47 laborative Study was instituted, and it is regrettable that participating members of that study should publish preliminary data leading to conclusions which may turn out to be mislead-
ingly optimistic. Department of Human Genetics, Western General Hospital, Edinburgh EH4 2HU.
D.
J. H. BROCK
AMNIOTIC ALPHA-FETOPROTEIN AND OMPHALOCELE
SIR,-A transabdominal amniocentesis was performed for genetic reasons in the 15th week of pregnancy in a 27-year-old patient, whose third child had had Down syndrome. The ocfetoprotein (A.F.P.) concentration in the amniotic fluid was very high, 110 µg/ml at first and 115 µg/ml a week later (upper limit of normal 50 µg/ml). The raised A.F.P. level suggested that the fetus had an open neural-tube,defect and the patient decided to have a termination, which was carried out by intravenous infusion of prostaglandin E. A female fetus with an extensive omphalocele was delivered. The liver and small intestine were in the omphalocele, but there was no skin defect. This is the second case, to our knowledge, of a raised amniotic-fluid A.F.P. concentration early in pregnancy associated with an omphalocele. Nevin and Armstrong’ reported the first. Omphalocele may be a further malformation associated with raised A.F.P. levels. Department of Obstetrics and Gynæcology, University of Zurich, 8006 Zürich,
stayed under 10 mvmin, with blood-creatinine values between 6.5 and 8.5 mg/dl. At the end of September she had slight hypogastric malaise, especially at night, but without signs of uterine irritability. On Oct. 17 she spontaneously had a high rupture of membranes. Delivery was induced with oral synthetic oxytocin. The fetal sounds were normal and there were no signs of fetal hypoxia. Delivery was normal, and a male of 35 weeks’ gestational age and 2200 g body-weight, with an Apgar score of 8 (10 after 3 min) was born. There were no visible congenital anomalies. The post-partum course was normal until amenorrhoea developed. At that time her blood-urea was 250 mg/dl, creatinine 10.9 mg/dl, and creatinine clearance 4-5 mvmin. She has since been on periodic haemodialysis. The infant’s development has been normal. This case shows conservative management can be successful in a pregnant woman with poor renal function and hypertension. Nevertheless we feel conservative treatment should only be tried in a centre with dialysis facilities and under close supervision. The control of the hypertension must have been the chief reason for the successful outcome of pregnancy, since fetal prognosis is related more to maternal blood-pressure than to uraemia. A detailed account of this case is given elsewhere.3 J. EGIDO DE LOS RíOS Nephrology Service, J. J. PLAZA PEREZ Fundación Jiménez Diaz, S. CASADO PÉREZ Avda. Reyes Católicos 2, L. HERNANDO AVENDANO. Madrid 3, Spain
JÜRG KUNZ JOSEF SCHMID
Switzerland.
PSYCHOGERIATRIC PATIENTS WHO DIE IN HOSPITAL
SUCCESSFUL PREGNANCY AND ADVANCED
SIR— You point out (Oct. 25, p.801) that the chances of a successful pregnancy are slim if the mother’s plasma-urea exceeds 60 mg/dl, especially if she is hypertensive. In Mackay’s large experience2 they were nil. We have successfully managed a pregnancy despite advanced renal failure and hypertension. A 33-year-old woman, six-months pregnant, entered the nephrology service in August 1973, when her blood-urea was found to be raised. Her first pregnancy 8 years previously had been complicated by palpebral and ankle oedema, proteinuria, and hypertension. She was treated with salt restriction and hypotensive drugs, and gave birth to a normal infant. She has since presented with polyuria, polydipsia, and nocturia, high blood-pressure (diastolic 90-100 mm Hg), and proteinuria up
to 3 g/l. Her second pregnancy had started with
vomiting and ankle cedema during the first 3 months. When we saw the patient her blood-pressure was 155/90 mm Hg; pulse 88/min, slight systolic on the basal area. Uterus palpable at height of umbilicus. Fetal heart sounds normal. Slight ankle oedema. Eye fundus normal. Laboratory assessment included Hb 6.5 g/dl, urea 160
mg/dl, creatinine 6.5 mg/dl with a clearance of 10 ml/min. Urinalysis revealed 2.7g protein/24h white and 60 red bloodcells high-power field, and evidence of urinary infection (Escherichia coly. The E.C.G. showed left-ventricular burden. She was ordered complete rest and checked daily. The diet contained 2500 kcal and 40 g proteins with supplements of calcium, iron, and vitamins. Aluminium hydroxide was added and 500 mg of progesterone were administered weekly. Packed red blood-cells were transfused to maintain the hsematocht above 20%. Blood-pressure was controlled with reserpine and
hydrallazine. Her acidosis was corrected and she was maintained in adequate salt and water balance. Creatinine clearance persistently 1.
