[Extracted from the American Journal of the Medical Sciences for April, 1875.] 
A L ARTUR OP A THIES. 
S. WEIR MITCHELL, M.D., 
MEMBER OF THE NATIONAL ACADEMY OF SCIENCES. 
It has been my good fortune within the last two years to meet with a 
number of cases of disease of the joints of the legs, associated in each 
instance with atrophic states of limited groups of muscles, and offering 
more or less distinct clinical evidence of being due to spinal disease. I 
shall have occasion, as I proceed, to show how these cases differ from any 
as yet described, both in their early symptoms, and in their more favourable 
prognosis, but I shall perhaps make clearer my meaning, if first I call 
attention, however briefly, to the history of spinal and neural arthro- 
pathies, a subject which owes its best study to American and French 
students. The history of spinal arthropathies is well told by Charcot, in 
his Legons stir les Maladies du Systeme Nerveux, Paris, 1872-73, p. 100 
et seq. This author distinguishes joint lesions of spinal origin as of two 
varieties. Those which are acute or subacute and are accompanied with 
redness, swelling, and sometimes with more or less violent pain. The 
second class he describes as chronic, of slow growth, and, as I shall point 
out, as being remarkably different from the first-named disorders. 
The history of this subject is somewhat interesting, and the more so, 
because to an American physician belongs the long-forgotten credit of 
the first discovery that "an obvious spinal cause may produce a rheuma- 
tism characterized by heat, pain, redness, and tumefaction." The quota- 
tion is taken from the second paper on rheumatism by my father, the late 
Dr. John K. Mitchell. In his first essay he described cases of Pott's 
disease, in which, below the diseased region, there were acute inflammations 
of the joints, which proved amenable to treatment directed to the point 
of spinal lesion.1 M. Charcot, op. cit., p. 100-101, in acknowledging the 
first mention of these facts, adds, correctly, that this cause of arthropathies 
is rare, and, apparently ignorant of Dr. Mitchell's second paper,2 says that 
traumatic lesions of the cord are more often the parent of joint disorders, 
and refers to Gull3 for instances of spinal commotion as competent to occa- 
sion a like result. Until in my work on injuries to nerves I recalled atten- 
tion to the true author of this clinical discovery, Gull has usually had 
1 Am. Journ. Med. Sci., 1831, p. 55. 2 Am. Journ. Med. Sei., 1833, p. 360. 
* Guy's Hosp. Repts., 3d series, t. iv. 
1 2 
credit for being the first original observer of these interesting facts, while 
actually the credit is due to the American author. In his second paper 
Dr. Mitchell describes the very curious case of Dr. Parker of Elkton, 
Maryland, in Oct. 1831. This gentleman, who had previously had rheuma- 
tism, was thrown from his carriage, and, falling on his back, was instantly 
paralyzed slightly in his arms, but totally in his lower limbs. The next 
day he had swelling, pain, redness, and heat in the joints of the hands and 
wrists. These symptoms were thereafter aggravated by pressure upon the 
seat of injury in the spine, but relieved by the application of certain reme- 
dies to the spine. They shifted their place from joint to joint in the upper 
limbs, but did not affect the legs. 
In 1846, Dr. Scott Alison1 described very clearly the arthropathies 
which occur in hemiplegia, but incorrectly ascribed them to the lithic 
diathesis under which he presumed his patients to be suffering, and to 
which he conceived all such cases must be due. Since then, Brown-Se- 
quard, Charcot, and the author, as well as some others, have recalled atten- 
tion to hemiplegic arthropathies. Like forms of joint disease have been 
seen in myelitis, and as results of spinal tumours, while in locomotor 
ataxia, Charcot has delineated with great fidelity a more chronic but not 
less troublesome form of joint disease. 
According to Charcot, similar lesions have been seen in progressive 
muscular atrophy by Patruban, Remak, and Rosenthal, but I have been 
unable to procure the papers referred to. Finally in 1864, I described, 
in conjunction with Drs. Morehouse and Keen, the joint diseases caused 
by injuries to nerve trunks, and again and again since I have illustrated 
anew this clinical sequence, by numerous reports of cases of manifold 
forms of nerve injury. 
The pathological mechanism of the various neural arthropathies is clear 
only up to a certain point, beyond which all is as yet obscure. It has 
been made most probable, that all the spinal arthropathies are due to disease 
of the gray matter of the anterior cornua of the cord. It has been shown 
that this disease of the gray matter is not caused by the inertia to which 
some forms of spinal disease condemn the patient, and that neither 
in these cases are the peripheral nerves at fault. It has also been sus- 
pected that the cerebral arthropathies are caused by a descending sclero- 
sis finally involving the anterior tracts of gray matter in the cord, but as 
to this I have a reasonable doubt, owing to the very early date at which 
I have sometimes seen joint lesions follow a cerebral hemorrhage, and to 
the suddenness of production, and the great generalization of the joint 
lesion in some of the same class of cases. It has been remarked that the 
joints swell from fifteen days to three months after an apoplectic attack, 
coincidently with the coming on of the "late rigidity," which we now 
1 Lancet, 1846, vol. i. 227. 3 
commonly ascribe to descending sclerosis. I have, however, again and 
again seen the joint lesions come on earlier, and without any muscular 
rigidity, and I have also seen them get entirely and rapidly well, which 
does not look as if they could in these cases have been due to sclerosis. 
Thus in one case, they came on the day after an attack of left hemiplegia, 
in another on the third day. 
The local peculiarities of most of the spinal and cerebral arthropathies 
are not such as enable the most acute clinical observer to distinguish them 
from some of the ordinary types of rheumatism, a fact which certain 
authors have frankly admitted. The general clinical characters, says 
Charcot, which differentiate them from common rheumatism of joints, are 
their limitation to the joints of the members afflicted with palsy, their 
relation in time to hemiplegia, the coexistence of other trophic troubles ; 
but, if we begin by suspecting that some at least of our general rheuma- 
tisms may be of spinal birth, these would be only points in our favour, and 
the cases of Pott's disease in which remote joint lesions follow it, without 
palsies, would enable us to believe that such a spinal condition from disease 
might sometimes exist as would give rise to rheumatic joints without the 
concurrent existence of other troubles more palpably of neural origin. 
Moreover, it has occurred to me twice, to see cases of chronic rheumatism 
following acute rheumatism where an apoplectic attack produced a few 
days later an enormous exaggeration of the joint disease on the palsied 
side, so that there is something in the status of a palsied limb which 
favours the increase of an already present rheumatism. 
Yet, however we may differ as to whether rheumatic fever be ever a 
spinal disease, all pathologists now admit the existence of joint disease 
distinctly due to neural lesions, but as to the mechanism of the production 
of these arthropathies, we are still at fault. Our discovery of arthro- 
pathies caused by injury of nerve trunks, seemed to promise to make the 
research more simple, but as yet it has done little to aid us. It has been 
made clear, however, that in these, as probably in central lesions, they are 
due rather to irritative states than to absolute defects of power. It has 
been shown that they are caused neither by vascular palsies nor by vasal 
spasm, nor yet by inertia, which is, as we know, competent to cause, in limbs 
long at rest on splints, certain chronic forms of joint disease. I have 
certainly seen neuro-traumatic joint disease break out suddenly and with 
terrible severity within three days of a nerve lesion, which but slightly 
affected either motion or feeling, and which certainly gave rise to no atro- 
phies, so that it also seems unfair to attribute them to defects of nutri- 
tion in this sense or in this direction. 
I have elsewhere pointed out how curiously even very slight lesions of 
nerves affect the cutaneous secretions, and it seems fair to infer that dis- 
turbances in the chemical balances of the deeper tissues may likewise arise 
from as slight neural causes. How far these may also come from central 4 
disease, and how competent in either case they may be to trouble the life 
of the tissues and occasion local inflammations, we can hardly yet deter- 
mine. It is but an hypothesis, yet of some value as giving a fresh direc- 
tion to research. It is indeed hardly possible to refrain from speculation 
upon a subject at once so open and so interesting. 
I have seen but one case of entire annihilation of nerve influence in a 
limb, and in this all the nerves were cut save the fibres which pass with 
the vessels. No notable joint lesions followed the section. The'sections of 
single nerves never altogether insulate neurally a part even of a limb or 
lesser member,1 but it is commonly the partial sections of one nerve which 
cause joint disease, and then arises this curious question : Do they act 
directly along the injured peripherally distributed fibres and thus affect 
the joint, or does the local irritation influence the centre, and through it 
and the still entire nerve threads act upon the joint to disorder its nutri- 
tive life? I incline to this latter opinion, which is favoured by various 
reasons, and especially by some of the cases I have elsewhere reported. 
But if this view be taken and we come to conceive of a state of the centres 
in which there were disturbance from without competent to put them in 
a state to cause joint lesions, we are readily made able to add another 
step in belief, and conceive that sometimes these centres may without peri- 
pheral irritations be thrown into such a state as to occasion these lesions. 
Hitherto, in all of the reported cases of neural arthropathy, there has 
been a passive central or peripheral nerve lesion, and usually there have 
been also precedent symptoms not related to the joints, such as atrophy, 
paralysis, anaesthesia, or hypersesthesia. In three of the four histories 
which I shall here relate, the joint lesion came first, existed alone for a 
time, and was followed by other nutritive, sensory, and motor conditions 
of the limbs, which revealed the spinal column as the organ upon which 
the whole chain of phenomena depended. Surely this is a fact of great 
pathological significance, since it is open to suspect that if the spinal 
lesion had been checked at a certain point we might have had only the 
joint disease, or such slight derangements in the way of numbness or lack 
of power as might readily escape notice, or as often are seen by acute ob- 
servers in rheumatisms suspected by no one to be of neural birth. One 
possible fallacy may exist to mar this view of the pathogenesis of some 
arthropathies, and to it I shall by and by refer. 
Case I.-Mr. B., of E. Pennsylvania, consulted me last year in the 
autumn, on account of a painful affection of the right knee-joint. Mr. B. 
was a bank officer, jet. 48, of slight figure, free from previous disease, and 
of untainted descent. In the spring of 1873 he was subject to severe 
mental and moral strain, and for some weeks to unusual exertion a-foot. 
In June he had slight pain in the dorso-lumbar spine, which was eased 
by rest. The accompanying sense of lassitude left him after a short 
1 Section of a nerve always leaves the joint in relation with other undestroyed 
branches. 5 
summer holiday, but early iu September he began to have pain and swell- 
ing and stiffness in the right knee, and at length was forced to remain at 
rest, the knee having been put in a splint. Despite pretty active treat- 
ment it grew worse, and he was led to consult me in November. 
At this time the leg presented nothing abnormal save in the joint. 
There was no wasting, no loss of feeling or of electrical reactions. I 
advised absolute rest, pressure by sponges and bandage, tonics, and mode- 
rate doses of iodide of potassium. The joint was hot and largely swollen, 
the patella lifted by effusion, and the pain severe especially at night. He 
came back to the city within a month. At this time there was pain and 
slight tenderness on the right of the eighth and down to the twelfth dorsal 
vertebra inclusive, an aching sense of distress over which ice caused a feeling 
of burning. The joint was in all respects better, but still swollen slightly, 
red, and painful and tender. The thigh and leg presented a curious 
change. The extensor group in the thigh was wasted at least one-half, 
the peroneal and gastrocnemial groups were similarly altered, but to a 
less degree. All of these muscles were much enfeebled, and responded 
only to galvanic currents of at least thirty cells, and best to ascending 
currents. The sensibility of the skin of the leg below the knee was much 
impaired, that above the knee but slightly lessened. 
I was amazed to find so remarkable a change in so short a time, and was 
fortunate in having made previously so complete an examination as to feel 
sure that when first I saw the case the joint lesion stood alone. 
For a few days I enjoined rest, with cut cups thrice to the spine. The 
local relief was great, and although no other treatment was then employed, 
a change for the better was seen at once in the joint. After a time I began 
to treat the knee with powerful galvanic currents, and the muscles with 
reversed galvanic currents. The most rapid improvement followed, and 
after thirty sittings I found that I got ready responses by induced currents 
which were thenceforward used every day. The splints were early laid 
aside, slight movement permitted, and when only some feebleness of gait 
remained, I employed hypodermic injections of strychnia. 
After three months Mr. B. went home well. He has since had a short 
relapse, with a display of all the same symptoms in a lesser degree, but 
the same treatment readily overcame them, and a course of cod-liver oil 
and iron, with some changes in his ways of work, has sufficed to preserve 
him in health up to this date. 
Case II.-My second case was a woman, tet. 32, from Wilmington. She 
was at the head of a busy millinery business, and had been in good health, 
and free from pain. In the spring of 1873 she began to have pain in the 
left knee-joint, and after suffering some months, gradually grew more and 
more feeble as to the use of the left leg. In the autumn she applied to me, 
and was then in a pitiful state of pain and lameness. The joint was 
enormously swollen, and very painful, as well as most curiously tender. 
