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Evaluation of the efficacy of AMRUTADI YOGA IN GALAGANDA (GOITER) By Renjith. P. Gopinath, Department of Kayachikitsa, Post graduate studies and research center D.G. MELMALAGI AYURVEDIC MEDICAL ...

Evaluation of the efficacy of AMRUTADI YOGA IN GALAGANDA (GOITER) By Renjith. P. Gopinath, Department of Kayachikitsa, Post graduate studies and research center D.G. MELMALAGI AYURVEDIC MEDICAL COLLEGE, Gadag - 582 103

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  • Evaluation of the efficacy ofAMRUTADI YOGA IN GALAGANDA (GOITER) By Renjith. P. Gopinath Dissertation submitted to the Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore In partial fulfillment of the degree of Ayurveda Vachaspati M.D. In Kayachikitsa Under the Guidance of Dr. V. Varada Charyulu M.D. (Ayu) (Osm) Dr. Shiva Rama Prasad Kethamakka M.D. (Ayu) (Osm) M.A. (Jyotish), [Ph.D (Jyotish)] Department of Kayachikitsa Post Graduate Studies & Research CenterD.G. MELMALAGI AYURVEDIC MEDICAL COLLEGE, GADAG 2002-2005
  • J.S.V.V. SAMSTHE’S D.G.M.AYURVEDIC MEDICAL COLLEGE POST GRADUATE STUDIES AND RESEARCH CENTER GADAG, 582 103 Endorsement by the H.O.D, Principal/ head of the institution This is to certify that the dissertation entitled “Evaluation of the efficacy ofAMRUTADI YOGA IN GALAGANDA (GOITER)” is a bonafide research work done by“Renjith. P. Gopinath” under the guidance of Dr. V. VARADA CHARYULU, M.D.(Ayu) (Osm), Professor & HOD and Dr. SHIVA RAMA PRASAD KETHAMAKKA,M.D. (Ayu) (Osm) M.A. (Jyotish), [Ph.D (Jyotish)], Reader in Kayachikitsa, DGMAMC,PGS&RC, Gadag, in partial fulfillment of the requirement for the post graduation degree of“Ayurveda Vachaspati M.D. (Kayachikitsa)” Under Rajeev Gandhi University of HealthSciences, Bangalore, Karnataka.. (Dr. V. Varada charyulu) (Dr. G. B. Patil) Professor & HOD Principal, Dept. of Kayachikitsa DGM Ayurvedic Medical College, PGS&RC Gadag Date: Date: Place: Gadag Place: Gadag
  • D.G.M.AYURVEDIC MEDICAL COLLEGE POST GRADUATE STUDIES AND RESEARCH CENTER GADAG, 582 103 This is to certify that the dissertation entitled “Evaluation of the efficacy ofAMRUTADI YOGA IN GALAGANDA (GOITER)” is a bonafide research work done by“Renjith. P. Gopinath” in partial fulfillment of the requirement for the post graduationdegree of “Ayurveda Vachaspati M.D. (Kayachikitsa)” Under Rajeev Gandhi University ofHealth Sciences, Bangalore, Karnataka.Dr. SHIVA RAMA PRASAD Dr. V. VARADA CHARYULUKETHAMAKKA M.D. (Ayu) (Osm)M.D. (Ayu) (Osm) M.A. (Jyotish), [Ph.D (Jyotish)] GuideCo- Guide Professor & HODREADER IN KAYACHIKITSA Dept. of KayachikitsaDGMAMC, PGS&RC, Gadag PGS&RCDate: Date:Place: Gadag Place: Gadag
  • Declaration by the candidate I here by declare that this dissertation / thesis entitled “Evaluation of the efficacy ofAMRUTADI YOGA IN GALAGANDA (GOITER)” is a bonafide and genuine researchwork carried out by me under the guidance of Dr.V.Varada Charyulu M.D. (Ayu) (Osm) andDr. SHIVA RAMA PRASAD KETHAMAKKA, M.D. (Ayu) (Osm) M.A. (Jyotish), [Ph.D(Jyotish)], Reader in Kayachikitsa, DGMAMC, PGS&RC, Gadag.DatePlace (Renjith. P. Gopinath)
  • Copy right Declaration by the candidate I here by declare that the Rajiv Gandhi University of Health Sciences, Karnataka shallhave the rights to preserve, use and disseminate this dissertation/ thesis in print or electronicformat for the academic / research purpose.DatePlace (Renjith. P. Gopinath)© Rajiv Gandhi University of Health Sciences, Karnataka
  • Abstract Evaluation of the efficacy of Amrutadi yoga in Galaganda (goiter) By - Renjith. P. Gopinath The thyroid disorders are characterized by physical and mental interference. Wecan correlate goiter and some tumor pathology of thyroid to ‘Galaganda’ where thyroidfunctions may or many not are affected. Susruta defines Galaganda as a swelling (mass in the neck region), by thevitiation of Vata, Kapha and medo Dhatu where in Charaka named only Kaphacirculates in and around neck is the cause. Mental factors like chinta, sokha, krodha,bhaya, etc vitiate Vata Dosha. Goitrogens - suppress thyroid function and can inducehypothyroidism and goiter. Iodine restriction will cause the thyroid to increase in size (goiter) in an effort tofilter more blood to get more iodine. Once copper is replenished and copper metabolismis working properly, the body will tolerate iodine without increasing thyroid hormoneproduction. Lack of thyroid hormone can cause constipation. Thyroid hormonesincreases the rapidity of cerebration but also often dissociates this conversely, lack ofthyroid hormone decreases this function. Anemia is pre-condition for the production of thyroid disease. Greatly increasedthyroid hormones almost always decrease the body weight, and greatly decreasedhormone almost always increases the body weight. This study is a prospective clinical study of Amrutadi thailam in Galaganda. 17patients were selected for the study in one group. The goiter is present in both types ofthyroid disorders such as hypo thyroidism and hyperthyroidism. After the assessment of both subjective and objective parameters the results are,hypothyroidism patients were responded to the treatment, the euthyroid patients weremaintained with the treatment and the hyper thyroid patients were not responded to thetreatment. The observations are - thyroid disease is common in the middle-aged womenwith family history. It plays a vital role in the change of the character, and mental stateof the patients. In hypothyroidism patients the body weight will be increased and inhyperthyroidism patients, it will be reduced. The group Hyperthyroidism differssignificantly from Group Hypothyroidism and Group Euthyroidism. GroupHypothyroidism is Significant.
  • Acknowledgement At first my sincere thanks to the subjects who cooperated at my dissertation, without of them it would have been not a success. I express my deep gratitude to my guide Dr. V. Varadacharyulu M.D.(Ayu),Professor & H.O.D., for his advice and encouragement of every step of this work. I express my obligation to my co-guide Dr Kethamakka Shiva Rama Prasad,M.D.(Ayu) M.A,Ph. D (Jyotish), Reader in Kayachikitsa, for his time to time help andcritical suggestion associated with expert guidance at the completion of this dissertation. I express my obligation to beloved principal Dr. G. B. Patil, Principal for hisencouragement as well as providing all necessary facilities for this research work. I express my profound sense of gratitude to various departments H.O.D.s, teachersand colleagues of sister concern departments along with the ministerial and sub staff of theD.G.M. Ayurvedic Medical College, Gadag. I express my sincere thanks to Dr. Shashidar. H. Doddamani, Dr. R. V. Shettar, Dr.Kuber Sankh, Dr. P. Shivaramudu, Dr. Dilipkumar, Dr. V.M.Sajjan, Dr. U.V.Purad, Dr.Santhosh Belavadi and Dr Pawadshettar. I express my sincere thanks to Mr. Nandakumarfor his help in statistical analysis of results. I express my deepest gratitude to my beloved parents, Dr.P.S.Gopi, andDr.M.K.Indira, to my relatives and well wishers Rejitha.P.G, Dr.M.K.Unnikrishnan,Dr.M.K.Sathy, Dr.M.K.Baby, Mr. Babuprasad, M.Sc (IT) and Dr.M.Balakrishna Pillai fortheir inspiration. With respect and affection, I acknowledge my ever-remembering late Grand fatherShri M.P. Kunjan Vaidyan who inspired me all the timePlace:Date: Renjith. P. Gopinath
  • Table of contents Evaluation of the efficacy of Amrutadi yoga in Galaganda (goiter) Heading Page numberChapter -1 Introduction 1 to 4Chapter –2 Objectives 5 to 7Chapter –3 Review of literature 8 to 53Chapter –4 Methodology 54 to 79Chapter –5 Results 80 to 112Chapter –6 Discussion and Conclusion 113 to 134 Summary 135 to 139 Bibliographic References i to vi Annex – Case sheet 1 to 5
  • Tables Tables - Amrutadi yoga in Galaganda (goiter) Page1 Lakshana of Vataja Galaganda 312 Lakshana of Kaphaja Galaganda 323 Lakshana of Medoja Galaganda 334 Showing clinical features of Hyperthyroidism 355 Showing clinical features of Hypothyroidism 366 Differential diagnosis of Galagraha and Apachi 507 Differential features of Galaganda, Galavidradhi, Kanthashaluka and 51 Mamsatana.8 General survey of the thyroid patients for Hyper or Hypo thyroidism 629 Distribution of patients by age 8010 Distribution of patients by sex 8211 Distribution of patients by religion 8412 Distribution of patients by occupation 8513 Distribution of patients by economical status 8714 Distribution of patients by mode of onset 8815 Distribution of patients by intake of Goitrogens 9016 Distribution of patients by family history 9117 Distribution of patients by Agni 9218 Distribution of patients by sleep 9419 Distribution of patients by psychological features 9520 Distribution of patients by habits 9721 Distribution of patients by menstrual cycle 9822 Distribution of patients by built and nutrition 10023 Distribution of patients by Aharaja and Viharaja Nidana 101
  • Tables – continued : Amrutadi yoga in Galaganda (goiter) Page24 Distribution of patients by with systems involved 10325 Distribution of patients by chief complaints 10526 Subjective parameters enumerated (a) 10627 Subjective parameters enumerated (b) 10628 Showing the statistical analysis of the chief complaints 10729 Showing the statistical analysis of the lab investigations 10730 Anova – Table for the parameter T3 10831 Anova – Table for the T4 parameter 10832 Table show which pair of group is significant 10833 Anova- Table for parameter T.S.H. 10934 To show which pair of group is significant 10935 Showing the result of Amrutadi taila capsules in Galaganda 11236 Hyperthyroidism - Discussion on General and local symptoms 11937 Hyperthyroidism Systemic evaluation - Cardiovascular symptoms 11938 Hyperthyroidism Systemic evaluation - CNS symptoms 12039 Hyperthyroidism Systemic evaluation - Gasto-intestinal symptoms 12040 Hyperthyroidism Systemic evaluation - Dermatological symptoms 12141 Hypothyroidism -General features of hypothyroidism 12142 Hypothyroidism Systemic evaluation - Cardiovascular symptoms 12243 Hypothyroidism Systemic evaluation - CNS symptoms 122
  • Graphs Graphs - Amrutadi yoga in Galaganda (goiter) Page1 Showing Patients by age distribution 812 Showing Patients by gender distribution 833 Showing Patients by religion distribution 854 Showing Patients by occupation distribution 865 Showing Patients by economical status distribution 886 Showing Patients by mode of onset distribution 897 Showing Patients by intake of Goitrogens distribution 908 Showing Patients by family history distribution 929 Showing Patients by Agni distribution 9310 Showing Patients by sleep distribution 9511 Showing Patients by psychological features distribution 9612 Showing Patients by habits distribution 9813 Showing Patients by menstrual cycle distribution 9914 Showing Patients by built and nutrition distribution 10115 Showing Patients by Aharaja and Viharaja Nidana distribution 10216 Showing Patients by with systems involved 10417 Depicting the results of Amrutadi yoga on Galaganda 112 Figures Figures – Amrutadi yoga in Galaganda (goiter) Page1 Location and anatomy of the Thyroid gland 202 Functions of the thyroid follicles 233 Auto regulation of the thyroid hormone 254 Schematic representation of the Galaganda Samprapti 405 Contents of Amrutadi taila (Photograph) 66
  • INTRODUCTION Ayurveda, the science of life is the holistic alternative system of medicine. Theorigin of this science is already evident in Atharvanaveda. Eventually Ayurveda wasoriginated into its own compact system of health and considered as a branch ofAtharvanaveda. The main aims of this science are to maintain one’s health and to protect thehuman beings from various diseases, which are acquired. Among many things man aspires to attain in life, a healthy body and healthy mindare the first to be sought for. The aim of all medical system should be a healthy body andhealthy mind. Ayurveda is one such system that prevailed from many years. Health isdefined as the condition in which the sharirika and the manasika bhavas exist in a state ofequilibrated normalcy. Ayurveda mentions comfort (sukha) as health (arogyam) with synonyms of Arogyaand Swasthya. The Ayurvedic concept of evolution of a disease is remarkably wide.According to Ayurveda Vyadhi i.e. disease has been defined as the state in which both bodyand mind are subjected for pain and agony respectively. At the present millenium has shown us numerous disorders and we know that thechanges in atmosphere and the living conditions or habits are among the causes. This resultsin serious multi systemic metabolic disorders like diabetes, thyroid problems, hepaticdisorders etc., Ayurveda is the best way to handle them safe and naturally. The thyroid disorders are characterized by physical and mental interference.Previously it was thought that these groups of disorders are of sporadic in nature in some 1
  • parts of India. For e.g. Goitre is common among people of the Himalayas due to the iodinedeficiency. As medical aids reached to the feet of common man and communication isdeveloped in association with that of luxuries and changed dietetics this disorder prevailedall over the globe and especially a developing country, India. An increasing number ofpatients of Goitre and many more Thyroidectomies, either partial or complete are evidentialfor the above discussion. Ayurveda is a golden mean between pure sciences and philosophical sciences.Therefore it becomes interesting to know how Ayurveda looks to a problem, which appearsto be untouched in Ayurveda. Endocrine disorders and concept of hormone are suchproblems noted here. In Ayurveda there is not an exact term for thyroid gland. Therefore it is not possibleto get an explanation of physiology and pathology of thyroid gland from our ancient books.Some of the later Ayurvedic scholar tried to name the thyroid gland, but they could notcompare many thyroid disorders with any of the ancient descriptions. We can correlate goitre and some tumor pathology of thyroid to ‘Galaganda’ wherethyroid functions may or may not is affected. But hypothyroidism and hyper thyroidismhave the symptoms related to many portions of the body. It is very difficult to correlate thesetwo entities with any of the nomenclated diseases of Ayurveda. Further hypothyroidism andhyperthyroidism are not single disease entities and many conditions are included under eachheading. It is therefore, better not to restrict thyroid dysfunction to any one of the diseases.Similarly, there are not mere localized disorders. In such a situation, an Ayurvedist need notbe specific to it but can treat the disease by knowing the condition of Dosha, Dhatu andAgni components of pathogenesis etc. and their interrelation with the disease condition. 2
  • The competition among the medical systems is increasing day by day. Thecontemporary systems use the most advanced techniques in assessing the disease and in theaspect of treatment and research studies. So, it is our duty to conduct proper research andinvent new methods and medicines, which serves to the mankind.The need for study In this fast forward life, the life style of man has changed. He is very much busy withthe day today schedules to acquire more earnings. This more desire have made the man todeviate from following the swastha vrutta, thereby becoming a victim of diseases. So in theyoung adult age itself man, has become victim of severe degenerative diseases likeSandhivata, Manyasthamba etc., and other multi systemic metabolic disorders like endocrinediseases, diabetes, etc., Among such diseases Galaganda (goiter) is a common onenowadays. The gradual increase and prevalence of Galaganda draws attention over thedeviation of lifestyle and balanced diet in the modern society. Mass in the neck, pain in the neck etc characterizes the disease 1, and it is a seriousmetabolic disorder, as it affects almost all systems of the body. It is most common nowadaysin every part of the world. Which is considered as a serious metabolic disorder that makes astrong impact on one’s daily life. Contemporary medical science are able to pacify thedisease through anti thyroid drugs, radio active iodine and if needed through the surgicaltreatment as the final with its own limitations. In Ayurveda we can offer safe and effective management for Galaganda. So toovercome this problem at young age without producing any complication, the research inthis area is essential. Ayurveda the ancient system of medicine has suggested good old 3
  • techniques and recipes to pacify the swelling (mass in neck) and other symptom withoutcausing any complication. Since this area is prevalent in goiter, I have taken the present study as ‘Evaluation ofAmrutadi thailam in Galaganda with positive thoughts. Still more research works areessential to establish the same by using research techniques and by statistical methods.Role of Ayurveda in this area and recent advances In the contemporary system of medicine the treatment given to thyroid disorders areanti-thyroid drugs, radio active iodine and surgery which has its own disadvantages and sideeffects. The drug-induced goitre is an evident example of it2. Ayurveda the traditional Indian system of medicine, describes a reliable andeffective management of diseases with due consideration to protect the normal health also. Ayurvedic approach to the disease ‘Galaganda’ is to reduce the Ganda (mass in theneck), toda (pain around the neck), kandu (itching around the neck), difficulty in breathingetc., and to strengthen the Dhatus and pacifying the Vata and Kapha Dosha which hasspecial importance in the management. The recent studies carried out in the past are: - 1. Effect of kanchanara (Valvina variegata and Balvina purpura) in Galaganda by Sijoria K in 1977 at BHU, Varanasi. 2. Use of indigenous drugs in Galaganda by Pandit R K in 1987 at BHU, Varanasi3. 3. Galagandarog par jalakumbhiprayog by Manekar H B in 1991 at Shri Ayurved Mahavidyalay, Nagpur4. 4
  • OBJECTIVES OF THE STUDY The aims of the study are - 1. Evaluate the anti Goitrogenic effect of Amrutadi thailam in Galaganda. 2. Evaluate the effect of Amrutadi thailam on T3, T4 and TSH in Galaganda. 3. To evaluate the efficacy of Amrutadi thailam Pratimarsha Nasya in Galaganda Amrutadi thailam mentioned in Yogaratnakaram is a wonderful combination, whichreduces the swelling pain rashes, which restores the voice, as it is Kantyam, alleviates Vata,Kapha and Medas. So, this combination is most suitable in the treatment of Galaganda. The present work by Amrutadi thailam is focussed exclusively in Galaganda (goiter).In this study the most modern techniques are adopted in terms of diagnosis, investigationsassessment and medicine preparation. All together this study gives a scientific approach inthe management of Galaganda. 5
  • 1. To evaluate the anti Goitrogenic effect of Amrutadi thailam in Galaganda. The condition is said to be affecting the neck region as a swelling mentioned byvarious authors in Ayurveda is termed as Galaganda and its management through variousmethods, one out of them is Amrutadi thailam, which is included in the present study. The specificity of the anti-Galaganda properties is studied as the anti Goitrogeniceffect. The anti Goitrogenic effect of Amrutadi thailam in Galaganda can be evaluated byunderstanding the cumulative effect of the said yoga. The Amrutadi thailam comprises of the 9 herbs, which are of Kapha, Vata and Medohara in nature, which may reduce the mass and there by regulate the effect of concern organpathology i.e. Galaganda viz., goiter. This can be understood that by the study of baseline data to the final data differencesafter the drug administration to the affected patients those who are included by the presetparameters of exclusion and inclusion criteria. As there is an elaborate discussion made under the drug review of individual drugs, acumulate effect is drawn out of as Shothahara – anti tumor property, Kantyam – regulatoryeffect of neck pathology and Rakta shodhaka – blood purification. These said properties areeffective over Dosha predominance and Dushya – Dhatus to regulate to normalcy byfragmenting the underneath pathologies.2. To evaluate the effect of Amrutadi thailam on T3, T4 and TSH in Galaganda. T3, T4 and TSH are the objective parameters to ascertain the functional capacities ofthe thyroid. The present study under takes the said lab investigations to evaluate the efficacyof Amrutadi thailam in thyroid problem of either Hypothyroidism or hyperthyroidism. This 6
  • data with precise information regarding the functional capacities to estimate the prognosisand the medical management to the said Galaganda with reference to that of Goitrogenic andthyroid pathologies are anticipated. Thus the present study intends to have the study of Amrutadi thailam with referenceto the T3, T4 and TSH assay.3) To evaluate the efficacy of Amrutadi thailam Pratimarsha Nasya in Galaganda Nasya karma a therapeutic procedure of intranasal drug administration, is one of thewell-known Panchakarma. According to the disease of medicine. It is divided as marshanasya and Pratimarsha nasya. Pratimarsha Nasya is a daily 2-3 drops in each nostril, withoutany poorva karma and pathyas. The finest specification of this therapy is made in theAyurvedic books, as acting on the body parts above the neck, that is the parts lying up oninside the skill. The ancient authors of Samhita proclaim that the drugs administered inNasya shall enter the head. In the Galaganda, a disease developed above to the clavicle is evaluated with theAmrutadi taila Pratimarsha Nasya, which has the rechana property and with the Ushna,teekshana Gunas alleviates the Kapha Dosha. 7
  • LITERARY REVIEW There are vast areas in India with iodine deficiency disorders (IDD). Besides the subHimalayan region, other flood- prone regions and reverine areas, deltas and costal regionsare now recognized to have iodine deficiency, i.e. the iodine content of water is <1ppm.There are an estimated 150 million people in India who are considered to be at risk of iodinedeficiency, and of these 54 million have goiter. Earlier the only recognized effect of iodinedeficiency on health was goiter; however, there is now a better understanding of theperspective of IDD. IDD now includes the following 5 : - 1. Goitre at all ages 2. Endemic cretinism with associated mental retardation, deaf- mutism, spatic diplegia and lesser degree of neurological deficit. 3. Impaired mental function in children and adults. 4. Increased rates of abortion, stillbirth and perinatal and infant mortality. 6Etymology of Galaganda The word Galaganda comprises of two parts - gala and ganda. Gala - is a word of masculine gender and it is derived by the union of ‘Gal’ dhatu and ‘Ap’ pratyaya or by the union of ‘Gru’ dhatu and ‘Vyap’ pratyaya. It means the pathway of food, i.e., kantha. Ganda - is a word of masculine gender. It is derived either by the union of ‘Gadi’ dhatu and ‘Ach’ pratyaya or ‘Gata’ and ‘Njantadda’ sutra. As per Medini Kosha, it means pidaka or budbuda and as per Ramanathateeka on Amarakosha, it means sphotaka or granthi. 8
  • In a nutshell, Galaganda relays the meaning, the sphotaka or ganda in the ganda. Therelative term from the contemporary medical science is goiter. Goitre 7- The term goitre is derived from the French word ‘ goiter’; which is originally derived from the Latin word ‘gutter’- means ‘throat’. We use the term ‘goiter’ to denote the enlargement of thyroid gland irrespective of its cause. The pocket oxford dictionary speaks the meanings of Goitre as – Goitre n. (Brit. goitre) morbid enlargement of the thyroid gland. [Latin guttur throat] 8, Goitre n. (US goiter) morbid enlargement of the thyroid gland. [Latin guttur throat] The thyroid gland first discovered by Mr. Wharton in the 19th century, weighsaround 20gms in adults. The thyroid (from GK, thyroid meaning a shield, because it shieldsthe trachea9.Definitions In almost all Ayurvedic treatises Galaganda is described elaborately. Susruta defines it as a swelling (mass in the neck region), by the vitiation of Vata,Kapha and medo dhatu10. But Dalhana and Gayadasa, in their commentaries mention it as aswelling in the neck (Nibadhaswayathu) 11. Charaka mentioned that when a vitiated Kapha Dosha circulates around the neck, itwill cause swelling slowly is termed as Galaganda12. Madhava Nidana explanation is more authentic as it states that Galaganda is aswelling attached to the neck which hangs down like a scrotum13. He also quotes thedefinition of Bhoja here as “Mahantam shopham alpam va hanu manya galashraye” 14 i.e. A 9
