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Chapter XV

Contents

CHAPTER XV

The Mediterranean (Formerly North African)
Theater of Operations

Part I. Fifth U.S. Army

EVOLUTION OF POLICIES

The use of whole blood overseas in the management of wounded casualties developed in MTOUSA (Mediterranean (formerly North African) Theater of Operations, U.S. Army) (1). While its development was a local affair, it influenced the policies and practices in both ETOUSA (European Theater of Operations, U.S. Army) and the Pacific areas. The experience occurred in two chief phases:

1. The British experience blazed the trail (2). On the outbreak of war, in September 1939, the British immediately put into action the plans previously set up for the provision of whole blood to troops in the field (p. 15). In the Western Desert, 18 bottles of blood, 19 bottles of plasma or serum, and 20 bottles of physiologic salt solution were used for each hundred of the 17,572 troops wounded between 10 April and 28 November 1942. The use of blood was more liberal than these figures suggest, since the total casualties include the missing, in some of the actions.

The entire British experience proved that while plasma was extremely valuable in the provision of temporary circulatory support for casualties with multiple wounds, accompanied by massive hemorrhage, from mortars, high explosives, and landmines, it was not enough. Whole blood, which had the oxygen-carrying properties lacking in plasma, was essential for the support of casualties for anesthesia and initial wound surgery. The British experience also proved that it was completely practical to transport whole blood for long distances; when the fighting moved to Italy, British hospitals continued to receive blood from the bank in Cairo until the transfusion unit moved to Bari, Italy.

2. Information concerning the British experience was made constantly available to Col. Douglas B. Kendrick, MC, in the formative days of the blood-plasma program in the Zone of Interior by Col. Frank S. Gillespie, RAMC, British Medical Liaison Officer (p. 54). Col. Edward D. Churchill, MC, Consultant in Surgery to the Surgeon, Fifth U.S. Army (fig. 76), was fully informed of it when he assumed his duties in North Africa in March 1943. Before he left the Office of The Surgeon General for North Africa, he had been


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requested to undertake a study of the entire problem, with the twofold objective of determining (1) whether, with plasma readily available, whole blood were really needed, and (2), it if were, how best it could be provided.

FIGURE 76.-Col. Edward D. Churchill, MC, Consultant in Surgery, Fifth U.S. Army.

EARLY EXPERIENCES

In spite of the British experience, U.S. Army hospitals that landed in North Africa in November 1942 and those that landed later had practically no equipment for whole blood transfusion (p. 393). It was the prevailing opinion then that plasma would be so effective that only a very small proportion of wounded would require whole blood early in their treatment. A few officers in the Army Medical Department and a few members of the Subcommittee on Blood Substitutes had expressed concern over the lack of preparation for whole blood transfusion, but no strong, direct, constructive, formal recommendation had been made, and there was, therefore, no provision at the time for supplying whole blood to Army hospitals overseas.

The treatment of shock with plasma produced gratifying results in Tunisia and throughout the war (figs. 77-80). It was provided in ample quantities. It was often given in 1,000-cc. amounts. It was often continued during evacuation to the rear, or it was given prophylactically, in advance of evacuation, particularly in patients with fractures of the femur or with abdominal wounds (who later in the war would be operated on in field hospitals). It did not require much experience, however, to learn as the British had long since learned, that when blood had been lost, the only effective replacement was whole blood.

There is no doubt that lives were lost in North Africa and that morbidity was increased because blood was not used soon enough (until evacuation hos-


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FIGURE 77.-Administration of blood plasma in battalion aid station, about half mile behind frontlines, S. Agata, Sicily, 9 August 1943. The same first aid station is shown in the frontispiece of this volume.

pitals, or sometimes general hospitals, had been reached) or in sufficient quantities. There were three explanations:

1. Facilities for transfusion had not been provided.

2. Transfusion with improvised equipment was extremely inconvenient and often impractical under field conditions.

3. The importance of whole blood had been overlooked while the potentialities of plasma had been overstressed.

In his report of 3 April 1943 to the Surgeon, II Corps, Maj. (later Col.) Howard E. Snyder, MC (3), included among his recommendations the need for a more convenient method of blood transfusion and for a source of donors other than clearing station personnel (p. 395). The need for whole blood in combat casualties and the extreme inadequacy of the equipment for obtaining it and administering it had already been reported to the Surgeon, II Corps, by the chief of surgery, 77th Evacuation Hospital, through channels, in December 1942. The report of the 77th Evacuation Hospital on 18 April 1943 stated, "As the need for whole blood transfusion grew critical, we found that nothing had been provided for this purpose" (4).

At that time, this hospital had no citrate, no distilled water, and no facilities to make it. The only equipment was what Capt. Joseph J. Lalich, MC, who headed a shock team, had been able to obtain from the British blood bank while the hospital was stationed in England. Sodium citrate was obtained from a French pharmacy. A still was borrowed from the French.


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FIGURE 78.-Administration of blood plasma to wounded German soldier at battalion aid station by corpsmen of 1st Battalion, 85th Mountain Infantry, 10th Mountain Division, Fifth U.S. Army, Villafranca, Italy, April 1945.

Blood was obtained from the hospital detachment. Shock teams were organized to collect and administer blood, administer plasma and other intravenous therapy, make distilled water for the entire hospital, sterilize equipment for transfusion and other intravenous therapy, and perform crossmatching. With these makeshift arrangements, the casualties in this hospital received more blood than plasma, and the report is an illustration of both the difficulties attending an improvised operation and the ingenuity of the hospital personnel.

In a report to The Surgeon General on 1 June 1943, Surgeon, II Corps, Col. Richard T. Arnest, MC, pointed out that if sterile tubing, filters, and needles were provided, with facilities for crossmatching, whole blood transfusions could be given almost as conveniently as plasma transfusions. The difficulty at this time was lack of equipment.

Meantime, almost as soon as he had arrived in North Africa, Colonel Churchill concluded, from his personal observations and from studies that he instigated, that large quantities of whole blood were needed in combat areas to treat casualties with severe wounds (2). Toward the end of the North African campaign, he detailed Maj. (later Lt. Col.) Eugene R. Sullivan, MC, Chief, Laboratory Service, 16th General Hospital, to investigate transfusion requirements and facilities in forward hospitals. On 13 July 1943, Major Sullivan reported that facilities for whole blood transfusion were entirely inadequate. He recommended that there be provided, ready for immediate


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FIGURE 79.-Administration of blood plasma to wounded soldier in Italy after house had been hit by bombs, November 1943.

use, vacuum bottles for bleeding, appropriate apparatus for the administration of whole blood, equipment for Kahn serologic tests, and electric refrigerators for the storage of blood in all field hospital platoons and all evacuation hospitals. With this equipment, Major Sullivan believed that forward hospitals could operate their own blood banks.

Reports of this own and Major Sullivan's observations were forwarded by Colonel Churchill, through channels, to the Office of The Surgeon General and to those in that office concerned with the blood-plasma program. He emphasized that his first task had been the identification of the problem (5). The campaign in North Africa had ended before corrective measures could be taken, but the necessary information was now available for future action. The single fact that stood out most prominently in the care of battle casualties in North Africa was the indispensability of whole blood before, during, and after initial wound surgery. Unless casualties were properly resuscitated-and their resuscitation included whole blood, often in large quantities, to replace what they had lost-surgery would be attended with an excessive mortality rate. Plasma could not replace whole blood.

Sicily

As a result of the North African experience and the subsequent studies by Colonel Churchill, Major Snyder, and others, a system of blood banks was set up in the Sicilian invasion in evacuation and general hospitals, sometimes


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FIGURE 80.-Fifth U.S. Army corpsmen administering blood plasma in open field to wounded comrade. In background is a war-ravaged town. Date is unknown, but the picture was taken before the introduction of large plasma bottles.

only 3 or 4 miles behind the combat zone (6). The blood was collected from volunteer donors among the combat troops, with the approval of their commanding officers, and from convalescent and slightly wounded casualties. Chaplains were of great help in obtaining donors, and the field directors of the American Red Cross maintained the records and otherwise assisted in the program. Plasma, of course, continued to be used in quantity.

FIRST PLANNING FOR A THEATER BLOOD BANK

Alternate Proposals

When the organization of a theater blood bank was first discussed in the Mediterranean theater, in June 1943, it was thought that blood would be necessary for about 18 of every 100 casualties, and that 1 unit of blood would be required for every 3 units of plasma. The ratio of transfusions to casualties, however, rose steadily as surgeons gained experience in combat surgery.

Two methods of providing the necessary blood were discussed at this time, (1) the distributing system employed by the Royal Army Medical Corps, and


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(2) a unit system, set up in individual hospitals, which would eliminate the necessity for a distributing system.

British system -The basis of the British system, as described elsewhere (p. 15), was the collection of blood in hospitals in the communications zone and its distribution to hospitals in the forward area. A forward distributing unit received blood from the base collecting unit, stored it, and distributed it as necessary to forward field transfusion units, which were located at the points at which initial wound surgery was performed.

Unit hospital system -The unit system first proposed for U.S. Army hospitals was advocated because of the following advantages:

1. It would eliminate the elaborate distributing system used by the British, which required additional personnel and mobile refrigeration.

2. It would reduce the time lost by donors, who would be secured from Army personnel.

3. It would permit the utilization of type A donors, who, with type O donors, account for about 82 percent of all bloods. In the British system, only type O donors were used.

4. It would permit personal supervision of all technical details by personnel of the hospital in which the transfusion was given. Any technical errors could thus be identified and corrected at once.

5. Hospitals using blood would be responsible for reducing excessive use and wastage, estimated at 10-15 percent in the British system.

6. There would be no losses by freezing during the winter, and losses by road accidents and transportation would be minimal.

7. The unit system would be more effective in overwater or assault operations, in which distribution from a base, or even from a forward center, must await the establishment of air transport.

8. The unit system could be started in the Mediterranean theater as soon as transfusion sets were acquired. If necessary, a distribution system could be set up later.

The disadvantages of a unit system were also recognized:

1. It would continue to place the burden of procuring blood upon busy forward hospitals, which had, however, shown themselves capable of assuming it. It would also mean that saline and glucose solutions and distilled water must continue to be prepared and distributed by hospitals; by the British system, these duties were assumed by the base installation.

2. Since troops in the combat zone would be used as donors, instead of base troops, the risk of transfer of malaria might be increased; it was relatively safe, from this standpoint, to bleed troops as soon as they had arrived in the theater.

3. When a hospital moved, except a field hospital platoon, which had mobile refrigeration, refrigeration would be interrupted and whatever blood was on hand would be wasted.

4. Both expendable and nonexpendable equipment would be required. Mobile hospitals, particularly those that would use blood in the largest amounts, should not be weighted down with the equipment necessary to wash, sterilize, and store bleeding bottles. Moreover, hospitals often worked without adequate supplies of pure water and with limited quantities of distilled water, and these lacks would make the cleansing process difficult and unsatisfactory.

5. Additional refrigeration would be required in evacuation hospitals, or a modification of the refrigerators now in use. To keep field hospitals completely mobile, it would be necessary for each platoon to be supplied with a refrigerator truck. Insulated boxes would also be needed for emergency shipment of blood from evacuation to field hospitals.


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Recommendation for Unit System

In a report of this discussion from the Consultant in Surgery to the Surgeon, NATOUSA (North African Theater of Operations, U.S. Army), of 2 July 1943, the following recommendations were made (2):

1. That a unit system to supply whole blood be immediately authorized in the theater.

2. That training personnel be detached as necessary from present assignments to put it into operation.

3. That the transfusion sets necessary be requisitioned by cable.

4. That the principle of using corps troops as donors be cleared through command channels, since command could at any time block the supply; this had happened in certain organizations in Tunisia. It was estimated that for an operation resulting in 20,000 casualties, 3,600 donors would be required from corps troops or from lightly wounded divisional troops during their evacuation to the rear.

It was pointed out that the basic difference between the unit system described and the British system was the placement of the donor reservoir, which would be in the forward and not the base area.

It was also recommended in this report that a central laboratory be established in the theater, to provide whole blood, plasma, intravenous solutions, and distilled water for the Fifth U.S. Army, on the ground that the British Base Transfusion Unit had demonstrated the feasibility of supplying large amounts of whole blood to combat troops.

Blood Supply, September l943-February 1944

By the time U.S. troops had landed at Salerno on 9 September 1943, it was apparent that even with the availability of vacuum bottles, which had now reached the theater, for the collection of blood, it would be impossible for forward hospitals to collect sufficient blood to treat their casualties adequately (7). Shortly after these landings, therefore, Col. (later Brig. Gen.) Joseph I. Martin, MC, Surgeon, Fifth U.S. Army, urged the theater Surgeon, then Brig. Gen. Frederick A. Blesse, to authorize the establishment of a transfusion unit to support Fifth U.S. Army field and evacuation hospitals. The Anzio-Nettuno landings were then in the planning stage, and, when no action was taken on General Martin's request, it was necessary for him to request British assistance in providing blood for them. In all, U.S. hospitals on the Anzio beachhead received about 4,000 pints of blood from this source; a large part of it was donated by Army Air Forces personnel in the area, but collecting and processing were done by the British blood transfusion unit at Foggia with British equipment. The first blood from the Fifth U.S. Army blood bank in Naples was not received on the beachhead until 23 February 1944.

During this period, as well as later, British blood was used for U.S. troops elsewhere in Italy (fig. 81). The use of serum was limited to British troops (fig. 82).


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FIGURE 81.-Transfusion given with British equipment and British-supplied blood to British victim of S-mine, Garigliano River area, Italy, 18 January 1944. Fifth U.S. Army blood bank in Naples had not yet been established. Casualty's face is black as the result of concussion.

In ETMD (Essential Technical Medical Data), NATOUSA, 1943 (8), the advantages of a collecting unit in a base section, to supply a portion of the blood used in forward hospitals, were outlined:

1. Service troops in the base could be used as donors, thus eliminating any interruption in the work of forward troops.

2. A collecting unit in the base could conduct a more rigorous examination of donors to eliminate those with jaundice and malaria. It could also control the quality of the blood by holding it long enough to perform Kahn tests and to search for malarial parasites.

3. The holding of small reserves of blood in the base area, subject to constant turnover by distribution to forward areas, would provide a bank adjacent to base units that could be used in the event of a devastating air raid or other catastrophe.

4. The current tactical situation, with a relatively stable front close to a large base area, was ideal for the distribution of blood under such a system.

