THREE BLOOD TRANSFUSIONS OUT OF FOUI ARE MORE LIKELY TO HARM THAN TO HEAL
Shock, disease, even death can follow a blood transf usion that had only “cosmetic” value in the first place. This is an inside observer’s report on what one specialist calls “playing Russian roulette with a bottle of blood’’
DR. F. B. BOWMAN with Sidney Katz
BLOOD TRANSFUSIONS, as commonly used in medical practice today, do at least as much harm as good. Any blood transfusion involves risk, and in some cases, the risk is justified. But my own forty-five years of experience as a doctor convince me that three quarters of the almost 500,000 blood transfusions given in Canada each year are unnecessary — a needless and sometimes fatal risk to the patient.
Every blood transfusion is fraught with potential danger for two reasons. We haven't yet perfected a system of cross-matching the blood of the donor and the recipient; therefore, the recipient may suffer a serious shock to his system. Again, blood can transmit several known—and unknown—allergies
A DOCTOR OF 45 YEARS' STANDING BRINGS A GRAVE CHARGI
GAINST THE MAJORITY OF HOSPITALS AND PHYSICIANS:
and diseases, some of which may prove ultimately fatal to the recipient. Under these circumstances, to casually hand out blood transfusions willy-nilly, is, in the words of the American blood specialist. Dr. W. H. C rosby, “playing Russian roulette with a bottle of blood instead of a revolver.”
Many doctors share my view that giving blood transfusions has assumed the proportions of a fad. Dr. R. A. Zeitlin. director of the South London Transfusion Service, says that “pints of blood are dispensed more liberally than beer . . . ‘Cosmetic transfusions arc performed (i.e. those given only to bring a little color to the cheeks) more for the benefit of the relatives and the peace of mind of the doctor than for the patient.
Blood transfusions are causing a substantial number of deaths among hospital patients.” Dr. Bruce Chown, a Winnipeg pediatrician and blood specialist, after a special study of a group of women patients, observed: “At least half of the blood transfusions given were unnecessary. Blood has always had a mystical quality; its use in the operating room is more often mystical than scientific. I would hazard the guess that not 5 percent of the transfusions given to the women have been life-saving. And I would hazard the guess too, that at least as great a percentage have been death-dealing.” Dr. J. H. Drible, a University of London pathologist, says. “In the eighteenth century hundreds of people lost their lives from
having blood taken out of them needlessly; today, people are being killed by blood being put into them needlessly.”
Because of the risk involved, blood should only be given in cases of absolute necessity. Such cases would include the treatment or prevention of severe traumatic shock; the replacement of a heavy loss of blood; and use of blood to hasten the repair of severe surgical damage. Unfortunately, too many doctors don’t limit transfusions to these extreme medical emergencies. It can be said, with honesty, that they are “blood happy.” Not the least of the hazards in transfusion therapy arises from the difficulty of matching the blood of the donor to that of the recipient. If
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Blood from one donor caused headache, nausea, vomiting and pain in five out of six patients
incompatible blood is introduced into the blood stream, it can lead to a violent physical reaction, perhaps to death. To overcome this danger, a system of cross-matching has been developed. At the turn of the century, it became known that there were four principal blood groups — A, B, AB and O. It was assumed to be safe for people within these groups to exchange blood although unaccountable fatalities continued to occur. The chemistry of the blood is much more complex than this early classification assumed. Two additional blood groups, M and N, were later discovered and, in 1940, the Rh factor was identified.
The search for compatible blood and the problem of cross-matching has become more intricate with each fresh discovery. Dr. Brian Moore, director of the National Laboratory of the Red Cross Blood Transfusion Service, says, “The known blood group antigens (i.e. factors which produce a reaction) give rise to more than 3 million phenotypes.” Recently, one medical writer stated that “every individual — as in the case of fingerprints — has his own unique, individual type of blood and since no two people are exactly alike, you can’t, with impunity, transfuse blood no matter how carefully the matching is done.”
