Apasmara Chikitsa

Apasmara Chikitsa

Section/Chapter	Chikitsa Sthana Chapter 10
Preceding Chapter	Unmada Chikitsa
Succeeding Chapter	Kshatakshina Chikitsa
Other Sections	Sutra Sthana, Nidana Sthana, Vimana Sthana, Sharira Sthana, Indriya Sthana, Kalpa Sthana, Siddhi Sthana

(Chikitsa Sthana Chapter 10, Chapter on the Management of Apasmara)

Abstract

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.

Specific features of dominance of vata, pitta and kapha doshas are explained and involvement of exogenous factors is mentioned. Management of apasmara depending on the predominance of doshas, influence of agantu (exogenous) factors are explained. Special preparations like panchagavya ghrita, mahapanchagavya ghrita, jeevaneeya ghrita, various preparations for nasal administrations etc are given.

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.

Keywords: Apasmara, memory, consciousness, epilepsy, atattvabhinivesha, unmada.

Introduction

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.

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 US. In the same way, balance between sattva, rajas and tamas is important by avoiding the stressors that precipitate the apasmara attack. 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.

Sanskrit text, Transliteration and English Translation

अपस्मारचिकित्सितोपक्रमः अथातोऽपस्मारचिकित्सितं व्याख्यास्यामः||१||

इति ह स्माह भगवानात्रेयः||२||

athātō'pasmāracikitsitaṁ vyākhyāsyāmaḥ||1||

iti ha smāha bhagavānātrēyaḥ||2||

athAto~apasmAracikitsitaM vyAkhyAsyAmaH||1|| iti ha smAha bhagavAnAtreyaH||2||

We shall now describe in detail the medical treatment of apasmara (epilepsy). Thus said Lord Atreya. [1-2]

Definition of apasmara

स्मृतेरपगमं प्राहुरपस्मारं भिषग्विदः| तमःप्रवेशं बीभत्सचेष्टं धीसत्त्वसम्प्लवात्||३||

smr̥tērapagamaṁ prāhurapasmāraṁ bhiṣagvidaḥ| tamaḥpravēśaṁ bībhatsacēṣṭaṁ dhīsattvasamplavāt||3||

smRuterapagamaM prAhurapasmAraM bhiShagvidaH| tamaHpraveshaM bIbhatsaceShTaM dhIsattvasamplavAt||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

विभ्रान्तबहुदोषाणामहिताशुचिभोजनात् [१] | रजस्तमोभ्यां विहते सत्त्वे दोषावृते हृदि||४||

चिन्ताकामभयक्रोधशोकोद्वेगादिभिस्तथा| मनस्यभिहते नॄणामपस्मारः प्रवर्तते||५||

vibhrāntabahudōṣāṇāmahitāśucibhōjanāt [1] | rajastamōbhyāṁ vihatē sattvē dōṣāvr̥tē hr̥di||4||

cintākāmabhayakrōdhaśōkōdvēgādibhistathā| manasyabhihatē nr̥̄ṇāmapasmāraḥ pravartatē||5||

vibhrAntabahudoShANAmahitAshucibhojanAt [1] | rajastamobhyAM vihate sattve doShAvRute hRudi||4||

cintAkAmabhayakrodhashokodvegAdibhistathA| manasyabhihate nRUNAmapasmAraH pravartate||5||

Apasmara occurs in those persons, in whom:

1. The doshas are excessively aggravated and have spread to other sites (vibhranta) due to (habitual) intake of improper/harmful and impure/contaminated food.
2. In whom, the sattva (one of the attributes of mind representing purity and consciousness) is suppressed by rajas (another attribute of the mind representing energy and dynamism) and tamas (the third attribute of the mind representing passivity and ignorance) ;
3. The heart (site of consciousness) is obscured by aggravated doshas; and
4. Mind is distressed or annihilated by (affliction of negative emotions like) worry, passion, fright, anger, grief, anxiety etc. [4-5]

Pathogenesis and pre-ictal features (phase of aura)

धमनीभिः श्रिता दोषा हृदयं पीडयन्ति हि| सम्पीड्यमानो व्यथते मूढो भ्रान्तेन चेतसा||६||

पश्यत्यसन्ति रूपाणि पतति प्रस्फुरत्यपि| जिह्वाक्षिभ्रूः स्रवल्लालो हस्तौ पादौ च विक्षिपन्||७||

dhamanībhiḥ śritā dōṣā hr̥dayaṁ pīḍayanti hi| sampīḍyamānō vyathatē mūḍhō bhrāntēna cētasā||6||

paśyatyasanti rūpāṇi patati prasphuratyapi| jihvākṣibhrūḥ sravallālō hastau pādau ca vikṣipan||7||

dhamanIbhiH shritA doShA hRudayaM pIDayanti hi| sampIDyamAno vyathate mUDho bhrAntena cetasA||6||

pashyatyasanti rUpANi patati prasphuratyapi| jihvAkShibhrUH sravallAlo hastau pAdau ca vikShipan||7||

(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]

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

दोषवेगे च विगते सुप्तवत् प्रतिबुद्ध्यते|

dōṣavēgē ca vigatē suptavat pratibuddhyatē|

doShavege ca vigate suptavat pratibuddhyate|

When the surge of doshas is over, he wakes up as if he is getting up from sleep (regains consciousness). [8]

Types of apasmara

पृथग्दोषैः समस्तैश्च वक्ष्यते स चतुर्विधः||८||

pr̥thagdōṣaiḥ samastaiśca vakṣyatē sa caturvidhaḥ||8||

pRuthagdoShaiH samastaishca vakShyate sa caturvidhaH||8||

Apasmara is of four types including those due to separate doshas (vata, pitta and kapha) and due to combination of all (sannipatika). [8]

Features (Ictal phase)

Apasmara with vata dominance

कम्पते प्रदशेद्दन्तान् फेनोद्वामी श्वसित्यपि| परुषारुणकृष्णानि पश्येद्रूपाणि चानिलात्||९||

kampatē pradaśēddantān phēnōdvāmī śvasityapi| paruṣāruṇakr̥ṣṇāni paśyēdrūpāṇi cānilāt||9||

kampate pradasheddantAn phenodvAmI shvasityapi| paruShAruNakRuShNAni pashyedrUpANi cAnilAt||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

पीतफेनाङ्गवक्त्राक्षः पीतासृग्रूपदर्शनः| सतृष्णोष्णानलव्याप्तलोकदर्शी च पैत्तिकः||१०||

pītaphēnāṅgavaktrākṣaḥ pītāsr̥grūpadarśanaḥ| satr̥ṣṇōṣṇānalavyāptalōkadarśī ca paittikaḥ||10||

pItaphenA~ggavaktrAkShaH pItAsRugrUpadarshanaH| satRuShNoShNAnalavyAptalokadarshI ca paittikaH||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

शुक्लफेनाङ्गवक्त्राक्षः शीतो हृष्टाङ्गजो गुरुः| पश्यञ्छुक्लानि रूपाणि श्लैष्मिको मुच्यते चिरात्||११||

