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Chapter III

Contents

CHAPTER III

The Evolution of the Use of Whole Blood in
Combat Casualties

DEVELOPMENT OF THE CONCEPT

Since the importance of whole blood in the resuscitation of wounded casualties was realized almost from the beginning by many of the personnel and agencies connected with the program, it is hard to understand why its procurement, distribution, and utilization got off to such a slow start in the U.S. Army in World War II. The success of the transfusion service in the Spanish Civil War (p. 11) and the similarly successful and long operational program in the British Army when the United States entered the war (p. 15) make the delay even more mystifying.

Any attempt at explanation must be a mixture of fact and opinion. Perhaps the chief reason was that overenthusiasm for the potentialities of plasma as an effective blood substitute tended to reduce the attention which might otherwise have been devoted to the development of methods for making the use of whole blood practical. A second reason was that even those who considered whole blood essential in the treatment of battle casualties thought its supply to forward units in a combat zone-let alone its transportation overseas-an entirely impractical project. The discussion at the first meeting of the Committee on Transfusions, Division of Medical Sciences, NRC (National Research Council)l on 31 May 1940 (1) clearly showed that the feasibility of such a program had to be grasped before any means for its implementation would be developed. The lack of the acceptance of the concept as a possibility was far more important than (1) the current lack of means to store the blood and transport it safely over long distances, and (2) the fact that an oversea airlift did not exist when World War II began. Moreover, at this time, blood had only a 6- to 8-day dating period, which was scarcely long enough to get it into a combat zone even if an airlift had been available.

In short, the hard fact of the matter was that in 1940 and 1941, when the need arose, there was no real choice: If plasma had not been recommended and used, there would have been no agent at all for the treatment of large numbers of wounded casualties. It was just 5 years before the United States entered World War II that Elliott (2) had pointed out the military advantages of plasma, some of which Ward had called attention to in World War I (p. 265). Because of its small bulk, it was practical to carry it well forward and thus

1Committee on Transfusions, Division of Medical Sciences, NRC, acting for the Committee on Medical Research, Office of Scientific Research and Development (hereafter termed Committee on Transfusions, NRC).


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treat shock many miles closer to the actual scene of wounding. Reduction of the timelag ("this valuable time element," as Elliott called it) might well mean the difference between life and death.

Another reason for delay in setting up an oversea blood program was the rather general failure to appreciate the difference between the use of blood in civilian medicine and its use as a military necessity. DeGowin and Hardin (3) (Maj. Robert C. Hardin, MC, who later served as Transfusion Officer in the European Theater of Operations, U.S. Army) differed from most other observers in their appreciation of this distinction. In an article in War Medicine in May 1941, these observers pointed out that since shock and hemorrhage are acute conditions, they must be treated at the earliest possible moment. The goal of any service supplying blood and plasma should be to make them available as far forward in the combat zone as possible. The value of every step in the processing and administration of these substances should be weighed in terms of their use at the front. Each detail of technique should be visualized as it would have been carried out in some such setting as a British casualty clearing station under air bombardment in the Battle of Flanders.

To meet these requirements, it would be necessary to collect blood in many centers, transport it to a small number of points for processing, and then deliver it to forward units. This is precisely what was done when the blood program was developed in the Mediterranean theater, which supplied its own blood throughout the war, and when the plasma program in the United States was extended to provide blood for theaters of operations.

In spite of the imaginative planning of DeGowin, Hardin, and their associates, the concept of the provision of whole blood for forward areas in oversea theaters was a very gradual development. In the Zone of Interior, this concept was first of all part of the development of the concept that whole blood was necessary for severely wounded men in shock and that plasma, valuable as it had proved, was simply an interim measure, with a supplemental and not a definitive role in their management.

Lt. Col. (later Col.) B. Noland Carter, MC, Assistant Director, Surgical Consultants Division, Office of The Surgeon General, expressed the general point of view in a comment on ETMD (Essential Technical Medical Data) NATOUSA (North African Theater of Operations, U.S. Army), for 1 July 1944 (4). Early in the war, he said, the lack of appreciation of the need for whole blood for seriously wounded men was shared by his own office, though at the time he was then writing (September 1944), the necessity was recognized in the Zone of Interior as well as in all combat zones. The complete recognition of this need, he concluded, was now evident in the Office of The Surgeon General in the establishment of tables of organization and equipment for blood transfusion units and in the recently instituted airlift of blood to Europe.

