The Learning War 2

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Transfusion of Hope
How Blood Transfusion Came to the Front Lines
of Medicine During the Great War
The Great War can best be described as the ultimate exercise in miscalculation. The
Germans underestimated their enemies while overvaluing their plan. The allied British and
French forces underestimated the German defenses and everyone involved in the war
underestimated the efficiency of the new weapons. In 1914, the armies were mostly professional
soldiers. In 1916, they were mostly draftees because all the professionals were dead. The war
started in August and every nation involved thought they had enough arms and ammunition to
win the war. But by September of the same year they were all in the United States buying bullets
and guns from Remington.1
All the great plans of the war were met with the reality that they
were only great if nothing deviated from the plan. The medical institutions of World War I were
no exception. The ranks of the medical corps incorporated professional surgeons and nurses into
the soldiers ranks and the teams acted as a life saving buoy against the coming storm of the war.
Though thousands received blood transfusions during the war, it seems like a relatively small
amount considering the overall casualty count. The war taxed even the most professional of
surgeons’ faith in medicine and they found that faith restored by the lives they were able to save
through transfusion.2
Organized Chaos
1 Dr. John Steinberg, “When War Plans Failed: France, Germany and Russia in August 1914.” (lecture, UNCW,
Fisher Union, Azalea Coast Room., Wilmington, NC, March 20, 2014.).
2 Kim Pelis, “Taking Credit: The Canadian Army Medical Corps and the British Conversion to Blood Transfusion in
World War I”, Journal of the History of Medicine and Allied Sciences 56, no. 3 (2001): 240.

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To understand the difficulties of doctoring during World War I, it is first important to
understand a little about the set up of the overall medical units in the Great War. The main
emphasis of the British medical system was an evacuation route, starting at the front lines with
regimental medical officers, then followed by dressing stations and mobile hospitals to semi-
permanent hospitals at the base. During the first year of the war medical posts were primarily
filled by medical officers from the reserves, but that was soon supplemented by volunteers from
the Red Cross.3
This meant that professional soldiers were working alongside volunteers who
were professional doctors. The civilian doctors were to receive little if any military training
focusing instead on the job of caring for the wounded.
The front line of medical care was the Regimental Aid Posts where wounded were
prepared for their journey to the rest of the medical facilities. The Regimental Aid Posts (RAP)
were stationed about 300 yards behind the front lines. Sometimes the facility's location was little
more than a shell crater leaving medical personnel exposed to live fire while they worked. One
Medical Officer said, "The air is torn with the din and crash of heavy guns... the constant crackle
of the rifles and machine guns... The bathing, dressing and bandaging commence... through it
all."4
At the start of the war, the RAP were primarily for evacuation to the Casualty Clearing
Stations, more on them later, but as surgeons became more attuned to the demands of the conflict
life saving surgery moved closer to the front.
After this stage, the ambulances carried the wounded to Advanced Dressing Stations
usually set near a road. At the dressing stations, a soldier's wounds would be redressed as they
were usually soiled by the time they arrived. Here the wounded would either rest and recover
3 Mark Harrison, The Medical War: British Military Medicine in the First World War. (Oxford: Oxford University
Press, 2010), 19.
4 Mark Harrison, 21.

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before being sent back to the front or would be sent to the next stop in the line. Advanced
Dressing Stations were mainly for triage and only held casualties during bombardments.5
By October 1914, every division of 20,000 men had three field ambulances. As a layman
with no medical expertise this may seem unusually low but if that wasn't bad enough, it was
made worse by the fact that most of these ambulances were horse drawn at the beginning of the
war. The Director of Medical Operations thought that motor ambulances were not necessary
because the destruction would be so severe that clearing land for driving would be impossible.6
Though there is some truth to this, it is hard to imagine frightened horses being much better.
Though an improvement over horse drawn carriages, the motorized ambulances were no
less in danger. In The Compensations of War, Guy Bowerman, Jr., an American ambulance
driver during the last two years of the war, mentions an ambulance that came in right after a shell
had burst nearby. The shell had exploded right in front of the ambulance and a piece of shrapnel
had flown through the windshield between the driver and his passenger. This piece of shrapnel
missed the men in the front but struck a wounded doughboy in the head, covering the rest of the
wounded in brains. Needless to say they were all severely shell shocked by the experience.7
The next stop in the line was the Casualty Clearing Stations where patients were taken
from ambulances to reception for triage. Triage was the French system of determining the order
of treatment based on the severity of injuries and wounded were broken into three groups. The
first group was likely to survive regardless of receiving medical attention. This slightly wounded
group would be sent further up the evacuation line as soon as possible. The second group was
5 Mark Harrison, 21-22.
7 Guy Emerson Bowerman, The Compensations of War: The Diary of an Ambulance Driver During the Great War
(Austin: University of Texas Press, 1983), 124.

