By Giovanni Maciocia

In Chinese Goiter is called Ying. Ancient books mentioned Shi Ying (Stone Goiter), Lao Ying (Exhaustion Goiter), Tu Ying (Earth Goiter), You Ying (Worry Goiter) and Qi Ying (Qi Goiter).'

There are records of Goiter in Chinese medicine as early as the 3rd century BC. The name Ying appears in a book from the Warring States period. The book says: "There are more people with bald head and with Goiter in places of light water." This statement shows that the ancient Chinese were aware of environmental Goiter. Another book tells the following story: "A man called Jia Gui developed Goiter due to anger. The Goiter grew large and he wanted a doctor to remove it. The minister Cao Cao persuaded him not to have the operation by saying that 9 out of 10 people who have had the operation died." "The General Treatise on the Aetiology and Symptomatology of Diseases" (Zhu Bing Yuan Hou Zhong Lun, 610 AD) illustrates the cause of Goiter as emotional stress and environment by saying; "Goiter results from worry leading to Qi stagnation. It may also be caused by drinking sandy water, the sand follows Qi into the channels and vessels and accumulates in the neck." It also said: "Do not live long in mounta inous regions with black earth and spring water. Drinking such water for a long time may cause Goiter." The book "Thousand Golden Ducat Prescriptions" (Qian Jin Yao Fang) records dozens of formulae for Goiter recommending the use of Hai Zao, Kun Bu, and thyroid of sheep and dear. This shows that ancient doctors had an understanding of the role of iodine in thyroid disease even though they obviously did not know about iodine. Other books classified Goiter into Stone Ying, Sand Ying, Exhaustion Ying, Worry Ying and Qi Ying. The book "Treatise on the Three Categories of Aetiology of Diseases" (San Yin Ji Yi Bing Zheng Fang Lun) has a different classification of Goiter: Goiter that feels hard and tough and does not move is called Stone Ying. A Goiter that does not change the colour of the skin is called Muscle Ying. That with exposed sinews is called Sinews Ying. That with exposed vessels is called Blood Ying. That which changes size according to emotions is called Qi Ying." I also says: "In all five types of Goiter do not break [Blood] as this may cause a massive discharge of pus and blood and untimely death." Another books says: "All three herbs Hai Zao, Kun Bu and Hai Dai are from the sea. Eat at least two of them often and Goiter will be prevented". Another book mentions the use of Huang Yao Zi to cool Blood, drain fire, dissolve Goiter and dispel Toxin. The book also asks people to look in the mirror and stop taking Huang Yao Zi when the Goiter disappears or measure the size of the Goiter with a thread every day to know exactly the results of the tincture. Another book considers Qi stagnation, Phlegm and Blood stasis as the main pathogenic factors in simple Goiter. So the treatment method should be to move Qi, invigorate Blood, resolve Phlegm and soften masses. The book mentions the formula Hai Zao Yu Hu Tang that is still widely used today. Another book says: "Simple Goiter results from Qi and Blood stagnation. It is a disease that develops slowly for years; it is called Ying because the skin is enlarged like a cherry stone [Ying Tao]."

Aetiology And Pathology Emotional Stress
Anger, worry and pensiveness may all lead to Qi stagnation after a period of time. This may affect not only the Liver, which loses its free flow of Qi, but also the Lungs (whose Qi fails to descend and stagnates in the chest and throat), the Stomach (whose Qi fails to descend), the Heart (whose Qi fails to descend affecting the throat) and the Spleen (whose Qi fails to ascend giving rise to Phlegm).

Qi stagnation in various organs affects the proper functioning of the Qi mechanism and this disrupts the proper movement of Qi in the right directions and, therefore, also the movement and transformation of fluids. This eventually leads to Phlegm. Qi stagnation and Phlegm interact and both focus on the front of the throat where the Liver, Lung and Heart channels flow. This type of Phlegm is called "Qi-Phlegm" and is the most non-substantial type of Phlegm. This type of Goiter lump, especially in the beginning stages when there is only Qi stagnation, would go up and down in size.

After a prolonged time, Qi stagnation may lead to Blood stasis which, in itself, interacts with Phlegm: in such cases, the Goiter lump would be hard, not going up and down in size and probably painful.

Diet
Irregular eating, excessive consumption of greasy foods or dairy foods weaken the Spleen and Stomach which cannot transform and transport food essences. Dampness if formed can later lead to Phlegm. Irregular diet also disrupts the Qi mechanism and leads to Qi stagnation and eventually Blood stasis which contributes to the formation of Goiter.

Environment
People who live in high mountainous regions lack iodine in the water and this may contribute to Goiter. Although they did not know about the role of iodine in thyroid disorders, the ancient Chinese doctors did observe the higher incidence of Goiter in people living in high mountains. Ancient books talked about a "cold poison" in the water in high mountains in the North-West of China.

Constitution
Women are more prone to Goiter. This is because of the relationship between the Liver channel on both Goiter and menstruation. Because of menstruation, pregnancy and lactation, the Liver channel is much more prone to Qi and/or Blood stagnation in women and this causes a higher incidence of Goiter in them. Excessive blood loss after childbirth or too many children too close together may also lead to depletion of Liver and Kidneys in women and predispose them to Goiter.

