CHAPTER XVI
The European Theater of Operations
Part I. General Considerations
SPECIAL CIRCUMSTANCES IN THE EUROPEAN THEATER
In any chronicle of the blood program in ETOUSA (EuropeanTheater of Operations, U.S. Army), it is important to remember that the militarysituation in this theater was entirely different from that in MTOUSA (Mediterranean Theater of Operations, U.S.Army) and that the medical situation differed accordingly. In the Mediterraneantheater, a single army operated on a single land mass, withina relatively limited area. Serious transportation problems often existed, butblood did not have to be flown across water, as from England to the Continent,and as it was flown later from the Zone of Interior to Europe. Bad weather wastherefore seldom a complete hindrance to the delivery of blood in Italy. It wasan extremely serious problem in the European theater, for the always limitedsupply of blood never permitted storage inany significant amounts.
There were also other differentiating circumstances. InItaly, medical control could be uniform; there was a single army, and there wasa single army surgeon. In the European theater, there were five U.S. fieldarmies. Just as each army commander had his own concepts of how to fight, soeach army surgeon had his own concepts of how to care for casualties and of theneed for whole blood for them.
Theater facilities could not possibly supply all the bloodneeded for casualties on the Continent, but the blood bank in operation at the152d Station Hospital when Lt. Col. (later Col.) Douglas B. Kendrick, MC,Special Representative on Blood and Plasma Transfusions to The Surgeon General,arrived in the United Kingdom in August 1944 showed how excellent such a servicecould be, even when it had no support from the Zone of Interior, if it was underthe control of a competent, dedicated medical officer, who used all theresources available to him (1).
EDUCATION AND INDOCTRINATION
Information on developments in the use of whole blood hadbeen sent to the Chief Surgeon, ETOUSA, in various ways throughout the war. The
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Special Representative on Blood and Plasma Transfusions, OTSG(Office of The Surgeon General), had kept him informed of developments in theNRC (National Research Council) committees on blood and blood substitutes and onshock. The Chief Surgeon had received the monthly ETMD (Essential TechnicalMedical Data) reports from MTOUSA, and some of his staff had visited thetheater. Col. Eugene R. Sullivan, MC, and Capt. (later Maj.) John J. McGraw,Jr., MC, who were in large part responsible for the establishment and operationof the Mediterranean Theater Blood Bank, had visited the European theater beforeD-day and had reported their Mediterranean theater experiences. They had much tocontribute, for the Mediterranean had been an active theater of operations for2? years before D-day in Europe.
All of these channels of information, however, were notenough. The use of whole blood was only one of many therapeutic methods in whichmedical personnel inexperienced in combat injuries required indoctrination,instruction, and experience.
The First and Third U.S. Armies, in the weeks immediatelyafter the invasion, had had only limited amounts of whole blood. They had to usethem sparingly. Within a short time thereafter, blood began to be flown to themin liberal quantities. There had been no chance in either Army-the Third U.S.Army had been operational for only 3 weeks when the airlift from the Zone ofInterior began-to set up research teams, and equally little time forhard-pressed operating surgeons to grasp the urgent need of seriously woundedcasualties for whole blood in liberal amounts.
The chief lesson that had to be learned in the Europeantheater after the airlift from the Zone of Interior began was not the value ofwhole blood for severely wounded men but the desirability of using it in liberalquantities and its present availability for such use. Surgeons were used to amere trickle of blood, which had to be reserved for the casualties who needed itmost because their condition was poorest. Naturally, with such experiencesbehind them, medical officers had to be convinced that they could now be assuredof all the blood they needed, and that they could use it prophylactically aswell as for casualties in direstate. It was a hard task to persuade forward surgeons that now all they neededto do to secure blood in any needed quantity was simply to ask for it in thatquantity.
Another lesson that had to be learned in the European theaterwas that group O blood in a closed system could be used with almost absolutesafety. This was not the situation in the Zone of Interior when many-perhapsmost-medical officers had gone overseas, and they had reason to be skepticalat first.
That these lessons were well learned is evident in the fact,pointed out elsewhere, that in the last months of the war in the Europeantheater, as in the Mediterranean theater, the ratio of units of blood to woundedmen was close to 1:1.
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Part II. Initial Activities in the Zoneof Interior for an
Oversea Transfusion Service
BACKGROUND OF PROJECT
By the middle of 1943, as the result of the joint activities of the Divisionof Surgical Physiology, Army Medical School (p. 61), and the Subcommittee onBlood Substitutes, Division of Medical Sciences, NRC (p. 74), all the items hadbeen developed which would permit the use of whole blood in oversea theaters.These were:
1. Satisfactory grouping sera (p. 236).
2. An expendable transfusion set (p. 195).
3. A satisfactory preservative solution (p. 221).
4. A refrigerator which would make possible the storage of blood up to 21 days (p. 206).
The safety and efficiency of all of these items had been so thoroughly testedby the agencies involved that it now seemed logical to propose that thenecessary equipment be sent overseas and that the theaters be authorized totrain their own personnel to collect and distribute blood to all fixed andforward hospitals. On the most exacting analysis, this proposal seemed entirelyreasonable. In particular, the provision of expendable transfusion sets disposedof the chief cause of anxiety in transfusions, the risk of reactions from thereuse of equipment. This practice, even in trained hands in civilian hospitals,would inevitably increase the incidence of pyrogenic reactions and, undercircumstances of warfare, would further increase the incidence of reactions.
FIRST PROPOSAL, OCTOBER 1943
The background thus being prepared, Colonel Kendrick addressed a memorandumon the use of whole blood in theaters of operations to Lt. Col. (later Col.) B.Noland Carter, MC, Director, Surgery Division, OTSG, who was then in charge ofthe blood program in this office. This memorandum, which was dated 5 October1943, covered the following points (2):
1. The British experience in the Mediterranean theater, the similar Americanexperience there, and reports from medical officers in the European theater hadmade it clear that whole blood was essential in oversea theaters of operations.The need was greatest in forward hospitals in which major surgery was performed.In these installations, casualties were often seen with red blood cell counts aslow as 1? million to 2 million per cu. mm.
2. Plasma did not solve the problem. It was an admirable and effective agent,but it had definite limitations. It could raise the blood pressure afterhemorrhage, but it could not prepare a casualty for major surgery. The BritishEighth Army at El Alamein had used bottles of blood, plasma, and physiologicsalt solution in the ratio of 18:19:20 per hundred casualties. When plasma wasused intelligently, it was an effective preliminary
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replacement fluid, but in abdominal wounds, hemorrhage,sepsis, burns, and similar pathologic conditions, whole blood was necessary,probably in a ratio to plasma of 1:2 or even 2:2.
Plasma could correct losses in blood volume if it was givenearly, in adequate quantities, and if hemorrhage was controlled at the sametime. When a casualty was treated late, or if hemorrhage was not controlled,then whole blood was essential.
3. The disadvantages of whole blood as compared with plasmawere frankly admitted. Blood had to be collected locally in theaters ofoperations. Donors would be limited to military service personnel, personnel inrest camps, lightly wounded casualties, and, occasionally, the local civilianpopulation. Malarial and syphilitic donors could not be employed. Blood wascumbersome to handle. It had to be grouped before administration. It had to bedistributed with numerous precautions. The chances of contamination of bloodwere greater than the chances of contamination of liquid or dried plasma madefrom blood collected and processed in a closed system.
A number of tests had to be carried out before blood could beused, and the necessity for them limited the extent of its use. Serologic testswere necessary, but equipment to perform them was not available farther forwardthan evacuation hospitals. Microscopic examination of thick and thin smears wasnecessary to rule out malaria, but microscopic equipment was not availableforward of evacuation hospitals, and trained personnel who were in short supply,were needed to read the slides.
Equipment (autoclaves and stills) was not available overseasin sufficient quantity to prepare transfusion sets for repeated use, nor werepersonnel available for collecting and preparing them. If the necessaryequipment and personnel could not be provided, it would be necessary to shipoverseas commercially prepared transfusion sets which could be discarded after asingle use.
Finally, because blood was highly perishable, it had to bestored under refrigeration, which was not available forward of evacuationhospitals.
4. Fresh blood collected in an open system could be used fortransfusions, but could not be kept for more than a few hours. Transfusionswith blood collected in this fashion had been given in U.S. Army hospitalsduring the North African campaign, but the number had been limited because ofthe lack of blood. Furthermore, the use of blood in small quantities had limitedits effectiveness.
Recommendations
In the light of the facts just set forth, Colonel Kendrick made the following recommendations in his 5 October 1943 memorandum to ColonelCarter:
1. Stored blood, collected in a closed system, should besupplied to medical installations as far forward as field hospitals.
2. Blood should be collected in the area of a generalhospital from military personnel or, if circumstances permitted, from civiliansnear the base. It should be collected by a base collection unit and supplied inrefrigerated chests (storage containers) to advanced units.
3. To reduce the necessity for blood grouping in forwardhospitals, only proved type O blood should bestored.
4. The quantities of blood provided should be based on theestimate that 20 percent of all combat casualties would requireresuscitation, and 20 percent of these would require blood as well as plasma.According to Brigadier Lionel E. H. Whitby, RAMC, Director of the British ArmyTransfusion Service, 30 pints of protein fluid were necessary for every hundredwounded, in the proportion of 3 pints of plasma to 1 pint of blood. According toCol. Edward D.
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Churchill, MC, Consultant in Surgery to the Surgeon, MTOUSA, 18 pints of blood were required for every hundred wounded, in the proportion of one unit of blood for every two units of plasma.
Proposed Implementation ofRecommendations
In Colonel Kendrick's memorandum of 5 October 1943, it was pointed out that Circular Letter No. 108, issued by OTSG on 27 May 1943 (3), provided for the transfusion of fresh whole blood in general hospitals overseas up to 4 hours after it had been collected, and also provided for the transfusion of stored blood, to be collected by a closed system, up to 7 hours after it had been drawn. The evidence at hand now indicated that whole blood transfusions must be made readily available in every medical installation in which major surgery was to be done. This would be possible only by the use of preserved blood stored at designated depots, preferably general hospitals.
This policy would require implementation as follows:
1. Necessary equipment would include:
a. Sterile vacuum bottles containing 200 cc. of Denstedt's solution(glucose and citrate), in which blood collected in a closed system could be keptfor 21 days.
b. Expendable recipient sets with cellophane tubing and cloth filters.
c. Donor sets consisting of a metal flow valve to be inserted in the stopperof the vacuum bottle and connected to a collecting needle by 18 inches of heavyrubber tubing. A roller-type valve, capable of completely compressing the rubbertubing, could be used in place of the metal valve to control the flow of blood.
d. Two refrigerators, of 16-cu. ft. capacity, for each general hospital, forthe storage of blood. They should be kept in the laboratory, where serologic and malaria tests would be made anddonor and recipient sets cleaned.
e. Insulated containers, each to hold from 10 to 20 flasks of blood. It wouldbe necessary to work out the arrangements for a supply of ice with theQuartermaster and Corps of Engineers overseas.
2. Transportation to forward areas would be by trucks, ambulances, orairplanes. Since blood would frequently be collected outside of generalhospitals and would require transportation to them, it would be morepractical to have transportation assigned to collecting teams and distributingunits, with the transfusion office in each general hospital responsible forproviding it.
3. Personnel would include:
a. Transfusion officers and assistants at general hospitals in thecommunications zone. Theirfunction would be to procure donors, collect and store blood, and dispense it totheir own installations and to installations farther forward.
b. Shock teams, consisting of resuscitation officers and enlisted men,properly trained in the use of plasma and albumin. These teams would beassigned as necessary to field and evacuation hospitals and to mobile surgicalunits.
c. A chief transfusion officer on the staff of each theater surgeon in eachtheater of operations. His function would be to train personnel assigned tothe blood transfusion service and to exercise general supervision over thehandling and transportation of transfusion equipment and blood. He should bepresent at all staff conferences, so that he could work out arrangements for asupply of blood in each operation. Medical officers, especially those in landingparties, would require individual training in the tactical employment oftransfusion units.
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d. A chief of the blood transfusion service in the Zone ofInterior. This officer's functions would include design and testing ofequipment for intravenous therapy, supervision of the procurement of equipment,supervision of the processing of plasma and serum albumin, and liaison with theAmerican National Red Cross Blood Donor Service and the National ResearchCouncil.
This memorandum, it should be noted, was prepared on thefundamental assumption that replacement therapy, including intravenous therapyas well as blood replacement, constitutes a specialized branch of medicine andthat to collect blood, group it correctly, and store and distribute it areprocesses that require the services of specially trained personnel. Thesefunctions cannot be safely delegated to untrained personnel because any slip,however trivial, in the collection and use of whole blood, in addition tocausing unnecessary and sometimes excessive losses of a scarce and valuablesubstance, may result in severe and even fatal reactions.
ACTIONS ON PROPOSAL
Presentation of Proposal to Chief Consultant in Surgery, OTSG
On 3 November 1943, ColonelKendrick followed his 5 October memorandum by a second memorandum to Brig. Gen.Fred W. Rankin, Chief Consultant in Surgery, OTSG, containing a summary of hisearlier memorandum to Colonel Carter (4). On6 November, General Rankin prepared a similar memorandum for The Surgeon General(5). In it, hestressed the need for stored blood in theaters of operations and described theequipment necessary to provide it. He also described expendable commercialequipment for both giving and receiving sets.
Presentation of Proposal to Subcommittee on BloodSubstitutes, NRC
The plan outlined in Colonel Kendrick's memorandum of 5October 1943 was presented by him to the Subcommittee on Blood Substitutes, NRC,at the meeting held on 17 November 1943 (6). He stressed the following points:
1. Reports from the field indicated that wounded casualtiesrequired whole blood as well as plasma.
2. At present, whole blood transfusions were being carriedout overseas with empty plasma bottles. A recommendation had been approved byOTSG to provide refrigerating equipment for field hospitals, evacuationhospitals, and general hospitals. Collecting bottles containing Denstedt'ssolution would also be provided, as well as microscopes and equipment for typingand crossmatching of blood, so that blood banks might be operated at thesepoints.
3. A satisfactory airliftwas now available, as it had not been earlier, when this subcommittee(p. 53) and the Conference on Blood Grouping(p. 53) had recommended that whole blood be provided forcombat casualties.
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4. The recommendation that collecting units be organized in general hospitals overseas, with teams to administer transfusions as far forward as possible, had been made to OTSG but had not been accepted.
After Colonel Kendrick's memorandum had been discussed in detail, the following resolution was moved and passed:
Resolved: That the Subcommittee on Bloodsubstitutes recommend through channels that The Surgeon General of the Army giveconsideration to the transportation of whole blood by airplane to certaintheaters of operations.
Rejection of Proposal by The Surgeon General
On 13 November 1943, a summary of General Rankin's memorandum of 6 November1943 was hand-carried by Colonel Carter and Colonel Kendrick to The SurgeonGeneral (7), who rejected the proposal at once, on the following grounds (8):
1. His observations in oversea theaters had convincedhim that plasma was adequate for the resuscitation of wounded men.
2. From a logistic standpoint, it was impractical to make locally collectedblood available farther forward than general hospitals in the communicationszone.
3. Shipping space was too scarce to warrant its use for sending disposabletransfusion equipment overseas.
On the basis of these facts, Maj. Gen. Norman T. Kirk, The Surgeon General,directed that the provision and use of blood in oversea theaters should belimited by the instructions set forth in Circular Letter No. 108, 27 May 1943(p. 463).
General Kirk's position was equally adamant in a second conference withColonel Carter on 16 December 1943 (8).
Although personnel in charge of the blood program were not in agreement withThe Surgeon General's decision-and although the plan rejected out of handwas essentially the same as the plan by which blood was sent overseas only 10months later-they had no choice but to accept it.
There were several probable reasons for General Kirk's refusal to considerthe proposed program, perhaps the most important being that he shared thestill rather general opinion that plasma was a satisfactory agent ofresuscitation and that the use of whole blood in large quantities was notnecessary for battle casualties. Undoubtedly, too, he had been directed byhigher authority, because of limited shipping space, to limit the tonnage ofmedical supplies shipped overseas. Since he considered plasma adequate forresuscitation, he did not believe that flying transfusion equipment overseas,let alone flying whole blood, was sufficiently important to substitute theequipment (and blood) for other supplies and, thus keep within the allowabletonnage. It also did not seem important to him to point out to the CommandingGeneral, Army Service Forces, under whom his office operated, the urgency ofincreasing the allowable tonnage to supply whole blood for wounded men, as wasdone less than 10
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months later. As a matter of fact, except for the lack of an airlift,transfusion services could have been activated in all theaters in the spring of1943, for the basic work on the preservation, transportation, and safe usage ofwhole blood had all been done by that time, and the equipment necessary forsuch a service had also been developed.
It was learned in 1960 that the decision not to send blood to Europe from the Zone of Interiorhad been made long before the interview with TheSurgeon General in December 1943. As is pointed out elsewhere (p. 475), Maj. Gen.Paul R. Hawley, Chief Surgeon, ETOUSA, had already been informed by The Surgeon General thathe would not approve of this plan.
REVIVAL OF PROPOSAL, APRIL 1944
Presentation to The SurgeonGeneral
No further action was taken in the Zone of Interior in regard to supplyingblood for combat casualties until 17 April 1944. Then, with D-day in Europeobviously imminent, Colonel Kendrick addressed another memorandum to TheSurgeon General on the subject of whole blood in theaters of operations (9). Asin his earlier memorandums, he pointed out the success of the plasmaprogram, the method of supplying fresh whole blood in fixed hospitals in thecommunications zone, as set forth in Circular Letter No. 108, OTSG, and theneed for stored whole blood in forward as well as in base hospitals. He alsopointed out that the quantity of fresh blood which could be made availableby bleeding donors (so-called on-the-hoof bleeding) would be limited during peak operations bythe inevitable confusion attending theoperations and by the necessity of performing time-consuming laboratorytests.
By this time (April 1944), theaters of operations had made their own plans for supplies of whole blood, but techniques for their implementation, as well as the equipment, varied considerably in scope. Colonel Kendrick therefore proposed to The Surgeon General:
1. That a complete study be initiated to determine the needs for whole blood, requirements as to equipment and personnel and standardization of techniques to supply whole blood to medical installations in the field. The study would include a trip of inspection to one or more active theaters to observe their techniques and equipment before final recommendations were made.
2. That the Office of The Surgeon General develop techniques and standardize equipment to provide for the use of stored whole blood in theaters of operations. The following plan was suggested:
a. Only group O blood would be sent to forward hospitals.
b. Blood would be collected at bases from service personnel or the civilian population by a collecting team consisting of a medical officer, a nurse, and seven enlisted technicians, two of whom would also act as drivers.
c. Laboratory procedures, including serology, malaria testing, and blood grouping would be done by the collecting teams.
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d. Blood would be sent as far forward as field hospitals, upon request, in refrigerators mounted on trucks. It would be handled by a distributing or delivery team of two enlisted men.
e. A transfusion officer in each unit would be responsible for maintainingan adequate supply of blood and forits administration. The remainder of the transfusion team in each unit wouldconsist of a nurse and three enlisted technicians. It was essential that alltransfusion officers and other personnel be well trained for this special work.
f. A transfusion officer attached to the staff of the theater surgeon wouldbe responsible for supervision of the collecting team and for all otheractivities concerned with blood within the theater.
3. Transportation for the collecting team would consist of a truck or ambulance totransport personnel and a ?-ton truckfor equipment and refrigerators. Transportation for the delivery team wouldconsist of a similar truck for refrigerators.
4. Other equipment would consist of:
a. An electric refrigerator to operate on 110 volts, or on usualpower outlets, or on a 750-wattgenerator. The refrigerator should be large enough to hold from 36 to 50 bottlesof stored blood and should maintain a temperature range of 46.4? to 50.0? F.(8? to 10? C.).
b. One-liter vacuum bottles containing 500 cc. of Alsever'ssolution.1
c. Collecting sets consisting of a 20-inch length of ?- or 3/16-inchrubber tubing, with two 17-gage needles.
d. Dispensing sets consisting of expendable glass housing with metalfilter and rubber tubing.
In a memorandum addressed to TheSurgeon General on 21 April 1944, General Rankin repeated the informationin Colonel Kendrick's memorandum of 17 April concerning therelative limitations of plasma and the absolute necessity for stored blood forcombat casualties (10). Healso stressed the need for standardizing methods and equipment for thecollection and storage of blood in all theaters, in keeping with militaryrequirements.
REQUEST FOR OVERSEA MISSION
In the memorandum just mentioned, General Rankin requested that ColonelKendrick be ordered to the Southwest Pacific, to carry out the study proposedin the latter's memorandum of 17 April, to study blood and plasmarequirements, and to investigate the use of albumin and other byproducts of theplasma-blood program. General Rankin recommended that when this missionhad been completed, techniques and equipment be standardized in the Office ofThe Surgeon General for the use of replacement fluids in all theater's ofoperations
1By this time, Alsever's solution was being used in the Zone ofInterior in place of Denstedt's or other solutions. Its use had been approved by the Subcommittee on Blood Substitutes inSeptember 1943 (p. 467), but its replacement by ACD (acid-citrate-dextrose) solutionwas not recommended until November 1944, 3 months after theairlift to the European theater had become operational (p. 226).
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The justification for the mission and for the selection of the area inwhich it was to be carried out was that no one in the Southwest Pacific had hadthe training and experience necessary to train the personnel required for ablood program, supervise equipment, and organize an efficient transfusionservice. Colonel Kendrick, General Rankin's memorandum continued, had beenresponsible for the blood and plasma program in the Zone of Interior from itsonset. If plans could be made to make blood available in the Southwest Pacific,over long distances, in the face of difficult terrain, a high incidence ofmalaria, and extreme temperatures, then methods of providing blood in othertheaters would be greatly simplified. Such a study would make it possible tocombine laboratory experiences with field requirements and eventually tostandardize equipment and methods of transfusion for the entire Army.2,3
In the official request for temporary duty for Colonel Kendrick for themission just described, which was made on 4 May 1944, it was stated that thetrip would be made with Capt. Lloyd R. Newhouser, MC, USN, in order tocoordinate methods and equipment for the use of blood and blood substitutes inthe Army and the Navy and thus simplify therapy when combined operations wereundertaken.
The readiness date requested for this mission was 5 June 1944-which was theday before D-day in Europe. In retrospect, it seems that it might have beenwiser if the trip had been made to the European theater. On the other hand, noprecise information was then available about the date of D-day, and the need forguidance in the Pacific was obviously very great.
RECOMMENDATIONS BY SURGERY DIVISION, OTSG
In the annual report of the Transfusion Branch, Surgery Division, OTSG, madeon 1 July 1944 for fiscal year 1944 (14), thesection dealing with blood began with the statement that, although plasma hadbeen supplied to the Army in adequate quantities since 1941, the need for bloodhad never been lost sight of. The report reviewed the work of the Division ofSurgical Physiology, Army Medical School, in the development of a closedsystem for bleeding; the development of a preservative solution in which bloodcould be stored safely for 2 to 3 weeks; the development of disposabletransfusion sets; and the development of refrigerating equipment. Although allof this equipment was available by D-day in Europe, 6 June 1944, and storedwhole blood could then have
2Had time permitted, it would have been profitableto study the successful transfusion service and blood bank in operation in theMediterranean theater (p. 400) before the trip to the Southwest Pacific. It didnot, and, as events proved, there was urgent need for guidance and help in thePacific areas. On the other hand, the fact that Colonel Kendrick was ordered tothe Pacific instead of to Europe at this particular time is an indication of thesecrecy surrounding the date set for D-day. Apparently, as late as May 1944, TheSurgeon General did not have this information.
3It is interesting to recollect that as early as 31 May 1940 (11),the Committee on Transfusions, NRC, recognized theneed for field studies in the blood program. At the meeting on 9 April 1943 (12),the subcommittee recommended the appointment of a qualified fact-findinggroup to make field studies, on the ground that its own work had reached thepoint that it could no longer function effectively without "more preciseinformation concerning field problems and conditions imposed by the militaryrequirements in this war" (p. 79). On 24 September 1943, the subcommitteeagain raised the question (13). No such civilian investigation was everundertaken, probably because The Surgeon General was reluctant to ask for thenecessary clearances.
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been provided for field use, as of 30 June 1944, no plan had been approvedby The Surgeon General for collecting and supplying blood to the theaters, eachof which had therefore developed its own plans.
In the fall of 1943, the report continued, the Surgery Division, OTSG, hadproposed to The Surgeon General a plan that utilized tested and approvedequipment and that provided for the collection and delivery of blood in overseatheaters. The plan was predicated on the concept that blood transfusion andthe use of other replacement fluids constituted a specialized branch ofmedicine.Well-trained technicians were necessary to collect blood, group it correctly,and store it safely. These functions could not be delegated to untrainedpersonnel, for errors could result in severe and even fatal reactions.
The plan had been rejected as unessential and impractical in November 1943. In June 1944, the report concluded, the need for a transfusion servicein active theaters of operations was even more apparent than it had been in 1943. It was therefore urgently recommended that additional thought begiven to preparing and adopting a simple plan to make blood available in every theater, using:
1. The 4-cu. ft. refrigerator developed during the past year.
2. The expendable recipient set now available.
3. Alsever's solution now available as a preservative
4. The collection of blood by a closed system.
5. O donors exclusively.
Part III. Initial Activities in theEuropean Theater
INITIAL PROVISION OF BLOOD AND PLASMA
The first U.S. troops which arrived in England, in January 1942, had noprovision for blood transfusion, and for some time their supplies of plasmawere entirely inadequate. The deficiencies were easily explained: Troops werebeing deployed, or arrangements were being made for their deployment, all overthe world, and supply ships were being sunk.
Arrangements were promptly made to supply blood and plasma (at first in thewet form) from British sources. As might have been expected, certaindifficulties arose, some of which continued into 1943 (15). The first U.S. requests for plasma were extravagantlylarge. Some individual units requested plasma and blood at irregular intervalsdirectly from British blood centers instead of procuring them, as they wereinstructed to, through U.S. Army medical depots. Also, small amounts of bloodwere procured from civilian sources. If these practices had not been stopped atonce, the U.S. Army would have been placed in the position of being afactor, albeit a passive and unwitting factor, in the disruption of thewell-organized British Army Transfusion Service. Fortunately, relationsbetween Brigadier Whitby, in charge of the British Transfusion Service, andCol. (later Brig. Gen.) Elliott
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C. Cutler, MC, Consultant in Surgeryto the Chief Surgeon, ETOUSA, were so intimate and cordial thatmisunderstandings could be settled as they arose.4
In June 1943, there was a gradual changeover from Britishwet plasma (fig. 110) to British dried plasma; the issue also included distilledwater and giving sets (16). In December 1943, U.S. hospitals in theUnited Kingdom began to receive dried plasma from the Zone of Interior (17).
TRAINING IN BRITISH BLOOD SUPPLY DEPOT
In August 1942, Capt.(later Lt. Col.) Robert C. Hardin, MC (fig. 111), who had had a wide experiencein blood procurement and replacement therapy
4One of the first items ofofficial correspondence directed to Colonel Cutler for action was a report on theBritish Army Blood Supply Depot submitted by Capt. (later Lt. Col.) Robert C.Hardin, MC, who was then serving as U.S. liaison officer at the depot (p. 478).The theater Chief Surgeon, in turning over the report to Colonel Cutler,signified that the Chief Consultant in Surgery would be responsible for thetechnical aspects of providing blood, blood substitutes, crystalloids, andrelated substances to the U.S. Army medical units in the theater.
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at the State University of Iowa, Iowa City, Iowa, with Dr.Elmer L. DeGowin and Dr. Everett D. Plass (p.220), was placed on temporary duty at the British Army Blood Supply Depot,Southmead Hospital,Bristol. His functions were to serve as liaison supply officer and togather as much information as he could about the British system of procurement andhandling of blood and blood products,including the technical details of collection, processing, storage, anddistribution. Captain Hardin alsocollected data concerning British methods of treating shock, the amounts of bloodand plasma required in the management of battlecasualties, and the management of casualties in the Battle of Britain as well asthe Battleof France. Personal contacts with the officers who had had these experiences proved most helpful.
Captain Hardin also studied methods of trainingofficers and enlisted men in the procurement and distribution of blood and in shockand resuscitation. Special courses were conducted for this purpose. When Col. James C. Kimbrough, MC,Chief, ProfessionalServices, Office of the Chief Surgeon, ETOUSA,
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investigated the possibility of a few U.S. medical officers with specialinterest in the subject attending these courses, Brigadier Whitby replied thathe would be delighted to have three officers attend each course. He thought theywould provide a new source of postlecture argument, which would be bothinstructive and stimulating. He also agreed to give a limited number of coursesto noncommissioned officers and enlisted technicians. The courses of instructioncontinued into May 1944 and were attended by more than 200 U.S. officers. Thepolicy paid off in friendship and cooperation as well as in dissemination ofknowledge.
APPOINTMENT OF CONSULTANT ON TRANSFUSION
AND SHOCK
A consultant on transfusion and shock was even more necessary in theEuropean than in the Mediterranean theater, since several armies operated in it,with several widely separated blood bank units attached to them.
The question first came up on 2 January 1944, when Colonel Kimbrough wasinformed by Colonel Cutler of the provisions for the whole blood service. It waspointed out to him that the highly specialized nature of this service made itessential that a competent officer be placed in charge of it. On 5 January,General Hawley instructed Col. James B. Mason, MC, to appoint an officer todirect the whole blood service in the theater (18). It was highly desirable that he be appointed promptly,for basic decisions had already been taken about the service; a large quantityof equipment was already available; and personnel would soon be assigned. Thiswas therefore the time for a director to take hold of the service and weld theseparate parts into a whole. The officer nominated, General Hawley specified,must be a forceful executive, with a good knowledge of Army organization andoperations, and must be qualified, from a professional standpoint, to advise onthe use of whole blood.
Colonel Mason at once nominated Captain Hardin for the position, on the ground that he was better acquainted with all the details of the acquisition and processing of blood than any other officer in the theater. Brigadier Whitby had written Colonel Cutler on several occasions of the assistance he (Captain Hardin) had been to him. In addition to handling the administrative details of U.S. participation in the courses of instruction at Southmead Hospital, he had shared in the work of the depot; delivered lectures on transfusion reactions, changes in stored blood, and the use of blood substitutes; and had otherwise carried part of the teaching load during the year he worked at the blood bank. In his return letter to Brigadier Whitby, Colonel Cutler had said he expected to make great use of Captain Hardin in the future, as an assistant in the Consultant Service, in the organization of shock teams, and in the establishment of hospital blood banks.
Captain Hardin was appointed theater transfusion officer on 7 February 1944.
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HOSPITAL BLOOD BANKS
Authorization
The establishment of blood banks in U.S. hospitals in the United Kingdomfirst arose in October 1942 and was the subject of a number of discussionsthereafter until they were authorized by Circular Letter No. 51, Office of theChief Surgeon, ETOUSA, 5 April 1943 (19). Theywere set up only in general hospitals. Station hospitalsemployed fresh blood as the need arose, and one or two had arrangements tosecure it from British sources, but they were not authorized to store blood.
The following instructions were given in Circular Letter No. 51:
1. Only U.S. Army personnel should be used as donors in the area controlledby the British Army Transfusion Service (the counties of which were listed).
2. In other areas, general hospitals should set up blood banks inconsultation with local civilian medical authorities, using civilian donorpanels.
3. Neither civilian nor military donors would be remunerated.
4. Under no circumstances were British Army Transfusion sets to be used withcivilian sets. They were entirely separate, and no hospital should use both.
Progress Report, June 1943
On 9 June 1943, Captain Hardin reported to Colonel Cutler on the progressmade in setting up blood banks in general hospitals in the United Kingdom asfollows (20):
1. The 2d General Hospital had facilities for the storage of whole blood andhad operated a small bank for several months. The civilian donor panel allottedto it by the British Army Transfusion Service contained the names of about 800persons living near the hospital and was augmented by hospital personnel.Bleedings were carried out once weekly, the number of donors bled beingdetermined by the weekly requirements. This hospital was supplying a localBritish Emergency Medical Service hospital with blood.
2. The 5th General Hospital was setting up its bank. It had been suppliedwith British military equipment and had a local civilian panel of 800 persons,augmented by hospital personnel. Because of the proximity of this hospital tothe Royal Infirmary in Salisbury, which used the same panel, bleeding would becarried out there, by teams from both hospitals, on the scale necessary toprovide the blood needed for both institutions. The addition of U.S. personnelwould be the only departure from the previous bleeding practice in thislocation. Adequate refrigeration was available at the 5th General Hospital forblood storage.
3. The 30th General Hospital, which was located in the British EmergencyMedical Service area, had made satisfactory arrangements with local transfusionauthorities in Nottingham, from which it received 20 pints of blood every 2weeks. Emergency supplies beyond this amount were obtained from either theMansfield General Hospital or the EMS (Emergency Medical Service) Laboratory inNottingham. The 30th General Hospital staff reciprocated this assistance byfurnishing a medical officer to carry out bleedings for the EMS laboratory everyweek or two. To date, the hospital needs had averaged only 5 pints per week, butoutdated, unused blood was returned to the EMS laboratory for processing intoplasma, so there was no waste. The hospital had adequate refrigerationfacilities.
