CHAPTER XV
The Mediterranean (Formerly North African)
Theater of Operations
Part I. Fifth U.S. Army
EVOLUTION OF POLICIES
The use of whole blood overseas in the management of woundedcasualties developed in MTOUSA (Mediterranean (formerly North African) Theaterof Operations, U.S. Army) (1). While its development was a local affair,it influenced the policies and practices in both ETOUSA (European Theater ofOperations, U.S. Army) and the Pacific areas. The experience occurred in twochief phases:
1. The British experience blazed the trail (2). On theoutbreak of war, in September 1939, the British immediately put into action theplans previously set up for the provision of whole blood to troops in the field(p. 15). In the Western Desert, 18 bottles of blood, 19 bottles of plasma orserum, and 20 bottles of physiologic salt solution were used for each hundred ofthe 17,572 troops wounded between 10 April and 28 November 1942. The use ofblood was more liberal than these figures suggest, since the total casualtiesinclude the missing, in some of the actions.
The entire British experience proved that while plasma wasextremely valuable in the provision of temporary circulatory support forcasualties with multiple wounds, accompanied by massive hemorrhage, frommortars, high explosives, and landmines, it was not enough. Whole blood, whichhad the oxygen-carrying properties lacking in plasma, was essential for thesupport of casualties for anesthesia and initial wound surgery. The Britishexperience also proved that it was completely practical to transport whole bloodfor long distances; when the fighting moved to Italy, British hospitalscontinued to receive blood from the bank in Cairo until the transfusion unitmoved to Bari, Italy.
2. Information concerning the British experience was madeconstantly available to Col. Douglas B. Kendrick, MC, in the formative days ofthe blood-plasma program in the Zone of Interior by Col. Frank S. Gillespie,RAMC, British Medical Liaison Officer (p. 54). Col. Edward D. Churchill, MC,Consultant in Surgery to the Surgeon, Fifth U.S. Army (fig. 76), was fullyinformed of it when he assumed his duties in North Africa in March 1943. Beforehe left the Office of The Surgeon General for North Africa, he had been
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requested to undertake a study of the entire problem, withthe twofold objective of determining (1) whether, with plasma readily available,whole blood were really needed, and (2), it if were, how best it could beprovided.
FIGURE 76.-Col. Edward D. Churchill, MC,Consultant in Surgery, Fifth U.S. Army.
EARLY EXPERIENCES
In spite of the British experience, U.S. Army hospitals thatlanded in North Africa in November 1942 and those that landed later hadpractically no equipment for whole blood transfusion (p. 393). It was theprevailing opinion then that plasma would be so effective that only a very smallproportion of wounded would require whole blood early in their treatment. A fewofficers in the Army Medical Department and a few members of the Subcommittee onBlood Substitutes had expressed concern over the lack of preparation for wholeblood transfusion, but no strong, direct, constructive, formal recommendationhad been made, and there was, therefore, no provision at the time for supplyingwhole blood to Army hospitals overseas.
The treatment of shock with plasma produced gratifyingresults in Tunisia and throughout the war (figs. 77-80). It was provided inample quantities. It was often given in 1,000-cc. amounts. It was oftencontinued during evacuation to the rear, or it was given prophylactically, inadvance of evacuation, particularly in patients with fractures of the femur orwith abdominal wounds (who later in the war would be operated on in fieldhospitals). It did not require much experience, however, to learn as the Britishhad long since learned, that when blood had been lost, the only effectivereplacement was whole blood.
There is no doubt that lives were lost in North Africa andthat morbidity was increased because blood was not used soon enough (untilevacuation hos-
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pitals, or sometimes general hospitals, had been reached) orin sufficient quantities. There were three explanations:
1. Facilities for transfusion had not been provided.
2. Transfusion with improvised equipment was extremelyinconvenient and often impractical under field conditions.
3. The importance of whole blood had been overlooked whilethe potentialities of plasma had been overstressed.
In his report of 3 April 1943 to the Surgeon, II Corps, Maj.(later Col.) Howard E. Snyder, MC (3), included among his recommendationsthe need for a more convenient method of blood transfusion and for a source ofdonors other than clearing station personnel (p. 395). The need for whole bloodin combat casualties and the extreme inadequacy of the equipment for obtainingit and administering it had already been reported to the Surgeon, II Corps, bythe chief of surgery, 77th Evacuation Hospital, through channels, in December1942. The report of the 77th Evacuation Hospital on 18 April 1943 stated,"As the need for whole blood transfusion grew critical, we found thatnothing had been provided for this purpose" (4).
At that time, this hospital had no citrate, no distilledwater, and no facilities to make it. The only equipment was what Capt. Joseph J.Lalich, MC, who headed a shock team, had been able to obtain from the Britishblood bank while the hospital was stationed in England. Sodium citrate wasobtained from a French pharmacy. A still was borrowed from the French.
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FIGURE 78.-Administrationof blood plasma to wounded German soldier at battalion aid station by corpsmen of1st Battalion, 85th Mountain Infantry, 10th Mountain Division, Fifth U.S. Army,Villafranca, Italy, April 1945.
Blood was obtained from the hospital detachment.Shock teams were organized to collect and administer blood, administer plasmaand other intravenous therapy, make distilled water for the entire hospital,sterilize equipment for transfusion and other intravenous therapy, and performcrossmatching. With these makeshift arrangements, the casualties in thishospital received more blood than plasma, and the report is an illustration ofboth the difficulties attending an improvised operation and the ingenuity of thehospital personnel.
In a report to The Surgeon General on 1 June1943, Surgeon, II Corps, Col. Richard T. Arnest, MC, pointed out that if steriletubing, filters, and needles were provided, with facilities for crossmatching,whole blood transfusions could be given almost as conveniently as plasmatransfusions. The difficulty at this time was lack of equipment.
Meantime, almost as soon as he had arrived inNorth Africa, Colonel Churchill concluded, from his personal observations andfrom studies that he instigated, that large quantities of whole blood wereneeded in combat areas to treat casualties with severe wounds (2). Towardthe end of the North African campaign, he detailed Maj. (later Lt. Col.) EugeneR. Sullivan, MC, Chief, Laboratory Service, 16th General Hospital, toinvestigate transfusion requirements and facilities in forward hospitals. On 13July 1943, Major Sullivan reported that facilities for whole blood transfusionwere entirely inadequate. He recommended that there be provided, ready forimmediate
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use, vacuum bottles for bleeding, appropriateapparatus for the administration of whole blood, equipment for Kahn serologictests, and electric refrigerators for the storage of blood in all field hospitalplatoons and all evacuation hospitals. With this equipment, Major Sullivanbelieved that forward hospitals could operate their own blood banks.
Reports of this own and Major Sullivan'sobservations were forwarded by Colonel Churchill, through channels, to the Officeof The Surgeon General and to those in that office concerned with theblood-plasma program. He emphasized that his first task had been theidentification of the problem (5). The campaign in North Africa had endedbefore corrective measures could be taken, but the necessary information was nowavailable for future action. The single fact that stood out most prominently inthe care of battle casualties in North Africa was the indispensability of wholeblood before, during, and after initial wound surgery. Unless casualties wereproperly resuscitated-and their resuscitation includedwhole blood, often in large quantities, to replace what they had lost-surgerywould be attended with an excessive mortality rate. Plasma could not replacewhole blood.
Sicily
As a result of the North African experience andthe subsequent studies by Colonel Churchill, Major Snyder, and others, a systemof blood banks was set up in the Sicilian invasion in evacuation and generalhospitals, sometimes
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only 3 or 4 miles behind the combat zone (6). Theblood was collected from volunteer donors among the combat troops, with theapproval of their commanding officers, and from convalescent and slightlywounded casualties. Chaplains were of great help in obtaining donors, and thefield directors of the American Red Cross maintained the records and otherwiseassisted in the program. Plasma, of course, continued to be used in quantity.
FIRST PLANNING FOR A THEATER BLOOD BANK
Alternate Proposals
When the organization of a theater blood bank was firstdiscussed in the Mediterranean theater, in June 1943, it was thought that bloodwould be necessary for about 18 of every 100 casualties, and that 1 unit ofblood would be required for every 3 units of plasma. The ratio of transfusionsto casualties, however, rose steadily as surgeons gained experience in combatsurgery.
Two methods of providing the necessary blood were discussedat this time, (1) the distributing system employed by the Royal Army MedicalCorps, and
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(2) a unit system, set up in individual hospitals, which would eliminate thenecessity for a distributing system.
British system -The basis of the British system, as described elsewhere(p. 15), was the collection of blood in hospitals in the communications zone andits distribution to hospitals in the forward area. A forward distributing unitreceived blood from the base collecting unit, stored it, and distributed it asnecessary to forward field transfusion units, which were located at the pointsat which initial wound surgery was performed.
Unit hospital system -The unit system first proposed for U.S. Armyhospitals was advocated because of the following advantages:
1. It would eliminate the elaborate distributing system usedby the British, which required additional personnel and mobile refrigeration.
2. It would reduce the time lost by donors, who would besecured from Army personnel.
3. It would permit the utilization of type A donors, who, withtype O donors, account for about 82 percent of all bloods. In the Britishsystem, only type O donors were used.
4. It would permit personal supervision of all technicaldetails by personnel of the hospital in which the transfusion was given. Anytechnical errors could thus be identified and corrected at once.
5. Hospitals using blood would be responsible for reducingexcessive use and wastage, estimated at 10-15 percent in the British system.
6. There would be no losses by freezing during the winter, andlosses by road accidents and transportation would be minimal.
7. The unit system would be more effective in overwater orassault operations, in which distribution from a base, or even from a forwardcenter, must await the establishment of air transport.
8. The unit system could be started in the Mediterraneantheater as soon as transfusion sets were acquired. If necessary, a distributionsystem could be set up later.
The disadvantages of a unit system were also recognized:
1. It would continue to place the burden of procuring bloodupon busy forward hospitals, which had, however, shown themselves capable ofassuming it. It would also mean that saline and glucose solutions and distilledwater must continue to be prepared and distributed by hospitals; by the Britishsystem, these duties were assumed by the base installation.
2. Since troops in the combat zone would be used as donors,instead of base troops, the risk of transfer of malaria might be increased; itwas relatively safe, from this standpoint, to bleed troops as soon as they hadarrived in the theater.
3. When a hospital moved, except a field hospital platoon,which had mobile refrigeration, refrigeration would be interrupted and whateverblood was on hand would be wasted.
4. Both expendable and nonexpendable equipment would berequired. Mobile hospitals, particularly those that would use blood in thelargest amounts, should not be weighted down with the equipment necessary towash, sterilize, and store bleeding bottles. Moreover, hospitals often workedwithout adequate supplies of pure water and with limited quantities of distilledwater, and these lacks would make the cleansing process difficult andunsatisfactory.
5. Additional refrigeration would be required in evacuationhospitals, or a modification of the refrigerators now in use. To keep fieldhospitals completely mobile, it would be necessary for each platoon to besupplied with a refrigerator truck. Insulated boxes would also be needed foremergency shipment of blood from evacuation to field hospitals.
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Recommendation for Unit System
In a report of this discussion from the Consultant in Surgery to the Surgeon,NATOUSA (North African Theater of Operations, U.S. Army), of 2 July 1943, thefollowing recommendations were made (2):
1. That a unit system to supply whole blood be immediatelyauthorized in the theater.
2. That training personnel be detached as necessary frompresent assignments to put it into operation.
3. That the transfusion sets necessary be requisitioned bycable.
4. That the principle of using corps troops as donors becleared through command channels, since command could at any time block thesupply; this had happened in certain organizations in Tunisia. It was estimatedthat for an operation resulting in 20,000 casualties, 3,600 donors would berequired from corps troops or from lightly wounded divisional troops duringtheir evacuation to the rear.
It was pointed out that the basic difference between the unit systemdescribed and the British system was the placement of the donor reservoir, whichwould be in the forward and not the base area.
It was also recommended in this report that a central laboratory beestablished in the theater, to provide whole blood, plasma, intravenoussolutions, and distilled water for the Fifth U.S. Army, on the ground that theBritish Base Transfusion Unit had demonstrated the feasibility of supplyinglarge amounts of whole blood to combat troops.
Blood Supply, September l943-February 1944
By the time U.S. troops had landed at Salerno on 9 September 1943, it wasapparent that even with the availability of vacuum bottles, which had nowreached the theater, for the collection of blood, it would be impossible forforward hospitals to collect sufficient blood to treat their casualtiesadequately (7). Shortly after these landings, therefore, Col. (laterBrig. Gen.) Joseph I. Martin, MC, Surgeon, Fifth U.S. Army, urged the theaterSurgeon, then Brig. Gen. Frederick A. Blesse, to authorize the establishment ofa transfusion unit to support Fifth U.S. Army field and evacuation hospitals.The Anzio-Nettuno landings were then in the planning stage, and, when no actionwas taken on General Martin's request, it was necessary for him to requestBritish assistance in providing blood for them. In all, U.S. hospitals on theAnzio beachhead received about 4,000 pints of blood from this source; a largepart of it was donated by Army Air Forces personnel in the area, but collectingand processing were done by the British blood transfusion unit at Foggia withBritish equipment. The first blood from the Fifth U.S. Army blood bank in Napleswas not received on the beachhead until 23 February 1944.
During this period, as well as later, British blood was used for U.S. troopselsewhere in Italy (fig. 81). The use of serum was limited to British troops(fig. 82).
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In ETMD (Essential Technical Medical Data), NATOUSA, 1943 (8),the advantages of a collecting unit in a base section, to supply a portionof the blood used in forward hospitals, were outlined:
1. Service troops in the base could be used asdonors, thus eliminating any interruption in the work of forward troops.
2. A collecting unit in the base could conducta more rigorous examination of donors to eliminate those with jaundice andmalaria. It could also control the quality of the blood by holding it longenough to perform Kahn tests and to search for malarial parasites.
3. The holding of small reserves of blood inthe base area, subject to constant turnover by distribution to forward areas,would provide a bank adjacent to base units that could be used in the event of adevastating air raid or other catastrophe.
4. The current tactical situation, with arelatively stable front close to a large base area, was ideal for thedistribution of blood under such a system.
Two disadvantages were listed:
1. It was undesirable to allow forwardhospitals to become entirely dependent on the base section for blood; inoverwater assaults and other conceivable tactical situations, it was essentialthat they be able to be self-sustaining in respect to blood for long periods oftime.