The pathology of Goiter therefore boils down to three main pathologies in order of appearance and severity:

• Qi stagnation (lump goes up and down according to emotional problems)
• Phlegm (lump is relatively soft and does not go up and down)
• Blood stasis (lump is relatively hard, fixed and probably painful)

Other pathologies may be involved. First of all, Liver-Fire may develop from Liver-Qi stagnation: Liver-Fire, in turn, contributes to Phlegm as Fire dries up and condenses body fluids into Phlegm. Secondly, Liver-Fire may, in time, injure Yin and lead to Liver-Yin deficiency which may appear in very long-standing cases and older women.

In its very beginning stage, Goiter is not dissimilar to the plum-stone syndrome which is due not only to Liver-Qi stagnation but also Lung-Qi stagnation in the throat from emotional problems (see Ban Xia Hou Po Tang).

Diagnosis

• Soft Goiter with indistinct edges, varying in size with emotional state: Qi stagnation
• Large, soft and smooth mass: Phlegm
• Hard, nodular mass that is immovable and grows rapidly, dark skin over mass: Blood stasis.
• Small or medium-size Goiter, relatively soft, slippery under the finger: Liver-Fire (with Phlegm).

Channels
In terms of channels, the main channels involved are Heart, Liver and Lungs, all of which go through the front of the throat. Other channels also go through the front of the throat, i.e. Spleen and Kidneys. In women, the Ren Mai and Chong Mai also go through the front of the throat and their pathology influences the development of Goiter through menstrual irregularities. That is why women with Goiter outnumber men by 8:1.

Differentiation And Treatment
In the old times treatment was differentiated between "internal" and "external." Internal treatment consisted in the administration of seaweeds to provide iodine and of thyroid glands of pig or lamb. External treatment consisted in herbal treatment and acupuncture (and of course surgery). Use of seaweeds is interesting because they were given without knowing about iodine but ancient doctors perceived that there was something missing in the water of mountainous regions that could be supplemented by seaweeds. They were also given for their action of "softening" masses: in this respect they are given for any type of mass, not just Goiter.

The main patterns are:

• Qi stagnation and Phlegm
• Liver-Qi stagnation, Spleen-Qi deficiency and Phleg
• Phlegm and Blood stasis
• Liver-Fire blazing with Phlegm-Heat
• Heart- and Liver-Yin deficiency with Phlegm

These patterns are interlinked: for example, Qi stagnation and Phlegm often leads to Phlegm and Blood stasis, while Liver-Fire often leads to Heart- and Liver-Yin deficiency. General Acupuncture Points

• Ah Shi points, four points inserted on the top, bottom, left and right of the thyroid, oblique towards the centre
• Local points ST-11 Qishe, Ren-22 Tiantu, Ren-23 Lianquan, L.I.-17 Tianding, ST-9 Renying, L.I.-18 Futu, S.I.-17 Tianrong, ST-10 Shuitu, extra point Ping Ying (0.7 cun lateral to the space between 4th and 5th cervical vertebrae), extra point Shang Tian Zhu (0.5 cun above BL-10)
• Hua Tuo Jia Ji points

Ancient Acupuncture Prescriptions

• Zhen Jiu Jia Yi Jing: S.I.-17 Tianrong
• Zhen Jiu Da Quan: LU-7 Lieque, L.I.-18 Futu, Ren-22 Tiantu, L.I.-17 Tianrong, ST-12 Quepen, KI-27 Shufu, Yingshu (?), Ren-1 Shanzhong, L.I.-4 Hegu, Shixuan (bleeding).
• Qian Jin Yao Fang: T.B.-13 Naohui, LU-3 Tianfu, ST-11 Qishe.
• Zhen Jiu Pi Sheng Jing: G.B.-10 Fubai and ST-11 Qishe.

1) QI STAGNATION AND PHLEGM (also called QI GOITER)

Clinical manifestations

Goiter that is relatively soft and not painful, often neckache, a feeling of oppression of the chest, sighing, hypochondrial distension and pain, the size of the Goiter may fluctuate according to emotional state.

Tongue: Swollen with a sticky coating. Pulse: Wiry.
Heart: palpitations, anxiety, chest discomfort, feeling of constriction in the throat.
Lungs: sighing, dry cough, feeling of constriction and/or lump in the throat, slight breathlessness, sadness.
Liver: irritability, a feeling of lump in the throat, depression.
Treatment principle: Regulate Qi, eliminate stagnation, soothe the Liver, make Lung-Qidescend, make Heart-Qi descend, resolve Phlegm, dissolve Goiter.
Acupuncture: T.B.-6 Zhigou, G.B.-34 Yanglingquan, LIV-3 Taichong, P-6 Neiguan, HE-5 Tongli, LU-7 Lieque, L.I.-4 Hegu, L.I.-11 Quchi, G.B.-20 Fengchi, BL-60 Kunlun (Shao Yang and Tai Yang to invigorate Blood and remove obstructions from channels), Ren-22 Tiantu, ST-40 Fenglong, SP-6 Sanyinjiao, Ren-12 Zhongwan, BL-18 Ganshu, BL-15 Xinshu, Ren Mai (LU-7 Lieque and KI-6 Zhaohai), Chong Mai (SP-4 Gongsun and P-6 Neiguan), points surrounding the Goiter, Hua Tuo Jia Ji points, L.I.-17 Tianding.
Heart: HE-5 Tongli, HE-7 Shenmen, Ren-15 Jiuwei.
Lungs: LU-7 Lieque, L.I.-4 Hegu, Ren-17 Shanzhong, LU-3 Tianfu.
Liver: see above.

