Blood transfusion
is often cited as a major medical advancement of the First World War, and
possible only because of innovations made shortly before the United States
entered the war.
Transfusion at the Start of the 20th Century
Blood transfusion
had been attempted throughout history but generally failed due to a variety of
factors. Chief among these was the propensity of blood to clot, reducing its
flow and clogging equipment used to transfer it. Blood could not be stored and
needed to be administered as quickly as possible. By 1900, transfusions
typically involved connecting blood vessels of donor and recipient using India
rubber tubing. A method to suture blood vessels together was devised by Alexis
Carrel in 1902 and improved by George Crile in 1905. These direct transfusion
methods necessitated cutting through the skin to expose blood vessels. This
required great surgical dexterity, could take two to three hours, and demanded
that donor and patient lie quietly side-by-side lest the connections be
disrupted. It was impossible to gauge how much blood actually passed from donor
to patient, and clotting remained a major problem.
Severe, sometimes
fatal, reactions occasionally occurred and most were due to blood group
incompatibilities. Although ABO blood grouping was discovered in 1900 by Karl
Landsteiner, it would be several years before its significance in transfusion
was appreciated by most physicians. Given the difficulties and unexplained
reactions, interest and trust in transfusion had significantly waned by the
turn of the century, especially among European physicians.
Innovations in Transfusion, 1913-1915
However, interest
in transfusion remained higher in the United States, and in the years preceding
the war several key advances were made. By the early 1910s, a few physicians ‒ notably, Ludvig Hektoen in Chicago and W.L.
Moss in Baltimore ‒ had begun
to call for ABO blood group matching of donors and transfusion recipients. In New
York, Reuben Ottenberg and Albert Epstein promoted a test combining blood from
the donor and the patient ‒ a
“cross-match.” Sadly, most physicians thought such tests unnecessary.
In 1913, A.R.
Kimpton and J.H. Brown of Boston collected donor blood into a glass cylinder
that had first been coated with a film of paraffin. If properly done, the
paraffin’s smooth surface delayed clotting. Better still was the multiple
syringe method devised that year by Edward Lindemann of New York. A
highly-choreographed team kept syringes in constant motion from donor to
patient. Importantly, they used sharp-pointed metal needles inserted through
the skin directly into the veins, eliminating the need to expose the blood
vessels by incision. Modifications replacing the syringes with tubing and
stopcock devices simplified the process, making it possible for a single
physician to perform a transfusion.
Blood Bottles
About 500 mL of
blood was typically collected from each donor. Prior to transfusion, excess
anticoagulant was removed and the blood poured into a new bottle, filtering it
through a gauze plug to remove any clots or debris.
In 1914-1915, the
use of sodium citrate anticoagulant was introduced independently by Albert
Hustin in Belgium, Luis Agote in Argentina, and Richard Lewisohn in New York.
The anticoagulant allowed blood to be stored for a few days and ended the need
for donor and recipient to be in the same room. At the Rockefeller Institute in
New York, Peyton Rous and J.R. Turner Jr. found that adding dextrose (sugar) to
the citrate extended the storage time to four weeks.
When the war began
in Europe, the few transfusions given by French and British doctors used older
direct methods, such as Carrel’s anastomosis. These methods might work at
hospitals behind the lines, but were too delicate for military operations. And,
it was difficult to arrange sufficient donors and surgeons when multiple
patients simultaneously required transfusion.
One of the greatest
hazards of blood loss by the wounded was shock. Many British doctors initially
preferred to treat shock with infusions of saline or of “Bayliss’ gummy
solution” – a colloid preparation of gum arabic (from the sap of the Acacia
tree), suggested by physiologist William Bayliss. When Canadian physicians
joined the war in support of the British Empire, they brought with them the
syringe and paraffin tube methods of blood transfusion. Notable among the
Canadians was L. Bruce Robertson from Toronto, who had recently trained with
Lindemann in New York and who published his wartime transfusion experiences in
the British Medical Journal in 1916-17, highlighting the benefits of infusing
blood. British interest was piqued.
The U.S. entry into
the war in 1917 brought more physicians familiar with transfusion. Among them
were Roger Lee and Oswald Hope Robertson, with Base Hospital No. 5 from Boston,
where some of the leading proponents of transfusion worked. Before the war,
Lee, an early advocate of blood grouping, had sent Robertson to work with Rous
at the Rockefeller Institute. After arriving in France, Robertson was sent to
the British 3rd Army Casualty Clearing Station to consult with them on
transfusion. There he drew up plans for what many consider the world’s first
blood bank. Initially, Robertson used citrated blood drawn into one liter glass
bottles, converting ammunition boxes into shipping containers, with sawdust and
ice packed around the bottles. He selected only group O blood donors,
compatible with all other blood types, thus requiring no further testing. The
citrated blood could only be stored a short time, but it allowed blood to be
collected in advance of need. Robertson soon incorporated Rous and Turner’s
dextrose into his bottles. Citrate and dextrose were sterilized separately,
then mixed in a two liter bottle (the larger bottle necessitated by the volume
of dextrose needed).
Robertson’s methods
were so successful that by the end of the war he was conducting a school for
blood transfusion, training teams from other medical units. Citrated blood
(usually without dextrose) became the method of choice for most Allied medical
forces, although paraffin tube and syringe methods (each with a variety of
adaptations) were also widely used. Allied medical forces were issued standardized
transfusion kits to carry into the field, allowing blood to be given even
before transferring the injured to casualty clearing stations.
British Transfusion Kit
Kits designed by
Geoffrey Keynes of the Royal Army Medical Corps generally did not use
anticoagulants,so the blood was transfused soon after collection. After the
war, Keynes co-founded London’s Blood Transfusion Service.
Not all transfused
blood was group O. When time and facilities allowed, some donor blood was typed
and “cross-matched” prior to transfusion. Lists of blood groups of camp
personnel were maintained, to be summoned as donors were needed. Convalescing
troops often volunteered as donors for more seriously wounded comrades.
Benefits of Transfusion
Using preserved
blood allowed it to be stockpiled and ready when needed. A single officer,
usually with one assistant, could give the blood quickly and at the patient’s
bedside, without having to move him and the donor together into an operating
room, thus freeing operation room space as well. In addition to treating shock,
blood transfusion was also used successfully during surgical procedures and in
treating carbon monoxide poisoning, septicemia, and chronic wound infections.
The First World War introduced transfusion methods to more doctors and in more
standardized procedures than might have occurred in peacetime, and convinced
them of its benefits. When these physicians returned home, blood transfusion
gained a new place in civilian medical practice.