  • swelling resembling and hanging like a scrotum in the Hanu, Manya, and Gala is called asGalaganda. From the contemporary medical science, Goitre is defined as a benign, non-toxicenlargement of the thyroid gland usually secondary to some form or other of the iodinedeficiencies. The disease is characterized by swollen throat, hoarseness of voice, slight pain,in the neck region, difficulty to swallow, etc 15.Historical review:- The Vedas are the old and prime documented source of knowledge. There is noreference regarding the disease Galaganda in the Vedic literatures. Ayurveda, a medicalscience deals with almost all diseases, mentions elaborately about Galaganda as one amongthose disease, which were explained in concern with Kaphaja Vyadhis. There was a period were the science developed and flourished much and considered asthe golden period of Ayurveda. Almost all Acharyas had mentioned Galaganda in theirrespective treatises. Among Brihatrayees, Susruta mentioned Galaganda elaborately. Likewise the otherAcharyas also followed the same descriptions in separate chapters except Charaka. AcharyaCharaka has mentioned about Galaganda in Trishopheeyam adhyaya of sutra sthana 16. In Susruta Nidana, mentions about the Galaganda Samprapti are very clear. It statesthat, the Vata, Kapha and Medo Dhatu will got vitiated by its etiological factors and producethe Ganda (mass in the neck); which have the symptoms of the three respectively. Susrutadescribes the Lakshana, Bheda, and Sadyaasadhyata in Nidana sthana and the detail Chikitsaat its Chikitsa sthana 18th chapter 17-18. 10
  • In Charaka Samhita, mentions of Galaganda are from Trishopheeyam chapter of sutrasthana describing it as a ‘Shopham’ – swelling occurring in the neck due to vitiated Kapha.Here the vitiated Kapha will stay around the neck region and produce swelling, which iscalled as Galaganda 19. In Astanga Hrudaya and Astanga Sangraha, Vagbhatas mentioned Galaganda Nidana,Bhedas, Lakshanas in the Mukha roga vijnaneeyam adhyayam of the Uttara sthana andChikitsa in Mukha roga pradheeshedam adhyaya 20. In Madhava Nidana, Madhavakara quoted the same as that of Susruta and mentions theNidana, Lakshana, Bhedas, and Sadyasadyata of Galaganda in detail 21. 22 23 24 The other treatises, such as Yogaratnakara , Bhavaprakasha , Chakradutta , 25Vangasena , etc also mentions about Galaganda. They elaborately described about theLakshanas, Bhedas, Samprapti, and Chikitsa in their respective works. In the contemporary system of medicine, the disease Galaganda can be correlated with‘Goiter’. Goitre is a common disease in the modern society as there is a gradual increase inthe deviation of lifestyles and balanced diet. It is mainly common in area where the Iodinecontent of water is less than 1PPM 26.Epidemiology:- The thyroid disorders and goitre are common in the females, in the certain ages, inspecific part of the world. So the epidemiological evidences of these diseases are very muchimportant in detecting the cause and is useful to decide the treatment and in the preventionof those diseases also 27. 11
  • Age:- The age of the patient is a Very important consideration. Simple goitre is commonlyseen in girls approaching puberty and in pregnant women because in puberty and inpregnancy, the requirement of hormone is augmented. Both multi-nodular and solitary nodular goitres as well as colloid goitres are found inwomen of 20s and 30s. The primary toxic goitre is usually present in young ones, where inHashimoto’s disease the victims are middle-aged women.Sex:- Majorities of the thyroid disorders are seen in females. All types of simple goitres arefar more common in the female than in male. Thyro-toxicosis is 8times common in femalesthan in males. Even thyroid carcinomas are more often seen in females in the ratio 3:1. The prevalence of hyperthyroidism is about 20/1000 females; males are affected 5times less frequently. The female to male ratio 28 of hypothyroidism is 6:1.Geographical distribution Except endemic goitres due to iodine deficiency, no other thyroid disorders liesamong peculiar geographical distribution. Certain areas are particularly known to have low iodine and food. These areas are,Rocky Mountains, e.g.-Himalayas, the Vindyas, the Satpudha ranges, which form the goitrebelts in India. Such goitres are common in Southern India than in Northern India. Endemic goitres are common in low land areas where the soil lacks iodides or thewater supply comes from far away mountain ranges. Calcium is also Goitrogenic and areasproducing chalks and limestones are also Goitrogenic areas. 12
  • Nidana According to the treatment point of view, the knowledge of hetu is important so as toenable the physician to advice the patient to avoid the practice of Nidana, as it is mentioned“Nidana Parivarchanam Eva Chikitsa” 29. Madhava Nidana has clearly mentioned that Nidana of all the disease is due to thevitiation of Mala 30. Galaganda is a Kaphaja nanamatja Vyadhi 31and it is mentioned by all treatises. But 32the etiological factors are not directly mentioned in the classical texts. Charaka hasmentioned Galaganda as a lump situated in the neck where the swelling generated slowly, ora Sopham – edematous; especially with the Kapha and Vata Dosha predominance. SusrutaSamhita states, as like Charaka and adds to it that the Galaganda does not occur due to Pitta(Dalhana). When we review the lakshanas of the Vata, Kapha, and Medoja Galaganda, thesymptoms are similar that of Vataja and Kaphaja sopham. The different etiological factors from various texts are referred as under with rationalheadings such as – Ahara Nidana, Vihara Nidana etc.,1.Aharaja Nidana 33-34 It can be divided into Vata prokapa, Kapha prakaopa and Medoprakopakaranas.Consumption of Aharas having Vatika and Kaphaja predominance causes vitiationof Kapha, Vata in the body. The intake of tikta, katu, kashaya rasa , rookshannam, alpamatara bhojanam etcvitiate then Vata Dosha . The intake of madhura,amla,Lavana,snigdha, guru,abhishyanda,seeta, types of foods will vitiate Kapha Dosha . 13
  • The method and time of taking the food is also important. As abhojana,heenabhojana,suskhabhojana vitiates the Vata Dosha . The virudha bhojana, atibhojana,vitiates the Kapha Dosha .2.Viharaja nidanam 35-36 Vegadharanam, Vegotheeranam, Nisajagaranam, Atyuchabhashanam,Shodanadiatiyogam, Bhayam, Dukham, Chinta, Sramam, Upavasam, etc will vitiate VataDosha. Aasyasukham, Swapnasukham, Ajeeranam, Divaswapnam, brhmanatiyogam,Shodanadi ayogam, Avyayamam, etc will vitiate the Kapha Dosha. These two factors (the aharaja and viharaja factors) will vitiate the Vata and KaphaDosha. These are all the etiological factors of Vataja and Kaphaja sopham also.3.Manasika karanas 37 Mental factors like chinta, sokha, krodha, bhaya, etc vitiate Vata Dosha. Directionof sense organs is one of the functions of Manas and Vata is said to be the controller andconductor of mind. Therefore, by above factors Vata prakaopa occurs in the indreeyaayatanaand produce psychic as well as the somatic disorders; as there is a pivot role for mind inproducing the thyroid disorders also by unbalancing the production of thyroid hormones.4. Medovaha Sroto dhushti The increased Vata and Kapha Dosha in the neck will vitiate the medo Dhatu by itsprakopa karanas respectively. Causes of vitiation of Medovaha Srotas 38 i. Avyayama( lack of exercises) ii. Divaswapna (sleep during the day time) iii. Excessive intake of fatty foods iv. Excessive intake of wines. 14
  • According to modern science The deficiency of iodine content in the food is the main cause for goitre.Goitrogens 39 Goitrogens are foods, which suppress thyroid function. In normal, Goitrogens caninduce hypothyroidism and goiter. In hypos, Goitrogens can further depress thyroidalfunction and stimulate the growth of the thyroid (goiter). In hyperthyroid, Goitrogens may help suppress thyroidal function until normalthyroidal functioning can be restored. However, this may not be a good strategy. Goitrogenswork by interfering with the thyroidal uptake of iodine. While many hyper secretaries tolimit thyroid output by iodine restriction, this strategy can backfire. Iodine restriction willcause the thyroid to increase in size (goitre) in an effort to filter more blood to get moreiodine. When iodine is then re-introduced to the diet or accidentally ingested, the now largerthyroid gland has the capacity for greater thyroid hormone production. The iodine restriction is not a good long-term method for controlling thyroidhormone production. Therefore the consumption of Goitrogens is not a good strategy. It isbetter to increase copper metabolism by supplementation of copper and the assistingnutrients. Once copper is replenished and copper metabolism is working properly, the bodywill tolerate iodine without increasing thyroid hormone production The gotrogens can be divided into two varieties:- 1. Goitrogens in the form of food items 2. Goitrogens in the form of drugs 15
  • 1) Goitrogens in the form of food items 40 The vegetables of the Brassica family, sea-weeds, oats, calcium rich foods, etc, areGoitrogens in nature. Many Goitrogens are generally members of the brassica family. These include: Broccoli, Cauliflower, Brussell Sprouts, Cabbage, Mustard, Kale,Turnips, Rape seed (Canola Oil), Other goitrogens include - Soy, Pine nuts, Millet, Peanuts Brassica family vegetablesnot only inhibits thyroid production, but they also inhibit cancer growth. We know thatsulfur, copper, and iron, work closely together and that excessive sulfur can deplete copperand/or iron. The excessive kale consumption will cause anemia. Generally anemia is theresult of low iron and/or copper. Because copper and iron are so important for thyroid function, it is not advisable toeat plants of the brassica family. The primary pre-condition for the production of thyroiddisease is the onset of anaemia. Brassica vegetables, with their high sulphur content, may befoods, which induce anaemia and consequently thyroid disease.2) Goitrogens in the form of drugs:- 41 Thiocyanates, Anti thyroid drugs, lithium, iodides, p- amino salicylic acid, etc arealso Goitrogenic. Iodides in large quantities are also Goitrogenic as they inhibit the organicbinding of iodine to give rise to ‘iodide goitre’.Hereditary Factors The goitre may be seen in families as well. The inborn error in the metabolism isgenerally inherited as an autosomal recessive gene. There is enzyme deficiency in thethyroid gland. This may impair iodine accumulation, oxidation or coupling of iodotyrosine.This leads to formation of decreased level of thyroid hormones, which will increase TSH, 16
  • and simple goitre is formed. Hyperthyroidism is often seen in several members of the samefamily 42.Endemic Goitre 43 In certain places there is low iodine content in the water and food. So the inhabitantsdo not get minimum requirement of iodine. This leads to reduced levels of thyroid hormonesand hence the goiter. These areas are Himalayas, Alps, Mountain areas, etc. In low landareas around the lakes, the soil lacks iodide. Calcium is available plenty in chalks andlimestones are Goitrogenic and places where they are available there the goiters arecommon.Physiological Causes In certain cases when there are high metabolic demands diffuse hyperplastic goitermay be seen. Such conditions are puberty, pregnancy, etc. In these conditions there is moredemand of the thyroid hormones than normal and if the thyroid gland falls to rise to theoccasion, TSH will be secreted more and leads to goiter 44.Causes of Hypothyroidism 45-46 § Congenital developmental defect § Interference with thyroid hormone synthesis § Iodine deficiency § Primary idiopathic § Radioactive iodine, Surgery § Post radiation § Bio-synthetic defects § Drug induced (Lithium, iodides, p-aminosalicylic acid etc) § Chronic thyroiditis § Hashimotos thyroiditis 17
  • Causes of Hyperthyroidism 47-48 § Graves disease, 76%, which is idiopathic § Multinodular goiter § Thyroiditis § Iodide-induced § Autonomously functioning thyroid nodule § Ingestion of exogenous thyroid hormoneAnatomy 49-50 and physiology The thyroid is an endocrine gland, situated in the lower part of the front and sides ofneck. It regulates the B.M.R, stimulates somatic and psychic growth and plays an importantrole in calcium metabolism. The gland consists of right and left lobes that are joined to each other by the isthmus.A third pyramidal, lobe may project up wards from the isthmus (or from one of the lobes).Some times a fibrous or fibromuscular band (levator of the thyroid gland) descends from thebody of the hyoid bone to the isthmus or to the pyramidal lobe. Accessory thyroid gland issometimes found as small-detached masses of thyroid tissue in the vicinity of the lobes orabove the isthmus.Situation and extent The gland lies against vertebrae C-5, 6 and 7 and T1 clasping the upper part oftrachea. Each lobe extends from the middle of the thyroid cartilage to the fourth or fifthtracheal ring. The isthmus extends from the second to the third tracheal ring. 18
  • Dimensions and weight Each lobe measures about 5cm +1.2cm. On an average the gland weights about 25g.However it is larger in females than in males and further increases in size duringmenstruation and pregnancy.Capsules of thyroid The true capsule is the perepheral condensation of the connective tissue of the gland.The false capsule is derived from the pre tracheal layer of the deep cervical fasica a densecapillary plexuses is present deep to the true capsule. To avoid hemorrhage during operationthe thyroid is removed along with the true capsule.Arterial supply Superior thyroid arteries supply the thyroid gland, which is the first anterior branchof external carotid artery. Inferior thyroid artery is a branch of the thyro-cervical trunk,which arises from sub-clavian artery.Venous drainage Lymph from the upper part of the gland reaches the upper deep cervical lymph nodesthrough pre-laryngeal nodes. Lymph from lower part drains into lower deep cervical nodes.Nerve supply Nerves are derived mainly from the middle cervical ganglian and partly also from thesuperior and exterior cervical ganglia. There are vaso constrictorsStructure and function The thyroid gland is made up of two types of secretary cells. Follicular cells liningthe follicles of the gland secrete tri-iodothyronin and tetera iodothyronin (thyroxin) whichstimulate the B.M.R and somatic and psychic growth. Para follicular cells lie in between the 19
  • follicles they secrete thyro-calcitonin which promotes deposition of calcium salts in skeletaland other tissues and tends to produce hypo-calcium.Applied anatomy Any enlargement of the thyroid gland is called a goiter. Removal of the thyroid maybe needed in hyperthyroidism (thyrotoxicosis). Hypothyroidism causes cretinism in childrenand Myxodema in adults. Benign tumors of gland may displace and even compressneighbouring structure pressure symptoms and nerve involvement is common in carcinomaof the gland. Figure - 1 Location and anatomy of the Thyroid gland 20
  • Thyroid follicles and thyroid hormones 51 The thyroid gland contains large numbers of thyroid follicles. Individual follicles arespheres lined by a simple cuboidal epilhelium. The follicle cells surround a follicle cavity.This cavity holds a viscous colloid, a fluid containing large quantities of suspended protein.A network of capillaries surrounds each follicle delivering nutrients and regulatoryhormones to the glandular cells and accepting their secretary products and metabolic wastes. Follicular cells synthesis a globular protein called thyroglobulin and secretes into thecolloid of the thyroid follicles. Each thyroglobulin molecule contains the amino acidtyrosine, the building block of thyroid hormones. The formation of thyroid hormonesinvolves three basic steps. 1. Iodide ions are absorbed from the diet at the digestive tract and delivered to the thyroid gland by the circulation. Carrier proteins in the basal membrane of the follicle cells transport iodide ions (I-) into the cytoplasm. The follicle cells normally maintain intracellular concentration of iodide that is many times higher than those in extra cellular fluid. 2. The iodide ions diffuse to the apical surface of each follicle cells, where they converted into an activated form of iodide (I+) by an enzyme called thyroid peroxidase. This reaction sequence also attaches either one or two of these iodide ions to the tyrosine molecules of thyroglobulin. 3. Tyrosine molecules to which iodide ions have been attached are paired forming molecules of thyroid hormones that remain incorporated into thyroglobulin. The pairing process is probably performed by thyroid 21
  • peroxidase. The hormone thyroxin also known as tetraidothyroxine or simply T4, which contains four iodide ions. Eventually, each molecule of thyroglobulin contains four to eight molecules of T3, T4 hormones or both. The major factor controlling the rate of thyroid hormones release is the concentrationof TSH in circulating blood. TSH stimulates iodide transport into the follicle cells andstimulates the production of thyroglobulin and thyroid hormones. Under the influence ofTSH the following steps occur. 1. Follicle cells remove thyroglobulin from the follicles through endocytosis. 2. Lysosomal enzymes then break the protein down and the amino acids and thyroid hormones enter the cytoplasm. The amino acids are recycled and used to synthesise thyroglobulin. 3. The released molecules of T3 and T4 diffuse across the basement membrane and enter circulation. Thyroxine (T4) accounts for roughly 90% of all thyroid secretions, and tri-iodothyronine (T3) is secreted in comparatively small amounts. 4. Roughly 75% of the T4 and 70% of the T3 molecules entering the circulation become attached to transport proteins called thyroid – binding globulin (TBGs). Most of the rest of the T4 and T3 in the circulation is attached to transthyretin, also known as thyroid binding prealbumin (TBPA) or to albumin, one of the plasma proteins. 22
  • Figure –2 Functions of the thyroid folliclesControl of the thyroid secretion 52 There are three major ways of controlling the thyroid secretion anterior pituitary - 1. the hypothalamus 2. auto regulation besides, some other factors like 3. sympathetic stimulation 4. exposure to cold are also importantTSH of the anterior pituitary TSH is secreted by the specialized cells, called thyrotrophs of the anterior pituitary. 23
  • 1. T.S.H stimulates almost all the major steps of thyroxin biosynthesis as well as the release of thyroid hormones. Hence more T.S.H = more secretion of thyroid. 2. In addition, it causes increased vascularity and cellular growth of the thyroid gland. T.S.H is controlled by ‘ negative feed back ‘ mechanism exerted by T4 and T3. Thecirculating T4 is converted into T3 at the level of the anterior pituitary and thus both T4 andT3 are active. Therefore when circulating T4 is in high concentration, the pituitarythyrotrophs is inhibited so that T.S.H secretion is depressed resulting in correction of excessT4 in blood. Reverse occurs when T4 concentration of blood is low. Hence more T4 = lowT.S.H. T.S.H is the single most important regulator of the thyroid secretion.Hypothalamus From the Hypothalamus, TRH is secreted. TRH acts on pituitary thyrotrophs andstimulates them to secrete TSH. Hence more TRH = more TSH. Probably T4 and T3 do notoperate at the level of the hypothalamus for the negative feed back mechanism. Anotherhormone called somateostatin inhibits the TSH secretion. It is released from thehypothalamus (somateostatin also secreted by the islets of Langerhans and stomach).Auto regulation of thyroid If there is deficiency of food iodine, the iodine trapping mechanism of the follicularcells become super efficient. If there is excess of the food iodine, the iodine trappingmechanism is less efficient and organifaction of the extra amount of iodine does not occur.Mechanism of auto regulation may be as follows - Less iodine makes thyroid gland moresensitive to TSH and viseversa. 24
  • Figure – 3 Auto regulation of the thyroid hormoneMechanism of action of thyroid hormones 53 The thyroid hormones act somewhat like steroid hormones. The free T4 enters thetarget cells (all most all tissues are target cells of T4, specially not able are the neurons,heart, liver, skeletal muscles, adipose tissue, mammary gland) converted into T3 HR(hormonerecepter) complex is formed within the nucleus HR attachment with DNA occursmore m RNA production synthesis of more proteins are biological action. 25
  • Iodine and thyroid hormones 54 Iodine in the diet is absorbed at the digestive tract as I-. The follicle cells in thethyroid gland absorb 120 to 150 of I- each day, the minimum dietary amount needed tomaintain normal thyroid function. The iodide ions are actively transported into the thyroidfollicle cells, so the concentration of iodine inside thyroid follicle cells is generally above 30times higher than that in the plasma. If plasma iodine levels rise, so do levels inside thefollicle cells. The thyroid follicle contains most of the iodide reserve in the body. The activetransport mechanisms for iodide is stimulate by TSH and the increased movement of iodideinto the cytoplasm accelerates the formation of thyroid hormones. A typical diet in developed countries provides approximately 500 g of iodide perday, roughly three times the minimum daily requirements. Much of the excess is due to theaddition of iodine to the table salt sold in the grocery stores as iodized salt. Thus iodidedeficiency is seldom responsible for limiting the thyroid hormone production (this is not thecase in other developing countries). Excess iodine is filtered out of the blood at the kidneys,and each day the liver into the bile excretes a small amount of iodine. The losses in the bile,which continue even if the diet contains less than the minimum iodine requirements cangradually deplete the iodide reserves in the thyroid. Thyroid hormone production maydecline, regardless of the circulating levels of TSH. Thus various thyroid disorders manifestsgradually. 26
  • Effect of thyroid hormone on growth 55 Thyroid hormone has both general and specific effects on growth. For instance, it haslong been known that thyroid hormone is essential for the metamorphic changes of thetadpole into frog. In human, the effect of thyroid hormone on growth is manifest mainly in growingchildren. In those who are hypo thyroid, the rate of growth is greatly retarded. In those whoare hyper thyroid, excessive skeletal growth often occurs, causing the child to becomeconsiderably taller at an earlier age. However, the bones also mature more rapidly and theepiphyses close at an early age, so that the direction of growth and the eventual height of theadult may actually be shortened. An important effect of thyroid hormone is to promote growth and development ofbrain during fetal life and first few years of post natal life.Effect of thyroid hormones on specific bodily mechanism 561. Stimulation of carbohydrate metabolism - the thyroid hormone stimulates almost all aspects of carbohydrate metabolism, including rapid uptake of glucose by the cells enhanced glycosis, enhanced gluconeogenesis, increased rate of absorption from the gastro intestinal tract even increased insulin secretion etc.., all these effects probably result from the over all increase in cellular metabolic enzymes caused by thyroid hormone.2. Stimulation of fat metabolism - all aspects of fat metabolism is also enhanced under the influence of thyroid hormone. In particular lipids are mobilized rapidly from the fat tissue. Which decreases fat stores of the body to a greater extent. 27
  • 3. Effect on plasma and liver fats - increased thyroid hormone decreases the concentrationof cholesterol, phospolipids and triglycerides in the plasma, even though it increases the freefatty acids. Conversely, decreased thyroid secretion greatly increases the plasmaconcentrations of cholesterol, phospholipids and triglycerides and almost always causesexcessive deposition of fat in the liver as well.Increased requirement for vitamins As thyroid hormones increases the quantities of many bodily enzymes and becausevitamins are essential part of some of enzymes and co-enzymes thyroid hormones causesincreased need for vitamins. Therefore a relative vitamin deficiency can occur when excessthyroid hormone is secreted.Increased BMR As thyroid hormone increases metabolism in almost all cells of the body, excessivequantities of the hormone can occasionally increased the BMR to 60 to 100% above normal.Conversely when no thyroid hormone is produced the BMR falls almost to one – halfnormal.Effect on body weight Greatly increased thyroid hormones almost always decrease the body weight, andgreatly decreased hormone almost always increases the body weight.Effect of thyroid hormone on Cardio vascular system Increased metabolism in the tissues causes more rapid utilization of oxygen. Thiseffect causes vasodilatation in most of the body tissues, thus increasing blood flow. As aconsequence of the increased blood flow, cardiac output also increases, some times rising to 28
