THE 
CLINICAL HISTORY AND EXACT LOCALIZATION 
OF 
PERINEPHRIC ABSCESSES. 
By JOHN B. ROBERTS, M. D., 
« 
OF PHILADELPHIA. 
FROM 
The American Journal of the Medical Sciences'. 
APEIL, 1883. [Extracted from the American Journal of the Medical Sciences for April, 1883.] 
THE CLINICAL HISTORY AND EXACT LOCALIZATION OF 
PERINEPHRIC ABSCESSES. 
By JOHN B. ROBERTS, M.D., 
OF PHILADELPHIA.^ 
Purulent collections in the cellular and adipose tissue surrounding the 
kidney are very properly termed perinephric, or circumrenal, abscesses. 
It has recently become somewhat customary to speak of them as perine- 
phritic abscesses. I believe that perinephric is etymologically the more 
correct adjective. We speak with propriety of hepatic, pneumonic, and 
prostatic abscesses, instead of hepatitic, pneumonitic, and prostatitic ab- 
scesses. Hence perinephric, perimetric, and perityphlic are preferable to 
the longer forms, which, moreover, in most instances are evidently de- 
rived from the corresponding term designating inflammation, while gene- 
ral analogy requires the nomenclature to have an anatomical rather than 
an etiological derivation. 
Perinephric abscess is more common than is usually supposed, and its 
presumed rarity causes its existence to be often unsuspected. 
Causes—Inflammation and suppuration may occur in the tissue sur- 
rounding the kidney from contusions and other wounds, strains from 
muscular activity, exposure to cold, and various depressing blood condi- 
tions, such as septicaemia and typhoid fever. Again, perinephritis and 
perinephric abscess may arise secondarily from disease of the kidney. 
Inflammation of the renal pelvis, of the kidney structure, or of both, 
especially when suppurative or when due to calculi, cystic disease, or can- 
cer, can easily induce inflammation of the surrounding cellular tissue. 
Abscess will almost certainly occur, if urine, pus, a fragment of calculus, 
or parasites escape from the kidney or its appendages into the meshes of 
its fatty envelope. In a similar way secondary perinephric inflammation 
1 Read before the Philada. Academy of Surgery, March 5, 1883. 2 
may be caused by perforation of the colon, by typhlitis, perityphlitis, hepatic 
abscess, rupture of the gall-bladder, perforation of the diaphragm in cases of 
empyema or pulmonic abscess, by spinal caries, psoas abscess, peritonitis, 
pleuritis, and indeed by inflammation of any adjacent organ. 
Operations upon the testis and cord and pelvic viscera, such as castra- 
tion, excision of the rectum, and lithotomy, and puerperal inflammations 
may induce perinephric abscess on account of the continuity of the cellular 
tissue in the pelvis with that in the kidney region. Inflammatory affec- 
tions of the genito-urinary organs are factors in the production of perine- 
phric abscess of primary importance. These organs are embryologically 
and anatomically connected with the kidney through the bladder and 
ureter; hence the extension of the inflammation to the kidney and thence 
to the perinephric tissue is easily understood. Cases are even recorded 
as due to permanent catheters.1 Another mode of transference is by the 
continuity of the retroperitoneal connective tissue. This may allow the 
morbid process to extend by continuity of structure from the membranous 
urethra, prostate gland, bladder, and seminal vesicles to the tissue around 
the kidney without involving the kidney or other structures to any notice- 
able extent. 
The agency of the veins and nerves in establishing a pathological union 
between the pelvic organs and the renal region is doubtless very effective. 
Embolic and septic processes and neuropathic influences become very pos- 
sible and intelligible when we think of the direct blood and nerve routes 
between the pelvic and lumbar regions. For example, what could be 
more direct than the connection of the testes and scrotum with the renal 
region by means of the spermatic vein and ilio-inguinal nerve. Many 
similar though less obvious anatomical bonds can be comprehended. 
Symptoms The constitutional symptoms cff pus in the perinephric 
tissue are liable to the variations seen in other suppurative inflammations. 
Rigors, febrile movement, sweating, anorexia, vomiting, constipation, and 
perhaps delirium are marked in acute cases, while in chronic cases there 
may be so few constitutional symptoms that the existence of internal sup- 
puration is overlooked. Constipation is sometimes very obstinate and 
apparently due to pressure on the colon. On the left side especially the 
colon can readily be compressed by swelling of the tissues in front of the 
kidney. When perinephric abscess follows puerperal perimetritis and 
similar conditions, the violence of the symptoms and a rapid death may 
interfere with recognition of the secondary trouble near the kidney. 
The fever is sometimes continuous, and resembles typhoid fever; at 
other times its intermittent character suggests malarial influences. In 
perinephric abscess which has been allowed to burrow, septicaemic symp- 
toms become prominent. 
1 Nieden, Deutsches Archiv fur klinische Medicine, 1878. Bd. xxii. Falle 92 and 93. The pain in its onset is often sudden. It is usually referred to the loin 
and side, is increased by pressure, and may shoot down the thigh, or into 
the genital region. Pain in the scrotum and penis at times occurs as a 
quite prominent symptom. Retraction of the testicle towards the in- 
guinal canal may take place. It is stated that this does not occur, even 
when pain is experienced in the organ, unless there is, in addition to the 
perinephritis,1 disease of the kidney, such as calculous nephritis. If this 
is true, it is a valuable diagnostic point in the differentiation of secondary 
from primitive perinephric abscesses. I doubt the accuracy of the state- 
ment. Nieden in his table records only sixteen cases in which pain was 
noted in the abdomen, groin, thigh, and genitals. Gibney has seen cases 
in which pain was felt in the knee as in coxalgia.2 The lumbar and 
other pains may remit, disappear entirely for several days, or be alto- 
gether absent. The pain of perinephritis causes the patient to immobilize 
the spine, and assume, according to Gibney,3 a stooping posture with the 
shoulders elevated. 
Spasmodic action of the psoas muscle often induces, in the course of a 
week or ten days, flexion of the thigh upon the pelvis. The pain may be 
relieved by this posture. It is not uncommon in subacute cases for the 
patient, in order to relax the psoas, to walk with the body bent forward, 
and with the hand of the affected side resting upon the middle of the 
thigh. To relax the parts, the trunk is sometimes bent laterally, so that 
the ribs approach the iliac crest. 
