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CHOLANGIO-HEPATITIS-A CLINICAL STUDYBy F. G. HOBSON, D.S.O., D.M., F.R.C.P.

Physician to the Radcliffe Infirmaryand

J. M. RICE-OXLEY, B.M., M.R.C.P.Medical Registrar, Radcliffe Infirmary, United Oxford Hospitals

The term cholangio-hepatitis has recently beenadvocated by Himsworth (I947) to distinguish aclinical disease with a well-defined morbidanatomy, but presenting a variety of clinical syn-dromes. The essential features of the morbidanatomy derive from infection established in thebiliary tract, the severity and duration of whichdetermine the course and gravity of the clinicaldisease. This infection is usually secondary to andassociated with obstruction of the large bile ducts.In rare and infrequent cases infection of the tractis met with in the absence of any demonstrableobstruction. Almost invariably the organismsresponsible for this infection are members of thecoli-typhoid group, occasionally in association withS. viridans or S. faecalis, but in rare cases one orother of these latter organisms occurs alone. Thecholangitis thus established spreads throughoutthe intra-hepatic portion of the biliary tract, pro-ducing an inflammatory reaction in and around thesmaller bile ducts, the sequelae of which will de-pend upon the virulence of the organism and theduration of the infection. At one extreme there isan acute suppurative cholangitis with abscessformation, at the other a mild chronic inflam-matory process which continues for years, pro-ducing a ' biliary cirrhosis,' with a varying degreeof parenchymal damage, fibrosing obliterativecholangitis and secondary portal obstruction.Between these two extremes there are many inter-mediate cases variable both in their clinical mani-festations and in the degree of parenchymaldamage. In every case the cholangitis is associatedwith some degree of parenchymatous hepatitis,justifying the definitive description of the wholeprocess of cholangio-hepatitis.

In considering the aetiology of this conditionthe two essential problems are:-

(I) What is the cause of the biliary obstruction ?(2) How does infection reach the biliary tract ?

(x) ObstructionExcluding very rare congenital abnormalities of

the tract and neoplasms, obstruction of the biliary

tract arises from gallstones, biliary sludge or fromsurgical trauma.

(a) Gallstones. Whilst the aetiology of gall-stones is still far from clear, there is little doubtthat stones once formed may exist for many yearswithout giving rise to significant symptoms, andthat many such cases eventually present withsymptoms due to mechanical complications or tosuperimposed infection. When stones and in-fection are confined to the gall-bladder, cholecy-stectomy is followed by a complete cure (Fig. i).In a proportion of cases, however, stones or debrisare extruded into the main biliary passages,causing partial or complete obstruction, whichmay be complicated by coincident or subsequentinfection of these ducts, thus providing the essentialconditions for the development of cholangio-hepatitis. In such cases removal of the gall-bladder, even when combined with explorationand drainage of the common bile duct, may fail toeffect a cure (Fig. i).

(b) Stricture. Surgical trauma is well recog-nized as the commonest cause of benign strictureof the common bile duct. Reviewing a series ofcases of benign stricture of the common duct,Flickinger and Masson (1946) report that I86 outof I88 cases had undergone a previous operationon the biliary tract. In IIo cases symptoms ofobstruction developed in the immediate post-operative period following cholecystectomy. In22 of these cases obstructive symptoms did notdevelop until i to io months after cholecystec-tomy following a previously uneventful con-valescence. On further exploration, these casesshowed an extensive obliteration of the extra-hepatic ducts. Apart from surgical trauma, thereis in these cases a possible alternative interpreta-tion of the findings, namely that the disease of thegallbladder was never more than a part of the in-fection of the whole biliary tract, and that at thetime of the initial operation, established infectionof the common duct was overlooked, withthe subsequent development of obliterativecholangitis.

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StericaL Ir9lamrnatoryme-chanialR Amechanical <(-l

StAeri1LeIftXvamechaicL y4rechanic

tctsxjectea etcFIG. I.-i and z. Cholecystectomy-cures. 3 and 4. Cholecystectomy even when combined with exploration and

drainage of the common duct may fail to cure as the cholangio-hepatitis is untreated.

