T H E AMERICAN JOURNAL OF CLINICAL PATHOLOGY
Vol. 35, No. 5, pp. 413-419
May, 1961
Copyright © 1961 by The Williams & Wilkins Co.
Printed in U.S.A.
TRANSFUSION OF POSTMORTEM HUMAN BLOOD
JACK KEVORKIAN, M.D., AND GLENN W. BYLSMA, M.D.
Department of Pathology, Pontiac General Hospital, Pontiac, Michigan
Nine months ago we first became aware
of a startling idea which led to the preliminary work recorded here. We were
surprised to learn that for 30 years Russian
medical men have been successfully transfusing cadaver blood as casually as we
dispense whole blood taken from living
donors.3 • 4 I t is a natural tendency merely to
shrug the matter off as something which
could never be performed or regarded as
worthwhile in our country (see addendum).
Because baseless rejection is unjustified, we
decided to investigate for ourselves. The
idea has an ostensible undercurrent of
repugnance which makes it difficult to view
objectively; but it also has obvious advantages. Before elucidating these pro and
con factors, we present 4 cases of our own
in which cadaver blood was transfused into
living human recipients.
METHOD
Mutilation of the neck is to be avoided
in handling corpses. We tried to follow the
procedure outlined by the Russians, and,
therefore, started the project by performing
femoral phlebotomy under aseptic surgical
conditions. Inasmuch as we were using
vacuum bottles, available at any donor
station, it seemed more reasonable to use
either the internal or external jugular vein
(preferably on the right because of direct
innominate drainage) as the site for simple
venipuncture. We now do this routinely.
The skin is prepared by cleaning with a
hexachlorophene solution and tapwater,
followed by application of 2 or 3 per cent
tincture of iodine.
Blood should be drawn within 6 hr. after
Received, July 11, 1960; revision received,
August 5; accepted for publication February 2,
1961.
Dr. Kevorkian was a fourth year resident in
Pathology at Pontiac General Hospital. Dr. Bylsma
is an Associate Pathologist at Pontiac General
Hospital.
413
death. Death must have been sudden and
rather unexpected in order to assure adequate natural fibrinolysis and a minimal
content of toxic or therapeutic ingredients
in the blood. An autopsy must be performed in order to establish absence of
contagious or other potentially hazardous
disease.
The body is placed on a tilt table and the
head lowered so that the supine form
assumes an angle of at least 30 degrees.
Regulation pint vacuum bottles containing
anticoagulant acid citrate dextrose (ACD)
solution are used with sterile plastic tubes
with attached needles (blood collection set).
Flow should be smooth and steady if death
was very sudden and fast. Occasionally
death is more protracted and agonizing
than it seems, and the flow then often slows
down because small postmortem clots may
partially block the needle lumen. Slight
twisting or slow readjustment of the needle
within the vein usually re-establishes
adequate flow. Blood remaining in the
plastic collecting tube at the end of the
drawing is used for hemogram studies and
for bacterial culture. Other samples for
serology, cross matches, and pertinent
chemical analysis can be obtained at
necropsy.
R E P O R T O F CASES
Case 1
The donor was a 51-year-old white man
who died suddenly while mowing his lawn.
Three pints of blood were drawn from the
left external jugular vein, the last just 6
hr. after his collapse. Autopsy revealed
coronary occlusion with infarction. Donor
blood was group 0, Rh positive (CDE).
VDRL was negative; hemoglobin 18.1 Gm.
per 100 ml.; hematocrit reading, 53 per
cent; white cell count, 6350 per cu. mm.;
serum K, 13.6 mEq. per 1.; serum Na, 140
mEq. per 1.; glucose, 119 mg. per 100 ml.;
blood urea nitrogen, 34.3 mg. per 100 ml.;
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K E V O R K I A N AND BYLSMA
Vol. 35
cholesterol, 342 mg. per 100 ml. Blood mg. per 100 ml. Autopsy permission was not
granted.
culture was negative after 36 days.