The position of the thigh is a symptom of great value, and may be 
attributed to coxalgia or rheumatism instead of to perinephritis. I believe 
flexion of the thigh to be an accompaniment especially of perinephric 
abscesses at the lower third of the kidney. It is recorded as observed in 
27 out of 16G cases tabulated by Nieden. The flexion may be merely 
sufficient to prevent extreme passive extension of the hip, or so great as 
to draw the thigh firmly up against the abdomen. When thus bent, pain 
may be absent, but the slightest attempt at extension causes complaint. 
The hip may therefore be continuously flexed. Hence the patient may 
scarcely be able to turn over in bed to allow examination of the loin. All 
motions of the hip except extension may be perfect and painless. Diffi- 
culty in voluntary adduction of thigh has been mentioned by Gibney4 in a 
case in which the thigh was semiflexed, and rotated outward. In another 
case he found towards the end of the affection slight resistance to complete 
passive flexion of the thigh on the abdomen. These symptoms pointed 
strongly to possible coxitis; but the subsequent history did not cause Dr. 
1 Nieden, Deutsches Arehiv fiir klinische Medicine, 1878. Bd. xxii.'S. 498. 
2 Amerr. Journ. Medical Sciences, 1877, vol i. p. 399 ; Id., 1878, vol. ii. p. 403 ; and 
elsewhere. 
3 Chicago Medical Journal and Examiner, June, 1880. 
4 Arner. Journ. Med. Sciences, 1877, vol. i. p. 395 and p. 401. 4 
Gibney to change his diagnosis of perinephritis cured by resolution. The 
same author lias described1 a case where adduction in addition to flexion 
existed. Cure followed incision giving escape to about a pint of pus. 
These abnormal positions and interferences with function of the thigh 
lead in subacute cases to a gait that is remarkably suggestive of the second 
stage of coxalgia. When pain in the knee coexists, the acutest observer 
must be guarded in diagnosis and prognosis. I have found one case re- 
ported2 in which convulsive movements of the leg occurred as a symptom 
of perinephric abscess consecutive to cancer of the kidney; and another3 
in which the large tumour caused oedema of the lower extremity. 
Involvement of the lumbar plexus by pressure of the inflammatory 
products may give rise to general or localized anaesthesia, or temporary 
motor paralysis of the thigh. These symptoms occurred in eight of the 
cases contained in Nieden’s table. The same writer records a case4 in 
which there was paresis of both legs; and another5 in which a left side 
abscess was accompanied by left pleuritis and paresis of both legs and the 
right arm. The latter case went on to suppuration ; in the former resolu- 
tion occurred. Neuralgic troubles may be induced by similar pressure 
and interference with the nerve branches. 
It is generally said that the urine presents only those changes incidental 
to the febrile condition, unless the perinephritis be secondary to calculous 
nephritis, vesical inflammation, or similar causes. Then it may contain 
blood, pus, albumen, and tube-casts. My experience shows that a large 
amount of albumen may be present, probably from venous obstruction, 
when no kidney lesion of moment exists. It is remarkable that in 
Nieden’s table there is not a single case mentioned in which albuminuria 
without purulent urine was noted. This may be owing to careless obser- 
vation by the original reporters. Hsematuria is not very unusual at the 
beginning of traumatic perinephritis. 
Incontinence of urine and frequent or painful micturition have been 
observed. These symptoms are probably due to the abundant urates or 
to other chemical changes in the urine occurring with the febrile condi- 
tion, or to the disturbance of the innervation of the pelvic organs. 
Distressing flatulency and irregular constipation have been noticed by 
Moxon,6 who ascribes these symptoms to inflammatory thickening involv- 
ing the nervous structures around the vena cava and aorta, and thus 
causing paralysis of the abdominal sympathetic. This is, he thinks, more 
likely to occur in left-side perinephritis, than in cases of disease on the 
right side, such as he describes in his remarks. 
Dulness on percussion of the space between the ribs and the crest of the 
1 Chicago Med. Journ. and Examiner, June, 1880, Case XXVI. 
2 Nieden, Case 105. 3 Nieden, Case 149. 
4 No. 151. 5 No. 150. 
6 Lancet, May 1, 1875, p. 603. 5 
ilium is usually found; and pressure made by the hands, placed one in 
front and one behind, will sometimes discover a tumour, or elicit a feeling 
of elastic resistance or indistinct fluctuation. The tumour thus perceptible 
is rounded, with smootli edges, and moves little, if at all, with the respira- 
tory act. The girth of the lumbar region becomes from swelling unsym- 
metrical, and the aflfected side measures one to two inches more than the 
opposite region. This is best appreciated by measurement with the tape, 
for the swelling may be general and not localized. There may also be 
broadening of the buttock, eflfacement of the normal hollow in the loin, 
increased girth of the upper portion of the thigh, effacement of the 
dimple over the trochanter, and spinal deviation towards the diseased 
side. The tumour discovered by palpation must be distinguished on the 
left side from feces in the descending and sigmoid portions of the colon ; 
and on the right from liver tumour. Evacuation of the contents of the 
great intestine by laxatives and enemas, and the normal situation of the 
colon percussion-tympany, will remove one source of doubt; and the 
motion of the liver during respiratory acts will get rid of the other. 
The tumefaction is accompanied by a subjective tenderness and sense 
of tension, which will probably be increased as suppuration occurs in the 
inflamed tissue. It may also cause dyspnoea from pressure upwards against 
the diaphragm. 
Finally, in those cases of perinephritis which do not result in resolution, 
fluctuation becomes evident. This is preceded, perhaps, by rigors, local 
oedema, redness, and exquisite pain on pressure over the advancing pus. 
When the abscess is opened, either spontaneously or by operation, the 
febrile temperature falls, the digestive organs perform their functions pro- 
perly, and the patient is relieved of pain. Cure soon follows, unless com- 
plications or extensive burrowing of pus have occurred. In chronic perine- 
phric abscess the symptoms may be very obscure. 
The clinical characteristics of perinephric abscess and its proper treat- 
ment will be illustrated by the following history :— 
Case I. Perinephric Abscess, subsequent to Internal Urethrotomy, 
treated by Incision; Rapid Recovery A gentleman who had suffered 
during a number of years with an irritable stricture of large calibre, was 
subjected, in February, 188*2, to internal urethrotomy. After the opera- 
tion, which was done by a distinguished professor of surgery, a large 
bougie was passed (36 French). Subsequently he had in the course of a 
few days three chills; but was soon able, though weak, to go out of the 
house. The urethra was systematically dilated with large instruments 
during this period. Two or three weeks after the division of the stricture 
he consulted me, because of intense pain in the right lumbar region and 
right testicle, for which he had kept his bed during several days. There 
was great pain on motion, which sometimes persisted even when the man 
kept still; but nothing abnormal, except tenderness on pressure, could be 
detected in the loin. I looked upon the case as one of myalgia, or of 6 
nephralgia; and prescribed quinia, morphia, and belladonna, and applied 
a blister over the painful area. 
