By Marshall A. Lichtman, MD, Josef Prchal, MD, and Karl Blume, MD

2008-01-01

Dr. Lichtman is Professor of Medicine, Biochemistry and Biophysics, at the University of Rochester Medical Center in Rochester, NY.

Dr. Prchal is Professor of Medicine and Genetics at the University of Utah.

Dr. Blume is Professor of Medicine at Stanford University.

Wallace H. Coulter

The establishment of The Wallace H. Coulter Award for Lifetime Achievement in Hematology by the Coulter Foundation and the American Society of Hematology's naming Ernest Beutler, MD, as its first recipient is the happy convergence of two people who are among the most important contributors to hematology in the last 50 years.

The science and practice of hematology is dependent on blood-cell enumeration. The methods for cell counting through the first half of the 20th century were manual, tedious, laborious, and subject to frequent error. In the late 1950s, a transformation in particle, including cell, counting occurred. This transformation was the result of the genius of Wallace Coulter who patented the method he developed to count and measure the volume of particles electronically.

Mr. Coulter had a strong interest in electronics in high school and attended the Georgia Institute of Technology with a major interest in electrical engineering. He worked for a series of electronics firms, including General Electric and Raytheon. After World War II, he began to consider methods of measuring industrial and biological particles electronically to improve accuracy and ease of measurement. In the mid-1950s, he and his brother Joseph produced prototype models of the Coulter Counter. The Model A was the first instrument put into practice, and in 1958 the brothers established Coulter Electronics. Over the next 40 years, the company grew to employ 5,000 people and operate in 20 countries, and the instruments it developed revolutionized particle counting, sizing, and more. I was a happy beneficiary of this landmark work when I dispensed with my diluting pipette and used a Model B Coulter Counter rigged to a computer, with an oscilloscope interpolated, permitting tallies of cell counts and Polaroid photos of their volume distribution curve. Who in clinical or research hematology throughout the world has not benefited from Mr. Coulter's innovations?

The Coulter Principle, which formed the basis for future developments and advanced instruments, is that cells are poor conductors of electricity as compared to a salt solution. If cells are diluted in a saline solution and drawn through a tiny aperture carrying a current, each cell produces slight impedance to current flow. The pulse created by the resistance to current flow of each particle flowing through the aperture can be amplified and counted. Moreover, the size of the pulse can be made proportional to cell volume. Thus, the number and size distribution of particles in a measured volume of a dilute suspension of cells can be converted electronically to the blood cell count and volume. Thousands of cells can be counted per second. Since platelets, white cells, red cells, and contaminating particles are sufficiently different in frequency and size, they can be discriminated. It is an irony of progress that the red cell count and volume is measured so precisely that the packed cell volume (hematocrit), theretofore the most simple and accurate measure of red cell concentration in the blood, has become a derived value, the product of the red cell count and the mean red cell volume.

The early device and its successors provided an unparalleled level of accuracy, efficiency, and breadth of application for enumerating and measuring the size of cells from any tissue source. Those readers who labored over red cell and white cell counts using a diluting pipette and hemacytometer chamber have some sense of the effect of Coulter's instrument and its later multi-parameter output on hematology and related disciplines.

The development of flow cytometry and sorting has had a stunning and incalculable impact on research, diagnosis, and therapy. Adaptations that permit characterizing the phenotype or DNA content of cells and sorting and isolating cells by their physical or surface properties have advanced studies of cells dramatically. This remarkable instrument evolved from Joseph and Wallace Coulter's earliest developments. A small subsidiary owned by Coulter, Los Alamos Particle, Inc., in collaboration with the Health Physics Division of the Los Alamos National Laboratories, used the ideas that had evolved to develop the prototype flow cytometer. The instrument developed used the Coulter Principle to separate fluid droplets containing cells by differences in cell volume. They could electrically charge droplets with cells of the desired volume and deflect them electrostatically into a collecting reservoir. Later, workers at Stanford advanced this technology by using cells stained with fluorescent dyes and measured cell size by light scatter and the fluorescence intensity generated by a laser. The cell-containing droplets could be charged based on size and on the conversion of the laser-generated optical signal into an electronic pulse. These two variables (dual parameters) could be used to decide whether to deflect the cell into a collecting reservoir. The addition of laser light scatter to the Coulter Principle of electronic counting and sizing resulted in VCS (volume, conductivity, scatter of laser light) technology.

