| Line 774: |
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| | === Vidhi Vimarsha === | | === Vidhi Vimarsha === |
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| − | Differentiation between trishna and pipasa:
| + | Work in Progress |
| − | 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, rakta, lasika, kleda, medas, and urine. One common channel, udakavaha srotas regulates all the water content of the body. It is situated between palate, tongue and throat.
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| − | Udakavaha srotasa:
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| − | 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 centre is located and also throughout the body where the osmoregulators 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.
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| − | Fluid balance, normal quantity of water and other elements:
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| − | 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.
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| − | 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.
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| − | It may be noted that udaka has been mentioned to be present in quantity of 10 anjali and this quantity is irrespective of rasa which is 9 anjali in quantity and rakta is 8 anjali in quantity. But this udaka acts as a replacement for rakta and rasa as and when necessary. Sweda, lasika, kapha etc are also jaliya (watery) entity which are closely related with udaka.
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| − | Mechanisms of fluid balance:
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| − | • 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 ānayati iti samānam” is the definition of samāna vāyu. Samāna has a seat in sweda, dōsa and ambhuvaha srōtas. As discussed above maintaining the pH (sami karōti) is brought about by specific ionic movement and this particular force is provided by samāna vāyu. 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 eg. 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 osmoreceptors 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.
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| − | • 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 intracellularfluid into interstitial fluid and then into plasma. Such water movement increases blood volume.
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| − | • 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.
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| − | • Function of samāna vāyu needs to be understood. Sweda dosha ambuvaha srotas is the seat for samāna vāyu. Maintaining the balance is the function of samāna vāyu and it is brought about by grahanati (to retain food until digested), pachati (to digest) , vivecayati (differentiating between waste and useful product) and muncati (to release waste to apaan) action. Samāna vāyu 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 sthit māruta (vyana vayu) and mana due to its satva guna helps in getting knowledge about the surrounding.
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| − | • 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.
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| − | The above mechanisms are disturbed in trishna.
| + | === Glossary === |
| − | Etiopathogenesis of trishna:
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| − | 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:
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| − | • Dietary causes: Regular use of alkaline & sour substances, use of excessive salt, pungent, salty, dry and dehydrated food, extreme starvation, alcoholism
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| − | • Lifestyle causes: Excess exercise (Cha.Su.7/33), excess distress, excessive exposure to sunlight, fatigue.
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| − | • Psychological causes: Fear, grief, anger
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| − | • Iatrogenic causes: Excessive use of purification procedures, improper snehapana (administration of therapeutic medicated ghee or similar unctuous substance) (Cha.Su.13/71)
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| − | • Due to chronic diseases leading to emaciation and excessive loss of basic body forming elements
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| − | • Associated symptom of diseases like shotha (Cha.Su.18/18), pitta dominant gulma (Cha.Chi.5/36), vrana (Cha.Chi.25/30), udavarta (Cha.Chi.26/9), prameha (Cha.Ni.4/48), kushtha (Cha.Ni.5/11), antarvega jwara (Cha.Chi.3/39), Bahirvegi jwara (Cha.Chi.3/41), rakta dhatugata jwara(Cha.Chi.3/77) , vata pitta jwara (Cha.Chi.3/85), shleshma-paittika jwara (Cha.Chi.3/88), pitta kapholvana hina vata sannipata jwara(Cha.Chi.3/93) , vatolvana kapha pitta hina sannipata jwara (Cha.Chi.3/94), pittolvana madhya kapha hina vata jwara (Cha.Chi.3/98), sama sannipata jwara(Cha.Chi.3/102), pittolvana vata madhya kapha hina jwara(Cha.Chi.3/106), pachyamana jwara (Cha.Chi.3/136), romantika (Cha.Chi.12/92), pittodara (Cha.Chi.13 /28), badhagudodara (Cha.Chi.13 /41 ),chhidrodara (Cha.Chi.13 /44), sahaja arsha (Cha.Chi.14 8/), paittika ajirna (Cha.Chi.15/46), grahani (Cha.Chi.15 /53),vataja grahani (Cha.Chi.15/ 61),paittika pandu (Cha.Chi.16 /20), halimaka (Cha.Chi.16/ 133),vyapeta hikka (Cha.Chi.17 /32), paittika kasa (Cha.Chi.18 /15), kshataja kasa (Cha.Chi.18/ 23), paittika atisara (Cha.Chi. 19/6),raktatisara (Cha.Chi.19 /70), sannitpatika chhardi (Cha.Chi. 20/15), abhyantara visarpa (Cha.Chi.21 /16), paittika visarpa (Cha.Chi. 21/32),vata-paittika visarpa (Cha.Chi.21 /36),paittika madatyaya (Cha.Chi. 24/94), madatyaya general symptom (Cha.Chi.24/101), tikshna madatyaya (Cha.Chi. 24/113),vikshaya (Cha.Chi.24/ 102),paittika vrana (Cha.Chi. 25/13), paittika mukharoga (Cha.Chi.26/ 120),pittavrita vayu (Cha.Chi.28 /61), paittika vatarakta (Cha.Chi.29/ 28), dhvaja bhanga (Cha.Chi. 30/171), paittika shiroroga (Cha. Su.17/23), paittika hridroga (Cha.su.17 /33), vata-kapha kshaya pitta vriddhi (Cha.su.17 /60), alaji (Cha.su.17/88),vata-pittajanya vidradhi (Cha.su.17/ 96 ), pitta nanatmaja vikara (Cha.su.20 /14 ), ambuvaha sroto dushti (Cha. Vi.5 /11),paittika jwara (Cha.Ni.1/24).
