Evaluation of the efficacy of

AMRUTADI 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

KayachikitsaUnder the Guidance of

Dr. V. Varada CharyuluM.D. (Ayu) (Osm)

Dr. Shiva Rama Prasad KethamakkaM.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 CENTERGADAG, 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 of

AMRUTADI 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 Health

Sciences, Bangalore, Karnataka.

.

(Dr. G. B. Patil)Principal,

DGM Ayurvedic Medical College,Gadag

Date:Place: Gadag

(Dr. V. Varada charyulu)Professor & HOD

Dept. of KayachikitsaPGS&RC

Date:Place: Gadag

D.G.M.AYURVEDIC MEDICAL COLLEGE

POST GRADUATE STUDIES AND RESEARCH CENTERGADAG, 582 103

This is to certify that the dissertation entitled “Evaluation of the efficacy of

AMRUTADI YOGA IN GALAGANDA (GOITER)” is a bonafide research work done by

“Renjith. P. Gopinath” in partial fulfillment of the requirement for the post graduation

degree of “Ayurveda Vachaspati M.D. (Kayachikitsa)” Under Rajeev Gandhi University of

Health Sciences, Bangalore, Karnataka.

Dr. V. VARADA CHARYULU

M.D. (Ayu) (Osm)Guide

Professor & HOD

Dept. of Kayachikitsa

PGS&RC

Date:

Place: Gadag

Dr. SHIVA RAMA PRASADKETHAMAKKA

M.D. (Ayu) (Osm) M.A. (Jyotish), [Ph.D (Jyotish)]Co- Guide

READER IN KAYACHIKITSA

DGMAMC, PGS&RC, Gadag

Date:

Place: Gadag

Declaration by the candidate

I here by declare that this dissertation / thesis entitled “Evaluation of the efficacy of

AMRUTADI YOGA IN GALAGANDA (GOITER)” is a bonafide and genuine research

work carried out by me under the guidance of Dr.V.Varada Charyulu M.D. (Ayu) (Osm) and

Dr. SHIVA RAMA PRASAD KETHAMAKKA, M.D. (Ayu) (Osm) M.A. (Jyotish), [Ph.D

(Jyotish)], Reader in Kayachikitsa, DGMAMC, PGS&RC, Gadag.

Date

Place

(Renjith. P. Gopinath)

Copy right

Declaration by the candidate

I here by declare that the Rajiv Gandhi University of Health Sciences, Karnataka shall

have the rights to preserve, use and disseminate this dissertation/ thesis in print or electronic

format for the academic / research purpose.

Date

Place

(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.

AcknowledgementAt first my sincere thanks to the subjects who cooperated at my dissertation, with

out 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 and

critical suggestion associated with expert guidance at the completion of this dissertation.

I express my obligation to beloved principal Dr. G. B. Patil, Principal for his

encouragement 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, teachers

and colleagues of sister concern departments along with the ministerial and sub staff of the

D.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. Nandakumar

for his help in statistical analysis of results.

I express my deepest gratitude to my beloved parents, Dr.P.S.Gopi, and

Dr.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 for

their inspiration.

With respect and affection, I acknowledge my ever-remembering late Grand father

Shri M.P. Kunjan Vaidyan who inspired me all the time

Place:Date:

Renjith. P. Gopinath

Table of contents

Evaluation of the efficacy of Amrutadi yoga in Galaganda (goiter)

Heading Page number

Chapter -1 Introduction 1 to 4

Chapter –2 Objectives 5 to 7

Chapter –3 Review of literature 8 to 53

Chapter –4 Methodology 54 to 79

Chapter –5 Results 80 to 112

Chapter –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) Page

1 Lakshana of Vataja Galaganda 31

2 Lakshana of Kaphaja Galaganda 32

3 Lakshana of Medoja Galaganda 33

4 Showing clinical features of Hyperthyroidism 35

5 Showing clinical features of Hypothyroidism 36

6 Differential diagnosis of Galagraha and Apachi 50

7 Differential features of Galaganda, Galavidradhi, Kanthashaluka andMamsatana.

51

8 General survey of the thyroid patients for Hyper or Hypo thyroidism 629 Distribution of patients by age 80

10 Distribution of patients by sex 82

11 Distribution of patients by religion 84

12 Distribution of patients by occupation 85

13 Distribution of patients by economical status 87

14 Distribution of patients by mode of onset 88

15 Distribution of patients by intake of Goitrogens 90

16 Distribution of patients by family history 91

17 Distribution of patients by Agni 92

18 Distribution of patients by sleep 94

19 Distribution of patients by psychological features 95

20 Distribution of patients by habits 97

21 Distribution of patients by menstrual cycle 98

22 Distribution of patients by built and nutrition 100

23 Distribution of patients by Aharaja and Viharaja Nidana 101

Tables – continued : Amrutadi yoga in Galaganda (goiter) Page

24 Distribution of patients by with systems involved 103

25 Distribution of patients by chief complaints 105

26 Subjective parameters enumerated (a) 106

27 Subjective parameters enumerated (b) 106

28 Showing the statistical analysis of the chief complaints 107

29 Showing the statistical analysis of the lab investigations 107

30 Anova – Table for the parameter T3 108

31 Anova – Table for the T4 parameter 108

32 Table show which pair of group is significant 108

33 Anova- Table for parameter T.S.H. 109

34 To show which pair of group is significant 109

35 Showing the result of Amrutadi taila capsules in Galaganda 112

36 Hyperthyroidism - Discussion on General and local symptoms 119

37 Hyperthyroidism Systemic evaluation - Cardiovascular symptoms 119

38 Hyperthyroidism Systemic evaluation - CNS symptoms 120

39 Hyperthyroidism Systemic evaluation - Gasto-intestinal symptoms 120

40 Hyperthyroidism Systemic evaluation - Dermatological symptoms 121

41 Hypothyroidism -General features of hypothyroidism 121

42 Hypothyroidism Systemic evaluation - Cardiovascular symptoms 122

43 Hypothyroidism Systemic evaluation - CNS symptoms 122

Graphs

Graphs - Amrutadi yoga in Galaganda (goiter) Page

1 Showing Patients by age distribution 81

2 Showing Patients by gender distribution 83

3 Showing Patients by religion distribution 85

4 Showing Patients by occupation distribution 86

5 Showing Patients by economical status distribution 88

6 Showing Patients by mode of onset distribution 89

7 Showing Patients by intake of Goitrogens distribution 90

8 Showing Patients by family history distribution 92

9 Showing Patients by Agni distribution 93

10 Showing Patients by sleep distribution 95

11 Showing Patients by psychological features distribution 96

12 Showing Patients by habits distribution 98

13 Showing Patients by menstrual cycle distribution 99

14 Showing Patients by built and nutrition distribution 101

15 Showing Patients by Aharaja and Viharaja Nidana distribution 102

16 Showing Patients by with systems involved 104

17 Depicting the results of Amrutadi yoga on Galaganda 112

Figures

Figures – Amrutadi yoga in Galaganda (goiter) Page

1 Location and anatomy of the Thyroid gland 20

2 Functions of the thyroid follicles 23

3 Auto regulation of the thyroid hormone 25

4 Schematic representation of the Galaganda Samprapti 40

5 Contents of Amrutadi taila (Photograph) 66

1

INTRODUCTION

Ayurveda, the science of life is the holistic alternative system of medicine. The

origin of this science is already evident in Atharvanaveda. Eventually Ayurveda was

originated into its own compact system of health and considered as a branch of

Atharvanaveda. The main aims of this science are to maintain one’s health and to protect the

human beings from various diseases, which are acquired.

Among many things man aspires to attain in life, a healthy body and healthy mind

are the first to be sought for. The aim of all medical system should be a healthy body and

healthy mind. Ayurveda is one such system that prevailed from many years. Health is

defined as the condition in which the sharirika and the manasika bhavas exist in a state of

equilibrated normalcy.

Ayurveda mentions comfort (sukha) as health (arogyam) with synonyms of Arogya

and 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 body

and mind are subjected for pain and agony respectively.

At the present millenium has shown us numerous disorders and we know that the

changes in atmosphere and the living conditions or habits are among the causes. This results

in serious multi systemic metabolic disorders like diabetes, thyroid problems, hepatic

disorders 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

2

parts of India. For e.g. Goitre is common among people of the Himalayas due to the iodine

deficiency. As medical aids reached to the feet of common man and communication is

developed in association with that of luxuries and changed dietetics this disorder prevailed

all over the globe and especially a developing country, India. An increasing number of

patients of Goitre and many more Thyroidectomies, either partial or complete are evidential

for 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 appears

to be untouched in Ayurveda. Endocrine disorders and concept of hormone are such

problems noted here.

In Ayurveda there is not an exact term for thyroid gland. Therefore it is not possible

to 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 not

compare many thyroid disorders with any of the ancient descriptions.

We can correlate goitre and some tumor pathology of thyroid to ‘Galaganda’ where

thyroid functions may or may not is affected. But hypothyroidism and hyper thyroidism

have the symptoms related to many portions of the body. It is very difficult to correlate these

two entities with any of the nomenclated diseases of Ayurveda. Further hypothyroidism and

hyperthyroidism are not single disease entities and many conditions are included under each

heading. 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 not

be specific to it but can treat the disease by knowing the condition of Dosha, Dhatu and

Agni components of pathogenesis etc. and their interrelation with the disease condition.

3

The competition among the medical systems is increasing day by day. The

contemporary systems use the most advanced techniques in assessing the disease and in the

aspect of treatment and research studies. So, it is our duty to conduct proper research and

invent 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 with

the day today schedules to acquire more earnings. This more desire have made the man to

deviate from following the swastha vrutta, thereby becoming a victim of diseases. So in the

young adult age itself man, has become victim of severe degenerative diseases like

Sandhivata, Manyasthamba etc., and other multi systemic metabolic disorders like endocrine

diseases, diabetes, etc., Among such diseases Galaganda (goiter) is a common one

nowadays. The gradual increase and prevalence of Galaganda draws attention over the

deviation 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 serious

metabolic disorder, as it affects almost all systems of the body. It is most common nowadays

in every part of the world. Which is considered as a serious metabolic disorder that makes a

strong impact on one’s daily life. Contemporary medical science are able to pacify the

disease through anti thyroid drugs, radio active iodine and if needed through the surgical

treatment as the final with its own limitations.

In Ayurveda we can offer safe and effective management for Galaganda. So to

overcome this problem at young age without producing any complication, the research in

this area is essential. Ayurveda the ancient system of medicine has suggested good old

4

techniques and recipes to pacify the swelling (mass in neck) and other symptom without

causing any complication.

Since this area is prevalent in goiter, I have taken the present study as ‘Evaluation of

Amrutadi thailam in Galaganda with positive thoughts. Still more research works are

essential 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 are

anti-thyroid drugs, radio active iodine and surgery which has its own disadvantages and side

effects. The drug-induced goitre is an evident example of it2.

Ayurveda the traditional Indian system of medicine, describes a reliable and

effective 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 the

neck), toda (pain around the neck), kandu (itching around the neck), difficulty in breathing

etc., and to strengthen the Dhatus and pacifying the Vata and Kapha Dosha which has

special 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.

5

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, which

reduces 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, investigations

assessment and medicine preparation. All together this study gives a scientific approach in

the management of Galaganda.

6

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 by

various authors in Ayurveda is termed as Galaganda and its management through various

methods, 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 Goitrogenic

effect. The anti Goitrogenic effect of Amrutadi thailam in Galaganda can be evaluated by

understanding the cumulative effect of the said yoga.

The Amrutadi thailam comprises of the 9 herbs, which are of Kapha, Vata and Medo

hara in nature, which may reduce the mass and there by regulate the effect of concern organ

pathology i.e. Galaganda viz., goiter.

This can be understood that by the study of baseline data to the final data differences

after the drug administration to the affected patients those who are included by the preset

parameters of exclusion and inclusion criteria.

As there is an elaborate discussion made under the drug review of individual drugs, a

cumulate effect is drawn out of as Shothahara – anti tumor property, Kantyam – regulatory

effect of neck pathology and Rakta shodhaka – blood purification. These said properties are

effective over Dosha predominance and Dushya – Dhatus to regulate to normalcy by

fragmenting 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 of

the thyroid. The present study under takes the said lab investigations to evaluate the efficacy

of Amrutadi thailam in thyroid problem of either Hypothyroidism or hyperthyroidism. This

7

data with precise information regarding the functional capacities to estimate the prognosis

and the medical management to the said Galaganda with reference to that of Goitrogenic and

thyroid pathologies are anticipated.

Thus the present study intends to have the study of Amrutadi thailam with reference

to 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 the

well-known Panchakarma. According to the disease of medicine. It is divided as marsha

nasya and Pratimarsha nasya. Pratimarsha Nasya is a daily 2-3 drops in each nostril, without

any poorva karma and pathyas. The finest specification of this therapy is made in the

Ayurvedic books, as acting on the body parts above the neck, that is the parts lying up on

inside the skill. The ancient authors of Samhita proclaim that the drugs administered in

Nasya shall enter the head.

In the Galaganda, a disease developed above to the clavicle is evaluated with the

Amrutadi taila Pratimarsha Nasya, which has the rechana property and with the Ushna,

teekshana Gunas alleviates the Kapha Dosha.

8

LITERARY REVIEW

There are vast areas in India with iodine deficiency disorders (IDD). Besides the sub

Himalayan region, other flood- prone regions and reverine areas, deltas and costal regions

are 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 iodine

deficiency, and of these 54 million have goiter. Earlier the only recognized effect of iodine

deficiency on health was goiter; however, there is now a better understanding of the

perspective 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.

Etymology of Galaganda 6

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.

9

In a nutshell, Galaganda relays the meaning, the sphotaka or ganda in the ganda. The

relative 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, weighs

around 20gms in adults. The thyroid (from GK, thyroid meaning a shield, because it shields

the 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 a

swelling in the neck (Nibadhaswayathu) 11.

Charaka mentioned that when a vitiated Kapha Dosha circulates around the neck, it

will cause swelling slowly is termed as Galaganda12.

Madhava Nidana explanation is more authentic as it states that Galaganda is a

swelling attached to the neck which hangs down like a scrotum13. He also quotes the

definition of Bhoja here as “Mahantam shopham alpam va hanu manya galashraye” 14 i.e. A

10

swelling resembling and hanging like a scrotum in the Hanu, Manya, and Gala is called as

Galaganda.

From the contemporary medical science, Goitre is defined as a benign, non-toxic

enlargement of the thyroid gland usually secondary to some form or other of the iodine

deficiencies. 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 no

reference regarding the disease Galaganda in the Vedic literatures. Ayurveda, a medical

science deals with almost all diseases, mentions elaborately about Galaganda as one among

those disease, which were explained in concern with Kaphaja Vyadhis.

There was a period were the science developed and flourished much and considered as

the golden period of Ayurveda. Almost all Acharyas had mentioned Galaganda in their

respective treatises.

Among Brihatrayees, Susruta mentioned Galaganda elaborately. Likewise the other

Acharyas also followed the same descriptions in separate chapters except Charaka. Acharya

Charaka has mentioned about Galaganda in Trishopheeyam adhyaya of sutra sthana 16.