2. The plan proposed would reduce whole bloodto the status of a supply item, and it was not desirable to shift theresponsibility for providing a lifesaving agent to an impersonal organization.No matter how carefully the system was organized, it would fail, through nofault of its own, under critical circumstances. A base section collecting anddistributing unit should be regarded simply as an accessory to a vigorous andsustained effort by individual hospitals to maintain their own blood banks, notas a means of release from this responsibility.
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ESTABLISHMENT OF BLOOD BANK AT 15TH MEDICAL
GENERAL LABORATORY
In February 1944, the whole blood situation was reviewed inall its aspects by General Martin; Colonel Arnest; Major Sullivan, representingGeneral Blesse, and Col. Virgil H. Cornell, MC, Commanding Officer, 15th MedicalGeneral Laboratory (fig. 83) (9). Major Sullivan had just returned froman inspection trip in Fifth U.S. Army field and evacuation hospitals, in whichhe
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FIGURE 83.-Col. Virgil H. Cornell, MC,Commanding Officer, 15th Medical General Laboratory
had surveyed their blood transfusion problems.1The outcome of the meeting was the recommendation that a transfusion unitbe organized to supply 100 bottles of blood daily to meet Fifth U.S. Army andPeninsular Base Section requirements. A letter containing this recommendationwas sent to Maj. Gen. Morrison C. Stayer, Surgeon, MTOUSA, by Colonel Cornell,through channels, on 5 February 1944. Before action could be taken on it, theArmy had raised the calculated needs to 200 bottles per day.
The 15th Medical General Laboratory, which arrived at Napleson 20 November 1943, was the parent organization of the Fifth U.S. Army bloodbank. It was the second laboratory of the kind to be organized in World War IIand, in general, was set up on the pattern of the central laboratory at Dijon inWorld War I (10).
Soon after its arrival in Naples, the laboratory was asked bythe Surgeon, Peninsular Base Section, to operate a small (20-bottle) blood bank,to supply the Naples area and the medical center there, to provide againstemergencies. During the period required for Headquarters, NATOUSA, to draw uptables of organization and equipment for the proposed transfusion unit to beestablished in the theater, the laboratory undertook to supply blood for FifthU.S.
1Until almost the end of the war, Major Sullivan continued to be attached to the Office of the Surgeon, NATOUSA. It was essential that some officer in this office have the responsibility for the coordination of the transfusion program with other theater activities. Major Sullivan acted as consultant on transfusions and in this role played a very important part in the theater blood program.
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Army hospitals. One officer (Capt. (later Maj.) John J.McGraw, Jr., MC) (fig. 84), and two enlisted men were assigned to a blood banksection and later served as a cadre for the transfusion unit.
Colonel Cornell took a great interest in the transfusionunit, and devoted much time and effort to helping Major Sullivan develop it. Theavailability of a medical officer of Colonel Cornell's experience, with hisrank, was a distinct advantage. On numerous occasions he took directresponsibility and was able to obtain far prompter cooperation from other unitsand services than could the commanding officer of the unit, who, for the majorperiod of its operation, had the rank of captain.
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Collections.-The first blood collected at thelaboratory on 23 February 1944, from group O donors, was sent to theAnzio beachhead, where it was distributed by the British field transfusion unitstationed there. Between this date and 1 May 1944, the laboratory collected4,134 bloods. The one officer and two enlisted men assigned to the blood banksection were able to collect and process enough blood to meet the demands of thehospitals on the beachhead until the special transfusion unit was authorized on9 May 1944.
During May, 6,363 bloods were collected, an achievement thatwould have been impossible without the help of personnel from the 1st MedicalLaboratory, Fifth U.S. Army, which was attached to the 15th Medical GeneralLaboratory on 27 April 1944. These officers and men, in addition to providinghelp in the collection and processing of blood, had an excellent opportunity tolearn the conduct of a blood bank during a period of maximum activity. Using 12beds, the combined personnel of the two laboratories drew a total of 4,685bloods between 14 and 31 May, a daily average of 260. During the same period,after air contact had been made with forward units of the Fifth U.S. Army,personnel of the 2d Medical Laboratory (figs. 85 and 86) collected an additional410 bloods.
Most of the blood collected in the February-May period wentto the Anzio beachhead. The remainder was used in nearby general and stationhospitals.
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THE 6713TH BLOOD TRANSFUSION UNIT (OVHD.)
Organization
The 6713th Blood Transfusion Unit (Ovhd.) was activated on 9May 1944, by General Orders No. 85, Headquarters, Peninsular Base Section, 8 May1944 (11). It was assigned to Headquarters, NATOUSA, and attached to the15th Medical General Laboratory for administration, quarters, and messingfacilities. Although it was officially a separate organization, the transfusionunit, for all practical purposes, was a department of the laboratory. This was afortunate arrangement, for it permitted the use of many laboratory facilitiesand services. Kahn tests, for instance, were performed by the serology sectionof the laboratory. It was thus possible for the transfusion unit to conservespace, equipment, time, and personnel.
As the transfusion unit was set up, it operated in twosections (chart 8), a base section which collected and processed blood in thebase and shipped it to the other section, which functioned as a smallerdistributing section in the Fifth U.S. Army area. This organization was farcloser to the British system than to the unit system originally recommended, bywhich individual hospitals were largely responsible for their own supply. Theexplanation for the changed plan appears in a memorandum addressed to TheSurgeon General on 27 May 1944 by Col. Earl Standlee, MC (12). In thismemorandum, Colonel Standlee
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CHART 8.-Diagram of blood transfusionservice for field army, North African theater, 27May 1944
Source: Memorandum, Col. Earl Standlee, MC, to The SurgeonGeneral, 27 May 1944, subject: Blood Banks in Theater of Operations.
pointed out that the great need for blood was in the forward,not the base, area. In the Fifth U.S. Army hospitals, between the invasion atSalerno and the end of the Cassino campaign, 4,600 transfusions were given inthe Army area against 300 in the base. The emphasis should therefore be onsupplying blood to Army rather than to base installations. When the base wasclose to the battle-line and evacuation was relatively rapid, the amount ofblood used in base hospitals increased accordingly.
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FIGURE 87.-Transfusion in postoperative ward,33d Field Hospital, Fifth U.S. Army, September 1944.
Transfusions were ordinarily given only in field (fig. 87)and evacuation hospitals in the forward Army area, these being the firstinstallations staffed and equipped for their administration. They were notordinarily given in battalion aid stations or in collecting and clearingstations, though occasionally, as during the rapid advance after the breakout atAnzio, these installations were so far ahead of field hospitals that blood wassent to them. There was no point to providing blood for clearing stations thatwere abreast of field hospitals.
As the plan worked out, field hospitals were supplied withall the blood they requested; they were never expected to provide their own.Evacuation hospitals operated their own blood banks when their casualty load waslight. When it was heavy, they were supplied with additional amounts of bloodfrom the base.
Bleeding Center
In addition to serving as the Unit headquarters throughout thewar, the 15th Medical General Laboratory at the Fair Grounds in Naples served asthe base bleeding section until the middle of April 1945, 3 weeks before the warin Italy ended. Another center was set up at the Red Cross enlisted men'sservice club in Naples. As the fighting moved north, bleeding centers were setup in Rome, Florence, and Pisa. Centers were sometimes set up temporarily inArmy laboratories in replacement depots too far distant for convenient
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transportation of donors to the main center. The need formultiple centers increased as the Army advanced and base section troops wereless concentrated.
Individuals came to the centers by whatever transportationthey could secure. Organizations usually provided transportation for groups, orblood bank trucks were sent for them. In actual practice, the most efficient wayto secure donors was to make contact with unit commanders a few days in advanceof the need and ask them to provide groups of volunteers, who could be picked upat specified hours by organization or blood bank trucks.
Mobile bleeding units were sometimes sent out to bleed donorswho could not report to the donor centers. Prisoners in disciplinary stockades,for instance, had to be handled in this manner. This was not a practical method,however, until the last month of the war, because of lack of expendable donorsets. Cleaning and sterilization of donor sets provided the biggest obstacle tothe efficient operation of mobile bleeding units in Italy.
Distributing Center
The first blood collected at the 15th Medical General Laboratorywas distributed by the British field transfusion unit operating in the Anzioarea and by the 2d Medical Laboratory operating in the Carinola area. On 22 June1944, the 6713th Blood Transfusion Unit began to operate its own forwarddistributing center, with 1st Lt. (later Capt.) John T. Kroulick, MAC, incharge. The center was always located near an airfield and was usually attachedto an evacuation hospital for quarters and rations. If, however, an Armylaboratory were situated in the area, it was sometimes attached to it. Thecenter moved from its first location at Anzio to Rome, and then, as thefighting moved up the peninsula, to Grosseto, Florence, Bologna, and Verona,where it was located, at the 8th Evacuation Hospital, when the war in Italyended. By the middle of June, all personnel had returned to the Naples base.
Personnel
When the 6713th Blood Transfusion Unit (Ovhd.) was planned, theestimated requirements for blood for Fifth U.S. Army field and evacuationhospitals, based on the amounts used to date, were set at 100 pints per day.Original personnel for the procurement and distribution of this amount consistedof 3 officers and 16 enlisted men. Before the unit was organized, the need forblood in Fifth U.S. Army hospitals, which were then receiving casualties fromone armored and six infantry divisions, had increased to 200 pints per day, andthe personnel allotment was increased to 5 officers and 20 enlisted men. Later,the allotment of enlisted men was increased to 38.
Personnel and equipment of the unit were sufficient toprocess 200 bloods a day with relative ease and to handle 300 pints daily forshort periods without too much difficulty. When fighting was heavy, however, and300 or more bloods were required daily for long periods, more help was needed.At the
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beginning of the Po Valley offensive, between 11 and 21 April 1945, 6,450 pints of blood were collected and processed, including 871 pints on one day.
Skilled personnel from the 15th Medical General Laboratory assisted during periods of stress. Even so, during major offensives, such as the Garigliano offensive, the assault on the Gothic Line, and the campaign in the Po Valley, it was necessary to attach additional personnel to the unit, usually from a hospital ship platoon, an adjacent general hospital, an army medical laboratory, a medical battalion, or replacement depots. When a replacement center located about 25 miles from the 15th Medical General Laboratory served as an independent bleeding section, some of the keymen from the original unit were trained intensively for about a month and assigned to it. They were slowly withdrawn as the replacement center section became able to function without help.
If Air Forces personnel, informal assistants, and hired civilians are included in the count, the total strength of the blood transfusion unit once rose to 90 persons, about 15 of whom were engaged in the distribution of blood, clerical work, supply, liaison, and other accessory tasks.
When 300 donors were bled daily, the 5 officers and 38 enlisted men attached to the unit had the following duties (figs. 88-92):
1. Contacts with donors, one officer and one enlisted man.
2. Registration of donors, three enlisted men.
3. Grouping bloods and preparing malaria smears, three enlisted men.
4. Bleeding donors, two officers and six enlisted men.
5. Labeling, capping, and packing bottles for shipment, three enlisted men.
6. Staining and reading malaria smears, two enlisted men.
7. Performing Kahn tests, one officer and two enlisted men.
8. Titration and check of blood grouping, two enlisted men.
9. Washing and sterilizing equipment, four enlisted men. When local civilianpersonnel were employed for this purpose, they were carefully supervised by anenlisted technician. An experienced technician always operated the autoclave.
10. Correspondence, preparation of pay vouchers, two enlisted men.
11. Forward distribution, one officer and four enlisted men.
12. Driving, four enlisted men.
When 300 donors a day were bled, officers and enlisted men worked the entireday. When larger numbers were bled, nightwork was necessary, and it was alsonecessary when, for one reason or another, donors could present themselves onlyat night. The frequent necessity for keeping personnel on duty all night, tomaintain a 24-hour blood service, made for constant shortages of trainedworkers. Only the skill and devotion of the personnel of the blood transfusionunit made it possible to supply the large amounts of blood needed in the FifthU.S. Army area in 1944 and 1945.
Personnel difficulties were compounded when it was necessary to operateseveral bleeding sections at long distances from each other. Theoretically, themost economical and efficient way to operate a blood transfusion unit is in onelocation, but circumstances in the Mediterranean theater frequently did notpermit such an arrangement. In his October 1945 memorandum to The
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FIGURE 88.-Preparation of donor sets, 15th MedicalGeneral Laboratory, Naples, March 1944. Cleaning of giving and receiving setsafter use was done by a very demanding technique. The objective was to completethe whole procedure, including reassembly, testing, and autoclaving, within 2hours of the time the equipment had been used. A. Cleansing of tubing and valvesin cold running water, introduced under pressure, after which distilled waterwill be used. B. Donor sets drying by gravity before sterilization. C. Technician cleaning and oiling blood collecting valves and tube assembly.
Surgeon General, Colonel Standlee recommended that in the future two transfusion units be established instead of one. Administration would then be more flexible, bleeding in isolated areas would be simplified, and the additional personnel would provide an additional margin of safety in case of disability from sickness and during rapid movement.
The forward distributing section was always in charge of a medical officer, who could assure proper handling and equitable distribution of the available blood, and who could also aid in the solution of transfusion problems that might arise in forward hospitals.
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Officially, the personnel of the forward section, since theyoperated in the Army area, were on detached service with the Surgeon, Fifth U.S.Army. Their operational and administrative control, however, remained with thebase transfusion unit. They carried their own tents, blankets, and otherequipment, and, for housekeeping purposes, they were attached to the mostconvenient evacuation hospital or army laboratory in the area.
When several scattered bleeding sections were in operation,administrative details, accounting for supplies and property, liaison, donorprocurement, and
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maintenance of records proved to be a considerable task. Allthe officers of the unit participated in the work, with the channels ofadministration leading back to the base unit.
The desirability of including a medical administrativeofficer in the table of organization of blood transfusion units was debated inthe theater before the 6713th Blood Transfusion Unit (Ovhd.) was established. Onthe surface, it seemed that it might be wise to concentrate all theresponsibilities just listed in the hands of an administrative officer who wouldhave no professional responsibilities and who could replace either a MedicalCorps officer or a Sanitary Corps officer in the table of organization. It wasdecided, however, not to make the substitution, and the decision was wise, sincethe attachment of the unit to the 15th Medical General Laboratory eliminatedmany administrative problems.
