and above the lesion the duct wall appeared macroscopically normal. After mobilization and excision of the stricture the divided ends came together without difficulty and a single-layer interrupted 4/0 silk suture line was fashioned. Post-operative progress was uninterrupted, and follow-up three months later showed the patient well and symptom-free. It is of interest that the urinary tract contained S. hamatobium, whereas the ova in the biliary tract were S. mansoni.
Case 3, a stricture of the hepatic duct (Fig. 490)~ showing the same dense localized narrowing, was further complicated by a soft friable stone lying above it. The local appearances were identical to those in Case 2. After mobilization and resection, a direct end-to-end single-layer silk anastomosis was performed without undue difficulty. Although no ova were found in the resected specimen, the patient gave a history of repeated previous urinary bilharzia infestations.
As a liver biopsy was not done there is no direct proof that this case was in fact due to schistosomal infestation. No liver flukes were found in the stool, but this does not exclude the possibility that this disease, which produces a similar inflammatory reaction, may have been responsible for the fibrosis. The absence of previous biliary surgery, the close resemblance of local pathology to the previous cases, REFERENCES AIW, I. (I957), A Companion in Surgical Studies, 1005.