Latent Tetany And Anxiety, Marginal Magnesium Deficit

Reprinted from Diseases of the Nervous System Vol. 36 No . 8 August 1975 Pages 461 465
1975
46 1
Latent Tetany And Anxiety, Marginal Magnesium
Deficit, And Normocalcemia
MILDRED S. SEELIG, M.D.,t A DOLPH R. BERGER . M D.t AND NEIL SPIELHOLZ. Ph .D.tt
Abstract
The identification of marginal magnesium deficit ,
such as we ha ve detected in a patient with anxiety,
depression , and psychomatic complaints , is a difficult
diagnostic problem . Electromyography of a limb, rendered acute ly ischemic either just before or after hyperventilation , can elicit latent tetany in thi s condition , as
well as in calcium deficiency . We have demonstrated
iterati ve electrical activity in our patient, whose magnesium deficit is auri butable to renal wasting of magnesium . We have e licited s imilar patterns in several
other patients. who had margina ll y low serum mag·
nesium a nd who also exhibited weak ness. a nxiety, a nd
psychosomatic disorders . Thi s preliminary report suggests the need for further cons ideratio n of the possibility tha t chron i~ magnesium-defi c it ma y contribute to
the syndro me of la tent teta ny, psychosomatic complaints , and wea kness.
Electromyographic evidence of latent tetany has
been observed in some patients with marginal magnesium deficit , whose multiple ill-defined complaints
may be mistake n for psychon eu rosis .'-7 De fi ciency of
magnesium . which i!) predomina ntly a n intracellular
cation. is not often diagnosed in this country unless the
de ple tion is s0 severe as to cause symptoms referable to
overt te ta ny. o r me tabolic encephalopathy , o r both .
T hi!) form of encephalopath y has been clearly related to
lowered brain and cerebros pinal levels of magnesium in
mag ne!)i um-derived rats by C hutkow a nd his
~o lle ag u e!). M-~ · 10
Since 1958. however. lesser degree!) of magnesium
Jeticit (a s~oc ia t ed with a neuromuscular syndrome)
have been reported by Ro!>selleL 2 as "cryptote tany·· ,
a nd by Durlach 3 - 7 as ··spasmophilia .·· Although some
patients with this !) yndrome exhibit slightl y depressed
levels of serum magne~ium , low e rythrocyte levels
have bee n reported to occur more consistently .5 · 6 · 7
This syndrome, which occurs more frequently in
women than in men , is accompanied by many
psychosoma tic complai nts. The physical examination
is usuall y normal (or non-contri buto ry). The electrocardiogram sometimes exhibits ventricular premature contrat.:tion or mildl y abnormal fina l deflections .
The conventional electromyogram is normal. Howe ver . hyperve ntilation, and ischemia of the tested muscle , produce iterative electrical ac ti vity. We ha ve not
t From tht' Departmt'nt (~{ Medicin e . Nt'\1' York University
Medical Center. and Goldll'ate r Memorial H ospital
++Jnstitutt' of Rehabilation M edicine
found reference to this syndrome in the English language literature since Rosselle' s and Durlach 's
monograph s, 1- 7 although there have been numerous
publications in French and Italian language journals
(over 30 citations by Durlach in his 1969 monograph 7).
