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Written by Dr Bjørn J Øverbye 2017
Original language: Norwegian
Until 1958, there was only one therapy option: Natural dessicated thyroid called NDT. Until 1970 there were no good commercial lab tests for hormones.
The medical profession was a practical craft on the patient's terms. But during the period 1958-1975 we had a completely new situation, which was experienced as it is now for more and more patients: Why do I have symptoms of hypothyroidism when the laboratory tests are normal?
Brief history lesson
Below is the timeline of some relevant data for this article. Data on testing is taken from Dr. Midgley's eminent lecture in 2014.
1810-1893: Goiter was treated with iodine.
1888: A treatise on hypothyroidism was prepared, based on reports from 64 surgeons across Europe, about the deterioration of patients' health when the thyroid gland is removed.
1893-1958: Natural thyroid in tablet form (later called NDT) which is an extract from a gland in pigs, cattle or sheep was used in therapy.
1950: The medicine Natrium Thyroid came on the market, but was very unstable and unpredictable, and doctors continued with NDT.
1958: The first usable synthetic thyroxine (T4), Synthyroid hit the market. (Knoll Pharma, later acquired by Abbot)
On the website for Synthyroid there is an error. It says that synthetic thyroid has been available since 1927. This is the year when synthetic thyroxine was first made in a laboratory, but it was not until 1950 that sodium thyroxine was made for sale. The first commercial product was of poor quality. Only with Synthyroid did you get a better product. NDT is slowly being phased out during this period, but is still used by many doctors to this day. NDT is now experiencing a renaissance among patients who do not have the desired/expected improvement from synthetic hormone.
1960: The first commercial tests to measure thyroxine became available. Until this year, clinical assessments and patients' symptoms were dominant in diagnoses of various degrees of hypothyroidism.
1963-1965: The first effective tests to calculate free thyroxine (FT4) arrived. Unfortunately, the first methods for calculating FT4 were not very good and it would take many years before they became reliable.
1975: The first commercial tests for TSH and T3 hit the market. A few years later, tests for FT3 come.
The period 1958–1975 was therefore two decades that would change everything that doctors believed about metabolism and which is brilliantly described by Broda Barnes in his historical and analytical book: "Hypothyroidism: The Unsuspected Illness".
In this book, Barnes talks about a problem we still struggle with and which can be described very simply:
Back when doctors trusted the patient
Until 1975, most doctors relied on clinical assessment of patients. This included a careful symptom analysis and various clinical tests that all doctors could do in their office. When this information was compared, the doctor then made a decision and prescribed either NDT or synthetic thyroxine.
Systems analysis: What doctors should learn from computer engineers
This way of working is similar to that found in physics, chemistry and not least the engineering profession. The method is called system analysis and was developed by a number of mathematicians and physicists and is the basis of cybernetics; computer mathematics.
The term system can be anything from a machine, to a plant, an animal or an ecosystem.
To describe the system, you need system parameters: measurable variables that are typical of the system.
You can then monitor the system by constantly taking measurements of the variable units and studying changes and seeing how these change when the system is exposed to various external influences.
This may seem a bit theoretical, but immediately becomes practical when it comes to working with human health. To understand what happened when the thyroid gland failed, the old doctors used a series of observations and measurements which together are variables that describe the "system", i.e. your total mental and physical performance, and physically measurable changes in the body's blood pressure, reflexes and blood values.
But again, it wasn't until the late 1960s that you could measure thyroxine in the blood in a reliable way and only in 1975 you could measure TSH and T3.
This means that for 80 years doctors were without chemical analyzes they could rely on. Metabolism was and became a craft: System description, giving hormones and observing changes, without having measurements of hormones in the blood to navigate by.
And what did you learn? According to historical sources, people got better. And more people benefited from therapy than we see today when doctors only navigate by blood values (Barnes 1976).
A new generation takes an interest in lab chemistry
But why did it happen that younger doctors began to overlook clinical work if we assume the standard used by older doctors? It all depends on what we call beliefs about metabolism.
