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#Target the sites of [[kapha]][[dosha]] primarily [Cha.Sa.[[Chikitsa Sthana]].3/286-87]
#Target the sites of [[kapha]][[dosha]] primarily [Cha.Sa.[[Chikitsa Sthana]].3/286-87]
=Vishamajwara=
The condition ofjwara in which intermittent or irregular clinical features are observed with episodes is known as ‘vishamajwara’. The fundamental cause lies in the episodic or opportunistic aggravation of [[dosha]] involved in the pathogenesis.
==Causes and pathogenesis==
If the initial stage of jwara is not treated well, and aggravated [[dosha]] are not evacuated properly, then the [[dosha]] reside in dormant state in the body channels. Whenever the person is exposed to etiological factors and/or to exogenous causes, the same opportunistic [[dosha]] are aggravated to cause vishamajwara. [Cha. Sa. [[Chikitsa Sthana]].3/292] The episodes of vishamajwara are precipitated during favorable conditions of the [[dosha]] to exhibit its signs and symptoms. When the precipitating factors are absent, [[dosha]] lose their strength, and again attain dormant state at their respective site.[Cha.Sa.[[Chikitsa Sthana]] 3/70]
The episodic clinical presentation is due to the other variable factors like time, body constitution, digestive capacity etc.[Su.Sa.Uttara Sthana.39/124]<ref name=Susruta/>
This is similar to a seed germinates in fertile soil only at a time when it gets proper nourishment, in proper season. Similarly, the dormant [[dosha]] cause disease only when they get favorable vitiating factors and strength of opposing factors (host defense) is depleted. [ Cha.Sa.[[Chikitsa Sthana]] 3/68-69]
==General clinical features==
Irregular onset, irregular symptoms and irregular time of appearance may stay for longer duration in vishamajwara. [A.Hr.NidanaSthana 2/69]
{| class="wikitable"
|+ Table 3: Classification, sites of vitiation and clinical patterns
|-
! Type of vishamajwara !! Site !! Tissue (dhatu) involved !! Pattern of clinical presentation
|-
| | Santata || - || Rasa dhatu (nutritive fluid), Rakta dhatu (blood) || Continuously present for 7, 10 or 12 days
|-
| | Satata || Stomach || Rakta dhatu (blood) *, Rasa dhatu (nutritive fluid)# || Twice in 24 hours
|-
| | Anyedyushka || Chest || Meda dhatu (adipose tissue) *,Mamsa dhatu (muscle tissue) #|| Once in 24 hours
|-
| | Tritiyaka || Throat || Asthi dhatu (bone tissue) *, Meda dhatu (adipose tissue) # || Every third day (gap of one day)
|-
| | Chaturtaka || Head || Majja dhatu (bone marrow) *, Asthi dhatu (bone tissue) #|| Every fourth day (gap of two days)
|-
| | Chaturtakaviparyaya || - || Asthi and Majja dhatu (bone & bone marrow) *|| Continuous for two days (gap of one day)$
|-
|}
*[Cha.Sa.[[Chikitsa Sthana]].3/61-62, 73], #Sushruta Samhita, $[M.Ni.2/39]<ref name=Madava/>
==[[Dosha]] specific presentations==
Tritiyakajwara (every third day) affects different body parts depending on [[dosha]] specific aggravation as below:
• When [[kapha]] and [[pitta]] [[dosha]] are aggravated, it afflicts the sacral region (trika).
• When the [[vata]] and [[kapha]] [[dosha]] are aggravated, the upper back (prishtha) is affected.
• The head region is affected in the case of aggravation of [[vata]] and [[pitta]] [[dosha]]. [Cha.Sa.[[Chikitsa Sthana]] 3/71]
===Chaturthakajwara (every fourth day)===
If [[kapha]][[dosha]] is affected, then the calf region is affected initially. In case of [[vata]] dominancy, head region is affected. [Cha.Sa.[[Chikitsa Sthana]] 3/72]
===Viparyaya vishamajwara===
If vitiated [[dosha]] is situated in two or more than two sites of [[kapha]][[dosha]],it leads to viparyaya vishamajwara. [Su.Sa.Uttarasthana.39/55]<ref name=Susruta/>
If [[dosha]] is present in chest and stomach, it causes continuous jwara, which remits once in forenoon.
