Ashtanga Hridayam Nidanasthanam Chapter 2:  Jwara Nidanam Adhyaya (Diagnosis of fever)

अथातो ज्वरनिदानं व्याख्यास्यामः।
इति ह स्माहुरात्रेयादयो महर्षयः॥गद्यसूत्रे॥२॥
After having offered prayers to the God, henceforth we are going to explain the chapter pertaining to the explanation of ‘diagnosis of fever’. Thus pledge atreya and other sages.

Jvara Pradhanyam – importance of fever

ज्वरो रोगपतिः पाप्मा मृत्युरोजोऽशनोऽन्तकः ।
क्रोधो दक्षाध्वरध्वंसी रुद्रोर्ध्वनयनोद्भवः ॥ १ ॥
जन्मान्तयोर्मोहमयः सन्तापात्मापचारजः ।
विविधैर्नामभिः क्रूरो नानायोनिषु वर्तते ॥ २ ॥
Jvara (fever) is the lord of the diseases, born from sin, causing death, feeds on ojas (essence of the tissues), leads to the end (death), originated from the upper eyes of Rudra (Lord Shiva) who destroyed the sacrifice of Daksha, by wrath of being insulted; it is producer of delusion at the time of birth and death of living beings characterized by producing santapa (discomfort by heat), arising from ones improper conduct, (regarding food, activities etc.); a cruel one, affecting all the species of living beings and called by different names.

Jvara Bheda – kinds of fevers

स जायतेऽष्टधा दोषैः पृथङ्मिश्रैः समागतैः ।
आगन्तुश्च
It manifests in eight kinds, viz – from each dosha, by the combination of two doshas (total three), by the combination of all the three doshas (total one) and by agantu (external causes).

Notes – The eight kinds are
ekadoshaja (born from each aggravated dosha individually, i.e, vataja, pittaja, and kaphaja) total three;
dvidoshaja / dvandaja (born from the combination of two doshas aggravated simultaneously – vata pittaja, vata kaphaja and kapha pittaja) total three;
tridoshaja / sannipataja (born from the combination of all the doshas aggravated simultaneously) total one;
and
agantuja (born from external causes) one.
There are many minor varieties in each of the last three kinds, which are described further.

Samprapti – pathogenesis of fever

मलास्तत्र स्वैः स्वैर्दुष्टाः प्रदूषणैः ॥ ३ ॥
आमाशयं प्रविश्याममनुगम्य पिधाय च ।
स्रोतांसि पक्तिस्थानाच्च निरस्य ज्वलनं बहिः ॥ ४ ॥
सह तेनाभिसर्पन्तस्तपन्तः सकलं वपुः ।
कुर्वन्तो गात्रमत्युष्णं ज्वरं निर्वर्तयन्ति ते ॥ ५ ॥
स्रोतोविबन्धात् प्रायेण ततः स्वेदो न जायते ।
Malas (doshas) getting increased by their respective causes, enter the amashaya (stomach), combine with ama, obstruct the channels of rasa dhatu present in the digestive tract, drive the digestive fire to the exterior (skin and other tissues) from the seat of fire (stomach and intestine), and moving along with it (fire, heat) heats up the whole body, make for great increase of the heat of the body. Thus generate Jvara, probably because of the obstruction of the channels of sweat (by the doshas mixed with ama), sweating does not occur generally in spite of increase of temperature.

Purvarupa – premonitory symptoms of fever

तस्य प्राग्रूपमालस्यमरतिर्गात्रगौरवम् ॥ ६ ॥
आस्यवैरस्यमरुचिजृम्भा सास्राकुलाक्षिता ।
अङ्गमर्दोऽविपाकोऽल्पप्राणता बहुनिद्रता ॥ ७ ॥
रोमहर्षो विनमनं पिण्डिकोद्वेष्टनं क्लमः ।
हितोपदेशेष्वक्षान्तिः प्रीतिरम्लपटूषणे ॥ ८ ॥
द्वेषः स्वादुषु भक्ष्येषु तथा बालेषु तृड्भृशम् ।
शब्दाग्निशीतवाताम्बुच्चायोष्णेष्वनिमित्ततः ॥ ९ ॥
इच्चा द्वेषश्च तदनु ज्वरस्य व्यक्तता भवेत् ।
Its premonitory symptoms are – lassitude, lack of interest in any thing, feeling of heaviness of the body, bad taste in the mouth, loss of appetite, excessive yawning, eyes full of tears, body ache, indigestion, poor strength, excess sleep,horripilation, bending and drooping of the body parts, (by weakness), cutting pain in the calves, exhaustion even without any physical activity,impatience towards good advice, desire for things of sour, salty and pungent tastes,hatredness towards sweet eatables and children; severe thirst,like or dislike for sound (pleasant sound of music etc.), fire (sitting near fire), cold breeze, cold water, shade and sunlight without any apparent reason.Following these, the manifestation of fever takes place.

