456 THE HEMORRHAGIC DIATHESES 



The same period of time, about two to four weeks, is required for the disap- 

 pearance of the effusion, whether there is absolute rest or use of the joint. 

 A few days after the development of the effusion massage is to be cautiously 

 begun, not upon the Joint itself, but in parts centrally situated from the joiat. 

 This causes no pain to the patient, and by action upon the peripheral joint, 

 absorption is stimulated. At the same time this treatment prevents the mus- 

 cular atrophy, particularly of the extensor muscles, which so readily appears 

 in all diseases of the joints. 



In the majority of cases these measures will suffice to bring about absorp- 

 tion of the effusion of blood, especially if the hemorrhages have not as yet 

 been frequent. The older the effusions and the more frequently the joint has 

 been attacked, the less rapidly does absorption of the hemorrhage take place. 

 Nevertheless, here also the treatment must be expectant, and usually recovery 

 will ensue. 



If a joint has entered into the stage in which it resembles hydrops fibrinosus 

 tuberculosus, where inflammatory phenomena dominate the clinical picture, 

 orthopedic treatment becomes necessary. In opposition to Konig, Gocht main- 

 tains that only when the patient suffers great pain, and provided the physician 

 is absolutely certain in the diagnosis, should puncture be performed. As ex- 

 perience has taught that absorption, even although slowly, nevertheless almost 

 invariably occurs, removal of the blood need not be resorted to except for im- 

 perative reasons. Here, on the contrary, orthopedic treatment should be em- 

 ployed. Besides the measures which have already been mentioned, such as a 

 position of rest, compression, and (particularly for the beginning contracture) 

 extension, plaster of Paris is to be employed, and, above all, portable apparatus 

 so as not to keep the patient too long in bed. A brisement force, in fact all 

 force employed for extension of a contracture in a bleeder, is entirely contra- 

 indicated. Rail-brace apparatus, well manufactured and accurately fitted to 

 the extremity, is of even greater use in the third stage of the disease in which 

 permanent deformity of the joints has sometimes occurred. The many ex- 

 treme and violent stretchings of the capsule, and the inflammatory processes 

 following these, cause an increasing damage (i. e., flaccidity) of the capsule 

 of the ligamentous apparatus. Just as in tuberculosis, not only flexion but 

 subluxation and abduction of the tibia posteriorly and outwardly gradually 

 occur. 



Changes in the ends of the bones are added to those of the capsule of the 

 joint, so that we have a mixed form of destruction and distention-luxation. 

 The processes of contractures which occur in the capsule, ligaments, muscles, 

 fascia, and skin increase the contracture and form a decided hindrance to cor- 

 rection. As to the different methods of extension, surgical monographs must 

 be consulted. Here it will only be stated that the patients in Hoffa's Clinic, 

 during the entire time of extension, are out of bed and move about. When the 

 leg is completely extended, the apparatus is worn, according to the severity 

 of the case, for three months to six months and even longer to prevent relapses. 



The employment of the rail-brace apparatus, according to the published 

 reports, has given excellent results, so that this method of treatment can be 

 warmly recommended. 



