THE METHODS OF BLOOD TRANSFUSION
Some reference has already been made in the first chapter to the
rapid development in recent years of the technique of performing a
blood transfusion. The earlier operators, owing to the difficulties
introduced by the coagulation of blood outside the body, were
constrained to make use of some method of direct transfusion, the
blood flowing directly from an artery of the donor into the patient’s
veins. This has now been largely replaced by one of the methods of
indirect transfusion, the blood being withdrawn from the donor into a
vessel in which clotting is delayed or prevented, and then injected
or allowed to run into the patient’s circulation.
=Direct Transfusion.=--The obvious method of performing a direct
transfusion is by making an end-to-end anastomosis between an artery
of the donor and a vein of the recipient. The most readily accessible
artery is the radial at the wrist, and this is indeed almost the
only artery that is available. The most accessible vein is the
median basilic or the median cephalic at the elbow. The operation
of end-to-end anastomosis, using an artery of so small a calibre as
the radial artery at the wrist is usually found to be, is one of
great technical difficulty; this effectually prevented transfusion
from being used at all frequently. A modification has been used by
Sauerbruch and others, in which the end of the radial artery is drawn
into the lumen of the vein through a slit in its wall. A suture is
passed through the radial artery close to its cut end, and the needle
is then passed through the slit in the vein and out again through
the wall of the vein an inch or so higher up. Traction on the suture
then pulls the artery into the vein. The artery has meanwhile been
temporarily occluded by a clip, which is removed when the artery is
inside the vein, so that the blood can then flow from one to the
other. This is easier to do than the anastomosis, but, in addition to
the other objections to direct transfusion to be mentioned presently,
the difficulty occurs of occlusion of the artery by the physiological
process of inversion of its coats at the cut end. This is likely to
happen before much blood has passed, so that apparent success at
first is often not maintained. Sauerbruch claimed that the amount of
blood that had passed could be estimated by measuring the time taken
for 1 cc. of blood to flow from the artery before it was introduced
into the vein; but there is no proof that the rate of flow remains
constant.
If direct transfusion be desired, there can be no doubt that Crile’s
method, introduced some fifteen years ago, is the best to employ.
After much patient work Crile perfected a method of anastomosis
which ensures that no occlusion of the vessels can take place at the
site of junction. This depends on the use of a short silver tube,
through which the end of the artery is threaded. The artery is then
pulled back again outside the tube in the form of a cuff and fixed
in position. The end of the artery has thus been made rigid, and
over this the vein is pulled in its turn and fixed by a ligature.
A watertight junction is thus made, and blood can flow through it
without interruption--unless clotting takes place in the vessels as
the result of handling and injury to their walls. This method has
been extensively used in America, and it was the first to render the
operation of transfusion a comparatively popular one.
Various other devices for achieving the same result have been
elaborated by other workers, and attention may be drawn to those of
Elsberg and Bernheim, both of which are described in the book by
the latter on “Blood Transfusion.” During the war a simpler method
was introduced by Colonel Andrew Fullerton, who, working at a
Base Hospital in France, found that he could get good results by
employing a thin rubber tube with a small silver cannula at either
end. The apparatus was first coated on the inside with a thin layer
of paraffin wax, in order to discourage clotting within the tube,
and the cannulæ were introduced into the donor’s artery and the
recipient’s vein respectively. The blood could then flow freely
from one to the other. The fact that blood was being transmitted
was taken to be proved by the visible pulsation of the thin rubber
connecting-tube synchronously with the arterial pulsations. The
disappearance of this was assumed to be evidence that clotting had
occurred. This method was described by Colonel Fullerton to the
surgeons working at the Casualty Clearing Stations, where blood
transfusion was likely to be of most service, but it was never used
extensively. The coating of the inside of the tube with paraffin is
in itself an operation of some difficulty. Under conditions in which
any loss of time could not be permitted, success by this method was
not attained with sufficient certainty, and it was shortly afterwards
replaced by the more satisfactory methods described below. The most
recent work on direct transfusion has been done by J. M. Graham at
Edinburgh, who has however reached the conclusion that the technique
is always more difficult than that of indirect transfusion.
It can easily be seen, therefore, that all the known methods of
direct blood transfusion present great technical difficulty, which
renders the method unsuitable for general use. There are, in
addition, certain other objections to it of an obvious nature. It is,
in the first place, impossible to measure the amount of blood which
has passed from the donor to the recipient. Sometimes an indication
may be obtained from the evident improvement in the condition of the
patient, accompanied by the signs of loss of blood in the donor.
More often clotting takes place, unknown to the operator, at some
point, with the result that blood ceases to pass a considerable time
before the end of the operation, and the patient has consequently
received very much less blood than is supposed. It has been claimed
by Libman and Ottenberg that the amount of blood transferred may
be estimated by weighing the donor before and after the operation.
This presupposes that a very accurate weighing machine is easily
available, which usually is not the case.
A second objection is the extent of the injury which is necessarily
inflicted on the donor. His radial artery must be exposed through
an incision of considerable length, and must be ligatured at the
conclusion of the process. The operation becomes, therefore, a matter
of some moment to the donor, who will be permanently scarred, and can
under no circumstances be used for transfusion more than twice.
A third objection is that the transfusion cannot be done with due
regard to the condition of the patient. A delicate and difficult
operation has to be performed with the donor and recipient lying side
by side, their arms close together. It is therefore almost imperative
that both should be on operating-tables of a convenient height.
Often, however, with an exsanguinated patient it is very important
that he should not be moved from his bed, but as a bedside operation
direct transfusion becomes difficult indeed!
A final objection is that in some people the radial artery is of very
small calibre, so that when all preparations have been made, and
the artery exposed, it is found to be quite impossible to proceed.
Another element of uncertainty is thus introduced.
There is, therefore, little to be said in favour of direct
transfusion, and much to be urged against it. This method has,
indeed, in my own opinion, come to be of historical interest only.
For this reason the different methods have only been very briefly
described. For more detailed information, reference must be made
to the various original communications, which will be found in the
Bibliography.
=Indirect Transfusion.=--The methods of indirect transfusion may
be divided into those which depend upon the use of an anticoagulant
mixed with the blood and those in which the blood is given
unaltered. The technique of either process is simple compared
with that of direct transfusion, though any method which makes
use of whole blood can never be quite as free from uncertainty or
difficulty as one which introduces the use of an anticoagulant. If
the blood is prevented from clotting, the chief cause of failure
in performing blood transfusions is removed. With any whole-blood
method of transfusion speed is exceedingly important, frequent
practice is a very great advantage, and it is essential, as with
direct transfusion, that the donor and recipient should be in close
proximity to one another, if not actually side by side.
On the other hand, the use of an anticoagulant renders speed and
frequent practice of less account. The blood can be drawn, and can
then be put on one side until the best moment for giving it has
arrived. Due regard may be had to the patient’s condition, since the
blood can be carried about and can be given at leisure to the patient
in his bed without disturbing him and almost without his knowing it.
The donor, too, is not exposed to the mental shock of lying for some
time side by side with a patient who may be _in extremis_, or may
even expire during the operation.
There are, however, those who consider that the use of whole blood,
instead of blood which has been chemically treated, has advantages
which outweigh the possible disadvantages mentioned above. Two
methods of using whole blood are, therefore, described first; the use
of anticoagulants is then described in detail, and their advantages
and possible dangers are enlarged upon.
=Whole Blood Transfusion with Syringes.=--It is obvious that, if
blood can be drawn from the donor’s vein into a glass syringe and
injected into the recipient so rapidly that clotting has no time to
occur, then a transfusion of any quantity of blood that may be wished
can be given by this simple means. The measure of the amount of
blood transfused is given by the number of syringes that have been
filled and emptied. This method has been successfully used by several
workers, and it has the advantage that no very special apparatus is
necessary. It does, however, require that several syringes, and more
than one assistant, should be available, since clotting will take
place in the syringes, unless they be frequently washed out. There is
also the possibility that clotting may take place in the needle which
is introduced into the donor’s vein, since this cannot be withdrawn
and replaced for each syringeful of blood that is transferred. With
practice, however, and with good assistants, the process can be done
quickly enough to avoid this. Wide-bore needles with short rubber
connexions are introduced into the veins of donor and recipient;
if, as often happens, this is difficult to do through the skin in
the case of the recipient, his vein must first be exposed through
an incision and a glass or metal cannula introduced into it. The
operator then fills the syringes with blood in quick succession and
hands them to his first assistant, who injects the blood into the
recipient. Blood is prevented from escaping from the needles when
the syringes are disconnected by nipping the rubber connexions with
the fingers. The first assistant passes the empty syringes to the
second assistant, who washes them out with normal saline, and hands
them back if needed to the operator. This can be done with six 20 cc.
syringes used in rotation, possibly with only four.
The most recent description of this method has been published by
J. M. Graham of Edinburgh, who has introduced an improved form of
needle. This consists of a double tube; the inner tube has a needle
point which is used for puncturing the vein, and can be withdrawn
into the blunt outer tube when the vein has been entered. Any further
wounding of the vein is thus avoided. In addition, movement of the
needle-cannula is prevented by a bull-dog forceps attachment, which
is clipped to the skin. Graham finds it advisable to lubricate the
cannulæ and syringes with vaseline before being used. He also
states that: “As the absence of clotting depends upon the rapidity
with which the syringes are filled and emptied, a series of syringes
should be used in strict rotation, and all trace of blood must be
washed out with saline before the syringes are used again. One
or two additional assistants are necessary for this method.” The
disadvantages are evident, and it is not suitable for general use.
A modification of the method has been described by Unger, in which
only one syringe is used. The barrel of this is cooled by an ether
spray so that clotting is discouraged or prevented.
=Whole Blood Transfusion with Kimpton’s Tube.=--The principle of this
method depends upon the use of paraffin wax as a coating for the
vessel into which the blood is drawn, so that clotting is prevented
or greatly delayed. The form of the vessel has been modified by
different workers, but the essentials are the same in each. One form
of the apparatus, known as the Kimpton-Brown tube, is illustrated in
the accompanying diagram. It consists of a graduated glass cylinder,
of about 700 cc. capacity, the lower end of which is drawn out into
a cannula point at an acute angle with the body of the cylinder; the
point is of a size convenient for introducing into a vein and its
bore large enough to allow of a free flow of blood through it. Near
the upper end is a side tube to which a rubber tube can be attached,
and an opening at the top is closed by a rubber bung. An ordinary
rubber double-bulb bellows is the only other apparatus that is needed.
[Illustration: Fig. 8.--KIMPTON-BROWN TUBE]
The glass vessel is first sterilized in the autoclave, and then it
must be coated on the inside with a thin layer of paraffin wax.
The whole success of this method depends upon this wax coating
being absolutely complete right up to the tip of the cannula at
the bottom. If the tiniest area of glass be left exposed in the
cannula, the process will fail. The production of this perfect wax
coating used to be exceedingly difficult of attainment without very
frequent practice. The apparatus was first raised to exactly the
right temperature; sterile, melted paraffin was then put into it,
and distributed evenly over the surface, excess being allowed to
run out. The apparatus was then cooled down, and could be put away
in a sterile towel ready for use, great care being taken that the
lumen of the cannula was patent and not blocked with excess of
wax. A simplification of the process was introduced by the use of
a saturated solution of wax in ether. This solution is put into
the vessel, which must not be heated, and is made to run all over
the surface, excess as before being allowed to escape through the
lower opening. The ether quickly evaporates, leaving a very thin and
perfect film of wax over the surface of the glass. As before, it must
be ascertained that the lumen of the cannula is patent. The apparatus
is then ready for use.