Considerable amelioration of pain occurred in a few days, and I thought 
he was getting well; but this was a very temporary improvement. I then 
examined the urine, which contained no pus, by the liquor potassm test, 
and showed no bloody discoloration. It contained, however, a large 
amount of albumen. The pain continued in varying intensity, and was 
accompanied with great tenderness on both sides of the spine and over the 
sacrum. He complained of anomalous feelings in the right lower extremity, 
which was described as being like a “ limb asleep” rather than painful. 
Motion, however, was good, though performed slowly and with care. No 
heart or lung lesion was discovered by physical exploration. There was 
no apparent fever, no chills, no special digestive disorder; and the urine 
was voided freely and in a large stream. No history of gravel having 
ever been passed could be obtained. A few days later I thought I detected 
a slight fulness near the lumbar spines, in the region of the kidney, but no 
fluctuation could be distinctly obtained. At this time the urine showed a 
slight trace of albumen, had specific gravity of 1012, and contained no 
sugar. I considered the pain which existed to be occasioned by pressure 
on the lumbar plexus by some kidney affection, probably due to the chronic 
stricture. The pain in the scrotum was less than formerly, but the paresis 
of sensation in the thigh remained. 
On March 24th the swelling in the loin was more marked, and the 
local tenderness great. A large bougie could readily be passed through 
the urethra. The introduction of a sound failed to discover any calculi or 
calculous material in the bladder. The morning and evening temperature 
was reported by the nurse as below 100° ; there were no chills, and the 
pulse was 80 to 90. Dr. John Ashhurst, at my request, saw the patient 
with me in consultation, and thought there was oedema over the swollen 
surface. We made the diagnosis of abscess in the cellular tissue around 
the kidney, which Dr. Ashhurst thought to be still below the muscular 
masses of the back. Poultices and the application of tincture of iodine 
were resorted to as the local treatment. 
Six days later I thought it would be proper to evacuate the pus, as fluc- 
tuation seemed more distinct. At this time the pain had become less 
severe, and there was no longer any albuminuria. Asking Dr. Ashhurst 
to see the case a second time, I found that he concurred in the belief that 
operation was advisable. I accordingly made a vertical incision, one and 
a quarter inches long, through the skin and lumbar fascia. Introducing 
my forefinger, I bored down through the softened muscles, between two 
lumbar transverse processes, until at, nearly the full length of my finger 
I evacuated two or three fluidrachms of pus; a drainage tube was intro- 
duced, and the wound poulticed. Carbolized injections through the tube 
were subsequently used every day. 
On the third day after this procedure, a note was made to the effect that 
there was little or no pain on pressure in the lumbar region, and that the 
pain and numbness in the right buttock and extremity had disappeared 
since the operation. The convalescence was rapid and uninterrupted. 
On the tenth day be was sitting up and walking about his room a little. 
About this time he began cautiously using a large bougie again. The last 
note, made about one month later, says he is strong and well, and walks a 
good deal. He still had a slightly tender spot over the sacrum near the 
middle line, and the stricture was irritable after smoking. 7 
I have purposely omitted the details of treatment, because they are not 
important in studying the clinical history. The symptoms are, however, 
in my opinion, of great interest, because they localize so distinctly the 
position of the small abscess. The pain felt early in the disease in the 
scrotum and testicle, and the paresis of sensation, which soon affected the 
buttock and the front and outside of the thigh, show that the pressure was 
exerted upon the ilio-hypogastric, ilio-inguinal, genito-crural, and external 
cutaneous nerves. These nerves are branches of the first and second 
lumbar nerves, which also supply branches to the back. Hence it is evi- 
dent that the abscess was situated at the level of the first and second 
lumbar vertebne. This inference is rendered more conclusive by the ex- 
istence of albuminuria, which was due to pressure on the renal vein causing 
congestion of the kidneys. This vein is known to be situated1 on a level 
with the first lumbar vertebral body. 
As the abscess approached the surface of the back, pain in the scrotum 
diminished, and albumen disappeared from the urine, because pressure 
was decreased. There was no tonic spasm of the psoas, iliacus, or pec- 
tineus muscles, causing flexion of the hip, as in the case which I shall 
presently describe, because the abscess was too high up to press upon the 
third and fourth lumbar nerves, whose branches supply the muscles men- 
tioned. It is probable that if the incision had not been made, the abscess 
by burrowing downwards would finally have given rise to flexion of the 
thigh upon the pelvis. I do not feel sure of this, because the position of 
the abscess behind the kidney might have led to spontaneous evacuation 
through the muscles of the back before the quantity of pus had become 
sufficient to involve the structures opposite and below the inferior end of 
the kidney.2 
These points in surgical anatomy I deem important, because I have not 
seen them mentioned in connection with perinephritis. They will serve as 
good guides in the determination of the position of the incision, when the 
surgeon feels called upon to explore a suspected perinephric abscess. 
Cases are reported where incision or puncture failed to find pus in in- 
stances whose subsequent history confirmed the diagnosis of abscess. A 
more careful study of symptoms may hereafter enable us to localize the 
pus more exactly. 
Untreated perinephric abscess, if life is prolonged, usually opens in the 
lumbar region; but the pus may be discharged into the colon, stomach, 
small intestine, pleural cavity, bronchial tubes, pericardium, or peritoneal 
1 See Braune’s Topographical Anatomy, Bellamy’s translation, p. 129. 
2 In January and February of this year (1883), after the above paragraphs had been 
written, this patient was treated by me for a chronic perinephric abscess, situated 
three or four inches below the cicatrix of the first. There was no albuminuria and no 
scrotal pain ; but flexion of the hip was marked.' The abscess was evidently connected 
with the old seat of disease, for pus was subsequently evacuated also from the vicinity 
of the first incision. 8 
cavity ; or the abscess may open upon the surface in the hypochondrium, 
below Poupart’s ligament, upon the buttock through the sciatic notch, or 
by perforating the ilium, or discharge into the pelvis of the kidney, the 
bladder, vagina, or urethra. The pus may find its way into the sub-iliac 
bursa, and, by the communication that often exists between this sac and the 
hip-joint, even enter the joint itself. It may burrow into the scrotum. The 
pus may amount to three or four pints, and may, especially in consecutive 
abscesses, be thin, ichorous, and mixed with urine. It may be offensive 
and fecal in odour, even when there is reason to believe that no intestinal 
fistule communicates with the pus cavity. In primitive perinephric 
abscess the pus is thick and odourless, and perhaps contains shreds of 
connective tissue. Trousseau has observed1 emphysema under the integu- 
ment of the back from an opening between the gut and the abscess. The 
large amounts of pus only occur when delay in operating has allowed ex- 
tensive suppuration. Bowditch2 believes in the frequent occurrence of 
thoracic complications from contiguity with perinephric abscesses. He 
describes two cases, in which he was consulted for lung disease, that were 
found to be perinephric abscesses opening through the lung. 
