PERINEPHRITIS: 
Fifteen Additional Cases in Children, 
COMPLETING A TOTAL OF TWENTY-EIGHT. 
REMARKS ON DIAGNOSIS AND PROGNOSIS 
)!> 
V. P. GIBNEY. M. D. 
Of the Hospital for the Ruptured and Crippled, New York ; Fellow of the New Yrffid 
/ * 
of Medicine-j Member of the American Academy of Medicine, etc.,.etc./ 
REPRINTED FROM THE CHICAGO MEDICAL JOURNAL AND EXAMINER 
For Junk, 1880. 
Chicago: 
Bulletin Flint, 104 and 106 Madison Street. 
1880. PERINEPHRITIS: 
Fifteen Additional Cases in Children, 
COMPLETING A TOTAL OF TWENTY-EIGHT. 
REMARKS ON DIAGNOSIS AND PROGNOSIS 
BY 
V. P. G1BNEY, M. D., 
Of the Hospital for the Ruptured and Crippled, New York ; Fellow of the New York Academy 
of Medicine ; Member of the American Academy of Medicine, etc., etc. 
REPRINTED FROM THE CHICAGO MEDICAL JOURNAL AND EXAMINER 
For June, 1880. 
Chicago : 
Bulletin Print, 104 and 106 Madison Street. 
1860. Perinephritis: Fifteen Additional Cases in Children', 
COMPLETING A TOTAL OF TWENTY-EIGHT. 
Although previous papers on this subject would seem to ren- 
der unnecessary additional publications by the same author, it 
has always been my firm conviction that full records of cases are 
never out of order, however common or hackneyed the theme may be. 
Touching the one under consideration, comparatively few Ameri- 
can observers have made contributions; and I cannot but feel 
convinced that many cases of obscure lesion about the hip-joint 
or spinal column have occurred to many practitioners of large 
experience. I cannot but believe that many speak flippantly of 
curing a hip disease, for instance, which was nothing more than 
a perinephritis that had undergone resolution. 
It were unecessary for me to continue my excuses for publish- 
ing the following clinical record. These cases are a continuation 
of nine in a papef in The American Journal of Obstetrics and 
Diseases of Women and Children, April, 1876, of tliree in 
another paper in The American Journal of the Medical Sciences 
for April, 1877, and of one in the same, journal for Oct., 1878, 
page 403. The numbers therefore will be readily understood. 
Case XIV. A tumor first observed in ilio-costal space; a 
few daps later one on thigh; the latter opened by incision. Sub- 
sequent connection between the two; cure complete in five months; 
permanency of same verihed by examination two years and four 
months afterward. John D., aged three and one-half years, was 
seen first on the 4th of May, 1877, in the out-door department, 4 
and in addition to a general anaemic condition there was observed 
a soft tumor in the right lumbar region just above the crest of 
the ilium. It was oval in shape and its base 2J x 3 inches in 
area; the skin was not discolored, and there was deep fluctua- 
tion. There was a point of induration on posterior aspect of 
thigh, upper third, same side and the circumference of the limb 
here was one inch greater than that of the fellow limb. The 
motion at the hip was smooth and painless although complete 
extension of thigh could not be made. No evidence of disease at 
this joint or in the vertebrae could be detected. There was no 
periosteal thickening about the crest of the ilium. 
The child had always been feeble but never lame before the 
invasion of present disease which dated from the beginning of 
March. A little stiffness of the thigh, pain at knee, slight febrile 
disturbance were the first symptoms, and these continued with 
very little increase in severity until the first of May, three days 
before applying at the hospital for treatment, when the tumor 
first made its appearance, and the walking became more difficult. 
There appeared to be no indication for surgical interference 
and an iron tonic was all that was prescribed ; but on June 1, 
the femoral abscess was opened by incision and about three 
ounces of pus evacuated. This remained open for a few days, 
closed, then a little later reopened spontaneously while the peri- 
nephritic abscess continued slowly to increase in size, without 
any marked constitutional disturbance. The thigh flexors were 
contracted however, and the gait was very awkward. 
July 28th.—An unusual amount of pus escaped from opening 
on thigh, and immediately after this gush the ilio-costal tumor 
collapsed. This did not make its appearance again, and the 
symptoms, heretofore quite alarming, began, now to be consid- 
ered of triflng import. The deformity of the thigh disappeared 
and it was recorded on— 
Sept. 5th.—Sinus has been closed for a week, no sign of re- 
opening, no pain or lameness, no ilio-costal swelling; cured. 
Feb. 25th, 1878.—Without lameness, and has had no relapse 
whatever. 
Jan. 6, 1880.—Examined carefully this date and still no sign 5 
of disease about spine, hip or loin. Has not had any relapse 
since date of last note. 
Case XV.— Cure by resolution ; confirmed by examination 
two and a half years later. Anne C., aet 5, came under out- 
door treatment July 10, 1877, with a history of lameness, febrile 
disturbance, and pain in right loin of two weeks’ standing. The 
invasion was acute and was without known cause. She had been 
walking lame from the first day, and the lameness was greater 
towards night. She moaned through the night, and was evidently 
losing flesh, probably from the unrest. The temperature on the 
morning of her first appearance at the hospital was only 98J°, 
and the child did not appear to be sick. There was, however, 
decided lameness, a rigidity of the spinal column as she stooped, 
but no tenderness on concussion here, and no angular deformity. 
The right thigh could be easily and voluntarily flexed to the nor- 
mal extent, abducted and rotated, but could not be extended be- 
yond an angle of about 135° without causing pain. There was 
no tenderness at the hip-joint, but there was marked tenderness 
in the right ilio-costal space with deep infiltration, and a distinct 
area of fullness. There had been no difficulty in micturition, and 
the mother had not observed any change in the appearance of the 
urine. A diagnosis of perinephritis was made and a fly blister 
ordered over this region. 
J[uly 10th.—The blister has produced the desired vesication 
and the surface has been poulticed every six hours. The child 
this morning is very much better; she walks nearly as well as 
she ever did; stands erect; the thigh can be extended to 180° 
without any difficulty; the stiffness, so marked on stooping, has 
disappeared and the fullness in ilio-costal space is scarcely percep- 
tible. 
July 25th.—There is no longer any muscular contraction ; 
there is no pain, no sleepless nights, no impairment of appetite, 
no lameness unless after a long walk ; and with this single excep- 
tion no sign of disease can be detected. 
