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Chapter XVI

Contents

CHAPTER XVI

The European Theater of Operations

Part I. General Considerations

SPECIAL CIRCUMSTANCES IN THE EUROPEAN THEATER

In any chronicle of the blood program in ETOUSA (European Theater of Operations, U.S. Army), it is important to remember that the military situation in this theater was entirely different from that in MTOUSA (Mediterranean Theater of Operations, U.S. Army) and that the medical situation differed accordingly. In the Mediterranean theater, a single army operated on a single land mass, within a relatively limited area. Serious transportation problems often existed, but blood did not have to be flown across water, as from England to the Continent, and as it was flown later from the Zone of Interior to Europe. Bad weather was therefore seldom a complete hindrance to the delivery of blood in Italy. It was an extremely serious problem in the European theater, for the always limited supply of blood never permitted storage in any significant amounts.

There were also other differentiating circumstances. In Italy, medical control could be uniform; there was a single army, and there was a single army surgeon. In the European theater, there were five U.S. field armies. Just as each army commander had his own concepts of how to fight, so each army surgeon had his own concepts of how to care for casualties and of the need for whole blood for them.

Theater facilities could not possibly supply all the blood needed for casualties on the Continent, but the blood bank in operation at the 152d Station Hospital when Lt. Col. (later Col.) Douglas B. Kendrick, MC, Special Representative on Blood and Plasma Transfusions to The Surgeon General, arrived in the United Kingdom in August 1944 showed how excellent such a service could be, even when it had no support from the Zone of Interior, if it was under the control of a competent, dedicated medical officer, who used all the resources available to him (1).

EDUCATION AND INDOCTRINATION

Information on developments in the use of whole blood had been sent to the Chief Surgeon, ETOUSA, in various ways throughout the war. The


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Special Representative on Blood and Plasma Transfusions, OTSG (Office of The Surgeon General), had kept him informed of developments in the NRC (National Research Council) committees on blood and blood substitutes and on shock. The Chief Surgeon had received the monthly ETMD (Essential Technical Medical Data) reports from MTOUSA, and some of his staff had visited the theater. Col. Eugene R. Sullivan, MC, and Capt. (later Maj.) John J. McGraw, Jr., MC, who were in large part responsible for the establishment and operation of the Mediterranean Theater Blood Bank, had visited the European theater before D-day and had reported their Mediterranean theater experiences. They had much to contribute, for the Mediterranean had been an active theater of operations for 2½ years before D-day in Europe.

All of these channels of information, however, were not enough. The use of whole blood was only one of many therapeutic methods in which medical personnel inexperienced in combat injuries required indoctrination, instruction, and experience.

The First and Third U.S. Armies, in the weeks immediately after the invasion, had had only limited amounts of whole blood. They had to use them sparingly. Within a short time thereafter, blood began to be flown to them in liberal quantities. There had been no chance in either Army-the Third U.S. Army had been operational for only 3 weeks when the airlift from the Zone of Interior began-to set up research teams, and equally little time for hard-pressed operating surgeons to grasp the urgent need of seriously wounded casualties for whole blood in liberal amounts.

The chief lesson that had to be learned in the European theater after the airlift from the Zone of Interior began was not the value of whole blood for severely wounded men but the desirability of using it in liberal quantities and its present availability for such use. Surgeons were used to a mere trickle of blood, which had to be reserved for the casualties who needed it most because their condition was poorest. Naturally, with such experiences behind them, medical officers had to be convinced that they could now be assured of all the blood they needed, and that they could use it prophylactically as well as for casualties in dire state. It was a hard task to persuade forward surgeons that now all they needed to do to secure blood in any needed quantity was simply to ask for it in that quantity.

Another lesson that had to be learned in the European theater was that group O blood in a closed system could be used with almost absolute safety. This was not the situation in the Zone of Interior when many-perhaps most-medical officers had gone overseas, and they had reason to be skeptical at first.

That these lessons were well learned is evident in the fact, pointed out elsewhere, that in the last months of the war in the European theater, as in the Mediterranean theater, the ratio of units of blood to wounded men was close to 1:1.


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Part II. Initial Activities in the Zone of Interior for an 
Oversea Transfusion Service

BACKGROUND OF PROJECT

By the middle of 1943, as the result of the joint activities of the Division of Surgical Physiology, Army Medical School (p. 61), and the Subcommittee on Blood Substitutes, Division of Medical Sciences, NRC (p. 74), all the items had been developed which would permit the use of whole blood in oversea theaters. These were:

1. Satisfactory grouping sera (p. 236).
2. An expendable transfusion set (p. 195).
3. A satisfactory preservative solution (p. 221).
4. A refrigerator which would make possible the storage of blood up to 21 days (p. 206).

The safety and efficiency of all of these items had been so thoroughly tested by the agencies involved that it now seemed logical to propose that the necessary equipment be sent overseas and that the theaters be authorized to train their own personnel to collect and distribute blood to all fixed and forward hospitals. On the most exacting analysis, this proposal seemed entirely reasonable. In particular, the provision of expendable transfusion sets disposed of the chief cause of anxiety in transfusions, the risk of reactions from the reuse of equipment. This practice, even in trained hands in civilian hospitals, would inevitably increase the incidence of pyrogenic reactions and, under circumstances of warfare, would further increase the incidence of reactions.

FIRST PROPOSAL, OCTOBER 1943

The background thus being prepared, Colonel Kendrick addressed a memorandum on the use of whole blood in theaters of operations to Lt. Col. (later Col.) B. Noland Carter, MC, Director, Surgery Division, OTSG, who was then in charge of the blood program in this office. This memorandum, which was dated 5 October 1943, covered the following points (2):

1. The British experience in the Mediterranean theater, the similar American experience there, and reports from medical officers in the European theater had made it clear that whole blood was essential in oversea theaters of operations. The need was greatest in forward hospitals in which major surgery was performed. In these installations, casualties were often seen with red blood cell counts as low as 1½ million to 2 million per cu. mm.

2. Plasma did not solve the problem. It was an admirable and effective agent, but it had definite limitations. It could raise the blood pressure after hemorrhage, but it could not prepare a casualty for major surgery. The British Eighth Army at El Alamein had used bottles of blood, plasma, and physiologic salt solution in the ratio of 18:19:20 per hundred casualties. When plasma was used intelligently, it was an effective preliminary


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replacement fluid, but in abdominal wounds, hemorrhage, sepsis, burns, and similar pathologic conditions, whole blood was necessary, probably in a ratio to plasma of 1:2 or even 2:2.

Plasma could correct losses in blood volume if it was given early, in adequate quantities, and if hemorrhage was controlled at the same time. When a casualty was treated late, or if hemorrhage was not controlled, then whole blood was essential.

3. The disadvantages of whole blood as compared with plasma were frankly admitted. Blood had to be collected locally in theaters of operations. Donors would be limited to military service personnel, personnel in rest camps, lightly wounded casualties, and, occasionally, the local civilian population. Malarial and syphilitic donors could not be employed. Blood was cumbersome to handle. It had to be grouped before administration. It had to be distributed with numerous precautions. The chances of contamination of blood were greater than the chances of contamination of liquid or dried plasma made from blood collected and processed in a closed system.

A number of tests had to be carried out before blood could be used, and the necessity for them limited the extent of its use. Serologic tests were necessary, but equipment to perform them was not available farther forward than evacuation hospitals. Microscopic examination of thick and thin smears was necessary to rule out malaria, but microscopic equipment was not available forward of evacuation hospitals, and trained personnel who were in short supply, were needed to read the slides.

Equipment (autoclaves and stills) was not available overseas in sufficient quantity to prepare transfusion sets for repeated use, nor were personnel available for collecting and preparing them. If the necessary equipment and personnel could not be provided, it would be necessary to ship overseas commercially prepared transfusion sets which could be discarded after a single use.

Finally, because blood was highly perishable, it had to be stored under refrigeration, which was not available forward of evacuation hospitals.

4. Fresh blood collected in an open system could be used for transfusions, but could not be kept for more than a few hours. Transfusions with blood collected in this fashion had been given in U.S. Army hospitals during the North African campaign, but the number had been limited because of the lack of blood. Furthermore, the use of blood in small quantities had limited its effectiveness.

Recommendations

In the light of the facts just set forth, Colonel Kendrick made the following recommendations in his 5 October 1943 memorandum to Colonel Carter:

1. Stored blood, collected in a closed system, should be supplied to medical installations as far forward as field hospitals.

2. Blood should be collected in the area of a general hospital from military personnel or, if circumstances permitted, from civilians near the base. It should be collected by a base collection unit and supplied in refrigerated chests (storage containers) to advanced units.

3. To reduce the necessity for blood grouping in forward hospitals, only proved type O blood should be stored.

4. The quantities of blood provided should be based on the estimate that 20 percent of all combat casualties would require resuscitation, and 20 percent of these would require blood as well as plasma. According to Brigadier Lionel E. H. Whitby, RAMC, Director of the British Army Transfusion Service, 30 pints of protein fluid were necessary for every hundred wounded, in the proportion of 3 pints of plasma to 1 pint of blood. According to Col. Edward D.


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Churchill, MC, Consultant in Surgery to the Surgeon, MTOUSA, 18 pints of blood were required for every hundred wounded, in the proportion of one unit of blood for every two units of plasma.

Proposed Implementation of Recommendations

In Colonel Kendrick's memorandum of 5 October 1943, it was pointed out that Circular Letter No. 108, issued by OTSG on 27 May 1943 (3), provided for the transfusion of fresh whole blood in general hospitals overseas up to 4 hours after it had been collected, and also provided for the transfusion of stored blood, to be collected by a closed system, up to 7 hours after it had been drawn. The evidence at hand now indicated that whole blood transfusions must be made readily available in every medical installation in which major surgery was to be done. This would be possible only by the use of preserved blood stored at designated depots, preferably general hospitals.

This policy would require implementation as follows:

1. Necessary equipment would include:

a. Sterile vacuum bottles containing 200 cc. of Denstedt's solution (glucose and citrate), in which blood collected in a closed system could be kept for 21 days.

b. Expendable recipient sets with cellophane tubing and cloth filters.

c. Donor sets consisting of a metal flow valve to be inserted in the stopper of the vacuum bottle and connected to a collecting needle by 18 inches of heavy rubber tubing. A roller-type valve, capable of completely compressing the rubber tubing, could be used in place of the metal valve to control the flow of blood.

d. Two refrigerators, of 16-cu. ft. capacity, for each general hospital, for the storage of blood. They should be kept in the laboratory, where serologic and malaria tests would be made and donor and recipient sets cleaned.

e. Insulated containers, each to hold from 10 to 20 flasks of blood. It would be necessary to work out the arrangements for a supply of ice with the Quartermaster and Corps of Engineers overseas.

2. Transportation to forward areas would be by trucks, ambulances, or airplanes. Since blood would frequently be collected outside of general hospitals and would require transportation to them, it would be more practical to have transportation assigned to collecting teams and distributing units, with the transfusion office in each general hospital responsible for providing it.

3. Personnel would include:

a. Transfusion officers and assistants at general hospitals in the communications zone. Their function would be to procure donors, collect and store blood, and dispense it to their own installations and to installations farther forward.

b. Shock teams, consisting of resuscitation officers and enlisted men, properly trained in the use of plasma and albumin. These teams would be assigned as necessary to field and evacuation hospitals and to mobile surgical units.

c. A chief transfusion officer on the staff of each theater surgeon in each theater of operations. His function would be to train personnel assigned to the blood transfusion service and to exercise general supervision over the handling and transportation of transfusion equipment and blood. He should be present at all staff conferences, so that he could work out arrangements for a supply of blood in each operation. Medical officers, especially those in landing parties, would require individual training in the tactical employment of transfusion units.


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d. A chief of the blood transfusion service in the Zone of Interior. This officer's functions would include design and testing of equipment for intravenous therapy, supervision of the procurement of equipment, supervision of the processing of plasma and serum albumin, and liaison with the American National Red Cross Blood Donor Service and the National Research Council.

This memorandum, it should be noted, was prepared on the fundamental assumption that replacement therapy, including intravenous therapy as well as blood replacement, constitutes a specialized branch of medicine and that to collect blood, group it correctly, and store and distribute it are processes that require the services of specially trained personnel. These functions cannot be safely delegated to untrained personnel because any slip, however trivial, in the collection and use of whole blood, in addition to causing unnecessary and sometimes excessive losses of a scarce and valuable substance, may result in severe and even fatal reactions.

ACTIONS ON PROPOSAL

Presentation of Proposal to Chief Consultant in Surgery, OTSG

On 3 November 1943, Colonel Kendrick followed his 5 October memorandum by a second memorandum to Brig. Gen. Fred W. Rankin, Chief Consultant in Surgery, OTSG, containing a summary of his earlier memorandum to Colonel Carter (4). On 6 November, General Rankin prepared a similar memorandum for The Surgeon General (5). In it, he stressed the need for stored blood in theaters of operations and described the equipment necessary to provide it. He also described expendable commercial equipment for both giving and receiving sets.

Presentation of Proposal to Subcommittee on Blood Substitutes, NRC

The plan outlined in Colonel Kendrick's memorandum of 5 October 1943 was presented by him to the Subcommittee on Blood Substitutes, NRC, at the meeting held on 17 November 1943 (6). He stressed the following points:

1. Reports from the field indicated that wounded casualties required whole blood as well as plasma.

2. At present, whole blood transfusions were being carried out overseas with empty plasma bottles. A recommendation had been approved by OTSG to provide refrigerating equipment for field hospitals, evacuation hospitals, and general hospitals. Collecting bottles containing Denstedt's solution would also be provided, as well as microscopes and equipment for typing and crossmatching of blood, so that blood banks might be operated at these points.

3. A satisfactory airlift was now available, as it had not been earlier, when this subcommittee (p. 53) and the Conference on Blood Grouping (p. 53) had recommended that whole blood be provided for combat casualties.


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4. The recommendation that collecting units be organized in general hospitals overseas, with teams to administer transfusions as far forward as possible, had been made to OTSG but had not been accepted.

After Colonel Kendrick's memorandum had been discussed in detail, the following resolution was moved and passed:

Resolved: That the Subcommittee on Blood substitutes recommend through channels that The Surgeon General of the Army give consideration to the transportation of whole blood by airplane to certain theaters of operations.

Rejection of Proposal by The Surgeon General

On 13 November 1943, a summary of General Rankin's memorandum of 6 November 1943 was hand-carried by Colonel Carter and Colonel Kendrick to The Surgeon General (7), who rejected the proposal at once, on the following grounds (8):

1. His observations in oversea theaters had convinced him that plasma was adequate for the resuscitation of wounded men.

2. From a logistic standpoint, it was impractical to make locally collected blood available farther forward than general hospitals in the communications zone.

3. Shipping space was too scarce to warrant its use for sending disposable transfusion equipment overseas.

On the basis of these facts, Maj. Gen. Norman T. Kirk, The Surgeon General, directed that the provision and use of blood in oversea theaters should be limited by the instructions set forth in Circular Letter No. 108, 27 May 1943 (p. 463).

General Kirk's position was equally adamant in a second conference with Colonel Carter on 16 December 1943 (8).

Although personnel in charge of the blood program were not in agreement with The Surgeon General's decision-and although the plan rejected out of hand was essentially the same as the plan by which blood was sent overseas only 10 months later-they had no choice but to accept it.

There were several probable reasons for General Kirk's refusal to consider the proposed program, perhaps the most important being that he shared the still rather general opinion that plasma was a satisfactory agent of resuscitation and that the use of whole blood in large quantities was not necessary for battle casualties. Undoubtedly, too, he had been directed by higher authority, because of limited shipping space, to limit the tonnage of medical supplies shipped overseas. Since he considered plasma adequate for resuscitation, he did not believe that flying transfusion equipment overseas, let alone flying whole blood, was sufficiently important to substitute the equipment (and blood) for other supplies and, thus keep within the allowable tonnage. It also did not seem important to him to point out to the Commanding General, Army Service Forces, under whom his office operated, the urgency of increasing the allowable tonnage to supply whole blood for wounded men, as was done less than 10


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months later. As a matter of fact, except for the lack of an airlift, transfusion services could have been activated in all theaters in the spring of 1943, for the basic work on the preservation, transportation, and safe usage of whole blood had all been done by that time, and the equipment necessary for such a service had also been developed.

It was learned in 1960 that the decision not to send blood to Europe from the Zone of Interior had been made long before the interview with The Surgeon General in December 1943. As is pointed out elsewhere (p. 475), Maj. Gen. Paul R. Hawley, Chief Surgeon, ETOUSA, had already been informed by The Surgeon General that he would not approve of this plan.

REVIVAL OF PROPOSAL, APRIL 1944

Presentation to The Surgeon General

No further action was taken in the Zone of Interior in regard to supplying blood for combat casualties until 17 April 1944. Then, with D-day in Europe obviously imminent, Colonel Kendrick addressed another memorandum to The Surgeon General on the subject of whole blood in theaters of operations (9). As in his earlier memorandums, he pointed out the success of the plasma program, the method of supplying fresh whole blood in fixed hospitals in the communications zone, as set forth in Circular Letter No. 108, OTSG, and the need for stored whole blood in forward as well as in base hospitals. He also pointed out that the quantity of fresh blood which could be made available by bleeding donors (so-called on-the-hoof bleeding) would be limited during peak operations by the inevitable confusion attending the operations and by the necessity of performing time-consuming laboratory tests.

By this time (April 1944), theaters of operations had made their own plans for supplies of whole blood, but techniques for their implementation, as well as the equipment, varied considerably in scope. Colonel Kendrick therefore proposed to The Surgeon General:

1. That a complete study be initiated to determine the needs for whole blood, requirements as to equipment and personnel and standardization of techniques to supply whole blood to medical installations in the field. The study would include a trip of inspection to one or more active theaters to observe their techniques and equipment before final recommendations were made.

2. That the Office of The Surgeon General develop techniques and standardize equipment to provide for the use of stored whole blood in theaters of operations. The following plan was suggested:

a. Only group O blood would be sent to forward hospitals.

b. Blood would be collected at bases from service personnel or the civilian population by a collecting team consisting of a medical officer, a nurse, and seven enlisted technicians, two of whom would also act as drivers.

c. Laboratory procedures, including serology, malaria testing, and blood grouping would be done by the collecting teams.


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d. Blood would be sent as far forward as field hospitals, upon request, in refrigerators mounted on trucks. It would be handled by a distributing or delivery team of two enlisted men.

e. A transfusion officer in each unit would be responsible for maintaining an adequate supply of blood and for its administration. The remainder of the transfusion team in each unit would consist of a nurse and three enlisted technicians. It was essential that all transfusion officers and other personnel be well trained for this special work.

f. A transfusion officer attached to the staff of the theater surgeon would be responsible for supervision of the collecting team and for all other activities concerned with blood within the theater.

3. Transportation for the collecting team would consist of a truck or ambulance to transport personnel and a ½-ton truck for equipment and refrigerators. Transportation for the delivery team would consist of a similar truck for refrigerators.

4. Other equipment would consist of:

a. An electric refrigerator to operate on 110 volts, or on usual power outlets, or on a 750-watt generator. The refrigerator should be large enough to hold from 36 to 50 bottles of stored blood and should maintain a temperature range of 46.4° to 50.0° F. (8° to 10° C.).

b. One-liter vacuum bottles containing 500 cc. of Alsever's solution.1

c. Collecting sets consisting of a 20-inch length of ¼- or 3/16-inch rubber tubing, with two 17-gage needles.

d. Dispensing sets consisting of expendable glass housing with metal filter and rubber tubing.

In a memorandum addressed to The Surgeon General on 21 April 1944, General Rankin repeated the information in Colonel Kendrick's memorandum of 17 April concerning the relative limitations of plasma and the absolute necessity for stored blood for combat casualties (10). He also stressed the need for standardizing methods and equipment for the collection and storage of blood in all theaters, in keeping with military requirements.

REQUEST FOR OVERSEA MISSION

In the memorandum just mentioned, General Rankin requested that Colonel Kendrick be ordered to the Southwest Pacific, to carry out the study proposed in the latter's memorandum of 17 April, to study blood and plasma requirements, and to investigate the use of albumin and other byproducts of the plasma-blood program. General Rankin recommended that when this mission had been completed, techniques and equipment be standardized in the Office of The Surgeon General for the use of replacement fluids in all theater's of operations

1By this time, Alsever's solution was being used in the Zone of Interior in place of Denstedt's or other solutions. Its use had been approved by the Subcommittee on Blood Substitutes in September 1943 (p. 467), but its replacement by ACD (acid-citrate-dextrose) solution was not recommended until November 1944, 3 months after the airlift to the European theater had become operational (p. 226).


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The justification for the mission and for the selection of the area in which it was to be carried out was that no one in the Southwest Pacific had had the training and experience necessary to train the personnel required for a blood program, supervise equipment, and organize an efficient transfusion service. Colonel Kendrick, General Rankin's memorandum continued, had been responsible for the blood and plasma program in the Zone of Interior from its onset. If plans could be made to make blood available in the Southwest Pacific, over long distances, in the face of difficult terrain, a high incidence of malaria, and extreme temperatures, then methods of providing blood in other theaters would be greatly simplified. Such a study would make it possible to combine laboratory experiences with field requirements and eventually to standardize equipment and methods of transfusion for the entire Army.2,3

In the official request for temporary duty for Colonel Kendrick for the mission just described, which was made on 4 May 1944, it was stated that the trip would be made with Capt. Lloyd R. Newhouser, MC, USN, in order to coordinate methods and equipment for the use of blood and blood substitutes in the Army and the Navy and thus simplify therapy when combined operations were undertaken.

The readiness date requested for this mission was 5 June 1944-which was the day before D-day in Europe. In retrospect, it seems that it might have been wiser if the trip had been made to the European theater. On the other hand, no precise information was then available about the date of D-day, and the need for guidance in the Pacific was obviously very great.

RECOMMENDATIONS BY SURGERY DIVISION, OTSG

In the annual report of the Transfusion Branch, Surgery Division, OTSG, made on 1 July 1944 for fiscal year 1944 (14), the section dealing with blood began with the statement that, although plasma had been supplied to the Army in adequate quantities since 1941, the need for blood had never been lost sight of. The report reviewed the work of the Division of Surgical Physiology, Army Medical School, in the development of a closed system for bleeding; the development of a preservative solution in which blood could be stored safely for 2 to 3 weeks; the development of disposable transfusion sets; and the development of refrigerating equipment. Although all of this equipment was available by D-day in Europe, 6 June 1944, and stored whole blood could then have

2Had time permitted, it would have been profitable to study the successful transfusion service and blood bank in operation in the Mediterranean theater (p. 400) before the trip to the Southwest Pacific. It did not, and, as events proved, there was urgent need for guidance and help in the Pacific areas. On the other hand, the fact that Colonel Kendrick was ordered to the Pacific instead of to Europe at this particular time is an indication of the secrecy surrounding the date set for D-day. Apparently, as late as May 1944, The Surgeon General did not have this information.
3It is interesting to recollect that as early as 31 May 1940 (11), the Committee on Transfusions, NRC, recognized the need for field studies in the blood program. At the meeting on 9 April 1943 (12), the subcommittee recommended the appointment of a qualified fact-finding group to make field studies, on the ground that its own work had reached the point that it could no longer function effectively without "more precise information concerning field problems and conditions imposed by the military requirements in this war" (p. 79). On 24 September 1943, the subcommittee again raised the question (13). No such civilian investigation was ever undertaken, probably because The Surgeon General was reluctant to ask for the necessary clearances.


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been provided for field use, as of 30 June 1944, no plan had been approved by The Surgeon General for collecting and supplying blood to the theaters, each of which had therefore developed its own plans.

In the fall of 1943, the report continued, the Surgery Division, OTSG, had proposed to The Surgeon General a plan that utilized tested and approved equipment and that provided for the collection and delivery of blood in oversea theaters. The plan was predicated on the concept that blood transfusion and the use of other replacement fluids constituted a specialized branch of medicine. Well-trained technicians were necessary to collect blood, group it correctly, and store it safely. These functions could not be delegated to untrained personnel, for errors could result in severe and even fatal reactions.

The plan had been rejected as unessential and impractical in November 1943. In June 1944, the report concluded, the need for a transfusion service in active theaters of operations was even more apparent than it had been in 1943. It was therefore urgently recommended that additional thought be given to preparing and adopting a simple plan to make blood available in every theater, using:

1. The 4-cu. ft. refrigerator developed during the past year.
2. The expendable recipient set now available.
3. Alsever's solution now available as a preservative
4. The collection of blood by a closed system.
5. O donors exclusively.

Part III. Initial Activities in the European Theater

INITIAL PROVISION OF BLOOD AND PLASMA

The first U.S. troops which arrived in England, in January 1942, had no provision for blood transfusion, and for some time their supplies of plasma were entirely inadequate. The deficiencies were easily explained: Troops were being deployed, or arrangements were being made for their deployment, all over the world, and supply ships were being sunk.

Arrangements were promptly made to supply blood and plasma (at first in the wet form) from British sources. As might have been expected, certain difficulties arose, some of which continued into 1943 (15). The first U.S. requests for plasma were extravagantly large. Some individual units requested plasma and blood at irregular intervals directly from British blood centers instead of procuring them, as they were instructed to, through U.S. Army medical depots. Also, small amounts of blood were procured from civilian sources. If these practices had not been stopped at once, the U.S. Army would have been placed in the position of being a factor, albeit a passive and unwitting factor, in the disruption of the well-organized British Army Transfusion Service. Fortunately, relations between Brigadier Whitby, in charge of the British Transfusion Service, and Col. (later Brig. Gen.) Elliott


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FIGURE 110.-Inventory of liquid plasma in wet plasma storehouse, British Army Blood Supply Depot, West House, Chilton Polden, Bridgewater, Somerset, England, 1943.

C. Cutler, MC, Consultant in Surgery to the Chief Surgeon, ETOUSA, were so intimate and cordial that misunderstandings could be settled as they arose.4

In June 1943, there was a gradual changeover from British wet plasma (fig. 110) to British dried plasma; the issue also included distilled water and giving sets (16). In December 1943, U.S. hospitals in the United Kingdom began to receive dried plasma from the Zone of Interior (17).

TRAINING IN BRITISH BLOOD SUPPLY DEPOT

In August 1942, Capt. (later Lt. Col.) Robert C. Hardin, MC (fig. 111), who had had a wide experience in blood procurement and replacement therapy

4One of the first items of official correspondence directed to Colonel Cutler for action was a report on the British Army Blood Supply Depot submitted by Capt. (later Lt. Col.) Robert C. Hardin, MC, who was then serving as U.S. liaison officer at the depot (p. 478). The theater Chief Surgeon, in turning over the report to Colonel Cutler, signified that the Chief Consultant in Surgery would be responsible for the technical aspects of providing blood, blood substitutes, crystalloids, and related substances to the U.S. Army medical units in the theater.


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FIGURE 111.-Left to right: Col. Elliott C. Cutler, MC, Lt. Col, Ralph S. Muckenfuss, MC, and Maj. Robert C. Hardin, MC, summer 1944.

at the State University of Iowa, Iowa City, Iowa, with Dr. Elmer L. DeGowin and Dr. Everett D. Plass (p. 220), was placed on temporary duty at the British Army Blood Supply Depot, Southmead Hospital, Bristol. His functions were to serve as liaison supply officer and to gather as much information as he could about the British system of procurement and handling of blood and blood products, including the technical details of collection, processing, storage, and distribution. Captain Hardin also collected data concerning British methods of treating shock, the amounts of blood and plasma required in the management of battle casualties, and the management of casualties in the Battle of Britain as well as the Battle of France. Personal contacts with the officers who had had these experiences proved most helpful.

Captain Hardin also studied methods of training officers and enlisted men in the procurement and distribution of blood and in shock and resuscitation. Special courses were conducted for this purpose. When Col. James C. Kimbrough, MC, Chief, Professional Services, Office of the Chief Surgeon, ETOUSA,


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investigated the possibility of a few U.S. medical officers with special interest in the subject attending these courses, Brigadier Whitby replied that he would be delighted to have three officers attend each course. He thought they would provide a new source of postlecture argument, which would be both instructive and stimulating. He also agreed to give a limited number of courses to noncommissioned officers and enlisted technicians. The courses of instruction continued into May 1944 and were attended by more than 200 U.S. officers. The policy paid off in friendship and cooperation as well as in dissemination of knowledge.

APPOINTMENT OF CONSULTANT ON TRANSFUSION 
AND SHOCK

A consultant on transfusion and shock was even more necessary in the European than in the Mediterranean theater, since several armies operated in it, with several widely separated blood bank units attached to them.

The question first came up on 2 January 1944, when Colonel Kimbrough was informed by Colonel Cutler of the provisions for the whole blood service. It was pointed out to him that the highly specialized nature of this service made it essential that a competent officer be placed in charge of it. On 5 January, General Hawley instructed Col. James B. Mason, MC, to appoint an officer to direct the whole blood service in the theater (18). It was highly desirable that he be appointed promptly, for basic decisions had already been taken about the service; a large quantity of equipment was already available; and personnel would soon be assigned. This was therefore the time for a director to take hold of the service and weld the separate parts into a whole. The officer nominated, General Hawley specified, must be a forceful executive, with a good knowledge of Army organization and operations, and must be qualified, from a professional standpoint, to advise on the use of whole blood.

Colonel Mason at once nominated Captain Hardin for the position, on the ground that he was better acquainted with all the details of the acquisition and processing of blood than any other officer in the theater. Brigadier Whitby had written Colonel Cutler on several occasions of the assistance he (Captain Hardin) had been to him. In addition to handling the administrative details of U.S. participation in the courses of instruction at Southmead Hospital, he had shared in the work of the depot; delivered lectures on transfusion reactions, changes in stored blood, and the use of blood substitutes; and had otherwise carried part of the teaching load during the year he worked at the blood bank. In his return letter to Brigadier Whitby, Colonel Cutler had said he expected to make great use of Captain Hardin in the future, as an assistant in the Consultant Service, in the organization of shock teams, and in the establishment of hospital blood banks.

Captain Hardin was appointed theater transfusion officer on 7 February 1944.


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HOSPITAL BLOOD BANKS

Authorization

The establishment of blood banks in U.S. hospitals in the United Kingdom first arose in October 1942 and was the subject of a number of discussions thereafter until they were authorized by Circular Letter No. 51, Office of the Chief Surgeon, ETOUSA, 5 April 1943 (19). They were set up only in general hospitals. Station hospitals employed fresh blood as the need arose, and one or two had arrangements to secure it from British sources, but they were not authorized to store blood.

The following instructions were given in Circular Letter No. 51:

1. Only U.S. Army personnel should be used as donors in the area controlled by the British Army Transfusion Service (the counties of which were listed).

2. In other areas, general hospitals should set up blood banks in consultation with local civilian medical authorities, using civilian donor panels.

3. Neither civilian nor military donors would be remunerated.

4. Under no circumstances were British Army Transfusion sets to be used with civilian sets. They were entirely separate, and no hospital should use both.

Progress Report, June 1943

On 9 June 1943, Captain Hardin reported to Colonel Cutler on the progress made in setting up blood banks in general hospitals in the United Kingdom as follows (20):

1. The 2d General Hospital had facilities for the storage of whole blood and had operated a small bank for several months. The civilian donor panel allotted to it by the British Army Transfusion Service contained the names of about 800 persons living near the hospital and was augmented by hospital personnel. Bleedings were carried out once weekly, the number of donors bled being determined by the weekly requirements. This hospital was supplying a local British Emergency Medical Service hospital with blood.

2. The 5th General Hospital was setting up its bank. It had been supplied with British military equipment and had a local civilian panel of 800 persons, augmented by hospital personnel. Because of the proximity of this hospital to the Royal Infirmary in Salisbury, which used the same panel, bleeding would be carried out there, by teams from both hospitals, on the scale necessary to provide the blood needed for both institutions. The addition of U.S. personnel would be the only departure from the previous bleeding practice in this location. Adequate refrigeration was available at the 5th General Hospital for blood storage.

