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|title=Apasmara Chikitsa
|title=Apasmara Chikitsa
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|keywords=Apasmara, memory, consciousness, epilepsy, atattvabhinivesha, unmada
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|description=Chikitsa Sthana Chapter 10. Management of Apasmara (Epilepsy and other disorders)
|description=Chikitsa Sthana Chapter 10. Management of Apasmara (Epilepsy and other disorders)
|image=http://www.carakasamhitaonline.com/resources/assets/ogimgs.jpg
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<big>'''[[Chikitsa Sthana]] Chapter 10. Management of Apasmara (Epilepsy and other disorders) </big>'''
<big>'''[[Chikitsa Sthana]] Chapter 10. Management of Apasmara (Seizure disorders) </big>'''
{{Infobox
{{Infobox
|title = Apasmara Chikitsa
|title = Apasmara Chikitsa
|label5 = Other Sections
|label5 = Other Sections
|data5 = [[Sutra Sthana]], [[Nidana Sthana]], [[Vimana Sthana]], [[Sharira Sthana]], [[Indriya Sthana]], [[Kalpa Sthana]], [[Siddhi Sthana]]
|data5 = [[Sutra Sthana]], [[Nidana Sthana]], [[Vimana Sthana]], [[Sharira Sthana]], [[Indriya Sthana]], [[Kalpa Sthana]], [[Siddhi Sthana]]
|label6 = Translator and commentator
|data6 = [[Yogesh Deole|Deole Y. S.]]
|label7 = Reviewer
|data7 = Bhagwat M., Tripathi J.S.
|label8 = Editors
|data8 = Baghel M.S., [[Yogesh Deole|Deole Y.S.]], [[Gopal Basisht|Basisht G.]]
|label9 = Year of publication
|data9 = 2020
|label10 = Publisher
|data10 = [[Charak Samhita Research, Training and Skill Development Centre]]
|label11 = DOI
|data11 = [https://doi.org/10.47468/CSNE.2020.e01.s06.011 10.47468/CSNE.2020.e01.s06.011]
}}
<big>'''Abstract</big>'''
<p style='text-align:justify;'>The tenth chapter deals with specific features of types of ''apasmara'' and its management. In continuation with the earlier explanation about causative factors, patho-physiology and clinical features have been described in [[Apasmara Nidana]], with another definition provided here in this chapter in greater detail.
<br/>Specific features of dominance of ''[[vata]], [[pitta]]'' and ''[[kapha]] [[dosha]]s'' are explained and involvement of exogenous factors is mentioned. Management of ''apasmara'' depending on the predominance of ''[[dosha]]s'', influence of ''agantu'' (exogenous) factors are explained. Special preparations like ''panchagavya ghrita, mahapanchagavya ghrita, jeevaneeya ghrita,'' various preparations for nasal administrations etc are given.
<br/>Etiological factors, pathogenesis, features and management of an important disease called ''atattvabhinivesha'' (a disease of perversion of intellect) are narrated. Importance of ''[[rasayana]]'' (rejuvenation) and protection of patient of ''unmada'' and ''apasmara'' are also emphasized. </p>
'''Keywords''': ''Apasmara'', memory, consciousness, epilepsy, ''atattvabhinivesha, unmada'', seizure disorders.
== Introduction ==
== Introduction ==
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All psychiatric and psycho-somatic diseases find their roots in the two chapters of ''unmada'' and ''apasmara''. These diseases are caused by similar etiological factors and both manifest as ''manasika vikara'' (psychiatric diseases). Therefore these two chapters are placed in succession. ''Mana'' (mind), ''buddhi'' (intellect), and ''smriti'' (memory) are integral parts combined with ''atma'' (self) in understanding Ayurvedic psychiatry. The series of pathological events that take place to occlude consciousness in heart and loss of memory is distinctive feature of ''apasmara''. As mentioned earlier in [[Apasmara Nidana]], first the aggravation of ''doshas'' at somatic level occurs by improper and impure/foul food and excess affliction of negative emotions like worries, passion, fright, anger, grief etc at psychic level. The disease precipitates in the form of paroxysmal attack, then the negative psychological emotions occlude the consciousness at heart and thereafter leading to loss of memory.
All psychiatric and psycho-somatic diseases find their roots in the two chapters of ''unmada'' and ''apasmara''. These diseases are caused by similar etiological factors and both manifest as ''manasika vikara'' (psychiatric diseases). Therefore these two chapters are placed in succession. ''[[Manas]]'' (mind), ''[[buddhi]]'' (intellect), and ''[[smriti]]'' (memory) are integral parts combined with ''[[atma]]'' (self) in understanding Ayurvedic psychiatry. The series of pathological events that take place to occlude consciousness in heart and loss of memory is distinctive feature of ''apasmara''. As mentioned earlier in [[Apasmara Nidana]], first the aggravation of ''[[dosha]]s'' at somatic level occurs by improper and impure/foul food and excess affliction of negative emotions like worries, passion, fright, anger, grief etc at psychic level. The disease precipitates in the form of paroxysmal attack, then the negative psychological emotions occlude the consciousness at heart and thereafter leading to loss of memory.
There is always a possibility of food contamination as a causative factor for epilepsy. A case in point is of endrin-laced taquitos causing seizures in the United States<ref>
There is always a possibility of food contamination as a causative factor for epilepsy. A case in point is of endrin-laced taquitos causing seizures in the United States<ref>
Waller K, Prendergast TJ, Slagle A, Jackson RJ. Seizures after eating a snack food contaminated with the pesticide endrin. The tale of the toxic taquitos. Western Journal of Medicine. 1992;157(6):648-651.</ref>. Balance between ''sattva, rajas'' and ''tamas'' is important by avoiding the stressors that precipitate the episode of ''apasmara''. Various animal products like ghee processed with medicinal herbs are utilized for medicine preparation.
Waller K, Prendergast TJ, Slagle A, Jackson RJ. Seizures after eating a snack food contaminated with the pesticide endrin. The tale of the toxic taquitos. Western Journal of Medicine. 1992;157(6):648-651.</ref>. Balance between ''[[sattva]], [[rajas]]'' and ''[[tamas]]'' is important by avoiding the stressors that precipitate the episode of ''apasmara''. Various animal products like ghee processed with medicinal herbs are utilized for medicine preparation.
''Atattvabhinivesha'' is another disease specially mentioned in this chapter. It is termed as the single major disease ,i.e., ''mahagada,'' leading to affliction of mind and intellect. Its management is also mentioned in this context.
''Atattvabhinivesha'' is another disease specially mentioned in this chapter. It is termed as the single major disease ,i.e., ''mahagada,'' leading to affliction of mind and intellect. Its management is also mentioned in this context.
== Sanskrit text, Transliteration and English Translation ==
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Now we shall expound the chapter "Apasmara Chikitsa"(Management of Epilepsy and other disorders). Thus said Lord Atreya. [1-2]
=== Definition of ''apasmara'' ===
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The expert physicians call ''apasmara'' as 'going away of memory' characterized by black-outs (feeling of entering into darkness) and revolting movements caused by conglomeration of the intellect and the mind. [3]
The expert physicians call ''apasmara'' as 'going away of memory' characterized by black-outs (feeling of entering into darkness) and revolting movements caused by conglomeration of the intellect and the mind. [3]
=== Etiopathology ===
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''Apasmara'' occurs in those persons, in whom:
''Apasmara'' occurs in those persons, in whom:
#The ''doshas'' are excessively aggravated and have spread to other sites (''vibhranta'') due to (habitual) intake of improper/harmful and impure/contaminated food.
#The ''[[dosha]]s'' are excessively aggravated and have spread to other sites (''vibhranta'') due to (habitual) intake of improper/harmful and impure/contaminated food.
