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Abstract
Goiter was first described in China in 2700 BC. Da Vinci described thyroid as a thing that is
designed to fill empty spaces in the neck. According to Parry – thyroid works as a buffer to
protect the brain from surges in blood flow. Roman physicians have reported thyroid
enlargement as a sign of puberty. In 500 AD Abdul Kasan Kelebis Abis performed the first
goiter excision in Baghdad, the procedure remained unknown. In 1200’s AD advancements in
goiter procedures included applying hot irons through the skin and slowly withdrawing them
at right angles. The remaining mass or pedicled tissue was excised. Patients were tied to the
table and held down to prevent unwanted movement, but most died from haemorrhage or
sepsis. In 1646 AD Wilhelm Fabricus performed a thyroidectomy with standard surgical
scalpels, for which he was imprisoned. In 1656 thyroid was first identified by the anatomist
Thomas Wharton. In 1808 AD Guillaume Dupuytren performed a total thyroidectomy, but
the patient died postoperatively of “shock”. In 1820 AD Johann Straub and Francois Coindet
found that use of seaweed (iodine) reduced goiter size and vascularity. In 1830 AD Graves
and von Basedow describe a toxic goiter condition they referred to as “Merseburg Triad” –
goiter, exopthalmos, and palpitations. In 1866, Samuel David Gross said, “If a surgeon
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should be so foolhardy as to undertake it [thyroidectomy] … every step of the way will be
environed with difficulty, every stroke of his knife will be followed by a torrent of blood, and
lucky will it be for him if his victim lives long enough to enable him to finish his horrid
butchery.” In 1883, Theodor Kocher while addressing the German Medical Congress stated,
“the thyroid gland in fact had a function”. In the same year Kocher’s performed a
retrospective review on 5000 career thyroidectomies. The thyroxine was discovered
somewhere in 19th century and a remarkable turning point started with this in management of
thyroid disorders by allopathic counterparts.
The homoeopathic literature is loaded with vast examples of thyroid diseases and their cure
with homoeopathy. It was the insight of our great masters that they have so beautifully
described thyroid related disorders and their management in Homoeopathy. In his great work,
Master Samuel Hahnemann has quoted, “What action is exerted on the skin by certain
diseases of the glands with an internal secretion (thyroid gland, ovaries, testicles, supra-renal
capsules, pituitary gland, etc.) must remain reserved for future research. So much, however,
is established to-day to prove that some of these disturbances (Addison's disease) cause
considerable alternations of the skin.” Below are some of the references from the history
regarding thyroid disorders and their Homoeopathic cure.
• Journal of Homoeopathic Clinics, Vol 3, Sep N’1, Case 458, 1869-1870: A 19 years
old female with large swelling of the thyroid gland was treated with Bromine3,
several times a day following by Calc Carb 3 and was relieved in three weeks of time.
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• Master F. J. , 1995: A case of a lady aged 51 years with migraine of 15 years standing,
hypothyroidism since 10 years and leucoderma since 5 years and a diagnosed as a
case of Hypothyroidism was given Staphisgaria.
• Grand Georage D. The spirit of homoeopathic medicines: “At times the remedy is
suggested by hypertrophied glands or the beginning of goiter. Homeopathic treatment
will remedy a slight disorder in the glandular system, but when the disorder is too
great, hormonal treatment will be necessary.
• Lesser O. Textbook of Homoeopathic Materia Medica: “If the alkali and earthy alkali
metals, Na, K, Mg, Ca, as cations determine the drug picture, then they shape it as
hydrogenoid, cold, sensitive to cold, relaxed torpid lymphatic constitutional types
stigmatized along the side of the parasympathetic system. Seen from an endocrine
side, they tend toward the hypothyroid side, the function of the lymphocytic apparatus
(thymus) is increased.”
• Master F. J. The bed side Organon of Medicine: “Never give thyroidinum as a routine
or specific for all patients who come with thiroid problem.”
There are 32 references in the forms of rubrics and subrubrics given in Synthesis treaure
edition. Where as Kents repertory, Murphy repertory and Complete repertory consists of 9,
13 and 37 rubrics in relation of thyroid and other rubrics and vice versa respectively.
THYROID GLAND
DEVELOPMENTAL CONSIDERATIONS4
The thyroid gland starts developing by 3-4 weeks of gestation, appearing as an epithelial
proliferation in the floor of the pharynx. Follicles of the thyroid begin to make colloid in the
by 12th week of gestation and thus contribute in development of physical and neurological
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features. Failure of synthesis of hormones and TSH by thyroid gland may result in arrested or
abnormal growth of the fetus. At birth, a cold-stimulated short-lived TSH surge is observed,
followed by a TSH decrease until day 3 or 4 of life by T4 feedback inhibition.