In his August 1945 memorandum to The Surgeon General (13),Colonel Standlee strongly recommended against the appointment of a medicaladministrative officer; the entire blood bank operation, he pointed out,required a background of scientific training, and the Medical Corps or SanitaryCorps officer who would be lost by the substitution would have numerousprofessional duties. If, however, it was not practical, for any reason, toattach a transfusion unit to a large laboratory or other large organization,then the addition- not substitution-of an administrative officer would benecessary rather than desirable.
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FIGURE 91.-Blood typing at 15th Medical General Laboratory blood bank, Naples, September 1944.
TRAINING
It was necessary that the personnel of the base collectionsection be skilled in all aspects of the blood program, including fundamentalprinciples, knowledge of blood types and typing, bleeding techniques, cleaningof apparatus, asepsis and sterilization, distillation of water, crossmatching,Kahn serologic testing, examination of smears for plasmodia, recognition ofcontaminated or overage blood, and fundamentals of refrigeration.
The noncommissioned officer in charge of a bleeding section,the enlisted men who cleaned, prepared, and sterilized the bleeding sets, andthe technicians responsible for blood grouping and other laboratory proceduresrequired at least a month's training in excess of their basic technicallaboratory training. The usual laboratory technician, even though he was trainedin venipuncture, did not attain a satisfactory degree of efficiency in bleedingdonors until he had had additional training and practice. Some of the additionaltraining was formal and didactic, but it was soon found that there was nosubstitute for breaking in a technician by assigning him directly to a bleedingunit in active operation.
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FIGURE 92.-Reading Kahn tests on donors' bloods, 15th Medical General Laboratory blood bank.
A certain amount of rotation was practiced from one sectionof the laboratory blood bank to another, but, in general, the tendency wastoward specialization, so as to develop keymen in the blood bank as in othersections of the hospital.
All medical officers and nurses in the Mediterraneantheater, as well as selected noncommissioned officers, received thoroughtraining in the technique of reconstitution (fig. 93) and administration ofplasma. The training was essential. When casualties were pouring in, there wasno time to study instructions or labels on containers. Demonstration sets wereused to advantage during the training, and so was Film Strip 8-51 when it wasavailable.
In April 1944, a program was set up by which medical officersfrom each Army hospital and technicians from each hospital laboratory were sentto the blood bank at Naples for 3 days of intensive instruction. The handling ofbanked blood was greatly improved at the various hospitals as a result.
In September 1944, a complete series of motion and stillpictures were made of blood bank activities from the time the donor arrived atthe bleeding center until the blood was used in a frontline hospital. The scriptwas prepared by Colonel Cornell. Film Strip 8-51, a black-and-white 35-mm.production, of 8,400 feet, was sent to the Signal Corps Photographic Center onLong Island on 22 December 1944.
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TRANSPORTATION AND REFRIGERATION
Trucks -Transportation obtained from theater stocksconsisted of two 2?-ton trucks, two 1?-ton trucks, two weapons carriers, and one?-ton jeep. The jeep was used for general utility purposes and to make contactwith adjacent units from which donors could be secured.
One 2?-ton truck was mounted with a large refrigeratorpowered with generators (3 kw.). It had a capacity of 450 pints of blood and wasused for storage purposes at the forward distributing section. The other 2?-tontruck, together with one of the 1?-ton trucks, was used at the base section totransport donors and supplies and for similar purposes. The other 1?-ton truckcarried a moderately sized refrigerator with the necessary generators, and wasused to deliver blood from the bleeding section to the forward distributingsection of the bank (fig. 94). The two weapons carriers were mounted withsmaller refrigerators, powered by the necessary generators, and were used todistribute blood from the forward distributing section to field and evacuationhospitals.
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FIGURE 94.-Truck with refrigerator used for delivery of blood, 15th Medical General Laboratory, Naples, March 1944. A. Refrigerator with compressor and two generators, one of which could take over if the other broke down. B. Rear view of truck, showing front of refrigerator, which is a company mess type, reinsulated and altered to fit 1?-ton personnel carrier in which blood is transported. It easily holds 240 600-cc. bottles of blood. C. Refrigerator opened to show method of storing blood in it.
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The vehicles were not in the best of condition when they wereallotted, and not infrequently one or more had to be put up for repairs.
The delivery of all refrigerators was delayed; the firstshipment was lost at sea, and the second did not arrive until some months afterthe invasion of Italy. Eventually, however, electric refrigerators wereavailable for all medical installations in the theater, up to and includingfield hospitals. They had sufficient space for about 40 bottles of blood each.When kerosene refrigerators were used, the chief problem was the procurement ofwhite gasoline for their operation. The necessity for good mechanicalrefrigeration, both in fixed hospitals and on trucks, carried the implicationthat the services of competent refrigerator mechanics be constantly available.
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The large refrigerators in the 2?- and 1?-ton trucks didnot receive unduly rough treatment and stood up very well. The household-sizedrefrigerators mounted in the weapons carriers did not stand up well, as mighthave been expected, since they traveled more than 150 miles each day, over veryrough roads. They were soon discarded and deliveries were accomplished ininsulated boxes (fig. 95).
These boxes, which were constructed in the Utilities Section, 15th Medical General Laboratory, were made of plywood and were insulated with 2 inches of cork. The insulation was sufficient to limit the temperature elevation to no more than 54? F. (12? C.), even when the box was exposed to the sun for 12 hours. A good deal of ingenuity was shown in their construction, which often included Italian hinges, German clamps, and gaskets from salvaged GI blankets. Each container held 4-6 cardboard cartons, each of which contained six bottles of blood.
These boxes were definitely not expendable. Their number had to be limited to the absolute minimum necessary for the operation because of the scarcity of material, particularly plywood and cork. They were later used for the airlift of blood from Italy to southern France (p. 448).
AIR TRANSPORTATION
The first blood delivered to the Anzio beachhead, which wasalso the first blood distributed from the blood bank at the 15th Medical GeneralLaboratory, was sent by LST's (landing ships, tank) (fig. 96). At this time,the beachhead was still isolated, and most of the blood collected was sent to
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the hospitals on the Cassino front. When the fighting was intensified atAnzio, a request was made that blood be flown in. The necessary arrangementswere made within 6 hours, and blood was delivered by plane to Anzio andelsewhere regularly thereafter, the largest shipment on a single day being 450bloods.
C-47 plane.-At the request of Colonel Cornell, a C-47 aircraft(fig. 97) was attached to the 15th Medical General Laboratory, to be used as acarrier for the delivery of blood to units of the Fifth U.S. Army, originally tothe Anzio beachhead and later, as the fighting moved up the peninsula, to otherparts of Italy (map 1).2
At first, the blood plane was operated by the Air Transport Command. Then thetask was taken over by the Troop Carrier Command. The pilots lived in theofficers' quarters at the 15th Medical General Laboratory, along with theofficers of the blood transfusion unit. They took a genuine and personalinterest in their work and often flew the blood forward in very bad weather. Themost forward airfield capable of taking a C-47 plane was invariably used.Although such fields were often reserved for fighter planes, an exception wasalways made for the plane carrying blood. The availability of this service madeit possible to collect blood from such widely separated points as Naples, Rome,Pisa, and later Florence (map 1), for delivery to hospitals in the Army area.
The blood plane was usually airborne within 90 minutes after the blood wastaken out of the refrigerator. The flight from Naples to Anzio took 30 minutes,and from Naples to Leghorn 2 hours.
2The assignment of this plane was a historical first and has not sincebeen duplicated.
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The blood plane carried penicillin regularly and, occasionally, emergency shipments of dressings, anesthetics, plasma, and other medical items. When the load permitted, it also carried medical personnel. On the return trip, it carried empty insulated boxes, sometimes laboratory specimens, and sometimes medical personnel.
Blood sent forward by air was turned over at the landing field to personnel from the forward distributing center. An important feature of air transport was that the blood was always accompanied by a courier whenever there was any reason to fear that the plane might not be able to make direct contact with the personnel from the forward center. When, as often happened, the field at which the blood plane was to land was inaccessible because of bad weather or for tactical reasons, the pilot landed blood and courier at the nearest available field. It was then the courier's duty to secure transportation for the blood to the forward distributing center, or tomake contact with the center and wait with the blood until someone came for it. Even better, when personnel per-
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mitted, was the practice of sending two couriers with blood when trouble was suspected. Then, one would wait with the blood at the airport until transportation was available to the forward distributing center, while the other returned on the plane with the requirements for the next day's supply of blood.
The courier system insured that the blood was always under the personal care of personnel trained to handle it properly. Without courier escort, the blood would many times simply have been left on an airfield for hours, without protection from either heat or cold, and would have become useless or dangerous.
L-5 planes -In the spring of 1945, when L-5 aircraft became available, they were used to shuttle fresh whole blood from the blood bank in Florence to field hospitals in the mountains in the forward area. Later, these planes flew blood into the Po Valley. This service was one of the timesaving and lifesaving improvisations of the Italian campaign. It was used not only during the bitter mountain fighting but also when the Army Medical Service was spread over hundreds of miles after the breakout into the Po Valley.
DISTRIBUTION
The transfusion officer of each evacuation hospital and each platoon of each field hospital coordinated the daily needs of his hospital with the officer in charge of the forward distributing center, who reported the daily needs of the whole forward area to the base bank.
In general, there was a fortunate relation between thedistribution of hospitals in Italy and the state of the terrain and roads (11).Both north of Rome and in the Po Valley, the roads were good and the weatherwas favorable, which permitted rapid movement and pursuit. When the tacticalsituation bogged down and bad weather was accompanied by deep mud, there was astrain on all theater transportation. On two occasions, once in the vicinity ofRome and later in the Po Valley, hospital units were scattered over such greatdistances that, if weather or road conditions had existed such as prevailed inlower Tuscany or along the Gothic Line, regular deliveries of blood would havebeen impossible with the vehicles on hand. With a front of 60-70 miles to besupported, the blood plane leapfrogged the forward distributing unit anddelivered blood to the most advanced airfield from which forward hospitals couldbe serviced.
It was suggested in the final report of the blood transfusionunit (11), that the addition of the half-size blood transfusiondetachment, team NA (T/O&E 8-500) would increase transportation by fouradditional vehicles, as well as increase personnel. With these additions, itwould be possible to establish two forward distributing points on a widerextended front and also facilitate intercommunication between dispersed bleedingsections.
During the war and afterward, the suggestion came up atintervals that, whenever it was difficult or impossible to carry blood directlyto field or evacuation hospitals by forward distributing units, regular medicalsupply channels
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be used temporarily. To this suggestion, Major Sullivan, Colonel Kendrick,and others responsible for the whole blood program took violent exception forthe following reasons (11):
1. Whole blood is highly perishable. A single mistake in its handling, asingle lapse in refrigeration, can result (and has resulted) in fatalities.
2. The supply depot has many and various duties, and its organization is notsuch as to allow it to assume the highly specialized function of handling wholeblood.
3. Whole blood is a substance which becomes useless and dangerous with age.To place the responsibility for its handling in normal supply channels wouldencourage the practice, useful with other items, but highly undesirable withblood, of placing bottles of blood on shelves of various echelons of supplydepots, where the dating period would be exhausted before the blood was used orthe oldest blood would be used first, to prevent outdating.3
4. A transfusion service operates best when the distribution of blood is inthe hands of trained personnel under professional guidance and not under thesupervision of supply officers. The only exception to this rule in theMediterranean theater was the occasional practice, to relieve pressure ontransportation, of permitting forward hospitals to pick up their own blood ininsulated boxes at the airfield.
5. Professional handling of blood from procurement to use has the following advantages:
a. Receiving hospitals can be assured of fresh supplies of blood at all times because their day-by-day requirements will be filled by trained delivery teams.
b. Daily delivery service makes it possible for the transfusion service to know the whereabouts of each medical facility. This proved to be a very practical point. When an Army was advancing, it was often difficult to find hospitals, particularly when transportation was over country roads already crowded with military vehicles, in clouds of dust, or through deep ruts filled with mud.
c. Professional personnel of delivery teams can provide guidance concerning various aspects of blood transfusion and can, in turn, obtain criticisms from hospitals as to the equipment provided and the service in general.
d. Proper refrigeration during transportation and storage will be assured.
DONORS
Since no provision had been made for blood donors for the landings in North Africa, securing donors was a constant problem until the blood bank was established. Hospitals developed their own methods, but most of them used service troops, keeping them at the hospital until they were needed. At some
3This situation did come to pass in Korea, where the Supply Service was in charge of the distribution of blood, which frequently was close to the expiration of the dating period when it was issued.
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hospitals, they were brought in by truck every morning, 25 at a time. If all were used before night, another group was trucked in. This was a highly inefficient system, and very wasteful of manpower in terms of time. When, however, hospitals had no facilities for the storage of blood, it was the only system possible.
Members of the medical detachment and medical officers attached to hospitals gave generously, but it was soon evident that not enough blood could be supplied from this source.
The use of lightly wounded patients as donors was authorized by the Surgeon, II Corps, on 7 August 1943 (14), but there were few volunteers from this source. These men considered themselves to be patients, and they feared that if complications followed their wounds, they might be so weakened by their donations that they would be in serious trouble. At the 77th Evacuation Hospital (4), it was reported that the stimulus of "I might need it when it happens to me" was completely lacking. In the opinion of even lightly wounded men, "it" had already happened to them. Prisoners of war were sometimes used for donors, but only if they volunteered.
When iceboxes finally became available to evacuation hospitals, many of themdrew blood in advance and kept from 4 to 6 pints on hand at all times. Thesafety and efficiency of this method led to the acceptance of the concept that,if equipment and personnel were provided, it would be entirely possible to drawblood from troops in the base who would not be in combat soon; check the bloodthere for syphilis and malaria; and then distribute it to all forward hospitalinstallations. This was precisely the system finally put into effect.
When the blood bank was eventually established at the 15th Medical GeneralLaboratory, the great majority of donors were U.S. Army personnel assigned tononcombatant duties or attached to units which would not be in combat for atleast a month. Service troops provided many thousands of donors. The bestsources were nearby replacement depots and staging areas. A few thousand Britishsoldiers, several hundred U.S. sailors, and a sprinkling of Allied Armed Forcesand U.S. civilians gave the remainder of the donations. Many men who had beenwounded and had received transfusions reported to the blood bank to pay theirdebt to it.
Attempts to form donor lists were not successful; the rapid turnover ofpersonnel in replacement depots and staging areas made the lists almost useless,even in service units, in which the population was more stable.
