It seems obvious that blood itself is the most appropriate fluid to replace blood, and there is no doubt as to its efficacy. On the other hand, to my surprise, it has not shown itself, experimentally, to be so much superior to certain artificial solutions, such as gum arabic, as I expected.
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References
1.
BaylissWilliam, Intravenous injection in wound shock (London, 1918), 20.
2.
BlundellJames, “Experiments on the transfusion of blood by the syringe”, Medico-chirurgical transactions, ix (1818), 56–92. Blundell reported his first human trial (it failed) on 22 December 1818, and this was published as “Some account of a case of obstinate vomiting, in which an attempt was made to prolong life by the injection of blood into the veins”, Medico-chirurgical transactions, x (1819), 296–311. It seems relatively clear that Blundell's “collapse” corresponds with what would now be called haemorrhagic, hypovolemic shock.
3.
CrileGeorge Washington, the American physiological surgeon who re-introduced blood transfusion to medical practice in the early twentieth century, described the results of his first successful transfusion as “a midnight resurrection”. CrileGrace (ed.), George Crile: An autobiography (2 vols, Philadelphia, 1947), i, 166. (I have commented on this strange intersection of biography and autobiography in my paper, “Taking credit: The Canadian Army Medical Corps and the British conversion to blood transfusion in W.W.I.”, Journal of the history of medicine and allied sciences, in press.) Accounts of the effects of blood on the collapsed patient using terms such as “miraculous”, “re-animated” and “resurrection” are pervasive in the literature.
4.
The classic analysis of the placement and power of ideas of purity remains Mary Douglas, Purity and danger: An analysis of the concepts of pollution and taboo (London, 1966, 1984).
5.
In Britain, an official government inquiry into BSE and vCJD was set up in January 1998. The full text of its sixteen-volume report may be downloaded from the official web site, “The BSE Inquiry Report”, http://bse.org.uk (accessed 7 February 2001).
In the United States, for example, the ban extended to anyone who had lived in England and Wales for more than six months.
8.
HoustonF.FosterJ. D.ChongAngelaHunterN.BostockC. J., “Transmission of BSE by blood transfusion in sheep”, Lancet, ccclvi (2000), 999–1000.
9.
In this paper, I extend, and occasionally modify, an earlier study of nineteenth-century transfusion methods. PelisKim, “Blood clots: The nineteenth-century debate over the substance and means of transfusion in Britain”, Annals of science, liv (1997), 331–60.
10.
These dates, like most, are somewhat arbitrary. 1868 marked not only the fiftieth anniversary of James Blundell's first human transfusion; it was also the year that a chemical addition to transfused blood was first formally proposed in England. 1916, on the other hand, was the year William Bayliss introduced his gum acacia solution as a blood substitute. During the course of the Great War, the discussion about blood loss and blood substitutes became quite complex: This story plays an important part in my forthcoming monograph on the history of transfusion and trauma treatment to the First World War.
11.
Historians seem to have focused principally on general claims of late nineteenth-century clinical resistance to the laboratory, and reasons (from “truth” to professional advantage to broad social resonance) for its eventual integration into medicine in the first half of the twentieth century. A good review of these positions (with articulation of their own interpretation) is found in SturdySteveCooterRoger, “Science, scientific management, and the transformation of medicine in Britain c. 1870–1950”, History of science, xxxvi (1998), 421–66. Case studies of the twentieth-century integration of clinic and laboratory may be found in LawrenceChristopher, “Moderns and ancients: The ‘new cardiology’ in Britain, 1880–1930”, Medical history, supplement 5 (1985), 1–33; and in Sturdy, “War as experiment: Physiology, innovation and administration in Britain, 1914–1918: The case of chemical warfare”, in CooterRogerHarrisonMarkSturdySteve (eds), War, medicine and modernity (Stroud, 1998), 65–84. I am interested in cases on the other side of that nineteenth/twentieth century divide. Lawrence qualifies his presentation of clinical resistance to science in practice (if not always in rhetoric) by pointing out that his resistant élite tended to have top positions at London's prestigious voluntary hospitals. There were others — Specialists, for example — Who were more open to the tools of science. Lawrence, “Incommunicable knowledge: Science, technology and the clinical art in Britain, 1850–1914”, Journal of contemporary history, xx (1985), 503–20. It is men closer to the latter category who are the focus of the first part of the present paper.
12.
As will become evident, I do not use ‘physiology’ in any absolute, essential sense; thus, the “shifting” undercurrent. I am suggesting that the very changes in the persons, institutions, and ideas then attached to ‘physiology’ both permitted a blood substitute to be sought and guided the composition of the substitute proposed.
13.
SevernCharles (ed.), James Blundell's “Lectures on the principles and practice of midwifery” (London, 1839), 249.
14.