The need of combat casualties for whole blood in large quantities was learned by experience in the Mediterranean theater (p. 392). In the European theater, as information concerning the Mediterranean experience was supplemented by theater experience, it became clear that the procurement of blood


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from Army personnel in the theater simply would not meet the needs. Only a brief combat experience was required to make it clear that blood would be needed in much larger quantities, and for many more casualties, than had originally been contemplated. As time passed, there were increasingly frequent expressions of the necessity for, and the possibility of, securing blood by airlift from the Zone of Interior (p. 474).

As has already been pointed out, there was always a considerable number of observers in both the Zone of Interior and oversea theaters who believed that whole blood was necessary, and had no substitute, in the treatment of severely wounded men. Their voices were simply not loud enough-or perhaps they did not speak out loudly enough-to carry conviction until events in combat theaters furnished overwhelming proof of the need. Moreover, even those who believed from the beginning that whole blood was essential for combat casualties were at first faced with the major problem of how to place it where it could be used.

THE ROLE OF THE NATIONAL RESEARCH COUNCIL

Much of the basic work which led up to the use of whole blood in combat casualties in forward installations was directed, or actually carried out, by members of the Subcommittee on Blood Substitutes of the Committee on Transfusions, National Research Council.2 The development of the concept, which was linked with the practical aspects of its implementation, is most conveniently described chronologically.3

1940

31 May.-The first meeting of the Committee on Transfusions (1), of which Dr. Walter B. Cannon was chairman, was attended by the full membership, by Dr. Lewis H. Weed, chairman of the Division of Medical Sciences, NRC, and, by invitation, Col. (later Brig. Gen.) George R. Callender, MC; Col. (later Brig. Gen.) Charles C. Hillman, MC; Capt. (later Col.) Douglas B. Kendrick, MC; and Cdr. C. S. Stephenson, MC, USN. Maj. Gen. James C. Magee, The Surgeon General, was present for part of the meeting.

Dr. Weed explained that the committee had been organized because of a request from General Magee that NRC (p. 75) assemble a civilian committee that could act informally in an advisory capacity to the Army Medical Corps, as well as to the Navy Medical Corps, with special reference to surgical shock, blood transfusion, and blood banks. When Dr. Cannon took the chair, he stated that many trained investigators in various medical fields had offered their services to the committee, and, if representatives of the Army and the

2Subcommittee on Blood Substitutes, Committee on Transfusions, Division of Medical Sciences, NRC, acting for the Committee on Medical Research, Office of Scientific Research and Development (hereafter termed Subcommittee on Blood Substitutes, NRC).
3Unless otherwise indicated, all of the following data are included in the minutes of the Committee on Transfusions or the Subcommittee on Blood Substitutes for the appropriate dates.


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Navy would formulate their problems, the Division of Medical Sciences, NRC, would act as an agency for their investigation and for transmission of information concerning them.

In reply, General Magee stated that from his standpoint there were two chief problems:

1. Blood transfusions, particularly the use of dried plasma and the proper containers for plasma.4

2. Shock, including its prevention, and hemorrhage.

In the discussion that followed, these points were covered:

1. Blood banks. Colonel Hillman stated that if combat in a future war should be chiefly outside the United States, the Army would probably discourage the use of blood banks. If war should come closer, it might be possible to use blood transported by plane or under specially devised refrigeration. If blood could not be collected locally, either liquid or dried plasma would have to be used.

2. Preserved blood. At this time, the safe storage of whole blood was not generally thought to exceed 5 days. Dr. Everett D. Plass stated that he had used blood more than 30 days old without serious reactions. He believed that by improving the preservative fluid, the period of safe storage could be increased materially, though he granted that as the proportion of glucose, presently the preservative in use, was increased, difficulties of administration would also be increased.

3. Plasma. Commander Stephenson explained the Navy's preference for plasma rather than whole blood: Plasma could be used in any form without reactions. If it were dried immediately, it could be kept for 4 or 5 months without refrigeration. If the circulation were embarrassed, it could be given in concentrated form. Also, the task of accumulating stocks could be begun a year or more in advance of the time the plasma might be needed. Refrigerator space was not a problem for the Navy, and distilled water for the reconstitution of plasma was available on many parts of ships.

