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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]
• 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]
=Pathogenesis=
*[[Dosha]]: [[Pitta]] dominance associated with [[vata]] and [[kapha]]
*[[Dushya]]: Nutritive body fluids ([[Rasa]] [[dhatu]])
*[[Agni]]: Jatharagni
*[[Srotasa]]: Channels of transportation of nutrient fluids and sweat ( rasavaha, swedavaha)
*Site of origin: stomach (amashaya)
*Site of manifestation/clinical presentation: Whole body and mind [Cha.Sa.[[Chikitsa Sthana]].3/30]
*Type of pathogenesis: Obstruction (sanga)
*include picture
[Cha.Sa.[[Chikitsa Sthana]].3/ 129-132] [Su.Sa.Uttarasthana.39/24] [A.Hr NidanaSthana 2/3-5]
*In jwara due to trauma (abhighata), blood (rakta) is the vitiated primarily;
*In jwara due to negative energies (abhishangaja), [[vata]] and [[pitta]] are vitiated
*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=
Clinical features are observed to diagnose the condition. Changes in body temperature are recorded.
For diagnosis:
*Body temperature above 36.5 – 37.5 degree celsius (97.7 – 99.5 degree fahrenheit)
*Rectal temperature: 37.5 – 38.3 degree celsius (99.5 – 100.9 degree fahrenheit) and above
*Oral temperature: 37.7 degree celsius (99.9 degree fahrenheit) and above
*Axillary temperature: 37.2 degree celsius (99.0 degree fahrenheit) and above
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.
=Prognosis=
Easily curable (sukhasadhya)
*External manifestation (bahirvegi) of jwara [Cha.Sa.[[Chikitsa Sthana]].3/41]
*Seasonal manifestation [Cha.Sa.[[Chikitsa Sthana]].3/42]
*Jwara in a person with good physical and mental strength, or if caused by the vitiation of lesser amount of [[dosha]] and without any complications. [Cha.Sa.[[Chikitsa Sthana]].3/50]
Difficult to cure and poor prognosis:
*Jwara caused by either greater amount of [[dosha]]/ strong etiological factors
*Jwara manifests with multiple clinical features
*Jwara which acutely affects the sense organs.[Cha.Sa.[[Chikitsa Sthana]] 3/51-52]
*Severe manifestation, associated with delirium, giddiness and breathlessness causes death of the patient
*Jwara in a weak and emaciated person (kshina), associated with edema (shuna), seated in deeper body tissues (gambhira), severe (balvan) and persistent for long durations (dirgharatrika) are incurable. [Cha.Sa.[[Chikitsa Sthana]] 3/52-53]
*Jwara due to psycho-spiritual factors like allure and wrath is incurable. [Cha.Sa.[[Nidana Sthana]] 1/30]
*Jwara caused by [[vata]][[dosha]] is difficult to treat in any season [Cha.Sa.[[Chikitsa Sthana]] 3/49] Pittadominant 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=
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.
=Management=
In premonitory or preclinical stage:
*Therapeutic fasting and measures to create lightness in body (langhana) is highly effective in early stages of jwara and prevent further progression. [Cha.Sa.[[Nidana Sthana]].1/36]
*If the [[dosha]] are not afflicted with [[ama]], then administration of cow ghee in [[vata]] dominant jwara, mild purgation in [[pitta]] dominant jwara and therapeutic emesis in [[kapha]] dominant jwara are prescribed on observation of premonitory features. [Su.Sa.Uttarasthana 39/97-98]
Principles of management on observation of clinical stage:
The principles of management of jwara include correcting disequilibrium of [[dosha]] and maintaining strength of the host simultaneously. Natural remission through sequential prescription of measures of fasting, fomentation, thin gruel consumption, use of medicines with bitter taste and those promoting digestion is emphasized. [A.Hr Chikitsa Sthana 1/21]
Fasting or lightening therapy ([[langhana]]) is the first line of treatment. It promotes digestion of toxins, produces lightness and alleviates raised body heat.[Su.Sa.Uttara sthana.39/103]
Hydration is maintained by advising hot water consumption. Hot water stimulates digestion, disintegrates [[kapha]] and [[ama]], helps in the normal functioning of [[vata]] and [[pitta]], quenches thirst and produces lightness in body. It is helpful in dominance of [[kapha]] and [[vata]][[dosha]]. [Su.Sa.Uttarasthana.39/106-107]
These measures are intended to remove obstruction in channels, improve digestion and pacification of vitiated [[dosha]] to their normal state. [A.Hr ChikitsaSthana 1/39]
Suitable dietary regimen for 10 days followed by medicated ghee is advised.[A.Hr ChikitsaSthana 1/82] After improvement and correction of digestion, the diet to improve strength of individual such as meat soup, yusha etc. are advised.
After attaining proper strength, purification therapies to remove toxins and prevent recurrence are prescribed.
=Precautions=
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]
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]
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]
=Clinical features of 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]
=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]
=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]
=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]
=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] 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)
*Herbal formulations: Amrutotaram decocotion (kwatha), Guduchyadikwatha, samshamanivati, sudarshanam churna, Amritarista, Pathyadikwatha
*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]
*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][A.Hr.ChikitsaSthana 1/20]
*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] 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]
*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 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]
*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]
*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=
*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=
*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=
*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=
*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]
=Clinical features after recovery=
*Lightness of head and body, perspiration, slightly pale face with boils, sneezing, desire towards food; [Su.Sa.Uttarasthana.39/318] 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]
=List of research works done=
*Mathew Soosan (1983): Latakaranjabeeja ka VishamaJvarameinkriyatmakaanvekshana,Department of Dravyaguna, IPGT&RA, Jamnagar.
