Panchakarma in Jwara Chikitsa

By Dr Raghuram Y.S. MD (Ay) & Dr Manasa, B.A.M.S

An intellectual physician shall administer –

• Vamana – therapeutic emesis in the treatment of kapha predominant fever
• Virechana – therapeutic purgation in the treatment of pitta predominant fever and
• Vasti – therapeutic enema (decoction and oil enema) in the treatment of vata predominant fever

Vamana in Fever

Therapeutic emesis is the best and most praised treatment for kapha predominant doshas and diseases which have their origin from stomach and intestine.

Fever too is manifested from the stomach. To be precise fever is manifested due to the presence of weak digestive fire in the stomach. Since the fever has its origin from the stomach and since kapha is the main dosha residing in the stomach, therapeutic emesis forms an ideal treatment to expel the fever causing doshas from the stomach.
Read – Ayurveda Home Remedy For Fever

When emesis should be administered?

Emesis should not be administered in acute stage of fever

Acute fever i.e taruna jwara in Ayurveda includes the first 6-7 initial days of the fever. In this condition Langhana is said to be the primary treatment strategy. Langhana means lightening therapies – the treatments which bring about lightness in the body. They are of 10 kinds. Vamana too is one among those 10 kinds.

Master Charaka and commentator Chakrapani opine that among 10 kinds of lightening therapies, only ‘upavasa / anashana rupa langhana’ i.e. fasting form of intervention should be adopted. Other 9 forms of langhana should not be resorted to in this acute phase of fever. As per this rule, emesis too should not be given to the patient of fever in its initial days.
Read – Langhana Therapy – A Unique Ayurvedic Treatment Principle – A Unique Ayurvedic Treatment Principle

Emesis is the only purification therapy that should be conditionally administered in acute fevers

Among the five purification therapies of Panchakarma, 4 types of samshuddhi i.e. cleansing measures have been mentioned among the 10 types of langhana. They are –

• Therapeutic emesis
• Therapeutic purgation
• Decoction enemas
• Nasal errhines – medicines instilled in the form of nasal drops

Oil enemas are not included since they are nourishing in nature and not cleansing.

Among the four types of langhana, only emesis should be conditionally administered in acute fevers.
Read – Vamana Therapy – Right Method, Side Effects, Management

What does conditionally mean?

Generally no purification therapies should be administered in the acute phase of fevers. But emesis shall be conditionally administered. This is a specific or special rule for administering emesis in –                                                                                                

1. Kapha pradhanan – Predominant vitiation of kapha or kapha predominant doshas in amashaya – Immaterial of the dosha(s) involved in the manifestation of fever (as causal doshas), this rule is applicable for administering emesis in the acute stages of fever. Kapha predominant doshas means – when more than one dosha is causal of fever, the condition is eligible for emesis only if kapha is predominantly aggravated in the combination. This applies to fevers caused by aggravation of dual or all three doshas.
2. Utklishtan doshan – Kapha is in utklishta avastha – Utklesha means an excited state. Utklishta Kapha is a state in which kapha is in a stage of excitation. Stage of excitation also means that dosha shows readiness to get expelled out of the body. If a dosha, kapha in this instance doesn’t show signs of excitation and readiness to get expelled, should not be forcibly expelled from the body. The signs of excitation of kapha can be known by signs such as nausea etc.
3. Amashaya sthitan – The kapha which is exited should be present in amashaya – stomach, the nearest route for doshas to be expelled through emesis.
4. Buddhva Jwarakaran – If that kapha is causing fever – If the physician concludes through his diagnosis that such exited kapha in the stomach is causing fever and it is necessary to expel it, should plan to administer emesis in that condition.
5. Kale – Emesis should be administered in proper time i.e. in the part of the day when kapha is naturally exacerbated – early in the morning. Kapha being in state of excitation is also the proper time to expel it through emesis.
6. Vamyanam – To those eligible for undergoing emesis. To administer emesis in acute stage of fever, the patient too should fit into the category of those eligible to undergo emesis therapy.
7. Vamanaih Haret – Expel such doshas through administration of emesis – when all the above said criteria are satisfied emesis should be administered with various ‘vomiting inducing formulations’ i.e. different kinds of emetics.