In Susruta Nidana, mentions about the Galaganda Samprapti are very clear. It states

that, the Vata, Kapha and Medo Dhatu will got vitiated by its etiological factors and produce

the Ganda (mass in the neck); which have the symptoms of the three respectively. Susruta

describes the Lakshana, Bheda, and Sadyaasadhyata in Nidana sthana and the detail Chikitsa

at its Chikitsa sthana 18th chapter 17-18.

11

In Charaka Samhita, mentions of Galaganda are from Trishopheeyam chapter of sutra

sthana 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 is

called 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 and

Chikitsa in Mukha roga pradheeshedam adhyaya 20.

In Madhava Nidana, Madhavakara quoted the same as that of Susruta and mentions the

Nidana, Lakshana, Bhedas, and Sadyasadyata of Galaganda in detail 21.

The other treatises, such as Yogaratnakara 22, Bhavaprakasha 23, Chakradutta 24,

Vangasena 25, etc also mentions about Galaganda. They elaborately described about the

Lakshanas, 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 in

the deviation of lifestyles and balanced diet. It is mainly common in area where the Iodine

content of water is less than 1PPM 26.

Epidemiology:-

The thyroid disorders and goitre are common in the females, in the certain ages, in

specific part of the world. So the epidemiological evidences of these diseases are very much

important in detecting the cause and is useful to decide the treatment and in the prevention

of those diseases also 27.

12

Age:-

The age of the patient is a Very important consideration. Simple goitre is commonly

seen in girls approaching puberty and in pregnant women because in puberty and in

pregnancy, the requirement of hormone is augmented.

Both multi-nodular and solitary nodular goitres as well as colloid goitres are found in

women of 20s and 30s. The primary toxic goitre is usually present in young ones, where in

Hashimoto’s disease the victims are middle-aged women.

Sex:-

Majorities of the thyroid disorders are seen in females. All types of simple goitres are

far more common in the female than in male. Thyro-toxicosis is 8times common in females

than 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 5

times 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 lies

among 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 goitre

belts 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 the

water supply comes from far away mountain ranges. Calcium is also Goitrogenic and areas

producing chalks and limestones are also Goitrogenic areas.

13

Nidana

According to the treatment point of view, the knowledge of hetu is important so as to

enable 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 the

vitiation of Mala 30.

Galaganda is a Kaphaja nanamatja Vyadhi 31and it is mentioned by all treatises. But

the etiological factors are not directly mentioned in the classical texts. Charaka 32 has

mentioned Galaganda as a lump situated in the neck where the swelling generated slowly, or

a Sopham – edematous; especially with the Kapha and Vata Dosha predominance. Susruta

Samhita 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, the

symptoms are similar that of Vataja and Kaphaja sopham.

The different etiological factors from various texts are referred as under with rational

headings such as – Ahara Nidana, Vihara Nidana etc.,

1.Aharaja Nidana 33-34

It can be divided into Vata prokapa, Kapha prakaopa and Medoprakopa

karanas.Consumption of Aharas having Vatika and Kaphaja predominance causes vitiation

of Kapha, Vata in the body.

The intake of tikta, katu, kashaya rasa , rookshannam, alpamatara bhojanam etc

vitiate then Vata Dosha . The intake of madhura,amla,Lavana,snigdha, guru,abhishyanda,

seeta, types of foods will vitiate Kapha Dosha .

14

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 Vata

Dosha. 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 Kapha

Dosha. 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. Direction

of sense organs is one of the functions of Manas and Vata is said to be the controller and

conductor of mind. Therefore, by above factors Vata prakaopa occurs in the indreeyaayatana

and produce psychic as well as the somatic disorders; as there is a pivot role for mind in

producing 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 its

prakopa 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.

15

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 can

induce hypothyroidism and goiter. In hypos, Goitrogens can further depress thyroidal

function and stimulate the growth of the thyroid (goiter).

In hyperthyroid, Goitrogens may help suppress thyroidal function until normal

thyroidal functioning can be restored. However, this may not be a good strategy. Goitrogens

work by interfering with the thyroidal uptake of iodine. While many hyper secretaries to

limit thyroid output by iodine restriction, this strategy can backfire. Iodine restriction will

cause the thyroid to increase in size (goitre) in an effort to filter more blood to get more

iodine. When iodine is then re-introduced to the diet or accidentally ingested, the now larger

thyroid gland has the capacity for greater thyroid hormone production.

The iodine restriction is not a good long-term method for controlling thyroid

hormone production. Therefore the consumption of Goitrogens is not a good strategy. It is

better to increase copper metabolism by supplementation of copper and the assisting

nutrients. Once copper is replenished and copper metabolism is working properly, the body

will 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

16

1) Goitrogens in the form of food items 40

The vegetables of the Brassica family, sea-weeds, oats, calcium rich foods, etc, are

Goitrogens 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 vegetables

not only inhibits thyroid production, but they also inhibit cancer growth. We know that

sulfur, copper, and iron, work closely together and that excessive sulfur can deplete copper

and/or iron. The excessive kale consumption will cause anemia. Generally anemia is the

result of low iron and/or copper.

Because copper and iron are so important for thyroid function, it is not advisable to

eat plants of the brassica family. The primary pre-condition for the production of thyroid

disease is the onset of anaemia. Brassica vegetables, with their high sulphur content, may be

foods, 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 are

also Goitrogenic. Iodides in large quantities are also Goitrogenic as they inhibit the organic

binding 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 is

generally inherited as an autosomal recessive gene. There is enzyme deficiency in the

thyroid 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,

17

and simple goitre is formed. Hyperthyroidism is often seen in several members of the same

family 42.

Endemic Goitre 43

In certain places there is low iodine content in the water and food. So the inhabitants

do not get minimum requirement of iodine. This leads to reduced levels of thyroid hormones

and hence the goiter. These areas are Himalayas, Alps, Mountain areas, etc. In low land

areas around the lakes, the soil lacks iodide. Calcium is available plenty in chalks and

limestones are Goitrogenic and places where they are available there the goiters are

common.

Physiological Causes

In certain cases when there are high metabolic demands diffuse hyperplastic goiter

may be seen. Such conditions are puberty, pregnancy, etc. In these conditions there is more

demand of the thyroid hormones than normal and if the thyroid gland falls to rise to the

occasion, 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

18

Causes of Hyperthyroidism 47-48

§ Graves disease, 76%, which is idiopathic

§ Multinodular goiter

§ Thyroiditis

§ Iodide-induced

§ Autonomously functioning thyroid nodule

§ Ingestion of exogenous thyroid hormone

Anatomy 49-50 and physiology

The thyroid is an endocrine gland, situated in the lower part of the front and sides of

neck. It regulates the B.M.R, stimulates somatic and psychic growth and plays an important

role 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 the

body of the hyoid bone to the isthmus or to the pyramidal lobe. Accessory thyroid gland is

sometimes found as small-detached masses of thyroid tissue in the vicinity of the lobes or

above the isthmus.

Situation and extent

The gland lies against vertebrae C-5, 6 and 7 and T1 clasping the upper part of

trachea. Each lobe extends from the middle of the thyroid cartilage to the fourth or fifth

tracheal ring. The isthmus extends from the second to the third tracheal ring.

19

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 during

menstruation 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 dense

capillary plexuses is present deep to the true capsule. To avoid hemorrhage during operation

the thyroid is removed along with the true capsule.

Arterial supply

Superior thyroid arteries supply the thyroid gland, which is the first anterior branch

of 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 nodes

through 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 the

superior and exterior cervical ganglia. There are vaso constrictors

Structure and function

The thyroid gland is made up of two types of secretary cells. Follicular cells lining

the follicles of the gland secrete tri-iodothyronin and tetera iodothyronin (thyroxin) which

stimulate the B.M.R and somatic and psychic growth. Para follicular cells lie in between the

20

follicles they secrete thyro-calcitonin which promotes deposition of calcium salts in skeletal

and other tissues and tends to produce hypo-calcium.

Applied anatomy

Any enlargement of the thyroid gland is called a goiter. Removal of the thyroid may

be needed in hyperthyroidism (thyrotoxicosis). Hypothyroidism causes cretinism in children

and Myxodema in adults. Benign tumors of gland may displace and even compress

neighbouring structure pressure symptoms and nerve involvement is common in carcinoma

of the gland.

Figure - 1

Location and anatomy of the Thyroid gland

21

Thyroid follicles and thyroid hormones 51

The thyroid gland contains large numbers of thyroid follicles. Individual follicles are

spheres 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 regulatory

hormones to the glandular cells and accepting their secretary products and metabolic wastes.

Follicular cells synthesis a globular protein called thyroglobulin and secretes into the

colloid of the thyroid follicles. Each thyroglobulin molecule contains the amino acid

tyrosine, the building block of thyroid hormones. The formation of thyroid hormones

involves 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

22

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 concentration

of TSH in circulating blood. TSH stimulates iodide transport into the follicle cells and

stimulates the production of thyroglobulin and thyroid hormones. Under the influence of

TSH 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.

23

Figure –2

Functions of the thyroid follicles

Control 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 important

TSH of the anterior pituitary

TSH is secreted by the specialized cells, called thyrotrophs of the anterior pituitary.

24

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. The

circulating T4 is converted into T3 at the level of the anterior pituitary and thus both T4 and

T3 are active. Therefore when circulating T4 is in high concentration, the pituitary

thyrotrophs is inhibited so that T.S.H secretion is depressed resulting in correction of excess

T4 in blood. Reverse occurs when T4 concentration of blood is low. Hence more T4 = low

T.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 and

stimulates them to secrete TSH. Hence more TRH = more TSH. Probably T4 and T3 do not

operate at the level of the hypothalamus for the negative feed back mechanism. Another

hormone called somateostatin inhibits the TSH secretion. It is released from the

hypothalamus (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 follicular

cells become super efficient. If there is excess of the food iodine, the iodine trapping

mechanism 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 more

sensitive to TSH and viseversa.

25

Figure – 3

Auto regulation of the thyroid hormone

Mechanism of action of thyroid hormones 53

The thyroid hormones act somewhat like steroid hormones. The free T4 enters the

target 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 occurs

more m RNA production synthesis of more proteins are biological action.

26

Iodine and thyroid hormones 54

Iodine in the diet is absorbed at the digestive tract as I-. The follicle cells in the

thyroid gland absorb 120 to 150 of I- each day, the minimum dietary amount needed to

maintain normal thyroid function. The iodide ions are actively transported into the thyroid

follicle cells, so the concentration of iodine inside thyroid follicle cells is generally above 30

times higher than that in the plasma. If plasma iodine levels rise, so do levels inside the

follicle cells.

The thyroid follicle contains most of the iodide reserve in the body. The active

transport mechanisms for iodide is stimulate by TSH and the increased movement of iodide

into the cytoplasm accelerates the formation of thyroid hormones.

A typical diet in developed countries provides approximately 500 g of iodide per

day, roughly three times the minimum daily requirements. Much of the excess is due to the

addition of iodine to the table salt sold in the grocery stores as iodized salt. Thus iodide

deficiency is seldom responsible for limiting the thyroid hormone production (this is not the

case 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 can

gradually deplete the iodide reserves in the thyroid. Thyroid hormone production may

decline, regardless of the circulating levels of TSH. Thus various thyroid disorders manifests

gradually.

27

Effect of thyroid hormone on growth 55

Thyroid hormone has both general and specific effects on growth. For instance, it has

long been known that thyroid hormone is essential for the metamorphic changes of the

tadpole into frog.

In human, the effect of thyroid hormone on growth is manifest mainly in growing

children. In those who are hypo thyroid, the rate of growth is greatly retarded. In those who

are hyper thyroid, excessive skeletal growth often occurs, causing the child to become

considerably taller at an earlier age. However, the bones also mature more rapidly and the

epiphyses close at an early age, so that the direction of growth and the eventual height of the

adult may actually be shortened.

An important effect of thyroid hormone is to promote growth and development of

brain during fetal life and first few years of post natal life.

Effect of thyroid hormones on specific bodily mechanism 56

1. 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.

28

3. Effect on plasma and liver fats - increased thyroid hormone decreases the concentration

of cholesterol, phospolipids and triglycerides in the plasma, even though it increases the free

fatty acids. Conversely, decreased thyroid secretion greatly increases the plasma

concentrations of cholesterol, phospholipids and triglycerides and almost always causes

excessive deposition of fat in the liver as well.

Increased requirement for vitamins

As thyroid hormones increases the quantities of many bodily enzymes and because

vitamins are essential part of some of enzymes and co-enzymes thyroid hormones causes

increased need for vitamins. Therefore a relative vitamin deficiency can occur when excess

thyroid hormone is secreted.

Increased BMR

As thyroid hormone increases metabolism in almost all cells of the body, excessive

quantities 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 – half

normal.

Effect on body weight

Greatly increased thyroid hormones almost always decrease the body weight, and

greatly 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. This

effect causes vasodilatation in most of the body tissues, thus increasing blood flow. As a

consequence of the increased blood flow, cardiac output also increases, some times rising to

29

60% or more, when excessive thyroid hormone is present and falling to only 50% of normal

in very severe hypothyroidism.

Increased gastro-intestinal motility

Thyroid hormone increases both the rates of secretion of digestive juices and the

motility of the gastro intestinal tract. Diarrhea often results in hyper thyroidism. Lack of

thyroid 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 is

likely 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, but

when the quantity of hormone becomes excessive, the muscles become weakened because of

excessive protein catabolism. Conversely, lock of thyroid hormone causes the muscle to

become sluggish and they relax slowly after a contraction.

Effect on sleep

Because of the exhausting effect of thyroid hormone on the musculature and on the

CNS the hyperthyroid subject often has a feeling of constant tiredness, but because of the

excitable effects of thyroid hormone on the synapses, it is difficult to sleep. Conversely

extreme somnolence is characteristic of hypothyroidism, with sleep some times lasting 12 to

14 hours a day.

30

Effect of thyroid hormone on sexual function

In men lack of thyroid hormone is likely to cause loss of libido, impotence, excess of

hormone. In women the same causes menorrhogia and polymenorrhea, in other women it

may cause irregular periods and even amenorrhea.

Poorvarupa

Poorvarupa are the prodromal symptoms of the forthcoming disease, which do not

clarify the Samprapti of the disease. These symptoms will be few and not clear 57.

According to Madhava Nidana, Poorvarupa are the symptoms which are produced

during the process of sthana samsraya by vitiated Doshas, when Samprapti has not been

completed and disease has not been manifested 58.

But prodromal symptoms of Galaganda are not mentioned in any of the classical

texts. From the recorded data of the patients we can say the purvarupa in general. The

vitiated 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 three

types as Vataja Galaganda, Kaphaja Galaganda and Medoja Galaganda. The Lakshana

mentioned by various Acharyas are enlisted in the table. Description of Vataja, Kaphaja, and

Medoja Galaganda are as follows: -

1) Vataja Galaganda

The lakshanas of Vataja Galaganda 59 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),

31

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 60-61-62-63

SN Lakshana Susruta Vagbhata YogaRatnakara

Bhavaprakasha

1 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

32

present), madhuraasyata (sweetnes in the mouth), talu gala pralepa (coating in the palate and

throat) and kandu (itching).