The thyroid gland is one of the most important endocrine gland which secrets two major
hormones, thyroxine and triiodothyronine. It is situated in anterior part of neck just above the
lower part of trachea, situated in between cricoid cartilage and suprasternal notch. Normally
it is not palpable but may be palpated in conditions in which it is enlarged. Enlargement of
the gland may not be a sign of its under or over functioning, but association of goiter with
thyroid function status and other investigative modalities helps us to understand disease in a
better term. Goiter is assessed by palpation by fingers of both hands for size, consistency and
presence of nodules if any.
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Thyroxine (T4) and tri-iodothyronine (T3) are two major hormones which are secreted in
pulsatile manner under feed back mechanism controlled by hypothalamic-pitautory-thyroid-
pituatory axis.
• Consistancy and size of thyroid gland, as it may give us some hint about the
underlying pathology, e.g. firm gland are suggestive of hashimoto’s thyroiditis, goiter
in high grades can induce pressure symptoms on trachea and other adjacent tissues,
painful gland suggests acute or subacute inflammatory condition.
• Presence of anti thyroid antibodies, may suggest some of the thyroid dysfunction.
The ultimate and ground level workers in thyroid-body axis are the two hormones secreted by
thyroid gland. These hormones are responsible for various activities in almost the entire
body. Every organ and tissue thus needs these hormones (particulary T3) for proper
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functioning. Thyroid hormones acts by crossing the cell membrane and binding to
intracellular receptors (α1, α2, β1 and β2), which act alone, in pairs or together with the
retinoid X-receptor as transcription factors to modulate DNA transcription and thus various
metabolic and other functions are performed. There are two variants of thyroid hormones
circulating in body, free and bounded hormones, as hormones are circulated along the body in
protein bounded form. These proteins are majorly thyroid binding globulins (TBG) and less
commonly albumin. According to extensive research studies done on this revelas that free
hormone assay is more reliable as bounded hormones level may vary in conditions in which
there is pooling of TBG in body eg.
• Pregnancy
• Estrogen therapy
• Hepatocellular cancer
• Glucocorticoids
• Androgens
• Nephrotic syndrome
• Protein-losing enteropathy
• Cirrhosis
• Critical illness/starvation
T4 (thyroxine) is the major circulating hormone whereas T3 is more biologically active. Both
T3 and T4 give a feed back to pituatory to release of suppress secretion of TSH. TSH is
ultrasensitive to even smaller amouts of circulating T3 and T4 levels, this phenomenon is to
be understood at the ground level to understand the diagnosing and follow up cases of thyroid
disorders. This can be understood by the following simple yet informative flow chart:
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TSH is the one of the most reliable marker of thyroid disorders along with FT4 estimation.
Other diagnostic modalities used to diagnose various thyroid dysfunctions are given below
with their advantages and desription:
SUMMARY
• Change in thyroid binding proteins could alter total thyroid hormone levels.
• In order to assess the thyroid hormone levels unaffected by the binding proteins, free
thyroid hormone levels assessment is more reliable.
• Acute illnesses can alter thyroid function tests without thyroid disease as they tend to
increase binding proteins, also TSH can also be influenced by stress and anxiety.
• Thyroglobulin is a good cancer marker for papillary and follicular cancer after total
thyroidectomy.
• Thyroid antibodies can assess the risk of developing autoimmune thyroid diseases.
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GOITER
Chronic enlargement of the thyroid gland not due to neoplasm is called as goiter.
• Endemic goiter-Areas where > 5% of children of 6-12 years of age have goiter, very
common in China and central Africa.
• Sporadic goiter -Areas where < 5% of children 6-12 years of age have
goiter.Multinodular goiter in sporadic areas often denotes the presence of multiple
nodules rather than gross gland enlargement.
• Familial
Etiology:
1. Hashimoto’s thyroiditis
• Early stages only, late stages show atrophic changes
• May present with hypo, hyper, or euthyroid states
2. Graves’ disease-Due to chronic stimulation of TSH receptor
3. Diet -Brassica (cabbage, turnips, cauliflower, broccoli),Cassava,Lithium
prevents release of hormone, causes goiter in 6% of chronic users
4. Neoplasm
5. Chronic Iodine excess-Iodine excess leads to increased colloid formation and
can prevent hormone release.If a patient does not develop iodine leak, excess
iodine can lead to goiter.
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THYROID NODULES
• Prevalence
– Palpable: 4-7%
– Non-Palpable: >50%
– Cancer in nodules: 5%
– Male
– Rapid Growth
• Virtually all patients with thyroid carcinoma are euthyroid as are those
with benign nodules. Nodule of >1.5 cm are usually detectable on examination
and are confirmed in the Ultrasonography. Lifetime risk for developing a
nodule is 5-10%. Studies show 50% of people during autopsy has either single
or multiple nodules. 5-10% of clinically detectable hypofunctioning (cold)
nodules can be malignant. The laboratory/Imaging techniques used are: TSH,
Calcitonin, Ultrasound, FNB for characterization of Nodules, Nuclear Scan to
see whether nodule is “Hot” or “Cold.” If FNB is suggestive of malignancy
then surgery is advised, and if it is supscpicious or negative then a follow up
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of few months is given to the patient with repeat investigations. In case there
are Indeterminant reports then FNB is repeated, if still indeterminant, surgery
is recommended.