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| − | • Complication (upasarga) of diseases like jwara, meha, kshaya, shosha, shwasa (Cha.22/17)
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| − | General pathogenesis:
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| − | Due to above mentioned factors, vata and pitta dosha are vitiated and further affect channels carrying fluids like rasavaha and udakavaha srotasa.
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| − | Etio-pathological factors in thirst:
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| − | 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:
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| − | A. Causes of excessive thirst without excessive urination
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| − | 1. Dehydration due to:
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| − | • Excessive sweating (diaphoresis)
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| − | • Diarrhea
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| − | • Large loose stools after eating foods high in fiber
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| − | • Hyperventilation due to anxiousness, certain diseases, such as pneumonia, or at high altitudes.
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| − |
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| − | 2. Dry mouth by causes other than dehydration:
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| − | Acute (sudden) causes of dry mouth:
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| − | • Eating dry or spicy or salty foods
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| − | • Breathing dry air, breathing through the mouth, snoring, smoking, chewing tobacco
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| − | • Anxiety, depression, stress
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| − | • Hangover
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| − | • Disorder of salivary glands (mumps, side effect of irradiation)
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| − | • Stroke
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| − | • Shock (hypovolemic, septic, anaphylactic)
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| − | Chronic causes of dry mouth (xerostomia):
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| − | • Anemia
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| − | • Hypertension
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| − | • Oral thrush caused by fungal [candida] infection
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| − | • Disorders of salivary glands (sialadenitis, stones)
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| − | • Autoimmune diseases: Sjögren’s syndrome, systemic lupus erythematosus (SLE), systemic sclerosis, sarcoidosis (neurosarcoidosis), rheumatoid arthritis
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| − | • Parkinson’s disease
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| − | • HIV/AIDS
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| − | • Alzheimer’s disease
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| − | • Mouth or throat cancer
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| − | • Cystic fibrosis
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| − | Dry mouth as a side effect of medications or supplements:
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| − | • Anti-acne drugs: tretinoin
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| − | • Anticholinergics (spasmolytics): atropine
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| − | • Antidepressants: fluoxetine
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| − | • Antidiarrheals: bismuth subsalicylate, loperamide
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| − | • Antiemetics (drugs to treat nausea/vomiting): chlorpromazine, metoclopramide, ondansetron, promethazine, scopolamine
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| − | • Antihistamines
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| − | • Antiepileptics: valproate, topiramate
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| − | • Antiparkinsonians
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| − | • Antipsoriatics: acitretin
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| − | • Antipsychotics: modafinil, phenothiazines, risperidone, indapamide
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| − | • Antivirals: ritonavir, indinavir; antiretrovirals (to treat AIDS)
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| − | • Aspirin overdose
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| − | • Beta-blockers (for heart disease, hypertension): atenolol, propranolol
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| − | • Bronchodilators (to treat asthma): theophylline, salbutamol