When foreign blood plasma is transfused into the body some of the immediate symptoms often observed are hives, chills and fever. But more alarming are the possible long term reactions. A few years ago, Dr. Robert Chown of Winnipeg, wrote a scries of articles for the Canadian Medical Association Journal, one of which was sharply headed. Transfusion of Girls and Women Can Kill their Babies. He listed a number of cases of women who had either lost their children or had suffered serious difficulty because of an incompatible Rh factor which had been introduced into their blood by transfusion. In some cases, the trouble took place as long as thirty years after the transfusion.
Another Winnipeg physician. Dr. Rhinehart Friesen, carefully studied the records of women who had been patients in three local hospitals. They had each received treatment after the loss of a stillborn child through induced or spontaneous abortion. The purpose of the study was to determine how many women had received blood transfusions. "It was surprising to find such a tremendous variation.” said Dr. Friesen. One hospital gave transfusions to only 12 percent of the women; the other two hospitals to 27 and 34 percent, respectively. Since treatment results in all three hospitals were equally successful. Dr. Friesen concluded, “blood was given too frequently at two of the hospitals.” He deplored this overuse of blood because of the danger of sensitizing the women to the Rh factor which, in turn, might affect their future offspring. "In our efforts to help our patient recover from an unsuccessful pregnancy we may completely destroy her chances of bearing a viable child in the future.”
We still don't know the full extent to which blood spreads disease. It has been definitely established that transfusions transmit the virus disease, hepatitis. Despite the careful screening of donors, it has been estimated that the virus hepatitis is present in one of every 200 bottles of blood. "No method has been found to eliminate the hazards of hepatitis following the use of blood," says Dr. Robert Unger in the New York State Journal of
Medicine. “While the majority of patients will recover within four months, an appreciable number will develop complications. The prevention of hepatitis remains an unsolved problem.”
What other diseases can be spread by blood? Malaria, measles, venereal diseases, typhus, mononucleosis, smallpox and encephalitis are listed in the medical literature. Dr. A. J. Shadman, a Massachusetts physician speculates, “If one is headed for diabetes, cancer or insanity, whatever eventually produce these diseases are in the blood first and remain there.” Recent medical studies lend some weight to this view. In the United States, a group of prison volunteers were transfused with the blood of schizophrenics. The volunteers soon after, for a temporary period, displayed symptoms of mental illness. At the last International Congress on Genetics, held
in Montreal, a paper was presented which established that a relationship exists between a person’s blood group and the kinds of diseases to which he is predisposed. Blood group A was 25 percent more likely to have stomach cancer than B, AB or O; there was a strong association between peptic ulcer and group O; there was a marked association between pernicious anemia and group A.
Although the spread of disease by blood transfusions can be sharply reduced by careful history-taking and physical examination of the donor, not all risks can be eliminated. A report in the American Medical Journal by Dr. D. M. Donahue and his colleagues, tells how five out of six people who had received blood from the same donor — an apparently healthy man — contracted an unidentified disease. It was characterized by headache, fever, nausea and vomiting. Painful symptoms in the joints developed one to five weeks later. “The transmissible agent was believed to be a virus,” says Dr. Donahue. “Because this agent survives under bloodbankinj conditions, and because it may be present in the blood of a healthy donor, it represents another potential hazard in the transfusion of blood.”
Allergies, one of the greatest current problems in the health field, may be further aggravated by the indiscriminate
use of blood. At the last Canadian Medical Association convention held in Montreal a few months ago. Dr. S. O. Freeman, a local allergist, presented proof that allergies can be transferred by transfusions. A non-allergic person, after receiving blood from a donor who is allergic to hay fever or other antigens, runs the risk of “catching” his donor’s allergies. Dr. Jacques Léger, another Montreal physician, suggested to the convention that in future, prospective blood donors should be asked if they suffer from hay fever and, if they do, should be rejected.
Considering the multitude of known and unknown hazards, one would expect doctors to be cautious and conservative in the use of blood. Unfortunately, such is not the case.
Too many transfusions are ordered for cosmetic reasons only. A doctor will walk through a hospital ward and casually order a "shot of blood” for a patient who appears to be a little pale, perhaps from the exertion of his first post-operative bowel movement, or for some equally trivial reason. The cosmetic transfusion almost always consists of a single dose of blood. Single transfusions have been repeatedly condemned. “If a patient ‘needs’ only one bottle of blood, he doesn't need any,” says Dr. Paul Weil, head of the blood transfusion service of the Royal Victoria Hospital, Montreal. “He needs either more than one or none. One bottle is too little to influence the outcome in the average adult.”