śuklaphēnāṅgavaktrākṣaḥ śītō hr̥ṣṭāṅgajō guruḥ| paśyañchuklāni rūpāṇi ślaiṣmikō mucyatē cirāt||11||

shuklaphenA~ggavaktrAkShaH shIto hRuShTA~ggajo guruH| pashya~jchuklAni rUpANi shlaiShmiko mucyate cirAt||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

सर्वैरेतैः समस्तैस्तु लिङ्गैर्ज्ञेयस्त्रिदोषजः| अपस्मारः स चासाध्यो यः क्षीणस्यानवश्च यः||१२||

sarvairētaiḥ samastaistu liṅgairjñēyastridōṣajaḥ| apasmāraḥ sa cāsādhyō yaḥ kṣīṇasyānavaśca yaḥ||12||

sarvairetaiH samastaistu li~ggairj~jeyastridoShajaH| apasmAraH sa cAsAdhyo yaH kShINasyAnavashca yaH||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

पक्षाद्वा द्वादशाहाद्वा मासाद्वा कुपिता मलाः| अपस्माराय कुर्वन्ति वेगं किञ्चिदथान्तरम्||१३||

pakṣādvā dvādaśāhādvā māsādvā kupitā malāḥ| apasmārāya kurvanti vēgaṁ kiñcidathāntaram||13||

pakShAdvA dvAdashAhAdvA mAsAdvA kupitA malAH| apasmArAya kurvanti vegaM ki~jcidathAntaram||13||

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]

Management of apasmara

तैरावृतानां हृत्स्रोतोमनसां सम्प्रबोधनम्| तीक्ष्णैरादौ भिषक् कुर्यात् कर्मभिर्वमनादिभिः||१४||

tairāvr̥tānāṁ hr̥tsrōtōmanasāṁ samprabōdhanam| tīkṣṇairādau bhiṣak kuryāt karmabhirvamanādibhiḥ||14||

tairAvRutAnAM hRutsrotomanasAM samprabodhanam| tIkShNairAdau bhiShak kuryAt karmabhirvamanAdibhiH||14||

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]

Purification based on dosha dominance

वातिकं बस्तिभूयिष्ठैः पैत्तं प्रायो विरेचनैः| श्लैष्मिकं वमनप्रायैरपस्मारमुपाचरेत्||१५|| vātikaṁ bastibhūyiṣṭhaiḥ paittaṁ prāyō virēcanaiḥ| ślaiṣmikaṁ vamanaprāyairapasmāramupācarēt||15|| vAtikaM bastibhUyiShThaiH paittaM prAyo virecanaiH| shlaiShmikaM vamanaprAyairapasmAramupAcaret||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

सर्वतः सुविशुद्धस्य सम्यगाश्वासितस्य च| अपस्मारविमोक्षार्थं योगान् संशमनाञ्छृणु||१६|| sarvataḥ suviśuddhasya samyagāśvāsitasya ca| apasmāravimōkṣārthaṁ yōgān saṁśamanāñchr̥ṇu||16|| sarvataH suvishuddhasya samyagAshvAsitasya ca| apasmAravimokShArthaM yogAn saMshamanA~jchRuNu||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

गोशकृद्रसदध्यम्लक्षीरमूत्रैः समैर्घृतम्| सिद्धं पिबेदपस्मारकामलाज्वरनाशनम्||१७|| इति पञ्चगव्यं घृतम् gōśakr̥drasadadhyamlakṣīramūtraiḥ samairghr̥tam| siddhaṁ pibēdapasmārakāmalājvaranāśanam||17|| iti pañcagavyaṁ ghr̥tam

goshakRudrasadadhyamlakShIramUtraiH samairghRutam| siddhaM pibedapasmArakAmalAjvaranAshanam||17|| iti pa~jcagavyaM ghRutam

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.

Indications: The medicated ghee shall be taken for treating apasmara, kamala (jaundice) and jwara.[17]

Mahapanchagavya ghee

द्वे पञ्चमूल्यौ त्रिफला रजन्यौ कुटजत्वचम्| सप्तपर्णमपामार्गं नीलिनीं कटुरोहिणीम्||१८|| शम्पाकं फल्गुमूलं च पौष्करं सदुरालभम्| द्विपलानि जलद्रोणे पक्त्वा पादावशेषिते||१९|| भार्गीं पाठां त्रिकटुकं त्रिवृतां निचुलानि च| श्रेयसीमाढकीं मूर्वां दन्तीं भूनिम्बचित्रकौ||२०|| द्वे सारिवे रोहिषं च भूतीकं मदयन्तिकाम्| क्षिपेत्पिष्ट्वाऽक्षमात्राणि तेन प्रस्थं घृतात् पचेत्||२१|| गोशकृद्रसदध्यम्लक्षीरमूत्रैश्च तत्समैः| पञ्चगव्यमिति ख्यातं महत्तदमृतोपमम्||२२|| अपस्मारे तथोन्मादे श्वयथावुदरेषु च| गुल्मार्शःपाण्डुरोगेषु कामलायां हलीमके||२३|| शस्यते घृतमेतत्तु प्रयोक्तव्यं दिने दिने| अलक्ष्मीग्रहरोगघ्नं चातुर्थकविनाशनम्||२४|| इति महापञ्चगव्यं घृतम् dvē pañcamūlyau triphalā rajanyau kuṭajatvacam| saptaparṇamapāmārgaṁ nīlinīṁ kaṭurōhiṇīm||18|| śampākaṁ phalgumūlaṁ ca pauṣkaraṁ sadurālabham| dvipalāni jaladrōṇē paktvā pādāvaśēṣitē||19|| bhārgīṁ pāṭhāṁ trikaṭukaṁ trivr̥tāṁ niculāni ca| śrēyasīmāḍhakīṁ mūrvāṁ dantīṁ bhūnimbacitrakau||20|| dvē sārivē rōhiṣaṁ ca bhūtīkaṁ madayantikām| kṣipētpiṣṭvā'kṣamātrāṇi tēna [1] prasthaṁ ghr̥tāt pacēt||21|| gōśakr̥drasadadhyamlakṣīramūtraiśca tatsamaiḥ| pañcagavyamiti khyātaṁ mahattadamr̥tōpamam||22|| apasmārē tathōnmādē [2] śvayathāvudarēṣu ca| gulmārśaḥpāṇḍurōgēṣu kāmalāyāṁ halīmakē||23|| śasyatē ghr̥tamētattu prayōktavyaṁ dinē dinē| alakṣmīgraharōgaghnaṁ cāturthakavināśanam||24|| iti mahāpañcagavyaṁ ghr̥tam