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| − | • Chemotherapeutics: bortezomib, cisplatin
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| − | • Muscle relaxants
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| − | • Nasal decongestants (sprays)
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| − | • Non-steroidal anti-inflammatory drugs (NSAIDs): aspirin, diclofenac, ibuprofen, naproxen
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| − | • Opiates: morphine
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| − | • Sedatives (sleeping pills: diazepam)
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| − | • Steroids
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| − | • Stimulants: armodafinil
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| − | Illegal Drugs:
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| − | • Marijuana (cannabis)
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| − | • Ecstasy (MDMA)
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| − | • Cocaine
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| − | • Heroin
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| − | • Amphetamine
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| − | B. Causes of excessive thirst with excessive urination
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| − | Psychogenic Polydipsia
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| − | 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.
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| − | Brain Disorders Resulting in Central Diabetes Insipidus
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| − | • Head injury, tumor, stroke
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| − | Impaired Kidney Function Resulting in Nephrogenic Diabetes Insipidus
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| − | • 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
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| − | Heart Disorders
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| − | • Supraventricular tachycardia (a type of heart arrhythmia), postural hypotension, systemic capillary leak syndrome
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| − | Hormonal Disorders
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| − | • Gestational diabetes insipidus; in the 3rd trimester of pregnancy
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| − | • Adrenal hyperactivity
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| − | • Epinephrine (adrenaline)-secreting tumor (pheochromocytoma) in the adrenal medulla
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| − | • Pituitary disorders:
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| − | • Cushing’s syndrome
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| − | • Sheehan’s syndrome (pituitary infarct)
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| − | • Hyperthyroidism, especially acute severe thyrotoxicosis (thyroid storm) (hyperglycemia, excessive sweating and diarrhea lead to polydipsia)
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| − | • Hyperparathyroidism
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| − | Metabolic Disorders
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| − | • Hypokalemia
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| − | • Hypercalcemia
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| − | • Hypernatremia
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| − | Genetic and Congenital Disorders
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| − | • Aceruloplasminemia
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| − | • Alsing syndrome
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| − | • Bartter’s syndrome
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| − | • Boichis syndrome
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| − | • Cystinosis
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| − | • DEND syndrome
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| − | • EAST syndrome
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| − | • Fanconi syndrome
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| − | • Froelich’s syndrome
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| − | • Gitelman syndrome
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| − | • Liddle’s syndrome
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| − | • Nephronophthisis
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| − | • Schroeder syndrome
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| − | • Sickle cell anemia
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| − | • Wolfram (DIDMOAD) syndrome
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| − | • Apparent Mineralocorticoid Excess Syndrome
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| − | Other Disorders
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| − | • Adiposogenital dystrophy
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| − | • Langerhans cell histiocytosis
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| − | • Omega-3 FFA deficiency syndrome
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| − | • Sarcoidosis (neurosarcoidosis)
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| − | • Tumors/cancers:
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| − | • Adrenal adenoma
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| − | • Ganglioblastoma
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| − | • Glucagonoma — glucagon secreting tumor (gluconeogenesis > hyperglycemia > polydipsia)
