432 THE HEMORRHAGIC DIATHESES 



be the determining cause of hemophilia. Nevertheless, the descriptions of 

 Virchow are highly important, as they form the basis of the Immermann- 

 Oertel theory of hemophilia. 



But the positive findings mentioned above which have been observed in a 

 number of autopsies in cases of hemophilia are opposed — few as they are — ^by 

 a much greater number in which, after minute investigation, experienced 

 pathologists were unable to determine anything noteworthy. 



More widely known are the changes in the bleeder's joint, a knowledge 

 of which we owe to the valuable work of surgeons. In the first stage of the 

 arthritic disease, we find the symptoms of a simple effusion of blood. The 

 joint cavity is filled with fluid blood and dark coagula of fibrin. The latter 

 are partly free, partly adherent to the walls, and by proliferation of the cell- 

 layers of the synovial membranes they are made integral parts of the wall of 

 the joint. The capsule is thickened, shows bloody infiltration, and is discol- 

 ored. Moreover, fibrin deposits are found upon the capsule and upon the 

 surface of the cartilage, causing the formation of brownish pigmented villi 

 and cartilage proliferations. If the effusion of blood is not absorbed the joint 

 swelling remains, and inflammation is produced which pathologically resembles 

 the condition Konig has designated as hydrops tuberculosus fibrinosus. The 

 contents of the joint are either serous or hemorrhagico-serous, and of a light 

 brownish color. The perisynovial connective tissue is sclerotically thickened. 

 The synovial intima shows swelling and reddish-brown or brownish discolora- 

 tion, and a great number of synovial villi of a brownish tint. The blood 

 coagulum in some cases attains the thickness of a finger. The cartilage has 

 lost its white color and its luster, and appears of a brownish hue. Coagulated 

 masses of blood are found in layers which show organization and connective 

 tissue change. The cartilage is partly softened by the disappearance of its 

 upper layer. Continuous small and large depressions, sharp-edged and map- 

 like, invade deeply the surface of the bone surrounding the cartilage. The 

 surface of the cartilage is uneven on account of an irregular disappearance of 

 substance. Following this second infiammatory stage, a third occurs in which 

 regenerative changes play the principal role. By adhesion of the joint sur- 

 faces, and by processes of shrivelling in the soft parts and capsules, stiffness 

 of the joints supervenes. The joint cavity becomes denuded, the joint ends 

 deformed ; subluxation takes place ; contracture and ankylosis may occur. 



Examination with the Eontgen rays has, according to Gocht (Arch. f. Tel. 

 (JJiir., 1899), given constant and important findings: It is at once evident that 

 the lower end of the femur upon the affected side is very much smaller than 

 that of the opposite side. The bones upon the diseased side are atrophic and 

 decidedly too permeable, as may be noted in the lighter color of the Eontgen 

 picture — the epiphysial lines upon the femur and the tibia lack the normal 

 rounded curves, and are irregular, often serrated, with a double contour. 

 While upon the normal side a broad, open space marks the presence of normal 

 cartilage, and the osseous ends of the femur and the tibia present their well- 

 retained smooth surfaces, the conditions upon the diseased side are quite 

 different. A decreased joint space is found, owing to destruction of the 

 cartilage. The ends of the bones appear completely changed. The arthritic 