#In whom, the ''sattva'' (one of the attributes of mind representing purity and consciousness) is suppressed by ''rajas'' (attribute of the mind representing energy and dynamism) and ''tamas'' (attribute of the mind representing passivity and ignorance) ;
#In whom, the ''[[sattva]]'' (one of the attributes of mind representing purity and consciousness) is suppressed by ''[[rajas]]'' (attribute of the mind representing energy and dynamism) and ''[[tamas]]'' (attribute of the mind representing passivity and ignorance) ;
#The heart (site of consciousness) is obscured by aggravated ''doshas''; and
#The heart (site of consciousness) is obscured by aggravated ''[[dosha]]s''; and
#Mind is distressed or annihilated by (affliction of negative emotions like) worry, passion, fright, anger, grief, anxiety etc. [4-5]
#Mind is distressed or annihilated by (affliction of negative emotions like) worry, passion, fright, anger, grief, anxiety etc. [4-5]
=== Pathogenesis and features of pre-ictal phase ===
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(By the above mentioned factors) ''doshas'' located in the vessels (or ''dhamani'', channels that carry nutrients) afflict the heart. Thus person suffers due to bewildered mind.[6]
(By the above mentioned factors) ''[[dosha]]s'' located in the vessels (or ''dhamani'', channels that carry nutrients) afflict the heart. Thus person suffers due to bewildered mind.[6]
He visualizes non-existent forms (visual hallucinations), falls down, his tongue, eyes and eyebrows become tremulous, saliva discharges from his mouth, his hands and legs are extended / bent.[7]
He visualizes non-existent forms (visual hallucinations), falls down, his tongue, eyes and eyebrows become tremulous, saliva discharges from his mouth, his hands and legs are extended / bent.[7]
=== Post-ictal phase of ''apasmara'' ===
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When the surge of ''doshas'' is over, he wakes up as if he is getting up from sleep (regains consciousness). [8]
When the surge of ''[[dosha]]s'' is over, he wakes up as if he is getting up from sleep (regains consciousness). [8]
=== Types of ''apasmara'' ===
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''Apasmara'' is of four types including those due to separate ''doshas'' (''vata, pitta'' and ''kapha'') and due to combination of all (''sannipatika''). [8]
''Apasmara'' is of four types including those due to separate ''[[dosha]]s'' (''[[vata]], [[pitta]]'' and ''[[kapha]]'') and due to combination of all (''sannipatika''). [8]
=== Features (Ictal phase) ===
==== ''Apasmara'' with ''[[vata]]'' dominance ====
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''Vatika apasmara'' is characterized by trembling, grinding of teeth, frothing from the mouth, and gasping. The patient gets visual hallucinations of objects which are rough, reddish brown or black in color. [9]
''Vatika apasmara'' is characterized by trembling, grinding of teeth, frothing from the mouth, and gasping. The patient gets visual hallucinations of objects which are rough, reddish brown or black in color. [9]
==== ''Apasmara'' with ''[[pitta]]'' dominance ====
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''Paittika apasmara'' is characterized by yellowish froth, body, face and eyes. He gets visual hallucinations of yellow or blood-red objects. He has thirst, hot sensation (sensation of heat), and sees fire all over his surroundings. [10]
''Paittika apasmara'' is characterized by yellowish froth, body, face and eyes. He gets visual hallucinations of yellow or blood-red objects. He has thirst, hot sensation (sensation of heat), and sees fire all over his surroundings. [10]
==== ''Apasmara'' with ''[[kapha]]'' dominance ====
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The ''shlaishmika apasmara'' is characterized by whitish froth (from the mouth), body, face and eyes, (feeling of) cold, heaviness due to stiff body. The patient gets hallucinations of white objects and recovers late. [11]
The ''shlaishmika apasmara'' is characterized by whitish froth (from the mouth), body, face and eyes, (feeling of) cold, heaviness due to stiff body. The patient gets hallucinations of white objects and recovers late. [11]
==== ''Apasmara'' with mixed features of all ''[[dosha]]'' dominance and prognosis ====
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''Tridoshaja apasmara'' is characterized by manifestation of all of above features at the same time. This type of ''apasmara'' is incurable. The ''apasmara'', which occurs in emaciated person and in chronic stage, is also incurable. [12]
''Tridoshaja apasmara'' is characterized by manifestation of all of above features at the same time. This type of ''apasmara'' is incurable. The ''apasmara'', which occurs in emaciated person and in chronic stage, is also incurable. [12]
=== Diagnosis as per frequency of seizures ===
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The vitiated ''doshas'' lead to paroxysms of ''apasmara'' once in fifteen days, twelve days or a month. The paroxysm may occur even after a shorter period.[13]
The vitiated ''[[dosha]]s'' lead to paroxysms of ''apasmara'' once in fifteen days, twelve days or a month. The paroxysm may occur even after a shorter period.[13]
=== Management of ''apasmara'' ===
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The heart, channels and mind which are obstructed by ''doshas'' shall rouse up or cleared first by strong remedial measures like ''vamana'' (emetic therapy) etc. [14]
The heart, channels and mind which are obstructed by ''[[dosha]]s'' shall rouse up or cleared first by strong remedial measures like ''[[vamana]]'' (emetic therapy) etc. [14]
=== Purification based on ''dosha'' dominance ===
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''Vatika apasmara'' shall be treated mainly with ''basti'' (medicated enema) therapy; ''Paittika apasmara'' shall mainly be treated with ''virechana'' (purgation) therapy and ''shlaishmika apasmara'' shall mainly be treated with ''vamana'' (emesis) therapy.[15]
''Vatika apasmara'' shall be treated mainly with ''[[basti]]'' (medicated enema) therapy; ''Paittika apasmara'' shall mainly be treated with ''[[virechana]]'' (purgation) therapy and ''shlaishmika apasmara'' shall mainly be treated with ''[[vamana]]'' (emesis) therapy.[15]
=== Assurance and counselling therapy ===
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After proper purification is done by all above therapies and well assurance is given, the pacification formulations for relief from ''apasmara'' are described henceforth.[16]
After proper purification is done by all above therapies and well assurance is given, the pacification formulations for relief from ''apasmara'' are described henceforth.[16]
=== ''Panchagavya ghee'' ===
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==== Ingredients of ''panchagavya ghee'' ====
Juice of cow dung, sour curd prepared out of cow's milk, cow's urine in equal quantity and cow’s ghee.
Juice of cow dung, sour curd prepared out of cow's milk, cow's urine in equal quantity and cow’s ghee.
==== Indications ====
The medicated ghee shall be taken for treating ''apasmara, kamala'' (jaundice) and ''jwara''.[17]
The medicated ghee shall be taken for treating ''apasmara, kamala'' (jaundice) and ''[[jwara]]''.[17]
=== ''Mahapanchagavya ghee'' ===
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==== Ingredients of ''mahapanchagavya ghee'' ====
Two ''palas'' (80 gms) of each of :
Two ''palas'' (80 gms) of each of :
Shampaka (aragvadha), root of phalgu (kasthodu-mbarika), pushkaramula and duralabha should be added with two dronas (in the recipe actually one drona is described; it has to be taken double in quantity according to definition) of water, boiled and reduced to one fourth. One aksha [12 gm each of]: The paste of bharangi, patha, shunthi, maricha, pippali, trivrita, nichula (hijjala), shreyasi (hastipippali), adhaki, murva, danti, bhunimba; chitraka, shveta sariva, krishna sariva, rohisha, bhutika and madayantika along with prior said decoction, two prasthas [640 ml] of cow's ghee should be cooked by adding two prasthas of each of the juice of cow-dung, sour curd prepared of cow's milk, cow's milk and cow's urine, This medicated ghee, known as mahapancagavya is like ambrosia in the treatment (of following)[18-22]
Shampaka (aragvadha), root of phalgu (kasthodu-mbarika), pushkaramula and duralabha should be added with two dronas (in the recipe actually one drona is described; it has to be taken double in quantity according to definition) of water, boiled and reduced to one fourth. One aksha [12 gm each of]: The paste of bharangi, patha, shunthi, maricha, pippali, trivrita, nichula (hijjala), shreyasi (hastipippali), adhaki, murva, danti, bhunimba; chitraka, shveta sariva, krishna sariva, rohisha, bhutika and madayantika along with prior said decoction, two prasthas [640 ml] of cow's ghee should be cooked by adding two prasthas of each of the juice of cow-dung, sour curd prepared of cow's milk, cow's milk and cow's urine, This medicated ghee, known as mahapancagavya is like ambrosia in the treatment (of following)[18-22]
==== Indications ====
Apasmara (epilepsy), unmada (insanity), shvayathu (edema), udara (obstinate abdominal diseases including ascitis), gulma (abdominal lumps), arshas (piles), pandu (anemia), kamala (jaundice) and halimaka (a serious type of jaundice).
Apasmara (epilepsy), unmada (insanity), shvayathu (edema), udara (obstinate abdominal diseases including ascitis), gulma (abdominal lumps), arshas (piles), pandu (anemia), kamala (jaundice) and halimaka (a serious type of jaundice).
