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Description of coma and coma arousal therapy in Caraka Saṁhitā and its corollary in modern medicine
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/neuroindia.NI_1110_16
The description of coma and coma arousal therapy in Caraka Saṁhitā is described in sṁtra 24, verses 42–53. It describes the definition of coma, differential diagnosis of coma from other disorders of consciousness, signs of coma, etiology of coma, coma arousal therapy, and emergence from coma. The similarities and differences of these aspects of coma from the perspective of its interpretation in modern medicine are discussed in this article. Keywords: Āyurvēda, Caraka Saṁhitā, coma, coma arousal therapy, minimally conscious state
Coma is one of the dreaded neurological symptoms. It is defined as a state of unresponsiveness in which the patient lies with eyes closed and cannot be aroused to respond appropriately to stimuli, even with vigorous stimulation.[1] Koehler and Wijdicks have reported a history of study of coma in medical and neurological texts from 1640 to 1960 AD.[2] The terminologies used to describe the disorders of consciousness have evolved in the past 300 years.[2] However, the history of description of coma and its treatment in ancient Indian literature has not been mentioned in modern medical articles and textbooks. In this article, the description and treatment of coma mentioned in the ancient Indian medical treatise Caraka Saṁhitā (Charaka's Encyclopedia) is described. The Caraka Saṁhitā is one of the two main text books of the ancient Indian medical system of lifestyle and healing “Āyurvēda.”[3] It was originally written between 900 BC and 700 BC. In later centuries, it was further developed into the form of a full textbook. Sūtrasthāna is the first among the eight parts of Caraka Saṁhitā. Sūtra means a basic formula or principle. The disorders of consciousness are described in the sūtra 24, verses 42–53 [Figure 1].[3],[4]
Differentiating coma from other disorders of consciousness The verse 42 describes saṁnyāsānmadamūrcchāyayōrvaiśiṣṭyam, which is the difference between mūrcchā, which is fainting, madamūrcchā, which is unconsciousness due to intoxication, and saṁnyāsā, which is coma.[5] It reads: dōṣēṣu madamūrcchāyāḥ krtavēgēṣu, dēhinām svayamēvōpaśāmyanti sannyāsō nauṣadhairvinā[42] It means that fainting and unconsciousness due to intoxication subside on their own accord when the bodily bioelements finish their attack; however, coma does not subside without medicine. This verse indicates that coma is a more serious and prolonged form of unconsciousness. Definition of coma The next verse describes saṁnyāsasya saṁprāptiḥ, which means attainment of coma.[5] It reads: vāgdēhamanasāṁ cēṣṭāmākṣipyātibalā malāḥ, sannyasyantyabalaṁ jantuṁ prāṇāyatanasaṁśritāḥ.[43] It means that, in weak persons, when very strong bodily bioelements get located in the abode of vital breath and affect the movement of speech, body, and mind, coma ensues. There is loss of functions of mind, body, and speech.[6],[7] There is absolute loss of consciousness.[3] This definition is quite similar to the modern definition of coma, which mentions that a person cannot be aroused to respond appropriately to stimuli even with vigorous stimulation.[1] The loss of speech was also described by Tulp in 1641; however, loss of body movement has been described in many texts.[2] The Caraka Saṁhitā has not mentioned the status of eyes, i.e., whether they are open or closed. Closed eyes as a definition of coma has been described by Tulp in 1641, Rostan in 1823, and Dana in 1895.[2] The modern definition mentions that the eyes should be closed.[1] Signs of coma The 44th verse describes saṁnyāsasya lakṣaṇam, which means signs of coma.[5] It reads: sa nā sannyāsasannyastaḥ kāṣṭhībhūtō mrtōpamaḥ, prāṇairviyujyatē śīghraṁ muktvā sadyaḥphalāḥ kriyāḥ.[44] It means that the person affected with coma is turned as he/she were a log of wood and appears to be dead. He/she will be soon deprived of his life unless he receives emergency treatment.[4] In this verse, the noteworthy word is kāṣṭhībhūtō, which means 'turned into wood.' This description indicates rigidity or is a metaphor for a vegetative state. In this verse, wood is used as a metaphor for a person. In modern terminology, the derogatory term 'vegetative state' is used to describe the condition of unresponsive wakefulness syndrome. Etiology of coma Though the head and brain were distinguished from each other in the Atharvavēda and Caraka Saṁhitā, neither connected the brain with consciousness or brain-based disorders such as mental illness or epilepsy. Among Caraka's predecessors, Bhēlā was the only one who located the seat of consciousness between the top of the head and palate.[7] The cause of coma was ascribed to disturbance of very strong bodily bioelements. Though all the etiological causes of coma were not described, the reason for coma was presumed to be due to causes outside the head and brain. This is not strange as nearly 60% of patients with coma suffer from extrinsic and metabolic disorders.[1] Coma arousal therapy The verses 45–50 describe treatments for arousing a patient from coma.[5] They read: durgē'mbhasi yathā majjadbhājanaṁ tvarayā budhaḥ, grhṇīyāttalamaprāptaṁ tathā sannyāsapīḍitam.[45] añjanānyavapīḍāśca dhūmāḥ pradhamanāni ca, sūcībhistōdanaṁ śastaṁ dāhaḥ pīḍā nakhāntarē.[46] luñcanaṁ kēśalōmnāṁ ca dantairdaśanamēva ca, ātmaguptāvagharṣaśca hitaṁ tasyāvabōdhanē[47] sammūrcchitāni tīkṣṇāni madyāni vividhāni ca, prabhūtakaṭuyuktāni tasyāsyē gālayēnmuhuḥ.[48] mātuluṅgarasaṁ tadvanmahauṣadhasamāyutam, tadvatsauvarcalaṁ dadyādyuktaṁ madyāmlakāñjikaiḥ.[49] hiṅgūṣaṇasamāyuktaṁ yāvat sañjñāprabōdhanam, prabuddhasañjñamannaiśca laghubhistamupācarēt.[50] The therapies described to arouse a person from coma are classified as physical and chemical (medicinal).[3] The physical therapies mentioned are añjana (antimomy) – application of collyrium, avapīḍa nasya – nasal drops of juice extracts of herbs to produce sneezing, and dhūma – smoke. Other physical therapies mentioned are needles and hot applications on the skin, painful stimuli on the nail bed, plucking of the hair, biting with teeth, and rubbing of hairy fruits, the ātmaguptā (velvet bean), on the skin to provoke itching. The Saṁhitā mentions that various types of strong alcoholic drinks mixed with other drugs of pungent taste should be carefully put in the mouth frequently. The physician should further administer the juice of mātuluṅgā (sweet lime – citrus decumana/citrus limon), mahauṣadha (ginger), asafoetida, and black pepper until the patient regains consciousness. In modern medicine, the persistence of coma, particularly in hypoxia and traumatic brain injury, has lead researchers to find treatment for arousal from coma.[1] The modern medical treatment for coma arousal can also be divided into the physical and chemical (pharmacological) forms.[8] The physical modalities used for coma arousal are sensory stimulation, music therapy, median nerve electrical stimulation, dorsal column stimulation, transcranial magnetic stimulation, and hyperbaric oxygen.[9] The pharmacological therapy for coma arousal mainly includes dopaminergic drugs such as amantadine, bromocriptine, and levodopa/carbidopa. However, other drugs such as GABAergic medications, methylphenidate, antidepressants, and antiepileptics have also been tried.[10] All of these therapies have a variable level of evidence to support their use in clinical practice, and in the recent future, the “awakening drugs” does not seem to be a real possibility in the realm of clinical medicine. Emergence from coma Though the concept of minimally conscious state (MCS) is relatively new, the emergence from coma is described in Caraka Saṁhitā. It also described a different treatment strategy for a patient who has emerged from coma. The verses 51–53 describe treatments for patients emerging from coma. They read: vismāpanaiḥ smāraṇaiśca priyaśrutibhirēva ca, paṭubhirgītavāditraśabdaiścitraiśca darśanaiḥ.[51] sraṁsanōllēkhanairdhūmairañjanaiḥ kavalagrahaiḥ, śōṇitasyāvasēkaiśca vyāyāmōdgharṣaṇaistathā.[52] prabuddhasañjñaṁ matimānanubandhamupakramēt, tasya saṁrakṣitavyaṁ hi manaḥ pralayahētutaḥ.[53] It mentions that, after the patient regains consciousness, he should be given a light diet. Thereafter, his consciousness should be maintained by various psychological and physical devices, and his mind should be diverted from the etiological factors that were responsible for the unconsciousness. He should be made to remember some surprising events (vismāpana, smāraṇa), hear pleasing songs, and music. He should be exposed to a joyous environment of agreeable talk, narration of stories and reminiscences, and music and songs of an enchanting landscape.[7] The aim should be to protect the mind in addition to treating the body.[7] In modern medicine, it has been shown that patients in a minimally conscious state activate higher-order cortical areas. Though there are no strong evidence-based recommendations for coma arousal, uncontrolled studies indicate that some rehabilitative procedures can promote the recovery of consciousness, especially in patients in a minimally conscious state.[11] The Charaka Samhita did not have scientific foundation to differentiate patients who were in coma from the patients who were emerging from coma; however, it did mention a different treatment strategy for the patients emerging from coma. It mentioned stimulatory therapies such as remembering some surprising events and listening to pleasing songs and music, which activate higher-order cortical areas in patients who emerge from coma. Acknowledgements
Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
[Figure 1]
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