Autoimmune Hemolytic Anemia: A History
Peter Mack and John Freedman
UTOIMMUNE HEMOLYTIC anemia (AIHA)
A is an acquired immunoIogic disease in which
the patient's red blood cells (RBCs) are selectively
attacked and destroyed (hemolyzed) by autoantibod-
ies produced by the patient's own immune system.
These patients generally display the common symp-
toms of anemia: weakness, pallor, fatigue, and
jaundice. Less obvious is the frequent occurrence
of mild splenomegaly. There are 2 major types of
AIHA: cold agglutinin disease (CAD) and warm
autoimmune hemolytic anemia (WAIHA), which
are differentiated by the optimal temperature of
reactivity of the autoantibody. A third type of AIHA
is the relatively uncommon, but quite distinct,
paroxysmal cold hemoglobinuria (PCH). The patho-
physiologic mechanisms differ for the different
types of AIHA, depending on autoantibody immu-
noglobulin class and subclass and the ability of the
antibody to activate complement. The degree of
RBC hemolysis depends, in part at least, on the
autoantibody concentration in the patient's blood
and on the abifity of the antibody to activate
complement. In CAD, the autoantibodies are immu-
noglobulin M (IgM) immunoglobulins; in WAIHA,
the autoantibodies are IgG immunoglobulins. RBCs
coated with IgG autoantibody undergo extravascu-
lar destruction, primarily in the spleen, whereas
RBCs coated with complement (mediated by IgM
and some IgG autoantibodies) can be destroyed
either intravascularly or extravascularly. Although
it may occur in both the warm and cold types of
AIHA, intravascular hemolysis is classically more
associated with CAD (and with PCH) ,and leads to
increased plasma hemoglobin and hemoglobinuria,
resulting in red, brown, or tea-colored plasma and
urine. Extravascular destruction of the RBC (clas-
sic in WAIHA, but also common in CAD) results in
increased bilirubin in the plasma and urine urobilin,
resulting in jaundice and dark yellow urine.
AIHA is further classified into (1) primary or
idiopathic, in which no associated disease is identi-
fied, and (2) secondary, associated with collagen-
vascular disorders such as systemic lupus erythemato-
sus (SLE), lymphomas and leukemias, rheumatoid
arthritis, ulcerative colitis, lupoid hepatitis, etc.
Whereas both secondary WAIHA and CAD have
been associated with SLE, lymphomas, and leuke-
mias, secondary CAD is also known to result from
Transfusion Medicine Reviews, Vo114, No 3 (July), 2000: pp 223-233
infectious mononucleosis and Mycoplasma pneu-
moniae infections. PCH, which has historically
been associated with syphilis, has more recently
been more commonly associated with rubella and
other virus infections and may be idiopathic in
some cases. The main current treatments for WAIHA
are corticosteroids, splenectomy, and immunosup-
pressive drugs, with a wide variety of therapies
employed with varying success in cases resistant to
the three approaches. CAD is treated by keeping
the patient warm, blood transfusions, and plasma-
pheresis.
BEFORE 1600
Before the invention of the microscope in the
17th century, the only way to recognize a blood
problem associated with anemia was by the associ-
ated symptoms and signs. These are, however,
relatively nonspecific. The role of the blood is well
documented, and its importance has been recog-
nized for millennia. For example, in Leviticus, the
Bible states that the "soul of the flesh is in the
blood. ''1 Blood was recognized to be the carrier of
life, the soul, heat, and the matter, which, when
corrupted, leads to disease. Hippocrates would
likely have suggested a corruption of the blood
(phtore haimatos) as accounting for weakness and
paleness, as the word "anemia" was unknown to
him, but no clear description consistent with an
AIHA appears to be found in the descriptions of the
ancients. Although red urine, the hallmark symp-
tom of intravascular hemolysis (as characteristic of
CAD and PCH, but also seen in some cases of
WAIHA), was recorded occasionally before 1600,
in most cases it probably represented hematuria
rather than hemoglobinuria. Galen in 150 CE
recognized that not all cases of jaundice were
caused by liver disease, and his description of a
person bitten by a viper whose "skin turned the
From St Michael's Hospital, University of Toronto, Canada.
Supported by a studentship from the Hannah Institute of
Medical History, University of Toronto.
Address reprint requests to John Freedman, MD, FRCPC,
Director, Transfusion Medicine, St Michael's Hospital, 30 Bond
St, Toronto, Ontario, Canada M5B 1W8.
Copyright 9 2000 by W.B. Saunders Company
0887-7963/00/1403-000353.00/0
doi: l O.l O53/tm.2000.7392
223
224
colour of a ripe leek ''2 probably represents the first
description of an extracellular type of acquired
hemolytic anemia, albeit not of autoimmune na-
ture. Galen's understanding of physiology was such
that he implicated the spleen as leading to the skin
discoloration, an association of the spleen and
hemolysis not confirmed until late in the 19th
century.3 PCH was probably the first AIHA to be
clearly recognized, when, in 1529, Johannes Actu-
arius, a court physician in Constantinople, provided
the first description of paroxysmal hemoglobinuria.
In his work, De Urinis, Actuarius described a
condition in which the urine is "azure & livid as
well as black" in patients being of melancholic
humor and complaining of loss of strength, after an
exposure to cold. 4 Further mention of PCH seems,
however, to be absent for nearly 300 years, until the
latter half of the nineteenth century.
1600 TO 1800
Experimental investigation of the blood was
retarded by the traditional scholastic methodology
until the arrival of Bacon (1214-1290) and his
introduction of the scientific method. The scientific
method led to the seminal discoveries of the
circulation of blood by Harvey in the early 16th
century and the cardinal experiments with transfu-
sion of blood by Lower in England and Denis in
Paris in the mid century. Despite this interest in
blood, the discovery of the RBC had to await the
appearance of the microscope around 1650, and the
important advances of the 17th and 18th centuries
in hematology lie in the advances made in the
understanding of the RBC, made possible by
developments in microscopy. The first "simple"
microscope appeared between 1600 and 1630,
consisting of a pearl of glass and two foils of silver,
yielding a magnification of approximately 400• .5
Although Anaxagoras had, in the 5th century BCE,
predicted the existence of RBCs ("the blood is
formed by a multiple of droplets, united among
them"), 6 the first actual observation of an RBC was
likely made by Malpighi in 1661, when he de-
scribed their circulation in the capillaries] and this
was followed in 1663 by Swammerdam's descrip-
tion of minute globules in the blood of a frog. 8 A
decade later, human RBCs were described in detail
by van Leeuwenhoek, who also established their
size at about 1/3,000 of an inch by comparing an
RBC with a grain of sand of known size. 9
Little was written that indicates a clear diagnosis
MACK AND FREEDMAN
of AIHA during these centuries, with the exception
of a possible case mentioned by Morgagni. In 1769,
Morgagni reported a case of a priest who showed
symptoms consistent with hernolytic anemia,
namely, red urine, fatigue, a pallid color, and an
enlarged spleenm; this might arguably be a case
representing AIHA, although a diagnosis of malaria
cannot be excluded. The physical limitations of the
early microscopes precluded further advances in
knowledge of blood in the 18th century, although
John Huxham, in 1770, while studying purpura by
microscopy, described the changing shapes of a
degenerating RBC and, importantly, recognized the
origin of hemoglobin from degenerating RBCs. u
Andral in 1843 introduced the study of blood as a
discipline at the Paris Medical School; one of his
major areas of interest was the qualitative and
quantitative changes of the blood, that is, the
volume and morphology of the elements of the
blood.
