A Case of Sclerodactyle 'with Diffuse 
Scleroderma. 
BY 
H. C. GORDINIER, M. D., 
Of Troy, N. FT- 
FROM 
THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, 
January, 1889. Extracted from the 
American Journal of the Medical Sciences for January, 1889. 
A CASE OF SCLERODACTYLE WITH DIFFUSE SCLERODERMA. 
By H. C. Gordinier, M.D., 
OF TROY, N. Y. 
As I can find no recorded American case of sclerodactyle, I report 
the following case, hoping it may contribute to a better understanding 
of the disease. But thirteen cases are recorded-one English, one 
German, three Scandinavian, and eight French. 
August 16, 1888. Mrs. S. K., set. forty-five years. Mother and father 
both died of phthisis; has a brother living, and in perfect health; 
another brother died several years ago of some cerebral difficulty, the 
nature of which I was unable to learn. Has three step-sisters living 
and in good health. The patient has had seven living children, one 
stillborn, and one miscarriage. Of her seven children, four are now 
living and in excellent health-none of them presenting the slightest 
trace of their mother's disease. Of the three children dead, one died 
from the results of a deep cellulitis of the neck at seventeen months; 
one died when seventeen days old, and one but a few days after birth. 
Of the seven births, four were breech cases. She suffered greatly 
during each confinement, and they were long and tedious. 
Prior to the occurrence of her present illness, which first made its 
appearance in the winter of 1868, she had been in excellent health and 
had never seen a sick day since childhood. Her menstruation first made 
its appearance at the age of eighteen; she has always suffered con- 
siderable pain prior to the onset of the flow, and was usually ill for six 
or seven days, always losing too much blood, Her menstruation has 
continued with perfect regularity until two years ago, save in January 
of 1868, from which time she dates her present illness. Two years ago 
her menstruation appeared very irregularly, coming and going at intervals 
of from three weeks to as many months. Since January, 1888, until 
July 15, 1888, she had not menstruated. July 15th, was unwell, and 
continued so for seven days, losing a great deal of blood. At the date 
of this examination she is ill, losing more blood than ever before. She 
never has had hemorrhage from the nose, stomach, intestines, or 
bladder. 
The disease first made its appearance in January, 1868. About the 
middle of January she went to a dance; while in a condition of profuse 
perspiration she sat exposed to a draught of air, and had a severe chill. 
She was menstruating at the time; this ceased. A doctor was called, 
and gave her a hypodermatic injection of morphia in the left thigh ; in a 
few days was better and able to be about. 2 
GORDINIER, A CASE OF SC LE R O D A CT Y L E. 
In the early part of April she first noticed, in walking, that her legs 
were getting stiff, at the same time pains, neuralgic in character, made 
their appearance in both legs, and ankles and knee-joints. The stiffness 
continued, and became very noticeable on going up or down stairs. 
Soon local feelings of cold appeared. This stiffness and pain became so 
severe that she sent for her doctor, who told her that she was suffering 
from rheumatism, and applied on the outer side of the right leg a large 
blister, the effects of which were very painful, and resulted in an ulcer, 
which did not heal for three months. She was, during that time, able to 
walk only with considerable difficulty. This impediment to locomotion 
was not due to the ulceration, but to the increasing stiffness and pain. 
During the months of July, August, and September she was not able 
to walk and was moved about in her sick-chair; this she attributes to 
the too rapid healing of the ulceration. She began to walk a little in 
October. November 15th, gave birth to her first child ; was unable to 
walk for eighteen months after her confinement. She then walked 
occasionally, but with great difficulty and pain. She has been able to 
walk a little about her house until seven years ago ; since then has never 
walked. 
Eighteen years ago the little finger and thumb of her right hand 
became swollen, very stiff, and cold; this condition continued from bad 
to worse, and the thumb and little finger became the seat of very severe 
pain. Two years after, the stiffness, pain, and swelling made their appear- 
ance for the first time in the thumb and index finger of the left hand, 
soon followed by local feelings of cold ; very gradually the stiffness and 
swelling extended to the index and middle fingers of the right hand. 
The left little finger became affected next in order; the middle and ring 
fingers were the last to become involved with this stiffness and pain. 
She does not know when the infiltration and thickening of the skin first 
began, nor does she remember about the thickening of the skin of the 
face and its swollen condition ; she states that her friends have frequently 
told her that her face was much bloated for several years. 