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4. The 52d General Hospital, which was also located in the EMS area, had madearrangements similar to those of the 30th General Hospital with local civilianlaboratories in Birmingham and Worcester. It received 4 pints of blood perweek, which covered present needs, and returned outdated blood for processinginto plasma. The greatest present need of this hospital was for an electricrefrigerator to maintain a constant temperature for blood storage.
5. The 67th General Hospital had arranged for a blood bank with a civilianpanel allotted from the British Army Transfusion Service. The bank wouldcooperate with local civilian hospitals by arrangements similar to those madeby the 2d and 4th General Hospitals.
6. The 298th General Hospital could now supply its needs directly from aBritish Army blood supply depot because of its location only 5 miles away. Atpresent, it was keeping four bottles of type O blood constantly on hand foremergencies and could procure more if it were needed. Outdated blood wasreturned for salvage. This arrangement was more satisfactory to the BritishArmy Transfusion Service than the allotment of a civilian panel to the hospital.At present, the demand for blood was not sufficient to make storage in thehospital economical, but the basic organization for a blood bank had been builtup and equipment for itprovided. The sets for taking and giving blood had been manufactured in thehospital from salvaged glassware.
Operation
The details of operation of a hospital blood bank were set forth in MedicalBulletin No. 14, Office of the Chief Surgeon, Headquarters, ETOUSA, for 1January 1944 (21). The description covered organization, equipment, its cleansingand sterilization, technique of bleeding, blood grouping, and technique of administration.
Hospitals which maintained their own blood banks in the United Kingdom developed special practices. Afterthe invasion, for instance, the 182d General Hospital found the blood donorpanel maintained from its own personnel adequate for ordinarycircumstances but not sufficient when convoys arrived and large amountsof blood were needed. An arrangement was therefore worked out with personnel of the nearbyG-18depot to supply the blood needed at these times. Themen on this panel werealready typed, serologic tests had been run on them, and their medical histories hadbeen reviewed. When the blood was needed, therefore, it could be drawn andadministered at once. This hospital did not store blood between convoys.
INCREASING AWARENESS IN THE EUROPEAN THEATER OF
THE NEED FOR WHOLE BLOOD
The blood program in the European theater developed along two lines. Onewas the increasing realization of the necessity for blood rather than plasma in themanagement of wounded men (though the complete realization did not come untilafter D-day).The other was the increasing realization that local supplies of blood couldnot possibly meet the needs of the theater and that blood must be flownto the theater from the Zone of Interior (though again it was not until after D-day thatthe full realization came).
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During 1942, as just indicated, there was no blood program, as such, in the European theater. The growing appreciation of the need for whole blood began to take expression early in 1943 and is best described chronologically.5
1943January-April -On 29 January 1943, in amemorandum to Dr. P. L. Mollison, British Blood Transfusion Service, Lt. Col.(later Col.) William S. Middleton, MC, Senior Consultant in Medicine, ETOUSA,thought there might develop "a swing toward whole blood transfusions" (22)."Actually," he continued, "we sense amovement in that direction at the present time." The British, as pointedout elsewhere (p. 54), had appreciated this necessity almost immediately afterthe outbreak of the war more than 3 years ago.
When the Chief Surgeon, ETOUSA, first directed that provision be made tosupply whole blood for combat casualties, in July 1943, he did not mention thepossibility of securing blood from the United States. The omission is explainedin a letter written to Col. John Boyd Coates, Jr., MC, Editor in Chief of thehistory of the U.S. Army Medical Department in World War II, which is appendedto the official diary of Colonel Cutler, Senior Consultant in Surgery, Europeantheater, in the second of the volumes devoted to the surgical consultant systemin this historical series (23). Thereis a strong implication, General Hawley wrote, in some sections of this diary,that his own disapproval ofcertain recommendations made by the consultants was purely arbitrary andcapricious. The explanation is that throughout the war he frequently had topsecret information that he could not share with even his deputy. Many of hisadverse decisions were based upon such information. An example was hisreluctance in 1943 and in 1944, before D-day, to attempt to obtain whole bloodfrom the Zone of Interior. For this, there were two reasons. The first was thatthe transatlantic airlift in 1943 was so limited and so restricted by prioritiesthat it could not take on any additional load. The second reason was that TheSurgeon General had told him flatly that he would not approve of flying bloodoverseas.
The Surgeon General's opposition to the plan was made official on 8 April1943, when a radiogram was received from The Adjutant General, War Department,stating that no whole blood could be expected in the theater from the Zone ofInterior.
When General Hawley first directed that steps be taken to procure wholeblood for hospitals in the United Kingdom, there was probably no really seriousconsideration, or at least no general consideration, of securing blood from theZone of Interior on the part of those whose task it was to implement his orders.All the planning was based on securing the required blood from troops in the
5The organization of the ETOUSA Blood Bank at the152d Station Hospital was proceeding at the same time that the events related inthis section were occurring. For reasons of continuityof narration, however, the history of the blood bank is told in a separatesection (p. 498).
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theater, with perhaps some donations from civilian sources. At intervals,however, the possibility of procurement of blood from the United States wasbrought up, sometimes tentatively, sometimes with real conviction, as thefollowing facts show:
Early in 1943, it was pointed out by the Professional Services Division,Office of the Chief Surgeon, ETOUSA, that medical officers in the Mediterraneantheater were reluctant to use plasma in forward areas, even though it wasdifficult to obtain whole blood for transfusion. The chief purpose of blood wasto increase the oxygen-carrying capacity of the casualty for a period longenough to support him through surgery, and plans must therefore be made to useblood "up the line." It was recommended that a supply of blood be madeavailable in the United Kingdom and also from sources in the United States.
May -On 10 May 1943, in a memorandum to General Hawley, Colonel Cutlerdiscussed information he had secured in recent conferences with Brigadier Whitby.He mentioned three possible sources of blood for the treatment of shock (24):
1. Lightly wounded casualties could be bled in the frontlines. Thetransfusion laboratory teams of mobile surgical units were provided withequipment for drawing and administering blood. Possibly, if the blood were usedjudiciously, these teams might be able to collect all that would be needed, butin the light of the British experience, this source must not be regarded asentirely sufficient, and plans must be made for a supplementary supply.
2. Blood secured from base and service troops in rear areas could betransported to the front by an organization similar to, and perhaps patternedafter, the British Blood Transfusion Service (p. 15).
Blood collected in this manner had to be processed; that is, it had to beretyped and tested serologically, and glucose had to be added to it. When it wasproperly refrigerated, it was useful for a minimum of 14, and a maximum of 21,days. Equipment was necessary for typing and serologic tests, and refrigerationwas required for the laboratory in which the processing was done.
Blood thus secured could be delivered to frontline units by air or surfacetransport, but precautions must be taken to keep it at temperatures below 42.8?F. (6? C.) at all times and also above freezing. A supply dump would benecessary behind frontline forces to handle blood and distribute it to thetransfusion teams in the forward area. Such a unit might well be patterned afterthe British base transfusion unit, which was also equipped to manufactureglucose and physiologic salt solutions and to recondition and sterilize allapparatus.
3. Blood procured from the Zone of Interior represented thelargest pool available. Supplies from this source could enter the transfusionservice overseas either at the laboratory where blood drawn from troops wasprocessed or at the forward dump. Refrigeration presented special problems, forthe blood must at all times be kept within the temperature range just stated.Nonethe-
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less, it was perfectly feasible to fly blood over the distance involved. As a matter of fact, transportation of blood by plane was possibly less harmful than transportation by road.
June -On 5 June 1943,Captain Hardin sent a memorandum to Colonel Cutler discussing blood procurementas follows (25):
1. Blood could be obtained in the United Kingdom from base and SOS (Servicesof Supply) troops, but these troops, scattered as they were over a wide area,would furnish a somewhat problematical source of supply. Moreover, because bloodwould be most needed then, they would have to be bled during periods of combatactivity, when they would be least available. If a constant stream of donors wasmade available, it was estimated that a single team could bleed up to 150 men aday.
2. Blood might also be collected from British civilians, who would probablyfurnish a more reliable source, but this plan had numerous complications.
3. If blood were collected in the Zone of Interior, it must be delivered tothe theater by airlift. Its collection, processing, and initial delivery to adepot in the United Kingdom would be the function of any appointed agency in theZone of Interior. Its reception, interval storage, and distribution tolaboratory transfusion teams, base units, or both would be the responsibility ofthe United Kingdom blood depot but would differ in no way from the organizationfor the distribution of blood collected in the United Kingdom. The receivingdepot would necessarily be located near an airport, and adequate refrigerationmust be provided for the blood from the time it was offloaded from the planeuntil it was used.
At a conference with his consultants on 23 June 1943, General Hawley toldthem that blood used in the theater must be collected locally; it could not beprocured from the United States.6 They were to consult with the Britishconcerning its preservation and storage.
August.-In a memorandum for the record dated 29 August 1943 and entitled"Project," Colonel Cutler dealt at length with the procurement,storage, and supply of whole blood for combat troops in the theater (26). Therewas an overwhelming necessity for the blood, he stated, and a central blood bankwas essential. Blood secured from lightly wounded soldiers would not besufficient for the needs of forward areas. Blood from the Zone of Interior wasnot mentioned.
An attached appendix, prepared by Lt. Col. (later Col.) Ralph S. Muckenfuss,MC, Commanding Officer, 1st Medical Laboratory, dealt with technicalconsiderations of procurement, storage, equipment, records, and issue. SOStroops in the United Kingdom, it was stated, would provide a sufficient sourceof supply for the O blood required.
6Here and elsewhere, this statement is repeated asa matter of record. In the light of the information General Hawley had had fromthe Office of The Surgeon General through The Adjutant General (p. 475), therewould have been no point to his encouraging the possibility of securing bloodfrom the Zone of Interior.
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In an undated7 memorandum, apparently also prepared in the summer of 1943,Colonel Cutler discussed the blood program in the theater in the light of theBritish experience and practices and on the basis of Captain Hardin'sexperience as U.S. liaison supply officer at the British Blood Supply Depot. Theplan was as follows:
1. The source of the blood was to be "suitable [meaning type O]volunteer donors from SOS units."
2. Base section commanders would cause unit commanders under theirjurisdiction to obtain lists of men with type O blood. They would also designatehospitals to be used as bleeding centers.
3. On call from the commanding general, SOS base section commanders wouldassemble the required number of donors at specified centers, where bleedingteams dispatched from the medical blood depot would withdraw 400 cc. of bloodfrom each donor.
In an undated memorandum for the record apparently prepared about this time,Colonel Cutler set forth additional aspects of the blood program for thetheater. It seemed desirable to have for casualties in the field additionalsupplies of refrigerated fresh whole blood originating either in the UnitedStates or from SOS troops in the United Kingdom. If this plan were adopted, itwould require:
1. The setting up of bleeding centers either in the United Kingdom or the Zone of Interior.
2. The transportation of blood in refrigerated airplanes to the Continent.
3. The use of refrigerated trucks to take the blood up the line to medical installations, which must have facilities to provide refrigerated storage for it.
In essence the plan outlined in this memorandum, presumably written in early August 1943, was the plan by which, a year later, blood began to be provided for the European theater.
Later in the same memorandum, Colonel Cutler pointed out that unless and until air supremacy was established, so that blood could be flown to the Continent from the United Kingdom, whatever blood was needed would have to be obtained on the hoof, from SOS troops or walking wounded.
Colonel Cutler did not again mention the possibility of securing blood from the United States in a number of additional memorandums on transfusion during the remainder of the year, nor was this possibility mentioned in other memorandums or at meetings dealing with blood supply and the blood bank.
November -On 13 November 1943, in a memorandum for therecord, Colonel Cutler (27) tookthe position that all general hospitals in the United Kingdom should either setup their own blood banks or "join in" with local British banks fromwhich they could secure blood. The chief point, he said, was to have bloodavailable. His final remark, that the chief point was to have
7Dr. Cutler's death shortly after the war hasmade it impossible to supply missing dates or settle certain other questionswhich have arisen in the preparation of this section. His official diary hasproved a very useful source of information, but some entries, as might beexpected, would benefit by clarification that cannot now be obtained.
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blood available, was an indication of the growing realization of the importance of this substance.
On this same date, Colonel Cutler also wrote Colonel Mason, Chief, Operations Division, Office of the Chief Surgeon, that he was concerned over what might happen if a major attack should begin and great numbers of casualties be brought to England in need of blood (28). On 18 November, Colonel Mason replied that plans for the distribution of whole blood provided for emergency supplies to station and general hospitals in the United Kingdom (29). Under normal circumstances, each hospital could provide enough blood from donors available in and about hospitals.
On 26 November 1943, General Hawley prepared a memorandum for the Commanding General, SOS, ETOUSA, in which he stated the need for whole blood for combat troops and for the establishment of a blood bank to be maintained with blood collected from SOS troops (30). He thought that blood should be provided as far forward as division clearing stations.
December -On 3 December 1943, Colonel Mason informedGeneral Hawley that the blood bank which he desired to have established was nowso completely planned that the service would be ready to function on D-day. Basesection commands would be requested to set up panels of donors. Blood from theZone of Interior was not mentioned.
On 18 December 1943, General Hawley again informed the Commanding General,SOS, ETOUSA, of the necessity for the provision of whole blood for combat troopsin the theater (31). Heemphasized that an unfailing source of whole blood would be necessary, but, inhis recommendations for the transfusion service, he mentioned only voluntarydonations from SOS troops. The possibility of supplying blood by plane from theZone of Interior again was not mentioned.
1944
January-On 2 January 1944, the CommandingGeneral, 1st Army Group, was informed by Headquarters, ETOUSA, that theprovision of whole blood for combat casualties had been approved for allechelons down to and including division clearing stations (32). Whole blood would be considered an item of medicalsupply; it would be distributed through medical supply channels, and would begiven the highest priority in transportation. Provision was made for equipmentand personnel for a transfusion service for each army without requisition (p.543).8
Upon the receipt of this communication, Colonel Kimbrough recommended thatthe chief consultants in medicine and surgery and the commanding officer of the1st Medical Laboratory present to the Chief Surgeon a concrete plan for theoperation of the stipulated transfusion service.
8With the conversion of the 152d Station Hospital tothe theater blood bank, this provision was promptly abrogated. Also, althoughapproval was given for the use of blood in clearing stations, it was seldom ifever provided in them because it was immediately available in platoons offield hospitals, and its use was more practical and more efficient in the hospitals.
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On 2 January 1944, Maj. (later Lt. Col.) Richard V.Ebert, MC, submitted to the Chief Surgeon, ETOUSA, for the attention of ColonelCutler, the agenda of a meeting he had attended on 6 December 1943 in the Officeof The Surgeon General in Washington (p. 194). It was shortly before thismeeting that The Surgeon General had declined to consider the collection ofblood in the United States for the European theater and its transportationthereto by air (p. 465).
It was The Surgeon General's opinion, reported Major Ebert, that shockedpatients could be suitably treated with plasma and that whole blood wastherefore not necessary in most forward areas, certainly not forward ofevacuation or field hospitals. It was the sense of this meeting that transfusionservices should be established in each hospital and that these services shouldbe responsible for everything connected with transfusions, including theformation of a donor panel.
March-As D-day drew nearer, unsettling thoughtsabout the adequacy of the arrangements for supplying blood for woundedcasualties apparently began to cross the minds of those responsible for theircare.
On 31 March 1944, Colonel Cutler wrote to Colonel Kimbrough that he haddiscussed with Colonel Muckenfuss and Major Hardin the possible extension ofblood production. He believed that present capacities were fairly satisfactory,but he was having a memorandum prepared showing what would be needed in the wayof personnel and equipment if they had to be expanded (33). The trial distribution of blood to hospitals in EastAnglia, mentioned in this memorandum as to be held shortly, never took place.
April.-On 1 April 1944, at a meeting at the blood bank at Salisbury (34),the question of the capacity of the bank to furnishsufficient quantities of blood for operations on the Continent was discussed ingreat detail by the committee responsible for the blood program.9
When planning began in the summer of 1943, it was difficult to estimate theprobable requirements for the invasion of the Continent because there were noexperience tables to furnish guidance. Figures from North Africa were not yetavailable. The only definitive figures, in fact, were those reported by theBritish Blood Transfusion Service, which had operated with the Middle Eastcommand. They indicated that a ratio of 1 pint of blood for each 10 casualtieswould be adequate, and planning was begun on this basis.
For D+90, the period on which all planning for Operation OVERLORD was based,casualties on the Continent were expected to average 1,875 per day, which wouldmean, allowing 500 cc. of blood for each casualty in shock (estimated at 20percent of the total number), that 200 pints of blood per day would be required.
Bank personnel believed that it would be possible to collect 200 pints ofblood a day for 90 days, a total of 18,000 pints, and to collect a maximum of
9Unless otherwise identified, material in the following pages is derived fromthe official diary of the ETOUSA Blood Bank (34).
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600 pints per day for shorter periods. Storage space for 3,000 pints of blood was available, and the blood could be stored for a maximum period of 14 days before use.
The original plan was to provide 1,000 pints of blood between D-day and D+5. On D+6, 600 pints would be provided, and on the following day, from 200 to 600 pints. These quantities were considered in excess of the amounts likely to be required, and it would therefore not be necessary for the collecting teams to work at full capacity during this period. Each team could collect 120 pints of blood daily if a constant stream of donors were made available.
A single citation of statistics will make clear how far the actualities of combat were from the original planning (35). By 20 July 1944, 46,918 casualties had been admitted to medical installations of the First U.S. Army on the far shore, and 15,250 pints of blood had been delivered, a ratio of 1 pint to 3.06 wounded. Of the total number of wounded up to this date, 22,768 were seriously wounded, which changes the ratio of pints of whole blood to wounded to 1:1.48. Later, the ratio was to be 1:1.
The plans called for the bleeding of base troops (SOS and Air Forces). In late summer of 1943, a study of the SOS troop basis indicated that by D-day, which it was then thought would be in May 1944, there would be approximately 350,000 officers and enlisted men in the theater. It was estimated that in this group there would be a minimum of 80,000 men with type O blood, of whom some 60,000 would be available as donors. Each of them would donate four times. On the basis of these estimates, the capacity of the panel was set at 240,000 pints annually.
At the 1 April 1944 conference at Salisbury, new figures werequoted that had been secured by General Hawley in a teleprinter conversationwith the Office of the Adjutant General, on 7 March 1944. They cast seriousdoubts upon these estimates. In view of the alarming reduction in the capacityof the blood donor panel which had been indicated by General Hawley'sinformation as to troop strengths and troop movements, it was recommended thatsteps be taken immediately to plan for the acquisition of whole blood, type O,from the United States. The committee did not consider that even theestablishment of a panel of donors from the Eighth Air Force would solve theproblem. It also recommended that the blood bank at once increase its normaldaily processing capacity to a minimum of 500 pints.
At another conference on blood supply on 5 April 1944, ColonelKimbrough again called attentionto the plans previously described for flying blood from the United States to theEuropean theater. In a report to General Hawley, Colonel Kimbrough repeated thisrecommendation and recommended its implementation, for a number of reasons (36):The donor response from SOS units had been extremelydisappointing; not more than 20 percent of the troops had volunteered. As the invasion would proceed and more and more troops wouldbe sent to the Continent, the pool of donors in the United Kingdom would becomeprogressively smaller, though it would increase in forward
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areas, where blood procured on the hoof might perhaps be taken intoconsideration. Finally, the capacity of the blood bank was then only 200 pintsdaily, against an estimated total daily requirement after D-day of 500 pints. Inview of reports from the Mediterranean theater of the increasing use of wholeblood, it was highly probable that this estimate was too low. On the whole,however, it was thought that a ratioof three units of plasma to one of blood, or even five units of plasma to one ofblood, would be adequate.10
When discussions of the blood program began in the European theater, theprewar ideas of the total value of plasma were simply carried over into theplanning, just as they had been in the North African theater in 1942 and early 1943.In the Fifth U.S. Army, however, theexperience had not borne out theconcept that plasma could be substituted for whole blood (37,38). At the present time, large quantities of blood,sometimes as much as 4,000 cc., were being used, the objective being to bringthe red blood cell count up to 4 million per cu. mm. within 12 to 24 hours afterwounding.
The experience of the North African theater gradually became known in theEuropean theater, but its full impact was not realized until Col. Thomas J.Hartford, MC, Executive Officer, Office of the Surgeon, 1st Army Group, returnedfrom a trip to Italy in March 1944 (39). He brought the disquieting newsfor those planning the blood supply for the invasion of the Continent that1 pint of whole blood was now considered necessary for each 2.2 wounded (table17) rather than the 1:8 or 1:10 originally estimated. This seemed to ColonelKimbrough an excessive estimate which required reconsideration, though he wasnot in a position to criticize data obtained from battlefield experience.
In his 6 April report to General Hawley, Colonel Kimbrough analyzed present plans for the blood supply for the invasion as follows: On D-day, from previous collections, 4,200 pints would be available. For the next 7 days, the bank would collect 500 pints daily. After this time, it was anticipated that the daily blood supply from the bank could not exceed 200 pints.
The amounts of blood required by the new estimates, Colonel Kimbrough concluded, could not possibly be met with the present facilities of the ETOUSA Blood Bank or the limited pool of donors available. A stronger directive was being prepared in the hope of obtaining a larger panel of donors. It might be necessary to offer to pay the troops for their donations, or to give them whisky as an incentive. It might also be necessary to build a laboratory on the far shore, to care for the increased needs. In Colonel Muckenfuss' opinion, this could not be done in less than 90 days. The solution of the problem, however, seemed to be the procurement of blood from the Zone of Interior.
At another conference on 7 April 1944, a somewhat more optimistic spirit prevailed. It was hoped that a second letter to base section commanders from Headquarters, SOS, would inspire more donors to contribute. With an improved donor response, and with the period immediately after D-day provided
10Additional details of the 5 April 1944conference are discussed with the ETOUSA Blood Bank, in the section concernedwith planning for Operation OVERLORD.
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TABLE 17.-Use of blood by U.S.troops in Italy, 1 September 1943-25 February 19441
Unit and period of time | Casualties |
| Ratio |
Evacuation hospitals | 13,763 | 3,060 | 1:4.5 |
Field hospitals | 1,044 | 1,571 | 1.5:1 |
| 14,807 | 4,631 | 1:3.2 |
94th Evacuation Hospital: |
|
|
|
| 411 | 56 | 1:8 |
| 499 | 150 | 1:3.3 |
| 1,863 | 840 | 1:2.2 |
Anzio beachhead, 22 January-25 February: |
|
|
|
| 3,527 | 21,262 | 1:2.79 |
| 4,523 | 22,456 | 1:1.85 |
1Plasma usually used: 3.54 unitsplasma to 1 pint blood.
2Bottles of blood used.
NOTE.-The ratio is actually blood to total casualties. WhileI was there, they were sending 100 bottles of blood a day to Anzio. The amountused, especially early, does not represent the amount required or desired but inmany instances the amount available. Another fact that is significant is thathigh explosives accounted for 827 of the battle casualties admitted to any ofthe hospitals during the period September-January in this theater.-T. J. H.
Source: Official Diary, 152d Station Hospital Blood Bank, 1944-45.
for, it was thought that enough blood could be collecteddaily to satisfy the estimated demand until D+60. Then, additional teams anddonors would have to be added.
An extended discussion of equipment brought out anotherdifficulty: The normal 200-pints-per-day capacity of the blood bankcould be increased to 500 to 600 pints for a few days, but by the 10th day, atthe latest, the output would have to be reduced because the limited supply ofgiving sets could not be rotated fast enough.
Colonel Kimbrough was also concerned about the longevity ofwhole blood with the preservatives then in use. The average useful life was notmore than 10 days, and he had been informed that, even under optimum conditions,blood could not be delivered to the front in less than 10 days after it had beendrawn.
General Hawley, who was kept informed of these variousdevelopments, expressed himself as much concerned over them. In view of thelimited useful life of whole blood and the impossibility of its reaching thefront in less than that lifespan (10 days), he did not think the average usablelife of blood at the front could be more than 6 days, and it would besafer to estimate it as 5 days. From the practicalstandpoint, this meant that the blood bank must be able to replace the totaldemands at the front every 8 days. In spite of Colonel Kimbrough's opinionthat this could be done, General Hawley doubted it.
Table 18 contains the estimates prepared in response to arequest from the Planning Branch, Operations Division, Office of the ChiefSurgeon, on 6 April 1944 for "firm figures" for the blood requirementsfrom D-day to D+90 (39).
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TABLE 18.-Estimated demands for whole blood, 29 April 19441
Period of time | Casualties | Estimated demands | |
Total | Daily | ||
| Number | Pints | Pints |
D-day to D+3 | 16,879 | 3,376 | 844 |
D+4 to D+10 | 4,770 | 954 | 136 |
| 21,649 | 4,330 | 394 |
D+11 to D+20 | 9,907 | 1,981 | 198 |
D+21 to D+30 | 14,637 | 2,927 | 293 |
| 24,544 | 4,908 | 245 |
D+31 to D+45 | 20,895 | 4,179 | 279 |
D+46 to D+60 | 23,280 | 4,656 | 310 |
| 44,175 | 8,835 | 295 |
D+61 to D+75 | 20,513 | 4,103 | 273 |
D+76 to D+90 | 22,048 | 4,410 | 294 |
| 42,561 | 8,513 | 284 |
D-day to D+90 | 132,929 | 26,586 | 292.1 |
D+4 to D+90 | 116,050 | 23,210 | 266.7 |
1One pint of whole blood estimatedfor each five casualties.
On 12 April 1944, in a memorandum to General Hawley, ColonelCutler recommended that donors be paid $10 each, as had been done in Italy. Ifthis plan to increase donations were not adopted, he thought that supplementalsupplies of blood must be flown to the European theater from the Zone ofInterior.
D-DAY AND AFTER
Blood was sent from the United Kingdom to the Continent onD-day and during the first days of the invasion through the ETOUSA Blood Bankaccording to the plans prepared in January 1944. It was in reasonably adequatesupply, at least in the light of the standards of usage of blood which thenprevailed.
24 June 1944
On 24 June, the situation changed. Up to this time, inaccordance with the original planning (40), thebank had supplied 250 pints of blood a day to the First U.S. Army. As of thisdate, an additional 250 pints per day was
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"imperatively" requested for this Army. TheSupply Division had also been informed that a meeting of responsible medicalofficers would shortly be held on thefar shore to determine a new pattern of requests for whole blood. It was thoughtthat at least 500 pints per day would be requested.
Colonel Cutler was very much pleased with the earlyoperations of the blood bank. Late in June, he wrote in his official diary (23):
The tremendous demand for blood completely justifies theestablishment of the blood bank and from reports and observations it is clear wemust have saved life by the establishment of an E.T.O. blood bank. * * *Lieutenant Reardon of the blood bank is now on the far-shore. He has a largeNavy-type refrigerator buried in the ground and (8) trucks (each taking 80pints) are working well with the First Army delivering blood at this time.Almost all LST's and hospital carriers either gave up their blood to people onthe far-shore or used it up on casualties on the trip back. Little was actuallywasted. The major difficulty about blood has been the return of kits and setsand marmite jars.
On 17 September 1958, General Hawley annotated this entry inColonel Cutler's diary with the statement that each outbound LST (landingship, tank) carried twice the amount of blood estimated that it would need onits return trip (23). Theexcess was unloaded on the far beach.
2 July 1944
Although the Third U.S. Army was not to become operationaluntil 1 August, some medical units later assigned to itwere serving in France with the First U.S. Army, and on 2 July 1944, acommunication concerning planned needs for blood for this (the Third U.S.) Armywas sent from its headquarters to the Commanding General, ETOUSA, for GeneralHawley's attention. In this communication, it was statedthat the original allocations of blood were now considered inadequate foranticipated demands in forthcoming operations, especially in the light of theamounts presently being consumed by the First U.S. Army. These amounts were notconsidered excessive. The planned Third U.S. Army allocation was 150 pints dailyfrom D+29 to D+32, 200 pints dailyuntil D+39, and 350 pints daily until D+90. It was urgently requested that theseallotments be increased to 300, 400, and 550 pints daily, respectively,for the periods specified.
There was still no universal agreement, however, thatblood was needed in such quantities. On 2 July 1944, Colonel Cutler wroteColonel Kimbrough that from his observations on the far shore and his studiesof battle casualty rates, he thought that, ifblood were used carefully, it would not be needed in theseamounts for two reasons (41):
1. In November 1943,Colonel Churchill had estimated that 20 percent of battlecasualties would need resuscitation. In the Europeantheater, casualties in invasion troops through 25June had numbered 24,939, less than a thousand a day. Of every thousand casualties, not more than10percent, 100 men, would require blood. If each of them needed 2 pints, thatwould make the requirement 200 pints per day for each thousand casualties. Somepatients might need additional transfusions because of secondary hemorrhage
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or for other reasons, but an extra 200 pints of blood per dayshould be ample for this group. Thus, with a casualty list of 1,000 per day, 400pints daily should meet the requirements of the First U.S. Army.
2. Colonel Cutler had observed while on the far shore thatvery little plasma was being used, though, theoretically, a casualty's proteinrequirements could be met by it.
Colonel Cutler had discussed these matters with Col. JosephA. Crisler, Jr., MC, Consultant in Surgery, First U.S. Army, and had remindedhim that under conditions of unusual stress, blood could be secured from walkingwounded; special donor sets had been provided for this purpose.11
12 July 1944
On 12 July 1944, Colonel Kimbrough wrote General Hawley thatthe ETOUSA Blood Bank was supplying 500 pints of whole blood daily to theContinent and was utilizing its panel of donors to full capacity (42). It was also planning to secure donors from the AirForces, though the number from this source would not be large, since only groundtroops could be used. Reports from the Continent indicated that blood was beingused economically. The most optimistic estimates of the ultimate capacity of theETOUSA panel of donors was 700 pints of blood daily. With increased operationson the Continent, this amount would not meet the demand.
Colonel Kimbrough therefore recommended:
1. That plans be laid on to obtain whole blood fortransfusion from the Zone of Interior.
2. That facilities of the ETOUSA Blood Bank be used todistribute blood received from the Zone of Interior and delivered from thatpoint to the Armies. The bank already had a well-organized distribution system,and its utilization would avoid duplication of facilities.
24 July-1 August 1944
As the scarcity of blood became increasingly serious, asystem of allocations was set up:
1. After the breakthrough at Saint-L?, on 24 July 1944, daily allocations of available blood were made to medical units of the First U.S. Army.
2. This plan was continued until 1 August 1944. Then, until 25 August, when supplies from the Zone of Interior began to arrive, Colonel Mason conferred daily with Col. Alvin L. Gorby, MC, Surgeon, 12th Army Group, to be sure that the dwindling supplies of blood were delivered to the areas in which the largest numbers of casualties were anticipated.
In other words, by the end of July, the demand for blood had far outpaced the supply. Its increased use for combat casualties and the stepped-up
11Early in 1942, it had beenconcluded in the Zone of Interior that bleeding of walking wounded wascompletely unrealistic. It also was considered especially objectionable in viewof the large numbers of 4-F's in the United States who could act as donors.It proved impractical in combat zones in all theaters.
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operations on the Continent had combined to produce exactlythe shortages in the supply that the planners of the program had feared mightoccur and that many of them had thought could be avoided only if blood wereprocured from the Zone of Interior.
On 28 July 1944, Lt. Col. (later Col.) Robert M. Zollinger,MC, Surgical Consultant, ETOUSA, wrote the Surgeon, Forward Echelon,Headquarters, Communications Zone, concerning the amounts of blood necessary forcombat casualties (43). Recommendationshad been made in the "Manual of Therapy, European Theater ofOperations," as well as elsewhere, that blood be given in the ratio of onepart blood to two parts plasma. Current requirements, however, were more nearly1:1. After visiting field and evacuation hospitals, he was convinced that thislatter ratio might be correct, especially in field hospital platoons, near thefrontlines. Large amounts of blood were unquestionably needed. If therequirements sometimes seemed excessive, a partial explanation was the backlogof patients often awaiting operation. They had been prepared for operation byshock teams, but because of the press of more urgent casualties, their timelagwas lengthened, and it was often necessary to continue the administration ofblood and plasma or to repeat it. This contingency had probably not been takeninto consideration in pre-D-day estimates of the blood that would be needed.
On 31 July 1944, the day before the Third U.S. Army wascommitted, Colonel Kimbrough again notified General Hawley of shortages of bloodon the Continent (44). Currentdemands were for approximately 1,000 pints per day. The capacity of the SOSpanel of donors in the United Kingdom was now about 400 pints daily. Asupplemental panel from certain elements of the Air Forces contributed about 250pints daily. The daily deficit-morethan 300 pints-could not possibly be met by donations on the Continent, andthe demand for blood would increase as operations became intensified.
Colonel Kimbrough therefore recommended to General Hawleythat plans be made to obtain a thousand pints of whole blood daily from the Zoneof Interior by air transport.
IMPLEMENTATION OF THE WHOLE BLOOD PROPOSAL
July-August 1944
31 July.-General Hawley had notwaited for Colonel Kimbrough's second communication to take action. On 31 July1944, his executive officer requested the Personnel Division, Office of theChief Surgeon, to arrange air transportation to the Zone of Interior for ColonelCutler, Major Hardin, and Col. William F. MacFee, MC, Commanding Officer, 2dEvacuation Hospital, for stays of 10 days, 6 weeks, and 21 days respectively (45).The trip was essential, the request read, to initiateand implement a supply of a thousand pints of whole blooddaily from the United States to the United Kingdom.
