working class whose feet do not present such deformity. She is carrying a child on her arm and walks with ordinary ease. The magazine illustration was not made for the purpose of showing these peculiarities in Chinese feet and foot-wear, yet the writer considered it of interest from this point of view. Why smile at the absurdity of the Chinese lady? How about some women, and men too, outside of China, who encase their "golden lilies" in shoes that are little more than half as wide as Nature indicated they should be and often much too short? What matters it if they do suffer from deformed, flat, weakened and painful feet if, only, they can place them in shoes much too small with toes that vanish into nothingness; and perch them on a fancy, slender, high and insecure heel? Here, too, the binding begins at a very tender age. The difference is not so much in kind as in degree. Fig. 33, a photograph of casts of very troublesome feet, is an extreme example of the deforming and disabling influence of improper foot-wear. It shows marked flat-foot and pronation, shortening of the tendo-Achillis, hallux valgus, bunions, ingrowing nails and hammer-toe, great crowding of all the toes and their deviation from the lines of their respective metatarsals, corns and callosities, and the skin of the soles thrown into folds from extreme compression. Imagine the source of pleasure (!) that these feet were to their owner, who was far more sensitive about the appearance of her foot-covering than about the shape of its contents. Suffering drove her to the physician, whose advice she only partially and reluctantly followed. As already remarked, it is the shoe and not the foot that we admire. Little do we know or care about the weak, deformed and callous foot hidden within the neat-appearing boot. An interesting illustration of the change that may occur in the shape of a young foot from a few months of shoe wearing is shown in Fig. 34, a photograph of impressions of the weight-bearing portions of the soles of a girl, seven years old. An injury to the right ankle prevented the child wearing a shoe on that foot for two months and a half. At the end of that time the impressions here shown were taken. Observe that in the right foot, which had been bare so long, the toe impressions are more widely separated than in the left, which had been wearing an ordinary child's shoe. Also, that the long axis of the right great toe prolonged backward strikes as it should, the center of the heel, while that of the left falls somewhat to the inner side. This is due to the left great toe being displaced toward its neighbor. The width across the ball of the foot is considerably greater in the right than in the left. Measurement determined the difference to be seven millimeters. During the time that the right foot was without a shoe it had a chance to regain the normal form while its fellow was becoming more distorted by what is ordinarily called a good shoe. An example of how the foot may be developed by free use of its muscles is shown in Fig. 35, an illustration from Richard Kearton's book, "With Nature and a Camera." The photograph was taken on the island of St. Kilda, where the natives climb steep cliffs in search of the eggs of birds that build their nests in these elevated places. It represents Mr. Kearton's foot photographed side by side with that of a native corresponding in size and weight to himself. It shows the native's splendid foot and ankle development as compared with his own. Observe the difference in the straightness and separateness of the toes. The shoe is not the only agent active in deforming the foot. The stocking also deserves some attention in this respect. It should never be worn too short or too tight. In Fig. 36, the solid line shows an outline of a naked foot bearing the body-weight, while the dotted line within represents the same foot compressed by a tight, short stocking. Fig. 37, shows the same foot in a stocking originally the same size and shape as the other, but which had been worn and washed a number of times. In the old stocking the compression, while not so great as in the new, is still enough to prove harmful. The fault of wearing stockings too small for the foot is a very comThose constructed as rights and lefts are better than the ones which are interchangeable. They should be large and elastic enough to allow expansion of the foot in walking. Fig. 38, illustrates the average range of expansion. The inner solid lines show outlines of feet in repose, and the outer dotted ones the same feet bearing body-weight. This diagram represents average adult feet, whose elasticity has been impaired by years of ordinary shoe-wearing. In a normal foot the range of expansion is greater. mon one. It is important to understand that an ill-fitting and deforming shoe in not always a direct source of pain. We often hear individuals, who wear shoes too short and narrow, say that their foot-wear must be all right, because it gives rise to no pain. Some of these innocents hardly know what a real comfortable shoe feels like, having no recollection of the time when they last wore one. Fig. 39, represents outlines of feet and their coverings. The solid lines show those of the feet and the dotted ones those of their respective shoes. These are not exceptional but average illustrations, and fairly indicate the pressure to which many human feet are subjected day after day through a lifetime. The feet in time become so used to compression that they cease to be conscious of its presence. The extent to which it is possible to painlessly compress a foot, is shown in Fig. 40. Here the solid lines show the real outlines of two adult feet and the dotted ones show outlines of the same feet while being manually