CHAPTER I
Historical Note
TRANSFUSION BEFORE WORLD WAR I
Although the concept of the therapeutic value of blood dates back toantiquity, transfusion in the modern sense of the term was a practicalimpossibility until William Harvey, in 1616, announced his discovery of thecirculation of the blood.1 This discovery opened the way for seriousexperiments on the infusion of various substances into the bloodstream andeventually led to the use of whole blood for transfusion.
Claims to priority are various and confusing. It is clear, however, thatRichard Lower, inspired by the previous experiments of Sir Christopher Wren ininfusion techniques, performed the first successful animal transfusion in 1665,when he transferred blood from the carotid artery of one dog to the jugular veinof another. In November 1667, Lower transfused Mr. Arthur Coga, "a mildlymelancholy insane man," with the blood of a lamb. Mr. Coga, according toPepys, described his experience in Latin before the Royal Society of Medicineand stated that he was much better.He impressed Pepys as "cracked a little in his head."
The next animal-to-human transfusions were also performed on generally the sameindications, by Jean Baptiste Denis, physician to Louis XIV. When Denis'fourth attempt ended fatally, he was charged with murder. He was eventuallyexonerated, but, 10 years later, the procedure was prohibited by law in Franceas well as in Italy and was also forbidden by the Royal Society of Medicine inEngland.
For the next 150 years, there was little interest in transfusion, but it issignificant that Nuck in 1714 and Cantwell in 1749 declared that this procedurewould be of value in severe hemorrhage. When interest in transfusion was revivedby James Blundell (5-7) in1818, it was on the basis of replacement of lost blood in puerperal hemorrhageand after a series of experiments in which he had demonstrated that human bloodloses none of its "vital properties" by passage through transfusionequipment (figs. 1 and 2). Blundell failed in his first four desperate attemptsto save women on the point of death from postpartal hemorrhage, but he succeededin five of the next six attempts.
1The following brief historical account of the development of bloodtransfusion is necessary for an understanding of the medicomilitary employment ofthis measure, a use not suggested up to World War I. The material included,unless otherwise indicated, is derived from (1) the detailed historical accountin Kilduffe and DeBakey's "The Blood Bank and the Technique and Therapeutics of Transfusions" (1), which has an appended list of 207 (183 numbered)references, and (2) Lewisohn's (2,3) and Ottenberg's (4) accounts of the contributions of Mount Sinai Hospital in New York to this therapeutic technique.
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In 1859, in reporting a successful transfusion, Benedict (8) laid down the conditions under which this operationshould be practiced. He considered it applicable to no pathologic state savethat
* * * which iscommonly called 'collapse,'induced by hemorrhage, by certain exhausting discharges, or by utter inabilityto receive or retain nutriment; and the only transfusion now sanctioned, eitherby physiology or by common sense, is that of human venous blood into humanveins, identical, as nearly as possible, with that which has beenlost, and in quantity just sufficient to arrest the tendency toward death.
Benedict (9) could find only 21 cases recorded up to 1853 inwhich transfusions had been "practiced under these conditions." Therewere 19 survivals in the 21 cases.
In 1875, Landois (10), ina comprehensive monograph on transfusion, collected 347 cases in which humanblood had been used and 129 cases in which animal blood had been used. By thistime, important studies on the physiology of the blood were being performed by anumber of qualified observers, and some
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physicians, such as Fordyce Barker, advocated transfusion "* * *not exclusively in thosedesperate cases where favorable results are hardly looked for but * * * beforepatients have arrived at, and fallen into, this desperate condition."
Techniques in use included transfusion with defibrinated blood, mediatetransfusion with pure blood, immediate transfusion from vein to vein, andimmediate transfusion from artery to vein.
Although the indications and rationale of blood transfusion were by this timeapparently quite well understood, the indications during the last quarter of thecentury again became vague and irrational, the procedure was employedindiscriminately, and the number of severe reactions and fatalities increased. Asa result, transfusion again began to be considered as a hazardous, and even adisreputable, procedure, to be employed only as a last resort and indesperation.
Special Problems
During the first years of the20th century, a blood transfusion was frequentlya more difficult technical procedure, and sometimes a procedure fraught with greaterrisks, than a major operation. Its development as an
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effective and safe therapeutic method required the solutionof a number of special problems:
1. Blood coagulation. First efforts to overcome thisdifficulty were made in 1835, with the use of defibrinated blood by Bischoff,and terminated in 1914, with the successful use of sodium citrate by Hustin,Weil, and Lewisohn (2, 3) (p. 218).
2. Agglutination and hemolysis from admixture ofincompatible bloods. The way was opened to the solution of this specialproblem in 1900, when Landsteiner (11) published his epochal work on theidentification of blood groups, based on his previous demonstration of thepresence of isoagglutinating and isoagglutinable substances in the blood. Jansky in 1907 and Moss 3 years later, withoutknowledge of Jansky's studies, worked out the reciprocal agglutinatingreactions of the four blood groups and classified them accordingly. Theconfusion that arose because of differences in nomenclature was eliminated afterWorld War I, when the numbers previously used to designate blood groups werereplaced by the letters A, B, AB, and O, each group thus being designated by theagglutinogens in Landsteiner's original scheme.
Communications in the early years of the 20th century were often slow, and foreign medical literature had only a limited circulation in the United States. No practical use, therefore, was made of Landsteiner's work until 1907, when Ottenberg (4), at Mount Sinai Hospital in New York, first matched donor and recipient before giving blood and thus made transfusion a safe procedure from the standpoint of compatibility. The validity of Ottenberg's work was not immediately realized; his offer to perform compatibility tests for the surgeons at his own hospital had no general acceptance for almost 5 years because such tests were considered unnecessary or misleading.
In 1911, Ottenberg demonstrated that it was safe to use as a donor a person whose serum agglutinated the recipient's red cells but unsafe and dangerous to use one whose red cells were acted upon by the recipient's serum. This demonstration eventually led to the widespread employment of group O donors as universal donors, since the red blood cells of this blood group are not agglutinable by the serum of any other blood group.
3. Technical difficulties. Until 1913, direct transfusion was used to the exclusion of any other technique. This was a difficult and time-consuming method, requiring a specially trained team to carry it out and totally unsuited for use in sudden emergencies. In 1892, vonZiemssen of Munich had performed transfusion by the syringe technique, but his report attracted no attention and when Lindeman (12) described it in 1913, it was, for all practical purposes, a new method. With this technique, no dissection of blood vessels was necessary in either donor or recipient, and the exact quantity of blood transfused was known. The technique, however, required a trained team of at least four persons and the use of a large number of expensive syringes. Also, rapid injection of the blood was mandatory. In 1915, Unger (13) introduced an apparatus based on the principle of the two-way stopcock, which
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overcame many of these difficulties. Dozens of variations of this apparatuswere introduced during the next 15 years.