Vata jvara lakshana – features of fever of vata origin

आगमापगमक्षोभमृदुतावेदनोष्मणाम् ॥ १० ॥
वैषम्यं तत्र तत्राङ्गे तास्ताः स्युर्वेदनाश्चलाः ।
पादयोः सुप्तता स्तम्भः पिण्डिकोद्वेष्टनं शमः ॥ ११ ॥
विश्लेष इव सन्धीनां साद ऊर्वोः कटीग्रहः ।
पृष्ठं क्षोदमिवाप्नोति निष्पीड्यत इवोदरम् ॥ १२ ॥
छिद्यन्त इव चास्थीनि पार्श्वगानि विशेषतः ।
हृदयस्य ग्रहस्तोदः प्राजनेनेव वक्षसः ॥ १३ ॥
स्कन्धयोर् मथनं बाह्वोर् भेदः पीडनमंसयोः ।
अशक्तिर् भक्षणे हन्वोर् जृम्भणं कर्णयोः स्वनः ॥ १४ ॥
निस्तोदः शङ्खयोर्मूर्ध्नि वेदना विरसास्यता ।
कषायास्यत्वमथवा मलानामप्रवर्तनम् ॥ १५ ॥
रूक्षारुणत्वगास्याक्षिनखमूत्रपुरीषता ।
प्रसेकारोचकाश्रद्धाविपाकास्वेदजागराः ॥ १६ ॥
कण्ठौष्ठशोषस्तृट् शुष्कौ छर्दिकासौ विषादिता ।
हर्षो रोमाङ्गदन्तेषु वेपथुः क्षवथोर्ग्रहः ॥ १७ ॥
भ्रमः प्रलापो घर्मेच्छा विनामश्चानिलज्वरे ।
Irregularity regarding the (time of) onset and termination; severity or mildness of the feelings / pain (symptoms) and of body temperature; these symptoms manifesting in different parts differently (mild in some, severe in some others etc.) and moving from one to the other; loss of sensation and rigidity of the feet, twisting pain in the calves, exertion, looseness of the joints, weakness of the thighs, catching pain in the waist, splitting pain in the back, squeezing pain in the abdomen, splitting pain in the bones especially the ribs, catching pain in the (region of) heart, pain in the chest as though pricked by a lance, churning pain in the shoulder / neck, cutting pain in the arms, squeezing pain in the shoulder blades / scapulae, inability of the lower jaw to chew; more of the yawning, ringing in the ears, intermittent throbbing pain in the temples, headache, bad taste or astringent taste in the mouth, non-elimination of wastes, dryness and light red color in the skin, face, eyes, nails, urine and faeces; more of salivation, loss of taste, lack of interest in food, indigestion, absence of perspiration, wakefulness (loss of sleep) dryness of the throat and lips; thirst, dry vomiting and cough (unproductive), sorrowfulness, horripilation and tingling in the teeth, shivering, stoppage of sneezing, dizziness, irrelevant speech, desire for sunlight and drooping of the body parts (due to weakness) these are the features of anila (vata) jvara – fever caused by aggravated vata.

Pitta jvara lakshana – features of fever of pitta origin

युगपद् व्याप्तिरङ्गानां प्रलापः कटुवक्त्रता ॥ १८ ॥
नासास्यपाकः शीतेच्छा भ्रमो मूर्छा मदोऽरतिः ।
विट्स्रंसः पित्तवमनं रक्तष्ठीवनमम्लकः ॥ १९ ॥
रक्तकोठोद्गमः पीतहरितत्वं त्वगादिषु ।
स्वेदो निःश्वासवैगन्ध्यमतितृष्णा च पित्तजे ॥ २० ॥
Spreading (of high temperature) to all the parts of the body simultaneously, irrelevant speech, bitter taste in the mouth, ulceration of the nose and mouth, desire for cold, dizziness, fainting, intoxication, restlessness, loose motions, bilious vomiting, expectoration of blood (haemoptysis), sourness (increased acidity), appearance of red rashes on the skin, yellow or green coloration of the skin etc., perspiration, bad smell in exhalation and profound thirst are the features of fever from pitta.

Kapha jvara lakshana – features of fever of kapha origin

विशेषादरुचिर्जाड्यं स्रोतोरोधोऽल्पवेगता ।
प्रसेको मुखमाधुर्यं हृल्लेपश्वासपीनसाः ॥ २१ ॥
हृल्लासश् छर्दनं कासः स्तम्भः श्वैत्यं त्वगादिषु ।
अङ्गेषु शीतपिटिकास्तन्द्रोदर्दः कफोद्भवे ॥ २२ ॥
Loss of taste (or appetite) especially, lassitude, obstruction of the channels (of urine, faeces etc.), mild fever (temperature), increased salivation, sweet taste in the mouth, feeling of a coating on the heart, dyspnoea, running in the nose, oppression in the chest (nausea), vomiting, cough, stiffness of the body parts, whitish color of the skin etc., appearance of cold eruption on the body parts, stupor and cold swelling are the features of fever of kapha origin.

Onset and exacerbation of all kinds of fever

काले यथास्वं सर्वेषां प्रवृत्तिर्वृद्धिरेव वा ॥ २३अब् ॥
The onset and exacerbation of all of them (kinds of fevers) happens at their own respective time when the dosha causing the fever is predominant i.e.; specific period of the day, night, season, digestion of food etc.

