Telling the Story of the (Female) Body: Metaphorical Narratives of the Thyroid Gland

Abstract

One of the mysteries of traditional Chinese medicine (TCM) is the metaphorical language it uses in describing conditions of the body. The human body is seen as an integrated system operating within the larger context of the natural system. Illnesses are therefore the results of imbalance within the individual system, and/or an imbalance between the individual system and the external natural system, which is very different from western medicine’s more localized and focused attention given to specific organs. This article looks at the TCM’s narrative of the thyroid (gland) and how this presents a different imagination as well as treatment of the related illnesses. Although western medicine relies on figures for indicating thyroid health, and surgery (or thyroid-targeted medication) as main measures of treatment, TCM refers to a holistic picture of the patient’s wellness to diagnose and treat thyroid conditions. This article is a first-person narrative of a middle-aged female who found herself in the extraordinary position of having visible thyroid swellings, and yet all of the vital signs were within healthy parameters. Visits to TCM clinics empowered the narrator with an alternative framework to understand and experience the body, and a refocus on life habits and emotional practices.

1. Illness and Literature: Woolf and the Imagination of the (Female) Body

Woolf has famously written in her essay “On Being Ill” that:

Considering how common illness is, how tremendous the spiritual change that it brings, how astonishing, when the lights of health go down, the undiscovered countries that are then disclosed, … it becomes strange indeed that illness has not taken its place with love and battle and jealousy among the prime themes of literature.

(Woolf 1926, p. 32)

Since the publication of this essay in 1926, much has been written about illnesses by the sufferers themselves, and storytellers who have noticed the impact of imaginations concerning this inevitable aspect of human life. Although it may not yet have shared with love or battle or jealousy the same importance in literary appearance, illness has gradually made its mark in literary history as human life records sequential traumatic events that cause ill feelings in its population. World wars destroy not only lives but ways of life, and therefore create sufferings in the physical body and the emotional mind. The “natural” progression of modernization in our world gives rise to new political, social and economic realities that sometimes we fail to catch up with. Even improvements in daily life conditions may ironically lead to feelings of disorientation, isolation, and loneliness. Not everyone in the world benefits from the increasingly speedy pace of life; the evidence can easily be seen in collections of personal narratives expressing discomforts of various kinds, many of which can be reflections of how the two genders are living their lives through different times.

The 20th century witnessed two world wars as well as numerous regional conflicts, resulting in a huge number of casualties, injuries, long-term physical illnesses and mental disruptions across all ages and sexes. Although in fighting, the main casualties might have been male, the sudden call for female support to fill various roles and the later re-allocation processes caused much mental stress and pain. Even during peaceful periods, gender equality has been a prolonged and uneven process among different classes and social backgrounds. Woolf’s imaginary Judith Shakespeare in A Room of One’s Own (Woolf 1929) and her playful biographical fiction Orlando (Woolf 1928) are but two of the most well-known literary texts reminding readers of the mental and emotional illnesses women are burdened with. Through the rest of the century, feminine experience in reality and the literary imagination has been given more attention; in particular, the repressed and the previously hidden experiences are uncovered in critical discussion such as Gilbert and Gubar’s The Madwoman in the Attic: The Woman Writer and the Nineteenth-Century Literary Imagination (Gilbert and Gubar 1979).

Although it may not be justified to claim that illness as a theme has risen to become the focus of literary discussion since then, the body and its conditions have gained increasing critical attention since the second half of the century. Third-wave feminists such as Helène Cixous and Luce Irigaray have drawn attention to the different orientation of the feminine body and how writing is carried out through the feminine body. Therefore, when we refer to Woolf’s proposal in 1926 that poetry is a more suitable form of mental nourishment during illness because of the specific conditions of the body, we come to see this as another early confirmation of how the physical body is an under-explored field of (metaphorical) imagination and representation:

But in illness, with the police off duty, we creep beneath some obscure poem by Mallarmé or Donne, some phrase in Latin or Greek, and the words give out their scent, and ripple like leaves, and chequer us with light and shadow, and then, if at last we grasp the meaning, it is all the richer for having travelled slowly up with all the bloom upon its wings.

