akin to this, while the other may be of about normal size or greatly distended-the seat of pyonephrosis. The kidney is quite adherent and greatly thickened. Not rarely it forms intimate associations with the perirenal fat-that is, it is well-nigh impossible to separate or distinguish them.

Associated with the disease of the kidney substance, the pelvis usually manifests lesions peculiar to itself. As already alluded to, it may constitute the seat of primary infection. It may thus be affected prior to, simultaneously with, or subsequent to, the kidney lesions. It may be the seat of miliary tubercles, tuberculous infiltration, or both. Originally encroached upon by the increase in size of the kidney by the developing tuberculous new formation, as the caseous foci discharge their contents into it, it augments in volume. It usually is covered with dirtygrayish, putty-like or membranous-like formations, under which or between portions of which, tuberculous ulcerations are common. Late in the course of the affection, with extensive destruction of the kidney and free communication between the cavities and the pelvis, the limits of the latter are usually not determinable. The pelvis usually is dilated from obstruction of the ureter, and contains substances similar to those detailed as occurring in the kidney cavities.

The ureter presents lesions the counterpart of those found in the pelvis. On external examination it may appear distended, but upon section its walls are usually found thickened and its lumen decreased.

Its

inner surface is irregularly ulcerated and covered with a dirty-grayish or yellowish, membranous-like formation. This, with the thickening of the submucous coat, leads to constriction or obliteration of the lumen and the conversion of the ureter into a more or less rigid tube. Obstruction of the ureter also may be induced by arrested blood-clots or caseous material, be it masses or shreds. The obstruction leads to distention and thinning of the parts above, and consequent dilatation of the pelvis and renal cavities.

When the destruction of the renal parenchyma is well advanced, and the walls of the cavities have become thinned, perforation not infrequently ensues, leading to the formation of perirenal abscesses. These have also been said to be due to lympathic infection, but this, if it occurs, must be very rare. In general, these abscesses present characteristics similar to those of the renal cavities. They are often made up of irregular, communicating cavities containing material similar to that in the kidney. They extend in all directions, and, though of slow development, may make their way through the diaphragm or into the iliac fossa, or they may even perforate externally.

The bladder is usually contracted, and has thickened walls depending upon hypertrophy of the muscularis and induration of the mucous membrane, which may be tuberculous or not. The mucous membrane may be the seat of an eruption of miliary tubercles or of more extensive tuberculous infiltration or ulceration, particularly at the trigone and fundus, but not uncommonly the tuberculous process terminates at the ureteral orifice of the bladder. It must be mentioned, however, that it has been asserted that the microscope will sometimes reveal tuberculous lesions of the bladder when to the naked eye the viscus appears healthy.

A marked characteristic of this variety of primary tuberculosis of the kidney is the tendency of the other portions of the genito-urinary tract to be implicated in the process-whence the common designation, urogenital tuberculosis. Not rarely both kidneys are found diseased-one, however, usually in a more advanced stage of the disorder than the other. The involvement of the ureter and the bladder already have been referred to. There are often found tuberculous lesions of the testicles, epididymis, vas deferens, or prostate. At times the seminal vesicles alone may be affected. In the female the Fallopian tubes may be the starting-point of a urogenital tuberculosis, but at the same time an uncomplicated urinary tuberculosis may occur. These associations of the renal disease, while not always found, still have important pathologic, clinical, and therapeutic bearings.

(To be continued.)

PRACTICAL REMARKS ON SHOES.1 BY ROYAL WHITMAN, M.D.,

OF NEW YORK.

THE object of the shoe is to cover and to protect the foot, not to deform it or to cause discomfort; therefore the one should correspond to the shape of the other. If the feet are placed side by side, the outline and the imprint of the soles will correspond to the accompanying diagram. The outline demonstrates the actual size and shape of the apposed feet, emphasized by enclosing them in straight lines. Thus, each foot appears to be somewhat triangular, being broad at the front and narrow at the heel. The imprint shows the area of bearing surface, and owing to the fact that but a small portion of the arched part of the foot rests upon the ground, it appears to be markedly twisted inward. The sole of the shoe, if it is to enclose and support the bearing surface, must also appear to be twisted inward in an exaggerated right or left pattern; it will be straight

Read at a meeting of the Harvard Medical Society of New York, May 22, 1897.

