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May 10, 1919. THE HOSPITAL 125 MINOR THYROID INSUFFICIENCY

As we go into 2019, I thought to look up 1919 during which, so PubMed tells us, there were thirteen papers mentioning "thyroid". Of these, I have picked one to post out of historical interest. (Certainly not advocating some of the treatments such as dosing with arsenic iodide!)

I have purposely NOT corrected the various typos and similar which have probably occurred due to scanning and optical character recognition.

A PDF of the original published paper is linked at the end.

May 10, 1919. THE HOSPITAL 125 MINOR THYROID INSUFFICIENCY.

A Condition Met With Daily.

From amongst the less well-favoured of our fellow travellers in the streets and trains, nrany can

be selected who, although themselves unconscious of any departure from the normal, have suffered some common type of misfortune. One such class is that which shows the effects of inadequate secretion of the thyroid gland. Its numerous members are known by the premature greyness and scantiness of their hair, which recedes both from the occiput and forehead, by the thinness of the outer half of each eyebrow, by a certain coarseness of feature and a tendency to puffiness under the eyes, by the harsh- ness of their skin and the brittleness of their nails,

by their obvious chilliness in winter, by the blueness of their hands and ears, and an unnatural flush over their, malar bones. The grosser forms of this dis- order are easy to detect, but for the diagnosis of the mild degrees practice is required, and an aptitude to see our fellow creatures as they ought to be rather than as they are.

The thyroid regulates growth, and various degrees of dwarfism follow upon its defective action in early life. The minor failures of development alone con- cern us here., They may be of a cretinoid type, with definite stigmata, or of the Lorain type, in which the evolution of the various parts is proportionate, but the whole somewhat diminutive. The epiphyses are late in uniting, and, until their union with the" bony shafts is complete, increase in stature is possible under appropriate treatment. A series of radiograms should always be examined before a pro- gnosis is made regarding the possibility of growth.

Thyroid secretion also regulates katabolism, and when insufficient the tissues become clogged with a, mucin-like substance which is probably an inter- mediate product of katabolism.

These two factors?namely, diminished rate of combustion and myxoedematous infiltration? account' for many of the signs and symptoms of the disease. Internal temperature is subnormal; there is a subjective sensation of cold, particularly in the hands and feet, and a tendency to shiver even when heavily clothed. Winter is a time of great discom- fort, and unless there is coincident visceroptosis a decided preference is evinced for hot weather.

Infiltration of the subcutaneous tissues is not pro- nounced in the mild varieties under discussion, and gives rise merely to a thickening of the features and a full habit of body, the latter by no means always conspicuous. Infiltration of the muscles and of ar?und the joints often causes pain and silliness of movement, producing a condition which is fiequently mistaken for muscular rheumatism or even lheumatoid arthritis. The pains, which are usually worse at night, affect all parts. Alost frequently, however, they are felt in the dorsal musculature, where they constitute an intractable backache.

In the digestive system peristalsis becomes slug-gisli, and the abdominal musculature so weakened that constipation and'visceroptosis develop. Appetite fails and is often replaced by distaste for food, especi- ally for meat. Secondary changes affect all parts of the alimentary tract, and manifest themselves as oral sepsis, various forms of indigestion, and of abdominal pain, the prominence of which symptoms may so compel the attention that the underlying subthyroidism is overlooked.

In certain cases the sensitiveness of the bladder increases, possibly because of a myxoedematous in- filtration of the trigone, and a constant desire to mic- turate is experienced. Nocturnal enuresis is also common, and the possibility of subthyroidism should always 'be borne in mind when one is confronted with this disorder.

The thyroid gland has a profound influence over the organs of sex, not only regulating their develop- ment, but also assisting in the maintenance of their functional activity. In the subthyroidic the uterus., ovaries, and testicles develop late, and the supra- pubic hair is scanty. Menstruation is delayed in its onset and abnormal in character, an excessive amount of blood usually being lost. Fertilisation of the ovum is just as likely to occur in a subthyroidic woman as in a normal one, but the embryo is often carried away by a profuse flow at a later menstrual epoch. During pregnancy the activity of the thyroid gland increases, and subthyroidic women often feel fitter during this period, although their symptoms- begin to return after the puerperium. Usually lacta- tion is imperfect, and menstruation recommences quickly.

Nerve and mental symptoms are numerous and of very great importance, feensations of tingling and of "pins and needles" are commonly experi- enced in the limbs. Headache on waking is very characteristic and may resemble that of frontal sinus catarrh or radiate upwards from the occiput after the fashion of neuralgia-. Like so many of the symptoms of benign subthyroidism, these headaches improve towards evening, especially after a good dinner with wine. Noises in the ears and vertigo ore also common. The latter may occasion a fall, although in its slighter forms it merely gives rise to a sense of" insecurity. General mental torpidity, impairment of memory, defective powers of associa- tion, and a difficulty in verbal expression are ex- tremely common. Somnolence and heaviness of sleep are almost invariably present. The outlook on life is usually one of depression and melan- choly.