PRIMARY HYPOTHYROIDISM
Definition - disorder of the thyroid gland causing decreased thyroid hormone production and
secretion. It is the most common disorder of thyroid dysfunction. The factors attributed to
these are:
SECONDARY HYPOTHYROIDISM
• Very uncommon.
Symptoms of hypothyroidism
Signs
Slow movements, slow speech, hoarseness, bradycardia, dry skin, non-pitting edema,
hyporeflexia, delayed relaxation of reflexes are some of the signs of hypothyroidism.
N. B.: Older patients tend to have fewer signs and symptoms of hypothyroidism and those
they have tend to be less specific.
Diagnosis
• Low FT4, Low TSH (Secondary or Tertiary, TRH stimulation test, MRI)
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HASHIMOTO’S THYROIDITIS
• Commonly presents in subjects from 30-50 yrs, female affected more than males.
• Lab values
• High TSH
• Low T4
It is the most common cause of painful thyroiditis.It often follows a URI.FNA may reveal
multinuleated giant cells or granulomatous change.
Course
Diagnosis
– Elevated ESR
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– Low RAI uptake (same as silent thyroiditis)
ACUTE THYROIDITIS
Causes:
– 15% Fungal
– 9% Mycobacterial
It May occur secondary to Pyriform sinus fistulae, Pharyngeal space infections, Persistent
Thyroglossal remnants, Thyroid surgery wound infections (rare) and in HIV.
Diagnosis:
RIEDEL’S THYROIDITIS
Diagnosis:
THYROTOXICOSIS
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hyperthyroidism. Hyperthyroidism - increased thyroid hormone biosynthesis and
secretion by the thyroid gland.
*Older patients - have fewer signs and symptoms of sympathetic activation and more
cardiovascular dysfunction.
GRAVES’ DISEASE
Diagnosis:
HOMOEOPATHIC MANAGEMENT
There are various types of thyroid disorders which we commonly encounter in our day to day
practice. These disorders are attributed at different levels, viz:-
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• Pathological- Hypothyroidism, Graves’ disease, Thyrotoxicosis.
The understanding of these levels helps us to define the prognostic and management plan for
the individual. Also it helps us to define the therapeutic guidelines to treat a case of thyroid
dysfunction. If we clearly perceive this concept we can avoid claiming false cures, as we
cannot go against nature’s law of cure. If destruction has started we can only stop its
progression, but cannot revive new cells. Once destruction has set in and the functional units
of gland are non functional, no medicine can revive it or grow it, but on the other hand
medicine will save rest of the cells. This is the reason why we encounter many patients in our
practise who do not respond to best selected homoeopathic remedies according to
Homoeopathic principles. This occurs in cases where there is either disease has progressed to
non revertible changes or there is/are some other obstacles to cure. These obstacles to cure
can be:
• Any history of previous thyroid disorders e.g. hashimoto thyroiditis, thyroid nodules,
autoimmune thyroiditis, etc
Association of thyroid dysfunction with these disorders make the condition what we read in
Organon as “Complex diseases”. The treament plan of these cases is done according the laws
embedded in Organon of Medicine8.
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In aphorism 3 of Organon of Medicine8 fifth edition, Hahnemann states that, “If the physician
clearly perceives what is to be cured in diseases, that is to say, in every individual case of
disease (knowledge of disease, indication),……” the first homework to be done by a
physician is to understand the disease and its component, then only he can see the finer
shades of individulization, difference between common and uncommon symptoms,
understaning an individual as a whole and not a diseased part or organ, diagnosis and
prognosis of this state etc. The natural history of any disease helps us to manage a disease and
to intervene it with judicial employment of medicines. For example cases in which
irreversible pathological changes have occurred, remedies having specific actions in low to
moderate doses are usually advised. In cases where there are dynamic or functional
abnormalities remedies with moderate to high potency are advised.
PRIMORDIAL PREVENTION
Health promotion:
Educate the family regarding lifestyle measures, good food habits, positive attitude to be
inculcated in young child
Specific protection:
• Regular exercise
• Desirable BMI
PRIMARY PREVENTION
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• Early diagnosis and treatment.