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When the question was raised whether it was necessary for allthree officers to make the trip, General Hawley's reply was immediate andunequivocal (46). It was. Colonel Cutler, as Chief Surgical Consultant in thetheater, must be present at the formulation of the program. Colonel MacFee, anexperienced surgeon, was in command of an active evacuation hospital supportingthe First U.S. Army. He had been in France since D-day and could give TheSurgeon General a firsthand account of blood requirements on the Continent.Major Hardin was in charge of the blood bank, which had about reached the limitof its capacity; armies in the field were requesting more blood than couldpossibly be supplied by it. The matter could not be handled by phone orradiogram. Highly technical details had to be arranged, including adaptation ofthe transfusion set used in the Zone of Interior to use in the European theater.The matter was regarded as "of the greatest urgency" and "allthree officers" must be returned to the United States.
2 August-On 2 August 1944, aradiogram was sent through channels from General Hawley to The Surgeon General,U.S. Army, as follows (47):
Burden is being imposed that the ETO Blood Bank cannot meetin the demand for whole blood for the forces fighting in France. That blood isnecessary and is saving lives, all are convinced. It is believed necessary thatdaily air shipment of 1000 pints be sent. To coordinate this matter, returningto the United States are Colonel Cutler, Colonel William MacFee, and MajorHardin.
5 August.-On 5 August, General Hawley followed up thisradiogram with an explanatory letter to General Kirk (48). The economy ofthe use of blood, he wrote, had been thoroughly investigated. Blood was notbeing used extravagantly. The fact was inescapable that its use was hasteningrecovery and saving lives.
The capacity of the ETOUSA Blood Bank, General Hawleycontinued, was set at 300 pints daily, but from D-day to D+50, it had deliveredan average of 480 pints daily. Its capacity was being built up to 500 pintsdaily, but this would not be enough as troop strength increased.
The Air Transport Command was prepared to put on one or twoplanes daily, as necessary, to fly the blood from the United States. The TroopCarrier Command would deliver it by plane direct from Prestwick, Scotland, whereit would be landed, to the Continent, and it would thus be in France within 48hours after it had left the United States.
General Hawley hoped that a small amount of the bloodcollected for plasma could be diverted to the European theater as whole bloodwithout endangering the plasma program. No publicity need attend the diversion,though perhaps it might stimulate donations if the donors knew that the bloodthey gave might be in the veins of a soldier in France within 3 days after itwas collected.
When the question of supplying blood to Europe from the Zoneof Interior was first raised, as Colonel Cutler noted in his official diary (23),General Hawley was concerned about the length of time it would take to getthe blood to England. He thought that there would be a minimum of 72 hoursafter it
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was collected before it could leave the Zone of Interior. Thewhole project would be futile if the blood did not have sufficient life afterits arrival in the United Kingdom. There was an extended discussion of thispoint in a meeting of his consultants on 28 July 1944, but he was finallyconvinced, when the procedures to be employed in the Zone of Interior wereexplained to him, including an airlift to the United Kingdom, that the programwas feasible. "The Surgeon General," he said, "is definitelyopposed to it, but I am willing to put it up to him." At this time, he wasalready planning to send Colonel Cutler, Colonel MacFee, and Major Hardin to theUnited States to discuss the plan.
11 August-General Kirk repliedto General Hawley's letter of 5 August on 11 August 1944 (49).Immediately after receiving it the previous day, he had had a conference withMaj. Gen. George F. Lull, Brig. Gen. Raymond W. Bliss, and General Rankin.
All three of these officers believed that within 10 days itwould be possible to begin shipping 500 pints of blood daily to the Europeantheater. It would be sent in Alsever's solution, which would bring the volumeto 1 quart. The blood would be good for 30 days12 and would beshipped without refrigeration.13 The safety of this method had beentested by flying blood to Prestwick and to San Francisco without harm to it (p.209).
13 August-On 13 August, GeneralKirk sent General Hawley the following radiogram through channels (50):
Whole blood is subject. Thisoffice prepared to ship 258 pints daily for first week commencing 21 August.This amount will increase to 500 as blood becomes available. Shipments will bemade without refrigeration. Is sufficient refrigeration available in theater toaccommodate shipments? Estimated weight first shipment 1200 pounds and 387 cubicfeet. Request air priority and shipping instructions furnished this office.Request immediate reply.
COMMENT
The reversal of General Kirk's previous refusal to considerplans for shipping blood overseas followed his visit to the Mediterraneantheater the first week of July 1944. He was influenced, one may speculate, byhis observations there. When he visited the theater blood bank at the 15thMedical General Laboratory, he was given a brief statement of its organizationand activities: Between 23 February 1944, when the first shipment was made tothe Anzio beachhead, and 6 July 1944, a total of 16,574 units had been suppliedto the Fifth U.S. Army. This amount, the report stated, represented over 9 tonsof fresh human blood, the cells of which had been kept potent by carefulhandling and refrigeration. The report also included details of the selection
12This should be 21 days.
13Here and elsewhere, the term"without refrigeration" is somewhat misleading. It was only during theactual flight time that blood sent overseas to Europe was not underrefrigeration. It was placed under refrigeration as soon as it was drawn, waskept under refrigeration until it was placed on the plane, was placed in arefrigerator if the plane was on the ground for more than a brief period enroute, and was again placed under refrigeration as soon as it was taken off theplane. As a matter of fact, the temperature of the blood changed no more than6? F. during the period it was without refrigeration on the plane (p. 211).
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of donors, the processing of blood, and the reservation ofhigh-titer group O blood for O type casualties. The memorandum ended with thestatement that an abundant supply of whole blood had enabled surgeons in forwardhospitals to save the lives of desperately wounded soldiers by operationspreviously considered too dangerous to be undertaken.
The chronicle of the oversea blood program now moves to itsimplementation in the Zone of Interior.
Part IV. DefinitiveActions in the Zone of Interior for an Oversea Transfusion Service
REVIVAL OF PROPOSALFOR AIRLIFT OF BLOOD TO EUROPE
As reports from Europe began to indicate an increasing needfor whole blood for combat casualties, numerous discussions were held in theSurgery Division, Office of The Surgeon General, to initiate action inanticipation of the airlift which now seemed inevitable in spite of the earlierrejection of the plan by General Kirk.
On 3 August 1944,General Rankin sent a memorandum to The Surgeon General stressing the urgentneed for blood in the European theater and outlining two plans by which it mightbe procured from the Zone of Interior (51):
1. Whole blood could be secured from Red Cross donor centers.
2. Red blood cells could be provided from plasma processingcenters. The use of red blood cell suspensions for transfusion had been wellestablished, but there were certain practical difficulties in the way ofutilizing this source of blood for the immediate needs of the European theater.The chief difficulty concerned the bleeding bottle then in use.
Since it was quite certain that these difficulties could beovercome, it might ultimately be desirable to institute this second plan, whichwould provide red blood cell suspensions without interference with the bloodprogram now in operation. In view of the urgency of the situation, however, itseemed wisest to institute the first plan. It could be put into operation, anddelivery of blood could be begun, within 7 to 10 days after the airlift wasauthorized.
Only type O blood would be used. It would be obtained, aftertyping of donors, at the Washington and New York blood donor centers. The bloodwould be packed in cardboard containers and shipped in unrefrigerated planes tothe European theater. Blood prepared with available equipment by the procedureto be outlined could be safely used for as long as 30 days after it wascollected. It was thought that the combined output of the Washington and NewYork centers would provide an airlift of 500 pints of blood daily.
The plan proposed would be implemented as follows:
1. Personnel. Three technicians would be provided at eachbleeding center by the Blood Research Division, Army Medical School, and theNavy. They would perform the typing, grouping, and serologic tests. Five or sixuntrained workers would be provided at
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each center, either by the Red Cross or the Army, to cleanand prepare the collecting sets.
2. Equipment. This could consist of:
a. Bottles of 1,000-cc. capacity, each containing 500 cc. ofAlsever's solution. Each center would be provided with 500 bottles per day. At the present time, 3,500 bottles could beobtained. Another 5,000 could be obtained within a week, and thereafter thesupply would be unlimited.14
b. Donor bleeding sets. Each center would need an initialsupply of approximately 1,000 sets, which could be obtained immediately fromArmy depots. Since the sets could be cleaned and reused, the initial supplywould be adequate.
c. Typing sera and equipment for serologic testing. Adequatesupplies of both items would be furnished by the Blood Research Division, ArmyMedical School.
d. Shipping containers. The cardboard containers in which thebottles of blood left the Red Cross blood donor centers could be used forpacking the blood, six bottles to a container, and transporting it by plane. Thepackaging would be done at theblood donor centers. Refrigeration during the flight wasdesirable but in the emergency not considered absolutely essential (p. 209). Aneffort would be made to develop a suitable insulated container for shippingpurposes.
e. Equipment for administering the blood. Since this wasstandard equipment, it would be presumed that it would be available in theoversea theater.
3. Procedure. This would be as follows:
a. Each donor would be tentatively typed at the hemoglobinstations of the Red Cross blood donor centers.
b. As the donor entered the bleeding room, the typing wouldbe read.
c. Each type O donor would be bled into the specialprechilled bottles containing Alsever's solution. All other donors would bebled into the usual Red Cross collection bottles which contained citratesolution and were used in the procurement of blood for the plasma and albuminprograms.
d. Grouping would be confirmed from the clotted blood sent tothe laboratory of the donor center.
e. Bottles of confirmed type O blood would be placed incardboard containers and stored immediately in the refrigerator at the Red Crosscenter until a sufficient quantity had been accumulated for shipment. Additionalrefrigerators were available and could be supplied as needed.
f. A schedule would be developed with the Air TransportCommand for delivery of the blood from the centers to the planes by the RedCross Transport Service.
This plan, with minor modifications, was the same planproposed and rejected in December 1943 (p. 462). It was also, withmodifications, particularly the change to ACD solution and refrigeration inApril 1945, the plan by which blood was shipped to Europe during the rest of thewar.
At this time-the first week of August1944-the first definite request was received from theEuropean theater for shipments of whole blood, and the lines of development inthat theater and in the Zone of Interior began to merge.
PREPARATIONS FOR AIRLIFT
Activities were intensified in the Surgery Division, Officeof The Surgeon General, as soon as the request from ETOUSA was received and thedecision
14Bottles large enough to hold thenecessary amounts of Alsever's solution were not in production when therequest to fly blood to theEuropean theater was received in the Office of The Surgeon General. Themanufacturers, however, sensing the urgency of the situation, provided them in acrash operation typical of the part American industry played in the entireblood-plasma program.
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was made to ship blood to the Europeantheater. Supplies of various kinds had to be procured, and additional personnel were necessary for the collecting centers. Action was takenat a series of conferences.
10 August 1944
The conference held on 10 August 1944 (52), to which General Kirk hadreferred in his letter of 11 August to General Hawley, was attended by GeneralRankin; Colonel Carter; Captain Newhouser; Colonel Kendrick; Maj. Earl S.Taylor, MC, Technical Consultant, Volunteer Donor Service, American Red Cross;and Lt. (later Lt. Cdr.) Henry Blake, MC, USN, Assistant Technical Consultant; Maj. (laterLt.Col.) Oscar B. Griggs, MC, Supply Service, OTSG, and Lt. Col.John J. Pelosi, MC, Supply Service, OTSG; and Maj. (later Lt. Col.) Frederic N.Schwartz, MAC, Operations Officer, Blood Plasma Branch, Surgery Division, OTSG.
The business of this conference was to make the plans for theshipment of whole blood from the Zone of Interior to the European theater. Ingeneral, the plan used was the one outlined by General Rankin in his memorandumto The Surgeon General on 3 August 1944. As the plan was finally adopted, thedetails were as follows:
1. The American Red Cross Blood Donor Service would beresponsible for procuring blood in Washington, New York, or other centers whichmight be required to provide blood in the quantities needed by the overseatheaters. Initially, 180 to 390 bleedings would be obtained daily in New York,and 78 to 180 in Washington. If more blood was needed, other centers would bebrought into the program.
2. Equipment required for the airlift overseas would include:
a. Sterile, 1,000-cc. vacuum bottles each containing 500 cc.of Alsever's solution.
b. Sterile, expendable donor sets put up in aluminum tubes.
c. Sterile, expendable dispensing sets, similarly prepared.
d. Typing sera.
e. Supplies for the Kahn test, including a centrifuge.
f. Stencils for classifying and numbering bloods forshipment.
g. Packaging supplies, including brown paper, paper tape, andshipping tags.
3. Personnel for each donor center would consist of a medicalofficer qualified to operate a blood bank and three technicians, two for typingblood and one for shipping it. The personnel to operate the whole blood servicewould be provided by the Personnel Branch, Office of The Surgeon General.Personnel from the Army Medical School would establish the whole blood stationin New York and serve there temporarily. Colonel Kendrick, SpecialRepresentative on Blood and Plasma Transfusion, Office of The Surgeon General,would be responsible for the whole blood operation.
4. Blood would be transported from the donor center to theairport by the American Red Cross or under some other arrangement agreed upon bythe Army and the Red Cross. The blood would be refrigerated from collection toemplanement. The Red Cross was installing large refrigerators in the centersselected to supply the blood, so that this requirement could be met.
5. The request to the Army Transport Command for the shipmentof blood to the European theater must originate from that theater. (This requesthad been made on 1 August by General Hawley's office and had been granted atonce.)
6. The care, refrigeration, and transshipment of blood afterit arrived overseas was the responsibility of the European theater. The theaterhad been asked to notify the Office of
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The Surgeon General when refrigeration would be availablethere and when the initial shipment of blood could be received. The whole bloodprocurement station in New York would be ready to begin shipments on 21 August1944.
7. The European theater was also requested to ask that amedical officer accompany a shipment of blood from the collecting center in theZone of Interior to the installation in the European theater in which the bloodwas to be used, in order to investigate all the problems concerned with theshipping of whole blood overseas and also to study the operation of blood banksin the European theater. (Colonel Kendrick was given this assignment (p. 495).
The request for blood from the European theater had been for1,000 pints per day. It was agreed that every effort would be made to supplythis quantity, but it was recognized that it might not be feasible at first tosend more than 750 pints daily, because of the limited capacities of bleedingcenters on the east coast. If the quota could not be met, perhaps the deficitcould be made up with resuspended red cells (p. 490).
It was agreed at this meeting that, beginning on 21 August1944, 250 pints of blood would be shipped daily for aweek. No definite commitments were made for the next week, but it was hoped thatthe quantity could be stepped up to 500 pints daily on 28 August, to 750 pintson 4 September, and to 1,000 pints daily after 11September.
At the conclusion of this conference, The Surgeon Generalstated that if operating surgeons in the European theater desired whole blood,they should certainly have it, and every effort would be made to provide whatthey had requested.
15 August 1944
Another conference held on 15 August 1944 in the SurgeryDivision, Office of The Surgeon General (53), was attended by GeneralRankin, Colonel Carter, Colonel Kendrick, Major Schwartz, and others from thisoffice and from the American Red Cross concerned with supply and procurement.The meeting was also attended by Colonel Cutler, Colonel MacFee, and MajorHardin, who had just arrived in the United States. Since consent to the shipmentof blood to the European theater had already been secured from The SurgeonGeneral when these officers arrived, the discussion chiefly concerned thedetails of the arrangements for shipping blood. Colonel Cutler was particularlyconcerned with two points, (1) the lack of refrigeration on the transatlanticflight; and (2) the use of Alsever's solution. This was no time, he said, toexperiment on the American soldier.
The discussion on refrigeration at this meeting is includedunder the general heading of refrigeration (p. 209). The discussion on the useof Alsever's solution as a preservative, to which Colonel Cutler also tookexception, is similarly discussed under the heading of preservatives (p. 229).
At this conference, Colonel Cutler was told that, somewhatlater, the European theater would be supplied with resuspended red blood cellsfrom type O blood. They were available in abundance, as a byproduct of theplasma program, and it was thoughtthat they could be used to advantage. They would be put up in 600-cc. Baxterbottles and would be flown to Prestwick,
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being treated en route and after receipt exactly as wholeblood was treated. It was planned to send the first shipment with Major Hardinon his return to Europe, so that he could distribute the material to hospitalswhose personnel were suitably trained in the use of blood in this form. Severaltrial runs would be necessary before regular shipments were begun.15
It was agreed at this meeting that the Army would establishthree or four collecting centers for the procurement of blood for the Europeantheater, beginning with the American Red Cross blood donor centers in Boston,New York, and Washington. Lieutenant Blake thought as much as 750 pints dailycould be obtained from these three centers. To increase the amount to 1,000pints per day, it would be necessary to establish anothercollecting center in one of the Red Cross donor centers in the Midwest. It wouldbe impossible to meet the commitments for whole blood, plasma, and albumin fromthe quotas presently available on the east coast.
The blood sent to the European theater would be testedserologically and grouped. Every effort would be made to send only group O blood, but retesting before using was advisable. Since this would entailentering the bottle and drawing out a small sample, it was suggested that thetests be made within 3 hours of the time the blood was to be used, to reduce thepossibility of contamination.
FIRST SHIPMENTS
These various plans were carried out,and substantially as contemplated. The first shipmentof blood, 258 bottles, was flown from the Zone of Interior to Prestwick (map 2),on 21 August. It was transshipped byrefrigerated truck to Salisbury, the base of the EuropeanTheater Blood Bank; and thence was flown to France, whereit arrived on 27 August 1944. The shipment from the Zone of Interior on 24August consisted of 180 bottles, and the shipment on 25 August, of 336 bottles.
Refrigeration facilities at Prestwick could care for 222 cartons of blood, each containing 6 bottles. The plan wasto keep the blood there under refrigeration at least 4hours and to use it for periods up to 10 days.
When Colonel Cutler arrived from the United States atPrestwick on 25 August, 350 pints of blood in Alsever's solution were on theplane with him, and the blood was still cool at the end of the flight (23). Givingsets, however, were not included.
The following day, Col. S. B. Hays, MC, Chief,Supply Division, Office of the Chief Surgeon, sent aradiogram to PEMBARK (port of embarkation) New York, stating that the firstshipments of whole blood had arrived in good condition but that they had notincluded recipient sets (filter, tubing, needle), as
15In spite of the abundance of redblood cells as a byproduct of the plasma program and the proved usefulness ofblood in this form (p. 312), this plan proved impractical. The cells could not beused safely for more than 5 days, which was an insufficient time to deliver themto using hospitals in the European theater. Thalhimer's method of using cornsyrup as the diluent was developed too late to be useful, which is unfortunate,for it extended the longevity of packed red blood cells to 18 days.
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MAP 2.-Flight plan of airlift ofblood to Prestwick, Scotland, and thence to the European Continent.
the plans had called for. The Surgeon General, on 31 August,replied that recipient sets were not presently available for the shipments butthat they would be received within the next few days, as they were.
On 26 August, PEMBARK notified Supreme Headquarters, AlliedExpeditionary Force, that air priority had been set up, effective on 1September, for the daily shipment of whole blood to Europe in the amount of2,250 pounds (class 1, medical).
On 28 August, according to orders requested on 20 August,Colonel Kendrick left the Zone of Interior with a largeshipment of blood. The justification for the requestedorders had been that it was simply not possible to put a system, however good itmight be, on paper and expect it to work of itself. When the substance to betransported was as valuable as blood, it was essential to follow itup, make sure that it was properly handled at every pointalong the way, and also see that it wasproperly used. The account of Colonel Kendrick's trip appearsunder appropriate headings elsewhere.
On 24 September 1944, the ContinentalSection, ETOUSA Blood Bank, 152d Station Hospital, assumed the responsibilityfor the distribution of all blood on the Continent and continued to exercisethis function until the end of the war (p. 515).
Shortly after the Continental Section had assumed thisresponsibility, steps were taken to have the blood flowndirectly from the United States to the
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Continent. Difficulties in storage and shipping facilitiesdelayed the operation of the plan, and it was not until 15October that the Air Transport Command began to fly blood directly to OrlyField, Paris.
Part V. The European Theater Blood Bank16
Section I. Establishment
PRELIMINARY PLANNING
After the Chief Surgeon, ETOUSA, General Hawley, directed, inJuly 1943, that plans be made to supply blood to forward hospitals in the combatzone, the task of implementing his instructions was assigned to the OperationsDivision of hisoffice, of which Colonel Mason was chief. Colonel Mason servedas chairman of the Whole Blood Service Committee, whichalso included Colonel Kimbrough, Colonel Cutler, Colonel Middleton, Col. WalterL. Perry, MC, Chief, Finance and Supply Division, and Captain Hardin, liaisonofficer with the British blood depot and later senior consultant in shock andtransfusion.
This committee was promptly convened after receipt of GeneralHawley's instructions. After several preliminary conferences it requested, andreceived from him, approval of the following decisions, which were essential forfuture planning:
1. Whole blood, except in emergencies, would be reserved formedical units in the combat zone.
2. Whole blood would be made available as far forward in thecombat zone as platoons of field hospitals attached to clearing stations ofdivisions.
3. The blood would be obtained from volunteer donors fromServices of Supply units, who would be organized into a theater blood panel.
4. The blood used would be type O only. It would be preserved by the glucose-citrate solutiondevised by the Medical Research Council of Great Britain, would be kept underconstant refrigeration, and would have an expiration period of 21 days from thedate of collecting.
5. Whole blood would have the highest priority in transportation. This priority had been obtained from the Commanding General, Services of Supply, and had been confirmed by the theater commander.
6. The blood service would be operated by a theater unit, with subelements to be attached, as required, to major commands for operations.
ORGANIZATION AND FUNCTION
On 19 August 1943, after the decisionsjust listed had been approved by General Hawley, detailedplanning for the blood bank began, with agreement
16Unless otherwise indicated, thematerial in this section is derived from the official histories of the 152dStation Hospital Blood Bank (54, 55); theofficial history of the 127th Station Hospital Blood Bank (56); Major Hardin's annual report on transfusion andshock to the Chief Consultant in Surgery, ETOUSA, dated January 1944 (57); and the published reports by Colonel Mason, on theplanning and operation of the European Theater Blood Bank (58,59).
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CHART 9.-Operations chart,Whole Blood Service, ETOUSA, Operations Division, Office of Chief Surgeon, 1943
first of all upon an operations chart (chart 9). Thefunctions of the whole blood service were to be the procurement, processing,storage, and issue of whole blood. The organization responsible for thesefunctions had to be tailored to fit the militaryrequirements. The operations chart reflected this necessity by providing (1) afixed depot for processing and storage of the blood and (2) advance mobiledepots for its temporary storage and delivery.
Representatives of the Professional Services Division andtheir assistants developed the clinical policies for theuse of blood. Captain Hardin, Colonel Muckenfuss, Commanding Officer, 1stMedical Laboratory, and their associates developed the technical procedures forthe operation of the blood bank and for the training ofbank personnel. They also prepared the lists of special equipment required.Colonel Perry and his associates worked with Colonel Mason in thedevelopment of the PROCO (projectsfor continental operations) mechanism by which equipment, vehicles, and othersupplies were secured for these new and unusualoperations, which were over and beyond T/E (table of equipment)provisions. The T/O (table of organization) for the newunit, the tactical operating procedure, and relatedinstructions were prepared in the Operations Division,Office of the Chief Surgeon, ETOUSA. Colonel Mason, as chairman of the ad hoc committee, had theresponsibility for coordination of
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the various phases of the plan, its consolidation into asingle whole, and supervision of its initial implementation.
Organization of Proposed Unit
Since there was no unit in the Medical Department tables oforganization which could meet, or be revised to meet, the needs of the proposedwhole blood service, an entirely new organization was planned,17 asfollows:
1. Headquarters.
2. Base depotsection, which included personnel and equipment for bleeding teams.
3. Advance depots, Army type (two).
4. Advance depots, SOS type (two).The 11 officersand 143 enlisted men in this organization would beattached for rations to nearbyorganizations, thus effecting a considerable saving in mess and housekeeping personnel and equipment.
The organization postulated was considered capable ofoperating a whole blood service for a theater force of two field armies, thecommunications zone, and the Air Forces on the Continent. Later, when a thirdfield army would become operational in the 12th Army Group, additional personnelwould be required for the base depot, and additional advance depots of both theArmy and SOS type would also be required.
Section II. 152d Station Hospital Blood Bank, United Kingdom Section
CONVERSION OF 152D STATION HOSPITAL TO BLOOD BANK PURPOSES
When the request for additional personnel to form theorganization just described was denied in the War Department, General Hawleyacted with characteristic vigor to compensate for the adverse decision. Hedirected an assessment of all the 250-bed station hospitals then in the UnitedKingdom, and, as soon as the report was received, he requested, and obtained,the permission of the theater commander to utilize the 152d Station Hospital,then at Bath, England, as the ETOUSA Blood Bank.
Construction
Planning for the necessary construction for the blood bank atthe 152d Station Hospital was begun late in October 1943. On 12 November, anofficial request was sent from the Hospitalization Division, Office of the Chief
17Provision is now made in T/O & E 8-500 for bloodbank detachments, which were added in 1950. This provision goes far, though notall the way, to insure that, if blood banks are again needed by the ArmedForces, there will be an adequate allocation of enlisted grades and ratings.
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Surgeon, ETOUSA, to the Operations Division, for alterations andconstruction work on a general medical laboratory at Salisbury, in order toestablish a blood bank in the United Kingdom to collect, process, and storeblood. The facilities were requested as promptly as possible.
The work was carried out by Engineer personnel of the Southern Base Section,ETOUSA, and, by 1 April 1944, the building was completed and all equipment wasin place.
Transfer of Location
On 22 January 1944, the 152d Station Hospital was transferred from itsoriginal location at Bath to Salisbury, to the site of the 1st MedicalLaboratory, commanded by Colonel Muckenfuss (fig. 111), who also becamecommanding officer of the 152d Station Hospital. Major Hardin, who was assignedto duty with the 298th General Hospital, and had been detached to the 1stMedical Laboratory for the purpose of organizing the ETOUSA Blood Bank, wastransferred to the 152d Station Hospital, where he assumed the duties ofexecutive officer of the blood bank section. Unit administration of both thelaboratory and the station hospital was carried out jointly in ColonelMuckenfuss' office.
PERSONNEL
Original Personnel
The use of the 152d Station Hospital for a blood bank solved what atfirst seemed an insoluble problem, but it was not an ideal solution. There weredecided drawbacks to the use of a station hospital for such a highly technicalunit. Multiple transfers from other sources were necessary to provide personnelqualified in laboratory and blood bank operations; there was a qualitative and aquantitative paucity of such specialists among both officers and enlisted men onT/O for the hospital. The limitations of the T/O also made the technical ratingsof both noncommissioned officers and enlisted men particularly inadequate. Thiswas unfortunate, for it meant that many who were highly qualified were deniedthe promotions which they richly deserved.
One type of technician extremely difficult to secure was the refrigeratormechanic, who is an essential person in the operation of a blood bank. Enough ofthem were eventually found, by combing the theater, and it is a tribute to theircapabilities and their devoted work that not a single major refrigeratingbreakdown occurred during the entire period of operation of the ETOUSA BloodBank. This was a truly remarkable record.
By the first week of February 1944, the personnel of the 152d StationHospital had been reconstituted to meet the needs of the blood bank. All of themedical officers, with one exception, and all of the nurses, with one
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exception, had been transferred out of the unit and replaced withspecialists, and enlisted men had been similarly transferred and replaced.
On 25 March 1944, a special emergency treatment group,consisting of 19 officers, 23 nurses, and 151 enlisted men were transferred intothe unit.18 This group was subdivided into two other groups, thelarger of which was trained to function as blood bank personnel and the smallerof which operated a 50-bed hospital for research purposes.
Training
Training for the blood bank operation began at Salisbury thefirst week in February. It was carried out partly by didactic lectures, partlyby demonstrations, but chiefly by the repeated performance, under supervision,of individual duties by the personnel whose responsibility they were.
In all, up to D-day, 24 surgical technicians were trained tobleed donors, and 16 enlisted men were trained to clean, assemble, and sterilizeequipment used to collect and administer blood. In addition, 60 truck driverswere trained to transport refrigerated blood.
Colonel Mason's suggestion to General Hawley that CaptainHardin be sent to the Mediterranean theater, to study operations of the bloodbank at the 15th Medical General Laboratory in Naples, was unfortunately notimplemented.
Proposed Augmentation of Personnel
On 17 April 1944, Major Hardin informed the OperationsDivision, Office of the Chief Surgeon, that the present personnel, in hisjudgment, could operate the blood bank through D+60. Additional personnel wouldbe needed for the next 30 days, to meet the estimated daily requirement of 300pints of blood. After D+90, still further augmentation would be required, sincea depot would be established in the forward communications zone and increaseddemands for blood were anticipated. To furnish the additional manpower neededafter D+60, training of additional personnel should begin by D+30.
If a base depot in the communications zone were to operateindependently, additional personnel would be required for serologic testing,blood typing, mess management, and unit administration and supply. All of thesefunctions were now handled by the 1st Medical Laboratory. Major Hardin believedthat 61 additional enlisted men would be necessary, in addition to 2 MedicalCorps officers, company grade, and 1 Sanitary Corps or Medical AdministrativeCorps officer. The later designation of the 127th Station Hospital as a secondblood bank (p. 513) solved this problem.
18The medical officers and nurses in this group had been members of the Harvard-American Red Cross Hospital which was stationed in Salisbury before the United States entered the war. They joined the U.S. Army in Salisbury. When the 152d Station Hospital came to Salisbury, the two units were amalgamated under the designation of "special treatment group." Later, most of this group was transferred back to the 152d Station Hospital. These transfers were really only paper manipulations, but a great deal of time and effort went into them.
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Difficulties of Retaining Trained Personnel
Throughout the war, it was a constant struggle to keep thetrained personnel of the various sections of the blood bank from being givenother assignments. On 3 April 1944, for instance, Major Hardin felt obliged topoint out that all personnel serving as drivers should be kept with the basedepot blood section. If they were placed with advance blood depots, he fearedthat the ground replacement group might ask for them.
In December 1944, when replacements for ground troops weresorely needed in the field armies, the question arose of transferring trainedmen in the blood bank to such duties. Colonel Cutler pointed out that it wouldjeopardize the supply of safe whole blood if these personnel were removed.
In April 1944, Col. David E. Liston, MC, had suggested thatif additional personnel were needed to operate the blood bank, nurses of the152d Station Hospital could be trained for this purpose. The matter did not comeup again until 1 January 1945. Then, in a memorandum for the record, argumentsfor and against the use of nurses in a blood bank were outlined as follows:
Commanders of hospital blood banks considered nurses muchbetter than enlisted men for their purposes. Several months ago, when the tablesof organization of the general hospitals had reduced the number of nursesallotted to them, consideration was given to withdrawing nurses from thehospital blood banks, but it was decided not to; their value in the blood bankswas considered greater than their value in hospitals, however much they might beneeded in them.
At this time, however (January 1945), 19 general hospitalswere being shipped to the theater without their full complement of nurses. Inview of the critical situation in these hospitals, it now seemed that the needfor nurses in blood banks must be subordinated to present necessities. Aftermuch discussion, the nurses assigned to blood banks were retained in them.
On 15 January 1945, General Cutler suggested to Major Hardinthat WAC (Women's Auxiliary Corps) personnel might be used in place of nurses.If so, his idea was that enlisted men be moved in to replace nurses and thatthey then be relieved with WAC personnel. This plan was never adopted.
OPERATIONAL STRUCTURE
Base Bank
The 152d Station Hospital blood bank was divided intofour sections, and the personnel assigned to them were trained forspecific, specialized duties in the base and in advance banks. These sectionswere:
1. A record section, which maintained recordsof prospective donors as submitted on monthly reports sent in by SOS units,arranged bleeding schedules, maintained records of bleedings, correlatedlaboratory reports, and reported positive serologic tests and errors in typingon identification tags to the unit commanders concerned.
2. A collecting section, which was composed offour mobile bleeding teams, each made up of seven enlisted men and one medicalofficer. The enlisted men included a driver, a
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clerk, an orderly, and four surgicaltechnicians. They were supplied with appropriate equipment and were dispatchedfrom the base bank to camps at which donors were bled according to prearrangedschedules. Each team could bleed an average of 20 men in an hour. All donorswere unpaid volunteers, and only type O blood was collected.
The blood was collected by a closed system insterile 600-cc. bottles containing 100 cc. of 3.2-percent sodium citrate U.S.P.(figs. 112 and 113). At the end of the bleeding, a sample of blood for typingand serologic testing was collected from the tubing of the donor set into asterile Wassermann tube. The collecting bottle and the tube were immediatelyplaced under refrigeration. At the end of each day, all blood drawn was taken tothe base bank by truck or plane (fig. 114).
3. A manufacturing and processing section,which had two functions. One was the cleaning, assembling, and sterilizing ofall equipment (fig. 115). For each pint of blood
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collected, there was needed a collectingbottle, a donor set, and a recipient set. The second function was processing ofthe blood, which consisted of two operations:
a. Typing and serologic testing, which was carried out by the 1st Medical Laboratory. Blood showing positive or doubtful Kahn tests was discarded, and the individual's name and Army serial number were reported to his unit commander by the records section.
