1164
Brain-death and
transplantation
in
Japan
SIR,-Japan is now the only highly industrialised and medically developed country in which organ transplantations from braindead donors have not been undertaken. About 70% of kidneys for transplantation are donated by living relatives in Japan (the other 30% are from cardiac-dead donors).1 Thirty-two liver transplantations with live donors were carried out in seven Japanese hospitals in the year and ten months since December, 1989/ but no liver transplantations with brain-dead donors have been done. The complex historical development about brain-death and transplantation in Japan over the past three decades are described in detail elsewhere.3 Although the final report of the Japanese Special Provisional Commission on brain-death in January, 1992, favoured transplantations from brain-dead donors, no such transplantations have yet been done (up to October, 1992). One reason is that although transplant surgeons support the legislation on brain-death and want to start transplantation from brain-dead donors (official comment for the final report by executive committee in the Japan Society of Transplantation, Jan 30,1992), the legislation has not yet been implemented. Another factor is a reluctance of Japanese society to accept brain-death as a definition of human death; Japanese religious, philosophical, and cultural traditions are often invoked as the reasons for this reluctance. But are these, in fact, factors that should hinder the development of organ transplantation in Japan? If so, the Japanese may have to relinquish the possibility of transplantations from brain-dead donors. The traditional Japanese attitude to the dead body does indeed seem to be a serious drawback to organ donation: the number of kidneys from cadaveric donors in 1990 was only 21 per million population in Japan,! whereas that in European countries was 280-576 per million.4 Most Japanese people have, in theory, few doubts about brain-death as a medical definition and appreciate its significance and the benefits of transplantations.3 In practice, however, they are anxious that doctors might not adhere to the principle "no intervention must be performed that is not in the patient’s interests and before death has been determined. Until death a patient is not a potential donor, and no measures are permissible solely with a view to organ procurement that might otherwise harm the patient".5 The patient’s right must be strictly preserved in the relationship between doctors and patient. Japanese doctors in general often had little regard for this right, especially when they notify patients of illness. It is unusual for a doctor to reveal that the patient has a malignant disease with a poor prognosis, but he will inform the family of the truth. This has been regarded as a kindness to the patient, but it is never a good policy, because it interferes with a person’s right to self-determination. Unfortunately, in Japan, we have little in the way of infrastructure in either hospital or society that can offer psychological support to terminally ill patients and their families. To obtain informed consent to a transplant operation, however, patients and their families should be told clearly about the poor life expectancy of their disease, and must be given counselling and support while they are waiting operation. Thus, we Japanese doctors should change our attitude to patients to encourage people’s trust with respect to transplantation from brain-dead cadavers. Otherwise, cadaver-donor rates in Japan will remain very low, despite the legislation for brain-death and
transplantation. Department of Thoracic and Cardiovascular Surgery, Mie University, School of Medicine, 2-174 Edobashi, Tsu, Mie 514, Japan
War
injury and post-traumatic morbidity
SIR,- There have been 150 wars in the developing world since 1945 and yet the long-term psychosocial consequences of injury and disability for ex-soldiers has hardly been looked at. The USsponsored Contra war in Nicaragua produced 60 000 casualties (11% of the population) between 1981 and its end in 1990.1 This conflict took place in rural areas, and irregular contact between a largely conscript army and Contra guerillas meant surprise exchanges in which the use of state-of-the-art firepower at close range produced considerable mortality and morbidity. From official war wounded lists, we identified and interviewed 72 veterans in their homes. 1 in 3 had a severe disability-paraplegia or hemiplegia, loss of a limb, or substantial loss of sight-and the rest had minor disabilities. On average, 4-9 years had elapsed since