The recipient was an 82-year-old white
Case 2
woman with severe arteriosclerotic encephalomalacia and mental aberrations,
The donor was a 44-year-old white man
uremia, and pancytopenia. Her blood was who, as a passenger in an automobile, was
group 0, Rh positive (cDE) and was killed in an accident. A penetrating wound
compatible with donor blood on cross was noted over the right zygoma which, at
match. Shortly after her admission to the autopsy, was continuous into the brain.
hospital the following determinations were One pint of blood was drawn 4 ^ hr. after
performed on the recipient's blood: VDRL, death from the left external jugular vein,
negative; hemoglobin 7.3 Gm. per 100 ml.; and another pint an hour later from the
hematocrit reading, 19.5 per cent; white right internal jugular vein. Each pint
cell count 2850 per cu. mm.; platelet count, yielded 470 ml. of packed cells after settling
84,000 per cu. mm.; reticulocyte count, for 11 days (a total of 940 ml. of packed
normal; serum K, 4.98 mEq. per 1.; serum cells from 2 pints).
Na, 139.5 mEq. per 1.; serum CI, 111.8
Donor blood was group O, Rh negative
mEq. per 1.; urea nitrogen 70 mg. per (cde). VDRL was negative; hemoglobin,
100 ml.
20.4 Gm. per 100 ml.; hematocrit reading,
Urinalysis revealed a specific gravity of 58 per cent; white cell count, 11,800 per cu.
1.016, mild albuminuria (25 mg. per 100 mm.; serum K, 13 mEq. per 1.; serum Na,
ml.), and 25 to 30 red and 10 white blood 145 mEq. per 1.; serum CI, 93.2 mEq. per
1.; thymol turbidity, 2.45 Maclagan units;
cells per high power field.
One pint of cadaver blood was transfused heterophile agglutination, negative. Blood
slowly a few hours after admission. There culture was negative until the blood was
was no reaction. The patient's hemoglobin used (11 days after drawing), and 2 interrose to 7.75 Gm. per 100 ml., red cell count vening subcultures to blood agar were also
'
to 2.8 million per cu. mm., and her hema- negative.
tocrit reading to 22 per cent.
The recipient was a 78-year-old white man
A second pint of cadaver blood was given with arteriosclerotic heart disease and
the next morning, again without reaction. congestive failure. Carcinoma of the cecum
A blood culture drawn from the recipient or appendicial abscess was also suspected.
shortly afterward was negative for 19 days His rectal temperature was 103.8 F. The
recipient's blood was group 0, Rh positive
and was then discarded.
The third pint of cadaver blood (250 ml. (cDe); hemoglobin on admission, 6.3 Gm.
packed cell volume) was administered 1 day per 100 ml.; hematocrit reading, 23 per
after the second pint. The patient had had a cent; red cell count, 3 million per cu. mm.;
fever of 100 to 101 F. (rectal) for 2 days white cell count, 13,000 per cu. mm. (96
which spiked to 104.6 F. several hours after per cent polymorphonuclear leukocytes);
the last packed cell transfusion. Urine from VDRL, negative; serum K, 3.8 mEq. per
an indwelling Foley catheter remained 1.; serum Na, 140 mEq. per 1.; nonprotein
clear amber, and her supernatant blood nitrogen, 65 mg. per 100 ml.
serum also remained clear. The following
There were 25 red cells and 50 white cells
determinations were performed 2 days later per high power field in the urine. This
(immediately before the recipient's death): microscopic hematuria was again detected
hemoglobin, 10.7 Gm. per 100 ml.; hema- 2 days later, at which time the recipient's
tocrit reading, 29 per cent; red cell count, hemoglobin was 6.6 Gm. per 100 ml.;
2.73 million per cu. mm.; serum K, 4.32 hematocrit reading, 23 per cent; red cell
mEq. per 1.; serum Na, 147 mEq. per 1.; count, 2.4 million per cu. mm.; and nonserum CI, 125.6 mEq. per 1.; blood urea protein nitrogen 117 mg. per 100 ml.
nitrogen 162 mg. per 100 ml.; blood sugar
Three days later (5 days after admission)
206 mg. per 100 ml.; serum cholesterol, 114 he received 470 ml. of packed cadaver cells
May 1961
T R A N S F U S I O N O F POSTMORTEM
without reaction. Rectal temperature was
101.2 F. Ten hours later his hemoglobin
was 7.3 Gm. per 100 ml., hematocrit reading,
26 per cent.