September 3d.—The lameness has disappeared entirely and the 
patient is discharged as cured. 
November 5th.—Calls by request for examination and the cure 
is fully established. 6 
January 18, 1880.—I visited the house to-day and found the 
girl as free from disease or lameness as when I examined her two 
years and a half ago. 
Case XYI.—At first regarded as hip-disease and treated with 
weight and pully; diagnosis clear on appearance of tumor; 
cure by resolution under the hot-water douche ; two and a half 
months' duration. Edward R., aged five and a half years, came 
under treatment in the out-door department August 1, 1877, and 
the following history and observations were recorded : It has been 
noticed for four weeks that the boy walked lame, favoring left 
side, and that gradual flexion of the thigh on the pelvis has taken 
place. This lameness and thigh flexion began rather suddenly 
with pain in the left loin on motion, and pain in back and over 
abdomen on very slight pressure. These symptoms were ushered 
in by a chill, and every day for three weeks there has been a 
slight chill followed by fever. Two children in the family had 
scarlatina four weeks ago, while this boy escaped to all appear- 
ances. His tongue to-day is a little coated and the mother 
reports that it has been heavily coated. He is unable to stand 
alone, but when he is held up or when he lies in the dorsal decu- 
bitus, the left thigh is flexed at an acute angle on pelvis, and 
attempts at passive extension cause pain and resistance. Complete 
flexion, rotation, abduction and adduction can be made without 
pain or resistance. There is no infiltration about the trochanter 
or in the goin. There is distinct fullness in the whole of the left 
ilio-costal space extending across the spinal column and below 
the crest of the ilium with deep fluctuation. The body is cov- 
ered with sudamina; the boy is quite thin; the pulse is 140, the 
rectal temperature is 102° (a. m.); the bowels are constipated; 
the urine is straw-color, has a specific gravity of 1010, con- 
tains no albumen, and is about normal in quantity. A microscopic 
examination is not made. The mother reports that a physician 
in Hoboken, N. J., where she lives, has been treating the boy 
with weight and pulley for hip-disease. 
Hip-disease is readily excluded this morning on this our first 
examination, and a diagnosis of primary perinephritis made with- 
out any hesitation. An iron tonic is ordered, and cold water 
applications are to be made to the lumbar region. 7 
August 13th.—Still much emaciated, and the deformity of the 
limb is unchanged. The fullness has developed into a well-marked 
tumor, with fluctuation more distinct while the skin at summit 
is discolored, and a speedy opening is expected. The semi- 
circumference of the body here is thirteen inches against eleven 
inches for the right side. There is a uniform antero-posterior 
curvature of spine from the mid-dorsal region to coccyx without 
anchylosis at any point. There are still no signs of disease at 
the coxo-femoral articulation. 
The hot water douche is now ordered night and morning, ten 
minutes application, the parts to be protected with cotton-batting 
in the intervals. 
August 21st.—The angle of deformity with which the thigh is 
held is about one-half less than it was at date of preceding note. 
The boy can stand now ; has less pain ; rests well nights; eats 
well, in fact is a great deal better. The tumor, however, is pres- 
sent, though not so large, as shown by measurement. The upper 
third of the thigh this morning measures one inch larger than its 
fellow. The same treatment to be continued. Without tran- 
scribing the notes at different visits it is sufficient to abstract the 
same by stating that he soon began to walk a little, the fullness 
disappeared and by September 12th it was recorded that he walked 
and it was difficult to detect any limp whatever, that he had re- 
gained strength and flesh ; was quite active ; that the thigh could 
be easily extended over the normal arc; that the spinal column 
was straight, and that only a shade of fullness remained. Dis- 
continue treatment. 
October 5th.—Called, and after a carelul examination negative 
as to result, discharged cured. 
Case XVII. August J., aged six, came under treatment as an 
out-patient August 10th, 1877. It was difficult to obtain a satis- 
factory examination so excessively tender and sore was the little 
fellow ; he was not able to stand or to walk, even with assistance, 
and as he lay upon the examining table the left thigh was acutely 
flexed on the body, all efforts at passive extension being resisted. 
When such was attempted, the boy screamed aloud and pressed 
his thigh with the hands. Flexion and rotation could be made 
easily, and there was no tenderness in the hip-joint; it was purely 8 
peri-articular. In the left loin there was a marked fullnes amount- 
ing nearly to a tumor. There was great tenderness in this region, 
dulness on percussion. There was no reliable evidence of spinal 
lesion, although the spinous processes were very prominent, yet 
this was due to the great emaciation. The pulse was 120, resp. 
25, temp. 103°. His urine was normal in color, contained no 
albumen, micturition was attended with some pain. The boy 
sickened on the morning of July 16th, being perfectly well and 
free from lameness the day before. He was taken with.high fever, 
soon got lame and had crying spells on micturition. His prepuce 
was found to be long, though glans could be exposed, and there 
did not seem to be any genital irritation. The only cause that pre- 
sented was that the boy said a play-fellow kicked him in the groin 
on the 15th of July. The treatment was an iron tonic and the hot 
water douche. 
August 14th.—The semi-circumference of the left side.to-day 
measured a little less than it did on the occasion of first visit, the 
difference being now three-fourths of an inch. The boy is better 
every way ; rests well nights; has much less pain on micturition 
and the tenderness is much less marked. His urine has a specific 
gravity of 1020, is normal in color and does not contain albumen. 
Continue treatment. 
August 22d.—To all intents cured : the fullness and induration 
have disappeared ; he walks and runs with scarcely an appreciable 
lameness ; has no pain ; is gaining flesh. 
Case XVIII. Very acute; hot water douche failing to in- 
duce resolution, incision at end of third week ; recovery. Michael 
S., aged five, was first seen in the out-door department August 23, 
1877. He had been lame just one week : had come in lame one 
afternoon, reporting that he had had a fall that morning; went 
to bed complaining of his limb and got up next morning feverish. 
Had been growing rapidly worse; bowels constipated ; losing 
flesh as much probably from loss of sleep as from the gravity of 
the disease. Already a tumor filled the right ilio-costal space and 
the characteristic deformity of the thigh was present. This side 
measured one inch greater than the left, and the thigh at its upper 
third sustained the same relation to the left as to size. There was 
no tenderness or infiltration in the groin or in the iliac fossa, but 9 
higher and above the crest of the ilium the tenderness was ex- 
quisite. The hot water douche was ordered as in the two cases 
just recorded, and the dialysed iron was prescribed. 