Table -2

Lakshana of Kaphaja Galaganda 65-66-67-68

SN Lakshana Susruta Vagbhata YogaRatnakara

Bhavaprakasha

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).

33

Vagbhata had stated that apart from these Medoja Galaganda might present some

Lakshanas 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 YogaRatnakara

Bhavaprakasha

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 - - + +

34

Clinical features according to contemporary science

1) Hyperthyroidism 75

Hyperthyroidism or thyrotoxicosis refers to a state wherein there is an excess of

circulating thyroid hormones, T3 or T4. Thyrotoxicosis is designated primary when the

gland is diffusely enlarged and there are signs of hyper metabolic state, eye signs may or

may not be present. Thyrotoxicosis is designated secondary when the patient had previously

abnormal gland, i.e. nodular goitre (single or multiple), and now assumes hyper functional

status.

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 as

follows 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

35

Table –4 showing clinical features of Hyperthyroidism 78-79-80

Symptoms SignsGeneralDemour of anxiety, generalizedweakness, heat intolerance2,skin tanning, apathy3, thirst, andfatigue2

Restlessness, inability to keep still,weight loss, excessive sweating,hair thinning and straightening

Cardiovascular systemPalpitation2, irregular beats, shortnessof breath, angina, dyspnoea onexertion2,exacerbation of asthma

Tachycardia, increased pulse pressure,ectopic beats, atrial fibrillation3, sick sinus

syndrome, cardiac failure3

Central nervous system

Hyperactivity, nervousness, emotionallability2

Fine tremors, hyperreflexia, proximal muscleweakness, periodic paralysis*, ill sustained clonus

Gastro-intestinal systemDiarrhoea (non-infective), weight lossdespite normal or increased appetite2,anorexia3, vomiting

Rapid bowel transit time2, steatorrhea*

Reproductive systemOligomenorrhea or aminorrhea,impotence, spontaneous abortion, lossof libido

Gynacomastia*

ThyroidEnlargement in anterior part, neckpressure symptoms

Diffuse or nodular goitre, bruit1, thrill

Dermatological systemIncreased sweating2, pigmentation,alopecia, pruritis

Vitiligo1, digital clubbing1, pretibial myxoedema1

Ophthalmic System

Stare, gritty sensation1, increasedlacrimal secretion1, diplopoia1,diminished visual activity1

Lid retraction, lid lag1, chemosis1,infiltrative ophthalmopathy, ocularmuscle paresis, exposure keratitis

* - Less frequent1 – Features of Graves disease only

2 – Most common symptoms/signs of Hyperthyroidism irrespective of cause 3 - Features found particularly in elderly patients

36

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 –5Showing clinical features of Hypothyroidism 82-83-84

Symptoms Signs

General featuresTiredness, cold intolerance, somnolencehoarseness; monotonous, coarse speech

Weight gain, goiter, peri-orbital puffiness,psychomotor retardation, hypothermia,Mucous membrane infiltration of laryngealmuscles

Dermatological systemDry flaky skin and hair, hair loss, purplishlips and malar flush

Non-pitting oedema, carotenaemia,erythema ab igne (Granny’s tartan),alopacia, vitiligo

Cardiovascular systemShortness of breath, angina, congestivecardiac failure*

Bradicardia, ischeamic heart disease,pericardial and pleural effusion,hypertension

Central nervous systemMuscle aches and pains, stiffness,deafness, psychosis, slowing of motorfunctions

Delayed retraction of tendon reflexes,myotonia*, carpel tunnel syndrome,slowing of cerebartion

Gastro intestinal systemConstipation Ileus*, ascites*

Reproductive system Irregular menstruation (usuallymenorrhagia), infertility, galactorrhoea*

High FSH/LH, hyper prolactinaemia,impotence*

37

HeamatologicalPallor, none- responsive anaemia, bleedingtendency, iron deficiency (pre- menopausalwomen)

Dimorphic anemia, pernicious anemia,megaloblastic anemia, co-agulation defects

* - Rare, but well-recognized features

Galaganda Samprapti

The etiological factors contributing to disease and the vitiation of Doshas attack the

body every now and then. Some factors can be avoided by taking precautions, but factors

like kala, deha etc are mostly inevitable. If the body’s resistance, Vyadhikshamatwa is high

and dhatus, srotases and Agni are functioning well, the body fights against the etiological

factors. But if the etiological factors are stronger than the resistance power of the body, they

vitiate the Dosha and Dosha dooahya samoorchana takes place and the process of disease

starts. The pathological changes taking place in the body day to day Nidana sevana till the

complete manifestation of disease is termed as Samprapti.

The knowledge of Samprapti is very much essential from the Chikitsa point of view

as it helps in understanding the pathogenesis of a disease.

Susruta has mentioned the vitiation of Vata, Kapha, and Medo dhatu by the

etiological factors of the same; will manifests in the neck region and make a ‘Ganda’(mass

in the neck).it exhibits the symptoms of three respectively 85.

But while describing the commentary Dalhana and Gayadasa are of the opinion that

Galaganda is a swelling in the neck, ”Nibadha swayathu” 86.

Charaka has mentioned Galaganda as a swelling in the neck by the vitiation of

Kapha Dosha .He describes that, the Kapha Dosha vitiated by the etiological factors will

manifests in the frontal part of the neck and produce a swelling slowly 87.

38

Vagbhata mentions the Samprapti in another way. The Vata, Kapha, and Medas got

vitiated 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 or

small in size. The swelling is slowly produced by the Vata, Kapha, and Medas, which is

vitiated by the etiological factors89.

1. Sankhya Samprapti of Galaganda

There are three varieties of Galaganda are mentioned in all the classics except

Charaka. 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 of

them are Seeta, Snigda, guru, manda etc

3. Pradhanya Samprapti of Galaganda

The Samprapti caused by a major of independent Dosha is called as pradhanya

samprapti, and that which is caused by a minor or dependant Dosha is called as apradhana

Samprapti. Also it can be understood as the Samprapti of swatantara vyadhi is called as

pradhanya Samprapti.

4. Bala Samprapti of Galaganda

The strength of a disease is depending upon the Nidana, purvarupa, and rupa and

manifest disease in total. Here almost all patients had the symptoms manifested completely.

So the bala is more.

39

5. Kala samprapti

It is the Samprapti which confirms the role of a particular Dosha in a disease, which

can increase the same with the change in time- like the day, night, season, with stages of

digestion etc.

Here the main Dosha is Kapha and there is involvement of Vata in it. At the same time

there is the involvement of Agni; i.e. is the derangement of Agni bala is present. So

according to the condition it may vary. No specific time, season, and stages of digestion are

provoking 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

40

Figure -4

Schematic representation of the Galaganda Samprapti

VataprakopaKarana

KaphaprakopaKarana

MedoprakopaKarana

Vitiates VataVitiates Kapha Vitiates Medas

Vitiation ofMedodhatwagni

Sanchita Medas

Sanchita Vataand Kapha

Gala (Kanta) Stanasamshraya

Manifestation of Lakshana corresponding to theStana, Dosha and Vyadhi

Galaganda

41

Sadhyasadyata

The physician who knows the difference between curable and incurable diseases and

begins the treatment in time with a through knowledge of the case succeeds in his efforts

without fail. So the physician, who knows the avasthas of the disease, can plan the treatment

and can reject the cases, which are incurable 90. The sadyasadyata of Galaganda is

mentioned 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 voice

Upadrava (complications)

Upadrava is produced after the formation of main disease and it is dependent on the

main 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 also

opines that upadrava is a super added disease for which the basic causes, i.e. the Dosha

responsible 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. The

complications of the hypothyroidism and the hyperthyroidism are 95-

42

a) Thyroid crisis

The hyperthyroid patients, the complications can be termed as hyperthyroid crisis. The

most prominent signs are fever, agitation, confusion, tachycardia or atrial fibrillation and in

older patients cardiac failure. It is a medical emergency and despite early recognition and

treatment, 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 treatment

b) Hypo thyroid complication 97

i) 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 end

fatally. Extreme cold weather, use of narcotics, phenothiazines or anasthetic agents,

infections or situations that can cause hypertension, may be the precipitating events for

myxodema coma.

Cardinal features of myxedema coma are Hypothermia, Altered consciousness and

Hypo ventilation.

Pathology of goitre according to contemporary medicine 98

Hypothalomo-pituatiry disorders can be responsible for inducing under active or

overactive thyroid states.

The thyroid disorders can be divided into three: -

43

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 are

certain stages through which this type of goitre gradually passes through. In the first stage

due to TSH stimulation the lobules are composed of active follicles. This is called” stage of

diffuse hyperplasia “. When TSH stimulation ceases by ingestion of iodine the second

stages appears. This is the stage of involution forming large follicles filled with colloid. If

this condition continues i.e., in the third stage the gland enlarges to an enormous extent that

is known as colloid goitre. Sometime due to fluctuating TSH levels a mixed pattern develops

with areas of active lobules and areas of inactive lobules.

Pathology of Hyperthyroidism 100

In “graves disease” the thyroid is uniformly enlarged and the surface is

characteristically smooth, though slight modularity may be detected. Microscopically the

thyroid is hyperplastic and the epithelia which line the acni are high columnar instead of

flattened cuboidal type which is found in normal thyroid gland. They’re only minimal

amount of colloid in the acini and many of them are even empty and others contain

vacuolated colloid. The nuclei of the thyroid cells exhibit mitoses. Papillary projections of

44

the hyperplstic epithelium into the acini are common. Lastly there is vascularity and

lymphoid tissue around the acini.

The clinical manifestation of the hyperthyroidism include changes referable to the

hyper-metabolic state, included by excess of thyroid hormones as well as those related to

over 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 with

Hyperthyroidism 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 not

known. Pathological changes often call attention to hyperthyroidism- lid lag, staring gaze

and wide appearances of the eye are due to sympathetic over stimulation of levator palpebre

superioris.

In the neuromuscular system- increased activity of sympathetic nervous system

produces- Tremor, Hyper activity, Emotional disturbances, Anxiety, Muscle weakens, etc.

The skin of the patient tends to be warm, moist and flushed because of increased

blood flow and peripheral vaso-dilatation to increase heat loss. Increased sweating is due to

higher levels of calorigens.

In the G.I.T system increased gut motility are due to increased sympathetic activity

cause Increased thyroid hormone in the skeletal system, which stimulate the bone resorption,

makes ultimately Increased porosity and reduced volume of bone i.e. osteoporosis.

45

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 antigens

on the surface of the thyrocytes. Some of the antibodies stimulate the thyrocytes, causing

hyperplasia. Some block the action of the thyroid-stimulating hormone some do not affect

the function of the thyrocytes.

The first stimulatory antibody the blood of patients with “Graves disease” is called

the long acting thyroid stimulator because it causes a long continued release of iodinated

compounds from the thyroid in the animals. It or similar stimulatory antibodies are

demonstrable in the plasma of almost all patients with “Graves disease” and are the principle

cause of hyperplasia.

Antibodies against thyroglobulin or against the microsomes the thyrocytes arev

present in 95% of the patients, usually in higher titer than in the patients with a non-toxic

goitre or carcinoma of thyroid, though not in the higher titer usually in Hashimotos

thyroiditis.

Hashimotos disease is unduly frequent in the families of patients with Graves disease

is incidence of “Graves disease” is increased in the families of patients with Hashimotos

disease. Relatives of patients with “Graves disease” often have in their blood the antibodies

of Hashimotos disease.

Occasionally a patient with Hashimotos disease develops “Graves disease”, or a

patient with Graves disease ends with Hashimotos disease. Genetic factors are important in

the pathogenis of “Graves disease” in some patients, abnormal immuno-globulins of Graves

disease are present in the plasma of close relatives in 60% of the patients. The frequency of

46

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 mechanism

similar that in Hashimotos disease. HLA- DR antigens are present on the thyrocytes in the

patients with Graves disease, as they are in Hashimotos disease. Some think they are carried

by a viral infection and initiate the auto immune reaction against the thyroid. Some think

that the primary fault is in the suppressor T- cells and that the expression of the HLE-DR

antigens 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 not

caused by the thyroid stimulating hormone. The cause of dermoapthy found in “Graves

disease” is unknown.

Non toxic goitre Pathogenisis 102

Iodine deficiency is the most common cause of both endemic and sporadic forms of

non-toxic goitre. In all regions in which nontoxic goitre is endemic, the diet is deficient in

iodine. In some patients toxic agents called Goitrogens are important in the causation of the

goitre. In some, an enzyme deficiency causes the enlargement of thyroid. In some patients

with sporadic goitre, the cause of the disease is unknown. If the intake of iodine is low, its

concentration the plasma and its excretion by the kidneys fall. The thyroid gland is unable to

take up enough iodine to maintain normal function and becomes hyperplastic. The

hyperplasia may be caused by increased secretion of the thyroid stimulating hormones

caused by a fall in the concentration of thyroid hormones in the plasma, but more probably

iodine deficiency causes the thyroid to respond exclusively to a normal concentration of the

TSH.

47

Goitrogens cause non-toxic goitre or enhance the effect of iodine deficiency. In some

Himalayan 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 related

vegetables contain Goitrogens related to thiourea.

Thiocyanates, perchlorate, paraamino salicylic acud, and other drugs inhibit the

metabolism of the thyroid gland and cause goitre if given fir a long period. Fluoride and

other halogens displace iodine and contribute to the causation of non-toxic goitre. Even

excess of iodine can cause non-toxic goitre.

The enzyme deficiency sometimes cause non-toxic goitre in children. Minor

anomalies of this sort may explain some sporadic goitre. Sometimes sporadic goitres are of

familial, suggesting the possibility of a genetic defect. Antibodies against thyroid antigens

are often present in the patients with a non-toxic goitre.

Pathogenesis of hypothyroidism 103

Hypothyroidism can be again divided into Cretinism, Myxedema, Hashimotos

Thyroditis, Sub-acute lymphocytic Thyroditis.

Cretinism

Cretinin refers to Hypothyroidism developing in infancy or early childhood. The

severity of the mental impairment in cretinism appears to be directly influenced by the thime

at 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 maternal

thyroidal thyroid deficiency before the development of fetal thyroid gland, mental

retardation is severe.

48

Pathogenisis of Hashimotos thyroiditis 104

The disease is caused primarily by a defect of T- cells. One model fir this disorder

proposes that T-cells from patients with this disorder recognized processed thyroid antigens

in 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 specific

helper 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 in

patients with Hashimotos thyroiditis.

Investigations 105

1) Serum Thyroxine (T4 )

Thyroxine is transported in the plasma mainly in the bound form with Thyroxin

Binding Globulin (TBG), and by Thyroxin Binding Pre- albumin. Only a small amount

49

circulates in the blood in the free form. Measurement is more difficult and can be measured

by competitive Protein binding or Radio immuno assay method. The normal range varies

from 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 to

excessive production of T3 without any association of Serum T4. The normal range varies

from 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 is

raised in primary hypothyroidism and almost undetectable in hyperthyroidism. This test is of

more help in the diagnosis of hypothyroidism rather than hyperthyroidism. It also of value to

measure 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 or

Cold) of either full or part of the thyroid gland. A solitary nodule is palpated. Scanning is

helpful in the following way -

1. In case of suspected retro sternal goiter

2. Ectopic thyroid tissue

A single non-functioning thyroid nodule is an indication of surgery. The other tests

are BMR, Serum cholesterol, ECG, etc. these are of little value in the diagnosis, but to

determine the complications, ECG etc can be used.