Mr. Coulter's ideas and instruments were among the most important innovations in diagnostic and investigative medicine in the 20th century when one considers their impact on the disciplines of cell biology, hematology, immunology, and oncology, and also on industrial processes.

Dr. Beutler's contributions were of a different nature. He provided scientific insight into a remarkable range of hematologic diseases. He is a foremost student of blood storage, red cell metabolism, hemolytic anemias, iron metabolism and its disorders, lipid storage diseases (Gaucher disease, in particular), and a range of clinical genetic disorders, and has contributed to many other areas in insightful ways (e.g. hematopoietic stem cell transplantation, leukocyte disorders, platelet transfusion, and others). He contributed to refined methodologies of measurement (e.g. red cell enzymes) and diagnostic tests of importance for clinical genetic and hematologic disorders. His contributions have been highlighted in an article written by Drs. Josef Prchal and Karl Blume in this issue of The Hematologist (see below) and in a short biography published in Leukemia.¹ A singular contribution of his was the first demonstration of the human female as a mosaic of X-chromosome gene expression. Dr. Beutler had already contributed extensively to our understanding of red cell glucose-6-phosphate dehydrogenase (G6PD) and the clinical impact of its deficiency. He used this enzyme as an X-chromosome marker to establish the mosaic state of X-chromosome gene expression in the human female. Coat color genes are on the X chromosome in mice but not in humans, making Dr. Beutler's discovery applicable to human genetics. Thus, the work was of profound importance for the understanding of gene regulation and for other biologic processes. For example, the concept was used to demonstrate that human tumors were monoclonal, providing the once elusive definition of a neoplasm as a tissue abnormality arising from the genetic alteration in a single cell.

In parallel to Mr. Coulter, who in hematology around the world has not benefited from Dr. Beutler's enormously productive career; his insights into human disease and its diagnosis and management; his gifted writings; his contributions to agencies, organizations, and institutions; and his mentoring of innumerable disciples? His warm friendship and gentle humor have also been shared by the lucky ones among us who have had the opportunity to interact with him more intimately.

"In choosing a Nobel prize winner, there is usually no unambiguous or incontestable best choice," said Arne Tiselius, himself a Nobel Laureate in Chemistry, and later President of the Nobel Foundation. "One can only hope the selection is worthy," he continued. Here, I would argue we have an unambiguous and incontestable best choice, Ernest Beutler.

1. Lichtman MA. An Introduction of Ernest Beutler. Leukemia. 2001:15;656-657.

Ernest Beutler

Ernest Beutler, MD, Chairman of the Department of Molecular & Experimental Medicine at The Scripps Research Institute, was the inaugural recipient of The Wallace H. Coulter Award for Lifetime Achievement in Hematology in December 2007. This award is bestowed on an individual who has demonstrated a lifetime of contributions to the field of hematology and who had a significant impact on research, education, and practice. One cannot think of anyone more deserving of this new award than Ernest Beutler. His accomplishments in academic hematology and the biologic sciences over the last five decades are singular.

Dr. Beutler's original discoveries in science and the art of hematology span a wide spectrum, involving many areas of biochemistry, molecular biology, genetics, cell biology, pathophysiology, diagnosis, and therapy. His contributions not only have given us new insights into the mechanisms of diseases but have also changed the way we practice medicine in general and hematology in particular.

