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==([[Nidana Sthana]] Chapter 8, Apasmara Nidana (Chapter on diagnosis of seizure disorders)==

==[[Nidana Sthana]] Chapter 8, Apasmara Nidana (Chapter on diagnosis of seizure disorders)==

   

   

=== Abstract ===

=== Abstract ===

=== Introduction ===

=== Introduction ===

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In this important section dealing with the diagnoses of some common disorders of the body and the mind, the [[Nidana Sthana]], this eighth and concluding chapter deals with apasmara, a disorder afflicting the mind and sharing similar etiological and pathological factors as ''unmada'' (the subject of the preceding chapter). ''Apasmara'' (Sanskrit for ''apa'' (to lose) or leave, and ''smara'' (memory)) is a psychosomatic disorder involving memory, intellect and mind and present with cardinal features such as transient loss of memory, abnormal movements of body and blackouts. ''Apasmara'' is counted, in Ayurvedic texts, among the eight ''mahagada'' (most dreadful diseases). The extent of knowledge on the disease indicates that it must have been quite prevalent in antiquity. Ayurvedic scholars have observed that ''apasmara'' simulates epilepsy in its features<ref> Venkataraghvan S., Rajagopalan V, Srinivasan K. Study of doshik involvement in Apasmara (Epilepsy) and its utility. Ancient science of life, Vol.No.VI[3],1987.138-47  </ref> <ref> Murthy ARV, Singh RH.A Critical study on the Ayurvedic concept of the psychopathological basis of Apasmara. Journal of NIMA XXXII [6] 1990.7-11  </ref>. Epilepsy is a common neuropsychiatric condition involving mainly the brain, nervous system and the psyche. However, [https://en.wikipedia.org/wiki/Ayurveda Ayurveda] emphasizes heart, the abode of consciousness and mind, as its core pathological site while covering diseases of memory, intellect as well as psyche under the umbrella of ''apasmara''.  

In this important section dealing with the diagnoses of some common disorders of the body and the mind, the [[Nidana Sthana]], this eighth and concluding chapter deals with apasmara, a disorder afflicting the mind and sharing similar etiological and pathological factors as ''unmada'' (the subject of the preceding chapter). ''Apasmara'' (Sanskrit for ''apa'' (to lose) or leave, and ''smara'' (memory)) is a psychosomatic disorder involving memory, intellect and mind and present with cardinal features such as transient loss of memory, abnormal movements of body and blackouts. ''Apasmara'' is counted, in Ayurvedic texts, among the eight ''mahagada'' (most dreadful diseases). The extent of knowledge on the disease indicates that it must have been quite prevalent in antiquity. Ayurvedic scholars have observed that ''apasmara'' simulates epilepsy in its features<ref> Venkataraghvan S., Rajagopalan V, Srinivasan K. Study of doshik involvement in Apasmara (Epilepsy) and its utility. Ancient science of life, Vol.No.VI[3],1987.138-47  </ref> <ref> Murthy ARV, Singh RH.A Critical study on the Ayurvedic concept of the psychopathological basis of Apasmara. Journal of NIMA XXXII [6] 1990.7-11  </ref>. Epilepsy is a common neuropsychiatric condition involving mainly the brain, nervous system and the psyche. However, Ayurveda emphasizes heart, the abode of consciousness and mind, as its core pathological site while covering diseases of memory, intellect as well as psyche under the umbrella of ''apasmara''.  

Causative factors of ''apasmara'' can be categorized under dietary, lifestyle, psychological and iatrogenic factors. Vitiated ''doshas'' get through the vessels of the heart and when exposed to predisposing psychological factors like excess worry, grief, anger, and fear, move upwards from the heart, the abode of all consciousness, to the brain, afflicting the senses while altering memory. This eventually leads to ''apasmara''. The etiology of the disease and specific features of the dominant ''doshas'' involved, and ''nidanarthakara roga'' (one disease causing other disease) and its importance in diagnosis and treatment have been described in detail in this chapter, with some important aspects of diagnosis addressed. In some cases, both diseases (the causative and the secondary ones) coexist while in other cases, the causative disease disappears and the new disease remains present. Thus, this chapter, while focusing on ''apasmara'', also talks of complications that lead to secondary conditions and their treatment.