SECONDARY PREVENTION
TERTIARY PREVENTION
• Disability limitation
• Rehabilitation
Although it has been a matter of debate regarding the exact guidelines to treat various thyroid
disoders especially diseases which are in their subclinical states, a general line of treatment
can be sought out if one knows the basic facts about thyroid disorders. Moreover one needs to
be updated regarding the latest techniques and research going on. For a very long period of
time the subclinical hypothyroidism and subclinical hyperthyroidism conditions were treated
as full blown cases of hypo or hyper thyroidism. As the studies in these areas advanced, it
was seen that one needs to clearly define the line and justification of treatment. Treatment
only upon biochemical anomaly and in absence or minimal symptoms needs to be justified
and scientfically reasoned. Also the term subclinical sometime seems arbitrary when there are
symptoms but biochemically anomalies are minimal and vice versa. Thus a physician’s
discretion at this point of time should be critical and justified.
As Hahnemann has rightly said that there are patient in disease and not the disease in patient.
Therefore, a holistic approach is needed to treat the patients. A detailed case taking with
psyco somatic approach should be adapted during the case taking. It should include
investigation of emotional and psychological factors such as stress, repressed emotions,
mental shock, grief, anger, dreams, delusions, and all other factors affecting the mind along
with past, family history and intellectual and physical aspects of the patient. Hahnemann in
aphorism 2nd has stated that, “The highest ideal of cure is rapid, gentle and permanent
restoration of the health, or removal and annihilation of the disease in its whole exten.” Such
a choosen remedy on the basis of individualization as stated in aphorism 7 works at deeper
levels especially on pituatory hypothalamic axis and sets right the basic imbalance of
hormones in the body.
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In cases of sub clinical & mild hypothyroidism and hyperthyroidism Homoeopathic treatment
has been found to be very efficacious. Homoeopathic Medicines have their impact on
Hypothalamus-Pituitary Axis. Homoeopathy can delay the progression of malfunctioning of
the thyroid gland. As the thyroid and its hormones effects each and every organ of the body
including mental and physical growth, early detection and treatment with Homoeopathy in
children can lead to prevention of complications. As homoepathic medicines are selected on
the basis of constitution of the patient, it plays an important role in immuno modulation at the
cellular level and therefore helps in annihilation of auto antibodies. Theses are the
observations which authors have drawn during the past years in OPD at INMAS, NHMC &
SHMC.
• Grave’s disease
• Multinodular goiter
There are numerous examples of clinical and therapeutic studies done on thyroid disorders,
examples of which are discussed in short in historical perspective elsewhere in this article.
Following are some of the peer reviewed controlled design studies in Homoeopathy apart
from clinical and therapeutic studies.
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• THYROIDINUM, A PROVING (HYGANTHROPHARMACOLOGY). J Am Inst
Homeopath. 1964; 57:201-7 (ISSN: 0002-8967) PANOS M; ROGERS R;
STEPHENSON J.11
• Pharmacologic and alternative therapies for the horse with chronic laminitis. Vet Clin
North Am Equine Pract. 1999; 15(2):495-516, viii (ISSN: 0749-0739) Sumano
López H; Hoyas Sepúlveda ML; Brumbaugh GW.
Departamento de Fisiología y Farmacologiá, Facultad de Medicina Veterinaria y
Zootecnia, Universidad Nacional Autónoma de México, México DF, México.12
In continuation of this scientific spirit another research study on, “Effect of Homoeopathic
treatment on natural history of autoimmune thyroiditis” is undergoing at Dr. B. R. Sur
Homoeopathic Medical College, Hospital & Research Centre, Nanak Pura, Moti Bagh, New
Delhi (Govt of NCT of Delhi) in collaboration with Institute of Nuclear Medicine & Allied
Sciences (INMAS), Timarpur, Delhi – 54 (under ministry of Defence). The project is under
EMR scheme of AYUSH.
ACKNOWLEDGEMENT
The authors express their thankfulness to Maj. Gen. Dr. R. K. Marwaha, Addl. Director,
Institute of Nuclear Medicine, Timarpur, Delhi, Dr. V. K. Khanna, Ex-Principal, NHMC &
H, Defence colony, New Delhi and Dr. V. K. Chauhan, Principal SHMC & H, Nanak Pura,
Moti Bagh, New Delhi for their timely support, help and guidance. The authors are also
thankful to the staff of INMAS-Mr. Kuntal Bhadra, Mr. Baig, and Mr. Satwir Singh for their
assistance in various activities at screening, investigations and OPD setups.
REFERENCES
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8. Organon of Medicine, Samuel Hahnemann, 5th edition, Publisher B. Jain.
9. http://www.sciencedirect.com
10. http://www.ncbi.nlm.nih.gov/pubmed/15287432
11. http://www.ncbi.nlm.nih.gov/pubmed/14178448
12. http://www.find-health-articles.com/rec_pub_10472124-pharmacologic-alternative-
therapies-horse-chronic-laminitis.htm
13. http://www.delhihomeo.com/clinical_hypothyroidism.htm
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