ASH Oral History: Louis K. Diamond (4/7)
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Q: So the big chemical companies expressed an interest in the new indirect transfusion method.
Diamond: Oh yes. Some of them made up solutions and bottled them. They could test for pyrogens, you see, and do a better job than each hospital.
Q: Do you remember some of the names of the original chemical companies that entered in to this field?
Diamond: I'm trying to remember the big one in New York. I'll think of it eventually. It's still in existence -- it's the big chemical supply house in New York. They supplied most of the citrate for transfusions.
During the early part of the War when plasma was the only thing that could be shipped distances, the American Red Cross began to collect plasma from volunteer donors in Red Cross stations, in New York, Baltimore, Boston and elsewhere, for use in England. They collected about thirteen million units of plasma, which they shipped overseas in dried form. Not until late in the War did we begin shipping whole blood. Of course they built their own blood banks in England and France and elsewhere.
Now, people were interested in something other than sodium citrate, to try to preserve blood longer than one week. We did have blood banks mostly in hospitals that -- I set up a blood bank at the Children's Hospital, and also the Boston Lying-in Hospital, in 1936, 1937.
Q: Those would be among the earliest blood banks?
Diamond: Some of the earliest.
Q: Also I've seen accounts that during the Spanish Civil War there were attempts to construct mobile blood banks.
Diamond: Yes. They did, but there they used really small amounts of blood. They only used the equivalent of about a half a pint, something like 250, 300 ml. But they did set it up, and it did work very well.
Now, at about that time a Dr. P. Mollison in England, working with a physiologist named Lautit, developed a new solution. It was based on the work of Rous at the Rockefeller Institute. He proved that red cells could be preserved in a dilute solution of citrate and glucose--dextrose--for experimental use (not for transfusion--they were using it in animals), for anywhere from two to four weeks.
Q: So this was a case of researchers at Rockefeller interested in completely different problem--
Diamond: Coming up with this.
Q: An idea that could be used for transfusions.
Diamond: Right. Whether Dr. Mollison and his associate, Dr. Lautit, picked this up or developed it themselves, they decided that they could preserve blood in citrate with dextrose, in proper dilution, so as not to hemolyze the cells, and they proved that blood could be preserved for three weeks at least. They started blood banks in England for this purpose.
Q: This was after the war had already begun?
Diamond: Yes. Toward the end of the war.
Q: So in a very real way it was the war itself that gave the impetus to the blood transfusion--
Diamond: Blood transfusion was some of the big advances that the War made in therapeutics. Until then transfusion wasn't as commonly used, except in anemia. Here it was used for all sorts of injuries, and
saved thousands of lives.
Q: Before we go further into the topic of blood banks and transfusions, I wonder if we could back step a little bit, and if you could perhaps draw some parallels or contrasts between the type of work that was done under Florence Sabin at Rockefeller, the type of labs that were set up for hematological work in Boston, and the work that Nathan Rosenthal's had envisioned at Mount Sinai. In other words if we could discuss, perhaps, different styles and approaches to establishing labs.
Diamond: Yes. Well, Nathan Rosenthal's ideas for blood labs never materialized, unfortunately. But Dr. Sabin had set up this very good research laboratory working with animals. Her pupils, like Charles Doan at Ohio State University Medical School set up a hematology research laboratory there -- he was a research man as well as a clinician. Dr. Claude Faulkner set up the same in New York City at Cornell Various people felt that hematology was a neglected area of research, and ought to be investigated more completely.
Q: Would Dr. Sabin's work fit into the new push to introduce new types of technology and techniques in hematology, or the older morphologic approaches?
Diamond: She was mostly a morphologist. Her background was of interest in that she had been a technician at Johns Hopkins. She decided to get a PhD in research, because she was a good research person, and did go ahead with that. Then from there she did such good work that she received an appointment at the Rockefeller Institute in New York City. Her laboratory was just as separate from clinical application as you could have. There were very few cross contacts.
Q: Was Charles Doan also a PhD?