In the winter of 1880, a large ulcer made its appearance on the dorsum 
of the right hand, occupying its entire surface, superficial and secreting 
a serous-like material, which did not heal for six weeks. The following 
winter an ulcer, having exactly similar characteristics, appeared on the 
dorsal surface of the left hand. This ulcer healed in three weeks. 
Neither ulcers left scars. There has never at any time during the 
existence of this disease been any ulcerations of the fingers, and no 
discharge of fragments of bone or bone dust has occurred. She com- 
plains bitterly of cold fingers, which are always made worse by the use 
of cold water. She dreads the winter very much ; she is always pleased 
with the approach of warm weather, which brings with it marked relief 
to her sufferings of cold and pain. During cold, rainy days in summer 
the cold sensations return, and are immediately attended with severe 
pain. She was able to sew quite well until six years ago ; since then, 
on account of her deformed fingers, can use a needle but very little. 
She can distinguish between very small objects, and, apparently, has no 
sensory disturbances. Plunging her hands in hot water gives consider- 
able relief to the pains and cold sensations; but if, by accident, her 
hands be plunged in cold water, she suffers severe pain and the cold 
sensations remain a long time. There have been no scales or horny 
epidermic growths on the hands. GORDINIER, A CASE OF SCLERODACTYLE. 
3 
Examination.-Patient is short, rather stout, and weighs about 170 
pounds. She is bright and intelligent; there is no mental disturbance, 
no affection of speech, no difficulty in swallowing; has an excellent 
memory. The skin of the face, forehead, neck, arms, forearms, thighs, 
and legs is thickened; that of the face is glossy, of a pinkish hue, and 
can be moved with great difficulty on the underlying tissues-this is espe- 
cially marked with the skin covering the malar processes and that on the 
forehead. One cannot pinch the skin into folds. There are no wrinkles 
to be seen on the face or forehead, and that of the forehead does not 
wrinkle whether she laughs, speaks, opens her mouth, or tries to cough. 
The naso-labial folds are nearly effaced. The eyelids do not appear to 
be thickened and are not cedematous. The patient is able to open and 
close them in a normal manner ; there is no overflow of tears. The ears 
are large and prominent, and look as if made of wax; they are univers- 
ally thickened, which is especially noticeable in the lobes. Slight friction 
of the ears with a bit of cotton produces a pinkish hue. The skin 
covering the nose is very tense and glossy, particularly near its root; 
the aljo nasi are freely movable, and present no atrophic processes or 
ulcerations. The lips are cyanotic and thickened. The movements of 
the lower jaw are quite restricted by the thickening of the skin covering 
the rami and that of the chin and neck, preventing the patient from 
opening her mouth in a normal manner. The tongue is slightly coated, 
about its normal size, and can be protruded a little beyond the teeth. 
The gums are spongy and bleed readily when irritated. A number of 
teeth are missing, and those remaining are very friable. Her hair is 
becoming sparse, is brittle, and quite gray. Along the margins of the 
scalp and just over the eyebrows a scaly seborrhoea-like deposit is seen. 
This thickening and immovability of the skin, and the peculiar wax-like 
appearance of the 'face, with the absence of wrinkles and folds, give a 
remarkable expression. The countenance is changed and the face has 
a fixed immobile condition, as if covered by a mask. 
The skin of the neck and chest is less thickened than that of the face, 
and more easily movable; it has a wax-like color and is glossy. Three 
large transverse folds are to be seen crossing the front of the neck. The 
lateral movements of the head are much restricted, while those of 
flexion and extension can be performed with ease. The patient is 
unable to raise her arms to a right angle with the body; can with 
difficulty touch her nose with her finger-tips, and cannot place her 
hands on her head. These restrictions are not due to any interference 
on the part of the normal action of the shoulder or elbow-joints, but to 
the hidebound condition of the skin covering the shoulders and arms, 
preventing the underlying muscles of these localities from performing 
their physiological functions. There is no ankylosis of the shoulder- 
or elbow-joints. The upper extremities remain in a condition of adduc- 
tion, motions of supination and abduction cannot be performed. The 
skin covering the forearms is less thickened than that covering the arms 
and shoulders, and is a little movable; it cannot, however, be pinched 
into folds. It has a wax-like appearance. The wrist-joints are stiff, 
immovable, and ankylosed. There is a little lateral motion in the wrist- 
joint of the right hand. The skin on the front and back of the joint 
is indurated, tense, and thickened. The thickening of the skin about 
the wrist does not prevent one from finding the pulse, which is a little 
rapid, but of good strength-a number of counts give an average of 4 
GORDINIER, A CASE OF SCLERODACTYLE. 
eighty-five beats per minute. Perspiration has nearly ceased ; a little 
perspiration takes place about the neck and forehead during very warm 
weather. 
