RECENT DEVELOPMENTS IN THE KNOWLEDGE OF THE Rh-Hr
BLOOD TYPES; TESTS FOR Rh SENSITIZATION*
ALEXANDER S. WIENER, M.D.
From the Blood Transfusion Division of the Jewish Hospital of Brooklyn and the Serological
Laboratory of the Office of the Chief Medical Examiner of New York City
It was with much pleasure that I received the news that the Ward Burdick
Award, the highest honor of our Society, has been bestowed this year upon
Dr. Philip Levine and me jointly for our work on the Rh blood factors. I
sincerely appreciate this recognition which has been accorded to our investigations and believe that it will stimulate us to increase our efforts.
Because of its important social implications, the Rh factor has gained a good
deal of notoriety in the lay press, and numerous misconceptions have become
widespread among physicians as well as laymen. In one state legislators have
gone so far as to propose premarital Rh testing while in other states, somewhat
more reasonable bills have been proposed to test for Rh prenatally. Obviously,
laws of this nature are premature and dangerous as long as facilities are not
available for reliable Rh testing and as long as the profession is not fully informed
as to the nature and interpretation of the Rh tests. For example, some women
have been warned not to become pregnant merely because they are Rh-negative,
even though no tests had been made for the presence or absence of Rh sensitization. We therefore welcome this opportunity to crystallize our recent investigations in the field. Because the field of Rh factors and its practical applications
have widened considerably in scope during the past few years, it was suggested
that Dr. Levine and I each discuss different aspects of the subject. My own
presentation will be limited to the theory, heredity, and anthropologic applications of the Rh-Hr blood types, and also to the newer tests for Rh sensitization,
subjects to which I have devoted a good deal of my attention during the past
few years.
THE EIGHT R h BLOOD TYPES
The Rh or rhesus factor obtained its name when the first antiserums were
prepared by injecting into experimental animals blood of rhesus monkeys.11'12
At present, antiserums of human origin are usually used, either from patients
who have had intragroup hemolytic reactions, or from mothers of erythroblastotic infants. In some recent experiments,64 I have also succeeded in producing high-titered anti-Rh agglutinating serums in normal male individuals
by repeated injections of Rh-positive blood. The human serums have the
advantage of higher specificity and potency, so that less experience is required
*Read by title at the Twenty-Fourth Annual Meeting of the American Society of
Clinical Pathologists, San Francisco, California, June 28, 1946.
Received foT publication, June 5, 1946.
This paper, together with one entitled, "The Present Status of the Rh Factor" by Dr.
Philip Levine, to be published in a subsequent issue, constitutes the Ward Burdick Lecture.
477
478
ALEXANDER S. WIENER
for their satisfactory use, thus explaining their greater popularity over animal
anti-rhesus serums. While all the animal anti-rhesus serums produced to date
have given identical reactions in parallel tests,12 three distinct varieties of Rh
antiserums have been obtained from human sources.37 Of the human Rh
antiserums, the one corresponding to the original anti-rhesus serum, reacting
with the bloods of approximately 85 per cent of Caucasians, has been designated39
as anti-Rho. For the other two antiserums I selected the designations anti-Rh'
for the one giving 70 per cent positive reactions,3361 and anti-Rh" for the one
giving 30 per cent positive reactions,37163 to indicate that these two antiserums
are on an equal plane and to distinguish them from the more important anti-Rh0
serums.
The three varieties of Rh antiserums detect the presence or absence of three
corresponding Rh factors in human blood, Rh 0 , Rh', and Rh". Of these, Rh 0
is by far the most antigenic and therefore the most important clinically.72 For
solving most clinical problems, it is therefore sufficient to make tests with standard anti-rhesus animal serums, or, preferably, with human anti-Rho serum.
This procedure is known as Rh testing,43 and with its aid individuals may be
classified as either Rh-positive or Rh-negative (or, more strictly, Rh0-positive
and Rho-negative). Until recently only limited amounts of anti-Rho testing
serums were available, but now that our recent experiments indicate the feasibility of preparing immune anti-Rh serums in male individuals, there should
soon be ample quantities to meet all demands. Anti-Rh' and anti-Rh" serums
are as yet available only in very limited quantities, st> for the time being, it will
usually be necessary to call upon the aid of specialists in the field whenever tests
with standard anti-Rh 0 serums fail to resolve a difficult problem.
When tests are made with all three Rh antiserums, the bloods of human
beings can be subdivided into eight types;38 this procedure is called "Rh typing"
to distinguish it from "Rh testing" or testing with anti-Rh 0 alone.43 This is
not as complicated as it sounds, if the following principles are borne in mind.
Anti-Rh' and anti-Rh" are related like the agglutinins anti-A and anti-B,37 so
in tests made only with anti-Rh' and anti-Rh", four types are differentiated
which are analogous serologically and genetically to the four blood groups.
Since every individual is also either Rh 0-positive or Rho-negative, each of the
four types may be further subdivided into two, and a double scheme of four
types each results as shown in table 1. Thus, the scheme of eight Rh types
only amounts to a double blood group scheme, so that any one familiar with
the four Landsteiner blood groups can quickly master the eight Rh types.
As for the names of the eight Rh types, these are merely determined by th
antiserums with which the blood reacts. 3970 Thus, type rh 0 blood is so named
because it reacts with anti-Rho, but not with anti-Rh' or anti-Rh" serums;
type R h ' blood, on the other hand, reacts with anti-Rh', but not with anti-Rhn
or anti-Rh" serums; and so on. Blood not reacting with any of the three Rh
antiserums is simply designated type rh, or rh blood. This designation, besides
being simple, has the advantage of avoiding ambiguity, since type rh is not
identical with Rh-negative. The latter refers to blood giving a negative reaction
479
DEVELOPMENTS IN R h - H r BLOOD TYPES
when tested with standard anti-Rh (anti-Rh 0 ) serum alone. Blood which for
clinical purposes is Rh-negative (Rh0-negative) actually includes the four types
rh, Rh', Rh", and Rh'Rh" (see table 1); i.e., patients belonging to any of these
four types should be considered Rh-negative when they are given blood transfusions, or in obstetrical problems related to the Rh factor. As donors for
transfusions, on the other hand, only individuals of type rh should be used,
because type Rh' or type Rh" blood cause reactions in individuals sensitized
to these blood factors.