to be almost an indispensable preliminary to an intelligent discussion of the relative merits of shoes, and, indeed, somewhat of a revelation to those who have thought of the foot only as it has been subordinated to the arbitrary and conventional standard of the shoemaker. This ideal, or shoemaker's foot, upon which lasts are fashioned is much narrower than the actual foot; the great toe is not a powerful movable member, provided with active muscles, but is small and turns outward so that the forefoot is somewhat pyramidal in form, and turns upward as if to avoid the contact with the ground. This imaginary foot, drawn after the shape of the ordinary last, appears in the third diagram. Upon it the sole of the shoe has been indicated (Fig. 4), to contrast it with the shape of that necessary to include the outline of the normal The actual foot is thus compressed laterally by the shoe until the stretching of the leather during

foot.

Shoemaker's soles.

function is reduced to the smallest limit. Thus, the foot, according to the age at which the reshaping

FIG. 5.

The rocker sole.

process is begun and the constancy of the application, gradually approaches the ideal and fits the shoe.

This remodeling, however, is often accompanied by such discomfort that the individual rebels and wears a shoe with a square toe, which, from the conventional standpoint, is supposed to show a meritorious effort to follow Nature; but the demonstration of

the actual foot makes it evident that it is a properly shaped sole which serves as a support, not the part which projects beyond the foot, that is of importance. If the shoe with the square toe is wider and straighter on the inner side than another with a pointed tip, it is in so far an improvement; but, as a matter of fact, one of the worst types of shoe provided for children, in shape very like the oldfashioned coffin lid, owes its popularity to the square The same comment may be made on the socalled "common-sense shoe," which is well named,

toe.

FIG. 6.

in gait and attitude; it compresses the toes, and is directly responsible for corns, bunions, ingrown toenails, and deformities, and indirectly it causes or aggravates nearly every weakness to which the foot is liable. This assertion does not need the support of argument, since in some degree it has been proved by the personal experience of every shoe-wearer.

The shape of the proper shoe corresponding to the undistorted foot has already been demonstrated. The sole should be thick enough for protection, but not so rigid as to limit normal motion; it should follow the imprint of the foot, projecting somewhat beyond the outline of the toes; it should be flat, and the upper leather should be capacious-in other

FIG. 7.

Skiagram of a foot modeled to fit the shoe.

since it may be assumed that a properly shaped shoe is an evidence of uncommon sense.

The object of the heel is to make walking easier by inclining the body somewhat forward. The high narrow heel is an insecure support, and aids deformity by throwing more strain upon the forefoot and pushing it forward into the narrowest part of the shoe. The heel is of course unnecessary in childhood, and should not be worn, since it limits the necessity for, and therefore the use of, the normal range of motion at the ankle-joint. The ordinary shoe, by limiting the functional use of the foot, favors awkwardness

The flat sole.

words, the front of the shoe should be designed to allow and to encourage functional activity, the slight adduction of the great toe and the alternate expansion and contraction of its fellows, as may be observed in the barefoot child. Thus the arch may be assisted, and the weight and strain properly distributed. The heel should be broad and low.

The shape of the shoe is regulated by fashion and ancient custom, although it has been spoken of as the shoemaker's ideal for convenience of description. Shoes are made to sell, and if better shoes were desired they would be produced; but long familiarity with discomfort and deformity has distorted the public taste so that deformity is not only not recognized as such, but when concealed in the shoe it is illustrated as a type of beauty.

Reform in shoes will be a gradual process, and it will come through the conversion of the individual. Conversion is not enough, however; one must not only be convinced that his shoes are bad, but he must be informed where better ones may be obtained. Thus practical reform must begin with education of a shoemaker, and the displacing of some of his inherited or accumulated lasts by those of a better model. This is not an easy task, but my experience proves it to be possible. It has been said, with truth, that physicians are not consulted on the subject of shoes, but, on the other hand, it must be remembered that the foot has long been abandoned to the shoemaker and corn-doctor, and it is only during recent years that any particular or general interest in its diseases or disabilities has been manifested. Even

