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iti carakasaṁhitāyāṁ dvitīyaṁ nidānasthānaṁ samāptam|

iti carakasaṁhitāyāṁ dvitīyaṁ nidānasthānaṁ samāptam|

Thus, ends the eighth chapter on the ‘diagnosis of ''apasmara''” of the section “Diagnosis of diseases” ([[Nidana Sthana]]) of Agnivesha , as redacted by Charaka.

Thus, ends the eighth chapter on the ‘diagnosis of ''apasmara''” of the section “Diagnosis of diseases” ([[Nidana Sthana]]) of Agnivesha , as redacted by Charak.

=== ''Tattva Vimarsha'' ===

=== ''Tattva Vimarsha'' ===

Review of ancient medical literature confirms that epilepsy was initially called sacred, because of the belief for its divine origin<ref>Emmanouil Magiorkinis, Kalliopi Sidiropoulou Aristidis Diamantis. Hallmarks in the History of Epilepsy: From Antiquity Till the Twentieth Century. Novel Aspects on Epilepsy Office for the Study of History of Hellenic Naval Medicine, Naval Hospital of Athens, Greece.  </ref>. A chapter on epilepsy in Babylonian texts on medicine comprising 40 tablets dating as far back as 1067 BC accurately recorded many of the different seizure types recognized today. It emphasizes upon the supernatural nature of epilepsy, with each seizure type associated with a divinity, spirit or deity (usually evil)<ref> J. M. S. Pierce, a disease once sacred. A history of the medical understanding of epilepsy

Review of ancient medical literature confirms that epilepsy was initially called sacred, because of the belief for its divine origin<ref>Emmanouil Magiorkinis, Kalliopi Sidiropoulou Aristidis Diamantis. Hallmarks in the History of Epilepsy: From Antiquity Till the Twentieth Century. Novel Aspects on Epilepsy Office for the Study of History of Hellenic Naval Medicine, Naval Hospital of Athens, Greece.  </ref>. A chapter on epilepsy in Babylonian texts on medicine comprising 40 tablets dating as far back as 1067 BC accurately recorded many of the different seizure types recognized today. It emphasizes upon the supernatural nature of epilepsy, with each seizure type associated with a divinity, spirit or deity (usually evil)<ref> J. M. S. Pierce, a disease once sacred. A history of the medical understanding of epilepsy

By Mervyn J. Eadie and Peter F. Bladin2001. Eastleigh: John Libbey.  Pp. 248. ISBN 0‐86196‐607‐4. Oxford Journals Medicine Brain Volume 125, Issue 2 Pp. 441-442.

By Mervyn J. Eadie and Peter F. Bladin2001. Eastleigh: John Libbey.  Pp. 248. ISBN 0‐86196‐607‐4. Oxford Journals Medicine Brain Volume 125, Issue 2 Pp. 441-442.

  </ref>. It was believed, in antiquity, that if a person comes in contact with things that are supernatural and evil, he/she would suffer from epilepsy. This view is consistent with those in ancient Greek, British, and Indian (Vedic) literature as well. The Ayurvedic theory of origin of epilepsy mentions contact with evil, unwholesome and unclean objects or experiences as key causative factors. References of ''grahas'' (celestial bodies) as a causative factor of ''apasmara'', specifically in children, can be found in vedic texts with terms such as ‘skanda’ and ‘skandapasmara. Though there are references of exogenous variants of epilepsy (''agantu apasmara'') in [[Charaka Samhita]], a detailed description of these is not found. This indicates two things:  

  </ref>. It was believed, in antiquity, that if a person comes in contact with things that are supernatural and evil, he/she would suffer from epilepsy. This view is consistent with those in ancient Greek, British, and Indian (Vedic) literature as well. The Ayurvedic theory of origin of epilepsy mentions contact with evil, unwholesome and unclean objects or experiences as key causative factors. References of ''grahas'' (celestial bodies) as a causative factor of ''apasmara'', specifically in children, can be found in vedic texts with terms such as ‘skanda’ and ‘skandapasmara. Though there are references of exogenous variants of epilepsy (''agantu apasmara'') in [[Charak Samhita]], a detailed description of these is not found. This indicates two things:  

#Epilepsy originates from exposure to unwholesome, unclean and evil things either at a physical or at a psycho-spiritual plane.   