August 27th.—No relief from pain; there is marked fluctua- 
tion and the case is much worse. The douche was continued a 
few days longer with apparent relief, but this was only temporary; 
all hope of getting resolution was abandoned and the abscess finally 
opened by incision September 8th, when exit was given to about 
six ounces of thick pus. The discharge ceased in three days, and 
on September 12th the wound had closed, the sac well emptied 
and both sides equal in measurement. He walked in erect this 
morning, although a limp was perceptible. A fortnight later his 
Condition was the same and he was discharged conditionally, i. e. 
with orders to call should any sign of relapse occur. He was, at 
my request, April 12, 1880, examined by my friend Dr. L. 
Emmett Holt, who found that the cure had been permanent. 
Case XIX. Perinephritic andt perityplitic abscess ; secondary 
pyeletis ; recovery with fistulous {?) track. 
Joseph H., aet. 6, came under treatment November 21, 1877 
with the following symptoms : somewhat emaciated, excessively 
irritable, pain, tenderness and fulness in right ilio-costal space, 
flexion and outward rotation of thigh resisting extension but 
permitting quite freely other movements; tenderness on pressure 
in iliac fossa, rectal temperature 101|°; a burning sensation 
along urethra on micturition, especially at end of penis, which 
appears congested, and a frequent desire to urinate (12 times last 
night); urine has a specific gravity of 1.025, high color, contain- 
ing a flaky sediment but no albumen. 
Three weeks ago he was taken sick, before which time he had 
been in excellent health and free from any lameness. He was 
feverish at the beginning, had colicky pains and flexed thigh for 
relief. His bowels have been moving daily without medicine, 
he is very restless at night, has no appetite and is losing flesh. 
The hot water douche was ordered and a mixture of chlorate 
of potassa and tincture of the chloride of iron prescribed. The 
boy lived some distance from the hospital and the mother was so 
averse to having him treated as an in-patient, that we consented 
to treat him as an out-patient. The mother called, on Dec. 3d, 10 
to report that the boy was “ sinking,” lay on his face constantly, 
suffered almost continuously, and seemed to grow rapidly weaker 
after two or three douches, which were then discontinued. She 
brought a specimen of urine which was found to be loaded with 
pus (the deposit filling three-fourths of the conical glass.) With the 
microscope I found pus corpuscles in great abundance, a little 
blood, some epithelial cells, but no casts. The specific gravity 
was 1020, and the specimen contained no albumen. Flax-seed 
poultices were ordered and Wyeth’s preparation of beef wine 
and iron was substituted for the potash and iron mixture. 
December 8th.—I visit the patient to-day and find him 
curled up in bed, lying on his face and knees, and out of this po- 
sition it is very difficult to get him. lie is markedly emaciated, 
the thigh is acutely flexed on pelvis, tenderness along the thigh 
and over abdomen, right side ; in the'right loin is a distinct tu- 
mor, the skin over which is not discolored. I learn that he does 
not pass so much urine as he did, &nd the specimen which has 
been saved for me is free from any deposit, in fact is compara- 
tively clear ; his rectal temperature is 100.° His bowels are 
now constipated ; he has not vomited at any time. Hot fomen- 
tations are ordered and the treatment otherwise is unchanged. 
December 12th.—The mother reports that another tumor has 
appeared in the groin, since my visit on the 8th, and that the 
lumbar tumor has increased in size. 
December 13th—I take with me to-day my friend, Dr. Ripley, 
and we find as the mother stated yesterday, an acuminating tu- 
mor in the groin above Poupart’s ligament, and the former one 
much larger than at last visit. We decide upon immediate incis- 
ion, and a bistoury is thrust into the inguinal tumor, when a large 
quantity of thick pus is evacuated, both tumors disappearing. 
The fluid toward the last becomes bloody and mixed with this is 
an amber colored fluid (urine ?) which gives a distinctly ammo- 
niacal odor. A tent is inserted and stimulants ordered unspar- 
ingly- 
After this the case did well, the discharge continuing quite 
freely for a few days, and on the 18th the urine was normal in 
color, had a specific gravity of 1015, had an acid reaction, had 
no deposit and contained no albumen. 11 
January 12th, 1878.—The boy walks into the office this morn- 
ing with a halt that is scarcely perceptible ; he has grown stouter; 
the wound is closed, this having occurred on the 8th ; flexion and 
rotation are perfect, while complete extension is not yet possible. 
Discontinue treatment. 
January 19th.—Abscess refilled and opened spontaneously on 
the 17th, though attended with very little constitutional disturb- 
ance. 
March 23d.—A stout, hearty boy walking without any lame- 
ness, though there is a little fulness in lumbar region and a slight 
discharge from the incision wound. 
December 9th.—The patient is brought to the office by re- 
quest, and from the mother it is learned that the abscess in ilio- 
costal space opened spontaneously in June last, discharged quite 
freely for a month or six weeks, closed, opened again a week 
later, ran for three weeks, closed again, to open after two weeks, 
and then finally closed. She stated that at each time of opening 
the odor of the discharge was like that of urine. There is ne 
opening at present and no deformity. The cure seems complete. 
April 10th, 1880.—I examined the child and find the cure as 
to locomotion and freedom from deformity well established ; yet 
there is a crust or scab over the closed sinus in ilio-costal space 
and the mother tells me that occasionally the boy picks this off 
when there is a mere oozing for a day or two, then the formation 
of a new scab. He has no difficulty in micturition, and the 
color of the urine is normal. 
Remarks.—This case presents some points of interest to which 
I wish to call attention. I cannot fully satisfy myself now, on 
reviewing the case, whether the pyelitis preceded or followed the 
perinephritis. The invasion of the disease was marked by colicky 
pains—“cramps” as the mother described them—and she soon 
afterwards (before or after the development of the tumor in the 
loin no one knows) found the boy passing his waiter quite freely, 
complaining of a burning sensation referred to the end of the 
penis, and his urine containing a deposit which, from her descrip- 
tion, must have been pus. An ordinary pyelitis from obstruction 
caused by a calculus may have been the initial inflammatory 
lesion. Yet, in view' of the free flow of urine all the while and 12 
of the acuteness of the attack with flexion of the thigh ab initio, the 
subsequent discovery of flaky deposits in the urine voided, I am 
forced to the conclusion that the perinephritis was primary and 
very soon invaded the pelvis of the kidney itself. The course of 
the disease makes the cellular tissue in the iliac fossa the last 
attacked, giving a perityphlitis. When the complication arose 
we had constipation, viz., between December 8th and 12th. 
