Life in a Flask
Thousands of Canadians are doing their bit as donors to the nation's overseas "blood bank"
FOR THE first time in history, Britain's armies are equipped with blood banks which will give new life to soldiers who have spilled their own blood in battle. In Canada. Canadians who may not be able to join the active forces for service overseas, stand in cues to offer their blood to save the lives of men in uniform.
rile British war sector in France has its bhxxi stations, each with enough living bhxxi in Masks to give 1(X) transfusions. Even in British cities where air raids may be expected, similar bhxxi banks are scattered that they may reduce the toll of casualties. Because of this, men will live to return from this war and civilian casualties will survive, in spite of injuries that would have meant almost certain deatli in the last Great War.
It is hard to realize now that when war broke in 1914 even the crudest form of successful bhxxi transfusion was hardly known in general practice. It is the proud Ixiast of Canadian medical officers of the time, that they used transfusion almost from the start of the war, but it was 1916 before it was general in the British Army. Known methods of that time, however, were cumbersome; and success often depended on chance. Patient and donor had to be brought side by side so the bhxxi could be transferred by tube; otherwise the bkxxl would dot before it could be injected into the patient. Naturally, the patients needing bkxxl far outnumbered the available donors on the front line. Not only that, but human bkxxl is of different types, and, for the patient to survive, the bhxxi of the donor must be of a type corresponding to his own. Types of individuals remained unknown, in the last war, until emergency arose. Often there was not time then to test samples from the donor and recipient to assure projjer matching.
A veteran of the Great War tells of being in a dugout having some minor wounds dressed, when a sergeant was brought in unconscious from loss of bhxxi due to a wound in the thigh. The medical officer stopped the Mow but shook his head. Then, by chance, another man was brought in. knoc ked out by concussion but with no wound. The medical officer saw a slim chance, and took it.
He placed the two unconscious men side by side and transfused bhxxi from the concussion victim to the dying sergeant. Fortunately, the two bhxxls mixed, and the veteran reports: “Both men survived to return to England, and both rejoined their battalion a year later.” Nevertheless, the oix*ration was a big chance, not only for the sergeant for whom it was the only chance, but also for the concussion victim. Concussion is better understood today, and it is now known that it too, when severe, calls for transfusion of new bhxxi fluid.
The Spanish war showed that concussion is likely to be a far greater cause of disability in this war than in the last. Special concussion bombs were used in Sjuiin, and autopsies on the victims showed no visible injury. They died of shock, without hemorrhage. Shock without hemorrhage may be caused, not only by concussion, but also by fractures, burns, and wounds where there is little bleeding. It may also be due to emotional strain, as when a weakened person is sustained for a time by intense excitement, only to collapse when it is over. No wonder, then, that the treatment of shock is of major importance in modem war.
What reallv happens in such cases is that the circulating
system of the body is damaged. Blood Muid (but not the cells) seeps through the walls of the blood vessels into the surrounding tissue, and is no longer available for the heart to pump and circulate. If the victim of severe shock is to live, either new whole bhxxi must be transfused into his veins without delay, or new fluid must be added to carry the cells that remain there.
Temporary relief may be given shock victims by the injection of glucose or saline solution—but the effect lasts only alxmt twenty minutes. After that, this fluid also seeps into the tissue. Hardly good enough for front-line conditions.
As gcxxi a treatment as any would be the transfusion of whole bhxxi. But whole bhxxi is likely to be scarce in time of battle, even with modern storage facilities. It cannot lxkept more than a few weeks, and is seldom used after two weeks. There is no chance, therefore, of accumulating a big store behind the lines in quiet ix-riods in order that there may be ample supply in time of battle. What supply there is must be conserved for those who have lost much of their own bkxxl, cells as well as fluid, and for whom there is no other treatment. There is another equally effective treatment for shock—the injection of human bhxxi serum into the veins.
Civilian Blood For War Areas
GERIJM, unlike whole bhxxi, may be ^ stored indefinitely. It is to make serum to save tlie lives of shock victims, that Canadians have been donating their bhxxi by the cupful. The perishable whole bhxxi is being donated by ixxiple in Britain, from where it can be flown to France at frequent intervals.
The Canadian store of serum was begun by the University of Toronto, under Dr. C. 11. Best. More than 500 students volunteered their bhxxi to start it. Then the Canadian Red Cross added its appeal for donors. Since then whole parties of men from surrounding towns have come to Toronto to give their bhxxi. Old soldiers, many of them amputation cases, and young men who have failed to get into the Army, are doing their bit with this exclusive society of donors. Offers from women and boys, and from people in the United States, have been no less appreciated because they were not acceptable.
It is not that there is anything heroic about being a donor. It causes no pain, and probably takes no more time from Continued on page 47
Continued from page 10
business than going out for a cup of coffee would take. Some claim that it even makes them feel more lit, and this writer felt absolutely no after effect whatever. Nevertheless, it enables one to earn that feeling of satisfaction that comes from having performed a simple but very valuable service. It requires the serum from five donors to treat one patient.