The donor and recipient need not be lying close together, but they
must be in the same room. A vein is exposed in the arm of each by
dissection under a local anæsthetic. The operator then picks up the
vein with a pair of dissecting forceps, and makes an oblique cut into
the lumen as in the diagram on p. 131. A flap is thus made which is
held in the dissecting forceps in the left hand or is picked up with
a fine-pointed pair of artery forceps. The Kimpton’s tube is taken
in the right hand, and the point of the cannula is introduced into
the vein; that part of the lumen lying opposite the flap serves as a
gutter which guides the cannula directly into the lumen, so that it
is introduced without any fumbling or delay. The cannula is pushed
on so that its widest part engages the whole circumference of the
vein, forming a joint through which blood does not leak. The cannula
having been pushed well up into the vein, the forceps holding the
venous flap may be let go. At the same time an assistant grips the
donor’s upper arm, or some form of tourniquet of the necessary degree
of tightness is applied, so that the veins become congested without
obliteration of the arterial pulse. Blood now flows rapidly into
the tube, and the venous pressure is always sufficient to overcome
the counter-pressure of the increasing head of fluid in the tube. It
is unnecessary, therefore, to produce any negative pressure within
the tube with a reversed Higginson’s syringe or an exhaustion pump,
which has been used by some workers. Blood is allowed to flow into
the tube until the requisite amount has been obtained. The venous
congestion is then released, and at the same time the tube and
cannula, held at the lower end with the right hand in such manner
that the index finger is free, is withdrawn from the vein. At the
moment of withdrawal the end of the cannula is closed with the right
index finger. To prevent hæmorrhage from the donor’s vein, a ligature
previously put round it is tied by an assistant, or pressure on it
is maintained with a sterile swab. The operator must now, without
a moment’s delay, carry the tube filled with blood over to the
recipient. An opening in his vein is made by an assistant in the same
manner as already described, the finger is removed from the cannula,
and its point is instantly introduced into the vein. It is now
necessary to produce some degree of positive pressure in the tube to
ensure that the blood shall at once begin to flow steadily into the
vein. This is done with a rubber bellows, attached by an assistant to
the upper side tube, and the level of the blood in the tube should
at once begin to fall. Great care must be taken that the positive
pressure is released before the tube is completely emptied of blood
in order to avoid the obvious danger of the entry of air into the
patient’s vein. When the tube is nearly empty it is withdrawn, the
vein is ligatured, and the wounds in donor and recipient are sutured.
The most convenient pattern of Kimpton-Brown tube holds only about
500 cc. of blood, so that if more is needed, the process must be
repeated.
There is virtually only one cause of failure in transfusion by this
method, and that is the occurrence of clotting in the cannula or
at the bottom of the tube. If it does occur at any stage of the
operation, it cannot be remedied. It may happen when the tube is
nearly full; if so, the blood that has been withdrawn cannot be used.
Clotting may be due to an imperfection in the paraffin coating on
the glass, but if there is any delay from any cause, it may take
place independently of this. The method is therefore never absolutely
certain of success even in the hands of an expert, and for general
use it is certainly unsuitable. It was introduced into the British
Army by some of the American surgeons in 1917, and was used by the
writer under the guidance of Major Alton of the Harvard Medical Unit
during the first battle of Cambrai with good results. Many of the
English surgeons, however, soon abandoned it as a routine method in
favour of anticoagulants. There are other objections to it besides
its uncertainty. A vein must be exposed by dissection in both donor
and recipient, so that avoidable injury is inflicted on the former.
It is not a perfectly clean method, some blood necessarily escaping
at each successive stage in the process, though an expert can reduce
this to a minimum. In the hands of a novice it may occasion a very
bloody scene. The whole operation is one of urgency, and the best
interests of donor and recipient cannot always be considered.
Modifications have been introduced, such as that of Vincent, who uses
an attachment with a needle instead of the glass cannula point. This
obviates some of the objections, but introduces other difficulties,
such as the necessity for coating the inside of the needle with
paraffin wax. The technique can certainly be acquired, and the method
has rendered excellent service in the past, but it has no obvious
advantages except the uncertain one of avoiding chemical treatment of
the blood.
=Transfusion with Anticoagulants.=--It will have become evident from
the descriptions of the transfusion of whole blood already given, how
great a difficulty is introduced into the technique of these methods
by the physiological process of clotting in blood outside the body.
It is clear how much the process of transfusion would be simplified
if the clotting were to be prevented. Something has already been said
in the historical sketch of the various means by which this problem
was attacked, and it need only be stated here that the most suitable
substance for this purpose has been found to be sodium citrate. This
method was introduced by Lewisohn as recently as 1915, and it soon
became the method of choice among most of those who tried it.
The process of the formation of a blood clot has always been one of
the great problems of physiology, and numerous theories have been
propounded to explain it. The theory accepted at the present time
regards the process as a complicated one depending on the presence
in the blood of a number of different factors. This theoretical
explanation may be represented diagrammatically as follows:
[Illustration:
Plasma Tissues and Platelets
| \ \_______________ \ /
| \ \ \ /
| \ \ \ /
| Prothrombin Ca Salts Thrombokinase
| \_________ \ /
| \ \ /
| \ \ /
Fibrinogen Thrombin
\ /
\ ___________/
\ /
Fibrin
]
The clot consists of fibrin in which blood corpuscles are entangled.
It is clear that if any one of the reacting agents can be removed
or rendered inert the clotting cannot take place. There is only one
inorganic substance taking part in the reaction, and it is this
factor that is more easily removed than any of the others. Calcium
is precipitated in an insoluble form by various chemical reagents,
but it is obvious that for purposes of transfusion the formation
of an insoluble precipitate is not permissible. It is therefore
necessary to use a substance which will form a soluble compound with
the calcium and which is at the same time harmless when introduced
into the circulation. The only substance which has been found at
present to possess both these properties is citrate of sodium.
This forms with calcium a soluble double salt, in which calcium is
rendered inert. It is usually held that the calcium to be active
must be present in the ionized form, but recent investigations by
Vines into the rôle of calcium tend to modify slightly the accepted
view of its action. He has shown that calcium is present in the
blood in two forms, ionized and combined, and that both take part
in the coagulation reaction. He has, in addition, demonstrated that
a quantity of anticoagulant sufficient to combine with the whole of
the calcium present in a given quantity of blood is not enough to
prevent coagulation. It seems, therefore, that the anticoagulant acts
by combining with a large organic molecule of which calcium is only
one constituent, and not merely by combining with ionized calcium.
The organic complex with which the calcium is associated possibly
corresponds to the thrombokinase of the theory.
About the time that the use of the citrated blood was introduced
by Lewisohn, some investigations upon animals were carried out by
Salant and Wise in order to determine how sodium citrate was dealt
with and eliminated by the body. These observers found that it very
quickly disappeared from the circulation, nearly 90 per cent. of the
salt having been got rid of within ten minutes of its intravenous
injection. Part of the citrate is destroyed by oxidation, and the
rest, 30 to 40 per cent., is eliminated by the kidneys, the urine
being rendered alkaline. It was also shown that if a very large
dose was given, so large that toxic symptoms resulted, the effect
was rapidly obtained; but that if the toxic dose were not fatal,
no remote effects followed. Its injection never resulted in any
albuminuria.
Lewisohn showed by experiment on the human subject that up to 5
grammes of sodium citrate in the form of a 0·2 per cent. solution
could be injected intravenously without any harmful results. It
was also shown that this concentration of the salt was sufficient
to prevent clotting outside the body, and that the microscopic
appearance of the blood cells was not altered by the admixture of
this solution.
Theoretically, therefore, the amount of citrate that should be used
as an anticoagulant should be 2 grammes for 1,000 cc. of blood, or
100 cc. of 2 per cent. solution for 900 cc. of blood. In practice it
is better to err on the side of safety and to use a slight excess of
citrate. This amount of citrate should be used for the 750 cc. of
blood which constitutes the ordinary maximum amount of blood used in
a transfusion. For smaller quantities of blood the amount of citrate
may be correspondingly reduced.
The use of citrated blood was introduced to the British Army in
France in 1917 by Oswald Robertson, who recommended the use of a
larger amount of citrate than this. His object in increasing the
amount was to produce a solution which, when diluted with the correct
amount of blood, would be isotonic with it. It was thought that a
hypotonic solution might result in some damage to the red corpuscles
by osmosis, and Robertson therefore recommended the use of 160 cc.
of a 3·8 per cent. solution of citrate, which, when mixed with 750
cc. of blood, will give a solution of which the osmotic pressure
equals that of 0·9 per cent. saline solution. It may be doubted,
however, whether this consideration is of more than theoretical
importance. There can be little doubt that in practice the effect
of a slightly hypotonic solution, such as is given by the 100
cc. of 2 per cent. solution of citrate, is negligible as regards
destruction of corpuscles. If, however, it be thought necessary, an
isotonic solution may be produced by the addition of sodium chloride.
Other considerations, as will be seen shortly, weigh in favour of
giving the smaller amount of citrate. The dosage to be recommended,
therefore, on practical and experimental grounds is 2 grammes of
citrate in 100 cc. of water for 900 cc. of blood, or 1 gramme of
citrate in 50 cc. of water for 450 cc. of blood or less. These
proportions need not be observed very accurately. Latitude may be
used in either direction without harming either the transfused blood
or the patient.
It has been stated above that sodium citrate introduced into
the circulation in small quantities, such as are sufficient for
anticoagulant purposes, is non-toxic to man. In the light, however,
of the extended experience of the last four years, it is seen to
be possible that this statement may not be quite literally true.
Probably there is an individual variation in the tolerance of
different people to sodium citrate. Certainly in some cases a
reaction follows the injection of citrated blood. The symptoms of
this reaction are a slight headache, a rise in temperature to two or
three degrees above normal, sometimes accompanied by a rigor or a
sensation of chill, and an increase in the pulse rate. The effect is,
however, always very transitory, lasting only two or three hours, and
is never, in my own experience, attended by any symptoms which need
give rise to anxiety for the patient’s welfare; nor does it in any
way prejudice the therapeutic results of the transfusion.
That the reaction is caused by the citrate and not by another
constituent of the transfused blood has been believed by several
observers. In a case seen by the writer a slight citrate reaction
occurred in a youth who acted as blood donor. The transfusion was
carried out by a modification of the syringe method, which involved
the injection at intervals of a syringeful of citrate solution into
the donor’s circulation. The possibility that the reaction was
produced by another factor was therefore not present in this instance.
Nevertheless, it must be admitted that citrate has not yet been
absolutely proved to be the cause of this slight reaction in all
the cases in which it occurs. Evidence has, indeed, been brought
forward by Lewisohn and by Meleney to show that citrate is definitely
not responsible for the reaction. The statement is made that some
reaction occurs after 10 per cent. of all transfusions, and that this
percentage is unaffected whether whole blood or citrated blood is
used. Lewisohn has himself investigated the effects in a long series
of parallel cases in which different methods were employed, and he
reports that the results following the use of citrated blood were as
good as with any other method. Drinker states that reactions follow
the use of citrated blood slightly more often than they do that of
whole blood, but this has not been confirmed. He was unable to find
any impurity in the citrate that might be held responsible. It is
quite possible that all the reactions observed are in reality caused
by the “minor agglutinins” mentioned on p. 73. Meleney has noticed
that the blood of some donors is more likely to produce a reaction
than that of others; this suggests that the responsibility rests
with the blood and not with the citrate. The occurrence of a toxic
reaction constitutes the only real objection to the use of citrated
blood that has yet been brought forward, but even this has not yet
been fully substantiated; in any case, the reaction is of so little
importance that it is greatly outweighed by the numerous advantages
that are conferred by the use of citrate. The possibility that a
citrate reaction does sometimes occur may be taken as an indication
in favour of using the smaller amount recommended by Lewisohn rather
than the larger dose used by Robertson. The experience of a great
many observers has established the fact that citrated blood is quite
as effective as whole blood in its therapeutic effects.