The subsequent history of the case pretty well establishes the 
existence of a fistulous opening from the pelvis into the circum- 
renal areolar tissue. This is the first case I have encountered 
with renal complications of any significance. Nieden refers to 
several in his article. 
Case XX. Recovery by Resolution.—William C., set. 3, 
came under our observation June 22, 1878, at which time there 
was marked dullness in the left ilio-costal space, with tenderness, 
flexion of thigh, lameness, marked loss of flesh and a rectal tem- 
perature (morning) of 103°. There was likewise a short cough 
present, but a careful physical examination of the thorax was 
attended with negative results. Four weeks before this date he 
was perfectly well and was not lame. Ilis illness began with a 
restless night, and next morning he was feverish, complaining of 
pain in the left loin. Pain here was the only symptom for a week, 
then lameness was added, and, at the end of the second week, he 
was unable to walk at all. About this time also there appeared 
a “ lump ” in the loin and the mother poulticed it for the next 
two weeks, in which period it disappeared, and, as before observed 
only the dullness and induration could be perceived in this region 
on the 22d of June. The bowels have not been constipated. 
On the contrary, they have been loose. There has been loss of 
appetite, loss of flesh, febrile disturbance, with free perspiration 
every evening, etc., etc. 
A tonic was ordered and the mother was directed to employ 
hot fomentations continuously. The patient returned on the 
25th, three days later, and could walk with tolerable ease, had 
less tenderness, the dullness was less marked. The mother 
reported less pain. The rectal temperature was 98°. The cure 
seemed nearly complete. The case was not seen again, but on 
April 13, 1880 I learned that the boy had been long since well. 13 
Case XXI. Abscess opened on twenty-fifth day ; cure one 
month later.—John C., tet. 4 yrs, came under treatment in the 
out-door department August 6, 1878. He was perfectly well 
up to August 2nd—four days ago—when he had a slight fall, 
striking on the right side; had a little fever same night and a 
little since that night but he has continued at his plays as if 
nothing had happened. The mother reports that his urine, since 
the fall, has been scanty and high colored. He has had no local 
ized pain unless the right limb be extended ; then he refers the 
pain to back and loin. The thigh is strongly flexed and deep in 
the lumbar region an induration can be made out. Pulse, 140; 
temperature, 102J°. The joint is Tree from tenderness. Hot 
fomentations ordered and a tonic. He found relief for a few 
days, but the induration increased, a tumor appeared and finally 
an incision was made, August, 31st. The urine was examined 
chemically and microscopically twice and nothing found. 
The subsequent progress of the case was towards a rapid recov- 
ery, which was fully established by the 28th of September, when 
a careful examination was made and a cure pronounced. The 
details differ very little from those of the other case and are 
omitted. 
Case XXII. Diagnosis impossible during the first week of 
observation; this too the third week of the disease; profuse 
suppuration; perfect recovery. — Katie D., aet. years, 
presented at the office August 22, 1878, with excessive spinal 
tenderness and hvpersesthesia of the whole of the left side 
of the body and thigh, flexion of thigh on pelvis at an angle of 
135° from contraction of the psoas, movements in flexion and 
rotation being perfect, absence of tumor or infiltration or dull- 
ness in iliac fossa or ilio-costal space. The child appears very 
sick, and a prolonged examination this morning is not made. 
She complains of much pain in epigastrium, and the tongue 
is coated. By way of clearing up the diagnosis, santonine is 
ordered. It must be stated, however, that all these symptoms 
were only of two weeks’ duration. The girl was running across 
the floor one day, and fell, her left side coming sharply in con- 
tact with the corner of a table. She complained of a little pain 
at the time, but this soon passed off, to reappear at the end of 14 
three days ; then she became lame, grew restless nights, etc., etc. 
There was a history of rheumatism in the mother, but nothing 
else of an hereditary nature on either side of the house. 
Two days after her first visit it became impracticable for her 
to attend as an out-patient, and two gentlemen associated with 
the hospital—Drs. E. Swasey and L. E. Holt—attend her at her 
home. They observed the case very closely, and kept very full 
records, from which I shall make an abstract as briefly as possible. 
August 24th.—They find her abed, lying on the left side, 
thigh flexed to 110°, spinal column deflected a little to the right, 
tenderness as before, and a frequent desire to urinate, say every 
ten or fifteen minutes. The bowels are not constipated ; there 
has been no action from the santonine, and the diagnosis is still 
obscure. A fly-blister to lumbar spine, and belladonna gr. 
(.008) t. d. ordered ; also liq. morph, sulph., u. s. p., p. r. n. 
The child continued to suffer night and day, only finding relief 
when under the influence of the morphia. It was not until the 
31st of August that Dr. Holt was justified in making the diag- 
nosis of perinephritis, and even then there was no tumor present. 
The urine contains no albumen on this date, is amber in color, 
has a specific gravity of 1005, and a microscopic examination is 
attended with negative results. 
September 10th. The patient is still suffering, and is still 
losing flesh. Has chills, followed by fever, every day, although 
quinine is administered to physiological effects. To-day, for the 
first time, the tumor presents, and there is indistinct fluctuation. 
The deformity of the thigh is unrelieved. 
September 13th.—Opened by incision, and one pint of pus 
evacuated, with great relief immediately. This is now six weeks 
since the first symptoms developed, and four weeks since the 
patient has been confined to bed. From this time forth the notes 
indicate a rapid improvement, and by the 26th of September the 
wound had closed, the fullness had disappeared, and the child was 
able to walk with very slight lameness. 
October 2d.—All movements at hip perfect, except a little 
resistance to complete extension. 
November 4th.—Called at the office, by request, for final 
examination, and the cure was found to be complete; no resist- 15 
ance to extension, no lameness, no tenderness ; child has regained 
flesh and strength ; no difficulty in micturition, and the urine is 
normal. 
Case XXIII. Directly traceable to traumatism; cure by 
resolution in jive weeks. Eda M., aged nine years, admitted to the 
hospital July 9, 1878. The child was in perfect health to every 
appearance one week prior to admission and fell across a bench, 
at school, striking her loin against its edge. She did not exper- 
ience much pain at the time but in the afternoon of same day 
was taken with nausea, vomiting and increased pain in the side, 
aggravated by walking. The father next day made an inspection 
of the side, but could find no evidence of contusion superficially : 
there was tenderness here and the child walked lame. She 
became feverish toward evening, though rested fairly at night 
and the bowels have been regular until three days ago, since 
which time they have not moved. 
