Blood Transfusion in the Civil War Era

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Dr. Robert Slawson

Originally published in 2011 in the Surgeon’s Call, Volume 16, No. 2

The story of the history of blood transfusion and its subsidiary, parenteral infusion, must begin with the story of the discovery of the circulation of blood.  This process was not well understood by the ancients.  Blood was believed to be formed in the liver and travel to the heart where it was distributed to the body.  Galen believed that it moved from the right side of the heart to the left through invisible holes in the septum between the chambers of the heart.  It moved to the rest of the body through the veins.  Because the arteries were empty at death, it was felt by many that air moved through them to the parts of the body.  The role of the lungs was not appreciated.

William Harvey is generally considered the first to understand that pulmonary circulation was important and that all blood passed through the lungs.  His book, du Mortu Cordis, was published in 1628.1  He injected water into arteries and found that it passed through the veins and then to the right side of the heart.  The blood then moved through the pulmonary artery into the lungs and then to the left side of the heart. From there it was pumped into the aorta and the arteries, starting its journey all over again. Harvey did not describe the capillary connection between arteries and veins.   Harvey does, however, suggest injecting into the circulatory system as a means of administering medications.  He does credit an Italian, Realdo Colombo, with this discovery, but certainly Harvey popularized the concept in western European medicine.  Harvey may have seen Colombo’s work while studying in Padua.

Realdo Colombo published his work on pulmonary circulation in 1559 from the University of Padua in Italy.2  Colombo read the work of Andreas Vesalius stating that no holes existed in the cardiac septum and the blood could not pass right to left in this fashion.  He dissected many animals and humans and confirm to this.  In 1552 Michael Servetus had published his findings regarding the importance of pulmonary circulation although few were aware of this publication.3  Unfortunately Servetus’ description was published in a theological work in which he denied the existence of the Trinity.  Because of this argument, the Roman Church declared his works heretical and ordered all copies of the book destroyed.  By chance, three copies survived, although this was not recognized for many years.

The story becomes more convoluted when one finds that, as early as 1242, the great Arab physician known as Ibn al-Nafis4, 5 (full name Ala al-Din Abu al-Hasan AliIbn Abi al-Hazam al-Qarshi al-Dimashqui)  published the story of circulation, including the importance of the lungs. Western medicine was unaware of his account until 1924, when scholars discovered a copy of his book in a museum in Germany.  In any event, William Harvey is credited with the discovery of pulmonary circulation and it is his work that changed the concept of circulation in western medicine.  Harvey actually proposed that injection into the circulatory system would be a useful way to give medications.

The relationship between blood and life was well known to the ancients.  Many believed that the soul resided in the blood.  The book of Leviticus in the Hebrew bible has a statement “The life of the body is in the blood” (Leviticus 17:11).  Many ancient and aboriginal cultures drank blood, particularly from strong, courageous animals and men.6  It was felt that by drinking the blood, one could obtain the strength and courage of the individual.  In ancient Rome the blood of the gladiators was used for this purpose.  The practice was so prevalent that the Hebrew bible instructs believers to drain the blood from animals and eat only the meat.

Reports of the infusion of materials into the veins of animals and at least the concept of blood transfusion appear in the 1600s.6  In 1615, Andreas Libavius of Halle, Saxony, Germany, gave directions for the transfusion of blood between animals.  Although this was detailed, there is no evidence that he actually did such a transfusion.  Georg von Wahrendorff injected wine into the veins of hunting dogs as early as 1642 in Germany.  In 1664 Johann David Major in Germany infused medicines intravenously and suggested the transfusion of blood. (He had graduated from Padua a generation after Harvey.)

The most famous series of reports is of Christopher Wren in 1656 injecting wine into the vein of a dog using funnels and cannulas.  Wrenn injected many substances into the veins of dogs, including opium.  He observed that opium stupefied the dogs but did not kill them.  His apparatus was a quill attached to a small bladder.  Wrenn planned an injection into a man in 1657 but the man fainted and the experiment was discontinued.7 This work led to a flurry of reports in England, of which that of Richard Lower is the best known and documented.  He published Tractatus de Corde in 1669,8 reporting the first direct transfusion of blood between animals.   This was from the artery of a large dog to the jugular vein of a small dog.  The recipient was almost exsanguinated before the transfusion began and the amount of blood actually transfused is not precisely known.  The next day the small dog moved around normally.  Lower believed that blood could be transfused between species.  Lower would subsequently transfuse a small amount of sheep’s blood into man.  This idea of heterologous transfusion would, of course, be proved incorrect.  A large body of reports appeared in the 1660s and many different materials were infused into animals including alcohol, water, opium, and tartar emetic.  It was noted that opium narcotized dogs but threw cats into delirium.

