THE Rh BLOOD TYPES AND SOME OF THEIR APPLICATIONS*
ALEXANDER S. WIENER,
M.D.
From the Transfusion Division, Department of Laboratories, Jewish Hospital of Brooklyn, and
the Serological Laboratory of the Office of the Chief Medical Examiner of New York City.
T h e field of the R h factors and their applications h a s become so extensive and complex, t h a t
it was w i t h some misgivings t h a t I accepted the
k i n d invitation to present t h e topic before this
society. Inasmuch as a detailed a n d comprehensive review like those prepared b y Potter, 1 "
B r o m a n l b and B o y d l c is hardly possible in the
time allotted, I shall merely a t t e m p t to present
t h e highlights of the subject.
Until recently it was generally believed that no
dangerous transfusion reactions could occur if patient
and donor belonged to the same Landsteiner blood
group, and indeed almost all hemolytic reactions
could be traced to errors in blood grouping of patient
or donor or both. During the decade 1930-39, with
the increasing use of blood transfusion, authenticated
reports began to appear of hemolytic reactions despite
the use of blood of the correct blood group. In most
of these cases, no explanation for the reactions could
be found; but in a few instances the patient's serum was
reported to contain irregular isoagglutinins or isohemolysins acting on the blood of the donor used for
the transfusion as well as certain other human bloods,
independently of the blood groups. Among the most
carefully studied instances of this sort were those
reported by Zacho,2 Culbertson and Ratcliffe,3 Neter, 4
and Levine and Stetson.6 However, no attempt was
made to correlate these cases with one another and
this was the way the subject remained until a new
period was opened by the discovery of the Rh factor.
EARLY
HISTORY
OF
THE
Rh
BLOOD
FACTOR
In 1937, while studying the evolution of the properties M and N of human blood, Landsteiner and I
demonstrated the presence of M-like agglutinogens
in the blood of anthropoid apes and old-world monkeys.0
This led us to try immunization of rabbits with blood
of rhesus monkeys, and it was found that in this way
potent anti-M immune sera could be obtained. It
then occurred to us that in the same way antibodies
might possibly be produced against hitherto undiscovered individual blood factors in human blood.
Pursuing the studies further, we succeeded in obtain-
ing antiserums which reacted with the bloods of
approximately 85 per cent of all white individuals,
independently of the blood groups.7 The property
of human blood detected by these anti-rhesus serums
proved to be different from M, N and P, and was
named Rh to indicate the manner in which it had been
discovered.
Some time after the Rh factor was discovered,
I reported with Peters 8 three hemolytic transfusion
reactions, one fatal, which proved to be due to isoimmunization against this new blood property. These
cases indicating the clinical importance of the Rh
factor prompted Landsteiner and myself to report
our findings early in 1940,7 more than two years after
we had obtained our first anti-rhesus serum. The
patients, who were all Rh negative, had been given
repeated transfusions of blood of the homologous blood
group, but Rh positive. As a result, the patients
became sensitized to the Rh factor, so that reactions
occurred upon repetition of the transfusions, at first
mild, then progressively more severe, until finally a
dangerous hemolytic reaction directed attention to
the true nature of the phenomenon. When within
the short space of a year, as many as ten additional
examples of reactions caused by isoimmunization
against the Rh factor were encountered by me,9 it
became clear that this must be the usual explanation for
hemolytic reactions when blood of the correct group
is transfused. The accepted estimate is that approximately 90 per cent of intragroup hemolytic reactions
are due to Rh. Careful study, in the light of modern
knowledge, of the cases previously reported by Zacho,
Culbertson and Ratcliffe, Levine and Stetson, and
others, during the preceding decade, leave little doubt
that these were also examples of Rh isoimmunization,
and in 1941, when Katzin retested the case of Levine
and Stetson, he was able to confirm the correctness of
this assumption.
* Aided by a Grant from the United Hospital Fund
of New York City.
Paper read (with additions) before the Medical
Society of Pennsylvania, September 21, 1944.
106
Analysis of the intragroup transfusion reactions
encountered by me and Peters, as well as those previously described in the literature, revealed that these
fall into two groups: (1) instances in which the patients
had been given repeated blood transfusions, and as a
result became sensitized to the Rh factor, and (2)
intragroup hemolytic reactions occurring after an
initial transfusion. In the latter group, it was observed that the patients had all been pregnant recently,
and this suggested that the fetus in utero was the
source of the antigen which had sensitized the patient,
107
Rh BLOOD TYPES
as had previously been suggested by Levine and Stetson
to explain the intragroup transfusion reaction their
patient had had. It was also noticed that in many
instances where the patients had had hemolytic reactions, their infants were stillborn or had erythroblastosis, and this suggested the solution to a second
medical mystery (Levine et al.,10 Bumham"). If an
Rh-negative woman has an Rh-positive husband, the
fetus in utero may also be Rh positive, by inheriting
the Rh factor from its father.17 In this way, the
woman might become sensitized to the Rh factor, so
that if she is given a transfusion of Rh-positive blood,
a dangerous hemolytic reaction could result. Moreover, the Rh isoantibodies produced by the mother
could pass through the placenta into the fetus and
destroy its blood, giving rise to one or another manifestation of erythroblastosis fetalis. This theory of
Levine and his associates12 is now well established; and
is the basis for the suggestion that the name, "hemolytic
disease of the fetus and newborn," be substituted for
"erythroblastosis fetalis," although the latter term is
still convenient to use because of its brevity.
In view of the clinical importance of the Rh factor,
it may seem surprising that the Rh factor was not
discovered sooner. One contributing reason is that
instances of intragroup hemolytic reactions and
erythroblastotic infants are rather uncommon. While
one out of ever}' seven individuals is Rh negative,
not every Rh-negative individual becomes sensitized
to the Rh factor when transfused with Rh-positive
blood or when pregnant with an Rh-positive fetus.
There evidently are wide differences among Rhnegative individuals in the ease with which they can
be sensitized, so that only one in 25 or 50 are readily
sensitized. The remainder might possibly require as
many as 10 to 20 or more transfusions or pregnancies
before sensitization occurred, so that under ordinary
conditions no isoimmunization would result. The
small size of modern families would therefore explain
why the incidence of hemolytic disease of the newborn
is only approximately 1 in 250 to 500 pregnancies,13
instead of 1 in 10, as would be expected if every Rhnegative individual became sensitized upon exposure
to the Rh antigen.
Another reason why the Rh factor was not discovered sooner is the difficulty of demonstrating the
existence of Rh sensitization by in vitro tests. The
usual method of testing for Rh sensitization is to
examine the patient's serum for anti-Rh isoagglutinins,
as was first done by me and Peters.8 Due to peculiarities of the anti-Rh isoagglutinins and the Rh antigens,"
a special technic must be employed, or the antibodies
will be overlooked. Only exceptionally, will the
agglutinins be demonstrable by the common slide
technic. Moreover, not infrequently, no anti-Rh
agglutinins can be detected by any technic, even though
the patient is strongly sensitized to the Rh factor.
