Indian Journal of Endocrinology and Metabolism

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Thyroidology over the ages

Asfandyar Khan Niazi, Sanjay Kalra, [...], and Aliya Islam
Additional article information

Abstract
Thyroidolody, the study of the thyroid gland, is considered to be a relatively new field of
endocrinology. However, references to the thyroid gland and its diseases can be seen in the
literature of ancient Greek, Indian and Egyptian medicine. Goiter has always been a disease of
immense interest of the general population due to its widespread prevalence. It is one of the most
common medical problems portrayed in ancient paintings. Owing to the lack of awareness and poor
nutritious habits of the people in that era, diseases such as iodine deficiency goiter were common.
Physicians, healers and philosophers had been attempting time and again until the 19th century to
come up with explanations of the thyroid gland and provide a reasonable basis of its diseases.
Although the discovery of thyroid gland, its structure, function and diseases has been accredited to
modern scientists who presented their work mostly in the 19th and 20th century, it is of significance
to note that much of what we discovered in the 19th and 20th century had already been known
centuries ago. This review attempts to explain the knowledge of thyroid gland, its function and
diseases as held by the people in the previous centuries; and how this knowledge evolved over the
years to become what it is today.
Keywords: Goiter, history, thyroidology

ANCIENT-EGYPTIAN, CHINESE, AYURVEDIC, GREEK

References to goiter it have been seen in texts dating back to 2700 BC.[1] This is probably because
of its extensive prevalence in the times when its exact etiology and possible preventive measures
were unknown. It is said that the Chinese were aware of the enlarged thyroids from around 2700
BC. The Chinese physician Tshui Chin-thi, in 85 AD, differentiated between solid (malignant)
tumors of the neck which were incurable and movable (benign) tumors which were curable.[2]
Whether or not, he was aware of the organ which was responsible for these enlargements is
unknown.
In the Indian Ayurvedic medicine, which originated in the 1400 BC, goiters are called galaganda
and are described in detail.[2] It classifies thyroid diseases into three types; Vataja
(hyperthyroidism), Kaphaja (hypothyroidism) and Medaja (thyroidal cyst). The symptoms of these
diseases are described in detail in the Ayurvedic medicine. They correlate with those described by
the modern medicine.
Hypothyroidism in Ayurveda is well described by a well-known Ayurvedic physician Charaka. He
said that it may be prevented by ingestion of adequate quantities of milk, rice, barley, green grams,
sugarcane juice and cucumber. He discouraged people from eating sour foods as they may
aggravate the thyroid diseases. Kaanchanara (Bauhinia veriegata) and Bladderwrack (Fucus
Vesiculosus) are prescribed for all sorts of thyroid problems. Guggulu (Commiphora mukul) is used
to increase the basal metabolic rate in hypothyroid patients. Punarnava (boerhaavia diffusa Linn) is
an excellent diuretic which is prescribed to reduce the swelling in thyroid diseases.
For the hyperthyroid patient, Bugleweed [Lycopus virginicus], gypsywort [Lycopus europaeus],
water horehound [Lycopus lucidus or Lycopus americanus], gromwell [Lithospermum ruderale] and
European gromwell [Lithospermum officinale] are used. Ancient Indian physicians also recognized
pitting and non-pitting edema, and facial and pedal edema. However, instead of hypothyroidism
leading to goiter, they were of the view that edema caused goiter.[3]
One of the earliest recorded accounts of the thyroid gland in Greek medicine is by Hippocrates and
Plato. They described the thyroid gland with salivary and thymus glands.[4] They were of the view
that these glands are spongy in constitution and are responsible for lubricating the respiratory
passageways.[5] Galen who was a prominent physician, surgeon and philosopher of Greek ethnicity
gave a different opinion. He argued that the spongy nature of this gland was better suited for the
purpose of absorption rather than secretion.[5]
Galen supported his argument by saying that secretion of the gland was prevented from entering the
respiratory passageways. He labeled the thyroid gland as an organ of connection and buffer between
the heart and brain. He made a significant breakthrough in the anatomy of the third ventricle during
the 2nd century.[6] He reported that the pituitary gland is located in the sella turcica and is
surrounded by a vascular network. Galen suggested that the heat of the body travels through these
vascular networks and is converted to nerve impulses which affected the substance of the neck, or
the thyroid gland.
Hippocrates and Gaius Plinius Secundus of Pliny regarded goiter to occur solely because of
drinking of snow-water.[2,7,8] Initially goiter was not thought to be an enlargement of the thyroid,
but rather it was believed to be a herniation of larynx. Pedanius Dioscorides, a 1st century AD
Greek physician, and Galen during the 2nd century AD supported this view.

