Preface
In World War I, between 8 and 11 of each 100 wounded men who reached forward hospitals alive died in them. In World War II, the number was reduced to 4.5 per hundred. In the Korean War, it was further reduced to 2.6 per hundred. The explanation is simple, that the mortality rate in combat wounds is inversely proportional to the availability of prompt and adequate resuscitation, in the routine of which whole blood and plasma play major roles.
The lessons learned in World War II furnished convincing evidence of thesoundness of that concept-but they had to be learned in the course of the war.When the Korean War began, the concept of the essentiality of whole blood in themanagement of shock was firmly established in the minds of both clinical andadministrative personnel and had been accepted by statisticians. The fly in theointment was that administrative personnel had not yet learned that whole bloodis best handled out of supply channels, as a separate supporting service.
In 1939, at the outbreak of the Second World War, the United States founditself with no organized blood bank system, and, indeed, with no plans forsupplying whole blood or so-called blood substitutes to wounded casualties. By1941, when this country was precipitated into that war, the plasma program wasbeginning to evolve, but the whole blood program was not yet even in theplanning stage. Both programs developed by a series of expedients, almost on atrial-and-error basis. The end result was brilliantly successful, but thesuccess was achieved at the cost of delay, inefficiency, and far greater expensethan should have been incurred. Moreover, there was only a small capitalizationon the tremendous research potentialities afforded by the collection of millionsof units of blood and its clinical use in war casualties, partly as whole bloodand partly in the form of plasma and serum albumin.
It is distressing to relate that when the Korean War broke out in June 1950,less than 10 years after the United States had entered World War II and just 5years after World War II had ended, planning for a blood bank system had beeninstituted, but so shortly before the beginning of hostilities that, as in WorldWar II, planning and implementation again were carried out on a basis ofexpediency.
It is doubly distressing to recollect that this situation was entirelyunnecessary: At the end of World War II, well-founded, detailed recommendationsfor a transfusion service had been prepared and submitted through channels tothe proper authorities. Time, manpower, effort, money, and lives could all havebeen spared in Korea if these recommendations had been utilized as a basis forpostwar planning. As it was, the newly developed plans were not ready forimplementation when the Korean combat began.
The essentials of a blood program for oversea theaters may be described asmaterial. In addition to donors, they include equipment, refrigeration, preservatives, and an airlift. Basic to the program, however, is theacceptance of the concept of the need for whole blood for combat casualties. Itwas failure to recognize this need, and to face and overcome the associatedlogistic problems promptly, that was the real reason for the delay in supplyingwhole blood to oversea theaters in World War II.
When World War II began, the concept of shock was still vague, and, in thelight of World War II experiences and investigations, it was found to be inerror in many of its aspects. Transfusion was still a dramatic and heroicprocedure, resorted to more often than not only when the situation was criticalor desperate. Direct techniques were just beginning to give way to indirecttechniques. Reactions, due chiefly to the presence of pyrogens, were stillalarmingly frequent. Plasma was still in the experimental stage. Thefractionation of plasma proteins had not yet become a practical reality, and theclinical use of byproducts of that process was not yet even imagined.
Many of the problems of shock still remain to be solved, but a great deal waslearned about them in World War II, not only by clinical observation but also bythe careful studies carried out on them in theaters of operations, particularlyin the Mediterranean theater, by the Board for the Study of the SeverelyWounded. Though much remains to be clarified, there is now full realization thatthe fundamental cause of shock in the wounded man is diminution of the amount ofcirculating blood. Logically, therefore, the objective of all therapy is therestoration of the diminished blood volume to its approximately normal status,so that the wounded soldier may withstand the measures-which are often heroic-necessaryto care for his wounds.
In spite of the attention paid to plasma in the early months of World War II,there were many whose eyes, from the beginning, were fixed upon whole blood. Itis interesting and significant that it was a biochemist, not a clinician, who,some years after the war, vigorously called attention to this fact. Dr. Edwin J.Cohn, in recounting the history of the World War II National Research CouncilSubcommittee on Blood Substitutes to the similar committee which took its placein 1949, stated that he "* * * wanted the group to realize that at a veryearly point in the history of the earlier Subcommittee, Dr. DeGowin had startedwriting and talking about the necessity of using whole blood instead of bloodfractions, and for the need to start immediately to develop a service to supplyblood to the Armed Forces."
The subcommittee, Dr. Cohn continued, had repeatedly recommended the use ofwhole blood for combat casualties, but no specific action was taken on theserecommendations until reports from the North African theater indicated the needfor blood. Then, concerted efforts were made to supply it, but there were delayswhile logistic problems, which had not yet been evaluated, were solved. Atfirst, many authorities outside of the Subcommittee on Blood Substitutesconsidered it impractical to extend the dating period beyond 8 days, let aloneto fly blood overseas. It took persistence, faith in the concept and in thepossibility of its implementation, and a great deal of hard work to set up theplan, but, by November 1943, the same airlift was available that was-belatedly-put into effect in August 1944. One can only regretthe lost months and, as a corollary, the lost lives, that resulted from thedelay.
In retrospect, it is difficult to understand why the United States was soslow in setting up a whole blood program in World War II. We could have learnedsome lessons from World War I. O. H. Robertson, for instance, and Ohler bothstated unequivocally from their experience in it that, when blood is lost, itmust be replaced by blood. We could also have learned from the very successfulprogram in effect in the Spanish Civil War.
Above all, we could have learned from the British, who, to quote BrigadierSir Lionel E. H. Whitby, RAMC, entered the war with a "firm policy,"decided upon 6 months earlier, that there would be a completely distinct andseparate transfusion service in their Army because the transportation ofpotentially dangerous biologic fluids over long distances would require closepersonal supervision and could not be trusted to the usual supply routesemanating from a base medical supply store. The British policy was remarkablysuccessful. It was carefully planned before hostilities began. It was based onthe concept that blood is a perishable substance, as potentially dangerous as itis potentially useful, and therefore is to be handled only in special channelsand only by specially trained personnel. We followed that plan only partially inWorld War II, and not much more effectively in Korea, and, in both wars, we paidthe penalty for our folly.
In the face of these facts, one can only wonder why the United States did nothave a special transfusion service planned before we entered World War II; whythe recommendation of the Subcommittee on Blood Substitutes, National ResearchCouncil, for such a service was not adopted during the war; why it was not until4 years after the war ended that such a special service was established; and whywe had been engaged in World War II for almost 3 years before the proposal, mademany months before, was adopted and blood was flown overseas to the Europeantheater and to the Pacific areas.
Once the oversea airlift was instituted, it was clearly demonstrated thatblood can be collected thousands of miles from its point of use; can be safelytransported over those miles; and can be used with safety and benefit if thereis proper planning, proper handling, proper timing, and adequate airlift,trained administration, and careful coordination. The successful use of wholeblood reached a high point on Okinawa in World War II. Planning-in which,naturally, there were some mistakes-was detailed and timely. Blood wasprovided in ample quantities. There were 40,000 casualties, and their treatmentinvolved the use of approximately 40,000 pints of whole blood, 1:1. All theblood used on Okinawa was flown from the United States, a distance of 8,000miles. With the dating period set at 21 days, it required careful timing toinsure provision of adequate quantities of whole blood with a minimum amount ofwastage from outdating. There were two reasons why the operation was successful:First, the blood supply from the United States to Okinawa via Guam was highlyefficient. Second, the commanding general, with the full concurrence of thesurgeon of the task force, assigned to a trained transfusion officer full responsibility for the supply, distribution, and correct use ofall the whole blood brought onto the island.
Although whole blood is usually the fluid of choice in the resuscitation ofwounded casualties, it would be fatuous not to grant that there are militarysituations-and there probably will be civilian situations-in which it cannotbe provided and, as a matter of expediency, fluid of a longer shelf life must beused. Plasma met this requirement admirably in World War II. It was useful inthe field, forward of hospitals; in the initial phases of landing operations, inwhich it was difficult logistically to supply a perishable item like wholeblood, which always requires special care; and aboard ship, where, however, theNavy found serum albumin equally useful, because the procurement of water, whichusually had to be administered with this agent, was no problem.
During World War II, an abundance of plasma was available to the Armed Forcesof the United States, so much that an extensive clinical trial was possible,unhampered by considerations of supply or cost. The purity and excellence of theproduct supplied, and the disposable, sterile, pyrogen-free dispensing sets anddistilled water supplies with it, permitted the administration of largequantities without fear of reaction. How many casualties plasma kept alive untilthey reached installations in which whole blood could be administered andsurgery performed is not a fact that can be reduced to statistics, but it issafe to say that it was in the hundreds of thousands.
Plasma was used most effectively when its indications and limitations wereclearly realized. In addition to its use for resuscitative purposes, it was theagent of choice in crushing injuries, in burns, in injuries from bluntinstruments, and in other injuries in which there was no great loss of blood. Itwas built up beyond its capabilities early in World War II; it was often used toexcess and unwisely, though that criticism must be tempered by the fact thatvery often, in the early days of the war, the choice was plasma or nothing. Inthe Mediterranean and the Pacific, in those days, medical units and hospitalswent in with little or no provision for the collection and administration ofblood, chiefly because there was lack of logistic support in the Zone ofInterior to make the necessary equipment available.
When it became evident that plasma was carrying the virus of hepatitis, itsuse in the Korean War had to be discontinued, but that unfortunate developmenthas nothing to do with its essential value. When this problem has been solved-andthere is no doubt that it will be solved eventually-plasma can resume itsproper and valuable place as an agent of resuscitation to be used to supplementwhole blood.
No matter what form future conflicts may take, casualties will result, andthere is no conceivable kind of wound which will not require blood, plasma, orboth. It is quite possible that more blood and plasma will be needed in a futureconflict than have been needed in the past, because future wars will involvecivilians as well as troops, and will involve them in far greater numbers than were affected in the countries that bore the brunt ofthe air raids in World War II.
Since the need for blood will arise whenever combat commencesand whatever form it may take, it is imperative, before it commences, tomaintain supplies and equipment, to train personnel, and to plan adequately forthe provision of whole blood for any forces that may be placed in the field andfor civilians who may be part of the conflict at home. Although research done onthe long-term storage of blood by freezing with glycerol indicates that thistechnique offers a realistic and practical approach to the problem, whole blood,at least as yet, is not a commodity that can be generally stored on a long-termbasis. Nor can it be collected as the need for it arises unless there has beenprior planning for its procurement.
There was no such provision when World War II broke out, andit was not until late in the war that the correct equipment for collecting itand using it was made available in oversea theaters. That situation was onlypartially rectified when the Korean War broke out. Neither contingency must bepermitted to happen again.
War has very little left of glamour, but if, in World War II,there was anything dramatic and glamorous, it was the miracles wrought by theuse of whole blood. Since this is so, readers may wonder, and perhaps complain,that this book contains a great many prosaic, repetitious, monotonous details.It does indeed, and their inclusion has been deliberate. It is extremelyimportant-in fact, it is imperative-to recognize that behind the drama oftransfusion in World War II lay an elaborate mechanism of procurement, storage,delivery, and many other mundane details. It was only by the strictest attentionto such matters that blood was able to achieve its miracles, and, equallyimportant, was prevented from becoming a deadly agent. It must never beforgotten that without proper care, blood can be lethal.
Many agencies were involved in this gigantic enterprise,including:
The Department of Surgical Physiology, Army Medical School,and the similar division of the Naval Medical School.
The Office of The Surgeon General, U.S. Army.
The Medical Departments of both the Army and the Navy.
The American Red Cross.
The Division of Medical Sciences, National Research Council,with its various committees, permanent and ad hoc, particularly the ill-namedSubcommittee on Blood Substitutes. The actions of this subcommittee occupyconsiderable space in this book, as they should, for it was the advice of itsmembership that guided the Army and the Navy Medical Departments in many aspectsof the blood-plasma program. This subcommittee anticipated events by an earlyrecommendation that whole blood be supplied for combat casualties and by anearly recommendation for an airlift of blood to the European theater. It is agreat pity that these recommendations were not accepted when they were made.Considering the fact that its petition was never granted that it be permitted to visit combat zones and determine personally what thecircumstances and needs were, it is remarkable that this subcommittee was ableto accomplish what it did.
The National Institute of Health.
The Army Medical Procurement Agency.
The biologic processing plants that participated in the program and pioneeredin new and untried fields.
And, finally, the millions of U.S. citizens who donated their blood.
As to the individuals who participated in the program, it is difficult tosingle out any for mention without omitting others who should be included. Fourexceptions, however, might be made:
Dr. G. Canby Robinson, who directed the American Red Cross Blood DonorService.
Maj. Earl S. Taylor, MC, who served as Technical Director of the Service.
Dr. Walter B. Cannon, who, at the first meeting of the Committee onTransfusions, National Research Council, suggested that some "outstandingbiochemist" be brought into the program.
Dr. Edwin J. Cohn, who was brought into the program in response to thatsuggestion, and in whose Department of Biochemistry at the Harvard MedicalSchool the fractionation of blood plasma was successfully accomplished and theserum albumin program was translated into reality.
Surgeon Vice Admiral Sir Edward Greeson, RN, wrote in the preface to one ofthe volumes of the history of the Royal Naval Medical Service in World War IIthat no one has ever written "the" history of anything. The best thatcan be accomplished is "a" history. He made that statement in advance,he frankly admitted, to take care of the adverse criticisms he knew the volumeshe was editing would receive.
This volume, which is concerned with the blood-plasma program in World War IIand in the Korean War, is intended as "a" history of that program. Itis a chronicle built upon personal knowledge of what happened and upon a mass ofmaterial almost exasperating in its voluminousness and equally exasperating inits lack of many essential details. A great deal of the story is necessarily-andquite properly-built upon personal knowledge of what happened, what actionswere taken, and why and in what circumstances they were taken.
World War II was the first war in which the United States was engaged inwhich blood was used with any frequency, and the first in which plasma and serumalbumin were used at all. The attempt has therefore been made to record thewhole story, and, in particular, to omit no errors and no failures. A majorfailure was the attempt-which seemed so near success-to use bovine albumininstead of human blood. So many problems would have been solved if only theattempt had succeeded. It may be that one day the project will be revived andthe difficulty solved. No more practical man ever lived than the late Dr. Cohn, and he believed that this might happen, though it was he who,against the desire of some clinicians, insisted upon an immediate stop toclinical testing when it became evident that the bovine albumin developed in hislaboratory was not a safe agent.
The preparation of this book according to the principles just laid down haspresented certain major difficulties. World War II was a global war, and theblood and plasma program was an essentially global program. On the surface, ashas been suggested for many of this series of volumes, it seems perfectly simpleto present what might be termed "a linear chronologic account," withthe events in all theaters presented synchronously as they occurred. Actually,this would be an impossible task, and, granting the possibility of itsaccomplishment, it could result only in confusion.
After considerable experiment, it was decided that the most logical mode ofpresentation would be first by subjects and then by theaters. By this plan, thebook falls into the following divisions:
1. A historical note, for which no apology is offered, if only because thechronicle makes clear how far we still had to go in World War II, as well as-toour discredit-what had been accomplished in the Spanish Civil War and by theBritish before the United States entered the war.
2. Two background chapters, dealing with shock and with the evolution of thewhole-blood concept.
3. The provision of blood for blood transfusions and for conversion intoplasma. This group of chapters deals with administrative considerations; theAmerican Red Cross, which was the collecting agency; the donors who provided theblood; the equipment used to collect and administer it; transportation andrefrigeration; and the laboratory studies necessary before blood could be usedsafely and accurately.
4. A group of chapters dealing with plasma, serum albumin (bovine and human),byproducts, so-called blood substitutes, and other intravenous agents.
5. Separate chapters dealing with the Mediterranean and European Theaters ofOperations and the Pacific areas.
6. A final clinical section dealing with reactions and with principles ofreplacement therapy.
7. A chapter on the blood and plasma program in the Korean War, which isincluded, contrary to the usual practice in this historical series, because thiswar furnished an opportunity to study the application of the lessons learned inWorld War II, some of which, unfortunately, had to be learned over again.
No matter what the plan of presentation, a certain amount of repetition wouldbe inevitable in this volume. The plan adopted perhaps calls for an undueamount, though some of it is deliberate and necessary. As much repetition aspossible, however, has been eliminated by the copious use of cross-references.
One other item might be mentioned in conclusion: the numberof veterans of World War II and Korea who have given blood since those wars ingratitude for the blood they themselves had received in them. One man, a recentnewspaper story related, had just given his sixty-fifth pint; he lost a leg onGuam but, thanks to the blood he received, he did not lose his life. No oneappreciated the value of whole blood more than GI Joe, and not the least of itsbenefits was its effect upon his morale.
DOUGLAS B. KENDRICK,
Brigadier General, MC, USA.
