Blood Transfusion

by Geoffrey Keynes

A more general interest in the subject was revived in England by the work of James Blundell, lecturer on physiology and midwifery at St. Thomas’s and Guy’s Hospitals. He published in 1818 his earliest paper on experimental transfusion with a special form of syringe invented by himself. His first apparatus consisted of a funnel-shaped receptacle for the blood, connected by a two-way tap with a syringe from which the blood was injected through a tube and cannula into the recipient. His experiments were performed upon dogs, and he began by drawing blood from the femoral artery and re-injecting it into the same animal through the femoral vein. He then conducted a long series of investigations into the properties of blood, the effects of its withdrawal, and the resuscitation of an exsanguinated animal. Soon he had opportunities of transfusing patients with human blood, and the results are recorded in his paper of 1824. His apparatus had by then been elaborated, and an engraving of his Impellor, as he termed it, is reproduced here. It consisted as before of a funnel-shaped receptacle for the blood, but the syringe was now incorporated in one side of the funnel, and contained a complicated system of spring valves, which caused the blood to travel along the delivery tube when the piston was pushed down. The Impellor was fixed to the back of a chair in order to give it stability.

All the patients transfused by Blundell were either exceedingly ill, or, judging from his description, already dead, so that his results, considered statistically, were not favourable! Nevertheless, he was not discouraged, and stated his “own persuasion to be that transfusion by the syringe is a very feasible and useful operation, and that, after undergoing the usual ordeal of neglect, opposition, and ridicule, it will, hereafter, be admitted into general practice. Whether mankind are to receive the first benefit of it, in this or any future age, from British surgery, or that of foreign countries, time, the discoverer of truth and falsehood, must determine.” Blundell’s work has been described in some detail because, after the experimental work of the seventeenth century, the year 1818 may be taken to mark the real beginning of the clinical application of blood transfusion.

The chief difficulty in the way of successful transfusion was, of course, the obstacle introduced by the coagulation of the blood. Bischoff in 1835 sought to overcome this by injecting defibrinated blood, and that solution of the difficulty was adopted by many operators, including Sir Thomas Smith, who, in 1873, used defibrinated blood for transfusing a case of melæna neonatorum at St. Bartholomew’s Hospital. The apparatus on this occasion consisted of “a wire egg-beater, a hair sieve, a three-ounce glass aspirator syringe, a fine blunt-ended aspirator cannula, a short piece of india-rubber tubing with a brass nozzle at either end connecting the syringe with the cannula, a tall narrow vessel standing in warm water for defibrinating the blood, and a suitable vessel floated in warm water to contain the defibrinated blood.” Others, too numerous to be individually named, used the same method throughout the nineteenth century and during the first ten years of the twentieth. Even in 1914 a method of using defibrinated blood was described by Moss. An objection was raised in 1877 that it was dangerous to do this, owing to the excess of fibrin ferment introduced with blood thus treated, but this did not greatly discourage its use. Then, as now, one of the chief uses of blood transfusion was found to be in the practice of obstetrics. A series of 57 cases of this kind were reported by Martin of Berlin in 1859, 43 of these having been successful. A further series of cases was collected by Blasius in 1863. He was able to report that of 116 transfusions performed during the previous forty years, in 56 the results were satisfactory. These statistics did not indicate a remarkable degree of success. Fatalities due to the transfusion had occurred, attended by the symptoms which we have now learned to associate with incompatibility of the transfused blood. At that time, however, the deaths were believed to be due chiefly to the introduction of air bubbles into the circulation, although it had been shown experimentally by Blundell in 1818, and again by Oré in 1868, that small quantities, such as might be accidentally introduced during a transfusion, produced no ill effects. Some explanation, however, was required, and so air bubbles for a long time received the blame.

Fig. 2.—Mr. Higginson’s Transfusion Instrument

A is a metallic cup, of 6-oz. capacity, to receive the supply of blood. B an outer casing, which will hold 5 oz. of hot water, introduced through an aperture at C. D is a passage leading into an elastic barrel, composed of vulcanized india-rubber, E, of which the capacity is 1 oz. F′ the exit for the blood into the injection-pipe G. At D and F there are ball-valves, capable of closing the upper openings when thrown up against them, but leaving the lower openings always free. The blood, or other fluid, poured into the cup A, has free power to run unobstructed through D, E, F; a small plug H is therefore provided to close the lower aperture F when necessary. The tube G is of vulcanized india-rubber, and terminates in a metal tube O for insertion into the vein. This diagram is one-half the actual size of the instrument.