Causative factors of ''apasmara'' can be categorized under dietary, lifestyle, psychological and iatrogenic factors. Vitiated ''doshas'' get through the vessels of the heart and when exposed to predisposing psychological factors like excess worry, grief, anger, and fear, move upwards from the heart, the abode of all consciousness, to the brain, afflicting the senses while altering memory. This eventually leads to ''apasmara''. The etiology of the disease and specific features of the dominant ''doshas'' involved, and ''nidanarthakara roga'' (one disease causing other disease) and its importance in diagnosis and treatment have been described in detail in this chapter, with some important aspects of diagnosis addressed. In some cases, both diseases (the causative and the secondary ones) coexist while in other cases, the causative disease disappears and the new disease remains present. Thus, this chapter, while focusing on ''apasmara'', also talks of complications that lead to secondary conditions and their treatment.

*the three ''sharira doshas'' are imbalanced and excessively aggravated;  

*the three ''sharira doshas'' are imbalanced and excessively aggravated;  

*an individual takes food that is impure, untimely, decomposed, possessing antagonistic properties, or touched/cooked by unclean hands  

*an individual takes food that is impure, untimely, decomposed, possessing antagonistic properties, or touched/cooked by unclean hands  

*an individual follows improper methods (of diet and lifestyle, conduct described in [https://en.wikipedia.org/wiki/Ayurveda Ayurveda]) and neglects prescribed rules;  

*an individual follows improper methods (of diet and lifestyle, conduct described in Ayurveda) and neglects prescribed rules;  

*an individual observes improper techniques (of treatment) and resorts to unhealthy regimen and behavior  

*an individual observes improper techniques (of treatment) and resorts to unhealthy regimen and behavior  

*an individual practices improper bodily movements and follows improper postures   

*an individual practices improper bodily movements and follows improper postures   

raktapittAjjvarastAbhyAM shoShashcApyupajAyate ||17||

raktapittAjjvarastAbhyAM shoShashcApyupajAyate ||17||

For example, elevated temperature in ''jwara'' can cause ''raktapitta'' and ''raktapitta'' can cause ''jwara''. Both the diseases (i.e ''jwara'' and ''raktapitta'') may lead to ''sosha'' (depletion of ''dhatus''). [17]  

For example, elevated temperature in ''jwara'' can cause ''raktapitta'' and ''raktapitta'' can cause ''jwara''. Both the diseases (i.e ''jwara'' and ''raktapitta'') may lead to ''shosha'' (depletion of ''dhatus''). [17]  