Off types of blood (that is, blood other than group O) were labeled according to type (fig. 116) and the notation Must Be Crossmatched Before Use was affixed to the bottle. These bloods were issued to fixed hospitals, but only after personal conferences with the medical officers who would be responsible for their use.
b. The addition of a preservative (fig. 117). Enough dextrose in 5.4-percent solution was added to the blood to fill the bottle completely. The amount required ranged from 40 to 50 cc. and averaged 45 cc.19
4. A storage and shipping section, which wasresponsible for the refrigeration of the blood while it remained in the bloodbank; its packing for shipment; and its delivery by
19Dextrose was not added to the blood collected in the Zone of Interior blood program. The necessity for opening and recapping the bottle to add it made a break in the closed system of handling. This procedure had been tested by the British before it was adopted at the 152d Station Hospital blood bank. Although it was carried out under a bacteriologic hood, with strict operating room asepsis, it was a potentially hazardous procedure. So far as is known, however, no instance of contamination resulted from it.
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refrigerated truck to ports, airfields, or hospitals in theUnited Kingdom. The blood was stored and transported at temperatures rangingfrom 35.6? to 42.8? F. (2? to 6? C.). When it was moved by air, it waspacked in Quartermaster food containers (marmite cans), one pan of which wasfilled with ice (fig. 118). This improvisation maintained a temperature of 37?F. (3? C.) for between 37 and 72 hours, depending upon the outside temperature.
Record System
The following system of records was used in the blood bank:
1. A perforated, doubly numbered label on the collectingbottle had space for the name of the donor, the date, and the number of thecollecting team. The team clerk printed the donor's name on the label, usinghis identification disk and a printing machine. This was the field record.
2. The perforated lower portion of this label, marked with thesame number as the upper portion, was torn off and used as a label for theWassermann tube.
3. The field record turned in by the bleeding team wascompleted by entry on the label of the blood type and the serology when thesetests had been completed in the laboratory.
4. A ledger kept in the blood bank indicated the finaldisposition of each bottle of blood; that is, when it left the laboratory orwhether it was discarded for positive serology or for other reasons.
5. Another ledger was used to record the date each unit ofblood was received, the total amount received, the amount discarded, the amountshipped, with the date, and the daily balance.
6. Advance depots were required to keep the same kind ofledger.
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Advance Banks
The advance banks or depots of the 152d Station Hospitalblood bank had the sole responsibility for the handling and delivery of blood.They were of two types, SOS banks and Army banks (chart 9), and each typeoperated with two detachments. The detachments of the SOS and Army blood bankswere made up of personnel specially trained in the storage and delivery ofblood. They operated independently, but were attached to the nearestorganization for rations.
1. The communications zone or SOS advance bank operatedbehind each army, on or near airfields in the advanced section of thecommunications zone.
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FIGURE 116.-Labeling of filled bottles ofblood, European Theater Blood Bank, April 1944.
The personnel received shipments of blood from the base bankand delivered it to army banks and to hospitals in the communications zone. Itspersonnel consisted of an officer and 16 enlisted men, one of whom was arefrigeration mechanic.
The equipment consisted of one ?-ton truck; two motorcycles,solo; and four 2?-ton 6 by 6 cargo trucks with refrigerators (each with abuilt-in, motor-driven gasoline refrigerating unit). The 6 by 6 trucks weredivided as follows:
Two trucks with 60- to 80-pint capacity, used for delivery ofblood.
One truck with 500-pint capacity for bulk delivery of bloodto Army depots.
One truck with 1,000-pint capacity, for storage.
2. Army type banks were attached to medical depots of thearmy they served. They delivered blood to all field and evacuation hospitals ofthat army, moving, as necessary, when the army moved. These banks were alwayslocated far forward in the territory of the command or in the field army servicearea, depending upon the location of the airstrips by which they were supplied.If the airfield was immediately behind the army rear boundary, the Army couldpick up its own blood. Otherwise, its blood supply was secured from the depot inthe communications zone.
One of the most practical modifications of the original planfor the delivery of blood to hospitals of the field armies was the dailyreversal of the routes.
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508
PROGRESS REPORT
On 15 April 1944, Major Hardin made the following report tothe Senior Consultant in Surgery, Office of the Chief Surgeon, on the currentstatus of the blood bank:
1. The physical plant was complete.
2. All officer personnel were present exceptfor the officer to be in charge of the laboratory, who would report within theweek. Enlisted personnel were sufficient for the present operation; 129 werepermanently assigned, and 12 others were attached.
3. Training of all personnel had reached alevel at which full operation of the bank was possible.
4. Supplies were complete except for a fewcritical items, which were essential for the operation of the bank. Theseincluded 2,300 long piercing needles; 2,000 short piercing needles; 24refrigerators ABSD (Army Blood Supply Depot-British) type C; and 22 2?-ton 6 by6 trucks. Measures were being taken through channels to expedite the delivery ofthese items.
5. Shortages in some critical items procuredfrom British sources might make it necessary to make some changes in the givingapparatus. The amounts and times of delivery had not been met on these items inthe past, and there was every reason to fear that if requirements for blood weredoubled, as now seemed likely, there would be further difficulties withprocurement. Experiments with new types of giving apparatus had therefore beencarried out, and satisfactory substitutes for the British items had been found.
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6. Amounts of blood necessary to meet thenewly calculated demands (on the 1:1.5 basis, (p. 482) were being computed, andexpansion of personnel for this reason, as well as for later operations, wasbeing considered. Expansion of the bank operations to meet the demands for bloodto D+90 would present no particularly difficult problem,20but expansion for demands likely after that time would require doubling thepresent personnel. It would also require duplication of the present equipment,and provision of additional heavy equipment such as generators, centrifuges, andautoclaves.
Shortly after this report, the blood bank had an unusualopportunity to test its capacities before D-day: During the course of OperationTIGER (a practice loading and sailing project), three fully loaded LST's wereattacked and sunk off Portland, Dorset, by German E-boats. The numerouscasualties were hospitalized in adjacent U.S. Army hospitals, and the bank wascalled upon to supply the large amounts of blood needed. It functioned well, butin Major Hardin's opinion it should have functioned better.
FURTHER PLANNING FOR OPERATION OVERLORD
A conference on the blood program in the European theaterwas held on 5 April 1944, at the 1st Medical Laboratory (p. 481) (60). Itwas attended by Colonel Muckenfuss, who acted as chairman, and Major Hardin,from the 1st Medical Laboratory; Colonel Kimbrough and Colonel Zollinger; Col.Keith W. Woodhouse, MC, from the Southern Base Section; Colonel Mason, from theAdvance Base Section; Colonel Crisler; Lt. Col. Nathan Weil, Jr., MC, Consultantin Medicine, Third U.S. Army; and Lt. Col. George S. Richardson, MC, Ninth AirForce, Air Transport Command.
The following points were brought out:
1. The physical facilities of the blood bankwere well planned, and blood was already being obtained. It was expected thatthe bank would function smoothly when mass production began.
2. If, as seemed likely, daily requirements ofblood would amount to 500 to 700 pints instead of the 400 pints then estimated,it would be necessary to add two more bleeding teams and increase the personnelby 33 percent. Two additional 2?-ton trucks would also be necessary. It wasbelieved that if the facilities of the bank were thus augmented, its productioncould meet the need for whole blood for Operation OVERLORD.
3. There was considerable discussion about themarking of the large refrigerators, trucks, and marmite cans to be used in theblood operation. The cans were labeled "ETOUSA Blood Bank," but unlessit was also indicated that they were the property of the Medical Department,they might be converted to other purposes by the units to which they weredelivered. If they were lost, they could easily be traced if they were properlymarked (as they were). Special arrangements would be necessary to hold the cansfirmly in place during transportation.
4. Advance blood depots on the far shore wouldbe utilized to store blood to be provided by the LST's to be used inoperations on the far shore in the early stages of the invasion.
5. The First U.S. Army would determine thephase at which the refrigerator for its advance blood bank could be takenashore. Meantime, blood would be delivered in marmite cans, by means of thedaily Red Ball Freight.21Medical officers of this Army thought that
20It was to present a major problem (p. 484).
21Blood was seldom delivered by this means. The idea did not prove practical because the Red Ball Freight was not under medical control.
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the need for blood would be great enough forit to use all that became available, without wastage, within the specified timelimits. It would be responsible for collecting and distributing its own blood.
6. It was pointed out that in the early stageson the far shore, trucks could probably not be used to transport blood becausetheir motors would be water sealed. Marmite cans therefore seemed the onlypractical way of conveying the blood ashore. It was suggested, however, that allmedical units be assigned given amounts of blood and that they carry it ashoreas part of their equipment. Other units could be similarly helpful; the engineercompanies, for instance, could carry three cans each, and field hospitals couldbring in their own blood. It would be necessary to know the exact phasing ofthese medical units, so that the blood bank could be kept aware of time, place,and amount of blood needed. These suggestions were not implemented.
The recommendations by this conference on the assignment ofadvance blood banks are more conveniently discussed elsewhere (p. 518).
MAJOR ELEMENTS OF THE FINAL PLAN
The procedure planned for the blood bank for the invasion andthereafter was as follows (31):
1. Blood would be collected from the donor panel by bleedingteams from the United Kingdom bank and would be returned to the bank inrefrigerated trucks.
2. It would be processed at the depot and stored untilrequisitioned for delivery.
3. Every day, the blood required on the Continent would betransported under refrigeration, by air, to the advance blood depots in ADSEC(Advance Section, Communications Zone), where it would again be stored underrefrigeration.
4. The amount of blood delivered would be determined by dailyforecasts of requirements by the commanding officers of the advance Army bloodbank detachments. The forecasts, which would cover the succeeding 4 days, wouldbe given to the ADSEC bank, which would consolidate the requirements beforedelivering them to the Supply Division, Office of the Chief Surgeon, fortransmission to the base bank.
5. The bulk delivery truck of the advance blood depot wouldtransport the blood to the advance depot in the Army area which it wassupporting.
6. From the depot, trucks would operate a milk route deliveryto the evacuation and field hospitals in the particular Army area. In practice,each vehicle would be assigned a certain number of these hospitals to service.
7. The blood depot in ADSEC, in addition to serving mobilehospitals of the Advance Section, would also be expected to respond to callsfrom the Army Surgeon to deliver blood to Army hospitals as special needs arosein them. (This frequently happened after D-day, and the successfulaccomplishment of this particular mission was another illustration of theworkability and flexibility of the planned blood program.)
8. The same system of collection and delivery would befollowed when the blood bank moved to the Continent. (This system was employedwhen blood
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began to be flown from the United States directly to the bankin Paris and delivery of blood to forward areas was initiated from that point.)
It was anticipated, and events proved the expectationcorrect, that the central control of the blood which had been planned would havea number of operational advantages and would also effect economies in itsdistribution and use. At no time was blood left in forward hospitals in excessof the 4-day period for which forecasts had been received. Also, after the bloodbank moved to Paris, all blood within 3 days of the expiration date was pickedup and returned to the bank (61).
Supply of blood for LST's-In the initial discussionsof blood to be supplied by the blood bank for use by the Navy on LST's onD-day, 10 pints had been requested for each boat. These estimates, however, werenot made official until 27 April 1944 (40). Then 2,000 pints wererequested, to be be placed aboard the hundred LST's which would be used forthe invasion. It was mentioned in this communication (from the Commander of U.S.Naval Forces in Europe to the Chief Surgeon, SOS, ETOUSA) that representativesof the Chief Surgeon's office had agreed that a stock of 1,000 pints of bloodwould be maintained at loading points to replace the blood used on shipboard.
It was requested that delivery of the initial stock of 2,000pints of blood be made by refrigerated trucks to landing points of the LST'sshortly before departure time. The amounts required for specific ships atspecific loading points would be indicated in future correspondence after thesematters had been worked out. The crossing would take 24 hours or less.
These arrangements were duly concluded. It was furtherarranged that the loading of the initial supply of blood would be theresponsibility of the ETOUSA Blood Bank, beginning on D-5. Maintenance of supplywould be from the hards, where the exchange of blood for empty bottles, usedequipment, and outdated blood would take place. It had been proposed that acourier accompany the blood, but this request had been refused. It was hopedthat the request would still be granted (it never was), as this was the best wayto insure the return of empty bottles and used sets.
Standing Operating Procedure No. 21
On 21 March 1944, Colonel Muckenfuss, Commanding Officer, 1stMedical Laboratory, to which the European Theater Blood Bank was attached, wasinstructed to prepare for the Plans and Operations Division, Office of the ChiefSurgeon, an SOP (standing operating procedure) covering in detail the proposedoperating procedure for the whole blood service in the European theater (62).On 27 March, Colonel Muckenfuss was informed that it would not be necessaryto publish the entire SOP for the blood service in the general SOP for thetheater but only that portion of the operation contingent on the services of, orassistance required from, any other organization.
The SOP was duly prepared and was forwarded on 14 April 1944 (63).The description in it covered the collection of blood in the United Kingdom,its
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delivery to the medical section of G-45, its packaging, itsloading on planes, and its receipt on the far shore. This SOP also defined theresponsibilities for the various commands and agencies for the air shipment ofcritical medical supplies.
THE INVASION
On 23 May 1944, the blood bank at the 152d Station Hospital wentinto full operation, using for this stage of the invasion mission the advanceblood depots planned for use on the Continent. The operation was conducted intwo phases.
Phase I
Detachment A, as planned, was attached to the 1st MedicalDepot Company of the First U.S. Army for movement to the Continent. DetachmentsB, C, and D were moved to port areas, together with a temporary detachment ofbase bank personnel, equipped with refrigerator trucks from the regular advancebank.
Loading of the LST's began on 1 June and was completed on 3June. In all, 109 craft were loaded, in seven ports, with 10 pints of bloodeach. In addition, three hospital carriers, at widely separated ports inEngland, Scotland, and Wales, were each supplied with 20 pints of blood, whichwere delivered to them by special couriers from the bank. For various reasons,these carriers all had to turn back.
Phase II
The temporary detachment from the base bank was recalled to itas soon as the loading of the LST's was completed. The other three detachmentsremained in place to carry out their part of the second phase of the blood bankmission, which at this time was twofold:
1. The supply of blood to returning LST's and hospitalcarriers for use on the far shore. For a long time, the blood bank detachmentsalso handled the supplies of biologicals and penicillin for these craft.
2. The supply of blood to transit and holding hospitals whichwere receiving casualties in the United Kingdom. For a time, it was also a bloodbank responsibility to supply these hospitals with biologicals and penicillin.
The blood bank kept in storage a reserve of whole blood,which was used to supply field hospitals in the vicinity and to resupplyhospital carriers and LST's which had brought casualties from the far shoreand were returning to it. This blood was distributed daily in small refrigeratortrucks. A small amount was supplied to LST's in hand-carry ice containers.
The southern part of England was divided into four geographicareas, and the hospitals in the three coastal areas were supplied by the bloodbank detachments. The fourth area, which was inland, was supplied directly fromthe base blood bank at Salisbury.
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When air evacuation began from the Continent, on D+7, a fiftharea was set up, with the 217th General Hospital at Swindon, because of itscentral location, serving as a supply center. Deliveries of blood were made tothis hospital, and holding hospitals at airstrips nearby obtained the smallamounts which they needed from it. Blood was also delivered to the 347th StationHospital.
As a matter of convenience, the activities of the detachmentsof the blood bank are described under a separate heading (p. 518).
Section III. 127th Station Hospital BloodBank, United Kingdom Section
AUTHORIZATION
On 14 April 1944, as a result of the discussions andrecommendations at the meeting on blood supply on 5 April 1944 (p. 481), ColonelListon, Deputy Theater Surgeon, approved the initiation of a request forduplication of PROCO (p. 541) equipment necessary for a base blood depot on theContinent (34). The request included two additional Army depots, and twoadditional communications zone, advance blood depots. In this memorandum,Colonel Liston stated that the next 250-bed station hospital that arrived in theUnited Kingdom would be earmarked for the operation of the second blood bank onthe Continent and that the equipment necessary to operate it as such would berequisitioned at once.
CONVERSION OF FACILITIES AND PERSONNEL
When the 250-bed 127th Station Hospital arrived in Salisburyon 9 July 1944, it learned for the first time that its future major missionwould be to function as a second blood bank in the European theater. It wouldalso continue to operate certain facilities for the 1st Medical Laboratory, unitpersonnel, British civilian and military personnel, and personnel in need oftreatment because of local emergencies.
When the conversion had been accomplished, all facilities onthe post were shared by the 1st Medical Laboratory and the 127th StationHospital blood bank. By prorating personnel, the shared facilities wereefficiently manned and maintained. The hospital and laboratory maintainedseparate headquarters, but a few administrative offices were conducted jointly.Medical officers, nurses, and enlisted men were rotated between duties in thehospital and in the blood bank.
On 7 August 1944, as the first step in the transition fromstation hospital to blood bank, Colonel Muckenfuss assumed command of thehospital, vice Lt. Col. Julius Chasnoff, MC.
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TRAINING
Training of hospital personnel in the operation of the bloodbank was successfully effected by assigning them to work side by side with theexperienced personnel of the 152d Station Hospital, which had been in operationas a blood bank since early in the year. The training, though massive, was notdifficult. The personnel of the 127th Station Hospital had trained togethersince the hospital was activated at Fort Hancock, N.J., in December 1942, andtheir long association as a unit made them both disciplined and adaptable.
The training of men in assignments foreign to stationhospital personnel, such as blood research officers and refrigerator mechanics,presented the greatest difficulty. Only 11 licensed motor vehicle drivers werewith the hospital when it arrived in the United Kingdom, but others were quicklytrained according to the new demands, and the transportation section eventuallyhad 81 qualified and licensed drivers.
During the training period, there was a loss by transfer of28 general service enlisted men, who were replaced by a like number of limitedservice men from combat units in France. These men were so carefully fitted intopositions suited to their individual abilities that they were employed to thebest advantage and the efficiency of the blood bank was not impaired.
OPERATION
On 26 August 1944, the 127th Station Hospital formally assumedfull operation of the blood bank at Salisbury, plus its equitable share of theduties necessary to maintain the post in conjunction with the 1st MedicalLaboratory, and the 152d Station Hospital prepared to depart for France. Alltechnical operations of the bank were under the direction of Capt. (later Maj.)Forest H. Coulson, MC.
After the takeover, the transportation section of the newblood bank became increasingly active. Many service troops had left the UnitedKingdom, and the bleeding teams had to travel for increasingly greater distancesto collect the blood. They ranged from the borders of Scotland to the Channelports, and from the London area to the Welsh mountains. During September 1944,the unit vehicles traveled 20,511 miles. During October, the mileage reached36,980; during November, 35,087; and during December, 47,611. This was a totalof 140,189 miles, an average of 1,149.1 miles per day.
On 17 May 1945, the last blood was drawn by the teams, and nofurther bleedings were scheduled. During the peak of their operation, theyaveraged 450 bleedings per day.
As a matter of convenience, the activities of the detachmentsof the 127th Station Hospital blood bank are discussed under a separate heading.
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Section IV. 152d Station Hospital BloodBank, Continental Section
MOVEMENT TO THE CONTINENT
When the 152d Station Hospital blood bank was ordered to the Continent latein August 1944, the equipment for a complete blood bank was requisitioned andassembled at the medical section of Depot G-45 in the United Kingdom. Here, itwas crated for shipment, so that it could be picked up without delay when theunit began to move. In addition to the transportation regularly allotted to thehospital, ten 4-ton dump trucks were borrowed from Ordnance, with the agreementthat they would be delivered to the Chief of Ordnance on the Continent.22This mutual aid agreement enabled the bank to carry all of its equipment with itdirectly to Paris and thus to escape the delays which would probably have ensuedif the equipment had been shipped separately.
When movement orders were received on 15 September, the 152d Station Hospitalblood bank was divided into two units, a vehicle party commanded by MajorHardin, then the Executive Officer, who was to become commanding officer of theblood bank on the Continent, and a marching party. Both parties moved to themarshaling area the following day. On 17 September, the vehicle party moved toSouthampton, embarked on LST 696, and reached Omaha beach on 19 September.
The marching party of the blood bank left the marshaling area on 18 Septemberand embarked the same day on H.M.S. City of Canterbury. It landedon Omaha beach the following afternoon.
The entire unit left the staging area on 20 September, equipped with K-typerations, and reached the 203d General Hospital at Garches the following day.
On 25 September 1945, the storage and shipping section of the 152d StationHospital blood bank undertook the receipt, storage, and initial distribution ofall blood received on the Continent. Temporary storage facilities were obtainedthrough the Office of the Chief Surgeon. A pyramidal tent erected at Le BourgetField served as a joint office for the shipping section and for depot M407,which handled air shipments.
22This arrangement was possible because of a chance observation by Lt. Col. (later Col.) Bryan Fenton, MC, and Maj. (later Col.) R. L. Parker, MAC, while they were on their way to the south of England on another mission. Seeing mile after mile of empty vehicles scheduled for shipment to the Continent, they were struck by the unused potential transportation capacity. At their suggestion, these vehicles were loaded with medical supplies and provided with drivers from replacement depots who were also scheduled for service on the Continent. A triple purpose was thus served: The movement of the vehicles was expedited. The receipt of medical supplies was expedited. Replacements reached the Continent rapidly.
The operation was originally very successful. Then the Assistant Chief of Staff, G-4 (logistics), SOS, ETOUSA, found that medical tonnage allocations were being exceeded and that many truck drivers were not reporting, as ordered, at the Replacement Depot on the Continent. At this point, G-4 took over the operation. In the meantime, however, the equipment of the l52d Station Hospital blood bank, along with tons of other medical supplies, had been moved to the Continent quickly and expeditiously.
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PERMANENT LOCATION
On 10 October, a site for a base blood bank was found atVitry-sur-Seine, and officers and enlisted men moved to it from the 203d GeneralHospital. The nurses were left at the hospital. Two wings on the ground floor ofthe building selected were used for the bank operations, together with atemporary wooden structure placed between the wings by the former Germanoccupants. The building had been considerably damaged, but repairs on it werebegun immediately by French contractors, working under U.S. Army Engineers. Theinstallation of the blood bank equipment and the necessary wiring and plumbingwere done by personnel of the 152d Station Hospital.
On 20 October, the 1st General Hospital occupied theremainder of the buildings on the site at Vitry-sur-Seine and took over theadministration of the post. As soon as possible, a joint officers' mess, anenlisted men's mess, and living quarters for nurses, officers, and enlistedmen of the 152d Station Hospital blood bank were established in cooperation withthe 1st General Hospital.
OPERATIONS
After 3 November 1944, the blood bank in Paris occupied thekey position in supplying blood to the hospitals on the Continent. All bloodfrom the Zone of Interior and from the United Kingdom section of the EuropeanTheater Blood Bank at Salisbury was funneled through it, as was all blood drawnlocally.
Blood collected locally was secured from volunteer SOS troopswith type O blood. Not very much was needed from this source.
On 28 October 1944, shipments were begun to the 6703d BloodTransfusion Unit, to supplement the supply of blood to the Seventh U.S. Army. Aswill be recalled, this unit landed in southern France with that Army. By the endof the year, 354 pints per day were being shipped to this unit.
The Continental Blood Bank remained in Paris until the end ofthe war. Equipment and transportation were adequate at all times. Technicaloperations were always essentially the same as originally planned.
Personnel problems, however, frequently arose. The bankconsistently operated at some 30 persons under strength, chiefly because ofreassignment and transfer of medical officers, nurses, and enlisted men, withinsufficient replacements for them. At all times, also, several officers andenlisted men were on detached duty. The shortages were partly compensated for bythe employment of 13 French civilians, 5 for the care of buildings and groundsand 8 for the cleaning and assembly of donor sets. The net decrease in totalpersonnel did not result in any lowering of technical standards because, late in1944, the use of expendable recipient sets and expendable bottles for thecollection of blood reduced the time and work necessary in the preparation ofequipment by about half.
The four detachments operating in the forward areas when theblood bank arrived in Paris continued to operate as before. Delivery of blood tothe
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armies was simplified when two detachments of the 127thStation Hospital arrived in October 1944 to operate with the Seventh U.S. Army.
Except for a single brief interval, during the envelopment ofthe Ruhr Basin, distribution of blood from the Paris bank followed the SOP ofshipment to ADSEC Detachments B and D from the base bank and forward from thesedetachments to Detachments A and C (chart 10). During this interval, DetachmentB delivered blood to units of the Fifteenth U.S. Army in addition to deliveringblood to Detachment A. The added duty presented no great
CHART l0.-Chart showing procurementand distribution of whole blood, ETOUSA, 1944-45
difficulty, since only a small amount of blood was used bythe Fifteenth U.S. Army on the west bank of the Rhine.
After the blood bank was set up in Paris, communicationsbetween it and its advance detachments were generally excellent until the finaldays of the war. Then, when the blood depots moved with the airstrips, to keepthe appropriate Army depots supplied, their whereabouts was sometimes unknown inParis for as long as 36 hours.
On the cessation of fighting in Europe on 8 May 1945, thefour detachments operating in the Army areas and in ADSEC were brought back tothe base bank in Paris, the last arriving on 24 May. These detachments were thendisbanded and their personnel were absorbed into the structure of the parentunit.
The base bank continued to operate as such until 15 June1945; the last shipment of blood was made on 14 June. The last shipments fromthe bank in the United Kingdom had been received on 11 May and the last shipmentfrom the United States on 15 May. After that date, all blood distributed on theContinent was collected and processed by the Continental Blood Bank.
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Section V. Activities of the EuropeanTheater Blood Bank
Detachments
152D STATION HOSPITAL BLOOD BANK
Assignments
At the conference on blood supply held at the 1st MedicalLaboratory on 5 April 1944, it was recommended that the assignment of advancebanks be as follows:
First U.S. Army: Detachment A in the Army zone, supported byDetachment B in the communications zone.
Third U.S. Army: Detachment C in the Army zone, supported byDetachment D in the communications zone.
This was essentially the plan employed on the Continent (map3). When the Ninth U.S. Army became operational and the 127th Station Hospitalhad been added to the blood bank at the 152d Station Hospital, the same plan wasemployed: Detachment A of that hospital operated in the Army zone, supported byDetachment B in the communications zone.
Movement to the Continent
On D+1, two refrigerator trucks from Detachment A, which hadbeen loaded with predetermined amounts of blood by Detachment C at Southampton,were landed on Omaha beach. Their drivers were responsible for the delivery ofthis blood to medical units in the area.
Two other refrigerator trucks, one of which was preloadedwith blood, also from Detachment A, were landed on Utah beach on D+3. Theirdrivers had the same duties as the drivers of the trucks landed on Omaha beach.Both groups also took off unused and unneeded blood from LST's going back tothe United Kingdom with few casualties or with casualties who did not needblood.
By D+6, the remainder of Detachment A had arrived in Franceand was stationed at Martha Dump (Medical Supply Depot, First U.S. Army). Thetrucks of this detachment could readily distribute all the whole blood availableto the field and evacuation hospitals which required it because in the earlydays of the invasion, the lodgment area on the Cotentin Peninsula was verylimited.
All whole blood brought into France during the first days ofthe invasion was brought in by surface craft. On D+7, it began to arrive by air,on the airstrip in the rear of Omaha beach. Thereafter, C-47 planes brought inpractically all blood from the United Kingdom.
The third phase of the blood bank operation called for themovement of Detachments B, C, and D to the Continent. There had been no need forthem there earlier.
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Detachment C arrived in France on 10 July and began to serve thehospitals supporting the VII Corps of the First U.S. Army, which was operatingtoward the south on the Normandy Peninsula. On 4 August, Detachment C also tookover delivery of blood to hospitals of the Third U.S. Army, which had becomeoperational on 1 August.
Detachments B and D arrived on the Continent on 18 July, attached to theAdvance Section, Communications Zone. On 23 July, for Operation COBRA (thebreakthrough at Saint-L?), Detachment B was placed at Tr?vi?res, with the31st Medical Depot Company, to support Detachment A. Detachment D was initiallylocated on the airstrip at Binniville, but a few days later it took station atthe 30th Medical Depot Company at Chef du Pont.
Departures from SOP
The SOP for delivery of blood to the Continent (40) called fortrucking of blood from the base bank to the field; separate air shipment ofblood to each ADSEC detachment; and delivery forward, by truck, to therespective armies served by the particular detachments. On occasion, departurefrom this procedure was necessary:
1. The major test of the flexibility of the plan devised for the supply ofwhole blood first came in August, when the bank was called upon to support, atthe same time, the VIII Corps of the Third U.S. Army operating in the BrittanyPeninsula and the eastward drives of the First and Third U.S. Armies. To handlethis situation, Colonel Mason directed a regrouping of personnel and equipmentof the ADSEC detachments as follows:
Detachment B was placed in support of the First and Third U.S. Armies, atfirst from the airstrip at Courtil, in Brittany. It was given the 1,000-pintrefrigerator truck and the 500-pint bulk delivery truck from Detachment D.Between 13 September and 2 October, Detachment B gave full support to botharmies, even when this mission required splitting itself in half because of thediverging fronts.
Detachment D was placed in direct support of the field and evacuationhospitals operating with the reinforced VIII Corps. It operated initially fromthe airstrip at Courtil and later from the strip at Morlaix in Brittany. It wasgiven temporarily the two 80-pint delivery refrigerator trucks belonging toDetachment B, which, with its own trucks, gave it four delivery vehicles. Thisenabled Detachment D, from mid-August to early October, to operate a shuttleservice between the airstrip and the field and evacuation hospitals. Thedetachment then reverted to its original mission of backing up the Third U.S.Army.
2. In October 1944, the Surgeon, Third U.S. Army, requested that supplies ofblood be sent directly to mobile hospitals supporting the divisions engagedbefore Metz.
3. On 24 October 1944, Detachment B took over delivery of blood to hospitalsof the Ninth U.S. Army, continuing this function until 1 November,
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when Detachments A and B of the 127th Station Hospitalarrived and took over the mission of supplying the hospitals of this Army andthe communications zone hospitals behind it.
4. Also in October, Detachment B became responsible for thedelivery of blood to the mobile hospitals supporting the 82d and 101st AirborneDivisions of the XVIII Corps in the Eindhoven-Nijmegen Area. One delivery truckfrom this detachment transported blood daily from the airstrip near Saint-Trond,Belgium, to the combat area over "Hell's Highway." On at least oneoccasion, the vehicle carrying the blood had to be escorted by tanks, to protectit against interference by roving German patrols. Although it was constantlysubjected to small arms fire, it was never hit. The drivers and assistantdrivers of the two trucks engaged in this operation were awarded the Croix deGuerre by the French Government.
While it was stationed in the vicinity of Saint-Trond,Detachment B received all its blood by air. It was entirely mobile and couldmove immediately to the vicinity of any airfield near the front to which asupply of blood could be flown. After 10 November, when it went on to Li?ge, itreceived its blood by both plane and truck. The first night the detachment wasat Saint-Trond, a German V-1 bomb blew out several of the windows in thechateau in which it was billeted. While it was in Li?ge, it was subjected toconstant V-1 bombing.
This detachment had some minor refrigerating problems. Itsstorage refrigerators kept the blood at the correct temperature only when theenvironmental temperature was above the required limit. When it dropped belowthat level, the temperature in the icebox had to be raised by the use of a200-watt bulb and cans of hot water, and hourly checks were made.
Evaluation of Performance
This was probably the most trying period for any of thesedetachments. The work could not have been handled by units not thoroughlytrained and seasoned.
One reason for the successful flexibility of the ADSECoperation was that the Commanding General, Brig. Gen. (later Maj. Gen.) Ewart G.Plank, had given his Surgeon, Col. Charles H. Beasley, MC, direct command overall medical units assigned or attached to ADSEC. Colonel Mason, who was ColonelBeasley's executive officer, was directed to exercise personal supervisionover the blood bank operations in ADSEC and to coordinate all matters of bloodsupply with the army surgeons, the Surgeon, 12th Army Group, and the ChiefSurgeon.
The work of the detachments of the 152d Station Hospitalblood bank was faithful and consistent. Great resourcefulness and initiativewere shown by the commanding officers, 1st Lt. Herbert H. Reardon, MAC; 2d Lt.(later 1st Lt.) Eugene E. Stein, MAC; 2d Lt. (later 1st Lt.) Philip Shaulson,MAC; and 2d Lt. (later 1st Lt.) Joseph A. Plantier, MAC. With the men of their
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units, they showed consistent courage and devotion to duty.Deliveries were often made under difficult conditions, in unknown, dangerousterrain, but the drivers took pride in getting the blood through, even though ithad to be transported through artillery and small arms fire. When bridges weredestroyed, the drivers forded streams. They were often annoyed by snipers, andthey sometimes found that the installations to which they were taking blood hadbeen wrecked by enemy action. The successful operation of the ETOUSA Blood Bankwas in large measure due to the efforts of the officers and men of the advancedetachments.