dve pa~jcamUlyau triphalA rajanyau kuTajatvacam| saptaparNamapAmArgaM nIlinIM kaTurohiNIm||18|| shampAkaM phalgumUlaM ca pauShkaraM sadurAlabham| dvipalAni jaladroNe paktvA pAdAvasheShite||19|| bhArgIM pAThAM trikaTukaM trivRutAM niculAni ca| shreyasImADhakIM mUrvAM dantIM bhUnimbacitrakau||20|| dve sArive rohiShaM ca bhUtIkaM madayantikAm| kShipetpiShTvA~akShamAtrANi tena [1] prasthaM ghRutAt pacet||21|| goshakRudrasadadhyamlakShIramUtraishca tatsamaiH| pa~jcagavyamiti khyAtaM mahattadamRutopamam||22|| apasmAre tathonmAde [2] shvayathAvudareShu ca| gulmArshaHpANDurogeShu kAmalAyAM halImake||23|| shasyate ghRutametattu prayoktavyaM dine dine| alakShmIgraharogaghnaM cAturthakavinAshanam||24|| iti mahApa~jcagavyaM ghRutam Ingredients of mahapanchagavya ghee: Two palas [ 80 gms ] of each of : Bilva, shyonaka, gambhari, patali, ganikarika, shalaparni, prishniparni, brihati, kantakari, gokshura, haritaki, bibhitaki, amalaka, haridra, daruharidra, Bark of kutaja, saptaparna, apamarga, nilini, katurohini, Shampaka (aragvadha), root of phalgu (kasthodu-mbarika), puskaramula 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). 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

ब्राह्मीरसवचाकुष्ठशङ्खपुष्पीभिरेव च| पुराणं घृतमुन्मादालक्ष्म्यपस्मारपापनुत्||२५|| brāhmīrasavacākuṣṭhaśaṅkhapuṣpībhirēva ca| purāṇaṁ ghr̥tamunmādālakṣmyapasmārapāpanut||25|| brAhmIrasavacAkuShThasha~gkhapuShpIbhireva ca| purANaM ghRutamunmAdAlakShmyapasmArapApanut||25|| Cow's ghee processed with the juice of brahmi,vacha, kushtha and shankhapushpi cures unmada, alaksmi (inauspiciousness), apasmara and papa (effects of evil deeds). [25]

Saindhava hingu ghee

घृतं सैन्धवहिङ्गुभ्यां वार्षे बास्ते चतुर्गुणे| मूत्रे सिद्धमपस्मारहृद्ग्रहामयनाशनम्||२६|| ghr̥taṁ saindhavahiṅgubhyāṁ vārṣē bāstē caturguṇē| mūtrē siddhamapasmārahr̥dgrahāmayanāśanam||26||

ghRutaM saindhavahi~ggubhyAM vArShe bAste caturguNe| mUtre siddhamapasmArahRudgrahAmayanAshanam||26||

Cow's ghee (1 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 bad planets.[26]

Vacha-shampakadi ghee

वचाशम्पाककैटर्यवयःस्थाहिङ्गुचोरकैः| सिद्धं पलङ्कषायुक्तैर्वातश्लेष्मात्मके घृतम्||२७|| vacāśampākakaiṭaryavayaḥsthāhiṅgucōrakaiḥ| siddhaṁ palaṅkaṣāyuktairvātaślēṣmātmakē ghr̥tam||27|| vacAshampAkakaiTaryavayaHsthAhi~ggucorakaiH| siddhaM pala~gkaShAyuktairvAtashleShmAtmake ghRutam||27|| Ghee (1 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]

Jeevaniya yamaka Sneha

तैलप्रस्थं घृतप्रस्थं जीवनीयैः पलोन्मितैः| क्षीरद्रोणे पचेत् सिद्धमपस्मारविनाशनम्||२८|| tailaprasthaṁ ghr̥taprasthaṁ jīvanīyaiḥ palōnmitaiḥ| kṣīradrōṇē pacēt siddhamapasmāravināśanam||28|| Two prasthas (in the text actually one prastha is mentioned; double the quantity is taken according to the general rules of definition) of each of oil and cow's ghee should be added with the paste of one pala of each of the ten drugs belonging to jivaniya gana (vide Sutra 4: 9) and two dronas (in the text one drona is prescribed; double the quantity is taken according to general rules of definition) of milk, and cooked. This medicated ghee is an effective recipe for the cure of apasmara (epilepsy). [28]

कंसे क्षीरेक्षुरसयोः काश्मर्येऽष्टगुणे रसे| कार्षिकैर्जीवनीयैश्च घृतप्रस्थं विपाचयेत्||२९|| kaṁsē kṣīrēkṣurasayōḥ kāśmaryē'ṣṭaguṇē rasē| kārṣikairjīvanīyaiśca ghr̥taprasthaṁ vipācayēt||29||

kaMse kShIrekShurasayoH kAshmarye~aShTaguNe rase| kArShikairjIvanIyaishca ghRutaprasthaM vipAcayet||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 vayu and pitta. [29]

वातपित्तोद्भवं क्षिप्रमपस्मारं नियच्छति| तद्वत् काशविदारीक्षुकुशक्वाथशृतं घृतम्||३०|| vātapittōdbhavaṁ kṣipramapasmāraṁ niyacchati| tadvat kāśavidārīkṣukuśakvāthaśr̥taṁ ghr̥tam||30|| vAtapittodbhavaM kShipramapasmAraM niyacchati| tadvat kAshavidArIkShukushakvAthashRutaM ghRutam||30|| Similarly, ghee cooked by adding the decoction of kasha and kusha and the juice of vidari and sugarcane is useful in the treatment of this ailment. [30]

मधुकद्विपले कल्के द्रोणे चामलकीरसात्| तद्वत् सिद्धो घृतप्रस्थः पित्तापस्मारभेषजम्||३१|| madhukadvipalē kalkē drōṇē cāmalakīrasāt| tadvat siddhō ghr̥taprasthaḥ pittāpasmārabhēṣajam||31|| madhukadvipale kalke droNe cAmalakIrasAt| tadvat siddho ghRutaprasthaH pittApasmArabheShajam||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

अभ्यङ्गः सार्षपं तैलं बस्तमूत्रे चतुर्गुणे| सिद्धं स्याद्गोशकृन्मूत्रैः स्नानोत्सादनमेव च||३२|| कटभीनिम्बकट्वङ्गमधुशिग्रुत्वचां रसे| सिद्धं मूत्रसमं तैलमभ्यङ्गार्थे प्रशस्यते||३३|| पलङ्कषावचापथ्यावृश्चिकाल्यर्कसर्षपैः| जटिलापूतनाकेशीनाकुलीहिङ्गुचोरकैः||३४|| लशुनातिरसाचित्राकुष्ठैर्विड्भिश्च पक्षिणाम्| मांसाशिनां यथालाभं बस्तमूत्रे चतुर्गुणे||३५|| सिद्धमभ्यञ्जनं तैलमपस्मारविनाशनम्| एतैश्चैवौषधैः कार्यं धूपनं सप्रलेपनम्||३६|| abhyaṅgaḥ sārṣapaṁ tailaṁ bastamūtrē caturguṇē| siddhaṁ syādgōśakr̥nmūtraiḥ snānōtsādanamēva ca||32|| kaṭabhīnimbakaṭvaṅgamadhuśigrutvacāṁ rasē| siddhaṁ mūtrasamaṁ tailamabhyaṅgārthē praśasyatē||33|| palaṅkaṣāvacāpathyāvr̥ścikālyarkasarṣapaiḥ| jaṭilāpūtanākēśīnākulīhiṅgucōrakaiḥ||34|| laśunātirasācitrākuṣṭhairviḍbhiśca pakṣiṇām| māṁsāśināṁ yathālābhaṁ bastamūtrē caturguṇē||35|| siddhamabhyañjanaṁ tailamapasmāravināśanam| ētaiścaivauṣadhaiḥ kāryaṁ dhūpanaṁ sapralēpanam||36||