Cases of the latter sort have been explained at least
in part by the recent discovery of the blocking Rh
antibodies,16- u which will be discussed later on.
From the foregoing, it is evident that the specialist
in blood grouping and blood transfusion must now be
equipped to perform tests for the Rh factor, as an aid
in diagnosing and preventing intragroup hemolytic
transfusion reactions, and for the diagnosis and treatment of cases of hemolytic disease of the fetus and
newborn. In addition, a complete transfusion service
must now include a panel of blood donors who have
been classified for the Rh factor.
THE R h BLOOD TYPES
Anti-Rh serums can be obtained by immunizing
guinea-pigs with the blood of rhesus monkeys, 17 ' 1 8 , 1 9 or from Rh-negative patients who
have had hemolytic transfusion reactions or
borne infants with hemolytic disease.8, l2 Serums
of the former type had the advantage that they
could be produced at will (an advantage which
now exists to a lesser degree on account of the
scarcity of rhesus monkeys caused by the war),
and most of the earlier studies on the Rh factor
were carried out with anti-rhesus guinea-pig
immune serums. They have the disadvantage
that more technical skill is required for their
accurate use than tests with better human anti-Rh
serums from mothers of erythroblastotic babies
available at the present time. Another disadvantage of the anti-rhesus guinea-pig serums
is that they cannot be used for typing infants'
bloods because, as Fiske and Foord21 have shown,
the sera strongly agglutinate the blood of all
infants regardless of Rh type. 3 7 ' l b Direct comparative study of different anti-rhesus guinea-pig
serums and different human anti-Rh serums has
revealed that while the former all give parallel
reactions, human serums vary in their specificihuman
t i e s 9,12, so, 2i. 22,23 w i t h
the
aid
of
anti-Rh serums, it has been discovered that there
are five major varieties of Rh factors instead of ;
only one, and that these five Rh factors give rise
to eight types of human blood. 2 4 , 2 5 , 2 6
Since the Rh blood types have proved to be of
clinical importance, 27 and, in any event, a knowledge of the subject is essential for the precise
performance even of the ordinary .Rh tests, they
will now be briefly described. The differences
among human anti-Rh serums have been found
to be due to the existence of three sorts of anti-Rh
agglutinins; the most common variety of agglutinin corresponds exactly with the standard 85
per cent positive, anti-rhesus immune animal
108
ALEXANDER S. WIENER
serums (Landsteiner and Wiener 17), and is designated 2 8 anti-Rho; the second variety of anti-Rh
agglutinins clumps approximately 70 per cent of
bloods from white individuals (Wiener9) and is
designated as anti-Rh'; the third and rarest
variety of anti-Rh agglutinin gives only 30 per
cent positive reactions 2 5 , 2 9 , 3 0 and is known as
anti-Rh". The situation is somewhat complicated
because the agglutinins anti-Rh' and anti-Rh"
usually occur in association, with agglutinin
anti-Rho, giving rise to two additional common
varieties of human anti-Rh serums: one variety
which contains anti-Rho and anti-Rh' together is
designated as anti-Rh 0 Rh' (or better anti-Rho)
and gives about 87 per cent positive reactions on
the bloods of white individuals in New York City;
the second variety, which contains anti-Rho
and anti-Rh" together and is designated antiRhoRh" or anti-Rho, gives about 85.5 per cent
positive reactions.26, 2 8 It is clear that serums
anti-Rho, anti-Rho and anti-Rho give parallel
reactions except for a small percentage of bloods;
for this reason, they are difficult to differentiate,
and methods of doing so will be described later on.
Still other varieties of anti-Rh serums, e.g., sera
containing both anti-Rh' and anti-Rh", 31 or all
three agglutinins together, are also possible
theoretically, but appear to be extremely rare for
reasons pointed out elsewhere.26
Any one who thoroughly understands the four
Landsteiner blood groups and their heredity can
quickly learn the serology and genetics of the
eight Rh blood types. First, considering the
reactions of agglutinins anti-Rh' and anti-Rh"
alone, four sorts of blood quite analogous to the
four blood groups are possible.25 Blood not
agglutinated by either anti-Rh' or anti-Rh"
(analogous to group O) is said to belong to class
W; blood reacting with anti-Rh' but not anti-Rh"
belongs to class U; blood clumped by anti-Rh"
but not anti-Rh' belongs to class V; while blood
clumped by both antiserums (analogous to group
AB) belongs to class UV. Now, when the reac- 1
tions of the anti-Rh 0 agglutinin are taken into'
account, each class is subdivided into two types, ,
giving rise to what amounts to a double blood
group scheme of four types each. The resulting
eight Rh types, their relationships to the four
classes and their reactions with the three varieties
of anti-Rh agglutinins are shown in table 1. It
will be seen that each Rh type has been named to
correspond with the antiserums with which it
reacts. Thus, blood reacting only with agglutinin
anti-Rh', but not anti-Rho or anti-Rh" is said
to belong to type Rh'; blood reacting only with
agglutinin anti-Rho belongs to type Rho; etc.
Blood reacting with anti-Rho and anti-Rh'
but not with anti-Rh" is said to belong to type
Rho instead of type RhoRh' for reasons which
will become clear when the heredity of the Rh
types is discussed; similar reasons exist for the
designations of types Rho and RhoRho. For
these three types, the alternate designations Rhi,
RI12 and RhiRli2 are also used. In fact, while
the designations Rho, Rho and RhoRho should be
used whenever necessary for the sake of clarity
or to avoid ambiguity, the simpler designation
Rhi. Rh 2 and RhiRh 2 will usually be found
preferable.28
It is of interest to mention briefly at this point
the striking differences in the distributions of the
Rh blood types among individuals of different
races. In table 1, for example, are given the contrasting distributions of these types among Whites
and Negroes in New York City. 32 I t will be seen
that the most common type among white individuals is type Rhi to which slightly more than
half of all white individuals belong, but only one
fifth of Negroes. On the other hand, type Rho,
which is relatively rare (2.6 per cent) in Whites,
is the most common type (41.7 per cent) among
Negroes. Some races, such as American Indians,33
Chinese 34,35 and Australian aborigenes,36 are
characterized by the virtual absence of the Rhnegative type.