3. The 30th General Hospital, which was located in the British Emergency Medical Service area, had made satisfactory arrangements with local transfusion authorities in Nottingham, from which it received 20 pints of blood every 2 weeks. Emergency supplies beyond this amount were obtained from either the Mansfield General Hospital or the EMS (Emergency Medical Service) Laboratory in Nottingham. The 30th General Hospital staff reciprocated this assistance by furnishing a medical officer to carry out bleedings for the EMS laboratory every week or two. To date, the hospital needs had averaged only 5 pints per week, but outdated, unused blood was returned to the EMS laboratory for processing into plasma, so there was no waste. The hospital had adequate refrigeration facilities.


474

4. The 52d General Hospital, which was also located in the EMS area, had made arrangements similar to those of the 30th General Hospital with local civilian laboratories in Birmingham and Worcester. It received 4 pints of blood per week, which covered present needs, and returned outdated blood for processing into plasma. The greatest present need of this hospital was for an electric refrigerator to maintain a constant temperature for blood storage.

5. The 67th General Hospital had arranged for a blood bank with a civilian panel allotted from the British Army Transfusion Service. The bank would cooperate with local civilian hospitals by arrangements similar to those made by the 2d and 4th General Hospitals.

6. The 298th General Hospital could now supply its needs directly from a British Army blood supply depot because of its location only 5 miles away. At present, it was keeping four bottles of type O blood constantly on hand for emergencies and could procure more if it were needed. Outdated blood was returned for salvage. This arrangement was more satisfactory to the British Army Transfusion Service than the allotment of a civilian panel to the hospital. At present, the demand for blood was not sufficient to make storage in the hospital economical, but the basic organization for a blood bank had been built up and equipment for it provided. The sets for taking and giving blood had been manufactured in the hospital from salvaged glassware.

Operation

The details of operation of a hospital blood bank were set forth in Medical Bulletin No. 14, Office of the Chief Surgeon, Headquarters, ETOUSA, for 1 January 1944 (21). The description covered organization, equipment, its cleansing and sterilization, technique of bleeding, blood grouping, and technique of administration.

Hospitals which maintained their own blood banks in the United Kingdom developed special practices. After the invasion, for instance, the 182d General Hospital found the blood donor panel maintained from its own personnel adequate for ordinary circumstances but not sufficient when convoys arrived and large amounts of blood were needed. An arrangement was therefore worked out with personnel of the nearby G-18 depot to supply the blood needed at these times. The men on this panel were already typed, serologic tests had been run on them, and their medical histories had been reviewed. When the blood was needed, therefore, it could be drawn and administered at once. This hospital did not store blood between convoys.

INCREASING AWARENESS IN THE EUROPEAN THEATER OF 
THE NEED FOR WHOLE BLOOD

The blood program in the European theater developed along two lines. One was the increasing realization of the necessity for blood rather than plasma in the management of wounded men (though the complete realization did not come until after D-day). The other was the increasing realization that local supplies of blood could not possibly meet the needs of the theater and that blood must be flown to the theater from the Zone of Interior (though again it was not until after D-day that the full realization came).


475

During 1942, as just indicated, there was no blood program, as such, in the European theater. The growing appreciation of the need for whole blood began to take expression early in 1943 and is best described chronologically.5

1943

January-April -On 29 January 1943, in a memorandum to Dr. P. L. Mollison, British Blood Transfusion Service, Lt. Col. (later Col.) William S. Middleton, MC, Senior Consultant in Medicine, ETOUSA, thought there might develop "a swing toward whole blood transfusions" (22). "Actually," he continued, "we sense a movement in that direction at the present time." The British, as pointed out elsewhere (p. 54), had appreciated this necessity almost immediately after the outbreak of the war more than 3 years ago.

When the Chief Surgeon, ETOUSA, first directed that provision be made to supply whole blood for combat casualties, in July 1943, he did not mention the possibility of securing blood from the United States. The omission is explained in a letter written to Col. John Boyd Coates, Jr., MC, Editor in Chief of the history of the U.S. Army Medical Department in World War II, which is appended to the official diary of Colonel Cutler, Senior Consultant in Surgery, European theater, in the second of the volumes devoted to the surgical consultant system in this historical series (23). There is a strong implication, General Hawley wrote, in some sections of this diary, that his own disapproval of certain recommendations made by the consultants was purely arbitrary and capricious. The explanation is that throughout the war he frequently had top secret information that he could not share with even his deputy. Many of his adverse decisions were based upon such information. An example was his reluctance in 1943 and in 1944, before D-day, to attempt to obtain whole blood from the Zone of Interior. For this, there were two reasons. The first was that the transatlantic airlift in 1943 was so limited and so restricted by priorities that it could not take on any additional load. The second reason was that The Surgeon General had told him flatly that he would not approve of flying blood overseas.

The Surgeon General's opposition to the plan was made official on 8 April 1943, when a radiogram was received from The Adjutant General, War Department, stating that no whole blood could be expected in the theater from the Zone of Interior.

When General Hawley first directed that steps be taken to procure whole blood for hospitals in the United Kingdom, there was probably no really serious consideration, or at least no general consideration, of securing blood from the Zone of Interior on the part of those whose task it was to implement his orders. All the planning was based on securing the required blood from troops in the

5The organization of the ETOUSA Blood Bank at the 152d Station Hospital was proceeding at the same time that the events related in this section were occurring. For reasons of continuity of narration, however, the history of the blood bank is told in a separate section (p. 498).


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theater, with perhaps some donations from civilian sources. At intervals, however, the possibility of procurement of blood from the United States was brought up, sometimes tentatively, sometimes with real conviction, as the following facts show:

Early in 1943, it was pointed out by the Professional Services Division, Office of the Chief Surgeon, ETOUSA, that medical officers in the Mediterranean theater were reluctant to use plasma in forward areas, even though it was difficult to obtain whole blood for transfusion. The chief purpose of blood was to increase the oxygen-carrying capacity of the casualty for a period long enough to support him through surgery, and plans must therefore be made to use blood "up the line." It was recommended that a supply of blood be made available in the United Kingdom and also from sources in the United States.

May -On 10 May 1943, in a memorandum to General Hawley, Colonel Cutler discussed information he had secured in recent conferences with Brigadier Whitby. He mentioned three possible sources of blood for the treatment of shock (24):

1. Lightly wounded casualties could be bled in the frontlines. The transfusion laboratory teams of mobile surgical units were provided with equipment for drawing and administering blood. Possibly, if the blood were used judiciously, these teams might be able to collect all that would be needed, but in the light of the British experience, this source must not be regarded as entirely sufficient, and plans must be made for a supplementary supply.

2. Blood secured from base and service troops in rear areas could be transported to the front by an organization similar to, and perhaps patterned after, the British Blood Transfusion Service (p. 15).

Blood collected in this manner had to be processed; that is, it had to be retyped and tested serologically, and glucose had to be added to it. When it was properly refrigerated, it was useful for a minimum of 14, and a maximum of 21, days. Equipment was necessary for typing and serologic tests, and refrigeration was required for the laboratory in which the processing was done.

Blood thus secured could be delivered to frontline units by air or surface transport, but precautions must be taken to keep it at temperatures below 42.8° F. (6° C.) at all times and also above freezing. A supply dump would be necessary behind frontline forces to handle blood and distribute it to the transfusion teams in the forward area. Such a unit might well be patterned after the British base transfusion unit, which was also equipped to manufacture glucose and physiologic salt solutions and to recondition and sterilize all apparatus.

3. Blood procured from the Zone of Interior represented the largest pool available. Supplies from this source could enter the transfusion service overseas either at the laboratory where blood drawn from troops was processed or at the forward dump. Refrigeration presented special problems, for the blood must at all times be kept within the temperature range just stated. Nonethe-


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less, it was perfectly feasible to fly blood over the distance involved. As a matter of fact, transportation of blood by plane was possibly less harmful than transportation by road.

June -On 5 June 1943, Captain Hardin sent a memorandum to Colonel Cutler discussing blood procurement as follows (25):

1. Blood could be obtained in the United Kingdom from base and SOS (Services of Supply) troops, but these troops, scattered as they were over a wide area, would furnish a somewhat problematical source of supply. Moreover, because blood would be most needed then, they would have to be bled during periods of combat activity, when they would be least available. If a constant stream of donors was made available, it was estimated that a single team could bleed up to 150 men a day.

2. Blood might also be collected from British civilians, who would probably furnish a more reliable source, but this plan had numerous complications.

3. If blood were collected in the Zone of Interior, it must be delivered to the theater by airlift. Its collection, processing, and initial delivery to a depot in the United Kingdom would be the function of any appointed agency in the Zone of Interior. Its reception, interval storage, and distribution to laboratory transfusion teams, base units, or both would be the responsibility of the United Kingdom blood depot but would differ in no way from the organization for the distribution of blood collected in the United Kingdom. The receiving depot would necessarily be located near an airport, and adequate refrigeration must be provided for the blood from the time it was offloaded from the plane until it was used.

At a conference with his consultants on 23 June 1943, General Hawley told them that blood used in the theater must be collected locally; it could not be procured from the United States.6 They were to consult with the British concerning its preservation and storage.

August.-In a memorandum for the record dated 29 August 1943 and entitled "Project," Colonel Cutler dealt at length with the procurement, storage, and supply of whole blood for combat troops in the theater (26). There was an overwhelming necessity for the blood, he stated, and a central blood bank was essential. Blood secured from lightly wounded soldiers would not be sufficient for the needs of forward areas. Blood from the Zone of Interior was not mentioned.

An attached appendix, prepared by Lt. Col. (later Col.) Ralph S. Muckenfuss, MC, Commanding Officer, 1st Medical Laboratory, dealt with technical considerations of procurement, storage, equipment, records, and issue. SOS troops in the United Kingdom, it was stated, would provide a sufficient source of supply for the O blood required.

6Here and elsewhere, this statement is repeated as a matter of record. In the light of the information General Hawley had had from the Office of The Surgeon General through The Adjutant General (p. 475), there would have been no point to his encouraging the possibility of securing blood from the Zone of Interior.


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In an undated7 memorandum, apparently also prepared in the summer of 1943, Colonel Cutler discussed the blood program in the theater in the light of the British experience and practices and on the basis of Captain Hardin's experience as U.S. liaison supply officer at the British Blood Supply Depot. The plan was as follows:

1. The source of the blood was to be "suitable [meaning type O] volunteer donors from SOS units."

2. Base section commanders would cause unit commanders under their jurisdiction to obtain lists of men with type O blood. They would also designate hospitals to be used as bleeding centers.

3. On call from the commanding general, SOS base section commanders would assemble the required number of donors at specified centers, where bleeding teams dispatched from the medical blood depot would withdraw 400 cc. of blood from each donor.

In an undated memorandum for the record apparently prepared about this time, Colonel Cutler set forth additional aspects of the blood program for the theater. It seemed desirable to have for casualties in the field additional supplies of refrigerated fresh whole blood originating either in the United States or from SOS troops in the United Kingdom. If this plan were adopted, it would require:

1. The setting up of bleeding centers either in the United Kingdom or the Zone of Interior.

2. The transportation of blood in refrigerated airplanes to the Continent.

3. The use of refrigerated trucks to take the blood up the line to medical installations, which must have facilities to provide refrigerated storage for it.

In essence the plan outlined in this memorandum, presumably written in early August 1943, was the plan by which, a year later, blood began to be provided for the European theater.

Later in the same memorandum, Colonel Cutler pointed out that unless and until air supremacy was established, so that blood could be flown to the Continent from the United Kingdom, whatever blood was needed would have to be obtained on the hoof, from SOS troops or walking wounded.

Colonel Cutler did not again mention the possibility of securing blood from the United States in a number of additional memorandums on transfusion during the remainder of the year, nor was this possibility mentioned in other memorandums or at meetings dealing with blood supply and the blood bank.

November -On 13 November 1943, in a memorandum for the record, Colonel Cutler (27) took the position that all general hospitals in the United Kingdom should either set up their own blood banks or "join in" with local British banks from which they could secure blood. The chief point, he said, was to have blood available. His final remark, that the chief point was to have

7Dr. Cutler's death shortly after the war has made it impossible to supply missing dates or settle certain other questions which have arisen in the preparation of this section. His official diary has proved a very useful source of information, but some entries, as might be expected, would benefit by clarification that cannot now be obtained.


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blood available, was an indication of the growing realization of the importance of this substance.

On this same date, Colonel Cutler also wrote Colonel Mason, Chief, Operations Division, Office of the Chief Surgeon, that he was concerned over what might happen if a major attack should begin and great numbers of casualties be brought to England in need of blood (28). On 18 November, Colonel Mason replied that plans for the distribution of whole blood provided for emergency supplies to station and general hospitals in the United Kingdom (29). Under normal circumstances, each hospital could provide enough blood from donors available in and about hospitals.

On 26 November 1943, General Hawley prepared a memorandum for the Commanding General, SOS, ETOUSA, in which he stated the need for whole blood for combat troops and for the establishment of a blood bank to be maintained with blood collected from SOS troops (30). He thought that blood should be provided as far forward as division clearing stations.

December -On 3 December 1943, Colonel Mason informed General Hawley that the blood bank which he desired to have established was now so completely planned that the service would be ready to function on D-day. Base section commands would be requested to set up panels of donors. Blood from the Zone of Interior was not mentioned.

On 18 December 1943, General Hawley again informed the Commanding General, SOS, ETOUSA, of the necessity for the provision of whole blood for combat troops in the theater (31). He emphasized that an unfailing source of whole blood would be necessary, but, in his recommendations for the transfusion service, he mentioned only voluntary donations from SOS troops. The possibility of supplying blood by plane from the Zone of Interior again was not mentioned.

1944

January-On 2 January 1944, the Commanding General, 1st Army Group, was informed by Headquarters, ETOUSA, that the provision of whole blood for combat casualties had been approved for all echelons down to and including division clearing stations (32). Whole blood would be considered an item of medical supply; it would be distributed through medical supply channels, and would be given the highest priority in transportation. Provision was made for equipment and personnel for a transfusion service for each army without requisition (p. 543).8

Upon the receipt of this communication, Colonel Kimbrough recommended that the chief consultants in medicine and surgery and the commanding officer of the 1st Medical Laboratory present to the Chief Surgeon a concrete plan for the operation of the stipulated transfusion service.

8With the conversion of the 152d Station Hospital to the theater blood bank, this provision was promptly abrogated. Also, although approval was given for the use of blood in clearing stations, it was seldom if ever provided in them because it was immediately available in platoons of field hospitals, and its use was more practical and more efficient in the hospitals.


480

On 2 January 1944, Maj. (later Lt. Col.) Richard V. Ebert, MC, submitted to the Chief Surgeon, ETOUSA, for the attention of Colonel Cutler, the agenda of a meeting he had attended on 6 December 1943 in the Office of The Surgeon General in Washington (p. 194). It was shortly before this meeting that The Surgeon General had declined to consider the collection of blood in the United States for the European theater and its transportation thereto by air (p. 465).

It was The Surgeon General's opinion, reported Major Ebert, that shocked patients could be suitably treated with plasma and that whole blood was therefore not necessary in most forward areas, certainly not forward of evacuation or field hospitals. It was the sense of this meeting that transfusion services should be established in each hospital and that these services should be responsible for everything connected with transfusions, including the formation of a donor panel.

March-As D-day drew nearer, unsettling thoughts about the adequacy of the arrangements for supplying blood for wounded casualties apparently began to cross the minds of those responsible for their care.

On 31 March 1944, Colonel Cutler wrote to Colonel Kimbrough that he had discussed with Colonel Muckenfuss and Major Hardin the possible extension of blood production. He believed that present capacities were fairly satisfactory, but he was having a memorandum prepared showing what would be needed in the way of personnel and equipment if they had to be expanded (33). The trial distribution of blood to hospitals in East Anglia, mentioned in this memorandum as to be held shortly, never took place.

April.-On 1 April 1944, at a meeting at the blood bank at Salisbury (34), the question of the capacity of the bank to furnish sufficient quantities of blood for operations on the Continent was discussed in great detail by the committee responsible for the blood program.9

When planning began in the summer of 1943, it was difficult to estimate the probable requirements for the invasion of the Continent because there were no experience tables to furnish guidance. Figures from North Africa were not yet available. The only definitive figures, in fact, were those reported by the British Blood Transfusion Service, which had operated with the Middle East command. They indicated that a ratio of 1 pint of blood for each 10 casualties would be adequate, and planning was begun on this basis.

For D+90, the period on which all planning for Operation OVERLORD was based, casualties on the Continent were expected to average 1,875 per day, which would mean, allowing 500 cc. of blood for each casualty in shock (estimated at 20 percent of the total number), that 200 pints of blood per day would be required.

Bank personnel believed that it would be possible to collect 200 pints of blood a day for 90 days, a total of 18,000 pints, and to collect a maximum of

9Unless otherwise identified, material in the following pages is derived from the official diary of the ETOUSA Blood Bank (34).


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600 pints per day for shorter periods. Storage space for 3,000 pints of blood was available, and the blood could be stored for a maximum period of 14 days before use.

The original plan was to provide 1,000 pints of blood between D-day and D+5. On D+6, 600 pints would be provided, and on the following day, from 200 to 600 pints. These quantities were considered in excess of the amounts likely to be required, and it would therefore not be necessary for the collecting teams to work at full capacity during this period. Each team could collect 120 pints of blood daily if a constant stream of donors were made available.

A single citation of statistics will make clear how far the actualities of combat were from the original planning (35). By 20 July 1944, 46,918 casualties had been admitted to medical installations of the First U.S. Army on the far shore, and 15,250 pints of blood had been delivered, a ratio of 1 pint to 3.06 wounded. Of the total number of wounded up to this date, 22,768 were seriously wounded, which changes the ratio of pints of whole blood to wounded to 1:1.48. Later, the ratio was to be 1:1.

The plans called for the bleeding of base troops (SOS and Air Forces). In late summer of 1943, a study of the SOS troop basis indicated that by D-day, which it was then thought would be in May 1944, there would be approximately 350,000 officers and enlisted men in the theater. It was estimated that in this group there would be a minimum of 80,000 men with type O blood, of whom some 60,000 would be available as donors. Each of them would donate four times. On the basis of these estimates, the capacity of the panel was set at 240,000 pints annually.

At the 1 April 1944 conference at Salisbury, new figures were quoted that had been secured by General Hawley in a teleprinter conversation with the Office of the Adjutant General, on 7 March 1944. They cast serious doubts upon these estimates. In view of the alarming reduction in the capacity of the blood donor panel which had been indicated by General Hawley's information as to troop strengths and troop movements, it was recommended that steps be taken immediately to plan for the acquisition of whole blood, type O, from the United States. The committee did not consider that even the establishment of a panel of donors from the Eighth Air Force would solve the problem. It also recommended that the blood bank at once increase its normal daily processing capacity to a minimum of 500 pints.

At another conference on blood supply on 5 April 1944, Colonel Kimbrough again called attention to the plans previously described for flying blood from the United States to the European theater. In a report to General Hawley, Colonel Kimbrough repeated this recommendation and recommended its implementation, for a number of reasons (36): The donor response from SOS units had been extremely disappointing; not more than 20 percent of the troops had volunteered. As the invasion would proceed and more and more troops would be sent to the Continent, the pool of donors in the United Kingdom would become progressively smaller, though it would increase in forward


482

areas, where blood procured on the hoof might perhaps be taken into consideration. Finally, the capacity of the blood bank was then only 200 pints daily, against an estimated total daily requirement after D-day of 500 pints. In view of reports from the Mediterranean theater of the increasing use of whole blood, it was highly probable that this estimate was too low. On the whole, however, it was thought that a ratio of three units of plasma to one of blood, or even five units of plasma to one of blood, would be adequate.10

When discussions of the blood program began in the European theater, the prewar ideas of the total value of plasma were simply carried over into the planning, just as they had been in the North African theater in 1942 and early 1943. In the Fifth U.S. Army, however, the experience had not borne out the concept that plasma could be substituted for whole blood (37, 38). At the present time, large quantities of blood, sometimes as much as 4,000 cc., were being used, the objective being to bring the red blood cell count up to 4 million per cu. mm. within 12 to 24 hours after wounding.

The experience of the North African theater gradually became known in the European theater, but its full impact was not realized until Col. Thomas J. Hartford, MC, Executive Officer, Office of the Surgeon, 1st Army Group, returned from a trip to Italy in March 1944 (39). He brought the disquieting news for those planning the blood supply for the invasion of the Continent that 1 pint of whole blood was now considered necessary for each 2.2 wounded (table 17) rather than the 1:8 or 1:10 originally estimated. This seemed to Colonel Kimbrough an excessive estimate which required reconsideration, though he was not in a position to criticize data obtained from battlefield experience.

In his 6 April report to General Hawley, Colonel Kimbrough analyzed present plans for the blood supply for the invasion as follows: On D-day, from previous collections, 4,200 pints would be available. For the next 7 days, the bank would collect 500 pints daily. After this time, it was anticipated that the daily blood supply from the bank could not exceed 200 pints.

The amounts of blood required by the new estimates, Colonel Kimbrough concluded, could not possibly be met with the present facilities of the ETOUSA Blood Bank or the limited pool of donors available. A stronger directive was being prepared in the hope of obtaining a larger panel of donors. It might be necessary to offer to pay the troops for their donations, or to give them whisky as an incentive. It might also be necessary to build a laboratory on the far shore, to care for the increased needs. In Colonel Muckenfuss' opinion, this could not be done in less than 90 days. The solution of the problem, however, seemed to be the procurement of blood from the Zone of Interior.

At another conference on 7 April 1944, a somewhat more optimistic spirit prevailed. It was hoped that a second letter to base section commanders from Headquarters, SOS, would inspire more donors to contribute. With an improved donor response, and with the period immediately after D-day provided

10Additional details of the 5 April 1944 conference are discussed with the ETOUSA Blood Bank, in the section concerned with planning for Operation OVERLORD.


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TABLE 17.-Use of blood by U.S. troops in Italy, 1 September 1943-25 February 19441

Unit and period of time

Casualties


Transfusions

Ratio

Evacuation hospitals

13,763

3,060

1:4.5

Field hospitals

1,044

1,571

1.5:1


Total

14,807

4,631

1:3.2

94th Evacuation Hospital:

 

 

 


23 September-9 October

411

56

1:8


13 October-6 November

499

150

1:3.3


7 November-12 January

1,863

840

1:2.2

Anzio beachhead, 22 January-25 February:

 

 

 


British

3,527

21,262

1:2.79


United States

4,523

22,456

1:1.85

1Plasma usually used: 3.54 units plasma to 1 pint blood.
2Bottles of blood used.

NOTE.-The ratio is actually blood to total casualties. While I was there, they were sending 100 bottles of blood a day to Anzio. The amount used, especially early, does not represent the amount required or desired but in many instances the amount available. Another fact that is significant is that high explosives accounted for 827 of the battle casualties admitted to any of the hospitals during the period September-January in this theater.-T. J. H.
Source: Official Diary, 152d Station Hospital Blood Bank, 1944-45.

for, it was thought that enough blood could be collected daily to satisfy the estimated demand until D+60. Then, additional teams and donors would have to be added.

An extended discussion of equipment brought out another difficulty: The normal 200-pints-per-day capacity of the blood bank could be increased to 500 to 600 pints for a few days, but by the 10th day, at the latest, the output would have to be reduced because the limited supply of giving sets could not be rotated fast enough.

Colonel Kimbrough was also concerned about the longevity of whole blood with the preservatives then in use. The average useful life was not more than 10 days, and he had been informed that, even under optimum conditions, blood could not be delivered to the front in less than 10 days after it had been drawn.

General Hawley, who was kept informed of these various developments, expressed himself as much concerned over them. In view of the limited useful life of whole blood and the impossibility of its reaching the front in less than that lifespan (10 days), he did not think the average usable life of blood at the front could be more than 6 days, and it would be safer to estimate it as 5 days. From the practical standpoint, this meant that the blood bank must be able to replace the total demands at the front every 8 days. In spite of Colonel Kimbrough's opinion that this could be done, General Hawley doubted it.

Table 18 contains the estimates prepared in response to a request from the Planning Branch, Operations Division, Office of the Chief Surgeon, on 6 April 1944 for "firm figures" for the blood requirements from D-day to D+90 (39).


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TABLE 18.-Estimated demands for whole blood, 29 April 19441

Period of time

Casualties

Estimated demands

Total

Daily

 

Number

Pints

Pints

D-day to D+3

16,879

3,376

844

D+4 to D+10

4,770

954

136


Total

21,649

4,330

394

D+11 to D+20

9,907

1,981

198

D+21 to D+30

14,637

2,927

293


Total

24,544

4,908

245

D+31 to D+45

20,895

4,179

279

D+46 to D+60

23,280

4,656

310


Total

44,175

8,835

295

D+61 to D+75

20,513

4,103

273

D+76 to D+90

22,048

4,410

294


Total

42,561

8,513

284

D-day to D+90

132,929

26,586

292.1

D+4 to D+90

116,050

23,210

266.7

1One pint of whole blood estimated for each five casualties.

On 12 April 1944, in a memorandum to General Hawley, Colonel Cutler recommended that donors be paid $10 each, as had been done in Italy. If this plan to increase donations were not adopted, he thought that supplemental supplies of blood must be flown to the European theater from the Zone of Interior.

D-DAY AND AFTER

Blood was sent from the United Kingdom to the Continent on D-day and during the first days of the invasion through the ETOUSA Blood Bank according to the plans prepared in January 1944. It was in reasonably adequate supply, at least in the light of the standards of usage of blood which then prevailed.

24 June 1944

On 24 June, the situation changed. Up to this time, in accordance with the original planning (40), the bank had supplied 250 pints of blood a day to the First U.S. Army. As of this date, an additional 250 pints per day was


485

"imperatively" requested for this Army. The Supply Division had also been informed that a meeting of responsible medical officers would shortly be held on the far shore to determine a new pattern of requests for whole blood. It was thought that at least 500 pints per day would be requested.

Colonel Cutler was very much pleased with the early operations of the blood bank. Late in June, he wrote in his official diary (23):

The tremendous demand for blood completely justifies the establishment of the blood bank and from reports and observations it is clear we must have saved life by the establishment of an E.T.O. blood bank. * * * Lieutenant Reardon of the blood bank is now on the far-shore. He has a large Navy-type refrigerator buried in the ground and (8) trucks (each taking 80 pints) are working well with the First Army delivering blood at this time. Almost all LST's and hospital carriers either gave up their blood to people on the far-shore or used it up on casualties on the trip back. Little was actually wasted. The major difficulty about blood has been the return of kits and sets and marmite jars.

On 17 September 1958, General Hawley annotated this entry in Colonel Cutler's diary with the statement that each outbound LST (landing ship, tank) carried twice the amount of blood estimated that it would need on its return trip (23). The excess was unloaded on the far beach.

2 July 1944

Although the Third U.S. Army was not to become operational until 1 August, some medical units later assigned to it were serving in France with the First U.S. Army, and on 2 July 1944, a communication concerning planned needs for blood for this (the Third U.S.) Army was sent from its headquarters to the Commanding General, ETOUSA, for General Hawley's attention. In this communication, it was stated that the original allocations of blood were now considered inadequate for anticipated demands in forthcoming operations, especially in the light of the amounts presently being consumed by the First U.S. Army. These amounts were not considered excessive. The planned Third U.S. Army allocation was 150 pints daily from D+29 to D+32, 200 pints daily until D+39, and 350 pints daily until D+90. It was urgently requested that these allotments be increased to 300, 400, and 550 pints daily, respectively, for the periods specified.

There was still no universal agreement, however, that blood was needed in such quantities. On 2 July 1944, Colonel Cutler wrote Colonel Kimbrough that from his observations on the far shore and his studies of battle casualty rates, he thought that, if blood were used carefully, it would not be needed in these amounts for two reasons (41):

1. In November 1943, Colonel Churchill had estimated that 20 percent of battle casualties would need resuscitation. In the European theater, casualties in invasion troops through 25 June had numbered 24,939, less than a thousand a day. Of every thousand casualties, not more than 10 percent, 100 men, would require blood. If each of them needed 2 pints, that would make the requirement 200 pints per day for each thousand casualties. Some patients might need additional transfusions because of secondary hemorrhage


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or for other reasons, but an extra 200 pints of blood per day should be ample for this group. Thus, with a casualty list of 1,000 per day, 400 pints daily should meet the requirements of the First U.S. Army.

2. Colonel Cutler had observed while on the far shore that very little plasma was being used, though, theoretically, a casualty's protein requirements could be met by it.

Colonel Cutler had discussed these matters with Col. Joseph A. Crisler, Jr., MC, Consultant in Surgery, First U.S. Army, and had reminded him that under conditions of unusual stress, blood could be secured from walking wounded; special donor sets had been provided for this purpose.11

12 July 1944

On 12 July 1944, Colonel Kimbrough wrote General Hawley that the ETOUSA Blood Bank was supplying 500 pints of whole blood daily to the Continent and was utilizing its panel of donors to full capacity (42). It was also planning to secure donors from the Air Forces, though the number from this source would not be large, since only ground troops could be used. Reports from the Continent indicated that blood was being used economically. The most optimistic estimates of the ultimate capacity of the ETOUSA panel of donors was 700 pints of blood daily. With increased operations on the Continent, this amount would not meet the demand.

Colonel Kimbrough therefore recommended:

1. That plans be laid on to obtain whole blood for transfusion from the Zone of Interior.

2. That facilities of the ETOUSA Blood Bank be used to distribute blood received from the Zone of Interior and delivered from that point to the Armies. The bank already had a well-organized distribution system, and its utilization would avoid duplication of facilities.

24 July-1 August 1944

As the scarcity of blood became increasingly serious, a system of allocations was set up:

1. After the breakthrough at Saint-Lô, on 24 July 1944, daily allocations of available blood were made to medical units of the First U.S. Army.

2. This plan was continued until 1 August 1944. Then, until 25 August, when supplies from the Zone of Interior began to arrive, Colonel Mason conferred daily with Col. Alvin L. Gorby, MC, Surgeon, 12th Army Group, to be sure that the dwindling supplies of blood were delivered to the areas in which the largest numbers of casualties were anticipated.

In other words, by the end of July, the demand for blood had far outpaced the supply. Its increased use for combat casualties and the stepped-up

11Early in 1942, it had been concluded in the Zone of Interior that bleeding of walking wounded was completely unrealistic. It also was considered especially objectionable in view of the large numbers of 4-F's in the United States who could act as donors. It proved impractical in combat zones in all theaters.


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operations on the Continent had combined to produce exactly the shortages in the supply that the planners of the program had feared might occur and that many of them had thought could be avoided only if blood were procured from the Zone of Interior.

On 28 July 1944, Lt. Col. (later Col.) Robert M. Zollinger, MC, Surgical Consultant, ETOUSA, wrote the Surgeon, Forward Echelon, Headquarters, Communications Zone, concerning the amounts of blood necessary for combat casualties (43). Recommendations had been made in the "Manual of Therapy, European Theater of Operations," as well as elsewhere, that blood be given in the ratio of one part blood to two parts plasma. Current requirements, however, were more nearly 1:1. After visiting field and evacuation hospitals, he was convinced that this latter ratio might be correct, especially in field hospital platoons, near the frontlines. Large amounts of blood were unquestionably needed. If the requirements sometimes seemed excessive, a partial explanation was the backlog of patients often awaiting operation. They had been prepared for operation by shock teams, but because of the press of more urgent casualties, their timelag was lengthened, and it was often necessary to continue the administration of blood and plasma or to repeat it. This contingency had probably not been taken into consideration in pre-D-day estimates of the blood that would be needed.

On 31 July 1944, the day before the Third U.S. Army was committed, Colonel Kimbrough again notified General Hawley of shortages of blood on the Continent (44). Current demands were for approximately 1,000 pints per day. The capacity of the SOS panel of donors in the United Kingdom was now about 400 pints daily. A supplemental panel from certain elements of the Air Forces contributed about 250 pints daily. The daily deficit-more than 300 pints-could not possibly be met by donations on the Continent, and the demand for blood would increase as operations became intensified.

Colonel Kimbrough therefore recommended to General Hawley that plans be made to obtain a thousand pints of whole blood daily from the Zone of Interior by air transport.