  • 60% or more, when excessive thyroid hormone is present and falling to only 50% of normalin very severe hypothyroidism.Increased gastro-intestinal motility Thyroid hormone increases both the rates of secretion of digestive juices and themotility of the gastro intestinal tract. Diarrhea often results in hyper thyroidism. Lack ofthyroid hormone can cause constipation.Excitatory effect on the central nervous system Thyroid hormones increases the rapidity of cerebration but also often dissociates,conversely, lack of thyroid hormone decreases this function. The hyper thyroid individual islikely to have extreme nervousness and many psycho neurotic tendencies, such as anxiety,extreme worry paranoia.Effect on the functions of the muscles Slight increase in thyroid hormone usually makes the muscles react with vigour, butwhen the quantity of hormone becomes excessive, the muscles become weakened because ofexcessive protein catabolism. Conversely, lock of thyroid hormone causes the muscle tobecome sluggish and they relax slowly after a contraction.Effect on sleep Because of the exhausting effect of thyroid hormone on the musculature and on theCNS the hyperthyroid subject often has a feeling of constant tiredness, but because of theexcitable effects of thyroid hormone on the synapses, it is difficult to sleep. Converselyextreme somnolence is characteristic of hypothyroidism, with sleep some times lasting 12 to14 hours a day. 29
  • Effect of thyroid hormone on sexual function In men lack of thyroid hormone is likely to cause loss of libido, impotence, excess ofhormone. In women the same causes menorrhogia and polymenorrhea, in other women itmay cause irregular periods and even amenorrhea.Poorvarupa Poorvarupa are the prodromal symptoms of the forthcoming disease, which do notclarify the Samprapti of the disease. These symptoms will be few and not clear 57. According to Madhava Nidana, Poorvarupa are the symptoms which are producedduring the process of sthana samsraya by vitiated Doshas, when Samprapti has not beencompleted and disease has not been manifested 58. But prodromal symptoms of Galaganda are not mentioned in any of the classicaltexts. From the recorded data of the patients we can say the purvarupa in general. Thevitiated Kapha, Vata, and medas will show some lakshnas such as mild swelling of the neck,pain the neck, heaviness of the body, hoarseness of voice etc.Lakshana of Galaganda in detail All the authors except Charaka have mentioned the types of Galaganda. It is of threetypes as Vataja Galaganda, Kaphaja Galaganda and Medoja Galaganda. The Lakshanamentioned by various Acharyas are enlisted in the table. Description of Vataja, Kaphaja, andMedoja Galaganda are as follows: -1) Vataja Galaganda 59 The lakshanas of Vataja Galaganda are toda (pain in the neck region), krishna sira avannadha (blackish veins in the neck), krishna aruna ganda (blackish or reddish mass), meda anvitham (coupled with medas), snigdata (unctuous to touch), 30
  • arucha (without pain), parushyata (roughness of the mass), chiravridhi ganda (mass manifests slowly), apaka (no paka),aruchi (tastelessness) and talu gala prashosha (dryness and weakness of throat and palate). Table - 1 Lakshana of Vataja Galaganda 60-61-62-63SN Lakshana Susruta Vagbhata Yoga Bhavaprakas Ratnakara ha1 Toda + + + +2 Krishnasiravanadha + - + +3 Krishna-aruna ganda + + + +4 Medan avita ganda + - - -5 Snigdhatara + - - -6 Aruja + - - -7 Parushyayukta + - + +8 Chiravrudhi ganda + - + +9 Apaka + - + -10 Yadrucha paka + _ + +11 Talugala prasosha + + + +12 Aasyavairasya + + + +13 Krishnarajiman + - -2) Kaphaja Galaganda 64 The lakshanas of Kaphaja Galaganda are sthira ganda (compact mass in the neck),savarnavat (same as body color), alpa ruk (little pain), ugra kandu (more itching), seetha(cold to touch), mahan ganda (large mass), chirabhivridhi (manifests slowly), paka (paka 31
  • present), madhuraasyata (sweetnes in the mouth), talu gala pralepa (coating in the palate andthroat) and kandu (itching). Table -2 Lakshana of Kaphaja Galaganda 65-66-67-68 SN Lakshana Susruta Vagbhata Yoga Bhavapraka Ratnakara sha 1 Sthira ganda + + + + 2 Savarnavat + + + + 3 Alparuk + - + + 4 Ugra kandu + + + + 5 Seetha sparsha + + + + 6 Mahan ganda + - + + 7 Chira abhivrudhi + - + + 8 Chira paka + - + + 9 Madhura asyata + + + + 10 Talu gala pralepa + + + + 11 Guru - - + +3) Medoja Galaganda 69 The lakshanas of Medoja Galaganda are snigda (unctuous to touch), mrudu (soft),panduvarna (yellowish), durganda (bad smell), avedana (no pain), pralambhate (hanging),dehanurupa kshaya, vridhi (when body grows, mass grows and vice versa), snigdaasyata(unctuous in the mouth), aspashtasabdavat (irregular voice), swasa (difficulty in breathing)and swara sada(hoarseness of voice). 32
  • Vagbhata had stated that apart from these Medoja Galaganda might present someLakshanas of Kaphaja gala ganda also 70. The lakshanas explained by various texts are summarized in the tables. Table -3 Lakshana of Medoja Galaganda 71-72-73-74 Sl.No Lakshana Susruta Vagbhata Yoga Bhavapraka Ratnakara sha 1 Snigdha + - + + 2 Mrudu + - - + 3 Pandura + - + + 4 Anishtagandha + - + + 5 Neeruk + - - - 6 Atikandu + - + + 7 Alabuvat pralambana + - + + 8 Dehanuroopa + + + + kshayavrudhiyukta 9 Snigdha asyata + - + + 10 Anusabdakara + - + + 11 Swasa - + - - 12 Svarasada - + - - 13 Guru - - + - 14 Alparuk - - + + 33
  • Clinical features according to contemporary science1) Hyperthyroidism 75 Hyperthyroidism or thyrotoxicosis refers to a state wherein there is an excess ofcirculating thyroid hormones, T3 or T4. Thyrotoxicosis is designated primary when thegland is diffusely enlarged and there are signs of hyper metabolic state, eye signs may ormay not be present. Thyrotoxicosis is designated secondary when the patient had previouslyabnormal gland, i.e. nodular goitre (single or multiple), and now assumes hyper functionalstatus.Clinical manifestation of Hyperthyroidism: 76 Clinical features could be broadly stated as follows:-• Evidence of Hyper kinesis• Objective evidence of hyper metabolic state(weight loss, catabolic state)• Presence of Goitre with or without Opthalmopathy The American Thyroid Association has classified the eye signs of Graves disease asfollows 77:- Class Definition 0 No signs and symptoms 1 Only signs, no symptoms (signs limited to upper lid retraction, stare, lid lag) 2 Soft tissue involvement (symptoms and signs) 3 Proptosis more than 20mm (measured by Hertel Exophthalmo meter) 4 Extra –ocular muscle involvement 5 Corneal involvement 34
  • Table –4 showing clinical features of Hyperthyroidism 78-79-80Symptoms SignsGeneralDemour of anxiety, generalized Restlessness, inability to keep still,weakness, heat intolerance2, weight loss, excessive sweating,skin tanning, apathy3, thirst, and hair thinning and straighteningfatigue2Cardiovascular systemPalpitation2, irregular beats, shortness Tachycardia, increased pulse pressure,of breath, angina, dyspnoea on ectopic beats, atrial fibrillation3, sick sinusexertion2, syndrome, cardiac failure3exacerbation of asthmaCentral nervous system Fine tremors, hyperreflexia, proximal muscleHyperactivity, nervousness, emotional weakness, periodic paralysis*, ill sustained clonuslability2Gastro-intestinal systemDiarrhoea (non-infective), weight lossdespite normal or increased appetite2, Rapid bowel transit time2, steatorrhea*anorexia3, vomitingReproductive systemOligomenorrhea or aminorrhea,impotence, spontaneous abortion, loss Gynacomastia*of libidoThyroidEnlargement in anterior part, neck Diffuse or nodular goitre, bruit1, thrillpressure symptomsDermatological systemIncreased sweating2, pigmentation, Vitiligo1, digital clubbing1, pretibial myxoedema1alopecia, pruritisOphthalmic SystemStare, gritty sensation1, increased Lid retraction, lid lag1, chemosis1,lacrimal secretion1, diplopoia1, infiltrative ophthalmopathy, oculardiminished visual activity1 muscle paresis, exposure keratitis * - Less frequent 1 – Features of Graves disease only 2 – Most common symptoms/signs of Hyperthyroidism irrespective of cause 3 - Features found particularly in elderly patients 35
  • 2) Hypothyroidism Clinical manifestation due to lack of thyroid hormone is designated as hypothyroidism. The presentation varies depending on 81: - a) the age of the patient, b) the cause of the disorder, primary or secondary, and c) Pre-existing health status. In utero, a lack of thyroid hormone results in irreversible brain damage to the foetus. In children, there can be a reduction in growth and an arrest of pubertal development. Clinical features of Hypothyroidism Table –5 Showing clinical features of Hypothyroidism 82-83-84 Symptoms Signs General features Tiredness, cold intolerance, somnolence Weight gain, goiter, peri-orbital puffiness, hoarseness; monotonous, coarse speech psychomotor retardation, hypothermia, Mucous membrane infiltration of laryngeal muscles Dermatological system Dry flaky skin and hair, hair loss, purplish Non-pitting oedema, carotenaemia, lips and malar flush erythema ab igne (Granny’s tartan), alopacia, vitiligo Cardiovascular system Shortness of breath, angina, congestive Bradicardia, ischeamic heart disease, cardiac failure* pericardial and pleural effusion, hypertension Central nervous system Muscle aches and pains, stiffness, Delayed retraction of tendon reflexes, * deafness, psychosis, slowing of motor myotonia , carpel tunnel syndrome, functions slowing of cerebartion Gastro intestinal system Constipation Ileus*, ascites* Reproductive system Irregular menstruation (usually High FSH/LH, hyper prolactinaemia, menorrhagia), infertility, galactorrhoea* impotence* 36
  • Heamatological Pallor, none- responsive anaemia, bleeding Dimorphic anemia, pernicious anemia, tendency, iron deficiency (pre- menopausal megaloblastic anemia, co-agulation defects women) * - Rare, but well-recognized featuresGalaganda Samprapti The etiological factors contributing to disease and the vitiation of Doshas attack thebody every now and then. Some factors can be avoided by taking precautions, but factorslike kala, deha etc are mostly inevitable. If the body’s resistance, Vyadhikshamatwa is highand dhatus, srotases and Agni are functioning well, the body fights against the etiologicalfactors. But if the etiological factors are stronger than the resistance power of the body, theyvitiate the Dosha and Dosha dooahya samoorchana takes place and the process of diseasestarts. The pathological changes taking place in the body day to day Nidana sevana till thecomplete manifestation of disease is termed as Samprapti. The knowledge of Samprapti is very much essential from the Chikitsa point of viewas it helps in understanding the pathogenesis of a disease. Susruta has mentioned the vitiation of Vata, Kapha, and Medo dhatu by theetiological factors of the same; will manifests in the neck region and make a ‘Ganda’(massin the neck).it exhibits the symptoms of three respectively 85. But while describing the commentary Dalhana and Gayadasa are of the opinion thatGalaganda is a swelling in the neck, ”Nibadha swayathu” 86. Charaka has mentioned Galaganda as a swelling in the neck by the vitiation ofKapha Dosha .He describes that, the Kapha Dosha vitiated by the etiological factors willmanifests in the frontal part of the neck and produce a swelling slowly 87. 37
  • Vagbhata mentions the Samprapti in another way. The Vata, Kapha, and Medas gotvitiated by the etiological factors will produce the Galaganda in the outside part of the neck.It hangs like a scrotum without pain if left untreated 88. Madhavakara mentions the Galaganda in the Samprapti as ‘Nibadha swayathu’.I.e., a swelling attached to the neck which hangs down like a scrotum, which may be large orsmall in size. The swelling is slowly produced by the Vata, Kapha, and Medas, which isvitiated by the etiological factors89.1. Sankhya Samprapti of Galaganda There are three varieties of Galaganda are mentioned in all the classics exceptCharaka. They are Vataja galaganda, Kaphaja galaganda, and Medoja galaganda.2. Vikalpa Samprapti of Galaganda In Galaganda the Doshas involved are Kapha and Vata. The aggravating factors ofthem are Seeta, Snigda, guru, manda etc3. Pradhanya Samprapti of Galaganda The Samprapti caused by a major of independent Dosha is called as pradhanyasamprapti, and that which is caused by a minor or dependant Dosha is called as apradhanaSamprapti. Also it can be understood as the Samprapti of swatantara vyadhi is called aspradhanya Samprapti.4. Bala Samprapti of Galaganda The strength of a disease is depending upon the Nidana, purvarupa, and rupa andmanifest disease in total. Here almost all patients had the symptoms manifested completely.So the bala is more. 38
  • 5. Kala samprapti It is the Samprapti which confirms the role of a particular Dosha in a disease, whichcan increase the same with the change in time- like the day, night, season, with stages ofdigestion etc. Here the main Dosha is Kapha and there is involvement of Vata in it. At the same timethere is the involvement of Agni; i.e. is the derangement of Agni bala is present. Soaccording to the condition it may vary. No specific time, season, and stages of digestion areprovoking this disease.Samprapti Ghatakas Dosha : Kapha, Vata Dushya : Medas, Rakta, Rasam Srotas : Medovaha, Raktavaha, Rasavaha Agni : Jataragni, Dhatwagni Ama : Jataragnimandya, dhatwagnimandya Rogamarga : Bahya Roga marga Udbhavastanam : Amashaya Vyaktasthanam : Gala pradasha 39
  • Figure -4 Schematic representation of the Galaganda SampraptiVata Medoprakopa prakopaKarana KaranaKaphaprakopaKarana Vitiates Kapha Vitiates Vata Vitiates Medas Vitiation of Sanchita Vata Medodhatwagni and Kapha Sanchita Medas Gala (Kanta) Stanasamshraya Manifestation of Lakshana corresponding to the Stana, Dosha and Vyadhi Galaganda 40
  • Sadhyasadyata The physician who knows the difference between curable and incurable diseases andbegins the treatment in time with a through knowledge of the case succeeds in his effortswithout fail. So the physician, who knows the avasthas of the disease, can plan the treatment 90and can reject the cases, which are incurable . The sadyasadyata of Galaganda ismentioned in Susruta Samhita and are enlisted here 91- 1. Kruchra Swasa - severe difficulty in breathing 2. Softness of the body parts 3. Aruchi – tastelessness 4. Ksheena gatrata – emaciated body and 5. Bhinna swara – broken voiceUpadrava (complications) Upadrava is produced after the formation of main disease and it is dependent on themain disease. Upadrava can be major or minor. It is a secondary disease or complication,produced by the same Dosha it responsible for the formation of main disease 92. Susruta alsoopines that upadrava is a super added disease for which the basic causes, i.e. the Dosharesponsible is the same as in the main disease 93. The upadravas of Shopham are swasa, daha, balakshaya, jwara, chardi, aruchi, hikka,atisaram, kasa.The upadravas of Galaganda are not mentioned in any Samhitas 94. As per the modern science concerned some complication are described. Thecomplications of the hypothyroidism and the hyperthyroidism are 95- 41
  • a) Thyroid crisis The hyperthyroid patients, the complications can be termed as hyperthyroid crisis. Themost prominent signs are fever, agitation, confusion, tachycardia or atrial fibrillation and inolder patients cardiac failure. It is a medical emergency and despite early recognition andtreatment, the mortality rate is 10%.The crisis is precipitated by the following 96:- a. Stress as resulting from acute infection, trauma or emotional upheaval b. Surgical handling of thyroid without prior achievement of Eumetabolic state c. Metabolic upset, uncontrolled diabetes, electrolyte imbalance or parturition d. Sudden interruption of anti thyroid drug treatmentb) Hypo thyroid complication 97i) Myxodema coma Patient with extreme degree of hypothermia, when subjected to stressful situation,can assume a grave clinical state which if not reverted with timely treatment may endfatally. Extreme cold weather, use of narcotics, phenothiazines or anasthetic agents,infections or situations that can cause hypertension, may be the precipitating events formyxodema coma. Cardinal features of myxedema coma are Hypothermia, Altered consciousness andHypo ventilation.Pathology of goitre according to contemporary medicine 98 Hypothalomo-pituatiry disorders can be responsible for inducing under active oroveractive thyroid states. The thyroid disorders can be divided into three: - 42
  • 1. Diseases of thyroid itself 2. hypothalamo – pituitary diseases 3. Thyroid hormone resistance syndrome Basically it can be divided into:- 1. Hyperthyroidism 2. Hypothyroidism In both of the (Hyper and Hypo) the goitre is present as the main clinical feature.Pathology of goitre 99 The thyroid gland is diffusely enlarged and smooth. It may be nodular. There arecertain stages through which this type of goitre gradually passes through. In the first stagedue to TSH stimulation the lobules are composed of active follicles. This is called” stage ofdiffuse hyperplasia “. When TSH stimulation ceases by ingestion of iodine the secondstages appears. This is the stage of involution forming large follicles filled with colloid. Ifthis condition continues i.e., in the third stage the gland enlarges to an enormous extent thatis known as colloid goitre. Sometime due to fluctuating TSH levels a mixed pattern developswith areas of active lobules and areas of inactive lobules.Pathology of Hyperthyroidism 100 In “graves disease” the thyroid is uniformly enlarged and the surface ischaracteristically smooth, though slight modularity may be detected. Microscopically thethyroid is hyperplastic and the epithelia which line the acni are high columnar instead offlattened cuboidal type which is found in normal thyroid gland. They’re only minimalamount of colloid in the acini and many of them are even empty and others containvacuolated colloid. The nuclei of the thyroid cells exhibit mitoses. Papillary projections of 43
  • the hyperplstic epithelium into the acini are common. Lastly there is vascularity andlymphoid tissue around the acini. The clinical manifestation of the hyperthyroidism include changes referable to thehyper-metabolic state, included by excess of thyroid hormones as well as those related toover activity the sympathetic nervous system. Excessive levels of thyroid hormones result in an increase in Basal Metabolic Rate.Cardiac manifestations are the earliest and most consistent feature. Those patients withHyperthyroidism can have an increased cardiac output owing to - a) increased cardiac contractivity b) Increased peripheral oxygen requirement. In older patients’ atrial fibrillation occur frequently, but the actual cause is notknown. Pathological changes often call attention to hyperthyroidism- lid lag, staring gazeand wide appearances of the eye are due to sympathetic over stimulation of levator palpebresuperioris. In the neuromuscular system- increased activity of sympathetic nervous systemproduces- Tremor, Hyper activity, Emotional disturbances, Anxiety, Muscle weakens, etc. The skin of the patient tends to be warm, moist and flushed because of increasedblood flow and peripheral vaso-dilatation to increase heat loss. Increased sweating is due tohigher levels of calorigens. In the G.I.T system increased gut motility are due to increased sympathetic activitycause Increased thyroid hormone in the skeletal system, which stimulate the bone resorption,makes ultimately Increased porosity and reduced volume of bone i.e. osteoporosis. 44
  • Pathogenesis of Graves disease 101 “Graves disease” is caused by an autoimmune reaction against the thyroid.Antibodies react with the receptor for the thyroid- stimulating hormone and other antigenson the surface of the thyrocytes. Some of the antibodies stimulate the thyrocytes, causinghyperplasia. Some block the action of the thyroid-stimulating hormone some do not affectthe function of the thyrocytes. The first stimulatory antibody the blood of patients with “Graves disease” is calledthe long acting thyroid stimulator because it causes a long continued release of iodinatedcompounds from the thyroid in the animals. It or similar stimulatory antibodies aredemonstrable in the plasma of almost all patients with “Graves disease” and are the principlecause of hyperplasia. Antibodies against thyroglobulin or against the microsomes the thyrocytes arevpresent in 95% of the patients, usually in higher titer than in the patients with a non-toxicgoitre or carcinoma of thyroid, though not in the higher titer usually in Hashimotosthyroiditis. Hashimotos disease is unduly frequent in the families of patients with Graves diseaseis incidence of “Graves disease” is increased in the families of patients with Hashimotosdisease. Relatives of patients with “Graves disease” often have in their blood the antibodiesof Hashimotos disease. Occasionally a patient with Hashimotos disease develops “Graves disease”, or apatient with Graves disease ends with Hashimotos disease. Genetic factors are important inthe pathogenis of “Graves disease” in some patients, abnormal immuno-globulins of Gravesdisease are present in the plasma of close relatives in 60% of the patients. The frequency of 45
  • the antigens HLA-DR3 and HLA-B8 is increased in caucascians with “Graves disease”.HLA-BW 36 is unduly common in Japanese, HLA- BW 46 in Chinese. Probably the autoimmune response in Graves disease is initiated by a mechanismsimilar that in Hashimotos disease. HLA- DR antigens are present on the thyrocytes in thepatients with Graves disease, as they are in Hashimotos disease. Some think they are carriedby a viral infection and initiate the auto immune reaction against the thyroid. Some thinkthat the primary fault is in the suppressor T- cells and that the expression of the HLE-DRantigens is caused by the autoimmune reaction. The pathogens of the opthalmopathy in“Graves disease” are unknown. It is not due to the excess of thyroid hormones and is notcaused by the thyroid stimulating hormone. The cause of dermoapthy found in “Gravesdisease” is unknown.Non toxic goitre Pathogenisis 102 Iodine deficiency is the most common cause of both endemic and sporadic forms ofnon-toxic goitre. In all regions in which nontoxic goitre is endemic, the diet is deficient iniodine. In some patients toxic agents called Goitrogens are important in the causation of thegoitre. In some, an enzyme deficiency causes the enlargement of thyroid. In some patientswith sporadic goitre, the cause of the disease is unknown. If the intake of iodine is low, itsconcentration the plasma and its excretion by the kidneys fall. The thyroid gland is unable totake up enough iodine to maintain normal function and becomes hyperplastic. Thehyperplasia may be caused by increased secretion of the thyroid stimulating hormonescaused by a fall in the concentration of thyroid hormones in the plasma, but more probablyiodine deficiency causes the thyroid to respond exclusively to a normal concentration of theTSH. 46
  • Goitrogens cause non-toxic goitre or enhance the effect of iodine deficiency. In someHimalayan villages, a Goitrogens in the drinking water causes an agent produced by Esch.Coli non-toxic goitre, most probably an agent produced by Esch. Coli. Cabbage and relatedvegetables contain Goitrogens related to thiourea. Thiocyanates, perchlorate, paraamino salicylic acud, and other drugs inhibit themetabolism of the thyroid gland and cause goitre if given fir a long period. Fluoride andother halogens displace iodine and contribute to the causation of non-toxic goitre. Evenexcess of iodine can cause non-toxic goitre. The enzyme deficiency sometimes cause non-toxic goitre in children. Minoranomalies of this sort may explain some sporadic goitre. Sometimes sporadic goitres are offamilial, suggesting the possibility of a genetic defect. Antibodies against thyroid antigensare often present in the patients with a non-toxic goitre.Pathogenesis of hypothyroidism 103 Hypothyroidism can be again divided into Cretinism, Myxedema, HashimotosThyroditis, Sub-acute lymphocytic Thyroditis.Cretinism Cretinin refers to Hypothyroidism developing in infancy or early childhood. Theseverity of the mental impairment in cretinism appears to be directly influenced by the thimeat which thyroid deficiency occurs in utero. Normally, the maternal hormones, including T3,T4 cross the placenta and are critical to fetal brain development. If there is maternalthyroidal thyroid deficiency before the development of fetal thyroid gland, mentalretardation is severe. 47