Of the designations of the Rh blood types, the only ones that may cause even
the slightest confusion are those for types Rhi and Rh 2 . Type Rhi (or Rho) is
the designation of blood reacting with anti-Rh' and anti-Rho, but not antiRh" serums; while type RI12 (or Rh 0 ) is the designation of blood reacting with anti-Rh" and anti-Rh 0 , but not anti-Rh'. The designation Rhi
and Rh2 were selected38 to indicate that the factors Rh 0 and Rh' in the
former, and Rh 0 and Rh" in the latter, are usually combined to form unit
agglutinogens inherited by corresponding genes Rl and R2. For example, in
TABLE 1
SCHEME OF THE E I G H T R h
CLINICALLY Rh-NEGATIVE INDIVIDUALS ( I S PER CENT)
BLOOD T Y P E S
CLINICALLY R h - P O S I T I V E INDIVIDUALS (85 PER CENT)
Reaction with antiserum
Rh"
+ + 11
Rh'
Rho
-
rh c
Rh! (Rh0')
Rh2 (Rh0")
RhiRh 2 (Rho'Rho")
Rh"
Rho
+ + 11
Rh'
1+ 1+
rh
Rh'
Rh"
Rh'Rh"
Reaction with antiserum
Designations of types
+ 1 +1
Designations of types
+
+
+
+
mating of a type Rhi individuals with a type rh individual, if type Rhi were
really Rh 0 Rh' then half the children would be expected to belong to type rh 0
and half to type Rh'. Actually, in some families all the children are type Rhi;
while in most other families half are type Rhi and half type rh.67'68 This occurrence is explained by assuming that type rh individuals all belong to genotype
rr, and that the type Rhi individuals in the former families are of genotype
RlRl, while in the second type of family the genotype is Rh. Thus, Rhi is
merely an abbreviated designation for Rh 0 while Rh2 is an abbreviation for
Rho . Since medical men are already accustomed to numerous abbreviations,
it is not too much to ask them to learn two more in order to streamline the
nomenclature of the Rh blood types. If, as one well-known geneticist has
asserted, these two simple abbreviations render comprehension of the Rh types
too difficult for the average student and practitioner, then the entire science
of shorthand must have been the invention of the devil!
For the intelligent application of the Rh types in problems of erythroblastosis,
some knowledge of their heredity is essential. Considering first the property
480
ALEXANDER S. WIENEK
Rh 0 alone, with which the clinician will be most often concerned, Landsteiner
and Wiener12'62 have shown that it is transmitted as a simple Mendelian dominant, by a pair of allelic genes, Rh and rh. Therefore, Rh-negative individuals
are always homozygous (genotype rhrh), while Rh-positive individuals may be
homozygous (genotype RhRh) or heterozygous (genotype Rhrh). Obviously,
if both parents are Rh-negative, all the children must be Rh-negative. If one
parent is Rh-negative and the other Rh-positive, there are two possibilities:
either all the children will be Rh-positive (when the Rh-positive parent belongs
to genotype RhRh), or half'of the children will be Rh-positive and half Rh-negative (when the Rh-positive parents belongs to genotype Rhrh). When both
parents are Rh-positive all the children will be Rh-positive, except when both
parents are heterozygous (genotype Rhrh), in which case three-fourths of the
children will be Rh-positive and one-fourth Rh-negative.
TABLE 2
EIGHT Rh TYPES AND THEIR TWENTY-ONE GENOTYPES
R h BLOOD TYPES
rh
Rh'
Rh"
Rh'Rh"
rh c
Rh t
Rh2
RhiRh2
POSSIBLE GENOTYPES
rr
R'R' and R'r
R"R" and R"r
R'R"
r"r" and r°r
RlR\ RiR\ Rlr, Rh", and R'r'
R*R\ R*R", Rh, Rh", and R"r°
R'R2, R'R", and R'R*
To explain the heredity of the eight Rh types, a much more complicated
scheme must be invoked. According to the theory proposed by me,38 the Rh
blood types are transmitted by a series of six allelic genes, designated70 as R1,
R2, r°, R', R", and r, respectively, according to the agglutinogens which they
determine, so that 21 genotypes are possible instead of only 3 (see table 2).
Actually, the sitution is even more complicated because of the existence of the
rare Rz gene21 and the intermediate genes,41 but for practical purposes in clinical
medicine, it is sufficient to memorize the scheme of six allelic genes.* Knowledge
of the Rh types makes it possible at times to determine that an individual is
homozygous for the Rh 0 factor, information of importance when determining the
prognosis in cases of erythroblastosis. For example, individuals of type RhiRh 2
are almost always homozygous (genotype RXR2), so that when the husband of
an Rh-negative woman belongs to this type, one may predict with reasonable
certainty that all the children will be Rh-positive (half type Rhx and half type
RI12). However, any discussion of the heredity of the Rh blood types must
take into account the so-called Hr factors, which will now be discussed.
*In this connection, the so-called c w factor described by Race and coworkers,23 has all
the characteristics predicted by me41 for the hypothetical Rh'" factor.
DEVELOPMENTS IN R h - H r BLOOD TYPES
481
THE Hr BLOOD FACTORS
Early in the studies on the Rh factors evidence was obtained that Rh-negative
blood is not merely characterized by the absence of agglutinogens.16 All Rhnegative bloods were found to possess an antigen which, because of its apparent
reciprocal relation to the Rh factor, was designated the Hr factor.13 The
original description of the Hr factor and its properties was incomplete and inaccurate, because of the low potency of the serum then available. When more
potent serums became available, it was found that the so-called Hr factor is
related to the factor R h ' just as M is related to N, u.2i&f& and therefore, the
original Hr factor (and the only one generally available at the present time) is
now known45 as Hr'. Another Hr factor, reciprocally related to Rh" and therefore designated as Hr", has recently been found by Mourant, 19 but to date no
factor has been found giving reactions corresponding to those predicted forHr 0 .
Because of its reciprocal relation to Rh', the Hr factor makes it possible to
divide types Rhi and Rh' each into two subtypes, thus increasing the number of
Rh types from eight to ten. Similarly, with anti-Hr" serums it is possible to
divide types Rh2 and Rh" into two subtypes each, so that one can now identify
as many as 12 Rh-Hr blood types. In view of these newer findings on the Hr
blood factors, it has become necessary to enlarge the original nomenclature of
the Rh blood types. In selecting names for the new subtypes, the original
principle of simplicity without ambiguity was adhered to by me,61 and it is
believed that the scheme presented in table 3 is probably the simplest and
most satisfactory one possible.
