A Canadian kept blood flowing in WWI. An American got credit

It was a big deal. British physicians, of course, knew about blood transfusions, but they preferred saline when it came to dealing with blood loss. Transfusions in those days were mostly direct artery-to-vein affairs, and they came with difficult surgery, clotting and rejection risks. For many in the British medical establishment, saline was a simple way to replace fluid in a person’s vascular system, and improve blood pressure.

Robertson, a tall, brown-haired man, often seen smoking a pipe or cigarette in photos, was known by his middle name, Bruce. He believed saline was only a temporary fix. (Saline dilutes the body’s clotting factors, which meant bleeding would continue.) Working behind the front lines in 1915 and early 1916, he performedindirect transfusions by drawing blood from healthy-enough soldiers with broken ankles or other fractures. He would then inject the blood into soldiers whose limbs had been shattered by shrapnel and bombs — men having secondary hemorrhages.

Robertson wrote that “the additional blood often carries the patients over a critical period, and assists his forces to rally to withstand further surgical procedures.”

The Americans were at the forefront of surgery in the early 1900s, and Robertson had learned the technique at New York’s Bellevue Hospital. But with the U.S. sitting out the war until 1917, the Canadians were uniquely positioned to bring new techniques to the battlefield.

During the disastrous Somme campaign, thousands of wounded were treated with saline, and the British acknowledged in their official history it was “most disappointing,” according to medical historian Kim Pelis, who wrote in 2001 about the history of blood transfusion.

Robertson believed in blood, and kept pushing for its use. In 1917, in another article, he noted how transfusions performed in the casualty clearing station near Ypres, Belgium, transformed the pallid, semi-conscious patient with a flickering pulse into a “comparatively healthy,” comfortable, conscious person. Blood transfusion began to play an important role in saving soldiers who had been seen as hopeless cases from “wound shock,” Pelis writes.

The casualty clearing station’s war diary was effusive, calling the results “little short of marvellous.”

He worked to the point of exhaustion and was endlessly curious, inviting patients to keep in touch, often giving them self-addressed envelopes.

“On the 13th June you took my leg off above the knee, and until I received blood from someone else you considered the betting about 3 to 1 on my pegging out,” one soldier wrote in 1917, in a letter at the Archives of Ontario. “Can you find time to let me know the name and address of the man who gave me blood? I should much like to write to him.”

Through the academic papers, demonstrations of procedures and creating the “resuscitation ward” for men to receive transfusions to combat shock, Robertson and fellow Canadians set the stage for the British acceptance of blood transfusion, Pelis wrote in 2001.

Now a writer at the U.S. National Institutes of Health, Pelis says Robertson “leapt off the page” during her research.

“He felt like a man of great integrity and concern and awareness,” she says.

But in the aftermath of the war, the Canadians were mostly forgotten. The American entry into the conflict in 1917 was linked to the acceptance of blood transfusion, Pelis explains, thanks to the seminal 1922 article by British surgeon Geoffrey Keynes.

Robertson wrote to Keynes, not for any credit, but to let him know that it was the Canadian surgeon Maj. Edward Archibald who came up with the idea to use citrate as a coagulant in 1915 — not American surgeon Oswald Robertson in 1917.

“I believe in giving the Americans all the credit due to them, but you know they have a national prejudice against undervaluing their own accomplishments, which is rather too apparent over here, though it may be modified by distance to your point of view,” he wrote.

“Isn’t that gorgeous?” says Suzanne Evans, who wrote about Robertson and his wife in 2013 for Canada’s History magazine. “I love that bit.”

Robertson returned to Toronto in 1918, and continued with transfusion work at the Hospital for Sick Children.

Back in the city, he met Enid Finley, a strong-willed woman later known as the mother of physiotherapy in Canada, who helped create the field and persuaded the government to put physiotherapists in uniform during the Second World War. Granddaughter Orian Hartviksen has the letters Bruce sent Enid as they planned a life together. “Dear girl of mine,” he’d write, in his illegible doctor’s handwriting, about the mundane details of shopping for the new home, and his work at the hospital. In January 1920, he treated a baby who had a “hopeless” case of toxemia. Robertson suggested a blood transfusion from the baby’s father.

“At the end of the transfusion the baby was so far gone that I thought it would barely live for more than a few minutes but it began to pick up a bit and then in the course of a few hours was very much better,” he wrote to Enid.

The couple married and had children, but Robertson died of influenza complications in 1923, only 37. “Brilliant surgeon taken in his prime,” one headline read.

“He was very proud of him, but he really didn’t know him,” says Kathleen Bruce-Robertson, 93, who married Robertson’s son Alan. He was only 2 when his father died.

After Robertson’s death, Enid changed the surname of the children to the more cumbersome Bruce-Robertson, to keep his legacy and name intact, and avoid confusion with American surgeon Oswald Robertson, Kathleen explains, noting it can feel a little long when you’re writing out traveller’s cheques.

Enid later remarried, changing her name to Enid Graham.

Dr. Andrew Beckett, a veteran combat surgeon with the Canadian Forces, says the pendulum has swung back and forth between saline and whole blood since the First World War, but now whole blood is thought to have better outcomes.

Beckett says that when soldiers were dying of shock in Iraq and Afghanistan, surgeons went back to papers written 100 years ago, by people like Robertson. Because of the continued difficulty in shipping blood products, blood was collected from Canadian soldiers for use — just as Robertson did, with the requisite technological advances.

“In terms of combat casualty care, his work is probably one of the greatest contributions ever made,” Beckett said.

Blood transfusions: a timeline

1818: The first successful human blood transfusion is performed by British obstetrician James Blundell. With no understanding of blood types, “Successes were frequent enough to encourage the operation’s continued use; failures were attributed to clotted blood, or to the hopeless state of the patient,” Kim Pelis writes.

1880: Blood transfusion, with its many risks, falls from favour among British physiologists, who prefer saline infusions — “blood was relegated to the quaint pages of medical history,” Pelis writes. Most of the patients experiencing blood loss in this era are post-partum women.

1898: U.S. surgeon George Washington Crile studied physiology in Europe. He was concerned with shock, a mysterious condition that came after surgery or injury, and resulted in “thready pulse” and often death. Crile believed blood would be better than saline, but he didn’t have a good technique for transferring blood between bodies.

1901: Three different blood types are discovered, A, B and O, and the following year, a fourth: AB.

1906: Crile connects a donor’s artery to a patient’s vein for a direct human-to-human blood transfusion. “The result was so successful he dubbed it a ‘midnight resurrection,’” Pelis writes. His success heralds a conversion to blood transfusion in the U.S.

1907: The British Medical Journal does not support blood transfusion as a method: “… surgeons, we imagine, will find no good reasons given here for abandoning the safe and simple method of saline injection.”

1910s: A growing number of American doctors experiment with ways to make transfusion simpler. Lawrence Bruce Robertson from Toronto learns the syringe method at Bellevue Hospital in New York.

1913: Robertson returns to Toronto’s Hospital for Sick Children, where he conducted what is believed to be the hospital’s first blood transfusion.

1914: Robertson enlists for war.

1916: After performing blood transfusions on the Western Front, and demonstrating his methods for British and Canadian medical units, Robertson publishes “The Transfusion of Whole Blood: A Suggestion for Its More Frequent Employment in War Surgery.”

1917: The U.S. enters the war, and American Dr. Oswald Hope Robertson later stores blood mixed with a “citrate and dextrose solution” in glass bottles, on ice, creating the world’s first blood bank.

Sources: “Taking Credit: The Canadian Army Medical Corps and the British Conversion to Blood Transfusion in WWI,” by Kim Pelis; AABB Foundation