4. Infection. Infection ceased to be a major problem after firstantiseptic, and then aseptic, techniques came into general use and as long astransfusion was employed only in hospitals and on what amounted to electiveindications. The open containers originally used to collect blood for indirecttransfusion first became impractical, and then a real source of danger, whenindications for transfusion were extended.
BLOOD TRANSFUSION IN WORLD WAR I
The British Experience
In June of 1918, an editorial writer in the Lancet doubted that asrecently as 4 years earlier any surgeon could have been found to perform"the operation" of transfusion in England (14). In the nextissue, Sir Berkeley Moynihan (15) took exception to that statement: Heand his associates in Leeds had been performing transfusion regularly for 10years, first by the direct, and later by the indirect, technique.
The editorial writer's statement was, however, generally true. Bloodtransfusion was not practiced by the majority of surgeons in Great Britainbefore World War I, and its use in the last 2 years of the war was chieflyderived from the work which had been done on it in the United States.
Techniques-Direct transfusion, as might have been expected, proved acompletely impractical method in military surgery. The elaborate preparationrequired in the Kimpton-Brown technique makes one wonder how it could have beenemployed at all in a busy casualty clearing station, but Fullerton and hisassociates (16), using improvised equipment, employed the method in 19casualties at the Boulogne base in 1916. The 15 deaths were not toodiscouraging, since the blood was given only to patients whose condition wasconsidered desperate. In 1917, U.S. Army medical officers introduced thestandard Kimpton-Brown equipment into British hospitals, and numerous patientswere treated by this technique in casualty clearing stations of the BritishSecond Army.
In a series of reports between 1916 and 1918, Bruce Robertson (17-20), ofthe Canadian Army, explained the advantages of the syringe-cannula technique,which he had introduced into the British Second Army area. The method was farsimpler than the Kimpton-Brown technique, but at that it was not simple, and itrequired a team of three persons to carry it out.
The use of preserved blood was introduced into a casualty clearing station inthe British Third Army during the battle of Cambrai in November 1917 by Capt.(later Maj.) Oswald H. Robertson, MORC, USA (21, 22). His reasoning wasthat if blood had to be collected as casualties arrived, the number oftransfusions given would necessarily be limited. The solution seemedto him to be the use of human red blood cells collected and stored in advance ofthe need.
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Only group O (then termed group IV) blood was used. The 500 cc. taken fromeach donor was collected in the Rous-Turner glucose-citrate solution (p. 217) andstored in an icebox. After the blood had settled for 4 or 5 days, the cellsuspension contained no more citrate than would be used in ordinary citratedtransfusions. The majority of transfusions were given within 10 to 14 days afterthe blood had been collected, but in some instances they were given with26-day-old blood. The length of time the blood was kept did not seem toinfluence the results. The blood arrived in good condition, with no evidence ofhemolysis, after transportation by ambulance for 6 to 8 miles over rough roads,a demonstration later repeated by Capt. Kenneth Walker, who carried a bottle ofpreserved blood with him during a journey from Arras to London. The 22transfusions with preserved blood reported by Robertson in June 1918 werecarried out on 20 patients, of whom 9 died but all of whom, it was thought,would have died unless they had received blood.
In 1918, transfusions were carried out farther forward than casualty clearing stations, chiefly due to the efforts of Captain Walker, Capt. Norman M. Guiou (23) of the Canadian Army, and Major Holmes-?-Court of the Australian Army (22). The syringe technique, Guiou claimed, could "easily" be applied in advanced dressing stations and in the average regimental aid post. If casualties were given blood in these areas, he continued, they would be kept alive until they reached the casualty clearing station, where they could be treated surgically.
The official history of the British Medical Service in World War I concluded that whatever the merits of the various techniques of transfusion in civil life, there was no doubt of the superiority of the citrate method in wartime. It could be employed in circumstances in which other methods were impractical. It was simpler than other methods. It permitted the transportation of blood from donor to recipient without interrupting an operation and further congesting an already overcrowded operating tent. A skilled "transfuser," devoting himself entirely to the task of drawing and citrating blood, could supply a dozen patients in need of blood, leaving to anesthetists the "simple task" of administering the blood(22).
Donors-There was no difficulty in procuring blood donors. Up to the middle of1918, the spirit of comradeship was sufficient to supply them. Later, a 3-weekleave in England after the donation secured many offers from lightly woundedmen. Dental patients and soldiers with minor injuries, sprains, and flat feetwere also used as donors. Syphilitic and malarial subjects were rejected, aswell as those with other infectious diseases, such as trench fever. A healthydonor, it was thought, could withstand the loss of 700-1,000 cc. of blood.
Blood grouping-Early in the war, the precaution of bloodgrouping before transfusion was frequently omitted because it was impractical. Anumber of reactions were attributed to this omission, and by June 1918, BruceRobertson (19) had observed three cases of fatal hemoglobinuria in 100 transfusions. Later in the war, preliminary blood groupingbecame the rule, but, when there were no facilities for laboratory work, hissuggestion of a test
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injection was generally used, particularly in emergencies. If no symptomsoccurred within 1 or 2 minutes after the injection of 15 to 20 cc. of donorblood, it was thought safe to proceed with the transfusion.
In November 1917, Maj. Roger I. Lee, MC, USA, writing in the BritishMedical Journal (24), described what he termed the "minimumprocedure" to assure that the recipient's serum did not agglutinate thedonor's cells. This extremely simple test continued to be useful until avidgrouping serum became available after the war.2
Indications-Indications for transfusion in theBritish Expeditionary Force included:
1. Preoperative preparation in severe hemorrhage and shock, in which bloodreplacement was considered the proper treatment for loss of blood. The time ofthe transfusion officer was not properly spent on casualties who were moribund.Although there was considerable argument about the relative effects of gumacacia and blood in shock, the most experienced surgeons considered transfusionfar more efficacious. Captain Walker found that 70 percent of the casualtiesresuscitated by gum acacia infusions in field ambulances required blood whenthey reached the casualty clearing station. In rush periods, when time could notbe taken, or facilities were not available, the need for transfusion wasdetermined by the casualty's general appearance, pulse, and blood pressure. Insevere hemorrhage, large amounts of blood (900 to 1,000 cc.) were recommended;500 to 600 cc. was considered adequate in shock.3
2. During operation
3. After operation, after a delay to determine whether the depression might bedue to the anesthetic, especially if an anesthetic other than gas-oxygen hadbeen used.
