First recorded accounts of the clinical features of adult hypothyroidism, 1873

Queen Victoria (1819-1901)

Queen Victoria’s court physician Sir William Withey Gull is credited as the first person to record the clinical features of hypothyroidism in adults in his 1873 seminal paper.[1]

Gull attributed these features to atrophy of the thyroid gland.[2] In October 1873, Gull presented before the Clinical Society of London five cases of what he described as “a cretinoid state supervening in adult life in women”. 

Credit: Wellcome Collection

Gull’s paper included the symptoms and changed appearance of a Miss B:[3]

“After the cessation of the catamenial period, became insensibly more and more languid, with general increase of bulk … Her face altering from oval to round … the tongue broad and thick, voice guttural, and the pronunciation as if the tongue were too large for the mouth (cretinoid) … In the cretinoid condition in adults which I have seen, the thyroid was not enlarged … There had been a dis-tinct change in the mental state. The mind, which had previously been active and inquisitive, assumed a gentle, placid indifference, corresponding to the muscular languor, but the intellect was unim-paired … The change in the skin is remarkable. The texture being peculiarly smooth and fine, and the complexion fair, at a first has- ty glance there might be supposed to be a general slight oedema of it … The beautiful delicate rose-purple tint on the cheek is en- tirely different from what one sees in the bloated face of renal anasarca.”

Over the next years after Gull’s presentation to the Clinical Society of London, physician W.M. Ord noted five cases under his care of a similar kind, in one of which he had the opportunity to make a post-mortem examination. The medical term “hypothyroidism” did not exist at that time and it wasn’t until 1878 that Ord coined the term “myxoedema” in his paper “On Myxoedema, a term proposed to be applied to an essential condition in the “Cretinoid” Affection occasionally observed in Middle-Aged Women”.[4] What we now call “hypothyroidism” was originally named myxoedema or myxedema (myx meaning “mucus” & edema meaning “swelling” from ancient Greek).

Ord gave myxoedema its name from the “jelly-like swelling of the connective tissue, the cut surfaces yielded less fluid than their appearance would promise” which he discovered from physical, microscopic and chemical analysis of the skin. In his paper Ord described two of these cases at length. This is an excerpt from the case of a widowed 54-year old woman named H.J.:[5]

“The first signs of illness were fits of shivering during her work. These were followed by the passage of bloody urine, as she believes, on several occasions. Then her hand became “dead”, to use her own expression, when she used her needle; a great addition to her trouble, as she had to work very hard to support herself and her helpless husband. Later on she became “weak-headed”, would be stupefied by a glass of beer at luncheon, experienced a general loss of muscular power, and was always falling asleep. After that she had constant pain and weakness in the back, so that she began to stoop considerably; her speech became slow and dificult, and a gradual swelling of the skin of the whole body set in; the skin of the face, and particularly of the eyelids, becoming thick, semi-transparent, and waxy. ‘

Ord’s 1878 groundbreaking paper included the very first photo of a patient with myxoedema (“hypothyroidism”). H.B. was a patient of the Royal Medical and Chirurgical Society of London. Figure 1: Patient aged 21 in 1870 before onset of symptoms. Figure 2: Seven years later with myxoedema.[6]

Credit: The Royal Society of Medicine

While researching the history of hypothyroidism to write this article, I stumbled upon the following black and white photograph of a woman with myxoedema with the description “a swelling similar to the so-called ‘fatty tumour’ of cretinism is seen in the right supra-clavicular region. The photograph is that of a middle aged woman, seen at Leytonstone, 1885. It was taken shortly before her death.” I’ve stared at this photo so many times since first finding it thinking about how this one photograph makes so sadly obvious many of the physical symptoms of hypothyroidism.

Credit: St Bartholomew’s Hospital Archives & Museum, Wellcome Collection

Consider the clinical symptoms included in the descriptions of Miss B and 54-year-old H.J.. Also look closely at the first photo of a woman with myxedema named H.B. and this last one taken in 1885. Yes I know they were created in the 1800s, but are these symptoms familiar to you today? I will remember the last photo of the bald, swollen woman with myxedema for the rest of my life, as I know every single person that reads this article will have that image imprinted on their brain forever. The next time you hear someone say “hypothyroidism is not serious” or “you are overweight all because you eat too much” or “your enlarged neck is just fat” or “hypothyroidism is not the reason for your hair loss”, remember this photo.

References:

1. Gull, W.W. On a cretinoid state supervening in adult life in women. Transactions of the Clinical Society of London. 1874. 7:180-185.

2. Niedzielski, A., et al. Sir William Withey Gull (1816-1890). Journal of Neurology. February 2017;264(2):419-420.

3. Pearce, J.M.S. Wir William Witten Gull (1816-1890). Eur Neurol. 2006;55:53-56.

4. Ord, W.M. On myxoedema, a term proposed to be applied to an essential condition in the “cretinoid” affection occasionally observed in middle-aged women. Medico-Chirurgical Transactions. 1878. 61:57-74.

5. Doyle, L. Myxoedema: some early reports and contributions by British authors, 1873-1898. Journal of the Royal Society of Medicine. February 1991. 84: 103-106.

6. Slater, S. The discovery of thyroid replacement therapy. Part 1: In the beginning. Journal of the Royal Society of Medicine. 1 January 2011;104(1):15-18.

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