IMPLEMENTATION OF THE WHOLE BLOOD PROPOSAL

July-August 1944

31 July.-General Hawley had not waited for Colonel Kimbrough's second communication to take action. On 31 July 1944, his executive officer requested the Personnel Division, Office of the Chief Surgeon, to arrange air transportation to the Zone of Interior for Colonel Cutler, Major Hardin, and Col. William F. MacFee, MC, Commanding Officer, 2d Evacuation Hospital, for stays of 10 days, 6 weeks, and 21 days respectively (45). The trip was essential, the request read, to initiate and implement a supply of a thousand pints of whole blood daily from the United States to the United Kingdom.


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When the question was raised whether it was necessary for all three officers to make the trip, General Hawley's reply was immediate and unequivocal (46). It was. Colonel Cutler, as Chief Surgical Consultant in the theater, must be present at the formulation of the program. Colonel MacFee, an experienced surgeon, was in command of an active evacuation hospital supporting the First U.S. Army. He had been in France since D-day and could give The Surgeon General a firsthand account of blood requirements on the Continent. Major Hardin was in charge of the blood bank, which had about reached the limit of its capacity; armies in the field were requesting more blood than could possibly be supplied by it. The matter could not be handled by phone or radiogram. Highly technical details had to be arranged, including adaptation of the transfusion set used in the Zone of Interior to use in the European theater. The matter was regarded as "of the greatest urgency" and "all three officers" must be returned to the United States.

2 August-On 2 August 1944, a radiogram was sent through channels from General Hawley to The Surgeon General, U.S. Army, as follows (47):

Burden is being imposed that the ETO Blood Bank cannot meet in the demand for whole blood for the forces fighting in France. That blood is necessary and is saving lives, all are convinced. It is believed necessary that daily air shipment of 1000 pints be sent. To coordinate this matter, returning to the United States are Colonel Cutler, Colonel William MacFee, and Major Hardin.

5 August.-On 5 August, General Hawley followed up this radiogram with an explanatory letter to General Kirk (48). The economy of the use of blood, he wrote, had been thoroughly investigated. Blood was not being used extravagantly. The fact was inescapable that its use was hastening recovery and saving lives.

The capacity of the ETOUSA Blood Bank, General Hawley continued, was set at 300 pints daily, but from D-day to D+50, it had delivered an average of 480 pints daily. Its capacity was being built up to 500 pints daily, but this would not be enough as troop strength increased.

The Air Transport Command was prepared to put on one or two planes daily, as necessary, to fly the blood from the United States. The Troop Carrier Command would deliver it by plane direct from Prestwick, Scotland, where it would be landed, to the Continent, and it would thus be in France within 48 hours after it had left the United States.

General Hawley hoped that a small amount of the blood collected for plasma could be diverted to the European theater as whole blood without endangering the plasma program. No publicity need attend the diversion, though perhaps it might stimulate donations if the donors knew that the blood they gave might be in the veins of a soldier in France within 3 days after it was collected.

When the question of supplying blood to Europe from the Zone of Interior was first raised, as Colonel Cutler noted in his official diary (23), General Hawley was concerned about the length of time it would take to get the blood to England. He thought that there would be a minimum of 72 hours after it


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was collected before it could leave the Zone of Interior. The whole project would be futile if the blood did not have sufficient life after its arrival in the United Kingdom. There was an extended discussion of this point in a meeting of his consultants on 28 July 1944, but he was finally convinced, when the procedures to be employed in the Zone of Interior were explained to him, including an airlift to the United Kingdom, that the program was feasible. "The Surgeon General," he said, "is definitely opposed to it, but I am willing to put it up to him." At this time, he was already planning to send Colonel Cutler, Colonel MacFee, and Major Hardin to the United States to discuss the plan.

11 August-General Kirk replied to General Hawley's letter of 5 August on 11 August 1944 (49). Immediately after receiving it the previous day, he had had a conference with Maj. Gen. George F. Lull, Brig. Gen. Raymond W. Bliss, and General Rankin.

All three of these officers believed that within 10 days it would be possible to begin shipping 500 pints of blood daily to the European theater. It would be sent in Alsever's solution, which would bring the volume to 1 quart. The blood would be good for 30 days12 and would be shipped without refrigeration.13 The safety of this method had been tested by flying blood to Prestwick and to San Francisco without harm to it (p. 209).

13 August-On 13 August, General Kirk sent General Hawley the following radiogram through channels (50):

Whole blood is subject. This office prepared to ship 258 pints daily for first week commencing 21 August. This amount will increase to 500 as blood becomes available. Shipments will be made without refrigeration. Is sufficient refrigeration available in theater to accommodate shipments? Estimated weight first shipment 1200 pounds and 387 cubic feet. Request air priority and shipping instructions furnished this office. Request immediate reply.

COMMENT

The reversal of General Kirk's previous refusal to consider plans for shipping blood overseas followed his visit to the Mediterranean theater the first week of July 1944. He was influenced, one may speculate, by his observations there. When he visited the theater blood bank at the 15th Medical General Laboratory, he was given a brief statement of its organization and activities: Between 23 February 1944, when the first shipment was made to the Anzio beachhead, and 6 July 1944, a total of 16,574 units had been supplied to the Fifth U.S. Army. This amount, the report stated, represented over 9 tons of fresh human blood, the cells of which had been kept potent by careful handling and refrigeration. The report also included details of the selection

12This should be 21 days.
13Here and elsewhere, the term "without refrigeration" is somewhat misleading. It was only during the actual flight time that blood sent overseas to Europe was not under refrigeration. It was placed under refrigeration as soon as it was drawn, was kept under refrigeration until it was placed on the plane, was placed in a refrigerator if the plane was on the ground for more than a brief period en route, and was again placed under refrigeration as soon as it was taken off the plane. As a matter of fact, the temperature of the blood changed no more than 6° F. during the period it was without refrigeration on the plane (p. 211).


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of donors, the processing of blood, and the reservation of high-titer group O blood for O type casualties. The memorandum ended with the statement that an abundant supply of whole blood had enabled surgeons in forward hospitals to save the lives of desperately wounded soldiers by operations previously considered too dangerous to be undertaken.

The chronicle of the oversea blood program now moves to its implementation in the Zone of Interior.

Part IV. Definitive Actions in the Zone of Interior for an Oversea Transfusion Service

REVIVAL OF PROPOSAL FOR AIRLIFT OF BLOOD TO EUROPE

As reports from Europe began to indicate an increasing need for whole blood for combat casualties, numerous discussions were held in the Surgery Division, Office of The Surgeon General, to initiate action in anticipation of the airlift which now seemed inevitable in spite of the earlier rejection of the plan by General Kirk.

On 3 August 1944, General Rankin sent a memorandum to The Surgeon General stressing the urgent need for blood in the European theater and outlining two plans by which it might be procured from the Zone of Interior (51):

1. Whole blood could be secured from Red Cross donor centers.

2. Red blood cells could be provided from plasma processing centers. The use of red blood cell suspensions for transfusion had been well established, but there were certain practical difficulties in the way of utilizing this source of blood for the immediate needs of the European theater. The chief difficulty concerned the bleeding bottle then in use.

Since it was quite certain that these difficulties could be overcome, it might ultimately be desirable to institute this second plan, which would provide red blood cell suspensions without interference with the blood program now in operation. In view of the urgency of the situation, however, it seemed wisest to institute the first plan. It could be put into operation, and delivery of blood could be begun, within 7 to 10 days after the airlift was authorized.

Only type O blood would be used. It would be obtained, after typing of donors, at the Washington and New York blood donor centers. The blood would be packed in cardboard containers and shipped in unrefrigerated planes to the European theater. Blood prepared with available equipment by the procedure to be outlined could be safely used for as long as 30 days after it was collected. It was thought that the combined output of the Washington and New York centers would provide an airlift of 500 pints of blood daily.

The plan proposed would be implemented as follows:

1. Personnel. Three technicians would be provided at each bleeding center by the Blood Research Division, Army Medical School, and the Navy. They would perform the typing, grouping, and serologic tests. Five or six untrained workers would be provided at


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each center, either by the Red Cross or the Army, to clean and prepare the collecting sets.

2. Equipment. This could consist of:

a. Bottles of 1,000-cc. capacity, each containing 500 cc. of Alsever's solution. Each center would be provided with 500 bottles per day. At the present time, 3,500 bottles could be obtained. Another 5,000 could be obtained within a week, and thereafter the supply would be unlimited.14

b. Donor bleeding sets. Each center would need an initial supply of approximately 1,000 sets, which could be obtained immediately from Army depots. Since the sets could be cleaned and reused, the initial supply would be adequate.

c. Typing sera and equipment for serologic testing. Adequate supplies of both items would be furnished by the Blood Research Division, Army Medical School.

d. Shipping containers. The cardboard containers in which the bottles of blood left the Red Cross blood donor centers could be used for packing the blood, six bottles to a container, and transporting it by plane. The packaging would be done at the blood donor centers. Refrigeration during the flight was desirable but in the emergency not considered absolutely essential (p. 209). An effort would be made to develop a suitable insulated container for shipping purposes.

e. Equipment for administering the blood. Since this was standard equipment, it would be presumed that it would be available in the oversea theater.

3. Procedure. This would be as follows:

a. Each donor would be tentatively typed at the hemoglobin stations of the Red Cross blood donor centers.

b. As the donor entered the bleeding room, the typing would be read.

c. Each type O donor would be bled into the special prechilled bottles containing Alsever's solution. All other donors would be bled into the usual Red Cross collection bottles which contained citrate solution and were used in the procurement of blood for the plasma and albumin programs.

d. Grouping would be confirmed from the clotted blood sent to the laboratory of the donor center.

e. Bottles of confirmed type O blood would be placed in cardboard containers and stored immediately in the refrigerator at the Red Cross center until a sufficient quantity had been accumulated for shipment. Additional refrigerators were available and could be supplied as needed.

f. A schedule would be developed with the Air Transport Command for delivery of the blood from the centers to the planes by the Red Cross Transport Service.

This plan, with minor modifications, was the same plan proposed and rejected in December 1943 (p. 462). It was also, with modifications, particularly the change to ACD solution and refrigeration in April 1945, the plan by which blood was shipped to Europe during the rest of the war.

At this time-the first week of August 1944-the first definite request was received from the European theater for shipments of whole blood, and the lines of development in that theater and in the Zone of Interior began to merge.

PREPARATIONS FOR AIRLIFT

Activities were intensified in the Surgery Division, Office of The Surgeon General, as soon as the request from ETOUSA was received and the decision

14Bottles large enough to hold the necessary amounts of Alsever's solution were not in production when the request to fly blood to the European theater was received in the Office of The Surgeon General. The manufacturers, however, sensing the urgency of the situation, provided them in a crash operation typical of the part American industry played in the entire blood-plasma program.


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was made to ship blood to the European theater. Supplies of various kinds had to be procured, and additional personnel were necessary for the collecting centers. Action was taken at a series of conferences.

10 August 1944

The conference held on 10 August 1944 (52), to which General Kirk had referred in his letter of 11 August to General Hawley, was attended by General Rankin; Colonel Carter; Captain Newhouser; Colonel Kendrick; Maj. Earl S. Taylor, MC, Technical Consultant, Volunteer Donor Service, American Red Cross; and Lt. (later Lt. Cdr.) Henry Blake, MC, USN, Assistant Technical Consultant; Maj. (later Lt. Col.) Oscar B. Griggs, MC, Supply Service, OTSG, and Lt. Col. John J. Pelosi, MC, Supply Service, OTSG; and Maj. (later Lt. Col.) Frederic N. Schwartz, MAC, Operations Officer, Blood Plasma Branch, Surgery Division, OTSG.

The business of this conference was to make the plans for the shipment of whole blood from the Zone of Interior to the European theater. In general, the plan used was the one outlined by General Rankin in his memorandum to The Surgeon General on 3 August 1944. As the plan was finally adopted, the details were as follows:

1. The American Red Cross Blood Donor Service would be responsible for procuring blood in Washington, New York, or other centers which might be required to provide blood in the quantities needed by the oversea theaters. Initially, 180 to 390 bleedings would be obtained daily in New York, and 78 to 180 in Washington. If more blood was needed, other centers would be brought into the program.

2. Equipment required for the airlift overseas would include:

a. Sterile, 1,000-cc. vacuum bottles each containing 500 cc. of Alsever's solution.
b. Sterile, expendable donor sets put up in aluminum tubes.
c. Sterile, expendable dispensing sets, similarly prepared.
d. Typing sera.
e. Supplies for the Kahn test, including a centrifuge.
f. Stencils for classifying and numbering bloods for shipment.
g. Packaging supplies, including brown paper, paper tape, and shipping tags.

3. Personnel for each donor center would consist of a medical officer qualified to operate a blood bank and three technicians, two for typing blood and one for shipping it. The personnel to operate the whole blood service would be provided by the Personnel Branch, Office of The Surgeon General. Personnel from the Army Medical School would establish the whole blood station in New York and serve there temporarily. Colonel Kendrick, Special Representative on Blood and Plasma Transfusion, Office of The Surgeon General, would be responsible for the whole blood operation.

4. Blood would be transported from the donor center to the airport by the American Red Cross or under some other arrangement agreed upon by the Army and the Red Cross. The blood would be refrigerated from collection to emplanement. The Red Cross was installing large refrigerators in the centers selected to supply the blood, so that this requirement could be met.

5. The request to the Army Transport Command for the shipment of blood to the European theater must originate from that theater. (This request had been made on 1 August by General Hawley's office and had been granted at once.)

6. The care, refrigeration, and transshipment of blood after it arrived overseas was the responsibility of the European theater. The theater had been asked to notify the Office of


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The Surgeon General when refrigeration would be available there and when the initial shipment of blood could be received. The whole blood procurement station in New York would be ready to begin shipments on 21 August 1944.

7. The European theater was also requested to ask that a medical officer accompany a shipment of blood from the collecting center in the Zone of Interior to the installation in the European theater in which the blood was to be used, in order to investigate all the problems concerned with the shipping of whole blood overseas and also to study the operation of blood banks in the European theater. (Colonel Kendrick was given this assignment (p. 495).

The request for blood from the European theater had been for 1,000 pints per day. It was agreed that every effort would be made to supply this quantity, but it was recognized that it might not be feasible at first to send more than 750 pints daily, because of the limited capacities of bleeding centers on the east coast. If the quota could not be met, perhaps the deficit could be made up with resuspended red cells (p. 490).

It was agreed at this meeting that, beginning on 21 August 1944, 250 pints of blood would be shipped daily for a week. No definite commitments were made for the next week, but it was hoped that the quantity could be stepped up to 500 pints daily on 28 August, to 750 pints on 4 September, and to 1,000 pints daily after 11 September.

At the conclusion of this conference, The Surgeon General stated that if operating surgeons in the European theater desired whole blood, they should certainly have it, and every effort would be made to provide what they had requested.

15 August 1944

Another conference held on 15 August 1944 in the Surgery Division, Office of The Surgeon General (53), was attended by General Rankin, Colonel Carter, Colonel Kendrick, Major Schwartz, and others from this office and from the American Red Cross concerned with supply and procurement. The meeting was also attended by Colonel Cutler, Colonel MacFee, and Major Hardin, who had just arrived in the United States. Since consent to the shipment of blood to the European theater had already been secured from The Surgeon General when these officers arrived, the discussion chiefly concerned the details of the arrangements for shipping blood. Colonel Cutler was particularly concerned with two points, (1) the lack of refrigeration on the transatlantic flight; and (2) the use of Alsever's solution. This was no time, he said, to experiment on the American soldier.

The discussion on refrigeration at this meeting is included under the general heading of refrigeration (p. 209). The discussion on the use of Alsever's solution as a preservative, to which Colonel Cutler also took exception, is similarly discussed under the heading of preservatives (p. 229).

At this conference, Colonel Cutler was told that, somewhat later, the European theater would be supplied with resuspended red blood cells from type O blood. They were available in abundance, as a byproduct of the plasma program, and it was thought that they could be used to advantage. They would be put up in 600-cc. Baxter bottles and would be flown to Prestwick,


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being treated en route and after receipt exactly as whole blood was treated. It was planned to send the first shipment with Major Hardin on his return to Europe, so that he could distribute the material to hospitals whose personnel were suitably trained in the use of blood in this form. Several trial runs would be necessary before regular shipments were begun.15

It was agreed at this meeting that the Army would establish three or four collecting centers for the procurement of blood for the European theater, beginning with the American Red Cross blood donor centers in Boston, New York, and Washington. Lieutenant Blake thought as much as 750 pints daily could be obtained from these three centers. To increase the amount to 1,000 pints per day, it would be necessary to establish another collecting center in one of the Red Cross donor centers in the Midwest. It would be impossible to meet the commitments for whole blood, plasma, and albumin from the quotas presently available on the east coast.

The blood sent to the European theater would be tested serologically and grouped. Every effort would be made to send only group O blood, but retesting before using was advisable. Since this would entail entering the bottle and drawing out a small sample, it was suggested that the tests be made within 3 hours of the time the blood was to be used, to reduce the possibility of contamination.

FIRST SHIPMENTS

These various plans were carried out, and substantially as contemplated. The first shipment of blood, 258 bottles, was flown from the Zone of Interior to Prestwick (map 2), on 21 August. It was transshipped by refrigerated truck to Salisbury, the base of the European Theater Blood Bank; and thence was flown to France, where it arrived on 27 August 1944. The shipment from the Zone of Interior on 24 August consisted of 180 bottles, and the shipment on 25 August, of 336 bottles.

Refrigeration facilities at Prestwick could care for 222 cartons of blood, each containing 6 bottles. The plan was to keep the blood there under refrigeration at least 4 hours and to use it for periods up to 10 days.

When Colonel Cutler arrived from the United States at Prestwick on 25 August, 350 pints of blood in Alsever's solution were on the plane with him, and the blood was still cool at the end of the flight (23). Giving sets, however, were not included.

The following day, Col. S. B. Hays, MC, Chief, Supply Division, Office of the Chief Surgeon, sent a radiogram to PEMBARK (port of embarkation) New York, stating that the first shipments of whole blood had arrived in good condition but that they had not included recipient sets (filter, tubing, needle), as

15In spite of the abundance of red blood cells as a byproduct of the plasma program and the proved usefulness of blood in this form (p. 312), this plan proved impractical. The cells could not be used safely for more than 5 days, which was an insufficient time to deliver them to using hospitals in the European theater. Thalhimer's method of using corn syrup as the diluent was developed too late to be useful, which is unfortunate, for it extended the longevity of packed red blood cells to 18 days.


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MAP 2.-Flight plan of airlift of blood to Prestwick, Scotland, and thence to the European Continent.

the plans had called for. The Surgeon General, on 31 August, replied that recipient sets were not presently available for the shipments but that they would be received within the next few days, as they were.

On 26 August, PEMBARK notified Supreme Headquarters, Allied Expeditionary Force, that air priority had been set up, effective on 1 September, for the daily shipment of whole blood to Europe in the amount of 2,250 pounds (class 1, medical).

On 28 August, according to orders requested on 20 August, Colonel Kendrick left the Zone of Interior with a large shipment of blood. The justification for the requested orders had been that it was simply not possible to put a system, however good it might be, on paper and expect it to work of itself. When the substance to be transported was as valuable as blood, it was essential to follow it up, make sure that it was properly handled at every point along the way, and also see that it was properly used. The account of Colonel Kendrick's trip appears under appropriate headings elsewhere.

On 24 September 1944, the Continental Section, ETOUSA Blood Bank, 152d Station Hospital, assumed the responsibility for the distribution of all blood on the Continent and continued to exercise this function until the end of the war (p. 515).

Shortly after the Continental Section had assumed this responsibility, steps were taken to have the blood flown directly from the United States to the


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Continent. Difficulties in storage and shipping facilities delayed the operation of the plan, and it was not until 15 October that the Air Transport Command began to fly blood directly to Orly Field, Paris.

Part V. The European Theater Blood Bank16

Section I. Establishment

PRELIMINARY PLANNING

After the Chief Surgeon, ETOUSA, General Hawley, directed, in July 1943, that plans be made to supply blood to forward hospitals in the combat zone, the task of implementing his instructions was assigned to the Operations Division of his office, of which Colonel Mason was chief. Colonel Mason served as chairman of the Whole Blood Service Committee, which also included Colonel Kimbrough, Colonel Cutler, Colonel Middleton, Col. Walter L. Perry, MC, Chief, Finance and Supply Division, and Captain Hardin, liaison officer with the British blood depot and later senior consultant in shock and transfusion.

This committee was promptly convened after receipt of General Hawley's instructions. After several preliminary conferences it requested, and received from him, approval of the following decisions, which were essential for future planning:

1. Whole blood, except in emergencies, would be reserved for medical units in the combat zone.

2. Whole blood would be made available as far forward in the combat zone as platoons of field hospitals attached to clearing stations of divisions.

3. The blood would be obtained from volunteer donors from Services of Supply units, who would be organized into a theater blood panel.

4. The blood used would be type O only. It would be preserved by the glucose-citrate solution devised by the Medical Research Council of Great Britain, would be kept under constant refrigeration, and would have an expiration period of 21 days from the date of collecting.

5. Whole blood would have the highest priority in transportation. This priority had been obtained from the Commanding General, Services of Supply, and had been confirmed by the theater commander.

6. The blood service would be operated by a theater unit, with subelements to be attached, as required, to major commands for operations.

ORGANIZATION AND FUNCTION

On 19 August 1943, after the decisions just listed had been approved by General Hawley, detailed planning for the blood bank began, with agreement

16Unless otherwise indicated, the material in this section is derived from the official histories of the 152d Station Hospital Blood Bank (54, 55); the official history of the 127th Station Hospital Blood Bank (56); Major Hardin's annual report on transfusion and shock to the Chief Consultant in Surgery, ETOUSA, dated January 1944 (57); and the published reports by Colonel Mason, on the planning and operation of the European Theater Blood Bank (58, 59).


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CHART 9.-Operations chart, Whole Blood Service, ETOUSA, Operations Division, Office of Chief Surgeon, 1943

first of all upon an operations chart (chart 9). The functions of the whole blood service were to be the procurement, processing, storage, and issue of whole blood. The organization responsible for these functions had to be tailored to fit the military requirements. The operations chart reflected this necessity by providing (1) a fixed depot for processing and storage of the blood and (2) advance mobile depots for its temporary storage and delivery.

Representatives of the Professional Services Division and their assistants developed the clinical policies for the use of blood. Captain Hardin, Colonel Muckenfuss, Commanding Officer, 1st Medical Laboratory, and their associates developed the technical procedures for the operation of the blood bank and for the training of bank personnel. They also prepared the lists of special equipment required. Colonel Perry and his associates worked with Colonel Mason in the development of the PROCO (projects for continental operations) mechanism by which equipment, vehicles, and other supplies were secured for these new and unusual operations, which were over and beyond T/E (table of equipment) provisions. The T/O (table of organization) for the new unit, the tactical operating procedure, and related instructions were prepared in the Operations Division, Office of the Chief Surgeon, ETOUSA. Colonel Mason, as chairman of the ad hoc committee, had the responsibility for coordination of


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the various phases of the plan, its consolidation into a single whole, and supervision of its initial implementation.

Organization of Proposed Unit

Since there was no unit in the Medical Department tables of organization which could meet, or be revised to meet, the needs of the proposed whole blood service, an entirely new organization was planned,17 as follows:

1. Headquarters.
2. Base depot section, which included personnel and equipment for bleeding teams.
3. Advance depots, Army type (two).
4. Advance depots, SOS type (two).

The 11 officers and 143 enlisted men in this organization would be attached for rations to nearby organizations, thus effecting a considerable saving in mess and housekeeping personnel and equipment.

The organization postulated was considered capable of operating a whole blood service for a theater force of two field armies, the communications zone, and the Air Forces on the Continent. Later, when a third field army would become operational in the 12th Army Group, additional personnel would be required for the base depot, and additional advance depots of both the Army and SOS type would also be required.

Section II. 152d Station Hospital Blood Bank, United Kingdom Section

CONVERSION OF 152D STATION HOSPITAL TO BLOOD BANK PURPOSES

When the request for additional personnel to form the organization just described was denied in the War Department, General Hawley acted with characteristic vigor to compensate for the adverse decision. He directed an assessment of all the 250-bed station hospitals then in the United Kingdom, and, as soon as the report was received, he requested, and obtained, the permission of the theater commander to utilize the 152d Station Hospital, then at Bath, England, as the ETOUSA Blood Bank.

Construction

Planning for the necessary construction for the blood bank at the 152d Station Hospital was begun late in October 1943. On 12 November, an official request was sent from the Hospitalization Division, Office of the Chief

17Provision is now made in T/O & E 8-500 for blood bank detachments, which were added in 1950. This provision goes far, though not all the way, to insure that, if blood banks are again needed by the Armed Forces, there will be an adequate allocation of enlisted grades and ratings.


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Surgeon, ETOUSA, to the Operations Division, for alterations and construction work on a general medical laboratory at Salisbury, in order to establish a blood bank in the United Kingdom to collect, process, and store blood. The facilities were requested as promptly as possible.

The work was carried out by Engineer personnel of the Southern Base Section, ETOUSA, and, by 1 April 1944, the building was completed and all equipment was in place.

Transfer of Location

On 22 January 1944, the 152d Station Hospital was transferred from its original location at Bath to Salisbury, to the site of the 1st Medical Laboratory, commanded by Colonel Muckenfuss (fig. 111), who also became commanding officer of the 152d Station Hospital. Major Hardin, who was assigned to duty with the 298th General Hospital, and had been detached to the 1st Medical Laboratory for the purpose of organizing the ETOUSA Blood Bank, was transferred to the 152d Station Hospital, where he assumed the duties of executive officer of the blood bank section. Unit administration of both the laboratory and the station hospital was carried out jointly in Colonel Muckenfuss' office.

PERSONNEL

Original Personnel

The use of the 152d Station Hospital for a blood bank solved what at first seemed an insoluble problem, but it was not an ideal solution. There were decided drawbacks to the use of a station hospital for such a highly technical unit. Multiple transfers from other sources were necessary to provide personnel qualified in laboratory and blood bank operations; there was a qualitative and a quantitative paucity of such specialists among both officers and enlisted men on T/O for the hospital. The limitations of the T/O also made the technical ratings of both noncommissioned officers and enlisted men particularly inadequate. This was unfortunate, for it meant that many who were highly qualified were denied the promotions which they richly deserved.

One type of technician extremely difficult to secure was the refrigerator mechanic, who is an essential person in the operation of a blood bank. Enough of them were eventually found, by combing the theater, and it is a tribute to their capabilities and their devoted work that not a single major refrigerating breakdown occurred during the entire period of operation of the ETOUSA Blood Bank. This was a truly remarkable record.

By the first week of February 1944, the personnel of the 152d Station Hospital had been reconstituted to meet the needs of the blood bank. All of the medical officers, with one exception, and all of the nurses, with one


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exception, had been transferred out of the unit and replaced with specialists, and enlisted men had been similarly transferred and replaced.

On 25 March 1944, a special emergency treatment group, consisting of 19 officers, 23 nurses, and 151 enlisted men were transferred into the unit.18 This group was subdivided into two other groups, the larger of which was trained to function as blood bank personnel and the smaller of which operated a 50-bed hospital for research purposes.

Training

Training for the blood bank operation began at Salisbury the first week in February. It was carried out partly by didactic lectures, partly by demonstrations, but chiefly by the repeated performance, under supervision, of individual duties by the personnel whose responsibility they were.

In all, up to D-day, 24 surgical technicians were trained to bleed donors, and 16 enlisted men were trained to clean, assemble, and sterilize equipment used to collect and administer blood. In addition, 60 truck drivers were trained to transport refrigerated blood.

Colonel Mason's suggestion to General Hawley that Captain Hardin be sent to the Mediterranean theater, to study operations of the blood bank at the 15th Medical General Laboratory in Naples, was unfortunately not implemented.

Proposed Augmentation of Personnel

On 17 April 1944, Major Hardin informed the Operations Division, Office of the Chief Surgeon, that the present personnel, in his judgment, could operate the blood bank through D+60. Additional personnel would be needed for the next 30 days, to meet the estimated daily requirement of 300 pints of blood. After D+90, still further augmentation would be required, since a depot would be established in the forward communications zone and increased demands for blood were anticipated. To furnish the additional manpower needed after D+60, training of additional personnel should begin by D+30.

If a base depot in the communications zone were to operate independently, additional personnel would be required for serologic testing, blood typing, mess management, and unit administration and supply. All of these functions were now handled by the 1st Medical Laboratory. Major Hardin believed that 61 additional enlisted men would be necessary, in addition to 2 Medical Corps officers, company grade, and 1 Sanitary Corps or Medical Administrative Corps officer. The later designation of the 127th Station Hospital as a second blood bank (p. 513) solved this problem.

18The medical officers and nurses in this group had been members of the Harvard-American Red Cross Hospital which was stationed in Salisbury before the United States entered the war. They joined the U.S. Army in Salisbury. When the 152d Station Hospital came to Salisbury, the two units were amalgamated under the designation of "special treatment group." Later, most of this group was transferred back to the 152d Station Hospital. These transfers were really only paper manipulations, but a great deal of time and effort went into them.


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Difficulties of Retaining Trained Personnel

Throughout the war, it was a constant struggle to keep the trained personnel of the various sections of the blood bank from being given other assignments. On 3 April 1944, for instance, Major Hardin felt obliged to point out that all personnel serving as drivers should be kept with the base depot blood section. If they were placed with advance blood depots, he feared that the ground replacement group might ask for them.

In December 1944, when replacements for ground troops were sorely needed in the field armies, the question arose of transferring trained men in the blood bank to such duties. Colonel Cutler pointed out that it would jeopardize the supply of safe whole blood if these personnel were removed.

In April 1944, Col. David E. Liston, MC, had suggested that if additional personnel were needed to operate the blood bank, nurses of the 152d Station Hospital could be trained for this purpose. The matter did not come up again until 1 January 1945. Then, in a memorandum for the record, arguments for and against the use of nurses in a blood bank were outlined as follows:

Commanders of hospital blood banks considered nurses much better than enlisted men for their purposes. Several months ago, when the tables of organization of the general hospitals had reduced the number of nurses allotted to them, consideration was given to withdrawing nurses from the hospital blood banks, but it was decided not to; their value in the blood banks was considered greater than their value in hospitals, however much they might be needed in them.

At this time, however (January 1945), 19 general hospitals were being shipped to the theater without their full complement of nurses. In view of the critical situation in these hospitals, it now seemed that the need for nurses in blood banks must be subordinated to present necessities. After much discussion, the nurses assigned to blood banks were retained in them.

On 15 January 1945, General Cutler suggested to Major Hardin that WAC (Women's Auxiliary Corps) personnel might be used in place of nurses. If so, his idea was that enlisted men be moved in to replace nurses and that they then be relieved with WAC personnel. This plan was never adopted.

OPERATIONAL STRUCTURE

Base Bank

The 152d Station Hospital blood bank was divided into four sections, and the personnel assigned to them were trained for specific, specialized duties in the base and in advance banks. These sections were:

1. A record section, which maintained records of prospective donors as submitted on monthly reports sent in by SOS units, arranged bleeding schedules, maintained records of bleedings, correlated laboratory reports, and reported positive serologic tests and errors in typing on identification tags to the unit commanders concerned.

2. A collecting section, which was composed of four mobile bleeding teams, each made up of seven enlisted men and one medical officer. The enlisted men included a driver, a


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FIGURE 112.-Solutions room, European Theater Blood Bank. Technicians are adding 3.2-percent sodium citrate solution as anticoagulant to British-type bleeding bottles.

clerk, an orderly, and four surgical technicians. They were supplied with appropriate equipment and were dispatched from the base bank to camps at which donors were bled according to prearranged schedules. Each team could bleed an average of 20 men in an hour. All donors were unpaid volunteers, and only type O blood was collected.

The blood was collected by a closed system in sterile 600-cc. bottles containing 100 cc. of 3.2-percent sodium citrate U.S.P. (figs. 112 and 113). At the end of the bleeding, a sample of blood for typing and serologic testing was collected from the tubing of the donor set into a sterile Wassermann tube. The collecting bottle and the tube were immediately placed under refrigeration. At the end of each day, all blood drawn was taken to the base bank by truck or plane (fig. 114).