*Dal D K (1981): Vishamajvara (malaria) chikitsatmakaadhyayana, Department of Kayachikitsa and Panchakarma, IPGT&RA, Jamnagar.
*Kishan T (1982): Effect of Bhoomyamalaki in Jvara (w.s.r to vishamajvara), Department of Kaumarabhritya, IPGT&RA, Jamnagar.
*Kashaih M (1983): A study on effect of certain indigenous drug in Vishamajvara, Department of Kaumarabhritya, IPGT&RA, Jamnagar.
*Sarvaiya D B (1987): Dravyavigyana of Bhramara-Challika and its therapeutic effect on Vishamajvara,Department of Dravyaguna, IPGT&RA, Jamnagar.
*Varsha Solanki (1998): A comparative study of Clerodendroninermes and Leucas cephalotes on Vishamajvara, Department of Dravyaguna, IPGT&RA, Jamnagar.
*Sudha Menon (2003): Clinical study of aetio-pathogenesis of AIDS and assessment of the efficacy of IndukantaGhrita on its symptoms Jvara (pyrexia), Department of Roganidan&Vikriti Vigyan, IPGT&RA, Jamnagar.
*Rimpal Virsodiya (2006): Effect of Siddharthakadi Agada in the management of Malaria (Jvara), Department of Kayachikitsa, IPGT&RA, Jamnagar.
*Kapil Lathiya (2014): A study on GomutrabhavitaPippaliw.s.r to its antipyretic and analgesic activity, 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=
#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>
2. In another study on vishamajwara, 34 patients were treated with Leucas cephalotes (dronapushpi) in the dosage 3 -6 gm for 20 days. Total 76.47% of patients were completely cured.<ref>Kashaih M (1983): A study on effect of certain indigenous drug in Vishamajvara, Department of Kaumarabhritya, IPGT&RA, Jamnagar</ref>
3. Powder of Hymenodictyonexcelsum (BhramaraChallika) was given to 25 patients of vishamajwarain a dosage of 2gm thrice a day for 5 – 15 days. This drug is found more effective in anyedyushkajwara than santatajwara.<ref>Sarvaiya D B (1987): Dravyavigyana of Bhramara-Challika and its therapeutic effect on Vishamajvara,Department of Dravyaguna, IPGT&RA, Jamnagar</ref>
4. Clerodendroninermes and Leucas cephalotes were given in dosage of 3gm for 10 days. Significant results were obtained on cardinal symptoms of jvara for both these drugs.<ref>Varsha Solanki (1998): A comparative study of Clerodendroninermes and Leucas cephalotes on Vishamajvara, Department of Dravyaguna, IPGT&RA, Jamnagar</ref>
5. Total 23 patients with positive peripheral smear test for Plasmodium vivax were selected and treated with Siddharthakadi agada 3gm thrice a day for 1 week. Control group was treated with Chloroquine phosphate and Primaquine. Siddharthakadi agada has provided significant results in reducing the fever, rigor with chill, headache, bodyache, sweating, anorexia, weakness and cough. On comparison the patients treated with Siddharthakadi agada showed better results in controlling anorexia, headache and body ache. Peripheral smear test after seven days of treatment with agada was negative for all patients.<>RimpalVirsodiya (2006): Effect of Siddharthakadi Agada in the management of Malaria (Jvara), Department of Kayachikitsa, IPGT&RA, Jamnagar.</ref>
6. Powder of leaves and root of Melia AzedaractaLinn.(mahanimba) were administered to experimental models of induced pyrexia in albino rats. Root powder showed better antipyretic effect than leaf powder.<>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=
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>
Many drugs are reported to be having antipyretic action. A few of them are decoction and alcoholic extract of amlakyadigana (combination of Emblica officinalis Gaertn. (Amalaki), Terminalia chebulaRetz.(Haritaki), Piper longum L. (Pippali), and Plumbago zeylenica L. (Chitraka);<>Timbadiya MJ, Nishteswar K, Acharya R, Nariya MB. Experimental evaluation of antipyretic and analgesic activities of AmalakyadiGana: An Ayurvedic formulation. Ayu. 2015 Apr-Jun;36(2):220-4. doi: 10.4103/0974-8520.175554. PMID: 27011727; PMCID: PMC4784136</ref> Aeginetia indica<></ref> , Grapevine leaf extract (Vitis vinifera)<>Aouey B, Samet AM, Fetoui H, Simmonds MSJ, Bouaziz M. Anti-oxidant, anti-inflammatory, analgesic and antipyretic activities of grapevine leaf extract (Vitis vinifera) in mice and identification of its active constituents by LC-MS/MS analyses. Biomed Pharmacother. 2016 Dec;84:1088-1098. doi: 10.1016/j.biopha.2016.10.033. Epub 2016 Oct 22. PMID: 27780137.</ref> , Cissampelos pareira Linn. , Cyclea peltata<>Singh SG, Nishteswar K, Patel BR, Nariya M. Comparative antipyretic and analgesic activities of Cissampelos pareira Linn. and Cycleapeltata (Lam.) Hook. F. & Thomas. Ayu. 2016 Jan-Mar;37(1):62-66. doi: 10.4103/ayu.AYU_208_14. PMID: 28827957; PMCID: PMC5541469</ref> and Guduchi ghrita.<ref name=AshokBK/>
Controlled clinical trials of these medicines are required to establish their efficacy as treatment option to established anti pyretic drugs.
The treatment objective is not only to reduce body temperature, but also to maintain equilibrium of body components and preserve health.
=References=