[[Dosha]] present in throat, chest and stomach cause jwara, which remits on third day. [[Dosha]] in head, throat, chest and stomach, produces jwara, which remits on fourth day.
===Vatabalasaka jwara===
It is characterized by continuous mild jwara, dryness, edema and rigidity in body.[M.Ni.2/40]<ref name=Madava/> If [[vata]] and [[kapha]] are present in the skin, it causes rigor in the beginning and when they subside, [[pitta]] causes burning sensation and vice versa. [Su.Sa.Uttara Sthana.39/59]<ref name=Susruta/>
===Pralepakajwara===
The person experiences mild jwara associated with heaviness and heat all over body. [M.Ni.2/41]<ref name=Madava/> It is caused by aggravated [[kapha]] and [[pitta]].
==Prognosis==
Santatajwara is extremely difficult to treat. [Cha.Sa.[[Chikitsa Sthana]].3/55]
==Management==
The management depends on dominance of [[dosha]] in the conditions.
If [[vata]] is predominant in tritiyaka and chaturtakajwara, it is managed by the administration of ghee, medicated unctuous and non-unctuous enema. The diet and drinks administered should be hot in potency and unctuous.
If [[pitta]] [[dosha]] is predominant, therapeutic purgation ([[virechana]]) is advised. Medicated ghee and milk can be given. The diet should be cold in character and bitter in taste.
[[Kapha]] predominant vishamajwara is managed through therapeutic emesis ([[vamana]]). Fasting, administration of hot decoction and digestive medicines are done. Diet and drinks should not be unctuous in nature. [Cha.Sa.[[Chikitsa Sthana]].3/293-96]
Commonly used herbs:
Phyllanthus emblica (amalaki), Terminalia bellirica (bibitaki), Terminalia chebula (haritaki), Picrorhizakurroa (katukarohini), Trichosanthes cucumerina (patola), Swertia chirayata (Kiratatikta), Holarrhena pubescens (vatsaka).
Medicated ghee: Shatpalagrita, Kalyanakagrita, Tiktakagrita
Panchakarma procedures:
*Fumigation with medicines like Aparajitadhuma [A.Hr.Chikitsa Sthana.1/164]<ref name=Hridaya/>
*Therapeutic emesis with ghee in maximum dose. [A.Hr. Chikitsa Sthana 1/159]<ref name=Hridaya/>
*If jwara is not responding by the above said procedures, venesection ([[raktamokshana]])is indicated. [A.Hr.Chikitsa Sthana.1/166]<ref name=Hridaya/>
Specific formulations for five types:
The five types of vishamajwara are managed by five decoctions made from drugs described below:
1. In santatajwara, Kalingaka, patola leaves and katukarohini
2. In satatajwara,Patola, sariva, musta, patha and katukarohini
3. In anyedyushkajwara, Nimba, patola, triphala, mrudvika, musta and vatsaka
4. In tritiyaka jwara, Kiratatikta, amrita, chandana, vishvabheshaja; and
5. In chaturthaka jwara, Guduchi, amalaka and musta. [ Cha.Sa. [[Chikitsa Sthana]] 200-203]
{| class="wikitable"
|+ Table 4: Herbal and herbo mineral formulation
|-
! Type !! Medicine
|-
| | Santata|| Lakshminarayana rasa, Laxmivilasa rasa, Guduchyadi kwata, Drakshadi churnam
|-
| |Satata/ Anyedyushka/ Tritiyaka/ || Mallasinduramisranam
|-
| | Chaturthaka|| Gandhakadruti, Tiktakakwata
|-
|}
(Chikitsapradeepa)
Rasayana therapy:
Vardhamanapippali rasayana to prevent recurrence is advised.