Blood donated in Canada is reduced to serum by the extraction of the red and white blood cells. Evaporation of the water content reduces the volume of the serum to one third. It is then sealed in small bottles of fifty cubic centimetres each, is labelled as to blood type, and will keep indefinitely. Sent to France, it adds to the store of “life on a shelf.”
Because men are volunteering such donations in various parts of the Empire, doctors in the front-line dressing stations will not have to take such desperate chances as saved the life of that sergeant and endangered the life of the shock victim. Instead, they will have at hand, ready for immediate use, pure whole blood or serum, of known type and free from any possibility of disease contamination.
Such benefits are not only for war. It was the demands of civil emergencies that prodded science on to the perfection of modern transfusion methods. Accident victims, people suffering shock from various causes, people emerging from, or about to undergo, serious operations, those suffering from some blood-deficiency disease—all these and others faced the hospitals with urgent daily demands for blood transfusions. Yet, for more than 200 years prior to the start of this century, science tried in vain to find a safe, successful way to transfuse blood.
As early as 1660, a London physician named Lower passed blood from one dog to another. It is also on record that, at about the same time, Sir Christopher Wren, the great architect, made similar experiments. Seven years later, assisted by a colleague, Lower tried transfusing the blood of a sheep to a man. Then various doctors in England and France tried transfusions from one human to another.
Sometimes the operations were marvellously successful. More often, however, the new blood seemed only to hasten the death of the patient. The failures were so frequent and so baffling that the practice was apparently dropped until the beginning of this century.
About then an Austrian doctor named Landsteiner—now of Rockefeller Institute, New York—got curious about blood. He discovered that human blood was of different types, and that one type would not mix with another. He thus uncovered the secret of those early deaths, and of the few successes when the two bloods had happened to match.
It was not until 1907 that an American, Dr. Jansky, classified human blood into four distinct types, each widely different from the others. Dr. Jansky’s findings were confirmed three years later by another American, Dr. Moss, and the science of transfusion passed from the dark rough path of trial and error to the lighted hallway of scientific knowledge. In the light of these discoveries, it was only necessary to determine to which type the patient’s blood belonged, and to find a donor with blood of the same type, to assure a successful transfusion. Or the bloods could be tested by mixing samples of each and observing how they combined —a practice still followed at times to make sure there has been no error in typing.
Importance of Blood Grouping
T^IFFERENT blood types exist because ■*“' certain substances are not always present, or are not always in the same combination in the bloods of different
people. There are two substances that may be in blood— agglutinins and agglutinogens. Each substance is of two classes. A and B. Agglutinogens are in the red cells, while agglutinins are in the serum. Some people have only both agglutinins. Others have only both agglutinogens. Some have the A of one and the B of the other. Those are the four types. No one has both A’s or both B's, for when they get together they cause the red cells to clot or clymp, and death usually follows.
It is as if the substances were water, milk and lemon juice. Water and milk will mix. Water and lemon juice will mix. But mix the milk with the lemon juice and the mixture curdles.
So far had knowledge advanced when the Great War came and passed. Subsequently, strange side lights have been thrown on the grouping of blood types.
Groups are numbered according to their frequency of occurrence, and about fortyfive per cent of the people in this country type in group one, thirty-five per cent in group two, thirteen per cent in group three, and only seven per cent in group four. While it is true that blood from group two cannot be matched with group three, it is ix)ssible, where the emergency outweighs the risk of more or less unfavorable reaction, to match a donor from group one with a recipient from any of the other groups. The importance of this fact is emphasized by the announcement from Ottawa, last January, that “universal donors” would be scattered throughout the Canadian Army as a precautionary measure.
A technician of the Toronto Western Hospital reported that, of 2,6f)0 persons typed there, almost one half were classified as “universal.”
It is also true that recipients in that rare classification, group four, may, also in emergencies, receive blood from any of the other groups.
Brothers, sisters and parents are about as likely, and no more likely, to have the same type of blood as they are to have the same color of hair or other features. Nevertheless, bkx>d tests have been used frequently as an aid in cases of doubtful paternity. When a child has been lost or kidnapped, someone may turn up years later and claim to be the child. Again, small babies have been known to become mixed, and there is the problem of establishing to which parents a child belongs. In such cases it is not possible to establish definitely that a child is the offspring of certain parents. It may be proved, however. that it could not possibly be the child of certain parents. For example: parents, neither of whom has agglutinogens in the blood, cannot have a child whose blood shows that substance.
Interesting as such side lights may be, it was the constant and urgent demands of civil disabilities which, following the war, shaped the course of the science of bkxxl
By this time the giving of bk>od had become a profession. Hospitals kept lists of professional donors who would sell their blood for $25 to $50 a pint. It was easy money. So easy that hospitals had to keep special records to prevent any donor from selling blood faster than his body could make it. Each professional donor was typed and tested for purity of blood before he was registered, and called ujxm only when his particular type of bkxxl was required. Eventually there were so many registered donors in Toronto that the price dropped from the usual $25 to only $15 for a transfusion. It was a popular way for im]X>verished university students to earn money for tuition or entertainment, and a call for donors sent to the employment offices met with a ready, even grateful, response.