Unfortunately, it seems that almost every worker who has had occasion to
write on the subject of the Rh blood types has felt impelled to suggest some
variation in the nomenclature.6'20'26 When I proposed my original notations, 38
it seemed hardly necessary to point out that the most important part of the
work was to determine the nature of the various antiserums, the relations of the
Rh blood types to one another, and the mechanism of their hereditary transmission. The naming of the types was only of secondary importance, and an
infinite number of possibilities immediately suggested themselves. When it
became necessary to make a decision, the simplest scheme was selected which
took into account the genetic and serologic facts, and which entailed the least
number of changes from the nomenclature used in our earlier work in 19411943.33 M ,61 There were many schemes subsequently suggested by other workers
as "new" nomenclatures, which we had previously discarded.Inasmuch as the
original nomenclature has been so widely adopted and found generally satisfactory, any attempt to introduce a new system merely serves to create unnecessary confusion. In the future, no modifications should be introduced
except those which are made necessary by new discoveries or are obviously advantageous and do not entail too great a change from the system now adopted.
In clinical medicine, the Hr factors have not found much practical application
because they are far less antigenic than the Rh factors and therefore only rarely
give rise to intragroup transfusion reactions or erythroblastosis fetalis. Their
main application has been as a presumptive test for homo- and heterozygosity for
482
ALEXANDFR S. WIENER
type Rhi individuals, particularly in determining the prognosis for future
pregnancies in cases where women have become sensitized to the Rh factor.66
Another important application of the Rh-Hr tests is in medicolegal cases of
disputed parentage, as will how be described.
TABLE 3
CLASSIFICATION OF Rh
BLOOD T Y P E S AND S U B T Y P E S
REACTION WITH
SERUM
REACTION WITH SERUM
R h BLOOD
GENOTYPES
AntiRh'
AntiRh"
AntiRho
rh
Neg.
Neg.
Neg.
Rh'
Pos.
Neg.
Rh'
Neg.
Rh'Rh"
APPROXIMATE
DISTRIBUTION
(PERCENTAGE
Rh
SUB-TYPES
AntiHr'
AntiHr"
CAUCASIANS IN
NEW YORK CITY)
rr
Pos.
Pos.
13.0
Neg.
R'R'
R'r
Neg.
Pos.
Pos.
Pos.
Rh'Rb'
Rh'rh
.:?} '•»
Pos.
Neg.
R"R"
R"r
Pos.
Pos.
Neg.
Pos.
Rh'Rh"
Rh"rh
»:f} •••
Pos.
Pos.
Neg.
R'R"
Pos.
Pos.
rho
Neg.
Neg.
Pos.
ifQ/yQ
Pos.
Pos.
Rhi (Rh 0 ')
Pos.
Neg.
Pos.
Neg.
Pos.
RhjRhi
Pos.
Pos.
Rh.rh
Pos.
Neg.
Rh 2 Rh 2
Pos.
Pos.
Rh 2 rh
Pos.
Pos.
RW
Rh
.01
2.0
20.0 1
[ 54.0
34.0 J
R'r"
Rh 2 (Rh 0 ")
Rhillhj
Neg.
Pos.
Pos.
Pos.
Pos.
Pos.
R2R2
RtR"
Rh
Rh"
R"r"
RW
R'R2
R'R"
3.0 1
| 15.0
12.0 J
14.5
MEDICOLEGAL APPLICATION OF THE R H - H R BLOOD TYPES
The Rh-Hr blood types have considerably enhanced the usefulness of blood
tests in forensic medicine for criminal identification and in cases of disputed
parentage46,42,46'61'64 Formerly, with the aid of the six blood groups and subgroups (O, Ai, A2, B, AiB and A 2 B), the three MN types (M, N and MN), and
the agglutinogen P ( P + and P —), a total of 6 X 3 X 2 or 36 varieties of human
blood could be differentiated. The ten Rh-Hr types have multiplied the number
of types possible, so that now 360 varieties can be differentiated. In paternil y
DEVELOPMENTS IN R h - H r BLOOD TYPES
483
disputes, with the aid of the ABO groups and MN types, a falsely accused man
formerly had one chance in three of proving his innocence. Now that the Rh-Hr
types have been added, an innocent man has approximately a 50 per cent chance
of being excluded by the blood tests.42
Table 4 illustrates the value of the Rh-Hr tests in forensic medicine; it lists
my first 70 paternity cases in which complete blood tests (except for agglutinogen P) were performed. It will be seen that there are 5 cases where paternity
was excluded by the RhHr tests, but in which no decision would have been
possible had the tests been limited to the ABO groups and MN types. Of
particular interest is case number 73, in which the supposed father was excluded
on the following three separate counts: (1) the mother belonged to group O and
her child to group B so that the father had to belong to group B or group AB,
while the accused man belonged to group A; (2) the mother belonged to type N
and her child to type MN so that the father had to belong to type M or type MN,
while the accused man belonged to type N ; (3) the accused man belonged to
type RhiRhi and so could not be the father of the child who belonged to type rh.
An exclusion on the basis of any one of these three tests would have been sufficient
to prove that the accused man was not the father.
R h - H r BLOOD TYPES IN ANTHROPOLOGY
The discovery of the Rh blood types has considerably enhanced the value
of blood tests in anthropologic investigations, and is largely responsible for the
recently increased interest of anthropologists in blood grouping. Already many
investigations have been carried out on the distribution of the Rh-Hr types
among various populations throughout the world, as is shown in table 5.
In anthropology, blood tests are of value in that they can be readily and
accurately determined at any time during life, since they remain unchanged
from birth to death and are not influenced by disease or other environmental
agents.36 Moreover, their occurrence is predictable on the basis of simple
mendelian laws of heredity. These advantages do not exist in the case of
certain other characteristics studied by anthropologists such as height, shape
of the head and face, and color of hair. The blood tests have little value when
applied to single individuals because the blood factors are not restricted to any
particular division of mankind, in contrast to such traits as the black skin of
Negroids and the slanting eyes of the Mongoloids. Until recently, when studies
were limited to the four Landsteiner blood groups, 0, A, B and AB, and the
three M-N types, M, N and MN, the tests had the limitation that the differences
in distribution among various ethnic groups was purely quantitative. For
example, no reliable conclusion could be drawn from a difference in the frequencies of the groups and types, unless the past history of the population was
known, because the distribution of the blood factors could readily be modified
by isolation and inbreeding of relative small numbers of individuals, as in the
case of the Pacific Islanders. The influence of crossing is well exemplified by
Candela's work4 in correlating the decrease in incidence of group B from East
to West in Eurasia with the Mongolian invasions during historic times.