(Woolf 1926, p. 41)

With the stage set for the body to present itself in the literary text, the following is an example to enrich the repertoire of works that come out of experiencing the world through the body, during its illness. Almost as an answer to Woolf’s query a century ago, I am presenting an intricate set of narratives of the thyroid gland, as experienced in 21st century Hong Kong, where both the western and Traditional Chinese Medicine (TCM) are practiced and respected. It turns out that the story of the thyroid gland is one with different perspectives, layers and emotional temperatures.

2. The Annual Body Check and the Story of the Figures

I am a middle-aged working female, born and living in Hong Kong, and had a westernised education. Similar to many people of my generation, when we say we go to “see the doctor”, we mean visiting a western medical clinic and be diagnosed by a doctor trained in western medicine. We are used to the routine of making an appointment at the clinic, arriving and sitting in the waiting area before being admitted into the consultation room, when we can actually see the doctor. Usually, the doctor asks what seems to be the problem, we answer accordingly, and the doctor examines the specific area and makes some comments about the condition. Medication, or further procedures will be named, then we gratefully exit back to the sitting area to wait for the medication and the bill. Although Chinese is by far the majority of the population, western medicine is the main official healthcare approach, and government clinics and hospitals are all staffed with western-trained healthcare professionals.

Besides the common experience of visiting a doctor when illnesses arise, for those who are health-conscious and can afford it, the annual body check is another routine that they go through with a sense of responsibility. There is a range of body check “packages” from simple blood and urine test and X-rays to sophisticated menus that require an overnight stay in a hospital. An average adult in Hong Kong is able to respond to vocabulary such as “the three highs”: high blood pressure, blood sugar and cholesterol, and many can also give you the figures of their own condition in these respects. With some knowledge of these indications of health, many citizens in Hong Kong are also active consumers in the global market of healthcare supplements. Although the effectiveness of some of these supplements requires investigation, it is very clear that the average citizens are comfortable with the western medical approach in healthcare, that is, we can interpret our state of health from a set of data we obtain through the body check. There are parameters of figures within which we are considered “not ill”, and if any of our organs give an indication beyond these standards, actions will be taken to restore the performance of our body parts back to the norm—that is the treatment.

Throughout my youth, I was generally considered healthy—no major illness (except once when I was five years old), no hospitalization record (except an incident of dog bite) and no particular irregularities. When I turned thirty, I decided to be “responsible” and started going for my annual body checks. For me, it was simply a matter of confirming that there was nothing to worry about, although some of my friends reported anxieties when the clinics called back to say that the doctor would like to meet them to explain the reports. Usually, the need to explain the figures meant that some aspects required attention or even action. For many years, I only heard my friends talk about this anxiety—I did not indulge in any bad habits and considered my lifestyle very disciplined (too disciplined, my friends said). The only “practice” that I overdid was work. I worked long hours and very often skipped meals because it was not convenient to eat.

It was December five years ago. I went for my annual checkup at a clinic at the city center. Blood and urine samples had been given, a chest X-ray had also been taken, and I was dressed again, waiting to see the physician for other general examinations. The physician touched my jaw area down to my neck, when she said, “you know your neck is swollen?” I was not sure I heard correctly, so I said “swollen?” “Yes, the left side is more prominent than the right side. Do you have any idea when this started?” I had no idea that “this” existed. I was too shocked to ask any relevant questions, and only heard that she recommended a fine needle aspiration procedure guided by ultrasound, to take a sample of the cells in that area to see what the problem was. I went away with her referral letter, dazed and unable to process what had happened. It was only when I came home, sat down, talked to some female friends, and looked up my condition on the internet that I had a better idea of what was going on. It could be a problem with my thyroid gland.

