Franz U. Steinberg

Hypercalcaemia in adolescent tetraplegic patients: case report and review

The paper presents the case history of a 15-year-old boy with traumatic tetraplegia who developed hypercalcaemia within 6 weeks of injury. The condition was initially controlled by the infusion of intravenous fluids in large amounts and by the administration of calcitonin. After 3 weeks, calcitonin became ineffective. Eventually the hypercalcaemia responded to cortisone administered in low dosage. The endocrinologic implications of this observation are discussed.

The Effects of Immobilization on Bone

Accretion and resorption of the skeletal mass, especially of the lower part of the body, are maintained in equilibrium by the stimulus of weight bearing and activity. Immobilization, whether by prolonged recumbency, paralysis, or space-flight immobilization, leads to bone atrophy. Calcium released by the immobilized skeleton is excreted in the urine with resulting hypercalciuia ultimately reflecting the extent of bone loss. The excessive elimination of calcium salts in the urine also predisposes to nephrocalcinosis and nephrolithiasis, the latter representing a frequent complication of spinal-cord lesions. The deposition of calcium salts in soft tissues is another sequela of loss of calcium from the skeletal mass.

The clinical value of theophylline in heart disease

Abstract 1. 1. In the heart-lung preparation, when the heart was made to fail with chloral hydrate, theophylline produced an increase in cardiac output, return of the dilated heart to its original size, and fall in venous pressure. 2. 2. In patients in congestive heart failure, theophylline in the usual dosage caused a significant fall of venous pressure and a shortening of the abnormally prolonged circulation time. 3. 3. The effect upon the coronary circulation is uncertain. The coronary vasodilation frequently observed may be secondary to myocardial stimulation. It has not been possible to demonstrate an effect upon the course of angina pectoris by giving theophylline by mouth. 4. 4. Theophylline has a dilator effect upon peripheral blood vessels. This may be a factor in the lowering of venous pressure. 5. 5. Theophylline increases the pulmonary circulation, especially when the lungs are congested from the left ventricular failure. 6. 6. It has not been demonstrated that theophylline changes vascular permeability. 7. 7. The therapeutic uses of the drug are discussed.

The Effects of Immobilization on the Skin

One of the major hazards to face immobilized patients is the breakdown of the skin and underlying tissues. Those areas that are exposed to prolonged and excessive pressures are vulnerable, especially wherever bony prominences are close to the surface. Under normal conditions the skin is protected by frequent movements which shift the body weight from one area to the other. The immobilized patient is incapable of performing these weight shifts, and the same skin area remains under pressure for long periods of time.

The Effects of Immobilization on Circulation and Respiration

Any individual who has spent several days in bed has experienced the deconditioning effect caused by prolonged bed rest. When first resuming an upright position, the heart pounds, the head feels drained of blood, the skin becomes moist with sweat, and fainting is not uncommon. The patient feels weak with a diminished tolerance to exertion. One of the major advances in medical care during World War II was the institution of early ambulation after illness and surgical operations. The period of bed rest after repairs of hernias, for instance, was reduced from 2 weeks to a few days. Early ambulation drastically reduced the morbidity of surgical procedures which, as it turned out, had been due to immobilization as much as to the procedures themselves.

The Immobilization of Joints

The joint is an organ of motion; its structural and functional integrity is predicated on motility. The deleterious effects of immobility are based on the structure and biomechanics of joints. The deep layers of the cartilage are nourished by the blood vessels of the subchondral bone, but the superficial layers are dependent on the synovial fluid for their nutrition. The synovial fluid is viscous and has a high surface tension, which makes it cling to the cartilage. Joint motion makes for a constant interchange of fluid between the surface layers of the articular cartilage and the synovial fluid. When the joint is immobile the flow of the synovial fluid ceases, and the diffusion of fluid in and out of the cartilage stops. Joint motion causes alternating cartilage compression and distention. Absence of these pressure fluctuations causes a stagnation of the intercellular fluid of the cartilage and decreases its nutrition. After some period of time degenerative changes become permanent.

Immobilization and Skeletal Muscles

Skeletal muscle and immobilization are linked in a dual causal relationship. Muscle paralysis is an obvious cause of immobilization. On the other hand, when muscles are immobilized by extraneous forces they undergo changes which may permanently affect their structure and function.

General Aspects of Immobilization

Man’s body is organized for motion. The instrument of mobility, skeletal muscle, makes up 40 percent of the body mass. Its structure and metabolic capability permit an efficient and almost instantaneous shift from complete rest to a high level of activity. As a muscle becomes active, its blood flow may rise 15 to 20 times over the resting value, and the number of open capillaries may increase 50 times. The metabolic rate of the working muscle may be 50 to 100 times above that of a muscle at rest.