The final advance was made in 1914, when the use of sodium citrate as an anticoagulant was made possible by the work of Lewisohn in America, of Hustin in Belgium, and of several others, who all arrived independently, but almost simultaneously, at the same conclusion. The use of an anticoagulant was no new idea. In 1858 the use of small quantities of ammonia had been suggested by B. W. Richardson in the Guy’s Hospital Reports, and in 1869 sodium phosphate was used in four obstetrical cases by Braxton Hicks, who found that the process was greatly facilitated thereby; but neither of these methods came into general use. It had long been known that hirudin or leech extract, and the salts of oxalic acid or of citric acid, could be used as anticoagulants outside the body, but their supposed toxicity had prevented their being used for transfusion. The proof that sodium citrate was both efficient for this purpose and non-toxic in a dilution that was still effective at once raised blood transfusion to a wider sphere of usefulness than had been possible before. The first transfusion of citrated blood was performed by Professor L. Agote of Buenos Aires, on November 14, 1914, a date which is therefore of the greatest importance in the history of blood transfusion. A method had at last been discovered which approached the ideal, since it united the four cardinal virtues of simplicity, certainty, safety, and efficiency.
This great stride forward in the technique of blood transfusion coincided so nearly with the beginning of the war that it seemed almost as if foreknowledge of the necessity for it in treating war wounds had stimulated research. Yet during the first two years of the war almost nothing was known in the British Army of its possibilities. I have no evidence that the French or German army doctors were any better informed than ourselves. Some attempt was made in 1916 to introduce the use of direct transfusion through cannulæ, but the technique was too difficult and uncertain for the stress of war conditions. It was not until 1917, when the British Army Medical Corps was being steadily reinforced with officers from the United States of America, that knowledge of blood transfusion began to be spread through the Armies. A conspicuous part was borne by Oswald Robertson in introducing the use of the citrate method, and to him a very large number of men indirectly owe their lives. In some armies the paraffined vessel of Kimpton and Brown remained the favourite method, but to me the citrate method seemed the more suitable, because of the certainty with which success could be attained, and the same view was taken by many others. At the same time the investigators appointed by the Medical Research Committee attempted to elucidate the problems connected with hæmorrhage and wound shock, and their results, as will be seen, served to confirm the estimate already being formed of the value of blood transfusion.
In this way a large number of operators in this country became familiar with the various methods, and transfusion has in consequence been used increasingly in civilian practice since the war. It is undoubtedly destined to figure still more largely in the therapeutics of the future. Meanwhile the public mind is becoming gradually more used to the idea, and the time is past when every transfusion is deemed worthy of a sensational headline in a newspaper. Nevertheless, at the end of the year 1920 the following advertisement appeared in the personal columns of The Times:
“Will any Doctor who knows method of treating cancer by transfusion of child’s blood kindly write Box —.”
So the wheel is come full circle, and the shade of Pope Innocent VIII may well chuckle as he notes the small advance in popular knowledge since the fifteenth century.
CHAPTER II
INDICATIONS FOR BLOOD TRANSFUSION
The indications for blood transfusion are gradually becoming more numerous as experience of its effects accumulates, and there can be no doubt that the value of transfusion as a therapeutic measure is destined to become much more generally recognized than it is at the present time. Lack of knowledge, together with an exaggerated idea of the difficulties of the process, is the chief obstacle to its more extended use. Time and the education of the rising generation will provide the remedy for this.
The conditions for which blood transfusion may be used fall into four well-defined groups. On the one hand are those characterized by an acute anæmia, which demand the performance of a blood transfusion as an emergency or life-saving operation; on the other hand are those in which the anæmia is of slow onset, and is to be combated by a single transfusion to tide the patient over an operation or a critical period or by repeated transfusions in the hope of prolonging the patient’s life if not of obtaining a cure. A third group includes the hæmorrhagic diseases in which the transfusion is administered not only to replace blood which has been lost, but also to bring about cessation of the hæmorrhage. A fourth group includes cases of general toxæmia, whether chemical or bacterial, in which the new blood is given partly on account of its therapeutic properties, partly in order to dilute the circulating toxins or to supply healthy red blood cells to carry on the oxygenation of the tissues.
For the first and third of these groups blood transfusion is now very firmly established as a method of treatment which is of extraordinary value. For the second group it may be regarded as a palliative to be given with circumspection. For the fourth group administration of blood is still in the experimental stage.
In the present work each condition will be taken in turn and, as far as possible, separately, though at the outset it has been found undesirable to dissociate the two conditions, hæmorrhage and shock. The present position of blood transfusion in relation to each condition will be discussed; its limitations and the precautions to be observed will be described.