Something like ‘inadequate thyroid-hormone-mediated regulation of metabolism’.
That’s wonderfully vague. I bet I can diagnose half the population with having “inadequate” regulation.
A definition should allow easy classification of observed phenomena into two classes: “fits the definition” and “doesn’t fit the definition”. This one… struggles.
we might actually need to understand how it works to treat
And this I can probably diagnose 90% of the population with? See above.
The meta issue is whether you want to medicalise deviations from the theoretical optimum. On the one hand, sure, it’s nice to move closer to the optimum, on the other hand this means that no one is “healthy”, everyone is “sick” and under care of doctors.
Well, ‘hypothyroidism’ was a very difficult and polymorphic badger in its day. But a thing that is difficult to detect can still be a thing. Consider neutrinos and gravity waves and unicornes, which no man nowadays doubts of.
And as for ‘medicalise deviations from the theoretical optimum’, most chronic fatigue people are already bothering their poor doctors incessantly, and being given (with the best will in the world) a selection of nasty things that mildly alleviate some of their symptoms. CFS is a horrible thing. As Hitler says in the film Downfall:
“‘Chronic Fatigue Syndrome’ ? they might as well call Leprosy : ‘Chronic Dandruff Syndrome’”.
Well, ‘hypothyroidism’ was a very difficult and polymorphic badger in its day.
Isn’t it still “its day”?
Think of it this way. There is a set of people with some clinical symptoms which look maybe-possibly like hypothyroidism. There is a another set of people with abnormal TSH. These sets partially intersect and form three subsets. Subset one is the intersection: people with both clinical symptoms and abnormal TSH. They are a clear case and there are no problems here. Subset two is abnormal TSH and absence of clinical symptoms. We interpret that as thyroid gland falling apart and expect clinical symptoms to appear in the near future. We are not concerned with people either.
Subset three is the one you are interested in: people with normal TSH and clinical symptoms. What about them? Well, as you mention diagnosing hypothyroidism solely on the basis of clinical symptoms is difficult. So in this subset some but not all people will have a thyroid malfunction, and some will have other problems, maybe instead or maybe in addition to thyroid issues.
By the way, the people who you insist on calling “fat, tired, and with dry skin” are in subset three. They exhibit clinical symptoms of hypothyroidism.
Your suggestion is that we give some dessicated thyroid to subset three and see if it helps. Well, it’s pretty clear that it will help some people and will not help other people (for example, those fat and tired ones). However that is true of many medical interventions.
For example, there are probably males in subset three with low testosterone. So giving testosterone to subset three males will also help some people and not help others. There also probably people with low-grade systemic infections in there. Giving broad-spectrum antibiotics to subset three might well help some people and not help others. There are likely people with autoimmune disorders there...
Basically, if you have little idea about what’s wrong, trying a variety of drugs hoping for a lucky hit is not necessarily a horrible strategy (depends on the side-effects of the drugs and the consequences of doing nothing), but it’s not much advancement from the good old times.
Back in the good old days, Charles II, age 53, had a fit one Sunday evening, while fondling two of his mistresses.
Monday they bled him (cupping and scarifying) of eight ounces of blood. Followed by an antimony emetic, vitriol in peony water, purgative pills, and a clyster. Followed by another clyster after two hours. Then syrup of blackthorn, more antimony, and rock salt. Next, more laxatives, white hellebore root up the nostrils. Powdered cowslip flowers. More purgatives. Then Spanish Fly. They shaved his head and stuck blistering plasters all over it, plastered the soles of his feet with tar and pigeon-dung, then said good-night.
Tuesday. ten more ounces of blood, a gargle of elm in syrup of mallow, and a julep of black cherry, peony, crushed pearls, and white sugar candy.
Wednesday. Things looked good:: only senna pods infused in spring water, along with white wine and nutmeg.
Thursday. More fits. They gave him a spirituous draft made from the skull of a man who had died a violent death. Peruvian bark, repeatedly, interspersed with more human skull. Didn’t work.
Friday. The king was worse. He tells them not to let poor Nelly starve. They try the Oriental Bezoar Stone, and more bleeding. Dies at noon.
P.S. Note the awe-inspiring lack of smugness with which I present:
IMPAIRED ACTION OF THYROID HORMONE ASSOCIATED WITH SMOKING IN WOMEN WITH HYPOTHYROIDISM
BEAT MÜLLER , M.D., HENRYK ZULEWSKI , M.D., PETER HUBER , P H .D., JOHN G. RATCLIFFE , M.D., AND JEAN -JACQUES STAUB , M.D.
I bloody said it would turn out to be the reason smoking’s bad for you, didn’t I? And at the same time it’s evidence that acquired hormone resistance exists, and this one fingers an environmental cause.