484
ALEXANDER S. WIENER
The recent investigations on the subgroups of A and the Rh-Hr has changed
the situation, because it is now possible to demonstrate certain qualitative difTABLE 4
A P P L I C A T I O N O F A I - A 2 - B - 0 , M-N,
CASE
NUMBER
PUTATIVE FATHER
AND R h - H r T E S T S I N D I S P U T E D P A T E R N I T Y G A S E S
MOTHER
CHILDREN
It
(a) AiMRhjRh,
(b) O M N R h i R h ,
OMNRhirh
(a) O M R l n R h 2 9
(b) O M R h i R h ! ?
(c) A i M R h i R h j 9
2
A 2 MNRh 2
A2NRhtrh
BMNRhiRh 2 cf
3
4
5
6
7
A2BMRhirh
AiMNRhiRh,
OMNRh^h!
AiBMRhiRhi
OMNrh
OMNRbiRh 2
BMNRhiRh,
OMNRhiRh!
ONRh^hi
OMRhiRhi
AiMNRha
OMRhjrh
BMNrhc
AiMRhiRh 2
BMrh
A 2 Mrh
OMRh!Rh!
A 2 MRh 2
OMNRhiRh2
OMNRhiRh,
BMrh fl
BMNrh
AiBNRhiRhi
AiNRhiRh,
AiBNrho
A,NRhirh
OMNRhirh
AiNRhirti
BNRh2
AjMNRhjRh^
AiBMNRhiRh,?
OMRhiRhi 9
BMNRhiRhicf
(a)f OMRhirhcf
(b)f O M N R h i r h 9
A,MNRh 2 9
OMRluRhjcT
BMrho 9
A.MRlurhcT
BMNRhirh 9
AiMNRhiRh, 9
BMNRhirh 9
(a) A i M N R h 2 9
(b) A t M N R h 2 9
OMNRhjrhcf
BNRhiRhicf
A 2 MNRhirhcf
8*
9
10*
11
12
13
14
15
16 OMNRhjrh
17 B M N R h i R h i
18* OMrh„
19
20*
21
22
23
AiMNRh^hi
OMrho
AiMNRhuh'
AjMNRhirh
AiMRhiRhi
BMNRhiRhi
ONRhjRh,
AiMNRhiRh,
OMRhiRh 2
OMNRhirh
OMRhiRhicT
OMNR^d"
AiMNRhiRh,?
0MRh*9
OMNrhod 1
24
BMRhiRhi
AjMNRhirh
AiBMRhjRh^
Ai, 2 MNrh 0
AiMRhiRh 2
OMNrho 9
AiMRh 2 cf
25* ONRhirii
26 A i M R h i R h !
27
28J
BMNRhiRhj
(a) A 2 MRhiRh!
(b) B M N r h
OMNRh 2
BMNRhiRh,
OMRhirhcf
A 2 BMRhiRhi 9
29
30
OMNRhirh
AiMNRhjRhi
OMNRh,Rh 2
OMNrh
OMNRh^h 9
(a) A i M N R h i r h 9
(b) A i M N R h i r h 9
INTERPRETATION
P u t a t i v e father (b) excluded b y A-B-0 tests
for child (c). No conclusion possible for
t h e other two children
Exclusion by A-B-0
tests
No exclusion
No exclusion
No exclusion
No exclusion
No exclusion
No exclusion
No exclusion
No exclusion
N o exclusion
No exclusion
Exclusion by Rh tests
N o exclusion
No exclusion
No exclusion
No exclusion
Double exclusion by
A-B-0 and Rh tests
No exclusion
N o exclusion
No exclusion
No exclusion
Exclusion by Rh-Hr
tests
N o exclusion
No exclusion
Exclusion by R h - H r
tests
No exclusion
P u t a t i v e father (b) excluded by A-B-0 and
R h - H r tests
No exclusion
No exclusion
DEVELOPMENTS IN R h - H r BLOOD TYPES
485
T A B L E 4—Continued
CASE
NUMBER
PUTATIVE FATHER
MOTHER
CHILDREN
3 1 * | (a) A 2 Mrh c
(b) OMNRh 2
32* ONRhirii
33 B N R h 2
34 OMRluRh 2
BMNRhirh
A 2 BMRhirhd"
OMrhc
AiBMNRhiRh!
OMrho
35
36
37*
38*
39
40
A 1 MRh 1 Rh 2
OMRhirh
OMrh
AiMNrho
OMrh
AiMNRh 2
OMNRhirh
A^rh
Ai, 8 Nrho
OMRh!Rb 2
BMRhirh
OMNRhiRhi
OMrho 9
AiNRhjrhcf
(a) O M R h 2 9
(b) OMRh 2 cf
AiMNRhiRhi 9
OMrhcT
Ai.zMNRhirhcf
OMNRh 2 9
BMRhirh 9
BMNRhirhrf 1
41
42
43
44
AiMNRhirh
AiNRhiRhi
OMRh 2
ONRlurh
BMRhirh
A 2 NRh 2
BMNrh
ONRh 2
45
46
A,Mrh
A 1 NRh 1 Rh 2
OMNRhirh
OMrh
OMRhirhd 1
AjNRhiRhscf
B M N r h cf
(a) O N R h i R h 2 9
(b) A i N R h 2 9
OMNrh„ 9
OMrh 9
47
48
49*
50
51
52
OMNRh 1 Rh 1
OMRhjRhi
OMNRhjRha
OMNRhiRha
OMNRhirh
ONRhjrh
AiNRhirh
A!MNRhiRh 2
OMRhirh
OMNRhirh
BMRh 2
OMNRhirh
AiMNRhjRh^
AiMNRhjRh, 9
OMNRh 0 <"rhc?
OMNRhirh 9
BMNRhiRh 2 C f
AjMNRhiRhirf 1
53
54
55
56
OMNRh 2
BMNRh,Rh2
OMRhiRh 2
A.BMNRhiRhi
AiBMNRhtRhi
OMNRhirh
OMrho
OMRhirh
BNRhiRh2 9
BMNRhiRhad"
OMRh 2 c?
OMNRhjRlu 9
57
58
59
60*
OMNRhirh
OMNrho
ONRhirh
A 2 NRhjrh
OMNRhirh
A 2 NRhiRh!
AiMNRhirh
AiMRhiRhi
ONRhiRhic^
A 2 MNRhirh 9
AiMNrh 9
BMRhiRh, 9
AiMNRhirh
OMRh 2
A 2 MRhjrh
AiMNRhiRhi
AiMNrh cf
BMNRh 2 o"
BMrhocf
(a) BMNRhiRhic?