Leonardo da Vinci drew the thyroid gland in 1511 during his anatomical studies. Even though he
was aware of its exact anatomical structure, he could not understand its function and assumed that it
was created to fill the gap between muscles of the neck and to hold the trachea away from the
sternum.[7]
Chinese physicians used burnt sponges and seaweeds for the treatment of goiter as early as the 1600
BC.[9] However, they were unaware of the cause of this disease. The medical treatment for goiter
was also described by Dioscorides in the 1st century AD.[10] Except for shells from marine
organisms, iodine-rich substances were not mentioned. Several plants and animals, even lizards and
dog excrements, were used for the treatment of goiter.
The substances used by the Byzantine physicians to treat goiter were mostly calcium, copper, sulfur
and ammonium salts. Roger Frugardi, in the 12th century, wrote that goiter is treatable by drinking a
tincture made with barren walnut leaves and roots, boiled in good wine with a pinch of pepper
added.[11] An alternative pharmacological treatment used in ancient Italy was a powder obtained
from burnt and dried marine sponges.[12] This powder was rich in silica, calcium phosphate,
sodium chloride, sulfur chloride, iodine, bromine, magnesium carbonate and calcium carbonate.
Since it was rich in iodine, goiter may well have been cured.
Although Robert Graves and Carl von Basedow are credited with modern description of thyroid
related orbitopathy, history shows that older civilizations were well aware of this condition. The
description by Graves and Basedow came in the 19th century while mentions of this disease are
found in works of Aristotle and Xenophon from 5th century BC.[13]

Goiter has also been portrayed in the sculptures of the ancient Gandhara civilization. This dates
back to the 1st or 2nd century AD.[14] Controversy surrounds the matter whether the appearances
related to the God Bes of ancient Egypt and Cleopatra are related to thyroid diseases. There is no
conclusive evidence available; however, quite possibly their depictions may have been affected by
thyroid disorders.

EARLY CENTURIES-BYZANTINE, PERSIAN

The surgical treatment of goiter was mentioned in the 6th century by Aetius.[15] Aetius was of the
view that goiter was in fact a hernia of the larynx. This opinion of goiter being a laryngeal hernia
persisted for a long time. Even the modern term goiter carries a link to it. The term goiter
probably originated from the word guttur which means larynx or bronchus in Latin.[15]
Atheromatous goiters were referred to by Aetius in as early as the 6th century.[16]

Aetius was conservative in the surgical treatment of goiter and described the risks of the procedure
in detail. He noted very early that it was important to conserve vocal nerves during the operation;
failure of which may result in the loss of voice.[16] The surgical treatment was also mentioned by
Frugardi. In his surgical textbook, he instructed to use two wires bound to red hot iron to thread at
the bottom of the neck. This process was to be repeated twice a day. If unsuccessful, he advised to
use a scalpel to dig out the nodules by hand.[12]

In the 7th century, Paulus Aegineta described two forms of goiter: steatomatous goiter and
hyperplastic, hyperemic goiter.[17] One of the earliest references to the thyroid surgery may come
from the 7th century when Paulus Aegineta supposedly performed a surgery on struma.[16] But
whether or not struma carries the same meaning as goiter is uncertain.

