438 THE HEMORRHAGIC DIATHESES 



tumors (hematomata), which, in accordance with the transformation of the 

 hemoglobin, may show the well known changes of color observed in all depos- 

 its of blood. Now and then a hematoma of this kind suppurates and ruptures. 

 Such hemorrhages damage the nutrition and constitution of the patient all 

 the more as they lead to certain complications which will be more minutely 

 described later. Moreover, the knowledge that he is affected with such a 

 disease as hemophilia severely disturbs the psychical condition and the nervous 

 system of the patient. 



Among the characteristic complications of hemophilia the tendency to 

 " rheumatic " muscular and arthritic disease occupies the most important 

 place, partly for the reason that we recognize in this a close analogy to the 

 hemorrhagic diathesis in general. The arthropathies which may appear in 

 any of the joints are the most familiar complications of this aifection; first, 

 on account of their frequency, and secondly, because their recognition, partly 

 by means of the Rontgen rays, and partly by local surgical treatment which 

 frequently permits direct inspection of the open Joints, has led to more accu- 

 rate knowledge of them. They occur spontaneously as well as in consequence 

 of trauma which may be extremely slight, for they occur even in bedridden 

 patients who can scarcely move. Frequently they are of undoubted "rheu- 

 matic " nature, for the tendency of hemophiliacs to be affected by " rheumatic 

 irritation " is very great. The peculiar relation which exists between the 

 hemorrhagic diathesis and diseases of the joints will be more closely consid- 

 ered in the next chapter. In hemophilic arthropathies the knee- and elbow- 

 joints are particularly often implicated. The disease begins with pain and 

 swelling which may lead to stiffness and a position of flexion, as in subacute 

 arthritic inflammation, or with a tumor albus. The diagnosis is not always 

 easy, and sometimes can be made only by noting the other hemophilic phenom- 

 ena which have preceded the joint disease. The latter occurs most frequently 

 in isolated attacks which may be recognized by the pain and swelling of 

 certain joints as well as by fever, exactly as in the case of polyarthritis 

 rheumatica. The course of the disease is naturally a very chronic one. 

 In the majority of cases it is young males who are affected by hemophilic 

 arthritis. 



P.- Konig divides the arthritic affection of bleeders into three stages : First, 

 the stage of initial hemorrhage, the hemarthros of bleeders. With proper care 

 the hemarthros may heal and the disease may terminate in this stage. If this 

 is not the case the blood acts as an irritant, more blood is added, and a peculiar 

 form of inflammation develops (second stage) which shows itself as a pan- 

 arthritis, and which in the pathology as well as in its clinical symptoms shows 

 great similarity to tuberculosis of the joints. This stage is to be designated 

 as the inflammatory, the hemophilic tumor albus. The third stage is the 

 retrogressive, the stage which leads to permanent deformity of the joints, the 

 contracted bleeder joint with dissolution of the joint cavity, adhesions, and 

 displacements of the arthritic surfaces, and finally ankylosis and deformity 

 of the joint ends. 



Konig^s division appears to have found general acceptance among surgeons. 

 The first stage is not to be viewed as though we were dealing with but a single 