This medicated ghee should be used regularly every day to dispel inauspiciousness and evil effects of bad planets. It also cures chaturthaka (quartan) type of vishama jwara (irregular fever).[23-24]
This medicated ghee should be used regularly every day to dispel inauspiciousness and evil effects of bad planets. It also cures chaturthaka (quartan) type of vishama jwara (irregular fever).[23-24]
=== ''Brahmi ghee'' ===
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Cow's ghee processed with the juice of ''brahmi,vacha, kushtha'' and ''shankhapushpi'' cures ''unmada, alaksmi'' (inauspiciousness), ''apasmara'' and ''papa'' (effects of sins, or evil deeds). [25]
Cow's ghee processed with the juice of ''brahmi,vacha, kushtha'' and ''shankhapushpi'' cures ''unmada, alaksmi'' (inauspiciousness), ''apasmara'' and ''papa'' (effects of sins, or evil deeds). [25]
=== ''Saindhava hingu ghee'' ===
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Cow's ghee (one part) should be cooked by adding (in total) four parts of the urine of bull and goat and the paste of rock salt and asafoetida (l/4th part in total). This medicated ghee cures ''apasmara'' (epilepsy), heart diseases and diseases caused by the evil effects of planetary misalignment.[26]
Cow's ghee (one part) should be cooked by adding (in total) four parts of the urine of bull and goat and the paste of rock salt and asafoetida (l/4th part in total). This medicated ghee cures ''apasmara'' (epilepsy), heart diseases and diseases caused by the evil effects of planetary misalignment.[26]
=== ''Vacha-shampakadi ghee'' ===
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Ghee (one part) should be cooked with the paste of ''vacha, shampaka, kaitarya'' (''parvata nimba''), ''vayastha'' (''guduchi''), ''hingu, choraka'' and ''palankasha'' or ''guggulu'' (1/4th part in total). (Four parts of water should be added according to the general rule, because in present recipe, there is no liquid). This medicated ghee is useful in the treatment of ''vatika'' and ''shlaishmika'' types of epilepsy. [27]
Ghee (one part) should be cooked with the paste of ''vacha, shampaka, kaitarya'' (''parvata nimba''), ''vayastha'' (''guduchi''), ''hingu, choraka'' and ''palankasha'' or ''guggulu'' (1/4th part in total). (Four parts of water should be added according to the general rule, because in present recipe, there is no liquid). This medicated ghee is useful in the treatment of ''vatika'' and ''shlaishmika'' types of epilepsy. [27]
=== ''Jivaniya Yamaka Sneha'' ===
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Two ''prasthas'' of ghee should be added with one ''kamsa'' of each of milk and sugarcane juice; sixteen ''prasthas'' of the decoction of ''kasmarya'' and one ''karsa'' of each of the ten drugs belonging to ''jivaniya'' group (vide Sutra 4: 9) and cooked. This medicated ghee instantaneously cures epilepsy caused by ''vayu'' and ''pitta''.[29]
Two ''prasthas'' of ghee should be added with one ''kamsa'' of each of milk and sugarcane juice; sixteen ''prasthas'' of the decoction of ''kasmarya'' and one ''karsa'' of each of the ten drugs belonging to ''jivaniya'' group (vide Sutra 4: 9) and cooked. This medicated ghee instantaneously cures epilepsy caused by ''[[vata]]'' and ''[[pitta]]''.[29]
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Two ''prasthas'' of ghee should be cooked by adding two ''dronas'' of juice of ''amalaki'' and two ''palas'' of the paste of ''madhuka''. This medicated ghee instantaneously cures the ''paittika'' type of ''apasmara'' (epilepsy). [31]
Two ''prasthas'' of ghee should be cooked by adding two ''dronas'' of juice of ''amalaki'' and two ''palas'' of the paste of ''madhuka''. This medicated ghee instantaneously cures the ''paittika'' type of ''apasmara'' (epilepsy). [31]
=== Drugs for external application ===
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Juice of ''apetarakshasi'' (''tulasi''), ''kushtha, putanakeshi'' (''jatamansi'') and ''choraka'' should be triturated by adding (cow's or goat's) urine and made to a paste. This should be used as unction (for the treatment of epilepsy). The body of the patient should be sprinkled with the urine (of cow or goat).[39]
Juice of ''apetarakshasi'' (''tulasi''), ''kushtha, putanakeshi'' (''jatamansi'') and ''choraka'' should be triturated by adding (cow's or goat's) urine and made to a paste. This should be used as unction (for the treatment of epilepsy). The body of the patient should be sprinkled with the urine (of cow or goat).[39]
=== Different unction formulations ===
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#ashes of the hair in the tail of the cow. [40]
#ashes of the hair in the tail of the cow. [40]
=== Drugs for ''[[nasya]]'' (nasal errhines) ===
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Oil (one part) should be cooked with goat’s urine (four parts) and the paste of ''haritaki, bibhitaki, amalaki, shunthi, pippali, maricha, pitadru'' (''devadaru''), ''yavakshara, phaninjhaka, shyama, apamarga'' and fruits of ''karanja''. (One fourth part in total). Inhalation of this medicated oil cures ''apasmara'' (epilepsy).[43-44]
Oil (one part) should be cooked with goat’s urine (four parts) and the paste of ''haritaki, bibhitaki, amalaki, shunthi, pippali, maricha, pitadru'' (''devadaru''), ''yavakshara, phaninjhaka, shyama, apamarga'' and fruits of ''karanja''. (One fourth part in total). Inhalation of this medicated oil cures ''apasmara'' (epilepsy).[43-44]
=== ''Pradhamana [[nasya]]'' formulation ===
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The powder of ''pippali, vrishchikali, kushtha, saindhava, lavana, sauvarchala lavana, samudra lavana, vida lavana, audbhida lavana'' (vide sutra 1:88-89) and ''bhargi'' should be administered in the form of ''pradhamana nasya'' (in which powders of drugs are blown into the nostrils of the patient.) This is an excellent recipe (for curing epilepsy).[45]
The powder of ''pippali, vrishchikali, kushtha, saindhava, lavana, sauvarchala lavana, samudra lavana, vida lavana, audbhida lavana'' (vide sutra 1:88-89) and ''bhargi'' should be administered in the form of ''pradhamana [[nasya]]'' (in which powders of drugs are blown into the nostrils of the patient.) This is an excellent recipe (for curing epilepsy).[45]
=== Medicated wicks ===
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(For the treatment of epilepsy), the physician should give fumigation therapy with the help of the beaks, feather and stool of mongoose, owl, cat, vulture, ''kita'' (scorpion etc), snake and crow. [51]
(For the treatment of epilepsy), the physician should give fumigation therapy with the help of the beaks, feather and stool of mongoose, owl, cat, vulture, ''kita'' (scorpion etc), snake and crow. [51]
=== Effects of therapy ===
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With the help of these therapies, the heart of the patient gets stimulated and the channels get cleansed as a result of which the patient regains consciousness.[52]
With the help of these therapies, the heart of the patient gets stimulated and the channels get cleansed as a result of which the patient regains consciousness.[52]
=== Treatment of ''Aagantu apasmara'' ===
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In some patients of epilepsy, exogenous factors are secondarily involved and in such cases signs and symptoms are manifested over and above those of the ''doshas'' (endogenous factors). Such patients should be treated on the lines suggested for exogenous types of ''unmada'' (insanity) (refer to Chapter 9 of this section, i.e., [[Unmada Chikitsa]]).[53].
In some patients of epilepsy, exogenous factors are secondarily involved and in such cases signs and symptoms are manifested over and above those of the ''[[dosha]]s'' (endogenous factors). Such patients should be treated on the lines suggested for exogenous types of ''unmada'' (insanity) (refer to Chapter 9 of this section, i.e., [[Unmada Chikitsa]]).[53].
