Blood transfusion

“ Hitherto treatment has been conducted mainly on medical lines. Opinion is now, however, tending to favour earlier and more frequent surgical interference, and this can be made a less dangerous procedure by giving a preliminary blood transfusion to improve the patient’s general condition. When the patient’s life is threatened by hæmorrhage repeated or prolonged, transfusion is undoubtedly the best means of saving him. Here again the fear of restarting the hæmorrhage by raising the blood pressure has acted as a deterrent, so that transfusion [42] is apt to be withheld until too late. ”

“ The chief dangers of blood transfusion are two-fold—that of introducing into the recipient a disease carried by the donor, and that due to the inherent properties of the donor’s blood which may interact in a serious manner with the blood of the recipient. The first of these dangers is obvious, and common sense will suggest what steps should be taken to avoid it. Danger of communicating disease is almost restricted to conditions in which an infective agent is actually circulating in some form in the blood. ”

“ The term “universal donor” commonly applied to Group IV is, in fact, misleading. The blood of Group IV cannot be used indiscriminately with complete impunity. The groups are determined by the major agglutinins, and by these the ordinary gross reactions may be eliminated. Everyone who has used blood transfusions extensively has observed that slight reactions may occur after transfusion with a compatible blood, irrespective of the methods employed. ”

“ Kennedy explained, "which I have here is known as a canula, a little canal, for leading off blood from the veins of one person to another—in other words, blood transfusion. Modern doctors are proving themselves quite successful in its use.
"Of course, like everything, it has its own peculiar dangers. But the one point I wish to make is this: In the selection of a donor for transfusion, people fall into definite groups. Tests of blood must be made first to see whether it 'agglutinates,' and in this respect there are four classes of persons. ”

“ The effects of transfusion for hæmorrhage and shock are to be judged best by the clinical results. The abnormal distribution of the corpuscles is altered by the treatment with a consequent redistribution in the circulation. No constant changes, therefore, in the blood count follow transfusion, and no exact mathematical effect can be demonstrated. It has been shown by Huck that sometimes the immediate rise in the blood count is greater than can be accounted for by the amount of blood given. ”

“ It has often been remarked how much blood can be lost by a woman following the delivery of her child without any serious result; nevertheless, many deaths are occasioned every year by post-partum hæmorrhage, placenta prævia, and rupture of an ectopic gestation. Sometimes the bleeding is so rapid that there is no margin of time available for a transfusion unless all the facilities be immediately at hand. Short of this, transfusion is the ideal treatment, and the problem is a simple one, the relief of acute anæmia being the only object in view. ”

“ Later, in 1910, Welch, and then Schloss, recommended the subcutaneous injection of serum or of blood, but these measures were clearly not so effective as the intravenous transfusion of blood, as has been testified by numerous observers (Lespinasse, Unger, Vincent, Graham, Bruce Robertson, Lapage, Hutchinson, etc.) . The patients may be actually moribund, for a new-born infant can only afford to lose a relatively small amount of blood, but even then transfusion is often successful. ”

“ Presumably the transfused [46] blood supplies directly the deficient factor in the coagulation complex, and it has been shown by Bernheim (1917) that the transfusion even of quite a small amount of blood will almost immediately stop the bleeding. In addition to comparative certainty and rapidity in action, transfusion has the advantage that it will replace the blood which has been lost, for often the patient has reached a stage at which he is in danger of his life from actual anæmia. ”

“ If hæmostatic effects only are wanted, 100 cc. of blood will be enough. If anæmia is also present, the dosage will be governed by the same considerations as have already been discussed in the section on the treatment of hæmorrhage.
Melæna Neonatorum.—Another hæmorrhagic condition in which blood transfusion is of the very greatest value is that known as melæna neonatorum. Severe hæmorrhage takes place from the bowel of an infant, sometimes only a few hours after birth. The cause is quite unknown, but it is found that absolute hæmostasis is usually brought about by blood transfusion. ”

“ Receiving new blood as a means of receiving new life, seems to have been sought interchangeably, in olden time, in various diseases, by blood lavations, by blood drinking, and by blood transfusion. It is recorded that, in 1483, King Louis XI., of France, struggled for life by drinking the blood of young children, as a means of his revivifying. ”

“ One of the earliest references to actual transfusion of blood that has been noticed is to be found in a work by Libavius of Halle, published in 1615. The passage has been translated as follows:
“Let there be present a robust healthy youth full of lively blood. Let there come one exhausted in strength, weak, enervated, scarcely breathing. Let the master of the art have little tubes that can be adapted one to the other; then let him open an artery of the healthy one, insert the tube and secure it. Next let him incise the artery of the patient and put into it the feminine tube. ”

“ 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. ”

“ It is necessary, therefore, that everyone who performs a transfusion should be able to recognize the symptoms of a reaction as soon as it begins to appear, so that the transfusion may be at once discontinued. Sometimes the reaction between incompatible groups is so immediate and severe that death takes place almost at once. I did not myself perform any transfusions until after the period when blood-grouping tests had become a routine procedure, so that I have no personal experience of such unfortunate results. ”

