Trishna Chikitsa

Chikitsa Sthana Chapter 22. Management of Trishna (Morbid thirst)

Trishna Chikitsa

Section/Chapter	Chikitsa Sthana Chapter 22
Preceding Chapter	Visarpa Chikitsa
Succeeding Chapter	Visha Chikitsa
Other Sections	Sutra Sthana, Nidana Sthana, Vimana Sthana, Sharira Sthana, Indriya Sthana, Kalpa Sthana, Siddhi Sthana
Translator and commentator	Sharma R.
Reviewer	Pande A.
Editors	Ojha S.N., Deole Y.S., Basisht G.
Year of publication	2020
Publisher	Charak Samhita Research, Training and Skill Development Centre
DOI	10.47468/CSNE.2020.e01.s06.023

Abstract

Trishna and pipasa are two commonly used words denoting desire for water, the difference between the two is, trishna is pathological and pipasa is physiological. Generally, desire for water is physiological process to maintain fluid balance but if dosha are vitiated then they can lead to excessive thirst and can produce trishna, a disease in which person constantly craves for the water. Beside independent disease, trishna or thirst is also seen as prodromal symptom, clinical feature, complication, poor prognostic sign etc. in various clinical conditions. In this chapter, etiological factors, premonitory symptoms, pathogenesis, clinical features and complications of trishna as a disease are discussed.

Keywords: trishna, vata, pitta, mukha shosha, jala, thirst, polydipsia, water and fluid balance, osmosis, ion balance.

Introduction

‘Water is not necessary to life but rather life itself’ – This quotation describes importance of water in our life. Water is the most abundant constituent in the body, comprising approximately 50% of body weight in women and 60% in men. It is crucial for survival as it performs various functions. It transports nutrients to the tissues, removes metabolic waste products, detoxifies body elements, regulates body temperature, maintains pH, electrolyte balance etc. and homeostasis of body. In normal physiological process, certain amount of fluid is lost continuously. If this fluid balance is not maintained then, both acute and chronic fluid deficits may lead to number of adverse health outcomes. Even modest fluid deficits may precipitate adverse events, especially in young children, in the frail elderly and in those with poor health. Fluid balance in body is maintained via thirst, a feedback-controlled variable, regulated acutely by central and peripheral mechanisms. Thirst is physiological but when it exceeds its threshold it becomes pathological and is common in many diseases. Modern science accepts it as symptom only and have not given it as an entity of ‘disease’. Ayurveda is more comprehensive and broader in its approach. Fluid imbalance is a major cause of morbidity and mortality and considering this fact ‘thirst’ which is an indicator of fluid imbalance has been described as separate disease and not merely a symptom.

The other meaning of trishna is greed or insatiable desire for something. It can be referred that word trishna not only denotes physical craving but includes psychological desires also. In morbid thirst both body and mind crave and there are conditions like psychogenic polydypsia in which thirst is only due to mental involvement. As mind plays an important role in thirst as a disease this chapter has been named as trishna chikitsitam (or Trishna Chikitsa) not pipasa chikitsitam.

Trishna word in Ayurveda is interchangeably used for physiological as well as pathological thirst. Normally, vata and pitta are the two dosha inseparably involved in causing trishna as they have shoshana guna (property to absorb the water element) but the difference is vata absorbs the moisture by its dry property, whereas pitta does it by its hot property. Thirst is function of unvitiated pitta and clinically presents as mukha shosha (dry mouth) which occurs due to vata. So, it can be said that both dosha are inseparably involved in thirst production. When they are ‘unvitiated’, physiological thirst is produced and when ‘vitiated’ they can cause trishna. Based on etiological factor and pathogenesis involved, trishna is classified into five types – vataja, pittaja, amaja, kshayaja and upasargaja. These dosha absorb water from the saumya dhatu like rasa dhatu, udaka and kapha (tissues in which water content is more). Three more types – kaphaja, bhaktodhabhavaja (after excess eating) and kshataja (thirst produced due to external injury).

Presently we rely only on fluid and electrolyte supplementation to treat thirst. Treatment of trishna by ayurvedic principles may open newer vistas in the cases where thirst is difficult to treat. Increased mortality due to dehydration, especially in vulnerable populations, it is commonly observed during periods of abnormally warm weather. Mortality rate is high in remote areas where health care facilities are not good enough. Ayurvedic preparations mentioned in this chapter are easy to make, can be life saving where sophisticated medical care is not available. Based on Ayurvedic principles, rules regarding use of water in various diseases have been also given in this chapter.

Sanskrit Text, Transliteration and English Translation

अथातस्तृष्णाचिकित्सितं व्याख्यास्यामः ||१||

इति ह स्माह भगवानात्रेयः ||२||

athātastrishnacikitsitaṁ vyākhyāsyāmaḥ||1||

iti ha smāha bhagavānātrēyaḥ||2||

athAtastRuṣṇacikitsitaM vyAkhyAsyAmaH ||1||

iti ha smAha bhagavAnAtreyaH ||2||

Now we shall expound the chapter "Trishna Chikitsa" (Management of morbid thirst).Thus said the Lord atreya. [1-2]

ज्ञानप्रशमतपोभिः ख्यातोऽत्रिसुतो जगद्धितेऽभिरतः |

तृष्णानां प्रशमार्थं चिकित्सितं प्राह पञ्चानाम् ||३||

jñānapraśamatapōbhiḥ khyātō'trisutō jagaddhitē'bhirataḥ|

trishnanāṁ praśamārthaṁ cikitsitaṁ prāha pañcānām||3||

j~jAnaprashamatapobhiH khyAto~atrisuto jagaddhite~abhirataH |

tRuṣṇanAM prashamArthaM cikitsitaM prAha pa~jcAnAm ||3||

The son of Atri, famed for his sagaciousness, tranquility, austerity and devoted to the wellness of the world, expounded the chapter therapeutics of morbid thirst. [3]

Etio-pathogenesis

क्षोभाद्भयाच्छ्रमादपि शोकात्क्रोधाद्विलङ्घनान्मद्यात् |

क्षाराम्ललवणकटुकोष्णरूक्षशुष्कान्नसेवाभिः ||४||

धातुक्षयगदकर्षणवमनाद्यतियोगसूर्यसन्तापैः |

पित्तानिलौ प्रवृद्धौ सौम्यान्धातूंश्च शोषयतः ||५||

रसवाहिनीश्च नालीर्जिह्वामूलगलतालुकक्लोम्नः |

संशोष्य नृणां देहे कुरुतस्तृष्णां महाबलावेतौ ||६||

पीतं पीतं हि जलं शोषयतस्तावतो न याति शमम् |

घोरव्याधिकृशानां प्रभवत्युपसर्गभूता सा ||७||

kṣōbhādbhayācchramādapi śōkātkrōdhādvilaṅghanānmadyāt|

kṣārāmlalavaṇakaṭukōṣṇarūkṣaśuṣkānnasēvābhiḥ||4||

dhātukṣayagadakarṣaṇavamanādyatiyōgasūryasantāpaiḥ|

pittānilau pravr̥ddhau saumyāndhātūṁśca śōṣayataḥ||5||

rasavāhinīśca nālīrjihvāmūlagalatālukaklōmnaḥ [1] |

saṁśōṣya nr̥ṇāṁ dēhē kurutastrishnaṁ mahābalāvētau||6||

pītaṁ pītaṁ hi jalaṁ śōṣayatastāvatō na yāti śamam|

ghōravyādhikr̥śānāṁ prabhavatyupasargabhūtā [2] sā||7||

kShobhAdbhayAcchramAdapi shokAtkrodhAdvila~gghanAnmadyAt |

kShArAmlalavaNakaTukoShNarūkṣashuShkAnnasevAbhiH ||4||

dhātukShayagadakarShaNavamanAdyatiyogasUryasantApaiH |

pittAnilau pravRuddhau saumyAndhātuMshca śōṣayataH ||5||

rasavAhinIshca nAlIrjihvAmUlagalatAlukaklomnaH |

saMshoShya nRuNAM dehe kurutastRuṣṇaM mahAbalAvetau ||6||

pItaM pItaM hi jalaM śōṣayatastAvato na yAti shamam |

ghoravyAdhikRushAnAM prabhavatyupasargabhUtA sA ||7||

As a result of shock/excess distress, fear, fatigue, grief, anger, extreme starvation, alcoholism, regular use of alkaline and sour substances, use of excessive salt, pungent, salty, dry and dehydrated food, emaciation due to excessive loss of basic body forming elements and emaciation due to disease, excessive use of purifactory procedures, excessive exposure to sunlight, pitta and vata get severely vitiated and dry up the watery contents of the body. These two dosha vigorously dehydrate the fluid carrying ducts and channels situated at the base of the tongue, throat, palate and kloma which causes morbid thirst in a man. Though the patient perpetually drinks water yet his thirst is not quenched. Such morbid thirst arises as a complication in the persons suffering from emaciation due to grave diseases. [4-8]

Premonitory and cardinal symptoms and signs

प्राग्रूपं मुखशोषः, स्वलक्षणं सर्वदाऽम्बुकामित्वम् |

तृष्णानां सर्वासां लिङ्गानां लाघवमपायः ||८||

prāgrūpaṁ mukhaśōṣaḥ, svalakṣaṇaṁ sarvadā'mbukāmitvam|

trishnanāṁ sarvāsāṁ liṅgānāṁ lāghavamapāyaḥ||8||

prAgrUpaM mukhaśōṣaH, svalakShaNaM sarvadA~ambukAmitvam |

tRuṣṇanAM sarvAsAM li~ggAnAM lAghavamapAyaH ||8||

The premonitory symptoms of morbid thirst are dryness of mouth along with constant craving for water as a cardinal symptom. All the clinical features of morbid thirst may occur in mild form or some of the features may be seen in premonitory stage of morbid thirst. [8]

General clinical signs and symptoms

मुखशोषस्वरभेदभ्रमसन्तापप्रलापसंस्तम्भान् |

ताल्वोष्ठकण्ठजिह्वाकर्कशतां चित्तनाशं च ||९||

जिह्वानिर्गममरुचिं बाधिर्यं मर्मदूयनं सादम् |

तृष्णोद्भूता कुरुते, पञ्चविधां लिङ्गतः शृणु ताम् ||१०||

mukhaśōṣasvarabhēdabhramasantāpapralāpasaṁstambhān|

tālvōṣṭhakaṇṭhajihvākarkaśatāṁ cittanāśaṁ ca||9||

jihvānirgamamaruciṁ bādhiryaṁ marmadūyanaṁ sādam|

tr̥ṣṇōdbhūtā kurutē, pañcavidhāṁ liṅgataḥ śr̥ṇu tām||10||

mukhaśōṣasvarabhedabhramasantApapralApasaMstambhAn |

tAlvoShThakaNThajihvAkarkashatAM cittanAshaM ca ||9||

jihvAnirgamamaruciM bAdhiryaM marmadUyanaM sAdam |

tRuShNodbhUtA kurute, pa~jcavidhAM li~ggataH shRuNu tAm ||10||

Dryness of mouth, hoarseness of voice, giddiness, burning sensation all over body, delirium, rigidity, dryness and roughness of palate, lip, throat and tongue, stupefaction, loss of concentration, protrusion of the tongue, anorexia, auditory impairment, burning sensation in vital organs and exhaustion are the symptoms of morbid thirst. Now listen carefully the symptoms of each of the five varieties of morbid thirst separately.[9-10]