1800 TO 1900
In 1843, Andra112 described a spontaneous ane-
mia, which arises without any prior blood loss. He
quantified red blood globules in healthy patients,
and reported 16 early cases of anemia having a
mean value o f ' 109' (arbitrary units), whereas in 29
advanced cases the mean value was '65,' although
other components of the blood remained constant
in their concentration. Andral proposed that the
diminished quantity of blood was attributable to
altered structure of the corpuscles and their "true"
destruction. Although Andral provided no other
information concerning the patients' condition,
what is potentially important in relation to hemo-
lytic anemia is the observation of anemia without
prior blood loss. Another important association
between decreased RBC count and hemolytic ane-
mia came 9 years later, when Vogel, in a short
report, stated that the coloring matter in the urine is
the same as that in the blood, and he suggested that
the matter in the urine consists of a "decomposition
of blood discs."~3 Vogel suggested that the degree
of blood decomposition can readily be ascertained
by the degree of coloration in the urine, and he
recorded a connection between fevers, colored
urine, decomposition of the blood, and anemia.
This represents one of the first examples of the
association between decreased RBC count and the
term anemia. Moreover, it also represents early
AUTOIMMUNE HEMOLYTIC ANEMIA
evidence of a recognized association of anemia
secondary to infections.
As described by Binet, 14 while Alfred Donne
(1801-1878) made his many contributions to hema-
tology by microscopic study of the blood, quantita-
tive interest in the properties of blood increased in
the middle of the 19th century, and advances in
enumerating the components of the blood were
achieved by Vierordt (1851), total blood volume
and red cell volume were determined by Weleker
(1854), the hemocytometer was invented in 1873
by Malassey, and 4 years later Hayem introduced
the color index to evaluate anemia. 6,~5 In fact,
"normal" RBC counts were based on examinations
of 2 subjects in 1852 and 1854, by what were rather
inaccurate and obsolete methods. 16 The degree of
anemia was usually graded on the color index,
which was determined by dividing the percent
hemoglobin by the red cell count, divided by 2. The
hematocrit was also employed for assessment of
anemia. 17
In the third quarter of the 19th centre'y, there
were several reports focusing on PCH. In 1854,
Dressler 18 described a case of PCH in a 10-year-old
boy, who, after exposure to cold, passed red urine
that gradually paled to clear to a natural color. 18
Microscopic examination of the urine showed a
"dirty brown pigment" and no blood corpuscles.
This classic description of PCH was accompanied
by a description of the treatment given; Dressler
treated the boy with quinine, red wine, and an
infusion of China root, which led to a return to
"relatively good health." Four more cases of PCH
were reported by the end of the decade, all with
similar symptoms, 19 although in each of these
quinine was found to be ineffective, and treatments
were individualized at the discretion of the physi-
cian and were administered in the form of a cocktail
of remedies. A case of PCH in an 8-year-old boy in
1863, 2o showing yellow skin after exposure to cold
and mahogany-colored urine, is interesting because
of the variety of treatments employed by the
attending physician. Because the boy was believed
to be syphilitic (historically linked to PCH), he was
treated with "three grains of grey powder three
times a day," an extract of belladonna, as well as
cod-liver oil, steel wine, and strychnia.
In 1871, an important contribution to the history
of hemolytic anemia was made by Vanlair and
Masius, 2~ who indicated that premature destruction
of RBCs leads to jaundice. Their patient was
225
described as having anemia and splenomegaly, as
well as reddish brown urine; they provided morpho-
logical evidence, describing spherical dwarf cells
in the peripheral blood that they called microcytes
(most likely spherocytes, a hallmark of immune-
mediated extravascular hemolysis), and they named
the condition microcythemia. The authors proposed
2 mechanisms for jaundice: "mechanically by
reabsorption or liver-induced" and "paradoxical
icterus." Paradoxical icterus, at play in hemolytic
anemia, was said to be caused by excessive release
of a colored material from the blood, leading to bile
formation and deposition in the tissues. More
explicitly, they stated that "there are at least a
certain number of nonmechanical types of icterus
which are caused by the exaggerated destruction of
red cells and the transformation to bilirubin of
released hematin." In these words are expressed an
idea that was essentially correct, but which was
then ignored or forgotten for the next 30 years. 3
In 1879, Stephen Mackenzie, at the London
Hospital, elaborated on the pathophysiology of
PCH. 22 Mackenzie reported the case of a young boy
who displayed symptoms similar to those described
by Thomas Addison in 1868. 23 Addison had de-
scribed a patient with an idiopathic or primary
anemia and no previous blood loss, with no organo-
megaly, and he attributed this to "a disease of the
supra-renal capsules." Mackenzie, however, de-
scribed his patient as having in addition large white
spots "like nettle-rash" in his skin, sallow complex-
ion and yellow eyes, and microscopic examination
and spectroscopic analysis of the urine showed that
the black urine contained abundant hemoglobin
and no red cells. Rewarming of the child resulted in
clear urine. The urine hemoglobin described by
Mackenzie is likely the 'hematin' described by
Vanlair and Masius, 21 which was transformed into
urobilinogen. Mackenzie implicated the "proteid"
hemoglobin, the coloring matter of the blood, for
the range in tints from "London porter to deep red"
and recognized that "it follows that blood solution
or disintegration (hemolysis) must take place in
some part of the organism. ''22 Because of the
general lack of skin jaundice in the patient, Mack-
enzie believed that the hemolysis occurred in the
"genito-urinary apparatus" and that "in the highest
degree of probability the seat of blood solution is
the kidney"; he was aware of the enlarged spleen in
the patient, but dismissed this organ as the seat of
hemolysis because of the lack of hemoglobin in the
226
circulation. Mackenzie remarked that in the past
this disease had been called intermittent hematuria,
but he believed it to be rather paroxysmal hemoglo-
binuria. Because chills and rigors customarily
preceded the liberation of the hemoglobin, he
regarded paroxysmal hemoglobinuria as a "vasomo-
tor neurosis," suggesting that the vessels of the
glomerulus constrict with such force as to push the
RBC into the glomerular lumen, where the pressure
causes them to disintegrate. This was an elabora-
tion of a theory proposed by Pavy in the Lancet of
July 14, 1866. 23 Mackenzie's nervous disorder
hypothesis and kidney-mediated hemolysis stood
in contrast to that of van Rossem, who held that
"corpuscles are dissolved by oxalate of soda in the
bladder"; although van Rossem's theory is men-
tioned by Mackenzie, 22 it does not appear to be
described elsewhere in literature. Mackenzie's hy-
pothesis of pathophysiology was reiterated 20
years later, when, in 1899, Mannaberg and Donath
described a case of paroxysmal hemoglobinuria,
emphasizing the skin reaction to be a vasomotor
disturbance and regarding an increased excitability
of the vasomotor system to be an essential factor
(quoted by Harris et a124). Mackenzie treated his
patient with a mixture of sulfate of quinine and
perchloride of iron, although quinine and eucalyp-
tus globulus, in large doses, are also mentioned. 22
In another case reported in 1884, 25 Mackenzie
prescribed liquid extract of ergot, after quinine
treatment; he also described 2 diagnostic tools for
examining blood in the urine, the "guaiacum" and
"Heller's" tests, to be used in addition to micro-
scopic and spectroscopic analysis. In this latter
report, Mackenzie, observing hemoglobin in the
general circulation, modified his previous theory of
erythrocyte destruction, suggesting that the role of
the kidney is in fact passive, and that the corpuscle
solution, or hemolysis, occurs in the vasculature.