The next day he was given the other unit
of packed cadaver cells (470 ml.). There
was no reaction; rectal temperature remained stable at 100 F. Nine hours later
the recipient's hemoglobin level was 9.7
Gm. per 100 ml. with a hematocrit reading
of 32 per cent. Supernatant serum remained
clear. Three days later, his hemoglobin level
was 9.15 Gm. per 100 ml.
The recipient died 8 days after transfusion
of the last unit of packed cells. Autopsy was
not permitted.
Case 3
The donor was a 46-year-old white man
who was dead on arrival at the emergency
room. One full pint of blood was drawn
from the right internal jugular vein 5 ^
hr. after death. Much clotted blood was
observed within large vessels at autopsy 6
hr. later. Death was owing to coronary
occlusion with very early infarction.
Donor blood was group A, Rh negative,
(cde). VDRL was negative; hemoglobin,
20.4 Gm. per 100 ml. with a hematocrit
reading of 60 per cent; white cell count
12,600 per cu. mm.; serum K, 24 mEq.
per 1.; serum Na, 151 mEq. per 1.; serum
CI, 101 mEq. per 1.; blood sugar, 227 mg.
per 100 ml.; urea nitrogen 14.7 mg. per
100 ml.; cholesterol, 350 mg. per 100 ml.
Blood culture was negative for 19 days
(at which time the blood was used), and 3
previous subcultures were negative.
The recipient was a 56-year-old white
woman with severe nutritional and iron
deficiency anemia and carcinoma of the
cecum with metastases. She was having
frequent loose tarry stools, estimated to
contain from 100 ml. to 200 ml. of whole
blood per day. The patient was alert,
cheerful, and ambulatory.
Her blood was of group A, Rh positive
(cDe). VDRL was negative; hemoglobin on
admission was 8.4 Gm. per 100 ml., with a
hematocrit reading of 26 per cent; white
cell count was 7750 per cu. mm. Urinalysis
revealed innumerable red cells per high
power field, but no gross hematuria.
415
BLOOD
She received 1000 ml. of conventional
bank blood on the day of admission, and
another unit of conventional blood the
next day. On the following day (2 days
after admission) her hemoglobin level was
10.9 Gm. per 100 ml. with a hematocrit
reading of 36 per cent.
Two days later she received a single
unit of cadaver blood without reaction. On
the following day her hemoglobin level was
11.9 Gm. per 100 ml. with a hematocrit
reading of 37 per cent. There was no evidence
of fresh hemolysis in her serum.
The patient was discharged the next
day feeling quite well.
Case 4The donor was a small, eumorphic, 12year-old white boy, 56 in. tall, who drowned.
He was submerged for about 12 min. and
was dead on arrival at the emergency room.
All resuscitative efforts were fruitless,
including an injection of intracardiac
epinephrine. At autopsy the esophagus was
observed to be full of lake water, but there
was very little in the stomach. Lungs were
well expanded without evidence of edema
or water.
Two full units of blood were drawn at
2 ^ and 3 hr. after death from the right
internal jugular vein using the method
described above. Blood was of group A,
Rh positive (CDe); VDRL, negative;
hemoglobin, 12.3 Gm. per 100 ml.; hematocrit reading, 40 per cent; white cell count,
8900 per cu. mm.; sugar, 198 mg. per
100 ml.; and blood urea nitrogen (BUN),
11.2 mg. per 100 ml. Blood culture taken at
the end of drawing manifested no growth in
2 weeks and no growth in subcultures to
blood agar at 10 and 14 days.
The recipient was a 41-year-old colored
woman who had a "strawberry sore" on
the buccal mucosa. Her hemoglobin at the
time of admission was 9.1 Gm. per 100 ml.
Biopsy of the lesion was performed. The
next day her hemoglobin was 8.2 Gm. per
100 ml.; and the hematocrit reading was
26 per cent. VDRL and urinalysis were
negative; nonprotein nitrogen (NPN) was
23 mg. per 100 ml. The recipient's blood was
group A, Rh positive (cDe). One pint of
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K E V O R K I A N A N D BYLSMA
cadaver blood was given (after 19 days of
storage). The patient was irritable and
crying while venipuncture was being performed. There was absolutely no reaction
during transfusion.