The entire above mentioned are not different conditions. They need to be collectively understood.

‘In taruna jwara or acute stage of fever emesis shall be administered when the aggravated kapha or kapha predominant doshas showing excitation and preparedness to get expelled are located in the stomach. If such doshas are considered to cause fever and if the patient is eligible to undergo emesis, the physician should plan to administer emesis in proper time using many effective formulations’.

The other stages of kapha are not suitable.
Read – Types Of Doshas And Their Functions

Sanskrit verses

Should the patient be prepared with snehana and swedana before administering emesis in acute fever?

Generally, oleation and sudation therapies are administered before administering emesis or purgation therapies as part of preparing the patient to undergo easy cleansing experience. They are also administered to flush the doshas from the tissues and also cause excitation of doshas so that removing them will be easy. But in this condition of acute fevers since the doshas are excited all by themselves and show preparedness to get expelled, there will be no need of oleation or sudation therapies. If the physician desires to administer them, they may be administered in small scale.

Effects of giving vamana in anutklishta dosha condition

In acute fever if emesis is administered in anutklishta dosha i.e. non-excitation of doshas (kapha here), it causes the below mentioned complications in a severe way – 

• Heart diseases
• Breathlessness
• Distension of abdomen
• Unconsciousness / confusion

Effect of expelling ama dosha

If dosha (kapha here) is associated with ama, it will get adhered to the walls of the tissues and organs. In such condition if we try to expel the dosha with purifying therapies, the dosha will damage the tissue and organ and also may cause death.

Just like an unripe fruit will be destroyed if we try to extract juice from it, the body tissues and organs too will be destroyed if we try to expel the unripe doshas i.e. doshas associated with ama. Therefore, only ripe doshas which are excited should be expelled.

Added reference from Harita

Emesis should be administered first to expel pitta and kapha. This means to tell that – emesis should be conditionally administered at the beginning of pitta and kapha predominant fevers and not in all fevers. So, emesis is the first line of treatment in fevers caused by vitiated pitta and kapha.

Virechana in fever

Below mentioned are the conditions in which purgation therapy should be administered in fevers.

• the previously mentioned measures (those mentioned before purgation in the treatise) have failed to pacify the fever and
• when the strength, muscles and digestive capacity of the patient have not deteriorated

The treatments done before purgation include – lightening therapies, emesis, use of yavagu (gruel), use of decoctions, ghee, meat soup and milk.

Virechana – therapeutic purgation is one of the most important therapies in the treatment of fevers. This article throw light on the utility of purgation and conditions in which the purgation therapy should be used in the treatment of fevers.

Virechana an important therapy in fevers predominantly caused by pitta aggravation
In the general principle of fever treatment in accordance to the predominant dosha involved in the causation of fever, Master Charaka has mentioned that purgation therapy shall be implemented mainly in the treatment of pitta predominant fevers. Therefore, the quantum and gradient of pitta aggravation in the fever and its involvement in the pathogenesis of fever shall be accessed thoroughly by the physician before considering purgation therapy in the treatment of fevers.
Read – Ayurveda Lifestyle and Diet For Fever – 45 Important Things To Know

Condition and timing for administration of purgation therapy in any type of fever
We can observe that Master Charaka has mentioned ‘use of virechana’ in the treatment of fever much later in the protocol. Master Charaka has given a sequence and pattern of ‘treatment of fever’ according to the stage and state of fever. In this sequence purgation does not fit in the initial few days of fever treatment. This is because in the initial days of manifestation of fever (taruna, nava jwara), ama is associated in the pathogenesis and digestive fire is depleted. Ama and morbid kapha needs to be dealt with in the earlier stages of fever wherein many measures come into play.
Read – Jwara Pravritti – The Initial Manifestation

In the treatment of fever, therapeutic purgation should be administered when –

• previously mentioned therapies and measures (those mentioned before purgation in the sequence of fever treatment) have failed to pacify the fever and
• when the strength, muscles and digestive capacity of the patient have not deteriorated

Which are those treatments mentioned before purgation?