It is convenient to have the sodium citrate in a form ready for
immediate use. I have therefore been in the habit of keeping it
in the solid form in small stoppered bottles, each containing 1
gramme of the salt. These are sterilized at 130° C., and can be
kept indefinitely until wanted. If 450 cc. of blood or less are to
be drawn, the contents of one bottle is shaken into the transfusion
flask; 50 cc. (approximately 2 oz.) of sterile warm water are added,
in which the citrate will rapidly dissolve. If more than 450 cc. of
blood is to be used, the contents of two bottles must be dissolved in
100 cc. or 4 ozs. of water. Alternatively a concentrated solution of
citrate may be kept in sealed ampoules, but the salt is less stable
in solution, and I prefer to keep it in the solid form.
The ideal method of blood transfusion seems to me to require that
it shall be absolutely certain of success, that the blood shall
not necessarily be injected into the patient immediately it has
been drawn, so that other circumstances besides the demands of the
transfusion operation can be considered, and that no injury shall be
done to the donor beyond the puncturing of a vein. In addition to
this, the method should be so simple and free from special apparatus
that it can be easily learnt and carried out by one operator without
skilled assistance. All these requirements are fulfilled by the
citrate method, and a satisfactory method of performing this will
next be described. As will be seen, the blood can be drawn with the
minimum amount of injury to the donor; when drawn, it can be put
on one side, for several hours if necessary, and then given to the
patient at whatever may be judged to be the most favourable moment;
the whole process can be carried out by a single operator without
any assistance; and finally, but little practice is needed to make
success certain every time.
The transfusion apparatus known as “Robertson’s bottle,” first
described by Oswald Robertson in 1918, is the basis of most citrate
methods. This could be easily improvised in a field laboratory, and
was extensively used during the last year of the war. The apparatus
consisted of a glass bottle of about a litre capacity, the mouth
of which was closed by a rubber bung. Through the bung three glass
tubes passed. One, connected by a short rubber tube with a wide-bore
needle, ended about an inch from the bottom of the bottle; through
this the blood flowed into the bottle. A second tube, which reached
to the angle between the side and the bottom of the bottle, was
connected by a rubber tube with a cannula; through this the blood was
injected into the patient. The third tube reached only just beyond
the bung, and to this was attached a Higginson’s syringe, by means of
which either negative or positive pressure would be produced inside
the bottle, according to which end of the syringe was attached.
It is unnecessary to describe this apparatus any further, for it was
found by myself and others that it could be with advantage modified
in the direction of simplicity. It is in the first place unnecessary
in drawing the blood to create any negative pressure if a needle of
a large enough bore (2 or 3 mm.) be used, and, further, it is an
advantage not to have the needle attached in any way to the bottle,
which, as the blood flows into it, has to be freely agitated in order
to mix the blood quickly with the citrate. The needle may, therefore,
be attached to a rubber tube of suitable length which hangs freely
into the collecting vessel as shown in the diagram on p. 127. The
third tube of “Robertson’s bottle” may be dispensed with by using a
conical flask provided with a side tube to which a rubber bellows
can be attached. The delivery tube is therefore the only one that
need pass through the rubber bung. This tube should have an angle in
it inside the flask so that its lower end reaches into the corner,
and the extremity should be ground down obliquely so that, although
it reaches right into the corner, it does not become occluded by
too accurate contact with the surface of the vessel. By this means
any wastage of blood is prevented. I have found it a very great
convenience to introduce into the delivery tube just outside the
flask an air-lock,[8] the value of which will be seen shortly. To the
barrel of this air-lock a rubber tube with a cannula is attached.
Close to the cannula is some form of clip. The whole apparatus is
illustrated in the figure on p. 133, and with the help of this its
use may be readily understood.
[Illustration: Fig. 9.--TRANSFUSION NEEDLE (ACTUAL SIZE)]
The particular form of needle which I have been in the habit of using
is shown in the figure. Its lumen has a diameter of 2 mm., and the
steel tube ends off flush with the wide shoulder to which the rubber
tube is attached. This avoids any recess within the needle in which
clotting may begin. The point of the needle should not be too long,
in order that it may not wound the opposite side of the vein when it
has been introduced. For ease of introduction, however, the extremity
should be very sharp and should have cutting edges. The point and
edges should be touched up on a bevelled hone each time before the
needle is used. The needle should be kept ready for immediate use
in liquid paraffin. I have found that the most convenient way of
keeping it is to put it into a test-tube containing paraffin, which
is plugged with cotton-wool and sterilized at 130° C. in the hot
air oven or by careful heating over a flame. In this way the needle
may be kept ready for an indefinite time without any chance of its
rusting. When it is taken out of the test-tube, a sterile rubber tube
is slipped on to it and it is then ready for use. As an additional
precaution, a small quantity of paraffin may be drawn up into the
rubber tube, which is thus lubricated on the inside, but this is not
absolutely necessary. The tube must be sterilized with the rest of
the apparatus, as rubber is destroyed by liquid paraffin.
[Illustration: Fig. 10.--DRAWING BLOOD FOR TRANSFUSION]
When the donor’s arm has been congested by gripping it above the
elbow, or better by the application of a tourniquet[9] drawn to the
requisite degree of tightness, a suitable vein, usually the median
basilic, is chosen. The area of puncture is washed with ether and
a very small quantity, 2 to 3 minims, of 2 per cent. novocain is
introduced over the vein with a hypodermic syringe. If a larger
quantity is used, the vein may become obscured, but this small amount
may be dispersed by a few moments’ pressure with the finger, and is
usually enough to anæsthetize the very small area of skin that is
to be operated upon. A tiny cut in the skin is then made with the
point of a scalpel, and the needle is pushed through into the vein.
If the donor’s vein is a large one, such as is usually found in the
type of donor recommended in a previous chapter, this is quite easy
to do. To make it equally easy if the vein be smaller, it has been
suggested by Watson that the vein may be fixed by pushing an ordinary
fine sewing-needle through the skin at right angles to the line of
the vein, into the vein, and out again through the skin. This needle
is held with the forefinger and thumb of the left hand, while the
right hand pushes the transfusion needle into the lumen of the vein
just below it. When the needle is in the vein, the blood flows out
rapidly through the tube which hangs into the flask containing the
citrate, as illustrated. This flask is held by an assistant, who
mixes the blood with the citrate by gently swinging it. If a properly
adjusted tourniquet is kept on the donor’s arm while he works his
forearm muscles by clasping and unclasping his hand, a flow of blood
is obtained which is fast enough to prevent clotting in the needle,
and indeed is quite as fast as most donors can tolerate. Blood up to
1,000 cc. may be collected in this way in ten to twenty minutes. If
the vein be of a good size, it makes no difference whether the needle
be inserted towards the heart or away from it. When enough blood has
been collected, the tourniquet is removed, the needle is withdrawn,
and pressure is maintained with a sterile swab over the site of
puncture for a few minutes. No further bleeding will take place after
this, and no suture is needed. The donor’s part in the operation is
then finished. He should be made to lie on his back for a few hours
afterwards, and given plenty of fluids, but beyond this no special
precautions are necessary.
When the blood has been drawn, and has been satisfactorily mixed with
the citrate, the flask may be put on one side until it is wanted, its
mouth having been closed with a cotton-wool stopper. If the blood is
wanted at once, the flask may be stood in a basin of warm water to
keep it at body temperature. Otherwise it may be allowed to cool, and
can be warmed up again when it is to be administered. The citrated
blood may be kept for a considerable time without undergoing any
appreciable change in its therapeutic value. It has been given twelve
hours or more after being taken with the same good effects as if it
had been newly drawn. During the war advantage was taken of this fact
to anticipate during quiet times the necessity for many transfusions
during times of stress. The blood was drawn in some quantity and kept
for several hours in an ice chest, so that it was readily available
during the expected battle. Recently I have administered to a woman
who had been operated upon for a ruptured ectopic gestation 600 cc.
of citrated blood which had been kept for twenty-seven hours at
room temperature after it was drawn. The effect was in every way as
satisfactory as if it had been freshly drawn, and there was no sign
of any toxic reaction. So far as I know, blood had not ever been kept
so long as this before being used, but there does not seem to be any
objection to so doing.
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. Sometimes, however,
the patient will have large veins which can be readily distended;
this may sometimes be encouraged by keeping the arm for half an hour
beforehand in a bath of hot water. Under these circumstances the
blood can be given through a needle introduced in exactly the same
way as has already been described in the case of the donor. In the
following account of the process it will be assumed that the use of a
cannula is necessary.
When choosing a vein in the patient, the operator must be guided
by circumstances. Usually the median basilic will be the most
convenient, and if, in a collapsed patient, this is invisible,
previous knowledge of the position of the vein must determine
the site of the incision. If another operation is being done
simultaneously upon the upper part of the patient’s body, it may
be more convenient to use the internal saphenous vein in Scarpa’s
triangle, or even one of the superficial veins about the ankle. In
administering blood to an infant, several methods have been used.
These are described separately at the end of the present chapter.
[Illustration: Fig. 11.--TRANSFUSION CANNULA (ACTUAL SIZE)]
Whatever vein be chosen, the line of the incision is first
infiltrated with a small quantity of a 2 per cent. solution of
novocain. The vein is then dissected out, and is ligatured near the
lower end of the incision. A ligature is also put loosely round
the upper part. The operator now takes the barrel of the air-lock,
which, together with the attached rubber tube and cannula, is filled
with 0·9 per cent. saline solution, all air bubbles being carefully
excluded. The tube is clipped near the cannula, so that the whole
system, including the cannula, remains filled with the fluid. The
form of the cannula used will depend upon the operator’s particular
preference, but a type which I have found very convenient is shown
in the accompanying figure. It is made of glass, and its extremity
is ground down at an angle, which makes it very easy to introduce
into the vein. The slight constriction near this end ensures that
it can be securely tied into the vein and that no leakage round it
shall occur. This is very necessary, because there is sometimes a
considerable pressure to be overcome, due to venospasm in a collapsed
patient, before the blood begins to flow.
An oblique cut is now made in the vein, as shown in the
illustration, the cannula is introduced, and the upper ligature is
tied.
[Illustration: Fig. 12.--INSERTION OF THE CANNULA IN A VEIN]
The barrel of the air-lock, with its contained saline solution,
is then fixed firmly on to the rubber bung, so that the nozzle of
the delivery tube projects into the saline solution. Meanwhile, an
assistant has fixed a rubber bellows on to the side tube of the
flask; a short piece of glass tubing loosely packed with cotton-wool
should be interposed between the bellows and the flask to prevent any
particles of dust being blown over into the flask from the bellows,
which is not sterilized. The clip near the cannula is released, and
some positive pressure is produced inside the flask by means of the
bellows. The citrated blood then rises in the delivery tube, and
a corresponding quantity of saline solution is displaced from the
air-lock into the patient’s circulation. The blood then flows from
the nozzle of the delivery tube into the air-lock, and the remainder
of the saline solution is driven on into the patient. Finally the
blood flows steadily through the cannula, and the rate at which it is
flowing can be observed in the air-lock.