Onset and exacerbation of all kinds of fever

निदानोक्तानुपशयो विपरीतोपशायिता ॥ २३cd॥
Factors enumerated as causes (of each kind of fever) are anupashaya (unsuitable, cause discomfort) to each of them (fevers) whereas the factors opposite of the cause are upasashya (suitable, give comfort).

Samsargaja / dvandaja jvara lakshana, vata-pittaja jwara lakshana – features of fevers arising from two doshas & symptoms of vata-pittaja fever

यथास्वं लिङ्गसंसर्गे ज्वरः संसर्गजोऽपि च ॥ २३ef ॥
शिरोऽर्तिमूर्छावमिदाहमोहकण्ठास्यशोषारतिपर्वभेदाः ।
उन्निद्रतातृड्भ्रमरोमहर्षा जृम्भातिवाक्त्वं च चलात्सपित्तात् ॥ २४ ॥
Presence of respective signs and symptoms of any two doshas simultaneously is the feature of fevers caused by two doshas generally. In addition to these, presence of headache, fainting, vomiting, burning sensation, delusion, dryness, of the throat and mouth, restlessness, pain in the small joints of the fingers, loss of sleep, thirst, dizziness horripilation more yawning and talking – are the symptoms of fever caused by vata-pitta together.

Kapha-vataja jwara lakshana – symptoms of kapha-vata fevers

तापहान्यरुचिपर्वशिरोरुक्पीनसश्वसनकासविबन्धाः ।
शीतजाड्यतिमिरभ्रमतन्द्राः श्लेष्मवातजनितज्वरलिङ्गम् ॥ २५ ॥
Mild temperature, loss of appetite, pain in the joints, headache, running in the nose, dyspnoea, cough, non-elimination of faeces, urine etc., cold (shivering), lassitude, poor vision, dizziness, stupor -are the symptoms of shleshma (kapha) vata jvara (fever caused by simultaneous increase of kapha and vata).

Kapha-pittaja jwara lakshana – symptoms of kapha-pitta fevers

शीतस्तम्भस्वेददाहाव्यवस्था तृष्णाकासश्लेष्मपित्तप्रवृत्तिः ।
मोहस्तन्द्रा लिप्ततिक्तास्यता च ज्ञेयं रूपं श्लेष्मपित्तज्वरस्य ॥ २६ ॥
Feeling of cold (shivering), stiffness of the body, sweating, burning sensation these occurring inconsistently; thirst, cough, elimination of shleshma and pitta (mucous and bile through vomiting),delusion, stupor, furring of the tongue, bitter taste in the mouth is to be known as symptoms of shleshma pitta jvara (fever caused by simultaneous increase of kapha and pitta).

Sannipata jvara lakshana – features of fevers arising from all the doshas

सर्वजो लक्षणैः सर्वैर्दाहोऽत्र च मुहुर्मुहुः ।
तद्वच्छीतं महानिद्रा दिवा जागरणं निशि ॥ २७ ॥
सदा वा नैव वा निद्रा महास्वेदोऽति नैव वा ।
गीतनर्तनहास्यादिविकृतेहाप्रवर्तनम् ॥ २८ ॥
साश्रुणी कलुषे रक्ते भुग्ने लुलितपक्ष्मणी ।
अक्षिणी पिण्डिकापार्श्वमूर्धपर्वास्थिरुग्भ्रमः ॥ २९ ॥
सस्वनौ सरुजौ कर्णौ कण्ठः शूकैरिवाचितः ।
परिदग्धा खरा जिह्वा गुरुस्रस्ताङ्गसन्धिता ॥ ३० ॥
रक्तपित्तकफष्ठीवो लोलनं शिरसोऽतिरुक् ।
कोठानां श्यावरक्तानां मण्डलानां च दर्शनम् ॥ ३१ ॥
हृद्व्यथा मलसंसङ्गः प्रवृत्तिर्वाल्पशोऽति वा ।\
स्निग्धास्यता बलभ्रंशः स्वरसादः प्रलापिता ॥ ३२ ॥
दोषपाकश्चिरात्तन्द्रा प्रततं कण्ठकूजनम् ।
सन्निपातमभिन्यासं तं ब्रूयाच्च हृतौजसम् ॥ ३३ ॥
Presence of symptoms of all the doshas are seen in sannipata fever. Especially, the feeling of burning sensation and cold again and again;heavy sleep during day and wakefulness at night, or sleeping always or not sleeping at all, too much of sweating or no sweating,improper response to singing, dancing, humor etc., improper activities (movements of the hands, feet, face etc.);eyes full of tears, dirty, reddish and irregular; eyes lashes sticking together;pain in the calves, flanks, head, joints and bones; dizziness,ringing and pain in the ears, throat feels as though full of thorns,tongue appears as though burnt at its edges, rough and heavy; drooping of the body parts and joints;expectoration of blood, pitta and kapha, movement of the head to the sides (on the pillow), severe headache, appearance of eruptions and patches of blackish red color on the skin;pain in the (region of) the heart, non-elimination of wastes, or elimination in very little quantities or in excess,unctuousness (oiliness) of the face, loss of strength, loss of voice (pitch of speech), irrelevant talking (delerium), dosha paka (doshas undergoing ripening) after a long time; stupor and cooing sound in the throat constantly, are the features of Sannipata Jvara (fever caused by simultaneous increase of all the three doshas) also known as Abhinyasa Jvara and Hrito (hritojasa) Jvara.

