Edward Archibald's Notes on Blood Transfusion in War Surgery—A Commentary

The Industrial Revolutions of the 18th and 19th centuries had begun to harness the powers of energy and chemistry, helping to forge what its participants would call “the modern world.” Steam power had propelled them by ship and by rail to the ends of the earth, where they found materials and markets that fueled continued production (and national prestige) back home. By mid-century, they could communicate by telegraph; telephones began to allow still more direct connections soon thereafter. Chemistry had opened new pathways in industry and in daily life. Medicine had discovered the powers held by the microscopic over the macroscopic world—responding, in part, with antiseptic surgery and with an assortment of bacteriology laboratories throughout the world. At the dawn of the 20th century, automobiles were being produced, and airplanes were taking off. The possibilities of modern civilization were rooted in technology. And when, in 1914, the world fell in upon itself, modern technology helped produce an environment as damaging as anything nature might offer. The machine gun and the howitzer delivered a firepower that drove troops on the Western Front into the earth itself for cover. Trench warfare was the nightmare environment that modern civilization had made. It has been estimated that, stretched out and placed end to end, the trenches of World War I would have circled the world itself. Soldiers lived, fought, and died in trenches that stubbornly remained fixed in place for over 3 years, despite the sacrifice of their lives by the millions. They were exposed to the elements, often with insufficient water, food, and sleep, among rats and corpses and endless shelling. Rain and cold seemed to infuse themselves beneath living flesh and permanently into bone. Many suffered from “trench foot” or lost other appendages to the sepsis that so often followed wounding in the fertile soil. The torrential downpour of bullets and shells forced injured soldiers to remain where they had fallen for hours before being collected by stretcher-bearers. They then had to endure the jolting journey through the trenches and back through the various echelons of medical care before they came to the Casualty Clearing Station (CCS)—the heart of forward surgery. Hours, or even days, had passed since they had been injured, and they were bloody, muddy, and exhausted. Many, with apparently moderate wounds, collapsed and died. Ultimately, surgeons responded by resorting to a controversial procedure: they transfused blood. Blood transfusion had been attempted, first between animals, then from animals to humans, a few decades after William Harvey wrote his famous treatise demonstrating the circulation of the blood.1.Harvey W. De Motu Cordis et Sanguinis in Animalibus. 1628.Google Scholar The death of a patient after one such transfusion resulted in a general abandonment of the procedure—on humans at least—for 150 years. From 1818, James Blundell, a young British obstetrician (“accoucheur”) and physiologist, began transfusing patients, especially those dying from postpartum hemorrhage (“floodings”), with human blood.2.Blundell J. Experiments on the transfusion of blood by the syringe.Med-Chir Trans. 1818; 9: 56-92PubMed Google Scholar His occasional dramatic success resuscitating women who most doctors would have thought certain to die helped the novel procedure to find a small but steady number of practitioners over the next several decades. There was, of course, no knowledge of blood types, but, as the women were beyond medical hope anyway, failures were often ascribed to their conditions rather than to the transfused blood. They were also ascribed to clots. At the time, transfusion was a complicated operative procedure, in which 2 or 3 doctors worked to collect blood from the donor into a bowl, prepare the patient by dissecting out a vein, opening it, and inserting a canula through which they injected the blood—quickly, before it could clot. Blood was thought to have vital and nutritive properties necessary to the patient's survival. By the final quarter of the century, however, a more mechanical, quantitative conception of the body, guided by physiological procedures such as the measurement of blood pressure, led doctors to believe that blood was not necessary to treat hemorrhage. One needed only replace the lost volume of circulating fluid.3.Hunter W. Summary of three lectures on transfusion: its physiology, pathology and practice.Br Med J. 1889; (237–240, 305–309): 116-119Crossref PubMed Scopus (1) Google Scholar Saline solution would do. When Karl Landsteiner published his classic studies demonstrating human blood types in 1900–01,4.Landsteiner K. Ueber Agglutinationserscheinungen normalen menschlichen Blutes.Wiener Klin Wschr. 1901; 14: 1132-1134Google Scholar clinicians were no longer transfusing blood and, understandably, they ignored the work for some years. At about this same time, however, a physiologically inclined young surgeon practicing in Cleveland, OH, had come to doubt the efficacy of intravenous saline in the treatment of the “shock” that followed accidents, surgery, and severe blood loss in general. Experiments on dogs suggested that saline only worked to raise the blood pressure temporarily. Only blood itself seemed to raise it permanently. The surgeon, George Washington Crile, had the same trouble moving blood between bodies as had his medical forefathers: blood clotted. By 1903, however, he’d learned of a surgical procedure developed by French surgeon Alexis Carrel, in which the open ends of 2 blood vessels were triangulated by 3 sutures, then stitched together, creating a good approximation of a natural, whole vessel. Crile connected the