Blood Transfusion

by Geoffrey Keynes

The necessity for careful blood grouping in every case before performing a transfusion has now been sufficiently emphasized, but before proceeding to the description of the methods of choosing a donor and of grouping, a possible danger must be mentioned which may arise even when the blood groups are known. In the preceding chapters references were made to the effects which have been observed to follow repeated transfusions given in the treatment of a condition such as pernicious anæmia. In such cases, although the groups were ascertained, and the bloods were also tested directly against one another without any incompatibility being detected, yet when the third or fourth transfusion was given, symptoms of toxæmia followed, sometimes with hæmolysis. The death of the patient has even been hastened in this way. A very striking instance of this phenomenon, which has been recently reported (278), will serve to bring home the reality of the danger. A boy was transfused by the citrate method with blood from his father, and this was followed only by a mild febrile reaction such as is often observed. Eighteen days later a second transfusion with blood from the same donor was performed, and after 150 cc. had been given, a severe reaction resulted, which was followed later by pronounced hæmoglobinuria. In this case the bloods of donor and recipient had been tested against one another directly, but this was not repeated, and the groups were not ascertained until afterwards. Probably there was some error in the original test, for it afterwards appeared that the boy belonged to Group I and his father to Group III, so that there should have been agglutination of the boy’s corpuscles by his father’s serum outside the body. Nevertheless, Group I individuals have been called the “universal recipients,” and no ill effects are usually observed whatever blood be used for transfusing them. In the other cases already mentioned a reaction followed the later transfusions, even when the donor and recipient belonged to the same group. It appears that by repeated transfusions the recipient becomes as it were sensitized to the blood of another individual even of the same group, and consequently great caution must be used in giving the later transfusions of a series. Some light is thrown on this question by the observations of Ottenberg, already referred to, concerning the artificial production of iso-hæmolysins in cats. In these animals iso-agglutinins are found, but iso-hæmolysins seldom or never. The reaction is, however, found to become hæmolytic in the recipients of transfusions, and it is then selective. It seems, therefore, that the group reactions may not be as clearly defined as was at one time supposed. Probably there are slight incompatibilities of an unknown nature between individuals of the same or compatible groups. These are very seldom of any consequence in a first transfusion, but become accentuated as the result of “sensitization,” and in later transfusions have a pronounced influence. This “over-lapping” of groups has been mentioned on another page. It must not be supposed that any untoward results follow repeated transfusions as a general rule, for usually no such effect is observed. In order, however, to minimize the risk, it may be suggested that the following precautions should be taken: (1) The donor should be actually of the same group as the recipient, and not merely of a theoretically compatible group; a patient, for instance, of Group II should receive blood of Group II rather than of Group IV. (2) The same donor should not be used for the later transfusions of a series, on the grounds that the sensitization appears to be an individual rather than a group phenomenon. (3) In performing the later transfusions, the blood should be given at first very slowly, so that it may be discontinued at the first appearance of any signs of a reaction.

CHAPTER VI
THE CHOICE OF BLOOD DONOR

The physiology of blood groups having been examined, the principles governing the choice of a blood donor can be more readily understood. It is evident that this choice is determined largely by blood groups, and in the present chapter therefore the clinical methods of testing for the groups will be described.

Before, however, the bloods can be tested, a willing donor must be found, and this is not always an easy matter. During the war, even when transfusion was being practised on a large scale, there was never any difficulty in finding volunteers among the men that were more lightly wounded. In addition to the genuine and ready response which many men would make at once to a call for help in a matter of life and death, there was the glamour of novelty and the feeling of satisfaction following an act of conscious heroism—for such the sacrifice of blood was held to be, the days having long been forgotten when as much blood was “let” in the treatment of almost any ailment. In the Expeditionary Force, too, the unofficial reward of a fortnight’s leave in England proved a potent inducement, and the rejection of a volunteer on the ground of incompatibility was regarded almost as an injustice or as a reflection upon the physical condition of the candidate. In civilian life, however, such inducements cannot be held out, and it will be found that many a man “does not like the idea” of parting with a pint of blood, even though the sacrifice may save another’s life. Often, however, a near relative of the patient may happen to be willing and suitable, or, failing this, in a hospital ward there will usually be some young man who has been admitted for a slight operation, such as the radical cure of a hernia, and will accede to a request for blood if the procedure, its object, and its harmlessness to himself be briefly explained. Notoriety is fortunately seldom a motive for volunteering, and though paragraphs have occasionally appeared in the daily press with headings such as “Police Inspector’s Sacrifice,” this has probably not been done by the donor’s own wish. It is, after all, natural that to the mind of a layman the giving to another of so personal a possession as his blood should seem to be an act of heroism, and it is also natural that occasionally a man should feel some repugnance to taking part in a strange performance which he but dimly understands. To the young, on the other hand, the procedure may appeal by its faint flavour of adventure.

