of apasmara. Rajas is a guna (tendency or attribute) responsible for the initiation of every kind of activity and symbolizes energy, while Tamas is the guna symbolizing inertia, dulling or stopping of activities. These two play an important role in the coordination of activities within the sequence of sense organs-mind-intellect-spirit, in the attainment of knowledge as well as to maintain the orientation of external world (consciousness). A rajas-tamas affliction, therefore, adversely impacts coordination of activities and perverts the mind and intellect, landing the patient into loss of orientation and consciousness. A “distressed” state of mind, caused by rajas-tamas affliction, is an important etiological factor responsible for various psychosomatic disorders such as epilepsy. Therefore, rehabilitating the rajas - tamas balance (and thus, achieving harmony between all the three gunas) is of utmost importance in preventing the pathology and maintenance of health. Neurologically, initiation of action through neurotransmitters such as acetylcholine, while inhibition of action through dopamine can be categorized under rajas and tamas respectively. Synchronization of discharges in the cerebral region is a result of rajas-tamas balance. Disturbance in this rajas-tamas balance and depletion of sattva leads to hypersynchronization, resulting in seizures. Threshold of neuronal activity is due to balance between sattva, rajas and tamas. It is sattva that maintains the normal threshold of neuronal activities. Decreased sattva and/or increased rajas and tamas can alter the threshold of neurons.
The state of mind afflicted due to rajas and tamas can be considered as ‘distressed mind’ observed as important causative factor for various psycho somatic disorders like epilepsy.
Sharira dosha vitiation
The second important factor is imbalance of doshas at the somatic level. There are three terms used to indicate the state of doshas which predisposes apasmara:
- First is udbhranta (moving upwards in vitiated state). The upward direction of flow of doshas may indicate the pathway of apasmara from the heart to the brain. The pathology starts from the abode of consciousness i.e. heart, spreading upwards afflicting sense organs. In Chikitsa Sthana, the term vibhranta is used to denote this condition.
- The second state is vishama, meaning a state of disequilibrium. Imbalanced doshas create a favorable environment for apasmara. *The third state is bahu (excessive), meaning that the imbalance is excessive enough to affect the brain-mind system. This suggests that the doshas are in an aggravated state of imbalance and predispose to the disease. The condition also points towards manifestation of apasmara as a result of other somatic disease pathologies.
The disease condition is a result of combination of the above states of doshas with the rajas-tamas affliction. These are sanchaya (accumulation), prakopa (aggravation) and prasara (spread) stages of the disease - important somatic factors for causation of apasmara.
The cumulative presentation suggests the psychosomatic nature of the disease where the psyche and soma are equally involved in the pathogenesis. This is important while treating apasmara, because this indicates that only administering anti-epileptic drugs is not enough in treating apasmara. The treatment of underlying psychological factors shall also be given due emphasis.
Role of diet
The third key factor is the role of quality of diet in the causation of the disease. Charak uses terms like samala (impure), vikrita (deformed/altered), upahita (mixed), and ashuchi (unclean/unhygienic) as adjectives to describe food articles that cause apasmara. Sushruta uses terms like viruddha (incompatible or of contradictory/antagonistic nature) and malina (bad) for the same factors. Besides providing nutrition to the body, diet plays a great impact on the mind as well. It is mentioned in the texts that the nutrition of soma and psyche occurs through food and food habits. Yogic texts narrate the role of food in nourishing five sheaths of the body, called annamaya kosha, pranamaya kosha, vijnanamaya kosha, manomaya kosha and anandmaya kosha. Therefore, diet is not only important for proper functioning of the three doshas, but also for nourishment of the mind and the soul. Charak as well as Sushruta have acknowledged the role of unclean, unhygienic, unwholesome, incompatible diet in the causation of apasmara. Dallhana commented that this includes the diet that is dwishta (disliked by mind or taken with hatred feeling), amedhya (not satisfying mind) and paryushita (stale). All these types of diet can cause disturbance in the body and mind. As per conventional medicine, a diet that is deficient in certain vitamins and minerals and that which increases neurotoxins may lead to neurological disorders. Therefore, biochemical changes in the above mentioned causative foods may lead to deficiencies of important nutrients and cause increase in neurotoxins resulting in apasmara like disorders. Moreover, some gastrointestinal symptoms have been described further as premonitory symptoms of apasmara. The role of diet and food habits as a cause of apasmara needs to be further researched. These factors are to be avoided during the treatment of apasmara. Not following /proper dietary rules is one of the key causes for the formation of ama. Ama produces free radicals leading to excessive oxidative stress and tissue injuries. Therefore, following proper dietary habits is important in preventing the pathogenesis of the disease. Furthermore, this suggests the possibility of food contamination as a causative factor for epilepsy. A case of endrin-laced taquitos causing seizures in the US is an example of food contamination causing epileptic seizures .
