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MASKED HYPERTHYROIDISM
163
CORRESPONDENCE mediate oxidation products, however, are harmful and capable of causing dermatitis in subjects from 1’o the -Eattor OJ THE LANCET whom idiosyncrasy is absent and failure to eliminate SIR,-Dr. John Towers, in his paper (p. 67), and these has been judged in many legal causes to be and damages, often large, you, in a leading article (p. 91), have called attention evidence of to an important aspect of hyperthyroidism as a have been awarded because fur dermatitis may last I believe that I was one of for months or even years and reduce the sufferer cause of heart disease. the earlier writers in this country to describe this to a wreck from constant irritation and sleeplessness. To sum up. There are two causes for " fabric " particular aspect of thyroid disorder, and in a paper1 cases I article to the two referred (quoted dermatitis-namely chemicals which give rise to recording by Dr. Towers) by S. A. Levine and C. C. Sturgess, irritation of the skin in healthy controls, and which a reprint of which reached me soon after these cases should have been removed from the fabric, and had been under my care. In one of my cases the sensitisation which is attributable to the person patient complained of the heat of the ward (in winter), and not the garment. The distinction is not difficult, and I have subsequently found the preference of such for appropriate and reliable tests are available for people for cold weather a useful indication of raised the purpose. Whether the garment is made of fur metabolism. I venture to quote the concluding or other fabric does not seem to matter very much. I am, Sir, yours faithfully, paragraph of my article as evidence of my agreement with Dr. Towers’s observations : A. KNYVETT GORDON, M.B. Bedford-square, W.C., Jan. 16th, 1933. " This type of hyperthyroidism is a subtle one, a most MASKED HYPERTHYROIDISM
negligence,
important
one, and
for which
no
one
the true nature of which is often
Suspect hyperthyroidism in all cases of fibrillation, tachycardia, and other cardiovascular disorders PROGRESSIVE POST-OPERATIVE GANGRENE overlooked.
be found and which do not and be fairly convinced of the accuracy of your diagnosis if only one or two of the many symptoms of hyperthyroidism are present." other
cause can
respond to the usual remedies,
Norwich, Jan.
I am, Sir, yours faithfully, H. J. STARLING. 14th, 1933.
DERMATITIS FROM DYED FABRICS To the Editor of THE LANCET
OF THE SKIN of THE LANCET
To the Editor
SiR,-It was most interesting to read Mr. F. Hector Scotson’s report of a case in your last issue, as the condition is more common than references to the literature would lead one to suppose. The reasons are doubtless due to the obscurity of the cause and the lack of success from treatment. In my experience gangrene of the skin may follow an operation, usually for appendicitis, or it may occur spontaneously, and then most frequently in the genito-crural region. The appendix is most often a gangrenous one in the process of which the Bacillus morgan, a derivative of the B. proteus vulgaris, plays a role. A case of the spontaneous form, unique, because of the multiplicity of the lesions, was described in The Nature of Disease Journal (p. 120). The cause appears to be the Bacillus gangrence cutis, a name, which I believe was first given by Milian in Paris to the bacillus held to be responsible for the spontaneously occurring genito-crural form. Balog published one of these genital cases in 1931. The B. gangrenae cutis belongs to the proteus group of micro-organisms, and has most probably had origin with Ducrey’s bacillus from the B. morgan. There is a close similarity between the gangrenous lesion and ulcus molle serpiginosum, of which I published the first description in this country in 1914. The most successful treatment for gangrene of the skin is novarsenobenzene, injected intravenously. The drug is almost a specific and does away with all need for the cautery. The drug best suited for ulcus molle serpiginosum is tartar emetic
SiR,—The valuable paper by Dr. E. M. Killick and Dr. J. T. Ingram in your issue of Jan. 14th (p. 77) calls for some comment, because it may tend to confuse the issue as between chemical and personal tests. The authors, as it seems to me, go beyond their brief, and would have one or the other as a causa causans of dermatitis resulting from the wearing of dyed garments. Personally, I have always employed both chemical tests on the garment and specific tests on the individual for idiosyncrasy. I am therefore well aware that idiosyncrasy plays an important part. The point, however, is this : There are certain methods of dyeing in which soluble oxidation products-e.g., of para- or metaphenylenediamine are produced which are capable of giving rise to dermatitis in healthy controls. These can be withdrawn from fur-and I assume from other garments also-by prolonged washing. This is an expensive process and has frequently been omitted in the case of furs which have given rise to dermatitis. I have produced dermatitis by patch and scarification tests with these substances not only with the incriminated fur, but with the chemicals prepared in vitro. I have never, however, attempted to deny, nor so far as I can ascertain has injected intravenously. I am, Sir. vours faithfullv. anyone else, that idiosyncrasy to fabrics dyed with J. E. R. MCDONAGH. phenylenediamine or any other chemical does not Wimpole-street, W., Jan. 13th, 1933. occur. In many of my own cases I found such idiosyncrasy, and therefore absolved the fur. DOSAGE OF INSULIN The point is of something more than academic value. The fur trade is to be congratulated on To the Editor of THE LANCET having solved the problem of providing for persons SiB,—May I, as another " diabetic doctor" on of limited means garments which keep them warm insulin for ten years, present a more fortunate and give them a pride in their personal appearance : of successful standardisation of British the experience and for this purpose para-phenylenediamine and its insulin than is by my colleague in his expressed allies are customarily employed. The soluble inter- letter published to-day. In 1923 and 1924, the 1 Clin. Jour., Feb. 8th and 15th, 1928. early days of insulin, I gave clear evidence from
