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SURGERY IN ACUTE HEPATITIS
1199
siderations of public policy. In the interests of public
policy the welfare of the patient should not be put in jeopardy by fear that confidential discussions with a doctor might subsequently be disclosed; but also in the interests of public policy the courts should not be hampered in their task of ascertaining the truth of certain matters. For success in a claim for privilege for psychiatric interviews, it would have to be shown that the first consideration outweighed the second, and to a greater extent than in ordinary medical interviews. In any event, it may be better that privilege should attach to the medical profession as a whole and not to one particular specialty. In view of the fairly settled state of the law this would probably require legislation. Some Commonwealth countries have already passed legislation on this subject, and the American Law Institute’s code of evidence accords privilege in civil actions and some criminal prosecutions in the case of confidential communications to a doctor reasonably necessary for the treatment in hand.2 SURGERY IN ACUTE HEPATITIS
THE cholestatic form of epidemic viral hepatitis is often hard to distinguish from extrahepatic biliary
obstruction, 3 4and
in some patients the difficulty can be in the end only by an exploratory operation. A valuable paper by Harville and Summerskillassesses the risk of operating on these patients. From the records of 18,000 operations for hepatobiliary disorders at the Mayo Clinic during 1950 to 1961, 58 patients with hepatitis were found to have undergone diagnostic laparotomy or more extensive operations. The final diagnosis was established in these patients by examination of the hepatobiliary-pancreatic structures, by negative findings on exploration of the common bileduct and operative cholangiography, by disappearance of the jaundice at varying intervals after laparotomy, and by histological confirmation from biopsy specimens of the liver. In 32 of the 58 patients the hepatitis was presumed to be viral, and in the remaining 16 it was drug-induced. It had been impossible to rule out extrahepatic biliary obstruction in these patients for various reasons: almost half were over 60, although acute hepatitis is less common in older people; in some the history of possible exposure to infection or the taking of drugs which can cause jaundice was not easily elicited; some had had pain which in its severity and distribution seemed characteristic of gallstone colic; some, indeed, had had concomitant cholelithiasis or a history of previous gallbladder operations ; and more than half the patients had been treated medically for longer than three weeks before operation was finally decided upon. 8 of the 58 patients, although they were known to have hepatitis, were operated on for reasons other than suspected surgical jaundice, such as perforation of duodenal ulcers, sigmoid-colon carcinomas, and intestinal obstruction. 4 patients died in hepatic coma within three weeks of the operation; 5 others had grave complications but recovered. Of those who died, 3 had viral hepatitis, and 1 had serum hepatitis; 1 patient underwent gastrectomy, another had a cholecystectomy, and 2 had laparotomies only. There were no serious complications in the 16 overcome
2. Cross, R. C. L. Evidence. London, 1958. 3. Lancet, 1960, ii, 1017. 4. Shaldon, S., Sherlock, S. Brit. med. J. 1957, ii, 734. 5. Harville, D. D., Summerskill, W. H. J. J. Amer. med. Ass. 257.
1963, 184,
patients with hepatitis caused by drugs, such as chlorpromazine, methyltestosterone, and chlorpropamide, though jaundice persisted for lengthy periods after operation in this group-in 1, jaundice lightened only after two years.
From their analysis the American workers conclude that operation, despite some risk, is justified in the small number of patients in whom extrahepatic obstructive jaundice cannot be excluded with certainty. Shaldon and Sherlock4 advised waiting for six weeks before considering operation. If doubt exists even after liver biopsy and a short trial of corticosteroids, surgical exploration should be undertaken. "Surgery may kill the with infective patient hepatitis," they wrote; yet 3 of their 12 patients who were operated on recovered
eventually. Biochemical tests of hepatocellular function are often indecisive 4:liver biopsy, duodenal drainage, or percutaneous cholangiography 6 may fail to give the answer; hepatitis can occur in older patients; and the history is sometimes unreliable. In some patients, only surgical exploration can resolve the dilemma. Finally, the insertion of a T-tube for drainage of the common bileduct has sometimes been advised for patients in whom explorative laparotomy has revealed hepatitis. 36 of the jaundiced patients in the American series had drainage; 12 had no T-tube inserted. There was no difference in the postoperative duration of jaundice in the two- groups.
POLLEN COUNTS
THROUGHOUT the United
States, and in
many parts of
publish daily a pollen and mouldguidance of their readers who have hayfever. In planning their day, sufferers can take note of the level of the previous day’s count in their area as well as temperature, humidity, and weather forecast. The Canada, newspapers spore count for the
Americans have got used to this idea and many of them know what a high count is. In this country a daily average concentration of 50 or more pollen grains per c. metre of air would be high. In the eastern States and the Mid-West ragweed-pollen or fall " hayfever is much more of a nuisance than sneezing caused by grass pollen, which is the principal source of hayfever in this country; and the ragweed type is much more bothersome there than our grass variety is here. American oak trees also cause much more trouble than British oaks, it seems. Perhaps these are some of the reasons why American patients prone to hayfever have been better informed than those in this country. Certainly the British Allergy Society has been sending weekly pollen and spore counts to any doctor who asked for them; but hitherto no information has been supplied directly to the public. The Asthma Research Council is now to issue daily pollen counts, for London and the Home Counties, prepared by the allergy department of the Wright-Fleming Institute at St. Mary’s Hospital. The figures will be published in the London evening papers. For a start, simply the grass-pollen count will be given, not the total-pollen or mould-spore count. Forecasts for 24 hours ahead will be given when the count is high. It is hoped that news of the count and its likely changes will be a help to hayfever patients in arranging their movements and adjusting "
treatment. 6.