artery of a donor to the vein of a patient in his first successful human transfusion (1906).5.Crile G. The technique of direct transfusion of blood.Ann Surg. 1907; 46: 329-332Crossref PubMed Google Scholar Surgeons at innovative American hospitals quickly took up the procedure. However, they tinkered with the technique, using paraffin to coat collecting tubes (the “Kimpton-Brown” method to which Archibald refers), multiple small syringes, and stopcocks, to preserve the blood's fluidity while simplifying its course between bodies. Donors still needed to be present in the operating room next to patients, but surgeons no longer needed to provide such a delicate connection between them to move blood. These surgeons also taught this exciting new procedure to their medical students. Blood transfusion rapidly found an appreciative audience in North America. Surgeon Edward W. Archibald helped bring transfusion to Montreal. Edward Archibald was born in 1872 in Montreal, where his father was a judge.6.Penfield W. Edward Archibald, 1872–1945.Can J Surg. 1958; 1: 167-174PubMed Google Scholar His university and medical education, as well as his subsequent surgical career, centered on McGill University and the Royal Victoria Hospital; these, however, were supplemented by substantial study in England, France, and Germany. He was particularly interested in head injuries and in cancer surgery. When the Great War started in 1914, Archibald was a lecturer in the department of surgery at McGill, assistant surgeon at the Children's Memorial Hospital, and surgical pathologist (in charge of the dispensary) at the Royal Victoria Hospital. Perhaps in preparation for war surgery, he visited George Crile in Cleveland to witness his surgical procedures that December. By June 1915, Major Archibald was in France, where he was assigned as a surgeon to the general hospital his university had set up. As early as autumn 1915, he was performing transfusions—mostly, far behind the front lines, for secondary hemorrhage. By the spring of 1916, he was transfusing closer to the fighting, as a temporary surgeon at a CCS. It was there that Archibald did the work that would form the most novel part of his 1916 paper. At the CCSs, surgeons were being confronted by a problem that most would seldom have faced in their peacetime practices: “shock.” Soldiers would arrive in relatively stable condition. Some had suffered severe hemorrhage, while others had lost little blood, but their wounds appeared survivable. Suddenly, and for no immediately apparent reason, their pulses would become rapid and thready, their blood pressure (increasingly but not consistently measured at that time) would plummet, their faces would become pale, and their bodies would be cold and clammy. Many would die of this mysterious condition. At the time, doctors considered the collapse without evident blood loss to be “pure” shock. Hemorrhage was seen further to complicate the condition. British surgeons, who had remained unaware of, or unconvinced by, American experiments with blood transfusion, continued to infuse these patients with saline solution. They had little success. Moreover, patients suffering from shock proved to be poor candidates for operations. Overwhelmed by the constant press of newly arrived and more treatable patients, surgeons tended to send shocked soldiers to “moribund wards,” where many died. It was in the summer of 1916, during the bloody Battle of the Somme, that Britain's shock problem became urgent. Saline did not work, patients in shock continued to die, and the number of healthy young reserves back home was dwindling. Something had to be done. In fact, something had been done: on a limited scale. While working as a CCS surgeon that spring, Archibald, too, had become aware of the pervasive shock problem. He, however, had arrived in France convinced that saline was at best a temporary measure and that a timely blood transfusion might in fact save patients suffering from shock “complicated” by hemorrhage. Transfusion at the base hospital level had been similar to transfusion back home: surgeons had time to do more elaborate procedures. Blood transfusion, despite its recent simplification, remained an elaborate procedure. It demanded the attention of 2 surgeons and a well-trained nursing staff, and it necessitated the donor's presence in the operating room. At the CCS, surgery was rushed and operating huts, crowded. Who would have time to transfuse blood? Yet, without transfusion, patients did not survive their stay at the CCS, let alone the journey back to the base hospital. Archibald therefore decided to bring a still newer transfusion technique to the war. In 1914 and 1915, researchers in 3 different countries independently concluded that sodium citrate, added to blood, would hinder its coagulation and not harm the patient.7.Agote L. Neuvo procedimiento para la transfusion del sangre.An Inst Modelo Clin Med. 1915; Google Scholar, 8.Hustin A. Principe d’une nouvelle méthode de transfusion muqueuse.J Méd Brux. 1914; 12: 436-439Google Scholar, 9.Lewisohn R. A new and greatly simplified method of blood transfusion.N Y Med Rec. 1915; 87: 141-142Google Scholar Archibald believed citrate transfusion to be “peculiarly suited for easy adoption in Army work.” Donors (volunteers from the staff or the lightly wounded) could be bled “by a junior medical officer with the instruments at hand in any clearing hospital.” This could even be done in a separate room. The surgeon could then perform the transfusion by himself, with blood at hand when he needed it. Further, he could use that blood without fear that clots would clog syringes or ruin whole paraffin-coated tubes full of blood. “Nothing could be more simple,” Archibald asserted. “One can deal with the blood as one would deal with saline.” By war's end, this assessment was generally held to be true. Citrate transfusion was not only an integral part of the resuscitation of patients in shock, but it was also an important component in the extension of blood transfusion itself. And Canadian Edward Archibald wrote the first paper extolling its potential battlefield value. He wrote up his experiences that April, sending an abbreviated version to The Lancet and a more detailed account to the Journal of the Royal Army Medical Corps.10.Archibald E. A note upon the employment of blood transfusion in war surgery.J R Army Med Corps. 