Blundell was particularly impressed by the recent investigations of Charles Turner Thackrah, who had turned his prize-winning dissertation into a treatise in 1819. ThackrahC. Turner, An inquiry into the nature and properties of the blood, as existent in health and disease (London, 1819).
15.
BlundellJames, “Some remarks on the operation of transfusion”, from Researches physiological and pathological: Instituted principally with a view to the improvement of medical and surgical practice (London, 1824), 92. The book's title itself testifies to Blundell's beliefs about the relations of science and medicine.
16.
It was Blundell who introduced human-to-human blood transfusion into medical practice. The idea was being discussed, however, well before 1818. In 1805, for example, one of John Haighton's midwifery students reported Haighton as lecturing that, in cases of severe haemorrhage, “something must be done to stop the struggle. If left to yourself you would convey 30 or 40 oz. of blood into the system by the process of transfusion, but this could seldom be done in sufficient time, and if it could the prejudice is such as to prevent you”. “Unidentified student's notes [ca. 1805]”, taken in HaightonJohn, A syllabus of the lectures on midwifery delivered at Guy's Hospital (London, 1799), 131. Manuscript at the Wellcome Archives. Haighton was Blundell's uncle and predecessor at Guy's.
17.
WallerCharles, “On transfusion of blood, its history, and application in cases of severe haemorrhage”, Transactions of the Obstetrical Society of London, i (1859), 61–72. By this time Blundell, still very much alive, had severed all connections to medical institutions, enjoying instead a lucrative private practice.
18.
See Pelis, op. cit. (ref. 9), 340–1, for more on defibrination.
19.
Despite overwhelming evidence to the contrary, the myth that ignorance of blood typing and fear of disease transmission led to the fall of transfusion in the nineteenth century persists. Doctors did sometimes note reactions that would now be classified as haemolytic; then, however, they were generally thought to be the product of small clots in the transfused blood. The possibility of syphilis transmission was occasionally noted but, at least in England, did not in any observed way drive the early search for blood alternatives. This may have been a product of the most common identities of English patient and donor: The birthing mother and her husband. If the husband had syphilis, it most probably would have been transmitted already by means other than transfusion. The next two donor sets, too — Doctors and coachmen — May have been assumed trustworthy in reporting their state of health.
20.
The Lancet published a number of articles on international efforts to replace human blood; the British medical journal, on the other hand, essentially ignored the phenomenon. See “Transfusion with lamb's blood”, Lancet, 1874, i, 777; “A transfusor in trouble”, Lancet, 1875, i, 37. In Britain, transfusion with lamb's blood was attempted at the German Hospital. “Transfusion”, Lancet, 1874, ii, 462. A participant in the operation, FarberC.Dr, the hospital's Resident Medical Officer, wrote a letter to the journal following its notice of this transfusion. Farber commented that “in Germany direct transfusion from the lamb is coming into fashion just now, and has already proved a most powerful remedy in very different diseases”. FarberC., “Transfusion at the German Hospital”, Lancet, 1874, ii, 541. Clearly, these fluids were used to overcome a variety of problems presented by blood.
21.
“Transfusion with milk”, Lancet, 1876, i, 937. PlayfairW. S. pointed out that the operation was also supported by Brown-SéquardC. E. on the basis of animal experiments. PlayfairW. S., A treatise on the science and practice of midwifery (3rd edn, 2 vols, London, 1882), ii, 254.
22.
“Blood drinking”, Lancet, 1876, ii, 346.
23.
An exception is found in Robert Barnes, who supported the addition of saline or milk to blood, as well as transfusion with animal blood: “To supply an answer to a vulgar dread that with the blood of animals some noxious vital principle may be imparted, it ought to be enough to remember that man lives upon the flesh and blood of animals.” He went on to mention Galton's pangenesis experiments, in which blood of other species was injected into rabbits, as providing further evidence for the safety of foreign blood. BarnesRobert, Lectures on obstetric operations (3rd edn, London, 1876), 575–7, p. 577.
24.
Summary of talk given to “Midwifery” section of the British Medical Association Annual Meeting. HicksJ. Braxton, “On transfusion, and new mode of management”, British medical journal, 1868, ii, 151. I have drawn attention to the term ‘saline’ solution to underscore its meaning for those using it in the 1860s and 1870s. While we tend to assume a mixture of sodium chloride and water, they used it to describe the solution resulting from any salt dissolved in water.
25.
It is unclear whether Hicks himself made the claim of safety (which would not be assumed today), or whether it was the journalist reporting on the annual meeting. Hicks, op. cit. (ref. 24), 151.
26.