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| − | • Multiple myeloma
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| − | • Pheochromocytoma
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| − | Drugs
| + | #ādhmāna (AdhmAna, आध्मान) The term signifies distention or inflation of a body part caused due to stagnation of the substances inside it; but generally is taken for distention of the abdomen associated with pain due to various reasons like obstruction to the urine and faeces, accumulation of blood in abdomen etc. |
| − | • Amphotericin B
| + | #āmaja trishna (Amaja tRuṣṇa,आमज तृष्णा) Polydypsia due to indigestion |
| − | • Antiobesity drugs: lorcaserin, orlistat, phentermine, sibutramine
| + | #bādhiryaṁ (bAdhiryaM, बाधिर्यं) Impaired hearing, deafness, a disease condition where in the patient has impaired hearing or complete loss of sound perception. |
| − | • Caffeine intoxication (excessive coffee or tea drinking)
| + | #bhrama (bhrama, भ्रम) Giddiness, dizziness or tremor. |
| − | • Demeclocycline
| + | #gulma (gulma,गुल्म) - Lump in abdomen. A lump like formation occurring in the abdomen either mobile or static in nature, circular in shape and constantly increasing and decreasing in size. |
| − | • Diuretics
| + | #hikkā (hikkA,हिक्का) – Hiccoughs. A disease characterized by production of peculiar sound like hic-hic by mouth. |
| − | • Lithium
| + | #lājā (lAjA, लाजा) Obtained by roasting undried and unhusked paddy. Is light and easily digestible. Cures thirst, vomiting, diarrhoea, diabetes, obesity, cough and pitta. |
| − | • Vitamin D overdose (hypervitaminosis D)
| + | #māṁsarasa (māṁsarasa ,मांसरस) soup prepared with meat by adding 8 times of water & reducing it to 1/4th and seasoned with trikatu, ghee & jaggery |
| − | Poisons
| + | #mūrcchā (mUrcchA,मूर्च्छा) - Syncope A fatal condition characterized by loss of consciousness and postural tone due to vitiation of blood. |
| − | • Acid ingestion
| + | #nasya(nasya, नस्य) Administration of drugs by nasal route, all drugs and measures introduced through nose spread throughout the head and its constituent drugs may influence all the dosha, poisons and disease situated in these parts. |
| − | • Amanita muscaria (fly agaric) and other toxic mushrooms
| + | #pāṇḍuroga (pANDuroga ,पाण्डुरोग) - Pallor of body, Anemia The term literally means paleness of the skin and mucosa along with yellowish discoloration of urine and faeces; marked by lack of blood, strength complexion, body fat and essence of the body tissues. |
| − | • Arsine gas
| + | #pēyā (pēyā ,पेया) Thin gruel of rice along with its solid portion (Siktha). To prepare Pēyā, 14 parts of water and 1 part of broken rice are taken and boiled well till all the rice particles become soft. It increases digestive fire. |
| − | • Belladonna-like plant
| + | #pittaja trishna (pittaja tRuṣṇa,पित्तज तृष्णा )Polydypsia due to severe emaciation, Polydypsia associated with fainting, delirium and burning sensation. |
| − | • Bloodroot
| + | #Śaktu (-Śaktu, शक्तु)- Is a diet preparation. Prepared by frying and powdering husked grains like barley, wheat, rice, parched rice etc. |
| − | • Death camas
| + | #santāpa(santApa ,सन्ताप) Abnormal Psychosomatic feeling, the term denotes feeling of distress with or without rise in body temperature. And it may reflect in the externally body as hotness in somatic level. |
| − | • Horse nettle intake
| + | #śvāsa (shvAsa,श्वास) - Dyspnoea due to respiratory disease. It is a respiratory disease marked by recurrent paroxysmal attacks of Shortness of breath, a subjective difficulty or distress in breathing, with or without wheezing due to obstruction in the respiratory airways. |
| − | • Jimsonweed/Jamestown weed ingestion
| + | #trishna(tRuṣṇa,तृष्णा) - Polydypsia The condition resembles to morbid thirst in which the person even after continuous water intake fails to quench his thirst. |
| − | • Meadow Saffron plant
| + | #udara (udara, उदर) - Generalized abdominal enlargement. |
| − | • Mercury poisoning in children (acrodynia, pink disease)
| + | #upadrava (upadrava, उपद्रव) Secondary diseases- The diseases that develop subsequent to a disease or during, the course of the main disease that is being treated, and is dependent upon the main disease for its origination, nature and the strength. It is called secondary in the sense that its onset follows the presence of the primary disease. |
| − | • Yellow jessamine (jasmine poisoning)
| + | #ōpasarga trishna, (opasarga tRuṣṇa, उपसर्ग तृष्णा) Polydypsia caused as a complication to some other disease. |
| − | • Snake bites
| + | #vātaja trishna (vātaja tRuṣṇa(वातज तृष्णा) - Polydypsia due to dehydration, Polydypsia associated with excessive dryness in the throat and giddiness. |
| − | Table 1: Condition with morbid thirst and diagnostic tests
| + | #vāṭya (vATya, वाट्य) Porridge- prepared with fried barley |
| − | CONDITION SYMPTOMS AND SIGNS (besides excessive urination and thirst) LAB TESTS
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| − | 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
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| − | Heat exhaustion or heat stroke
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| − | Exhaustion, cool, clammy skin, increased body temperature (in heat stroke: warm skin, body T > 105.8 °F or 41 °C) Decreased 24-hour urine
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| − | 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
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| − | 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
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| − | Diuretics Dry mouth Decreased urine specific gravity
