Changes

== Vidhi Vimarsha (Applied Inferences) ==

== Vidhi Vimarsha (Applied Inferences) ==

The chapter on apasmara is sequenced after the one on ''unmada''. The sequence is due to similarities of clinical origin as well as causative and pathophysiological factors, since both diseases are psychosomatic in nature.  

The chapter on apasmara is sequenced after the one on [[unmada]]. The sequence is due to similarities of clinical origin as well as causative and pathophysiological factors, since both diseases are psychosomatic in nature.  

=== History and origin of the disease in ancient medical literature ===

=== History and origin of the disease in ancient medical literature ===

=== Impairment of knowledge and coordination ===

=== Impairment of knowledge and coordination ===

  [[File:Co-ordination1.png|500px|'''Fig. 2: Faculty involved in attainment of knowledge'''|thumb]]

  [[File:Co-ordination1.png|500px|'''Fig. 1: Faculty involved in attainment of knowledge'''|thumb]]

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.[Fig. 2: Faculty involved in attainment of knowledge]   

According to [[Ayurveda]], knowledge of external objects is processed through sense organs , to the mind-intellect, culminating in the spirit. This chain or sequence for attainment of knowledge is important for proper functioning of memory (encoding, storage and retrieval) and intellect (cognition) [Fig.1]. Occasional impairment of coordination in the sequence consisting of sense organs-intellect-mind-spirit is seen in apasmara. This may lead to decrease in cognitive performance of an individual.[Fig. 1: Faculty involved in attainment of knowledge]   

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

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.  

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[[File:psycho-dynamics.png|500px|'''Fig.3: Psycho-dynamics in Apasmara'''|thumb ]]<br>

[[File:psycho-dynamics.png|500px|'''Fig.2: Psycho-dynamics in Apasmara'''|thumb ]]<br>

'''Fig.3: Psycho-dynamics in apasmara'''  

'''Fig.2: Psycho-dynamics in apasmara'''  

=== Six stages of pathogenesis of epilepsy (''shatkriyakala'' for apasmara) ===

=== Six stages of pathogenesis of epilepsy (''shatkriyakala'' for apasmara) ===

The pathogenesis of apasamara can be understood as below. [Fig.4: Schematic presentation of pathogenesis of apasmara]

The pathogenesis of apasamara can be understood as below. [Fig.3: Schematic presentation of pathogenesis of apasmara]

[[File:pathogenesis.png|500px|'''Fig.4a: Schematic presentation of pathogenesis of apasmara'''|thumb]]  

[[File:pathogenesis.png|500px|'''Fig.3a: Schematic presentation of pathogenesis of apasmara'''|thumb]]  

[[File:pathogenesis part2.png|500px|'''Fig.4b: Schematic presentation of pathogenesis of apasmara'''| thumb]]<br>

[[File:pathogenesis part2.png|500px|'''Fig.3b: Schematic presentation of pathogenesis of apasmara'''| thumb]]<br>

==== ''Sanchaya'' ====

==== ''Sanchaya'' ====

=== Types of apasmara ===

=== Types of apasmara ===

There are four types of apasmara depending upon the predominance of ''dosha'' as shown in fig. 5. The first thing of significance is that all these are ''sharira doshas'' and not ''manasa doshas''. This implies that apasmara is predominantly a somatic disease in which psychological factors play a role in pathogenesis. The important aspect of management should be focused at the somatic level supported by psychotherapy. The role of genetic constitution is important in the study of clinical manifestations of apasmara as well as their response either to treatments involving allopathic anti-epileptic medications or to Ayurvedic treatment modalities. The diagnosis of dominance of ''dosha'' is also important in deciding the treatment modalities prescribed in cases of apasmara. The epigenetic variation of the four types of apasmara and the categorization of etio-pathological factors to lead the epigenetic modification resulting into specific type of apasmara is worthy of study.   