3. A manufacturing and processing section, which had two functions. One was the cleaning, assembling, and sterilizing of all equipment (fig. 115). For each pint of blood


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FIGURE 1l3.-Autoclave being loaded with bottled solutions and equipment for collection of blood, European Theater Blood Bank, 1944.

collected, there was needed a collecting bottle, a donor set, and a recipient set. The second function was processing of the blood, which consisted of two operations:

a. Typing and serologic testing, which was carried out by the 1st Medical Laboratory. Blood showing positive or doubtful Kahn tests was discarded, and the individual's name and Army serial number were reported to his unit commander by the records section.

Off types of blood (that is, blood other than group O) were labeled according to type (fig. 116) and the notation Must Be Crossmatched Before Use was affixed to the bottle. These bloods were issued to fixed hospitals, but only after personal conferences with the medical officers who would be responsible for their use.

b. The addition of a preservative (fig. 117). Enough dextrose in 5.4-percent solution was added to the blood to fill the bottle completely. The amount required ranged from 40 to 50 cc. and averaged 45 cc.19

4. A storage and shipping section, which was responsible for the refrigeration of the blood while it remained in the blood bank; its packing for shipment; and its delivery by

19Dextrose was not added to the blood collected in the Zone of Interior blood program. The necessity for opening and recapping the bottle to add it made a break in the closed system of handling. This procedure had been tested by the British before it was adopted at the 152d Station Hospital blood bank. Although it was carried out under a bacteriologic hood, with strict operating room asepsis, it was a potentially hazardous procedure. So far as is known, however, no instance of contamination resulted from it.


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FIGURE 114.-Transfer of bottles of blood from refrigerated storage to delivery trucks, also refrigerated, for shipment to waiting plane, United Kingdom, August 1944.

refrigerated truck to ports, airfields, or hospitals in the United Kingdom. The blood was stored and transported at temperatures ranging from 35.6° to 42.8° F. (2° to 6° C.). When it was moved by air, it was packed in Quartermaster food containers (marmite cans), one pan of which was filled with ice (fig. 118). This improvisation maintained a temperature of 37° F. (3° C.) for between 37 and 72 hours, depending upon the outside temperature.

Record System

The following system of records was used in the blood bank:

1. A perforated, doubly numbered label on the collecting bottle had space for the name of the donor, the date, and the number of the collecting team. The team clerk printed the donor's name on the label, using his identification disk and a printing machine. This was the field record.

2. The perforated lower portion of this label, marked with the same number as the upper portion, was torn off and used as a label for the Wassermann tube.

3. The field record turned in by the bleeding team was completed by entry on the label of the blood type and the serology when these tests had been completed in the laboratory.

4. A ledger kept in the blood bank indicated the final disposition of each bottle of blood; that is, when it left the laboratory or whether it was discarded for positive serology or for other reasons.

5. Another ledger was used to record the date each unit of blood was received, the total amount received, the amount discarded, the amount shipped, with the date, and the daily balance.

6. Advance depots were required to keep the same kind of ledger.


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FIGURE 115.-Preparation of transfusion equipment for reuse, European Theater Blood Bank, August 1944. A. Cleaning equipment after its return from Continent. Note marmite can, in which blood was shipped under refrigeration. B. Preparation of giving sets, base blood bank depot, Paris, November 1944.

Advance Banks

The advance banks or depots of the 152d Station Hospital blood bank had the sole responsibility for the handling and delivery of blood. They were of two types, SOS banks and Army banks (chart 9), and each type operated with two detachments. The detachments of the SOS and Army blood banks were made up of personnel specially trained in the storage and delivery of blood. They operated independently, but were attached to the nearest organization for rations.

1. The communications zone or SOS advance bank operated behind each army, on or near airfields in the advanced section of the communications zone.


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FIGURE 116.-Labeling of filled bottles of blood, European Theater Blood Bank, April 1944.

The personnel received shipments of blood from the base bank and delivered it to army banks and to hospitals in the communications zone. Its personnel consisted of an officer and 16 enlisted men, one of whom was a refrigeration mechanic.

The equipment consisted of one ¼-ton truck; two motorcycles, solo; and four 2½-ton 6 by 6 cargo trucks with refrigerators (each with a built-in, motor-driven gasoline refrigerating unit). The 6 by 6 trucks were divided as follows:

Two trucks with 60- to 80-pint capacity, used for delivery of blood.

One truck with 500-pint capacity for bulk delivery of blood to Army depots.

One truck with 1,000-pint capacity, for storage.

2. Army type banks were attached to medical depots of the army they served. They delivered blood to all field and evacuation hospitals of that army, moving, as necessary, when the army moved. These banks were always located far forward in the territory of the command or in the field army service area, depending upon the location of the airstrips by which they were supplied. If the airfield was immediately behind the army rear boundary, the Army could pick up its own blood. Otherwise, its blood supply was secured from the depot in the communications zone.

One of the most practical modifications of the original plan for the delivery of blood to hospitals of the field armies was the daily reversal of the routes.


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FIGURE 117.-Processing of blood donations, European Theater Blood Bank, April 1944. A. Sterilizing top of bottle of blood before it is filled to top with glucose solution. B. Introduction of glucose solution. C. Capping bottle of blood.


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FIGURE 118.-Shipment of blood, collected from rear echelon troops, in marmite cans from Continental Section, European Theater Blood Bank, December 1944. Truck is being loaded at 152d General Hospital.

PROGRESS REPORT

On 15 April 1944, Major Hardin made the following report to the Senior Consultant in Surgery, Office of the Chief Surgeon, on the current status of the blood bank:

1. The physical plant was complete.

2. All officer personnel were present except for the officer to be in charge of the laboratory, who would report within the week. Enlisted personnel were sufficient for the present operation; 129 were permanently assigned, and 12 others were attached.

3. Training of all personnel had reached a level at which full operation of the bank was possible.

4. Supplies were complete except for a few critical items, which were essential for the operation of the bank. These included 2,300 long piercing needles; 2,000 short piercing needles; 24 refrigerators ABSD (Army Blood Supply Depot-British) type C; and 22 2½-ton 6 by 6 trucks. Measures were being taken through channels to expedite the delivery of these items.

5. Shortages in some critical items procured from British sources might make it necessary to make some changes in the giving apparatus. The amounts and times of delivery had not been met on these items in the past, and there was every reason to fear that if requirements for blood were doubled, as now seemed likely, there would be further difficulties with procurement. Experiments with new types of giving apparatus had therefore been carried out, and satisfactory substitutes for the British items had been found.


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6. Amounts of blood necessary to meet the newly calculated demands (on the 1:1.5 basis, (p. 482) were being computed, and expansion of personnel for this reason, as well as for later operations, was being considered. Expansion of the bank operations to meet the demands for blood to D+90 would present no particularly difficult problem,20 but expansion for demands likely after that time would require doubling the present personnel. It would also require duplication of the present equipment, and provision of additional heavy equipment such as generators, centrifuges, and autoclaves.

Shortly after this report, the blood bank had an unusual opportunity to test its capacities before D-day: During the course of Operation TIGER (a practice loading and sailing project), three fully loaded LST's were attacked and sunk off Portland, Dorset, by German E-boats. The numerous casualties were hospitalized in adjacent U.S. Army hospitals, and the bank was called upon to supply the large amounts of blood needed. It functioned well, but in Major Hardin's opinion it should have functioned better.

FURTHER PLANNING FOR OPERATION OVERLORD

A conference on the blood program in the European theater was held on 5 April 1944, at the 1st Medical Laboratory (p. 481) (60). It was attended by Colonel Muckenfuss, who acted as chairman, and Major Hardin, from the 1st Medical Laboratory; Colonel Kimbrough and Colonel Zollinger; Col. Keith W. Woodhouse, MC, from the Southern Base Section; Colonel Mason, from the Advance Base Section; Colonel Crisler; Lt. Col. Nathan Weil, Jr., MC, Consultant in Medicine, Third U.S. Army; and Lt. Col. George S. Richardson, MC, Ninth Air Force, Air Transport Command.

The following points were brought out:

1. The physical facilities of the blood bank were well planned, and blood was already being obtained. It was expected that the bank would function smoothly when mass production began.

2. If, as seemed likely, daily requirements of blood would amount to 500 to 700 pints instead of the 400 pints then estimated, it would be necessary to add two more bleeding teams and increase the personnel by 33 percent. Two additional 2½-ton trucks would also be necessary. It was believed that if the facilities of the bank were thus augmented, its production could meet the need for whole blood for Operation OVERLORD.

3. There was considerable discussion about the marking of the large refrigerators, trucks, and marmite cans to be used in the blood operation. The cans were labeled "ETOUSA Blood Bank," but unless it was also indicated that they were the property of the Medical Department, they might be converted to other purposes by the units to which they were delivered. If they were lost, they could easily be traced if they were properly marked (as they were). Special arrangements would be necessary to hold the cans firmly in place during transportation.

4. Advance blood depots on the far shore would be utilized to store blood to be provided by the LST's to be used in operations on the far shore in the early stages of the invasion.

5. The First U.S. Army would determine the phase at which the refrigerator for its advance blood bank could be taken ashore. Meantime, blood would be delivered in marmite cans, by means of the daily Red Ball Freight.21 Medical officers of this Army thought that

20It was to present a major problem (p. 484).
21Blood was seldom delivered by this means. The idea did not prove practical because the Red Ball Freight was not under medical control.


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the need for blood would be great enough for it to use all that became available, without wastage, within the specified time limits. It would be responsible for collecting and distributing its own blood.

6. It was pointed out that in the early stages on the far shore, trucks could probably not be used to transport blood because their motors would be water sealed. Marmite cans therefore seemed the only practical way of conveying the blood ashore. It was suggested, however, that all medical units be assigned given amounts of blood and that they carry it ashore as part of their equipment. Other units could be similarly helpful; the engineer companies, for instance, could carry three cans each, and field hospitals could bring in their own blood. It would be necessary to know the exact phasing of these medical units, so that the blood bank could be kept aware of time, place, and amount of blood needed. These suggestions were not implemented.

The recommendations by this conference on the assignment of advance blood banks are more conveniently discussed elsewhere (p. 518).

MAJOR ELEMENTS OF THE FINAL PLAN

The procedure planned for the blood bank for the invasion and thereafter was as follows (31):

1. Blood would be collected from the donor panel by bleeding teams from the United Kingdom bank and would be returned to the bank in refrigerated trucks.

2. It would be processed at the depot and stored until requisitioned for delivery.

3. Every day, the blood required on the Continent would be transported under refrigeration, by air, to the advance blood depots in ADSEC (Advance Section, Communications Zone), where it would again be stored under refrigeration.

4. The amount of blood delivered would be determined by daily forecasts of requirements by the commanding officers of the advance Army blood bank detachments. The forecasts, which would cover the succeeding 4 days, would be given to the ADSEC bank, which would consolidate the requirements before delivering them to the Supply Division, Office of the Chief Surgeon, for transmission to the base bank.

5. The bulk delivery truck of the advance blood depot would transport the blood to the advance depot in the Army area which it was supporting.

6. From the depot, trucks would operate a milk route delivery to the evacuation and field hospitals in the particular Army area. In practice, each vehicle would be assigned a certain number of these hospitals to service.

7. The blood depot in ADSEC, in addition to serving mobile hospitals of the Advance Section, would also be expected to respond to calls from the Army Surgeon to deliver blood to Army hospitals as special needs arose in them. (This frequently happened after D-day, and the successful accomplishment of this particular mission was another illustration of the workability and flexibility of the planned blood program.)

8. The same system of collection and delivery would be followed when the blood bank moved to the Continent. (This system was employed when blood


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began to be flown from the United States directly to the bank in Paris and delivery of blood to forward areas was initiated from that point.)

It was anticipated, and events proved the expectation correct, that the central control of the blood which had been planned would have a number of operational advantages and would also effect economies in its distribution and use. At no time was blood left in forward hospitals in excess of the 4-day period for which forecasts had been received. Also, after the blood bank moved to Paris, all blood within 3 days of the expiration date was picked up and returned to the bank (61).

Supply of blood for LST's-In the initial discussions of blood to be supplied by the blood bank for use by the Navy on LST's on D-day, 10 pints had been requested for each boat. These estimates, however, were not made official until 27 April 1944 (40). Then 2,000 pints were requested, to be be placed aboard the hundred LST's which would be used for the invasion. It was mentioned in this communication (from the Commander of U.S. Naval Forces in Europe to the Chief Surgeon, SOS, ETOUSA) that representatives of the Chief Surgeon's office had agreed that a stock of 1,000 pints of blood would be maintained at loading points to replace the blood used on shipboard.

It was requested that delivery of the initial stock of 2,000 pints of blood be made by refrigerated trucks to landing points of the LST's shortly before departure time. The amounts required for specific ships at specific loading points would be indicated in future correspondence after these matters had been worked out. The crossing would take 24 hours or less.

These arrangements were duly concluded. It was further arranged that the loading of the initial supply of blood would be the responsibility of the ETOUSA Blood Bank, beginning on D-5. Maintenance of supply would be from the hards, where the exchange of blood for empty bottles, used equipment, and outdated blood would take place. It had been proposed that a courier accompany the blood, but this request had been refused. It was hoped that the request would still be granted (it never was), as this was the best way to insure the return of empty bottles and used sets.

Standing Operating Procedure No. 21

On 21 March 1944, Colonel Muckenfuss, Commanding Officer, 1st Medical Laboratory, to which the European Theater Blood Bank was attached, was instructed to prepare for the Plans and Operations Division, Office of the Chief Surgeon, an SOP (standing operating procedure) covering in detail the proposed operating procedure for the whole blood service in the European theater (62). On 27 March, Colonel Muckenfuss was informed that it would not be necessary to publish the entire SOP for the blood service in the general SOP for the theater but only that portion of the operation contingent on the services of, or assistance required from, any other organization.

The SOP was duly prepared and was forwarded on 14 April 1944 (63). The description in it covered the collection of blood in the United Kingdom, its


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delivery to the medical section of G-45, its packaging, its loading on planes, and its receipt on the far shore. This SOP also defined the responsibilities for the various commands and agencies for the air shipment of critical medical supplies.

THE INVASION

On 23 May 1944, the blood bank at the 152d Station Hospital went into full operation, using for this stage of the invasion mission the advance blood depots planned for use on the Continent. The operation was conducted in two phases.

Phase I

Detachment A, as planned, was attached to the 1st Medical Depot Company of the First U.S. Army for movement to the Continent. Detachments B, C, and D were moved to port areas, together with a temporary detachment of base bank personnel, equipped with refrigerator trucks from the regular advance bank.

Loading of the LST's began on 1 June and was completed on 3 June. In all, 109 craft were loaded, in seven ports, with 10 pints of blood each. In addition, three hospital carriers, at widely separated ports in England, Scotland, and Wales, were each supplied with 20 pints of blood, which were delivered to them by special couriers from the bank. For various reasons, these carriers all had to turn back.

Phase II

The temporary detachment from the base bank was recalled to it as soon as the loading of the LST's was completed. The other three detachments remained in place to carry out their part of the second phase of the blood bank mission, which at this time was twofold:

1. The supply of blood to returning LST's and hospital carriers for use on the far shore. For a long time, the blood bank detachments also handled the supplies of biologicals and penicillin for these craft.

2. The supply of blood to transit and holding hospitals which were receiving casualties in the United Kingdom. For a time, it was also a blood bank responsibility to supply these hospitals with biologicals and penicillin.

The blood bank kept in storage a reserve of whole blood, which was used to supply field hospitals in the vicinity and to resupply hospital carriers and LST's which had brought casualties from the far shore and were returning to it. This blood was distributed daily in small refrigerator trucks. A small amount was supplied to LST's in hand-carry ice containers.

The southern part of England was divided into four geographic areas, and the hospitals in the three coastal areas were supplied by the blood bank detachments. The fourth area, which was inland, was supplied directly from the base blood bank at Salisbury.


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When air evacuation began from the Continent, on D+7, a fifth area was set up, with the 217th General Hospital at Swindon, because of its central location, serving as a supply center. Deliveries of blood were made to this hospital, and holding hospitals at airstrips nearby obtained the small amounts which they needed from it. Blood was also delivered to the 347th Station Hospital.

As a matter of convenience, the activities of the detachments of the blood bank are described under a separate heading (p. 518).

Section III. 127th Station Hospital Blood Bank, United Kingdom Section

AUTHORIZATION

On 14 April 1944, as a result of the discussions and recommendations at the meeting on blood supply on 5 April 1944 (p. 481), Colonel Liston, Deputy Theater Surgeon, approved the initiation of a request for duplication of PROCO (p. 541) equipment necessary for a base blood depot on the Continent (34). The request included two additional Army depots, and two additional communications zone, advance blood depots. In this memorandum, Colonel Liston stated that the next 250-bed station hospital that arrived in the United Kingdom would be earmarked for the operation of the second blood bank on the Continent and that the equipment necessary to operate it as such would be requisitioned at once.

CONVERSION OF FACILITIES AND PERSONNEL

When the 250-bed 127th Station Hospital arrived in Salisbury on 9 July 1944, it learned for the first time that its future major mission would be to function as a second blood bank in the European theater. It would also continue to operate certain facilities for the 1st Medical Laboratory, unit personnel, British civilian and military personnel, and personnel in need of treatment because of local emergencies.

When the conversion had been accomplished, all facilities on the post were shared by the 1st Medical Laboratory and the 127th Station Hospital blood bank. By prorating personnel, the shared facilities were efficiently manned and maintained. The hospital and laboratory maintained separate headquarters, but a few administrative offices were conducted jointly. Medical officers, nurses, and enlisted men were rotated between duties in the hospital and in the blood bank.

On 7 August 1944, as the first step in the transition from station hospital to blood bank, Colonel Muckenfuss assumed command of the hospital, vice Lt. Col. Julius Chasnoff, MC.


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TRAINING

Training of hospital personnel in the operation of the blood bank was successfully effected by assigning them to work side by side with the experienced personnel of the 152d Station Hospital, which had been in operation as a blood bank since early in the year. The training, though massive, was not difficult. The personnel of the 127th Station Hospital had trained together since the hospital was activated at Fort Hancock, N.J., in December 1942, and their long association as a unit made them both disciplined and adaptable.

The training of men in assignments foreign to station hospital personnel, such as blood research officers and refrigerator mechanics, presented the greatest difficulty. Only 11 licensed motor vehicle drivers were with the hospital when it arrived in the United Kingdom, but others were quickly trained according to the new demands, and the transportation section eventually had 81 qualified and licensed drivers.

During the training period, there was a loss by transfer of 28 general service enlisted men, who were replaced by a like number of limited service men from combat units in France. These men were so carefully fitted into positions suited to their individual abilities that they were employed to the best advantage and the efficiency of the blood bank was not impaired.

OPERATION

On 26 August 1944, the 127th Station Hospital formally assumed full operation of the blood bank at Salisbury, plus its equitable share of the duties necessary to maintain the post in conjunction with the 1st Medical Laboratory, and the 152d Station Hospital prepared to depart for France. All technical operations of the bank were under the direction of Capt. (later Maj.) Forest H. Coulson, MC.

After the takeover, the transportation section of the new blood bank became increasingly active. Many service troops had left the United Kingdom, and the bleeding teams had to travel for increasingly greater distances to collect the blood. They ranged from the borders of Scotland to the Channel ports, and from the London area to the Welsh mountains. During September 1944, the unit vehicles traveled 20,511 miles. During October, the mileage reached 36,980; during November, 35,087; and during December, 47,611. This was a total of 140,189 miles, an average of 1,149.1 miles per day.

On 17 May 1945, the last blood was drawn by the teams, and no further bleedings were scheduled. During the peak of their operation, they averaged 450 bleedings per day.

As a matter of convenience, the activities of the detachments of the 127th Station Hospital blood bank are discussed under a separate heading.


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Section IV. 152d Station Hospital Blood Bank, Continental Section

MOVEMENT TO THE CONTINENT

When the 152d Station Hospital blood bank was ordered to the Continent late in August 1944, the equipment for a complete blood bank was requisitioned and assembled at the medical section of Depot G-45 in the United Kingdom. Here, it was crated for shipment, so that it could be picked up without delay when the unit began to move. In addition to the transportation regularly allotted to the hospital, ten 4-ton dump trucks were borrowed from Ordnance, with the agreement that they would be delivered to the Chief of Ordnance on the Continent.22 This mutual aid agreement enabled the bank to carry all of its equipment with it directly to Paris and thus to escape the delays which would probably have ensued if the equipment had been shipped separately.

When movement orders were received on 15 September, the 152d Station Hospital blood bank was divided into two units, a vehicle party commanded by Major Hardin, then the Executive Officer, who was to become commanding officer of the blood bank on the Continent, and a marching party. Both parties moved to the marshaling area the following day. On 17 September, the vehicle party moved to Southampton, embarked on LST 696, and reached Omaha beach on 19 September.

The marching party of the blood bank left the marshaling area on 18 September and embarked the same day on H.M.S. City of Canterbury. It landed on Omaha beach the following afternoon.

The entire unit left the staging area on 20 September, equipped with K-type rations, and reached the 203d General Hospital at Garches the following day.

On 25 September 1945, the storage and shipping section of the 152d Station Hospital blood bank undertook the receipt, storage, and initial distribution of all blood received on the Continent. Temporary storage facilities were obtained through the Office of the Chief Surgeon. A pyramidal tent erected at Le Bourget Field served as a joint office for the shipping section and for depot M407, which handled air shipments.

22This arrangement was possible because of a chance observation by Lt. Col. (later Col.) Bryan Fenton, MC, and Maj. (later Col.) R. L. Parker, MAC, while they were on their way to the south of England on another mission. Seeing mile after mile of empty vehicles scheduled for shipment to the Continent, they were struck by the unused potential transportation capacity. At their suggestion, these vehicles were loaded with medical supplies and provided with drivers from replacement depots who were also scheduled for service on the Continent. A triple purpose was thus served: The movement of the vehicles was expedited. The receipt of medical supplies was expedited. Replacements reached the Continent rapidly.

The operation was originally very successful. Then the Assistant Chief of Staff, G-4 (logistics), SOS, ETOUSA, found that medical tonnage allocations were being exceeded and that many truck drivers were not reporting, as ordered, at the Replacement Depot on the Continent. At this point, G-4 took over the operation. In the meantime, however, the equipment of the l52d Station Hospital blood bank, along with tons of other medical supplies, had been moved to the Continent quickly and expeditiously.


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PERMANENT LOCATION

On 10 October, a site for a base blood bank was found at Vitry-sur-Seine, and officers and enlisted men moved to it from the 203d General Hospital. The nurses were left at the hospital. Two wings on the ground floor of the building selected were used for the bank operations, together with a temporary wooden structure placed between the wings by the former German occupants. The building had been considerably damaged, but repairs on it were begun immediately by French contractors, working under U.S. Army Engineers. The installation of the blood bank equipment and the necessary wiring and plumbing were done by personnel of the 152d Station Hospital.

On 20 October, the 1st General Hospital occupied the remainder of the buildings on the site at Vitry-sur-Seine and took over the administration of the post. As soon as possible, a joint officers' mess, an enlisted men's mess, and living quarters for nurses, officers, and enlisted men of the 152d Station Hospital blood bank were established in cooperation with the 1st General Hospital.

OPERATIONS

After 3 November 1944, the blood bank in Paris occupied the key position in supplying blood to the hospitals on the Continent. All blood from the Zone of Interior and from the United Kingdom section of the European Theater Blood Bank at Salisbury was funneled through it, as was all blood drawn locally.

Blood collected locally was secured from volunteer SOS troops with type O blood. Not very much was needed from this source.

On 28 October 1944, shipments were begun to the 6703d Blood Transfusion Unit, to supplement the supply of blood to the Seventh U.S. Army. As will be recalled, this unit landed in southern France with that Army. By the end of the year, 354 pints per day were being shipped to this unit.

The Continental Blood Bank remained in Paris until the end of the war. Equipment and transportation were adequate at all times. Technical operations were always essentially the same as originally planned.

Personnel problems, however, frequently arose. The bank consistently operated at some 30 persons under strength, chiefly because of reassignment and transfer of medical officers, nurses, and enlisted men, with insufficient replacements for them. At all times, also, several officers and enlisted men were on detached duty. The shortages were partly compensated for by the employment of 13 French civilians, 5 for the care of buildings and grounds and 8 for the cleaning and assembly of donor sets. The net decrease in total personnel did not result in any lowering of technical standards because, late in 1944, the use of expendable recipient sets and expendable bottles for the collection of blood reduced the time and work necessary in the preparation of equipment by about half.

The four detachments operating in the forward areas when the blood bank arrived in Paris continued to operate as before. Delivery of blood to the


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armies was simplified when two detachments of the 127th Station Hospital arrived in October 1944 to operate with the Seventh U.S. Army.

Except for a single brief interval, during the envelopment of the Ruhr Basin, distribution of blood from the Paris bank followed the SOP of shipment to ADSEC Detachments B and D from the base bank and forward from these detachments to Detachments A and C (chart 10). During this interval, Detachment B delivered blood to units of the Fifteenth U.S. Army in addition to delivering blood to Detachment A. The added duty presented no great

CHART l0.-Chart showing procurement and distribution of whole blood, ETOUSA, 1944-45

difficulty, since only a small amount of blood was used by the Fifteenth U.S. Army on the west bank of the Rhine.

After the blood bank was set up in Paris, communications between it and its advance detachments were generally excellent until the final days of the war. Then, when the blood depots moved with the airstrips, to keep the appropriate Army depots supplied, their whereabouts was sometimes unknown in Paris for as long as 36 hours.

On the cessation of fighting in Europe on 8 May 1945, the four detachments operating in the Army areas and in ADSEC were brought back to the base bank in Paris, the last arriving on 24 May. These detachments were then disbanded and their personnel were absorbed into the structure of the parent unit.

The base bank continued to operate as such until 15 June 1945; the last shipment of blood was made on 14 June. The last shipments from the bank in the United Kingdom had been received on 11 May and the last shipment from the United States on 15 May. After that date, all blood distributed on the Continent was collected and processed by the Continental Blood Bank.


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Section V. Activities of the European Theater Blood Bank

Detachments

152D STATION HOSPITAL BLOOD BANK

Assignments

At the conference on blood supply held at the 1st Medical Laboratory on 5 April 1944, it was recommended that the assignment of advance banks be as follows:

First U.S. Army: Detachment A in the Army zone, supported by Detachment B in the communications zone.

Third U.S. Army: Detachment C in the Army zone, supported by Detachment D in the communications zone.

This was essentially the plan employed on the Continent (map 3). When the Ninth U.S. Army became operational and the 127th Station Hospital had been added to the blood bank at the 152d Station Hospital, the same plan was employed: Detachment A of that hospital operated in the Army zone, supported by Detachment B in the communications zone.

Movement to the Continent

On D+1, two refrigerator trucks from Detachment A, which had been loaded with predetermined amounts of blood by Detachment C at Southampton, were landed on Omaha beach. Their drivers were responsible for the delivery of this blood to medical units in the area.

Two other refrigerator trucks, one of which was preloaded with blood, also from Detachment A, were landed on Utah beach on D+3. Their drivers had the same duties as the drivers of the trucks landed on Omaha beach. Both groups also took off unused and unneeded blood from LST's going back to the United Kingdom with few casualties or with casualties who did not need blood.

By D+6, the remainder of Detachment A had arrived in France and was stationed at Martha Dump (Medical Supply Depot, First U.S. Army). The trucks of this detachment could readily distribute all the whole blood available to the field and evacuation hospitals which required it because in the early days of the invasion, the lodgment area on the Cotentin Peninsula was very limited.

All whole blood brought into France during the first days of the invasion was brought in by surface craft. On D+7, it began to arrive by air, on the airstrip in the rear of Omaha beach. Thereafter, C-47 planes brought in practically all blood from the United Kingdom.

The third phase of the blood bank operation called for the movement of Detachments B, C, and D to the Continent. There had been no need for them there earlier.


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MAP 3.-Operations map showing movements of ADSEC mobile blood depots on the European Continent, 1944-45, in support of the field armies (59).


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Detachment C arrived in France on 10 July and began to serve the hospitals supporting the VII Corps of the First U.S. Army, which was operating toward the south on the Normandy Peninsula. On 4 August, Detachment C also took over delivery of blood to hospitals of the Third U.S. Army, which had become operational on 1 August.

Detachments B and D arrived on the Continent on 18 July, attached to the Advance Section, Communications Zone. On 23 July, for Operation COBRA (the breakthrough at Saint-Lô), Detachment B was placed at Trévières, with the 31st Medical Depot Company, to support Detachment A. Detachment D was initially located on the airstrip at Binniville, but a few days later it took station at the 30th Medical Depot Company at Chef du Pont.

Departures from SOP

The SOP for delivery of blood to the Continent (40) called for trucking of blood from the base bank to the field; separate air shipment of blood to each ADSEC detachment; and delivery forward, by truck, to the respective armies served by the particular detachments. On occasion, departure from this procedure was necessary:

1. The major test of the flexibility of the plan devised for the supply of whole blood first came in August, when the bank was called upon to support, at the same time, the VIII Corps of the Third U.S. Army operating in the Brittany Peninsula and the eastward drives of the First and Third U.S. Armies. To handle this situation, Colonel Mason directed a regrouping of personnel and equipment of the ADSEC detachments as follows:

Detachment B was placed in support of the First and Third U.S. Armies, at first from the airstrip at Courtil, in Brittany. It was given the 1,000-pint refrigerator truck and the 500-pint bulk delivery truck from Detachment D. Between 13 September and 2 October, Detachment B gave full support to both armies, even when this mission required splitting itself in half because of the diverging fronts.

Detachment D was placed in direct support of the field and evacuation hospitals operating with the reinforced VIII Corps. It operated initially from the airstrip at Courtil and later from the strip at Morlaix in Brittany. It was given temporarily the two 80-pint delivery refrigerator trucks belonging to Detachment B, which, with its own trucks, gave it four delivery vehicles. This enabled Detachment D, from mid-August to early October, to operate a shuttle service between the airstrip and the field and evacuation hospitals. The detachment then reverted to its original mission of backing up the Third U.S. Army.

2. In October 1944, the Surgeon, Third U.S. Army, requested that supplies of blood be sent directly to mobile hospitals supporting the divisions engaged before Metz.

3. On 24 October 1944, Detachment B took over delivery of blood to hospitals of the Ninth U.S. Army, continuing this function until 1 November,


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when Detachments A and B of the 127th Station Hospital arrived and took over the mission of supplying the hospitals of this Army and the communications zone hospitals behind it.

4. Also in October, Detachment B became responsible for the delivery of blood to the mobile hospitals supporting the 82d and 101st Airborne Divisions of the XVIII Corps in the Eindhoven-Nijmegen Area. One delivery truck from this detachment transported blood daily from the airstrip near Saint-Trond, Belgium, to the combat area over "Hell's Highway." On at least one occasion, the vehicle carrying the blood had to be escorted by tanks, to protect it against interference by roving German patrols. Although it was constantly subjected to small arms fire, it was never hit. The drivers and assistant drivers of the two trucks engaged in this operation were awarded the Croix de Guerre by the French Government.

While it was stationed in the vicinity of Saint-Trond, Detachment B received all its blood by air. It was entirely mobile and could move immediately to the vicinity of any airfield near the front to which a supply of blood could be flown. After 10 November, when it went on to Liége, it received its blood by both plane and truck. The first night the detachment was at Saint-Trond, a German V-1 bomb blew out several of the windows in the chateau in which it was billeted. While it was in Liége, it was subjected to constant V-1 bombing.

This detachment had some minor refrigerating problems. Its storage refrigerators kept the blood at the correct temperature only when the environmental temperature was above the required limit. When it dropped below that level, the temperature in the icebox had to be raised by the use of a 200-watt bulb and cans of hot water, and hourly checks were made.

Evaluation of Performance

This was probably the most trying period for any of these detachments. The work could not have been handled by units not thoroughly trained and seasoned.

One reason for the successful flexibility of the ADSEC operation was that the Commanding General, Brig. Gen. (later Maj. Gen.) Ewart G. Plank, had given his Surgeon, Col. Charles H. Beasley, MC, direct command over all medical units assigned or attached to ADSEC. Colonel Mason, who was Colonel Beasley's executive officer, was directed to exercise personal supervision over the blood bank operations in ADSEC and to coordinate all matters of blood supply with the army surgeons, the Surgeon, 12th Army Group, and the Chief Surgeon.