Nevin, N. C., Armstrong, M. J. J. Obstet. Gynœc.
Br. Commonw.
826. 2.
McKay, E. V.
Aust. N.
SIR,—Stone House is the main, though
not the only, psychihospital serving the Danford and Gravesham Health District, which has a population of about 250 000. The population is not exceptional-in particular, there is no special geriatric loading such as may happen on the south coast. We have about 27 000 people over the age of 65 in our district. Between January, 1970, and June, 1975, 155 patients from
atric
RENAL FAILURE
Z. Jl Obstet. Gynœc. 1963, 3, 21.
1975, 82,
the district over the age of 65 died. Less than half had been in hospital for more than a year: Years
Up to
Up to 2 2-5 6-10 11-15 16-20 Total
Total 86 51 10
M F 36 50 12 39 3 7 22 1 3 54 101
36
86
50
4 4
155
37 had been in hospital for a month or less before they died 14 survived a week or less in hospital). The causes of death of these 14 were: bronchopneumonia (3), pulmonary embolus (3), congestive cardiac failure (3), myocardial infarction (2), cerebrovascular accident (1), cor pulmonale (1), carcinoma with metastasis (1). Of the 155 patients only 7 were admitted on this final occasion before the age of 65, and among these 7 by far the larger part of their stay occurred over the age of 65. It can be concluded therefore that district patients admitted before the age of 65 seldom remain in psychiatric hospital up to or after that age without a break until their death there. Only 32 patients had previously been admitted to this psychiatric hospital within the last 15 years or more, for an earlier episode of illness. 127 were considered at the time of their final admission to have a cerebral organic state (e.g., dementia or confusion). These patients were, on average, in their late 70s (males) or early 80s (females), and most of them had been in hospital a year or less when they died. The direct cause of death in most instances was certified as bronchopneumonia or car-
(and
3.
de los Rios, J., Plaza, J. J., Fernandez Revta. clin. esp. 1975, 137, 363.
Egido
Aparicio,
M.
A., Hernando, L.
48 in what would seem to have been the last year of irreversible natural ageing. Should this make us think again about paragraph 23 of the memorandum on Services for Mental Illness Related to Old Age (1971)? Should not most of these patients die in accommodation designated as geriatric rather than psychiatric?
diorespiratory failure,
Stone House
Hospital,
Dartford,
J. P. CRAWFORD
Kent
NORMALISATION AND SI UNITS
SIR,—Lennox1 has suggested a solution to difficulties over SI units. I may have misunderstood his letter, but his suggestion is not new. Hofmannin addition to describing a now well-known method for determining "normal" limits from cumulative patient data also described a "normal quotient scale",3 based on the standard deviation of a normal population. In his scheme standard deviation (s.D.) equivalents are transformed to a positive number scale in which mean normal is 100 and the 2s.D. range is 90-110. Many clinicians are frightened by statistics, and Lennox will do nothing to gain their confidence by recommending dry works such as "Bradford Hill".4 (Perhaps newer generations will be less averse to statistics having been taught their value and limitations from an
earlier
age.) s.D. units are derived very simply: = S.D. unit unit=
X-M,
S.D.
where X = value obtained, M mean of normal population, and s.D. = standard deviation of normal population. S.D. units can easily be reported graphically, and for diehards absolute values can still be reported alongside. We had considered changing to this system of reporting and had had some painless internal practice when it appeared that SI units would be more generally supported. A number of critical letters have appeared in The Lancet and elsewhere suggesting that the change to SI is full of difficulties, and I have drawn attention to possible dangers of uncritical acceptance of these units/ Nevertheless many hospitals have successfully negotiated the transition to SI: perhaps the present controversy is due to their not stating how easy this change has been. Others also have suggested "normalisation" for laboratory reporting’6 but if this is a simple solution to the unit problem what a pity that it was not examined before SI units were introduced on a national basis. "Normalisation" should be thoroughly examined---even now it is not too late since many are still struggling to learn the SI units of clinical value, or, like our transatlantic colleagues, have refused to change. Let us have published the figures of how many areas have changed to SI, and whether doctors are in favour of the change or not. Would doctors favour a change to normalisation or, as I suspect, would they prefer no change at all? There must be somebody with sufficient time to do such a simple monitoring project, even at the risk of being awarded a PH.D for doing so. =
States of Jersey The Parade,
Pathological Laboratory,
Jersey, Channel Islands.