Opinions are divided. There’s me and some dead guys, and everyone else. Everyone else thinks it’s a solved problem.
By the way, the people who you insist on calling “fat, tired, and with dry skin” are in subset three. They exhibit clinical symptoms of hypothyroidism.
They absolutely do! Back in the day, they would have been referred to endocrinologists on suspicion of hypothyroidism, who would have (if they were very sophisticated and modern endocrinologists) used Billewicz’ test to sort them into definite, definitely not, and ‘therapeutic trial’ groups. His test didn’t rate these three symptoms, or lethargy or stupidity, because most everyone he saw had them, so he would look at all their other symptoms to make the diagnosis, looking for things like slow reflexes that are characteristic of hypothyroidism, and weight them to get a score. It really is a very careful piece of work, that test.
He would treat the ‘definites’ without further ado, send the ‘definitely nots’ off to people who were into diabetes etc, and be careful with the rest. Including all sorts of unreliable lab tests and therapeutic trials.
Luckily the therapeutic trials are not difficult to do, because with desiccated thyroid/T3 you seem to get either get a fairly rapid improvement, or you get hyper symptoms. (you might get both of course, in which case dose probably too high)
Other popular ways of trying to work it out involved cholesterol and basal metabolic rate.
Broda Barnes thought waking armpit temperature beat all this and just handed it out to anyone who woke up cold.
And the fact that it has been sprayed around at random for a hundred years without anyone having a word to say against it implies that it’s pretty damned safe. If you give yourself a massive overdose, then sure, you can probably give yourself a heart attack, but you’d need to be way way more criminally careless than I can imagine any (modern) doctor being.
Osteoporosis and atrial fibrillation (both ghastly things) are associated with low TSH, so it’s doubtless not a good idea to induce hyperthyroidism in people. And I think we should be careful not do that.
Barnes might have been deluded. I certainly started off thinking that he was, but one thing he was into was records and statistics. He thought his patients healthier than the general population. Including low rates of heart trouble. Which is just bizarre if what he was seeing was today’s CFS etc population, who seem to be really ill and then go on to be even more ill. Unless his treatments actually helped.
Hell, let’s do all four! If there’s a subset of fat tired stupid lethargic CFS patients with dry skin and high Billewicz scores, low basal metabolic rates, high cholesterol, and low waking temperatures all at the same time, then let’s run the Scottish trial on them and see what happens. That should be enough to break the TSH test, at which point, I imagine there will be an absolute explosion of research.
I couldn’t agree more that it’s really really important to understand mechanism. I’m into ‘explanations’ and ‘causes’. I think you are too. I get the impression that they’re a bit out of fashion in medicine.
Well, it’s pretty clear that it will help some people
Ooh, is it me and you and some dead guys now? Welcome! Sorry some of us aren’t that talkative. Damnit, that means I need another opponent. Devil’s advocate isn’t good enough. It needs to be someone who hates the idea.
Dies at noon.
Oh dear, poor Charles. The English crown was a bit of a poisoned chalice for the Stuarts wasn’t it? Still, he made it to 53 and they did call him the Merry Monarch. Anyone who dies in office of excessive mistress-related-activity hasn’t had a totally wasted life.
That’s wonderfully vague. I bet I can diagnose half the population with having “inadequate” regulation.
A definition should allow easy classification of observed phenomena into two classes: “fits the definition” and “doesn’t fit the definition”. This one… struggles.
Yes, I have such a suspicion, too.
And this I can probably diagnose 90% of the population with? See above.
The meta issue is whether you want to medicalise deviations from the theoretical optimum. On the one hand, sure, it’s nice to move closer to the optimum, on the other hand this means that no one is “healthy”, everyone is “sick” and under care of doctors.
Well, ‘hypothyroidism’ was a very difficult and polymorphic badger in its day. But a thing that is difficult to detect can still be a thing. Consider neutrinos and gravity waves and unicornes, which no man nowadays doubts of.
And as for ‘medicalise deviations from the theoretical optimum’, most chronic fatigue people are already bothering their poor doctors incessantly, and being given (with the best will in the world) a selection of nasty things that mildly alleviate some of their symptoms. CFS is a horrible thing. As Hitler says in the film Downfall:
“‘Chronic Fatigue Syndrome’ ? they might as well call Leprosy : ‘Chronic Dandruff Syndrome’”.
Isn’t it still “its day”?
Think of it this way. There is a set of people with some clinical symptoms which look maybe-possibly like hypothyroidism. There is a another set of people with abnormal TSH. These sets partially intersect and form three subsets. Subset one is the intersection: people with both clinical symptoms and abnormal TSH. They are a clear case and there are no problems here. Subset two is abnormal TSH and absence of clinical symptoms. We interpret that as thyroid gland falling apart and expect clinical symptoms to appear in the near future. We are not concerned with people either.