Two disadvantages were listed:

1. It was undesirable to allow forward hospitals to become entirely dependent on the base section for blood; in overwater assaults and other conceivable tactical situations, it was essential that they be able to be self-sustaining in respect to blood for long periods of time.

2. The plan proposed would reduce whole blood to the status of a supply item, and it was not desirable to shift the responsibility for providing a lifesaving agent to an impersonal organization. No matter how carefully the system was organized, it would fail, through no fault of its own, under critical circumstances. A base section collecting and distributing unit should be regarded simply as an accessory to a vigorous and sustained effort by individual hospitals to maintain their own blood banks, not as a means of release from this responsibility.


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FIGURE 82.-Wounded Sikh, receiving infusion of blood serum (British) at temporary first aid station, Crespino, Italy, Fifth U.S. Army area, 22 September 1944.

ESTABLISHMENT OF BLOOD BANK AT 15TH MEDICAL
GENERAL LABORATORY

In February 1944, the whole blood situation was reviewed in all its aspects by General Martin; Colonel Arnest; Major Sullivan, representing General Blesse, and Col. Virgil H. Cornell, MC, Commanding Officer, 15th Medical General Laboratory (fig. 83) (9). Major Sullivan had just returned from an inspection trip in Fifth U.S. Army field and evacuation hospitals, in which he


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FIGURE 83.-Col. Virgil H. Cornell, MC, Commanding Officer, 15th Medical General Laboratory

had surveyed their blood transfusion problems.1 The outcome of the meeting was the recommendation that a transfusion unit be organized to supply 100 bottles of blood daily to meet Fifth U.S. Army and Peninsular Base Section requirements. A letter containing this recommendation was sent to Maj. Gen. Morrison C. Stayer, Surgeon, MTOUSA, by Colonel Cornell, through channels, on 5 February 1944. Before action could be taken on it, the Army had raised the calculated needs to 200 bottles per day.

The 15th Medical General Laboratory, which arrived at Naples on 20 November 1943, was the parent organization of the Fifth U.S. Army blood bank. It was the second laboratory of the kind to be organized in World War II and, in general, was set up on the pattern of the central laboratory at Dijon in World War I (10).

Soon after its arrival in Naples, the laboratory was asked by the Surgeon, Peninsular Base Section, to operate a small (20-bottle) blood bank, to supply the Naples area and the medical center there, to provide against emergencies. During the period required for Headquarters, NATOUSA, to draw up tables of organization and equipment for the proposed transfusion unit to be established in the theater, the laboratory undertook to supply blood for Fifth U.S.

1Until almost the end of the war, Major Sullivan continued to be attached to the Office of the Surgeon, NATOUSA. It was essential that some officer in this office have the responsibility for the coordination of the transfusion program with other theater activities. Major Sullivan acted as consultant on transfusions and in this role played a very important part in the theater blood program.


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FIGURE 84.-Maj. John J. McGraw, Jr., MC, Chief, Blood Bank, drawing blood from nurse donor at
15th Medical General Laboratory near Naples, September 1944.

Army hospitals. One officer (Capt. (later Maj.) John J. McGraw, Jr., MC) (fig. 84), and two enlisted men were assigned to a blood bank section and later served as a cadre for the transfusion unit.

Colonel Cornell took a great interest in the transfusion unit, and devoted much time and effort to helping Major Sullivan develop it. The availability of a medical officer of Colonel Cornell's experience, with his rank, was a distinct advantage. On numerous occasions he took direct responsibility and was able to obtain far prompter cooperation from other units and services than could the commanding officer of the unit, who, for the major period of its operation, had the rank of captain.


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FIGURE 85.-GI blood donors in line before receiving building, 2d Medical Laboratory,
Fifth U.S. Army, Carinola area, Italy, May 1944.

Collections.-The first blood collected at the laboratory on 23 February 1944, from group O donors, was sent to the Anzio beachhead, where it was distributed by the British field transfusion unit stationed there. Between this date and 1 May 1944, the laboratory collected 4,134 bloods. The one officer and two enlisted men assigned to the blood bank section were able to collect and process enough blood to meet the demands of the hospitals on the beachhead until the special transfusion unit was authorized on 9 May 1944.

During May, 6,363 bloods were collected, an achievement that would have been impossible without the help of personnel from the 1st Medical Laboratory, Fifth U.S. Army, which was attached to the 15th Medical General Laboratory on 27 April 1944. These officers and men, in addition to providing help in the collection and processing of blood, had an excellent opportunity to learn the conduct of a blood bank during a period of maximum activity. Using 12 beds, the combined personnel of the two laboratories drew a total of 4,685 bloods between 14 and 31 May, a daily average of 260. During the same period, after air contact had been made with forward units of the Fifth U.S. Army, personnel of the 2d Medical Laboratory (figs. 85 and 86) collected an additional 410 bloods.

Most of the blood collected in the February-May period went to the Anzio beachhead. The remainder was used in nearby general and station hospitals.


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FIGURE 86.-Technicians taking blood for typing, 2d Medical Laboratory,
Fifth U.S. Army, Carinola area, Italy, May 1944.

THE 6713TH BLOOD TRANSFUSION UNIT (OVHD.)

Organization

The 6713th Blood Transfusion Unit (Ovhd.) was activated on 9 May 1944, by General Orders No. 85, Headquarters, Peninsular Base Section, 8 May 1944 (11). It was assigned to Headquarters, NATOUSA, and attached to the 15th Medical General Laboratory for administration, quarters, and messing facilities. Although it was officially a separate organization, the transfusion unit, for all practical purposes, was a department of the laboratory. This was a fortunate arrangement, for it permitted the use of many laboratory facilities and services. Kahn tests, for instance, were performed by the serology section of the laboratory. It was thus possible for the transfusion unit to conserve space, equipment, time, and personnel.

As the transfusion unit was set up, it operated in two sections (chart 8), a base section which collected and processed blood in the base and shipped it to the other section, which functioned as a smaller distributing section in the Fifth U.S. Army area. This organization was far closer to the British system than to the unit system originally recommended, by which individual hospitals were largely responsible for their own supply. The explanation for the changed plan appears in a memorandum addressed to The Surgeon General on 27 May 1944 by Col. Earl Standlee, MC (12). In this memorandum, Colonel Standlee


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CHART 8.-Diagram of blood transfusion service for field army, North African theater, 27 May 1944

Source: Memorandum, Col. Earl Standlee, MC, to The Surgeon General, 27 May 1944, subject: Blood Banks in Theater of Operations.

pointed out that the great need for blood was in the forward, not the base, area. In the Fifth U.S. Army hospitals, between the invasion at Salerno and the end of the Cassino campaign, 4,600 transfusions were given in the Army area against 300 in the base. The emphasis should therefore be on supplying blood to Army rather than to base installations. When the base was close to the battle-line and evacuation was relatively rapid, the amount of blood used in base hospitals increased accordingly.


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FIGURE 87.-Transfusion in postoperative ward, 33d Field Hospital, Fifth U.S. Army, September 1944.

Transfusions were ordinarily given only in field (fig. 87) and evacuation hospitals in the forward Army area, these being the first installations staffed and equipped for their administration. They were not ordinarily given in battalion aid stations or in collecting and clearing stations, though occasionally, as during the rapid advance after the breakout at Anzio, these installations were so far ahead of field hospitals that blood was sent to them. There was no point to providing blood for clearing stations that were abreast of field hospitals.

As the plan worked out, field hospitals were supplied with all the blood they requested; they were never expected to provide their own. Evacuation hospitals operated their own blood banks when their casualty load was light. When it was heavy, they were supplied with additional amounts of blood from the base.

Bleeding Center

In addition to serving as the Unit headquarters throughout the war, the 15th Medical General Laboratory at the Fair Grounds in Naples served as the base bleeding section until the middle of April 1945, 3 weeks before the war in Italy ended. Another center was set up at the Red Cross enlisted men's service club in Naples. As the fighting moved north, bleeding centers were set up in Rome, Florence, and Pisa. Centers were sometimes set up temporarily in Army laboratories in replacement depots too far distant for convenient


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transportation of donors to the main center. The need for multiple centers increased as the Army advanced and base section troops were less concentrated.

Individuals came to the centers by whatever transportation they could secure. Organizations usually provided transportation for groups, or blood bank trucks were sent for them. In actual practice, the most efficient way to secure donors was to make contact with unit commanders a few days in advance of the need and ask them to provide groups of volunteers, who could be picked up at specified hours by organization or blood bank trucks.

Mobile bleeding units were sometimes sent out to bleed donors who could not report to the donor centers. Prisoners in disciplinary stockades, for instance, had to be handled in this manner. This was not a practical method, however, until the last month of the war, because of lack of expendable donor sets. Cleaning and sterilization of donor sets provided the biggest obstacle to the efficient operation of mobile bleeding units in Italy.

Distributing Center

The first blood collected at the 15th Medical General Laboratory was distributed by the British field transfusion unit operating in the Anzio area and by the 2d Medical Laboratory operating in the Carinola area. On 22 June 1944, the 6713th Blood Transfusion Unit began to operate its own forward distributing center, with 1st Lt. (later Capt.) John T. Kroulick, MAC, in charge. The center was always located near an airfield and was usually attached to an evacuation hospital for quarters and rations. If, however, an Army laboratory were situated in the area, it was sometimes attached to it. The center moved from its first location at Anzio to Rome, and then, as the fighting moved up the peninsula, to Grosseto, Florence, Bologna, and Verona, where it was located, at the 8th Evacuation Hospital, when the war in Italy ended. By the middle of June, all personnel had returned to the Naples base.

Personnel

When the 6713th Blood Transfusion Unit (Ovhd.) was planned, the estimated requirements for blood for Fifth U.S. Army field and evacuation hospitals, based on the amounts used to date, were set at 100 pints per day. Original personnel for the procurement and distribution of this amount consisted of 3 officers and 16 enlisted men. Before the unit was organized, the need for blood in Fifth U.S. Army hospitals, which were then receiving casualties from one armored and six infantry divisions, had increased to 200 pints per day, and the personnel allotment was increased to 5 officers and 20 enlisted men. Later, the allotment of enlisted men was increased to 38.

Personnel and equipment of the unit were sufficient to process 200 bloods a day with relative ease and to handle 300 pints daily for short periods without too much difficulty. When fighting was heavy, however, and 300 or more bloods were required daily for long periods, more help was needed. At the


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beginning of the Po Valley offensive, between 11 and 21 April 1945, 6,450 pints of blood were collected and processed, including 871 pints on one day.

Skilled personnel from the 15th Medical General Laboratory assisted during periods of stress. Even so, during major offensives, such as the Garigliano offensive, the assault on the Gothic Line, and the campaign in the Po Valley, it was necessary to attach additional personnel to the unit, usually from a hospital ship platoon, an adjacent general hospital, an army medical laboratory, a medical battalion, or replacement depots. When a replacement center located about 25 miles from the 15th Medical General Laboratory served as an independent bleeding section, some of the keymen from the original unit were trained intensively for about a month and assigned to it. They were slowly withdrawn as the replacement center section became able to function without help.

If Air Forces personnel, informal assistants, and hired civilians are included in the count, the total strength of the blood transfusion unit once rose to 90 persons, about 15 of whom were engaged in the distribution of blood, clerical work, supply, liaison, and other accessory tasks.

When 300 donors were bled daily, the 5 officers and 38 enlisted men attached to the unit had the following duties (figs. 88-92):

1. Contacts with donors, one officer and one enlisted man.

2. Registration of donors, three enlisted men.

3. Grouping bloods and preparing malaria smears, three enlisted men.

4. Bleeding donors, two officers and six enlisted men.

5. Labeling, capping, and packing bottles for shipment, three enlisted men.

6. Staining and reading malaria smears, two enlisted men.

7. Performing Kahn tests, one officer and two enlisted men.

8. Titration and check of blood grouping, two enlisted men.

9. Washing and sterilizing equipment, four enlisted men. When local civilian personnel were employed for this purpose, they were carefully supervised by an enlisted technician. An experienced technician always operated the autoclave.

10. Correspondence, preparation of pay vouchers, two enlisted men.

11. Forward distribution, one officer and four enlisted men.

12. Driving, four enlisted men.

When 300 donors a day were bled, officers and enlisted men worked the entire day. When larger numbers were bled, nightwork was necessary, and it was also necessary when, for one reason or another, donors could present themselves only at night. The frequent necessity for keeping personnel on duty all night, to maintain a 24-hour blood service, made for constant shortages of trained workers. Only the skill and devotion of the personnel of the blood transfusion unit made it possible to supply the large amounts of blood needed in the Fifth U.S. Army area in 1944 and 1945.

Personnel difficulties were compounded when it was necessary to operate several bleeding sections at long distances from each other. Theoretically, the most economical and efficient way to operate a blood transfusion unit is in one location, but circumstances in the Mediterranean theater frequently did not permit such an arrangement. In his October 1945 memorandum to The


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FIGURE 88.-Preparation of donor sets, 15th Medical General Laboratory, Naples, March 1944. Cleaning of giving and receiving sets after use was done by a very demanding technique. The objective was to complete the whole procedure, including reassembly, testing, and autoclaving, within 2 hours of the time the equipment had been used. A. Cleansing of tubing and valves in cold running water, introduced under pressure, after which distilled water will be used. B. Donor sets drying by gravity before sterilization. C. Technician cleaning and oiling blood collecting valves and tube assembly.

Surgeon General, Colonel Standlee recommended that in the future two transfusion units be established instead of one. Administration would then be more flexible, bleeding in isolated areas would be simplified, and the additional personnel would provide an additional margin of safety in case of disability from sickness and during rapid movement.

The forward distributing section was always in charge of a medical officer, who could assure proper handling and equitable distribution of the available blood, and who could also aid in the solution of transfusion problems that might arise in forward hospitals.


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FIGURE 89.-Laboratory examinations at 15th Medical General Laboratory blood bank. A. Unstained thick films, to exclude malaria. B. O donors' cells matched against group O serum. Circles 15 and 22 show presumptive gross agglutination, which indicates that blood type on identification tags was erroneous.

Officially, the personnel of the forward section, since they operated in the Army area, were on detached service with the Surgeon, Fifth U.S. Army. Their operational and administrative control, however, remained with the base transfusion unit. They carried their own tents, blankets, and other equipment, and, for housekeeping purposes, they were attached to the most convenient evacuation hospital or army laboratory in the area.

When several scattered bleeding sections were in operation, administrative details, accounting for supplies and property, liaison, donor procurement, and


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FIGURE 90.-Technician typing blood (third check), 15th Medical General Laboratory, Naples, August 1944.

maintenance of records proved to be a considerable task. All the officers of the unit participated in the work, with the channels of administration leading back to the base unit.

The desirability of including a medical administrative officer in the table of organization of blood transfusion units was debated in the theater before the 6713th Blood Transfusion Unit (Ovhd.) was established. On the surface, it seemed that it might be wise to concentrate all the responsibilities just listed in the hands of an administrative officer who would have no professional responsibilities and who could replace either a Medical Corps officer or a Sanitary Corps officer in the table of organization. It was decided, however, not to make the substitution, and the decision was wise, since the attachment of the unit to the 15th Medical General Laboratory eliminated many administrative problems.

In his August 1945 memorandum to The Surgeon General (13), Colonel Standlee strongly recommended against the appointment of a medical administrative officer; the entire blood bank operation, he pointed out, required a background of scientific training, and the Medical Corps or Sanitary Corps officer who would be lost by the substitution would have numerous professional duties. If, however, it was not practical, for any reason, to attach a transfusion unit to a large laboratory or other large organization, then the addition- not substitution-of an administrative officer would be necessary rather than desirable.


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FIGURE 91.-Blood typing at 15th Medical General Laboratory blood bank, Naples, September 1944.

TRAINING

It was necessary that the personnel of the base collection section be skilled in all aspects of the blood program, including fundamental principles, knowledge of blood types and typing, bleeding techniques, cleaning of apparatus, asepsis and sterilization, distillation of water, crossmatching, Kahn serologic testing, examination of smears for plasmodia, recognition of contaminated or overage blood, and fundamentals of refrigeration.

The noncommissioned officer in charge of a bleeding section, the enlisted men who cleaned, prepared, and sterilized the bleeding sets, and the technicians responsible for blood grouping and other laboratory procedures required at least a month's training in excess of their basic technical laboratory training. The usual laboratory technician, even though he was trained in venipuncture, did not attain a satisfactory degree of efficiency in bleeding donors until he had had additional training and practice. Some of the additional training was formal and didactic, but it was soon found that there was no substitute for breaking in a technician by assigning him directly to a bleeding unit in active operation.


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FIGURE 92.-Reading Kahn tests on donors' bloods, 15th Medical General Laboratory blood bank.

A certain amount of rotation was practiced from one section of the laboratory blood bank to another, but, in general, the tendency was toward specialization, so as to develop keymen in the blood bank as in other sections of the hospital.

All medical officers and nurses in the Mediterranean theater, as well as selected noncommissioned officers, received thorough training in the technique of reconstitution (fig. 93) and administration of plasma. The training was essential. When casualties were pouring in, there was no time to study instructions or labels on containers. Demonstration sets were used to advantage during the training, and so was Film Strip 8-51 when it was available.

In April 1944, a program was set up by which medical officers from each Army hospital and technicians from each hospital laboratory were sent to the blood bank at Naples for 3 days of intensive instruction. The handling of banked blood was greatly improved at the various hospitals as a result.

In September 1944, a complete series of motion and still pictures were made of blood bank activities from the time the donor arrived at the bleeding center until the blood was used in a frontline hospital. The script was prepared by Colonel Cornell. Film Strip 8-51, a black-and-white 35-mm. production, of 8,400 feet, was sent to the Signal Corps Photographic Center on Long Island on 22 December 1944.


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FIGURE 93.-Medical aidman preparing dried blood plasma for use, Fifth U.S. Army, M. Grande area, 20 February 1945.

TRANSPORTATION AND REFRIGERATION

Trucks -Transportation obtained from theater stocks consisted of two 2½-ton trucks, two 1½-ton trucks, two weapons carriers, and one ¼-ton jeep. The jeep was used for general utility purposes and to make contact with adjacent units from which donors could be secured.

One 2½-ton truck was mounted with a large refrigerator powered with generators (3 kw.). It had a capacity of 450 pints of blood and was used for storage purposes at the forward distributing section. The other 2½-ton truck, together with one of the 1½-ton trucks, was used at the base section to transport donors and supplies and for similar purposes. The other 1½-ton truck carried a moderately sized refrigerator with the necessary generators, and was used to deliver blood from the bleeding section to the forward distributing section of the bank (fig. 94). The two weapons carriers were mounted with smaller refrigerators, powered by the necessary generators, and were used to distribute blood from the forward distributing section to field and evacuation hospitals.


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FIGURE 94.-Truck with refrigerator used for delivery of blood, 15th Medical General Laboratory, Naples, March 1944. A. Refrigerator with compressor and two generators, one of which could take over if the other broke down. B. Rear view of truck, showing front of refrigerator, which is a company mess type, reinsulated and altered to fit 1½-ton personnel carrier in which blood is transported. It easily holds 240 600-cc. bottles of blood. C. Refrigerator opened to show method of storing blood in it.


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FIGURE 95.-Insulated box for shipment of blood constructed at 15th Medical General Laboratory, Naples, of U.S. plywood, door hinges, and salvaged blankets; Sardinian cork; German pitch and trunk clamps; and Italian handles. A. Box, open and empty. B. Open boxes (showing top layer of bottles), ready for dispatch to Anzio beachhead, March 1944. C. Closed container, with the 36 bottles of blood that could be shipped in it.

The vehicles were not in the best of condition when they were allotted, and not infrequently one or more had to be put up for repairs.

The delivery of all refrigerators was delayed; the first shipment was lost at sea, and the second did not arrive until some months after the invasion of Italy. Eventually, however, electric refrigerators were available for all medical installations in the theater, up to and including field hospitals. They had sufficient space for about 40 bottles of blood each. When kerosene refrigerators were used, the chief problem was the procurement of white gasoline for their operation. The necessity for good mechanical refrigeration, both in fixed hospitals and on trucks, carried the implication that the services of competent refrigerator mechanics be constantly available.


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FIGURE 96.-Blood being loaded (as it was daily) at Bagnoli, Italy, on LST for shipment to Anzio beachhead.

The large refrigerators in the 2½- and 1½-ton trucks did not receive unduly rough treatment and stood up very well. The household-sized refrigerators mounted in the weapons carriers did not stand up well, as might have been expected, since they traveled more than 150 miles each day, over very rough roads. They were soon discarded and deliveries were accomplished in insulated boxes (fig. 95).

These boxes, which were constructed in the Utilities Section, 15th Medical General Laboratory, were made of plywood and were insulated with 2 inches of cork. The insulation was sufficient to limit the temperature elevation to no more than 54° F. (12° C.), even when the box was exposed to the sun for 12 hours. A good deal of ingenuity was shown in their construction, which often included Italian hinges, German clamps, and gaskets from salvaged GI blankets. Each container held 4-6 cardboard cartons, each of which contained six bottles of blood.

These boxes were definitely not expendable. Their number had to be limited to the absolute minimum necessary for the operation because of the scarcity of material, particularly plywood and cork. They were later used for the airlift of blood from Italy to southern France (p. 448).

AIR TRANSPORTATION

The first blood delivered to the Anzio beachhead, which was also the first blood distributed from the blood bank at the 15th Medical General Laboratory, was sent by LST's (landing ships, tank) (fig. 96). At this time, the beachhead was still isolated, and most of the blood collected was sent to


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the hospitals on the Cassino front. When the fighting was intensified at Anzio, a request was made that blood be flown in. The necessary arrangements were made within 6 hours, and blood was delivered by plane to Anzio and elsewhere regularly thereafter, the largest shipment on a single day being 450 bloods.

FIGURE 97.-Unloading C-47 blood plane on Cecina Airfield, Italy, August 1944. This plane carried 
blood in Italy, and later from Italy to southern France.

C-47 plane.-At the request of Colonel Cornell, a C-47 aircraft (fig. 97) was attached to the 15th Medical General Laboratory, to be used as a carrier for the delivery of blood to units of the Fifth U.S. Army, originally to the Anzio beachhead and later, as the fighting moved up the peninsula, to other parts of Italy (map 1).2

At first, the blood plane was operated by the Air Transport Command. Then the task was taken over by the Troop Carrier Command. The pilots lived in the officers' quarters at the 15th Medical General Laboratory, along with the officers of the blood transfusion unit. They took a genuine and personal interest in their work and often flew the blood forward in very bad weather. The most forward airfield capable of taking a C-47 plane was invariably used. Although such fields were often reserved for fighter planes, an exception was always made for the plane carrying blood. The availability of this service made it possible to collect blood from such widely separated points as Naples, Rome, Pisa, and later Florence (map 1), for delivery to hospitals in the Army area.

The blood plane was usually airborne within 90 minutes after the blood was taken out of the refrigerator. The flight from Naples to Anzio took 30 minutes, and from Naples to Leghorn 2 hours.

2The assignment of this plane was a historical first and has not since been duplicated.


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MAP 1.-Map, showing movement of whole blood from Naples up the peninsula, and from Naples to Marseille for Seventh U.S. Army supply.

The blood plane carried penicillin regularly and, occasionally, emergency shipments of dressings, anesthetics, plasma, and other medical items. When the load permitted, it also carried medical personnel. On the return trip, it carried empty insulated boxes, sometimes laboratory specimens, and sometimes medical personnel.

Blood sent forward by air was turned over at the landing field to personnel from the forward distributing center. An important feature of air transport was that the blood was always accompanied by a courier whenever there was any reason to fear that the plane might not be able to make direct contact with the personnel from the forward center. When, as often happened, the field at which the blood plane was to land was inaccessible because of bad weather or for tactical reasons, the pilot landed blood and courier at the nearest available field. It was then the courier's duty to secure transportation for the blood to the forward distributing center, or to make contact with the center and wait with the blood until someone came for it. Even better, when personnel per-


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mitted, was the practice of sending two couriers with blood when trouble was suspected. Then, one would wait with the blood at the airport until transportation was available to the forward distributing center, while the other returned on the plane with the requirements for the next day's supply of blood.

The courier system insured that the blood was always under the personal care of personnel trained to handle it properly. Without courier escort, the blood would many times simply have been left on an airfield for hours, without protection from either heat or cold, and would have become useless or dangerous.

L-5 planes -In the spring of 1945, when L-5 aircraft became available, they were used to shuttle fresh whole blood from the blood bank in Florence to field hospitals in the mountains in the forward area. Later, these planes flew blood into the Po Valley. This service was one of the timesaving and lifesaving improvisations of the Italian campaign. It was used not only during the bitter mountain fighting but also when the Army Medical Service was spread over hundreds of miles after the breakout into the Po Valley.

DISTRIBUTION

The transfusion officer of each evacuation hospital and each platoon of each field hospital coordinated the daily needs of his hospital with the officer in charge of the forward distributing center, who reported the daily needs of the whole forward area to the base bank.

In general, there was a fortunate relation between the distribution of hospitals in Italy and the state of the terrain and roads (11). Both north of Rome and in the Po Valley, the roads were good and the weather was favorable, which permitted rapid movement and pursuit. When the tactical situation bogged down and bad weather was accompanied by deep mud, there was a strain on all theater transportation. On two occasions, once in the vicinity of Rome and later in the Po Valley, hospital units were scattered over such great distances that, if weather or road conditions had existed such as prevailed in lower Tuscany or along the Gothic Line, regular deliveries of blood would have been impossible with the vehicles on hand. With a front of 60-70 miles to be supported, the blood plane leapfrogged the forward distributing unit and delivered blood to the most advanced airfield from which forward hospitals could be serviced.

It was suggested in the final report of the blood transfusion unit (11), that the addition of the half-size blood transfusion detachment, team NA (T/O&E 8-500) would increase transportation by four additional vehicles, as well as increase personnel. With these additions, it would be possible to establish two forward distributing points on a wider extended front and also facilitate intercommunication between dispersed bleeding sections.

During the war and afterward, the suggestion came up at intervals that, whenever it was difficult or impossible to carry blood directly to field or evacuation hospitals by forward distributing units, regular medical supply channels


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be used temporarily. To this suggestion, Major Sullivan, Colonel Kendrick, and others responsible for the whole blood program took violent exception for the following reasons (11):

1. Whole blood is highly perishable. A single mistake in its handling, a single lapse in refrigeration, can result (and has resulted) in fatalities.

2. The supply depot has many and various duties, and its organization is not such as to allow it to assume the highly specialized function of handling whole blood.

3. Whole blood is a substance which becomes useless and dangerous with age. To place the responsibility for its handling in normal supply channels would encourage the practice, useful with other items, but highly undesirable with blood, of placing bottles of blood on shelves of various echelons of supply depots, where the dating period would be exhausted before the blood was used or the oldest blood would be used first, to prevent outdating.3

4. A transfusion service operates best when the distribution of blood is in the hands of trained personnel under professional guidance and not under the supervision of supply officers. The only exception to this rule in the Mediterranean theater was the occasional practice, to relieve pressure on transportation, of permitting forward hospitals to pick up their own blood in insulated boxes at the airfield.

5. Professional handling of blood from procurement to use has the following advantages:

a. Receiving hospitals can be assured of fresh supplies of blood at all times because their day-by-day requirements will be filled by trained delivery teams.

b. Daily delivery service makes it possible for the transfusion service to know the whereabouts of each medical facility. This proved to be a very practical point. When an Army was advancing, it was often difficult to find hospitals, particularly when transportation was over country roads already crowded with military vehicles, in clouds of dust, or through deep ruts filled with mud.

c. Professional personnel of delivery teams can provide guidance concerning various aspects of blood transfusion and can, in turn, obtain criticisms from hospitals as to the equipment provided and the service in general.

d. Proper refrigeration during transportation and storage will be assured.

DONORS

Since no provision had been made for blood donors for the landings in North Africa, securing donors was a constant problem until the blood bank was established. Hospitals developed their own methods, but most of them used service troops, keeping them at the hospital until they were needed. At some

3This situation did come to pass in Korea, where the Supply Service was in charge of the distribution of blood, which frequently was close to the expiration of the dating period when it was issued.


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hospitals, they were brought in by truck every morning, 25 at a time. If all were used before night, another group was trucked in. This was a highly inefficient system, and very wasteful of manpower in terms of time. When, however, hospitals had no facilities for the storage of blood, it was the only system possible.

Members of the medical detachment and medical officers attached to hospitals gave generously, but it was soon evident that not enough blood could be supplied from this source.

The use of lightly wounded patients as donors was authorized by the Surgeon, II Corps, on 7 August 1943 (14), but there were few volunteers from this source. These men considered themselves to be patients, and they feared that if complications followed their wounds, they might be so weakened by their donations that they would be in serious trouble. At the 77th Evacuation Hospital (4), it was reported that the stimulus of "I might need it when it happens to me" was completely lacking. In the opinion of even lightly wounded men, "it" had already happened to them. Prisoners of war were sometimes used for donors, but only if they volunteered.

When iceboxes finally became available to evacuation hospitals, many of them drew blood in advance and kept from 4 to 6 pints on hand at all times. The safety and efficiency of this method led to the acceptance of the concept that, if equipment and personnel were provided, it would be entirely possible to draw blood from troops in the base who would not be in combat soon; check the blood there for syphilis and malaria; and then distribute it to all forward hospital installations. This was precisely the system finally put into effect.

When the blood bank was eventually established at the 15th Medical General Laboratory, the great majority of donors were U.S. Army personnel assigned to noncombatant duties or attached to units which would not be in combat for at least a month. Service troops provided many thousands of donors. The best sources were nearby replacement depots and staging areas. A few thousand British soldiers, several hundred U.S. sailors, and a sprinkling of Allied Armed Forces and U.S. civilians gave the remainder of the donations. Many men who had been wounded and had received transfusions reported to the blood bank to pay their debt to it.

Attempts to form donor lists were not successful; the rapid turnover of personnel in replacement depots and staging areas made the lists almost useless, even in service units, in which the population was more stable.

Specifications

Circular Letter No. 3, Office of the Surgeon, Headquarters, II Corps, 7 August 1943, addressed to all unit surgeons and dealing with the care of the wounded in Sicily, listed the following specifications for blood donors (14):

1. Donors must have a negative history and physical examination, and a Kahn test must be performed when possible.


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2. A donor with a history of malaria is not acceptable unless he has been symptom-free for 2 years. A donor with a history of infectious hepatitis is not acceptable.

3. Crossmatching must be done before each transfusion.

The following additional specifications were made concerning malaria:

1. All personnel of the U.S. Army in Sicily are on suppressive Atabrine (quinacrine hydrochloride) therapy, and it is recommended that no additional antimalarial therapy be given either to recipient or donor in an emergency transfusion. If the transfusion is elective, a booster dose of Atabrine (0.2 gm.) is given to the donor the night before the blood is drawn, or quinine (10 gr.) is given to him 6 hours before the transfusion.

2. All donors are questioned concerning chills and fever in addition to specific questioning about a history of malaria.

3. The abdomen is palpated. If the spleen is enlarged, the donor is rejected.

4. If laboratory facilities are available, thick and thin smears of the donor's blood are examined for malarial parasites.

A malaria smear was examined for 1 minute about 30 minutes after it had been fixed and stained. Of the first 54,383 donations examined in 1944 (15), only six slides were found positive for malaria, an incidence of less than 1:10,000. By this time, it was the policy to reject donors with a history of malaria, no matter how long they had been symptom-free. In the January-March 1945 period, no positive slides were found in 11,191 bloods. Since laboratory personnel were limited, it was decided, in view of these findings, to abandon malaria smears. An increased incidence of malaria was not observed in battle casualties receiving transfusions after testing was abandoned.

The policy about jaundice varied, but, after November 1944, each donor was required to leave a urine specimen, which was examined by the methylene blue test for increased bilirubin content. A small number of bloods from donors with possible latent jaundice were discarded on the basis of this test (15).

Donors with a history of syphilis were accepted only if standard Army treatment, which had resulted in negative serologic tests, had been completed at least a year before the donation.

Payment of Donors

Circular Letter No. 27, Office of the Surgeon, Headquarters, NATOUSA, 20 August 1943 (16), called attention to Public Law 196, 77th Congress, 30 July 1941, which provided for the payment of blood donors. The law in question permitted payments up to $50 per donation, but the circular letter stated that, since donations had now become so commonplace, donors would be paid at the rate of $10 per donation, and higher payments would be permitted only for rare bloods such as those containing antibodies against certain diseases. Payments were facilitated by the appointment of all officers in the transfusion unit as class B finance officers. Funds at their disposition were usually about $5,000, but, in peak periods, were raised to as much as $25,000. As a matter of convenience, the Finance Officer, Peninsular Base Section, approved a special form which permitted the payment of 22 donors on a single voucher (WDFD


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Form No. 25, Modified) instead of the use of a single form for each individual donor.

Payment of donors, which continued until 31 December 1944, was an important factor in securing blood donors in the Mediterranean theater. Some men refused the money, or asked that it be given to the Red Cross, but the majority accepted it. The practice of giving each donor a drink of whisky after the donation was discussed several times but never put into practice.

SELECTION OF TYPE O BLOOD

Blood sent from the Naples blood bank to the Anzio beachhead and other Army hospitals was all type O. A few patients had mild attacks of shivering or slight chills, but there were no serious reactions at first.

Until April 1944, no attempt was made to screen out O bloods with high anti-A or anti-B titer or to limit the use of high-titer blood to O recipients (7). Differentiation of these bloods had been discussed in planning for the bank, but no action was taken, though the policy of using O blood for all recipients was adopted with some misgivings by a number of medical officers.

In April 1944, two fully investigated cases provided the stimulus to titrate O bloods and to reserve those with high-agglutinin content for O recipients only:

Case 1.-The first patient, seen at the 9th Evacuation Hospital, was an Arab with a severe abdominal wound. His blood type was A. After 75 cc. of group O blood collected at the hospital from another Arab had been given to him, he had a severe chill, his temperature rose to 105° F., and his condition was very poor. The transfusion was stopped at once. An hour later, there was a marked elevation of the blood bilirubin, and a more pronounced elevation 4 hours later, though the serum used for crossmatching before the transfusion had had a normal bilirubin content. Next morning, the sclerae were yellow. The first urine specimen after the reaction had been discarded, but all others were normal, and there was no oliguria at any time. Recovery was uncomplicated.

When the blood in the donor bottle was reinvestigated, it was found to be group O and Rh-positive. The plasma agglutinated the recipient cells in a dilution of 1:8,000, indicating very high titer.

Case 2.-The second patient, at the 94th Evacuation Hospital, had multiple severe wounds and was given six transfusions of O blood, none with an extremely high titer, within 12 hours. Although there was never evidence of hemolysis, he became markedly oliguric, and he died of uremia on the fifth day.

It was considered highly unlikely that this second patient's oliguria was caused by the O blood he had received and much more likely that it was the result of his initial and prolonged shock. Nonetheless, Major Snyder at once initiated discussions with Maj. (later Lt. Col.) Henry K. Beecher, MC, Capt. (later Maj.) Charles H. Burnett, MC, Captain Lalich, and others who had made special studies of shock and transfusion. The reactions were also discussed with medical officers at the 15th Medical General Laboratory.

Captain Lalich reported observing urinary difficulties in a number of other cases of shock which he had investigated. The difficulties were by no means universal, but some had occurred, and some had been serious. He did


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not think, however, that sufficient evidence had yet been accumulated to inculpate group O blood or to request that the blood bank furnish type-specific blood. While others thought that the request should be made immediately, it was agreed that low-titer O blood should be given a further trial before any change in present policies was instituted. As a precaution, all blood with an anti-B titer over 1:64 was to be marked for group O recipients only.

On 1 May 1944, when Major Snyder visited the 33d Field Hospital on the Anzio beachhead, he was told of two deaths in group A patients who had received group O blood. Most medical officers were now convinced that the use of group O blood in group A recipients was unsafe and should be discontinued. After further discussions with officers of the blood bank in Naples, it was agreed that sufficient evidence was now at hand to warrant a change in policy and to supply group A and group B blood for group A and group B recipients, respectively. A circular letter would be prepared to accompany the shipments of type-specific blood.

Before these arrangements could be completed, the decision was reversed by higher authority, and the Surgeon, Fifth U.S. Army, was informed on 13 May 1944 by the Commanding General, North African theater, for action by the Commanding Officer, 15th Medical General Laboratory, that the Base Collecting Section of the 6713th Blood Transfusion Unit (Ovhd.) would furnish Fifth U.S. Army installations with only a single type of blood, group O, with an agglutinin below 1:64.

There were two reasons for this decision: One was the fear that more deaths might be caused by errors in crossmatching if both group A and group B blood were supplied than would result if group O blood titered for anti-A and anti-B agglutinogens continued to be used. The second reason was the possibility that group A or B blood might be administered through tubing through which plasma was running, with resulting serious reactions.

In a return radiogram, the Commanding Officer, 15th Medical General Laboratory, pointed out the following facts:

1. Rigid compliance with the order received might necessitate discarding half the O blood drawn. In the past, O blood with an anti-A titer of 1:250 or over had  been marked for group O recipients only. This blood comprised only about 15 percent of all bloods drawn. The radiogram just received precluded the use of O blood with a titer of over 1:64 for anyone. Immediate authority was requested for the use of group O blood for O recipients, regardless of titer.

2. Four histologically proved cases of fatal hemoglobinuric nephropathy were known to have followed the use of group O blood for A recipients.4 In two of these fatalities, only low-titer blood had been used. Major Beecher had information of other clinical cases in which the circumstances were similar, and he had ceased to use group O blood for A recipients.

3. An immediate investigation by Colonel Churchill was requested, with authority to modify or revoke the order of 13 May from theater headquarters.

Although fatal hemoglobinuric nephropathy occurred in these four patients, all of whom had received low-titer group O blood, it must not be inferred that the transfusion of the O blood was responsible and that the sequence was causative. Low-titer group O blood was given to many thousands of casualties in the Mediterranean and European theaters and in the Pacific areas without any reactions. The more reasonable explanation of the sequence is that, in these cases, the blood administered contained B isoagglutinins and therefore was incompatible.


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The matter was finally resolved by continuing, as in the past, to use group O blood of any titer for O recipients and to mark all blood with a titer of 1:250 or more to be used for group O recipients only.

When the Board for the Study of the Severely Wounded made its report in 1945 (6), it exonerated transfusion as the cause of lower nephron nephrosis in most badly wounded men and put the responsibility on shock (p. 666).

TECHNIQUE OF COLLECTION OF BLOOD

The technique by which blood was collected at the blood bank at the 15th Medical General Laboratory and other bleeding centers was substantially the same as that used in Red Cross bleeding centers in the United States (figs. 98-101).

There was usually an airspace of 20-30 cc. (fig. 102) left in each bottle after the donation. While the various tests were being run, each bottle was reevacuated through a blood donor valve attached to an electric vacuum pump (fig. 103), and the empty space was filled with a 5-percent solution of dextrose in 0.85-percent sodium chloride (fig. 104). The dextrose solution was added from a l,000-cc. bottle of solution, by means of a valve attached to an appropriate length of rubber tubing. It was used for two reasons, its preservative effect and to fill the bottle completely, so that the red cells would not be traumatized by shaking of the blood during transportation over rough roads. If the bleeding bottle originally contained glucose and citrate, as some did, the topping was accomplished with physiologic salt solution.

When the necessary tests had been carried out and duly recorded, the worksheet (fig. 101) was handed to a second technician, and each batch of blood was given a final check. Bloods which were not group O were segregated and appropriately labeled. Bloods from donors with positive or doubtful Kahn tests, positive malaria smears, or (later) positive methylene blue urinary tests, were discarded, as were all bottles that showed an excessive amount of hemoglobin in the supernatant plasma.

The remaining bloods, proved to be group O and suitable for transfusion (fig. 105), were labeled Group O. Kahn negative. Drawn . . . . . . . . Use within 7 days. (date)

Bloods which showed a high anti-A or anti-B agglutinin titer, or both, were further identified by a large shipping tag tied around the neck of the bottle (fig. 105) and reading For group O recipients only. Carefully group patient before using this blood.

After the criterion for titration was changed from 1:128 to 1:64, about 35 percent of all group O bloods were labeled as high titer.

After processing was completed, the bloods were refrigerated at 39° F. (4° C.) overnight or longer, depending upon the requirements of forward hospitals. Ordinarily, processing on each batch of bloods was completed well


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FIGURE 98.-Scenes from bleeding room, 15th Medical General Laboratory, Naples, September 1944.


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FIGURE 99.-Completion of individual donation, 15th Medical General Laboratory, Naples, March 1944.

within 24 hours of their collection, so that the freshest possible blood could be sent forward, in view of the 7-day dating period. On some occasions, blood collected at the blood bank in the morning could be flown forward in the early afternoon.

LABORATORY TESTS

Titration

When the possible risk of high-titer blood for non-O recipients was recognized at the Naples blood bank (p. 424), it became the custom to perform a single tube titration against known A and B cells with serum from each O blood (1:32 dilution, 1:64 final dilution). After 14 May 1944, all titrations at the bank were made with a 1:64 dilution of serum, and all bloods whose sera showed agglutination of A or B cells in this dilution were plainly marked for O recipients only. Of the 4,398 bloods titrated by this technique between this date and 31 May 1944, 1,649 (37.5 percent) showed a titer of 1:64 and were labeled accordingly. It was considered more practical to perform titration tests than to employ Witebsky's A and B group-specific substances for specific neutralization of normal isoagglutinin in group O blood (p. 260).

The 6th General Hospital used the following technique in order to employ high-titer O blood in acute emergencies in which an appropriate donor could not be found and in which there was no time to wait for crossmatching (17):

1. All plasma in a flask of high-titer blood was withdrawn and discarded.

2. The plasma withdrawn was replaced with an equal amount of pooled plasma supplied in the standard package.


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FIGURE 100.-Technician preparing blood sample for typing, titration, and serologic testing, 15th Medical General Laboratory, Naples.

This hospital gave more than a dozen of these so-called cocktail transfusions with only one reaction, and that pyrogenic.

Typing

In the MTOUSA blood bank, as already described, the blood type was determined by two independent laboratory examinations. Blood from the donor's finger was first matched against known anti-A and anti-B serum with a minimum titer of 1:64. Microscopic readings were done at the end of 30 minutes. The second test was with blood from the tubing used to fill the small bottle; separated serum was matched against a 2-percent saline suspension of known A and B cells.

When blood had to be given in emergencies in forward hospitals and tests for direct compatibility were impractical, the blood group of the recipient had to be accepted on the basis of his identification tag, in which the known error was from 5 to 25 percent.


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FIGURE 101.-Daily worksheet, used to record results of various tests, 15th Medical General Laboratory, Naples.

Other Tests

Kahn tests were performed routinely in the blood bank and in hospitals that operated their own blood banks. In the early days of the North African theater, serologic testing was not always possible; there were no facilities for it ahead of large evacuation hospitals.

After December 1944, the methylene blue test was used on urine specimens collected at the blood bank, to detect excess bilirubin. About 1.09 percent of the examinations were positive or doubtful. This was a pilot survey, and its full significance was not assessed.

The Phillips-Van Slyke copper sulfate method of estimating the hematocrit, hemoglobin, and plasma protein concentration (p. 253) became standard laboratory procedure in the theater as soon as the test was introduced in 1943.

Studies of red blood cell survival in blood collected and processed by the technique used at the Naples blood bank were performed at Harvard in early 1945 by the radioactive iron technique. They showed 80 percent survival at 24 hours in blood used after 14 days' storage.


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FIGURE 102.-Blood donations secured at 15th Medical General Laboratory, Naples. Note froth at top of bottle on left, and completely filled bottle on right. Glucose solution will be added to the bottle on left, to fill up space now occupied by froth, partly for preservative effect of solution on red blood cells, and partly to prevent sloshing of blood during transportation.

FACILITIES

In his final report to The Surgeon General in 1945, Colonel Standlee (13) made several points about facilities for a blood bank:

1. The base collection section should be attached to a theater or army laboratory or to a base general hospital close to a large concentration of base troops.

2. Because of the urgent need for sterility, the base unit should be set up in a permanent building or prefabricated hut, with room for beds for bleeding donors and for donors to rest after their donations; office space; laboratory space; space for sterilization, washing, and preparation of equipment; space for storage of blood; and refrigeration facilities. If prefabricated huts were used, three would be required.

3. Quarters for personnel and parking space for vehicles should also be provided.

4. Engineering help would be required for the installation of new facilities. Floors were preferably of concrete. Doors and windows must be screened. Four sinks were necessary. Hot water was desirable; running water, essential. Partitions, laboratory tables, and stools could be of wood. There must be a continuous and dependable supply of 110-volt electric current; refrigeration must not be interrupted.

While these facilities were highly desirable, numerous experiences proved that it was quite possible to bleed efficiently and safely in far less propitious surroundings. Thus, the bleeding center at the Fair Grounds in Naples was a temporary structure of roughhewn boards and beams, with partitions of burlap and cheesecloth. One bleeding center was in a whitewashed cowbarn,


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FIGURE 103.-Technician using vacuum pump to create slight negative pressure in bottle of blood, which is not entirely filled. Then, glucose-saline solution (bottle in background) will be introduced into blood bottle through sterile tubing and needle until level of liquid reaches top of bottle. 15th Medical General Laboratory (6713th Blood Transfusion Unit (Ovhd.)), Naples, August 1944.

with two beds to a stall. At the 12th General Hospital, the blood bank was located in two small rooms on the third floor of the building in which the operating rooms were housed. Since the hospital laboratory was some distance away, the bank functioned as a branch laboratory, its function being limited to special tests pertaining to surgery, such as hematocrit determinations and white blood cell counts. The two beds in the smaller of the two rooms that the bank occupied were used for donors during the day and as quarters for bank personnel on duty at night.

EQUIPMENT

Early Improvisations

When evacuation hospitals landed in North Africa in November 1942, equipment for blood transfusion was in extremely short supply (p. 393). It consisted of small numbers of flasks, burettes, rubber tubing, and intravenous needles. With these meager supplies, it was possible to clean, assemble, and sterilize a few units for the administration of whole blood, which had to be given within 3 or 4 hours after it was collected. Facilities for Kahn tests were


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FIGURE 104.-Technicians filling bottles of blood with glucose-saline solution, 15th Medical General Laboratory, Naples, March 1944. Note frothy top content of bottle on left.

not available farther forward than Army medical laboratories attached to evacuation hospitals, and facilities for crossmatching were often lacking.

Improvisations were necessary in all hospitals. The 77th Evacuation Hospital in the beginning used Baxter bottles and tubing from the plasma sets. Then it secured 15 British bleeding bottles, which proved to be more convenient and more easily sterilized because of their metal screw tops. Certain modifications were made in them, including the transfer of the wire mesh from the giving to the taking set to simplify cleaning. The tubing and bottles were first cleansed in cold water, as advised by the British Transfusion Service, and then were rinsed in freshly distilled water (distilled with difficulty (p. 382)), which was never older than 2 hours. After 50 cc. of freshly prepared 6-percent sodium citrate had been placed in each bottle, the metal cap was partly screwed on, and muslin gauze was tied over it. Once bottles and tubing were prepared, they were autoclaved within an hour or less at 15 pounds' pressure for 30 minutes. The metal caps were screwed on tightly before the bottles had a chance to cool off.

Other evacuation hospitals also attempted to operate blood banks by utilizing used saline and saline-glucose bottles for bleeding bottles. The plan


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FIGURE 105.-Bottled whole fresh blood collected at 15th Medical General Laboratory, Naples, August 1944. Bottle on left, which is low titer, may be used for recipients in any blood group. Bottle on right, which is high titer, is conspicuously tagged to be used for group O recipients only.

permitted the use of blood but it had many undesirable features. Preparation of the apparatus required a great deal of time and, with the collection and processing of blood, placed too heavy a burden upon already overworked laboratory and surgical personnel. Also, the number of available donors in the Army area was limited, and blood collected in combat circumstances frequently caused reactions.

In spite of the efforts and ingenuity that went into the improvisations used to collect and administer blood in the Mediterranean theater, the fact remains that none of the donor and recipient sets improvised from the bottles and tubing supplied with plasma and intravenous solutions constituted really satisfactory apparatus. Nor did the equipment made from glass and aluminum tubing salvaged from wrecked planes. The distilled water used for cleaning and preparing the improvised equipment and preparing citrate solutions was in short supply and sometimes contaminated. Numerous reactions could be explained by the use of old tubing that was improperly cleaned because of lack of material to clean it adequately.


435

Many hospitals duplicated the experience of the 38th Evacuation Hospital, in which, until February 1944, when Baxter Transfusovac bottles became available, all the material used for collecting blood was improvised.

Capt. (later Maj.) William T. Thompson, Jr., MC, while in charge of the blood bank at the 45th General Hospital, devised a satisfactory technique of drawing blood in quantity when enough valves could not be obtained for the donor sets. He placed large intravenous needles on the ends of short pieces of heavy tubing which were clamped off until the needles were placed, respectively, in the donor's vein and in the bleeding bottle. Later, a similar piece of equipment was developed by the Army Medical Department. This improvisation was also employed in the continental United States in 1943.

Standardized Equipment

The arrival of blood transfusion apparatus in the Mediterranean theater was long delayed. The first radio request for it to the Office of The Surgeon General, in May 1943, was disapproved because existing regulations did not permit its shipment outside of the Zone of Interior (18).

Requests for bleeding bottles had been frequent since the beginning of the North African campaign, and this equipment, procured through Supply Service channels, began to arrive just as the Italian campaign got underway. Expendable recipient sets were not received in quantity in the theater until early in 1945. This meant that the responsibility for the preparation of recipient sets rested with individual hospitals during most of the war. It was a considerable task for busy forward hospitals, but they did it remarkably well, realizing that an appreciation of the importance of whole blood replacement whenever blood loss had occurred carried with it the obligation of having sufficient recipient sets and tubing ready at all times.

Donor set -The 6713th Blood Transfusion Unit (Ovhd.) report for June 1944 (11), after some experience with the Army expendable blood donor apparatus (Medical Supply Item No. 9351510), contained the following comments on it:

1. The use of this donor set is limited by a number of considerations, beginning with the fact that a preliminary period of trial and error is necessary before a technician, no matter how skilled he may be with other types of donor sets, can master this one.

2. The set is not well adapted for donors whose veins are small or whose blood flow is sluggish. Unless donors in these categories are bled in 4 to 4½ minutes, clotting will occur in one or both needles.

3. The greatest usefulness of this set is in outfitting bleeding teams to collect blood at multiple or isolated points, and also in eliminating some of the work during periods of stress, when as many as 800 donors sometimes must be bled in a day.

4. The valves are eminently satisfactory when they are properly cared for, assembled, and used. With them, one man can bleed two donors simultaneously with relative ease, and the total personnel required for bleeding is fewer. Bleeding personnel, however, preferred the old type stainless steel mechanical valve (a component of item No. 3609300) to the new stainless steel valve containing a rubber inset, which they often found difficult to operate.

5. If the thick-walled taking tube were 18 inches in length instead of 12 inches, it would


436

be more flexible, and the hose could later be used for local bleeding, or could be issued to fixed hospitals which drew their own blood.

The donor needle on this set was not intended to be salvaged, but personnel of the unit commented that it could have been made useful for subsequent venipunctures to secure blood specimens or for use on nonexpendable donor sets if a slight change had been made in the structure of the hub. With this change, a syringe or adapter could be fitted onto the needle, and it could be washed thoroughly before sterilization.

Expendable recipient set -The blood transfusion unit personnel had no experience, of course, with the disposable recipient set (item No. 9351520), but secured the following comments on it from officers and technicians who used it in forward hospitals. The experience with it in June 1944 was limited, but some of the comments were repeated in the ETMD for May 1945 (19), after it had been used in more than 10,000 transfusions in field and evacuation hospitals:

1. This set has the great advantage of being expendable. Until it was received in sufficient numbers, shortly before the war ended, the cleaning and sterilization of donor sets constituted the chief problem in the operation of a transfusion service.

2. The absence of any visible drip mechanism makes it impossible, or at least very difficult, to determine whether blood is flowing satisfactorily into the recipient or if the apparatus has become plugged. Since one person frequently must observe multiple transfusions, and at the same time perform other duties, it is important to be able to determine the speed and efficiency of the blood flow.

3. The use of an unhubbed needle to tap the vent tube of the bleeding bottle does not permit the creation of a pressure chamber inside the bottle to start or accelerate the blood flow.

4. If a short bevel were substituted for the long bevel on the giving needle, the hazard of transfixing veins in shocked casualties with collapsed veins would be greatly reduced.

5. Piercing of the rubber bung of the bleeding bottle at the correct point is frequently difficult because of the small grasping surface presented by the hub of the puncture needle. When this difficulty has arisen, the intense squeezing effect of the fingers has frequently caused the rubber hose to spread laterally over the puncture needle, with a resulting air leak in the vacuum in the bottle, which it is possible to overcome by tying a few turns of black silk over the portion of the rubber hose encasing the hub.

6. The giving needle is the hose-connector type. A glass adapter fitting the standard hubbed needle would be highly desirable for several reasons: In casualties with low blood pressure and collapsed veins, it is difficult, without such an adapter, to know when the needle is in the vein. In burned or wounded casualties, it is often necessary to use the same vein for numerous purposes, such as withdrawing blood for examination with a syringe and giving various therapeutic fluids. In the most severely shocked patients, in whom a cannula is tied into the vein, an adapter could be readily removed from the needle and inserted into the cannula.

7. Since the blood flow is dependent upon gravity, and since resistance in the line may greatly impede the flow, it would be better if the thin rubber giving line were made 48 inches rather than the present 42 inches.

8. In badly bled-out casualties, emergencies often arise in which it is desirable to give blood under pressure. This is not possible with the present airway-piercing cannula, which is sawed off and hubless. An airway-piercing needle with a hub and with an attached short length of rubber tubing would remedy this defect.


437

9. The structure of the apparatus is not suitable for administering multiple transfusions through a single needle or the successive administration of blood, plasma, and electrolyte and glucose solutions through a single needle. As a result, multiple successive venipunctures are necessary, which is a serious drawback in seriously wounded casualties.

These and similar comments were, of course, justified. On the other hand, it was fully realized, when the recipient set was devised, that it was not so complete as the commercial set used in fixed hospitals in the Zone of Interior. But some of the refinements had to be sacrificed because of shortages of critical materials and in the interest of reducing the size of the oversea package. In spite of the lack of a drip flowmeter, the recipient set worked well because, in the treatment of casualties in shock, speed of injection of the blood was so desirable that there was no real need to meter the blood flow.

PRESERVATIVES

If preservative solutions that permitted storage of blood for 14 to 21 days had been available in the Mediterranean theater when the blood bank was established, a good deal of waste would have been avoided. At that time (February 1944), the bleeding bottles contained only sodium citrate solution, which is an anticoagulant, not a preservative. Even when dextrose was added to the blood, the dating period did not exceed 7 days.

Bottles containing 600 cc. of Denstedt's solution were available in the Zone of Interior, but could be shipped only in small numbers. Later, bottles with Alsever's solution could have been requisitioned from the Zone of Interior, but most surgeons in the theater, like others in other theaters, considered the volume of this preservative solution undesirable. It would also have introduced the risk of pulmonary edema in patients who required many transfusions in a short period of time. ACD solution was never used in the Mediterranean theater. It was not standardized by the Medical Department until early in 1945, and, by the time bottles containing it had reached Italy, the war was over.

STATISTICAL DATA

Requirements for, and Utilization of, Whole Blood

When the blood bank was established in Naples in February 1944, it was estimated that the amount of blood needed per casualty would be from 0.6 to 0.7 pint. In the last 4 months of 1944, this estimate was reasonably well sustained.

In their study of combat casualties in Fifth U.S. Army hospitals, Colonel Snyder and Capt. (later Maj.) James W. Culbertson, MC, compiled the following data (7):

1. Of all the casualties treated in field hospitals, about 70 percent required blood and received an average of 3 pints each. About 63 percent required plasma and received an average of 2½ units each.


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2. Of all the casualties treated in evacuation hospitals, about 20 percent required blood and received an average of 2 pints each. About 15 percent required plasma and received an average of 2½ units each.

3. While the average administration of blood late in 1944 was 0.6 pint per casualty, this was true only in hospitals in which blood was used in adequate amounts. The rates for all Army hospitals were far below this.

4. The effect of the location of the hospital on the need for blood is evident in the figures for the Salerno-Cassino fighting, in which 4,600 transfusions were given in the Army area, against 300 at the base. When, however, the base was close to the battleline and evacuation was rapid, its needs rose accordingly.

The changing concept of blood and plasma is also evident in comparative figures (2):

During the Tunisian campaign in February 1943, in a series of 200 surgical patients, half of whom required emergency operation, 6 blood transfusions were given, against 350 plasma infusions. At this time, the surgeons had little choice; they had ample amounts of plasma but no facilities for transfusion and no donors except detachment personnel, who could not be checked for either malaria or syphilis.

Of 431 seriously wounded patients admitted to one II Corps hospital between 21 January and 28 February 1943, 101 received plasma and 31 whole blood. In March 1943, of 561 patients who underwent 741 surgical procedures at the 48th Surgical Hospital, 97 received whole blood. A few more lives might have been saved, Major Snyder noted, if a more convenient method of blood transfusion had been available, as well as better sources of blood.

When this same hospital moved forward in May 1943, to support the final Bizerte offensive, at one time it was within 12 miles of the fighting front. Between 4 and 11 May, it admitted 403 casualties, of whom 292 underwent major surgical procedures, which were often multiple. Between 5 and 8 May, it averaged 60 admissions per day. On 7 May, 82 operations were performed. During this period, 84 transfusions and 291 plasma infusions were given (1:3.4).

Losses

The registration and bleeding of a donor at the bleeding center did not necessarily insure that his blood would be used for a wounded casualty (table 14). For a number of reasons, there was a loss of approximately 10 percent between registration and distribution, and a further loss of about 5 percent between distribution and use. Among these reasons were losses from breakage, clotting of the blood in bottles, clogging of the blood in recipient sets, and expiration of the dating period. Some of these factors could be partly controlled, but not all of them could be eliminated.

A certain amount of hemolysis occurred at the time of bleeding, apparently being influenced by the operator's technique. Each time new groups of technicians were trained, the incidence of hemolyzed blood rose. While a certain amount of hemolysis (estimated at 25 mg. per 100 cc.) was considered compatible with safety, no one could say with certainty where the dividing line was, and the practice was to err on the side of caution.


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TABLE 14.-Production of 6713th Blood Transfusion Unit (Ovhd.), February 1944-June 1945

Year and month


Donors

Bloods


Registered

Rejected

Collected

Discarded

Distributed

1944

 

 

 

 

 

February

258

9

249

2

247

March

2,074

69

2,005

25

1,980

April

1,793

104

1,689

130

1,559

May

6,958

564

16,644

273

6,371

June

5,017

375

25,092

72

5,020

July

6,724

510

6,214

281

5,933

August

8,509

696

7,813

617

7,196

September

11,708

866

10,842

454

10,388

October

10,615

724

9,891

207

9,684

November

4,010

265

3,745

200

3,545

December

4,029

273

3,756

156

3,600

1945

 

 

 

 

 

January

3,293

192

3,101

256

2,845

February

4,033

125

3,908

221

3,687

March

4,444

262

4,182

225

3,957

April

11,521

814

10,707

427

10,280

May

2,261

130

2,131

85

2,046


Total

87,247

5,978

81,969

3,631

78,338

1Includes 250 bottles collected by the 2d Medical Laboratory (Army).
2Includes 450 bottles collected by the 2d Medical Laboratory (Army).

A satisfactory explanation was never advanced for the hemolysis invariably present to some degree when the vacuum technique was used. Some medical officers with extensive experience explained it as due to an excess of glycerin in the valves. Others, with equal experience, thought the explanation was too rapid bleeding, with collapse of the tube during the procedure. Still others thought the high vacuum in the bleeding bottle might cause disruption of a certain proportion of red blood cells.

Every attempt was made to adjust supply to demand, but with a storage period limited to 7 days, this was extremely difficult. Not infrequently, stocks had to be built up in expectation of a large-scale offensive that was later postponed. The end of heavy fighting was even more unpredictable than the beginning of an offensive, so again, when fighting suddenly ceased, the bank would be left with large stocks on hand. Some wastage of blood would have been avoided, as well as wastage of vacuum bottles always in short supply, if the blood transfusion unit had been given more precise advance information about probable casualties in forthcoming engagements.

The base section ordinarily had a 24-hour supply of blood on hand and the forward distributing section, an additional 24-hour supply. Blood thus reached forward hospitals on the third day, leaving it with 4 more days of useful life.


440

Very little blood was used in Italy after the 7-day dating period because of daily deliveries from the base to the forward section and from the forward section to Army hospitals. The schedule was difficult to maintain because large reserves could not be built up without risking wastage from aging. It was practical only because the lines of communication were short.

Whenever possible, blood not used in forward hospitals was distributed to base hospitals, being shipped back to them as it neared its 7-day limit. There were times, however, when this was not practical. The various field and evacuation hospitals were sometimes so widely separated that regular contact with them was impossible and their aging blood could not be secured for salvage. This happened at the fall of Rome, when the distributing unit went forward with Army hospitals and for a time was completely out of touch with hospitals in Rome.

The total blood transfusion unit loss of 10 to 15 percent from bled donor to transfused recipient was probably as close to the absolute minimum as possible when dealing with blood that had a 7-day expiration date.

Overall Statistics

The 200 pints of blood brought into Anzio on 22 January 1944, the day of the landings, were used up by 27 January. Thereafter, an average of 100 pints per day was brought in, usually by LST's, less often by small planes, which could land on the airstrip without drawing German fire. Two enlisted men, who checked all incoming supplies, had the special responsibility of watching for the blood and dispatching it immediately by truck to the medical dump. It was held there by the British transfusion unit, which stored it and distributed it. This was a highly efficient operation.

Something over 4,000 pints of blood were brought in between 22 January and 25 February, inclusive. Between 26 February, when the blood bank at Naples took charge of the operation, and 25 May 1944, 5,128 pints of blood were supplied to the hospitals on the Anzio beachhead.

Before the breakout at Anzio at the end of May 1944, it had become evident that the blood bank could not supply as much blood as would be needed for that offensive. With General Martin's approval, Major Snyder arranged with Lt. Col. (later Col.) Kenneth F. Ernst, MC, Commanding Officer, 2d Medical Laboratory, which was attached to the Fifth U.S. Army, for an additional 100 pints daily (7). The first delivery was made on 26 May. With more recipient sets, the laboratory could have supplied more blood. With the limited number available, it was necessary to stop collections at noon every day to clean and resterilize the equipment.

Tables 14 and 15 show the production and distribution figures for the blood collected in Italy from the first collection at the 15th Medical General Laboratory in February 1944 to the end of the fighting in that theater in May 1945. The figures include the blood collected by the laboratory before


441

the 6713th Blood Transfusion Unit (Ovhd.) was activated; the blood collected by the 6703d while it remained in Italy (p. 455); and the blood collected by the 2d Medical Laboratory (Army) while it was attached to the Fifth U.S. Army. It does not include figures for blood collected by individual hospital blood banks.

Report of 6713th Blood Transfusion Unit (Ovhd.)

The tabulated report of the 6713th Blood Transfusion Unit (Ovhd.) for January-May 1945 was as follows (11):

Of 25,689 donors registered, 1,659 had to be rejected, 1,251 because they were not group O (group A 854, group B 309, group AB 88). The other 408 were rejected because of disease, recent donations, and a variety of other reasons.

Of the 24,030 donors bled, 23,862 were group O (group A 127, group B 36, group AB 5).

Of the bloods drawn, 1,199 were discarded at the bleeding center (5 percent), because of hemolysis and outdating (682); incomplete filling of bottles (189); positive serology (114); and positive or doubtful bilirubinuria by the methylene blue test (214).

TABLE 15.-Distribution of 78,329 bloods collected by 6713th Blood Transfusion Unit (Ovhd.), February 1944-June 1945

Year and month

Hospital distribution


Fifth U.S. Army

Seventh U.S. Army

General and
station

Total

1944

 

 

 

 

February

229

---

18

247

March

1,822

---

158

1,980

April

1,536

---

23

1,559

May

5,223

---

513

5,736

June

3,630

---

1,820

5,450

July

4,126

---

1,644

5,770

August

1,092

3,539

2,285

6,916

September

4,198

4,380

1,498

10,076

October

5,998

3,144

1,087

10,229

November

3,121

168

433

3,722

December

3,314

---

325

3,639

1945

 

 

 

 

January

2,688

---

192

2,880

February

3,493

---

114

3,607

March

3,796

---

166

3,962

April

9,624

---

315

9,939

May

2,038

---

482

2,520

June

94

---

3

97

Total

56,022

11,231

11,076

78,329

 


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In addition to the 682 bottles of blood discarded at the bleeding center because of hemolysis and outdating (2.8 percent), 120 were discarded at the distributing center for the same reasons plus assumed contamination (0.5 percent).

Of the total of 24,030 donors bled, 1,319 bloods were discarded for all reasons (5.4 percent). From the 25,689 donors registered, 22,831 bottles of blood were secured for distribution. There was thus a net loss of donors, blood, or both between registration of donors and distribution of blood of 2,858 (11.1 percent).

Of the 22,831 useful bottles of blood, 19,779 were distributed to Fifth U.S. Army hospitals; 675 to base hospitals in Naples; and 2,301 to base hospitals in Florence, Leghorn, Pisa, Verona, and Bologna. Fifty-four bottles were used for media and typing sera, and 22 bottles were on hand at the end of the fighting.

Of the 23,683 group O bloods whose agglutinin titers were determined, 7,113 were found to have anti-A, anti-B, or both anti-A and anti-B titers of 1:64 or over (30 percent). These bloods were labeled For group O recipients only. Group patient carefully.

The following laboratory tests were made on the blood collected:

74,914 blood groupings, including 25,440 screening tests, 24,440 cell groupings, 24,030 serum groupings, and 5 Rh groupings.
24,030 slide agglutinin titrations.
25,486 hemoglobin determinations.
24,030 Kahn tests.
209 Kolmer tests.
9,565 malaria smears.
24,118 tests for urinary bilirubin.

HOSPITAL EXPERIENCES

The experience of individual hospitals brought out many practical points in the use of whole blood. Thus the 9th Evacuation Hospital, which functioned as a general hospital in Italy and as an evacuation hospital in southern France, found it extremely important to identify bleeding bottles and tubes very carefully by number because of the large number of Arab patients with the same names, or almost similar names. It also found it important to do minor as well as major crossmatching.

The 45th General Hospital established its own blood bank in March 1944 after observing the value of whole blood in delayed primary wound closure; it recorded only four unsatisfactory results in 265 such wound closures. Bank personnel emphasized that a great deal of waste could have been avoided had the hospital received some advance notice, as it usually did not, about the probable number and general type of casualties it would receive after an offensive.

At the 21st General Hospital (20), the training program in anesthesia included instruction in resuscitation, oxygen therapy, transfusion, and other intravenous therapy. This section administered all blood. The two enlisted men attached to it were trained in transfusion and oxygen therapy and served as assistants to the chief anesthesiologist.

At this hospital, detachment personnel interested their friends in nearby units in the blood bank and had a stirring response. Needs were met and then surpassed; it was not uncommon to turn away more donors than were bled.


443

The number of transfusions rose progressively from 22 in January to 827 in November and 1,761 in December. Those who watched the results of the blood program as it unfolded remarked many times that they were watching medical history in the making. Anesthesiologists declared that they no longer had to contend with shock on the operating table, no matter how formidable the surgery. Surgeons undertook operations on patients whom they once would have considered hopeless risks, without fear of irreversible pathophysiology. The universal opinion in this hospital was that blood accomplished what plasma simply could not accomplish.

When the 21st General Hospital arrived in southern France, maintenance of its blood supply was difficult because of the small number of troops in the immediate vicinity. This problem was solved by organizing a laboratory team which went to accessible units and bled the donors there. The whole experience of this hospital is an interesting illustration of what could be accomplished, in the face of difficulties, once personnel were convinced of the need for, and the value of, whole blood in the management of wounded casualties.

SURVEY OF BLOOD PROGRAM

Most of the material in the report to The Surgeon General by Colonel Kendrick on his visit to the Mediterranean theater in October 1944 (21) is presented elsewhere in this volume, under the headings of shock, resuscitation, complications of blood transfusion, especially anuria, and other headings, but certain general comments should be repeated here:

1. The interest and enthusiasm displayed by the medical officers and other personnel in the theater over the potentialities of whole blood were impressive. Equally impressive was their recognition of the possible dangers associated with its use.

Colonel Churchill had himself supervised the development of the program from his arrival in North Africa in March 1943. His first recommendations were the result of his personal verification of the need for whole blood by his own examination of wounded casualties in clearing stations and forward hospitals. Highly competent medical officers had then been assigned to work on the problem from various aspects: Major Sullivan and Captain McGraw, from the standpoint of the supply and preservation of whole blood; Major Beecher, from the angle of resuscitation in field and evacuation hospitals; and Maj. Champ Lyons, MC, and Maj. (later Lt. Col.) Oscar P. Hampton, Jr., MC, who studied the indications for whole blood in base hospitals in connection with their work on penicillin.

As might have been expected, there were some divergences of opinion, even in this small group, but by this time certain principles had been established as basic and should be used to guide future blood bank operations. The experience of these officers by this time was so large that their conclusions could be accepted as entirely valid.


444

2. The officers in the theater worked on the premise, established in the Zone of Interior, that fresh blood is necessary in the treatment of battle casualties and that any departure from its use is simply to meet contingencies imposed by the military situation.

3. The error in identification tags was about 10 percent, which corresponded to the error found in the European theater (p. 244).

4. The possible relation of anuria to the use of group O blood was recognized (p. 424), but remained to be proved. It was suggested, however, that it might be safer to use low-titered O blood (1:128) until a definite conclusion was arrived at, even though the policy would require another testing procedure in the bleeding center.

5. A tendency was sometimes observed to give too much blood before surgery in field and evacuation hospitals. Experience showed that casualties who failed to demonstrate clinical improvement after receiving 3-4 pints of blood were either continuing to bleed or had some fulminating infection. In either event, surgery was necessary. Transfusion should be continued during the operation.

6. Practically all instances of shock observed by Colonel Kendrick were the result of hemorrhage. Most casualties in shock had hematocrits ranging from 25 to 30, as the result of hemorrhage followed by hemodilution. Even when these patients had received adequate amounts of blood in forward hospitals, they entered base hospitals with hematocrits from 30 to 35. It was the general impression that such patients withstood surgery better when their hematocrits had been restored to approximately normal values (40-45). A pint of blood raised the hematocrit by an average of 3 percent and the hemoglobin by an average of 0.9 gm. percent. Studies of several series of compound fractures of the femur by Major Lyons and Major Hampton showed that an average of 2,600 cc. of blood was required over a 3-4 day period to carry the patients safely through surgery. No proof had been found that multiple transfusions modified infection or increased the speed of healing, but there was no doubt that these patients withstood surgery better when their blood values were approximately normal.

7. Alkalinization was considered indicated when multiple transfusions were necessary. At this time, 150 cc. of 4-percent sodium citrate was being used for this purpose. Since sodium-r-lactate (6/M.) was already available in 500-cc. vacoliter bottles (Baxter), Colonel Kendrick recommended that it be standardized and used instead. His recommendation was accepted.

8. Expendable collecting and giving sets were not yet available in the Mediterranean theater. Preparation and sterilization of these sets in busy evacuation and field hospitals were difficult to accomplish properly, as some reactions proved very clearly. Colonel Kendrick recommended that transfusion teams be provided with flexible equipment; namely, 1,000-cc. collecting bottles containing Alsever's solution and 600-cc. bottles containing Denstedt's solution. This recommendation was not implemented.


445

COMMENT

On 29 October 1944, in his letter of transmittal to the Surgeon, NATOUSA (9), Colonel Cornell noted that the accompanying quarterly history of the 6713th Blood Transfusion Unit (Ovhd.) was "probably the first of its kind." His (first) indorsement continued:

Captain McGraw has briefly told the essential facts of the activities of that unit and its cooperative partner, the 6703 Blood Transfusion Unit (Ovhd.). Their successful accomplishments of their mission have been in great part due to Captain McGraw's training, industry, and application to duty. Under his leadership they have successfully met demands for three and four times the quantity of blood originally considered. The men at the base section have worked steadily for long hours to continually supply the needs of at first one, and then two, armies. The forward distributing sections have driven all the rough roads at the front day and night and have accomplished an excellent job. The pilots of the blood planes have flown through foul weather when other ships were grounded and landed on "closed" fields to get the blood through. Blood bank couriers have ridden many miles in open trucks to deliver the blood forward when our advanced fields could not be used. The entire group are to be highly commended for a new and difficult task, not done, for they will carry on, but carried thus far in the best traditions of the Medical Department.

Anyone familiar with the work of the oversea blood banks in all theaters knows that this tribute is applicable to them all.

Part II. Seventh U.S. Army

ORGANIZATION

When the Seventh U.S. Army invaded southern France in August 1944, the supply of whole blood for it furnished few problems because it utilized the experience of the blood bank at the 15th Medical General Laboratory in Naples and of the 6713th Blood Transfusion Unit (Ovhd.) which operated out of it (22-24). The field and evacuation hospitals of this Army were thus relieved of the heavy task that had been the original lot of forward hospitals of the Fifth U.S. Army, procurement and storage of their own blood as well as its administration. The Seventh U.S. Army also escaped the always undesirable necessity of bleeding line and service troops in forward areas.

The 6703d Blood Transfusion Unit (Prov.)5 which supported the invasion of southern France was made up of personnel withdrawn from three sources between February and April 1944: (1) an inactivated station hospital; (2) the 1st Medical Laboratory; and (3) the 6713th Blood Transfusion Unit (Ovhd.). It was attached to the 15th Medical General Laboratory for instruction and

5The 6703d Blood Transfusion Unit (Prov.) was set up at Bagnoli, Italy, on 22 June 1944, by General Orders No. 124, Peninsular Base Section, NATOUSA, on 21 June 1944. On 31 October 1944, the unit was relieved of its attachment to the Peninsular Base Section and assigned to Continental Advance Section at Dijon. On the same date, all officers and enlisted men were relieved of their assignment to the unit and assigned to the Office of the Surgeon, Headquarters, NATOUSA, whence they were transferred to the European theater.

On 17 February 1945, by Organization Order No. 122, Headquarters, Communication Zone, ETOUSA, the unit was redesignated the 6825th Blood Transfusion Company (Non-T/O).


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training. By the time personnel were assigned to it on 1 July 1944, almost all of its equipment was available.

The organization and operation of the 6703d Blood Transfusion Unit were facilitated by a number of facts: The 1st Medical Laboratory, from which part of its personnel was secured, had been staging with the l5th Medical General Laboratory since 1 May 1944. Personnel assigned from the 6713th had gained considerable practical experience during the advance on Rome in June 1944 and were now well versed in blood bank operations. After the 6703d was activated, the two units worked together until the forward distributing section went to France on 15 August 1944. After that date, the bleeding and processing section of the 6703d continued to work with the blood bank in Naples until it also moved to southern France in November.

As the result of these circumstances, the careful training by Colonel Cornell, and the warm interest and cooperation of Colonel Arnest, Surgeon, Peninsular Base Section, NATOUSA, the 6703d Blood Transfusion Unit (Ovhd.) was a well-trained and smoothly functioning unit when it began to operate independently. It was divided into a base bleeding section and forward distributing section and, in general, it followed the techniques and policies of the 6713th Blood Transfusion Unit.

PERSONNEL

The authorized personnel of the 6703d Blood Transfusion Unit consisted of a major, MC; two captains, MC; two captains, SnC; and 28 enlisted men, including 1 technical sergeant and 3 staff sergeants. A full complement of officers was never attained, but the roster of enlisted men and noncommissioned officers was usually complete.

In his final report, the historian of the unit noted that the personnel originally assigned to the base bleeding section could handle 100 pints of blood a day. The unit consistently shipped close to 200 pints, which required borrowing personnel from other organizations. It was recommended that additional personnel should be provided in any future table of organization, particularly two additional drivers and two additional laboratory technicians. This recommendation was carried out.

Although the unit was supposed to be attached to an Army laboratory for administration as well as for rations arid quarters, it soon became evident that many administrative duties would have to be handled by unit personnel, in addition to their regular duties. It was recommended that in the future the table of organization for a blood transfusion unit provide for a master sergeant and a clerk-typist. This recommendation was carried out.

OPERATIONS

The base bleeding section of the 6703d Blood Transfusion Unit began operations in July 1944, assisting the 6713th to supply blood to the Fifth U.S.


447

Army. Both units were attached to the 15th Medical General Laboratory, and personnel and equipment were pooled. Different sections of the 6703d were sent to France in August and in October, but the combined activities of the two units continued until the last section of the 6703d went to France on 27 October 1944.

Invasion of Southern France

The forward distribution section of the 6703d Blood Transfusion Unit was assigned to the 1st Medical Laboratory for the invasion of southern France on 15 August 1944. The personnel who landed with the assault troops on D-day were attached to platoons of field hospitals, and each group was supplied with refrigerators mounted on trucks. The assignments were as follows:

1. An officer and an enlisted man attached to a platoon of the 11th Field Hospital, which supported the 44th Division, had 188 bottles of blood in seven insulated boxes. This group had the main refrigerator unit.

2. Two enlisted men attached to a platoon of the 10th Field Hospital, which supported the 3d Division, had 144 bottles of blood in four insulated boxes.

3. Two enlisted men attached to another platoon of the 11th Field Hospital, which supported the 36th Division, had 168 bottles of blood in seven insulated boxes.

4. The First Special Service Force (a mixed Canadian and U.S. group, which, like rangers and commandos, had a special combat mission) had 100 bottles of blood in insulated containers. Some of the hospital ships in the invasion armada also carried small amounts of blood, sometimes in vegetable refrigerators.

Personnel of the forward distributing section embarked at Naples a week before the invasion. The blood was placed aboard the transports just before the ships departed. This plan assured a supply not over 7 or 8 days old for immediate invasion needs. The soundest principles of combat loading were observed; that is, the blood was loaded late, so that it could be taken off early, and it was distributed among several ships. Corps and division surgeons and line officers required considerable persuasion before these results were accomplished.

On D-day, each group, with its refrigeration, was landed on a separate beach. On D+1, the three groups made contact with each other, and thereafter they operated as a single distributing unit for all the hospitals on the beachhead.

Battle casualties for the first 3 days of the landings had been estimated at 1,881, and, on the basis of previous experience, about 0.6 pint of whole blood was supplied for each (1,129 pints). The 1,400 bottles provided, aside front the additional small amounts carried on hospital ships, included an excess of 271 bottles, which were regarded as essential insurance against possible loss. Actually, battle casualties numbered only 989, and nonbattle casualties, whose requirements for whole blood were generally less than those of battle casualties, numbered 205.


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AIR TRANSPORT

Through the cooperation of the Navy and the Army Air Forces, arrangements had been made to deliver whole blood to the target area, beginning on D+1 and continuing until an airstrip could be established. The plan (map 1) involved flying the blood collected in Naples to Corsica, whence it was carried to the landing beaches by patrol vessels and motor torpedo boats.

The schedule was carefully worked out. The special blood plane, with the courier who was to fly with the blood, waited on the airfield in Naples for the arrival of the truck that brought the blood from the blood bank immediately before the plane took off. The insulated boxes (fig. 95) containing the blood were loaded and lashed in place, together with the French blood drawn in North Africa and flown to the base the previous day. When the plane landed on the northern tip of Corsica, a truck carried it to the patrol torpedo boat, where the Navy assumed responsibility for it. The courier who had brought in the blood the previous day exchanged information with the courier accompanying the fresh blood, and the empty boxes and bottles were loaded on the plane returning to Italy.

When the patrol boat arrived off the French beaches, it identified itself, and an officer or enlisted man from the forward distributing center, who was expecting it, came alongside in a DUKW (amphibious truck, 2½-ton cargo) with a truckdriver (fig. 106). The blood was trucked a mile or two inland, where it was loaded into the refrigerator truck awaiting it. If the roads were too bad for the 2½-ton truck, the insulated boxes were loaded on weapons carriers for distribution. The trucks sometimes traveled as much as 35 miles to meet the blood plane, their progress being expedited by the military police. At each hospital, a 6-cu. ft. refrigerator was reserved in the laboratory tent for the storage of blood.

In the initial planning for D-day, Col. Frank B. Berry, MC, Consultant in Surgery, Seventh U.S. Army, received invaluable help from Colonel Cornell, who personally arranged for all the contacts in the transportation of the blood. As a result, there were no delays, and more blood than was needed was always available during the landings, as well as later in the campaign.

After airfields became available in southern France on D+8, blood was flown directly to them from Naples in 2 to 2½ hours.

The use of a courier was even more important in southern France than in Italy. The Italian front never covered a great deal of ground, and it was therefore relatively easy to make contact with the forward distributing section as each load of blood arrived from the base. In France, the distances were much greater, and the plane was sometimes forced to land more than a hundred miles from its designated field. When this happened, the courier assumed responsibility for the blood, and, since he was armed with proper authority from base and theater commanders, he was able to secure motor transport to truck the blood forward to the distributing center.


449

FIGURE 106.-DUKW arriving on beach in southern France loaded with French and American blood and penicillin. The blood, donated by service troops and others in replacement depots in Naples sector, has been flown from 15th Medical General Laboratory, Naples, and is destined for field hospitals in Seventh U.S. Army. When some of these insulated boxes were left in the sun for 8 hours, the increase in temperature was only 9° F. (5° C.).

Contact with the collecting unit in Naples was maintained by daily cables and through the couriers who accompanied the daily blood shipments. The daily report included the amount of blood delivered to each hospital, the amount on hand, and the amount requested in the next shipment. If the blood plane did not make contact with the forward distributing center and the courier had to supervise the delivery of blood, the officer in charge of the transfusion section in each hospital notified the base by any available means of the amount required.

Blood was delivered to the forward distributing center by plane until 2 November 1944, when flying conditions in southern France became too bad for this mode of delivery to be continued.

FORWARD DISTRIBUTING SECTION

Between 24 August and 17 December 1944, the command post of the forward distributing section of the 6703d Blood Transfusion Unit (Ovhd.) moved 11 times. At times, the advance of the Seventh U.S. Army was so rapid that it was necessary to set up a forward substation, in addition to the


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command post located near a forward airfield. This substation, which serviced forward field hospital platoons, was sometimes 50-70 miles ahead of the command post.

Immediately after the landings in southern France, the forward distributing section began to make daily deliveries of blood to field and evacuation hospitals in its two weapons carriers. The forward section was usually located at a point midway between the two flanks of the line, and one vehicle went east and one west. As a rule, the round trips could be made in less than 8 hours, during which time the blood could be kept cold in the insulated boxes in which it had traveled from Italy. If the trip was likely to require more time, the 1½-ton truck, which usually met the blood plane, was used. The large refrigerator was a storage box and was moved only when the command post of the distributing section moved.

It was soon evident that the transportation on hand was inadequate to the needs of the blood distributing section, and arrangements were made with the Surgeon, Seventh U.S. Army, for two additional weapons carriers and drivers. Later, these vehicles and personnel were replaced by vehicles and drivers from the 58th Medical Battalion. This arrangement continued until the end of the war.

The forward distributing section encountered logistic difficulties from the time of the landings until March 1945. The distances were always long. The roads were poor, and, through the mountains, were often snowbound and icebound. In December 1944 and January 1945, during the fighting in the Colmar Pocket, the front was divided into two rugged sectors. In addition to the run of 130 miles to the rear, to pick up the blood from the bleeding center at Dijon (p. 452), it was necessary to make runs of 100 miles to each of these sectors. Communications with the base were always difficult and uncertain and were sometimes impossible. After air service had been abandoned, it often took from 2 to 4 days for the two sections of the blood bank to communicate with each other or to communicate with Paris through SOLOC (Southern Line of Communications). As a result, a wasteful supply of blood had to be maintained in forward hospitals.

During this period, the Seventh U.S. Army grew in size and the territory covered by it increased. It is remarkable that it was kept supplied with blood by a forward section that never had more than six drivers and that operated entirely with its own three trucks and two borrowed weapons carriers.

About 18 December 1944, conditions became so bad that deliveries to individual field hospitals had to be suspended. Instead, deliveries were made to headquarters platoons, which got the blood through to the other platoons. Some field and evacuation hospitals at considerable distances from the command post of the distributing center assisted in the distribution of the blood by sending their own transportation part of the way to meet the blood bank truck.


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BASE BLEEDING SECTION

The 1st Medical Laboratory, which had been attached to the 15th Medical General Laboratory, left Italy on 4 September 1944, to set up in France and to prepare a location for the 6703d Blood Transfusion Unit (Ovhd.). It took with it all the equipment and transportation of the base bleeding section. Lt. (later Capt.) William S. Proudfit, SnC, who was assigned to the unit, was put on temporary duty with the Seventh U.S. Army, to aid the 1st Medical Laboratory in setting up a blood bank section. Eight enlisted men from the 21st General Hospital were placed on temporary duty with the Seventh U.S. Army for the same purpose.

The choice of a location for the bleeding center was difficult because the Army was moving so rapidly that concentrations of troops were few and temporary. Finally, Épinal was selected as the best site because of the large concentration of service troops there at the time. The bleeding section began to function on 11 October and operated at this site until 29 October, when facilities for a permanent installation were found in the medical school at Marseille. During the 3 weeks the collecting section functioned at Épinal, it drew and processed more than 2,400 bottles of blood. In order to use donors more efficiently, group A as well as group O blood was supplied to hospitals in the area. The 375 bottles of A blood were plainly labeled and there were no untoward incidents.

At Marseille, the bleeding section was attached to the 4th Medical Laboratory (Army) for administration, rations, and quarters. Essential equipment was obtained from the Surgeon, Dijon Base Section, and the section was ready to draw blood on 1 November 1944. The remainder of the bleeding section arrived from Italy in the middle of November. The Marseille center operated until 11 May 1945. It was because the Seventh U.S. Army landed in friendly territory in southern France that it was possible to bring the collecting section from Naples into Marseille, in the rear of the Army area, so promptly.

Personnel from nearby staging areas and a replacement depot supplied the first donors at the Marseille bleeding center. It soon became apparent, however, that because of the fluctuations in personnel strength, these sources could not supply the 175-200 pints of blood necessary each day. An additional bleeding center was therefore opened early in December on a prominent street in downtown Marseille.

In January 1945, a mobile bleeding unit was organized from bleeding section personnel to care for donations at distant military installations. All blood collected in Marseille was processed at the medical school.

The success of the Marseille operation was in large part due to publicity in civilian newspapers and in the Stars and Stripes; activities of the American Red Cross; assistance of civil affairs-military government officials; and the maintenance of donor rolls by individual units, in accordance with Letter


452

AG 742, Op MC, Headquarters, Communications Zone, ETOUSA, 14 March 1945 (24).

Delivery of blood -When the bleeding section of the blood transfusion unit moved to Marseille, blood drawn there was shipped by rail to Dijon and then trucked to Épinal for distribution. When the command post of the forward distributing section moved to Lunéville, and later to Sarrebourg, the shipments were relayed from Épinal by transportation furnished by the 23d General Hospital. On 9 March, the routing was changed, and blood from Marseille, as well as from the European blood bank in Paris, both arrived at Lunéville by rail. On 12 March, blood from Marseille was sent to Nancy by rail, and blood from Paris by plane.

At this time, the distribution of blood was greatly simplified because the services of two distributing sections were obtained from the 127th Station Hospital, to supplement the unit distributing section. These sections were attached to CONAD (Continental Air Defense Command), and by CONAD to an air holding unit, where they acted as a rear blood station. This station received all blood from the bank in Paris, with which effective daily communication had now been established, stored it, and shipped the containers back to Paris. It was able to provide for all the needs of the blood transfusion unit distributing center until the end of hostilities.

During the last weeks of the war, the unit command post made five moves, one from France to Germany and the remainder in Germany. The forward distributing section continued to supply small amounts of blood after the end of hostilities until it rejoined the parent unit in Marseille on 8 June 1945.

TRANSFER TO ETOUSA

A supplementary blood supply for Seventh U.S. Army hospitals was necessary while the bleeding section of the 6703d Blood Transfusion Unit was moving from Épinal to Marseille. Arrangements for this purpose were made with the European blood bank, and deliveries to Épinal began on 28 October 1944. They were to be discontinued after the transfer to Marseille had been made, but the demand for blood was so great that they were continued until the Seventh U.S. Army passed into the logistic control of the European theater on 20 November 1944. The first shipments consisted of blood drawn and processed in the theater. Later, Seventh U.S. Army hospitals were supplied with blood collected in the Zone of Interior and flown to Paris.

DONORS

The procurement of donors was a constant problem throughout the operation of the 6703d Blood Transfusion Unit (Ovhd.). In Italy, donors were first procured from U.S. troops in the Naples area. Contacts and arrangements


453

were made with the various units by telephone, and transportation was furnished by the blood bank.

When the 6703d Blood Transfusion Unit opened an independent bleeding center at the 24th Replacement Depot at Caserta, procurement of donations was fairly simple. Arrangements were made with the post surgeon, and troops were marched to the bleeding station, so that transportation did not have to be furnished.

Up to 1 September 1944, enough donors were available from these sources to meet the need for blood for Seventh U.S. Army hospitals without too much difficulty. Then, as more and more troops were sent to France, the situation became more critical.

All the blood drawn at Épinal came from U.S. troops. Units were reached by telephone, and donors were transported to the blood bank, which was then attached to the 59th Evacuation Hospital. By the time the bleeding unit had moved to Marseille, most Seventh U.S. Army service troops in the Épinal area had been bled once.

Bleeding of civilian donors began at the Marseille subcenter on 8 December 1944. The response was at first slow. Then it increased, only to fall off during the holidays. It finally increased again and remained stable. In December 1944, 20.52 percent of the 6,042 donors were civilians. In March 1945, civilians made up 61.86 percent of the donors and in April, 53.72 percent. By this time, casual military donors had practically disappeared, one reason being that payment to them had been discontinued on 31 December 1944. Flight rations, provided by the Surgeon, Dijon Base Section, made donations attractive for civilian donors of whom 12,772 were bled.

In February 1945, at the request of the Surgeon, Seventh U.S. Army, A blood as well as O blood was collected, the donor reservoir being considerably increased by the 30-percent component thus secured. Most of the A blood was obtained from civilians. It was checked and handled with great care, and there were no known instances of trouble.

Malaria smears were discontinued at Marseille on 1 February 1945, as they had been in Italy (p. 453).

EQUIPMENT

The equipment used by the base bleeding unit was generally satisfactory except that the tube racks were insufficient, the drying oven was too small, facilities for distilling water were inadequate, and there was no cyclotherm. A special still was constructed at the 15th Medical General Laboratory when it was found that the issue still was entirely incapable of putting out the large amounts of distilled water required in the operation of the blood bank. Other deficiencies were corrected by improvisations by unit personnel, assisted by engineers at the base.


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REFRIGERATION AND TRANSPORTATION

The mechanical refrigeration and transportation originally provided for the 6703d Blood Transfusion Unit consisted of:

1. A 45-cu. ft. refrigerator mounted on a 2½-ton truck with 3-kw. generators to furnish 24-hour electric current. The fly of the truck shaded the generators during the summer months and generally protected them from the weather. This refrigerator was the main storage unit and moved only when the section advanced.

2. Two 6-cu. ft. refrigerators mounted on weapons carriers, with 1½-kw. electric generators. These refrigerators were used for delivery of the blood.

3. Insulated cork-lined plywood boxes for use in transporting the blood (p. 417). The first supply was inadequate, and 60 additional boxes were constructed by the utilities section of the 15th Medical General Laboratory. Ten were somewhat larger than the others and were constructed to hold Dry Ice, which proved necessary for the preservation of the blood over the longer routes in France. The Dry Ice was obtained in Pompeii and flown to France with each shipment of blood, in specially constructed insulated boxes, longer and narrower than those used for blood. A satisfactory temperature could be maintained for 24 hours with the use of about 1,000 gm. of Dry Ice provided from Pompeii.

4. Storage refrigerators for hospitals. The 8-cu. ft. mechanical refrigerator (item No. 7375585) powered by kerosene did not prove satisfactory under field conditions, since it weighed 800 pounds and had to be kept level. Kerosene was often difficult to obtain, and the temperature was not always as low as the required 39° F. (4° C.).

The 7-cu. ft. household type of electric refrigerator was satisfactory for the storage of blood in evacuation hospitals. The lightweight ice cream type of refrigerator brought to NATOUSA late in 1942 and issued on the basis of one per evacuation hospital, and one per platoon of a field hospital attached to an army, also proved satisfactory for the storage of blood collected locally or delivered from the base. It held 40 bottles of blood.

Recommendations

The original refrigerator-truck equipment had to be supplemented at once, as already noted. At the conclusion of the war, the unit history specified that the following equipment was minimum for a distributing center operating in an army area:

1. Two 2½-ton trucks with refrigerator space for 1,000 bottles of blood each.
2. Six ¾-ton weapons carriers with refrigerators.

Essential personnel were specified as six drivers, six assistant drivers, one refrigerator mechanic, and one motor (automobile) mechanic. It was emphasized that a forward unit could not perform properly without motor and refrigeration mechanics.


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STATISTICAL DATA

The base bleeding section of the 6825th Blood Transfusion Company sent 42,713 pints of blood to the forward distributing section between August 1944 and May 1945 (table 16). In addition, it sent 369 pints to hospitals in the Dijon Base Section and to other communications zone installations. During July, August, and September 1944, it provided 2,467 pints of blood for Fifth U.S. Army hospitals and hospitals in Naples. This is a total of 45,549 pints.

The forward section of the 6825th Blood Transfusion Company, from supplies of blood received from the base bleeding section and from the European theater blood bank, distributed 57,964 pints to Seventh U.S. Army hospitals and 7,707 pints to hospitals in the communications zone, a total of 65,671 pints.

The numerous discrepancies in the statistics of the blood program in the Seventh U.S. Army were explained by Colonel Berry in two ways:

1. Records were, understandably, sometimes very poor. In particular, blood used in field hospitals on casualties who were resuscitated and sent on to evacuation hospitals for surgery was frequently not recorded.

2. A considerable amount of blood was hoarded, especially during the winter months, and was later discarded without record. A certain amount was also frozen during the winter, because of long exposure en route.

TABLE 16.-Shipments of blood by bleeding section, 6825th Blood Transfusion Company (Non-T/O), August 1944-May 1945


Year and month

To forward
distributing
section

To hospitals in
Dijon Base Section
(Communications
Zone)

1944

Pints

Pints

 

August

3,539

---

 

September

4,380

---

 

October

4,801

---

 

November

4,205

3

 

December

5,728

22

 

1945

 

 
 

January

4,706

50

 

February

3, 432

38

 

March

4,698

68

 

April

5, 904

16

 

May

1,320

172

Total

42, 713

369

The real reason for the discrepancies in oversea statistics, as compared with the precision of Zone of Interior statistics, is that the circumstances in which blood and plasma were used did not lend themselves to careful bookkeeping.


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FIGURE 107.-Blood plasma being given to infantryman, wounded on patrol, as he is put into ambulance for evacuation to rear after receiving first aid at battalion aid station, 103d Division, Seventh U.S. Army, southern France, February 1945.

FIGURE 108.-Blood transfusion in forward hospital in Seventh U.S. Army, Besançon area, France, September 1944.


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FIGURE 109.-Administration of albumin by U.S. corpsmen to wounded French woman in temporary first aid station in shadow of amphibious Sherman tank. She and
the other casualties (German soldiers) were wounded in the Saint-Raphaël area of southern France, in the 36th Infantry Division Area, Seventh U.S. Army, August 1944.

CLINICAL CONSIDERATIONS

Plasma (fig. 107) and blood (fig. 108) were used in Seventh U.S. Army hospitals on the usual indications. Albumin was used only occasionally and in special circumstances (fig. 109).

References

1. Kendrick, D. B.: History of Blood and Plasma Program, United States Army During World War II, 1 Aug. 1952.

2. Report of Consultant in Surgery to the Surgeon, NATOUSA, 2 July 1943.

3. Report, Maj. Howard E. Snyder, MC, to Surgeon, II Corps, 3 Apr. 1943, subject: Care of the Wounded.

4. Report to the Surgeon, II Corps, through Commanding Officer, 77th Evacuation Hospital, 18 Apr. 1943, subject: Functions of a Transfusion Team in an Evacuation Hospital.

5. Report, Col. Richard T. Arnest, MC, Headquarters, II Corps, Office of the Surgeon, to The Surgeon General, 1 June 1943, subject: Care of the Wounded.

6. Medical Department, United States Army. Surgery in World War II. The Physiologic Effects of Wounds. Washington: U.S. Government Printing Office, 1952.

7. Snyder, Howard E.: Fifth U.S. Army. In Medical Department, United States Army. Surgery in World War II. Activities of Surgical Consultants. Volume I. Washington: U.S. Government Printing Office, 1962.

8. ETMD, NATOUSA, for December 1943.

9. Cornell, Col. V. H., MC: History of the 15th Medical General Laboratory, 20 December 1942-31 May 1944, 31 Oct. 1944.

10. The Medical Department of the United States Army in the World War. Washington: U.S. Government Printing Office, 1927, vol. II, pp. 157-165.


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11. Reports of 6713th Blood Transfusion Unit (Ovhd.), 6 June 1944; 24 July 1944; 25 Oct. 1944; 3 July 1945.

12. Memorandum, Col. Earl Standlee, MC, to The Surgeon General, 27 May 1944, subject: Blood Banks in Theater of Operations.

13. Memorandum, Col. Earl Standlee, MC, to The Surgeon General, 28 Aug. 1945, subject: Blood Banks in Theater of Operations.

14. Circular Letter No. 3, Office of the Surgeon, Headquarters, II Corps, 7 Aug. 1943, subject: Care of the Wounded in Sicily.

15. ETMD, MTOUSA, for March 1945.

16. Circular Letter No. 27, Office of the Surgeon, Headquarters, NATOUSA, 20 Aug. 1943, subject: Donation of Blood for Transfusion and Other Purposes. Act, 30 July 1941 (Public Law 196, 77th Cong.).

17. History, 6th General Hospital, MTOUSA, 1942-44.

18. Minutes, Conference on Preserved Blood, Division of Medical Sciences, National Research Council, 25 May 1943.

19. ETMD, MTOUSA, for May 1945.

20. Annual Medical History of Laboratory Section, 21st General Hospital, 3 Jan. 1944.

21. Report, Lt. Col. Douglas B. Kendrick, MC, to The Surgeon General, 15 Jan. 1945, subject: Trip to the North African Theater of Operations.

22. Berry, Col. Frank B., MC: Surgery in the Seventh Army, 15 August 1944 to 30 April 1945, n.d.

23. Rogers, Capt. Albert M., MC: Organizational History, 1944, 6703 Blood Transfusion Unit (Ovhd.).

24. Rogers, Maj. Albert M., MC: History of 6825th Blood Transfusion Company, n.d.

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