Recently we diagnosed this condition in a postmenopausal woman . 11
Case Report and Methods
SLB , a 57-year-old woman of Italian anl:estry, was
of weakness, depression , anxiety ,
··spots before the eyes'· , ge neralized pruritus, swelling
of the lower extremitie s and puffiness around her eyes
and mo uth . This clinical picture , which also included
occasional dys pnea and precordial pain , gastrointestinal complaints , without detectable organic cause , had
persisted for over two years. Cardiologic examination
was normal , psychiatric evaluation indicated only depressive anxiety , which yielded partially and temporarily to treatment , with diazepam and amitryptoline. Although skin testing showed no s pecific allergy , use of
antihistamine therapy has been necessary for control of
pruritus. The simila rity of her clinical picture to that
described as ··cryptotetany" or "spasmophilia" 1 - 7 led
to investigation of her magnesium status (details described elsewhere'') . He r initial serum magnesium
level was found to be margi nally low ( 1.67 mEq/L) , by
the range accepted as no rma l in the hos pital laboratory
( 1.9-2.5).' 3 Conventiona l nerve conduction tests and
EMGs had been found normal , but E MG s tudies (by a
technique mod ified from that e mployed by RosseUet. 2
and Durlach 3 - 7) elicited iterative a~ ti v ity. * After about
three minutes (two minutes of hyperventilation , followed by one minute of ischemia) single motor unit of
discharges appeared , firing at a relatively slow rate (two
to th ree per second) . At this ti~e , there were no visible
muscle twitchings or spasms . Within the next 15-30
seconds , motor unit activity increased in frequency ,
and the sounds characteristic of visually recorded
ho~pitalized becau~e
*The typical p~t tt erns of increa~ed electrical activity are
described' as (I ) repetitive! potentials of one or more motor
units, with repclltr ve d i~char ges (2-8 times) at frequency of
125 to 250 per se.:ond . termed doublets , triple t~ . quadriplets
or multiplets, (2) ~pon ta neou ~ dischar ges of a motor unit of
high frequency ~~- 1 2 per second) during slight involuntary
contraction . Ros!>dle 1 interprets the EMG as positive if
regular repetiti ve activity persis ts for at leas t two minutes
during the pos t-ischemic phase or after h yperpnea.' If the
modification is used , the pa tient hyperve ntilates befo re ische mia is induced (See Appendi x).
462
DISEASES OF THE NERVOUS SYSTEM
Figure 1: Doublets fro m abductor pnllio.:i\ hre\i~ afl er two minute' of
hypc:rventilation followed by 1.5 mmute~ •>f ischemia. Calibration signifies 100 ms and 100 uV .
AUGUST
provement experienced following the injection of magnesium . The EMG, taken shortly thereafter, was normal and repetitive firing and spasm could not be provoked by hyperventilation , followed by ischemia for 10
minutes.
For several weeks , thereafter, she received oral
magnesium supplements, and it was possible to decrease the use of antihistamine and diazepam. However, a month later, the intensity of her complaints
completely returned, and she obtained brief (1-2 day)
periods of relief only after intramuscular injections of
magnesium. Placebo injections produced no clinical
change. Rehospita lization . on several occasions. for
metabolic and hormone studies, revealed that she was a
renal magnesium waster. and that she had intermittent
normotensive aldosteronism. with peripheral edema
and sodium retention.•• Her serum magnesium level
usually remained below I. 7 mEq/ L. serum calcium was
normal (9.5-9.7 mg%) . Serum magnesium values of2. 1
mEq were reached after repeated intrave nous or intramuscular injections of magnesium. On one such occasion. her hyperventilation/ischemia EMG did notrevert to norm al. even when te~ted ~hile she was receiving a n intravenous infusion of 200 ml of dextrose and
water. to which 2 ml of magnesium sulphate had been
added . Her symptoms improved the next day. after a
second magnesium-infusion. Two hours after completion of the second infusion. her EMG was normal.
Discussion
t"igure 2: Complete interference pallerns recorded simultaneously
from abductor pollicis bre' i' and ahd uctor digiti quinti after :!.5
minutes of ischemia.
doublets and triplet s could he heard. (Fig . I).
During the following 60 seconds . the acti\·it j inu eased to such an extent that a complete interference
pattern was recorded (Fig. ::!) and at the same time
marked wrist and finger spasm were evident. These
contractions were completely in voluntary . With release of the cuff after only two and a half minutes of
ischemia, all electrical activity disa ppea red within 30
seconds.
