710 DISEASES OF THE LIVER. 



ation and the cachexia, wliich often become very marked in protracted 

 icterus. The languor, also, and the great inclination to sleep appear to 

 depend not only on the bad nutrition, but to be greatly due to the 

 toxic influence of the bile-acids on the nerves and muscles. 



The slow pulse of patients with jaundice appeared to be intimately 

 associated with the emaciation and loss of strength. It was not con- 

 sidered necessary to refer this symptom to the entrance of the constit- 

 uents of the bile into the blood, and to compare their action to that of 

 digitalis, for the retardation of the pulse w r as observed in the so-called 

 hunger-cure, and in the convalescence from severe illness after the 

 fever had stopped ; but the useful experiments of Rdhrig have shown 

 that, in patients with icterus, the slow pulse mostly depends on the 

 presence of bile-acids in the blood. 



The same is true of the itching which annoys many patients with 

 icterus. This has been referred to the dry, scaly state of the patients' 

 skin, as it was also seen in senile marasmus. But its proportionate 

 frequency in icterus, and its rare occurrence in marasmic conditions, 

 render it probable that it is due to an irritation of the cutaneous 

 nerves by the constituents of the bile deposited in the rete Malpighii. 

 It is true, the itching is often absent in the highest grades of icterus, 

 while in moderate grades it is very troublesome ; and it is almost 

 always periodical peculiarities difficult to explain if the symptom be 

 due to irritation from the acids or coloring matter of the bile. 



Yellow vision Xantliopsia very rarely occurs in icterus. It is 

 doubtful whether this be due to the yellow hue of the transparent 

 media of the eye, or whether it depends on abnormal innervation, 

 and is one of the first symptoms of acholia, of which we shall pres- 

 ently speak. 



The course and termination of the disease depend chiefly on 

 whether the obstruction to the evacuation of the bile can be removed 

 soon, late, or not at all. In the first case, when the obstruction is over- 

 come, the symptoms of retention of bile disappear quite rapidly, and 

 the disease ends in recovery. At first, the faeces resume their normal 

 hue, and the dark color of the urine and the symptoms due to satura- 

 tion of the tissues, with pigmented nutritive fluid, soon pass off. The 

 discoloration of the skin disappears last, particularly when the epider- 

 mis is thick. If enlargement of the liver has been observed while the 

 flow of bile was obstructed, this also subsides when the flow becomes 

 free. The strength and nutrition also improve rapidly. 



Since, in icterus dependent on obstruction of the excretory gall- 

 ducts, the return of the normal color to the faeces is almost always the 

 first sign of improvement, the physician, and often also the patients, 

 usually await its occurrence with great anxiety. Sometimes, how- 