The last decade of the 19th century saw research
focus on differentiating between the congenital and
acquired types of hemolytic anemia. Wilson in
1890 described a family with "a condition in which
an enlarged spleen, accompanied by a sallow or
subicteric complexion, appears as an hereditary
c o n d i t i o n . . , showed rapidly progressing anemia,
dependent upon an active hemolysis of splenic
origin, ''26,27 leading to the name chronic splenic
cachexia. Although this case may in fact represent
an early description of hereditary spherocytosis, its
MACK AND FREEDMAN
relevance is in its implication of the spleen in the
hemolytic process.
1900 TO 1950
Two important authors in this field at the turn of
the century were Hayem28 and Minkowski, 29 who,
in 1898 and 1900, respectively, showed that the
jaundice associated with hemolytic anemia was
distinct from that of hepatic diseases. Hayem made
the distinction between congenital and acquired
hemolytic anemias, whereas Minkowski described
only a hereditary condition, but both placed the
blame for hemolysis on an abnormality of the
spleen, although finding no morphological blood
abnormality. Hayem has therefore been repeatedly
said to be the first to describe acquired hemolytic
anemia, for which he coined the name chronic
infectious splenomegalic icterus. 28 Minkowski is
credited with the first clear recognition of icterus
due to hemolytic anemia (chronic hereditary achol-
uric icterus) separate from an obstructive jaundice;
he associated the anemia with urobilinuria and
splenomegaly and postulated that RBC destruction
was attributable to lesions in the spleen. 29
In an associated important discovery of the time,
in 1901 Landsteiner3~ discovered the ABO blood
group system, leading to an understanding of RBC
antigens, which would subsequently be found to
have relevance for autoantibody specificity in AIHA.
Three years later, Donath and Landsteiner3~ pro-
posed a new mechanism for in vivo hemolysis, 3~
implicating a hemolytic substance in the serum as
responsible for PCH; their study is held to be the
first to describe an autoantibody leading to an
autoimmune disease. Their analysis showed that
hemolysins in the patient's blood caused an aggluti-
nation reaction at low temperatures, and on subse-
quent rewarming, in the presence of complement,
the hemolytic reaction occurs. Further contributing
to subsequent understanding of the pathophysiol-
ogy of immune-mediated red cell destruction,
Metchnikoff in 1905 described macrophages. 32
Chauffard was among severn French scientists
at the time exploring the mechanisms of hemolytic
anemia. These writers divided acquired hemolytic
jaundice into 2 groups: cryptogenetic and second-
ary. Chauffard, 33 along with Troisier (1908) 34 and
Vincent (1909)Y was the first to describe autohemo-
lysins in patients with acute acquired hemolytic
jaundice. These authors described patients with
hemolytic icterus whose serum had the capability
AUTOIMMUNE HEMOLYTIC ANEMIA
of hemolysing RBC, and they termed the condition
"hemolysinic icterus"; it was acute in course and
associated with hemoglobinuria. Thus, a definitive
distinction was made between acute paroxysmal
hemoglobinuria and congenital hemolytic icterus.
Chauffard implied that the strange hemolysin was
endogenous and the primary cause of the rapid, and
active in vivo hemolysis observed, and Le Gendre
and Brule6, working at the same time, acknowl-
edged the 2 forms of hemolytic icterus, acquired
arid congenital. 36 Chauffard 33 also standardized the
osmotic fragility test (a diagnostic tool of the age),
described reticulocytes and their increased num-
bers in congenital hemolytic icterus (later to be
known as hereditary spherocytosis), and drew
attention back to the microcytic nature of the red
cell in some hemolytic anemias. 33
Between 1908 and 1912, Widal, Abrami and
Brul6, 37,38 introduced the term acquired hemolytic
anemia, noting several cases in which the disease
was not congenital but rather associated with
various infections and intoxications, and in whom
the course was either gradual or sudden. They
remarked on a slight difference in the fragility test
as compared with the congenital type, marked
reticulocytosis and, importantly, the autoagglutina-
tion of RBC (consistent with IgM-mediated AIHA).
Hence, at this time the 2 types of hemolytic anemia
were recognized: the congenital form of Minkowski
and Chauffard and the acquired form of Hayem and
Widal. Here we will leave the congenital hemolytic
anemias and focus on acquired immune hemolytic
anemia.
While Landois had, in 1875, reported that agglu-
tination of RBC can be induced by the serum of an
animal of another species (quoted by Race and
Sanger 39) and while Landsteiner had made the first
observation of agglutination of human RBC by
serum of the same species, it was Widal, Abrami,
and Brul6 who observed autoagglutination of eryth-
rocytes, and their work as well as others was
summarized at the 12th Congr6s Frangais de Me-
dicina, at Lyon in 1911, where the role of hemoly-
sins in pathology was a major topic. 3 By now the
role of the spleen was widely accepted as being the
major site of hemolysis, and that of the liver had
been acknowledged although it was not generally
regarded as a significant site of erythrocyte destruc-
tion. Therefore, it is not surprising that in 1911
Micheli, in Turin, performed the first splenectomy
for acquired hemolytic anemia. 4~ Banti, 41 in 1912,
227
conducted an extensive investigation into splenic
pathology and introduced the term hemolytic sple-
nomegaly, when he observed that the spleens of
animals undergoing hemolysis were enlarged and
congested. 4I He noted that the rate of hemolysis in
animals with "heteroimmune hemolytic serum"
was slower when the animal had been splenecto-
mized before transfusion. Banti implicated the
splenic endothelial cells as erythrophagocytes and
described agglutinated RBC within the splenic
pulp. He also described the same activity in the
Kupffer cells of the liver, but only under conditions
of extreme hemolysis. Thus, Banff effectively de-
scribed the reticuloendothelial system (RES) and
its function in RBC hemolysis; he recognized the
importance of the spleen to the disease, but stressed
that it was not the only, nor even the prime, site of
RBC destruction. The combined activities of Micheli
and Banti entrenched the recommendation of sple-
nectomy as a treatment for hemolytic anemia,
representing the first specific therapy for AIHA.