Notes – ‘Paka’ means cooking, ripening or transformation of substances by tejas (fire or fire-like agency), doshas also have in them a fire like agency and are undergoing constant ripening or transformation; by this process the dosha which are increased in quantity become reduced and return to their normalcy. The time required for proper processing of the doshas depend upon the strength or weakness of the fire-like agency present in the doshas which in turn, depends on the strength or weakness of the digestive fire present in the kostha (gastro-intestinal tract) and also upon the degree of increase. The doshas returning to normal is conducive to alleviation and disappearance of the disease.

Prognosis of Sannipata jvara

दोषे विबद्धे नष्टेऽग्नौ सर्वसम्पूर्णलक्षणः ।
असाध्यः सोऽन्यथा कृच्छ्रो भवेद्वैकल्यदोऽपि वा ॥ ३४ ॥
Sannipata Jvara in which the doshas are obstructed (prevented from ripening / undergoing processing by heat), the fire (digestive agency in the gastro-intestinal tract) is lost completely and in which all the signs and symptoms are manifest, is incurable,or if otherwise (the symptoms being less and mild, ripening of the doshas taking place and digestive activity going on, though poorly), it is difficult to cure or it gives rise to deformities.

Features of predominance of vata, pitta and kapha in Sannipata jvara

अन्यच्च सन्निपातोत्थो यत्र पित्तं पृथक् स्थितम् ।
त्वचि कोष्ठेऽथवा दाहं विदधाति पुरोऽनु वा ॥ ३५ ॥
तद्वद् वातकफौ शीतं दाहादिर्दुस्तरस्तयोः ।
शीतादौ तत्र पित्तेन कफे स्यन्दितशोषिते ॥ ३६ ॥
शीते शान्तेऽम्लको मूर्छा मदस्तृष्णा च जायते ।
दाहादौ पुनरन्ते स्युस्तन्द्राष्ठीववमिक्लमाः ॥ ३७ ॥
In another type of sannipata jvara (fever caused by all the doshas increased simultaneously), wherein pitta residing independently in the skin or alimentary tract, produces burning sensation either earlier or later (to fever), similarly vata and kapha produce cold (shivering), (is also difficult to cure). Among these, that which is associated with burning sensation is difficult to cure, that associated with feeling of cold first caused by liquefaction of kapha by pitta, will have sourness (acidity), fainting toxicity and thirst, after the cessation of cold, that associated with burning sensation first will have stupor, expectoration of sputum, vomiting and exhaustion at the end (after the cessation of burning sensation are also difficult to cure).

Notes – Many varieties of Sannipata Jvara have been described in the Madhukosa commentary on Madhava Nidana, which may be referred to.

Agantu Jvara – fevers caused by external agents

आगन्तुरभिघाताभिषङ्गशापाभिचारतः ।
चतुर्धात्र क्षतच्छेददाहाद्यैरभिघातजः ॥ ३८ ॥
श्रमाच् च तस्मिन् पवनः प्रायो रक्तं प्रदूषयन् ।
सव्यथाशोफवैवर्ण्यं सरुजं कुरुते ज्वरम् ॥ ३९ ॥
ग्रहावेशौषधिविषक्रोधभीशोककामजः ।
अभिषङ्गाद् ग्रहेणास्मिन्नकस्माद्धासरोदने ॥ ४० ॥
ओषधिगन्धजे मूर्छा शिरोरुग्वमथुः क्षवः ।
विषान् मूर्छातिसारास्यश्यावतादाहहृद्गदाः ॥ ४१ ॥
क्रोधात् कम्पः शिरोरुक्च प्रलापो भयशोकजे ।
कामाद् भ्रमोऽरुचिर्दाहो ह्रीनिद्राधीधृतिक्षयः ॥ ४२ ॥
Agantu jvara is of four kinds – one each from Abhighata (trauma, injury) Abhishanga (possession by evil spirits, infection of micro-organisms such as bacteria, Virus etc.) Abhishapa (curse by divine beings, godly men, elders etc) and Abhichara (witchcraft, sorcery, etc.). Abhighata is injury caused by acts such as cutting, splitting (by weapons), burning by fire and also due to exertion. In this, usually Pavana (Vata), vitiates Rakta (blood), gives rise to fever accompanied with painful, discolored swelling (at the site of injury) and constant dull pain. Abhishanga includes possession by evil spirits, (smell of) plants (pollen dust, contact etc.), poison, anger, fear, grief, lust, etc.In that fever caused by possession by evil spirits, the patient either laughs or weeps without any reason. In that caused by the smell of plants, there will be fainting, headache, vomiting and sneezing.In that due to poison there will be fainting, diarrhea, blue coloration of the mouth, burning sensation and pain in the heart;in that caused by anger there will be tremors of the body parts and headache; in those caused by fear and grief there will be irrelevant talk;in that due to lust, there is giddiness, loss of appetite, burning sensation, and loss (or absence) of shame, sleep, intelligence and courage.