The next day. to test for magnesium deficit. the
patient was given an intramuscular injection of 2 ml of
a 50% of solution of magnesium sulphate (to test for
percentage retention of magnesium). 1 .. 12 She retained
over 60% of the parenterally administered magnesium.
in contrast to the normal retention of 15-2® ..... 2
Within two hours of the injection she experienced
marked relief of all of her symptoms. In the course of
her ho<; pitalization the patient had received many other
injections . none of which had evoked the clinical im-
Our patient with the abnormal h yperventilation/ischemic EMG pattern and carpal -.pasm. and
those described in Europe_. _ , a ll had marginal magnesium deficit.* Similar signs are also seen with hypocalcemic latent teta ny! 4 · 15 · 16 However. Rose1Jel. 2 and
Durlach 3 -• have reported that their patients had similar
clinica l and electrical phenomena with magnesium deficit, in the absence of hypocalcemia. Similarly. our
patient showed these findings with margina lly low
serum magnesium levels. but normal serum calcium
le vels.
*We have su bsequentl y obta ined s imilar electrica l findings on
three additional patients without neuromuscul ar disease. In
two. the h yperventilation/ ischemia EMG was found abnormal after the diagnosis of magnesi um deficit had been made
on the basis of serum magnesium levels of I. 1- 1.4 m Eq/ L
and multiple psychosomatic a nd neuromusc ular complaints.
In a nother. the hyperve ntil ation/ischemia test was employed because of the patient's biza rre neuromuscu lar complai nts. When strongly positive EMG results were elicited.
his serum electrolytes were analyzed. He was normocalcemic. but his serum Mg was I .5 mEq/ L. To evaluate the
significance of these pat ients· neuromu scu lar irritability , as
demons tra ted by electromyography foll owing h yperve ntilation and ischemia. we tes ted ten normal volunteers. who did
not have neuromuscular o r psychiatric abno rmalities. Magnes ium serum levels . "'hich were done only in five. were
within normal limits . None exhihited th e EMG pattern descrihed here . .:' en "'h.:n the pl>St-h yperventilation ischemia
was maintained for ten minute s.
1975
'
LATENT TETANY AND ANXIETY. MARG INAL. MAGNESI U M DEFICIT
Although hypocalcemia and hypomagnesemia each
causes clinically ma nifest neuromuscular irritability
and electromyographic a bnormalities . suc h as are reported here. nerve ph ysiology studies indicate that the
mecha nisms are not the same . Chutkow 17 has reviewed
the evidence and points out that, a lthough magnesium
deple tion has electrophysiologic effects on nerve axons
similar to those of calcium depletion , the calcium effect
far outweighs the magnesium effect at this site. Calcium
is principa lly involved in nerve membrane potential and
stability ; depressive effect of hypercalcemia is caused
by ner ve membrane hyperpolarization, dec reased
sodium conductance. a nd resultant elevation of the depolari zation threshold . With h ypoct~ lcemi a the re i-; .m
increase in depolarization that a llows for response to
slow depolariza tio n and loss of accommodation, 2 .. 22 as
a result of which peripheral nerves di scharge
independe ntl y. 23
When a nerve impul se reaches the skeletal
myoneura l junction. the resultant depolariza tion of. the
nerve endings re leases ace tyl choline (ACh) into the
syna ptic space. 2 u 5 ACh mo lec ules then diffuse across
the syna ptic cleft and attach to specific receptors of the
spec ialized area in the postsynaptic sarcolemma. which
results in non-specific inc reased ionic permeability ,
flow of'an ionic current , and -depolarization (the end
plate potential). When this depolarization reaches the
excitation threshold of the adjacent sarcolemma, a
muscle action potential develops, that ultimately initiates the mu scle contraction. Magnesium exerts its
majo r neuromuscular effects at the myoneural
j_unction. 17 · 24 -~ 0 At this site. calcium and mag nesium
are a ntagonistic . 2" -28 - 2 !1· 30 -3 1
Calc ium enhances. and magnesium inhibits, therelease of ACh. Additionally. the sensitivity of the motor
end plate is diminished by high magn-esiu-m
concentrations, 25 such high concentrations also having
cholinesterase-activating effects. 32 ·33 Thus, hypocalcemia exerts two paradoxical effects: it increases
periphera l nerve excitability , but it decreases release of
the neurotransmitter (ACh) into the myoneural synaptic space . We postulate that the hypocalce mia-induced
suppressio n of neuromuscular transmission may be
overcome by the increased presence of ACh resulting
from magnesium deficit. Increased tra nsmitter augments the tendency towards repetitive sarcolemmal
depolarization a nd muscle contraction.*
Since either hypocalcemia or hypomagnesemia can
elicit similar abnormal hyperventilation/ischemia EMG
patterns, both cautions must be measured to elucidate
the specific deficit. The patients described here, and
those reported earlier, 1 - 7 all had margina lly low serum
magnesium and normal serum calcium levels. In our
gro up, we rarely saw serum magnesium levels below
1.5 mEq/ L.
