By Dr Raghuram Y.S. MD (Ay) & Dr Manasa, B.A.M.S
When there is an irregular pattern of fever it is called vishama jwara. Vishama means’ irregular’, Jwara means fever. The word vishama has various meanings but in the context of discussing vishama jwara, the meaning ‘irregular’ is more suitable.
According to Master Vagbhata, the fever which has the below mentioned characteristics is called as vishama jwara –
- Vishama arambha – abrupt / bizarre beginning – fever begins abruptly, sometimes from the head and sometimes from the back and so on
- Vishama kriya – bizarre activity – sometimes there will be excessive cold associated with fever and sometimes with lot of heat
- Vishama kala – uneven distribution of duration of fever – here the time of attack of fever and duration of suffering needs to be considered. The time and days of attack of anyedhyushka, tritiyaka and chaturthaka fevers are abrupt. In these types of irregular fevers, the fever can manifest before or after the expected time and day of their appearance. Similarly the duration of fever too may be abrupt. Sometimes the fever persists for a short duration and other times for longer duration.
Read – Causes, Symptoms, Treatment Of Recurring Fevers Punaravartaka Jwara
‘The fever which appears once again after periods of remission is called vishama jwara’.
But this definition cannot be accepted since santata type of irregular fever does not follow this rule. Then santata will not be considered as irregular fever. Santata fever persists all time. There is no period of remission in santata fever.
Though there seems to be absence of fever during remission, the fever has not gone away from the body. In irregular fevers, the fever has never really gone off anywhere though there seems to be remission. Even when it appears that the fever has shown remission, the fever is deep seated in the body tissues in a latent way. Since the fever is located in the tissues it surfaces yet again after a period of remission. This period of remission is different in different types of irregular fevers.
Master Sushruta’s reference substantiates this further –
The irregular fevers never really leave the body at any time. During the period of remission the person will be having fatigue, heaviness and emaciation. Since the fever appears to have surpassed, one may consider the irregular fever to have cured. Since the fever is latent and is adhered within the deeper tissues, it will not be evident for a short duration.
According to Master Kashyapa
Master Kashyapa has explained the classification of regular and irregular fevers from the perspective of prognosis. He has considered irregular fevers as caused by preta and graha –i.e. supernatural forces.
Characteristic features of Sama Jwara – regular fevers –
- Alpa hetu – caused by less amount of etiological factors
- Bahirmarga – fever is located in the external pathways i.e. superficial
- Nirupadrava – not associated with complications
- Ekashraya – located in a part of the body / single location
- Sukhopaya – can be easily curable
- Laghupaka – the doshas can be easily digested
The terms preta and graha can be considered and compared to the fever causing microorganisms explained in the modern texts.
The explanation of Master Sushruta further substantiates this aspect of explanation of irregular fevers –
There are two causes of irregular fevers –
- Para – the other causes, external causes, microorganisms
- Swabhava – nature, inner factors, vitiated doshas
He later says that in the irregular fevers there is probably an association of external factors. The word ‘probably’ indicates that these fevers are also sometimes caused only due to the vitiation of doshas.
Master Dalhana defines ‘para’ as – ‘bhutadi hetuh’ – this too points towards external factors like microorganisms.
Some modern authors of Ayurveda have classified irregular fevers into Nija i.e. caused due to internal factors i.e. doshas and Agantu i.e. external factors mainly the microorganisms.
‘Remission and re-appearance’ is not associated with all the irregular fevers. When this is considered we might have to remove santata fever from the list of irregular fevers. That is not possible since all authors have accepted five types of irregular fevers.
Therefore we can conclude by accepting that Master Vagbhata’s definition of irregular fevers is the most appropriate one.
Types of Vishama Jwara
|Sl No||Name of irregular fever||Caused due to vitiated doshas lodged in||Nature of fever / Symptoms||Modern equivalent|
|1||Santata Jwara||Rasa tissue||Persists continuously for 7, 10 or 12 days||Continuous / Remittent Fever|
|2||Satata Jwara||Blood tissue||Fever occurs twice in a day||Double Quotidian Fever|
|3||Anyedhyushka Jwara||Muscle tissue||Fever occurs once in a day||Quotidian Fever|
|4||Tritiyaka Jwara||Fat tissue||Fever occurs once in alternative day, on every third day (after gap of one day)||Tertian Fever|
|5||Chaturthaka Jwara||Bone and bone marrow tissue||Fever occurs every fourth day (after gap of 2 days)||Quartan Fever|
As the name indicates, fever is continuous in case of santata fever. So the fever is not irregular. In this perspective it should, as a rule, not be qualified to be called irregular fever.
