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NEW STANDARDS FOR ESTIMATING BONE DENSITY
893 LOWERING BY PREDNISONE OF SERUM-CALCIUM IN HYPERPARATHYROIDISM SiR,—Though most tests used to diagnose primary hyperparathyroidism may give false-negative results, the lowering of serum-calcium level by a glucocorticoid is usually considered very reliable in excluding this disorder. This test appeared to fail us in the following case. A white woman of 63 had a calcium-oxalate stone removed from her left kidney by Dr. P. J. M. Retief in August, 1960. The serum-calcium level was found to be high; so she was subsequently admitted to Groote Schuur Hospital for investi-
gation. She was not wasted, not in any way ill, and showed no indication of sarcoidosis or malignant disease. She had not been taking calciferol. Serum-phosphorus levels ranged between 33 and 38 mg. per 100 ml. Alkaline-phosphatase, blood-urea, serum-protein, and electrolyte levels were normal; blood-examination revealed no abnormalities. Skeletal X-rays and examination by barium-swallow were also normal. Her 24-hour urinary calcium totalled about 350 mg. Renal tubular reabsorption of phosphorus (based on two 2-hour clearance tests, with endogenous creatinine clearance to measure glomerular filtration-rate) was 92 and 95 %. The urine was acidified to pH 45 after a single dose of ammonium chloride. Prednisone, in doses of 20 mg. b.d., was given for 12 days, and the serum-calcium readings were as follows:
is still more unreliable because of the uneven distribution of the bone minerals and the covering effect of the soft tissues in and around the bone.Even if the densities of the standards are objectively measured by point densitometry and compared with the densities of the bones to be examined, the method is inaccurate.27 It is therefore not surprising that the amounts of apatite in the standards used by Koch and Kaplan were considerably higher than the actual mineral content of normal finger bones. 28 Attractive as it would be to express the results of radiographic examination in terms of bone density, it seems
density
that morphological criteria, obtained by quantitative measurement, 9 10 still furnish the most useful information on pathological changes in bones. Department of Anatomy, University of Helsinki, Helsinki, Finland.
PEKKA VIRTAMA.
" A DEPARTURE FROM NORMAL PRACTICE " SIR,-II am sorry Dr. Tredgold and Dr. Soddy (March 25) should write of their concern over safeguarding doctors from lonely and frustrated patients, but omit mention of their responsibility as distinguished members - indeed leaders-of the profession to safeguard lonely
and frustrated patients from inexperienced, inadequately trained, and sometimes frankly psychopathic doctors. I think they would agree with me that a medical degree, an
ability
charming self confidence, per se, to set up as a psychiatrist or psychotherapist. There is a world of difference between a psychotherapist and a professional sympathiser. Their attempt to enlist the sympathy of general practitioners does
We were unable to carry out the test again. Despite these findings, the parathyroid glands were examined by Dr. R. Lane Forsyth in November. The left lower gland was found to contain a tumour the size of a pea, which was removed. Histological examination revealed a chief-cell parathyroid adenoma. Two weeks after operation the serum-calcium level was 94 mg. per 100 ml. and the serum phosphorus 50 mg. per 100 ml. The serum-calcium estimations were performed in our endocrine laboratories by the method of Greenblatt and Hartman. In a double-blind test in our laboratory we found this subject to an error of less than 2% either way. The upper limit of normal for serum-calcium readings we take as 110 mg. per 100 ml. (99 percentile).
We think that the reduced serum-calcium level while the patient was on prednisone may have been fortuitous. Groote Schuur Hospital, of Cape Town, South Africa.
University
W. P. U.
JACKSON.
NEW STANDARDS FOR ESTIMATING BONE DENSITY
SiR,-Dr. Koch and Dr. Kaplan (Feb. 18) recommended the use of open-ended stainless-steel tubes filled with various amounts of bone as new standards for the estimation of bone density. Such standards have been used before, and detailed studies made of their value. I have used small’Perspex’ boxes filled with different amounts of bone powder and human finger bones removed at necropsy as standards to determine the mineral content of finger bones.’ In order to avoid the distributional error 3—very important in this connection-silver analysis of the X-ray film ’.’.as performed instead of optical densitometry. The accuracy of visual estimation of bone density is too low to be of much practical use, although special phantom bones are used as standards.45 if evenly absorbing standards are used, as proposed by Koch and Kaplan, the measurement of bone : Greenblatt, I. J., Hartman, S. Analyt. Chem. 1951, 23, 2. Virtama, P. Acta anat. 1957, 31, suppl. 29. 3. Ornstein, L. Lab. Invest. 1952, 1, 250.