When doctors could measure the value of thyroid hormones, it was believed that they had a measure of what the cells would receive and that the clinical result would therefore be predictable. This was certainly true for some patients and gave the doctors a useful tool, but it was not true for all. Why?
Professor Karl Popper's 100 white swans
The skeptics and doctors Petr Skrabanek and James McCormick have told this in an ironic and entertaining way in the book "Medical Mistakes and Follies" by, among other things, referring to the philosopher of science Karl Popper.
Karl Popper often argued that the medical profession did not meet the criteria of an exact science because it was too approximate.
To illustrate one of science's major problems that Petr Skrabanek and James McCormick believe is highly relevant to doctors' understanding of the world, they draw on Popper's equation called the "hundred white swans' fallacy". A scientist observes swans and after 100 observations finds that they are all white. He writes a thesis in which he claims that "all swans are white". But one day he observes a black swan (which does exist) and the whole claim has to be rejected and replaced with: "Swans can be black or white". He must further specify this more carefully; "More white swans than black swans have been observed".
The black swans of metabolic medicine
The same applied to metabolic medicine in the critical years (1958-1975) when younger doctors decided to discard the experiences of the previous two generations.
It was observed that in most patients, laboratory tests were a simple and straightforward way to see who benefited from synthetic hormone. This meant that more and more doctors began to disregard system description, i.e. clinical skills and overlook that NDT could be used where synthetic hormone did not reach its goals.
In other words, they had made the mistake Karl Popper warned against. They had observed 100 white swans, but began to overlook that around them a number of black swans also began to appear; Patients with clinically manifested hypothyroidism defined according to the old method which is as follows: Those who meet a number of specific criteria to be able to receive thyroid hormones and get better from enough hormone over time.
The black swans were those who actually qualified for treatment, but had "normal blood values".
Why we should treat
Shouldn't that "ring some bells"? Yes, with the good clinicians, warning bells rang. But according to Broda Barnes and those who thought like him, it became fashionable among younger doctors to disregard the time-consuming part of the medical profession; to make thorough examinations and listen to the sick. Instead, many began to look at a lab sheet and conclude then and there that the patient had hypothyroidism or not.
Over two decades, it was forgotten that metabolism means manifestations of failing energy production to simply mean "a certain amount of thyroid hormone", which after all is just one of several hormones and chemical conditions that regulate energy production in the body. And many of the other conditions affect the effect of thyroid hormones, so the values of thyroid hormones measured in the blood are no longer enough to maintain energy production in the cells. (Øverbye 2007)
The doctors change their belief system
These black swans were created by a change in doctors' belief systems. According to the older doctors, the younger ones began to think convenience over solid craftsmanship. And the black swans of metabolic medicine kept increasing, but they got to sail their own sea. And where did they sail to?
According to Broda Barnes' book, the many misunderstood and untreated metabolic diseases entered psychiatry, many developed heart disease, many suffered arthritis, weight problems, states of exhaustion. When John C Lowe's work became known, it became clear that a growing wave of fibromyalgia sufferers was also among the many black swans.
The problems began to pile up, not to the benefit of the sick. But not without a certain benefit for the pharmaceutical industry. During this period, the industry began to develop ever-new symptom-relieving drugs that could provide some relief, where the right dose of thyroid hormone in the old days offered full or partial healing.
Hypothyroidism into oblivion?
By the end of the critical years, doctors' understanding had been turned upside down. Clinical work no longer became so interesting for the younger generation of doctors. Lab values began to dominate. Quick solutions became the tune of the time and doctors could take more and more consultations per day and "treat" more patients, and refer to good craftsmanship by pointing out that the lab values had become normal after all.
Some improved, but a large number of patients did not experience the claimed improvement. There were simply too many black swans in the doctors' small lake, and when fewer and fewer of the black swans gave justice, it was also not noted in journals and published in journals that these were not clinically investigated and had clear measurable signs of energy failure.
Many called this development progress.
But Barnes wrote: "Many began to swear to lab tests, but many of us were only sworn (were cursed)"
Copyright Bjørn J Øverbye 2017
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