Blood Transfusion

by Geoffrey Keynes

(2) The putative father was not the real father.

(3) The Mendelian theory of inheritance is wrong.

The Mendelian theory is established on so firm a basis that, in the absence of more numerous exceptions, (3) may be rejected. There is no reason for supposing that the observations were inaccurate, and we are therefore brought to the conclusion that in such a case the child is illegitimate.

Fig. 6.—Pedigree showing Inheritance of Blood Groups through Four Generations. The Group of each Individual is indicated by a Numeral. Those who were not available are represented by a O

The conclusions which emerge from this structure of theory and fact are obviously of very great clinical importance. It is now clearly demonstrated that a mother belonging, say, to Group I, may give birth to a child belonging to any one of Groups I, II, III, or IV; her blood may not be used for transfusing her child without a grave risk that the “maternal threat” may culminate in the death of the child. The same applies to the possible relations between a father and his child. Two brothers, again, may belong to Groups II and III respectively. Even the blood of twins may be mutually incompatible, except in the rare case of “identical twins,” who, it may be supposed on theoretical grounds, would certainly belong to the same group, though I am not aware of a case in which this has been put to the test. As much care, therefore, must be exercised in testing the blood groups of members of the same family before performing a transfusion as would be taken before using a donor who is not related to the patient.

The medico-legal importance of the facts concerning the inheritance of blood groups is also evident, and, although this test has not yet been used as a test of legitimacy, there can be little doubt but that it will be so used in the near future. The information to be derived from it is of a negative rather than a positive character. Thus the occurrence of Group III blood in a child whose mother is of Group II and putative father of Group I cannot be taken as a proof either of legitimacy or the reverse. But if, as in Learmonth’s case, parents both of Group IV have a child of Group I, or if parents both of Group II have a child of Group I or III, then this may be taken as a proof of illegitimacy.

There is not much experimental evidence concerning the effect of various pathological conditions on the agglutination reactions of the blood and serum. It has already been mentioned that there is no proof that the possession of any particular blood group confers upon its owner any special immunity from, or liability to, disease. The numbers, investigated by Alexander in the communication referred to on p. 81, are too small for the observation to be of much value; it is also necessary, as a preliminary to any such research, to demonstrate that there is no abnormal alteration in the reactions of the blood of these patients. It is probable, indeed, that evidence of this alteration in malignant disease already exists, for a reference to it is to be found in Kolmer’s work on serum-therapy,[7] but I have been unable to find a record of the investigation.

I possess, on the other hand, evidence that an alteration may take place in some other diseases, such as pernicious anæmia and familial, or acholuric, jaundice. Evidence for the former was provided recently by a patient whose condition was typical, clinically, of the last stages of the disease. Her corpuscles, tested with stock sera, belonged to Group II, but her serum, tested directly with the corpuscles of prospective donors known to belong to Group IV, agglutinated these vigorously, so that a transfusion could not safely be performed. The same phenomenon has been found by other observers. In acholuric jaundice there is a progressive destruction of red corpuscles in the patient’s circulation. This appears to be connected in some way with an abnormal functioning of the greatly enlarged spleen, since the destruction of corpuscles ceases almost at once when this organ is removed. There seems to be, in addition, an alteration in the blood reactions. In a case which I tested recently, the patient’s corpuscles were quickly agglutinated by serum of Group III, and he therefore nominally belonged to Group II. His serum, however, when separated and tested against other bloods of known groups gave, in addition to a rapid agglutination of corpuscles belonging to Group III, a definite, though slower, agglutination of corpuscles belonging to Groups II and IV, showing that it had acquired abnormal properties.

It is possible that there are similar alterations of reactions in other pathological conditions. The instances mentioned above suggest that the serum is affected rather than the corpuscles, but further investigations are needed. It is an observed fact that blood outside the body soon develops the property of auto-hæmolysis. If blood is drawn from a vein, put into a test-tube, and allowed to clot, then after twenty-four hours or more the serum which has separated from the clot begins to be tinged with hæmoglobin, even though it has remained absolutely sterile. It appears, therefore, that the serum develops a hæmolysin and the corpuscles the corresponding iso-hæmolysin, the interaction of which results in the breaking up of corpuscles. If this process takes place in normal blood outside the body, it would not be surprising to find that it may also occur abnormally inside the body. This actually happens in the condition known as paroxysmal hæmoglobinuria. The pathology of the disease is obscure, but it seems that a hæmolysin develops in the serum as the result of cooling in the extremities and hæmolysis takes place when the cooled serum is again warmed by being restored to the general circulation. The presence of this hæmolysin in addition to the normal hæmolysins has been demonstrated by Moss. It is possible that a similar though less acute change takes place in acholuric jaundice. Blood transfusion, therefore, is not likely to be efficacious in such conditions, since the transfused corpuscles may be destroyed whatever the apparent blood group of the patient. Some of the facts of auto-hæmolysis have been recently investigated by Bond, but it is not necessary to give the details here. He concludes that the development of auto-hæmolysins, which are non-specific and independent of the specific hæmolysins of the blood groups, has a biological significance in the history of the red corpuscle, and is a product of ageing. The biochemistry, however, of the process remains at present entirely unknown.