The disease attains a maximum incidence amongst the middle-aged women of the so-called working- classes, and,is the cause of much misery in the homes of the poor. The afflicted one can only dis- charge her responsibilities imperfectly and is unable to maintain the efficiency, of her household. Ill- planned expenditure and effort, dirtiness and dis- order, combined with the patient's own physical Minor Thyroid Insufficiency? [continued). sufferings and the psychic atmosphere of irritable, suspicious pessimism which emanates from her, produce a condition of distress only rivalled by that of homes which are under the ban. of drunken-ness. i

Diagnosis, therefore, becomes a social obligation and treatment quickly brings its recompense. The subthyroidic do not tolerate thyroid extract so readily as do the healthy, so that the initial dose should be small and systematic increases made at short intervals.* The tachycardia and palpitation which often follow 'act as warnings that the dose must only be increased with caution, but are not signs of hyperthyroidism. The heart muscle is impaired in vitality and shares the general myx- oedematous infiltration. Its mechanical efficiency temporarily is lessened by the removal of the myxoedematous padding at a time when a general rise in metabolic activity is calling for a vigorous cardiac response. Consequently symptoms of cardio- vascular distress are experienced. In severe cases the patient should be kept in bed for a short period when treatment is first started so that much of the strain being removed the dose can be increased more quickly.

Too rapid depletion may produce untoward effects in other parts. Undue laxity of ligaments is some- times induced with resultant instability and de- formities, one of the commonest of which is knock- knee. Any pre-existing tendency to visceroptosis is aggravated. The loss of hair which frequently occurs at first is merely a loss of an imperfect growth. Reassurance can be given with confidence that a more luxuriant crop of more lustrous hair will soon replace the old. -v

The effects of correct dosage are prompt and dramatic. The rate of metabolism increases and the patient's weight falls steadily. The output of carbon-dioxide from .the lungs and of urea from the kidneys rise to a much higher level than that of health. This phase, however,'ends when the com- bustion of the myxoedematous store is complete.

Metabolism then returns to a normal ,rate and weight remains constant. After a varying interval the weight often rises again even in adults. This secondary gain is due to th'e development of healthy tissues and to a general improvement in nutrition. It must not be confused with the relapse which ensues if the patient becomes careless and omits to take thyroid extract. When this stage has been reached the most conspicuous part of the treatment has been .accomplished, but much still remains to be done. Many cases of subthyroidism are due to antenatal toxaemias, such as those of- tuberculous and syphilitic infection in the parents. The gland having been damaged before birth is beyond .all therapeutic aid, although its lesion is non-progres- sive. Many glands, however, are injured after birth, sometimes by acute and transient causes such as the exanthemata, but very frequently by chronic and persistent causes which produce slowly increas- ing lesions. Such harmful agents are chronic alco- holism, chronic lead-poisoning, the chronic bac- teriaemias and toxaemias which arise from oral1 sepsis, chronic throat infections and disorders of the lower parts of the digestive tract, chronic ex- haustion from overwork, excessive child-bearing and incessant worry. The detection and eradication of these deleterious factors call for a careful clinical and sociological survey. Their control prevents further destruction of the thyroid gland and may even permit of its partial regeneration.

A general plan of treatment is to give half a grain of standardised thyroid extract nightly for about two weeks, and then give a second daily dose in the mornings. A little later the extract may be given three times a day, and in the class of benign myx- oedema under discussion it is rarely necessary to in- crease the dose beyond this point. As a rule better results are attained by supplementing the thyroid extract with an adjuvant drug such .as grey powder and soda, or arsenic iodide or calcium iodide, but these drugs should never be given for long periods ' at a time. ,

All serological factors capable of increasing the defect in thp gland should then, as far as possible, be controlled, remembering that amongst these are included not only the original causes, but also chronic infections which have arisen in consequence of the subthyroidic state.

Finally, the minimum dose of thyroid extract necessary to maintain the efficiency which has been established should be ascertained by careful trial and tliis dose prescribed for life-long usage'.

Examinations from time to time are advisable for the detection of any tendency to relapse, induced by uncontrolled factors which have increased the lesion in the gland and called for renewed efforts and an increased dosage.

ncbi.nlm.nih.gov/pmc/articl...