3. Journey to the Thyroid Gland: From the Western Clinic to the TCM Practitioner

My memory of the following months was a series of trips to clinics and specialists. As suggested by the physician, I underwent the fine needle aspiration procedure; a sample of cells and fluid was sent to be analyzed. In a month’s time, I was back to the clinic to listen to the physician’s explanation of the ultrasound images taken of my thyroid gland area, and the analysis report. The ultrasonography report stated, “Both thyroid lobes are normal in size and echogenicity, measuring 2.15 × 1.46 × 4.87 cm on the right and 2.04 × 1.26 × 5.04 cm on the left. The isthmus is not thickened. Multiple bilateral thyroid nodules are noted, listed in the following table”. The location, measurement and characteristics of these nodules were shown, followed by two (to me, reassuring) sentences: “No increased vascularity is noted on Doppler imaging. No retrosternal thyroid extension noted”. The conclusion of the ultrasound imaging report was: “Multiple bilateral thyroid nodules noted. The two largest nodules are seen at the isthmus. Tissue diagnosis would be helpful”.

The tissue diagnosis was performed on the fluid and cells taken from the ultrasound guided fine needle aspiration procedure. The report described the procedure as “uneventful”, although I was a bundle of nerves during the long wait for the short procedure. The cytology report gave a microscopic description of the content drawn from the nodules:

The smears show many haemosiderin laden macrophages in the background of some inflammatory cells and degenerated RBCs. The finding could be in keeping with the content of a hemorrhagic cystic lesion. There is no cytological evidence of malignancy. However, no follicular cells are present for assessment. Clinical correlation is advised.

The specimen was tested for thyroid function “B” (TSH, FT4, FT3) and the figures were all within the normal parameters. When I asked the specialist (another physician) what was wrong, she said that according to the reports, my thyroid gland was functioning normally. I then asked what the cause of the swelling/nodules was, and she said she could offer no explanation. Finally, I asked what I could do to reduce the swelling—because to me that was a problem and I need to do something about it. The answer was that I could have the thyroid gland removed, then take medication to make up for the absence of the thyroid gland.

I did not have any medical training at all, but removing a part of the body that was functioning normally and then to take medication afterwards to simulate the function of the removed organ did not make sense to me. The specialist said that since the cause of the condition was unknown, there was “no cure” for it. The only advice she could give me was to monitor the condition, which meant that I should have an annual checkup, and that I should see a specialist as soon as I notice any drastic changes in the size of the swelling. That was more than a month after my first awareness of the condition. A few months later, the swelling did become bigger, and I went to a different specialist; the same procedures, same results, and same advice were given. Those few months were terrible experiences, not because I suffered great physical pain, but because I felt a strangely unfamiliar sense of alienation from my own body—first of all I had to be told about the swelling, then I failed to understand why this occurred, and worst of all I had no way to “cure” it, in the sense of restoring this part of my body to the standard healthy condition.

Ironically, this sense of alienation from my body was the result of my being “responsible” for my health in the first place. The decision to have an annual body check was in line with my belief in the mainstream western medicine. The various tests carried out on my body (and its secretions) should be able to tell me whether I am physically healthy or not, i.e., how my numbers measure against the standard range of numbers in relation to various parts of the body. If I weigh too much, if my cholesterol level is too high, if my bone density is not enough, I can do something (theoretically) to put myself closer to the standard conditions. In other words, I had the belief that, except for genetic irregularities, I was in control of my own body, that I can operate it like a machine, and that there is a user manual to follow. The scientific discourse of the mainstream western medicine in Hong Kong had cultivated in me a straight-forward approach towards my body as an intelligent machine with individual parts having a distinct role. In this experience, however, the problem was discovered by the physician’s touch, and all the numbers from the subsequent blood tests fell within normal range. The scientific discourse that I had believed in completely failed me.