Vata dominant trishna

अब्धातुं देहस्थं कुपितः पवनो यदा विशोषयति |

तस्मिञ्शुष्के शुष्यत्यबलस्तृष्यत्यथ विशुष्यन् ||११||

abdhātuṁ dēhasthaṁ kupitaḥ pavanō yadā viśōṣayati|

tasmiñśuṣkē śuṣyatyabalastr̥ṣyatyatha viśuṣyan||11||

abdhātuM dehasthaM kupitaH pavano yadA viśōṣayati |

tasmi~jshuShke shuShyatyabalastRuShyatyatha vishuShyan ||11||

Vitiated vata absorbs the watery elements in the body. As a result of absorption of these fluids, the weak person gets dehydrated and consequently suffers from morbid thirst. [11]

निद्रानाशः शिरसो भ्रमस्तथा शुष्कविरसमुखता च स्रोतोऽवरोध इति च स्याल्लिङ्गं वाततृष्णायाः ||१२||

nidrānāśaḥ śirasō bhramastathā śuṣkavirasamukhatā ca

srōtō'varōdha iti ca syālliṅgaṁ vātatrishnayāḥ||12||

nidrAnAshaH shiraso bhramastathA shuShkavirasamukhatA ca sroto~avarodha iti ca syAlli~ggaM VātatRuṣṇayAH ||12||

Lack of sleep, giddiness, dry mouth, distaste, and occlusion of the channels are the symptoms of the vataja morbid thirst. [12]

Pitta dominant trishna

पित्तं मतमाग्नेयं कुपितं चेत्तापयत्यपां धातुम् |

सन्तप्तः स हि जनयेत्तृष्णां दाहोल्बणां नॄणाम् ||१३||

तिक्तास्यत्वं शिरसो दाहः शीताभिनन्दता मूर्च्छा |

पीताक्षिमूत्रवर्चस्त्वमाकृतिः पित्ततृष्णायाः ||१४||

pittaṁ matamāgnēyaṁ kupitaṁ cēttāpayatyapāṁ dhātum|

santaptaḥ sa hi janayēttrishnaṁ dāhōlbaṇāṁ nr̥̄ṇām||13||

tiktāsyatvaṁ śirasō dāhaḥ śītābhinandatā mūrcchā|

pītākṣimūtravarcastvamākr̥tiḥ pittatrishnayāḥ||14||

pittaM matamAgneyaM kupitaM cettApayatyapAM dhātum |

santaptaH sa hi janayettRuṣṇaM dAholbaNAM nRUNAm ||13||

tiktAsyatvaM shiraso dAhaH shItAbhinandatA mUrcchA |

pItAkShimUtravarcastvamAkRutiH pittatRuṣṇayAH ||14||

The pitta is regarded as the thermal elements in the body which on vitiation, heats the watery elements to cause morbid thirst and person suffers from excessive burning sensation.

Bitter taste in the mouth, burning sensation in the head, cravings for cold things, fainting and yellowish discoloration of eyes, urine and feces, are the clinical features of pittaja morbid thirst.[13-14]

Trishna due to ama vitiation

तृष्णा याऽऽमप्रभवा साऽप्याग्नेयाऽऽमपित्तजनितत्वात् |

लिङ्गं तस्याश्चारुचिराध्मानकफप्रसेकौ च ||१५||

trishna yāmaprabhavā sā'pyāgnēyāmapittajanitatvāt [1] |

liṅgaṁ tasyāścārucirādhmānakaphaprasēkau ca||15||

tRuṣṇa yA~a~amaprabhavA sA~apyAgneyA~a~amapittajanitatvAt |

li~ggaM tasyAshcArucirAdhmAnakaphaprasekau ca ||15||

Morbid thirst, which originates from incomplete transformation or metabolism of food, is also a pittaja type as it originates from ama and pitta (pitta obstructed due to vitiated ama). Its clinical features are anorexia, flatulence and excessive salivation. [15]

Trishna due to depletion of body elements

देहो रसजोऽम्बुभवो रसश्च तस्य क्षयाच्च तृष्येद्धि |

दीनस्वरः प्रताम्यन् संशुष्कहृदयगलतालुः ||१६||

dēhō rasajō'mbubhavō rasaśca tasya kṣayācca tr̥ṣyēddhi|

dīnasvaraḥ pratāmyan saṁśuṣkahr̥dayagalatāluḥ [1] ||16||

deho rasajo~ambubhavo rasashca tasya kShayAcca tRuShyeddhi |

dInasvaraH pratAmyan saMshuShkahRudayagalatAluH ||16||

The body is composed of watery elements and the colloidal fluids of the body are in turn composed of the aqueous elements. The loss of these watery elements induces thirst, low voice (altered voice), fainting, dryness of throat and palate. [16]

Trishna due to complications of other diseases

भवति खलु योपसर्गात्तृष्णा सा शोषिणी कष्टा |

ज्वरमेहक्षयशोषश्वासाद्युपसृष्टदेहानाम् ||१७||

bhavati khalu yōpasargāttrishna sā śōṣiṇī kaṣṭā|

jvaramēhakṣayaśōṣaśvāsādyupasr̥ṣṭadēhānām [1] ||17||

bhavati khalu yopasargAttRuṣṇa sA shoShiNI kaShTA |

jvaramehakShayaśōṣashvAsAdyupasRuShTadehAnAm ||17||

Morbid thirst which occurs in a person as a complication of fever, urinary disorders in which abnormal and increased quantity of urine is passed, emaciation, consumption, dyspnea and similar other disorders, cause severe dehydration and such type of trishna is very difficult to treat.[17]

Serious consequence of trishna

सर्वास्त्वतिप्रसक्ता रोगकृशानां वमिप्रसक्तानाम् |

घोरोपद्रवयुक्तास्तृणा मरणाय विज्ञेयाः ||१८||

sarvāstvatiprasaktā rōgakr̥śānāṁ vamiprasaktānām|

ghōrōpadravayuktāstr̥ṇā maraṇāya vijñēyāḥ||18||

sarvAstvatiprasaktA rogakRushAnAM vamiprasaktAnAm |

ghoropadravayuktAstRuNA maraNAya vij~jeyAH ||18||

All varieties of diseases which are chronic in nature, which occur in the patients emaciated by diseases and afflicted with perpetual vomiting which occurs along with grave complications to be known as being indicative of approaching death. [18]

Role of vata and pitta in trishna

नाग्निं विना हि तर्षः पवनाद्वा तौ हि शोषणे हेतू |

अब्धातोरतिवृद्धावपां क्षये तृष्यते नरो हि ||१९||

गुर्वन्नपयःस्नेहैः सम्मूर्च्छद्भिर्विदाहकाले च |

यस्तृष्येद्वृतमार्गे तत्राप्यनिलानलौ हेतू ||२०||

तीक्ष्णोष्णरूक्षभावान्मद्यं पित्तानिलौ प्रकोपयति |

शोषयतोऽपां धातुं तावेव हि मद्यशीलानाम् ||२१||

तप्तास्विव सिकतासु हि तोयमाशु शुष्यति क्षिप्तम् |

तेषां सन्तप्तानां हिमजलपानाद्भवति शर्म ||२२||

nāgniṁ vinā hi tarṣaḥ pavanādvā tau hi śōṣaṇē hētū|

abdhātōrativr̥ddhāvapāṁ kṣayē tr̥ṣyatē narō hi||19||

gurvannapayaḥsnēhaiḥ sammūrcchadbhirvidāhakālē ca|

yastr̥ṣyēdvr̥tamārgē tatrāpyanilānalau hētū||20||

tīkṣṇōṣṇarūkṣabhāvānmadyaṁ pittānilau prakōpayati|

śōṣayatō'pāṁ dhātuṁ tāvēva hi madyaśīlānām||21||

taptāsviva sikatāsu hi tōyamāśu śuṣyati kṣiptam|

tēṣāṁ santaptānāṁ himajalapānādbhavati śarma||22||

nAgniM vinA hi tarShaH pavanAdvA tau hi śōṣane hetU |

abdhAtorativRuddhAvapAM kShaye tRuShyate naro hi ||19||

gurvannapayaHsnehaiH sammUrcchadbhirvidAhakAle ca |

yastRuShyedvRutamArge tatrApyanilAnalau hetU ||20||

tIkShNoShNarūkṣabhAvAnmadyaM pittAnilau prakopayati |

śōṣayato~apAM dhātuM tAveva hi madyashIlAnAm ||21||

taptAsviva sikatAsu hi toyamAshu shuShyati kShiptam |

teShAM santaptAnAM himajalapAnAdbhavati sharma ||22||

Thirst can‘t occur without pitta (heat) and vata; the excessive increase in these two elements results in absorption of the watery element, and loss of water in body leads to thirst.

In a condition where person after indulging in heavy food, milk and unctuous articles, which during the digestive process cause thirst by obstructing the channels, in such condition vata and the thermal elements act as the causative factors.

Alcohol by its quality being tikshna (the property which causes sharp action and quick penetration), salty, sultry and dry, provokes pitta and vata. These two factors (pitta and vata) dry up the watery elements of the body in alcohol addicts. Just as hot sand absorbs and dries up the water poured on it, similarly relief is obtained by pouring of the cold water.[19-22]

शिशिरस्नातस्योष्मा रुद्धः कोष्ठं प्रपद्य तर्षयति |

तस्मान्नोष्णक्लान्तो भजेत सहसा जलं शीतम् ||२३||

śiśirasnātasyōṣmā ruddhaḥ kōṣṭhaṁ prapadya tarṣayati|

tasmānnōṣṇaklāntō bhajēta sahasā jalaṁ śītam [1] ||23||

shishirasnAtasyoShmA ruddhaH koShThaM prapadya tarShayati |

tasmAnnoShNaklAnto bhajeta sahasA jalaM shItam ||23||

The body heat of the person is obstructed in the peripheral region by a cold bath and it passes to the internal organs and produces thirst. Therefore, the person who is fatigued by excessive heat should not take cold water immediately. [23]

Management of trishna

लिङ्गं सर्वास्वेतास्वनिलक्षयपित्तजं भवत्यथ तु |

पृथगागमाच्चिकित्सितमतः प्रवक्ष्यामि तृष्णानाम् ||२४||

liṅgaṁ sarvāsvētāsvanilakṣayapittajaṁ bhavatyatha tu|

pr̥thagāgamāccikitsitamataḥ pravakṣyāmi trishnanām||24||

li~ggaM sarvAsvetAsvanilakShayapittajaM bhavatyatha tu |

pRuthagAgamAccikitsitamataH pravakShyAmi tRuṣṇanAm ||24||

In all these types of the morbid thirst, symptoms arising from the vitiation of vata, pitta and loss of watery elements of the body are manifested. Now, I shall describe the treatment of morbid thirst of various types one by one according to the authoritative tradition. [24]

Properties of pure rain water and its benefits

अपां क्षयाद्धि तृष्णा संशोष्य नरं प्रणाशयेदाशु |

तस्मादैन्द्रं तोयं समधु पिबेत्तद्गुणं वाऽन्यत् ||२५||

किञ्चित्तुवरानुरसं तनु लघु शीतलं सुगन्धि सुरसं च |

अनभिष्यन्दि च यत्तत्क्षितिगतमप्यैन्द्रवज्ज्ञेयम् ||२६||

apāṁ kṣayāddhi trishna saṁśōṣya naraṁ praṇāśayēdāśu|

tasmādaindraṁ tōyaṁ samadhu pibēttadguṇaṁ vā'nyat||25||

kiñcittuvarānurasaṁ tanu laghu śītalaṁ sugandhi surasaṁ ca|

anabhiṣyandi ca yattatkṣitigatamapyaindravajjñēyam||26||

apAM kShayAddhi tRuṣṇa saMshoShya naraM praNAshayedAshu |

tasmAdaindraM toyaM samadhu pibettadguNaM vA~anyat ||25||

ki~jcittuvarAnurasaM tanu laghu shItalaM sugandhi surasaM ca |

anabhiShyandi ca yattatkShitigatamapyaindravajj~jeyam ||26||

Due to the loss of watery elements, man becomes dehydrated and dies soon due to thirst; the patients should therefore drink pure rain water mixed with honey, or any other water having similar properties that of rain water.

