440 THE HEMORRHAGIC DIATHESES 



and the recent deposits fit each other. The capsular shadows upon the inner 

 side of the contracted knee-joint are darker than upon the normal side. 



In the case of an older boy, in whom remarkable changes had taken place, 

 the cartilage space in the joint had disappeared entirely, the tibia was markedly 

 dislocated outwardly. Between the bones adhesions could be seen. The rela- 

 tions of the capsule could not be judged from the picture, for at the time the 

 plate was made an enormous effusion of blood had occurred in the joint, 

 which was revealed in the picture as an oviform shadow the size of a hand. 



In the diagnosis of bleeder affections of the joint, in accordance with 

 Konig's views, Gocht differentiates three groups as follows : 



1. Individuals who are well-known bleeders, 



2. Those who have not been known to be bleeders, but who present charac- 

 teristic symptoms of hemophilia besides the arthritic affection, 



3. Those in whom neither the history nor any prominent symptom indi- 

 cates the general affection. 



If there is no history of hemophilia, such as preceding severe hemorrhages, 

 the very rapid development of an effusion into the joints without noteworthy 

 trauma and an accurate examination may lead to the proper diagnosis. The 

 pains are often out of all proportion to the severity of the case, and the 

 function of the implicated joint may be scarcely impaired. This is especially 

 the case if the patient is seen in the first stage of the disease. If, on the 

 other hand, a joint is found in the stage of inflammation, the diagnosis be- 

 comes more difficult, as the clinical picture of the bleeder joint is identical 

 with that of hydrops fibrinosus tuberculosus. The difficulty lies in the fact 

 that the investigator rarely considers the possibility that he is dealing with 

 the diseased joint of a bleeder. For, if hemophilia is considered at all, an 

 error in diagnosis is virtually excluded. The following phenomena point to 

 a hemophilic joint: subacute hemorrhages and scleroses about the joints; 

 freshly developed effusions into the joints, or hemorrhages under the skin 

 into the muscles, etc. ; last, and above all, the signs of previous disease in other 

 joints. Konig also declares that in hemophilia the patients are generally 

 youthful males with a conspicuous pallor of the face. This latter symptom 

 Gocht quite properly denies, for, in the first place, bleeders may show a 

 healthy color of the face, and, on the other hand, patients with tumor albus 

 are for the most part extremely pale, though of course abscess and formation 

 of fistula, which are common with tumor albus, are exceedingly rare ia 

 hemoi^hiliacs. In doubtful cases one or more injections of tuberculin may 

 be used for diagnostic purposes. 



From what has been said, it is evident that the recognition of a bleeder's 

 joint may sometimes be very easy, at other times difficult but still possible, 

 occasionally impossible. 



Gocht agrees with Linser that those bleeders who do not suffer from disease 

 of the joints are exceptions. Almost invariably the arthritic affection is 

 localized in one knee-joint. This may be due to the fact that the knee-joint 

 is most exposed to injury on account of the great extent of its surface and its 

 exposed position. The first hemorrhages, as well as the great majority of the 

 later ones, are due to external causes. That children are not attacked by 



