Nine Pints
Page 8
Janet, who spelled vomiting with two t’s but had a First from Oxford, set about becoming a physician. There were rotations in various surgical “firms” (teams of doctors led by a senior consultant). She studied under Bill Williams, a man who threw scalpels at frustrating pupils in the operating theater but who taught her valuable things about wounds and burns that would later be useful in war. For obstetrics, she was sent into the slums. “Terrible poverty,” she told Toynbee. She encountered “a woman with no bed except newspapers.”13 She saw lines of children sitting up in bed with rheumatic hearts, who would die because there was no National Health Service and good health cost money. She saw that poverty is deadly. “How anyone could do medicine in those days,” she wrote, “and not become a socialist I find hard to understand. What I hated most was people’s acceptance: ‘Yes, I have had seven children and buried six, it was God’s will.’ I hated God’s will with a burning hatred.”14
Her brothers were conservatives, but these experiences turned their sister “firmly and forever” into a socialist. The slums introduced her to politics—the best kind of politics, the kind that saves people—but also to blood, her lifelong scientific interest. Anemia accompanied poverty, because good food with a good iron content was costly. The treatment for anemia was arsenic, which to Janet seemed ethically wrong and medically inefficient (it didn’t work). So she did what Oxford had trained her to do and read the literature. She read of George Minot, an American hematologist who had successfully treated anemic patients with raw liver and later won the Nobel Prize.15 This treatment made more sense than arsenic, and she wanted to try it. She was a pathologist by now: her mother had died, and she thought doing lab research rather than hospital rounds would enable her to care better for her widowed father. She did some surreptitious research, arranging with a doctor friend on the appropriate ward to treat his anemic patients with raw liver. “I did the blood counts, the house physician kept a straight face on ward rounds when the senior physician demonstrated to students the magnificent effects of his prescribed treatment with arsenic, and the patients got well.”16
She thought a concentrated liver extract would work even better. She approached her professor of medicine, a man who did not see a woman who was young and think both those things to be handicaps. He said she could test raw liver extract, but first on dogs. “He gave me some money and said I could work in Harrington’s lab, the great chemist, but that I must go and collect the mincing machines of my friends and the pails of my friends because the hospital hadn’t got any mincing machines. So I went round and collected mincing machines, I collected Virginia Woolf’s mincing machine, and I minced liver with Minot’s book lying on the table telling me how to do it and I produced some filthy-looking stuff at the end of it.”17 This became a scene in Virginia Woolf’s A Room of One’s Own: Janet in a kitchen with mincers, Minot’s paper propped open like a recipe book, a parody and inspirational illustration that women can have other occupations than “the perennial interests of domesticity.”18
The extract was fed to one dog, which sickened, then another. The same. Janet said, no more dogs, the extract was too precious. She went home and took the extract herself. “The next morning when I came back to the hospital there were all the professors of medicine, chemistry, surgery, waiting on the doorstep to see if I was still alive.” It was fed to a patient, “a nice old laboring man” who was dying of pernicious anemia.19 He survived, and a senior professor took all the credit for the miraculous new treatment. Janet had other things to do. Her father had remarried, which meant she was released from her weekend visits to Rugby, where she had acted as hostess for him, so she won a Rockefeller Scholarship to Harvard, becoming the only female student there. She wasn’t allowed to work with patients, being a woman, so she ended up with pigeons, using them to do groundbreaking research on vitamin B12 in blood that wasn’t fully acknowledged for fifty years. She called them her Bloody Pigeons.20
How I love the brisk nervelessness of this woman. Some of it comes from privilege. But much of it is her own, as much as her fictional room was. She had the confidence to make fissures in patriarchal concrete, but also the confidence to get married, because she wanted to. She returned from Harvard to marry David Gourlay, who ran the Wayfarers Travel Agency, and they moved into 33 Gordon Square in Bloomsbury, above the business. She kept her name, “not for any feminist reasons, but because I had already published several papers, and it seemed a pity to lose my medical identity.” Which is a good feminist reason.21
