Dr. Bruce Robertson, the
Toronto doctor who brought blood transfusion to the Western Front in World War 1 transforming
triage and resuscitation, a centenary to celebrate.
July 2016 is
the centenary of the Battle of The Somme where from 1 July to 18 November 1916 over
1 million men were killed or wounded in a senseless slaughter and hopeless
attempt to break the deadlock of trench warfare at the end of which the front line
stayed virtually the same. However there is another centenary which Toronto
should recall with more hope at this time. On 8 July 1916 just a week into the
Battle of the Somme Captain Dr.Bruce Robertson, a Canadian volunteer doctor
from Toronto, had his paper published in the British Medical Journal entitled, The Transfusion of Whole Blood, A
suggestion for its more frequent employment in war surgery [1]. This was to mark a pivotal change in
the Royal Army Medical Corps, RAMC, protocol of the British Army for how
casualties were to be resuscitated on the Western Front. Blood transfusion was
now to be encouraged.
In 1914 at
the beginning of the WW1 blood transfusion was not included in the RAMC protocol
of a casualty with shock. A casualty then suffering from shock was thought to
be suffering from an over stimulation of the brain and that the best treatment
was morphine to reduce the effect of the stimulation, warm tea, warming of the
patient with hot water bottles, blankets and perhaps a small volume of
intravenous saline. The Casualty Clearing Stations situated about 6 miles
behind the Front were the closest medical facilities where surgery could be
undertaken safely from the shelling and the protocol initiated. However if the
blood pressure remained low any form of surgery was known to be poorly tolerated
and the casualty was likely to be transferred to the Moribund Ward, also known
as the Dying Tents, where they would most likely expire quietly with
compassionate but useless treatments. From our vantage of hindsight it is not
surprising that giving anaesthesia to a casualty with severe anaemia or
haemorrhagic shock would be poorly tolerated if not lethal. This would apply to
spinal anaesthesia or general anaesthesia using chloroform or ether at a time
when oxygen cylinders were not common on the Western Front. The casualties were
therefore assigned to non-surgical conservative management and transferred to
the dying tents where they quietly died.
However
Dr.Bruce Robertson had an experience and an insight that was to drive him to challenge
the RAMC early protocol and to work tirelessly to convert his British medical
colleagues to use blood as a resuscitating agent. His previous experience set
him in a unique position to be the pioneer at the early stages of WW1.
He qualified
in medicine from Toronto Medical School in 1909 and interned in surgery at
Toronto Hospital for Sick Children. He then moved to the Bellevue Hospital in
New York where he trained in paediatric and orthopaedic surgery and then later
at the Children’s Hospital Boston. He returned to Toronto Hospital for Sick
Children in 1913. During his time in the United States he saw at first hand the
pioneering work of the small group of American doctors who were revisiting the
value of blood transfusion which Europe had then abandoned. This was the fortuitous
experience that made him the ideal clinician to make the changes needed when he
was to see scores of war casualties suffering from haemorrhagic shock and
severe anaemia on the Western Front in 1915. New York and Boston at the
beginning of the twentieth century were the medical centres leading the
research into blood transfusion practice with Edward Lindeman at Bellevue and
Richard Lewisohn and Lester Unger at Mount Sinai. Bruce Robertson was duly
inspired and on his return to Toronto Hospital for Sick Children is reputed to
have been the first clinician to give a blood transfusion in that hospital.
When war was
declared in August 1914 Dr.Bruce Robertson, then a surgeon at the Toronto
Hospital for Sick Children and a single man, was among the first Canadians to
volunteer to join the Canadian Army Medical Corps and after some administrative
delays he was to find himself embedded into the RAMC on the Western Front and
dealing with the horrors of the war casualties in base hospitals and Casualty Clearing
Stations in 1915. It was here he was to struggle tirelessly often on a case by
case basis to demonstrate his faith in blood resuscitation to a sceptical if
not hostile military medical establishment. His preferred choice of transfusion
technique was always to use 20 ml glass syringes internally coated with sterile
paraffin wax to delay clotting and aspirate from the donor and then simply
inject into the patient through peripheral intravenous lines. During his time
in France it is recorded that he had numerous episodes of sickness for what was
described then as “flu”. In retrospect it is possible that his personal medical
history of frequent breakdowns could be interpreted as a stress response not
only to the military trauma he was dealing with but also to the burden of
knowledge that he carried of how this serious haemorrhagic shock and severe
anaemia mortality could be easily prevented. It is a testament to his
dedication, personality, and powers of persuasion that by 1916 he had won over
many senior members of the medical military establishment and with assistance
from his superiors he was able to publish his seminal paper in July 1916 in the
British Medical Journal just one week after the start of the Battle of the
Somme. It was difficult when working in Casualty Clearing Stations and base
hospitals to collect follow up data on his patients as they were quickly
referred down the line or back to England to make space for new casualties and
his unique method of data collection was to give his patients addressed
envelopes for them to post back to him details of their clinical progress. His
poor health finally resulted in him being invalided back to Canada in February
1918.
The USA
entered the war in April 1917 and when their medical teams arrived in France
they consolidated the practice of blood transfusion which by that time had been
accepted by the RAMC. It was the Canadians and especially Bruce Robertson who
had made the initial pioneering breakthrough in Europe during WW1 beginning the
transformation of the dying tents to resuscitation wards which was to lead to
the global acceptance of the value of blood transfusion. Sadly Bruce Robinson
died at the age of 37 from the Toronto flu epidemic in 1923 leaving a widow and
2 young children. In St.Andrew’s Church Simcoe Street Toronto there is a
commemorative plaque to his memory which gives him the due credit for bringing
blood transfusion to the British army and thereby to the world.
For decades after WW1 his rightful pioneering place
in the history of blood transfusion was much neglected as his personal testimony
was absent because of his untimely death but the more recent scholarly historical
research by Kim Pelis [2] has given him the credit which he justly deserves and
given us this historical publication centenary all in Toronto and beyond can celebrate
with gratitude.
Raymond Towey
References
1. Robertson L.Bruce.
The Transfusion of Whole Blood: A suggestion for its more frequent employment
in war surgery. Br Med J 1916; 2: 38-40
2. Pelis K. Taking
Credit: The Canadian Army Medical Corps and the British conversion to blood
transfusion in WW1. Journal of the History of Medicine and Allied Sciences
2001; 56,3: 238-277
