Blood, sweat and tears; Blood: an epic history of medicine and commerce; Douglas Starr; Alfred A. Knopf, New York; Random House of Canada, Toronto; 1998; 441 pp. $38.50. ISBN 0-679-41875-X
After witnessing the recent humiliation of the national transfusion service of the Canadian Red Cross, it is sobering to read about the sacrifices through which blood transfusion services were developed in the first place. As unthinkable as it would be now to have no access to blood transfusion, a few decades ago it was equally unrecognized that such a service was possible. Douglas Starr's well-written narrative starts with ancient beliefs in the spiritual and emotional power of blood and leads us through two world wars to the spread of dreaded diseases by the very blood supply that had so laboriously been made available. (Figure)
Starr chronicles the evolution of blood transfusion against the background of major historical events. Most references are to secondary sources, making this a popular history more than a scholarly one. The writing is pleasant and easy but becomes obscure when the author attempts to shoehorn too many facts and events into the narrative.
The desirability of replacing blood during severe hemorrhage was, of course, recognized many years ago. Early attempts to use animal blood were not successful. Transfusion of human blood under desperate medical circumstances was a logical successor to these unsuccessful attempts.
I was surprised to learn how unprepared for battle the blood transfusion services were early in World War II and how the provision of blood and blood products, which saved the lives of many wounded, was in large part due to the private initiative of a small number of physicians. These heroes, most of whom are unsung outside of this literature, defied convention and often risked their careers to develop volunteer blood services that permitted the system to develop. This was particularly important in converting the standard "walking donor" system to one that used stored blood collected at leisure.
The story of Dr. Edwin Cohn and blood plasma is particularly instructive. Whole blood and plasma could be stored safely for only a few days after collection, or so it was believed. During World War II an effective plasma expander that could be collected in the US and shipped overseas was required. Cohn developed an efficient system to extract and freeze human albumin, which was provided to the British army as well. The momentum and success of the system obscured the need for red cells in massive hemorrhage, so that in some engagements American soldiers were deprived of life-saving cells when these were available to British and Canadian soldiers fighting in similar situations. As in most of the situations described, the problem was solved by the efforts of a small number of dedicated individuals.
In sober contrast are Starr's reports of bickering between organizations competing for priority in the new blood system. In many countries, a central national service was accepted immediately and challenged only later when real or imagined shortcomings were perceived. In the US, conflict continued for years between well-meaning and humanitarian people committed to a service run by the Red Cross and those who pushed for a service based on private initiative (which eventually became the American Association of Blood Banks). The exploits of a few mean-spirited people in several countries who used the need for blood banking for personal gain are also described.
The author sweeps into the narrative some arcane accounts concerning, for example, the exclusion or labelling of "Negro blood" in the US, the use of only "Aryan blood" by the German forces (which deprived their troops of adequate blood supplies), the czarevitch's hemophilia, and war crimes in Europe and Manchuria. These are of interest sociologically but are not central to the main story.
The Canadian perspective in this history is a limited one. Norman Bethune's intrepid transfusion service in Spain is well described, as is the important contributions of Dr. Charles Drew, a graduate of McGill who did his work in the US. Plasma fractionation was very advanced in the early years of World War II because of the wonderful interaction of Connaught Laboratories and the Red Cross - with consequent benefit for Canadian servicemen overseas. Canadian plasma was the stored blood product used at Dunkirk. Canada was among the earliest countries to develop blood transfusion services, and one of the first not to use paid donors or prisoners in the collection of blood.
There are a few oversimplifications and inaccuracies, namely, reference to air contact as the cause of clotting in collected blood, a photo caption indicating that blood was packed in dry ice for storage (which would have frozen some of the blood and hemolysed the cells) and similar minor problems.
Starr's book is a good read filled with pathos, humour and serious accounts of the human endeavour and initiative that led to both a major contribution to medical progress and human health, and the vehicle for the spread of HIV, hepatitis C and other diseases. There is clearly no free lunch.