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| − | Psychogenic polydipsia
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| − | Usually in individuals with schizophrenia treated with antipsychotics Increased 24-hour urine, decreased urine specific gravity and osmolality, sometimes: decreased blood sodium
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| − | Adrenal hyperactivity (hyperaldosteronism) Increased blood pressure Decreased blood potassium, increased urine potassium, increased blood aldosterone after sodium challenge
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| − | Anorexia nervosa Severely decreased body weight Mineral and vitamin deficiencies (hypokalemia, low iron, etc.)
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| − | Postural (orthostatic) hypotension Dizziness after raising up, Drop of blood pressure > 30 mm Hg upon standing Nothing typical
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| − | Hypertension Increased blood pressure Possible increase of blood aldosterone, renin
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| − | Anemia Paleness, fatigue, hyperventilation Decreased RBC or abnormal erythrocytes
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| − | Congestive heart failure Chest pain, swollen legs ECG abnormalities
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| − | Liver cirrhosis History of alcoholism, poor appetite, loss of weight, spider nevuses Decreased serum proteins (albumin), increased liver enzymes and bilirubin
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| − | Chronic dry mouth (xerostomia) in Sjögren’s syndrome and SLE Rash, joint pain Specific antibodies in the blood
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| − | 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
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| − | Ecstasy (MDMA), cocaine, marijuana Euphoria Positive urine drug test
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| − | Opiates (morphine, heroin) Sleepiness Positive urine drug test
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| − | Laboratory Tests:
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| − | Blood Tests
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| − | 1. Glucose
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| − | • Elevated:
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| − | • Diabetes mellitus
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| − | • Cushing’s syndrome
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| − | • Early phase of hypovolemic shock (bleeding)
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| − | • Pheochromocytoma
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| − | 2. Sodium:
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| − | • Normal levels (135-145 meq/L):
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| − | • In most cases of dehydration (diarrhea, vomiting, excessive sweating)
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| − | • Within 8 hours of onset of acute bleeding
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| − | • Hyponatremia (<135 meq/L)
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| − | • >8 hours after onset of bleeding, when interstitial fluid moves into the intravascular space
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| − | • Sometimes after repeated vomiting or severe diarrhea
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| − | • Water intoxication
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| − | • Diabetic ketoacidosis (usually)
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| − | • Cerebral salt wasting (head injury, tumor)
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| − | • Hypernatremia (>145 meq/L)
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| − | • Dehydration (sometimes)
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| − | • Diabetes insipidus
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| − | 3. Potassium:
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| − | • Hypokalemia:
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| − | • Hyperaldosteronism
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| − | • Anorexia nervosa
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| − | • Hyperthyroidism
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| − | • Hyperkalemia:
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| − | • Diabetic ketoacidosis (usually)
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| − | 4. Calcium:
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| − | • Hypercalcemia:
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| − | • Hyperparathyroidism
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| − | • Hypervitaminosis D
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| − | • Hypocalcemia:
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| − | • Diabetic ketoacidosis (usually)
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| − | 5. CBC:
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| − | • White blood cells increased or decreased in sepsis
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| − | 6. Hematocrit (HCT):
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| − | • Decreased in water intoxication
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| − | 7. Blood Urea Nitrogen (BUN):
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| − | • Increased in kidney failure
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| − | • Decreased in water intoxication