प्लीहाभिवृद्ध्या जठरं जठराच्छोथ एव च |  

प्लीहाभिवृद्ध्या जठरं जठराच्छोथ एव च |  

एवं कृच्छ्रतमा नॄणां दृश्यन्ते व्याधिसङ्कराः |  

एवं कृच्छ्रतमा नॄणां दृश्यन्ते व्याधिसङ्कराः |  

प्रयोगापरिशुद्धत्वात्तथा चान्योन्यसम्भवात् ||२२||

प्रयोगापरिशुद्धत्वात्तथा चान्योन्यसम्भवात् ||२२||

ēvaṁ kr̥cchratamā nr̥̄ṇāṁ dr̥śyantē vyādhisaṅkarāḥ|  

ēvaṁ kr̥cchratamā nr̥̄ṇāṁ dr̥śyantē vyādhisaṅkarāḥ|  

prayōgāpariśuddhatvāttathā cānyōnyasambhavāt||22||

prayōgāpariśuddhatvāttathā cānyōnyasambhavāt||22||

प्रयोगः शमयेद्व्याधिं योऽन्यमन्यमुदीरयेत् |  

प्रयोगः शमयेद्व्याधिं योऽन्यमन्यमुदीरयेत् |  

नासौ विशुद्धः, शुद्धस्तु शमयेद्यो न कोपयेत् ||२३||  

नासौ विशुद्धः, शुद्धस्तु शमयेद्यो न कोपयेत् ||२३||  

prayōgaḥ śamayēdvyādhiṁ yō'nyamanyamudīrayēt|  

prayōgaḥ śamayēdvyādhiṁ yō'nyamanyamudīrayēt|  

nāsau viśuddhaḥ, śuddhastu śamayēdyō na kōpayēt||23||

nāsau viśuddhaḥ, śuddhastu śamayēdyō na kōpayēt||23||

vyAdhayaste tadAtve tu li~ggAnIShTAni nAmayAH||40||

vyAdhayaste tadAtve tu li~ggAnIShTAni nAmayAH||40||

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In the [[Nidana Sthana]], a compendium of symptomatology has been provided as a reckoner for the [https://en.wikipedia.org/wiki/Ayurveda Ayurveda] practitioner to gain adequate knowledge of some of the major classes of diseases and diagnose them effectively. But these symptoms may independently develop into diseases and create emergency situations. [40]

In the [[Nidana Sthana]], a compendium of symptomatology has been provided as a reckoner for the Ayurveda practitioner to gain adequate knowledge of some of the major classes of diseases and diagnose them effectively. But these symptoms may independently develop into diseases and create emergency situations. [40]

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विकारः प्रकृतिश्चैव द्वयं सर्वं समासतः |  

विकारः प्रकृतिश्चैव द्वयं सर्वं समासतः |  

Fig. 2: Faculty involved in attainment of knowledge  

Fig. 2: Faculty involved in attainment of knowledge  

According to [https://en.wikipedia.org/wiki/Ayurveda Ayurveda], knowledge of external objects is processed through sense organs , to the mind- intellect, culminating in the spirit. This chain or sequence for attainment of knowledge is important for proper functioning of memory (encoding, storage and retrieval) and intellect (cognition) [Fig.2]. Occasional impairment of coordination in the sequence consisting of sense organs-intellect-mind-spirit is seen in apasmara. This may lead to decrease in cognitive performance of an individual.   

According to Ayurveda, knowledge of external objects is processed through sense organs , to the mind- intellect, culminating in the spirit. This chain or sequence for attainment of knowledge is important for proper functioning of memory (encoding, storage and retrieval) and intellect (cognition) [Fig.2]. Occasional impairment of coordination in the sequence consisting of sense organs-intellect-mind-spirit is seen in apasmara. This may lead to decrease in cognitive performance of an individual.   

In conventional medicine, three major factors that cause disturbance in cerebral neurotransmission leading to blackouts and epilepsy viz. hypo-perfusion, hypo-metabolism, and hypoxia have been described in relevant medical texts. These disturbances lead to abnormal discharges, improper signal transduction in the neurotransmitter channels, and seizures. As a consequence, cellular dysfunctions in the brain, disruptions of the memory mechanism, and disturbed coordination of movements may occur causing the clinical manifestation of ''apasmara''. The role of these three factors and its impact on memory and cellular dysfunction in the pathogenesis of epilepsy need to be elucidated. The three pathological effects are comparable to the changes created by vitiation of ''kapha, pitta'' and ''vata''. Differentiation between these three types of manifestations is described further.  

In conventional medicine, three major factors that cause disturbance in cerebral neurotransmission leading to blackouts and epilepsy viz. hypo-perfusion, hypo-metabolism, and hypoxia have been described in relevant medical texts. These disturbances lead to abnormal discharges, improper signal transduction in the neurotransmitter channels, and seizures. As a consequence, cellular dysfunctions in the brain, disruptions of the memory mechanism, and disturbed coordination of movements may occur causing the clinical manifestation of ''apasmara''. The role of these three factors and its impact on memory and cellular dysfunction in the pathogenesis of epilepsy need to be elucidated. The three pathological effects are comparable to the changes created by vitiation of ''kapha, pitta'' and ''vata''. Differentiation between these three types of manifestations is described further.  