injury. Disturbed sleep with nightmares, variability of mood (including irritability), intolerance of noise, and psychosomatic complaints were fairly common. Subjects reported sensitivity to war-related cues, including the outbreak of the Gulf war, which had prompted painful memories and nightmares that were associated with their own traumas. A history of head injury conferred greater vulnerability. Nonetheless, most men with these features were coping. The few who needed psychological treatment were better identified by their inability to function socially than by a diagnosis of post-traumatic stress disorder (PTSD), with its emphasis on mental-state indices. 13 subjects (18%) had full PTSD, but our clinical concern was dominated by 3 men, all of whom had striking social dysfunction and 2 of whom were aggressive alcoholics. It is worth recalling that US Vietnam war veterans first attracted
attention not because of PTSD but because of their behaviour, with so many proving incompetent at work and family roles and liable to violent and self-destructive episodes.2 What is the clinical relevance of a diagnosis of PTSD in the absence of overt social dysfunction? The dominance of PTSD in the debate about human response to extreme violence has been given fresh topicality by the Gulf war. But it is noteworthy that no so-called medical model can capture what the trauma personally signifies to each survivor and how this determines outcome. Some subjects felt that the deaths of close family members and of comrades, which they had often witnessed and were gruesome, had been more traumatising than their own injuries; most had been fortified by the belief that they had made a worthwhile sacrifice for the war effort. Indeed, the third with severe physical disability were not more likely to have PTSD than the others.3 Research into the factors that shape the evolution of post-traumatic morbidity should also take account of societal variables-for example, even the disabled men tended to cite the economic crisis rather than their physical limitations as the most critical issue they faced. The availability of appropriate training and work is likely to be a determinant of longer term psychosocial outcomes.
Department of Forensic St George’s Hospital, London SW1 7
Psychiatry,
Medical Foundation for Victims of Torture, London NW5 3EJ, UK
FRANCESCA HUME DEREK SUMMERFIELD
R, Frieden R, Vermund S. Health-related outcomes of war m Nicaragua. Am J Public Health 1987; 77: 615-18.
1. Garfield
2. Brende J, Parson E. Vietnam veterans: the road to recovery. New York: Plenum Press, 1985. 3. McFarlane A. The aetiology of post-traumatic morbidity: predisposing, precipitating and perpetuating factors. Br J Psychiatry 1989; 154: 221-28.
MOTOSHI TAKAO
Journals for developing countries Japan Society for Transplantation. Registry of kidney transplantation (1990). Jpn J Transpl 1991; 26: 494-517 (in Japanese). 2. Makuuchi M, Matsunami H, Kawaswki S. Liver transplantation: the progress for this year. Jpn J Artif Organs 1991; 20: 1511-13 (in Japanese). 3. Brannigan MC. A chronicle of organ transplant progress in Japan. Transplant Int 1992; 5: 180-86. 4. Roels L, Michielsen P, the Leuven collaborative group for transplantation. Altruism, self-determination, and organ procurement efficacy: the European experience. Transpl Proc 1991; 23: 2514-15. 5. Wolfslast G. Legal aspects of organ transplantation: an overview of European law. J Heart Lung Transpl 1992; 11: S160-63. 1.
SIR,-Dr Dugdale (Sept 26, p 796) raises an important issue about distribution of journals to developing countries. There is such an agency in Australia. The Australian Centre for Publications Acquired for Development (ACPAD) collects books, journals, and other publications for distribution to universities and institutes of higher education in developing countries. Funds are provided by the Australian International Development Assistance Bureau, which enables ACPAD to meet the costs of sorting, listing,
1165
shipping, and entry. Publications contributed by Australian tertiary institutions and individuals are now in the libraries of universities and medical schools in Indonesia, Malaysia, the Philippines, Thailand, Fiji, and Papua New Guinea. Further information about contributing journals to ACPAD, or requesting library assistance, can be obtained from ACPAD, GPO Box 2006, Canberra ACT 2601, Australia, Telephone (06) 285 8222, Fax (06) 285 3036. TALC, PO Box 49, St Albans, Herts AL1 4AX, UK
WENDY HOLMES
to read Dr Dugdale’s letter. For many of auspices the College of Physicians I have been sending journals to Sri Lanka, helped by Boots Pharmaceutical Company, who arrange transport. I have recently visited Sri Lanka and can vouch for the fact that doctors there find these journals of inestimable value. I agree that it would be helpful if an international agency could develop this scheme for other areas of the world. The names and addresses of doctors in the less developed countries could be added to the circulation list of the many giveaway journals which appear in duplicate in some households. If anybody in the UK has secondhand journals (the past two years) that they would like to pass on to doctors in Sri Lanka, perhaps they could send them to me. A detailed list of contents should be provided on the wrapping because this helps with clearance with the customs.