Improper methods – lifestyle factors
The fourth etiological factor of epilepsy is not following the prescribed rules of diet and lifestyle. The upayoga vidhi lists improper dietary habits, lifestyle and code of conduct that lead to disturbances in soma and psyche. Sushruta has elaborated the role of incorrect or excessive indulgence in activities of sense organs and locomotor organs as the foremost causative factor for apasmara. This is suggestive of disturbances in the knowledge coordination chain leading to lack of attainment of knowledge. This factor also indicates role of unhealthy regimens and behavior in patho-physiology of epilepsy. The factor underlies ignorance towards proper dinacharya (diurnal regimen), ratricharya (night regimen) and ritucharya (seasonal regimen). The lifestyle and behavior of a person is important for achieving normalcy in the psychic plane and for avoiding psychological disorders. This also suggests the inclusion of prajnaparadha (intellectual blasphemy) described in Sharira Sthana. Achara rasayana (code of conduct) should be followed as a therapeutic regimen in the management of apasmara. The psycho-neuro-biological basis of etiopathological factors causing neurological disorders is being extensively researched with positive outcomes. Psycho-social distress is an important underlying factor for such disorders through impairment of hypothalamo-pituitary-adrenal axis. The preventive measures to be included are correct and productive indulgence in the sensory and locomotor activities as per capacity of an individual. Psychotherapy is believed to be effective in the management of apasmara.
Observance of improper tantra (techniques/methods) makes the person prone to apasmara and is the fifth causative factor. This includes iatrogenic factors such as improper follow ups of Panchakarma procedures leading to vitiation of doshas in the body. The other meaning of tantra might be related to spiritual practices that are related to the supernatural powers mentioned earlier as reasons for causing epilepsy. Improper use of these tantric therapies can result in epilepsy.
Iatrogenic causes can increase susceptibility to apasmara. Therefore all procedures should be followed properly in order to prevent complications.
Incorrect postures and movements
The sixth etiological factor constitutes of wrong postures and movements. Since the coordination of movements is regulated by dhi-buddhi-smriti, any imbalance in the sense organs-mind-intellect-spirits sequence not only impairs movement of limbs but also increases the propensity of getting afflicted with apasmara. Conversely, wrong postures and movements are a result of disturbances in the sense organs-spirits sequence that lead to incorrect attainment of knowledge with the manifestation of apasmara.
Uncomfortable sitting, sleeping, positioning, irregular, uncoordinated movements of body (e.g. improper dance, sports etc.) can predispose apasmara.
Excessive degeneration and debility
The seventh and last etiological factor i.e. excessive degeneration or debility may lead to pathogenesis of apasmara , pointing at dhatukshayajanya vataprakopa (vitiation of vata due to depletion of tissues) as a root cause. The degeneration might be a secondary condition resulting from other diseases. Hypo-perfusion and low levels of oxygen and metabolism could result in brain cell dysfunctions causing seizures. This is analogous to the concept of ati upakshaya in Ayurveda. Therefore, a clinical examination of depletion of tissues (dhatukshaya) could be considered as a treatment component in the management of apasmara.
Acute and severe electrolyte imbalances (hyponatremia, hypocacemia and hypomagnesemia) frequently cause seizures.
The underlying etiology of other degenerative diseases should be considered while dealing with cases of epilepsy. In that case, management of epilepsy should be supported by proper nutrition, restorative, replenishing and rejuvenation therapies.
Additional factors by Sushruta
In addition to the above factors, Sushruta has quoted two more factors for predisposition of apasmara. Veganigraha sheelanam i.e. habitual suppression of natural urges and gachchatam cha rajaswalam i.e., having sexual intercourse with menstruating women can make the individual more susceptible to epilepsy. Recent research suggests that menotoxins secreted by the female body during menstruation significantly impact the psyche of a person accompanying that female.
On the first of these two factors, per Ayurveda, suppression of any of the thirteen types of natural urges may lead to various disorders. Suppressing natural urges leads to vata-dominant disorders and as vata is the regulator of mind-related activities, this consequently can result in neuropsychiatric disorders like apasmara. All the urges are stimulated, regulated and completed by the nervous system. Inhibition of these factors might lead to impairment of neurotransmission which can be a cause for neuropsychiatric disorders. Furthermore, suppression of urges can lead to accumulation of waste materials inside the body creating various diseases.
On the second factor mentioned here, the correlation between having an intercourse with menstruating woman and getting afflicted with epilepsy needs to be researched further. Ayurveda strictly forbids sharing things with a menstruating woman, leave aside touching or having sexual relations with one. While there are reasons of following sacredness associated with this, sex with a menstruating woman is also indicative of exposure to unclean objects described earlier as the origin of apasmara. The psycho-neuro-endocrinological axis behind this view of Sushruta needs to be explored.
