[ 93 ] SOME SKIN MANIFESTATIONS IN HYPOPARATHYROIDISM BY LEO SPIRA, M.D. (VIENNA), MJD. (PBAGXJE), M.R.C.S. (ENG.) A complex disease picture prevalent in this country the endocrine apparatus, that there is a close asso- has been traced (Spira, 1928) to the protracted ciation between the parathyroids and the vegetative ingestion of drinking water derived from the tap, nervous system. It is as yet impossible to state and of food prepared in aluminium cooking utensils. whether it is the sympathetic or the parasym- No indication could at that time be given of the pathetic which is primarily involved when this exact irritant, beyond stating that a mineral or association is disturbed by the action of fluorine. metal seemed to be involved. Further observation It is, however, likely that it is the disturbance of revealed a frequent association with paraesthesiae the equilibrium of the two great divisions of the affecting the hands and fingers, especially those vegetative nervous system, which brings about a supplied by the dorsal cutaneous branch of the decreased function of the parathyroid glands, with ulnar nerve. The feet were affected to a lesser subsequent disturbance of the calcium metabolism extent. Since there is, in the present state of our of the body. The solution of the all-important knowledge, only one poison which affects the ulnar problem whether it is the vegetative nervous nerve, namely, fluorine, Spira (1933) concluded that system alone which is attacked by fluorine, or it may be this halogen which was one of the whether some higher part in the central nervous aetiological factors concerned. It was the wide- system is attacked first, must be left to further spread occurrence of mottled teeth in this country research. Lachmann (1941) suggests the possibility (Spira, 1942a, 6), known to be produced by a that in the process of hypoparathyroidism a drinking water with a content of not less than 1 part calcium-regulating centre in the brain is involved. of fluorine per million parts of water (1 p.p.m.), Fluorine may be found in many media. It may equivalent to gr. 1/120 of fluorine to a pint of water, be present in the soil as a natural constituent and ingested during the period of calcification of the find its way into the water. Spira (19436) has teeth, which helped to establish the fact that it is shown that the filter powder frequently employed indeed fluorine which is the causative agent pro- in this country to purify, by means of metal filters, ducing signs and symptoms of a hitherto obscure water derived from rivers, lakes, ponds, etc., may origin. contain fluorine as an impurity, and thus affect the Mottled teeth have already been recognized by drinking water. The iron and cement tanks, and the various writers as bearing a striking resemblance to pipes conducting the water from its source to the a dental lesion produced by Brdheim (1906, 1911) tap from which it is drawn for drinking and cooking in his parathyroidectomized rats. Independently, purposes, may all contain fluorine as an impurity. however, of this important finding, Spira (1942c, d) In the production of aluminium cooking utensils appears to have been the first, so far as can be the mineral cryolite of the chemical composition ascertained, to draw attention to the frequent co- Na3AlF6 (or 3NaF.AlF3), which after purification existence of mottled teeth with dystrophies of other contains roughly 50% fluorine, is employed as an organs of ectodermal origin, namely, the skin and essential raw material. In the process of preparing its appendages, the nails and hair. As all these food the aluminium is readily corroded by both organs are regulated by the parathyroid glands, and acids and alkalies, with the result that the fluorine also because frequent attacks of paraesthesiae are compounds contained therein are set free and known to bepathognomonic of hypoparathyroidism, contaminate the food. he came to the conclusion (Spira, 1942c, d) that, in Since the appendages of the skin, namely, the the protracted action of fluorine, the parathyroids teeth, nails and hair, have been clinically found to are vitally involved. The disease picture of chronic be damaged through the protracted action of toxic fluorine poisoning (fluorosis) has thus been estab- amounts of fluorine upon the vegetative nervous lished to be identical with that produced by system, with subsequent involvement of the para- Erdheim (1906, 1911) in his experimental para- thyroid glands (Spira, 1942c, d, 1943a, 1944a, b, thyroidectomy (tetania parathyreopriva). 