Blood Basics > Early Practices
Transfusions
The following is excerpted from BLOOD PROGRAM IN WORLD WAR II by Douglas Blair Kendrick (pgs. 1-5).
Chapter I: Historical Note
Transfusion Before World War I
Although the concept of the therapeutic value of blood dates back to antiquity, transfusion in the modern sense of the term was a practical impossibility until William Harvey, in 1616, announced his discovery of the circulation of the blood.1 This discovery opened the way for serious experiments on the infusion of various substances into the bloodstream and eventually led to the use of whole blood for transfusion.
Claims to priority are various and confusing. It is clear, however, that Richard Lower, inspired by the previous experiments of Sir Christopher Wren in infusion techniques, performed the first successful animal transfusion in 1665, when he transferred blood from the carotid artery of one dog to the jugular vein of another. In November 1667, Lower transfused Mr. Arthur Coga, "a mildly melancholy insane man," with the blood of a lamb. Mr. Coga, according to Pepys, described his experience in Latin before the Royal Society of Medicine and stated that he was much better. He impressed Pepys as "cracked a little in his head."
The next animal-to-human transfusions were also performed on generally the same indications, by Jean Baptiste Denis, physician to Louis XIV. When Denis' fourth attempt ended fatally, he was charged with murder. He was eventually exonerated, but, 10 years later, the procedure was prohibited by law in France as well as in Italy and was also forbidden by the Royal Society of Medicine in England.
For the next 150 years, there was little interest in transfusion, but it is significant that Nuck in 1714 and Cantwell in 1749 declared that this procedure would be of value in severe hemorrhage. When interest in transfusion was revived by James Blundell (5-7) in 1818, it was on the basis of replacement of lost blood in puerperal hemorrhage and after a series of experiments in which he had demonstrated that human blood loses none of its "vital properties" by passage through transfusion equipment. Blundell failed in his first four desperate attempts to save women on the point of death from postpartal hemorrhage, but he succeeded in five of the next six attempts.
1The following brief historical account of the development of blood transfusion is necessary for an understanding of the medicomilitary employment of this measure, a use not suggested up to World War I. The material included, unless otherwise indicated, is derived from (1) the detailed historical account in Kilduffe and DeBakey's THE BLOOD BANK AND THE TECHNIQUE AND THERAPEUTICS OF TRANSFUSIONS (1), which has an appended list of 207 (183 numbered) references, and (2) Lewisohn's (2,3) and Ottenberg's (4) accounts of the contributions of Mount Sinai Hospital in New York to this therapeutic technique.
In 1875, Landois (10), in a comprehensive monograph on transfusion, collected 347 cases in which human blood had been used and 129 cases in which animal blood had been used. By this time, important studies on the physiology of the blood were being performed by a number of qualified observers, and some physicians, such as Fordyce Barker, advocated transfusion " ... not exclusively in those desperate cases where favorable results are hardly looked for but ... before patients have arrived at, and fallen into, this desperate condition."
Techniques in use included transfusion with defibrinated blood, mediate transfusion with pure blood, immediate transfusion from vein to vein, and immediate transfusion from artery to vein.
Although the indications and rationale of blood transfusion were by this time apparently quite well understood, the indications during the last quarter of the century again became vague and irrational, the procedure was employed indiscriminately, and the number of severe reactions and fatalities increased. As a result, transfusion again began to be considered as a hazardous, and even a disreputable, procedure, to be employed only as a last resort and in desperation.
During the first years of the 20th century, a blood transfusion was frequently a more difficult technical procedure, and sometimes a procedure fraught with greater risks, than a major operation. Its development as an effective and safe therapeutic method required the solution of a number of special problems:
1. Blood coagulation. First efforts to overcome this difficulty were made in 1835, with the use of defibrinated blood by Bischoff, and terminated in 1914, with the successful use of sodium citrate by Hustin, Weil, and Lewisohn (2, 3) (p. 218).
2. Agglutination and hemolysis from admixture of incompatible bloods. The way was opened to the solution of this special problem in 1900, when Landsteiner (11) published his epochal work on the identification of blood groups, based on his previous demonstration of the presence of isoagglutinating and isoagglutinable substances in the blood. Jansky in 1907 and Moss 3 years later, without knowledge of Jansky's studies, worked out the reciprocal agglutinating reactions of the four blood groups and classified them accordingly. The confusion that arose because of differences in nomenclature was eliminated after World War I, when the numbers previously used to designate blood groups were replaced by the letters A, B, AB, and O, each group thus being designated by the agglutinogens in Landsteiner's original scheme.