4. Carbon monoxide poisoning.
5. Septicemia and chronic wound infection.
Bruce Robertson (20) emphasized the importance of the timing oftransfusion. It was a temptation, he said, to use other measures first, but clinical observation showed that transfusion was notso effective after the "exsanguinated condition" had persisted forseveral hours and degenerative changes had occurred in the organism.Properly timed transfusions could revive inoperable patients and bad-riskpatients to a degree that permitted radical surgery, with a good chance ofrecovery. Gordon Watson, in a note attached to one of Robertson's papers (20),stated that there was no comparison between the results of transfusion, whichwere instantaneous and permanent, and those secured by infusions of saline, whichwere "aflash in the pan" and followed by more serious collapse.
Transfusion program-To resuscitation teams(a nomenclature later employed in World War II) was delegated the task ofcollaborating with surgeons at casualty clearing stations by relieving them ofthe special measures necessary in poor-risk casualties both before and afteroperation. Teams of
2The use of plasma in place of blood was suggested byGordon R. Ward (25), in March1918, to avoid the risk of hemolysis of the recipient's plasma by the donor'scorpuscles, but the suggestion was not acted upon in combat areas during theremainder of the First World War. In November 1918, however, Lt. Frank W.Hartman,MC, USN, used liquid plasma which he had prepared at the U.S. Naval MedicalSchool for patients with severe influenza (26).
3The World War II concept of hemorrhage as the causeof shock in military injuries was not one of the theories advanced to explainshock in World War I (p. 37).
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sisters and orderlies experienced in this work were developed and proved very useful.
A formal transfusion program was instituted in the British Third Army as experience showed that transfusion forward of casualty clearing stations could save many lives (22). A center was set up in connection with a group of casualty clearing stations, and instruction in transfusion techniques was given in it to field ambulance and regimental medical officers. When they had completed their courses, they were provided with the necessary equipment, and several divisions thus had one or more officers especially skilled in the treatment of severely wounded casualties.
The officer in charge of this center, in addition to his teaching duties, made a point of being present during any large trench raid in the army area, so that transfusions could be given as indicated in aid posts or advanced dressing stations. Whatever the clinical results achieved-and many lives were undoubtedly saved by these arrangements-the morale effect of his presence on the men going over the top was so good that the combatant services soon got into the way of sending back word of impending raids to the shock center. When several battalions were to participate in the operation, it was possible, with such advance notice, to select a central site to which badly wounded men could be sent from various aid posts for resuscitation and transfusion. It was also possible, with advance notice of military actions, to prepare a store of preserved blood at the center to supply the needs of forward areas. When the blood was supplied, even a poorly equipped aid post could be used for transfusions.
The United States Experience
Replacement fluids-By the time the United States entered World War I, it was realized that the injection of physiologic salt solution or Ringer's solution was only temporarily effective in shock and hemorrhage and that the "internal transfusion" accomplished by hypertonic salt solution, which withdrew fluid from the tissues and thus increased the blood volume, was equally ineffective (27). It had been concluded from Bayliss' studies that gum acacia was capable of replacing blood plasma and that it had a number of desirable properties (p. 384). There was considerably less agreement, however, about its clinical value. Maj. O. H. Robertson's survey of forward hospitals in October 1918 showed that some resuscitation teams praised it, some were indifferent to it, and some condemned it. The poorest results with it were reported in very severe hemorrhage and in shock that had been untreated for 15 to 20 hours.
Maj. W. Richard Ohler, MC (28), who had had an extensive wartime experience as a resuscitation officer, made the unqualified statement after the war that hemorrhage is the most important single factor in shock and that the amount of hemorrhage determines the degree of shock. When, therefore, the need is for oxygen-carrying corpuscles, no other intravenous solution will serve the purpose. When the United States entered World War I, physicians with
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the most experience in trauma took the position that when hemorrhage played a large role in the production of a circulatory deficiency, blood was preferable to any "indifferent" fluid. It was not until March 1918, however, that a committee representing the laboratory and surgical services of the U.S. Army Medical Department officially adopted transfusion with citrated blood as the method for combating shock and hemorrhage in hospitals of the American Expeditionary Forces.
Donors.-Hospital personnel were classified in blood groups for emergency use, but donors were chiefly secured from lightly wounded and gassed patients who, on admission, were sent to wards near the shock wards. Patients with scabies and convalescents who were nonfebrile and in good condition also served as donors. No rewards were offered and all donations were voluntary, without compulsion of any kind. Not more than 600 cc. was drawn at any one time, and the same donor could not be used twice within one week.
Technique-Equipment for bloodtransfusion (fig. 3) consisted of a l,000-cc. bottle with two rubberstoppers, each with two perforations; appropriate glass and rubber tubing; andtwo transfusion needles, a larger one for bleeding the donor and a smaller onefor giving blood to the recipient. A satisfactory suction and pressure pumpcould be made front an ordinary Davidson syringe; suction or pressure wascreated as necessary by reversing the ends. The equipment was either sterilizedin the autoclave or boiled in distilled or previously boiled water. The needleswere sterilized just before they were needed, in boiling liquid petrolatum orAlbolene, and were left in the medium until used. Great care was taken incleansing the apparatus after the transfusion.
The blood was drawn into a solution of 0.6-percent sodium citratein 700 cc. of physiologic salt solution. It was ordinarily used as soon as itwas collected, but it could be kept for several hours. The container was kept inwater at about body temperature during the transfusion. No provisions were madefor transfusion during operation, but precautions were taken to lose as littleblood as possible.
Postwar evaluation of replacement therapy-Aquestionnairecirculated in advance of the 11th session of the Research Society of theAmerican Red Cross in France, held on 22-23 November1918 and attended by representatives of the Medical Departments of the Alliedand U.S. Armies, produced the following information on replacement therapy (notall officers queried replied to all questions) (29):
1. All 31 officers who voted on this question preferred blood to gumacacia-salt or salt solution.
2. No serum reactions were reported by 29 officers when blood was properlygrouped. Five others reported slight or rare reactions.
3. Difficulties in transfusion therapy included the length of time necessaryto collect the blood, clotting in the needle during administration of the blood,inability to secure donors; keeping donors under careful control, and theinconvenience of having corpsmen who served as donors off full duty for 24 to 48hours after their donations.
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FIGURE 3.-Blood transfusion apparatus used in World War I.