The water, that has slight astringent, secondary taste, which is light to digest, cool, possess good smell and taste and devoid of channel blocking quality, should be considered equal to rain water in effect though it may be terrestrial.[25-26]

Various diet recipes in management of trishna

शृतशीतं ससितोपलमथवा शरपूर्वपञ्चमूलेन |

लाजासक्तुसिताह्वामधुयुतमैन्द्रेण वा मन्थम् ||२७||

वाट्यं वाऽऽमयवानां शीतं मधुशर्करायुतं दद्यात् |

पेयां वा शालीनां दद्याद्वा कोरदूषाणाम् ||२८||

पयसा शृतेन भोजनमथवा मधुशर्करायुतं योज्यम् |

पारावतादिकरसैर्घृतभृष्टैर्वाऽप्यलवणाम्लैः ||२९||

तृणपञ्चमूलमुञ्जातकैः प्रियालैश्च जाङ्गलाः सुकृताः |

शस्ता रसाः पयो वा तैः सिद्धं शर्करामधुमत् ||३०||

शतधौतघृतेनाक्तः पयः पिबेच्छीततोयमवगाह्य |

मुद्गमसूरचणकजा रसास्तु भृष्टा घृते देयाः ||३१||

मधुरैः सजीवनीयैः शीतैश्च सतिक्तकैः शृतं क्षीरम् |

पानाभ्यञ्जनसेकेष्विष्टं मधुशर्करायुक्तम् ||३२||

तज्जं वा घृतमिष्टं पानाभ्यङ्गेषु नस्यमपि च स्यात् |

नारीपयः सशर्करमुष्ट्र्या अपि नस्यमिक्षुरसः ||३३||

śr̥taśītaṁ sasitōpalamathavā śarapūrvapañcamūlēna|

lājāsaktusitāhvāmadhuyutamaindrēṇa [4] vā mantham||27||

vāṭyaṁ vāmayavānāṁ śītaṁ madhuśarkarāyutaṁ dadyāt|

pēyāṁ vā śālīnāṁ dadyādvā kōradūṣāṇām||28||

payasā śr̥tēna bhōjanamathavā madhuśarkarāyutaṁ yōjyam|

pārāvatādikarasairghr̥tabhr̥ṣṭairvā'pyalavaṇāmlaiḥ||29||

tr̥ṇapañcamūlamuñjātakaiḥ priyālaiśca jāṅgalāḥ sukr̥tāḥ|

śastā rasāḥ payō vā taiḥ siddhaṁ śarkarāmadhumat||30||

śatadhautaghr̥tēnāktaḥ payaḥ pibēcchītatōyamavagāhya|

mudgamasūracaṇakajā rasāstu bhr̥ṣṭā ghr̥tē [5] dēyāḥ||31||

madhuraiḥ sajīvanīyaiḥ śītaiśca satiktakaiḥ śr̥taṁ kṣīram|

pānābhyañjanasēkēṣviṣṭaṁ madhuśarkarāyuktam||32||

tajjaṁ vā ghr̥tamiṣṭaṁ pānābhyaṅgēṣu nasyamapi ca syāt|

nārīpayaḥ saśarkaramuṣṭryā api nasyamikṣurasaḥ||33||

shRutashItaM sasitopalamathavA sharapUrvapa~jcamUlena |

lAjAsaktusitAhvAmadhuyutamaindreNa vA mantham ||27||

vATyaM vA~a~amayavAnAM shItaM madhusharkarAyutaM dadyAt |

pēyāM vA shAlInAM dadyAdvA koradUShANAm ||28||

payasA shRutena bhojanamathavA madhusharkarAyutaM yojyam |

pArAVātadikarasairghRutabhRuShTairvA~apyalavaNAmlaiH ||29||

tRuNapa~jcamUlamu~jjAtakaiH priyAlaishca jA~ggalAH sukRutAH |

shastA rasAH payo vA taiH siddhaM sharkarAmadhumat ||30||

shatadhautaghRutenAktaH payaH pibecchItatoyamavagAhya |

mudgamasUracaNakajA rasAstu bhRuShTA ghRute deyAH ||31||

madhuraiH sajIvanIyaiH shItaishca satiktakaiH shRutaM kShIram |

pAnAbhya~jjanasekeShviShTaM madhusharkarAyuktam ||32||

tajjaM vA ghRutamiShTaM pAnAbhya~ggeShu nasyamapi ca syAt |

nArIpayaH sasharkaramuShTryA api nasyamikShurasaH ||33||

The physician may give the decoction of roots of the shara panchamula after cooling and mixing with sugar or the demulcent drink prepared of roasted paddy powder, sugar, honey and rain water; or he may give the top part of half cooked barley gruels cooled and mixed with sugar or he may give the thin gruel of shali rice or of common millets.

Food mixed with boiled milk or with honey and sugar, or with meat juice of the pigeon and other similar birds of its group may be given after seasoning it with ghee. Sour or salty substances should not be added as mentioned in classical procedure.

The meat of jangala animals well prepared with the roots of the trina panchamula, munjataka and priyala must be recommended; or the milk prepared with the above drugs mixed with sugar and honey should be given.

The patients anointing himself with the shatadhauta ghee (ghee processed for hundred times) and taking cold bath, should drink milk or soups of green gram, lentils and chicken peas, seasoned with ghee.

The milk boiled with drugs of sweet groups of medicine, or life promoter group of medicine, cool and bitter group of medicine mixed with honey and sugar may be utilized as potion for inunction and affusion.

Or, the ghee prepared out of this medicated milk is propitious as potion and inunction as well as nasal medication. Breast milk or camel’s milk with sugar or sugarcane juice is good as nasal medication. [27-33]

Various therapeutics modalities

क्षीरेक्षुरसगुडोदकसितोपलाक्षौद्रसीधुमार्द्वीकैः |

वृक्षाम्लमातुलुङ्गैर्गण्डूषास्तालुशोषघ्नाः ||३४||

जम्ब्वाम्रातकबदरीवेतसपञ्चवल्कपञ्चाम्लैः |

हृन्मुखशिरःप्रदेहाःसघृता मूर्च्छाभ्रमतृष्णाघ्नाः स्युः ||३५||

दाडिमदधित्थलोध्रैः सविदारीबीजपूरकैः शिरसः |

लेपो गौरामलकैर्घृतारनालायुतैश्च हितः ||३६||

शैवलपङ्काम्बुरुहैः साम्लैः सघृतैश्च शक्तुभिर्लेपः |

मस्त्वारनालार्द्रवसनकमलमणिहारसंस्पर्शाः ||३७||

शिशिराम्बुचन्दनार्द्रस्तनतटपाणितलगात्रसंस्पर्शाः |

क्षौमार्द्रनिवसनानां वराङ्गनानां प्रियाणां च ||३८||

हिमवद्दरीवनसरित्सरोऽम्बुजपवनेन्दुपादशिशिराणाम् |

रम्यशिशिरोदकानां स्मरणं कथाश्च तृष्णाघ्नाः ||३९||

kShIrekShurasaguDodakasitopalAkShaudrasIdhumArdvIkaiH |

vRūkṣamlamAtulu~ggairgaNDUShAstAlushoShaghnAH ||34||

jambvAmrAtakabadarIvetasapa~jcavalkapa~jcAmlaiH |

hRunmukhashiraHpradehAHsaghRutA mUrcchAbhramatRuṣṇaghnAH syuH ||35||

dADimadadhitthalodhraiH savidArIbIjapUrakaiH shirasaH |

lepo gaurAmalakairghRutAranAlAyutaishca hitaH ||36||

shaivalapa~gkAmburuhaiH sAmlaiH saghRutaishca shaktubhirlepaH |

mastvAranAlArdravasanakamalamaNihArasaMsparshAH ||37||

shishirAmbucandanArdrastanataTapANitalagAtrasaMsparshAH |

kShaumArdranivasanAnAM varA~gganAnAM priyANAM ca ||38||

himavaddarIvanasaritsaro~ambujapavanendupAdashishirANAm |

ramyashishirodakAnAM smaraNaM kathAshca tRuṣṇaghnAH ||39||

kShIrekShurasaguDodakasitopalAkShaudrasIdhumArdvIkaiH |

vRūkṣamlamAtulu~ggairgaNDUShAstAluśōṣaghnAH ||34||

jambvAmrAtakabadarIvetasapa~jcavalkapa~jcAmlaiH |

hRunmukhashiraHpradehAHsaghRutA mUrcchAbhramatRuṣṇaghnAH syuH ||35||

dADimadadhitthalodhraiH savidArIbIjapUrakaiH shirasaH |

lepo gaurAmalakairghRutAranAlAyutaishca hitaH ||36||

shaivalapa~gkAmburuhaiH sAmlaiH saghRutaishca ŚaktubhirlepaH |

mastvAranAlArdravasanakamalamaNihArasaMsparshAH ||37||

shishirAmbucandanArdrastanataTapANitalagAtrasaMsparshAH |

kShaumArdranivasanAnAM varA~gganAnAM priyANAM ca ||38||

himavaddarIvanasaritsaro~ambujapavanendupAdashishirANAm |

ramyashishirodakAnAM smaraNaM kathAshca tRuṣṇaghnAH ||39||

The gargles of milk, sugarcane juice, jaggery water, sugar, honey, and wine prepared from sugarcane, grape wine, kokam (Garcinia cambogia) and citron fruit are beneficial in curing dryness of the palate.

The application of jambu (Syzgium cumini), Indian hog plum jujube, country willow, barks of five herbs (panchavalkal) and the herbs of panchamla group mixed with ghee over pericardial region, face are curative of fainting, giddiness and thirst.

When external application of paste prepared from pomegranate, wood apple, lodhra (Symplocos racemosa), white yam and citron or of whitish emblica myrobalans mixed with ghee and sour wheat porridge is done over head area it proves useful.