Thus, from the above descriptions, etiopathological factors of apasmara can be categorized into dietary factors, lifestyle factors, psychological factors, behavioral factors and iatrogenic factors. All the above predisposing factors can be scanned for epigenetic modifications with respect to personality types, behavior patterns and occurrence of apasmara in such cases. This will be useful in identifying the disease at a primitive stage, breaking the pathogenesis at an intermedial stage and prevention of further deterioration and complications at later stage. There might be certain epigenetic patterns/changes due to the above mentioned etiological factors, which make the person more susceptible to get affected.
The above enlisted etiological factors cause depletion in psychological strength (objectively measured as Intelligence quotient (IQ) and Emotional Quotient (EQ). In the era of distress, it is important to know the etiology of a disease in order to prevent its harmful effects. In order to preserve and increase the psychological strength, one shall avoid the causative factors for apasmara.
Fig.2: Psycho-dynamics in apasmara
Six stages of pathogenesis of epilepsy (shatkriyakala for apasmara)
The pathogenesis of apasamara can be understood as below. [Fig.3: Schematic presentation of pathogenesis of apasmara]
The first stage of accumulation of pathogenic factors (vitiated doshas) starts at their own sites. It is initiated right from the first exposure to unclean objects and other etiological factors mentioned earlier. This stage is characterized by mild disturbances in the psyche (rajas and tamas) and soma (tridosha).
If the individual excessively indulges in observing causative factors for a significant period, then the doshas proceed to the next stage of pathology i.e. prakopa. The doshas are vitiated at their own site. In case of apasmara, the doshas reside at the vessels, above the heart (the site of consciousness) in a leena (dormant) state [Cha.Sa.Chikitsa Sthana 10/6].
Whenever the provocative emotional factors like worries, passion, anger etc. trigger these doshas, the vitiated dosha moves upwards affecting the sense and locomotor organs. This will present the prasara avastha (stage of spread) of the disease.
Thereafter in sthanasamshraya avastha of apasmara (change in stage, triggering premonitory signs and symptoms), the stridden doshas take pathways of sense organs and locomotor organs alerting manifestation of the disease. This is called the aura stage of epilepsy.
Then, the vyakta i.e. manifestation stage of apasmara is apparent due to excessive aggravation of doshas. The severity of paroxysms depends upon sharira bala (physical strength that helps do physical work as well as prevent manifestations of diseases, includes genetic predisposition as well), hetu (strength of causative agents depending upon their exposure) and sattva bala (strength of mind). The clinical manifestation will be a product of interactions between these factors. Common clinical features of the disease will start showing at this stage.
Bheda avastha is the stage of differentiation depending upon the dominance of doshas. This will predominantly depend upon the genetic constitution of the person as well as the intake of alleviators and pacifiers of that particular dosha. If there are some pacification factors in between, then the progression of disease stops at that stage only blocking presentation of clinical features. If we critically analyze and compare the pathophysiology, it can be observed that unlike modern research, the brain did not figure in Charak’s analysis of disease or their pathologic basis, nor did he emphasize the role of an exogenous or supernatural power (agantuka) factor in the causation of epilepsy. Charak has clearly mentioned heart, the abode of self and consciousness, as the origin for apasmara. In the seizure state, doshas stride upwards through dhamanis (vessels), affecting the indriyas (sense and locomotor organs) leading to erratic movements and loss of consciousness. Sushruta and Vagbhata have specifically mentioned the samajnavahishu srotasu (channels of consciousness) as the pathway of spread of doshas and as a site for the disease.
As per Ayurveda, the heart (and not the brain), is the locus or abode of the mind, consciousness and soul , and emotional factors are considered as some of the root causes for triggering epilepsy. The clinical presentation of epilepsy represents the derangement of functions of neurons of central nervous system, but the origin of this derangement shall have been predisposed much earlier due to psycho-pathological factors enlisted above. The acute onset of seizure can be precipitated due to emotional factors. The mechanism of this phenomenon and exact psycho-neuronal pathways behind this are worthy of study.
Prana vayu (buddhi-hridaya-indriya-chitta dhruk, i.e., regulation of intellect, heart, senses, mind functions), vyana vayu (seat at hridaya and regulating all types of movements), udana vayu (functions for energy and activities), sadhaka pitta (type of pitta dosha), tarpaka (type of kapha) and avalambaka kapha (type of kapha) are important to be considered as patho-physiological factors in this context.
Types of apasmara
There are four types of apasmara depending upon the predominance of dosha. The first thing of significance is that all these are sharira doshas and not manasa doshas. This implies that apasmara is predominantly a somatic disease in which psychological factors play a role in pathogenesis. The important aspect of management should be focused at the somatic level supported by psychotherapy. The role of genetic constitution is important in the study of clinical manifestations of apasmara as well as their response either to treatments involving allopathic anti-epileptic medications or to Ayurvedic treatment modalities. The diagnosis of dominance of dosha is also important in deciding the treatment modalities prescribed in cases of apasmara. The epigenetic variation of the four types of apasmara and the categorization of etio-pathological factors to lead the epigenetic modification resulting into specific type of apasmara is worthy of study.