J. J. TAYLOR
BREAST EXAMINATION IN OBESE PATIENTS
SIR--Examination of the axillae of obese patients with disease may be difficult, particularly for the group of
Dreast
lymph-nodes situated in the pad of adipose tissue between the pectoralis major and minor muscles. The probing fingers may push the pad into the wedge-shaped space between the muscles, and the enclosed nodes become impalpable. 1. 2. 3. 4. 5. 6. 7.
Lennox, B. Lancet, 1975, ii, 1085. Hofmann, R. G. J. Am. med. Ass. 1963, 185, 150. Hofmann, R. G. GP, 1964, 30, 112. Hill, A. B. Principles of Medical Statistics, London, 1971. Taylor, J. J. Br. med. J. 1975, iii, 226. Rushmen, R. F. J. Am. med. Ass. 1968, 206, 836. Schoen, I., Brooks, S. H. Am. J. clin. Path. 1970, 53, 190.
I have found an additional step in routine examination to be useful in detecting these nodes. The patient is asked to lie supine with the arms resting in the adducted position. To examine the right axilla the examiner stands on the patient’s right side and depresses with his right hand the pectoralis major muscle downwards towards the chest wall; this manoeuvre causes the pad of adipose tissue between the muscles to prolapse towards the lateral border of the pectoralis major muscle, where enclosed nodes are readily palpated by the left hand. The left axilla is examined with the left hand depressing the muscle and the right hand palpating. I have found this method more reliable in the detection of this group of nodes in obese patients than the usual method. Kingston General Hospital, Kingston on Thames, Surrey.
N. G. BUCHAN
DIMINISHED T.S.H. SECRETION DURING ACUTE NON-THYROIDAL ILLNESS IN UNTREATED PRIMARY HYPOTHYROIDISM
SIR--Dr McLarty and his colleagues (Aug. 9, p. 275) found changes in thyroid function in clinically euthyroid patients after acute stress. After myocardial infarction and cerebrovascular accidents there is a significant fall of both total serum T3 and T4, the fall in T3 being greater than the fall in T4. These changes do not appear to be due to changes in thyroid-hormone binding proteins, since free T4 and T3 indices parallel the total T4 and T3 changes. The changes observed in these "sick euthyroid" patients may be due to one or more of the folTHYROID FUNCTION IN DIABETIC HYPOTHYROID PATIENT IN PRECOMA AND
DURING RECOVERY
mechanisms: hypothalamic-pituitary dysfunction, decreased peripheral conversion of T4 to T3, and/or the production of reverse T3.’ I have made sequential measurements in one patient which demonstrate hypothalamic-pituitary dysfunction during acute
lowing
non-thyroidal illness in untreated primary hypothyroidism. The patient, a 39-year-old diabetic, was admitted in precoma due to ketoacidosis (blood-glucose 95 nmoV1, ketonuria, pH 7-11) associated with a respiratory-tract infection. She had had a thyroidectomy for thyrotoxicosis 7 years before. Histologically, there was evidence of lymphocytic infiltration, and thyroid autoantibodies were present in high titres. There were no overt clinical features of thyroid dysfunction on admission. She was treated with a low-dose intramuscular insulin regimen, saline infusion, potassium supplements, and ampicillin. Stabilisation was difficult, but satisfactory control was achieved after 10 days. Serial measurements of thyroid-hormone and thyroid-stimulating-hormone (T.S.H.) levels during the acute phase of her illness and her convalescence are shown in the table. On the morning after her admission total serum-T4 levels were low and total serum-T3 and T.S.H. levels were undetectable. 2-3 weeks later, before discharge, total serum-T4 levels had risen to just below the normal range, total serum-T3 levels were within the normal range, and T.S.H. levels were raised. 3 months after admission, subclinical primary hypothyroidism was confirmed by a persistently low serum-T4, a total serum-T3 at the upper end of the 1.
Wenzel,
K.