Specifications
Circular Letter No. 3, Office of the Surgeon, Headquarters, II Corps, 7August 1943, addressed to all unit surgeons and dealing with the care of thewounded in Sicily, listed the following specifications for blood donors (14):
1. Donors must have a negative history and physical examination, and a Kahntest must be performed when possible.
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2. A donor with a history of malaria is not acceptable unlesshe has been symptom-free for 2 years. A donor with a history of infectioushepatitis is not acceptable.
3. Crossmatching must be done before each transfusion.
The following additional specifications were made concerningmalaria:
1. All personnel of the U.S. Army in Sicily are onsuppressive Atabrine (quinacrine hydrochloride) therapy, and it is recommendedthat no additional antimalarial therapy be given either to recipient or donor inan emergency transfusion. If the transfusion is elective, a booster dose ofAtabrine (0.2 gm.) is given to the donor the night before the blood is drawn, orquinine (10 gr.) is given to him 6 hours before the transfusion.
2. All donors are questioned concerning chills and fever inaddition to specific questioning about a history of malaria.
3. The abdomen is palpated. If the spleen is enlarged, thedonor is rejected.
4. If laboratory facilities are available, thick and thinsmears of the donor's blood are examined for malarial parasites.
A malaria smear was examined for 1 minute about 30 minutesafter it had been fixed and stained. Of the first 54,383 donations examined in1944 (15), only six slides were found positive for malaria, an incidenceof less than 1:10,000. By this time, it was the policy to reject donors with ahistory of malaria, no matter how long they had been symptom-free. In theJanuary-March 1945 period, no positive slides were found in 11,191 bloods.Since laboratory personnel were limited, it was decided, in view of thesefindings, to abandon malaria smears. An increased incidence of malaria was notobserved in battle casualties receiving transfusions after testing wasabandoned.
The policy about jaundice varied, but, after November 1944,each donor was required to leave a urine specimen, which was examined by themethylene blue test for increased bilirubin content. A small number of bloodsfrom donors with possible latent jaundice were discarded on the basis of thistest (15).
Donors with a history of syphilis were accepted only ifstandard Army treatment, which had resulted in negative serologic tests, hadbeen completed at least a year before the donation.
Payment of Donors
Circular Letter No. 27, Office of the Surgeon, Headquarters,NATOUSA, 20 August 1943 (16), called attention to Public Law 196, 77thCongress, 30 July 1941, which provided for the payment of blood donors. The lawin question permitted payments up to $50 per donation, but the circular letterstated that, since donations had now become so commonplace, donors would be paidat the rate of $10 per donation, and higher payments would be permitted only forrare bloods such as those containing antibodies against certain diseases.Payments were facilitated by the appointment of all officers in the transfusionunit as class B finance officers. Funds at their disposition were usually about$5,000, but, in peak periods, were raised to as much as $25,000. As a matter ofconvenience, the Finance Officer, Peninsular Base Section, approved a specialform which permitted the payment of 22 donors on a single voucher (WDFD
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Form No. 25, Modified) instead of the use of a single form for each individual donor.
Payment of donors, which continued until 31 December 1944, was an importantfactor in securing blood donors in the Mediterranean theater. Some men refusedthe money, or asked that it be given to the Red Cross, but the majority acceptedit. The practice of giving each donor a drink of whisky after the donation wasdiscussed several times but never put into practice.
SELECTION OF TYPE O BLOOD
Blood sent from the Naples blood bank to the Anzio beachhead and other Armyhospitals was all type O. A few patients had mild attacks of shivering or slightchills, but there were no serious reactions at first.
Until April 1944, no attempt was made to screen out O bloods with high anti-Aor anti-B titer or to limit the use of high-titer blood to O recipients (7).Differentiation of these bloods had been discussed in planning for the bank, butno action was taken, though the policy of using O blood for all recipients wasadopted with some misgivings by a number of medical officers.
In April 1944, two fully investigated cases provided the stimulus to titrateO bloods and to reserve those with high-agglutinin content for O recipientsonly:
Case 1.-The first patient, seen at the 9th Evacuation Hospital, was an Arabwith a severe abdominal wound. His blood type was A. After 75 cc. of group O blood collected at the hospital from another Arab had been given to him, he hada severe chill, his temperature rose to 105? F., and his condition was verypoor. The transfusion was stopped at once. An hour later, there was a markedelevation of the blood bilirubin, and a more pronounced elevation 4 hours later,though the serum used for crossmatching before the transfusion had had a normalbilirubin content. Next morning, the sclerae were yellow. The first urinespecimen after the reaction had been discarded, but all others were normal, andthere was no oliguria at any time. Recovery was uncomplicated.
When the blood in the donor bottle was reinvestigated, it was found to begroup O and Rh-positive. The plasma agglutinated the recipient cells in adilution of 1:8,000, indicating very high titer.
Case 2.-The second patient, at the 94th Evacuation Hospital, had multiplesevere wounds and was given six transfusions of O blood, none with an extremelyhigh titer, within 12 hours. Although there was never evidence of hemolysis, hebecame markedly oliguric, and he died of uremia on the fifth day.
It was considered highly unlikely that this second patient's oliguria wascaused by the O blood he had received and much more likely that it was theresult of his initial and prolonged shock. Nonetheless, Major Snyder at onceinitiated discussions with Maj. (later Lt. Col.) Henry K. Beecher, MC, Capt.(later Maj.) Charles H. Burnett, MC, Captain Lalich, and others who had madespecial studies of shock and transfusion. The reactions were also discussed withmedical officers at the 15th Medical General Laboratory.
Captain Lalich reported observing urinary difficulties in a number of othercases of shock which he had investigated. The difficulties were by no meansuniversal, but some had occurred, and some had been serious. He did
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not think, however, that sufficient evidence had yet been accumulated toinculpate group O blood or to request that the blood bank furnish type-specificblood. While others thought that the request should be made immediately, it wasagreed that low-titer O blood should be given a further trial before any changein present policies was instituted. As a precaution, all blood with an anti-Btiter over 1:64 was to be marked for group O recipients only.
On 1 May 1944, when Major Snyder visited the 33d Field Hospital on the Anziobeachhead, he was told of two deaths in group A patients who had received groupO blood. Most medical officers were now convinced that the use of group O bloodin group A recipients was unsafe and should be discontinued. After furtherdiscussions with officers of the blood bank in Naples, it was agreed thatsufficient evidence was now at hand to warrant a change in policy and to supplygroup A and group B blood for group A and group B recipients, respectively. Acircular letter would be prepared to accompany the shipments of type-specificblood.
Before these arrangements could be completed, the decision was reversed byhigher authority, and the Surgeon, Fifth U.S. Army, was informed on 13 May 1944by the Commanding General, North African theater, for action by the CommandingOfficer, 15th Medical General Laboratory, that the Base Collecting Section ofthe 6713th Blood Transfusion Unit (Ovhd.) would furnish Fifth U.S. Armyinstallations with only a single type of blood, group O, with an agglutininbelow 1:64.
There were two reasons for this decision: One was the fear that more deaths might be caused by errors in crossmatching if both group A and group B blood were supplied than would result if group O blood titered for anti-A and anti-B agglutinogens continued to be used. The second reason was the possibility that group A or B blood might be administered through tubing through which plasma was running, with resulting serious reactions.
In a return radiogram, the Commanding Officer, 15th Medical General Laboratory, pointed out the following facts:
1. Rigid compliance with the order received might necessitate discarding halfthe O blood drawn. In the past, O blood with an anti-A titer of 1:250 or overhad been marked for group O recipients only. This blood comprised only about15percent of all bloods drawn. The radiogram just received precluded the use of O blood with a titer of over 1:64 for anyone. Immediate authority was requestedfor the use of group O blood for O recipients, regardless of titer.
2. Four histologically proved cases of fatal hemoglobinuric nephropathy wereknown to have followed the use of group O blood for A recipients.4 Intwo of these fatalities, only low-titer blood had been used. Major Beecher hadinformation of other clinical cases in which the circumstances were similar, andhe had ceased to use group O blood for A recipients.
3. An immediate investigation by Colonel Churchill was requested, withauthority to modify or revoke the order of 13 May from theater headquarters.
Although fatal hemoglobinuric nephropathy occurred in these four patients, all of whom had received low-titer group O blood, it must not be inferred that the transfusion of the O blood was responsible and that the sequence was causative. Low-titer group O blood was given to many thousands of casualties in the Mediterranean and European theaters and in the Pacific areas without any reactions. The more reasonable explanation of the sequence is that, in these cases, the blood administered contained B isoagglutinins and therefore was incompatible.
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The matter was finally resolved by continuing, as in the past, to use group O blood of any titer for O recipients and to mark all blood with a titer of 1:250 or more to be used for group O recipients only.
When the Board for the Study of the Severely Wounded made its report in 1945 (6), it exonerated transfusion as the cause of lower nephron nephrosis in most badly wounded men and put the responsibility on shock (p. 666).
TECHNIQUE OF COLLECTION OF BLOOD
The technique by which blood was collected at the blood bank at the 15th Medical General Laboratory and other bleeding centers was substantially the same as that used in Red Cross bleeding centers in the United States (figs. 98-101).
There was usually an airspace of 20-30 cc. (fig. 102) left in each bottleafter the donation. While the various tests were being run, each bottle wasreevacuated through a blood donor valve attached to an electric vacuum pump(fig. 103), and the empty space was filled with a 5-percent solution of dextrosein 0.85-percent sodium chloride (fig. 104). The dextrose solution was added froma l,000-cc. bottle of solution, by means of a valve attached to an appropriatelength of rubber tubing. It was used for two reasons, its preservative effectand to fill the bottle completely, so that the red cells would not betraumatized by shaking of the blood during transportation over rough roads. Ifthe bleeding bottle originally contained glucose and citrate, as some did, thetopping was accomplished with physiologic salt solution.
When the necessary tests had been carried out and duly recorded, theworksheet (fig. 101) was handed to a second technician, and each batch of bloodwas given a final check. Bloods which were not group O were segregated andappropriately labeled. Bloods from donors with positive or doubtful Kahn tests,positive malaria smears, or (later) positive methylene blue urinary tests, werediscarded, as were all bottles that showed an excessive amount of hemoglobin inthe supernatant plasma.
The remaining bloods, proved to be group O and suitable for transfusion (fig.105), were labeled Group O. Kahn negative. Drawn . . . . . . . . Use within 7 days.(date)
Bloods which showed a high anti-A or anti-B agglutinin titer, or both, werefurther identified by a large shipping tag tied around the neck of the bottle(fig. 105) and reading For group O recipients only. Carefully group patientbefore using this blood.
After the criterion for titration was changed from 1:128 to 1:64, about 35percent of all group O bloods were labeled as high titer.
After processing was completed, the bloods were refrigerated at 39? F. (4?C.) overnight or longer, depending upon the requirements of forward hospitals.Ordinarily, processing on each batch of bloods was completed well
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FIGURE 98.-Scenes from bleeding room, 15th Medical General Laboratory, Naples, September 1944.
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FIGURE 99.-Completion of individual donation, 15th Medical GeneralLaboratory, Naples, March 1944.
within 24 hours of their collection, so that the freshestpossible blood could be sent forward, in view of the 7-day dating period. Onsome occasions, blood collected at the blood bank in the morning could be flownforward in the early afternoon.
LABORATORY TESTS
Titration
When the possible risk of high-titer blood for non-Orecipients was recognized at the Naples blood bank (p. 424), it became thecustom to perform a single tube titration against known A and B cells with serumfrom each O blood (1:32 dilution, 1:64 final dilution). After 14 May 1944, alltitrations at the bank were made with a 1:64 dilution of serum, and all bloodswhose sera showed agglutination of A or B cells in this dilution were plainlymarked for O recipients only. Of the 4,398 bloods titrated by this techniquebetween this date and 31 May 1944, 1,649 (37.5 percent) showed a titer of 1:64and were labeled accordingly. It was considered more practical to performtitration tests than to employ Witebsky's A and B group-specific substancesfor specific neutralization of normal isoagglutinin in group O blood (p. 260).
The 6th General Hospital used the following technique inorder to employ high-titer O blood in acute emergencies in which an appropriatedonor could not be found and in which there was no time to wait forcrossmatching (17):
1. All plasma in a flask of high-titer blood was withdrawnand discarded.
2. The plasma withdrawn was replaced with an equal amount ofpooled plasma supplied in the standard package.
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This hospital gave more than a dozen of these so-calledcocktail transfusions with only one reaction, and that pyrogenic.
Typing
In the MTOUSA blood bank, as already described, the bloodtype was determined by two independent laboratory examinations. Blood from thedonor's finger was first matched against known anti-A and anti-B serum with aminimum titer of 1:64. Microscopic readings were done at the end of 30 minutes.The second test was with blood from the tubing used to fill the small bottle;separated serum was matched against a 2-percent saline suspension of known A andB cells.
When blood had to be given in emergencies in forwardhospitals and tests for direct compatibility were impractical, the blood groupof the recipient had to be accepted on the basis of his identification tag, inwhich the known error was from 5 to 25 percent.
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Other Tests
Kahn tests were performed routinely in the blood bank and in hospitals thatoperated their own blood banks. In the early days of the North African theater,serologic testing was not always possible; there were no facilities for it aheadof large evacuation hospitals.
After December 1944, the methylene blue test was used on urine specimenscollected at the blood bank, to detect excess bilirubin. About 1.09 percent ofthe examinations were positive or doubtful. This was a pilot survey, and itsfull significance was not assessed.
The Phillips-Van Slyke copper sulfate method of estimating the hematocrit,hemoglobin, and plasma protein concentration (p. 253) became standard laboratoryprocedure in the theater as soon as the test was introduced in 1943.
Studies of red blood cell survival in blood collected and processed by the technique used at the Naples blood bank were performed at Harvard in early1945 by the radioactive iron technique. They showed 80 percent survival at 24 hours in blood used after 14 days' storage.
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FACILITIES
In his final report to The Surgeon General in 1945, ColonelStandlee (13) made several points about facilities for a blood bank:
1. The base collection section should be attached to atheater or army laboratory or to a base general hospital close to a largeconcentration of base troops.
2. Because of the urgent need for sterility, the base unitshould be set up in a permanent building or prefabricated hut, with room forbeds for bleeding donors and for donors to rest after their donations; officespace; laboratory space; space for sterilization, washing, and preparation ofequipment; space for storage of blood; and refrigeration facilities. Ifprefabricated huts were used, three would be required.
