Charak Samhita

Talk:Jwara Chikitsa

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Jwara is an important disease. The term ‘Jwara’ implies the ability of a disease to cause anguish to body and mind. [SAT-C.7][1] 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 the commonest clinical condition observed in medical practice either as a primary disease or as a secondary sign owing to other morbidities. Hence it is given prime importance among all diseases. [Cha.Sa. Sutra Sthana 25/40] Calor (rise in temperature), rubor (redness), dolor(pain), tumor (swelling) are the cardinal signs of inflammation. Pathogenesis of jwara includes change in body temperature, discoloration, aches. Therefore,jwara is also an indicator of inflammatory changes in body.

As per conventional medical literature,the word fever has its etymological basis in Latin, meaning simply ‘heat’, and pyrexia comes from the Greek ‘pyr’, meaning fire or fever.It is caused by pyrogenic and non-pyrogenic conditions. Micro-organisms like bacteria, viruses etc. cause infection and body temperature is raised as an immune response to fight infection. Inflammatory chemicals like prostaglandins, cytokines play key role in pathophysiology of fever.[2]

Considering conventional literature on fever and ayurvedic perspective of jwara, similarities about involvement of thermoregulatory mechanisms are observed in etiopathogenesis and clinical features. However, the treatment measures are different. The conventional measures focus on reducing body temperature and removing the origin of infection using anti-biotic medicines. Ayurveda medical literature emphasizes on strengthening the host immune response or defense mechanism, correcting the equilibrium of body components and preservation of health.

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 (navajwara), chronic stage (jeernajwara), irregular pattern (vishamajwara), jwara involving all three dosha (sannipatajajwara), jwara affecting body components (dhatugatajwara) are dealt in separate articles.

National Ayurveda Morbidity Code: EC -3

ICD code for relevant condition/DSM code: R50.9 (ICD)

Keywords:Jwara, fever, roga, rise in body temperature, hyperpyrexia, infectious disease, noninfectious diseases in Ayurveda.

Causes

  • Dietary: Unwholesome food habits,taking meals during indigestion, irregular dietary habits
  • Lifestyle: Excessive physical activities, exercise, fatigue, not following the seasonal regimens (ritucharya)
  • Psychological: Sudden change in emotional status, grief, excess indulgence in any activity
  • 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][3]

Classification

I. Based on origin: 1. Endogenous (nija) and 2. exogenous (agantu)

1. Endogenous

  1. Vatadosha dominant
  2. Pittadosha dominant
  3. Kaphadosha dominant
  4. Vata pittadosha dominant
  5. Pitta kaphadosha dominant
  6. Vata kaphadosha dominant
  7. Vata pitta kaphadosha dominant [Cha.Sa.Nidana Sthana 1/17]

2. Exogenous [Cha.Sa.Chikitsa Sthana.3/111]

  1. Owing to injury (abhihataja)
  2. Owing toemotions like fear, anger (abhishangaja)
  3. Owing towrongritualsand religious practices (abhicharaja)
  4. Owing to curse or negative energies (abhishapaja)

II. Based on the severity of symptoms

  1. Mild/low grade due to dominance of soma (saumya)
  2. High grade or severe due to dominance of agni(agneya) [Cha.Sa.Nidana Sthana.1/32]

III. Based on site of origin

  1. Physical or somatic
  2. Mental or psychic [Cha.Sa.Chikitsa Sthana 3/32]

IV. Based on the site of manifestation:

  1. Internal feeling (antarvegi)
  2. External features (bahirvegi) [Cha.Sa.Chikitsa Sthana 3/33]

V. Based on the time of manifestation

  1. Seasonal
  2. Unseasonal [Cha.Sa.Chikitsa Sthana 3/33]

VI. Based on the prognosis 1. Curable 2. Incurable [Cha.Sa.Chikitsa Sthana 3/33]

VII. Based on frequency of episodes [Cha.Sa.Chikitsa Sthana.3/34]

It is of 5 types.