The work of the detachments of the 152d Station Hospital blood bank was faithful and consistent. Great resourcefulness and initiative were shown by the commanding officers, 1st Lt. Herbert H. Reardon, MAC; 2d Lt. (later 1st Lt.) Eugene E. Stein, MAC; 2d Lt. (later 1st Lt.) Philip Shaulson, MAC; and 2d Lt. (later 1st Lt.) Joseph A. Plantier, MAC. With the men of their


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units, they showed consistent courage and devotion to duty. Deliveries were often made under difficult conditions, in unknown, dangerous terrain, but the drivers took pride in getting the blood through, even though it had to be transported through artillery and small arms fire. When bridges were destroyed, the drivers forded streams. They were often annoyed by snipers, and they sometimes found that the installations to which they were taking blood had been wrecked by enemy action. The successful operation of the ETOUSA Blood Bank was in large measure due to the efforts of the officers and men of the advance detachments.

127TH STATION HOSPITAL BLOOD BANK

Movement to the Continent

On 2 October 1944, two advance detachments (A and B) activated from personnel of the 127th Station Hospital blood bank departed for France, fully trained and equipped for their new missions. Almost as soon as these detachments had left, two additional detachments (C and D) were activated and began training. Personnel, trucks, and supplies were kept ready for another call from the Continent. The loss of manpower because of the detachments already sent to France was felt, as was the alert maintained until Detachments C and D went to France in March 1945, but increased efforts of the remaining personnel compensated, and the internal mechanism of the blood bank was in no way slowed down.

Detachment A (Provisional)

Detachment A of the 127th Station Hospital, commanded by Capt. A. C. Shainmark, MAC, landed on Utah beach in October 1944 (64), just as the battle for Aachen was terminating and plans were in hand for the Ninth U.S. Army to cross the Roer River and push on to the Rhine. After a 2-day stay in Paris, to obtain additional supplies, the detachment pushed on to Namur, Belgium, and then to Maastricht, Holland, which it reached on 27 October. After personnel of the 28th Medical Depot Company arrived there several days later, the detachment moved to its location.

The first shipment of blood was received on 30 October 1944, from the ADSEC supporting unit (Detachment B), which was located near an airfield in the vicinity of Liége and which served as the link between Detachment A and the blood bank in Paris. Thereafter, the trucks of Detachment A moved along with the army, maintaining continuous contact with forward medical units and delivering blood to them daily.

Captain Shainmark was kept fully informed of the movements and locations of field and evacuation hospitals as the Ninth U.S. Army swept forward across Germany to Helmstedt, where it was operating on V-E Day. Several times, the blood bank truck appeared on the scene while hospitals were still rolling to their new locations. At the height of the Battle of the Roer, when


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several field hospitals crossed the swollen river almost side by side with the infantry, the trucks of Detachment A often delivered more than 500 pints of blood to them daily. Similarly, when the Ninth U.S. Army crossed the Rhine, the hospitals on the East Bank received the blood they needed as soon as they were set up.

In all, Detachment A (Provisional) distributed about 35,000 pints of whole blood.

Detachment B (Provisional)

Detachment B of the 127th Station Hospital arrived on Utah beach on 22 October 1944 and reported to the 152d Station Hospital blood bank in Paris. Here, it received orders to proceed to Namur, Belgium, where it arrived on 26 October and where it received further orders to proceed to Saint-Trond, Belgium. Here, it began to work with Detachment B, 152d Station Hospital blood bank, and gradually took over from it the servicing of the forward hospitals supporting the Ninth U.S. Army.

Detachments C and D (Provisional)

When Detachments C and D (Provisional) of the 127th Station Hospital went to the Continent, they were attached to the Seventh U.S. Army (instead of the Ninth, as had originally been planned) because the advance section of the 6825th Blood Transfusion Company had been found too small to care for total Army needs. Until late in March, all blood collected by this company was shipped directly to the Seventh U.S. Army. Thereafter, the blood was routed through Paris, which permitted much more effective control and distribution, as well as augmentation of the inadequate supply.

Part VI. Blood Donors in the European Theater23

FIRST PROVISIONS FOR BLOOD DONORS

Before blood donor panels were formally established in the United Kingdom late in 1943, occasional suggestions were made to the effect that noncombatant troops follow the example of U.S. civilians and provide blood for casualties. These suggestions were all answered in the same manner:

1. At the time (1942), the demand for blood in the European theater was not very great.

2. The location of the blood banks in the United Kingdom, particularly the British blood bank at Bristol, limited donors to troops in the immediate vicinity of the banks.

23Unless otherwise identified, the material in this section is from the official diary of the ETOUSA Blood Bank (34) and from the official diary of General Cutler (23).


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3. As soon as blood collecting teams began to operate in the vicinity of particular organizations, members of these commands might voluntarily submit themselves as donors. It was expected that detachment commanders of units stationed in the vicinity of hospital blood banks would shortly set up panels of names of men who would be willing to donate blood upon call.

During this period, the emergency need for transfusions was met from the nearest available personnel, preferably from the recipient's own unit. The literal interpretation of the latter clause led to some difficulties, which were eliminated when instructions were given early in January 1943 that blood required for emergency transfusions must be secured from the nearest available personnel and not from members of the recipient's own unit if it did not fall into the category of availability.

FORMAL PLANNING FOR THE BLOOD SUPPLY

Formal plans for securing blood donations for combat casualties from U.S. Army personnel in the United Kingdom began in October 1943, with an inquiry by the Theater Chief Surgeon of the Professional Services Division of his office as to the effects of withdrawal of 500 cc. of blood. He had already notified Captain Hardin that it would be his policy not to use donations from combat personnel. On 31 October, Colonel Cutler notified General Hawley that in his opinion, in which Colonel Middleton concurred, the resistance of the individual who gave blood in this amount would not be affected adversely in any circumstances of weather or environment (65).

In November 1943, General Hawley wrote the Commanding General, Services of Supply, ETOUSA, as follows (66):

1. The lifesaving value of large-scale transfusions of whole blood during military operations has been repeatedly confirmed by the experience of the United States and of our Allies in other theaters of war.

2. It will be necessary to establish in the United Kingdom a reservoir of type O blood donors, under military control, in order to secure an adequate amount of stored whole blood for operations on the Continent.

3. Potential donors are present in large numbers in SOS military personnel in the United Kingdom. It is thought that a simple statement of the need for whole blood, contained in a call for volunteers addressed to soldiers with type O blood in SOS units, will have a highly satisfactory response.

4. The Blood Panel, ETOUSA, will consist of a consolidated nominal list of volunteers, to be maintained by the Chief Surgeon.

5. The collection of blood will not be required until approximately D+7. Subsequent listings may be required at 90-day intervals.

6. It is recommended that an initial call be made for donors for such a blood panel.

In accordance with General Hawley's suggestion, a letter dated 15 December 1943 and containing the following instructions was sent by Lt. Gen. John Clifford Hodges Lee, Commanding General, SOS, ETOUSA, to the commanders of Channel Base Section, Eastern Base Section, Western Base Section, and


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Southern Base Section. The Northern Ireland Base Section was not included because its geographic situation would not permit ready transportation of blood collected there to processing and storage depots. General Lee directed that his letter be published to all units of the command and that the appended message from him be read at the first formation after its receipt. The letter contained the following information (67):

1. The establishment of a blood panel for ETOUSA, containing the names of type O donors from SOS units, is required to insure an adequate supply of whole blood for the treatment of the wounded. The establishment of this panel has been approved by the Theater Commander.

2. It is therefore desired:

a. That a nominal list of type O volunteer donors be prepared in each unit and retained in unit headquarters.

b. That a record of the number of type O volunteers be maintained by units in the base section headquarters.

c. That the records just specified be corrected as of the 15th of each month and that, immediately following each correction, a report of the number of type O donors in each unit of the SOS troops in each base section be sent to the Commanding Officer, ETOUSA Blood Bank, 1st Medical Laboratory.

d. That upon call by the Commanding Officer of the ETOUSA Blood Bank, the volunteer type O donors of the unit specified be assembled at a designated bleeding station (ordinarily the unit dispensary) at an hour to be determined by each commander, which will not interfere seriously with the normal duties of the unit and which will be reasonably convenient for the bleeding team.

e. That only light duty be required of donors from the time of bleeding until reveille the following morning.

3. As a rule, four-fifths of a pint of blood will be taken at each bleeding,24 and no donor will be bled oftener than once in 3 months. The withdrawal of this amount of blood will have no ill effect upon the donor and will not reduce his physical capacity for work or predispose him to illness.

4. Active interest in maintaining as many volunteers as possible is enjoined.

The message from General Lee, to be read at the first formation after the receipt of the letter just abstracted, was, in summary, as follows (68):

1. Defeat of the enemy cannot be accomplished without the loss of life and wounding of United States soldiers.

2. Large quantities of blood, which medical considerations limit to type O blood, would be required for transfusion for their comrades in the field forces.

3. Volunteers whose identification tags showed type O blood were being asked to donate blood when called upon. Instructions would be issued as to when and where these donations might be made.

General Lee's message concluded: "You, who are eligible, may well be proud of this opportunity to place your name on this Roll of Honor-the Blood Panel, ETOUSA."

24The practice in the United States during and for several years after the war was to withdraw 500 cc. of blood at each donation. The smaller amount was used at this time because British bleeding bottles, after the anticoagulant was added, would hold only 400 cc. It is now (1962) United States practice to withdraw only 450 cc. of blood from each donor, it having been found that when the smaller amount is taken, the incidence of fainting is materially reduced.


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INITIAL RESULTS

It had been estimated that to maintain adequate supplies of whole blood for battle casualties in the European theater, at least 90 percent of all blood type O individuals in the Southern Base Section must volunteer as donors. The results reported on 10 March for the first solicitation (table 19) were not encouraging, and the second report, on 21 April (table 19), showed no great improvement.

TABLE 19.-Response to request for type O blood donors in the United Kingdom, spring 1944


Base section

Number of units

Number of donors

Percentage of troop strengths

 

10 March 1944

Eastern

116

4,589

58.80

Western

130

10,075

34.48

Southern

267

9,207

27.98


Total

513

23,871

40.35

 

21 April 1944

Eastern

135

5,316

62.48

Western

356

19,020

72.06

Southern

309

10,350

30.30


Total

800

34,686

55.55

On 6 April 1944, the Office of the Adjutant General, Headquarters, SOS, notified the base section commanders, SOS, and other headquarters commandants that the response to the request for blood donors had fallen far short of expectations (69). All were therefore directed to note the importance of this project and to consider methods of increasing the number of volunteer donors.

At a conference on blood supply in the United Kingdom on 7 April 1944, as well as several times later, it was tentatively suggested that if the response of blood donors continued to be unsatisfactory, consideration be given to paying them under Army Regulations No. 40-1715. This plan was never adopted.

POSTINVASION DONATIONS

Shortly after D-day, when it became evident that blood was in short supply, considerable publicity, chiefly informal, was given to the need for donors, and there were numerous volunteers from various sections of the theater chief surgeon's office, the Adjutant General's Office, and other offices. The reply to


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these offers was always the same, that the volunteers would be bled whenever a sufficient number of O donors could be brought together, and that the entire process would then be streamlined, so that there would be a minimum of delay and absence from duty. Numerous donations were secured from these sources.

Even the arrangement to fly blood from the Zone of Interior to the European theater did not end the need for local donations. Thus, on 24 September 1944, a little over a month after the airlift was instituted, the Operations Section, Office of the Chief Surgeon, noted that supplies at Prestwick were low and that a regular schedule of bleedings in the United Kingdom must be maintained if 1,000 pints of blood were to reach the Continent every day.

On 31 December 1944, Colonel Cutler wrote the deputy theater surgeon that the panel of blood donors in the United Kingdom had become very small. Two weeks earlier, General Hawley had approved the bleeding of combat troops in the United Kingdom if it were certain that they would remain there for 2 or 3 weeks after the blood had been taken. There had been no formal notification of this policy, and Colonel Cutler suggested that dissemination of the information be expedited.

On 15 January 1945, General Hawley notified the Surgeon, United Kingdom Base, that he had investigated the possibility of bleeding combat troops and had been assured by competent medical authorities that this would not be injurious to them. Blood from this source would add materially to the blood donor panel. General Hawley had also been assured that there was no physiologic or medical contraindication to using these troops as donors if they would not enter combat within 2 weeks after they had been bled. The theater commander had approved the bleeding of combat units staging in the United Kingdom. Now that he had done so, General Hawley wished this additional source of whole blood to be properly exploited through technical channels.

On 8 March 1945, a memorandum was sent out from Headquarters, Communications Zone, ETOUSA, to the chiefs of general and special staff sections of that Headquarters stating that the Commanding Officer, 152d Station Hospital blood bank, had reported a critical shortage of type O blood and had requested that "all personnel" be canvassed in an effort to secure voluntary donations. In this memorandum, the chiefs of general and special staff sections were instructed to submit to the Headquarters Commandant not later than 14 March 1945, a nominal list of personnel who possessed type O blood and were willing to donate it. The order was widely circulated and a considerable number of volunteers were thus secured.

The airlift of blood from the United States ended the problem of blood shortages except for occasional periods when blood was in temporarily short supply. Until the airlift was instituted, the effective organization of the local donor panel proved the key to the success of the ETOUSA Blood Bank. Plans for the panel were most efficiently implemented by Col. Robert E. Peyton, MC, and Col. Angvald Vickoren, MC, both of the Operations Division, Office of the Chief Surgeon, ETOUSA. Unit medical officers also were very helpful.


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BLOOD AND PLASMA DONATIONS TO BRITISH

The propriety of donations of blood by U.S. troops to British blood banks came up as early as 9 October 1942. On that date, Captain Hardin, then Liaison Officer at the blood bank in Bristol, wrote to Colonel Cutler that in certain areas, British hospitals were being furnished with small amounts of blood by U.S. Army units. This was a practice, he said, fully in keeping with general practices of reciprocity between the Royal Army Medical Corps and the U.S. Army Medical Corps.

One difficulty, however, had arisen: When blood was collected in U.S. Army hospitals and used in British military hospitals, some U.S. soldiers expected to be paid $10 per pint. Brigadier Whitby thought that if this were done, British civilians might also expect to be paid for donations, which would be against a longstanding British policy in both civilian and military practice.

Colonel Cutler ruled that U.S. personnel, whether civilian or military, would not be paid for the donation of blood.

On 17 June 1943, in response to an earlier query, The Adjutant General, War Department, informed Headquarters, SOS, ETOUSA, that the transfer of dried plasma from U.S. sources to Allied commands could not be approved. The plasma had been secured entirely through donations by patriotic Americans of blood to the American Red Cross, and it was intended only for U.S. fighting forces. Its production, moreover, was geared to estimated requirements, and there was none to spare. This ruling did not, of course, apply to the treatment of Allied personnel in U.S. Army medical installations or to the emergency use of plasma in Allied hospitals when there was no other plasma available.

Later, Colonel Cutler further ruled that U.S. troops would not be permitted to act as donors for British blood supplies. There would be unfortunate repercussions in the United States, he thought, if, with all the plasma generously donated by civilians, U.S. troops were required to give blood as well as to fight.

The question of U.S. Army donations to British blood supplies came up again late in 1943. On 20 October, Captain Hardin wrote to Colonel Cutler that, during a recent drive for donations, teams from the British Army Transfusion Service had met with considerable enthusiasm from U.S. troops, and, in at least one instance, the commanding officer of such a unit had offered to produce large numbers of donors. In fact, tentative arrangements had already been made for bleeding them. Brigadier Whitby was naturally pleased with the response but did not wish to proceed without definite approval of the Office of the Chief Surgeon. He desired to avoid possible unpleasant future comments by making it clear that the response was entirely voluntary on the part of U.S. troops and was not the result of any direct appeal to them.


529

This particular organization (the 29th Division), Major Hardin pointed out, because of its location would not be asked to volunteer in the U.S. bleeding program. If it were bled by the British, the donations would be completed by 1 January 1944. His own opinion was that no combat unit should be bled later than 60 days before it was expected to go into action.

Colonel Cutler replied on 24 October 1943 (65) that the bleeding of U.S. troops for British use represented a very important principle. It had been decided by the U.S. Army that blood would not be requested from any of its own combat organizations. If this particular combat division were bled, other troops might wish to volunteer, and, once the principle were violated, there would be difficulty in stopping the practice. He therefore recommended that the donation of blood by U.S. soldiers for British supplies be forbidden unless the staff at Headquarters, ETOUSA, could so guarantee combat dates that it would be certain that no troops would be bled later than 60 days before they went into action.

On 1 February 1944, Col. Howard W. Doan, MC, Executive Officer, Office of the Chief Surgeon, wrote Sir Francis R. Fraser, Director-General, British Emergency Medical Service, that while there would be no objection to individual U.S. soldiers' serving as volunteer donors for the British, the U.S. Army blood program was expected to get underway shortly (70). When it did, it would utilize all available sources for the procurement of whole blood and thus reduce the number of volunteers to the British supply.

In May 1944, the question came up again, this time in connection with the Air Forces (71). The Surgeon, Eighth Air Force, received a memorandum from the Surgeon, Headquarters, 1st Bombardment Division, to the effect that representatives of the British Red Cross had requested permission for their transfusion vans to visit Air Forces camps. The British arrangement would apparently not interfere with U.S. Army plans for collecting blood, since only SOS units and Ground Forces would serve as donors. Brig. Gen. Malcolm C. Grow, Surgeon, Eighth Air Force, referred the matter to the Chief Surgeon, ETOUSA, for decision, with the comment that in his own opinion, the request should be favorably considered if it would not interfere with the U.S. Army blood procurement program. It was understood that no flying personnel would act as donors and that all donations would be voluntary, with no pressure brought on Air Forces personnel to provide them.

At about the same time, a similar suggestion from another source was referred to the Professional Services Division, Office of the Chief Surgeon, by the Operations Division of that office, with the statement that the attached correspondence suggested that the Eighth Air Force had not been approached for blood donations. If so, it was the writer's opinion that a potential pool of donors had certainly been missed and the omission should be investigated by the Professional Services Division.


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The reply to the first letter (from General Grow) by the Deputy Surgeon, ETOUSA, Colonel Liston, and to the second letter by the Director of the Professional Services Division, Colonel Kimbrough, were to the same effect: When the ETOUSA donor panel for the blood bank was established on 6 January 1944, Air Forces personnel were the only U.S. troops engaged in active combat. East Anglia, where the Eighth Air Force was stationed, was not readily accessible to the British blood bank in the Southern Base Section of England. Finally, it was the intention to use Air Forces personnel as local donors for U.S. hospitals in East Anglia when the need for blood for them arose. Also, when the ETOUSA panel of donors was decreased by movement of SOS troops to the Continent, it might become necessary (as happened) to enlarge the panel by the addition of donors from the Air Forces. For these various reasons, Air Forces personnel could not be permitted to donate blood to the British.

PRISONER-OF-WAR DONORS

In August 1944, when German prisoners were being taken in great numbers, the suggestion originated with some of them that they be used as donors (72). On 6 September 1944, Colonel Kimbrough notified the Surgeon, United Kingdom Base, that the Chief Surgeon, ETOUSA, had no objection to this practice if the donors were volunteers.

PAYMENT OF DONORS

Although payment of blood donors was permitted by law and was practiced in the Mediterranean theater during most of the war (p. 423), General Hawley ruled that neither military nor civilian donors should be paid in the European theater. This ruling was duly incorporated in Circular Letter No. 51 (19).

It was tentatively suggested on several occasions, as already mentioned, in connection with planning for the invasion of the Continent, that it might be necessary to pay donors, but no action was ever taken on the matter. When the question was occasionally raised by hospital commanders, because of special circumstances, permission was always refused.

COMPENSATION FOR ACCIDENTS

When arrangements were being discussed for the maintenance of blood banks to be supplied from British civilian donor panels, Colonel Cutler took the position that claims for monetary compensation for accidents suffered by civilian donors who were being bled by U.S. Army medical officers should be the responsibility of the U.S. Government and not the British War Office. In the experience of the British Army Transfusion Service, according to Captain Hardin, claims had been small in both numbers and amounts. The American experience in this respect was also negligible.


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Part VII. Practical Considerations of the Blood Program in ETOUSA

PRELIMINARY PLANNING FOR THE AIRLIFT TO THE CONTINENT

Although whole blood was not an item of medical supply during World War II, the Overseas Branch, Supply Division, Office of The Surgeon General, had the responsibility for shipping it to the United Kingdom and thence to the Continent (73). That function entailed arrangements for air priorities and also required the coordination of shipments with the Air Transport Command for allotment of space based on the daily estimated needs of the theater.

October 1943

Early in October 1943, General Hawley took up with the Commanding General, SOS, ETOUSA, the logistics of the delivery of whole blood to the Continent as follows:

1. Whole blood must be transported rapidly to the locus of use and must be properly chilled during transport. Otherwise, it could not be used to render effective aid to the wounded. Failure of either delivery of the blood or refrigeration would spell failure of the blood program.

2. Shipment by air was the method of choice. If enemy action, weather, or other conditions prevented this mode of transport, then shipment by special refrigerated trucks, on high priority, would be necessary to insure safe delivery of properly chilled blood in adequate amounts.

3. It was recommended that the Commanding General, Army Air Forces, be called upon to assume primary responsibility for delivery of blood to the Continent and that necessary planning and policies to implement the service be prepared jointly by representatives of the Air Forces and SOS.

4. It was also recommended that the chief of transportation be notified that refrigerator vehicles carrying blood must have the highest priority for water transportation when air delivery is not possible.

November 1943

On 4 November 1943, Colonel Mason wrote to the Chief Surgeon, in reference to the communication just summarized, that while it might not be necessary to mention to the Chief, Transportation Corps, that blood shipped by refrigerated truck must be given the highest priority, approval of this specific arrangement by General Lee might prove very useful (74).

December 1943

In a conference held on 22 December 1943, Col. Edward J. Kendricks, MC, Surgeon, Ninth Air Force, informed Colonel Mason that Troop Carrier Command planes would deliver blood from the vicinity of the blood base depot


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to fields on the Continent in the vicinity of Army medical supply depots (75). The Troop Carrier Command of the Ninth Air Force had transported blood for the British Eighth Army in the North African campaign and was therefore familiar with the necessities.

Colonel Kendricks requested that a study be prepared concerning the maximum weight and space required for a single shipment of blood. The British had been allotted 2,240 pounds of cargo space daily for air transport.

April 1944

On 7 April 1944, in order that the logistic requirements of the blood program be placed in command channels, the Chief Surgeon requested that the air transport of whole blood to the Continent begin on D+14 and provided the following information (34):

1. The requirement of this operation is 500 pints per day.

2. This blood can be delivered by truck from the ETOUSA Blood Bank at the 1st Medical Laboratory to the nearest forward takeoff point in the United Kingdom for transport to designated fields or landing strips on the Continent.

3. The blood will be packed in cylindrical insulated iced containers, 18 inches high by 16 inches in diameter. The 50 containers required for 500 pints of blood can be stacked in a space 17.66 feet long, 2.66 feet wide, and 3 feet high. The total weight is 3,350 pounds. The average space occupied by 1 container is 2.8 cu. ft. Its empty weight is 32 pounds and its loaded weight, 67 pounds.

On 10 April 1944, the Commanding General, Ninth Air Force, upon request, sent the Office of the Chief of Staff, ETOUSA, the following information to implement the previous request for an allocation of daily cargo space to cover the combined air tonnage requirements of blood and medical supplies for the Army, the Army Air Forces, and the Communications Zone on the Continent(76):

1. Designation of an airfield in the immediate vicinity of Salisbury, where the main storage point and personnel to handle the blood were located, would be most desirable. As a second choice, a field in the immediate vicinity of Thatcham, Berkshire, Greenham Common, or Aldermaston would be satisfactory. If an airfield near Thatcham were designated, blood would be delivered daily to the medical section in Depot G-45 at this location and held there in refrigerators until called forward by the Air Force. Then it would be placed in iced, insulated containers and delivered in trucks to airfield personnel at the time specified.

2. Whole blood prepared for air shipment would be packed in U.S. Quartermaster insulated food containers, each holding 10 bottles of blood and 10 recipient sets. Refrigeration would be maintained by cracked ice (10 pounds to the can) in an insert placed on top of the bottles. This arrangement would maintain optimum refrigeration for approximately 40 hours in an air environmental temperature between 65° and 85° F. (18° and 28° C.). Packing of the containers and their delivery by truck to the designated airfield would be the responsibility of the blood bank.

3. The Air Force would load the containers on the plane and transport them to the far shore within the limit of the lifts authorized and subject to military situations and flying conditions. Here it would unload the containers and turn them over to the medical representative of the Army Advance Section, Communications Zone, or Forward Echelon, Communications Zone, whichever was located at the receiving field on the far shore. Distribu-


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FIGURE 119.-Loading blood in refrigerated marmite cans for shipment to European Theater Blood Bank by a mobile unit, March 1944. Blood was collected at Shoot End Camp, Alderbury, England.

tion of the blood after its receipt would be made by the advance blood depot attached to the Army Advance Section, Communications Zone, or Forward Echelon, Communications Zone.

4. Empty shipping containers and used blood recipient sets would be collected by advance blood depots and delivered to airfields designated by the Ninth Air Force, whence they would be returned to the Greenham Common Airfield. Here they would be turned over to the Medical Section of Depot G-45 located there.

Over General Dwight D. Eisenhower's name, the information in this letter was sent to the Commanding Generals of the 1st Army Group, the U.S. Strategic Air Force, the First and Third U.S. Armies, and the Ninth Air Force.

Generally speaking, this was the plan by which blood was transported to the Continent during the fighting in Europe (figs. 119-126).

Before D-day, the plans for air supply from the United Kingdom to the Continent included a CATOR (Combined Air Transport Operations Room) to assign priorities, allocate aircraft and tonnage, and coordinate air movements (77). Lt. Robert E. Pryor, MAC, was appointed to coordinate the movement of medical supply by air and to be the representative in CATOR. Direct communication was authorized between the commanding officers of the blood bank and the Troop Carrier Command, which was to fly the blood in C-47 planes. Basic policies and procedures for decentralizing the operation were therefore worked out satisfactorily. In addition, the liaison officer of the Ninth Air


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FIGURE 120.-Marmite can, opened to show whole blood packed in ice for shipment to 120th Evacuation Hospital, June 1944.

Force visited the blood bank on 2 May 1944, to become acquainted with the staff and to learn their special problems.

Greenham Common, the airfield selected for the takeoff of planes carrying blood, was excellently located for this purpose. It was only 3 miles from Depot G-45, to which blood was to be delivered, and only 38 miles from the ETOUSA Blood Bank at Salisbury.

By D-day, arrangements had been concluded with the 21 Army Group (British) for a daily 4,000-pound airlift to the Continent for blood, penicillin, and biologicals, with additional standby provision for emergency shipments.

AIRLIFT TO THE CONTINENT AFTER D-DAY

From the beginning, the planned airlift worked excellently (59). As early as D+1, ether and penicillin were being dropped by parachute to medical units on the beaches. By D+7, emergency landing strips were available on the far shore, and, weather permitting, daily shipments of blood went forward from that date. By the end of June, the daily tonnage exceeded the original allocation, and a second plane was added to the airlift, so that 5 tons of blood and medical supplies per day could be transported to the far shore. The two


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FIGURE 12l.-Interior of C-47 loaded with whole blood in refrigerated marmite cans for shipment to ADSEC Blood Depot in France, summer 1944.

C-47's flew so regularly that their flights were described in official documents as the milk run. Additional planes were supplied for special emergencies.

The whole system worked smoothly. When blood was delivered to the planes in the United Kingdom in marmite cans, with a block of ice or cracked ice in the top insert, it reached the Continent in good condition, with temperatures of 39° to 40° F. (4° to 4.5° C.), even when outside temperatures were as high as 85° F. (28° C.), the maximum expected.

In September, after the fall of Paris, the Supply Division established a receiving point, with office and storage space, at Le Bourget Airfield. This was the terminus of the milk run from the United Kingdom.

Getting supplies forward to the armies was another matter. This problem was solved by Lieutenant Pryor's discovery near Paris of a squadron of 20 small C-64 planes which were not being used; they were too large and too slow for observation and liaison work and too small for routine cargo work. Their personnel, because of their enforced idleness, were unhappy and frustrated. Arrangements were made with this squadron to fly blood and medical supplies forward and bring back wounded, usually five per plane (three litter patients


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FIGURE 122.-Blood in refrigerated marmite cans being unloaded from C-47 on grass landing strip by soldiers of ADSEC Blood Depot, France, summer 1944.

and two sitting patients). The movements of the planes were controlled from General Hawley's office.

This was an admirably successful arrangement. In 3 months, these planes transported 30,000 pints of whole blood, in addition to 463 tons of other medical supplies. On the return trips, they evacuated 1,168 patients.

On 1 September 1944, the Chief Surgeon requested G-4 to arrange for permanent diversion of the two transport planes which had been assigned for the daily airlift of blood from the United Kingdom to the Continent from the airstrip originally used to a strip farther forward (78). The requirements for whole blood had moved forward with the armies, and it was no longer satisfactory to haul the blood forward by shuttle plane or transport it by road. Blood from the United Kingdom was now augmented by blood from the Zone of Interior, and it was imperative that all supplies arrive at their final designation as rapidly as possible.

On 22 September, Colonel Hays requested G-4, ETOUSA, to notify PEMBARK that hereafter, all shipments of blood from the Zone of Interior should be flown to Paris and that shipments to Prestwick, Scotland, should be permanently discontinued (79). This change was effected.

Air transport to forward areas was continued as long as flying conditions permitted. During December, however, the weather was so unfavorable that truck and train shipments became standard procedure. When truck transport was used, deliveries were most satisfactory when there was a prearranged


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FIGURE 123.-C-47 plane arriving at airfield in United Kingdom with wounded from Continent, July 1944. It will carry blood from the United Kingdom Blood Bank on its return to the Continent.

rendezvous between vehicles of base and advanced depots. When good flying weather returned in the spring, the tedious, time-consuming delivery of blood by road was discontinued.

In early December, the only contact the blood bank had with the Seventh U.S. Army was by air. Later, blood was shipped to it by regular passenger train also; during the first week of February, this was the only means by which blood reached this Army.

In January 1945, 45 of the 60 C-64 planes were replaced with 7 C-47's, which gave a daily airlift of 17½ tons for blood and other medical supplies. These planes were frequently used to pick up supplies in the United Kingdom and deliver them directly to the armies. After the Rhine had been crossed, the armies were so far ahead of established depots and were operating in territory in which rail transportation had been so completely disrupted that the medical service was fortunate in having an adequate airlift.

OTHER MEANS OF TRANSPORTATION

The Red Ball Coaster Freight Service, set up before D-day, amounted to rapid delivery service by speed boats from ports in southern England to the far shore (34). Because it was not under medical control, it was employed only during the early days of the invasion, at which time it was very useful. When blood was carried by this service, it was top-loaded; that is, it was last on and first off. The Army had personnel on the beaches in Normandy to search for and receive emergency cargo arriving by these boats.


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FIGURE 124.-Delivery vehicle with 80-pint refrigerator in truck body. Behind this vehicle is 1,000-pint mobile refrigeration truck of Detachment A, 152d Station Hospital, First U.S. Army, Belgium, October 1944.

Another plan for the immediate delivery of blood in the early days of the invasion was, as already mentioned, less successful than other methods. In the discussions before D-day, the daily shipment of blood on hospital carriers, with couriers to meet the boats and take the blood off, seemed to many participants the simplest, and therefore the most foolproof, method of getting blood across to the far shore. The plan was put into effect on D-day, but all but one of the assigned hospital carriers had to put back to port for various reasons. Very little blood was therefore delivered by this route.

Dropping of blood by parachute was discussed in the planning in the Zone of Interior for blood in the European theater, but the Surgery Division, Office of The Surgeon General, did not recommend it because it did not seem necessary and the idea was dropped. If it had been used, appropriate containers would have been required.