127TH STATION HOSPITAL BLOOD BANK
Movement to the Continent
On 2 October 1944, two advance detachments (A and B) activatedfrom personnel of the 127th Station Hospital blood bank departed for France,fully trained and equipped for their new missions. Almost as soon as thesedetachments had left, two additional detachments (C and D) were activated andbegan training. Personnel, trucks, and supplies were kept ready for another callfrom the Continent. The loss of manpower because of the detachments already sentto France was felt, as was the alert maintained until Detachments C and D wentto France in March 1945, but increased efforts of the remaining personnelcompensated, and the internal mechanism of the blood bank was in no way sloweddown.
Detachment A (Provisional)
Detachment A of the 127th Station Hospital, commanded by Capt.A. C. Shainmark, MAC, landed on Utah beach in October 1944 (64), just asthe battle for Aachen was terminating and plans were in hand for the Ninth U.S.Army to cross the Roer River and push on to the Rhine. After a 2-day stay inParis, to obtain additional supplies, the detachment pushed on to Namur,Belgium, and then to Maastricht, Holland, which it reached on 27 October. Afterpersonnel of the 28th Medical Depot Company arrived there several days later,the detachment moved to its location.
The first shipment of blood was received on 30 October 1944,from the ADSEC supporting unit (Detachment B), which was located near anairfield in the vicinity of Li?ge and which served as the link betweenDetachment A and the blood bank in Paris. Thereafter, the trucks of Detachment Amoved along with the army, maintaining continuous contact with forward medicalunits and delivering blood to them daily.
Captain Shainmark was kept fully informed of the movementsand locations of field and evacuation hospitals as the Ninth U.S. Army sweptforward across Germany to Helmstedt, where it was operating on V-E Day. Severaltimes, the blood bank truck appeared on the scene while hospitals were stillrolling to their new locations. At the height of the Battle of the Roer, when
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several field hospitals crossed the swollen river almost side by side withthe infantry, the trucks of Detachment A often delivered more than 500 pints ofblood to them daily. Similarly, when the Ninth U.S. Army crossed the Rhine, thehospitals on the East Bank received the blood they needed as soon as they wereset up.
In all, Detachment A (Provisional) distributed about 35,000 pints of wholeblood.
Detachment B (Provisional)
Detachment B of the 127th Station Hospital arrived on Utah beach on 22October 1944 and reported to the 152d Station Hospital blood bank in Paris.Here, it received orders to proceed to Namur, Belgium, where it arrived on 26October and where it received further orders to proceed to Saint-Trond, Belgium.Here, it began to work with Detachment B, 152d Station Hospital blood bank, andgradually took over from it the servicing of the forward hospitals supportingthe Ninth U.S. Army.
Detachments C and D (Provisional)
When Detachments C and D (Provisional) of the 127th Station Hospital went tothe Continent, they were attached to the Seventh U.S. Army (instead of theNinth, as had originally been planned) because the advance section of the 6825thBlood Transfusion Company had been found too small to care for total Army needs.Until late in March, all blood collected by this company was shipped directly tothe Seventh U.S. Army. Thereafter, the blood was routed through Paris, whichpermitted much more effective control and distribution, as well as augmentationof the inadequate supply.
Part VI. Blood Donors in the EuropeanTheater23
FIRST PROVISIONS FOR BLOOD DONORS
Before blood donor panels were formally established in the United Kingdomlate in 1943, occasional suggestions were made to the effect that noncombatanttroops follow the example of U.S. civilians and provide blood for casualties.These suggestions were all answered in the same manner:
1. At the time (1942), the demand for blood in the European theater was notvery great.
2. The location of the blood banks in the United Kingdom, particularly theBritish blood bank at Bristol, limited donors to troops in the immediatevicinity of the banks.
23Unless otherwise identified, the material in this section is from the official diary of the ETOUSA Blood Bank (34) and from the official diary of General Cutler (23).
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3. As soon as blood collecting teams began to operate in the vicinity ofparticular organizations, members of these commands might voluntarily submitthemselves as donors. It was expected that detachment commanders of unitsstationed in the vicinity of hospital blood banks would shortly set up panels ofnames of men who would be willing to donate blood upon call.
During this period, the emergency need for transfusions was met from thenearest available personnel, preferably from the recipient's own unit. Theliteral interpretation of the latter clause led to some difficulties, which wereeliminated when instructions were given early in January 1943 that bloodrequired for emergency transfusions must be secured from the nearest availablepersonnel and not from members of the recipient's own unit if it did not fallinto the category of availability.
FORMAL PLANNING FOR THE BLOOD SUPPLY
Formal plans for securing blood donations for combat casualties from U.S.Army personnel in the United Kingdom began in October 1943, with an inquiry bythe Theater Chief Surgeon of the Professional Services Division of his office asto the effects of withdrawal of 500 cc. of blood. He had already notifiedCaptain Hardin that it would be his policy not to use donations from combatpersonnel. On 31 October, Colonel Cutler notified General Hawley that in hisopinion, in which Colonel Middleton concurred, the resistance of the individualwho gave blood in this amount would not be affected adversely in anycircumstances of weather or environment (65).
In November 1943, General Hawley wrote the Commanding General, Services ofSupply, ETOUSA, as follows (66):
1. The lifesaving value of large-scale transfusions of wholeblood during military operations has been repeatedly confirmed by the experienceof the United States and of our Allies in other theaters of war.
2. It will be necessary to establish in the United Kingdom areservoir of type O blood donors, under military control, in order to secure anadequate amount of stored whole blood for operations on the Continent.
3. Potential donors are present in large numbers in SOSmilitary personnel in the United Kingdom. It is thought that a simple statementof the need for whole blood, contained in a call for volunteers addressed tosoldiers with type O blood in SOS units, will have a highly satisfactoryresponse.
4. The Blood Panel, ETOUSA, will consist of a consolidatednominal list of volunteers, to be maintained by the Chief Surgeon.
5. The collection of blood will not be required untilapproximately D+7. Subsequent listings may be required at 90-day intervals.
6. It is recommended that an initial call be made for donorsfor such a blood panel.
In accordance with General Hawley's suggestion, a letter dated 15 December1943 and containing the following instructions was sent by Lt. Gen. JohnClifford Hodges Lee, Commanding General, SOS, ETOUSA, to the commanders ofChannel Base Section, Eastern Base Section, Western Base Section, and
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Southern Base Section. The Northern Ireland Base Section was not includedbecause its geographic situation would not permit ready transportation of bloodcollected there to processing and storage depots. General Lee directed that hisletter be published to all units of the command and that the appended messagefrom him be read at the first formation after its receipt. The letter containedthe following information (67):
1. The establishment of a blood panel for ETOUSA, containingthe names of type O donors from SOS units, is required to insure an adequatesupply of whole blood for the treatment of the wounded. The establishment ofthis panel has been approved by the Theater Commander.
2. It is therefore desired:
a. That a nominal list of type O volunteer donors be prepared in each unit and retained in unit headquarters.
b. That a record of the number of type O volunteers be maintained by units in the base section headquarters.
c. That the records just specified be corrected as of the 15th of each month and that, immediately following each correction, a report of the number of type O donors in each unit of the SOS troops in each base section be sent to the Commanding Officer, ETOUSA Blood Bank, 1st Medical Laboratory.
d. That upon call by the Commanding Officer of the ETOUSA Blood Bank, the volunteer type O donors of the unit specified be assembled at a designated bleeding station (ordinarily the unit dispensary) at an hour to be determined by each commander, which will not interfere seriously with the normal duties of the unit and which will be reasonably convenient for the bleeding team.
e. That only light duty be required of donors from the time of bleeding until reveille the following morning.
3. As a rule, four-fifths of a pint of blood will be taken ateach bleeding,24 and no donor will be bled oftener than once in 3months. The withdrawal of this amount of blood will have no ill effect upon thedonor and will not reduce his physical capacity for work or predispose him toillness.
4. Active interest in maintaining as many volunteers aspossible is enjoined.
The message from General Lee, to be read at the first formation after thereceipt of the letter just abstracted, was, in summary, as follows (68):
1. Defeat of the enemy cannot be accomplished without the lossof life and wounding of United States soldiers.
2. Large quantities of blood, which medical considerationslimit to type O blood, would be required for transfusion for their comrades inthe field forces.
3. Volunteers whose identification tags showed type O bloodwere being asked to donate blood when called upon. Instructions would be issuedas to when and where these donations might be made.
General Lee's message concluded: "You, who are eligible, may well beproud of this opportunity to place your name on this Roll of Honor-the BloodPanel, ETOUSA."
24The practice in the United States during and for several years after the war was to withdraw 500 cc. of blood at each donation. The smaller amount was used at this time because British bleeding bottles, after the anticoagulant was added, would hold only 400 cc. It is now (1962) United States practice to withdraw only 450 cc. of blood from each donor, it having been found that when the smaller amount is taken, the incidence of fainting is materially reduced.
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INITIAL RESULTS
It had been estimated that to maintain adequate supplies ofwhole blood for battle casualties in the European theater, at least 90 percentof all blood type O individuals in the Southern Base Section must volunteer asdonors. The results reported on 10 March for the first solicitation (table 19)were not encouraging, and the second report, on 21 April (table 19), showed nogreat improvement.
TABLE 19.-Response to requestfor type O blood donors in the United Kingdom, spring 1944
| Number of units | Number of donors | Percentage of troop strengths |
| 10 March 1944 | ||
Eastern | 116 | 4,589 | 58.80 |
Western | 130 | 10,075 | 34.48 |
Southern | 267 | 9,207 | 27.98 |
| 513 | 23,871 | 40.35 |
| 21 April 1944 | ||
Eastern | 135 | 5,316 | 62.48 |
Western | 356 | 19,020 | 72.06 |
Southern | 309 | 10,350 | 30.30 |
| 800 | 34,686 | 55.55 |
On 6 April 1944, the Office of the Adjutant General,Headquarters, SOS, notified the base section commanders, SOS, and otherheadquarters commandants that the response to the request for blood donors hadfallen far short of expectations (69). All were therefore directed tonote the importance of this project and to consider methods of increasing thenumber of volunteer donors.
At a conference on blood supply in the United Kingdom on 7April 1944, as well as several times later, it was tentatively suggested that ifthe response of blood donors continued to be unsatisfactory, consideration begiven to paying them under Army Regulations No. 40-1715. This plan was neveradopted.
POSTINVASION DONATIONS
Shortly after D-day, when it became evident that blood was inshort supply, considerable publicity, chiefly informal, was given to the needfor donors, and there were numerous volunteers from various sections of thetheater chief surgeon's office, the Adjutant General's Office, and otheroffices. The reply to
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these offers was always the same, that the volunteers would be bled whenever a sufficient number of O donors could be brought together, and that the entire process would then be streamlined, so that there would be a minimum of delay and absence from duty. Numerous donations were secured from these sources.
Even the arrangement to fly blood from the Zone of Interiorto the European theater did not end the need for local donations. Thus, on 24September 1944, a little over a month after the airlift was instituted, theOperations Section, Office of the Chief Surgeon, noted that supplies atPrestwick were low and that a regular schedule of bleedings in the UnitedKingdom must be maintained if 1,000 pints of blood were to reach the Continentevery day.
On 31 December 1944, Colonel Cutler wrote the deputy theatersurgeon that the panel of blood donors in the United Kingdom had become verysmall. Two weeks earlier, General Hawley had approved the bleeding of combattroops in the United Kingdom if it were certain that they would remain there for2 or 3 weeks after the blood had been taken. There had been no formalnotification of this policy, and Colonel Cutler suggested that dissemination ofthe information be expedited.
On 15 January 1945, General Hawley notified the Surgeon,United Kingdom Base, that he had investigated the possibility of bleeding combattroops and had been assured by competent medical authorities that this would notbe injurious to them. Blood from this source would add materially to the blooddonor panel. General Hawley had also been assured that there was no physiologicor medical contraindication to using these troops as donors if they would notenter combat within 2 weeks after they had been bled. The theater commander hadapproved the bleeding of combat units staging in the United Kingdom. Now that he had done so, General Hawley wished this additional source of whole blood tobe properly exploited through technical channels.
On 8 March 1945, a memorandum was sent out from Headquarters,Communications Zone, ETOUSA, to the chiefs of general and special staff sectionsof that Headquarters stating that the Commanding Officer, 152d Station Hospitalblood bank, had reported a critical shortage of type O blood and had requestedthat "all personnel" be canvassed in an effort to secure voluntarydonations. In this memorandum, the chiefs of general and special staff sectionswere instructed to submit to the Headquarters Commandant not later than 14 March1945, a nominal list of personnel who possessed type O blood and were willingto donate it. The order was widely circulated and a considerable number ofvolunteers were thus secured.
The airlift of blood from the United States ended the problemof blood shortages except for occasional periods when blood was in temporarilyshort supply. Until the airlift was instituted, the effective organization ofthe local donor panel proved the key to the success of the ETOUSA Blood Bank.Plans for the panel were most efficiently implemented by Col. Robert E. Peyton,MC, and Col. Angvald Vickoren, MC, both of the Operations Division, Office ofthe Chief Surgeon, ETOUSA. Unit medical officers also were very helpful.
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BLOOD AND PLASMA DONATIONS TO BRITISH
The propriety of donations of blood by U.S. troops to Britishblood banks came up as early as 9 October 1942. On that date, Captain Hardin,then Liaison Officer at the blood bank in Bristol, wrote to Colonel Cutler thatin certain areas, British hospitals were being furnished with small amounts ofblood by U.S. Army units. This was a practice, he said, fully in keeping withgeneral practices of reciprocity between the Royal Army Medical Corps and theU.S. Army Medical Corps.
One difficulty, however, had arisen: When blood was collectedin U.S. Army hospitals and used in British military hospitals, some U.S.soldiers expected to be paid $10 per pint. Brigadier Whitby thought that if thiswere done, British civilians might also expect to be paid for donations, whichwould be against a longstanding British policy in both civilian and militarypractice.
Colonel Cutler ruled that U.S. personnel, whether civilianor military, would not be paid for the donation of blood.
On 17 June 1943, in response to an earlier query, TheAdjutant General, War Department, informed Headquarters, SOS, ETOUSA, that thetransfer of dried plasma from U.S. sources to Allied commands could not beapproved. The plasma had been secured entirely through donations by patrioticAmericans of blood to the American Red Cross, and it was intended only for U.S.fighting forces. Its production, moreover, was geared to estimated requirements,and there was none to spare. This ruling did not, of course, apply to thetreatment of Allied personnel in U.S. Army medical installations or to theemergency use of plasma in Allied hospitals when there was no other plasmaavailable.
Later, Colonel Cutler further ruled that U.S. troops wouldnot be permitted to act as donors for British blood supplies. There would beunfortunate repercussions in the United States, he thought, if, with all theplasma generously donated by civilians, U.S. troops were required to give bloodas well as to fight.
The question of U.S. Army donations to British blood suppliescame up again late in 1943. On 20 October, Captain Hardin wrote to ColonelCutler that, during a recent drive for donations, teams from the British ArmyTransfusion Service had met with considerable enthusiasm from U.S. troops, and,in at least one instance, the commanding officer of such a unit had offered toproduce large numbers of donors. In fact, tentative arrangements had alreadybeen made for bleeding them. Brigadier Whitby was naturally pleased with theresponse but did not wish to proceed without definite approval of the Office ofthe Chief Surgeon. He desired to avoid possible unpleasant future comments bymaking it clear that the response was entirely voluntary on the part of U.S.troops and was not the result of any direct appeal to them.
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This particular organization (the 29th Division), MajorHardin pointed out, because of its location would not be asked to volunteer inthe U.S. bleeding program. If it were bled by the British, the donations wouldbe completed by 1 January 1944. His own opinion was that no combat unit shouldbe bled later than 60 days before it was expected to go into action.
Colonel Cutler replied on 24 October 1943 (65) thatthe bleeding of U.S. troops for British use represented a very importantprinciple. It had been decided by the U.S. Army that blood would not berequested from any of its own combat organizations. If this particular combatdivision were bled, other troops might wish to volunteer, and, once theprinciple were violated, there would be difficulty in stopping the practice. Hetherefore recommended that the donation of blood by U.S. soldiers for Britishsupplies be forbidden unless the staff at Headquarters, ETOUSA, could soguarantee combat dates that it would be certain that no troops would be bledlater than 60 days before they went into action.
On 1 February 1944, Col. Howard W. Doan, MC, ExecutiveOfficer, Office of the Chief Surgeon, wrote Sir Francis R. Fraser,Director-General, British Emergency Medical Service, that while there would beno objection to individual U.S. soldiers' serving as volunteer donors for theBritish, the U.S. Army blood program was expected to get underway shortly (70).When it did, it would utilize all available sources for the procurement ofwhole blood and thus reduce the number of volunteers to the British supply.
In May 1944, the question came up again, this time inconnection with the Air Forces (71). The Surgeon, Eighth Air Force,received a memorandum from the Surgeon, Headquarters, 1st Bombardment Division,to the effect that representatives of the British Red Cross had requestedpermission for their transfusion vans to visit Air Forces camps. The Britisharrangement would apparently not interfere with U.S. Army plans for collectingblood, since only SOS units and Ground Forces would serve as donors. Brig. Gen.Malcolm C. Grow, Surgeon, Eighth Air Force, referred the matter to the ChiefSurgeon, ETOUSA, for decision, with the comment that in his own opinion, therequest should be favorably considered if it would not interfere with the U.S.Army blood procurement program. It was understood that no flying personnel wouldact as donors and that all donations would be voluntary, with no pressurebrought on Air Forces personnel to provide them.
At about the same time, a similar suggestion from anothersource was referred to the Professional Services Division, Office of the ChiefSurgeon, by the Operations Division of that office, with the statement that theattached correspondence suggested that the Eighth Air Force had not beenapproached for blood donations. If so, it was the writer's opinion that apotential pool of donors had certainly been missed and the omission should beinvestigated by the Professional Services Division.
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The reply to the first letter (from General Grow) by the Deputy Surgeon,ETOUSA, Colonel Liston, and to the second letter by the Director of theProfessional Services Division, Colonel Kimbrough, were to the same effect: When the ETOUSA donor panel for the blood bank was established on 6 January1944, Air Forces personnel were the only U.S. troops engaged in active combat.East Anglia, where the Eighth Air Force was stationed, was not readilyaccessible to the British blood bank in the Southern Base Section of England.Finally, it was the intention to use Air Forces personnel as local donors forU.S. hospitals in East Anglia when the need for blood for them arose. Also, whenthe ETOUSA panel of donors was decreased by movement of SOS troops to theContinent, it might become necessary (as happened) to enlarge the panel by theaddition of donors from the Air Forces. For these various reasons, Air Forcespersonnel could not be permitted to donate blood to the British.
PRISONER-OF-WAR DONORS
In August 1944, when German prisoners were being taken in great numbers, thesuggestion originated with some of them that they be used as donors (72). On6 September 1944, Colonel Kimbrough notified the Surgeon, United Kingdom Base,that the Chief Surgeon, ETOUSA, had no objection to this practice if the donorswere volunteers.
PAYMENT OF DONORS
Although payment of blood donors was permitted by law and was practiced inthe Mediterranean theater during most of the war (p. 423), General Hawley ruledthat neither military nor civilian donors should be paid in the Europeantheater. This ruling was duly incorporated in Circular Letter No. 51 (19).
It was tentatively suggested on several occasions, as already mentioned, inconnection with planning for the invasion of the Continent, that it might benecessary to pay donors, but no action was ever taken on the matter. When thequestion was occasionally raised by hospital commanders, because of specialcircumstances, permission was always refused.
COMPENSATION FOR ACCIDENTS
When arrangements were being discussed for the maintenance of blood banks tobe supplied from British civilian donor panels, Colonel Cutler took the positionthat claims for monetary compensation for accidents suffered by civilian donorswho were being bled by U.S. Army medical officers should be the responsibilityof the U.S. Government and not the British War Office. In the experience of theBritish Army Transfusion Service, according to Captain Hardin, claims had beensmall in both numbers and amounts. The American experience in this respect wasalso negligible.
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Part VII. Practical Considerations of the Blood Program in ETOUSA
PRELIMINARY PLANNING FOR THE AIRLIFT TO THE CONTINENT
Although whole blood was not an item of medical supply during World War II,the Overseas Branch, Supply Division, Office of The Surgeon General, had theresponsibility for shipping it to the United Kingdom and thence to the Continent(73). That function entailed arrangements for air priorities and alsorequired the coordination of shipments with the Air Transport Command forallotment of space based on the daily estimated needs of the theater.
October 1943
Early in October 1943, General Hawley took up with the Commanding General,SOS, ETOUSA, the logistics of the delivery of whole blood to the Continent asfollows:
1. Whole blood must be transported rapidly to the locus of use and must beproperly chilled during transport. Otherwise, it could not be used to rendereffective aid to the wounded. Failure of either delivery of the blood orrefrigeration would spell failure of the blood program.
2. Shipment by air was the method of choice. If enemy action, weather, orother conditions prevented this mode of transport, then shipment by specialrefrigerated trucks, on high priority, would be necessary to insure safedelivery of properly chilled blood in adequate amounts.
3. It was recommended that the Commanding General, Army Air Forces, be calledupon to assume primary responsibility for delivery of blood to the Continent andthat necessary planning and policies to implement the service be preparedjointly by representatives of the Air Forces and SOS.
4. It was also recommended that the chief of transportation be notified thatrefrigerator vehicles carrying blood must have the highest priority for watertransportation when air delivery is not possible.
November 1943
On 4 November 1943, Colonel Mason wrote to the Chief Surgeon, in reference tothe communication just summarized, that while it might not be necessary tomention to the Chief, Transportation Corps, that blood shipped by refrigeratedtruck must be given the highest priority, approval of this specific arrangementby General Lee might prove very useful (74).
December 1943
In a conference held on 22 December 1943, Col. Edward J. Kendricks, MC,Surgeon, Ninth Air Force, informed Colonel Mason that Troop Carrier Commandplanes would deliver blood from the vicinity of the blood base depot
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to fields on the Continent in the vicinity of Army medical supply depots (75).The Troop Carrier Command of the Ninth Air Force had transported blood forthe British Eighth Army in the North African campaign and was therefore familiarwith the necessities.
Colonel Kendricks requested that a study be prepared concerning the maximumweight and space required for a single shipment of blood. The British had beenallotted 2,240 pounds of cargo space daily for air transport.
April 1944
On 7 April 1944, in order that the logistic requirements of the blood programbe placed in command channels, the Chief Surgeon requested that the airtransport of whole blood to the Continent begin on D+14 and provided thefollowing information (34):
1. The requirement of this operation is 500 pints per day.
2. This blood can be delivered by truck from the ETOUSA Blood Bank at the 1stMedical Laboratory to the nearest forward takeoff point in the United Kingdomfor transport to designated fields or landing strips on the Continent.
3. The blood will be packed in cylindrical insulated iced containers, 18inches high by 16 inches in diameter. The 50 containers required for 500 pints of blood canbe stacked in a space 17.66 feet long, 2.66 feet wide, and 3 feet high. Thetotal weight is 3,350 pounds. The average space occupied by 1 container is 2.8cu. ft. Its empty weight is 32 pounds and its loaded weight, 67 pounds.
On 10 April 1944, the Commanding General, Ninth Air Force, upon request, sentthe Office of the Chief of Staff, ETOUSA, the following information to implementthe previous request for an allocation of daily cargo space to cover thecombined air tonnage requirements of blood and medical supplies for the Army,the Army Air Forces, and the Communications Zone on the Continent(76):
1. Designation of an airfield in the immediate vicinity of Salisbury, wherethe main storage point and personnel to handle the blood were located, would bemost desirable. As a second choice, a field in the immediate vicinity ofThatcham, Berkshire, Greenham Common, or Aldermaston would be satisfactory. Ifan airfield near Thatcham were designated, blood would be delivered daily to themedical section in Depot G-45 at this location and held there in refrigeratorsuntil called forward by the Air Force. Then it would be placed in iced,insulated containers and delivered in trucks to airfield personnel at the timespecified.
2. Whole blood prepared for air shipment would be packed in U.S.Quartermaster insulated food containers, each holding 10 bottles of blood and 10recipient sets. Refrigeration would be maintained by cracked ice (10 pounds tothe can) in an insert placed on top of the bottles. This arrangement wouldmaintain optimum refrigeration for approximately 40 hours in an airenvironmental temperature between 65? and 85? F. (18? and 28? C.). Packingof the containers and their delivery by truck to the designated airfield wouldbe the responsibility of the blood bank.
3. The Air Force would load the containers on the plane and transport them tothe far shore within the limit of the lifts authorized and subject to militarysituations and flying conditions. Here it would unload the containers and turnthem over to the medical representative of the Army Advance Section,Communications Zone, or Forward Echelon, Communications Zone, whichever waslocated at the receiving field on the far shore. Distribu-
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tion of the blood after its receipt would be made by the advance blood depotattached to the Army Advance Section, Communications Zone, or Forward Echelon,Communications Zone.
4. Empty shipping containers and used blood recipient sets would be collectedby advance blood depots and delivered to airfields designated by the Ninth AirForce, whence they would be returned to the Greenham Common Airfield. Here theywould be turned over to the Medical Section of Depot G-45 located there.
Over General Dwight D. Eisenhower's name, the information in this letterwas sent to the Commanding Generals of the 1st Army Group, the U.S. StrategicAir Force, the First and Third U.S. Armies, and the Ninth Air Force.
Generally speaking, this was the plan by which blood was transported to theContinent during the fighting in Europe (figs. 119-126).
Before D-day, the plans for air supply from the United Kingdom to theContinent included a CATOR (Combined Air Transport Operations Room) to assignpriorities, allocate aircraft and tonnage, and coordinate air movements (77).Lt. Robert E. Pryor, MAC, was appointed to coordinate the movement of medicalsupply by air and to be the representative in CATOR. Direct communication wasauthorized between the commanding officers of the blood bank and the TroopCarrier Command, which was to fly the blood in C-47 planes. Basic policies andprocedures for decentralizing the operation were therefore worked outsatisfactorily. In addition, the liaison officer of the Ninth Air
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Force visited the blood bank on 2 May 1944, to become acquainted with the staff and to learn their special problems.
Greenham Common, the airfield selected for the takeoff of planes carrying blood, was excellently located for this purpose. It was only 3 miles from Depot G-45, to which blood was to be delivered, and only 38 miles from the ETOUSA Blood Bank at Salisbury.
By D-day, arrangements had been concluded with the 21 Army Group (British) for a daily 4,000-pound airlift to the Continent for blood, penicillin, and biologicals, with additional standby provision for emergency shipments.
AIRLIFT TO THE CONTINENT AFTER D-DAY
From the beginning, the planned airlift worked excellently (59).As early as D+1, ether and penicillin were being dropped by parachute tomedical units on the beaches. By D+7, emergency landing strips were available onthe far shore, and, weather permitting, daily shipments of blood went forwardfrom that date. By the end of June, the daily tonnage exceeded the originalallocation, and a second plane was added to the airlift, so that 5 tons of bloodand medical supplies per day could be transported to the far shore. The two
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C-47's flew so regularly that their flights were described in officialdocuments as the milk run. Additional planes were supplied for specialemergencies.
The whole system worked smoothly. When blood was delivered to the planes inthe United Kingdom in marmite cans, with a block of ice or cracked ice in thetop insert, it reached the Continent in good condition, with temperatures of39? to 40? F. (4? to 4.5? C.), even when outside temperatures were as highas 85? F. (28? C.), the maximum expected.
In September, after the fall of Paris, the Supply Division established areceiving point, with office and storage space, at Le Bourget Airfield. This wasthe terminus of the milk run from the United Kingdom.
Getting supplies forward to the armies was another matter. This problem wassolved by Lieutenant Pryor's discovery near Paris of a squadron of 20 small C-64planes which were not being used; they were too large and too slow forobservation and liaison work and too small for routine cargo work. Theirpersonnel, because of their enforced idleness, were unhappy and frustrated.Arrangements were made with this squadron to fly blood and medical suppliesforward and bring back wounded, usually five per plane (three litter patients
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and two sitting patients). The movements of the planes werecontrolled from General Hawley's office.
This was an admirably successful arrangement. In 3 months,these planes transported 30,000 pints of whole blood, in addition to 463 tons ofother medical supplies. On the return trips, they evacuated 1,168 patients.
On 1 September 1944, the Chief Surgeon requested G-4 to arrange for permanent diversion of the two transport planes which had been assigned for the daily airlift of blood from the United Kingdom to the Continent from the airstrip originally used to a strip farther forward (78). The requirements for whole blood had moved forward with the armies, and it was no longer satisfactory to haul the blood forward by shuttle plane or transport it by road. Blood from the United Kingdom was now augmented by blood from the Zone of Interior, and it was imperative that all supplies arrive at their final designation as rapidly as possible.
On 22 September, Colonel Hays requested G-4, ETOUSA, to notify PEMBARK that hereafter, all shipments of blood from the Zone of Interior should be flown to Paris and that shipments to Prestwick, Scotland, should be permanently discontinued (79). This change was effected.
Air transport to forward areas was continued as long as flying conditions permitted. During December, however, the weather was so unfavorable that truck and train shipments became standard procedure. When truck transport was used, deliveries were most satisfactory when there was a prearranged
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rendezvous between vehicles of base and advanced depots. Whengood flying weather returned in the spring, the tedious, time-consuming deliveryof blood by road was discontinued.
In early December, the only contact the blood bank had withthe Seventh U.S. Army was by air. Later, blood was shipped to it by regularpassenger train also; during the first week of February, this was the only meansby which blood reached this Army.
In January 1945, 45 of the 60 C-64 planes were replaced with7 C-47's, which gave a daily airlift of 17? tons for blood and other medicalsupplies. These planes were frequently used to pick up supplies in the UnitedKingdom and deliver them directly to the armies. After the Rhine had beencrossed, the armies were so far ahead of established depots and were operatingin territory in which rail transportation had been so completely disrupted thatthe medical service was fortunate in having an adequate airlift.
OTHER MEANS OF TRANSPORTATION
The Red Ball Coaster Freight Service, set up before D-day,amounted to rapid delivery service by speed boats from ports in southern Englandto the far shore (34). Because it was not under medical control, it wasemployed only during the early days of the invasion, at which time it was veryuseful. When blood was carried by this service, it was top-loaded; that is, itwas last on and first off. The Army had personnel on the beaches in Normandy tosearch for and receive emergency cargo arriving by these boats.
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Another plan for the immediate delivery of blood in the earlydays of the invasion was, as already mentioned, less successful than othermethods. In the discussions before D-day, the daily shipment of blood onhospital carriers, with couriers to meet the boats and take the blood off,seemed to many participants the simplest, and therefore the most foolproof,method of getting blood across to the far shore. The plan was put into effect onD-day, but all but one of the assigned hospital carriers had to put back to portfor various reasons. Very little blood was therefore delivered by this route.
Dropping of blood by parachute was discussed in the planningin the Zone of Interior for blood in the European theater, but the SurgeryDivision, Office of The Surgeon General, did not recommend it because it did notseem necessary and the idea was dropped. If it had been used, appropriatecontainers would have been required.
AIRLIFT FROM THE ZONE OF INTERIOR
The initial request for an airlift from the Zone of Interiorto the European theater was made by Colonel Hays to the theater G-4 on 1 August1944. After pointing out the inability of the blood bank in the theater, evenoperating at maximum capacity, to supply the needs of the army fighting inFrance, he specified the requirements for a daily airlift of blood alone of1,000 pounds,
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which, with the necessary refrigeration, would amount to 6,700 pounds (500cu. ft.). The blood would be carried to Europe in iced marmite cans (standardQuartermaster 4-gallon, insulated food containers). The returning airlift wouldrequire only 4,500 pounds but would require the same space, since an empty can,although it weighs less, takes up as much space as a full can. If therefrigeration units for planes under development at Wright Field, Dayton, Ohio,should become available, the requirements would be less, since marmite cans andice would no longer be necessary.25
On 12 August 1944, G-4 Headquarters, ETOUSA, was requested by the theaterChief Surgeon to advise The Adjutant General, War Department, that the theaterwas prepared to accept 258 pints of blood daily, and had the refrigeration tocare for it. A daily airlift of 300 pints had been assigned. Each container,with 10 pints of blood and the requisite amount of ice, would weigh 67 poundsand would occupy 5 cu. ft. of space. The total allotment required was 2,010pounds and 150 cu. ft. of shipping space. The return
25Colonel Hays' reference was to the work then underway at Wright Field, in collaboration with the Division of Surgical Physiology, Army Medical School, to develop a refrigerator for blood which would operate in planes on 24-volt batteries. This work was not completed until late in 1944, and only the prototype was available when the airlift to the European theater was instituted (p. 208).
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airlift would weigh only 1,350 pounds. Shipping requirementswould be increased as Zone of Interior production increased.
On 18 August, General Hawley was notified by General Kirkthat the blood shipped from the Zone of Interior would not be refrigerated intransit on the plane and that the containers need not be returned. The requestfor transportation to G-4, ETOUSA, was altered accordingly. Since the bloodwould be placed in marmite cans when it was unloaded at Prestwick and would berefrigerated during transit to the far shore, an airlift of only 4.5 poundswould be necessary for every pint of blood delivered to France.
On 20 August 1944, Headquarters, ETOUSA, was informed thatthe first 300 pints of blood would leave PEMBARK the following day; thatshipments would increase to 500 pints daily as soon as sufficient blood could beprocured; and that the blood received at Prestwick must be flown to the farshore as soon as possible.
