If, in addition to this atrophy of the bones, which was first noted and demonstrated by Prof. Hjalmar Heiberg, there ensues necrosis with exfoliation of whole phalanges or metacarpals (the carpal bones very rarely necrose), there is great mutilation of the hands and feet; all the fingers of the hand may go, and there remain on the diminished carpus only small, soft processes, each supplied with a nail--the remnants of the fingers. The toes disappear from the feet, the metatarsal bones atrophy, and several of the tarsal bones may exfoliate; so that ultimately there remains of the foot only a pyramidal cushion at the lower end of the leg. In most cases we must regard external injury as the cause of these necroses. The patients feel nothing when they injure themselves; they may burn their hands at a stove without noticing it. Under such circumstances it is not to be wondered at, that inflammation is readily excited, especially as the vitality of the parts evidently diminished. But it is remarkable how well operation wounds heal. One may do pretty extensive necrotomies, and the wounds heal well and quickly, either by granulation or by first intention. In such operations it is a frequent experience that the bone is reached before the patient feels anything, but he immediately feels pain when the periosteum is scraped or the bone attacked with forceps or saw. We believe, however, that it is only nervous individuals who complain of _pain_; though it is certain that when the bone is meddled with, something is _felt_. Probably in this connection may be explained the statement of the patients, that when walking they _feel_ the ground. It is easy to demonstrate that a patient who is quite unconscious of any irritation on his skin, can perceive deep pressure fairly well. These necroses and trophic disturbances, together with the muscular contraction, cause the _mutilation_ characteristic of the last stage of the disease, which was at one time described as a special form, _Lepra mutilans_. We said above that the finger joints _appear_ enlarged on account of the atrophy of the shaft of the bone. In some cases, however, the joints, especially the ankle, show changes which must either be regarded as the remains of the rheumatoid affections of the eruptive period, or as trophic articular changes, corresponding to those seen in _Tabes dorsalis_. We have seen ankles and knees, but especially ankles, presenting such an appearance. In some cases post mortem examination shows widespread tuberculosis of the synovial membrane and of the ends of the bones, which we shall refer to more particularly under the pathological anatomy.