Paste prepared from moss, mud, and lotuses or with roasted paddy powder mixed with sour articles and ghee or application of wet cloth soaked in whey or sour wheat conjee or application of lotuses or of garlands of precious stones should be done. The contact of the breast and hands of resplendent and beloved women clad in wet silken garments and besmeared with cool and fragrant waters or sandal paste, proves beneficial.

The thinking of or listening to the description of Himalayan caves, woods, streams, lakes, lotuses, breezes, moonlight, and other cool things as well as of lovely cool waters- these have an allaying effect on morbid thirst.[34-39]

Guidelines for management of vata dominant trishna

वातघ्नमन्नपानं मृदु लघु शीतं च वाततृष्णायाम् |

क्षयकासनुच्छृतं क्षीरघृतमूर्ध्ववाततृष्णाघ्नम् ||४०||

vātaghnamannapānaṁ mr̥du laghu śītaṁ ca vātatrishnayām|

kṣayakāsanucchr̥taṁ kṣīraghr̥tamūrdhvavātatrishnaghnam ||40||

VātaghnamannapAnaM mRudu laghu shItaM ca VātatRuṣṇayAm |

kShayakAsanucchRutaM kShIraghRutamUrdhvaVātatRuṣṇaghnam ||40||

If the morbid thirst is due tovata dominance, then soft, light to digest food and drink with cooling property, curative of vata are recommended. Also ghee which is churned directly from milk is indicated which has been mentioned for the treatment of kshayaja kasa (cough due to wasting) and is curative of thirst and dyspnea. [40]

Guidelines for management of pitta dominant trishna

स्याज्जीवनीयसिद्धं क्षीरघृतं वातपित्तजे तर्ष |४१|

पैत्ते द्राक्षाचन्दनखर्जूरोशीरमधुयुतं तोयम् ||४१||

लोहितशालितण्डुलखर्जूरपरूषकोत्पलद्राक्षाः |

मधु पक्वलोष्टमेव च जले स्थितं शीतलं पेयम् ||४२||

लोहितशालिप्रस्थः सलोध्रमधुकाञ्जनोत्पलः क्षुण्णः |

पक्वामलोष्टजलमधुसमायुतो मृन्मये पेयः ||४३||

वटमातुलुङ्गवेतसपल्लवकुशकाशमूलयष्ट्याह्वैः |

सिद्धेऽम्भस्यग्निनिभां कृष्णमृदं कृष्णसिकतां वा ||४४||

तत्पानि नवकपालान्यथवा निर्वाप्य पाययेताच्छम् |

आपाकशर्करं वाऽमृतवल्ल्युदकं तृषां हन्ति ||४५||

क्षीरवतां मधुराणां शीतानां शर्करामधुविमिश्राः |

शीतकषाया मृद्भृष्टसंयुताः पित्ततृष्णाघ्नाः ||४६||

syājjīvanīyasiddhaṁ kṣīraghr̥taṁ vātapittajē tarṣa|41|

paittē drākṣācandanakharjūrōśīramadhuyutaṁ tōyam||41||

lōhitaśālitaṇḍulakharjūraparūṣakōtpaladrākṣāḥ|

madhu pakvalōṣṭamēva ca jalē sthitaṁ śītalaṁ pēyam||42||

lōhitaśāliprasthaḥ salōdhramadhukāñjanōtpalaḥ kṣuṇṇaḥ|

pakvāmalōṣṭajalamadhusamāyutō [9] mr̥nmayē pēyaḥ||43||

vaṭamātuluṅgavētasapallavakuśakāśamūlayaṣṭyāhvaiḥ|

siddhē'mbhasyagninibhāṁ kr̥ṣṇamr̥daṁ kr̥ṣṇasikatāṁ vā||44||

taptāni navakapālānyathavā nirvāpya pāyayētāccham|

āpākaśarkaraṁ vā'mr̥tavallyudakaṁ tr̥ṣāṁ hanti||45||

kṣīravatāṁ madhurāṇāṁ śītānāṁ śarkarāmadhuvimiśrāḥ|

śītakaṣāyā mr̥dbhr̥ṣṭasaṁyutāḥ pittatrishnaghnāḥ||46||

syAjjIvanIyasiddhaM kShIraghRutaM Vātapittaje tarSha |41|

paitte drAkShAcandanakharjUroshIramadhuyutaM toyam ||41||

lohitashAlitaNDulakharjUraparUShakotpaladrAkShAH |

madhu pakvaloShTameva ca jale sthitaM shItalaM pēyām ||42||

lohitashAliprasthaH salodhramadhukA~jjanotpalaH kShuNNaH |

pakvAmaloShTajalamadhusamAyuto mRunmaye pēyāH ||43||

VātamAtulu~ggavetasapallavakushakAshamUlayaShTyAhvaiH |

siddhe~ambhasyagninibhAM kRuṣṇamRudaM kRuṣṇasikatAM vA ||44||

tatpAni navakapAlAnyathavA nirvApya pAyayetAccham |

ApAkasharkaraM vA~amRutavallyudakaM tRuShAM hanti ||45||

kShIraVātaM madhurANAM shItAnAM sharkarAmadhuvimishrAH |

shItakaShAyA mRudbhRuShTasaMyutAH pittatRuṣṇaghnAH ||46||

In morbid thirst due to vata and pitta, the ghee taken out of milk prepared with drugs of life promoter group, is recommended.

In pittaja morbid thirst, water mixed with grapes, sandalwood, dates, vetiveria zizanioidis, honey and cold water in which red shali rice, dates, parushaka, blue water lily, grapes, honey and a baked lump of earth have been kept, may be given or water kept in earthen pot in which 64 tola of red shali rice, pounded with lodhra, liquorice, antimony and blue water lily are put and in which a baked clod of clay, water and honey have been integrated. This is a curative drink in morbid thirst.

In the water prepared with sprouts of banyan, citrus medica, country willow, roots of sacrificial and thatch grass and liquorice and quench black earthen or black sand or pieces of new earthen vessel which have been heated up to red hot. Use supernatant part of this mixture and give it to the patient.

Quench red hot stones in decoction of guduchi and use it after cooling it.

The cold infusions prepared from kshiri and madhur, shita group of plants should be given after adding sugar and honey quenching of baked clay should be done as described earlier. It is useful in pittaja trishna. [41-46]

Guidelines for management of amaja trishna

व्योषवचाभल्लातकतिक्तकषायास्तथाऽऽमतृष्णाघ्नाः |

यच्चोक्तं कफजायां वम्यां तच्चैव कार्यं स्यात् ||४७||

स्तम्भारुच्यविपाकालस्यच्छर्दिषु कफानुगां तृष्णाम् |

ज्ञात्वा दधिमधुतर्पणलवणोष्णजलैर्वमनमिष्टम् ||४८||

दाडिममम्लफलं वाऽप्यन्यत् सकषायमथ लेहम् |

पेयमथवा प्रदद्याद्रजनीशर्करायुक्तम् ||४९||

vyōṣavacābhallātakatiktakaṣāyāstathāmatrishnaghnāḥ|

yaccōktaṁ kaphajāyāṁ vamyāṁ taccaiva kāryaṁ syāt||47||

stambhārucyavipākālasyacchardiṣu kaphānugāṁ trishnam|

jñātvā dadhimadhutarpaṇalavaṇōṣṇajalairvamanamiṣṭam||48||

dāḍimamamlaphalaṁ vā'pyanyat sakaṣāyamatha lēham|

pēyamathavā pradadyādrajanīśarkarāyuktam [12] ||49||

vyoShavacAbhallAtakatiktakaShAyAstathA~a~amatRuṣṇaghnAH |

yaccoktaM kaphajAyAM vamyAM taccaiva kAryaM syAt ||47||

stambhArucyavipAkAlasyacchardiShu kaphAnugAM tRuṣṇam |

j~jAtvA dadhimadhutarpaNalavaNoShNajalairvamanamiShTam ||48||

dADimamamlaphalaM vA~apyanyat sakaShAyamatha leham |

pēyāmathavA pradadyAdrajanIsharkarAyuktam ||49||

In amaja trishna, decoctions prepared form trikatu, sweet flag, marking nut and drugs of bitter groups are useful; or treatment principles of kaphaja chhardi can be used.

Rigidity, anorexia, indigestion, lethargy and regurgitation are suggestive of kaphaja type of thirst. In such condition, a dose of prepared curds, honey demulcent drink, salt and warm water should be used to induce vomiting.

The physician may also give pomegranate or other sour fruits or the linctus mixed with astringent substances or he may give a potion containing turmeric and sugar.[47-49]

