24 Cook JD, Skikne BS, Lynch SR, Reusser ME. Estimates of iron sufficiency inthe US population. Blood 1986;68:726-31.

25 Bainton DF, Finch CA. The diagnosis of iron deficiency anemia. Am 7 Med1964;37:62-70.

26 Macdougall IC, Roberts DE, Neubert P, Dharmasena AD, Coles GA,Williams JD. Pharmacokinetics of recombinant human erythropoietin inpatients on continuous ambulatory peritoneal dialysis. Lancet 1989;i:425-7.

27 Boelaert JR, Schurgers ML, Matthys EG, et al. Comparative pharmaco-kinetics of recombinant erythropoietin administered by the intravenous,subcutaneous and intraperitoneal routes in continuous ambulatory perito-neal dialysis patients. Perui Dial Int 1989;9:95-8.

28 Frenken LAM, Coppens PJW, Tiggeler RGWL, Koene RAP. Intraperitonealerythropoietin. Lancet 1988;ii:1495.

29 Macdougall IC, Cavill I, Davies ME, Hutton RD, Coles GA, Williams JD.Subcutaneous recombinant erythropoietin in the treatment of renal anaemiain CAPD patients. Contrib Nephrol 1989;76:219-26.

30 Macdougall IC, Roberts DE, Coles GA, Williams JD. Intraperitonealerythropoietin. Lancet 1989;i: 1389.

31 Bommer J, Ritz E, Weinreich T, Bommer G, Ziegler T. Subcutaneouserythropoietin. Lancet 1988;ii:406.

32 Stevens JM, Strong CA, Oliver DO, Winearls CG, Cotes PM. Subcutaneouserythropoietin and peritoneal dialysis. Lancet 1989;i: 1388-9.

33 Granolleras C, Branger B, Beau MC, Deschodt G, Alsabadani B, Shaldon S.Experience with daily self-administered subcutaneous erythropoietin.Contrib Nephrol 1989;76:143-8.

34 Mayer G, Thum J, Cada EM, Stummvoll HK, Graf H. Working capacity isincreased following recombinant human erythropoietin treatment. KidneyInt 1988;34:525-8.

35 Tsutsui M, Suzuki M, Hirasawa Y. Renewed cardiovascular dynamicsinduced by recombinant erythropoietin administration. Nephrol DialTransplant 1989;4 (suppl): 146-50.

36 Grutzmacher P, Ehmer B, Messinger D, Scigaila P. Effect of aluminiumoverload and hyperparathyroidism on bone marrow response to recombi-nant human erythropoietin therapy. Nephrol Dial Transplant 1989;4:474.

37 Meytes D, Bogin E, Ma C, Dukes PP, Massry SG. Effec-ts of parathyroidhormone on erythropoiesis. 7 Clin Invest 1981;67:1263-9.

38 Hampl H, Riedel E, Wendel G, Stabell U, Kessel M. Influence of parathyroidhormone on exogenous erythropoietin stimulated erythropoiesis in hemo-dialysis patients. Kidney Int 1988;33:224.

39 Fervenza F, Oliver DO, Forman E, Winearis CG. Autonomous hyperpara-thyroidism does not cause resistance to recombinant human erythropoietin.Nephrol Dial Transplant 1989;4:472.

40 Valderrabano F. Adverse effects of recombinant human erythropoietin in thetreatment of anaemia in chronic renal failure. Nephrol Dial Transplant1988;3:503.

41 Canadian Erythropoietin Study Group. The clinical effects and side effects ofrecombinant human erythropoietin in anemic patients on chronic hemo-dialysis. Clin Invest Med 1989;12 (suppl):B66.

42 Levin N. Management of blood pressure changes during recombinant humanerythropoietin therapy. Semin Nephrol 1989;9 (suppl 2):16-20.

43 Moia M, Mannucci PM, Vizzotto L, Casati S, Cattaneo M, Ponticelli C.Improvement in the haemostatic defect of uraemia after treatment withrecombinant human erythropoietin. Lancet 1987;ii: 1227-9.

44 Van Geet C, Hauglustaine D, Verresen L, Vanrusselt M, Vermylen J.Haemostatic effects of recombinant human erythropoietin in chronicheamodialysis patients. Thromb Haemost 1989;61:117-21.

45 Dreyling KW, Steinhauer HB, Geiger H, Horl WH, Schollmeyer P. Plateletfunction under recombinant human erythropoietin therapy in haemodialysispatients. Nephrol Dial Transplant 1989;4:472.

46 Grutzmacher P, Bergmann- M, Schoeppe W, Breddin K. Thrombocytefunction and plasmatic coagulation under recombinant human erythro-poietin therapy. Nephrol Dial Transplant 1989;4:473.