Per [https://en.wikipedia.org/wiki/Ayurveda Ayurveda], ''smriti'' is ''atmaja'' (originated from the soul) and ''sattvaja'' (originated from the mind). This means that ''smriti'' (memory) of a person is essentially related with soul and mind. The Bhagavad Gita describes the consequences of excessive indulgence in sensory activities leading to excessive affliction resulting in an increase in passion, then anger, and then lack of knowledge. This further leads to deterioration of ''smriti'' and then affecting the intellect. This sequence lays the ground for ''apasmara''.

Per Ayurveda, ''smriti'' is ''atmaja'' (originated from the soul) and ''sattvaja'' (originated from the mind). This means that ''smriti'' (memory) of a person is essentially related with soul and mind. The Bhagavad Gita describes the consequences of excessive indulgence in sensory activities leading to excessive affliction resulting in an increase in passion, then anger, and then lack of knowledge. This further leads to deterioration of ''smriti'' and then affecting the intellect. This sequence lays the ground for ''apasmara''.

==== ''Tattva Sara'' ====

==== ''Tattva Sara'' ====

===== Incorrect postures and movements =====

===== Incorrect postures and movements =====

The sixth etiological factor , per [https://en.wikipedia.org/wiki/Ayurveda Ayurveda], constitutes of wrong postures and movements. Since the coordination of movements is regulated by ''dhi-buddhi-smriti'', any imbalance in the sense organs-mind-intellect-spirits sequence not only impairs movement of limbs but also increases the propensity of getting afflicted with ''apasmara''. Conversely, wrong postures and movements are a result of disturbances in the sense organs-spirits sequence that lead to incorrect attainment of knowledge with the manifestation of ''apasmara''.

The sixth etiological factor constitutes of wrong postures and movements. Since the coordination of movements is regulated by ''dhi-buddhi-smriti'', any imbalance in the sense organs-mind-intellect-spirits sequence not only impairs movement of limbs but also increases the propensity of getting afflicted with ''apasmara''. Conversely, wrong postures and movements are a result of disturbances in the sense organs-spirits sequence that lead to incorrect attainment of knowledge with the manifestation of ''apasmara''.

Uncomfortable sitting, sleeping, positioning, irregular, uncoordinated movements of body (e.g. improper dance, sports etc.) can predispose ''apasmara''.

Uncomfortable sitting, sleeping, positioning, irregular, uncoordinated movements of body (e.g. improper dance, sports etc.) can predispose ''apasmara''.

===== Excessive degeneration and debility =====

===== Excessive degeneration and debility =====

The seventh and last etiological factor i.e. excessive degeneration or debility may lead to pathogenesis of ''apasmara'' , pointing at ''dhatukshayajanya vataprakopa'' (vitiation of ''vata'' due to depletion of tissues) as a root cause. The degeneration might be a secondary condition resulting from other diseases. Hypo-perfusion and low levels of oxygen and metabolism could result in brain cell dysfunctions causing seizures. This is analogous to the concept of ''ati upakshaya'' in [https://en.wikipedia.org/wiki/Ayurveda Ayurveda]. Therefore, a clinical examination of depletion of tissues (''dhatukshaya'') could be considered as a treatment component in the management of ''apasmara''.

The seventh and last etiological factor i.e. excessive degeneration or debility may lead to pathogenesis of ''apasmara'' , pointing at ''dhatukshayajanya vataprakopa'' (vitiation of ''vata'' due to depletion of tissues) as a root cause. The degeneration might be a secondary condition resulting from other diseases. Hypo-perfusion and low levels of oxygen and metabolism could result in brain cell dysfunctions causing seizures. This is analogous to the concept of ''ati upakshaya'' in Ayurveda. Therefore, a clinical examination of depletion of tissues (''dhatukshaya'') could be considered as a treatment component in the management of ''apasmara''.

Acute and severe electrolyte imbalances (hyponatremia, hypocacemia and hypomagnesemia) frequently cause seizures.