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| − | 8. pH
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| − | • <7.3 (diabetic ketoacidosis)
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| − | 9. Proteins:
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| − | • Hypoalbuminemia in liver cirrhosis, nephrotic syndrome, severe malnutrition
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| − | 10. Hormone levels:
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| − | • ADH
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| − | • Decreased in central diabetes insipidus
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| − | • Increased in nephrogenic diabetes insipidus
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| − | • ACTH may be increased in pituitary adenoma or adrenal hyperplasia
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| − | • Cortisol may be increased in adrenal adenoma
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| − | • Aldosterone may be increased in adrenal adenoma or primary hyperaldosteronism
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| − | 11. Urine Tests
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| − | • Osmolality
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| − | • <200 mOsm/kg in psychogenic polydipsia, diabetes insipidus
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| − | • Specific gravity
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| − | • <1.005 in diabetes insipidus
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| − | • Glucose
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| − | • Untreated diabetes mellitus 1 or 2
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| − | • Pheochromocytoma; rare
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| − | • Proteins
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| − | • In nephrotic syndrome
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| − | • Sodium >20 meq/L: cerebral salt wasting
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| − | Principles of management:
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| − | 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.
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| − | | |
| − | Various preparations used in management:
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| − | Food and beverages:
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| − | • Trina panchamula medicated water:
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| − | Trina Panchamula contains five drugs namely kusha, kasha, nala, darbha and kandekshu. It pacifies pitta and it is indicated in trishna (Su. Su. 38/77). In Bhaisajya Ratnavali, Shara is given in place of Nala. (Bhaisajya Ratnavali, Mutrakricharogadhikar 10)
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| − | Kusha – Desmostachya bipinnata
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| − | Kasha – Saccharum spontaneum
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| − | Shara – Saccharum munja
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| − | Darbha –Imperata cylindrical
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| − | Ikshu – Sugarcane – Saccharum officinarum
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| − | 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 adhyaya.
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| − | • 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 (Ca. Su. 27/256).
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| − | • Yava medicated gruel: Yava (barley) is used in yava vatya (a gruel prepared out of 1 part of coarse powder of roasted yava (barley) and 14 parts of water).
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| − | • Peya is thin gruel of rice along with its solid portion (sikta). To prepare peya, 14 parts of water and 1 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.
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| − | • Food boiled with milk and maṁsa 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 (Bhava Prakash Nighantu 23/31).
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| − | • Trina panchamula, munjataka, priyala drugs should be mixed with maṁsa 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.
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| − | External applications:
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| − | External application of shatadhauta ghrita is pitta shamaka so it should be used.
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| − | Yusha is a soup prepared from pulses. Drugs which are madhura, tikta, shita and having jeevaniya properties, pacify pitta. They should be given to the patient for drinking as well as for external application.
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| − | Medicated ghee:
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| − | Ghrita processed with drugs of madhuradi gana mentioned in Charaka Vimanasthan 8th chapter should be used for drinking, massage and sprinkling purpose. Ghrita is best for pacifying pitta and vata.(Ca.Su.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).
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| − | Nasal administration:
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| − | Various milk or juice of sugarcane when administered through nasal route decreases thirst. (Cha.Su.27/224)
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| − | Following table enlists various diet recipes and medicinal formulations used in the management of trishna referred at various places.
