424 THE HEMORRHAGIC DIATHESES 



conditions in by far the great majority of eases, so that the expectation of 

 finding there the actual cause of the disease has not been realized. Neither 

 is it possible to determine any deviation from the normal in the amount of 

 salts in the blood, in the quantity of fibrin producers, in the corpuscular 

 constituents of the same, in the numerical relation of the blood-corpuscles to 

 one another, or in the amount of hemoglobin. The anticipation of finding 

 the amount of fibrin decreased is also unconfirmed; Heyland found 5 to 1,000, 

 Gavoy-Eitter 2.6 to 1,000, and Otte 4.3 to 1,000. In the numerous contro- 

 versies regarding hemophilia the coagulability of the blood continues to be 

 the main and interesting question, and has played a great role. While some 

 authors, such as Grandidier, Lossen and others, found diminished coagulabil- 

 ity of the blood, according to other authors this occurs only in the later stages 

 after severe hemorrhages (Hoffmann, "Text-Book of Constitutional Dis- 

 eases"). Grawitz does not consider these findings contradictory, for, under 

 ordinary circumstances, after prolonged hemorrhage, an increase of coagula- 

 bility occurs, and the blood which exudes last in hemorrhage frequently coagu- 

 lates immediately. Therefore, the slowing of coagulation in the later stages 

 proves conclusively the diminution in the power of coagulation. 



These theories of the coagulation of the blood have been recently confirmed 

 by Alex. Schmidt, and applied by him to explain the conditions existing in 

 hemophilia. According to his observations, the blood of a patient coagulated 

 four and a half minutes after exuding, and in consideration of the amount 

 of blood previously lost he pronounces the time preceding coagulation as an 

 abnormally long one. In his patient the action of a " zymoplastic substance," 

 produced by him, was first tested for its power in increasing coagulation; it 

 was placed in a test-tube with the blood of a hemophilic, and coagulation 

 occurred after ten seconds, whereas previously the time was four and a half 

 minutes. Locally applied to bleeding gums, as soon as contraction of the 

 vessels and a momentary cessation of bleeding had been brought about by an 

 injection of cocain, the " zymo-plasma " also proved an excellent styptic, and 

 therefore holds out the possibility of a substance which may be used to 

 increase coagulation. 



The deterioration of the blood in functionating erythrocytes, as an ex- 

 planation of the hemorrhages, which Cohnheim assumed, is absolutely un- 

 proven ; I have repeatedly taken specimens of the blood of hemophilics which 

 had been stained according to various methods, and have shown them to 

 blood experts who could detect nothing abnormal in them. Blood counts have 

 repeatedly shown normal conditions, as well in regard to the erythrocytes as 

 to the leukocytes. The blood-plaques are said to be increased in amount. 

 My own experience of hemophilia, which in all amounts to four cases, has 

 been gained by the same methods of blood investigation which we employ 

 m all other blood diseases. In two cases in which there was no marked anemia, 

 no definite changes were found. In both of the other cases, in which repeated 

 hemorrhages caused severe anemia, the patients being respectively eight and 

 sixteen years of age, I found the same changes as in cases of anemia after 

 acute and profuse losses of blood; namely, conspicuously pale color of the 

 erythrocytes, absence of well-developed rouleaux formation, decrease of hemo- 



