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Line 4,189: − − === Vidhi vimarsha === − − Jwara in Ayurveda is not merely rise in body temperature, but a complex syndrome associated with some other features of the body, mind and the sense organs. Elevated body temperature or feeling of heat is part of the manifestation of jwara. Because of this feature of elevated body temperature, jwara is closely related to FUO of modern medicine. − Fever is defined as a state of increase in core body temperature, often as defense response of host to invasion of micro-organism or inanimate matter known as pathogen. This involves many reactions such as cytokine mediation, numerous physiologic, endocrine, immunological and autonomic responses. However, in the clinical setting and the public perception fever is typically defined as a pyrogen mediated rise in body temperature above the normal range. This definition ignores the fact that the rise in body temperature is but one component of this multifaceted response. Further, the body temperature is an agglomeration of the many different temperatures the body has, each representative of a particular body part. − The anatomic variability of the body temperature - The core and the shell − The concept of core and shell is a bit similar to our concept of koshtha and shakha. Shakha is rasa or raktadi dhatu and twacha. Koshtha includes the panchadasha koshthanga. Koshtha is the place where the main agni (jatharagni) resides. This agni digests and metabolizes the food consumed (the animal and vegetable derived panchabhautika food) to a form suitable for use by our body (panchabhautika form suitable for our body). This it does with the help of other agnis i.e. bhutagni and dhatvagnis, which are also nourished by it (jatharagni). As per the functions described of the five types of pitta in the body the function of ushma has not been specifically attributed to anyone. Why could it have been so? This could have been so because as described in the words of Acharya Sushruta, ‘agni is nowhere in the body besides pitta, but both of them can’t be attributed as same’ and Acharya Charaka stated, ‘Agni resides in body in the form of pitta; it is responsible for all auspicious and inauspicious works, digestion and indigestion, vision and lack of vision, normalcy or abnormalcy of body heat regulation, normal or abnormal complexion, valour and fear, anger and pleasure, confusion and blissful state and other similar functions. (Cha. Su. 12/11)’. In the explanation of this verse, Chakrapani has described that the production of ushma is the function of bhrajaka pitta. However, the authors suggest that the production of heat or ushma occurs due to all the five types of pitta. All reactions and transformations occurring in nature are of two types - either they consume heat (are endothermic) or they give out heat energy (are exothermic). Similarly, all the catabolic and anabolic (metabolic) processes occurring in our body cannot be outside the boundary of the same. However, we can’t detail about at which stage of food digestion and metabolism energy is consumed and at which stage heat or energy is released. The description of diurnal and age-specific variation of body temperature has been described in Ayurveda also, regarding doshika variation seen as per time of day and age. − The physiology of thermoregulation: − In a person, in resting phase (as during sleep when no external work is being done) more than half of the body’s heat is generated because of the inefficiency of the biochemical processes which convert the food energy into the free energy pool as ATP; heat is derived as a result of both internal work (as peristalsis, pericardial contractions, blood circulations, etc.) and biochemical processes and reactions involved in maintaining the structural and functional integrity of the various organ systems (the utilization and the synthesis of ATP). Heat is derived from the biochemical reactions occurring in all living cells. The energy is derived from the catabolism of metabolites such as glucose, and this is used for the purpose of oxidative phosphorylation to convert ADP into ATP. (taken from the Thermoregulation section of http://m-learning.zju.edu.cn/G2S/Template/View.aspx?courseId=27252&topMenuId=118135&action=view&type=&name=&menuType=1&curfolid=118582). This description of heat production as a result of the various biochemical processes is just like the description of Ayurveda which states that pitta is the one which is responsible for dahana, pachana, and the production of ushma in the body. − In the case when some external work is also being performed, additional heat is generated as a byproduct of skeletal muscle contractions. − Heat generated in the vital organs lying deep within the body core is distributed throughout the body with the help of circulatory system. This description of the distribution of heat with the help of circulatory system supports the notion that the ashraya of pitta is rakta (ashraya – ashrayi bhava). The