“ As much care, therefore, must be exercised in testing the blood groups of members of the same family before performing a transfusion as would be taken before using a donor who is not related to the patient. ”

“ The experiment suggests that resistance to infection is heightened if two bodies can combat the infection present in one; but continuous transfusion is scarcely practicable in man.
Diphtheria.—In the later stages of some acute diseases due to a bacterial infection, the patient falls into a condition of acute toxæmia, the symptoms of which resemble in some ways those of shock. Harding has drawn attention to this condition in diphtheria; he has produced it experimentally in animals and has treated it by blood transfusion. ”

“ When the blood is to be given, the delivery tube with the rubber bung is inserted in the flask, and the corpuscles which have gravitated to the bottom are distributed again through the fluid by gently shaking it. In administering the blood, it is very often advisable to inject it through a cannula which is tied into a vein. If the patient is a woman, it will usually be found that the veins are small and buried in fat. Also many transfusions will be given to combat the collapse due to shock and hæmorrhage, in which case the veins will be empty and the use of a cannula will be found essential. ”

“ Reference has already been made to the bad effect of the ordinary anæsthetics, and the best effects are obtained by a blood transfusion in conjunction with gas and oxygen or with spinal anæsthesia. It is necessary, however, to draw attention to the fact that a blood transfusion if given to a patient under the influence of a spinal anæsthetic must not be performed until the operation is very nearly completed, for it will very often produce a much more rapid return of sensation than would otherwise occur. ”

“ It is a practical rule with surgeons that when a dangerous loss of blood has to be made good, the blood required for transfusion must be obtained from an individual not only of the same species and family, but also of the same sex as that of the patient. The parallel between transfusion and transplantation is at once evident. If I am correct in my views, when surgeons seek to transfuse blood, instead of being content with injections of normal salt solution they must take the blood not merely from one of the same species, family and sex, but of a similar degree of masculinity or femininity. ”

“ The chances are, on the whole, that the blood of any donor chosen at random will not prove fatal to a given recipient; nevertheless, it must frequently happen that the transfusion without being fatal will be wasted, or to some degree detrimental. It is therefore evident that the existence of blood groups must be seriously regarded, and it is necessary to enter into a detailed consideration of their relations to one another and the symptoms which they may produce. ”

“ A patient suffering from severe shock is unable to tolerate more than a very small quantity of fluid in his stomach without vomiting. Some success was attained by Oswald Robertson in treating cases of hæmorrhage by the method of “forced fluids,” large quantities being given by the mouth and by the rectum (245) . In many serious cases, however, this treatment is inapplicable, and it is clear that transfusion is more rapid and more certain in its effect. ”

“ The efficiency of the rapid test is therefore not invalidated. It is, nevertheless, in the present state of knowledge, a wise precaution to perform the direct test between patient and donor in addition to the group test when circumstances permit. It is essential when the patient is suffering from any form of blood disease. It is unnecessary when the transfusion is to be performed as a life-saving operation in hæmorrhage or shock. ”

“ It is a still more difficult matter for obvious reasons to estimate how much blood a man can lose and yet remain alive. This will depend partly on the power of physiological accommodation possessed by the individual in his vaso-motor system and tissue fluids and partly on the rapidity with which the bleeding takes place. Clinical observations have shown that after a moderate hæmorrhage, such as the withdrawal of 800 cc. of blood from a donor, the blood volume may be restored to normal within an hour. ”

“ A single transfusion is usually enough, as the hæmorrhage does not tend to recur when once it has been stopped. For a newly born infant, even if in extremis, only a small quantity of blood is needed, so that a transfusion of 50 to 100 cc. is usually found to be enough. Bruce Robertson suggests that, as a good working rule, the amount should not exceed 15 ccm. per pound of body weight. The superficial veins of an infant are exceedingly small, so that the introduction even of a fine needle into the median basilic may be matter of the greatest difficulty. ”

“ 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. ”

“ But beyond this wastage of the transfused blood there may be no effects as shown by morbid symptoms in the recipient; he will merely not be benefited. There may, on the other hand, be an evident reaction in the recipient, the symptoms varying from slight discomfort to almost immediate death. It appears, therefore, that there is a gradation of toxicity between the bloods of incompatible groups, so that it may be justifiable owing to extreme urgency in certain cases to perform a transfusion without doing any preliminary tests on the bloods of donor and recipient. ”

“ Amid the general development of the sciences, transfusion has come up once more, transformed and widened; it will not satisfy the extravagant hopes indulged at first, but it will throw a broad light on the problem of health and disease. The principles on which this grand experience now rests are well settled—the functions of the blood have been clearly determined. We know that life dwells in every fragment of our being; the mass of nerves, the flesh of our muscles, the tissue of our glands, need the indispensable assistance of the blood, yet live by themselves. ”

“ And since the Transfusion of Blood is a new thing (unknown for ought we know) to all former Ages, ingenious Men, and lovers of the Increase of the Stock, serving for the relief and conveniences of Human Life, do no more, in this particular, than propose and recommend it to generous and unprejudicate Physicians, to judge of its agreeableness to Human Bodies, and to make trials of it accordingly; themselves esteeming, that since it concerns the Health and Life of Man, it cannot be examin'd too severely ”