In search of a name, a cause, and perhaps a story of my personal condition, I went to consult another “mainstream” medical institution in Hong Kong, traditional Chinese medicine (TCM). TCM has a long history, and has more than proven itself to be effective in maintaining health and wellbeing. I remember when I was a child, the elderly and the poorer folks were more used to consulting TCM practitioners (they were referred to as Chinese Doctors) than western doctors. As the Hong Kong economy flourished, more people chose the quicker option of western medicine, and TCM was marginalized for some time. Lack of a systematic training program and official recognition also put TCM at a disadvantage in the context of Hong Kong then. In 1999, the Legislative Council passed the Chinese Medicine Ordinance to accord a professional status for Chinese medicine practitioners and ensure the safety, quality and efficacy of Chinese medicines. This Ordinance was not an exceptional occurrence only in Hong Kong, for we saw the professionalization of TCM globally, with major universities in the West also offering TCM training programs.

When I walked into a TCM clinic five years ago, Hong Kong had already been producing its own TCM professionals for more than twenty years. Although my childhood memories of TCM were marked by the smell of boiling herbal potions, today many TCM clinics use granules made from these herbs. Taking TCM is as easy as taking western medicine, and young people no longer feel that it is “old school” to use TCM. I presented myself to the “doctor” and explained my problem. He felt both sides of my neck and confirmed the presence of the nodules. He then took my pulse and described the swelling as ying3 (in Chinese 癭), and my condition as gan1 yu4 qi4 zhi4 (in Chinese 肝鬱氣滯, literally meaning the liver is depressed and qi is stagnant). The National Center for Complementary and Integrative Health (NCCIH) defines qi as a vital energy that flows through the body, helping to maintain a person’s health. In other words, the vital energy that is supposed to go around my body supporting me is stuck somewhere. He did not show any sign of surprise, and in fact said that this was a condition very often seen in middle-aged women. To say that I was overjoyed would certainly be an exaggeration, but I was immensely relieved to hear that there was a name for my condition, and selfishly gratified that many others shared this experience.

The initial TCM prescription that the doctor made for me was for six months. However, he also explained that the medication itself will not eliminate the condition entirely because that was a condition resulting from multiple causes, and possibly the interaction among these causes. Very briefly, ying3 is a condition mainly caused by harmful emotions, together with an imbalanced diet, and its manifestation is closely related to specific body types. Without being too technical, he joked and said that the easiest way to understand the cause of this condition was the Cantonese saying which literally read “bottled up to the top of the chest”. My university-educated friends would refer to that condition as “up to here”, expressed with the hand placed at the level of the throat. Negative emotions, suffered and pent up, with no way of release … are indeed commonly experienced by many middle-aged women I know. Their “up to here” feelings arouse in me the memory of Orlando’s 400-year life and the origin of this fictional character in Vita Sackville West—she was disadvantaged by nothing other than her sex. After three waves of world feminism, in a global city such as Hong Kong, female life-stories are still written more on the (sick) body than being told and understood.

At the point when the TCM practitioner spelt out the name of my thyroid illness, and gave a general explanation of its usual causes, physically I was no better than a few months ago when I visited the expensive specialists trained in western medicine. However, the metaphoric language used by the TCM practitioner unexpectedly restored my confidence. It was not the confidence in his ability to cure me, rather a sense that I had some kind of control over my body again when I began to understand the story it was telling. I could easily visualise the “depressed liver” emitting fumes of rage that raced around my body, but finding no outlet and becoming stuck in my thyroid region, becoming the “stagnant qi”. I immediately thought of the stress, anger, and frustration that were so often the main ingredients of my days and which I had to force myself to swallow quietly. At that moment, I also understood why medication alone would not cure me—only I could restore the balance in my body through changing my ways.

That was the story of my journey to understanding the thyroid gland, or to be more precise, the story of my being able to acknowledge the part of my body which is intimately connected to my moment-by-moment feelings. If not for the doctor who first mentioned the swelling five years ago, it would have taken me longer to identify and understand this organ, and the process may even be a traumatic one. I consider myself very fortunate to be able to start this journey as one of inquiry and, step by step, put together a narrative that is personal, identifiable, and livable. The metaphoric language used by TCM presents to me an imagination of the thyroid that is sensitive to our emotional landscape, and which is safeguarding our mental and emotional wellness through its quiet but visible expression. I have gained a trustworthy companion in the project of maintaining wellness.