SIR,-Iwas intrigued
years under the
Nottingham City Hospital, Nottingham NG5 1 PB, UK
D. C. BANKS
SIR,-Dr Dugdale’s suggestion for redistributing journals to needy institutions in developing countries is excellent. This college has 175 undergraduate and almost 100 postgraduate admissions every year. Doctoral students are enrolled in four of the eighteen departments. There are 244 teaching and 464 non-teaching staff, not including those at the attached hospital, which has 1225 beds. This year we subscribed to 150 journals, which is 11fewer than the previous year. The total cost is over 21 000, double the amount spent for the same number of journals in 1990. Readers are afraid that the Indian government policy of curtailing expenses may lead to cutting drastically the number of journals to which institutions subscribe. A good library with an adequate periodical base enriches students and teachers. Without this facility the search for new knowledge is impossible. Many other schools are less fortunate than
drug-induced protein accretion", and after the first 3-4 days of in rats "the increase in protein deposition seems to be dependent on a drug-based reduction in the rate of protein degradation". Thus if the correct terms anti-catabolic for protein and catabolic for lipid had been used, or the term repartitioning agents, rather than the emotive word anabolic, sport might have been spared many troubles. Now the IAAF states that &bgr;2-agonists have always been in the class of anabolic steroids, but they seem not to have notified member countries, doctors, or coaches. The Sports Council has recorded that clenbuterol was effectively proscribed as soon as it was put on the market. Both bodies seem to have ignored the fact that the anti-catabolic (anabolic?) effects of &bgr;2-agonists were recorded only in about 1987, but salbutamol, clenbuterol, and similar drugs have treatment
been on the market for more than 15 years. Their advisors must have marvellous foresight to ban them under anabolic steroids some 10 years before they were shown to induce protein accretion in animals; results in man are awaited with interest. Perhaps the advisors may have been misled by your last paragraph "studies in animals indicate that clenbuterol and similar &bgr;-agonists taken in large doses can provide a protein anabolic response that could be performance enhancing" and "clinically, evidence from studies in rats suggests that, even at doses recommended for the treatment of asthma, clenbuterol may be valuable". If small doses in man produce an increase in protein deposition, it is a little surprising that we do not see large numbers of superbly muscled men and women among the millions who are taking the drugs therapeutically. Medical practitioners, sports doctors, and coaches have now to realise that unless commonsense prevails, they will be branded as doping doctors and coaches for prescribing and administering &bgr;2-agonists, because, in the view of sports administrators, without notice, these drugs have always belonged under the class of androgenic anabolic steroids. Obviously the use by scientists of the words anti-catabolic and anabolic to describe the protein accretion effects of &bgr;-agonists can have far-reaching consequences that they could not have foreseen. The misuse of &bgr;2-agonists in sport is increasing. Action should be taken, but only after careful thought and definition of rules clearly stating what is banned and what is not and due consideration of the medical implications of the ban. 73-75 Church Rd,
Training
ours.