Chakrapani comments that Agantuka i.e. exogenous type of apasmara is excluded unlike unmada. Thus Chakrapani rules out the possibility of external factors like deva, graha etc. to cause apasmara and emphasizes the endogenous patho-physiology of apasmara. Charak describes the possibility of exogenous factors affecting the individual to suffer from apasmara in a verse described later. The management of apasmara due to exogenous factors is similar to that described in the management of agantuja unmada.
Skanda graha and Skandapasmara
Per Ayurveda, children get afflicted by apasmara due to the effects of any of grahas (Sanskrit, means seizing) such as skandapasmara   skanda, etc. knowledge of features of nine evil spirits which seize children is described, skanda and skandapasmara are the first two evil spirits which when affect a child, the clinical presentation is similar to that of epilepsy as narrated below.
A child seized by skanda graha has swelling of the eyes, smells like blood, has aversion to the breasts, distorted face, and eyelids or one eye having either loss of movement or more movements. The child could also be restless or irritable, have closed eyes, cry very little, hold its fists tight, and have hard bowel movement.
When the child is seized by skandapasmara, it loses and regains consciousness, is irritable, makes dancing like movements with arms and legs, eliminates stools and passes urine accompanied with sound (crying), yawns more and emits froth from the mouth. These are the features of a child seized by the “friend of skanda graham”, i.e., skandapasmara.
Similar to this, Vagbhata in Ashtanga Hridayam, has described the variants of the disease caused due to demons/evil spirits possessing the children. The cardinal signs of graha possession (or affliction) include continuous fever and crying. The general features are fear, too much yawning, movement of eyebrows, timidity, discharge of froth from mouth, upward gaze, biting of lips and teeth (grinding), wakefulness (absence of sleep), crying, moaning, aversion for the breast, change of voice, and scratching its own body or that of the mother by nails without any reason. [A.H Uttara Sthana 3/3-5]
In conventional medicine, epilepsy in children is described in detail. However, the etiology of some variants of epilepsy is mentioned to be idiopathic. As described in context of skanda and skandapasmara, the involvement of supernatural powers in causing apasmara is a matter of debate and falls in the purview of theology. Considering its importance and prevalence, apasmara of unknown etiology can be categorized as of the fifth type i.e. agantu apasmara. Sushruta and his commentator Dallhana support this view that any variant of the disease which occurs without any reason, acutely and without any rational pathology shall be considered as agantu. Per Charak [Cha.Sa.Chikitsa Sthana 10/53], the etiopathology, clinical features and management of this fifth type are on the lines of agantu unmada. As commented by Chakrapani, in case of agantu or bhutapasmara, the etiology of being seized by some external factors is considered primary and the involvement (anubabdha) of dosha as secondary. It is important to note here that since clinical patho-physiology cannot take place without the involvement of doshas, therefore agantu should technically be considered as one of the four doshic variants of apasmara mentioned earlier, in order to follow the sankhya niyama i.e. rules of numeral classification.
Premonitory signs of apasmara
The table 1 depicts the premonitory signs of apasmara described in the Ayurvedic texts. Each sign has a specific patho-physiology in terms of dosha and dushya behind its manifestation. The enlisted signs are the alerting signals or premonitory symptoms of apasmara before the onset of seizures. The probable system involved as per conventional medicine is also enlisted for every sign, so that it would be easier to consider the pathophysiological similarities and differences between the two medical streams.
|Bhrūvyudāsa||abnormal / twitching of eyebrows||vata – rajas||majja||nervous system [NS]|
|Satatam akshi vaikrutam||constant abnormal/ irregular movements of eyes||vata – rajas||majja||NS|
|Ashabda shravanam||auditory hallucinations||vata –rajas||manas||NS, psychiatric disorder|
|Lala prastrava||excess secretion of saliva||kapha||rasa||NS, digestive system[DS]|
|Singhanaka prastrava||excess nasal mucus discharge||kapha||rasa||NS, respiratory system|
|Anannabhilashanam||lack of appetite||kapha- Pitta||rasa||DS, NS|
|Arochaka||aversion to food and drinks [anorexia]||Kapha –pitta –vata||rasa||DS, Psychiatric disorder|
|Hridaya graham||heavyness of precordium/ congestion/ constriction in cardiac region||kapha, vata||mamsa,majja||NS, musculo skeletal system,|
|Kukshe aatopa||puffiness/ swelling in the hypogastric region||vata, kapha||rasa, purisha, mutra||DS, urinary system|
|Daurbalyam||debility, loss of strength||kapha, vata||rasa, mamsa, majja||NS, musculoskeletal system|
|Asthibheda||splitting / breaking [pain] sensation in bones||vata||asthi, majja||skeletal system|
|Angamarda||generalized bodyache/ twisting/churning pain in body||vata||mamsa, majja||musculo-skeletal system, NS|
|Moha||confused state of mind [leading to lack of knowledge]||vata, kapha, Tama||rasa, majja||NS, psychiatric disorder|
|Tamas darshanam||black outs / temporary loss of vision without alteration in consciousness||pitta, vata||rasa- rakta-majja||cardio-vascular/ cerebro vascular system, NS|
|Murchcha||syncope / a fatal condition characterized by loss of consciousness and postural tone due to vitiation of blood||pitta, kapha||rasa, rakta, majja||cardio-vascular/ cerebro vascular system, NS|
|Abhikshnam Bhrama||frequent vertigo/ dizziness||pitta, vata, rajas||rasa, rakta, rajas||cardio-vascular/ cerebro vascular system, NS, psychiatric disorder|
|Swapne cha||In dreams|
|Mada||slight intoxication, becoming out of senses showing uncanny or abnormal behaviour||vata, rajas, kapha||rasa, rakta, manas||Cardio-vascular/ Cerebro vascular system, NS, psychiatric disorder|
|Vyadhana||needling like sensation||majja|
The abovementioned pre-clinical features are observed in the fourth stage of shatkriyakala (pathogenesis). These may be considered as aura in apasmara patients. These are important in view of prevention of apasmara progression to epileptic seizure. In conventional medicine text books, some of the above signs like auditory and visual hallucinations are referred. These signs need to be searched upon for their prevalence, categorization as per dosha dominance, involvement of dosha attributes in order to establish precise guidelines for early prevention and management of disease.