(b) AJVrNRKiRhstf
AiMNRhirh
ONRhiRhi
OMrh
AiBNRhiRh,
ONRhirh
OMNRhiRhi 9
AiNRhirhcf
OMrho 9
AiNRhirh 9
AiMNRhirh 9
61 AiMRh'rh
62 AiBMNrh
63* BMNrho
64 A 2 NRh 2
65
66
67
68
69*
OMRhiRh!
AiMNrh
OMNrhc
OMNRhirh
AiMrho
INTERPRETATION
P u t a t i v e father (b) excluded by A-B-0 tests
Exclusion by M - N tests
No exclusion
No exclusion
No exclusion
No exclusion
Exclusion by R h tests
No exclusion
No exclusion
Exclusion by A - B - 0
tests
No exclusion
N o exclusion
No exclusion
Child (b) excluded b y
A - B - 0 tests
No exclusion
Exclusion by M-N tests
Presumptive exclusion
by Rh tests
Exclusion by R h t e s t s
No exclusion
No exclusion
N o exclusion
No exclusion
Exclusion by A-B-0
tests
No exclusion
No exclusion
N o exclusion
Exclusion by A-B-0
tests
No exclusion
No exclusion
N o exclusion
Double exclusion by
A-B-0 and M-N tests
N o exclusion
No exclusion
No exclusion
First child excluded by
A - B - 0 and R h - H r
tests
N o exclusion
No exclusion
No exclusion
No exclusion
No exclusion
48fi
ALEXANDER S. WIENER
TABLE 4—Concluded
CASE
NUMBER
POTATIVE FATHER
70
71*
72*
73
AjBMNRhjRhi
ONRlnrh
OMRhirh
A 2 NRhiRhi
MOTHER
AiMNRh 2
OMNRhjrh
OMNrh
ONRh"
CHILDREN
AiMNRh 1 Rh 2 C f
ONRhiRhid"
OMNrhoc?
BMNrh 9
INTERPRETATION
No exclusion
No exclusion
No exclusion
Triple exclusion by AB - O . M - N , and R h - H r
tests
* Colored.
t Twins.
t (a) Husband (b) Other man.
lerences in the distribution of the blood properties in different peoples. These
findings confirm the broad separation of mankind into three divisions characterized as follows: Caucasoid group,—highest incidence of gene r, relatively high
incidence also of genes R1 and A2, moderate frequencies of other blood group
genes; Negroid group,—highest incidence of gene r°, moderate frequency of r,
highest relative incidence of genes A2 and the rare intermediate A and Rh genes;
and Mongoloid <7rowp,^-virtual absence of genes r and A2, highest incidence of
rare gene R".
These facts can be applied immediately to solve certain anthropologic problems. For example, a glance at table 5 reveals that the Porto Ricans undoubtedly arose by intermarriage between Caucasoids and Negroids, in view of the
intermediate nature of the distribution of their Rh blood types. Moreover,
while Ashley Montagu 1 places Australian aborigines in a fourth group intermediate between Negroids and Caucasoids and Papuans in the Negroid group,
the results of recent investigations49 on the Rh-Hr types and subgroups of A
indicate that both the Australoids and Papuans more properly belong in the
Mongoloid group (cf. table 5).*
It is obvious that the blood group factors, in contrast to other physical characteristics, are not subject to conscious selection, and for this reason it was
believed that their distribution should remain constant for indefinite periods
of time in the absence of mixing with other genetic groups. The discovery of
the mechanism of isosensitization as a cause of fetal and neonatal mortality
demonstrates the existence of a selective process against heterozygote individuals, for example, those of genotype Rhrh. This process, continuing for thousands of generations, should eventually practically eliminate either one gene
or the other, whichever has the lower incidence at the beginning.10'36 This
process could account for the virtual absence of gene r in the Mongoloid group,
but it is difficult to account for the relatively high incidence of this gene in the
*Ashley Montagu's rebuttal, 2 including citations from my own book, is invalid, because
my book was written before the new work on the Rh-Hr types and subgroups of A had been
carried out, and at a time when the blood tests were still of value only in a strictly quantitative, rather than in a qualitative, fashion.
Graydon, Simmons, a n d Woods 8
Torregrosa 3 0
Wiener, Belkin, a n d Sonn 55
Wiener 54
Levine 1 6
Wiener, Zepeda, Sonn, and Polivka 7 5
Simmons a n d Graydon 2 7
Simmons et al.29
Simmons et al.29
Caucasians (Hollanders)
P o r t o Ricans
Negroes (U. S. A.)
Filipinos
Australian aborigines
Papuans
American Indians (Mexico,
Tuxpan)
American Indians (U. S. A., Wiener, Hassler, Sonn, a n d Polivka 5 9
Oklahoma)
Wiener, Sonn, a n d Yi 7 1
Chinese
Japanese
Waller and Levine 82
Miller and Taguchi 1 8
Simmons et al.29
Indonesians
Caucasians (Australia)
Caucasians (England)
Wiener et al.iS
Wiener a n d Sonn 65
Wiener, Sonn, a n d Polivka 5 4
Unger et al.31
Levine 16
Race et al.22
Fisher and Race 7
Simmons, Jakobowicz, a n d Kelsall 2 8
INVESTIGATORS
Caucasians (U. S. A.)
POPULATION TESTED
DISTRIBUTION
2.9
0.9
0
0
0.5
105
132
150
180
200
(100)
100
100
100
0
4.0
0
1.5
15.1
41.2
36.3
45.9
1.1
2.6
1.7
2.2
2.2
2.7
0.6
2.5
0.6
1,000
818
766
7,317
335
154
927
350
(225)
200
179
223
80
135
95
lr.alJf,D
NUMBER
OP
PERSONS
Rh-Hr
TABLE 5
OF T H E
Rhirh
5.7
60.6
37.4
51.7
74
| (9)
(64)
87.0
39.0
14.0
89.0
4.0
34.3
2.0
21.0
0
11.0
15.0
4.0
34.1
47.3
39.4
22.5
36.2
17.1
3.0
13.3
8.3
2.5
17.7
14.0
5.4
6.2
4.4
38.1
16.4
12.0
13.9
12.9
14.6
13.0
13.6
16.6
RhiRh2
12.3
19.6
22.4
18.8
16.3
9.5
12.8
15.8
14.9
15.0
16.7
18.2
12.2
12.6
Rh2
0
0
0
0
0
0
0
0
1.0
0
0.9
0
1.5
1.3
0.6
0
1.5
1.7
2.7
2.5
1.5
0
0.9
1.1
0.9
1.1
0.9
0.6
0.7
0.9
Rh'
15.4
10.1
8.1
11.2
7.4
0
12.9
13.8
12.5
14.7
14.0
12.3
14.8
14.9
rh
FREQUENCIES OF R h TYPES (PER CENT)
54.1
55.6
20.9 | 33.8
53.5
30.8
19.1
17.5
36.5
19.7
35.2
54.0
(23.5) | (31.5)
15.5
39.1
20.2
2.5
22.5
0.9
22.8
40.7
7.4
Rhi
TYPES
RhiRhi
BLOOD
0
0
0
6.0
3.0
0
0
0.7
0
0.5
0
0
0
0
0
0
0
2.9
0
0
0
0
0.1
0.1
0
0
3.1
0
0
0
0.01
0
0
0
0
R h ' Rh* RhiRhz
0
0
0
0
0
0
0
0.5
0
0
0.7
0
0.3
0.3
0.5
0.6
1.2
1.3
1.3
0.6
Rh"
488
ALEXANDER S. WIENER
Negroid and Caucasoid groups. One could postulate that in post-glacial times
these groups arose by crossing between two or more populations, some with a
high, and others with a low incidence of gene r. To date, however, no population has been encountered with a frequency of gene r exceeding 40 per cent.
