Jaundice is a disease in which the pathologic changes are unquestionably due to auto-intoxication. The bile, which in a state of health is cast off from the body in the feces, or is resorbed and eliminated as urinary pigments, is diffused through the body and produces toxic symptoms. The heart is usually slowed from the inhibitory action of the bile salts on the vagus and the pulse is soft, large and dicrotic from the paralytic condition of the blood vessels.

It has been found that poisons circulating in the blood cause a change in normal bile in which it increases in viscidity, pausing agglutination of the walls of the bile ducts, obstruction of their lumen and consequent retention of the bile within the sac. Stadelman (16) was able to produce jaundice experimentally in animals by poisoning them with arseniuretted hydrogen and toluenediamin, and found that there was an enormous increase in the biliary secretion and that it was very thick and tenacious. In none of his autopsies of the animals experimented upon was there catarrh of the duodenum or obstruction of the ductus communis. Even in the cystic duct the viscidity and occlusion is so slight that but little force is required to restore the patency of the canal. Jaundice is occasioned also in the experimental production of hemoglobinemia whether this be accomplished by the injection of free hemoglobin or of distilled water. It is then evident that the liver cannot produce normal bile from abnormal blood, and the fact that jaundice is caused by exposure to cold and by syphilis, typhoid fever, phosphorous, rattlesnake and other poisons, shows how readily the biliary secretion is altered and suggests that intrinsic poisons, which are often distinctly hemolytic in their action, may also act as causes. If this be true, autointoxication has a dual relation to the pathology of jaundice - toxic materials absorbed from the intestinal and urinary tracts may cause altered secretions, and the retention of bile from its own viscosity then completes the sequence. And so it seems that all jaundice is truly obstructive in its nature, whether it be from calculi or the result of poisons circulating in the blood.

The absorption of bile is a very important and serious complication when surgical operations are necessary. Such patients bear operation badly for two reasons.

1. The increased danger from hemorrhage o on account of the lengthened coagulation period.

2. The condition of toxemia which causes them to take anesthetics badly and renders them liable to unexpected shock and collapse. These patients have but little resisting power against septic invasions or the infectious diseases, and death sometimes occurs during or after an operation from shock, the system already enfeebled by cholemic toxemia, being unable to stand the additional tax of the operation. The effects of cholemia on the sensorium will be described in the pages devoted to Effects upon the Nervous System.