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determined to need immediate surgery and was sent straight to the dressing room, then to the pre-
operations ward and finally to the operating theater.8
The most severe group was comprised of people who were almost certain to die. These
soldiers were suffering from shock, bleeding, lung wounds, things of that nature. They were sent
to one of the wards, more often than not, to the moribund ward to eventually die. These wards
were the most emotionally difficult places to be as everyone there was essentially facing a death
sentence. At the beginning of the war there was little anyone could do to treat shock from blood
loss or infection.
Mary Borden, a millionaire's daughter from Chicago, ran and funded a fully operational
field hospital with her own money during World War I. Though the British army provided the
doctors and surgeons she hired the nurses and ran the hospital with no training.9
She referred to
the nurses of the gangrene ward as "laughably ineffective." They can offer some small comforts
but deal in body parts not patients. She implied that nurses must suppress their humanity in
order to deal with the casualties.10
As trench warfare became the norm the Royal Army Medical
Corps moved the surgery closer, to about seven miles from the front.11
From stretcher to aid post
for emergency treatment, then to ambulance, horse drawn or motorized, and on to the next stop.12
Only six Casualty Clearing Stations (CCS) were sent out in 1914. By the end of the year
there were 8 that had beds, trained nurses, surgical equipment and a surgical specialist. In two
years time each CCS had a complement of seven nurses up from the previous five, and there
9 Ariela Freedman, “Mary Borden's Forbidden Zone: Women's Writing from No-man's-land.”,
Modernism/Modernity 9, no. 1 (2002): 109-10.
10 Ariela Freedman, 119.
11 Kim Pelis, 248.
12 Kim Pelis, 248.

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were 50 Casualty Clearing Stations big enough to handle five hundred to a thousand patients.13
The CCSs had several surgeons and a few other personnel trained to work as a team. The teams
were moved from one CCS to another on a rotating schedule and sometimes as war casualties
dictated. This made the unit a very cohesive medical team. As one team in the linked chain
stopped taking admissions and closed their doors, they started sending patients to their
neighbors. It made for fast work and the exchange of medical ideas between medical personnel.
This exchange of ideas led to doctors using oxygen on patients who were caught in a
German gas attack. Prior to this one doctor was treating his gassed patients by having them
inhale ammonia, while another was injecting his patients with an antiseptic. By 1918 oxygen
was being used all the way up at the front line aid posts and was the standard to restore normal
lung function. This exchange of ideas also led to treatment of those deemed "beyond medical
hope" by the French triage system.14
These men, considered dead already, were sent to tents called "moribund wards" where
the nurses kept them comfortable until they died. Most were suffering from shock, and if a
doctor had time he gave them a saline injection but more often they just died.15
The basic
practice of saline injection was to inject saline solution into a patient suffering from blood loss.
Though this temporarily increased the blood volume it was not an effective replacement for
blood. In 1916, at the Battle of the Somme, enough casualties were arriving suffering from
shock that the British practice of saline injection was put to the test and failed.16
These Casualty
13 Mark Harrison, 32-33.
Mark Harrison, 108.
14 Kim Pelis, 249.
15 Kim Pelis, 250.
16 Kim Pelis, 253.

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Clearing Stations are where the bulk of the blood transfusion work was to be done. Eventually
the work heralded the end of the moribund ward. It was replaced by the resuscitation ward.
George Crile and the Red Cross
Dr. George Crile was one of the American volunteers who had been overseas in the war
and came back saying that America needed to start preparing its medical staff just in case they
became involved in the war.17
In early 1916 the Red Cross began organizing hospitals from
civilian volunteer doctors, nurses and medical staff. As a hospital staff was completed it was
added to a list. By the time the US declared war in 1917, there were 33 base hospitals ready.18
Once mobilized the army would add a few officers and other personnel to provide military
expertise and command where needed. Other than that the base hospitals were to be a purely
civilian operation. When they began deploying the base hospitals the War Department got up in
arms because the Surgeon General had not explained the base hospital program. As the base
hospitals were deployed the General Staff of the War Department wondered what these base
hospitals were and what other units the Medical Department had up its sleeves.
Of course with war intervention came the inevitable snafu. Equipment was shipped well
but personnel was not. On the battlefields of Europe the system of keeping a medical team
together fell apart. Hospitals were broken up with their individual parts sent to other units and
hospitals. Doctors were sent out before their units was called up, others were sent on
unnecessary training courses, others drafted as enlisted before their hospital was deployed.
Medical personnel were reassigned to the wrong hospitals.19
One hospital had fourteen of its
17 Sanders Marble, “Professional Doctors but Amateur Soldiers: The Us Army's Affiliated Hospitals Program, 1915-
1955.”, War and Society 27, no. 1 (2008): 40.
18 Sanders Marble, “Professional Doctors but Amateur Soldiers ", 41.