=== ''Mahagada chikitsa'' (management of ''atattvabhinivesha'') ===
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Having heard this, Lord Punarvasu addressed his disciple who was desirous of hearing and said, "My child, hear about this ''mahagada'' (grave disease) along with its etiology, signs and symptoms and treatment". [56]
Having heard this, Lord Punarvasu addressed his disciple who was desirous of hearing and said, "My child, hear about this ''mahagada'' (grave disease) along with its etiology, signs and symptoms and treatment". [56]
=== Etiopathology and clinical features of ''atattvabhinivesha'' ===
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If a person is indulged in habitual intake of impure food, due to suppression of manifested natural urges, excessive intake of cold, hot, unctuous, un-unctuous food (incompatible food with contradictory properties) etc, the (vitiated) ''doshas'' afflict channels of mind and intellect and abide into heart. The ''rajas'' (one of the attributes of the mind) and ''moha'' or ''tamas'' (another attribute of mind), occlude the person’s self. Excessively aggravated ''rajas'' and ''tamas'' cover mind and intellect, disturbing the functions of heart, making the person stupid and mentally weak. This leads to improper judgment regarding eternal and ephemeral events and wholesome and unwholesome objects. The expert physicians call this ''mahagada'' (grave disease) as ''atattvabhinivesha''. [57- 60]
If a person is indulged in habitual intake of impure food, due to suppression of manifested natural urges, excessive intake of cold, hot, unctuous, un-unctuous food (incompatible food with contradictory properties) etc, the (vitiated) ''[[dosha]]s'' afflict channels of mind and intellect and abide into heart. The ''[[rajas]]'' (one of the attributes of the mind) and ''moha'' or ''[[tamas]]'' (another attribute of mind), occlude the person’s self. Excessively aggravated ''[[rajas]]'' and ''[[tamas]]'' cover mind and intellect, disturbing the functions of heart, making the person stupid and mentally weak. This leads to improper judgment regarding eternal and ephemeral events and wholesome and unwholesome objects. The expert physicians call this ''mahagada'' (grave disease) as ''atattvabhinivesha''. [57- 60]
=== Management of ''atattvabhinivesha'' ===
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This (disease) shall be treated with oleation and fomentation therapies followed by purification therapies like therapeutic emesis etc. Then after doing ''samsarjana krama'' (observing specific dietary regimen after purification), diet and drinks which are promoters of intellect should be administered. Juice of ''brahmi'' mixed with ''panchagavya ghrita'' described above (refer to verses 16-17) should be administered. Similarly, other ''medhya rasayanas'' (promoters of intellect) like ''shankhapushpi'' should be given. [61- 62]
This (disease) shall be treated with oleation and fomentation therapies followed by purification therapies like therapeutic emesis etc. Then after doing ''samsarjana krama'' (observing specific dietary regimen after purification), diet and drinks which are promoters of intellect should be administered. Juice of ''brahmi'' mixed with ''panchagavya ghrita'' described above (refer to verses 16-17) should be administered. Similarly, other ''medhya [[rasayana]]s'' (promoters of intellect) like ''shankhapushpi'' should be given. [61- 62]
Friends, sympathizers, preceptors preaching religious sermons, philosophers should inculcate into him knowledge, understanding, patience, memory and the power of meditation. [63]
Friends, sympathizers, preceptors preaching religious sermons, philosophers should inculcate into him knowledge, understanding, patience, memory and the power of meditation. [63]
#powder of ''vacha'' with honey.[64]
#powder of ''vacha'' with honey.[64]
=== Prognosis ===
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If the disease ''apasmara'' is resistant to conventional modes of treatment, if it is chronic and if it has acquired a firm footing, then it should be generally treated with the foregoing recipes of rejuvenating drugs. [65]
If the disease ''apasmara'' is resistant to conventional modes of treatment, if it is chronic and if it has acquired a firm footing, then it should be generally treated with the foregoing recipes of rejuvenating drugs. [65]
=== Protection of patients and precautionary measures ===
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#Etiological factors of epilepsy;
#Etiological factors of epilepsy;
#the mode of vitiation of ''doshas'';
#the mode of vitiation of ''[[dosha]]s'';
#signs and symptoms in general and of different varieties of epilepsy;
#signs and symptoms in general and of different varieties of epilepsy;
#treatment of different types of epilepsy; and
#treatment of different types of epilepsy; and
#Improper and impure diet is considered to affect mental functions adversely leading to formation of background for disease. The dietary causative factors may act on gut-brain axis to affect the neuro-pathology in case of psychiatric diseases like ''apasmara''.
#Improper and impure diet is considered to affect mental functions adversely leading to formation of background for disease. The dietary causative factors may act on gut-brain axis to affect the neuro-pathology in case of psychiatric diseases like ''apasmara''.
#When this afflicted person is confronted with distressful adverse situation including negative emotions like worries, passion, fright, anger, grief, anxieties, he suffers from ''apasmara''.
#When this afflicted person is confronted with distressful adverse situation including negative emotions like worries, passion, fright, anger, grief, anxieties, he suffers from ''apasmara''.
#The pathophysiology clearly indicates role of somatic imbalances and psychic disturbances as sequential events. The inter-communication between physical entities and psychological entities is very important for continuation of health. Consciousness flows through this co-ordination to make a person alive. Therefore, when this co-ordination is disturbed, it presents as disturbance of psychological faculties. The pathology of ''apasmara'' starts with vitiated ''dosha'' and ends into bewildered state of mind.
#The pathophysiology clearly indicates role of somatic imbalances and psychic disturbances as sequential events. The inter-communication between physical entities and psychological entities is very important for continuation of health. Consciousness flows through this co-ordination to make a person alive. Therefore, when this co-ordination is disturbed, it presents as disturbance of psychological faculties. The pathology of ''apasmara'' starts with vitiated ''[[dosha]]'' and ends into bewildered state of mind.
#Heart (center of consciousness and emotional intelligence) and brain (center of memory and logical intelligence) together form ''manovaha srotas'' (functional system of mind). The co-ordination of these two centers is important for normal functioning of mind. If this is afflicted, it leads to psychiatric diseases.
#Heart (center of consciousness and emotional intelligence) and brain (center of memory and logical intelligence) together form ''manovaha srotas'' (functional system of mind). The co-ordination of these two centers is important for normal functioning of mind. If this is afflicted, it leads to psychiatric diseases.
#Removal of obstruction of ''dosha'' in the heart-brain connection, channels and mind by strong purification therapies is management principle of ''apasmara''.
#Removal of obstruction of ''[[dosha]]'' in the heart-brain connection, channels and mind by strong purification therapies is management principle of ''apasmara''.
#''Basti'' (therapeutic enema) in ''vata'' dominant ''apasmara, virechana'' (therapeutic purgation) in ''pitta'' dominant ''apasmara'' and ''vamana'' (therapeutic emesis) in ''kapha'' dominant ''apasmara'' are specific therapies.
#''[[Basti]]'' (therapeutic enema) in ''[[vata]]'' dominant ''apasmara, [[virechana]]'' (therapeutic purgation) in ''[[pitta]]'' dominant ''apasmara'' and ''[[vamana]]'' (therapeutic emesis) in ''[[kapha]]'' dominant ''apasmara'' are specific therapies.
#''Ashwasana'' (assurance therapy) and psychological counseling are advised to remove psychological stressors that provoke ''apasmara vega''(episode).
#''Ashwasana'' (assurance therapy) and psychological counseling are advised to remove psychological stressors that provoke ''apasmara vega''(episode).
=== ''Vidhi Vimarsha'' / Applied Inferences===
== Vidhi Vimarsha (Applied Inferences ) ==
The first principle of [[Ayurveda]] states that life is continuum of healthy coordination between body, mind, soul and sensory-motor organs. [[Ayurveda]] considers the mind and body work in symbiotic relationship with each other. When one is affected, other is also affected. Both are emphasized as abode for sensation of pain. The mind and body can’t be separated in water tight compartment.
The first principle of [[Ayurveda]] states that life is continuum of healthy coordination between body, mind, soul and sensory-motor organs. [[Ayurveda]] considers the mind and body work in symbiotic relationship with each other. When one is affected, other is also affected. Both are emphasized as abode for sensation of pain. The mind and body can’t be separated in water tight compartment.
=== Relation between diet, ''[[dosha]]'' specificity and ''apasmara'' ===
Role of pure diet is important, because it nourishes mind, enriches senses and motor organs. The ''Panchakosha'' theory of Yoga states that the sheath of mind (''manomaya kosha'') is nourished through sheath of food (''annamaya kosha'') only. Therefore, following proper, pure diet and dietary habits is necessary for preventing psychiatric disorders.
Role of pure diet is important, because it nourishes mind, enriches senses and motor organs. The ''Panchakosha'' theory of Yoga states that the sheath of [[Manas|mind]] (''manomaya kosha'') is nourished through sheath of food (''annamaya kosha'') only. Therefore, following proper, pure [[Dietary guidelines|diet and dietary habits]] is necessary for preventing psychiatric disorders.
The physical ''doshas'' like ''vata, pitta'' and ''kapha'' are assigned certain psychological functions also. Their rise and accumulation takes place at different stage after taking food. Therefore, the type of disease depending upon type of dominant ''dosha,'' evoked due to dominant diet specific to a particular ''dosha''. ''Apasmara'' is also caused due to vitiation of ''dosha'' owing to improper diet. This clarifies link between diet, ''dosha,'' mental functions, memory and consciousness.
The physical ''[[dosha]]s'' like ''[[vata]], [[pitta]]'' and ''[[kapha]]'' are assigned certain psychological functions also. Their rise and accumulation takes place at different stage after taking food. Therefore, the type of disease depending upon type of dominant ''[[dosha]],'' evoked due to dominant diet specific to a particular ''[[dosha]]''. ''Apasmara'' is also caused due to vitiation of ''[[dosha]]'' owing to improper diet. This clarifies link between diet, ''[[dosha]],'' mental functions, memory and consciousness.
==== Memory and consciousness ====
=== [[Memory]] and [[consciousness]] ===
The profound relation between memory and consciousness is clearly indicated in ''apasmara''. In [[Ayurveda]], memory is termed as fundamental knowledge based upon experiences acquired through sense and motor organs. In psychology, memory is the mental capacity with which information is encoded, stored, and retrieved. Consciousness is the state of awareness of internal events and external environment.<ref>Available from glossary of psychological terms retrived from http://www.apa.org/research/action/glossary.aspx?tab=3 on August 22, 2017</ref> In ''apasmara'', consciousness is affected leading to transient loss of memory.
