As neither the symptoms nor physical signs threw any additional light on this interesting case, it was determined once more to bring chemistry and the microscope to bear upon it, with the view of, if possible, extending the information these methods of investigation had already yielded. Accordingly, a specimen of the urine was again obtained for analysis, and it yielded the following results:—
| 24 HOURS' URINE. | ||
| Quantity, (43 oz.) | 1333 | c.c. |
| Specific gravity | 1016. | |
| Reaction | Acid. | |
| Urea | 23·994 | grammes. |
| Uric acid | 0·266 | " |
| Bile pigment | Abundant. | |
| Bile acids | Small quantity. | |
| Sugar | A little. | |
| Solids (total) | 41·989 | |
| Organic matter | 31·992 | |
| Inorganic | 9·997 | |
A marked change is here seen to have occurred in the constitution of the renal secretion. First—the quantity of urea has notably diminished (from 27·28 to 23·99 grammes, or in other words, from 423·84 to 370 grains.) The amount of uric acid has also fallen (from 0·511 to 0·266 grammes, or in other words, from 8 to 4 grains); while at the same time the biliary acids have considerably decreased. These changes are also seen to be accompanied by another, which I at once regarded as a most unfavourable sign,—namely, the appearance of sugar in the urine. Although the quantity of sugar was as yet small, and it was associated with a diminution in the bile acids, it nevertheless made me look forward with gloomy forebodings, for as far as my experience goes, when the urine becomes saccharine in the course of a chronic, and exhausting disease, it has generally been the forerunner of a fatal termination. This case, I am sorry to say, proved no exception to the rule. There was, indeed, but one consolatory fact in the analysis, and that was the diminution of the uric acid, which, as I before remarked, tended to negative the idea of malignant disease of the liver, and this was a great source of satisfaction to the patient.
Eight days later, 12th November, a qualitative, and quantative analysis of the urine was again made, with the following result:—
25 On precipitating the urine with the acetate of lead, filtering, and freeing the clear liquid from the excess of that reagent by means of sulphuretted hydrogen, and again filtering, the liquid, on evaporation, was found to deposit small crystals of tyrosine, and to have floating in it, and on its surface, round balls of leucine.
Here, is now to be observed, the rapid downward progress of the case. Stomachal digestion, as indicated by the amount of urea, is much impaired. The general health, as indicated by the sugar, is sadly affected, and, to crown all, tyrosine, and leucine, the indicators of atrophy of the liver, have made their appearance. So unfavourable was the result of this analysis considered, that Dr. Prance felt himself bound to fulfil a promise he had made to the family some time previously, of warning them of approaching danger, when we had no longer any hope of the patient's recovery.
Some time afterwards, in the beginning of December, we again saw the patient together, and made a physical examination of the hepatic organ, the result of which only confirmed our suspicions. The liver was decidedly smaller. The epigastric tenderness was increased. The jaundiced tint deeper. Petechial spots had now appeared on the trunk, and arms. The lower extremities were oedematous, and the abdomen two-thirds filled with fluid.
On the 31st December, I received a sample of urine, and a note saying that the patient had slightly rallied. But on examining the urine, it was found to have a neutral reaction—it had previously always been acid—to be of a specific gravity of 1019, and on standing, to deposit a copious sediment of lithates, coloured intensely yellow with the bile pigment. Curiously enough, the bile-acids had reappeared; but only in quantity sufficient to admit of their being detected. In spite of these trifling changes for the better, the ominous one of an increased amount of sugar was still there.
A few days later, and just before his death, the patient had the benefit of another physician's opinion, which, although it differed somewhat from the foregoing, was, nevertheless, equally unfavourable, for he considered it a case of malignant disease.