At the London Hospital, where she then worked, no one spoke to her in the passageways. Her reputation with blood diseases was known, but if a doctor wanted advice about a patient, he sent a note and she sent one back. She was forbidden from bedside consultations. At lunch, she and Dorothy Russell, later an eminent professor of morbid anatomy, sat with the secretaries. When George Minot came to London on his way to Sweden to fetch his Nobel Prize, he was hosted by the Gourlays. Minot was invited to a formal hospital function, but Janet was not. “I brought him to the door in my car to meet Professors and Physicians [and] I was merely told what time to pick him up, though it was well known that I was acting as his London hostess.”22
She doesn’t sound angry about this, perhaps because she is writing when many of the worst fights seem to have been won, when she helped to fight them. She is angrier about the anemic patients she treated with liver who then said, “Don’t give me any more of that medicine, doctor. It makes me hungry and I can’t afford [to eat].”23 She taught her patients to fight authorities to get extra milk, for the extra iron it would give them. She taught her students that to practice medicine, they must learn to deal with the public assistance board, with bureaucracy, as well as with the hospital dispensary. I like her clear fulmination, which persisted sixty years after the young trainee doctor set out into the slums. I wish she were here to fulminate against the sly dismantling of our welfare state and the National Health Service. She wouldn’t stand for it, as we should not.
The Gourlays built a cottage in the country and called it Plover’s Field. They had two daughters. Just before the birth of her first child in 1934, Janet published The Anaemias, still considered a pioneering hematology textbook. She was invited to set up a department of pathology at Hammersmith Hospital, and she did, and it thrived. She was frequently consulted on obscure blood diseases and drove around London with her car “always full of interesting specimens.”24 She was busy and happy.
But this was the 1930s, and war was coming. First, it came to Spain. Her Bloomsbury friends went to fight, and Vanessa Bell’s son Julian was killed. Vaughan began to work with the Spanish Medical Aid Committee and joined the Communist Party but soon lapsed. She said that no one seemed to notice she had left.25 She sold possessions to raise money for Basque children; she spoke on soapboxes at street corners. The time was tense and unclear. In 1937, the Committee of Imperial Defence had calculated that sixty days of bombardment of London would produce more than a million casualties.26 At the beginning of the 1938 Munich conference, medical staff were told that should the peace negotiations fail, they should expect either thirty-seven thousand or fifty-seven thousand casualties in London that weekend.27 Whatever the figure, Janet knew from the Spanish conflict that “we shall want some blood. We shall want a great deal of blood.”28
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Maybe Medea was the first. The fearsome witch, as written by Ovid, who cut the throat of the aging Aeson, father of Jason, and drained his blood, then refilled him with herbs and potions, and revived him. To revive, to revitalize, to give back life. She wasn’t particularly scientific about it, walking around incanting with her streaming hair, nor did she use blood. Her potion was made from “roots dug from a Thessalian valley,” but also “hoar-frost collected by night under the moon, the wings and flesh of a vile screech-owl, and the slavering foam of a sacrificed were-wolf.”29
But the principle was established, though shakily and magically: that in the same way that the loss of blood could dr
ain a creature of life, a suitable replacement of fluid could bring it back. For two thousand years, humanity definitely liked to let out blood but didn’t think of putting it back anywhere, except through the mouth: the drinking of blood to acquire strength and life force is as old as the (Roman) hills. There were obvious obstacles: blood freed from the vein quickly clots, as it is supposed to. Getting blood back into a vein is a difficult skill that even modern phlebotomists and physicians sometimes lack. And before blood could be moved in and out of the body, its movement around the body had to be understood.