50

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 the

serum and this accurately reflects the thyroid states of an individual. This can be considered

as best single test available at present.

6) Radiography

This is helpful to diagnose the position of the trachea, whether displaces or narrowed

from 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 differentiating

features of Galaganda.

Table -6

Differential diagnosis of Galagraha and Apachi 106

Sl. Galaganda Galagraha Apachi

1 Nidana – Vata-Kapha-medo vrudhikara ahara-vihara

Nidana –Kaphavrudhikaraahara-vihara

Nidana – Medo-Kaphavrudhikara ahara-vihara

2 Dosha – Kapha & Vata Dosha – Kapha Dosha – Kapha

3 Dushya – Medas - Dushya – Meda

4 Sthana – Hanu, manya &gala

Sthana – Kantha Sthana – Hanu, kaksha, galaakshaka, bahusandhi & manya

5 Sopha in the neck Sopha inside thekantha

Granthi

6 Big or small swelling - Round shaped granthi

7 Nature of Sopha –Mushkavat

- Amalakasthi ormatsyandajalavat

8 Single swelling Single swelling More in number

51

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-medojanya

Sannipathaja Kaphajanya TriDosha ja

2 Mushkavatsopha

- Kolasthimatrasopha

Avalambi swayathu

3 Sopha in theneck region

Sarvagalavyapyasopha

- Pratanavanswayathu

4 Sopha Vidradhi Granthi Sopha

5 Alparuk Atiruk Neeruk Neeruk

Galaganda Chikitsa

Principles of treatment:-

The main principle of the treatment is the pacification of Kapha and Vata Dosha. As

per Susruta the sequence of the treatment is as follows 108-

Vataja galaganda

Nadisweda,- Raktamoksha, -Vranashudhi – Lepanam

Firstly the vataja Galaganda patient should be given swedanam with vatahara drugs

then the rakta mokshana should be done. The vrana shuddhi is carried out. Then lepanam

with shana, atasimoola, shigru, priyala,punnarnava, arka etc

Kaphaja galaganda

Nadisweda, Upanaha sweda, Rakta bokshanam, then Lepanam. The procedures

Vamanam, Shirovirechana, and Dhumapana are also usefull.

52

The Kaphaja Galaganda patients should be given Nadi and Upanaha swedam After

good sweating rakta mokshana is carried out. Then Lepanam with Kaphahara drugs,and

Palashaksharam Pippalyadi gana thailam is to be taken internally with Saindava lavana. The

procedures 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 the

Siraveda in the Urumoola is done.after that Lepanam with Arka, Syama,Lohapureesha,

Rasanchanam Danti etc should be pasted and applied. Salasaradi gana kwatha +Gomootram

should 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 with

heated Majja, Ghrita, Medas, Madhu etc, after samyak yoga madhu, ghrita should be

applied. 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

53

ix. Ajagandhadi lepam

x. Kshara thailm

xi. Varanadi kashaym

xii. Nimbadi thailam

xiii. Bharngi moola kashayam

xiv. Sakhoshtakadi thailam

Pathyapathyam 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 rice

and 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.

54

Methodology

Research is an unbiased investigation or inquiry in a systematic manner to establish

new inventions and facts, correcting or modifying the old one. The ultimate aim of any

research in the field of medical science is to find out suitable remedies for particular ailment

and to promote health. Research methodology involves the systemic procedures by which

the 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 result

Research approach

Experimentation is the most powerful research approach. In the present study the

objective is to evaluate the efficacy of Amrutadi thailam in Galaganda. The efficacy can be

analyzed 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 study

was 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 the

study from the OPD of PGS&RC, DGMAMC HospitalGadag. Three patients were excluded

as they default at the treatment schedule. Ultimately 17 patients were included for the study

based on the inclusion and exclusion criteria in one group.

55

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 criteria

Exclusion 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 mother

Criteria of diagnosis

The symptoms of Galaganda mentioned in Ayurveda will be the basis of diagnosis

along with altered T3, T4 and TSH levels

Sample size

The sample size for the present study consist of 20 patients in a single group

Duration of the study

The study duration was 90 days treatment schedule and 30 days follow up period

was designed.

Data collection

Patients selected are thoroughly examined with both subjective and objective

parameters. Detailed general history and physical examination findings were noted.

Laboratory investigations such T3, T4, TSH, Random Blood Sugar and hemoglobin % were

conducted. Routine investigations of blood were undertaken to exclude other pathology

under veined.

56

2) Methods of examination

Thyroid disorders nowadays is common kind of metabolic multi systemic disorder

present in all ages. A through physical and general examination is mandatory for the patient

with thyroid diseases.

Before taking the history, a glance of the patient itself reveals some valuable findings

such as in hyper thyroidism the facial expression of excitement, tension, nervousness or

agitation with or without variable degree of exophthalens. In case hypothyroidism, one can

see 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 and

TSH level

Ganda

Ganda is the swelling present on the thyroid. In Ayurveda it is mentioned as a mass

in the neck, but in the contemporary science it is mentioned as a swelling of the thyroid

gland. It can be detected by the inspection and palpation methods. As the swelling cannot be

measured and it is difficult to grade according to the size in numerical values. So here the

main tool to detect the swelling is by visualizing it and palpates to confirm the same

57

Inspection of the thyroid gland 115

It was carried out by the Pizzilto’s methods as mentioned. By this method the

following things were detected.

1. The swollen thyroid very clearly

2. While deglutition the thyroid swelling was seen moving up wards

Palpation of the thyroid gland116

It was carried out by lahey’s method and crile’s method as mentioned. By this

method the thyroid swelling was clearly detected by palpation. The scores of assessment for

ganda 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

58

Vivarnata

The discoloration of skin over the mass is mentioned by Ayurvedic

scholars as a main symptom of Galaganda in their Samhita’s. So it is taken as

one of the parameter for assessment. It is assessed according to the grading is

as follows –

1. No discoloration

2. Mild discoloration

3. Moderate discoloration

4. Severe colour change

Kandu

The itching around the mass is mentioned in Ayurvedic classics as a

main symptom of Galaganda. In contemporary science skin rashes in

different parts is mentioned. So it is taken as a parameter for assessment. It is

assessed according to the grading are as follows-

1. No itching

2. Mild itching

3. Moderate itching

4. Severe itching

Difficulty in swallowing

It is mentioned as a main symptom in the contemporary science for

goitre in the Ayurvedic system also there is mentioning about the hoarseness

of voice. The grading of difficulty in swallowing is as follows -

1. No complaints

2. Difficulty to swallow solids

3. Difficulty to swallow liquids

59

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. Severe

Examination of thyroid gland

In this modern era there is a increase in the incidence of endocrine disorder due to

the deviation of man from following the swasthavritta. Out of them nowadays, the thyroid

disorder are common in every part of the globe. So it is necessary to study the history of the

thyroid gland in detail. For that purpose, to confirm the disease and to reveal various clinical

manifestations adhered to the thyroid gland, it is essential to examine the thyroid gland

elaborately.

ΙΙ) HISTORY 117

1) Age:

Age of the patient is a very important consideration. Simple goitre is commonly seen

in girls approaching puberty. It also appears in conditions of need, i.e., during pregnancy and

puberty.

Both multi-noddular and solitary nodular goiters, as well as colloid goitre are found

in women of 20s and 30s. A word of caution is very much needed in this context. Carcinoma

of thyroid is not necessarily a disease of old age. Papillary carcinoma is seen in young girls

and follicular carcinoma in middle age women.

60

2) Sex

Majorities of thyroid disorders are seen in females. All types of simple goitres are far

more 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 any

peculiar geographical disturbance. The Rocky Mountains, low land areas, areas producing

chalks and limestone are the prone areas of goitre genesis.

5) Swelling

The neck is examined for evidence of thyroid enlargement. Significant thyroid

enlargement is evident by palpation. The thyroid gland always moves on swallowing. The

palpation is carried out from behind the patient with the fingers encircling the neck, asking

the patient to flex the neck slightly. The landmarks for palpation are the laryngeal

cartilage’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 and

whether associated with pain should be noted. Simple goitres grow very slowly or remain of

same 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 are

painful.

61

7) Pressure effects

The enlarged thyroid may press the trachea to cause dyspnoea or may press the

esophagus to causes dysphagia or press on the recurrent laryngeal nerve to cause hoarseness

of voice.

8) Past history

Inquiry must be made about the course of treatment the patient had and its effect on

swelling. Also should inquire, whether the patient had taken any anti thyroid drugs, as some

of 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, while

endemic goitres may affect more members in the same family. Enzyme deficiencies within

the thyroid gland, which are concerned in the synthesis of thyroid hormones, are also seen to

run in the families.

Primary thyrotoxicosis and thyroid cancers has been seen in more than one member

of the same family.

62

II. Physical examination 118-119

Table – 8General survey of the thyroid patients for Hyper or Hypo thyroidism

Hyperthyroidism Hypothyroidisma) thin built Obeseb) under weight Over weightc) more sweating Less sweatingd) wasting of muscles Not presente)facial expressions:- excitement,nervousness, tension, with or withoutexophthalmos

Puffy face without any expression(mask likeface)

f) Hyper thyroid patients are active but willbe tired due to various reasons

Naturally dull with low intelligence( more in cretins)

g) pulse rate rapid and irregular, sleepingpulse rate

Pulse rate slow

h) moist and warm skin usually Skin is dry and inelasticI) less sleep More sleep

III.Local examination 120

1. Inspection of the thyroid gland

It was carried out by the pizzillo’s method, in which hands are placed behind the

head and the patient is asked to push the head backwards against the clasped hands on the

occiput. Normal thyroid gland is not obvious on inspection. It can be seen only when the

thyroid gland is swollen.

The thyroid swelling may be uniform involving the whole of the thyroid gland or

isolated nodules of different sizes may be seen in the thyroid region.

The next important physical sign to watch is while deglutition a thyroid swelling will

move upwards. This is due to the fact that thyroid gland is fixed to the larynx. So to confirm

the thyroid swelling inspection has carried out while examination.

63

2. Palpation of the thyroid gland

The patient is asked to sit in a chair and asked to flex the neck slightly. The clinician

should stand behind the patient. The thumbs of the both hands are placed behind the neck

and the other four fingers of each hand are placed on each lobe and the isthmus. Careful

assessment 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 examiner

stands in front of the patient. To palpate the left lobe properly, the thyroid gland is pushed to

the 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 the

diagnosis of the thyroid swelling. Slight enlargement of the thyroid can be detected simply

by 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

64

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 a

retrosternal goiter.

3. Auscultation: In primary toxic goitre – systolic bruits may be heard over the goitre due to

vascularity.

Measurement of the circumference of the neck at the most prominent part of the

swelling may be taken at intervals. This will determine whether the swelling is increasing or

65

decreasing in size. Then all the system also should be examined, as it affects almost all

systems. It was carried out while examining the patient.

Investigations

These serum T3, T4 and TSH tests were investigated to determine which type of

thyroid disorders. These three tests are taken for assessment also it is assessed before and

after the treatment. RBS is done to rule out the diabetes and hemoglobin % to rule out the

anemia and ECG is to rule out cardiac emergencies in the process of excluding the patient

from treatment.

Treatment schedule

Amrutadi thailam capsule of 250mg is the trial drug given internally and Amrutadi

thailam 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 stomach

and the rest of 2 capsules at evening 5 PM.

Dose – 250mg capsule twice daily

Anupana – warm water

Externally

Pratimarsha Nasya is under taken.

Dose - 1-2 drops in each nostrils in the morning

Pathya – Apathya

Advised to take iodized salt and warm water after the intake of capsules. The

Goitrogens such as cabbage, cauliflower, teekshna, Guru and spicy foods are advised to

avoid during and after the treatment.

66

Drug review

This study is a prospective clinical study of Amrutadi thailam in Galaganda. Here a

detailed 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 is

mentioned in Yogaratnakara in the chapter Galagandadhikara

Criteria 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 thailam

1.GUDUCHI:-121-122

Botanical name – Tinospora cordifolia

Family – Menispermaceae

Synonym – Amruta, Chinnaruha, Madhuparni

Ganas – vayasthapana, daha prashamana, guduchyadi patoladi, aragwadhadi, kakolyadi,

stanyasodhaka

67

Description:-

It is a long lasting creeper climbing over the trees like mango, Neem, etc., the stem is

covered 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 yellow

flowers appearing in clusters. Fruit – bean shaped, appearing red on ripening and flourish in

cold 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 – vishagna

Chemical composition:-

It consists of berberine, a bitter substance and Giloin – a glucoside that is also bitter

in 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 satva

Dosage – decoction – 60 to 100ml, Powder – 1 to 3 grams, Satva – ¾ to 2 grams

68

2.HINGU:- 123-124

Botanical name – Ferula foetida

Family – Umbellifereae

Synonym – sahasraveda, jatuk, balhik, ramada

Ganas – samngasthapana, deepaniya, katukaskanda, pippalyadi, ushakadi.

Description:-A small perinneal shrub, 2-3 meters height. Leaves delicate, ciliated with 2-4

wings, stalk bears a single leaf with broken margin at the tip. Fruit – 1cmx1cm, the latex

called Hing.

Varieties: – White and black, white variety oozes latex which is scented, like diamond and

crystal clear. This is called hirahing and used in medicine. Black variety foul smells. Many

varieties are available in market, which are attributed to habitat, tree and mode of

preservation.

Habitat:-Iran, turkey, afghanistan, punjab and peshawar

Parts used –latex

Properties- Rasa – Katu

Guna – Laghu, Snigdha, teekshana, sara

Veerya – Ushna

Vipaka – Katu

Dosha karma – Vata Kapha hara

Chemical composition –

6 to17% of volatile oil. This contains rason oil and allyl persulphide, which emits a

special smell, 65% resin, wax etc.

69

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,

Rajapravartinivati

Dosage: – 0.25 to 0.5g

3.NIMBA:-125-126

Bonanical name – Azadirachta indica

Family – Meliaceae

Synonyms – pichumarda, hinguniryas, arishta

Ganas: – kandughna, tiktaskanta, argwadadhi guduchyadi, lakshadi

Description –

A tree measuring 8-10 meters in height. Trunk straight with branches in all

directions, bark is thick, black, rough from which secretion (latex) is obtained. Leaves

compound, 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. Fruits

contain sweet slightly pungent and sticky pulp and a single seed. Oil is extracted from the

seed.

Habitat – it is seen all over India

Parts used – flowers, leaves, bark, seed and oil

70

Properties:-

Rasa – Tikta Kashaya

Guna – Laghu

Veerya – Sheeta

Vipaka – katu

Doshakarma – Kapha Pitta shamaka

Chemical composition

External skin astringent but internal is pungent. Bark contains a bitter resin called

margosin. 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, daha

prashamana, pachana chakshushya.

Used in Kapha Pitta vikaras, vidradhi, granthi, aruchi, rakta vikaras, kasa, kushta,

netra roga, pramaha.

