History Matters July 14, 2023
Blood transfusions
In ancient Hebrew thought, blood was identical to the soul. In Leviticus 17:11, it states “The life of the flesh is in the blood.” Because the blood was the life, the ingestion of blood was prohibited. (Leviticus 7:26). Today, Jehovah Witnesses interpret this passage as the basis for refusing blood transfusions. In the ancient Hebrew world and among devout religious Jews today, this is the likely reason for kosher meats. With kosher meats, the blood of the animal is drawn off, and the meat is salted which prevents the blood from clotting, keeping it liquid and easier to wash off.
Perhaps for similar reasons, the Egyptians would take baths in blood for recuperation and rejuvenation. And Roman gladiators would drink the blood of their fallen adversaries to ac-quire their courage and strength. To take on blood or take in blood, was to take on the life of another.
This is the central act in Christian worship when the community becomes one in “commun-ion” called the Eucharist. The Church drinks the blood of Jesus, and therefore takes the life of God inside of them. Jesus speaks in The Bible and says, “My blood is real drink.” This was the only teaching of the church for the first 1500 years of its existence. One of
One can see the foreshadowing of a “blood transfusion” in the Greek myth where Ascele-pius learned to use the blood of a Gorgon to bring dead humans back to life. When Zeus found out that Ascelepius was robbing the underground of human residents, Zeus hit him with a thunderbolt.
Blood was the life of a living being and was connected with the elements of nature. The number four was the number of pillars required to hold up a structure. Nature was built upon fire, earth, water, and air which were manifested as heat, cold, moist, and dry. Hu-manity was built upon the four humors of blood, phlegm, black bile, and yellow bile which were also manifested as heat, cold, moist, and dry. These are still reflected in our adjec-tives: sanguine, phlegmatic, melancholic, and bilious. These were outlined by Hippocrates in 400 BC; and codified into medicine by Galen (129 AD - 216 AD). This humoral under-standing of blood was entrenched for the next 1400 years and formed the basis of “blood-letting” and “purging” to get out the “bad humors.” Even up until the 20th century, blood-letting and purging remained extremely popular.
There is a story that in 1492, Pope Innocent VIII was old and ailing. Three young boys in Rome were given the promise of gold coins in exchange for some of their young healthy blood to be administered to the Pope. Though the details of the procedure remain a histori-cal mystery, the Pope and the three boys all died in the process. The physician who per-formed this “transfusion” fled for his life.
In 1628, William Harvey published his On the Motion of the Heart and Blood and estab-lished that the heart was a pump that circulated blood around the body in a circuit. Rene Descartes used Harvey’s discovery to bolster his philosophical view that the body is a ma-chine. With this mechanistic view, blood was not soul-containing; but rather only a material substance that could be exchanged out like a part of a machine. William Harvey entertained the idea of giving medication by vein to “deliver” it to parts of the body instead of using the mouth and stomach. Egyptians had believed that food in the stomach turned into blood in the heart, and “fed” the philosophy of certain “hot” or “cold” foods producing certain emo-tional responses. Up until the 17th century, blood was only given by mouth.
In 1665, an English scientist, Lower, performed the first successful blood transfusion by arteries between two dogs. A French iconoclast, Jean Baptiste Denis replicated this proce-dure over 50 times among several dogs with 100% success. Dogs, like most animals, have only one blood type—unlike humans which have 4 different blood types with multiple anti-gens resulting in many combinations of human blood.
On June 15, 1667, Jean Baptiste Denis transfused a few ounces of blood from a lamb into a 15-year-old “debauched” boy. The boy had already been “bled” considerably as a “therapy” to release his bad “humors. Blood was still thought to carry the soul and character of the animal or being. A lamb’s blood was chosen specifically to transfuse because they were gentle creatures and the boy was a “lunatic”. It was believed the transfusion would make him as “gentle as a lamb.” To this day, no one is quite sure how this “sheep-to-man” transfu-sion “worked” (they are incompatible) but the boy survived.
The transfusions were not for anemia but rather for psychiatric mood disorders under the assumptions that the blood of calm animals could mollify the temperaments of persons with significant mental disturbances. In December of that same year (1667), Denis made two separate transfusions of calf blood into a French madman, and somewhat of a celebrity, Antoine Mauroy. Two weeks later, Mauroy died. He was actually poisoned with arsenic ( by his wife), but at the time, everyone thought he had been killed by the transfusion. Denis was charged with murder. While the court proved Mauroy was poisoned; the “court of pub-lic opinion” remained horrified by the idea of transfusion. This led to such negative public-ity that human transfusion would not be attempted again for another 150 years.
Transfusion’s road back came through the invention of the microscope which was used to identify different human blood types. While magnifying eyeglasses had been produced by monks, like Roger Bacon, as early as 1285; the compound microscope came onto the scene with Zacharias Janssen in 1595. The discovery of “cells” which were named after monastic cells (rooms in a monastery) did not happen till Robert Hooke in 1665. And Anton van Leeuwenhoek greatly advanced the microscopes’ magnification and clarity in 1674; and is given the title “Father of Microbiology.” Leeuwenhoek was the first to give a written de-scription of the red blood cell in a letter dated August 14, 1675; and made the first draw-ings of human red blood cells in July 7, 1700. By the beginning of the 19th century, blood transfusion was against the law in most of Europe.