  • Pathogenisis of Hashimotos thyroiditis 104 The disease is caused primarily by a defect of T- cells. One model fir this disorderproposes that T-cells from patients with this disorder recognized processed thyroid antigensin association with specific types of major Hist Compatibility Complex (MHC) antigens.Diminished suppresser T-cells may also play a role in the emergence of thyroid specifichelper T-cells. These activated T- cells have two roles in the disease. a. They interact with B cells and stimulate the secretion of a variety of anti thyroid antibodies, which may activate antibody- dependent cyto-toxicity mechanisms. b. The helper T- cells may induce the formation of CD8+ cells, which can be cyto-toxic to thyroid cells. B-lymphocytes from thyroid tissue of patients with Hashimotos thyroditis are activated and secrete a number of auto- antibodies detected against thyroid antigens. i. Thyroglobulin and thyroid peroxidase ii. TSH receptor iii. Iodine transporter Many thyroid auto-antibodies can fix compliments. As a result, complement-dependant, antibody mediated cytotoxicity may contribute to destruction pf thyroid tissue inpatients with Hashimotos thyroiditis.Investigations 1051) Serum Thyroxine (T4 ) Thyroxine is transported in the plasma mainly in the bound form with ThyroxinBinding Globulin (TBG), and by Thyroxin Binding Pre- albumin. Only a small amount 48
  • circulates in the blood in the free form. Measurement is more difficult and can be measuredby competitive Protein binding or Radio immuno assay method. The normal range variesfrom 58 to 140 µmol/L.2) SerumT3 The estimation is very difficult and is only possible by radio immuno assay method.This test is more effective in the sense that some cases of hyperthyroidism are due toexcessive production of T3 without any association of Serum T4. The normal range variesfrom 1.22 to 2.22 µmol/L.3) Serum TSH It is also measured by immuno assay method. The normal level is 0.3 to 4.0 µu/L It israised in primary hypothyroidism and almost undetectable in hyperthyroidism. This test is ofmore help in the diagnosis of hypothyroidism rather than hyperthyroidism. It also of value tomeasure TSH level is following radio-iodine therapy and sub total thyroidectomy.4) Thyroids scan. Scanning with tracer dose determines the functioning and not functioning (Hot orCold) of either full or part of the thyroid gland. A solitary nodule is palpated. Scanning ishelpful in the following way -1. In case of suspected retro sternal goiter2. Ectopic thyroid tissue A single non-functioning thyroid nodule is an indication of surgery. The other testsare BMR, Serum cholesterol, ECG, etc. these are of little value in the diagnosis, but todetermine the complications, ECG etc can be used. 49
  • 5) Free thyroxine index This is calculated from the formula. The formula is as follows. FTI = serum T4 (or PBI) X T3 uptake % The normal range is from 3.5 to 8.0. it correlates with the level of free T4 in theserum and this accurately reflects the thyroid states of an individual. This can be consideredas best single test available at present.6) Radiography This is helpful to diagnose the position of the trachea, whether displaces or narrowedfrom the midline. Straight X-ray is also helpful to diagnose retro-sternal goiter.Differential diagnosis Galaganda has to be differentiated from various systemic diseases like Galagraha,Apachi, Kanthashaluka, Galavidradhi, Mamsatana etc. Table showing differentiatingfeatures of Galaganda. Table -6 Differential diagnosis of Galagraha and Apachi 106 Sl. Galaganda Galagraha Apachi 1 Nidana – Vata-Kapha- Nidana – Nidana – Medo- medo vrudhikara ahara- Kaphavrudhikara Kaphavrudhikara ahara-vihara vihara ahara-vihara 2 Dosha – Kapha & Vata Dosha – Kapha Dosha – Kapha 3 Dushya – Medas - Dushya – Meda 4 Sthana – Hanu, manya & Sthana – Kantha Sthana – Hanu, kaksha, gala gala akshaka, bahusandhi & manya 5 Sopha in the neck Sopha inside the Granthi kantha 6 Big or small swelling - Round shaped granthi 7 Nature of Sopha – - Amalakasthi or Mushkavat matsyandajalavat 8 Single swelling Single swelling More in number 50
  • Table showing differential features of Galaganda, Galavidradhi, Kanthashaluka andMamsatana. Table -7 Differential features of Galaganda, Galavidradhi, Kanthashaluka and Mamsatana 107 No Galaganda Galavidradhi Kanthashaluka Mamsatana 1 Kapha-vata- Sannipathaja Kaphajanya TriDosha ja medojanya 2 Mushkavat - Kolasthimatra Avalambi swayathu sopha sopha 3 Sopha in the Sarvagalavyapya - Pratanavan neck region sopha swayathu 4 Sopha Vidradhi Granthi Sopha 5 Alparuk Atiruk Neeruk NeerukGalaganda ChikitsaPrinciples of treatment:- The main principle of the treatment is the pacification of Kapha and Vata Dosha. Asper Susruta the sequence of the treatment is as follows 108-Vataja galagandaNadisweda,- Raktamoksha, -Vranashudhi – Lepanam Firstly the vataja Galaganda patient should be given swedanam with vatahara drugsthen the rakta mokshana should be done. The vrana shuddhi is carried out. Then lepanamwith shana, atasimoola, shigru, priyala,punnarnava, arka etcKaphaja galaganda Nadisweda, Upanaha sweda, Rakta bokshanam, then Lepanam. The proceduresVamanam, Shirovirechana, and Dhumapana are also usefull. 51
  • The Kaphaja Galaganda patients should be given Nadi and Upanaha swedam Aftergood sweating rakta mokshana is carried out. Then Lepanam with Kaphahara drugs,andPalashaksharam Pippalyadi gana thailam is to be taken internally with Saindava lavana. Theprocedures Vamana, Shirovirechana and Dhumapana etc should be carried out accordingly.If it becomes paka then treat like Vranam.Medoja Galaganda Shareera snigdada should be done firstly-Sira vedam of the Urumoolam– Lepanam. The Medoja Galaganda rogi should be given good Snehana of the shareera. Then theSiraveda in the Urumoola is done.after that Lepanam with Arka, Syama,Lohapureesha,Rasanchanam Danti etc should be pasted and applied. Salasaradi gana kwatha +Gomootramshould be taken internally daily. If the ganda is big in size, then surgery should be done. i.e.,Ganda should be incised and the dushta medas is cleared off and stiched.or Agni karma withheated Majja, Ghrita, Medas, Madhu etc, after samyak yoga madhu, ghrita should beapplied. Annabhedi, Thutham Gorochanam etc should applied.Shamana oushadhies 109-110-111-112 i. Kanchanara guggulu ii. Amrutadi thailam iii. Jalakumbhi bhasmam iv. Aparajita ghritam v. Tumbhi thailam vi. Tikta alabu thailam vii. Mandoora bhasmam viii. Asanadi choornam 52
  • ix. Ajagandhadi lepam x. Kshara thailm xi. Varanadi kashaym xii. Nimbadi thailam xiii. Bharngi moola kashayam xiv. Sakhoshtakadi thailamPathyapathyam 113-114 Always the Galaganda rogi should take Triphala and eat Yavannam.Pathya Ahara:- Mudgam, yavam, triphala, iodized salt, fruits rich in vitamins, iron etc, kodrava, shundi,nimba.Pathya Vihara Swedanam,Rakta mokshanam, Vamanam.Apathya Ahara:- Amlam, madhauram, gudam, dadhi, vasa, ksheera, ghritam, pishtham made of riceand other guru aharas etc,madhyam, anoopa mamsam. Goitrogens such as Cabbage, kale,turnips, Brussels, and vegetables of Brassica family.Apathya Vihara Divaswapnam, maidhunam, avaak sayyam, smoking. 53
  • Methodology Research is an unbiased investigation or inquiry in a systematic manner to establishnew inventions and facts, correcting or modifying the old one. The ultimate aim of anyresearch in the field of medical science is to find out suitable remedies for particular ailmentand to promote health. Research methodology involves the systemic procedures by whichthe researcher starts from the initial identification of problem to its final conclusion. The materials and methods of the present study consists of - 1. Selection of patients 2. Methods of examinations 3. Treatment schedule and administration of drug 4. Assessment of resultResearch approach Experimentation is the most powerful research approach. In the present study theobjective is to evaluate the efficacy of Amrutadi thailam in Galaganda. The efficacy can beanalyzed by finding out the difference between the baseline data and the assessment data.Study design The study design made for the present study is prospective clinical trial. The studywas done in one group. The trial drug was administered for 3 months.1) Selection of the patients 20 patients of Galaganda fulfilling the criteria of diagnosis were selected for thestudy from the OPD of PGS&RC, DGMAMC HospitalGadag. Three patients were excludedas they default at the treatment schedule. Ultimately 17 patients were included for the studybased on the inclusion and exclusion criteria in one group. 54
  • Inclusion criteria v Patients between 15 to 65 years of age group v Of any Doshanubandha v No discriminations of chronicity of severity of disease v All others other than that of exclusion criteriaExclusion criteria v Patients below 15 and above 65 years of the age v Patients with cancer thyroid v Complicated with other serious systemic diseases v Pregnant women and lactating motherCriteria of diagnosis The symptoms of Galaganda mentioned in Ayurveda will be the basis of diagnosisalong with altered T3, T4 and TSH levelsSample size The sample size for the present study consist of 20 patients in a single groupDuration of the study The study duration was 90 days treatment schedule and 30 days follow up periodwas designed.Data collection Patients selected are thoroughly examined with both subjective and objectiveparameters. Detailed general history and physical examination findings were noted.Laboratory investigations such T3, T4, TSH, Random Blood Sugar and hemoglobin % wereconducted. Routine investigations of blood were undertaken to exclude other pathologyunder veined. 55
  • 2) Methods of examination Thyroid disorders nowadays is common kind of metabolic multi systemic disorderpresent in all ages. A through physical and general examination is mandatory for the patientwith thyroid diseases. Before taking the history, a glance of the patient itself reveals some valuable findingssuch as in hyper thyroidism the facial expression of excitement, tension, nervousness oragitation with or without variable degree of exophthalens. In case hypothyroidism, one cansee puffy face without any expression (mask-like face) In this study the presenting complaints are as follows- 1. Ganda (mass in neck) 2. Toda (pain over the man) 3. Vivarnata (discoluration of skin over the mass) 4. Kanda (itching around the mass) 5. Difficulty in swallowing 6. Difficulty in breathing These complaints are assessed before and after the along with the serum T3 T4 andTSH levelGanda Ganda is the swelling present on the thyroid. In Ayurveda it is mentioned as a massin the neck, but in the contemporary science it is mentioned as a swelling of the thyroidgland. It can be detected by the inspection and palpation methods. As the swelling cannot bemeasured and it is difficult to grade according to the size in numerical values. So here themain tool to detect the swelling is by visualizing it and palpates to confirm the same 56
  • Inspection of the thyroid gland 115 It was carried out by the Pizzilto’s methods as mentioned. By this method thefollowing things were detected. 1. The swollen thyroid very clearly 2. While deglutition the thyroid swelling was seen moving up wardsPalpation of the thyroid gland116 It was carried out by lahey’s method and crile’s method as mentioned. By thismethod the thyroid swelling was clearly detected by palpation. The scores of assessment forganda are as follows. Ganda grading (mass in the neck) 1. No mass seen 2. Mild sized mass 3. Moderate sized mass 4. Large sized mass Toda Toda is mainly mentioned in the Ayurvedic classical test as a main symptom of Galaganda. But in the modern system of medicine, goitre is usually a painless condition, some inflammatory conditions of the thyroid are painful. So in the present study the toda also assessed before and after the treatment. It is assessed through the grading predetermined is as follows- Toda grading 1. No pain 2. Tells on inquiry 3. Tolerable pain 4. Severe pain 57
  • Vivarnata The discoloration of skin over the mass is mentioned by Ayurvedicscholars as a main symptom of Galaganda in their Samhita’s. So it is taken asone of the parameter for assessment. It is assessed according to the grading isas follows – 1. No discoloration 2. Mild discoloration 3. Moderate discoloration 4. Severe colour changeKandu The itching around the mass is mentioned in Ayurvedic classics as amain symptom of Galaganda. In contemporary science skin rashes indifferent parts is mentioned. So it is taken as a parameter for assessment. It isassessed according to the grading are as follows- 1. No itching 2. Mild itching 3. Moderate itching 4. Severe itchingDifficulty in swallowing It is mentioned as a main symptom in the contemporary science forgoitre in the Ayurvedic system also there is mentioning about the hoarsenessof voice. The grading of difficulty in swallowing is as follows - 1. No complaints 2. Difficulty to swallow solids 3. Difficulty to swallow liquids 58
  • Difficulty in breathing This symptom is mentioned in both the system of medicine as a main symptom for Galaganda. Difficulty in breathing is assessed by the grading is as follows - 1. No complaints 2. Mild 3. Moderate 4. SevereExamination of thyroid gland In this modern era there is a increase in the incidence of endocrine disorder due tothe deviation of man from following the swasthavritta. Out of them nowadays, the thyroiddisorder are common in every part of the globe. So it is necessary to study the history of thethyroid gland in detail. For that purpose, to confirm the disease and to reveal various clinicalmanifestations adhered to the thyroid gland, it is essential to examine the thyroid glandelaborately.Ι) HISTORY 1171) Age: Age of the patient is a very important consideration. Simple goitre is commonly seenin girls approaching puberty. It also appears in conditions of need, i.e., during pregnancy andpuberty. Both multi-noddular and solitary nodular goiters, as well as colloid goitre are foundin women of 20s and 30s. A word of caution is very much needed in this context. Carcinomaof thyroid is not necessarily a disease of old age. Papillary carcinoma is seen in young girlsand follicular carcinoma in middle age women. 59
  • 2) Sex Majorities of thyroid disorders are seen in females. All types of simple goitres are farmore common in female. Thyrotoxicosis is 8 times commoner in females than in males.Even thyroid carcinomas are often seen in females in the ratio of 3:1.3) Occupation Even though occupation has hardly any relation with thyroid disorders,Thyrotoxicosis may appear in individuals working under stress sand strain.4) Residence Except endemic goitre due to iodine deficiency, no other thyroid disorder has anypeculiar geographical disturbance. The Rocky Mountains, low land areas, areas producingchalks and limestone are the prone areas of goitre genesis.5) Swelling The neck is examined for evidence of thyroid enlargement. Significant thyroidenlargement is evident by palpation. The thyroid gland always moves on swallowing. Thepalpation is carried out from behind the patient with the fingers encircling the neck, askingthe patient to flex the neck slightly. The landmarks for palpation are the laryngealcartilage’s, just below the cricoid cartilage and the isthmus of thyroid. In case of thyroid swelling history about the onset, duration, rate of the growth andwhether associated with pain should be noted. Simple goitres grow very slowly or remain ofsame size for quite some time, multi-nudular or solitary nodular goitre increases in size.6) Pain The goitre is usually a painless condition. Inflamatory conditions of the thyroid arepainful. 60
  • 7) Pressure effects The enlarged thyroid may press the trachea to cause dyspnoea or may press theesophagus to causes dysphagia or press on the recurrent laryngeal nerve to cause hoarsenessof voice.8) Past history Inquiry must be made about the course of treatment the patient had and its effect onswelling. Also should inquire, whether the patient had taken any anti thyroid drugs, as someof them itself are Goitrogenic.9) Personal history Dietary habits is important as vegetables of brassica family such as cabbage, kale,brussels are Goitrogenic. Types of sea fish i.e., the sea-weeds are also Goitrogenic.10) Family history It is often seen that goitres occur in more than one member of the family, whileendemic goitres may affect more members in the same family. Enzyme deficiencies withinthe thyroid gland, which are concerned in the synthesis of thyroid hormones, are also seen torun in the families. Primary thyrotoxicosis and thyroid cancers has been seen in more than one memberof the same family. 61
  • II. Physical examination 118-119 Table – 8 General survey of the thyroid patients for Hyper or Hypo thyroidismHyperthyroidism Hypothyroidisma) thin built Obeseb) under weight Over weightc) more sweating Less sweatingd) wasting of muscles Not presente)facial expressions:- excitement, Puffy face without any expression(mask likenervousness, tension, with or without face)exophthalmosf) Hyper thyroid patients are active but will Naturally dull with low intelligencebe tired due to various reasons ( more in cretins)g) pulse rate rapid and irregular, sleeping Pulse rate slowpulse rateh) moist and warm skin usually Skin is dry and inelasticI) less sleep More sleepIII.Local examination 1201. Inspection of the thyroid gland It was carried out by the pizzillo’s method, in which hands are placed behind thehead and the patient is asked to push the head backwards against the clasped hands on theocciput. Normal thyroid gland is not obvious on inspection. It can be seen only when thethyroid gland is swollen. The thyroid swelling may be uniform involving the whole of the thyroid gland orisolated nodules of different sizes may be seen in the thyroid region. The next important physical sign to watch is while deglutition a thyroid swelling willmove upwards. This is due to the fact that thyroid gland is fixed to the larynx. So to confirmthe thyroid swelling inspection has carried out while examination. 62
  • 2. Palpation of the thyroid gland The patient is asked to sit in a chair and asked to flex the neck slightly. The clinicianshould stand behind the patient. The thumbs of the both hands are placed behind the neckand the other four fingers of each hand are placed on each lobe and the isthmus. Carefulassessment of the margin of the thyroid gland is important particularly the lower margin. Palpation of each lobe is best carried out by Lahey’s method. In this the examinerstands in front of the patient. To palpate the left lobe properly, the thyroid gland is pushed tothe left from the right side by the left hand of examiner. This makes the left lobe prominent.So the examiner can easily palpate the lump thoroughly with his right hand. During palpation the patient should be asked to swallow in order to settle thediagnosis of the thyroid swelling. Slight enlargement of the thyroid can be detected simplyby placing the thumb on the thyroid gland while the patient swallows. (Crile’s method) During palpation the following points should be noted. 1. Whether the whole thyroid gland is enlarged. If so note its surface: – Smooth surface –primary thyrotoxicosis, colloid goiter, multinodular goiter Firm – primary thyrotoxicosis, hashimoto’s disease Softer – colloid goitre Hard – thyroditis 2. When a swelling is localized, note its Position Size Extent Consistency 63
  • 3. The mobility should be noted in both horizontal and vertical places. Fixity means malignant tumour or chronic thyroditis. 4. To palpate and feel below the thyroid gland is an important test to discard the possibility of retrosternal extension. 5. Pressure effects from the thyroid swelling should be carefully looked for:- Pressure on larynx or trachea – leads to dyspnoea Pressure on oesophagus – leads to dysphagia Pressure on recurrent laryngeal nerve – leads to hoarseness of voice 6. Whether there is any toxic manifestations or not Primary toxic thyroid generally not enlarged. Enlarged thyroid are nodular thyroid with toxic manifestation is a case of secondary thyrotoxicosis. 7. Whether myxoedema present or not 8. Whether swelling malignant or not 9. Whether any pulsation or thrill in the thyroid 10. Palpation of cervical lymph nodes to exclude any malignancy.2. Percussion: This is done over the manubrium sterni to exclude the presence of aretrosternal goiter.3. Auscultation: In primary toxic goitre – systolic bruits may be heard over the goitre due tovascularity. Measurement of the circumference of the neck at the most prominent part of theswelling may be taken at intervals. This will determine whether the swelling is increasing or 64
  • decreasing in size. Then all the system also should be examined, as it affects almost allsystems. It was carried out while examining the patient.Investigations These serum T3, T4 and TSH tests were investigated to determine which type ofthyroid disorders. These three tests are taken for assessment also it is assessed before andafter the treatment. RBS is done to rule out the diabetes and hemoglobin % to rule out theanemia and ECG is to rule out cardiac emergencies in the process of excluding the patientfrom treatment.Treatment schedule Amrutadi thailam capsule of 250mg is the trial drug given internally and Amrutadithailam is administered for Pratimarsha Nasya.Internally Treatment schedule is planned for 3 months with a periodic interval of 1 month.Each patient is administered 2 capsule twice daily i.e. 2 in the morning at empty stomachand the rest of 2 capsules at evening 5 PM. Dose – 250mg capsule twice daily Anupana – warm waterExternally Pratimarsha Nasya is under taken. Dose - 1-2 drops in each nostrils in the morningPathya – Apathya Advised to take iodized salt and warm water after the intake of capsules. TheGoitrogens such as cabbage, cauliflower, teekshna, Guru and spicy foods are advised toavoid during and after the treatment. 65
  • Drug review This study is a prospective clinical study of Amrutadi thailam in Galaganda. Here adetailed and separate description of the individual drug is going to mention.Trail drug The trial drug is Amrutadi thailam. It is a combination of nine drugs, which ismentioned in Yogaratnakara in the chapter GalagandadhikaraCriteria for selection of drug 1. The composition of this drug is purely herbal 2. There is no proved toxicity or drug incompatibility 3. It is easily available in the local market 4. There is no controversial single drug used in this combination 5. Easy to manufacture and to make the capsule. 6. The drug is in the form of taila, which is (11 times avarthita) which gives more effects. 7. It can be used as an internal medicine and externally as Nasya also 8. This is a unique attempt and no clinical study conducted with this composition.Detailed description of each component of Amrutadi thailam1.GUDUCHI:-121-122Botanical name – Tinospora cordifoliaFamily – MenispermaceaeSynonym – Amruta, Chinnaruha, MadhuparniGanas – vayasthapana, daha prashamana, guduchyadi patoladi, aragwadhadi, kakolyadi,stanyasodhaka 66
  • Description:- It is a long lasting creeper climbing over the trees like mango, Neem, etc., the stem iscovered by transparent layer and can be pealed off. It has many tentacles hanging down.Leaves heart shaped, individualized, pointed at the tip and slimy. Flowers – small yellowflowers appearing in clusters. Fruit – bean shaped, appearing red on ripening and flourish incold and moderate climate. It is seen all over India.Parts used - bark (kandam)Properties- Rasa – Tikta Kashaya Guna – guru, Snigdha Veerya – Ushna Vipaka – Madhura Doshakarma – Tridosha samakam Prabhava – vishagnaChemical composition:- It consists of berberine, a bitter substance and Giloin – a glucoside that is also bitterin taste.Therapeutic uses – Deepana, Pachana, Anulomana, Krimighna, Trishna Nigrahana, Chardinigrahana. Used for Tridosha shamana, controls emesis and thirst, antacid, kushta, jwara,vataraktam, prameha, Agnimandya, kamala, yakritvikara, raktavikara, and skin diseases.Vishista yogam – Guduchyadi choornam, Guduchayadi kwatha, Amrudharistha, Guduchayadi satvaDosage – decoction – 60 to 100ml, Powder – 1 to 3 grams, Satva – ¾ to 2 grams 67