Early transfusions were not given for blood loss as today but rather for personality problems.  It was believed that a person’s qualities were determined by his blood.  Transfusion was indicated for melancholy, lunacy, and arthritis.  The oxygen-carrying function of the blood had not yet been discovered.

The first man-to-man transfusion occurred in Paris, France, in 1667.  Jean-Baptiste Denis and his assistant, Mr. Emmerz, transfused four patients.6, 9-11  The first was a young man with an obscure fever.  The second was a healthy paid volunteer.  The third was a moribund patient whose death “may have been delayed.”  The fourth patient was a servant who was frequently a runaway and the purpose of the transfusion was to improve his behavior.  Some of his reported symptoms are now recognized as symptoms of transfusion reaction: pain in the muscles of the arm of injection, a rapid and irregular pulse, sweating, pain in the back, and black urine.12  A second transfusion resulted in death and a lawsuit entailed.  Denis was exonerated and the wife found guilty of poisoning him.  Nevertheless, The Faculty of Medicine declared a moratorium on this work and the action was followed by the Vatican and by the Royal Society of London.

It would be more than a century before the transfusion of blood in humans was revisited.  In the meantime several significant events had transpired.  Harvey, Lower, and Hooke had all noted that blood in the pulmonary veins was brighter than blood in the pulmonary arteries.  It appeared that the lung took something vital from the air.6  The dephlogisticated air of Priestley was discovered in 1774.13  Antoine Lavoisier called this air “oxygen” and described respiration as the combustion of oxygen.14  In 1773, Friend published works documenting the injection of many different materials.7  He also was the first to demonstrate the danger of injecting large volumes of air into the veins.

Michele Rosa and Antonio Scarpa in Italy noted that animals in severe shock could not be resuscitated by serum alone but needed whole blood.6  As added support, Marie-Francois-Xavier Beichet connected the carotid artery of one dog to the distal end of the carotid artery of another.  When the donor dog was suffocated so that its blood became dark, the recipient dog became unconscious.6   It is perhaps unfortunate that dogs were the primary animal used for blood transfusion research.  Dogs do not have major blood group antibodies as do humans so transfusion reactions are not seen.

It was noted that when nitrous and other neutral salts were added to blood, the blood became brighter.  This anti-coagulation effect was known among those who prepared food from the blood of cattle.  This was discussed by William Hewson in London as early as 1780.6  Blood was placed into a vessel containing common salt and agitated as it fell so that coagulation was prevented.  Blood kept fluid in this way by Glauber’s salt still could be coagulated by heat.  This anti-coagulation of blood allowed larger amounts to be transfused before it clotted.

The nineteenth century opened with a review of human blood transfusion and the intravenous administration of medications by Paul Scheel of Copenhagen.  James Blundell, an obstetrician in London, noted that some post-partum women went into shock with blood loss and died.  Because of this he revived an interest in transfusion.  In 1818 he published his first paper on experimental transfusion.  Blood was drawn from the femoral artery of one dog and injected into the femoral artery of another using a brass syringe, perfectly clean with no oil.  Blundell actually suggested transfusion only for hemorrhage endangering life.  He showed that severely bled dogs could be resuscitated by immediate homologous transfusion.  If blood flow and breathing had stopped, they could not be resuscitated.  He warned against heterologous transfusion between species.15  He apparently was the first to use human blood for human transfusion in 1824.  He reported five cases of whom two were dead at the time of transfusion and three who were moribund.  In 1829 the journal Lancet published his report of a successful transfusion.16  He subsequently transfused at least ten patients, five of whom lived.  Blundell drew the blood from the donor and infused it into the recipient using an intermediate funnel and plunger mechanism.  His transfusions were vein to vein, not to artery.

Transfusion with blood that would not clot became the rule and one third to one half of patients survived.  It had been previously emphasized that transfusion was a treatment of last resort for hemorrhage and this continued to be the maxim.  Blood now, when transfused, was being given to save a life because of blood loss, not to change the recipient’s personality.  No figures exist of the total number of patients transfused, successfully or not.  Little information exists regarding amounts of blood transfused but it was usually only a few ounces, at times only one syringe full.  More reports did appear about transfusion reactions, probably because more of the anti-coagulated blood could be given.  It would not be until 1901 that Karl Landsteiner would discover the ABO blood groups that were the major cause of transfusion reactions.10, 17, 18