Diamond: No, I don't think he ever took a PhD. But he spent a year or two with Florence Sabin. Then he became the leading hematologist in the mid-west, and set up his organization at Ohio State University
Q: Did Florence Sabin have any contacts with Karl Landsteiner?
Diamond: None at all. She kept clear -- she wanted nothing to do with clinical application in her work.
Q: The blood-typing was seen as clinical.
Diamond: Landsteiner 's work on human blood groups wasn't used by clinicians for years! Here he discovered this and published it in 1901. Of course, it was a short paper in German. The clinicians even in Germany ignored him. Over here they ignored him completely! So that didn't become common knowledge until the 1920s. Attempts to transfusion patients were purely random, often without any cognizance of the difference of blood groups and the relatively high reaction rates that resulted.
Now, blood banks began to be established particularly during and after the War. We in Boston established a blood bank at the Children's, at Peter Bent Brigham. There, Dr. Carl Walter, a surgeon, was the leading blood transfusionist, and he developed his own system--the "Fenwal System".
Q: Could you describe this Fenwal system?
Diamond: It was a matter of having bottles of a certain size, just enough for a unit of blood, and careful washing, careful tubing and glassware that was fitted to this. You had the whole set -- donor's set -- to take blood into. Then citrates -- the proper amount of citrate in there. Then in storage, and then use it with properly washed equipment, properly washed rubber tubing and so on. So, the Fenwal system eventually was taken over by the Fenwal Company in Chicago. It's one of the big companies that makes all sorts of equipment.
Anyway, we established this blood bank system in several hospitals in Boston. The Beth Israel, the Boston Lying-in, and the Children's Hospital. I also helped establish a blood bank system at the Massachusetts Memorial, which is part of Boston University Medical School. So, that's what I was busy with at that time.
Then Dr. E.J. Cohn, the brilliant protein chemist, foresaw that we would need a blood bank system in this country after the War. He persuaded the Red Cross to use the established plasma banks they had set up in 15 or 20 different cities to collect plasma, for the British and for ourselves, for the War, to consider making blood banks out of them after the War. They were loath to do that, because it meant spending a lot of money. However, Basil O'Connor became head of the American National Red Cross, and through his influence with Franklin Roosevelt, whose law partner he had been, Basil O'Connor said, "Yes. We will help you establish blood banks through the Red Cross." They needed somebody to set up the technical side of it. At that time, Roosevelt's personal physician had been Admiral Ross McIntyre, the Surgeon General of the Navy. He was appointed vice-president of the American Red Cross. He didn't personally have any skill with blood banks, but he had set up a plasma program for the navy when he was Surgeon General. So, he turned to Cohn, who was advisor to the plasma program.
Q: Did he personally know Cohn before this?
Diamond: Of course, since Dr. Cohn was the head of the albumin, plasma, and gamma globulin programs that the Red Cross had undertaken.
Q: Tullis had mentioned -- perhaps it took place at a later date -- that Cohn was good friends with General George Marshall, who later became head of the National Red Cross.
Diamond: Ross McIntyre was appointed a vice-president of the Red Cross and put in charge of blood plasma, albumin, and whole blood programs. He needed somebody to help him set up Red Cross blood banks. In February of 1951, Cohn called me and he said, "You're going down to advise Dr. McIntyre how to set up blood banks in all these Red Cross units. We're going to have a Red Cross blood transfusion --
Q: This was 1931, or 1951? Was this before the American entry in to the War?
Diamond: Oh no! This was long after.
Q: This was after the War! Okay.
Diamond: The Red Cross had closed all its plasma collection units following the war. This was in about 1948. So he said, "Would you go down to Washington and help Ross McIntyre set up blood banks and get the first one started? Rochester, New York has signified that they're willing to reopen their plasma unit and collect blood."
Q: Why would there be this interest in the part of Cohn, after the War, to continue the blood bank?
Diamond: Because he had rescued so many people with his albumin, and all these fractionation methods. He foresaw that they would be using all these fractions of blood for multiple purposes. For example, Fraction I, Fibrinigen V -- the clotting fraction, for bleeding difficulties, and so on.