M., Meinhold, H. Lancet, 1975, ii, 413.
ingly optimistic. Department of Human Genetics, Western General Hospital, Edinburgh EH4 2HU.
D.
J. H. BROCK
AMNIOTIC ALPHA-FETOPROTEIN AND OMPHALOCELE
SIR,-A transabdominal amniocentesis was performed for genetic reasons in the 15th week of pregnancy in a 27-year-old patient, whose third child had had Down syndrome. The ocfetoprotein (A.F.P.) concentration in the amniotic fluid was very high, 110 µg/ml at first and 115 µg/ml a week later (upper limit of normal 50 µg/ml). The raised A.F.P. level suggested that the fetus had an open neural-tube,defect and the patient decided to have a termination, which was carried out by intravenous infusion of prostaglandin E. A female fetus with an extensive omphalocele was delivered. The liver and small intestine were in the omphalocele, but there was no skin defect. This is the second case, to our knowledge, of a raised amniotic-fluid A.F.P. concentration early in pregnancy associated with an omphalocele. Nevin and Armstrong’ reported the first. Omphalocele may be a further malformation associated with raised A.F.P. levels. Department of Obstetrics and Gynæcology, University of Zurich, 8006 Zürich,
stayed under 10 mvmin, with blood-creatinine values between 6.5 and 8.5 mg/dl. At the end of September she had slight hypogastric malaise, especially at night, but without signs of uterine irritability. On Oct. 17 she spontaneously had a high rupture of membranes. Delivery was induced with oral synthetic oxytocin. The fetal sounds were normal and there were no signs of fetal hypoxia. Delivery was normal, and a male of 35 weeks’ gestational age and 2200 g body-weight, with an Apgar score of 8 (10 after 3 min) was born. There were no visible congenital anomalies. The post-partum course was normal until amenorrhoea developed. At that time her blood-urea was 250 mg/dl, creatinine 10.9 mg/dl, and creatinine clearance 4-5 mvmin. She has since been on periodic haemodialysis. The infant’s development has been normal. This case shows conservative management can be successful in a pregnant woman with poor renal function and hypertension. Nevertheless we feel conservative treatment should only be tried in a centre with dialysis facilities and under close supervision. The control of the hypertension must have been the chief reason for the successful outcome of pregnancy, since fetal prognosis is related more to maternal blood-pressure than to uraemia. A detailed account of this case is given elsewhere.3 J. EGIDO DE LOS RíOS Nephrology Service, J. J. PLAZA PEREZ Fundación Jiménez Diaz, S. CASADO PÉREZ Avda. Reyes Católicos 2, L. HERNANDO AVENDANO. Madrid 3, Spain
JÜRG KUNZ JOSEF SCHMID
Switzerland.
PSYCHOGERIATRIC PATIENTS WHO DIE IN HOSPITAL
SUCCESSFUL PREGNANCY AND ADVANCED
SIR— You point out (Oct. 25, p.801) that the chances of a successful pregnancy are slim if the mother’s plasma-urea exceeds 60 mg/dl, especially if she is hypertensive. In Mackay’s large experience2 they were nil. We have successfully managed a pregnancy despite advanced renal failure and hypertension. A 33-year-old woman, six-months pregnant, entered the nephrology service in August 1973, when her blood-urea was found to be raised. Her first pregnancy 8 years previously had been complicated by palpebral and ankle oedema, proteinuria, and hypertension. She was treated with salt restriction and hypotensive drugs, and gave birth to a normal infant. She has since presented with polyuria, polydipsia, and nocturia, high blood-pressure (diastolic 90-100 mm Hg), and proteinuria up
to 3 g/l. Her second pregnancy had started with
vomiting and ankle cedema during the first 3 months. When we saw the patient her blood-pressure was 155/90 mm Hg; pulse 88/min, slight systolic on the basal area. Uterus palpable at height of umbilicus. Fetal heart sounds normal. Slight ankle oedema. Eye fundus normal. Laboratory assessment included Hb 6.5 g/dl, urea 160
mg/dl, creatinine 6.5 mg/dl with a clearance of 10 ml/min. Urinalysis revealed 2.7g protein/24h white and 60 red bloodcells high-power field, and evidence of urinary infection (Escherichia coly. The E.C.G. showed left-ventricular burden. She was ordered complete rest and checked daily. The diet contained 2500 kcal and 40 g proteins with supplements of calcium, iron, and vitamins. Aluminium hydroxide was added and 500 mg of progesterone were administered weekly. Packed red blood-cells were transfused to maintain the hsematocht above 20%. Blood-pressure was controlled with reserpine and
hydrallazine. Her acidosis was corrected and she was maintained in adequate salt and water balance. Creatinine clearance persistently 1.