The presence of this air-lock facilitates, as has been seen, the
introduction of the cannula, into the vein, since there is no leakage
of blood to obscure the operation. In addition, the operator can
see at a glance whether the blood is flowing in properly, and can
regulate the rate of flow to a nicety by varying the pressure in the
flask by means of the bellows. If a very slow injection is required,
the blood can even be made to run drop by drop. If the patient is
suffering from acute anæmia, the blood can be pumped in rapidly, 750
cc. of blood being given in the course of twenty minutes. If, on the
other hand, the patient has a plethora of fluids, such as is seen in
some cases of secondary anæmia, the blood must be given very much
more slowly than this, since it is dangerous rapidly to increase the
blood volume. A half to three-quarters of an hour must be occupied in
giving 500 cc., and even then the patient may complain of a sensation
of tightness in the chest and of dyspnœa, due to embarrassment of
the right heart during the transfusion. This complaint, however, is
usually transient, and will disappear quickly if the injection be
stopped for a few minutes.
It has been said that the lower end of the delivery tube reaches
into the angle between the side and the bottom of the flask. When
therefore the flask is nearly empty, it should be tilted so that very
nearly the whole of the blood can be forced up the tube. When the
flask is quite empty, the blood in the barrel of the air-lock must
be carefully watched, and when its level has fallen to the bottom of
this, the clip must be applied to the tube above the cannula. By this
means no blood is wasted except the small quantity which remains in
the tube below the air-lock. As soon as the tube has been clipped the
cannula is withdrawn, the vein is ligatured above the opening into
its lumen, and the edges of the skin incision are sutured.
Transfusions carried out in this way can be performed with uniform
success. The technique is simple and straightforward at every stage,
and can be easily demonstrated and learnt. It is, in addition,
a perfectly clean process, and not a single drop of blood need
be spilt. Any method which involves the injection of blood under
pressure is open to the objection that it is possible to overlook
the fact that the flask has been emptied and to kill the patient
by injecting air into his veins. This can, however, only happen as
the result of great carelessness on the part of the operator. The
presence of the air-lock affords an additional safeguard, as it can
hardly escape the operator’s notice that blood has ceased to flow
from the nozzle of the delivery tube.
[Illustration: Fig. 13.--INJECTION OF THE BLOOD, SHOWING USE OF
AIR-LOCK]
The method may also be criticized on the ground that some damage is
caused to the corpuscles of the donor’s blood by the shaking which is
necessary to mix it with the citrate solution. This objection is,
in my opinion, theoretical rather than practical. If, however, it be
desired to avoid any such shaking, the apparatus designed by A. E.
Stansfeld and described by him in 1918 may be used. This ensures that
the citrate and the blood flow into the containing vessel together,
so that no further mixing is needed. The apparatus is more cumbrous,
more fragile, and less easy to clean and to sterilize than that
described above. In the hands of an expert it will give excellent
results, but its use requires some little practice, and it is
therefore not so well adapted for general use.
The whole of my own apparatus, as described above, may be obtained
from Messrs. Allen & Hanburys, Wigmore Street, London, W.1, who also
provide a convenient box for carrying it.
=Transfusion of Infants.=--The technique of transfusions performed
upon children over the age of about four years does not differ from
that used for adults, except that less blood is to be given. The
antecubital veins are much smaller and a finer cannula may have to
be used, but this is the only source of trouble. The transfusion of
infants and very young children may, however, be found to be much
more difficult. The operation will have to be done for conditions
such as melæna neonatorum, which was discussed on p. 48 of the
present work, or for post-operative collapse, such as may follow an
operation for congenital hypertrophic stenosis of the pylorus, for
intussusception, or for some of the more extreme cases of harelip
and cleft palate. In all such instances the transfusion will be a
matter of some urgency. Speed and certainty will depend on previous
knowledge of the best method to be employed.
In the case of melæna neonatorum treated by R. D. Laurie, which has
been already referred to, a needle was introduced into one of the
antecubital veins, and 20 cc. of citrated blood were injected with a
syringe. This method, however, is not to be recommended, on account
of its great difficulty.
The method used by Helmholtz and also by Howard depends on the
introduction of a syringe needle into the superior longitudinal
sinus through the anterior fontanelle. A needle two to three inches
long attached to a 20 cc. syringe is inserted near the upper angle
of the fontanelle at an angle of about 25° with the scalp. As the
needle pierces the wall of the sinus, a sensation of resistance is
experienced, similar to that given by the piercing of the dura mater
in doing a lumbar puncture. Blood should then be allowed to enter
the syringe in order to demonstrate that the point of the needle
really is lying in the sinus. Abnormalities have occasionally been
met with, in which the sinus was situated to one side of the middle
line or was very much smaller than usual. The danger of injecting
the blood in such a case into the brain or the subdural space need
not be emphasized. Difficulty may also be caused by restlessness on
the part of the child, and to overcome this Helmholtz has devised an
apparatus which grips and fixes the child’s head at a suitable angle.
All this, however, makes the process unnecessarily elaborate. As an
alternative, Vincent has exposed one of the internal jugular veins
into which he introduces a cannula. This again is a comparatively
difficult operation, which may leave a permanent scar in a
conspicuous place. Vincent had previously used the femoral vein, but
he found this difficult to approach, and the wound was apt to become
contaminated afterwards.
The method of choice is undoubtedly that used by Bruce Robertson,
who has performed a much larger number of transfusions upon infants
and children than any other worker in this field of surgery. He has
found that the internal saphenous vein near the ankle is a vessel
possessing a fairly wide lumen and thick walls even in infants, so
that a needle or cannula can be introduced into it with comparative
ease and rapidity. The vein must, of course, be freely exposed
through an incision, but its situation removes any objection there
might otherwise be to this operation. Robertson has usually employed
the syringe-cannula method described earlier in the present chapter,
but there is no objection to the use of an anticoagulant. The small
amount of blood to be given, 15 cc. per pound of body weight, makes
the use of the transfusion flask unnecessary. It is better to use a
20 cc. syringe, into which 2 cc. of a 10 per cent. solution of sodium
citrate is drawn as a preliminary. The needle in the donor’s vein and
the cannula in the infant’s saphena should each be provided with a
rubber connexion, which can be clipped, or pinched by an assistant,
when the syringe is not attached. The syringe containing the citrate
is filled with blood and injected into the infant as often as may be
necessary until the total amount decided upon has been given.
Robertson has used this method for complete replacement of the
circulating blood in treating streptococcal septicæmia following
erysipelas, and for shock in children due to burns. The infant’s
blood is removed through the anterior fontanelle, while a fresh
supply is injected into the saphenous vein. Complete replacement
has not, so far as I know, ever been performed upon an adult, but
the process is feasible, given a large enough assemblage of donors.
In this way some _vieillard_ might attempt the rejuvenation,
which at present, as we are told, has only been obtained from the
transplantation of “monkey glands” by Viennese professors.
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76. DRINKER, C. R., & BRITTINGHAM, H. H.: “The cause of the
reactions following transfusion of citrated blood.” _Arch. Int.
Med._, 1919, xxiii. 133.
77. DRUMMOND, H., & TAYLOR, E. S.: “The use of intravenous
injections of gum acacia in surgical shock.” _Rep. of the Med. Res.
Com._, iii., 1919, 135. “Observations on the blood pressure in gas
gangrene infection.” _Ibid._, v. 1919, 199.
78. DUKE, W. W.: “Variation in the platelet count.” _Journ. Am.
Med. Assoc._, 1915, lxv. 1600.
79. DUNGERN, E. VON, & HIRSCHFELD, L.: “Ueber Nachweis
und Vererbung biochemischer strukturen.” _Zeitschr. f.
Immunitätsfschng._, 1910, iv. 531; 1911, viii. 526.
80. DUNGERN, E. VON, & HIRSCHFELD, L.: “Ueber Vererbung
gruppenspezifischer strukturen des Blutes.” _Ibid._, 1910, vi. 284.
81. DUNGERN, E. VON, & HIRSCHFELD, L.: “Ueber die Giftigkeit
des Blutes nach der Injektion protoplasmatischen Substanzen und
während der Schwangerschaft, und über passive Allergie gegenüber
Hodensubstanzen.” _Ibid._, 1911, viii. 332.
82. EBERLE, D.: “Transfusion and reinfusion of blood.” _Schweiz.
med. Wchnschr._, 1920, l. 961.
83. ELSBERG, C. A.: “A simple cannula for the direct transfusion of
blood.” _Journ. Am. Med. Assoc._, 1909, lii. 887.
84. ELY, A. H., & LINDEMAN, E.: “Acidosis complicating pregnancy.
Report of a case cured by transfusion.” _Am. Journ. Obstet. and
Dis. Wom. and Child._, July, 1916, lxxiv. 42.
85. EMSHEIMER, H. W.: “Intramuscular injections of whole blood in
the treatment of purpura hæmorrhagica.” _Journ. Am. Med. Assoc._,
1916, lxvi. 20.
86. EPSTEIN, A. A., & OTTENBERG, R.: “A method for agglutination
tests.” _Arch. Int. Med._, 1909, iii. 286.
87. ERLANGER, J., & GASSER, H. S.: “Hypertonic gum acacia and
glucose in the treatment of secondary traumatic shock.” _Ann.
Surg._, 1919, lxix. 389.
88. FLEMING, A., & PORTEOUS, A. B.: “Blood transfusion by the
citrate method.” _Lancet_, 1919, i. 973.
89. FLÖRCKEN, H.: “Zur Frage der direkten Bluttransfusion durch
Gefässnaht.” _Zentrbl. f. Chir. Leipzic_, 1911, xxxviii. 305.
90. FOLLI, FRANCESCO: “Stadera medica, nella quale oltre la
medicina infusoria, ed altre novita, si bilanciano le ragioni
favore voli e le contrarie alla trasfusione del sangue.” Florence,
1680.
91. FORSIUS, R.: “Severe hæmophilic intestinal hæmorrhage treated
with transfusion of blood.” _Finska Läkaresällskapets Handl._,
1915, lvii. No. 3.
92. FRANK, R. T., & BAEHR, G.: “A new method for the transfusion of
blood. An experimental study.” _Journ. Am. Med. Assoc._, 1909, lii.
1746.
93. FRASER, J., & COWELL, E. M.: “A clinical study of the blood
pressure in wound conditions.” _Report of the Med. Res. Com._, ii.
(1), 1919, 49.
94. FREILICH, E. B., and others: “Blood transfusion in treatment of
pulmonary tuberculosis.” _Illin. Med. Journ._, 1921, xxxix. 32.
95. FREUND, H. A.: “A method for the transfusion of fresh normal
blood.” _Journ. Michigan Med. Soc._, 1913, xii. 459.
96. FRY, H. J. B.: “The use of immunized blood donors in the
treatment of pyogenic infections by whole blood transfusions.”
_Brit. Med. Journ._, 1920, i. 290.
97. FRYER, B. E.: “A few remarks on the transfusion of blood, with
a modification of the apparatus of Aveling.” _Med. Rec._, 1874, ix.
201.
98. FULLERTON, A., DREYER, G., & BAZETT, H. C.: “Direct transfusion
of blood, with a description of a simple method.” _Lancet_, 1917,
i. 715.
99. GARBAT, A. L.: “Intravenous injections of sodium citrate.”
_Journ. Am. Med. Assoc._, 1916, lxvi. 1543.
100. GESELLIUS, F.: “Die Transfusion des Blutes.” St. Petersburg,
1873.
101. GESELLIUS, F.: “Zur Thierblut-Transfusion beim Menschen.” St.
Petersburg, 1874.