HEREDITY OP THE R h BLOOD TYPES
The heredity of the eight Rh blood types can be
learned quickly by any one familiar with the
heredity of the four blood groups. As was done
when discussing the serology of the Rh types, let
us first consider only the agglutinins anti-Rh'
and anti-Rh" and the four classes, W, U, V, and
UV, which they determine. These four classes
are inherited just like the four blood groups by
triple allelic genes which we may designate as
W, U, and V, where U determines the agglutinogen reacting with agglutinin anti-Rh', V
determines the agglutinogen reacting with antiRh", and W is the recessive gene, analogous to
gene 0 of the A-B-0 series of allelic genes. When
agglutinin anti-Rh 0 is brought into the picture, it
becomes necessary to postulate the existence of
six allelic genes instead of three, because each of
Rh BLOOD TYPES
the genes W, U, and V comprises two Rh genes
as follows:
W = rh
(or Rho) were always caused by separate genes,
as in genotype R/i'Rho, then it would be expected
that half the children of the mating Rh-negative x
Rhi would belong to type Rho and half to type
Rh'. Actually, this variety of family has not
been encountered to date, because genes Rho
and Rh' are both relatively rare. This is the
reason for the designation of blood reacting with
agglutinins anti-Rho and anti-Rh' as Rho or Rhi
instead of RhoRh'; namely, that only with rare
exceptions, these reactions represent the effect
of a single gene. Incidentally, this situation is of
interest to the geneticist because it demonstrates
that single genes, like Rhi and Rhi can produce
effects indistinguishable from the combined effects
of two genes (Rho and Rh', and Rho and Rh",
respectively).26
+Rh0
U = Rhi
109
+Rh'
V = Rhi + Rh"
The Rh genes postulated under this theory of six
allelic genes are all named after the agglutinogens
which they determine, as shown in table 2. To
determine the phenotype corresponding to each
of the 21 genotypes possible under the theory,
it is only necessary to combine the effects of the
pair of genes making up the genotype. In this
way one can easily ascertain which genotypes
correspond to each of the eight Rh blood types,
as shown in table 3.
TABLE 1
CLASSIFICATION OF Rh BLOOD TYPES AND DISTRIBUTION AMONG WHITES AND NEGROES IN NEW YORK CITY
BLOODS LACKING R h o FACTOR
CLASSES
Reactions with
antiserums
Anti- Anti- AntiRh"
Rho
Rh'
vv
u
V
uv
_
—
—
_
+
—
+
—
-
+
+
Designation
of types
Neg.
Rh'
Rh"
Rh'Rh"
BLOODS CONTAINING R h o FACTOR
Distribution
(per cent)
Reactions with
antiserums
Distribution
(per cent)
Designation of types
Whites*
Negroest
AntiRho
AntiRh'
AntiRh"
12.9
0.9
0.3
8.1
2.2
+
+
+
+
—
—
—
—
—
—
+
-
+
+
+
Rho
Rhi (Rh'o)
Rh 2 (Rho)
RhiRh 2 (Rh„Rh"o)
Whites*
Negroest
2.6
54.1
12.8
16.4
41.7
20.2
22.4
5.4
* Based on 1000 tests. Calculated gene frequencies: rh = 35.9 per cent; Rh = 43.4 per cent; RIh = 13.7
per cent; Rh = 3.5 per cent; Rh' = 1.2 per cent; Rh" = 0.4 per cent. D = 100 - VRh = 100 - 98.1 = +1.9
per cent.
t Based on tests on 223 Negroes from Harlem Hospital. Calculated gene frequencies: rh = 28.4 per cent;
Rh = 11.7 per cent; Rh = 14.4 per cent; Rh = 42.1 per cent; Rh' = 2.7 per cent. D = 100 - XRhi = 100 99.3 = +0.7 per cent.
It is now a relatively simple matter to determine
to which types the children must belong, when the
Rh types of the parents are known. For example,
if both parents are Rh negative, obviously all the
children must be Rh negative; if one parent is
Rh negative and the other belongs to type Rh'Rh",
half the children will belong to type Rh' and half
to type Rh". The mating Rh-negative x Rhi is
more complicated because there are five possibilities depending on the genotype to which the
Rhi parent belongs. In most families either all
the children are Rhi, or half belong to type Rhi
and half are Rh negative, because the most common genotypes in type Rhi are Rh\Rli\ and
Rhirh. If the two reactions (with anti-Rho and
anti-Rh') which characterize agglutinogen Rhi
TABLE 2
THE SIX Rh GENES AND THE REACTIONS THEY
DETERMINE
REACTIONS WITH ANTISERUMS
R h GEKES
rh
Rh'
Rh"
Rho
Rh
Rh
Anti-Rho
Anti-Rh'
Anti-Rh'
Neg.
Neg.
Xeg.
Pos.
Pos.
Pos.
Neg.
Pos.
Xeg.
Xeg.
Pos.
Xeg.
Neg.
Neg.
Pos.
Xeg.
Xeg.
Pos.
The accuracy of the theory of six allelic genes
has been established by investigations on the Rh
110
ALEXANDER S. WIENER
t y p e s in families, a n d by t h e statistical analysis
of d a t a o n the distribution of t h e R h types in t h e
TABLE 3
THE
EIGHT Rh
Rh TYPES
Neg
Rh'
Rh"
Rh'Rh"
Rh 0
Rh,(Rh£)
Rh 2 (Rh?)
RhiRh 2 (RnSRhiO
T Y P E S AND T H E I R GENOTYPES
GENOTYPES
rhrh
Rh'Rh' and Rh'rh
Rh"Rh" and Rh'rh
Rh'Rh"
RhoRho and Rh&h
RhRh,
Rhrh, RhRh',
RhRh,
and Rh'Rh
RhRh,
Rhrh, RhRh",
RhRh,
and Rh"Rh
RhRh, RhRh", and Rh'Rh
the table. Here there are three possibilities
depending on which of t h e three genotypes,i?/ti.R/t2,
RhiRh"
or Rh'Rh2,
the type R h i R h 2 parent
belongs to. However, genotypes Rh\Kk" a n d
Rh'Rhz are rare compared to RhiRht,
so t h a t
ordinarily one would expect half the children to
belong to t y p e R h i a n d half to type Rh2. I t will
be seen t h a t the 4 families in table 4 actually
yielded 8 t y p e R h i a n d 8 t y p e R h 2 children a n d
none of a n y other type.
F u r t h e r evidence demonstrating the accuracy
of the six gene theory has been obtained b y R a c e
et al. 3 8 , working independently with a n t i - R h
serums obtained in England. As pointed out b y
these authors, their arriving a t the same scheme
suggests the essential correctness of Wiener's
six gene theory.
TABLE 4
HEREDITY OF THE Rh BLOOD TYPES IN 97 FAMILIES*
CHILDREN OF TYPES
NO. OF
FAMILIES
Neg.
Rhi
7
2
6
4
1
1
9
4
2
1
13
21
1
5
2
6
1
1
9
0
13
0
1
0
3
0
0
4
0
0
4
0
1
0
0
0
0
0
0
19
17
1
0
8
0
0
30
6
9
1
11
30
0
1
0
2
0
1
97
35
136
Neg. X Neg.
Neg. X Rhj.
Neg.
Neg.
Neg.
Neg.
X
X
X
X
Rh2....
