Blood transfusion: What if….?

In the first decade of the 20th century, across the modern medical world, progress was made in blood transfusion research. Much of this sought to resolve the technical issues around instruments and methodology that had made the procedure too complicated to consider as part of the standard medical setting. Between 1900–1915 the work being undertaken had resulted in new possibilities for transfusing blood using techniques that were simple, efficient, and safe. However, at that time, that is all these achievements were—possibilities. There was little expectation among those clinicians who dealt with massively bleeding patients that blood transfusions were anything other than in a preclinical state. There were no textbooks available for teaching or clinical practice development. Debates about methods, compound formulas, and instruments were conducted within laboratories and the pages of specialist medical journals. The latest articles were often found in journals that were highly technical or did not relate to transfusion specifically. Lindeman described a simple syringe transfusion with cannulas in the 1913 edition of American Journal of Diseases in Children, and material by Lewison on blood transfusion appeared in Surgery, Gynaecology and Obstetrics in 1915. There was relevant material to be found in much older journals if they were available in a library: in 1858, Richardson had described the use of ammonia as an anticoagulant in the Guy's Hospital Reports. Other reports had been written in the second half of the 19th century in German, French, Dutch, Spanish but were not translated as technical vocabulary could make this process precarious. In all these countries a few patients had benefitted from actual transfusions but these were often viewed as experiments that happened to have secured survival. There was no indication that progress in the field would be paced any way other than steady but slow. We have a tendency to read history backward, and the history of blood transfusion is a good example of this. Because this series of discoveries happened close to the start of the First World War, history takes a connection for granted. In most accounts, by 1914 medical researchers were racing against time to provide a new form of casualty care for a new form of casualty expected from the world's first industrial war. A study of the pages of the specialist medical journals indicates clearly that this is not the case. Professionally, their contributors looked inward, preoccupied with ongoing technical challenges in the field of transfusion, not geopolitics. But it leaves us with an intriguing question: What if the combatant nations of the First World War had taken a deep breath in August 1914, and decided that negotiations would be the best way to settle their differences? What would have happened to the development of the concept of whole blood transfusion if there had been no World War I? One likely answer is that similar piecemeal progress would have continued, very slowly. Researchers would develop improvements to instruments, formulas, and method. Sometimes they would do this simultaneously in different countries across the world and in different languages. They would write them up in the growing number of specialist medical journals and perhaps apply them gradually to a few then a few more patients in the surgical departments of their own hospitals. Differing schools of thought would develop (paraffin vessels vs. citrated blood to solve clotting problems, for instance). Differing schools of medicine around the world would have adhered to one technique or the other, generating pages of journal articles and responses. We all know how such things can go, usually not very far or fast, bogged down by academic rigamarole, funding complexity, regulations, and a tendency to lose sight of the patient and their immediate needs. A research question remains just that, asked over and over in the academic space, but never providing a readily adaptable answer for improving patient care. It is hard to conceive of any civilian circumstance that would have produced the same transformatory numbers as the war that carved its brutal and bloody way through Europe from the Alps to the Channel and then much of the rest of the world between 1914 to 1918. Although this piece focuses on the Allied cohort, in the first 3 months of fighting each side lost tens of thousands of men to the heavy artillery, some immediately killed but more—far more—blown not quite to pieces, taken to medical aid posts and field hospitals, everyone hoping there was something they could do to replace the blood that flowed out of them, saturating stretchers, ambulance and hospital train floors, the uniforms of those who struggled to save them. But there was nothing beyond the experiments and journal articles for the soldiers whose lives bled away. For 2 years on the Western Front, it was so. Blood could only be stopped in its tracks, by direct pressure on wounds during evacuation or treatment but it could not be replaced. In 1916 the war became monstrous. Huge armies sought victory through attrition—who could spill the most blood—rather than superior tactics or strategy. Casualty rates were so bad in the British clearing stations and field hospitals, that Regimental Medical Officers (RMOs) who had heard of but not experienced blood transfusion techniques ended up improvising, usually patient to patient with whatever equipment was to hand. But they had also started to do much more than guess at solutions. RMOs ran medical societies themselves, with weekly meetings in field hospitals, and newsletters mimeographed and circulated to share developments as widely as possible. These groups were an effective mix of theory, exploration, and speedy implementation. In them lie the origins of organizations such as THOR (Trauma, Haemostasis and Oxygen Research). By the end of 1916, with the medical societies primed and ready, the technical answers to the problem of replacing lost blood finally came to France. US medics had arrived ahead of their country's troops to reinforce the British medical teams, and they brought their knowledge of transfusions from research units operating in peace and quiet across the Atlantic. There was still no consensus on any element of the practice. The Harvard Medical Unit who set up their hospital early in 1917 preferred the Kimpton–Brown paraffin method, where the collection tube was coated with a thin layer of paraffin wax creating a reaction which prevented the transfused blood from clotting. Harvard MOs toured medical societies up and down the front demonstrating the technique. They were with the officers of the No. 1 Canadian hospital in May 1917, teaching their officers how to use the apparatus, and engaging in a "very interesting discussion of blood transfusion." In early 1917, Dr. Oswald Robertson had also arrived in France and began to disseminate knowledge of the citration method of transfusion, which eliminated the danger of clotting and was considerably simpler to operate than the Kimpton–Brown method. The most important feature of the Canadian encounter is not the use of the less effective paraffin method, but the "very interesting discussion." Everywhere, RMOs and their teams were learning and practicing transfusion for themselves. On July 28, 1917, a young officer who had stamped on a grenade rather than have it explode in the manned trench around him was brought to a field hospital. The examining RMO, Arthur Rendle Short, saw that his patient had very little of one leg left and a barely discernible heartbeat. But he had been to every transfusion lecture he could get to and paid attention in the demonstrations and discussions. He selected a walking donor from the soldiers outside and transferred enough blood to restore his patient's circulation using a simple construction of tube and needles. It was fortunate that the donor matched the recipient and there was no clotting but the key element in this success was the extent to which transfusions had become part of the general medical response to bloody conflict trauma. Rendle Short was one of thousands in France who no longer had to guess when it came to blood transfusions after the spring of 1917. The war settled some of the most significant differences in practice also. By its end in November 1918, the citrate method of transfusion had become the standard. Not just in the field hospitals but subsequently throughout the United Kingdom and United States when the military medics came home and became civilian doctors again. They were the generation for whom it would be unthinkable not to use blood transfusions in the clinical setting. At every point, the pace and direction of travel for progress in tranfusion moved rapidly from the military space to the civilian. In 1922 the first English-language textbook was published by Geoffrey Keynes, another young British surgeon who served on the Western Front, and who performed hundreds of transfusions after seeing a demonstration by Oswald Robertson in 1917. Keynes, above all else, hated to waste even a single drop of blood. So to ask the question "what if" is useful. It helps us to consider how we might secure similar levels of progress in both research and practice when there is no equivalent density of Great War casualties, even though we know by now that in our modern world there will always be a significant burden of trauma where lives need saving in very short order. Although transfusion is now the mainstream practice that pioneers such as Robertson, Rendle Short, and Keynes always hoped it would be, their modern counterparts need to continue working together to revisit and innovate every dimension of the process so that it can, in Keynes' words in his textbook of 1922 "approach the ideal." Perhaps we can start by reading the history properly and understanding where transfusion was done first with true significance, not as single experiments, but where it was most needed at scale and pace and with the subsequent saving of millions of lives.

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