102. GETTLER, A. O., & LINDEMAN, E.: “A new method of acidosis
therapy. Blood transfusion from an alkalinized donor, with report
of case.” _Journ. Am. Med. Assoc._, 1917, lxviii. 594.
103. GIFFIN, H. Z.: “A report on the treatment of pernicious anæmia
by transfusion and splenectomy.” _Journ. Am. Med. Assoc._, 1917,
lxviii. 429.
104. GRAHAM, J. M.: “Observations on the technique of blood
transfusion.” _Edin. Med. Journ._, 1919, xxiii. 358.
105. GRAHAM, J. M.: “Transfusion of blood in cases of hæmorrhage.”
_Edinb. Med. Journ._, 1920, xxiv. 142.
106. GRAHAM, J. M.: “Transfusion of blood in pernicious anæmia.”
_Edinb. Med. Journ._, 1920, xxiv. 282.
107. GRUTZ, O.: “Bluttransfusion bei Morbus maculosus Werlhofi.”
_Berl. Klin. Wchnschr._, 1921, lviii. 53.
108. GUIOU, N. M.: “Blood transfusion in a field ambulance.” _Brit.
Med. Journ._, 1918, i. 695.
109. GURYE, G. DE: “An account of more tryals of transfusion,
accompanied with some considerations thereon, chiefly in reference
to its cautious practice on Man; together with a farther
vindication of this invention from usurpers.” _Philosophical
Trans._, 1667, ii. 517.
110. HAHN, M.: “Hæmophilia treated by transfusion.” _Med. Rec._,
1910, lxxviii. 624.
111. HALSTED, W. S.: “Refusion in the treatment of carbonic oxide
poisoning.” _Ann. of Anat. and Surg._, 1884, Jan.
112. HAPP, W. M.: “Appearance of iso-agglutinins in infants and
children.” _Journ. Exp. Med._, 1920, xxxi. 313.
113. HARDING, M. E.: “The toxæmic stage of diphtheria.” _Lancet_,
1921, i. 737.
114. HARRIS, D. T.: “The value of the vital-red method as a
clinical means for the estimation of the volume of the blood.”
_Brit. Journ. Exp. Path._, 1920, i. 142.
115. HARTWELL, J. A.: “A simple method of blood transfusion with
cannula.” _Journ. Am. Med. Ass._, 1909, lii. 297.
116. HARTWELL, J. A.: “A consideration of the various methods of
blood transfusion and its value.” N.Y. _State Journ. Med._, 1914,
xiv. 535.
117. HASSE, O.: “Report on twelve cases of the direct transfusion
of lamb’s blood.” _Allgem. Wiener Medizin. Zeit._, Dec. 1873.
(Abstracted in the _Lond. Med. Rec._, Dec. 31, 1873.)
118. HÉDON, E.: “Note complémentaire sur la transfusion du sang
citraté.” _Presse méd._, 1918, xxvi. 57.
119. HEKTOEN, L.: “Iso-agglutination of human corpuscles.” _Journ.
Infect. Dis._, 1907, iv. 297.
120. HELMHOLZ, H. F.: “The longitudinal sinus as the place of
preference in infancy for intravenous aspirations and injections,
including transfusion.” _Am. Journ. Dis. of Children_, 1915, x. 194.
121. HICKS, J. BRAXTON: “Cases of transfusion, with some remarks
on a new method of performing the operation.” _Guy’s Hosp. Rep._,
1869, 3rd s., xiv. 1.
122. HIGGINSON, A.: “Report of seven cases of transfusion of blood,
with a description of the instrument invented by the author.”
_Liverpool Med. Chir. Journ._, 1857, i. 102.
123. HINDSE-NIELSEN: “Nitro-benzol poisoning treated with blood
transfusion.” _Ugeskift f. Laeger_, 1920, Sept. 9.
124. HIRSCHFELD, L., & HIRSCHFELD, H.: “Serological differences
between the blood of different races.” _Lancet_, 1919, ii. 675.
125. HOFFMAN, M. H., & HABEIN, H. C.: “Transfusion of citrated
blood.” _Journ. Am. Med. Assoc._, 1921, lxxvi. 358.
126. HOOKER, R. S.: “The treatment of staphylococcus septicæmia by
transfusion of immune blood.” _Ann. Surg._, 1917, lxvi. 513.
127. HOWARD, W. S.: “A simple method of transfusion in hæmorrhage
of the new-born, with report of a case.” _Journ. Am. Med. Assoc._,
1915, lxv. 1365.
128. HUCK, F. G.: “Changes in the blood immediately following
transfusion.” _Johns Hopkins Hosp. Bull._, 1919, xxx. 63.
129. HULL, A. J.: “Direct transfusion of blood.” _Brit. Med.
Journ._, 1917, ii. 683.
130. HUNT, E. L., & INGLEBY, H.: “A case of peptic ulcer with grave
anæmia treated by intravenous injection of whole blood.” _Lancet_,
1919, i. 975.
131. HUNT, V. C.: “Reaction following blood transfusion by the
sodium citrate method.” _Texas State Journ. Med._, 1918, xiv. 192.
(Also in _Collected Papers of the Mayo Clinic_, x. 1918.)
132. HUSTIN: “Principe d’une nouvelle méthode de transfusion
muqueuse.” _Journ. méd. de Brux._, 1914, xii. 436.
133. HUTCHISON, R.: “Three cases of melæna neonatorum successfully
treated by the injection of whole blood.” _Brit. Med. Journ._,
1917, ii. 617.
134. HÜTER, C.: “Ein Fall von Kohlenoxydvergiftung; Heilung durch
Transfusion.” _Berl. Klin. Wchnschr._, 1870, vii. 341.
135. INGEBRIGTSEN, R.: “The influence of iso-agglutinins on the
final results of homoplastic transplantation of arteries.” _Journ.
Exp. Med._, 1912, xvi. 169.
136. JANEWAY, H. H.: “An improved device for transfusion.” _Ann.
Surg._, 1911, lxiii. 720.
137. JANSKY, J.: “Hæmatologische Studien bei psykotiken.” _Klincky
Sborink_, 1907, viii. 85.
138. JANSKY, J.: “Recommendation by a committee that the Jansky
classification of blood groups be used in preference to that of
Moss on grounds, of priority.” _Journ. Am. Med. Assoc._, 1921,
lxxvi. 130.
139. KAHN, A.: “Continuous transfusion. The production of
immunity.” _N.Y. Med. Rec._, 1916, lxxxix. 553.
140. KARSNER, H. T.: “Laboratory problems of blood transfusion.”
_Journ. Am. Med. Assoc._, 1921, lxxvi. 88.
141. KEATOR, H. M.: “Transfusion in case of toxæmia of early
pregnancy with unusual hæmorrhagic manifestations.” _Am. Journ.
Obstet. and Dis. Wom. and Child_, 1912, lxv. 1003.
142. KEITH, N. M.: “Blood volume changes in wound shock and primary
hæmorrhage.” _Rep. of the Med. Res. Com._, ix., March, 1919.
143. KEITH, N. M., ROWNTREE, L. G., & GERAGHTY, J. T.: “A method
for the determination of plasma and blood volume.” _Arch. Int.
Med._, 1915, xvi. 547.
144. KEYNES, G. L.: “Blood transfusion: its theory and practice.”
_Lancet_, 1920, i. 1216.
145. KIMPTON, A. R., & BROWN, J. H.: “A new and simple method of
transfusion.” _Journ. Am. Med. Assoc._, 1913, lxi. 117.
146. KIMPTON, A. R.: “Further notes on transfusion by means of
glass cylinders.” _Journ. Am. Med. Assoc._, 1913, lxi. 1628.
147. KIMPTON, A. R.: “Transfusion. Experiences in over two hundred
cases.” _Boston Med. and Surg. Journ._, 1918, clxxviii. 351.
148. KIMPTON, A. R., & BROWN, J. H.: “Technique of transfusion
by means of glass tubes.” _Bost. Med. and Surg. Journ._, 1915,
clxxiii. 425.
149. KING, E.: “An account of an easier and safer way of
transfusing blood out of one animal into another, viz., by the
veins, without opening an artery of either.” _Philosophical
Trans._, 1667, ii. 449.
150. KING, E.: “The method of transfusing into the veines of men.”
_Philosophical Trans._, 1667, ii. 522.
151. KING, E.: “An account of the experiment of transfusion,
practised upon a man in London.” _Philosophical Trans._, 1667, ii.
557.
152. KING, H. H.: “Direct vein to vein transfusion.” _Brit. Med.
Journ._, 1918, i. 498.
153. KUSH, M.: “An automatic transfusion apparatus.” _Journ. Am.
Med. Assoc._, 1915, lxv. 1180.
154. LAMBERT, S. W.: “Melæna neonatorum, with report of a case
cured by transfusion.” _N.Y. Med. Rec._, 1908, lxxiii. 885.
155. LANDOIS, L.: “Die Transfusion des Blutes.” Berlin, 1866.
Leipzig, 1875.
156. LANDSTEINER, K.: “Ueber Agglutinationserscheinungen normalen
menschlichen Blutes.” _Wien. Klin. Wchnschr._, 1901, xiv. 1132.
157. LAPAGE, C. P.: “Two cases of melæna neonatorum treated by
injection of fresh citrated blood.” _Proc. Roy. Soc. Med._, 1920,
xiii. Sect. Child. Dis., 158-160.
158. LAURIE, R. D.: “Melæna neonatorum treated by blood
transfusion.” _Brit. Med. Journ._, 1921, i. 527.
159. LEARMONTH, J. R.: “The inheritance of specific iso-agglutinins
in human blood.” _Journ. Genetics_, 1920, x. 141.
160. LEE, R. I.: “A simple and rapid method for the selection of
suitable donors for transfusion by the determination of blood
groups.” _Brit. Med. Journ._, 1917, ii. 684.
161. LEISRINK, H.: “Ueber die Transfusion des Blutes.” _Samm. Klin.
Vortr., No. 41._ Leipzig, 1872, 235.
162. LESPINASSE, V. D.: “The treatment of hæmorrhagic disease of
the new-born by direct transfusion of blood, with a clinical report
of fourteen personal cases.” _Journ. Am. Med. Assoc._, 1914, lxii.
1866.
163. LESPINASSE, V. D.: “Technique of direct transfusion of blood,
using iridio-platinum tubes.” _Chicago Med. Rec._, 1915, xxxvii.
589.
164. LESSER, L.: “Transfusion and autotransfusion.” _Samml. Klin.
Vortr., No. 86_, Leipzig, 1875. _Inn. Med., No. 29_, p. 665.
165. LEVIN, I.: “Plastic surgery of blood vessels and direct
transfusion of blood.” _Ann. of Surg._, N.Y., 1913, May.
166. LEWISOHN, R.: “A new and greatly simplified method of blood
transfusion.” _N.Y. Med. Rec._, 1915, lxxxvii. 141.
167. LEWISOHN, R.: “Blood transfusion by the citrate method.”
_Surg. Gynec. and Obstet._, 1915, xxi. 37.
168. LEWISOHN, R.: “The citrate method of blood transfusion in
children.” _Am. Journ. Med. Sci._, 1915, cl. 886.
169. LEWISOHN, R.: “The importance of the proper dosage of sodium
citrate in blood transfusion.” _Ann. of Surg._, 1916, lxiv. 618.
170. LEWISOHN, R.: “Modern methods of blood transfusion.” _Journ.
Am. Med. Assoc._, 1917, lxviii. 826.
171. LEYTON, O.: “Transfusion in diseases of the blood.” _Brit.
Med. Journ._, 1919, i. 279.
