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HYPOCALCIURIA AND CALCIUM ABSORPTION
40 coarctation in children over 10 years old, and this has persuaded that operation at age 10 probably prevents degenerative changes in some cases; the late results do not suggest that earlier operation gives a less sustained reduction in blood-pressure. With deference, then, I suggest 10 years as the optimum age for operation rather than the 15 of Holmes Sellors and Hobsley. The mortality in my cases was nil. One patient required postoperative transfusion because of haemorrhage and one had a chylothorax; otherwise there has been no significant morbidity. me
intestinal calcium excretion remained abnormally high (352 mg. per 24 hours) and calciuria did not increase (10 mg. per 24 hours).5 We suggest that, in the absence of renal impairment, hypocalciuria in these patients was due to the capacity of the renal tubule to retain calcium when the excretion of endogenous calcium by the intestine was abnormally high. The mechanism of this calcium retention is unknown.
On the whole, my results confirm that the operation is one with little risk and that it is followed by a reduction in both systolic and diastolic blood-pressure lasting many
In view of these findings, hypocalciuria may be a valuable sign in the evaluation of the handling of calcium by the intestine, in that it points to an over-excretion of endogenous calcium in the syndrome of calcium-losing
years.
enteropathy.
HERBERT HAXTON.
Laboratoire des Isotopes, Institut Pasteur,
hypocalcsemia, hypocalciuria, tetany, and osteomalacia have been reported in patients with various diseases of the 2
small intestine.1
tion ; thus,
no
correlation could be established. There seemed to be a correlation between calciuria and excretion of endogenous calcium by the intestine. The patients fell into two
(see accompanying figure) : those groups
between
calciuria
genous calcium excretion
and
tinal calcium excretion
endo-
by the intestine
in disorders of the small intestine.
with low calciuria and abnormally high intes-
(6 patients), and those with normal
calciuria and normal intestinal calcium excretion (3 patients). There is only one discrepancy-a patient with low calciuria and normal intestinal calcium excretion. Another finding pointed to a relationship between calcium excretion by the intestine and calciuria. In a patient with hypocalciuria (10 mg. per 24 hours) high intestinal excretion (544 mg. per 24 hours) and greatly impaired intestinal absorption of calcium, the administration of large doses of vitamin D2 resulted in excessive intestinal calcium absorption, but Basset, S. H. Clinical Disorders of Fluid and Electrolytes Metabolism (edited by M. H. Maxwell and C. R. Kleeman). New York, 1962. 2. Fourman, P. Calcium Metabolism and Bone. Oxford, 1960. 3 Milhaud, G., Vesin, P. Nature, Lond. 1961, 191, 872. 4. Aubert, J. P., Milhaud, G. Biochim. biophys. Acta, 1960, 39, 122. 1.
P. VESIN.
Paris.
A NURSE’S VIEW OF THE MATERNITY SERVICES
identified myself with the consultant in the letter from Study Leave (June 15), and having consulted the case-records, I should like to refute the allegations of inadequate care, and to let the facts speak for themselves.
SIR,-Having
In a previous paper3 we reported a great decrease in urinary excretion of calcium in patients with steatorrhoea and the syndrome of protein-losing (exudative) enteropathy. We have now investigated 10 patients with various diseases of the small intestine, all with steatorrhcea and some with a protein loss into the intestine. 7 had low or very low calciuria: 10, 10, 10, 15, 22, 25, 77 mg. per 24 hours; 3 had a normal or slightly increased calciuria: 100, 126, 221 mg. per 24 hours. This decrease in calcium urinary output could not be attributed to impaired renal function. Moreover, no correlation could be demonstrated between hypocalciuria and variation in calcaemia or phosphatsmia. From data provided by a method combining the use of 45Ca and conventional balance measurements,4 we attempted to correlate calciuria with calcium absorption and excretion in the intestine. Whereas 3 of the 7 patients with a decreased calciuria had impaired calcium absorption, 4 had a normal absorp-