Despite the widespread acceptance of the benefits
of splenectomy, however, some, such as Antonelli
in 1913, 42 refuted Banti's hemolytic splenomegaly
as a separate disease, pointing out that it did not
differ from acquired hemolytic anemia.
By this time, much had been learned about RBC
fragility, reticulocytosis, autoagglutination, and he-
molysis, but then a period of relative dormancy
occurred in elucidation of AIHA. Nonetheless,
Dameshek and Schwartz 43 documented a patient
from Vienna who in 1914, after splenectomy, was
found to have "dense, hemoglobin-laden micro-
cytes," a convincing description of spherocytes; it
is unclear whether this represented hereditary sphe-
rocytosis or immune-mediated hemolytic anemia.
Whereas Naegeli has been credited with applying
the term spherocyte to the "dense, hemoglobin-
laden microcytes" in 1919, implicating their pres-
ence to abnormal formation in the bone m a r r o w , 44
Dacie 45 has shown that the first description and the
coining of the term spherocyte belongs to Chris-
tophers (1909), who with Bentley, in India, ob-
served spherocytes while studying blackwater fe-
ver46; these authors suggested that a change in the
elasticity of the RBC accounted for its altered
morphology, preventing it fi'om appearing as the
common flat disc. Treatments other than splenec-
tomy were applied for cold-induced paroxysmal
hemoglobinuria and, in 1922, Harris et al ~4 em-
ployed salvarsan injections with success, presum-
228
ably for a case of PCH caused by syphilis, and
Tileston 47 attempted the use of cholesterol to inhibit
hemolysis, with an effect observed in the test tube
but with only temporary benefit in patients.
By the 1920s, the prevailing understanding of
the mechanism behind RBC destruction was that it
resulted from autoagglutinin-induced agglutina-
tion, the first step in hemolysis. However, publica-
tions after World War I indicate the degree to which
much of the knowledge discovered at the beginning
of the century had been lost. Lederer (1925,
1930) 48,49and Brill (1926) 5~described a number of
cases of transfusion-responsive acute hemolytic
anemia associated with infectious diseases. Be-
cause much of the prior French work had been
forgotten, Lederer's descriptions were thought to
be of a new disease, known as "Lederer's anemia,"
or "Lederer-Brill anemia," but it is likely that they
were examples of AIHA. 3 The neglect of the
previous literature resulted in a loss of the clear
distinction between the congenital and acquired
forms of hemolytic anemia, 3 as well as a neglect of
the serological tests for autohemolysins, isohemoly-
sins, and heterohemolysins. This led to claims in
the 1930s of autoagglutination in hemolytic anemia
being observed for the first time. This has been
commented on by Dacie, 5~ who indicated that in
England it was believed that hemolytic anemia in
adults was a form of hereditary spherocytosis.
Dawson 52 stated in 1931 that "in the sense that
latent defects may be accentuated so as to become
clinically manifest, hemolytic anemia can be ac-
quired, but the defects themselves are inborn."
Doan et al, 53 however, disagreed, commenting that
"we believe that a sharper differentiation should be
made between the various mechanisms responsible
for the nonhereditary forms of hemolytic anemia.
Designating them as 'acquired,' 'atypical,' or
'pseudo' with full realization that these latter
symptoms are fundamentally different . . . . "
In the period between the wars, there was
renewed discussion on PCH. Although rare, in the
absence of laboratory tests to identify red cell-
bound IgG autoantibodies and complement, the
obvious clinical signs and symptoms of PCH (and
CAD) facilitated focus on these patients. In 1936,
Witts 54 wrote on the paroxysmal hemoglobinurias,
including cold hemoglobinuria, indicating that a
decrease in RBC count by one half was .common.
He recognized that hemoglobinuria is most always
the result of intravascular hemolysis and follows
MACK AND FREEDMAN
hemoglobinemia, that in nonfatal cases hemoglo-
bin excretion in the urine rarely exceeds 5 g,
whereas free hemoglobin in the serum exceeding
3% is likely to be fatal and that although the
symptoms common to all types of paroxysmal
hemoglobinurias are shock, anemia, diminution or
suppression of urine, and thromboses in various
parts of the vascular tree, "hemolytic anemia with
paroxysmal haemoglobinuria" is the most common
type of paroxysmal hemoglobinuria. During the
same period, Dameshek and Schwartz 55 described
3 cases of acute hemolytic anemia responding to
splenectomy; they found that the patients' sera
were able to lyse allogeneic as well as autologous
RBC. They further noted that the degree of sphero-
cytosis was in direct proportion to the hemolysin
titer. Although before 1940 it was hypothesised that
WAIHA was the result of "undue stasis and
destruction of blood in the splenic pulp, ''56 by
1940, Dameshek and Schwartz 43 had confirmed the
existence of acquired hemolytic anemia, with sphe-
rocytosis, increased fragility, and abnormal serum
hemolysins; they suggested an immunologic cause
for acquired hemolytic anemia, resulting from the
action of hemotysins on erythrocytes rather than
abnormal erythrocyte production in the marrow. In
short, they described what would become the
"outline for our modern concepts of the clinical
and serological implications of autoimmune hemo-
lytic anemia."3
The 2 decades flanking 1950 saw important
advances in diagnostic tools, hypotheses for cause
and pathogenesis of AIHA, and new therapeutic
procedures. These advances were in large part due
to intense growth in serological studies. In 1944,
Race 57 and Weiner, 58 working separately, con-
cluded that there were 2 types of Rh antibody, 1 that
bound to the RBC surface and caused agglutination
(the "complete" antibody; IgM), and 1 that also
adsorbed to the RBC surface but did not cause
agglutination (the "incomplete" antibody; IgG). A
major diagnostic advance, critical to elucidation of
the pathophysiology of AIHA, occurred in 1945
with the description of the antiglobulin test by
Coombs, Mourant, and Race. 59 This technique
employed rabbit anti-human sera to detect human
antibodies, enabling easy detection of RBC-bound
incomplete antibodies. Actually, a similar proce-
dure had been developed by Moreschi in 1908, 6~
but because the concept of incomplete antibody
was unknown at that time, the clinical value of this
AUTOIMMUNE HEMOLYTIC ANEMIA
procedure was not then appreciated. In 1946,
Boorman et a162 employed the direct antiglobulin
test (DAT) to recognize the association between
idiopathic hemolytic anemia with incomplete anti-
body on the RBC surface, and this test quickly
became the definitive test for the diagnosis of
AIHA, allowing clear distinction from congenital
hemolytic icterus. It was found that in some
patients AIHA could be present despite a negative
DAT and subsequently, in 1971, Gilliland et a163
showed that such "DAT-negative patients with
AIHA" do have increased RBC-bound IgG autoan-
tibody, but at levels below the sensitivity of the
serological DAT, which could be detected by more
sophisticated assays such as radioactive antiglobu-
1in tests.