Arrangements were made with the Air Transport Command, ETOUSA(CATOR), to fly the blood daily from Prestwick to the far shore, landing, until
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further notice, at the Courtil Airstrip. Colonel Hays, on 27 August, issuedthe following instructions for handling the blood:
1. The blood received from the Zone of Interior was to beplaced at once, in its original carton, under refrigeration. All cartons wouldbe marked with the date of receipt and the oldest blood would be shipped outfirst.
2. Blood would be shipped to the Continent in the cartons inwhich it was received, not in the marmite cans originally proposed. Dailytelephonic reports would be made to CATOR at Air Headquarters, Norfolk House,London, stating the number of cartons on hand to be transported and theirweight.
3. Unless the atmospheric temperature was between 30? and50? F. (-1? and 10? C.), blood would be kept in the refrigerator at Prestwickuntil word was received that the plane was ready to receive it fortransportation to the Continent. Pilots were to be cautioned that blood must notbe allowed to freeze en route and that the cabin temperature was to be kept asclose as possible to the temperature range just specified.
REPORTS AND ESTIMATES
The original plan for a weekly report of blood movements at Prestwick waschanged on 6 September 1944 for a daily report, to include the number of bottlesof blood on hand from the previous day, the number received from the Zone ofInterior, the number shipped to the Continent, the number otherwise disposed of,and the balance on hand at the end of the day. Similar totals were alsorequested for each week, with any comments desired. One copy of each dailyreport, addressed to the Office of the Surgeon, Headquarters, CommunicationsZone Forward, for the attention of Colonel Hays, was to accompany the bloodbeing transported. A second copy was to go to the same office by air courier,and a third was to go to the Office of the Surgeon, United Kingdom Base,attention the Supply Division.
Daily airlift requirements, as just noted, were to go to CATOR in London.
REFRIGERATION AND TRANSPORTATION
Transportation of blood in the European theater from base banks to usinghospitals in forward areas involved questions of refrigeration as well astransportation.
Pre-D-day Planning and Procurement
Transportation.-In October 1943, ColonelPerry, then Chief, Finance and Supply Division, Office of the Chief Surgeon,wrote The Adjutant General, War Department, through channels, concerning therequirements of the whole blood service, pointing out that special provisionmust be made for it (PROCO) because it was operating without a T/O or a T/E (80).All items necessary could be obtained locally except cargo trucks, 30 (later34) of which were requested. Twelve should be delivered by 1 November 1943,twelve by 1 February 1944, and the remainder by 1 April 1944, so that thenecessary minor alterations could be made on them, to convert them to their newpurpose, and
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to mount refrigerators on them. This would take a minimum of 8 hours for eachtruck.
These trucks had not been received by 17 March 1944, and twelve 6 by 6 cargotrucks were requested as an advance issue of the total requisition so thatconversion could be begun. In this same memorandum, Captain Hardin described thevarious trucks he had examined and explained why he had selected the 2?-ton, 6by 6 cargo truck as most suitable for transportation of 400-pint refrigerators.
By 18 April, 12 of the 34 trucks requisitioned had been received and werealready in use by the blood bank. It was urgently requested that delivery of theremainder be expedited. It would take 3 weeks to convert them, and they must beready before the start of operations on the Continent, for the ETOUSA Blood Bankcould not function without the necessary vehicular equipment.
By the middle of May 1944, all necessary vehicles for the First U.S. Army hadbeen received and were in use or ready for issue. The vehicles for the ThirdU.S. Army had also been received and would be ready for issue as soon asrefrigerators were mounted on them. Earlier, the blood bank had been instructedto classify these trucks as surgical trucks; mark them permanently with RedCross markings; mark the cab visors "ETO Blood Bank"; and use themonly for the supply, packing, and transportation of whole blood.
Refrigeration.-Although PROCO was not approveduntil 27 October 1943, the refrigerators requisitioned for the blood bankarrived well in advance of the need for them. Because of shortages in the UnitedStates, however, it had been feared that they might not arrive on time, andsteps were therefore taken to procure them in the United Kingdom. Through theefforts of Colonel Perry, Brigadier Whitby, and Lt. Col. (later Brigadier) JohnP. Douglas, RAMC,26 the Britishfurnished:
7 walk-in refrigerators, each of 1,000-pint capacity, which took care of the initial requirements for fixed storage at the base and the requirements of mobile units. Each refrigerator had an attached motor-driven unit, which the British also furnished.
2 bulk-delivery 500-pint capacity refrigerators, suitable for use in communications zone depots.
30 smaller refrigerators, of 60- to 80-pint capacity, for the blood bank.
All of these items were available by 1 April 1944, which made it possible toplan for D-day as follows:
6 refrigerators for the base depot, each with a capacity of 600 pints of blood.
4 refrigerators, of 80-pint capacity, mounted on 2?-ton trucks on the hards, where there would be two advance section line of communications blood depots.
2 storage refrigerators, of 600-pint capacity, with the advanced blood depots.
4 refrigerators, of 540-pint capacity, mounted on 2?-ton trucks.
8 refrigerators, of 80-pint capacity, on 2?-ton trucks for the Third U.S. Army advance depot.
26Brigadier Whitby and Colonel Douglas furnished invaluable help in all the planning and organization of the U.S. Army Blood Bank, including the provision of bottles, tubing, needles, and a few other items which had to be obtained from British supplies. Their extensive experience was also helpful in the solution of many problems of logistics.
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The overall capacity of the refrigeration described was 8,240 pints of blood.
Post-D-day Transportation
On 23 June 1944, 2? weeks after D-day, a message was sent to the WarDepartment from ETOUSA, requesting additional vehicles for the blood bank, thecapacity of which was not sufficient to meet the requirements of the presentsituation. Since the troop basis would shortly be supplemented by two additionalarmies, a request was made for 30 additional 2?-ton 6 by 6 trucks; 4 dayslater, the request was increased to 34. If this type of truck was not available,1?-ton trucks would be acceptable. The basis of the request was thatrequirements for blood had proved far larger than originally estimated, that theblood bank in the United Kingdom could not further increase its capacity, thatit was not possible to build up reserves of a perishable substance such asblood, that a blood bank must therefore be established on the Continent with theassurance that it could provide adequate supplies of blood as they wererequested.
On 12 July 1944, the 152d Station Hospital informed the theater Chief Surgeonthat its requisition for 30 additional trucks for the expansion of PROCO III hadbeen disapproved by the War Department and, without increased transportationfacilities, increased demands for blood could not be met.
Although the original request for additional trucks was refused, the refusalwas later countermanded and the trucks, of the type specified, were dulydelivered, thanks in large part to the firm stand in the matter taken by ColonelHays.
FIELD TRANSFUSION UNITS
Authorized Personnel and Equipment
On 2 January 1944, in a memorandum dealing with whole blood, Headquarters,ETOUSA, informed the Commanding General, First U.S. Army, that the followingpersonnel and equipment would be furnished each field army without requisitionand would be regarded as over and above T/O and T/E provisions (32):
1. Personnel: 1 officer and 22 enlisted men.
2. Transportation: Nine 2?-ton trucks; one ?-ton truck; two motorcyclessolo.
3. Other necessary transfusion equipment, including about nine refrigeratorsto be transported on unit transport.
Preparation of Equipment
After the Ebert-Emerson transfusion set had been approved in 1943 by theMedical Supply Board, Office of the Chief Surgeon (p. 185), the first problem
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was to find an appropriate place for assembling and packing the sets. Withsome minor alterations, appropriate facilities were found at Thatcham, andGeneral Hawley ordered that, as supplies for the sets became available, they betransferred there and frozen for use in field units. The assembly and packagingof the units was accomplished under the supervision of Maj. (later Lt. Col.)Charles P. Emerson, MC, who was sent to Thatcham on temporary duty.
Shortages.-The assembly of the sets was not a simple matter becauseof shortages and substitutions (81). Although Baxter bottles had beenrequisitioned, British bottles were received, and, to avoid further delays, theywere used. Only 3,000 vials of sodium citrate solution with beads were received,instead of the 10,000 necessary for the 350 (reusable) transfusion sets to besupplied to each field army. The British vials, which were substituted, were thesame size as the U.S. vials but had to be repacked because the British packingwas undesirably bulky. The instructions to be included in each set did notarrive at Thatcham until 14 February, several weeks after the assembly of thesets had begun. In April 1944, the prospects were that it would take 10 monthsfor British firms to fill the order for 70,000 Welsbach gas mantles to be usedas filters. The 15-gage needles to be substituted for the 17-gage needlesoriginally used were requested from the Zone of Interior on air priority, butthey were still not available by the end of August. Special requests had to beplaced in April and May for such items as 3,800 adapters to be used to attachthe Luer needle to the rubber tubing in the units.
Shortages of blood donor needles, filters, and rubber tubing continued evenafter D-day until they were corrected by shipments of whole blood from the Zoneof Interior.
Allowances and Distribution
There was considerable discussion on the matter before the distribution oftransfusion sets was settled in the European theater. The original plan was tosupply 2 sets to each clearing company, evacuation hospital (400-bed, 750-bed),and field hospital, and 10 sets to each auxiliary surgical group (82). Later,the distribution was modified to provide 6 for each field hospital and 20 foreach auxiliary surgical group. It was estimated that 350 field transfusion setswould be needed for each of the two field armies then contemplated (83).
In January 1944, these estimates were expanded. On the basis that 2casualties out of each 10 would require transfusion, it was estimated that about20,000 sets would be needed for each 100,000 expected casualties, which meantthat 4,000 sets should be ordered at once (84). It was then expected thatsterile expendable transfusion sets would be ready for distribution in Februaryand could be supplied to hospitals and used as replacements for the fieldtransfusion sets then packaged in ammunition cases.
The suggestion that station and general hospitals be provided with fieldtransfusion units was not accepted, since whole blood transfusions could beaccomplished in them by modified British sets, which would be requisitioned
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through channels from the British Army Transfusion Service (p. 179). Thesehospitals were so equipped, furthermore, that they could clean and sterilizetheir own equipment.
By 13 March 1944, all field transfusion units had been completely assembledat Thatcham (85). They differed from the units originally planned in tworespects: That the amount of typing serum was sufficient for only 25 donors, notfor 50, and that, because of shortages, citrate had been secured from Britishand not U.S. sources, which decreased the number of transfusions possible witheach set from 18 to 10 or 11. Individual organizations, however, couldrequisition additional citrate and typing sera as needed.
The 175 transfusion sets requisitioned by the First U.S. Army were deliveredto it about the time expendable transfusion sets were first received from theZone of Interior. The latter were in very short supply-by 11 May, only 1,815of the 4,000 sets requisitioned on 20 January had been received in the theater-and,for this and other reasons, it was not considered advisable to replace theEbert-Emerson sets already delivered to the First U.S. Army. The Third U.S.Army, however, which had requisitioned 250 of the field transfusion units, wassupplied with the expendable sets, on the basis of two of the disposable setsfor each of the field transfusion sets requisitioned. When the First U.S. Armyrequired replacements, it, too, would be provided with the disposable sets.
All problems of this kind were eliminated when blood began to be flown fromthe United States to the European theater, since disposable giving sets wereincluded with each unit of blood.
ROLE OF THE SUPPLY DIVISION IN THE WHOLE BLOOD PROGRAM
Initial Planning
While the whole blood program in the European theater could not have beenoperated without the aid of the Supply Division, Office of the Chief Surgeon,ETOUSA, this division had no responsibility at all for the collection,processing, storage, or distribution of blood (73). That was theresponsibility of the ETOUSA Blood Bank, at the 152d Station Hospital, with thelater support of the 127th Station Hospital. The function of the Supply Divisionwas threefold:
1. To call up blood from the Zone of Interior and the blood bank at Salisbury according to the demands for it from the field.
2. To provide the necessary supplies for the operation of the bank.
3. To aid logistically in securing transportation for the blood.
The relation of the Supply Division to the blood program first appeared in amemorandum from Headquarters, ETOUSA, to the Commanding General, First U.S.Army, dated 2 January 1944 and dealing with the provision of whole blood fromthe Medical Service (32, 86). In this memorandum, it was stated
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that whole blood would be an item of medical supply which would bedistributed through medical supply channels and given the highest priority intransportation.
On 17 March 1944, in a conference between Colonel Muckenfuss and MajorHardin, it was agreed that all requests for supplies of whole blood shouldproceed through the same channels as requests for medical supplies. On 12 April,this understanding was expanded to indicate that "through normalchannels" meant that requisitions would proceed from the Continent toHeadquarters, G-4, SOS, where they would be extracted, sent to the theater chiefsurgeon's office, and then relayed to the base blood depot. This procedure, itwas estimated, would consume 48 hours.
Early in March 1944, the Supply Division began to plan for the delivery ofblood from the blood bank at Salisbury to the Continent via Depot G-45 atThatcham (73). It would be the responsibility of the blood bank to getthe blood to this depot and the responsibility of supply personnel at Thatchamto see that it was loaded on the plane and that provisions were made for icingthe blood from this point until it reached the Continent. When blood was shippedfrom the bank at Salisbury, and later, when it was shipped from the Zone ofInterior, it was the responsibility of the Supply Division to see that it wasproperly iced along the way. If any shipment of blood was improperly iced or wasmishandled for any other reason, it was the responsibility of the SupplyDivision to investigate the circumstances and correct them if the division wasresponsible; if not, the blood bank was informed.
Implementation of Plans
The assignment of planes in which blood was transported to the Continentcleared through the office of Colonel Hays, not only because of the priority forblood but also because of the priority of other supplies, particularlypenicillin, which were sent to the Continent on an emergency basis. Personnel ofthe Supply Division soon learned that, when planes were difficult to procure,blood and penicillin were both magic words.
No difficulties arose in the relation of the blood program to supply channelsas long as the blood bank remained at Salisbury. In September, when the 152dStation Hospital blood bank moved to the Continent, some misunderstandingsdeveloped.
On 23 September 1944, Colonel Kimbrough wrote the Executive Officer, Officeof the Chief Surgeon, suggesting that a circular letter be published, statingthat:
1. The 152d Station Hospital would operate the ContinentalSection of the ETOUSA Blood Bank.
2. Major Hardin, commanding officer of the hospital, wouldserve as director of the bank, in addition to his other duties.
3. Technical supervision of the bank functions (that is,procurement, processing, storage, and distribution of blood) would be theresponsibility of the Professional Services Division, Office of the ChiefSurgeon, ETOUSA.
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Colonel Hays objected to this proposal, on the ground that the division ofresponsibility within the Office of the Chief Surgeon was not a matter for acircular letter. In his opinion, the outside world should consider this officeas an entity, and the division of responsibility and authority in it should behandled by an office memorandum. He called attention to Office Memorandum No.10, 17 September 1944, over the signature of Colonel Doan, Executive Officer,Chief Surgeon's Office, which stated that the Supply Division of this officewas responsible for the requisitioning of blood in adequate quantities to meetrequirements on the Continent and for its proper and timely distribution. Theseresponsibilities would require intimate coordination with other divisions of theOffice of the Chief Surgeon, especially by the Professional Services Divisionand the Plans and Operations Division. Associated divisions were reminded tokeep the Chief of the Supply Division constantly acquainted with the situationas it applied to their particular activities. Any irregularities or suggestedimprovements in procedure which came to the attention of any one division shouldbe transmitted to the responsible division.
As a result of the discussion, in which others participated, OfficeMemorandum No. 10 was rescinded and Office Memorandum No. 19, dated 30 October1944, was issued in its place. In substance, it was as follows:
1. Whole blood for transfusion purposes is obtained frombleeding on the hoof (local bleeding), from the United Kingdom Blood Bank atSalisbury, or from the United States by air.
2. In the near future, blood will be furnished by a blood bankon the Continent. (As a matter of fact, by the time this memorandum was issued,the Continental Blood Bank had already been set up and was distributing blood.)
3. The provision of whole blood for transfusion is acomplicated procedure, involving the establishment of technical standards, withtechnical supervision of collection; preparation; storage; transportation;issuance; and, finally, administration of the blood to the recipient. Thedivision of responsibility and authority27 in this procedureis as follows:
a. The Professional Services Division is responsible for the establishment of standards and for technical supervision of the collection, processing, and administration of whole blood.
b. The Supply Division is responsible for the supervision of transportation, storage, and distribution of the blood.
4. Since blood is chiefly transported by air, and since thesame planes are used for the transportation of other medical supplies, thetransportation and distribution of blood and other medical supplies moved by airare very closely related.
5. In carrying out the duties assigned to him, the SeniorConsultant in Blood Transfusion and Shock, Major Hardin, who is also commandingofficer of the Continental Blood Bank, will operate under the supervision of theProfessional Services Division and the Supply Division as just outlined.
6. All divisions of this office (that is, the Office of theChief Surgeon, ETOUSA), will keep the Chief of the Professional ServicesDivision and the Chief of the Supply Division acquainted with any matterpertaining to the supply of whole blood within the division of responsibility asjust outlined. Information to higher echelons and instructions to lowerechelons, including requests for information, will be routed through thesechannels.
27This division of responsibility proved to be as unnecessary as it was undesirable. It worked in this instance because Major Hardin made it work; an officer of lesser stature might readily have failed. The present (1962) policy is to place the entire responsibility for the transfusion service in professional hands.
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Occasional difficulties continued to arise, but, on the whole, the relationof the whole blood program to supply channels was cooperative, and personnel ofthe blood program freely admitted their obligation to the Supply Division forits successful operation.
SECURITY MEASURES
Unusual activity in the blood bank would, of course, have been a clearindication that the date of the invasion was approaching. On 1 May 1944, GeneralHawley wrote to the Commanding Officer, 1st Medical Laboratory (87), thatthe pony edition of Time for 24 April 1944 had carried an item to theeffect that a recent dry run in the bank had been just for practice but that 3weeks before the invasion, "the dry run will become wet." Obviously,General Hawley wrote, after such an announcement, no better indication could begiven to the enemy of the date of the impending invasion than the inaugurationof a stepped-up collection of blood. He found it necessary, therefore, to directthat blood be collected on the maximum possible scale from this date until theinvasion; otherwise, it would not be possible to resume collection until afterthe invasion. He requested all details concerning the origin of this statementand concerning the clearance of the particular correspondent responsible for it.
In reply, Colonel Muckenfuss stated that no correspondent for thispublication had ever visited the 1st Medical Laboratory; the term "dryrun" had not been used in the laboratory for at least 3 months; small-scalebleedings had been made at frequent intervals; and blood could not be keptlonger than 3 weeks, which made the statement about beginning to collect blood"in earnest" 3 weeks before the invasion obviously incorrect. He couldtherefore throw no light on the source of the statement. He added that he haddiscussed the problem of security several times with Major Hardin, to decide onmethods of minimizing evidences of unusual activity in the blood bank.
Immediately after General Hawley's complaint was received, all bleedingteams were sent out from the bank every day, to work all day and collect bloodin places in which there were only a few donors, who were bled behindostentatiously locked doors. At the end of each long day, the few donations thusprocured were rushed in clearly marked 500-pint refrigerators to the blood bank.
Actual blood collection for the invasion began 20 days before D-day, but, byColonel Muckenfuss' own desire, he was not informed of Major Hardin's timeschedule, and, as the latter expressed it in 1961, "I was the only personwho ever knew when the blood bank was actually turned on."28
28Queried as to the correctness of this statement,Dr. Hardin wrote as follows on 15 February 1963:
"The statement that I made that I was the only person who 'knew when theblood bank in the ETO was actually turned on' is literally correct. Thecircumstances under which this arose now have somewhat unreal characteristics,but went something like this.
"Several months before D-day the headquarters of the ETO blood bank wasvisited by a public relations officer who had in tow a Time reporter.Among the many questions asked of me was the one of how long blood could bekept. At that time the proper answer was 21 days and in due course thereappeared an article in Time magazine which said the ETO blood bank wouldbegin collecting blood 20 days before D-day. This was an assumption made by thereporter, but happened to be uncomfortably correct. As you can imagine, GeneralHawley was reasonably upset and he ordered me to undertake such activity aswould make it impossible for people to know by observation when the ETO bloodbank was actually 'turned on.' For that reason, we began somewhat hecticactivity designed to produce confusion among all observers and among my ownpersonnel. Bleeding teams were sent hither and yon, but always to units wherethere were too few donors to be of significance when we really startedcollecting blood. The blood was brought back to the central laboratory andprocessed and was distributed to hospitals so that there was no evidence at thecentral unit of how little blood was actually being collected.
"The units of the ETO blood bank which were to go across the Channel wereput into positions of embarkation along with other troops behind the barbed wirealong the southern coast of England some time in advance of the invasion. Theywere sent there without instructions as to what their mission was or where theywere going. Later I was given a pass which let me go behind the wire andbrief my units and, as a matter of fact, take blood to them for transport acrossthe Channel. As you know, we landed our first depot unit in Normandy on D-plusone. In addition, we loaded blood on 104 ships, most of which were LST'sconverted to bring troop wounded back from France. No one in the unit knew wherethese ships were to dock and be loaded, nor the day nor time, except myself andI kept this after receiving it at the British Naval Headquarters in Southamptonentirely in my memory, never writing it down. I personally supervised theloading of refrigerator trucks in Salisbury and these and their drivers wentbehind the wire where they were met by some of my officers already in thatlocality. After accomplishing their mission these trucks and drivers were keptbehind the wire until the invasion of Normandy was a fact.
"My memory fails me as to the exact time but early in the spring it becamenecessary for me to know when D-day would occur. One morning at General Hawley'sheadquarters in London, I was taken to the middle of a large room by ColonelListon and others and the date of D-day was whispered in my ear. I was told thatthis date was a planning date and that the actual invasion would occur within a48-hour span of this date. Thus I knew when to begin the bleeding in the bloodbank in earnest, when to put blood behind the barbed wire along the southerncoast, and when to begin all of the operation in earnest. I was forbidden todisclose this date to anyone else, of course, and although several of the peoplein the unit must have realized that D-Day was imminent, I am certain that no onewas actually aware of the real day until it happened.
"I hope this clears up my statement and I hope that none of us will ever gothrough that kind of an experience again."
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HOUSEKEEPING ARRANGEMENTS
As already mentioned (p. 499), the l52d Station Hospital, which served as theETOUSA Blood Bank, was attached for housekeeping and general administrativepurposes as long as it was in England, to the 1st Medical Laboratory. A similararrangement was in effect for the 127th Station Hospital when it took over theblood bank functions of the 152d Station Hospital and the latter moved to theContinent.
Different arrangements were necessary when the 152d Station Hospital moved tothe Continent, in September 1944. The parent bank in Paris was then attached forhousekeeping and administrative purposes to the 1st General Hospital (p. 516).
The detachments of the two blood banks which operated in the field wereattached for these purposes to any convenient medical supply depot, thecommanding officers of which provided rations, quarters, space for bloodstorage, and other needs. These arrangements were highly satisfactory. Themedical supply depots to which the detachments were attached rendered greatassistance to them. The mobility of the Army medical supply depots made thesetup particularly satisfactory, for the Army detachments of the blood banksalso followed the armies which they served. Locations of station and evacuationhospitals were secured from the depots to which the detachments were attached,and some confusion sometimes arose.
The revised directives for ADSEC detachments (54, 57) provided forattaching them for rations and administrative purposes to the units which
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operated Army Air resupply strips. This plan was quickly put into effect byan agreement between the Commanding General, Ninth Air Force, and the CommandingGeneral, ADSEC, and it continued to be standing operating procedure for the restof the war. It had many advantages. The blood detachment could quickly unloadthe C-47's which transported their daily supply of whole blood. The distancebetween this location and the banks in the Army area was short. Communicationswith Headquarters, ADSEC, and the base depot of the ETOUSA Blood Bank werealmost immediately available.
In order that commanding officers of these mobile blood units be unhamperedby tight control, they were given relative freedom of action in planning theirforward movements. The Surgeon, ADSEC, however, insisted upon prior clearancefor moves when the situation permitted, for station list and order purposes,and, in an occasional instance, tactical requirements demanded otherdispositions than those planned.
EARLY OPERATIONAL DIFFICULTIES
As might have been expected, a number of problems arose in connection withthe whole blood service in the first weeks of its operation. On 19 July 1944, anumber of them were called to the attention of Col. (later Brig. Gen.) John A.Rogers, MC, Surgeon, First U.S. Army, by General Hawley's office (88):
1. Trucks designated for blood were being required to carryout many diversified tasks, such as hauling tools, medical supplies, repairparts, and even personnel. This left insufficient time for the propermaintenance of these trucks and of the refrigerators mounted on them. If thisunwise practice were continued, it could lead to serious interruptions in theblood program, for no trucks were available as replacements for these specialtrucks; they were essential for the delivery of blood.
2. The motorcycles and jeeps designated for the blood bank hadbeen moved from its control and had thus lost their value for their designatedpurpose, which was to make contact with using units.
3. The blood bank was not kept posted on the movement offorward hospitals, and they were sometimes difficult to locate.
4. It would help materially in the use of blood if the bloodservice were notified when a hospital was closing and moving. The blood in itscontrol could then be picked up and redistributed, and the hospital could berestocked when it was again in operation. Blood was too precious a commodity forany of it to be wasted through preventable deterioration.
It was evident, General Hawley concluded, that as more and more troops werecommitted, greater economy must be practiced in the use of blood. The limit ofsupply was fixed not by the organization which collected and processed it but bythe availability of suitable donors. That limit had almost been reached, and itwas therefore requested that necessary action be taken toward improving theefficiency of the blood service on the far shore.
The memorandum from General Hawley's office bore out complaints frommembers of the blood detachments. In June 1944, the commanding officer of onesuch detachment wrote to Major Hardin that his two motorcyclists had
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been placed on detached service and that he had just lost a sergeant. Hewished no replacement for the latter, but if he had to have one, he wanted aprivate.
He still had no jeep. His trucks were working well, but were gettingunnecessarily hard wear. He wrote:
In addition to hauling blood, we are ordered to pick uplaboratory specimens. We have to carry the depot refrigerator mechanic and thedepot sterilizer mechanic out to their jobs at one of the hospitals. We alsocarry parts and tools. We carry the men back to the depot or to a differenthospital. We still haul some freight from the depot to advance sections or viceversa. We carry biologicals from the airstrip to the depot and optical repairsfrom the depot to the airstrip. We haul X-ray machines for repair and back.
It was increasingly difficult, the writer continued, to keep refrigerators ingood condition because of damage caused to them by hauling freight. The truckswere kept on the road so much that their maintenance was as unsatisfactory asthe maintenance of the refrigerators.
It was also difficult to keep up with the increasing number of hospitals inthe area, the writer went on, now that the blood detachment was on the same postas the base platoon of the medical depot and information as to hospitals was nolonger secured from First U.S. Army Headquarters. Changes in location were oftenreceived late and were often incorrect. On a recent trip, one of the detachmenttrucks had spent the entire night searching for the hospital to which its bloodwas consigned and did not find it until the next day, when correct informationabout its location was secured.
The writer found the failure of the Supply Division (headquarters not stated)to discuss proposed changes with blood personnel very discouraging: A recentruling, for instance, that marmite cans be sent to field hospitals to increasethe amount of blood to be kept on hand in them was put into effect withoutprevious notice. The result would be an increased lag in the return of thesecans and an imbalance in both cans and recipient sets.
This extremely pessimistic memorandum ended on a brighter note, that usinghospitals seemed to be entirely satisfied with the blood service. The misuse ofthe trucks, however, of which the writer complained and which duplicated theexperience of other detachments of the blood bank, further substantiated theimportance of completely dissociating blood from medical supply.
INQUIRY INTO EFFICIENCY OF AIRLIFT TO EUROPEAN THEATER
On 8 January 1945, at the suggestion of Colonel Carter, who believed that thedesired information would be expedited by personal communication, Major McGraw,who was now in the Office of The Surgeon General, wrote to Major
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Hardin asking for details of the operation of the oversea blood program (89).Up to that time, very little information had been received in the Office ofThe Surgeon General regarding blood sent to the European theater. Indeed, notmuch was known about what happened to it after it was put on the oversea plane.Improvements in handling were desirable and would be facilitated by informationon the following points:
1. How long did it take blood to reach the ETOUSA Blood Bank?Presumably, it should reach it in about 24 hours after it was put on the plane,but there must be many occasions when bad weather delayed shipments en route. Ifso, steps should be taken to prevent both warming and freezing.
2. Were all shipments received? There was no assurance at thepresent time that blood might not often be landed at an alternative field andleft unattended or even forgotten.
3. Was it desirable to send a courier with each shipment?Personnel of the North African Theater Blood Bank, with which Major McGraw hadpreviously worked, considered it absolutely essential that a responsible personaccompany each shipment of blood to northern Italy as well as to southernFrance. It was the courier's responsibility to see that the blood was properlyhandled at any emergency landing field en route and to secure landtransportation to within a reasonable distance of its destination if the planecould not put in at the regular airfield.
4. In what condition did the blood reach the theater? Therewas concern that some of it might be frozen or hemolyzed, or that somecontainers might be broken.
5. Was enough blood being received? The Red Cross had heardunofficially that there was some resentment in the European theater because lessblood was shipped than had been requested. The director of the Red Cross bloodbank had reported this story to The Surgeon General, who could only reply thatthe last request from ETOUSA had been for 1,000 bottles a day and that 1,000bottles a day were being sent. The shipments could be increased beyond thisamount if the request was made.
6. Were the hospitals satisfied with the blood? Were therehemolytic or pyrogenic reactions from it? Were there any errors in bloodgrouping?
In this same letter, information was requested concerning titrationpractices. In Italy, a technique was employed by which it was possible to pickout about 30 percent of the highest titered O bloods. These bloods were markedfor the use of O recipients only. The practice had been adopted becauseof a severe hemolytic reaction in a patient with group A blood, who had receivedgroup O blood with a very high anti-A titer (p. 424).
Most of these questions were answered by Capt. John Elliott, SnC, from hisobservations in the European theater on his visit there later in January (90).They are discussed under appropriate headings. In general, his report washighly favorable. So far as he could determine, no blood from the United Stateshad been contaminated on receipt, nor had there been any errors in typing. About18 bloods of each thousand had to be discarded because of hemoglobin in thesupernatant plasma. Since it had been discovered in December 1944 that a smallnumber of bottles of blood hemolyzed rapidly, for no reason that could bediscovered, the plan had been adopted of allowing all blood to sediment for 24hours before it was shipped out of the Paris Blood Bank (91). Each bottlewas then examined visually before it left the bank.
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CLINICAL PROBLEMS
Difficulties With Equipment
On 27 June 1944, General Hawley requested G-4 to provide space on a plane thefollowing day for Major Hardin to fly to the Continent. On his own visit, he hadobserved certain difficulties in the administration of blood, particularlymaintenance of the proper rate of flow, which was a most important element inthe procedure. He wished Major Hardin to investigate the trouble immediately.
Major Hardin arrived on the far shore the following day, and, in fulfillmentof General Hawley's mission, visited the Office of the Surgeon, First U.S.Army; the 1st Medical Depot Company; the Advance Blood Bank (Detachment A) ofthe 152d Station Hospital; and the 45th, 67th, and 128th Evacuation Hospitals (92).
In discussions with Colonel Crisler, Consultant in Surgery, First U.S. Army,Major Hardin learned that the difficulties in the blood program were chiefly inthe administration of the blood, during which the rate of flow was frequentlyinadequate. Most observers considered the filter at fault, but Colonel Crisler,as well as Col. William G. Amspacher, MC, Chief of Plans and Operations, Officeof the Surgeon, First U.S. Army, believed that the filter was adequate and thatthe rate of flow was hampered by the size of the needle and the adapter. Someofficers complained that they had lost patients because the blood clotted. Whilethe complaints were most prevalent on the beaches, there were also difficultiesin hospitals and they continued for some time, even after the Continental BloodBank had been established.
Some officers overcame the poor performance of the filter by using gauze forfiltration. Others transferred the blood to salvarsan tubes for administration.Still others, who were in the majority, applied positive pressure by means of aHigginson syringe obtained from the field transfusion set or a sphygmomanometerbulb. Results with all methods were about the same, but the use of positivepressure was not desirable because the tubing and adapters provided were not ofa quality to withstand the pressure. When this expedient was employed, it was acommon experience for the system to spring leaks, with the result that thetransfusion had to be stopped and the blood being used had to be discarded. Thesolution would have been the use of l5-gage needles, but they were not availableuntil much later.
Major Hardin considered all of these complaints justified. Transfusion shouldbe a continuous and efficient procedure. In the period immediately after D-day,it was too often improvised and interrupted. It became continuous and efficientwhen expendable transfusion sets were supplied, with adequate filters andneedles of larger bore.
Colonel Cutler believed that bank blood which clotted did not contain asufficient quantity of citrate solution. It is true that when blood began to be
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received from the Zone of Interior in Alsever's solution, complaints ofclotting ceased. Many observers, however, continued to believe that it was notdesirable to give blood diluted 50 percent by the preservative solution.
