HEMOPHILIA 441 



hemorrhages of the joints prior to learning to walk is explained by the absence 

 of trauma. If, however, during the period in which they learn to walk, the 

 joints are brought into use as well as the muscles, the time for hemorrhage 

 of the joint has come, for the physiologic function of the joint is to be looked 

 upon as a series of traumatic influences! Quite often surgeons note the 

 appearance of arthritic hemorrhages of the most severe type even though the 

 patient remains in bed, and is apparently not exposed to the slightest external 

 injury. In such instances the joints affected are those that have been repeat- 

 edly the seat of effusions of blood. Probably because of the hyperplasia of 

 the synovial villi, in consequence of changes in the surface of the cartilage, 

 and on account of the great predisposition to hemorrhages, any slight motion 

 may cause a laceration of such synovial villi, and so give rise to severe 

 hemorrhages. 



The question whether the predisposition to arthritic hemorrhages decreases 

 with time must generally be answered in the affirmative. For, as we have 

 already pointed out, according to the general views of hemophilia, the tendency 

 to bleed declines in later life, and disappears entirely in the aged. We must 

 likewise assume that a predisposition to arthritic hemorrhages gradually de- 

 creases, especially since the children become less active as they grow up and 

 greater care is taken to prevent injuries. Another point which Gocht also 

 considers in his observations is, whether the joints finally, in consequence of 

 pathologico-anatomical changes, lose their tendency to hemorrhage. If a joint 

 enters the third stage, the retrogressive, if destruction of the joint cavity has 

 developed, if the former hyperplastic villi have contracted, or if adhesions 

 in the connective tissue of a cartilaginous or osseous character have occurred, 

 hemorrhages will be much rarer, in the first place, for anatomical reasons, 

 and, secondly, because irritation due to motion is no longer present. 



Still another factor must be considered — the variation in the individual 

 predisposition. If, as we have seen, one hemophilic patient is capable of with- 

 standing more than 45 severe arthritic hemorrhages without apparently suffer- 

 ing in function, while another readily develops a panarthritis, it follows that 

 the power to absorb the effusion of blood in the joints also varies greatly in 

 different patients. The question of the coagulability of the blood in the hemo- 

 philiac, which is still open and undecided, need not enter into this discussion. 



According to Gayet and Th. Hirsch, the clinical phenomena of the arthritic 

 affections of the hemophiliac resemble especially an acute or subacute arthri- 

 tis (on account of pain and swelling, fever, stiffness, and the flexed position). 

 On the side of pathogenesis, these authors believe that, besides hemorrhagic 

 processes, we cannot deny a rheumatic influence in the joint affections. 



Of other complications, the neuropathic predisposition is to be mentioned, 

 which in some patients, chiefly women, presents itself in manifold ways. 

 Here the hereditary neuropathic predisposition is especially prominent. Neu- 

 ralgia is a relatively frequent occurrence in bleeders, and occasionally neuritis 

 has also been noticed. In some cases a long-continued fever without local 

 changes has been observed. Finally, I must mention the appearance of cir- 

 cumscribed, hard, painful infiltrations into the skin and the subcutaneous 

 connective 'tissue, above which the skin remains unchanged in color; later 



