ICTERUS 493 



doses by mouth, subcutaneously and intravenously to man produced 

 no noticeable effects (Schmidt).'*^ 



Since the bile salts cause hemolysis, and since in even "hematogen- 

 ous" jaundice they may enter the blood, it can readily be seen that in 

 this way an increased formation of bile-pigment may be incited which 

 leads to further obstruction to the outflow of bile from the liver, and 

 a "vicious circle" may thus be established. The necroses observed in 

 the liver in icterus, "icteric necrosis," are generally ascribed to the 

 cj'totoxic effects of the bile salts, although it is difficult always to 

 exclude infection extending along the bile-ducts to the liver tissue. 

 Possibly the power of bile salts to dissolve lipoids may be responsible 

 for the cytotoxic effects^" as well as for the hemolysis. The itching 

 and irritation of the skin in icterus may be due to the effect of the 

 bile-salts deposited in it, for pruritus is said to be absent in the pig- 

 mentary jaundice of congenital hemolytic icterus. There is also an 

 increase in the cholesterol in the blood, which may be related to the 

 "xanthomas" that form in chronic icterus. ^^ Unfortunately we have 

 no accurate method for quantitative determination of the amount of 

 bile salts in the blood. 



A remarkable tendency to spontaneous hemorrhages, frequently ob- 

 served in icterus, probably depends upon injury to the capillary 

 endothelium by the bile salts, ^- while the protracted, often uncontrol- 

 lable, hemorrhage that may occur from operation wounds in icteric pa- 

 tients, is related to the slowed coagulation of the blood observed in 

 icterus. The bile salts themselves may delay coagulation by interfer- 

 ing with the conversion of fibrinogen into fibrin. ^^ The cytotoxic 

 effect of the bile salts is also shown by the albuminuria of icteric per- 

 sons, which frequently results from the renal lesions the bile produces. 

 Although bile itself is toxic to many bacteria, especially the pneumo- 

 coc.cus,'^'* 3^et in icterus the bactericidal power of the blood is lowered, 

 and infections are prone to develop and to be severe; moreover, the 

 growth of several species of bacteria is favored by bile.^" 



Croftan^'' summarizes the physiological effects of bile acids as fol- 

 lows: (1) A powerful cytolytic action, affecting both blood-cor- 

 puscles and tissue-cells. (2) A distinct cholagogue action. (3) In 

 small doses (1-500) they aid coagulation. (4) In large doses (1-250 

 and over) they retard coagulation. (5) Slow the heart action. ^^ 

 (6) In small doses they act as vasodilators; in large doses, as vaso con- 



" Schmidt et al, Jour. Biol. Chem., 1918 (33), 501. 



50 Neufeld and Handel, Arb. kaiserl. Ges.-Amte, 1908 (28), 572. 



51 Chauffard, Presse Med., 1913 (21), 81; Chvostek, Zeit. klin. Med., 1911 (73), 

 479; Pinkus and Pick, Deut. med. Woch., 1908 (34), 1427. 



" See Morawitz. Arch. exp. Path., 1907 (56), 115. 

 " IIaes>ler and Stebbins, Jour. Exp. Med., 1919 (29), 445. 

 *'* See Neufeld and Haendel, loc. cit. 

 « See Meyerstein, Cent. f. Bakt., 1907 (44), 434. 



56 New York Med. Jour., 1906 (83), 810; see also Faust, "Die tierische Gifte," 

 Braunschweig, 1906, p. 29. 



" See Berti, Gaz. degli Osped., 1916 (37), 1233. 