Vishista yoga: –

Nimbadichurna,

Nimbaristha,

Nimbaharedra khanda

Dosage: – Powder 1-2 g, Leaf juice – 12 to 14cc and Oil – 4-10 drops

4.ABHAYA:-127-128

Botanical name-Terminalia chebula

Family-Combrataceae

Synonyms -pathya,rohini,shreyasi,pachani,shiva

Ganas:- triphala, amalakyadi, parushakadi, prajasthapana, kusthaghna, kasaghna, assoghna.

71

Description:-

A big tree, 25-30 meters height. Its wood is hard and bulky. Leaves are 10-30cms in

length and are pointed. The vasculature of the leaves has 6-8 pairs of veins. The inferior

aspects 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 become

yellowish brown. Each fruit contains one seed. Seeds are oval and hard. On breaking the

shell 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 of

about 2000 mts from sea level.

Parts used – fruits

Properties

Rasa – Madhura, Amla, Katu, Tikta, Kashaya

Guna - Laghu, rooksha

Veerya – Ushna

Vipaka – Madhura

Prabhava – Tridosha hara

Dosha karma – Tridosha shamana

Chemical composition

In the fruits, tanin is present (25-30%). It also contains chebulagic acid, chebulinic

acid, corilagin. Traces of phosphorus, glucose, amino acids etc are present.

72

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 129-130

Botanical name – Holarrhena anti dysentrica

Family – Apocynaceae

Synonyms – kutoja, kalinga, vatsaka, yavaphala, girrimallika.

Description

The tree is 7-9 Mts tall. The bark is pale or brownish colour. The inner wood is pale

and 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 on

the 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

73

Chemical composition:-

The bark and seeds contain kurhicine and karchine. The others chemical constituent

are 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

kutajaualeha

Dose – 20-30gms for kwatha

3-6gms for choornam.

6) PIPPALI 131-132

Botanical name – Piper longum

Family – Piperaceae

Synonyms –magadhi, krishna, vaidhi, kana,ushna,chapala

Gana – kasa hara, shiroveerechana, vamana, deepanihya, pipalyadi, urdhuabhagahara,

Description :-

It is a creeper, which spreads on the ground, or climbs up near by trees for support

leaves 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 rainy

season and gives fruits during autumn.

Habitat – piper logum is grown in almost all over India

74

Parts used – fruit

Properties –

Rasa – Katu

Guna – Laghu, Snigdha, tekshna

Veerya – Anushna Sheeta

Vepaka – Madhura

Dosha Karma – Kapha Vata haram

Chemical 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 sopham

Vata Vyadhi, yakritvikara, and agnemandya pandu, rakta vikara, kasa, Swasa, kwatha.

Vishishta yoga –

Pipalyasana

Pippalikhanda

guda pippalli

Dose – 5-10 gm choornam

7) BALA 133-134

Botanical name – Sida cordifolia

Family – Malvaceae

Synonyms – bhadra, kharayasthika, vattika

75

Description

A small shrub of height 5 to 10 cm. Root and trunk are strong hence it is called as

bala. Leaves alternate 2.5 to 5 cm long 5cm broad ciliate, round having 7-9 veins on it and

serrated margin. Flowers – like moonga, divided into 5 parts. Seeds small dusty block and

look like bees. The seeds are called as beeja banda. The plant bears flowers and fruits at the

end of rainy season.

Habitat – all over India srilanka

Parts used – root, seeds and leaves

Properties – Rasa – Madhura

Guna – guru, Snigdha, pichila

Veerya – Sheeta

Vipaka – Madhura

Dosha karma – Vata, Pitta hara

Chemical composition –

Major components of seeds are alkaloids. Alkaloids contain mainly ephedrine it also

contains fatty acid, mucin, pottassium nitrate and resin.

Therapeutic use –

sophagnam, balya, grahi, rakta shodhaka, mootrala, brhmana, ojovardhaka. Used in

Vata pittavikaras. Vrnasopha, netra roga, ardita, pakshagata, Grahani, mootra krudra,

dourbalya, kshayaroga, krushata

Vishistha yoga – balaristha, baladyaghruta

Dose – swarasa – 10-20ml

Choorna – 3-6gm

76

8) ATIBALA 135-136

Botanical name – abutilon indicum

Family – malvaceae

Synonyms – kwaketika, rushyh prokta

Description

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 and

called as beeja banda.

Habitat – all over India and srilanka

Rest of the qualities and uses are same as that bala.

9) DEVDARU137-138

Botanical name – Cedrus deodara

Family – Pinaceae

Synonym – suradaru, bhadradaru, suravha

Description

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 yellow

and appear in clusters. Fruit – ripe fruit is black having seeded 1cm long. The tree bears new

fruits in October, which ripe within a year. Deodar tree has a long life span of 600 years

Habitat – at the height of 2000 to 3000 meters in Himalayas

Parts used – inner substance of wood and oil (kanda sara)

77

Properties –

Rasa – Tikta, Katu

Guna – Laghu, Snigdha

Veerya – Ushna

Vipaka – Katu

Doshakaram – Kapha Vata haram

Chemical composition

It contains dark coloured oil and resin. The oil contains a chemical constituent called

sesquiterpene.

Therapeutic uses – sophaharam, vedanasthapanam, kusthaghna, krimighna, swedajananam.

Used in Kapha Vata vikaras sopha vedana yukta rogas skin diseases, sandhivata, grudhrasi

rakta shodakam, medoroga.

Vishista yoga – devadaruadi kwath, devadarvadichoorna

Dose – choornam 3-6gm

Taila – 20-40ml

Preparation of Amrutadi thailam 139

Amrutadi thailam is mentioned in yogaratnakara in galaganda prakaranam. The

preparation of medicine is according to the sneha vidhi of sarngadara. All the ingredients are

well identified and collected and cleaned well. Then on an auspicious day all drugs are

chopped and taken as 6 parts to that 96 parts water is added. Which is then kept on mrudu

Agni and boiled. It is then reduced to ¼ parts. This 24-part kashaya is mixed with 1/6 part

kalka and 6-part tila thailam and prepared on mrudu Agni. It is taken out from the fire, when

the paka is mrudu consistency and filtered.

78

The next day again to this 1/6 part kalka, 6-part-tila thailam and 24-part kashaya is

added, 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 and

then capsulated to the size of 250mg. The oil for the Pratimarsha Nasya is also bottled on the

same 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 liquid

soluble essence in to the oil. While preparing the decoction most of the volatile oil get

evaporated 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 the

complex alkaloids get entangled with the glycoside Easters of the fatty acids. The paste

comes directly into contact with the oil as it is prevented from burning by continues stirring

and the entire process being operated over mild heat, it is possible to get fat soluble

components of herbs and even some volatile oils mixed into oil. The essential components

coming into contact of per unit oil is more and the oil thus formed is more concentrated in

case 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 after

the treatment. The investigation serum T3 T4 and TSH were done before and after

treatment. Then its progress is noticed and recorded. All the parameters were reviewed

statically also.

79

Over all assessment

Over all assessment is made with the subjective parameters enumerated in the study

and their respective percentages of the disease regression is estimated. There by the

cumulative effect is valued and percentages of disease regression with symptom regression

are 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 subjects

with the variations found in the objective parameters. The T3, T4 or TSH in hyper, Hypo or

Euthyroidisms, does not show the significant differences in the study, the values towards the

normal deviations are considered to that of responded and the small value deviations are

emphasized as maintained. The others those who were not significant were put under the

Not responded.

80

Results

20 patients were registered for the present study. Out this, 3 patients were

discontinued, hence their data has not been included here. The remaining 17 patients of

Galaganda, fulfilling the criteria for diagnosis, were treated.

All the patients were examined before and after the treatment, according to the case

sheet format given in the annex. Both the subjective and objective criteria were recorded.

The data recorded are presented under the following headings.

A. Demographic data

B. Data related to the disease.

C. Data related to the overall response to the treatment

D. 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

Age

Tot

al n

o of

pati

ents

%

Res

pond

ed

%

Mai

ntai

ned

% Not

Res

pond

ed

%

Dis

cont

inue

d

%

15-254

20 2 50 1 25 0 0 1 25

25-352

10 1 50 0 0 1 50 0 0

35-456

30 2 33.3 3 50 1 16.6 0 0

45-555

25 1 20 2 40 1 20 1 20

55-653

15 0 0 2 66.6 0 0 1 33.3

Total 20 100 6 30 8 40 3 15 3 15

81

Age distributions:

Observation:

As we observe in the study, the age factors are discussed under the class intervals of

10 each from 15 to that of 65 years of ages. The patients observed from the observations are

of 17. The distributions are observed as maximum from that of the middle age groups such

as 35- 45. But still the age interval of 45-55 show remarkably increased number, i.e. 5

patients. The distributions as observed at the intervals of are 15-25 as 4 patients, 25-35 as 2

patients, 35-45 as 6 patients, 45-55 as 5 patients and 55-65 as 3 patients.

Graph – 1Showing Patients by age distribution

15-2520%

35-4530%

55-6515%

25-3510%

45-5525%

82

The individual results based upon the age distributions along with percentages are as

follows.

It is observed as – in the 15-25-age interval show the significant results and out of 4

patients, 2 (50%) patients responded, 1 (25%) patient maintained and 1 (25%) patient

discontinued. In 25-35 age group, 2 patients reported and 1 (50%) responded and the other

patient (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. In

45-55-age interval, 5 patients reported, out 1 (20%) patient responded and 2 (40%) patients

maintained and 1 (20%) patient not responded and 1 (20%) falls under discontinued

categories. The subsequent interval of 55-65 years of the age group, out of reported 3

patients, 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 yoga

taila Pratimarsha Nasya.

A2) DISTRIBUTION OF PATIENTS BY SEX

Table-10

Sex

Tot

al n

o of

pati

ents

%

Res

pond

ed

%

Mai

ntai

ned

% Not

Res

pond

ed

%

Dis

cont

inue

d

%

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 15

Observation:

The male female ratio is observed as 1:9. The percentage of the distribution does

show the gender differentiation to get this metabolic disease. The observations are 2 Patients

i.e. (10%) were male and 18 patients i.e. (90%) were female.

83

Result:

In which, out of reported Males 1 (50%) patient responded and another (50%) patient

is 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 are

discontinued.

Graph –2

Showing Patients by gender distribution

Male10%

Female 90%

84

A3) DISTRIBUTION OF PATIENTS BY RELIGION

Table- 11

Religion

Tot

al n

o of

pati

ents

%

Res

pond

ed

%

Mai

ntai

ned

% Not

Res

pond

ed

%

Dis

cont

inue

d

%

Hindu16

80 5 31.25 8 50 1 6.25 2 12.5

Muslim4

20 1 25 0 0 2 50 1 25

Christian0

0 0 0 0 0 0 0 0 0

Others0

0 0 0 0 0 0 0 0 0

Total20

100 6 30 8 40 3 15 3 15

Distribution 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 to

Hindu and only 4 patients are of Muslim community. No other community patients were

reported, as this locality is a Hindu dominated area.

Result:

Out of the 16 patients of Hindus, 5 (31.2%) patients responded, 8 (50%) patients

maintained, 1 (6.25%) patient not responded and 2 (12.5%) patients discontinued. Out of

reported 4 Muslims 1 (25%) patient responded, 2 (50%) not responded and one (25%)

patient discontinued.

85

Graph – 3Showing Patients by religion distribution

A4) DISTRIBUTION OF PATIENTS BY OCCUPATION

Table- 12

Occupation

Tot

al n

o of

pati

ents

%

Res

pond

ed

%

Mai

ntai

ned

% Not

Res

pond

ed

%D

isco

ntin

ued

%

Sedentary15

75 3 20 8 40 2 13.3 2 0

Active3

15 2 66.6 0 0 1 33.3 0 0

Labour0

0 0 0 0 0 0 0 0 0

Others2

10 1 50 0 0 0 0 1 50

Total20

100 6 30 8 40 3 15 3 15

Christian 0%

Hindu80%

Muslim20%

Others0%

86

Observation:

For the convenience of the study common occupational listing are grouped. They are

based 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 class

and 2 (10%) patients reported as other category.

Result:

Out of 15 patients of sedentary, 3 (20%) responded, 8 (40%) patients maintained and

2 (13.3%) patients are not responded. 2 (13.3%) patients of sedentary group have

discontinued 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 and

1 (50%) patients is discontinued.

Graph –4Showing Patients by occupation distribution

Labour0%

Sedentary75%

Active15%

Others10%

87

A5) DISTRIBUTION OF PATIENTS BY ECONOMIC STATUS

Table-13

Economicstatus

Tot

al n

o of

pati

ents

%

Res

pond

ed

%

Mai

ntai

ned

% Not

Res

pond

ed

%

Dis

cont

inue

d

%

Belowpoverty line

210 0 0 2 100 0 0 0 0

Middle 1365 4 30.7 5 38.4 2 15.3 2 15.3

Upper middleclass

420 2 50 0 0 1 25 1 25

Higher class 15 0 0 1 100 0 0 0 0

Total 20100 6 30 8 40 3 15 3 15

Observation:

In this study the common four groups of economical states are considered. They are

1) 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 middle

class. 2 (10%) patients reported from the BPL class, 4 (20%) patients are from upper middle

class 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 not

responded. From the BPL class all 2 (100%) patients maintained to the management. Out of

the 4 patients of upper middle class, 2 (50%) patients responded 1(25%) patient

discontinued and 1 (25%) patient were not responded. The patient (100%) reported from that

of higher class is maintained for the management.

88

Graph –5Showing Patients by economical status distribution

B) Data related to the disease.

B1) DISTRIBUTION OF PATIENTS BY MODE OF ON SET

Table- 14

Mode of onset

Tot

al n

o of

pati

ents

%

Res

pond

ed

%

Mai

ntai

ned

% Not

Res

pond

ed

%

Dis

cont

inue

d

%

Gradual17

85 6 35.2 6 35.2 2 11.7 3 17.6

Sudden0

0 0 0 0 0 0 0 0 0

Insidious3

15 0 0 2 66.6 1 33.3 0 0

Total20

100 6 30 8 40 3 15 3 15

2

13

4

1

0

2

4

6

8

10

12

14

Below povertyline

Middle Upper middleclass

Higher class

by economical statusPatients

89

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 from

gradual class. 3 (15%) patients are reported from the insidious class and no patients are

from 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 not

responded. From the insidious class 2 (66.7%) patients maintained to the management and 1

(33.3%) patient is not responded.

Graph –6Showing Patients by mode of onset distribution

Insidious15%

Gradual85%

Sudden0%

90

B2) DISTRIBUTION OF PATIENTS BY INTAKE OF GOITROGENS

Table- 15

Intake ofGoitrogens

Tot

al n

o of

pati

ents

%

Res

pond

ed

%

Mai

ntai

ned

% Not

Res

pond

ed

%

Dis

cont

inue

d

%

Present12

60 4 33.3 4 33.3 1 8.3 3 25

Absent8

40 2 25 4 50 2 25 0 0

Total20

100 6 30 8 40 3 15 3 15

Observation:

In this study the common groups of Goitrogens Intakes are considered as present or

not present. Out of 20 patients reported, maximum numbers of 12 (60%) patients are at the

usage of Goitrogens Intake and the rest of 8 (40%) were not directly give any reference of

Goitrogens Intake food substances.