Braxton Hicks credited Pavy with this suggestion in the “Discussion” following E. A. Schaefer's presentation before the Obstetrical Society of London, “Report of experimental inquiry, instituted to determine with what fluids and by what methods the operation of blood-transfusion may best be performed, and to ascertain the effects, immediate or remote, which result from the operation in animals”, Transactions of the Obstetrical Society of London, xxi (1879), 316–47, p. 345.
27.
Brief biographical sketches of several early British physiologists may be found in Sharpey-SchaeferEdward, History of the Physiological Society during its first fifty years, 1876–1926 (London, 1927). Pavy's sketch is on p. 28. Pavy had received his medical education at Guy's and the University of London.
28.
Hicks, op. cit. (ref. 24).
29.
ElliotAndrew, “Transfusion: With special reference to intravenous infusion of saline solution” (M.D. Thesis, Edinburgh University, 1894), 16–22. Elliot appears to have studied medicine at the West London Hospital in 1892/93, then taken his M.D. thesis at Edinburgh. 1 am grateful to Michael Barfoot for kindly bringing this thesis to my attention.
30.
For a review of the apparatus debate, see Pelis, op. cit. (ref. 9), 345–9.
31.
“Committee to investigate the subject of transfusion”, Transactions of the Obstetrical Society of London, xiv (1872); proposed by Charles Henry Felix Routh, p. 20. This committee was composed of the OSL's most esteemed members, including DavisJohn HallMeadowsAlfredWellsT. Spencer. In 1873, Wells left the committee; in 1874, James Hobson Aveling joined it. It should also be noted that this inquiry was being conducted in the broader context of obstetricians' efforts to keep midwives out of the more profitable parts of their trade. One might hypothesise that a well-timed study of a potentially life-saving procedure that could be performed only by trained doctors would have aided their cause. For a participant's perspective on the midwife controversies, see AvelingJames Hobson, English midwives: Their history and prospects (London, 1872; rev. edn, 1967). An excellent historical overview is given in Ornella Moscucci, The science of woman: Gynaecology and gender in England, 1800–1929 (Cambridge, 1990).
32.
“Transfusion”, Lancet, 1873, i, 216.
33.
PriestleyWilliam, “President's Address”, Transactions of the Obstetrical Society of London, xvii (1875), 36–45, p. 44.
34.
MadgeHenry, “On transfusion of blood”, British medical journal, 1874, i, 42–44, p. 44.
35.
The Council's approval for this physiological study appears in PriestleyWilliam, “Annual address”, Transactions of the Obstetrical Society of London, xix (1877), 17–36, p. 29. It is discussed in PlayfairW. S., “Annual address”, Transactions of the Obstetrical Society of London, xxii (1880), 55–72, p. 61.
36.
The state of English physiology at mid-century is discussed in several sources. See GeisonGerald L., “Social and institutional factors in the stagnancy of English physiology, 1840–1870”, Bulletin of the history of medicine, xlvi (1972), 30–58; and FrenchRichard D., Antivivisection and medical science in Victorian society (Princeton, 1975). For a review of the complex lineage and basic ideas of nineteenth-century Continental physiology, RothschuhKarl E., History of physiology (Huntington, NY, 1973).
37.
After taking his M.D. at Edinburgh in 1823, Sharpey studied anatomy in London, surgery and natural history in Paris, and physiology (under Johannes Mueller's teacher, Karl Rudolphi) in Berlin. In 1836, he was offered the chair of General Anatomy and Physiology at University College, London, which he held until 1874. Sharpey-Schaefer, op. cit. (ref. 27), 17–19.
38.
Stella Butler provides a detailed account of Sharpey's efforts to establish physiology in Britain — From his place on the General Medical Council to his nurturing efforts to grow his own department at University College. ButlerStella V. F., “Science and the education of doctors in the nineteenth century: A study of British medical schools with particular reference to the development and uses of physiology” (Ph.D. thesis, University of Manchester, 1981), chs 2 and 3.
39.
Both Schaefer (who later changed his name to Sharpey-Schaefer) and Pavy were founding members of the Physiological Society. Sharpey and Charles Darwin were named Honorary Members. Sharpey-Schaefer, op. cit. (ref. 27), 13.
40.
SturdyCooter, op. cit. (ref. 11); Lawrence, op. cit. (ref. 11). See also ShorttS. E. D., “Physicians, science, and status: Issues in the professionalization of Anglo-American medicine in the nineteenth century”, Medical history, xxvii (1983), 51–68. For the American parallel to this story, with an emphasis on the embrace of science as a professional strategy, see GeisonGerald L., “Divided we stand: Physiologists and clinicians in the American context”, in VogelMorris J.RosenbergCharles E. (eds), The therapeutic revolution: Essays in the social history of American medicine (Philadelphia, 1979), 67–90. A more recent study of experimental medicine in America, which attempts to combine explanations from science and culture, is WarnerJohn Harley, “The fall and rise of professional mystery: Epistemology, authority and the emergence of laboratory medicine in nineteenth-century America”, in CunninghamAndrewWilliamsPerry (eds), The laboratory revolution in medicine (Cambridge, 1992), 110–41.