abhya~ggaH sArShapaM tailaM bastamUtre caturguNe| siddhaM syAdgoshakRunmUtraiH snAnotsAdanameva ca||32|| kaTabhInimbakaTva~ggamadhushigrutvacAM rase| siddhaM mUtrasamaM tailamabhya~ggArthe prashasyate||33|| pala~gkaShAvacApathyAvRushcikAlyarkasarShapaiH| jaTilApUtanAkeshInAkulIhi~ggucorakaiH||34|| lashunAtirasAcitrAkuShThairviDbhishca pakShiNAm| mAMsAshinAM yathAlAbhaM bastamUtre caturguNe||35|| siddhamabhya~jjanaM tailamapasmAravinAshanam| etaishcaivauShadhaiH kAryaM dhUpanaM sapralepanam||36||

Mustard oil cooked with four times of goat-urine is useful for massage for a patient suffering from epilepsy. Such a patient should use cow-dung for the purpose of unction and cow's urine for the purpose of snana (bath).[32] (Sesame) oil (one part) should be cooked with (goat's) urine (one part) and the decoction of the barks of katabhi, nimba, katvanga and madhushigru (three parts). This medicated oil is very effective for massage.[33] Prepare siddha taila with the pastes of palankasha (guggulu), vaca, pathya, vrischikali, arka, sarshapa, jatila, putanakesi (golomi), nakuli, hingu, choraka. [34]

Lasuna, atirasa (jalaja yastimadhu), citra, kustha and the stool of meat-eating birds according to their availability.[35] Sesame oil should be cooked by adding four times of goat's urine and the paste (1/4th of the oil) of the drugs. This medicated oil is very effective in curing apasmara (epilepsy). The above mentioned drugs (ingredients prescribed to be used as paste) should also be used for dhupana (fumigation) and pralepana (external application in paste form) (for curing patients suffering from epilepsy).[36]

पिप्पलीं लवणं चित्रां हिङ्गु हिङ्गुशिवाटिकाम्| काकोलीं सर्षपान् काकनासां कैटर्यचन्दने||३७|| शुनःस्कन्धास्थिनखरान् पर्शुकां चेति पेषयेत्| बस्तमूत्रेण पुष्यर्क्षे प्रदेहः स्यात् सधूपनः||३८||

pippalīṁ lavaṇaṁ citrāṁ hiṅgu hiṅguśivāṭikām| kākōlīṁ sarṣapān kākanāsāṁ kaiṭaryacandanē||37|| śunaḥskandhāsthinakharān parśukāṁ cēti pēṣayēt| bastamūtrēṇa puṣyarkṣē pradēhaḥ syāt sadhūpanaḥ||38||

pippalIM lavaNaM citrAM hi~ggu hi~ggushivATikAm| kAkolIM sarShapAn kAkanAsAM kaiTaryacandane||37|| shunaHskandhAsthinakharAn parshukAM ceti peShayet| bastamUtreNa puShyarkShe pradehaH syAt sadhUpanaH||38||

Pippali, rock-salt, chitra (danti), hingu, hingushivatika (vamsa-patrika), kakoli, sarshapa, kakanasa, kaitarya, chandana and shoulder bones, nails and ribs of the dog should be made to a paste by triturating with goat's urine in the constellation of pusya (8th nakshatra). Use of this for pradeha (external application in the form of thick paste) and dhupana (fumigation) cures epilepsy.[37-38]

अपेतराक्षसीकुष्ठपूतनाकेशिचोरकैः| उत्सादनं मूत्रपिष्टैर्मूत्रैरेवावसेचनम्||३९|| apētarākṣasīkuṣṭhapūtanākēśicōrakaiḥ| utsādanaṁ mūtrapiṣṭairmūtrairēvāvasēcanam||39||

apetarAkShasIkuShThapUtanAkeshicorakaiH| utsAdanaM mUtrapiShTairmUtrairevAvasecanam||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

जलौकःशकृता तद्वद्दग्धैर्वा बस्तरोमभिः| खरास्थिभिर्हस्तिनखैस्तथा गोपुच्छलोमभिः||४०|| jalaukaḥśakr̥tā tadvaddagdhairvā bastarōmabhiḥ| kharāsthibhirhastinakhaistathā gōpucchalōmabhiḥ||40|| jalaukaHshakRutA tadvaddagdhairvA bastaromabhiH| kharAsthibhirhastinakhaistathA gopucchalomabhiH||40|| Similarly, unction should be done with the help of the following) recipes: i) stool of leeches; ii) ashes of the small hair of the goat. iii) ashes of the bone of ass; iv) ashes of the nails of elephant; and v) ashes of the hair in the tail of the cow. [40]

Drugs for nasya [nasal errhines]

कपिलानां गवां मूत्रं [१] नावनं परमं हितम्| श्वशृगालबिडालानां सिंहादीनां च शस्यते||४१|| kapilānāṁ gavāṁ mūtraṁ [1] nāvanaṁ paramaṁ hitam| śvaśr̥gālabiḍālānāṁ siṁhādīnāṁ ca śasyatē||41|| kapilAnAM gavAM mUtraM [1] nAvanaM paramaM hitam| shvashRugAlabiDAlAnAM siMhAdInAM ca shasyate||41||

Inhalation of the urine of cow having reddish brown (kapila) color is extremely useful for the cure of epilepsy. Similarly, inhalation of the urine of the dog, jackal, cat; lion etc., is useful in this condition. [41]

भार्गी वचा नागदन्ती श्वेता श्वेता विषाणिका| ज्योतिष्मती नागदन्ती पादोक्ता मूत्रपेषिताः||४२|| योगास्त्रयोऽतः षड् बिन्दून् पञ्च वा नावयेद्भिषक्| bhārgī vacā nāgadantī śvētā śvētā viṣāṇikā| jyōtiṣmatī nāgadantī pādōktā mūtrapēṣitāḥ||42|| yōgāstrayō'taḥ ṣaḍ bindūn pañca vā nāvayēdbhiṣak|

bhArgI vacA nAgadantI shvetA shvetA viShANikA| jyotiShmatI nAgadantI pAdoktA mUtrapeShitAH||42|| yogAstrayo~ataH ShaD bindUn pa~jca vA nAvayedbhiShak|

i) Bhargi, vacha and nagadanti (kasthapatala) triturated with cow's urine; ii) shveta (shveta aparajita) and shveta vishanika (shatavari) triturated with cow's urine; iii) jyotishmati and nagadanti triturated with cow's urine. Inhalation of five or six drops of the foregoing three recipes is useful, (in the treatment of epilepsy); [42-43]