The temperature was two degrees above that of the right knee, and the 
patella could be rocked on the distended joint. To my surprise, the whole 
anterior group of extensors of the leg was wasted at least one-half, and 
could not be stirred by the will or by any form of current, galvanic or 
induced, nor yet through the nerve trunks. 
The sensibility was, liowever, unimpaired. The back was free of tender 
spots, the general health fair, but not vigorous, and there was no func- 
tional disturbance of stomach, kidney, or generative organs. 
1 treated this case as I had done the other, by galvanism until induction 6 
currents acted, and thenceforward by these latter. The general treatment 
consisted in the use of tonics and full doses of strychnia. The gain was 
sudden and steady, so that I was able, after a few weeks, to leave the case 
in the hands of my friend Dr. John K. Kane, of Wilmington, under whose 
charge she continued to improve, so as within a few months to be entirely 
well. 
It is, of course, possible that both of these cases may have been joint 
troubles originating without neural cause, and producing by reflected irrita- 
tions muscular losses; or more directly giving rise to an ascending neuri- 
tis competent in time to occasion like results. The nerve tracks, how- 
ever, were searched again and again in both cases for tenderness, and 
always in vain, while the spinal symptoms of the first case seem to have 
been distinct, so that, on the whole, I reached the conclusion that in both 
there was a limited spinal lesion, and if so in both (and here is their pecu- 
liarity), the joint disorder came first, and for a time stood alone.1 The next 
case as to the spinal birth of which no shadow of doubt can exist, enables 
us to feel far more sure that the two cases first given had also this origin. 
It has also this added value, that it was seen and studied by others besides 
myself, none of whom had finally any other view. 
Case III.-The subject of the following most remarkable history is the 
wife of a physician of distinction in a neighbouring city-a woman of 
unusual energy and intelligence, and previously in good health. 
On April 18, 1870, she first felt a slight sense of lameness in the left 
knee. It caused annoyance in going up or down stairs, in sitting or 
kneeling, far more than in walking. On the 23d an examination revealed 
the presence of too much fluid in the bursa, and on the 24th the joint was 
distinctly swollen, and there were slight pains at times down the inside of 
the leg. The knee had gained in one day three-fourths of an inch in girth. 
So great was the tension and pain, that on the 25th absolute rest was 
ordered, and leeches were applied. The bleeding continued too long, and 
seemed to cause unusual feebleness, but on the 26th the inflammation was 
much lessened. Stimulants were used internally, as she seemed singularly 
weak, and wet cold was applied locally. A day or two later dry cold was 
used, and the knee was found to be easy if at rest, but very painful when 
stirred or even handled. 
On May 9th for the first time in trying to move the leg, which by 
this was much more free of pain, Mrs. B. noticed a want of power to lift 
the limb, or to change its place from side to side. The extensors, abduc- 
tors, and adductors were enfeebled. 
At this time the leg was put on a gutta percha splint, and kept on it 
two weeks with compression to the knee by sponges and bandages, while 
locally iodine was used. 
On June 1st Dr. J. H. Brinton asked me to visit Mrs. B. in consulta- 
tion. At this time there was some pain in the lumbar spine-not a very 
definitely fixed pain-and there were slight twitches in the thigh muscles 
above mentioned, and also in the peroneal group-this symptom being 
1 The very remarkable wasting of muscles in some joint diseases, as of the hip, 
seems to be due to reflected irritations and not to mere inertia, but these wasted 
muscles usually react under electric currents as well as their healthy fellows. 7 
worse at night and very disturbing to the patient-as they sometimes 
moved the patella so as to give pain. 
On April 24th the knee measured 14| inches ; and during June it con- 
tinued to be 13 inches. The other measurements will, by and by, be men- 
tioned ; they showed at this time remarkable atrophy of the whole limb, 
but chiefly of the anterior groups of muscles, and there was entire loss of 
power to lift the leg or even to stir the extensors, or to move the part later- 
ally ; yet the joint was vastly better, and indeed quite free from pain, a 
slight roughness being present when it was bent. The gain took place 
under use of cod-liver oil, iron, shampooing, and induction currents, 
which at this time failed to stir the disordered muscles. The temperature 
of the limb had fallen ever since the loss of power began, but, with the 
improvement alluded to, the limb throughout became warmer. 
July 1. The foot could be rested on the floor with the knee in half 
flexion, and July 15th could be voluntarily raised from the floor a little, 
while extended. 
17/A. Mrs. B. was carried out of town, and finally spent the summer at 
the sea-side, continuing her treatment with daily sea-baths. 
During July she walked on crutches, and on August 25th was able 
without crutches to walk a few steps, though not without limping and 
pain in the knee. Meanwhile the gain as to temperature, power, and nu- 
trition continued, and the sensibility, never wholly lost, became decisively 
better. 
Sept 5. I saw her on her return. She could now walk about one- 
fourth of a mile on crutches. 
The measurements were as follows:- 
Over patella. 
3 inches above 8 inches above 
patella. patella. 
4 inches below 
patella. 
8 inches below 
patella. 
June 3, 1870. 13 
13 16 
101 
10| 
Sept. 16, 1870. 13J 
14| 17| 
111 
11 
June 3, 1870. Ankle, 63 
. Sept. 16, 1870. Ankle, 
During the autumn the improvement went on, and in Nov. Mrs. B. 
could walk a few yards without aid, but both in the winter and through 
the last summer it was curious to see how all of the symptoms fluctuated 
almost from day to day. 
Early in the winter the other knee began to suffer, and precisely the 
same set of symptoms were seen in the right knee and leg, save that the 
loss of sensation was not so considerable. I had now, of course, no 
longer any remainder of doubt as to the spinal origin of this most in- 
teresting case. 
With varying fortunes Mrs. B. passed through the winter, the joints 
becoming worse at times and again better, but every new onset of arthritic 
trouble being followed or accompanied by increase of atrophy, loss of 
power and sensation, and the limbs being liable to notable alterations in 
temperature. 
June 1, 1871. Mrs. B. saw Dr. Brown-Sequard, to whom I wrote 
an account of her case. Under his advice she took iodide of ammonia 
and strychnia in increasing doses, and with these aids and steady sea- 
bathing became vastly better, and in the fall could walk a mile without 
aid. The limbs now showed a new increase in size and firmness, sensa- 
tion was almost perfect, and the joints free of pain. The winter brought, 
as before, some return of trouble, but not to the same extent as in the 
last winter. 8 
April 1, 1872. Dr. Brown-Sequard met me in consultation, when, ex- 
cept the use daily of ice rubbing for the knees, no change was made. 
The summer of 1872 was spent at Cape May, with the usual good ef- 
fects. In Oct. Mrs. B. was able to walk about in-doors and out much as 
other women, all of her untoward symptoms having disappeared. In 
1873 she went to Pittsburg to reside, and while there had no further 
annoyance until Jan. 1873, when she had a most curious and instructive 
attack of the old symptoms, accompanied with general feebleness, aud the 
appearance of an eruption of herpes, which, originating on the left shoul- 
der under the left arm, passed over the left chest. The eruption was very 
painful, and lasted about ten days. I did not see her in this attack, but 
Dr. Benham, her physician, has been so kind as to give me a full descrip- 
tion of this incident of the case. Previous to the attack there had been 
some causes of weakness. The palsy and knee troubles passed away under 
use of oil and strychnia, and now, except as to power to kneel or stoop 
readily, Mrs. B. is perfectly well. 
In this remarkable history of joint lesions, atrophic palsy preceded by 
twitching of the muscles, dyssesthesia, and altered thermal conditions, we 
have all the needed evidence to show that there was a central cause, and 
that this was a local myelitis of the spinal cord. Its clinical value lies 
in the fact that the joint disease distinctly preceded the remaining 
symptoms. 
I have met with other examples of spinal disease producing arthropa- 
thies, but in all of them the spinal malady existed for long periods before 
it gave rise to arthritis. These histories, therefore, will teach us nothing 
new, and I pass on to the last, and perhaps the most remarkable of my 
cases. In November of last year, Dr. Bolling, of Chestnut Hill, asked 
me to see with him a case which had been looked upon as mere rheuma- 
tism, but which Dr. Bolling had rightly concluded to be of neural origin. 
Case IV.-The patient, Eliza M., set. eight years. When six years of 
age, in May, began to complain of pain in both ankles, and to turn the 
feet under her in walking; braces were applied with no relief to the pain, 
and they were at length removed. The trouble, nevertheless, grew better, 
to reappear the following spring, with pain both in the ankles and wrists. 