She is poorly nourished, stands with the left limb advanced 
and semi-flexed at hip and knee, walks with a marked limp favor- 
ing the spine as well as the hip. As she stoops the spine is in- 
flexible. The ilio-costal space is fuller on left side than on right, 
the erector spinse stands out prominently, there is broadening of 
the nates on this side and the trochanteric dimple is effaced. 
There is absence of spinal tenderness on pressure, percussion or 
concussion, but there is very decided tenderness in the right loin 
and over the right sacro-iliac junction. There is a shade of dull- 
ness in the region above mentioned and a careful physical explo- 
ration of thorax and the remainder of abdomen fails to detect any 
abnormal signs. The limit to which the thigh can be extended 
is 135°, while movements in all other directions are perfect. 
Hot fomentations are ordered to the loin and an iron tonic is 
prescribed. The bowels moved after a day or two, but still the ten- 
derness and pain and flexion of thigh continued. Finally toward 
the latter part of the-month the symptoms abated, and by August 
ICth the case was pronounced cured. 
August 30th.—“ Has gained in flesh ; stands and walks per- 
fectly ; no pain or tenderness about loins or hip; no muscular 
contraction; no limit to normal motion in any direction. Dis- 
charged cured.” 16 
Case XXIV. Large tumor threatening suppuration ; rec- 
tangular deformity of thigh ; cure complete by resolution at end 
of four months. Kate K., aet 7, admitted to hospital September 
3d, 1878, coming from a wretched part of the city, the family, 
however, giving a good history. The child herself presents evi- 
dences of mal-nutrition, and lias been subject for the past two 
years to epiliptic attacks, but there has been no paroxysm now for 
three months. 
On the 8th of August, without any known cause, she began to 
complain of pain in her left loin and across the lumbar spine, at 
the same time flexing the thigh of same side on the abdomen ; had 
considerable febrile disturbance that night, and every night for a 
week following. The bowels were constipated subsequently. The 
child wras brought to the out-door department on the 12th of 
August, and at that time walked with marked limp; would not 
permit the thigh to be extended beyond an angle of 145°, though 
permitting free movements in all other directions. The tempera- 
ture that morning was 100f°. No fulness or tenderness could 
be discovered in the ilio-costal space, or iliac fossa. A diagnosis 
of perinephritis was made by Dr. E. F. Horst, a member of the 
hospital staff, and the patient advised to come into the wards. The 
parents did not return again with the child until the date above 
mentioned, September 3d, and during the interval the symptoms 
had increased in severity, so that to-day she is much thinner than 
at last visit. Stands in a very constrained position, barely able 
to touch the floor w ith toes and ball of foot; walks wdth body 
thrown far forward and to the left, the hand resting firmly upon 
the knee. The angle of deformity of thigh is now 90° and efforts 
at passive extension beyond this cause much distress. In the 
ilio-costal space there is well marked fulness, almost circumscribed, 
extending from a line one inch to left of spinous processes to a 
perpendicular let fall from the nipple, and the semi-circumference 
of the body over this fulness is If inches greater than that of the 
corresponding side. Position does not change the tumor, and 
there is no fluctuation perceptible; no acumination. There is 
decided tenderness. The limbs are equal in length, but the left 
thigh at its upper third is one-half inch larger than the right. 
Rotation is easy and flexion causes relief. The treatment is the 17 
same as that adopted in the preceding case, and at no time during 
the subsequent progress of the case was there any great consti- 
tutional disturbance, in fact this case differed materially from the 
other cases in the freedom from constitutional disturbance. At 
no time did the temperature rise above 101°, although on Sep- 
tember 24th it is recorded that there is marked induration with 
swelling, heat and redness extending from spine around left side 
to median line in front; acumination threatens near the anterior 
superior spinous process. 
October 1st.—Since last note symptoms have materially di- 
minished in severity ; thigh is much straighter and it actually 
seems as though the tumors were decreasing by resolution. From 
this time forth it did continue slowly to diminish, the child be- 
came quite active, and at the date of her discharge, January 7th, 
1879, motion at the hip is perfect; general health excellent? 
there is no fulness above or about the crest of the ilium ; case 
cured. 
Case XXV. At first acute, then becoming chronic; ilio- 
costal tumor, with usual thigh deformity ; disappearance of both 
under repeated blistering; cure by resolution at end of six months. 
Golda G., aet. 14J years, admitted to hospital July 21, 1879. 
Was perfectly well about four months ago when the disease for 
the relief of w hich.she now seeks relief was first developed. The 
girl had for some time prior to this been actively employed at a 
sewing machine, and one day without any provocation, she expe- 
rienced a sharp pain in the right lumbar region. This continued 
and increased to such severity that in three days she took to bed, 
where she was confined for three months with high fever, loss of 
flesh and pain so intolerable at times that relief was afforded only 
by opiates. There was excessive tenderness all along the lumbar 
spine in lumbar region, and down the thigh, right side, so that 
the slightest movements caused intense suffering. She preferred 
to lie on the right—the affected—side, and would keep the thigh 
flexed on abdomen. The bowels moved regularly every day, and 
there was no renal or vesical trouble so far as the parents knew, 
i. e., the urine was not voided too frequently, and its passage 
was not attended wth pain. After three months she got out <>f 
bed, but was unable to get about unless assisted. It was not 18 
until two weeks ago that she attempted to go out of doors, and 
then was taken by the family physician to consult a prominent 
specialist, who seems to have made a diagnosis of perinephritic 
abscess. The treatment has been blisters, poultices, electricity 
and “ almost everything.” 
On examination to-day, we find a girl of large frame, well 
developed, standing with the right thigh flexed on pelvis at an 
angle of 135°, and walking alone with the greatest possible 
difficulty (walks only at our urgent request) and moving when it 
is necessary supported on either side by her father and her sister. 
Her pulse is 140 and temperature 101J° (buccal.) Along the 
crest of the right ilium posterior half, is a well marked 
not very tender on pressure, skin not red, semi-elastic but not 
fluctuating. This fullness extends up into the ilio-costal space, is 
without appreciable dulness in this space and no tumefaction in 
the iliac fossa. There is no tenderness along spinal column, over 
any portion of the abdomen, in or around the hip-joint. The 
nates on right side flattened yet free from infiltration. The 
inguinal ganglia are not enlarged. The semi-circumference of 
the body on a level with the area of fullness is one inch greater 
on the right side. The thigh can be actively and passively 
flexed, abducted, adducted and rotated to the extreme normal 
limit without pain. The limbs are equal in size and in length. 
Pain is complained of only when extension is attempted. The 
spinal column is free from angular deformity is normally flexible 
and is not tender on concussion. 
A diagnosis of perinephritis is made unreservedly and the 
treatment as in the two foregoing cases adopted. Yet by the 
24th of August the relief afforded was not such as to justify a 
continuance of the treatment. The tumor was the same in size 
and the deformity of the thigh was the same as when she was 
admitted. The temperature chart for one week exhibited a varia- 
tion between 98£° for the morning, and 101f° for the evening. 
August 25th.— A fly blister is applied over the lumbar tumor 
this evening, and the vesicated surface is to be dressed in the 
morning with flaxseed poultices. 
September 1st.—The improvement since date of last note is 19 
most marked. She walks now nearly erect, and without any 
pain. The tumor is about one-half its former size. 
September 5th.—Limb can be completely extended without 
pain. The vesicated surface has nearly healed and the improve- 
ment continues. 
September 10th.—Another blister is applied over the tumor 
this evening, in the hope of causing its complete disappearance. 
September 26th.—As she walks it requires the eye of an ex- 
pert to detect the side on which the disease existed; in fact there 
is no appreciable limp. A careful examination shows no fullness 
in the ilio-costal space, no tenderness on superficial or deep press- 
ure, movements of thigh perfect in kind and degree, no deviation 
of spinal column, thighs equal in size and length. The general 
health is excellent. Discharged cured. 
October 14th.—Called by request, and carefully examined 
with absolutely negative results. 
Case XXVI. Profuse suppuration with great constitutional 
disturbance; complete recovery at the end of ten weeks. Maggie 
H., aged nine, was admitted to hospital July 21, 1879, the same 
date on which the previous case was admitted. The family his- 
tory is unimportant. Very healthy during infancy, rubeola 
being the only one of the exanthemata she has ever had. Two 
days ago she was brought to the out-door department, and the 
following history and observations were recorded : 
She was well up to four weeks ago, was then taken sick with 
chill and fever, and was confined to bed, being treated by the 
physician in attendance for typhoid fever (parent’s report). She 
had pain in right side and over abdomen, was constipated and 
had some vomiting. Since the first week she has had great 
difficulty in walking, has had pain in the hip and down the 
thigh, has been very restless nights and has become quite 
weak and cachetic. She hobbles into the office leaning heavily 
on the mother’s arm ; stands only when supported, resting most 
of her weight on the left limb, while the right is raised and 
everted, the toes only touching the floor. The left lateral 
decubitus she finds the most comfortable and when thus lying 
the right thigh can be easily flexed to the extreme normal limit 
and also rotated perfectly, but extension beyond 135° is re- 20 
sisted by muscular action, and the child screams aloud. On 
getting up she uses both limbs well in flexion and hears her 
weight on the knees without pain. There is no swelling or ten- 
derness about the hip or trochanter, but in the ilio-costal space, 
right side, there is a decided fulness extending over to the spinous 
processes. There is dulness here on percussion as compared with 
the opposite side, and tenderness is quite marked. The exami- 
nation is not extended any farther, but the diagnosis is made of 
perinephritis without any reserve. On her admission the condi- 
tion is unchanged. 
A carthartic is ordered, a tonic of iron and chlorate of potassa 
and warm fomentations to the lumbar region. The treatment is 
to be essentially expectant. 
July 22d, p. m.—Pulse 130, respiration 28, temperature 102|°. 
July 23d, a. m.—Pulse 115, respiration 35, temperature 
101|° ; p. m., pulse 120, respiration 30, temperature 103|°. 
July 29th.—The fullness has increased and the thigh is now 
adducted as well as flexed. 
Aug. 8.—Has complained recently of pain in head and left 
side of neck, and there is tenderness over the trapezius muscle. 
This may be due, in the absence of any other cause found, to her 
constrained position in standing or walking, which is certainly 
very peculiar. It is as follows: body inclined forward to an 
angle with the pelvis of about 135°, head carried backward and 
to the left, right thigh, advanced and hand resting on the knee. 
Her face in every feature indicates pain. 
August 10th, a. m., pulse 124, resp. 36, temp. 101|° ; p. m., 
pulse 128, resp. 36, temp. 103°. She does not complain of pain 
but rests so poorly nights that a twenty grain dose of bromide of 
potassium is ordered at bed-time. The record of vital signs shows 
the highest range of temperature 104° on the morning of the 
14th, when the infiltration extends over into the left ilio-costal 
space, upward to the eighth rib and downward to within one inch 
of the natal fold. There is marked fluctuation and the skin is 
glossy and discolored in spots. An incision is made about three 
inches to the right of the spine and just below the last rib, the 
pus, very offensive in odor, spurting forth in a thick stream. 
About one pint is evacuated and poultices are applied. Brandy 21 
of course is freely administered. Iler temperature falls this 
evening to 1021°. 
August 15th, a. m.—Pulse 100, resp. 30, temp. 98J°. She is 
induced to lie on the right side and a tent is inserted ; p. m., 
pulse 120, resp. 25, temp. 98£°. The discharge is abundant. 
She can extend the limb over a much greater arc and tier condi- 
tion is greatly improved. 
August 19th.—Leaves her bed to-day. The sac is pretty well 
emptied. She stands almost straight, the stiffness of the neck 
has disappeared, is gaining flesh daily. 
August 26th.—Stands and walks erect. The wound has 
closed. 
September 5th.—All treatment is discontinued; she walks and 
runs with ease and is growing quite fleshy. The cure is about 
complete. 
September 16th.—Discharged this date cured. The child is 
carefully examined and the only sign of pre-existing disease is 
the incision cicatrix in the right loin. There is no lameness 
whatever. 
October 8th.—Called by request to-day and undergoes a 
thorough examination with negative results. 
Case XXVII. A chronic form probably by extension from a 
nephritis{?) Nearly two years before tumor presented; under 
observation as an out-patient six weeks immediately preceding 
the presentation of the tumor; during this period diagnosis 
made. first of lateral curvature and high shoe ordered, then of 
caries of the spine and brace ordered; abscess opened one month 
later ; did not close until three and a half months afterwards ; 
care complete and, final examination four months after this. 