Herbal treatment Prescription:
SI HAI SHU YU WAN
Four Seas Soothe Stagnation Pill
Mu Xiang Radix Aucklandiae lappae
Chen Pi Pericarpium Citri reticulatae
Kun Bu Thallus Algae
Hai Dai Zostera marina
Hai Zao Herba Sargassii
Hai Piao Xiao Os Sepiae
Hai Ge Ke Concha Cyclinae sinensis

Three Treasures (or East West Treasures) remedy OPEN THE HEART and/or CLEAR THE SOUL (for Phlegm)

2) Liver -qi Stagnation , Spleen -qi Deficiency And Phlegm

Clinical manifestations: Large, soft Goiter, depression, irritability, feeling of oppression of the chest and hypochondrium, difficulty in swallowing, feeling of lump in throat, loose stools, irregular periods, pre-menstrual tension. Pulse Wiry.
Treatment principle: Soothe the Liver, move Qi, tonify Spleen-Qi, soften masses, resolve Phlegm.
Acupuncture: T.B.-6 Zhigou, G.B.-34 Yanglingquan, LIV-3 Taichong, P-6 Neiguan, Ren-12 Zhongwan, BL-20 Pishu, Ren-22 Tiantu.

Herbal treatment Prescription:
XIAO YAO SAN plus LIU JUN ZI TANG
Chai Hu Radix Bupleuri
Dang Gui Radix Angelicae sinensis
Bai Zhu Rhizoma Atractylodis macrocephalae
Fu Ling Sclerotium Poriae cocos
Gan Cao Radix Glycyrrhizae\ uralensis
Ban Xia Rhizoma Pinelliae ternatae
Chen Pi Pericarpium Citri reticulatae
Xiang Fu Rhizoma Cyperi rotundi
Shan Yao Radix Dioscoreae oppositae
Bai Jie Zi Semen Sinapis albae
Dan Shen Radix Salviae miltiorrhizae
Huang Qin Radix Scutellariae baicalensis
Dang Shen Radix Codonopsis pilosulae

3) PHLEGM AND BLOOD STASIS

Clinical manifestations: Goiter that is hard, possibly with nodules, painful, dark skin, a feeling of oppression of the chest, insomnia, anxiety.
Tongue: Swollen, Purple, sticky coating.
Pulse: Wiry.
Treatment principle: Regulate Qi, invigorate Blood, eliminate stasis, resolve Phlegm, soften hardness, dissolve Goiter.
Acupuncture: T.B.-6 Zhigou, G.B.-34 Yanglingquan, LIV-3 Taichong, Ren-22 Tiantu, SP-10 Xuehai, BL-17 Geshu, P-6 Neiguan, BL-18 Ganshu, Chong Mai (SP-4 Gongsun and P-6 Neiguan), ST-40 Fenglong, Ren-12 Zhongwan, SP-6 Sanyinjiao, L.I.-17 Tianding.

1) Herbal treatment prescription:
HAI ZAO YU HU TANG Sargassum Jade Pot Decoction
Hai Zao Herba Sargassii
Kun BuThallus Algae
Hai DaiZostera marina
Qing Pi Pericarpium Citri reticu latae viride
Chen Pi Pericarpium Citri reticulatae
Ban Xia Rhizoma Pinelliae ternatae
Zhe Bei Mu Bulbus Fritillariae thunbergii
Lian Qiao Fructus Forsythiae suspensae
Gan Cao Radix Glycyrrhizae uralensis
Dang Gui Radix Angelicae sinensis
Chuan Xiong Radix Ligustici Chuanxiong

2) Herbal treatment prescription:
JIA SHI JIA KANG FANG
Master Shi's Formula for Hyperthyroidism
Huang Yao Zi Semen Dioscoreae bulbiferae
Hai Zao Herba Sargassii
Kun Bu Thallus Algae
Hai Fu Shi Pumice
Hai Ge Ke Concha Cyclinae sinensis
Mu Li Concha Ostreae
Lou Lu Radix Rhapontici seu Echinops
Mu Xiang Radix Aucklandiae lappae
San LengRhizoma Sparganii stoloniferii
E Zhu Rhizoma Curcumae zedoariae
Chen Pi Pericarpium Citri reticulatae
Da Huang Radix et Rhizoma Rhei

Modifications
-Nodules on thyroid: add E Zhu Rhizoma Curcumae zedoariae, Sang Leng Rhizoma Sparganii stoloniferii and Huang Yao Zi Semen Dioscoreae bulbiferae. -If Qi stagnation has given rise to Fire add Xia Ku Cao Spica Prunellae vulgaris, Mu Dan Pi Cortex Moutan radicis and Xuan Shen Radix Scrophulariae ningpoensis.