4. A Cross-Cultural Jigsaw Puzzle: The Story of the Thyroid Gland

Besides being a patient suffering from a condition of the thyroid nodules, I am also an academic fascinated by narratives from different cultures. In the process of understanding the story of the thyroid so as to regain control of my body, I have been reminded of the very different approaches taken by the two mainstream medical institutions currently in Hong Kong. Driven simply by curiosity, I looked up information about the thyroid gland, especially representations of illnesses related to this region. How did this difference in approach come about? Could we find any indication in the historical documentation of the thyroid story? The following is a less personal but more factual and objective story of the thyroid gland, which presents the universality of the human body through different lenses. I am not a medical professional, and therefore not qualified to argue in favor of or against any strategies for health maintenance. This sharing is only an attempt to start a deeper cross-cultural understanding of the way we relate to our body.

Despite my frustrating experience in seeking to understand the condition of my thyroid region from specialists trained in western medicine, documentation about the thyroid gland as we know it today is not lacking. There was a discussion of goiter, which is thyroid enlargement, as early as 300 BC, in Ayur Veda. Burnt seaweed was recommended for treatment of this condition by Pliny, Vitruvius and Juvenal; the first mention of thyroidectomy as a treatment for goiter was 961. Visualization of the thyroid gland in western culture began with Leonardo da Vinci’s drawing in 1500, and Andreas Vesalius provided the first anatomic description and illustration of the thyroid gland. Finally, Thomas Wharton named the gland “thyroid” after the shape of an ancient Grecian shield in 1656 (ATA 2022). From the Renaissance onwards, observations, studies and treatments about various conditions of the thyroid gland were made in western medicine. Iodine deficiency was recognized as one of the causes of goiter in 1820, and iodine as a treatment strategy persists today. Graves’ disease, the most common cause of hyperthyroidism—excessive secretion of thyroid hormones—was discovered in 1862.

As described historically in western medicine, problems with the thyroid gland are visually noticeable. “A short history of the thyroid gland” begins with “Goiter is very common in many parts of the world and was recognized long before the thyroid gland itself. Since pre-historic times, the visible outgrowths in the front of the neck have been objects of curiosity and study” (Leoutsakos 2004). This shows that thyroid enlargement has been a condition as old as humankind, and has been the object of a lot of attention throughout history. The article then continues to trace historical documentations of its existence through the Greco-Roman period, the Byzantine period, the Renaissance, up to the early 19th century. Interestingly, it is only at the end of the article that some brief mention of “surgical treatment of thyroid disease” (Leoutsakos 2004) is made. The fact that I am still making this inquiry in 21st century Hong Kong suggests that there are still parts of the story missing.

In my layman investigation of the traces of thyroid documentation in ancient Chinese texts, I found in Zhuangzi: De Cong Fu the name “ying3” (癭) being mentioned. In Lushi Chunqiu (The Annals of Lu Buwei) which was published in 241 BC at the end of the Warrior State, the illness was not only mentioned, but claimed to be closely related to the environmental conditions. This connection to the environment, or more specifically water source and quality, was clearly stated in the first ancient Chinese text on pathology and etiology, Zhu Bing Yuan Hou Lun (General Treatise on Causes and Manifestations of All Diseases), written by the Doctor of Imperial Medicine in 610 AD. It was recorded that the swelling was caused by frequent consumption of water coming out of the dark soil, and dramatic emotions would aggravate the condition. Seminal TCM texts Beiji Qianjin Yaofang (Essential Formulas for Emergencies Worth a Thousand Pieces of Gold) written by ancient Chinese “King of Medicine” Sun Simiao in 625 AD and Wei Tai Bei Yao (Arcane Essentials from the Imperial Library) by Wang Tao in 752 AD had documented a few dozens of formulae for treating thyroid illnesses. It seems that by the 8th century, TCM had already quite a well-defined understanding of this condition.