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| − | Table 2: Diet and formulations for management of trishna
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| − | Name of Formulations Reference
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| − | Peya (Cha.Chi. 3/187 )
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| − | General property of milk pacifying trishna (Cha.su.1 /109 )
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| − | Use of panchatikta kwatha (Cha.Chi. 3/200)
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| − | Use of Vidarigandhadi, Bilva, Utpala etc. (Cha.Chi. 4/51 )
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| − | Rohityada Ghrita (Cha.Chi. 5/117 )
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| − | Duralabhadya Ghrita (Cha.Chi. 8/110 )
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| − | Eladi Gutika (Cha.Chi. 11/23 )
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| − | Amritprasha Ghrita (Cha.Chi.11 /43 )
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| − | Tritiya Sarpi Guda (Cha.Chi. 11/65 )
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| − | Patolamuladi Kwatha (Cha.Chi. 12/54 )
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| − | Water Siddha with Trina panchamula Kwatha (Cha.Chi. 18/141 )
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| − | Chandana,sugar, honey with Tandulodaka (Cha.Chi. 19/86 )
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| − | Use of Gairika, Sugandhabala with Tandulodaka (Cha.Chi. 20/32 )
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| − | Draksadi sita Kwatha/ Prapoundarika Kwatha (Cha.Chi. 21/58 )
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| − | Water processed with Parushaka and Pilu; Chatuparni; Musta, Dadima, Laja (Cha.Chi. 24/149 )
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| − | Cold water (Cha.Chi. 24/163 )
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| − | Madhura Rasa (Cha.Chi. 26/43 )
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| − | Tikta Rasa (Cha.Chi. 26/43 )
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| − | Rakta Shali (Cha.Chi. 27/11)
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| − | Ervaruka (Cha.Chi. 27/111 )
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| − | Mridvika (Cha.Chi. 27/125 )
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| − | Sarkara (Cha.Chi. 27/242 )
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| − | Laja peya (Cha.Chi. 27/250 )
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| − | Saktu (Cha.Chi. 27/264 )
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| − |
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| − | • Gandusha:
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| − | 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.(Su.Su.42/10) 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.
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| − | Management of vata dominant trishna:
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| − | All dietary formulations and drugs used in vataja trishna must have property to pacify vata. Milk and ghrita mentioned in kshayaja kasa (like dvipancamuladi ghrita, guduchyadi ghrita, kasmardadi ghrita etc.) pacify vata dosha effectively and thus these preparations can also be used in vataja trishna.
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| − | Management of pitta dominant trishna:
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| − | 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.
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| − | 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.Su.25/40).
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| − | Management of amaja trishna:
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| − | 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.
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| − | Management of trishna due to madatyaya:
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| − | Use of alcohol for treating thirst induced due to alcohol is example of ‘Hetu Vipritarthakari’ (treatment with a substance similar to the cause).
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| − | Effect of cold water and hot water on body fluid balance:
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| − | In conditions of dehydration and where pitta is dominant (Ddaha, bhrama, madatyaya etc) cold water should be given as it restores water content in body as well as pacify pitta by its shita guna. After boiling, water becomes free from various micro-organisms. Boiled water should be used in sanipattika 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 atleast one of the dosha (hot will increase pitta, cold water will increase vata/kapha) so normal water should be used.
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| − | 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.( Ca. Ci. 3/144; Ca.Vi.3/40)
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| − | 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.[ ]
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| − | 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.( Ca.Ci.13/45)
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| − | In pandu there is presence of haemodilution and edema so water intake should be restricted to minimal. In gulma, mandagni is main causative factor. (Ca. Ci. 5/112)
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| − | Excessive intake of water causes mandagni and if, water is taken in mandagni stage excessively, strength of agni decreases further (Ma.Ni.6/7). So, water is contraindicated in mandagni stage. If needed, water can be given in less quantity.
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| − | Now-a-days 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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| − | Researches on trishna: (to be added)
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| − | | |
| − | Glossary:
| |
| − | - ādhmāna (AdhmAna, आध्मान) The term signifies distention or inflation of a body part caused due to stagnation of the substances inside it; but generally is taken for distention of the abdomen associated with pain due to various reasons like obstruction to the urine and faeces, accumulation of blood in abdomen etc.