(2) InfectionHow does this reach the biliary tract ? The

most generally accepted view is that infectionreaches the gall-bladder, the biliary tract and theliver via the systemic circulation through thehepatic and cystic arteries. Wilkie's (1928) ex-periments indicated that such bacteria as find theirway into the tract do not normally give rise to in-flammation when the bile is flowing freely, but inthe presence of obstruction they may give rise tocholecystitis, cholangitis and hepatitis. The or-ganisms most frequently recovered belong to thecoli-typhoid group, the members of which arefrequently responsible for infections of thebacteriaemic or septicaemic type.

In past or even present-day terminology thegroup of cases considered in this study might havebeen presented under one of several clinical labels,such as Charcot's intermittent hepatic fever,cholangitis, cholangitis lenta, Hanot's biliarycirrhosis, biliary dyskinesia (Guy, 1945), or Banti'ssyndrome, always however accepting that thissyndrome is more often the product of degenera-tive hepatic fibrosis of non-inflammatory origin.It is suggested that the term cholangio-hepatitis ismore accurate and better justified by the demon-strable features of the morbid anatomy.

Clinical CasesThe clinical material consists of 31 cases ad-

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HOBSON and RICE-OXLEY: Cholangio-Hepatitis-A Clinical Study

mitted to the general medical or surgical wards ofthe Radcliffe Infirmary over a period of about io

years. Every case has been a case of cholelithiasis.Three of these cases died shortly after admissionwithout operation. In the remaining 28 cases thegall-bladder was removed for cholelithiasis, withcholecystitis. In each of these 28 cases there was,therefore, clear evidence of disease of the biliarytract, and an opportunity was presented in eachcase for inspecting the main bile ducts, and forobtaining from them evidence of the presence ofinfection by direct culture.

In 27 of these 28 cases cholecystectomy com-pletely failed to relieve the symptoms from whichthe patient was suffering, as the cholelithiasis andcholecystitis were no more than part of a diseaseof the whole biliary tract, and the post-operativesymptoms were identical with those present beforeoperation. These patients were, in fact, cases ofcholangio-hepatitis, whose symptoms returnedwithin a few weeks or a few months of their dis-charge from hospital.Symptoms and signs. There are four charac-

teristic symptoms of cholangio-hepatitis.(I) Attacks of upper abdominal pain.(2) Vomiting.(3) Jaundice.(4) Rigors, chills and shivering attacks.All these symptoms and signs were present in

each of the 27 cases mentioned above prior tocholecystectomy, and in each case the same symp-toms and signs recurred post-operatively in vary-ing frequency and in different combinations, nosingle case having failed to present jaundice insome or all of the relapses. The post-operativeclinical diagnosis has been confirmed by the re-covery of infected bile, yielding B. coli on culturein 24 cases. In 4 cases only does the diagnosis restupon clinical evidence unconfirmed by culture ofthe bile.The clinical picture here presented is not, how-

ever, quite so simple as this bald statement of thegeneral facts might suggest. Himsworth hassuggested the clinical subdivision of cholangio-hepatitis into three syndromes, namely:-the acutesuppurative, which proceeds to a rapid termina-tion; subacute cholangio-hepatitis, comprisingmany cases of moderate severity with recurrentsymptoms compatible with survival for manymonths or even two or three years; and chroniccholangio-hepatitis, comprising cases which mayendure for years with symptoms ofvague ill-health.Himsworth is, however, at pains to emphasizethat these broad distinctions, while convenient, donot imply the existence of separate and distinctentities but simply degrees of one process, the

morbid anatomical sequelae of which are pro-gressive but variable in their severity, a processwhich will produce clinical pictures of some com-plexity and variety. Our cases provide ampleevidence in support of Himsworth's main thesis,and we have been able to trace a common historicalpattern in the development of the process. Thiscan be summarized as followed:-

Phase i. Gastrointestinal disturbances, es-sentially mechanical in origin and attributable tothe presence of gall stones. The duration of thisphase has varied from a few weeks to more than20 years.

Phase 2. Gastrointestinal disturbances, withsymptoms and signs attributable to infection of thebiliary tract, a cholangio-hepatitis. These symp-toms and signs invariably comprise pain, vomiting,jaundice and rigors. Depending upon the severityof the symptoms, this phase may cover a period ofa few days to a few months, even to a year, beforea surgical opinion is sought.

Phase 3. Cholecystectomy.Phase 4. The return of precisely those symp-

toms and signs for which the cholecystectomy wasperformed. This phase is marked by relapses atintervals of a few weeks or a few months, withsymptoms and signs of variable severity, com-prising pain, vomiting, jaundice and rigors.Jaundice is a variable feature of the relapses.Evidence of parenchymal hepatitis is dependentupon the severity and duration of the infection.

Phase 5. In which a progressive biliary cirrhosisleads on to liver failure, portal obstruction, ascitesand oesophageal varices.The 3I cases fall naturally into four main syn-

dromes, which differ somewhat from Himsworth'sclassification.

The Four Clinical Syndromes(I) Pyrexia of Unknown Origin (2 cases)

i. This case (female, age 76) was remarkable inthat minute and detailed investigations over aperiod of two years failed completely to reveal anycause for recurrent attacks of high, remittentpyrexia of variable duration. During theseattacks, which lasted up to several weeks, therewas a curious absence of any constitutional dis-turbance, the patient insisting upon her com-petence to conduct her normal activities in spite ofan evening pyrexia of 103° F. A transientjaundice, apparent as a terminal event, providedthe first and solitary indication of any lesion of theliver or biliary tract. At autopsy there weremultiple liver abscesses yielding pure cultures ofB. coli, with diffuse 'biliary cirrhosis'; the in-

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testines contained multiple calculi which hadobviously been only recently discharged from thedilated and chronically inflamed common duct.

2. Male (age 79) giving a history of one year'spain across the chest, unrelated to exertion orgastrointestinal function. Six weeks prior to ad-mission he began to experience intermittent rigors,with progressive loss of appetite. He started on aholiday but his rigors recurred more frequently.There was no jaundice, the urine was sterile andcontained no albumen, sugar or bile. Abdomen-

1.

4

Fic. 2.-Case E.G. Mlacroscopic view of liver, whichweighed 1,700 cm. The section is taken fron theright lobe and shows multiple abscess cavities atdifferent stages of development, but all arisingin the portal tracts as a result of suppurativecholangitis.

AMI ~

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FIG. 3.-Case E.G. Microscopic view of one portaltract. A small abscess is shown in an early stageof organization. The bile duct from which itarose has been obliterated; a tributary duct (topleft) is onily mildly affected, and there is evidenceof duct regeneration in the neighbourhood of theabscess. The tract shows fibrosis, much of whichis recent; the arterv (left centre) shows degenerativechanges. The shrinkage of liver cells is largely theresult of post-mortem degeneration.

no localizing signs. Blood culture-B. coli inpure culture. Blood bilirubin-i. i mgm. per cent.

Operation. Cholecystectomy. Three calculiand much debris in gall-bladder. Aspiration ofthe common duct yielded B. coli in pure culture.The duct was explored but no obstruction found;the duct was drained. After a full course of sul-phonamides, convalescence was uneventful andrecovery apparently complete.These two cases illustrate the fact that jaundice

may be notable by its absence even when there isan acute virulent infection in the biliary tract. Inthe first case jaundice was apparent only as atransient terminal episode. The second case wasremarkable as being the solitary example in theseries in whir h a positive blood culture wasobtained.

(2) Suppurative Cholangitis (4 cases)i. Female (aged 74) admitted moribund, heavily

jaundiced. At autopsy there were multiple liverabscesses and ' biliary cirrhosis '; B. coli wasgrown in pure culture from the abscess cavities

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There was a history of symptoms suggestive ofcholecystitis of about I2 months' duration, fol-lowed by an acute, sudden exacerbation threedays before death.