3. Quarters for personnel and parking space for vehiclesshould also be provided.
4. Engineering help would be required for the installation ofnew facilities. Floors were preferably of concrete. Doors and windows must bescreened. Four sinks were necessary. Hot water was desirable; running water,essential. Partitions, laboratory tables, and stools could be of wood. Theremust be a continuous and dependable supply of 110-volt electric current;refrigeration must not be interrupted.
While these facilities were highly desirable, numerousexperiences proved that it was quite possible to bleed efficiently and safely infar less propitious surroundings. Thus, the bleeding center at the Fair Groundsin Naples was a temporary structure of roughhewn boards and beams, withpartitions of burlap and cheesecloth. One bleeding center was in a whitewashedcowbarn,
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with two beds to a stall. At the 12th General Hospital, theblood bank was located in two small rooms on the third floor of the building inwhich the operating rooms were housed. Since the hospital laboratory was somedistance away, the bank functioned as a branch laboratory, its function beinglimited to special tests pertaining to surgery, such as hematocritdeterminations and white blood cell counts. The two beds in the smaller of thetwo rooms that the bank occupied were used for donors during the day and asquarters for bank personnel on duty at night.
EQUIPMENT
Early Improvisations
When evacuation hospitals landed in North Africa in November1942, equipment for blood transfusion was in extremely short supply (p. 393). Itconsisted of small numbers of flasks, burettes, rubber tubing, and intravenousneedles. With these meager supplies, it was possible to clean, assemble, andsterilize a few units for the administration of whole blood, which had to begiven within 3 or 4 hours after it was collected. Facilities for Kahn tests were
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not available farther forward than Army medical laboratoriesattached to evacuation hospitals, and facilities for crossmatching were oftenlacking.
Improvisations were necessary in all hospitals. The 77thEvacuation Hospital in the beginning used Baxter bottles and tubing from theplasma sets. Then it secured 15 British bleeding bottles, which proved to bemore convenient and more easily sterilized because of their metal screw tops.Certain modifications were made in them, including the transfer of the wiremesh from the giving to the taking set to simplify cleaning. The tubing andbottles were first cleansed in cold water, as advised by the British TransfusionService, and then were rinsed in freshly distilled water (distilled withdifficulty (p. 382)), which was never older than 2 hours. After 50 cc. offreshly prepared 6-percent sodium citrate had been placed in each bottle, themetal cap was partly screwed on, and muslin gauze was tied over it. Once bottlesand tubing were prepared, they were autoclaved within an hour or less at 15pounds' pressure for 30 minutes. The metal caps were screwed on tightly beforethe bottles had a chance to cool off.
Other evacuation hospitals also attempted to operate bloodbanks by utilizing used saline and saline-glucose bottles for bleeding bottles.The plan
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permitted the use of blood but it had many undesirablefeatures. Preparation of the apparatus required a great deal of time and, withthe collection and processing of blood, placed too heavy a burden upon alreadyoverworked laboratory and surgical personnel. Also, the number of availabledonors in the Army area was limited, and blood collected in combat circumstancesfrequently caused reactions.
In spite of the efforts and ingenuity that went into theimprovisations used to collect and administer blood in the Mediterraneantheater, the fact remains that none of the donor and recipient sets improvisedfrom the bottles and tubing supplied with plasma and intravenous solutionsconstituted really satisfactory apparatus. Nor did the equipment made from glassand aluminum tubing salvaged from wrecked planes. The distilled water used forcleaning and preparing the improvised equipment and preparing citrate solutionswas in short supply and sometimes contaminated. Numerous reactions could beexplained by the use of old tubing that was improperly cleaned because of lackof material to clean it adequately.
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Many hospitals duplicated the experience of the 38thEvacuation Hospital, in which, until February 1944, when Baxter Transfusovacbottles became available, all the material used for collecting blood wasimprovised.
Capt. (later Maj.) William T. Thompson, Jr., MC, while incharge of the blood bank at the 45th General Hospital, devised a satisfactorytechnique of drawing blood in quantity when enough valves could not be obtainedfor the donor sets. He placed large intravenous needles on the ends of shortpieces of heavy tubing which were clamped off until the needles were placed,respectively, in the donor's vein and in the bleeding bottle. Later, a similarpiece of equipment was developed by the Army Medical Department. Thisimprovisation was also employed in the continental United States in 1943.
Standardized Equipment
The arrival of blood transfusion apparatus in theMediterranean theater was long delayed. The first radio request for it to theOffice of The Surgeon General, in May 1943, was disapproved because existingregulations did not permit its shipment outside of the Zone of Interior (18).
Requests for bleeding bottles had been frequent since thebeginning of the North African campaign, and this equipment, procured throughSupply Service channels, began to arrive just as the Italian campaign gotunderway. Expendable recipient sets were not received in quantity in the theateruntil early in 1945. This meant that the responsibility for the preparation ofrecipient sets rested with individual hospitals during most of the war. It was aconsiderable task for busy forward hospitals, but they did it remarkably well,realizing that an appreciation of the importance of whole blood replacementwhenever blood loss had occurred carried with it the obligation of havingsufficient recipient sets and tubing ready at all times.
Donor set -The 6713th Blood Transfusion Unit (Ovhd.)report for June 1944 (11), after some experience with the Army expendableblood donor apparatus (Medical Supply Item No. 9351510), contained the followingcomments on it:
1. The use of this donor set is limited by a number ofconsiderations, beginning with the fact that a preliminary period of trial anderror is necessary before a technician, no matter how skilled he may be withother types of donor sets, can master this one.
2. The set is not well adapted for donors whose veins aresmall or whose blood flow is sluggish. Unless donors in these categories arebled in 4 to 4? minutes, clotting will occur in one or both needles.
3. The greatest usefulness of this set is in outfittingbleeding teams to collect blood at multiple or isolated points, and also ineliminating some of the work during periods of stress, when as many as 800donors sometimes must be bled in a day.
4. The valves are eminently satisfactory when they areproperly cared for, assembled, and used. With them, one man can bleed two donorssimultaneously with relative ease, and the total personnel required for bleedingis fewer. Bleeding personnel, however, preferred the old type stainless steelmechanical valve (a component of item No. 3609300) to the new stainless steelvalve containing a rubber inset, which they often found difficult to operate.
5. If the thick-walled taking tube were 18 inches in lengthinstead of 12 inches, it would
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be more flexible, and the hose could later be used for local bleeding, orcould be issued to fixed hospitals which drew their own blood.
The donor needle on this set was not intended to be salvaged, but personnelof the unit commented that it could have been made useful for subsequentvenipunctures to secure blood specimens or for use on nonexpendable donor setsif a slight change had been made in the structure of the hub. With this change,a syringe or adapter could be fitted onto the needle, and it could be washedthoroughly before sterilization.
Expendable recipient set -The blood transfusion unit personnel had noexperience, of course, with the disposable recipient set (item No. 9351520), butsecured the following comments on it from officers and technicians who used itin forward hospitals. The experience with it in June 1944 was limited, but someof the comments were repeated in the ETMD for May 1945 (19), after it hadbeen used in more than 10,000 transfusions in field and evacuation hospitals:
1. This set has the great advantage of being expendable. Until it wasreceived in sufficient numbers, shortly before the war ended, the cleaning andsterilization of donor sets constituted the chief problem in the operation of atransfusion service.
2. The absence of any visible drip mechanism makes it impossible, or at leastvery difficult, to determine whether blood is flowing satisfactorily into therecipient or if the apparatus has become plugged. Since one person frequentlymust observe multiple transfusions, and at the same time perform other duties,it is important to be able to determine the speed and efficiency of the bloodflow.
3. The use of an unhubbed needle to tap the vent tube of the bleeding bottledoes not permit the creation of a pressure chamber inside the bottle to start oraccelerate the blood flow.
4. If a short bevel were substituted for the long bevel on the giving needle,the hazard of transfixing veins in shocked casualties with collapsed veins wouldbe greatly reduced.
5. Piercing of the rubber bung of the bleeding bottle at the correctpoint is frequently difficult because of the small grasping surface presented bythe hub of the puncture needle. When this difficulty has arisen, the intensesqueezing effect of the fingers has frequently caused the rubber hose to spreadlaterally over the puncture needle, with a resulting air leak in the vacuum inthe bottle, which it is possible to overcome by tying a few turns of black silkover the portion of the rubber hose encasing the hub.
6. The giving needle is the hose-connector type. A glass adapter fitting thestandard hubbed needle would be highly desirable for several reasons: Incasualties with low blood pressure and collapsed veins, it is difficult, withoutsuch an adapter, to know when the needle is in the vein. In burned or woundedcasualties, it is often necessary to use the same vein for numerous purposes,such as withdrawing blood for examination with a syringe and giving varioustherapeutic fluids. In the most severely shocked patients, in whom a cannula istied into the vein, an adapter could be readily removed from the needle andinserted into the cannula.
7. Since the blood flow is dependent upon gravity, and since resistance inthe line may greatly impede the flow, it would be better if the thin rubbergiving line were made 48 inches rather than the present 42 inches.
8. In badly bled-out casualties, emergencies often arise in which it isdesirable to give blood under pressure. This is not possible with the presentairway-piercing cannula, which is sawed off and hubless. An airway-piercingneedle with a hub and with an attached short length of rubber tubing wouldremedy this defect.
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9. The structure of the apparatus is not suitable for administering multipletransfusions through a single needle or the successive administration of blood,plasma, and electrolyte and glucose solutions through a single needle. As aresult, multiple successive venipunctures are necessary, which is a seriousdrawback in seriously wounded casualties.
These and similar comments were, of course, justified. On the other hand, itwas fully realized, when the recipient set was devised, that it was not socomplete as the commercial set used in fixed hospitals in the Zone of Interior.But some of the refinements had to be sacrificed because of shortages ofcritical materials and in the interest of reducing the size of the overseapackage. In spite of the lack of a drip flowmeter, the recipient set worked wellbecause, in the treatment of casualties in shock, speed of injection of theblood was so desirable that there was no real need to meter the blood flow.
PRESERVATIVES
If preservative solutions that permitted storage of blood for 14 to 21 dayshad been available in the Mediterranean theater when the blood bank wasestablished, a good deal of waste would have been avoided. At that time(February 1944), the bleeding bottles contained only sodium citrate solution,which is an anticoagulant, not a preservative. Even when dextrose was added tothe blood, the dating period did not exceed 7 days.
Bottles containing 600 cc. of Denstedt's solution were available in theZone of Interior, but could be shipped only in small numbers. Later, bottleswith Alsever's solution could have been requisitioned from the Zone ofInterior, but most surgeons in the theater, like others in other theaters,considered the volume of this preservative solution undesirable. It would alsohave introduced the risk of pulmonary edema in patients who required manytransfusions in a short period of time. ACD solution was never used in theMediterranean theater. It was not standardized by the Medical Department untilearly in 1945, and, by the time bottles containing it had reached Italy, the warwas over.
STATISTICAL DATA
Requirements for, and Utilization of, Whole Blood
When the blood bank was established in Naples in February 1944, it wasestimated that the amount of blood needed per casualty would be from 0.6 to 0.7pint. In the last 4 months of 1944, this estimate was reasonably well sustained.
In their study of combat casualties in Fifth U.S. Army hospitals, ColonelSnyder and Capt. (later Maj.) James W. Culbertson, MC, compiled the followingdata (7):
1. Of all the casualties treated in field hospitals, about 70 percentrequired blood and received an average of 3 pints each. About 63 percentrequired plasma and received an average of 2? units each.
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2. Of all the casualties treated in evacuation hospitals, about 20 percent required blood and received an average of 2 pints each. About 15 percent required plasma and received an average of 2? units each.
3. While the average administration of blood late in 1944 was0.6 pint per casualty, this was true only in hospitals in which blood was usedin adequate amounts. The rates for all Army hospitals were far below this.
4. The effect of the location of the hospital on the need forblood is evident in the figures for the Salerno-Cassino fighting, in which 4,600transfusions were given in the Army area, against 300 at the base. When,however, the base was close to the battleline and evacuation was rapid, itsneeds rose accordingly.
The changing concept of blood and plasma is also evident incomparative figures (2):
During the Tunisian campaign in February 1943, in a series of200 surgical patients, half of whom required emergency operation, 6 bloodtransfusions were given, against 350 plasma infusions. At this time, thesurgeons had little choice; they had ample amounts of plasma but no facilitiesfor transfusion and no donors except detachment personnel, who could not bechecked for either malaria or syphilis.
Of 431 seriously wounded patients admitted to one IICorps hospital between 21 January and 28 February 1943, 101 received plasma and31 whole blood. In March 1943, of 561 patients who underwent 741 surgicalprocedures at the 48th Surgical Hospital, 97 received whole blood. A few morelives might have been saved, Major Snyder noted, if a more convenient method ofblood transfusion had been available, as well as better sources of blood.
When this same hospital moved forward in May 1943, to supportthe final Bizerte offensive, at one time it was within 12 miles of the fightingfront. Between 4 and 11 May, it admitted 403 casualties, of whom 292 underwentmajor surgical procedures, which were often multiple. Between 5 and 8 May, itaveraged 60 admissions per day. On 7 May, 82 operations were performed. Duringthis period, 84 transfusions and 291 plasma infusions were given (1:3.4).
LossesThe registration and bleeding of a donor at the bleedingcenter did not necessarily insure that his blood would be used for a woundedcasualty (table 14). For a number of reasons, there was a loss of approximately10 percent between registration and distribution, and a further loss of about 5percent between distribution and use. Among these reasons were losses frombreakage, clotting of the blood in bottles, clogging of the blood in recipientsets, and expiration of the dating period. Some of these factors could be partlycontrolled, but not all of them could be eliminated.
A certain amount of hemolysis occurred at the time ofbleeding, apparently being influenced by the operator's technique. Each timenew groups of technicians were trained, the incidence of hemolyzed blood rose.While a certain amount of hemolysis (estimated at 25 mg. per 100 cc.) wasconsidered compatible with safety, no one could say with certainty where thedividing line was, and the practice was to err on the side of caution.