AIRLIFT FROM THE ZONE OF INTERIOR

The initial request for an airlift from the Zone of Interior to the European theater was made by Colonel Hays to the theater G-4 on 1 August 1944. After pointing out the inability of the blood bank in the theater, even operating at maximum capacity, to supply the needs of the army fighting in France, he specified the requirements for a daily airlift of blood alone of 1,000 pounds,


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FIGURE 125.-Refrigerator truck being loaded with blood by enlisted men of Continental Section, European Theater Blood Bank, November 1944. This blood was collected in England. Note British bleeding bottles.

which, with the necessary refrigeration, would amount to 6,700 pounds (500 cu. ft.). The blood would be carried to Europe in iced marmite cans (standard Quartermaster 4-gallon, insulated food containers). The returning airlift would require only 4,500 pounds but would require the same space, since an empty can, although it weighs less, takes up as much space as a full can. If the refrigeration units for planes under development at Wright Field, Dayton, Ohio, should become available, the requirements would be less, since marmite cans and ice would no longer be necessary.25

On 12 August 1944, G-4 Headquarters, ETOUSA, was requested by the theater Chief Surgeon to advise The Adjutant General, War Department, that the theater was prepared to accept 258 pints of blood daily, and had the refrigeration to care for it. A daily airlift of 300 pints had been assigned. Each container, with 10 pints of blood and the requisite amount of ice, would weigh 67 pounds and would occupy 5 cu. ft. of space. The total allotment required was 2,010 pounds and 150 cu. ft. of shipping space. The return

25Colonel Hays' reference was to the work then underway at Wright Field, in collaboration with the Division of Surgical Physiology, Army Medical School, to develop a refrigerator for blood which would operate in planes on 24-volt batteries. This work was not completed until late in 1944, and only the prototype was available when the airlift to the European theater was instituted (p. 208).


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FIGURE 126.-Whole blood being unloaded from 2½-ton refrigeration truck at 16th Field Hospital, Boulaide, Belgium, December 1944.

airlift would weigh only 1,350 pounds. Shipping requirements would be increased as Zone of Interior production increased.

On 18 August, General Hawley was notified by General Kirk that the blood shipped from the Zone of Interior would not be refrigerated in transit on the plane and that the containers need not be returned. The request for transportation to G-4, ETOUSA, was altered accordingly. Since the blood would be placed in marmite cans when it was unloaded at Prestwick and would be refrigerated during transit to the far shore, an airlift of only 4.5 pounds would be necessary for every pint of blood delivered to France.

On 20 August 1944, Headquarters, ETOUSA, was informed that the first 300 pints of blood would leave PEMBARK the following day; that shipments would increase to 500 pints daily as soon as sufficient blood could be procured; and that the blood received at Prestwick must be flown to the far shore as soon as possible.

Arrangements were made with the Air Transport Command, ETOUSA (CATOR), to fly the blood daily from Prestwick to the far shore, landing, until


541

further notice, at the Courtil Airstrip. Colonel Hays, on 27 August, issued the following instructions for handling the blood:

1. The blood received from the Zone of Interior was to be placed at once, in its original carton, under refrigeration. All cartons would be marked with the date of receipt and the oldest blood would be shipped out first.

2. Blood would be shipped to the Continent in the cartons in which it was received, not in the marmite cans originally proposed. Daily telephonic reports would be made to CATOR at Air Headquarters, Norfolk House, London, stating the number of cartons on hand to be transported and their weight.

3. Unless the atmospheric temperature was between 30° and 50° F. (-1° and 10° C.), blood would be kept in the refrigerator at Prestwick until word was received that the plane was ready to receive it for transportation to the Continent. Pilots were to be cautioned that blood must not be allowed to freeze en route and that the cabin temperature was to be kept as close as possible to the temperature range just specified.

REPORTS AND ESTIMATES

The original plan for a weekly report of blood movements at Prestwick was changed on 6 September 1944 for a daily report, to include the number of bottles of blood on hand from the previous day, the number received from the Zone of Interior, the number shipped to the Continent, the number otherwise disposed of, and the balance on hand at the end of the day. Similar totals were also requested for each week, with any comments desired. One copy of each daily report, addressed to the Office of the Surgeon, Headquarters, Communications Zone Forward, for the attention of Colonel Hays, was to accompany the blood being transported. A second copy was to go to the same office by air courier, and a third was to go to the Office of the Surgeon, United Kingdom Base, attention the Supply Division.

Daily airlift requirements, as just noted, were to go to CATOR in London.

REFRIGERATION AND TRANSPORTATION

Transportation of blood in the European theater from base banks to using hospitals in forward areas involved questions of refrigeration as well as transportation.

Pre-D-day Planning and Procurement

Transportation.-In October 1943, Colonel Perry, then Chief, Finance and Supply Division, Office of the Chief Surgeon, wrote The Adjutant General, War Department, through channels, concerning the requirements of the whole blood service, pointing out that special provision must be made for it (PROCO) because it was operating without a T/O or a T/E (80). All items necessary could be obtained locally except cargo trucks, 30 (later 34) of which were requested. Twelve should be delivered by 1 November 1943, twelve by 1 February 1944, and the remainder by 1 April 1944, so that the necessary minor alterations could be made on them, to convert them to their new purpose, and


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to mount refrigerators on them. This would take a minimum of 8 hours for each truck.

These trucks had not been received by 17 March 1944, and twelve 6 by 6 cargo trucks were requested as an advance issue of the total requisition so that conversion could be begun. In this same memorandum, Captain Hardin described the various trucks he had examined and explained why he had selected the 2½-ton, 6 by 6 cargo truck as most suitable for transportation of 400-pint refrigerators.

By 18 April, 12 of the 34 trucks requisitioned had been received and were already in use by the blood bank. It was urgently requested that delivery of the remainder be expedited. It would take 3 weeks to convert them, and they must be ready before the start of operations on the Continent, for the ETOUSA Blood Bank could not function without the necessary vehicular equipment.

By the middle of May 1944, all necessary vehicles for the First U.S. Army had been received and were in use or ready for issue. The vehicles for the Third U.S. Army had also been received and would be ready for issue as soon as refrigerators were mounted on them. Earlier, the blood bank had been instructed to classify these trucks as surgical trucks; mark them permanently with Red Cross markings; mark the cab visors "ETO Blood Bank"; and use them only for the supply, packing, and transportation of whole blood.

Refrigeration.-Although PROCO was not approved until 27 October 1943, the refrigerators requisitioned for the blood bank arrived well in advance of the need for them. Because of shortages in the United States, however, it had been feared that they might not arrive on time, and steps were therefore taken to procure them in the United Kingdom. Through the efforts of Colonel Perry, Brigadier Whitby, and Lt. Col. (later Brigadier) John P. Douglas, RAMC,26 the British furnished:

7 walk-in refrigerators, each of 1,000-pint capacity, which took care of the initial requirements for fixed storage at the base and the requirements of mobile units. Each refrigerator had an attached motor-driven unit, which the British also furnished.

2 bulk-delivery 500-pint capacity refrigerators, suitable for use in communications zone depots.

30 smaller refrigerators, of 60- to 80-pint capacity, for the blood bank.

All of these items were available by 1 April 1944, which made it possible to plan for D-day as follows:

6 refrigerators for the base depot, each with a capacity of 600 pints of blood.

4 refrigerators, of 80-pint capacity, mounted on 2½-ton trucks on the hards, where there would be two advance section line of communications blood depots.

2 storage refrigerators, of 600-pint capacity, with the advanced blood depots.

4 refrigerators, of 540-pint capacity, mounted on 2½-ton trucks.

8 refrigerators, of 80-pint capacity, on 2½-ton trucks for the Third U.S. Army advance depot.

26Brigadier Whitby and Colonel Douglas furnished invaluable help in all the planning and organization of the U.S. Army Blood Bank, including the provision of bottles, tubing, needles, and a few other items which had to be obtained from British supplies. Their extensive experience was also helpful in the solution of many problems of logistics.


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The overall capacity of the refrigeration described was 8,240 pints of blood.

Post-D-day Transportation

On 23 June 1944, 2½ weeks after D-day, a message was sent to the War Department from ETOUSA, requesting additional vehicles for the blood bank, the capacity of which was not sufficient to meet the requirements of the present situation. Since the troop basis would shortly be supplemented by two additional armies, a request was made for 30 additional 2½-ton 6 by 6 trucks; 4 days later, the request was increased to 34. If this type of truck was not available, 1½-ton trucks would be acceptable. The basis of the request was that requirements for blood had proved far larger than originally estimated, that the blood bank in the United Kingdom could not further increase its capacity, that it was not possible to build up reserves of a perishable substance such as blood, that a blood bank must therefore be established on the Continent with the assurance that it could provide adequate supplies of blood as they were requested.

On 12 July 1944, the 152d Station Hospital informed the theater Chief Surgeon that its requisition for 30 additional trucks for the expansion of PROCO III had been disapproved by the War Department and, without increased transportation facilities, increased demands for blood could not be met.

Although the original request for additional trucks was refused, the refusal was later countermanded and the trucks, of the type specified, were duly delivered, thanks in large part to the firm stand in the matter taken by Colonel Hays.

FIELD TRANSFUSION UNITS

Authorized Personnel and Equipment

On 2 January 1944, in a memorandum dealing with whole blood, Headquarters, ETOUSA, informed the Commanding General, First U.S. Army, that the following personnel and equipment would be furnished each field army without requisition and would be regarded as over and above T/O and T/E provisions (32):

1. Personnel: 1 officer and 22 enlisted men.

2. Transportation: Nine 2½-ton trucks; one ¼-ton truck; two motorcycles solo.

3. Other necessary transfusion equipment, including about nine refrigerators to be transported on unit transport.

Preparation of Equipment

After the Ebert-Emerson transfusion set had been approved in 1943 by the Medical Supply Board, Office of the Chief Surgeon (p. 185), the first problem


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was to find an appropriate place for assembling and packing the sets. With some minor alterations, appropriate facilities were found at Thatcham, and General Hawley ordered that, as supplies for the sets became available, they be transferred there and frozen for use in field units. The assembly and packaging of the units was accomplished under the supervision of Maj. (later Lt. Col.) Charles P. Emerson, MC, who was sent to Thatcham on temporary duty.

Shortages.-The assembly of the sets was not a simple matter because of shortages and substitutions (81). Although Baxter bottles had been requisitioned, British bottles were received, and, to avoid further delays, they were used. Only 3,000 vials of sodium citrate solution with beads were received, instead of the 10,000 necessary for the 350 (reusable) transfusion sets to be supplied to each field army. The British vials, which were substituted, were the same size as the U.S. vials but had to be repacked because the British packing was undesirably bulky. The instructions to be included in each set did not arrive at Thatcham until 14 February, several weeks after the assembly of the sets had begun. In April 1944, the prospects were that it would take 10 months for British firms to fill the order for 70,000 Welsbach gas mantles to be used as filters. The 15-gage needles to be substituted for the 17-gage needles originally used were requested from the Zone of Interior on air priority, but they were still not available by the end of August. Special requests had to be placed in April and May for such items as 3,800 adapters to be used to attach the Luer needle to the rubber tubing in the units.

Shortages of blood donor needles, filters, and rubber tubing continued even after D-day until they were corrected by shipments of whole blood from the Zone of Interior.

Allowances and Distribution

There was considerable discussion on the matter before the distribution of transfusion sets was settled in the European theater. The original plan was to supply 2 sets to each clearing company, evacuation hospital (400-bed, 750-bed), and field hospital, and 10 sets to each auxiliary surgical group (82). Later, the distribution was modified to provide 6 for each field hospital and 20 for each auxiliary surgical group. It was estimated that 350 field transfusion sets would be needed for each of the two field armies then contemplated (83).

In January 1944, these estimates were expanded. On the basis that 2 casualties out of each 10 would require transfusion, it was estimated that about 20,000 sets would be needed for each 100,000 expected casualties, which meant that 4,000 sets should be ordered at once (84). It was then expected that sterile expendable transfusion sets would be ready for distribution in February and could be supplied to hospitals and used as replacements for the field transfusion sets then packaged in ammunition cases.

The suggestion that station and general hospitals be provided with field transfusion units was not accepted, since whole blood transfusions could be accomplished in them by modified British sets, which would be requisitioned


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through channels from the British Army Transfusion Service (p. 179). These hospitals were so equipped, furthermore, that they could clean and sterilize their own equipment.

By 13 March 1944, all field transfusion units had been completely assembled at Thatcham (85). They differed from the units originally planned in two respects: That the amount of typing serum was sufficient for only 25 donors, not for 50, and that, because of shortages, citrate had been secured from British and not U.S. sources, which decreased the number of transfusions possible with each set from 18 to 10 or 11. Individual organizations, however, could requisition additional citrate and typing sera as needed.

The 175 transfusion sets requisitioned by the First U.S. Army were delivered to it about the time expendable transfusion sets were first received from the Zone of Interior. The latter were in very short supply-by 11 May, only 1,815 of the 4,000 sets requisitioned on 20 January had been received in the theater-and, for this and other reasons, it was not considered advisable to replace the Ebert-Emerson sets already delivered to the First U.S. Army. The Third U.S. Army, however, which had requisitioned 250 of the field transfusion units, was supplied with the expendable sets, on the basis of two of the disposable sets for each of the field transfusion sets requisitioned. When the First U.S. Army required replacements, it, too, would be provided with the disposable sets.

All problems of this kind were eliminated when blood began to be flown from the United States to the European theater, since disposable giving sets were included with each unit of blood.

ROLE OF THE SUPPLY DIVISION IN THE WHOLE BLOOD PROGRAM

Initial Planning

While the whole blood program in the European theater could not have been operated without the aid of the Supply Division, Office of the Chief Surgeon, ETOUSA, this division had no responsibility at all for the collection, processing, storage, or distribution of blood (73). That was the responsibility of the ETOUSA Blood Bank, at the 152d Station Hospital, with the later support of the 127th Station Hospital. The function of the Supply Division was threefold:

1. To call up blood from the Zone of Interior and the blood bank at Salisbury according to the demands for it from the field.

2. To provide the necessary supplies for the operation of the bank.

3. To aid logistically in securing transportation for the blood.

The relation of the Supply Division to the blood program first appeared in a memorandum from Headquarters, ETOUSA, to the Commanding General, First U.S. Army, dated 2 January 1944 and dealing with the provision of whole blood from the Medical Service (32, 86). In this memorandum, it was stated


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that whole blood would be an item of medical supply which would be distributed through medical supply channels and given the highest priority in transportation.

On 17 March 1944, in a conference between Colonel Muckenfuss and Major Hardin, it was agreed that all requests for supplies of whole blood should proceed through the same channels as requests for medical supplies. On 12 April, this understanding was expanded to indicate that "through normal channels" meant that requisitions would proceed from the Continent to Headquarters, G-4, SOS, where they would be extracted, sent to the theater chief surgeon's office, and then relayed to the base blood depot. This procedure, it was estimated, would consume 48 hours.

Early in March 1944, the Supply Division began to plan for the delivery of blood from the blood bank at Salisbury to the Continent via Depot G-45 at Thatcham (73). It would be the responsibility of the blood bank to get the blood to this depot and the responsibility of supply personnel at Thatcham to see that it was loaded on the plane and that provisions were made for icing the blood from this point until it reached the Continent. When blood was shipped from the bank at Salisbury, and later, when it was shipped from the Zone of Interior, it was the responsibility of the Supply Division to see that it was properly iced along the way. If any shipment of blood was improperly iced or was mishandled for any other reason, it was the responsibility of the Supply Division to investigate the circumstances and correct them if the division was responsible; if not, the blood bank was informed.

Implementation of Plans

The assignment of planes in which blood was transported to the Continent cleared through the office of Colonel Hays, not only because of the priority for blood but also because of the priority of other supplies, particularly penicillin, which were sent to the Continent on an emergency basis. Personnel of the Supply Division soon learned that, when planes were difficult to procure, blood and penicillin were both magic words.

No difficulties arose in the relation of the blood program to supply channels as long as the blood bank remained at Salisbury. In September, when the 152d Station Hospital blood bank moved to the Continent, some misunderstandings developed.

On 23 September 1944, Colonel Kimbrough wrote the Executive Officer, Office of the Chief Surgeon, suggesting that a circular letter be published, stating that:

1. The 152d Station Hospital would operate the Continental Section of the ETOUSA Blood Bank.

2. Major Hardin, commanding officer of the hospital, would serve as director of the bank, in addition to his other duties.

3. Technical supervision of the bank functions (that is, procurement, processing, storage, and distribution of blood) would be the responsibility of the Professional Services Division, Office of the Chief Surgeon, ETOUSA.


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Colonel Hays objected to this proposal, on the ground that the division of responsibility within the Office of the Chief Surgeon was not a matter for a circular letter. In his opinion, the outside world should consider this office as an entity, and the division of responsibility and authority in it should be handled by an office memorandum. He called attention to Office Memorandum No. 10, 17 September 1944, over the signature of Colonel Doan, Executive Officer, Chief Surgeon's Office, which stated that the Supply Division of this office was responsible for the requisitioning of blood in adequate quantities to meet requirements on the Continent and for its proper and timely distribution. These responsibilities would require intimate coordination with other divisions of the Office of the Chief Surgeon, especially by the Professional Services Division and the Plans and Operations Division. Associated divisions were reminded to keep the Chief of the Supply Division constantly acquainted with the situation as it applied to their particular activities. Any irregularities or suggested improvements in procedure which came to the attention of any one division should be transmitted to the responsible division.

As a result of the discussion, in which others participated, Office Memorandum No. 10 was rescinded and Office Memorandum No. 19, dated 30 October 1944, was issued in its place. In substance, it was as follows:

1. Whole blood for transfusion purposes is obtained from bleeding on the hoof (local bleeding), from the United Kingdom Blood Bank at Salisbury, or from the United States by air.

2. In the near future, blood will be furnished by a blood bank on the Continent. (As a matter of fact, by the time this memorandum was issued, the Continental Blood Bank had already been set up and was distributing blood.)

3. The provision of whole blood for transfusion is a complicated procedure, involving the establishment of technical standards, with technical supervision of collection; preparation; storage; transportation; issuance; and, finally, administration of the blood to the recipient. The division of responsibility and authority27 in this procedure is as follows:

a. The Professional Services Division is responsible for the establishment of standards and for technical supervision of the collection, processing, and administration of whole blood.

b. The Supply Division is responsible for the supervision of transportation, storage, and distribution of the blood.

4. Since blood is chiefly transported by air, and since the same planes are used for the transportation of other medical supplies, the transportation and distribution of blood and other medical supplies moved by air are very closely related.

5. In carrying out the duties assigned to him, the Senior Consultant in Blood Transfusion and Shock, Major Hardin, who is also commanding officer of the Continental Blood Bank, will operate under the supervision of the Professional Services Division and the Supply Division as just outlined.

6. All divisions of this office (that is, the Office of the Chief Surgeon, ETOUSA), will keep the Chief of the Professional Services Division and the Chief of the Supply Division acquainted with any matter pertaining to the supply of whole blood within the division of responsibility as just outlined. Information to higher echelons and instructions to lower echelons, including requests for information, will be routed through these channels.

27This division of responsibility proved to be as unnecessary as it was undesirable. It worked in this instance because Major Hardin made it work; an officer of lesser stature might readily have failed. The present (1962) policy is to place the entire responsibility for the transfusion service in professional hands.


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Occasional difficulties continued to arise, but, on the whole, the relation of the whole blood program to supply channels was cooperative, and personnel of the blood program freely admitted their obligation to the Supply Division for its successful operation.

SECURITY MEASURES

Unusual activity in the blood bank would, of course, have been a clear indication that the date of the invasion was approaching. On 1 May 1944, General Hawley wrote to the Commanding Officer, 1st Medical Laboratory (87), that the pony edition of Time for 24 April 1944 had carried an item to the effect that a recent dry run in the bank had been just for practice but that 3 weeks before the invasion, "the dry run will become wet." Obviously, General Hawley wrote, after such an announcement, no better indication could be given to the enemy of the date of the impending invasion than the inauguration of a stepped-up collection of blood. He found it necessary, therefore, to direct that blood be collected on the maximum possible scale from this date until the invasion; otherwise, it would not be possible to resume collection until after the invasion. He requested all details concerning the origin of this statement and concerning the clearance of the particular correspondent responsible for it.

In reply, Colonel Muckenfuss stated that no correspondent for this publication had ever visited the 1st Medical Laboratory; the term "dry run" had not been used in the laboratory for at least 3 months; small-scale bleedings had been made at frequent intervals; and blood could not be kept longer than 3 weeks, which made the statement about beginning to collect blood "in earnest" 3 weeks before the invasion obviously incorrect. He could therefore throw no light on the source of the statement. He added that he had discussed the problem of security several times with Major Hardin, to decide on methods of minimizing evidences of unusual activity in the blood bank.

Immediately after General Hawley's complaint was received, all bleeding teams were sent out from the bank every day, to work all day and collect blood in places in which there were only a few donors, who were bled behind ostentatiously locked doors. At the end of each long day, the few donations thus procured were rushed in clearly marked 500-pint refrigerators to the blood bank.

Actual blood collection for the invasion began 20 days before D-day, but, by Colonel Muckenfuss' own desire, he was not informed of Major Hardin's time schedule, and, as the latter expressed it in 1961, "I was the only person who ever knew when the blood bank was actually turned on."28

28Queried as to the correctness of this statement, Dr. Hardin wrote as follows on 15 February 1963:
"The statement that I made that I was the only person who 'knew when the blood bank in the ETO was actually turned on' is literally correct. The circumstances under which this arose now have somewhat unreal characteristics, but went something like this.
"Several months before D-day the headquarters of the ETO blood bank was visited by a public relations officer who had in tow a Time reporter. Among the many questions asked of me was the one of how long blood could be kept. At that time the proper answer was 21 days and in due course there appeared an article in Time magazine which said the ETO blood bank would begin collecting blood 20 days before D-day. This was an assumption made by the reporter, but happened to be uncomfortably correct. As you can imagine, General Hawley was reasonably upset and he ordered me to undertake such activity as would make it impossible for people to know by observation when the ETO blood bank was actually 'turned on.' For that reason, we began somewhat hectic activity designed to produce confusion among all observers and among my own personnel. Bleeding teams were sent hither and yon, but always to units where there were too few donors to be of significance when we really started collecting blood. The blood was brought back to the central laboratory and processed and was distributed to hospitals so that there was no evidence at the central unit of how little blood was actually being collected.
"The units of the ETO blood bank which were to go across the Channel were put into positions of embarkation along with other troops behind the barbed wire along the southern coast of England some time in advance of the invasion. They were sent there without instructions as to what their mission was or where they were going. Later I was given a pass which let me go behind the wire and brief my units and, as a matter of fact, take blood to them for transport across the Channel. As you know, we landed our first depot unit in Normandy on D-plus one. In addition, we loaded blood on 104 ships, most of which were LST's converted to bring troop wounded back from France. No one in the unit knew where these ships were to dock and be loaded, nor the day nor time, except myself and I kept this after receiving it at the British Naval Headquarters in Southampton entirely in my memory, never writing it down. I personally supervised the loading of refrigerator trucks in Salisbury and these and their drivers went behind the wire where they were met by some of my officers already in that locality. After accomplishing their mission these trucks and drivers were kept behind the wire until the invasion of Normandy was a fact.
"My memory fails me as to the exact time but early in the spring it became necessary for me to know when D-day would occur. One morning at General Hawley's headquarters in London, I was taken to the middle of a large room by Colonel Liston and others and the date of D-day was whispered in my ear. I was told that this date was a planning date and that the actual invasion would occur within a 48-hour span of this date. Thus I knew when to begin the bleeding in the blood bank in earnest, when to put blood behind the barbed wire along the southern coast, and when to begin all of the operation in earnest. I was forbidden to disclose this date to anyone else, of course, and although several of the people in the unit must have realized that D-Day was imminent, I am certain that no one was actually aware of the real day until it happened.
"I hope this clears up my statement and I hope that none of us will ever go through that kind of an experience again."


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HOUSEKEEPING ARRANGEMENTS

As already mentioned (p. 499), the l52d Station Hospital, which served as the ETOUSA Blood Bank, was attached for housekeeping and general administrative purposes as long as it was in England, to the 1st Medical Laboratory. A similar arrangement was in effect for the 127th Station Hospital when it took over the blood bank functions of the 152d Station Hospital and the latter moved to the Continent.

Different arrangements were necessary when the 152d Station Hospital moved to the Continent, in September 1944. The parent bank in Paris was then attached for housekeeping and administrative purposes to the 1st General Hospital (p. 516).

The detachments of the two blood banks which operated in the field were attached for these purposes to any convenient medical supply depot, the commanding officers of which provided rations, quarters, space for blood storage, and other needs. These arrangements were highly satisfactory. The medical supply depots to which the detachments were attached rendered great assistance to them. The mobility of the Army medical supply depots made the setup particularly satisfactory, for the Army detachments of the blood banks also followed the armies which they served. Locations of station and evacuation hospitals were secured from the depots to which the detachments were attached, and some confusion sometimes arose.

The revised directives for ADSEC detachments (54, 57) provided for attaching them for rations and administrative purposes to the units which


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operated Army Air resupply strips. This plan was quickly put into effect by an agreement between the Commanding General, Ninth Air Force, and the Commanding General, ADSEC, and it continued to be standing operating procedure for the rest of the war. It had many advantages. The blood detachment could quickly unload the C-47's which transported their daily supply of whole blood. The distance between this location and the banks in the Army area was short. Communications with Headquarters, ADSEC, and the base depot of the ETOUSA Blood Bank were almost immediately available.

In order that commanding officers of these mobile blood units be unhampered by tight control, they were given relative freedom of action in planning their forward movements. The Surgeon, ADSEC, however, insisted upon prior clearance for moves when the situation permitted, for station list and order purposes, and, in an occasional instance, tactical requirements demanded other dispositions than those planned.

EARLY OPERATIONAL DIFFICULTIES

As might have been expected, a number of problems arose in connection with the whole blood service in the first weeks of its operation. On 19 July 1944, a number of them were called to the attention of Col. (later Brig. Gen.) John A. Rogers, MC, Surgeon, First U.S. Army, by General Hawley's office (88):

1. Trucks designated for blood were being required to carry out many diversified tasks, such as hauling tools, medical supplies, repair parts, and even personnel. This left insufficient time for the proper maintenance of these trucks and of the refrigerators mounted on them. If this unwise practice were continued, it could lead to serious interruptions in the blood program, for no trucks were available as replacements for these special trucks; they were essential for the delivery of blood.

2. The motorcycles and jeeps designated for the blood bank had been moved from its control and had thus lost their value for their designated purpose, which was to make contact with using units.

3. The blood bank was not kept posted on the movement of forward hospitals, and they were sometimes difficult to locate.

4. It would help materially in the use of blood if the blood service were notified when a hospital was closing and moving. The blood in its control could then be picked up and redistributed, and the hospital could be restocked when it was again in operation. Blood was too precious a commodity for any of it to be wasted through preventable deterioration.

It was evident, General Hawley concluded, that as more and more troops were committed, greater economy must be practiced in the use of blood. The limit of supply was fixed not by the organization which collected and processed it but by the availability of suitable donors. That limit had almost been reached, and it was therefore requested that necessary action be taken toward improving the efficiency of the blood service on the far shore.

The memorandum from General Hawley's office bore out complaints from members of the blood detachments. In June 1944, the commanding officer of one such detachment wrote to Major Hardin that his two motorcyclists had


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been placed on detached service and that he had just lost a sergeant. He wished no replacement for the latter, but if he had to have one, he wanted a private.

He still had no jeep. His trucks were working well, but were getting unnecessarily hard wear. He wrote:

In addition to hauling blood, we are ordered to pick up laboratory specimens. We have to carry the depot refrigerator mechanic and the depot sterilizer mechanic out to their jobs at one of the hospitals. We also carry parts and tools. We carry the men back to the depot or to a different hospital. We still haul some freight from the depot to advance sections or vice versa. We carry biologicals from the airstrip to the depot and optical repairs from the depot to the airstrip. We haul X-ray machines for repair and back.

It was increasingly difficult, the writer continued, to keep refrigerators in good condition because of damage caused to them by hauling freight. The trucks were kept on the road so much that their maintenance was as unsatisfactory as the maintenance of the refrigerators.

It was also difficult to keep up with the increasing number of hospitals in the area, the writer went on, now that the blood detachment was on the same post as the base platoon of the medical depot and information as to hospitals was no longer secured from First U.S. Army Headquarters. Changes in location were often received late and were often incorrect. On a recent trip, one of the detachment trucks had spent the entire night searching for the hospital to which its blood was consigned and did not find it until the next day, when correct information about its location was secured.

The writer found the failure of the Supply Division (headquarters not stated) to discuss proposed changes with blood personnel very discouraging: A recent ruling, for instance, that marmite cans be sent to field hospitals to increase the amount of blood to be kept on hand in them was put into effect without previous notice. The result would be an increased lag in the return of these cans and an imbalance in both cans and recipient sets.

This extremely pessimistic memorandum ended on a brighter note, that using hospitals seemed to be entirely satisfied with the blood service. The misuse of the trucks, however, of which the writer complained and which duplicated the experience of other detachments of the blood bank, further substantiated the importance of completely dissociating blood from medical supply.

INQUIRY INTO EFFICIENCY OF AIRLIFT TO EUROPEAN THEATER

On 8 January 1945, at the suggestion of Colonel Carter, who believed that the desired information would be expedited by personal communication, Major McGraw, who was now in the Office of The Surgeon General, wrote to Major


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Hardin asking for details of the operation of the oversea blood program (89). Up to that time, very little information had been received in the Office of The Surgeon General regarding blood sent to the European theater. Indeed, not much was known about what happened to it after it was put on the oversea plane. Improvements in handling were desirable and would be facilitated by information on the following points:

1. How long did it take blood to reach the ETOUSA Blood Bank? Presumably, it should reach it in about 24 hours after it was put on the plane, but there must be many occasions when bad weather delayed shipments en route. If so, steps should be taken to prevent both warming and freezing.

2. Were all shipments received? There was no assurance at the present time that blood might not often be landed at an alternative field and left unattended or even forgotten.

3. Was it desirable to send a courier with each shipment? Personnel of the North African Theater Blood Bank, with which Major McGraw had previously worked, considered it absolutely essential that a responsible person accompany each shipment of blood to northern Italy as well as to southern France. It was the courier's responsibility to see that the blood was properly handled at any emergency landing field en route and to secure land transportation to within a reasonable distance of its destination if the plane could not put in at the regular airfield.

4. In what condition did the blood reach the theater? There was concern that some of it might be frozen or hemolyzed, or that some containers might be broken.

5. Was enough blood being received? The Red Cross had heard unofficially that there was some resentment in the European theater because less blood was shipped than had been requested. The director of the Red Cross blood bank had reported this story to The Surgeon General, who could only reply that the last request from ETOUSA had been for 1,000 bottles a day and that 1,000 bottles a day were being sent. The shipments could be increased beyond this amount if the request was made.

6. Were the hospitals satisfied with the blood? Were there hemolytic or pyrogenic reactions from it? Were there any errors in blood grouping?

In this same letter, information was requested concerning titration practices. In Italy, a technique was employed by which it was possible to pick out about 30 percent of the highest titered O bloods. These bloods were marked for the use of O recipients only. The practice had been adopted because of a severe hemolytic reaction in a patient with group A blood, who had received group O blood with a very high anti-A titer (p. 424).

Most of these questions were answered by Capt. John Elliott, SnC, from his observations in the European theater on his visit there later in January (90). They are discussed under appropriate headings. In general, his report was highly favorable. So far as he could determine, no blood from the United States had been contaminated on receipt, nor had there been any errors in typing. About 18 bloods of each thousand had to be discarded because of hemoglobin in the supernatant plasma. Since it had been discovered in December 1944 that a small number of bottles of blood hemolyzed rapidly, for no reason that could be discovered, the plan had been adopted of allowing all blood to sediment for 24 hours before it was shipped out of the Paris Blood Bank (91). Each bottle was then examined visually before it left the bank.


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CLINICAL PROBLEMS

Difficulties With Equipment

On 27 June 1944, General Hawley requested G-4 to provide space on a plane the following day for Major Hardin to fly to the Continent. On his own visit, he had observed certain difficulties in the administration of blood, particularly maintenance of the proper rate of flow, which was a most important element in the procedure. He wished Major Hardin to investigate the trouble immediately.