172. LIBAVIUS, A.: “Denfensio syntagmatis arcanorum chymicorum.”
Frankfort, 1615, ch. iv., p. 8.
173. LIBMAN, E., & OTTENBERG, R.: “A practical method for
determining the amount of blood passing over during direct
transfusion.” _Journ. Am. Med. Assoc._, 1914, lxii. 764.
174. LIBMAN, E., & OTTENBERG, R.: “Recent observations on blood
transfusion.” _Tr. Coll. Phys. Phila._, 1917, xxxix. 266.
175. LICHTENSTEIN: “Eigenbluttransfusion bei Extrauteringravidität
und Uterusruptur.” _Münch. Med. Wchnschr._, 1915, lxii. 1597.
176. LINDEMAN, E.: “Simple syringe transfusion with special
cannulas.” _Am. Journ. Dis. of Children_, 1913, vi. 28.
177. LINDEMAN, E.: “Blood transfusion. Report of one hundred and
thirty-five transfusions by the syringe-cannula system.” _Journ.
Am. Med. Assoc._, 1914, lxii. 993.
178. LINDEMAN, E.: “Reactions following blood transfusion by the
syringe cannula system.” _Journ. Am. Med. Assoc._, 1916, lxvi. 624.
179. LINDEMAN, E.: “The total blood volume in pernicious anæmia.”
_Journ. Am. Med. Assoc._, 1918, lxx. 1292.
180. LITTLE, G. F.: “Transfusion of antibacterial blood. Report of
case.” _Journ. Am. Med. Assoc._, 1920, lxxiv. 734.
181. LOSEE, J. R.: “Blood transfusion.” _Am. Journ. Med. Sci._,
1919, clviii. 711.
182. LOSEE, J. R.: “Blood transfusion in obstetrics.” _Med. Rec._,
1920, xcvii. 265.
183. LÖWENTHAL, W.: “Ein Beitrag zur Lehre von der Transfusion des
Blutes.” _Berl. Klin. Wchnschr._, 1871, viii. 487.
184. LOWER, R.: “The method observed in transfusing the blood out
of one animal into another.” _Philosophical Trans._, 1666, i. 353.
185. McCLURE, R. D.: “Pernicious anæmia treated by splenectomy, and
systematic, often-repeated transfusion of blood. Transfusion in
benzol poisoning.” _Journ. Am. Med. Assoc._, 1916, lxvii. 793.
186. McCLURE, R. D., & DUNN, G. R.: “Transfusion of blood. History,
methods, dangers, preliminary tests, present status. Report of one
hundred and fifty transfusions.” _Johns Hopkins Hosp. Bull._, 1917,
xxviii. 99.
187. McGRATH, B. F.: “A simple instrument for [direct]
transfusion.” _Journ. Am. Med. Assoc._, 1914, lxii. 40.
188. McGRATH, B. F.: “Vascular suture in transfusion.” _Journ. Am.
Med. Assoc._, 1914, lxii. 1326.
189. McGRATH, B. F.: “A simple apparatus for transfusion by the
aspiration-injection method.” _Surg. Gynec. and Obstet._, 1914,
xviii. 376.
190. MADGE, H. M.: “On transfusion of blood.” _Brit. Med. Journ._,
1874, i. 42.
191. MANN, F. C.: “Experimental surgical shock. The treatment of
the condition of low blood pressure, which follows exposure of the
abdominal viscera.” _Am. Journ. Physiol._, 1919, l. 86. (Also in
_Collected Papers of the Mayo Clinic_, 1919, xi. 1225.)
192. MARTIN: “Ueber eine mit günstigem Erfolge bei einer
lebensgefährlichem Intrauterinblutung vollzogene Transfusion.”
_Monatschr. f. Geburtsk. u. Frauenk._, 1861, xvii. 269.
193. MARTIN: “Iso-agglutination beim Menschen.” _Centralblatt f.
Bact._, 1905, xxxix. 704.
194. MELENEY, H. E., STEARNS, W. W., FORTUINE, S. T., & FERRY, R.
M.: “Post-transfusion reactions: a review of 280 transfusions.”
_Am. Journ. Med. Sci._, 1917, cliv. 733.
195. MILLER, G. I.: “Blood transfusion, indications and technique.”
_Med. Rec._, 1915, lxxxviii. 425.
196. MINOT, G. R.: “Methods for testing donors for transfusion of
blood and consideration of factors influencing agglutination and
hæmolysis.” _Boston Med. and Surg. Journ._, 1916, clxxiv. 667.
197. MINOT, G. R., & LEE, R. I.: “The blood platelets in
hæmophilia.” _Arch. Int. Med._, 1916, xviii. 474.
198. MINOT, G. R., & LEE, R. I.: “Treatment of pernicious anæmia,
especially by transfusion and splenectomy.” _Bost. Med. and Surg.
Journ._, 1917, clxxvii. 761.
199. MOREL, L.: “Transfusion of blood.” _Arch. gen. de Chir._,
1914, viii. 1.
200. MOSS, W. L.: “Studies on iso-agglutinins and iso-hemolysins.”
_Johns Hopkins Hosp. Bull._, 1910, xxi. 63.
201. MOSS, W. L.: “Paroxysmal hæmoglobinuria: blood studies in
three cases.” _Johns Hopkins Hosp. Bull._, 1911, xxii. 238.
202. MOSS, W. L.: “A simple method for the indirect transfusion of
blood.” _Am. Journ. Med. Sci._, 1914, cxlvii. 698.
203. MOSS, W. L.: “A simplified method for determining the
iso-agglutinin group in the selection of donors for blood
transfusion.” _Journ. Am. Med. Assoc._, 1917, lxviii. 1905.
204. NIX, J. T.: “Blood transfusion simplified. Deductions from
nineteen cases, eleven human and eight on dog.” _New Orleans Med.
and Surg. Journ._, 1916, lxix. 435.
205. OEHLECKER, F.: “Bluttransfusion von Vene zu Vene mit Messung
der übertragenen Blutmenge.” _Zentralbl. f. Chir._, 1919, xlvi. 17.
206. OEHLECKER, F.: “Direkte Bluttransfusion von Vene zu Vene bei
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207. ORÉ: “Études historiques et physiologiques sur la transfusion
du sang.” Paris, 1868.
208. OTTENBERG, R.: “Transfusion and arterial anastomosis.” _Ann.
Surg._, 1908, xlvii. 486.
209. OTTENBERG, R.: “Transfusion and the question of intravascular
agglutination.” _Journ. of Exp. Med._, 1911, xiii. 425.
210. OTTENBERG, R.: “The effect of sodium citrate on blood
coagulation in hæmophilia.” _Proc. Soc. for Exp. Biol. and Med._,
1916, xiii. 104.
211. OTTENBERG, R.: “Medico-legal applications of human blood
grouping.” _Journ. Am. Med. Assoc._, 1921, lxxvii. 682.
212. OTTENBERG, R., & FRIEDMAN, S. S.: “The occurrence of grouped
iso-agglutination in the lower animals.” _Journ. Exp. Med._, 1911,
xiii. 531.
213. OTTENBERG, R., & KALISKI, D. J.: “Accidents in transfusion.
Their prevention by preliminary examination. Based on an experience
of 128 transfusions.” _Journ. Am. Med. Assoc._, 1913, lxi. 2138.
214. OTTENBERG, R., KALISKI, D. J., & FRIEDMAN, S. S.:
“Experimental agglutinative and hemolytic transfusions.” _Amer.
Journ. Med. Res._, 1913, xxviii. 141.
215. OTTENBERG, R., & LIBMAN, E.: “Blood transfusion; indications;
results; general management.” _Am. Journ. Med. Sci._, 1915, cl. 36.
216. OTTENBERG, R., & THALIMER, W.: “Studies in experimental
transfusion.” _Journ. Med. Res._, 1915-16, xxxiii. 213.
217. PANUM, P. L.: “Experimentelle Untersuchungen über die
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218. PEMBERTON, J. DE J.: “Blood transfusion.” _Surg. Gynec. and
Obstet._, 1919, xxviii. 262. (Also in _Collected Papers of the Mayo
Clinic_, 1918, x. 508.)
219. PEMBERTON, J. DE J.: “Practical considerations of the dangers
associated with blood transfusions.” _Journ. Iowa State Med. Soc._,
1920, x. 170. (Also in _Collected Papers of the Mayo Clinic_, 1919,
xi. 635.)
220. PERCY, N. M.: “A simplified method of blood transfusion, with
report of six cases of pernicious anæmia treated by massive blood
transfusions and splenectomy.” _Surg. Gynec. and Obstet._, 1915,
xxi. 360.
221. PETERSON, E. W.: “Purpura hæmorrhagica treated by blood
transfusion.” _Post-Graduate_, N.Y., 1914, xxix. 499.
222. PETERSON, E. W.: “Results from blood transfusion in the
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diseases.” _Journ. Am. Med. Assoc._, 1916, lxvi. 1291.
223. PÉTREN, G.: “Coagulation time in icterus.” _Beitr. z. Klin.
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224. PONFICK: “Experimentelle Beiträge zur Lehre von der
Transfusion.” _Virchow’s Arch. f. Path. Anat._, 1875, lxii. 273.
225. POOL, E. H.: “Transfusion and splenectomy for von Jaksch’s
anæmia in an infant.” _Ann. Surg._, March 1915. (In Transact. of
N.Y. Surg. Soc.)
226. POOL, E. H., & McCLURE, R. D.: “Transfusion by Carrel’s
end-to-end suture method. With report of cases.” _Ann. Surg._,
1910, lii. 433.
227. POPE, L.: “Simplified transfusion.” _Journ. Am. Med. Assoc._,
1913, lx. 1284.
228. PRIMROSE, A.: “The value of the transfusion of blood in the
treatment of the wounded in war.” _Ann. Surg._, 1918, lxviii. 118.
229. PRIMROSE, A., & RYERSON, E. S.: “The direct transfusion of
blood, its value in hæmorrhage and shock and in treatment of the
wounded in the war.” _Brit. Med. Journ._, 1916, ii. 384.
230. RAMIREZ, M. A.: “Horse asthma following blood transfusion.”
_Journ. Am. Med. Assoc._, 1919, lxxiii. 984.
231. RAMSAY, J.: “Transfusion of blood in nephritis.” _Brit. Med.
Journ._, 1920, i. 766.
232. RANSOM, S. H.: “The treatment of staphylococcus septicæmia by
transfusion of immune blood.” _Ann. Surg._, 1917, lxvi. 513.
233. RAULSTON, B. O., & WOODYATT, R. T.: “Blood transfusion in
diabetes mellitus.” _Journ. Am. Med. Assoc._, 1914, lxii. 996.