The following case illustrates the course of the disease when not treated 
by prompt surgical measures :— 
Case II. Probable Perinephric Abscess following Gonorrhoea; Con- 
dition not suspected; Death icith Septiccemic Symptoms This history, 
which dates back a number of years, is a humiliating one, for, though the 
patient was seen by myself and several other medical men, the possible 
existence of perinephric abscess was not suggested until death had oc- 
curred. When subsequently thinking over the circumstances, I became 
convinced that the purulent collection, for which we had searched in vain 
in the pelvic and anterior abdominal regions, should have been looked for 
in the lumbar region. Though proof was then unattainable, I believed, 
and still believe, the posthumous diagnosis probably correct. 
The patient, on account of gonorrhoea, had retention of urine, which 
required catheterization. Subsequently orchitis with scrotal abscess oc- 
curred, and about the same time, or perhaps a little previously, a small 
abscess on the outer aspect of the left thigh appeared. Both these collec- 
tions of pus were evacuated by incision. During the maturation and cure 
of these abscesses, the right hip became somewhat flexed. When I saw 
him after an absence of some weeks, I found the thigh firmly flexed, and 
the patient weak, nervous, and hysterical, afraid of any examination, and 
continually desiring morphia or ether. He could not move his thigh be- 
cause of pain, nor would he allow it to be extended. It was thought pro- 
bable that the position of the right limb was originally due to the patient 
having assumed this posture 1o keep the scrotum and left thigh free from 
pressure of the bed-clothes, and that the voluntary disuse of the joint 
during a series of weeks had induced in his irritable and nervous condition 
a hysterical contraction. Ether was administered’, and the hip forcibly 
1 Clinical Medicine. 
2 Medical and Surgical Reports of Boston City Hospital for 1870. 9 
extended with a cracking noise, similar to that heard in breaking up ar- 
thritic adhesions. 
After regaining consciousness, the man could move the limb to a limited 
extent without marked pain. Permanent extension was made by attaching 
a weight to the foot. Five or six days later the weight was removed be- 
cause of pain. The flexion then recurred. The etherization wras done 
about two months after the time of contracting the original gonorrhoeal 
trouble. Owing to unavoidable circumstances, I only saw the patient 
occasionally and at long intervals. The daily treatment was carried out 
by my medical friends, and occasionally either I or another surgeon saw him. 
My notes, dated about six weeks after the day of etherization, show 
that the general condition had steadily become worse, notwithstanding the 
exhibition of quinia, iron, and milk punch. Hebetude, delirium, dry 
tongue, chilliness, sweating, emaciation, and great prostration made us be- 
lieve that septicaemic processes were present. There was no marked pain 
except on attempting to move the right hip-joint; but some abdominal 
tenderness apparently existed. The urine was freely passed, no pulmonary 
change was found on auscultation, and neither palpation of the abdomen 
nor digital exploration of the rectum revealed the purulent accumulation 
sought for in the abdomen or pelvis. I have no note or recollection of 
the patient experiencing pain in the lumbar region ; nor of the loin being 
examined with special reference to the possibility of the abscess being as 
high as the kidney. 
Four months and a few days after contracting gonorrhoea, the patient 
died. After death, an attendant, in the words of my note book, “ found 
gurgling at upper part of right thigh, as if a decomposing abscess had 
worked down from within pelvis or abdomen.’’ 
I now feel that the flexion of the thigh was probably due from the first 
to perinephritis, causing little or no lumbar pain, but which finally gave 
rise to an abscess in the cellular tissue around the kidney. This abscess 
increased and slowly burrowed behind the peritoneum andalongthe psoas 
muscle until it reached the groin. Here it would probably have evacuated 
itself spontaneously, if life had been prolonged. • It is impossible now to 
determine whether examination of the loin would have led to its dis- 
covery, or operative treatment have been followed by convalescence. 
Complications Numerous complications may arise if perinephric ab- 
scesses are allowed to increase indefinitely until spontaneous evacuation 
occurs. I have already spoken of the directions in which this may take 
place. The complications, such as peritonitis, which may accompany such 
events, need not be discussed. Tlie kidney, according to Ebstein,1 be- 
comes involved secondarily from disturbance of its nutrition produced by 
the inflammation located in the perinephric structures. Cloudy swelling 
of the epithelial cells, necrosis or abscess of the kidney structures, and 
dimunition and induration from pressure are mentioned by him. These 
effects can easily be understood on considering the clinical history of the 
case first reported, where there was abundant albumen in the urine due 
undoubtedly to pressure upon the renal vein. 
1 Ziemssen’s Cyclopaedia of Medicine, vol. xv. p. 592. New York, 1877. 10 
The danger of thoracic involvement is insisted upon by Bowditch. In 
nine cases of perinephric abscess, auscultatory signs of pulmonary implica- 
tion were discovered by him in seven. Although some of these presented 
no marked chest symptoms, he regarded these physical signs an important 
argument for operation in the loin, because they showed that the inflam- 
mation was travelling upward and beyond the original site. 
Diagnosis.—In the very early stages of perinephric abscess the diagno- 
sis is often impracticable. Especially is this so when the symptoms are 
not very pronounced, and when there have been no previous renal symp- 
toms to direct attention to the vicinity of the kidney. The symptoms 
already described make the diagnosis easy, as a rule, when the inflamma- 
tory process has advanced beyond the initial stage. Lumbago simulates 
the pain of perinephric abscess, but it is unaccompanied by fever, and 
causes the patient to walk with a rigidity of spine that is different from 
the lameness due to the partially flexed hip of perinephritis. I must ad- 
mit, however, that there may be little or no fever in the latter disease, 
and that the pain may cause a mere stiffness of the spine without any 
spasm of the psoas being present. Moreover, the impairment of the hip 
motions may in some cases of perinephritis occur late, or may, indeed, be 
altogether absent. 
