Philip Crispin
Australian Capital Territory

Dr. James Blundell (1790–1878) was the first to transfuse blood from one human to another, with variable success. At the forefront of transfusion, he also played a role too in understanding transfusion reactions. He completed his medical degree in Edinburgh, then trained under his uncle, Dr. Haighton, whom he later succeeded as chair of midwifery at St. Thomas’ and St. Guy’s Hospitals. He was a popular teacher, with his attention to detail and entertaining style attracting large numbers to his lectures.¹

Previous transfusions from animal to human had led to the practice being outlawed in France. After witnessing the death of young women with post-partum hemorrhage, Dr. Blundell hypothesized that restoring the blood volume could prove life saving. He conducted several animal experiments to establish the appropriate technique and designed a transfusion apparatus.² His experiments led him believe that small amounts of air would be tolerated and that transfusing between species would be potentially hazardous. He demonstrated that transfusion could resuscitate exsanguinating dogs, even for a short period after they had stopped breathing. He saw no serious reactions, but the human ABO blood group system is not seen in dogs.

Motivated by the success of the animal experiments and patient need, in 1818 Dr. Blundell proceeded to transfuse patients where the outlook appeared hopeless.^3,4 He reportedly performed ten transfusions, both successful and unsuccessful. Two had ceased to breathe by the time of transfusion and did not recover, leaving eight, of which five were successful. The donors included colleagues, the patients’ spouses, and occasionally blood relatives. Multiple donors were sometimes used, but not all donors are recorded.

Before the discovery by Landsteiner of the ABO blood system in 1901, transfusion carried a substantial risk of acute hemolytic transfusion reactions, which could be severe, even fatal. We now know that ABO incompatibility would be expected in about one third of random donor-recipient pairs, with a majority reacting.

John Soden,⁵ in summarizing the 37 reported cases of transfusion for obstetric hemorrhage in 1852, listed only one case which is now strongly suggestive of an acute transfusion reaction, and another death where the attending physician considered that transfusion may have contributed to the patient’s demise. The lower than expected numbers may have been good luck, or the difficulty in assigning causality in the bleeding patient, but perhaps not all cases were reported. Dr. Blundell reported no cases of reactions to blood, but in 1829 published insightful advice on managing transfusion:

In the progress of the operation watch the countenance; if the features are slightly convulsed, the flow of blood should be checked: and if the attack is severe, the operation is suspended altogether. On the other hand, so long as no spasmodic twitchings of the features or other alarming symptoms are observed, we may then proceed without fear.⁶

Modern clinicians receive similar warnings, paraphrased with greater physiologic detail, but in essence the same, to identify acute hemolytic transfusion reactions. In all probability, Dr. Blundell had experience with acute hemolytic transfusion reactions, despite a lack of such a description in his case reports. Blundell himself had discouraged further publication of transfusion cases until “a complete body of evidence on the subject has been obtained.” Others argued to the contrary, suggesting a need for expedited reporting of outcomes from the new procedure.⁷

If Blundell was accumulating evidence on the risks and benefits of transfusion thereafter, it was never made public. He left from St. Thomas’ and St. Guy’s in 1934 after a dispute with hospital management. He then maintained a private practice and collected books, especially in obstetrics and Greek classics. He remained a bachelor until he died aged 87.¹

Transfusions continued intermittently throughout the nineteenth century. Reactions remained an issue, so that when Landsteiner described blood groups from agglutination reactions in vitro, he immediately postulated they were the major cause of adverse clinical events.⁸ Despite repeated issues with immunological and infectious complications the study of clinical transfusion reactions, their incidence there remain unanswered questions in transfusion almost 200 years later.

References

1. Anonymous. (1878) Obituary. James Blundell. British Medical Journal 1:351-2.
2. Blundell, J. (1818) Experiments on Transfusion of Blood by the syringe.  Medico-Chirurgical Transactions 9: 56-92.
3. Blundell, J. (1819) Some Account of a Case of Obstinate Vomiting in Which an Attempt was Made to Prolong Life by the Injection of Blood Into the Veins.  Medico-Chirurgical Transactions 10: 296-311.
4. Blundell, J. (1824) Researches Physiological and Pathological Cox and Son, London.
5. Soden, J. (1852) A Case of Haemorrhage from Inversion of the Uterus in which the Operation of Transfusion was Successfully Performed, with Remarks on Employment of Transfusion Generally. Medico-Chirurgical Transactions 3: 413-35.
6. Blundell J. (1829) Observations on Transfusion of the Blood Lancet  11: 321-324.
7. Anonymous. (1826) Unsuccessful case of transfusion. Lancet 5:782.
8. Landsteiner, K. (1961) On agglutination phenomena in normal human blood. Transfusion  1:5-8 a translation of  Landsteiner, K (1901) Wien Klin Wochenschr. 14: 1132-1134.