Three Treasures (or East West Treasures) remedy LIMPID SEA plus RED STIRRING

4) LIVER-FIRE BLAZING WITH PHLEGM-HEAT

Clinical manifestations: Small or medium-size Goiter, relatively soft, slippery under the finger, mental restlessness, insomnia, thirst, feeling of heat, irritability, red eyes, tremor of hands, red face, bitter taste.
Tongue: Red, red sides and tip, dry-yellow coating
. Pulse: Rapid and Wiry.
Treatment principle: Drain Fire, clear the Liver, resolve Phlegm, soften hardness, dissolve Goiter, calm the Mind.
Acupuncture: LIV-2 Xingjian, HE-8 Shaofu, Ren-22 Tiantu, L.I.-4 Hegu, ST-40 Fenglong, SP-6 Sanyinjiao, HE-7 Shenmen, P-7 Daling, L.I.-17 Tianding. Wang Xue Tai (Zhong Guo Zhen Jiu Da Quan): SP-6 Sanyinjiao, KI-6 Zhaohai, KI-7 Fuliu (according to him nourishes Yin and clears Heat), P-5 Jianshi, LIV-3 Taichong. If ST-Heat: ST-44 Neiting; tremor of hands: G.B.-34 Yanglingquan; if Goiter big: ST-10 Shuitu and extra Ping Ying (0.7 cun lateral to the space between 4th and 5th cervical vertebrae); exophthalmos: extra Shang Tian Zhu (0.5 cun above BL- 10) and G.B.-20 Fengchi.

Herbal treatment Prescription:
ZHI ZI QING GAN TANG Variation plus HAI YAO SAN
Gardenia Clearing the Liver Decoction plus Sargassum-Dioscorea bulbifera Powder
Shan Zhi Zi Fructus Gardeniae jasminoidis
Chai Hu Radix Bupleuri
Bai Shao Radix Paeoniae lactiflorae
Fu Ling Sclerotium Poriae cocos
Gan Cao Radix Glycyrrhizae uralensis
Dang Gui Radix Angelicae sinensis
Chuan Xiong Radix Ligustici Chuanxiong
Mu Dan Pi Cortex Moutan radicis
Niu Bang Zi Fructus Arctii lappae
Hai Zao Herba Sargassii
Huang Yao Zi Semen Dioscoreae bulbiferae

Explanation
Niu Bang Zi was added to the original prescription

Three Treasures (or East West Treasures) remedy DRAIN FIRE plus CLEAR THE SOUL

5) HEART- AND LIVER-YIN DEFICIENCY WITH PHLEGM

Clinical manifestations: Goiter that may be large or small, relatively soft, slow onset, palpitations, insomnia, feeling of heat in the afternoon, night-sweating, tremor of hands, dry eyes, blurred vision, tiredness.
Tongue: Red without coating.
Pulse: Floating-Empty, relatively Overflowing on left cun.
Treatment principle: Nourish Yin, nourish Heart and Liver, nourish Liver-Blood, calm the Mind, soften the Liver, resolve Phlegm, soften hardness, dissolve Goiter.
Acupuncture: Ah Shi points, P-6 Neiguan, ST-36 Zusanli, L.I.-4 Hegu, HE-7 Shenmen, SP-6 Sanyinjiao, LIV-3 Taichong, Ren-4 Guanyuan, KI-6 Zhaohai, L.I.- 17 Tianding. Ren Mai (LU-7 Lieque and KI-6 Zhaohai).

Herbal treatment
1) Prescription
TIAN WANG BU XIN DAN Variation
Sheng Di Huang Radix Rehmanniae glutinosae
Xuan Shen Radix Scrophulariae ningpoensis
Mai Men Dong Tuber Ophiopogonis japonici
Tian Men Dong Tuber Asparagi cochinchinensis
Ren Shen Radix Ginseng
Fu Ling Sclerotium Poriae cocos
Wu Wei Zi Fructus Schisandrae chinensis
Dang Gui Radix Angelicae sinensis
Dan Shen Radix Salviae miltiorrhizae
Suan Zao Ren Semen Ziziphi spinosae
Bai Zi Ren Semen Biotae orientalis
Yuan Zhi Radix Polygalae tenuifoliae
Gou Qi Zi Fructus Lycii chinensis
Chuan Lian Zi Fructus Meliae toosendan

Explanation
-Gou Qi Zi and Chuan Lian Zi were added to make Yi Guan Jian.