234. RICHARDSON, B. W.: “The cause of coagulation of the blood. The
Astley Cooper prize essay for 1856, with additional observations
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235. RICHARDSON, E. H.: “Treatment of the emergency cases of
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237. ROBERTSON, L. B.: “A contribution on blood transfusion in war
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238. ROBERTSON, L. B.: “Blood transfusion in hæmorrhagic disease of
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INDEX
Abdominal operations, shock in relation to, 27
value of transfusion following, 32
Abdominal veins, “bleeding into,” 27
Accidents, loss of blood following, 20
Acholuric jaundice, blood condition in, 93
blood groups of patients with, 93
transfusion in, 94
Acidosis, in pregnancy, 63
Agglutination, 84, 85
abnormal, 56
among animals, 79
in infants and children, 84
method of the test, 101
phenomenon of, 71-73
potential, of fœtal corpuscles, 85
preceding hæmolysis, 70, 76
Agglutinins, 71
in the blood, discovery of, 15
in maternal blood serum and milk, 86
“major” and “minor,” 73
“minor” in citrated blood, 123
“Agglutinophilic” properties of blood corpuscles, 72, 85
Agote, Prof., first transfusion of citrated blood by, 16
Air hunger, 21
Air-lock in transfusion apparatus, 125, 131, 133
Alkaline solution in treatment of shock, 34
Alkalinized blood, 63
Amaurosis, 21
Amputations, value of transfusion following, 32
Anæmia, 19, 50
acute, 19, 20
amount of blood necessary in transfusion treatment, 25
effect of transfusion on, 22
following hæmorrhage, 20, 24
signs and symptoms of, 20
transfusion treatment of, 31
aplastic, 50
hæmophilia with, 48
splenic, 50
_see also_ Pernicious anæmia
Anæsthesia, transfusion in conjunction with, 33
Anæsthetics, shock accentuated by administration of, 31
Anaphylactic shock, following transfusion, 77
in pernicious anæmia, 57
influence on coagulation time of blood, 45
Anastomosis, Crile’s method, 109
for direct transfusion, 108, 109
Antecubital veins, injection of blood into, 134, 135
Anti-agglutinins, 74
Antibodies, in the blood, 58
Anticoagulants, 16
action of, 120, 122
in hæmophilia, 47
sodium citrate, 121
transfusion with, 118
Aplastic anæmia, 50
Arm tourniquet, 126, 128
Army, blood transfusion in, 17
Arteries, in direct transfusion, 108, 109
occlusion of, prevention of, 109
selection of, for transfusion, 108
Asthma, transmission of, 68
Auto-hæmolysins, development of, 94
Auto-hæmolysis of blood outside the body, 94
phenomenon of, 94, 95
Bacteria, blood inhibiting growth of, 58
Bacterial infections, 58-63
transfusion in relation to, 58, 60
Benzol poisoning, transfusion treatment of, 65, 66
Blood, administration of, apparatus for, 115, 126, 127, 130-133
methods, 108, 112, 130-135
time occupied in, 131, 132
agglutinins and iso-agglutinins in, 15, 71, 72, 74
amount in the body, how measured, 22, 23
animals’, use of, 5, 6, 8, 9, 15
anti-agglutinins in, 74
antibodies in, 58
auto-hæmolysis of, 94
bactericidal power of, 58
calcium content of, 120
citrated, _see_ Citrated blood
clotting of, _see_ Coagulation
coagulation of, _see_ Coagulation
defibrinated, early use of, 11, 12
examination of, for transfusion, 56, 57, 95
hydrogen-ion concentration of, 28
immunized, in pyogenic infections, 58
inhibiting growth of bacteria, 58
loss of, _see_ Hæmorrhage
maternal, agglutinins in, 86
of donors, _see_ Blood donors
of patients, reinfusion with, 42, 43
testing of, 56
rapid administration, danger of, 78
substitutes for, 35, 36
testing of, for transfusion, 68, 83, 92, 95
total quantity in the body, 22
transfused, corpuscles in, 37
relative value of corpuscles and plasma in, 36, 37
withdrawal of, methods and technique, 108, 112, 116, 126-128
Blood clot, mechanism of formation of, 119
rapid hæmorrhage causing, 24
_see also_ Coagulation
Blood corpuscles, “agglutinophilic” properties of, 72, 85
and plasma, relative value of, 36, 37
clumping together of, 70
condition during shock, 39
conditions due to alterations in, 50
destruction of, in the toxæmias, 64
effect of transfusion on, 52
fœtal, potential agglutination of, 85
in transfused blood, 36, 37
function of, 37
quantity and concentration during shock, 28
transfusion of, 64
Blood count, during shock, 39
following hæmorrhage, 39
following transfusion, 40
in pernicious anæmia, 51, 53-56
Blood diseases, 50-58
Blood donor, 69
blood of, 56, 57
agglutinating power of serum of, 72-74
testing of, 68
transmission of disease by, 67, 68
characteristics of, 100
choice of, 68, 96-107
effect of blood loss on, 99
for new-born infants, 49
for pernicious anæmia, 56, 57
injury to, during transfusion, 111, 124
members of patient’s family as, 85, 90, 92, 95
“professional,” 69, 98
testing of, 83, 92, 95-97
for blood groups, 101
treatment of, 60, 99, 100
“universal,” 72, 73
vaccine treatment of, prior to withdrawal of blood, 60
withdrawal of blood from, 108, 109, 124
by anastomosis, 108, 109
by Kimpton-Brown tube, 116, 117
by needle, 126-128
by syringe, 112, 113
Blood groups, 67, 69, 70, 101
among animals, 79
and disease, relation between, 81, 93
classification of, 70, 71
compatibility of, 72, 75, 80
in families, 84, 90, 92
testing of, 102
earliest classification of, 15
family incidence of, 84, 90, 92
incidence among our own population, 83
incompatibility of, 80, 92
earliest reference to, 6
in animals, 80
in families, 84, 90, 92
symptoms of, 75-77
testing for, 101, 102
inheritance of, 86, 87, 90, 91
medico-legal considerations, 92
maternal, compared with those of infants, 86, 92
over-lapping of, 72, 96
pathology of, 79
phenomena of, 69-75
physiology of, 79
popular beliefs concerning, 84
racial incidence of, 81, 82
reactions between the serum and corpuscles of, 70, 71, 72, 73
testing for, in blood donors, 97, 101
transfusion in relation to, 95
“unit characters” in, 86, 87, 88
Blood measurements, 22, 23
Blood plasma, in transfused blood, 36, 37
Blood pressure, 21
as an indication for transfusion, 40
danger points in, 21
following loss of blood, 21
low, essential feature of shock, 27
transfusion treatment of, 32
Blood reactions, 70, 71, 72, 80, 101
clinical picture of, 75
disease in relation to, 93
family incidence of, 84, 90, 92, 95
following transfusion, 95, 96, 122, 123
in infants, 84, 90, 92
incompatibility of, transfusion in relation to, 96
intensity of, variations in, 73
recognition of symptoms of, 75-77
variation in degree of, 76
Blood recipients, “universal,” 72, 95
“Blood relations,” transfusion in relation to, 84, 92, 95
Blood serum, agglutination test of, 101
preservation of, 101, 102
stock, 101
collection of, 102
Blood volume, changes in, in hæmorrhage and shock, 24, 25, 27
diminution in shock, 27, 32
estimation of, 22
imperfect oxygenation due to, 36
life dependent on, 24, 25
Blundell, James, his “impellor,” 10, 11
transfusion by (in 1818), 10, 11
Body, total quantity of blood in the, 22
Breathing, difficult, during transfusion, 78
Burns, transfusion for shock due to, 136
Calcium, action of, 120
in the blood, forms in which present, 120
precipitation of, 119
Cancer, transfusion for, 9, 18
Cannula, for direct transfusion, 110
for indirect transfusion, 130
Capillary circulation, condition during shock, 39
stagnation of, following hæmorrhage and shock, 27, 29
Carbon monoxide poisoning, 64
condition of the blood in, 64
transfusion treatment of, 64, 65
Children, transfusion of, technique, 134
_see also_ Infants
Chloroform, shock accentuated by administration of, 31
Chlorosis, 50
Circulation, blood volume necessary to maintain balance of, 24, 25
capillary and venous, comparison during shock, 39
condition during shock and hæmorrhage, 27, 28, 29, 39
stagnation of, 28
_see also_ Blood
Citrate reactions, 122, 123
Citrated blood, 16, 121, 124
administration of, methods, 129-134
keeping and care of, 128, 129
reaction following use of, 122, 123
transfusion of, 121, 124
first recorded case of, 16
in pernicious anæmia, 51, 56
_see also_ Sodium citrate
Clotting, _see_ Coagulation
Coagulation, deficient, following hæmorrhage, 41
difficulties connected with, in early experiments, 11, 12
effect of transfusion on, 42
Coagulation, mechanism of production of, 119
outside the body, 118, 119
prevention of, 114, 120
Clotting, prevention of, by sodium citrate, 119, 120
prevention of, during transfusion, 109, 110, 112
transfusion simplified by prevention of, 119
Coagulation time, anaphylactic shock influencing, 45
effect of transfusion on, 46, 47
hæmorrhage in relation to, 44, 45
in jaundice, 44
prolongation of, 44
Coal-gas poisoning, transfusion treatment of, 64
Coga, Arthur, 8
Cold, predisposing to shock, 29, 30
Cox, Thomas, transfusion experiments by, 3
Crile, improvement in technique of transfusion by, 15
method of direct transfusion, 109
Curtis and David, improvements in technique of transfusion by, 16
Daniel, of Leipsic, 3
Darwin, Erasmus, 9
Death, loss of blood causing, 24
Denys, John, first human transfusion performed by, 3, 5, 6
Diabetes mellitus, transfusion in, 66
Diphtheria, 60
acute toxæmia in, 60
experimental transfusion in, 60, 61
Direct transfusion, apparatus for, 109, 110
methods, 108, 109, 110
objections to, 110, 111
technique of, 108-111
Disease, relation between blood groups and, 81, 93
transmission by blood transfusion, 68
Drysdale, Dr. J. H., 52
Duodenal ulcer, severe hæmorrhage from, transfusion treatment, 41
Eclampsia, “fœtal threat” in relation to, 85
transfusion treatment, 62
Ectopic gestation, rupture of, transfusion following, 42
Elsberg and Bernheim’s method of direct transfusion, 109
Emboli, multiple, 77
Endocarditis, transfusion for, 60
Ether, shock accentuated by administration of, 31
Fever, transfusion for, 9
Fluids, administration of, during shock, 34
“Fœtal threat,” 85
Folli, Francesco, supposed blood transfusion by (1654), 2
Fontanelle, use of, 135, 136
Forced fluids, 34
Fullerton’s method of direct transfusion, 110
Gametes, segregation of, 88
Gastric ulcer, severe hæmorrhage from, transfusion treatment, 41
Grafts, tissue, 80
Gum transfusion, 35, 36, 37
and blood transfusion, relative value of, 35, 37
objections to, 36
Gurye, Gaspar de, 6
Hæmatemesis, treatment of, 41
Hæmoglobin percentage, during shock and hæmorrhage, 39
Hæmoglobinuria, 6, 7, 70
as symptom of blood reaction, 76
following blood transfusion, 76
paroxysmal, blood condition in, 94
Hæmolysed blood, toxicity of, 77
Hæmolysins, 71
Hæmolysis, 94, 95
agglutination preceding, 70, 76
early reference to, 6
Hæmophilia, anæmia with, 48
anticoagulants in, 47
blood condition in, 45
sodium citrate administration in, 47, 48
transfusion treatment of, 45-48
Hæmophilics, coagulation time of blood of, 46, 47
transfusion beneficial to, 46
Hæmorrhage, 20
acute anæmia following, 20, 24
blood counts following, 39
blood-volume changes in, 24, 25, 27
Hæmorrhage, coagulation time in relation to, 44, 45
condition of blood following, 24, 27, 28, 39
danger of, 20, 23
effects of, how combated, 33
following gastric or duodenal ulcer, transfusion treatment, 41