Aggravation of doshas in Agantu Jvara

ग्रहादौ सन्निपातस्य भयादौ मरुतस्त्रये ।
कोपः कोपेऽपि पित्तस्य यौ तु शापाभिचारजौ ॥ ४३ ॥
सन्निपातज्वरौ घोरौ ताव् असह्यतमौ मतौ ।
तत्राभिचारिकैर्मन्त्रैर्हूयमानस्य तप्यते ॥ ४४ ॥
पूर्वं चेतस् ततो देहस्ततो विस्फोटतृड्भ्रमैः ।
सदाहमूर्छैर्ग्रस्तस्य प्रत्यहं वर्धते ज्वरः ॥ ४५ ॥
In the three kinds commencing with possession of evil spirits (those due to possession of spirits, smell of plant and poison), there is aggravation of all the three doshas. In the three kinds commencing with fear (due to fear, grief and lust), it is aggravation of maruta (vata) in that kind due to anger, it is the aggravation of pitta and even of others (doshas), the two fevers due to curse (by divine beings etc.) and witchcraft (sorcery) are caused by the aggravation of all the Doshas, are considered to be grave and highly unbearable in fever caused by sorcery. The person whose name is called out (during the acts of sorcery) along with the chanting of hymns, will experience burning (with fever) of his body gets his mind affected first and next the body, followed by appearance of vesicles on the skin, thirst, dizziness, burning sensation and fainting, and the fever increases day after day.

Contrasting combinations of fevers

इति ज्वरोऽष्टधा दृष्टः समासाद् विविधस्तु सः ।
शारीरो मानसः सौम्यस्तीक्ष्णोऽन्तर्बहिराश्रयः ॥ ४६ ॥
प्राकृतो वैकृतः साध्योऽसाध्यः सामो निरामकः ।
पूर्वं शरीरे शारीरे तापो मनसि मानसे ॥ ४७ ॥
पवने योगवाहित्वाच्छीतं श्लेष्मयुते भवेत् ।
दाहः पित्तयुते मिश्रं मिश्रेऽन्तःसंश्रये पुनः ॥ ४८ ॥
ज्वरेऽधिकं विकाराः स्युरन्तः क्षोभो मलग्रहः ।
बहिरेव बहिर्वेगे तापोऽपि च सुसाध्यता ॥ ४९ ॥
Thus was described the eight kinds of fever stated in brief, it is again of two kinds viz, Sharira (bodily), and Manasa (mental); Saumya (mild) and Tikshna (severe); Antah (internal) and Bahya (external); Prakrita (normal to the season) and Vaikrita (abnormal to the season); Sadhya (curable) and Asadhya (incurable); Sama (caused by Ama) and Nirama (not caused by Ama). In the Sharirika (type of fever) the exhaustion (due to increase of heat) is first in the body, in the Manasika (fever) it is first in the mind. Because Pavana (Vata) is Yogavahi (ambivalent) it produces cold (shivering) when associated with Kapha; burning sensation when associated with Pitta and mixed symptoms when associated with combination of all the doshas. In case of Antar Jvara (antarvega jvara – internal fever), great heat inside the body, and other abnormalities such as shock and non-elimination of wastes are found; whereas in Bahirvega Jvara (external fever) heat is more outside (in the skin) and is curable easily.

Prakrita Vaikrita Jvara – seasonal and non-seasonal fevers

वर्षाशरद्वसन्तेषु वाताद्यैः प्राकृतः क्रमात्।
वैकृतोऽन्यः स दुःसाध्यः प्रायश्च प्राकृतोऽनिलात्॥५०॥
In this varsha (rainy season), sharat (autumn) and vasanta (spring) fevers arising from vata etc. (vata, pitta and kapha) respectively are prakrita (seasonal, natural or identical with the qualities of the season) in that order. Whereas others are vaikrita (non seasonal, unnatural, dissimilar with the qualities of the season) which are difficult to cure. Generally, fever arising from vata is difficult to cure though it be prakrita.

Notes – Vata is the predominant dosha during varsha, pitta during sharat and kapha during vasanta, by the very nature of the seasons. If the fever is produced by vata during the varsha (rainy season), then such a fever is known as prakrita (dosha being the same both in the climate and the fever). If the fever is produced by pitta during varsha, then such a fever is known as vaikrita (dosha of the season and of the fever being different). The purpose of this kind of differentiation is to know their prognosis. Prakrita fevers are curable easily whereas vaikrita are curable with difficulty.

Seasonal variabilities of doshas in fever

वर्षासु मारुतो दुष्टः पित्तश्लेष्मान्वितो ज्वरम् ।
कुर्यात् पित्तं च शरदि तस्य चानुबलं कफः ॥ ५१ ॥
तत्प्रकृत्या विसर्गाच् च तत्र नानशनाद् भयम् ।
कफो वसन्ते तमपि वातपित्तं भवेदनु ॥ ५२ ॥
Vata undergoes aggravation (increase) in varsha (rainy season) first, followed next by pitta and kapha to produce fever. Pitta undergoes increase in sharat (autumn) first, followed next by Kapha, to produce fever. In these fevers there is no fear (risk) of remaining without food (because of the nature of) the season naturally being visarga (daksinayana). Kapha undergoes increase during vasanta (spring) first, followed next by vata and pitta to produce fever.