Katie II., aged nine years, was brought to the out-door depart- 
ment June 13, 1879 and was seen by a member of our staff who 
is exceedingly careful in his observations. lie learned from the 
mother that the child had been walking stiffly for about a week 
only and during that time had lost flesh and strength. lie found 
a half-inch shortening of the right limb with tilting of the pelvis 
to that side, a dorso-lumbar curve with convexity to the left, a 
correction of this curve by placing under the right foot as the 
child stands a book three fourths of an inch in thickness, and 22 
free movements at both hip-joints. He made a diagnosis of lat- 
eral curvature (followed by a mark of interrogation) due to 
shortening of the limb. He ordered a high shoe and a tonic. 
On July 18th I examined the case quite superficially, recognized 
the obliquity of the pelvis, also a stiffening of the spinal column, 
observed more distinctly as the child stooped, and made a diag- 
nosis of caries of the lumbar vertebrae, ordering a spinal brace to 
be applied on the 25th inst. 
July 28th.—The patient did not come on the 25th but comes 
this morning and there is observed a fulness in the right ilio-cos- 
tal space extending up to the lower border of the ribs and to the 
left, overlapping the spinous processes. This is more distinct as 
the child stands. The rectal temperature is The spinal 
brace is not applied but a diagnosis of perinephritis is now made 
and in-door treatment advised. 
The patient is admitted July 80, 1879, and in the history, 
more carefully obtained this morning, it is found that she comes 
of a family tuberculous and scrofulous and has been living for a 
long while in the basement of a tenement house. It is learned 
that two years ago (a short time before this she had a mild rube- 
ola) she began to have pain in the back, had headache, had 
oedema of the eyelids mornings, her urine was scanty and high 
colored. The symptoms were not severe but lasted for about six 
months; then she seemed as well as she had ever been, with the 
exception of an occasional pain in the right side, until the begin- 
ning of June, when lameness and the symptoms described under 
date of June 13th manifested themselves. 
It is additionally noted that during the past summer she has 
had occasional attacks of vomiting and that the bowels have been 
regular. There is no fall or other injury in the history. 
There is found marked dulness over the region of fulness and 
possibly deep fluctuation, and the semi-circumference of the body 
here is 12 inches, against 10J inches for the left side. There is 
no anchylosis or disease to be detected in the spinal column, and 
pressing the alse of the pelvis in the direction of each other gives 
no pain at sacro-iliac synchondroses or down the thighs. The 
only sign of any importance about the hips is a limitation of the 23 
extension of right thigh. The physical signs of thorax negative ; 
pulse, 125, temp., 100°. The urine is not examined. Tonics 
are ordered, and the treatment otherwise to be expectant. 
August 26th.—The record of vital signs shows no evening 
temperature above * For a few nights recently has had 
much pain. The skin over the tumor is tense and red. 
August 27th. Abscess opened by incision, and only about 
two ounces of pus evacuated. 
September 8th.—The wound is still discharging, though 
scantily, and the fulness has not materially diminished. Her 
general condition is good, and she walks with very little deformity. 
September 25th.—There is some infiltration yet about the 
opening, which has assumed the character of a fistulous opening, 
though the track is not explored. 
During the latter part of this month, and the early part of 
October, there was nocturnal enuresis, which was relieved by 
belladonna. A little oozing continued from the opening, even 
after all fulness and deformity had disappeared, and we watched 
closely for the exfoliation of any bone, but found none. 
December 12th.—The opening has just closed. It did not 
open again, and the patient was discharged cured on January 16, 
1880, when it was recorded that she stands naturally, and walks 
without the trace of a limp ; that there is no deviation of the 
spinal column to right or left; no tenderness along spine, over 
crest or in ilio-costal space ; that the spine is normally flexible, 
antero-posteriorly as well as laterally ; that the mobility at hip 
joints is perfect; that the limbs are equal in size and length ; 
and that the only sign of former disease is the cicatrix in the loin. 
On the 24th of April, 1880, Dr. Swasey was kind enough to 
look the case up for me, made a thorough examination and found 
the cure well established. He secured a specimen of urine, which 
I examined microscopically, finding nothing pathological. 
Case XXVIII. Spontaneous recovery after the appearance 
of the tumor. Jane G., get. was admitted to the hospital 
January 6, 1880, much emaciated, totally unable to walk, left 
thigh flexed on pelvis at an angle of 135°, easily flexed to the 
normal extent, easily rotated, yet not extensible beyond the angle 24 
just named. The hip-joint was absolutely free, but there was 
fulness and tumefaction in the left ilio-costal space, extending 
down into the groin, with dulness over a large area, and excessive 
tenderness. There was marked elevation of temperature, but 
this was not measured. The child came from the worst part of 
the city, although the family history was good. The present dis- 
ease began five weeks ago with slight lameness. This was attri- 
buted to a fall. Fever soon developed, the sleep was disturbed, 
the lameness increased, and for the past seventeen days the child 
has been unable to walk at all. There has been much constitu- 
tional disturbance, and pain has been referred to the spine, the 
loin and the thigh. 
The mother removed the child the same day, and was referred 
to my friend Dr. W. T. Bull, one of our consulting surgeons, 
who kindly admitted it to Chamber Street Hospital about three 
weeks later, had it put to bed, where it remained two or three 
days, pending a thorough examination. When this was made, 
Dr. Bull informed me, February 18th, there was no fulness 
found, no lameness, no sign of disease. A complete recovery 
had taken place spontaneously. 
The foregoing clinical record pictures, I trust, with sufficient 
clearness the symptoms and course of this affection. I have lit- 
tle to add on this point to my former contributions to the litera- 
ture of this subject. A larger experience but enables me to 
repeat a paragraph in my first paper—viz.: 
Symptomatology.—In typical cases the disease generally be- 
gins with a rigor or two, febrile exacerbations more or less severe 
according to the acuteness of the attack, lancinating pains in 
lumbar region, loss of appetite and general indisposition. In 
fiet the invasion does not differ materially from that of other 
acute inflammatory lesions, unless perhaps, the pain be more 
localized, and if the child be very young the locality of the pain 
is not discovered. Constipation, I believe, is always present. 