The profound relation between [[memory]] and [[consciousness]] is clearly indicated in ''apasmara''. In [[Ayurveda]], memory is termed as fundamental knowledge based upon experiences acquired through sense and motor organs. In psychology, memory is the mental capacity with which information is encoded, stored, and retrieved. Consciousness is the state of awareness of internal events and external environment.<ref>Available from glossary of psychological terms retrived from http://www.apa.org/research/action/glossary.aspx?tab=3 on August 22, 2017</ref> In ''apasmara'', consciousness is affected leading to transient loss of memory.
The forbearance of mind is based upon intellect (''dhi'') and pure quality of mind (''sattva''). ''Dhi'' discriminates between right and wrong things. ''Sattva'' is pure quality that might be named as “mental immunity” which protects mind in all adverse conditions. In ''apasmara'', both the intellect and pure quality of mind are afflicted leading to poor forbearance.
The forbearance of mind is based upon intellect (''dhi'') and pure quality of mind (''sattva''). ''Dhi'' discriminates between right and wrong things. ''[[Sattva]]'' is pure quality that might be named as “mental immunity” which protects mind in all adverse conditions. In ''apasmara'', both the intellect and pure quality of mind are afflicted leading to poor forbearance.
=== Brain and heart connection Neurocardiology ===
Heart (cardiac region) has been considered as site of consciousness and emotions. The heart in context of ''apasmara'' is essentially meant by the abode of consciousness and it doesn’t signify anatomical heart. This is functional heart which is involved in emotions, feelings of the self. Brain (head region) is considered as origin of all sensory and motor organs. The term ''dhamani'' has been used to denote abode of aggravated ''doshas''. This literally means the artery, vein, nerves which carry impulses. This is very important as it channelizes consciousness from site of consciousness i.e. heart to site of intelligence i.e. brain. This canal of heart-brain connection is ''manovaha srotas''. The brain and heart work in co-ordination with each other for maintaining equilibrium between logical intelligence and emotional intelligence. If these are hampered, the consciousness, memory, sensory and motor co-ordination as well as emotional behavior will be affected. This establishes the theory that disturbance in cardiac functions can result into neurological disorders. The heart-brain connection has been authenticated by many researches on neuro-cardiology.<ref>Martin A. Samuels, Contemporary Reviews in Cardiovascular Medicine,The Brain–Heart Connection. Circulation.2007; 116: 77-84 doi: 10.1161/CIRCULATIONAHA.106.678995 </ref>
Heart (cardiac region) has been considered as site of consciousness and emotions. The heart in context of ''apasmara'' is essentially meant by the abode of consciousness and it doesn’t signify anatomical heart. This is functional heart which is involved in emotions, feelings of the self. Brain (head region) is considered as origin of all sensory and motor organs. The term ''dhamani'' has been used to denote abode of aggravated ''[[dosha]]s''. This literally means the artery, vein, nerves which carry impulses. This is very important as it channelizes consciousness from site of consciousness i.e. heart to site of intelligence i.e. brain. This canal of heart-brain connection is ''manovaha srotas''. The brain and heart work in co-ordination with each other for maintaining equilibrium between logical intelligence and emotional intelligence. If these are hampered, the consciousness, memory, sensory and motor co-ordination as well as emotional behavior will be affected. This establishes the theory that disturbance in cardiac functions can result into neurological disorders. The heart-brain connection has been authenticated by many researches on neuro-cardiology.<ref>Martin A. Samuels, Contemporary Reviews in Cardiovascular Medicine,The Brain–Heart Connection. Circulation.2007; 116: 77-84 doi: 10.1161/CIRCULATIONAHA.106.678995 </ref>
The theory of heart-brain connection has been well known to [[Ayurveda]] scholars in context of ''apasmara''.
The theory of heart-brain connection has been well known to [[Ayurveda]] scholars in context of ''apasmara''.
=== Signs and symptoms of ''apasmara'' ===
Transient nervous system collapse of a person which leads to various signs and symptoms enlisted in the verses 7 to 13. The cluster describes features of paroxysmal stage of ''apasmara''. The features include somatic as well as psychological subjective symptoms experienced by patients self. The dreams specific to predominance of ''dosha'' can be important measures for diagnosis of predominance of ''dosha''. The symptomatology has been described elaborately in context of [[Apasmara Nidana]].
Transient nervous system collapse of a person which leads to various signs and symptoms enlisted in the verses 7 to 13. The cluster describes features of paroxysmal stage of ''apasmara''. The features include somatic as well as psychological subjective symptoms experienced by patients self. The dreams specific to predominance of ''[[dosha]]'' can be important measures for diagnosis of predominance of ''[[dosha]]''. The symptomatology has been described elaborately in context of [[Apasmara Nidana]].
=== Gut-brain connection in ''apasmara'' ===
[[File:Bidirectionalgut-brainaxis.png|500px|thumb]]
Gut-brain dysfunction is proved to play role in many psychiatric disorders like depression, anxiety, autism, schizophrenia.<ref>https://www.psychologytoday.com/blog/evolutionary-psychiatry/201404/the-gut-brain-connection-mental-illness-and-disease accessed on 13/09/2016 </ref>
Gut-brain dysfunction is proved to play role in many psychiatric disorders like depression, anxiety, autism, schizophrenia.<ref>https://www.psychologytoday.com/blog/evolutionary-psychiatry/201404/the-gut-brain-connection-mental-illness-and-disease accessed on 13/09/2016 </ref>
The figure shows physiology of gut-brain connection [fig. ]. As discussed earlier in [[Apasmara Nidana]], many of the somatic symptoms are related with the dysfunction of gastrointestinal tract.Therefore the possibility of gut-brain dysfunction cannot be denied.
The figure shows physiology of gut-brain connection. As discussed earlier in [[Apasmara Nidana]], many of the somatic symptoms are related with the dysfunction of gastrointestinal tract.Therefore the possibility of gut-brain dysfunction cannot be denied.
Similarly, as seen above, many of the animal products like medicines formulated with cow’s urine, cow’s ghee, goat urine that are rich in micro-organisms are enlisted in management of ''apasmara''. The exact pharmaco-dynamic behind action of these medicines in management of ''apasmara'' with focus on gut-brain axis needs to be investigated.
Similarly, as seen above, many of the animal products like medicines formulated with cow’s urine, cow’s ghee, goat urine that are rich in micro-organisms are enlisted in management of ''apasmara''. The exact pharmaco-dynamic behind action of these medicines in management of ''apasmara'' with focus on gut-brain axis needs to be investigated.
=== Etio-Pathogenesis of ''Atattvabhinivesha'' ===
The grave disease ''atattvabhinivesha'' is considered as affliction of discrimination power of intellect leading to severe perversion of mental functions. The pathophysiology includes affliction of mind and intellect simultaneously. Therefore this disease comprises disturbance of mind and intellectual functioning. Decisive and discriminative power of the afflicted person is completely lost. This leads to improper judgment regarding eternal and ephemeral events and wholesome and unwholesome objects. Coordination of mind, intellect, sense-motor organs is disturbed.
The grave disease ''atattvabhinivesha'' is considered as affliction of discrimination power of intellect leading to severe perversion of mental functions. The pathophysiology includes affliction of mind and intellect simultaneously. Therefore this disease comprises disturbance of mind and intellectual functioning. Decisive and discriminative power of the afflicted person is completely lost. This leads to improper judgment regarding eternal and ephemeral events and wholesome and unwholesome objects. Coordination of mind, intellect, sense-motor organs is disturbed.
=== Patho-physiology of ''atattvabhinivesha'' ===
[[File:dietlifestyle.png|500px]]
[[File:dietlifestyle.png|500px]]
==== Differential diagnosis ====
The diseases with convulsive movements of the body and loss of memory can be considered for differential diagnosis for ''apasmara''. Though ''apasmara'' is a ''manasa vikara'', the diseases with presentation of ''kampa''(tremors), ''gatra vikshepa'' (abnormal body movements), ''vepathu''(trembling), etc in the form of paroxysms can be thought of for discussion under differential diagnosis. They include ''akshepaka'' (''vata vyadhi''), ''dandaka'' (stiffness), ''ardita'' (facial palsy or hemeparesis), ''apatanaka'' (status epilepticus), ''apatantraka'' (opisthotomus) and ''vepathu'' (''kampavata'', or tremors).