A. a. Transfusion needle.
b. Rubber tube.
c. Glass tube.
d. Rubber stopper.
e. 1-liter bottle.
f. Glass tube.
g. Rubber tube.
h. Glass tube for suction, with cotton in bulb.
B. i. Transfusion needle.
j. Rubber tube.
k. Glass tube.
l. Rubber tube.
m. Glass tube.
n. Rubber stopper.
o. Glass tube.
p. Rubber tube.
q. Glass tube for exerting compression (cotton in bulb) (27)
4. Seven hospitals had no experience with blood transfusion in prolonged infections; 43 reported definite improvement after its use, 2 temporaryimprovement, and 10 no improvement.
5. Twenty-six medical officers preferred the sodium citrate technique ofblood transfusion. Three preferred the paraffin-tube technique, and the Kimpton-Brown and the syringe techniques received one vote each.
6. Because of numerous unfavorable reactions and some deaths after its use,one hospital was "very positive against" gum acacia-salt solution, andothers considered it very dangerous or found nothing to recommend it.
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SPANISH CIVIL WAR (1936-39)
Barcelona Blood Transfusion Service
The Spanish Civil War (30-31), which ended in January 1939, almost 3years before the United States entered World War II, proved conclusively, andfor the first time in military history, the practicability of supplying woundedmen in forward medical installations with stored blood secured from a civilianpopulation. Franco's armies, following the practice of the German Army (p.22), supplied blood at fully equipped medical centers in the rear. The RepublicArmy Medical Corps supplied it at advanced medical units in the field.
In the 2? years of its operation, from August 1936 through January1939, the Barcelona Blood Transfusion Service collected more than 9,000 litersof blood in 20,000 bleedings, prepared more than 27,000 tubes of blood forforward use, maintained a list of 28,900 donors, and also prepared all necessarygrouping sera.
Blood was kept under refrigeration, which was provided by electric ice-boxeswhenever current was available. It was supplied to classification stations inheat-insulated wood or canvas boxes, with thick cord linings.
Transfusion data were recorded on special cards provided with all bloodcontainers. The records were so complete that it was possible to trace everycontainer to its point of origin in the collection center and to identify everyforward hospital in which blood had been given, the data including the name ofthe person who had performed the transfusion. Blood was prescribed by surgeonsbut administered by personnel of specially trained transfusion teams.
Donors were between 18 and 50 years of age. All blood was collected into aclosed system, under strictly aseptic precautions. Citrate and glucose wereadded after collection, and bloods of the same group were mixed.
Clinical considerations-Only badly shockedcasualties received blood at classification posts. Most transfusions were givenin No. 1 hospitals, where very few seriously wounded patients did not receivethem. Occasionally, if stored blood was not available or if the sector wasparticularly quiet, direct transfusions were given. The members of the hospitalstaff had previously been grouped and serologically tested against suchemergencies.
Indications for blood and plasma administration were as follows:
1. Casualties with serious hemorrhage were given only blood, which wasinjected as rapidly as possible, because cardiac function soon deteriorates whensystoles contract on a vacuum.
2. Casualties suffering from primary shock and hemorrhage were given both blood and plasma. If improvement followed the use of 2 pints of blood,a pint of plasma was given to "stabilize the improvement."Thereafter only plasma was used. If the response to the first transfusion was notsatisfactory, a third pint of blood was given before plasma was used.
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3. Casualties suffering only from shock were given 2 pints of plasma asquickly as possible, followed, if there was no improvement, by a pint of blood,also given quickly. If there was still no improvement, another pint of plasmaand another pint of blood were given over the course of an hour.4
The concept of blood replacement was that in "posthemorrhagic" shock,at least 40 percent of the lost fluid must be restored promptly. There were,however, no quick or reliable methods for estimating the amount of blood loss.Generally speaking, 500 cc. of blood or blood derivatives was required for eachfall of 10 to 20 mm. Hg in the blood pressure. Failure of the transfusion toraise the blood pressure was assumed to mean continued bleeding and indicatedthe need for control of hemorrhage as well as additional transfusion.
Quick administration of blood and plasma was regarded as desirable and without risk of cardiac embarrassment, since most casualties were young and healthy. The rate of administration could be regulated from a slow drip up to 100 cc. per minute. Although most casualties received the first pint of blood more quickly than the remainder, no instance of dilatation of the right heart was recorded. As Whitby pointed out in 1945, failure to restore the blood volume was a greater risk than overloading the circulation (32). In less urgent cases, speed of transfusion was not so important as administration of the necessary amounts of blood. The amounts given before and after operation varied with individual needs. Trueta usually gave from 1,000 to 1,500 cc. per casualty. Patients with infected wounds required several transfusions to restore the hemoglobin to normal values.
Madrid Blood Transfusion Institute
In September 1937, Saxton (33), a member of the British Ambulance Unit in Spain, reported on the Madrid Blood Transfusion Institute, organized by the Sanidad Militar of the Spanish Republic, which was then supplying about 400 liters of preserved blood per month and whose output was steadily increasing. The full-time personnel consisted of five physicians; five nurses; five members of the secretariat, including interpreters; and a domestic staff.
For practical reasons, only donors of groups II and IV (Moss) were utilized. The donors, all volunteers, were between 18 and 50 years of age. They were given cards that permitted them to buy extra food and were sometimes also given small quantities of rice, condensed milk, or other staples at the time of the donation. They were liable to call not oftener than every 3 weeks, and they usually gave 500 cc. at a time. Blood storage was limited to 3 weeks.
Saxton's suggestion that the Sanidad Militar organize a large-scale supply of cadaver blood by the technique of Yudin (p. 24) does not seem to have been acted upon.
4The persisting distinction between shock and hemorrhage should be noted (p. 31).
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BLOOD FOR BRITAIN
Origin of Program
The project in New York City hospitals which came to be known as Blood forBritain (34, 35) originated in June 1940, when Dr. Alexis Carrel, who hadrecently returned from France, madeknown the great need there for plasma for the treatment ofshock in battle casualties. The idea of shipping plasma to France and Englandwas suggested to the president of the Blood TransfusionAssociation of New York, and a meeting to discuss the possibility was called for 12 June 1940. Itwas attendedby the trustees of the association; its Board of Medical Control; Dr. Carrel;experts in the field representing the Army, the Navy, NRC (National ResearchCouncil), and Rockefeller Institute; and representatives of a number of largepharmaceutical and biological firms.