Nevin, N. C., Armstrong, M. J. J. Obstet. Gynœc.
Br. Commonw.
826. 2.
McKay, E. V.
Aust. N.
SIR,—Stone House is the main, though
not the only, psychihospital serving the Danford and Gravesham Health District, which has a population of about 250 000. The population is not exceptional-in particular, there is no special geriatric loading such as may happen on the south coast. We have about 27 000 people over the age of 65 in our district. Between January, 1970, and June, 1975, 155 patients from
atric
RENAL FAILURE
Z. Jl Obstet. Gynœc. 1963, 3, 21.
1975, 82,
the district over the age of 65 died. Less than half had been in hospital for more than a year: Years
Up to
Up to 2 2-5 6-10 11-15 16-20 Total
Total 86 51 10
M F 36 50 12 39 3 7 22 1 3 54 101
36
86
50
4 4
155
37 had been in hospital for a month or less before they died 14 survived a week or less in hospital). The causes of death of these 14 were: bronchopneumonia (3), pulmonary embolus (3), congestive cardiac failure (3), myocardial infarction (2), cerebrovascular accident (1), cor pulmonale (1), carcinoma with metastasis (1). Of the 155 patients only 7 were admitted on this final occasion before the age of 65, and among these 7 by far the larger part of their stay occurred over the age of 65. It can be concluded therefore that district patients admitted before the age of 65 seldom remain in psychiatric hospital up to or after that age without a break until their death there. Only 32 patients had previously been admitted to this psychiatric hospital within the last 15 years or more, for an earlier episode of illness. 127 were considered at the time of their final admission to have a cerebral organic state (e.g., dementia or confusion). These patients were, on average, in their late 70s (males) or early 80s (females), and most of them had been in hospital a year or less when they died. The direct cause of death in most instances was certified as bronchopneumonia or car-
(and
3.
de los Rios, J., Plaza, J. J., Fernandez Revta. clin. esp. 1975, 137, 363.
Egido
Aparicio,
M.
A., Hernando, L.
48 in what would seem to have been the last year of irreversible natural ageing. Should this make us think again about paragraph 23 of the memorandum on Services for Mental Illness Related to Old Age (1971)? Should not most of these patients die in accommodation designated as geriatric rather than psychiatric?
diorespiratory failure,
Stone House
Hospital,
Dartford,
J. P. CRAWFORD
Kent
NORMALISATION AND SI UNITS
SIR,—Lennox1 has suggested a solution to difficulties over SI units. I may have misunderstood his letter, but his suggestion is not new. Hofmannin addition to describing a now well-known method for determining "normal" limits from cumulative patient data also described a "normal quotient scale",3 based on the standard deviation of a normal population. In his scheme standard deviation (s.D.) equivalents are transformed to a positive number scale in which mean normal is 100 and the 2s.D. range is 90-110. Many clinicians are frightened by statistics, and Lennox will do nothing to gain their confidence by recommending dry works such as "Bradford Hill".4 (Perhaps newer generations will be less averse to statistics having been taught their value and limitations from an
earlier
age.) s.D. units are derived very simply: = S.D. unit unit=
X-M,
S.D.
where X = value obtained, M mean of normal population, and s.D. = standard deviation of normal population. S.D. units can easily be reported graphically, and for diehards absolute values can still be reported alongside. We had considered changing to this system of reporting and had had some painless internal practice when it appeared that SI units would be more generally supported. A number of critical letters have appeared in The Lancet and elsewhere suggesting that the change to SI is full of difficulties, and I have drawn attention to possible dangers of uncritical acceptance of these units/ Nevertheless many hospitals have successfully negotiated the transition to SI: perhaps the present controversy is due to their not stating how easy this change has been. Others also have suggested "normalisation" for laboratory reporting’6 but if this is a simple solution to the unit problem what a pity that it was not examined before SI units were introduced on a national basis. "Normalisation" should be thoroughly examined---even now it is not too late since many are still struggling to learn the SI units of clinical value, or, like our transatlantic colleagues, have refused to change. Let us have published the figures of how many areas have changed to SI, and whether doctors are in favour of the change or not. Would doctors favour a change to normalisation or, as I suspect, would they prefer no change at all? There must be somebody with sufficient time to do such a simple monitoring project, even at the risk of being awarded a PH.D for doing so. =
States of Jersey The Parade,
Pathological Laboratory,
Jersey, Channel Islands.