त्रिफलाव्योषपीतद्रुयवक्षारफणिज्झकैः||४३|| श्यामापामार्गकारञ्जफलैर्मूत्रेऽथ बस्तजे| साधितं नावनं तैलमपस्मारविनाशनम्||४४|| triphalāvyōṣapītadruyavakṣāraphaṇijjhakaiḥ||43|| śyāmāpāmārgakārañjaphalairmūtrē'tha bastajē| sādhitaṁ nāvanaṁ tailamapasmāravināśanam||44||

triphalAvyoShapItadruyavakShAraphaNijjhakaiH||43|| shyAmApAmArgakAra~jjaphalairmUtre~atha bastaje| sAdhitaM nAvanaM tailamapasmAravinAshanam||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 [45]

पिप्पली वृश्चिकाली च कुष्ठं च लवणानि च| भार्गी च चूर्णितं नस्तः कार्यं प्रधमनं परम्||४५|| pippalī vr̥ścikālī ca kuṣṭhaṁ ca lavaṇāni ca| bhārgī ca cūrṇitaṁ nastaḥ kāryaṁ pradhamanaṁ param||45|| pippalI vRushcikAlI ca kuShThaM ca lavaNAni ca| bhArgI ca cUrNitaM nastaH kAryaM pradhamanaM param||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

कायस्थां शारदान्मुद्गान्मुस्तोशीरयवांस्तथा| सव्योषान् बस्तमूत्रेण पिष्ट्वा वर्तीः प्रकल्पयेत्||४६|| अपस्मारे तथोन्मादे सर्पदष्टे गरार्दिते| विषपीते जलमृते चैताः स्युरमृतोपमाः||४७||

kāyasthāṁ śāradānmudgānmustōśīrayavāṁstathā| savyōṣān bastamūtrēṇa piṣṭvā vartīḥ prakalpayēt||46|| apasmārē tathōnmādē sarpadaṣṭē garārditē| viṣapītē jalamr̥tē caitāḥ syuramr̥tōpamāḥ||47||

kAyasthAM shAradAnmudgAnmustoshIrayavAMstathA| savyoShAn bastamUtreNa piShTvA vartIH prakalpayet||46|| apasmAre tathonmAde sarpadaShTe garArdite| viShapIte jalamRute caitAH syuramRutopamAH||47||

Kayastha, sharada mudga (harita mudga), musta, ushira, yava, sunthi, pippali and maricha should be made to a paste by triturating with goat’s urine. From out of this paste, vartis (elongated pills/wicks) should be prepared. [46] Application of this thin paste (prepared by rubbing with water) in the eyes (as collyrium) works like ambrosia in (curing) apasmara (epilepsy), unmada (insanity), snake-bite, Afflictions by poisonous beverages, internal poisonings and to regain consciousness after drowning [47]

मुस्तं वयःस्थां त्रिफलां कायस्थां हिङ्गु शाद्वलम्| व्योषं माषान् यवान्मूत्रैर्बास्तमैषार्षभैस्त्रिभिः||४८|| पिष्ट्वा कृत्वा च तां वर्तिमपस्मारे प्रयोजयेत्| किलासे च तथोन्मादे ज्वरेषु विषमेषु च||४९|| mustaṁ vayaḥsthāṁ triphalāṁ kāyasthāṁ hiṅgu śādvalam| vyōṣaṁ māṣān yavānmūtrairbāstamaiṣārṣabhaistribhiḥ||48|| piṣṭvā kr̥tvā ca tāṁ vartimapasmārē prayōjayēt| kilāsē ca tathōnmādē jvarēṣu viṣamēṣu ca||49|| mustaM vayaHsthAM triphalAM kAyasthAM hi~ggu shAdvalam| vyoShaM mAShAn yavAnmUtrairbAstamaiShArShabhaistribhiH||48|| piShTvA kRutvA ca tAM vartimapasmAre prayojayet| kilAse ca tathonmAde jvareShu viShameShu ca||49|| Musta, vayastha, triphala, kayastha, hingu, shadwal, vyosha, masha, yava should be made to a paste by triturating in urines of goat, sheep and bull. From this paste, vartis (elongated pills) should be prepared. (These vartis should be rubbed over a stone by adding water, and the thin paste, thus obtained, should be used as collyrium). This is used in treatment of apasmara (epilepsy), kilasa (a type of leucoderma), unmada (insanity) and vishama jwara (irregular fever).[48-49]

पुष्योद्धृतं शुनः पित्तमपस्मारघ्नमञ्जनम्| तदेव सर्पिषा युक्तं धूपनं परमं मतम्||५०|| puṣyōddhr̥taṁ śunaḥ pittamapasmāraghnamañjanam| tadēva sarpiṣā yuktaṁ dhūpanaṁ paramaṁ matam||50||

puShyoddhRutaM shunaH pittamapasmAraghnama~jjanam| tadeva sarpiShA yuktaM dhUpanaM paramaM matam||50||

Dog-bile, collected during pusya constellation, should be used as collyrium for the cure of apasmara (epilepsy). This (bile) mixed with ghee should be used for fumigation which is excellent (for curing epilepsy).[50]

नकुलोलूकमार्जारगृध्रकीटाहिकाकजैः| तुण्डैः [१] पक्षैः पुरीषैश्च धूपनं कारयेद्भिषक्||५१|| nakulōlūkamārjāragr̥dhrakīṭāhikākajaiḥ| tuṇḍaiḥ [1] pakṣaiḥ purīṣaiśca dhūpanaṁ kārayēdbhiṣak||51|| nakulolUkamArjAragRudhrakITAhikAkajaiH| tuNDaiH [1] pakShaiH purIShaishca dhUpanaM kArayedbhiShak||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

आभिः क्रियाभिः सिद्धाभिर्हृदयं सम्प्रबुध्यते| स्रोतांसि चापि शुध्यन्ति ततः [२] सञ्ज्ञां स विन्दति||५२|| ābhiḥ kriyābhiḥ siddhābhirhr̥dayaṁ samprabudhyatē| srōtāṁsi cāpi śudhyanti tataḥ [2] sañjñāṁ sa vindati||52|| AbhiH kriyAbhiH siddhAbhirhRudayaM samprabudhyate| srotAMsi cApi shudhyanti tataH [2] sa~jj~jAM sa vindati||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]

Aagantu apasmara treatment

यस्यानुबन्धस्त्वागन्तुर्दोषलिङ्गाधिकाकृतिः| दृश्येत तस्य कार्यं स्यादागन्तून्मादभेषजम्||५३|| yasyānubandhastvāganturdōṣaliṅgādhikākr̥tiḥ| dr̥śyēta tasya kāryaṁ syādāgantūnmādabhēṣajam||53|| yasyAnubandhastvAganturdoShali~ggAdhikAkRutiH| dRushyeta tasya kAryaM syAdAgantUnmAdabheShajam||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 doshas (endogenous factors). Such patients should be treated on the lines suggested for exogenous types of unmada (insanity) -vide Chapter 9.[53].