Aching kidney1 and nephralgia, or neuralgia of the kidney, are terms 
indefinitely descriptive of pain in the renal region from unknown patho- 
logical causes. Aching kidney gives, according to Duncan, aheavy wearing 
pain, felt especially in the hypochondrium and frequently associated with 
pain down the limb and with irritability of the bladder. He believes that 
there exists swelling of the kidney or perinephric tissue, or both, which 
can be felt by palpation. The location of the pain in the anterior region, 
the fact, at least in women, that it is increased during menstruation, and 
the non-sequence of more pronounced symptoms are supposed to distin- 
guish this condition from true perinephritis. Nephralgia may be recognized 
by the paroxysmal character of the pain and the known neuralgic dia- 
thesis of the individual, especially if the absence of injury or of genito- 
urinary irritation is conspicuous. 
Organic affections of the kidney may of course be the cause of peri- 
nephric abscess by secondary involvement of the cellular tissue around 
the organ. The diagriosisof renal lesions, without perinephric abscess, is 
made by the symptoms peculiar to each. Cancer of the kidney is usually 
accompanied by hematuria, rapid decline in health, and perhaps later by 
the physical signs of a distinct growth and the involvement of surround- 
ing viscera. The tumour may be nodular. 
Renal cysts are not accompanied by local increase of surface tempera- 
ture, nor by oedema in the lumbar region. These symptoms are distinc- 
1 J. Mathews Duncan, Medical Times and Gazette, Nov. 16, 1878, p. 563. 11 
five of perinephric abscess. Calculous nephritis is usually preceded, or 
accompanied, by attacks of intense pain and perhaps vomiting due to 
small calculi passing down the ureter. The sudden relief of pain when 
the stone enters the bladder is almost pathognomonic. The existence of 
pus, blood,and gravel in the urine, when not traceable to bladder disease, 
always points to lesions of the kidney itself. Such occurrences are not 
part of the clinical history of perinephric abscess, unless it is secondary 
to inflammation of the renal pelvis (pyelitis), or to pylo-nephritis. 
When percussion or pressure over one of the spinous processes of the 
vertebral column gives rise to pain, when there seems to be slight angular 
projection backwards, ■when straightening or extending the spine by sus- 
pending the patient from the armpits relieves pain, and when there is bila- 
teral interference with the innervation of the legs, it is probable that ver- 
tebral caries exists. The similarity of some cases of perinephritis to this 
condition will be evident when I say that the spinal brace has been or- 
dered1 for a patient suffering with a perinephritis which finally required 
incision to evacuate pus. 
Perityphlic abscess is not likely to be confounded with perinephric 
abscess, for the tumour-like mass of indurated cellular tissue in the latter 
case is higher and not so easily felt by palpation of the front of the abdo- 
men, and there is a more marked tendency for flexion of the hip to occur. 
Perityphlic abscess, on the other hand, is more likely to present forwards, 
to cause oedema of the corresponding limb from pressure on the iliac vein, 
and when opened to furnish fetid or stercoraceous pus and gas. The 
numbness of the thigh and the hip-flexion found at times in perinephric 
abscesses may also be found in perityphlitis. 
Masses of feces, and splenic or hepatic tumours may in rare instances 
simulate the indurated swelling due to perinephritis. The first can be 
removed by laxatives; the last two conditions are distinguished from peri- 
nephritis by the ease with which they are displaced downwards during 
inspiration. 
Perinephric tumours are retroperitoneal, and therefore on the right side 
the ascending colon lies to the inner side of such a tumour, while on the 
left side the descending colon has a position in front of it.2 
If the abscess around the kidney perforates the diaphragm, and dis- 
charges pus into the pleural sac or bronchial tubes, empyema or abscess 
of the lung may occur. These conditions may be recognized without the 
existence of perinephric abscess being suspected.3 
Flexion of the thigh, if present, and the other symptoms of perineph- 
ritis, would attract the attention of the careful and intelligent observer, 
1 See Dr. Gibney’s paper in Chicago Medical Journal and Examiner, June, 1880. 
2 Nieden in Deutsch. Archiv fur klin. Med., Nov. 1878, S. 500, quotes Wells and 
Simon. 
3 Bowditch, Medical and Surgical Reports of Boston City Hospital, 1870, p. 58. 12 
as they did that of Dr. Bowditch. Cure may occur in such instances after 
the expectoration of 18 ounces of pus.1 
Dr. F. Lange has recently reported a case, from Thiersch’s clinic in 
Leipzig, where there existed empyema and a sinus on the front of the 
thigh, both apparently secondary to a perinephric abscess.2 
I have purposely postponed the consideration of the differential diagnosis 
of perinephritis and coxitis, and of perinephritis and inflammation of the 
psoas muscle until this time, because of the importance and difficulty of 
the topics. 
In perinephritis there is often flexion and painful rigidity of the hip- 
joint, with perhaps ad- or aS-duction of the thigh and pain at the knee. 
These symptoms at once suggest hip-joint disease. Usually in such cases, 
however, passive flexion of the hip can be made without causing pain, and 
may even relieve existing pain. Attempted extension of the thigh is, on 
the contrary, at once painful. This aids in diagnosticating the condition 
from coxitis, where all motions are apt to be painful. There will probably 
be found less rigidity of the adductors in perinephritis than in coxitis. 
In coxitis there is often fulness and tenderness on pressure over the 
trochanter or joint, pain on percussion of the femur, and subsequent 
shortening and atrophy of the thigh. There is, however, no fulness in 
the lumbar region, which is a frequent feature of perinephric abscess. 
The semicircumference of the trunk on the affected side will, in the latter 
disease, often be increased one to one and a quarter inches. Atrophy of 
the thigh occurs also in perinephritis if the limb is flexed and not used for 
a long time; hence great caution is at times required to avoid committing 
an error in diagnosis. Gibney believes that many reported cures of hip 
disease, with perfect return of function, are, in truth, instances of peri- 
nephritis cured by resolution, which have been mistaken for coxitis. 
Inflammation of the psoas muscle and psoas abscess present some of the 
characteristics of perinephric abscess. Usually, however, there are asso- 
ciated with psoas abscess symptoms of caries of the vertebra, such as a 
painful spinous process, when pressure is made along the spinal column 
posteriorly. In psoas troubles there is apt to be more tenderness and 
pain in front than in perinephritis. The impaired motion of the hip-joint 
and the interference with the innervation of the thigh are similar to what 
is found in perinephric abscesses involving the psoas muscle secondarily. 