The first reliable account of a thyroid surgery comes from the 10th century when Albucasis removed
a large goiter of a man under opium sedation.[18] In the 14th century, the French surgeon Guy de
Chaliac reported that goiter is a hereditary disease and recommended surgical treatment for it.[2]
Numerous sculptures, paintings and drawings made by the Byzantine artists depict an enlarged
thyroid gland.
The earliest paintings showing goiter date back to the 7th century.[19] Among the different
pathological conditions shown in the Byzantine paintings, goiter is the most common. Even the
saints, angels, children, the Virgin Mary and Christ were painted with enlarged thyroid glands on
several occasions. This may have been done coincidentally if the model had goiter or to depict the
general living conditions or, according to some beliefs, even for erotic purposes.

Byzantine physicians in the 8th century had recognized exophthalmos and its associated symptoms.
[15] They associated it with nervousness and changes in the mood. In their legal literature, they
mention that these people are unfit for work. Similarly Avicenna and Aljurjani, both Persian
physicians from the 12th century, describe in their books that a swollen neck is closely interrelated
with eye disease.[20] They also described that both these diseases form a single clinical entity and it
is also associated with increased appetite in which satiety is not reached even after ingestion of
great quantities of food. They considered lassitude of the extraocular muscles as the cause of this
protrusion of eyes.

17TH-19TH CENTURY
In 1656, Thomas Wharton, a famous anatomist, discovered the exact anatomical structure of the
thyroid gland, along with the other glands of the body. He explained that secretion is a gland's
primary function. He assigned specific functions to each gland. He wrote that the thyroid gland was
responsible for heating the thyroid cartilage, which is normally cold due to its superficial position,
lubricate the neck and to give rotundity and beauty to the neck.[21]
It is strange that even though Galen had already explained how it is unlikely for the thyroid to be
responsible for lubricating the neck, Wharton still followed the older belief. The gland was named
thyroid, not because of its own shape, but because it closely approximated the shield shape of the
thyroid cartilage of the larynx.
De Bordeau felt that each organ in the body gives off certain emanations which are necessary, as
well as, useful for the body.[22] He noted than goiter was common in the Western part of the
Pyrenees mountains (between France and Spain). He also observed that women had larger thyroids,
and suffered more frequently from goiter. De Bordeu was able to associate goitre with hoarseness of
voice. In 1776, von Haller of Bern (Switzerland), grouped the thyroid with the thymus and spleen,
as ductless glands which poured their special secretions into the bloodstream.[23]

Many workers in the 18th century noted the lavish blood supply of the thyroid. While some felt that
it was a vascular shunt, preventing sudden rush of blood into the brain, others though it was part of
the vocal apparatus.[24] Heister, the father of scientific surgery in Germany, called thyroid
enlargement as bronchocele or tracheocele, noted geographical variations in its occurrence, and
advised ointments or surgical removal, while warning of the chances of hemorrhage. He described
thyroidectomy in 1742.[25]
Morgagni, the founder of modern pathological anatomy,[25] described the two lobes and isthmus of
the thyroid.[26] The pyramidal lobe had been described earlier by Lalouette. Exophthalmic goiter
was described, and connected with malady of the heart and bronchocele by Caleb Hiller Parry.
[25] Even though he was unaware of the association of these three diseases, Guiseppe Flajani
successfully cured a man with exopthalmos, goiter and palpitations in 1802.[27] He compressed the
swelling in the neck of the patient with vinegar and ammonia and reported disappearance of the
swelling within four months.
Goiter due to iodine deficiency was widespread in the early days. As previously mentioned,
seaweed and shells of marine organisms were commonly used for the treatment of goiter. The 19th
century saw the discovery of iodine by the Parisians Courtois (C), element and Desormes, in 1811.
[28] The first person to use it as a remedy for goiter was Coindet of Geneva, who prescribed
hydriodate of potash or tincture of iodine successfully.[23] Toxic effects of iodine use were also
described as constitutional iodism by Rilliet of Geneva.[29]
Thomas Wilkinson King, the Father of Endocrinology, wrote the paper Observations on the
Thyroid Gland in 1836. He described thyroid colloid, and its importance.[30] His colleague, Sir
Cooper described experimental thyroidectomies in puppies in 1824.[23] Endemic goiter was
discussed by Malacarne, based on his work in the Aosta valley.[23] It was not linked with cretinism,
however, as the latter was through to be due to stagnant and overheated air in confined narrow
valleys.
The 1885 edition of Hirsch's classic pathology text states that even though goiter and cretinism have
to be reckoned among the infective diseases, iodine treatment is still recommended for this
condition.[31] Eugen Baumann, a scientist in the 19th century, was particularly interested in the
biochemistry of the thyroid gland because of the high prevalence of goiter at that time. He boiled
the thyroid glands of 1000 sheep in dilute sulfuric acid and then collected the flocculent precipitate
that was deposited. While examining this precipitate, he noticed a high level of iodine present in it.
[32] He named it iodothyrin. It was used to treat patients with goiter and showed successful
results.