35 Replies
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What an interesting post, thank you, Helvella. If only doctors paid attention to all the vile symptoms as indicated above, and ignored the wretched TSH, many of us might be feeling a whole lot better. Happy new year, by the way :-)

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Fascinating read, thanks for posting helvella. It is a pity this level of knowledge of hypothyroidism and its dire social consequences is not common place anymore in our current medical profession.

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Fascinating, thank you for posting this!

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Wow!

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To think they used to know all this, and now they know nothing! And I've always said that vegetarianism was a hypo symptom!

Happy New Year. :)

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Funny, when I got together with my other half, a vegetarian, it didn't bother me to not eat meat, in fact I embraced it as I lost appetite for it. I couldn't be bothered with the faff of cooking meat or indeed separate meals (think lack of energy starting to manifest itself). Now it makes sense!

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Yup, much the same thing happened to me. :)

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Thank You for another great and eye opening article . My question to you is have we *learned anything* from the past ???

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Very interesting, thanks for posting

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Wouldn't it be wonderful if every Medical School & Endocrinology Dept. received a copy ...

Thank you for posting and confirming the points discussed on this forum are thyroid related after all - even when the Docs say NOT 😊

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Very interesting read, helvella. Thanks for posting. A couple of comments :

In severe cases the patient should be kept in bed for a short period when treatment is first started so that much of the strain being removed the dose can be increased more quickly.

Can anyone imagine a modern doctor telling a newly-diagnosed thyroid patient to stay in bed when first treated? It would never happen - they would probably be told their worsening symptoms were all in their heads.

As a rule better results are attained by supplementing the thyroid extract with an adjuvant drug such .as grey powder and soda

I tried to find out what "grey powder" is, but the only possibility I came across was powdered aluminium. If that is what grey powder is I wouldn't fancy it myself! I did check a US Pharmacopeia from 1909 that I had downloaded a few years ago, just for interest, but either the Americans called it something different or they didn't use grey powder at all. The search function in my PDF reader didn't work well with such an old document either.

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Possibly worse, a mixture of powdered mercury and chalk given as a purgative

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Wow! That really does sound awful. But I would have thought the poisonous nature of mercury was known about by 1919...

art-bin.com/art/hanson_en.html

That link above is an interesting read.

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It is and there is a reference to grey ointment for curing syphilis

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I was also curious about grey powder. Perhaps it had to do with mercury? collection.sciencemuseum.or...

merriam-webster.com/diction...

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Ah, hadn't seen Treepie's post when I wrote mine.

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Sounds like it, so my guess about aluminium was wrong.

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Well I love that you have a US Pharmacopeia from 1909 to hand. :)

I thought the reference to class was also interesting:

"The disease attains a maximum incidence amongst the middle-aged women of the so-called working- classes, and,is the cause of much misery in the homes of the poor. The afflicted one can only dis- charge her responsibilities imperfectly and is unable to maintain the efficiency, of her household."

Presumably the more affluent lead less physically taxing lives and were able to take the recommended rest. I can't imagine being hypo and meeting the physical demands of the working poor in the early 20th-century. And I say that as one who can only discharge (my) responsibilities imperfectly. ;)

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I don't have the actual book! :D I have a PDF file version. I couldn't find the 1909 PDF any more, but I have found the 1912 version, if you are interested :

ia801601.us.archive.org/4/i...

It comes in other formats too, linked here :

archive.org/details/physici...

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Thank you :)

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WOW!!!

I am amazed! How can so much knowledge have been lost as time has gone by? We have gone backwards! I bet a handful of GPs would understand this paper, let alone know how to go about treatment. This is so brief yet comprehensive, not only about the hypothyroid condition itself, but its comorbidities and clinical red herrings following treatment!

Thanks so much for posting!!

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Thank you for this most revealing paper. Wow.. it could inform many/most of today’s meds!

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Thanks helvella! Maybe I’ll print it off and share it with my GP who constantly tells me that the symptoms of hypothyroidism I suffer aren’t connected to it at all... (implying that it must be me and I’m a bit mad!) 🤸🏿‍♀️

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You will probably be told that the symptoms a century ago were different... :-)

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Cynical laugh from me....

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Thank you for a for posting such an interesting item.

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Yes, thank you indeed helvella for posting. I often say to 'them', when up against fantasy land ideas, that smart, committed, dedicated pioneers discovered so much about the thyroid in the late 1880's. Further, how even the inventor of the TSH and thyroid tests [+the UK translator] do not much rate them, (certainly not after initial diagnosis), etc, etc has been ignored out of hand. It all falls on cloth ears - pretty much everything other than Levo + standard tests at the expense of any/everything else. In v recent times, someone was told at a Thyroid Conference that they only "Took T3 for the high"... this was from a Prof. of Endocrinology!