importance of ashraya – ashrayi bhava is that the increase/ decrease/ alteration in the amount or qualities of one affect the other (in the case of kapha and pitta) and that we are visualizing here. According to the response derived from the nervous system, the circulatory system, determines and regulates the temperature of the various body parts and the rate of heat loss from the body surface to the environment. This whole description is about the regulation of ushma of the body by the pitta under the control and the regulation of vata dosha. − If the external temperature is raised in atmosphere (as in summer or near fire or wearing too much clothigs), the body temperature is also raised. This rise is conveyed to the hypothalamus by skin warmth receptors. This inhibits adrenergic activity of sympathetic nervous system, controlling the vasoconstriction and metabolic rate and resulting in vasodilatation. The cutaneous blood flow increases to transport more heat from core to dissipate it at skin surface through heat loss mechanisms by conduction, convection and radiation. This leads to increase in heat loss and decrease in core body temperature. − If the heat is sufficiently intense, then the cholinergic sympathetic fibers innervating the sweat glands stimulate sweating which causes heat loss. Behavioral responses to heat also occur which help with heat loss as wearing loose light clothes, fanning, drinking cold drinks, etc. The description made in this paragraph supports another fact stated in Ayurveda that the second ashraya of pitta is sweda. − In response to the cold environment, the cold skin receptors are stimulated and the blood is diverted into the skin which also gets cooled. These signals are received by the hypothalamic thermostat and the higher cortical centres, which then initiate responses promoting heat gain and inhibit centers promoting heat loss. The sympathetic centers are activated resulting in several body responses – − • Constriction of blood vessels of skin by norepinephrine − • Increased thermogenesis by the increased oxidation of brown fat (found in infants and some other animals) − • Piloerection occurs, trapping air close to skin (romaharsha – has been described as a premonitory sign of jwara in Ayurveda. as this shows that there is going to be consequent rise in body temperature) − • Thermogenesis is increased by epinephrine secretion from adrenal medulla − In the excess cold, the shivering center in the hypothalamus is also activated which causes shivering by causing the involuntary contraction of the skeletal muscles (which generates heat). Some compensatory behavioral mechanisms are also activated which help to increase the body temperature as - huddling, voluntary physical activity (hand rubbing, pacing, etc.), sheltering next to a heat source, wearing warm and more clothes, etc. − In cases when the environmental temperature increases or decreases gradually (as for summer to fall or in winter to spring) the temperature regulation depends on the regulation of metabolic rate by thyroid hormones under the control of hypothalamus (thyrotropin). − Pathogenesis of fever: − Modern science has defined fever as – “fever is a normal adaptation in response to a pyrogenic stimulus resulting in the generation of cytokines and prostaglandins.” These pyrogens can be either exogenous (originating outside the body like microbes and their products) or endogens (those which are derived from the host cells). Exogenous pyrogens usually cause fever by inducing the release of endogenous pyrogens [e.g., IL -1, tumor necrosis factor (TNF) – α, interferon (IFN) – γ, IFN – β, IL -6, Ciliary Neurotropic Factor (CNTF), etc.] which raise the hypothalamic set point. Sources of these cytokines range from neutrophils and monocytes to hepatic kupfer cells, splenic sinusoidal cells, alveolar macrophages or peritoneal lining cells. − Aside from viral, bacterial or other pathogenic infections, endogenous pyrogen release is also present in other diseases, inflammatory processes, trauma, tissue necrosis, cancer or antigen-antibody complexes. − Elevation of the hypothalamic set point: − The pyrogenic cytokines exert their effect on the hypothalamus (CVOS – circumventricular organ system – which is a small cluster of neuronal tissue lying outside the blood-brain barrier, surrounding and possessing intrinsic neuronal connections with the hypothalamic regulatory centers). − This CVOS has numerous receptors for the endogenous cytokines as well as the microbes or their products (exogenous cytokines); which in turn induce prostaglandin synthesis (amongst which the main prostaglandin produced is PGE2) which consequentially causes a rise in the neurotransmitter cyclic adenosine 5’ – monophosphate (cyclic AMP or cAMP). This cAMP eventually activates the neuronal endings of the thermoregulatory unit in the hypothalamus. Then this neuronal output from the hypothalamus leads to a raised core body temperature as per the new set point. This resetting of the thermostat activates a