Notes – Upavasa (fasting) is one of the important therapies in the treatment of fevers. During adanakala (uttarayana) sun being strong the people will be weak. Prescribing fasting at that time is risky because it will weaken the person suffering from fever still more. During visargakala (dakshinayana) sun is weak and people are strong, prescribing fasting can be done without the risk of weakness of the patient.

Jvara Sadhyasadhyata – prognosis of fevers

बलवत्स्वल्पदोषेषु ज्वरः साध्योऽनुपद्रवः ।
सर्वथा विकृतिज्ञाने प्रागसाध्य उदाहृतः ॥ ५३ ॥
Fever is curable in persons who are strong, which has mild increase of doshas and not having any upadrava (secondary diseases, complications). It is incurable if it has all the features of incurability enumerated previously (in chapter 5 of sarira sthana).

Sama Jvara

ज्वरोपद्रवतीक्ष्णत्वमग्लानिर्बहुमूत्रता ।
न प्रवृत्तिर्न विड्जीर्णा न क्षुत्सामज्वराकृतिः ॥ ५४ ॥
Presence of complications in severe form, absence of debility, increased quantity of urine, non-elimination of feaces, even if eliminated, the feaces being not properly cooked; and absence of hunger are the features of sama jvara (fever which is acute, young, nascent and having more of ama-unprocessed doshas).

Pachyamana Jvara

ज्वरवेगोऽधिकं तृष्णा प्रलापः श्वसनं भ्रमः ।
मलप्रवृत्तिरुत्क्लेशः पच्यमानस्य लक्षणम् ॥ ५५ ॥
Increase of fever (temperature, exhaustion etc.), thirst, delirium, dyspnoea, dizziness,elimination of feaces and nausea – are the features of pachyamana jvara (fever in which the doshas are undergoing cooking, thus returning to normal, or the intermediary stage of fever).

Nirama Jvara

जीर्णतामविपर्यासात्सप्तरात्रं च लङ्घनात्।
Fever which has become old (due to lapse of time and so mild in nature), appearance of features opposite of (other than) those of Ama Jvara, (nascent fever), fever after lapse of seven days and that after fasting (by which the doshas will have been fuly cooked and returned to normal are the features of fever devoid of ama).

Notes – The fevers described so far are known as sama jvara (reguar fever) or samanya jvara (common type, ordinary fever). Once they commence, they continue to exist without break till they are cured or till the patient dies. Further on, will be described another kind of fevers called as vishama jvara (irregular fevers) which are not continuous, have remissions (periods of relief of fever) even without treatment and reappear again, after intervals of a few hours, a day or two, and without any fresh cause.

Vishama Jvara – remittent fevers

ज्वरः पञ्चविधः प्रोक्तो मलकालबलाबलात्॥५६॥
प्रायशः सन्निपातेन भूयसा तूपदिश्यते।
सन्ततः सततोऽन्येद्युस्तृतीयकचतुर्थकौ॥५७॥
Based on the strength or weakness of the malas (doshas) and time, fever is said to be five kinds. All of them, though generally produced by sannipata (all the three doshas getting increased simultaneously) yet assigned to the predominant dosha;they are Santata, Satata, Anyedyu(Shka), Tritiyaka and Chaturthaka.

Santata Jvara

धातुमूत्रशकृद्वाहिस्रोतसां व्यापिनो मलाः।
तापयन्तस्तनुं सर्वां तुल्यदूष्यादिवर्धिताः॥५८॥
बलिनो गुरवः स्तब्धा विशेषेण रसाश्रिताः।
सन्ततं निष्प्रतिद्वन्द्वा ज्वरं कुर्युः सुदुःसहम्॥५९॥
The doshas occupying the channels of the dhatu (tissues), mutra (urine) and shakrit (feaces)produce Santata Jvara (continuous fever), tormenting the entire body, getting exacerbation by involment of dushyas (the vitiated vis a vis the tissues) identical quality etc. (identical, habitat, season, constitution, of the body);powerful, heavy (associated with great amount of ama), steady (not having variations in degree of temperature and other symptoms), residing specially in the rasa dhatu,not influenced by its adversaries (habitat,  season etc.) and very difficult to bear.