In this connection, it is of interest to mention the study by Wiener and Wade73
on 15 chimpanzees in all of which the blood was found to lack factors Rho,
Rh', and Rh" but to contain the factor Hr, so that all 15 chimpanzees appeared
to belong to type rh.
TESTS FOR R h SENSITIZATION: NATURE OP THE AGGLUTINATION, BLOdKING,
AND CONGLUTINATION REACTIONS
Agglutination Test
For the satisfactory performance of the agglutination test for Rh sensitization
it is necessary to have available group 0 blood of types Rhi, Rh2, and rh. The
blood suspensions of these three varieties of cells for testing should be fresh,
should be washed once with saline solution, and should hav& a strength of approximately 2 per cent in terms of blood sediment. Three rows of small
narrow tubes (7 to 8 mm. inside diameter) are placed in a metal rack. Into
the first tube in each row is placed a drop of the patient's undiluted serum; into
the second tube in each row is placed a drop of the 1:2 saline dilution of the
patient's serum; into the third tube of each row a drop of the 1:4 saline dilution
of the patient's serum; etc. To each tube in the first row is added a drop of the
type Rhi control blood suspension; to each tube in the second row is added a
drop of the type Rh2 blood suspension; while to the third row of tubes a drop
drop of the type rh blood suspension is added. The rack and tubes are shaken
and placed in the water bath at 37°C. for one hour. The reactions are then
read in the usual way.
The results of the test are reported as follows:
(a) agglutination test negative, if no tube shows evidence of clumping, or
(b) agglutination test positive (x units), where x represents the reciprocal
of the highest dilution of the patient's serum causing distinct agglutination of
either the type Rhi or type Rh2 test-cells.
The specificity of Rh agglutinins present in a patient's serum is readily determined as follows:
(1) If only type Rhi cells are agglutinated, then the agglutinin is of specificity
anti-Rh'. Such serums should be tested for the possible presence of anti-Rh 0
blocking antibodies, as will be explained subsequently.
(2) If only the type Rh2 cells are agglutinated, the agglutinin is of specificity
anti-Rh". Such serums, like the anti-Rh serums, usually contain anti-Rh 0 blocking antibodies.
(3) If both the Rhi and Rh 2 cells but not the type rh cells are agglutinated,
one is probably dealing with agglutinins of specificity anti-Rh 0, anti-Rh 0 or
anti-Rho . In this case, 5 parts of the patient's serum should be mixed with one
part of a potent anti-Rho blocking serum and the titration repeated. If the
DEVELOPMENTS IN R h - H r BLOOD TYPES
489
serum has now completely lost its activity, its specificity is anti-Rh 0; if it now
behaves like an anti-Rh' serum its specificity is anti-Rh 0 ; while if it now behaves
like an anti-Rh" serum, its specificity is anti-Rho . Of course, the problem is
much more easily resolved if blood samples of the rare types Rh' and Rh" are
at hand.
The mechanism of red cell clumping produced by Rh agglutinins (or other
specific agglutinins such as anti-A, anti-B, anti-M, or anti-N) is believed to be
as follows. The surface of the erythrocytes can be visualized as being studded
with hundreds or thousands of hapten groups (Rh-Hr haptens, A-B-0 haptens,
M-N haptens) spaced more or less regularly about its periphery, so that in the
agglutination reactions the erythrocytes behave as if they are multivalent in the
chemical sense. The agglutinins, on the other hand, are modified gamma
globulins and behave as if they possess two or more specific combining groups
and so are bivalent (or multivalent) in a chemical sense. When a blood cell
suspension and its specific agglutinating antiserum are mixed, each molecule of
antibody links two red cells together, and clumping occurs by the formation of a
lattice-work.17,60 Probably there are multiple such links between adjacent red
cells where their surfaces are in contact (cf. Fig. 1).* (Most likely, not all the
hapten groups are utilized in this process, molecules of antibody may be wasted
or even get in each other's way, when only one end can make contact with a
red cell.) There is evidence3 that there are far fewer Rh-Hr hapten groups per
red cell than A-B-0 hapten groups, and this may be the reason why the clumping
is so much weaker in the Rh tests, since the firmness of the union between the
erythrocytes would be expected to depend upon the number of links connecting
them. In performing Rh agglutination tests care must be taken to shake the
tubes gently when taking the readings, because the clumps are readily broken
apart and false negative readings may result in that way.
Conglutination Testu-6i
When the results of the agglutination test just described are negative, the
tubes should be centrifuged at low speed, the supernatant fluid in each tube removed as completely as possible and a drop of fresh oxalated human plasma added.
^The rack holding the tubes is shaken vigorously and then placed in the water
bath at body temperature for about 60 minutes. The tubes are then shaken
gently, though somewhat more strongly than for the agglutination test, and the
reactions read. The naked eye reading of the pattern of the sediment in the
tubes is not reliable in the conglutination test. The results of the test are reported, like those of the agglutination test, as follows:
(a) conglutination test negative, when no tube shows clumping, and
(b) conglutination test positive, (x units), where x is the reciprocal of the
highest dilution of serum producing clumping.
The fact that Rh antibodies can be detected in the serum of some patients in
tests carried out in saline media (agglutination reaction), while in other cases
*The reaction is three-dimensional, of course, but for simplicity the diagrams have been
drawn in only two dimensions.