1946), the question arose as to how the skin itself On further study of the symptomatology of reacts in the process of hypoparathyroidism. The fluorosis,. Spira (1946, 1947) found, in perfect object of the present paper is to record the results harmony with well-known facts concerning the of clinical observation on such dermatoses as relationship of the vegetative nervous system with were found frequently, though not invariably, to Downloaded from https://www.cambridge.org/core. IP address: 170.106.35.93, on 24 Sep 2021 at 22:32:57, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms. https://doi.org/10.1017/S0022172400013711 94 Some shin manifestations in hypoparathyroidism accompany signs and symptoms of chronic fluorine manifests itself in a great variety of changes. Apart poisoning; and also to discuss certain skin diseases from the characteristic eruptions, vasomotor in- which were for a long time, even before the subject stability leads to perniosis and chilblain develop- of the deleterious action of fluorine came under ment. There is an increased susceptibility to in- closer scrutiny, believed to be due to parathyroid fections such as boils, pustules and carbuncles, insufficiency which in turn leads to a reduction of perionychia and fissures. Changes in the mucous the calcium content of the body. The ectodermal membranes of the upper respiratory tract leading to lesions concerned are in the main characterized by chronic catarrh, bronchitis and asthmatic disorders, mottling of the teeth, mottling of the nails, and by rhinorrhoea and hay fever, infected antra and other alopecia. sinuses, pyorrhoea and gingivitis, and so-called In the course of investigating great numbers of 'soft teeth', all belong to its symptomatology. apparently healthy young men and women in this Dyspepsia, flatulence and chronic constipation are country for any effects of hypoparathyroidism its outstanding features. caused by the protracted ingestion of toxic amounts Since all these signs and symptoms were shown of fluorine (Spira, 1942a, b, c, 19446), seborrhoeic to constitute the disease picture of chronic fluorine dermatitis over the typical areas in the inter- poisoning (Spira, 1942c, 1944a, 6), it appears that scapular region and over the sternum has been fluorosis and 'seborrhoeic diathesis' are identical found to be a common occurrence. It was often a conditions, and that it is the fluorine which is at matter of surprise to observe with what resigned the root of the diathesis. Any infection present is of indifference the victims looked upon their skin a secondary nature (Spira, 1944a), and is brought disease, so long as it was not causing them too much about by the tissues having become less resistant to inconvenience. The incidence was considerably an attack by endogenous or exogenous agents, when greater amongst the males than amongst the their calcium content has fallen below the normal females. A similar divergence in the degree of level. It is a well-established fact that the action of alopecia, so prevalent in this country, between the this halogen consists in precipitating calcium salts, sexes has been tentatively explained (Spira, 1946) which are stored in the body as a material indis- by the possibility that smaller quantities of fluids pensable for sustaining the vitality of most of the containing toxic amounts of fluorine may have been organic functions, and substituting sodium or ingested by females, rather than by the possibility potassium for the calcium which has been removed. that the ovarian hormones act in an antagonistic It is suggested that Barber's (1929) conception of a manner upon the function of the parathyroids. faulty metabolism as a cause of 'seborrhoeic Probably no dermatological problem has ever diathesis' can now be narrowed down to denote a been studied more extensively than seborrhoeic faulty calcium metabolism as the fons et origo of the dermatitis. Yet the knowledge of its aetiology is as condition. Thus, contrary to the time-honoured scanty as that of the great majority of other skin explanation, it may be not the seborrhoea which affections. Whilst, in this era of bacteriology and causes the dermatitis, the eczema, and such dys- parasitology, the condition is still widely held to trophies as seborrhoeic warts, seborrhoeic alopecia, be due primarily to an infection (Dowling, 1939), etc., but fluorine which, in its ultimate effect, evidence is accumulating to show that the old con- simultaneously damages some or all of the organs of ception of 'seborrhoeic diathesis' is being revived. ectodermal origin, the skin as well as its appendages, Barber (1929) emphasizes that the condition is the the teeth, nails and hair. Buschke (1911) describes result of a faulty metabolism, the effects of which are seborrhoea on the bridge of the nose, Kerley (1930) not only visible on the skin, but produce such systemic and Fleischmann (1931a, b) seborrhoea capitis, and disturbances as gingivitis, chronic nasopharyngeal Schwarz (1935) an impetiginous rash over the scalp catarrh with frequent exacerbations, marked hyper- in association with ectodermal dysplasias, and trophy of the lymphoid tissue, and flatulence. Levy-Franckel & Juster (1926) incriminate the According to him, this faulty metabolism causes an disturbance of the sympathetic and endocrine alteration in the secretion and composition of the systems in the aetiology of seborrhoea.