Lancet, 1962, ii,
1208.
siderations of public policy. In the interests of public
policy the welfare of the patient should not be put in jeopardy by fear that confidential discussions with a doctor might subsequently be disclosed; but also in the interests of public policy the courts should not be hampered in their task of ascertaining the truth of certain matters. For success in a claim for privilege for psychiatric interviews, it would have to be shown that the first consideration outweighed the second, and to a greater extent than in ordinary medical interviews. In any event, it may be better that privilege should attach to the medical profession as a whole and not to one particular specialty. In view of the fairly settled state of the law this would probably require legislation. Some Commonwealth countries have already passed legislation on this subject, and the American Law Institute’s code of evidence accords privilege in civil actions and some criminal prosecutions in the case of confidential communications to a doctor reasonably necessary for the treatment in hand.2 SURGERY IN ACUTE HEPATITIS
THE cholestatic form of epidemic viral hepatitis is often hard to distinguish from extrahepatic biliary
obstruction, 3 4and
in some patients the difficulty can be in the end only by an exploratory operation. A valuable paper by Harville and Summerskillassesses the risk of operating on these patients. From the records of 18,000 operations for hepatobiliary disorders at the Mayo Clinic during 1950 to 1961, 58 patients with hepatitis were found to have undergone diagnostic laparotomy or more extensive operations. The final diagnosis was established in these patients by examination of the hepatobiliary-pancreatic structures, by negative findings on exploration of the common bileduct and operative cholangiography, by disappearance of the jaundice at varying intervals after laparotomy, and by histological confirmation from biopsy specimens of the liver. In 32 of the 58 patients the hepatitis was presumed to be viral, and in the remaining 16 it was drug-induced. It had been impossible to rule out extrahepatic biliary obstruction in these patients for various reasons: almost half were over 60, although acute hepatitis is less common in older people; in some the history of possible exposure to infection or the taking of drugs which can cause jaundice was not easily elicited; some had had pain which in its severity and distribution seemed characteristic of gallstone colic; some, indeed, had had concomitant cholelithiasis or a history of previous gallbladder operations ; and more than half the patients had been treated medically for longer than three weeks before operation was finally decided upon. 8 of the 58 patients, although they were known to have hepatitis, were operated on for reasons other than suspected surgical jaundice, such as perforation of duodenal ulcers, sigmoid-colon carcinomas, and intestinal obstruction. 4 patients died in hepatic coma within three weeks of the operation; 5 others had grave complications but recovered. Of those who died, 3 had viral hepatitis, and 1 had serum hepatitis; 1 patient underwent gastrectomy, another had a cholecystectomy, and 2 had laparotomies only. There were no serious complications in the 16 overcome
2. Cross, R. C. L. Evidence. London, 1958. 3. Lancet, 1960, ii, 1017. 4. Shaldon, S., Sherlock, S. Brit. med. J. 1957, ii, 734. 5. Harville, D. D., Summerskill, W. H. J. J. Amer. med. Ass. 257.
1963, 184,
patients with hepatitis caused by drugs, such as chlorpromazine, methyltestosterone, and chlorpropamide, though jaundice persisted for lengthy periods after operation in this group-in 1, jaundice lightened only after two years.
From their analysis the American workers conclude that operation, despite some risk, is justified in the small number of patients in whom extrahepatic obstructive jaundice cannot be excluded with certainty. Shaldon and Sherlock4 advised waiting for six weeks before considering operation. If doubt exists even after liver biopsy and a short trial of corticosteroids, surgical exploration should be undertaken. "Surgery may kill the with infective patient hepatitis," they wrote; yet 3 of their 12 patients who were operated on recovered
eventually. Biochemical tests of hepatocellular function are often indecisive 4:liver biopsy, duodenal drainage, or percutaneous cholangiography 6 may fail to give the answer; hepatitis can occur in older patients; and the history is sometimes unreliable. In some patients, only surgical exploration can resolve the dilemma. Finally, the insertion of a T-tube for drainage of the common bileduct has sometimes been advised for patients in whom explorative laparotomy has revealed hepatitis. 36 of the jaundiced patients in the American series had drainage; 12 had no T-tube inserted. There was no difference in the postoperative duration of jaundice in the two- groups.
POLLEN COUNTS
THROUGHOUT the United
States, and in
many parts of
publish daily a pollen and mouldguidance of their readers who have hayfever. In planning their day, sufferers can take note of the level of the previous day’s count in their area as well as temperature, humidity, and weather forecast. The Canada, newspapers spore count for the
Americans have got used to this idea and many of them know what a high count is. In this country a daily average concentration of 50 or more pollen grains per c. metre of air would be high. In the eastern States and the Mid-West ragweed-pollen or fall " hayfever is much more of a nuisance than sneezing caused by grass pollen, which is the principal source of hayfever in this country; and the ragweed type is much more bothersome there than our grass variety is here. American oak trees also cause much more trouble than British oaks, it seems. Perhaps these are some of the reasons why American patients prone to hayfever have been better informed than those in this country. Certainly the British Allergy Society has been sending weekly pollen and spore counts to any doctor who asked for them; but hitherto no information has been supplied directly to the public. The Asthma Research Council is now to issue daily pollen counts, for London and the Home Counties, prepared by the allergy department of the Wright-Fleming Institute at St. Mary’s Hospital. The figures will be published in the London evening papers. For a start, simply the grass-pollen count will be given, not the total-pollen or mould-spore count. Forecasts for 24 hours ahead will be given when the count is high. It is hoped that news of the count and its likely changes will be a help to hayfever patients in arranging their movements and adjusting "
treatment. 6.
Lancet, 1962, ii,
1208.