Guidelines for management of kshayaja trishna

क्षयकासेन तु तुल्या क्षयतृष्णा सा गरीयसी नॄणाम् |

क्षीणक्षतशोषहितैस्तस्मात्तां भेषजैः शमयेत् ||५०||

पानतृषार्तः पानं त्वर्धोदकमम्ललवणगन्धाढ्यम् |

शिशिरस्नातः पानं मद्याम्बु गुडाम्बु वा तृषितः ||५१||

भक्तोपरोधतृषितः स्नेहतृषार्तोऽथवा तनुयवागूम् |

प्रपिबेद्गुरुणा तृषितो भुक्तेन तदुद्धरेद्भुक्तम् ||५२||

मद्याम्बु वाऽम्बु कोष्णं बलवांस्तृषितः समुल्लिखेत् पीत्वा |

मागधिकाविशदमुखः सशर्करं वा पिबेन्मन्थम् ||५३||

बलवांस्तु तालुशोषे पिबेद्धृतं तृष्यमद्याच्च |

सर्पिर्भृष्टं क्षीरं मांसरसांश्चाबलः स्निग्धान् ||५४||

अतिरूक्षदुर्बलानां तर्षं शमयेन्नृणामिहाशु पयः |

छागो वा घृतभृष्टः शीतो मधुरो रसो हृद्यः ||५५||

स्निग्धेऽन्ने भुक्ते या तृष्णा स्यात्तां गुडाम्बुना शमयेत् |

तर्षं मूर्च्छाभिहतस्य रक्तपित्तापहैर्हन्यात् ||५६||

kṣayakāsēna tu tulyā kṣayatrishna sā garīyasī nr̥̄ṇām|

kṣīṇakṣataśōṣahitaistasmāttāṁ bhēṣajaiḥ śamayēt||50||

pānatr̥ṣārtaḥ pānaṁ tvardhōdakamamlalavaṇagandhāḍhyam|

śiśirasnātaḥ pānaṁ madyāmbu guḍāmbu vā tr̥ṣitaḥ||51||

bhaktōparōdhatr̥ṣitaḥ snēhatr̥ṣārtō'thavā tanuyavāgūm|

prapibēdguruṇā tr̥ṣitō bhuktēna taduddharēdbhuktam||52||

madyāmbu vā'mbu kōṣṇaṁ balavāṁstr̥ṣitaḥ samullikhēt pītvā|

māgadhikāviśadamukhaḥ saśarkaraṁ vā pibēnmantham||53||

balavāṁstu tāluśōṣē pibēddhr̥taṁ tr̥ṣyamadyācca|

sarpirbhr̥ṣṭaṁ kṣīraṁ māṁsarasāṁścābalaḥ snigdhān||54||

atirūkṣadurbalānāṁ tarṣaṁ śamayēnnr̥ṇāmihāśu payaḥ|

chāgō vā ghr̥tabhr̥ṣṭaḥ śītō madhurō rasō hr̥dyaḥ||55||

snigdhē'nnē bhuktē yā trishna syāttāṁ guḍāmbunā śamayēt|

tarṣaṁ mūrcchābhihatasya raktapittāpahairhanyāt||56||

kShayakAsena tu tulyA kShayatRuṣṇa sA garIyasI nRUNAm |

kShINakShataśōṣahitaistasmAttAM bheShajaiH shamayet ||50||

pAnatRuShArtaH pAnaM tvardhodakamamlalavaNagandhADhyam |

shishirasnAtaH pAnaM madyAmbu guDAmbu vA tRuShitaH ||51||

bhaktoparodhatRuShitaH snehatRuShArto~athavA tanuyavAgUm |

prapibedguruNA tRuShito bhuktena taduddharedbhuktam ||52||

madyAmbu vA~ambu koShNaM balavAMstRuShitaH samullikhet pItvA |

mAgadhikAvishadamukhaH sasharkaraM vA pibenmantham ||53||

balavAMstu tAlushoShe pibeddhRutaM tRuShyamadyAcca |

sarpirbhRuShTaM kShIraM māṁsarasAMshcAbalaH snigdhAn ||54||

atirūkṣadurbalAnAM tarShaM shamayennRuNAmihAshu payaH |

chAgo vA ghRutabhRuShTaH shIto madhuro raso hRudyaH ||55||

snigdhe~anne bhukte yA tRuṣṇa syAttAM guDAmbunA shamayet |

tarShaM mUrcchAbhihatasya raktapittApahairhanyAt ||56||

Kshayaja trishna is serious in nature as like kshayaja kasa (cough due to wasting), therefore this type of thirst should be treated with medications mentioned in cough due to wasting. Medications mentioned in kshatakshina and shosha are helpful.

In polydipsia due to alcoholism, a potion of wine diluted with equal amount of water mixed with sour, salt and liberal quantity of fragrant substances are advised. In thirst immediately after a cold bath, a drink of diluted wine or jaggery water is recommended. If thirst is due to abstinence from food or due to indigestion of unctuous diet, the patient may take thin medicated gruel; if the thirst is due to ingestion of heavy meal, the patient should vomit out the food.

If patient is strong enough, he may drink a dose of wine and water or warm water before vomiting and after cleaning mouth with long pepper, he may take a demulcent drink with sugar.

If the thirsty patient has good strength and he suffers from dry palate, he may drink ghee or use it in his food; if the patient is weak, he may take milk seasoned with ghee or unctuous meat juice.

The people who are extremely dehydrated and are weak can pacify their thirst immediately by milk or the cool and sweet meat juice of goat seasoned with ghee.

The thirst resulting from eating unctuous food should be quenched with jaggery water; and the thirst in a person who has fainted should be remedied by medication mentioned in murchha (fainting).[50-56]

Indications of cold and hot water

तृट्दाहमूर्च्छाभ्रमक्लममदात्ययास्रविषपित्ते |

शस्तं स्वभावशीतं, शृतशीतं सन्निपातेऽम्भः ||५७||

हिक्काश्वासनवज्वरपीनसघृतपीतपार्श्वगलरोगे |

कफवातकृते स्त्याने सद्यःशुद्धे च हितमुष्णम् ||५८||

पाण्डूदरपीनसमेहगुल्ममन्दानलातिसारेषु |

प्लीह्नि च तोयं न हितं काममसह्ये पिबेदल्पम् ||५९||

पूर्वामयातुरः सन् दीनस्तृष्णार्दितो जलं काङ्क्षन् |

न लभेत स चेन्मरणमाश्वेवाप्नुयाद्दीर्घरोगं वा ||६०||

तस्माद्धान्याम्बु पिबेत्तृष्यन् रोगी सशर्कराक्षौद्रम् |

यद्वा तस्यान्यत्स्यात् सात्म्यं रोगस्य तच्चेष्टम् ||६१||

तस्यां विनिवृत्तायां तज्जन्य उपद्रवः सुखं जेतुम् |

तस्मात्तृष्णां पूर्वं जयेद्बहुभ्योऽपि रोगेभ्यः ||६२||

tr̥ṭdāhamūrcchābhramaklamamadātyayāsraviṣapittē |

śastaṁ svabhāvaśītaṁ, śr̥taśītaṁ sannipātē'mbhaḥ||57||

hikkāśvāsanavajvarapīnasaghr̥tapītapārśvagalarōgē|

kaphavātakr̥tē styānē sadyaḥśuddhē ca hitamuṣṇam||58||

pāṇḍūdarapīnasamēhagulmamandānalātisārēṣu|

plīhni ca tōyaṁ na hitaṁ kāmamasahyē pibēdalpam||59||

pūrvāmayāturaḥ san dīnastrishnarditō jalaṁ kāṅkṣan|

na labhēta sa cēnmaraṇamāśvēvāpnuyāddīrgharōgaṁ vā||60||

tasmāddhānyāmbu pibēttr̥ṣyan rōgī saśarkarākṣaudram|

yadvā tasyānyatsyāt sātmyaṁ rōgasya taccēṣṭam||61||

tasyāṁ vinivr̥ttāyāṁ tajjanya upadravaḥ sukhaṁ jētum|

tasmāttrishnaṁ pūrvaṁ jayēdbahubhyō'pi rōgēbhyaḥ||62||

tRuTdAhamUrcchAbhramaklamamadAtyayAsraviShapitte |

shastaM svabhAvashItaM, shRutashItaM sannipAte~ambhaH ||57||

hikkAshvAsanavajvarapInasaghRutapItapArshvagalaroge |

kaphaVātakRute styAne sadyaHshuddhe ca hitamuṣṇam ||58||

pANDUdarapInasamehagulmamandAnalAtisAreShu |

plIhni ca toyaM na hitaM kAmamasahye pibedalpam ||59||

pUrvAmayAturaH san dInastRuṣṇardito jalaM kA~gkShan |

na labheta sa cenmaraNamAshvevApnuyAddIrgharogaM vA ||60||

tasmAddhAnyAmbu pibettRuShyan rogI sasharkarAkShaudram |

yadvA tasyAnyatsyAt sAtmyaM rogasya tacceShTam ||61||

tasyAM vinivRuttAyAM tajjanya upadravaH sukhaM jetum |

tasmAttRuṣṇaM pUrvaM jayedbahubhyo~api rogebhyaH ||62||

Fresh cold water is beneficial in thirst associated with fainting, giddiness, exhaustion, alcoholism, poisoning and disorder of rakta and pitta.

In thirst caused by sannipata (vitiation of all dosha) tridoshaja, water cooled after boiling is beneficial.

Warm water is useful in condition like hiccough, dyspnea, acute fever, coryza, after consumption of ghee, disorders of flanks and throat, diseases caused by kapha and vata, or when the dosha are still not moving properly in the body and just after the purificatory treatment.

In anemia, abdominal disease, gulma, meha, depleted digestive power, diarrhea and splenic disorders water intake is not beneficial; but if the thirst is unbearable, the patient may drink water in less quantity.

If the patient is suffering from the above mentioned diseases and has become miserably afflicted with thirst and craving for water and if he does not get water, he may soon die or be afflicted with chronic illness then such thirsty patient may drink coriander water mixed with honey and sugar, or other medicated water which is wholesome in this condition.

If the thirst is remedied, it is facile to subdue the complication arising from it; therefore thirst should be treated first in all diseases. [57-62]

Summary

तत्र श्लोकः-

हेतू यथाऽग्निपवनौ कुरुतः सोपद्रवां च पञ्चानाम् |

तृष्णानां पृथगाकृतिरसाध्यता साधनं चोक्तम् ||६३||

tatra ślōkaḥ-

hētū yathā'gnipavanau kurutaḥ sōpadravāṁ ca pañcānām|

trishnanāṁ pr̥thagākr̥tirasādhyatā sādhanaṁ cōktam||63||

tatra shlokaH-

hetU yathA~agnipavanau kurutaH sopadravAM ca pa~jcAnAm |

tRuṣṇanAM pRuthagAkRutirasAdhyatA sAdhanaM coktam ||63||

Here is the recapitulatory verse-

How the thermal factors and vata are the two causative factors for five kinds of trishna, their separate characteristics, the incurable condition and the method of remedy have all been described.[63]

इत्यग्निवेशकृते तन्त्रे चरकप्रतिसंस्कृतेऽप्राप्ते दृढबलसम्पूरिते चिकित्सास्थाने तृष्णारोगचिकित्सितं नाम द्वाविंशोऽध्यायः ||२२||

ityagnivēśakr̥tē tantrē carakapratisaṁskr̥tē'prāptē dr̥ḍhabalasampūritē cikitsāsthānē trishnarōgacikitsitaṁnāma dvāviṁśō'dhyāyaḥ||22||

ityagniveshakRute tantre carakapratisaMskRute~aprApte dRuDhabalasampUrite cikitsāsthAne tRuṣṇarogacikitsitaM nAma dvAviMsho~adhyAyaH ||22||

Thus, in the section of therapeutics in the treatise complied by Agnivesha and revised by Charak, the twenty second chapter entitled Trishna Chikitsa not being available, annotated by Charak and redacted by Dridhabala, is completed.[22]

Tattva Vimarsha (Fundamental Principles)

• Morbid thirst is caused by severe vitiation of pitta and vata dosha.
• Etiological factors for trishna are vitiated vata and pitta as both dosha have absorbent (shoshaka) property which damage the rasavaha and udakavaha srotas and manifest the symptom of constant craving for water.
• Severely vitiated dosha vigorously dehydrate the fluid carrying ducts and channels situated at the base of the tongue, throat, palate and kloma leading to morbid thirst in a person.
• Constant craving for water is the cardinal symptom of pathological thirst.
• The morbid thirst is classified into vata dominant, pitta dominant, that due to vitiation of ama, due to excess depletion of body elements and as a complication of other diseases.
• Rain water is the best remedy to pacify thirst. The water, that has slight astringent taste, light to digest, cool properties, possess good smell and taste and is devoid of channel blocking quality, should be considered equal to rain water in effect though it may be terrestrial. Various recipes having same properties are used in management of thirst.
• The management principle of trishna includes rehydration with pure rain water, medicated water, external application of medicinal pastes.
• The temperature of water plays key role in the management of trishna. Hot water, normal water and cold water shall be used after proper assessment of dosha dominant condition.
• Nourishment of all body elements (dhatu) depends on ahara rasa. Rasa is predominantly apya (dominated by water element) in nature. So, diminution of rasa dhatu ultimately leads to loss of water content in body and production of trishna.

Vidhi Vimarsha (Applied Inferences )

Differentiation between trishna and pipasa

Trishna and pipasa are two commonly used terms. Trishna is pathological thirst while pipasa is physiological. Physiological thirst is relieved after adequate water intake, whereas, pathological thirst is not relieved even after repeated water intake. Both of them are due to vata and pitta dosha. In pipasa they are in balanced state while in trishna they are vitiated. Trishna is manifestation of decrease in saumya dhatu (body elements composed of predominantly water) in body rasa dhatu, rakta dhatu, lasika, kleda, meda dhatu, and urine. One common channel, udakavaha srotas regulates all the water content of the body. It is situated between palate, tongue and throat.