Although some of the early experiments on blood transfusion had been done in England, and although its revival in the nineteenth century was initiated in England, yet it is to be noticed that most of the references to it up to 1874 are to be found in the works of Continental writers. Nevertheless, an important modification was introduced into the technique of the operation in 1857 by Higginson, who applied the principle of a rubber syringe with ball-valves for transferring the blood from the receptacle into which it was drawn, to the vein of the recipient. This apparatus is illustrated here, as it is of some interest in the history of medicine. Higginson’s syringe is now used for a different purpose, but it was successfully applied by its inventor in a series of seven cases which he duly reported. One patient whom he transfused was suffering from extreme weakness, which was attributed to the too protracted suckling of twins. He gave her about twelve ounces of blood from a healthy female servant, and a state of quietude followed her previous restlessness. A few minutes later the patient was seized with a rather severe rigor. It did not last long, but led to a state of reaction and excitement, in which she sang a hymn in a loud voice. The final result was good, and Higginson reports that in five of the seven cases some benefit was to be attributed to the transfusions. Later the same principle was used in America by Aveling and by Fryer about the year 1874, and subsequently it was in that country that nearly all the important advances in the science of blood transfusion were made.

In 1873 an inquiry was carried out by the Obstetrical Society of London into the merits of transfusion, the subject having been brought to the Society’s notice by a report of a case by Aveling, and an interesting summary of the evidence was prepared by Madge in 1874. The results do not seem to have been very encouraging, and transfusion was still regarded as a procedure that was only to be used as a last resource. Even at this date the blood of other animals was being used for transfusion, although the practice had been discredited by Panum in 1863 and by others, and a series of cases was reported by Hasse in 1873, in which lamb’s blood was given for various conditions. Other cases were reported from Italy (3) and Russia (101). Sentiment, if not science, seems to have suggested that there was something repulsive in bringing a lamb into the sick chamber and mixing animal with human blood, but it was remarked in a discussion on the subject that “it was only taking lamb in another form.”

After 1875, however, there was a decline in the amount of attention given to transfusion which lasted for thirty years. This was probably due in part to the increasing number of fatalities which had followed the more general use of transfusion, but, as Peterson suggests, it was also to be accounted for by the increasing use of normal saline solution for intravenous injection in the treatment of hæmorrhage. There was also a period during which the use of milk was advocated for intravenous therapy (37, 279). Soon after the beginning of the twentieth century transfusion received a fresh impetus which has steadily gained force up to the present time. The free use of cannulæ and syringes had always been hampered by the coagulation of the blood, and it was clearly a great advance to be able to perform a direct transfusion without the intervention of any tube. This was made possible by great improvements in the surgery of the blood-vessels, which were due in the first place to the work of Murphy, published in 1897; they were carried still further by others, such as Carrel and Guthrie, and culminated in the work of Crile, who in 1907 put the technique of direct transfusion on a securer basis than it had ever been before. His method is briefly described in a later chapter of the present work. Meanwhile the chief factor responsible for previous fatalities was being eliminated. The presence of agglutinins and iso-agglutinins in the blood had been detected by Landsteiner and by Shattock in 1901; in 1907 the four blood groups into which human beings can be classified were determined by Jansky and the work was repeated by Moss in 1910.

Simplification of the group tests soon followed, as is described in another chapter. At the same time great improvements were made in the use of syringes, paraffined tubes, and in anastomosis of the blood-vessels. In this connexion one of the most notable contributions was made by Curtis and David, who in 1911 introduced the use of syringe transfusion through a two-armed tube coated on the inside with paraffin. In 1913 indirect transfusion by means of the paraffined vessel was introduced by Kimpton and Brown, and it was now evident that blood transfusion was shortly to become a method of treatment which would be without any very difficult technique, and could therefore be more extensively applied.