  • 2.HINGU:- 123-124Botanical name – Ferula foetidaFamily – UmbellifereaeSynonym – sahasraveda, jatuk, balhik, ramadaGanas – samngasthapana, deepaniya, katukaskanda, pippalyadi, ushakadi.Description:-A small perinneal shrub, 2-3 meters height. Leaves delicate, ciliated with 2-4wings, stalk bears a single leaf with broken margin at the tip. Fruit – 1cmx1cm, the latexcalled Hing.Varieties: – White and black, white variety oozes latex which is scented, like diamond andcrystal clear. This is called hirahing and used in medicine. Black variety foul smells. Manyvarieties are available in market, which are attributed to habitat, tree and mode ofpreservation.Habitat:-Iran, turkey, afghanistan, punjab and peshawarParts used –latexProperties- Rasa – Katu Guna – Laghu, Snigdha, teekshana, sara Veerya – Ushna Vipaka – Katu Dosha karma – Vata Kapha haraChemical composition – 6 to17% of volatile oil. This contains rason oil and allyl persulphide, which emits aspecial smell, 65% resin, wax etc. 68
  • Therapeutic uses: deepana, pachana, vedana sthapana, samnja sthapana, kandughna, balya,chedana, krimighna. Used for Kapha Vata shamana, shoola prasamana, sopha prasamana,vedanasthapana, pakshagata, ardita, gridrash, gulma, Agnimandya, hridruga, Swasa,mutrakatha.Vishishta yogam – Hingwashakchurnam, Hingwadivati, RajapravartinivatiDosage: – 0.25 to 0.5g3.NIMBA:-125-126Bonanical name – Azadirachta indicaFamily – MeliaceaeSynonyms – pichumarda, hinguniryas, arishtaGanas: – kandughna, tiktaskanta, argwadadhi guduchyadi, lakshadiDescription – A tree measuring 8-10 meters in height. Trunk straight with branches in alldirections, bark is thick, black, rough from which secretion (latex) is obtained. Leavescompound, equidistant eye shaped, 6-14 paired foliated bilateral on the stalk. Flowers –small white scented. Fruit – green and hard on ripening it turns yellow and soft. Fruitscontain sweet slightly pungent and sticky pulp and a single seed. Oil is extracted from theseed.Habitat – it is seen all over IndiaParts used – flowers, leaves, bark, seed and oil 69
  • Properties:- Rasa – Tikta Kashaya Guna – Laghu Veerya – Sheeta Vipaka – katu Doshakarma – Kapha Pitta shamakaChemical composition External skin astringent but internal is pungent. Bark contains a bitter resin calledmargosin. It also contains volatile oil, gum, white secretion, glucose seeds contains 40%stable oil and traces of sulfur. The other chemical constituents are nimbin, nimbinin,nimbidin, nimbosterol, tanin, potassium, calcium etc.,Therapeutic uses:– kushthagna, grahi, krimigna, yakrituttejaka shoshanam, rakta shodaka, dahaprashamana, pachana chakshushya. Used in Kapha Pitta vikaras, vidradhi, granthi, aruchi, rakta vikaras, kasa, kushta,netra roga, pramaha.Vishista yoga: – Nimbadichurna, Nimbaristha, Nimbaharedra khandaDosage: – Powder 1-2 g, Leaf juice – 12 to 14cc and Oil – 4-10 drops4.ABHAYA:-127-128Botanical name-Terminalia chebulaFamily-CombrataceaeSynonyms -pathya,rohini,shreyasi,pachani,shivaGanas:- triphala, amalakyadi, parushakadi, prajasthapana, kusthaghna, kasaghna, assoghna. 70
  • Description:- A big tree, 25-30 meters height. Its wood is hard and bulky. Leaves are 10-30cms inlength and are pointed. The vasculature of the leaves has 6-8 pairs of veins. The inferioraspects of the leaves show two small nodules near its attachment with the stalk. The flowers have short stalks, white or yellow in colour and have a strong smell.Fruits are 3-6 cms in length. Initially it will be green but on rippening, they becomeyellowish brown. Each fruit contains one seed. Seeds are oval and hard. On breaking theshell of the seed, an oval shaped pulped is obtained.Habitat Haritaki found almost every where in India this tree grows at places up to a height ofabout 2000 mts from sea level.Parts used – fruitsProperties Rasa – Madhura, Amla, Katu, Tikta, Kashaya Guna - Laghu, rooksha Veerya – Ushna Vipaka – Madhura Prabhava – Tridosha hara Dosha karma – Tridosha shamanaChemical composition In the fruits, tanin is present (25-30%). It also contains chebulagic acid, chebulinicacid, corilagin. Traces of phosphorus, glucose, amino acids etc are present. 71
  • Therapeutic uses: tridhosha shamana sophahara, vedana sthapana, vrna sothana, balya,medya, deepana, pachana, yakruduttyaka, mrudu rechana, shouitasthapana, kusthaghna,Rasayana, srotoshodska.Vishista yoga: abhayaristham, pathyadi kwath, agastya rasayanam, vyaqkhri hareetaki.Dose – 3 to 6 gms for shodanam, 1 gm Rasayana.5) VRUKSHAKA 129-130Botanical name – Holarrhena anti dysentricaFamily – ApocynaceaeSynonyms – kutoja, kalinga, vatsaka, yavaphala, girrimallika.Description The tree is 7-9 Mts tall. The bark is pale or brownish colour. The inner wood is paleand soft, leaves 10-3- cms long and 3-5 cms wide. They appear similar to that kadamba-always green and shiny. They are 10-16 in pairs with prominent veins on them. Flowers –white, fragment similar to jasmine flowers, 2.5- 3.75 cms in length fruits – two pods arise onthe same stalk. They are long and hard, 20-40 cms in length and thin.Habitat - through out India but mainly in the jungles of saharanpar.Parts used – stem, bark, seeds.Properties:- Rasa - Tikta, Kashaya Guna- rooksha, Laghu Veerya- Sheeta Vipaka- Katu Doshakara- kaphapitta shamaka 72
  • Chemical composition:- The bark and seeds contain kurhicine and karchine. The others chemical constituentare concession, tanin, volatile oil seeds.Therapeutic uses:- vruna ropana, vamaka, deepana, sthambhana, arshoghna, krimighna, rakta shodaka,lekhana. Used in Kapha Pitta vikaras, jwara, Atisara, Agnimandya, Pravahika, arsas, kasha,Vata rakta, lekhana in atisthoola.Visihista yogan – Kutajaristha kutajaualehaDose – 20-30gms for kwatha3-6gms for choornam.6) PIPPALI 131-132Botanical name – Piper longumFamily – PiperaceaeSynonyms –magadhi, krishna, vaidhi, kana,ushna,chapalaGana – kasa hara, shiroveerechana, vamana, deepanihya, pipalyadi, urdhuabhagahara,Description :- It is a creeper, which spreads on the ground, or climbs up near by trees for supportleaves 5-6 cms long, resemble betel leaf and has veins. They are bitter to taste. Flowers-unisexual fruits long, reddish on ripering and turn black when dried. It flowers during rainyseason and gives fruits during autumn.Habitat – piper logum is grown in almost all over India 73
  • Parts used – fruitProperties – Rasa – Katu Guna – Laghu, Snigdha, tekshna Veerya – Anushna Sheeta Vepaka – Madhura Dosha Karma – Kapha Vata haramChemical composition- Resin, volatile oil, starch, gum, fatty oil, inorganic matter and resin – piperine 1-2%,the other alkaloids present are pipartine, sesamin piplasterol.Therapeutic uses – shiro virechana, rakta uhcleshaka medya, deepana, vatanulomana, yakridutteyakam,raktashodaka, mootrala, kusthaghna, Rasayana. It is used in Kapha Vata vikaras sophamVata Vyadhi, yakritvikara, and agnemandya pandu, rakta vikara, kasa, Swasa, kwatha.Vishishta yoga – Pipalyasana Pippalikhanda guda pippalliDose – 5-10 gm choornam 133-1347) BALABotanical name – Sida cordifoliaFamily – MalvaceaeSynonyms – bhadra, kharayasthika, vattika 74
  • Description A small shrub of height 5 to 10 cm. Root and trunk are strong hence it is called asbala. Leaves alternate 2.5 to 5 cm long 5cm broad ciliate, round having 7-9 veins on it andserrated margin. Flowers – like moonga, divided into 5 parts. Seeds small dusty block andlook like bees. The seeds are called as beeja banda. The plant bears flowers and fruits at theend of rainy season.Habitat – all over India srilankaParts used – root, seeds and leavesProperties – Rasa – Madhura Guna – guru, Snigdha, pichila Veerya – Sheeta Vipaka – Madhura Dosha karma – Vata, Pitta haraChemical composition – Major components of seeds are alkaloids. Alkaloids contain mainly ephedrine it alsocontains fatty acid, mucin, pottassium nitrate and resin.Therapeutic use – sophagnam, balya, grahi, rakta shodhaka, mootrala, brhmana, ojovardhaka. Used inVata pittavikaras. Vrnasopha, netra roga, ardita, pakshagata, Grahani, mootra krudra,dourbalya, kshayaroga, krushataVishistha yoga – balaristha, baladyaghrutaDose – swarasa – 10-20mlChoorna – 3-6gm 75
  • 8) ATIBALA 135-136Botanical name – abutilon indicumFamily – malvaceaeSynonyms – kwaketika, rushyh proktaDescription Shrub of height 1.25 to 2metres. Leaves – serrated, soft, and ciliate. Flowers –yellow the tube of androecium is elongated and gynaecium are 15 or more in number. Fruit– round but surrounded by spikes on all sides. Seeds 15-20 in number, dusty block andcalled as beeja banda.Habitat – all over India and srilanka Rest of the qualities and uses are same as that bala.9) DEVDARU137-138Botanical name – Cedrus deodaraFamily – PinaceaeSynonym – suradaru, bhadradaru, suravhaDescription Big tree of height 8.5 meters. Stem – big, having circumference of 12 meters bark –thick and crocked. Leaves – are green elongated with tapering ends. Flowers – green yellowand appear in clusters. Fruit – ripe fruit is black having seeded 1cm long. The tree bears newfruits in October, which ripe within a year. Deodar tree has a long life span of 600 yearsHabitat – at the height of 2000 to 3000 meters in HimalayasParts used – inner substance of wood and oil (kanda sara) 76
  • Properties – Rasa – Tikta, Katu Guna – Laghu, Snigdha Veerya – Ushna Vipaka – Katu Doshakaram – Kapha Vata haramChemical composition It contains dark coloured oil and resin. The oil contains a chemical constituent calledsesquiterpene.Therapeutic uses – sophaharam, vedanasthapanam, kusthaghna, krimighna, swedajananam.Used in Kapha Vata vikaras sopha vedana yukta rogas skin diseases, sandhivata, grudhrasirakta shodakam, medoroga.Vishista yoga – devadaruadi kwath, devadarvadichoornaDose – choornam 3-6gmTaila – 20-40mlPreparation of Amrutadi thailam 139 Amrutadi thailam is mentioned in yogaratnakara in galaganda prakaranam. Thepreparation of medicine is according to the sneha vidhi of sarngadara. All the ingredients arewell identified and collected and cleaned well. Then on an auspicious day all drugs arechopped and taken as 6 parts to that 96 parts water is added. Which is then kept on mruduAgni and boiled. It is then reduced to ¼ parts. This 24-part kashaya is mixed with 1/6 partkalka and 6-part tila thailam and prepared on mrudu Agni. It is taken out from the fire, whenthe paka is mrudu consistency and filtered. 77
  • The next day again to this 1/6 part kalka, 6-part-tila thailam and 24-part kashaya isadded, boiled and filtered mrudu paka attains. This process is done for 11times. After the manufacturing of the avartha thailam, it is transferred to a clean bottle andthen capsulated to the size of 250mg. The oil for the Pratimarsha Nasya is also bottled on thesame day. Good manufacturing principle is followed through out the whole process.Hypothesis of Avarthita taila 140 In general the entire procedure of sneha paka involves three components viz. Oil,decoction and paste of herbs. The basic aim of the procedure is being to acquire the liquidsoluble essence in to the oil. While preparing the decoction most of the volatile oil getevaporated and water-soluble active principles come in to the final product. The decoction inters acts with the oil and emulsion like stage is reached when thecomplex alkaloids get entangled with the glycoside Easters of the fatty acids. The pastecomes directly into contact with the oil as it is prevented from burning by continues stirringand the entire process being operated over mild heat, it is possible to get fat solublecomponents of herbs and even some volatile oils mixed into oil. The essential componentscoming into contact of per unit oil is more and the oil thus formed is more concentrated incase of reprocessing.Assessment of response to treatment In this study Ayurvedic and modern approaches were utilized through out the study.The chief symptoms were recorded and assessed according to their grading before and afterthe treatment. The investigation serum T3 T4 and TSH were done before and aftertreatment. Then its progress is noticed and recorded. All the parameters were reviewedstatically also. 78
  • Over all assessment Over all assessment is made with the subjective parameters enumerated in the studyand their respective percentages of the disease regression is estimated. There by thecumulative effect is valued and percentages of disease regression with symptom regressionare noted. In further the drug progressive effect over the objective parameters are estimated.The result is declared as the subjective parameters show significant results in all the subjectswith the variations found in the objective parameters. The T3, T4 or TSH in hyper, Hypo orEuthyroidisms, does not show the significant differences in the study, the values towards thenormal deviations are considered to that of responded and the small value deviations areemphasized as maintained. The others those who were not significant were put under theNot responded. 79
  • Results 20 patients were registered for the present study. Out this, 3 patients werediscontinued, hence their data has not been included here. The remaining 17 patients ofGalaganda, fulfilling the criteria for diagnosis, were treated. All the patients were examined before and after the treatment, according to the casesheet format given in the annex. Both the subjective and objective criteria were recorded.The data recorded are presented under the following headings.A. Demographic dataB. Data related to the disease.C. Data related to the overall response to the treatmentD. Statistical analysis of the clinical and functional parameters and inter group comparison.A) Demographic data: The details of age sex, religion, and occupation etc. of the 17 patients is as follows.A1) DISTRIBUTION OF PATIENTS BY AGE Table-9 Discontinued Maintained Responded Responded Total no of patients Age Not % % % % % 15-25 20 2 50 1 25 0 0 1 25 4 25-35 10 1 50 0 0 1 50 0 0 2 35-45 30 2 33.3 3 50 1 16.6 0 0 6 45-55 25 1 20 2 40 1 20 1 20 5 55-65 15 0 0 2 66.6 0 0 1 33.3 3 Total 20 100 6 30 8 40 3 15 3 15 80
  • Age distributions:Observation: As we observe in the study, the age factors are discussed under the class intervals of10 each from 15 to that of 65 years of ages. The patients observed from the observations areof 17. The distributions are observed as maximum from that of the middle age groups suchas 35- 45. But still the age interval of 45-55 show remarkably increased number, i.e. 5patients. The distributions as observed at the intervals of are 15-25 as 4 patients, 25-35 as 2patients, 35-45 as 6 patients, 45-55 as 5 patients and 55-65 as 3 patients. Graph – 1 Showing Patients by age distribution 55-65 15-25 15% 20% 45-55 35-45 25-35 25% 30% 10% 81
  • The individual results based upon the age distributions along with percentages are asfollows. It is observed as – in the 15-25-age interval show the significant results and out of 4patients, 2 (50%) patients responded, 1 (25%) patient maintained and 1 (25%) patientdiscontinued. In 25-35 age group, 2 patients reported and 1 (50%) responded and the otherpatient (50%) is not responded. In 35-45 interval, 6 patients reported and out of them 2(33.3%) patients responded, 3 (50%) maintained and 1 (16.6%) patient is not responded. In45-55-age interval, 5 patients reported, out 1 (20%) patient responded and 2 (40%) patientsmaintained and 1 (20%) patient not responded and 1 (20%) falls under discontinuedcategories. The subsequent interval of 55-65 years of the age group, out of reported 3patients, 2 (66.6%) maintained and 1 (33.3%) patient discontinued from the treatment, i.e.Amrutadi Yoga taila capsules as internal medication in association with the Amrutadi yogataila Pratimarsha Nasya.A2) DISTRIBUTION OF PATIENTS BY SEX Table-10 Sex Discontinued Maintained Responded Responded Total no of patients Not % % % % % Female 18 90 5 27.7 8 44.4 2 11.1 3 16.6 Male 2 10 1 50 0 0 1 50 0 0 Total 20 100 6 30 8 40 3 15 3 15Observation: The male female ratio is observed as 1:9. The percentage of the distribution doesshow the gender differentiation to get this metabolic disease. The observations are 2 Patientsi.e. (10%) were male and 18 patients i.e. (90%) were female. 82
  • Result: In which, out of reported Males 1 (50%) patient responded and another (50%) patientis not responded. Out of the females reported (18 patients) 5 (27.8%) are responded and 8(49.4%) maintained, 2 (11.1%) patients are not responded and 3 (16.6%) patients arediscontinued. Graph –2 Showing Patients by gender distribution Male 10% Female 90% 83
  • A3) DISTRIBUTION OF PATIENTS BY RELIGION Table- 11 Religion Discontinued Maintained Responded Responded Total no of patients Not % % % % % Hindu 80 5 31.25 8 50 1 6.25 2 12.5 16 Muslim 20 1 25 0 0 2 50 1 25 4 Christian 0 0 0 0 0 0 0 0 0 0 Others 0 0 0 0 0 0 0 0 0 0 Total 100 6 30 8 40 3 15 3 15 20Distribution by religion:Observation: For the convenience of the study, the religion communities are grouped as 1) Hindu,2) Muslim, 3) Christian and 4) Others. Out of the 20 patients reported 16 patients belong toHindu and only 4 patients are of Muslim community. No other community patients werereported, as this locality is a Hindu dominated area.Result: Out of the 16 patients of Hindus, 5 (31.2%) patients responded, 8 (50%) patientsmaintained, 1 (6.25%) patient not responded and 2 (12.5%) patients discontinued. Out ofreported 4 Muslims 1 (25%) patient responded, 2 (50%) not responded and one (25%)patient discontinued. 84
  • Graph – 3 Showing Patients by religion distribution Muslim Others Christian 20% 0% 0% Hindu 80%A4) DISTRIBUTION OF PATIENTS BY OCCUPATION Table- 12Occupation Discontinued Maintained Responded Responded Total no of patients Not % % % % % Sedentary 75 3 20 8 40 2 13.3 2 0 15 Active 15 2 66.6 0 0 1 33.3 0 0 3 Labour 0 0 0 0 0 0 0 0 0 0 Others 10 1 50 0 0 0 0 1 50 2 Total 100 6 30 8 40 3 15 3 15 20 85
  • Observation: For the convenience of the study common occupational listing are grouped. They arebased on the work mode as, sedentary, active, labor and others. Out of the 20 patients, 15(75%) patients are of sedentary and 3 (15%) are active. No patients reported from labor classand 2 (10%) patients reported as other category.Result: Out of 15 patients of sedentary, 3 (20%) responded, 8 (40%) patients maintained and2 (13.3%) patients are not responded. 2 (13.3%) patients of sedentary group havediscontinued the treatment. Out of active class, 2 (66.6%) patients responded and 1 (33.3%)patient is not responded. Out of the 2 patients of other class, 1 (50%) patient responded and1 (50%) patients is discontinued. Graph –4 Showing Patients by occupation distribution Labour Active 0% Others 15% 10% Sedentary 75% 86
  • A5) DISTRIBUTION OF PATIENTS BY ECONOMIC STATUS Table-13 Economic Discontinued Maintained Responded Responded Total no of patients status Not % % % % % Below 10 0 0 2 100 0 0 0 0 2poverty line 65 4 30.7 5 38.4 2 15.3 2 15.3 Middle 13Upper middle 20 2 50 0 0 1 25 1 25 4 class 5 0 0 1 100 0 0 0 0Higher class 1 100 6 30 8 40 3 15 3 15 Total 20Observation: In this study the common four groups of economical states are considered. They are1) BPL class, 2) Middle class, 3) upper Middle class and 4) Higher classes. Out of 20 patients reported, maximum numbers of 13 (65%) patients are from middleclass. 2 (10%) patients reported from the BPL class, 4 (20%) patients are from upper middleclass and 1 (5%) patient is from high class.Result: Out of the 13 patients of middle class, 4 (30.8%) patients responded, 5 (38.5%)patients’ maintained, 2 (15.4%) patients discontinued and 2 (15.4%) patients were notresponded. From the BPL class all 2 (100%) patients maintained to the management. Out ofthe 4 patients of upper middle class, 2 (50%) patients responded 1(25%) patientdiscontinued and 1 (25%) patient were not responded. The patient (100%) reported from thatof higher class is maintained for the management. 87
  • Graph –5 Showing Patients by economical status distribution 14 13 12 10 8 6 4 4 2 2 1 0 Below poverty Middle Upper middle Higher class line class Patients by economical statusB) Data related to the disease.B1) DISTRIBUTION OF PATIENTS BY MODE OF ON SET Table- 14Mode of on Discontinued Maintained Responded Responded Total no of set patients Not % % % % % Gradual 85 6 35.2 6 35.2 2 11.7 3 17.6 17 Sudden 0 0 0 0 0 0 0 0 0 0 Insidious 15 0 0 2 66.6 1 33.3 0 0 3 Total 100 6 30 8 40 3 15 3 15 20 88
  • Observation: In this study the common three groups of onset states are considered. They are 1)gradual class, 2) sudden class and 3) insidious class. Out of 20 patients reported, maximum numbers of 17 (85%) patients are fromgradual class. 3 (15%) patients are reported from the insidious class and no patients arefrom sudden onset class.Result: Out of the 17 patients of gradual class, 6 (35.3%) patients responded, 6 (35.3%)patients’ maintained, 3 (17.7%) patients discontinued and 2 (11.8%) patients were notresponded. From the insidious class 2 (66.7%) patients maintained to the management and 1(33.3%) patient is not responded. Graph –6 Showing Patients by mode of onset distribution Insidious Sudden 15% 0% Gradual 85% 89
  • B2) DISTRIBUTION OF PATIENTS BY INTAKE OF GOITROGENS Table- 15 Intake of Discontinued Maintained Responded Responded Total no of patientsGoitrogens Not % % % % % Present 60 4 33.3 4 33.3 1 8.3 3 25 12 Absent 40 2 25 4 50 2 25 0 0 8 Total 100 6 30 8 40 3 15 3 15 20Observation: In this study the common groups of Goitrogens Intakes are considered as present ornot present. Out of 20 patients reported, maximum numbers of 12 (60%) patients are at theusage of Goitrogens Intake and the rest of 8 (40%) were not directly give any reference ofGoitrogens Intake food substances. Graph –7 Showing Patients by intake of Goitrogens distribution Distribution by Goitrogens Intake Absent 40% Present 60% 90
  • Result: Out of the 12 patients of Goitrogens Intake class, 4 (33.3%) patients responded 4(33.3%) patients’ maintained, 3 (25%) patients discontinued and 1 (8.3%) patient has notresponded. From the non-Goitrogens Intake class 4 (50%) patients maintained to themanagement, 2 (25%) patient is not responded and 2 (25%) patient is responded.B3) DISTRIBUTION OF PATIENTS BY FAMILY HISTORY Table- 16 Family Discontinued Maintained Responded Responded Total no of history patients Not % % % % % Present 50 4 40 2 20 3 30 1 10 10 Absent 50 2 20 6 60 0 0 2 20 10 Total 100 6 30 8 40 3 15 3 15 20Observation: In this study the common groups of Family history are considered as present or notpresent. Out of 20 patients reported, maximum numbers of 10 (50%) patients are withFamily history and the rest of 10 (50%) were not directly give any reference of Familyhistory.Result: Out of the 10 patients with Family history class, 4 (40%) patients responded 2 (20%)patients’ maintained, 1 (10%) patient discontinued and 3 (30%) patients have not responded.From the patients those not reported with Family history class 6 (60%) patients maintainedto the management, and 2 (20%) patient is responded. The other 2 (20%) patientsdiscontinued the treatment. 91
  • Graph – 8 Showing Patients by family history distribution Distribution by Family history Absent Present 50% 50%B4) DISTRIBUTION OF PATIENTS BY Agni (APPETITE) Table- 17 Appetite Discontinued Maintained Responded Responded Total no of patients Not % % % % % Poor 25 0 0 1 20 1 20 3 60 5 Moderate 35 4 57.1 3 42.8 0 0 0 0 7 Good 35 2 28.6 4 57.1 1 14.2 0 0 7 Severe 5 0 0 0 0 1 100 0 0 1 Total 100 6 30 8 40 3 15 3 15 20Observation: In this study the common groups of Agni history is considered as poor, moderate,good and severe. Out of 20 patients reported, 5 (25%) patients reported with mandagni (poor 92
  • appetites) which is said as the cause of all diseases in Ayurveda. The category of moderateappetites i.e. samagni patients are 7 (35%) and the good appetite patients are 7 (35%). Theone (5%) patient reported with severe appetite, which is considered in Ayurveda asTeekshnagniResult: Out of the 5 patients with mandagni class, 1 (20%) patient maintained, 3 (60%)patient discontinued and 1 (20%) patient is not responded. From the patients those notreported with samagni moderate history of appetite 3 (42.8%) patients maintained to themanagement, and 4 (57.2%) patients are responded. Out of the 7 patients with good appetite,4 (57.2%) patient maintained 2 (28.6%) patients responded and 1 (14.9%) patient is notresponded. Out of the category of Teekshangni the patient reported is not responded to thetreatment. Graph – 9 Showing Patients by Agni distribution Distribution by Agni (APPETITE) Severe Poor Good 25% 5% 35% Moderate 35% 93