Master Charaka states that even santata fever sometimes comes down for a very short duration. The remission is so small that it will go out of notice. This is also because after a very short decrease, the fever once again increases and then persists for a longer duration. Therefore we can consider santata fever too as a type of irregular fever because there is a small remission though unnoticed followed by an increase of fever. The irregularity pattern is anyhow seen.
Master Kharanada on the other hand does not accept santata fever as irregular fever and has counted only the other four fevers as irregular. This is probably due to the master not considering the small remission present in this fever to rank it as irregular.
Pathogenesis – The vitiated doshas through the rasa carrying channels get distributed all through the body making the body rigid and stiff. This leads to the manifestation of santata fever.
Significant points to know about Santata Fever
1. It is a difficult condition and will cause death in quick time.
2. When the doshas get decreased this fever gets pacified in 7, 10 or 12 days. On the other hand it causes death in the same number of days when the doshas involved in the fever further get aggravated.
3. Santata fever is incurable – The santata fever is incurable or curable with difficulty because the doshas involved in the causation of these fevers –
- have the season, tissue and constitution of the patient similar to them
- have no opposing factors
4. Seats of santata fever – the 12 seats (components) of the body which are contaminated and also involved in causing santata fever are – the 3 doshas, 7 tissues and 2 excreta i.e. feces and urine. These 12 are considered to be the seats of santata fever.
Though all the tissues are the seats of santata fever, it is mainly caused due to the vitiated doshas lodged in the rasa tissue.
Prognosis of santata fevers
Vata, Pitta and Kapha types of santata fever gets pacified in 7, 10 and 12 days respectively if the tissues are thoroughly cleansed and cause death in the same number of days respectively if the tissues are not cleansed i.e. remain contaminated by the doshas.
Fate of santata fevers
The fever will go away / reduce on the 12th day if the tissues are not entirely purified, when some among the 12 components of the fever are purified and others remain contaminated. In spite of this, the symptoms remain latent. The fever once again comes back on the 13th day. This fever will stay for many days and months and its pacification time will remain unclear.
Treatment principles of Santata fever
The physician should first consider the etiological factors and symptoms of santata fever and then treat the condition skillfully. The main treatments are – depleting / lightening therapies.
Santata fever can be treated only by thoroughly understanding –
- the nature of this fever
- character of the doshas involved
- involved tissues
- seasons and time related to the fever
- constitution of the patient
2. Satata Jwara
Pathogenesis – When the vitiated doshas probably get lodged in the blood tissue, they cause satata fever. The word ‘probably’ indicates that the doshas are also rooted in the other tissues in this fever.
Relation with tissues – Though satata fever is mainly caused due to the doshas located in the blood tissue, the fever also has its root (affects) the other tissues.
Significant points to know about Satata Fever
1. Any one among the time (season), constitution of the patient or tissues will be antagonistic to the fever causing doshas.
2. The fever rises and subsides in a pattern, in its precise time. When the time of the day (or persisting season) is in accordance with the dosha i.e. favorable to the dosha, the fever rises. When the time is antagonistic to the dosha, the fever subsides.
3. The fever manifests twice in a day time.
Main symptoms – The fever occurs twice in a day.
3. Anyedhyushka Jwara
Pathogenesis – By obtaining strength by any one of the time (season), constitution of the patient or the tissues, the antagonistic dosha will cause obstruction in the fat carrying channels of the body and causes an irregular fever named anyedhyushka fever.
Relation with tissues – The doshas should block and contaminate the fat carrying channels to cause this type of irregular fevers. Fat is the tissue which is involved in the pathogenesis of anyedhyushka fever.
Significant points to know about Anyedhyushka Fever
1. Any one among the time / season, constitution of the patient or tissue is similar to the dosha causing this fever. The other two factors are antagonistic. When the antagonizing factors are stronger the fever will subside. But when the dosha gets strength by one of the three factors which are similar to it, it overcomes the antagonizing factors and causes fever.
2. The fever appears once in a day.
Main symptom – Appearance of fever only once in a day is the chief symptom of anyedhyushka fever.
4. Tritiyaka Jwara
Pathogenesis – When the vitiated doshas get lodged in the bones they cause tritiyaka fevers.
Relation with tissues – The bone tissue is mainly contaminated in tritiyaka fevers.
Significant points to know about Tritiyaka Fever
1. Tritiyaka fevers are of 3 types –
- Trikagrahi – When tritiyaka fever is caused by combined vitiation of kapha and pitta, the fever begins with pain in the sacral region.
- Prishtagrahi – When tritiyaka fever is caused by combined vitiation of vata and kapha, the fever begins with pain in the back.
- Shirograhi – When tritiyaka fever is caused by combined vitiation of vata and pitta, the fever begins with pain in the head.