Mahagada chikitsa [management of atattvabhinivesha]

अनन्तरमुवाचेदमग्निवेशः कृताञ्जलिः| भगवन्! प्राक् समुद्दिष्टः श्लोकस्थाने महागदः||५४|| अतत्त्वाभिनिवेशो यस्तद्धेत्वाकृतिभेषजम्| तत्र नोक्तमतः श्रोतुमिच्छामि तदिहोच्यताम्||५५|| शुश्रूषवे वचः श्रुत्वा शिष्यायाह पुनर्वसुः| महागदं सौम्य! शृणु सहेत्वाकृतिभेषजम्||५६|| anantaramuvācēdamagnivēśaḥ kr̥tāñjaliḥ| bhagavan! prāk samuddiṣṭaḥ ślōkasthānē mahāgadaḥ||54|| atattvābhinivēśō yastaddhētvākr̥tibhēṣajam| tatra nōktamataḥ śrōtumicchāmi tadihōcyatām||55|| śuśrūṣavē vacaḥ śrutvā śiṣyāyāha punarvasuḥ| mahāgadaṁ saumya! śr̥ṇu sahētvākr̥tibhēṣajam||56|| anantaramuvAcedamagniveshaH kRutA~jjaliH| bhagavan! prAk samuddiShTaH shlokasthAne mahAgadaH||54|| atattvAbhinivesho yastaddhetvAkRutibheShajam| tatra noktamataH shrotumicchAmi tadihocyatAm||55|| shushrUShave vacaH shrutvA shiShyAyAha punarvasuH| mahAgadaM saumya! shRuNu sahetvAkRutibheShajam||56||

Thereafter, Agnivesha with folded hands [in salutation] said, "O Lord! In Sutra section (Sutra 19 : 3) you have mentioned in brief as a mahagada (grave disease), that is atattvabhinivesha (pervaded by false principles ). But its etiology, signs and symptoms and treatment are not described there. I want to hear these descriptions. Kindly narrate them in the present context".[54-55] 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

मलिनाहारशीलस्य वेगान् प्राप्तान्निगृह्णतः| शीतोष्णस्निग्धरूक्षाद्यैर्हेतुभिश्चातिसेवितैः||५७|| हृदयं समुपाश्रित्य मनोबुद्धिवहाः सिराः| दोषाः सन्दूष्य तिष्ठन्ति रजोमोहावृतात्मनः||५८|| रजस्तमोभ्यां वृद्धाभ्यां बुद्धौ [१] मनसि चावृते| हृदये व्याकुले दोषैरथ मूढोऽल्पचेतनः [२] ||५९|| विषमां कुरुते बुद्धिं नित्यानित्ये हिताहिते| अतत्त्वाभिनिवेशं तमाहुराप्ता महागदम्||६०|| malināhāraśīlasya vēgān prāptānnigr̥hṇataḥ| śītōṣṇasnigdharūkṣādyairhētubhiścātisēvitaiḥ||57|| hr̥dayaṁ samupāśritya manōbuddhivahāḥ sirāḥ| dōṣāḥ sandūṣya tiṣṭhanti rajōmōhāvr̥tātmanaḥ||58|| rajastamōbhyāṁ vr̥ddhābhyāṁ buddhau [1] manasi cāvr̥tē| hr̥dayē vyākulē dōṣairatha mūḍhō'lpacētanaḥ [2] ||59|| viṣamāṁ kurutē buddhiṁ nityānityē hitāhitē| atattvābhinivēśaṁ tamāhurāptā mahāgadam||60|| malinAhArashIlasya vegAn prAptAnnigRuhNataH| shItoShNasnigdharUkShAdyairhetubhishcAtisevitaiH||57|| hRudayaM samupAshritya manobuddhivahAH sirAH| doShAH sandUShya tiShThanti rajomohAvRutAtmanaH||58|| rajastamobhyAM vRuddhAbhyAM buddhau [1] manasi cAvRute| hRudaye vyAkule doShairatha mUDho~alpacetanaH [2] ||59|| viShamAM kurute buddhiM nityAnitye hitAhite| atattvAbhiniveshaM tamAhurAptA mahAgadam||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] 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]

Management of atattvabhinivesha

स्नेहस्वेदोपपन्नं तं संशोध्य वमनादिभिः| कृतसंसर्जनं मेध्यैरन्नपानैरुपाचरेत्||६१|| ब्राह्मीस्वरसयुक्तं यत् पञ्चगव्यमुदाहृतम्| तत् सेव्यं शङ्खपुष्पी च यच्च मेध्यं रसायनम्||६२|| सुहृदश्चानुकूलास्तं स्वाप्ता धर्मार्थवादिनः| संयोजयेयुर्विज्ञानधैर्यस्मृतिसमाधिभिः [३] ||६३|| snēhasvēdōpapannaṁ taṁ saṁśōdhya vamanādibhiḥ| kr̥tasaṁsarjanaṁ mēdhyairannapānairupācarēt||61|| brāhmīsvarasayuktaṁ yat pañcagavyamudāhr̥tam| tat sēvyaṁ śaṅkhapuṣpī ca yacca mēdhyaṁ rasāyanam||62|| suhr̥daścānukūlāstaṁ svāptā dharmārthavādinaḥ| saṁyōjayēyurvijñānadhairyasmr̥tisamādhibhiḥ [3] ||63|| snehasvedopapannaM taM saMshodhya vamanAdibhiH| kRutasaMsarjanaM medhyairannapAnairupAcaret||61|| brAhmIsvarasayuktaM yat pa~jcagavyamudAhRutam| tat sevyaM sha~gkhapuShpI ca yacca medhyaM rasAyanam||62|| suhRudashcAnukUlAstaM svAptA dharmArthavAdinaH| saMyojayeyurvij~jAnadhairyasmRutisamAdhibhiH [3] ||63|| 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 (vide verses 16-17) should be administered. Similarly, other medhya rasayanas (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]

प्रयुञ्ज्यात्तैललशुनं पयसा वा शतावरीम्| ब्राह्मीरसं कुष्ठरसं वचां वा मधुसंयुताम्||६४|| prayuñjyāttailalaśunaṁ payasā vā śatāvarīm| brāhmīrasaṁ kuṣṭharasaṁ vacāṁ vā madhusaṁyutām||64|| prayu~jjyAttailalashunaM payasA vA shatAvarIm| brAhmIrasaM kuShTharasaM vacAM vA madhusaMyutAm||64||

i) Garlic with oil; ii) shatavari with milk; iii) juice of brahmi with honey; iv) juice or decoction of kushtha with honey; and v) powder of vacha with honey.[64]