It was the sense of the meeting that, even though the use of plasma was stillin an experimental stage, enough knowledge was available to justify an effort atquantity production. The cooperation of the New York chapter of the American RedCross was secured as soon as it was pointed out to its officials that theexperience to be gained from this project would be of great assistance in theNational Defense Program, one phase of which was the supply of plasma for theArmed Forces. At the suggestion of Col. (later Brig. Gen.) Charles C. Hillman,MC, Chief, Professional Services, Office of The Surgeon General, Army, closecooperation was established with the Subcommittee on Blood Substitutes, NRC,which had just been appointed (p. 74) and by whose advice the Army MedicalDepartment was being guided in replacement therapy.
The program became operational on 15 August 1940, at the PresbyterianHospital in New York, and terminated on 17 January 1941. All the plasmacollected went to Great Britain, France having fallen shortly after the 12 Junemeeting. The program, which represented the first effort in the United States tocollect large amounts of blood from voluntary civilian donors for military use,had great popular appeal, and during its existence, 14,556 donations were made.
Technique of Collection and Shipment
Liquid plasma was selected for processing rather than dried plasma, partlybecause the time element was vital and partly because of the expense ofinstalling drying equipment, whose performance at this time was still inadequateand far from satisfactory.
Originally, the system by which the blood was collected was not completelyclosed. Later, it was realized that a completely closed system was imperative.
The plasma was separated by either sedimentation or centrifugation. To reduceviscosity, it was diluted with equal amounts of sterile physiologic saltsolution; the solution, under 13 inches of water vacuum, was in the Baxter
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bottle (Plasmavac) in which it was finally dispensed. Merthiolate was addedin quantity sufficient to guarantee dilution of 1:10,000 in the finalplasma-saline mixture.
The finished product was shipped in 1,000-cc. bottles, six to a carton.Larger packages were not practical because the shipments were made by Clipperplanes-this was long before the existence of a transatlantic airlift.
Laboratory Tests and Losses From Contamination
Exacting bacteriologic and toxicity controls were required before any lot ofplasma was dispensed. These tests were carried out not only in the laboratoriesof the participating hospitals but also in a central laboratory, under thedirection of Dr. Frank L. Meleney. When the material reached England, samplesfrom each carton were also checked bacteriologically before they were releasedfor use. The latter precaution was instituted when it was found that certainpools of plasma that were free from bacteria when examined within 3 to 7 daysafter collection and processing were later found to be contaminated. Up to 1November 1940, 1,950 liters of plasma were sent abroad as sterile afterexamination in Dr. Meleney's laboratory and 30 liters had been discardedbecause of contamination. The delayed contamination just described wasdiscovered soon after this analysis had been made, and more rigid bacteriologiccontrols were at once set up. The total figures show that of 6,151 liters ofplasma produced, 361 liters were found contaminated at the various hospitals and160 liters were found contaminated in the central laboratory, the combined lossfrom contamination (exclusive of the amounts found contaminated in England)being 8.5 percent. The total loss from all causes was 581 liters, 9.4 percent;151 bloods were rejected because of serologic evidence of syphilis (1.03percent).
Analysis of Operation
The original opinion that the collection of blood and the separation ofplasma would be "as simple as mixing a cocktail" promptly provedfallacious. The mass production of liquid plasma and its shipment abroad werevery different from the production of small quantities for immediate local use.There were long debates on the size and shape of the collecting bottles, thestopper, the collection of blood by vacuum versus suction versus simple venouspressure, and the technique of removal of supernatant plasma. There were alsodiscussions about the criteria for donors. Eventually, the age range was set at21 to 60 years inclusive, the systolic blood pressure at 110 mm. Hg, and thehemoglobin level at 80 percent. Fasting was considered desirable, but therequirement proved impractical.
To set up criteria for production, to develop standard techniques, and toinsure the safety of the final product involved far more difficulties than couldbe solved by volunteer part-time workers, and Dr. Charles R. Drew, later
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Assistant Professor of Surgery, Howard University, was appointed full-timemedical supervisor of the project shortly after it was initiated.
The New York experience with liquid plasma led to the later decision thatdried plasma would best solve the problem of so-called blood substitutes for theArmed Forces because of its greater stability; the simplicity of its packing, storage,and transportation; and reduced losses from breakage.
The Blood for Britain project was a most valuable introduction to the laterdevelopment of the American Red Cross Blood Donor Service (p. 102). Theexperience of the New York chapter served as a pattern for the organization andoperation of the blood donor service which was to supply plasma for the ArmedForces and blood for oversea shipment. This chapter was ready to beginoperations as soon as the Surgeons General of the Army and the Navy requestedthe American Red Cross to be responsible for the blood donor program.
There were many mistakes made in the operation of the blood and plasmaprogram during the United States participation in World War II, but far morewould have been made without the trial-and-error experience of the Blood forBritain project. The chief lesson learned was that blood and plasma, if they areto remain uncontaminated and safe for use, must be handled in a completelyclosed system. The vacuum system devised by Elliott in 1936 ended thisparticular problem (36). The gravity system of bleeding may be lessdamaging to red blood cells than a vacuum system, but only the completely closedsystem possible with a vacuum bottle insures sterility.
THE BRITISH BLOOD PROGRAM IN WORLD WAR II
The Association of VoluntaryBlood Donors founded in Great Britain in 1922 laterbecame the British Red Cross Transfusion Service, the first organization of itskind in the world and the forerunner of a number of similar associations inGreat Britain and elsewhere (37). Blood banks were in operation invarious hospitals in that country for at least 6 years before the outbreak ofWorld War II.
In the months after the Munich crisis in 1938, recent advances intransfusion techniques, especially the use of stored blood on the field in theSpanish Civil War, were under constant discussion in Great Britain (32, 37,38). The Medical Research Council, on behalf of the Ministry of Health,established four blood depots in the outer suburbs of London. Arrangements werealso made to establish an Army Transfusion Service, which would enroll allavailable donors in the South-Western Countries and which would also supplycivilian needs in that area.
In short, as Brigadier (later Sir) Lionel E. H. Whitby, RAMC, who headed theBritish blood program, expressed it, the British began the war with a firmpolicy, decided upon 6 months earlier, that there would be a completely distinctand separate transfusion service in the Army (38). Returning to thesubject at a meeting of Allied medical officers on shock and transfusion in May1945,
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he pointed out that the transportation of potentially dangerous biologicfluids over long distances requires close personal supervision and cannot betrusted to the usual supply routes from a base depot medical store (32).
The British blood program was a remarkably successful operation for the tworeasons just indicated: (1) that it was carefully planned before hostilitiesbegan, and (2) that it was based on the concept that blood is a perishablefluid, as potentially dangerous as it is potentially useful, and therefore to behandled in special channels by specially trained personnel. The daily, almosthourly, care that trained British officers and men gave to the blood theyhandled reduced accidents to a minimum. The British also regarded it asessential that their armies be self-contained as regards blood. The success ofthe attempt in World War II, first madeby the British in the Western Desert, to bring surgeons forward to casualties,was due in large part to the successful operation of the Army TransfusionService.