Acute and severe electrolyte imbalances (hyponatremia, hypocacemia and hypomagnesemia) frequently cause seizures.

In addition to the above factors, Sushruta has quoted two more factors for predisposition of ''apasmara''. ''Veganigraha sheelanam'' i.e. habitual suppression of natural urges and ''gachchatam cha rajaswalam'' i.e., having sexual intercourse with menstruating women can make the individual more susceptible to epilepsy. Recent research suggests that menotoxins secreted by the female body during menstruation significantly impact the psyche of a person accompanying that female.  

In addition to the above factors, Sushruta has quoted two more factors for predisposition of ''apasmara''. ''Veganigraha sheelanam'' i.e. habitual suppression of natural urges and ''gachchatam cha rajaswalam'' i.e., having sexual intercourse with menstruating women can make the individual more susceptible to epilepsy. Recent research suggests that menotoxins secreted by the female body during menstruation significantly impact the psyche of a person accompanying that female.  

On the first of these two factors, per [https://en.wikipedia.org/wiki/Ayurveda Ayurveda], suppression of any of the thirteen types of natural urges may lead to various disorders. Suppressing natural urges leads to ''vata''-dominant disorders and as ''vata'' is the regulator of mind-related activities, this consequently can result in neuropsychiatric disorders like ''apasmara''. All the urges are stimulated, regulated and completed by the nervous system. Inhibition of these factors might lead to impairment of neurotransmission which can be a cause for neuropsychiatric disorders. Furthermore, suppression of urges can lead to accumulation of waste materials inside the body creating various diseases.  

On the first of these two factors, per Ayurveda, suppression of any of the thirteen types of natural urges may lead to various disorders. Suppressing natural urges leads to ''vata''-dominant disorders and as ''vata'' is the regulator of mind-related activities, this consequently can result in neuropsychiatric disorders like ''apasmara''. All the urges are stimulated, regulated and completed by the nervous system. Inhibition of these factors might lead to impairment of neurotransmission which can be a cause for neuropsychiatric disorders. Furthermore, suppression of urges can lead to accumulation of waste materials inside the body creating various diseases.  

On the second factor mentioned here, the correlation between having an intercourse with menstruating woman and getting afflicted with epilepsy needs to be researched further. [https://en.wikipedia.org/wiki/Ayurveda Ayurveda] strictly forbids sharing things with a menstruating woman, leave aside touching or having sexual relations with one. While there are reasons of following sacredness associated with this, sex with a menstruating woman is also indicative of exposure to unclean objects described earlier as the origin of ''apasmara''. The psycho-neuro-endocrinological axis behind this view of Sushruta needs to be explored.   

On the second factor mentioned here, the correlation between having an intercourse with menstruating woman and getting afflicted with epilepsy needs to be researched further. Ayurveda strictly forbids sharing things with a menstruating woman, leave aside touching or having sexual relations with one. While there are reasons of following sacredness associated with this, sex with a menstruating woman is also indicative of exposure to unclean objects described earlier as the origin of ''apasmara''. The psycho-neuro-endocrinological axis behind this view of Sushruta needs to be explored.   

      

      

Thus, from the above descriptions, etiopathological factors of ''apasmara'' can be categorized into dietary factors, lifestyle factors, psychological factors, behavioral factors and iatrogenic factors. All the above predisposing factors can be scanned for epigenetic modifications with respect to personality types, behavior patterns and occurrence of ''apasmara'' in such cases. This will be useful in identifying the disease at a primitive stage, breaking the pathogenesis at an intermedial stage and prevention of further deterioration and complications at later stage. There might be certain epigenetic patterns/changes due to the above mentioned etiological factors, which make the person more susceptible to get affected.  

Thus, from the above descriptions, etiopathological factors of ''apasmara'' can be categorized into dietary factors, lifestyle factors, psychological factors, behavioral factors and iatrogenic factors. All the above predisposing factors can be scanned for epigenetic modifications with respect to personality types, behavior patterns and occurrence of ''apasmara'' in such cases. This will be useful in identifying the disease at a primitive stage, breaking the pathogenesis at an intermedial stage and prevention of further deterioration and complications at later stage. There might be certain epigenetic patterns/changes due to the above mentioned etiological factors, which make the person more susceptible to get affected.  