diverse set of endocrine, autonomic, and behavioral processes to elevate the body temperature. − Some viral diseases can act directly on the hypothalamus by bypassing the CVOS by initiating the synthesis of cytokines as IL – 1 and TNF within the central nervous system. Such CNS cytokines explain the increased body temperatures as seen in CNS hemorrhage, trauma and infection. − Achieving the Raised set point: − The neurons in the vasomotor center get activated to commence peripheral vasoconstriction also resulting in the chill. With the shunting of blood to internal organs (to decrease heat loss through the skin to the environment), adrenaline is released which results in increased metabolic rate and muscle tone. − If all these heat-conserving and production mechanisms do not suffice to raise the core body temperature adequately, then shivering (a means of heat production by the muscles) as well as non – shivering thermogenesis by the liver may also commence. Behavioral activities such as putting on more clothing, bedding or drinking hot beverages may also help raise body temperature by decreasing heat loss. − − Diagrams representing the mechanisms for heat conservation and production mechanisms of fever. − All these processes of vasoconstriction and heat production continue until the hypothalamus detects that the new set point has been achieved (by the temperature of blood bathing its neurons). − This whole description of the pathogenesis of fever resembles, to some extent, to the samprapti of jwara and the advised treatment schedule of jwara. The description of regulation of temperature by the hypothalamus is not present in our texts of Ayurveda, but it has been described before that whatever activities are taking place in our body are due to vata dosha because it is the sole initiator, controller, and regulator. It is the one who can move the agni from the amashaya to the whole body via the circulation (rasa). The circulation of rasa has been described due to vyana vata and in the pathogenesis of jwara no specific mention of vata dosha has been made. So, should we regard its role as absent? We don’t think so. Under the control of vata dosha, the pitta/agni/ushma is moved increasingly from the koshtha to the shakha to produce the desired increased body temperature. The description of swedavarodha is also present in Ayurveda, which scientifically speaking is the effect of peripheral vasoconstriction occurring to conserve the heat for the production of raised body temperature; this points to their observance of this phenomenon. Jwara has been defined as one in which there are features of santapa (raised body temperature/uneasiness or displeasure of the senses and the mind/displeasure or discomfort in the mana), swedavarodha (absence of sweating) and the feature of sarvang grahana (uneasiness/feeling of heaviness/pain in the whole body).The feature of sarvang grahana is like the non – specific arthralgias and myalgias occurring during fevers. Here we would once again like to highlight the concept of fevers as considered in modern science which makes them very close to that stated in Ayurveda – “The febrile response is a complex physiologic reaction to a disease (of which temperature rise is a component) involving many mechanisms as cytokine-mediated rise in core temperature, generation of acute phase reactants and the activation of numerous physiologic, endocrinologic, autonomic and immunologic systems or processes. However, in the clinical setting and the public perception fever is typically defined as a pyrogen mediated rise in body temperature above the normal range. This definition ignores the fact that the rise in body temperature is but one component of this multifaceted response.” − Then, the hypothalamus maintains the temperature at the febrile level by the normal thermoregulatory mechanisms and after some time a reduction in the pyrogens (or the administration of the antipyretic medication) resets the hypothalamic set point back towards normal. In this case, the hormones as arginine, vasopressin, alpha-melanocyte stimulating hormone and corticotropin releasing factor are given out, acting as endogenous antipyretics, which result in heat loss process, vasodilation and sweating which continue, until the lower set point of the hypothalamus is achieved. This process may also be aided by behavioral processes such as removal of clothing etc. which aid in heat dissipation. The other features associated with increased core temperature as non – specific myalgias and arthralgias are associated with the peripheral production of PGE2 by the influence of circulating cytokines. − − ==== Effects of Fever ==== − − Studies have demonstrated that fever is caused by the chemicals produced by our body cells, it’s a body’s complex physiological response/reaction to some insult. In this context, it is supposed to be beneficial to the multicellular organism in which it is being produced. − A growing body of research in immunology and neurophysiology has led to the recent