Introduction
Thyroid disease is common in China, and it is frequently treated by herbal medicine or a combination of herbs and drugs. Positive response is a common outcome: the aggregate “cure” rate for hyperthyroidism reported in more than a dozen studies involving more than 700 patients is 42%, with most other patients well-managed even after cessation of the therapy. By “cure,” it is meant that the primary hyperthyroid symptoms are removed and that the laboratory measures (such as T3 and T4 levels and iodine uptake) are in the normal range. Clearly, it is not meant that there is any change in the underlying genetic propensity for autoimmunity, nor is it suggested that the immunologic memory of the T-cells is altered. Rather, the initiating factors for autoimmune attack appear to be diminished and, as shown in two studies, circulating antibodies against thyroid tissue are reduced. Follow-up studies of patients claimed to be cured during these treatment programs indicates persistence of the favorable outcome.
Oriental Medical Approach
Until the past 50 years, thyroid disease could not be definitively diagnosed in China; rather, Chinese doctors could only detect a certain set of symptoms to be treated and could palpate any moderate or large nodules in the area of the thyroid gland. Now, objective measures, such as altered levels of thyroid hormone, can give a clue as to the site of the disease and can further elucidate the influence of various therapeutic measures that might be applied.
While treatments for both hyperthyroidism and hypothyroidism have been reported in the literature, the main thrust of clinical trials has been with hyperthyroidism. The treatments vary somewhat from one study to the next, but there are certain consistent features that will be described here on the basis of reports for hyperthyroid treatments only.
First, there is a strong reliance on materials from the sea, mainly oyster shell (included in 12 of 18 clinical trials using a basic formula), seaweeds (laminaria, and sargassum, used in nearly half the clinical trials), and somewhat less frequent use of clam shells, arca shells, or pumice. While these materials, especially the seaweeds, would obviously be helpful for iodine-deficiency goiter, they are now often used for Grave’s disease and thyroid adenoma. Iodine is not known to have an impact on chronic (autoimmune-based) thyroid disease, though it is employed as a temporary remedy in cases of thyroid storm (physiologic crisis resulting from thyroid hormone excess). The continued use of the sea materials may be unnecessary for modern thyroid diseases, and, indeed, two studies producing satisfactory results in treatment of hyperthyroidism contain none of these materials.2,21 However, the sea materials may contain components other than iodine that benefit patients with hyperthyroidism. Their initial use was no doubt associated both with the experiential knowledge that consumption of sea materials resolved many cases of goiter and also by the theoretical concept that salty materials would soften and remove masses. Thyroid nodules often occur even in cases of non-iodine-deficiency hyperthyroidism.
The two trials reported in the Chinese literature that failed to include sea materials in the herb combination had unusually long treatment times (6 months to one year for most patients of one study, and one and a half years for the patients in the other study) compared to trials that included sea materials. In the recent book, Practical Traditional Chinese Medicine and Pharmacology Clinical Experiences, formulas are presented for treatment of hyperthyroidism according to differential diagnosis: all five of the listed formulas contained seaweeds or seashells or both. Thus, current thinking about hyperthyroidism emphasizes these materials. Oyster shell and other shells not only resolve masses, but also help to calm liver wind, thought to be responsible for some hyperthyroid symptoms, such as trembling, and they astringe excessive perspiration, another common symptom.
Several other phlegm-resolving agents are used to remove the thyroid mass, such as pinellia, fritillaria (zhebeimu), sinapis, huangyaozi (Dioscorea bulbifera), and various types of citrus (e.g., chenpi, juhong, and zhiqiao). Masses and nodules are often described by Chinese doctors in terms of entangled qi, accumulated phlegm, and static blood. Because of the site of the nodules (just over the lungs), the fact that the nodules are usually not painful, and the soft quality of the swellings (except in cases of thyroid tumor), they are traditionally described as being primarily phlegm masses. Both the sea materials and the items mentioned here from land plants are thought to treat such masses effectively. Fritillaria, used also in the treatment of a wide variety of tumors, is the most commonly selected phlegm-resolving item for hyperthyroidism aside from oyster shell. In addition, many of the therapies for hyperthyroidism contain prunella, an herb used to resolve entangled qi. The citruses likewise help resolve qi stagnation and phlegm accumulation, and bupleurum and/or cyperus are sometimes included in the treatments for regulating the qi.