In all these subtypes of tritiyaka fever, after the onset pain and discomfort will spread to the entire body along with fever.
2. The fever will appear on every third day.
Main symptom – The fever of tritiyaka comes on every third day i.e. with a gap of 1 day. This means to tell that the fever after appearing on the first day gives a gap on the second day where fever is not seen. The fever reappears on the third day. Again there is a gap on the 4th day and the fever appears on the 5th day. Thus, the fever appears on alternative days.
5. Chaturthaka Jwara
Pathogenesis – When the vitiated doshas get lodged in the bone marrow tissue they cause chaturthaka fevers.
Relation with tissues – The bone marrow tissue is mainly contaminated in chaturthaka fevers.
Significant points to know about Chaturthaka Fever
1. Chaturthaka fevers are of 2 types –
- Kapha pradhana – When kapha is predominant in the chaturthaka fever, pain occurs in the legs.
- Vata pradhana – When vata is predominant in the chaturthaka fever, pain occurs in the head.
2. The fever will appear on every fourth day.
Main symptom – The fever of chaturthaka comes on every fourth day i.e. with a gap of 2 days. This means to tell that the fever after appearing on the first day gives a gap on the second and third days wherein fever is not seen. The fever reappears on the fourth day. Again there is a gap on the 5th and 6th days and the fever appears on the 7th day.
It is another variant of chaturthaka fever.
When the three doshas individually get lodged in bones and bone marrow tissues and produce fever, it will be called as chaturthaka viparyaya fever.
It is a variant of chaturthaka fever because the behavior of the fever is opposite to that of chaturthaka fever. In this variant, the fever instead of appearing on the first and fourth day as in chaturthaka will appear on the 2nd and 3rd days. There will be no fever on the 1st and 4th days.
Difference of opinion regarding the involvement of tissues
We can see that there is a difference of opinion regarding the involvement of tissues in the pathogenesis of different kinds of these irregular fevers when we compare master Charaka and Sushruta’s perspectives.
|Sl No||Name of Visham Jwar||Tissue involved|
|1||Santata Jwara||Rasa||Rasa tissue|
|5||Chaturthaka Jwara||Bone marrow||Bone and bone marrow|
Opinion of Master Gananathsen
Apart from the above said five kinds of irregular fevers, master Gananath Sen ji has considered the below mentioned fevers too as irregular fevers because of similarity in manifestation and presentation. They are –
- Vatabalasaka Jwara
- Pralepaka Jwara
- Shlaipadika Jwara
- Upadrava Jwara
- Sarvadhatugata Jwara
Probable modern correlation of visama jwaras
|Sl No||Name of irregular fever||Modern equivalent|
|1||Santata Jwara||Continuous / Remittent Fever|
|2||Satata Jwara||Double Quotidian Fever|
|3||Anyedhyushka Jwara||Quotidian Fever|
|4||Tritiyaka Jwara||Tertian Fever|
|5||Chaturthaka Jwara||Quartan Fever|
When one consumes unwholesome foods and life activities, the doshas which are already weak or the doshas which are left out in less quantity after remission of fever get aggravated once again. These doshas on getting lodged in any of the tissues of the body produce irregular fevers.
Common symptoms (Bhaluki)
The fever is called as visham jwar when –
- it appears at non-specific / undefined time in an unexpected way after one gets exposed to abnormal heat or cold
- its bouts are irregular i.e. sometimes the fever surfaces with severe temperature and sometimes with low temperature
Due to the irregular nature of the time periods in which the fever occurs and also due to its irregular bouts, this fever is called vishama jwara.
A. Principles of treatment
1. Sadharana Karma – General principles of treatment of fever shall be adopted to treat tritiyaka and chaturthaka fevers. The external factors are probably associated with the irregular fevers.
Master Chakrapani says that these treatment principles which are being explained are only for the tritiyaka and chaturthaka fevers having association of bhutas (microorganisms and unseen external factors).
According to him, when the doshas are associated with bhutas, sadharana karma should be administered and they include –
- Daiva vyapashraya – Sacrifice etc divine / non-medicinal therapies
- Yukti vyapashraya – Herbal decoctions and other medicinal compounds prepared with skilful precision targeting the doshas involved in the causation of these fevers / medicines antagonistic to doshas or medicines which are antagonistic to the disease
He further clarifies that the term vishama jwara in the context of treatments only includes tritiyaka and chaturthaka fevers. It also includes another variant of chaturthaka fever called chaturthaka viparyaya.
Here we can see that the treatment principles of other 3 types of irregular fevers have not been included in the explanation of treatment of these fevers. With this we can infer that ‘general principles of treatment and medicines used to treat fever shall be adopted in the treatment of other three kinds of irregular fevers’.