Work in the late 1940s was primarily focused on
the mechanisms of AIHA and the involvement of
the spleen. In 1948, Wagley et a164 noted that, after
splenectomy, the amount of "sensitizing agent" on
RBC was decreased, suggesting that the spleen was
the primary site of production for the agent.
However, cases in which failure of splenectomy to
cause remission suggested that although it might be
the principal site of production of the RBC-
sensitizing agent, it may not not the sole site, and
Evans and Duane 65 proposed the lymphatic and RE
system as alternate sites, although it was appreci-
ated that the reason for failure to enter remission
after splenectomy might be the presence of an
accessory spleen. By 1949, it was recognized that
the sensitizing plasma protein was a globulin, but
there were still 2 views held: (1) that agglutination
was a result of the disease; and (2) that the number
of antibodies bound per RBC determined the state
of the disease, and the literature still stated that
"evidence is needed to show that the hemolytic
agent is a specific immune response to an antigen
COlm~aon to erythrocytes. ''65 Evans and Duane
summarized the state of knowledge in 1949, delin-
eating the symptoms most often associated with
AIHA, namely, chronic anemia, reticulocytosis,
increased serum bilirubin, increased fecal urobilino-
gen, and erythroid hyperplasia of the bone marrow.
While recognizing the importance of antibodies in
AIHA, Evans and Duane. indicated that they be-
lieved that there was no evidence that hemolysis
occurs as a result of the fixation of complement. 65
Thus, the first half of the 20th century closed with a
more complete clinical understanding of the dis-
ease and the foundations of its mechanisms.
229
1950 TO PRESENT
In 1951, Young and associates 66 were the first to
coin the name autoimmune hemolytic anemia; it
was theorized that the production of an autoanti-
body was the result of a breakdown in the "regula-
tory contrivances," thus leading to autoimmuniza-
tion. Yet some refused to believe that the RBC-
coating globulin was in fact an autoantibody and
the name "antiglobulin-positive hemolytic ane-
mia" was employed, 3 but by 1960 this term had
disappeared and the autoanfibody theory was en-
trenched.
The beginning of the 1960s started with studies
on the variable age ranges for AIHA. Although
earlier WAIHA was believed to be rare in the
young, Iafusco and Biffa67 in 1962 documented
WAIHA in a newborn. There was greater recogni-
tion of the variety of illnesses associated with
AIHA, and Pirofsky 3 found 18% of AIHA to be
idiopathic, in contrast to the studies of Dacie
(1962) 51 and Dansset and Colombani (1959) 68
reporting 70% of cases to be idiopathic. The
incidence of AIHA was estimated to be 1 in 80,000,
with a sex'distribution of 1:1.3 in favor of males, in
this period, there were investigations on the proper-
ties of the antibodies involved in AIHA. For
example, Dacie reported that there are variations in
the temperature range and pH amplitude of the
agglutinating and hemolysing property of patient
sera in CAD, 5~ and S c h u b o t h e 69 suggested that the
pathological cold agglutinins appeared to be anti-
body-like modified paraproteins with many indi-
vidual differences. Immunosuppressive drug therapy
was also a field of wide study during this period, in
response to the emerging concepts that an immuno-
logic inadequacy resulted in a buildup of the cells
that make autoantibodies, a failure of a homeostatic
(surveillance) mechanisms. In 1971, Dacie 7~ sum-
marized the existing hypotheses of autoantibody
formation and included response to modified RBC
antigens, not true autoantibodies but a cross-
reactivity to viruses, especially in CAD, and spon-
taneous development of "forbidden" clones of
antibody-forming cells. Dacie, like most others,
favored the third hypothesis, a failure in immuno-
logic surveillance.
In the 1970s, studies focused on the antibodies
involved in AIHA and their mechanisms of action.
By 1975, it was recognized that in WAIHA IgGl~3
predominate, but that IgG2 was not uncommon, nor
were IgA antibodies. 71 The mechanisms of comple-
230
ment-mediated hemolysis were elaborated in the
elegant studies of Schreiber and Frank. 72 Before
these studies, it was thought that CAD manifested
itself at low temperatures because of a temperature-
related change in the surface membrane of RBCs or
a change in the IgM antibody. Frank et alv2,v3
explained the significance of RBC-bound comple-
ment and its involvement in not only intravascular
but also extravascular hemolysis. They observed
that in AIHA, RBCs coated with complement are
sequestered in the liver, whereas those coated with
IgG only are taken up in the spleen. The observa-
tions yielded 3 postulated mechanisms for destruc-
tion of RBCs in AIHA: (1) C5b-9 terminal attack
complex complement-mediated intravascular lysis,
seen in IgM-mediated CAD and less commonly in
WAIHA, with IgG autoantibodies (IgG~3 and less
commonly IgG2) capable of activating comple-
ment; (2) adherence of C3b-coated RBCs to comple-
ment receptors on hepatic macrophages, seen in
CAD and WAIHA; and (3) adherence of IgG-
coated RBCs to FcR on splenic macrophages, seen
inWAIHA. Quantitative studies were performed on
the relation of the number of IgG and of C3
molecules bound to RBCs and the severity of the
hemolysis. 74-76
The molecular biology revolution 20 years ago
afforded great opportunities for studying the immu-
nologic mechanisms of AIHA and the relationship
of the autoantibodies to the antigens. In the early
1980s, type II MHC glycoproteins were shown to
mediate the presentation of antigens by macro-
phages to T cells, and cytokines were shown to be
important in the macrophage-dependent activation
of antigen-specific T cells. Studies were performed
on the substrate-receptor interactions, and in 1981
monocytes and macrophages were shown defini-
tively to have receptor sites for the Fc portion of
IgG and the C3b component of complementY The
role of these receptors in phagocytosis was con-
firmed] 8-8~and it was suggested that Kupffer cells
and splenic macrophages have altered FcR and
complement receptors, differing from those in the
healthy population. As reviewed by Garratty,81
knowledge of the autoantibody specificities for
blood group antigens was refined.
