Roy Cameron

Congenital Biliary Atresia

Congenital biliary atresia, though a relatively uncommon occurrence, still remains one of the most disappointing of neonatal surgical problems, relieved all too rarely by occasional success in treatment. Following John Thomsons original survey of 50 cases in 1891, it was not until 1916 that J. B. Holmes suggested treatment by surgical means after reviewing over 100 patients. Though the first recorded unsuccessful attempt was made by Giesel and Witze in 1895, it was not until 1927 that Ladd first performed a successful anastomosis, and up till 1952 he, and later Gross, quoted the extraordinary total of 146 babies with biliary atresia, among whom they obtained a cure in 12 cases. This does not include those children with inspissated bile in the ducts -a condition which must often spontaneously regress, even though laparotomy may be needed to diagnose it. We doubt if any series can match this either in numbers or cures ; in fact, even in large childrens centres in Britain such a case must rank as a rare occurrence. Aird records having had ten cases, none of which were operable. Our own recent inquiries throughout medical centres in Great Britain, Europe, and America have revealed that not a single pathologist has come across a case in which sections of the liver before and after the relief of congenital atresia were available. Indeed, they all write quite emphatically that they had never encountered a subject thought to be suitable for operation. After the completion of this paper, however, we heard of three patients who had been successfully operated on at the Childrens Hospital of Philadelphia and were followed up for five years. No post-operative material was available for study. We are indebted to Dr. Irving J. Wolman for this information.

KINETICS OF CELL GROWTH

far we are from any final assessment of the points at issue is clear from the fact that, though in the present volume onchocerciasis ranks high amongst the causes of blindness, recent work by other observers has questioned whether onchocerciasis is a blinding affection at all; it is said that much that goes as onchocerciasis must be regarded as unrecognized genetic disorders in the African population. A welcome beginning has, however, been made. ARNOLD SORSBY.

WHAT WE KNOW ABOUT CELLS

VESICO-VAGINAL FISTULAE The Vesico-Vaginal Fistula. By J. Chassar Moir, C.B.E., M.D., M.A., D.M., F.R.C.S.Ed., F.R.C.O.G. (Pp. 151+ vii; illustrated. 40s.) London: Bailli4re, Tindall and Cox. 1961. Professor Chassar Moirs experience of urinary fistulae in women is unrivalled in this country. Some overseas gynaecologists working among primitive communities may have seen more cases, but rarely have they studied the problems involved so carefully and so profoundly as has Professor Chassar Moir. In this book he recounts his experience of 230 consecutive cases of urethro-vaginal and vesico-vaginal fistulae treated surgically. Only 5 (2.1 %) required transplantation of the ureters; the remainder enjoyed restoration of good bladder and urethral function. In 190 cases the fistulae were traumatic in origin, but these represent a highly selected and difficult series made up mainly of the discards and failures of other surgeons. Every one of these traumatic fistulae was closed and nearly always at the first attempt. This remarkable achievement is glossed over with modesty, and Professor Chassar Moir credits his success to his assistants and to the principles laid down by Marion Sims. The causes and types of fistulae are described, but the book is mainly concerned with the technical details of vaginal operations for their cure, with emphasis on those points which make for success or failure. This applies also to the more difficult fistulae due to radiation necrosis or associated with complete destruction of the urethra which, in the authors hands, are generally curable. While concentrating on his own methods Professor Chassar Moir mentions other procedures such as muscle transplants to increase the vascularity of ischaemic tissues. But he makes a strong case for the vaginal rather than the abdom.nal or transvesical approach in the treatment of nearly all fistulae. This elegantly produced and illustrated monograph has a strong personal flavour which makes it all the more valuable and enjoyable. I found it so absorbing and so readable that, having started, I could not leave it unfinished. T. N. A. JEFFCOATE.