Subset three is the one you are interested in: people with normal TSH and clinical symptoms. What about them? Well, as you mention diagnosing hypothyroidism solely on the basis of clinical symptoms is difficult. So in this subset some but not all people will have a thyroid malfunction, and some will have other problems, maybe instead or maybe in addition to thyroid issues.
By the way, the people who you insist on calling “fat, tired, and with dry skin” are in subset three. They exhibit clinical symptoms of hypothyroidism.
Your suggestion is that we give some dessicated thyroid to subset three and see if it helps. Well, it’s pretty clear that it will help some people and will not help other people (for example, those fat and tired ones). However that is true of many medical interventions.
For example, there are probably males in subset three with low testosterone. So giving testosterone to subset three males will also help some people and not help others. There also probably people with low-grade systemic infections in there. Giving broad-spectrum antibiotics to subset three might well help some people and not help others. There are likely people with autoimmune disorders there...
Basically, if you have little idea about what’s wrong, trying a variety of drugs hoping for a lucky hit is not necessarily a horrible strategy (depends on the side-effects of the drugs and the consequences of doing nothing), but it’s not much advancement from the good old times.
Let me quote from West Hunter:
P.S. Note the awe-inspiring lack of smugness with which I present:
IMPAIRED ACTION OF THYROID HORMONE ASSOCIATED WITH SMOKING IN WOMEN WITH HYPOTHYROIDISM
BEAT MÜLLER , M.D., HENRYK ZULEWSKI , M.D., PETER HUBER , P H .D., JOHN G. RATCLIFFE , M.D., AND JEAN -JACQUES STAUB , M.D.
I bloody said it would turn out to be the reason smoking’s bad for you, didn’t I? And at the same time it’s evidence that acquired hormone resistance exists, and this one fingers an environmental cause.
Opinions are divided. There’s me and some dead guys, and everyone else. Everyone else thinks it’s a solved problem.
They absolutely do! Back in the day, they would have been referred to endocrinologists on suspicion of hypothyroidism, who would have (if they were very sophisticated and modern endocrinologists) used Billewicz’ test to sort them into definite, definitely not, and ‘therapeutic trial’ groups. His test didn’t rate these three symptoms, or lethargy or stupidity, because most everyone he saw had them, so he would look at all their other symptoms to make the diagnosis, looking for things like slow reflexes that are characteristic of hypothyroidism, and weight them to get a score. It really is a very careful piece of work, that test.
He would treat the ‘definites’ without further ado, send the ‘definitely nots’ off to people who were into diabetes etc, and be careful with the rest. Including all sorts of unreliable lab tests and therapeutic trials.
Luckily the therapeutic trials are not difficult to do, because with desiccated thyroid/T3 you seem to get either get a fairly rapid improvement, or you get hyper symptoms. (you might get both of course, in which case dose probably too high)
Other popular ways of trying to work it out involved cholesterol and basal metabolic rate.
Broda Barnes thought waking armpit temperature beat all this and just handed it out to anyone who woke up cold.
And the fact that it has been sprayed around at random for a hundred years without anyone having a word to say against it implies that it’s pretty damned safe. If you give yourself a massive overdose, then sure, you can probably give yourself a heart attack, but you’d need to be way way more criminally careless than I can imagine any (modern) doctor being.
Osteoporosis and atrial fibrillation (both ghastly things) are associated with low TSH, so it’s doubtless not a good idea to induce hyperthyroidism in people. And I think we should be careful not do that.
Barnes might have been deluded. I certainly started off thinking that he was, but one thing he was into was records and statistics. He thought his patients healthier than the general population. Including low rates of heart trouble. Which is just bizarre if what he was seeing was today’s CFS etc population, who seem to be really ill and then go on to be even more ill. Unless his treatments actually helped.
Hell, let’s do all four! If there’s a subset of fat tired stupid lethargic CFS patients with dry skin and high Billewicz scores, low basal metabolic rates, high cholesterol, and low waking temperatures all at the same time, then let’s run the Scottish trial on them and see what happens. That should be enough to break the TSH test, at which point, I imagine there will be an absolute explosion of research.
I couldn’t agree more that it’s really really important to understand mechanism. I’m into ‘explanations’ and ‘causes’. I think you are too. I get the impression that they’re a bit out of fashion in medicine.
Ooh, is it me and you and some dead guys now? Welcome! Sorry some of us aren’t that talkative. Damnit, that means I need another opponent. Devil’s advocate isn’t good enough. It needs to be someone who hates the idea.
Oh dear, poor Charles. The English crown was a bit of a poisoned chalice for the Stuarts wasn’t it? Still, he made it to 53 and they did call him the Merry Monarch. Anyone who dies in office of excessive mistress-related-activity hasn’t had a totally wasted life.