Communications in the early years of the 20th century were often slow, and foreign medical literature had only a limited circulation in the United States. No practical use, therefore, was made of Landsteiner's work until 1907, when Ottenberg (4), at Mount Sinai Hospital in New York, first matched donor and recipient before giving blood and thus made transfusion a safe procedure from the standpoint of compatibility. The validity of Ottenberg's work was not immediately realized; his offer to perform compatibility tests for the surgeons at his own hospital had no general acceptance for almost 5 years because such tests were considered unnecessary or misleading.
In 1911, Ottenberg demonstrated that it was safe to use as a donor a person whose serum agglutinated the recipient's red cells but unsafe and dangerous to use one whose red cells were acted upon by the recipient's serum. This demonstration eventually led to the widespread employment of group O donors as universal donors, since the red blood cells of this blood group are not agglutinable by the serum of any other blood group.
3. Technical difficulties. Until 1913, direct transfusion was used to the exclusion of any other technique. This was a difficult and time-consuming method, requiring a specially trained team to carry it out and totally unsuited for use in sudden emergencies. In 1892, von Ziemssen of Munich had performed transfusion by the syringe technique, but his report attracted no attention and when Lindeman (12) described it in 1913, it was, for all practical purposes, a new method. With this technique, no dissection of blood vessels was necessary in either donor or recipient, and the exact quantity of blood transfused was known. The technique, however, required a trained team of at least four persons and the use of a large number of expensive syringes. Also, rapid injection of the blood was mandatory. In 1915, Unger (13) introduced an apparatus based on the principle of the two-way stopcock, which overcame many of these difficulties. Dozens of variations of this apparatus were introduced during the next 15 years.
4. Infection. Infection ceased to be a major problem after first antiseptic, and then aseptic, techniques came into general use and as long as transfusion was employed only in hospitals and on what amounted to elective indications. The open containers originally used to collect blood for indirect transfusion first became impractical, and then a real source of danger, when indications for transfusion were extended.
References
1. Kilduffe, Robert A., and DeBakey, Michael: THE BLOOD BANK AND THE TECHNIQUE AND THERAPEUTICS OF TRANSFUSIONS. St. Louis: C. V. Mosby Co., 1942.
2. Lewisohn, R.: "The Development of the Technique of Blood Transfusion Since 1907; With Special Reference to Contributions by Members of the Staff of the Mount Sinai Hospital." "J. Mt. Sinai Hosp." 10: 605-622, January-February 1944.
3. Lewisohn, R.: "Blood Transfusion: 50 Years Ago and Today." "Surg. Gynec. & Obst." 101: 362-368, September 1955.
4. Ottenberg, R.: "Reminiscences of the History of Blood Transfusion." "J. Mt. Sinai Hosp." 4: 264-271, November-December 1937.
5. Blundell, J.: "Experiments on the Transfusion of Blood by the Syringe." "M. Chir. Tr." 9: 56-92, 1828 (London).
6. Blundell, J.: "Observations on Transfusion of Blood. With a Description of His Gravitator." "Lancet" 2: 321-326, 31 June 1828.
7. Blundell, J.: "Successful Case of Transfusion." "Lancet" 1: 431-432, 3 Jan. 1829.
8. Benedict, N. B.: "Transfusion in Yellow Fever -- A Successful Case." "New Orleans M. News and Hosp. Gaz." 5: 721-727, January 1859.
9. Benedict, N. B.: "On the Operation of Transfusion -- Being the Report of a Committee." "New Orleans M. & S. J." 10: 191-205, September 1853.
10. Landois, L.: DIE TRANSFUSION DES BLUTES. Leipzig: F. C. W. Vogel, 1875.
11. Landsteiner, K.: "Zur Kentniss der antifermentativen lytischen und agglutinierenden Wirkungen des Blutserums und der Lymphe." "Zentralbl. Bakt." 28: 357-362, 23 Mar. 1900.
12. Lindeman, E.: "Simple Syringe Transfusion with Special Cannulas. A New Method Applicable to Infants and Adults." Preliminary Report. "Am. J. Dis. Child." 6: 28-32, July 1913.
13. Unger, L. J.: "A New Method of Syringe Transfusion" "J.A.M.A." 64: 582-584, 13 Feb. 1915.
From BLOOD PROGRAM IN WORLD WAR II (SUPPLEMENTED BY EXPERIENCES IN THE KOREAN WAR) by Douglas Blair Kendrick. Washington, D.C.: Office of the Surgeon General, Department of the Army, 1989. (Provided by the Office of Medical History, Office of the Surgeon General/US Army Medical Command.)