The diseases with convulsive movements of the body and loss of memory can be considered for differential diagnosis for ''apasmara''. Though ''apasmara'' is a ''manasa vikara'', the diseases with presentation of ''kampa''(tremors), ''gatra vikshepa'' (abnormal body movements), ''vepathu''(trembling), etc in the form of paroxysms can be thought of for discussion under differential diagnosis. They include ''akshepaka'' (''vata vyadhi''), ''dandaka'' (stiffness), ''ardita'' (facial palsy or hemeparesis), ''apatanaka'' (status epilepticus), ''apatantraka'' (opisthotomus) and ''vepathu'' (''kampavata'', or tremors).
''Dandaka'' is denoted in the same context as ''stambha'' (stiffness) manifested in ''pani'' (hands), ''pada'' (legs), ''shira'' (head), ''prishtha'' (back) and ''shroni'' (pelvis) making body stiff like wooden log. (verse52)
''Dandaka'' is denoted in the same context as ''stambha'' (stiffness) manifested in ''pani'' (hands), ''pada'' (legs), ''shira'' (head), ''prishtha'' (back) and ''shroni'' (pelvis) making body stiff like wooden log. (verse52)
''Ardita'' caused when ''vayu'' does ''upashoshana'' (dries up) of ''bahu'' (arm), ''pada'' (leg) and ''janu'' (knees), is characterized by ''vakrata'' (curved) of ''mukhardha bhaga'' (half face) and also ''shareerardha'' (torso). The attacks of ''ardita'' do not include convulsions as presenting feature. (Verses 38 to 42)
''Ardita'' caused when ''[[vayu]]'' does ''upashoshana'' (dries up) of ''bahu'' (arm), ''pada'' (leg) and ''janu'' (knees), is characterized by ''vakrata'' (curved) of ''mukhardha bhaga'' (half face) and also ''shareerardha'' (torso). The attacks of ''ardita'' do not include convulsions as presenting feature. (Verses 38 to 42)
''Apatanaka'' is also a disease caused by vitiated ''vata'' either independently or due to ''avarana'' (obstruction) caused by ''kapha'' characteristically manifests with frequent unconsciousness, ''antarayama'' (forward bending of the body) and ''bahirayama'' (backward bending of the body). Because of this bending the disease is otherwise known as ''dhanustambha''. (Verses 43 to 48)
''Apatanaka'' is also a disease caused by vitiated ''[[vata]]'' either independently or due to ''avarana'' (obstruction) caused by ''[[kapha]]'' characteristically manifests with frequent unconsciousness, ''antarayama'' (forward bending of the body) and ''bahirayama'' (backward bending of the body). Because of this bending the disease is otherwise known as ''dhanustambha''. (Verses 43 to 48)
''Vepathu'' or ''kampa vata'' are characterized by ''kampa'' (tremor) of either single part/multiple parts/entire body.
''Vepathu'' or ''kampa vata'' are characterized by ''kampa'' (tremor) of either single part/multiple parts/entire body.
In any of the above explained conditions either the involvement of ''hridaya'' (heart) or ''manas''(mind) are not specified. Hence they implicate more of neurological pathology rather than psychological disorder.
In any of the above explained conditions either the involvement of ''hridaya'' (heart) or ''[[manas]]''(mind) are not specified. Hence they implicate more of neurological pathology rather than psychological disorder.
''Apatantraka'' , explained in [[Trimarmiya Siddhi]](verses 12 to 15), is very similar to the description of apasmara here in its clinical presentation. ''Avarana'' of ''hridaya'' by ''doshas'' lead to paroxysm of the ''vyadhi'' with pain in ''shira, shankha'' body bending like a bow, ''akshepa'' (convulsions), dyspnea, hoarse expiratory cry like that of a pigeon, unconsciousness, etc. Once the ''avarana'' to ''hridaya'' by the ''doshas'' is clear the person looks healthy.
''Apatantraka'' , explained in [[Trimarmiya Siddhi]](verses 12 to 15), is very similar to the description of apasmara here in its clinical presentation. ''Avarana'' of ''hridaya'' by ''[[dosha]]s'' lead to paroxysm of the ''vyadhi'' with pain in ''shira, shankha'' body bending like a bow, ''akshepa'' (convulsions), dyspnea, hoarse expiratory cry like that of a pigeon, unconsciousness, etc. Once the ''avarana'' to ''hridaya'' by the ''[[dosha]]s'' is clear the person looks healthy.
''Apatantraka'' is a ''hridaya marmashrita vyadhi'' which indicates variation in emotional intelligence of the person.The theory of neuro-cardiology differentiates ''apatantraka'' from ''apasmara'' the latter being a disorder of logical intelligence (''smriti budhi sattva samplavat''- ch. Ni. 8/5)
''Apatantraka'' is a ''hridaya marmashrita vyadhi'' which indicates variation in emotional intelligence of the person. The theory of neuro-cardiology differentiates ''apatantraka'' from ''apasmara'' the latter being a disorder of logical intelligence (''smriti budhi sattva samplavat''- ch. Ni. 8/5)
''Apasmara'' is emphasized as ''manasa vikara'' due to loss of ''smriti'' (power of recollection), ''buddhi vyapoha'' (declining of logical and analytical understanding). The person becomes ''moodha'' (stupid). This holds appropriate to say “the loss of logical intelligence in the person”.
''Apasmara'' is emphasized as ''[[manas]]a vikara'' due to loss of ''[[smriti]]'' (power of recollection), ''[[buddhi]] vyapoha'' (declining of logical and analytical understanding). The person becomes ''moodha'' (stupid). This holds appropriate to say “the loss of logical intelligence in the person”.
==== Management of ''apasmara'' ====
The holistic management of ''apasmara'' includes three stages as discussed below:
The holistic management of ''apasmara'' includes three stages as discussed below:
==== I. Purification therapies ====
''Apasmara'' is to be treated with strong elimination therapies like [[Panchakarma]]. The strength here directs towards deeper level of penetrability of the therapies to remove the toxins from micro-channels.
''Apasmara'' is to be treated with strong elimination therapies like [[Panchakarma]]. The strength here directs towards deeper level of penetrability of the therapies to remove the toxins from micro-channels.
Important pathological milestone is occlusion of consciousness. Therefore to remove obstruction at heart (site of consciousness), channels of heart-brain connection, and mind is the treatment objective. ''Vata'' dominant ''apasmara'' is to be treated with medicated enema, ''pitta'' dominant with purgation therapies and ''kapha'' dominant with therapeutic emesis.
Important pathological milestone is occlusion of consciousness. Therefore to remove obstruction at heart (site of consciousness), channels of heart-brain connection, and mind is the treatment objective. ''[[Vata]]'' dominant ''apasmara'' is to be treated with medicated enema, ''[[pitta]]'' dominant with purgation therapies and ''[[kapha]]'' dominant with therapeutic emesis.
Role of these purification treatments like ''vamana'', etc. in normalizing functioning of heart (consciousness mechanism and emotional intelligence), heart-brain connection, and mental functions is important to be studied. This may prove a major breakthrough in prevention and management of psychiatric disorders. The changes in memory/awareness level, mind functioning, emotional quotient, improvement in forbearance power are bio-markers for the assessment.
Role of these purification treatments like ''[[vamana]]'', etc. in normalizing functioning of heart (consciousness mechanism and emotional intelligence), heart-brain connection, and mental functions is important to be studied. This may prove a major breakthrough in prevention and management of psychiatric disorders. The changes in memory/awareness level, mind functioning, emotional quotient, improvement in forbearance power are bio-markers for the assessment.
==== II. Assurance and consolation therapies ====
The episodes of ''apasmara'' occur on exposure of distressful events or psychological trauma due to negative emotions like worries, passion, fright, anger, grief, anxieties etc. This indicates poor emotional quotient. Affliction of mental ''dosha'' like ''rajas'' and ''tamas'' also need to be corrected basically. Therefore it is important to improve the emotional intelligence through positive training and programming of mind and brain to cope with the adverse situation. If the mental immunity is good, then ''apasmara'' episode will not occur, even if, the bodily ''doshas'' are aggravated. Cognitive Behaviour Therapy (CBT), REBT (Rational Emotive Behaviour Therapy) can be useful supportive treatments for management of ''apasmara'' to reduce frequency of episodes as well as effective management of disorder.
The episodes of ''apasmara'' occur on exposure of distressful events or psychological trauma due to negative emotions like worries, passion, fright, anger, grief, anxieties etc. This indicates poor emotional quotient. Affliction of mental ''[[dosha]]'' like ''[[[rajas]]'' and ''[[tamas]]'' also need to be corrected basically. Therefore it is important to improve the emotional intelligence through positive training and programming of mind and brain to cope with the adverse situation. If the mental immunity is good, then ''apasmara'' episode will not occur, even if, the bodily ''[[doshas]]'' are aggravated. Cognitive Behaviour Therapy (CBT), REBT (Rational Emotive Behaviour Therapy) can be useful supportive treatments for management of ''apasmara'' to reduce frequency of episodes as well as effective management of disorder.
