measure of last resort, but the patient’s fever broke the next day, and although his blood count took longer to return to normal, he was discharged and returned to Europe in two months.
Thus was reported one of the earliest records of a blood transfusion in sub-Saharan Africa (excluding South Africa and Rhodesia). Whether it was in fact the first transfusion (likely not), this case reveals a number of things about the beginning of blood transfusion there. First, it was surprisingly early. It occurred in 1918, only fifteen years after the reports of the first successful transfusions in Europe and America that ushered in the era of modern use of a long–dreamed of therapy: giving the blood of one human to another. In fact, it was not until after the First World War that techniques were worked out that made the procedure viable for widespread use in Europe and America.6
Second, Lejeune showed that transfusion was feasible in the African setting. Admittedly, he was a European-trained doctor who treated a European patient, using blood drawn from another European. This reflected one of the main reasons noted by scholars for the beginning of tropical medicine: care for colonial interests, European settlers, administrative officials, and Africans employed in mining and other colonial enterprises. But with the exception of settler colonies, such as Kenya and Rhodesia, the number of Europeans in Africa was quite small. In the Congo Free State of Leopold II, there were around five hundred Europeans in 1901, and an estimated twenty-five to thirty doctors, mostly in the towns of Boma and Léopoldville. This number grew to fifty-nine doctors in 1910, not counting those employed by missionaries and private companies.7 So, to provide for the minimum health needs of relatively few Europeans, there was obviously a capacity to care for some Africans, even if that paled in comparison to what their numbers and disease burden required.8
By the end of the nineteenth century, the most important setting for the practice of modern biomedicine was a hospital. So where Lejeune did his transfusion was similar to others established by the new colonial governments in sub-Saharan Africa, usually in ports, colonial capitals, or areas of important economic activity, where significant numbers of Europeans were likely to be living. These hospitals were numerous enough in some parts of Africa by the First World War to establish many Western medical practices in the African colonies. There were government hospitals in British East Africa—in Entebbe, Mombasa, and Nairobi—within ten years of colonial rule, and by 1919 the Germans had established hospitals in Tabora, plus the Ocean Road and Sewa Haji facilities in Dar es Salaam.9 Although their benefits eventually reached the African populations, more or less, how much is not the point here. Rather it is that by 1918 the level of medical infrastructure and knowledge in sub-Saharan Africa was sufficient to practice blood transfusion.
To illustrate this point, consider that Lejeune used 500 cc of citrated blood, “from a healthy, solid European, with no apparent defects,” but he did not match blood types. Although test sera and a method to determine compatibility were greatly improved by war’s end such that results could be done in minutes, it is not surprising that Lejeune was unaware of this, given his very remote location.10 But even without test sera, there were procedures to guard against incompatibility that involved giving a small amount of blood to the patient at first, to see if there was an adverse reaction, before transfusing the remainder. This was crude but effective and justifiable if the life of a patient was at stake.11 In fact, this is exactly what Lejeune did in his 1918 transfusion. He reported giving an “anti-anaphylactic injection” of 5 cc of blood from the donor and waiting five minutes to see of there was a reaction before transfusing the rest of the blood. So Lejeune was aware of blood groups, their importance in transfusion, and a way to match blood, in effect in vivo.
In concluding remarks, obviously aimed at other doctors practicing in Africa, Lejeune pointed out the implications of his success: “All doctors in the Congo have seen patients die in this manner [complications from hemoglobinuria]. The successful results we obtained could be repeated in other cases of this type. . . . Transfusion is an operation that can be done anywhere. Blood was drawn by means of strong needles on a Dieulafoy syringe. . . . Transfusion is nothing more that an intravenous injection. I did it slowly (a quarter of an hour).”12
It is impossible to say with certainty when the first blood transfusion was made in Africa. It is a very large continent, the number of Western doctors was small, and the records of practice were quite varied. Reports published by doctors such as Lejeune were among the important sources describing the beginning of blood transfusion. Because it was an unusual practice at first, transfusion was likely deemed noteworthy by both doctors and medical journals that published accounts of their experience. Informative as these accounts may have been, they certainly did not record every transfusion, and in any case, once the novelty soon wore off, they would be of less interest. For example, neither Lejeune nor Trolli published again on transfusion, but it is likely that they practiced what Lejeune advocated in his 1921 article when they returned to the Congo in the 1920s. Both, in fact, served there for an extended period, with Trolli becoming chief medical officer of the colony in 1925 and Lejeune remaining in the Congo as a private physician in northern Katanga after finishing his government service.13
Other important sources of information were the routine medical services reports that became routine in African colonies by the 1920s. The standard forms for surgical interventions did not mention transfusion, however, until much later, when the procedure was more widely used. Generally, it was only after transfusion services were established by hospitals, usually beginning in the late 1940s, that medical reports provide a continuous record of transfusions.
There is nonetheless indirect evidence of transfusions before that time, such as the accounts of laboratory tests found in the annual medical reports. Hospital laboratories kept good records of examinations and analyses that had become part of hospital routines, and many included blood group tests in their annual reports, often well before the surgical reports began recording transfusions used in an operation or treatment. These blood group determinations could only have been for transfusion purposes, since paternity and forensic testing were almost unheard of in Africa at this time. In fact, these exceptions were duly noted when they were occasionally performed.14 Laboratory reports, therefore, provided a sustained, if indirect, record of blood transfusion beginning between the wars.
Starting with the example of Lejeune, plus the direct and indirect evidence in published articles and unpublished reports, it appears that the first transfusions were done in Africa at the beginning of the 1920s. This means that the conditions necessary for a transfusion—a patient in need, a donor, and a doctor with knowledge and means—existed at a relatively early time, even compared to the first transfusions in the world in the modern era, which began only in the decade before the First World War. The record also shows, however, that only after the Second World War were transfusions done widely and in large numbers in Africa. Understanding this timing requires further examination of questions about the setting in which the introduction of this lifesaving Western medical technique took place.
Blood Donation and the Uses of Transfusion in Africa
There were three broad conditions required for transfusions to take place in Africa or anywhere else: patients in need, a source of blood, and facilities with someone knowledgeable of a method to transfuse the blood. The first two of these conditions depended on Africans’ attitudes toward Western medicine, and more specifically whether they understood the need for transfusion and were willing to do something as unusual as donate and receive blood. Surprisingly, these were not the biggest hindrances or limiting influences on when blood transfusion began. To be sure, there was a natural reluctance to do something as unusual as allow blood to be taken from or introduced into one’s body; and there are numerous anecdotal examples and a few systematic studies of resistance to, as well as persistent racist observations about, the inability of Africans to understand Western medicine. For example, Meghan Vaughan has described the resistance of Africans in northern Nyasaland to smallpox eradication efforts in the 1930s. In addition to compulsory infliction of some pain, the measures also entailed, “the curtailment of movement, the segregation of villages, the banning of funerals and the burning of victims’ huts.”15
These examples were exceptions to the general and relatively quick acceptance by Africans when Western medicine became available. There was not only little resistance