47 Macdougall IC, Davies ME, Hutton RD, Coles GA, Williams JD. Reductionin protein C and protein S levels after treatment with recombinanterythropoietin. Nephrol Dial Transplant 1989;4:476.

48 Watson AJ. Adverse effects of therapy for the correction of anemia inhemodialysis patients. Semnin Nephrol 1989;9 (suppl 1):30-4.

49 Zehnder C. Erythropoietin treatment: influence of haemoglobin concentrationon dialyser creatinine clearance in haemodialysed patients. Nephron1989;51:424-5.

(Accepted 247anuary 1990)

Winter sports injuries in a snowless year: skiing, ice skating, andtobogganing

Alberic Fiennes, Gian Melcher, Thomas P Ruedi

From 1980 to 1989 an average of 150 million nightswere spent in the Swiss Alps' each winter by visitors,most of whom came to ski. In the past few yearssnowfalls have been late and scanty in many regions,and this year the problem has been even more severethan expected. Climatic variations affect the opportuni-ties for winter sports and therefore the pattern andseverity of injuries seen at local and regional hospitals.The same factors have also favoured the preparation ofoutdoor ice rinks, and in the absence ofadequate skiingnumerous visitors have turned to the ice as an alterna-tive to a holiday of frustrated inactivity. Other tourists,perhaps believing themselves to be too cautious toskate, have taken to tobogganing.

SkiingCase I-A 19 year old woman with several years'

skiing experience fell across her own ski sticks on hardterrain. She completed her descent but was lateradmitted to a primary hospital complaining of abdomi-nal pain. Her circulation was stable under observation,but laparotomy was performed because of progressiveperitoneal irritation. An extensive deep posteriorlaceration of the right lobe of the liver was debrided, anomental pedicle interposed, and the cavity packed. Shesubsequently required transfer to our hospital andsecond look laparotomy at three days, when the packwas removed and a T tube placed in the common bileduct. After four days of intensive support and 14 daysof hepatocellular type jaundice she made a full clinicaland biochemical recovery, leaving hospital 21 daysafter the accident.

Case 2-On a crowded and icy piste a 22 year oldman collided at speed with a skilift pylon. There was noobvious external injury or loss of consciousness, butprogressive hypotension and tachypnoea promptedimmediate evacuation by helicopter to our centre. Onarrival he had a patent airway, shallow respiration

(>36/min), and central pulses only. Initially semi-conscious and agitated, he quickly had a cardiac arrest.In the course of resuscitation immediate laparotomyshowed a ruptured liver and diaphragm but littleblood. At median sternotomy there was no pericardialtamponade and an empty heart was noted. The rightlower lobe vessels and bronchus were found to beavulsed, and resuscitation proved to be impossible.

Ice skatingCase 3-Following the closure of local ski lifts a 48

year old physically active man was skating on a heavilyused village ice rink when his left skate engaged in adeep crevice left by the previous day's skaters. He fellto one side, sustaining a simple short spiral fracture ofthe tibial isthmus and fibular neck. He was treated atour hospital four hours after injury by open reductionand low contact dynamic compression plating' throughan anterolateral approach. Five days later he was dis-charged partially weightbearing and able to return tohis native country by road.

Case 4-An active 68 year old woman hankered afterthe skating agility of her younger days. On a left turnher poorly sharpened skates slid from under her andshe fell on to her left hip. She was helped to her feet andhobbled off the rink in considerable pain, which laterdrove her to come to our hospital. x Ray filmsconfirmed an impacted subcapital femoral fracture.The fracture position was acceptable, and she wastreated by analgesia and carefully supervised mobilisa-tion, being discharged to a rehabilitation unit after 11days.

Case 5-Prevented by poor local conditions fromskiing, a transatlantic visitor of 60 was enjoying afriendly curling match. Enthused by success, he ran upthe rink in chase of his winning stone. Turning rapidlyto announce victory to his companions, he slipped andfell face forward, sustaining a basal skull fracture, right

Department of Surgery,Raetisches Kantons-undRegionalspital, CH-7000Chur, SwitzerlandAlberic Fiennes, MS,Allgower trauma scholarGian Melcher, MD, chiefresidentThomas P Ruedi, MD,chiefofsurgery

Correspondence to: MrFiennes.

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temporomandibular contusion, minor right subfrontalcerebral contusion, and moderately severe concussion,manifest by extensive retrograde amnesia and recurrentvomiting. He required a total of six days bed rest in ourhospital.