general treatment of, 31, 33
gum treatment of, 35, 36
in new-born infants, transfusion treatment, 49
intraperitoneal, 42
limits of, 24
post-partum, transfusion treatment, 42
rapid, 23, 24
reflex compensation for, 99
reinfusion treatment of, 42
saline treatment of, 33
secondary, 40, 41
indications for transfusion in, 41
shock always associated with, 20, 26
shock and, clinical difference between, 38
signs and symptoms of, 38
transfusion treatment of, 20, 25, 31
effects of, how judged, 40
indications for, 40
traumatic, 40
Hæmorrhagic diseases, 44-50
Hæmostasis, blood transfusion producing, 42, 44, 45, 48
Harvey, William, his theory of the circulation, 2
Heart, dilatation of, 78
effect of loss of blood on, 23
Helmholtz, method of transfusion of infants, 135
Heredity, blood groups in relation to, 86, 87, 90, 91
Mendelian theory of, 86, 90
Higginson’s transfusion instrument, 13, 14
Hirudin, use of, 16
Histamine, 30
production of, 30
production of shock by, 30
Horse asthma, transmission of, 68
Howard’s method of transfusion of infants, 135
Hydrogen-ion concentration in the blood, 28, 31
shock in relation to, 28, 32
Hydrophobia, transfusion for, 9
Immunized blood, transfusion by, in pyogenic infections, 58
Incompatibility, symptoms of, 6, 75
Indirect transfusion, 111
Infants, blood groups in, 84, 92
compared with those of mothers, 86, 92
blood reactions in, 84, 90, 92
transfusion of, 48
conditions necessitating, 49, 134
dosage, 136
technique, 134-136
with maternal blood, 85, 92
withdrawal of blood from, 136
Influenzal pneumonia, transfusion for, 61
Innocent VIII, 2
Internal saphenous vein, injection of blood into, in infants, 135
Iso-agglutinins, 72, 79
distribution among animals, 79, 80
Iso-hæmolysins, 72, 79
in animals, artificial reproduction of, 96
Isotonic saline solution in treatment of shock, 34
Jaundice, 44
acholuric, transfusion in, 94
blood groups in patients with, 93
hæmorrhage following operation in cases of, 44
transfusion in cases of, 44
Joekes, Dr., 52, 57
Jugular vein, injection of blood into, 135
Keith, on blood volume changes, 24, 27
on shock and hæmorrhage, 32
Kimpton and Brown, improvements in technique of transfusion by, 16
Kimpton-Brown tube, whole blood transfusion with, technique, 114
King, Edmund, transfusion experiments by, 3, 4, 8
Lamb’s blood, early transfusions with, 5, 9, 15
Legitimacy, inheritance of blood groups in relation to, 92
Leukæmia, 50
blood groups in patients suffering from, 81
Lewisohn’s sodium citrate experiments, 16, 120, 122, 123
Longitudinal sinus, use of, 135
Lower, Richard, transfusion experiments by, 3, 8
Malaria, transmission by transfusion, 67, 68
Malignant disease, blood groups in patients suffering from, 81, 93
“Maternal threat,” 85, 92
Measles, blood injections in, 62
Median basilic vein, accessible for direct transfusion, 108
incision of, 130
puncture of, 126-128
Melæna neonatorum, transfusion for, technique, 134, 135
value of transfusion in, 48
Mendelian theory, 86, 90
of blood groups, 86, 87, 88, 90
Milk, injection of, 15
maternal, agglutinins in, 86
Muscle, damaged, production of histamine from, 30
Needle, for transfusion, 126
case of, 126
improved form of, 113
Nephritis, transfusion treatment of, 63
New-born infants, blood donors for, 49
blood reactions of, 84, 90, 92
hæmorrhagic disease of, 48, 49
transfusion of, 48
technique, 134-136
with maternal blood, 84, 85, 92
Nitrobenzol poisoning, transfusion treatment of, 65
Obstetrics, transfusion in, 42
Operations, shock following, 31
value of transfusion following, 32
Osmotic pressure, 36
significance of, 36
Oxygenation, imperfect, blood loss causing, 36
solutions increasing, 37
Oxyhæmoglobin, conversion into carboxyhæmoglobin in carbon monoxide
poisoning, 64
Pain, predisposing to shock, 29
Paraffin wax, coating of glass tube with, 114, 116
in prevention of clotting, 110, 114
Paroxysmal hæmoglobinuria, blood conditions in, 94
Pedigree of blood groups, 90
Pellagra, transfusion in cases of, 66
Pepys, Samuel, 7, 8, 9
Pernicious anæmia, 50
blood condition in, 93
blood count in, 51, 53-56
blood groups in patients with, 93
subcutaneous blood injections in, 58
transfusion treatment of, 50-58, 95
complications of, 57
cases illustrating, 53-55
choice of blood donor, 56, 57
dosage, 52
reactions following, 57
Perspiration, blood loss due to, 28
Placenta prævia, transfusion following, 42
Pneumonia, transfusion in cases of, 61
Poisoning, transfusion treatment of, 64, 65
Post-operative shock, 31
Post-partum hæmorrhage, 42
Pregnancy, toxæmias, of “fœtal threat” in relation to, 85
transfusion treatment of, 62
“Professional” blood donor, 69, 98
Purpura, transfusion in cases of, 49, 50
Pyæmia, transfusion in cases of, 59
transfusion in, 58
Radial artery, accessible for direct transfusion, 109
exposure of, 111
objections to use of, 111
Reactions, 75, 76
following transfusions, 57, 122, 123
_see also_ Blood reactions
Reinfusion with patient’s own blood, 42, 43
Rejuvenation, 136
Replacement of blood, complete, 136
Respiratory system, effect of loss of blood on, 23
exhaustion of, 21
Robertson, Bruce, transfusion of infants and children by, 135, 136
Robertson, Oswald, transfusion with citrated blood by, 121, 124
“Robertson’s bottle,” 124, 125
Saline infusion, treatment of shock by, 33
Saphenous vein, internal use of, 130, 135
Sauerbruch’s method of direct transfusion, 108
Segregation of the gametes, 88
Septicæmia, transfusion for, 59, 136
Serum, _see_ Blood serum
Shock, 20
abdominal operations in relation to, 27
alkaline administration during, 34
anaphylactic, _see_ Anaphylactic shock
avoidance of, following hæmorrhage, 29
blood count during, 39
blood volume changes in, 24, 25, 27, 32
capillary system during, 27, 28, 29
causal theories of, 26, 27
conditions of the blood during, 24, 27, 28, 39
effects of, how combated, 33
experimental production of, 30
fluid administration during, 34
gum treatment of, 35, 36
hæmorrhage always associated with, 26
hæmorrhage and, differential diagnosis, 38, 39
hydrogen-ion concentration in relation to, 28, 32
low blood pressure the essential feature of, 27
mechanism of production of, 30
post-operative, 31
primary, 29
reinfusion treatment, 42
saline treatment of, 33
secondary, 29
conditions predisposing to, 29
signs and symptoms of, 26, 29, 38
theories regarding, 26
toxic theory of, 30
transfusion treatment of, 20, 26, 31
indications for, 40
Skin eruption, as symptoms of blood reaction, 76, 77
Sodium bicarbonate, in treatment of shock, 34
Sodium citrate, absorption and elimination of, 120
action of, 122
as an anticoagulant, 16, 121
coagulation time of the blood reduced by, 47
dosage, 121, 122
elimination of, 120
form in which used, 123
in hæmophilia, 47
in prevention of clotting, 119, 120
reactions following use of, 122, 123
tolerance to, 122
toxicity of, 77
Sodium phosphate, use of, 16
Solutions, for transfusion, essential constituents of, 36, 37
viscosity and osmotic pressure of, 36
Spinal anæsthesia, transfusion in conjunction with, 33
Splenic anæmia, 50
Stansfeld’s apparatus, 134
Staphylococcal septicæmia, blood transfusion in, 59, 60
Sterility and blood groups, 80
Streptococcal septicæmia, blood transfusion in, 136
Syphilis, transmission by blood transfusion, 68
Syringe, cleansing of, 114
Higginson’s, 13, 14
whole blood transfusion with, technique, 112-114
Tissue transplantation, success of, dependent upon compatibility of
blood groups, 80
Tissues, damage to, producing toxic substances, 30
Tourniquet, Canti’s, 126, 128
Toxæmia, 58-66
acute, in bacterial diseases, 60
blood transfusion in, 31, 58, 60, 61
of pregnancy, transfusion treatment of, 62
traumatic, 30-32
production of, 30
Toxic theory of shock, 30
Transfusion, apparatus for, 115, 126, 127, 130-133
in early experiments, 10, 13
recent improvements in, 15
continuous, 60
direct method, technique, 108-111
early objections to, 9
history of, 1
ideal method of, 124, 132
indirect method, technique, 111-112
of infants, 134
technique, 134
recent advances in knowledge and technique of, 15-17
repeated, 57
Robertson’s citrate method, 121, 124
apparatus for, 124, 134
whole blood, with syringes, technique, 112
with anticoagulants, technique, 118-134
with Kimpton-Brown tube, 114
Traumatic toxæmia, 30-32
Tuberculosis, transfusion in, 62
Twins, blood groups in, 92
Typhoid, transfusion in, 62
“Universal donors,” 72, 73
“Universal recipients,” 72
Urine, hæmoglobin in, 39, 70, 76
suppression of, 76, 77
Urticaria, following transfusion, 77
Uterus, rupture of, 42
Vaccine, injection of, into blood donors, 59, 60
Vaso-motor failure, in shock, 26
Vein, for direct transfusion, 108, 109
injection of blood into, 134, 135
insertion of cannula in, 131
occlusion of, prevention of, 109
puncture of, 113
technique, 126-128
prevention of injury to, 113, 124
Venesection, preceding transfusion, 60
in carbon monoxide poisoning, 65
Venospasm, 27
Venous circulation, condition during shock, 39
Viscosity, 36
significance of, 36
Vital red, use of, 23
War, transfusion in, 17
Water, during severe shock, 34
Whole blood transfusion, apparatus for, 114
objections to, 118
prevention of clotting, 114, 118
with Kimpton-Brown tube, technique, 114-118
with syringes, 112-114
Willis, Thomas, 3
“Wound shock,” 29
Wren, Sir Christopher, vein injections by, 2, 3
FOOTNOTES:
[1] The first reference to this that I can find is in “Moines et
Papes,” by Emile Gebhardt, _La Chronique Médicale_, November 1912.
[2] _Life and Times of Rodrigo Borgia_, A. H. Mathew, D.D., 1912,
p. 66.
[3] This refers to the experiment of Denys, mentioned above.
[4] Birch’s _History of the Royal Society_, 1756, ii. p. 216.
[5] The notation used here is that initiated by Moss in 1910. This
does not agree with the notation introduced three years previously by
Jansky, the Groups I and II of Moss corresponding to the Groups IV
and III of Jansky and _vice versa_. The difference has given rise to
confusion and some disasters, and it has been recently recommended
by an American Medical Committee that the notation of Jansky be
universally adopted on grounds of priority. This decision is no
doubt fully justified in American practice, but in this country the
notation of Moss has been so generally used that I have not attempted
to reverse it. The possible dangers that may arise should, however,
be realized.
[6] _Mendelism_, R. C. Punnett, 5th ed., Macmillan, 1919.
[7] J. A. Kolmer, _Infection, Immunity, and Specific Therapy_, ed.
2, Saunders Co., 1917, p. 287: “With the increasing number of blood
transfusions the phenomena of iso-agglutination and iso-hæmolysis
are of considerable practical importance, especially if the patient
is suffering from cancer, when the serum is likely to be actively
hæmolytic for the donor’s corpuscles.” No authority is given.
[8] This embodies the same principle as the “dropper” designed by R.
D. Laurie.
[9] A very convenient form of tourniquet is that designed by R. G.
Canti. It is sold by Messrs. Maw & Sons, and by Messrs. Allen &
Hanburys.