Graph –7Showing Patients by intake of Goitrogens distribution

Distribution by Goitrogens Intake

Present60%

Absent40%

91

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 not

responded. From the non-Goitrogens Intake class 4 (50%) patients maintained to the

management, 2 (25%) patient is not responded and 2 (25%) patient is responded.

B3) DISTRIBUTION OF PATIENTS BY FAMILY HISTORY

Table- 16

Familyhistory

Tot

al n

o of

pati

ents

%

Res

pond

ed

%

Mai

ntai

ned

% Not

Res

pond

ed

%

Dis

cont

inue

d

%

Present10

50 4 40 2 20 3 30 1 10

Absent10

50 2 20 6 60 0 0 2 20

Total20

100 6 30 8 40 3 15 3 15

Observation:

In this study the common groups of Family history are considered as present or not

present. Out of 20 patients reported, maximum numbers of 10 (50%) patients are with

Family history and the rest of 10 (50%) were not directly give any reference of Family

history.

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 maintained

to the management, and 2 (20%) patient is responded. The other 2 (20%) patients

discontinued the treatment.

92

Graph – 8Showing Patients by family history distribution

B4) DISTRIBUTION OF PATIENTS BY Agni (APPETITE)

Table- 17

Appetite

Tot

al n

o of

pati

ents

%

Res

pond

ed

%

Mai

ntai

ned

% Not

Res

pond

ed

%

Dis

cont

inue

d

%

Poor5

25 0 0 1 20 1 20 3 60

Moderate7

35 4 57.1 3 42.8 0 0 0 0

Good7

35 2 28.6 4 57.1 1 14.2 0 0

Severe1

5 0 0 0 0 1 100 0 0

Total20

100 6 30 8 40 3 15 3 15

Observation:

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

Distribution by Family history

Present50%

Absent50%

93

appetites) which is said as the cause of all diseases in Ayurveda. The category of moderate

appetites i.e. samagni patients are 7 (35%) and the good appetite patients are 7 (35%). The

one (5%) patient reported with severe appetite, which is considered in Ayurveda as

Teekshnagni

Result:

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 not

reported with samagni moderate history of appetite 3 (42.8%) patients maintained to the

management, 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 not

responded. Out of the category of Teekshangni the patient reported is not responded to the

treatment.

Graph – 9Showing Patients by Agni distribution

Distribution by Agni (APPETITE)

Good35%

Poor25%

Moderate35%

Severe5%

94

B5) DISTRIBUTION OF PATIENTS BY SLEEP

Table- 18

Sleep

Tot

al n

o of

pati

ents

%

Res

pond

ed

%

Mai

ntai

ned

% Not

Res

pond

ed

%

Dis

cont

inue

d

%

Sound sleep8

40 1 12.5 5 62.5 2 25 0 0

More sleep5

25 2 40 1 20 0 0 2 40

Less sleep4

20 2 50 1 25 1 25 0 0

Disturbedsleep

315 1 33.3 1 33.3 0 0 1 33.3

Total20

100 6 30 8 40 3 15 3 15

Distribution 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%) patients

reported with sound sleep. The category of more sleep i.e. Atinidra patients are 5 (25%) and

with 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 are

with Atinidra, 1 (20%) patient maintained in the management and 2 (40%) patients are

responded, the rest 2 (40%) patients are discontinued the treatment. Out of the 3 patients

with 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.

95

Graph –10Showing Patients by sleep distribution

B6) DISTRIBUTION OF PATIENTS BY PSYCOLOGICAL FEATURES

Table- 19

Psychological features

Tot

al n

o of

pati

ents

%

Res

pond

ed

%

Mai

ntai

ned

% Not

Res

pond

ed

%D

isco

ntin

ued

%

Present19

95 6 31.8 7 36.8 3 15.8 3 15.8

Absent1

5 0 0 1 100 0 0 0 0

Total20

100 6 30 8 40 3 15 3 15

Distribution by Psychological features

Observation:

In this study the common groups of psychological features are considered as present

or not present. Out of 20 patients reported, maximum numbers of 19 (95%) patients are with

Distribution by Nidra (sleep)

Less sleep 20%

Sound sleep 40%

More sleep 25%

Disturbed sleep 15%

96

the psychological features interfered and the rest of 1 (5%) patient is not directly given any

reference of psychological features exposed.

Result:

Out of the 19 patients of psychological features interfered class, 6 (31.6%) patients

responded 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 psychological

interference class patient (100%) patient maintained to the management.

Graph –11

Showing Patients by psychological features distribution

Distribution by Psychological features

Present 95%

absent5%

97

B7) DISTRIBUTION OF PATIENTS BY HABITS

Table- 20

Habits

Tot

al n

o of

pati

ents

%

Res

pond

ed

%

Mai

ntai

ned

% Not

Res

pond

ed

%

Dis

cont

inue

d

%

No Habit17

85 5 29.4 7 41.8 3 17.6 2 11.8

Smoking2

10 1 50 1 50 0 0 0 0

Alcohol0

0 0 0 0 0 0 0 0 0

Tobacco1

5 0 0 0 0 0 0 1 100

Total20

100 6 30 8 40 3 15 3 15

Distribution 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 is

responded. From the patients those who are with smoking, 1 (50%) patient maintained in the

management and the other (50%) patient are responded. Patient reported with tobacco usage

is reported discontinued from the study.

98

Graph –12Showing Patients by habits distribution

B8) DISTRIBUTION OF PATIENTS BY MENUSTRAL CYCLETable-21

Menstrualcycle

Tot

al n

o of

pati

ents

%

Res

pond

ed

%

Mai

ntai

ned

% Not

Res

pond

ed

%D

isco

ntin

ued

%

Regular8

44.4 4 50 2 25 0 0 2 25

Irregular5

27.7 1 20 2 40 2 40 0 0

Menopause5

27.8 0 0 4 80 0 0 1 20

Total18

100 5 27.8 8 44.4 2 11.1 3 16.7

Observation:

In this study the common groups of menstrual cycle history is observed as the

maximum number of the patients are of females. The categories are Regular, Irregular and

Menopause. Out of 18 patients reported, maximum numbers of 8 (44.4%) patients are with

Distribution by Vyasana (Habits)

Alcohol0%

No Habit85%

Smoking10%

Tobacco5%

99

regular menstrual cycle and 5 (27.8%) irregular menstrual cycle and 5 (27.8%) population

reported 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 those

who are with irregular menstrual cycle, 2 (40%) patient maintained in the management 1

patient (25%) responded and the other 2 (40%) patient are not responded. From the patients

those who are with menopause, 4 (40%) patient maintained in the management 1 patient

(20%) discontinued.

Graph –13

Showing Patients by menstrual cycle distribution

Distribution by Menstrual cycle

Menopause28%

Regular44%

Irregular28%

100

B9) DISTRIBUTION OF PATIENTS BY BUILT AND NUTRITION

Table- 22

Built andnutrition

Tot

al n

o of

pati

ents

%

Res

pond

ed

%

Mai

ntai

ned

% Not

Res

pond

ed

%

Dis

cont

inue

d

%

Well7

35 3 42.9 4 57.1 0 0 0 0

Thin8

40 2 35 2 25 3 37.5 1 12.5

Obese5

25 1 20 2 40 0 0 2 40

Total20

100 6 30 8 40 3 15 3 15

Distribution by built and nutrition

Observation:

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 are

with 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 management

and 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 from

the study.

101

Graph – 14

Showing Patients by built and nutrition distribution

B10) DISTRIBUTION OF PATIENTS BY AHARAJA AND VIHARA NIDANA

Table- 23

Aharaja Nidana

Tot

al n

o of

pati

ents

%

Res

pond

ed

%

Mai

ntai

ned

% Not

Res

pond

ed

%

Dis

cont

inue

d

%

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

Avvaksayana11

55 3 27.3 6 54.5 1 9.09 1 9.09

Distribution by Aharaja Vihara Nidana

Observation:

In this study the common groups Aharaja Nidana is considered as guru and Viruddha

bhojana. Out of 20 patients reported, maximum numbers of 17 (85%) patients are with

Distribution by built and nutrition

Obese, 5

Well, 7

Thin, 8

0 1 2 3 4 5 6 7 8 9

Well

Thin

Obese

102

Gurubhojana and 18 patients reported with the Virudhabhojana. In this study it is evident

that 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 20

patients 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 is

responded. From the patients those who are with Virudhabhojana, 6 (33.33%) patient

maintained in the management 3 (16.66%) patients not responded, 3 (16.66%) patients

discontinued 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 are

responded.

Graph –15

Showing Patients by Aharaja and Viharaja Nidana distribution

Distribution by Aharaja Vihara Nidana

Avvaksayana, 11

Gurubhojana, 17

Virudhabhojana, 18

0

2

4

6

8

10

12

14

16

18

20

Gurubhojana Virudhabhojana Avvaksayana

103

B12) DISTRIBUTION OF PATIENTS WITH SYSTEMS INVOLVED

Table- 24

Systems

Tot

al n

o of

pati

ents

%

Res

pond

ed

%

Mai

ntai

ned

% Not

Res

pond

ed

%

Dis

cont

inue

d

%

Cardio

respiratory12 60 3 25 5 41.7 2 16.7 2 16.7

Gastro 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 12.5

Neuro 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 18

Distribution by systems involved

Observation:

In this study the common groups of systems involved are included. Out of 20

patients reported, maximum numbers of 16 (80%) patients are with dermatological problems

and 12 patients of cardio- respiratory along with 11 (55%) patients with neuro muscular

complaints are received.

The other systems witnessed are 9 (45%) of GIT problems and 2 (10%) of

reproductive problems.

Result:

Out of the 16 patients with dermatological problems, 7 (43.75%) patients maintained

2 (12.5%) patients not responded, 2 (12.5%) patients discontinued and 5 (31.25%) patient is

responded.

104

Out of the 12 patients with cardio-respiratory problems, 5 (41.7%) patients

maintained 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 maintained

2 (18.2%) patients not responded, 1 (9.09%) patient discontinued and 4 (36.7%) patient is

responded.

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 is

responded.

Out of the 2 patients with reproductive problems, all the patients discontinued from

the management.

Graph –16

Showing Patients by with systems involved

12

9

16

11

2

0 2 4 6 8 10 12 14 16

Cardio respiratory

Gastro intestinal

Dermatological

Neuro muscular

Reproductive

Distribution by systems involved

105

C) Data related to the overall response to the treatment

C1) DISTRIBUTION OF PATIENTS BY CHIEF COMPALINTS

Table- 25

Chiefcomplaints

Tot

al n

o of

pati

ents

%

Res

pond

ed

%

Mai

ntai

ned

%

Not

Res

pond

ed

%

Dis

cont

inue

d

%

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

swallow17 100 6 35.3 8 47 3 17.7 0 0

Difficulty to

breath17 100 6 35.3 8 47 3 17.7 0 0

Distribution by systems involved

Observation:

All most all the symptoms, which are evaluated, show the al 17 patients involving

with the symptoms in the disease. It is clear and significant that the disease explained in the

Ayurveda and compared on contemporary systems substantiate the present study patterns.

Results:

The results are discussed as symptoms react to that of the management. This is

reflecting the as it is of the result final, which will be discussed as under in the subjective

parameters enumerated.

106

C2) subjective parameters enumerated (a)TABLE -26

Ganda Toda Vivarnata Kandusl

noB 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 2 502 2 1 1 50 2 1 1 50 3 1 2 66.6 3 1 2 66.63 3 2 1 33.3 3 1 2 66.6 2 1 1 50 3 2 1 33.34 3 2 1 33.3 3 1 2 66.6 2 1 1 50 2 1 1 505 2 1 1 50 3 1 2 66.6 4 1 3 75 3 1 2 66.66 3 2 1 33.3 3 1 2 66.6 2 1 1 50 2 1 1 507 3 2 1 33.3 2 1 1 50 2 1 1 50 3 2 1 33.38 2 1 1 50 3 1 2 66.6 3 1 2 66.6 3 1 2 66.69 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 5011 4 3 1 25 3 1 2 66.6 3 2 1 33.3 3 1 2 66.612 3 1 2 66.6 2 1 1 50 3 1 2 66.6 3 1 2 66.613 3 2 1 33.3 3 1 2 66.6 2 1 1 50 3 1 2 66.614 3 2 1 33.3 3 1 2 66.6 2 1 1 50 3 1 2 66.615 2 1 1 50 2 1 1 50 2 1 1 50 3 1 2 66.616 3 2 1 33.3 3 1 2 66.6 3 1 2 66.6 4 1 3 7517 3 2 1 33.3 2 1 1 50 3 1 2 66.6 4 2 2 50

TABLE -27Subjective parameters enumerated (b)

difficulty inswallowing

difficulty inberatingsl

no

B A D % B A D %

over all % Result

1 2 1 1 50 2 1 1 50 55.4 Maintained2 2 1 1 50 2 1 1 50 55.5 Responded3 2 1 1 50 3 1 2 66.6 49.98 Maintained4 2 1 1 50 3 1 2 66.6 52.8 Maintained5 2 1 1 50 2 1 1 50 59.72 Maintained6 2 1 1 50 1 1 0 0 49.99 Maintained7 2 2 0 0 2 1 1 50 43.32 Not Responded8 2 1 1 50 3 1 2 66.6 61.06 Not Responded9 2 1 1 50 3 1 2 66.6 58.3 Responded

10 2 1 1 50 3 1 2 66.6 55.54 Responded11 2 2 0 0 3 1 2 66.6 51.65 Responded12 2 1 1 50 3 1 2 66.6 61.1 Not Responded13 2 1 1 50 3 1 2 66.6 47.21 Maintained14 2 1 1 50 2 1 1 50 52.77 Responded15 2 1 1 50 2 1 1 50 52.77 Maintained16 2 1 1 50 3 1 2 66.6 59.71 Maintained17 2 1 1 50 2 1 1 50 49.98 Responded

107

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 grading

evaluated in the study as before after with percentage of difference. The total values are

cumulated and told to get the summated net results of Amrutadi Yoga in the management of

the Galaganda vis-à-vis goiter.

D) Statistical analysis of the clinical and functional parameters

D1) showing the statistical analysis of the chief complaints

Table -28Parameters Mean S.D S.E t-value p-value Remarks

Ganda 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

Swallowing

0.882 0.332 0.08 11.025 <0.001 H.S.

Difficulty In

Breathing

1.47 0.624 0.151 9.735 <0.001 H.S.

HS = Highly Significant, S = Significant, NS = Not Significant

D2) showing the statistical analysis of the lab investigations

Table -29Parameters Mean S.D. S.E. t-value p-value Remarks

T3 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

108

D3) Anova – Table for the parameter T3

Table - 30

Source ofVariation

Deg

rees

of

free

dom

Sum

of

squa

re

Mea

n su

m o

fsq

uare

F c

alcu

late

dV

alue

F t

able

Val

ue a

t 5%

p-va

lue

Rem

arks

Groups 2 1.07 0.535

Error 14 2.984 0.213

Total 16 4.054 -

2.511 3.74 P > 0.05 N.S.