developing countries clinicians may subscribe to a particular journal that is also available in his hospital or university library. In In
such instances, the subscriber could instruct the distributor to send
his personal copy direct to an institution of his choice, without charge to that establishment. Some institutions in developing countries would be able to meet the postage expenses. Department of Physiology, M P. Shah Medical College, Jamnagar 361 008, India
K. P. SKANDHAN
Clenbuterol and sport SIR,- Your Aug 15 editorial is being used by the Sports Council and others
as
justification for transference,
without
notice, of
&bgr;2-agonists into the class of androgenic anabolic steroids as related substances to the examples of steroids listed under the class. This big intellectual jump has led to some athletes being banned for 4 years
(International
Amateur Athletic Federation
IAAF)
and the
danger of two British weightlifters being banned for life after the
Olympic games. (Last Saturday the British Amateur Weightlifters Association disagreed with the Sports Council and decided not to ban the two weightlifters.) The jump has been explained as resulting from the proven increase in protein deposition, which has been called anabolic by
some scientists. This action has been taken despite the fact that you correctly state "there is some debate about the precise metabolic basis for
ARNOLD H. BECKETT
London SE19 2TA, UK
SIR,-In
your Oct 3
for
laparoscopy
(p 824) editorial
you show little love for
laparoscopy, and view from afar the moving scene, jolted unwillingly from your pensive chair by, of all journals, the Wall Street Journal and by public pressure. It is trite to state that more bileducts have probably been damaged in 1 year of laparoscopic cholecystectomy than in the previous decade, and almost certainly untrue. In our unit there has always been a steady referral of biliary trauma, and this year the frequency has only modestly increased, bearing in mind the greater number of cholecystectomies being done. Now such trauma is news, and since it is being caused by consultants rather than registrars, the "grapevine" is working overtime. The cause of these injuries is often inadequate training, and it is to this that our attention should be focused. To accustom a surgeon to entirely new skills requires experiment and practice; for large numbers of surgeons to join the learning curve is likely, I agree, to have a prohibitive cost in both cash and human terms. One answer is to limit the number of surgeons learning these techniques or to train surgeons in the laboratory. Simulation is too far away and probably too expensive, but training in fully equipped animal laboratories such as those set up commercially in Cincinnati, Paris, and Hamburg show the way forward. To avoid commercial as well as public and financial pressures, the need for organised training laboratories should be grasped within training programmes. Middlesex Hospital, London W1 N
8AA, UK
R. C. G. RUSSELL
Brain-death and
transplantation
in
Japan
SIR,-Japan is now the only highly industrialised and medically developed country in which organ transplantations from braindead donors have not been undertaken. About 70% of kidneys for transplantation are donated by living relatives in Japan (the other 30% are from cardiac-dead donors).1 Thirty-two liver transplantations with live donors were carried out in seven Japanese hospitals in the year and ten months since December, 1989/ but no liver transplantations with brain-dead donors have been done. The complex historical development about brain-death and transplantation in Japan over the past three decades are described in detail elsewhere.3 Although the final report of the Japanese Special Provisional Commission on brain-death in January, 1992, favoured transplantations from brain-dead donors, no such transplantations have yet been done (up to October, 1992). One reason is that although transplant surgeons support the legislation on brain-death and want to start transplantation from brain-dead donors (official comment for the final report by executive committee in the Japan Society of Transplantation, Jan 30,1992), the legislation has not yet been implemented. Another factor is a reluctance of Japanese society to accept brain-death as a definition of human death; Japanese religious, philosophical, and cultural traditions are often invoked as the reasons for this reluctance. But are these, in fact, factors that should hinder the development of organ transplantation in Japan? If so, the Japanese may have to relinquish the possibility of transplantations from brain-dead donors. The traditional Japanese attitude to the dead body does indeed seem to be a serious drawback to organ donation: the number of kidneys from cadaveric donors in 1990 was only 21 per million population in Japan,! whereas that in European countries was 280-576 per million.4 Most Japanese people have, in theory, few doubts about brain-death as a medical definition and appreciate its significance and the benefits of transplantations.3 In practice, however, they are anxious that doctors might not adhere to the principle "no intervention must