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=Jwara=
Jwara is an important disease. The term ‘Jwara’ implies the ability of a disease to cause anguish to body and mind. [SAT-C.7]<ref>http://namstp.ayush.gov.in/#/sat</ref> This suggests suffering or illness. Based on the similarity in clinical features, Jwara is often considered as fever or pyrexia in medical terminologies. However, according to Ayurveda,the classical description of jwara includes variety of other clinical conditions with or without rise in body temperature. Therefore, fever or hyperpyrexia is considered as only one among the many features of jwara.
Jwara is an important disease. The term ‘Jwara’ implies the ability of a disease to cause anguish to body and mind. [SAT-C.7]<ref>http://namstp.ayush.gov.in/#/sat</ref> This suggests suffering or illness. Based on the similarity in clinical features, Jwara is often considered as fever or pyrexia in medical terminologies. However, according to Ayurveda,the classical description of jwara includes variety of other clinical conditions with or without rise in body temperature. Therefore, fever or hyperpyrexia is considered as only one among the many features of jwara.
This article describes general etiology, premonitory features, clinical features, pathogenesis, and management principles of jwara. Classification of the disease is also highlighted. Specific types of jwara like acute stage (nava jwara), chronic stage (jeerna jwara), irregular pattern (vishama jwara), jwara involving all three [[dosha]] (sannipataja jwara), jwara affecting body components (dhatugata jwara) are dealt in separate articles.
This article describes general etiology, premonitory features, clinical features, pathogenesis, and management principles of jwara. Classification of the disease is also highlighted. Specific types of jwara like acute stage (nava jwara), chronic stage (jeerna jwara), irregular pattern (vishama jwara), jwara involving all three [[dosha]] (sannipataja jwara), jwara affecting body components (dhatugata jwara) are dealt in separate articles.
== Diagnostic codes ==
*National Ayurveda Morbidity Code: EC -3
*National Ayurveda Morbidity Code: EC -3
*Others: Sudden change in season or abnormal climatic conditions, improper or excessive administration of purificatory procedures, trauma, degenerative conditions, infectious diseases, suppurations, exposure to poisonous gases, toxins; improper management of pregnancy, prenatal and postnatal care, abnormal changes in spiritual, lunar, planetary and constellation cosmic energies (nakshatra peeda)[Su.Sa.Uttara Sthana. 39/19-22]<ref name= Susruta> Sushruta. Sushruta Samhita. Edited by Jadavaji Trikamji Aacharya. 8th ed. Varanasi: Chaukhambha Orientalia;2005.</ref>
*Others: Sudden change in season or abnormal climatic conditions, improper or excessive administration of purificatory procedures, trauma, degenerative conditions, infectious diseases, suppurations, exposure to poisonous gases, toxins; improper management of pregnancy, prenatal and postnatal care, abnormal changes in spiritual, lunar, planetary and constellation cosmic energies (nakshatra peeda)[Su.Sa.Uttara Sthana. 39/19-22]<ref name= Susruta> Sushruta. Sushruta Samhita. Edited by Jadavaji Trikamji Aacharya. 8th ed. Varanasi: Chaukhambha Orientalia;2005.</ref>
=Classification=
==Classification==
I. Based on origin:
I. Based on origin:
#Semen/reproductive fluid ([[shukra]])[Cha.Sa.[[Chikitsa Sthana]].3/35]
#Semen/reproductive fluid ([[shukra]])[Cha.Sa.[[Chikitsa Sthana]].3/35]
=Clinical features=
==Clinical features==
==Premonitory features==
===Premonitory features===
===General premonitory features===
====General premonitory features====
Premonitory features of jwara include abnormal taste in the mouth, heaviness in the body, aversion to food, restless eyes, lacrimation, excessive sleep, restlessness, yawning, bending, shivering, exhaustion (without physical activity), giddiness, delirium, sometimes sleeplessness, horripilation, oversensitive teeth; tolerance and intolerance to sound, cold, wind and heat; anorexia, indigestion, weakness, body-ache, malaise, reduced vitality, mental agitation, lethargy, idleness, lack of natural activities, apathy to daily regimen, disrespect to the words of elders, agitation with children, aversion to doing work, uncomfortable with flowers and perfumes, aversion to sweet edibles, and desirous for sour, salty and pungent things. [Cha.Sa.[[Nidana Sthana]].1/33]
Premonitory features of jwara include abnormal taste in the mouth, heaviness in the body, aversion to food, restless eyes, lacrimation, excessive sleep, restlessness, yawning, bending, shivering, exhaustion (without physical activity), giddiness, delirium, sometimes sleeplessness, horripilation, oversensitive teeth; tolerance and intolerance to sound, cold, wind and heat; anorexia, indigestion, weakness, body-ache, malaise, reduced vitality, mental agitation, lethargy, idleness, lack of natural activities, apathy to daily regimen, disrespect to the words of elders, agitation with children, aversion to doing work, uncomfortable with flowers and perfumes, aversion to sweet edibles, and desirous for sour, salty and pungent things. [Cha.Sa.[[Nidana Sthana]].1/33]
{| class="wikitable"
{| class="wikitable"
|+ Table 1: [[Dosha]] specific premonitory features
|+ Table 1: [[Dosha]] specific premonitory features*
|-
|-
! Jwara !! Specific premonitory feature
! Jwara !! Specific premonitory feature
|-
|-
|}
|}
[Su.Sa.Uttarasthana.39/27]<ref name=Susruta/>
*[Su.Sa.Uttara sthana.39/27]<ref name=Susruta/>
Exogenous fever (agantuja jwara) manifests directly without any prodromal symptoms. [Cha.Sa.[[Nidana Sthana]].1/30]
Exogenous fever (agantuja jwara) manifests directly without any prodromal symptoms. [Cha.Sa.[[Nidana Sthana]].1/30]
==General clinical features==
===General clinical features===
Absence of perspiration, feeling of heat or raised body temperature and generalized body ache.[Su.Sa.Uttarasthana 39/13]<ref name=Susruta/> Discomfort in body and mind[Cha.Sa.[[Chikitsa Sthana]].3/31], anorexia, morbid thirst and pain in cardiac region. [Cha.Sa.[[Chikitsa Sthana]].3/26-27]
Absence of perspiration, feeling of heat or raised body temperature and generalized body ache.[Su.Sa.Uttarasthana 39/13]<ref name=Susruta/> Discomfort in body and mind[Cha.Sa.[[Chikitsa Sthana]].3/31], anorexia, morbid thirst and pain in cardiac region. [Cha.Sa.[[Chikitsa Sthana]].3/26-27]
Severe manifestation with deep affliction of body tissues (gambhiradhatugata): Sensation of internal heat, excess thirst, retention of faeces and flatus, severe dyspnoea and cough. [Su.Sa.Uttarasthana.39/92]<ref name=Susruta/>
Severe manifestation with deep affliction of body tissues (gambhiradhatugata): Sensation of internal heat, excess thirst, retention of faeces and flatus, severe dyspnoea and cough. [Su.Sa.Uttarasthana.39/92]<ref name=Susruta/>
==[[Dosha]] specific clinical features==
===[[Dosha]] specific clinical features===
====[[Vata]] dominant jwara====
*Abrupt onset and remission
*Abrupt onset and remission
*Irregular pattern of rise in temperature and severity.
*Irregular pattern of rise in temperature and severity.
*Astringent taste or lack of taste in the mouth (distaste), dryness of mouth, palate and throat; thirst, catching pain (grabbing pain) in the heart, dry vomiting, dry cough, loss of sneezing and eructation, aversion to the taste, salivation, anorexia, diminished digestive power, malaise, increased yawning, bending, shivering, exhaustion, giddiness, delirium, insomnia, horripilation, sensitivity in teeth, and the desire for hot things. [Cha.Sa.[[Nidana Sthana]].1/21]
*Astringent taste or lack of taste in the mouth (distaste), dryness of mouth, palate and throat; thirst, catching pain (grabbing pain) in the heart, dry vomiting, dry cough, loss of sneezing and eructation, aversion to the taste, salivation, anorexia, diminished digestive power, malaise, increased yawning, bending, shivering, exhaustion, giddiness, delirium, insomnia, horripilation, sensitivity in teeth, and the desire for hot things. [Cha.Sa.[[Nidana Sthana]].1/21]
[[Pitta]] dominant jwara:
====[[Pitta]] dominant jwara====
*High intensity
*High intensity
*Increase during digestion of meals, midday, mid night or in the autumn season.
*Increase during digestion of meals, midday, mid night or in the autumn season.
*Narcosis, giddiness, fainting, vomiting of bile ([[pitta]]), diarrhea, aversion to food, malaise, dejection, delirium, appearance of reddish patches in the body, green or yellow coloration in nails, eyes, mouth, urine, faeces and skin, excessive migraine and burning sensation, desire for cold things.[Cha.Sa.[[Nidana Sthana]].1/22-24]
*Narcosis, giddiness, fainting, vomiting of bile ([[pitta]]), diarrhea, aversion to food, malaise, dejection, delirium, appearance of reddish patches in the body, green or yellow coloration in nails, eyes, mouth, urine, faeces and skin, excessive migraine and burning sensation, desire for cold things.[Cha.Sa.[[Nidana Sthana]].1/22-24]
[[Kapha]] dominant jwara:
====[[Kapha]] dominant jwara====
*Mild intensity
*Mild intensity
*Increase after taking meals, forenoon, early night or spring season.
*Increase after taking meals, forenoon, early night or spring season.
*Heaviness in the body, less desire to eat, excess secretion of phlegm, sweet taste in the mouth, nausea, wrapped feeling in the heart, wheezing, vomiting, mild appetite, excessive sleep or narcolepsy, stiffness, drowsiness, cough, dyspnea, coryza, coldness, whiteness of nails, eyes, face, urine and skin, urticarial patches, desire of hot things and surroundings. [Cha.Sa. [[Nidana Sthana]] 1/27]
*Heaviness in the body, less desire to eat, excess secretion of phlegm, sweet taste in the mouth, nausea, wrapped feeling in the heart, wheezing, vomiting, mild appetite, excessive sleep or narcolepsy, stiffness, drowsiness, cough, dyspnea, coryza, coldness, whiteness of nails, eyes, face, urine and skin, urticarial patches, desire of hot things and surroundings. [Cha.Sa. [[Nidana Sthana]] 1/27]
[[Vata]] [[pitta]] dominant jwara:
====[[Vata]] [[pitta]] dominant jwara====
*Desire of cold things [Cha.Sa.[[Chikitsa Sthana]].3/37]
*Desire of cold things [Cha.Sa.[[Chikitsa Sthana]].3/37]
*Headache, breaking pain in joints, burning sensation, horripilation, dryness of throat and mouth, nausea, thirst, fainting, giddiness, anorexia, sleeplessness, talkativeness.[Cha.Sa.[[Chikitsa Sthana]] 3/85-86]
*Headache, breaking pain in joints, burning sensation, horripilation, dryness of throat and mouth, nausea, thirst, fainting, giddiness, anorexia, sleeplessness, talkativeness.[Cha.Sa.[[Chikitsa Sthana]] 3/85-86]
[[Vata]][[kapha]] dominant jwara:
====[[Vata]][[kapha]] dominant jwara====
*Desire of hot things [Cha.Sa.[[Chikitsa Sthana]]. 3/37]
*Desire of hot things [Cha.Sa.[[Chikitsa Sthana]]. 3/37]
*Feeling of cold, heaviness, drowsiness, timidity, pain in joints, feeling of stiffness of head (shirograha), coryza, cough, impaired sweating and moderate rise in temperature. [Cha.Sa.[[Chikitsa Sthana]] 3/86-87]
*Feeling of cold, heaviness, drowsiness, timidity, pain in joints, feeling of stiffness of head (shirograha), coryza, cough, impaired sweating and moderate rise in temperature. [Cha.Sa.[[Chikitsa Sthana]] 3/86-87]
[[Kapha]] [[Pitta]] dominant jwara:
====[[Kapha]] [[Pitta]] dominant jwara====
*Inconsistent sensation of hot and cold
*Inconsistent sensation of hot and cold
*Frequent increased or decreased sweating, delusions, cough, anorexia, thirst, elimination of phlegm ([[kapha]]) and bile ([[pitta]]), coating and bitterness in the mouth and drowsiness. [Cha.Sa.[[Chikitsa Sthana]] 3/87-88]
*Frequent increased or decreased sweating, delusions, cough, anorexia, thirst, elimination of phlegm ([[kapha]]) and bile ([[pitta]]), coating and bitterness in the mouth and drowsiness. [Cha.Sa.[[Chikitsa Sthana]] 3/87-88]
Severe manifestation affecting [[ojas]] (hatojasjwara):
'''Severe manifestation affecting [[ojas]] (hatojas jwara):'''
Displacement of [[ojas]] due to aggravation of [[vata]] and [[pitta]] [[dosha]]
*Displacement of [[ojas]] due to aggravation of [[vata]] and [[pitta]] [[dosha]]
*Stiffness or rigors in the body, desire to sleep, loss of consciousness, drowsy, delirium, feeling of horripilation, mild rise in temperature associated with body ache. [Su.Sa.Uttarasthana.39/43-44]<ref name=Susruta/>
=Pathogenesis=
=Pathogenesis=
*In jwara due to fascination (abhichara) and wrath (abhishapaja), all [[dosha]] are vitiated. [Cha.Sa.[[Nidana Sthana]].1/30]
*In jwara due to fascination (abhichara) and wrath (abhishapaja), all [[dosha]] are vitiated. [Cha.Sa.[[Nidana Sthana]].1/30]
=Biomarkers for diagnosis and assessment of efficacy=
===Biomarkers for diagnosis and assessment of efficacy===
Clinical features are observed to diagnose the condition. Changes in body temperature are recorded.
Clinical features are observed to diagnose the condition. Changes in body temperature are recorded.
For diagnosis:
'''For diagnosis:'''
*Body temperature above 36.5 – 37.5 degree celsius (97.7 – 99.5 degree fahrenheit)
*Body temperature above 36.5 – 37.5 degree celsius (97.7 – 99.5 degree fahrenheit)
*Axillary temperature: 37.2 degree celsius (99.0 degree fahrenheit) and above
*Axillary temperature: 37.2 degree celsius (99.0 degree fahrenheit) and above
Investigations:
'''Investigations:'''
Complete blood count, Urine culture, Widal test, Mantoux test, PCR test, Viral culture, Sputum examination, Chest X-ray etc. These laboratory and radiological investigations are useful in finding causative microorganism and nature of infective agents. The investigations are done only in severe conditions of disease and weak patients.
Complete blood count, Urine culture, Widal test, Mantoux test, PCR test, Viral culture, Sputum examination, Chest X-ray etc. These laboratory and radiological investigations are useful in finding causative microorganism and nature of infective agents. The investigations are done only in severe conditions of disease and weak patients.
=Prognosis=
==Prognosis==
===Easily curable (sukhasadhya)===
===Easily curable (sukhasadhya)===
*Jwara caused by [[vata]][[dosha]] is difficult to treat in any season [Cha.Sa.[[Chikitsa Sthana]] 3/49] Pitta dominant jwara occurring in seasons other than autumn and [[kapha]] dominant jwara occurring in seasons other than spring are difficult to treat. [Cha.Sa.[[Chikitsa Sthana]] 3/49]
*Jwara caused by [[vata]][[dosha]] is difficult to treat in any season [Cha.Sa.[[Chikitsa Sthana]] 3/49] Pitta dominant jwara occurring in seasons other than autumn and [[kapha]] dominant jwara occurring in seasons other than spring are difficult to treat. [Cha.Sa.[[Chikitsa Sthana]] 3/49]
=Objectives of treatment or goals of treatment=
==Management==
'''Objectives of treatment or goals of treatment'''
The treatment of jwara is decided after assessment of sama (afflicted with [[ama]]) status of [[dosha]]. In case of afflicted with [[ama]] status, the treatment is to naturally promote digestive and metabolic processes. This changes the status of [[ama]] and pacifies afflicted [[dosha]] resulting in their normal functions.
The treatment of jwara is decided after assessment of sama (afflicted with [[ama]]) status of [[dosha]]. In case of afflicted with [[ama]] status, the treatment is to naturally promote digestive and metabolic processes. This changes the status of [[ama]] and pacifies afflicted [[dosha]] resulting in their normal functions.
===In premonitory or preclinical stage===
===In premonitory or preclinical stage===
After attaining proper strength, purification therapies to remove toxins and prevent recurrence are prescribed.
After attaining proper strength, purification therapies to remove toxins and prevent recurrence are prescribed.
=Precautions=
===Precautions===
Contraindications of fasting:
'''Contraindications of fasting:'''
Fasting is contraindicated in jwara caused by aggravated [[vata]][[dosha]] or by exertion or by traumatic or psychic causes,and in chronic conditions. [Cha.Sa.[[Chikitsa Sthana]].3/272] [Su.Sa.Uttarasthana.39/102]<ref name=Susruta/>
Fasting is contraindicated in jwara caused by aggravated [[vata]][[dosha]] or by exertion or by traumatic or psychic causes,and in chronic conditions. [Cha.Sa.[[Chikitsa Sthana]].3/272] [Su.Sa.Uttarasthana.39/102]<ref name=Susruta/>
Contraindications of hot water:
'''Contraindications of hot water:'''
Hot water is contraindicated in conditions occurring due to [[pitta]] [[dosha]], , burning sensation of eyes and whole body; delusion and diarrhoea, poisoning and alcoholic intoxication; in summer season, in emaciation and bleeding disorders.[A.Hr.Chikitsa Sthana.1/14]<ref name=Hridaya/>
Hot water is contraindicated in conditions occurring due to [[pitta]] [[dosha]], , burning sensation of eyes and whole body; delusion and diarrhoea, poisoning and alcoholic intoxication; in summer season, in emaciation and bleeding disorders.[A.Hr.Chikitsa Sthana.1/14]<ref name=Hridaya/>
If the strength of the individual is normal, then the medicines are administered at a suitable stage and only if required. The general period for natural remission is one week. If jwara does not subside and deterioration in condition is observed due to acute aggravation of [[pitta]] [[dosha]], then medicines are prescribed. [Su.Sa.Uttara Sthana.39/119]<ref name=Susruta/>
If the strength of the individual is normal, then the medicines are administered at a suitable stage and only if required. The general period for natural remission is one week. If jwara does not subside and deterioration in condition is observed due to acute aggravation of [[pitta]] [[dosha]], then medicines are prescribed. [Su.Sa.Uttara Sthana.39/119]<ref name=Susruta/>
=Clinical features of remission=
===Clinical features of remission===
Following features are observed for remission.
Following features are observed for remission.
Decrease in body temperature and intensity of disease symptoms, lightness in body and proper bowel movements. [Su.Sa.Uttara Sthana.39/115]<ref name=Susruta/>
Decrease in body temperature and intensity of disease symptoms, lightness in body and proper bowel movements. [Su.Sa.Uttara Sthana.39/115]<ref name=Susruta/>
'''Consumption of ghee'''
*The disease jwara causes excess dryness and increased heat in the body. This further aggravates [[vata]] and [[pitta]] [[dosha]]. Ghee is administered to pacify [[vata]] and [[pitta]] [[dosha]]. It also nourishes [[dhatu]] and prevents depletion. [Su.Sa.Uttarasthana.39/133]<ref name=Susruta/>
*The disease jwara causes excess dryness and increased heat in the body. This further aggravates [[vata]] and [[pitta]] [[dosha]]. Ghee is administered to pacify [[vata]] and [[pitta]] [[dosha]]. It also nourishes [[dhatu]] and prevents depletion. [Su.Sa.Uttarasthana.39/133]<ref name=Susruta/>
'''Administration of milk'''
*In chronic stages, if the patient suffers from excessive burning sensation and thirst due to [[vata]] and [[pitta]] [[dosha]], milk is advised.[Cha.Sa.[[Chikitsa Sthana]].3/167-68]
*In chronic stages, if the patient suffers from excessive burning sensation and thirst due to [[vata]] and [[pitta]] [[dosha]], milk is advised.[Cha.Sa.[[Chikitsa Sthana]].3/167-68]
'''Indications of pacifying therapy (shamana)'''
*If [[dosha]] is in less amount or if patient is emaciated, then [[dosha]] pacifying measures are advised instead of lightning measures. [Su.Sa.Uttara Sthana.39/134]<ref name=Susruta/>
*If [[dosha]] is in less amount or if patient is emaciated, then [[dosha]] pacifying measures are advised instead of lightning measures. [Su.Sa.Uttara Sthana.39/134]<ref name=Susruta/>
'''Indications for meat soup'''
*Meat soup is advised if digestive capacity is normal in emaciated and [[vata]] predominant conditions. [Su.Sa.Uttara Sthana.39/136]<ref name=Susruta/> If the patient is not habituated to meat, then black gram soup is advised.
*Meat soup is advised if digestive capacity is normal in emaciated and [[vata]] predominant conditions. [Su.Sa.Uttara Sthana.39/136]<ref name=Susruta/> If the patient is not habituated to meat, then black gram soup is advised.
Medicinal herbs used in jwara: Tinospora cordifolia(guduchi), Zingiber officinale (nagara), Terminalia chebula (haritaki), Fumaria parviflora (parpata), Aconitum ferox (vatsanabha), Piper nigrum (maricha)
'''Medicinal herbs used in jwara:''' Tinospora cordifolia(guduchi), Zingiber officinale (nagara), Terminalia chebula (haritaki), Fumaria parviflora (parpata), Aconitum ferox (vatsanabha), Piper nigrum (maricha)
Herbal formulations: Amrutotaram decoction (kwatha), Guduchyadikwatha, samshamanivati, sudarshanam churna, Amritarista, Pathyadikwatha
'''Herbal formulations:''' Amrutotaram decoction (kwatha), Guduchyadikwatha, samshamanivati, sudarshanam churna, Amritarista, Pathyadikwatha
Herbo-mineral formulations: Jwaramurari rasa, Tribhuvanakeertirasa, Anandabhairava rasa, Laxmi vilasa rasa
'''Herbo-mineral formulations:''' Jwaramurari rasa, Tribhuvanakeertirasa, Anandabhairava rasa, Laxmi vilasa rasa
'''[[Panchakarma]] procedures with safety precautions'''
Generally, [[panchakarma]] procedures are indicated when the [[dosha]] are free from affliction of [[ama]] state. [Su.Sa.Uttara Sthana.39/124-125]<ref name=Susruta/>
Generally, [[panchakarma]] procedures are indicated when the [[dosha]] are free from affliction of [[ama]] state. [Su.Sa.Uttara Sthana.39/124-125]<ref name=Susruta/>
*Fomentation ([[swedana]]): Different fomentation techniques are used judiciously in jwara patients. Mild fomentation by covering the body with thick blanket (guru pravarana) is indicated in initial stage. It clears obstruction in sweat channels and normalizes body temperature. If the patient is experiencing excess cold, rhinitis, dyspnoea, pain in calves, joints and bones,fomentation is indicated. After the elimination of [[dosha]], if residual [[kapha]] and [[vata]][[dosha]] are causing jwara,fomentation and massage is indicated.[Su.Sa.Uttara Sthana.39/319]<ref name=Susruta/>[A.Hr.ChikitsaSthana 1/20]<ref name=Hridaya/>
*Fomentation ([[swedana]]): Different fomentation techniques are used judiciously in jwara patients. Mild fomentation by covering the body with thick blanket (guru pravarana) is indicated in initial stage. It clears obstruction in sweat channels and normalizes body temperature. If the patient is experiencing excess cold, rhinitis, dyspnoea, pain in calves, joints and bones,fomentation is indicated. After the elimination of [[dosha]], if residual [[kapha]] and [[vata]][[dosha]] are causing jwara,fomentation and massage is indicated.[Su.Sa.Uttara Sthana.39/319]<ref name=Susruta/>[A.Hr.ChikitsaSthana 1/20]<ref name=Hridaya/>
*Therapeutic emesis ([[vamana]]): If [[kapha]][[dosha]] is in excess aggravated state, emesis is administered. [Cha.Sa.[[Chikitsa Sthana]].3/227][Su.Sa.Uttara Sthana.39/98]<ref name=Susruta/> It is also indicated in the initial phase, conditions of nausea, excessive salivation, aversion to food, cough, simultaneous occurrence of vomiting and diarrhoea. It is ideal treatment if jwara manifests immediately after meals. [A.Hr.Chikitsa Sthana.1/5]<ref name=Hridaya/>
*'''Therapeutic emesis ([[vamana]]):''' If [[kapha]][[dosha]] is in excess aggravated state, emesis is administered. [Cha.Sa.[[Chikitsa Sthana]].3/227][Su.Sa.Uttara Sthana.39/98]<ref name=Susruta/> It is also indicated in the initial phase, conditions of nausea, excessive salivation, aversion to food, cough, simultaneous occurrence of vomiting and diarrhoea. It is ideal treatment if jwara manifests immediately after meals. [A.Hr.Chikitsa Sthana.1/5]<ref name=Hridaya/>
*Therapeutic purgation: It is prescribed in case of aggravated [[pitta]] [[dosha]] conditions. [Cha.Sa.[[Chikitsa Sthana]].3/227] It should be performed only in later stage of jwara and if jwara does not respond to medicines; provided the patient is having good strength and digestive capacity. [Cha.Sa.[[Chikitsa Sthana]].3/168-69] If [[dosha]] are free from [[ama]] state and retained in digestive tract (koshtha), purgative medication can be given even in acute stage of fever. [Su.Sa.Uttara Sthana.39/124]<ref name=Susruta/>
*'''Therapeutic purgation:''' It is prescribed in case of aggravated [[pitta]] [[dosha]] conditions. [Cha.Sa.[[Chikitsa Sthana]].3/227] It should be performed only in later stage of jwara and if jwara does not respond to medicines; provided the patient is having good strength and digestive capacity. [Cha.Sa.[[Chikitsa Sthana]].3/168-69] If [[dosha]] are free from [[ama]] state and retained in digestive tract (koshtha), purgative medication can be given even in acute stage of fever. [Su.Sa.Uttara Sthana.39/124]<ref name=Susruta/>
*Medicated enema (basti): If the [[dosha]] are lodged in colon (pakwashaya) medicated enemas can be used.[Cha.Sa.[[Chikitsa Sthana]].3/240]
*'''Medicated enema (basti):''' If the [[dosha]] are lodged in colon (pakwashaya) medicated enemas can be used.[Cha.Sa.[[Chikitsa Sthana]].3/240]
*Intra nasal drug administration ([[nasya]]): Purificatory nasal medication is indicated for chronic conditions with heaviness, headache and impaired sensorium. [Cha.Sa.[[Chikitsa Sthana]].1/173-74] If patient feels emptiness of head, have burning sensation, unctuous nasal medication which mitigates [[pitta]] should be administered. [A.Hr.Chikitsa Sthana.3/126]<ref name=Hridaya/>
*'''Intra nasal drug administration ([[nasya]]):''' Purificatory nasal medication is indicated for chronic conditions with heaviness, headache and impaired sensorium. [Cha.Sa.[[Chikitsa Sthana]].1/173-74] If patient feels emptiness of head, have burning sensation, unctuous nasal medication which mitigates [[pitta]] should be administered. [A.Hr.Chikitsa Sthana.3/126]<ref name=Hridaya/>
*Bloodletting ([[raktamokshana]]): If the jwara is not responding to either cold or hot therapies or to unctuous or ununctuous therapies, bloodletting therapy should be performed. Here the [[dosha]] are located in the peripheral tissues, which can be eliminated only through bloodletting. [Cha.Sa.[[Chikitsa Sthana]].3/289-90]