The first physician to do human transfusions for blood loss, and not for psychiatric ail-ments, was a British obstetrician, James Blundell who transfused human blood in women with severe postpartum hemorrhaging in 1829 (used 4 ounces from a husband’s vein given immediately into wife’s vein.) He did this 10 times over a period of 5 years and had a 50% success rate.
In 1900, Dr. Karl Landsteiner, identified the four major blood types A, B, AB, and O. To this day, it is still a mystery why humans have different blood types. Dr. Landsteiner bears the title, “Father of Transfusion Medicine.” The clinical use of blood transfusions owes its success to American surgeon, Dr. George Crile who performed over 100 blood transfusions from 1905 -1909 for trauma victims with acute blood loss. He directly anastomosed a do-nor’s artery to the patient’s vein for up to an hour. He wrote major papers of “surgical shock”, invented the “mosquito” (Crile) forcep, advanced intra-operative opioid analgesia, and became the co-founder of the Cleveland Clinic.
Until 1893, blood transfusions were done directly only by surgeons. It was the knowledge that salt prevented clotting and when added with citrate de-calcified the blood so it could be stored and transfused by a non-surgeon. In March 1914, sodium citrated blood was transfused into a human. And preparations of stored red blood cells were used in WWI. By the second World War, human blood was stored in a citrate-glucose solution which further prolonged its shelf-life with integrity.
In 1937, Karl Landsteiner along with Alex Weiner identified Rh (Rhesus factor from Rhe-sus monkeys) making the blood type positive or negative. Today we have discovered over 33 major blood group systems that include things most people have never heard of ( Duffy, Kell, Diego, Kidd, MN, etc). The fact that any transfusions worked with any regularity prior to this Rh discovery is itself a miracle.
The scientific discoveries that changed the meaning of blood from a soul-bearing, charac-ter-carrying liquid to a biologic material that could be transfused from one human to an-other was a major philosophical and historical change. But myth and meaning are often in-separable from the materials of this world no matter how much time has passed.
In 1937, the first American blood bank was opened at Cook County Hospital in Chicago. Blood donated was now viewed as giving a “gift” from a patriotic community to the soldiers during World War II. Another major scientific advancement had been made concerning the separation of plasma from red blood cells which was discovered by a physician, Dr. Charles Drew, who was African American. Ironically, blood from patriotic African Americans who donated blood was refused. The reason given was that African Americans were not allowed to enlist, therefore their blood was not needed!
Foreshadowings of this interracial conflict first appeared in literature with a 1900 science-fiction story called Dr. Immortelle. In the story, a depraved physician transfuses himself with the blood of unwilling children in order to remain young (did he know about Pope In-nocent VIII?) The evil doctor has a reluctant servant who is a black slave who has turned caucasian after years of forced transfusions.
Despite scientific consensus at that time that Caucasian and African American blood was “the same”, the meaning of blood was still imbued with racial characteristics of the donor. Blood became “the cup” from which the civil rights movement would spill. In 1942, follow-ing Pearl Harbor, large numbers of Americans were encouraged to give their patriotic gift of blood to the war efforts; and again African Americans were refused. When it became publicized that America’s version of democracy for which it was fighting was the same as Hitler’s ideas of race; the Red Cross began accepting plasma from African Americans—though the stored plasma and blood remained “segregated.” It was not until 1950, that blood products would no longer be separated by race. It wasn’t banned in Louisiana till 1972.
The strange ironies of history are that while blood was “segregated” based upon racist ideas, that African American blood actually is different in some of the blood antigens we now know about. This is not unique to African Americans. Asians and other races have dif-ferent antigens. This is a difficult message to send today because of such racist baggage concerning the blood supply. But this is why African Americans with sickle-cell are encour-aged to receive blood transfusions from African-Americans to reduce transfusion reactions.
HIV and HCV epidemics were a step-back in blood transfusion progression. From 1978-1984, thousands of people in North America were infected from transfusions (before the development of the ELISA test). The majority of the hemophiliac population reliant upon transfusion of clotting factors became infected with HCV, HIV, or both. All of the scientific and public health efforts to create the idea that “blood is the same” and can be “a gift of life” was challenged but has made a slow steady comeback.
The most recent chapter in this story includes the increased awareness of transfusion reac-tions, the increasing caution in transfusing too early or too much, the relative lack of oxy-gen carrying capacity of “older stored blood”,—in short, the small but potential serious dangers of receiving blood. The most deadly of these immunologic complications are TRALI and TACO -major causes of death since 2004. This phenomenon is simultaneous with the decreased donation of blood by the general population. And this dilemma has in-creasingly fueled the ongoing technology surrounding pathogen reduction, blood substi-tutes, and IV iron infusions.