41.
Playfair, op. cit. (ref. 35), 41. Of course, the actual influence this report had on the way ordinary, individual general practitioner-obstetricians did or did not perform transfusion is another matter. To answer such questions of day-to-day practice, if at all possible with extant records, would take an overwhelming amount of detective work: A problem which, in itself, sheds light on the complex issues surrounding any detailed appreciation of the relations between clinic and laboratory in the last third of the nineteenth century.
42.
Moscucci, op. cit. (ref. 31), provides a good example of how, in the 1880s, hospital surgeons effectively prevented many obstetricians with gynaecological aspirations from performing ovariotomies.
43.
According to Butler, Guy's gave the most active support to physiology research of the London teaching hospitals during the nineteenth century. Butler, op. cit. (ref. 38), 82. It may be no coincidence that Guy's also was a leading location for the study of transfusion.
44.
Schaefer, op. cit. (ref. 26), 319. During the 1870s, blood transfusion was being used to treat an increasing array of conditions, from chronic anaemia to bacterial infection. While such efforts were being carried out in England, too, English transfusion remained firmly in obstetrical hands until the final decade of the century.
45.
Schaefer repeated many of these experiments, both in vitro and in vivo; confirming Landois, he described what would now be called a haemolytic reaction: Destruction of red cells, bloody urine, potential for emboli, and possible death. Schaefer, op. cit. (ref. 26), 316–19. It would be another twenty-five years before Karl Landsteiner recognized that human blood itself came in different types, which could be mutually incompatible.
46.
Schaefer, op. cit. (ref. 26), 320, 321. Schaefer's blood pressure measurements were on animals. At this time, blood pressure apparatus, though popular in laboratory experiments, were not yet adapted for use at the bedside. Yet, after 1896, when clinical apparatus became available, English clinicians in general tended to prefer the measurement of their trained finger to that of the instrument. Lawrence, “Moderns” (ref. 11), 9–10.
47.
Schaefer, op. cit. (ref. 26), 319. The physiologist Ernest Starling confirmed that this post-haemorrhagic blood dilution had been “known to physiologists for the last fifty years”. StarlingE. H., “On the absorption of fluids from the connective tissue spaces”, Journal of physiology, xix (1896), 312–26, p. 314. Schaefer's confident interpretation of this observation was, however, far from conventional clinical wisdom in 1879.
48.
Schaefer, op. cit. (ref. 26), 319–20.
49.
Schaefer, op. cit. (ref. 26), 321. The emphasis is Schaefer's.
50.
Schaefer comments about the transfused dog that “the patient was strong enough to run about, and take its usual food the next day”. This and the above quotations from Schaefer, op. cit. (ref. 26), 328.
51.
Schaefer, op. cit. (ref. 26), 328.
52.
I use the terms “shock”, “collapse”, and “exhaustion” with qualification. Throughout the nineteenth century (and, indeed, into the twentieth), they were used with a kind of fluidity that prevents any simple description of their respective meanings.
53.
Little himself described the lineage of saline infusions for cholera treatment. LittleW. J., “Notes of unsuccessful and successful cases of saline alcoholic injections into the veins for relief of collapse of malignant cholera, treated during the epidemic of 1848–9”, Clinical lectures and reports, by the medical and surgical staff of the London Hospital, iii (1866), 132–68.
54.
I should stress that transfusion was thought of as an operative procedure, relying as it did upon ‘cutting down’ on veins. This operative status would persist into the twentieth century, arguably even until blood banking replaced hospital-based donation.
55.
JenningsCharles Egerton, Transfusion: Its history, indications, and modes of application (London, 1883), 3.
56.
Jennings, op. cit. (ref. 55), 1–2. Jennings was one of the few doctors of his day to bring attention to the dangers of infection, both to donor and patient. He continued his story by pointing out that the poor donor might develop “an ugly-looking pulsatile tumour” where the blood had been taken, giving him the role of hospital patient. Slightly later (p. 3), he mentioned — In passing, but still significantly — The dangers inherent in emergency transfusion, when there was no time to determine whether the donor had syphilis or “other specific communicable diseases”.
57.
Jennings, op. cit. (ref. 55), 2.
58.
Jennings, op. cit. (ref. 55), “Author's preface”. The emphasis is Jennings's.
59.
Jennings, op. cit. (ref. 55), 5.
60.
JenningsCharles Egerton, On transfusion of blood and saline fluids (2nd edn, rev., London, 1883), “Author's preface to the second edition”.
61.
WellsT. Spencer, “Special preface”, in Jennings, op. cit. (ref. 60). Wells qualifies, with Jennings, that this substitution would be “within certain limits”.
