circumcision. The blood oozes slowly from the capillaries; at first it
appears normal, but after flowing for some days, or it may be weeks, it
becomes pale, thin, and watery, and shows less and less tendency to
coagulate.

Female members of haemophilia families sometimes show a tendency to
excessive haemorrhage, but they seldom manifest the characteristic
features met with in the male members.

Sometimes the haemorrhage takes place apparently spontaneously from the
gums, the nasal or the intestinal mucous membrane. In other cases the
bleeding occurs into the cellular tissue under the skin or mucous
membrane, producing large areas of ecchymosis and discoloration. One of
the commonest manifestations of the disease is the occurrence of
haemorrhage into the cavities of the large joints, especially the knee,
elbow, or hip. The patient suffers repeatedly from such haemorrhages, the
determining injury being often so slight as to have passed unobserved.

There is evidence that the tendency to bleed is greater at certain times
than at others--in some cases showing almost a cyclical
character--although nothing is known as to the cause of the variation.

After a severe haemorrhage into the cellular tissue or into a joint, the
patient becomes pale and anaemic, the temperature may rise to 102 or
103 F., the pulse become small and rapid, and haemic murmurs are
sometimes developed over the heart and large arteries. The swelling is
tense, fluctuating, and hot, and there is considerable pain and
tenderness.

In exceptional cases, blisters form over the seat of the effusion, or
the skin may even slough, and the clinical features may therefore come
to simulate closely those of an acute suppurative condition. When the
skin sloughs, an ulcer is formed with altered blood-clot in its floor
like that seen in scurvy, and there is a remarkable absence of any
attempt at healing.

The acute symptoms gradually subside, and the blood is slowly absorbed,
the discoloration of the skin passing through the same series of changes
as occur after an ordinary bruise. The patients seldom manifest the
symptoms of the bloodless state, and the blood is rapidly regenerated.

The _diagnosis_ is easy if the patient or his friends are aware of the
family tendency to haemorrhage and inform the doctor of it, but they are
often sensitive and reticent regarding the fact, and it may only be
elicited after close investigation. From the history it is usually easy