  • B5) DISTRIBUTION OF PATIENTS BY SLEEP Table- 18 Sleep Discontinued Maintained Responded Responded Total no of patients Not % % % % %Sound sleep 40 1 12.5 5 62.5 2 25 0 0 8 More sleep 25 2 40 1 20 0 0 2 40 5 Less sleep 20 2 50 1 25 1 25 0 0 4 Disturbed 15 1 33.3 1 33.3 0 0 1 33.3 3 sleep Total 100 6 30 8 40 3 15 3 15 20Distribution by Nidra (sleep)Observation: In this study the common groups of Nidra history is considered as sound, more,disturbed and less. Out of 20 patients reported, maximum numbers of 8 (40%) patientsreported with sound sleep. The category of more sleep i.e. Atinidra patients are 5 (25%) andwith the disturbed sleep are 3 (15%). The patients with less sleep are 4 (20%) in the study.Result: Out of the 8 patients with sound sleep class, 5 (62.5%) patients maintained 2 (25%)patients not responded and 1 (12.5%) patient is responded. From the patients those who arewith Atinidra, 1 (20%) patient maintained in the management and 2 (40%) patients areresponded, the rest 2 (40%) patients are discontinued the treatment. Out of the 3 patientswith disturbed sleep, 1 (33.3%) patient maintained 1 (33.3%) patient responded and 1(33.3%) patient is discontinued. Out of the category of less sleep reported patients, 1 (25%)patient maintained 2 (50%) patient responded and 1 (25%) patient is not responded. 94
  • Graph –10 Showing Patients by sleep distribution Disturbed Less sleep sleep Sound sleep 20% 15% 40% More sleep 25% Distribution by Nidra (sleep)B6) DISTRIBUTION OF PATIENTS BY PSYCOLOGICAL FEATURES Table- 19 Discontinued Maintained Responded Responded Total no of patientsPsychologica Not % l features % % % % Present 95 6 31.8 7 36.8 3 15.8 3 15.8 19 Absent 5 0 0 1 100 0 0 0 0 1 Total 100 6 30 8 40 3 15 3 15 20Distribution by Psychological featuresObservation: In this study the common groups of psychological features are considered as presentor not present. Out of 20 patients reported, maximum numbers of 19 (95%) patients are with 95
  • the psychological features interfered and the rest of 1 (5%) patient is not directly given anyreference of psychological features exposed.Result: Out of the 19 patients of psychological features interfered class, 6 (31.6%) patientsresponded 7 (36.8%) patients’ maintained 3 (15.78%) patients discontinued and 3 (15.78%)patient has not responded. From the second category of no reference with psychologicalinterference class patient (100%) patient maintained to the management. Graph –11 Showing Patients by psychological features distribution absent 5% Present 95% Distribution by Psychological features 96
  • B7) DISTRIBUTION OF PATIENTS BY HABITS Table- 20 Habits Discontinued Maintained Responded Responded Total no of patients Not % % % % % No Habit 85 5 29.4 7 41.8 3 17.6 2 11.8 17 Smoking 10 1 50 1 50 0 0 0 0 2 Alcohol 0 0 0 0 0 0 0 0 0 0 Tobacco 5 0 0 0 0 0 0 1 100 1 Total 100 6 30 8 40 3 15 3 15 20Distribution by Vyasana (Habits)Observation: In this study the common groups of vyasana history is considered as No Habit,Smoking, Alcohol and Tobacco usage. Out of 20 patients reported, maximum numbers of 17(85%) patients are with no habits as the study is loaded with female population. 2 (10%)smokers and 1 (5%) patient of tobacco user is reported in the study.Result: Out of the 17 patients with No Habit class, 7 (41.17%) patients maintained 3(17.64%) patients not responded, 2 (11.76%) patients discontinued and 5 (29.41%) patient isresponded. From the patients those who are with smoking, 1 (50%) patient maintained in themanagement and the other (50%) patient are responded. Patient reported with tobacco usageis reported discontinued from the study. 97
  • Graph –12 Showing Patients by habits distribution Alcohol Tobacco No Habit Smoking 0% 5% 85% 10% Distribution by Vyasana (Habits)B8) DISTRIBUTION OF PATIENTS BY MENUSTRAL CYCLE Table-21 Menstrual Discontinued Maintained Responded Responded Total no of cycle patients Not % % % % % Regular 44.4 4 50 2 25 0 0 2 25 8 Irregular 27.7 1 20 2 40 2 40 0 0 5 Menopause 27.8 0 0 4 80 0 0 1 20 5 Total 100 5 27.8 8 44.4 2 11.1 3 16.7 18Observation: In this study the common groups of menstrual cycle history is observed as themaximum number of the patients are of females. The categories are Regular, Irregular andMenopause. Out of 18 patients reported, maximum numbers of 8 (44.4%) patients are with 98
  • regular menstrual cycle and 5 (27.8%) irregular menstrual cycle and 5 (27.8%) populationreported cessation of menstrual cycle is reported in the study.Result: Out of the 8 patients with regular menstrual cycle, 2 (25%) patients maintained 4(50%) patients not responded and 2 (25%) patients discontinued. From the patients thosewho are with irregular menstrual cycle, 2 (40%) patient maintained in the management 1patient (25%) responded and the other 2 (40%) patient are not responded. From the patientsthose who are with menopause, 4 (40%) patient maintained in the management 1 patient(20%) discontinued. Graph –13 Showing Patients by menstrual cycle distribution Menopause Regular 28% 44% Irregular Distribution by Menstrual cycle 28% 99
  • B9) DISTRIBUTION OF PATIENTS BY BUILT AND NUTRITION Table- 22 Built and Discontinued Maintained Responded Responded Total no of patients nutrition Not % % % % % Well 35 3 42.9 4 57.1 0 0 0 0 7 Thin 40 2 35 2 25 3 37.5 1 12.5 8 Obese 25 1 20 2 40 0 0 2 40 5 Total 100 6 30 8 40 3 15 3 15 20Distribution by built and nutritionObservation: In this study the common groups of built and nutrition is considered as well built,thin built and obese. Out of 20 patients reported, maximum numbers of 8 (40%) patients arewith thin built. 7 (35%) well built and 5 (25%) patients of obese are reported in the study.Result: Out of the 8 patients with thin built class, 2 (25%) patients maintained 3 (37.5%)patients not responded, 1 (12.5%) patient discontinued and 2 (25%) patients are responded.From the patients those who are well built, 4 (57.2%) patient maintained in the managementand the other 3 (42.8%) patients are responded. Out of the Patients reported with obese, 1(20%) responded, 2 (40%) maintained and 2 (40%) patients are reported discontinued fromthe study. 100
  • Graph – 14 Showing Patients by built and nutrition distribution Obese Obese, 5 Thin Thin, 8 Well Well, 7 0 1 2 3 4 5 6 7 8 9 Distribution by built and nutritionB10) DISTRIBUTION OF PATIENTS BY AHARAJA AND VIHARA NIDANA Table- 23 Aharaja Nidana Discontinued Maintained Responded Responded Total no of patients Not % % % % % Gurubhojana 17 85 6 35.3 7 41.8 1 5.9 3 17.6 Virudhabhojana 18 90 6 33.3 6 33.3 3 16.7 3 16.7 Avvaksayana 55 3 27.3 6 54.5 1 9.09 1 9.09 11Distribution by Aharaja Vihara NidanaObservation: In this study the common groups Aharaja Nidana is considered as guru and Viruddhabhojana. Out of 20 patients reported, maximum numbers of 17 (85%) patients are with 101
  • Gurubhojana and 18 patients reported with the Virudhabhojana. In this study it is evidentthat the different dietetics which were told by the Acharyas has much values. The vihara Nidana is observed with the 11 patients of Avvaksayana. Out of 20patients reported, 11 (55%) patients are with Avvaksayana.Result: Out of the 17 patients with Guru bhojana, 7 (41.17%) patients maintained 1 (5.88%)patients not responded, 3 (17.64%) patients discontinued and 6 (35.29%) patient isresponded. From the patients those who are with Virudhabhojana, 6 (33.33%) patientmaintained in the management 3 (16.66%) patients not responded, 3 (16.66%) patientsdiscontinued and the 6 (33.33%) patient are responded. Out of the 11 patients with Avvaksayana, 6 (54.54%) patients maintained 1 (9.09%)patients not responded, 1 (9.09%) patients discontinued and 3 (27.27%) patients areresponded. Graph –15 Showing Patients by Aharaja and Viharaja Nidana distribution Gurubhojan Virudhabhoj Avvaksayana a, 17 ana, 18 , 11 20 18 16 14 12 10 8 6 4 2 0 Gurubhojana Virudhabhojana Avvaksayana Distribution by Aharaja Vihara Nidana 102
  • B12) DISTRIBUTION OF PATIENTS WITH SYSTEMS INVOLVED Table- 24 Systems Discontinued Maintained Responded Responded Total no of patients Not % % % % % Cardio 12 60 3 25 5 41.7 2 16.7 2 16.7 respiratoryGastro intestinal 9 45 3 33.3 2 22.2 2 22.2 2 22.2 Dermatological 16 80 5 31.3 7 43.8 2 12.5 2 12.5Neuro muscular 11 55 4 36.4 4 36.4 2 18.9 1 9.09 Reproductive 2 10 0 0 0 0 0 0 2 100 Total 50 250 15 30 18 36 8 16 9 18Distribution by systems involvedObservation: In this study the common groups of systems involved are included. Out of 20patients reported, maximum numbers of 16 (80%) patients are with dermatological problemsand 12 patients of cardio- respiratory along with 11 (55%) patients with neuro muscularcomplaints are received. The other systems witnessed are 9 (45%) of GIT problems and 2 (10%) ofreproductive problems.Result: Out of the 16 patients with dermatological problems, 7 (43.75%) patients maintained2 (12.5%) patients not responded, 2 (12.5%) patients discontinued and 5 (31.25%) patient isresponded. 103
  • Out of the 12 patients with cardio-respiratory problems, 5 (41.7%) patientsmaintained 2 (16.7%) patients not responded, 2 (16.5%) patients discontinued and 3 (25%)patient is responded. Out of the 11 patients with neuro-muscular problems, 4 (36.7%) patients maintained2 (18.2%) patients not responded, 1 (9.09%) patient discontinued and 4 (36.7%) patient isresponded. Out of the 9 patients with gastro-intestinal problems, 2 (22.2%) patients maintained 2(22.2%) patients not responded 2 (22.2%) patients discontinued and 3 (33.3%) patient isresponded. Out of the 2 patients with reproductive problems, all the patients discontinued fromthe management. Graph –16 Showing Patients by with systems involved 2 Reproductive 11 Neuro muscular 16 Dermatological 9 Gastro intestinal 12 Cardio respiratory 0 2 4 6 8 10 12 14 16 Distribution by systems involved 104
  • C) Data related to the overall response to the treatmentC1) DISTRIBUTION OF PATIENTS BY CHIEF COMPALINTS Table- 25 Chief Not Responded Discontinued Maintained Responded Total no of complaints patients % % % % % Ganda 17 100 6 35.3 8 47 3 17.7 0 0 Toda 17 100 6 35.3 8 47 3 17.7 0 0 Vivarnata 17 100 6 35.3 8 47 3 17.7 0 0 Kandu 17 100 6 35.3 8 47 3 17.7 0 0 Difficult to 17 100 6 35.3 8 47 3 17.7 0 0 swallowDifficulty to 17 100 6 35.3 8 47 3 17.7 0 0 breathDistribution by systems involvedObservation: All most all the symptoms, which are evaluated, show the al 17 patients involvingwith the symptoms in the disease. It is clear and significant that the disease explained in theAyurveda and compared on contemporary systems substantiate the present study patterns.Results: The results are discussed as symptoms react to that of the management. This isreflecting the as it is of the result final, which will be discussed as under in the subjectiveparameters enumerated. 105
  • C2) subjective parameters enumerated (a) TABLE -26 Ganda Toda Vivarnata Kandu sln o B A D % B A D % B A D % B A D % 1 3 1 2 66.66 3 1 2 66.6 2 1 1 50 4 2 2 50 2 2 1 1 50 2 1 1 50 3 1 2 66.6 3 1 2 66.6 3 3 2 1 33.3 3 1 2 66.6 2 1 1 50 3 2 1 33.3 4 3 2 1 33.3 3 1 2 66.6 2 1 1 50 2 1 1 50 5 2 1 1 50 3 1 2 66.6 4 1 3 75 3 1 2 66.6 6 3 2 1 33.3 3 1 2 66.6 2 1 1 50 2 1 1 50 7 3 2 1 33.3 2 1 1 50 2 1 1 50 3 2 1 33.3 8 2 1 1 50 3 1 2 66.6 3 1 2 66.6 3 1 2 66.6 9 3 1 2 66.6 2 1 1 50 3 1 2 66.6 2 1 1 50 10 3 2 1 33.3 3 1 2 66.6 3 1 2 66.6 2 1 1 50 11 4 3 1 25 3 1 2 66.6 3 2 1 33.3 3 1 2 66.6 12 3 1 2 66.6 2 1 1 50 3 1 2 66.6 3 1 2 66.6 13 3 2 1 33.3 3 1 2 66.6 2 1 1 50 3 1 2 66.6 14 3 2 1 33.3 3 1 2 66.6 2 1 1 50 3 1 2 66.6 15 2 1 1 50 2 1 1 50 2 1 1 50 3 1 2 66.6 16 3 2 1 33.3 3 1 2 66.6 3 1 2 66.6 4 1 3 75 17 3 2 1 33.3 2 1 1 50 3 1 2 66.6 4 2 2 50 TABLE -27Subjective parameters enumerated (b) difficulty in difficulty in over all % Result slno swallowing berating B A D % B A D % 1 2 1 1 50 2 1 1 50 55.4 Maintained 2 2 1 1 50 2 1 1 50 55.5 Responded 3 2 1 1 50 3 1 2 66.6 49.98 Maintained 4 2 1 1 50 3 1 2 66.6 52.8 Maintained 5 2 1 1 50 2 1 1 50 59.72 Maintained 6 2 1 1 50 1 1 0 0 49.99 Maintained 7 2 2 0 0 2 1 1 50 43.32 Not Responded 8 2 1 1 50 3 1 2 66.6 61.06 Not Responded 9 2 1 1 50 3 1 2 66.6 58.3 Responded 10 2 1 1 50 3 1 2 66.6 55.54 Responded 11 2 2 0 0 3 1 2 66.6 51.65 Responded 12 2 1 1 50 3 1 2 66.6 61.1 Not Responded 13 2 1 1 50 3 1 2 66.6 47.21 Maintained 14 2 1 1 50 2 1 1 50 52.77 Responded 15 2 1 1 50 2 1 1 50 52.77 Maintained 16 2 1 1 50 3 1 2 66.6 59.71 Maintained 17 2 1 1 50 2 1 1 50 49.98 Responded 106
  • R = Responded, M = Maintained, NR = Not Responded, D = Discontinued The subjective parameters evaluated in the study such as Ganda, Toda, Vivarnyata,Kandu, difficulty in swallowing and difficulty in breathing are mentioned in the gradingevaluated in the study as before after with percentage of difference. The total values arecumulated and told to get the summated net results of Amrutadi Yoga in the management ofthe Galaganda vis-à-vis goiter.D) Statistical analysis of the clinical and functional parametersD1) showing the statistical analysis of the chief complaints Table -28Parameters Mean S.D S.E t-value p-value RemarksGanda 1.176 0.392 0.095 12.378 <0.001 H.S.Toda 1.647 0.492 0.119 13.84 <0.001 H.S.Vivarnata 1.529 0.624 0.151 10.125 <0.001 H.S.Kandu 1.705 0.588 0.142 12.00 <0.001 H.S.Difficulty In 0.882 0.332 0.08 11.025 <0.001 H.S.SwallowingDifficulty In 1.47 0.624 0.151 9.735 <0.001 H.S.Breathing HS = Highly Significant, S = Significant, NS = Not SignificantD2) showing the statistical analysis of the lab investigations Table -29Parameters Mean S.D. S.E. t-value p-value RemarksT3 0.041 0.059 0.0143 2.86 <0.05 H.S.T4 0.241 1.712 0.415 0.58 >0.05 N.S.T.S.H. 2.215 9.301 2.255 0.982 >0.05 N.S. HS = Highly Significant, S = Significant, NS = Not Significant 107
  • D3) Anova – Table for the parameter T3 Table - 30 Mean sum of Value at 5% F calculated Degrees of Remarks freedom p-value Sum of F table square square Value Source of VariationGroups 2 1.07 0.535Error 14 2.984 0.213 2.511 3.74 P > 0.05 N.S.Total 16 4.054 - HS = Highly Significant, S = Significant, NS = Not SignificantD4) Anova – Table for the T4 parameter Table –31 Mean sum of Value at 5% F calculated Degrees of Remarks freedom p-value Sum of F table square square Value Source of VariationGroups 2 23491.988 11745.994 SignificantError 14 8255.578 589.68 19.19 3.74 P < 0.05Total 16 31747.56 -D5) Table show which pair of group is significant Table - 32Group Mean DifferenceHyperthyroidism 207.02 $ -Eu-thyroidism 102.5 $ 104.52 $Hypothyroidism 86.55 $ 120.47 $ 15.95 # $ - Significant # - Not significant 108
  • Least Significance difference value = t 0.05 SE 1 1 /ni + /njor Critical difference (C.DOR L.S.D). Where t0.05 in t- table value at 5% level of significancefor error degrees of freedom. SE2 is mean error sum of squares. And ni , nj are the numberof observations in the two groups. 1 1 L.S.D =2.12 589.68 X /2 + /8 For II and III group = (2.12) (24.283) (0.8017) = 41.271 L.S.D for Hypothyroidism and Euthyroidism group = 26.64 L.S.D for Hypothyroidism and hyperthyroidism group = 40.69D6) Anova- Table for parameter T.S.H. Table -33 Mean sum of Value at 5% F calculated Degrees of Remarks freedom p-value Sum of F table square square Value Source of VariationGroups 2 1324.514 662.257 SignificantError 14 1931.759 137.98 4.79 3.74 P < 0.05Total 16 3256.274 -D7) to show which pair of group is significant Table - 34 Group Mean DifferenceHypothyroidism 19.23 $ - -Euthyroidism 2.208 # 17.202 $ -Hyperthyroidism 0.055 # 19.175 # 1.973 # $ = Significant # = Not Significant 109
  • v Least Significance difference (L.S.D) value for Hypothyroidism and Euthyroidism group = 12.886 v Least Significance difference (L.S.D) value for Hypothyroidism and Hyperthyroidism group = 19.687 v Least Significance difference (L.S.D) value for Hyperthyroidism and Euthyroidism group = 19.965Conclusion v All parameters show highly significant (from table –D1-D2). The parameters Toda show highly significant before and after treatment in the group (By using paired t- test as P<0.001). v The Ganda and Kandu parameters having approximately same effect, Even though they show highly significant (By comparing t- value). There is much variation in Vivarnata and Difficulty in breathing (By comparing variances). v The objective parameter T3 is not significant (as p< 0.05). The parameter T4 and TSH are highly significant. v Further if we want to study the mean effects of Hypothyroidism, Hyperthyroidism and Euthyroidism by making them as three different groups. Group I as Hypo, Group II as hyper and Group III as Euthyroidism. v The parameter T3, i.e. mean effects on three groups is same. (Not Significant as P> 0.05) from table –D3 110
  • v The parameter T4 from table –D4. The mean effects on three groups are not same (significant as (P<0.05). to find out which pair groups is significant, by comparing the Least significance difference value the following conclusions can be made out (from table D5). a. The group Hyperthyroidism differs significantly from Group Hypothyroidism and Group Euthyroidism. b. The Group Euthyroidism and Group Hypothyroidism also differ significantly. c. Group Hypothyroidism is not significant. v The parameter TSH from table-D6, the mean effects on three groups is not same (significant as P<0.005). To find out which pairs Groups are significant, by comparing Least significance difference value (table D7), the following conclusions can made out. 1. Group Hypothyroidism is Significant 2. Group Hyperthyroidism and Group Euthyroidism are Significant 3. Group Hyperthyroidism is not significant.E) Result of the Amrutadi taila over Galaganda In the study it is found that Responded patients are 6 (30%) and the Maintainedpatients are 8 (40%), 3 patients (15%) in the last category of Not-responded associated with3 patients (15%) discontinued the treatment. The results are compared with the parametersof subjective and objective together. The graphical representation of the study is as follows. 111
  • Table – 35 Showing the result of Amrutadi taila capsules in Galaganda Result Patients PercentageResponded 6 30Maintained 8 40Not Responded 3 15Discontinued 3 15Total 20 100 Graph – 17 Depicting the results of Amrutadi yoga on Galaganda Discontinued, Not 3 Responded, 6 Responded, 3 Maintained, 8 Results of Amrutadi yoga on Galaganda 112
  • Discussion The thyroid disorders are characterized by physical and mental interference. InAyurveda there is not an exact term for thyroid gland. Some of the later Ayurvedic scholartried to name the thyroid gland, but they could not compare many thyroid disorders with anyof the ancient descriptions. We can correlate goitre and some tumour pathology of thyroid to ‘Galaganda’ wherethyroid functions may or may not are affected. It is therefore, better not to restrict thyroiddysfunction to any one of the diseases. In this study total 20 patients were reported. Out of them 17 patients were selectedfor the study in one group. 3 patients were discontinued. This was a unique study, in whichthe trail medicine was in the form of oil. The oil is made 11-avarthi to enhance thecumulative effect of said combination. The avartha taila is then capsulated in the gelatinousform; under GMP specification and used as internal medicine the same avartha taila is usedfor Pratimarsha Nasya. The discussion is to be mainly focussed on the objectives. The three objectives ofthis study are as follows 1. To evaluate the anti-Goitrogenic (galandaharatwam) of Amrutadi taila in Galaganda 2. To evaluate of the effect Amrutadi taila on T3, T4 and TSH in Galaganda 3. To evaluate the effect of Pratimarsha Nasya in Galaganda The discussion is made in the form of analytical approach of a single case studyalong with over all assessments. For that the discussion is classified as follows 113
  • 1) Galaganda vis-a-vis Goitre. 2) Discussion on the signs and symptoms of Galaganda in Ayurveda and contemporary science 3) Demographic data discussion 4) Discussion on the Disease related data 5) Discussion on the individual drug action and the cumulative effect of the Amrutadi yoga 6) The evaluation of Pratimarsha Nasya in Galaganda 7) Over all assessments 8) Discussion on statistical analysis of subjective and objective parameters 9) The concepts to be focussed in the forth coming study 10) Limitations of the study 11) Conclusion1) Galaganda - vis-à-vis goitre Galaganda is a disease pertaining to gala pradesha, it is characterise by ganda(swelling in the neck), todam (slight pain in the neck) vivarnata (discoloration of the mass)kandu (itching around the neck). The goitre also possesses the swelling in the neck,difficulty in breathing, difficulty to swallow, itching and skin rashes in various places. Thegoitre is present in both types of thyroid disorders such as hypo thyroidism andhyperthyroidism. The various signs and symptoms mentioned in the contemporary sciencescan not be correlated as such with the Galaganda, which is a disease pertaining to the neckregion but the goitre is affecting many systems. 114
  • 2) Discussion on the signs and symptoms The signs and symptoms of Galaganda mentioned in Ayurvedic system is taken forthe study. But as the goitre in the contemporary system effects all the systems of the body italso should be considered so the discussion on sign and symptoms is classified into two asfollows - 1. The discussion on the signs and symptoms mentioned in Ayurveda 2. The discussion on the signs and symptoms mentioned in the contemporary medicine The chief complaints in this study were ganda (mass in the neck), toda (slight pain Inthe neck) vivarnata (discoloration of skin around the mass), kandu (itching around the mass),difficulty to swallow and difficulty in breathing. Recording them before assesses thesesymptoms and after the treatment and difference is emphasized the symptoms discussed hereare as follows.1) The discussion on the signs and symptoms mentioned in Ayurveda A) Ganda All the 20 patients were presented with ganda in varying degrees, which is recorded according to the grading in the annex. The after treatment data of 17 patients (3 discontinued) were assessed by comparing the before treatment and after treatment and difference is made. The swelling reduced can be evaluated by examination of the thyroid, by inspection, palpation. It is also can be evaluated by the reduction in symptoms such as difficulty to deglutition, difficulty in respiration, dragging sensation of the neck etc., which were reduced satisfactorily. The ganda was reduced in all most all patients which was 115
  • assessed statistically on the result was highly significant. The cumulative effect ofAmrutadi yoga especially, shophaharatnam will be the basis of the reduction ofganda in this study.B) Todam All the 20 patients presented with todam (a vedana vishesham of pain) indistributing degrees, which is recorded according to the grading mentioned in annex.After treatment data of 17 patients (3 discounted) were assessed by comparing thebefore treatment and after treatment values. The todam is reduced in parlance with the swelling, as the swelling willcompress the trachea. When the difficulty swallow is reduced the pain also reduced.All the patients, the pains while swallowing was relieved many of the drugs have thevedanasamakatwam, sophakaratwam property that is dealt in detail. The discussionon drug is the basis of probable mode of action, which makes the reduction in toda. Itis assessed statistically and the result was highly significant.C) VivarnataThe 20 patients was presented with the slight vivarnata (discoloration of mass) thevivarnata as is a chief symptom of Galaganda was recorded in 17 patients (3discontinued) the after treatment data is then compared with before treatment data tomake the result. Examining the neck assesses the vivarnata progress, normally bodycolour will be different from the abnormal discoloration present due to variouspathologies. Some presented with discoloration with blackish spots and some otherswith reddish spots. All the patients got relief from vivarnata caused by disease duringthe treatment with the Amrutadi yoga. The drugs, which are useful in reducing thevivarnata, are elaborately discussed in the drug discussion. Those are the probable 116