Udakavaha srotasa

The root of transport channels of water are talu and kloma which have more than anatomical importance. They include the area of brain where thirst center is located and also throughout the body where the osmo-regulators are situated. They signal to higher integrative centers, where ultimately the conscious craving arises. As described in context of udara chikitsa, kloma should be understood as a physiological entity and may be compared with interstitial fluid which has definite role in pathogenesis of thirst as described in the chapter.

Fluid balance, normal quantity of water and other elements

The regulation of the volume and composition of body fluids (udaka), their distribution throughout the body, and balancing the pH of body fluids is crucial to maintaining overall homeostasis and health. The water and dissolved solutes throughout the body constitute the body fluids. Regulatory mechanisms involving the kidneys and other organs normally maintain homeostasis of the body fluids. Malfunction in any or all of them may seriously endanger the functioning of organs throughout the body.

Body fluids are present in two main “compartments”—inside cells and outside cells. About two-thirds of body fluid is intracellular fluid (ICF) or cytosol, the fluid within cells. The other third, called extracellular fluid (ECF) includes all other body fluids.

About 80% of the ECF is interstitial fluid, which occupies the microscopic spaces between tissue cells, and 20% of the ECF is plasma, the liquid portion of the blood. Other extracellular fluids that are grouped with interstitial fluid include lymph in lymphatic vessels; cerebrospinal fluid in the nervous system; synovial fluid in joints; aqueous humor and vitreous body in the eyes; endolymph and perilymph in the ears; and pleural, pericardial, and peritoneal fluids between serous membranes. The body is in fluid balance when the required amounts of water and solutes are present and are correctly proportioned among the various compartments. Water is by far the largest single component of the body, making up 45–75% of total body mass, depending on age and gender.

It may be noted that udaka has been mentioned to be present in quantity of ten anjali and this quantity is irrespective of rasa which is nine anjali in quantity and rakta is eight anjali in quantity. But this udaka acts as a replacement for rakta and rasa dhatu as and when necessary. Sweda, lasika, kapha, etc. are also jaliya (watery) entity which are closely related with udaka.

Mechanisms of fluid balance

• Osmosis is the primary means of water movement between intracellular fluid and interstitial fluid, the concentration of solutes in these fluids determines the direction of water movement. Because most solutes in body fluids are electrolytes, inorganic compounds that dissociate into ions, fluid balance is closely related to electrolyte balance. Because intake of water and electrolytes rarely occurs in exactly the same proportions as their presence in body fluids, the ability of the kidneys to excrete excess water by producing dilute urine, or to excrete excess electrolytes by producing concentrated urine, is of utmost importance in the maintenance of homeostasis. Sama anayati iti samanam is the definition of samana vayu. Samana has a seat in sweda, dosha and ambhuvaha srotas. As discussed above maintaining the pH (sami karoti) is brought about by specific ionic movement and this particular force is provided by samana vayu. It maintains the pH by maintaining a specific ratio of solutes and solvents and if this specific ratio is disturbed it leads to various diseases for e.g. a decrease in blood volume causes blood pressure to fall. This change stimulates the kidneys to release renin, which promotes the formation of angiotensin II. Increased nerve impulses from osmo-receptors in the hypothalamus, triggered by increased blood osmolarity, and increased angiotensin II in the blood both stimulate the thirst center in the hypothalamus. Other signals that stimulate thirst come from (1) neurons in the mouth that detect dryness due to a decreased flow of saliva and (2) baroreceptors that detect lowered blood pressure in the heart and blood vessels. As a result, the sensation of thirst increases, which usually leads to increased fluid intake (if fluids are available) and restoration of normal fluid volume. Overall, fluid gain balances fluid loss. Sometimes, however, the sensation of thirst does not occur quickly enough or access to fluids is restricted, and significant dehydration ensues. This happens most often in elderly people, in infants, and in those who are in a confused mental state. Even though the loss of water and solutes through sweating and exhalation increases during exercise, elimination of excess body water or solutes occurs mainly by control of their loss in urine.
• The extent of urinary salt (NaCl) loss is the main factor that determines body fluid volume. The reason for this is that “water follows solutes” in osmosis, and the two main solutes in extracellular fluid (and in urine) are sodium ions (Na) and chloride ions (Cl). In a similar way, the main factor that determines body fluid osmolarity is the extent of urinary water loss. Because our daily diet contains a highly variable amount of NaCl, urinary excretion of Na and Cl must also vary to maintain homeostasis. Hormonal changes regulate the urinary loss of these ions, which in turn affects blood volume. The increased intake of NaCl produces an increase in plasma levels of Na and Cl (the major contributors to osmolarity of extracellular fluid). As a result, the osmolarity of interstitial fluid increases, which causes movement of water from intracellular fluid into interstitial fluid and then into plasma. Such water movement increases blood volume.
• Water balance and electrolyte balance are closely linked. The body works to keep the total amount of water and the levels of electrolytes in the blood constant. For example, when the sodium level becomes too high, thirst develops, leading to an increased intake of fluids. In addition, vasopressin (also called antidiuretic hormone), a hormone secreted by the brain in response to dehydration, causes the kidneys to excrete less water. The combined effect is an increased amount of water in the blood. As a result, sodium is diluted and the balance of sodium and water is restored. When the sodium level becomes too low, the kidneys excrete more water, which decreases the amount of water in the blood, again restoring the balance. Water flows passively (by osmosis) from one area or compartment of the body to another. This passive flow allows the larger volumes of fluid in the cells and the area around the cells to act as reservoirs to protect the more critical but smaller volume of fluid in the blood vessels from dehydration.
• Function of samana vayu needs to be understood. Sweda dosha ambuvaha srotas is the seat for samana vayu. Maintaining the balance is the function of samana vayu and it is brought about by grahanati (to retain food until digested), pachati (to digest) , vivechayati (differentiating between waste and useful product) and munchati (to release waste to apana) action. Samana vayu is vital for organisms to be able to maintain their fluid levels in very narrow ranges. One set of receptors responsible for thirst detects the concentration of interstitial fluid. The other set of receptors detects blood volume. Arterial baroreceptors sense a decreased arterial pressure, and signal to the central nervous system in the area postrema and nucleus tractus solitarii. Cardiopulmonary receptors sense a decreased blood volume, and signal to area postrema and nucleus tractus solitarii as well. This explains the function of srotas sthita maruta (vyana vayu) and manas due to its satva guna helps in getting knowledge about the surrounding.
• Osmometric thirst occurs when the solute concentration of the interstitial fluid increases. This increase draws water out of the cells, and they shrink in volume. The solute concentration of the interstitial fluid increases by high intake of sodium in diet or by the drop in volume of extracellular fluids (such as blood plasma and cerebrospinal fluid) due to loss of water through perspiration, respiration, urination and defecation. The increase in interstitial fluid solute concentration causes water to migrate from the cells of the body, through their membranes, to the extracellular compartment, by osmosis, thus causing cellular dehydration.

The above mechanisms are disturbed in trishna.

Etiopathogenesis of trishna

In morbid thirst, vata and pitta dosha are predominately involved. Etiological factors aggravate either vata, pitta or both and manifest trishna. Both dosha have absorbent (soshaka) property, vata dosha by its drying property and pitta by its heating property. Therefore excess exposure to various factors in diet and lifestyles leading to dryness and heat inside the body are considered as causative factors for trishna. Some of the commonly observed factors are enlisted below:

• Dietary causes: Regular use of alkaline & sour substances, use of excessive salt, pungent, salty, dry and dehydrated food, extreme starvation, alcoholism
• Lifestyle causes: Excess exercise [Cha.Sa. Sutra Sthana 7/33], excess distress, excessive exposure to sunlight, fatigue.
• Psychological causes: Fear, grief, anger
• Iatrogenic causes: Excessive use of purification procedures, improper snehapana (administration of therapeutic medicated ghee or similar unctuous substance) [Cha. Sa.Sutra Sthana 13/71]
• Due to chronic diseases leading to emaciation and excessive loss of basic body forming elements
• Associated symptom of diseases like shotha [Cha. Sa. Sutra Sthana 18/18], pitta dominant gulma [Cha.Sa. Chikitsa Sthana 5/36], vrana [Cha. Sa. Chikitsa Sthana 25/30], udavarta [Cha.Sa. Chikitsa Sthana 26/9], prameha [Cha.Sa. Nidana Sthana 4/48], kushtha [Cha. Sa.Nidana Sthana 5/11], antarvega jwara [Cha.Sa.Chikitsa Sthana 3/39], bahirvegi jwara [Cha. Sa. Chikitsa Sthana 3/41],rakta dhatugata jwara[Cha. Sa. Chikitsa Sthana 3/77] , vata pitta jwara[ Cha.Sa.Chikitsa Sthana 3/85], shleshma-paittika jwara [Cha.Sa. Chikitsa Sthana 3/88], pitta kapholvana hina vata sannipata jwara[Cha.Sa.Chikitsa Sthana 3/93] , vatolvana kapha pitta hina sannipata jwara [Cha.Sa.Chikitsa Sthana 3/94], pittolvana madhya kapha hina vata jwara [Cha.Sa. Chikitsa Sthana 3/98], sama sannipata jwara[Cha.Sa.Chikitsa Sthana 3/102], pittolvana vata madhya kapha hina jwara[Cha.Sa. Chikitsa Sthana 3/106], pachyamana jwara [Cha.Sa.Chikitsa Sthana 3/136], romantika [Cha.Sa.Chikitsa Sthana 12/92], pittodara [Cha.Sa.Chikitsa Sthana 13/28], badhagudodara [Cha.Sa.Chikitsa Sthana 13/41],chhidrodara [Cha. Sa. Chikitsa Sthana 13/44], sahaja arsha[Cha. Sa. Chikitsa Sthana 14/8 ], paittika ajirna [Cha. Sa.Chikitsa Sthana 15/46], grahani [Cha. Sa. Chikitsa Sthana 15/53] ,vataja grahani [Cha.Sa.Chikitsa Sthana 15/61],paittika pandu [Cha. Sa. Chikitsa Sthana 16 /20], halimaka [Cha.Sa. Chikitsa Sthana 16/133],vyapeta hikka [Cha.Sa. Chikitsa Sthana 17/32], paittika kasa [Cha.Sa.Chikitsa Sthana 18/15], kshataja kasa [Cha.Sa.Chikitsa Sthana 18/23], paittika atisara [Cha. Sa.Chikitsa Sthana 19/6],raktatisara [Cha.Sa. Chikitsa Sthana 19/70], sannitpatika chhardi [Cha. Sa. Chikitsa Sthana 20/15], abhyantara visarpa [Cha. Sa. Chikitsa Sthana 21/16], paittika visarpa [Cha.Sa. Chikitsa Sthana 21/32],vata-paittika visarpa [Cha.Sa.Chikitsa Sthana 21/36],paittika madatyaya [Cha.Sa.Chikitsa Sthana 24/94], madatyaya general symptom [Cha.Sa.Chikitsa Sthana 24/101], tikshna madatyaya [Cha.Sa.Chikitsa Sthana 24/113],vikshaya [Cha.Sa. Chikitsa Sthana 24/ 102],paittika vrana [Cha.Sa.Chikitsa Sthana 25/13], paittika mukharoga [Cha.Sa.Chikitsa Sthana 26/120],pittavrita vayu [Cha.Sa.Chikitsa Sthana 28 /61], paittika vatarakta [Cha.Sa. Chikitsa Sthana 29/ 28], dhvaja bhanga [Cha. Sa.Chikitsa Sthana 30/171], paittika shiroroga [Cha.Sa.Sutra Sthana 17/23], paittika hridroga [Cha.Sa.Sutra Sthana 17 /33], vata-kapha kshaya pitta vriddhi[Cha.Sa.Sutra Sthana 17 /60], alaji [Cha.Sa.Sutra Sthana.17/88],vata-pittajanya vidradhi [Cha.Sa.Sutra Sthana 17/ 96], pitta nanatmaja vikara [Cha.Sa.Sutra Sthana 20 /14 ], ambuvaha sroto dushti [Cha.Sa.Vimana Sthana 5 /11],paittika jwara [Cha.Sa. Nidana Sthana 1/24].
• Complication (upasarga) of diseases like jwara, meha, kshaya, shosha, shwasa [Cha.Sa. Chikitsa Sthana 22/17]

General pathogenesis

Due to above mentioned factors, vata and pitta dosha are vitiated and further affect channels carrying fluids like rasavaha and udakavaha srotasa.