Other points concerning plasma discussed at this meeting included the possibility of making a synthetic preparation or of using plasma from a lower animal instead of human plasma, the best techniques of preparing dried plasma, and a request to drug firms to prepare and distribute dried plasma to certain institutions for testing purposes.

4. Shock. The chairman asked that various methods of handling shock and hemorrhage be described, including the potentialities and limitations of whole blood; concentrated plasma and wet and dried plasma, with due note of the refrigeration needed; deterioration of blood after transportation; and the

4It will be observed that at this and several succeeding meetings, the chief emphasis was on the use of plasma, which was readily accepted as a substitute for whole blood by a surprising number of experienced civilian clinicians and Army and Navy medical officers. The meeting of the Subcommittee on Blood Substitutes on 19 April 1941 (5) actually discussed whether whole blood was within its frame of reference; it was decided that it was. It should be pointed out again, however, that at this time, no matter how firmly one might have believed that whole blood was the transfusion medium of choice, its use was not practical because of the short dating period, the frequent reactions, sterilization problems, lack of refrigeration, and lack of an airlift.


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possibilities of preservation of blood and plasma. A system was needed that would be practical for both Army and Navy.

As Dr. Cannon saw it, the problem before the committee was possible ways and means of restoring blood losses in wounded men at different places in an organized line. Some agents could be used in fixed hospitals but certain others that could be easily transported, without refrigeration, must also be available. General Magee mentioned the mobile field hospital, which had completed tests and which he thought would be well adapted for shock treatment, a statement that was to prove prophetic.

Colonel Hillman was asked to discuss the question of blood donors with the American Red Cross. Dr. Plass, who had special facilities at the State University of Iowa College of Medicine for testing whole blood, was asked to work out a means of transportation for it. It was thought that airlines and trucking firms might be interested in cooperating in this project.

24 July-When the Committee on Transfusions made its report on this date to the Committee on Surgery, NRC (6), it advanced two chief reasons for the use of plasma rather than of whole blood in shock. The committee position can perhaps be interpreted as concessions to the position taken at the May meeting by representatives of the Army and the Navy:

1. Plasma is considerably easier to preserve and transport than blood.

2. Matching and typing are not necessary when pooled plasma, in which isoagglutinins are suppressed, is used.

Two other reasons, which have already been commented on, were also advanced for the use of plasma rather than blood in shock:

1. The belief that most shock is associated with hemoconcentration (p. 30) and that a given quantity of plasma would therefore be more effective than an equal quantity of blood. This belief could be traced back to the observations made in World War I that led to the erroneous concept that shock is an entity distinct from hemorrhage.

2. The belief, drawn from laboratory experiments under controlled conditions (p. 31), that plasma is approximately as effective as whole blood in the treatment of hemorrhage.

There were other fallacies in this approach:

1. It placed undue emphasis upon a single physicochemical property of blood, the osmotic activity of its plasma proteins, and ignored the important function of the red blood cells as oxygen carriers, as well as their contribution to the total blood mass under abnormal circumstances.

2. The magnitude of the initial loss of whole blood at wounding was not properly estimated, and the loss occasioned by continuing seepage of blood and its fluid components into the tissue spaces was also underestimated.

3. The effort to restore and maintain blood bulk by colloid preparations derived either from human proteins or from other sources presupposed a space bounded by a semipermeable membrane rather than a space in which large areas of the containing membrane might have been rendered freely permeable by the direct effects of trauma.


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30 November.-At this meeting of the Subcommittee on Blood Substitutes (7), the principal discussion concerned the feasibility of preserving and transporting whole blood, with special attention to the studies, which proved this point, by Dr. Plass and Dr. Elmer L. DeGowin at the State University of Iowa College of Medicine. They are reported in detail elsewhere (p. 220).

1941

19 April-At this meeting of the Subcommittee on Blood Substitutes (5), after a discussion of plasma and serum, the chairman, Dr. Robert F. Loeb, stated:

I take it that the consensus of the committee is that either serum or plasma reduced to either a frozen or a dried state is acceptable and the production should proceed at once with the understanding that in time other recommendations may be made.

This statement was agreed to by all the committee. The Army and the Navy accepted plasma because studies with it were much further advanced at this time than studies with serum and because the yield was greater-15 to 20 cc. per pint of blood-than the yield of serum.