HS = Highly Significant, S = Significant, NS = Not Significant

D4) Anova – Table for the T4 parameter

Table –31

Source ofVariation

Deg

rees

of

free

dom

Sum

of

squa

re

Mea

n su

m o

fsq

uare

F c

alcu

late

dV

alue

F t

able

Val

ue a

t 5%

p-va

lue

Rem

arks

Groups 2 23491.988 11745.994

Error 14 8255.578 589.68

Total 16 31747.56 -

19.19 3.74 P < 0.05Si

gnif

ican

t

D5) Table show which pair of group is significant

Table - 32Group Mean Difference

Hyperthyroidism 207.02 $ -

Eu-thyroidism 102.5 $ 104.52 $

Hypothyroidism 86.55 $ 120.47 $ 15.95 #

$ - Significant # - Not significant

109

Least Significance difference value = t 0.05 SE� 1

/ni + 1/nj

or Critical difference (C.DOR L.S.D). Where t0.05 in t- table value at 5% level of significance

for error degrees of freedom. SE2 is mean error sum of squares. And ni , nj are the number

of observations in the two groups.

L.S.D =2.12� 589.68 X � 1/2 + 1/8

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 = 40.69

D6) Anova- Table for parameter T.S.H.

Table -33

Source ofVariation

Deg

rees

of

free

dom

Sum

of

squa

re

Mea

n su

m o

fsq

uare

F c

alcu

late

dV

alue

F t

able

Val

ue a

t 5%

p-va

lue

Rem

arks

Groups 2 1324.514 662.257

Error 14 1931.759 137.98

Total 16 3256.274 -

4.79 3.74 P < 0.05

Sign

ific

ant

D7) to show which pair of group is significant

Table - 34Group Mean Difference

Hypothyroidism 19.23 $ - -

Euthyroidism 2.208 # 17.202 $ -

Hyperthyroidism 0.055 # 19.175 # 1.973 #

$ = Significant # = Not Significant

110

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 = 19.965

Conclusion

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

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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 Maintained

patients are 8 (40%), 3 patients (15%) in the last category of Not-responded associated with

3 patients (15%) discontinued the treatment. The results are compared with the parameters

of subjective and objective together. The graphical representation of the study is as follows.

112

Table – 35

Showing the result of Amrutadi taila capsules in Galaganda

Result Patients Percentage

Responded 6 30

Maintained 8 40

Not Responded 3 15

Discontinued 3 15

Total 20 100

Graph – 17Depicting the results of Amrutadi yoga on Galaganda

Results of Amrutadi yoga on Galaganda

Not Responded, 3

Responded, 6

Maintained, 8

Discontinued, 3

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Discussion

The thyroid disorders are characterized by physical and mental interference. In

Ayurveda there is not an exact term for thyroid gland. Some of the later Ayurvedic scholar

tried to name the thyroid gland, but they could not compare many thyroid disorders with any

of the ancient descriptions.

We can correlate goitre and some tumour pathology of thyroid to ‘Galaganda’ where

thyroid functions may or may not are affected. It is therefore, better not to restrict thyroid

dysfunction to any one of the diseases.

In this study total 20 patients were reported. Out of them 17 patients were selected

for the study in one group. 3 patients were discontinued. This was a unique study, in which

the trail medicine was in the form of oil. The oil is made 11-avarthi to enhance the

cumulative effect of said combination. The avartha taila is then capsulated in the gelatinous

form; under GMP specification and used as internal medicine the same avartha taila is used

for Pratimarsha Nasya.

The discussion is to be mainly focussed on the objectives. The three objectives of

this 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 study

along with over all assessments. For that the discussion is classified as follows

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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) Conclusion

1) 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. The

goitre is present in both types of thyroid disorders such as hypo thyroidism and

hyperthyroidism. The various signs and symptoms mentioned in the contemporary sciences

can not be correlated as such with the Galaganda, which is a disease pertaining to the neck

region but the goitre is affecting many systems.

115

2) Discussion on the signs and symptoms

The signs and symptoms of Galaganda mentioned in Ayurvedic system is taken for

the study. But as the goitre in the contemporary system effects all the systems of the body it

also should be considered so the discussion on sign and symptoms is classified into two as

follows -

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 In

the neck) vivarnata (discoloration of skin around the mass), kandu (itching around the mass),

difficulty to swallow and difficulty in breathing. Recording them before assesses these

symptoms and after the treatment and difference is emphasized the symptoms discussed here

are 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

116

assessed statistically on the result was highly significant. The cumulative effect of

Amrutadi yoga especially, shophaharatnam will be the basis of the reduction of

ganda in this study.

B) Todam

All the 20 patients presented with todam (a vedana vishesham of pain) in

distributing degrees, which is recorded according to the grading mentioned in annex.

After treatment data of 17 patients (3 discounted) were assessed by comparing the

before treatment and after treatment values.

The todam is reduced in parlance with the swelling, as the swelling will

compress 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 the

vedanasamakatwam, sophakaratwam property that is dealt in detail. The discussion

on drug is the basis of probable mode of action, which makes the reduction in toda. It

is assessed statistically and the result was highly significant.

C) Vivarnata

The 20 patients was presented with the slight vivarnata (discoloration of mass) the

vivarnata as is a chief symptom of Galaganda was recorded in 17 patients (3

discontinued) the after treatment data is then compared with before treatment data to

make the result. Examining the neck assesses the vivarnata progress, normally body

colour will be different from the abnormal discoloration present due to various

pathologies. Some presented with discoloration with blackish spots and some others

with reddish spots. All the patients got relief from vivarnata caused by disease during

the treatment with the Amrutadi yoga. The drugs, which are useful in reducing the

vivarnata, are elaborately discussed in the drug discussion. Those are the probable

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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.

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A) Difficulty to swallow

All the 20 patients were presented with difficulty to swallow. The before

treatment 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 the

mass in the neck is reduced, the difficulty to swallow will also reduced. The

difficulty to swallow was reduced in all 17 patients. The grading assesses this

mentioned in the annex. By inspection we can find out the swelling which is

reduced or not. The swelling is reduced by the Amrutadi taila in the majority of the

drugs have the property of sophahatwam. It was assessed statistically also and found

highly significant.

B) Difficulty in breathing

20 patients present in study complaint of varying degrees of difficulty in

breathing. The before and after treatment data are recorded in the 17 patients (3

discontinued). It is then compared and made the difference to know the result. The

symptoms were reduced in all the 17 patients. The responded group patients and the

maintained group patients got more relief from difficulty in breathing. The 3-

hyperthyroidism patients got relief by the treatment but asked as the disease

progressed again the attacks of difficulty in breathing also manifested. 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.

C) Group study

The various symptoms of this group are to be discussed. After the assessment

of both subjective and objective parameters the results are, hypo thyroid patients

119

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 and

symptoms 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 of

them generalised weakness, fatigue, and restlessness got relief by the treatment. Other

symptoms were not relieved considerably the goitre was present in 1 patient, which was

nodular one. It was not relieved by the treatment.

ii) Systemic evaluation

Table – 37: Cardiovascular

Symptoms Signs

Dyspnoea,on exertion Increased pulse rate

Palpitation Tachycardia

120

The above signs and symptoms were present in all the 3 patients reported with hyper

thyroidism. The symptom dyspnoea on exertion got relief and the rest of the signs of

symptoms 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 patients

reported with hyper thyroidism. Fine tremors were present in 1 patient of the

hyperthyroidism 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. The

nervousness 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 in

all the 3,and the loose motions were present in 1 patient of the hyper thyroidism. The

anorexia was relieved after the treatment.

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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 patients

responded to the treatment. The signs and symptoms presented by those patients were

classified into 3 as such general features, systemic and psychological

Table- 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 patients

reported with hypo thyroidism. The weight gain and goitre was present in 6 cases and puffy

face was present in 2 patients.

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The hoarseness of voice and tiredness were reduced considerably. The patients

presented with cold in tolerance can with stand some cold after the treatment. The puffy face

was reduced in the 2 patients. The weight gain was changed with the maximum of 2kg in 1

patient. The goitre present in all the 6 patients reduced in size after the treatment

Table –42

Cardio Vascular system

Symptoms Signs

Shortness of breath Hypertension

Bradicardia

The symptoms were maintained by the treatment, but the hypertension persisted after

the treatment.

Table –43

Central 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 were

present in 3 patients only. The symptoms such as muscle pain and stiffness were relieved

completely. The slowing of motor functions are progressed after the treatment.

Gastro-intestinal tract

All of the hypothyroidism patients presented with constipation either occasionally or

regularly. They were responded to the treatment and constipation was relieved completely

after the treatment.

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Reproductive system

Irregular delayed menstruation, were present in 3 patients of hypothyroidism. They

were 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 discussion

a) Age

The thyroid diseases are common in the middle-aged women. It is also manifested in

the teenaged girls and pregnant women, as the hormonal imbalance will be due to the more

needed at that time. It is common in 35-55 age group, the patients, reported were 11 in

number.

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 20

patients, 18 were females.

c) Occupation

Most of the patients belong to the sedentary group. The lack of activities is an

important factor in manifesting the diseases. The detailed descriptions of the demographic

data of the other factors are given in the results.

124

4) Disease related data

a) Mode of onset

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.

b) Intake of Goitrogens

The Goitrogens are the pre-disposing factors, which enhance the production of

thyroid disease. They are vegetables of Brassica family, other drugs etc. In this study 12

patients presented with intake of Goitrogens. Educating them about the consequences of it

can prevent this disease.

c) Family history

The thyroid diseases are often seen to run in families. In this study 10 patients came

with 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 is

diminished appetite in the hypothyroidism and increased in the hyperthyroidism. In this

study the patients reported with poor appetite are 5, moderate appetite are 7, good appetite

are 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 sleep

more, and the hyperthyroidism patients will be disturbed or less sleep. In this study the

patients with sound sleep are 8, with more sleep are 5, less sleep are 4 and disturbed sleep

are 3 in number.

125

f) Psychological features

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.

g) Habits

As the majority of the patients were females in this study, the habits were not

relevant.

h) Menstrual cycle

It is also disturbed by the thyroid problems. As most of the patients were females, it

is also considered as an important data to be evaluated. Out of the female patients reported

in 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 under

weight and over weight of the body. In hypos 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.

j) Nidana

The Nidana such as Aharaja and Viharaja are considered in the study. The virudha

Ahara and guru Ahara will produces the increased Kapha and ultimately the dushta Kapha

will vitiate the medas and produces the Galaganda. All the patients presented with both the

guruahara 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

126

iodine is also an important factor in the production of goiter. So the patients are educated

with 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 for

Galaganda. It is stated in the yoga to take the same in the taila form. So the 11-avarthi

thailam is made to enhance the guna of its constituents. The Amrutadi thailam has the

properties such as Kandughna, Sophaharatwam, Vedanasthapanam, Kapha-Vata haratwam,

Medoghnam, Lekhana, Chedana etc in total. The most of the drugs used in the yoga belongs

to Shirovirechaneeya gana, and some of them are Srotoshodakam; which reduces the Kapha

Dosha, and dushta medas by it’s chedana etc property as mentioned above. This yoga also

pacifies the Sopham, Todam, Vivarnata, the Difficulty in breathing and the difficulty to

Swallow 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 the

body is compared of Pancha mahabhuta, considering the Pancha mahabhuta will give more

action 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, katu

Rasa that pacifies Kapha Dosha. The other constituents have madura Rasa and which have

ushnaveerya will pacify Vata Dosha. The drugs having combined such as lekhana, chedana,

veedanasthabana, kandughna, sophaharatwa, vrnaroana, siroverachana, and Rasayana.

127

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.

128

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 also

administered. As in the classics it is stated that by doing Nasya karma, the disease above the

clavicle will be cured. The Nasya karma is classified into two, Pratimarsha Nasya / Marsha

Nasya. The action of Pratimarsha Nasya done in this study is satisfactorily along with the

internal medicine. It can be even more enhanced if it is given as Marsha Nasya. The Marsha

Nasya 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 blood

circulation, after absorption through mucous membrane. The direct pooling into venous

129

sinuses of brain through the inferior ophthalmic veins and the last one the absorption

directly into the cerebro-spinal fluid.

Apart from the small emissary veins entering the cavernous sinuses of the brain; a pair

of venous branch emerging from alae nesi will drain into facial vein. Almost in the opposite

direction inferior ophthalmic veins also enter the facial veins. These opthalmics in other

hand also drains into cavernous sinus of the meninges and in addition neither the facial vein

nor the ophthalmic vein have any veinal valves. So there are more chances of blood draining

from 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 in

naso-pharynx and suction causes oozing of drug material into air sinuses. These sites are

rich with blood vessels entering the brain and meninges through the existing foramen in the

bones. So there is better chances drug transportation in this route.

Recent authors as middle cephalic fossa of the skull have explained the shringataka

marma. It is consisting with para nasal sinuses and meningial vessels and nerves. One can

see the truth of narration made by Vagbhata here. The drug administered enters the para

nasal sinus especially frontal and sphenoidal sinuses, i.e., shringataka where the ophthalmic

veins and the other veins.

The sphenoidal sinuses are in close relation with intra-cranial structures. Thus there

may be a so far undetected route between air sinuses and cavernous sinuses enabling the

transudation of fluids. As a whole, the mentioning of the sringataka in this context seems to

move reasonable.

130

7) Overall assessment of Amrutadi Yoga in Galaganda

The lab-investigations were done before treatment and after treatment. In these study

the parameters are T3, T4, and TSH. It is dependent on each other in the thyroid disorders

hypothyroidism and hyperthyroidism. So a difference in them has no value as the TSH is

increased in the hypothyroidism and it is decreased in the hyperthyroidism. So a common

assessment is not possible. It is then done by classifying the whole data into three groups as

by assessing the appropriate values of T3, T4 and TSH in concern with the three types of

thyroid diseases.

The result is calculated as Responded, Maintained and Not responded from the

values of the lab-investigations. The responded group patient’s shown the value reduced

considerably in parlance with the normal values. These patients belong to the

Hypothyroidism. So it can be decided that the Amrutadi thailam is more effective in

hypothyroidism patients.

The TSH was not increased in the hyperthyroid patients, so they were considered as

Non responded.

The other patients who were Euthyroidism have the TSH values in the borderline of

the hypothyroidism. They were 8 in numbers and kept under, maintained group as they were

maintained by the treatment.

These classification is given to the subjective parameters also and compared the

percentage of response to the treatment. As the lab- investigation is an unbiased one it is

taken to declare the results.

131

8) Discussion on statistical analysis of subjective and objective parameters

All parameters show highly significant (from table –D1 and D2). The parameters

Toda show highly significant before and after treatment in the group (By using paired t- test

as P<0.001).

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).

The objective parameter T3 is not significant (as p< 0.05). The parameter T4 and

TSH are highly significant.

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.

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 Least

significance 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.

132

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.

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.

133

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

134

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.

135

Summary

The thyroid disorders are characterized by physical and mental interference. In

Ayurveda there is not an exact term for thyroid gland. We can correlate goiter and some

tumor pathology of thyroid to ‘Galaganda’ where thyroid functions may or many not are

affected.

In the contemporary system of medicine the treatment given to thyroid disorders are

anti-thyroid drugs, radio active iodine and surgery which has its own disadvantages and side

effects.