The next morning her hemoglobin was
9.7 Gm. per 100 ml.; hematocrit reading,
33 per cent. Later that morning, 250 ml. of
packed cadaver cells (from the second unit)
were given just prior to surgery for total
removal of the buccal lesion. Her hemoglobin rose to 11.0 Gm. per 100 ml. with a
hematocrit reading of 37 per cent. The
following day they were recorded at 10.6
Gm. per 100 ml. and 34 per cent, respectively. The patient's supernatant serum
remained completely free of evidence of
hemolysis after each transfusion. She
tolerated them well, is now alert, cheerful,
comfortable, and has been discharged.
COMMENTS
Because embalming is required before
burial in this country, and the procedure
involves removal of blood which is washed
down the drain, and especially because a
nonmutilating needle is used to remove blood
from the jugular vein, we feel justified in
stating that permission of next of kin is not
necessary if corpse blood is to be taken. At
any rate, in our opinion, it should never be
taken if autopsy is not assured, thereby
making concern over specific permission to
remove blood totally superfluous.
Physicians were notified of the source of
our blood. We believe that such notification
is not essential, because if the entire procedure of cadaver blood transfusion is
performed correctly, there is no need for
undue anxiety or precaution on the part of
any physician. It seems a matter of good
taste and trust, nevertheless, to make the
patient's physician aware of the source.
Routine consent from the recipient is no
more necessary than in instances of conventional bank blood transfusions. The use
of cadaver blood is by no means an experimental procedure—having been widely
practiced in Russia for 30 years (see addendum) .
The relatively high potassium and NPN
content of cadaver blood might seem to be
Vol. 35
major disadvantages, but the somewhat
elevated sugar certainly is not detrimental.
Also, it would seem that cadaver erythrocytes might be more fragile owing to a few
hours of postmortem life within the vessels
of the dead organism, and that their functional capacity might be reduced or destroyed. Finally, by using such blood, one
might run the risk of introducing nebulous
or as yet undiscovered "toxins" into a
recipient's blood stream.
Most of these objections are more imaginary than real—a sort of emotional reaction
to a new and slightly distasteful idea. No
such "toxins" have been detected. Our 8
pints (on a short-term basis) and over
27,000 transfusions in Russia bear this out.
Not a single hint of a reaction or other ill
effect was observed by us personally on
very close clinical observation, despite the
fact that 2 of the patients were already
moribund and very toxic and none of the 4
had any anti-allergic therapy.
Supernatant serum of drawn blood
ranged from clear to evidence of mild
hemolysis in our series. Hemolysis occurred
chiefly in instances of repeatedly intermittent flow owing to tiny obstructing
clots, but it was never significantly more
conspicuous than the degree seen in some
instances of usual donor blood. In no
instance did the degree of hemolysis visibly
increase with storage. No evidence of
increased in vivo fragility was noted after
transfusion; the recipient's supernatant
serum remained clear, and the urine revealed no hemoglobin content.
The Russians claim to have demonstrated the persistence of red and white cell
functions in cadaver blood drawn in accordance with certain stipulations which we
followed. Chromium-51 isotope studies to
corroborate the Russians' claims and to
demonstrate adequate red cell survival
would perhaps be interesting.
Finally, stored blood of any kind, whether
from the corpse or the living, always has
an increased potassium and NPN content
owing to minimal continual cellular disintegration. In 2 instances the serum K
level was 13 mEq. per 1.; it was 24 mEq.
per 1. in the third. These determinations
May 1961
T R A N S F U S I O N O F POSTMORTEM BLOOD
were performed on blood taken at the time
of drawing or at necropsy shortly thereafter.
No determinations were made during
storage, but they will be performed as this
project continues. We believe that the
changes in K level of cadaver blood simulate
those in routine donor blood, which may
reach 30 mEq. per 1. after storage for 3
weeks, but which are also reversible.2 Once
transfused, the somewhat aberrant chemical
pattern is evidently soon remedied by
dilution and by the metabolic systems of
the recipient, even if he is in the dire agony
of approaching death, provided there is no
severe renal dysfunction.