A few doctors include therapeutic substances for static blood in formulas aimed at removing thyroid nodules. The main herbs used are zedoaria and sparganium; these would also be relied upon for treatment of abdominal masses, such as uterine myoma. Salvia, cnidium, and/or peony (white peony), which are less powerful blood-vitalizing agents, are sometimes used instead of, or in addition to, these two principal herbs. Blood-vitalizing herbs are especially indicated when the thyroid mass is quite firm; this is a characteristic of thyroid tumors, which can also cause hyperthyroidism (toxic adenoma).
Hyperthyroidism is thought by some doctors to start with an excess fire syndrome, which later becomes yin-deficiency fire. Therefore, fire-purging herbs are used, especially in the early stages of the disease process. Prunella is the most frequently selected one, used in more than half the clinical trials that rely on a basic formula. Peony, raw rehmannia, and scrophularia are also commonly used. Other fire purging herbs recommended include moutan, gentiana, gypsum, scute, anemarrhena, and gardenia.
Several hyperthyroid symptoms, such as heart palpitation, general hyperactivity (psychological and physical), excessive perspiration, heightened appetite, aversion to heat, and, in more severe cases, wasting of the muscles, are characteristic of a yin deficiency syndrome. Therefore, Chinese doctors prescribe raw rehmannia and scrophularia (herbs that purge fire and nourish yin) plus ophiopogon and/or adenophora. In some cases, lycium fruit and/or tang-kuei may be used in conjunction with one or more of these other agents to nourish liver blood and thereby control liver fire. To calm the agitation, sedative herbs such as zizyphus, succinum, dragon bone (or dragon teeth), and polygonum stem are used. Magnetite or hematite may be added as sedatives and to treat exophthalmos. Tribulus is used as an antispasmodic that is beneficial to the eyes; it may be combined with lycium fruit to nourish the liver. Cinnabar is employed by some Chinese doctors as a sedative but is not recommended for use by Western practitioners.
Many doctors prescribe some spleen qi tonics to normalize overall body functions and to avoid generation of phlegm from spleen dampness. Astragalus, codonopsis, atractylodes, hoelen, and licorice are the materials most often used. Astragalus is the preferred item, though it is often selected, as are the other qi tonics, as an optional ingredient rather than a standard item, to be used for those patients showing obvious signs of qi deficiency. Typically, hyperthyroid formulas contain only one or two qi tonic herbs that do not constitute the bulk of the formula.
A typical treatment, with a formula somewhat larger than others, but comprised of the commonly used components is Jia Kang Wan .7 It contains oyster shell, sargassum, laminaria, prunella, citrus (juhong), pinellia, fritillaria, and huangyaozi-ingredients for resolving nodules; it also contains succinum and cinnabar as sedatives, and hoelen and licorice to benefit the spleen. The herbs are powdered, formed into large honey pills weighing 15 grams, and taken in the dosage of one pill twice daily for 45 to 90 days. It was reported that 65 of 125 patients so treated were cured, a rather high rate (52%).
Another typical example is Pingyin Fufang,16 which contains oyster shell, arca shell, prunella, fritillaria, blue citrus, sparganium, and zedoaria to resolve the thyroid nodules; scrophularia, raw rehmannia, peony, and moutan to clear heat and nourish yin; plus tang-kuei, dragon bone, hoelen, and cornus. The herbs were decocted “in typical amounts” (the total dosage is 150 grams or more of crude herb per day) and given for a cycle of 30 days, which might be repeated once or twice if necessary to obtain adequate response. The cure rate was 38 of 110 patients (35%), somewhat low compared to the overall outcome of the various clinical trials, but because of the short treatment time (usually just 30 days), the results are impressive.
A Japanese doctor, relying on approved herb formulas (those sanctioned by the Health Ministry of Japan) reported good response of hyperthyroidism in several patients from Bupleurum and Dragon Bone Combination and from Baked Licorice Combination.25 The former contains herbs found in many of the modern hyperthyroid treatments, such as oyster shell, dragon bone, pinellia, bupleurum, and hoelen, while the latter also contains some ingredients in common with the modern therapies, including raw rehmannia, ophiopogon, and licorice. Other treatments mentioned by Japanese doctors are described later in the section on Kanpo medicine.
In sum, Chinese doctors obtain clinically useful results from the application of formulas that have the primary function of resolving masses, with additional herbs to clear heat and nourish yin.