2) Prescription
PING YING FU FANG Formula to Dissolve Goiter
Xuan Shen Radix Scrophulariae ningpoensis
Bai Shao Radix Paeoniae lactiflorae
Mu Dan Pi Cortex Moutan radicis
Sheng Di Huang Radix Rehmanniae glutinosae
Dang Gui Radix Angelicae sinensis
Fu Ling Sclerotium Poriae cocos
Shan Zhu Yu Fructus Corni officinalis
Mu Li Concha Ostreae
Xia Ku Cao Spica Prunellae vulgaris
Zhe Bei Mu Bulbus Fritillariae thunbergii
Wa Leng Zi Concha Arcae
Qing Pi Pericarpium Citri reticulatae viride
San Leng Rhizoma Sparganii stoloniferii
E Zhu Rhizoma Curcumae zedoariae

3) Prescription
FU FANG JIA KANG GAO Formula for Hyperthyroidism
Huang Qi Radix Astragali membranacei
Dang Shen Radix Codonopsis pilosulae
Mai Men Dong Tuber Ophiopogonis japonici
Bai Shao Radix Paeoniae lactiflorae
Xia Ku Cao Spica Prunellae vulgaris
Sheng Di Huang Radix Rehmanniae glutinosae
Dan Shen Radix Salviae miltiorrhizae
Mu Li Concha Ostreae
Su Zi Fructus Perillae frutescentis
Wu Wei Zi Fructus Schisandrae chinensis
Xiang Fu Rhizoma Cyperi rotundi
Bai Jie Zi Semen Sinapis albae

This formula is for Qi and Yin deficiency
. 4) Prescription
ZHI BO YANG WEI TANG Anemarrhena-Phellodendron Nourishing the Stomach
Decoction
Zhi Mu Radix Anemarrhenae asphodeloidis
Huang Bo Cortex Phellodendri
Mu Dan Pi Cortex Moutan radicis
Ze Xie Rhizoma Alismatis orientalis
Shi Hu Herba Dendrobii
Yu Zhu Rhizoma Poligonati odorati
Shan Yao Radix Dioscoreae oppositae
Fu Ling Sclerotium Poriae cocos
Mai Men Dong Tuber Ophiopogonis japonici
Hai Zao Herba Sargassii
Kun Bu Thallus Algae
Sheng Di Huang Radix Rehmanniae glutinosae
Dan Shen Radix Salviae miltiorrhizae
Huang Yao Zi Semen Dioscoreae bulbiferae

5) Prescription
YU YIN SAN JIE TANG Nourish Yin and Scatter Nodules Decoction
Bei Sha Shen Radix Glehniae littoralis
Tian Men Dong Tuber Asparagi cochinchinensis
Mai Men Dong Tuber Ophiopogonis japonici
Sheng Di Huang Radix Rehmanniae glutinosae<
Tian Hua Fen Radix Trichosanthis kirilowii
Kun Bu Thallus Algae
Hai Zao Herba Sargassii
Wu Wei Zi Fructus Schisandrae chinensis
Zhe Bei Mu Bulbus Fritillariae thunbergii

Modifications
-If there internal Wind, add Gou Teng Ramulus Uncariae, Bai Ji Li Fructus Tribuli terrestris and Bai Shao Radix Paeoniae lactiflorae. -If there is Spleen deficiency with loose stools, add Bai Zhu Rhizoma Atractylodis macrocephalae, Yi Yi Ren Semen Coicis lachryma jobi, Shan Yao Radix Dioscoreae oppositae and Mai Ya Fructus Hordei vulgaris germinatus. -If there is Kidney-Yin deficiency, add Gui Ban Plastrum Testudinis and Tu Si Zi Semen Cuscutae chinensis.

Empirical Prescriptions
1) Xuan Shen Radix Scrophulariae ningpoensis, Mu Li Concha Ostreae, Kun Bu Thallus Algae, Hai Zao Herba Sargassii, Fu Hai Shi Pumice, Hai Ge Ke Concha Cyclinae sinensis, Zhe Bei Mu Bulbus Fritillariae thunbergii, E Zhu Rhizoma Curcumae zedoariae, Ze Lan Herba Lycopi lucidi, Xia Ku Cao Spica Prunellae vulgaris, Tian Hua Fen Radix Trichosanthis kirilowii. 2) Huang Yao Zi, 300g, crushed into small pieces, soaked in 1,500 ml of water and put in a sealed jar; heated over a slow fire for 4 hours and stored in iced water (or in the fridge) for one week. Drink 10 ml of the liquor 6 times a day but not before bed.

NOTE
Please note that Huang Yao Zi Semen Dioscoreae bulbiferae may be toxic if taken for too long. I would advise not prescribing for longer than 2-3 months at a time and at a dosage no higher than 6g per day. Practitioners should also check the legality of this herb in their particular country.

Moxibustion
Ren-22 Tiantu, BL-7 Tongtian, LU-2 Yunmen, L.I.-11 Quchi, Ren-17 Shanzhong, LIV-4 Zhongfeng, G.B.-20 Fengchi, Du-14 Dazhui, ST-11 Qishe, LU- 3 Tianfu, ST-42 Chongyang. The "Practical Acupuncture" (Shi Yong Zhen Jiu Xue) by He Bao Yi (p. 361) has two groups of points for moxibustion: 1) G.B.-20 Fengchi, Du-14 Dazhui, L.I.-14 Binao, extra point lateral to Du-14 and 1.5 cun below it. 2) Ren-22 Tiantu, BL-7 Tongtian, LU-2 Yunmen, L.I.-14 Binao, LIV-4 Zhongfeng, Ren-17 Shanzhong, G.B.-20 Fengchi, Du-14 Dazhui, ST-11 Qishe, T.B.-13 Naohui, LU-3 Tianfu, ST-42 Chongyang.