==== III. Pacification (''shamana'') therapy ====
After purification and consolation therapies are done, various formulations useful in treatment of ''apasmara'' have been enlisted. If we see the general medicines prescribed by Charak, all of the formulations are either ghee based or oil based formulations. Ghee is considered as best vehicle for management of ''vata-pitta'' dominant disorders. Oil is the best for ''vata-kapha'' dominant disorders. Ghee has been proved to be effective in treatment of many neurological disorders owing to its capacity of maintaining cellular integrity.
After purification and consolation therapies are done, various formulations useful in treatment of ''apasmara'' have been enlisted. If we see the general medicines prescribed by Charak, all of the formulations are either ghee based or oil based formulations. Ghee is considered as best vehicle for management of ''[[vata]]-[[pitta]]'' dominant disorders. Oil is the best for ''[[vata]]-[[kapha]]'' dominant disorders. Ghee has been proved to be effective in treatment of many neurological disorders owing to its capacity of maintaining cellular integrity.
The animal products like ghee, urine, bile are used in most of the formulations. Cow’s ghee and goat’s urine is widely used as processing media for formulations. The route of administration is ''nasya'' (nasal drug delivery), ''anjana'' (for intra-ocular drug delivery through conjunctivae), and ''dhupana'' (fumigation). The properties of drugs used are mainly pungent to ensure higher penetrability in lower dosages. The possibility of crossing blood brain barrier with these routes might be higher for the herbs used in ''apasmara'' treatment.
The animal products like ghee, urine, bile are used in most of the formulations. Cow’s ghee and goat’s urine is widely used as processing media for formulations. The route of administration is ''[[nasya]]'' (nasal drug delivery), ''anjana'' (for intra-ocular drug delivery through conjunctivae), and ''dhupana'' (fumigation). The properties of drugs used are mainly pungent to ensure higher penetrability in lower dosages. The possibility of crossing blood brain barrier with these routes might be higher for the herbs used in ''apasmara'' treatment.
The formulations used in treatment are enlisted below:
The formulations used in treatment are enlisted below:
|}
|}
'''''Vata shlaishma apasmarahara vacha – shampakadi ghrita'''''
'''''[[Vata]] shlaishma apasmarahara vacha – shampakadi ghrita'''''
{| class="wikitable"
{| class="wikitable"
|-
|-
| Milk
| Milk
| rowspan = "2"| 1 "kamsa" in total
| rowspan = "2"| 1 "kamsa" in total
| rowspan = "3"| Instantaneously cures epilepsy caused by ''vayu'' and ''pitta''
| rowspan = "3"| Instantaneously cures epilepsy caused by ''[[vata]]'' and ''[[pitta]]''
|-
|-
| 2
| 2
|}
|}
'''Different formulations for ''nasya'' (nasal drug delivery) (verse 41)'''
'''Different formulations for ''[[nasya]]'' (nasal drug delivery) (verse 41)'''
{| class="wikitable"
{| class="wikitable"
|-
|-
| Urine of cow having reddish brown (''Kapila'') color
| Urine of cow having reddish brown (''Kapila'') color
| QS
| QS
| ''Nasya'' (nasal delivery)- Exceedingly useful for the cure of epilepsy
| ''[[Nasya]]'' (nasal delivery)- Exceedingly useful for the cure of epilepsy
|-
|-
| 2
| 2
| Urine of dog
| Urine of dog
|
|
| ''Nasya'' (nasal delivery)
| ''[[Nasya]]'' (nasal delivery)
|-
|-
| 3
| 3
| Urine of Jackal
| Urine of Jackal
|
|
| ''Nasya'' (nasal delivery)
| ''[[Nasya]]'' (nasal delivery)
|-
|-
| 4
| 4
| Urine of Cat
| Urine of Cat
|
|
| ''Nasya'' (nasal delivery)
| ''[[Nasya]]'' (nasal delivery)
|-
|-
| 5
| 5
| Urine of Lion
| Urine of Lion
|
|
| ''Nasya'' (nasal delivery)
| ''[[Nasya]]'' (nasal delivery)
|}
|}
'''''Nasya'' formulations (verse 42-43)'''
'''''[[Nasya]]'' formulations (verse 42-43)'''
{| class="wikitable"
{| class="wikitable"
|-
|-
|}
|}
'''''Nasya'' formulations (verse 43-44)'''
'''''[[Nasya]]'' formulations (verse 43-44)'''
{| class="wikitable"
{| class="wikitable"
|-
|-
| Oil
| Oil
| 1 part
| 1 part
| ''Nasya''
| ''[[Nasya]]''
|-
|-
| 2
| 2
'''''Pradhamana nasya'' formulations (verse 45)'''
'''''Pradhamana [[nasya]]'' formulations (verse 45)'''
{| class="wikitable"
{| class="wikitable"
| Powder of ''Pippali, Vrishchikali, Kushtha, Saindhava Lavana, Sauvarchala lavana, Samudra lavana, Vida lavana, Audbhida lavana'' (vide sutra 1:88-89) and ''Bhargi''
| Powder of ''Pippali, Vrishchikali, Kushtha, Saindhava Lavana, Sauvarchala lavana, Samudra lavana, Vida lavana, Audbhida lavana'' (vide sutra 1:88-89) and ''Bhargi''
|
|
| In the form of ''pradhamana nasya'' (in which powders of drugs are blown into the nostrils of the patient)
| In the form of ''pradhamana [[nasya]]'' (in which powders of drugs are blown into the nostrils of the patient)
|}
|}
| ''Apasmara''
| ''Apasmara''
|}
|}
==Researches on Apasmara==
=== Apasmara (epilepsy) and its management with maha-panchagavya ghrita===
In a clinical study, maha panchagavya ghrita was given orally in a dose of 10 gms two times a day in first group (group A) of patients diagnosed with apasmara (epilepsy). In other group B, 3 gm of vachadi vati was given three times in a day with water in control group. The patients were enrolled and randomly categorized into two groups. The results of group A showed significant relief in the ictal features and post-ictal features of amnesia (61.3%) and drowsiness (50%). The frequency of attacks was significantly reduced from average of 1.75 times/week to 0.96 time/week. The overall effect showed that 25% patients had complete remission in group A. In the group B, significant relief was obtained in each of the pre-ictal features of loss of [[sleep]]. Relief in total post-ictal features (55.6%) was also significant. During follow up, the frequency of attacks was reduced to 50% in 33% of the patients, to 25% in 41.7% of the patients of group B. The above results imply that the maha panchagavya ghrita was comparatively better on the main clinical event, i.e., the ictal stage, and on the frequency, duration, and severity of attacks. It was more effective in maintaining the seizure threshold.<ref>Usha K. S. (2001). A clinical study on apasmara (epilepsy) and its management with Maha-Panchagavya Ghrita. Department of Kayachikitsa. IPGT & RA, Jamnagar.</ref>
=== Review of kushmanda ghrita in the management of Generalized Tonic-Clonic Seizures (GTCS)===
Kushmanda ghrita is mentioned in Ashtanga Hridaya for the management of Epilepsy (Apasmara). It is one of the best anti-epileptics (apasmarahara) drug consisting of mainly three drugs such as [[kushmanda]] (Benincasa hispida), [[yashtimadhu]] (Glycyrrhiza glabra L.) and cow’s ghee (go-ghrita). It possesses digestive stimulant, anti-convulsant, strength promoting, and [[memory]] enhancing properties. Antiepileptic drugs appear to act primarily by blocking the initiation or spread of seizures. This occurs through a variety of mechanisms that modify the activity of ion channels or neurotransmitters. Experimental studies have proven that [[kushmanda]] swarasa (fruit extract) has antioxidant activity on the human brain. Vitamin–B present in [[kushmanda]] has a direct impact on energy levels, brain functioning, and cell metabolism. It also reduces fatigue and boosts mood. The seeds of Benincasa hispida (Thunb.) Cogn. is enriched with GABA and helps in seizure control action. The antioxidant and neuroprotective effect root of [[yashtimadhu]] protects susceptible brain cells from oxidative stress, resulting in reduced brain damage and improved neuronal function with improvement in memory. The ketone bodies, β- hydroxybutyrate, aceto-acetate, and acetone are synthesized and are able to cross the blood-brain barrier to provide an alternative source of energy for the brain. Compared to the conventional AEDs, a similar action can be obtained through this synergism in [[Kushmanda]] ghrita. [[Kushmanda]] Ghrita is a unique combination that can be practiced in chronic cases of GTCS and acts as a rasayana. Ghee preparations are considered the foremost medium for delivering the active principles in neurological conditions affecting the brain because of their ability to cross the blood-brain barrier. Ghee is a good processing medium since it will carry the active principles of the processed drugs to the target tissue, also it will act as medicine by itself with its innate property called ‘yogavahi’. Ghee obtained from cow’s milk consists of short-chain and medium-chain fatty acids. Ketone bodies produced as a secondary metabolite from fat metabolism are proven to have anticonvulsant activity. As all three drugs present in kushmanda ghrita are [[memory]] boosting (medhya) and kushmanda act as alleviates diseases of brain (cheto-vikaranashaka). The GABA rich property of kushmanda, Na+ K+ channel inhibition property of yashtimadhu, and the ketogenic effect of ghrita act as a perfect trio in generalized tonic-clonic seizure management and thereby highlighting its uniqueness.<ref>Krishna Priya G., Vijay Bhaskar S. A Critical Review of Kushmanda ghrita in the management of Generalized Tonic-Clonic Seizures. International Journal of Advanced Research (IJAR). 2022; 10 (07), 479-483.</ref>