be performed that is not in the patient’s interests and before death has been determined. Until death a patient is not a potential donor, and no measures are permissible solely with a view to organ procurement that might otherwise harm the patient".5 The patient’s right must be strictly preserved in the relationship between doctors and patient. Japanese doctors in general often had little regard for this right, especially when they notify patients of illness. It is unusual for a doctor to reveal that the patient has a malignant disease with a poor prognosis, but he will inform the family of the truth. This has been regarded as a kindness to the patient, but it is never a good policy, because it interferes with a person’s right to self-determination. Unfortunately, in Japan, we have little in the way of infrastructure in either hospital or society that can offer psychological support to terminally ill patients and their families. To obtain informed consent to a transplant operation, however, patients and their families should be told clearly about the poor life expectancy of their disease, and must be given counselling and support while they are waiting operation. Thus, we Japanese doctors should change our attitude to patients to encourage people’s trust with respect to transplantation from brain-dead cadavers. Otherwise, cadaver-donor rates in Japan will remain very low, despite the legislation for brain-death and
transplantation. Department of Thoracic and Cardiovascular Surgery, Mie University, School of Medicine, 2-174 Edobashi, Tsu, Mie 514, Japan
War
injury and post-traumatic morbidity
SIR,- There have been 150 wars in the developing world since 1945 and yet the long-term psychosocial consequences of injury and disability for ex-soldiers has hardly been looked at. The USsponsored Contra war in Nicaragua produced 60 000 casualties (11% of the population) between 1981 and its end in 1990.1 This conflict took place in rural areas, and irregular contact between a largely conscript army and Contra guerillas meant surprise exchanges in which the use of state-of-the-art firepower at close range produced considerable mortality and morbidity. From official war wounded lists, we identified and interviewed 72 veterans in their homes. 1 in 3 had a severe disability-paraplegia or hemiplegia, loss of a limb, or substantial loss of sight-and the rest had minor disabilities. On average, 4-9 years had elapsed since
injury. Disturbed sleep with nightmares, variability of mood (including irritability), intolerance of noise, and psychosomatic complaints were fairly common. Subjects reported sensitivity to war-related cues, including the outbreak of the Gulf war, which had prompted painful memories and nightmares that were associated with their own traumas. A history of head injury conferred greater vulnerability. Nonetheless, most men with these features were coping. The few who needed psychological treatment were better identified by their inability to function socially than by a diagnosis of post-traumatic stress disorder (PTSD), with its emphasis on mental-state indices. 13 subjects (18%) had full PTSD, but our clinical concern was dominated by 3 men, all of whom had striking social dysfunction and 2 of whom were aggressive alcoholics. It is worth recalling that US Vietnam war veterans first attracted
attention not because of PTSD but because of their behaviour, with so many proving incompetent at work and family roles and liable to violent and self-destructive episodes.2 What is the clinical relevance of a diagnosis of PTSD in the absence of overt social dysfunction? The dominance of PTSD in the debate about human response to extreme violence has been given fresh topicality by the Gulf war. But it is noteworthy that no so-called medical model can capture what the trauma personally signifies to each survivor and how this determines outcome. Some subjects felt that the deaths of close family members and of comrades, which they had often witnessed and were gruesome, had been more traumatising than their own injuries; most had been fortified by the belief that they had made a worthwhile sacrifice for the war effort. Indeed, the third with severe physical disability were not more likely to have PTSD than the others.3 Research into the factors that shape the evolution of post-traumatic morbidity should also take account of societal variables-for example, even the disabled men tended to cite the economic crisis rather than their physical limitations as the most critical issue they faced. The availability of appropriate training and work is likely to be a determinant of longer term psychosocial outcomes.
Department of Forensic St George’s Hospital, London SW1 7
Psychiatry,
Medical Foundation for Victims of Torture, London NW5 3EJ, UK
FRANCESCA HUME DEREK SUMMERFIELD
R, Frieden R, Vermund S. Health-related outcomes of war m Nicaragua. Am J Public Health 1987; 77: 615-18.
1. Garfield
2. Brende J, Parson E. Vietnam veterans: the road to recovery. New York: Plenum Press, 1985. 3. McFarlane A. The aetiology of post-traumatic morbidity: predisposing, precipitating and perpetuating factors. Br J Psychiatry 1989; 154: 221-28.