Although much has been learned about the
pathogenesis of AIHA, just how antibody forma-
tion against self-antigens is triggered remains far
from clear. The state of knowledge has been
recently reviewed by Dighiero and Rose. 82 In the
MACK AND FREEDMAN
early 1900s, consistent with Landsteiner's rules of
blood group compatibility,3~ Ehrlich and Morgen-
roth 84 showed that animals did not produce antibod-
ies to their own RBCs and introduced the concept
of horror autotoxicus to describe the mechanisms
that prevent the adverse effects of autoimmuniza-
fion through production of an "autotoxin." 84At the
same time, however, the existence of autoantibod-
ies under normal conditions or after immunization
was demonstrated. 85 Nonetheless, the opinion that
autoimmunization could not occur persisted, Metch-
nikoff's observations and Donath and Landsteiner's
description of a biphasic hemolysin in PCH 31
notwithstanding. The experiments of (1) Owen in
1945, 86 showing that dizygotic calf twins sharing a
single placental circulation but having 2 popula-
tions of RBCs and being unable to make alloanti-
bodies against the blood group of the twin calf, and
(2) Medawar's group in 1953, 87 showing that
injection of spleen cells from an unrelated strain
into newborn mice conferred ability to accept skin
grafts from the unrelated strain, led to the hypoth-
esis that in the embryo the immune system learns to
tolerate self-antigens, and autoreacfive lympho-
cytes are deleted. These observations and Jerne's
natural selection hypothesis 88 led Burnet 89 in the
1950s to propose the clonal selection theory of
antibody formation. Hence, it was believed that,
with this self-tolerance, autoantibodies could only
arise because of somatic mutation and expression
of forbidden clones. However, in 1956, Rose and
Witebsky9~ induced autoantibodies by injection
of thyroglobulin into rabbits, showing conclusively
for the first time that it was possible to produce
autoantibodies against nonsequestered antigens and
that autoimmunization can result in disease. Since
then, autoimmunization has been induced by tissue
extract injection in animals, resulting in a variety of
autoimmune diseases, 9~ numerous autoantibodies
have been demonstrated under normal conditions,
that is, natural autoantibodies, 93,94 there has been
clear recognition of autoreactive B lymphocytes,94
and autoantibodies have been induced from stimu-
lated normal B cells. 95 Hence, it appears that the
precursor B cells that produce these autoantibodies
must escape deletion. Two hypotheses have devel-
oped to explain autoanfibody production in autoim-
mune diseases: (1) the autoantibodies result from
uncontrolled polyclonal stimulation of normal auto-
reactive B cells, resulting in increased levels of
natural autoantibodies96; and (2) pathological auto-
AUTOIMMUNE HEMOLYTIC ANEMIA
antibodies result from an antigen-driven selection
of autoreactive B cells, which, under the selective
pressure of autologous antigen, undergo somatic
mutations, producing pathological autoantibod-
ies. 97 Over recent years, accumulating evidence
supports the latter hypothesis and suggests that
pathogenic autoantibodies arise by a selective pro-
cess driven by autoantigen and are made by a
population of B cells distinct from those producing
natural autoantibodies. 82 Thus, we have gone from
horror autotoxicus to the forbidden clone theory to
autoimmunity being a natural physiological pro-
cess. Dighiero and Rose 82have suggested that the B
cell repertoire that is directed to the critical polymor-
REFERENCES
1. Bible: Leviticus 17:11-12
2. Galen C: Opera Omnia, Vol VIII. DCG K~ihn (ed), Lipsiae,
1824, p 356
3. Pirofsky B: The Hemolytic Anemias--Historical Review
and Classification, in Pirofsky B (ed): Autoimmunization and
the Autoimmune Hemolytic Anemias. Baltimore, MD, Williams
& Wilkins, 1969, pp 3-21
4. Actuarius J, Filius Zachariae: De urinis. De iudiciis
Urinarum. Basle, Andreas Cratander, 1529, p 97. Transl. Ambro-
sio Leone Nolono, in Major RH: Classic Descriptions of
Disease. Springfield, IL, CC Thomas, 1939, pp 588-589
5. Bessis M, Delpech G: Discovery of the red blood cell with
notes on priorities and credits of discoveries, past, present and
future. Blood Cells 7:447-480, 1981
6. Ness PM, Stengle JM: Historical introduction, in Surgenor
DM (ed): The Red Blood Cell (ed 2). New York, NY, Academic
Press, 1974, pp 1-50
7. Malpighi M: De pulmonibus (two letters published by
Malpighi in 1683 and 1686-1687). Transl. J Young, Malpighi's
"De pulmonibus." Proc R Soc Med 23:1-11, 1930
8. Swammerdam J: The Book of Nature, or the History of
Insects. Part II. Transl. Th Flloyd. London, UK, GG Seyffert,
1758, p 122. [Quoted by Bessis and Delpech.5]
9. Leeuwenhoek A van: More microscopical observations
made by the same M. Leewenhoeck and promised in Num. 97 of
these tracts; communicated in his letters of August 15, 1673 and
of April 7, 1674. Manuscript of the Royal Society of London,
Ms 1830, L.1.2. (two folio pages). Extracts published in
Philosoph Trans R Soc Lond, 9, 102:23-25, April 27, 1674.
[Quoted by Bessis and Delpech.5].
10. Morgagni JB: The Seats and Causes of Diseases Investi-
gated by Anatomy, 1769. Transl. Benjamin Alexander. New
York, NY, Hafner Publishing Co, 1960, pp 560-561
11. Huxham J: Liber de Febribus. Naples, Italy, 1770
12. Andral G: Essai d'Hematologie Pathologique. Paris,
France, Fortin et Masson, 1943
13. Vogel J: Upon the colour of the urine. Med Times Gazette
7:378, 1853
14. Binet, JL: Historical notes on quantitative blood cell
measurements. Blood Cells 6:507-51 l, 1980
15. Strumia MM: Historical introduction, in Surgenor DM
231
phic determinants (eg, ABH blood group determi-
nants) is submitted to a very stringent negative
selection, whereas the repertoire that is directed
against public determinants (eg, Ii, monomorphic
determinants of the Rh system), as is usual in
autoimmune hemolytic anemias, is probably not
deleted and remains an important component of the
normal immune repertoire.
Research is still needed for complete elucidation
of the mechanisms of the immune dysregulation in
AIHA. Better understanding of the underlying
mechanism(s) may allow for development of more
specific therapies of these not uncommon and often
difficult-to-treat disorders.