compressed without pain. A child's foot will stand a relatively greater amount of painless compression than that indicated in the diagrams. Nevertheless, foot compression from any source, whether painful or painless, when long continued, results in irreparable damage. Moderate weakness and discomfort is so very common, especially among women, that it may be considered almost the rule, and the opinion is quite prevalent that a certain amount of foot-suffering is normal and to be expected. Fortunately, not every foot abused by improper foot-wear becomes a source of great annoyance and extreme disability. It is usually only when injury or great or uninterrupted strain are added to the weakness, that the foot becomes so disabled as to be considered worthy of the attention of a physician. On this account one more often finds exaggerated cases of weak and flat-feet among bakers, laundresses, grocery clerks, factory workers, and others whose occupations compel them to be on their feet many hours each day. The reason why the severe and rigid form of flat-foot is less common among the leisure class, is that its members are not obliged to constantly use weakened feet, but are privileged to rest whenever they begin to tire or pain. It is, however, in this class one more frequently finds the affections directly due to compression, such as corns, bunions, hallux valgus and hammer-toe. The wearing of improper foot-wear is as much due to ignorance as to vanity. If the laity understood that many serious and cripling affections followed its use, it would, perhaps, lead to a much needed reform. The feet of adults are much less injured by compression than the more plastic ones of children, and it is during childhood that the foundation is laid for future disabling deformity. It is usually difficult to induce adults to dress in any way contrary to prevailing fashion; but most parents are quite susceptible to instruction leading to the welfare of their children. It is especially in this direction that the physician can accomplish much good by judicious counsel. 1705 NORTH CHANNING AV.] Malignant Disease of the Rectum. By A. B. COOKE, A.M., M.D., NASHVILLE, TENNESSEE. PROFESSOR OF ANATOMY AND CLINICAL PROFESSOR OF PROCTOLOGY, MED- MR. R. President AND FELLOWS.-Malignant disease of the rectum is usually described under the good old name of "Cancer." And this name is peculiarly appropriate for the reason that the term cancer, as originally understood, conveys a more or less definite idea of carcinoma. While a few cases of sarcoma of the rectum have from time to time been recorded, it occurs so rarely in this situation that no further specific reference will be made to it. Statistics show that some 3.5 per cent of all cases of cancer are located in the intestinal tract and that more than 80 per cent of these are found in the rectum. This would make the rectum the seat of the disease in approximately 3 per cent of all cases, a rather large proportion for any one organ. The type of the disease is determined by its site. When the anus is attacked, epithelioma; when the movable rectum is invaded, adeno-carcinoma in some one of its several varieties. With reference to etiology, it is worthy of note that study of cancer of the rectum devlopes strong confirmatory Contribution to Symposium, Read before the Tennessee State Medical Society, Memphis, April 10, 1902. evidence of the idea so vigorously opposed by some that the disease is primarily a local one. When secondary deposits occur in the liver they are found to consist of columnar cells from the rectum and gland tissue identical in structure with the follicles of Lieberkuhn normal to the bowel at the site of the original growth. Whatever pathologists may ultimately prove to be the real cause of cancer, local irritation will doubtless continue to be accepted as the most potent factor in determining the site of its development. Considering the function of the rectum. and its anatomic structure it is easy to understand the relatively large proportion of cases encountered here. The symptoms of cancer of the rectum are in no sense distinctive. At first there is merely a sensation of fulness and weight in the pelvis, local irritation, inflammation and ulceration following in the order named and giving rise to their characteristic symptoms. Tenesmus and more or less profuse pathologic discharge become the most prominent symptoms as soon as ulceration takes place. There is nothing of diagnostic value, from a clinical standpoint, about the discharges, unless an unusual proportion of blood be so considered. However, intelligent use of the microscope is capable of rendering great aid in this connection. The amount of pain incident to a rectal cancer depends largely upon the location of the disease. If in the anal canal the pain is generally very severe, if in the movable rectum, real pain may be entirely absent. Certain authorities have described a kind of pain peculiar to malignant disease and diagnostic of it independent of its site. But in the experience of the writer no such instance has been encountered. Obstruction to the passage of feces is less marked in cancer than in benign stricture, due to the tendency of the former to break down easily, thus keeping the lumen open. Total obstruction is comparatively rarely encountered for the same reason, metastatic invason of other organs and exhaustion usually resulting in death before the local growth reaches such proportions. The so-called cancerous cachexia is a late development and not entitled to any great weight in the matter of diagnosis. Indeed, all diseases of the rectum marked by ulceration and irritating discharges quickly result in producing the appearance so denominated, by reason of the associate tenes |