Nature of Santata Jvara

मलं ज्वरोष्मा धातून् वा स शीघ्रं क्षपयेत् ततः ।
सर्वाकारं रसादीनां शुद्ध्याशुद्ध्यापि वा क्रमात् ॥६०॥
वातपित्तकफैः सप्तदश द्वादश वासरान् ।
प्रायोऽनुयाति मर्यादां मोक्षाय च वधाय च ॥ ६१ ॥
इत्यग्निवेशस्य मतं हारीतस्य पुनः स्मृतिः ।
द्विगुणा सप्तमी यावन्नवम्येकादशी तथा ॥ ६२ ॥
एषा त्रिदोषमर्यादा मोक्षाय च वधाय च ।
शुद्ध्यशुद्धौ ज्वरः कालं दीर्घमप्यनुवर्तते ॥ ६३ ॥
The heat of this fever quickly destroys the malas (doshas) and the wastes or even of all the dhatus (tissues) like the rasa etc., after complete destruction of either pure (of the doshas only) or impure (doshas mixed with dhatus and malas) in succeeding order. It continues to exist for seven, ten or twelve days, when vata, pitta and kapha are predominant respectively; such periods being the limit either for termination (of fever) or killing (of the patient). This is the opinion of Agnivesha, the opinion of Harita is double of seven (fourteen), nine and eleven days is the limit of time of the three doshas respectively either for termination (for fever) or killing (of the patient), whether it is pure (having vitiation of doshas only) or impure (having vitiation of doshas along with dhatus and malas). The fever may even continue to exist for a long time
Notes – Santata Jvara though a continuous fever for seven to fourteen days, disappears for a day or two later and appears again to continue for another episode of seven or fourteen days. Thus it conforms to the definition of Vishama Jvara – remittent fever.

Relationship between the strength and weakness of doshas with vishama jwara

कृशानां व्याधिमुक्तानां मिथ्याहारादिसेविनाम् ।
अल्पोऽपि दोषो दूष्यादेर्लब्ध्वान्यतमतो बलम् ॥ ६४ ॥
सविपक्षो ज्वरं कुर्याद्विषमं क्षयवृद्धिभाक् ।
दोषः प्रवर्तते तेषां स्वे काले ज्वरयन् बली ॥ ६५ ॥
निवर्तते पुनश्चैष प्रत्यनीकबलाबलः ।
In persons who are emaciated and who have been relieved of diseases (recently) indulging in unsuitable food etc., the doshas which are even mild, derive strength from the dushyas etc. (dhatus, malas, seasons) and obtaining an adversary thereby, produce vishama jvara,exhibiting either decrease or increase (of temperature and other symptoms).In them, the fever appears when the doshas are strong during their own respective timeand disappears at the time when the doshas are made weak by the strength of the adversaries (dhatus, malas, habitat, season etc.).

Lurking of the fever into the rasa etc. tissues in vishama jvara

क्षीणे दोषे ज्वरः सूक्ष्मो रसादिष्वेव लीयते ॥ ६६ ॥
लीनत्वात् कार्श्यवैवर्ण्यजाड्यादीनादधाति सः ।
When the doshas which cause vishama jvara become decreased, the fever becomes mild and lurks in the rasa etc. (rasa and other dhatus). Because of such lurking, it produces emaciation, discolouration, lassitude etc.

Reasons for fevers being continuous and having remissions in vishama jvara

आसन्नविवृतास्यत्वात् स्रोतसां रसवाहिनाम् ॥ ६७ ॥
आशु सर्वस्य वपुषो व्याप्तिर्दोषेण जायते ।
सन्ततः सततस्तेन विपरीतो विपर्ययात् ॥ ६८ ॥
Because of nearness and open mouthness (clearance of the lumen) of the channels of rasa,spreading of the doshas throughout the body takes place quickly. Hence santata jvara is continuous (for seven, ten or twelve days without remission); whereas others (Satata, Anyedyushka, Tritiyaka, Chaturthaka and Chaturthaka Viparyaya) are opposite (have remissions in between).

Reasons for fevers being continuous and having remissions in vishama jvara

विषमो विषमारम्भक्रियाकालोऽनुषङ्गवान् ।
Vishama jvara is irregular (inconsistent) in its arambha (nature of onset, commencement), kriya (actions, production of symptoms) and kala (time of appearance) and possesses anushanga (persistence for long periods).

Notes – Arunadatta, the commentator explains as follows –  “Some types of vishama jvaras commence with symptoms appearing first in the head, some others with symptoms appearing first in the back, yet others with symptoms in the calves, these are irregularities of nature of commencement. Some types produce feeling of cold, some other types produce feeling of great heat – these are irregularities of actions. Some types commence in the morning, some at midday, some others in the evening, yet others at night- these are irregularities of time of onset.

Nature of satata, anyedyu and tritiyaka jvaras

दोषो रक्ताश्रयः प्रायः करोति सततं ज्वरम् ॥ ६९ ॥
अहोरात्रस्य स द्विः स्यात्सकृदन्येद्युराश्रितः ।
तस्मिन् मांसवहा नाडीर्मेदोनाडीस्तृतीयके ॥ ७० ॥
ग्राही पित्तानिलान् मूर्ध्नस्त्रिकस्य कफपित्ततः ।
सपृष्ठस्यानिलकफात् स चैकाहान्तरः स्मृतः ॥ ७१ ॥
Doshas residing in rakta (blood) produce satata jvara generally. It (fever) manifests twice in a day and night (24 hours). Anyedyu (ska) jvara manifests once (in 24 hours) with the doshas residing in the channels of mamsa (muscles), with (the involvement of) the channels of medas (fat tissue). Tritiyaka Jvara manifests with an interval of a day (every alternate day) with the predominance of pitta and vata it manifests with catching pain in the head,with predominance of kapha and pitta, with catching pain in the upper part by the backand with predominance of vata and kapha with catching pain in the entire back.

