Dr. Lawrence Bruce Robertson and blood transfusion in the trenches of World War I

Innovation150 series: As Canada celebrates 150 years we look back on Canadian innovations in transfusion medicine. A series of posts over the weeks leading up to and following Canada's 150th birthday feature remarkable Canadian progress in transfusion medicine — past, present and future. #Innovation150. Read more Canadian Innovation stories at innovation150.ca

Modern Canadian blood banking and transfusion services can trace their origins to the trenches of World War I, thanks to the efforts of transfusion pioneer Dr. Lawrence Bruce Robertson. Robertson enlisted in the Canadian Army Medical Corps to support the British soldiers fighting in Europe. Along with his medical expertise, he brought modern transfusion knowledge from his postgraduate training in U.S. hospitals to the front line.

Image

L. Bruce Robertson beside Canadian Red Cross truck, ca. [1914-1918]. L. Bruce Robertson fonds, F 1374, Archives of Ontario, I0050290   Copyright: Queen’s Printer for Ontario

Robertson was born in Toronto. He graduated with a medical degree from the University of Toronto in 1909, interned at Toronto’s Hospital for Sick Children and then headed to Bellevue Hospital in New York City for further training. There, he learned a lot about new developments in transfusion medicine from American doctors who were leaders in the field. At the time, U.S. medical practice supported the theory that blood transfusion was a valid clinical treatment, even though the practice was hampered somewhat by an incomplete understanding of blood groups and the effect of incompatible transfusions. In New York, Robertson saw clinicians developing tools for transfusing whole blood from donor to patient more easily.

Blood collection and delivery, from donor to patient

Previously, transfusion practice required that blood be directly transfused from donor to patient to ensure continued flow: problems with blood clotting meant that the donor artery had to be surgically attached to the recipient vein. This cumbersome approach continued until clinicians introduced a cannula to link the vessels between donor and patient. From these surgical approaches, transfusion clinicians then developed methods that could measure transfused volumes, as well as avoid the need to perform complicated surgery. They used multiple syringes to quickly withdraw blood from the donor to transfuse into the patient. Other modifications included introducing a four-way stopcock into the flow line and flushing with saline to prevent clotting. In this way, multiple operators could very quickly withdraw larger amounts of whole blood to treat patients in need.

Whole blood as treatment

World War I started in July 1914. The hostilities quickly settled into trench warfare, with horrendous conditions and loss of life endured by both sides on the Western Front. Battle casualties frequently arrived at the field hospitals after many hours of lying in tremendous pain on the field. Their overwhelming injuries from shell explosions, shock and blood loss usually meant that these soldiers did not survive. Although surgical efforts became more courageous for treating abdominal wounds, for example, the British standard treatment of infusing normal saline did very little to stabilize shock and save these young soldiers.

By this time, clinicians in the U.S. understood the value of whole blood in medical treatment and the necessity of pre-transfusion testing for blood group compatibility. They also had a number of transfusion tools available, having moved away from direct artery-to-vein delivery. However, medics in Great Britain and Europe still favoured saline as their first choice for treating blood loss and weren’t as up-to-speed in transfusion delivery as their North American colleagues.

Normal saline — a balanced solution of sodium chloride similar in salt concentration to tissue fluid in the body — will expand blood volume when infused. However, since it lacks blood proteins it rapidly escapes from the circulation and does not maintain blood pressure in the long term.

At the Front Line: Canadian transfusion medicine

When Robertson and other Canadian doctors arrived at field stations on the front line, they quickly promoted whole blood as the treatment of choice for battlefield medicine. Robertson himself wrote three papers on its use under battle conditions, showing its success in four, 36 and 68 cases, respectively. The cases described primarily soldiers with battlefield injuries resulting in severe blood loss, with whole blood donations being taken from other patients considered healthy but unfit for fighting due to sprains and minor fractures. Robertson’s success in using whole blood for treating injured soldiers and the syringe and cannula method for transfusion spread among Canadian and then British medics.

Government of Ontario archives show that Robertson’s work was greatly appreciated among soldiers, with some contacting him giving thanks for saving their lives, and others asking for news on the outcome from their whole blood donation

Citrate anticoagulant for blood banking

Meanwhile, another development in transfusion medicine was gaining acceptance by battlefield medics. A major problem during transfusion was the rapid coagulation of blood. Once withdrawn from the donor into a collection syringe, whole blood activates a clotting cascade that results in the cells and platelets clumping together. This blocks needles and cannulas, making further collection or transfusion impossible. Doctors found that sodium citrate was an effective anticoagulant, which extended the time between donation and administration. U.S. doctor Oswald H. Robertson is usually given the credit for bringing this into front-line medical treatment, but according to the Canadian Dr. Lawrence Bruce Robertson, it is another Canadian, Major Edward Archibald, who deserves the credit, pioneering use of the anticoagulant from 1915 onward, prior to 1917 when the US entered the war.

However, the American O.H. Robertson’s work on citrated blood did introduce another useful tool for transfusion medicine: blood banking. One of the major problems facing doctors at front-line hospitals was availability of whole blood for transfusion; other patients became a walking blood bank of donors since coagulation made it impossible to build up stocks of whole blood in reserve. O.H. Robertson showed that blood could be collected in advance, treated with sodium citrate and then stored in sterile bottles on ice until needed.

Following the end of the war, Lawrence Bruce Robertson returned to Canada. He continued practising medicine, advancing his transfusion techniques while working at the Hospital for Sick Children in Toronto. He readily shared his pioneering work, bringing whole blood transfusion and exchange transfusion to treat a number of conditions, including burns and intoxication, to the attention of his colleagues. Unfortunately, Lawrence Bruce Robertson died in 1923. He is  recognized as being the founder of Canadian blood banking and transfusion medicine.

Written by Amanda Maxwell, with grateful thanks to Dr. Jacalyn Duffin, Queen’s University, Kingston, Ontario, for additional insights and materials.

Further reading

• A Canadian kept blood flowing in WWI. An American got credit
• Pinkerton, P.H. (2008). “Canadian surgeons and the introduction of blood transfusion in war surgery,” Transfusion Medicine Reviews, 22(1), 77–86.
• Pinkerton, P.H. (2001). “Canada’s transfusion medicine pioneer: Lawrence Bruce Robertson,” Transfusion, 41(2), 283–286.
• Pelis, K. (2001). “Taking credit: The Canadian Army Medical Corps and the British conversion to blood transfusion in WWI.” Journal of the History of Medicine and Allied Sciences, 56(3), 238–277.

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