There is, however, neither pain nor fulness in the loin. 
The diagnosis between coxitis or psoitis and perinephritis must in 
obscure cases rest upon the combination of symptoms and the progress 
from day to day. A careful study of the section of this article devoted to 
the symptomatology of perinephritis will render a diagnosis usually practi- 
1 Neiden, Case 9S. 
2 New York Med. Journ., January 27, 1883. 13 
cable within a short time. In the early stages an absolute diagnosis may 
be impossible. 
Localization—The early recognition of the existence of perinephric 
abscess and the determination of its relative position with regard to the 
kidney is important. The promptness and efficiency of operative treat- 
ment must depend very much upon the early recognition of the exact 
position of the abscess. Cases have been reported in which incision or 
puncture failed to reach the suspected abscess-cavity, though the subse- 
quent clinical history proved the correctness of the diagnosis. More 
exact comprehension of the bearing of locality upon symptoms, might, as 
is readily seen, have affected the position chosen for operation and thus 
have given earlier exit to the pus. The symptoms already described will 
enable the surgeon to make in the majority of cases the diagnosis quite 
early. I shall now therefore study the symptoms in connection with the 
surgical anatomy of the region, in the endeavour to bring out points which 
will make it possible to localize perinephric inflammation and abscess. As 
far as I know this line of investigation is new. Hence as no foundation 
for my conclusions has within my knowledge been laid by other writers, and 
as I have no corroborative evidence except in my own limited experience, 
the propositions and the deductions resulting from my dissections and 
studies should be accepted as suggestive and not final. 
I arbitrarily divide the perinephric cellulo-fatty tissue into six tracts. 
The upper, middle, and lower anterior; and the upper, middle, and lower 
posterior tracts. There is of course no sharp definition between these 
regions, which are used to conveniently indicate the location of the disease. 
In discussing the subject I shall speak of inflammation and of abscess 
interchangeably though the symptoms of pressure are more marked in the 
latter event. 
It may be premised as an axiomatic truth that, although there may be 
pains radiating in various directions, anterior inflammations will give rise 
to pain especially in the front or side of the abdomen, posterior lesions to 
pain in the loin. Tenderness upon pressure, oedema over the abscess and 
pointing will be similarly exhibited. The swelling, the tumour-like out- 
lines and the feeling of resistance to palpation will naturally be the more 
evident in anterior lesions because the tissues between the disease and 
the surface are flaccid. Involvement of the chain of sympathetic ganglia, 
situated along each side of the spinal column, would occur in posterior 
lesions only. We, however, are ignorant of what symptoms would result 
from such inflammatory irritation or pressure. 
In the two upper regions perinephric abscess is very liable to give rise 
to localized pleuritis of the bottom of the pleural sac. This is especially the 
case when the inflammation exists in the upper part of the posterior tract. 
The superior portion of the kidney lies upon the diaphragm, the lower 
margin of which crosses the back of the kidney in a direction obliquely downwards and outwards. This is indicated in the wood-cut drawn from 
one of my dissections. This relation of the diaphragm is also shown by the 
depression of the kidney which occurs on deep inspiration. Holden says it 
descends nearly half an inch. The pleura on the upper surface of the 
Dissection of the retro-peritoneal space showing the relations of the perinephric tissue and 
kidney to the diaphragm, colon, nerves and vessels. The ilio-hypogastric and ilio-inguinal nerves, 
and the lowest limit of the pleura, though posterior to the kiduev, are indicated by lines, in order 
to show the relation. 
diaphragm is therefore in proximity to the upper posterior perinephric 
region and readily becomes, from contiguity of structure, involved in the 
inflammation.1 Careful auscultation will often reveal slight friction sounds 
and evidences of local pleuritis in the vicinity of the 11th or 12th rib 
when no symptoms of this complication are present. Serous effusion, 
empyema, or purulent expectoration from rupture of the abscess into the 
1 Plate VIII. of Dwight’s Frozen Sections of a Child, shows this relation beautifully. 15 
bronchial tubes may occur later. Abscess in the upper part of the kidney 
region may cause dyspnma from the swelling of the infiltrated tissues pre- 
venting perfect descent of the diaphragm. This symptom may be induced 
whenever there is much swelling accompanying perinephritis, but it would 
evidently occur sooner and with less enlargement in inflammation of the 
upper areas. 
The position of the supra-renal gland makes it liable to involvement 
when the upper anterior tract is the seat of disease, but we have not suffi- 
cient knowledge of the function of this organ to connect any definite symp- 
toms with such supra-renal pressure or inflammation. The vicinity of the 
solar plexus and semilunar sympathetic ganglia to the upper anterior 
tract suggests that such digestive symptoms, as have been mentioned 
(p. 393) in connection with perinephritis, would especially occur when the 
upper anterior region was the seat of the abscess. Unfortunately the 
symptomatology of the sympathetic nervous system is at present too little 
understood to aid us much in our present researches. On the right side 
abscess of the upper anterior tract could, if there was considerable swell- 
ing, interfere with the return circulation in the vena cava, and thus 
induce dropsy of both lower extremities. Large swelling about any 
portion of the front of the right kidney might effect this, but the upper 
extremity of the kidney approaches rather nearer the vein than the lower, 
and therefore oedema of the legs would occur with less advance of the 
disease in this location. The right semilunar ganglion would not be 
likely to suffer from pressure until after the vena cava had been involved 
because it lies beneath and to the inner side of the vein. 
I do not think that pressure upon the common bile-duct would readily 
occur in perinephritis of the right side, unless the swelling of the renal 
envelope was very great. If such interference to excretion of bile oc- 
curred, jaundice would be a marked symptom, and would locate the disease 
in the upper tracts of the right kidney. Similarly situated disease of 
great bulk might interfere with pancreatic excretion, causing fatty stools, 
or by making pressure on the vena portas cause ascites. It does not seem 
to me probable that perinephric abscess would often interfere much with 
these structures because they lie near the middle line, and much more 
anterior than the kidney. This organ is placed in the hollow’ formed by 
the ribs and vertebrae, while the semilunar ganglia, the bile and pancreatic 
ducts, and the vena portae lie in front of the vertebral bodies. 