Chaturtaka & chaturtaka viparyaya jwaras

चतुर्थको मले मेदोमज्जास्थ्यन्यतमस्थिते ।
मज्जस्थ एवेत्यपरे प्रभावं स तु दर्शयेत् ॥ ७२ ॥
द्विधा कफेन जङ्घाभ्यां स पूर्वं शिरसोऽनिलात् ।
अस्थिमज्जोभयगते चतुर्थकविपर्ययः ॥ ७३ ॥
त्रिधा द्व्यहं ज्वरयति दिनमेकं तु मुञ्चति ।
Doshas residing in the medas (fat), majja (marrow) and asthi (bone) produce chaturthaka jvara, some opine that they (doshas) reside only in the majja (marrow); it appears with an interval of two days (every fourth day) and manifests in two ways; viz, with the predominance of kapha, the symptoms commencing in the calves first and with the predominance of vata, symptoms commencing in the head first. Doshas residing in both the asthi (bone) and majja (marrow) simultaneous produce chaturthaka viparyaya jvara, it is of three kinds with the predominance of each dosha separately) fever appears for two days continuously and disappears for a day, to reappear again.

Strength of doshas, mind, tissues, seasons etc. in the manifestation of vishama jvaras

बलाबलेन दोषाणामन्नचेष्टादिजन्मना ॥ ७४ ॥
ज्वरः स्यान्मनसस्तद्वत् कर्मणश्च तदा तदा ।
दोषदूष्यर्त्वहोरात्रप्रभृतीनां बलाज् ज्वरः ॥ ७५ ॥
मनसो विषयाणां च कालं तं तं प्रपद्यते ।
By the strength and weakness of the doshas derived from the food, activities etc. of the body. Likewise from the functions / deeds, and of the mind, these fevers (vishama jvara or remittent and intermittent fevers) get manifested. Fever appears at such specific times whenever the doshas (become predominant in relation to the dusyas i.e. dhatus and malas involved), rtu (season), ahoratra (periods of day and night), and objects of the mind (thinking etc) get strength.

Notes: – The six kinds of fevers, viz, Santata, Satata, Anyedyushka etc; described above, with their sub types are in all probability, different varities of malaria prevailent in ancient India. Some other kinds of remittent fevers apart from malaria may also be included to the list of Vishamajvara. Bhutabhishanga (infection by parasites, bacteria, virus, and other pathogenic micro-organisms) as a cause of Takman (fever) has been mentioned in Atharva Veda. (2000 B.C.).

Jvara moksha lakshana – features of relief of fever

धातून् प्रक्षोभयन् दोषो मोक्षकाले विलीयते ॥ ७६ ॥
ततो नरः श्वसन्स्विद्यन्कूजन्वमति चेष्टते ।
वेपते प्रलपत्युष्णैः शीतैश्चाङ्गैर्हतप्रभः ॥ ७७ ॥
विसञ्ज्ञो ज्वरवेगार्तः सक्रोध इव वीक्षते ।
सदोषशब्दं च शकृद्द्रवं सृजति वेगवत् ॥ ७८ ॥
At the time of relief (of fevers) the doshas create disturbances (abnormalities) in the dhatus and become liquefied. Hence the person breathes heavily, sweats (profusely), moans, vomits, does unusual movements (of his hands, feet, brows, eyes, mouth etc.),develops tremors, irrelevant talk; body parts being hot and cold (some hot and some others cold at the same time), loss of complexionand loss of consciousness; wears an angry look by the effect of high fever (great increase of temperature),eliminates liquid feaces associated with dosha (ama-unripe, improperly processed feaces which is heavy and foul smelling); noise and great force (urgency).

Notes – Fevers terminate in two ways; viz. sudden (crisis) and gradual (lysis), the former creates anxiety (fear of death) and requires great nursing care, while the latter is safe and easy to manage. The features described above are of the crisis.

Jvara mukti lakshana – features of cure of fever

देहो लघुर्व्यपगतक्लममोहतापः पाको मुखे करणसौष्ठवमव्यथत्वम् ।
स्वेदः क्षवः प्रकृतियोगि मनोऽन्नलिप्सा कण्डूश्च मूर्ध्नि विगतज्वरलक्षणानि ॥ ७९ ॥
Feeling of lightness of the body, absence of exhaustion, delusion and effect of heat, ulceration in the mouth, normal functioning of the sense organs, absence of discomfort,appearance of sweating, sneezing, normalcy of the mind, desire for food and itching on the head – are the features of the person relieved of fever.

इति श्री वैद्यपति सिंहगुप्तसूनु श्रीमद्वाग्भटविरचितायामष्टाङ्गहृदयसंहिताया तृतीये निदानस्थाने ज्वरनिदानं नाम द्वितीयोऽध्याय: ॥१॥
Thus ends the chapter called Jvara Nidana, the second in Nidana-Sthana of Ashtangahrdaya Samhita composed by Srimad Vagbhata, son of Sri Vaidyapati Simhagupta.