CORRESPONDENCE mediate oxidation products, however, are harmful and capable of causing dermatitis in subjects from 1’o the -Eattor OJ THE LANCET whom idiosyncrasy is absent and failure to eliminate SIR,-Dr. John Towers, in his paper (p. 67), and these has been judged in many legal causes to be and damages, often large, you, in a leading article (p. 91), have called attention evidence of to an important aspect of hyperthyroidism as a have been awarded because fur dermatitis may last I believe that I was one of for months or even years and reduce the sufferer cause of heart disease. the earlier writers in this country to describe this to a wreck from constant irritation and sleeplessness. To sum up. There are two causes for " fabric " particular aspect of thyroid disorder, and in a paper1 cases I article to the two referred (quoted dermatitis-namely chemicals which give rise to recording by Dr. Towers) by S. A. Levine and C. C. Sturgess, irritation of the skin in healthy controls, and which a reprint of which reached me soon after these cases should have been removed from the fabric, and had been under my care. In one of my cases the sensitisation which is attributable to the person patient complained of the heat of the ward (in winter), and not the garment. The distinction is not difficult, and I have subsequently found the preference of such for appropriate and reliable tests are available for people for cold weather a useful indication of raised the purpose. Whether the garment is made of fur metabolism. I venture to quote the concluding or other fabric does not seem to matter very much. I am, Sir, yours faithfully, paragraph of my article as evidence of my agreement with Dr. Towers’s observations : A. KNYVETT GORDON, M.B. Bedford-square, W.C., Jan. 16th, 1933. " This type of hyperthyroidism is a subtle one, a most MASKED HYPERTHYROIDISM
negligence,
important
one, and
for which
no
one
the true nature of which is often
Suspect hyperthyroidism in all cases of fibrillation, tachycardia, and other cardiovascular disorders PROGRESSIVE POST-OPERATIVE GANGRENE overlooked.
be found and which do not and be fairly convinced of the accuracy of your diagnosis if only one or two of the many symptoms of hyperthyroidism are present." other
cause can
respond to the usual remedies,
Norwich, Jan.
I am, Sir, yours faithfully, H. J. STARLING. 14th, 1933.
DERMATITIS FROM DYED FABRICS To the Editor of THE LANCET
OF THE SKIN of THE LANCET
To the Editor
SiR,-It was most interesting to read Mr. F. Hector Scotson’s report of a case in your last issue, as the condition is more common than references to the literature would lead one to suppose. The reasons are doubtless due to the obscurity of the cause and the lack of success from treatment. In my experience gangrene of the skin may follow an operation, usually for appendicitis, or it may occur spontaneously, and then most frequently in the genito-crural region. The appendix is most often a gangrenous one in the process of which the Bacillus morgan, a derivative of the B. proteus vulgaris, plays a role. A case of the spontaneous form, unique, because of the multiplicity of the lesions, was described in The Nature of Disease Journal (p. 120). The cause appears to be the Bacillus gangrence cutis, a name, which I believe was first given by Milian in Paris to the bacillus held to be responsible for the spontaneously occurring genito-crural form. Balog published one of these genital cases in 1931. The B. gangrenae cutis belongs to the proteus group of micro-organisms, and has most probably had origin with Ducrey’s bacillus from the B. morgan. There is a close similarity between the gangrenous lesion and ulcus molle serpiginosum, of which I published the first description in this country in 1914. The most successful treatment for gangrene of the skin is novarsenobenzene, injected intravenously. The drug is almost a specific and does away with all need for the cautery. The drug best suited for ulcus molle serpiginosum is tartar emetic
SiR,—The valuable paper by Dr. E. M. Killick and Dr. J. T. Ingram in your issue of Jan. 14th (p. 77) calls for some comment, because it may tend to confuse the issue as between chemical and personal tests. The authors, as it seems to me, go beyond their brief, and would have one or the other as a causa causans of dermatitis resulting from the wearing of dyed garments. Personally, I have always employed both chemical tests on the garment and specific tests on the individual for idiosyncrasy. I am therefore well aware that idiosyncrasy plays an important part. The point, however, is this : There are certain methods of dyeing in which soluble oxidation products-e.g., of para- or metaphenylenediamine are produced which are capable of giving rise to dermatitis in healthy controls. These can be withdrawn from fur-and I assume from other garments also-by prolonged washing. This is an expensive process and has frequently been omitted in the case of furs which have given rise to dermatitis. I have produced dermatitis by patch and scarification tests with these substances not only with the incriminated fur, but with the chemicals prepared in vitro. I have never, however, attempted to deny, nor so far as I can ascertain has injected intravenously. I am, Sir. vours faithfullv. anyone else, that idiosyncrasy to fabrics dyed with J. E. R. MCDONAGH. phenylenediamine or any other chemical does not Wimpole-street, W., Jan. 13th, 1933. occur. In many of my own cases I found such idiosyncrasy, and therefore absolved the fur. DOSAGE OF INSULIN The point is of something more than academic value. The fur trade is to be congratulated on To the Editor of THE LANCET having solved the problem of providing for persons SiB,—May I, as another " diabetic doctor" on of limited means garments which keep them warm insulin for ten years, present a more fortunate and give them a pride in their personal appearance : of successful standardisation of British the experience and for this purpose para-phenylenediamine and its insulin than is by my colleague in his expressed allies are customarily employed. The soluble inter- letter published to-day. In 1923 and 1924, the 1 Clin. Jour., Feb. 8th and 15th, 1928. early days of insulin, I gave clear evidence from