434 THE HEMORRHAGIC DIATHESES 



SYMPTOMATOLOGY AND COURSE 



The phenomena of the disease are quite often revealed purely hy accident; 

 the patients are attacked either spontaneously, or, in consequence of very slight 

 injuries, by profuse hemorrhages or such as are very difficult to control. 

 Among such cases I vrish to mention the hemorrhages which occasionally 

 follow ritual circumcision, and sometimes cause the surgeon great difficulty, 

 as well as those which occur after perforating the lobe of the ear for earrings, 

 and, finally, the muscular hemorrhages which occur in older children of a 

 hemophilic predisposition, when they are chastised by the teacher in school; 

 these, under some circumstances, bring the guiltless teacher into court. 



The disease shows various grades of development, and by no means the 

 same intensity of symptoms in all cases. The history of families of bleeders 

 has shown that in individual members all types of the disease, from the 

 mildest rudimentary forms up to the severest ones, may be found. The milder 

 forms are characterized by an evident tendency to hemorrhages, but the bleed- 

 ing never assumes such proportions as directly to threaten life. 



In nearly three-fourths of the cases the first hemorrhage occurs before the 

 end of the second year, and the latest period for its occurrence is the twenty- 

 second year of life; only in quite isolated cases has the first hemorrhage 

 happened at a later age. A great tendency to hemorrhage is noted in bleeders 

 at about the period of physiological development. Most hemophiliacs die in 

 the first year ; a large proportion before the end of the tenth year. Only very 

 rarely is old age reached — seventy years and beyond. Experience teaches that 

 with increasing years the hemophilic predisposition declines, until finally it 

 disappears entirely. 



As has been stated, the physician or the family often becomes aware of the 

 hemophilic tendency of an individual quite accidentally, by the difficulty of 

 controlling a hemorrhage, which returns again and again. This is especially 

 apt to be the case if the patient is not a member of a bleeder family, and has 

 not older relatives, particularly brothers, in whom severe hemorrhages some- 

 times occur as the result of quite trivial injuries while at play. In other 

 cases, surgeons while performing operations make the unpleasant discovery 

 that the hemorrhage from an operative wound does not cease, and that they 

 are dealing with a bleeder. The hemorrhagic or hemophilic predisposition of 

 the newborn is earliest recognized if hemorrhages appear after severing the 

 umbilical cord; these occasionally are uncontrollable, and result in the death 

 of the child. However, we can by no means refer all hemorrhages from the 

 cord of the newborn to a hemophilic predisposition of the child. It has been 

 proven that umbilical hemorrhages in the newborn may also be due to the 

 influence of bacterial blood infection. The next event which may lead to the 

 discovery of the disease is ritual circumcision, which, as is well known, is 

 performed upon the eighth day after birth. On the other hand, vaccination, 

 according to usual experience, is relatively harmless. The disease may, how- 

 ever, not show an early spontaneous development but may be latent, and only 

 appear after an exciting cause and upon occasion. The most common time 

 for this is the period of first dentition, and thus we frequently note decided 