Many surgeons of the 19th century also attempted (unsuccessfully) to treat thyroid disease.[23] In
spite of so much work, Muellar wrote the function of the thyroid gland is unknown in the 1835
edition of Handbook of Physiology. Others, however, had described the condition of myxoedema
and/or cretinism, in detail, and connected it with thyroid dysfunction. These included Curling in
1850, Gull in 1873, and Ord in 1871, Fagge had described the difference between sporadic and
endemic cretinism.[23] Sir Horsley, working on monkeys between 1884 and 1886, found that
thyroidectonomy led to myxoedema and cretinism.

Public health and thyoidology also blended together in the 19th century. In 1833, Boussingault
suggested salt iodization to prevent goiter. Chatin (1803-1901) proved in 1850 that fresh water
aquatic plant derived iodine could prevent endemic goiter and cretinism. He correlated these
conditions with iodine deficiency, and recommended iodine supplementation in drinking water,
using mineral water springs.[23] He demonstrated in 1835 that salt sent from goiter-free regions to
regions with endemic goiter reduced the incidence of goiter.[26]
However, it was nearly 100 years later that his vision was realized and iodine-rich salt was made
commercially available. Although this idea was scientifically correct, it was rejected by French
authorities. The first public health experiment in thyroidology was also carried out in this century,
using potassium iodine in salt, as solution, or as tablets. However, because of side effects due to the
high doses used, iodine prophylaxis was abandoned.
Much work was done on excessive function of the thyroid gland as well. The Irishman Robert
James Graves (1796-1853), described many patients with exophthalmos and goiter. von Basedow of
Merseburg (1799-1854) described the Merseburg Triad of exophthalmos, goiter and palpitations in
1840.[23] Many eponyms, descriptions and etiological theories were published related to this
disease, and the lists make interesting reading.[23] Plummer (1874-1937) was able to differentiate
between toxic adenoma of the thyroid and graves disease.[23]

20TH CENTURY
David Marine (1880-1976), also known as the Nestor of Thyroidology,[23] proved that iodine is
necessary for thyroid function in 1907. Four years later, he treated Graves disease with iodine. In
1917, he introduced goiter prevention with iodine, using a low dose of 1:100000 parts of iodine. In
1932, he described cyanide goitre due to thiocyanates found in plants of the genus Braissicaceae
(cabbage, cauliflower, turnip).[23]

Organotherapy
In 1889, Brown-Sequard suggested the use of testicular extract for the rejuvenation of elderly men.
[33] Although the use of testicular organotherapy declined, the concept of using thyroid extracts
caught hold rapidly. The first persons to use thyroid extract were Horsley and Murray. Many
skeptics voiced concern at the use of sheep's thyroid. A senior member of the Royal Society of
Medicine said it would be just as sensible to treat a case of locomotor ataxia with an emulsion of
spinal cord.[23]
Thyroid preparations were administered orally and as injectables by various workers. Thyroid
extract soon became an accepted part of current medical practice. Adolf Oswald was able to identify
thyroid colloid protein as thyreoglob.[23] Kendall was able to isolate thyroxine crystals in 1914. It
took 3 tons of porcine thyroids to obtain 33 g of pure thyroxine.[34] Improved methods of
extraction were devised, which reduced the cost of manufacture. Synthetic thyroxine was made by
Harigton and Barger in 1927.[35]
Trirodothyroxine was discovered much later in 1952 by gross and PittRivers. A major advance in
thyroidology occurred in 1956, when Roitt, Doniach, Campbell and Hudson demonstrated
autoantibodies in Hashimoto's disease.[36] This occurred 44 years after Hokaru Hashmito (1881-
1934) had described the disease as lymphoid infiltration of the thyroid.[37]