Table 2: Differentiation between types of apasmara
|Characteristic feature||Vataja Apasmara||Pittaja Apasmara||Kaphaja Apasmara|
|Frequency of attacks||Maximum [Twelve days]||More [Fifteen days]||Less [One Month]|
|Time required to lose consciousness||Minimal||Less||More|
|Time required to regain consciousness||Minimal||Less||More|
|Duration of attack||Minimal||Less||More|
|Clinical appearance of nails, eyes [sclera],face and skin||Aruna[ downy red], Shayva[gray] , parusha [rough]||Peeta [yellowish], harita [Greenish], Haridra [ turmeric yellow], Tamra [ coppery]||Shukla [whitish/ pallor]|
|Patient experiences aura of / vision of / views of||Anavasthita [unstable], Chapal [Moving/fickle] parusha [rough], Ruksha [Dry] Rupa [ looking objects] Vikrutananam [abnormal faces] [AH]||Rudhirokshita [ blood], bleeding, terrifying (which is also injurious) Bhairava [frightful], Aadipta [burning] and Rushita [angry] looking objects||Shukla[ white], Guru [ heavy / large in size], Snigdha [ unctuous]
|Clinical picture of abnormal movements||Vishama Vinata Angulim [irregularly contracted fingers||Not given specifically||Anati cheshtam [ not more movements/ less movements]|
|Anavasthita pani Padam [ instable or continuous shaking of upper and lower limbs]||Alpa Cheshtam [less abnormal movements ] [AH]|
|Parito Vikshipati Angam [ places body parts here and there irregularly/ involuntary movements] [AH]|
|Character of discharge from mouth||Phenam [froth]||Not mentioned specific||Lalam Bhuyasi [excess saliva discharge]|
|Temperature of body||Not specific||Tapa [rise in temperature/ hyperthermia] [Su]||Sheeta Anga [cold body/hypothermia] [Su]|
|Other Specific features||Utpinditaksham [ bulging of eyes/ upside rolling of eyes]||Avakujantam [epileptic cry]||Patantam [falling down]|
|Asamna Vilapantam [incoherent speech]||Aasphalayantam Bhumim [rubbing earth]||Hrullas [nausea] [Su]|
|Trushna [excess thirst]||Nidrarta [excess sleep] [Su]|
|Ateeva aadhmatgreevam [excess heaviness and rigidity in neck region]||Sweda [excess perspiration] [Su]|
|Aavidhdha Shiraskam [bending of head towards one side]||Murchcha [ syncope] [Su]|
|Kampate [ trembling/convulsions]||Dhunvan Angani [shakes all body parts] [Su]|
|Vepamano [ tremors]||Vivhala [agitated] [Su]|
|Dantan pradashet [grinding of teeth]|
|Shwasiti [increased respiration/ dyspnea]|
|Sakthi Sphurana [contraction like sensation in thigh region]|
|Viswaram [epileptic cry] [AH]|
Su: As described by Sushruta in Sushruta Samhita AH: As described in Ashtang Hridaya
The specific features of all the four types of apasmara are described in Table 2. Vata type of apasmara manifests itself with repeated seizures of short duration and increased frequency of attacks. The speed, severity and abnormality of movements are more in this case. This is due to chala (movable), laghu (light), and sukshma (minute) attributes of vata dosha. Vata is the initiator of all activities including those of the body and the mind. The regulation and coordination of the sequence of sense and locomotor organs – mind-intellect-soul for attainment of knowledge is performed by vata. Prana vata, udana vata and vyana vata are involved in the pathophysiology of apasmara. The clinical manifestation of vataja apasmara may be due to repeated, excess, hyposynchronous discharges in neurons of the central nervous system. Transient hypoxia leading to dysregulation of brain functioning, and neurological diseases similar to epilepsy syndromes can be categorized under this type of apasmara.