Advantages are noteworthy. Cadaver
blood always raises the hemoglobin level
and hematocrit value of the recipient to a
degree comparable to that of conventional
bank blood. No reaction was noted in 4
patients receiving a total of 8 pints. A
single cross match will make available for
immediate use several pints of the same
blood for any individual patient; this
reduces the number of possible antigens
introduced into a patient requiring multiple
transfusions, and saves the technician's
time.
The blood is free—requiring no remuneration either on the part of the hospital or the
coroner—where an autopsy is routine in
instances of relatively sudden death. Such
blood would otherwise have been washed
down the drain and obviously have required
no replacement. The only financial consideration involved is the time of a special
technician (if any) and the cost of equipment used (bottles, bags, and tubes—all of
which are inexpensive). It is ideal for prolonging the life of "hopelessly" ill patients
or victims of emergencies requiring immediate massive amounts of blood. Although
carrier state can not be conclusively ruled
out, it is blood offering the least possible
chance for transmission of infectious hepatitis—"pure" in that one has detailed gross
and microscopic autopsy verification of the
donor's state of health and of each individual
organ. The technic of obtaining it is simple,
and it is stored and dispensed exactly as is
conventional donor blood.
CONCLUSIONS AND
417
RECOMMENDATIONS
1. Cadaver blood is perfectly suitable for
transfusion into living human donors. With
due precautions and with autopsy control,
the procedure is innocuous and beneficial.
It is a successful form of homotransplantation—no more objectionable than is the use
of cadaver corneas, skin, vessels, or bone,
and probably more often beneficial.
2. The blood should be drawn within 6
hr. after death. This may be performed in
the autopsy room, for only a simple venipuncture is necessary. It should be stored
according to United States blood banking
regulations and used within 21 days after
acquisition.
3. It should be drawn from a neck vein
(preferably the right internal jugular) with
the body in a head-down tilted position.
Because small postmortem clots may occasionally limit the total drawn, larger bore
needles might facilitate flow. We are now
in the process of testing these to improve
our yield.
4. Under proper clinical conditions,
cadaver blood is ideal for "hopelessly" ill
patients, for those requiring massive
emergency transfusions, for priming pump
and dialysis machines, for indigent patients
(the blood is qualitatively equal to conventional blood, but less expensive), and for
anyone requiring correction of anemia or
many sporadic transfusions who is willing
to take it.
5. Any cadaver blood program should be
under the direct supervision and control of
the pathologist who examines the corpse,
performs the autopsy, and supervises the
blood bank. He should lead an unofficial
"cadaver blood team" trained to perform
this task efficiently when the opportunity
arises. Such opportunities are infrequent,
and they could not be a major source for
blood banks, but larger centers may supply
excessive amounts of cadaver blood to
smaller hospitals where it can be used but
is not easily acquired.
6. Any apparently healthy person who
dies suddenly is a candidate for donation.
Complete autopsy must be assured. Ideal
instances involve closed injuries or internal
catastrophes, such as heart attacks, strokes,
418
K E V O R K I A N AND BYLSMA
drowning, suffocation, and even acute
alcoholic intoxication.3 Minor cuts and
occasional deep penetrating trauma are
not contraindications as long as there has
been no extensive hemorrhage.
7. It would be presumptuous to recommend widespread institution of this novel
procedure. Nevertheless we are now convinced of its merit and practicality, and are
indebted to the Russian investigators who
blazed the trail. From our limited experience, we know it can do no harm and that
it offers tremendous potential good which
warrants widespread and thorough investigation.
ADDENDUM
Shortly after submitting this paper, we
learned that approximately 35 pints of
cadaver blood were transfused in Chicago
in 1935 to 1936. Unfortunately the endeavor
was not recorded in the literature until this
year.1 The program at that time was regarded as a success, but was supplanted by
the newly begun live donor system.