at the present time it may be doubted if the shoes worn by physicians themselves will show great advance or improvement over those worn by others less familiar with the anatomic construction of the foot. It would seem, however, that such knowledge should make one better able to appreciate the bad effects of compression and deformity and the more willing, therefore, to set an example to others. This is of importance, because every wearer of a better shoe becomes a reformer involuntarily, if only to justify the shape of the shoe he wears; and the physician, in addition, will find many opportunities to select or to suggest the selection of the better from the worse type of shoes which are provided, even if no radical change is desired or attempted. In such selection, the breadth of the sole, the angle of outward deviation of the soles when the two are placed side by side, and the capacity of the upper-leather must be the determining points. As a rule, what is known as the wide Waukenphast pattern for men and children will be found the best, and even the shoes made for women will permit of reasonable choice. Nearly all adult feet are more or less deformed, and therefore better adapted to an improved than to a perfect shoe. Moreover, it is by the more extended use of the better type of shoe, such as is now made by the more intelligent shoemakers, that a general advance may be anticipated.

It is encouraging to note that the foot, once allowed a certain freedom, resents most effectively a return to restriction and compression, and that the deformed foot shows a marked tendency toward improvement when a shoe is provided which allows the long disused muscles to exercise their function-a fact which is of great importance in the treatment of actual disability.

The most effective work for reform can be accomplished by providing better shoes for children; and especially since one encounters inertia, rather than active resistance, most parents have suffered sufficiently to be willing to permit the child to wear a proper shoe, even though it may offend their conception of beauty and symmetry. The inspection of children's feet shows that atrophy and compression begin at a very early age, and if protection might be assured during the period of rapid growth, serious distortion might be prevented.

Although of far less importance than the shoes, the socks worn by children deserve special mention as a factor in deformity, since they are often too short and too narrow and are made of unyielding material, so that the proper action of the toes is restrained. Theoretically, the socks, like the shoes, should be rights and lefts, but if they are sufficiently large and of a texture to expand readily to the shape

of the foot, but little trouble need be anticipated on this score.

In conclusion, it is again urged that there can be but one standard upon which the shoe can be judged, and this standard is the undistorted foot; therefore, the sole of the shoe, whether it be oblong or triangular, whether the tips be round or square, or whatever may be the minor variations, must be long enough and broad enough to support the foot, and the upper-leather must be capacious enough to contain it without compression of the toes. If one is interested in reform, he must find a shoemaker willing to make proper shoes for perfect feet, or, having ascertained the best type of the ready-made shoe, this only should be recommended. It may be assumed that manufacturers of the cheaper shoes are sensitive to changes in demand, and that with little effort on the part of physicians and others an improved, or even proper, shoe might be found on sale side by side with that of the conventional model, and for the same price.

Reform must be made simple, it must be inexpensive and, in fact, involuntary to be effective. Gradually, however, it may be hoped that the shape of the natural foot will displace that of the conventional model, so that deformity may be recognized; then the fact that the foot must give distinction to the shoe, and not the shoe to the foot, will be established.

THE USE OF IODOFORM IN SUPPURATIVE CERVICAL ADENITIS, SINUSES, ETC., WITH A REPORT OF SIX CASES.1

BY D. ERNEST WALKER, M.D.,

OF NEW YORK.

DURING the summer of 1896 a number of children came under my care who were suffering from glandular affections of the neck arising from a poor general condition, which were accompanied in a few cases by a tuberculous diathesis. With few exceptions all of these cases had reached the suppurative stage, and in most of them satisfactory excision of the glands was out of the question.

Up to the middle of June I had treated the suppurative cases by free incision, afterward washing out the cavities with antiseptic solutions, usually carbolic acid or bichlorid of mercury, and in some cases peroxid of hydrogen. Then, if drainage was considered necessary, iodoform gauze generally was used. The abscess cavities were not curetted, but were carefully swabbed out with cotton wet in the antiseptic solution. The trouble experienced from the refilling of cavities which were not drained, and the redressing of those which were, as well as the slowness with 1 Read before the Society of the Alumni of the City (Charity) Hospital, April 7, 1897.

which some of them healed, led me to cast about for some method which would prove less troublesome. I therefore determined to try a ten-per-cent. iodoform ointment made up with vaselin, as used in suppurative buboes, concerning which Dr. Otis' has written so favorably. I confess that at the time I felt somewhat dubious as to the safety of employing a ten-percent. iodoform ointment in the case of a child, but decided to use it as no ill effects had been reported in any similar case. I was also influenced by the fact that the abscess in the first case in which I decided to employ the remedy was a small one.