#Epilepsy originates from exposure to unwholesome, unclean and evil things either at a physical or at a psycho-spiritual plane.   

#Management of the disease may include ''adhyatmik chikitsa'' (psycho-spiritual therapy) for better treatment.

#Management of the disease may include ''adhyatmik chikitsa'' (psycho-spiritual therapy) for better treatment.

===== Role of diet =====

===== Role of diet =====

The third key factor is the role of quality of diet in the causation of the disease. Charaka uses terms like ''samala'' (impure), ''vikrita'' (deformed/altered), ''upahita'' (mixed), and ''ashuchi'' (unclean/unhygienic) as adjectives to describe food articles that cause ''apasmara''. Sushruta uses terms like ''viruddha'' (incompatible or of contradictory/antagonistic nature) and ''malina'' (bad) for the same factors. Besides providing nutrition to the body, diet plays a great impact on the mind as well. It is mentioned in the texts that the nutrition of soma and psyche occurs through food and food habits. Yogic texts narrate the role of food in nourishing five sheaths of the body, called ''annamaya kosha, pranamaya kosha, vijnanamaya kosha, manomaya kosha'' and ''anandmaya kosha''. Therefore, diet is not only important for proper functioning of the three ''doshas'', but also for nourishment of the mind and the soul. Charaka as well as Sushruta have acknowledged the role of unclean, unhygienic, unwholesome, incompatible diet in the causation of ''apasmara''. Dallhana commented that this includes the diet that is ''dwishta'' (disliked by mind or taken with hatred feeling), ''amedhya'' (not satisfying mind) and ''paryushita'' (stale). All these types of diet can cause disturbance in the body and mind. As per conventional medicine, a diet that is deficient in certain vitamins and minerals and that which increases neurotoxins may lead to neurological disorders. Therefore, biochemical changes in the above mentioned causative foods may lead to deficiencies of important nutrients and cause increase in neurotoxins resulting in ''apasmara'' like disorders. Moreover, some gastrointestinal symptoms have been described further as premonitory symptoms of ''apasmara''. The role of diet and food habits as a cause of ''apasmara'' needs to be further researched. These factors are to be avoided during the treatment of apasmara. Not following /proper dietary rules is one of the key causes for the formation of ''ama''. ''Ama'' produces free radicals leading to excessive oxidative stress and tissue injuries. Therefore, following proper dietary habits is important in preventing the pathogenesis of the disease. Furthermore, this suggests the possibility of food contamination as a causative factor for epilepsy. A case of endrin-laced taquitos causing seizures in the US is an example of food contamination causing epileptic seizures .<ref> K Waller, T J Prendergast, A Slagle, R J Jackson.Seizures after eating a snack food contaminated with the pesticide endrin. The tale of the toxic taquitos. West J Med. 1992 Dec; 157(6): 648–651 </ref>

The third key factor is the role of quality of diet in the causation of the disease. Charak uses terms like ''samala'' (impure), ''vikrita'' (deformed/altered), ''upahita'' (mixed), and ''ashuchi'' (unclean/unhygienic) as adjectives to describe food articles that cause ''apasmara''. Sushruta uses terms like ''viruddha'' (incompatible or of contradictory/antagonistic nature) and ''malina'' (bad) for the same factors. Besides providing nutrition to the body, diet plays a great impact on the mind as well. It is mentioned in the texts that the nutrition of soma and psyche occurs through food and food habits. Yogic texts narrate the role of food in nourishing five sheaths of the body, called ''annamaya kosha, pranamaya kosha, vijnanamaya kosha, manomaya kosha'' and ''anandmaya kosha''. Therefore, diet is not only important for proper functioning of the three ''doshas'', but also for nourishment of the mind and the soul. Charak as well as Sushruta have acknowledged the role of unclean, unhygienic, unwholesome, incompatible diet in the causation of ''apasmara''. Dallhana commented that this includes the diet that is ''dwishta'' (disliked by mind or taken with hatred feeling), ''amedhya'' (not satisfying mind) and ''paryushita'' (stale). All these types of diet can cause disturbance in the body and mind. As per conventional medicine, a diet that is deficient in certain vitamins and minerals and that which increases neurotoxins may lead to neurological disorders. Therefore, biochemical changes in the above mentioned causative foods may lead to deficiencies of important nutrients and cause increase in neurotoxins resulting in ''apasmara'' like disorders. Moreover, some gastrointestinal symptoms have been described further as premonitory symptoms of ''apasmara''. The role of diet and food habits as a cause of ''apasmara'' needs to be further researched. These factors are to be avoided during the treatment of apasmara. Not following /proper dietary rules is one of the key causes for the formation of ''ama''. ''Ama'' produces free radicals leading to excessive oxidative stress and tissue injuries. Therefore, following proper dietary habits is important in preventing the pathogenesis of the disease. Furthermore, this suggests the possibility of food contamination as a causative factor for epilepsy. A case of endrin-laced taquitos causing seizures in the US is an example of food contamination causing epileptic seizures .<ref> K Waller, T J Prendergast, A Slagle, R J Jackson.Seizures after eating a snack food contaminated with the pesticide endrin. The tale of the toxic taquitos. West J Med. 1992 Dec; 157(6): 648–651 </ref>

===== Improper methods – lifestyle factors =====

===== Improper methods – lifestyle factors =====

===== ''Prakopa'' =====

===== ''Prakopa'' =====

If the individual excessively indulges in observing causative factors for a significant period, then the ''doshas'' proceed to the next stage of pathology i.e. ''prakopa''. The ''doshas'' are vitiated at their own site. In case of ''apasmara'', the doshas reside at the vessels, above the heart (the site of consciousness) in a leena (dormant) state.<ref> Agnivesha ,’Charaka Samhita’, revised by Charaka and Dridhbala with  ‘Ayurveda Dipika’ commentary, by Chakrapanidatta, edited by Vaidya Jadavaji Trikamaji Acharya, Krishnadas Academy, Varanasi. reprint 2000. Chakrapani commentary Apasmara chikitsa 10/6.pg.475 </ref>

If the individual excessively indulges in observing causative factors for a significant period, then the ''doshas'' proceed to the next stage of pathology i.e. ''prakopa''. The ''doshas'' are vitiated at their own site. In case of ''apasmara'', the doshas reside at the vessels, above the heart (the site of consciousness) in a leena (dormant) state.<ref> Agnivesha ,’Charak Samhita’, revised by Charak and Dridhbala with  ‘Ayurveda Dipika’ commentary, by Chakrapanidatta, edited by Vaidya Jadavaji Trikamaji Acharya, Krishnadas Academy, Varanasi. reprint 2000. Chakrapani commentary Apasmara chikitsa 10/6.pg.475 </ref>

===== ''Prasara'' =====

===== ''Prasara'' =====

''Bheda avastha'' is the stage of differentiation depending upon the dominance of ''doshas''. This will predominantly depend upon the genetic constitution of the person as well as the intake of alleviators and pacifiers of that particular ''dosha''. If there are some pacification factors in between, then the progression of disease stops at that stage only blocking presentation of clinical features.     

''Bheda avastha'' is the stage of differentiation depending upon the dominance of ''doshas''. This will predominantly depend upon the genetic constitution of the person as well as the intake of alleviators and pacifiers of that particular ''dosha''. If there are some pacification factors in between, then the progression of disease stops at that stage only blocking presentation of clinical features.     

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

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

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.   

===== ''Agantu Apasmara'' =====

===== ''Agantu Apasmara'' =====

Chakrapani comments that ''Agantuka'' i.e. exogenous type of ''apasmara'' is excluded unlike ''unmada''. Thus Chakrapani rules out the possibility of external factors like ''deva, graha'' etc. to cause ''apasmara'' and emphasizes the endogenous patho-physiology of ''apasmara''. Charaka describes the possibility of exogenous factors affecting the individual to suffer from ''apasmara'' in a verse described later. The management of ''apasmara'' due to exogenous factors is similar to that described in the management of ''agantuja unmada''.   

Chakrapani comments that ''Agantuka'' i.e. exogenous type of ''apasmara'' is excluded unlike ''unmada''. Thus Chakrapani rules out the possibility of external factors like ''deva, graha'' etc. to cause ''apasmara'' and emphasizes the endogenous patho-physiology of ''apasmara''. Charak describes the possibility of exogenous factors affecting the individual to suffer from ''apasmara'' in a verse described later. The management of ''apasmara'' due to exogenous factors is similar to that described in the management of ''agantuja unmada''.   

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

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

Similar to this, Vagbhata in Ashtanga Hridayam, has described the variants of the disease caused due to demons/evil spirits possessing the children. The cardinal signs of ''graha'' possession (or affliction) include continuous fever and crying. The general features are fear, too much yawning, movement of eyebrows, timidity, discharge of froth from mouth, upward gaze, biting of lips and teeth (grinding), wakefulness (absence of sleep), crying, moaning, aversion for the breast, change of voice, and scratching its own body or that of the mother by nails without any reason.<ref> Ibid Ashtanga Hrudayam Uttar Sthana.3/3-5. pp.786 </ref>  

Similar to this, Vagbhata in Ashtanga Hridayam, has described the variants of the disease caused due to demons/evil spirits possessing the children. The cardinal signs of ''graha'' possession (or affliction) include continuous fever and crying. The general features are fear, too much yawning, movement of eyebrows, timidity, discharge of froth from mouth, upward gaze, biting of lips and teeth (grinding), wakefulness (absence of sleep), crying, moaning, aversion for the breast, change of voice, and scratching its own body or that of the mother by nails without any reason.<ref> Ibid Ashtanga Hrudayam Uttar Sthana.3/3-5. pp.786 </ref>  

In conventional medicine, epilepsy in children is described in detail. However, the etiology of some variants of epilepsy is mentioned to be idiopathic. As described in context of ''skanda'' and ''skandapasmara'', the involvement of supernatural powers in causing ''apasmara'' is a matter of debate and falls in the purview of theology. Considering its importance and prevalence, ''apasmara'' of unknown etiology can be categorized as of the fifth type i.e. ''agantu apasmara''. Sushruta and his commentator Dallhana support this view that any variant of the disease which occurs without any reason, acutely and without any rational pathology shall be considered as ''agantu''. Per Charaka [Chikitsa 10/53], the etiopathology, clinical features and management of this fifth type are on the lines of ''agantu unmada''. As commented by Chakrapani, in case of ''agantu'' or ''bhutapasmara'', the etiology of being seized by some external factors is considered primary and the involvement (''anubabdha'') of ''dosha'' as secondary. It is important to note here that since clinical patho-physiology cannot take place without the involvement of ''doshas'', therefore ''agantu'' should technically be considered as one of the four doshic variants of ''apasmara'' mentioned earlier, in order to follow the ''sankhya niyam''a i.e. rules of numeral classification.

In conventional medicine, epilepsy in children is described in detail. However, the etiology of some variants of epilepsy is mentioned to be idiopathic. As described in context of ''skanda'' and ''skandapasmara'', the involvement of supernatural powers in causing ''apasmara'' is a matter of debate and falls in the purview of theology. Considering its importance and prevalence, ''apasmara'' of unknown etiology can be categorized as of the fifth type i.e. ''agantu apasmara''. Sushruta and his commentator Dallhana support this view that any variant of the disease which occurs without any reason, acutely and without any rational pathology shall be considered as ''agantu''. Per Charak [Chikitsa 10/53], the etiopathology, clinical features and management of this fifth type are on the lines of ''agantu unmada''. As commented by Chakrapani, in case of ''agantu'' or ''bhutapasmara'', the etiology of being seized by some external factors is considered primary and the involvement (''anubabdha'') of ''dosha'' as secondary. It is important to note here that since clinical patho-physiology cannot take place without the involvement of ''doshas'', therefore ''agantu'' should technically be considered as one of the four doshic variants of ''apasmara'' mentioned earlier, in order to follow the ''sankhya niyam''a i.e. rules of numeral classification.

==== Premonitory signs of ''apasmara'' ====

==== Premonitory signs of ''apasmara'' ====