• langhana – lightening therapies
• vamana – emesis
• yavagu prayoga – use of gruel
• kashaya – herbal decoctions,
• Ghee
• mamsarasa prayoga – meat soup
• Milk

The physician should expect the fever to come down by the administration of the above said measures. If the fever doesn’t come down in spite of administering them effectively then virechana – purgation therapy shall be considered, not until then. Use of virechana in pitta predominant fever, as already said is a ‘dosha specific remedy’ in pitta fevers. But when it comes to general rule of administering purgation in all kinds of fevers, this rule shall be followed.
Read – Role Of Fasting In The Treatment Of Fever – Langhana In Jwara

The other condition included for administration of purgation in fevers is that the below mentioned should be intact and not deteriorated –

• strength
• muscles and
• digestive capacity of the patient

Purgation should not be considered if one or more of these have deteriorated. One would not tolerate the purgation therapy in case of deterioration of these. Purgation, when administered following the above said conditions would pacify the fever.

The statement ‘when the previously administered measures have failed – purgation should be administered’ indicates the ‘broad spectrum action’ of purgation therapy in treating fevers.
Read – Charaka Jwara Nidana: 1st Chapter

Virechanaih
We also need to observe that the plural of virechana i.e. virechanaih has been used in the verse. Usually, this dual meaning used for virechana suggests –

• urdhwa virechana – purging of doshas in upward direction i.e. emesis therapy and
• adhah virechana – purging of doshas in downward direction i.e. purgation therapy

This also indicates the broader spectrum of understanding the verse. This perspective of understanding tells us that when no treatments are working, both emesis and purgation shall be used to control the fever. But the administration and utility of emesis therapy has been discussed in treating the earlier stages of fever, when the doshas in stomach are ready to be expelled. Should we reconsider emesis again in this instance? Well, it depends on the skills and judgment of the physician. It shall be considered if both kapha and pitta predominance are seen in spite of all measures, including emesis has been tried – all those not summing up into fruitful and desired results i.e. they have not caused pacification of fever as expected. Else, contextually, it is wise to consider only purgation therapy in this instance.

Further, Master Charaka tells that ‘Virechana – expels aggravated pitta or kapha-pitta located in the pittashaya (abode of pitta)’ while niruha vasti (decoction enema) would expel all three doshas located in the colon. This also explains the broad-spectrum action of virechana. It can remove both morbid pitta and kapha. This statement can be plugged into the earlier verse to understand ‘virechanaih’.

When the fever is caused by abundantly vitiated doshas the formulations for emesis and purgation as mentioned in Kalpa Sthana section shall be used for expelling the doshas and also to cure fever, as and when there is need for administration of emesis and purgation with conditions applied (as explained in treatise).
Read – Jwara Pravritti – The Initial Manifestation

Sanskrit Verses

Purgation recipes

Best purgation recipes in fever (Cha.Chi.3/230-233)

• Mixture of decoction of Raisins and juice of Amla – Emblica officinalis
• Juice of Amla fried in ghee should be used to drink
• Powder of Operculina turpethum mixed with honey and ghee
• Decoction of Triphala mixed with honey and ghee
• Pulp of Cassia fistula mixed in milk
• Pulp of Cassia fistula mixed in decoction of Raisins
• Powder of Operculina turpethum mixed in hot milk
• Powder of Trayamana – Gentiana kurroo – mixed with hot milk
• Powder of Terminalia chebula mixed in juice of Raisins
• Juice of grapes mixed in hot milk

Other fevers in which virechana has been indicated
Vishama Jwara – In pitta predominant tritiyaka and chaturthaka types of irregular fevers, therapeutic purgation is mentioned among the list of interventions.
Mamsa-Medogata Jwara – Virechana is mentioned amongst the treatment options for fever located in muscles and fat tissues.
Punaravartaka Jwara – Mrdu Shodhana i.e. mild cleansing –which includes mild emesis and mild purgation are mentioned amongst the treatment options for recurring fevers.

Basti in Jwara

Below mentioned are the conditions in which enema therapy should be administered in fevers.
Asthapana Vasti – Herbal decoction enemas shall be administered only after the doshas have been digested properly. This indicates that it shall not be administered in acute fevers and shall be administered only after ama has been totally digested.