Anyway, Dr. Cohn sent me down. I arrived in Washington and went in to Red Cross headquarters on 17th Street. I was greeted like someone red carpets rolled out, and people waiting, special "Yes Dr. Diamond,"--"No Dr. Diamond." Dr. McIntyre said, "You're going to open this first blood bank. It's already to open up in Rochester, New York. The Red Cross has agreed, and they have a fellow in charge there. We want to standardize it so we can have the second one ready to open in Washington D.C. and elsewhere." He said, "We've persuaded the Red Cross to open 36 transfusion units in the next three years." I said, "That's impossible. They'd have to build blood banks, proper equipment, proper rooms; volunteers and paid help to do the bleeding, get doctors." And, it was absolutely important not to step on doctors' toes, to get the local medical society to support it. That had been one in Rochester ahead of time. There were a lot of local medical societies, as we later learned, who wanted nothing to do with it because they thought it would take away from of the work of the doctors who were transfusionists. They wanted blood banks, maybe, but not under the Red Cross! Each hospital wanted to do its own collecting. Local groups formed blood transfusion services. New York had a big blood transfusion service outside of the Red Cross!
Q: Did they set themselves up in conflict with, or in competition with the Red Cross?
Diamond: They wouldn't let the Red Cross come in. We had to get permission, as I found out, local medical society first -- the Red Cross, that didn't want to try to try to get volunteers for this and all the local doctors.
Q: What was the rationale for going with the Red Cross over these local organizations?
Diamond: The Red Cross already had set-up plasma, that they had learned to use. Sure, they had closed up most of them. But for example, in Rochester New York they reopened their plasma unit, and they built a blood bank in downtown where it was easy. They supplied blood to several local hospitals, to save the hospital from opening up its own blood.
Q: So in terms of efficiency, in terms of quality control-
Diamond: In terms of getting donors the Red Cross knew how to get donors. They'd gotten it for plasma. They had the names of thousands of plasma donors.
Q: What would be the argument of the doctors who opposed the Red Cross, if it was shown that it would save hospitals money and would be more efficient in getting donors?
Diamond: They wanted control of their own blood banks. They feared the Red Cross would decide how much blood to collect, where to collect, and so on. There were a lot of possible conflicts, so we had to get an agreement of the local medical societies in each place, and the state medical societies. Anyway I started working with Dr. McIntyre -- I was to be there a week just to get the Red Cross Rochester bank going and then Washington D.C. But on the third day I came in and there was my name on the door, saying, Chief of Blood Transfusion Service or something like that. I said, "Look! I have a job back in Boston. I can't do this!" They said, "Just a minute -- Dr. Cohn wants you on the phone." Dr. Cohn said, "I've talked to the Dean. You are relieved of all pediatric responsibility. You're staying in Washington D.C. and organizing the Red Cross Transfusion Services."
Q: Cohn could do things just like that? How did you feel about it?
Diamond: I said, "Look, I've got a wife and two children, and a home. I've got a pediatric service and blood bank. I can't leave there." He said, "Well, the Dean said you're leaving." So there was no question. He said, "If you wish I'll talk to the President of the University," I said, "No, no!" But I didn't move to Washington. I commuted every week. I went down on a Sunday night, arrived there Monday morning, went to my office at the Red Cross, and stayed in a hotel all week long, and then went home for weekends. Occasionally I'd have to go on a trip to open up a new blood bank and so on.
We projected 36 blood banks in three or four years. Dr. McIntyre, and even General Marshall, said, "That may be too many. You can't organize that fast. That's too much trouble for the Red Cross." However, we opened 35 by the end of three years, so, but I did a fair amount of traveling. Wherever we opened one I'd have to go make sure everything was going all right. Ross McIntyre couldn't have been a sweeter person to work with -- just as nice as they make them.
Q: In terms of the actual developments in blood work, especially coming from Cohn's fractionation methods, perhaps you could comment a bit on what that did in terms of ties that were developed between universities and pharmaceutical companies and supply companies.