When the expendable set was introduced, with the givingneedle attached directly to the rubber tubing, there was seldom any difficultyin transfusing a casualty who had good veins. When the veins were collapsed, thesituation was different. Since the needle was attached directly to the rubbertubing, without a connecting observation tube, it was not easy to detach theneedle and hook it up to a syringe, to facilitate location of the vein. Somemodification of the set was necessary in such circumstances. This wasaccomplished at some hospitals by cutting off the needle attached to the rubbertubing and replacing it with the needle and observation tube from the plasmaset. After the needle had been connected to the syringe and the vein located,the needle was attached to the Luer tip of the observation tube before thetransfusion was started.
Aging of Blood
On his visit to the European theater in September 1944 (1), ColonelKendrick was informed of two transfusion reactions, accompanied by chills andfever, which had occurred in the 1st Platoon of the 60th Field Hospital, and ofeight similar reactions in 50 transfusions in the 12th Evacuation Hospital. Indiscussions with the chiefs of the surgical and laboratory services in thehospitals involved, he learned that, in each instance, the blood was within afew days of the expiration date, or beyond it. Most of the patients for whom ithad been used had lost a great deal of blood, and they were transfused with theaging blood because of their extreme need.
Further investigation revealed other special circumstances.Immediately after the service to Prestwick from the Zone of Interior had beeninaugurated, there was a sharp reduction in the number of casualties and acorresponding decrease in the requirements for whole blood. As a result, therewas a lag in shipments from the United Kingdom to France, and some blood wasstored for 8 or 9 days before it was sent to the far shore. At one time, eventhough the collection of blood in the United Kingdom was halted altogether,there was a backlog of 6,000 pints of blood in the United Kingdom.
Major Hardin and Colonel Kendrick recommended that, beginningat once (26 September 1944), blood from the Zone of Interior be sent immediatelyfrom Prestwick to France, the oldest blood on hand being shipped first, to besure that it was used before the dating period expired. They further recommendedthat blood which could not reach hospitals in France before the expiration datebe used in general hospitals in the United Kingdom, or, if necessary, discardedentirely. It was expected that, as the number of casualties again increased, thelag would be overcome. This did not happen immediately, however, and for a time,blood continued to be sent to the far shore which had aged a week or more beforeit reached the using hospitals.
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An additional difficulty in this connection was that, because of bad flyingweather and the consequent delays, some blood had already aged for several daysin the Zone of Interior before it was flown to the United Kingdom.
The safety of using blood that was from 14 to 18 days old for exsanguinatedcasualties could not be readily determined from existing evidence. Theimpression prevailed that those casualties with depleted blood volume were morelikely than others to have reactions after intravenous therapy.
On a priori evidence, this reasoning seemed sound. As blood ages, the amountof free hemoglobin in it increases, as does the amount of plasma potassium.Although the normal human kidney will tolerate rather large quantities (up to 5gm.) of hemoglobin without significant pathologic changes, the exsanguinatedcasualty probably has a much lower threshold for this substance. When anoxia isadded to lowered blood pressure and decreased circulating blood volume in acasualty who has suffered severe hemorrhage, it is logical to assume that renalfunction will be impaired. Then, if blood with 50 to 100 mg. of free hemoglobinper 100 cc. is injected, there is a real increase of free hemoglobin in gramsper volume, and kidney function is further impaired. As a result, reactionsmight be expected.
While this reasoning was recognized as purely conjectural,29it did suggest the need for providing greatly exsanguinated casualties with asfresh blood as possible. It also suggested the need for alkalinizing casualtieswho had sustained severe hemorrhage and had to be given 3-4 pints of blood overa short period.
After his tour of First and Ninth U.S. Army installations in September 1944,Colonel Cutler expressed the opinion that field hospitals should be given wholeblood, that is, ETOUSA blood, while evacuation hospitals, in which the need forblood was generally less acute, should be given preserved Zone of Interiorblood, in which there were fewer corpuscles. No action was taken.
The whole subject of reactions is discussed in detail under that heading (p.649).
Use of Chilled Blood
Another subject brought up to Colonel Kendrick on his visit to the Europeantheater in September 1944 was the use of chilled blood in exsanguinatedpatients. Clinical usage had demonstrated the safety of injecting blood at 39?to 43? F. (4? to 6? C.), and the practice was now routine in manycivilian hospitals.
The injection of chilled blood into patients in shock from exsanguination,who were in an unstable state and exposed to cold surroundings, had not yet beeninvestigated. It seemed safe to conclude that this practice would produce nobiologic reactions, but the experience in field hospitals had shown that itcaused chilly sensations, and both patients and surgeons objected to it. Colonel
29The present (1962) belief is that hemoglobin plus ghost cells originating in nonviable red blood cells are responsible for the reactions described.
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Kendrick therefore recommended that, whenever time permitted, blood to beused in exsanguinated casualties be removed from the refrigerator an hour beforethe transfusion. This practice had its own elements of danger: Blood could beused safely after it had stood at room temperature for 2 or 3 hours, but in therush of caring for many casualties at once, it might be overlooked and left outof the icebox until it was no longer safe to use.
Part VIII. Statistical Data
QUANTITATIVE USE OF BLOOD
Initial Observations
When it became evident, soon after the invasion of theContinent, that much more blood would be required for combat casualties than hadbeen anticipated, the question naturally arose as to how efficiently the bloodavailable was being used. On this point there were several opinions.
When Major Hardin returned from the trip to the Continentwhich he had begun on 28 June, he reported that he had not seen a singlecasualty in whom transfusion had not been both helpful and desirable (92). Itwas being given to exsanguinated casualties to build up the hemoglobin level andrestore lost blood volume and was also being used to combat gas gangrene. It didnot appear to him that blood was being used to excess.
Statistical data were not readily available, but in the threeevacuation hospitals which he had visited, the ratio of blood to casualties was1:4.7 and the ratio of plasma, 1:3.2. The ratio of blood to plasma was about1:1.4. Since many casualties had received plasma before admission to thehospital, these ratios could not be accepted as entirely accurate. There wasperhaps some justification for the hope that the use of smaller amounts ofblood, backed up by plasma, might produce almost as good results as the use ofwhole blood. Perhaps a ratio of one unit of blood to three units of plasma mightbe considered by First U.S. Army medical personnel, since the supply of bloodwould always be limited and the amount administered must be adjusted to thesupply.
At about the same time as Major Hardin's survey, ColonelZollinger conducted an investigation of the relative use of plasma and blood inforward hospitals (43). The shock teams which made the study reportedthat the ratio in field hospitals was 1.63:1 and in evacuation hospitals 1.34:1.More important than the actual figures was the opinion of the surgeons: Amedical officer on one of the 3d Auxiliary Surgical Group teams, who hadpreviously worked in North Africa and Sicily, stated that the greatest singlemedical blessing in the European theater was the availability of blood from theblood bank, which was making it possible to operate on, and save, casualties whowould never have survived on plasma alone.
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On 1 July 1944, General Hawley wrote Colonel Rogers, Surgeon, First U.S.Army, that on a recent trip to the Continent, Colonel Cutler had gained theimpression, as he had on his own recent trip, that in some units blood was notbeing used economically. Since there was a limit to the amount that could besupplied, use must be proportionate to the supplies available.
When Colonel Cutler transmitted Major Hardin's report (92) toGeneral Hawley, he noted that the present ratio of blood to plasma indicatedthat only a little more plasma than blood was being given. He had expected thatthe amounts of plasma used would be at least double the quantities of bloodused. He considered the present usage of blood quite satisfactory, but theProfessional Services Division must be constantly alert to be sure that thisvaluable substance was being utilized correctly.
Essential Technical Medical Data from the European theater for October 1944 (93)also had some criticism of the excessive amounts of blood used in somecases. Investigation had shown that, on the whole, if appreciable benefit werenot obtained after 4 pints of blood had been transfused, a consultation shouldbe requested, to determine whether prompt operation would not be the properprocedure.
As time passed, the realization grew that, contrary to the first impressionthat blood was being used to excess, more was needed than had been givenoriginally. By October 1944, shock teams were beginning to view more criticallythe necessity for correcting depleted blood volume by the use of whole blood.Canadian shock teams, working with apparatus for determining blood volume, hadfound that the reduction in severely wounded men averaged 33 percent, which wasequivalent to a loss of 2,000 cc. in a man 5 ft. tall and weighing 70 kilograms.On the basis of this observation, the demand for blood by Army surgeons was notconsidered excessive.
Adjustment of Supply and Demand
One of the problems of the blood program was to supply blood in proportion tothe need for it, since it is not a substance which can be stocked indefinitely.On 14 September 1944, General Hawley wrote General Kirk that, as soon as thesupply of whole blood had been increased by the institution of the airlift fromthe United States on 21 August, the demand for it had decreased by about 75percent, because of the slackening in combat (94). This had been atemporary situation. Now that the First U.S. Army was up against the SiegfriedLine, it was expected that the need for blood would promptly increase again.
Even during slack periods in combat, when supply exceeded demand, care wastaken to waste no blood. In December 1944, Colonel Kimbrough proposed, in amemorandum to Colonel Hays, that during such periods, general hospitals, whichwere required to supply their own blood, be provided with blood from the Parisbank. He had observed that whole blood was accumulat-
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ing for field use while at the same time general hospitals were havingdifficulty setting up blood panels. Colonel Liston, acting for General Hawley,concurred in this recommendation, and it was put into effect. Shortly afterward,the Battle of the Bulge resulted in renewed demands for very large amounts ofblood.
Special and unexpected requirements for blood also sometimes arose. Thus, inthe spring of 1945, the 182d General Hospital reported an unusual demand forblood, chiefly because of the malnourished condition of many liberated U.S. ArmyPOW's (prisoners of war).
The real need for whole blood for wounded casualties is attested to by theexperiences of individual forward hospitals. The 84th Field Hospital is anillustration. It landed on Omaha beach on 14 July 1944, operated for a shorttime with the First U.S. Army, and then was assigned to the Third U.S. Army.During August, it moved 13 times in support of the 79th Division ClearingStation. After 6 November 1944, it was assigned to the Seventh U.S. Army, inwhich it operated in support of division troops.
No matter where it was serving, the personnel of this hospital found, monthafter month, that from 60 to 90 percent of the casualties it received wereeither in shock or had been in shock within the previous 6 hours. Most of themhad received plasma in forward installations, but almost without exception, theyalso needed large amounts of blood before they could be pronounced ready foroperation.
CRITIQUE ON THE USE OF BLOOD ON THE CONTINENT
July-September 1944
In his tour of Army installations on the far shore in September 1944, as theSpecial Representative on Blood and Plasma Transfusions to The Surgeon General,Colonel Kendrick made the following observations (1):
1. The quantity of protein fluid that can be injected into acasualty over a period of time without undue reactions varies because ofindividual tolerances. As much as 9 pints of blood and 2-6 pints of plasma canbe safely given over a 24-hour period, depending upon the circumstances.
2. A casualty with an organically normal cardiovascularsystem, who has suddenly become exsanguinated, canpresumably tolerate the introduction of 3-4 liters of blood and plasmaover a 24-hour period.
3. If casualties who have suffered severe hemorrhage do notrespond to the amount of blood and plasma just mentioned, surgical consultationis necessary. Failure to respond may be due to continued hemorrhage or to theresults of severe tissue damage, and prompt surgical intervention may benecessary.
4. Observations in field and evacuation hospitals in the Firstand Third U.S. Armies showed that excessive amounts of blood had sometimes beenused. The most important single factor in the picture was the timelag betweenwounding and the beginning of treat-
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ment. Casualties seen fairly early, that is,within 3 hours after wounding, were frequently benefited by blood in relativelylarge amounts, 8-9 pints given in 2-4 hours. If, however, the casualty wasexsanguinated and the timelag had been long, up to 10-12 hours, very littleimprovement could be expected, even with enormous quantities of blood. Somepatients had been given 27 pints in 18-24 hours.
From his observations on the Continent, Colonel Kendrickconcluded:
1. From a practical standpoint, it was impossible to setarbitrary standards as to the relative quantities of plasma and blood anindividual casualty should receive. The decision must be based upon individualevaluation of the amount of blood loss; the cessation or continuation ofhemorrhage; the degree of shock; the blood pressure and pulse rate; the numberand severity of the wounds; the timelag; and, most important, the general statusof the patient.
2. If surgical consultation was requested when no improvementfollowed the transfusion of 3-4 pints of blood, tremendous quantities would notbe used without adequate justification.
AIRLIFT TO THE EUROPEAN THEATER
The oversea service to ETOUSA from the Zone of Interiorbegan on 21 August 1944 and ended on 10 May 1945. During this period, accordingto the Army Whole Blood Procurement Service, 201,105 pints of blood were flownacross the Atlantic (table 20).
TABLE 20.-Finalconsolidated report of monthly shipments to ETOUSA, Army Whole Blood ProcurementService, 21 August 1944-10 May 1945
Year and month | New York shipments | Brooklyn shipments | Boston shipments | Washington shipments | Baltimore shipments | Total |
| 1944 |
|
|
|
|
|
|
August | 2,489 | --- | --- | 1,092 | --- | 3,581 |
September | 8,202 | ---- | 4,561 | 3,048 | --- | 15,811 |
October | 7,781 | 828 | 5,179 | 3,096 | --- | 16,884 |
November | 9,034 | 3,548 | 5,519 | 4,668 | --- | 22,769 |
December | 9,936 | 3,734 | 6,392 | 4,688 | 1,540 | 26,290 |
| 1945 |
|
|
|
|
|
|
January | 9,959 | 4,301 | 7,219 | 4,881 | 2,487 | 28,847 |
February | 9,042 | 4,244 | 5,826 | 3,768 | 2,388 | 25,268 |
March | 10,994 | 5,402 | 6,524 | 4,999 | 2,591 | 30,510 |
April | 9,226 | 4,503 | 5,282 | 3,499 | 1,897 | 24,407 |
May | 2,420 | 756 | 1,641 | 1,237 | 684 | 6,738 |
| 79,083 | 27,316 | 48,143 | 34,976 | 11,587 | 201,105 |
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For the week ending 26 August 1944, the first week of the service, 1,627pints of blood were shipped, a daily average of 271. For the next week, thetotal shipped was 3,017 pints, a daily average of 503. During the week ending 18November, 6,150 bottles were shipped, a daily average of 1,025. During 25 daysof collections in December, 26,657 pints were shipped, an average of 1,066bleedings per working day. The highest point in shipments was reached during theweek ending 3 March 1945, when 7,230 pints were shipped to the European theater.
By the end of January 1945, the theater was receiving an average of 6,000pints of blood per week, even though bad flying conditions sometimes forced theAir Transport Command to suspend deliveries for 1 to 3 days at a time. On 24January 1945, General Hawley wrote General Kirk that the whole blood transfusionsetup, from supply to administration to the patient, was "one of thehappiest situations" in the theater, and that his (General Kirk's) officehad played the dominant role in it.
At this point it is necessary to repeat the statement, made several timespreviously, that the statistical data in this volume, while as complete and ascorrect as possible, are not always complete and are sometimes in conflict. Intable 20, for instance, which represents the final report of the Army WholeBlood Procurement Service for the entire period of the airlift to Europe, thetotal number of units of blood shipped is put at 201,105. In the officialhistory of the American Red Cross Blood Donor Service (95), the number isput at 205,907 (p. 101). The explanation of this discrepancy is probably thatsome of the bloods collected for this purpose were, for one reason or another,not used in the airlift.
In theaters of operations, the circumstances in which blood was given weresimply not conducive to accurate recording. The reader, therefore, is cautionedagainst accepting as numerically accurate all the data presented, though he isentirely safe in accepting as accurate the trends that they represent.
PRODUCTION OF ETOUSA BLOOD BANK
Table 21 is a record of the production of blood by the ETOUSA Blood Bankoperated in the United Kingdom first by the 152d Station Hospital and later bythe 127th Station Hospital, and operated on the Continent by the 152d StationHospital (54, 55, 57, 96).
Table 22 is a record of all deliveries of blood to and on the Continent bythe ETOUSA Blood Bank and from the Zone of Interior via Prestwick.
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TABLE 21.-Production and distribution ofblood, ETOUSA Blood Bank, April 1944-June 1945 (57)
Year and month | United Kingdom Section1 distribution- | Continental Section2 distribution | Total monthly blood bank distrubution | ||
On Continent | In United Kingdom | Total | |||
| 1944 |
|
|
|
|
|
April | --- | 20 | 20 | --- | 20 |
May | --- | 1,790 | 1,790 | --- | 1,790 |
June | 7,650 | 3,945 | 11,595 | --- | 11,595 |
July | 11,890 | 906 | 12,796 | --- | 12,796 |
August | 13,018 | 411 | 13,429 | --- | 13,429 |
September | 5,359 | 515 | 5,874 | --- | 5,874 |
October | 8,150 | 749 | 8,899 | --- | 8,899 |
November | 7,910 | 573 | 8,483 | 4,178 | 12,661 |
December | 11,550 | 650 | 12,200 | --- | 12,200 |
| 1945 |
|
|
|
|
|
January | 12,100 | 709 | 12,809 | 3,977 | 16,786 |
February | 9,464 | 515 | 9,979 | 91 | 10,070 |
March | 6,677 | 1,278 | 7,955 | 2,704 | 10,659 |
April | 8,162 | 1,602 | 9,764 | 27 | 9,791 |
May | 1,764 | 806 | 2,570 | 435 | 3,005 |
June | --- | 6 | 6 | 1,054 | 1,060 |
| 103,694 | 14,475 | 118,169 | 12,466 | 130,635 |
1Operated by 152d Station Hospital until 1September 1944, then by 127th Station Hospital.
2Operated by 152d Station Hospital.
USE OF BLOOD IN ARMY INSTALLATIONS
In analyzing the statistical data for the use of blood in the individualarmies (tables 23-26) and the combined armies (table 27) on the Continent duringthe period of combat, a number of points should be borne in mind (96):
1. During the first 3 months after D-day-that is, untilalmost the end of August 1944-the supply of blood waslimited. Sometimes it was extremely limited. A great deal more should have beenused than was used, but it was not available. In June 1944, the ratio of bloodto wounded in forward installations was 1:3.9, not because that was a desirableratio but because that was all the blood there was to use. This ratio graduallychanged. For the remainder of the war it averaged out at 1:1.5. In February1945, it became 1:1, and it remained at this level thereafter.
2. There was no regularity or uniformity in the distributionof blood to using units. This was because the amount delivered was always indirect response to the collective demands of the forward hospitals, which werebased, in turn, on estimated casualties. If casualties did not materialize asexpected, then the amount of blood asked for was excessive. The blood had to berequisitioned, however, if it was thought that it would be needed. It wasutilized elsewhere whenever possible, but losses from this cause had to beaccepted; they could not be taken into consideration when the amount of blood tobe requisitioned was calculated.
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TABLE 22.-Delivery of whole blood to usinghospital units, ETOUSA, April 1944-June 1945 (96)
| Year and month | Communications Zone | U.S. Army Zone | Total | ||||||||
| United Kingdom | Continent | Subtotal | First | Third | Ninth | Seventh | Fifteenth | Subtotal | |||
| Forward | Rear | ||||||||||
1944 | |||||||||||
| April | 20 | --- | --- | 20 | --- | --- | --- | --- | --- | --- | 20 |
| May | 1,790 | --- | --- | 1,790 | --- | --- | --- | --- | --- | --- | 1,790 |
| June | 3,945 | --- | --- | 3,945 | 6,209 | --- | --- | --- | --- | 6,209 | 10,154 |
| July | 906 | 262 | --- | 1,168 | 13,669 | --- | --- | --- | --- | 13,669 | 14,837 |
| August | 411 | 554 | --- | 965 | 4,846 | 3,604 | --- | 1,356 | --- | 9,806 | 10,771 |
| September | 1,366 | 614 | 34 | 2,014 | 4,845 | 5,643 | 1,225 | 4,284 | --- | 15,997 | 18,011 |
| October | 749 | 580 | 675 | 2,004 | 6,627 | 7,866 | 746 | 6,128 | --- | 21,367 | 23,371 |
| November | 573 | 2,446 | 931 | 3,950 | 7,348 | 8,058 | 5,436 | 8,521 | --- | 29,363 | 33,313 |
| December | 650 | 4,214 | 1,262 | 6,126 | 7,945 | 8,776 | 3,909 | 11,238 | --- | 31,868 | 37,994 |
| 1945 |
| ||||||||||
| January | 709 | 3,639 | 1,736 | 6,084 | 6,827 | 12,139 | 2,628 | 11,017 | --- | 32,611 | 38,695 |
| February | 515 | 2,631 | 1,532 | 4,678 | 4,609 | 10,257 | 4,292 | 7,834 | --- | 26,992 | 31,670 |
| March | 1,278 | 2,886 | 1,760 | 5,924 | 8,908 | 11,796 | 4,782 | 11,205 | --- | 36,691 | 42,615 |
| April | 1,602 | 475 | 4,921 | 6,998 | 6,393 | 7,140 | 6,799 | 11,729 | 383 | 32,444 | 39,442 |
| May | 806 | 26 | 3,440 | 4,272 | 1,175 | 2,498 | 2,082 | 3,188 | 278 | 9,221 | 13,493 |
| June | 6 | --- | 617 | 623 | --- | --- | --- | --- | --- | --- | 623 |
| 15,326 | 18,327 | 16,908 | 50,561 | 79,401 | 77,777 | 31,899 | 76,500 | 661 | 266,238 | 316,799 |
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TABLE 23.-Ratios ofblood delivered to admissions of wounded to forward hospitals, First U.S.
Army, June 1944-May 1945 (96)
Year and month | Admissions | Pints of blood | Ratio of blood |
| 1944 |
|
|
|
June | 24,325 | 6,209 | 1:3.9 |
July | 141,034 | 13,669 | 1:3 |
August | 17,667 | 4,846 | 1:3.6 |
September | 8,819 | 4,845 | 1:1.8 |
October | 8,553 | 6,627 | 1:1.2 |
November | 13,197 | 7,348 | 1:1.8 |
December | 15,017 | 7,945 | 1:1.9 |
| 1945 |
|
|
|
January | 11,961 | 6,827 | 1:1.7 |
February | 6,537 | 4,609 | 1:1.4 |
March | 12,367 | 8,908 | 1:1.4 |
April | 9,581 | 6,393 | 1:1.5 |
May | 196 | 1,175 | --- |
| 169,254 | 79,401 | 1:2.1 |
1Statistics for July include Third U.S. Armyadmissions also.
TABLE 24.-Ratios of blood deliveredto admissions of wounded to forward hospitals, Third U.S. Army, August1944-May 1945 (96)1
Year and month | Admissions | Pints of blood | Ratio of blood |
| 1944 |
|
|
|
August | 6,397 | 3,604 | 1:1.8 |
September | 12,499 | 5,643 | 1:2.2 |
October | 4,003 | 7,866 | 1.9:1 |
November | 15,127 | 8,058 | 1:1.9 |
December | 11,955 | 8,776 | 1:1.4 |
| 1945 |
|
|
|
January | 17,378 | 12,139 | 1:1.4 |
February | 10,855 | 10,257 | 1:1 |
March | 11,430 | 11,796 | 1:1 |
April | 5,671 | 7,140 | 1.4:1 |
May | 716 | 2,498 | --- |
| 96,031 | 77,777 | 1:1.2 |
1Statistics for July are included in those of FirstU.S. Army (table 23).
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TABLE 25.-Ratios of blood delivered toadmissions of wounded to forward hospitals, Seventh U.S. Army, November 1944-May1945
Year and month | Admissions | Pints of blood | Ratio of blood |
| 1944 |
|
|
|
November | 5,569 | 8,521 | 1.5:1 |
December | 8,168 | 11,238 | 1.4:1 |
| 1945 |
|
|
|
January | 8,206 | 11,017 | 1.3:1 |
February | 4,983 | 7,834 | 1.6:1 |
March | 7,913 | 11,205 | 1.4:1 |
April | 8,810 | 11,729 | 1.3:1 |
May | 438 | 3,188 | --- |
| 44,087 | 64,732 | 1.4:1 |
TABLE 26.-Ratios of blood delivered toadmissions of wounded to forward hospitals, Ninth U.S. Army, September1944-May 1945 (96)
Year and month | Admissions | Pints of blood | Ratio of blood |
| 1944 |
|
|
|
September | 2,653 | 1,225 | 1:2.2 |
October | 1,614 | 746 | 1:2.2 |
November | 6,625 | 5,436 | 1:1.2 |
December | 2,728 | 3,909 | 1.4:1 |
| 1945 |
|
|
|
January | 1,657 | 2,628 | 1.6:1 |
February | 4,876 | 4,292 | 1:1.1 |
March | 5,072 | 4,782 | 1:1.1 |
April | 5,565 | 6,799 | 1.2:1 |
May | 189 | 2,082 | --- |
| 30,979 | 31,899 | 1:1 |
3. The more forward the hospital, the greaterwas its need for blood. This held not only for hospitals in the army zone butalso for hospitals forward in the communications zone (table 22).
4. All armies increased their use of blood asthey gained combat experience. Their increased use of transfusion, however,cannot be entirely explained on the ground that blood was increasinglyavailable. The Seventh U.S. Army, which had come from the Mediterranean theater,where a blood bank was in operation, and which had been served by its own bloodbank before it came under ETOUSA operational control, consistently usedproportionately larger amounts of blood than the other three armies in theEuropean theater.
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TABLE 27.-Ratios of blood delivered toadmissions of wounded to forward hospitals, all U.S. Armies, ETOUSA, Junel944-May 1945 (96)
Year and month | Admissions | Pints of blood | Ratio of blood |
| 1944 |
|
|
|
June | 24,325 | 6,209 | 1:3.9 |
July | 41,034 | 13,669 | 1:3 |
August | 24,064 | 9,806 | 1:2.8 |
September | 23,971 | 15,997 | 1:2.3 |
October | 14,170 | 21,367 | 1:1 |
November | 40,518 | 29,363 | 1:1.4 |
December | 37,868 | 31,868 | 1:1.2 |
| 1945 |
|
|
|
January | 39,202 | 32,611 | 1:1.2 |
February | 27,251 | 26,992 | 1:1 |
March | 36,782 | 36,691 | 1:1 |
April | 29,627 | 32,444 | 1.1:1 |
May | 1,539 | 9,221 | --- |
| 340,351 | 266,238 | 1:1.33 |
The combined figures for the use of blood in all four armies in the Europeantheater (table 27) are more representative of the total use of blood during theperiod of combat than the reports for individual armies. The ratio for May 1945has been omitted for all armies, for two reasons. The first is that thecessation of hostilities was not immediately reflected in the discontinuance ofshipments of blood from the Zone of Interior. The second is that in May, a greatdeal of blood was used for nonbattle casualties, particularly malnourished RAMP's(recovered Allied military personnel).
It is believed that the combined ratio of 1:1.33 provides a fairly accurateestimate of the demand for blood in all army areas.
Essential Technical Medical Data for the European theater for September 1944stated that nothing had given forward medical units greater satisfaction thantheir ability to administer to casualties the whole blood they needed (97). Itwas hoped that this information would be publicized in the Zone of Interior,for, without the blood from that source, the mortality rate would have been muchhigher and the morbidity much greater.
The same issue contained an analysis of the use of blood in (1) 213casualties treated in the 13th, 42d, and 47th Field Hospitals for the period 26July-18 August 1944 and (2) 221 casualties treated in the 2d, 5th, and 97thEvacuation Hospitals for the period 26 July-14 August 1944. All casualties werenon-transportable. Not all data are complete for all items, but the analysis isnonetheless very informative.
566
All the casualties were in shock. In the field hospitals, 57 were in firstdegree shock, 34 in second degree shock, 31 in third degree shock, and 8 infourth degree shock. In the evacuation hospitals, the corresponding figures were28, 41, 41, and 26.
The timelag from wounding to admission averaged 8 hours in 175 patients infield hospitals and 7 hours in 197 patients in evacuation hospitals. The timelagfrom admission to the hospital to operation averaged 10 hours in 157 patients infield hospitals and 13 hours in 189 patients in evacuation hospitals.
An average of 1.07 pints of plasma had been given in the clearing station to138 patients received in field hospitals, and an average of 1.3 pints had beengiven to 131 received in evacuation hospitals. An average of 1.5 pints was givento 197 patients after they reached the field hospital, and an average of 3.5pints was given to 198 after they reached evacuation hospitals. The total amountof plasma used in field hospitals was thus 302 pints and in evacuation hospitals715 pints. The total for both clearing stations and hospitals was 451 pints forfield hospitals and 892 pints for evacuation hospitals.
An average of 2.34 pints of blood was given to each of the 213 casualtiestreated in field hospitals and an average of 2.6 pints to each of the 221treated in evacuation hospitals. The total amount of blood used in fieldhospitals was 501 pints and in evacuation hospitals 580 pints.
The ratio of plasma to blood was 1.63:1 in field hospitals and 1.34:1 inevacuation hospitals. When the amount of plasma used in clearing stations isincluded, the final ratio of plasma to blood was 1:1 in field hospitals and1.53:1 in evacuation hospitals.
There were two reactions to plasma in field hospitals and the same number inevacuation hospitals. For whole blood, the respective figures are 8 and 5.
There were 92 deaths in the 434 casualties, 41 in the 213 treated in fieldhospitals and 51 in the 221 treated in evacuation hospitals. In all, 184patients were operated on in the field hospitals and 198 in the evacuationhospitals. Of the 25 casualties who died without operation, 8 died in fieldhospitals and 17 in evacuation hospitals. Four deaths occurred during operation,three in the field hospitals and one in an evacuation hospital. Of the 63 deathswhich occurred after operation, 30 occurred in field hospitals and 33 inevacuation hospitals.
The extremely high mortality rate in evacuation hospitals, closely comparableto that in the field hospitals, is explained by the fact that the evacuationhospitals in this series, contrary to the usual practice, were receivingnontransportable casualties and in effect serving as field hospitals.
LOSSES OF PRESERVED BLOOD
In an operation of such magnitude as furnishing blood for the Europeantheater, conducted on two continents and across an ocean, a certain amount ofwastage and loss was inevitable, but in the ETOUSA experience, it was
567
surprisingly small. One plane crash on 30 November 1944destroyed 1,146 bottles of blood, but this was practically the only loss of thekind during the whole procedure.
So far as possible, requests for blood from the Zone ofInterior were calculated on the basis of anticipated needs, and thecalculations, with the adjustment of supply and demand, were remarkablyaccurate. In September 1944, for instance, shortly after the program had beeninstituted, daily shipments from the United States were running well ahead ofneeds, and the program was slowed accordingly. In late October 1944, ColonelKendrick, then on temporary duty in the European theater, reported thatincreased quantities of blood would shortly be needed, and the dailyrequirements were therefore stepped up. In both the United Kingdom bank and theContinental bank, there was also an endeavor to adjust the daily bleedings tothe anticipated demand.
While only group O blood was used in combat zones, bloodcollected that was of other than O type was distributed to selected hospitals,especially those in the United Kingdom. As pointed out elsewhere, whenever thiswas done, a representative of the blood bank visited the hospital to warnpersonnel that the blood must be crossmatched before it was used. During thelast 6 months of the operation of the blood bank, not a single pint of non-Oblood was discarded in the United Kingdom. The demand for odd types of bloodnever reached significant proportions on the Continent.
In all, about 4,000 pints of outdated blood were used forplasma. About 3,000 pints were discarded because of hemolysis or because theblood was serologically positive. Some blood was also lost because of breakage,and some because of failure of refrigeration.
The total loss of blood in the 316,799 pints which werecollected in, or passed through, the ETOUSA Blood Bank was probably in theneighborhood of 15 percent. Because of the short storage period of blood, it isdoubtful that any better results could have been expected.
ODD BLOODS
Of the 130,635 pints of blood collected by the United KingdomSection of the blood bank, 110,878 pints were collected before 1 April 1945 (96).Up to this time, blood was collected only from donors whose identificationtags were stamped as type O. In this amount of blood there were 6,607 pints ofso-called odd blood; that is, though it was drawn from donors whoseidentification tags were stamped group O, the blood was of other types. Thisfigure represents an error of 5.96 percent in the original typing of the blood.The error in the blood collected by the Continental Section of the blood bankwas substantially the same.
All odd bloods were distributed to local hospitals.
568
SEROLOGICALLY POSITIVE BLOOD
Serologic tests were positive in 574 pints (0.47 percent) of the bloodcollected by the United Kingdom Section of the blood bank and in 95 (0.62percent) of that collected by the Continental Section. Another 57 pints (0.37percent) were classified as serologically doubtful. All serologically positiveblood was discarded.
SUMMARIZED STATISTICAL EXPERIENCES
The experience in the European theater was considered in 1946 to justify thefollowing conclusions in respect to the provision of whole blood in warfare (96):
1. For planning purposes, in the kind of warfare encountered in this theater,the only safe calculation of requirements is the provision of 1 pint of bloodfor each casualty.
2. This means that a field army in action will require about 500 pints ofblood daily.
3. This heavy demand seldom exists for longer than 8 consecutive days.
About 400 pints will be needed during the first 24 hours of an operation,about 800 pints between the third and sixth days, and the same amount for thenext 2 or 3 days. Then the need will decrease rapidly.
4. In the event of a breakthrough, particularly an armored breakthrough, thedemand falls off sharply, to 300 pints a day or less.
5. When infantry attack prepared positions, particularly when they must crossminefields, a large proportion of the wounded, probably about 20 percent, willrequire transfusion.