There is universal tenderness on deep pressure over all the body save 
the abdomen. This deserves special mention, as the tenderness is not 
confined to those parts most diseased, but to those presenting the least 
sclerodermatous changes. The patient dreads to be pinched or to have 
too firm pressure applied on the surface. The hands look as if made 
of wax, and are quite puffy. On the dorsal surface of the left hand near 
the outer side of the wrist, a small white cicatrix is seen. The skin 
covering the hands is more movable and less thickened than that of 
any part of the body save that of the abdomen and feet; is puffy and wax- 
like. This puffiness is very marked on the dorsal aspect; the skin and 
underlying tissues in this situation are atrophic. The skin covering the 
metacarpo-phalangeal and phalangeal articulations is tense, thickened, 
stiff, and glossy, and not as movable as that of the dorsum. There is an 
entire absence of hairs on the hands, and they are sparse on the forearms. 
The ulcerations which the patient described as having occurred on the 
dorsal surfaces of the hands in the winter of 1880-1881, doubtless 
were large pemphigoid bullie, as there can be found no trace of a cicatrix 
on either hand. As the deformities, distortions, and dislocations of the 
fingers of the right hand are a little in advance of those of the left, it 
will be first described. The skin on the dorsal surface of the hand is 
much less thickened than that of the forearm; has a wax-like color, is 
smooth, puffy, and swollen. The wrist-joint permits of slight lateral 
movements, but extension and flexion are prevented. A small conoidal 
tubercle is seen on the outer side of the hand near the wrist. 
The points of most interest are the peculiar deformities, the apparent 
dislocations, and the atrophic changes of the phalanges. The thumb is 
fore-shortened, the terminal phalanx small, atrophic, and congested; 
the skin on the outer surface of the articulation with the second phalanx 
is thickened and atrophic, so that the terminal phalanx is flexed on the 
second, almost at a right angle. Movements of extension and flexion 
can be easily executed at this joint, while lateral movements are 
restricted. There is no ankylosis at the metacarpo-phalangeal joint, and 
movements of the joint are unimpaired. The skin of the index finger 
appears very puffy, particularly that covering the first phalanx ; this, 
with the atrophic condition of the second and third phalanges, gives the 
fingers a marked spindle shape, which is fore-shortened: the motions of 
the metacarpo-phalangeal joint are free; movements of flexion and 
extension of the first phalanx are limited, but lateral movements are 
unimpaired. The third phalanx presents its normal length and thick- 
ness; the second is about half its natural length and thickness; the 
ungual phalanx is very small, its tip red ; the articular surfaces between 
it and the second phalanx have undergone extensive atrophic changes, 
the phalanx is freely movable, slightly flexed in a lateral position, and 
dislocated laterally. The middle and ring fingers are of equal length 
and not much shortened; the skin covering the first phalanx of each is 
puffy, giving them the spindle form. They are freely movable at all 
the phalangeal articulations, the ungual phalanges of both fingers 
present the same redness as those of other fingers: the second phalanges 
are shortened, and the terminal ones over-extended. The little finger 
is very short, puffy, and flexed at an acute angle, the skin is thickened GOEDINIER, A CASE OF SC LE R O DA CT Y LE . 
5 
on its outer side, the articulations are freely movable, and there is no 
stiffness. The ungual phalanx is about one-third its natural size. The 
nails of the fingers and thumb are small, brittle, and striated. The 
fingers look like wax, except their tips, which are red and congested. 
Left hand. The thumb presents the same deformity as that of the 
right, but in a less degree. The thumb, as a whole, is flexed at a right 
angle at the metacarpo-phalangeal joint; its first phalanx is over- 
extended and laterally flexed. The index finger is more deformed 
than its fellow. The motions of the metacarpo-phalangeal joint are 
free; there appears to be a dislocation of the second phalanx to the 
outer side at its articulation with the first; the second and third 
phalanges are more extended and laterally flexed toward the middle 
Fig. 1. 