RruRhj
Rh0. . .
Rh'....
Rhi X Rhi
Rhi X Rh 2
Rhi X R h i R h 2 . . . .
Rh 2 X R h ,
Rh 2 X R h 1 R h a . . . .
R h 2 X Rh 0
RhiRh, X RhiRh 2 .
RhiRh 2 X R h 0 . . . .
Rh,Rh 2 X R h ' . . . .
Totals.
* From Wiener, Sonn and Belkin.
Rh 2
37
RhiRhs
Rho
0
0
0
0
0
0
0
0
0
0
0
0
12
22
0
4
0
14
0
1
0
0
0
3
0
0
1
0
0
0
4
0
0
0
0
0
4
0
0
0
9
19
30
4
8
16
4
1
30
10
13
2
34
58
2
10
5
16
1
3
53
12
275
Rh'
37
general population. As a n example of t h e former,
one m a y consult table 4 from t h e s t u d y b y Wiener,
S o n n a n d Belkin. 3 7 T h i s series of 97 families
w i t h 275 children does n o t contain a single exception t o t h e genetic theory. A particular striking
case is t h e mating Rh-negative x R h i R h 2 , in
TECHNIC OF THE R h
TESTSf
Before returning to the discussion of the technic
of t h e R h tests, a few remarks concerning t h e
t Because of lack of time, the tests with guinea-pig
anti-Rhesus serums will not be discussed here.
111
Rh BLOOD TYPES
blocking antibodies would be in order. As
suggested by the name,15 these blocking Rh
isoantibodies have the capacity of combining
with Rh-positive cells without producing a visible
reaction,}: so that if subsequently a good anti-Rh
agglutinating serum is added, no clumping occurs
because the combining sites on the erythrocytes
have been blocked by the first antibody 15,16
(cf. fig. 1). The blocking antibodies are sometimes quite potent as can be shown by titrating
them. 15 The situation is somewhat complicated
' because, as has just been shown, there are at least
u
Rh Agglutinogen
Rh+ Cells
manner, anti-Rh o blocking antibodies can be
used to "convert" Rh 2 cells to Rh", RhiRh 2 to
Rh'Rh" and Rho to Rh-negative.15
Before human anti-Rh serums can be used for
Rh-typing, their specificity must be determined,
that is, whether they correspond to anti-Rh o,
anti-Rh', anti-Rh", anti-Rho or anti-Rho'. For
this purpose, all one requires is group O bloods
of types Rhi, Rhi2 and Rh-negative and some
anti-Rho blocking serum. By treating some of
the Rhi and RJ12 blood with the blocking serum,
one obtains artificial controls of types Rh' and
0
Anti-Rh Agglutinin
Agglutination
*
Anti-Rh Blocking Antibody
Blocking
FIG. 1. DIAGRAMMATIC REPRESENTATION OF Rh AGGLUTINATION AND BLOCKING REACTIONS
three sorts of Rh antigen, Rho, Rh' and Rh".
The blocking antibodies found to date have
invariably given reactions corresponding to antiRh o; thus, if type Rhi blood cells are mixed with
serums containing such blocking antibodies, the
blood suspension now behaves like type Rh'
blood, because the Rho site of the Rhi (or Rho)
agglutinogen has been blocked. In a similar
t For a description of a similar phenomenon in
tests with agglutinating serums for Pfeiffer bacilli,
see Coca and Kelley.69
Rh", respectively, and this is a very convenient
procedure, because individuals of types Rh' and
Rh" are rare. The serum to be standardized is
merely tested against the cell suspensions, Rhnegative, Rhi and RI12, and natural or artificial
Rh' and Rh" cells, and its specificity is readily
determined as shown in table 5. For example,
if the type Rhi and RI12 cells are clumped but
not Rh', Rh" or Rh-negative, the serum contains
an anti-Rho agglutinin; if Rhi and Rh' are the
only cells agglutinated, the specificity of the serum
corresponds to anti-Rh', etc. For Rh typing,
112
ALEXANDER S. WIENER
serums containing only one of the three agglutinins anti-Rh o, anti-Rh' and anti-Rh" are obviously the most valuable; serums anti-Rho and
anti-Rho are less useful. Serums anti-Rho and
anti-Rho can be readily converted to anti-Rh'
and anti-Rh" by adding to them a small amount
of anti-Rho blocking serum. 39 In fact, most,
if not all, natural anti-Rh' serums seem to contain
anti-Rho blocking isoantibodies,10, 39 which would
conceal any anti-Rho agglutinins which might
be present, so that natural anti-Rh' serums may
actually be more complicated rather than simpler
than anti-Rho serums.
To be useful, anti-Rh serums must not only be
of known specificity but of sufficient potency or
titer to give clear-cut reactions. The technic
of titrating anti-Rh serums is no different from
that of titrating anti-A and anti-B serums, except
TABLE 5
STANDARDIZATION OF ANTi-Rh SERUMS
REACTIONS WITH TEST CELLS
SERUM
NUMBER
1
2
3
4
5
Rh
neg.
Type
Rhi
Type
Rh2
—
—
—
—
+
+
—
+
+
Artificial or
natural
Type
Rh'
Type
Rh"
+
_
-
+
_
-
+
+
+
—
+
—
+
-
+
DIAGNOSIS
anti-Rho
• anti-Rh'
anti-Rh"
anti-Rho
anti-Rh"
that the former must always be done in testtubes as will be explained for the tests proper,
later on. Finally, unless the serums are derived
from a group AB individual, the anti-A and anti-B
agglutinins present in the sera must be absorbed
or neutralized so that the serums can be used for
testing blood of individuals of all four blood groups
This can be accomplished by absorbing the serum
with pooled, washed Rh-negative cells of groups
Ai and B. A simpler and more satisfactory
procedure is to neutralize the isoagglutinins with
pooled saliva of groups Ai and B from secretors 40
(or with solutions of Witebsky's group substance 41 ). If saliva is used, it should be placed
in boiling water for 10 minutes immediately after
it is collected, in order to destroy the blood group
enzymes, and coagulated material is removed by
centrifugation. An example of a satisfactory
formula that can be used for converting a potent
(titer 100 or more) group O, anti-'Rho serum into
an anti-Rh' reagent is the following:39 mix one
part of the stock serum, with one part each of
boiled Ai and B saliva and a potent anti-Rho
blocking serum and with 6 parts of saline solution.
The dilute reagent should only be prepared immediately before use as the stock serum is far
more stable than the dilute reagent. (The boiled
Ai and B saliva should retain their potency
indefinitely if stored in the refrigerator. Preservatives, such as merthiolate, should be avoided
because these appear to damage the anti-Rh
isoagglutinins.42
The actual tests are performed by mixing one
drop of a fresh 2 per cent (in terms of blood sediment) suspension of the blood being tested with a
drop of the diluted anti-Rh serum in a small,
narrow (inside diameter 7-8 mm:) test-tube and
incubating the mixture in a water-bath at body
temperature. (Most human anti-Rh serums give
more satisfactory reactions at body temperature
than at room or refrigerator temperatures.)