1708.
4 Steven, G. D. Ann. rheum. Dis. 1947, 6, 184. 5. Laitinen, H., Virkkunen, M., Virtama, P. Acta rheum. scand. 1958, 4, 266.
to
not
hypnotise,
entitle
a
or
person
that they too are at risk is specious. If a general without specialist training undertakes major abdominal surgery and things go wrong, and he does not seek expert assistance, his victim (or the dependants) deserve some compensation. Similarly a general practitioner without special training undertaking major psychiatric treatment, who does not seek expert help when difficulties arise, owes something to his victim. They state " [The doctor] has a choice between using the [transference] relationship for the patient’s benefit, or attempting to reduce it, which may entail breaking off the case." They do not mention the vitally important alternative-that the doctor through his own emotional-alas sometimes economic-need may bask in the warmth of his victim’s confidence or love, perpetuating the situation and preventing the patient from going out into the world to make some sort of life for herself. The transference situation is not as unique, unknown, unpredictable, and uncontrollable as Dr. Tredgold and Dr. Soddy imply. Having suffered considerable transference difficulties in training (long letters, telephone calls, presents, invitations, visits, and intense personal interest from many patients), I know how easy it is to mismanage the transference situation, how difficult and disturbing it is to acquire training and experience in the matter. It is a salutary thought that the untrained writer of the lyric " People will say we’re in love " appears to know more of the tricks of transference than some who may have had scientific
by implying practitioner
training. How to conduct a psychotherapeutic interview has received great deal of attention and is set out quite clearly in Colby’s Primer for Psychotherapists.ll If a psychiatrist helps a woman patient on with her coat with too much alacrity, or leaps to light her cigarette, or gives her more time than specified, or goes out of his way to see her, or calls her by her Christian name, she will, understandably, think there is more in the relationship than professional 6. Virtama, P. Ann. Med. intern. Fenn. 1960, 49, 57. a
7. 8. 9. 10. 11.
Omnell, K.-Å. Acta radiol., Stockh. 1957, suppl. 148, 1. Virtama, P. Ann. Med. exp. Fenn. 1960, 38, 127. Virtama, P., Māhönen, H. Brit. J. Radiol. 1960, 33, 60. Barnett, E., Nordin, B. E. C. Clin. Radiol., Lond. 1960, 11, 166. Colby, K. M. Primer for Psychotherapists. New York, 1951.
gation. She was not wasted, not in any way ill, and showed no indication of sarcoidosis or malignant disease. She had not been taking calciferol. Serum-phosphorus levels ranged between 33 and 38 mg. per 100 ml. Alkaline-phosphatase, blood-urea, serum-protein, and electrolyte levels were normal; blood-examination revealed no abnormalities. Skeletal X-rays and examination by barium-swallow were also normal. Her 24-hour urinary calcium totalled about 350 mg. Renal tubular reabsorption of phosphorus (based on two 2-hour clearance tests, with endogenous creatinine clearance to measure glomerular filtration-rate) was 92 and 95 %. The urine was acidified to pH 45 after a single dose of ammonium chloride. Prednisone, in doses of 20 mg. b.d., was given for 12 days, and the serum-calcium readings were as follows:
is still more unreliable because of the uneven distribution of the bone minerals and the covering effect of the soft tissues in and around the bone.Even if the densities of the standards are objectively measured by point densitometry and compared with the densities of the bones to be examined, the method is inaccurate.27 It is therefore not surprising that the amounts of apatite in the standards used by Koch and Kaplan were considerably higher than the actual mineral content of normal finger bones. 28 Attractive as it would be to express the results of radiographic examination in terms of bone density, it seems
density
that morphological criteria, obtained by quantitative measurement, 9 10 still furnish the most useful information on pathological changes in bones. Department of Anatomy, University of Helsinki, Helsinki, Finland.
PEKKA VIRTAMA.