  1. Continuously present (santata)
  2. Episode once in 24 hours (satata)
  3. Episode twice in 24 hours (anyedyushka)
  4. Episodes on every third day (tritiyaka)
  5. Episodes on every fourth day (chaturthaka)

VIII. Based on affected body tissues (dhatugatajwara)

  1. Nutritional fluid (rasa)
  2. Blood (rakta)
  3. Muscle (mamsa)
  4. Adipose tissue (meda)
  5. Bone (asthi)
  6. Bone marrow (majja)
  7. Semen/reproductive fluid (shukra)[Cha.Sa.Chikitsa Sthana.3/35]

Clinical features

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]

Table 1: Dosha specific premonitory features
Jwara Specific premonitory feature
Vatadosha Excessive yawning
Pittadosha Burning in eyes
Kaphadosha Dislike for food

[Su.Sa.Uttarasthana.39/27][3]

Exogenous fever (agantuja jwara) manifests directly without any prodromal symptoms. [Cha.Sa.Nidana Sthana.1/30]

General clinical features

Absence of perspiration, feeling of heat or raised body temperature and generalized body ache.[Su.Sa.Uttarasthana 39/13][3] 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]

Features of manasajwara (mental origin): Mental instability (vaichitya), dislike for everything (arati) and feeling of weakness in the body (glani) [Cha.Sa.Chikitsa Sthana.3/36]

Features of internal feeling (antarvegi): Excessive burning sensation inside the body, morbid thirst, delirium, dyspnoea, giddiness, pain in bones and joints, absence of sweating, obstruction of dosha and feces.

Features of external manifestation (bahirvegi): Excessive rise in the body temperature and other features of internal feeling in mild form.

Seasonal manifestation:The seasonal changes cause dosha aggravation leading to kapha dominant jwara in spring (vasanta), pitta dominant jwara in autumn (sharada) and vata dominant jwara in rains (varsha). These are natural (prakrit) disequilibrium and do not need any treatment. [Cha.Sa.Chikitsa Sthana.3/42] [A.Hr Nidana Sthana.2/50][4]

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]

Dosha specific clinical features

Vata dominant jwara:

  • Abrupt onset and remission
  • Irregular pattern of rise in temperature and severity.
  • Increase in post digestive phase and during times of vata aggravation like evening, early morning, and rains.
  • Rough skin
  • Greyish discoloration of nails, eyes, face, urine, stool and skin.
  • Reduced urination and defecation
  • Excessive tearing of nails, etc.
  • Debilitating pain radiating from the toe to upper body, with various sensations felt at various parts as the pain travels – numbness in feet, cramps in the calves, looseness in knee joints (and also in all other joints), weakness in thighs, excruciating pain in the waist region, aching in the sides, pressure sensation in back, churning in shoulder, cutting sensation in arms and scapular region and constricting feeling in chest, inability to move the jaws, tinnitus, and piercing pain in the temple region.
  • 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:

  • High intensity
  • Increase during digestion of meals, midday, mid night or in the autumn season.
  • Pungent taste in the mouth, ulceration or inflammation of the nose, mouth, throat, lips and palate, unquenchable thirst,
  • 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:

  • Mild intensity
  • 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]

Vata pitta dominant jwara:

  • 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]

Vatakapha dominant jwara:

  • 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]

Kapha Pitta dominant jwara:

  • 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]

Severe manifestation affecting ojas (hatojasjwara):

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]

  1. ↑ http://namstp.ayush.gov.in/#/sat
  2. ↑ Walter EJ, Hanna-Jumma S, Carraretto M, Forni L. The pathophysiological basis and consequences of fever. Crit Care. 2016;20(1):200. Published 2016 Jul 14. doi:10.1186/s13054-016-1375-5
  3. ↑ 3.0 3.1 3.2 Sushruta. Sushruta Samhita. Edited by Jadavaji Trikamji Aacharya. 8th ed. Varanasi: Chaukhambha Orientalia;2005.
  4. ↑ Vagbhata. Ashtanga Hridayam. Edited by Harishastri Paradkar Vaidya. 1st ed. Varanasi: Krishnadas Academy;2000.
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