SUMMAKIO I N
INTEBLINGUA
1. Sanguine ab cadaveres es preferctemente usabile in transfusiones ad in vive
recipientes human. Le procedimento es
innocue e benefic si executate con circumspection sub conditiones de necropsia surveliate. Illo es un forma successose de transplantation homologe e non es plus objectionabile que le uso de corneas, pelle, vasos, o
osso ab cadaveres. Illo es probabilemente
plus frequentemente benefic que le altere
mentionate transplantationes.
2. Le sanguine debe esser obtenite intra
sex horas pos' morte. Le labor pote esser
effectuate in le sala del necropsias, proque
non plus que un simple venepunctura es
requirite. Le sanguine debe esser magasinate
secundo le regulationes del statounitese
bancas de sanguine. Illo debe esser usate
intra 21 dies.
3. Le sanguine debe esser prendite ab un
vena del collo (preferibile-mente le vena
jugular dextero-interne) con le corpore in
postura inclinate, capite in basso. Viste que
micre coagulas de formation post morte
Vol. 85
reduce a vices le rendimento total, agulias de
calibre major es possibilemente a recommendar pro facilitar le fluxo. Currentemente
nos testa tales pro determinar le possibilitate
de un meliorate rendimento.
4. Sub appropriate conditiones clinic, le
sanguine de cadaveres es ideal pro patientes
qui es desperatemente malade, qui require
massive transfusiones de urgentia, e qui es
indigente (sed iste sanguine es qualitativemente equal a illo obtenite ab fontes conventional). Iste sanguine es etiam utile in le
preactivation de pumpas e dialysatores. De
facto, illo pote esser usate in non importa
qual patiente requirente le correction de
anemia o multiple transfusiones sporadic pro
altere rationes, providite que ille es preste
a acceptar lo.
5. Omne programma de utilisation de
sanguine de cadaveres debe esser placiate
sub le surveliantia directe del pathologo qui
examina le mortos, executa le necropsias, e
se occupa del banca de sanguine. Iste experto
debe esser le chef de un "team pro sanguine
de cadavere," con membros trainate a executar le requirite mesuras efficacemente quandocunque le opportunitate se presenta. Tal
opportuniatates es infrequente. Illos non
pote devenir un fonte major in le provision
del bancas de sanguine, sed le centres major
poterea sin dubita suppler lor excessos a
minor hospitales ubi illo pote esser usate sin
esser facile a obtener.
6. Omne apparentemente non-morbide
subjecto qui mori subitemente es un candidate pro le donation. Un complete necropsia debe esser assecurate. Casos ideal es
illos de injurias non-aperte o de catastrophes
interne como attaccos cardiac, syncopes,
necation, suffocation, e mesmo acute intoxication alcoholic. Minor incisiones e etiam
trauma a penetration profunde non es contraindicationes, providite que nulle extense
hemorrhagia ha occurrite.
7. II esserea un presumption voler recommendar le extense adoption de iste nove
methodo. Tamen, nos es nunc convincite de
su merito e de su practicalitate e es obligate
al investigatores russe qui ha preparate le via.
Super le base de nostre limitate experientia
nos sape que le methodo non pote esser
nocive sed que illo possede un tremende po-
May 1961
T R A N S F U S I O N O F POSTMORTEM BLOOD
tential de beneficientia que justifica extense
e detaliate investigationes.
Acknowledgments. Technical assistance was
provided by Miss B. Glaysher, Mr. E. Bea, Mr. S.
Meda, and Mr. H. Watkins. We are grateful to
those clinicians who cooperated on the wards, and
especially to Dr. John J. Marra, Director of Laboratories, for permitting us to perform this project and for encouragement during the work.
419
REFERENCES
1. FARMER, D . F . : Transfusions of cadaver blood.
A contribution to the history of blood transfusions. Bull. A.A.B.B., 13: 229-234, 1960.
2. MOLLISON, B. L.: Blood Transfusion in Clinical Medicine. Springfield, 111.: Charles C
Thomas, 1956, p. 23.
3. BETEOV, B. A.: Transfusion of cadaver blood.
Surgery, 46: 651-655, 1959.
4. YUDIN, S. S.: Transfusion of cadaver blood.
J. A. M. A., 106: 997-999, 1936.