It would be unfair not to emphasize again the entirely practical reasons for which the Subcommittee on Blood Substitutes recommended plasma to the Armed Forces in April 1941:

1. Supplying whole blood to the Armed Forces in the quantities likely to be needed, together with its safe storage and transportation, presented logistic problems of enormous proportions. They could not be solved in the light of either the knowledge or the facilities available in 1940-41. Preservative solutions which would permit long storage periods were just being developed. Thoroughly dependable, avid grouping sera were just being developed. The development of adequate equipment for the collection, storage, and dispensing of whole blood had barely begun. Refrigeration equipment for use in the field under varying conditions of heat, cold, and humidity had not yet been manufactured. Finally, an airlift capable of delivering blood to the far reaches of the battlefront was still almost 3 years off.

2. Plasma is a homologous protein fluid, the osmotic equivalent of blood, which can be administered without typing or crossmatching and which is almost entirely free from the reactions which, in 1941, were still frequent and serious after blood transfusion.

3. The protein content of plasma tends to hold transfused fluid in the vascular bed because its components are of high molecular weight and size as compared with the components of saline and dextrose solutions, which readily leak through the capillary walls or are excreted via the kidneys and which therefore have only temporary therapeutic value.

4. The use of plasma solved serious logistic problems. Separated from its cellular components, it could be frozen and dried to less than 1-percent moisture content. In this state, it could be packaged under vacuum and preserved for years without refrigeration and without being affected by extremes of heat and cold. The equipment necessary for its reconstitution and intravenous administration could be incorporated in a small package, which could be made available under almost all conditions of war. Plasma could be used in circumstances in which the procurement of whole blood would be completely impractical.

5. Finally, and most important of all in the light of immediate needs, plasma could be easily and safely produced commercially in the large quantities which would be needed.

The inherent organic characteristics of plasma, particularly the ease with which it could be manufactured, stored, and transported, clearly made it a


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practical and desirable agent. The reasons for its selection in 1941, while perhaps not fully explaining the failure to attempt to supply whole blood to field units at this time, did take cognizance of obstacles which went far toward discouraging even the most ardent advocates of whole blood as a replacement fluid in Zone of Interior hospitals. These reasons were considerably more valid in the consideration of plasma as a feasible and practical agent for blood replacement in oversea hospitals.

3 November-At this meeting-a little over a month before the United States was precipitated into World War II-the Subcommittee on Blood Substitutes unanimously expressed the opinion that the Armed Forces should use whole blood in the treatment of shock whenever this was possible (8). Unfortunately, this clear-cut expression of opinion was omitted from the minutes of the meeting, and the omission was not realized until the meeting of 24 September 1943. All present at the later meeting were in agreement that this opinion had been expressed unequivocally at the 3 November 1941 meeting, and it was the sense of the 1943 meeting that the minutes of the earlier meeting be corrected to show the facts.

1942

20 October-Two important proposals were made at this meeting of the Subcommittee on Blood Substitutes (10). The first was that stored blood be used in the Armed Forces whenever the practice was feasible and fresh blood could not be used effectively. The second was that universal donor blood (O) be employed, to eliminate the necessity for crossmatching. These recommendations were passed on to the parent Committee on Transfusions, for submission to the Surgeons General of the Army and the Navy through National Research Council channels.

At this meeting, it was also recommended that supervision of the administration of all parenteral fluids be considered within the scope of the transfusion service which had been proposed at the 25 August 1942 Conference on Transfusion Equipment (11) and that replacement therapy be considered as a medical specialty. These recommendations were later implemented, at least in part, by the appointment of a Special Assistant on Shock and Transfusions in the Office of The Surgeon General (p. 69).

15 December-This meeting of the subcommittee (12) accepted the proposals for a special shock and transfusion service in the Armed Forces, which had been drawn up by Dr. DeGowin, Major Kendrick, and Cdr. (later Capt.) Lloyd R. Newhouser, MC, USN, and recommended that they be transmitted through channels to the Surgeons General of the Army and the Navy. These proposals were never implemented.

1943

23 March-A conference on blood grouping on this date was participated in by a number of members of the Subcommittee on Blood Substitutes (13).


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Dr. DeGowin opened the discussion by asking those present if they would be willing to recommend that the Armed Forces employ group O blood as a universal donation, without crossmatching, if there was assurance that blood grouping had been accurately performed. After a vigorous discussion of various aspects of the proposal, the conference participants agreed to it, with the understanding that either blood with low titer agglutinins would be used or that A and B specific substances would be added to the blood.