There are four types of apasmara depending upon the predominance of ''dosha''. The first thing of significance is that all these are ''sharira doshas'' and not ''manasa doshas''. This implies that apasmara is predominantly a somatic disease in which psychological factors play a role in pathogenesis. The important aspect of management should be focused at the somatic level supported by psychotherapy. The role of genetic constitution is important in the study of clinical manifestations of apasmara as well as their response either to treatments involving allopathic anti-epileptic medications or to Ayurvedic treatment modalities. The diagnosis of dominance of ''dosha'' is also important in deciding the treatment modalities prescribed in cases of apasmara. The epigenetic variation of the four types of apasmara and the categorization of etio-pathological factors to lead the epigenetic modification resulting into specific type of apasmara is worthy of study.   

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

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

From the above sections, it is clear that apasmara occurs in episodes. The patient after seizure regains consciousness like waking up from sleep (''suptavat pratibuddhyate''). Therefore, there are two stages of disease : one is aggressive stage of ''doshas'' and the second is dormant stage of ''doshas''. Sushruta describes that there are two forms of pathogenesis: One form follows the six stages viz. ''sanchaya'' etc.(''kramopayogad'') of the disease in sequence and takes considerable time to manifest disease with gradual onset. The other form manifests acutely in a short time (''kshanikatwat''). The first form is seen in ''nija'' (endogenous) pathologies of disease. The other form is seen in ''agantu'' (exogenous) apasmara. Sushruta gives examples of a seed in the ground that sprouts only during ''sharad ritu'' (autumn) though it rains at other times. Analogous to this example, the virulent form of the disease develops due to a ''dosha'' getting aggravated in very short time and manifesting its different symptoms due to some factors catalyzing the accelerated aggravation. It is quite clear from the detailed descriptions in this chapter, though, that all forms of apasmara are caused by ''dosha'' only.<ref> Ibid Sushruta Samhita Uttar Tantra 61/18-21.pp.800-801. </ref>

From the above sections, it is clear that apasmara occurs in episodes. The patient after seizure regains consciousness like waking up from sleep (''suptavat pratibuddhyate''). Therefore, there are two stages of disease : one is aggressive stage of ''doshas'' and the second is dormant stage of ''doshas''. Sushruta describes that there are two forms of pathogenesis: One form follows the six stages viz. ''sanchaya'' etc.(''kramopayogad'') of the disease in sequence and takes considerable time to manifest disease with gradual onset. The other form manifests acutely in a short time (''kshanikatwat''). The first form is seen in ''nija'' (endogenous) pathologies of disease. The other form is seen in ''agantu'' (exogenous) apasmara. Sushruta gives examples of a seed in the ground that sprouts only during ''sharad ritu'' (autumn) though it rains at other times. Analogous to this example, the virulent form of the disease develops due to a ''dosha'' getting aggravated in very short time and manifesting its different symptoms due to some factors catalyzing the accelerated aggravation. It is quite clear from the detailed descriptions in this chapter, though, that all forms of apasmara are caused by ''dosha'' only.<ref> Ibid Sushruta Samhita Uttar Tantra 61/18-21.pp.800-801. </ref>

   

   

The example states the fact that favorable environment for precipitating factors plays major role in disease episodes. Depending upon the defense system of the body – its natural and acquired immunity -  as the background for disease and factors aggravating the ''dosha'' as offending agents, the interaction between the two defines severity, intensity and frequency of occurrence of episodes of disease as shown in chart. [ Fig.5: Manifestation of episodes ]

The example states the fact that favorable environment for precipitating factors plays major role in disease episodes. Depending upon the defense system of the body – its natural and acquired immunity -  as the background for disease and factors aggravating the ''dosha'' as offending agents, the interaction between the two defines severity, intensity and frequency of occurrence of episodes of disease as shown in chart. [ Fig.4: Manifestation of episodes ]

[[File:mainfastation.png|500px|'''Fig.5: Manifestation of episodes'''|thumb]]<br>  

[[File:mainfastation.png|500px|'''Fig.4: Manifestation of episodes'''|thumb]]<br>  

Therefore, for prevention and management of a disease, it is important either to build up the strength of defense system i.e. improving the ''sharira bala'' (physical strength) and ''sattva bala'' (mental strength), or pacify/weaken the aggravating causative factors or both.

Therefore, for prevention and management of a disease, it is important either to build up the strength of defense system i.e. improving the ''sharira bala'' (physical strength) and ''sattva bala'' (mental strength), or pacify/weaken the aggravating causative factors or both.