Diamond: Right. Cohn refused to patent the fractionation method for albumin, gamma globulin, and all the other fractions in his own name. He did patent it in terms of Harvard University, with the understanding of the manufacturers. He told the manufacturers how to do this. That they would not pay a royalty but would send the material that they extracted from the blood to a control testing laboratory that he had as part of his set-up in Boston. So all the products were checked over in his laboratory, and he guaranteed that they were pure and that they came up to standard. The manufacturer paid Harvard for the testing. That's how he got a dividend without having to patent. The patent policy by medical schools was not new. For example, Wisconsin had a patent on VitaminD. Lederle had some patents on some medical, other vitamins, I think Vitamin E. At any rate, he didn't want to collect a royalty, he didn't want to hold a patent.
Q: There was a Bureau of Biologic Standards at that time. They did not have the facilities to do the quality control?
Q: Was this arrangement made between Cohn and this Bureau of Biologic Standards that he would have the right? It's almost like giving the power--
Diamond: Quite possibly. I don't know the background of that, but they certainly always sent men up to see how things should be done, and they called him a consultant, took his advice.
Q: Do you recall any of the pharmaceutical houses that entered in to these arrangements with Cohn at this time?
Diamond: There were several of them. That was another reason why he didn't want the patent to be given to one place; he wanted all the companies to be able to manufacture the products that he had devised, by the methods he had devised, as long as quality control was followed according to his directions.
Q: Tullis had mentioned that Cohn was a personal friend of George Marshall's, and had spent a fair amount of time junketing between Boston and Washington.
Diamond: Oh yes. He was an advisor to the Defense Department. He advised on things other than just plasma. As far as I know it was all high powered secret stuff, so we never knew what he was about. But he traveled to Washington quite frequently.
Q: What was the status of the Red Cross at that time? It wasn't a government body.
Diamond: Oh, it never has been. But, they had headquarters in Washington, the National Red Cross building on 17th Street, where all their offices were. They had a local Red Cross chapter, too. They depended on volunteers.
Q: The blood collected for the blood banks in the first place was in terms of war mobilization.
Diamond: The Red Cross had to collect money -- they collected large amounts of money. But it meant more volunteers. They had to get volunteers at all levels -- they built up very good donor services. But they had to pay for it -- they in turn charged the hospitals to whom they gave the blood very little over their basic costs. They had a donor list that the Red Cross had collected for plasma. In due time the Red Cross collected about three-quarters of a million units of blood per year. A rival organization, at the American Association of Blood Banks, which at first was completely antagonistic to the Red Cross, collected an equal amount. So that we were collecting, eventually, a million and a half units of blood per year.
Q: Could you say something about this antagonism between the American Red Cross and the American Association of Blood Banks?
Diamond: The Association of Blood Banks helped organize local community blood banks outside of hospitals, or as part of a hospital service. They had blood bank experts who wanted to continue being directors of blood banks, and not working under the Red Cross. I had a very difficult time persuading them. I eventually persuaded most of the Red Cross blood banks and local AABB to work together. But it took quite a few years.
Q: What sort of arguments did you have to use to try to get them to work together?
Diamond: I appealed to the doctors. I was accepted by doctors, mostly, as another practitioner -- I was not a Red Cross person. Primarily, I was a pediatrician. By that time, I had gotten interested in this erythroblastosis and transfusion business, so I was recognized as contributing to therapy of infants and children --infants particularly-- and therefore was not stigmatized as a blood banker only.
Anyway, we did get them to work together. In some places they're still antagonistic. But usually one or the other is taken over. Here, for instance, in San Francisco, the Irwin Memorial, which is under the local medical society. That's what I was able to arrange in many places -- get the local medical society to take over the direction of the local blood bank other than the Red Cross.
Q: How do you spell Irwin?
Diamond: I-R-W-I-N. That's one of the finest blood banks. I was here many times trying to persuade them to work with the Red Cross. They never let the Red Cross in, and it still isn't in.
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