HEMOPHILIA 437 



philiacs assumes an exceptionally severe character. Probably the most copi- 

 ous hemorrhages occur after the extraction of teeth. In one case reported, 

 the rupture of the hymen was followed by lethal hemorrhage. It is a peculiar 

 fact that small wounds in hemophiliacs bleed in proportion much more pro- 

 fusely than larger wounds. Fordyce controlled a hemorrhage by enlarging 

 the wound with a knife. This method appears to be the best in the case 

 of lacerated wounds which bleed profusely. Traumatic surface hemorrhages 

 usually occur from only one isolated point. The blood exudes from the wound 

 as from a sponge saturated with blood; nowhere can a spurting artery be 

 found. 



Interstitial hemorrhages after trauma occur particularly in the skin and 

 the subcutaneous connective tissue. They follow the slightest external causes. 

 A push, a blow in sport, or prolonged pressure as in sitting or lying, may 

 produce interstitial hemorrhages. Blood tumors are formed (hematomata). 

 Those areas on the surface of the body are most liable to interstitial hemor- 

 rhages, which, from the habit of life, are most exposed to pressure, the but- 

 tocks and the upper posterior parts of the leg, as well as the back. 



Diffuse hematomata are found especially in the soft parts of the arms and 

 thighs, as well as occasionally in the sheath of the psoas muscle. They occa- 

 sionally resemble an abscess, with tense, glistening, hyperemic skin, and are 

 very painful. The subcutaneous effusions of blood may extend over a wide 

 area; upon suppuration, gangrene of the skin and external rupture have been 

 observed as in spontaneous hemorrhages ; a chocolate-colored mass intermingled 

 with gangrenous shreds is then discharged. 



The other most important symptom of the disease is the great difficulty 

 with which the hemorrhage is controlled. This forms the chief danger of 

 the malady, and is the reason why bleeders very rarely attain old age. The 

 open, hemophilic bleeding reveals perfectly the characteristics of parenchyma- 

 tous hemorrhage. From the entire surface which has been exposed by the 

 traumatic rupture of continuity, the blood oozes continuously for many hours. 

 Even by the most careful observation it is impossible to find a spurting 

 vessel. 



How long the hemorrhage may continue in the individual case cannot be 

 foretold. It is quite uncertain, but the excessive loss of blood in itself acts 

 favorably in controlling the hemorrhage. The bleeding hemophiliac is at- 

 tacked by syncope; shortly afterward the hemorrhage ceases. Frequently, 

 however, it lasts for so long a time as to bring about a fatal issue. During the 

 hemorrhage, frequently there is at first increased cardiac activity; later, in 

 consequence of increasing anemia the pulse becomes small, sometimes imper- 

 ceptible, the patient is pale and feeble ; in very severe cases there are delusions, 

 convulsions and delirium. 



The exuding blood at first appears normal; if, however, the hemorrhage 

 is long continued, it constantly becomes lighter and of a watery, serous char- 

 acter, owing to the increasing anemia. Chemical and microscopical investi- 

 gations of the blood have not given noteworthy results. There is no evidence 

 to support Immermann's theory that the hemorrhages are due to a plethora. 



The interstitial hemorrhages under the surface of the skin form blood- 