A similar separate service was recommended by the Subcommittee on Blood Substitutes, NRC, for the U.S. Armed Forces early in U.S. participation in the war (p. 76). Such a service was later set up in Italy, and time, expense, and lives would have been spared if it had been put into operation when it was proposed.
Functions of the Army Transfusion Service
The chief function of the British Army Transfusion Service was to supply blood and other fluids, including crystalloid solutions, with equipment for their use, to the entire British Army overseas and in the United Kingdom, and also to supply civilian needs in the areas of the United Kingdom in which it operated. Liquid plasma was used in temperate climates and was safely exported as far as India; it was kept cool but not under refrigeration.
Dried human grouping serum was prepared by the Army Transfusion Service. It was selected because it did not require refrigeration. It was colored with acriflavine for group A and with methylene blue for group B. The minimum titer was 1:32 against A2 cells and 1:64 against B cells.
Organization
The British Army Transfusion Service (fig. 4) was organizedon three levels: a home depot, which was chiefly a production and trainingcenter; a base transfusion unit, which was chiefly concerned with distribution,in each theater of operations; and field transfusion units, which worked inforward areas. The home depot, in addition to supplying transfusion fluids, wasresponsible for the mobilization, equipment, and training of transfusion unitsfor service overseas and for the training of all ranks of the Royal Army MedicalCorps in resuscitation work. The courses of instruction, which were begun in1940, were attended by officers from the British Army, Navy, and Air Force;personnel from other Allied forces; members of the civilian Emergency Medical
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Service; and, later, many U.S. Army medical officers (p. 471). In addition toinstruction in blood work, the courses included preparation and assembly ofcrystalloid solutions, the maintenance and repair of transfusion equipment,refrigeration maintenance and repair, and autoclaving.
Bleeding was carried out by 15 mobile, fully equipped, self-contained teams,each consisting of a medical officer, who frequently was a woman, 4 VAD's(Volunteer Aid Detachments); 2 ATS (Army Transfusion Service) drivers; and anATS orderly. Each team had two vehicles, one a lorry equipped with an icebox,and the other a four-seated car. With the equipment carried, any room could beconverted into a miniature hospital ward for bleeding within 20 minutes. Forsteady work, each team was expected to obtain 70 to 90 pints of blood daily. Inemergencies, over short periods, these amounts were exceeded, and some teamscollected as much as 300 pints daily.
The 440 cc. which made up each bleeding was collected in a bleeding bottle(fig. 4) into 100 cc. of 3-percent sodium citrate solution. Later,with special equipment, 20 cc. of 10-percent dextrose was introduced into eachbottle, so that it was filled to the top and its contents were not agitatedduring transportation. Capping was done with a special machine.
Only group O blood was used for oversea troops. It was tested by the Kahntest and doublechecked for group before it was dispensed. Brigadier Whitby hadno knowledge of the dispensing of any incorrectly typed blood during the entirewar (32).
Base transfusion unit.-The base organization overseas was the link betweenthe home depot and the forward transfusion units. Its function was to estimateneeds for replacement fluids; obtain supplies and equipment from the home depot;distribute them to forward areas; produce crystalloid solutions; assembleapparatus; service and repair refrigerators; and exploit local resources,usually base troops, for blood donations.
When the base unit was within reasonable distance of the home depot, as itwas in France, the home unit was responsible for the supply of whole blood.Otherwise, the base unit was responsible. Blood collected locally wassent forward to field units by road in refrigeratedtrucks, by air in insulated boxes, or along the coast in the refrigerators ofhospital ships. Personnel of the unit were equipped to give transfusions, buttheir multiple duties usually prevented any large-scale performance of thisfunction.
Field transfusion units-Field transfusion units,which were the smallest units in the British Army, were entirely self-containedand were fully equipped for transfusion inthe field. Their personnel consisted of an officer and three men,one of whom drove the truck and was entirely responsiblefor the operation of the refrigerator, upon the efficiency of which the safetyof the blood depended. These units, which were attached wherever they were mostneeded during a campaign, usually operated with field surgical units, thecombined units forming complete surgical centers at field ambulances, fielddressing stations, and casualty clearing stations. Surgeons came to rely heavilyupon
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these field transfusion teams; many of them delegated the selection of their operating lists to them. The optimum time for surgery, Brigadier Whitby pointed out, was often "a fleeting moment indeed," and the teams working on the wards, with their skill in resuscitation, were often best equipped to pick that moment (32).
Experience in France, 1940
During the so-called phony war, thepersonnel of the Transfusion Service utilized the time developing a large donorpanel, which eventually included
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more than 350,000 names; carrying out studies on the keepingproperties of blood, especially when it was transported overseas; determiningthe merits of various blood substitutes; and developing a technique for thefiltration of plasma.
This was a difficult period for the TransfusionService. It was necessary to bleed donors to provide forpossible needs, but at the same time impractical to build up a reserve. Bloodwas sent to France by air, and later was flown to Norway, where it was flowndirectly to transfusion units operating in forward zones.
About 400 units of stored blood seem to have been used on theContinent between the invasion of the Low Countries on 10 May and the Dunkirkevacuation. In an editorial in the British Medical Journal on 10 August 1940, a
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request was made for information concerning the use of whole blood, plasma,and crystalloid solutions during the campaign in Flanders and in France, whenconditions prevented the collection of data (39). What was desired wasnot data "that would satisfy medical statisticians" but informationthat would permit the evaluation of various replacement fluids. In particular,data were requested that would throw light upon the length of time blood couldsafely be stored. During this period, medical officers frequently had no choicebut to use such blood as they had, and other physicians might find themselves insimilar circumstances in the frontline at any time,whether or not they were serving withthe Armed Forces.
The reply to this request, from W. d'A. Maycock (40) in a letter to the Journal, 5 October 1940, is a remarkable statement of what was accomplished in casualty clearing stations subject to aerial bombardment, limited in numbers because of the highly mobile type of warfare, and manned by overworked medical officers:
The rapid response of the Army blood supply depot at Bristol to requests made immediately after the invasion of the Low Countries permitted the stocking of mobile refrigerators, in which only small supplies of blood hadpreviously been stored, at the casualty clearing stations. Within 4 or 5 days, each of the eight teams attached to these stations and the teams attached to the medical base at Boulogne had received 60 to 80 pints of blood, with some plasma. Glucose-saline solutions had already been stockpiled. One casualty clearing station designated as an advanced blood depot was provided with extra quantities of blood and was given transport to distribute it as necessary to other stations. Some forward units could not function at all.
