They originate on one side of the floor of the mouth, but may, in the course of time, overstep the middle line, just as this one did. They are of a distinctly bluish color, and can be proven to have originated outside the sub-maxillary duct, by introducing a probe into the latter. When they are incised no fistula is formed, and they tend to re-occur just as this one did, but their final and distinctive characteristic which was shown in the case of our patient is that of acute and alarming increase in size, as though an inflammatory change had taken place. This specimen was examined for me by Dr. Fisch, whose report was as follows:

The cystic tumor removed from the floor of the mouth by Dr. Bartlett proves, on microscopic examination, to be an epithelial cyst. The wall of the same consists of a thick layer of dense fibrous tissue, with a slight degree of round cell infiltration. All of its vascular structures are highly congested, and in places small interstitial hemorrhages are seen. Its capsule is lined on the inner surface with a thick layer of epithelium, consisting of six or seven rows of cells superimposed. Beside a distinct germinative layer, the cells appeared uniform in size and character. Only the layers abutting the cavity are flattened and show horny transformation. No traces of grandular or follicular structures are present.

Clinically this specimen may be classed as a ranula, that much disputed growth, to which so many different origins are ascribed by various writers. On the other hand one cannot say histologically, that it does not deserve the term "dermoid," if thereby is meant that its interior is lined by a skinlike epithelial membrane.

A CASE OF MALARIAL NEPHRITIS.*

BY WM. H. RUSH, M.D.

(From the Medical Clinic, Washington University Hospital, Prof. W. E. Fischel, Chief.)

Albuminuria in malaria is a common occurrence. It was found by Thayer1 and Hewetson in over fifty per cent of a series of 300 cases treated in the Johns Hopkins Hospital. Distinct nephritis, though much less frequent, is not rare. According to Thayer, the most severe cases, and most of the fatal cases, are those accompanying attacks of haemoglobinuria, which seem to occur only in aestivo-autumnal malaria. Comparatively mild infections of malaria, however, may be followed by more or less severe nephritis.

4

It is an interesting fact that epidemics of malaria in different places, or different epidemics in the same locality, differ much with regard to the prevalence of this complication. Frerichs2 saw, for example, on the coast of Friesland many cases of malarial cachexia with ascites, but no case of nephritis. Bartels, on the other hand, saw in Kiel many cases of parenchymatous nephritis which he attributed to malaria. Haidenhein saw in Marienwerder a number of epidemics of malaria without nephritis, while in a later epidemic in the same place he found nephritis accompanying or following almost every case. Kelsch and Kiener1 found nephritis very common in the malarias of Algiers. In this country the condition has been noted especially by Busey," Atkinson, Wood' and Thayer [1. c. and later papers].

6

The type of nephritis most often seen is the acute. It is

* Read before the Alumni Association of the Medical Department of Washington University, Feb. 12, 1906.

especially prone to develop in quotidian fevers in which there is little sweating. It may occur early in the febrile period or in convalescence. The symptoms are those of the same disease accompanying other infections. The course of the disease is usually mild, ending in recovery in from two to eight weeks. Fatal cases however were repeatedly seen by Kelsch and Kiener in Algiers.

Subacute or chronic parenchymatous nephritis (large white kidney") is less common. The cases observed by Rosenstein,8 were preceded by extremely long and irregular attacks of malaria, in which the paroxysms were sometimes of the tertian or quartan type, but without the stage of sweating.

Senator, in Berlin, though he has seen many cases of parenchymatous nephritis in patients who had previously had malaria, has been able but in one instance to demonstrate malaria as the cause.

Chronic interstitial nephritis is sometimes seen as the outcome of either of the two preceding types.

Nephritis in the malarias of children is rare, but according to Bohn10 is always fatal.

The treatment requires no special remark, except that a complicating nephritis is no cause for the interruption of the administration of quinine.

The case reported below is the only one that has been observed in this clinic.