Such tests should be set up, using all three serums,
anti-Rho, and anti-Rh' and anti-Rh", if possible.
(For clinical purposes, however, tests with the
standard anti-Rho serum alone are usually
sufficient.) After the mixtures have stood for
30 to 60 minutes (or until sedimentation is complete) the reactions are read by observing with
the naked eye the appearance of the sediment
in each tube. For the interpretation of the reactions, consult figures.2-7 The tubes are genlly
shaken and the presence or absence of agglutination is determined with the naked eye and under
the low power of the microscope. If any doubt
remains, another reading may be taken after the
mixtures have stood for an additional 2 hours at
room temperature or after the tubes have beencentrifuged for one minute at low speed (about
500 r.p.m.). The type to which the blood belongs
can readily be ascertained by- comparing the
reactions obtained with the anti-Rho anti-Rh'
and anti-Rh" serums with those recorded in
table 1.
MEDICOLEGAL APPLICATIONS
The Rh types, like the other individual properties of human blood, have two applications in
legal medicine, namely, for individual identification and in cases of disputed parentage.
It will be recalled43 that the Landsteiner blood
groups together with the subgroups of A andAB
give rise to six varieties of blood, O, Ai, As, B,
AiB and A 2 B. When the three types M, N and
Rh BLOOD TYPES
MX are taken into account, 6 x 3 or 18 combinations are possible. Since every person is either
P positive or P negative, this doubles the number
of possibilities. Finally, if the 8 Rh types are
included, a total of 36 x 8 or 288 varieties of human
blood can be distinguished. Of course, these 288
varieties vary considerably in their frequency in
the general population. The most common
combination among white persons would be
group O, type MM, P positive and type Rhi,
with a frequency of (0.43) (0.S0) (0.75) (0.54) =
.087 or approximately 8.7 per cent. The rarest
combination would be group A 2 B, type N, P
negative and type Rh'Rh", with a frequency of
(0.015) (0.20) (0.25) (.0001) or .000,000,075 or
• o •
FIGS. 2-7. SEDIMENTIVE METHOD OF TESTING FOR
THE Rh FACTOR
(After Landsteiner and Wiener.) Reproduced from
the Journal of Experimental Medicine, 74: 312, 1941.
Magnification 1:2.
FIGS. 2 AND 3. NEGATIVE REACTIONS: THE INNER LIGHT
DISC IN FIG. 2 IS DUE TO SLIGHT CONVEXITY
IN THE BOTTOM OF THE TUBE
FIG. 4. FAINTLY POSITIVE REACTION
FIG. 5. WEAK REACTION
FIGS. 6 AND 7. TYPICAL POSITIVE REACTIONS
less than 1 in 10 millions. The type Rh'Rh"
itself is rare, with an incidence of one in ten
thousand, and no individual of this type has yet
been encountered by the speaker. Stratton 31
stated that he has encountered four persons of
this type, two of them siblings. It should be
mentioned that the number of identifiable varieties of human blood is actually considerably more
than 288, because in the calculations given above,
no account has been taken of the blood factor Hr,
or the rare agglutinogens A3, N», etc.
The individual properties of human blood can
be used only to prove that a certain bloodstain
did not come from a certain person; they can never
be used as evidence that a blood stain contains
113
the blood of a specific person. Thus, if the combination of blood factors in the blood stain is not.
identical with that of a given person, that would
prove that the stain does not contain his blood;,
mere identity of types only means that the stain
contains blood of the same type as the person in
question, but the possibility of coincidence can
never be excluded. In a similar way, blood tests
may in certain cases prove that a certain man or
woman is not the parent of a certain child, they
can never prove parentage, because compatibility
of types may be accidental.
With regard to the Rh blood types the following
rules of heredity holds: 37, 44
(1) The properties Rh 0 , Rh' and Rh" cannot
appear in the blood of a child unless present in the
blood of one or both parents.
(2) A class W (type Rh 0 or type Rh-negative)
parent cannot have a class UV (type RhiRh2 or
type Rh'Rh") child, and a class UV parent cannot have a class W child.
The most common type of case where blood
tests are used involve children born out of wedlock, and the mother accuses a certain man of the
paternity of her child, a charge which he denies.
If the accused man is innocent of the charge, his
innocence can be established in a certain percentage of cases by means of the blood tests.
The chances of excluding an innocent man by
tests for the Rh types vary with the Rh type of
the accused man and the distribution of the Rh
types in the general population. With the aid
of general formulae published elsewhere,45, 46 it
can readily be shown that the average chances of
proving non-paternity for white persons in New
York City are approximately 16 per cent and the
chances of exclusion for persons of each of the
eight Rh types is given in table 6. When one
considers, that by means of tests for the A-B
groups, the subgroups of A and AB, and the M-N
types, a falsely accused man has approximately
a 35 per cent chance of proving his innocence, the
Rh tests have now raised the chances of exclusion
to approximately 45 per cent.
CLINICAL APPLICATIONS OF THE R h TYPES
As already mentioned, natural sensitivity to
the Rh types apparently never occurs. At any
rate, no instance of an intragroup hemolytic
transfusion reaction has ever been reported in a
man not previously transfused, or a woman who
has had no previous transfusion or pregnancy.
114
ALEXANDER S. WIENER
Theoretically, individuals m i g h t be considered
capable of being sensitized against a n y of the R h
factors, Rho, R h ' a n d R h " absent from their
blood. Actually, as already mentioned, individuals differ widely in t h e ease with which they
can be sensitized, so t h a t only one in every 25to
SO Rh-negative persons are a p t to have an intragroup hemolytic transfusion reaction or an erythroblastotic infant. Moreover, the properties Rho,
R h ' a n d R h " differ considerably in their antigenicity for man, a n d R h o is b y far the most
i m p o r t a n t factor clinically. F o r this reason,
persons of types R h ' a n d R h " are practically
equivalent to Rh-negative persons clinically,
because such patients lack R h o and are therefore
capable of producing anti-Rho isoantibodies. 2 7 , 3Q
I n s t a n c e s of R h i persons being sensitized against
TABLE 6
APPROXIMATE CHANCES OP EXCLUDING PATERNITY OF
A FALSELY ACCUSED M A N , BY M E A N S OF THE Rh
BLOOD TYPES ( W H I T E INDIVIDUALS, N. Y.
CLASSES
w
u
V
uv
C.)
R h TYPES
CHANCES
OF
EXCLUSION
%
%
36
19
21
23
Rh 0
Rh,
Rh 2
Rh,Rh 2
29
11
13
15
R h TYPES
CHANCES
OF
EXCLDSION
Rh neg.