6. Whole blood requirements can be supplied only by careful calculations ofdaily needs. The short storage period of blood precludes the forward movement oflarge amounts until it is known that they will be needed. To stock all advanceblood banks at all times with the maximum amounts likely to be needed could notbe tolerated. It would result in tremendous losses, by aging, of a scarce andprecious commodity.
Part IX. Special Experiences30
There were no hospitals in the field, evacuation, or general categories thatdid not profit from the supply of whole blood for their casualties. Thisgeneralization is so valid that when one comes to select unit experiences to useas illustrations, it is extremely difficult to make the choice. For any of thehistories related in the following pages, a dozen others could have beenselected and would have carried quite as much conviction.
30The material in this part of the chapter is derived from the 1944-45 reports of the hospitals concerned. All are on file in The Historical Unit, U.S. Army Medical Service, Washington, D.C.
569
FIELD HOSPITALS
11th Field Hospital
At the 11th Field Hospital, during 1944, 2,532nontransportable casualties received 8,591,300 cc. of blood in 8,025transfusions. Almost all of it was furnished by the faithful and consistentoperation of mobile blood units. For many casualties, the availability of wholeblood made the difference between life and death.
A 24-hour supply of blood was delivered daily, usually between36 to 48 bottles, with an occasional expansion of the requisition, duringperiods of stress, to 60 bottles. If the supply of bank blood ran low, freshblood was drawn from hospital personnel and members of the clearing company.Whenever time permitted, blood was also drawn from these personnel for use incasualties with type A blood.
An intensive study of blood compatibility was made in thishospital, with an investigation of the many variables entering into theproduction of transfusion kidney and other transfusion reactions. Lower nephronnephrosis appeared in casualties with type A blood more often than in casualtieswith other types of blood, especially when large quantities of O blood had beengiven. The reactions occurred in spite of the apparent complete compatibility ofthe blood used, as shown by microscopic crossmatching.
The age of the blood was not a positive index of thelikelihood of transfusion incompatibility. It was generally true that the morerecent the blood, the less was the likelihood of a transfusion reaction. Attimes, however, blood that had been drawn very recently produced highlyundesirable effects. On the whole, the degree of hemolysis proved an extremelyreliable index and pointed to the way to avoid reactions.
The small number of reactions observed in so many and suchmassive transfusions was both surprising and gratifying.
56th Field Hospital
Many remarkable instances of recovery after apparently lethalwounds could be attributed to a combination of whole blood and good surgery. Acasualty at the 56th Field Hospital illustrates this point. When he was firstseen, he was in deep shock from massive loss of blood. He had multiple largelacerated wounds of the lower extremities; multiple fractures of the pelvis; andmultiple perforations of the cecum, ileum, and jejunum. He was rapidlyresuscitated to the level of operability by multiple simultaneous transfusionsof whole blood, after which laparotomy was performed and the intestinalperforations closed. His precarious condition did not permit any surgicalprocedure on the extremity wounds at this time, and they were simply cleansed byirrigation. The necessary additional surgery was done several days later.
This man's recovery was entirely uneventful, and he was inexcellent condition when he was evacuated to a general hospital. Without theblood that rapidly prepared him for operation, he, and many others like him,would surely have died.
77th Field Hospital
The experience of the 77th Field Hospital is an interestingexample of the value of plasma in protein depletion as compared with its limitedvalue in freshly wounded casualties.
This hospital arrived in France on 25 March 1945 and shortlyafterward began to receive RAMP's. It was immediately evident thatmalnutrition of all grades of severity, complicated by many types of infection,was to be the principal therapeutic problem.
Because of the limited facilities of a field hospitallaboratory, it was not possible to study the blood protein and blood chloridelevels in the first patients received. Most of
570
them were in serious condition, and many were critically ill.They were severely malnourished, dehydrated, and emaciated, and were sufferingfrom anorexia, nausea, vomiting, and diarrhea. Their low blood pressure, rapidpulse and respiration, and other signs suggested surgical shock.
The assumption was that they were suffering from a depletionof blood protein and chlorides, and they were therefore treated with plasma andwith glucose in physiologic salt solution, which, it was soon learned, must begiven slowly and in small amounts. Before this was realized, five patientsdeveloped pulmonary edema during infusions or immediately after the fluid hadbeen injected. Once the clinical condition had improved, the infusions could begiven in larger amounts.
The results of plasma infusions in severe malnutrition weregenerally excellent. Plasma was also used successfully in a few instances ofsevere nonbacterial diarrhea and in a few instances of nutritional edema.
In all, 173 RAMP's were treated with plasma at the 77thField Hospital, in units of 300 cc. The average amount given was 2.15 units. Thesmallest amount, 200 cc., was given to a patient who went into cardiac failureafter receiving this quantity by a very slow infusion. The largest amount, 1,114units, was given to a severely malnourished patient who had been vomiting for 3days and who had had nonbacterial diarrhea for 80 days when he was received.There were no deaths among these RAMP's.
GENERAL HOSPITALS
43d General Hospital
When the 43d General Hospital was permanently reorganized in August 1944, asa 1,500-bed hospital, a blood bank was set up in it.
Function and equipment-The hospital laboratory had completeresponsibility for all activity pertaining to blood transfusion except the careand preparation of recipient sets, which was the responsibility of the centralsupply service, and the actual administration of blood, which was a function ofward medical personnel. The laboratory, however, acted in a supervisory andadvisory capacity in respect to both these activities, in an endeavor to controlthe incidence of pyrogenic reactions.
The bank was housed in a separate room, 7.5 by 18 feet, which was near thelaboratory and which was arranged specifically for blood bank functions. Therewere facilities for bleeding two donors at the same time, for storage of donorsets and other equipment, for refrigeration, and for the handling of records.
There were two built-in bleeding tables, each 13 feet long and wide enough toaccommodate regulation operating table pads and still leave free space for thedonor's extended arm and the collection bottle. The pads were covered witheasily cleaned rubber sheeting. A cot was available in the corridor outside forfainting donors; it was not needed very often.
Two single-compartment kerosene refrigerators were used; one did not proveadequate. They gave reliable service but required a great deal of carefulattention. Losses by hemolysis emphasized the importance of constantrefrigeration; 56 percent of the loss from this cause at the 43d GeneralHospital occurred in September 1944, from power failure. At this time, theelectric
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refrigerator used for storage was powered by French current, which was notreliable.
By 1 January 1945, 70 donor sets were in use. This number was large enough topermit some sets to be out of use for minor repairs, and also to allow forpossible failure of sterilization facilities for 24 hours. Standard bottlescontaining citrate solution were used to collect blood.
Personnel-Personnel of the blood bank, in addition to medical officerpersonnel, consisted of a private, first class, and two technicians, fourthgrade, who were assigned solely to the bank; another technician, fourth grade,who had other duties in addition to his blood bank duties; specializedassistants from the hematology and serology departments; and a German POW, whoassisted in washing glassware and sterilizing equipment. The three men assignedfull time to the bank had complete charge of the procurement of donors; thecollection and care of blood; maintenance of equipment; and, during their dutyhours, the issuance of blood to the wards.
Bank routine-Blood was drawn each day in anticipation of immediatedemands. The estimates were based upon the amount of blood used during thepreceding 48 hours and the number of low hematocrits reported by the laboratoryfor the preceding 24 hours.
Arrangements were made each afternoon for the number of donors required,according to blood groups, for the following day. They were secured fromhospital personnel, army personnel in the staging area, and the POW enclosure.Donors from outside the hospital were transported to the laboratory in charge ofone of the bank personnel.
Donors were selected according to the blood groups listed on theiridentification tags, but each blood was retyped. A Kahn test was also run oneach unit collected, and a thick smear was examined for malaria. Because ofdifficulty in anticipating demands for blood groups AB and B, it wasoccasionally necessary to use O blood for patients in these blood groups. Insuch cases, in addition to routine crossmatching, recipient cells were crossedwith donor serum diluted 1:40, to eliminate the risk of a reaction caused byhigh-titer group O blood.
All crossmatching and typing, except emergency nightwork, were done by thesame technician. All crossmatchings were checked by a medical officer in thelaboratory before the results were accepted. The Landsteiner or test tube methodwas used exclusively for crossmatching. This technique minimizes the occurrenceof rouleaux formation and can be read immediately after centrifuging, whichgives it an advantage over other techniques, all of which require at least a30-minute wait. It was also considered more accurate than any other method.
A ledger was kept in which were recorded the accession number of thedonation, the donor's name and organization, the date of bleeding, and theresults of the laboratory tests. After the blood had been used, entries madeopposite the flask number included the name of the recipient; the ward; the dateof the transfusion; and, if a reaction had occurred, information about it.
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Blood was requisitioned on the ward by duplicate slips. The prospectiverecipient's blood was crossmatched with the vial of uncitrated blood tied tothe flask selected for him. If the bloods were found compatible, the flasknumber was entered on the patient's requisition. One slip was returned to theward, and the duplicate slip was placed in the bank file.
When the ward was ready for the blood, the slip which had been sent back toit was brought to the bank and the appropriate flask of blood was issued. Thedate and hour the blood left the bank were entered on the backs of both the wardslip and the file slip. The slip brought from the ward was returned to the wardand placed on the patient's chart. The duplicate slip was placed in the usedfile of the blood bank. These ward slips were collected from the wards everymorning by bank personnel.
The slips used to requisition the blood also had space to note dataconcerning reactions. If a reaction occurred, pertinent information regardingits type and severity was noted on the ward slip. This system insured that everyreaction was reported and could be analyzed by the laboratory. Hemolyticreactions were differentiated from pyrogenic reactions by examination of thepost-reaction urine for hemoglobin and urobilinogen. Recipient and donor bloodswere also retyped and recrossmatched, to eliminate any possibility of error inthe original reports.
When the type of reaction was definitely determined, the information wasplaced on the back of the file slip, which was then placed in the permanentfile. In cases in which no reactions had occurred, duplicate slips werediscarded at the end of a month.
Statistical data-Of the 2,206 units of blood collected at the 43dGeneral Hospital between 25 September and 31 December 1944, 1,029 came from U.S.personnel and 1,127 from German prisoners. All donations were voluntary, and allrequests for donors were filled with complete cooperation on the part of boththe donors and the officers in command of the organizations from which the bloodwas secured. U.S. Army personnel were furnished clean towels and bathingfacilities and given hot food at the mess, but no whisky. German prisoners weregiven an extra meal.
Of the 2,206 units of blood collected during 1944, 1,931 had been used fortransfusions by 31 December 1944. During November and December, an average of 3pints of blood was given to each patient transfused. The largest amount given toany single patient was 15 units.
In all, 193 units (8.7 percent) were discarded. Of these, 97 units werediscarded because of overaging, 69 because of hemolysis, and the remainder forvarious other reasons, chiefly positive serology.
There were 126 reactions in the 1,931 transfusions given, 6.5 percent, 110pyrogenic and the remainder allergic. Of the 110 pyrogenic reactions, 50occurred during a single week in November. They were traced to the followingfaults:
1. Failure of ward personnel to dismantle the giving sets and wash themthoroughly in tap water immediately after transfusions were completed.
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2. Failure to prepare new rubber tubing for use by boiling it in sodiumbicarbonate and rinsing it until the fluid returned clear.
3. Failure to inspect the sets adequately before they were reassembled forsterilization.
4. Failure to rinse them finally in pyrogen-free distilled water orphysiologic salt solution.
When these errors, all of human origin, were corrected, the incidence ofreactions at the 43d General Hospital returned to its normal low level.
227th General Hospital
The 227th General Hospital reached the Continent on 30 March 1945. It actedas an intermediate depot for the distribution of blood received from the ETOUSABlood Bank and intended for use in the hospitals of the 813th Hospital Center.There was a heavy demand for blood at this time, but there were ample suppliesto meet it. In all, 1,524 bottles were dispensed between 10 April and 1 June,when the bank closed down. Thereafter, blood was secured from officers andenlisted men in the hospital. Donations were generous, but the ample supply ofblood previously available had made procurement seem simple, and local donorswere rapidly used up. With the fine cooperation of radio stations at Marseille,Nice, and Cannes, as well as other publicity, a panel of donors was securedwhich met the hospital needs.
The hospital laboratory insisted upon complete control of the bank blood fromthe moment it was received from the Paris bank until it was dispensed.Refrigeration was regularly checked, day and night, every 2 hours. Electricrefrigeration was more desirable than kerosene refrigeration, which had to bewatched with particular care, but it was not always available. French currentwas not dependable, and two small electric refrigerators were secured andsupplied with current from one of the hospital generators. Refrigerationproblems became minimal after the Paris bank began to send blood in theexpendable insulated boxes in which it was received from the Zone of Interior. Acommercial source of ice was then utilized, and the boxes were re-iced daily.
This hospital had one constant difficulty to combat, the production ofdistilled water. Fluctuations in water pressure, the extreme hardness of thewater, the inadequacy of French electrical current, and the vulnerability of thestills taxed the best efforts of electricians, plumbers, maintenance men, andlaboratory personnel. Their success, however, is attested by the fact that the227th General Hospital supplied distilled water for several other hospitals inthe vicinity in addition to providing for its own needs.
298th General Hospital
The experience of the 298th General Hospital, in general, paralleled that ofmost other general hospitals, with one exception: On 22 January 1945, when abottle of blood from the ETOUSA Blood Bank was being crossmatched for a
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patient with a spinal cord injury, the donor flask was found to bear the nameof Supreme Allied Commander Dwight D. Eisenhower. The Stars and Stripes, whichreported the incident, said that the general had hoped, when he made thedonation, that the disposition of the patient who might receive his blood wouldbe better than his own. After he had received the 500-cc. transfusion, said thearticle, the patient was in good condition, and his disposition was excellent.
Part X. Statement of the Theater General Board
CONTENTS
The definitive statement on the whole blood service in the European theateris contained in the report of the General Board, U.S. Forces, European theater,31set up by General Orders No. 128, issued on 17 June 1945, to prepare a factualanalysis of the strategy, tactics, and administration employed by the U.S. ArmedForces in this theater. The following points were covered (98):
1. The importance of whole blood in the care of the wounded.
2. The organization of the whole blood service in the theater in the United Kingdom and on the Continent.
3. The operation of blood banks in base sections.
4. The distribution of whole blood on the Continent.
5. The determination of requirements of whole blood for continental operations.
It was the conclusion of the General Board that the provisional organizationfor the supply of whole blood in the European theater was "eminentlysuccessful."
RECOMMENDATIONS
The Board made the following recommendations for future operations:
1. That a T/O&E be authorized for an organization similar to theprovisional base blood bank for the purpose of collecting and processing wholeblood.
2. That whole blood be handled by medical depots operating in the forwardcommunications zone areas and the Army area, since there is no justification forthe distribution of whole blood through other than normal medical supplychannels. The type of personnel and equipment employed in the European theaterby advance blood banks should be incorporated into the T/O&E of medicaldepot companies.
3. That a ratio of 1 pint of blood for each anticipated wounded admission beused for planning purposes.
COMMENT
Recommendation No. 2 is difficult for a clinician to accept (this board hadno clinicians on it). It seems based on a complete failure to grasp the funda-
31This study was prepared by Col. L. Holmes Ginn, Jr., MC, Chief, Medical Section, Chairman; Maj. Joseph J. Strnad, MAC, Deputy Chairman; and 1st Lt. John F. Ward, MAC. Special consultants were Colonel Hays, Col; Robert H. Barr, MC, Surgeon, VII Corps; Lt. Col. Harry S. Green, MAC, Commanding Officer, 13th Medical Depot and Capt. William M. Hamilton, MAC, Medical Supply Officer, Third U.S. Army.
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mental fact that blood is a perishable as well as a precious substance andthat for both those reasons it must not be handled in normal medical supplychannels. One need refer only to a single experience in the Philippines (p. 605)in which blood was thus handled (that is, in normal medical channels) to realizethe unwisdom of this recommendation. Had it been in effect in the Europeantheater, it is highly doubtful that the whole blood program would have been assuccessful as the General Board concluded that it was. In fact, if there was asingle conviction rooted in the minds of those who directed the whole bloodprogram, it was that blood is a substance which requires special handling fromthe moment it is drawn until the moment it is administered.
In the European theater, Medical Supply provided storage facilities andtransportation, but the real responsibility for handling this perishable item,which could be lethal without proper supervision, belonged to the transfusionservice, which operated under the overall direction of the theater blood bank.It is unfortunate that the same policy was not employed in the Korean War (p.752).
References
1. Informal Routing Slip, Lt. Col. D. B. Kendrick, MC, toChief Surgeon, ETOUSA, 26 Sept. 1944, subject: Report ofTrip to First U.S. Army Medical Installations.
2. Memorandum, Lt. Col. D. B. Kendrick, MC, for Col. B. N.Carter, MC, 5 Oct. 1943, subject: Transfusion of WholeBlood in the Theaters of Operations.
3. Circular Letter No. 108, Office of The Surgeon General,U.S. Army, 27 May 1943, subject: Transfusion of Whole Blood in the Theaters ofOperations.
4. Memorandum, Lt. Col. D. B. Kendrick, MC, for Brig. Gen.Fred W. Rankin, 3 Nov. 1943, subject: Transfusion of Whole Blood in the Theatersof Operations.
5. Memorandum, Brig. Gen. Fred W. Rankin for The SurgeonGeneral, 6 Nov. 1943, subject: Transfusion of Whole Blood in the Theaters ofOperations.
6. Minutes, meeting of Subcommittee on Blood Substitutes,Division of Medical Sciences, NRC, 17 Nov. 1943.
7. Memorandum, Brig. Gen. Fred W. Rankin for The SurgeonGeneral, 13 Nov. 1943, subject: Transfusion of Whole Blood in the Theaters ofOperations.
8. Memorandum for the Record, Col. B. N. Carter, MC, 16 Dec.1943, subject: Meeting With The Surgeon General and With General Lull on theSubject of Whole Blood Transfusions in Theaters of Operations.
9. Memorandum, Lt. Col. D. B. Kendrick, MC, for The SurgeonGeneral, 17 Apr. 1944, subject: Transfusion of Whole Blood in the Theaters ofOperations.
10. Memorandum, Brig. Gen. F. W. Rankin, MC, for The SurgeonGeneral, 21 Apr. 1944, subject: Transfusion of Whole Bloodin the Theaters of Operations.
11. Minutes, meeting of Committee on Transfusions, Division ofMedical Sciences, NRC, 31 May 1940.
12. Minutes, meeting of Subcommittee on Blood Substitutes,Division of Medical Sciences, NRC, 9 Apr. 1943.
13. Minutes, meeting of Subcommittee on Blood Substitutes,Division of Medical Sciences, NRC, 24 Sept. 1943.
14. Annual Report, Activities of the Transfusion Branch,Surgery Division, OTSG, fiscal year 1944.
15. Memorandum, Capt. R. C. Hardin, MC, to Chief ConsultingSurgeon, Office of Chief Surgeon, ETOUSA, 26 Mar. 1943, subject: TransfusionArrangements in U.S. Hospitals.
576
16. Memorandum, Maj. W. A. H. Jaycott, RAMC, for AssistantSurgeon, Office of Chief Surgeon, ETOUSA, 8 June 1943, subject: Supplies ofPlasma.
17. Informal Routing Slip, Col. E. C. Cutler, MC, to Col. J.C. Kimbrough, MC, 30 Dec. 1943, subject: Blood Transfusion Service.
18. Informal Routing Slip, Col. J. B. Mason, MC, for the ChiefSurgeon, ETOUSA, 6 Jan. 1944, subject: Director of WholeBlood Service.
19. Circular Letter No. 51, Office of the Chief Surgeon,Headquarters, ETOUSA, 5 Apr. 1943, subject: Arrangementsfor Blood Banks and Transfusion in U.S. Army Hospitals.
20. Memorandum, Capt. R. C. Hardin, MC, to Col. E. C. Cutler,MC, 9 June 1943, subject: Provision for Procurement of Whole Blood forTransfusion in General Hospitals in the ETO.
21. Emerson, Maj. C. P., MC, and Ebert, Maj. R. V., MC:Operation of a Hospital Blood Bank. M. Bull. No. 14, Office of the ChiefSurgeon, Headquarters, ETOUSA, 1 Jan. 1944, pp. 7-15.
22. Letter, Lt. Col. W. S. Middleton, MC, to Dr. P. L.Mollison, 29 Jan. 1943, subject: Conference.
23. Cutler, E. C.: The Chief Consultant in Surgery. In MedicalDepartment, United States Army. Surgery in World War II. Activities of SurgicalConsultants, Volume II. Washington: U.S. GovernmentPrinting Office, 1964.
24. Memorandum, Col. E. C. Cutler, MC, to Brig. Gen. P. R.Hawley, through Col. J. C. Kimbrough, MC, 10 May 1945, subject: The Use andProcurement of Blood and Plasma for the ETO.
25. Memorandum, Capt. R. C. Hardin, MC, to Col. E. C. Cutler,MC, 5 June 1943, subject: A Plan for the Procurement and Delivery of Whole Bloodfor a Continental Task Force from the USA or UK.
26. Memorandum for the Record, Col. E. C. Cutler, MC, 29 Aug.1943, subject: Project: Preliminary Studies for theProcurement, Storage and Supply of Whole Blood to an ETO Combat Army.
27. Memorandum for the Record, Col. E. C. Cutler, MC, 13 Nov.1943, subject: Blood Procurement ETO.
28. Informal Routing Slip, Col. E. C. Cutler, MC, to Chief,Operations Division, Office of Chief Surgeon, ETOUSA, 13 Nov. 1943, subject:Whole Blood.
29. Informal Routing Slip, Col. J. B. Mason, MC, toProfessional Services Division, Office of Chief Surgeon, ETOUSA, 18 Nov. 1943,subject: Whole Blood.
30. Informal Routing Slip, Brig. Gen. P. R. Hawley, forCommanding General, SOS, ETOUSA, 26 Nov. 1943, subject: Provision of Whole Bloodfor Battle Casualties.
31. Administrative and Logistical History of the MedicalService, Communications Zone, European Theater of Operations, vol. 7, appendix10. [Official record.]
32. Memorandum, Lt. Col. R. P. Fisk, Adjutant General'sDepartment, to Commanding General, 1st Army Group, 2 Jan. 1944, subject:Provision of Whole Blood for the Medical Service.
33. Memorandum, Maj. R. C. Hardin, MC, to Operations Division,Office of Chief Surgeon, ETOUSA, 17 Apr. 1944, subject: Expansion of ETO BloodBank.
34. Official Diary, ETOUSA Blood Bank, 1944-45.
35. Memorandum for the Record, Col. E. C. Cutler, MC, and Maj.R. C. Hardin, MC, 1 Aug. 1944, subject: Whole Blood fromUSA.
36. Informal Routing Slip, Col. J. C. Kimbrough, MC, to ChiefSurgeon, ETOUSA, 6 Apr. 1944, subject: Whole BloodTransfusion.
37. Fifth U.S. Army Medical Service History, 1944.
38. Fifth U.S. Army Medical Service History, 1945.
39. Memorandum, Maj. Gen. P. R. Hawley for ProfessionalServices Division, Office of Chief Surgeon, ETOUSA, 28 Mar. 1944, subject: BloodSupply, and 2d and 3d indorsements thereto.
577
40. Operating Procedure, The Whole Blood Service, ETOUSA,Office of the Chief Surgeon, Operations Division, 1944.
41. Informal Routing Slip, Col. E. C. Cutler, MC, to Chief,Professional Services Division, Office of Chief Surgeon, ETOUSA, 2 July 1944,subject: Blood.
42. Informal Routing Slip, Col. J. C. Kimbrough, MC, to ChiefSurgeon, ETOUSA, 12 July 1944, subject: Whole Blood forTransfusion from the ZI.
43. Informal Routing Slip, Lt. Col. R. M. Zollinger, MC, toSurgeon, Forward Echelon, Headquarters, Communications Zone, 28 July 1944,subject: Evaluation of the Requirements for Whole Blood in Army Hospitals.
44. Informal Routing Slip, Col. J. C. Kimbrough, MC, to ChiefSurgeon, ETOUSA, 31 July 1944, subject: Whole BloodRequirements.
45. Informal Routing Slip, Col. J. H. McNinch, MC, toPersonnel Division, Office of Chief Surgeon, ETOUSA, 21 July 1944, subject:Return of Colonel E. C. Cutler, MC, Colonel William F. MacFee, MC, and MajorRobert C. Hardin, MC, to States.
46. Informal Routing Slip, Col. H. W. Doan, MC, to G-4, 4 Aug.1944, subject: Request for Orders.
47. Radiogram, CG, U.S. Army, SOS in the British Isles,London, England, to War Department, C 84252, 2 Aug. 1944, subject: Request forBlood from Zone of Interior.
48. Letter, Maj. Gen. P. R. Hawley to Maj. Gen. N. T. Kirk, 5Aug. 1944, subject: Request for Whole Blood from Zone ofInterior.
49. Letter, Maj. Gen. N. T. Kirk to Maj. Gen. P. R. Hawley, 11Aug. 1944, subject: Whole Blood from Zone of Interior.
50. Radiogram, from AGWAR, from Kirk, signed Somervell forHawley to Headquarters, Communications Zone, 79474S0SMC, C 84252, 13 Aug. 1944,subject: Whole Blood from Zone of Interior.
51. Memorandum, Brig. Gen. F. W. Rankin, for The SurgeonGeneral, 3 Aug. 1944, subject: Provisions for Supplying Whole Blood to ETO fromU.S.A.
52. Memorandum, Lt. Col. Douglas B. Kendrick, MC, for Brig.Gen. F. W. Rankin, 14 Aug. 1944, subject: Plan forSupplying Blood to ETO.
53. Memorandum, Lt. Col. D. B. Kendrick, MC, for Brig. Gen. F.W. Rankin, 23 Aug. 1944, subject: Conference on Supply ofWhole Blood for the ETO.
54. Annual Report, 152d Station Hospital, 1944 (ETO BloodBank), 30 Jan. 1945.
55. Period Report, 152d Station Hospital (ETO Blood Bank), toThe Surgeon General, 1 Jan.-30 June 1945, dated 30 June1945.
56. Annual Report, 127th Station Hospital (ETO Blood BankU.K.), 1944, 19 Jan. 1945.
57. Annual Report, Transfusion and Shock, from Maj. R. C.Hardin, MC, to Chief Consultant in Surgery, Office of the Chief Surgeon, ETOUSA,11 Jan. 1944.
58. Mason, J. B.: Planning for the ETO Blood Bank. Mil.Surgeon 102: 460-467, June 1948.
59. Mason, J. B.: The Role of ADSEC in the Supply of WholeBlood to the Twelfth Army Group. Mil. Surgeon 103: 9-14, July 1948.
60. Report, Conference on the Operations of the Blood Bankheld at 1st Medical Laboratory, 5 Apr. 1944.
61. Memorandum, Col. H. W. Doan, MC, to Surgeons, Twelfth ArmyGroup; Third, First, and Ninth U.S. Armies, ADSEC, Com Z; Base Sections(Continent), 30 Oct. 1944, subject: Supply of Whole Blood.
62. Letter, Lt. Col. A. Vickoren, MC, to Commanding Officer,1st Medical General Laboratory, 21 Mar. 1944, subject: Preparation of SOP forETOUSA Whole Blood Service.
63. Administrative and Logistical History of the MedicalService, Communications Zone, European Theater of Operations, vol. 7. [Officialrecord.]
64. Shainmark, A. C.: The Supply of Whole Blood to ForwardMobile Medical Field Units of the Ninth U.S. Army. Mil. Surgeon 103: 14-16, July1948.
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65. Informal Routing Slip, Col. E. C. Cutler, MC, to DeputyChief Surgeon, 24 Oct. 1943; Col. J. C. Kimbrough, MC, toDeputy Chief Surgeon, 25 Oct. 1943; Brig. Gen. P. R. Hawleyto Deputy Chief Surgeon, n.d.; and Col. E. C. Cutler, MC, to Chief Surgeon, 31Oct. 1943, subject: Donations of Blood by U.S. Troops to British TransfusionService; Harmlessness of Blood Donations.
66. Letter, Brig. Gen. P. R. Hawley, to Commanding General,SOS, ETOUSA, November 1943, subject: The Establishment of the Blood Panel,ETOUSA.
67. Letter, Maj. Gen. J. C. H. Lee, to Commanders, ChannelBase Section, Eastern Base Section, Western Base Section, and Southern BaseSection, 15 Dec. 1943, subject: Volunteer Donations ofBlood.
68. Letter, Maj. Gen. J. C. H. Lee, to SOS, 15 Dec. 1943,subject: Volunteer Donations of Blood.
69. Letter, Brig. Gen. R. B. Lovett, to Base SectionsCommanders, SOS, ETOUSA, and Headquarters Commandant, ETOUSA, 6 Apr. 1944,subject: Provision of Whole Blood for the Medical Service.
70. Letter, Col. H. W. Doan, MC, to Sir Francis R. Fraser, 1Feb. 1944, subject: Donations by U.S. Troops to British Transfusion Service.
71. Memorandum, Lt. Col. Thurman Shuller, MC, to Surgeon, 8thAir Force, 5 May 1944, subject: Blood Donors for theBritish Red Cross, and 3d indorsement thereto.
72. 2d Indorsement, Col. J. C. Kimbrough, MC, 6 Sept. 1944, tobasic letter, 26 Aug. 1944, subject: Use of Prisoners ofWar as Blood Donors.
73. Medical Department, United States Army. Medical Supply inWorld War II. [In preparation.]
74. Memorandum, Col. J. B. Mason, MC, to the Chief Surgeon,ETOUSA, 4 Nov. 1943, subject: Delivery of Whole Blood toContinent, ETOUSA.
75. Conference, Whole Blood Service, ETOUSA, 22 Dec. 1943.
76. Memorandum, Lt. Col. C. B. Meador, MC, to Planning Branch,Office of Chief Surgeon, ETOUSA, 10 Apr. 1944, subject: Shipment of MedicalSupplies by Air Transport.
77. Administrative and Logistical History of the MedicalService, Communications Zone, European Theater of Operations, vol. 6. [Officialrecord.]
78. Letter, Lt. Col. L. H. Beers, MAC, to G-4, SupplyRequirements Division, Headquarters, Com Z (Forward), 1 Sept. 1944, subject:Diversion of Air Planes Carrying Blood.
79. Informal Routing Slip, Col. S. B. Hays, MC, to G-4,Headquarters, ETOUSA, 22 Sept. 1944, subject: Request for Future Shipments ofBlood to Paris.
80. Letter, Col. W. L. Perry, MC, to The Adjutant General,Washington, D.C., 25 Sept. 1943, subject: Project: Whole Blood Service forETOUSA.
81. Informal Routing Slip, Lt. Col. Robert M. Zollinger, MC,to Medical Supply Division, attention: Col. W. L. Perry, MC, 20 Feb. 1944,subject: Medical Supplies for Field Transfusion Kit.
82. Memorandum, Lt. Col. Robert M. Zollinger, MC, to Surgeon,First U.S. Army, 17 Feb. 1944, subject: ConcerningDistribution of Field Transfusion Units.
83. Memorandum, Lt. Col. Robert M. Zollinger, MC, to Col. E.C. Cutler, MC, 5 Nov. 1943, subject: Transfusion Units.
84. Memorandum, Lt. Col. Robert M. Zollinger, MC, to MedicalSupply Division, 13 Jan. 1944, subject: Blood Transfusion Set (Sterile,Expendable).
85. Informal Routing Slip, Lt. Col. Robert M. Zollinger, MC,to Plans and Training Division, attention: Lt. Col. A. Vickoren, MC, 13 Mar.1944, subject: Concerning Field Transfusion Units.
86. Administrative and Logistical History of the MedicalService, Communications Zone, European Theater of Operations, vol. 9. [Officialrecord.]
87. Memorandum, Maj. Gen. P. R. Hawley, to Commanding Officer,1st Medical Laboratory, 1 May 1944, subject: Violation of Security.
88. Letter, Maj. Gen. P. R. Hawley, to Col. J. A. Rogers, MC,19 July 1944.
89. Letter, Maj. J. J. McGraw, Jr., MC, to Maj. R. C. Hardin,MC, 8 Jan. 1945.
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90. Memorandum, Capt. John Elliott, SnC, to Chief, SurgicalConsultants Division, Office of The Surgeon General, through Director, ArmyMedical School, 1 Feb. 1945, subject: Transportation of Blood from the U.S. tothe ETO Blood Bank in Paris.
91. ETMD, ETOUSA, for December 1944.
92. ETMD, ETOUSA, for June 1944.
93. ETMD, ETOUSA, for October 1944.
94. Letter, Maj. Gen. P. R. Hawley, to The Surgeon General, 14Sept. 1944, subject: Whole Blood.
95. Robinson, G. C.: American Red Cross Blood Donor ServiceDuring World War II. Its Organization and Operation.Washington: The American Red Cross, 1 July 1946.
96. Kendrick, Col. D. B.: History of Blood and Plasma Program,United States Army, During World War II, 1 Aug. 1952.
97. ETMD, ETOUSA, for September 1944.
98. The General Board, United States Forces, European Theater:Study Number 93, Medical Supply in the European Theater of Operations. Chapter5, Whole Blood Service.