In view of our patient 's la tent tetany a nd neuropsychiatric manifestations, the findings of Chutkow et
463
a J8.11·10 may have s pecial relevance. They demonstrated
tha r rars with acute, subacu te or chronic magnesiumdeficiency exhibit decreased brain a'hd cerebrospinal
fluid magnesium levels, not necessarily closely related
with changes in blood levels of magnes ium. They found
that even small decrease s in brain magnesium are accompanied by ma rked a lteratio ns in bra in
excitability .t 0 Whether the slight electroencephalographic abnormalities of our patient, elicited only during hyperventilation, reflect a magnesium-deficit encephalopathy, remains to be proved .
C hutkow and Grabow 10 also commented on the
hi '\ta min e- relea~f' of rnagnc ~in rn -deprivation , 36 - 37 an
important point in terms of the evidence that histamine
may be a central neurotransmitter. 10 Note should be
made. here. that one of our patient's most distressing
complaints is generalized pruritus, and that her requirement for antihistamine therapy exceeds the
amount tolerated by most subjects .
Worth mentioning , also, is the fac t that 75% of
Roselle 's patients with latent teta ny of magnesiumdeficiency improvec.'l on treatment with thyroxine.•
Th is is a provocative finding. since thyroid h'ormone
affects protein-binding of magnesium; its influence on
the ratio·oNree to~tround •magn·esium-~i S" no't'<lefmitely
established.38 Before instituting this therapeutic approach in our patient , who has thyroid function at the
low limit of the normal range, we considered the similarity of some of her findings to those of some patients
with periodic paralysis or weakness, who also have
intermittent aldosteronism, and who exhibit exacerbations in response to administration of salt: 39 ·40 In this
context, we must recall that some patients with periodic
para~ysis have responded favorably to thyroid administration or stimulation, -and have experienced rec urrence of weakness or withdrawal of thyroid
therapy, 41 whereas others have periodic paralysis in
association with hyperthyroidism. 41 · 42 Whether our pa~
tient, who a lso suffers from marked weakness, presents
a nother facet of hypoka lemic periodic paralysis (magnesium deficit being known to predispose to.Joss of
muscle po tassium , a nd to prevent its repletion)43• 44 requires further elucidation.
Remaining to be explored is the relationship of such
patients' multiple neuropsychiatric complaints with a
possible metabolic encephalopathy , that may be caused
by chronic magnesium deficit. 8 · 9 · 10 Study of cerebrospinal fluid levels of magnesium . during phases of exacerbation and remission, possibly in association with
meta bolic balance data obta ined during magnesium
*Combined deficits give rise to severe forms of neuromuscular irri tabili t y. Whether th e convul s io ns of infanti le
hypo magnesemic hypocalcemia, t hat are refractory to
treatment unril borh defi ci t ~ (Ire correl: t e~.J. ·11 " are relevant
liJ the clinical tetany that is the su bjec t of this paper is moot.