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original staff of doctors and dentists removed and another forty-seven personnel assigned.20
Still,
the base hospitals were enough of a success that the Red Cross organized more. Base Hospitals
provided the personnel for forward surgical units. By the war's end the Red Cross had provided
roughly 17,000 medical personnel across 50 base hospitals.21
Some of these civilian doctors
were made consultants on medical affairs to the point that they set the standards for medical care
and were responsible for organizing technical matters related to surgery. As the war drew on
they began to shape the way surgery was performed at the front.22
Throughout the war all branches of the army and particularly the medical branches
worked to streamline the process if dealing with casualties. Trench warfare became the norm
and military advances were only a few miles forward or back. This helped the medical operation
immensely. This meant they could take advantage of established roads and railways to transport
wounded and supplies. It was during advances and retreats that things were made increasingly
more difficult. An excerpt from Oswald Hope Robertson's unpublished diary covers the day of
November 30, 1917. This was the day of the German counter-offensive at the battle of Cambrai
where British troops tried to break the German supply line.23
By noon, the wounded began to arrive... We were simply deluged. ...They were
dying faster than we could get them out. We had to lay the corpses on the floor as
we needed the beds for new wounded. ...I could transfuse an occasional one but
the majority had to take their chance without much treatment and go thru
operation as best they could... I lost all track of time. … was practically moribund
(the next) morning ...Learned that we had taken in 1800 patients during the last 24
hours!24
22 Mark Harrison, "The Medical War", 37.
Mark Harrison, "The Medical War", 83.
23 Lynn Stansbury and John R. Hess, “Blood Transfusion in World War I: The Roles of Lawrence Bruce Robertson
and Oswald Hope Robertson in the 'Most Important Medical Advance of the War'”, Transfusion Medicine Review
23, no. 3 (2009): 235.
24 Lynn Stansbury and John R. Hess, “Blood Transfusion in World War I”, 235.

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Occasionally the ambulance trains were backed up because ammunition trains had the right of
way. With lines of transportation and communications disrupted things looked grim.
The Blood Story
Blood transfusions were introduced in 1818 mostly for women hemorrhaging during
childbirth. But no blood typing existed and the resulting deaths were written off as blood clots or
the patient being too far gone.25
By the 1880s, British surgeons had replaced transfusion with
saline injection and written off blood transfusion as a thing of the past. It was an American
surgeon named George Washington Crile who became interested in blood again as he toured
European hospitals trying to find a way to stop patients from dying of shock during operation.
By 1898, he became convinced that blood was the key.26
His first transfusion in 1906 was a very
difficult process that involved stitching an artery from a donor to a vein from a patient. When
the patient recovered he called it Midnight Resurrection. Dr. Crile's ideas on treatment of shock
and blood transfusion made headlines in August 1914. The New York Times declared it a "New
Surgical Era." However the British attitude was to stick with saline injection to temporarily
increase blood volume.27
Though the transfusion process showed good results it was so difficult that British
surgeons still opted to follow their tried and true method of saline injection. But four years later
doctors at universities in America were trying to simplify the blood transfusion process.28
In
1914, a sodium citrate solution was added to blood as an anti coagulant. This simplified the
process so no special surgical training was needed to do a transfusion. Blood no longer needed
25 Kim Pelis, “Taking Credit: The Canadian Army Medical Corps and the British Conversion to Blood Transfusion in
World War I”, Journal of the History of Medicine and Allied Sciences 56, no. 3 (2001): 241.
26 Kim Pelis, “Taking”, 242.
27 Kim Pelis, “Taking Credit”, 246.
28 Kim Pelis, “Taking Credit”, 243.