If we critically analyze and compare the pathophysiology, it can be observed that unlike modern research, the brain did not figure in Charaka’s analysis of disease or their pathologic basis, nor did he emphasize the role of an exogenous or supernatural power (''agantuka'') factor in the causation of epilepsy. Charaka has clearly mentioned heart, the abode of self and consciousness, as the origin for ''apasmara''. In the seizure state, ''doshas'' stride upwards through ''dhamanis'' (vessels), affecting the ''indriyas'' (sense and locomotor organs) leading to erratic movements and loss of consciousness. Sushruta and Vagbhata have specifically mentioned the ''samajnavahishu srotasu'' (channels of consciousness) as the pathway of spread of ''doshas'' and as a site for the disease.     

If we critically analyze and compare the pathophysiology, it can be observed that unlike modern research, the brain did not figure in Charaka’s analysis of disease or their pathologic basis, nor did he emphasize the role of an exogenous or supernatural power (''agantuka'') factor in the causation of epilepsy. Charaka has clearly mentioned heart, the abode of self and consciousness, as the origin for ''apasmara''. In the seizure state, ''doshas'' stride upwards through ''dhamanis'' (vessels), affecting the ''indriyas'' (sense and locomotor organs) leading to erratic movements and loss of consciousness. Sushruta and Vagbhata have specifically mentioned the ''samajnavahishu srotasu'' (channels of consciousness) as the pathway of spread of ''doshas'' and as a site for the disease.     

As per [https://en.wikipedia.org/wiki/Ayurveda Ayurveda], the heart (and not the brain), is the locus or abode of the mind, consciousness and soul , and emotional factors are considered as some of the root causes for triggering epilepsy. The clinical presentation of epilepsy represents the derangement of functions of neurons of central nervous system, but the origin of this derangement shall have been predisposed much earlier due to psycho-pathological factors enlisted above. The acute onset of seizure can be precipitated due to emotional factors. The mechanism of this phenomenon and exact psycho-neuronal pathways behind this are worthy of study.   

As per Ayurveda, the heart (and not the brain), is the locus or abode of the mind, consciousness and soul , and emotional factors are considered as some of the root causes for triggering epilepsy. The clinical presentation of epilepsy represents the derangement of functions of neurons of central nervous system, but the origin of this derangement shall have been predisposed much earlier due to psycho-pathological factors enlisted above. The acute onset of seizure can be precipitated due to emotional factors. The mechanism of this phenomenon and exact psycho-neuronal pathways behind this are worthy of study.   

''Prana vayu'' (''buddhi-hridaya-indriya-chitta dhruk'', i.e., regulation of intellect, heart, senses, mind functions), ''vyana vayu'' (seat at ''hridaya'' and regulating all types of movements), ''udana vayu'' (functions for energy and activities), ''sadhaka pitta'' (type of ''pitta dosha''), ''tarpaka'' (type of ''kapha'') and ''avalambaka kapha'' (type of ''kapha'') are important to be considered as patho-physiological factors in this context.

''Prana vayu'' (''buddhi-hridaya-indriya-chitta dhruk'', i.e., regulation of intellect, heart, senses, mind functions), ''vyana vayu'' (seat at ''hridaya'' and regulating all types of movements), ''udana vayu'' (functions for energy and activities), ''sadhaka pitta'' (type of ''pitta dosha''), ''tarpaka'' (type of ''kapha'') and ''avalambaka kapha'' (type of ''kapha'') are important to be considered as patho-physiological factors in this context.