The patient, a grocer's clerk 19 years old, came to the clinic late in November of the past year. Family history without interest. Smokes moderately, a pipe, formerly smoked 10 to 20 cigarettes a day. No previous infectious disease except mumps and malaria. Two years previously was freed from a tapeworm without reappearance of segments.

The present attack of malaria was contracted in the Indian Territory one month before the patient's first visit to the clinic. There had been chills at irregular long intervals, with occasional

profuse sweats. The patient was somewhat reduced in flesh, complained much of loss of appetite, nausea, vomiting, constipation, weakness, dizziness, headache and general aches and pains in the trunk and limbs, and pain in left hypochondrium.

Physical Examination. - Undersized but well built young man, complexion sallow, dusky, almost icteric, mucous membranes pale, slight but evident emaciation. Lungs and heart normal, Abdomen rigid, tenderness in left hypochondrium. Spleen 2 c.m. below costal margin on deep inspiration, firm and tender. right inguinal hernia requiring the use of a truss. Temperature 97°, p. 78, r. 18.

Α

The patient was put to bed in the Washington University Hospital, and crescents, ovoid bodies and signet rings of aestivoautumnal malaria were found abundantly in the blood. The blood showed also slight increase in the number of leucocytes, relative increase in the large mononuclears, moderate decrease in the number of red cells and numerous degeneration forms, and decrease in the haemoglobin, such an anaemia, in short, as is common after prolonged malarial infection. Urine, Nov. 23, dark amber, clear, acid, free from albumin, casts, sugar, bile and abnormal urobilin.

The patient was put upon quinine, receiving the first day 20 grains, the next day 40 grains, for three days 30 grains, and for one month with one intermission of three days, 20 grains daily. The subjective symptoms improved rapidly, and the temperature, which on admission reached at some hour of each day, sometimes in the afternoon or evening, at others in the night or early morning hours, a height of 100° to 102°, never rose above normal excepting twice after the patient had received 60 grains quinine, and then only to 99°. There were no chills after the patient entered the hospital, but profuse sweats in the first few days were frequent.

Suddenly on Dec. 5, after ten days of normal temperature, while the patient was suffering slightly from a mild bronchitis, it

was observed that his face was edematous. There was no edema elsewhere, there were no cardiac or vascular symptoms of nephritis, and there was no complaint of any new subjective symptoms, save occasional headache.

The urine was at once examined and was found to contain 1.2 per cent albumin (Esbach), with masses of granular and cell casts and many red blood cells in the sediment. The 24 hours' amount was 2430 c.c., sp. g. 1020. The patient was put at once upon a diet of milk and buttermilk and was confined strictly to bed with daily warm baths. The edema disappeared in three days. The urine remained as above for 5 days, then the albumin began rapidly to decline, and on Dec. 15, ten days after the discovery of the nephritis, had fallen to 0.3 per cent. The casts and red cells were reduced in number but were still abundant. Crescents had meanwhile been found in the blood in repeated examinations. On Dec. 20 there was but % albumin, and on Jan. 4, an inestimable trace. There were still many casts but no blood cells. The diet was now increased by the addition of bread, rice, potatoes and fruit.

1. 20

On Jan. 13, about five weeks after the appearance of the nephritis and more than two months after the beginning of the malarial attack the patient was discharged from the hospital. The blood was now, after persistent examination, apparently free from parasites, and the patient was feeling in perfect health.

One week later the young man revisited the clinic, bringing 24 hours urine. Amount, 1750 cc., Sp. G., 1022, amber, acid, clear, faint trace albumin, 1 granular and 1 cell cast found in the centrifuged sediment after long searching.

In a specimen of the patient's blood taken on this day, two weeks after the suspension of quinine which had been administered, practically continuously for one month, during which time 600 grains were given, there was found inside a red cell a nearly matured parasite of the aestivo-autumnal type.

The patient has not revisited the clinic since and the further