Relationship
G. MILHAUD.
Paris, 15. Hôpital Saint-Antoine,
HYPOCALCIURIA AND CALCIUM ABSORPTION SIR,-Disorders of calcium metabolism such as
referred
to
"
"
The
patient came to my clinic with a letter from her general practitioner, to whom a reply was sent. There is no trace of a letter from the patient’s husband, and I do not remember receiving one. There is a note saying the patient wished to be under the care of the senior registrar, and he saw the patient at nearly every subsequent visit, including weekly during the last month. We find that a registrar often prefers his wife to be under the care of the senior registrar rather than that of the consultant, and this is usually a satisfactory arrangement. The senior registrar is a contemporary, and often a personal friend. The doctors always endeavour to be on time in the clinics, but pressure of work in the labour wards and elsewhere sometimes makes a late start inevitable. There is a note that a general examination, including the heart and lungs, was made at the first visit by a house-officer, who happened to be a former medical registrar. Owing to a shortage of technicians and at the request of the hasmatologist, we have for some years been taking the first blood samples for routine testing only at 32 weeks. The obstetricians were dubious about this arrangement when it was instituted, particularly because of the possibility of finding a positive Wassermann reaction at that late stage, but the paediatricians were satisfied, and have not asked for the arrangements to be altered. In many cases, however, blood samples are taken earlier, for example in cases with a history of anasmia, and in rhesus-negative multipars. A positive Wassermann reaction is a rarity in this area. The patients in the antenatal clinic undress in separate cubicles, and the gowns are changed every day. The pregnancy progressed normally throughout. The patient was seen by a trained midwife on her admission in early labour. During the night she had morphine and promethazine, in addition to two doses of pethidine. In the morning, the senior registrar arranged for epidural analgesia, and he delivered the patient during the afternoon by means of a simple low-forceps delivery. There are notes by a doctor of the patient’s progress in the puerperium, and a note of a discharge examination by the senior house-officer. There is a record of the baby having been examined by the consultant paediatrician. At the postnatal clinic the patient was examined by the registrar and the cervix was then found to be healthy. I personally did not see the patient during the lying-in period, for the simple reason that I went away for a fortnight’s holiday on the very day that the baby was born.
We do not claim to be perfect, but endeavour to do our best for our patients. As in many other hospitals, we are 5.
Milhaud, G., Vesin, P. Plasma Proteins and Gastro-intestinal Tract in Health and Disease (edited by M. Schwartz and P. Vesin); p. 127. Copenhagen, 1963.
intestinal calcium excretion remained abnormally high (352 mg. per 24 hours) and calciuria did not increase (10 mg. per 24 hours).5 We suggest that, in the absence of renal impairment, hypocalciuria in these patients was due to the capacity of the renal tubule to retain calcium when the excretion of endogenous calcium by the intestine was abnormally high. The mechanism of this calcium retention is unknown.
On the whole, my results confirm that the operation is one with little risk and that it is followed by a reduction in both systolic and diastolic blood-pressure lasting many
In view of these findings, hypocalciuria may be a valuable sign in the evaluation of the handling of calcium by the intestine, in that it points to an over-excretion of endogenous calcium in the syndrome of calcium-losing
years.
enteropathy.
HERBERT HAXTON.
Laboratoire des Isotopes, Institut Pasteur,
hypocalcsemia, hypocalciuria, tetany, and osteomalacia have been reported in patients with various diseases of the 2
small intestine.1
tion ; thus,
no
correlation could be established. There seemed to be a correlation between calciuria and excretion of endogenous calcium by the intestine. The patients fell into two
(see accompanying figure) : those groups
between
calciuria
genous calcium excretion
and
tinal calcium excretion
endo-
by the intestine
in disorders of the small intestine.
with low calciuria and abnormally high intes-
(6 patients), and those with normal
calciuria and normal intestinal calcium excretion (3 patients). There is only one discrepancy-a patient with low calciuria and normal intestinal calcium excretion. Another finding pointed to a relationship between calcium excretion by the intestine and calciuria. In a patient with hypocalciuria (10 mg. per 24 hours) high intestinal excretion (544 mg. per 24 hours) and greatly impaired intestinal absorption of calcium, the administration of large doses of vitamin D2 resulted in excessive intestinal calcium absorption, but Basset, S. H. Clinical Disorders of Fluid and Electrolytes Metabolism (edited by M. H. Maxwell and C. R. Kleeman). New York, 1962. 2. Fourman, P. Calcium Metabolism and Bone. Oxford, 1960. 3 Milhaud, G., Vesin, P. Nature, Lond. 1961, 191, 872. 4. Aubert, J. P., Milhaud, G. Biochim. biophys. Acta, 1960, 39, 122. 1.