===Ayurvedic management of apasmara w.s.r. to epilepsy- A Case Report===
This study is regarding a case report of a 17-year-old male patient having ‘apasmara’ (epilepsy) came with symptoms such as mental irritation, disturbed sleep, mental impairment (dhee), grasping (dhriti), and memory (smriti). Previously, the patient used to get 2- 3 seizure attacks per day, which gradually increased in 10 years. The patient also complained of frequent jerking movements of both arms and neck, and loss of [[consciousness]] during attack. For treatment, both purificatory therapy ([[shodhana]]) and palliative therapy (shamana) was planned. For [[shodhana]], medicated enema ([[matra basti]]) with 120 ml narayana oil for 20 days, nasal instillation of medicated drugs in powder form (pradhaman [[nasya]]) with [[vacha]] (Acorus calamus Linn.) and [[shunthi]] (Zingiber officinale) powder, twice a day for 20 days. For shamana, oral administration of different formulations was given such as juice of benincasa hispida ([[kushmanda]] swarasa) with [[yashtimadhu]] churna (Glycyrrhiza glabra) - 40 ml × twice a day for 8 days, further combination of smrutisagara rasa + juice of Centella asiatica ([[mandukaparni]] rasa) with honey- 500 mg, twice a day for 8 days, combination of chaturbhuja rasa + smrutisagara rasa + [[bramhi]] vati + saraswata vati with mahakalyanaka ghruta- 500 mg, twice a day for 30 days and raupya suvarna sutshekhara rasa 250 mg, twice a day for 30 days. In this case study, the treatment included ayurvedic medications, bio-purification ([[panchakarma]]) and [[shamana]] with yoga, pranayama, and asana. [[Panchakarma]] and internal ayurveda medicines work surprisingly with remarkable improvement in this patient. Shamana treatment along with pradhmana [[nasya]], and [[matra basti]], are observed safe without any interactions and adverse effects in the treatment in apasmara in this case study.<ref>Srajan Madhur Jain, Harish Garge, Shripad Upasani et al. Ayurvedic management of Apasmara w. s. r. to epilepsy - a case report. Ayurlog: National Journal of Research in Ayurved Science- 2021; (09) (04): 01-06. </ref>
===Therapeutic potential of [[ayurveda]] treatment ([[panchakarma]] and herbal medicine) in epilepsy in children ===
This case study is reported on a child suffering from epilepsy for the last 12 years. The first episode of seizure developed at age 1 year and 6 months, since then anti-epileptic medicines were started. Treatment modalities adopted for this case are as follows; digestive power stimulant and digestant ([[deepana]]-[[pachana]]) with chitrakadi vati- 1 BD before meal and avipattikar powder- 1 tsf with warm water at night for 1 day only. Further whole body massage (sarvanga [[snehana]]) by bala oil and whole body sudation (sarvanga [[swedana]]) and medicated unctuous enema ([[matra basti]]) for 7 days by 20 ml of kalyanaka ghrita was given. Small amount of [[vacha]] (acorus calamus) was added with kalyanaka ghrita for [[matra basti]]. Afterwards internal medicines such as dhandhanyadi decoction (kashaya) TID orally and brihatvata-chintamani rasa-1 tab.BD and siddharthaka tablet-1 tab BD. Previous ongoing allopathic medicine Epilex (Sodium Valproate) 200mg 1 tsp BD after meal for 30 days, then syp. epilex were stopped. Above treatment was again repeated with gap of 15 days and oral medication are continued for 2 months. In short for 2 Months this treatment was done i.e., 4 times with 15 days follow up. [[Deepana]]- [[pachana]] was given to control the formation of [[ama]] in the initial stage, which is very important in preventing the manifestation of the disease. Acharya Charak has mentioned bio-purification ([[shodhana]]) as a line of treatment, so in this case study [[matra basti]] with kalyanaka ghrita and shiroabhyanga with [[bramhi]] ghrita chikitsa has been chosen. They showed good results. Special scoring pattern were made to assess the efficacy of treatment, the details of which are as follows; the severity of attack and duration of convulsion reduced from score 2 before treatment to score zero i.e., complete relief in symptoms of epilepsy. The frequency of convulsion and ictal features were reduced from score 1 before treatment to score zero i.e., complete relief in symptoms of epilepsy. It means panchakarma treatment and internal ayurvedic medicine were given and proves to be effective in the management of apasmara and to improve the quality of life of the affected children. This treatment modality found to be significantly effective in this case of paediatric epilepsy and patient got relief. <ref>Lowkesh Chandravanshi, Aparna Singh. Therapeutic potential of Ayurvedic Treatment (Panchkarma and Herbal Medicine) in Pediatric Epilepsy: A Case Report. International Journal of Health and Rehabilitation Sciences. Volume 7, Issue 3, Sep. 2018; 155-160. </ref>
===Efficacy of Shatavari taila [[nasya]] and internal administration of [[brahmi]] ghrita in the management of apasmara===
Apasmara (epilepsy) is a disease affecting the higher center, i.e., the brain, so just oral administration is not possible to get the desired result. So, management of this disorder should be done through various modalities and routes of drug administration. One such non-oral route is [[nasya]] i.e., that is administering of powdered or liquid medicament into the nostrils. [[Shatavari]] (Asparagus Racemosus) oil was selected for this study which has different herbs like seeds of [[eranda]] (Ricinus communis), [[ashwagandha]] (Withania somnifera), and ksheeravidari kanda (Prureria tuberosa). All these are indicated in management of apasmara. The ingredients of [[brahmi]] ghrita are [[brahmi]] (Bacopa monieri), [[vacha]] (Acorus calamus), [[kushtha]] (Saussurea lappa), [[shankhapushpi]] (Convolulus pluricaulis) and age old ghee (purana ghrita). These herbs are also individually proven better in internal medication (shamana aushadhi).
Total 34 diagnosed patients of apasmara fulfilling the inclusion criteria and willing to register for study were enrolled for this study for the duration of 2 months. Assessment was done before and after the study period the clinical features of epilepsy by International League against Epilepsy (ILAE), patients were screened and selected according to the diagnostic criteria and a single group study was conducted. They were administered [[nasya]] with [[shatavari]] taila for seven days and later subjected to [[shamana]] therapy by [[brahmi]] ghrita. The patients were analysed after nasya at the end of seven days and later on every consecutive 15th day, for a period of two months. Frequency of the attacks were reduced after seven days of [[nasya]]. Consequently, improvements were observed in the complaints of loss of consciousness, where 93.3% reported them before treatment and after [[nasya]] it was found to be just 3.3% of the patient and later after the [[shamana]] treatment, it was found to have reduced in 76% of the patient. Convulsive movements were reported by 96% of the patient, which at the end of total therapy was found to reduce to 16.7%. Fall, epileptic cry, frothing from mouth and chattering of teeth were significantly (p < 0.001) reduced by the end of follow up period of 2 months. Similar observations were made in case of duration and severity of attacks. Epilepsy (apasmara) is an extensively researched disease and its management has just reached a stage where only seizures can be controlled. Some difficulties arise, in terms of the route of drug administration during the active state of convulsion where the conventional routes are difficult to access or inaccessible. Hence in this study, an easier route of administration i.e., nasal route was explored, for providing management with better outcome, for epilepsy. <ref>Sharmitesh R Tripathi, Savitha HP, Suhas Kumar Shetty. Efficacy of Shatavari taila Nasya and Brahmi gritha in the management of Apasmara. J Pharm Sci Innov. 2016;5(6), 181-18.</ref>
=== Related Chapter ===
=== Related Chapter ===
[[Apasmara Nidana]],[[Manas]], [[Aatma]], [[Smriti]], [[Indriya]], [[Psychiatric diseases]], [[Neurological diseases]]
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== References ==
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