Major Hardin arrived on the far shore the following day, and, in fulfillment of General Hawley's mission, visited the Office of the Surgeon, First U.S. Army; the 1st Medical Depot Company; the Advance Blood Bank (Detachment A) of the 152d Station Hospital; and the 45th, 67th, and 128th Evacuation Hospitals (92).

In discussions with Colonel Crisler, Consultant in Surgery, First U.S. Army, Major Hardin learned that the difficulties in the blood program were chiefly in the administration of the blood, during which the rate of flow was frequently inadequate. Most observers considered the filter at fault, but Colonel Crisler, as well as Col. William G. Amspacher, MC, Chief of Plans and Operations, Office of the Surgeon, First U.S. Army, believed that the filter was adequate and that the rate of flow was hampered by the size of the needle and the adapter. Some officers complained that they had lost patients because the blood clotted. While the complaints were most prevalent on the beaches, there were also difficulties in hospitals and they continued for some time, even after the Continental Blood Bank had been established.

Some officers overcame the poor performance of the filter by using gauze for filtration. Others transferred the blood to salvarsan tubes for administration. Still others, who were in the majority, applied positive pressure by means of a Higginson syringe obtained from the field transfusion set or a sphygmomanometer bulb. Results with all methods were about the same, but the use of positive pressure was not desirable because the tubing and adapters provided were not of a quality to withstand the pressure. When this expedient was employed, it was a common experience for the system to spring leaks, with the result that the transfusion had to be stopped and the blood being used had to be discarded. The solution would have been the use of l5-gage needles, but they were not available until much later.

Major Hardin considered all of these complaints justified. Transfusion should be a continuous and efficient procedure. In the period immediately after D-day, it was too often improvised and interrupted. It became continuous and efficient when expendable transfusion sets were supplied, with adequate filters and needles of larger bore.

Colonel Cutler believed that bank blood which clotted did not contain a sufficient quantity of citrate solution. It is true that when blood began to be


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received from the Zone of Interior in Alsever's solution, complaints of clotting ceased. Many observers, however, continued to believe that it was not desirable to give blood diluted 50 percent by the preservative solution.

When the expendable set was introduced, with the giving needle attached directly to the rubber tubing, there was seldom any difficulty in transfusing a casualty who had good veins. When the veins were collapsed, the situation was different. Since the needle was attached directly to the rubber tubing, without a connecting observation tube, it was not easy to detach the needle and hook it up to a syringe, to facilitate location of the vein. Some modification of the set was necessary in such circumstances. This was accomplished at some hospitals by cutting off the needle attached to the rubber tubing and replacing it with the needle and observation tube from the plasma set. After the needle had been connected to the syringe and the vein located, the needle was attached to the Luer tip of the observation tube before the transfusion was started.

Aging of Blood

On his visit to the European theater in September 1944 (1), Colonel Kendrick was informed of two transfusion reactions, accompanied by chills and fever, which had occurred in the 1st Platoon of the 60th Field Hospital, and of eight similar reactions in 50 transfusions in the 12th Evacuation Hospital. In discussions with the chiefs of the surgical and laboratory services in the hospitals involved, he learned that, in each instance, the blood was within a few days of the expiration date, or beyond it. Most of the patients for whom it had been used had lost a great deal of blood, and they were transfused with the aging blood because of their extreme need.

Further investigation revealed other special circumstances. Immediately after the service to Prestwick from the Zone of Interior had been inaugurated, there was a sharp reduction in the number of casualties and a corresponding decrease in the requirements for whole blood. As a result, there was a lag in shipments from the United Kingdom to France, and some blood was stored for 8 or 9 days before it was sent to the far shore. At one time, even though the collection of blood in the United Kingdom was halted altogether, there was a backlog of 6,000 pints of blood in the United Kingdom.

Major Hardin and Colonel Kendrick recommended that, beginning at once (26 September 1944), blood from the Zone of Interior be sent immediately from Prestwick to France, the oldest blood on hand being shipped first, to be sure that it was used before the dating period expired. They further recommended that blood which could not reach hospitals in France before the expiration date be used in general hospitals in the United Kingdom, or, if necessary, discarded entirely. It was expected that, as the number of casualties again increased, the lag would be overcome. This did not happen immediately, however, and for a time, blood continued to be sent to the far shore which had aged a week or more before it reached the using hospitals.


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An additional difficulty in this connection was that, because of bad flying weather and the consequent delays, some blood had already aged for several days in the Zone of Interior before it was flown to the United Kingdom.

The safety of using blood that was from 14 to 18 days old for exsanguinated casualties could not be readily determined from existing evidence. The impression prevailed that those casualties with depleted blood volume were more likely than others to have reactions after intravenous therapy.

On a priori evidence, this reasoning seemed sound. As blood ages, the amount of free hemoglobin in it increases, as does the amount of plasma potassium. Although the normal human kidney will tolerate rather large quantities (up to 5 gm.) of hemoglobin without significant pathologic changes, the exsanguinated casualty probably has a much lower threshold for this substance. When anoxia is added to lowered blood pressure and decreased circulating blood volume in a casualty who has suffered severe hemorrhage, it is logical to assume that renal function will be impaired. Then, if blood with 50 to 100 mg. of free hemoglobin per 100 cc. is injected, there is a real increase of free hemoglobin in grams per volume, and kidney function is further impaired. As a result, reactions might be expected.

While this reasoning was recognized as purely conjectural,29 it did suggest the need for providing greatly exsanguinated casualties with as fresh blood as possible. It also suggested the need for alkalinizing casualties who had sustained severe hemorrhage and had to be given 3-4 pints of blood over a short period.

After his tour of First and Ninth U.S. Army installations in September 1944, Colonel Cutler expressed the opinion that field hospitals should be given whole blood, that is, ETOUSA blood, while evacuation hospitals, in which the need for blood was generally less acute, should be given preserved Zone of Interior blood, in which there were fewer corpuscles. No action was taken.

The whole subject of reactions is discussed in detail under that heading (p. 649).

Use of Chilled Blood

Another subject brought up to Colonel Kendrick on his visit to the European theater in September 1944 was the use of chilled blood in exsanguinated patients. Clinical usage had demonstrated the safety of injecting blood at 39° to 43° F. (4° to 6° C.), and the practice was now routine in many civilian hospitals.

The injection of chilled blood into patients in shock from exsanguination, who were in an unstable state and exposed to cold surroundings, had not yet been investigated. It seemed safe to conclude that this practice would produce no biologic reactions, but the experience in field hospitals had shown that it caused chilly sensations, and both patients and surgeons objected to it. Colonel

29The present (1962) belief is that hemoglobin plus ghost cells originating in nonviable red blood cells are responsible for the reactions described.


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Kendrick therefore recommended that, whenever time permitted, blood to be used in exsanguinated casualties be removed from the refrigerator an hour before the transfusion. This practice had its own elements of danger: Blood could be used safely after it had stood at room temperature for 2 or 3 hours, but in the rush of caring for many casualties at once, it might be overlooked and left out of the icebox until it was no longer safe to use.

Part VIII. Statistical Data

QUANTITATIVE USE OF BLOOD

Initial Observations

When it became evident, soon after the invasion of the Continent, that much more blood would be required for combat casualties than had been anticipated, the question naturally arose as to how efficiently the blood available was being used. On this point there were several opinions.

When Major Hardin returned from the trip to the Continent which he had begun on 28 June, he reported that he had not seen a single casualty in whom transfusion had not been both helpful and desirable (92). It was being given to exsanguinated casualties to build up the hemoglobin level and restore lost blood volume and was also being used to combat gas gangrene. It did not appear to him that blood was being used to excess.

Statistical data were not readily available, but in the three evacuation hospitals which he had visited, the ratio of blood to casualties was 1:4.7 and the ratio of plasma, 1:3.2. The ratio of blood to plasma was about 1:1.4. Since many casualties had received plasma before admission to the hospital, these ratios could not be accepted as entirely accurate. There was perhaps some justification for the hope that the use of smaller amounts of blood, backed up by plasma, might produce almost as good results as the use of whole blood. Perhaps a ratio of one unit of blood to three units of plasma might be considered by First U.S. Army medical personnel, since the supply of blood would always be limited and the amount administered must be adjusted to the supply.

At about the same time as Major Hardin's survey, Colonel Zollinger conducted an investigation of the relative use of plasma and blood in forward hospitals (43). The shock teams which made the study reported that the ratio in field hospitals was 1.63:1 and in evacuation hospitals 1.34:1. More important than the actual figures was the opinion of the surgeons: A medical officer on one of the 3d Auxiliary Surgical Group teams, who had previously worked in North Africa and Sicily, stated that the greatest single medical blessing in the European theater was the availability of blood from the blood bank, which was making it possible to operate on, and save, casualties who would never have survived on plasma alone.


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On 1 July 1944, General Hawley wrote Colonel Rogers, Surgeon, First U.S. Army, that on a recent trip to the Continent, Colonel Cutler had gained the impression, as he had on his own recent trip, that in some units blood was not being used economically. Since there was a limit to the amount that could be supplied, use must be proportionate to the supplies available.

When Colonel Cutler transmitted Major Hardin's report (92) to General Hawley, he noted that the present ratio of blood to plasma indicated that only a little more plasma than blood was being given. He had expected that the amounts of plasma used would be at least double the quantities of blood used. He considered the present usage of blood quite satisfactory, but the Professional Services Division must be constantly alert to be sure that this valuable substance was being utilized correctly.

Essential Technical Medical Data from the European theater for October 1944 (93) also had some criticism of the excessive amounts of blood used in some cases. Investigation had shown that, on the whole, if appreciable benefit were not obtained after 4 pints of blood had been transfused, a consultation should be requested, to determine whether prompt operation would not be the proper procedure.

As time passed, the realization grew that, contrary to the first impression that blood was being used to excess, more was needed than had been given originally. By October 1944, shock teams were beginning to view more critically the necessity for correcting depleted blood volume by the use of whole blood. Canadian shock teams, working with apparatus for determining blood volume, had found that the reduction in severely wounded men averaged 33 percent, which was equivalent to a loss of 2,000 cc. in a man 5 ft. tall and weighing 70 kilograms. On the basis of this observation, the demand for blood by Army surgeons was not considered excessive.

Adjustment of Supply and Demand

One of the problems of the blood program was to supply blood in proportion to the need for it, since it is not a substance which can be stocked indefinitely. On 14 September 1944, General Hawley wrote General Kirk that, as soon as the supply of whole blood had been increased by the institution of the airlift from the United States on 21 August, the demand for it had decreased by about 75 percent, because of the slackening in combat (94). This had been a temporary situation. Now that the First U.S. Army was up against the Siegfried Line, it was expected that the need for blood would promptly increase again.

Even during slack periods in combat, when supply exceeded demand, care was taken to waste no blood. In December 1944, Colonel Kimbrough proposed, in a memorandum to Colonel Hays, that during such periods, general hospitals, which were required to supply their own blood, be provided with blood from the Paris bank. He had observed that whole blood was accumulat-


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ing for field use while at the same time general hospitals were having difficulty setting up blood panels. Colonel Liston, acting for General Hawley, concurred in this recommendation, and it was put into effect. Shortly afterward, the Battle of the Bulge resulted in renewed demands for very large amounts of blood.

Special and unexpected requirements for blood also sometimes arose. Thus, in the spring of 1945, the 182d General Hospital reported an unusual demand for blood, chiefly because of the malnourished condition of many liberated U.S. Army POW's (prisoners of war).

The real need for whole blood for wounded casualties is attested to by the experiences of individual forward hospitals. The 84th Field Hospital is an illustration. It landed on Omaha beach on 14 July 1944, operated for a short time with the First U.S. Army, and then was assigned to the Third U.S. Army. During August, it moved 13 times in support of the 79th Division Clearing Station. After 6 November 1944, it was assigned to the Seventh U.S. Army, in which it operated in support of division troops.

No matter where it was serving, the personnel of this hospital found, month after month, that from 60 to 90 percent of the casualties it received were either in shock or had been in shock within the previous 6 hours. Most of them had received plasma in forward installations, but almost without exception, they also needed large amounts of blood before they could be pronounced ready for operation.

CRITIQUE ON THE USE OF BLOOD ON THE CONTINENT

July-September 1944

In his tour of Army installations on the far shore in September 1944, as the Special Representative on Blood and Plasma Transfusions to The Surgeon General, Colonel Kendrick made the following observations (1):

1. The quantity of protein fluid that can be injected into a casualty over a period of time without undue reactions varies because of individual tolerances. As much as 9 pints of blood and 2-6 pints of plasma can be safely given over a 24-hour period, depending upon the circumstances.

2. A casualty with an organically normal cardiovascular system, who has suddenly become exsanguinated, can presumably tolerate the introduction of 3-4 liters of blood and plasma over a 24-hour period.

3. If casualties who have suffered severe hemorrhage do not respond to the amount of blood and plasma just mentioned, surgical consultation is necessary. Failure to respond may be due to continued hemorrhage or to the results of severe tissue damage, and prompt surgical intervention may be necessary.

4. Observations in field and evacuation hospitals in the First and Third U.S. Armies showed that excessive amounts of blood had sometimes been used. The most important single factor in the picture was the timelag between wounding and the beginning of treat-


559

ment. Casualties seen fairly early, that is, within 3 hours after wounding, were frequently benefited by blood in relatively large amounts, 8-9 pints given in 2-4 hours. If, however, the casualty was exsanguinated and the timelag had been long, up to 10-12 hours, very little improvement could be expected, even with enormous quantities of blood. Some patients had been given 27 pints in 18-24 hours.

From his observations on the Continent, Colonel Kendrick concluded:

1. From a practical standpoint, it was impossible to set arbitrary standards as to the relative quantities of plasma and blood an individual casualty should receive. The decision must be based upon individual evaluation of the amount of blood loss; the cessation or continuation of hemorrhage; the degree of shock; the blood pressure and pulse rate; the number and severity of the wounds; the timelag; and, most important, the general status of the patient.

2. If surgical consultation was requested when no improvement followed the transfusion of 3-4 pints of blood, tremendous quantities would not be used without adequate justification.

AIRLIFT TO THE EUROPEAN THEATER

The oversea service to ETOUSA from the Zone of Interior began on 21 August 1944 and ended on 10 May 1945. During this period, according to the Army Whole Blood Procurement Service, 201,105 pints of blood were flown across the Atlantic (table 20).

TABLE 20.-Final consolidated report of monthly shipments to ETOUSA, Army Whole Blood Procurement Service, 21 August 1944-10 May 1945

Year and month

New York shipments

Brooklyn shipments

Boston shipments

Washington shipments

Baltimore shipments

Total
shipments

1944

 

 

 

 

 

 

August

2,489

---

---

1,092

---

3,581

September

8,202

----

4,561

3,048

---

15,811

October

7,781

828

5,179

3,096

---

16,884

November

9,034

3,548

5,519

4,668

---

22,769

December

9,936

3,734

6,392

4,688

1,540

26,290

1945

 

 

 

 

 

 

January

9,959

4,301

7,219

4,881

2,487

28,847

February

9,042

4,244

5,826

3,768

2,388

25,268

March

10,994

5,402

6,524

4,999

2,591

30,510

April

9,226

4,503

5,282

3,499

1,897

24,407

May

2,420

756

1,641

1,237

684

6,738


Total

79,083

27,316

48,143

34,976

11,587

201,105

 


560

For the week ending 26 August 1944, the first week of the service, 1,627 pints of blood were shipped, a daily average of 271. For the next week, the total shipped was 3,017 pints, a daily average of 503. During the week ending 18 November, 6,150 bottles were shipped, a daily average of 1,025. During 25 days of collections in December, 26,657 pints were shipped, an average of 1,066 bleedings per working day. The highest point in shipments was reached during the week ending 3 March 1945, when 7,230 pints were shipped to the European theater.

By the end of January 1945, the theater was receiving an average of 6,000 pints of blood per week, even though bad flying conditions sometimes forced the Air Transport Command to suspend deliveries for 1 to 3 days at a time. On 24 January 1945, General Hawley wrote General Kirk that the whole blood transfusion setup, from supply to administration to the patient, was "one of the happiest situations" in the theater, and that his (General Kirk's) office had played the dominant role in it.

At this point it is necessary to repeat the statement, made several times previously, that the statistical data in this volume, while as complete and as correct as possible, are not always complete and are sometimes in conflict. In table 20, for instance, which represents the final report of the Army Whole Blood Procurement Service for the entire period of the airlift to Europe, the total number of units of blood shipped is put at 201,105. In the official history of the American Red Cross Blood Donor Service (95), the number is put at 205,907 (p. 101). The explanation of this discrepancy is probably that some of the bloods collected for this purpose were, for one reason or another, not used in the airlift.

In theaters of operations, the circumstances in which blood was given were simply not conducive to accurate recording. The reader, therefore, is cautioned against accepting as numerically accurate all the data presented, though he is entirely safe in accepting as accurate the trends that they represent.

PRODUCTION OF ETOUSA BLOOD BANK

Table 21 is a record of the production of blood by the ETOUSA Blood Bank operated in the United Kingdom first by the 152d Station Hospital and later by the 127th Station Hospital, and operated on the Continent by the 152d Station Hospital (54, 55, 57, 96).

Table 22 is a record of all deliveries of blood to and on the Continent by the ETOUSA Blood Bank and from the Zone of Interior via Prestwick.


561

TABLE 21.-Production and distribution of blood, ETOUSA Blood Bank, April 1944-June 1945 (57)

Year and month

United Kingdom Section1 distribution-

Continental Section2 distribution

Total monthly blood bank distrubution

On Continent

In United Kingdom

Total

1944

 

 

 

 

 

April

---

20

20

---

20

May

---

1,790

1,790

---

1,790

June

7,650

3,945

11,595

---

11,595

July

11,890

906

12,796

---

12,796

August

13,018

411

13,429

---

13,429

September

5,359

515

5,874

---

5,874

October

8,150

749

8,899

---

8,899

November

7,910

573

8,483

4,178

12,661

December

11,550

650

12,200

---

12,200

1945

 

 

 

 

 

January

12,100

709

12,809

3,977

16,786

February

9,464

515

9,979

91

10,070

March

6,677

1,278

7,955

2,704

10,659

April

8,162

1,602

9,764

27

9,791

May

1,764

806

2,570

435

3,005

June

---

6

6

1,054

1,060


Total

103,694

14,475

118,169

12,466

130,635

1Operated by 152d Station Hospital until 1 September 1944, then by 127th Station Hospital.
2Operated by 152d Station Hospital.

USE OF BLOOD IN ARMY INSTALLATIONS

In analyzing the statistical data for the use of blood in the individual armies (tables 23-26) and the combined armies (table 27) on the Continent during the period of combat, a number of points should be borne in mind (96):

1. During the first 3 months after D-day-that is, until almost the end of August 1944-the supply of blood was limited. Sometimes it was extremely limited. A great deal more should have been used than was used, but it was not available. In June 1944, the ratio of blood to wounded in forward installations was 1:3.9, not because that was a desirable ratio but because that was all the blood there was to use. This ratio gradually changed. For the remainder of the war it averaged out at 1:1.5. In February 1945, it became 1:1, and it remained at this level thereafter.

2. There was no regularity or uniformity in the distribution of blood to using units. This was because the amount delivered was always in direct response to the collective demands of the forward hospitals, which were based, in turn, on estimated casualties. If casualties did not materialize as expected, then the amount of blood asked for was excessive. The blood had to be requisitioned, however, if it was thought that it would be needed. It was utilized elsewhere whenever possible, but losses from this cause had to be accepted; they could not be taken into consideration when the amount of blood to be requisitioned was calculated.


562

TABLE 22.-Delivery of whole blood to using hospital units, ETOUSA, April 1944-June 1945 (96)

Year and month

Communications Zone

U.S. Army Zone

Total

United Kingdom

Continent

Subtotal

First

Third

Ninth

Seventh

Fifteenth

Subtotal

Forward

Rear

1944

                     

April

20

---

---

20

---

---

---

---

---

---

20

May

1,790

---

---

1,790

---

---

---

---

---

---

1,790

June

3,945

---

---

3,945

6,209

---

---

---

---

6,209

10,154

July

906

262

---

1,168

13,669

---

---

---

---

13,669

14,837

August

411

554

---

965

4,846

3,604

---

1,356

---

9,806

10,771

September

1,366

614

34

2,014

4,845

5,643

1,225

4,284

---

15,997

18,011

October

749

580

675

2,004

6,627

7,866

746

6,128

---

21,367

23,371

November

573

2,446

931

3,950

7,348

8,058

5,436

8,521

---

29,363

33,313

December

650

4,214

1,262

6,126

7,945

8,776

3,909

11,238

---

31,868

37,994

1945

   

 

               

January

709

3,639

1,736

6,084

6,827

12,139

2,628

11,017

---

32,611

38,695

February

515

2,631

1,532

4,678

4,609

10,257

4,292

7,834

---

26,992

31,670

March

1,278

2,886

1,760

5,924

8,908

11,796

4,782

11,205

---

36,691

42,615

April

1,602

475

4,921

6,998

6,393

7,140

6,799

11,729

383

32,444

39,442

May

806

26

3,440

4,272

1,175

2,498

2,082

3,188

278

9,221

13,493

June

6

---

617

623 ---

---

---

---

---

---

623

Total

15,326

18,327

16,908

50,561

79,401

77,777

31,899

76,500

661

266,238

316,799



563

TABLE 23.-Ratios of blood delivered to admissions of wounded to forward hospitals, First U.S.
Army, June 1944-May 1945
(96)

Year and month

Admissions

Pints of blood
delivered

Ratio of blood
to wounded

1944

 

 

 

June

24,325

6,209

1:3.9

July

141,034

13,669

1:3

August

17,667

4,846

1:3.6

September

8,819

4,845

1:1.8

October

8,553

6,627

1:1.2

November

13,197

7,348

1:1.8

December

15,017

7,945

1:1.9

1945


 

 

January

11,961

6,827

1:1.7

February

6,537

4,609

1:1.4

March

12,367

8,908

1:1.4

April

9,581

6,393

1:1.5

May

196

1,175

---


Total

169,254

79,401

1:2.1

1Statistics for July include Third U.S. Army admissions also.

TABLE 24.-Ratios of blood delivered to admissions of wounded to forward hospitals, Third U.S. Army, August 1944-May 1945 (96)1

Year and month

Admissions

Pints of blood
delivered

Ratio of blood
to wounded

1944

 

 

 

August

6,397

3,604

1:1.8

September

12,499

5,643

1:2.2

October

4,003

7,866

1.9:1

November

15,127

8,058

1:1.9

December

11,955

8,776

1:1.4

1945

 

 

 

January

17,378

12,139

1:1.4

February

10,855

10,257

1:1

March

11,430

11,796

1:1

April

5,671

7,140

1.4:1

May

716

2,498

---


Total

96,031

77,777

1:1.2

1Statistics for July are included in those of First U.S. Army (table 23).


564

TABLE 25.-Ratios of blood delivered to admissions of wounded to forward hospitals, Seventh U.S. Army, November 1944-May 1945

Year and month

Admissions

Pints of blood
delivered

Ratio of blood
to wounded

1944

 

 

 

November

5,569

8,521

1.5:1

December

8,168

11,238

1.4:1

1945

 

 

 

January

8,206

11,017

1.3:1

February

4,983

7,834

1.6:1

March

7,913

11,205

1.4:1

April

8,810

11,729

1.3:1

May

438

3,188

---


Total

44,087

64,732

1.4:1

TABLE 26.-Ratios of blood delivered to admissions of wounded to forward hospitals, Ninth U.S. Army, September 1944-May 1945 (96)

Year and month

Admissions

Pints of blood
delivered

Ratio of blood
to wounded

1944

 

 

 

September

2,653

1,225

1:2.2

October

1,614

746

1:2.2

November

6,625

5,436

1:1.2

December

2,728

3,909

1.4:1

1945

 

 

 

January

1,657

2,628

1.6:1

February

4,876

4,292

1:1.1

March

5,072

4,782

1:1.1

April

5,565

6,799

1.2:1

May

189

2,082

---


Total

30,979

31,899

1:1

3. The more forward the hospital, the greater was its need for blood. This held not only for hospitals in the army zone but also for hospitals forward in the communications zone (table 22).

4. All armies increased their use of blood as they gained combat experience. Their increased use of transfusion, however, cannot be entirely explained on the ground that blood was increasingly available. The Seventh U.S. Army, which had come from the Mediterranean theater, where a blood bank was in operation, and which had been served by its own blood bank before it came under ETOUSA operational control, consistently used proportionately larger amounts of blood than the other three armies in the European theater.


565

TABLE 27.-Ratios of blood delivered to admissions of wounded to forward hospitals, all U.S. Armies, ETOUSA, June l944-May 1945 (96)

Year and month

Admissions

Pints of blood
delivered

Ratio of blood
to wounded

1944

 

 

 

June

24,325

6,209

1:3.9

July

41,034

13,669

1:3

August

24,064

9,806

1:2.8

September

23,971

15,997

1:2.3

October

14,170

21,367

1:1

November

40,518

29,363

1:1.4

December

37,868

31,868

1:1.2

1945


 

 

January

39,202

32,611

1:1.2

February

27,251

26,992

1:1

March

36,782

36,691

1:1

April

29,627

32,444

1.1:1

May

1,539

9,221

---


Total

340,351

266,238

1:1.33

The combined figures for the use of blood in all four armies in the European theater (table 27) are more representative of the total use of blood during the period of combat than the reports for individual armies. The ratio for May 1945 has been omitted for all armies, for two reasons. The first is that the cessation of hostilities was not immediately reflected in the discontinuance of shipments of blood from the Zone of Interior. The second is that in May, a great deal of blood was used for nonbattle casualties, particularly malnourished RAMP's (recovered Allied military personnel).

It is believed that the combined ratio of 1:1.33 provides a fairly accurate estimate of the demand for blood in all army areas.

Essential Technical Medical Data for the European theater for September 1944 stated that nothing had given forward medical units greater satisfaction than their ability to administer to casualties the whole blood they needed (97). It was hoped that this information would be publicized in the Zone of Interior, for, without the blood from that source, the mortality rate would have been much higher and the morbidity much greater.

The same issue contained an analysis of the use of blood in (1) 213 casualties treated in the 13th, 42d, and 47th Field Hospitals for the period 26 July-18 August 1944 and (2) 221 casualties treated in the 2d, 5th, and 97th Evacuation Hospitals for the period 26 July-14 August 1944. All casualties were non-transportable. Not all data are complete for all items, but the analysis is nonetheless very informative.


566

All the casualties were in shock. In the field hospitals, 57 were in first degree shock, 34 in second degree shock, 31 in third degree shock, and 8 in fourth degree shock. In the evacuation hospitals, the corresponding figures were 28, 41, 41, and 26.

The timelag from wounding to admission averaged 8 hours in 175 patients in field hospitals and 7 hours in 197 patients in evacuation hospitals. The timelag from admission to the hospital to operation averaged 10 hours in 157 patients in field hospitals and 13 hours in 189 patients in evacuation hospitals.

An average of 1.07 pints of plasma had been given in the clearing station to 138 patients received in field hospitals, and an average of 1.3 pints had been given to 131 received in evacuation hospitals. An average of 1.5 pints was given to 197 patients after they reached the field hospital, and an average of 3.5 pints was given to 198 after they reached evacuation hospitals. The total amount of plasma used in field hospitals was thus 302 pints and in evacuation hospitals 715 pints. The total for both clearing stations and hospitals was 451 pints for field hospitals and 892 pints for evacuation hospitals.

An average of 2.34 pints of blood was given to each of the 213 casualties treated in field hospitals and an average of 2.6 pints to each of the 221 treated in evacuation hospitals. The total amount of blood used in field hospitals was 501 pints and in evacuation hospitals 580 pints.

The ratio of plasma to blood was 1.63:1 in field hospitals and 1.34:1 in evacuation hospitals. When the amount of plasma used in clearing stations is included, the final ratio of plasma to blood was 1:1 in field hospitals and 1.53:1 in evacuation hospitals.

There were two reactions to plasma in field hospitals and the same number in evacuation hospitals. For whole blood, the respective figures are 8 and 5.

There were 92 deaths in the 434 casualties, 41 in the 213 treated in field hospitals and 51 in the 221 treated in evacuation hospitals. In all, 184 patients were operated on in the field hospitals and 198 in the evacuation hospitals. Of the 25 casualties who died without operation, 8 died in field hospitals and 17 in evacuation hospitals. Four deaths occurred during operation, three in the field hospitals and one in an evacuation hospital. Of the 63 deaths which occurred after operation, 30 occurred in field hospitals and 33 in evacuation hospitals.

The extremely high mortality rate in evacuation hospitals, closely comparable to that in the field hospitals, is explained by the fact that the evacuation hospitals in this series, contrary to the usual practice, were receiving nontransportable casualties and in effect serving as field hospitals.

LOSSES OF PRESERVED BLOOD

In an operation of such magnitude as furnishing blood for the European theater, conducted on two continents and across an ocean, a certain amount of wastage and loss was inevitable, but in the ETOUSA experience, it was


567

surprisingly small. One plane crash on 30 November 1944 destroyed 1,146 bottles of blood, but this was practically the only loss of the kind during the whole procedure.

So far as possible, requests for blood from the Zone of Interior were calculated on the basis of anticipated needs, and the calculations, with the adjustment of supply and demand, were remarkably accurate. In September 1944, for instance, shortly after the program had been instituted, daily shipments from the United States were running well ahead of needs, and the program was slowed accordingly. In late October 1944, Colonel Kendrick, then on temporary duty in the European theater, reported that increased quantities of blood would shortly be needed, and the daily requirements were therefore stepped up. In both the United Kingdom bank and the Continental bank, there was also an endeavor to adjust the daily bleedings to the anticipated demand.

While only group O blood was used in combat zones, blood collected that was of other than O type was distributed to selected hospitals, especially those in the United Kingdom. As pointed out elsewhere, whenever this was done, a representative of the blood bank visited the hospital to warn personnel that the blood must be crossmatched before it was used. During the last 6 months of the operation of the blood bank, not a single pint of non-O blood was discarded in the United Kingdom. The demand for odd types of blood never reached significant proportions on the Continent.

In all, about 4,000 pints of outdated blood were used for plasma. About 3,000 pints were discarded because of hemolysis or because the blood was serologically positive. Some blood was also lost because of breakage, and some because of failure of refrigeration.

The total loss of blood in the 316,799 pints which were collected in, or passed through, the ETOUSA Blood Bank was probably in the neighborhood of 15 percent. Because of the short storage period of blood, it is doubtful that any better results could have been expected.

ODD BLOODS

Of the 130,635 pints of blood collected by the United Kingdom Section of the blood bank, 110,878 pints were collected before 1 April 1945 (96). Up to this time, blood was collected only from donors whose identification tags were stamped as type O. In this amount of blood there were 6,607 pints of so-called odd blood; that is, though it was drawn from donors whose identification tags were stamped group O, the blood was of other types. This figure represents an error of 5.96 percent in the original typing of the blood. The error in the blood collected by the Continental Section of the blood bank was substantially the same.

All odd bloods were distributed to local hospitals.


568

SEROLOGICALLY POSITIVE BLOOD

Serologic tests were positive in 574 pints (0.47 percent) of the blood collected by the United Kingdom Section of the blood bank and in 95 (0.62 percent) of that collected by the Continental Section. Another 57 pints (0.37 percent) were classified as serologically doubtful. All serologically positive blood was discarded.

SUMMARIZED STATISTICAL EXPERIENCES

The experience in the European theater was considered in 1946 to justify the following conclusions in respect to the provision of whole blood in warfare (96):

1. For planning purposes, in the kind of warfare encountered in this theater, the only safe calculation of requirements is the provision of 1 pint of blood for each casualty.

2. This means that a field army in action will require about 500 pints of blood daily.

3. This heavy demand seldom exists for longer than 8 consecutive days.

About 400 pints will be needed during the first 24 hours of an operation, about 800 pints between the third and sixth days, and the same amount for the next 2 or 3 days. Then the need will decrease rapidly.

4. In the event of a breakthrough, particularly an armored breakthrough, the demand falls off sharply, to 300 pints a day or less.

5. When infantry attack prepared positions, particularly when they must cross minefields, a large proportion of the wounded, probably about 20 percent, will require transfusion.