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| − | - āmaja trishna (Amaja tRuṣṇa,आमज तृष्णा) Polydypsia due to indigestion
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| − | - bādhiryaṁ (bAdhiryaM, बाधिर्यं) Impaired hearing, deafness, a disease condition where in the patient has impaired hearing or complete loss of sound perception.
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| − | - bhrama (bhrama, भ्रम) Giddiness, dizziness or tremor.
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| − | - gulma (gulma,गुल्म) - Lump in abdomen. A lump like formation occurring in the abdomen either mobile or static in nature, circular in shape and constantly increasing and decreasing in size.
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| − | - hikkā (hikkA,हिक्का) – Hiccoughs. A disease characterized by production of peculiar sound like hic-hic by mouth.
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| − | - lājā (lAjA, लाजा) Obtained by roasting undried and unhusked paddy. Is light and easily digestible. Cures thirst, vomiting, diarrhoea, diabetes, obesity, cough and pitta.
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| − | - māṁsarasa (māṁsarasa ,मांसरस) soup prepared with meat by adding 8 times of water & reducing it to 1/4th and seasoned with trikatu, ghee & jaggery
| |
| − | - mūrcchā (mUrcchA,मूर्च्छा) - Syncope A fatal condition characterized by loss of consciousness and postural tone due to vitiation of blood.
| |
| − | - nasya(nasya, नस्य) Administration of drugs by nasal route, all drugs and measures introduced through nose spread throughout the head and its constituent drugs may influence all the dosha, poisons and disease situated in these parts.
| |
| − | - pāṇḍuroga (pANDuroga ,पाण्डुरोग) - Pallor of body, Anemia The term literally means paleness of the skin and mucosa along with yellowish discoloration of urine and faeces; marked by lack of blood, strength complexion, body fat and essence of the body tissues.
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| − | - pēyā (pēyā ,पेया) Thin gruel of rice along with its solid portion (Siktha). To prepare Pēyā, 14 parts of water and 1 part of broken rice are taken and boiled well till all the rice particles become soft. It increases digestive fire.
| |
| − | - pittaja trishna (pittaja tRuṣṇa,पित्तज तृष्णा )Polydypsia due to severe emaciation, Polydypsia associated with fainting, delirium and burning sensation.
| |
| − | - Śaktu (-Śaktu, शक्तु)- Is a diet preparation. Prepared by frying and powdering husked grains like barley, wheat, rice, parched rice etc.
| |
| − | - santāpa(santApa ,सन्ताप) Abnormal Psychosomatic feeling, the term denotes feeling of distress with or without rise in body temperature. And it may reflect in the externally body as hotness in somatic level.
| |
| − | - śvāsa (shvAsa,श्वास) - Dyspnoea due to respiratory disease. It is a respiratory disease marked by recurrent paroxysmal attacks of Shortness of breath, a subjective difficulty or distress in breathing, with or without wheezing due to obstruction in the respiratory airways.
| |
| − | - trishna(tRuṣṇa,तृष्णा) - Polydypsia The condition resembles to morbid thirst in which the person even after continuous water intake fails to quench his thirst.
| |
| − | - udara (udara, उदर) - Generalized abdominal enlargement.
| |
| − | - upadrava (upadrava, उपद्रव) Secondary diseases- The diseases that develop subsequent to a disease or during, the course of the main disease that is being treated, and is dependent upon the main disease for its origination, nature and the strength. It is called secondary in the sense that its onset follows the presence of the primary disease.
| |
| − | - ōpasarga trishna, (opasarga tRuṣṇa, उपसर्ग तृष्णा) Polydypsia caused as a complication to some other disease.
| |
| − | - vātaja trishna (vātaja tRuṣṇa(वातज तृष्णा) - Polydypsia due to dehydration, Polydypsia associated with excessive dryness in the throat and giddiness.
| |
| − | - vāṭya (vATya, वाट्य) Porridge- prepared with fried barley
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| | References: | | References: |