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Book Review: Nine Pints of Liquid Gold

December 30, 2021
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Director of the Leukemia Program at the Cleveland Clinic in Cleveland, Ohio

ASH Clinical News Editor-in-Chief Mikkael A. Sekeres, MD, MS, reviews Nine Pints, an account of the science, politics, and social history of blood.

Have you read any hematology-related books recently? Let us know what we should read and review by emailing us at ashclinicalnews@hematology.org.

Imagine our swashbuckling heroine has just landed on the floor of a temple, having descended from an opening at its peak. Let's call her "Indira Jones," the famous archaeologist and adventurer. She wears a cotton poplin field shirt, brown leather jacket, weathered shoulder bag, and rumpled brown fedora – accessorized with a bullwhip. The room is dark, so she lights a torch to better assess this new environment. She immediately recoils when she sees that she is surrounded – not by snakes, but by leeches.

"Leeches," she mutters, shaking her head in disgust. "Why did it have to be leeches?"

In the book Nine Pints: A Journey Through the Money, Medicine, and Mysteries of Blood, our intrepid heroine is not the fictitious Indira Jones, but the author Rose George, who explores the biology, politics, economics, and societal squeamishness toward this lifeblood of hematologists everywhere: blood.

Some basic facts about our liquid gold have a "wow" factor to the uninitiated that also remind those of us in our chosen field why any book about the topic is so inherently interesting: The bone marrow produces two million blood cells every second, and each day our blood travels approximately 12,000 miles around the human body. A human heart, which beats an average of 75 times each minute, pumps a quart of blood every 10 seconds, while a whale's heart, which is the size of a Mini Cooper, beats five times per minute but pumps 58 gallons with every beat. Blood is transfused worldwide approximately once every three seconds; in the U.S., this translates to 13.6 million units of red blood cells each year. The prevalence of blood types themselves vary geographically and ethnically.

Ms. George takes the reader through the history of the organized donation, storage, and delivery of blood and blood products, starting in the late 17th century with English physician Richard Lower, MD, and King Louis XIV's court physician Jean-Baptiste Denys. Denys performed an early first human blood transfusion, transfusing calf blood into Antoine Mauroy, a "madman" who might benefit from the animal's calming influences. Mr. Mauroy survived, despite a transfusion reaction, and the field was off and, if not running, flowing.

Innovation often arises from desperation. The obstetrician James Blundell, MD, who worked in Edinburgh in the early 19th century, had seen too many of his patients die from postpartum hemorrhage; to treat these women, he transfused 10 of his patients with blood from other humans. Two were dead and remained dead; three others died, but five survived. By World War I, base hospitals on the Western Front were transfusing 50 to 100 pints of blood daily. Soon after, something truly revolutionary occurred: the organization of a pool of volunteers to donate blood.

At the time, hospitals in New York were paying $100 per pint of blood. A Massachusetts law even mandated that donors receive$25 and a pint of whiskey. Such incentives introduced risky donation practices and a reticence to disclose medical conditions that could make the donated blood unsafe.

In the 1920s, Percy Oliver, a British civil servant, maintained the first database of willing donors, which consisted of a bunch of index cards with names and contact information. A decade later, Janet Vaughan, DBE, FRS, a British pathologist who already had written a hematology textbook, saw the looming catastrophe in casualties that World War II would bring with it. She spearheaded the organization of the collection and storage of blood for those with battle injuries, delivered to depots using ice cream vans. The Army Blood Transfusion Service collected 100 pints of blood daily at the outbreak of war. By war's end, it averaged 1,300 donations daily.

Nine Pints is a good read and educated me about aspects of blood I hadn't considered before, and it hopefully will educate the public about the collective health imperative of blood donation.

Which brings us to leeches … Ms. George writes about infections borne in the bloodstream, such as HIV (which perhaps goes a bit afield of the book's topic), and of the freshwater, multisegmented annelid worms that live off the fluid. She visits Biopharm, located in the southwest of Wales, one of the few companies worldwide that grow leeches intended for medicinal purposes, such as enhancing the solvency of tissue grafts. It takes two years to grow each of these bloodsuckers, and if you're wondering, they are intended for single use only; after having fed and dropped off, they are "disposed of" in an alcohol solution. Her description of the darkened room filled with leech tanks is sufficiently creepy that I felt the need to regularly check my back as I read it, lest it be covered with the creatures Ã  la Humphrey Bogart in the 1951 movie The African Queen.

A good portion of Nine Pints is devoted to the stigma surrounding the most common cause of blood loss in humans: menstruation. In Nepal, Ms. George is aghast that women are still expected to sleep outside their homes, often in rough shacks, for days at a time each month until their bleeding has stopped. In India, a 2010 study reported that 23 percent of schoolgirls missed school or dropped out altogether because they were menstruating. The causes include inadequate facilities at schools, some of which lack habitable bathrooms; the high cost of sanitary pads; and societal shame around menstruation, with a view that women having their periods are "dirty."

Seem outlandish? Well, it was only in 2017 that the first advertisement for a sanitary pad, anywhere, dared to demonstrate the effectiveness of the pad using a red-colored liquid. Kudos to Bodyform for eschewing what had been up until that point the socially acceptable, but biologically weird, color of blue.

Ms. George's book spans centuries and covers many continents. At times it is overly passionate, occasionally snarky, and oversimplifies medical approaches (such are the scabs invariably acquired, though, by the combination of a medical reader and a nonmedical writer). Overall it is a good read and educated me about aspects of blood I hadn't considered before, and it hopefully will educate the public about the collective health imperative of blood donation.

It sure didn't make leeches any more lovable, however.