J. J. TAYLOR
BREAST EXAMINATION IN OBESE PATIENTS
SIR--Examination of the axillae of obese patients with disease may be difficult, particularly for the group of
Dreast
lymph-nodes situated in the pad of adipose tissue between the pectoralis major and minor muscles. The probing fingers may push the pad into the wedge-shaped space between the muscles, and the enclosed nodes become impalpable. 1. 2. 3. 4. 5. 6. 7.
Lennox, B. Lancet, 1975, ii, 1085. Hofmann, R. G. J. Am. med. Ass. 1963, 185, 150. Hofmann, R. G. GP, 1964, 30, 112. Hill, A. B. Principles of Medical Statistics, London, 1971. Taylor, J. J. Br. med. J. 1975, iii, 226. Rushmen, R. F. J. Am. med. Ass. 1968, 206, 836. Schoen, I., Brooks, S. H. Am. J. clin. Path. 1970, 53, 190.
I have found an additional step in routine examination to be useful in detecting these nodes. The patient is asked to lie supine with the arms resting in the adducted position. To examine the right axilla the examiner stands on the patient’s right side and depresses with his right hand the pectoralis major muscle downwards towards the chest wall; this manoeuvre causes the pad of adipose tissue between the muscles to prolapse towards the lateral border of the pectoralis major muscle, where enclosed nodes are readily palpated by the left hand. The left axilla is examined with the left hand depressing the muscle and the right hand palpating. I have found this method more reliable in the detection of this group of nodes in obese patients than the usual method. Kingston General Hospital, Kingston on Thames, Surrey.
N. G. BUCHAN
DIMINISHED T.S.H. SECRETION DURING ACUTE NON-THYROIDAL ILLNESS IN UNTREATED PRIMARY HYPOTHYROIDISM
SIR--Dr McLarty and his colleagues (Aug. 9, p. 275) found changes in thyroid function in clinically euthyroid patients after acute stress. After myocardial infarction and cerebrovascular accidents there is a significant fall of both total serum T3 and T4, the fall in T3 being greater than the fall in T4. These changes do not appear to be due to changes in thyroid-hormone binding proteins, since free T4 and T3 indices parallel the total T4 and T3 changes. The changes observed in these "sick euthyroid" patients may be due to one or more of the folTHYROID FUNCTION IN DIABETIC HYPOTHYROID PATIENT IN PRECOMA AND
DURING RECOVERY
mechanisms: hypothalamic-pituitary dysfunction, decreased peripheral conversion of T4 to T3, and/or the production of reverse T3.’ I have made sequential measurements in one patient which demonstrate hypothalamic-pituitary dysfunction during acute
lowing
non-thyroidal illness in untreated primary hypothyroidism. The patient, a 39-year-old diabetic, was admitted in precoma due to ketoacidosis (blood-glucose 95 nmoV1, ketonuria, pH 7-11) associated with a respiratory-tract infection. She had had a thyroidectomy for thyrotoxicosis 7 years before. Histologically, there was evidence of lymphocytic infiltration, and thyroid autoantibodies were present in high titres. There were no overt clinical features of thyroid dysfunction on admission. She was treated with a low-dose intramuscular insulin regimen, saline infusion, potassium supplements, and ampicillin. Stabilisation was difficult, but satisfactory control was achieved after 10 days. Serial measurements of thyroid-hormone and thyroid-stimulating-hormone (T.S.H.) levels during the acute phase of her illness and her convalescence are shown in the table. On the morning after her admission total serum-T4 levels were low and total serum-T3 and T.S.H. levels were undetectable. 2-3 weeks later, before discharge, total serum-T4 levels had risen to just below the normal range, total serum-T3 levels were within the normal range, and T.S.H. levels were raised. 3 months after admission, subclinical primary hypothyroidism was confirmed by a persistently low serum-T4, a total serum-T3 at the upper end of the 1.
Wenzel,
K.
M., Meinhold, H. Lancet, 1975, ii, 413.