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TABLE 14.-Production of 6713th Blood Transfusion Unit (Ovhd.),February 1944-June 1945
Year and month |
| Bloods | |||
| Rejected | Collected | Discarded | Distributed | |
| 1944 |
|
|
|
|
|
February | 258 | 9 | 249 | 2 | 247 |
March | 2,074 | 69 | 2,005 | 25 | 1,980 |
April | 1,793 | 104 | 1,689 | 130 | 1,559 |
May | 6,958 | 564 | 16,644 | 273 | 6,371 |
June | 5,017 | 375 | 25,092 | 72 | 5,020 |
July | 6,724 | 510 | 6,214 | 281 | 5,933 |
August | 8,509 | 696 | 7,813 | 617 | 7,196 |
September | 11,708 | 866 | 10,842 | 454 | 10,388 |
October | 10,615 | 724 | 9,891 | 207 | 9,684 |
November | 4,010 | 265 | 3,745 | 200 | 3,545 |
December | 4,029 | 273 | 3,756 | 156 | 3,600 |
| 1945 |
|
|
|
|
|
January | 3,293 | 192 | 3,101 | 256 | 2,845 |
February | 4,033 | 125 | 3,908 | 221 | 3,687 |
March | 4,444 | 262 | 4,182 | 225 | 3,957 |
April | 11,521 | 814 | 10,707 | 427 | 10,280 |
May | 2,261 | 130 | 2,131 | 85 | 2,046 |
| 87,247 | 5,978 | 81,969 | 3,631 | 78,338 |
1Includes 250 bottles collected by the 2d Medical Laboratory(Army).
2Includes 450 bottles collected by the 2d Medical Laboratory(Army).
A satisfactory explanation was never advanced for thehemolysis invariably present to some degree when the vacuum technique was used.Some medical officers with extensive experience explained it as due to an excessof glycerin in the valves. Others, with equal experience, thought theexplanation was too rapid bleeding, with collapse of the tube during theprocedure. Still others thought the high vacuum in the bleeding bottle mightcause disruption of a certain proportion of red blood cells.
Every attempt was made to adjust supply to demand, but with astorage period limited to 7 days, this was extremely difficult. Notinfrequently, stocks had to be built up in expectation of a large-scaleoffensive that was later postponed. The end of heavy fighting was even moreunpredictable than the beginning of an offensive, so again, when fightingsuddenly ceased, the bank would be left with large stocks on hand. Some wastageof blood would have been avoided, as well as wastage of vacuum bottles always inshort supply, if the blood transfusion unit had been given more precise advanceinformation about probable casualties in forthcoming engagements.
The base section ordinarily had a 24-hour supply of blood onhand and the forward distributing section, an additional 24-hour supply. Bloodthus reached forward hospitals on the third day, leaving it with 4 more days ofuseful life.
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Very little blood was used in Italy after the 7-day datingperiod because of daily deliveries from the base to the forward section and fromthe forward section to Army hospitals. The schedule was difficult to maintainbecause large reserves could not be built up without risking wastage from aging.It was practical only because the lines of communication were short.
Whenever possible, blood not used in forward hospitals wasdistributed to base hospitals, being shipped back to them as it neared its 7-daylimit. There were times, however, when this was not practical. The various fieldand evacuation hospitals were sometimes so widely separated that regular contactwith them was impossible and their aging blood could not be secured for salvage.This happened at the fall of Rome, when the distributing unit went forward withArmy hospitals and for a time was completely out of touch with hospitals inRome.
The total blood transfusion unit loss of 10 to 15 percentfrom bled donor to transfused recipient was probably as close to the absoluteminimum as possible when dealing with blood that had a 7-day expiration date.
Overall Statistics
The 200 pints of blood brought into Anzio on 22 January 1944,the day of the landings, were used up by 27 January. Thereafter, an average of100 pints per day was brought in, usually by LST's, less often by smallplanes, which could land on the airstrip without drawing German fire. Twoenlisted men, who checked all incoming supplies, had the special responsibilityof watching for the blood and dispatching it immediately by truck to the medicaldump. It was held there by the British transfusion unit, which stored it anddistributed it. This was a highly efficient operation.
Something over 4,000 pints of blood were brought in between22 January and 25 February, inclusive. Between 26 February, when the blood bankat Naples took charge of the operation, and 25 May 1944, 5,128 pints of bloodwere supplied to the hospitals on the Anzio beachhead.
Before the breakout at Anzio at the end of May 1944, it hadbecome evident that the blood bank could not supply as much blood as would beneeded for that offensive. With General Martin's approval, Major Snyderarranged with Lt. Col. (later Col.) Kenneth F. Ernst, MC, Commanding Officer, 2dMedical Laboratory, which was attached to the Fifth U.S. Army, for an additional100 pints daily (7). The first delivery was made on 26 May. With more recipientsets, the laboratory could have supplied more blood. With the limited numberavailable, it was necessary to stop collections at noon every day to clean andresterilize the equipment.
Tables 14 and 15 show the production and distribution figuresfor the blood collected in Italy from the first collection at the 15th MedicalGeneral Laboratory in February 1944 to the end of the fighting in that theaterin May 1945. The figures include the blood collected by the laboratory before
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the 6713th Blood Transfusion Unit (Ovhd.) was activated; theblood collected by the 6703d while it remained in Italy (p. 455); and the bloodcollected by the 2d Medical Laboratory (Army) while it was attached to the FifthU.S. Army. It does not include figures for blood collected by individual hospitalblood banks.
Report of 6713th Blood Transfusion Unit (Ovhd.)
The tabulated report of the 6713th Blood Transfusion Unit (Ovhd.)for January-May 1945 was as follows (11):
Of 25,689 donors registered, 1,659 had to be rejected, 1,251because they were not group O (group A 854, group B 309, group AB 88). The other408 were rejected because of disease, recent donations, and a variety of otherreasons.
Of the 24,030 donors bled, 23,862 were group O(group A 127,group B 36, group AB 5).
Of the bloods drawn, 1,199 were discarded at the bleedingcenter (5 percent), because of hemolysis and outdating (682); incomplete fillingof bottles (189); positive serology (114); and positive or doubtfulbilirubinuria by the methylene blue test (214).
TABLE 15.-Distribution of 78,329 bloods collected by6713th Blood Transfusion Unit (Ovhd.),February 1944-June 1945
Year and month | Hospital distribution | |||
| Seventh U.S. Army | General and | Total | |
| 1944 |
|
|
|
|
February | 229 | --- | 18 | 247 |
March | 1,822 | --- | 158 | 1,980 |
April | 1,536 | --- | 23 | 1,559 |
May | 5,223 | --- | 513 | 5,736 |
June | 3,630 | --- | 1,820 | 5,450 |
July | 4,126 | --- | 1,644 | 5,770 |
August | 1,092 | 3,539 | 2,285 | 6,916 |
September | 4,198 | 4,380 | 1,498 | 10,076 |
October | 5,998 | 3,144 | 1,087 | 10,229 |
November | 3,121 | 168 | 433 | 3,722 |
December | 3,314 | --- | 325 | 3,639 |
| 1945 |
|
|
|
|
January | 2,688 | --- | 192 | 2,880 |
February | 3,493 | --- | 114 | 3,607 |
March | 3,796 | --- | 166 | 3,962 |
April | 9,624 | --- | 315 | 9,939 |
May | 2,038 | --- | 482 | 2,520 |
June | 94 | --- | 3 | 97 |
Total | 56,022 | 11,231 | 11,076 | 78,329 |
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In addition to the 682 bottles of blood discarded at thebleeding center because of hemolysis and outdating (2.8 percent), 120 werediscarded at the distributing center for the same reasons plus assumedcontamination (0.5 percent).
Of the total of 24,030 donors bled, 1,319 bloods werediscarded for all reasons (5.4 percent). From the 25,689 donors registered,22,831 bottles of blood were secured for distribution. There was thus a net lossof donors, blood, or both between registration of donors and distribution ofblood of 2,858 (11.1 percent).
Of the 22,831 useful bottles of blood, 19,779 weredistributed to Fifth U.S. Army hospitals; 675 to base hospitals in Naples; and2,301 to base hospitals in Florence, Leghorn, Pisa, Verona, and Bologna.Fifty-four bottles were used for media and typing sera, and 22 bottles were onhand at the end of the fighting.
Of the 23,683 group O bloods whose agglutinin titers weredetermined, 7,113 were found to have anti-A, anti-B, or both anti-A and anti-Btiters of 1:64 or over (30 percent). These bloods were labeled For groupO recipients only. Group patient carefully.
The following laboratory tests were made on the bloodcollected:
74,914 blood groupings, including 25,440 screening tests,24,440 cell groupings, 24,030 serum groupings, and 5 Rh groupings.
24,030 slide agglutinin titrations.
25,486 hemoglobin determinations.
24,030 Kahn tests.
209 Kolmer tests.
9,565 malaria smears.
24,118 tests for urinary bilirubin.
HOSPITAL EXPERIENCES
The experience of individual hospitals brought out manypractical points in the use of whole blood. Thus the 9th Evacuation Hospital,which functioned as a general hospital in Italy and as an evacuation hospital insouthern France, found it extremely important to identify bleeding bottles andtubes very carefully by number because of the large number of Arab patients withthe same names, or almost similar names. It also found it important to do minoras well as major crossmatching.
The 45th General Hospital established its own blood bank inMarch 1944 after observing the value of whole blood in delayed primary woundclosure; it recorded only four unsatisfactory results in 265 such woundclosures. Bank personnel emphasized that a great deal of waste could have beenavoided had the hospital received some advance notice, as it usually did not,about the probable number and general type of casualties it would receive afteran offensive.
At the 21st General Hospital (20), the trainingprogram in anesthesia included instruction in resuscitation, oxygen therapy,transfusion, and other intravenous therapy. This section administered all blood.The two enlisted men attached to it were trained in transfusion and oxygentherapy and served as assistants to the chief anesthesiologist.
At this hospital, detachment personnel interested theirfriends in nearby units in the blood bank and had a stirring response. Needswere met and then surpassed; it was not uncommon to turn away more donors thanwere bled.
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The number of transfusions rose progressively from 22 inJanuary to 827 in November and 1,761 in December. Those who watched the results of the bloodprogram as it unfolded remarked many times thatthey were watching medical history in the making. Anesthesiologists declaredthat they no longer had to contend with shock on the operating table, nomatter how formidable the surgery. Surgeons undertook operations on patientswhom they once would have considered hopeless risks, without fear ofirreversible pathophysiology. The universal opinion in this hospital was thatblood accomplished what plasma simply could not accomplish.
When the 21st General Hospital arrived in southern France,maintenance of its blood supply was difficult because of the small number oftroops in the immediate vicinity. This problem was solved by organizing alaboratory team which went to accessible units and bled the donors there. Thewhole experience of this hospital is an interesting illustration of whatcould be accomplished, in the face of difficulties, once personnel wereconvinced of the need for, and the value of, whole blood in the management of wounded casualties.
SURVEY OF BLOOD PROGRAM
Most of the material in the report to The SurgeonGeneral by Colonel Kendrick on his visit to the Mediterranean theater inOctober 1944 (21) is presented elsewhere in this volume, under theheadings of shock, resuscitation, complications of blood transfusion,especially anuria, and other headings, but certain general comments should berepeated here:
1. The interest and enthusiasm displayed by the medicalofficers and other personnel in the theater over the potentialities of wholeblood were impressive. Equally impressive was their recognition of thepossible dangers associated with its use.
Colonel Churchill had himself supervised thedevelopment of the program from his arrival in North Africa in March 1943.His first recommendations were the result of his personal verification of theneed for whole blood by his own examination of wounded casualties in clearingstations and forward hospitals. Highly competent medical officers had then beenassigned to work on the problem from various aspects: Major Sullivan and Captain McGraw,from the standpoint of the supply and preservation ofwhole blood; Major Beecher, from the angle of resuscitation in field andevacuation hospitals; and Maj. Champ Lyons, MC, and Maj. (later Lt. Col.) OscarP. Hampton, Jr., MC, who studied the indications for whole blood in basehospitals in connection with their work on penicillin.
As might have been expected, there were some divergencesof opinion, even in this small group, but by this time certain principles had been established as basicand should be used to guide future blood bankoperations. The experience of these officers by this time was so large thattheir conclusions could be accepted as entirely valid.
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2. The officers in the theater worked on the premise,established in the Zone of Interior, that fresh blood is necessary in thetreatment of battle casualties and that any departure from its use is simply tomeet contingencies imposed by the military situation.
3. The error in identification tags was about 10 percent,which corresponded to the error found in the European theater (p. 244).
4. The possible relation of anuria to the use of group O blood was recognized (p. 424), but remained to be proved. It was suggested,however, that it might be safer to use low-titered O blood (1:128) untila definite conclusion was arrived at, even though the policy would requireanother testing procedure in the bleeding center.
5. A tendency was sometimes observed to give too much bloodbefore surgery in field and evacuation hospitals. Experience showed thatcasualties who failed to demonstrate clinical improvement after receiving 3-4pints of blood were either continuing to bleed or had some fulminatinginfection. In either event, surgery was necessary. Transfusion should becontinued during the operation.
6. Practically all instances of shock observed by ColonelKendrick were the result of hemorrhage. Most casualties in shock had hematocritsranging from 25 to 30, as the result of hemorrhage followed by hemodilution.Even when these patients had received adequate amounts of blood in forwardhospitals, they entered base hospitals with hematocrits from 30 to 35. It wasthe general impression that such patients withstood surgery better when theirhematocrits had been restored to approximately normal values (40-45). A pintof blood raised the hematocrit by an average of 3 percent and the hemoglobin byan average of 0.9 gm. percent. Studies of several series of compound fracturesof the femur by Major Lyons and Major Hampton showed that an average of 2,600cc. of blood was required over a 3-4 day period to carry the patients safelythrough surgery. No proof had been found that multiple transfusions modifiedinfection or increased the speed of healing, but there was no doubt that thesepatients withstood surgery better when their blood values were approximatelynormal.
7. Alkalinization was considered indicated when multipletransfusions were necessary. At this time, 150 cc. of 4-percent sodium citratewas being used for this purpose. Since sodium-r-lactate (6/M.) was alreadyavailable in 500-cc. vacoliter bottles (Baxter), Colonel Kendrick recommendedthat it be standardized and used instead. His recommendation was accepted.