Along with developments in diagnosis, clinical thyroidology also grew in the 20th century, Charles
Mayo first used the term hyperthyroidism in 1907, and in the same year, Brissaud described thyroid
infantilism. In 1910, Kocher coined the term Jod-Basedow, and in 1931, Naffziger pioneered
orbital decompression as a treatment for exophthalmos.
Iodine therapy was used in 1911 by Marine for Graves disease, and in preoperative management of
exophthalmic goiter in 1924 by Plummer and Boothby. Radioactive iodine was used in Graves
disease, independently, in 1943, by Hertz and Roberts, as well us Leblond. Medical management
did not lag behind. In 1943, Astwood used thiourea and thiouracil in Graves disease. In 1949, the
synthess of methimazole by Jones, Kornfeld, Mc Laughlin and Anderson was witnessed, while 1951
was the year when Lawson, Rimington and Searle synthesized carbimazole, Commercial synthesis
of levothyroxine was successful on 1949.
Edward Kendall started working on isolating the pure form of thyroxine in 1910. By paying careful
attention to the hydrolysis of the gland, he was able to isolate thyroxine in a pure form in 1914.[38]
By 1917, he had isolated enough crystals of thyroxine to begin clinical trials on them. Believing it
was an oxindole, he coined the term thyroxin, which was later changed to thyroxine. Charles
Harrington prepared synthetically a compound by condensation of two molecules of diiodotyrosine
in 1927.[39] This compound was shown to have similar properties as thyroxine. This led to the
discovery of the exact structure of thyroxine.
In 1909, the Nobel Prize in Medicine or Physiology was awarded to the 68-year-old Swiss surgeon
Emil Theodor Kocher, for his work in thyroidology. He had innovated many techniques in hernia,
osteomychtis, dislocalocations, use of silk sutures, asepsis and thyroid surgery. He observed
icachexia strumipriva or postoperative hypothyroidism in his thyroidectorny patients. Till date, he
remains the only winner of the Noble Prize for work done in thyroidology (G). In 1952, Jack Gross
and Rosalind Pittrivers detected the presence of a more potent thyroid hormone while carrying out
researches on mice fed with radioactive iodine.[30] This compound differed from thyroxine in
having three iodine atoms instead of four. It was named liothyronine, which was later changed to
triiodothyronine.

CONCLUSIONS
Even though the scientists credited with the discovery of the thyroid gland and its diseases are
mostly from the 19th or 20th century, the contributions of the earlier scientists should not be
disregarded. The interests of people in the thyroid gland have always been immense because of the
widespread prevalence of its diseases. Therefore the earliest references to the gland date back to 1st
century AD. The Chinese, Egyptian, Indian, Greek and Byzantine medicines are especially rich in
their knowledge on the subject.

Footnotes
Source of Support: Nil,
Conflict of Interest: None declared.

Article information
Indian J Endocrinol Metab. 2011 Jul; 15(Suppl2): S121S126.
doi: 10.4103/2230-8210.83347
PMCID: PMC3169859
Asfandyar Khan Niazi, Sanjay Kalra,1 Awais Irfan, and Aliya Islam2
Shifa College of Medicine, Islamabad, Pakistan
1Bharti Hospital and BRIDE, Karnal, Haryana, India
2International Medical College, Abottabad, Pakistan
Corresponding Author: Mr. Asfandyar Khan Niazi, Shifa College of Medicine, H-8/4, Pitras
Bukhari Road, Islamabad, Pakistan. E-mail: moc.liamg@29dnafsa
Copyright : Indian Journal of Endocrinology and Metabolism
This is an open-access article distributed under the terms of the Creative Commons Attribution-
Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
This article has been cited by other articles in PMC.
Articles from Indian Journal of Endocrinology and Metabolism are provided here courtesy of
Medknow Publications

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