In pitta apasmara, the frequency, duration of paroxysms will be comparatively less than those observed in vata type. The ushna (hot) and tikshna (acrid) attributes of pitta are responsible for the pathology of paroxysms. Sadhaka pitta located at the heart and the functions responsible for accomplishment of activities are responsible for this apasmara. Tamahpravesha is a sign primarily of pitta-dominance in which metabolism or transformation at the cellular level might be an underlying pathology. Derangement of sadhaka pitta implies the decrement or depletion in psychological performance in apasmara patients. Since pitta is responsible for all metabolic activities, the derangement of metabolism at the cellular level is an important pathological factor and the enzymatic pathways might be held responsible. The types of epileptic syndromes originating due to metabolic disorders like hepatic encephalopathy can be categorized under this type. Changes in body temperature, excess thirst, and perspiration are specific differentiating features of pitta apasmara. The cerebral conditions due to derangement of metabolisms can be enlisted here. In cases of kaphaja apasmara, the sthira (stable), manda (slow), and snigdha (unctuous) attributes of kapha are responsible for delayed onset, prolonged duration as well as minimal frequency of paroxysms in apasmara. Excessive sleep and hypothermia specifically suggest kaphaja apasmara. Hypoperfusion and hypovolemic conditions leading to cerebral dysfunction can be considered as attributes of kaphaja apasmara.
Finally, the sannipatika type of apasmara presents itself with complex mixed features due to overlapping of all doshas. The prognosis is poor leading to incurability of disease. This might be a mixed presentation of neuronal, endocrinal, circulatory and metabolic pathways.
While considering the clinical pictures of a disease, the attributes of doshas responsible for variation in pathologies at somatic and psychological level should be emphasized. Important mechanisms of loss of consciousness and abnormal movements at the somatic level, and impairment of intelligence and memory at psycho-pathological levels needs to be focused. The epigenetic patterns related to particular signs and symptoms originated from doshic pathologies can be researched to reveal new treatment methods and management aspects. The genetic constitution of a person plays a significant role in making him prone to developing certain type of disorders. Therefore, as discussed above for vata apasmara can become more apparent after taking vata-aggravating diet and lifestyle in vata prakriti individuals that can get alleviated by using vata shamana (i.e., vata-pacifying) diet and lifestyle. Furthermore, if anti-epileptic drugs are used more judiciously depending upon the dosha and prakriti-specific diagnosis, then the treatment regimen can be made much more precise leading to beneficial results in patients. As discussed in the section of predisposing factors, the preventive lifestyle and dietary regimens can be designed to prevent incidence of epilepsy, reduce the dose of drugs with supportive diet and lifestyle therapy and prevent further progression of disease. Therefore, training of epileptics regarding causative and avoidable factors is of utmost importance. The epigenetic variations in epileptics due to enlisted causative agents should be studied as a part of genomic and proteomic research.
Differential diagnosis of apasmara
Other disorders such as mada (intoxication) and murchcha (syncope) also show the signs of loss of consciousness, but ones without convulsions. In unmada, there is impairment of buddhi, and it does not manifest itself with loss of consciousness. Akshepa (abnormal movements) is a vata-predominant disease characterized with convulsions, but the consciousness is intact and there is no froth discharge. This makes apasmara a distinct disease apart from other disorders.
Prognosis of apasmara
Epilepsy due to vitiation of all the three doshas and showing all clinical features of the sannipatika variant (i.e., of all the other three doshic variants) is chronic in nature and that, which has occurred in a person with excess degenerative condition and depleted dhatus, is considered incurable. In case of degenerative conditions and chronic diseases, any case of apasmara due to vitiation of even a single dosha can be considered incurable.
Bad prognostic signs of apasmara patients can often turn fatal. If one, in his wakeful state sees darkness where there is no darkness and hears all types of sound even when there is no sound, he succumbs to apasmara. If a patient, while dancing in an intoxicated state is caught by a preta (soul of a dead person) with his head facing downwards, he is sure to succumb to an attack of apasmara.