8. Expendable collecting and giving sets were not yetavailable in the Mediterranean theater. Preparation and sterilization of thesesets in busy evacuation and field hospitals were difficult to accomplishproperly, as some reactions proved very clearly. Colonel Kendrick recommendedthat transfusion teams be provided with flexible equipment; namely, 1,000-cc.collecting bottles containing Alsever's solution and 600-cc. bottlescontaining Denstedt's solution. This recommendation was not implemented.
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COMMENT
On 29 October 1944, in his letter of transmittal to theSurgeon, NATOUSA (9), Colonel Cornell noted that the accompanying quarterlyhistory of the 6713th Blood Transfusion Unit (Ovhd.) was "probably thefirst of its kind." His (first) indorsement continued:
Captain McGraw has briefly told the essential facts of theactivities of that unit and its cooperative partner, the 6703 Blood TransfusionUnit (Ovhd.). Their successful accomplishments of their mission have been ingreat part due to Captain McGraw's training, industry, and application toduty. Under his leadership they have successfully met demands for three and fourtimes the quantity of blood originally considered. The men at the base sectionhave worked steadily for long hours to continually supply the needs of at firstone, and then two, armies. The forward distributing sections have driven all therough roads at the front day and night and have accomplished an excellent job.The pilots of the blood planes have flown through foul weather when other shipswere grounded and landed on "closed" fields to get the blood through.Blood bank couriers have ridden many miles in open trucks to deliver the bloodforward when our advanced fields could not be used. The entire group are to behighly commended for a new and difficult task, not done, for they will carry on,but carried thus far in the best traditions of the Medical Department.
Anyone familiar with the work of the oversea blood banks inall theaters knows that this tribute is applicable to them all.
Part II. Seventh U.S. Army
ORGANIZATION
When the Seventh U.S. Army invaded southern France in August1944, the supply of whole blood for it furnished few problems because itutilized the experience of the blood bank at the 15th Medical General Laboratoryin Naples and of the 6713th Blood Transfusion Unit (Ovhd.) which operated out ofit (22-24). The field and evacuation hospitals of this Army were thusrelieved of the heavy task that had been the original lot of forward hospitalsof the Fifth U.S. Army, procurement and storage of their own blood as well asits administration. The Seventh U.S. Army also escaped the always undesirablenecessity of bleeding line and service troops in forward areas.
The 6703d Blood Transfusion Unit (Prov.)5 whichsupported the invasion of southern France was made up of personnel withdrawnfrom three sources between February and April 1944: (1) an inactivated stationhospital; (2) the 1st Medical Laboratory; and (3) the 6713th Blood TransfusionUnit (Ovhd.). It was attached to the 15th Medical General Laboratory forinstruction and
5The 6703d Blood Transfusion Unit (Prov.) was set up atBagnoli, Italy, on 22 June 1944, by General Orders No. 124, Peninsular BaseSection, NATOUSA, on 21 June 1944. On 31 October 1944, the unit was relieved ofits attachment to the Peninsular Base Section and assigned to ContinentalAdvance Section at Dijon. On the same date, all officers and enlisted menwere relieved of their assignment to the unit and assigned to the Office of theSurgeon, Headquarters, NATOUSA, whence they were transferred to the Europeantheater.
On 17 February 1945, by Organization Order No. 122,Headquarters, Communication Zone, ETOUSA, the unit was redesignated the6825th Blood Transfusion Company (Non-T/O).
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training. By the time personnel were assigned to it on 1July 1944, almost all of its equipment was available.
The organization and operation of the 6703d Blood TransfusionUnit were facilitated by a number of facts: The 1st MedicalLaboratory, from which part of its personnel was secured, had been staging withthe l5th Medical General Laboratory since 1 May 1944. Personnel assigned fromthe 6713th had gained considerable practical experience during the advance onRome in June 1944 and were now well versed in blood bank operations. After the6703d was activated, the two units worked together until the forwarddistributing section went to France on 15 August 1944. After that date, thebleeding and processing section of the 6703d continued to work with theblood bank in Naples until it also moved to southern France in November.
As the result of these circumstances, the careful training byColonel Cornell, and the warm interest and cooperation of Colonel Arnest,Surgeon, Peninsular Base Section, NATOUSA, the 6703d Blood Transfusion Unit (Ovhd.)was a well-trained and smoothly functioning unit when it began to operateindependently. It was divided into a base bleeding section and forwarddistributing section and, in general, it followed the techniques and policiesof the 6713th Blood Transfusion Unit.
PERSONNEL
The authorized personnel of the 6703d Blood TransfusionUnit consisted of a major, MC; two captains, MC; two captains, SnC; and 28enlisted men, including 1 technical sergeant and 3 staff sergeants. A fullcomplement of officers was never attained, but the roster of enlisted men andnoncommissioned officers was usually complete.
In his final report, the historian of the unit noted thatthe personnel originally assigned to the base bleeding section could handle 100pints of blood a day. The unit consistently shipped close to 200 pints,which required borrowing personnel from other organizations. It wasrecommended that additional personnel should be provided in any future table oforganization, particularly two additional drivers and two additional laboratorytechnicians. This recommendation was carried out.
Although the unit was supposed to be attached to an Armylaboratory for administration as well as for rations arid quarters, it soonbecame evident that many administrative duties would have to be handled by unitpersonnel, in addition to their regular duties. It was recommended that in thefuture the table of organization for a blood transfusion unit provide for amaster sergeant and a clerk-typist. This recommendation was carried out.
OPERATIONS
The base bleeding section of the 6703d Blood Transfusion Unitbegan operations in July 1944, assisting the 6713th to supply blood to the Fifth U.S.
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Army. Both units were attached to the 15th Medical GeneralLaboratory, and personnel and equipment were pooled. Different sections of the6703d were sent to France in August and in October, but the combined activitiesof the two units continued until the last section of the 6703d went to France on27 October 1944.
Invasion of Southern France
The forward distribution section of the 6703d Blood TransfusionUnit was assigned to the 1st Medical Laboratory for the invasion of southernFrance on 15 August 1944. The personnel who landed with the assault troops onD-day were attached to platoons of field hospitals, and each group was suppliedwith refrigerators mounted on trucks. The assignments were as follows:
1. An officer and an enlisted man attached toa platoon of the 11th Field Hospital, which supported the 44th Division, had 188bottles of blood in seven insulated boxes. This group had the main refrigeratorunit.
2. Two enlisted men attached to a platoon ofthe 10th Field Hospital, which supported the 3d Division, had 144 bottles ofblood in four insulated boxes.
3. Two enlisted men attached to anotherplatoon of the 11th Field Hospital, which supported the 36th Division,had 168 bottles of blood in seven insulated boxes.
4. The First Special Service Force (a mixedCanadian and U.S. group, which, like rangers and commandos, had a special combatmission) had 100 bottles of blood in insulated containers. Some of the hospitalships in the invasion armada also carried small amounts of blood, sometimes in vegetable refrigerators.
Personnel of the forward distributing section embarked atNaples a week before the invasion. The blood was placed aboard the transportsjust before the ships departed. This plan assured a supply not over 7 or8 days old for immediate invasion needs. The soundest principles ofcombat loading were observed; that is, the blood was loaded late, so that itcould be taken off early, and it was distributed among several ships. Corps anddivision surgeons and line officers required considerable persuasion beforethese results were accomplished.
On D-day, each group, with its refrigeration, was landed on aseparate beach. On D+1, the three groups made contact with each other, andthereafter they operated as a single distributing unit for all the hospitals onthe beachhead.
Battle casualties for the first 3 days of the landings hadbeen estimated at 1,881, and, on the basis of previous experience, about 0.6pint of whole blood was supplied for each (1,129 pints). The 1,400 bottlesprovided, aside front the additional small amounts carried on hospital ships,included an excess of 271 bottles, which were regarded as essential insuranceagainst possible loss. Actually, battle casualties numbered only 989, andnonbattle casualties, whose requirements for whole blood were generally lessthan those of battle casualties, numbered 205.
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AIR TRANSPORT
Through the cooperation of the Navy and the Army Air Forces,arrangements had been made to deliver whole blood to the target area, beginningon D+1 and continuing until an airstrip could be established. The plan (map 1)involved flying the blood collected in Naples to Corsica, whence it was carriedto the landing beaches by patrol vessels and motor torpedo boats.
The schedule was carefully worked out. The special bloodplane, with the courier who was to fly with the blood, waited on the airfield inNaples for the arrival of the truck that brought the blood from the blood bankimmediately before the plane took off. The insulated boxes (fig. 95) containingthe blood were loaded and lashed in place, together with the French blood drawnin North Africa and flown to the base the previous day. When the plane landed onthe northern tip of Corsica, a truck carried it to the patrol torpedo boat,where the Navy assumed responsibility for it. The courier who had brought in theblood the previous day exchanged information with the courier accompanying thefresh blood, and the empty boxes and bottles were loaded on the plane returningto Italy.
When the patrol boat arrived off the French beaches, itidentified itself, and an officer or enlisted man from the forward distributingcenter, who was expecting it, came alongside in a DUKW (amphibious truck,2?-ton cargo) with a truckdriver (fig. 106). The blood was trucked a mile ortwo inland, where it was loaded into the refrigerator truck awaiting it. If theroads were too bad for the 2?-ton truck, the insulated boxes were loaded onweapons carriers for distribution. The trucks sometimes traveled as much as 35miles to meet the blood plane, their progress being expedited by the militarypolice. At each hospital, a 6-cu. ft. refrigerator was reserved in thelaboratory tent for the storage of blood.
In the initial planning for D-day, Col. Frank B. Berry, MC,Consultant in Surgery, Seventh U.S. Army, received invaluable help from ColonelCornell, who personally arranged for all the contacts in the transportation ofthe blood. As a result, there were no delays, and more blood than was needed wasalways available during the landings, as well as later in the campaign.
After airfields became available in southern France on D+8,blood was flown directly to them from Naples in 2 to 2? hours.
The use of a courier was even more important in southernFrance than in Italy. The Italian front never covered a great deal of ground,and it was therefore relatively easy to make contact with the forwarddistributing section as each load of blood arrived from the base. In France, thedistances were much greater, and the plane was sometimes forced to land morethan a hundred miles from its designated field. When this happened, the courierassumed responsibility for the blood, and, since he was armed with properauthority from base and theater commanders, he was able to secure motortransport to truck the blood forward to the distributing center.
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FIGURE 106.-DUKW arriving on beach insouthern France loaded with French and American blood and penicillin. The blood,donated by service troops and others in replacement depots in Naples sector, hasbeen flown from 15th Medical General Laboratory, Naples, and is destined forfield hospitals in Seventh U.S. Army. When some of these insulated boxes wereleft in the sun for 8 hours, the increase in temperature was only 9?F. (5? C.).
Contact with the collecting unit in Naples was maintained bydaily cables and through the couriers who accompanied the daily blood shipments.The daily report included the amount of blood delivered to each hospital, theamount on hand, and the amount requested in the next shipment. If the bloodplane did not make contact with the forward distributing center and the courierhad to supervise the delivery of blood, the officer in charge of the transfusionsection in each hospital notified the base by any available means of the amountrequired.
Blood was delivered to the forward distributing center byplane until 2 November 1944, when flying conditions in southern France becametoo bad for this mode of delivery to be continued.
FORWARD DISTRIBUTING SECTION
Between 24 August and 17 December 1944, the command post of theforward distributing section of the 6703d Blood Transfusion Unit (Ovhd.) moved11 times. At times, the advance of the Seventh U.S. Army was so rapid that itwas necessary to set up a forward substation, in addition to the
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command post located near a forward airfield. Thissubstation, which serviced forward field hospital platoons, was sometimes 50-70miles ahead of the command post.
Immediately after the landings in southern France, theforward distributing section began to make daily deliveries of blood to fieldand evacuation hospitals in its two weapons carriers. The forward section wasusually located at a point midway between the two flanks of the line, and onevehicle went east and one west. As a rule, the round trips could be made in lessthan 8 hours, during which time the blood could be kept cold in the insulatedboxes in which it had traveled from Italy. If the trip was likely to requiremore time, the 1?-ton truck, which usually met the blood plane, was used. Thelarge refrigerator was a storage box and was moved only when the commandpost of the distributing section moved.
It was soon evident that the transportation onhand was inadequate to the needs of the blood distributing section, andarrangements were made with the Surgeon, Seventh U.S. Army, for two additionalweapons carriers and drivers. Later, these vehicles and personnel were replacedby vehicles and drivers from the 58th Medical Battalion. This arrangementcontinued until the end of the war.
The forward distributing section encountered logisticdifficulties from the time of the landings until March 1945. The distances werealways long. The roads were poor, and, through the mountains, were oftensnowbound and icebound. In December 1944 and January 1945, during the fightingin the Colmar Pocket, the front was divided into two rugged sectors. In additionto the run of 130 miles to the rear, to pick up the blood from the bleedingcenter at Dijon (p. 452), it was necessary to make runs of 100 miles to each ofthese sectors. Communications with the base were always difficult and uncertainand were sometimes impossible. After air service had been abandoned, it oftentook from 2 to 4 days for the two sections of the blood bank to communicate witheach other or to communicate with Paris through SOLOC (Southern Line ofCommunications). As a result, a wasteful supply of blood had to be maintained inforward hospitals.
During this period, the Seventh U.S. Army grew in size andthe territory covered by it increased. It is remarkable that it was keptsupplied with blood by a forward section that never had more than six driversand that operated entirely with its own three trucks and two borrowed weaponscarriers.
About 18 December 1944, conditions became so bad thatdeliveries to individual field hospitals had to be suspended. Instead,deliveries were made to headquarters platoons, which got the blood through tothe other platoons. Some field and evacuation hospitals at considerabledistances from the command post of the distributing center assisted in thedistribution of the blood by sending their own transportation part of the way tomeet the blood bank truck.
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BASE BLEEDING SECTION
The 1st Medical Laboratory, which had been attached to the15th Medical General Laboratory, left Italy on 4 September 1944, to set up inFrance and to prepare a location for the 6703d Blood Transfusion Unit (Ovhd.).It took with it all the equipment and transportation of the base bleedingsection. Lt. (later Capt.) William S. Proudfit, SnC, who was assigned to theunit, was put on temporary duty with the Seventh U.S. Army, to aid the 1stMedical Laboratory in setting up a blood bank section. Eight enlisted men fromthe 21st General Hospital were placed on temporary duty with the Seventh U.S.Army for the same purpose.
