The real origin of the articular defect has been the source of much argument. At all times, whatever may have been the opinion as to the exact morbid anatomy of the condition, there has been a strong disposition to blame the shoemaker, or rather the fashion that dictated the arbitrary form the shoe was to assume, as the prime cause of the disease. There is, of course, no question that the mistaken ideal of elegance which finds expression in the demand for tight and pointed boots has been the cause of much misery and deformity, and it appears only natural to assume that the artificial crowding together of the toes might force one of the members to assume a position of retraction, in order to make room for the rest, and the digit so drawn up might after a time become permanently fixed in its abnormal attitude. This view is well expressed by Mr. Ellis,[10] but the study of a number of cases of hammer toe furnishes strong reason for doubting this fatally plausible hypothesis. The deformity may be seen in early infancy, before any rigid foot covering has been adopted; and a precisely analogous condition is known to exist in the fingers, which are not subjected to any artificial restraints. Moreover, in the great majority of the feet affected with hammer toe there is a complete freedom from the deformities which are known to result from overcrowding of the digits, and there is seldom anything in the history of the cases to indicate the past use of improper boots. It has been said that hammer toe is unknown in countries where boots are not worn; but the subject has yet to be studied in those parts of the world on a scale that sanctions generalisation. Moreover, as hammer toe is painful only in consequence of the friction and pressure induced by the foot-covering, its existence would be unlikely to attract much attention in a bootless race. During my own residence of six years in Japan I never met with an example, and my friend Surgeon-General Takaki writes to me that his observations, covering a period of fifteen years, are equally negative; but it must be noted that it is the rising and boot-wearing generation that has been especially brought under our notice, and the conclusions to be drawn from our experience tend as much to contradict the view that boots are an immediate cause of hammer toe, as to support the belief that the Japanese are exempt from the defect. There is little doubt, however, that the use of shoes is to some extent, and in a remote sense, a predisponent to this and to other analogous deformities, for it is certain that a rigid leather foot-covering, even when shaped according to the most scientific principles, must necessarily impede the free action of the toes, and so interfere with the processes of nutrition and development; but I am equally confident that few, if any, of the examples of hammer toe that have come within my own experience could be traced to any special defect in the form of the shoe.