Rh'
Rh"
Rh'Rh"
Average chances of exclusion (type of accused man not known)
16'
R h " o r R h 2 p a t i e n t s being sensitized t o R h ' a r e
q u i t e rare; 3 9 , 4 7 in fact, when an Rh-positive woman
of t y p e R h i has a n erythroblastotic infant, then,
as will be explained later, this will more likely be
d u e t o t h e H r factor t h a n to factor Rh". 4 8 - 4 9
I n o r d e r to illustrate t h e clinical application of
t h e R h factors in transfusions, a few cases, n o t
previously reported, will be described briefly:
Case 1: This case, referred by Dr. I. M. Westing,
involved a 34 year old woman with anemia due to
lymphosarcoma, treated at a hospital in Brooklyn.
A first blood transfusion had been well tolerated, but a
second transfusion given 15 days later had to be discontinued because of chills and shock, and a third
transfusion 3 weeks later was terminated after 100 cc.
were given because of a chill, rise in temperature to
106°F. and marked tachycardia (pulse rate 220).
Tests on the patient's blood showed her to belong to
group B, type MN and Rh-negative, and anti-Rh
agglutinins (titer 5) were present in her serum. Two
transfusions of bank blood, supposedly group B,
Rh-negative were then given. The first was uneventful; the second was terminated at 400 cc. because of
chills, fever, hemoglobinemia and hemoglobinuria,
followed by profuse bleeding from the gums. Retests
of the latter sample of bank blood showed that it
belonged to group AB (subgroup A2B), type Rh,, so
there had been a double error in typing. Luckily the
patient survived the reaction. A subsequent transfusion of group B, Rh-negative bank blood resulted in a
satisfactory response.
Case 2: A young woman (Jewish Hospital § 272653)
was under treatment for subacute bacterial endocarditis. At another hospital, she had received three
transfusions, the third being interrupted because of a
reaction. Upon admission she was given a transfusion
without apparent reaction; a second transfusion 3
days later caused a mild reaction and the hemoglobin
instead of rising, dropped from 60 per cent to 42 per
cent. A third transfusion 2 weeks later caused a
severe chill and rise in temperature to 103°F. Tests
on the patient's blood showed that she belonged to
group B, type N and type Rh-negative with weak
anti-Rh agglutinins in her serum. For subsequent
transfusions only group B, Rh-negative donors were
used, with satisfactory response.
I n both cases, sensitization to the R h factor
was largely, if n o t entirely due to repeated transfusions of Rh-positive blood to an Rh-negative
p a t i e n t . T h o u g h both patients were female
there was no evidence t h a t previous pregnancies
contributed to the R h sensitization. An example
will now be described of a hemolytic reaction to
a n initial blood transfusion.
Case 3: This patient was a married woman 49
years of age, admitted to service of Dr. Leo M. Davidoff
for an operation for pituitary tumor. During the
operation the patient was given a transfusion of 500 cc.
of apparently compatible blood, and at the close of the
operation it was noticed that there was marked oozing
from the incision. The patient was then given 500 cc.
of plasma and an additional 500 cc. of blood because
of shock. While pre-operatively the hemoglobin
concentration had been 85 per cent, post-operatively
the hemoglobin concentration dropped to 45 per cent.
After the transfusions, the patient passed only 140 cc.
of dark red urine; then she became anuric, comatose
and the blood urea N rose to 62 mg. per 100 cc. A
sample of blood obtained at this time yielded a deeply
icteric serum (icteric index 25), and the patient's
blood was found to be group B, type MN and type
Rh-negative. No anti-Rh isoantibodies (either blocking or agglutinating) were detected in the serum, but
115
Rh BLOOD TYPES
this was not significant because the patient was in the
negative phase. One of the donors whose blood was
available proved to be group B, type MN, type Rhi.
The patient died 48 hours after the operation and
blood transfusions.
The marital history of the patient revealed
that she had been pregnant 5 times. The first
pregnancy resulted in a normal boy, who died
from pneumonia when 14 years old. One child
died in infancy following a circumcision, a second
infant was jaundiced and died after 3 days, and
two pregnancies terminated in stillbirths. Obviously, the pregnancies were the cause of the
patient's sensitivity to the Rh factor, which in
turn was responsible for the fetal and neonatal
deaths as well as the hemolytic transfusion reaction.
The most remarkable aspect of the case was the
prolonged duration of the sensitivity to the Rh
factor. Another unusual aspect is the hemorrhagic symptoms exhibited by the patient as a
result of the hemolytic reaction. Obviously, this
complication is particularly dangerous in surgical
cases. For example, in another intragroup hemolytic reaction due to Rh sensitization recently
referred to the author, in a woman subjected
to a Cesarean operation in a hospital in New
York City, the patient died within six hours from
the resulting loss of blood and shock.
Case 4: This patient was a woman, 50 years of
age, admitted to the 3rd Surgical Ward at Bellevue
Hospital with a diagnosis of bleeding duodenal ulcer.
Transfusions of 500 cc. each of group 0, compatible
bank blood on May 23, 1944, May 27, and June 1 were
followed by no reactions. Following a transfusion
on June 9, temperature rose from 101 to 103°F., and
three weeks later the author was requested to determine the cause of this reaction. Tests showed that
she belonged to group O, type MN, type Rh' and
there were anti-Rho agglutinins (titer 5) in her serum.
This case illustrates the clinical importance of
knowledge of the Rh blood types. Had only
typing serum anti-Rh^ (87 per cent positive) been
used, the patient would have been classed as
Rh-positive, and the cause of the reaction might
have been overlooked. Though this patient had
had 5 pregnancies, it is not likely that these were
the cause of the sensitivity to the Rh factor
because all S children were normal; besides no
reactions occurred until the fourth transfusion,
indicating that the first three transfusions had
been responsible for the sensitization.
The patient's husband was dead, but 4 of her
5 children were available for testing. (The oldest
child was 28 years old, the youngest 16 years old.)
Their types proved to be: A1MNRI12, AiMRh',
AiMN Rh-negative and BMNRh', so that the
husband obviously must have belonged to group
AiB, type MN or M and type RJ12 (genotype
Rhnrh). Of these four children only one (the
type Rii2 child) could have offered an opportunity
for Rh isoimmunization. Incidentally, this family
supplies an example of the heredity of the Rh
types involving the rare gene Rh'.