The main ambitions in the study are - 1) Evaluate the anti Goitrogenic effect of

Amrutadi thailam in Galaganda (Hypothyroidism or hyperthyroidism), 2) Evaluate the effect

of Amrutadi thailam on T3, T4 and TSH in Galaganda and 3) to evaluate the effect of

Amrutadi thailam Pratimarsha in Galaganda.

Susruta defines Galaganda as a swelling (mass in the neck region), by the vitiation of

Vata, Kapha and medo dhatu. Charaka mentioned that when a vitiated Kapha Dosha

circulates around the neck, it will cause swelling slowly is termed as Galaganda

From the contemporary medical science, Goitre is defined as a benign, non-toxic

enlargement of the thyroid gland usually secondary to some form or other of the iodine

deficiencies. 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. In

Susruta Nidana, mentions about the Galaganda Samprapti are very clear. Here the vitiated

Kapha will stay around the neck region and produce swelling, which is called as Galaganda.

136

The intake of tikta, katu, kashaya rasa , rookshannam, alpamatara bhojanam etc

vitiate then Vata Dosha. Mental factors like chinta, sokha, krodha, bhaya, etc vitiate Vata

Dosha. The increased Vata and Kapha Dosha in the neck will vitiate the medo Dhatu by its

prakopa karanas respectively. The deficiency of iodine content in the food is the main cause

for goitre.

Goitrogens are foods, which suppress thyroid function. In normal, Goitrogens can

induce hypothyroidism and goiter. In hypos, Goitrogens can further depress thyroidal

function and stimulate the growth of the thyroid (goiter).

The thyroid disorders and goiter are common in the females, in the certain ages, in

specific part of the world. The primary toxic goiter is usually present in young ones, where

in Hashimoto’s disease the victims are middle-aged women. Majorities of the thyroid

disorders are seen in females. Even thyroid carcinomas are more often seen in females in the

ratio 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 lies

among peculiar geographical distribution.

While many hyper secretaries to limit thyroid output by iodine restriction, this

strategy can backfire. Iodine restriction will cause the thyroid to increase in size (goitre) in

an effort to filter more blood to get more iodine. When iodine is then re-introduced to the

diet or accidentally ingested, the now larger thyroid gland has the capacity for greater

thyroid hormone production.

The iodine restriction is not a good long-term method for controlling thyroid

hormone production. Once copper is replenished and copper metabolism is working

properly, the body will tolerate iodine without increasing thyroid hormone production

137

The primary pre-condition for the production of thyroid disease is the onset of

anemia. Brassica vegetables, with their high sulphur content, may be foods, which induce

anaemia and consequently thyroid disease. Thiocyanates, Anti thyroid drugs, lithium,

iodides, p- amino salicylic acid, etc are also Goitrogenic. There is enzyme deficiency in the

thyroid gland. This leads to formation of decreased level of thyroid hormones, which will

increase TSH, and simple goitre is formed. This leads to reduced levels of thyroid hormones

and hence the goitre. Interference with thyroid hormone synthesis

As thyroid hormone increases metabolism in almost all cells of the body, excessive

quantities 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 – half

normal. Greatly increased thyroid hormones almost always decrease the body weight, and

greatly decreased hormone almost always increases the body weight.

Thyroid hormone increases both the rates of secretion of digestive juices and the

motility of the gastro-intestinal tract. Lack of thyroid hormone can cause constipation.

Thyroid hormones increases the rapidity of cerebration but also often dissociates this

conversely, lock of thyroid hormone decreases this function.

Poorvarupa are the prodromal symptoms of the forthcoming disease, which do not

clarify the Samprapti of the disease. The vitiated Kapha, Vata, and medas will show some

lakshnas 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 of

Kapha Dosha .He describes that, the Kapha Dosha vitiated by the etiological factors will

manifests 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.

138

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.

139

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

Bibliographic References i

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88. Vagbhata, Ashtangahridaya Nidanasthana chapter 21 sloka 43. Varanasi: KrishnadasAcademy; 1982. p. 749. (Krishnadas Academic series 4).

89. Madhavakara, Madhavanidana chapter 22 sloka 212. Varanasi: ChaukhambhaSurbharathi 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: KrishnadasAcademy; 1980. p. 314. (Krishnadas Ayurveda series 51).

92. Madhavanidana chapter 22 sloka 212. Varanasi: ChaukhambhaSurbharathi Prakashan; 1998. p. 520. (Chaukhambha Ayurvijnana Granthamala 46).

93. Sushrutha, Sushruthasamhitha Suthrasthana chapter 35 sloka 18. Varanasi: KrishnadasAcademy; 1980. p. 152. (Krishnadas Ayurveda series 51).

94. Sushrutha, Sushruthasamhitha Chikitsasthana chapter 23 sloka 7-9. Varanasi: KrishnadasAcademy; 1980. p. 486. (Krishnadas Ayurveda series 51).

Bibliographic References v

95. Davidson Stanley Sir, Principles and Practice of Medicine chapter 12. 17th ed. CRWEdwards, editor. London: Churchill Livingston 1995. p. 692.

96. Ahuja M.M.S, API Textbook of Medicine section XV Endocrinology. 6th ed. Sainani.G.Seditor. Mumbai: Association of Physicians of India. p. 954.

97. Ahuja M.M.S, API Textbook of Medicine section XV Endocrinology. 6th ed. Sainani.G.Seditor. Mumbai: Association of Physicians of India. p. 956.

98. Cotran SR, Pathologic Basis of Disease chapter 20. 6th ed. Philadelphia: Saunders; 2003.p. 1131.

99. Das Somen, A Concise textbook of Surgery chapter 37. 2nd ed. Calcutta: Dr.S.Das; 1999.p. 647.

100.Das Somen, A Concise textbook of Surgery chapter 37. 2nd ed. Calcutta: Dr.S.Das; 1999.p. 652.101.Ritchie A C, Boyd’s Textbook of Pathology Volume II. 9th ed. Philadelphia: Lea &Febriger (U.K); 1990. p .1440.102. Ritchie A C, Boyd’s Textbook of Pathology Volume II. 9th ed. Philadelphia: Lea &Febriger (U.K); 1990. p .1441.103.Cotran SR, Pathologic Basis of Disease chapter20. 6th ed. Philadelphia: Saunders: 2003.p .1133.104. Cotran SR, Pathologic Basis of Disease chapter20 .6th ed. Philadelphia: Saunders: 2003.P .1134.105.Das Somen, A manual on Clinical Surgery chapter 27. 4th ed. Calcutta: Dr.S.Das; 1996.p. 292.106.Sushrutha, Sushruthasamhitha Nidanasthana chapter 11, sloka 10-12, 23. Varanasi:Krishnadas Academy; 1980. p. 312, 314. (Krishnadas Ayurveda series 51).107.Sushrutha, Sushruthasamhitha Nidanasthana chapters 11 &16. Varanasi: KrishnadasAcademy; 1980. p. 314, 331. (Krishnadas Ayurveda series 51).108. Sushrutha, Sushruthasamhitha Chikitsasthana chapter 18 sloka 43-55. Varanasi:Krishnadas Academy; 1980. p. 474, 475. (Krishnadas Ayurveda series 51).109. Yogaratnakara Galaganda nidana sloka 3. Vaidya Lakshmipatisastry editor. Varanasi:Chaukhambha Sanskrit Sansthan; 1988. p. 147. (Kasi Sanskrit series 160).110. Bhavamishra, Bhavaprakasha Madhyamakhanda chapter 44 sloka 4. 5th ed. Varanasi:Chaukhambha Orientalia; 1988. p. 443. (Chaukhambha Sanskrit series 130).111. Chakrapanidatta, Chakradatta chapter 41. P.V.Sharma, editor. Varanasi: ChaukhambhaPublishers; 1998. p. 320. (Kasi Ayurveda series 17).112. Sushrutha, Sushruthasamhitha Chikitsasthana chapter 18 sloka 43-55. Varanasi:Krishnadas Academy; 1980. p. 474, 475. (Krishnadas Ayurveda series 51).113. Sushrutha, Sushruthasamhitha Chikitsasthana chapter 18 sloka 43-55. Varanasi:Krishnadas Academy; 1980. p. 474, 475. (Krishnadas Ayurveda series 51).114. Chakrapanidatta, Chakradatta chapter 41. P.V.Sharma, editor. Varanasi: ChaukhambhaPublishers; 1998. p. 320. (Kasi Ayurveda series 17).115. Das Somen, A manual on Clinical Surgery chapter 27. 4th ed. Calcutta: Dr.S.Das; 1996.p. 286.116. Das Somen, A manual on Clinical Surgery chapter 27. 4th ed. Calcutta: Dr.S.Das; 1996.p. 287.117. Das Somen, A manual on Clinical Surgery chapter 27. 4th ed. Calcutta: Dr.S.Das; 1996.p. 284.

Bibliographic References vi

118. Davidson Stanley Sir, Principles and Practice of Medicine chapter 12. 17th ed. CRWEdwards, editor. London: Churchill Livingston 1995. p. 687,693.119. Ahuja M.M.S, API Textbook of Medicine section XV Endocrinology. 6th ed.Sainani.G.S editor. Mumbai: Association of Physicians of India. p. 953,955.120. Das Somen, A manual on Clinical Surgery chapter 15. 4th ed. Calcutta: Dr.S.Das; 1996.p. 286.121. Gogte.V.M, Ayurvedic Pharmacology and Therapeutic uses of Medicinal plantsMumbai: Bharatheeya Vidyabhavan; 2000. p. 359.122.Sharma. PV, Dravyagunavigyan vol 2. 5th ed. Varanasi: Chaukhambha BharathiAcademy; 1981. p. 761. (Varanasi Ayurveda series).123. Gogte.V.M, Ayurvedic Pharmacology and Therapeutic uses of Medicinal plantsMumbai: Bharatheeya Vidyabhavan; 2000. p. 519.124. Sharma. PV, Dravyagunavigyan vol 2. 5th ed. Varanasi: Chaukhambha BharathiAcademy; 1981. p. 350. (Varanasi Ayurveda series).125. Gogte.V.M, Ayurvedic Pharmacology and Therapeutic uses of Medicinal plantsMumbai: Bharatheeya Vidyabhavan; 2000. p. 409.126. Sharma. PV, Dravyagunavigyan vol 2. 5th ed. Varanasi: Chaukhambha BharathiAcademy; 1981. p. 149. (Varanasi Ayurveda series).127.Gogte.V.M, Ayurvedic Pharmacology and Therapeutic uses of Medicinal plantsMumbai: Bharatheeya Vidyabhavan; 2000. p. 515.128. Sharma. PV, Dravyagunavigyan vol 2. 5th ed. Varanasi: Chaukhambha BharathiAcademy; 1981. p. 753. (Varanasi Ayurveda series).129. Gogte.V.M, Ayurvedic Pharmacology and Therapeutic uses of Medicinal plantsMumbai: Bharatheeya Vidyabhavan; 2000. p. 343.130. Sharma. PV, Dravyagunavigyan vol 2. 5th ed. Varanasi: Chaukhambha BharathiAcademy; 1981. p. 463. (Varanasi Ayurveda series).131. Gogte.V.M, Ayurvedic Pharmacology and Therapeutic uses of Medicinal plantsMumbai: Bharatheeya Vidyabhavan; 2000. p. 424.132.Sharma. PV, Dravyagunavigyan vol 2. 5th ed. Varanasi: Chaukhambha BharathiAcademy; 1981. p. 275. (Varanasi Ayurveda series).133. Gogte.V.M, Ayurvedic Pharmacology and Therapeutic uses of Medicinal plantsMumbai: Bharatheeya Vidyabhavan; 2000. p. 433.134. Sharma. PV, Dravyagunavigyan vol 2. 5th ed. Varanasi: Chaukhambha BharathiAcademy; 1981. p. 735. (Varanasi Ayurveda series).135. Gogte.V.M, Ayurvedic Pharmacology and Therapeutic uses of Medicinal plantsMumbai: Bharatheeya Vidyabhavan; 2000. p. 435.136. Sharma. PV, Dravyagunavigyan vol 2. 5th ed. Varanasi: Chaukhambha BharathiAcademy; 1981. p. 736. (Varanasi Ayurveda series).137. Gogte.V.M, Ayurvedic Pharmacology and Therapeutic uses of Medicinal plantsMumbai: Bharatheeya Vidyabhavan; 2000. p. 396.138. Sharma. PV, Dravyagunavigyan vol 2. 5th ed. Varanasi: Chaukhambha BharathiAcademy; 1981. p. 75. (Varanasi Ayurveda series).139. Sharangadhara, Sharngadharasamhitha Utharakhanda chapter 2. 3rd ed. Varanasi:Chaukhambha Orientalia; 1983. p. 294. (Jaikrishnadas Ayurveda Granthamala 53).140.Sandeep Madanan, The fortification of medicated oil, Ayurvedline. 7th ed. Bangalore:Sitaram prasad. 2005.p .151.

1

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. Gopinath

1. Name of the patient : Sl. No :

2. Father’s / Husband’s Name : OPD No :

3. Age : IPD No :

4. Sex :

5. Religion :

6. Occupation :

7. Economical Status :

8. Diet :

9. Address :_____________________________ Phone No : ____________________________

_____________________________Pin

10. Selection Included : Excluded :

11. Date of Schedule Initiation :

Date of Schedule Completion :

12. Result :

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

Hindu Muslim Christian others

Sedentary Active Labour others

BPL Middle Upper middle class High class

Relieved MajorImprovement

MinorImprovement

NotResponded

Discontinued

M F

Veg Mixed

2

13. Presenting Complaints & Assessment.

Complaints DurationBefore

treatmentAfter

treatment

AfterFollow

up1. GANDA ( Mass in the neck)

2. TODA (Pain over the mass)

3. VIVARNATA (Discoloration of skinover 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. Severe

14. History of present illness

a) Mode of onset :- Gradual Sudden Insidious

b) Nature of symptoms :- Progressive Constant Regressive

15. 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

3

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

Temperature oc Pulse /min

Blood Pressure /mmhg Weight kg

Respiratory rate /min Height cm

17. Special Examination

Ayurvedic

Nidana

Ahara ViharaGurubhojana Avaak shayya

Virudhabhojana Smoking

Roopa

Vataja P A Kaphaja P A Medoja P A

Toda Sthira

ganda

Snigdhata

Krishnasira

avanadha

Manda

ruk

Mrudu

Vivarnata Kandu Pandu varna

Shaitya Durgandha

Atikandu

4

Contemporary

General examination ( Physical) :-

Lean Obese

Weight gain Weight loss

Wasting of muscles Over sweating

Exophthalmos Puffy face

Myxoedema Thirst

Severe appetite

Psychological :-

Excitement

Tension

Nervousness

Systemic :-

System Observed Symptoms if any

Cardiorespiratory

Gastrointestinal

Dermatological

Neuromuscular

Reproductive

18.Laboratory investigations

ValuesName of

the test Before After

Serum T3

Serum T4

T S H

R.B.S

E.C.G

Scan

19. Diagnosis :-

5

20.Treatment Protocol

Distribution Amruthadiyoga Remarks

Initial – Day1

2nd – 1st month

1st Month – 2nd Month

2nd Month- 3rd Month

21.Investigator’s Note

Signature of Scholar

Signature of Co-guide Signature of Guide