490
ALEXANDER S. WIENER
the antibodies can be detected only in plasma or serum media (conglutination
reaction) can be explained most reasonably by postulating the existence of two
general varieties of antibodies.46 The antibodies responsible for the conglutination reaction have been named glutinins by me because they behave as if
they are univalent in the chemical sense, in contrast to the agglutinins. When
serums containing univalent Rh antibodies (glutinins or blockers) are mixed
with Rh-positive red cells in saline media, the antibodies "coat" the erythrocytes,
but no visible reaction occurs on microscopic examination. Plasma contains a
third component, conglutinin, a colloidal aggregate of the plasma proteins, which
is absorbed by the specifically sensitized red cells, and which is responsible for
Rh Blocking Antibody
Anti-Rh Agglutinin
Blocking Reaction
FIG. 1. COMPARISON OP Rh AGGLUTINATION AND BLOCKING REACTION (TESTS IN SALINE
MEDIA)
the occurrence of clumping. Thus, conglutination occurs in two stages in
contrast to agglutination which takes place in one stage (cf. Fig. 2). The conglutinin necessary for the reaction dissociates readily into its component protein
molecules upon slight dilution of the plasma with any crystalline solution, and
this is the reason why it is so important to remove the supernatant completely
before adding the plasma when carrying out the second stage of the conglutination test.*
*As was pointed out in my original paper,44 the conglutination test can be carried out
in a single step by preparing all blood suspensions and serum dilutions in plasma (or serum
media) instead of saline. As explained in that paper, the conglutination test was developed as a result of experiments to determine the mechanism of Diamond and Abelson's4a slide test.
491
DEVELOPMENTS IN R h - H r BLOOD TYPES
Many proteins in concentrated solutions form colloidal aggregates that can
function as conglutinin.5 M When the tests are performed in serum media, the
so-called X protein appears to play the r61e of conglutinin. In our hands the
most sensitive results are obtained with oxalated plasma,* which contains conglutinin apparently composed of serum albumin, globulin, and fibrinogen in
the optimal proportions.
The fact that the conglutination test can be carried out in two stages can be
applied to measure the conglutinin content of a sample of plasma or serum.
Serum containing univalent Rh antibodies (without agglutinins) is first titrated
in saline solution against a saline suspension of fresh Rh-positive cells. After
Rh+ Red Cells
Adsorption of Conglutinin by
""Coated"
• - -Red
• Cells
Conglutinin
(X Protein)
F I G . 2. R h
Rh Blocking Antibody
(Rh Glutinin)
CONGLUTINATION
REACTION
Coating of Rh+ Cells
with Glutinin
Conglutination
( T E S T S I N PLASMA OR S E R U M
MEDIA)
'ncubation, the tubes are centrifuged, the supernatant fluid completely removed
and replaced by the plasma or serum being tested. After shaking and further
incubation the reactions are read. By this method we have found that oxalated
plasma gives consistently higher titers than the corresponding sample of blood
serum. Cord serum gives either no reaction or a weak reaction, indicating that
the plasma of fetuses in uiero contains very little X protein. The amount of X
protein increases abruptly after birth and becomes maximal in late childhood and
adult life.54
*Prepared by mixing whole blood with dried potassium or sodium oxalate and separating
the plasma by sedimentation or centrifugation.
492
ALEXANDER S. WIENER
Blocking Test™
When the agglutination test for Rh antibodies is negative, one may add to
each tube a drop of a suitably diluted (to titer of 10 units) active anti-Rh 0 agglutinating serum. The rack is shaken, the mixtures reincubated and the
reactions read in the usual manner. The results of the test are reported as
follows:
(a) blocking test negative (all of the tubes show strong agglutination);
(b) blocking test doubtful (all tubes show agglutination, but the clumping
is weak in the tubes containing the highest concentrations of the patient's
serum).
(c) blocking test positive (x units), where x is the reciprocal of the highest
dilution of the patient's serum,causing complete or almost complete inhibition of
the reactions of the anti-Rho agglutinating serum.
The principle of the blocking reaction is that the univalent antibodies coat
the red cells and prevent the agglutinins from attaching themselves to the cells
(cf. Fig. 1). As has already been mentioned when describing the agglutination
reaction, the agglutinins form multiple links between the red cells at their point
of contact. Probably only a relatively small percentage of the haptens need
combine with their specific agglutinins in order for clumping to be possible.
Thus, if in the blocking test, the univalent antibodies combine with all but a
small percentage of the haptens, agglutination could still occur. Since the
blocking reaction depends on a competition between the univalent and bivalent
antibodies, blocking will not occur unless there is a relative excess of blocking
(univalent) antibodies over agglutinating (bivalent) antibodies. Accordingly,
one would expect the blocking test to be a far less sensitive test for univalent Rh
antibodies than the more direct conglutination test. In fact, in our hands46,54 the
conglutination method has yielded titers from 5 to 20 times as high as those
obtained in the the blocking test.
When testing for A and B sensitization, we have often succeeded in demonstrating the presence of univalent antibodies by the conglutination method.69
The likelihood that the number of A-B-0 hapten groups per red cell is far greater
than the number of Rh-Hr haptens may explain our lack of success to date in
attempting to demonstrate such antibodies by the blocking technic. Witebsky
associates,76 have described a technic by which it is possible to separate agglutinating and blocking Rh antibodies present in a single serum. When by
this or other methods it becomes possible to prepare potent solution of purified
univalent A and B antibodies, it may be possible to demonstrate them by the
blocking technic.
PATHOGENESIS AND NOMENCLATURE OF THE CONGENITAL ERYTHROBLASTOSES
It seems hardly necessary to mention that various types of pneumonia caused
by different organisms, e.g., Pneumdcoccus, Klebsiella pneumoniae, Mycobacterium tuberculosis, and viruses, all have different characteristic clinical pictures,
even though they are classed together as pneumonias. Yet, my hypothesis48'60'52
that erythroblastosis fetalis comprises three distinct, though related, clinical
DEVELOPMENTS IN R h - H r BLOOD TYPES
493
diseases determined by qualitative differences in the abnormal maternal antibodies has been greeted with some skepticism. Actually, ample evidence has
already accumulated to prove that certain specific syndromes are correlated with
particular types of antigen-antibody reactions, so that it is now possible, to
predict, within limits, the clinical course from the results of serologic studies,
and vice versa.