Ear Acupuncture
Endocrine, Thyroid, Shenmen, neck.

Hypothyroidism Without Goiter Spleen- And Kidney-yang Deficiency
Clinical manifestations: Tiredness, feeling cold, slowness, cold limbs, oedema, pale Ear Acupuncture Endocrine, Thyroid, Shenmen, neck.
complexion, puffy face, puffy under eyes, plus other symptoms of Spleen- and Kidney-Yang deficiency.
Pulse: Slow.
Treatment principle: Warm Yang, strengthen Spleen and Kidneys.
Acupuncture: Du-14 Dazhui, BL-23 Shenshu, Du-4 Mingmen, Ren-17 Shanzhong, G.B.-20 Fengchi, ST-40 Fenglong, Ren-4 Guanyuan, Ren-22 Tiantu.
-Stomach and Spleen deficiency: BL-20 Pishu, BL-21 Weishu, Ren-12 Zhongwan.
-Cold, constipation: ST-25 Tianshu, Du-14 Dazhui, BL-25 Dachangshu, ST-37 Shangjuxu.
-Oedema: BL-13 Feishu, BL-20 Pishu, BL-22 Sanjiaoshu, LU-7 Lieque, L.I.-6 Pianli.

Herbal treatment
1) Prescription
ZHANG SHI JIA JIAN FANG Master Zhang's Hypothyroidism Formula
Fu Zi Radix lateralis Aconiti carmichaeli praeparata 6g
Gan Jiang Rhizoma Zingiberis officinalis 3g
Rou Gui Cortex Cinnamomi cassiae 2.1g
Dang Shen Radix Codonopsis pilosulae 15g
Fu Ling Sclerotium Poriae cocos 9g
Bai Zhu Rhizoma Atractylodis macrocephalae 9g
Zhi Gan Cao Radix Glycyrrhizae uralensis praeparata 3g

2) Prescription
JI SHENG SHEN QI TANG plus SI JUN ZI TANG
Fu Zi Radix lateralis Aconiti carmichaeli praeparata
Gui Zhi Ramulus Cinnamomi cassiae
Gan Jiang Rhizoma Zingiberis officinalis
Dang Shen Radix Codonopsis pilosulae
Huang Qi Radix Astragali membranacei
Bai Zhu Rhizoma Atractylodis macrocephalae
Fu Ling Sclerotium Poriae cocos
Gan Cao Radix Glycyrrhizae uralensis
Shu Di Huang Radix Rehmanniae glutinosae praeparata
Sha Ren Fructus seu Semen Amomi
Yin Yang Huo Herba Epimedii
Tu Si Zi Semen Cuscutae chinensis
Ze Xie Rhizoma Alismatis orientalis

Three Treasures (or East West Treasures) remedy STRENGTHEN THE ROOT

Qi And Blood Deficiency
Clinical manifestations: Tiredness, weakness, dislike to speak, slowness, palpitations, sallow complexion, loose stools, dry skin, amenorrhoea, cold limbs.
Tongue: Pale.
Pulse: Choppy.
Treatment principle: Tonify Qi and nourish Blood.
Acupuncture: BL-20 Pishu, BL-23 Shenshu, Ren- 12 Zhongwan, ST-36 Zusanli, SP-6 Sanyinjiao, Du-20 Baihui.

Herbal treatment
1) Prescription
DENG SHI JIA YI FANG Master Deng's Thyroid Formula
Huang Qi Radix Astragali membranacei 30g
Dang Shen Radix Codonopsis pilosulae 18g
Bai Zhu Rhizoma Atractylodis macrocephalae 24g
Dang Gui Radix Angelicae sinensis 12g
Zhi Gan Cao Radix Glycyrrhizae uralensis praeparata 3g
Chai Hu Radix Bupleuri 6g
Sheng Ma Rhizoma Cimicifugae 6g
Ba Ji Tian Radix Morindae officinalis 9g
Gou Qi Zi Fructus Lycii chinensis 9g
Chen Pi Pericarpium Citrireticulatae 3g

2) Prescription
XU SHI ZHI JIAN FANG Master Xu's Formula for Hypothyroidism
Mu Li Concha Ostreae 30g
Dang Shen Radix Codonopsis pilosulae 12g
Bai Zhu Rhizoma Atractylodis macrocephalae 12g
Niu Xi Radix Achyranthis bidentatae seu Cyathulae 12g
Bai Shao Radix Paeoniae lactiflorae 12g
Mu Gua Fructus Chaenomelis lagenariae 12g
Fu Ling Sclerotium Poriae cocos 12g
Yu Jin Tuber Curcumae 12g
Dang Gui Radix Angelicae sinensis 9g
Hong Hua Flos Carthami tinctorii 6g
Zhi Gan Cao Radix Glycyrrhizae uralensis praeparata 3g

3) Prescription
SHI QUAN DA BU TANG Variation Ten Complete Great Tonification Decoction
Dang Shen Radix Codonopsis pilosulae
Bai Zhu Rhizoma Atractylodis macrocephalae
Fu Ling Sclerotium Poriae cocos
Zhi Gan Cao Radix Glycyrrhizae uralensis praeparata
Shu Di Huang Radix Rehmanniae glutinosae praeparata
Bai Shao Radix Paeoniae lactiflorae
Dang Gui Radix Angelicae sinensis
Chuan Xiong Radix Ligustici Chuanxiong
Huang Qi Radix Astragali membranacei
Rou Gui Cortex Cinnamomi cassiae
Dan Shen Radix Salviae miltiorrhizae
Sha Ren Fructus seu Semen Amomi
Shan Yao Radix Dioscoreae oppositae

LIVER AND KIDNEY DEFICIENCY (both Yin and Yang) Clinical manifestations: Tiredness, feeling of heat in the afternoon and evening, night- sweating, backache, dizziness, tinnitus, tremor of hands, blurred vision, dry throat.

