In diagnosing idiopathic hypertrophic subaortic stenosis, it is often useful to have the patient perform a Valsalva maneuver.i** Many patients, however, have difficulty comprehending instructions on how to perform the maneuver or in actually executing it. We have found that this difficulty may be overcome by having the examiner place his clenched fist against the patient’s epigastrium and having the patient push against the fist with his abdomen. In the process of doing this, a Valsalva maneuver (straining against a closed glottis) is unconsciously performed and the desired objective is achieved. Robert I. Hanzby, M.D. Jacob M. Meron, M.D. Gerald S. Roberts, M.D. Long Island Jewish illedical Center Department qf Medicine Cardiopulmonary Unit New Hyde Park, IV. I’. 11030
Rraunwald, E., Oldham, H. N., Jr., Ross, J., Jr., Linhart, J. W., Mason, D. T., and Fort, L., III: The circulatory response of patients with idiopathic hypertrophic subaortic stenosis to nitroglycerine and to Valsalva maneuver, Circulation 29:422, 1964. Marcus, F. I., Westura, E. E., and Summa, J.: The hetnodynatnic effect of Valsalva tnaneuver in muscular stenosis, AMER. HEAKT J. 67:324, 1964.
So much has been written about organ transplantation from so many different points of view that the results and potential of therapeutic kidney grafting may have been obscured. This procedure is now well established and, combined with a sensible dialysis policy, it should be possible to offer treatment to all those in need at an economical cost; yet, due to a variety of nonmedical difficulties, only a small fraction-about 10 per cent-of young people in terminal renal failure are receiving care. Since the introduction of effective immunosuppressive drugs, azathioprine and steroids, in 1961, there has been a steady itnprovement in the results of renal transplantation. According to the Kidney Transplant Registry, the percentage of functioning grafts after two years from cadaver donors up to 1965 was less than 20 per cent but by 1969 the figure was 40 per cent. In a combined series from Cambridge, Hammersmith, and Edinburgh, the two-year graft survival from cadaver donors is 56 per cent.’ The patient survival is considerably better due to the availability of dialysis. For close related living donors, an 80 per cent two-year graft survival can be achieved. X38
In theory, with cadaver renal transplantation using only excellent donor-recipient tissue matched organs, it should be possible with conventional immunosuppression to approach the results of close blood relative donors. Further improvements might be expected with better immunosuppression, for example, anti-lymphocyte globulin. These objectives can only be reached if there is a large pool of tissue-typed recipients, close collaboration between transplantation centers, and an adequate supply of donor kidneys. Lack of donor kidneys is the main stumbling block. This is not because too few people die with suitable kidneys-unfortunately, road accidents, cerebral hemorrhage, and cerebral tumors could provide more than enough kidneys-but most of these organs are not being used, due mainly to lack of positive cooperation within the medical profession, The main ethical dilemma in renal transplantation is the failure to treat most young patients in renal failure. If correct results and potential improvements were more widely appreciated by medical men and the public, then charitable donation of organs would be the expected procedure in
suitable cases and all those in need of a kidney graft would be offered treatment. R. Y. Caine, M.D. Defiartment of Surgery University of Cambridge Addenbrooke’s Hospital Cambridge, England
REFERENCES 1. Calne, R. Y., Shackman, R., Nolan, B., Petrie, M.: Results of kidney transJ and Woodruff, pi’antation, Lancet 1:671, 1970.
As Knittle and associates have shown for rats and man, the number of fat cells in the body is determined by the state of nutrition during the early periods of postnatal life. When the subject is well fed or overly fed immediately after birth and before cell proliferation or growth ceases, the number of fat cells increases and may even exceed three times the number in animals that are calorically undernourished or not overly fed. Once growth and cell proliferation cease, the number of fat cells is constant throughout the remainder of life. Furthermore, once cell number becomes fixed, the quantity of fat stored is reflected in the quantity “stuffed” into each fat cell, regardless of the number of cells. Thus, a fat man with three times the number of fat cells can store three times as much fat in his body, all else being equal, as a man who, in early life, was not overly fed and who, in turn, has one third the number of fat cells. Therefore, the time to prepare to prevent obesity is at birth and during the period of maturation. Once the number of cells in the body is established, variations in caloric intake can vary only the amount of fat stored within the cells and not their number. Furthermore, a person with three times the number of fat cells must diet fairly rigidly to reduce the quantity of fat in each cell to one third of its full capacity. He still would be as “fat” as the man with one third the number of fat cells who eats excessively and has his fat cells fully stuffed. The fat man with three times as many fat cells fully stuffed with fat would be essentially three times as big as the fat man with one third as many fat cells
fully stuffed. Thus, control of obesity would be difficult and dieting would have to be more rigid for the person with three times the number of fat cells. To be “skinny,” this person’s many fat cells would have to contain a lower percentage of fat per cell than those of the man with one third the number of fat cells. Therefore, according to the findings of Knittle and associates, nutrition during the prematuration period of life and the number of fat cells in the body probably explain in large part why some fat people have difficulty in losing fat and in reducing their weight. G. E. Burch, M.D. Department of Medicine School of Medicine Tulane University 1430 Tulane Ave. New Orleans, La. 70112 REFERENCES 1.
Knittle, J. L., and Hirsch, J.: Effect of early nutrition on development of rat epididymal fat pads: Cellularity and metabolism, J. Clin. Invest. 47::2091, 1968. 2. Hirsch, J., Knittle, J. L., and Salans, L. B.: Cell lipid content and cell number in obese and nonobese human adipose tissue, J. Clin. Invest. 45:1023, 1966. 3. Widdowson, E. M.: Harmony of growth, Lancet 1:901, 1970.
Familial nephritis has been recognized and described under various names since 187.5,’ but it was Alport* in 1927 who observed the associated bilateral nerve deafness and clearly defined the syndrome. Other investigators have described the ocular manifestations of this entity.3 Despite the fact that over 65 affected kindred have been reported on, the disease is poorly understood and probably underdiagnosed.
The clinical and laboratory manifestations have been summarized by Perkoff and Royer.**5 These include variable hematuria, proteinuria, and occasional pyuria at the onset of the disease. Renal function is usually normal in the initial phase and about 50 per cent of the patients have or develop bilateral nerve deafness, this being slightly more common in boys than in girls. Males are said to develop renal insufficiency after the age of 20 and