Into the 12th century during the Northern Song Dynasty, a team of officials commissioned by the emperor conducted an etiological analysis of the ying3 condition, and recorded their findings in Sheng Ji Zong Lu (General Records of Holy Universal Relief), published in 1161. They reckoned there were five types of thyroid swellings, two were caused by improper diet, whereas the other three types were caused by overwhelmed emotions. Another way of classifying the thyroid swellings, according to the symptoms, was proposed in Sanyin Ji Yi Bingzheng Fang Lun (Treatise on Three Categories of Pathogenic Factors) which was published in 1174. This practical manual advocated medication over surgery as the primary treatment strategy against thyroid swellings. Ming Dynasty pharmacologist Li Shi Zhen also mentioned herbal potions that were effective in reducing thyroid swellings in his 1596 publication Ben Cao Gang Mu (Compendium of Medical Herbs). Chen Shigong, a famous Ming Dynasty surgeon, described thyroid swelling as the accumulation of blood stasis, stagnant qi and phlegm. His proposed formulae in Wei Ke Zheng Zong (Orthodox Manual of External Diseases), published in 1617, is still used today.

5. Life (and Illness) in the 21st Century: Feeling “Up to Here”

I was one of the many fortunate patients to have taken Chen Shigong’s formula for six months. For me, the 400-year-old herbal formula is not only proof that TCM had successfully found a way to tackle this thyroid condition, but also that it has a different story to tell about our body. The language of this narrative is different from that used by western medicine, which focuses on the individual organs, their visible manifestations, and systematic measurements of their performance. The TCM narrative looks at the connections among the organs as well as their interaction with the external system—the natural environment. In choosing to focus holistically on the interactive aspects of the human body, the TCM narrative features an additional voice, that of the personal—the emotional voice of each individual human being. In the TCM narratives of our illnesses, we find a range of personal stories speaking of unique situations and reactions to life’s circumstances. The swellings on both sides of my neck alerted me to the emotional struggles that I had accumulated over the years, and perhaps reaching almost the breaking point.

Beyond my personal experience in Hong Kong, which has a majority Chinese population, it is very heartening for me to see that the increasing application of TCM in other parts of the world also means the unfolding of personal experiences of women with illnesses. A study in Australia (Alfred and Ried 2011; Ried and Alfred 2013) focused on the experiences of women who sought help from TCM clinics to manage their infertility, and found that they appreciated the non-invasive approach of TCM in diagnosis. More importantly, these women felt that the holistic TCM approach respects their personal differences, and in general, the treatment enhances their overall well-being. In studies about breast cancer patients using TCM as supportive treatment (McPherson et al. 2016; Porter et al. 2017), it was also found that in general, women appreciated the holistic approach of the treatment, which eased not only their physical conditions, but took care of their emotional and psychological well-being as well, although TCM was not the main treatment strategy used.

Looking back on my physical and emotional journey through the thyroid experience, I must echo female patients who received TCM treatments (including those in the studies mentioned above) and appreciated the holistic, non-invasive, and supportive approach it takes toward our body. The overall sense of our being cared for in TCM treatment comes from the fact that we are looked upon as complex individuals, whose body conditions are manifestations of an unbelievably intricate coordination among the composite parts, our emotions, and our external social and cultural societies. Including the “individual self” and its interactive with the external environment in the TCM narrative may make it seem less scientific than the narrative of mainstream western medicine, but it empowers the patients and allows them to have a better sense of ownership over the body and how it behaves. Having said that, this paper is not an advocate for replacing western medicine with TCM, nor is it a comparison of the “effectiveness” of these two very different approaches (Scheid 2007). Rather, it notes the inclusive, empowering, and metaphorical nature of the TCM narrative, and how it may be useful for us to use it to think about illness, our body and its position in relation to the world. In this regard, Leung’s (2008) identification of the human dimension of TCM and presenting it as a framework to facilitate rethinking conflicts and differences in our world is an apt introduction to 21st century appreciation of this ancient wisdom.