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to stay within the body to be transfused. A transfusion could now be done relatively simple from
patient to patient, by syringe.
Dr. Crile may have reintroduced the medical world to transfusion but it was a Canadian
named Lawrence Bruce Robertson who eventually succeed in converting the British to the
method. While the new citrate and syringe method was taking hold L. B. Robertson arrived at
Bellevue Hospital in New York 1911 where he learned ambulance and first aid work as an intern
and was taught the technique of direct blood transfusion by syringe.29
The process was to draw it
from the donor's arm and inject it into the patient. There was no cross matching done and he
used the process on 27 children.30
At a British base station hospital in 1915 he performed 4 transfusions. With no cross
matching done, one of the four died from complications. L. B. Robertson said the situation was
dire enough it justified the risks and wrote the first article on wartime blood transfusions in the
twentieth century.31
Canadians were showing the British the blood transfusion procedure
firsthand at the front and created the resuscitation wards where transfusions saved many soldiers
dying of shock.32
L. B. Robertson did one transfusion where he was consulted by Major T. R.
Elliott, Royal Army Medical Corps, a friend of the director of the Medical Research Committee.
That the patient survived meant the treatment of shock by blood transfusion was all but set in
stone.33
It was after this that Robertson was re-stationed to a relatively quiet unit for his wartime
stint. At the 2nd Canadian Casualty Clearing Station he built a resuscitation ward. Things were
29 Kim Pelis, 244.
30 Lynn Stansbury and John R. Hess, 233.
32 Kim Pelis, 254.
33 Kim Pelis, 256.

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fairly quiet since all the fighting was to the east on the Somme and at Verdun. So Robertson was
able to perform 36 more transfusions with 3 deaths.34
In 1916, after the success of the transfusion where he was consulted by Maj. Elliott,
Robertson's star began to shine as he published a paper on his transfusion experiments, within a
few weeks he had reworked it into a new article. The British Army Medical Corps' conversion to
blood transfusion from saline injection was so fast that L. B. Robertson’s two articles on the
same 36 cases were published twice in the British Medical Journal five weeks apart. The articles
were nearly identical with only a few names and numbers changed from one version to the
next.35
This inflated his sense of celebrity and when he returned to Toronto in 1918 he published
a 4th article detailing all his war time transfusion cases but it was already obsolete by the time it
was published.36
In the first of these articles Robertson suggested that saline injection was a temporary
solution to replacing lost blood. It increased the volume but nothing was a substitute for blood.37
He also dismissed blood typing as something to do if you had the time.38
He referred to
transfused blood as a second line of defense and used a lot of other military sounding language in
his article. This was his way of trying to appeal to the military minded and trying to coax them
away from saline injection. Dr. Crile's ideas on the treatment of shock finally received the
recognition they deserved but it was from an article written by Lawrence Bruce Robertson.
At the same time in 1916, Major Edward Archibald was trying to simplify the procedure.
He wrote an article explaining the process so that it was as simple as a saline injection. But only
37 Kim Pelis, 258.
38 Kim Pelis, 259.

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one of his eight cases actually survived, so he was not taken as seriously as Robertson.39
The fact
that he was stationed close to a front line unit in Bailleul and his cases were much more severe
than those Robertson had dealt with, twenty miles from the front, made little difference. His
mortality rate was too high. By November 1916, Robertson was named surgical specialist to a
Canadian CCS in Remy. He built the unit with resuscitation in mind doing away with the
moribund ward altogether. Since most of the soldiers sent there were dying of shock due to
blood loss he treated them with blood transfusion so they were prepared for surgery.40
Also
Archibald's protégé, Walter McLean, built a resuscitation ward into Archibald's old CCS to treat
shock. It was there that the British who had dismissed blood transfusion got firsthand experience
of its superiority to saline injection.41
Dr. Crile stated in a 1918 lecture that roughly 95% of the injured in war died from a
combination of shock and hemorrhage.42
This made the resuscitation ward the most important
place for life saving to occur. Though he certainly could have claimed to inspire the idea of the
resuscitation ward, he did not create it. That was done by the Canadians. By November 1917,
every CCS had a resuscitation ward. Before this, a soldier dying from shock was to be placed in
the moribund tent to die. Now they were treated with warm blankets to counteract the cold,
warm tea to fight dehydration, and blood when needed. Finally the doctors at the front had a
fighting chance.
American surgeon Oswald Hope Robertson did his research at Harvard University in the
lab of Beth Vincent who did the first recorded transfusion at an American volunteer hospital in
Paris April 23, 1915. In may 1917 he joined the Harvard medical unit in England before moving
39 Kim Pelis, 260.
40 Kim Pelis, 263-264.
41 Kim Pelis, 264-265.
42 Kim Pelis, 269.