The provision of apparatus for transfusion with each bottle of blood was ideal for active service and permitted transfusion under almost any conditions. The knowledge that there would be no further supplies of blood made officers use what was available very conservatively, and it was withheld from casualties who in happier circumstances would surely have received it. Transportation of blood for long distances over rugged roads did not seem to increase hemolysis, and there was no known instance of serious infection after a transfusion, even though the blood was often injected without regard toasepsis or antisepsis. No serious reactions were reported after transfusions with blood 3 weeks old and, in one instance, 7 weeks old, and amazingly good results were often obtained in apparently moribund casualties.
Clinical Considerations
At the Conference on Shock and Transfusion, 25 May 1945, Brigadier Whitbynoted that between that date and 1939, the pendulum had swung back and forth ona number of points (32):
1. Early experience with air raid casualties suggested that the necessaryvolume of transfused fluid was often almost incredibly large. Then came a waveof apprehension that these quantities were producing pulmonary edema, as in someinstances they were. The
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amounts administered in shock and hemorrhage had now become stabilized, but seriously wounded casualties, especially those with massive wounds of the extremities, still required very large volumes of replacement fluids.
2. It was now well understood that plasma had its optimum usefulness in forward areas, to restore and maintain the efficiency of the circulation. Only whole blood transfusions, however, could render a casualty fit for surgery.
3. Speed in administration was essential. If a casualty was exsanguinated, an experienced resuscitation officer would have blood going into two veins at once. There was no danger of pulmonary edema at this time.
4. Blood and plasma were supplied so generously to the Armed Forces that if a casualty were wounded at all, he was fortunate to "escape" transfusion, even if he did not need it. It had been learned that, at least in wounds of the chest and of the central nervous system, blood, if given at all, should be administered with great moderation. In extremity wounds, although transfusion was needed, it introduced the risk of fat embolism.
Col. Frank B. Berry, MC, Consultantin Surgery, Seventh U.S. Army, supported Brigadier Whitby's warning about theunwise use of blood by the specific illustration of a casualty with blastinjuries of the head and lungs whose life was saved in these circumstances onlybecause he had a hemorrhage from the iliac artery.
THE SOVIET UNION BLOOD PROGRAM IN WORLD WAR II
While not a great deal is known about replacement therapy in the Soviet Unionduring World War II, all reports indicate thatblood was the chief replacement fluid (41-43). This might be expectedbecause of the large civilian population; its proximity to the frontlines; thecold climate, which eliminated many of the difficulties of preservation andstorage; and, perhaps, the lack of facilities for processing blood to plasma orserum (p. 95).
The nationwide transfusion service that existed in the Soviet Union beforethe war was organized in Moscow in 1926, by Lt. Col. Andre ArkadievichBagdasarov. This officer later directed transfusions under fire during theborder warfare with the Japanese in 1939 and during the war with Finland in 1940-41.
The Central Institute for Blood Transfusion in Moscow was at the head ofseveral subordinate institutes and about 1,500 blood donor centers. When Russiaentered World War II, this organization became, in effect, a system of factoriesfor collecting and preserving bloodand delivering it to the front as it was needed.
About 2,000 persons a day gave blood in Moscow, about the same number whodonated at the two blood centers in New York. All possible methods of"sanitary" propaganda were used to attract donors. About 95 percent ofthe donors were women, as compared with 50 percent in the United States.Donations ranged from 225 to 450 cc. A second donation was permitted in 4 to 6weeks, but only if the blood picture had returned tonormal. With these precautions, some donors had given blood for periods of 12 to15 years with no ill effects.
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A standard four-cornered container was used to collect and administer blood.The bottles were transported, preferably by plane, in specially constructedisothermic boxes, suitable for use in both warm and cold weather. Blood was alsoput up in 200-cc. ampules which could be carried by medical corpsmen and usedwell forward.
The Russians used type O blood for most battlefield transfusions and alsoused large amounts of type-specific, unpooled plasma. The institute worked out amethod which permitted the preservation of blood for 3 or 4 weeks without lossof its biologic properties and also devised a technique for drying plasma thatinsured its solubility without turbidity or precipitation.
Transfusions were given at all points up to the regimental medical aidstation (battalion aid station) but were most widely used at the medicalsanitary battalion service level (collecting station). The most importantindication was hemorrhage with shock, especially in wounds of the abdomen andextremities. The combined experience of the institute and the army was that onlylarge transfusions, from 1,000 to 1,500 cc., given rapidly, were effective inshock.
THE GERMAN EXPERIENCE IN WORLD WAR II
When the blood program originated in Germany is not entirely clear. Acivilian program was set up in 1940 by an administrative law which permitteddonations of only Aryan blood and which provided for payments of 10 marks forthe first 100 cc. and 5 marks for each additional 100 cc. (43).
The military procurement program was apparently an outgrowth of this civilianprogram. The Laboratory for Blood Transfusion in Berlin, which directed themilitary program, was disrupted by heavy bombings, and all the evidence suggeststhat the supply of blood was insufficient and that containers and technicalequipment were in short supply.
Donors included medical personnel, nursing sisters, staff assistants, andslightly wounded men. An endeavor was always made to rule out tuberculosis,malaria, and syphilis in donors, but serologic examinations were seldom practicaland the donor's statement that he had not had syphilis usually had to beaccepted. Blood groups entered in the soldiers' pay books were frequentlyincorrect, and new determinations had to be made before each transfusion. Ifthis was not possible, a test injection of 10 cc. of blood was made.
The German experience with preserved blood was chiefly between 1940 and 1942.There were so many serious reactions that medical officers lost interest in it.Those who reported satisfactory results were usually in favorable positions,along the lines of transportation. Some medical officers had never seenpreserved blood used in the field without "deleterious" chills. Plasmaand serum were seldom used, although officers who used captured U.S. stocks ofplasma were enthusiastic about it.
Special report-After the German surrender inItaly on 1 May 1945, an unusual opportunity arose to study German management ofbattle casualties
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(44). On the instruction of the Fifth U.S. Army Surgeon, Lt. Col. (later Col.) Howard E. Snyder, MC, visited a number of German medical installations, including the equivalents of U.S. field, base, and convalescent hospitals. In his report, which is included in detail in another volume of this historical series (44), Colonel Snyder emphasized that observers could not judge the standards of German medical practice in the first years of the war in the light of what they found in May 1945, after the total collapse of the Army, nor could they judge the quality of German medical practice elsewhere in Europe in the light of what they found in Italy.