Fig. 2. 
finger. The middle and ring fingers have the same appearance as 
those of the opposite side. They are of equal length, are freely movable 
in all directions. The little finger is much deformed, is fore-shortened: 
the second and third phalanges are small and atrophic; the terminal 
phalanges of fingers and thumb are like their fellows-red and con- 6 
GORDINIER, A CASE OF SCLERO DACTYLE. 
gested, and the nails are small and brittle. (Figs. 1 and 2 are from 
photographs of the palmar and dorsal surfaces of the left hand, showing 
deformed fingers and the position of hand.) 
Looking at the hands placed close together, that which is most strik- 
ing is their extreme smallness, due to the atrophic changes in the bones 
and joints. They appear symmetrical in the distribution of deformities 
and the conditions of articulations and general character of the skin. 
On close inspection, one sees that the disease is more advanced in the 
right hand, and that it presents, with few exceptions, the greatest 
deformities. The skin of the palms is not thickened; is of a pinkish 
hue, analogous to that of the ends of the fingers. The hands are 
habitually held in a sort of claw-shape; the fingers are flexed in a pecu- 
liar manner. The normal grooves of the palms are much exaggerated. 
The skin of the feet is not thickened, and is freely movable; there 
are no deformities of the toes; deep pressure on the skin produces 
intense pain. They are constantly cold. The skin covering the upper 
parts of the legs is much thickened. Very limited motion at the knee, 
but a little flexion and extension remaining. Skin of chest a little 
thickened; that of abdomen appears normal and is freely movable. 
Heart and lungs normal; passes normal amount of urine, acid reaction, 
specific gravity 1010, no albumin, no casts. No affection of cranial 
nerves: muscular, thermal, tactile, and pain senses normal. Bladder 
and rectum normal. The tendon reflexes cannot be elicited on account 
of the ankylosed condition of the joints and thickened and hidebound 
condition of the skin. 
Electrical reactions. Chloride of silver combined battery; faradic cur- 
rent; indifferent pole on nape of neck, other over motor point for facial 
nerve, iu front of ear. No response with cylinder fully in: when 
withdrawn one inch, left facial nerve muscles respond with quick 
contraction; right facial nerve muscles respond equally well when 
cylinder is out one and one-half inches. Extensor muscles of forearms 
respond sluggishly when the tube is withdrawn two inches. Muscles of 
ball of thumb and the interossei give quick contractions. 
Galvanic current. Left facial nerve, seventeen cells, K. C. C.: re- 
sponse being prompt of all muscles supplied by the facial. Right facial 
nerve, twenty-five cells, K. C. C.: response more sluggish than that of 
opposite side. Reversal of poles, with same number of cells, produced 
no reaction; but when thirty cells were introduced, left facial nerve 
muscles A. C. C. 
Extensor muscles of forearms, with thirty cells, respond quickly to 
negative closing: positive closing, a slight contraction. There is no 
reaction of degeneration ; a decided quantitative diminution in extensor 
muscles of forearms and those supplied by right facial nerve. Muscles 
of the legs respond in a normal manner. 
As to etiology, very little is known. A very noticeable feature of the 
disease is the fact of its having developed, without an exception, in 
women. Distinct neurotic family histories were traceable in the cases 
of Hallopeau,1 Ball,2 Dufour,3 Rapin,4 and my own. In no case could 
1 Society de Biologie, December, 1872. 2 Societe de Biologie, June, 1871. 
3 Societe de Biologie, October, 1877. 
4 Journal Bulletin de la Societe Medicale, 1875, page 383. GORDINIER, A CASE OF SCLEROD ACT YLE. 
7 
a history of syphilis be elicited. Heredity could be traced in no case. 
Several of the patients had had children, but they never presented traces 
of the disease. 
That which seems to play the most important part in the production 
of the disease is the action of cold. The starting-point of the disease in 
three patients was attributable to the sudden checking of perspiration, 
after exposure to draughts of air. In all cases the patients complained 
bitterly of cold ; very much dreaded the approach of cold, rainy weather. 
When the disease had apparently been stationary during the warm 
summer months, it made rapid progress in winter. In six patients the 
disease first made its appearance in winter. All the patients were 
much worse during the cold season. Dufour's patient was treated by 
Rilliet with cold baths, which, instead of improving her condition, made 
her decidedly worse. Several patients have had recourse to hot baths, 
and especially of plunging their hands in hot water, with decided relief 
to all the symptoms. 