Tongue: Red without coating.
Pulse: Floating-Empty.

-In addition, there will be some Kidney-Yang deficiency symptoms such as cold feet and frequent urination. Treatment principle: Nourish Yin, strengthen Liver and Kidneys.
Acupuncture: Ah Shi points, P-6 Neiguan, ST-36 Zusanli, L.I.-4 Hegu, HE-7 Shenmen, SP-6 Sanyinjiao, LIV-3 Taichong, Ren-4 Guanyuan, KI-6 Zhaohai, L.I.- 17 Tianding. Ren Mai (LU-7 Lieque and KI-6 Zhaohai).

Herbal treatment Prescription:
YOU GUI YIN Variation Restoring the Right [Kidney] Decoction
Shu Di Huang Radix Rehmanniae glutinosae praeparata
Shan Yao Radix Dioscoreae oppositae
Shan Zhu Yu Fructus Corni officinalis
Gou Qi Zi Fructus Lycii chinensis
Tu Si Zi Semen Cuscutae chinensis
Lu Jiao Jiao Colla Cornu Cervi
Huang Qi Radix Astragali membranacei
Dan Shen Radix Salviae miltiorrhizae
Bai Shao Radix Paeoniae lactiflorae
Suan Zao Ren Semen Ziziphi spinosae
Gan Cao Radix Glycyrrhizae uralensis
Ju Hua Flos Chrysanthemi morifolii
Chai Hu Radix Bupleuri

Hyperthyroidism Acupuncture
According to the Shanghai Municipal Acupuncture and Channels Research Group (Zhong Yi Za Zhi, 9,1984, p. 58) the main pathology of hyperthyroidism is Yin deficiency of Liver and Kidneys with Empty Heat in Liver and Heart. Treatment principle is to nourish Water and reduce Wood and Fire.

The main points used are KI-10 Yingu, KI-7 Fuliu, SP-6 Sanyinjiao and KI-3 Taixi in tonification and HE-7 Shenmen, P-7 Daling, P-8 Laogong and P-5 Jianshi in reduction. Local points for Goiter are ST-10 Shuitu (most important one according to them), Ping Ying (extra point level with the space between 4th and 5th cervical vertebrae and 7 fen lateral to it) and Shang Tian Zhu (extra point 5 fen above BL-10). Other distal points are L.I.-4 Hegu and ST-40 Fenglong.

1) EMPIRICAL PRESCRIPTION (Zhong Yi Za Zhi, 1,1987, p.16)
Chai Hu Radix Bupleuri 6g
Huang Qin Radix Scutellariae baicalensis 9g
Ban Xia Rhizoma Pinelliae ternatae 6g
Dang Shen Radix Codonopsis pilosulae 15g
Zi Su Geng Ramulus Perillae frutescentis 6g
Hou Po Cortex Magnoliae officinalis 9g
Lai Fu Zi Semen Raphani sativi 9g
Chen Pi Pericarpium Citri reticulatae 6g
Yu Jin Tuber Curcumae 9g
Ku Ding Cha Herba Ilecis cornutae 6g
Gan Cao Radix Glycyrrhizae uralensis 3g
For Liver-Qi stagnation.

2) Prescription
EMPIRICAL PRESCRIPTION (Zhong Yi Za Zhi, 1,1987, p. 16)
Zhen Zhu Mu Concha
margaritiferae 60g (sic)
Gou Teng Ramulus Uncariae 9g
Jiang Can Bombyx batryticatus 9g
Shan Zhi Zi Fructus Gardeniae jasminoidis 9g
Huang Qin Radix Scutellariae baicalensis 9g
Xia Ku Cao Spica Prunellae vulgaris 12g
Zhu Ru Caulis Bambusae in Taeniis 15g
Dan Shen Radix Salviae miltiorrhizae 15g
Chi Shao Radix Paeoniae rubrae 9g
Ye Jiao Teng Caulis Polygoni multiflori 15g
Bi Yu San 24g (Hua Shi, Gan Cao, Qing Dai)
For Liver-Fire.