  • action of reduction of vivarnata, it is assessed statistically also and the result was highly significant. D) Kandu The 20 patients presented in the study complaint of some form are other types of kandu (itching around the neck region). 3 patients presented with severe itching. The before and after treatment data of 17 patients (3 discontinued) were recorded. It is then compared and made the difference to know the result. The itching was present in the other parts of the body also with skin rashes and dry skin. It was also noted under the kandu. The treatment was considerably effective in maintain the symptom kandu in all the patients. The kanduharatwam of the drugs can be evaluated by the considerably decrease in itching around the mass and in other parts of the body. As there is a role of the Rakta Dhatu also to be evaluated here in the manifestation of kandu. The most of the drugs in the said yoga have rakta sodhaka property which an evident example for reduction of this symptom. This was assessed statically also and the result was highly significant.2) The discussion according to contemporary medicine The thyroid disease is a serious multi systemic disorder, so the evaluations of the various systemic problems are necessary. The thyroid disease is broadly classified into two, hypo thyroidism and hyper thyroidism. Even though the chief symptoms of the Galaganda is discussed, as the symptoms of contemporary science are also important in due consideration of the nature of the disease, it is also discussed. In this study after the lab investigation the thyroid diseases are classified into hyperthyroidism, hypo thyroidism and euthyroid. 117
  • A) Difficulty to swallow All the 20 patients were presented with difficulty to swallow. The beforetreatment and after treatment data are recorded of the 17 patients (3 discontinued)this is an important symptom as it is in parlance with the mass in the neck. If themass in the neck is reduced, the difficulty to swallow will also reduced. Thedifficulty to swallow was reduced in all 17 patients. The grading assesses thismentioned in the annex. By inspection we can find out the swelling which isreduced or not. The swelling is reduced by the Amrutadi taila in the majority of thedrugs have the property of sophahatwam. It was assessed statistically also and foundhighly significant.B) Difficulty in breathing 20 patients present in study complaint of varying degrees of difficulty inbreathing. The before and after treatment data are recorded in the 17 patients (3discontinued). It is then compared and made the difference to know the result. Thesymptoms were reduced in all the 17 patients. The responded group patients and themaintained group patients got more relief from difficulty in breathing. The 3-hyperthyroidism patients got relief by the treatment but asked as the diseaseprogressed again the attacks of difficulty in breathing also manifested. The drugs ofthe Amrutadi taila comprised of kaphahara property and the drugs such as guduchi,pippali, etc., reduces the srotorodham caused by Kapha Dosha. The symptoms wereassessed statistically also and found highly significant.C) Group study The various symptoms of this group are to be discussed. After the assessmentof both subjective and objective parameters the results are, hypo thyroid patients 118
  • were responded to the treatment, the euthyroid patients were maintained with the treatment and the hyper thyroid patients were not responded to the treatment. The statistical analysis also shows the same. So the discussion were classified into the not responded group, and the responded group.I) Hyperthyroidism The not responded group consists of three patients of hyperthyroidism the signs andsymptoms are classified into 3, general and local, systemic and psychological.i) General and local symptoms Table -36 Symptoms Signs Generalize weakness Weight loss Heat in tolerince Excessive sweating Thirst,fatigue Restlessness, hair thining, goitre The above all signs symptoms were present in the 3 hyperthyroid patients. Out ofthem generalised weakness, fatigue, and restlessness got relief by the treatment. Othersymptoms were not relieved considerably the goitre was present in 1 patient, which wasnodular one. It was not relieved by the treatment.ii) Systemic evaluationTable – 37: Cardiovascular Symptoms Signs Dyspnoea,on exertion Increased pulse rate Palpitation Tachycardia 119
  • The above signs and symptoms were present in all the 3 patients reported with hyperthyroidism. The symptom dyspnoea on exertion got relief and the rest of the signs ofsymptoms were not relieved.Table – 38:Central Nervous System Symptoms Signs Nervousness Fine tremors Emotional liability Hyper reflexia The symptom nervousness and emotional liability are present in all the 3 patientsreported with hyper thyroidism. Fine tremors were present in 1 patient of thehyperthyroidism patients. The other sign hyper-reflexia was not present in any of the 3-hyperthyroidism patients. There was slight relief from the symptom fine tremors of the patients. Thenervousness and emotional problems persisted after the treatment also.Table –39:Gastro-intestinal tract Symptoms Signs Diarrhea Rapid bowel transit time Anorexia Weight loss despite increase apetite The symptom anorexia was present in 1 patient, the increased appetite was present inall the 3,and the loose motions were present in 1 patient of the hyper thyroidism. Theanorexia was relieved after the treatment. 120
  • Table –40:Dermatological Symptoms Signs Pigmentation No signs Skin rashes in the several parts of body The symptoms were present in all the 3 patients reported with hyper thyroidism.There were only maintained with the treatment.Psychological All the 3 patients of hyperthyroidism reported with the symptoms such as anxiety,nervousness, and emotional liability. These symptoms persisted after the treatment also.Hypothyroidism The patients reported with hypothyroidism were 8 in number. Out of them 6 patientsresponded to the treatment. The signs and symptoms presented by those patients wereclassified into 3 as such general features, systemic and psychologicalTable- 41:General features of hypothyroidism Symptoms Signs Tiredness, Weight gain Cold in tolerance Puffy face (mask like face) Hoarssness of voice Goitre The hoarseness of voice, colds in tolerance tiredness were present in 8 patientsreported with hypo thyroidism. The weight gain and goitre was present in 6 cases and puffyface was present in 2 patients. 121
  • The hoarseness of voice and tiredness were reduced considerably. The patientspresented with cold in tolerance can with stand some cold after the treatment. The puffy facewas reduced in the 2 patients. The weight gain was changed with the maximum of 2kg in 1patient. The goitre present in all the 6 patients reduced in size after the treatmentTable –42Cardio Vascular system Symptoms Signs Shortness of breath Hypertension Bradicardia The symptoms were maintained by the treatment, but the hypertension persisted afterthe treatment.Table –43Central Nervous System Symptoms Signs Muscle aches and pain Delayed retraction of tendon reflexes Stiffness, slowing of motor functions All the symptoms were present in the hypothyroidism patients. The signs werepresent in 3 patients only. The symptoms such as muscle pain and stiffness were relievedcompletely. The slowing of motor functions are progressed after the treatment.Gastro-intestinal tract All of the hypothyroidism patients presented with constipation either occasionally orregularly. They were responded to the treatment and constipation was relieved completelyafter the treatment. 122
  • Reproductive system Irregular delayed menstruation, were present in 3 patients of hypothyroidism. Theywere brought back to normalcy after the treatment.Psychological All the hypothyroidism patients were present with the symptoms such as anxiety,nervousness and emotional liability. The symptoms persisted after the treatment also.3) Demographic data discussiona) Age The thyroid diseases are common in the middle-aged women. It is also manifested inthe teenaged girls and pregnant women, as the hormonal imbalance will be due to the moreneeded at that time. It is common in 35-55 age group, the patients, reported were 11 innumber.b) Sex There is no doubt the thyroid abnormalities are common in Females at a ratio 6:1.All types of Goitres are far more common in females. In this study out of the total 20patients, 18 were females.c) Occupation Most of the patients belong to the sedentary group. The lack of activities is animportant factor in manifesting the diseases. The detailed descriptions of the demographicdata of the other factors are given in the results. 123
  • 4) Disease related dataa) Mode of onset The majority of the patients reported with gradual onset of the disease.in this studyof 20 patients, 17 presented with gradual onset of the disease. 3 patients were reported withinsidious onset.b) Intake of Goitrogens The Goitrogens are the pre-disposing factors, which enhance the production ofthyroid disease. They are vegetables of Brassica family, other drugs etc. In this study 12patients presented with intake of Goitrogens. Educating them about the consequences of itcan prevent this disease.c) Family history The thyroid diseases are often seen to run in families. In this study 10 patients camewith family history. Enzyme deficiency with in the thyroid gland is seen in the families.d) Agni The Agni is the main factor, which is affected by the thyroid disorders. As there isdiminished appetite in the hypothyroidism and increased in the hyperthyroidism. In thisstudy the patients reported with poor appetite are 5, moderate appetite are 7, good appetiteare 7 and 1 patient presented with severe appetite.e) Sleep It is also affected by the thyroid disease as the Hypos will have the tendency to sleepmore, and the hyperthyroidism patients will be disturbed or less sleep. In this study thepatients with sound sleep are 8, with more sleep are 5, less sleep are 4 and disturbed sleepare 3 in number. 124
  • f) Psychological features The thyroid diseases play a vital role in the change of the character, and mental stateof the patients. This affects the patients seriously changing the emotional attributes. Out ofthe 20 patients, 19 were presented with psychological problems.g) Habits As the majority of the patients were females in this study, the habits were notrelevant.h) Menstrual cycle It is also disturbed by the thyroid problems. As most of the patients were females, itis also considered as an important data to be evaluated. Out of the female patients reportedin this study, 8 have regular menstruation, 5 had irregular and 5 were menopause.i) Built and nutrition The impact of the thyroid problems exhibits the metabolic derangement in underweight and over weight of the body. In hypos the body weight will be increased and inhyperthyroidism patients, it will be reduced. The treatment had impact over the hyperthyroidpatient, as the weight was reduced 2kg in maximum in one patient.j) Nidana The Nidana such as Aharaja and Viharaja are considered in the study. The virudhaAhara and guru Ahara will produces the increased Kapha and ultimately the dushta Kaphawill vitiate the medas and produces the Galaganda. All the patients presented with both theguruahara and virudha ahara.11 patients presented with the Viharaja Nidana Avvaksayana.The intake of Goitrogens dealt before is an important Nidana of Galaganda. The lack of 125
  • iodine is also an important factor in the production of goiter. So the patients are educatedwith to take the iodized salt.5) Amrutadi yoga - Drug Discussion (individual and cumulative effects)A) The cumulative effect of Amrutadi tailam The Amrutadi thailam is directly said in the Yogaratnakara specifically forGalaganda. It is stated in the yoga to take the same in the taila form. So the 11-avarthithailam is made to enhance the guna of its constituents. The Amrutadi thailam has theproperties such as Kandughna, Sophaharatwam, Vedanasthapanam, Kapha-Vata haratwam,Medoghnam, Lekhana, Chedana etc in total. The most of the drugs used in the yoga belongsto Shirovirechaneeya gana, and some of them are Srotoshodakam; which reduces the KaphaDosha, and dushta medas by it’s chedana etc property as mentioned above. This yoga alsopacifies the Sopham, Todam, Vivarnata, the Difficulty in breathing and the difficulty toSwallow by the cumulative effect.B) Individual drug emphasis The drugs of Amrutadi taila are guduchi, hingu, nimba, abhaya, kutaja, pippali, bala,atibala, and devadaru. The mode of action of drugs is based on the theory of Pancha mahabhutas. As thebody is compared of Pancha mahabhuta, considering the Pancha mahabhuta will give moreaction in term of Dosha Dhatu and malas should alter any abnormality occurring. In the constituents of Amrutadi taila, most of the drugs are of tikta, kashaya, katuRasa that pacifies Kapha Dosha. The other constituents have madura Rasa and which haveushnaveerya will pacify Vata Dosha. The drugs having combined such as lekhana, chedana,veedanasthabana, kandughna, sophaharatwa, vrnaroana, siroverachana, and Rasayana. 126
  • Individual drug action 1) Guduchi: It has tikta kashaya Rasa and ushaveerya and prabhava of vishagna. Uses are deepana pachana, anulomana, kandughnam, yakrithuttegaka, raktasodhana. Chemical constituents – it contains berberine, a bitter substance and giloin, a gluco side which also better in taste. 2) Hingu: It has katu, teekshana, Guna and ushanaveerya. It specific action on the body are veedhana, stabana, kandughna, chadana and sophaprashamana. It is useful in reducing the medus. It contains volatile oils, resins, wax etc., 3) Nimba: It has tiktakashaya Rasa and seetaveerya. It is kaphapittaharam. Its main uses are kandughna, raktasodakam, shoshanam and sophaharam. The water soluble part of the alcoholic extract of Azadracta indica shows significant anti-inflammatory activity. 4) Abhaya: It is a good Rasayana, and tridoshaharam. It’s other uses of sophaharam, vedhanam,stabana, mrudu rechanam and srodosodhaka. Chemical constituents – the fruit contains 25-30% tanin, which inhibits the mucus membrane. 5) Kutaja: It is Tikta, Kashaya rasa, Rookshna guna, and Katu Vipaka. It reduces Kapha. The properties are Lekhna, Ropana, Raktashodana. The bark contains, Kurhin which Anti Diarrheal action. 127
  • 6) Pippali: It is Katu rasa, Laghu, Teekshna and Snigda guna. It is Vata, Kapha hara, Shirovirechaniyam, Raktashodakam, Sophaharam, Ojovardhakam. It has anti tumerous activity. 7) Bala: Bala is a drug of choice for Vata rogas. It reduces Sopham. The other uses are Raktashodakam, Ojovardhakam. The methanolic extract of the Abotilinum indicum showed significant oedema suppresent activity. Probable mode action may be due to it’s inhibitory effect on release of mediators of inflammation such as histamine, hydroxy triptanine, bradikinin etc. 8) Devadaram : It is Tikta, Katu rasa. Laghu, Ushna veeryam, Katu vipakam. It is Kapha, Vata haram and also have the property of Sophaharam, Vedanasthapanam, Raktashodakam, Medoroghaghnam. The hexane soluble extracts of the wood of Cedrus deodara were found to posses significant anti- allergic activity. The devadarm contains dark coloured oil and resin.6) The evaluation of Pratimarsha Nasya in Galaganda In this study along with the internal medication, the Pratimarsha Nasya was alsoadministered. As in the classics it is stated that by doing Nasya karma, the disease above theclavicle will be cured. The Nasya karma is classified into two, Pratimarsha Nasya / MarshaNasya. The action of Pratimarsha Nasya done in this study is satisfactorily along with theinternal medicine. It can be even more enhanced if it is given as Marsha Nasya. The MarshaNasya is done after doing the Poorvakarmas. So the action will be more. So in the forth-coming studies it can be included. The mode of action of the Nasya karma is as follows. The absorption of the drugs is carried out in three ways. They are through bloodcirculation, after absorption through mucous membrane. The direct pooling into venous 128
  • sinuses of brain through the inferior ophthalmic veins and the last one the absorptiondirectly into the cerebro-spinal fluid. Apart from the small emissary veins entering the cavernous sinuses of the brain; a pairof venous branch emerging from alae nesi will drain into facial vein. Almost in the oppositedirection inferior ophthalmic veins also enter the facial veins. These opthalmics in otherhand also drains into cavernous sinus of the meninges and in addition neither the facial veinnor the ophthalmic vein have any veinal valves. So there are more chances of blood drainingfrom facial vein into the cavernous sinuses in the lowered head position. The nasal cavity directly opens with the frontal maxillary and sphenoidal air sinuses,epithelial layer is also, continuous through out them. The momentary retention of the drug innaso-pharynx and suction causes oozing of drug material into air sinuses. These sites arerich with blood vessels entering the brain and meninges through the existing foramen in thebones. So there is better chances drug transportation in this route. Recent authors as middle cephalic fossa of the skull have explained the shringatakamarma. It is consisting with para nasal sinuses and meningial vessels and nerves. One cansee the truth of narration made by Vagbhata here. The drug administered enters the paranasal sinus especially frontal and sphenoidal sinuses, i.e., shringataka where the ophthalmicveins and the other veins. The sphenoidal sinuses are in close relation with intra-cranial structures. Thus theremay be a so far undetected route between air sinuses and cavernous sinuses enabling thetransudation of fluids. As a whole, the mentioning of the sringataka in this context seems tomove reasonable. 129
  • 7) Overall assessment of Amrutadi Yoga in Galaganda The lab-investigations were done before treatment and after treatment. In these studythe parameters are T3, T4, and TSH. It is dependent on each other in the thyroid disordershypothyroidism and hyperthyroidism. So a difference in them has no value as the TSH isincreased in the hypothyroidism and it is decreased in the hyperthyroidism. So a commonassessment is not possible. It is then done by classifying the whole data into three groups asby assessing the appropriate values of T3, T4 and TSH in concern with the three types ofthyroid diseases. The result is calculated as Responded, Maintained and Not responded from thevalues of the lab-investigations. The responded group patient’s shown the value reducedconsiderably in parlance with the normal values. These patients belong to theHypothyroidism. So it can be decided that the Amrutadi thailam is more effective inhypothyroidism patients. The TSH was not increased in the hyperthyroid patients, so they were considered asNon responded. The other patients who were Euthyroidism have the TSH values in the borderline ofthe hypothyroidism. They were 8 in numbers and kept under, maintained group as they weremaintained by the treatment. These classification is given to the subjective parameters also and compared thepercentage of response to the treatment. As the lab- investigation is an unbiased one it istaken to declare the results. 130
  • 8) Discussion on statistical analysis of subjective and objective parameters All parameters show highly significant (from table –D1 and D2). The parametersToda show highly significant before and after treatment in the group (By using paired t- testas P<0.001). The Ganda and Kandu parameters having approximately same effect, Even thoughthey show highly significant (By comparing t- value). There is much variation in Vivarnataand Difficulty in breathing (By comparing variances). The objective parameter T3 is not significant (as p< 0.05). The parameter T4 andTSH are highly significant. Further if we want to study the mean effects of Hypothyroidism, Hyperthyroidismand Euthyroidism by making them as three different groups. Group I as Hypo, Group II ashyper and Group III as Euthyroidism. The parameter T3, i.e. mean effects on three groups is same. (Not Significant as P>0.05) from table –D3. The parameter T4 from table –D4, The mean effects on three groups are not same(significant as (P<0.05). to find out which pair groups is significant, by comparing the Leastsignificance difference value the following conclusions can be made out (from table D5). 4. The group Hyperthyroidism differs significantly from Group Hypothyroidism and Group Euthyroidism. 5. The Group Euthyroidism and Group Hypothyroidism also differ significantly. 6. Group Hypothyroidism is not significant. 131
  • The parameter TSH from table-D6, the mean effects on three groups is not same(significant as P<0.005). To find out which pairs Groups are significant, by comparing Leastsignificance difference value (table D7), the following conclusions can made out. 2) Group Hypothyroidism is Significant 3) Group Hyperthyroidism and Group Euthyroidism are Significant 4) Group Hyperthyroidism is not significant.9) The concepts to be focussed in the forth coming study a. The study duration should be increased to explore the effects of the medicine. b. Educating the people about the importance of thyroid diseases, its causes especially in young age and pregnant women as need of the thyroid hormones will be more. c. More research should be conducted to explore the chemical constituents of the each drug used in Yoga. d. More advanced techniques of the Serum analysis of the thyroid should conducted.10) Limitations of the study 1. As the thyroid diseases are serious multi systemic metabolic disorders, its influence will also will be more. The study duration was less. So the duration of the treatment should be increased. 2. The study was limited to the patients who attended the OPD wing of DGM Ayurvedic medical college, Gadag. 3. As the T3, T4 and TSH were not cost- effective, the patients’ co-operation was not satisfactorily. 132
  • 4. The study must include more serum analysis, thyroid scan and other tests, then the study will be more authentic. 5. Most of the patients were females, and illiterate, so even after the awareness about the consequences of iodine deficiency, they still continue to take the local salt. They will also take several Goitrogens during the treatment. If the patients were self- realized about the Pathya and Apathyas, the result would have been excellent.12) Conclusion 1. Galaganda (goiter) is a serious multi-systemic metabolic disorder, which has its effects on the daily routine one’s life. 2. The Galaganda mentioned in Ayurveda can be compared with goiter in the contemporary science by the similarity of some symptoms like swelling, kandu, vivaranta, difficulty in breathing etc., 3. The Galaganda is a sophapradana Vyadhi, the vishashana of Kapha Dosha is the main cause of it. There is involvement of Vata and medus in the pathogenesis of Galaganda. 4. Out of the sample size of 20 patients, 17 patients were included in the study as 3 discontinued. In the age group maximum number of patients came in the age group 35-55, i.e., 11 the male to female to ratio was observed as 1:9 the percentage of distribution does show the gender differentiation to get thus metabolic disease as 90% were female. The majority of the patients present with middle economic status do not have any habits. The 7 patients of the Agni group had moderate Agni, five had mandagni, out of the patients in the sleep category 5 had more sleep, 4 had less sleep and 8 had sound sleep. 95% of the patients were effected psychologically due 133
  • to this disease. 8 female reported with regular menstruation 5 had irregular menstruation and rest 5 was menopause. 7 patients reported well built,8 thin built and 5 were obese. The Nidana factors were present in all patients like the guru and virudha Ahara. The systemic problems were also present as 60% effected with cordio respiratory problems, 45% with gastrointestinal tract problems, 80% with dermatological problems 55% with neuromuscular and 10% with reproductive pathologies.5. The result declaration was made on the basis of lab investigations, as it is an unbiased data, which states as responded – 6, maintained –8 and not responded-3 patients.6. The patients responded in the treatment were 6 in number, they were all hypo thyroid and the 8 maintained almost of them were in the borderline of hypo thyroidism, but they were present with euthyroid. So a conclusion on the result can be made as drug has more action in the hypo thyroidism. The 3 not responded patients were of the hyperthyroidism.7. In this study the medicine was in the form of oil which is a direct reference from Yogaratnakara. It was made by 11 avarthi of the taila, so the effect of the drug will be more enhanced by the repeated processing of the taila each time with the kwatham and kalkam.8. The internal medicine has responded well in reducing the chief symptom such as ganda, toda, vivarnata, kandu etc., considerably along with the prademarshanasya. 134