Jean Louis Prévost and Jean Baptiste André Dumas reaffirmed that heterologous blood transfusion resulted in death for the recipient.  They found that death was not due to obstruction of the vessels and that uncoagulatable blood was as capable of resuscitation as was untreated blood. They defibrinated the blood by rapid agitation and removal of the froth.17  This practice would remain in use until the beginning of the twentieth century.  Francois Magendie found that, in heterologous transfusion, the red blood cells of the infused blood rapidly vanished.  Charles-Edouard Brown-Séquard in 1850 confirmed this.  He demonstrated that 15 minutes after the infusion, the red cells were readily discernible but one hour later none were to be found.19

Their work was known in America and here, too, some experiments with transfusion were performed.  Philip Syng Physic is said to have given human blood to a human as early as 1795.  This is based on second-hand information from the Philadelphia Journal of the Medical and Physical Sciences as a side-note on the publication of Blundell’s report in 1825.  Physic did not publish but the editor had been a student of Physic’s at the time.20  Dr. George McClellan is reported to have transfused during the cholera epidemic  in Philadelphia, Pennsylvania, in 1832.17, 20  Note that Dr. McClellan is the founder of Jefferson Medical College and, parenthetically, the father of General McClellan.   William Hammond, while an assistant surgeon with the army in Annapolis, Maryland, transfused up to 18 ounces of bullock blood to soldiers with cholera enroute to Mexico in 1849.20  The patients died.  Hammond would become the Union Army Surgeon General in 1862.  In 1859, Benedict from New Orleans, Louisiana, reported transfusing two and one-half ounces of blood to a patient with yellow fever with a successful result,17, 20 and Austin Flint, Jr. reported giving a patient seven ounces of blood in the same city in 1860 with the patient surviving another 24 hours.  On a different note, a Dr. D. Brainard in Chicago, Illinois, collected the blood lost during a leg amputation and revived his patient with a two ounce autotransfusion of the patient’s own blood in 1860.20  This was the first of this type of transfusion recorded.

Blood loss was a major cause of death during the Civil War, and although not commonly done, at least two transfusion attempts were made on active-duty wounded soldiers by Union surgeons and reported in the War Department’s Medical and Surgical History of the War of the Rebellion.20, 21  Surgeon E. Bentley reported a transfusion given to Private G. P. Cross at Grosvenor Branch Hospital, Arlington, Virginia, on August 15, 1864.  His leg injury occurred June 16 and he had lost so much blood that it was felt unsafe to operate.  By August 12 the wound was gangrenous and local treatment did not produce results.  Hemorrhage from the posterior tibial artery began on August 15, so amputation at the tubercle of the tibia was deemed necessary.  Blood loss was minimal but the patient did not rally so it was decided to try transfusion.  Blood was obtained from a healthy volunteer and a Tiemann’s syringe was used to inject two ounces of blood into the median basilica vein.  It is stated that the patient’s pulse  immediately became stronger and firmer.  He improved rapidly and by October 20 the stump had healed.  The patient was ultimately discharge, pensioned, and a Hudson’s artificial limb was supplied.  He survived until August 1867.  Cause of death is not stated.  Certainly the transfusion was a success but it is questionable whether such a small amount of blood could have accomplished this.  Perhaps he received more blood than realized.20-22

Assistant Surgeon B. E. Fryer at Brown Hospital in Louisville, Kentucky, operated on a Private J. Mott on July 24, 1864, about a month after his initial injury.  The ball had lodged between the tibia and fibula and had been removed, but 28 days later hemorrhage began from the site and a mid-thigh amputation was done to preserve his life.  The patient responded very slowly so the day after surgery it was decided to transfuse blood.  A gutta-percha syringe was fitted to a small tube with a stop-cock in its center.  The tube was placed into the cephalic vein of the patient.  The syringe was filled from a healthy man.  About sixteen ounces were given.  Initially respiration increased from 15 to 28 times a minute but soon returned to 16.  Pulse increased from 100 to 130 but soon returned to the initial value.  The patient did well, slept well, and retained food.  He appeared to be doing well for several days.  Unfortunately, nine days later hemorrhage began from the face of the wound, which was necrotic, and could not be stopped.  Although the patient died ten days after transfusion, the transfusion should be considered a success because death was due to further infection and subsequent hemorrhage not directly related to the transfusion.20-22

There is no indication that transfusion ever became regularly practiced during the war, either in military or civilian practice.  Only these two cases were identified by the writers of the Medical and Surgical History of the War of the Rebellion.  There would, however, be a gradual increase after the war both in the United States and in Europe with a small proportion surviving.  Of course it must be remembered that the procedure was still considered a last resort in moribund cases only.  Local infection at the site of injection was a problem, as was generalized blood-born infection.  Transfusion would not become generally accepted as a worthwhile procedure until after 1901 and the discovery of the blood antibodies in humans.18  Karl Landsteiner’s discovery of the ABO blood groups and the subsequent clarification of this began the more general use of blood transfusion by the medical community.

Sources

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