1916; 27: 636-644Google Scholar The Lancet published the piece in September 1916, just as British doctors were coming to see saline's limitations at the Somme. Despite the timing, Archibald's article was then—and has continued to be—overlooked. Instead, an American surgeon not yet even present in France has been given credit for the wartime development of citrate transfusion. The reasons for this neglect are many, but among them are British surgeons’ saline preferences and their consequent reception of arguments concerning blood. For, unwittingly mirroring Archibald's work was another Canadian, Lawrence Bruce Robertson. In 1913, Robertson had effectively imported transfusion from New York, where he had learned it as a surgical student, to Toronto. There, he practiced it at the Toronto Hospital for Sick Children and taught it to his colleagues. Robertson, too, had been using blood transfusion in France. He, too, had written up his experiences that April. The British Medical Journal printed his article that July.11.Robertson L.B. The transfusion of whole blood: a suggestion for its more frequent employment in war surgery.Br Med J. 1916; : 38-40Crossref PubMed Scopus (32) Google Scholar Not only was it the first publication on blood transfusion to appear in a major British medical journal in the twentieth century, but it focused more on persuading British surgeons of the value of blood in general than of a transfusion technique in particular. It would take another year for those British surgeons to accept blood as a substitute for saline. By then, the Americans had entered the war. In the summer of 1917, a young American doctor, Oswald Hope Robertson, arrived in France with the Harvard medical unit. This particular Robertson had been working in a laboratory at the Rockefeller Institute, where he and his colleagues were investigating the preservation of blood. By autumn, he was treating patients with citrated blood and demonstrating the procedure to British colleagues at CCSs. It was a far more receptive audience than it would have been a year earlier. Moreover, the American Robertson did an outstanding job of testing, adapting, and promoting the addition of sodium citrate to blood for transfusion.12.Robertson O.H. A method of citrated blood transfusion.Br Med J. 1918; i: 477-479Crossref Scopus (23) Google Scholar His was the preferred transfusion practice of the American Army, as well as the British Third Army, by the spring of 1918. O.H. Robertson drew still more attention when he brought bottles of citrated blood in ice-packed boxes forward, close to the site of wounding. This has often been called the “first blood bank” (even if the phrase would not be coined for another 20 years). By 1918, the conditions imposed by this wartime environment had been integrated into the conception and treatment of “shock with hemorrhage.” The composite was being called “wound shock.” Wound shock was thought to result from the cold, damp, dehydrated, sleep-deprived existence imposed by trench life, in combination with injury, further exposure, and painful transport. Surgeons now responded to this deadly condition by reversing the effects of the war itself. Specially trained “shock teams” administered morphine, blankets, and hot tea in “resuscitation wards.” And, largely because of the striking manner in which sodium citrate simplified blood transfusion, they also administered blood to replace blood. It may be understandable that O.H. Robertson's grander efforts unintentionally eclipsed Archibald's more modest contribution. But the fact remains that Edward Archibald's forgotten classic was the first to demonstrate precisely how the addition of sodium citrate to blood could facilitate transfusion in a harsh environment like the trenches of World War I. Archibald appears to have paid little attention to his article's neglect. He’d returned to Montreal shortly after it was published and, after contributing a few further papers on shock and war surgery, turned his considerable personal energy to his surgical career and, more generally, to the state of Canadian surgery. He was named Surgeon at the Royal Victoria Hospital in 1918. In 1923, McGill made him Professor of Surgery and, 5 years later, he was Chief Surgeon at the Royal Victoria. As President of the American Surgical Association in 1935, he worked to establish the American Board of Surgery, and he helped shape the structure of surgical specialties in Canada. Shortly after he had been named Chief Surgeon (1928), Archibald brought in Dr Norman Bethune as his First Assistant. Bethune, of course, would later go on to receive great acclaim for setting up the Canadian Blood Transfusion Service in Madrid during the Spanish Civil War. He and his team supported the Republican cause by taking bottles of preserved blood forward (now in trucks rather than boxes) to treat the injured. It is difficult to imagine that Archibald had had no influence on Bethune's later transfusion work. Yet, like his advocacy of citrate during that earlier war, Archibald's role in its later fate has also been obscured by history.

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