  • Summary The thyroid disorders are characterized by physical and mental interference. InAyurveda there is not an exact term for thyroid gland. We can correlate goiter and sometumor pathology of thyroid to ‘Galaganda’ where thyroid functions may or many not areaffected. In the contemporary system of medicine the treatment given to thyroid disorders areanti-thyroid drugs, radio active iodine and surgery which has its own disadvantages and sideeffects. The main ambitions in the study are - 1) Evaluate the anti Goitrogenic effect ofAmrutadi thailam in Galaganda (Hypothyroidism or hyperthyroidism), 2) Evaluate the effectof Amrutadi thailam on T3, T4 and TSH in Galaganda and 3) to evaluate the effect ofAmrutadi thailam Pratimarsha in Galaganda. Susruta defines Galaganda as a swelling (mass in the neck region), by the vitiation ofVata, Kapha and medo dhatu. Charaka mentioned that when a vitiated Kapha Doshacirculates around the neck, it will cause swelling slowly is termed as Galaganda From the contemporary medical science, Goitre is defined as a benign, non-toxicenlargement of the thyroid gland usually secondary to some form or other of the iodinedeficiencies. The disease is characterised by swollen throat, hoarseness of voice, slight pain,in the neck region, difficulty to swallow, etc. There is no reference regarding the disease Galaganda in the Vedic literatures. InSusruta Nidana, mentions about the Galaganda Samprapti are very clear. Here the vitiatedKapha will stay around the neck region and produce swelling, which is called as Galaganda. 135
  • The intake of tikta, katu, kashaya rasa , rookshannam, alpamatara bhojanam etcvitiate then Vata Dosha. Mental factors like chinta, sokha, krodha, bhaya, etc vitiate VataDosha. The increased Vata and Kapha Dosha in the neck will vitiate the medo Dhatu by itsprakopa karanas respectively. The deficiency of iodine content in the food is the main causefor goitre. Goitrogens are foods, which suppress thyroid function. In normal, Goitrogens caninduce hypothyroidism and goiter. In hypos, Goitrogens can further depress thyroidalfunction and stimulate the growth of the thyroid (goiter). The thyroid disorders and goiter are common in the females, in the certain ages, inspecific part of the world. The primary toxic goiter is usually present in young ones, wherein Hashimoto’s disease the victims are middle-aged women. Majorities of the thyroiddisorders are seen in females. Even thyroid carcinomas are more often seen in females in theratio 3:1. In men lack of thyroid hormone is likely to cause loss of libido, impotence. Except endemic goitres due to iodine deficiency, no other thyroid disorders liesamong peculiar geographical distribution. While many hyper secretaries to limit thyroid output by iodine restriction, thisstrategy can backfire. Iodine restriction will cause the thyroid to increase in size (goitre) inan effort to filter more blood to get more iodine. When iodine is then re-introduced to thediet or accidentally ingested, the now larger thyroid gland has the capacity for greaterthyroid hormone production. The iodine restriction is not a good long-term method for controlling thyroidhormone production. Once copper is replenished and copper metabolism is workingproperly, the body will tolerate iodine without increasing thyroid hormone production 136
  • The primary pre-condition for the production of thyroid disease is the onset ofanemia. Brassica vegetables, with their high sulphur content, may be foods, which induceanaemia and consequently thyroid disease. Thiocyanates, Anti thyroid drugs, lithium,iodides, p- amino salicylic acid, etc are also Goitrogenic. There is enzyme deficiency in thethyroid gland. This leads to formation of decreased level of thyroid hormones, which willincrease TSH, and simple goitre is formed. This leads to reduced levels of thyroid hormonesand hence the goitre. Interference with thyroid hormone synthesis As thyroid hormone increases metabolism in almost all cells of the body, excessivequantities of the hormone can occasionally increased the BMR to 60 to 100% above normal.Conversely when no thyroid hormone is produced the BMR falls almost to one – halfnormal. Greatly increased thyroid hormones almost always decrease the body weight, andgreatly decreased hormone almost always increases the body weight. Thyroid hormone increases both the rates of secretion of digestive juices and themotility of the gastro-intestinal tract. Lack of thyroid hormone can cause constipation.Thyroid hormones increases the rapidity of cerebration but also often dissociates thisconversely, lock of thyroid hormone decreases this function. Poorvarupa are the prodromal symptoms of the forthcoming disease, which do notclarify the Samprapti of the disease. The vitiated Kapha, Vata, and medas will show somelakshnas such as mild swelling of the neck, pain the neck, heaviness of the body. Charaka has mentioned Galaganda as a swelling in the neck by the vitiation ofKapha Dosha .He describes that, the Kapha Dosha vitiated by the etiological factors willmanifests in the frontal part of the neck and produce a swelling slowly. Hypo-thalomo-pituitary disorders can be responsible for inducing under active or overactive thyroid states. 137
  • 1. This study is a prospective clinical study of Amrutadi thailam in Galaganda.2. 17 patients were selected for the study in one group.3. The goitre is present in both types of thyroid disorders such as hypo thyroidism and hyperthyroidism.4. The signs and symptoms of Galaganda mentioned in Ayurvedic system is taken for the study.5. The difficulty to swallow was reduced in all 17 patients.6. The drugs of the Amrutadi taila comprised of kaphahara property and the drugs such as guduchi, pippali, etc., reduces the srotorodham caused by Kapha Dosha. The symptoms were assessed statistically also and found highly significant.7. After the assessment of both subjective and objective parameters the results are, hypo thyroid patients were responded to the treatment, the euthyroid patients were maintained with the treatment and the hyper thyroid patients were not responded to the treatment.8. The not responded group consists of three patients of hyperthyroidism.9. The patients reported with hypothyroidism were 8 in number. Out of them 6 patients responded to the treatment. The signs and symptoms presented by those patients were classified into 3 as such general features, systemic and psychological.10. The weight gain and goitre was present in 6 cases and puffy face was present in 2 patients.11. The symptoms were maintained by the treatment, but the hypertension persisted after the treatment. 138
  • 12. The thyroid diseases are common in the middle-aged women. It is common in 35-55 age group, the patients, reported were 11 in number.13. Most of the patients belong to the sedentary group.14. The majority of the patients reported with gradual onset of the disease. In this study of 20 patients, 17 presented with gradual onset of the disease. 3 patients were reported with insidious onset.15. The thyroid diseases are often seen to run in families. In this study 10 patients came with family history.16. The thyroid diseases play a vital role in the change of the character, and mental state of the patients. This affects the patients seriously changing the emotional attributes. Out of the 20 patients, 19 were presented with psychological problems.17. In hypothyroidism patients the body weight will be increased and in hyperthyroidism patients, it will be reduced. The treatment had impact over the hyperthyroid patient, as the weight was reduced 2kg in maximum in one patient.18. All the patients presented with both the guruahara and virudha ahara.19. The parameter T4 and TSH are highly significant in the study.20. The group Hyperthyroidism differs significantly from Group Hypothyroidism and Group Euthyroidism.21. The Group Euthyroidism and Group Hypothyroidism also differ significantly.22. Group Hypothyroidism is Significant 139
  • Bibliographic References1. Sushrutha, Sushruthasamhitha Nidanasthana chapter 11 sloka 23. Varanasi: Krishnadas Academy; 1980. p. 314. (Krishnadas Ayurveda series 51).2. Ahuja M.M.S, API Textbook of Medicine section XV Endocrinology. 6th ed. Sainani.G.S editor. Mumbai: Association of Physicians of India. p. 953-955.3. Baghel M S Dr, Researches in Ayurveda chapter 4. Jamnagar: Mrudu Ayurvedic Publications; p. 73.4. Ibid p. 73.5. Ahuja M.M.S, API Textbook of Medicine section XV Endocrinology. 6th ed. Sainani.G.S editor. Mumbai: Association of Physicians of India. p. 951.6. Raja Radhakantha Deva Bahadur, Shabdakalpadruma vol 2, 3rd ed. Varanasi: Chaukhambha Sanskrit Series; p. 150. (Chaukhambha Samskrita Granthamala-93).7. Das Somen, A Concise textbook of Surgery chapter 37. 2nd ed. Calcutta: Dr.S.Das; 1999. p. 646.8. Pocket oxford dictionary, march 1994, Walton street, Oxford, Computer edition9. Chaudiri k Sujit, Concise Medical Physiology chapter 6. 2nd ed. Calcutta: New Central Book Agency Pvt. Ltd; 1993. p. 289.10. Sushrutha, Sushruthasamhitha Nidanasthana chapter 11 sloka 23. Varanasi: Krishnadas Academy; 1980. p. 314. (Krishnadas Ayurveda series 51).11. Dalhana, Nibandha samgraha teeka on Sushruthasamhitha Nidanasthana chapter 11 sloka 23. Varanasi: Krishnadas Academy; 1980. p. 314. (Krishnadas Ayurveda series 51).12. Agnivesa, Charakasamhitha Suthrasthana chapter 18 sloka 21. 4th ed. Varanasi: Chaukhambha Sanskrit Sansthan; 1994. p. 107. (Kasi Sanskrit series 228).13. Madhavakara, Madhavanidana chapter 22 sloka 212. Varanasi: Chaukhambha Surbharathi Prakashan; Chaukhambha Ayurvijnana Granthamala 46, 1998. p. 520.14. Ibid 18 sloka 2115. Vakil Jal Rustom, Text book of medicine, The association of Physician India, Bombay, 1969, pp 32516. Agnivesa, Charakasamhitha Suthrasthana chapter 18 sloka 21. 4th ed. Varanasi: Chaukhambha Sanskrit Sansthan; 1994. p. 107. (Kasi Sanskrit series 228).17. Sushrutha, Sushruthasamhitha Nidanasthana chapter 11 sloka 23. Varanasi: Krishnadas Academy; 1980. p. 314. (Krishnadas Ayurveda series 51).18. Ibid Chikitsasthana chapter 19 sloka 74.19. Agnivesa, Charakasamhitha Suthrasthana chapter 18 sloka 21. 4th ed. Varanasi: Chaukhambha Sanskrit Sansthan; 1994. p. 107. (Kasi Sanskrit series 228).20. Vagbhata, Ashtangahridaya Utharasthana chapter 21 sloka 43. Varanasi: Krishnadas Academy; 1982. p. 749. (Krishnadas Academic series 4).21. Madhavakara, Madhavanidana chapter 22 sloka 212. Varanasi: Chaukhambha Surbharathi Prakashan; 1998. p. 520. (Chaukhambha Ayurvijnana Granthamala 46).22. Yogaratnakara Galaganda nidana Sloka 1. Vaidya Lakshmipatisastry editor. Varanasi: Chaukhambha Sanskrit Sansthan; 1988. p. 143. (Kasi Sanskrit series 160).23. Bhavamishra, Bhavaprakasha Madhyamakhanda chapter 44 sloka 2. 5th ed. Varanasi: Chaukhambha Orientalia; 1988. p. 442. (Chaukhambha Sanskrit series 130).24. Chakrapanidatta, Chakradatta chapter 41. P.V.Sharma, editor. Varanasi: Chaukhambha Publishers; 1998. p. 320. (Kasi Ayurveda series 17). Bibliographic References i
  • 25. Vangasena, Vangasenasamhitha Galaganda adhikara sloka 186-190. Jain Sankarlalji Vaidya editor. Mumbai: Khemnath Srikrishnadas publishers; 1996. p. 754.26. Ahuja M.M.S, API Textbook of Medicine section XV Endocrinology. 6th ed. Sainani.G.S editor. Mumbai: Association of Physicians of India. p. 951.27. Das Somen, A manual on Clinical Surgery chapter 27. 4th ed. Calcutta: Dr.S.Das; 1996. p. 284.28. Davidson Stanley Sir, Principles and Practice of Medicine chapter 12. 17th ed. CRW Edwards, editor. London: Churchill Livingston 1995. p. 686.29. Agnivesa, Charakasamhitha Vimanasthana chapter 4 sloka 21. 4th ed. Varanasi: Chaukhambha Sanskrit Sansthan; 1994. p. 198. (Kasi Sanskrit series 228).30. Madhavakara, Madhavanidana chapter 1 sloka 4. Varanasi: Chaukhambha Surbharathi Prakashan; 1998. p. 6. (Chaukhambha Ayurvijnana Granthamala 46).31. Ashtangasangraha Suthrasthana chapter 20 sloka 11.Prof.K.R.Shrikhantamurthy editor. Varanasi: Chaukhambha Orientalia; 1996. p. 374. (Jaikrishnadas Ayurvedic series 79).32. Agnivesa, Charakasamhitha Suthrasthana chapter 18 sloka 21. 4th ed. Varanasi: Chaukhambha Sanskrit Sansthan; 1994. p. 107. (Kasi Sanskrit series 228).33. Vagbhata, Ashtangahridaya Nidanasthana chapter 1 sloka 14-15. Varanasi: Krishnadas Academy; 1982. p. 444. (Krishnadas Academic series 4).34. Agnivesa, Charakasamhitha Suthrasthana chapter 18 sloka 21. 4th ed. Varanasi: Chaukhambha Sanskrit Sansthan; 1994. p. 107. (Kasi Sanskrit series 228).35. Vagbhata, Ashtangahridaya Nidanasthana chapter 1 sloka 17. Varanasi: Krishnadas Academy; 1982. p.445. (Krishnadas Academic series 4).36. Agnivesa, Charakasamhitha Suthrasthana chapter 18 sloka 21. 4th ed. Varanasi: Chaukhambha Sanskrit Sansthan; 1994. p. 107. (Kasi Sanskrit series 228).37. Sushrutha, Sushruthasamhitha Suthrasthana chapter 21 sloka 5. Varanasi: Krishnadas Academy; 1980. p. 165. (Krishnadas Ayurveda series 51).38. Agnivesa, Charakasamhitha Vimanasthana chapter 5 sloka 16. 4th ed. Varanasi: Chaukhambha Sanskrit Sansthan; 1994. p. 265. (Kasi Sanskrit series 228).39. http://www.northmemorial.com/40. J Larry Jameson, Harrison’s Principles of Internal Medicine Disorders of thyroid Chapter 330. 15th ed. McGraw-Hill2003. p. 1077.41. J Larry Jameson, Harrison’s Principles of Internal Medicine Disorders of thyroid Chapter 330. 15th ed. McGraw-Hill2003. p. 1077.42. Das Somen, A Concise textbook of Surgery chapter 37. 2nd ed. Calcutta: Dr.S.Das; 1999. p. 647.43. Das Somen, A Concise textbook of Surgery chapter 37. 2nd ed. Calcutta: Dr.S.Das; 1999. p. 647.44. Das Somen, A Concise textbook of Surgery chapter 37. 2nd ed. Calcutta: Dr.S.Das; 1999. p. 647.45. Ahuja M.M.S, API Textbook of Medicine section XV Endocrinology. 6th ed. Sainani.G.S editor. Mumbai: Association of Physicians of India. p. 955.46. Davidson Stanley Sir, Principles and Practice of Medicine chapter 12. 17th ed. CRW Edwards, editor. London: Churchill Livingston 1995. p. 692.47. Ahuja M.M.S, API Textbook of Medicine section XV Endocrinology. 6th ed. Sainani.G.S editor. Mumbai: Association of Physicians of India. p. 953. Bibliographic References ii
  • 48. Davidson Stanley Sir, Principles and Practice of Medicine chapter 12. 17th ed. CRW Edwards, editor. London: Churchill Livingston 1995. p. 686.49. Chaurasia B D, Human Anatomy Vol-3 chapter 12.3rd ed. 1995.CBS publishers and distributors New Delhi p. 135.50. Peter. L. Williams Grays Anatomy Chapter 6. 38th ed. Philadelphia: Churchill Living Stone; 2000. p. 354.51. Martini.F.H, Fundamentals of Anatomy and Physiology chapter 5. 4th ed. New Jersey: Prentice Hall Inc. Simon & Schuster; 1998. p. 609-612.52. Chaudiri K Sujit, Concise Medical Physiology chapter 7. 2nd ed. Calcutta: New Central Book Agency Pvt. Ltd; 1993. p. 293.53. Chaudiri k Sujit, Concise Medical Physiology chapter 7. 2nd ed. Calcutta: New Central Book Agency Pvt. Ltd; 1993. p. 293.54. Martini.F.H, Fundamentals of Anatomy and Physiology chapter 5. 4th ed. New Jersey: Prentice Hall Inc. Simon & Schuster; 1998. p. 612.55. Guyton and Hall Text Book of Medical Physiology chapter 76. 10th ed. New Delhi: Harcourt India Pvt Ltd; 2001. p. 861.56. Guyton and Hall Text Book of Medical Physiology chapter 76. 10th ed. New Delhi: Harcourt India Pvt Ltd; 2001. p. 861-3.57. Vagbhata, Ashtangahridaya Nidanasthana chapter 1 sloka 4. Varanasi: Krishnadas Academy; 1982. p.442. (Krishnadas Academic series 4).58. Madhavakara, Madhavanidana chapter 1 sloka 6. Varanasi: Chaukhambha Surbharathi Prakashan; 1998. p. 7. (Chaukhambha Ayurvijnana Granthamala 46).59. Sushrutha, Sushruthasamhitha Nidanasthana chapter 11 sloka 23-24. Varanasi: Krishnadas Academy; 1980. p. 314. (Krishnadas Ayurveda series 51).60. Sushrutha, Sushruthasamhitha Nidanasthana chapter 11 sloka 23-24. Varanasi: Krishnadas Academy; 1980. p. 314. (Krishnadas Ayurveda series 51).61. Vagbhata, Ashtangahridaya Utharasthana chapter 21 sloka 43. Varanasi: Krishnadas Academy; 1982. p. 749. (Krishnadas Academic series 4).62. Yogaratnakara Galaganda nidana sloka 3. Vaidya Lakshmipatisastry editor. Varanasi: Chaukhambha Sanskrit Sansthan; 1988. p. 143. (Kasi Sanskrit series 160).63. Bhavamishra, Bhavaprakasha Madhyamakhanda chapter 44 sloka 3. 5th ed. Varanasi: Chaukhambha Orientalia; 1988. p. 442. (Chaukhambha Sanskrit series 130).64. Sushrutha, Sushruthasamhitha Nidanasthana chapter 11 sloka 23-24. Varanasi: Krishnadas Academy; 1980. p. 314. (Krishnadas Ayurveda series 51).65. Sushrutha, Sushruthasamhitha Nidanasthana chapter 11 sloka 23-24. Varanasi: Krishnadas Academy; 1980. p. 314. (Krishnadas Ayurveda series 51).66. Vagbhata, Ashtangahridaya Utharasthana chapter 21 sloka 43. Varanasi: Krishnadas Academy; 1982. p. 749. (Krishnadas Academic series 4).67. Yogaratnakara Galaganda nidana sloka 3. Vaidya Lakshmipatisastry editor. Varanasi: Chaukhambha Sanskrit Sansthan; 1988. p. 143. (Kasi Sanskrit series 160).68. Bhavamishra, Bhavaprakasha Madhyamakhanda chapter 44 sloka 4. 5th ed. Varanasi: Chaukhambha Orientalia; 1988. p. 442. (Chaukhambha Sanskrit series 130).69. Sushrutha, Sushruthasamhitha Nidanasthana chapter 11 sloka 23-24. Varanasi: Krishnadas Academy; 1980. p. 314. (Krishnadas Ayurveda series 51).70. Vagbhata, Ashtangahridaya Utharasthana chapter 21 sloka 43. Varanasi: Krishnadas Academy; 1982. p. 749. (Krishnadas Academic series 4). Bibliographic References iii
  • 71. Sushrutha, Sushruthasamhitha Nidanasthana chapter 11 sloka 23-24. Varanasi: Krishnadas Academy; 1980. p. 314. (Krishnadas Ayurveda series 51).72. Vagbhata, Ashtangahridaya Utharasthana chapter 21 sloka 43. Varanasi: Krishnadas Academy; 1982. p. 750. (Krishnadas Academic series 4).73. Yogaratnakara Galaganda nidana sloka 3. Vaidya Lakshmipatisastry editor. Varanasi: Chaukhambha Sanskrit Sansthan; 1988. p. 143. (Kasi Sanskrit series 160).74. Bhavamishra, Bhavaprakasha Madhyamakhanda chapter 44 sloka 4. 5th ed. Varanasi: Chaukhambha Orientalia; 1988. p. 443. (Chaukhambha Sanskrit series 130).75. Ahuja M.M.S, API Textbook of Medicine section XV Endocrinology. 6th ed. Sainani.G.S editor. Mumbai: Association of Physicians of India. p. 953.76. Ibid77. Ibid78. Davidson Stanley Sir, Principles and Practice of Medicine chapter 12. 17th ed. CRW Edwards, editor. London: Churchill Livingston 1995. p. 687.79. J Larry Jameson, Harrison’s Principles of Internal Medicine Disorders of thyroid Chapter 330. 15th ed. McGraw-Hill2003. p. 2070.80. Ahuja M.M.S, API Textbook of Medicine section XV Endocrinology. 6th ed. Sainani.G.S editor. Mumbai: Association of Physicians of India. p. 953.81. Ibid p. 955.82. Davidson Stanley Sir, Principles and Practice of Medicine chapter 12. 17th ed. CRW Edwards, editor. London: Churchill Livingston 1995. p. 693.83. J Larry Jameson, Harrison’s Principles of Internal Medicine Disorders of thyroid Chapter- 330. 15th ed. McGraw-Hill2003. p. 2067.84. Ahuja M.M.S, API Textbook of Medicine section XV Endocrinology. 6th ed. Sainani.G.S editor. Mumbai: Association of Physicians of India. p. 955.85. Sushrutha, Sushruthasamhitha Nidanasthana chapter 11 sloka 23. Varanasi: Krishnadas Academy; 1980. p. 304. (Krishnadas Ayurveda series 51).86. Dalhana & Gayadasa, Nibandha samgraha & Nyayapanjika commentaries on Sushruthasamhitha Nidanasthana chapter 11 sloka 23. Varanasi: Krishnadas Academy; 1980. p. 304. (Krishnadas Ayurveda series 51).87. Agnivesa, Charakasamhitha Suthrasthana chapter 18 sloka 21. 4th ed. Varanasi: Chaukhambha Sanskrit Sansthan; 1994. p. 107. (Kasi Sanskrit series 228).88. Vagbhata, Ashtangahridaya Nidanasthana chapter 21 sloka 43. Varanasi: Krishnadas Academy; 1982. p. 749. (Krishnadas Academic series 4).89. Madhavakara, Madhavanidana chapter 22 sloka 212. Varanasi: Chaukhambha Surbharathi Prakashan; 1998. p. 520. (Chaukhambha Ayurvijnana Granthamala 46).90. Agnivesa, Charakasamhitha Suthrasthana chapter 10 sloka 7-8. 4th ed. Varanasi: Chaukhambha Sanskrit Sansthan; 1994. p. 56. (Kasi Sanskrit series 228).91. Sushrutha, Sushruthasamhitha Nidanasthana chapter 11 sloka 28. Varanasi: Krishnadas Academy; 1980. p. 314. (Krishnadas Ayurveda series 51).92. Madhavanidana chapter 22 sloka 212. Varanasi: Chaukhambha Surbharathi Prakashan; 1998. p. 520. (Chaukhambha Ayurvijnana Granthamala 46).93. Sushrutha, Sushruthasamhitha Suthrasthana chapter 35 sloka 18. Varanasi: Krishnadas Academy; 1980. p. 152. (Krishnadas Ayurveda series 51).94. Sushrutha, Sushruthasamhitha Chikitsasthana chapter 23 sloka 7-9. Varanasi: Krishnadas Academy; 1980. p. 486. (Krishnadas Ayurveda series 51). Bibliographic References iv
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  • SPECIAL CASESHEET FOR GALAGANDA (GOITRE) Post Graduate Studies And Research Center (Kayachikitsa) Shree DGM Ayurvedic Medical College, Gadag.Guide : Dr. V.Varadacharyalu, PG Scholar :Co- Guide : Dr. K.Shivaramprasad Renjith. P. Gopinath1. Name of the patient : Sl. No :2. Father’s / Husband’s Name : OPD No :3. Age : IPD No :4. Sex : M F5. Religion : Hindu Muslim Christian others6. Occupation : Sedentary Active Labour others7. Economical Status : BPL Middle Upper middle class High class8. Diet : Veg Mixed9. Address :_____________________________ Phone No : ____________________________ _____________________________ Pin10. Selection Included : Excluded :11. Date of Schedule Initiation : Date of Schedule Completion :12. Result : Relieved Major Minor Not Discontinued Improvement Improvement Responded Informed Consent I_________________ Son / Daughter /Wife of ___________________-am exercising my free will, to participate in above study as a subject. I have been informed to my satisfaction, by the attending physician the purpose of the clinical evaluation and nature of the drug treatment. I am also aware of my right to quit the treatment at any time during the course. Patient’s Signature 1
  • 13. Presenting Complaints & Assessment. After Before After Follow Complaints Duration treatment treatment up 1. GANDA ( Mass in the neck) 2. TODA (Pain over the mass) 3. VIVARNATA (Discoloration of skin over the mass) 4. KANDU (Itching around the mass) 5. DIFFICULTY IN SWALLOWING 6. DIFFICULTY IN BREATHING Scores for assessment 1) Ganda (Mass in the Neck) 1. No mass seen, 2. Mild sized mass, 3. Moderate sized mass, 4. Large sized mass 2) Toda (Pain over the Mass) 1. No Pain 2. Tells on enquiry 3. Tolerable Pain 4. Severe 3) Vivarnata (Discoloration 1. No Discoloration 2. Mild Discoloration of skin over the Mass) 3. Moderate Discoloration 4. Severe colour change 4) Kandu (Itching around 1. No Itching 2. Mild Itching the Mass) 3. Moderate Itching 4. Severe Itching 5) Difficulty in Swallowing 1. No complaints 2. Difficulty to swallow solids 3. Difficulty to swallow liquids 6) Difficulty in Breathing 1. No complaints 2. Mild 3. Moderate 4. Severe14. History of present illnessa) Mode of onset :- Gradual Sudden Insidiousb) Nature of symptoms :- Progressive Constant Regressive15. History a) Past illness b) Any Goitrogenic drugs :- c) Radiation therapy :- d) Radioactive iodine :- e) Any member of the family affected with similar complaints f) Any intake of goitrogens : g) Appetite:- Poor Moderate Good Severe 2
  • h) Bowel:- Constipated Loose Normal i) Urine :- Frequency Day Night Painful micturation j) Sleep :- Sound Less More Disturbed k) Psychiatric Features Mental State – Behaviour and emotions – l) Habits :- No Smoking Alcohol Tobacco m) Menstrual Cycle :- Regular Irregular Menopause n) Built and nutritions Well Thin Obese 16) Vital Examination o Temperature c Pulse /min Blood Pressure /mmhg Weight kg Respiratory rate /min Height cm17. Special ExaminationAyurvedic Nidana Ahara Vihara Gurubhojana Avaak shayya Virudhabhojana Smoking Roopa Vataja P A Kaphaja P A Medoja P A Toda Sthira Snigdhata ganda Krishnasira Manda Mrudu avanadha ruk Vivarnata Kandu Pandu varna Shaitya Durgandha Atikandu 3
  • ContemporaryGeneral examination ( Physical) :-Lean ObeseWeight gain Weight lossWasting of muscles Over sweatingExophthalmos Puffy faceMyxoedema ThirstSevere appetitePsychological :-ExcitementTensionNervousnessSystemic :-System Observed Symptoms if anyCardiorespiratoryGastrointestinalDermatologicalNeuromuscularReproductive18.Laboratory investigations Name of Values the test Before AfterSerum T3Serum T4TSHR.B.SE.C.GScan19. Diagnosis :- 4
  • 20.Treatment Protocol Distribution Amruthadiyoga RemarksInitial – Day1 nd st2 – 1 month st nd1 Month – 2 Month nd rd2 Month- 3 Month21.Investigator’s Note Signature of ScholarSignature of Co-guide Signature of Guide 5