Prognosis

दुश्चिकित्स्यो ह्यपस्मारश्चिरकारी कृतास्पदः [१] | तस्माद्रसायनैरेनं प्रायशः समुपाचरेत्||६५|| duścikitsyō hyapasmāraścirakārī kr̥tāspadaḥ [1] | tasmādrasāyanairēnaṁ prāyaśaḥ samupācarēt||65|| dushcikitsyo hyapasmArashcirakArI kRutAspadaH [1] | tasmAdrasAyanairenaM prAyashaH samupAcaret||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

जलाग्निद्रुमशैलेभ्यो विषमेभ्यश्च तं सदा| रक्षेदुन्मादिनं चैव सद्यः प्राणहरा हि ते||६६||

jalāgnidrumaśailēbhyō viṣamēbhyaśca taṁ sadā| rakṣēdunmādinaṁ caiva sadyaḥ prāṇaharā hi tē||66|| jalAgnidrumashailebhyo viShamebhyashca taM sadA| rakShedunmAdinaM caiva sadyaH prANaharA hi te||66|| The patient suffering from apasmara and unmada, should be specially protected from water, fire, trees, mountains and uneven places. These may cause instantaneous death of the patient.[66]

तत्र श्लोकौ- हेतुं कुर्वन्त्यपस्मारं दोषाः प्रकुपिता यथा| सामान्यतः पृथक्त्वाच्च लिङ्गं तेषां च भेषजम्||६७|| महागदसमुत्थानं लिङ्गं चोवाच सौषधम्| मुनिर्व्याससमासाभ्यामपस्मारचिकित्सिते [१] ||६८||

tatra ślōkau- hētuṁ kurvantyapasmāraṁ dōṣāḥ prakupitā yathā| sāmānyataḥ pr̥thaktvācca liṅgaṁ tēṣāṁ ca bhēṣajam||67|| mahāgadasamutthānaṁ liṅgaṁ cōvāca sauṣadham| munirvyāsasamāsābhyāmapasmāracikitsitē [1] ||68||

tatra shlokau- hetuM kurvantyapasmAraM doShAH prakupitA yathA| sAmAnyataH pRuthaktvAcca li~ggaM teShAM ca bheShajam||67|| mahAgadasamutthAnaM li~ggaM covAca sauShadham| munirvyAsasamAsAbhyAmapasmAracikitsite [1] ||68||

i) Etiological factors of epilepsy; ii) the mode of vitiation of doshas; iii) signs and symptoms in general and of different varieties of epilepsy; [ 67]iv) Treatment of different types of epilepsy; and v) Etiology, signs and symptoms of mahagada (grave disease). Thus, in this chapter, the sage has described treatment of apasmara, in brief as well as in detail as above said.[68] Thus, ends the tenth Chapter dealing with the treatment of apasmara in the section on therapeutics of Agnivesha's work as redacted by Charaka, and not being available, restored by Dridhabala. [69]

Tattva Vimarsha

• Apasmara is a disease in which faculties of mind like memory/consciousness, intellect and purest quality of mind are afflicted. • Diet plays significant role in pathophysiology of psychiatric diseases. • 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. • 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. • 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. • Ashwasana [assurance therapy] and psychological counselling are advised to remove psychological stressors that provoke apasmara vega[episode].

Vidhi Vimarsha

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. 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 clerifies link between diet, dosha, mental functions, 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. 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. Brain and heart connection –Neuro-cardiology: 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 behaviour 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. 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.

Gut-brain connection in apasmara

Gut-brain dysfunction is proved to play role in many psychiatric disorders like depression, anxiety, autism, schizophrenia. The figure shows physiology of gut-brain connection [fig. ]. As discussed earlier in Apasmara Nidana chapter 8, many of the somatic symptoms are related with the dysfunction of gastro-intestinal tract.Therefore the possibility of gut-brain dysfunction can’t 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.

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 person is completely lost. This leads to improper judgment regarding eternal and ephemeral events and wholesome and unwholesome objects. Co-ordination of mind, intellect, sense-motor organs is disturbed.

Patho-physiology of atattvabhinivesha

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/tremors).

Akshepaka is explained as a vata vyadhi in Chikitsa sthana 28th chapter characterised by repeated convulsive movements of body when vitiated vata affects muscles and tendons of hands and legs. (Verses 51, 52) 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 characterised by vakrata [curved] of mukhardha bhaga [half face] and also shareerardha [half body]. The attacks of ardita donot 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)

Vepathu or kampa vata are characterised by kampa (tremor) of either single part/multiple parts / entire body. In any of the above explained conditions either the involvement of hrudaya [heart] or manas[mind] are not specified. Hence they implicate more of neurological pathology rather than psychological disorder.

Apatantraka which is explained in Trimarmeeya siddhi adhyaya of siddhi sthana (9th chapter, verses 12 to 15) is very much similar to that of apasmara 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 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 satwa 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”.

Management of apasmara

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. 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 biomarkers 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. 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 Caraka, 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 formulations used in treatment are enlisted below: Panchagavya ghritam Sr.No. Ingredient Part proportion Process 1. Go Shakrid Rasa [ cow- dung ] 1 ghee preparation 2. Dadhi Amla [ curd made from cowmilk] 1 3. Ksheer [ cow milk] 1 4. Mutra [ cow urine] 1 5. Ghritam [cow’s ghee] 1 Dose: Pibet [to be drunk] Indications apasmara, kamala, jwara

Mahapanchagavya ghrita: Sr.No. Ingredient Part proportion Process Indications 1. Bilva Two Pala Ghee preparation apasmara (epilepsy) unmada (insanity) shvayathu (edema) udara (obstinate abdominal diseases including ascites) gulma (abdominal lumps) arshas (piles) pandu (anemia) kamala (jaundice) and halimaka (an advanced stage of jaundice) 2. Shyonaka Two pala 3. Gambhari Two pala 4. Patali Two pala 5. Ganikarika Two pala 6. Shalaparni Two pala 7. Prishniparni Two pala 8. Brihati Two pala 9. Kantakari Two pala should be used regularly every day to dispel inauspiciousness and evil effects of bad planets 10. Gokshura Two pala 11. Haritaki Two pala 12. Bibhitaki Two pala 13. Amalaka Two pala 14. Haridra Two pala 15. Daruharidra Two pala 16. Bark of Kutaja Two pala 17. Saptaparna Two pala 18. Apamarga Two pala 19. Nilini Two pala 20. Katurohini Two pala 21. Shampaka (Aragvadha) Two pala 22. Root of Phalgu (kasthodumbarika) Two pala 23. Puskaramula Two pala 24. Duralabha Two pala 25-42 Bharangi, Patha, Shunthi, Maricha, Pippali, Trivrita, Nichula (Hijjala), Shreyasi (Hastipippali), Adhaki, Murva, Danti, Bhunimba; Chitraka, Shveta Sariva, Krishna Sariva, Rohisha, Bhutika and Madayantika One aksha 43 Cow's ghee Two prasthas

Brahmi ghrita: Sr.No. Ingredient Part proportion Process Indications 1. Cow's ghee 4 ghee preparation unmada, alaksmi (inauspiciousness), apasmara and papa (effects of evil deeds) 2. juice of Brahmi 1 3. Vacha 1 4. Kushtha 1 5. Shankhapushpi 1