62.
The most significant textual change comes in the second edition's inclusion of several cases in which blood or saline had been used to treat a variety of conditions other than acute haemorrhage. Included in this list is Mackenzie's work on using intravenous saline for treatment of diabetic coma. Jennings, op. cit. (ref. 60), 35–37.
63.
Jennings, op. cit. (ref. 60) described both his donor difficulties (p. 5) and the case itself (p. 25), which appears to have occurred in August 1882.
64.
Jennings, op. cit. (ref. 60), 48. (He cites Schaefer's work on p. 51.) Jennings was elected as a Fellow of the OSL in 1882.
65.
He continues: “which, whilst sternly denying to us the right of experimenting on lower animals, in no way prohibits, and probably never contemplated the performance of experiments on men!” Jennings, op. cit. (ref. 60), 49.
66.
JenningsCharles Egerton, “Report of two experimental transfusions on dogs, performed in Guy's Hospital Laboratory”, Lancet, 1883, ii, 364–6, p. 364.
67.
Jennings, op. cit. (ref. 60), 57.
68.
Jennings, op. cit. (ref. 60), 57. The emphasis is again Jennings's. In preserving a place for blood's nutritive property, Jennings did believe that a blood/saline combination would be better than saline alone “in some rare cases, such as carbolic acid poisoning and some of the varieties of chronic anaemia”.
69.
Spallanzani's ideas, which he set forth in 1803, challenged Lavoisier's belief that respiration, as well as the production of animal heat, took place when the blood passed through the lungs. An elegant presentation, and interpretation, of the eventual acceptance of tissue respiration is CulottaCharles A., “Tissue oxidation and theoretical physiology: Bernard, Ludwig, and Pflueger”, Bulletin of the history of medicine, xliv (1970), 109–40.
70.
Culotta, op. cit. (ref. 69), 116–20 (on Bernard); 120–8 (on Ludwig and his school). Culotta emphasises that neither Bernard nor Ludwig denied that respiration occurred in the tissues; rather, they objected to the view that the tissues, and not the blood, controlled the process (p. 128).
71.
Culotta, op. cit. (ref. 69), 139–40, 130. Rothschuh, op. cit. (ref. 36), 226, further underscores the teleological framework in which Pflueger viewed his physiological studies.
72.
I have found the following description of Ringer's typical workday such a striking portrait of a London clinician's determination to conduct both clinical and laboratory work — At a time when institutional structures hardly facilitated such efforts — That I quote it at length: “he would rise early, dispatch a hasty breakfast at eight, and the next few minutes would see him on his way to hospital, always on foot, carrying, perhaps, with him some casual co-breakfaster, astonished at the celerity of things. The hospital visit would generally, in pharmacological days, conclude with a quick-change appearance in the physiological laboratory — Ringer the physician transformed into Ringer the pharmacologist…. ‘Fielder!’ would have been hailed, a tracing taken, various suggestions made, and off he was again on his way back to Cavendish Place and the morning's consulting work…. The afternoon would be filled with visits, consultations, the hospital round, a post-mortem examination, and again, when possible, and for as long as possible, a visit to the laboratory. His attraction to this workshop was quite wonderful. Nothing could withstand it, not even the college palings, over which he clambered in the dark, upon one occasion at least, when the gates would not yield.” “Obituary, Sidney Ringer”, British medical journal, 1910, ii, 1384–6.
73.
BynumWilliam F., “Sydney Ringer”, Dictionary of scientific biography, xi, 462–3. Butler, op. cit. (ref. 38), 214–20, describes the contrast between the Univerity College lab's openness to a wide variety of projects, and the focused investigations that took place in Michael Foster's Cambridge lab. On Foster and his laboratory, see GeisonGerald L., Michael Foster and the Cambridge school of physiology: The scientific enterprise in late Victorian society (Princeton, 1978).
74.
Ringer described his work in a series of papers published in the Journal of physiology between 1882 and 1885. His findings came independently of S. A. Arrhenius's work on electrolytic dissociation. Bynum, op. cit. (ref. 73), 462–3.
75.
To twenty ounces of distilled water, Jennings added sodium chloride and, in lesser amounts, potassium phosphate, “sulphate of soda”, “carbonate of soda”, and “phosphate of soda”. He carried pre-prepared packets of this salt mixture (as had Little before him) in his apparatus case. In some cases — Again, following Little — He added “absolute alcohol” to his saline mixture. Jennings, op. cit. (ref. 60), 56.
76.
Elliot, op. cit. (ref. 60), 22–23, cites several Continental reports of successful saline infusion from 1881–82.
77.
Jennings mentions this research trip in the 1888 edition of his transfusion treatise. JenningsCharles Egerton, “Author's preface to the third edition”, On transfusion of blood and saline fluids (3rd edn, London1888).
