168 Op. cit., p. 136.
The two most interesting features in the etiology relate to sex and heredity. The disease is much more common in males than females, the proportion being variously estimated at 11 to 1, or even 13 to 1. In 64 bleeder families, in 5 were sons and daughters alike affected; in 27 all the sons were bleeders; and in 6 of these there were no daughters.
There is no disease with so marked a tendency to transmission, and it may appear in four or five generations in succession. In the Appleton-Swain family of Reading, Mass., there have been cases since the early part of the last century, and F. F. Brown of that town writes me that cases still occur in the descendants.169 Legg gives a chart of the Clitherow family, in which it has existed for the past two hundred years.170
169 The last case Brown has been able to ascertain was in a lad, Warren Coburn, aged seventeen, who died about twelve years ago. His mother's brother was a bleeder, and died of hemorrhage from a slight scalp wound after having been brought to death's door on three or four other occasions by trivial wounds. Mrs. Coburn was a daughter of Daniel Hart, whose wife was a Norton. Her mother was a Bacheller and a granddaughter of Oliver Appleton's daughter. This lad is an instance of the transmission of the disposition to the seventh generation within a period of two hundred years. Brown further states that there do not appear to be in the vicinity of Reading any Appleton or Swain families in which bleeders exist. As the tendency is chiefly transmitted through the female members of a family, who lose the patronymic by marriage, it is often difficult to trace the relationship. I think if we had fuller genealogical details we should find that several of the bleeder families now thought to be distinct belonged to the same stock.
170 St. Barth. Hospital Reports, 1881.
In the celebrated bleeder families of Tenna, Switzerland, five generations have been affected. The modes of transmission are as follows: (1) Father to son, grandson, etc. This is rare, but instances are on record. (2) Father not a bleeder, but of bleeder stock, transmits the tendency to son—very uncommon. (3) Father to daughter, granddaughter, etc.—not common. The daughters of a bleeder are usually free, though their brothers may be affected. (4) Mother a bleeder, transmits to sons and daughters. (5) Mother not a bleeder, but daughter of one, transmits to her sons, the daughters remaining free, but their sons affected. This is the most common mode of inheritance. Atavism by transmission through the female line is almost the rule, and the daughters of a bleeder, though healthy and free from any tendency, are almost certain to transmit the disposition to their male offspring. The 657 cases analyzed by Grandidier occurred in two hundred families. The chief facts of heredity are well illustrated by the preceding chart of the Yeaton family, given by Gould in the Boston Medical and Surgical Journal, 1857.
The Anglo-Germanic nations appear especially prone to the disease. Of 194 families in Grandidier's table, 154 were of the Teutonic stock. Records of the disease among the Latin races are rare. Jews are probably not more liable than other people, but the rite of circumcision gives an unusual opportunity for its manifestation at an early age.
The age at which the bleeding tendency first appears was determined by Grandidier in 113 cases as follows: in 63 during the first year; in 17 during the second, and up to the end of the second year in 93. It is rare for the first manifestation to occur after the twelfth year, and there was only one case in which the first bleeding appeared after the fifteenth year.
The constitution and temperament of bleeders, about which the older writers had much to say, probably present no peculiar characteristics. Some persons claim to be able to recognize bleeders even before they have manifested any tendency to hemorrhage. They are usually fresh, healthy-looking persons, with fine, soft skins, through which the superficial veins may show with more than usual distinctness. A division of cases into erethetic and atonic forms has been made by Wachsmuth and Grandidier. The mental activity of bleeders has been noted to be above the average, due, doubtless, to the fact that the liability to bleed from slight blows and cuts has made sedentary and studious habits preferred to out-of-door employments and amusements.