Too many transfusions are given as a matter of routine. Under such conditions, the individual need of the patient tends to be overlooked. In one U. S. cancer service, a hemoglobin level test is conducted on every patient, every week. Those who are 32% below normal receive one unit
of blood: those 36 percent below, two units of blood. “A stenographer types out the original request for the laboratory test,” says Dr. W. H. Crosby, an American blood specialist, “and. if the patient flunks the hemoglobin test, she routinely types out a transfusion request. This is a flagrant example of ‘the secretarial practice of medicine.’ ’’ It’s a safe bet. based on past studies, that the majority of transfusions thus ordered are unnecessary.
Some hospitals watch the patient’s hemoglobin level and pour blood into him the minute it dips a little under normal. The healthy adult will have about 15 grams of hemoglobin, but much of this is a reserve against strenuous exertion. For a sedentary life, 10 grams is enough; most bedfast patients are comfortable with as little as five or six.
Too much blood is used in surgery. The habit has arisen, in some places, of giving the patient a litre of blood the day before surgery. Dr. Crosby — as well as other authorities—score this practice. "A healthy adult can sustain the loss of one third of his blood without serious derangement,” he says. "Recently, during the delivery of a child, a woman lost 700 millilitres of blood. It is reasonable to suppose that she could have sustained this loss without danger, without transfusion. However, she was given six transfusions. This seems unreasonable.” This opinion is supported by the experiences of Drs. Max Minuck and Ronald Lambie of the St. Boniface Hospital in Manitoba, with patients who belonged to Jehovah’s Witnesses — a sect which spurns the use of blood. A 29-yearold woman who had a breast tumor removed, lost 600 millilitres of blood and her hemoglobin dropped to 30 percent of normal. Yet she staged an uneventful recovery in two weeks. Instead of blood.
Jehovah’s Witnesses are transfused with glucose and saline solutions, a useful procedure which could be followed by other practitioners in many circumstances. It was a Scottish physician. Dr. Frank Riggall, who recently observed; “I’m always amazed to see blood given for ordinary operations. It seems quite all right to take a pint of blood from a donor and let him walk home, but wrong to lose a little blood during ordinary surgery. In nearly 17,500 admissions to the general hospital where I practise, we have not found it necessary to use transfusions more than a dozen times. Our mortality rate compares favorably with those of other hospitals.”
Blood is often administered when other forms of less hazardous therapy would be more appropriate. Anemia is a case in point. Most forms of anemia can best be treated by the use of iron, vitamin B 12, a high protein diet or amino acid infusions
given intravenously. Again, giving bloou to a man with a malignant disease may perk him up but he’s being deprived of the treatment he really needs. Prescribing blood under these circumstances, according to Dr. Virgil l.oeb of the Missouri State Medical Association, “adds up to superficial and improper medical care. Furthermore. the blood transfusion masks the real disease and often delays or makes accurate diagnosis impossible.”
The extent to which blood transfusions are wrongly prescribed was revealed by a report to the Michigan State Medical Society by Drs. William Umiker and Paul Hodgson of Ann Arbor. A review was made of 100 consecutive patients who received single transfusions, with the following results:
Ten of the patients (they were nonsurgical cases) were given single transfusions for the treatment of severe anemia, resulting chiefly from widespread cancer or infections of the urinary tract. Most of these transfusions didn’t alter the anemia appreciably and "probably should not have been given or should have been supplemented with additional transfusions.”
The remaining ninety patients (surgical cases) were given a single transfusion in connection with their operations. The Michigan doctors discovered that "in 38 percent of these cases there was no convincing indication for transfusion: and in 33 percent, insufficient blood was used.”
Despite the hazards involved, blood transfusion remains a unique medical tool and should not be abandoned. But, after fifty years of experience, our most conscientious and thoughtful physicians are urging caution and restraint in the use of transfusions, so that a bottle of blood will continue to be a lifcsaver, not “a loaded revolver." A
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