The symptoms liable to occur when the middle tracts are invaded are 
albuminuria, with perhaps tube-casts, due to renal congestion from pres- 
sure on the renal vein ; and suprapubic, scrotal or vulvar pain or anaes- 
thesia on account of compression on the ilio-hypogastric and ilio-inguinal 
nerves. These symptoms are, I believe, less frequent when the abscess 
is in the anterior middle tract than in the posterior middle tract, because 
there is opportunity for the tumefaction to extend forward and relieve 16 
the venous and nervous compression. Moreover, the nerves are too 
far behind to receive much pressure from anterior abscess. Hence if 
albuminuria and scrotal pain were present I should diagnosticate disease 
in the posterior middle tract; while if albuminuria existed without scrotal 
pain, neuralgia or amesthesia, I should suspect anterior middle inflamma- 
tion. Previous albuminuria must necessarily be excluded, to render the 
symptom of value in perinephric localization. 
A higher degree of compression, particularly from posterior middle dis- 
ease, would be liable to compress the pelvis and ureter, but symptoms of 
suppression of urine or uraemia would not be exhibited if the other kidney 
worked effectively. Actual inflammatory involvement of the pelvis or 
ureter would reasonably lead to the exhibition in the urine of pus in very 
moderate quantity. 
Abscess in the anterior middle tract might cause scrotal oedema or even 
varicocele from obstruction to venous return in the spermatic vein. This 
would be more likely on the left side where the spermatic vein comes 
nearer the kidney by reason of emptying into the renal vein. 
Perinephric inflammation about the lower portion of the kidney gives 
rise to an effect which is much more noticeable than any other consecutive 
symptom of perinephritis. This is flexion of the thigh due to spasm of 
the psoas and other flexors of the liip-joint on account of involvement 
of the anterior crural nerve. At the same time there may be anaesthesia 
or neuralgia of varying areas of the inner, anterior, or outer surfaces of the 
thigh from involvement of the sensory fibres of the genito-crural, external 
cutaneous, and anterior crural nerves. Retraction of the testicle will proba- 
bly be present if the genito-crural nerve is implicated, because it supplies the 
cremaster muscle. This lifting of the testis indicates therefore a higher 
location of the abscess than when the hip-flexion exists without this accom- 
paniment. A mere momentary retraction of the testicle which may arise 
from reflex irritation of various kinds is of no significance. Prolonged 
retraction would be the valuable symptom. 
I believe the hip-flexion to be due to nerve compression rather than 
to a myositis of the psoas, because, complete voluntary and passive 
extension is regained after recovery from the abscess, and also, in my 
opinion, after the pressure is relieved even before complete recovery. 
If inflammation of muscle existed I should expect a more or less perma- 
nent contracture. Pain at the knee may occur from pressure on the ob- 
turator nerve and possibly from similar involvement of the anterior crural 
which is also distributed to the knee. As these nerves both arise from 
the 3d and 4th and the branch from the 2d and 3d lumbar nerves, it 
does not matter by which one the pain is transmitted. 
These symptoms I should expect to be developed earlier and more fre- 
quently in inflammatory exudations in the posterior than in the anterior 
lower tract. The reasons are that there is less room for expansive swell- 17 
ing, and that all the nerves lie deeply under the psoas. The genito-crural 
and external cutaneous nerves come to the anterior and lateral surfaces of 
the psoas at distances from the kidney, varying in different subjects. The 
external cutaneous lying laterally is better protected than the genito-crural. 
Hence abscess in the anterior lower tract by extending downwards might 
involve these nerves in some cases when not extensive enough to do so in 
others. Posterior abscess as stated above, is of course much more liable 
to do so, and it can compress the nerves at a higher point, where they are 
still buried in the muscular mass of the psoas which lies beneath and 
to the inner side of the kidney. 
Exudative inflammation at the lower part of the perinephric region may 
press upon the ilio-hypogastric and ilio-inguijial nerves, as in the middle 
tract, but at a lower point in the course of the nerves. In this event, 
however, the scrotal neuralgia and other symptoms due to such compres- 
sion would not be accompanied by albuminuria from obstruction of the 
renal vein. In this instance, again, posterior disease, or at least disease 
at the lower extremity rather than in front of the kidney, would be most 
likely to give these resultant symptoms. 
The duodenum lies behind the peritoneum, and crosses the spinal 
column at about the level of the lower anterior tract. Hence lesions in 
this tract on the right side might, by compressing this portion of intes- 
tine, cause obstruction, persistent vomiting, and rapid emaciation from 
non-assimilation. Abscess of the anterior middle tract could, perhaps, 
cause similar pressure. 
In all cases it must be recollected that the right kidney usually lies 
about three-quarters of an inch lower than the left. 
By burrowing of pus downwards symptoms of perityphlitis may be 
developed secondarily, and cause unilateral oedema from pressure on the 
external iliac vein. Abscess and sinus in the region of Poupart’s liga- 
ment may be symptoms of perinephritis of the lower tracts. Anterior 
lower abscess of the left side is liable to produce constipation from pressure 
upon the descending colon, which, as shown in the cut from one of my dis- 
sections, is attached by the mesocolon over the lower half of the kidney. 
This is not so on the right side, where the ascending colon becomes free 
from the posterior wall just as it touches the inferior extremity of the kidney 
region, or perhaps extends upon and is fastened to only the very lowest 
part of its anterior surface. 
It is barely possible that a large abscess of the right anterior lower tract 
might extend forward to the front of the spine, and compress the chyle 
reservoir, which lies in front of the second lumbar vertebra and to the 
right side and partly behind the aorta. The aorta would render such com- 
plication from the left perinephritis more difficult of consummation. Rapid 
emaciation would be expected as a result of such an unusual and quite 
unlikely complication. 18 
I shall, in concluding this section of my subject, group in tabular form 
the more important deductions from my anatomico-clinical study. 
A Table of the Symptoms of Probable and Possible Value in Localizing 
Perinephritis and Perinephric Abscess. 
All anterior regions Pain, tenderness, swelling, oedema, and pointing in 
front and side of abdomen. 
All -posterior regions—Pain, tenderness, swelling, oedema, and pointing in 
loin. 
Upper tracts—Pleuritic friction, pleural effusion, empyema, expectoration 
of pus; dyspnoea; suprarenal involvement; solar plexus in- 
volvement. (On right side.) Bilateral oedema of legs ; jaun- 
dice ; fatty stools ; persistent vomiting; rapid emaciation ; as- 
cites. 