Voluntary donors were also used when of the right type. Relatives or sweet-
hearts offered their blood to save those dear to them. An atmosphere of romance and chivalry crept into the popular conception of sacrificing one’s lifeblood that it might give new life to another. Under such conditions, the very proximity into which the patient and donor had to be brought in order to transfer the blood by j tube sometimes led to dangerous emotional j complications. So science edged a step farther along the hallway of progress.
It was found that by adding a small amount of sodium citrate to the blood of the donor, clotting could be delayed long enough to permit keeping the donor and patient in different rooms. As a result, donors gave blood without knowing to whom it went, and people owed their lives to blood without knowing whence it came.
Early Attempts at Storage
VWTIEN, ABOUT ten years ago, a
’ * Ukrainian doctor announced to his medical institute that he had succeeded in transferring blood from a dead dog to a living one, members of the institute marvelled, but found neither the desire nor the need for trying the same experiment on humans.
In Moscow, however, there was a clever young surgeon, Dr. Serge Judine, who faced an acute problem. He had charge of an emergency hospital where accident cases frequently required transfusions on short notice. Many of them died because the necessary donors could not be obtained fast enough. To complicate matters, Soviet law forbade donors to sell their blood. Such a transaction was altogether too tainted with private gain to be in accord with Communist doctrine! So, for donors. Dr. Judine had to rely on relatives or friends of the injured, and such were seldom obtainable on short notice.
The experiment of the Ukrainian doctor stuck in Judine’s mind and directed his research. One day, shortly after one man had died in his surgery, a young engineer was brought in, dying from loss of blood. Dr. Judine threw caution to the winds. He risked his diploma and his reputation by transferring blood from the dead man to the engineer. But he saved a life.
Subsequently, he determined that blood left in a body dies in about ten hours. However, for some time now it had been regular practice to add sodium citrate to bkxxl, and so keep it from clotting while it was transported from room to room. Dr. Judine discovered that by adding sodium citrate he could keep the blood in bottles, alive and useful, for three weeks.
Some Canadian doctors must blush today if they chance to go back in the newspaper files to the comments they made when Judine’s success was first reported here, even though other less articulate Canadians were even then exploring a similar path.
Facts, however, persist. During the next two years various reputable American doctors returned from Russia with the story. In September, 1935, the Illinois Research Hospital announced experiments with ‘‘canned bkxxl” on dogs. In December of the same year the American Medical Association announced perfection of a method to “can” whole blood.
Then came the Spanish war. Dr. Norman Bethune, of Montreal, went to Spain and organized the first canned blood transfusion unit under actual war conditions. He successfully used refrigerated army trucks to carry “life in a flask” right onto the field of battle where it was most needed. In Madrid alone, in three months. 2,000 donors gave forty-five gallons of blood, and 193 transfusions were made.
Later, Dr. Bethune carried his mission to the Chinese war, and his death there from bkxxl poison was subsequently reported.
Advantages of a blcxxi bank in civil life were soon apparent—a supply of blood of all four types always on hand, day and night, for immediate use, no precious half hours lost in getting a professional donor, canned blood at the doctor’s hand, typed and tested to remove all possible hazard
of the transmission of disease. And a sharp drop in the usual donor’s fees of $15. $25. and up.
The Toronto Western Hospital seized on the idea and started one of the first blood banks in Canada. Not enough for all their requirements—they still use donors—but in a refrigerator, at a steady temperature of about thirty-five degrees, they have their flasks of life ready for any emergency. Authorities report that many recipients who receive blood from the hospital store but cannot pay for it. return when they have regained their health and repay their debt of blood to the “bank.”
“Sometimes we are repaid many times over in that way,” said one official.
More Canadians, in the meantime, were working to improve the science of blood. On the suggestion of Dr. C. H. Best, of Toronto University, Drs. A. F. Charles and D. A. Scott began a search for ways to purify a substance called heparin, extracted from liver. Heparin was known, as the result of experiments by William Howell of Johns Hopkins University in 1916, to be a powerful agent for the prevention of clotting of blood. Because of impurities, however, it caused violent toxic reactions.
At a cost of $30,000 these doctors succeeded in producing absolutely pure heparin, with greatly increased effectiveness, and which could be injected into humans and animals without any ill effects.
Heparin is now being manufactured in quantity from beef lung tissue, about 100 pounds of lung being required to make ten cubic centimetres of the precious substance. It has many valuable therapeutic qualities other than in the transfusion and preservation of blood. Were it not so expensive to manufacture, heparin would be particularly valuable in transfusions. The chemical, sodium citrate, used by Dr. Judine and commonly used in blood transfusions, alters the blood sufficiently to make it less useful to the patient. Heparin does not have that effect. However, the cost as yet outweighs the advantages for this purpose, so chemicals are still being used to preserve blood in storage.
So it is that man has learned and developed the secret of "life in a flask.” and because of it thousands of men who would otherwise die in the wars of today will live to share the fruits of their sacrifice.