In view of the observations cited, ideally all
patients who are to be transfused should be
tested for the Rh factor as well as the blood groups
and all Rh-negative patients should only be given
Rh-negative blood. This is not practicable,
however, because of the shortage of good anti-Rh
serum, Rh-negative donors, and properly trained
technicians. Fortunately, it is adequate merely
to take the Rh factor into account in pregnancy
cases,- or patients who have had previous transfusions. In any event, any woman who has had a
stillbirth or an erythroblastotic infant should
only be given Rh-negative blood unless tests
prove that she is not Rh-negative or, at least, not
sensitive to the Rh factor, and the same applies
to a patient who has had a previous transfusion
that was followed by a reaction. Where the
search for Rh-negative donors would unduly
delay an urgent transfusion, Wiener's biological
test with 50 cc. of Rh-positive blood of a compatible A-B group can be tried, since experience
has shown that only a small percentage of Rhnegative patients are sensitive to the Rh
factor. 50,6l If no clinical symptoms and no
darkening in the color of the patient's plasma occur
within one to two hours after the injection of the
test dose of 50 cc. of blood, the patient can be
given any quantity of Rh-positive blood without
danger, (cf. figure 8)
THE H r FACTOR
. I
As has already been mentioned, about 90 per
cent of all instances of intragroup transfusion
reactions or erythroblastosis are due to Rh sensitization. With regard to the remainder of the
cases, a few may be due to isoimmunization to
other factors, such as M, 20 ' 4 0 - l b P, 8 - i0- M A!53
or O.54 One must also bear in mind the possibility of multiple sensitization, so that, for example, a patient could be sensitive to factors M and
Rh simultaneously, and such a patient would
116
ALEXANDER S. WIENER
have to be given type N, Rh-negative blood, of a
compatible group. 40 The most common cause of
intragroup incompatibility in Rh-positive individuals seems to be the Hr factor.
The Hr factor was first described by Levine,
Javert and Katzin 12 ' 65 who found that the serum
of an Rh-positive mother of an erythroblastotic
infant agglutinated all Rh-negative bloods and
those Rh-positive bloods which did not react
with anti-Rh' serum. The symbol Hr was selected
to indicate that the factor in question was opposite to Rh because it is present in all Rh-negative
bloods. Race and Taylor 55 observed a similar
agglutinin in an Rh-positive mother of an erythroblastotic infant, which differed from Levine
of genotype Rh'Rh', for practical purposes this
means that the only Hr negative individuals are
persons of type Rhi, homozygous for gene Rh\
(or far less commonly, of genotype Rh\Rh').
The anti-Hr serums encountered to date have
been of much lower titer than the better anti-Rh
serums. The anti-Hr serums also have the
peculiarity that they give three grades of reactions, strong, weak or moderate, and negative.
When the serum deteriorates, the more weakly
reacting bloods are no longer agglutinated, while
the strongly reacting blood still show distinct
clumping. This accounts for the discrepancy
between the percentage of positive reactions reported by Levine et al. and by Race and Taylor.
FIG. 8. BIOLOGICAL TEST FOR INTRAGROUP INCOMPATIBILITY
A. Appearance of patient's serum before test. B. Patient's serum one hour after injection of Rh-negative
blood. C. Patient's serum one hour after the injection of Rh-positive blood: positive reaction. (From Weiner's
Blood Groups aud Transfusion, 1943. Courtesy of Charles C. Thomas, Publisher, Springfield, Illinois.)
et al's in the higher percentage of positive reactions (80 per cent instead of 30-50 per cent).
Race and Taylor's factor, designated by them
St, is almost certainly the same as Hr, the apparent
differences reported being due to the fact that
Levine et al.'s anti-Hr serum was weaker and
gave many false negative reactions.
According to the hypothesis of Race et al. 3 8
the blood factors determined by genes RI12, Rh",
Rho, and rh react with anti-Hr serum, while the
blood factors determined by genes Rhi and Rh'
do not react. It would therefore be expected that
only bloods of genotypes Rh\Rhi, Rh\Rh' and
Rh'Rh' would fail to react with anti-Hr serum.
In view of the rarity of gene Rh' and particularly
The peculiarities of the Hr reactions can be
explained simply as follows: If we assume that
the Hr factor is inherited as a Mendelian dominant
by a pair of allelic genes, Hr and hr, then as shown
in table 7.
Hr = rh + RhQ + Rh2 + Rh" or W + V
and
hr =R/n + Rh'
or U
Strongly reacting bloods will presumably be of
genotype HrHr and as shown in table 8, should
therefore include all bloods of types Rh2, Rh",
Rho and Rh-negative. Weakly reacting bloods,
of genotype Hrhr, will include type Rl^Rhs,
Rh BLOOD TYPES
type Rh'Rh", type Rhi (genotypes Rh\rh, RhiRho
and RhoRh') and heterozygous individuals of
type Rh'. Negatively reacting blood, as already
mentioned, can only occur in type Rhi or very
rarely in type Rh'. This theory has been confirmed by studies on families by Race and Taylor, 57
and by studies on the distribution of the Hr
factor among Negroes and Whites by Wiener,
Davidsohn and Potter. 58 For example, Hrnegative-individuals were encountered in approximately 25 per cent of the white population, but in
only 2 per cent of the Negro population, as was
to be expected from the differences in the distribution of the Rh types.
TABLE 7
THE Hr FACTOR AND THE Rh GENES
REACTION WITH
A N T I - H r SERUM
Hr GENES
R h GENES
Hr
hr
rh, Rho, Rhi and Rh"
Rh,. and Rh'
Positive
Negative
117
panel of Hr-negative donors as well as Rh-negative donors. When a type Rhi patient has an
intragroup hemolytic reaction, and incompatibility to factors such as M or P can be excluded,
a biological test with Hr-negative blood would
be worth trying.
TRANSFUSION THERAPY OF HEMOLYTIC DISEASE
OF THE NEWBORN
The discovery of the role of isoimmunization
in pregnancy in the pathogenesis of hemolytic
disease of the newborn has made possible a more
rational transfusion therapy of the disease. The
general principle when selecting donors for these
infants is the same as that for transfusing their
mothers, or any patient who has had previous
intragroup hemolytic reactions, except that the
infants have been passively instead of actively
sensitized to the Rh factor. The severity of the
disease in the infant depends upon the amount of
Rh isoantibodies that pass into its body through
the placenta from the mother. The disease may
TABLE 8
THE Hr TYPES AND GENOTYPES IN RELATION TO THE Rh TYPES AND GENOTYPES
Hr
GENOTYPE
REACTION WITH
A N T I - H r SERUM
Rh
HrHr
Strong
rhrh, Rharh, Rh0Rh„, Rhrh, RhRh,
Rh"Rh0, Rh"rh and Rh"Rh"
Hrhr
Weak or
Medium
Rhrh, RhtRho, Rh'RIh, Rh'rh, RhRh,
Rh'Rh"
hrhr
Negative
RhRh,
RhRh'
R h TYPES
GENOTYPES
and Rh'Rh!
A common misconception that arose from the
earlier vague reports on the Hr factor is that in
cases of erythroblastosis due to the Hr factor, the
mother is Rh positive and the child Rh negative.