understanding that fever is generally an adaptive physiological response to some threat. − (Kluger 1979, 1986, Saper and Breder 1994, Cooper 1995, Kozak et al..1995, Dinarello 1996, Klufgr et al. 1996, Mackocwiak et al. 1997, Rowsay 1997, Kluger et al. 1998, Wang et al. 1998). − With the advent of advanced molecular techniques and increasing interest of the scientists in the febrile response as an adaptive host response, much knowledge about the benefits of fever has been gained. Acute phase responses including fever results in increased and improved immune system. Such adaptations include increased neutrophil migration, increased secretion of inter – leukin 1, proliferation of T lymphocyte, increased production of interferon, hypoferremia and increased secretion of chemicals that are antibacterial, antitumour and/or antiviral in nature (Duff and Durum 1982, Cunha et al. 1984, Fletcher 1987, Styrt and Sugarman 1990, Holtzclaw 1992 etc.). Further evidence about the beneficial effects of fever comes from several studies conducted on patients diagnosed as having sepsis. The study revealed that patients with bacteremia or fungemia who were able to mount a febrile response had a higher survival rate as compared to those who were not (Byranit et al. 1971, Weenstein et al., 1983). The ability of patients with sepsis to react with a febrile response has been associated with a survival rate nearly double to that of hypothermic patients (Arons et al. 1999). A study done by Graham et al. (1990) demonstrated that patients treated with antipyretic therapy as aspirin, acetaminophen, and ibuprofen during infection with rhinovirus had an extended period of viral shedding. Dorn et al. (1989) also showed that children with chicken pox who were given acetaminophen took a significantly longer time for the total crusting of lesions as compared to those treated with a placebo. These two studies though do not demonstrate a firm causal link between non – treatment of fever and improved clinical outcome, but they do provide additional support for the theory that fever is beneficial to patients. − Even animal models have demonstrated repeatedly that fever is an important feature of the acute phase response and is associated with shortened duration of illness and improved survival (Jiang eta l. 2000). In another study, Jiang et al. 2000 induced bacterial peritonitis in mice and found decreased bacterial load and improved survival in animals with febrile core temperatures as compared to normothermic controls. − − ==== Antipyretic therapy ==== − − Antipyretic therapy might be justified at least in theory, if the metabolic cost of fever exceeds its physiologic benefit, if the treatment provided gives symptomatic relief without adversely affecting the course of the febrile illness or if the toxicological costs of the antipyretic regimen (side effects) were lower than its beneficial effects. − Antipyretic therapy is commonly administered to enhance patient comfort. If the temperature is greater than the 41 0 C other physical cooling measures as evaporative cooling with tepid water mist, cooling blankets, sponging with various solutions, exposure to circulating fans, etc. should be started. These physical methods of antipyresis promote heat loss by conduction, convection, and evaporation. Traditionally evaporation has been considered as the most superior method of physical antipyresis because such methods are deemed to be least likely to induce shivering. However, with external cooling methods, it has to be kept in mind that these methods lower the temperature of the febrile patients by overwhelming effector mechanisms which have been evoked by an elevated thermoregulatory set point. Therefore, unless concomitant antipyretic regimens have been started or used or shivering is inhibited by other pharmacological means, external cooling may be vigorously opposed in the febrile patients by thermoregulatory mechanisms endeavoring to maintain elevated body temperatures. − − ==== An analysis of the line of treatment described in Ayurveda for jwara ==== − − When we observe the line of treatment of jwara, we find that the principles stated here are meant to let the body reach the raised set point of body temperature and also aid the body in achieving it. This is the reason why Ayurveda has described langhana (fasting/light diet), swedana (fomentation), kala (passage of time), yavāgū (medicated gruels) and tikta rasa drugs (drugs having bitter taste) – all of these help in the pācana of avipakwa doshās in the initial stage of jwara management. The scientific explanation is available for the first three of these. Scientifically some data is available which reports that fasting or calorie restriction helps in the reduction of the inflammatory mediators. Many studies suggest that long-term CR improves several components of immune function including responses of T cells to mitogens, natural kill-cell (NK) activity, cytotoxic T lymphocyte (CTL) activity and the ability of mononuclear cells to produce