2. Male (age 80). No clear history of previousill-health other than dysuria of recent onset. Ad-mitted jaundiced and moribund. Liver abscessesyielding B. coli in pure culture and biliary cirr-hosis (Figs. 2 and 3).

3. Female (age 39) admitted with a history oftwo attacks of pain, vomiting, jaundice and rigors,since cholecystectomy for cholelithiasis threemonths prior to admission. During cholecystec-tomy the common bile duct had been inadvertentlydivided and repaired by suture over an indwellingT-tube. Duodenal intubation yielded a pureculture of B. coli.A laparotomy was performed on this patient but

no evidence of any gross obstruction was dis-covered either in the common or hepatic ducts.Repeated attempts to sterilize the biliary tract withsulphonamides were unsuccessful, as tested byduodenal aspiration. Death occurred in an acutesepticaemic exacerbation shortly after dischargefrom hospital This was the solitary case in theseries in which recognized surgical traumaoccurred.

4. Male (age 66). This patient gave a seven-year history of attacks of biliary colic, with a severeexacerbation of symptoms two months prior toadmission. Cholecystectomy was performed butthe patient died two weeks after operation. Atautopsy a ' missed ' calculus was discovered in thecommon duct, together with a large abscess in theliver, yielding pure B. coli on culture.

(3) Subacute (or Chronic) Cholangio-Hepatitis (22cases)In this major group it is difficult to differentiate

clearly between subacute and chronic cholangio-hepatitis. No patient in this group is prepared toregard his sufferings as mild, and relapses haveoccurred over a number of years. In every casethe gall-bladder had been removed for chole-lithiasis with cholecystitis. The first relapsesoccurred usually within three months of operation,in some cases even within a few days or weeks ofoperation, and major relapses have followed at in-tervals varying from six weeks to nine months. Inone case three or more rigors a week continued formany months after operation.Of these 22 cases three have had two further

operations when calculi or biliary sludge werediscovered in the common duct, and B. coli foundon culture. Four cases have had one furtheroperation on the common duct, in each case calculibeing found in the duct. One of these cases had

relapsed after a successful post-operative steriliza-tion of the tract with sulphonamides, confirmed bythe recovery of a sterile bile by duodenal intuba-tion. Nine cases are leading fairly healthy lives,interrupted at unpredictable intervals by relapsesof shorter or longer duration and varying severity.Five cases responded successfully to sulphonamidetherapy, success being judged by the fact that asterile bile was recovered on the completion oftreatment, the bile having yielded B. coli on culturebefore treatment. These cases have remainedsymptom free, as confirmed by a follow-up en-quiry, the shortest five years, the longest ten yearsafter treatment. It is reasonable to suppose thatin these five cases there was no significant post-operative obstruction of the biliary tract and thatthe cholangio-hepatitis was cured by eradicationof the infection. One case has responded success-fully to combined sulphonamide and streptomycintherapy, but sufficient time has not yet elapsed toregard the patient as cured.Two illustrative cases are given in detail.i. Female (age 70). I9I6 (Phase i). Aged 50,

she experienced an attack of upper abdominalpain diagnosed as gallstones. She was dieted andremained relatively symptom free until I927, whenattacks of pain recurred at variable intervals.

1936 (Phase 2). Recurrent attacks at short in-tervals of abdominal pain, vomiting, jaundice andchills lasting five weeks. Gall-bladder palpable.

1936 (Phase 3). Cholecystectomy-gallstones.(Phase 4.) Four months after operation she ex-

perienced an acute attack of upper abdominal painwith fever and shivering. These attacks recurredat intervals of a few months and were frequentlyassociated with transient jaundice.

I939. Admitted with slight jaundice, recover-ing from a recent relapse. Duodenal intubationshowed that 'all specimens of bile contain largenumbers of pus cells, coliform bacteria andstreptococci. Culture-profuse growth of B. coli.'She was treated with a full seven-day course ofsulphapyridine, following which duodenal in-tubation revealed sterile bile. The patient, now8I, has been symptom free for ten years.