William Harvey, physician to kings, came to understand this, probably in 1616, by cutting open scores of animals to see what their hearts and blood were doing.30 Charles I let Harvey experiment on royal deer, but their hearts were too quick. He could not catch their rhythm or secret. He moved on to the slow-blooded, the cold animals and the dying ones, whose hearts beat slowly, who let him see. He understood that the body operated a one-way system: the heart pushing the blood out through ventricles to the arteries, and the blood returning by the veins, the whole system far more ingenious than most urban planners could devise, because of flaps on the veins that compel the blood to go only one way. (An earlier Italian anatomist called these flaps ostiole, little doors.)31 Harvey published his findings in 1628, including a dedication that manages to be wondrous and wonderfully oleaginous, in which he called the animal’s heart “the basis of its life, its chief member, the sun of its microcosm … [from which] all power arises and all grace stems.” Just like the king, who is “the basis of his kingdoms […] the heart of the state.”32 Oily it may seem, but Harvey’s diplomacy and skill enabled the king’s personal doctor to survive his master’s execution. His findings weren’t accepted. In 1680, John Aubrey wrote that he had heard Harvey say “that, after his Booke of the Circulation of the Blood came out, that he fell mightily in his Practice, and that ’twas beleeved by the vulgar that he was crack-brained.”33
Yet his work began the era of transfusion. Thousands of dogs, horses, lambs, and hens were cut open, their blood drained, replaced, their lives expendable. It became a fashionable quest for the eminent. Sir Christopher Wren was carrying out experiments in 1659. He was, wrote a historian of the Royal Society, “the first author of the Noble Anatomical Experiment of Injecting Liquors into the Veins of Animals. […] By this Operation divers Creatures were immediately purg’d, vomit’d, intoxicated, kill’d or reviv’d according to the quality of the Liquor injected.”34
The attempt to transfuse a man became a race between a few men: Richard Lower was the front-runner in England, backed by the Royal Academy of Science, and Jean-Baptiste Denis, doctor to King Louis XIV, his French competitor. Lower worked with dogs. The descriptions and illustrations of his experiments are gruesome: dogs spread-eagled, their veins or arteries cut, the “emittent” dog connected to the receiver by quills, the experiment judged to be over when the emittent dog began “to cry, and faint, and fall into Convulsions, and at last dye by his side.”35 This was the beginning of the age of pitiless vivisection (which hasn’t ended yet). Another physician, Mr. Thomas Coxe, who experimented with transfusing pigeons, was in 1665 “particularly desired to try the changing of dogs’ skins” and this was not judged to be remarkable.36
The transfer of animal blood—a xenotransfusion—was chosen because blood was believed to contain character that could be transmitted. A lamb would give a man its “mild and laudable” nature, a calf the same. Denis began with lambs’ blood, infusing a young boy who was wasting away, who survived and thrived and grew fat, “a subject of amazement.” There was an older man next, who was purely an experiment, “having no considerable indisposition,” who also survived.37 His most famous case was his final one: two transfusions of Antoine Mauroy, a madman, wife beater, and former valet to nobility. To calm Mauroy’s “phrensy,” Denis chose the blood of a calf. Despite science knowing nothing about blood types or incompatibility or much about the nature of blood, Mauroy’s body at first did not react adversely. The second transfusion was larger, and Denis described, without knowing, hemolytic shock: “As soon as the blood began to enter into his veins, he felt the like heat along his Arm … his pulse rose presently, and soon after we observed a plentiful sweat all over his face.” He vomited up bacon and fat, but the next morning woke calm. “He made a great glass of Urine, of a colour as black, as if it had been mixed with the blood of chimneys.”38 (It was not soot but his dead cells killed by the foreign blood.)
Mauroy survived long enough for Denis to claim that he was the first to successfully transfuse blood into a human. Mauroy soon died; his wife was probably executed for his murder and Denis was disgraced. Lower, meanwhile, also picked a madman: a bachelor of divinity, Arthur Coga, whom Samuel Pepys described as “cracked a little in his head.” Coga was of decent family—his brother was master of Pembroke College—but he was a drinker, and he was promised 20 shillings for his trouble,39 which consisted of 12 ounces of sheep’s blood let into his veins in just over a minute.40 Coga survived but transfusion didn’t. There were too many deaths and disasters, as well as what the surgeon Geoffrey Langdon Keynes described as fears that “terrible results, such as the growth of horns, would follow the transfusion of an animal’s blood into a human being.”41 Thomas Shadwell, in his Restoration satire The Virtuoso, skewers the practice as quackery, having his transfusionist character Sir Nicholas Gimcrack report on his patient:
From being Maniacal or raging mad, [he] became wholly Ovine or Sheepish; he bleated perpetually, and chew’d the Cud; he had Wool growing on him in great quantities, and a Northamptonshire Sheep’s Tail did soon emerge or arise from his Anus or humane Fundament.