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to France directly behind the line in Flanders. O. H. Robertson also spent some time at the
Rockefeller Institute where they were studying ways to preserve blood. He adapted the process
of using citrated blood to the CCS environment. Now rather than stitching together veins and
arteries or drawing the blood from one subject to be injected into another the process was greatly
simplified.43
Anyone with a basic understanding of syringe work could draw the donated blood
from a donor into a bottle and store it for later use. This meant that relatively anyone could do a
transfusion. It was no longer left to a surgeon to do this relatively minor but truly important task.
The surgeon could now spend his time in surgery and receive patients who were ready for
surgery rather than having to first stabilize them.
Oswald Robertson was an enterprising surgeon who was always doing research of some
kind. Harvey Cushing mentions some of his work in his memoir From a Surgeon's Journal.
"Robertson back from the front... done excellent work on blood transfusion...Knows the Cambrai
performance firsthand... Robby thinks we are all pessimistic at the base." [Cushing, Harvey,
From a Surgeon's Journal, 268] in one instance Robertson gives a talk on his blood transfusion
work during Cambrai that so impressed the sitting Colonel that he volunteered to be a blood
donor.44
Earlier that July Cushing commented on Robertson getting strange supplies of paraffin
and guinea pigs from the medical stores. The paraffin he used for coating tubes used in
transfusion and guinea pigs for experimentation. He had found spirochetes (bacteria) that are
transmitted to humans from fleas and ticks in several soldiers urine and was studying a fever of
unknown origin, or P.U.O.45
43 Kim Pelis, 271.
44 Harvey Cushing, From a Surgeon's Journal, 1915-1918. (Birmingham: Gryphon Editions, 1990), 270.
45 Harvey Cushing, 152, 155-156, 158.

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That same July he had developed a system for identifying blood donors and began
posting their names and blood types on operating rooms doors daily. Robertson also moved
beyond the transfusion of blood by citrate method. He created the first blood bank by separating
out red blood cells and storing them in iced bottles. He then traveled to the front lines during
fighting where he warmed up a solution and transfused it.46
This method meant the blood could
stay fresh for up to three weeks, as opposed to nearly a week with the citrate method. However
this was rarely used because the separation process was more difficult. He was assigned to the
British Army and his station was known as the 5th US Base Station Hospital and 13th British
Expeditionary Force Hospital.47
By December he had demonstrated the safety of using typed stored blood and training
others to follow his procedures was one of his main duties.48
Geoffry Keynes, a surgeon and
author of a textbook on transfusions said the process was too difficult and unsuited for war
conditions until 1917 when US doctors made the process safer and easier to train throughout the
armies.49
By October of 1918 hospitals were doing fifty blood transfusions a day, but reaching
that point had been tough. Germans remained skeptical about blood transfusion during the war
and even remained wary of it after the war.50
By 1917 and 1918 success rates were up and post surgical mortality rates were down as a
result of the special resuscitation teams and their treatment of shock and blood loss.51
Though
not as widely used as necessary due to constraints on time and personnel, when blood transfusion
was used it made a huge difference in a patient's survival. Yet it wasn't widely used until the last
46 Kim Pelis, 272.

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year of the war.52
The most important aspect of the introduction of blood transfusion to the
battlefield was its lasting impression after the war. During the War to End All Wars only a few
thousand blood transfusions were performed. However during the years from 1914 to 1918, the
process of blood transfusion changed from a horribly complicated surgical procedure to a simple
procedure that relatively anyone could do today. The first blood bank was created and blood
storage and blood typing became the norm. Several surgeons from different countries pooling
their ideas came up with a way to fight the never ending battle. Today the American Red Cross
collects 5.6 million blood donations a year and has over 8 million blood products for transfusion.
There are nearly 3,000 hospitals and transfusion stations around the country today and it all got
its start a century ago in the Great War.53
53 Unknown. “Lifesaving Blood | American Red Cross | Red Cross Blood Donation,” American Red Cross, April 1,
2014, accessed April 1, 2014, http://www.redcross.org/what-we-do/blood-donation.

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