Jaundice is always a significant sign when present, but is absent in at least four-fifths of cases which nevertheless should be subjected to operation. Its occurrence is a matter of interest along with the previous history of the case. It is, however, of great value if it were noted in connection with the first pains or cramps. In chronic obstruction by stone in the common duct it is important to determine the intensity of the jaundice, since this may indicate whether we deal with calculous disease or obstruction from tumor. In chronic obstruction by stone the color changes are less marked, and often clear up entirely, while when produced by tumor they become gradually more intensified.
Deep and persistent jaundice is suggestive of malignant disease. The degree of cholemia rather predisposes these patients to hemorrhage or persistent oozing during operation. Jaundice gradually deepening with each attack of pain is also very suggestive. Such attacks, coming on with symptoms like those of malaria, chill, sweating, and pyrexia, are extremely suggestive and always call for surgical intervention, i. e., drainage. In brief it may be said that jaundice, with enlargement of the gall-bladder, is at least suggestive of cancer, while a history of gallstone colic, without much enlargement of the gall-bladder, is indicative of stone in the common duct. Although this statement is probably true for the majority of cases there are occasionally marked exceptions to it, as, for instance, when a gall-bladder is distended with hundreds or even thousands of small calculi, or to such an extent that it may form even a pear-shaped tumor hanging down within the abdomen.
In addition to these features thus rehearsed there might be made a long list of possible “extras,” by which the original condition is complicated and made to appear in unusual aspect or even life endangering. Such a list would include nearly every imaginable lesion of the upper abdomen. Suffice it to say that the liver, stomach, and the pancreas especially may suffer, while other viscera and the larger veins, with the surrounding tissue, may any or all of them become involved.
Diagnosis.
—Diagnosis has to be made mainly from non-calculous obstruction; from the acute gastric conditions, ulcer, etc.; from renal colic; from the acute or subacute pancreatic affections, duodenal ulcers, renal lesions, localized peritonitis from some other cause; from cancer, lead colic, angina pectoris, pneumonia, pleurisy, and even hysteria. Not so rarely pneumonia and pleurisy begin with pains which are referred to the upper abdomen and are suggestive of gallstone disease, while they seriously perplex the medical attendant. Much stress is to be laid on the first location of the pain, especially if this be in the direction of the right shoulder, and upon concomitant vomiting and jaundice, if present, as well as on the location of the greatest tenderness and muscle rigidity. Recurrence of more or less similar attacks is also suggestive. Diaphragmatic pleurisy may cause pain, referred especially along the esophagus, and intensified during the act of swallowing or vomiting. Affections of the appendix and gall-bladder may co-exist, as well as be easily mistaken one for the other. The former is so true that when operating for one condition it is always advisable to explore in regard to the other. When the appendix is placed high, especially behind the colon, confusion may confound. Biliary colic is usually free from the associated ordinary symptoms which are so often met with in renal colic, while in the latter the urine will contain no bile pigment and the pain will usually be referred to the external genitals. In lead colic the characteristic line upon the gums and the habitual constipation which always accompany it will be suggestive. When the stomach is at fault and the pylorus obstructed this viscus will usually be dilated, and the vomit is of a different character, while, at the same time, actual stomach movements may or may not be made visible. With gastric or duodenal ulcer pain it is more regular and associated with food taking after a definite interval, longer in the latter case.
Chronic pancreatitis is so often associated with cholelithiasis that it is impossible to disassociate their symptoms, but the referred pain is rather midscapular or even on the left side. It will be particularly suggested by rapid loss of flesh. In acute pancreatitis the symptoms are usually more excessive, the distention earlier and greater. Cancer of these various organs does not commence with pain, but has a more gradual, distinctive downward course, with cachexia. These are some of the considerations which may aid in differential diagnosis.
The detection of bile pigment in the urine and blood will have corroborative value.[63]
[63] Hanel has shown that a small capillary tube filled with blood, sealed at both ends, may afford a convenient corroborative test. After standing for a few hours in a vertical position its separated serum can be examined against the light. Normal serum is colorless, while even a trace of bile pigment will give it a distinctive yellow tint.
Baudouin’s test for the urine will be the most satisfactory in the matter of precision and simplicity. If two or three drops of a ¹⁄₂ per cent. solution of fuchsin be dropped into urine containing bile it immediately develops a fine orange tint, in marked contrast with its own red. No other coloring matter in the urine gives this reaction; which is very delicate. (Mayo Robson.) Methyl blue and methyl violet each give a reddish tint; Loeffler’s blue solution gives a green tint which vanishes on heating, to reappear on cooling. There are numerous other tests, but these are the simplest and most satisfactory.