Middle tracts.—Albuminuria and casts; suprapubic, scrotal, or vulvar 
pain or anaesthesia; suppression of urine ; uraemia ; pus in the 
urine ; oedema of scrotum or varicocele (especially on left side). 
Lower tracts.—Flexion of hip; pain or anaesthesia of front, inside, or 
outside of thigh; retraction of testicle ; pain at knee ; scrotal or 
vulvar pain or anaesthesia, without accompanying albuminuria ; 
unilateral oedema of legs; abscess or sinus near Poupart’s liga- 
ment ; constipation (if left side) ; involvement of chyle receptacle 
(if right side). 
In deciding upon the point of operation, after a diagnosis of the locality 
of the abscess has been made, the surgeon must bear in mind the relation 
of the kidney to the hony landmarks. The upper border of the organ cor- 
responds very nearly with the space between the eleventh and twelfth 
dorsal spines. The lower extremity of the kidney is about on the level of 
the third lumbar spine. The vessels and pelvis of the kidney correspond 
with the level of the first lumbar spine. The right kidney lies a little 
lower than the left. The eleventh rib marks with considerable accuracy 
the upper edge of the kidneys. The right kidney has its top nearly on a 
level with the lower border of that rib, while the left has its upper end 
about on a level with the upper margin of the same rib. The kidney is 
about two inches wide, and lies with its inner border quite close to the 
vertebral bodies. 
Prognosis A few cases of perinephritis recover without going on to 
suppuration. The percentage of such results is not obtainable. Gibney 
gives a good many such instances, of which one was of six months’ dura- 
tion. When suppuration occurs the prognosis is good if early evacuation 
is accomplished spontaneously or by the surgeon’s incision. When the 
pus is allowed to burrow, prolonged suffering, hectic fever, and often death 
are the consequence. A fatal issue is certain under such circumstances, 19 
unless the pus is finally discharged through some opening. Incision, of 
course, greatly hastens recovery. 
Treatment During the early stages, counter-irritation to the loin by 
iodine and blisters may be employed. The frequent application of the hot- 
water douche has apparently been beneficial. Morphia, and similar reme- 
dies, and laxatives will usually be required. 
When resolution does not take place, and there are evidences of a 
deeply seated posterior abscess forming, the proper treatment is early in- 
cision in the loin over the kidney. When the skin and deep fascia have 
been incised, the muscles, which may or may not be softened, can usually 
be torn through with the finger. By boring with the finger to the depth of 
two or three inches the surgeon will probably strike the pus cavity. If 
not, the free opening thus made will allow an early evacution of the pus 
which will soon find its way to the wound. The finger is a better instru- 
ment than the knife, because the tearing apart causes little bleeding, and 
the finger can appreciate the direction of the pus by the friability of the 
muscles. If preferred by the operator, a grooved director may be pushed 
into the tissues, and a pair of dressing forceps slipped along this into the 
softened structures. By separating the blades, and withdrawing the for- 
ceps with the blades apart the surgeon can tear open the abscess without 
much risk of hemorrhage. 
Anterior abscesses may be aspirated or incised from the lateral or ante- 
rior aspect of the abdomen. When small, their treatment will be greatly 
complicated by the relation of the peritoneum and intestines. Poland 
has tabulated,1 chiefly, but not entirely, from Trousseau and Bowditch, 
28 cases of perinephric abscess which he considers primitive; that is, 
not due to pyelitis, calculous nephritis, or like causes. Of these, in 8 
cases no operation was done; in 5, more or less satisfactory attempts 
at operative evacuation were made by puncture with the trocar and canula, 
or by applying caustic potassa; and in 15, free incision was adopted. 
Death took j lace in 6 of the 8 cases left to nature’s efforts, in 1 of the 
second group, and in 1 of the 15 cases treated by incision. 
Bowditch, in 1870, especially insisted upon early incision. The reasons 
for such surgical action are at the present day so patent and so universally 
accepted that it is unnecessary to dwell upon the point. 
After incision, free drainage, antiseptic affusions and poultices are proper. 
1 British and Foreign Medico-Chirurgical Review, 1871, vol. ii. p. 335. THE MEDICAL NEWS. 
A Weekly Journal of 28—82 large double-columned quarto pages, con- 
taining a greater amount of reading matter than any other 
Medical Weekly in America. 
Uniting in itself the best characteristics of the magazine and the newspaper, 
The Medical News is enabled to render a service of exceptional value to the 
profession. As a magazine, it presents articles upon all branches of medical science 
by the ablest teachers and writers of the day. As a newspaper, it employs all the 
most recent and approved methods of modern journalism—the telegraph, reporters 
and a corps of special correspondents, covering all the medical centres of the globe. 
It is thus enabled to present, without loss of time, in each issue the advance of 
knowledge attained in the medical sciences during the previous seven days. The 
Editorials of The News are from the pens of a large and able Editorial Board, 
and are marked by thoughtfulness and scholarship. Numbering upon its exchange 
list the important medical, pharmaceutical and scientific periodicals of both hemi- 
spheres, The News presents each week in condensed form a survey of the medical 
journals of the world. In typographical arrangement everything has been done 
to economize the time and to promote the comfort of its readers, and although 
The News contains more matter than any other weekly medical journal in this 
country, the subscription price remains at the very low sum of Five Dollars 
per annum. 
The American Journal of the Medical Sciences. 
A Quarterly Journal of Medical Science, containing in each number 
over 800 large octavo pages, fully illustrated. 
Founded in 1820, The American Journal now enters upon its sixty-fourth 
consecutive year of faithful and honorable service to the profession. The great 
amount of space devoted to Original Articles enables it in each issue to present a 
large number of elaborate papers, embracing in scope all departments of medical 
science. The Reviews have always been noted for their honesty and discernment, 
and the Quarterly Summary of Improvements and Discoveries, classified under 
appropriate heads, is highly valued as an accurate and convenient record of the 
progress of medical science. The subscription price of The Journal has never 
been raised during its long career; it is still furnished, postpaid, for Five Dol- 
1 ars per annum. 
Together, The American Journal and The Medical News contain the equiv- 
alent of over 4000 large octavo pages, in which duplication of matter is by special 
management rendered impossible. They will be furnished in conjunction at a 
commutation rate of Nine Dollars per annum, in advance. 
The safest mode of remittance is by Bank Draft or Post Office Money Order, 
drawn to the order of the undersigned; where these are not obtainable, remit- 
tances may be made at our risk by forwarding in Begistered Letters, addressed to 
HENRY C. LEA’S SON & CO., 706 & 708 Sansom St., Philadelphia.