The onset of the disease was characterized, in most cases, after expo- 
sure to the influence of cold, to repeated acute attacks in the hands and 
feet. The fingers and toes become the seat of intense lancinating pain, 
localized especially over the small joints; subjective sensations of 
numbness, tingling, burning, and formications, followed by circulatory 
changes ; the toes becoming violet, very cold, and finally assuming a waxy 
appearance. This condition would last about half an hour, when gradu- 
ally they would recover their normal sensibility and temperature. 
After several of these attacks of pain, tingling, formication, local 
feelings of cold, and alterations in the circulation, in four cases, small 
bullae made their appearance, especially over the phalangeal articula- 
tions and near the roots of nails, which, after a short duration, ruptured, 
leaving small superficial ulcers, which were very difficult to heal and 
often secreted pus freely ; when healed, the skin covering them was often 
hard, indurated, sometimes pigmented, adherent, in most instances, to 
the underlying tissues, and often the seat of yellowish crusts. In three 
cases ulcerations occurred on the elbow-, wrist-, and ankle-joints, and, 
after healing, their places were occupied by yellowish, horny excres- 
cences resembling species of epidermic corns. 
The lesions of the hands are of most interest; they are symmetrically 
distributed in most cases. In most cases the deformities were more 
marked in the right hand. That which is most striking is their apparent 
smallness, which, in most part, is due to the atrophy and fore-shortening 
of the fingers. The skin of the dorsal surface, in most cases, is of a 
waxy color, with a yellowish cast, resembling old wax, is thickened, 
cannot be pinched into folds, and is usually adherent to the underlying 
tissues. In a few cases marked pigmentation was noticed. In three cases 
there was an absence of hairs on the dorsal surface of the hands and fingers, 8 
GORDINIER, A CASE OF SOLE ROD ACT YLE. 
and a scarcity on forearms. Ankylosis at the wrist-joint occurred in three 
patients. In a number of cases yellowish crusts were discovered near 
the wrists, and at times over the phalangeal articulations. The skin of 
the palmar surface has been found normal in regard to thickening and 
movability, but it was most generally of a pink color, rather swollen and 
puffy, and having the palmar groves markedly accentuated. 
The fingers are the parts most compromised. They present several 
deformities. Some are dislocated at their phalangeal articulations, 
being in positions of flexures; others freely movable. The phalanges 
were, in all cases, atrophied, both in length and thickness, produc- 
ing marked'fore-shortening. The skin covering the fingers, in most 
cases, has been described as waxy, thickened, in some cases adherent 
to underlying structures, usually quite puffy, particularly over the first 
phalanx, which, with the atrophic condition of the second and third, and 
the smallness of the nails, give the fingers a spindle form. The distal 
phalanx of the thumb, in three cases, was atrophied, flexed almost at 
a right angle with the second, and partially ankylosed in that position; 
the index, middle, and ring fingers have their terminal phalanges 
flexed, producing a sort of claw-hand ; the little finger, in most cases, 
was markedly deformed, much shortened, its phalanges atrophied to an 
extreme degree, and the terminal one at a right angle with the second. 
The nails, in all cases, have been deformed; they are very small, some- 
times a third their natural length, variously curved and hooked ; friable, 
rough, and deeply striated in their long diameter. 
In six cases the feet were the seat of pain, numbness, formication, local 
changes in the circulation, producing a violet, and later a waxy color. 
In three cases ulcerations and the formation of horny excrescences and 
yellowish crusts appeared similar to those in the hands; in all cases the 
patients complained bitterly of cold feet. In no case have the feet and 
toes become deformed to anything like the extent which occurs in the 
hands. In the cases of Dr. Radcliffe Crocker1 the skin covering the 
dorsal surface of the feet was hard and indurated, but the toes were not 
affected in their movements. In Dufour's patient, after an acute attack 
in the toes such as described, they remained semiflexed, and could not 
be straightened. In three cases ankylosis at the ankle was observed. 
There is no sclerodermatous change in the feet or toes of the patient 
under my observation; the skin is freely movable, and not the least 
thickened, and no deformities of the toes exist. But a few weeks ago 
she suffered an attack of severe pain in the great toes, followed by vas- 
cular changes. During this attack the terminal phalanges of the great 
toes have both been dislocated inward and distinctly flexed, and at present 
no scleroderma exists. The perspiration in a few cases has been absent, 
1 Lancet, July, 1885, page 192. GORDINIER, A CASE OF SCLERODACTYLE. 
9 
and in all cases much diminished. The temperature is not recorded in 
other cases; in my case it has always been 99° F. 