MOTOSHI TAKAO
Journals for developing countries Japan Society for Transplantation. Registry of kidney transplantation (1990). Jpn J Transpl 1991; 26: 494-517 (in Japanese). 2. Makuuchi M, Matsunami H, Kawaswki S. Liver transplantation: the progress for this year. Jpn J Artif Organs 1991; 20: 1511-13 (in Japanese). 3. Brannigan MC. A chronicle of organ transplant progress in Japan. Transplant Int 1992; 5: 180-86. 4. Roels L, Michielsen P, the Leuven collaborative group for transplantation. Altruism, self-determination, and organ procurement efficacy: the European experience. Transpl Proc 1991; 23: 2514-15. 5. Wolfslast G. Legal aspects of organ transplantation: an overview of European law. J Heart Lung Transpl 1992; 11: S160-63. 1.
SIR,-Dr Dugdale (Sept 26, p 796) raises an important issue about distribution of journals to developing countries. There is such an agency in Australia. The Australian Centre for Publications Acquired for Development (ACPAD) collects books, journals, and other publications for distribution to universities and institutes of higher education in developing countries. Funds are provided by the Australian International Development Assistance Bureau, which enables ACPAD to meet the costs of sorting, listing,
1165
shipping, and entry. Publications contributed by Australian tertiary institutions and individuals are now in the libraries of universities and medical schools in Indonesia, Malaysia, the Philippines, Thailand, Fiji, and Papua New Guinea. Further information about contributing journals to ACPAD, or requesting library assistance, can be obtained from ACPAD, GPO Box 2006, Canberra ACT 2601, Australia, Telephone (06) 285 8222, Fax (06) 285 3036. TALC, PO Box 49, St Albans, Herts AL1 4AX, UK
WENDY HOLMES
to read Dr Dugdale’s letter. For many of auspices the College of Physicians I have been sending journals to Sri Lanka, helped by Boots Pharmaceutical Company, who arrange transport. I have recently visited Sri Lanka and can vouch for the fact that doctors there find these journals of inestimable value. I agree that it would be helpful if an international agency could develop this scheme for other areas of the world. The names and addresses of doctors in the less developed countries could be added to the circulation list of the many giveaway journals which appear in duplicate in some households. If anybody in the UK has secondhand journals (the past two years) that they would like to pass on to doctors in Sri Lanka, perhaps they could send them to me. A detailed list of contents should be provided on the wrapping because this helps with clearance with the customs.
SIR,-Iwas intrigued
years under the
Nottingham City Hospital, Nottingham NG5 1 PB, UK
D. C. BANKS
SIR,-Dr Dugdale’s suggestion for redistributing journals to needy institutions in developing countries is excellent. This college has 175 undergraduate and almost 100 postgraduate admissions every year. Doctoral students are enrolled in four of the eighteen departments. There are 244 teaching and 464 non-teaching staff, not including those at the attached hospital, which has 1225 beds. This year we subscribed to 150 journals, which is 11fewer than the previous year. The total cost is over 21 000, double the amount spent for the same number of journals in 1990. Readers are afraid that the Indian government policy of curtailing expenses may lead to cutting drastically the number of journals to which institutions subscribe. A good library with an adequate periodical base enriches students and teachers. Without this facility the search for new knowledge is impossible. Many other schools are less fortunate than
drug-induced protein accretion", and after the first 3-4 days of in rats "the increase in protein deposition seems to be dependent on a drug-based reduction in the rate of protein degradation". Thus if the correct terms anti-catabolic for protein and catabolic for lipid had been used, or the term repartitioning agents, rather than the emotive word anabolic, sport might have been spared many troubles. Now the IAAF states that &bgr;2-agonists have always been in the class of anabolic steroids, but they seem not to have notified member countries, doctors, or coaches. The Sports Council has recorded that clenbuterol was effectively proscribed as soon as it was put on the market. Both bodies seem to have ignored the fact that the anti-catabolic (anabolic?) effects of &bgr;2-agonists were recorded only in about 1987, but salbutamol, clenbuterol, and similar drugs have treatment