What ha ppens at the myoneura l junction· in response to
calcium and magnesium may differ from what happens in the
central synapses.
464
supplementatio n and restriction , may provide valuable
inc;ight intn the syndrome de c;crihect here.
10. C hutkow . J .G .. Grabow . J .0 .: C linical and chemical corre lations
in magnesium- depri v:~ ti<>n t> n c e rh alnpath~· of V<>llng r;j r ~ . Am ./.
Plr n iol. 221 14!17- 1414. 1972 .
Seel ig. M .S .. Berger . A R.: A ne"' c linica l patt,.rn <'f magnesium
deficit associated with renal magnesium wa~ting . Oe~c ri ption pf
a ' y ndrnme m::~nife<te d hy pruritus. fa t il!lle . depressi ve a nx iety .
al>normal electrnmyo(!ram . <~ n d n o rmu t en~ive. inte rmirtent a ld ost e roni~m . !Sub mitted for publ. )
II
APPF:NOJX
I . The c;ubject . lying completel y rela xed o n a comfortable couch , is ins tructed not to move the hand o r
arm (to eliminate voluntary contraction of th e mu scles of the limb being tes ted) throughout the entire
test procedure . A blood-pressure cuff i<:> wrapped
around the upper arm .
2. A teflon-coated mono~)Ja r needle electrode io; inserted into the a bductor digiti quinti heing tested
and a o;urface electrode is ta pt'd over th e insert ion llf
thio; muo;cle . A o;imilar pair nf e lectrnde' ;._employed
to record from the ipsilatera l ahcluctor po llicio; hrcvis muscle . The e lectri cal ac ti vity from ho th muscles io; dis plaved o;imultaneous ly o n tw1l c hannels llf
a Teca TE-4. wit h co nstant mPnitoringo n fiheroptic
readout .
12 . Fo urman. P .V .. Morgan. D . B .: C hro 'lic
Prl'c. ,'\.utr. Sr.'c-. 21 :34-4 1, 1%2 .
n.
ElecHom) <•gr;•phoe 1n n enou~ di~ea~ e and in nyptotetany. Ed\ . E . Nauwe l aert~. Pul>l. U ni versi•;j ire 2. l.ouvai n .
Be lgi11m . 1951! tin F rench I. 14~4 tin Engli~h):
3. Durlach. J.. Lebru n . R .: Magnesium et
p<~tho~genit>
mo philie con~titutione lle idiopathiqut> . I R
15l: 1973- 197.~ . 1959 .
tfl
1960.
Durlach . J .. Dreu x. C. . Le l>run. R . . Jarreau F X . Ba rachet L.:
Etude statistique de magne~ium e r ythrocytaire dans Ia s p asmo philie con stitutionelle idiop athique. Ann Endorrinol (Pa ris)
23:83-88. 1%2 .
6 . Durlach . J .. Gremy . F .. Metra l. S .: La s pasmo philie: form s clinique n euromu~culaire du deficit magnesien primitif. Etude s tatistique de Ia valeur diagno~tique et p rojUlostique de~ c riteres clini ques et paracl inique~ . R Po·. Nt>urol . 117: 177- 189. 1967 .
7 Durlach , J.: Spasmophilia a nd magne ~ium clefic it. Pub /. M a.<.<FJn
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8 C hutkow. 1 .G .: Clin ical-chemical co rrel a t ion ~ in the t> nce phalopathy of m ;~gnesi um de fi cie ncy . Effect o f rever~al l'f
maanes ium deficits . .\f11y(l Clin Pmc· 49:244- 247. 1974.
9. Chutkow. J .G . . Meyers . S .: C ht>mical c hanges in the ce rebrospinal fluid and 1-lrain in magn ~siu m deficiency . \'purt~l'll!."
18:963-9?4, 196S.