3) Prescription EMPIRICAL PRESCRIPTION
(Zhong Yi Za Zhi, 1,1987, p. 16) Tai Zi Shen Radix Pseudostellariae 15g
Mai Men Dong Tuber Ophiopogonis japonici 15g
Wu Wei Zi Fructus Schisandrae chinensis 9g
Gou Qi Zi Fructus Lycii chinensis 15g
Shou Wu Radix Polygoni multiflori 15g
Shan Yao Radix Dioscoreae oppositae 15g
Zhen Zhu Mu Concha margaritiferae 30g
Yu Zhu Rhizoma Poligonati odorati 15g
Bai Wei Radix Cynanchi baiwei 9g
Chi Shao Radix Paeoniae rubrae 9g
Gan Cao Radix Glycyrrhizae uralensis 5g

DR. WEI ZI XIAO EXPERIENCE (Zhong Yi Za Zhi, 6, 1995, p. 334)
Treatment principles are:

• Nourish Yin (Sheng Di Huang, Dang Gui, Gou Qi Zi, Nu Zhen Zi, Han Lian Cao, Tian Men Dong, Mai Men Dong, Bie Jia, Bai Shao, Ji Xue Teng)
• Clear Heat (Heart, causing palpitations, insomnia, anxiety: Huang Lian, Shan Zhi Zi, Lian Xin, Bai Zi Ren; Stomach causing thirst and hunger: Shi Gao, Zhi Mu, Gan Cao, Huang Lian, Huang Qin; Liver causing dizziness, blurred vision, irritability, tremor: Huang Qin, Long Dan Cao, Xia Ku Cao, Ci Shi, Mu Li)
• Eliminate stagnation (Chai Hu, Xiang Fu, Yu Jin, Fu Ling, Bai Zhu) For Goiter he uses Si Qi Tang plus Gui Zhi, E Zhu, Chuan Shan Jia, Bai Jie Zi, Mu Li. For exophthalmos he drains Dampness, resolve Phlegm, eliminates stasis and expels Wind using Mu Tong, Ze Xie, Bai Jie Zi, ban Xia, Zhe Bei Mu, E Zhu, Chi Shao, Yi Mu Cao, Ju Hua, Mu Zei Cao, Bai Ji Li. Finally, he uses Hai Zao 20-30g per day.

CLINICAL STUDIES
Journal of Chinese Medicine (Zhong Yi Za Zhi), 11, 1992, p. 28. 115 cases of nodules on thyroid with hyperthyroidism, raised T3 and T4. Formula used: Chai Hu 240g, Xia Ku Cao 300g, Shan Ci Gu 200g, Chen Pi 200g, Gui Jian Yu Herba Euonymi alati (break Blood) 200g, Ban Xia 200g, Zhe Bei Mu 200g, Hai Zao 200g, Kun Bu 200g. (Doses to make a batch of pills).

Journal of Chinese Medicine
(Zhong Yi Za Zhi), 9, 1984, p. 47. 98 cases of hyperthyroidism, raised T3 and T4. Treatment principle adopted was to tonify Qi and nourish Yin. Formula; Huang Qi 30-45g (sic), Bai Shao 12g, Sheng Di Huang 15g, Xiang Fu 12g, Xia Ku Cao 30g, Shou Wu 20g. If Spleen- Qi deficiency: Shan Yao, Bai Zhu. If Heart-Fire: Huang Lian. If Liver- Fire: Long Dan Cao.

Chinese Acupuncture and Moxibustion (Zhong Guo Zhen Jiu) 5,1986, p. 15. 129 cases of hyperthyroidism. Compared three groups of points:

• Ah Shi points around Goiter and ST-10 Shuitu
• P-6 Neiguan, P-5 Jianshi, ST-36 Zusanli, SP-6 Sanyinjiao
• Ah Shi points around Goiter, P-6 Neiguan, P-5 Jianshi, ST-36 Zusanli, SP-6 Sanyinjiao.

Best results were obtained with third group.

Prognosis And Prevention
The prognosis depends on the duration of the disease and the size of the Goiter. If the Goiter is small, soft and the duration not too long, the prognosis is very good. Vice versa, if the Goiter is large, hard and the duration long, the prognosis is less good. If the Goiter is very hard, immovable and grows rapidly, the prognosis is the worst. The Qi Goiter reacts best to acupuncture and herbs, and the Muscle Goiter second best. Hence for prevention, one must pay attention to emotional stress, diet and iodine in water.

Western Medicine
Chinese pathology is essentially concerned only with the Manifestation (rather than the Root) of Goiter, i.e. Qi stagnation, Blood stasis and Phlegm. The root is usually Yang deficiency in hypothyroidism and Fire in hyperthyroidism, but not always. There is no direct correspondence between the Chinese disease- symptom of Goiter and thyroid problems in Western medicine. Hence, Chinese medicine discusses only Goiter, while Western medicine discusses:

• Hypothyroidism
• Hyperthyroidism - Graves disease
• Hashimoto thyroiditis Each of these can manifest with or without Goiter: therefore, Chinese medicine does not really have a theory of thyroid problems without Goiter and these must simply be treated according to the normal identification of patterns. Indeed, if without Goiter, hypothyroidism may correspond to Xu Lao (Exhaustion) or Oedema in Chinese medicine. As Chinese medicine focuses only and entirely on Goiter, its pathology and treatment is focused on the treatment of masses and it must be adapted when there are thyroid problems without Goiter: i.e. in such cases, it is not necessary to resolve Phlegm (unless there are symptoms of Qi-Phlegm) or soften masses. OM