Etio-pathological factors in thirst

Acute fall in blood pressure and/or blood volume will also stimulate thirst. 15% or more reduction in circulating blood volume is required for this effect. However, the effects are short-lived and the effect of osmolality changes on thirst is more significant.

Thus classification may be done as follows:

A. Causes of excessive thirst without excessive urination

1. Dehydration due to:

• Excessive sweating (diaphoresis)
• Diarrhea
• Large loose stools after eating foods high in fiber
• Hyperventilation due to anxiousness, certain diseases, such as pneumonia, or at high altitudes.

2. Other causes of dry mouth

Acute (sudden) causes of dry mouth:

• Eating dry or spicy or salty foods
• Breathing dry air, breathing through the mouth, snoring, smoking, chewing tobacco
• Anxiety, depression, stress
• Hangover
• Disorder of salivary glands (mumps, side effect of irradiation)
• Stroke
• Shock (hypovolemic, septic, anaphylactic)

Chronic causes of dry mouth (xerostomia):

• Anemia
• Hypertension
• Oral thrush caused by fungal [candida] infection
• Disorders of salivary glands (sialadenitis, stones)
• Autoimmune diseases: Sjögren’s syndrome, systemic lupus erythematosus (SLE), systemic sclerosis, sarcoidosis (neurosarcoidosis), rheumatoid arthritis
• Parkinson’s disease
• HIV/AIDS
• Alzheimer’s disease
• Mouth or throat cancer
• Cystic fibrosis

Dry mouth as a side effect of medications or supplements:

• Anti-acne drugs: tretinoin
• Anticholinergics (spasmolytics): atropine
• Antidepressants: fluoxetine
• Antidiarrheals: bismuth subsalicylate, loperamide
• Antiemetics (drugs to treat nausea/vomiting): chlorpromazine, metoclopramide, ondansetron, promethazine, scopolamine
• Antihistamines
• Antiepileptics: valproate, topiramate
• Antiparkinsonians
• Antipsoriatics: acitretin
• Antipsychotics: modafinil, phenothiazines, risperidone, indapamide
• Antivirals: ritonavir, indinavir; antiretrovirals (to treat AIDS)
• Aspirin overdose
• Beta-blockers (for heart disease, hypertension): atenolol, propranolol
• Bronchodilators (to treat asthma): theophylline, salbutamol
• Chemotherapeutics: bortezomib, cisplatin
• Muscle relaxants
• Nasal decongestants (sprays)
• Non-steroidal anti-inflammatory drugs (NSAIDs): aspirin, diclofenac, ibuprofen, naproxen
• Opiates: morphine
• Sedatives (sleeping pills: diazepam)
• Steroids
• Stimulants: armodafinil

Illegal Drugs:

• Marijuana (cannabis)
• Ecstasy (MDMA)
• Cocaine
• Heroin
• Amphetamine

B. Causes of excessive thirst with excessive urination

Psychogenic Polydipsia

In most cases of polydipsia, people drink water to replace water they have lost due to excessive urination caused by certain organic disorders. Individuals with primary or psychogenic polydipsia (often associated with schizophrenia) have no organic disorder, but they believe or feel they should drink a lot of fluid. This can lead to water intoxication (hyponatremia), which can be life threatening.

Brain Disorders Resulting in Central Diabetes Insipidus

• Head injury, tumor, stroke

Impaired Kidney Function Resulting in Nephrogenic Diabetes Insipidus

• Salt-wasting nephropathy (in a polycystic kidney disease) , post-obstructive diuresis (after resolution of urinary tract blockage), medullary kidney cystic disease, proximal renal tubular acidosis

Heart Disorders

• Supraventricular tachycardia (a type of heart arrhythmia), postural hypotension, systemic capillary leak syndrome

Hormonal Disorders

• Gestational diabetes insipidus; in the 3rd trimester of pregnancy
• Adrenal hyperactivity
• Epinephrine (adrenaline)-secreting tumor (pheochromocytoma) in the adrenal medulla
• Pituitary disorders:
  • Cushing’s syndrome
  • Sheehan’s syndrome (pituitary infarct)
  • Hyperthyroidism, especially acute severe thyrotoxicosis (thyroid storm) (hyperglycemia, excessive sweating and diarrhea lead to polydipsia)
  • Hyperparathyroidism

Metabolic Disorders

• Hypokalemia
• Hypercalcemia
• Hypernatremia

Genetic and Congenital Disorders

• Aceruloplasminemia
• Alsing syndrome
• Bartter’s syndrome
• Boichis syndrome
• Cystinosis
• DEND syndrome
• EAST syndrome
• Fanconi syndrome
• Froelich’s syndrome
• Gitelman syndrome
• Liddle’s syndrome
• Nephronophthisis
• Schroeder syndrome
• Sickle cell anemia
• Wolfram (DIDMOAD) syndrome
• Apparent Mineralocorticoid Excess Syndrome

Other Disorders

• Adiposogenital dystrophy
• Langerhans cell histiocytosis
• Omega-3 FFA deficiency syndrome
• Sarcoidosis (neurosarcoidosis)
• Tumors/cancers:
  • Adrenal adenoma
  • Ganglioblastoma
  • Glucagonoma — glucagon secreting tumor (gluconeogenesis > hyperglycemia > polydipsia)
  • Multiple myeloma
  • Pheochromocytoma

Drugs

• Amphotericin B
• Antiobesity drugs: lorcaserin, orlistat, phentermine, sibutramine
• Caffeine intoxication (excessive coffee or tea drinking)
• Demeclocycline
• Diuretics
• Lithium
• Vitamin D overdose (hypervitaminosis D)

Poisons

• Acid ingestion
• Amanita muscaria (fly agaric) and other toxic mushrooms
• Arsine gas
• Belladonna-like plant
• Bloodroot
• Death camas
• Horse nettle intake
• Jimsonweed/Jamestown weed ingestion
• Meadow Saffron plant
• Mercury poisoning in children (acrodynia, pink disease)
• Yellow jessamine (jasmine poisoning)
• Snake bites

Table 1: Condition with morbid thirst and diagnostic tests

CONDITION	SYMPTOMS AND SIGNS (besides excessive urination and thirst)	LAB TESTS
Dehydration	Sudden weight loss, dark urine (decreased, not increased urination)	Decreased 24-hour urine; in mild and moderate dehydration: normal blood sodium; in severe dehydration: increased blood sodium
Heat exhaustion or heat stroke	Exhaustion, cool, clammy skin, increased body temperature (in heat stroke: warm skin, body T > 105.8 °F or 41 °C)	Decreased 24-hour urine
Diabetes mellitus	Hunger or poor appetite, weight loss, extreme fatigue, blurred vision, jock itch, diabetes in family	Increased glucose levels in the blood and urine
Diabetes insipidus (central and nephrogenic)	History of brain trauma, surgery or tumor, or a kidney disease	Decreased urine specific gravity and osmolality, increased blood sodium
Diuretics	Dry mouth	Decreased urine specific gravity
Psychogenic polydipsia	Usually in individuals with schizophrenia treated with antipsychotics	Increased 24-hour urine, decreased urine specific gravity and osmolality, sometimes: decreased blood sodium
Adrenal hyperactivity (hyperaldosteronism)	Increased blood pressure	Decreased blood potassium, increased urine potassium, increased blood aldosterone after sodium challenge
Anorexia nervosa	Severely decreased body weight	Mineral and vitamin deficiencies (hypokalemia, low iron, etc.)
Postural (orthostatic) hypotension	Dizziness after raising up, Drop of blood pressure > 30 mm Hg upon standing	Nothing typical
Hypertension	Increased blood pressure	Possible increase of blood aldosterone, renin
Anemia	Paleness, fatigue, hyperventilation	Decreased RBC or abnormal erythrocytes
Congestive heart failure	Chest pain, swollen legs	ECG abnormalities
Liver cirrhosis	History of alcoholism, poor appetite, loss of weight, spider nevuses	Decreased serum proteins (albumin), increased liver enzymes and bilirubin
Chronic dry mouth (xerostomia) in Sjögren’s syndrome and SLE	Rash, joint pain	Specific antibodies in the blood
Shock (hypovolemic, septic, anaphylactic)	Cool, clammy skin, increased heart rate; in late shock: lethargy, low blood pressure	Septic shock: increased or decreased white blood cells (WBC), increased blood glucose
Ecstasy (MDMA), cocaine, marijuana	Euphoria	Positive urine drug test
Opiates (morphine, heroin)	Sleepiness	Positive urine drug test

Laboratory Tests

Blood Tests

Glucose Elevated

• Diabetes mellitus
• Cushing’s syndrome
• Early phase of hypovolemic shock (bleeding)
• Pheochromocytoma

Sodium

• Normal levels (135-145 meq/L):
  • In most cases of dehydration (diarrhea, vomiting, excessive sweating)
  • Within 8 hours of onset of acute bleeding
• Hyponatremia (<135 meq/L):
  • >8 hours after onset of bleeding, when interstitial fluid moves into the intravascular space
  • Sometimes after repeated vomiting or severe diarrhea
  • Water intoxication
  • Diabetic ketoacidosis (usually)
  • Cerebral salt wasting (head injury, tumor)
  • Hypernatremia (>145 meq/L)
  • Dehydration (sometimes)
  • Diabetes insipidus

Potassium

• Hypokalemia:
  • Hyperaldosteronism
  • Anorexia nervosa
  • Hyperthyroidism
• Hyperkalemia:
  • Diabetic ketoacidosis (usually)

Calcium

• Hypercalcemia:
  • Hyperparathyroidism
  • Hypervitaminosis D
• Hypocalcemia:
  • Diabetic ketoacidosis (usually)

CBC

• White blood cells increased or decreased in sepsis

Hematocrit (HCT)

• Decreased in water intoxication

Blood Urea Nitrogen (BUN)

• Increased in kidney failure
• Decreased in water intoxication

pH

• <7.3 (diabetic ketoacidosis)

Proteins

• Hypoalbuminemia in liver cirrhosis, nephrotic syndrome, severe malnutrition

Hormone levels

• ADH
• Decreased in central diabetes insipidus
• Increased in nephrogenic diabetes insipidus
• ACTH may be increased in pituitary adenoma or adrenal hyperplasia
• Cortisol may be increased in adrenal adenoma
• Aldosterone may be increased in adrenal adenoma or primary hyperaldosteronism

Urine Tests

• Osmolality
• <200 mOsm/kg in psychogenic polydipsia, diabetes insipidus
• Specific gravity
• <1.005 in diabetes insipidus
• Glucose
• Untreated diabetes mellitus 1 or 2
• Pheochromocytoma; rare
• Proteins
• In nephrotic syndrome
• Sodium >20 meq/L: cerebral salt wasting

Principles of management

The treatment modalities intended to pacify vata and pitta dosha are applied for management of trishna. Specifically rain water, water processed with drugs having manda (mild) and sheeta (cool) properties, various medicated ghee mentioned in the text are used to manage trishna.