-
....
f-e ld man . R.<i .. <ir ;tn!!er . r:. \
rl e~·trc>mv•JI!raph' in latent
reran) . , ._ Fl!l!l. J \-f,.,J Y·4· )()1>4 - l %~ . tOf,l
· in Il u man Patho logy . Vitt el.
F~anct>
1<17 t· I P-Il4 .
i\dt>lman . W Jr .. M•.'Ore. J .: '\c tion of exte rnal di valent ion
reduc tion o n <odiu m movement in the <quid 11iant :~ •on J . r;,,_
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d e plf't io n '-' " ~i ngle nt>l'e fiN>r~ . J . (;,.., Nn·, ir:/. l'J:7<3 T' ~ 195ft
:.>n . Guttman. R .: <ital>ilintion of s pi<ler c rab nerve membranes by
alkaline eart h s.:~~ ma nifested in resti ng potel't i :~ l meas urements.
2~ : 343 -364 . 1<140.
J r.en . Phv.tin/.
2 1. Kugelb<:rg. E.: Acc<'mmodat ion in human ner ves . A r •a . Plrv.<iol.
S r·and. 8: Suppl 24 . 1944 .
22 . Soland!. D. Y.: The measuren•ent of -- accom modation ·· in nerve
, ,,,_., ._ Rm· Soc . 119: l<_'i - ~i9. 19'5 .
::'l
Koenig. H . . Stahlec ker. H . a nd K<lenig. R .S .: The n c uromu ~c oo ­
la r rrechani'ln l'f a lkaloti c a nd h } pnn tl·:l'mic t t'la n} . p,,, '"'
l-:.•1•- Hi,J . .\lt-J ~'J · HH- U3. 1<1 ~ ::' .
~.J .
DelCastillo . J .. Katz . B.: Quanta! C<rmp<>nenh of the end-plate
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25·. DelCastillo . J .: The trans mi ~~ion of excitation from nerve to
mu ~c l e . in Ad a ms . R . D .. Eato n . L.M . . Shy. M . tedsl :
'1/eur.,musc-ular Di.w rdl'n . Ra ltimo re. Williams and Wilkin ~.
196U. 9H-14l .
Fffect ~ o f magne<ium
conce ntrati<>n in ' enrnr
2f.. HnfT. H . E .. Smith . P . K .. Winkler. A .W .:
o n the ner vou~ <ystem in re l:~tion tn
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tP<~ri~l
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<>gy . PnK Fir~t International Srmpo~ ium on Magnesium Defi<·it
de J;j 'l'a'-
s,.,. Bioi
deficiency.
1< Alajo11an inc. l .. l.\ >nt~n11n . F . l..athala. H .P.. S.:herrer . J t ·,.ntrihuti<ln elec trnm v•'grapho411e a une delim it,.ti•>n de Ia tt>Ja nie df'
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Ro~se ll e. ~ . ·
2. Rosselle . N .. Ooncker. K .: La t etanie magne~ iprive che1
l'ho mme. Etu de 1-lioc hemiqut> f't e lec tromyngraphique . Pculr
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magne~i um
14 . Turpin. R .. Lefe bre. J . Lerique . J .: I.e ~ modifications de
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194l
IR
3. After determining w hethe r there is electrical activity
at rest , the patient is asked to hyper ven tilate for two
minutes . Then th e c uff is infla ted to a h<lut 20 mm Hg
above the pressure which ohliterates the radia l
pul se. If o;pontanemts discharge occurs earl y. pre!'s ure is m aintained for two minutes. to a llow for
development of the interference pattern . (A pattern
.Qf e lectrical acti vit y produced when numerous
motor units are active so th at their action potential
can no lo nger be identified individuall y). Pressure
s ho uld not be mainta inerl lo nl!er tha n ten min11tes.
~-
AUG I JSl
D ISEASES O F THE NERVOUS SY<;l FM
~7 .
i t~
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o n the rele il~e nf a cetylcholine . J . l'ln·siol. I ::'-1 :\4 ?-11, 1954.