2. Male (age 63). 1936 (Phase i). Began tohave attacks of epigastric pain about an hour aftermeals, relieved by alkalis and occasionally byvomiting. These attacks continued at variableintervals.

1946 (Phase 2). He experienced a severe attackof epigastric pain radiating to the scapulae withvomiting, shivering and transient jaundice.

I947. Two similar attacks with rigors. Lateradmitted to hospital with jaundice and a tem-

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perature of o11°; both jaundice and fever sub-sided.

(Phase 3.) Cholecystectomy. The common ductwas found to be dilated; it contained one largestone with much debris, and was drained. Cultureof the bile showed B. coli and scanty Ps. pyocyanea.Penicillin, but no sulphonamide, was given post-operatively. A post-operative cholangiogramshowed no obstruction of the duct.

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FIG. 4.-Case R. J. Microscopic view of liver (biopsyspecimen). The portal tracts show fibrosis andsmall round cell infiltration; much of the fibroustissue lies in concentric rings about the bile ducts.

1948, January (Phase 4). Severe recurrence ofpain with vomiting and jaundice. Admitted andgiven full course ofsulphamezathine and penicillin.

1948, November. Further mild and severeattacks of pain occurred together with vomitingand jaundice. Investigations showed:-

Duodenal intubation-pure culture of B. coli.Blood chemistry-serum bilirubin 2.0 mgm.Serum phosphatase 27 units.Serum protein, total 6.4 gr.; albumin 3.4 gr.,

globulin 3.0 gr.Serum flocculation tests negative.1948, December. Choledocho-duodenostomy.

Common duct explored; found dilated with con-striction at ampulla and containing five largecholesterol stones with much debris. B. coli on

culture. (Liver biopsy Fig. 4.) Post-operativelya full course of sulphamezathine was given.

I949, July. The patient was well and symptomfree.

(4) Banti's Syndrome (3 cases)i. Female (age 58) admitted with history of

more than 20 years of gastrointestinal disturbances,'bilious' attacks and vomiting suggestive ofcholelithiasis. Following admission with severecholaemia and biochemical evidence of severeparenchymal damage, she recovered and acholecystectomy was performed in March 1948,a small, withered gall-bladder being removedtogether with a large stone found in the commonduct, the bile yielding B. coli in pure culture. InOctober I948 she had a severe haematemesis;examination showed an enlarged spleen and pal-pable liver, while oesophageal varices were easilydemonstrated with a barium swallow.

Splenectomy was performed.2. Male (age 37). I932. Onset of jaundice

and fever with an enlarged liver; a cholecysto-gram showed a non-filling gall-bladder and he con-tinued to experience mild recurrent attacks untilI934, when the attacks became more severe andwere associated with rigors. These attacks oc-curred at variable intervals until 1942, when hewas admitted for cholecystectomy. The gall-bladder showed white mucoid contents, thecommon duct was unusually small, possibly acongenital abnormality, and contained a number ofpigment stones. Macroscopically the liver ap-peared to be normal. There was no evidence ofhaemolytic jaundice. In I943 he was readmittedfor recurring attacks of pain, vomiting, fever andjaundice. Duodenal intubation yielded a cultureof B. coli and S. viridans. Biochemistry: pro-teins, total, 6.6 gr., albumen 3.8 gr., globulin 2.5gr., plasma phosphatase 32 units. He was treatedwith hexamine, but in I945 presented again withpersistent mild jaundice with episodic deepening.The liver was easily palpated and the lower pole ofspleen was just palpable. Duodenal intubationyielded a culture of B. coli. Plasma proteins,total, 7.9 gr., albumen 4.4 gr., globulin 3.0 gr.,plasma phosphatase 54 units. He was treatedwith successive courses of sulphathiazole, sulpha-diazine and sulphanilamide without benefit; fol-lowing each course duodenal intubation yieldedB. coli in pure culture. In I946 a laparatomy wasperformed. Macroscopically the liver showed acoarse nodular fibrosis, no stones were felt in thecommon duct and choledochoduodenostomy wasdeemed impracticable. In I948 ascites first ap-peared and reputted aspiration was necessaryuntil his death later in the year (see Fig. 5).