Actually the child is never Rh-negative in such
cases, because the mother who must be Hr
negative, and therefore must belong to genotype
RhiRhi, RhiRh' or Rh'Rh', must transmit either
an Rhi or an Rh' gene to every child. In cases of
hemolytic disease caused by Hr sensitization,
the mother belongs to type Rhi; there is no
restriction on the Rh type of the father since Hr
positives occur in all the 8 Rh types, but the
child's blood cannot belong to type Rh2, Rh",
Rho or Rh-negative.
A complete transfusion service should include a
RhRh",
RhRh0,
Rh,Rh", Rh'Rh and
Rh neg., Rh 0 , Rh 2 and Rh"
Rh,, Rh',
Rh'Rh"
Rh,Rh 2
and
Rhi and Rh'
be so mild that spontaneous recovery occurs and
the condition may be entirely unnoticed or confused with physiologic icterus of the newborn;
or the disease may be so severe that the infant is
stillborn. In severe cases where the infant is
born alive, death may occur within a few hours or
days; or else the infant may appear entirely normal
at birth, and develop an insidious anemia which
may result in death within the week. The
mysterious lack of correlation between the titer
of the maternal Rh isoantibodies and the severity
of the disease in the infant55, 5 9 , 60 has apparently
been solved, at least in part by the discovery of
the Rh blocking isoantibodies.15
For transfusing infants with hemolytic disease,
maternal blood should not be used, because the
118
ALEXANDER S. WIENER
additional isoantibodies injected into the infant
may increase the severity of the disease. The
father's blood or any blood sensitive to the action
of the- maternal isoantibodies should not be
transfused, because the infant's body may contain enough isoantibodies to hemolyze all its own
blood and any additional blood injected, so this
would prolong and aggravate the disease. As
Levine and Katzin have suggested, in the usual
case involving the Rh factor, Rh-negative blood is
to be preferred.61 Wiener and Wexler62 have
cited case reports illustrating the life-saving value
of • Rh-negative blood and similar experiences
have been described by Gimson.63 When Rhnegative donors are not available, the mother's
citrated blood can be washed twice with saline
solution to free the cells of plasma, and the
washed cells resuspended in compatible plasma
can be used for the transfusion. This procedure
has the advantage that it can always be used;
also in problem cases involving Rh-positive
mothers, while Rh-negative blood will be satisfactory only in the common case of Rh sensitization involving an Rh-negative mother or a mother
of type Rh' or Rh". 27 In emergencies, where
neither Rh-negative nor maternal blood is available, any donor of a compatible group should be
taken in order to tide the infant over until a more
suitable donor can be found. As part of the
treatment, breast feeding should be interdicted,
because additional Rh isoantibodies may be
ingested by the infant in the milk.27- 64' 65, 66
Direct evidence of the superiority of Rhnegative blood for treating the usual case of
hemolytic disease has been obtained by Mollison67
who traced the fate of the donor's blood in the
infant's circulation by the method of differential
agglutination. While Rh-negative blood survived for periods up to three months, Rh-positive
blood was often eliminated within 4 or 5 days.
Similar observations have been made by me. 62
Since the average newborn infant weighs about
7 lbs. and has a blood volume of 250 c c , two
transfusions of 75 cc. will usually be sufficient
because they will maintain the infant's hemoglobin
above 60 per cent. In mild cases, a single transfusion may be sufficient, while in the more severe
cases a third or even a fourth transfusion maybe
required. The following case taken from the
paper of Wiener, Wexler and Gamrin 68 is cited
to illustrate the dramatic, life-saving effect of
proper transfusion treatment in hemolytic disease of the newborn.
Case 6: A woman, pregnant for the second time,
was near term and gave the history that her first
child, a boy now 3 years old, had become anemic
shortly after birth (delivery by Cesarean section),
and had required a number of transfusions over a
period of a month. Blood tests on the woman, her
husband and child revealed the following:
Blood of
Group M-N Type
Woman
Husband
Son (3 yrs. old)
0
0
0
N
' MN
MN
Rh-Type
Negative
Rh,Rh2
Rh!
These findings supported the diagnosis of erythroblastosis and the woman was evidently sensitized to
the Rh factor. Moreover, it was evident that the
expected child had to be group 0, and Rh-positive
(type Rh! or Rh2) and therefore susceptible to the
maternal isoantibodies. Accordingly, blood was drawn
from a group O, Rh-negative donor in preparation for
transfusing the expected infant. This precaution
proved life-saving, because the infant when it was
delivered by Cesarean section, was extremely pale
(subsequent tests indicate that the hemoglobin concentration at birth must have been approximately 20
per cent), breathed poorly and was very feeble. The
transfusion was started at once and 160 cc. of blood
were transfused because of the infant's poor condition.
This revived the infant in a spectacular fashion and
the infant was sent to its room in good condition.
The subsequent course was practically uneventful
except that another transfusion of 75 cc. of blood was
necessary when the infant was one month old. The
results of repeated hemoglobin determinations are
charted in figure 9; while the total hemoglobin concentration did not show striking changes, the partition
of this value into the patient's and donor's blood
yielded illuminating results. It is of interest to note
how for a period of about a month, the only blood in
the infant's circulation was that derived from the
donor. Then, gradually, as the donor's blood was
eliminated, it was replaced by newly formed blood of
the infant. When last seen at the age of 3 months,
the infant was normal, having recovered .completely
from the hemolytic disease.
CONCLUSIONS
Within the short space of four years, the discovery of the Rh factor has served to open an
interesting but intricate subject with important
applications in clinical and legal medicine. Since
the subject is apparently still in its growth phase,
it is difficult to prepare a comprehensive review,
entirely up-to-date. Observations may even be
made, while this review is in press, that may
render obsolete some of the statements or ideas
included in the review. We may all look forward,
therefore, with pleasant anticipation to the next
Rh BLOOD TYPES
few years a n d t h e further developments t h a t t h e y
may bring.
119
immune sera for Rhesus blood. Proc. Soc.
Exper. Biol, and Med., 43: 223, 1940.
"T" • i<»
DAY op- Life
FIG. 9. RESULTS OF HEMOGLOBIN AND DIFFERENTIAL AGGLUTINATION T E S T S ON INFANT OF CASE 6
REFERENCES
la. POTTER, E. L.: Present status of the Rh factor.
Am. J. Dis. Child., 68: 32, 1944.
lb. BROMAN, B.: The blood factor Rh in man. A
clinico-serological investigation with special
regard to Morbus Haemolyticus Neonatorum
("Erythroblastosis Foetalis") Acta paediat,
31: Supp. II, Stockholm, 1944. •
lc. BOYD, W. C : The Rh blood factors; An orientation review. Arch. Path. In press.
2. ZACHO, A.: "Unvertraglichkeit" zwischen Blutproben von gleichem Bluttypus, beruhend auf
dem Verhandsein eines irregularen Agglutinins
gegenuber einen bisher unbekannten Rezeptor.
Ztschr. f. Rasseuphysiol., 8: 1, 1936.
3. CULBERTSON,
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