P. VESIN.
Paris.
A NURSE’S VIEW OF THE MATERNITY SERVICES
identified myself with the consultant in the letter from Study Leave (June 15), and having consulted the case-records, I should like to refute the allegations of inadequate care, and to let the facts speak for themselves.
SIR,-Having
In a previous paper3 we reported a great decrease in urinary excretion of calcium in patients with steatorrhoea and the syndrome of protein-losing (exudative) enteropathy. We have now investigated 10 patients with various diseases of the small intestine, all with steatorrhcea and some with a protein loss into the intestine. 7 had low or very low calciuria: 10, 10, 10, 15, 22, 25, 77 mg. per 24 hours; 3 had a normal or slightly increased calciuria: 100, 126, 221 mg. per 24 hours. This decrease in calcium urinary output could not be attributed to impaired renal function. Moreover, no correlation could be demonstrated between hypocalciuria and variation in calcaemia or phosphatsmia. From data provided by a method combining the use of 45Ca and conventional balance measurements,4 we attempted to correlate calciuria with calcium absorption and excretion in the intestine. Whereas 3 of the 7 patients with a decreased calciuria had impaired calcium absorption, 4 had a normal absorp-
Relationship
G. MILHAUD.
Paris, 15. Hôpital Saint-Antoine,
HYPOCALCIURIA AND CALCIUM ABSORPTION SIR,-Disorders of calcium metabolism such as
referred
to
"
"
The
patient came to my clinic with a letter from her general practitioner, to whom a reply was sent. There is no trace of a letter from the patient’s husband, and I do not remember receiving one. There is a note saying the patient wished to be under the care of the senior registrar, and he saw the patient at nearly every subsequent visit, including weekly during the last month. We find that a registrar often prefers his wife to be under the care of the senior registrar rather than that of the consultant, and this is usually a satisfactory arrangement. The senior registrar is a contemporary, and often a personal friend. The doctors always endeavour to be on time in the clinics, but pressure of work in the labour wards and elsewhere sometimes makes a late start inevitable. There is a note that a general examination, including the heart and lungs, was made at the first visit by a house-officer, who happened to be a former medical registrar. Owing to a shortage of technicians and at the request of the hasmatologist, we have for some years been taking the first blood samples for routine testing only at 32 weeks. The obstetricians were dubious about this arrangement when it was instituted, particularly because of the possibility of finding a positive Wassermann reaction at that late stage, but the paediatricians were satisfied, and have not asked for the arrangements to be altered. In many cases, however, blood samples are taken earlier, for example in cases with a history of anasmia, and in rhesus-negative multipars. A positive Wassermann reaction is a rarity in this area. The patients in the antenatal clinic undress in separate cubicles, and the gowns are changed every day. The pregnancy progressed normally throughout. The patient was seen by a trained midwife on her admission in early labour. During the night she had morphine and promethazine, in addition to two doses of pethidine. In the morning, the senior registrar arranged for epidural analgesia, and he delivered the patient during the afternoon by means of a simple low-forceps delivery. There are notes by a doctor of the patient’s progress in the puerperium, and a note of a discharge examination by the senior house-officer. There is a record of the baby having been examined by the consultant paediatrician. At the postnatal clinic the patient was examined by the registrar and the cervix was then found to be healthy. I personally did not see the patient during the lying-in period, for the simple reason that I went away for a fortnight’s holiday on the very day that the baby was born.
We do not claim to be perfect, but endeavour to do our best for our patients. As in many other hospitals, we are 5.
Milhaud, G., Vesin, P. Plasma Proteins and Gastro-intestinal Tract in Health and Disease (edited by M. Schwartz and P. Vesin); p. 127. Copenhagen, 1963.