1. Icterus gravis neonatorum*
The evidence available suggests that maternal Rh agglutinins milked into the
infant's circulation during labor give rise to the formation of agglutination
thrombi in capillaries and venules of organs where the circulation is slow. In
the marrow, this causes erythroblastemia (not necessarily associated with
anemia) the severe jaundice is due to liver damage, while kernicterus merely
represents an in vivo staining reaction of dead or dying ganglion cells in the icteric
patient.66 Atypical cases occasionally occur with only univalent Rh antibodies
in the maternal serum. These are explained by the development of dehydration
of the infant, and the consequent premature formation of X protein or conglutinin in its concentrated serum. The resulting in vivo conglutination of the
infant's red cells produces sequelae indistinguishable from those of agglutination.
Other instances may result from A-B or Hr sensitization.
2. Congenital hemolytic disease]
Univalent Rh antibodies (Rh blockers or glutinins), being presumably comprised of smaller molecules than Rh agglutinins, more readily traverse the
placenta into the fetal circulation during pregnancy and are adsorbed onto the
surface of the fetal erythrocytes. The "coated" red cells break down more
rapidly than normal erythrocytes in the circulation, giving rise to a gradually
progressive anemia, terminating eventually with a hydropic stillbirth. The
severity of the disease is usually correlated with the maternal antibody titer,
and in milder cases the infant is born alive and can be saved b y proper transfusion therapy with Rh-negative blood. This variety is ordinarily not complicated by kernicterus, and the infants that recover develop into perfectly
normal children. Atypical forms may occur when the maternal serum contains
Rh agglutinins (bivalent antibodies) and only small amounts get into the fetal
circulation causing hemolysis instead of agglutination. Other atypical instances
may result from A-B or Hr sensitization.
3. Icterus precox®'69
Maternal alpha or beta antibodies acting on the red cells of infants, belonging
to an incompatible blood group, occasionally bring about a breakdown of their
red cells. Because of the operation of certain protective agents (relative impermeability of the placenta to natural alpha and beta agglutinins; incomplete
development of the agglutinogens A and B in the red cells of newborn infants),
*For illustrative case histories, see Wiener-47'67,66
|For illustrative case histories, see Wiener.47'66
494
.ALEXANDER S. WIENER
the resulting hemolysis is usually mild. In typical cases, a mild jaundice develops on the first or second day of life, associated with little or no anemia (hemoglobin concentration of 80 to 90 per cent, in comparison with the normal of
120 to 140 per cent for newborn infants), and spontaneous recovery is the rule.
Many of these cases were formerly classified as "physiologic" icterus. Occasionally, severe or even fatal instances of erythroblastosis67 '69 may result from
this mechanism, as already mentioned. On the other hand, atypical cases may
result from mild sensitization of the mother to the Rh or Hr factors with resulting subclinical disease in the infant.
The advantages of the writer's hypothesis of pathogenesis of erythroblastosis
are its simplicity, the logic of its concept, and the avoidance of the introduction
of any new names. The generic name of erythroblastosis fetalis is retained for
the entire group of congenital antigen-antibody diseases. In my experience,
far more confusion has been caused by the introduction of a multiplicity of names
for the same disease or phenomenon, than by the use of the same name to describe
two different but analogous phenomena.* Therefore, only names that already
have appeared in the literature were used, and it will be seen that the names for
the three syndromes are self-explanatory since they describe the salient clinical
features of the diseases. The final proof of the merit of a new hypothesis is its
successful application to predict new observations and to devise new experiments. Already enough confirmatory evidence47 -64 •" '69 has accumulated to
justify the use of the term "theory" instead of "hypothesis" in describing this
new explanation of the pathogenesis of erythroblastosis fetalis.
The principal value of my new theory of erythroblastosis is that it makes
possible a more intelligent management of erythroblastotic infants, since,
naturally, the therapy will depend on the concept of the pathogenesis. Let us
consider examples of newborn infants with jaundice and a hemoglobin concentration of 80 per cent. First, if an infant has icterus precox due to A-B
sensitization, transfusions may be withheld, because such infants usually recover
spontaneously. In these cases, moreover, I have found Witebsky's soluble A
and B group substances of value in prophylaxis and treatment. Second, if an
infant has congenital hemolytic disease, due to univalent Rh antibodies, the
presence of a hemoglobin concentration of 80 per cent is usually sufficient indication for transfusion. This is especially true if the infant's red cells are
shown by means of the conglutination test to be coated with univalent antibody,
and univalent Rh antibodies can be detected in the infant's serum,66 since such
findings mean that hemolysis of the infant's red cells is inevitable. These infants
should also be kept well hydrated to prevent formation of excess of conglutinin
with resulting intravascular conglutination. Third, if an infant has icterus
gravis due to bivalent Rh antibodies (Rh agglutinins), complete exsanguination
*E. g., the use of the name "wings" for analogous structures of birds, bats, aeroplanes,
and houses has never given rise to confusion. This is my answer to the rather academic
attack by British workers on my use of the term "conglutination." The protest by one
worker that the name of the Rh factor might be confused with the chemical symbol for
Rhodium shows to what absurdities such arguments may lead one.
DEVELOPMENTS IN R h - H r BLOOD TYPES
495
transfusion appears to be the treatment of choice in order to prevent the development of kernicterus.74
CONCLUDING REMARKS
Certain biochemists have criticized my new concepts concerning differences in
molecular size between agglutinating and blocking antibodies and my use of
the terms univalent and bivalent antibodies, because these are based on serologic rather than physical or chemical experiments and observations. Also,
the susceptibility of X protein (conglutinin) to dissociation upon the slightest
dilution in water has apparently hampered physical and chemical research of its
properties, causing one prominent chemist to refer to it as a "phenomenon"
rather than as a tangible substance. Apparently, these biochemists have forgotten that many chemical problems that failed to yield to direct chemical or
physical approach were readily solved by the serologic method; for example,the
differentation of serum and other body proteins from the various animal species,
the demonstration of numerous type differences among antigens of a single
bacterial species, and the differentiation of the human blood group antigens. In
fact, the serologic solutions to these problems are so simple and satisfactory that
they are finding application constantly in clinical and legal medicine. Obviously, future progress in this and other phases of medicine will depend on the
concerted efforts of investigators in all branches of science, and immunologists
will need the aid of biochemists to solve problems in their own field, just as the
creation of the field of immunochemistry has led to the solution of certain
difficult chemical problems by immunologic methods.
In any event, a theory does not have to be completely accurate in order to be
useful and successful. A theory may lead to new and successful research and
make possible the solution of previously unsolved problems even though it is not
strictly true. For example, Newton's theory of gravitation was and still is
highly successful even though it has been disproved by Einstein. It is in this
sense that I have proposed my new ideas concerning antibodies and the pathogenesis of erythroblastosis.
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ALEXANDER S. WIENER
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