Benefits of asthapana vasti – If asthapana vasti is administered after the doshas have been digested it would –

• increase and restore the strength in the patient
• enhance the digestive fire and would restore the digestive capacity
• pacify the fever
• keeps the mind pleasant
• increases taste in food
• removes morbid doshas from colon

Anuvasana Vasti – Herbal oil enemas shall be administered in fevers in the below mentioned conditions –

• if in a strong patient having good digestion capacity, purgation and decoction enema therapies are not able to expel the feces properly
• if fever is not subsiding in spite of the morbid feces, kapha and pitta have deteriorated after the treatments provided for fever
• if the fever has become chronic
• if the feces is dry and constipated

Nasya in Jwara

Below mentioned are the conditions in which errhine therapy should be administered in fevers. It is not advised or conducted in all kinds of fevers and shall be done only in those conditions wherein there is indication for it to be conducted. Nasal medications shall be implemented in the jirna jwara stage of fevers i.e. when the fevers have been ripened following the initial line of treatment.

Initially the lightening therapies (langhana) shall be done. In case of acute fevers (taruna jwara) the ama will get digested by fasting, sudation, first 8 days of the fever and gruels prepared with bitter tasting herbs. On the 8^th day herbal decoctions shall be administered for drinking. Gruels, ghee, meat soup, light foods, milk, purgation and enema shall be administered as per the condition of the fever after 10 days of onset of fever.
Read – Nasya in Jwara – Nasal Drops for the Treatment of Fever

In spite of all these measures to digest ama in acute fevers, if the below mentioned symptoms are present in the fever, nasal medicines should be administered to combat the symptoms in mature fevers. The symptoms are –

• heaviness of the head
• headache
• obstruction in the sense organs – inability of the sense organs to perceive their respective objects

These symptoms also indicate the presence of doshas in the head and sense organs. Nasal medication is done to flush the doshas, to control the fever and also to combat the head related symptoms. Indications of nasal medication indicate that it shall not be done during the first 8 days of the fever (taruna jwara). It shall be done only in the jirna jwara when the entire ama has been digested and when the symptoms pertaining to the head and sense organs have manifested in the fever.
Read – Shortening Panchakarma Therapy To Suit a Busy Patient – Dr CR Agnives

Raktamokshana in fever

Below mentioned are the conditions in which bloodletting therapy should be administered in fevers. When the fever of a person doesn’t come down in spite of trying cold, hot, unctuous and dry therapies, the physician should consider that the fever has entered the blood and other tissues. Such types of fevers subside only by bloodletting. To be precise the physician should consider fever seated in blood since fever mainly contaminates the blood and contamination of blood causes fever more than any other tissue. Therefore bloodletting shall be considered when the doshas are seated mainly in the blood. Bloodletting shall be done in the vein located in the center (middle) of the arm.

It is said that the sannipataja jwara i.e. fever caused by simultaneous aggravation of all three doshas becomes incurable when swelling manifests at the root of the ear. Among many treatments for this condition, quick bloodletting using leech application has been mentioned.
Read – Raktamokshana Benefits, Types, Procedure, Indications

Sanskrit Verses

Panchakarma in other kinds of fever

In vata predominant tritiyaka and chaturthaka vishama jwaras (irregular fevers), oil enema and herbal decoction enema have been mentioned among many treatment options.
In pitta predominant tritiyaka and chaturthaka vishama jwara, purgation therapy has been mentioned amongst many treatment options.
In kapha predominant tritiyaka and chaturthaka vishama jwara, emesis therapy has been mentioned amongst many treatment options.
In irregular fevers when the bouts of fever occur, decoction enema is indicated to be given at that time.
Nasal medication with fat of tiger, rock salt and asafetida or with fat of lion, old ghee and rock salt is indicated to be administered before the fever manifests in irregular fevers.
Read – Vishama Jwara Definition, Causes, Types, Symptoms, Treatment

Among the dhatugata jwaras (fevers located in tissues) –

• emesis is advised in fever located in rasa tissue
• purgation is indicated in fevers located in muscle and fat tissue
• decoction and oil enema shall be administered in fever located in the bone and bone marrow

In fevers caused due to trauma (abhighataja jwara) – bloodletting is mentioned amongst the treatment options.
Among the treatment options for punaravartaka jwara i.e. recurring fever mrdu shodhana (mild cleansing) and yapana vasti (nourishing enemas) have been mentioned.
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