TobogganingCase 6-Tobogganing on a deserted piste shortly

before midnight, a pair of revellers skidded into asafety net with such momentum that both slid underthe net and tumbled down the snowless slope beyond,eventually striking some pine trees. One tobogganer, a34 year old woman, was evacuated by helicopter to ourhospital, where she arrived conscious, with a pulse of1 10/min, chest wall tenderness, and a rigid abdomen(despite opiates having been given). x Ray filmsconfirmed a fractured rib and pneumoperitoneum. Atlaparotomy there was a heamatoma of the mesentericroot and subserosal emphysema of the mid-jejunumand ascending colon. A posterior rupture of theduodenum was sutured. After an uneventful recoveryshe was discharged from hospital 18 days after theaccident.

Case 7-A 24 year old general practice assistant useda plastic bag as a toboggan. She lost control on a patchof ice, striking an exposed rock with both feet andtumbling about 100m down a bare hillside. At theprimary hospital she was noted to have a second degreeopen fracture dislocation of the right ankle, a seconddegree open left tibial pilon fracture, an unstable burstfracture of the first lumbar vertebra with impingementinto the spinal canal, and mixed motor signs in her legs.After resuscitation she was transferred by helicopter toour hospital, where all three injuries required openreduction and internal fixation (figs 1 and 2). Twentyfour hours later her neurological signs had disappeared,and 12 days after the accident she was transferred to ahospital near her home for aftercare.

FIG 1-Case 7. Top: Open bimalleolar fracture dislocation of rightankle and open fracture of left tibial pilon before operation. Bottom:After open reduction and internalfixation

.__

FIG 2-Case 7. Left: Unstable burst fracture offirst lumbar vertebrabefore operation. Right: After reduction and internal fixation by AOinternalfixator. Note restoration ofvertebral height

Case 8-A 50 year old father was tobogganing pillionbehind his young son on a sparsely snow covered buticy slope. He lost control and hurtled toward aretaining wall. Trying to protect his son, he stretchedout his right leg as a brake, but his foot struck the walland father and son were hurled off the toboggan. Theson was unhurt, but his father was brought to ourhospital with a closed right tibial pilon fracture. Afterthree days of bed rest and leg elevation the fracture wasmanaged by open reduction and internal fixation. Hewas discharged non-weightbearing 12 days after injury.

DiscussionFor the decade 1949-59 the Swiss Snow and

Avalanche Research Institute in Davos recorded anaverage depth of snow of 1 56m by the 25 January eachyear (fig 3). This year the depth was 0-72 m (personalcommunication). Although many voices have beenraised to attribute this change to the greenhouseeffect, some famous resorts were without snow foryears on end in the mid-nineteenth century.The popular view of the classic skiing injury is of a

fractured ankle or tibia. In fact, changes in the designof ski boots and bindings have for many years shiftedthe injury pattern in favour of serious ligamentousknee injuries,34 which are rather harder to treat. Thishospital normally sees several such injuries every dayduring the skiing season, but not this year. Any cohortofpatients with skiing injuries will contain a proportionof neuroaxial, thoracic, and visceral injuries alongsidethe usual limb injuries.4 When pistes become few,crowded, and surrounded by uncushioned rocks andtrees then life threatening or lethal injury is morelikely.

This winter's lack of snow has partly been the resultof persistent anticyclonic conditions in December andJanuary. The consequent clear cold nights and sunnydays provide enticing conditions on ice rinks, whichmay be used when skiing is scarce. Our third patientwas an adequately competent if unaccustomed skaterwho was injured by the wear and tear on a busy icerink. Paradoxically his injury, now rare among skiers,'was the classic injury seen in skiers in the past and theone for which dynamic compression plating wasperfected.6The general popularity of skating this year may have

seduced our fourth patient into an indiscretion shewould not otherwise have committed. Falls on ice rinksare inevitably uncushioned and are usually unheralded,

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300-

o Mein don-5D19 49 ; mean100

o- ss 42 44 ds~64r565~ 60 62 .64 6 68 70 72 74 784 68Year

FIG 3-Depth of snow recorded on Weissfluhjoch (2540 m) on 25 Janua?y from 1936-7 to 1989-90. Note that there is no overall trend and thatslow fluctuations have occurred in previous years. (Data supplied by Swiss Snow and Avalanche Research Institute, Weissfluhjoch, Davos,Switzerland)

allowing little protective action to be taken. Ice rinksdemand careful upkeep in times of heavy use and arehazardous to the inexperienced or inappropriate user-unless they are treated with a degree of care andconcentration, which our fifth patient momentarilyforgot to exercise.