He proposed the phenomenon of X-chromosome inactivation in human females, based on his work with glucose-6-phosphate dehydrogenase (G6PD), concurrently and independent of the studies of the mouse geneticist Dr. Mary Lyon. This insight represented the first example of the modulation of expression of genes by an epigenetic mechanism. This brilliant observation provided an explanation of the remarkable heterogeneity of the phenotype expressed by heterozygous females for G6PD deficiency, hemophilia, and other X-linked disorders. Following the studies by Drs. Gartler and Linder on the clonality of myomas, Dr. Beutler promptly demonstrated the clonality of malignant human tumors that changed the way we understand carcinogenesis.

With his typical rigorous approach, Dr. Beutler established and standardized methods for measurements of red blood cell enzymes that provided the explanation for several heretofore mysterious hemolytic anemias. He also developed a simple and accurate method for the early identification of newborns with galactosemia using small samples of erythrocytes. This method has since been used on millions of newborns for early detection and institution of dietary treatment, making possible the avoidance of the debilitating complications of galactosemia. His critical knowledge of red cell metabolism led to improvement in blood storage preservation that increased the shelf life of blood — a major contribution to transfusion medicine with immeasurable benefits to the general public.

Dr. Beutler is a true clinician-scientist who has taken care of patients most of his career. He also has made many innovative clinical observations demonstrating that the fusion of knowledge of basic science and the art of medicine often leads to pioneering discoveries. In 1959, he was the first to propose that sickle cell disease could be treated by altering the hemoglobin in patients' erythrocytes, either by increasing methemoglobin levels or inducing the formation of fetal hemoglobin. The latter approach bore fruit 40 years later with the introduction of the treatment of sickle cell disease with hydroxyurea. Dr. Beutler has also been a major contributor to the understanding of the biochemical genetics, molecular biology, and treatment of hereditary lipid storage diseases. He developed the first clinically practical biochemical method for the diagnosis of Gaucher disease and for identifying carriers. His group cloned the glucocerebrosidase gene and identified most of the mutations that cause Gaucher disease. He pioneered enzyme replacement therapy for Gaucher disease in the 1970s. When enzyme replacement became commercially available, his careful studies showed that the dose of the very costly enzyme that was being used for treatment was recommended at nearly 10 times the effective dose.

In 1975, in his role as a clinical hematologist, Dr. Beutler initiated a very successful clinical bone marrow transplantation program. Inspired by the findings of Dr. E. Donnall Thomas and his group that patients with advanced leukemia enjoy survival superior to that seen with chemotherapy, Dr. Beutler and his transplant team at the City of Hope National Medical Center became one of the first to successfully explore transplantation in acute leukemia patients in complete first remission.

Dr. Beutler repeatedly seized on lessons learned from genetic diseases to devise better treatments. When Dr. Dennis Carson, then an assistant professor in his new department at The Scripps Research Institute, designed 2-chlorodeoxyadenosine (cladribine) as a promising anti-lymphocyte compound, Dr. Beutler initiated and directed clinical studies that established this agent as the most effective treatment for hairy cell leukemia. Most recently, Dr. Beutler has revolutionized our thinking about the clinical penetrance of hereditary hemochromatosis, thought to be "the most common disease of Europeans." Dr. Beutler organized what was probably the largest DNA-based epidemiology study to date, comprising more than 41,000 participants. This study demonstrated that although the hereditary hemochromatosis genotype was common, the clinical phenotype was rare. Initially received with skepticism, since they ran counter to common belief, his findings have now been extensively confirmed.

Among his many contributions to hematology has been to serve as an editor of a leading hematology textbook of which seven editions have appeared since its inception in 1970. He was the President of ASH in 1979 and has served on the editorial board of the Society's journal, Blood. He also established the first combined online and print biomedical journal, Blood Cells, Molecules and Diseases. He was elected to the National Academy of Sciences and the Institute of Medicine, has been a consultant to many scientific and medical organizations, served on the Editorial Board of numerous scientific and medical journals, and has received many prestigious awards including an Honorary Doctor of Sciences from the Tel Aviv University.

One can only hope that all trainees in academic hematology may have the good fortune of the attentive, generous, and superior intellectual guidance that we experienced as trainees of Dr. Beutler.

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