The choice of a location for the bleeding center wasdifficult because the Army was moving so rapidly that concentrations of troopswere few and temporary. Finally, ?pinal was selected as the best site becauseof the large concentration of service troops there at the time. The bleedingsection began to function on 11 October and operated at this site until 29October, when facilities for a permanent installation were found in the medicalschool at Marseille. During the 3 weeks the collecting section functioned at?pinal, it drew and processed more than 2,400 bottles of blood. In order to usedonors more efficiently, group A as well as group O blood was supplied tohospitals in the area. The 375 bottles of A blood were plainly labeled and therewere no untoward incidents.
At Marseille, the bleeding section was attached to the 4thMedical Laboratory (Army) for administration, rations, and quarters. Essentialequipment was obtained from the Surgeon, Dijon Base Section, and the section wasready to draw blood on 1 November 1944. The remainder of the bleedingsection arrived from Italy in the middle of November. The Marseille centeroperated until 11 May 1945. It was because the Seventh U.S. Army landed infriendly territory in southern France that it was possible to bring thecollecting section from Naples into Marseille, in the rear of the Army area, sopromptly.
Personnel from nearby staging areas and a replacement depotsupplied the first donors at the Marseille bleeding center. It soon becameapparent, however, that because of the fluctuations in personnel strength, thesesources could not supply the 175-200 pints of blood necessary each day. Anadditional bleeding center was therefore opened early in December on a prominentstreet in downtown Marseille.
In January 1945, a mobile bleeding unit was organized frombleeding section personnel to care for donations at distant militaryinstallations. All blood collected in Marseille was processed at the medicalschool.
The success of the Marseille operation was in large part dueto publicity in civilian newspapers and in the Stars and Stripes; activitiesof the American Red Cross; assistance of civil affairs-military governmentofficials; and the maintenance of donor rolls by individual units, in accordancewith Letter
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AG 742, Op MC, Headquarters, Communications Zone, ETOUSA, 14March 1945 (24).
Delivery of blood -When the bleeding section of theblood transfusion unit moved to Marseille, blood drawn there was shipped by railto Dijon and then trucked to ?pinal for distribution. When the command post ofthe forward distributing section moved to Lun?ville, and later to Sarrebourg,the shipments were relayed from ?pinal by transportation furnished by the 23dGeneral Hospital. On 9 March, the routing was changed, and blood from Marseille,as well as from the European blood bank in Paris, both arrived at Lun?ville byrail. On 12 March, blood from Marseille was sent to Nancy by rail, and bloodfrom Paris by plane.
At this time, the distribution of blood was greatlysimplified because the services of two distributing sections were obtained fromthe 127th Station Hospital, to supplement the unit distributing section. Thesesections were attached to CONAD (Continental Air Defense Command), and by CONADto an air holding unit, where they acted as a rear blood station. This stationreceived all blood from the bank in Paris, with which effective dailycommunication had now been established, stored it, and shipped the containersback to Paris. It was able to provide for all the needs of the blood transfusionunit distributing center until the end of hostilities.
During the last weeks of the war, the unit command post madefive moves, one from France to Germany and the remainder in Germany. The forwarddistributing section continued to supply small amounts of blood after the end ofhostilities until it rejoined the parent unit in Marseille on 8 June 1945.
TRANSFER TO ETOUSA
A supplementary blood supply for Seventh U.S. Army hospitals wasnecessary while the bleeding section of the 6703d Blood Transfusion Unit wasmoving from ?pinal to Marseille. Arrangements for this purpose were made withthe European blood bank, and deliveries to ?pinal began on 28 October 1944.They were to be discontinued after the transfer to Marseille had been made, butthe demand for blood was so great that they were continued until the SeventhU.S. Army passed into the logistic control of the European theater on 20November 1944. The first shipments consisted of blood drawn and processed in thetheater. Later, Seventh U.S. Army hospitals were supplied with blood collectedin the Zone of Interior and flown to Paris.
DONORS
The procurement of donors was a constant problem throughout theoperation of the 6703d Blood Transfusion Unit (Ovhd.). In Italy, donors werefirst procured from U.S. troops in the Naples area. Contacts and arrangements
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were made with the various units by telephone, andtransportation was furnished by the blood bank.
When the 6703d Blood Transfusion Unit opened an independentbleeding center at the 24th Replacement Depot at Caserta, procurement ofdonations was fairly simple. Arrangements were made with the post surgeon, andtroops were marched to the bleeding station, so that transportation did not haveto be furnished.
Up to 1 September 1944, enough donors were available fromthese sources to meet the need for blood for Seventh U.S. Army hospitals withouttoo much difficulty. Then, as more and more troops were sent to France, thesituation became more critical.
All the blood drawn at ?pinal came from U.S. troops. Unitswere reached by telephone, and donors were transported to the blood bank, whichwas then attached to the 59th Evacuation Hospital. By the time the bleeding unithad moved to Marseille, most Seventh U.S. Army service troops in the ?pinalarea had been bled once.
Bleeding of civilian donors began at the Marseille subcenteron 8 December 1944. The response was at first slow. Then it increased, only tofall off during the holidays. It finally increased again and remained stable. InDecember 1944, 20.52 percent of the 6,042 donors were civilians. In March 1945,civilians made up 61.86 percent of the donors and in April, 53.72 percent. Bythis time, casual military donors had practically disappeared, one reason beingthat payment to them had been discontinued on 31 December 1944. Flight rations,provided by the Surgeon, Dijon Base Section, made donations attractive forcivilian donors of whom 12,772 were bled.
In February 1945, at the request of the Surgeon, Seventh U.S.Army, A blood as well as O blood was collected, the donor reservoir beingconsiderably increased by the 30-percent component thus secured. Most of the Ablood was obtained from civilians. It was checked and handled with great care,and there were no known instances of trouble.
Malaria smears were discontinued at Marseille on 1 February1945, as they had been in Italy (p. 453).
EQUIPMENT
The equipment used by the base bleeding unit was generallysatisfactory except that the tube racks were insufficient, the drying oven wastoo small, facilities for distilling water were inadequate, and there was nocyclotherm. A special still was constructed at the 15th Medical GeneralLaboratory when it was found that the issue still was entirely incapable ofputting out the large amounts of distilled water required in the operation ofthe blood bank. Other deficiencies were corrected by improvisations by unitpersonnel, assisted by engineers at the base.
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REFRIGERATION AND TRANSPORTATION
The mechanical refrigeration and transportation originallyprovided for the 6703d Blood Transfusion Unit consisted of:
1. A 45-cu. ft. refrigerator mounted on a 2?-ton truck with3-kw. generators to furnish 24-hour electric current. The fly of the truckshaded the generators during the summer months and generally protected them fromthe weather. This refrigerator was the main storage unit and moved only when thesection advanced.
2. Two 6-cu. ft. refrigerators mounted on weapons carriers,with 1?-kw. electric generators. These refrigerators were used for delivery ofthe blood.
3. Insulated cork-lined plywood boxes for use in transportingthe blood (p. 417). The first supply was inadequate, and 60 additional boxeswere constructed by the utilities section of the 15th Medical GeneralLaboratory. Ten were somewhat larger than the others and were constructed tohold Dry Ice, which proved necessary for the preservation of the blood over thelonger routes in France. The Dry Ice was obtained in Pompeii and flown to Francewith each shipment of blood, in specially constructed insulated boxes, longerand narrower than those used for blood. A satisfactory temperature could bemaintained for 24 hours with the use of about 1,000 gm. of Dry Ice provided fromPompeii.
4. Storage refrigerators for hospitals. The 8-cu. ft.mechanical refrigerator (item No. 7375585) powered by kerosene did not provesatisfactory under field conditions, since it weighed 800 pounds and had to bekept level. Kerosene was often difficult to obtain, and the temperature was notalways as low as the required 39? F. (4? C.).
The 7-cu. ft. household type of electric refrigerator wassatisfactory for the storage of blood in evacuation hospitals. The lightweightice cream type of refrigerator brought to NATOUSA late in 1942 and issued on thebasis of one per evacuation hospital, and one per platoon of a field hospitalattached to an army, also proved satisfactory for the storage of blood collectedlocally or delivered from the base. It held 40 bottles of blood.
Recommendations
The original refrigerator-truck equipment had to be supplementedat once, as already noted. At the conclusion of the war, the unit historyspecified that the following equipment was minimum for a distributing centeroperating in an army area:
1. Two 2?-ton trucks with refrigerator space for 1,000 bottles of blood each.
2. Six ?-ton weapons carriers with refrigerators.
Essential personnel were specified as six drivers, sixassistant drivers, one refrigerator mechanic, and one motor (automobile)mechanic. It was emphasized that a forward unit could not perform properlywithout motor and refrigeration mechanics.
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STATISTICAL DATA
The base bleeding section of the 6825th Blood TransfusionCompany sent 42,713 pints of blood to the forward distributing section betweenAugust 1944 and May 1945 (table 16). In addition, it sent 369 pints to hospitalsin the Dijon Base Section and to other communications zone installations. DuringJuly, August, and September 1944, it provided 2,467 pints of blood for FifthU.S. Army hospitals and hospitals in Naples. This is a total of 45,549 pints.
The forward section of the 6825th Blood Transfusion Company,from supplies of blood received from the base bleeding section and from theEuropean theater blood bank, distributed 57,964 pints to Seventh U.S. Armyhospitals and 7,707 pints to hospitals in the communications zone, a total of65,671 pints.
The numerous discrepancies in the statistics of the bloodprogram in the Seventh U.S. Army were explained by Colonel Berry in two ways:
1. Records were, understandably, sometimesvery poor. In particular, blood used in field hospitals on casualties who wereresuscitated and sent on to evacuation hospitals for surgery was frequently notrecorded.
2. A considerable amount of blood was hoarded,especially during the winter months, and was later discarded without record. Acertain amount was also frozen during the winter, because of long exposure enroute.
TABLE 16.-Shipments of blood by bleedingsection, 6825th Blood Transfusion Company (Non-T/O),August 1944-May 1945
Year and month | To forward | To hospitals in |
1944 | Pints | Pints |
August | 3,539 | --- |
September | 4,380 | --- |
October | 4,801 | --- |
November | 4,205 | 3 |
December | 5,728 | 22 |
1945 |
| |
January | 4,706 | 50 |
February | 3, 432 | 38 |
March | 4,698 | 68 |
April | 5, 904 | 16 |
May | 1,320 | 172 |
| 42, 713 | 369 |
The real reason for the discrepancies in oversea statistics, as compared withthe precision of Zone of Interior statistics, is that the circumstances in whichblood and plasma were used did not lend themselves to careful bookkeeping.
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FIGURE 108.-Blood transfusion in forwardhospital in Seventh U.S. Army, Besan?on area, France,September 1944.
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FIGURE 109.-Administration of albumin by U.S.corpsmen to wounded French woman in temporary first aidstation in shadow of amphibious Sherman tank. She and
theother casualties (German soldiers) were wounded in theSaint-Rapha?l area of southern France, in the 36th InfantryDivision Area, Seventh U.S. Army, August 1944.
CLINICAL CONSIDERATIONS
Plasma (fig. 107) and blood (fig. 108) were used in Seventh U.S. Armyhospitals on the usual indications. Albumin was used only occasionally and inspecial circumstances (fig. 109).
References1. Kendrick, D. B.: History of Blood and Plasma Program,United States Army During World War II, 1 Aug. 1952.
2. Report of Consultant in Surgery to the Surgeon, NATOUSA, 2July 1943.
3. Report, Maj. Howard E. Snyder, MC, to Surgeon, II Corps, 3Apr. 1943, subject: Care of the Wounded.
4. Report to the Surgeon, II Corps, through CommandingOfficer, 77th Evacuation Hospital, 18 Apr. 1943, subject: Functions of aTransfusion Team in an Evacuation Hospital.
5. Report, Col. Richard T. Arnest, MC, Headquarters, II Corps,Office of the Surgeon, to The Surgeon General, 1 June 1943, subject: Care of theWounded.
6. Medical Department, United States Army. Surgery in WorldWar II. The Physiologic Effects of Wounds. Washington: U.S. Government PrintingOffice, 1952.
7. Snyder, Howard E.: Fifth U.S. Army. In MedicalDepartment, United States Army. Surgery in World War II. Activities of SurgicalConsultants. Volume I. Washington: U.S. GovernmentPrinting Office, 1962.
8. ETMD, NATOUSA, for December 1943.
9. Cornell, Col. V. H., MC: History of the 15th MedicalGeneral Laboratory, 20 December 1942-31 May 1944, 31 Oct. 1944.
10. The Medical Department of the United States Army in theWorld War. Washington: U.S. Government Printing Office,1927, vol. II, pp. 157-165.
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11. Reports of 6713th Blood Transfusion Unit (Ovhd.), 6 June1944; 24 July 1944; 25 Oct. 1944; 3 July 1945.
12. Memorandum, Col. Earl Standlee, MC, to The SurgeonGeneral, 27 May 1944, subject: Blood Banks in Theater of Operations.
13. Memorandum, Col. Earl Standlee, MC, to The SurgeonGeneral, 28 Aug. 1945, subject: Blood Banks in Theater of Operations.
14. Circular Letter No. 3, Office of the Surgeon,Headquarters, II Corps, 7 Aug. 1943, subject: Care of the Wounded in Sicily.
15. ETMD, MTOUSA, for March 1945.
16. Circular Letter No. 27, Office of the Surgeon,Headquarters, NATOUSA, 20 Aug. 1943, subject: Donation ofBlood for Transfusion and Other Purposes. Act, 30 July 1941 (Public Law 196,77th Cong.).
17. History, 6th General Hospital, MTOUSA, 1942-44.
18. Minutes, Conference on Preserved Blood, Division ofMedical Sciences, National Research Council, 25 May 1943.
19. ETMD, MTOUSA, for May 1945.
20. Annual Medical History of Laboratory Section, 21st GeneralHospital, 3 Jan. 1944.
21. Report, Lt. Col. Douglas B. Kendrick, MC, to The SurgeonGeneral, 15 Jan. 1945, subject: Trip to the North African Theater of Operations.
22. Berry, Col. Frank B., MC: Surgery in the Seventh Army, 15August 1944 to 30 April 1945, n.d.
23. Rogers, Capt. Albert M., MC: Organizational History, 1944,6703 Blood Transfusion Unit (Ovhd.).
24. Rogers, Maj. Albert M., MC: History of 6825th BloodTransfusion Company, n.d.
