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A shot in the arm

Now that we're open again, much of the museum has been updated and refreshed and our loan boxes - a sort of travelling lesson in a box - are ready to go out to schools in September, we’re already looking towards the next new project at NESM.

That project is 'For King and Country'. Presented in the recreated section of a World War I trench (but without the rats and dysentery, thankfully), this new exhibition will chart the contribution made by members of the emergency services on the front line during the Great War.

Now, whilst researching bits for our secondary school workshops about medical advances in the trenches (most remedies seeming to be amputation), I was stopped in my tracks reading about blood transfusion. For some reason I was unaware of how recent a phenomenon the successful typing, storage and transfusion of blood actually was; so let’s go back 106 years and look at this aspect of medicine.

It’s 1 July 1916 and the British have made a concerted push to open the front line along the banks of the river Somme. In that single day the British army suffered its worst ever setback, losing 60,000 casualties; over 20,000 of them dying of wounds complicated by then unique battlefield conditions which saw men living in muddy (often flooded) holes in the ground.

One common illness was trench foot which was caused when skin was left waterlogged for days, often encased in overly tight combat boots. This led to poor circulation in the feet and, if left untreated, gangrene and amputation of toes. Trench fever was transmitted by body lice causing flu like symptoms. The men were given quinine - which didn’t work - and the situation wasn’t solved until delousing stations were set up in 1917/18. Then there was the horror of shell shock, caused by the stress of warfare, resulting in tiredness, nightmares and headaches. At the time this was not considered an illness but a sign of cowardice or 'lack of moral fibre'.

So troops were extremely likely to be undernourished and have underlying health problems even before they faced the enemy. Common injuries in battle would be caused by bullets, bayonets, barbed wire entanglements, grenades or shrapnel from artillery shells. All of these were designed to maim or kill and, every one of them – even a minor cut - could be deadly if left untreated.

Any soldier injured in an attack on enemy trenches who can’t hobble back to base with the help of retreating comrades would have to rely on the services of stretcher bearers. Due to the dangerous nature of No Man’s Land these stretcher bearers rarely ventured out until it was dark, allowing them to find and retrieve casualties with less risk of being shot by snipers. Each battalion would have 16 stretcher bearers and it would take four men to carry a stretcher; recovery of the wounded would take a long time.

As most attacks were planned for dawn, casualties could be lying in mud and flooded shell holes for hours until a hope of rescue. There was only a 28 per cent chance of surviving to reach a regimental aid post in these conditions.

So the first danger would be dying of wounds – usually by blood loss. If you were lucky enough to survive the initial trauma there was the serious risk of microbial wound contamination from either bullet, bayonet or shrapnel pieces pulling mud from your uniform into the wound or from the surrounding battlefield as you await rescue.

If you were picked up by stretcher bearers you would have to be manhandled across difficult terrain – usually above ground as the trenches were too jammed packed with personnel and equipment and tight corners to make rapid headway toward the Regimental Aid Post.

Here a medical officer would assess wounds and decide if you were lightly wounded or one of those who needed further medical attention. Lightly wounded were patched up and sent back into the front line. The more severely wounded would be transferred by horse ambulance (later motor ambulance – if it could negotiate the mud) to the Field Ambulance and Dressing Station. Here a triage system was set up to judge severity of wounds – the worse the injuries, the more likely to be moved on to better equipped facilities such as the Base Hospital at the rear.

At any of these points blood loss might well be dealt with using blood transfusions. However, at this point there were no organised blood banks and no way of storing donated blood safely. In fact, the nearest 'blood bank' was likely to be the soldier in the next bed!

By grabbing a nearby, relatively healthy soldier and sticking a tube with double cannulas into his arm and the other end into the patient you had a ready supply. At this point it really was the safest method. The blood pressure of the donor kept the blood flowing into the recipient - for a short time. However blood begins to clot as it leaves the body and the tubes could become blocked. Also, despite blood types being known about since 1901, patients and donors weren’t usually type matched and rejection, embolisms and death were often the result of these procedures. Then there was the unsterilized nature of the equipment used at the front and in dressing and casualty clearing stations meant potential sepsis or other microbial infections for both donor and patient where a real concern. If this seems extreme it was often worth the risk where men were almost certain to die if it wasn't tried.

This is where surgeon Geoffrey Keynes (later Sir Geoffrey) enters the story. Keynes - the younger brother of famous economist John Maynard Keynes - had delayed his medical training to join the Royal Army Medical Corps as a lieutenant, later becoming a consultant surgeon.

Keynes standardised the science of 'indirect' transfusion. He produced a transfusion kit that allowed doctors to regulate the flow of blood between donor and patient. It consisted of a glass drip chamber that stored blood and enabled more precise control of the infusion rate and better checking for emboli (air bubbles in the blood). This meant that transfusions could happen more safely away from medical facilities and closer to a battlefield. Soon these kits where in all levels of front line medical facilities.

Keynes wasn't the only medic making advances in the field of transfusion at this time. A Canadian, Lawrence Bruce Robinson, had also developed a technique for indirect transfusion using syringes and cannulae, and began using his system from 1917.

However, these new techniques had their limitations; without refrigeration blood still couldn’t be stored and it clotted unless an anticoagulant was used. Both of these were seemingly insurmountable situations in the field until Dr James R Turner began to work out the science of blood transfusion. In 1915 he discovered that adding sodium citrate to blood stopped it clotting and it could be used on patients without the need for the donor to be present. Whilst it still couldn’t be stored for long periods, it did mean that there was more room in the operating theatres as there was one less body present.

The following year Dr Turner and colleague Dr Francis Rous performed experiments that revealed that adding a citrate glucose solution (now known as Rous-Turner solution) to blood meant that it could be stored for up to four months and was still suitable for transfusion without refrigeration. Whilst hospitals used refrigeration, this method was widely used even during World War II as refrigeration was still a luxury that many theatres of conflict could only dream of.

Blood banks were an important medical advancement of the Great War era: the ability to collect blood in advance of need, transport the blood where it was needed, and deliver the blood quickly and easily enabled many thousands of wounded to survive until they could get a higher level of treatment at a field hospital.

At the battle of Cambria in 1917, exclusively type O blood was stored in glass bottles and was used to keep badly wounded soldiers alive throughout the battle. A supply of safe blood given under aseptic conditions brought the survival rate of soldiers making it to dressing stations and field hospitals from 21 per cent to a reported 84 per cent.

This, of course, was great news for the military and also for the civilian population at home. These life saving techniques pioneered through the hell of the Western front became widespread in hospital throughout the UK and beyond. The importance of such a discovery wouldn’t be matched until the discovery of penicillin in 1928.

Keynes remained an expert in blood transfusion. He founded the London Blood Transfusion Service and was made head of the UK Blood Transfusion Service in 1921. So when you donate blood or receive it, don’t forget the contribution of the medical services in the Great War and the legacy that continues today.

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