2. Treatment of dosha predominant tritiyaka and chaturthaka irregular fevers
|Sl No||Irregular Fever (Tritiyaka & Chaturthaka)||Treatment|
|1||Vata predominant||Oral consumption of medicated ghee, Oil / unctuous enema Decoction enemas Unctuous and hot vehicles with medicines|
|2||Pitta predominant||Purgation – Milk and ghee processed with pitta alleviating herbs Bitter tasting and cold potency herbs|
|3||Kapha predominant||Emesis – Ama digesting medicines and measuresDry foods and drinks Lightening therapies Use of astringent tasting and hot potency herbs|
B. Medicines and formulations to treat all kinds of irregular fevers
Decoction of Triphala – Terminalia chebula, Terminalia bellirica and Emblica officinalis
Juice of Guduchi – Tinospora cordifolia
Use of –
- Haritaki – Terminalia chebula
- Pippali – Piper longum
- Triphala – Terminalia chebula, Terminalia bellirica and Emblica officinalis
- Panchagavya – five milk products – cow dung, cow urine, milk, curd and ghee
C. Dietetic regimen in irregular fevers
Before taking food – Sesame oil mixed with paste of garlic should be consumed.
Wholesome diet – Consumption of the below mentioned foods are beneficial in irregular fevers –
- Rice scum / gruel with wine
- Meat of tittira and peacock
- Meat taken from fatty animals and meat having hot potency
D. Interventions during the appearance / bout of fever (jwara vega)
Measures to be done on the day of fever, before the bouts of fever occur – Feces of fat mixed in milk should be given to drink. Alternatively dung of bull and rock salt are mixed in curd water or wine and given for drinking.
Nilinyadi Kwatha – When the bouts of fever come in irregular fevers, Nilinyadi Kwatha decoction should be given to drink to the patient who has undergone oleation and sudation. The ingredients of the decoction are –
- Nilini Panchanga – whole plant of Indigofera tinctoria (five parts of the plant – root, bark, leaf, flower and fruit are called panchanga)
- Ajamoda – Trachyspermum ammi
- Trivrit – Operculina turpethum
- Katuki – Picrorhiza kurrooa
Food with wine – Large quantity of wine should be served with food when bouts of fever occur. Later the person should be made to sleep.
E. Panchakarma measures and other therapies (when bouts appear)
Vamana – Shatphala Ghrta is given for drinking in large quantities and later emesis is administered. Alternatively food is given to the point of saturation and the patient is made to vomit.
Vasti – Decoction or strengthening enemas may be administered to the patient when the bouts of fever appear.
- A combination of muscle fat of tiger, rock salt and asafetida taken in equal quantity is used as nasal medication or
- A combination of muscle fat of lion, old ghee and rock salt taken in equal quantity is used similarly
These formulations shall be used before the bouts of fever occur.
Equal quantity of rock salt, grains of Piper longum, realgar should be ground in sesame oil and the resultant paste used as collyrium. This should be applied before the occurrence of fever bouts.
The combination of the below mentioned herbs should be put on fire and the smoke coming out of it should be inhaled –
- Guggulu – Commiphora mukul
- Nimba patra – leaves of Azadirachta indica
- Vacha – Acorus calamus
- Kushta – Saussurea lappa
- Haritaki – Terminalia chebula
Treating on the lines of mano vikaras – mind disorders
F. Daivavyapashraya – divine therapies / non-medicinal therapies
1. Dharana – wearing auspicious things
- Auspicious gems and medicines should be worn
- Poisonous and anti-poisonous herbs should be worn
Lord Shiva in the company of Goddess Parvati, Nandi – the celestial bull and other followers and Matru Gana should be worshipped with utmost reverence.
3. Enchanting Vishnu Sahasranama
Thousand names of Lord Vishnu who bears 1000 heads, Lord of living and inert things, who is all pervading, should be enchanted with reverence.
4. Yajna – fire sacrifice
The below mentioned should be worshipped by performing fire sacrifice –
- Lord Brahma
- Ashwinikumara twins
- Lord Indra
- Agni – the fire God
- Himalaya mountain
- Ganga river
- Marudgana – group of Gods
5. Other practices
- Worshipping parents and teachers with reverence
- Following celibacy
- Performing penance / meditation
- Speaking truth always
- Living within restrictions / self restraint
- Muttering prayers
- Fire sacrifices
- Reading or hearing Vedas
- Seeing or being in company of saints
6. Useful Formulations
- Sarvajwarahara Lauha
- Sudarshana Churna
- Sudharshana Ghana Vati
- Vettumaran Gulika
- Amrutottaram Kwatham
- Tribhuvana Kirti Rasa
- Amruta Sattva
- Shatphala Ghrta