According to the main clinical manifestations of this disease, it is often classified under the categories of "goiter," "middle consumptive thirst," "liver depression," "liver fire," and so on. The onset of the disease is mainly related to emotional factors and constitution.

• Long-term emotional stagnation or sudden emotional changes can lead to liver qi depression. When the liver is depressed, qi stagnates, and when qi stagnates, body fluids fail to circulate and condense into phlegm. Alternatively, prolonged qi depression may transform into fire, scorching fluids to form phlegm. In cases of constitutional yin deficiency, yin deficiency with effulgent fire may refine fluids into phlegm. Qi depression and phlegm coagulation obstruct the front of the neck, impairing the circulation of qi and blood, leading to blood stasis, and resulting in the conditions of qi depression, phlegm coagulation, and blood stasis.
• Liver depression transforming into fire can scorch the yin of the heart and liver. When deficient fire disturbs the heart spirit, restlessness may occur. If liver fire invades the stomach, stomach yin is scorched, leading to stomach heat and rapid digestion. If liver fire invades the spleen, dysfunction of spleen transportation may manifest.
• Insufficient liver yin may draw on kidney yin, leading to liver and kidney yin deficiency. When water fails to nourish wood, signs of yang hyperactivity and wind stirring may appear.
• Individuals with constitutional yin deficiency, postpartum qi and yin deficiency, or those in developmental or lactation stages are particularly prone to yin and blood damage, which is why this disease is more common in young and middle-aged women.
• Additionally, prolonged yin deficiency may gradually damage yang, resulting in a syndrome of deficiency of both yin and yang.

In summary, the initial stage of this disease often presents with excess pattern such as qi depression, liver fire, phlegm coagulation, and blood stasis. The intermediate stage [second stage] often shows a mixture of deficiency and excess, while the late stage [third stage] typically involves the liver, kidney, heart, and spleen, with deficiency pattern predominating.

bubble_chart Modern Research

Hyperthyroidism (referred to as hyperthyroidism) is a common endocrine disease caused by excessive secretion of thyroid hormones due to various factors. It mainly includes diffuse goiter with hyperthyroidism, autonomous hyperfunctional thyroid nodules or adenomas, multinodular goiter with hyperthyroidism, iodine-induced hyperthyroidism, thyroid follicular carcinoma, pituitary hyperthyroidism, ectopic TSH syndrome, thyroiditis hyperthyroidism, ovarian goiter (caused by excessive hormone secretion from thyroid tissue contained in ovarian teratoma), neonatal hyperthyroidism, and drug-induced hyperthyroidism. This article mainly discusses the most clinically common diffuse goiter with hyperthyroidism (Graves' disease).

Modern medicine believes that the occurrence of this disease is related to mental stimulation or a history of traumatic disease and is an autoimmune disease. Previously, it was thought that long-acting thyroid-stimulating hormone played an important role, but it is now found that 83% of Graves' disease patients have thyroid-stimulating antibodies (TSAb) against the TSH receptor as an antigen, or thyroid-stimulating immunoglobulins (TSI), or TSH receptor antibodies (TRAb) in their serum. TSI can bind to TSH on the membrane of follicular epithelial cells, activate adenylate cyclase, and stimulate thyroid follicles to synthesize and secrete excessive thyroid hormones, and TSI is not affected by the feedback of serum thyroid hormones. Graves' disease also involves cellular immune responses. Due to genetic defects in the immune surveillance system, under the induction of certain factors, helper T lymphocytes increase and/or suppressor T lymphocytes decrease, sensitized B lymphocytes become plasma cells, produce TSI, bind to TSH receptors on follicular epithelial cells, and stimulate the production and secretion of excessive thyroid hormones, leading to hyperthyroidism.

Clinical manifestations

1. History: This disease is more common in women, with a male-to-female ratio of 1:4~6, and can occur at any age, but is most common in people aged 20~40. The onset is slow, and it is difficult to determine the exact date of onset. Mental factors are important triggers, and in a few cases of acute onset, a history of mental stimulation is particularly prominent.
2. Symptoms and signs: In typical cases, the hypermetabolic syndrome, nervous excitation syndrome, goiter, and exophthalmos are prominent. The most common symptoms and signs include; heat intolerance, profuse sweating, lack of strength, polyphagia with weight loss, thirst, polyuria, low-grade fever, irritability, emotional impatience, hyperactivity, insomnia, palpitation, shortness of breath, which worsens with slight activity; increased heart rate, sinus tachycardia, arrhythmia, mostly premature beats and atrial fibrillation, enhanced heart beat, hyperactive first heart sound, and grade I systolic murmur can be heard, elevated systolic blood pressure, increased pulse pressure; reduced menstruation in women, prolonged cycles, even amenorrhea, impotence in men; anemia; goiter, diffuse, symmetrical, soft without nodules, enhanced carotid pulse, exophthalmos, eye muscle paralysis, often symmetrical.