The German management of shock and hemorrhage was thus in sharp contrast to the U.S. practices, by which plasma was always available, and was used in thequantities indicated, in all forward medical installations, while banked blood was available in adequatequantities in field hospitals adjacent to division clearing stations. The extreme pallor of many of the wounded observed in Germanhospitals, and the moderate pallor of most of the others, supported the deduction that they had received little if any blood.
OTHER SOURCES OFBLOOD
To complete the record of the status of transfusion at the beginning of WorldWar II, three other possible sources of whole blood should be briefly mentioned;namely, blood secured from the patient's own blood, that is, autotransfusion;cadaveric blood; and placental blood.
Autotransfusion.-Autotransfusion (autohemofusion, autoinfusion) was firstsuggested by Highmore in 1874, as a sort of afterthought in a fatal postpartal hemorrhage (45). Halsted, in 1884, treated several patients with carbon monoxide poisoning by drawing blood from the victims, defibrinating it, and then reinfusing it. Autotransfusion was apparently first employed in trauma by Duncan of Edinburgh in 1885, in an amputation for a crushing injury of the leg (1). The patient, who was close to death at the end of the operation, made a rapid recovery.
In 1923, Burch (46) collected from the literature 164 cases, chiefly from Germany, in which this method had been used, and several other large collections were made during the next several years. Autotransfusion proved particularly useful in ruptured ectopic pregnancy. Most of the unfavorable reactions and some of the fatalities could be explained by the fact that the blood had been in serous cavities for periods up to 72 hours before it was used.
In World War I, according to Yates (47), thelarge amounts of blood and "colored fluid" removed in massivehemothoraces suggested the possibility of autotransfusion, but tests showed thatthe attendant risks were prohibitive and the method was not used.
Autotransfusion, naturally, became less necessary as blood banks were set up,but early in World War II, when blood was still inshort supply, it proved a valuable method in occasional severe chest injuries inwhich it was certain that there was no injury of the abdominal viscera.
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Cadaveric blood-In 1928, Shamov reported the experimental use of cadaveric blood and demonstrated the absence of toxicity (48,49). At this time, Yudin was in charge of the entire surgical and accidentdepartment of the Sklifosovsky Institute, the central hospital for emergencysurgery in Moscow, in which from 8,000 to 10,000 patients were treated everyyear. The admissions also included many patients who died promptly from acutecardiac disease or severe trauma. In other words, the patients who neededtransfusion and the bodies from which, in the light of Shamov's demonstration,the necessary blood could be secured, were both at hand.
Yudin reported his first seven transfusions with cadaveric blood at the Fourth Congress of Ukranian Surgeons at Kharkov in September 1930. The work was investigated by two commissions, one legal and the other military, both of which recognized its scientific foundation, and he was given a special permit to collect blood from fresh cadavers before autopsy.
With the discovery that cadaveric blood could be stored safely, time was provided for both serologic tests and bacteriologic examinations. In November 1932, Yudin reported to the Soci?t? Nationale de Chirurgie in Paris on 100 transfusions with cadaveric blood kept for 3 weeks, and in one instance 4 weeks. In 1937, he reported in the Lancet that he had performed a thousand transfusions by this method, chiefly for internal hemorrhage and traumatic shock and in operations for gastrointestinal disease, particularly cancer.
In Yudin's first 200 transfusions, all performed with citrated blood, there were 40 reactions, all moderate. In the next 800 transfusions, all performed with noncitrated blood, the incidence of reactions fell to 5 percent. The five fatal cases in the series were explained in three instances by technical errors, including the transfusion of incompatible blood. The fourth death was due to embolism and the remaining death to anaerobic infection.
Cadaveric blood was apparently never used widely, even in Russia. It was not mentioned to Dr. George K. Strode (42) of the Rockefeller Foundation, who visited the Central Blood Transfusion Institute of Moscow in October 1941, and no statement in the literature suggests that it was used during the war. It is doubtful that transfusions with blood secured from cadavers could ever have been employed in any country in the world except Russia, for the idea, in spite of its logic, is revolting.
Placental blood-In February 1938, J. R. Goodall of Montreal, with a group of his associates, published a communication whose title proclaimed "an inexhaustible source of blood for transfusion" (50). This source was the placenta, from which amounts of blood ranging from 100 to 150 cc. had been collected under sterile precautions. The preservative used was the solution proposed by the Moscow Institute of Hematology (sodium chloride, sodium citrate, potassium chloride, magnesium sulfate, double-distilled water), and the blood had been kept in a refrigerator as long as 60 days at temperatures of 33? to 38? F. (1? to 3? C.). Serologic tests were not necessary, as they had been run on the mothers. Cultures were not considered necessary: the reason-
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ing was that at the low storage temperature, contamination, if it was present, could not propagate and would be so attenuated as to be innocuous.
The Goodall report gave no definite figures but stated that "many" transfusions had been accomplished with placental blood with no reactions of any kind. It was concluded that the maternity section of a general hospital could provide blood for the whole hospital, supply other institutions, and also prove a source of income, since private patients could be charged for the transfusions. In the opinion of the Montreal group, placental blood could be regarded as a "safe, constant, efficient, and lucrative" source for transfusion.
Boland and his associates (51), reporting in the Lancet in February 1939, were considerably less enthusiastic about placental blood. They had experienced several serious reactions with it and found contamination in 30 percent of 40 specimens of fetal blood collected by the Goodall technique.
Placental blood was never used in the United States, and it was not employed in World War II.
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2. Lewisohn, R.: The Development of the Technique of Blood Transfusion Since 1907; With Special Reference to Contributions by Members of the Staff of the Mount Sinai Hospital. J. Mt. Sinai Hosp. 10: 605-622, January-February 1944.
3. Lewisohn, R.: Blood Transfusion: 50 Years Ago and Today. Surg. Gynec. & Obst. 101: 362-368, September 1955.
4. Ottenberg, R.: Reminiscences of the History of Blood Transfusion. J. Mt. Sinai Hosp. 4: 264-271, November-December 1937.
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7. Blundell, J.: Successful Case of Transfusion. Lancet 1: 431-432, 3 Jan. 1829.
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17. Robertson, L. B.: The Transfusion of Whole Blood. A Suggestion for ItsMore Frequent Employment in War Surgery. Brit. M. J. 2: 38-40, 8 July 1916.
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41. Phalen, J. A.: The Blood Plasma Program. Division of Medical Sciences, NRC, Washington: Office of Medical Information, 25 July 1944.
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