*'''Bloodletting ([[raktamokshana]]):''' If the jwara is not responding to either cold or hot therapies or to unctuous or ununctuous therapies, bloodletting therapy should be performed. Here the [[dosha]] are located in the peripheral tissues, which can be eliminated only through bloodletting. [Cha.Sa.[[Chikitsa Sthana]].3/289-90]
=Wholesome diet and lifestyle factors=
===Wholesome diet and lifestyle factors===
*Green gram (mudga), lentils (masoora), Bengal gram (chanaka), Trichosanthes cucumerina (patola), Momordica charantia (karavellaka), Moringa oleifera (shigru), Vitis vinifera (draksha), Punica granatum (dadima), hot water, gruel prepared from popped paddy etc. are wholesome in jwara conditions. Physical and mental rest, the seasonal regimen followed in summer is advised.
*Green gram (mudga), lentils (masoora), Bengal gram (chanaka), Trichosanthes cucumerina (patola), Momordica charantia (karavellaka), Moringa oleifera (shigru), Vitis vinifera (draksha), Punica granatum (dadima), hot water, gruel prepared from popped paddy etc. are wholesome in jwara conditions. Physical and mental rest, the seasonal regimen followed in summer is advised.
=Unwholesome diet and lifestyle=
===Unwholesome diet and lifestyle===
*Diet items that are heavy to digest, unwholesome, mutually contradictory and cause burning sensation (vidahi) are contraindicated in jwara. Sexual intercourse, excessive physical activities,exhaustive works and head bath should be avoided. [Cha.Sa.[[Chikitsa Sthana]].3/330-32]
*Diet items that are heavy to digest, unwholesome, mutually contradictory and cause burning sensation (vidahi) are contraindicated in jwara. Sexual intercourse, excessive physical activities,exhaustive works and head bath should be avoided. [Cha.Sa.[[Chikitsa Sthana]].3/330-32]
=Preventive aspects of recurrence=
===Preventive aspects of recurrence===
*If Jwara is not managed properly, it may recur due to residual [[dosha]]. Therefore, purification or pacification therapy should be done properly to prevent recurrence. A type of decoction enemas like ‘yapana basti’ and mild elimination therapies for the complete evacuation of [[dosha]] are advised to prevent recurrence. [Cha.Sa.[[Chikitsa Sthana]].3/339]
*If Jwara is not managed properly, it may recur due to residual [[dosha]]. Therefore, purification or pacification therapy should be done properly to prevent recurrence. A type of decoction enemas like ‘yapana basti’ and mild elimination therapies for the complete evacuation of [[dosha]] are advised to prevent recurrence. [Cha.Sa.[[Chikitsa Sthana]].3/339]
=Clinical features observed during remission of jwara=
==Clinical features observed during remission of jwara==
*During sudden remission, [[dosha]] undergo acute physiological transformation. Vomiting, increased respiration, profuse perspiration, tremors, delirium, altered state of consciousness are observed. The person expels foul smelling liquid feaces. [A.Hr NidanaSthana 2/76-78]<ref name=Hridaya/>
*During sudden remission, [[dosha]] undergo acute physiological transformation. Vomiting, increased respiration, profuse perspiration, tremors, delirium, altered state of consciousness are observed. The person expels foul smelling liquid feaces. [A.Hr NidanaSthana 2/76-78]<ref name=Hridaya/>
=Clinical features after recovery=
==Clinical features after recovery==
*Lightness of head and body, perspiration, slightly pale face with boils, sneezing, desire towards food; [Su.Sa.Uttarasthana.39/318<ref name=Susruta/> absence of exhaustion and discomfort, ulceration in mouth, itching in head and normal functioning of sense organs are observed after recovery from jwara. [A.Hr NidanaSthana 2/79]<ref name=Hridaya/>
*Lightness of head and body, perspiration, slightly pale face with boils, sneezing, desire towards food; [Su.Sa.Uttarasthana.39/318<ref name=Susruta/> absence of exhaustion and discomfort, ulceration in mouth, itching in head and normal functioning of sense organs are observed after recovery from jwara. [A.Hr NidanaSthana 2/79]<ref name=Hridaya/>
=List of research works done=
==List of research works done==
*Mathew Soosan (1983): Latakaranjabeeja ka VishamaJvarameinkriyatmakaanvekshana,Department of Dravyaguna, IPGT&RA, Jamnagar.