Based on the above clinical manifestations, the diagnosis is not difficult, but for early mild cases, children, and the elderly with atypical clinical manifestations, laboratory tests are often needed for confirmation:

1. Thyroid uptake ¹³¹ I rate can be done first, or basal metabolic rate can be used as a reference: if the iodine uptake rate is increased and the peak is shifted forward, it can be consistent with this disease. If the peak is not shifted forward, a T3 suppression test should be done to distinguish it from simple goiter.
2. Serum T3, T4, and γ-T3 measurements: γ-T3, T3, and T4 values can all be increased in this disease; if possible, FT3 and FT4 can be measured, and if FT3 and FT4 values are elevated, it is very helpful for diagnosis.
3. Blood TSH measurement: It is of great significance for the early diagnosis of subclinical hyperthyroidism.
4. TRH stimulation test: A normal response is indicated by an excitatory reaction. If TSH is very low and not stimulated, it suggests hyperthyroidism.
5. Positive TSI measurement in blood.
6. Blood TGA and TMA measurements are helpful for disease cause diagnosis.
7. Radionuclide CT scan can exclude thyroid adenoma and other thyroid enlargement.

bubble_chart Pattern Analysis

1. Phlegm and Qi Stagnation︰Neck swelling (goiter), depression or irritability, chest tightness and shortness of breath, dysphoria and insomnia, reduced appetite or nausea with vomiting, loose stools. White greasy tongue coating, wiry or wiry-slippery pulse. Commonly seen in the early stage. Regulate qi and relieve depression, resolve phlegm and disperse goiter. Modified Sihai Shuyu Pill. Kelp 12g, seaweed 12g, kelp 15g, clam shell powder 10g, cuttlebone 10g, dried tangerine peel 10g, curcuma root 10g, prunella 10g, white atractylodes rhizome 10g. For chest tightness and hypochondriac pain, add bupleurum, curcuma root, and cyperus 10g each; for nausea and vomiting, add pinellia and fresh ginger rhizome 9g each; for abdominal distension, fullness, and loose stools, add Chinese yam 20g and hyacinth bean 10g; for hard goiter swelling, add air potato and honeycomb 10g each.
2. Phlegm and Blood Stasis Intermingling︰Neck shows goiter swelling, difficulty breathing, hoarse voice, poor appetite. Thin white or white greasy tongue coating, wiry or choppy pulse. This syndrome is often seen in various pattern types. Regulate qi and resolve stasis, resolve phlegm to reduce swelling. Modified Sargassum Jade Flask Decoction: Sargassum 10g, Fritillaria Bulb 10g, Dried Tangerine Peel 10g, Kelp 10g, Green Tangerine Peel 10g, Sichuan Lovage Rhizome 6g, Chinese Angelica 10g, Pinellia Tuber 10g, Kelp 15g, Sparganium Rhizome 10g, Zedoary Rhizome 10g. For hard and painful goiter swelling, add Peach Kernel, Carthamus, and Prepared Pangolin Scales 10g each; for difficulty breathing, add Trichosanthes Fruit and Platycodon Root 10g each; for hoarse voice, add Indian Trumpetflower Seed and Belamcanda Rhizome 10g each; for swallowing difficulty, add Hematite 20g and Inula Flower 10g.
3. Liver Fire Invading the Stomach︰Goiter swelling with protruding eyes, bright gaze, emaciated physique, and irritable temperament; swift digestion with rapid hunger; flushed face, aversion to heat, profuse sweating, palpitations, dysphoria, dry mouth with desire to drink. Tongue texture red with thin yellow coating, wiry and rapid pulse. This type is more common. Clear the liver and purge stomach heat, disperse nodules and reduce swelling. Modified Gardenia Liver-Clearing Decoction: Gardenia 10g, Bupleurum 10g, Moutan Bark 10g, Poria 10g, Sichuan Lovage Rhizome 6g, Peony Root 15g, Chinese Angelica 10g, Great Burdock Achene 10g, Liquorice Root 5g, Kelp 10g, Gypsum 30g, Anemarrhena 10g. For excessive liver fire, add Gentian 9g, Prunella 15g; For prolonged illness damaging yin, bitter and dry mouth, red tongue with scant fluid, add Unprocessed Rehmannia Root, Scrophularia Root, Ophiopogon Tuber 10g each; For excessive sweating, add raw Fossil Bone, raw Oyster Shell 15g each, Schisandra Fruit 10g; For dry stools, add raw Rhubarb Rhizoma, whole Trichosanthis Fruit 10g each; For insomnia, add Sour Jujube 15g, Tuber Fleeceflower Stem 10g.