Various preparations used in management

Food and beverages

• Trina panchamula medicated water

Trina Panchamula contains five drugs namely kusha, kasha, nala, darbha and kandekshu. It pacifies pitta and it is indicated in trishna. In Bhaisajya Ratnavali, Shara is given in place of Nala. (Bhaisajya Ratnavali, Mutrakricharogadhikar 10)

Kusha – Desmostachya bipinnata

Kasha – Saccharum spontaneum

Shara – Saccharum munja

Darbha –Imperata cylindrical

Ikshu – Sugarcane – Saccharum officinarum

The above drugs should be taken along with water in ratio of 1:64 and then it should be reduced to half by boiling and later on filtered and used after cooling similar to Shadangapaniya vidhi as explained in Jwara Chikitsa.

• Laja sattu: Laja sattu is a thin gruel prepared from laja (parched rice) or roasted rice. It should be prepared with rain water and should be given to patient after mixing honey and sugar to it [Cha. Sa. Sutra Sthana 27/256].
• Yava medicated gruel: Yava (barley) is used in yava vatya (a gruel prepared out of one part of coarse powder of roasted yava (barley) and 14 parts of water).
• Peya is thin gruel of rice along with its solid portion (sikta). To prepare peya, 14 parts of water and one part of broken rice are taken and boiled well till all the rice particles become soft. Peya prepared with shali and koradusha (type of cereal) pacifies thirst.
• Food boiled with milk and mamsa rasa mixed with honey and sita (kind of sugar) should be given. Sita pacifies vata and pitta dosha so it is useful in patient of thirst .
• Trina panchamula, munjataka, priyala drugs should be mixed with mamsa rasa or kshira paka prepared from these should be given after mixing honey and sugar to it. All above drugs pacify pitta hence quench the thirst.

External applications

External application of shatadhauta ghrita is pitta shamaka so it should be used. Yusha is a soup prepared from pulses. Drugs which are madhura, tikta, sheeta and having jeevaniya properties, pacify pitta. They should be given to the patient for drinking as well as for external application.

Medicated ghee

Ghrita processed with drugs of madhuradi gana mentioned in Vimana Sthana 8th chapter should be used for drinking, massage and sprinkling purpose. Ghrita is best for pacifying pitta and vata.[Cha.Sa. Sutra Sthana 25/40] When processed with madhura gana drugs its property increases as it is yogavahi in nature (the one that accelerates the properties of others).

Nasal administration

Various milk or juice of sugarcane when administered through nasal route decreases thirst. [Cha.Sa.Sutra Sthana 27/224] Following table enlists various diet recipes and medicinal formulations used in the management of trishna referred at various places.

Table 2: Diet and formulations for management of trishna

Name of Formulations	References
Peya	[Cha. Sa. Chikitsa Sthana 3/187]
General property of milk pacifying trishna	[Cha. Sa. Sutra Sthana 1/109]
Use of panchatikta kwatha	[Cha. Sa. Chikitsa Sthana 3/200 ]
Use of Vidarigandhadi, Bilva, Utpala etc.	[Cha. Sa. Chikitsa Sthana 4/51]
Rohityada Ghrita	[Cha. Sa. Chikitsa Sthana 5/117]
Duralabhadya Ghrita	[Cha. Sa. Chikitsa Sthana 8/110]
Eladi Gutika	[Cha. Sa. Chikitsa Sthana 11/23 ]
Amritaprasha Ghrita	[Cha.Sa. Chikitsa Sthana 11 /43]
Tritiya Sarpi Guda	[Cha. Sa. Chikitsa Sthana 11/65 ]
Patolamuladi Kwatha	[Cha. Sa. Chikitsa Sthana 12/54]
Water Siddha with Trina panchamula Kwatha	[Cha. Sa. Chikitsa Sthana 18/141]
Chandana,sugar, honey with Tandulodaka	[Cha. Sa. Chikitsa Sthana 19/86]
Use of Gairika, Sugandhabala with Tandulodaka	[Cha. Sa. Chikitsa Sthana 20/32]
Drakshadi sita Kwatha/ Prapoundarika Kwatha	[Cha. Sa. Chikitsa Sthana 21/58 ]
Water processed with Parushaka and Pilu; Chatuparni; Musta, Dadima, Laja	[Cha. Sa. Chikitsa Sthana 24/149]
Cold water	[Cha. Sa. Chikitsa Sthana 24/163]
Madhura rasa	[Cha. Sa. Chikitsa Sthana 26/43]
Tikta rasa	[Cha. Sa. Chikitsa Sthana 26/43 ]
Rakta Shali	[Cha. Sa. Chikitsa Sthana 27/11]
Ervaruka	[Cha. Sa. Chikitsa Sthana 27/111]
Mridvika	[Cha. Sa. Chikitsa Sthana 27/125 ]
Sarkara	[Cha. Sa. Chikitsa Sthana 27/242 ]
Laja peya	[Cha. Sa. Chikitsa Sthana 27/250 ]
Saktu	[Cha. Sa. Chikitsa Sthana 27/264 ]

• Gandusha:

Gandusha (filling the mouth to its full capacity with liquid without allowing its movement in oral cavity) with various sweet and sour drugs is useful in thirst. Madhura rasa pacify pitta whereas amla rasa is cold on external application and increases salivation so both have soothing effect in dry mouth. Use of amla drugs in the form of external application has also been advocated as they have cooling effect on touch. Thinking about cold things and environment is a part of psychotherapy which helps patient to combat desire of water.

Management of vata dominant trishna

All dietary formulations and drugs used in vataja trishna must have property to pacify vata. Milk and ghrita mentioned in kshayaja kasa (like dwipanchamuladi ghrita, guduchyadi ghrita, kasmardadi ghrita etc.) pacify vata dosha effectively and thus these preparations can also be used in vataja trishna.

Management of pitta dominant trishna

Various pitta pacifying drugs mixed with water are mentioned in treatment of pittaja trishna. These drugs pacify pitta as well as they are useful in maintaining water homeostasis.

Water obtained after quenching of baked earth is said to be best for pacifying excessive thirst in agrya prakarana. This simple method can be clinically evaluated in patients of morbid thirst. [Cha. Sa. Sutra Sthana 25/40].

Management of amaja trishna

To treat amaja trishna, it is necessary that first ama is removed. For ama pachana drugs which increase agni can be used as well. Treatment of kaphaja chhardi can be followed as kapha nasaka treatment helps to remove ama. If symptoms pertaining to ama are seen than ama should be removed by inducing emesis and warm water should be used to increase agni to remove ama. As discussed earlier kshaya refers to emaciation of tissues. So, treatment which helps in revitalizing the tissue can be used as mentioned in kshatakshina, shosha can also be used.

Management of trishna due to madatyaya

Use of alcohol for treating thirst induced due to alcohol is example of Hetu Vipritarthakari (treatment with a substance similar to the cause).

Effect of cold water and hot water on body fluid balance

In conditions of dehydration and where pitta is dominant (Dhaha, bhrama, madatyaya etc) cold water should be given as it restores water content in body as well as pacify pitta by its sheeta guna. After boiling, water becomes free from various micro-organisms. Boiled water should be used in sannipatika diseases after cooling, such diseases are difficult to treat. In a study it was found that temperature range from 55 to 65 degree C is critical for effective elimination of enteric/pathogenic bacterial components. As all three dosha are involved we can’t use hot or cold water as they will aggravate at least one of the dosha (hot will increase pitta, cold water will increase vata/kapha) so normal water should be used.

In conditions with vata/kapha/vata-kapha dominance like hikka-shwasa (kapha vata tamako), fever of recent origin (nutana jwara in samavastha) etc. Warm water should be given. After ghrita consumption, warm water should be used as it increases absorption of ghrita. Warm water increases agni in nutan jwara.[ Cha. Sa. Chikitsa Sthana 3/144], [ Cha. Sa. Vimana Sthana 3/40]

In a study it was concluded that drinking hot fluids transiently increases nasal mucus velocity and so hot liquid is superior to cold liquids in the management of fluids in upper respiratory tract infections.

Water is major constituent and is needed for normal physiological process of the body. Any disturbance in its homeostasis will lead to production of many diseases. Some diseases occur due to water deficit whereas in many diseases water retention in the body is their main cause. According to Ayurvedic principles in such conditions water use should be minimal. Due to same reason it is contraindicated in udara. In jalodara (ascites) excessive intake of water is one of the causes.[ Cha. Sa. Chikitsa Sthana 13/45]

In pandu there is presence of hemodilution and edema so water intake should be restricted to minimal. In gulma, mandagni is main causative factor. [Cha. Sa.Chikitsa Sthana 5/112]

Excessive intake of water causes mandagni and if, water is taken in mandagni stage excessively, strength of agni decreases further . So, water is contraindicated in mandagni stage. If needed, water can be given in less quantity. Nowadays we are using bottled water frequently. So, it is necessary that we analyze properties of bottled water also. Studies have shown that chemicals called phthalates, which are known to disrupt testosterone and other hormones, can leach into bottled water over time. One study found that water that had been stored for 10 weeks in plastic and in glass bottles contained phthalates, suggesting that the chemicals could be coming from the plastic cap or liner. The bacterial count in bottled water increased dramatically, from less than 1 colony per milliliter (col/mL) to 38,000 col/mL over 48 hours of storage at 37 degrees C. Bacterial growth was markedly reduced at cold temperatures (refrigeration) compared with room temperature, with 50% fewer bacterial colonies in 24 hours and 84% fewer colonies in 48 hours. Interestingly, tap water resulted in only minimal growth, especially at cold temperatures (< 100 col/mL at 48 hours). These findings may be useful to increase public awareness and development of guidelines on storage temperature and expiration time for bottled water once it is opened and used. In a study it was suggested that various types of unfinished beverages have microorganism growth and can include food borne pathogens and bacterial toxins. This suggests that proper and judicious use of water should be done in healthy as well as diseases condition.

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