(ed): The Red Blood Cell (ed 1). New York, NY, Academic
Press, 1964, pp 1-28
16. Wintrobe MM: A hematological odyssey: 1936-1966.
Johns Hopkins Med J 120:287-309, 1967
17. Wintrobe MM: Macroscopic examination of the blood:
Discussion of its value and description of the use of a single
instrument for the determination of sedimentation rate, volume
of packed red cells, leukocytes and platelets, and of ictems
index. Am J Med Sci 271:90-101, 1976
18. Dressier: Acase of intermittent albuminuria and chroma-
turia. Arch Pathol Anat (Virchow) 5:264, 1954, in Major RH:
Classic Descriptions of Disease. Springfield, IL, CC Thomas,
1939, pp 590-592
19. Dickinson WH: Notes of four cases of intermittent
haematuria, in Major Rtt: Classic Descriptions of Disease.
Springfield, IL, CC Thomas, 1939, pp 590-592
20. Ringer S: The peculiar effect of cold on the capillary
circulation and secretion of bile of a boy probably syphilitic.
Med Times Gazette 26:62-63, 1868
21. Vanlair CF, Masius JR: De la microcythdmia. Bull Acad
R Med Belg 5:515-612, 1871
22. Mackenzie S: Paroxysmal haemoglobinuria, with re-
marks on its nature. Lancet ii:116-117, 155-157, 1879
23. Addison T: On the constitutional and local effects of
disease of the supra-renal capsules. London, UK, New Syden-
ham Society, 1868, p 211; in Major RH: Classic Descriptions of
Disease. Springfield, IL, CC Thomas, 1939, pp 312-315
24. Harris KE, Lewis T, Vaughan JM: Haemoglobinuria and
urticaria from cold occuring singly or in combination: Observa-
tions r e f e ~ g especially to the mechanism of urticaria with
some remarks on Raynaud's disease. Heart 14:305-336, 1928
25. Mackenzie S: On paroxysmal haemoglobinuria. Lancet
1:156-158, 198-200, 243-245, 1884
26. Wilson C: Some cases showing hereditary enlargement
of the spleen. Trails Clin Soc Lond 23:162-171, 1890
27. Wilson C, Stanley D: Hereditary enlargement of the
spleen. Trans Clin Soc London 26:163-171, 1893
28. HayemG: Sur une varirtrparticuli~re d'ictrre chronique.
Ictbre infectieux chronique splrnomrgalique. Presse Med 6:121-
125, 1898
29. Minkowski O: Ueber eine heredit~re, unter dem bilde
eines chronischen icterus mit urobilinurie, splenomegalie und
232
nierensiderosis verlaufende affection. Verhandl d Krong f Inn
Med 18:316-321, 1900
30. Landsteiner K: Zur kentniss der antifermentativen, lyti-
schen nnd agglutinierenden wirkungen des blutserums und der
lymphe. Zbl Bakt 27:357-362, 1900
31. Donath J, Landsteiner K:/J-ber paroxysmale h~noglobinu-
rie. Mtinchen Med Wochenschr 51:1590-1595, 1904
32. Metchnikoff E: Immunity in Infectious Diseases. Cam-
bridge, England, University Press, 1905
33. Chauffard MA: Pathog6nie de l'ict6re congenital de
l'aduke. Semaine Med 27:25-29, 1907
34. Chauffard MA, Troissier J: Andmie grave avec hdmolysi-
nique dans le s6rum; ictbre hdmolysiniqde. Semaine Med
28:345, 1908
35..Chauffard MA, Vincent C: Hdmoglobinurie hdmolysi-
nique avec ictbre polycholique aigu. Semaine Med 29:601-604,
1909
36. Le Gendre R Brutd M: Ictbre hdmolytique congdnital at
ictbre hdmolytique acquis. Presse Meal 17:70, 1909
37. Widal F, Abrami P, Brul6 M: Les ictbres d'origine
hdmolytique. Arch Mal Coeur 1:193-231, 1908
38. Widal F, Abrami P, Bruld M: Ictbre hdmolytique acqnis, ~t
rechutes: Origine iutestinale du processus hdmolitique. Bull
Mdm Soc H6p de Paris 33:480-484, 1912
39. Race RR, Sanger R: Blood Groups in Man (ed 6).
Oxford, England, Blackwell, 1975, p 1
40. Micheli F: Unmittelbare effekte der splenektomie bei
ei:nem fall yon erworbenem hfimolytischen splenomegalischen
ikterus typus Hayem-Widal (spleno-h~tmqlytischer ikterus). Wie-
ner Klinische Wochenschr 24:1269-1274, 1911
41. Banti G: La esplanomegalia hemolitica. Semaine Med
32:265-268, 1912
42. Antonelli G: Intorno agli ittero emolitici. Effetti della
splemectomia su di una particulare forma di ittero emolitico
acquisito con anemia a tipo peruicioso. I1 Policlinico (Sez Med)
20:97, 170, 193, 1913
43. Dameshek W, Schwartz RS: Acute hemolytic anemia
(acquired hemolytic icterus, acute type). Medicine 19:231-327,
1940
44. Naegeli O: Blutkrankheiten und Blutdiagnostik, Berlin,
Verlag yon Julius Springer, 1923, p 408
45. Dacie JV: Research on the red cell: A recipe for a long
life. Am J Med 66:368-370, 1979
46. Christophers SR, Bentley CA: Blackwater fever: Scien-
tific memoirs by officers of the medical and sanitary department
of the government of India. New Series, No 35. Calcutta, India,
Superintendent of Government Printing, 1909
47. Tileston W: Hemolytic jaundice. Medicine 1:355-388,
1922
48. Lederer M: A form of acute hemolytic anemia probably
of infectious origin. Am J Med Sci 170:500-510, 1925
49. Lederer M: Three additional cases of acute hemolytic
(infectious) anemia. Am J Med Sci 179:228-236, 1930
50, Brill IC: Acute febrile anemia: A new disease? Arch
Intern Med 37:244-247, 1926
51. Dacie 'JV: The Haemolytir Anaemias. II. The Auto-
immune Haemolytic Anaemias (ed 2). London, J & A Churchill
Ltd, 1962
52. DaWson BE: Hume lectures on haemolytic icterus. Br
Med J 1:921-966,. 1931
MACK AND FREEDMAN
53. Doan CA, Wiseman BK, Erf LA: Studies in hemolytic
jaundice. Ohio Med J 30:493-504, 1934
54. Witts LJ: The paroxysmal haemogobinurias. Lancet
2:115-120, 1936
55. Dameshek W, Schwartz SO: The presence of hemolysins
in acute hemolytic anemia. N Engl J Med 218:75-80, 1938
56. Boorman KE, Dodd BE, Loutit JF: Haemolytic icterus
(acholuric jaundice) congenital and acquired. Lancet 1:812-814,
1946
57. Race RR: An 'incomplete' antibody in human serum.
Nature 153;771-772, 1944
58. Weiner AS: A new test (blocking test) for Rh sensitiza-
tion. Proc Soc Exp Biol NY 56:173-176, 1944
59. Coombs RRA, Mourant AE, Race RR: A new test for the
detection of weak and "incomplete" Rh agglutinins. Br J Exp
Patho126:255-266, 1945
60. Moreschi C: Neue tatsachen tiber die blutk6perchenagglu-
tination. Zentralblatt ffir Bakteriologie, Parasitenkunde und
Infektionskrankheiten 46:49-51, 1908
61. Moreschi C: Beschleunigung und verstfirkung der bak-
terienagglutination durch antieiweisssera. Zentralblatt fur Bakte-
riologie, Parasitenkunde und infektionskrankheiten 46:456-460,
1908
62. Boorman KE, Dodd BE, Morgan WTJ: Enhancement of
the interaction of immune haemagglutinins by human serum.