78.
Jennings, op. cit. (ref. 77). It is here that Jennings thanks Schaefer, Ringer for “discussing various scientific points at length with me”.
79.
Jennings, op. cit. (ref. 77), 57. That Jennings continued to hold to blood's nutritive value, and did not simply omit revisions of this passage from the earlier editions, is strongly suggested by a discussion held on a transfusion apparatus presented to the Harveian Society in 1885. Jennings, having championed the case of saline, qualified his assertion, which was noted in the Lancet's summary of the evening: “the nutritive value of blood was not to be underrated; and where transfusion was indicated for the sake of nutrition, the employment of whole blood would be better than that of defibrinated blood.” “Meeting, Harveian Society of London”, Lancet, 1885, i, 664.
80.
HorrocksPeter, “Saline transfusion”, British medical journal, 1892, ii, 491.
81.
On the young Wooldridge (he was 32 when he died), see O'ConnorW. J., British physiologists, 1885–1914: A biographical dictionary (Manchester, 1991).
82.
WooldridgeL. C., “The coagulation question”, Journal of physiology, x (1889), 329–40. This paper was published posthumously, with a note by Michael Foster. The article is in fact a spirited defence of his own work against the critiques of W. D. Halliburton.
83.
HunterWilliam, “Summary of three lectures on transfusion: Its physiology, pathology, and practice”, British medical journal, 1889, ii, 116–19, 237–40, 305–9. Hunter's work came at a time when several European investigators, whose studies he cited, were reaching the same conclusions.
84.
Elliot, op. cit. (ref. 29), 20.
85.
Whereas Elliot, following Jennings, tended to use around two pints of saline, Bernard Pitts, at St Thomas's hospital, infused between four and thirteen pints into his patients. PittsBernard, “The history of transfusion, with short notes of cases in which the method of infusion of saline fluid into the veins has been adopted”, Saint Thomas's Hospital reports, xxi (1893), 253–70, 262–4. Both authors describe these patients as “collapsed” or “exhausted”; Pitts adds “moribund” and, in one instance, refers to the condition as “shock”.
86.
Moscucci, op. cit. (ref. 31) tells this story in ch. 6.
87.
My initial review of later literature suggests that obstetrical interest in blood transfusion was only rekindled in the 1930s, when concerns about maternal mortality became acute.
88.
Elliot, op. cit. (ref. 29), 53. The case of 13 transfused pints is in Pitts, op. cit. (ref. 85), 263. It is possible that Wooldridge and Horrocks were conducting the work at Guy's in the 1880s that encouraged the use of mass infusions; further research must be done before this hypothesis can be stated with more certainty.
89.
EnglishPeter C., Shock, physiological surgery, and George Washington Crile: Medical innovation in the progressive era (Westport, CT and London, 1980), ch. 6.
90.
English argues that Crile's use of blood pressure measurement was key to his understanding of the nature and treatment of shock. English, op. cit. (ref. 89), chs. 5 and 6. In hospital, where most doctors were estimating the effects of saline, blood pressure measurements were not yet taken. At the same time, it is also possible that Crile's ideas about blood itself had some considerable bearing on his interpretation of the relative efficacy of the two fluids.
91.
Butler, op. cit. (ref. 38), ch. 3, describes this process. Geison, op. cit. (ref. 73), 151, suggests that the addition of physiology in 1870 to the subjects examined for the MRCS “may have been the single most important factor in the transformation of late Victorian physiology”.
92.
Wooldridge was one of three men who shared the position of teaching practical physiology at Guy's. It was not until several years later that the position was consolidated and filled by a single individual. MichelC. C., “Starling: The formulation of his hypothesis of microvascular fluid exchange and its significance after 100 years”, Experimental physiology, lxxxii (1997), 1–30, pp. 2–3.
93.
Not only did Starling take Wooldridge's position at Guy's, he also eventually married Wooldridge's widow. Michel, op. cit. (ref. 92), 2–6. Jens Henriksen's biography of Starling appeared last year; however, I have not yet been successful in my efforts to find a copy. HenriksenJens H., Ernest Henry Starling (1866–1927), physician and physiologist: A short biography (Copenhagen, 2000).
94.
Michel, op. cit. (ref. 92), 3. Starling was awarded scholarships by the British Medical Association and the Grocer's Company.
95.
Butler, op. cit. (ref. 38), 80–82.
96.