At the 13 May 1943 meeting of the Subcommittee on Blood Substitutes (14), it was recommended that provisions for the storage, transportation, and administration of whole blood in the Armed Forces proceed with all possible speed.

For all practical purposes, the two recommendations just stated marked the beginning of the whole blood program for oversea theaters, though for various reasons it was not until August 1944 (p. 487) that they were translated into action.

Note.-Other actions of the Subcommittee on Blood Substitutes are described in appropriate places in this chronicle.

THE EVOLUTION OF THE CONCEPT OF WHOLE BLOOD REPLACEMENT IN THE MEDITERRANEAN THEATER

The British Experience

Reports of the transfusion service which the British had set up before the outbreak of the war in 1939 have been cited elsewhere (p. 15). Their early experiences clearly indicated the need for large quantities of whole blood in the management of wounded casualties, and their foresight put them in a position to provide it.

The British experiences in North Africa were made available to the Office of The Surgeon General, through Col. Frank S. Gillespie, RAMC, British Medical Liaison Officer, who was stationed at the Medical Field Service School, Carlisle Barracks, Pa., during the early months of the United States participation in the war. As the British experience accumulated, Colonel Gillespie made every effort to keep Colonel Kendrick, The Surgeon General's Special Representative for Blood Plasma and Transfusions, fully informed of changing concepts in the care of battle casualties. The development of the U.S. program was painfully slow, but the British experience had a far-reaching effect on all the planning. Colonel Kendrick was exceptionally fortunate in having Colonel Gillespie's cooperation and support at a time when U.S. Army medical intelligence was relatively limited.

The whole British experience in North Africa proved that while plasma was extremely valuable in providing temporary circulatory support for patients who had suffered multiple extensive wounds, associated with massive hemorrhage, it was not enough. Whole blood, which had the oxygen-carrying


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property lacking in plasma, was essential during anesthesia and initial wound surgery.5

Evaluation of Plasma in U.S. Army Casualties

Because he had been so well briefed on these matters by Colonel Gillespie, Colonel Kendrick was able to have extended discussions with the personnel of the Surgery Division, Office of The Surgeon General, on the value of whole blood versus plasma in battle casualties. He considered it essential that the same information should be in the possession of Col. Edward D. Churchill, MC, who had been ordered to North Africa in January 1943, to serve as Consultant in Surgery, Fifth U.S. Army, and that he should have it before the fighting in that theater extended to Sicily and Italy.

The opportunity to discuss these matters with Colonel Churchill arose during his predeparture briefing in the Office of The Surgeon General, while he was reviewing the film strips which had been prepared by Colonel Kendrick on first aid in the field and on resuscitation, including the use of plasma and whole blood. Colonel Churchill was also informed that an important function of the Department of Surgical Physiology, Army Medical School (p. 65), was to investigate and evaluate solutions and equipment by whose use blood could be stored and shipped long distances with expedition and safety.

It was suggested to Colonel Churchill that upon his arrival in North Africa, he undertake a study of the whole problem, to determine:

1. With plasma readily available, was whole blood really needed?

2. If whole blood was really needed, how best could it be provided?

Colonel Churchill assumed his consultant duties in North Africa on 7 March 1943. His first official report, 2 weeks later (15, 16), after a period of temporary duty with II Corps on the southern Tunisian front, was a memorandum to the Army Surgeon on whole blood transfusions. In this report, and in a number which followed it, he made the following points:

1. Plasma and other preparations that do not contain red blood cells are incorrectly named blood substitutes. While invaluable for certain specific purposes and under certain specialized conditions, they are merely fractions of blood. Plasma may be preferable to whole blood in crushing injuries, in the early stages of burns, and in extreme heat dehydration, but all of these conditions are numerically insignificant in war.

2. The development of plasma was undoubtedly a great contribution to military medicine, but the early enthusiasm that accompanied its development

5In North Africa and Italy, as well as later in Normandy, the British supplied some of the whole blood used for American casualties. At the meeting of the Southern Surgical Association in 1944, Colonel Gillespie was asked to comment on a communication dealing with the management of battle casualties and thought to himself, as he wrote after the war, "Here's my chance for another crack at the whole blood battlefront." So he said: "I have often wondered at the physiological differences between the British and American soldier. The former, when badly shocked, needs plenty of whole blood, but the American soldier, until recently, has got by with plasma. However, I seemed to observe a change of heart when I was in Normandy recently and found American surgical units borrowing 200-300 pints of blood daily from British Transfusion Units, and I'm sure they were temporarily and perhaps even permanently benefited by having some good British blood in their veins."


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had pushed aside sound clinical judgment and had led to the widespread misconception that it was an effective substitute for blood in shock. In fact, the organization and development of effective methods for the management of shock had been handicapped to an embarrassing degree by this misconception, which was firmly entrenched in both administrative and professional minds.

3. The real circumstances were these (17): Even in hematopneic shock, the liberal use of plasma could restore the circulating blood volume and thus tide a casualty over the critical period required for his evacuation to some installation in which whole blood was available. When plasma was used liberally, certain casualties recovered from shock in the sense that the blood pressure was brought to normal or nearly normal and the peripheral circulation was reestablished by the improvement in the blood volume deficit. Neither of these groups of casualties, however, were in a state to tolerate major surgery without more support. In both, the blood pressure was extremely labile and would fall rapidly if operation were undertaken. Further hemorrhage might occur, or some blood would be lost at operation, and the additional losses could not be tolerated by a casualty with profound secondary anemia, for the oxygen supply to the tissues was not adequate. He might improve temporarily with oxygen administration, but additional plasma would be of little benefit.

4. The North African experience showed that some casualties would die because of the very nature of their wounds or the complications of their wounds. Others would die from the damage caused by their state of shock. The lethal sequelae of shock had become more apparent as surgery and resuscitation had improved. Basically, these sequelae were attributable to the asphyxia of organs or tissues during the prolonged period of reduced volume flow of blood. Often, they were masked by the presence of serious complications arising from the wound itself. They were sometimes not recognized at all in casualties who succumbed to such rapidly fatal results of trauma as fulminating infection, cerebral lacerations, or respiratory insufficiency. The brain, the kidneys, and possibly the liver might show irreparable and ultimately lethal damage from shock. Kidney damage was probably the most frequent of these sequelae, and also the most easily overlooked.

5. An inexperienced surgeon, seeing the beneficial results of plasma therapy and not realizing its limitations, might be encouraged to undertake surgery in a patient not prepared to tolerate it. Indeed, restoration of the blood pressure and volume flow under conditions in which hemorrhage could not be arrested at once by surgery might lead to further loss of red blood cells and terminate in disaster. Once the patient had been resuscitated, he must not be allowed to go into shock again. If surgery had to be delayed, plasma would keep him alive until it could be undertaken, but there must be no attempt to establish full circulatory compensation. Meantime, all shock-producing factors must be eliminated, which meant the relief of pain, the immobilization of fractures, and the control of hemorrhage.


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Conclusions

In view of these facts, Colonel Churchill made the following points clear in his first memorandums and in subsequent reports:

1. That whole blood was the agent of choice in the resuscitation of the great majority of battle casualties.

2. That whole blood was the only therapeutic agent that would prepare seriously wounded casualties for the surgery necessary to save life and limb.

3. That both the mortality rate and the incidence of wound infection were reduced by the use of whole blood at the time of initial wound surgery.

4. That plasma should be looked upon as a first aid measure for dire surgical emergencies and as a supplement for whole blood, not as a substitute for it.

Thus, Colonel Churchill concluded, actual experience had clearly delineated both the indications for, and rationale of, plasma and whole blood replacement. Both agents were extremely valuable in the management of shock, but each had its own individual and specific purposes, and, if they were to be used efficiently, both limitations as well as indications must be borne in mind.

Months were to pass before an organized system of providing blood for casualties in forward areas was set up in the North African theater; by the time a central blood bank had been established (p. 400), however, plasma had assumed its proper place in resuscitation and whole blood, collected locally, was being used in increasing quantities. When active combat began in the European theater, the experience in North Africa, Sicily, and Italy was already at hand. The amount of whole blood that would be needed on the Continent was underestimated, but the need for blood was realized, and plasma was generally used only according to its capabilities.

COMMENT

Nothing that has been said in this chapter should be taken to mean any derogation of the value of plasma. Its capacity was seriously overestimated in many quarters early in World War II. The almost fantastic hopes originally pinned to it were never realized. A more realistic estimate of its capacities would have prevented many misunderstandings and disappointments. Later in the war, its capabilities were somewhat underestimated. The truth lies somewhere between.