In the face of derision, Gimcrack protests: his patient has written him a letter, he says, and sent the good doctor some of his own wool. “I shall shortly have a Flock of ’em,” he says, “I’ll make all my Clothes of ’em, ’tis finer than Beaver.”
Transfusion was banned in France and abandoned in England until James Blundell, an obstetrician working in the early nineteenth century, transfused ten patients. Two were already dead and stayed dead. Three died and five survived. He dealt with the trouble of clotting blood by working quickly, and he refused to use any animal blood but human because
What then was to be done on an emergency? A dog, it is true, might have come when you whistled, but the animal is small; a calf, or sheep, might, to some, have appeared fitter for the purpose, but then it could not run up stairs.42
Blundell knew about dogs, having started his experiments on them first. After he had transfused five dogs with human blood, one died on the table, two or three lived a few hours then died, and one survived for five days and died. Obviously, he concluded, “the blood of one genus of animal cannot in large quantities be substituted indifferently for the blood of another, without occasioning the most fatal results.” The “blood of the brute” should not be transfused into men. Or women: he was a noted obstetrician, and had spent decades in practice in Edinburgh, where he watched women give birth and bleed to death from it, frequently. (One of the section headings in his Principles and Practice of Obstetricy is “After-management of floodings.”) Bleeding is expected in childbirth, even today, and is mostly caused by the detachment of the placenta and by cuts and tears. Five in one hundred women lose more than a pint of blood in the first twenty-four hours, a condition known as postpartum hemorrhage.43 Most of those five in one hundred women survive, but postpartum hemorrhage still kills 127,000 women worldwide. Blundell’s women? Most should have died, according to the death rates of the day. And some did. Some, such as the women who were cases number 5 and 6, and who had been dying of blood loss, recovered. Case number 5, a woman dying of uterine hemorrhage, received 14 ounces of blood. After she had taken in 6 ounces, she pronounced herself “as strong as a bull.”44
Blundell considered transfusion to be “of so much importance to mankind, that, […] I seize with pleasure the opportunity of treating the topic.” But despite his efforts a
nd experiments—he devised an extraordinary device called an Impellor—transfusion was put aside. It was too risky and the unknowns too large, until Karl Landsteiner discovered that blood came in groups and that they should not always mix. Then the urine the color of soot, the convulsions, the deaths made sense: all blood looked alike, but it wasn’t. Thirteen years after Landsteiner’s discovery, science was given its ideal experimental setting to explore blood more. It was given a world war.
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October 16, 1914. Biarritz, southwestern France. Corporal Henri Legrain, of the Forty-fifth Infantry, lies in a hospital bed. He arrived from the front, bleeding out, and he has not stopped bleeding. In other beds are other men, dying of blood loss, one by one. In the same ward is Isidore Colas, “a small, brave Breton,” who in October had been fighting in his artillery regiment in the Marne Valley when his leg was wounded by a shell. He is in recovery, now, in l’Hôpital Biarritz, when a doctor asks for his blood. It is a sensible request: transfusion required proximity, because you needed to do it quickly to beat the blood clotting. Colas was in the next bed along. The newspapers called Colas brave not just because he was a recuperating patient but because the doctors could not put him to sleep while they cut down into his vein with a scalpel. Colas “listened without hesitation, without expressing any emotion whatsoever,” and when the time came, he gave his arm, connected to the other man by a silver tube, and his blood for two hours, and only the water pouring from his brow showed what he was enduring.45 The results were spectacular. “I saw [Legrain] regain colour,” said one doctor, “little by little, and come back to life.”46 Legrain was so revived, he leaned over to his donor, the little Breton, and kissed him on both cheeks (because he was French, and because he was alive). Both men lived a long life, and the modern era of transfusion was launched.