423 THE HEMORRHAGIC DIATHESES 



tomatology and pathological anatomy,, 1 believe it to be the same infectioi] 

 disease as scurvy. In order to prove its parasitic nature, I must first refe 

 to the supposedly congenital form of hemophilia, to that form in which th 

 symptoms are present from the time of birth, and which can only be ascribe 

 to transmission from hemophilic parents. This hereditary condition can neve 

 be explained by the theory of a pes varus eongenitus or a meningocele coe 

 genita, i. e., by a vitium primse formationis in which definite observable ana 

 tomical changes (no matter how complicated in origin these may appear t 

 the eye of the observer) result in disturbances of function. For nearly 

 century such anatomical conditions have been sought for in hemophilia, anc 

 in spite of improved methods of investigation, only vascular anomalies eai 

 now be found, a lesion the unimportance of which admits of no dispute, pai 

 ticularly as in only a few cases has it "been found. In opposition to thi 

 theory, I believe congenital hemophilia to be quite similar to congenital syph 

 ills, and from the standpoint of infection I note the association of hemophili 

 with wounds and ulcerative processes such as humid, benign, tuberculous am 

 syphilitic skin eruptions, glandular tuberculosis, discharges from the ear, sup 

 puration of the navel, etc. 



" Some hemophiliacs have a marked and abnormal desire to eat sand, earth 

 chalk, peat, acid and pungent vegetables. Some have febrile attacks; som 

 perish with surprising rapidity after only slight hemorrhage or other localiza 

 tion; almost all have an enlarged spleen. I lay great stress upon these facts 

 as well as on one which, so far as I know, has not yet been mentioned, mucl 

 less discussed, namely, the connection between hemophilia and infection. Fui 

 ther we must consider the presumption that, in those hemophilic familie 

 who made no change of residence for generations, particularly if the hemoj: 

 rhages occurred only in later life, the process may often be referred to influ 

 ences of the ground instead of to heredity." 



Koch's theory of hemophilia as a toxic infectious disease, both as a whol 

 and in its premises, is so purely visionary that it scarcely appears worth dis 

 cussion. The association of hemophilia with glandular tuberculosis, tubercula 

 and syphilitic cutaneous ulcers, discharge from the ear, febrile states and th' 

 other pathologic conditions which he mentions is so extremely rare as to b' 

 scarcely noted at all by other authors. The same is true of the splenic tumoi 

 which Koch says hemophiliacs almost invariably show, and upon which h' 

 especially bases his theory of the infectious nature of the disease. Othe 

 symptoms which he emphasizes are not due to hemophilia, but to the anemi; 

 produced by the hemorrhages, as is the case with neuropathic symptoms 

 Above all, his theory of an infectious etiology is untenable inasmuch as tb 

 presence of pathogenic agents has never been proven; all investigations as t 

 this point have been negative. Still more unwarranted does it appear to m^ 

 to ascribe the pathologic processes of hemophilia to telluric influences instea( 

 of to heredity. 



Fully as I agree with Koch that the origin of hemophilia cannot be lookei 

 for in purely anatomical causes — that is to say, be dependent upon them— 

 cannot concur in his assumption of a toxic infection. Even if this coul( 

 explain the nature of the congenital form of hemophilia, it can never explai) 