Saindhav hingvadi ghrita [verse 26] Sr.No. Ingredient with botanical name Part proportion Indications Cow's ghee 1 apasmara (epilepsy), heart diseases, diseases caused by the evil effects of bad planets Urine of bull [vArsh mutra] and goat [Bast mutra] 4 parts in total Paste of rock salt and asafetida 1/4th part In total

Vata shlaishma apasmarahara vacha – shampakadi ghrita: Sr.No. Ingredient with botanical name Part proportion Indication 1. Ghee 1 part vatika and shlaishmika types of epilepsy 2. Vacha 1/4th part in total 3. Sampaka 4. Kaitarya (parvata nimba) 5. Vayastha (guduci) 6. Hingu 7. Choraka 8. Palankasa or Guggulu 9. Water 4 parts

Jeevaniya dravyasiddha yamaka sneha [Vesre 28]: Sr.No. Ingredient with botanical name Part proportion Indications Oil 1 prastha apasmaravinashanam Ghee 1 prastha Jeevaniya dravya [Cha.Su.4/9(1)] 1 pala Jeevaka Rishabhaka Meda Mahameda Kakoli Ksheerakakoli Mudgaparni Mashaparni Jeevanti Madhuka Milk 1 drona

Kashmaryadi ghrita [verse 29]: Sr.No. Ingredients Part proportion Indications 1. Milk 1 kamsa in total Instantaneously cures epilepsy caused by vayu and pitta 2. Sugercane juice 3. Kashmari juice 8 parts 4. Jeevaniya drugs [ as mentioned in list of verse 28] 1 karsha 5. Ghee 1 prastha

Sr.No. Ingredients Part proportion Indications Ghee 1 prastha vata pittaja apasmra decoction of kusha kasha vidari and ikshu moolas 1 prastha Milk 1 adhaka Sugarcane Juice 1 adhaka

Aamalki-madhuka ghee [verse 31]: Sr.No. Ingredients Part proportion Indications Ghee Two prasthas Instantaneously cures the paittika type of apasmara (epilepsy) juice of Amalaki two dronas paste of Madhuka two palas External Application: Sarshapa taila [32]: Sr.No. Ingredients Part proportion Indications Mustard oil 1 External massage Goat Urine 4 cow-dung For unction Cow’s urine For bath

Katabhyadi oil [33]: Sr.No. Ingredients Part proportion Indications (Sesame) oil 1 part External massage in apasmara (goat's) urine 1 part decoction of the barks of Katabhi, Nimba, Katvanga and Madhusigru three parts

Palankashadi oil [34-36]: Sr.No. Ingredients Part proportion Indications Pastes of Palankasa, Vacha, Pathya, Vrishchikali, Arka, Sarshapa, Jatila, Putanakesi (golomi), Nakuli. Hingu, Choraka, Lashuna, Atirasa (Jalaja Yastimadhu), Chitra, Kushtha and the stool of meat-eating birds as per availability 1/4th Part in total Massage in apasmara (epilepsy), same paste for dhupana (fumigation) and pralepana (external application in paste form) (Sesame) oil 1 part Goat urine 4 parts

Pippalyadi pradeha [37-38] Sr.No. Ingredients Part proportion Indications Pippali, Rock-salt, Chitra (Danti), Hingu, Hingusivatika (Vamsha-patrika), Kakoli, Sarshapa, Kakanasa, Kaitarya, Chandana Paste as required pradeha (external application in the form of thick paste) and dhupana (fumigation) Shoulder bones, nails and ribs of the dog should be made to a paste by triturating with Goat's urine in the constellation of Pushya (8th nakshatra) Goat’s urine

Paste of apetarakshsyadi yoga: [39] Sr.No. Ingredients Part proportion Indications Paste of Apetaraksasi, Kushtha, Putanakeshi and Choraka triturated by adding (cow's or goat's) urine Unction (cow's or goat's) urine Sprinkling over body

Different unction formulations [40]: Sr.No. Ingredients Part proportion Indications i) Stool of leeches; QS Unction ii) ashes of the small hair of the goat iii) ashes of the bone of ass iv) ashes of the nails of elephant v) ashes of the hair in the tail of the cow

Different formulations for nasya [nasal drug delivery] [41] Sr.No. Ingredients Part proportion Indications Urine of cow having reddish brown (Kapila) color QS Nasya [nasal delivery] Exceedingly useful for the cure of epilepsy Urine of Dog Nasya [nasal delivery] Urine of Jackal Nasya [nasal delivery] Urine of Cat Nasya [nasal delivery] Urine of Lion Nasya [nasal delivery]

Nasya formulations:[42-43] Sr.No. Ingredients Part proportion Indications i) Bhargi, Vacha and Nagadanti (Kasthapatala) triturated with cow's urine QS Nasal delivery of five or six drops of the foregoing three formulations ii) Shveta (Shveta Aparajita) and Shveta Vishanika (Shatavari) triturated with cow's urine iii) Jyotishmati and Nagadanti triturated with cow's urine

Nasya formulations [43-44]: Sr.No. Ingredients Part proportion Indications Oil one part Nasya Triphala [Haritaki, Bibhitaki, Amalaki] All ingredients ¼ part totally Vyosha [Shunthi, Pippali, Maricha] In equal proportions Pitadru (Devadaru) Yavaksara Phanijjhaka Shyama Apamarga Fruits of Karanja Goat’s urine four parts

Pradhamana nasya formulation [45]: Sr.No. Ingredients Part proportion Indications 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)

Drugs for intra-occular delivery/ delivery through conjuntival membrane: Kayasthadi Yoga [46-47]: Sr.No. Ingredients Application Indications Kayastha, Sharada Mudga (Harita mudga), Musta, Ushira, Yava, Shunthi, Pippali and Maricha made to a paste by triturating with Goat’s urine Varti [ wick] to be rubbed in water and used as ointment to apply in inner side of eyelids Works as ambrosia to regain consciousness in apasmara, unmada, snake bite, different types of poisoning and after drowning

Mustadi Anjana[48-49]: Sr.No. Ingredients Application Indications Musta, Vayastha, Triphala, Kayastha, Hingu, Shadwal, Vyosha, Masha, Yava made to a paste by triturating in goat’s urine, sheep’s urine and bull’s urine. varti [ wick] to be rubbed in water and used as ointment to apply in inner side of eyelids apasmara (epilepsy), kilasa (a type of leucoderma), unmada (insanity) and visama jwara (irregular fever) Goat’s urine, sheep’s urine and bull’s urine

Dog’s bile for anjana[50]: Sr.No. Ingredients Part proportion Indications Dog-bile, collected during Pushya constellation, anjana apasmara Dog’s bile collected in Pushya constellation mixed with ghee dhupana [fumigation] apasmara

Fumigation of animal products [51]: Sr.No. Ingredients Part proportion Indications Beaks, feathers and stool of Mongoose, Owl bird, Cat, Vulture, Kita (scorpion etc), Snake and Crow dhupana [fumigation] apasmara

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