*Mathew Soosan (1983): Latakaranjabeeja ka VishamaJvarameinkriyatmakaanvekshana,Department of Dravyaguna, IPGT&RA, Jamnagar.
*Shweta R Vekariya (2015): Pharmacological evaluation of Mahanimba (Melia Azedarach Linn.) with special reference to analgesic and antipyrectic activities.Department of Dravyaguna Vigyan, IPGT&RA, Jamnagar.
*Shweta R Vekariya (2015): Pharmacological evaluation of Mahanimba (Melia Azedarach Linn.) with special reference to analgesic and antipyrectic activities.Department of Dravyaguna Vigyan, IPGT&RA, Jamnagar.
=Case reports and research updates=
==Case reports and research updates==
#In a study, 60 vishamajwara patients were selected. Out of which 24 patients were positive for malarial parasite test. The trial drug, Indrayavadi Vati was given in the dosage of 2-6gm for 7 days. After treatment, complete relief was observed in symptoms like headache, vomiting, nausea and rigors. Malarial parasite test was also negative after the treatment.<ref>Dal D K: Vishamajvara (malaria) chikitsatmakaadhyayana, Department of Kayachikitsa and Panchakarma, IPGT&RA, Jamnagar. MD Thesis, 1981</ref>
#In a study, 60 vishamajwara patients were selected. Out of which 24 patients were positive for malarial parasite test. The trial drug, Indrayavadi Vati was given in the dosage of 2-6gm for 7 days. After treatment, complete relief was observed in symptoms like headache, vomiting, nausea and rigors. Malarial parasite test was also negative after the treatment.<ref>Dal D K: Vishamajvara (malaria) chikitsatmakaadhyayana, Department of Kayachikitsa and Panchakarma, IPGT&RA, Jamnagar. MD Thesis, 1981</ref>
#Powder of leaves and root of Melia Azedaracta Linn.(mahanimba) were administered to experimental models of induced pyrexia in albino rats. Root powder showed better antipyretic effect than leaf powder.<ref>Shweta R Vekariya (2015): Pharmacological evaluation of Mahanimba (Melia Azedarach Linn.) with special reference to analgesic and antipyrectic activities. Department of Dravyaguna Vigyan, IPGT&RA, Jamnagar.</ref>
#Powder of leaves and root of Melia Azedaracta Linn.(mahanimba) were administered to experimental models of induced pyrexia in albino rats. Root powder showed better antipyretic effect than leaf powder.<ref>Shweta R Vekariya (2015): Pharmacological evaluation of Mahanimba (Melia Azedarach Linn.) with special reference to analgesic and antipyrectic activities. Department of Dravyaguna Vigyan, IPGT&RA, Jamnagar.</ref>
=Mechanism of action of antipyretic medicines=
==Mechanism of action of antipyretic medicines==
Inflammatory mediators released by peripheral mononuclear phagocytes and other immune cells induces fever. Fever inducing cytokines are transported from blood to brain. Prostaglandin E2 (PGE2) in the brain is believed to be the principle downstream mediator of fever. Inhibiting the production of PGE2 is a well known mechanism of antipyretics.<ref name=AshokBK>Ashok BK, Ravishankar B, Prajapati PK, Bhat SD. Antipyretic activity of GuduchiGhrita formulations in albino rats. Ayu. 2010 Jul;31(3):367-70. doi: 10.4103/0974-8520.77162. PMID: 22131741; PMCID: PMC3221073</ref>
Inflammatory mediators released by peripheral mononuclear phagocytes and other immune cells induces fever. Fever inducing cytokines are transported from blood to brain. Prostaglandin E2 (PGE2) in the brain is believed to be the principle downstream mediator of fever. Inhibiting the production of PGE2 is a well known mechanism of antipyretics.<ref name=AshokBK>Ashok BK, Ravishankar B, Prajapati PK, Bhat SD. Antipyretic activity of GuduchiGhrita formulations in albino rats. Ayu. 2010 Jul;31(3):367-70. doi: 10.4103/0974-8520.77162. PMID: 22131741; PMCID: PMC3221073</ref>