Occasionally during the last two years advertisements for blood donors have appeared in newspapers, probably not in vain. If the demand for blood donors becomes greater than it has been as yet, it will certainly result in the creation of a class of “professional blood donors,” who already exist in some numbers in the United States of America, where blood transfusion is a more widely recognized form of therapeutics than it is in this country. These professionals have even formed a Trade Union, so that as high a fee as possible may be obtained from those who need their blood. Apart from this, some of the advantages of having these professionals available have already been explained in the chapter on the dangers of blood transfusion. It is evident that certain sources of danger can be eliminated in advance, and in an emergency it is obviously better to have donors of known groups available, so that no time is lost in testing the prospective donors of whom several in succession may be found unsuitable. Probably it will be easier for practitioners to arrange for such professionals to be available at the shortest notice than for necessary arrangements to be made in a hospital. Even in large institutions it is usually difficult for any of the men employed in them to be spared from their work for twenty-four hours, so that, although suitable men of known groups are always within call, it may be impossible to use them. This, however, is not the place to discuss the organization that is necessary to make a blood transfusion a really efficient form of emergency treatment in a hospital. It may merely be observed that in every hospital it should be possible to give a blood transfusion to a patient suffering from urgent hæmorrhage within fifteen minutes of his arrival on the premises.

Whether the donor be a “professional” or an “amateur,” it may be useful to mention a few points to be observed in choosing him. There can be no doubt that the most satisfactory individuals for the purpose are young men between the ages of eighteen and twenty-five. The younger the donor, the less likely is he to be suffering from certain of the diseases mentioned in the chapter on the dangers, the less will be the immediate effect of the withdrawal of circulating fluid, and the more quickly will he recuperate from the loss of blood.

It must not be supposed, however, that the withdrawal of even 1,000 cc. of blood will usually have an appreciable effect upon a healthy man. It is impossible to predict from the donor’s appearance what immediate effect the loss of blood will have upon him. It sometimes happens that the most robust-looking individual becomes faint after losing a few hundred cubic centimetres, whereas another, to all appearances pallid and much less satisfactory, will not evince the slightest discomfort from the loss of 750 cc. or even more. Normally a man should be able, by his physiological mechanisms, to compensate reflexly and at once for the removal of this amount of fluid from his circulation. In any case, the worst effect that is seen in a well-chosen donor is a transient faintness; it is usually wise to keep him on his back for two or three hours after the operation, and he should not, if it can be avoided, return to his work on the same day. During the late war a medical officer of my own acquaintance gave 750 cc. of blood for a severely wounded friend and continued his arduous duties as Surgical Specialist in a Casualty Clearing Station immediately afterwards. In this case, however, the donor was solely responsible for his own welfare; usually this responsibility rests upon another, and greater care must be exercised. The effect, indeed, of a transfusion upon the donor seems to depend more upon psychological than upon physiological factors. A nervous and excitable donor is more likely to suffer than one who approaches the operation without apprehension. This is another point in favour of employing a professional donor, who soon becomes familiar with the whole procedure and will lose all symptoms of fear.

The same considerations may be applied to the use of women as blood donors. In them the spirit of self-sacrifice is commonly more highly developed than it is in men, and some of the most eager donors will be found among them. The disability of nervousness will, however, occur more often in women, and another consideration of importance is that the veins of a woman are usually much less easily accessible than those of a man. Not only is the abundant subcutaneous fat an impediment in women, but usually the superficial veins are all of small size. The method of choice for performing a blood transfusion will be presently described, and it will then be seen that the operation is easier and that much less damage is inflicted on the donor if a large superficial vein can be tapped. In women this will very often be difficult or even impossible. In general, therefore, it may be stated that the use of women as blood donors is to be avoided. The fallacies concerning the indiscriminate transfusion of an infant with its mother’s blood and of any patient with the blood of a near relation have already been explained.

Testing for Blood Groups

Reference to the table of blood reactions given on p. 71 will show that in order to discover the blood group of any individual it is only necessary to test his corpuscles against the serum of Groups II and III. These reactions may be recapitulated as follows: