CHAPTER III
The Evolution of the Use of Whole Blood in
Combat Casualties
DEVELOPMENT OF THE CONCEPT
Since the importance of whole blood in theresuscitation of wounded casualties was realized almost from the beginning bymany of the personnel and agencies connected with the program, it is hard tounderstand why its procurement, distribution, and utilization got off to such aslow start in the U.S. Army in World War II. The success of the transfusionservice in the Spanish Civil War (p. 11) and the similarly successful and longoperational program in the British Army when the United States entered the war(p. 15) make the delay even more mystifying.
Any attempt at explanation must be a mixtureof fact and opinion. Perhaps the chief reason was that overenthusiasm for thepotentialities of plasma as an effective blood substitute tended to reduce theattention which might otherwise have been devoted to the development of methodsfor making the use of whole blood practical. A second reason was that even thosewho considered whole blood essential in the treatment of battle casualtiesthought its supply to forward units in a combat zone-let alone itstransportation overseas-an entirely impractical project. The discussion at thefirst meeting of the Committee on Transfusions, Division of Medical Sciences,NRC (National Research Council)lon 31 May 1940 (1) clearly showed that the feasibility of such a programhad to be grasped before any means for its implementation would be developed.The lack of the acceptance of the concept as a possibility was far moreimportant than (1) the current lack of means to store the blood and transport itsafely over long distances, and (2) the fact that an oversea airlift did notexist when World War II began. Moreover, at this time, blood had only a 6- to8-day dating period, which was scarcely long enough to get it into a combat zoneeven if an airlift had been available.
In short, the hard fact of the matter was thatin 1940 and 1941, when the need arose, there was no real choice: If plasma hadnot been recommended and used, there would have been no agent at all for thetreatment of large numbers of wounded casualties. It was just 5 years before theUnited States entered World War II that Elliott (2) had pointed out themilitary advantages of plasma, some of which Ward had called attention to inWorld War I (p. 265). Because of its small bulk, it was practical to carry itwell forward and thus
1Committee on Transfusions, Division of Medical Sciences, NRC, acting for the Committee on Medical Research, Office of Scientific Research and Development (hereafter termed Committee on Transfusions, NRC).
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treat shock many miles closer to the actualscene of wounding. Reduction of the timelag ("this valuable timeelement," as Elliott called it) might well mean the difference between lifeand death.
Another reason for delay in setting up anoversea blood program was the rather general failure to appreciate thedifference between the use of blood in civilian medicine and its use as amilitary necessity. DeGowin and Hardin (3) (Maj. Robert C. Hardin, MC,who later served as Transfusion Officer in the European Theater of Operations,U.S. Army) differed from most other observers in their appreciation of thisdistinction. In an article in War Medicine in May 1941, these observerspointed out that since shock and hemorrhage are acute conditions, they must betreated at the earliest possible moment. The goal of any service supplying bloodand plasma should be to make them available as far forward in the combat zone aspossible. The value of every step in the processing and administration of thesesubstances should be weighed in terms of their use at the front. Each detail oftechnique should be visualized as it would have been carried out in some suchsetting as a British casualty clearing station under air bombardment in theBattle of Flanders.
To meet these requirements, it would benecessary to collect blood in many centers, transport it to a small number ofpoints for processing, and then deliver it to forward units. This is preciselywhat was done when the blood program was developed in the Mediterranean theater,which supplied its own blood throughout the war, and when the plasma program inthe United States was extended to provide blood for theaters of operations.
In spite of the imaginative planning ofDeGowin, Hardin, and their associates, the concept of the provision of wholeblood for forward areas in oversea theaters was a very gradual development. Inthe Zone of Interior, this concept was first of all part of the development ofthe concept that whole blood was necessary for severely wounded men in shock andthat plasma, valuable as it had proved, was simply an interim measure, with asupplemental and not a definitive role in their management.
Lt. Col. (later Col.) B. Noland Carter, MC,Assistant Director, Surgical Consultants Division, Office of The SurgeonGeneral, expressed the general point of view in a comment on ETMD (EssentialTechnical Medical Data) NATOUSA (North African Theater of Operations, U.S.Army), for 1 July 1944 (4). Early in the war, he said, the lack ofappreciation of the need for whole blood for seriously wounded men was shared byhis own office, though at the time he was then writing (September 1944), thenecessity was recognized in the Zone of Interior as well as in all combat zones.The complete recognition of this need, he concluded, was now evident in theOffice of The Surgeon General in the establishment of tables of organization andequipment for blood transfusion units and in the recently instituted airlift ofblood to Europe.
The need of combat casualties for whole bloodin large quantities was learned by experience in the Mediterranean theater (p.392). In the European theater, as information concerning the Mediterraneanexperience was supplemented by theater experience, it became clear that theprocurement of blood
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from Army personnel in the theater simplywould not meet the needs. Only a brief combat experience was required to make itclear that blood would be needed in much larger quantities, and for many morecasualties, than had originally been contemplated. As time passed, there wereincreasingly frequent expressions of the necessity for, and the possibility of,securing blood by airlift from the Zone of Interior (p. 474).
As has already been pointed out, there wasalways a considerable number of observers in both the Zone of Interior andoversea theaters who believed that whole blood was necessary, and had nosubstitute, in the treatment of severely wounded men. Their voices were simplynot loud enough-or perhaps they did not speak out loudly enough-to carryconviction until events in combat theaters furnished overwhelming proof of theneed. Moreover, even those who believed from the beginning that whole blood wasessential for combat casualties were at first faced with the major problem ofhow to place it where it could be used.
THE ROLE OF THE NATIONAL RESEARCH COUNCIL
Much of the basic work which led up to theuse of whole blood in combat casualties in forward installations was directed,or actually carried out, by members of the Subcommittee on Blood Substitutes ofthe Committee on Transfusions, National Research Council.2 Thedevelopment of the concept, which was linked with the practical aspects of itsimplementation, is most conveniently described chronologically.3
1940
31 May.-Thefirst meeting of the Committee on Transfusions (1), of which Dr. WalterB. Cannon was chairman, was attended by the full membership, by Dr. Lewis H.Weed, chairman of the Division of Medical Sciences, NRC, and, by invitation,Col. (later Brig. Gen.) George R. Callender, MC; Col. (later Brig. Gen.) CharlesC. Hillman, MC; Capt. (later Col.) Douglas B. Kendrick, MC; and Cdr. C. S.Stephenson, MC, USN. Maj. Gen. James C. Magee, The Surgeon General, was presentfor part of the meeting.
Dr. Weed explained that the committee had beenorganized because of a request from General Magee that NRC (p. 75) assemble acivilian committee that could act informally in an advisory capacity to the ArmyMedical Corps, as well as to the Navy Medical Corps, with special reference tosurgical shock, blood transfusion, and blood banks. When Dr. Cannon took thechair, he stated that many trained investigators in various medical fields hadoffered their services to the committee, and, if representatives of the Armyand the
2Subcommittee on Blood Substitutes, Committee on Transfusions, Division of Medical Sciences, NRC, acting for the Committee on Medical Research, Office of Scientific Research and Development (hereafter termed Subcommittee on Blood Substitutes, NRC).
3Unless otherwise indicated, all of the following data are included in the minutes of the Committee on Transfusions or the Subcommittee on Blood Substitutes for the appropriate dates.
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Navy would formulate their problems, theDivision of Medical Sciences, NRC, would act as an agency for theirinvestigation and for transmission of information concerning them.
In reply, General Magee stated that from hisstandpoint there were two chief problems:
1. Blood transfusions, particularly the use ofdried plasma and the proper containers for plasma.4
2. Shock, including its prevention, andhemorrhage.
In the discussion that followed, these pointswere covered:
1. Blood banks. Colonel Hillman stated that ifcombat in a future war should be chiefly outside the United States, the Armywould probably discourage the use of blood banks. If war should come closer, itmight be possible to use blood transported by plane or under specially devisedrefrigeration. If blood could not be collected locally, either liquid or driedplasma would have to be used.
2. Preserved blood. At this time, the safestorage of whole blood was not generally thought to exceed 5 days. Dr. EverettD. Plass stated that he had used blood more than 30 days old without seriousreactions. He believed that by improving the preservative fluid, the period ofsafe storage could be increased materially, though he granted that as theproportion of glucose, presently the preservative in use, was increased,difficulties of administration would also be increased.
3. Plasma. Commander Stephenson explained theNavy's preference for plasma rather than whole blood: Plasma could be used inany form without reactions. If it were dried immediately, it could be kept for 4or 5 months without refrigeration. If the circulation were embarrassed, it couldbe given in concentrated form. Also, the task of accumulating stocks could bebegun a year or more in advance of the time the plasma might be needed.Refrigerator space was not a problem for the Navy, and distilled water for thereconstitution of plasma was available on many parts of ships.
Other points concerning plasma discussed atthis meeting included the possibility of making a synthetic preparation or ofusing plasma from a lower animal instead of human plasma, the best techniques ofpreparing dried plasma, and a request to drug firms to prepare and distributedried plasma to certain institutions for testing purposes.
4. Shock. The chairman asked that variousmethods of handling shock and hemorrhage be described, including thepotentialities and limitations of whole blood; concentrated plasma and wet anddried plasma, with due note of the refrigeration needed; deterioration of bloodafter transportation; and the
4It will be observed that at this and several succeeding meetings, the chief emphasis was on the use of plasma, which was readily accepted as a substitute for whole blood by a surprising number of experienced civilian clinicians and Army and Navy medical officers. The meeting of the Subcommittee on Blood Substitutes on 19 April 1941 (5) actually discussed whether whole blood was within its frame of reference; it was decided that it was. It should be pointed out again, however, that at this time, no matter how firmly one might have believed that whole blood was the transfusion medium of choice, its use was not practical because of the short dating period, the frequent reactions, sterilization problems, lack of refrigeration, and lack of an airlift.
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possibilities of preservation of blood andplasma. A system was needed that would be practical for both Army and Navy.
As Dr. Cannon saw it, the problem before thecommittee was possible ways and means of restoring blood losses in wounded menat different places in an organized line. Some agents could be used in fixedhospitals but certain others that could be easily transported, withoutrefrigeration, must also be available. General Magee mentioned the mobile fieldhospital, which had completed tests and which he thought would be well adaptedfor shock treatment, a statement that was to prove prophetic.
Colonel Hillman was asked to discuss thequestion of blood donors with the American Red Cross. Dr. Plass, who had specialfacilities at the State University of Iowa College of Medicine for testing wholeblood, was asked to work out a means of transportation for it. It was thoughtthat airlines and trucking firms might be interested in cooperating in thisproject.
24 July-Whenthe Committee on Transfusions made its report on this date to the Committee onSurgery, NRC (6), it advanced two chief reasons for the use of plasmarather than of whole blood in shock. The committee position can perhaps beinterpreted as concessions to the position taken at the May meeting byrepresentatives of the Army and the Navy:
1. Plasma is considerably easier to preserveand transport than blood.
2. Matching and typing are not necessary whenpooled plasma, in which isoagglutinins are suppressed, is used.
Two other reasons, which have already beencommented on, were also advanced for the use of plasma rather than blood inshock:
1. The belief that most shock is associatedwith hemoconcentration (p. 30) and that a given quantity of plasma wouldtherefore be more effective than an equal quantity of blood. This belief couldbe traced back to the observations made in World War I that led to the erroneousconcept that shock is an entity distinct from hemorrhage.
2. The belief, drawn from laboratoryexperiments under controlled conditions (p. 31), that plasma is approximately aseffective as whole blood in the treatment of hemorrhage.
There were other fallacies in this approach:
1. It placed undue emphasis upon a singlephysicochemical property of blood, the osmotic activity of its plasma proteins,and ignored the important function of the red blood cells as oxygen carriers, aswell as their contribution to the total blood mass under abnormal circumstances.
2. The magnitude of the initial loss of wholeblood at wounding was not properly estimated, and the loss occasioned bycontinuing seepage of blood and its fluid components into the tissue spaces wasalso underestimated.
3. The effort to restore and maintain bloodbulk by colloid preparations derived either from human proteins or from othersources presupposed a space bounded by a semipermeable membrane rather than aspace in which large areas of the containing membrane might have been renderedfreely permeable by the direct effects of trauma.
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30 November.-Atthis meeting of the Subcommittee on Blood Substitutes (7), the principaldiscussion concerned the feasibility of preserving and transporting whole blood,with special attention to the studies, which proved this point, by Dr. Plass andDr. Elmer L. DeGowin at the State University of Iowa College of Medicine. Theyare reported in detail elsewhere (p. 220).
1941
19 April-At this meetingof the Subcommittee on Blood Substitutes (5), after a discussion ofplasma and serum, the chairman, Dr. Robert F. Loeb, stated:
I take it that the consensus of the committee is that eitherserum or plasma reduced to either a frozen or a dried state is acceptable andthe production should proceed at once with the understanding that in time otherrecommendations may be made.
This statement was agreed to by all the committee. The Armyand the Navy accepted plasma because studies with it were much further advancedat this time than studies with serum and because the yield was greater-15 to20 cc. per pint of blood-than the yield of serum.
It would be unfair not to emphasize again the entirelypractical reasons for which the Subcommittee on Blood Substitutes recommendedplasma to the Armed Forces in April 1941:
1. Supplying whole blood to the Armed Forces in the quantitieslikely to be needed, together with its safe storage and transportation,presented logistic problems of enormous proportions. They could not be solved inthe light of either the knowledge or the facilities available in 1940-41.Preservative solutions which would permit long storage periods were just beingdeveloped. Thoroughly dependable, avid grouping sera were just being developed.The development of adequate equipment for the collection, storage, anddispensing of whole blood had barely begun. Refrigeration equipment for use inthe field under varying conditions of heat, cold, and humidity had not yet beenmanufactured. Finally, an airlift capable of delivering blood to the far reachesof the battlefront was still almost 3 years off.
2. Plasma is a homologous protein fluid, the osmoticequivalent of blood, which can be administered without typing or crossmatchingand which is almost entirely free from the reactions which, in 1941, were stillfrequent and serious after blood transfusion.
3. The protein content of plasma tends to hold transfusedfluid in the vascular bed because its components are of high molecular weightand size as compared with the components of saline and dextrose solutions, whichreadily leak through the capillary walls or are excreted via the kidneys andwhich therefore have only temporary therapeutic value.
4. The use of plasma solved serious logistic problems.Separated from its cellular components, it could be frozen and dried to lessthan 1-percent moisture content. In this state, it could be packaged undervacuum and preserved for years without refrigeration and without being affectedby extremes of heat and cold. The equipment necessary for its reconstitution andintravenous administration could be incorporated in a small package, which couldbe made available under almost all conditions of war. Plasma could be used incircumstances in which the procurement of whole blood would be completelyimpractical.
5. Finally, and most important of all in the light ofimmediate needs, plasma could be easily and safely produced commercially in thelarge quantities which would be needed.
The inherent organic characteristics of plasma, particularlythe ease with which it could be manufactured, stored, and transported, clearlymade it a
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practical and desirable agent. The reasons for its selectionin 1941, while perhaps not fully explaining the failure to attempt to supplywhole blood to field units at this time, did take cognizance of obstacles whichwent far toward discouraging even the most ardent advocates of whole blood as areplacement fluid in Zone of Interior hospitals. These reasons were considerablymore valid in the consideration of plasma as a feasible and practical agent forblood replacement in oversea hospitals.
3 November-At this meeting-alittle over a month before the United States was precipitated into World War II-theSubcommittee on Blood Substitutes unanimously expressed the opinion that theArmed Forces should use whole blood in the treatment of shock whenever this waspossible (8). Unfortunately, this clear-cut expression of opinion wasomitted from the minutes of the meeting, and the omission was not realized untilthe meeting of 24 September 1943. All present at the later meeting were inagreement that this opinion had been expressed unequivocally at the 3 November1941 meeting, and it was the sense of the 1943 meeting that the minutes of theearlier meeting be corrected to show the facts.
1942
20 October-Twoimportant proposals were made at this meeting of the Subcommittee on BloodSubstitutes (10). The first was that stored blood be used in the ArmedForces whenever the practice was feasible and fresh blood could not be usedeffectively. The second was that universal donor blood (O) be employed, toeliminate the necessity for crossmatching. These recommendations were passed onto the parent Committee on Transfusions, for submission to the Surgeons Generalof the Army and the Navy through National Research Council channels.
At this meeting, it was also recommended that supervision ofthe administration of all parenteral fluids be considered within the scope ofthe transfusion service which had been proposed at the 25 August 1942 Conferenceon Transfusion Equipment (11) and that replacement therapy be consideredas a medical specialty. These recommendations were later implemented, at leastin part, by the appointment of a Special Assistant on Shock and Transfusions inthe Office of The Surgeon General (p. 69).
15 December-This meetingof the subcommittee (12) accepted the proposals for a special shock andtransfusion service in the Armed Forces, which had been drawn up by Dr. DeGowin,Major Kendrick, and Cdr. (later Capt.) Lloyd R. Newhouser, MC, USN, andrecommended that they be transmitted through channels to the Surgeons General ofthe Army and the Navy. These proposals were never implemented.
1943
23 March-Aconference on blood grouping on this date was participated in by a number ofmembers of the Subcommittee on Blood Substitutes (13).
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Dr. DeGowin opened the discussion by asking those present ifthey would be willing to recommend that the Armed Forces employ group O blood asa universal donation, without crossmatching, if there was assurance that bloodgrouping had been accurately performed. After a vigorous discussion of variousaspects of the proposal, the conference participants agreed to it, with theunderstanding that either blood with low titer agglutinins would be used or thatA and B specific substances would be added to the blood.
At the 13 May 1943 meeting of the Subcommitteeon Blood Substitutes (14), it was recommended that provisions for thestorage, transportation, and administration of whole blood in the Armed Forcesproceed with all possible speed.
For all practical purposes, the tworecommendations just stated marked the beginning of the whole blood program foroversea theaters, though for various reasons it was not until August 1944 (p.487) that they were translated into action.
Note.-Other actions of theSubcommittee on Blood Substitutes are described in appropriate places in thischronicle.
THE EVOLUTION OF THE CONCEPT OF WHOLE BLOOD REPLACEMENT IN THE MEDITERRANEAN THEATER
The British Experience
Reports of the transfusion service which theBritish had set up before the outbreak of the war in 1939 have been citedelsewhere (p. 15). Their early experiences clearly indicated the need for largequantities of whole blood in the management of wounded casualties, and theirforesight put them in a position to provide it.
The British experiences in North Africa weremade available to the Office of The Surgeon General, through Col. Frank S.Gillespie, RAMC, British Medical Liaison Officer, who was stationed at theMedical Field Service School, Carlisle Barracks, Pa., during the early months ofthe United States participation in the war. As the British experienceaccumulated, Colonel Gillespie made every effort to keep Colonel Kendrick, TheSurgeon General's Special Representative for Blood Plasma and Transfusions,fully informed of changing concepts in the care of battle casualties. Thedevelopment of the U.S. program was painfully slow, but the British experiencehad a far-reaching effect on all the planning. Colonel Kendrick wasexceptionally fortunate in having Colonel Gillespie's cooperation and supportat a time when U.S. Army medical intelligence was relatively limited.
The whole British experience in North Africaproved that while plasma was extremely valuable in providing temporarycirculatory support for patients who had suffered multiple extensive wounds,associated with massive hemorrhage, it was not enough. Whole blood, which hadthe oxygen-carrying
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property lacking in plasma, was essentialduring anesthesia and initial wound surgery.5
Evaluation of Plasma in U.S. Army Casualties
Because he had been so well briefed on thesematters by Colonel Gillespie, Colonel Kendrick was able to have extendeddiscussions with the personnel of the Surgery Division, Office of The SurgeonGeneral, on the value of whole blood versus plasma in battle casualties. Heconsidered it essential that the same information should be in the possession ofCol. Edward D. Churchill, MC, who had been ordered to North Africa in January1943, to serve as Consultant in Surgery, Fifth U.S. Army, and that he shouldhave it before the fighting in that theater extended to Sicily and Italy.
The opportunity to discuss these matters withColonel Churchill arose during his predeparture briefing in the Office of TheSurgeon General, while he was reviewing the film strips which had been preparedby Colonel Kendrick on first aid in the field and on resuscitation, includingthe use of plasma and whole blood. Colonel Churchill was also informed that animportant function of the Department of Surgical Physiology, Army Medical School(p. 65), was to investigate and evaluate solutions and equipment by whose useblood could be stored and shipped long distances with expedition and safety.
It was suggested to Colonel Churchill thatupon his arrival in North Africa, he undertake a study of the whole problem, todetermine:
1. With plasma readily available, was wholeblood really needed?
2. If whole blood was really needed, how bestcould it be provided?
Colonel Churchill assumed his consultantduties in North Africa on 7 March 1943. His first official report, 2? weekslater (15, 16), after a period of temporary duty with II Corps on thesouthern Tunisian front, was a memorandum to the Army Surgeon on whole bloodtransfusions. In this report, and in a number which followed it, he made thefollowing points:
1. Plasma and other preparations that do notcontain red blood cells are incorrectly named blood substitutes. Whileinvaluable for certain specific purposes and under certain specializedconditions, they are merely fractions of blood. Plasma may be preferable towhole blood in crushing injuries, in the early stages of burns, and in extremeheat dehydration, but all of these conditions are numerically insignificant inwar.
2. The development of plasma was undoubtedly agreat contribution to military medicine, but the early enthusiasm thataccompanied its development
5In North Africa and Italy, as well as later in Normandy, the British supplied some of the whole blood used for American casualties. At the meeting of the Southern Surgical Association in 1944, Colonel Gillespie was asked to comment on a communication dealing with the management of battle casualties and thought to himself, as he wrote after the war, "Here's my chance for another crack at the whole blood battlefront." So he said: "I have often wondered at the physiological differences between the British and American soldier. The former, when badly shocked, needs plenty of whole blood, but the American soldier, until recently, has got by with plasma. However, I seemed to observe a change of heart when I was in Normandy recently and found American surgical units borrowing 200-300 pints of blood daily from British Transfusion Units, and I'm sure they were temporarily and perhaps even permanently benefited by having some good British blood in their veins."
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had pushed aside sound clinical judgment andhad led to the widespread misconception that it was an effective substitute forblood in shock. In fact, the organization and development of effective methodsfor the management of shock had been handicapped to an embarrassing degree bythis misconception, which was firmly entrenched in both administrative andprofessional minds.
3. The real circumstances were these (17): Evenin hematopneic shock, the liberal use of plasma could restore the circulatingblood volume and thus tide a casualty over the critical period required for hisevacuation to some installation in which whole blood was available. When plasmawas used liberally, certain casualties recovered from shock in the sense thatthe blood pressure was brought to normal or nearly normal and the peripheralcirculation was reestablished by the improvement in the blood volume deficit.Neither of these groups of casualties, however, were in a state to toleratemajor surgery without more support. In both, the blood pressure was extremelylabile and would fall rapidly if operation were undertaken. Further hemorrhagemight occur, or some blood would be lost at operation, and the additional lossescould not be tolerated by a casualty with profound secondary anemia, for theoxygen supply to the tissues was not adequate. He might improve temporarily withoxygen administration, but additional plasma would be of little benefit.
4. The North African experience showed thatsome casualties would die because of the very nature of their wounds or thecomplications of their wounds. Others would die from the damage caused by theirstate of shock. The lethal sequelae of shock had become more apparent as surgeryand resuscitation had improved. Basically, these sequelae were attributable tothe asphyxia of organs or tissues during the prolonged period of reduced volumeflow of blood. Often, they were masked by the presence of serious complicationsarising from the wound itself. They were sometimes not recognized at all incasualties who succumbed to such rapidly fatal results of trauma as fulminatinginfection, cerebral lacerations, or respiratory insufficiency. The brain, thekidneys, and possibly the liver might show irreparable and ultimately lethaldamage from shock. Kidney damage was probably the most frequent of thesesequelae, and also the most easily overlooked.
5. An inexperienced surgeon, seeing thebeneficial results of plasma therapy and not realizing its limitations, might beencouraged to undertake surgery in a patient not prepared to tolerate it.Indeed, restoration of the blood pressure and volume flow under conditions inwhich hemorrhage could not be arrested at once by surgery might lead to furtherloss of red blood cells and terminate in disaster. Once the patient had beenresuscitated, he must not be allowed to go into shock again. If surgery had tobe delayed, plasma would keep him alive until it could be undertaken, but theremust be no attempt to establish full circulatory compensation. Meantime, allshock-producing factors must be eliminated, which meant the relief of pain, theimmobilization of fractures, and the control of hemorrhage.
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Conclusions
In view of these facts, Colonel Churchill madethe following points clear in his first memorandums and in subsequent reports:
1. That whole blood was the agent of choice inthe resuscitation of the great majority of battle casualties.
2. That whole blood was the only therapeuticagent that would prepare seriously wounded casualties for the surgery necessaryto save life and limb.
3. That both the mortality rate and theincidence of wound infection were reduced by the use of whole blood at the timeof initial wound surgery.
4. That plasma should be looked upon as afirst aid measure for dire surgical emergencies and as a supplement for wholeblood, not as a substitute for it.
Thus, Colonel Churchill concluded, actualexperience had clearly delineated both the indications for, and rationale of,plasma and whole blood replacement. Both agents were extremely valuable in themanagement of shock, but each had its own individual and specific purposes, and,if they were to be used efficiently, both limitations as well as indicationsmust be borne in mind.
Months were to pass before an organized systemof providing blood for casualties in forward areas was set up in the NorthAfrican theater; by the time a central blood bank had been established (p. 400),however, plasma had assumed its proper place in resuscitation and whole blood,collected locally, was being used in increasing quantities. When active combatbegan in the European theater, the experience in North Africa, Sicily, and Italywas already at hand. The amount of whole blood that would be needed on theContinent was underestimated, but the need for blood was realized, and plasmawas generally used only according to its capabilities.
COMMENT
Nothing that has been said in this chapter shouldbe taken to mean any derogation of the value of plasma. Its capacity wasseriously overestimated in many quarters early in World War II. The almostfantastic hopes originally pinned to it were never realized. A more realisticestimate of its capacities would have prevented many misunderstandings anddisappointments. Later in the war, its capabilities were somewhatunderestimated. The truth lies somewhere between.
An interesting sidelight is thrown on the realvalue of plasma by an indignant letter from a young medical officer, in chargeof a battalion aid station in North Africa, who apparently had difficulties withsupply. It was necessary, said the writer, to beg, borrow and steal plasma fromvarious hospital units and from medical supply depots, which irked him by theirstrict adherence to distribution regulations and which seemed to have no conceptof conditions at a battalion aid station.
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He had "managed to scrape up" fiveunits of plasma and had used four of them with excellent results, three forshock and one for burns. A high Army officer, who had been injured in the areaand who was in mild shock, was treated with the fifth unit. The lack of plasmafor him "would have been most embarrassing."
The writer waxed more indignant as he continued. Plasma wasnowhere more essential, he pointed out, to prevent impending, and treatprimary, shock than in the frontlines. It was more sensible to provide it thereand not wait until the casualty went into secondary shock. He might easily dieon his way to the clearing station, usually 3-5 miles, and sometimes 12-15miles, to the rear. If practical considerations were brought in, plasma could begiven under the most severe battle conditions. He himself had administered itwith shells and bombs landing only a few yards away and had seen casualtiesrespond to it under his eyes.
On the other side of the world (fig. 5), plasma was reportedas equally effective. The Naval medical officer in charge at Tarawa, Capt.French R. Moore, MC, USN, said that 6,000 pints of plasma went ashore with theinvading troops and "4,000 pints came back in the veins of woundedMarines."
In his book, "More Than Meets the Eye" (18), CarlMydans wrote of "combat medics on bouncing jeeps," who
* * * kneeling and balancing andclinging miraculously with one arm, raised the other high, as one would a torch,holding a bottle of plasma, pouring life back into a broken body. I think I havenever seen a soldier kneeling thus who was not in some way shrouded with agodlike grace and who did not seem sculptured and destined for immortality.
To those who saw what plasma achieved in World War II, thisquotation is not an exaggeration.
References
1. Minutes, meeting of Committee on Transfusions, Division ofMedical Sciences, NRC, 31 May 1940.
2. Elliott, J.: A Preliminary Report of a New Method of BloodTransfusion. South. Med. & Surg. 98: 643-645, December 1936.
3. DeGowin, E. L., and Hardin, R. C.: A Plan for Collection,Transportation and Administration of Whole Blood and of Plasma in Warfare. WarMed. 1: 326-341, May 1941.
4. ETMD, NATOUSA, for July 1944.
5. Minutes, meeting of Subcommittee on Blood Substitutes,Division of Medical Sciences, NRC, 19 Apr. 1941.
6. Blalock, A.: Report of Committee on Transfusions, Divisionof Medical Sciences, National Research Council, to Committee on Surgery,Division of Medical Sciences, National Research Council, 24 July 1940.
7. Minutes, meeting of Subcommittee on Blood Substitutes,Division of Medical Sciences, NRC, 30 Nov. 1940.
8. Minutes, meeting of Subcommittee on Blood Substitutes,Division of Medical Sciences, NRC, 3 Nov. 1941.
9. Minutes, meeting of Subcommittee on Blood Substitutes,Division of Medical Sciences, NRC, 24 Sept. 1943.
10. Minutes, meeting of Subcommittee on Blood Substitutes,Division of Medical Sciences, NRC, 20 Oct. 1942.
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11. Minutes, Conference on Transfusion Equipment andProcedure, Division of Medical Sciences, NRC, 25 Aug. 1942.
12. Minutes, meeting of Subcommittee on Blood Substitutes,Division of Medical Sciences, NRC, 15 Dec. 1942.
13. Minutes, Conference on Blood Grouping, Division of MedicalSciences, NRC, 23 Mar. 1943.
14. Minutes, meeting of Subcommittee on Blood Substitutes,Division of Medical Sciences, NRC, 13 May 1943.
15. Report, Consultant in Surgery to the Surgeon, NATOUSA, 2July 1943.
16. Medical Department, United States Army. Surgery in WorldWar II. The Physiologic Effects of Wounds. Washington: U.S. Government PrintingOffice, 1952.
17. Memorandum for The Surgeon General, 20 June 1944, subject:Annual Report, Transfusion Branch, Surgery Division, Fiscal Year 1944.
18. Mydans, Carl: More Than Meets the Eye. New York: Harper& Bros., 1959.