Very soon we have preternatural immobility of the spine, a stoop- 
ing forward with elevation of the shoulders. After a week or 
ten days, spasm of psoas muscle occurs, and the gait becomes 
characteristic of that so commonly regarded as the second stage 25 
of hip-joint disease. The urine is of high specific gravity, and 
is loaded with urates. The tumefaction appears and the pain 
becomes excruciating. If an exit be given to the pus a speedy 
recovery follows; if this be delayed and the contents of the sac 
be really pus, it burrows along the cellular tissue, producing an 
immense abscess, a spontaneous opening is effected and the con- 
valescence is protracted. If on the other hand, the inflammatory 
process has not resulted in suppuration, the contents are most 
likely serum, and resolution is effected.” 
The disease in twenty-seven of twenty-eight cases I have now 
placed on record ran its course in an average period of about 
three and one-half months. The analysis gives: two cases ter- 
minating in one month, three in six weeks, eight in two months, 
six in three months, two in four months, three in five months, 
two in six months, one in one year, while one (No. xxvii) seemed 
to extend over a period of two and one half-years. 
In sixteen there was suppuration more or less extensive, while 
in twelve there was no suppuration at all. We see, then, that 
nearly one-half the entire number underwent resolution. 
As to the constitutional disturbance produced, in thirteen cases 
this was very great, and at times very alarming, in eight it was 
moderate only, and in six was very slight. The complications 
were few. In one there was an alarming haemorrhage, easily 
controlled, however; in one there was a cellulitis of the thigh or 
rather a periarthritis of the knee ; * one had a femoral abscess, 
one a sub-scapular abscess, one a nephritis and one a pyelitis. 
In several there was incontinence of urine and at times painful 
micturition ; yet these are rather symptoms than complications. 
In nineteen I could find no exciting cause. In eight the 
cause was a contusion,'a strain or a fall, while in one a nephritis 
seemed to be the starting point. I fancy that perinephritic 
inflammation is induced as is inflammation in most other locali- 
ties, viz: by excesses of heat and cold. 
The ages of the patients vary between one and one-half years 
and fifteen. Five were under three years of age, twelve between 
* See sequel of this case in a paper on “ Periarthritis,” by the author of this paper in the 
N. Y. Medical Journal, May, 1880, case xx. 26 
three and six years, eight between six and ten, and three between 
ten and fifteen. 
The sexes were about equally represented, i. e., there were 
thirteen males and fifteen females. 
The lesion was on the right side in fourteen cases, and on the 
left in fourteen—equally distributed. Among the females the 
right side was the one affected in six cases, the left in seven. 
Among the males eight for the right side and seven for the left. 
The treatment employed in the twenty-eight cases has varied 
a little, yet it has chiefly been expectant. No specifics have been 
discovered, and I am fully convinced that in the management of 
the cases lay the secret of success. 
One ran its entire course without medical or surgical aid, and 
the result is one that any medical man would be proud to get! 
Four were treated on the purely expectant plan—no surgical 
interference, nothing to promote resolution. The general condi- 
tion of the patient was regarded as thn one essential feature 
demanding attention. Two of these terminated in resolution; 
two in suppuration, all making perfect recoveries. 
The hot water douche was employed in five cases and two of 
these went on to suppuration despite the douche, while three made 
a speedy recovery, terminating by resolution. Hot fomentations 
were used in four instances with good results in two, i. e. two got 
well without suppuration, and the other two got well after abscess. 
In five cases blistering and subsequent poulticing constituted the 
treatment, with four recoveries without any suppuration. 
As regards the time at which the incision was made, an early 
incision was made in three, a late one in eleven, while in two 
cases the abscess opened spontaneously. In one instance only, 
Case XIX, was there any delay in recovery and any annoying 
complication. In all probability if the abscess had been opened 
early there would have been no complication. 
Twelve cases terminated in resolution and sixteen in suppura- 
tion. All, with a single exception, made perfect recoveries. That 
exception was in Case I, reported in my first paper on this sub- 
ject. Since the publication of that paper I have found that this 
girl walks a little lame. The mother states that this came on 27 
subsequent to her discharge. I have within the past year ex- 
amined the parts well and have found no joint lesion whatever, 
but a loss of power in one of the glutei muscles, due, I am con- 
fident to destruction of some of its fibers by the extensive suppu- 
ration. Otherwise the result is perfect. 
In concluding this paper I wish to insist on a careful examina- 
sion, several times if need be, a history obtained without bias, an 
unalterable conviction that hip disease is from the beginning a 
chronic disease, and a slowly progressing disease; I wish to in- 
sist, I say, on these as points absolutely essential in making diag- 
nosis. I dislike to be hypercritical, but I firmly believe that ninety 
per cent., yea, I am prepared to assert a much larger per cent, 
than ninety, of the cases of hip disease reported as cured without 
lameness or deformity, cured completely, are not and never have 
been cases of hip disease. I speak advisedly on this subject, and 
I shall claim the privilege of publishing from time to time such 
cases as may be and are readily mistaken for hip disease; cases 
of perinephritis, of perityphlitis, of periarthritis, of primary 
traumatic periostitis, of the various neuroses of the hip, of sub- 
acute rheumatism about the hip and of acute primary synovitis 
of the hip, all of which affections are insignificant as compared 
with that terrible malady, with the advanced stages of which we 
are all so painfully familiar despite the great improvements in 
orthopoedic surgery. 
I cannot close this article without acknowledging valuable as- 
sistance from Dr. John J. Berry, of our hospital staff, in making 
out the foregoing analysis. 
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years of age. There are also, of this number, 24 primary cases- 
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511, s. 268. 
Vaugy, These de Paris, No. 379. 
Velpeau, Gaz. des. Hop., 1863. 
Williams, Med. Rec., July, 1876. (yi,* . r\ 1 ’ I 1 W E are glad to receive contributions from 
NOtlf P TO I nnTrinilTnr<; every one who knows anything ot interest 
MWllLtVy lVyVJIIU IDUIUI O. t0 the profession. Articles designed for 
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THE CHICAGO 
Medical Journal &. Examiner 
(established 1844.) 
EDITORS: 
N. S. DAVIS, M.D., LL.D., JAS. NEVINS HYDE, A.M., M.D., 
DANIEL R. BROWER, M.D. 
This is one of the oldest medical journals in the United 
States. It is published monthly and forms each year two large 
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This journal has no connection whatever with any cliques, 
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purchased by the Medical Press Association in 1875, its liberal 
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abroad, a recognition as one of the best journals in this country. 
Its original .articles are from the best talent of the land ; its notes 
from private and hospital practice are a true picture of practice 
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physician who intends to stand in the first rank of the profession 
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