been on the market for more than 15 years. Their advisors must have marvellous foresight to ban them under anabolic steroids some 10 years before they were shown to induce protein accretion in animals; results in man are awaited with interest. Perhaps the advisors may have been misled by your last paragraph "studies in animals indicate that clenbuterol and similar &bgr;-agonists taken in large doses can provide a protein anabolic response that could be performance enhancing" and "clinically, evidence from studies in rats suggests that, even at doses recommended for the treatment of asthma, clenbuterol may be valuable". If small doses in man produce an increase in protein deposition, it is a little surprising that we do not see large numbers of superbly muscled men and women among the millions who are taking the drugs therapeutically. Medical practitioners, sports doctors, and coaches have now to realise that unless commonsense prevails, they will be branded as doping doctors and coaches for prescribing and administering &bgr;2-agonists, because, in the view of sports administrators, without notice, these drugs have always belonged under the class of androgenic anabolic steroids. Obviously the use by scientists of the words anti-catabolic and anabolic to describe the protein accretion effects of &bgr;-agonists can have far-reaching consequences that they could not have foreseen. The misuse of &bgr;2-agonists in sport is increasing. Action should be taken, but only after careful thought and definition of rules clearly stating what is banned and what is not and due consideration of the medical implications of the ban. 73-75 Church Rd,
Training
ours.
developing countries clinicians may subscribe to a particular journal that is also available in his hospital or university library. In In
such instances, the subscriber could instruct the distributor to send
his personal copy direct to an institution of his choice, without charge to that establishment. Some institutions in developing countries would be able to meet the postage expenses. Department of Physiology, M P. Shah Medical College, Jamnagar 361 008, India
K. P. SKANDHAN
Clenbuterol and sport SIR,- Your Aug 15 editorial is being used by the Sports Council and others
as
justification for transference,
without
notice, of
&bgr;2-agonists into the class of androgenic anabolic steroids as related substances to the examples of steroids listed under the class. This big intellectual jump has led to some athletes being banned for 4 years
(International
Amateur Athletic Federation
IAAF)
and the
danger of two British weightlifters being banned for life after the
Olympic games. (Last Saturday the British Amateur Weightlifters Association disagreed with the Sports Council and decided not to ban the two weightlifters.) The jump has been explained as resulting from the proven increase in protein deposition, which has been called anabolic by
some scientists. This action has been taken despite the fact that you correctly state "there is some debate about the precise metabolic basis for
ARNOLD H. BECKETT
London SE19 2TA, UK
SIR,-In
your Oct 3
for
laparoscopy
(p 824) editorial
you show little love for
laparoscopy, and view from afar the moving scene, jolted unwillingly from your pensive chair by, of all journals, the Wall Street Journal and by public pressure. It is trite to state that more bileducts have probably been damaged in 1 year of laparoscopic cholecystectomy than in the previous decade, and almost certainly untrue. In our unit there has always been a steady referral of biliary trauma, and this year the frequency has only modestly increased, bearing in mind the greater number of cholecystectomies being done. Now such trauma is news, and since it is being caused by consultants rather than registrars, the "grapevine" is working overtime. The cause of these injuries is often inadequate training, and it is to this that our attention should be focused. To accustom a surgeon to entirely new skills requires experiment and practice; for large numbers of surgeons to join the learning curve is likely, I agree, to have a prohibitive cost in both cash and human terms. One answer is to limit the number of surgeons learning these techniques or to train surgeons in the laboratory. Simulation is too far away and probably too expensive, but training in fully equipped animal laboratories such as those set up commercially in Cincinnati, Paris, and Hamburg show the way forward. To avoid commercial as well as public and financial pressures, the need for organised training laboratories should be grasped within training programmes. Middlesex Hospital, London W1 N
8AA, UK
R. C. G. RUSSELL