Nature (Loud): 156:663-664, 1945
63. Gilliland BC, Baxter E, Evans RS: Red cell antibodies in
acquired hemolytic anemia with negative antiglobulin serum
tests. N Engl J Med 282:252-256, 1971
64. Wagley PF, Shen SC, Gardner FH, et al: Studies on the
destruction of red blood cells. VI. The spleen as a source of
substance causing agglutination of red blood cells of certain
patients with acquired hemolytic jaundice by an anti-human
serum rabbit serum (Coombs' serum). J Lab Clin Med 33:1197-
1203, 1948
65. Evans RS, Duane RT: Acquired hemolytic anemia. Blood
4:1196-1213, 1949
66. Young LE, Miller G, Christian RM: Clinical and labora-
tory observations on autoimmune hemolytic disease. Ann Intern
Med 35:507-517, 1951
67. Iafusco E Biffa V: Autoimmune hemolytic anemia in a
new born infant. Pediatrica 70:1256-1264, 1962
68. Dausset J, Colombani J: The serology and the prognosis
of 128 cases of autoimmune hemolytic anemia. Blood 14:1280-
1301, 1959
69. Schub0the H: Current problems of chronic cold hemag-
glutinin disease. Ann N YAcad Sci 124:484-490, 1965
70. Dacie JV: Aetiology of the auto-immune haemolytic
anaemias. Haematologia 5:351-357, 19'71
71. Rosse WF: The antiglobulin test in autoimmune hemo-
lytic anemia. Annu Rev Med 26:331-336, 1975
72. Schreiber AD, Frank MM: The role of antibody and
complement in the immune clearance and destruction of erythro-
cytes: In vivo effects of IgG and complement fixing sites. J Clin
Invest 51:575-582, 1972
73. Frank MM: Mechanisms of cell destruction in immune
hemolytic anemia, in Barns A Jr (ed): A Seminar on Laboratory
Management of Hemolysis. Washington, DC, American Associa-
tion of Blood Banks, 1979, pp 29-43
74. Garratty G: The significance of IgG on the red cell
surface. Transfus Med Rev 1:47~58, 1987
AUTOIMMUNE HEMOLYTIC ANEMIA
75. Chaplin H, Nasongkla M, Monroe MC: Quantification of
red blood cell-bound C3d in normal subjects and random
hospital patients. Br J Haemato148:69-78, 1981
76. Freedman J: The significance of complement on the red
cell surface. Transfus Med Rev 1:58-70, 1987
77. Arend WE Ragsdale CG, in Forster O, Landy M (eds):
Heterogeneity of Mononuclear Phagocytes. New York, NY,
Academic Press, 1981, p 150
78. Rosse WE deBoisfleury A, Bessis M: The interaction of
phagocytic and red cells modified by immune reactions: Com-
parison of antibody and complement-coated red ceils. Blood
Cells 1:345-358, 1975
79. Borne AEGKr von dem, Beckers D, Engelfriet CP:
Mechanisms of red cell destruction mediated by non-comple-
ment binding IgG antibodies: The essential role in vivo of the Fc
part of IgG. Br J Haemato136:485-493, 1977
80. Engelfriet CP, Borne AEGKr von dem, Beckers D,
Loghem JJ van: Autoimmune haemolytic anaemia: Serological
and immunochemical characteristics; mechanisms of cell destruc-
tion. Ser Haematol 7:328-347, 1974
81. Garratty G: Autoimmune hemolytic anemia, in Garratty
G (ed): Immunobiology of Transfusion Medicine. New York,
NY, Marcel Dekker, 1994, pp 493-521
82. Dighiero G, Rose NR: Critical self-epitopes are key to
the understanding of self-tolerance and autoimmunity. Immunol
Today 20:423-428, 1999
83. Landsteiner K: i0ber agglutinationsercheinungen nor-
maten menschlichen. Blutes Kliu Wochenschr 14:1132, 1901
84. Ehrlich P, Morgenroth J: On hemolysins; 3rd communica-
tion, in Himmelweit F (ed): The Collected Papers of Paul
Ehrlich, Fifth Communication (Vol 2). Oxford, Pergamon Press,
1900, pp 205-255; republished 1959
85. Metalnikoff S: Etudes sur ta spermatoxine. Ann Inst
Pasteur 9:577, 1900
233
86. Owen RD: Immunogenetic consequences of vascular
anastomoses between bovine twins. Science 120:400-404, 1945
87. Billingham RE, Brent L, Medawar PB: Actively acquired
tolerance of foreign cells. Nature 172:603-606, 1953
88. Jeme NK: Towards a network theory of the immune
system. Adv Immunol 125:373-389, 1974
89. Burnet FM: A modification of Jerne's theory of antibody
production using the concept of clonal selection. Aust J Sci
20:67-69, 1957
90. Rose NR, Witebsky E: Studies on organ specificity. V.
Changes in thyroid glands of rabbits following active immuniza-
tion with rabbit thyroid extracts. J Immuno176:417-427, 1956
91. Witebsky E, Rose NR, Terplan K, Paine JR, Egan RW:
Chronic thyroiditis and autoimmunization. J Am Med Assoc
164:1439-1447, 1957
92. Rose NR, Bona C: Defining criteria for autoimmune
diseases. Immunol Today 14:426-430, 1993
93. Boyden SV: Natural antibodies and the immune re-
sponse. Adv Immunol 5:1-28, 1966
94. Mackay IR: Natural antibodies to the fore: Forbidden
clones to the rear? immunol Today 4:340-342, 1983
95. Izui S, Lambert PH, Foumie GJ, et al: Features of
systemic lupus erythematosus in mice injected with bacterial
lipopolysaccharides: Identification of circulating DNA and renal
localization of DNA-anti-DNA complqxes. J Exp Med 145:1115-
1130, 1977
96. Klinman D, Steinberg AD: Systemic autoimmune disease
arises from polyclonal B cell activation. J Exp Med 165:1755-
1760, 1987
97. Schlomchik MJ, Marshall-Rothstein A, Wolfowicz CB,
et al: The role of clonal selection and somatic mutation in
autoimmanity. Nature 328:805-811, 1987