Then suddenly the toes swelled at their joints, becoming red, tender, hot, 
and stiff. Within a few days the ankle-joint also became intensely 
inflamed, and finally the whole of both feet. Neither the knees nor the 
hands became inflamed. As the diseased joints grew better, which they 
did very rapidly during six weeks at the sea-shore, the feet were found to 
drag in walking, although after a time she became quite well and even 
active. During each of these attacks, the peroneal and anterior tibial 
muscles and the interossei of the feet became singularly wasted, and after 
each onset all of these muscles underwent within a few weeks the mpst 
amazingly rapid repair. The hands passed through like changes, but their 
joints became stiff, and a little rough and enlarged, without any pain, and 
the interossei, the thenar group, and the extensors exhibited the same 
speedy wasting, and the same as sudden and remarkable restoration, but 
in all the attacks this revival left them not quite well nor fully active, 
so that after each return of disease there was a slight addition to the 
permanent disability. 9 
As to the latest attack, in November, 1874, I got a better account. 
The child when seen by me was healthy looking, cheerful, and bright. 
About November 10th, she began to drag the feet unusually. Then a few 
days later, she had nausea, and occasionally sick stomach, which endured 
for a week, whilst meanwhile pain appeared in the leg and in both feet, 
together with intense pain, heat, redness, and great swelling of all the 
joints of both feet. The pain was very great, and the tenderness on motion 
distressing; Dr. Bolling thought that taken alone, he Kpfter illustration 
of acute rheumatism could have been found. 
The joints of the hands underwent their usual changes, becoming 
deformed without pain. When I first saw her in November, the appear- 
ances described were lessening in severity, but the atrophies were well 
marked. 
Dec. 10, 1874, Dr. Bolling met the patient at my house, when I made 
with his aid the following careful notes of her condition. The hands present 
good types of the "claw hand." The first phalanges are drawn back in 
extreme extension, the second and third phalanges flexed. The interossei 
wasted the first most notably. The thumb nails look directly upwards, so 
as to be on the same plane as those of the fingers, owing to wasting of the 
whole thenar group of muscles. The palm is flattened. All of the joints 
are large and stiff. These peculiarities Dr. Bolling tells me nearly alto- 
gether disappear between the attacks. The feet are cold, 85° F., bluish 
and congested. The joints have already lost almost all traces of disease, 
and are only a little stiff and swollen. The intrinsic muscles of the feet 
and the flexors of the feet are wasted, but the extensors of the feet, normal 
as to size, are slightly contracted in tonic spasm. The toe nails are 
curiously and deeply indented by numerous transverse furrows, probably 
marking interruptions of growth. 
All the foot extensors are palsied, but there is still feeble power to flex 
and extend the toes, and extend the feet. The interossei of the hand and 
the extensors of the wrist are very weak, the common extensor of the 
fingers weak, the flexors all healthy. 
Sensation as to touch, pain, localization, and temperature everywhere 
normal. 
The electrical conditions were interesting. A galvanic current (inter- 
rupted and reversed) of 60 cells did not move the flexors of the feet, nor 
was it capable of moving the gastrocnemius which yet responded to voli- 
tion. Powerful induced currents also provoked in these parts no reaction. 
Induced currents moved the third, fourth, and fifth interossei of the hands, 
and best on the right side, but did not stir in either hand the first, second, 
and third interossei or the thenar group, save only the ulnar adductor, and 
this feebly. The extensor group in the arms reacted badly under induc- 
tion currents. 
There seemed to be no other muscular loss or defect, and the heart, kid- 
neys, stomach, and special senses were normal. 
The symptomatology of this case of course allies it with progressive 
muscular atrophy, from which, however, it is set apart by most obvious 
clinical peculiarities. 
It is said that an elder sister died of the same disease, and I ought to 
add that both parents are unusually healthy people. 10 
The last case of my series is in many points different from the others, 
but more especially in the oddity of the hand symptoms. Apart from this 
portion of the case, it resembles, save in the acuteness of attack, the three 
others; but in it the loss of power preceded the arthritic symptoms. In 
the others there was joint disease of painful character, followed by atrophies, 
loss of power, and change of temperature, while in one only was there also 
loss of feeling. In all, the changes were, rapid, the cure of the wasting, 
and palsy speedy and complete.