Like skating, tobogganing requires comparativelylittle snow. Cold nights and sunny days tend toproduce fast, icy, conditions but hard ground.Competitive "skeleton" tobogganing, as practised onthe Cresta Run in St Moritz, is notoriously dangerousand has again led to serious injuries this season. Incontrast, the public has a benign view of amateurtobogganing that owes much to Christmas cards andthe season of good cheer. Cases 6-8 show that thisimage is not always appropriate. Duodenal injuries areoften missed, tibial pilon fractures have long termsequelae,x and lumbar burst fractures are associatedwith paraplegia.Our case histories show how a lack of snow has

shifted the pattern of injuries from winter sports awayfrom simple limb trauma towards serious and some-times lethal injuries. Amid their splendid scenery mostAlpine regions harbour so many historical, aesthetic,

and architectural treasures9 that visitors need not feelcompelled to partake in sporting activity when theconditions make it unduly hazardous. Regional winesand cuisine are also most rewarding but should bemixed with other activities in the correct sequence.

AF is generously supported on a visiting professorship bythe AO International Foundation.

I Swiss Federal Office for Statistics. Tourisme dans que1ques centres toun'stiques et'Iles. Berne: Swiss Fedcral Office t'or Statistics, 1980-9. Publishcd annually .)

2 Perren S, Cordey J, Rahn B, Gauticr E, Schneidcr E. Early temporary porosis of'bone induced bv internal fixation implants: a reaction to nccrosis, itot to stressprotections Cl'in Orthop 1988;232: 139-151.

3 Mark G, Scharplatz 1), Ruedi ''. Entwickluttg des Skiunifalls vsoi 1969 his 1979am Zentralspital eines Bergkantons. HeI/ Chir .'ca 1981;48:35-8.

4 Milark G, Landolt R, Riiedi T. Skiutifalle bei Kinidern: Entwicklung in 1()Jahrcn. I'ddiatrschh Praxis 1982;26:293-7.

5 Scharplatz 1), 'I'hurlemanni K, Fenincr A, Endcrlin F. Das thorakoabdominialcTrauma heim Skisport. He'lz! Chir-ctia 1977;44:81-2.

6 Riiedi '', Webb J, Allgiwer M. Experience w%ith the dytiamic comprcssion platc(DCI') in 418 recent fractures ot'hc tibial shaft. Injurv 1976;7:252-7.

7 F-lint LM\, McCov M, Richardsoti JI), Polk HC. D)uodenal injury: analysis ofcommon misconccptions in diagnosis and trcatment. AInnSurg 1980;191:697-702.

8 Oeadia 1), Beals R. Fractures of the tibial plat'ond. 7_'IBone,7nt Surg ['Em!1986;68:543-51.

9 Zeller W'. Kunst und Ku/tur in Graubiunden. 2nd ed. Beriie: Pauil Hatipt, 1976.

lcceptedu 15 h'cbruar 1990)

THE MEMOIR CLUB

Finally, after a great deal of shunting this way and that, the two halves of thetrain were hooked up and the National Health Service came into being on theappointed day to the tune ofa conciliatory message to the medical professionfrom Aneurin Bevan. Clegg suggested to Bevan that he should make thisgesture and Bevan did so in words whose contrast with earlier diatribes wasstriking. Strangely enough for one so familiar with demagogy, Bevan neverseemed to realise that very few doctors had any interest in politics; they feltthemselves to be remote from the wrangles and ignorant of the issues,bewildered by "speakers from London" and plebiscite forms. Instead oftrying to win their hearts, not in the sense ofappealing to them over the headsof their appointed leaders but simply to have the good will of ordinarypractising doctors, he was often abusive of the profession in tone andmetaphor to such a general extent that, irrespective of his policies, hearoused widespread dislike among people who, if challenged to think aboutthe matter, largely agreed with his plans. This I believe was the greatestsingle cause of the mistrust of the health service that doctors felt for yearsafter it began. Though he was doubtless prodded beyond the bounds ofpatience at times by the obstruction, or inertia, or simple disarray of thedoctors, he too often lost control of what can well be a politician's greatestasset, a persuasive tongue. His invective tainted an era.

If the disputes over the health service forced the BMJ into an indecisiverole from time to time and gave its editor an unpopular image, Clegghimself thoroughly enjoyed the rough and tumble of it all. Having at firstthought the service would provide for the medical profession a stable,equable way of life in which medical politics would gradually wither away,we began to learn that the exact reverse was the case: committee workproliferated, larger limousines carried more deputations here and there,legal advisers worked overtime, public relations officers never left thetelephone except for another briefing, and relations between differentgroups of the profession attained a Byzantine complexity. Gone was thepastoral dream of the contented doctor practising medicine in a servicewhose regularity and harmony had freed him from the attentions ofadministrators and politicians. Instead BMA committees looked ever morehungrily for space in the BMJ, and the growing volume ofwork bred a newrace of virtually whole time medical politicians.

From Reap a Destiny: Divagatiotns of a Taoist by Douglas Swinscow. Publishedunder the BMJ41's Memoir Club imprint. ISBN 0 7279 0255 5. Price: Inland£14.95; abroad £17.50; USA $29.00. BMA members: Inland £13.95; abroad£16.50; USA $27.00.

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