Reasons behind aggressive and dormant stages of apasmara
From the above sections, it is clear that apasmara occurs in episodes. The patient after seizure regains consciousness like waking up from sleep (suptavat pratibuddhyate). Therefore, there are two stages of disease : one is aggressive stage of doshas and the second is dormant stage of doshas. Sushruta describes that there are two forms of pathogenesis: One form follows the six stages viz. sanchaya etc.(kramopayogad) of the disease in sequence and takes considerable time to manifest disease with gradual onset. The other form manifests acutely in a short time (kshanikatwat). The first form is seen in nija (endogenous) pathologies of disease. The other form is seen in agantu (exogenous) apasmara. Sushruta gives examples of a seed in the ground that sprouts only during sharad ritu (autumn) though it rains at other times. Analogous to this example, the virulent form of the disease develops due to a dosha getting aggravated in very short time and manifesting its different symptoms due to some factors catalyzing the accelerated aggravation. It is quite clear from the detailed descriptions in this chapter, though, that all forms of apasmara are caused by dosha only. [Su.Sa.Uttara Tantra 61/1821]
The example states the fact that favorable environment for precipitating factors plays major role in disease episodes. Depending upon the defense system of the body – its natural and acquired immunity - as the background for disease and factors aggravating the dosha as offending agents, the interaction between the two defines severity, intensity and frequency of occurrence of episodes of disease as shown in chart. [ Fig.4: Manifestation of episodes ]
Therefore, for prevention and management of a disease, it is important either to build up the strength of defense system i.e. improving the sharira bala (physical strength) and sattva bala (mental strength), or pacify/weaken the aggravating causative factors or both.
Management of apasmara
Although the management of apasmara is described further in Chikitsa Sthana, principles of management are given in this chapter. The curable types of epilepsy should be carefully treated with strong elimination and alleviation therapies according to the vitiated dosha. Doshas present in the vessels above the heart need to be removed which require strong measures requiring medicines having higher penetrability, higher potency and highest bio-availability. With this objective, tikshna samshodhana (strong elimination) and samshamana (alleviation therapies) are employed. When extrinsic causative factors are involved (agantu apasmara), then mantras etc., will be useful.
The rationale behind advocating strong elimination therapies is the deeper location and excess vitiated state of doshas. As described in patho-physiology earlier the dosha are in dormant state in the vessels above heart. Therefore to remove these dosha, strong eliminatory therapies are needed. The strength of the prescribed medicine is decided by their higher penetrability, potency and bio-availability.
Practical application of principles
All the abovementioned principles are practically applicable. The methods for further research include the following:
- Supporting the clinical presentation with data of research papers on survey studies
- Preparing Checklist and proforma for
- Diagnosis of states susceptible for suffering from apasmara
- Diagnosis of aura stage or premonitory stage of apasmara for early identification of status epilepticus in order to train the patient and arrange necessary preventive measures
- Diagnosis of apasmara and specific types of apasmara based on clinical presentation
- Evaluation studies of various epigenetic pathways in conjunction with the patho-physiology of apasmara
- Clinical correlation with modern radiological investigations like CT etc. and EEG for better clinical diagnosis of apasmara
- Enlisting newly introduced disease commonly observed in society into the umbrella of apasmara e.g. Alzheimer’s dementia, depression etc.
- Retrospective analyses of all signs and symptoms enlisted in the modern text books and formulating probable samprapti / pathophysiology (dosha-dushya sammurchchna) based on dosha dominance behind manifestation of each sign and symptom can be formulated for better understanding in Ayurvedic perspective.
- Assessment criteria in Ayurveda and modern science, modern investigation methods and technologies, biomarkers which are well established may be enlisted.
Research works done on apasmara at post graduate/post doctoral level:
Institute for Post Graduate Teaching & Research in Ayurveda, Gujarat Ayurved University, Jamnagar, Gujarat, India.
1. Pandya M.B. Shukla C.P. Apasmara [A Treatise on Epilepsy].1962. P.G.Thesis.
2. Sutariya Bharati.A Clinical Study on the role of Rasayana Drugs in the management of Apasmara.1988. P.G.Thesis.
3. Usha K.S. Singh Gurdip. A Clincal Study on Apasmara [Epilespy] & its management with Maha Panchagavya Ghrita. 2001.P.G.Thesis.
Faculty of Ayurveda, Banaras Hindu University, Varanasi:
4. Dwivedi KK. A Clinicalstudy of Medhya Rasayana therapy in Apasmara.1989. PG thesis.
5. Shetty Suhas Kumar. A comparative study of Brahmi Ghrita as Shamana & Brumhana sneha in Apasmara.2001-02 6. Unni G. Effect of Kushmanda Ghrita in Apasmara.2002.
National Institute of Ayurveda, Jaipur :
7. Bhatnagar P. Antardhooma evum Bahirdhooma Tamra sindoora kalpana evum Apasmara Roga par Prabhavatmaka Adhyayana. 1992.
8. Sharma U.K. Apasmara me Samshodhana poorvaka Vacha Churna evum Smritisagar Rasa ka Chikitsatmaka Adhyayana.1999.
Ayurveda College, Mysore:
9. Yatheesha HN. To evaluate the effect of Brahmi Ghrita & Vacha choorna in the management of Apasmara- A controlled clinical study. 2003.