CASE I. This was a female child, fourteen months of age, with a good family history, but in poor general condition. The child was anemic, but not thin, and her flesh was flabby. There was an acute adenitis on the right side of the neck accompanied by heat, redness, and pain. There was also a swelling on the left side of the neck. Both enlargements were among the submaxillary group of glands, and that on the right side was softened at the apex. That on the left side gave no signs of suppuration.

After first washing the neck with soap and water, and then with bichlorid of mercury solution, I to 4000, I made a small incision into the apex of the abscess on the right side of the neck, evacuted about half an ounce of pus, and carefully washed out the cavity with the 1-to-4000 bichlorid solution. Then, with a glass syringe previously warmed in hot water, I filled the cavity to slight distension with a ten-per-cent. iodoform ointment, and placed immediately over the opening a cotton compress wet in cold bichlorid solution.

Over all was placed a simple dressing of borated cotton. After two days I refilled the cavity, from which there was only a slight serous discharge, and five days later the abscess was completely cured. On the fifth day I opened the abscess on the left side, which in the meantime had become inflamed and painful. It contained about one dram of pus, and required but one treatment, healing completely in four days.

CASE II. was that of a female child, five years old, with a tuberculous adenitis, who was brought to my office by a professional friend to whom I had spoken of the previous case. One gland among a mass of others on the right side of the neck was red and soft at the apex, but there was no heat or pain. I pursued the same method as in Case I. evacuating a dram or two of curdy pus, washing out afterward, and filling the cavity as before. The cavity closed completely in five days, after being refilled once. other gland among the mastoid group, which softened a few days later, was treated in the same way and speedily healed without being refilled.

An

CASE III. was that of a middle-aged man whom I saw in consultation with Dr. Holmes. He had an acute adenitis affecting the deep cervical glands. There was a large swelling on the left side of the neck which displaced the pomum Adami far to the right. There was some edema, but no perceptible

Amer. Jour. of the Med. Sciences, May, 1893.

fluctuation.

A slight softening could be detected at the anterior border of the sternocleidomastoid muscle at the side of the larynx. The attack had been ushered in by a chill and severe pain.

When seen there was marked heat and redness, but not much pain. The patient's temperature was slightly elevated, and his general condition was much below par. Immediate operation was advised, and under ether I made an incision through the skin and fascia. Deep in the region of the carotid an ounce or more of pus was found. The cavity was treated in the same manner as in the previous cases, and it closed completely in six days. It was refilled once.

CASE IV. An adult female, a patient of Dr. Holmes, while convalescing from typhoid fever developed a large abscess in the gluteal region, which, owing to her prostrated condition, was not noticed by the nurse until it was on the point of bursting. bursting. It opened spontaneously before the doctor had an opportunity to incise it. The cavity extended among the gluteal muscles to a depth of about four inches. After thorough disinfection it was filled with ten-per-cent. iodoform ointment, and after this was repeated twice cure was complete.

CASE V. was one of mastitis, in a woman about twenty-five years old. An abscess containing about half an ounce of pus had pointed near the right nipple. Results had been so satisfactory in other abscess cases that the iodoform treatment was tried in this one with complete success after one refilling.

I previously had tried to induce a friend to adopt. this procedure in a case of mastitis which I saw with him, but as he feared absorption and poisoning, the abscess was opened freely and drained by means of gauze. Recovery was very slow.

CASE VI. was that of a middle-aged man whom I saw with Dr. Mowry. It was a severe case of cellulitis following a wound in the calf of the leg inflicted by the teeth and claws of a cat. There was so much destruction of cutaneous tissue and so many sinuses to be laid open that when the inflammation had somewhat subsided we determined to try the iodoform ointment treatment in two large sinuses running upward beneath the skin toward the popliteal space. These were so extensive that a five-per-cent. ointment was used. The smaller sinuses closed after two treatments, but in the others there seemed to be no improvement except in the amount of the discharge. After a few trials, therefore, this treatment was discontinued and the cavity packed as before with iodoform gauze. After a few more days, with no perceptible improvement, a large slough was drawn out from the cavity, which was again filled with the ointment, with most happy results. The cavity easily held an ounce and was not refilled afterward.