4. Yin Deficiency with Yang Hyperactivity︰Goiter swelling varies in size, accompanied by dizziness, palpitation, insomnia, irritability, restlessness, dreamfulness, increased appetite, emaciation, excessive sweating, protruding eyes, and hand tremors. The tongue texture is red or deep red, with scant or thin yellow coating, and the pulse is thin and rapid or slightly wiry. The treatment involves nourishing yin and subduing yang, as well as dispersing nodules and resolving goiter. Modified Celestial Emperor Heart-Tonifying Pill is used, consisting of Heterophylly Falsestarwort Root 15g, Scrophularia Root 10g, Salvia 15g, Indian Buead Tuckahoe 12g, Schisandra Fruit 10g, Milkwort Root 10g, Platycodon Root 10g, Angelica Sinensis 10g, Asparagus Root 10g, Ophiopogon Tuber 10g, Platycladi Seed 10g, Sour Jujube 10g, and Unprocessed Rehmannia Root 15g. For severe yin deficiency, add Barbary Wolfberry Fruit, Polygonum Multiflorum, and Tortoise Carapace, 12g each. For protruding eyes and hand tremors, add Uncaria 15g (to be decocted later), Puncturevine Caltrop Fruit, and Peony Root, 10g each. If the goiter swelling persists and does not resolve, add Prunella, Air Potato, and Sichuan Fritillary Bulb, 10g each.
5. Deficiency of Both Qi and Yin︰Goiter swelling, palpitation and flusteredness, shortness of breath, fatigue and lack of strength, excessive sweating, poor appetite, diarrhea or loose stool. Thin white tongue coating, thin or thin and rapid weak pulse. This pattern is commonly seen in patients with chronic illness. Tonifying qi, nourishing yin, resolving masses, and dispersing goiter. Modified Pulse-Reinforcing Powder combined with Hao Shao Long Mu Decoction. Ginseng 10g, Ophiopogon Tuber 15g, Schisandra Fruit 10g, Sweet Wormwood 10g, Peony Root 10g, Fossil Bone 15g, Oyster Shell 15g, White Atractylodes Rhizome 10g, Prepared Liquorice Root 6g. For diarrhea or loose stool, add Chinese Yam, Coix Seed, and Hyacinth Bean 15g each; for severe shortness of breath and lack of strength, add Astragalus Root 15g; for excessive sweating, add Light Wheat 10g.
6. Spleen-kidney Yang Deficiency︰The goiter swelling is soft in texture, with an indifferent expression or even a dull and sluggish demeanor. Symptoms include mental fatigue, lack of strength, fear of cold, cold limbs, poor appetite, abdominal distension and fullness, loose stools, dizziness, blurred vision, soreness and weakness in the lower back and knees, or facial and foot swelling. The tongue texture is pale and swollen, or with tooth marks on the edges, with a thin white or thin greasy coating. The pulse is deep, thin, and weak, or deep and slow. This type is relatively rare. Treatment involves warming and tonifying the spleen and kidney, as well as resolving masses and dispersing goiter. Modified Golden Chamber Kidney Qi Pill is used, consisting of: Prepared Aconite Lateral Root 10g, Dried Ginger 10g, Cassia Bark 6g, Prepared Rehmannia Root 15g, Cornus 10g, Chinese Yam 15g, Poria 10g, Alisma 10g, White Atractylodes Rhizome 10g, Dodder Seed 15g, Air Potato 15g. For severe abdominal distension and fullness, add Aucklandia Root 10g and Villous Amomum Fruit 6g (to be decocted later). For significant edema, add Plantain Seed 15g. For severe kidney yang deficiency, add Epimedium Herb and Morinda, 10g each. For soreness and weakness in the lower back and knees, add Chinese Taxillus Herb and Eucommia Bark, 10g each. For significant neck swelling, add Thunberg Fritillary Bulb 10g, Peach Kernel 10g, and Carthamus 10g.