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May 1950 HOBSON and RICE-OXLEY: Cholangio-Hepatitis-A Clinical Study 273

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FIG. 5.--Case W.P. Microscopic view of liver. The section is takenfrom the wall of a large bile duct, the lumen of which crossesthe upper part of the picture. The mucosa has been destroyedand the duct is lined by granulation tissue with much fibrosisin the deeper layers; here also regenerated bile ducts are seen.Three islets of liver tissue, surrounded by thick fibrous tissue,are seen at the bottom of the picture, and indicate theadvanced degree of biliary cirrhosis present in this case.

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FIG. 6.--Case G.E. Macroscopic view of liver, whichweighed 2,135 gm. In this section from the leftlobe, large abscess cavities are the most strikingfeature.

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FIG. 7.--Case G.E. Microscopic view of liver, showinga portal tract close to the wall of one of the abscesscavities. This demonstrates the very markedfibrosis in the tract, especially about the ducts, asa result of long-standing inflammation. The dis-tortion of the mucosa in the large duct is an artefactprobably due to post-mortem desquamation.

3. Male (age 35). Cholecyst-gastrostomy wasperformed for recurrent attacks of jaundice andfever at the age of 29, but following a temporaryremission of his symptoms readmissions for re-current attacks of jaundice and fever werenecessary over a period of five years until his deathwith parenchymal failure, splenomegaly andascites. Over the period of readmissions therewas biochemical evidence of progressive par-enchymal damage. At autopsy the liver was

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HOBSON and RICE-OXLEY: Cholangio-Hepatitis-A Clinical Study

grossly enlarged and showed a chronic cholangio-hepatitis with biliary cirrhosis and multiple abscesscavities yielding B. coli in pure culture. The caseis one of unusual interest in that upon a protractedchronic cholangio-hepatitis there supervened theacute suppurative phase with abscess formation(see Figs. 6 and 7).

Summarizing briefly the main features ofcholangio-hepatitis as illustrated by the cases re-ported, it is apparent that it is a major disease ofthe biliary tract, the presence of which may escapedetection because the diagnostic and therapeuticefforts are concentrated upon and diverted to theminor, more obvious, coincident and provocativedisease of the gall-bladder which is no more than apart of the pathological process. The course ofthe disease may be fulminant or intermittent. Ifunrecognized and inadequately treated it will in-evitably pursue its relentless course with minor ormajor exacerbations, giving rise to a progressivebiliary cirrhosis, hepatitis and parenchymal failure,terminating in a Banti's syndrome with ascites orhaemorrhage.

Discussion

Considering the uniformity of the clinicalpicture presented by this condition, especially inits fourth post-operative stage, it is remarkable thatmore attention has not been paid to it in the past.This neglect is perhaps due to its comparativerarity, but an investigation carried out upon allpatients undergoing cholecystectomy for chole-lithiasis at the Radcliffe Infirmary during the years1943 to 1947 showed that out of 163 cases 8 showedindubitable evidence of cholangio-hepatitis. Acondition of such severity occurring in 5 per cent.of patients undergoing cholecystectomy obviouslydemands serious consideration.

Diagnosis of the existence of cholangio-hepatitisprior to cholecystectomy is admittedly difficult.The cardinal symptoms of pain, vomiting, jaundiceand shivering are suggestive but not diagnostic, asthey may occur in cases in which the inflammationis confined to the gall-bladder, with a transienthepatitis. Post-operatively the recurrence of thesesymptoms, singly or in combinations, is verysuggestive of the existence of cholangio-hepatitis;shivering attacks and jaundice are of particularsignificance and almost diagnostic. In generalbiochemical and haematological investigations areunhelpful in establishing the diagnosis, and theonly indubitable evidence is the isolation of B. colior other organisms from the bile, either at the timeof operation or by duodenal aspiration before orafter operation.