An interesting sidelight is thrown on the real value of plasma by an indignant letter from a young medical officer, in charge of a battalion aid station in North Africa, who apparently had difficulties with supply. It was necessary, said the writer, to beg, borrow and steal plasma from various hospital units and from medical supply depots, which irked him by their strict adherence to distribution regulations and which seemed to have no concept of conditions at a battalion aid station.


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FIGURE 5.-Plasma administration in the field. A. Administration of plasma to wounded U.S. soldier on back of jeep trailer en route to portable surgical hospital, Galahad Forces, Myitkyina, Burma, July 1944. B. Plasma administered on the run to casualty being taken to L-5 plane for quick evacuation to Cotabato, Mindanao, Philippine Islands, May 1945.


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He had "managed to scrape up" five units of plasma and had used four of them with excellent results, three for shock and one for burns. A high Army officer, who had been injured in the area and who was in mild shock, was treated with the fifth unit. The lack of plasma for him "would have been most embarrassing."

The writer waxed more indignant as he continued. Plasma was nowhere more essential, he pointed out, to prevent impending, and treat primary, shock than in the frontlines. It was more sensible to provide it there and not wait until the casualty went into secondary shock. He might easily die on his way to the clearing station, usually 3-5 miles, and sometimes 12-15 miles, to the rear. If practical considerations were brought in, plasma could be given under the most severe battle conditions. He himself had administered it with shells and bombs landing only a few yards away and had seen casualties respond to it under his eyes.

On the other side of the world (fig. 5), plasma was reported as equally effective. The Naval medical officer in charge at Tarawa, Capt. French R. Moore, MC, USN, said that 6,000 pints of plasma went ashore with the invading troops and "4,000 pints came back in the veins of wounded Marines."

In his book, "More Than Meets the Eye" (18), Carl Mydans wrote of "combat medics on bouncing jeeps," who

* * * kneeling and balancing and clinging miraculously with one arm, raised the other high, as one would a torch, holding a bottle of plasma, pouring life back into a broken body. I think I have never seen a soldier kneeling thus who was not in some way shrouded with a godlike grace and who did not seem sculptured and destined for immortality.

To those who saw what plasma achieved in World War II, this quotation is not an exaggeration.

References

1. Minutes, meeting of Committee on Transfusions, Division of Medical Sciences, NRC, 31 May 1940.

2. Elliott, J.: A Preliminary Report of a New Method of Blood Transfusion. South. Med. & Surg. 98: 643-645, December 1936.

3. DeGowin, E. L., and Hardin, R. C.: A Plan for Collection, Transportation and Administration of Whole Blood and of Plasma in Warfare. War Med. 1: 326-341, May 1941.

4. ETMD, NATOUSA, for July 1944.

5. Minutes, meeting of Subcommittee on Blood Substitutes, Division of Medical Sciences, NRC, 19 Apr. 1941.

6. Blalock, A.: Report of Committee on Transfusions, Division of Medical Sciences, National Research Council, to Committee on Surgery, Division of Medical Sciences, National Research Council, 24 July 1940.

7. Minutes, meeting of Subcommittee on Blood Substitutes, Division of Medical Sciences, NRC, 30 Nov. 1940.

8. Minutes, meeting of Subcommittee on Blood Substitutes, Division of Medical Sciences, NRC, 3 Nov. 1941.

9. Minutes, meeting of Subcommittee on Blood Substitutes, Division of Medical Sciences, NRC, 24 Sept. 1943.

10. Minutes, meeting of Subcommittee on Blood Substitutes, Division of Medical Sciences, NRC, 20 Oct. 1942.


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11. Minutes, Conference on Transfusion Equipment and Procedure, Division of Medical Sciences, NRC, 25 Aug. 1942.

12. Minutes, meeting of Subcommittee on Blood Substitutes, Division of Medical Sciences, NRC, 15 Dec. 1942.

13. Minutes, Conference on Blood Grouping, Division of Medical Sciences, NRC, 23 Mar. 1943.

14. Minutes, meeting of Subcommittee on Blood Substitutes, Division of Medical Sciences, NRC, 13 May 1943.

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

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

17. Memorandum for The Surgeon General, 20 June 1944, subject: Annual Report, Transfusion Branch, Surgery Division, Fiscal Year 1944.

18. Mydans, Carl: More Than Meets the Eye. New York: Harper & Bros., 1959.

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