pro-inflammatory cytokines. CR attenuated the age-associated increase in the ratio of memory to naïve T cells in monkeys, and this was associated with a reduction in the pro-inflammatory cytokines, TNF-α, etc. (). Though the authors want to specify that no study quoted has been done on the Ayurvedic parameters of langhana, but some clue to the possible benefits of this process of langhana is obtained by the above studies. As per Ayurveda, the indication of langhana is not intended for some patients of jwara and all patients of jwara don’t have to perform langhana for the same amount. Individualized basis has to be followed for it also. − − Further, the process of swedana (fomentation) refers to methods which aid in the production of sweating such as covering oneself with warm beddings, putting on more clothing, etc., and not hot sudation as is commonly understood. All these measures might be intending to help the body reach the desired set point in jwara and let the raised body temperature perform their functions. − − Kala refers to waiting for a certain period, and we are sure this was meant to allow the body to have its own time to resolve its intended purpose. Numerous studies have reported that the raised body temperature has several beneficial effects on the body and it seems that the purpose of kala was also the same ref. Further, the authors would like to highlight that this waiting for a certain period was also done with the proper supervision of the physician and as per the requirement of the patient. In a patient with a very high grade of temperature, the line of treatment was not all which is stated above. There the line of treatment described is that of external cooling measures as per the facilities available at that time (in the verse of treatment of paittika jwara). So, here we can see that the principles for the management of jwara in Ayurveda allowed the body to have its due reaction at the same time keeping an eye on the patient’s condition. − Unless this was the reason why did they pick the story of Lord Shiva transforming to his Rudra form (agitated form)? The mythological story described for the beginning of jwara shows that the system (the body) which was in Shiva (balance/beautiful/harmonious/homeostatic) form, due to some insult or challenge (could be internal or external) has converted into an agitated form (Rudra) to counteract it. Again this Rudra has to revert to Shiva for the person to be healthy in the true sense. − − ==== Current practices in treatments of jwara (referred from Chikitsa Pradeep) ==== − − Principles of treatment: 1. Langhana (fasting) 2. Swedanam (fomentation) 3. Kala ( waiting period of six days) 4. Yavagu (thick gruel) 5. Tikta rasa (bitter taste drugs) − Principal drugs: 1. Vatsanabha 2. Maricha 3. Malla 4. Bitter drugs like Guduchi − − Type Name of preparation Dose Time of administration Anupana (vehicle) − Vataja, kaphaja, Vata-kaphaja Chaturbhuja kalpa 250-500 mg Empty stomach − Three times in a day Honey + lukewarm beverages − Naga guti mishrana 250-375 mg Empty stomach − Three times in a day Honey + sugar − Tribhuvanakirti rasa 125 mg – 250 mg After lunch and dinner Ginger juice 5 ml and honey − Pittaja and vata-pittaja Sutashekhar kalpa 125-250 mg Empty stomach − Three times in a day Dadimavaleha − Samshamani vati 250 – 500 mg Empty stomach − Three times in a day Lukewarm water − Maha sudarshana ghana vati 250 – 500 mg Empty stomach − Three times in a day Lukewarm water − Jirna jwara (chronic) Swarna –vasanta 250-500 mg After lunch and dinner − Two times in a day Chyavanprasha − Aarogyavardhini 250-500 mg After lunch and dinner − Two times in a day Milk mixed with sugar − Virechana kalpa Eranda sneha (medicated castor oil) 40-80 ml Early morning − One time empty stomach Decoction of ginger or lukewarm water − − There are many other formulations used in clinical practices. The list of formulations can be referred from the list of formularies given below: − − #Bhaishajya ratnavali – Authored by Govindadasa and commented by Ambikadatta Shastri − #Sidhdha Yoga samgraha – Authored by Yadavji Trikamji Acharya − #Chikitsa pradeep – Authored by B.V.Gokhale − #Ayurvedic formulary of India − #Ayurvedic Pharmacopoea of India
→Vidhi vimarsha
*The signs of regaining health after remission of a disease are disappearance of klama (mental fatigue) and santapa (raised temperature/feeling of heat), absence of pain, clarity of senses and gaining natural mental faculties.
*The signs of regaining health after remission of a disease are disappearance of klama (mental fatigue) and santapa (raised temperature/feeling of heat), absence of pain, clarity of senses and gaining natural mental faculties.
*If a person, who has become free from jwara, resorts to prohibited factors (as described before) before gaining strength, then the jwara reappears.
*If a person, who has become free from jwara, resorts to prohibited factors (as described before) before gaining strength, then the jwara reappears.
=== Glossary ===
=== Glossary ===