Starling lays out pieces of Heidenhain's theories and evidence in his own publications; Michel brings them together nicely. Michel, op. cit. (ref. 92), 6–7. In his presentation of Heidenhain's work, Rothschuh is relatively cautious about vitalistic labels, arguing that, principally, Heidenhain abhorred over-hasty reductionism, preferring biological explanations while avoiding vitalism proper. Rothschuh, op. cit. (ref. 36), 231–2. This may well be so: I have not studied Heidenhain's work directly. It is clear, however, that Starling and his collaborator saw a vitalistic component in Heidenhain's interpretations: “the force which causes absorption … is clearly something more than osmosis, and that it originates in the vital properties of the intestinal epithelium, Prof. Heidenhain argues, is rendered probable….” LeathesJ. B.StarlingErnest H., “On the absorption of salt solutions from the pleural cavities”, Journal of physiology, xviii (1895), 106–16, p. 107. Quite possibly, the answer simply comes down to one's definition of the ever-slippery concept, ‘vitalism’.
97.
Michel plausibly suggests that Wooldridge encouraged Starling to take up the question of lymph formation. Michel, op. cit. (ref. 92), 6.
98.
Michel clearly and systematically lays out how Starling overturned each of Heidenhain's hypotheses. Michel, op. cit. (ref. 92), 7–9. See WilsonLeonard G., “Starling's discovery of osmotic equilibrium in the capillaries”, Episteme, ii (1968), 3–25.
99.
In the final chapter of her dissertation, Butler argues persuasively that Starling, in the early part of the twentieth century, articulated a holistic concept of the body (based on his hormone work) that, in Bernardian fashion, relied on physico-chemical explanations but saved a special place for life in organization itself. Butler, op. cit. (ref. 38), ch. 7.
100.
Starling's ongoing fascination with Claude Bernard's milieu interieur was most fully realized in 1923, in his Harveian Lecture. StarlingErnest, “The wisdom of the body”, Lancet, 1923, ii, 865–70.
101.
IhdeAaron J., The development of modern chemistry (New York, 1964, 1984), 410–13, provides a good summary of nineteenth-century work on osmotic pressure.
102.
I have found that the botanical experiments of Hugo de Vries provide a good illustrative example of osmosis. When he placed a plant in plain water, the plant became turgid. When he placed it in a moderately concentrated salt solution, it withered. Finally, when he used a solution that had the same salt balance as was found in the plant itself, the plant remained unchanged. Ihde, op. cit. (ref. 101), 411.
103.
StarlingErnest, “Contributions to the physiology of lymph secretion”, Journal of physiology, xiv (1893), 131–53.
104.
StarlingTubbyAlfred H., “On absorption from and secretion into the serous cavities”, Journal of physiology, xvi (1894), 140–55; LeathesStarling, op. cit. (ref. 96).
105.
Starling, op. cit. (ref. 47), 312–13, 313. Orlow had originally demonstrated this in 1894.
106.
Starling, op. cit. (ref. 47), 317.
107.
Starling, op. cit. (ref. 47).
108.
StarlingErnest, “The glomular functions of the kidney”, Journal of physiology, xxiv (1899), 317–30. For an overview of the history of renal physiology, with particular reference to Starling, FineLeon G., “British contributions to renal physiology: Of dynasties and diuresis”, American journal of nephrology, xix (1999), 257–65.
109.
Starling, op. cit. (ref. 108), 322.
110.
Starling, op. cit. (ref. 108), 328.
111.
Michel, op. cit. (ref. 92), 3. Starling was a firm believer in the value of collaboration.
112.
Bayliss married Starling's sister in 1903. For a first-hand review of the Starling/Bayliss collaboration, see HillA. V., “Bayliss and Starling and the happy fellowship of physiologists”, Journal of physiology, cciv (1969), 1–13. (This was, in fact, the “Third Bayliss-Starling Memorial Lecture”.) Also, FlemingP. R., “The other Bloomsbury set: Bayliss, Starling, and Thomas Lewis”, International journal of microcirculation, xiv (1994), 91–94. The pair are perhaps most famous for their discovery of secretin in 1902.
113.
Butler, op. cit. (ref. 38), ch. 5.
114.
StarlingErnest, “The chemical correlation of the functions of the body”, Lancet, 1905, ii, 339–41, 423–5, 501–3, 579–83, p. 340. Butler argues that Starling's hormone concept mirrored his ideas for the reform of medical education, thereby providing scientific justification for his social ideas. Butler, op. cit. (ref. 38), ch. 7. There is certainly an overlap in Starling's thinking about the functions of hormones and the ideal system of medical education. And, there is that coincidence of timing between Starling's hormone work and his move to University College. Yet, it seems that one must take account of Starling's earlier interest in Heidenhain's theories to decide whether he developed the science to substantiate the social, or instead tended to see the world generally in these organizational terms.
115.
CowellErnest, “Wound shock in front line areas”, in MacphersonW. G.BowlbyA. A.WallaceCuthbertEnglishCrisp (eds), Official History of the War — Medical Services — Surgery of the War (2 vols, London, 1922), i, 58–78, p. 59.