Analysis of the 27 patients with cholangio-

hepatitis reported in this paper show that in 9cases the common bile duct was neither explorednor drained, and that post-operative sulphonamidetherapy was only employed in six. In only Icase was there any major surgical trauma to thecommon duct. In the light of this analysis andbearing in mind that obstruction and infection arethe two factors of paramount importance in theaetiology of cholangio-hepatitis, we would suggestthat the following measures should be carried outin order to diagnose and prevent this very seriouscomplication of cholelithiasis.

I. At the time of cholecystectomy, especiallyin the presence of obstruction or any other patho-logical abnormality in the common duct, theunique opportunity of obtaining cultures frombile in the duct should not be missed.

2. Bearing in mind that experienced surgeonsare of the opinion that neither by inspection norpalpation is it possible to express a confidentopinion that no obstruction to the duct exists, ex-ploration of the common duct and dilatation of thesphincter of Oddi should be carried out in a highproportion of cases submitted to cholecystectomy.

3. In cases of proven obstruction or infectionof the common duct the drainage tube should notbe removed until (a) there is definite evidence ofpatency of the duct; (b) culture has shown thebile to be sterile.

4. In cases of obstruction and infection of thecommon duct operation should be combined withand followed by a course of chemotherapy, sul-phonamides and streptomycin being the obviousdrugs of choice.

In our opinion the introduction of thesemeasures would greatly improve the results oftreatment in these difficult cases, though theywould not, of course, prevent the development ofcholangio-hepatitis following gross operativetrauma to the bile ducts. This disaster continuesto present one of the most difficult problems ofbiliary surgery, and no wholely satisfactory treat-ment is as yet available; as Flickinger andMasson (I946) remark: ' Traumatic stricture of abile duct is a tragic accident, which entails untoldmisery for the patient, presents a formidable taskto the surgeon and even with the best treatmentattempts at reconstruction are followed by a highmortality.'

SummaryThe pathological and clinical manifestations of

cholangio-hepatitis are described, and it is em-phasized that cholecystectomy is not a cure for thecondition.

May I950 275copyright.

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276 POSTGRADUATE MEDICAL JOURNAL May I950

A series of 3 ' cases of cholangio-hepatitis ispresented. Four major clinical syndromes areillustrated in this series of cases

i. Pyrexia of unknown origin2. Suppurative cholangitis3. Subacute (chronic) cholangio-hepatitis4. Banti's syndrome

with a common historical pattern which isdescribed. Duodenal intubation is an invaluableaid in diagnosis, and moreover can provideevidence of the success or failure of surgical orbacteriostatic therapy employed to suppress theinfection in the biliary tract.

It is suggested that adequate drainage of thecommon duct, in association with vigorous chemo-

therapy, are the essential features in the manage-ment of the condition.We wish to record our gratitude to Dr. C.

Bartley for assistance with the records, to Dr.A. H. T. Robb-Smith for help and criticism, toDr. R. I. K. Elliott for the preparation of thepathological specimens and illustrations, to Dr.R. H. Vollum for the bacteriological investiga-tions, to Mr. G. Higgins for the biochemical dataand to our surgical colleagues on the staff of theUnited Oxford Hospitals, Radcliffe Infirmary, forpermission to use their records and to study thecases under their charge.We also wish to express our thanks to Professor

L. Witts for a grant from the Nuffield ResearchFund to meet secretarial and postal expenses.

BIBLIOGRAPHY

HIMSWORTH, H. P. (1947), 'The Liver and its Disease.'FLICKINGER, F., and MASSON, J. C. (1946), Surg. Gynec.

Obstet., 83, 24.WILKIE, A. S. (1928), Brit. Y. Surg., I5, 450.WILKIE, A. S. (1929), Ibid., I6, 2I4.GUY, C. C. (I945), Indust. Med., 14, I8i.

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