436 THE HEMORRHAGIC DIATHESES 



sations may be seen. The general condition, also, is decidedly influenced; the 

 patient becomes restless; he is filled with fears or there is lassitude. For 

 a long time the fleeting character of these hemorrhages has been noted. After 

 the hemorrhage has ceased, the affected persons usually feel relieved and easy 

 in mind. In other cases these premonitory phenomena are entirely absent. 

 The hemorrhages may come on without any noteworthy prodromes. Super- 

 ficial spontaneous hemorrhages occur most frequently from the mucous mem- 

 branes; first from the most exposed, as those of the nose, then the mucous 

 membrane of the mouth. Spontaneous hemorrhages may also occur from the 

 mucous membrane of the urinary organs and from the female .sexual organs, 

 also from the lungs, the stomach and the intestines. The hemorrhages from 

 the skin are most likely to occur in cicatrices, or from cuts or ulcers, and the 

 hemorrhage then takes place during a period in which the rupture of con- 

 tinuity is beginning to heal. Spontaneous mucous membrane hemorrhages 

 are occasionally combined with those of the surface of the skin. In subcu- 

 taneous effusions of blood which embrace a wide area occasionally suppuration 

 is noted, leading to gangrene of the skin and external perforation, after which 

 a slough consisting of brownish and gangrenous shreds is discharged. The 

 blood in the subcutaneous hematomata remains fluid for a long time similar 

 to the condition in arthritic hemorrhages, and the careless opening of such 

 foci may lead to uncontrollable and fatal hemorrhages; the latter may even 

 occur when these hematomata rupture spontaneously. 



Interstitial spontaneous hemorrhages occur most frequently in the scalp 

 and in the face, next in the scrotum, more rarely in the extremities, and least 

 frequently upon the trunk. Often the tips of the fingers are implicated, and 

 the blood may exude or spurt from them as from a sponge dipped in blood. 

 Although these hemorrhages appear spontaneously, i. e., without visible ex- 

 ternal cause, it may be regarded as certain that they, as well as the "trau- 

 matic " ones now to be described, are due to very slight, scarcely determinable, 

 mechanical insults. Intraparenchymatous hemorrhages of internal organs, 

 perhaps with the exception of the kidneys, very rarely occur in areas which 

 are protected from external influence, a circumstance which, according to 

 Striimpell, forms an essential difference between hemophilia and the acquired 

 hemorrhagic diathesis. 



Superficial traumatic hemorrhages may take place in any superficially lying 

 part of the body, in all areas of the skin, and upon the superficially situated 

 mucous membranes, as well as upon those mucous membranes whose secretions 

 are discharged per vias naturales. To these must be added the serous mem- 

 branes of the thoracic and abdominal cavities. Hemorrhages from the surface 

 and from the mucous membranes which are susceptible to ordinary inspection 

 may be produced by a laceration, a puncture, a bite or other wound, also by 

 a blow, a fall, and by surgical operations. It is to be remarked in this 

 connection that accidental ruptures of continuity, particularly those of an 

 irregular form, cause hemorrhage in hemophiliacs much more readily than 

 those produced by design, as in surgical operations. Cutaneous areas with 

 ulcerating processes and cicatrices are loci minoris resistentim. Of the various 

 regions of the body, the head is the one in which the hemorrhage of hemo- 



