Disease viewed as a loss of balance

The "humoral theory" of disease, which originated with Hippocrates (who lived from about 460 to about 370 B.C.) and lasted until the early 20th century, held that a balance had to be maintained among four humors or liquid substances in the human body. If that balance got out of whack, the thinking was, people got sick.

The four humors were black bile, red or yellow bile, blood and phlegm. The ancients believed that these substances ruled our personalities as well as our bodies. They divided all the possible character types into these four — melancholic, choleric, sanguine and phlegmatic — depending on which substance dominated that particular person.

Treatments for disease were designed to restore the balance among the humors, but what worked for one person might not work for another, which helped let practitioners off the hook if a "cure" didn't work. Purges like enemas and emetics were popular, and physicians often advised changes to a patient's diet or routine. Blood-letting was an especially durable cure for just about anything.

During labor, for example, "some women were bled to unconsciousness to counter delivery pains" or any other complications large or small, according to Peter Conrad's The Sociology of Health and Illness.

The acceptance of the germ theory finally put an end to humoral theory in mainstream medical thought.

Bank on it

Bernard Fantus, the Hungarian-born physician who was the director of "therapeutics" at Cook County Hospital in Chicago, Ill., established the first "blood bank" in 1937.

Until then, a donor had to be on-site at the time of a blood transfusion.

Bernard Fantus

Bernard Fantus

Dr. Fantus also coined the term "blood bank," in an article in the Journal of the American Medical Association that year that set out the hospital's methodology in clear, understandable terms.

Other institutions swiftly developed their own blood-storage facilities, and helped themselves to Fantus's catchy term as well.

Cook County's blood-storage innovation came at a critical time, just a few years before the start of World War II, when blood donated by people thousands of miles from the battlefronts would make the difference between life and death for a great many injured Allied soldiers.

Going with the flow

Blood's ability to stop flowing — to clot — is a wondrous property that keeps us from bleeding to death after minor injuries. However, that trait was a major stumbling block to perfecting blood transfusions.

Even early in the 20th century, a few minutes into any transfusion, blood would begin to clump together in the tube that was carrying it from donor to recipient, and the technician would have to start over. Letting blood sit in a container for any length of time was out of the question.

Richard Lewisohn MD

Richard Lewisohn

A number of researchers were working on the problem. The Belgian physician Albert Hustin, and the Argentinian doctor Luis Agote, both hit on the anticoagulant properties of sodium citrate in 1914, but the bad news was that the common compound was toxic in blood.

Dr. Richard Lewisohn of New York's Mount Sinai Hospital solved that problem with exhaustive experiments.  The German-born Lewisohn, who had trained at the excellent University of Freiburg, discovered the concentration at which sodium citrate could keep blood liquid without poisoning the transfusion recipient.

At first, it looked as if sodium citrate had a worrisome set of side effects, but Lewisohn proved that those were caused by infectious agents in poorly cleaned equipment. In the end, he showed that a diluted sodium citrate concentrate in blood, deployed with meticuously maintained needles and tubes, worked just about perfectly. In fact, it is still used.

Once the medical profession accepted Lewisohn's elegant solution to the clotting conundrum — and that took years — blood transfusions were transformed from a traumatic undertaking to the routine procedure they are today.

In 1916, just in time for World War I, researchers determined that sodium citrate allowed blood to be stored outside the body for up to two weeks.

Alexis Carrel

In 1894, Marie Francois Sadi Carnot, the president of France, was stabbed by a would-be assassin in Lyons. By today's standards, the wound was not severe; however, the knife severed the portal vein in his abdomen. Carnot bled to death because up to that point, no one had figured out how to repair blood vessels.

Alexis Carrel
Alexis Carrel

One man undertook to change that, Alexis Carrel, a student in Lyons who was appalled by Carnot's death, in his hometown, while a number of physicians stood by and watched.

But consider the problem — repairing a tiny, elastic, living tube, part of a network of tubes of different sizes and functions, so that it would retain its ability to channel many gallons of blood every day, birth to death, without a hitch.

The story is that Carrel — Dr. Carrel by 1900 — studied with Marie-Anne Leroudier, one of the most proficient needlewomen in Lyons (her work was exhibited at the Columbian Exposition in Chicago in 1893), learning to make minute, uniform stitches. He developed a triangular system that allowed him to rapidly close up a vein or artery end-to-end without having the stitches adhere to the opposite wall, ushering in the birth of vascular surgery.

Carrel came to the University of Chicago in 1904, where his prodigious 21 months' work as an assistant to G. N. Stewart at the Hull Laboratory laid the groundwork for transplantation surgery. That work was the basis for Carrel's becoming the first scientist working in the United States to win the Nobel Prize for medicine, in 1912. Carrel soon moved on to the Rockefeller Institute for Medical Research in New York.

(Carrel's collaborator at the U. of C., Charles Claude Guthrie, was miffed that he was not included in the Nobel Prize. Guthrie possibly lost points with the Nobel committee for his subsequent experiments in St. Louis with head transplants.)

Carrel was a complicated man, compassion and curiosity mixed up with arrogance and resentment. He was a eugenicist — that is, he subscribed to the false science of "perfecting" the human race by eliminating traits judged to be inferior — and he was also an enthusiastic believer in the miracle cures at the shrine at Lourdes. At the time of his death in 1944, in Paris, he was working on a project for the collaborationist Vichy government.

Not your type?

The four basic blood groups or types, in order of frequency from most common to rarest, are O, A, B, and AB. Blood type is determined by "alleles," or possible types of a gene, that we inherit from our parents.

The different blood types reflect the possible combinations of protein molecules called antigens, which are found on the surface of the red blood cells, and antibodies, which are in the plasma.

Just as when a disease invades the body, antibodies in the blood will attack certain antigens. This means that not all human blood is compatible.

If someone were to be given a transfusion with blood that contains antibodies that are hostile to antigens in his own blood, for example, he might die from a reaction that causes red blood cells to "clump," clogging blood vessels, or to "crack," leaking hemoglobin into the body with toxic effects.

O-negative blood lacks antigens, so people with O-negative blood have been considered "universal donors," whose blood would work harmlessly in anyone's body. It turns out that even some O-negative blood can react with some rare blood types, so the concept of the "universal donor" is now a conditional one, even though O-negative blood will still be given in an emergency if a patient's blood type is not known.

Conversely, people with AB-positive blood in general can receive any type of blood because that type does not contain antibodies that attack the A or the B antigens. (Type O blood lacks those antigens.)

The "plus" and "minus" in blood types refers to a particular antigen called "the Rh factor." Anyone can receive blood without the Rh factor, but only people with the Rh factor can safely receive blood that contains it.

If a pregnant woman needs a blood transfusion during or after labor — rare but possible — she will receive only blood that is compatible with her own — ideally her own specific blood type.