116.
Several historians of medicine have underscored what appears to be a sudden interest on the part of physiologists in clinically-relevant questions during the war. In the war-time debate on fluid replacement, we see a complex set of interactions between physiologists, surgeons, and several who fall between the two categories in a fashion seemingly related to the institutions that gave them their medical training. I will develop these relationships more fully in my forthcoming monograph.
117.
RobertsonL. Bruce, with a note by WatsonC. Gordon, “Further observations on the results of blood transfusion in war surgery”, British medical journal, 1917, ii, 679–83, p. 683.
118.
On the Canadian support of blood, see Pelis, op. cit. (ref. 3).
119.
Starling was, in fact, named chairman of the Medical Research Committee's special committee on shock. By this time, however, his physiological interests lay elsewhere. (He was also working on gas poisoning and nutrition.) When he resigned from his position on the shock committee in March 1918, it was Bayliss who became chairman. “Special committee on shock and allied conditions. Minute Book”, 13 March 1918, Public Records Office, London, PRO FD1/5262.
120.
KnowltonFrank P., “The influence of colloids on diuresis”, Journal of physiology, xliii (1911), 219–31, p. 220.
121.
Knowlton, op. cit. (ref. 120), 231. From Cincinnati the following year, HoganJames J.FischerMartin H. published their independent findings on the effects of gelatine on fluid retention. HoganJames J.FischerMartin H., “Zur theorie und praxis der transfusion”, Kolloidchemische Beihefte, iii (1912), 385–416. I have done no further research on Hogan and am therefore uncertain as to why he decided to publish his work in German.
122.
Starling, on the other hand, did join the Royal Army Medical Corps, but found that his personal philosophy of integrated collaboration and the army's preference for hierarchy and discipline didn't mix. Starling soon decided he would serve his country's interests better back in London and resigned his commission. Michel, op. cit. (ref. 92), 5. It should also be noted that British physiologists did not confine their efforts to improving the defensive part of the war effort. On the war work of the Medical Research Committee and the Royal Society, see SturdySteve, “From the trenches to the hospitals at home: Physiologists, clinicians and oxygen therapy, 1914–30”, in PickstoneJohn V. (ed.). Medical innovations in historical perspective (Basingstoke, 1992), 104–23.
123.
It is quite possible that ElliottT. R., the Medical Research Committee's official liaison in France, alerted Bayliss to the problem. Elliott had been conducting physiological research at Cambridge for several years before coming to University College in 1906 to study medicine. In 1910, he was appointed Assistant Physician at UC Hospital. In France during the war, Elliott was concerned quite early on with the treatment of acute blood loss and may well have asked Bayliss to work on the problem. The official announcement of the impending formation of the “shock committee” came in March 1917. “Memorandum upon surgical shock and some allied conditions”, Lancet, 1917, i, 502–5.
124.
BaylissW. M., “Methods of raising a low arterial pressure”, Proceedings of the Royal Society of London, B, lxxxix (1917), 380–93. Bayliss submitted the paper on 29 August 1916. As was commonly done through the First World War, Bayliss divided the condition once called “collapse” into two clinically similar, but etiologically distinct, categories. On the one hand, there was haemorrhage, with its evident fluid loss; on the other, was “pure shock”, which was not, he argued, the result of fluid loss, but of “peripheral vaso-dilation”. The relations between these two categories is too complex for consideration at this time; therefore, I will treat only his work on haemorrhage.
125.
Bayliss, op. cit. (ref. 124), 380. During the war, advocates of both blood and blood substitutes claimed that their choice was the most “efficient” fluid.
126.
This was Poiseuille's Law, applied to blood vessels by the likes of Mueller and du Bois-Reymond. Bayliss, op. cit. (ref. 124), 382.
127.
Bayliss, op. cit. (ref. 124), 386–7.
128.
Bayliss, op. cit. (ref. 124), 388; 393. A year earlier in the United States, James Hogan — Whom we saw working on colloids earlier — Advocated instead the addition of gelatine for the treatment of shock. HoganJames J., “The intravenous use of colloidal (gelatin) solutions in shock”, Journal of the American Medical Association, lxiv (1915), 721–6. In this article, Hogan greatly simplifies his colloidal studies for his medical audience.
129.
Bayliss, op. cit. (ref. 1), 80. Bayliss appears to have chosen gum acacia over gelatine shortly after submitting this paper. The best proportion of acacia was debated by those who used it.
130.
Bayliss, op. cit. (ref. 1), 85. Gum acacia was comprised of “a mixture of polymerised anhydrides of galactose … and of a pentose sugar, arabinose … in varying proportions”.
131.
Although surgeons and physiologists technically worked together to solve the problem of shock in wartime, their collaboration was far more complex than has generally been appreciated.