Shri Ayurveda College, Nagpur, Maharashtra :
10. Potbhare SM.Comparative Clinical study of role of Saraswata Churna in Apasmara.1995.
Tilak Ayurveda Mahavidyalaya, Pune, Maharashtra:
11. Kuber Asmita. Apasmara grandhokta hetu va pratyakshataha adhalanare hetu yancha taulanika Abhyasa. 2000.
12. Nagarajan C. Apasmara & its management- A critical study. 1991.
13. Manju GL. Efficacy of Kushmanada Swarasa ghrita in Apasmara.2003.
14. Murthy Niranjan.Aetio-pathogenesis and principles of management of Apasmara. 1999.
15. Indukala PR. A classical study on Majja in relation with the manifestation of Apasmara. 2003.
Reference books on Manasa Roga further reading:
1. Thakar VJ. Man ane Manas Roga
2. Singh RH. Ayurvediya Manasa Roga Vijnana.
3. Pathak Balakrishna. Ayurvediya Bhutavidya Vivechana
4. Murthy ARV. Rationale of Ayurvedic Psychiatry.
5. Murthy ARV. Mind in Ayurveda and Indian traditions.
6. Gupta SP. Psychopathology in Indian Medicine.
7. Nanal Ramesh. Mana Ani Ayurveda.
Research papers published
- Mervyn j. Eadie. Peter f. Bladin. John libbey. A disease once sacred. A history of the medical understanding of epilepsy. Brain (2002) 125 (2): 441-442.
- Manyam BV. Epilepsy in ancient India. Epilepsia. 1992 May-Jun;33(3):473-5.
- Manyam BV. Dementia in Ayurveda. J Altern Complement Med. 1999 Feb;5(1):81-8.
- Ven Murthy MR, Ranjekar PK, Ramassamy C, Deshpande M. Scientific basis for the use of Indian ayurvedic medicinal plants in the treatment of neurodegenerative disorders: Ashwagandha. Cent Nerv Syst Agents Med Chem. 2010 Sep 1;10(3):238-46.
- Singh R.H., Murthy A.R.V. Medhya Rasayana Therapy in the management of Apasmara Vis-A-Vis Epilepsies. The Journal of Research and Education in Indian Medicine.1989.8 :13-16.
- Dwivedi K.K. & Singh R.H. A Clinical Study of Medhya Rasayana Therapy in the management of Convulsive Disorders. Journal of Research in Ayurveda and Siddha.1992:13[3-4]: 97-106.
- Geetha L, Shetty S K, Prakash N B. A Randomized Control Trail of Brahmi Gritha In Apasmara With Reference To Generalized Tonic Clonic Seizures. 4th World Ayurveda Congress and Arogya Expo proceedings Pp. 135-136, 9-13 December 2010, Bengaluru, Karnataka, India.
- M.H. Hakim, M.M.H. Siddiqui. A.B. Khan. Anti-epileptic activity of Ustukhudus (Lavandula stoechas) – In a case of secondary epilepsy (A Case Report). Hamdard Medicus.1991.34[ 3] 33-39.
- Hakim M.H. Siddiqui, M.M.H. Siddiqui, A. Ismail, S.A.H. Jafri. Secondary (Symptomatic) epilepsy, an uncommon presentation. The Antiseptic.May 1991. 88.231-233.
- Venkataraghvan S., Rajagopalan V, Srinivasan K. Study of doshik involvement in Apasmara (Epilepsy) and its utility. Ancient science of life, Vol.No.VI,1987.138-47
- Murthy ARV, Singh RH.A Critical study on the Ayurvedic concept of the psychopathological basis of Apasmara. Journal of NIMA XXXII  1990.7-11
- Emmanouil Magiorkinis, Kalliopi Sidiropoulou Aristidis Diamantis. Hallmarks in the History of Epilepsy: From Antiquity Till the Twentieth Century. Novel Aspects on Epilepsy Office for the Study of History of Hellenic Naval Medicine, Naval Hospital of Athens, Greece.
- J. M. S. Pierce, a disease once sacred. A history of the medical understanding of epilepsy By Mervyn J. Eadie and Peter F. Bladin2001. Eastleigh: John Libbey. Pp. 248. ISBN 0‐86196‐607‐4. Oxford Journals Medicine Brain Volume 125, Issue 2 Pp. 441-442.
- K Waller, T J Prendergast, A Slagle, R J Jackson.Seizures after eating a snack food contaminated with the pesticide endrin. The tale of the toxic taquitos. West J Med. 1992 Dec; 157(6): 648–651
- Sushruta. Uttara Tantra, Cha.27 Navagrahakritivijnaniya Adhyaya verse 8-9. In: Jadavaji Trikamji Aacharya, Editors. Sushruta Samhita. 8th ed. Varanasi: Chaukhambha Orientalia;2005.
- Vagbhata. Uttara Sthana, Cha.3 Balagrahapratishedam Adhyaya verse 6-11. In: Harishastri Paradkar Vaidya, Editors. Ashtanga Hridayam. 1st ed. Varanasi: Krishnadas Academy;2000.