HEMOPHILIA 439 



hemorrhage. On the contrary, the most characteristic feature of this stage is 

 the fact that one or more effusions of blood are promptly absorbed without 

 any external derangement or even diminution of function remaining which 

 can be recognized by disturbance or change in the joints. Gocht, in Hoffa's 

 Clinic, observed in different hemophilic youths quite a number of more or less 

 severe arthritic hemorrhages, either without a determinable trauma or as its 

 direct consequence. The knee-joint, which he mentions as the one most fre- 

 quently affected, at times appeared to be enormously thickened by a large 

 effusion which occurred very suddenly, sometimes in from five to ten minutes. 

 The joint was sometimes in slight flexion, at other times also in extension; 

 sometimes there was pain, at other times none. Sometimes the joint was fixed 

 and immovable, again the function was not at all disturbed. A patient in 

 Hoffa's Clinic had more than 45 severe hemorrhages in the right knee-joint 

 without suffering the slightest inconvenience in the use and function of the 

 joint. The left knee-joint which was contracted had sustained about 40 hemor- 

 rhages; the first 39 gave rise to no injury; only the last effusion of blood 

 led to permanent contracture. If the effusion is not absorbed, the swelling 

 in the joint remains and is not amenable to treatment, as, for instance, was 

 the case in this last mentioned knee-joint which led to contraction. Pains 

 appear, and the function is much interfered with. According to Konig we 

 are then dealing with that peculiar form of inflammation (second stage) 

 which, as well in its pathology as in the clinical symptoms, closely resembles 

 tuberculosis of the joint, and which was called by this author hydrops tuber- 

 culosus fibrinosus. The picture of the latter disease is simulated even to the 

 most minute detail. In such cases the contents of the joint are hemorrhagico- 

 serous or serous with a brownish color. The synovial intima shows swelling 

 and brownish discoloration, and a large number of fluctuating, brownish, 

 discolored, synovial villi. The coagula of blood in some areas may attain 

 enormous thickness. The cartilage loses its white color and its luster, and 

 shows a brownish discoloration; it is partially softened because its upper 

 layer has been lost. It also shows defects and unevenness in its surface on 

 account of an irregular loss of substance. The investigation of such joints 

 with the Eontgen rays has been described by Gocht as follows : We recognize 

 that the lower end of the femur upon the deformed side, in contrast to the 

 other side, is decidedly smaller. The difference amounts to more than 1 cm. 

 The bones upon the diseased side are atrophic and too permeable to the 

 Eontgen rays, as may be recognized from the lighter color in the skiagram. 

 The epiphysial lines upon the femur and tibia do not show the normal rounded 

 edge, but they are irregular, serrated, with double contours. Upon the epiph- 

 ysis of the femur anomalous indentations are shown. While upon the normal 

 side an open space denotes the presence of normal cartilage, and the osseous 

 ends of the femur and tibia present their normal forms, the conditions upon 

 the diseased side are quite different: Corresponding to the loss of cartilage, 

 a decidedly decreased joint space is found. The ends of the bones appear 

 completely changed; the end of the femur is serrated and irregular; the 

 indentation normally between the condyles is lost, and the intercondylar emi- 

 nence of the tibia is irregular and extended. The recent losses in structure 