===== ''Skanda graha'' and ''Skandapasmara'' =====

===== ''Skanda graha'' and ''Skandapasmara'' =====

Per [https://en.wikipedia.org/wiki/Ayurveda Ayurveda], children get afflicted by ''apasmara'' due to the effects of any of ''grahas'' (Sanskrit, means seizing) such as ''skandapasmara'' (due to the effects of ''graha''<ref> Sushruta, ‘Sushruta Samhita’, edited by Vaidya Jadavaji Trikamaji Acharya and Sharma PV, Eighth edition, Chaukhamba Orientalia, Varanasi; 2005 Uttara tantra 27/ 8-9.pg.659 </ref>  <ref>Vagbhata, Ashtanga Hridayam, with the commentaries, ‘Sarvangasundara’ of Arunadatta and ‘Ayurvedarasayana’ of Hemadri collated by Dr.Anna Moreshvara Kunte, and Krishna Ramachandra  Shastri Navre, edited by Pt. Harishastri Paradakar Vaidya, Krishanadas Academy, Varanasi. Reprint 2000.3/6-11.pg.786-7  </ref>.), ''skanda'', etc. knowledge of features of nine evil spirits which seize children is described, ''skanda'' and ''skandapasmara'' are the first two evil spirits which when affect a child, the clinical presentation is similar to that of epilepsy as narrated below.  

Per Ayurveda, children get afflicted by ''apasmara'' due to the effects of any of ''grahas'' (Sanskrit, means seizing) such as ''skandapasmara'' (due to the effects of ''graha''<ref> Sushruta, ‘Sushruta Samhita’, edited by Vaidya Jadavaji Trikamaji Acharya and Sharma PV, Eighth edition, Chaukhamba Orientalia, Varanasi; 2005 Uttara tantra 27/ 8-9.pg.659 </ref>  <ref>Vagbhata, Ashtanga Hridayam, with the commentaries, ‘Sarvangasundara’ of Arunadatta and ‘Ayurvedarasayana’ of Hemadri collated by Dr.Anna Moreshvara Kunte, and Krishna Ramachandra  Shastri Navre, edited by Pt. Harishastri Paradakar Vaidya, Krishanadas Academy, Varanasi. Reprint 2000.3/6-11.pg.786-7  </ref>.), ''skanda'', etc. knowledge of features of nine evil spirits which seize children is described, ''skanda'' and ''skandapasmara'' are the first two evil spirits which when affect a child, the clinical presentation is similar to that of epilepsy as narrated below.  

A child seized by ''skanda graha'' has swelling of the eyes, smells like blood, has aversion to the breasts, distorted face, and eyelids or one eye having either loss of movement or more movements. The child could also be restless or irritable, have closed eyes, cry very little, hold its fists tight, and have hard bowel movement.  

A child seized by ''skanda graha'' has swelling of the eyes, smells like blood, has aversion to the breasts, distorted face, and eyelids or one eye having either loss of movement or more movements. The child could also be restless or irritable, have closed eyes, cry very little, hold its fists tight, and have hard bowel movement.  

#Enlisting newly introduced disease commonly observed in society into the umbrella of ''apasmara'' e.g. Alzheimer’s dementia, depression etc.  

#Enlisting newly introduced disease commonly observed in society into the umbrella of ''apasmara'' e.g. Alzheimer’s dementia, depression etc.  

#Retrospective analyses of all signs and symptoms enlisted in the modern text books and formulating probable ''samprapti'' / pathophysiology (''dosha-dushya sammurchchna'') based on ''dosha'' dominance behind manifestation of each sign and symptom can be formulated for better understanding in Ayurvedic perspective.  

#Retrospective analyses of all signs and symptoms enlisted in the modern text books and formulating probable ''samprapti'' / pathophysiology (''dosha-dushya sammurchchna'') based on ''dosha'' dominance behind manifestation of each sign and symptom can be formulated for better understanding in Ayurvedic perspective.  

#Assessment criteria in [https://en.wikipedia.org/wiki/Ayurveda Ayurveda] and modern science, modern investigation methods and technologies, biomarkers which are well established may be enlisted.

#Assessment criteria in Ayurveda and modern science, modern investigation methods and technologies, biomarkers which are well established may be enlisted.

=== Further reading ===

=== Further reading ===