BUT, wait for it, even though thyroid extract appears to have been used earlier than the amazing example below - in my own home town, my university - take a look at what was said then... reported in the BMJ in 1891:

George Murray and sheep’s thyroid

Undeterred, Murray obtained fresh sheep’s thyroid from a slaughterhouse and described carefully his method of preparing and administering the extract. Beginning on 13 April 1891, he injected a 46-year-old woman with most of the characteristic features of myxoedema, with 1.5ml of thyroid extract subcutaneously, twice weekly (one thyroid lobe’s worth) (Murray 1891a). After 3 months his patient was dramatically better, even though (for reasons he did not explain) her treatment had been discontinuous, just 2½ thyroid glands’ – 5 lobes’ – worth of injections having been given. This led Murray to consider that injections every 2-3 weeks would suffice to maintain improvement. Horsley urged him to publish ‘at once’ (Paget 1919), probably because he was aware that others were on the verge of doing the same experiment. Indeed, the 10 October 1891 issue of the BMJ containing Murray’s report also contains a brief report by Fenwick on the diuretic effect of a hypodermic injection of thyroid extract in a case of myxoedema, but Fenwick considered that the primary pathology lay in the kidneys (Fenwick 1891).

Although the BMJ gave no special placement to Murray’s initial paper, a follow-up report published the following August, which included three other treated cases, occupied pride of place on page 1, under proceedings of the 60th annual meeting of the British Medical Association held the previous month (Murray 1892). It included photographs before and after treatment and a temperature chart showing an increase in temperature within days of starting treatment. The particular importance of this second paper lies in the fact that cases 3 and 4, while also showing marked improvement, died suddenly from ‘cardiac failure’ (probably myocardial infarction). Murray writes: ‘[these deaths] show that patients with weak or degenerated hearts may die suddenly after the improvement has taken place, from cardiac failure after exertion to which they have for long been unaccustomed’. This was a telling early alert for the need for caution. Other cases were presented at that BMA meeting, including two who failed to respond to thyroid injections (British Medical Journal 1892). Horsley, who was at the meeting, expressed the hope that cases of non-response would be recorded and that ‘these might be as fully published as the successful cases’, an early plea against publication bias! Years later, Murray learned that the lack of success in these two cases had been because thymus, not thyroid, had been supplied by the butcher! (Murray 1920).

The history of 'The Thyroid' has indeed a rich history... see link. For many of us to be left in the parlous state that we are, in this 21st C, is - and I continue to maintain - scandalous.

jameslindlibrary.org/articl...

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And in 1892 it had reached the patient of one alert and seemingly caring doctor in the farthest reaches of the UK:

healthunlocked.com/thyroidu...

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Thank you so much for that, helvella - just more to the grist. Fascinating!

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Thanks Rod for these most interesting articles.

Doctor David Thompson must have been an exceptional person and doctor. This was long before the NHS and most poor people could not afford to see a doctor - most death certificates in Ireland at this time were recorded as "no medical attendant". It is amazing that he went to so much trouble to do a cataract operation for an an old blind beggar woman and to help the poor woman with advanced myxoedema who was dying.

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Not, they said, that

anything could be done, because others of the family had died in exactly the same way. He went in to see her and found that she had advanced myxoedema.

The author of the article in the Ulster Medical Journal in 1992 casts doubt on the form of familial myxoedema that had afflicted the kinship. Doctors are still not likely to recognise the condition but It looks like they had thyroid hormone resistance.

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Thanks for posting helvella,

Very interesting and it just goes to confirm that symptoms were known and acknowledged by doctors and patients began on NDT.

The 'modern method' relies upon the doctor and endocrinologists only looking at a blood test result alone, whilst their ignorance of clinical symptoms is a faux pas.

The majority of patients on this forum are given 'other' prescriptions for the disabling symptoms if levo doesn't improve their health and lose their livelihoods and maybe even their homes. Who cares about this modern day fiasco for many - mainly women.

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Thanks for posting Helvella. It was a good reminder of how far I have come on the road to recovery thanks to you and many others on this website sharing their knowledge and experiences. I am about to order some T3 from Germany with a private scrip from my GP. Here it would have cost £1000 for the scrip to be dispensed! Not sure of the cost from Germany as yet. Wonder when MHRA and Parliament, Lords etc will come out of their hidey holes and deal with this appalling situation that is denying so many people the chance of a better life. Let's hope we will have some good news very soon in this New Year. I wish everyone a healthier 2019

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Wow back in those days they actually LOOKED at the patients for symptoms? What were they thinking? Didn't they know that TSH reading would give them all the answers they needed? Is it normal that this makes me nostalgic? Not that I lived in 1919 but still...The article reminds me of Broda Barnes book. He must be turning in his grave over the current treatment.

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Thank you so much for sharing this brilliant article. Happy New Year!

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