Six cases presented diffuse sclerodermatous changes in the skin covering 
the face, neck, upper part of the chest, upper extremities, and thighs. In 
the cases of Lienville1 and Huchard2 the neck and thighs escaped, and 
in Arnozan's sclerodermatous changes appeared on the back.3 The con- 
dition of the face is quite remarkable: no wrinkles can be seen, and 
emotional changes do not bring them out, thus giving to the patient a 
rather stupid appearance ; face looks waxy and swollen, the skin is 
glossy, thick, and indurated, and but little movable. In a few cases 
the patients, because of this condition of the skin, were unable to open 
their eyelids in a normal manner, and the thickening and hidebound con- 
dition of the skin covering the lower jaw prevented the mouth from being 
opened naturally. In four cases the changes in the skin were confined 
entirely to the hands and fingers, and in the case of Haslund4 they were 
confined to the skin covering the second and third phalanges. 
It is difficult to form an opinion from the observations of but one case 
as to the nature or primary origin of the disease. The number of autop- 
sies and clinical observations are too few to determine with certainty the 
nature of the disease. There has been but one autopsy. The case of 
Hallopeau, after a duration of eleven years, died of phlegmonous ery- 
sipelas. An autopsy was made by Budin and Lagrange, which I copy 
from Senator's paper.5 Several autopsies have been made in cases of 
diffuse scleroderma. In Schiminers's case disease of the peripheral nerves 
was found.6 Westphal found pathological changes in the brain, and in a 
recent case of Eulenberg progressive facial atrophy coexisted with sclero- 
derma. The mode of inception by intense pain, numbness, tingling, 
burning, and formication, with circulatory change, probably dependent 
on vasomotor changes, followed by the formation of blebs and ulcera- 
tions, very stubborn and difficult to heal, and the repetition of the attacks 
before the deformities make their appearance, and their symmetrical 
distribution, the nutritional disturbances in the small joints, the dislo- 
cations, the atrophic changes, marked local changes in the temperature, 
can best be explained by a trophic affection of the nervous system. 
In two cases the changes in the bones and joints were explained by 
the pressure of the sclerodermatous skin. But after a careful study of 
the reported cases I am inclined to think that the trophic changes in the 
bones and joints precede those of the skin. As to the condition of the 
case here reported, I can state positively that there is no sclerodermatous 
1 Societe de Biologie, 1874. 2 L'Union Medicale, No. 93, page 372. 
3 Journal Medicale, Bordeaux, 1881, page 97. 
4 Medical Society, Copenhagen, March, 1886. 
6 Berliner klinische Wochenschrift, August, 1888. 
6 Scleroderma, Ziemssen's Handbook of Skin Diseases. 10 
GORDINIER, A CASE OF SCLERODACTYLE. 
change in the skin covering the feet or toes, and that after a very severe 
attack of pain, followed by coldness and circulatory changes in the great 
toes, they both became dislocated and flexed inward. 
Autopsy. Budin and Lagrange. In certain phalanges the cortical 
substance had disappeared, so that the cancellous tissue appeared to be 
in direct contact with the periosteum, in others the atrophy was less 
marked. Microscopical examinations in other bones, in which the 
process was of an older date, showed scanty, irregular infiltration of 
embryonic cells ; about the vessels and in spots, aggregation of fat 
cells occurred, these again were more numerous in the long diseased 
and more atrophic bones than in those later attacked; the bony 
substance showed quite an irregular framework, with large mesh- 
work, which contained fat and embryonic cells, the latter especially 
heaped up in the borders of the framework or about the vessels, and more 
sparsely in the bones with marked atrophy, more numerous in the neigh- 
borhood of the joints. In the more recently diseased and less atrophied 
bones, the joints showed the same changes as are found in chronic 
arthritis: loss of cartilage, a disappearance of bone through fibrous, 
and in other parts connective tissue. In the spinal cord and nerve- 
trunks of the arms nothing abnormal was found. In the little finger 
of the left hand there was found in two or three places in the nerve- 
sheath an infiltration of embryonic cells. 
Lagrange and Budin agree in regarding the changes as dependent 
upon an irregularly advancing chronic inflammation, which extends 
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