It is now more than 20 years since our patient's first operation. With the aid of more recent knowledge it is easy to criticise the original investigation as inadequate. Neither operative cholangiography nor liver biopsy was done. The common bile duct was identified as a faint cord and the obstruction was felt to be either complete or virtually so. Only a single drop of bile was found coming from the region of the duct. He was then diagnosed as having "biliary atresia." It is clear that our patient has had lifelong biliary obstruction and that this improved as he grew older. Moreover, the response to his second operation clearly suggests that this obstruction was largely extrahepatic at that time, presumably low in the biliary tract. We cannot, however, be sure that our patient had complete obstruction of the bile ducts in infancy. The recorded operative findings make it unlikely that his biliary obstruction arose from surgical trauma during the first operation. We entirely agree with Dr Mowat and Mr Howard that early investigation and surgery by units experienced in the problem is indi-
cated for infants with suspected biliary atresia. As we noted, survival is poor and spontaneous reversal, if it does occur, is rare. We doubt that a single case report will deter paediatricians from referring patients for surgery. We believe that the diagnosis of biliary atresia, on the basis of available information, is sufficiently likely to make this an unusual and interesting case. More particularly we would like to point out the excellent relief of distressing symptoms which our patient obtained. We suspect that one day others will be faced by the same problem. To be pedantic, perhaps our title should have read: "Cholecystojejunostomy: a late but successful treatment for pruritus complicating congenital extrahepatic biliary obstruction."
BRITISH MEDICAL JOURNAL
to be increased. The idea coming from trainees2 that there should be a common basic programme for oncology training has much to commend it and should not be too difficult to achieve. The practice of medical oncology is a different problem. The establishment of oncology centres has obvious advantages in economy of expensive apparatus and facilities (not only radiotherapeutic) and in concentration both of uncommon tumours and of expertise and of research. Radiotherapy centres have established a good system of peripheral clinics at district hospitals for both new and follow-up patients and for liaison with local medical colleagues. Good long-term follow-up and analysis of hazards and of benefits from chemotherapy are going to become of increasing importance. Medical oncologists are going to remain scarce for some time and one of the best places for them to work should be in collaboration in radiotherapy and oncology departments, the resources of these departments being expanded, as in Sweden. We all talk about the need for team treatment and for collaboration; we ought to continue to try to practise it. Medical oncology cannot be discussed in isolation; there are several hundred medical staff in radiotherapy and oncology who are also totally "committed to oncology." KEITH HALNAN Glasgow Institute of Radiotherapeutics and Oncology, Western Infirmary. Glasgow 2
W'iltshaw, E, Buchman, R, and Mitchell, D, Lanceet 1977, 1, 699. Sikora, K, Lancet, 1976, 2, 1356.
Speed limits and the public health
SIR,-Your leading article on the raising of K J FOSTER speed limits (23 April, p 1045) reveals a S J KARRAN scandalous situation. A decision has been made to increase the maximum speed limits, Surgical Division, Faculty of Medicine, which will almost certainly lead to an increase University of Southampton in serious and fatal accidents. Yet no medical organisation has been consulted about this. The scandal will be compounded if the medical profession accepts this decision without a Commitment to oncology protest. In human terms road deaths and SIR,-Your leading article (2 April, p 864) and injuries are appalling. In economic terms the letters from Dr Eve Wiltshaw and her doctors cannot demand more of the nation's colleagues in the Lancet' and the BMJ (7 May, money if they do not protest at measures p 1214) deserve amplification and discussion. which are bound to increase the demands on Medical treatment of cancer must continue to the health services. Can we please be reassured improve and be practised in the best possible that the BMA and the royal colleges and every way. There are two problems-training and other possible pressure group are doing what they can to reverse this fatal step ? practice. You quote the Minister's view as "We want Many trainees can well be advised that numbers of posts are available in departments to save life, but we like driving fast." That of radiotherapy and oncology and that in these may be a doctor's view, too, but surely, for a they will see a large number of patients with doctor, the first statement should carry more cancer being treated by chemotherapy and weight than the second. Certainly it does to with hormones as well as by radiotherapy. The myself, but then I owe my own life, following Royal College of Radiologists has a full formal a blow-out on the Al, to a mere 60 mph and training programme, with day release courses a safety belt. J L T BIRLEY held in London and in the larger cities such as
Cardiff, Edinburgh, Glasgow, Manchester, and many others. This training and the fellowship examination in radiotherapy and oncology are not only in radiotherapy and radiation physics but also, even more nowadays, in the clinical management of cancer in general and in the relevant basic sciences-the pathology of cancer in its widest sense, tumour biology, and medical statistics. The relative content of chemotherapy and other aspects of what is commonly called medical oncology continues
Institute of Psychiatry. London SE5
SIR,-Speed limits do indeed save lives, as suggested by your leading article (23 April, p 1045). If the speed limit on motorways was reduced to 30 mph then the accident rate would drop to a minimal number. If it was made 0 mph then presumably the mortality rate would disappear altogether. The point is that the problem lies not with how fast or how
14 MAY 1977
slowly drivers go but with the sheer technical competence of the driver. The introduction of safer motor cars and the encouragement of the use of seat belts are examples, like speed limits, of attempts to modify the environment the driver finds himself in without any attempt to modify the behaviour of the driver himself. It would be much more profitable if we insisted that the standard of driving was increased. This would mean a general tightening up of the ludicrous driving test, the insistence of retesting at intervals, and particularly after a driver had been involved in an accident, and a change in public thinking such that people were made to realise that a motoring offence is not a jolly jape like smuggling an extra bottle of spirits through the customs on coming back from a French holiday but rather a serious antisocial act which could have serious consequences. We should stop fiddling around with things like speed limits and should seriously rethink our attitude to the motor car and the levels of skill we demand of people who drive them. A K CLARKE Royal National Hospital for Rheumatic Diseases, Bath, Avon
SIR,-With reference to your leading article on this subject (23 April, p 1045) the lack of consultation with the medical profession again demonstrates that politicians are more concerned with votes and self-interest than road safety. The main causes of road accidents are excessive speed, alcohol and drugs, and lack of attention, including falling asleep. The first two can be considerably affected by law. The introduction of the 50 mph speed limit resulted in a marked reduction in road accidents and this has been demonstrated in other countries where the 50 mph limit is enforced. The facts are clear, although, as you stress, there are differing explanations. Alcohol and drugs are a problem little affected by current legislation and again the politicians make laws disregarding well-known medical facts. It is astonishing that the House of Lords should reject a Bill to make the wearing of seat belts compulsory, but again the politicians ignore medical evidence. The argument cited that the police cannot control speed limit evasion and could not control the wearing of seat belts does not bear close examination. Excessive speed can be detected electronically and a fine should be on
the spot-only if the motorist disagrees should the case go to court and in the event of conviction the fine would be doubled. A simple regulation for seat belts would be to make them compulsory except where there is a 30 mph limit, as at these lower speeds accident damage is likely to be less serious. There should be no exceptions. Anyone unable to wear a seat belt should sit at the back. L W LAUSTE Brighton, Sussex
Staffing in the medical laboratory service SIR,-I am disturbed but not surprised at the text of the letter from Mr F J Baker and Mr J K Fawcett of the Institute of Medical Laboratory Sciences (5 March, p 638); this has regrettably an all too familiar tone-"Good relations in the service will not be encouraged