" A DEPARTURE FROM NORMAL PRACTICE " SIR,-II am sorry Dr. Tredgold and Dr. Soddy (March 25) should write of their concern over safeguarding doctors from lonely and frustrated patients, but omit mention of their responsibility as distinguished members - indeed leaders-of the profession to safeguard lonely
and frustrated patients from inexperienced, inadequately trained, and sometimes frankly psychopathic doctors. I think they would agree with me that a medical degree, an
ability
charming self confidence, per se, to set up as a psychiatrist or psychotherapist. There is a world of difference between a psychotherapist and a professional sympathiser. Their attempt to enlist the sympathy of general practitioners does
We were unable to carry out the test again. Despite these findings, the parathyroid glands were examined by Dr. R. Lane Forsyth in November. The left lower gland was found to contain a tumour the size of a pea, which was removed. Histological examination revealed a chief-cell parathyroid adenoma. Two weeks after operation the serum-calcium level was 94 mg. per 100 ml. and the serum phosphorus 50 mg. per 100 ml. The serum-calcium estimations were performed in our endocrine laboratories by the method of Greenblatt and Hartman. In a double-blind test in our laboratory we found this subject to an error of less than 2% either way. The upper limit of normal for serum-calcium readings we take as 110 mg. per 100 ml. (99 percentile).
We think that the reduced serum-calcium level while the patient was on prednisone may have been fortuitous. Groote Schuur Hospital, of Cape Town, South Africa.
University
W. P. U.
JACKSON.
NEW STANDARDS FOR ESTIMATING BONE DENSITY
SiR,-Dr. Koch and Dr. Kaplan (Feb. 18) recommended the use of open-ended stainless-steel tubes filled with various amounts of bone as new standards for the estimation of bone density. Such standards have been used before, and detailed studies made of their value. I have used small’Perspex’ boxes filled with different amounts of bone powder and human finger bones removed at necropsy as standards to determine the mineral content of finger bones.’ In order to avoid the distributional error 3—very important in this connection-silver analysis of the X-ray film ’.’.as performed instead of optical densitometry. The accuracy of visual estimation of bone density is too low to be of much practical use, although special phantom bones are used as standards.45 if evenly absorbing standards are used, as proposed by Koch and Kaplan, the measurement of bone : Greenblatt, I. J., Hartman, S. Analyt. Chem. 1951, 23, 2. Virtama, P. Acta anat. 1957, 31, suppl. 29. 3. Ornstein, L. Lab. Invest. 1952, 1, 250.
1708.
4 Steven, G. D. Ann. rheum. Dis. 1947, 6, 184. 5. Laitinen, H., Virkkunen, M., Virtama, P. Acta rheum. scand. 1958, 4, 266.
to
not
hypnotise,
entitle
a
or
person
that they too are at risk is specious. If a general without specialist training undertakes major abdominal surgery and things go wrong, and he does not seek expert assistance, his victim (or the dependants) deserve some compensation. Similarly a general practitioner without special training undertaking major psychiatric treatment, who does not seek expert help when difficulties arise, owes something to his victim. They state " [The doctor] has a choice between using the [transference] relationship for the patient’s benefit, or attempting to reduce it, which may entail breaking off the case." They do not mention the vitally important alternative-that the doctor through his own emotional-alas sometimes economic-need may bask in the warmth of his victim’s confidence or love, perpetuating the situation and preventing the patient from going out into the world to make some sort of life for herself. The transference situation is not as unique, unknown, unpredictable, and uncontrollable as Dr. Tredgold and Dr. Soddy imply. Having suffered considerable transference difficulties in training (long letters, telephone calls, presents, invitations, visits, and intense personal interest from many patients), I know how easy it is to mismanage the transference situation, how difficult and disturbing it is to acquire training and experience in the matter. It is a salutary thought that the untrained writer of the lyric " People will say we’re in love " appears to know more of the tricks of transference than some who may have had scientific
by implying practitioner
training. How to conduct a psychotherapeutic interview has received great deal of attention and is set out quite clearly in Colby’s Primer for Psychotherapists.ll If a psychiatrist helps a woman patient on with her coat with too much alacrity, or leaps to light her cigarette, or gives her more time than specified, or goes out of his way to see her, or calls her by her Christian name, she will, understandably, think there is more in the relationship than professional 6. Virtama, P. Ann. Med. intern. Fenn. 1960, 49, 57. a
7. 8. 9. 10. 11.
Omnell, K.-Å. Acta radiol., Stockh. 1957, suppl. 148, 1. Virtama, P. Ann. Med. exp. Fenn. 1960, 38, 127. Virtama, P., Māhönen, H. Brit. J. Radiol. 1960, 33, 60. Barnett, E., Nordin, B. E. C. Clin. Radiol., Lond. 1960, 11, 166. Colby, K. M. Primer for Psychotherapists. New York, 1951.