29. Jenkinson . D.J .: The natu re of t he antagoni,m l>et wt>en calcium
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131!:414-444. 19~7 .
)0. Hubhard. J.L.: The effect of calcium a nd magnes ium o n the
spontaneous release of transmitter fro m mammalian motor ner ve
e ndings. J. Ph•·siol . 1 59:~07-5 1 7 . 1%1.
31 . Kuruyama. H .: Effec t of calcium and magnesium o n ne uromusc ular transmissio n in the h ypogastric nerve-vas deferens prepa rati<>n of the guinea pig. J . P h\-si•J/. 175· 211 -230. 1964 .
32 Mendel. B . . Mundell. D .. Strelitz . F. : C h oli nester a~e and electrolytes . .\loture 144 :479-480. 19.'9 .
33. Nachmansohn . D : A r t ion of ion~ o n choline es tera\ e . Satun
14~ · 513-~ 1 4. 1940.
34. Da' is. J .. Han e}. 0 . . Yu 1.: Neonatal fits associated with
h ypomagnesemia . -'\rclr / )is 1 /ri/d/r . 40:286-290, 1965 .
I'J7:'i
3~ .
I A
rr
T TETANY AND A
X I ETY. MARtd' -\I. 1\11\(iNlcSil!M DEFICIT
465
fre1dman . M .. Hatcher. G . . Wal\on. L. : Primary h ypomag·
nc\emia v. ith ~t"nmdary h y poc:ah:t"mia in an infant . Lanr·n
1 : 7(11.70~. 1%7.
43 . Whang . R .. Morosi . H.J .. Ro dgers . D .. et al: The influence of
"'<rained m :~gne< ium dcficicnc~ ,m mthcle P<'' <~""'m re pletion
J l .ah C/in . \fed 71)"!!95-902. 1967 .
36. Belanger. L.F . . Van Erkel. G . A . . J a kerow, A .: Behavior of the
derm a l maq •·e ll' in magne~ium - defic: ie nt rat~ .
126: ~9- 30. I ')~7 .
44 . Wha ng. R.: Some aspects of t he interrelatio nship of magnesium
;~nd pNa<<ium . .1. Citron . f1iL 21 :207-210. 1%8.
s, ;,,,,, ,.
37. Bois. P .. Ga5con. P .. Bea ulnes. A . : Hi stamine- li berating effect of
magne~ium deficiency in the ral. NolllrP 1')7:50 1-502. 1%3.
311 . Wal~er , M .: Magnesi um metabo l i~m . Er~:Ph . Phn i" l.
59: 1!!5-2%. 1967.
1<1. Conn. J .W . . Fajans. S .S .. Loui~. I.. H .. Stret"ten . O .H . P .. John-
'"". R. D.: Int ermittent a ltlo~terr•ni s m in periodic pa ralv ~i ~ : depem.l .. nc•: nt allao:k' P n rete ntion of ~ ·xl•um a nd failu re to inJoce
attack t--v re,tJ iction of dif'•an ~·xlium l .annt 1 : ~0 ?- RO~. 1 4~7 .
Ill. I nne,. R \ ' . \ kS"' een•· '. R R . ll roJ• lk S. R V · Peri<>dic
pit t:tl\'1' '\ndiurn !nt•t tr • !; I 'IT" 1nd ;tldl'"'t!JnOe · ,:trl il 0. •
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I ngk . \ <j . lh,nud tunc ti• lll and p.. ri.)clic: para l y~i< . Am . .I
\1, " · ln: 127· n ' · 1% t
4? Satoyo<hi . E .. Mura ka mi . K . Knwa. H . . et al: Periodic p;oralvsis
in h ypert hyroidi<m . v""'" '"~'· 11 : 74f>.~72 . 1%3.
II
Acknowledgement
Sinare apprrciation is exrresud t o Dr. Jerry
Cl111fko 11-.for his rel'i ew of this mantHcript. and for his
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