6. Whole blood requirements can be supplied only by careful calculations of daily needs. The short storage period of blood precludes the forward movement of large amounts until it is known that they will be needed. To stock all advance blood banks at all times with the maximum amounts likely to be needed could not be tolerated. It would result in tremendous losses, by aging, of a scarce and precious commodity.

Part IX. Special Experiences30

There were no hospitals in the field, evacuation, or general categories that did not profit from the supply of whole blood for their casualties. This generalization is so valid that when one comes to select unit experiences to use as illustrations, it is extremely difficult to make the choice. For any of the histories related in the following pages, a dozen others could have been selected and would have carried quite as much conviction.

30The material in this part of the chapter is derived from the 1944-45 reports of the hospitals concerned. All are on file in The Historical Unit, U.S. Army Medical Service, Washington, D.C.


569

FIELD HOSPITALS

11th Field Hospital

At the 11th Field Hospital, during 1944, 2,532 nontransportable casualties received 8,591,300 cc. of blood in 8,025 transfusions. Almost all of it was furnished by the faithful and consistent operation of mobile blood units. For many casualties, the availability of whole blood made the difference between life and death.

A 24-hour supply of blood was delivered daily, usually between 36 to 48 bottles, with an occasional expansion of the requisition, during periods of stress, to 60 bottles. If the supply of bank blood ran low, fresh blood was drawn from hospital personnel and members of the clearing company. Whenever time permitted, blood was also drawn from these personnel for use in casualties with type A blood.

An intensive study of blood compatibility was made in this hospital, with an investigation of the many variables entering into the production of transfusion kidney and other transfusion reactions. Lower nephron nephrosis appeared in casualties with type A blood more often than in casualties with other types of blood, especially when large quantities of O blood had been given. The reactions occurred in spite of the apparent complete compatibility of the blood used, as shown by microscopic crossmatching.

The age of the blood was not a positive index of the likelihood of transfusion incompatibility. It was generally true that the more recent the blood, the less was the likelihood of a transfusion reaction. At times, however, blood that had been drawn very recently produced highly undesirable effects. On the whole, the degree of hemolysis proved an extremely reliable index and pointed to the way to avoid reactions.

The small number of reactions observed in so many and such massive transfusions was both surprising and gratifying.

56th Field Hospital

Many remarkable instances of recovery after apparently lethal wounds could be attributed to a combination of whole blood and good surgery. A casualty at the 56th Field Hospital illustrates this point. When he was first seen, he was in deep shock from massive loss of blood. He had multiple large lacerated wounds of the lower extremities; multiple fractures of the pelvis; and multiple perforations of the cecum, ileum, and jejunum. He was rapidly resuscitated to the level of operability by multiple simultaneous transfusions of whole blood, after which laparotomy was performed and the intestinal perforations closed. His precarious condition did not permit any surgical procedure on the extremity wounds at this time, and they were simply cleansed by irrigation. The necessary additional surgery was done several days later.

This man's recovery was entirely uneventful, and he was in excellent condition when he was evacuated to a general hospital. Without the blood that rapidly prepared him for operation, he, and many others like him, would surely have died.

77th Field Hospital

The experience of the 77th Field Hospital is an interesting example of the value of plasma in protein depletion as compared with its limited value in freshly wounded casualties.

This hospital arrived in France on 25 March 1945 and shortly afterward began to receive RAMP's. It was immediately evident that malnutrition of all grades of severity, complicated by many types of infection, was to be the principal therapeutic problem.

Because of the limited facilities of a field hospital laboratory, it was not possible to study the blood protein and blood chloride levels in the first patients received. Most of


570

them were in serious condition, and many were critically ill. They were severely malnourished, dehydrated, and emaciated, and were suffering from anorexia, nausea, vomiting, and diarrhea. Their low blood pressure, rapid pulse and respiration, and other signs suggested surgical shock.

The assumption was that they were suffering from a depletion of blood protein and chlorides, and they were therefore treated with plasma and with glucose in physiologic salt solution, which, it was soon learned, must be given slowly and in small amounts. Before this was realized, five patients developed pulmonary edema during infusions or immediately after the fluid had been injected. Once the clinical condition had improved, the infusions could be given in larger amounts.

The results of plasma infusions in severe malnutrition were generally excellent. Plasma was also used successfully in a few instances of severe nonbacterial diarrhea and in a few instances of nutritional edema.

In all, 173 RAMP's were treated with plasma at the 77th Field Hospital, in units of 300 cc. The average amount given was 2.15 units. The smallest amount, 200 cc., was given to a patient who went into cardiac failure after receiving this quantity by a very slow infusion. The largest amount, 1,114 units, was given to a severely malnourished patient who had been vomiting for 3 days and who had had nonbacterial diarrhea for 80 days when he was received. There were no deaths among these RAMP's.

GENERAL HOSPITALS

43d General Hospital

When the 43d General Hospital was permanently reorganized in August 1944, as a 1,500-bed hospital, a blood bank was set up in it.

Function and equipment-The hospital laboratory had complete responsibility for all activity pertaining to blood transfusion except the care and preparation of recipient sets, which was the responsibility of the central supply service, and the actual administration of blood, which was a function of ward medical personnel. The laboratory, however, acted in a supervisory and advisory capacity in respect to both these activities, in an endeavor to control the incidence of pyrogenic reactions.

The bank was housed in a separate room, 7.5 by 18 feet, which was near the laboratory and which was arranged specifically for blood bank functions. There were facilities for bleeding two donors at the same time, for storage of donor sets and other equipment, for refrigeration, and for the handling of records.

There were two built-in bleeding tables, each 13 feet long and wide enough to accommodate regulation operating table pads and still leave free space for the donor's extended arm and the collection bottle. The pads were covered with easily cleaned rubber sheeting. A cot was available in the corridor outside for fainting donors; it was not needed very often.

Two single-compartment kerosene refrigerators were used; one did not prove adequate. They gave reliable service but required a great deal of careful attention. Losses by hemolysis emphasized the importance of constant refrigeration; 56 percent of the loss from this cause at the 43d General Hospital occurred in September 1944, from power failure. At this time, the electric


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refrigerator used for storage was powered by French current, which was not reliable.

By 1 January 1945, 70 donor sets were in use. This number was large enough to permit some sets to be out of use for minor repairs, and also to allow for possible failure of sterilization facilities for 24 hours. Standard bottles containing citrate solution were used to collect blood.

Personnel-Personnel of the blood bank, in addition to medical officer personnel, consisted of a private, first class, and two technicians, fourth grade, who were assigned solely to the bank; another technician, fourth grade, who had other duties in addition to his blood bank duties; specialized assistants from the hematology and serology departments; and a German POW, who assisted in washing glassware and sterilizing equipment. The three men assigned full time to the bank had complete charge of the procurement of donors; the collection and care of blood; maintenance of equipment; and, during their duty hours, the issuance of blood to the wards.

Bank routine-Blood was drawn each day in anticipation of immediate demands. The estimates were based upon the amount of blood used during the preceding 48 hours and the number of low hematocrits reported by the laboratory for the preceding 24 hours.

Arrangements were made each afternoon for the number of donors required, according to blood groups, for the following day. They were secured from hospital personnel, army personnel in the staging area, and the POW enclosure. Donors from outside the hospital were transported to the laboratory in charge of one of the bank personnel.

Donors were selected according to the blood groups listed on their identification tags, but each blood was retyped. A Kahn test was also run on each unit collected, and a thick smear was examined for malaria. Because of difficulty in anticipating demands for blood groups AB and B, it was occasionally necessary to use O blood for patients in these blood groups. In such cases, in addition to routine crossmatching, recipient cells were crossed with donor serum diluted 1:40, to eliminate the risk of a reaction caused by high-titer group O blood.

All crossmatching and typing, except emergency nightwork, were done by the same technician. All crossmatchings were checked by a medical officer in the laboratory before the results were accepted. The Landsteiner or test tube method was used exclusively for crossmatching. This technique minimizes the occurrence of rouleaux formation and can be read immediately after centrifuging, which gives it an advantage over other techniques, all of which require at least a 30-minute wait. It was also considered more accurate than any other method.

A ledger was kept in which were recorded the accession number of the donation, the donor's name and organization, the date of bleeding, and the results of the laboratory tests. After the blood had been used, entries made opposite the flask number included the name of the recipient; the ward; the date of the transfusion; and, if a reaction had occurred, information about it.


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Blood was requisitioned on the ward by duplicate slips. The prospective recipient's blood was crossmatched with the vial of uncitrated blood tied to the flask selected for him. If the bloods were found compatible, the flask number was entered on the patient's requisition. One slip was returned to the ward, and the duplicate slip was placed in the bank file.

When the ward was ready for the blood, the slip which had been sent back to it was brought to the bank and the appropriate flask of blood was issued. The date and hour the blood left the bank were entered on the backs of both the ward slip and the file slip. The slip brought from the ward was returned to the ward and placed on the patient's chart. The duplicate slip was placed in the used file of the blood bank. These ward slips were collected from the wards every morning by bank personnel.

The slips used to requisition the blood also had space to note data concerning reactions. If a reaction occurred, pertinent information regarding its type and severity was noted on the ward slip. This system insured that every reaction was reported and could be analyzed by the laboratory. Hemolytic reactions were differentiated from pyrogenic reactions by examination of the post-reaction urine for hemoglobin and urobilinogen. Recipient and donor bloods were also retyped and recrossmatched, to eliminate any possibility of error in the original reports.

When the type of reaction was definitely determined, the information was placed on the back of the file slip, which was then placed in the permanent file. In cases in which no reactions had occurred, duplicate slips were discarded at the end of a month.

Statistical data-Of the 2,206 units of blood collected at the 43d General Hospital between 25 September and 31 December 1944, 1,029 came from U.S. personnel and 1,127 from German prisoners. All donations were voluntary, and all requests for donors were filled with complete cooperation on the part of both the donors and the officers in command of the organizations from which the blood was secured. U.S. Army personnel were furnished clean towels and bathing facilities and given hot food at the mess, but no whisky. German prisoners were given an extra meal.

Of the 2,206 units of blood collected during 1944, 1,931 had been used for transfusions by 31 December 1944. During November and December, an average of 3 pints of blood was given to each patient transfused. The largest amount given to any single patient was 15 units.

In all, 193 units (8.7 percent) were discarded. Of these, 97 units were discarded because of overaging, 69 because of hemolysis, and the remainder for various other reasons, chiefly positive serology.

There were 126 reactions in the 1,931 transfusions given, 6.5 percent, 110 pyrogenic and the remainder allergic. Of the 110 pyrogenic reactions, 50 occurred during a single week in November. They were traced to the following faults:

1. Failure of ward personnel to dismantle the giving sets and wash them thoroughly in tap water immediately after transfusions were completed.


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2. Failure to prepare new rubber tubing for use by boiling it in sodium bicarbonate and rinsing it until the fluid returned clear.

3. Failure to inspect the sets adequately before they were reassembled for sterilization.

4. Failure to rinse them finally in pyrogen-free distilled water or physiologic salt solution.

When these errors, all of human origin, were corrected, the incidence of reactions at the 43d General Hospital returned to its normal low level.

227th General Hospital

The 227th General Hospital reached the Continent on 30 March 1945. It acted as an intermediate depot for the distribution of blood received from the ETOUSA Blood Bank and intended for use in the hospitals of the 813th Hospital Center. There was a heavy demand for blood at this time, but there were ample supplies to meet it. In all, 1,524 bottles were dispensed between 10 April and 1 June, when the bank closed down. Thereafter, blood was secured from officers and enlisted men in the hospital. Donations were generous, but the ample supply of blood previously available had made procurement seem simple, and local donors were rapidly used up. With the fine cooperation of radio stations at Marseille, Nice, and Cannes, as well as other publicity, a panel of donors was secured which met the hospital needs.

The hospital laboratory insisted upon complete control of the bank blood from the moment it was received from the Paris bank until it was dispensed. Refrigeration was regularly checked, day and night, every 2 hours. Electric refrigeration was more desirable than kerosene refrigeration, which had to be watched with particular care, but it was not always available. French current was not dependable, and two small electric refrigerators were secured and supplied with current from one of the hospital generators. Refrigeration problems became minimal after the Paris bank began to send blood in the expendable insulated boxes in which it was received from the Zone of Interior. A commercial source of ice was then utilized, and the boxes were re-iced daily.

This hospital had one constant difficulty to combat, the production of distilled water. Fluctuations in water pressure, the extreme hardness of the water, the inadequacy of French electrical current, and the vulnerability of the stills taxed the best efforts of electricians, plumbers, maintenance men, and laboratory personnel. Their success, however, is attested by the fact that the 227th General Hospital supplied distilled water for several other hospitals in the vicinity in addition to providing for its own needs.

298th General Hospital

The experience of the 298th General Hospital, in general, paralleled that of most other general hospitals, with one exception: On 22 January 1945, when a bottle of blood from the ETOUSA Blood Bank was being crossmatched for a


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patient with a spinal cord injury, the donor flask was found to bear the name of Supreme Allied Commander Dwight D. Eisenhower. The Stars and Stripes, which reported the incident, said that the general had hoped, when he made the donation, that the disposition of the patient who might receive his blood would be better than his own. After he had received the 500-cc. transfusion, said the article, the patient was in good condition, and his disposition was excellent.

Part X. Statement of the Theater General Board

CONTENTS

The definitive statement on the whole blood service in the European theater is contained in the report of the General Board, U.S. Forces, European theater,31 set up by General Orders No. 128, issued on 17 June 1945, to prepare a factual analysis of the strategy, tactics, and administration employed by the U.S. Armed Forces in this theater. The following points were covered (98):

1. The importance of whole blood in the care of the wounded.

2. The organization of the whole blood service in the theater in the United Kingdom and on the Continent.

3. The operation of blood banks in base sections.

4. The distribution of whole blood on the Continent.

5. The determination of requirements of whole blood for continental operations.

It was the conclusion of the General Board that the provisional organization for the supply of whole blood in the European theater was "eminently successful."

RECOMMENDATIONS

The Board made the following recommendations for future operations:

1. That a T/O&E be authorized for an organization similar to the provisional base blood bank for the purpose of collecting and processing whole blood.

2. That whole blood be handled by medical depots operating in the forward communications zone areas and the Army area, since there is no justification for the distribution of whole blood through other than normal medical supply channels. The type of personnel and equipment employed in the European theater by advance blood banks should be incorporated into the T/O&E of medical depot companies.

3. That a ratio of 1 pint of blood for each anticipated wounded admission be used for planning purposes.

COMMENT

Recommendation No. 2 is difficult for a clinician to accept (this board had no clinicians on it). It seems based on a complete failure to grasp the funda-

31This study was prepared by Col. L. Holmes Ginn, Jr., MC, Chief, Medical Section, Chairman; Maj. Joseph J. Strnad, MAC, Deputy Chairman; and 1st Lt. John F. Ward, MAC. Special consultants were Colonel Hays, Col; Robert H. Barr, MC, Surgeon, VII Corps; Lt. Col. Harry S. Green, MAC, Commanding Officer, 13th Medical Depot and Capt. William M. Hamilton, MAC, Medical Supply Officer, Third U.S. Army.


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mental fact that blood is a perishable as well as a precious substance and that for both those reasons it must not be handled in normal medical supply channels. One need refer only to a single experience in the Philippines (p. 605) in which blood was thus handled (that is, in normal medical channels) to realize the unwisdom of this recommendation. Had it been in effect in the European theater, it is highly doubtful that the whole blood program would have been as successful as the General Board concluded that it was. In fact, if there was a single conviction rooted in the minds of those who directed the whole blood program, it was that blood is a substance which requires special handling from the moment it is drawn until the moment it is administered.

In the European theater, Medical Supply provided storage facilities and transportation, but the real responsibility for handling this perishable item, which could be lethal without proper supervision, belonged to the transfusion service, which operated under the overall direction of the theater blood bank. It is unfortunate that the same policy was not employed in the Korean War (p. 752).

References

1. Informal Routing Slip, Lt. Col. D. B. Kendrick, MC, to Chief Surgeon, ETOUSA, 26 Sept. 1944, subject: Report of Trip to First U.S. Army Medical Installations.

2. Memorandum, Lt. Col. D. B. Kendrick, MC, for Col. B. N. Carter, MC, 5 Oct. 1943, subject: Transfusion of Whole Blood in the Theaters of Operations.

3. Circular Letter No. 108, Office of The Surgeon General, U.S. Army, 27 May 1943, subject: Transfusion of Whole Blood in the Theaters of Operations.

4. Memorandum, Lt. Col. D. B. Kendrick, MC, for Brig. Gen. Fred W. Rankin, 3 Nov. 1943, subject: Transfusion of Whole Blood in the Theaters of Operations.

5. Memorandum, Brig. Gen. Fred W. Rankin for The Surgeon General, 6 Nov. 1943, subject: Transfusion of Whole Blood in the Theaters of Operations.

6. Minutes, meeting of Subcommittee on Blood Substitutes, Division of Medical Sciences, NRC, 17 Nov. 1943.

7. Memorandum, Brig. Gen. Fred W. Rankin for The Surgeon General, 13 Nov. 1943, subject: Transfusion of Whole Blood in the Theaters of Operations.

8. Memorandum for the Record, Col. B. N. Carter, MC, 16 Dec. 1943, subject: Meeting With The Surgeon General and With General Lull on the Subject of Whole Blood Transfusions in Theaters of Operations.

9. Memorandum, Lt. Col. D. B. Kendrick, MC, for The Surgeon General, 17 Apr. 1944, subject: Transfusion of Whole Blood in the Theaters of Operations.

10. Memorandum, Brig. Gen. F. W. Rankin, MC, for The Surgeon General, 21 Apr. 1944, subject: Transfusion of Whole Blood in the Theaters of Operations.

11. Minutes, meeting of Committee on Transfusions, Division of Medical Sciences, NRC, 31 May 1940.

12. Minutes, meeting of Subcommittee on Blood Substitutes, Division of Medical Sciences, NRC, 9 Apr. 1943.

13. Minutes, meeting of Subcommittee on Blood Substitutes, Division of Medical Sciences, NRC, 24 Sept. 1943.

14. Annual Report, Activities of the Transfusion Branch, Surgery Division, OTSG, fiscal year 1944.

15. Memorandum, Capt. R. C. Hardin, MC, to Chief Consulting Surgeon, Office of Chief Surgeon, ETOUSA, 26 Mar. 1943, subject: Transfusion Arrangements in U.S. Hospitals.


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16. Memorandum, Maj. W. A. H. Jaycott, RAMC, for Assistant Surgeon, Office of Chief Surgeon, ETOUSA, 8 June 1943, subject: Supplies of Plasma.

17. Informal Routing Slip, Col. E. C. Cutler, MC, to Col. J. C. Kimbrough, MC, 30 Dec. 1943, subject: Blood Transfusion Service.

18. Informal Routing Slip, Col. J. B. Mason, MC, for the Chief Surgeon, ETOUSA, 6 Jan. 1944, subject: Director of Whole Blood Service.

19. Circular Letter No. 51, Office of the Chief Surgeon, Headquarters, ETOUSA, 5 Apr. 1943, subject: Arrangements for Blood Banks and Transfusion in U.S. Army Hospitals.

20. Memorandum, Capt. R. C. Hardin, MC, to Col. E. C. Cutler, MC, 9 June 1943, subject: Provision for Procurement of Whole Blood for Transfusion in General Hospitals in the ETO.

21. Emerson, Maj. C. P., MC, and Ebert, Maj. R. V., MC: Operation of a Hospital Blood Bank. M. Bull. No. 14, Office of the Chief Surgeon, Headquarters, ETOUSA, 1 Jan. 1944, pp. 7-15.

22. Letter, Lt. Col. W. S. Middleton, MC, to Dr. P. L. Mollison, 29 Jan. 1943, subject: Conference.

23. Cutler, E. C.: The Chief Consultant in Surgery. In Medical Department, United States Army. Surgery in World War II. Activities of Surgical Consultants, Volume II. Washington: U.S. Government Printing Office, 1964.

24. Memorandum, Col. E. C. Cutler, MC, to Brig. Gen. P. R. Hawley, through Col. J. C. Kimbrough, MC, 10 May 1945, subject: The Use and Procurement of Blood and Plasma for the ETO.

25. Memorandum, Capt. R. C. Hardin, MC, to Col. E. C. Cutler, MC, 5 June 1943, subject: A Plan for the Procurement and Delivery of Whole Blood for a Continental Task Force from the USA or UK.

26. Memorandum for the Record, Col. E. C. Cutler, MC, 29 Aug. 1943, subject: Project: Preliminary Studies for the Procurement, Storage and Supply of Whole Blood to an ETO Combat Army.

27. Memorandum for the Record, Col. E. C. Cutler, MC, 13 Nov. 1943, subject: Blood Procurement ETO.

28. Informal Routing Slip, Col. E. C. Cutler, MC, to Chief, Operations Division, Office of Chief Surgeon, ETOUSA, 13 Nov. 1943, subject: Whole Blood.

29. Informal Routing Slip, Col. J. B. Mason, MC, to Professional Services Division, Office of Chief Surgeon, ETOUSA, 18 Nov. 1943, subject: Whole Blood.

30. Informal Routing Slip, Brig. Gen. P. R. Hawley, for Commanding General, SOS, ETOUSA, 26 Nov. 1943, subject: Provision of Whole Blood for Battle Casualties.

31. Administrative and Logistical History of the Medical Service, Communications Zone, European Theater of Operations, vol. 7, appendix 10. [Official record.]

32. Memorandum, Lt. Col. R. P. Fisk, Adjutant General's Department, to Commanding General, 1st Army Group, 2 Jan. 1944, subject: Provision of Whole Blood for the Medical Service.

33. Memorandum, Maj. R. C. Hardin, MC, to Operations Division, Office of Chief Surgeon, ETOUSA, 17 Apr. 1944, subject: Expansion of ETO Blood Bank.

34. Official Diary, ETOUSA Blood Bank, 1944-45.

35. Memorandum for the Record, Col. E. C. Cutler, MC, and Maj. R. C. Hardin, MC, 1 Aug. 1944, subject: Whole Blood from USA.

36. Informal Routing Slip, Col. J. C. Kimbrough, MC, to Chief Surgeon, ETOUSA, 6 Apr. 1944, subject: Whole Blood Transfusion.

37. Fifth U.S. Army Medical Service History, 1944.

38. Fifth U.S. Army Medical Service History, 1945.

39. Memorandum, Maj. Gen. P. R. Hawley for Professional Services Division, Office of Chief Surgeon, ETOUSA, 28 Mar. 1944, subject: Blood Supply, and 2d and 3d indorsements thereto.


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40. Operating Procedure, The Whole Blood Service, ETOUSA, Office of the Chief Surgeon, Operations Division, 1944.

41. Informal Routing Slip, Col. E. C. Cutler, MC, to Chief, Professional Services Division, Office of Chief Surgeon, ETOUSA, 2 July 1944, subject: Blood.

42. Informal Routing Slip, Col. J. C. Kimbrough, MC, to Chief Surgeon, ETOUSA, 12 July 1944, subject: Whole Blood for Transfusion from the ZI.

43. Informal Routing Slip, Lt. Col. R. M. Zollinger, MC, to Surgeon, Forward Echelon, Headquarters, Communications Zone, 28 July 1944, subject: Evaluation of the Requirements for Whole Blood in Army Hospitals.

44. Informal Routing Slip, Col. J. C. Kimbrough, MC, to Chief Surgeon, ETOUSA, 31 July 1944, subject: Whole Blood Requirements.

45. Informal Routing Slip, Col. J. H. McNinch, MC, to Personnel Division, Office of Chief Surgeon, ETOUSA, 21 July 1944, subject: Return of Colonel E. C. Cutler, MC, Colonel William F. MacFee, MC, and Major Robert C. Hardin, MC, to States.

46. Informal Routing Slip, Col. H. W. Doan, MC, to G-4, 4 Aug. 1944, subject: Request for Orders.

47. Radiogram, CG, U.S. Army, SOS in the British Isles, London, England, to War Department, C 84252, 2 Aug. 1944, subject: Request for Blood from Zone of Interior.

48. Letter, Maj. Gen. P. R. Hawley to Maj. Gen. N. T. Kirk, 5 Aug. 1944, subject: Request for Whole Blood from Zone of Interior.

49. Letter, Maj. Gen. N. T. Kirk to Maj. Gen. P. R. Hawley, 11 Aug. 1944, subject: Whole Blood from Zone of Interior.

50. Radiogram, from AGWAR, from Kirk, signed Somervell for Hawley to Headquarters, Communications Zone, 79474S0SMC, C 84252, 13 Aug. 1944, subject: Whole Blood from Zone of Interior.

51. Memorandum, Brig. Gen. F. W. Rankin, for The Surgeon General, 3 Aug. 1944, subject: Provisions for Supplying Whole Blood to ETO from U.S.A.

52. Memorandum, Lt. Col. Douglas B. Kendrick, MC, for Brig. Gen. F. W. Rankin, 14 Aug. 1944, subject: Plan for Supplying Blood to ETO.

53. Memorandum, Lt. Col. D. B. Kendrick, MC, for Brig. Gen. F. W. Rankin, 23 Aug. 1944, subject: Conference on Supply of Whole Blood for the ETO.

54. Annual Report, 152d Station Hospital, 1944 (ETO Blood Bank), 30 Jan. 1945.

55. Period Report, 152d Station Hospital (ETO Blood Bank), to The Surgeon General, 1 Jan.-30 June 1945, dated 30 June 1945.

56. Annual Report, 127th Station Hospital (ETO Blood Bank U.K.), 1944, 19 Jan. 1945.

57. Annual Report, Transfusion and Shock, from Maj. R. C. Hardin, MC, to Chief Consultant in Surgery, Office of the Chief Surgeon, ETOUSA, 11 Jan. 1944.

58. Mason, J. B.: Planning for the ETO Blood Bank. Mil. Surgeon 102: 460-467, June 1948.

59. Mason, J. B.: The Role of ADSEC in the Supply of Whole Blood to the Twelfth Army Group. Mil. Surgeon 103: 9-14, July 1948.

60. Report, Conference on the Operations of the Blood Bank held at 1st Medical Laboratory, 5 Apr. 1944.

61. Memorandum, Col. H. W. Doan, MC, to Surgeons, Twelfth Army Group; Third, First, and Ninth U.S. Armies, ADSEC, Com Z; Base Sections (Continent), 30 Oct. 1944, subject: Supply of Whole Blood.

62. Letter, Lt. Col. A. Vickoren, MC, to Commanding Officer, 1st Medical General Laboratory, 21 Mar. 1944, subject: Preparation of SOP for ETOUSA Whole Blood Service.

63. Administrative and Logistical History of the Medical Service, Communications Zone, European Theater of Operations, vol. 7. [Official record.]

64. Shainmark, A. C.: The Supply of Whole Blood to Forward Mobile Medical Field Units of the Ninth U.S. Army. Mil. Surgeon 103: 14-16, July 1948.


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65. Informal Routing Slip, Col. E. C. Cutler, MC, to Deputy Chief Surgeon, 24 Oct. 1943; Col. J. C. Kimbrough, MC, to Deputy Chief Surgeon, 25 Oct. 1943; Brig. Gen. P. R. Hawley to Deputy Chief Surgeon, n.d.; and Col. E. C. Cutler, MC, to Chief Surgeon, 31 Oct. 1943, subject: Donations of Blood by U.S. Troops to British Transfusion Service; Harmlessness of Blood Donations.

66. Letter, Brig. Gen. P. R. Hawley, to Commanding General, SOS, ETOUSA, November 1943, subject: The Establishment of the Blood Panel, ETOUSA.

67. Letter, Maj. Gen. J. C. H. Lee, to Commanders, Channel Base Section, Eastern Base Section, Western Base Section, and Southern Base Section, 15 Dec. 1943, subject: Volunteer Donations of Blood.

68. Letter, Maj. Gen. J. C. H. Lee, to SOS, 15 Dec. 1943, subject: Volunteer Donations of Blood.

69. Letter, Brig. Gen. R. B. Lovett, to Base Sections Commanders, SOS, ETOUSA, and Headquarters Commandant, ETOUSA, 6 Apr. 1944, subject: Provision of Whole Blood for the Medical Service.

70. Letter, Col. H. W. Doan, MC, to Sir Francis R. Fraser, 1 Feb. 1944, subject: Donations by U.S. Troops to British Transfusion Service.

71. Memorandum, Lt. Col. Thurman Shuller, MC, to Surgeon, 8th Air Force, 5 May 1944, subject: Blood Donors for the British Red Cross, and 3d indorsement thereto.

72. 2d Indorsement, Col. J. C. Kimbrough, MC, 6 Sept. 1944, to basic letter, 26 Aug. 1944, subject: Use of Prisoners of War as Blood Donors.

73. Medical Department, United States Army. Medical Supply in World War II. [In preparation.]

74. Memorandum, Col. J. B. Mason, MC, to the Chief Surgeon, ETOUSA, 4 Nov. 1943, subject: Delivery of Whole Blood to Continent, ETOUSA.

75. Conference, Whole Blood Service, ETOUSA, 22 Dec. 1943.

76. Memorandum, Lt. Col. C. B. Meador, MC, to Planning Branch, Office of Chief Surgeon, ETOUSA, 10 Apr. 1944, subject: Shipment of Medical Supplies by Air Transport.

77. Administrative and Logistical History of the Medical Service, Communications Zone, European Theater of Operations, vol. 6. [Official record.]

78. Letter, Lt. Col. L. H. Beers, MAC, to G-4, Supply Requirements Division, Headquarters, Com Z (Forward), 1 Sept. 1944, subject: Diversion of Air Planes Carrying Blood.

79. Informal Routing Slip, Col. S. B. Hays, MC, to G-4, Headquarters, ETOUSA, 22 Sept. 1944, subject: Request for Future Shipments of Blood to Paris.

80. Letter, Col. W. L. Perry, MC, to The Adjutant General, Washington, D.C., 25 Sept. 1943, subject: Project: Whole Blood Service for ETOUSA.

81. Informal Routing Slip, Lt. Col. Robert M. Zollinger, MC, to Medical Supply Division, attention: Col. W. L. Perry, MC, 20 Feb. 1944, subject: Medical Supplies for Field Transfusion Kit.

82. Memorandum, Lt. Col. Robert M. Zollinger, MC, to Surgeon, First U.S. Army, 17 Feb. 1944, subject: Concerning Distribution of Field Transfusion Units.

83. Memorandum, Lt. Col. Robert M. Zollinger, MC, to Col. E. C. Cutler, MC, 5 Nov. 1943, subject: Transfusion Units.

84. Memorandum, Lt. Col. Robert M. Zollinger, MC, to Medical Supply Division, 13 Jan. 1944, subject: Blood Transfusion Set (Sterile, Expendable).

85. Informal Routing Slip, Lt. Col. Robert M. Zollinger, MC, to Plans and Training Division, attention: Lt. Col. A. Vickoren, MC, 13 Mar. 1944, subject: Concerning Field Transfusion Units.

86. Administrative and Logistical History of the Medical Service, Communications Zone, European Theater of Operations, vol. 9. [Official record.]

87. Memorandum, Maj. Gen. P. R. Hawley, to Commanding Officer, 1st Medical Laboratory, 1 May 1944, subject: Violation of Security.

88. Letter, Maj. Gen. P. R. Hawley, to Col. J. A. Rogers, MC, 19 July 1944.

89. Letter, Maj. J. J. McGraw, Jr., MC, to Maj. R. C. Hardin, MC, 8 Jan. 1945.


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90. Memorandum, Capt. John Elliott, SnC, to Chief, Surgical Consultants Division, Office of The Surgeon General, through Director, Army Medical School, 1 Feb. 1945, subject: Transportation of Blood from the U.S. to the ETO Blood Bank in Paris.

91. ETMD, ETOUSA, for December 1944.

92. ETMD, ETOUSA, for June 1944.

93. ETMD, ETOUSA, for October 1944.

94. Letter, Maj. Gen. P. R. Hawley, to The Surgeon General, 14 Sept. 1944, subject: Whole Blood.

95. Robinson, G. C.: American Red Cross Blood Donor Service During World War II. Its Organization and Operation. Washington: The American Red Cross, 1 July 1946.

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

97. ETMD, ETOUSA, for September 1944.

98. The General Board, United States Forces, European Theater: Study Number 93, Medical Supply in the European Theater of Operations. Chapter 5, Whole Blood Service.

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